Session Guide
Designing Effective Printed Educational Materials

PURPOSE AND CONTENT
OBJECTIVES
PREPARATION
SESSION NOTES
ACTIVITY ONE
ACTIVITY TWO
VISUAL AIDS
EXAMPLES OF PRINTED MATERIALS
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While printed educational and advocacy materials may not by themselves bring about behavioral change, they can be valuable tools in intervention programs. Printed materials may take many forms: posters for display in health centers or public places; pamphlets for physicians, health workers, or patients; resource materials for health worker and development training programs; standard treatment guidelines or drug bulletins for mass distribution; t-shirts for public education or materials for use in one-to-one educational encounters.

However, many such materials are not designed in a way that increases their chances of being read and understood, and acted on.

Based on research and experience in many countries, this unit will enable you to discuss and implement the key principles of designing effective, printed educational materials.

 OBJECTIVES

To develop your ability to:

1. Identify the most important principles of effective and persuasive educational materials.

2. Evaluate the feasibility and potential impact of existing educational materials.

3. Design simple but effective educational materials to target specific drug utilization problems.

1. Read the Session Notes.

2. Briefly review the instructions for Activity One.

SESSION NOTES

Let us assume that you have already identified an important and correctable drug use problem in a region. For example:

• The irrational and potentially unsafe use of antibiotic injections for minor infections which require no drug, or which could be treated with oral antibiotics.

• Use of expensive non-steroidal anti-inflammatory drugs (NSAIDs) for mild pain when paracetamol or aspirin would be equally effective and less expensive.

Also, assume that you have already completed some initial investigations (interviews or group discussions) with prescribers and patients to learn why they are behaving in these "irrational" ways. One first step in tackling the problem is to produce objective and effective educational materials, which can help, increase knowledge and improve behavior of the prescribers and/or patients involved. The following material explains some of the basic techniques and principles to ensure that these efforts are as cost-effective as possible.

There are some basic principles for any persuasive print materials these are:

Understand the reasons for prescribing or patient choice

Be oriented toward decisions and actions

Emphasize a few key messages

Capture attention with headlines

Use visually appealing illustrations

Use brief & simple text

Repeat important messages

Have respected sponsors

Involve users

Effective educational materials cannot be developed without knowing why specific "incorrect" prescribing practices occur in the first place. For example:

• Do health workers who give unnecessary antibiotic injections understand or care about the risks of infection; or do they understand these risks and, nevertheless, respond to strong cultural beliefs that injections are much stronger than oral antibiotics, even for minor infections?

• Do prescribers recommend expensive analgesics for mild pain to satisfy patient demand; or because they don't understand that aspirin is just as effective; or because their supervisors use them?

If, after initial investigations, like in-depth interviews or group discussions, you have a good grasp of the principal reasons for their behavior, these motivations can be targeted in the educational materials. For example:

• If prescribers are giving expensive analgesics due to patients' demands, include a section (or a separate pamphlet) on how to convince the patient that aspirin is a powerful "wonder drug." See Figure 1 in the Annex. This patient education pamphlet was designed to be given by physicians to their patients.

• Patients and prescribers may be unaware of the risks of serious infections caused by injections, but will be very concerned when informed of these risks. If this is the case, these risks may be headlined in the printed materials.

In most cases, educational materials should emphasize what prescribers and patients should do or not do for common clinical problems. For example:

• Which infections should be treated with antibiotics, and what is the first-line therapy?

• What is the preferred therapy for treating mild pain (paracetamol, instead of more expensive analgesics)?

This concept is very similar to "Standard Treatment Guidelines." If you wish to change specific prescribing practices, this behavioral approach is more effective than simply handing out lists of drugs with all of their uses. Focusing on the correct treatments or actions for specific problems makes learning easier and more useful. There are exceptions to these principles, however -- for example, in alerting prescribers and consumers to serious adverse effects of specific drugs or behavior, regardless of their indication. In the case of advocacy material, it is helpful to explain the behavior being promoted in the light of the advantages that will accrue to the community from its adoption.

Prescribers and patients throughout the world need easily accessible and objective information about appropriate drug use. Complex and lengthy informational materials are expensive to produce and difficult to digest. And lack of time to meet professional, family, and community responsibilities is a problem for everyone. Once program managers have an understanding of the major reasons for drug use, and after prioritizing key areas for intervention, the educational materials developed should focus on two, three, or at most four main messages to communicate for each targeted behavior. If at all possible, these messages should include:

• The behavior you wish to promote (e.g., use of ORT).

• The behavior you wish to modify (if applicable, e.g., use of antibiotics).

• Key information or knowledge gaps (e.g., that injections can cause serious infections; or that antibiotics are not effective in treating viral illness). These messages become major "selling points" which support the actions you wish prescribers to take.

• Other behavioral/motivational forces (e.g., ways to convince patients that unnecessary injections are dangerous).

If resources and time are available, it is fine to give more details to back up the main messages; if not, the primary messages may suffice. Printed educational material produced in Kenya includes two major message to pharmacists: for diarrhea, promote ORS and refer complicated cases.

Major headlines with the largest type should be reserved for the most important behavior-change message. To be successful, headlines must capture the attention of the audience, and encourage them to read the rest of the text. Headlines can be interesting questions as well as statements. Headlines which offer a benefit or provocative can be very effective in attracting attention.

A good example is the Philippines poster  which reads:

Secondary headlines can be used to emphasize other important messages (e.g., the basic facts supporting the recommended behavior and to lead to eye down into the body of the text or illustration. In addition to emphasizing the major messages, different type sizes make the educational materials more visually interesting to read. The actual type face used is also important. Typefaces with serifs (the tiny lines that cross the endings of strokes of most characters) facilitate reading and should be used for the body (main) text. Type without serifs, known as sans serifs, is better for headlines. Both Italic text and capitals significantly reduce readability and should only be used for individual words or to highlight short blocks of text. Typefaces also have their own character: some appear more authoritative, some modern, some traditional. The number of words on a line also influences readability. As a general rule, the number of words on a line should not exceed thirteen. If possible, consult someone knowledgeable about typesetting and layout when planning materials.

These are an excellent way to communicate behavioral or informational messages. (In some settings where literacy levels are low, it may be necessary to communicate the entire message in pictures.) Visually stimulating, humorous, or otherwise striking pictures can often capture attention and awaken the interest of readers. Illustrations are also an effective way to visually reinforce written messages. If at all possible, show the behavior you wish others to adopt. For example:

• a physician explaining to a mother that ORT is more powerful than antibiotics in curing her child's diarrhea.

It is important to emphasize that illustrations and graphs do not need to be very expensive. Effective educational materials can be developed with simple line drawings or sketches.

The text and language should be brief, simple, and appropriate. This does not imply that better educated people's intelligence would be insulted -- simply that complex and difficult-to-understand words should be replaced with more understandable language. This principle is often violated in educational materials. The problem can be avoided by testing the readability of materials in real world settings before printing them, with people who have similar skills and backgrounds to the target audience. This group can then comment on their understanding of the major messages, as well as point out unclear phrases or illustrations.

The following is an example of a sentence with overly complex words:

"Aspirin is indicated as an effective, mild analgesic in patients able to tolerate potential gastrointestinal disturbances."

A more straightforward expression of the above ideas follows:

"Choose aspirin to treat mild pain in patients without stomach problems."

Another important point is to ensure that the language used is appropriate for the target group. Language suitable for educational materials targeted at prescribers will not necessarily be suitable for a lay audience. Also, different cultural groups within the same country may have different ways of naming or defining illness. Once again, testing materials with the target group is an absolute requirement.

In the past, health educators have tried to improve health practices of consumers by using strong scare tactics, such as showing sections of cancerous lungs to smokers. These practices are controversial and some research suggests that mild rather than strong fear-appeals are most effective because people tend to deny the possibility of rare, but terrible outcomes (such as sudden death and disability). Similarly, prescribers may not react favorably to strong fear appeals which overstate the possibility of serious adverse effects due to incorrect prescribing. Nevertheless, a realistic appraisal of these risks (e.g., antibiotic resistance) may sometimes be useful.

Repetition of the most important messages is a foundation of advertising and communication. Repetition increases memory and learning. If at all possible, the main behavior-change message should not only be included in the major headline at the front of an educational material but should also be repeated in the concluding section.

Credibility of the information presented is usually very important in convincing a target audience to change their behavior. For example, what makes your recommendation that antibiotics are not needed for most upper respiratory infections more believable than the drug company representative's message that they should be prescribed in these situations?

One important principle is to establish a credible and objective identity with no bias towards one point of view. Sponsorship by government agencies or ministries of health may not always be the best method for achieving credibility. Just as drug companies may be biased in favor of over-promotion and over-selling of drugs, governments may be seen as biased in the direction of promoting lower-cost and perhaps "lower-quality" drugs.

Ways to enhance credibility include:

• Obtaining the sponsorship of a respected medical school, medical society, or other professional organizations. Their cooperation and sponsorship of the program should be included in a prominent place on the educational materials.

• Referencing the most respected medical evidence supporting the main messages.

• Referencing international publications, or materials produced by WHO.

• Referencing community leaders, or, for public education materials, popular sportsmen/women or entertainers.

Figure 4 in the Annex provides an example of the front of a pamphlet which attempted to improve treatment of diarrhea in Kenya pharmacies. Note on the bottom of the front page the reference to WHO, which was found in focus group to be the most credible source of information among people working in pharmacies.

Successful printed material is relevant to the user. This can be achieved by involving local experts in its development. For example, clinical pharmacologists at a region's primary medical school would be an excellent resource for this activity. Often, such people are aware of prescribing problems and very receptive to becoming involved in educational outreach programs. It is essential to investigate what materials the prescribers themselves would like to have or what the community would like to know more about. Materials development should not be a top-down approach, but rather a partnership in which information relevant to the prescriber and the community is shared. The more collaboration there is in materials development, the greater the commitment to its wide-scale dissemination and use..

10. SUMMARY OF PRINCIPLES OF PRINTED EDUCATIONAL MATERIALS

1. The first and most important principle is: always pretest materials on the target audience before production.
2. Simplify the illustrations and avoid extraneous details. When possible, present only one message per page.
3. Expressions, activities, clothing, buildings, and other objects which are familiar to the audience help to communicate messages more effectively. People are attracted to pictures with which they can identify.
4. Drawings that realistically portray people or objects as they occur in day-to-day life are often the easiest to recognize. Drawings that do not look like things that people normally see are harder to understand.
5. Avoid unusual angles and drawings with too much perspective.
6. In general, objects should be in scale and in context. Enlargement of detail may have a negative effect on understanding of the message.
7. Some kinds of pictures are easier to recognize than others. For example, photos and shaded line drawings can be clearer to target audiences than simple line drawings. The more stylized a drawing is, the less success it is likely to have.
8. People look at printed material in different ways, especially people who are not used to reading. People who learn to read from right to left will probably "read" pictures on a page that way, too. It often proves helpful to ask several members of the target audience to arrange the individual messages in a sequence that seems most logical to them.
9. Be sure that colors are carefully tested with audiences, as colors can have different connotations in different cultures.
10. Symbols must be used with caution. Crosses, arrows, check marks, inserts, and balloons that represent conversations and thoughts may be misunderstood. Such symbols, when used, must be very carefully tested.
11. Whenever possible, use a positive approach, as a negative message may be alienating or discouraging, rather than motivating.
12. Cartoon figures may not be well understood by some audiences, and humor should be used with care.
13. Pictures should be large enough for people to see. The print should be clear and simple so that people not accustomed to reading can decipher it without difficulty.
14. When designing a booklet or flip chart, limit the number of concepts covered. If there are too many messages, readers may become restless or bored, or find them hard to remember.

RATIONALE

In this unit some basic principles of effective printed communications are proposed as part of an overall effort to improve drug use. Often resources and expertise needed to meet all of these criteria are lacking; however, even within limited budgets print materials can be graphic and effective.

This activity will give you experience in the evaluation of existing materials in relation to the principles discussed in the session notes. In addition, you will be asked to assess the potential feasibility, cost, and impact of this type of material in educating primary care health workers in your country.

INSTRUCTIONS

1. You will be given two examples of educational materials which have been published and disseminated in different parts of the world.
2. Begin by rapidly reviewing one. First try to quickly understand the major messages, and spend only about five minutes reading the text.
3. Your task will be to evaluate the examples on Worksheet #1.1 according to the principles outlined in this unit. After review, answer the questions on Worksheet #1.1, page 1 and page 2.
4. Mark a "+" if the material satisfies a principle, and a "-" if it does not. For example, if there are no headlines or pictures which give the main behavior-change message, give it a "-" for this criterion.

If there is time, proceed to the second example.

For the other questions on page 2, simply write a brief response.

Worksheet #1.1. (continued)

1. In what settings might such material be useful in your country? (Don't worry about the problem addressed as much as the approach.)

2. What resources might be available to produce similar materials in your country? Is it feasible?

Example B:

3. What impact might such material have? Would anyone pay attention to it? Who?

Worksheet #1.1. (continued)

4. How would you improve the material?

RATIONALE

The purpose of this activity is to give you some experience in designing a simple educational leaflet or poster to target a specific drug utilization problem. This will also enable you to evaluate the applicability of the principles reviewed to real-world drug use problems in your own country.

1. Your group will select a problem from the list below that describes an important and correctable drug use problem in your country:

(Spend a maximum of ten minutes deciding what problem to tackle)

• Over-use of extravagant and risky analgesics, such as dyprone, when cheaper alternatives (e.g., aspirin) are just as effective.
•  
• Use of antibiotic injections for dysentery when oral antibiotics are safer and more effective.
• Prescribing of oral antibiotics for mild diarrhea when ORT is the therapy of choice.
• Failure to complete a course of treatment when symptoms disappear.
• Another common prescriber or patient problem of your choice.

2. List one to three reasons why you think prescribers or patients are behaving in an "irrational" manner. Can you think of any reason for the behavior which makes it rational from their perspective?

3. Pick an important target group for an educational pamphlet and/or poster to address this problem.

4. Sketch and outline a two- or four-sided educational leaflet or poster to help bring about the behavioral change required of the target group. Include:

• At least one headline.
• One simple illustration (or state what the illustration would be, where to place it, and how large it should be).
• Show where the text would go, and what information would be included.
• Indicate on the front cover whether the information has been endorsed, sponsored, or approved by an objective and respected medical or health organization.

5. After completing this activity, each group will present the material to other participants for comments and recommendations.

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