Graphic Medicine Quantified: An Annotated Bibliography
by A. David Lewis
A challenge for Graphic Medicine is its being juxtaposed alongside biomedical and scientific fields of work that operate largely in the realm of statistics and quantifiable analytics. Often, the scholarship in Graphic Medicine comes without numbers. It is anecdotal, experiential, aesthetic/literary, or theoretical, customarily, and only occasionally calculable.
This is neither a flaw nor weakness of Graphic Medicine, but it is also adaptable. If practitioners and clinicians utilizing elements of Graphic Medicine so choose, they can opt to perform further studies on its measurable effects. This is not a matter of if but when; this is not a matter of opportunity but will.
To that end, the following annotated bibliography is being offered to highlight just a few of the cases where Graphic Medicine has already delivered quantifiable results. The sources cut across several different populations (children, parents, medicals students, patients, etc.) and several different medical situations (hospital discharge, university classes, patient empathy, etc.). As a whole, though, they demonstrate quantifiable approaches to the field and provide an initial proving ground for expanded studies of Graphic Medicine’s impact on healthcare.
Austin, P.E., Matlack, R., Dunn, K.A., Kesler, C.& Brown, C.K. (1995). Discharge instructions: do illustrations help our patients understand them? Annals of Emergency Medicine 25(3): 317-320. https://doi.org/10.1016/S0196-0644(95)70286-5.
This randomized, blind study sought to determine whether the addition of illustrations improved patient comprehension of discharge instructions. Utilizing 101 patients diagnosed with lacerations, the results found that illustrated instructions increased comprehension of their post-discharge directions overall; on a follow-up set of test questions, those with illustrated instructions “were 1.5 times more likely to choose five or more correct responses” (p. 317). The illustrations boosted specific demographic answers, improving responses with nonwhite patients, women, or those with no more than a high school education.
Berg, A., & Lecointe, K.-N. (2020, March 11). Comics in graduate education: Preliminary findings. Graphic Medicine. https://www.graphicmedicine.org/comics-in-graduate-education-preliminary-findings/
This preliminary study of 22 speech-language pathology students at Pace University demonstrated improved engagement across five categories of a reflective activity, potential in academic and clinical training, and potential for clinical practicum experience after reading Cece Bell’s El Deafo (2014). The procedure for the study included students creating a shared comic together on the communication impediment of their choosing.
Brand, A., Gao, L., Hamann, A., Crayen, C., Brand, H., Squier, S., Stangl, K., Kendel, F., & Stangle., V. (2019). Medical graphic narratives to improve patient comprehension and periprocedural coronary intervention: a randomized trial. Annals of Internal Medicine. Retrieved from https://doi.org/10.7326/M18-2976
One-hundred thirty-five (135) coronary angiography patients in Berlin were split between receiving informed consent documents in written (ICcomics) and comics (ICcomics) form, along with physician explanation of their procedure. Both before and after their care, they reported on their anxiety levels (STAI) as well as client satisfaction (CSQ-8) and procedure knowledge. Both patient comprehension and satisfaction were higher with the ICcomics group, and those receiving the written information were made more anxious about their procedure while those receiving the comic had their baseline anxiety decrease by approximately 7% (a total difference of over 12% from the written-only group).
Green, M. J. (2015). Comics and medicine: Peering into the process of professional identity formation. Academic Medicine: Journal of the Association of American Medical Colleges, 90(6), 774–779. https://doi.org/10.1097/ACM.0000000000000703
Over the course of a six-year period, nearly sixty fourth-year medical students took a graduate-level course in medical graphic narratives with Michael J. Green. In addition to producing their own comics, the students reported comics contributing to a significant increase in their empathy skills, communication with patients, clinical reasoning skills, communication with colleagues, and a number of other professional abilities. Green encourages further evaluation to determine “whether comics courses can change a medical school’s culture and whether they have long-term effects on the attitudes and skills of participants” (p. 779).
Hanson, A., Drendel, A. L., Ashwal, G., & Thomas, A. (2017). The Feasibility of Utilizing a Comic for Education in the Emergency Department Setting. Health Communication, 32(5), 529–532. https://doi.org/10.1080/10410236.2016.1211076
Fifty children between the ages of 4-18 complaining of pain-related symptoms were given a comic education module, a short instructional story and drawing prompt, upon discharge. Upon follow-up, nearly all of the children reported enjoying and understanding the comic, but it was 86% of the children’s caregivers who correctly recalled the three salient education points at 72 hours after discharge.
Hosler, J., & Boomer, K. B. (2011). Are comic books an effective way to engage nonmajors in learning and appreciating science?. CBE Life Sciences Education, 10(3), 309–317. https://doi.org/10.1187/cbe.10-07-0090
Following a preinstruction assessment (Biology Attitude Scale or BAS), excerpts from the comic textbooks Optical Allusions were given to four classes of students from a small, rural liberal arts college. A postinstruction assessment revealed not only improvement in knowledge scores, to be expected, but a major positive BAS shift with the comic, particularly by those who had previously reported the least investment, in Sensory Biology and Organic Evolution.
Leiner, M., Peinado, J., Baylon, A., Lopez, I., & Pathak, I. (2018). Divide and conquer: improving parental understanding of health-related instructions using sequential pictorial instructions. Health Education Research, 33(2), 104–113. https://doi.org/10.1093/her/cyy004
Over three-hundred parents of pediatric patients were split into two groups, one being given medical instructions for their children’s non-emergency care that included, rather than pictograms, Sequential Pictorial Instructions (SPI) as opposed to only written text. Upon later testing of this population, the SPI comics yielded greater recall of the instructions in English speakers and Spanish speakers alike, with highly significant effects on prescription and emergency steps. Notably, there was no significant difference between literacy or income levels.
Mendelson, A., Rabinowicz, N., Reis, Y., Amarilyo, G., Harel, L., Hashkes, P. J., & Uziel, Y. (2017). Comics as an educational tool for children with juvenile idiopathic arthritis. Pediatric Rheumatology Online Journal, 15(1), 69. https://doi.org/10.1186/s12969-017-0198-5
Over 60 children between the ages of 8-18 with juvenile idiopathic arthritis (JIA) were tested for their knowledge about the illness both before and after reading Neta and the Medikidz Explain JIA. Scores improved 17% after reading the comic book, and, one year later, more than half fully retained the knowledge on JIA. Analysis also revealed Jewish children initially scoring higher than their non-Jewish peers, but both groups scored similarly after the comic book.
Mickel, C. F., Shanovich, K. K., Evans, M. D., & Jackson, D. J. (2017). Evaluation of a School-Based Asthma Education Protocol. The Journal of School Nursing: The Official Publication of the National Association of School Nurses, 33(3), 189–197. https://doi.org/10.1177/1059840516659912
The asthma education program Iggy and the Inhalers class and comic was given to 173 children with asthma between the ages of 7-11 through their schools. Of them, 147 completed tests both before and after Iggy, leading to significant increases in asthma knowledge that also suggest an improved likelihood of self-management behaviors; Iggy, therefore, is at least as – if not moreso – effective than traditional asthma programs in schools.
Muzumdar, J. M., & Pantaleo, N. L. (2017). Comics as a Medium for Providing Information on Adult Immunizations. Journal of health communication, 22(10), 783–791. https://doi.org/10.1080/10810730.2017.1355418
Two flyers on vaccine information, one designed by the CDC and the other adapting that information as a comic, were given to adults at an ambulatory care center. The surveys completed by 265 flyer-recipients showed they found the comics iteration both more informative and more welcome than the CDC-designed alternative.
Myers, K. R., George, D. R., Huang, X., Goldenberg, M. D. F., Van Scoy, L., Lehman, E., & Green, M. J. (2019). Use of a Graphic Memoir to Enhance Clinicians’ Understanding of and Empathy for Patients with Parkinson Disease. The Permanente Journal, 24. https://doi.org/10.7812/TPP/19.060
After reading Peter Dunlap-Stohl’s My Degeneration: A Journey through Parkinson’s, a dozen care team clinicians reported increased confidence in their understanding of patients’ experiences as well as that of their families. Qualitative and quantitative data in tandem reflected increased empathy for the lived experience of Parkinson’s as well as appreciation for comics themselves.
Naro, M. (2019). When “Peanuts” went all-in on vaccinations. The Nib. Retrieved from https://thenib.com/when-peanuts-went-all-in-on-vaccinations/
Comics journalist Maki Naro recounts the unsuccessful effects of the U.S. Center for Disease Control’s campaign to eliminate measles. In January 1968, Charles M. Shulz’s Peanuts was employed to convey the message to vaccinate, but, unlike Shultz’s support of smallpox vaccinations, the overall campaign did not meet its goals on measles. Naro suggests that cultural, racial, and economic divides were not properly taken into account for the efforts to be widespread.
This bibliography is neither representative nor complete: there has been and remains to be a great deal of work done that is not captured here. Any absences or gaps on this list are more due to the fecklessness of databases and paywalls rather than interest or potential. That said, we return to the stated motivation behind this document, to encourage new and more powerful studies on Graphic Medicine’s effect in a number of healthcare scenarios.
Graphic Medicine is a space for immense creativity, holistic impact, and quantifiable study. However, this sample of entries above showcases the many directions in which it can go for quantitative analysis and data collection. In short, if we choose, Graphic Medicine can also go by the numbers.
Editor’s Note: Readers of this bibliography may find additional references in the recently published review article: Mapping the Use of Comics in Health Education: A Scoping Review of the Graphic Medicine Literature.
Thank you for the annotated bibliography. It is useful for researchers and teachers alike.