Student Voices Mar. 24 2017

A Picture is Worth a Thousand Words

Assessing the health communication tools for patients with chronic kidney disease

Chronic kidney disease affects over 10 percent of adults in the United States, or more than 20 million people. Late-stage kidney disease requires dialysis several times a week and severely decreases both quality and length of life. It is an illness that requires careful management of diet, fluid intake and exercise to avoid its progression. Therefore, it is important that health communication materials for patients are easy to understand and act on.

Suzanne Kirkendal, MPH '18To address this issue, I did work at the University of Sydney as a part of a summer research scholarship, with specialists in health literacy and health communication—who also had experience with kidney disease and epidemiology. I was set to start my first year at Mailman's department of Sociomedical Sciences last year, where I have been earning a certificate in health promotion, research, and practice, so it was exciting to partner with my undergraduate university’s school of public health before arriving here. 

Using existing health literacy and linguistics assessment tools, we evaluated 26 written health materials for patients with chronic kidney disease and developed a new checklist for assessing images in health materials. Our criteria were based on the image’s clarity, contribution to meaning, contradiction with intent, the caption used with the image, and the cultural context of its readers.    

Using this new checklist, we found that out of 223 images and graphics in the materials, half of the materials used at least one unclear image. Less than half of the visual aids contributed to meaning and most images were included only as decoration, rather than as informational tools. Sometimes the images even hurt the message, and three of the documents had at least one contradiction between an image and the text. For example, all patients with chronic kidney disease are required to restrict their salt intake, yet one image showed a woman eating a meal with a salt shaker clearly near her plate.

The full results of our research are in the Journal of Health Communication.

Meal being eaten with salt.Chronic kidney disease is a condition that requires complicated management of nutrition, and other lifestyle factors depending on how far along you are in the five stages of the disease. In the early stages, for example, patients are allowed to consume a lot of fluid and phosphorus-containing foods (like nuts and legumes). But as the disease progresses, these foods and fluids must be restricted because the kidneys can’t process them as well. This sort of nutritional advice can be challenging to remember, since most mainstream health messages promote these foods as healthy.

Since physicians don’t have the time go over every self-management detail in a memorable way with each patient, non-profit organizations and health facilities have produced a variety of materials such as pamphlets and booklets for patients to help manage their illness. However, there has not been a consistent standard for how these materials are written, including how the information is laid out visually and what images are used.

This is a problem because 20-25 percent of patients with chronic kidney disease have a lower ability to obtain, process and understand health information. Chronic kidney disease is mainly caused by diabetes and high blood pressure, which is more common in people who have lower education and income levels. Research has also shown that people in these circumstances often do not have the knowledge, time or money to develop their health understanding and behavior.

These disparities are further compounded by the fact that one of the side effects of the disease is the development of attention and memory problems, most likely due to cerebrovascular disease and increased inflammation. Ideally, materials for these patients need to be written for a fifth grade reading level or lower and should make effective use of pictures, since images have been proven to be more effective for people with low health literacy.

Taken together, these findings show that most of the written health communication materials intended to help patients manage their chronic illness are not doing their job. One of the most important ways to enhance communication is to always keep your audience in mind, and to meet them where they are, rather than assuming they have the same ability to digest new information that you do as a trained public health worker.

To develop more effective communication materials, authors need to ensure they are taking into account their patients’ health literacy levels so patients can modify their health behaviors. Images and layout can be a wonderful way to enhance understanding, but only if used correctly–otherwise, these elements can do more harm than good.

Hopefully, this work will enhance the toolkit that is available to health communicators, so that they can follow our checklist and other guidelines, and create the most effective health materials for patients managing chronic disease. This will help patients better understand what they need to do to manage their health. As health professionals we must communicate in ways that anyone can understand, because everyone, no matter their education or income, deserves to live a long, healthy life.


Suzanne Kirkendall is a first-year MPH student specializing in Health Promotion who has recently returned to America after nine years in Sydney, Australia.  She is keen to continue to build a career in health communication and chronic disease prevention strategies that incorporate mHealth and eHealth innovations.

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