Wendy Hiller Gee, M.A.
When patient education materials are developed certain assumptions
about the audience must be made, such as gender ratio, ethnicity,
and age. Diseases and conditions are often found in particular subsets
of the population, which will determine the focus of text and illustrations
in education materials. In the absence of condition-specific audience
information, census data can help form an understanding of the end-user
Assumptions about audience literacy
are also often made when developing patient education materials. Illiteracy
is a widespread problem in the United States, and can be further described
in terms of health literacy. This concept has direct bearing on the
choices health educators make when designing, writing, and illustrating
patient education materials. Medical illustrators can create more
effective illustrations for a target patient audience when they understand
the issues associated with low health literacy. They also are uniquely
positioned to advocate for health literacy appropriate art and text
when working with writers and health educators to develop patient
Who Is the “Patient” in Patient Education?
As we develop patient education materials, we often make certain assumptions
(e.g., age, ethnicity, or literacy) about our end users—the
people who ultimately, we hope, will read and understand the information
we present to them. We make decisions on art, text, and organization
based on what we believe about the audience we’re hoping to
educate. However, such beliefs and assumptions may not reflect the
true nature of the population we are attempting to serve. To understand
the characteristics of the target audience is to have an initial framework
for making decisions about how to present information. This article
describes facts about general demographic characteristics to clarify
what is known about the American population. In addition, this article
will discuss the concept of health literacy and how it affects patient
Who Is the American Patient?
There is obviously no simple answer to this question, but we can learn
a lot from demographics. As educators, we concern ourselves primarily
with the following information about people:
- Age group
Based on the 2000 U.S. Census data (U.S. Census Bureau n.d.), we
can derive some basic answers about the U.S. population as a whole
(the total population was reported in that census as 281,421,906).
One of the things we hear often is that the baby-boomer (Americans
born between 1946 and 1964) population is getting older, and as it
ages, marketing and other trends shift to accommodate it. The 2000
Census does indeed report the majority of the population in that age
Age (in years)
Percent of total population
18 to 24
25 to 44
45 to 46
65 and over
Biology generally dictates an almost-even chance of male and female
births, and the population reflects that: 49.1 percent male and 50.9
percent female. However, the breakdown shifts in certain age groups.
For example, of the population aged 18 years and over (total = 209,128,094),
48.3 percent is male and 51.7 percent is female. However, of the population
aged 67 years and over (total = 31,101,522) the percentages change
to 40.5 percent male and 59.5 percent female. Certain diseases or
conditions affect men and women disproportionately, but considering
all factors we can still safely make two common assumptions about
- There are roughly the same numbers of men and women overall.
- Women tend to live longer than men.
Ethnicity expressed in patient education materials is highly influenced
by regional, socioeconomic, and cultural factors. Certain ethnicities
are prone to specific disease conditions; for example, there is a high
prevalence of hypertension in the African-American population. This
kind of specific information naturally forms the basis for decisions
about art and text. At the same time, it is helpful to note the overall
breakdown of the population by ethnicity (note that these census numbers
reflect persons reporting their ethnicity as one race alone or in combination
with one or more other races):
Percent of total population
Note: These numbers do not equal 100 because of individuals
reporting as two or more races.
Demographics and Medical Illustration
The basic demographic information described above can help medical
illustrators in planning out patient education pieces. For example,
suppose that a patient education piece is targeted to the general
population and an illustration is being planned to show a typical
group of people. The illustrator can use demographic information as
a rational basis for showing a higher percentage of women to men,
a higher overall age group, or estimating a ratio of differing ethnicities.
Or perhaps a purely anatomic illustration that is non-gender specific
may be better suited to a female form than to a male form, based on
the age group of the target audience. Even very diagrammatic art can
be sensitive to demographics through the subtle use of varying skin
tones or silhouettes. Further study to determine the efficacy of demographically
sensitive illustrations would be helpful.
One of the most challenging parts of creating patient education materials
is to ensure that the target audience will understand and retain the
necessary health information. To serve end users, patient education
materials need to take into account basic literacy and health literacy
skills in the United States.
Health literacy is defined as the “degree to which individuals
have the capacity to obtain, process, and understand basic health
information and services needed to make appropriate health decisions”
(Mayer, 2004). This definition takes basic literacy another step—not
only do patients need to be able to read, they must have the ability
to comprehend what they read and act on it. This broadens our understanding
of “low-lit” readers enormously. Mayer reports that the
1992 National Adult Literacy Survey (NALS) estimates 21-23 percent
of the U.S. population (40-44 million people) is functionally illiterate
(defined as the inability to do simple reading or mathematical tasks).
According to that same study, an additional 25-28 percent of U.S.
adults (50 million people) have marginal literacy (defined as the
ability to locate information in a text and
make basic inferences from written materials). This means that a staggering
90 million people in the United States have serious health literacy
challenges, making it difficult for these people to understand even
simple instructions, such as a directional sign in a hospital.
An important factor contributing to health literacy (or lack of it)
is, of course, language. Many patients with low health literacy speak
English as a second language. Census data (U.S. Census Bureau n.d.)
show that 82.1 percent of the population speaks English only.The remaining
17.9 percent represents 46,951,595 U.S. citizens who speak a primary
language other than English.
Another factor impacting health literacy is age. According to the
American Public Health Association (Medscape, 2004), two-thirds of
U.S. adults age 60 or over have literacy problems. At a public hospital,
81 percent of such patients were unable to understand fundamental
written materials such as a prescription label on a pill bottle.
A report by the Institute of Medicine (IOM) (Health Illiteracy, 2004)
suggests a complexweb of factors contributing to health illiteracy,
including language, age, ethnic or racial bias, the education system,
culture, and society, among others. The American Medical Association
has developed a health literacy training kit for physicians in order
to begin raising awareness of the health literacy problem among health
care professionals. The IOM recommends a broad range of actions that
medical, educational, insurance, governmental, and other entities
can take to begin addressing the health literacy problem in the United
There is as yet no clear data on whether visuals are easier to comprehend
than text for low-literate readers, but we do know that uncomplicated
illustrations with a story are effective in conveying health-care
messages (Doak, 1996). Further study is needed to understand the role
of visuals in health literacy.
Medical Illustration and Health Literacy
How do the communication problems inherent in low literacy and low
health literacy affect medical illustrators? Understanding the literacy
trends in the United States can giveillustrators another frame of
reference for making decisions about appropriate art for a given target
audience. For example, knowing that close to 20 percent of the U.S.
population speaks English as a second language may be a basis in some
cases for a medical illustrator to keep leader lines and labeling
to a minimum, use common anatomicterms where possible, or make text
elements of an illustration secondary to the visual message. Or, realizing
that age is a significant factor in health literacy, an illustrator
can plan images that are larger on the page, with room for text elements
at a larger point size.
There is still little data about how visuals are interpreted by low-literacy
readers, but medical illustrators can use demographic data and an
awareness of health illiteracy to develop illustrations of appropriate
complexity for patient education materials. Not every illustration
needs to be diagrammatic, but medical illustrators should carefully
consider factors such as level of detail, anatomic orientation, and
consistency among groups of illustrations when developing a patient
Medical illustrators are often in a position to advocate for appropriate
text and visuals when partnering with writers and health care professionals
on a patient education project. For instance, charts and graphs or
exaggerated perspectives may not be easily interpreted by low-literacy
readers, and would not be a good choice for certain patient education
materials reaching a wide range of end users. Basic demographic and
literacy information can be a factual basis to ask a client more detailed
questions about a target audience, as well as to suggest ways to develop
an effective product.
More study about how specific types of visual materials are interpreted
by low-literacy and particular demographic groups is needed. For instance,
how do functionally illiterate patients interpret standard anatomic
sections and views? Can visuals alone result in improved patient health
outcomes in low-literacy populations? Questions also arise about how
cultural awareness may play a role in developing appropriate patient
education materials. For example, how are different colors interpreted
among cultural subsets of the U.S. population? As the population of
the United States grows more diverse, understanding some of its characteristics
may help illustrators in developing effective patient education materials.
Wendy Hiller Gee is a Certified Medical Illustrator with a master’s
degree in medical illustration from the University of Texas Southwestern
Medical Center. She is currently Senior Medical Art Manager at Krames
Communications in San Bruno, Calif.
Court-Johnson, Susan, ed. “Health ‘Illiteracy’
May Cause Disparities in Care.” Patient Education Management
11, no. 6 (June 2004): 68-70.
Doak, C. C., L. G. Doak, and J.H. Root. 1996. Teaching Patients
with Low Literacy Skills, Philadelphia: JB Lippincott.
States 2000 Census Summary Part 1
States 2000 Census Summary Part 2
States 2000 Census Summary Part 3
U.S. Census Bureau
Mayer, G.G., Villaire M. Low health literacy and its effects on patient
care. J Nurs Adm. 2004 Oct;34(10):440-442.