Maximising the acceptability and utility of information for use by patients has become a central feature of attempts to improve the quality and engagement of patients in the field of self-management [
1]. Cartoons have been used in therapeutic encounters to promote the understanding and articulation of emotional difficulties and promote engagement with talking therapies (where people explore feelings and thoughts with a therapist) [
2] and thus potentially might contribute to the production and utilisation of information for self-management support. There is evidence of cartoons being viewed as an effective means of communicating important medical and health concerns. For example in the US a political and social critique formed the bases of cartoons which provided the public with a focus on the opportunities for preventing illness and accidents [
3]. However, more generally the use of cartoons remains the exception rather than a rule and a marginalised activity viewed as quirky rather than a mainstream form of information communication, packaging and delivery [
4]. In long-term condition management, where the demand for information by patients and the public is increasing but evidence of the effectiveness of written information on its own to radically change behaviour is equivocal [
4], we argue that the use of cartoons has significant potential.
It is worth noting that to date the primary focus of the dissemination of information has been orientated to making language clearer and more user friendly [
5]. Increasing treatment burden for patients with complex health and social problems suggests the need to strategically develop material in a way which is ‘minimally disruptive’ [
6]. Cartoons offer a potentially more normalised and accessible way of engaging with self-management options than some established therapies because of their humorous associations with everyday dilemmas. Cartoons are part of everyday life so they provide a normalised connecting point of visual communication and continuity during the biographical reconstruction necessary to adapt to living with a long-term condition [
7]. However, this leaves open the question of what might need to be done in addition, i.e. using different media. How patients relate to others through informational media is important particularly through identification with helpful or unhelpful thoughts and beliefs (this requires encapsulating patient experience differently). This has been found to be important in both communication and patient activation relating to self-management activities. It may also be the case that cartoons can act as a resource for others in need of practical help to explain the lay actualization of everyday self-care resources (such as how to engage with other people, food information and local clubs and activities). There is a strong driver to reciprocate in chronic illness and to be seen to be of use to others [
8,
9]; to which users can help through participating in a process of developing user focused information.
This paper is a description of the process of involving patients in developing cartoons for self-management guidebooks and a reflection on the use of humour and metaphor intrinsic to accompanying information conveyed by cartoons.
Humour for communication and promoting self-management
Humour is used a great deal in everyday communication and surveys of public health and patient information show that cartoons are used to amuse or inform through several formats (written, audio-visual or online media). However, it is less clear how actual cartoons are developed or how they can be used to the greatest effect. In particular, there is little literature concerning the rationale behind the use of cartoons or visual images in patient information. However, there is a recognition of the need to develop an evidence base so that images in health care can be used to ‘maximise good and minimize harm’ [
10] and that the potential to alienate or disempower is recognised [
7]. Conventional metaphors are made real in cartoons (e.g. expression of emotions and feelings). Illness has also been powerfully conveyed as metaphor [
11] suggesting a vehicle in the translation, conveyance and sharing of health information via cartoons and humour which perhaps provide an even more powerful hook [
12].
People with long-term conditions and their significant others often use humour as a way of coping with the associated stresses, anxieties and embarrassments of their lives [
13‐
19]. This is rarely acknowledged as a formal self-management strategy but seems linked to the ontological desire to continue with living life despite having to put up with the vagaries of dealing continuously with a long-term condition [
6]. Humour works for people on a number of levels. It can be a source of resilience. Recent empirical research has found that humour serves a number of functions in social relationships including affiliation, deflecting attention from the self, as a protection in risky circumstances, reduction of discomfort, avoiding embarrassment, maintaining a light-hearted outlook, amusement and breaking up monotony [
20]. It is relevant then to acknowledge and recognise these functions of humour in developing information resources. Whilst studies which have explored the role of humour have aided understanding of reactions to health events, the therapeutic value and utility for self-management might be captured and used through the medium of cartoons. For example, for people with irritable bowel syndrome (a condition which is experienced as embarrassing) humour appears to be valued as a preferred and officially unrecognised strategy for management which does not appear in formal self-management strategies such as action planning [
19]. Men with cancer have been found to use humour and jokes to manage feelings and reduce tensions [
13].
In a review of the purpose and function of humour in health [
14], three theories of how humour and health might be linked are explored: Superiority Theory or Tendentious or Disparagement Theory (Hobbes 1588–1679): An aggressive form of humour which takes pleasure in others’ failings or discomfort, this includes self-deprecating humour used against the self; Incongruity Theory (Kant 1724–1804): Humour where the punch line or resolution is inconsistent or incongruous with the set-up; and Relief or Release Theory (Freud 1856–1938): Humour released by ‘excess’ nervous energy which actually masks other motives or desires.
Humour and laughter can be seen as having a direct and physiological effect on health, as well as an indirect effect by enhancing coping abilities so moderating stress. McCreaddie and Wiggins [
14] found limited evidence on the direct effects of humour but wider acceptance of the evidence for indirect effects. They question whether certain types of humour, in particular the self-depreciation widely used by patients, is adaptive (indicative of good social skills and ability to cope) or maladaptive (indicative of self-loathing). A further utility of humour in the management of long-term conditions relates to a link between humour, hierarchy and subversion. In the context of interprofessional relationships humour has been associated with a strategy used by rank and file members to resist and attenuate instructions coming from powerful professionals [
21]. In the context of self-management, which can be construed in a part as delegated work to patients, there is a similar potential means by which humour can be used by patients to subvert, challenge or resist the instructions of health professionals which at the same time enables an empowering and positive means of being able to self-manage. A less subservient approach to professionals and strategic non-compliance have been identified as essential elements in achieving a balance in a person’s life and attaining a sense of well-being in managing diabetes [
22].
One purpose of cartoons is to help provide clarity, insight and understanding [
23]. The use of pictures or cartoons in patient information has been shown to be more effective than using text alone [
15,
24‐
26]. This has most salience where health literacy is conceptualised as a personal asset, orientated to developing skills and capacities which enable individuals to exert more mastery and control over their health and the factors that influence health and illness [
27]. Non-text-based approaches or visual methods including collage, photo-elicitation (where photos are used as part of an interview), self-portraits and other drawing-based activities such as relational maps and timelines are increasingly used in research. Drawings have been used as an insightful research method to explore the ways in which people understand and make sense of their illness conditions, in particular for people with low levels of literacy [
28]. Here we extended this rationale to the development of information resources for long-term conditions.
One of the specific purposes for developing cartoons to accompany self-management information could be to address concerns related to health literacy (conceptualised as a risk and asset) [
27]. We see the use of cartoons as addressing health literacy in a number of ways: To impart humour (which improves recall and understanding of information) [
24]; to provide resonance with shared experiences (a visual reminder that other people have similar problems and have found solutions); to communicate complex ideas (which often take a lot of words to explain and a cartoon may provide a simplified short-cut); and to illustrate, illuminate and show ways of dealing with embarrassing situations (people unable to read about other people’s health problems may feel so embarrassed about their symptoms that they are unable to talk about them – a cartoon showing such symptoms might be enough to prompt help-seeking). Cartoons can be used to present situations in a non-threatening way and their simplicity can give a clear focus to an idea or thought; it has been found that photos can be confusing when there is too much detail [
24].
It is recognised that patients and recipients of information should be consulted to ensure that cartoons or pictures are meaningful and not used in a way which is counter-productive [
24]. However, there is currently nothing in the literature which explores how ideas for cartoons can be generated and translated in a collective and reciprocal way to engender engagement with self-management support. It appears that in the main, the ideas result from clinicians and researchers who commission illustrators, but it is unclear whether or how patients’ voices or experiences are incorporated into the ideas for translating messages and ideas for support for living with a long-term condition.
The research question of interest to us is: Can patient experiences and views be translated into cartoons which are acceptable and useful in self-management information? Here we start by outlining an approach to use lay views and patient experiences to create cartoons during the development of self-management guidebooks. We then use the most recently developed guidebook for people with early stage chronic kidney disease (CDK) as an exemplar of the methods used to develop and refine cartoons and as the subject for a qualitative evaluation of their impact.
Outline of an approach using patient experiences to develop cartoons
Over the past two decades, we have refined an approach to develop cartoons for use in patient information. A series of self-management guidebooks have been written with and for people with inflammatory bowel disease, irritable bowel syndrome, diabetes, chronic obstructive pulmonary disease and CKD [
29‐
33]. In the guidebooks, lay informed experiences have been given equal weight to medically and clinically informed evidence. To collect and synthesise views and experiences we used qualitative methods (focus groups) and thematic analysis to generate topics and themes. We tapped into the core feature of the focus group process: the interaction between participants was used to generate a collective voice that could translate into the development of a cartoon image [
34]. The cartoons were intended to encourage engagement with self-management and convey the universality of daily dilemmas and uncertainties of living with a long-term condition to patients to highlight the relevancy of the information.
The cartoon development drew on discussions about patient practices and experiences concerning: the experience of living with the condition, common situations, dilemmas of day-to-day management, the opportunities and difficulties of making decisions or choices, or the uncertainties associated with the condition. For each booklet, a list of topics for cartoons was developed by the research team using the empirical data and linked to a patient quote if possible. A cartoonist willing to take on the brief was found and an iterative process was used to refine the cartoons.