Pictures in health information and their pitfalls: Focus group study and systematic review

Background: Health information often includes different categories of pictures. This study comprises: A) exploration of the perception of photos presented in a brochure on the prevention of osteoporosis and B) a systematic review on the effects of pictures in health information. Methods: A) We conducted four focus groups. Participants with heterogeneous cultural and educational background were included. The interviews were subjected to qualitative content analysis. B) We searched PubMed, CENTRAL, PSYNDEX, PsycINFO, CINAHL, Campbell Collaboration and DIMDI. Randomized controlled trials (RCTs) on predefined cognitive and affective outcomes were included. Two reviewers independently extracted data and assessed the quality of evidence. Descriptive data synthesis was conducted. Results: A) Within the focus groups comprising 37 participants, four generic categories were identified: comprehension, perception, congruence between photos and content, and alternatives. Identification with portrait photos and the connection between photos and text were important to participants. B) In total, 13 RCTs were included. Quality of evidence was moderate. Types of pictures and their intention varied between studies. Cartoons enhanced comprehension, satisfaction and readability. Photos did not improve cognitive or affective outcomes. Effects of anatomical pictures, pictographs, and drawings were ambiguous. Conclusion: The overall effect of using pictures in health information remains unclear. The type of pictures and readers' characteristics may influence both perception and interpretation. Type, amount, and intention of the pictures should be considered carefully.