A scoping review of visual communication of written patient health information preferences including a Māori perspective

Abstract

This scoping review examines the visual design elements of written patient information (WPI), specifically focusing on imagery, colour, layout and content presentation, and their impact on health information communication, understanding, behaviour and preferences among patients. Understanding patient preferences allows for patient-informed WPI design, which is important for Māori (Indigenous peoples of Aotearoa New Zealand) living in a colonial society. Nine studies were analysed, primarily investigating the integration of visual illustrations within WPI. Participants generally favoured the inclusion of images alongside text, finding them instrumental in enhancing comprehension and making health information more approachable. The preference for simpler and less detailed visuals, such as cartoons, was highlighted, although there was variability depending on literacy levels and cultural backgrounds. The use of colour, layout features (e.g. font type and white space) and content framing (e.g. positive versus negative framing of risk information) were explored for their effects on information reception and behavioural outcomes. Currently, there is a paucity of literature on Māori preferences and requires further research. Overall, this scoping review highlights the importance of designing WPIs with visual elements that cater to diverse literacy levels and cultural preferences to optimize communication effectiveness and patient engagement.

Introduction

Patient education materials are utilized by healthcare professionals (HCP), patients and their whānau (extended family/kinship group) to enhance their understanding of medical information. Written patient information leaflets (WPI) are important because they contain valuable information on medical condition symptoms, diagnostics, medical procedures, medication, guidelines for seeking assistance and self-care. This enhances patients’ comprehension of health conditions and contributes to supporting health literacy, fostering informed decision-making and facilitating whānau involvement in their own healthcare [1, 2]. In Aotearoa New Zealand, optimizing health outcomes and health information supporting these health outcomes is a priority for whānau Māori (Indigenous peoples of Aotearoa New Zealand) given the obligations for equitable health and well-being for Māori described in the fundamental document Te Tiriti of Waitangi (the Treaty of Waitangi) [3].

Studies have indicated that patients prefer direct HCP–patient interaction over other forms of communication [4, 5] and WPI serve as valuable tools for HCP, assisting counselling through the provision of visual aids and prompting HCP to address areas that could potentially be overlooked. WPI also allow patients to revisit the information at a later time and facilitate the reinforcement of information without further assistance from HCP [6]. This is important due to time pressure on the HCP and patients’ ability to understand information when unwell [7].

Given that WPI are commonly provided by HCP to patients, it is crucial that both the medical and visual content meet the needs of patients and their whānau. Health education, as defined by the World Health Organization (WHO), is ‘fostering the motivation, skills and confidence (self-efficacy) necessary to take action to improve health’ and ‘the communication of information concerning the underlying social, economic and environmental conditions impacting on health, as well as patient risk factors and risk behaviours, and use of the health care system’ [8]. Therefore, health education involves more than simply conveying information, it requires fostering patients and their whānau ability to make informed health decisions. This is especially important for Māori who will often make decisions as a collective [9].

Effective design of WPI is crucial. WPI should be crafted to engage and inform patients and their whānau. Designing WPI is an evolving domain, necessitating constant improvements to align with contemporary visual preferences. Even in an era of digitalization, WPI such as leaflets and other written information are still preferred by some patients [4, 10]. It has been shown that well-designed WPI have the ability to impact patients’ knowledge and/or satisfaction, as well as behaviour, depending on the gravity of the clinical context [4]. Incorporating design considerations when developing WPI is important to ensure they contain essential information, delivered in a way that meets their needs, and are easily understood.

As mentioned earlier, Māori have the right to equitable health outcomes, aligned with Te Tiriti o Waitangi [3]. This includes ensuring delivery of health information occurs in a way that meets their needs and supports informed decision-making. Kōrero Mārama: Health Literacy and Māori, a study by the Aotearoa Manatu Hauora (New Zealand Ministry of Health), demonstrated that Māori are not receiving sufficient medical information to support equitable health outcomes [11]. The development of WPI is required to facilitate equitable health outcomes and contribute to Māori being fully informed with written and visual information that is culturally appropriate [12].

There are multiple tools used to evaluate written content in WPI. There are fewer tools used to evaluate images for their ability to convey information [13]. This means that there may be insufficient guidance for creators of WPI to ensure they are creating resources that will be impactful and effective and that support patients and their whānau, including those with limited health literacy, to understand health information that is provided to them. Furthermore, many WPI continue to only include text, without images to enhance understanding. Inclusion of diverse visual images within WPI has been shown to help promote awareness and discussion on racism, contributing to culturally safe practices within health [14]. Including Māori imagery within WPI will likely facilitate a connection between the person reading the WPI and the content presented in the WPI to enhance health knowledge acquisition.

This scoping review aims to explore the existing literature and identify evidence related to visual design preferences for health-related WPI. The primary objectives of this review are to determine the impact of visual design in the communication of health information in WPI and to understand patients’ preferences regarding the delivery of health information, especially for Māori.

Materials and methods

This scoping literature review used the Preferred Reporting Items for Systematic Meta-Analysis for Scoping Reviews (PRISMA-ScR) methodological framework and reported the PRISMA-ScR process [15].

Eligibility criteria

Publications on visual design for WPI in health or Māori health were included. Publications are limited to full text and English language. Only articles that had discussed visual design in-depth and were related to health were included. The search is also limited to articles published after 2013 for relevance to contemporary visual design.

Exclusion criteria

Literature reviews, letters to the editor, opinion pieces, full text or English text not available, and publications prior to 2013 were excluded.

Information sources

This scoping review was conducted in August 2024 and three databases were used: PubMed, Scopus and EBSCOhost (Academic Search Complete).

Search strategy

The same string of search terms was used in each database and was finalized after consultation with two reviewers (L.K. and A.Y.). The key search terms used were leaflet, brochure, art, design, image, preference and Māori. Full search terms are available in  Appendix 1. All database searches were refined by the publication year and language, only including results that were published between 2013 and 2024 and limited to the English language. Further literature was searched for in the reference list of included articles.

Selection of sources of evidence

One reviewer (a.c.) independently screened study titles and abstracts and assessed publications located in the three databases for eligibility with a focus on the global context and then for Māori. Selection was completed in three stages: (i) all titles were screened and those with relevant titles were compiled and documented in Microsoft Word, (ii) relevant studies had their abstracts checked and if the abstract was insufficient for a clear understanding, the full text was assessed for eligibility and (iii) all articles that passed the second round had their full texts screened resulting in the final number of studies.

Data charting processes and data items

Two reviewers (a.c. and L.K.) codeveloped the data charting form to identify data to be extracted. The data were then independently charted by one reviewer (a.c.) and was revised after receiving feedback from two reviewers (L.K. and A.Y.). The final data table was created after reaching a consensus by all authors.

Data synthesis

The extracted data were summarized and categorized by one reviewer (a.c.) (Table I). The demographic context of the data was summarized (author, year, country and population type). The aims, methods, study objective, Indigenous context and key findings were summarized.

Table I.

Basic characteristics of the studies included in the scoping review

First author, year	Country	Study design	Aim(s)	Population (if applicable)	Indigenous context	Type of written patient information (if applicable)	Summarized methods	Summarized key findings
Brand, 2023 [25]	Germany	RCT	To investigate illustrative cartoon design versus excerpt from a booklet on WPI.	301	Ethnicity data not included	Visual printed	An illustrative brochure on informed consent for transcatheter aortic valve replacement was assessed for patient comprehension. Anxiety was assessed before and after informed consent.	Participants in the illustrative brochure group had higher comprehension and lower anxiety.
Kreuzmair, 2017 [19]	Switzerland	2 × 2 between-subjects factorial design	To explore how low versus high iconicity in pictographs can affect information processing strategies, icon liking and decision-making and how they are influenced by numeracy, with the overall aim of improving medical risk communication.	188	Ethnicity data not collected	Pictographs	Participants were shown low and high iconicity pictographs and data were collected through eye tracking. Participants completed three questionnaires regarding numeracy, recall and liking of icons used. Participants were debriefed and questions were answered.	Icon use influences an improvement in recall and could promote higher motivation, personal involvement and motivation. Iconicity and numeracy did not influence icon liking. There was no difference between processing pictographs depicting medical versus nonmedical probabilities.
Strong, 2013 [24]	UK	Cross sectional study	To clarify the preferences towards visual detail and explore how they vary based on visual complexity of the subject for two primary audiences of medical art: laypersons and medical professionals.	169 (medical professional: n = 37, layperson: n = 132)	Ethnicity data not collected	Medical illustrations	Participants were given a questionnaire depending on their category and asked for preferences on two booklets, each depicting three levels of design: low, mid and high detail.	Generally, variations in preference for detail of medical illustrations were not seen. Highly detailed illustrations were preferred by most over low- and mid-detail levels.
Van Beusekom, 2015 [23]	Netherlands	Cross-sectional study	To evaluate organ icons featuring systematic design variations to provide guidance for the development of pictograms in patient leaflets for individuals with low literacy.	191	Ethnicity data not collected	Pictograms	Participants were asked which four organ images represented the organ most clearly.	Low-literate individuals preferred isolated organ images (e.g. lung icon) over showing the context of placement in the body when there is no need to infer the visual of the organ. A subanalysis showed that between native versus non-native speakers, low-literate native speakers preferred the images with less detail. When systematically designing visuals of internal organs, utilizing the skeleton is the most appropriate choice for both groups.
Van Beusekom, 2016 [18]	Netherlands	Qualitative study	To understand how individuals with low literacy use and evaluate written drug information and to determine areas of improvement towards the use of images.	45	Ethnicity data not collected	Leaflet	Semi-structured interviews were held at an individual and group level and participants were asked questions regarding the use of written drug information, their evaluation of it and suggestions.	Ideally, leaflets should only be one A4-sized sheet in a legible font size. Headings were appreciated to easily navigate through text. The biggest problem is having unnecessary complex language. The majority expressed enthusiasm for incorporating visuals alongside text. Visual cues are found to be helpful, and images also potentially have a role in memory retention.
Champlin, 2014 [21]	USA	Experimental study	To investigate how low, mid or high levels of design quality elicit varying levels of objective attention and positive evaluation.	46	Ethnicity data not collected	Visual printed messages	Eleven advertisements were chosen from low to high levels of design quality, each was shown to the participant whose eyes were observed by an eye-tracking monitor. Participants gave a score for each ad.	Mid- and high-level designs were observed for a longer duration, indicating that improved design quality can affect the need to capture attention. Mid-design levels received a more positive evaluation, suggesting that increased detail is not always better.
Kish-Doto, 2014 [26]	USA	Mixed methods study	To enhance understandability and usefulness of PMI that may potentially contribute to future development of more user-friendly PMI.	90 (Black: n = 59, Asian: n = 1, Hispanic: n = 1, White: n = 29)	No Indigenous data	Handout	Participants were shown three sets of two different handouts varying in format, font and order of content. Participants were asked about their preferences for general opinion, specific comments and suggestions.	Age was seen as a factor in patient preferences. Preference for bubble format was seen in 18–69 years old compared to old OTC format in those >70 years old. The majority preferred Arial compared to Times New Roman as the font of choice.
Voss, 2018 [28]	USA	RCT	To understand how colour associations and framing can influence behaviour in terms of sunscreen application.	280	Ethnicity data not collected	Pamphlet	Participants completed questionnaires about different pamphlets that emphasized positive or negative consequences and the design was displayed in red, orange, blue and purple.	The combination of positive framing and short wavelength colours (blue/purple) may be best for positive health behaviour motivation in nonusers of sunscreen.
Grudniewicz, 2015 [20]	Canada	Mixed methods study design	To explore how to better redesign WPI for primary care physicians and understanding if using user preferences and design principles can increase usability and selection.	184 primary care physicians	Ethnicity data not collected	WPI	An old WPI was redesigned, and participants had to pick their preferred new versus old version. Usability was assessed using the System Usability Scale and a think-aloud process.	WPI with too much information can be overwhelming to the reader. Scientific information not directly relating to patient needs was preferred to be omitted. WPIs were easier to skim due to layout, colour coding, bullet points and point form text. White space that was not too large and a big font size were preferred.
Morrongiello, 2014 [22]	Canada	Experimental study	To evaluate parental appraisals of various image variations and identify characteristics that improve attention towards safety messages.	60 (Caucasian: n = 56, other: n = 4)	No Indigenous data presented	Images	Participants were shown eight pairs of images in which they had to choose the best accompaniment for a safety message and give a reason for their choice. Images were rated according to how they fit the safety message, emotional arousal, communication of danger and attention elicitation.	Showing negative consequences of injury heightened the images’ effectiveness and they were considered more emotionally arousing, capturing their attention and overall, a better fit for the corresponding safety message.
Krasnorya-dtseva, 2020 [16]	AoNZ	RCT	To study the effects on perception of educational material, illness beliefs and information comprehension when different medical illustrations are included in leaflets.	204 (Māori: n = 21, Pacific Peoples: n = 12, New Zealand European: n = 95, Other European: n = 12, Chinese: n = 15, Indian: n = 38, other: n = 14)	6% (n = 3) Māori	Leaflet	Participants completed a questionnaire on one of the four gout leaflets which had the same text but different images (anatomical, cartoon and CT scan), including one control leaflet with no image.	Cartoons elicit correct responses, but anatomical drawings were deemed beneficial. Cartoons and anatomical drawings improved visual appeal compared to a CT scan.
Raval, 2015 [17]	AoNZ	Cross-sectional study	To assess the effect of ethnicity on patient preferences for different ways of expressing risk and treatment benefits.	376 (Māori: n = 55, Pacific Peoples: n = 95, New Zealand European/other: n = 187, Indian: n = 39)	Differences in outcomes based on ethnicity were reported.	N/A	Patient preferences were collected using a cross-sectional survey from nine different general practices ranging from lower, middle and affluent socioeconomic populations.	Māori and Pacific ethnicities favoured pictures over numbers for the presentation of treatment benefits. Chart format was preferred over bar graphs across all ethnicities. Two-thirds of the sample preferred positively framed risk information. Preference for using RR instead of AR or NNT.
Young, 2018 [27]	AoNZ	Cross-sectional study	To investigate self-reported provision of medicine information leaflets by NZ GPs and pharmacists, assess their opinions on existing leaflets and determine their support for customizing information leaflets for patients.	269 (GPs: n = 143, pharmacists: n = 126)	Ethnicity data not collected	Leaflet	Participants completed a questionnaire (1 for GPs and 1 for pharmacists) regarding information leaflets.	Simple, easy-to-read and understandable leaflets were preferred by the majority of participants. Favoured A4 format, large print leaflets which include images. Preference for tailored versus general leaflets.

AoNZ, Aotearoa New Zealand; CT, computed tomography; N/A, not applicable; NZ, New Zealand; RR, relative risk; AR, attributable risk; NNT, number needed to treat; PMI, patient medication information; GP, general practitioner; RCT, randomized controlled trial.

Results

Thirteen studies were included in the review (Fig. 1) and summarized (Table I). Among the 13 studies, 11 centred on visual illustration within WPI [16–25] and 7 explored various aspects of colour and presentation [17, 18, 20, 21, 26–28]. All studies included were published between 2013 and 2020 and were conducted in Aotearoa New Zealand, the United States, the Netherlands, Switzerland, Germany, Canada and the United Kingdom. All studies included participants aged 18 years and above.

Fig. 1.

PRISMA-ScR flow chart detailing the number of title/abstract citations identified, duplicates removed, full texts included/excluded and reasons for their exclusion.

Visual illustrations and imagery

Eleven studies evaluated illustrations and imagery. The most common finding from one paper was most participants favoured including images [27] and found images to be a helpful addition to assist comprehension of health information, making it more appealing and less daunting to use [16, 18, 25]. Participants also signalled a preference towards using images instead of written information to understand risks [17] and pictograms for a visual overview [18]. Some participants in one study suggested that pictograms could eliminate the need for written information [18]. Images could be used as a visual cue to assist navigation through WPI, which was shown to be particularly beneficial for those with low reading levels, enabling them to seek assistance with a particular section by requesting text to be read aloud [18, 20].

In terms of images used, one study focused on the best visual representation for communicating health information [16]. In this study, cartoons were the only type of image that conveyed information about treatment better than text and were more likely to elicit correct responses to questions indicating they improved comprehension [16]. Similarly, another study that included older adults found that the use of comics helped improve comprehension and reduce anxiety [25]. One study also found that people with low literacy preferred images that tell them exactly what to do [18].

The simplicity of images was identified as important in two studies [20, 23]. In one study, primary care physicians were more accepting of simple and small graphics [20]. This is supported by another study where human organs displayed with an empty background (i.e. more simply) were preferred, especially by low-literate individuals; this suggests that visual contextualization is not always necessary if it overcomplicates the content [23]. Conversely, highly detailed illustrations that show greater levels of feature and design complexity were favoured in two studies [21, 24].

For communicating specific information, one study focused on images and their effect on parents’ understanding of safety messages; this found that images depicting negative consequences improved their effectiveness in understanding these messages [22]. However, another study found that the majority of participants preferred positive framing of risk information blocks [17]. Another study focused on iconicity and found that pictographs with icons (people) helped improve recall and had a low construal level (could promote higher motivation and personal involvement) compared to pictographs with blocks [19].

Colour and presentation of content

Seven studies evaluated colour and presentation of content. A common layout preference was the use of an easy-to-read font, specifically Arial [26] and a legible font size [18, 20, 26] with one study particularly using size 11 [26], set in A4 format [18, 27] with generous use of white space [20], bullet points and headings [18, 20]. One study investigated different formats of presenting text, comparing the ‘bubbles’ format (information presented in rounded boxes separated into two vertical columns) with the Over the Counter (OTC) format (which is like an OTC drug facts label in a box that filled the whole width of the page). In this study, the “bubbles” format was preferred by those aged 18–69 years old, and the OTC format was preferred for those aged over 70 years [26]. Similarly, Grudniewicz et al. found that sectioning, using boxes for additional information, was recommended by participants for easy navigation of the layout [20]. Voss Jr. et al. identified that combining positive framing and short wavelength colours (blue/purple) may be best for positive health behaviour motivation [28].

One study revealed that participants favour mid-level (modest application of design principles and mid-level rating of design complexity) design of the overall visual health message, as this level of design created a good balance for consuming information, capturing the viewer’s attention and gaining a more positive reception without overstimulation [21]. Also, people with low literacy found the overall look of patient information to be discouraging because of the difficulty of understanding and navigating through text [18]. Using unnecessary complex language was seen as one of the biggest issues [18] and the preference for leaflets to be simple and easily read was favoured, as complex leaflets can be misinterpreted [27].

Numerical results should be compact and always linked to a written explanation within the WPI text [20]. Simple presentations of numerical data using charts were preferred [17, 20], for example, displaying risk data in WPI was the most effective format for understanding a relative risk, and the least effective was natural frequencies and numbers needed to treat, although Pacific people preferred the use of natural frequencies [17]. Māori and Pacific ethnicities were also found to favour pictures over numbers for the presentation of treatment benefits [17]. No other study included in this review investigated Māori images to communicate medical information.

Discussion

This study highlights the results of the 13 studies included in this scoping review which indicate that contemporary visual illustrations continue to be an important addition to WPI in this digital age. Images have conveyed history and narratives, dating back to the earliest forms of human expression, such as cave art and hieroglyphics. Given this long-standing history, it is unsurprising that there is a strong preference for incorporating images alongside text in modern communication [29]. Dewan suggests that this trend represents a return to our ‘pictorial roots’, acknowledging that visual elements have always played a fundamental role in communication, and that verbal and visual memories are processed and stored separately in the brain, and therefore its combination further improves recall. However, the type of imagery preferred by patients remains subjective. This presents an opportunity for future research to explore further and to ensure user testing is carried out to effectively cater towards the correct audience and to consider the varying preferences among different age groups and ethnic groups as each generation may have distinct views on what constitutes effective presentation of health information. Although not demonstrated in our review, several studies also advocate for the use of culturally sensitive materials to enhance the relevance and effectiveness of health content across diverse cultural contexts [30–33]. Cultural diversity influences how health topics are understood and how imagery is perceived by different populations, making it challenging to create universally applicable WPI. Thus, tailoring WPI to specific geographical and cultural contexts is essential to maximize their impact. Given the obligations of Te Tiriti in Aotearoa New Zealand, the prioritization of Māori imagery to optimize WPI for whānau supporting improved health engagement and outcomes is paramount. This review highlights the paucity of research currently.

Simplicity in written content in WPI was emphasized in the literature included in this scoping review [18, 20, 27] and is supported by other existing literature [6, 34–36]. This includes strategies such as avoiding technical jargon [6, 34] using simple language [35] and employing short words and sentences [34]. These practices are integral to enhancing health literacy and ensuring effective communication of health information. In addition to simplicity, the impact of colour on emotions is suggested as a subject warranting further investigation, although much remains unknown about the effect of colour on WPI. Babin suggests that in a medical environment context, cool tones such as blues or greens, balanced with a natural element, should be used as these hues help create a calm and comfortable environment [37]. Some also discuss the use of red if a task requires vigilant attention and describe blue as having an approach motivation effect, encouraging the use of creative processes to complete a task compared to red which has an avoidance motivation effect for detail-oriented tasks that require full attention [38]. Other studies also emphasize the effectiveness of pictorial health information as valuable visual aids, especially for patients with low literacy [30, 39]. Houts et al. also highlight the significance of images by demonstrating their impact on attention, comprehension, recall and adherence [40]. Based on the studies reviewed, all aspects showed improvement, with the exception of adherence, where positive or negative behaviour is dependent on the emotional response to the image [40]. This finding aligns with the study conducted by Morrongiello, where the depiction of a negative context positively influenced parents’ approach to child safety, as they were able to effectively obtain the appropriate emotional response to achieve favourable outcomes [22].

Limitations

Given that this was a retrospective study aiming to identify existing WPI, it is possible that some WPI were not included. However, by employing a structured and thorough approach, the study likely captured most WPI. Although we aimed to include Māori perspectives, it is important to note the paucity of available literature. This highlights the importance of WPI development to include Indigenous input, with an Indigenous worldview and a strength-based approach to ensure that the WPI developed meet the needs of whānau in Aotearoa New Zealand. Further work could be carried out to include the global Indigenous community. Cultural and literacy differences may affect the perception of medical images and warrant further investigation. This research was also limited to the English language affecting its ability to be generalized, and given the growing te reo Māori-speaking population in Aotearoa New Zealand, it is timely to consider this in WPI development alongside other principals such as imagery. As the studies included in this review encompassed a wide age range, with participants aged 18 years and over, a more specific review for studies focusing on different age groups may be of benefit. Given the studies used concentrated on delivering health information, it is crucial to recognize the importance of context and its influence on the way information is interpreted. For example, specific patient factors [30], such as a particular health condition, target age group and gender-specific characteristics [36], should be considered. Additionally, involving the end users in the creation of visual aids improves comprehension and adherence to health education materials [31].

Visual design plays a significant role in health communication due to its ability to effectively communicate concise and accurate information to whānau. Currently, there is a paucity of Indigenous literature that provides opportunities for engagement, direction and future directions for WPI development. WPI that include simple and impactful messages are likely to meet whānau needs.

Acknowledgements

The authors wish to acknowledge Thelma Fisher’s (Subject Librarian) expertise in search strategies.

Funding

He Rau Kawakawa ki Ōtākou Whakaihu Waka (School of Pharmacy, University of Otago) to A.C.

Conflict of interest

None declared.

Appendix 1 Full search terms

The full list of search terms is as follows: (leaflet OR handout OR pamphlet OR patient information leaflet OR brochure) AND (art OR design OR illustration OR visual OR layout OR composition OR color* OR colour* OR pictogram* OR comic* OR cartoon* OR image* OR font OR text OR picture*) AND (preference* OR perspective OR perception OR view* OR attitude* OR choice OR opinion OR understand* OR comprehend*) OR Māori.