Comics in Pediatric Patient Education: Superheroes, Monstrous Villains & Helpful Dinosaurs! Presented at the Comics & Medicine 2014 conference at Johns Hopkins University School of Medicine. Authors: Alex Thomas, MD and Gary Ashwal, MA from Booster Shot Comics.

1. Comics & Medicine 2014 Conference, Johns Hopkins University
Alex Thomas, MD and Gary Ashwal, MA
Comics in Pediatric Patient Education
Superheroes, Monstrous Villains & Helpful Dinosaurs!

2. Booster Shot Comics
is an independent
company.
The study is
funded by a grant from
Friends of U.Wisconsin
Hospital and Clinics
Disclosures
Gary to unmasked font
http://www.friendsofuwhc.orghttp://boostershotcomics.com

3. Gary Ashwal, MA Alex Thomas, MD

4. Background
• Asthma is the third-ranking
cause of hospitalization
children
• 36,000 children miss school
every day due to asthma
• The estimated cost in the
U.S. of treating asthma in
those younger than 18 years
of age is $3.2 billion per year.
Portnoy J, Jennings D. Utilization patterns in an asthma intervention. Ann Allergy Asthma Immunol. 2006;97(Suppl 1):S25-S30.
CDC Vital Signs, May 2011.
#IggyaDay

5. What can contribute to an
asthma exacerbation requiring
hospitalization?
1. Inherent severity of underlying disease
2. Problems with medication use
3. Exposure to environmental factors
4. Deficits in education regarding asthma
diagnosis and management
EPR-3. Expert panel report 3: guidelines for the diagnosis and management of asthma (EPR-3 2007). NIH Publication Number 08-5846. Bethesda, MD:
U.S. Department of Health and Human Services; National Institutes of Health; National Heart, Lung, and Blood Institute; National Asthma Education and
Prevention Program; 2007.

6. Medication Adherence
• Rescue inhalers bring immediate relief to
asthma symptoms only offer temporary relief
(2 hours)
• More long lasting improvement and
prevention of symptoms come with
Controllers (must be taken daily)
• Controller use in children with persistent
asthma is low
Finkelstein JA, Lozano P. Underuse of controller medications among medicaid-insured children
with asthma. Arch Pedatr Adolesc Med. 2002; 156: 562-7
Adams RJ, Fuhlbrigge A, Finkelstein JA, Lozano P et al. Use of inhaled anti-inflammatory medication
in children with asthma in managed care settings. Arch Pedatr Adolesc Med. 2001; 155 (4): 501-7

7. Education is Key
• Asthma education to promote self-management
in children has been shown to improve lung
function, asthma symptoms, reduce health care
utilization and school absenteeism
• According to guidelines, asthma education
programs should be delivered to children during
or following discharge from the ED or the
hospital
Finkelstein JA, Lozano P. Underuse of controller medications among medicaid-insured children with asthma. Arch Pedatr Adolesc Med. 2002; 156: 562-7
EPR-3. Expert panel report 3: guidelines for the diagnosis and management of asthma (EPR-3 2007). NIH Publication Number 08-5846. Bethesda, MD:
U.S. Department of Health and Human Services; National Institutes of Health; National Heart, Lung, and Blood Institute; National Asthma Education and
Prevention Program; 2007.

8. Kathleen Shanovich, NP
• Kathleen Shanovich, NP:
education specialist for
inpatient asthma consults
• When not available, education
is provided by floor nurse
coordinating discharge, RT
• But primary care clinics often
do not have the time/staffing
for individualized education
Asthma Education

9. When an education
specialist is not available
• Greater reliance on the available
educational materials
– Inconsistent in quality
– Inconsistent in how it is presented to kids
• When one-on-one teaching is not
available- with appropriate content,
children can be challenged to play a more
active role in the learning process

10. Create appropriate content to teach kids:
1. Difference between medications
2. Mechanisms of action for each medication
Objective
10

11. Rescue
Bronchodilator
Proventil
Albuterol
Controller
Corticosteroid
Qvar
Beclomethasone

12. Rescue
Bronchodilator
Pro Air
Controller
Corticosteroid
Flovent

13. Rescue
Bronchodilator
Ventolin
Controller
Corticosteroid
Budesonide
Other blue one?

15. Approach
• Kids can retain a great depth of knowledge in topics that
interest them
15
http://www.pokemon.com/

16. Approach
• By anthropomorphizing medications into characters
with personalities and physical traits directly related to
their mechanism of action, understanding can be much
more intuitive
16http://cars.disney.com/
Lightning McQueen Mater

17. Controller
Inhaled Corticosteroid
© 1993, 1997, and 2009 by Alex Thomas; © 2013 Booster Shot Comics
17
Bronchodilator
Albuterol
Anthropomorphized Medications

18. 18
Sequential Art
Pathophysiology

19. 19
Sequential Art
Bronchodilator – Mechanism Of Action

20. 20
Sequential Art
Corticosteroid – Mechanism Of Action

21. 21
Story-driven Patient Education
Social Learning Theory – Modeling

23. Same messages. Multiple formats.
23
Comic
Video
Trading Cards

24. Focus Group Testing
• 30 kids
• 2 clinics (1 suburban, 1 urban)
• Used feedback to make adjustments to characters,
visuals, text
– Comparison of normal to asthma airway
– Indications of time
• Ideal age is 8-11yrs
– Age 6-7 enjoyed visuals
– Age 5 and under could not understand

25. Madison Asthma Camp
• Approximately 50 children (ages 8-13)
– Higher risk group (identified by school nurses in
the Dane count school districts)
– Predominantly minority population
• All day camp at UW School of Medicine
• Goal to educate and empower children with
asthma and allergies
• Volunteers- Nurses, Nurse Practitioners, Allergists,
Allergy Fellows, Respiratory Therapists,
Pharmacists, Pharmacy Students, Parents
25

26. Asthma Camp Trials
• Asthma Camp 2011
– Comic Book
• Asthma Camp 2012
– Comic Book, Trading Cards, Small Groups
• Asthma Camp 2013
– Comic Book, Trading Cards, Video, Small
Groups
• Asthma Camp 2014
– Comic Book, Trading Cards, Video, Posters,
Games
– Integration into entire camp curriculum

27. Comic Books

28. Comic Posters

29. Comic Posters as Teaching Tools

30. Educational Video

31. Games

32. Trading Cards

33. Pre-Test Post-Test
2013 Asthma Camp Qualitative
Evaluation
33

34. Pre-Test Post-Test
2013 Asthma Camp Qualitative
Evaluation
34

35. Pre-Test Post-Test
2013 Asthma Camp Qualitative
Evaluation
35

36. Pre-Test Post-Test
2013 Asthma Camp Qualitative
Evaluation
36

37. 2014 Asthma Camp Evaluation
• Updated
quantitative survey
instrument for pre-
and post-test
based on the
educational
information in the
Iggy and The
Inhalers materials
– Pre Test n=22
– Post Test n=33
Asthma Knowledge Test Version 5
April 2014
TESTYOURASTHMAKNOWLEDGE!
(Pre-Test)
Checkoneanswer for eachquestion.
1. Which one of these does NOT happen to an asthma airway?
1 The muscle bands around the airways tighten
2 The airways become swollen/inflammation happens
3 Mucus plugs the airways
4 The airways and lungs collapse
2. Which one of these is NOT one of the Asthma Rules of Two?
1 You have asthma symptoms more than 2 days a week
2 You use your rescue inhaler more than 2 days a week
3 You wake up with asthma more than 2 nights a month
4 You have more than 2 medicines for your asthma
3. Which of the following can make asthma worse/trigger your asthma?
1 Allergies, like pets, pollen, molds
2 Exercise
3 Tobacco smoke
4 All of these
4. Which one of these is FALSE about your asthma controller medicine:
1 Helps with the swelling and inflammation in the airways
2 Is also called a rescue medicine
3 It takes time to fix things, but is long lasting
4 You need to use it every day
5. Which one of these in NOT a symptom of asthma?
1 Cough
2 Ear ache
3 Wheeze
4 Short of breath
6. Your asthma bronchodilator medicine works fast (5-15 minutes) to make you feel better.
1 True
0 False

38. 2014 Asthma Camp Evaluation
1. Which one of these does
NOT happen to an asthma
airway?
1 The muscle bands around
the airways tighten
2 The airways become
swollen/inflammation
happens
3 Mucus plugs the airways
4 The airways and lungs
collapse
50%
55%
60%
65%
70%
75%
80%
85%
90%
PreTest Post Test
Question 1 (% Correct)
PreTest
Post Test
77%
85%
n=22 n=33

39. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
PreTest Post Test
Question 2 (% Correct)
PreTest
Post Test
2014 Asthma Camp Evaluation
2. Which one of these is NOT
one of the Asthma Rules of
Two?
1 You have asthma symptoms
more than 2 days a week
2 You use your rescue inhaler
more than 2 days a week
3 You wake up with asthma
more than 2 nights a month
4 You have more than 2
medicines for your asthma
68%
56%
n=22 n=33

40. 50%
55%
60%
65%
70%
75%
80%
85%
90%
PreTest Post Test
Question 3 (% Correct)
PreTest
Post Test
2014 Asthma Camp Evaluation
3. Which of the following
can make asthma
worse/trigger your
asthma?
1 Allergies, like pets,
pollen, molds
2 Exercise
3 Tobacco smoke
4 All of these
68%
79%
n=22 n=33

41. 0%
10%
20%
30%
40%
50%
60%
70%
80%
PreTest Post Test
Question 4 (% Correct)
PreTest
Post Test
2014 Asthma Camp Evaluation
4. Which one of these is FALSE
about your asthma
controller medicine:
1 Helps with the swelling and
inflammation in the airways
2 Is also called a rescue
medicine
3 It takes time to fix things,
but is long lasting
4 You need to use it every
day
18%
68%
n=22 n=33

42. 50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
PreTest Post Test
Question 5 (% Correct)
PreTest
Post Test
2014 Asthma Camp Evaluation
5. Which one of these in NOT
a symptom of asthma?
1 Cough
2 Ear ache
3 Wheeze
4 Short of breath
82%
91%
n=22 n=33

43. 50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
PreTest Post Test
Question 6 (% Correct)
PreTest
Post Test
2014 Asthma Camp Evaluation
6. Your asthma bronchodilator
medicine works fast (5-15
minutes) to make you feel
better.
1 True
0 False
86%
97%
n=22 n=33

44. Madison Asthma Camp
(50 campers/year)
School Health Fairs
(~200 students per fair)
20 South Park Pediatrics
(100 patients/month)
UW Health Allergy Clinics
(160 patients/month)
American Family Children’s Hospital
(10 patients/month)
Implementation

45. A Big Thanks to the Kids!

46. Thank you!
46
Alex Thomas, MD
alex@boostershotcomics.com
Gary Ashwal
gary@boostershotcomics.com
BoosterShotComics.com
/boostershotcomics
/boostershotcmx
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