Beyond the Written Word: Health Literacy and the Role of Pictures

ken thorlton headshotToday’s guest post comes from Ken Thorlton, SVP, Creative Director, of HealthEd. Ken has been with HealthEd since 2004, now serving as senior vice president, creative services. In this role, he manages design teams and oversees all aspects of creative development¢‚Ǩ”interpreting clients communication strategies, visually capturing patient insights and needs, and unifying that vision into a strategic creative concept. He is also proficient in the field of educational design and health literacy principles as they pertain to the creation of patient education materials.

Throughout his career, Ken has delivered creative solutions to pharmaceutical companies, hospitals, health benefit providers, and retail healthcare companies. His designs have garnered many industry awards.


by Ken Thorlton (@HE_KenT)

Ever think about how pictures affect what you do in your daily life? Have you ever tipped a waiter a little more because he drew a smiley face on the bottom of your check? Or donated money to a local humane society when you saw pictures of puppies in its literature? Studies have shown that the frequency and size of a waiters tips were greater when the smiley face was present. And that more money was donated when puppy pictures were shown, versus text-only materials.

A recent paper I came across highlights the importance of pictures in all communications, and especially in health education.

The Fry formula, the Flesch-Kincaid system, the SMOG. These are all health literacy assessment tools that help estimate the grade reading level of written words on a page. According to experts, some of these tools are better than others.

HealthEd applies health literacy guidelines to all of its patient materials, not just the written parts. We understand that the grade reading level of written health education plays a major role in helping patients comprehend and apply positive behaviors to their treatment. And in light of the fact that 50 percent of all Americans read below the eighth-grade level, the written word (and its associated grade level) becomes even more important.

But the grade reading level of health education materials alone is only one guideline of many that help to produce effective patient education. According to the US Department of Health and Human Services, we must “use measures of reading grade level only in combination with other factors to judge ease of reading. As a creative director, and one who speaks frequently on the role of design in creating health literate materials, pictures and visuals are those “other factors.

Do pictures really affect comprehension of health education materials? A recent study assessed the effects of incorporating pictures on understanding medication instructions among 60 low-literate respondents. Of those who received a leaflet with pictures, 93% responded correctly to the question “How must you take this medicine? versus 47% for those that received text-only instructions. And when asked, “What are the actual times?, 73% answered correctly who had been given the text plus pictures versus only 3% that received the text-only version.

There are many other health education studies that seem to have the same conclusion. Incorporating pictures into health education materials will help patients better understand the information. But, as health educators, we know its not just about a patients ability to comprehend the information. We want them to act on the information as well.

Do pictures influence peoples intentions and behavior in response to medical instructions? According to a study of 234 emergency room patients, those who were given instructions for managing lacerations with pictures were 77% were more likely to do what was recommended versus only 54% for those who received text-only instructions. And another study of 78 non-literate women showed that, on average, women who received picture instructions took 90% of the pills prescribed for the affected time period versus 78% for the women who received only spoken instructions.

So, it seems logical to assume that incorporating pictures into health education can not only enhance a readers comprehension, but also help them accept the message as something they should act on. With that in mind, here are some recommendations for using pictures in health education:

  • Look for ways to include pictures
    • Think from a visual perspective and ask, “where can I use pictures to support key points
  • Try and use the most basic drawings or photographs
    • This helps viewers with low literacy skills to understand the intended message and not become distracted by unimportant details
  • Visually guide how pictures are interpreted by the viewer
    • Use captions that describe what is happening in the picture and link to text through proximity
  • Be sensitive to the culture of the intended audience
    • Readers want to see themselves and their concerns related in the piece. If they dont, chances are they are not fully understanding the information
  • Evaluate the effect of including pictures
    • If possible, try to conduct follow-up interviews that assess attention, understanding, remembrance, and adherence as it pertains to the inclusion of pictures in the piece

We understand the grade-reading level of health education materials can be a “make it or break it point for patient comprehension. Writing at a lower level can certainly help readers understand the information better. But words alone wont do the trick. As referenced above, pictures along with copy allow for more comprehension, better recall, and ongoing adherence to treatment regimes than just plain text with no visuals.

And can also lead to better tips. Just ask the waiter with the smiley face.


Houts PS, Doak CC, Doak LG, Loscalzo MJ. The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence. Patient Educ Couns. 2006 Dec; 64(1-3:393-4. Accessed October 3, 2011.

Guegun N, Logeherel P. Effect on tipping of barman drawing a sun on the bottom of customers checks. Psychol Rep 2000;87:223-6. Accessed October 3, 2011.

Perrine RM, Heather S. Effects of picture and even-a-penny-will-help appeals on anonymous donations to charity. Psychol Rep 2000;86:551-9. Accessed October 3, 2011.

Centers for Medicare and Medicaid Services. Writing and Designing Print Materials for Beneficiaries: A Guide for State Medicaid Agencies. Washington, DC: US Dept of Health and Human Services; 1999. Publication 10145.

Mansoor LE, Dowse R. Effect of pictograms on readability of patient information materials. Ann Pharmacother 2003;37:1003-9. Accessed October 3, 2001.

Delp C, Jones J. Communicating information to patients: the use of cartoon illustrations to improve comprehension of instructions. Acad Emerg Med 1996;3:264-70. Accessed October 3, 2011.

Ngoh LN, Shepard MD. Design development, and evaluation of visual aids for communicating prescription drug instructions to non-literate patients in rural Cameroon. Patient Educ Counsel 1997;31:245-61. Accessed October 3, 2011.

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