Report of a Wellcome-funded project looking at the potential uses of educational comics

1. Using educational
comics with patients
and families
Sarah McNicol
September 2015

2. Overview of the
research findings
The impact of educational comics on feelings and
attitudes towards health conditions
The Wellcome Trust
Nov 2014 – Apr 2015

3. 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?

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

5. 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)

6. Features of comics
• Accessibility
• Images
• Characterisation
• Metaphors
• Humour

7. 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)

8. 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)

9. 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)

10. 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)

11. 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)

12. 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)

13. Uses of comics
• Awareness raising
• Discussion starters
• Self-awareness
• Empathy & companionship

14. 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)

15. 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)

16. 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)

17. 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)

18. 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)

19. Possible negative impacts
• Attitudes towards comics
• Negative messages
• Emotional impact

20. 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)

21. 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)

22. 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)

23. 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)

24. 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?

25. 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