The individual, societal and economic costs of preventable ill health and disease are significant, accounting for between a quarter and a half of the burden on health and social care and deaths globally.1–3 Modifiable behavioural risk factors such as sedentary behaviour, unhealthy diet, not attending health screenings and high-risk sexual behaviours contribute to the increasing global burden of ill health and disease.4 Public health communication science can play a crucial role in ensuring that accurate and accessible health messages are communicated to individuals, communities and populations to promote health and health behaviours and reduce morbidity and mortality.5 Health literacy—the knowledge and competencies needed to access, understand and use information to promote health6—is critical to the effectiveness of these communications. Studies have found that poor health literacy relates to less healthy behaviours, worse health outcomes and health inequalities.7 Disadvantaged groups, including those with local language and cultural barriers, face additional health literacy barriers,8 and therefore, the transmission of public health messages that do not rely on language or text can help to address these barriers.
Make it visual
‘Make it visual’ is one of four tactics set out within the WHO Strategic Communications Framework to apply to make health communications understandable.9 Underpinning this is evidence from (1) cognitive psychology demonstrating that visual information is more memorable than textual information (Picture Superiority Effect)10 and (2) reviews of health communication using pictures, which have concluded that knowledge, understanding, attention and recall are improved when pictures are used compared with using text alone.11 12 Importantly, these effects are robust and extend to those who may find text-only information more challenging, for example, individuals who lack literacy skills12 and those with cognitive impairment.13
Digital advances, together with evidence from literature outside of health that demonstrates the benefits to learning and cognitive load of animations14 (a simulated motion picture depicting the movement of drawn (or simulated) objects15) compared with static pictures, have resulted in visual health communications commonly adopting an animated format to digitally deliver health messages using moving pictures and either complementing or replacing written text. These animations can be made using traditional animation or other techniques (eg, three-dimensional, whiteboard and stop motion) and can be formatted in multiple ways, including video, Graphics Interchange Format and Animated Portable Network Graphics. Consequently, animated health communications (hereafter referred to as health animations) have the potential to be easily and widely shared via the internet, apps and social media, which, in turn, has catalysed their widespread global application to deliver public health information and promote health behaviour change.
Current evidence base for health animations
Despite the increasing use and potential reach of health animations, the evidence base underpinning them remains unclear, partly due to the significant differences between study designs and comparators. For example, one study of polio vaccination messages found that animated messages led to greater improvement of health knowledge when compared with written messages,16 whereas a study of colorectal screening messages found that only when animated messages were combined with spoken text was greater message recall observed in people with low health literacy.17 This lack of clarity also somewhat stems from a lack of research into what elements and features of videos, including health animations, are most engaging and impactful in delivering health messages.18 This gap in research is noted in a WHO case study of a highly viewed and award-winning health animation by the Global Health Media Project that communicated information about COVID-19 transmission during the pandemic. Even though the case study describes the features of the animation and how the content was informed by science, the animation has not been formally evaluated.19
A recent systematic review has synthesised literature specifically in relation to the effectiveness of video animations as information tools when compared with other formats of delivery and concluded that video animations over other formats have promise to improve knowledge but that the evidence is highly variable.20 Similarly, a recent review and meta-analysis of the effectiveness of animated videos on patient learning concluded that animated videos can improve patient knowledge over a range of health and clinical contexts.21 Evidence from health animations designed to promote public health preventive behaviours more broadly has yet to be reviewed.
Within the literature, not only are there significant differences between studies of health animations in terms of the study design and comparators, but there are also significant differences between the design and content features of the animations themselves, including the length, tone, number of messages, health context, target audience and use of text, language, sound and behaviour change theory. The use of cultural identifiers in the characters and settings and voiceovers in local languages and accents have also been considered in health animation design.22 One such health animation, ‘The Magic Glasses’, was developed as part of a larger intervention for Chinese schoolchildren to prevent soil-transmitted helminth infection.23 The 12-min animation is in narrative form with cultural identifiers in the characters, settings, language and music, and has also been culturally adapted for use in the Philippines. Contrastingly, a health animation where the intended audience was global was designed to have no cultural indicators, be wordless and have featureless characters.24 This 2-min 30-s animation was able to successfully increase knowledge and intentions for preventive behaviours, such as hand hygiene, during the COVID-19 pandemic across cultures. Given the heterogeneity and contextual complexity of health animations, syntheses of studies need to recognise the different factors or contexts that may affect their impact. Additionally, as health animations have not always been formally evaluated, it could be helpful to look beyond published research at other sources of information to be able to uncover the specific causal mechanisms being triggered that facilitate certain outcomes.
Therefore, we will use a realist review approach to understand why, how, for whom, to what extent and in which contexts health animations are expected to produce their effects. We will not consider health animations to be uniform but rather identify the underlying and context-sensitive causal mechanisms and the specific outcome(s) affected by these mechanisms. In doing so, we will generate knowledge about the causes of outcomes in particular circumstances in terms of context-mechanism-outcome configurations (CMOCs) of realist reviews and syntheses. When considering CMOCs, a useful heuristic can be to ask ‘if, then, because’ where ‘if’ identifies the context, ‘then’ the outcome, and ‘because’ the mechanism.25 These CMOCs will become part of an initial programme theory of health animations to be tested and refined, ultimately informing recommendations for the design of health animations.
In line with global agendas on the prevention and control of communicable and non-communicable diseases, we will focus this realist review on studies of health animations that have been designed to promote public health behaviours through primary, secondary or tertiary prevention. Such behaviours include lifestyle (eg, being more physically active and stopping smoking), hygiene (eg, handwashing to reduce the chance of spreading infectious diseases) and attending preventive health appointments (eg, screenings and health checks). We will not focus on animations designed to treat illness and disease, which are more likely to adopt a clinical rather than public health angle.
This post was originally published on https://bmjopen.bmj.com