Using educational comics with patients

and familiesSarah McNicol

September 2015

Overview of the research findingsThe impact of educational comics on feelings and attitudes towards health conditionsThe Wellcome TrustNov 2014 – Apr 2015

Research questions• In what ways can educational comics provide support in

dealing with feelings and attitudes towards health conditions, as well as improving understanding of factual information?

• How should educational comics be evaluated to ensure that their impact on patients’/relatives’ feelings and attitudes is considered, in addition to factual recall?

Methods

• 11 in-depth interviews (range of mental and physical conditions, patients/family members)• Comics as stimulus material

Gaps in existing health information• …they’re very generic a lot of the information and that’s one of

the frustrations when you go on the internet; you can never find that absolute, specific information that fits you case…it can be a bit frustrating at times when you can’t find something that’s particularly personal to you, or empathises with what you’re going through at that point. (Interviewee J)

• I think it’s still hard to understand what someone’s going through…you can’t understand why they’re in pain… (Interviewee F)

Features of comics

•Accessibility • Images•Characterisation•Metaphors•Humour

Accessibility• …they were definitely more accessible than I thought. I thought

it would be a really heavy read and I’d have to sit down and study them…it was actually fine; it really wasn’t so bad…really easy to read and understand as well. (Interviewee D)

• … it’s better gone through as a story rather than an adult telling them…it would be more relatable as a story than as an explanation…(Interviewee E)

• It hasn’t got a lot of jargon in either, which is quite nice…things that are hard to pronounce or remember…I think having the medical jargon out of it is really, really important… (Interviewee J)

Use of images• …if I was on a website and I read “Patients with lewy bodies may

experience hallucinations”, I might…”Okay then” and move on, but this made me imagine it quite a bit more, so it gave me quite a bit more insight into it. (Interviewee D)

• I couldn’t really describe the pictures, I found it a bit messy…so seeing this picture I feel very…stressed and everything…I can’t really tell what the picture is, but…it causes me the feeling that I do not want to have… (Interviewee K)

• I think without the pictures it would be more serious…I don’t know, I think the pictures take the seriousness out of that particular issue… (Interviewee J)

Characterisation• …and it’s almost like you can relate to expressions and people’s

feelings more when you see an image rather than just than on a leaflet with no images. (Interviewee C)

• … I think it is the best way to do it ‘cos if you link yourself with someone, you remember it better then. If you link yourself with the character you remember about the information that’s being given to you. (Interviewee A)

Metaphors• That does make it easier to

understand… you think “Oh, insulin…oh, sugar… glucose…it’s all confusing!” …I didn’t think of it that way [before]. That’s an interesting way of putting it…he can’t deliver his parcels if the doors aren’t open. (Interviewee I)

Humour• It definitely works, humour…To make my situation…more

relaxing or laugh with myself …it’s nice to use humour to describe these kind of situations otherwise it wouldn’t be that pleasant to read. (Interviewee K)

• …but other people might think, “Why are you making a joke about me having to go to the toilet 10 times a day? It’s not funny”. (Interviewee B)

Complexity• She [interviewee’s mother] said that when she’s read other

things about it [lupus], all they say is it’s older people, but actually it’s not; she was about 25. So she said this one’s really good because it makes you think, “Oh, it can be a person with a young child that are diagnosed with it”. (Interviewee C)

• …a bit cringey...and I felt like they’ve had a list of stereotypes about what you go through when you get diabetes…and that they were just ticking the boxes as they went through. (Interviewee E)

Uses of comics

• Awareness raising• Discussion starters• Self-awareness• Empathy & companionship

Awareness raising• MS is not one…illnesses that you would know about so that’s

good. (Interviewee F)

• …when she was diagnosed not many people know about it. It’s not a well-known illness, so there’s not much out there and even when you go online (Interviewee C)

• It’s a good way to get information across actually…Those are really, really good if they could be directed around the general public. (Interviewee G)

Discussion starters• It could be a good starting point…It might help you to talk to

somebody about how it feels… (Interviewee J)

• …my mum doesn’t like to tell people how she’s feeling, so a lot of people in the family just wouldn’t know. So I think this is quite a good thing, say, “I’ve got this, just have a read of it” and you make a mental note, “Oh, that’s why they’re like that on certain days”... this gives you an insight into behind the scenes where she might keep that back from family members… (Interviewee C)

Potential use with healthcare professionals• I think it’s just a good starting point for a dialogue… I talk quite

openly about it now, but [in the past] I had to go to my GP and had it written down: “I can’t talk to you, but this is what I’m feeling”. You could quite happily hand those over: “This is what I feel at this moment in time”. (Interviewee J)

• They have to be selected very carefully; you have to know the patients and how they would react before showing them, but it could be useful in breaking through that sense of isolation and helping people to recognise various things about depression… (Interviewee G)

Self-awareness• It just brought it back to my awareness because I live with it all

the time I don’t even think about it. It helped in that way…it brought things up into my mind that were in my mind but…suppressed. Definitely has helped in that way… It made realise…I try to think that I haven’t got it, so I was like, “I have got it and this is what I’ve got to deal with”. It made me realise that I’m doing alright considering…I’ve got all this going on as well, I just don’t realise that I’m doing it. It made me think, “Yeah I’ve got it and this is what I’m facing”. (Interviewee B)

Empathy and companionship• For me, it was the relief, “Oh, this isn’t just me…” When she

was describing that she didn’t want to exist…It’s not that I ever wanted to kill myself, I just wanted to stop existing… How she describes a button that could blink her out of existence…that really resonated with me… I thought that was unusual for me to think that…that is interesting to show just how much that is actually thought about. (Interviewee G)

• It did make me think more about my dad’s experience at that age, ‘cos he was at university when he was diagnosed, so the impact that would have had on him at that point, how that would have changed… (Interviewee E)

Possible negative impacts

• Attitudes towards comics• Negative messages• Emotional impact

Reactions to health education comics• I didn’t even know stuff like this was out there… I didn’t know

they were used in this way. I think, “Comics, The Beano”…I didn’t realise… (Interviewee B)

• …the word comic in itself…You say the word comic…pretty much all of them will think Marvel or DC or something like that…or light-hearted comedy…This is a comic about depression, then people would think, “That’s an oxymoron surely. What’s going on?”. (Interviewee G)

• I think I found them quite difficult to follow…even how they’re set out; I never know which bubble to read first to make the conversation make sense…I think that’s one of the reasons why I struggled. (Interviewee J)

Changing attitudes to comics• …that comics can be more informative because in the past I’ve

just seen them for entertainment, but I definitely think they can be more informative and be used in a really positive way…portraying serious information, but in a light-hearted sense. (Interviewee D)

Negative messages• Interviewee: It was a bit gloom and doom; they’re a bit dark

aren’t they; everything seems a bit bad for them…things keep going worse for them.

• Interviewer: Would you have preferred it more positive?• Interviewee: Yes, slightly more positive. If people read that and

they start thinking, “Oooh, uh-oh…” It’s all bad news, but there’s obviously good things as well that can happen…Maybe a bit more about what the good things were rather than just the bad. (Interviewee A)

Emotional impact• Well obviously people may see themselves in the comics; it

may bring up old feelings…depression if they see the people are reacting, sad faces in comics…the gloom of the man when he’s found out he’s got…seeing the bad side of things, relating themselves to the bad side of the character, they might think, “Am I going to be this upset? Is it going to be this daunting for me?”. (Interviewee A)

Using health education comics• Pick one or more comics you might use• Who would you use it with? (patient, family group, support

group, children, older people, men, women…)• How would you use it? And for what purpose(s)?• How would you introduce it to the audience, or make them

aware of it? (e.g. would you call it a ‘comic’? What would you suggest the benefits of reading it/positive features might be?)

• What might the challenges be? (e.g. negative perceptions) and how could you overcome these?

• How do you think it would fit with other information sources available?

• How would you evaluate it - not necessarily formally, but what would ‘success’ look like?

Useful links• Project report: http://

dx.doi.org/10.6084/m9.figshare.1512330

• Comics identified through the research: https://sites.google.com/site/healtheducationcomics/home

• Graphic Medicine: http://www.graphicmedicine.org/

• Nurse Groups, Medical Humanities Resources: http://www.nursegroups.com/nursing-article/medical-humanities-resources.html