This has been a fascinating and very useful discussion.  I wanted to
mention our experience in dealing with non-literate population in
developing countries.  As you might imagine there is a plethora of
experience and formative research coming out of more than 40 years of
practice in the field.  
 
1. Pictures are just as abstract as letters - i.e., hieroglyphics.
People must be taught to recognize their meaning.  This is why
pretesting of specific drawings is so critical.  People can learn simple
pictures easier than written language, but we found there is no
universal symbol language that speaks intuitively to everyone. 
 
2. While developing  pictorial packet instruction to teach mixing a
sugar and salt solution for infants, mothers did not even recognize that
the pictures were instructions.  They thought they were decoration.  The
solution was a series of radio broadcast that taught mothers to
recognize and decipher the pictures. 
 
3. Finally, people like to talk to other people.  They don't like to
read instructions. We spend so much time on "reading" and "printing"
because somehow we think that people should read and that printed
materials are so easy to disseminate. But we know from study after study
that only a small fraction of people read everything.  The joke about
men reading instructions as a last resort grows out of a great truth. 
Een highly literate people often do not read when they can have someone
tell them. And the populations we care about the most want to be talked
to.  
 
Talking is the new frontier of literacy - using the new technologies to
provoke conversation, question and answers to replace our default
dependence on direct mail, pamphlets, and brochures.  Why can't we give
people what they want (someone to talk to) instead of spending so much
time and agony finding visual symbols some don;t understand and others
don;t want to bother reading?  
 
Wm. Smith
Executive Vice President
Academy for Educational Development
1825 Connecticut Ave., NW
Washington, D.C. 20009

Organize policy until self-interest
does what justice requires.
Phone: 202-884-8750
Fax: 202-884-8752
e-mail: bsmith at aed.org 


>>> "Brach, Cindy (AHRQ)" <Cindy.Brach at ahrq.hhs.gov> 3/3/2008 11:29 AM

>>>

        Thanks for mentioning Judy's work, Sue. 
      
    If you want to read a short summary of the article that appeared in
AHRQ's "Research Activities" go to 
http://www.ahrq.gov/research/jun05/0605RA40.htm   and scroll down to
Shea. 

        _____  

        From:   healthliteracy-bounces at nifl.gov on behalf of Sue
Stableford 
  Sent:   Mon 3/3/2008 9:55 AM 
  To:   The Health and Literacy Discussion List 
  Subject:   [HealthLiteracy 1818] Re: pill card 
    

        
  Just to add one more great article to suggested reading about how
adults understand pictures, check this article: 
Shea Judy et al. Developing an Illustrated Version of the Consumer
Assessment of Health Plans (CAPHS). Joint Commission on Accreditation of
Healthcare Organizations. January 2005;31(1):32-42. This is an excellent
article about how line drawings to explain important health survey
issues were designed and tested with an American audience. While not
"icons," the drawings had to be simple representations of complex
concepts. I often recommend this article to help people learn about the
importance of audience testing. 
  
Best, 
Sue Stableford 
  
  
  
Sue Stableford, MPH, MSB, Director 
Health Literacy Institute 
Center for Health Policy, Planning  &  Research 
University of New England 
716 Stevens Ave. 
Portland, Maine 04103 
Tel: 207-221-4567 
email: sstableford at une.edu 
fax: 207-523-1914 
www.HealthLiteracyInstitute.net 
www.ClearLanguageGroup.com 
  
  
  >  >  >  Joan Medlen  < joan at ipns.com >  2/29/2008 9:55 AM  >  >  > 

This is absolutely spot on. You will also find good information on
creating 
visual materials within the autism community - take a look at Visual 
Strategies for Improving Communication by linda Hodgdon and "Teaching
by 
Design" by Kimberly Voss. I have used all these techniques in my work 
adapting nutrition education materials for people with intellectual 
disabilities and find that it crosses over to ESOL work and work in
health 
literacy very nicely.   It's all about being understood and your target

audience/individual being able to show you that. 
  
I would highly recommend background free images if you are using 
photographs. Many tools for people with autism have a lot of these
images. 
The owner of Silverlining Multimedia may be willing to create some of
these 
images for you if photographs are preferable. You can reach her at 
www.silverliningmm.com . I use her Visual Foods CD all the time. 
  
You can also download some of the symbol-based communication programs
for a 
free trial. Boardmaker has a great library of symbols, but is also a
bit 
expensive. you can find it, and pix writer, here: www.mayerjohnson.com

  
Take care, 
  
Joan 
  
------- 
Joan E Guthrie Medlen, R.D., L.D. 
Clinical Advisor, Health Literacy  &  Communications 
Special Olympics Healthy Athletes 
joan at DownSyndromeNutrition.com 
  
At 06:30 AM 2/29/2008, you wrote: 
  > One place that you will find a large body of knowledge about icons
for 
  > language is in the field of alternative and augmentative 
  > communication.   Many communication systems use pictographic
symbols to 
  > store message components.   You will find that this is a very
complex 
  > area.   While you would think that photographic images are easiest
to 
  > associate, they can be too complex to process easily.   Line
drawings 
  > are easiest to identify and discriminate, but the association can
be 
  > hard to establish.   And, as you've noted, as soon as the ideas
become 
  > even a little bit abstract, the images can be complicated. 
  >  
  > Do you use the same symbol for a Papillon and a Great Dane?   Both
are 
  > dogs, but sure don't look alike.   What do you use to indicate 
  > "justice" or "faint?"   In AAC, people have been wrestling with
this 
  > for some time, and I recommend at least looking at the body of work
as 
  > an aid to literacy work. 
  >  
  > Denis Anson, MS, OTR 
  > Misericordia University 
  > Dallas, PA 
  >  
  > On Feb 29, 2008, at 2:34 AM, Ros Dowse wrote: 
  >  
  >   >  Yes, Julie, I think development of images in the classroom
setting 
  >   >  provides students with a valuable opportunity to gain valuable

  >   >  insight into the reality of communicating ideas and actions in
a 
  >   >  visual form rather than a text-based form. What my research
students 
  >   >  and I have done is to conduct a workshop with our undergrad
pharmacy 
  >   >  students to stimulate ideas for image development e.g. our
most 
  >   >  recent one was concerned with illustrating the side effects of
ARVs. 
  >   >  Although we are a South African university, our students come
from 
  >   >  all around Africa, so we had a wonderful melting pot of
cultures, 
  >   >  experiences and ideas to draw from. The outcomes were really
useful 
  >   >  and provided us with a great foundation from which we could
further 
  >   >  develop individual images. They are currently being tested to

  >   >  determine acceptability in terms of international criteria
(ISO and 
  >   >  ANSI). 
  >   >  
  >   >  Bob, I strongly agree with your opinion that all pictograms
should 
  >   >  be tested in the target patient population before being used
in 
  >   >  practice. I have seen far too many examples of cases where
this has 
  >   >  obviously not been done. 
  >   >  
  >   >  Regards 
  >   >  Ros 
  >   >  
  >   >  Ros Dowse 
  >   >  Associate Professor 
  >   >  Faculty of Pharmacy 
  >   >  Rhodes University 
  >   >  Grahamstown, South Africa 
  >   >  +27 (0)46 603 8070(w) 
  >   >  +27 (0)83 556 9796 (mobile) 
  >   >  
  >   >  -----Original Message----- 
  >   >  From: healthliteracy-bounces at nifl.gov 
  >  [ mailto:healthliteracy-bounces at nifl.gov   
  >   >  ] On Behalf Of Julie McKinney 
  >   >  Sent: 28 February 2008 11:22 PM 
  >   >  To: healthliteracy at nifl.gov 
  >   >  Subject: [HealthLiteracy 1803] Re: pill card 
  >   >  
  >   >  I think that these concerns of graphics being meaningful to
any given 
  >   >  population is exactly the reason why this is such a good
activity to 
  >   >  do 
  >   >  in a classroom setting with students (whether they are health
students 
  >   >  or literacy students). The whole point in making this with the
people 
  >   >  who will be using it is that they can choose their own images,
and the 
  >   >  process itself will add meaning. You could do this in a
classroom and 
  >   >  have magazines to cut pictures out of, along with a variety of

  >   >  sun/rooster/breakfast-type images. Or they could use photos of
them in 
  >   >  their house doing what they do at certain times of day. If
people are 
  >   >  creating this themselves, the images they choose WILL be
meaningful! 
  >   >  
  >   >  Not to mention the literacy skills that can be practiced by
doing and 
  >   >  processing such an activity... 
  >   >  
  >   >  Do people agree? Has anyone done this? 
  >   >  
  >   >  Julie 
  >   >  
  >   >  P.S. Funny this came up just now...I am working with a team on
a 
  >   >  health 
  >   >  literacy curriculum in Florida, and we just included an
activity like 
  >   >  this! 
  >   >  
  >   >  Julie McKinney 
  >   >  Discussion List Moderator 
  >   >  World Education/NCSALL 
  >   >  jmckinney at worlded.org 
  >   >  
  >   >  >  >  >  "Dickerson, Robert"  < DICKERR2 at ihs.org >  02/28/08
1:21 PM  >  >  >  
  >   >  While this tool appears to be a step in the right direction I
also 
  >   >  agree 
  >   >  with and share the concerns of both Laurie Anson and Marcia.
Some of 
  >   >  the 
  >   >  other graphics I saw on the site I would not necessarily
equate with 
  >   >  the 
  >   >  terms they are supposed to signify. For example the graphic
that I 
  >   >  believe is supposed be a bag of sugar to represent diabetes
did not 
  >   >  connect for me until I realized is was supposed to represent a
bag of 
  >   >  sugar. I just saw a bag of something??? 
  >   >  
  >   >  Of course making the connection between the graphic and
intended 
  >   >  meaning 
  >   >  may be influenced by context and the patient's medical
conditions (the 
  >   >  sugar bag may make more sense to a diabetic than a
non-diabetic). I'm 
  >   >  curious if there are truly universal graphics, symbols,
pictures or 
  >   >  visuals that are understood by a majority of people. Of course
unique 
  >   >  cultural difference may make even "universal" graphics
meaningless in 
  >   >  some cases. In this event alternatives should be made
available. 
  >   >  
  >   >  I'm also curious if the graphics in this application were used
because 
  >   >  they are conveniently available clip art or if they have truly
been 
  >   >  studied and shown effective for a variety of patient
populations. 
  >   >  
  >   >  Thanks, 
  >   >  Bob Dickerson, MSHSA, RRT 
  >   >  Quality Improvement Coordinator, Clinical Quality 
  >   >  Iowa Health - Des Moines 
  >   >  Des Moines, Iowa 
  >   >  Phone: (515) 263-5792 
  >   >  Fax: (515) 263-5415 
  >   >  E-mail: DICKERR2 at ihs.org 
  >   >  Website: www.ihsdesmoines.org 
  >   >  
  >   >  
  >   >  -----Original Message----- 
  >   >  From: healthliteracy-bounces at nifl.gov 
  >   >  [ mailto:healthliteracy-bounces at nifl.gov   On Behalf Of
Trenter, 
  >   >  Marcia L 
  >   >  Sent: Wednesday, February 27, 2008 5:11 PM 
  >   >  To: The Health and Literacy Discussion List 
  >   >  Subject: [HealthLiteracy 1795] Re: pill card 
  >   >  
  >   >  
  >   >  I agree with Ms. Anson. Considering culture/understanding
ethnicity 
  >   >  will 
  >   >  help us understand others' interpretations of graphics. We
live in a 
  >   >  multi-cultural society. We need to accept that "one size does
not fit 
  >   >  all"; one presentation will rarely be interpreted universally.
Thus, 
  >   >  strategic targeting of visuals, cultural awareness, focus
testing, and 
  >   >  hopefully teach-back orientation.   Here's a graphic challenge
for all. 
  >   >  
  >   >  What graphic(s) would depict the following. 
  >   >  
  >   >  3x daily without food. 
  >   >  
  >   >  Graphics for: Morning 
  >   >                                              Mid-afternoon 
  >   >                                              Bedtime 
  >   >  
  >   >  3x daily with food. 
  >   >  
  >   >  Graphics for: Breakfast 
  >   >                                              Lunch 
  >   >                                              Dinner 
  >   >  
  >   >  We used a rising sun with a rooster to depict "morning" and
several 
  >   >  focus participants thought it meant, "breakfast with chicken".

  >   >  
  >   >  I will be very interested to hear your response and grateful.

  >   >  
  >   >  Thanks, 
  >   >  Marcia 
  >   >  
  >   >  ___________________ 
  >   >  Marcia L. Trenter 
  >   >  Special Assistant to the Office Director Office of Training
and 
  >   >  Communications Center for Drug Evaluation and Research U.S.
Food and 
  >   >  Drug Administration Rm 2436, Bldg. 51 
  >   >  10903 New Hampshire Avenue 
  >   >  Silver Spring, MD 20993-0002 
  >   >  301-796-3172 
  >   >  Fax 301-847-8718 
  >   >  E-mail marcia.trenter at fda.hhs.gov 
  >   >  ______________________ 
  >   >  
  >   >  
  >   >  -----Original Message----- 
  >   >  From: healthliteracy-bounces at nifl.gov 
  >   >  [ mailto:healthliteracy-bounces at nifl.gov   On Behalf Of Laurie
Anson 
  >   >  Sent: Wednesday, February 27, 2008 5:03 PM 
  >   >  To: The Health and Literacy Discussion List 
  >   >  Subject: [HealthLiteracy 1794] pill card 
  >   >  
  >   >  To the List - 
  >   >  
  >   >  As an RN, I recall having heard of the use of pill cards
similar to 
  >   >  the 
  >   >  one shown. As I remember, there were some difficulties with
the 
  >   >  symbols 
  >   >  used (sunrise, sunset, moon) across cultural lines. I think
the use of 
  >   >  pill cards is an excellent idea, as long as great care is
taken to 
  >   >  explain the symbols to the client. For instance, if there is
no 
  >   >  "sunset" 
  >   >  to compare to "sunrise", then there might be some confusion
about the 
  >   >  significance of that particular symbol. 
  >   >  
  >   >  
  >   >  Laurie Anson 
  >   >  ansons at epix.net 
  >   >  
  >   >  
  >   >  
  >   >  ---------------------------------------------------- 
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