CALD Appropriate Communication

According to the Australian Bureau of Statistics (ABS) (Australian Bureau of Statistics (ABS) 2011), 27% of Australia's resident population were born overseas (almost 6 million migrants, born in over 200 countries), as at June 2010. The largest group of overseas-born residents is people born in the United Kingdom accounting for 1.2 million people followed by those born in New Zealand (544,000 people), China (380,000 people), India (341,000) and Italy (216,000).

As at June 2010, the majority (76%) of overseas-born residents were of working age, 15–64 years. However, migrants born in Asia, America and Africa had proportionally larger younger (0–14 years) and working age (15–64 years) populations compared to those from Europe.

The literature indicates that there is need to re-contextualize our understanding of what the CALD user group in Australia looks like. Rather than constructing the CALD user group as being made up of purely ethnic groups with needs that are unique to each group's traditional background, we should allow for the CALD community to also exist as a group of diverse individuals who are united by the challenges and opportunities of interacting with Australian culture. This perspective can inform pathology data that is embodied within the narrative structure of a story, coupled with the use of universal health icons to establish a common language that is accessible despite specific cultural backgrounds.

In terms of cultural sensitivity, demographical and low literacy factors, research has shown that:

• Pictograms which had been developed locally (Africa) were more successful in eliciting correct interpretations than those obtained from an international source (USP pictograms) (Asimakopoulou et al. 2008).
• There is evidence that people prefer pictures in health messages that are culturally sensitive and include representations of people like themselves. This suggests that they are more likely to notice such messages (Houts et al. 2006). Douse and Ehlers (Duman et al. 2011) showed that pictures were heavily laden with “culture bound conventions” that designers needed to be aware of. In their work with South Africans with low literacy they found that small changes in graphics to reflect local conventions made a significant difference to the understanding of instructions for medication such as “take with water” or “take at night”. They recommend that the target population be involved in all stages of development of the tool.
• In a study of a group of patients aged 50 years and older from diverse ethnic and educational backgrounds, there was no statistically significant effect of presentation format on participants' comprehension of cancer information. Format of numeric risk information was not a significant factor in the comprehension of cancer risk information in this (Donelle et al. 2009).
• Graphic imagery was associated with increased understanding of risk more than text in a small sample of American Indian adults (Sprague et al. 2011).
• Tables (compared to text) improve comprehension of health information for parents with low numeracy and literacy skills (Tait et al. 2010).
• Choi (Tetlan 2009) states that simple line drawings (Pictographs) were found to improve both comprehension of and compliance with prescription drug instructions among non-literate women in rural Cameroon compared with a control group trained without such illustrations.
• Among various visual aids, pictographs using simple line drawings combined with simplified text are the most efficient and effective tool to improve discharge education for low-literate older adults in acute healthcare settings (Tetlan 2009).
• Mwingira and Dowse (Mwingira and Dowse 2007) conducted a study to design and develop a simple, easily readable patient information leaflet (PIL) (simple text and pictograms) for a commonly used antiretroviral (ARV) regimen and to evaluate its readability and acceptability in a Tanzanian population. The PIL was designed according to established good design guidelines, modified during a multi-stage iterative testing process and piloted in a South African Xhosa population. The main outcome measure was the comprehension of the written information in an overall percentage understanding. The overall average percentage comprehension of the PIL was 95%. The target set by the European Commission (EC) guideline that at least 80% of participants correctly locate and understand the information was achieved for 19 of the 20 questions.

All participants correctly understood five of the six instructions illustrated by pictograms. The only patient characteristics significantly associated with comprehension were educational level and self-reported ease of reading the PIL. Acceptability of the PIL was high and positive comments were associated with simplicity, good design, easy readability and user-friendliness, the latter enhanced by the inclusion of pictograms. The PIL designed for this study was shown to be effective in communicating information about ARVs. They concluded that patient characteristics must be taken into account when developing written information, and the final document must be tested for comprehension in the target population.


Figure 5: Adding culturally relevant pictograms can assist patient comprehension

De Cossio (González de Cossío 2009) conducted a study to help people from different backgrounds (in Mexico) understand complex issues, such as the relationship between level of education and income level using data visualizations. The visualizations consist of bar graphs in motion and images that help users identify themselves with various living situations. De Cossio found that the use of a bar graph to convey educational and socio-economic level was adequate because it contained discrete information and participants understood the communicated information. However, the isometric presentation was quite new to users because they did not expect two graphs in the same display and a third panel with pictures; even less expected was the presentation of images that were related to their own way of living, leading to their self-identification with the display.

Based on the findings of this study, using the isometric presentation (Figure 6) to present the information is not recommended. The isometric presentation employed the junction of the planes to set axes x, y and z; two planes are used for graphs and a third plane displays a visual translation of data. This means that including two graphs (two axes) at the same time, but each graph has to be understood separately and a third axe displays a visual translation of data (De Cossio, p.252). Although participants have understood the information conveyed by each graph separately, they have not liked the idea of presenting the three graphs (axes) together in the same display because this was the first time they saw such a presentation. In addition, participants have not liked using images (as one axis) that are related to their own way of living, leading to their self-identification with the display.


Figure 6: The back plane shows images that depict the socio-economic situation of people with secondary and preparatory studies. (p. 254)

CALD communication is enhanced when it contains (a) international information systems that go beyond the written text and (b) information that is accessible to all users regardless of literacy levels. In order to achieve this when communicating complex health information to multiple cultural receivers it is helpful to use a system that couples visual forms such as icons with storytelling (Bronheim and Sockalingam 2003). Icons should be used in the following ways:

• The use of icons coupled with storytelling means that the information is communicated both non-verbally and verbally in the user’s own language
• The icons are universal and provide cohesion to linguistically specific storytelling.
• The stories being told in the listener’s native language provide the comfort of familiarity and increase the resonance of the message.
• The stories can also be told in English which allows the health professional access to the culturally specific aspects of the data, facilitating a shared understanding of the message and how it is being conveyed.
• The consistency of icons across health messages provides recurring motifs that help build relationship between each health report.
• The icons provide common ground of a visual document, on which all parties can share important information.
• There are several innovative learning paths (Lynell, and Brocklebank, 2011) that target CALD communities such as:
  1. Known to the unknown’ Indigenous Learning - This information system presents content within a visual recall system, spoken in the primary language of the learner. The user does not have to be able to read or write or understand English to fully use this information system.
  2. ‘Beyond the Eclipse’ Cross-cultural communication - This information system presents content in a multi-lingual visual document. This provides common ground, of a visual document, on which all parties can stand and share important information.

The screen shots below illustrate the way in which data is presented through the use of health icons:


Figure 7: Visual health icons help tell a story conveying important health information.


Figure 8: The use of health icons establishes a common language that is accessible to all despite specific cultural backgrounds.