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Project 4: Using verbal and visual presentation formats in HIV/AIDS instructional documents

Who & When
Main Objectives
General Background
Research Questions
Theoretical Embedding
Research Methodology
Work Plan
Expected Outcomes


Who & When

Project co-ordinator Prof. Dr. A. Carstens
Researcher Ms Lilian Gangla (PhD)
Supervisors Prof A Maes (University of Tilburg)
Prof A Carstens (University of Pretoria)
Other researchers Students from participating universities
Starting date: June 2003
Date of completion: June 2006


up Main objectives

The main purpose of the study is to investigate how the effectiveness of printed instructions for low-literate South Africans and their caregivers on aspects of coping with HIV/AIDS can be optimised through manipulation of visual and verbal presentation formats. The results will be used to develop theory-based and research-driven heuristics for using text and visuals in instructional health communication, focusing on both the cultural diversity of SA and the topical context of HIV/AIDS.



up General background

Printed materials play an important role in HIV/AIDS intervention programmes since small media is relatively cheap and can be widely distributed. Furthermore, print materials can fulfil different communicative purposes, such as informing people (for instance, giving facts about how the disease is spread), persuading people to practice safe sex, instructing people on using condoms, safe breastfeeding, caring for patients with AIDS, and advising HIV-positive people and their caregivers on healthy living and healthy eating.

Two important problems associated with printed documents are the literacy (educational) level and the linguistic diversity of the South African population. A large-scale survey conducted in 1996 (1,898 former DET learners in 20 rural schools in the Western Cape, the Eastern Cape, KwaZulu/Natal, the Free State, the Northern Cape and Gauteng) undertaken for READ indicated that only 33.6% of the grade 5 learners were found to possess "average" reading skills, with 38.5% of the grade 6 learners and 45.5% of the grade 7 learners. An adult illiteracy figure close to 50% does not seem to be too far fetched. However, most of the health education materials distributed by the Department of Health, the Gauteng Department of Health and Soul City and LoveLife, require a literacy level of grade 9 or above.

It is widely acknowledged that the use of visuals can improve the effectiveness of printed instructions for low-literates significantly. Doak et al (1996: 91) claim that visual presentation is 43 percent more persuasive than unaided presentations. Moreover, research on visuals and graphics shows that the memory systems in the brain favour visual storage. Particularly in the case of instructional materials visuals are very important, because generally people understand, learn and remember procedures better when they see the message together with step-by-step visuals. Furthermore, visuals carry memorable emotional messages far surpassing that of words (Doak et al. 1996:94).

This project then focuses on the interaction of verbal and visual information in designing effective health instructions, specifically the effectiveness of different visual and verbal presentation formats for low-literate South Africans; and the preferences and information needs of different cultural groups.



up Research questions

Main question

  • How can the effectiveness of health care instructions for HIV positive, low-literate South Africans from different cultural groups be optimised?
Derived questions
  1. Which theories and models of information processing and socio-cognitive behaviours can assist researchers to understand the nature of readers' problems in successfully processing and utilizing printed information on health care in the domain of HIV/AIDS?

  2. Which presentation formats (verbal and visual) are the most effective in conveying health care instructions for HIV positive low-literate patients and their caregivers in South Africa, and how do cultural, affective and cognitive variables influence the effectiveness of such combinations?

  3. How can the formulation and application of a set of theory-based heuristics assist document designers and health professionals in South Africa to optimise the effectiveness of printed instructions in health care programmes for low-literate HIV positive patients and their caregivers?


up Theoretical embedding

For the purposes of this study, the literature survey will be approached from the perspectives of socio-cognitive behaviours, information processing, and effective document design. This focus will necessitate a thorough review of the literature on relevant theoretical issues:
  1. Sociocognitive theories (how people think about illness and how they cope with terminal diseases), e.g. illness cognitions, coping theory, crisis theory (Moos & Schaefer 1984; Taylor 1983).

  2. General theories and models of information processing, learning and instruction, with particular emphasis on how these processes are facilitated by printed materials, e.g. dual-coding theory, cognitive load theory and c-hip model (Paivio 1971; Marcus, Cooper & Sweller 1996; Wogalter, DeJoy & Laughery 1999; Mayer 1999).

  3. Theories on how low-literate persons comprehend, remember and use printed information in the domain of health care (Doak and Doak 1996; Aitchison 1996).
Since these results have been obtained predominantly within normal cognitive conditions and a neutral cultural context this subproject will investigate the validity of the claims with regard to specific target group characteristics, such as low literacy and culture.



up Research methodology

  1. Survey of the literature (building a theoretical framework)

  2. Corpus-analytic/descriptive research (text-focused)
    Materials collection and analysis according to standard principles of document design

  3. Experimental research (user-focused)
    • Testing different combinations of verbal and visual instructions with low-literate South Africans from at least two cultural groups. .Methods of participatory audience research, e.g. focus group discussions, will be used (Mody 1991; Servaes, Jacobson & White: 1996).
    • Testing prototypes of instructional documents (which will be the result of applying empirical and theoretical evidence) among members of the particular cultural groups through qualitative and quantitative research methods.


up Work plan

Phase 1
June November 2003
Literature review
  • Materials selection

  • Preparation of different visual and verbal formats
Phase 2
January March 2004
Determining the effectiveness of different formats through participatory research

Phase 3
April June 2004
Determining relevant document variables. Compiling and fine-tuning of heuristics

Phase 4
July December 2004
Designing, pretesting and adapting prototypes

Phase 5
February April 2005
Ms. Gangla receives supervision by Prof. Maes at Tilburg University

Phase 6
May - November 2005
Processing results, adapting prototypes and retesting them if necessary

Phase 7
January - June 2006
Writing the final report (PhD thesis) and preparing an article for publication



up Expected outcomes

Expected main findings
  1. An overview and critical evaluation of existing literature on verbal cum visual instructions, with special reference to the predictive and descriptive value of existing theoretical models.

  2. Experimental evidence on the effectiveness of different verbal and visual presentation formats for low-literate South Africans from different cultural gro ups (including the comprehensibility, memorability, learnability, etc. of materials presented in different formats).

  3. Development of a research-based and theory-driven set of heuristics for both evaluating the use of visuals in existing instructional documents for HIV-positive patients, and for designing new documents with a similar purpose.
Expected packaged results
  1. PhD

  2. Survey article

  3. Workshop contributions