**5. Semiotic analysis of health communication: editorial cartoons**

#### **5.1 How is coronavirus spread?**

In terms of visual elements, this collection of comics contains noteworthy characteristics, but is not thoroughly prepared to be used in a clinical setting. For example, in **Figure 1** there is a character that may be interpreted to be a patient, and if adapted for health communication, this character may be more specifically drawn as a patient. In comics used as health communication, the portrayal of patients, doctors, and other health professionals may allow the viewer to connect more deeply with the information presented [24–27]. Along with developing the use of characters, however, these comics could do more with representing inanimate objects such as medical supplies, procedures, body parts, and illnesses. **Figure 1** represents disease, or its symptoms quite simply: coughing.

Vectors are an important communicative value within comics. Vectors are anything that forms a line of sight directing a motion or movement within an image [28, 29]. In **Figure 1**, an arrow is used to link the name "coronavirus" with its image. In addition, the particles create a vector spraying outward from the patient's nose and mouth. Vectors may help the viewer find the important parts of the image or determine movement within the image. In the first image, the main character sneezes and shoots COVID-19 aerosols in front of him; these particles

*Medical Communication and SARS-CoV-2: Novel Approaches to Global Health Crises… DOI: http://dx.doi.org/10.5772/intechopen.95943*

#### **Figure 1.** *How is coronavirus spread?*

disseminating from this person are shown to the reader through the use of vectors. Without the use of vectors in this image, one may not understand that COVID-19 aerosols spread via air through the act of coughing.

These comics could be better adapted to suit medical communication by incorporating color. These comics are all black and white, including **Figure 1**; color can convey different moods and emotions [30, 31]; different colors represent universal thoughts or feelings [32]. For example, in many cultures the color white is associated with purity [33], while red is associated with boldness, hastiness, anger, or fear [34, 35]. These colors can be used when incorporated into medical comics by engaging the patient and assisting in the management of feelings and expectations through the use of culturally learned associations with specific colors [36]. For example, in **Figure 1**, color could be used to enhance our understanding of how the character feels: probably feverish which could be portrayed with red or orange-tint colors.

In terms of effectiveness, **Figure 1** is indeed one of the more effective comics in this collection. It explains an illness in concise and non-jargonous language accompanied by a simple image to illustrate the topic. It is easy to understand and may be informational to the patient. For such reasons, lessons of communicative value from this comic may be referenced for future development.

These visuals, along with the use of simple language to explain medical conditions or diagnoses, may be easier for the patient to digest [37, 38]. Furthermore, the link between visuals and memory is well established and thus may aid in recall of

this material in the future [39–41]. This is illustrated in **Figure 1**, as the character in the comic is portrayed as coughing, and COVID-19 aerosol particles are shown moving in a projectile motion in front of the character. By using simple visuals instead of complex language in trying to explain COVID-19's ability to spread when someone coughs, it is easier for the patient to understand through the simple image of projectile particles.

Overall, in **Figure 1**, the manner in which information is disseminated is appropriate for the medium used. With a comic as the medium of transmission, simple language is indeed appropriate. This comic presents quality information, which enables patients to make informed decisions. Information of quality allows the patient to retain their autonomy— the information is easy to understand, therefore aiding the patient in making informed decisions.

When examining the quantity of health information distributed among patients within their communities, it is important to consider the biomedical ethical principle of justice [42]. It can be determined whether or not the spread of such information upholds this principle, depending on whether the information shared with one group of patients is drastically different than what is shared with another group of patients. That is not to say that information should not be specifically created and modified for individual groups of patients to best suit their needs; rather, the bioethical principle of justice states that patients across all communities and socioeconomic strata should be treated the same [43]. All patients must receive the same quality of information in a way that is accessible to them, so they can come to appropriate decisions about their health without the privilege of one group over another. Assuming comics developed for use in clinics, hospitals, or outpatient centers alike are not only dispersed in one demographic at the disregard of another, this may be easily avoided.

The relevance of information presented to patients in medicine is highly important: this comic may therefore need an update. Although this collection was not used in a medical context, analysis shows that if it were to be used, the relevance of information would require an update. In particular, **Figure 1** places emphasis on the spread of COVID-19 via surfaces. The CDC has stated that although this is indeed a risk, it is not a central modality of transmission; and so this comic's information may need to be altered to de-emphasize this risk.

#### **5.2 What supplements do doctors recommend for people with COVID-19?**

In terms of visual representations, this comic does not detail any specific disease, or symptom. Rather, it is the general asking of questions, as in all *Health Capsules* that may have its own outlet in medicine. Similar to a *Frequently Asked Questions* brochure, comics could be developed to present *FAQ* information to patients more efficiently, understandably, and memorably. In any event, a more effective use would have specifically represented the discourse of the comic in the illustration. Instead of visuals that illustrate the various supplemental treatments, the viewer is presented with an image of a physician.

This image's portrayal of a doctor, who is presumably someone by the name of Dr. Pescatore, a pop-science author and internist, is exclaiming that the size of his nose is too big. Not only is this image seemingly unrelated to the topic being discussed, it may cause confusion to patients who may be led to link COVID-19 symptoms or the taking of supplements to having a big nose. As Dr. Pescatore is not a household name, one would have to research the name to establish the relevance, search if he has written anything about the nose or nasal functions, and then in the final efforts of searching, find images of him to see that he has a large nose; after

*Medical Communication and SARS-CoV-2: Novel Approaches to Global Health Crises… DOI: http://dx.doi.org/10.5772/intechopen.95943*

that process they may still justifiably wonder what this information has to do with anything. Unfortunately, the images and dialogue included with the written text are not on topic for the question that is asked. If comics are to be used in medical care, the images that are accompanying the text should stay on topic and only illustrate what is relevant so as not to confuse patients.

Emotional connections are highly important in healthcare as humans are emotional beings [44]. Therefore, any materials developed to be used in medicine should be aware of the emotional aspect of humanness. In this collection, **Figure 2**'s use of emotion may be helpful to a patient reading it. In **Figure 2**, the character represented is shown clearly smiling, as demonstrated by the curvature of his mouth and the orientation of his eyes. This demonstrates the universal emotion of happiness through facial features. The display of universal emotions through facial features can also help patients feel heard or represented during their care and can serve as an outlet for coping [45].

Not all emotional connections are displayed through facial features. In **Figure 2**, the use of an ominous black space, or ellipsis, to the left of the image is a tool that can help represent fear, discomfort, or the unknown [46]. When seeking medical treatment, patients may be afraid of the unknown [47]. Using an intentionally black space creates a sort of canvas for patients to imagine or even physically draw how they might be feeling or express their worry. In comics that are specifically designed

**Figure 2.** *What supplements do doctors recommend?*

to be used in medicine, it may be helpful to include areas within the image that are black, blank, or negative space to represent the unknown and allow the patients to realize their own emotions or fears.

Along with helping to mitigate patient fear, humor is another way to aid memory. Comics tend to include humor or catchy slogans and sayings which are more likely to be remembered by the patient. Studies show that information that stands out, as well as information that elicits a response from the receiver, will be more likely remembered [4].

In this collection, the language is relatively simple and concise, and hence, appropriate in manner. However, **Figure 2** represents an exception. In this comic, the language used could be very confusing to a patient who is not familiar with dosages of supplements. To make this language more appropriate in manner, plainer phrases should be used [48, 49]. For example, a simpler phrase, such as "two doses of vitamin C for the duration of the symptoms." Providing such dense information, such as "50,000 IU of vitamin D for two days, then 15,000 IU per day until COVID resolves" could be experienced as unnecessarily confusing, and beyond the scope of a *FAQ-style* comic.

Along with manner is the biomedical ethical principle of beneficence. Following this principle ensures that everything done within a clinical setting aims at benefiting the patient. Therefore, the manner in which medical communication is created and disseminated must also be created with the benefit of the patient in mind. Generally, the manner of information presented in this collection of comics is beneficent toward the patient. The simple level of language and information presented aids the patient by not using language that is too complex to understand. However, in **Figure 2**, it is uncertain as to whether or not the language used would be widely accessible or beneficial.

Altogether, the quality of this information for comics that are not intended to be used in medicine, could be easily adapted. For example, in **Figure 2**, there is information that is unnecessarily confusing. In a clinical environment, it is of importance to have quality information in an accessible modality available for patients. The quantity of information present in **Figure 2** is appropriate; any more information added to this small comic could cause confusion. Relevance and non-maleficence do come in to question in **Figure 2**, however. In **Figure 2**, it is asked which supplements are recommended for people who have COVID-19. The author then proceeds to accompany this text with an image of a doctor stating that his nose is too big: whatever this information is to mean, it is not entirely relevant, or not at all relevant, to the topic attempting to be communicated to patients. The information presented in the visual is vastly different than the topic and text of the comic. From a more extreme standpoint, the inclusion of non-relevant information could be viewed as maleficent.

#### **5.3 Where did the coronavirus originate?**

In **Figure 3**, the character pictured is shown in a frustrated or worried state. The portrayal of emotion in health communication may allow the patient to see such emotion and guide them toward coming to terms with their own [50, 51]. Early on in the SARS-CoV-2 pandemic, there was an arousal of worry about wearing face coverings to help prevent the spread of the virus— this character presented with a concerned expression, and asking about the efficacy of his mask, may be highly relatable to those of the general public.

In addition, in **Figure 3** language is written at a level that is accessible to people of lower literacy. However, just as in **Figure 2**, the image and its dialogue are not directly related to the main text of this comic. This could be viewed as highly confusing. Admittedly, the information about face coverings could be viewed as

*Medical Communication and SARS-CoV-2: Novel Approaches to Global Health Crises… DOI: http://dx.doi.org/10.5772/intechopen.95943*

**Figure 3.** *Where did the coronavirus originate?*

important; although, it should warrant a separate panel, so as not to distract from the main text of this comic on the topic of the origin of the coronavirus.

Physical distance between characters within the comic, or between characters and the reader, is another way that comics can create meaning [22, 52]. Depending on how close the characters within the comic are drawn to the outward face of the frame, different social connections can be established. For example, the character in **Figure 3** is drawn from the chest up. Close physical proximity to the reader invites a closer social connection to the characters within the comics. On the other hand, if a medical comic only showed characters far back in the frame with their full bodies in view, from feet to head, distance between the reader and the characters may be interpreted [37, 53]. This may have special implications during the COVID-19 pandemic when citizens are encouraged to *social distance.* The portrayal of characters physically distant from each other could serve to model appropriate behavior.

In terms of quality, there are some inaccuracies within this figure that would need to be properly corrected in order to be used in a medical setting as defined by the communicative maxims [54]. For example, in **Figure 3**, it is stated, "the CDC says masks are not recommended for preventing coronavirus." This comic was created early on in the SARS CoV-2 pandemic when this may have been accurate; however the CDC has since reversed its stance on the subject. At the time of production this *Health Capsule* was appropriate in quality, and therefore lent itself to patient autonomy, though it no longer does so. In addition, this comic is still freely accessible on the internet providing inaccurate information to the non-discerning viewer.

When creating health communication, it is also important to include the proper quantity of information, so as not to confuse the patient. This figure provides only brief information in response to a simple question asked. For this reason, it could be considered appropriate in the quantity of information that it provides. It is important to not give the patient too much information and leave them to sort through what is important or not. Healthcare practitioners must claim that duty and only pass along the information that is important and helpful. Though the quantity of information provided in this figure may be appropriate, other areas like manner and relevancy may need oversight.

In **Figure 3**, in which the origin of the coronavirus is in question, an answer is provided along with an illustration that is off-topic stating that masks are not recommended to be worn during the coronavirus pandemic. While this information could be valuable, it is not relevant to the task at hand within this comic and therefore should be excluded.

Rather, in cases where irrelevant information is presented to patients, it may break the principle of non-maleficence, and harm may come to the patient. In this comic the author states that masks are not recommended for preventing the coronavirus. As this information is no longer relevant to current health guidelines, the spread of this information could have negative effects on the health of the patient. To be non-maleficent and appropriate in relevance, health communication should be updated constantly or removed from circulation.

#### **5.4 Does how I breath affect my risk of Getting COVID?**

One valuable semiotic facet from this collection of COVID-19 comics comes from **Figure 4**. This comic gives a brief demonstration of how to breathe more appropriately during the COVID-19 pandemic. Such demonstrations like this may be used to inform a patient how to take their medication correctly or how a surgery will be performed; both of which provide clarity that may ease a patient's fear and aid successful treatment [55–57].

Along with **Figures 1** and **4** is another demonstration of effectiveness in this collection. It explains a health-related topic in plain language and uses visuals to guide the reader toward understanding. Of particular note is the instructional value of providing a step-by-step tutorial for the patient. In this comic, the character is asking the best way to breathe to avoid getting COVID-19. It is unknown if a particular breathing pattern significantly protects someone from contracting the virus. However, this image uses vectors in the form of arrows to demonstrate a movement in medical terms, illustrating breathing in through the nose and out through the mouth. This type of instruction may be highly effective in medical contexts to illustrate and provide clarity on important issues [58–60]. For example, using arrows or vectors can help demonstrate how a diabetic patient experiencing lower extremity swelling should keep their feet elevated until the swelling goes down.

Of course, quality health communication must be evidence based. In this *Health Capsule*, it is asked how breathing effects the risk of contracting COVID-19. After brief research, no readily-available clinical evidence on the effects of how one's breathing affects their contraction of COVID-19 has been found. Information and any materials distributed to patients must be checked for accuracy, clarity, and comprehensiveness, which requires the use of clinically proven information only.

The quality of information presented in medical settings is important when respecting the autonomy of the patient [61]. If the patient is not presented with correct information, it disregards their ability to be actively and informatively involved *Medical Communication and SARS-CoV-2: Novel Approaches to Global Health Crises… DOI: http://dx.doi.org/10.5772/intechopen.95943*

**Figure 4.** *Does how I breath affect my risk?*

in their medical experience. As previously discussed, the quality of information presented within this collection of comics could be quite confusing and, in some places, is outdated or clinically unverifiable. If this collection were to be used in its current form in a clinical setting, the patient would not be able to achieve perfect autonomy in their health.

In health communication, relevance is of key importance, as information that is not relevant could allow harm to the patient [62]. This communicative maxim is aligned with the biomedical principle of non-maleficence. By presenting information that is relevant to the patient, and in support of the task at hand, it helps ensure the patient's safety. **Figure 4**, may present information that could cause harm. Should this information be taken too literally, a patient may believe that simply by breathing in through their nose they can avoid contracting COVID-19, which is of course a misconstrual of information.

#### **6. Discussion**

Through the analysis of this collection of *Health Capsules* on COVID-19 as a whole, several characteristics that would be beneficial to health communication were identified. The analysis of these comics reveals that this form of communication may be effective for transmission of medical information with implications for future use, due to the ability to increase patient understanding and recall [63–65]. These images are highly accessible to the average patient and are emotionally relatable [66]. As a response to the WHO's request for health communication research during a pandemic, this analysis posits that comics could be used as successful means of communication during public health crises because of their simplicity.

In the context of health communication, it should be readily apparent that medical comics must uphold communicative principles to be most effective in their effort to provide information to patients. Furthermore, properly vetted communication is of even more importance in medicine; if incorrect or irrelevant information is provided, bodily harm may behold the patient. For this reason, communication's potential to directly inflict harm on patients, health communication must meet biomedical ethical standards. The biomedical ethical principles state that no harm should be inflicted upon the patient. To include medical comics under the scope of health communication, it is evident that medical comics must encourage communicative and medical ethics.

Furthermore, as comics create meaningful discourse through the use of semiotics, such visual semiotic elements need to be payed appropriate attention. Semiotics show that meaning may be gathered from any part of a visual; therefore it is important that patients gather the correct meaning from what they read. Just as verbal language has its own syntactical practices, it may be beneficial for medical comics to have the same level of standardization. With the application of biomedical ethics to health communication, and comics specifically, standards must be set in order to prevent unnecessary confusion or harm. The syntax of comics has already been developed in the field of comics scholarship, as evidenced in this chapter; however, the structure and function comics as a form of health communication could benefit from further study and recommendations of best practices for their use.

As semiotic elements can create emotional connections through facial expressions, invite patient participation through ellipses, set tone through physical proximities, direct the reader's eye though vectors, aid patient recall through humor, increase comprehension through simple language, and guide patients through step-by-step instruction, they are valuable modalities within health communication, so long as they are submitted to bioethical oversight.

### **6.1 Emotional connections**

Creating emotional connections through facial expressions may aid in connecting with the patient, as some expressions are easily recognizable and relatable [67]. For example, a patient may be portrayed as displaying anger; since this emotion transcends culture and may be treated as an iconic facial display, a patient may see this image and be able to make a stronger connection with the comic and the information contained within it. Other iconic facial expressions, such as happiness and sadness, may also be incorporated into health communication to facilitate patient understanding [68]. Relatable information may be very useful in health communication. Due to comics high accessibility, they may be a perfect modality to accomplish this. The representation of patients in medical comics may help patients feel more understood. For example, the use of angry, sad, or happy facial expressions, viewed within this collection, in a medical comic on coping with a terminal cancer diagnosis could help the patient feel justified in their emotions through the stages of their illness. The simple feeling of being understood and emotionally supported could improve the medical experience [69].

*Medical Communication and SARS-CoV-2: Novel Approaches to Global Health Crises… DOI: http://dx.doi.org/10.5772/intechopen.95943*

### **6.2 Patient participation**

Patient participation may be invited through an ellipsis, or an intentional black or blank space within the image that the patient is free to fill in [70]. As interpreted from this discussion, this may allow the patient to take an active role in medical literature that may be overly focused on diagnosing or prescribing. Allowing patients to take an active role in their illness narrative has shown to increase healing and patient satisfaction [71]. In medicine, diagnosing a patient often inadvertently prescribes the patient an illness narrative; allowing the patient to be the creator of their own illness narrative and empowering them to visualize it for themselves may be an important technique to help patients find their role or their voice in their treatment [72]. For example, in a comic about a diagnosis of major depression, a panel could be left blank with a prompt encouraging the patient to draw or write how they feel. Or, in this same situation, a comic panel could be completely blackened, with a prompt asking the patient to close their eyes and imagine what this diagnosis looks like to them. These modalities allow the patient to take a more active role in their illness narrative and could also serve as a therapeutic outlet of expression.

#### **6.3 Physical proximity**

Setting tone through physical proximities could be another way to create meaning within comics as a form of health communication. This collection of comics portrayed all characters in close physical proximity– from the chest up— which may serve to create a stronger bond between characters and readers [73]. Medical practice and hospitals could be viewed as a cold experience [74, 75]; throughout such bodily positioning, the reader of medical comics is invited to make a stronger connection with what they are reading [76]. It is arguably a small difference compared to the interpersonal relationship between the patient and the doctor, but if the patient could feel more welcomed or more understood through the positioning of characters represented through visual medical literature, it may be viewed as enhancing the overall medical experience. In addition to creating a closer connection with the patient, the strategic placement of characters in comics may also portray important values. In this analysis, for example, characters placed front and center in visuals were observed. In situations where the patient may often feel overlooked, by placing the patient front and center in a visual— when the patient may not feel centrally important in their own illness experience— the patient may feel acknowledged as the center of their care.

#### **6.4 Vectors**

Directing the reader's eye though vectors guides the line of sight in certain directions to place emphasis [77]. This visual technique to portray meaning could be successfully adapted to place emphasis within comics in health communication. For example, as demonstrated in *Health Capsules*, a patient may be reading a medical comic about obesity, and instead of placing emphasis on the various symptoms depicted, vectors could be illustrated through placement of images to place emphasis on the underlying cause. For example, a comic depicting obesity could demonstrate the symptoms and emotionally acknowledge the frustrations a patient may be experiencing, while at the same time directing the reader's eye toward solutions, such as physical exercise and moderation of food intake. Whether or not a patient is cognizant of the fact that their attention is being directed in this way may not matter; what matters is the microcognitive process that follows in which the patient may subconsciously classify the object to which their attention is being drawn, such as physical activity, as more important.
