Comic books an untapped medium for health promotion.
Abstract: Comic books are often stigmatized as a lowbrow medium. Nonetheless, emerging research suggests they may serve an educational purpose by encouraging children to read and introducing more complicated or high-level concepts. This article reviewed health-promotion interventions that used comics as a primary or secondary intervention strategy. A total of nine interventions met the inclusion criteria. Based on this review, a definitive efficacy of comics in health promotion could not be established as most studies used comics as supplemental material to another intervention. However comics appear to be a promising strategy for health promotion. Studies with more rigorous evaluations are needed.
Subject: Comic books, strips, etc.
Physical fitness
Authors: Branscum, Paul
Sharma, Manoj
Pub Date: 09/22/2009
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Fall, 2009 Source Volume: 24 Source Issue: 4
Product: Product Code: 2721510 Comics NAICS Code: 51112 Periodical Publishers SIC Code: 2721 Periodicals
Accession Number: 307670895
Full Text: INTRODUCTION

Comic books (or comics) have historically been stigmatized as a lowbrow medium among scholars, parents and educators (Wright, 2003). The book, 'Seduction of the Innocent' was published in 1953 by psychiatrist Fredrick Wertham, in which he describes his accounts and theory that comics play a role in causing juvenile behavioral disorders and should be banned among youth (Potenza, Verhoeff, & Weiss, 1996). However, this stigma has subsided over the past few decades, while the popularity of comics and graphic novels (larger collections of comics) have grown, and are becoming better accepted in academia and society. For example, Art Spiegelman's graphic novel 'Maus: A Survivors Tale', won the Pulitzer Prize in 1992. This graphic novel accounts his father's experiences as a prisoner in a Nazi concentration camp during World War II. The Young Adult Library Service Association also awarded their honorary Michael L Prinz Award to Gene Luan Yang's for his graphic novel 'American Born Chinese' (Mulholland, 2004; Williams, & Peterson, 2009; Wright, 2003). In the Library of Congress Authority file, graphic novels have also been given their own subject heading. Groups like the American Library Association have also embraced them as a way to motivate young readers (Bitz, 2009). The sales of graphic novels have also significantly increased in recent years. Sales from comics in 2002 were reported as $110 million, then nearly doubled in 2004 to $207 million, and more than tripled in 2005 to $395 million (Williams, et al., 2009). However, comics have not been critically examined as rigorously or given the same attention as other cultural mediums such as films, television, music, and art, and deserve a critical review for use in education (McCloud, 1993; Wright, 2003).

It is unknown when or how comics began, however comics as we know them started as comic strips printed in newspapers in the 1890's. In the 1930's publishers reprinted and sold these strips as collections in small magazines. During this time comics were considered a lowbrow art, and as an artistic profession ranked just above pornography. Some authors and artists even opted to publish their work using a pseudonym. By World War II the popularity of comics grew, as they were used to support the war effort in two ways. First they were sent to soldiers overseas as a form of entertainment and second they were sold to young readers in the US to promote patriotism. For example, Batman and Robin encouraged boys and girls to buy war bonds and stamps and Captain America taught children how to collect paper and scrap metal to be recycled. After World War II, comic sales significantly increased due to their new audiences. The war also helped lift America out of the Great Depression, giving households, and in turn children, more discretionary money. During the early 1950's almost all children read comics, with industry estimates of readership as high as 95% of boys and 91% of girls (ages 6-11). Shortly after this 'comic boom', there was an apparent backlash on comics from the notion that they caused juvenile delinquency, and parents discouraged their children from buying or reading them. Also, by 1955 nearly three quarters of home in the US had televisions, which quickly predominated children's leisure time (Wright, 2003). Today, fewer children report reading comics, and more are being produced for older groups such as teenagers and young adults. In a study with middle and lower income middle-school children, it was reported that 25% of the boys and 1% of the girls from the middle-income schools, and 19% of the boys and 5% of the girls from the lower income schools read comics, showing that not only are fewer children reading them, but boys are also their predominate consumer (Ujiie, & Krashen, 1996).

Some educators are skeptical comics can be beneficial for use in education. This stigma has even been observed among high school students, who have reported comics as a medium for 'immature adults.' (Viadero, 2009) Critics argue that comic reading may displace other kinds of 'educational' or 'wholesome' reading, however, this has been disputed (Millard, & Marsh, 2001). Some reports indicate that children, who read comics, read as much as non-comic readers and in some cases read more overall than non-comic readers. It has also been reported that among middle and lower income youth, when compared with non-comic readers, child comic-readers engage in significantly more pleasure reading, and report greater enjoyment for reading. While not significant, researchers also noted that those who read comics also generally read more (Ujiie, et al., 1996).

Emerging research suggest comics can serve educational purposes. Comics can help younger struggling readers, or those of any age learn English, by combining pictures and words, giving visual cues as to what the text is explaining (Viadero, 2009). Children also like to read comics because of their 'fun factor,' which can attract the interest of reluctant readers, and encourage more overall 'pleasure reading' (Serchay, 2008). Consider the film industry as a testament to the popularity of comic book superheroes. Movies based on comic book superheroes hold six of the top twenty-five all time domestic grossing films, with the highest being 'The Dark Knight' which has a lifetime gross of approximately $533,000,000.00 (www.boxofficemojo. com). Comics can also expose children to more rare or higher level words and concepts, which in turn could improve their vocabulary. With slightly more of these words than the average children's book, and five times as many than the average conversation between a child and adult, consider how many children could learn the five-syllable word 'in-vuln-er-ab-le' from a Superman comic. 'Punctual', 'implications', and 'polymer' are also words that have been reportedly been in Spiderman comic. If a child read one comic book a day, over the course of a year they would be exposed to approximately 500,000 words, which is half the average reading volume of most middle school children (Serchay, 2008). Comic reading may also displace television viewing, which has increases among all children in recent years, and has been associated with the increase prevalence of childhood overweight (Crespo, Smit, Troiano, Bartlett, Macera, & Aderson, 2001).

Like other pop-culture mediums, comics often reflect the times for which they are written. When comics first started in the 1930's, many were written by natives of New York City; a city known for political corruption. In an early Superman comic, Superman rescues a trapped cave miner, and afterward his alter-ego Clark Kent investigates the accident. Later Kent finds that the accident was due to a faulty safety device, and when he confronts management, they reply without remorse 'I'm a business man, not a humanitarian.' (Wright, 2003) In the 1960's Marvel comics addressed the issue of racial discrimination with their X-Men comics. The X-Men are a group of mutants, born with special abilities, led by profession Charles Xavier. Since the X-Men are different in appearance, they are often feared and discriminated in society. Charles Xavier, an archetype of Martin Luther King Jr., strives for peaceful coexistence between humans and mutants, while their villain is Magneto, who represents an archetype of Malcolm X, believes mutants should fight for freedom using force.

Health concerns and disparities are a prevailing issue today, which comics could be an ideal medium for intervention. The history for comic use in health promotion is quite profound. In the 1970's, under the Nixon administration, the US Department of Health, Education, and Welfare asked Marvel comics to incorporate anti-drug messages in their stories. In turn, a prominent author of the time, Stan Lee, wrote a three-issue mini-series focusing on Spiderman promoting an anti-drug abuse campaign (Wright, 2003). In 1975, the US Environmental Protection Agency also published the comic 'Farm Workers: Pesticide Safety' in both English and Spanish to distribute culturally relevant material. Many more examples of such publications could be listed; however, few studies have been done to evaluate the usefulness of comics in health promotion and education (Trent, & Kinlaw, 1979). Comics may also be a relatively inexpensive intervention strategy. The purpose of this review is to report how comics have been used and evaluated in health promotion, and make recommendations for future interventions based on the findings.

METHODS

A literature review was conducted to collect studies for inclusion in this review. The databases PubMed, ERIC, CINAHL and CMMC (Communication & Mass Media Complete) were used. Three searches were done using keywords "Comic Book", "Health Comic Book", and "Graphic Novel." The inclusion criteria for including studies in this review were: (1) publication in English language; (2) a primary research article with comics serving as a form of intervention strategy (both primary strategies as well as secondary strategies). Exclusion criteria were articles in languages other than English, and review articles. Since the literature is limited on this subject matter, no time limit was given for the year of publication, and any other articles that the authors knew of that contained comics as an intervention strategy were used. A total of nine studies met the criteria. Articles will be reviewed in chorological order, with the earliest articles reviewed first.

RESULTS

Table 1 summarizes the nine interventions included in this review. The first intervention was done in 1978. The North Carolina Expanded Food and Nutrition Education Program (EFNEP) found that nearly all homemakers in their area watched daytime serials or soap operas. With permission from television producers of the show, 'The Edge of Night,' researchers created comics based on the show and infused six nutrition behaviors identified by Extension specialist, which were important to target. Comics were then distributed weekly for 6 weeks to a random sample of EFNEP homemakers. Using a pre and posttest design, results indicated that 94% of their audience read the comics, and gained both knowledge and skills related to targeted behaviors. Attitudes towards the comics were also generally favorable. On a scale of 1 to 10 (with 1 being very positive and 10 very negative), the mean score was 3.69 (Trent, et al., 1979).

The second intervention was done in 1997. Among adolescents in the United States, sexually transmitted diseases, especially HIV and AIDS, are growing problems. Previous reports indicate information alone techniques are not adequate to facilitate behavior change thus a theory based intervention using the theory of reasoned action and social cognitive theory was developed to emphasize skill development for communication and negotiation skills for condom use, and short-term consequences of condom use, to promote safer sex practices for HIV/AIDS and other STD's prevention. Three intervention strategies were developed and tested: a 16-page comic alone intervention (used as a control group), a 27-minute instructional video (with addition of the comic) and an 8-hour group skills training session, broken into two 4-hour day sessions (with the addition of the video and comic). All three strategies contained basic information on HIV/AIDS and other STD's, attempted to minimize negative beliefs of condom use, gave proper instructions for condom usage, presented skills for talking with your partner on condom use, and gave information on where to get free or low-cost condoms, and STD screenings. The comic only group was treated as a control group, given it's informative nature, and researchers predicted the comic alone would not be adequate to elicit behavior change. Despite the researchers' rigorous intervention strategies, there were few reported differences between the three treatment groups for measured psychosocial behaviors (i.e. self efficacy, and outcome beliefs) or sexual practices (i.e. condom use and refusing sex without condom use) (Gillmore, Morrison, Richey, Balassone, Gutierrez, & Farris, 1997).

The third intervention was implemented in China. It is estimated that annually 5% of residents in rural areas of China are infected with schistosomiasis, a parasitic disease caused by fluke in freshwater areas where residents swim, fish, farm, and bathe. Children are especially vulnerable since they swim and use water for recreation purposes, so researchers created a classroom based curriculum using a cartoon video and comic book to explain the transmission of schistosomiasis, as well as discourage them from playing in known infected waters. The comic book portrays two boys from the video, looking for a place to swim. During their trip, they discuss the lakes and canals they encounter, and identify unsafe waterways they should avoid. When compared with five control villages, 4th grade children from five villages receiving the video and comic book had significantly more knowledge on schistosomiasis prevention (p < 0.001), and a significant difference for self-reported water contact whereby those in the intervention group increased use of safe water and decreased use of unsafe water, while the control group decreased safe water and increased unsafe water practices (p < 0.001) (Yuan, Manderson, Tempongko, Wie, & Aigue, 2000).

The fourth intervention was designed to promote fruit, juice and vegetable (FJV) consumption for cancer prevention. The intervention targeted these dietary behaviors in African American boy scouts. Over the course of eight weeks during their troop meetings, a dietitian delivered an intervention to target children's 'asking skills' to increase availability and accessibility of FJV at home, increase preference of FJV and train them on making FaSST (fast (and low fat), simple, safe, and tasty) healthy recipes for meals and snacks at home, as well as on camping trips. Every week after the intervention, children were given a small 4-page comic that reinforced the messages covered during the day's lesson. Compared to children in a control group (delay-intervention design) there was no significant difference for fruit, juice or vegetable consumption alone, or knowledge, and the only significant difference between both groups was the consumption and preference for FJV-combined; however these differences was marginal (treatment-2.5 servings/control-2.4 servings). A process evaluation indicated that only 54% of parents were aware their child brought home a comic during the intervention and only 17% reported their child brought home at least four (or half) of the comics. Most parents (60%) reported their child never read the comics. (Baronowski, et al., 2002)

The fifth intervention pertained to Lymphatic filariasis (LF), a parasitic disease that affects the lymphatic system and can lead to elephantiasis. A reemergence of the disease was observed in the 1980's and is mostly endemic in the Nile delta region of the world. The World Health Organization has started a global elimination program that relies heavily on a Mass Drug Administration (MDA) of diethyl carbamazine and albendazole, and the Egyptian Ministry of Health and Population (MOHP) aims to target all endemic areas in Egypt. Since children are more apt to mosquito bites, they are also more susceptible for LF, therefore early intervention on prevention and MDA acceptability is critical. A comic was created and distributed to 2nd and 3rd grade children to increase their knowledge and influence attitudes for stigma reduction, methods of LF transmission and prevention and acceptability of MDA. The comic was pilot tested with twenty 2nd and 3rd graders to assess readability and included sections for: defining LF, describing areas of the world where prevalence was high, methods of disease prevention, transmission, and treatment (through MDA), management of elephantiasis, stigma reduction for LF patients and a game which tested the covered areas. After reading the comic, children significantly reduced their fear that LF is a killer disease, increased knowledge on targeted aspects of LF, increased positive attitudes towards LF patients, and fewer children reported they would avoid an LF patient. The comic also helped to raise awareness that MDA was the ideal prevention method. The comic was also well received, with 96.2% reporting to have liked the comic contents and ~40% reported their brothers and/or sisters reading the comic (El Setouhy, & Rio, 2003).

The sixth intervention was from South Africa, where the most prevalent form of preventable cancer among women is cervical cancer. While women are screened for this type of cancer, many do not understand the screening process and are not likely to attend needed follow-up visits. To increase public awareness, a tailored mass media intervention was chosen in the form of a radio-drama, since radio is commonplace in South Africa, as well as a photocomic book. Two Xhosa language, photo-comics were randomly allocated to women, in Khayelitsha, South Africa: the first was entitled Nokwhezi's Story, which was a story set in 'Soul City,' a popular, tested mass media intervention, and the second was a placebo comic How to Save for Your Dreams, which contained information on personal finances and no health messages. One month after the photocomics were distributed, a radio drama based on 'Soul City' was broadcast 10 separate times over the coarse of a month, at times women 35-65 would be likely to listen. Community listenership of the radio-drama was estimated at 40%. There was no significant difference between the intervention and control group for self-reporting a cervical screening during the six month follow-up and both groups reported low prevalence of having a screening: only 6.4% of the intervention group had a screening as well as 6.7% of the control group. The only significant predictor for having a screening was being able to recall the radio drama (Risi, et al., 2004).

The seventh intervention was from United States, where smoking prevalence is high among adolescents, and national indicators report 12.2% of 8th grade and 29.5% of 12th grade students have used cigarettes in the past 30 days. It is believed that the youth go through three phases which leads them to smoke: first the formation of favorable attitudes about smoking, second they become more susceptible to experiment with smoking and finally they engage in regular smoking. Little is known how children form favorable attitudes for smoking, however parents are usually noted as a strong influential factor in the onset of such attitudes. An intervention was developed and tested to assess children's (ages 10-12) attitudes and perceptions on smoking 20 months after receiving a smoking prevention packet, which contained a parent handbook, videotape, pens, stickers and a comic book. The comic used was called Tobacco Comics, however, details of the content were not reported. At baseline, lower family cohesiveness was significantly associated with children's positive attitudes towards smoking, and approximately one-third of the youth reported they could smoke without becoming addicted. Twenty months after receiving the intervention packets positive attitudes increased. For example 9.6% of youth responded "YES" to 'Smoking can help people relax' at baseline, while 17.1% of youth responded, "YES" during the follow-up. Also at the follow-up, parental tobacco use was the only significant predictor of children's positive attitude towards smoking (p=0.03). (Bush, et al., 2005)

The eighth intervention targeted pesticide safety among immigrant families in the United States. In 2004, it was reported by the American Association of Poison Control Centers, that 71,000 children were involved in pesticide related poisonings or exposures in their homes. Children from agricultural families often are at higher risk for pesticide exposure, because parents working in fields may inadvertently bring harmful pesticides in their homes, through their clothing or other means. To lessen this problem, the Migrant Clinicians Network, Inc. trained lay health educators (or promotoras de salud) to teach such families pesticide safety and risk reduction strategies, through in home or worksite educational sessions. A 16-page Spanish-language comic was also read to the famers to reinforce the messages given during the sessions. No inferential statistics were performed on outcome data, however it was noted that among 40 households, knowledge for: the proper use of pesticides, routes of exposure of pesticides and understanding why children are especially vulnerable to pesticides, understanding symptoms of pesticide poisoning and proper storage of pesticides, were all gained (Leibman, Juarez, Leyva, & Corona, 2007).

The final intervention was from Canada. In Canada, prostate cancer is the most frequently diagnosed cancer and third deadliest cancer among men. However, if men received colorectal exams regularly, this type of cancer can be highly preventable or even treatable. Since this issue can be sensitive among men, researchers created a multimedia social marketing campaign in 2007, featuring the middle-aged superhero 'Prostate Man.' Along with billboards, website banners and public appearance of an actor playing prostate man, an online and hardcopy comic was developed to teach men about risk factors, signs and symptoms and actionable advise about prostate cancer and prostate cancer prevention. While no formal evaluation of the intervention was done, other indicators suggest this campaign was a success. Campaign materials were requested by a chief executive officer of one of Canada's largest banks, for use at a speaking engagement on prostate cancer awareness. Their website was also visited by 3,882 guests, with more than 83% of those visit counts unique, and 2530 visits are from Canadians. The average time on the website was 2 minutes and 9 seconds, with a majority of the time spent looking at the comic, which was 1 minute and 46 seconds (Lyzun, & McMullen, 2009).

DISCUSSION

As a communication medium, comics are typically stigmatized as 'juvenile;' however, emerging research suggests there may be benefits for use in education. Comics used in health education, while sparse, have not shown a positive track record, as shown in this review. In spite of this, it could be argued that a limitation to the studies presented in this article were they were generally pilot-studies, the comics were largely used to raise awareness about an issue instead of facilitate behavior change, and only two studies used comics as a primary intervention strategy (El Setouhy, et al., 2003; Trent, et al., 1979), while all other studies used the comic as a reinforcement method. Another limitation for these studies is that the descriptions given for their comics were generally vague or inadequate. Four studies outlined the process for their comic development. Lyzan and McMullen reported preliminary work was done to find plain and appropriate language for messaging, and to find a suitable role-model for their comic. Risi, and colleagues, and Gillmore and colleagues, conducted focus groups, and researchers linked findings from focus groups to story development for their comic. El Setouhy and Rio pilot tested their comic with their target population.

Another limitation to the studies reviewed in this article was it is unknown whether the participants in the interventions actually read the comic. It can be certain that subjects were exposed to the comic in only one study, since researchers reported reading the comic to families in Leibman, Juarez, Leyva, & Corona. However, many studies did not report any type of assessment for whether the comic was actually read. Another limitation with the studies presented in this review, is only five were based on theory, with two based on social-marketing theory (Lyzan, et al., 2009; Risi, et al., 2004), one on social cognitive theory (Baronowski, et al., 2002), one on experiential learning (Leibman, et al., 2007), and one used aspects of the theory of reasoned action and social cognitive theory (Gillmore, et al., 1997). Knowledge was an aim that was generally evaluated and reported, but antecedents of behavior were rarely evaluated. Studies with more rigorous evaluation and intervention designs, such as in Gillmore, Morrison, Richey, Balassone, Gutierrez, & Farris, might give a better picture for the appropriateness and effectiveness of comics in health promotion. Studies should also consider giving a brief description of the comic, just as most studies give brief descriptions of their interventions, which are implemented.

A major limitation to this study is we were unable to assess whether comics are appropriate or inappropriate for any group, given the diverse groups targeted in these evaluations. Four studies were international, targeting different groups and different health concerns: schistosomiasis prevention in school children in China (Yuan, et al., 2000); stigma reduction and improved knowledge and attitudes toward lymphatic filariasis patients in Egypt (El Setouhy, et al., 2003); cervical cancer screening promotion in women in South Africa (Risi, et al., 2004); and prostate cancer screening promotion in older men in Canada (Lyzan, et al., 2009). Five studies in the US also had different target groups: food and nutrition promotion among female homemakers (Trent, et al., 1979); STD's and HIV/AIDS prevention among adolescents (Gillmore, et al., 1997); FJV consumption among African American boys (Baronowski, et., al., 2002); smoking prevention among adolescents (Bush, et al., 2005); and pesticide safety among immigrant farm workers (Leibman, et al., 2007). Another limitation has been that the review included only those studies that were published in English language. This restricted the pool of available studies.

Photo-comics were used in two studies in this review (Risi, et. al., 2004; Lyzan, et al., 2009), which are comics that use photographs in place of artwork. While this may not seem like a limitation, Scott McCloud reports in Understanding Comics, that cartoon imagery is an important aspect of comics, because it makes the characters universal. He points out that when you look at a photograph of an individual, you see an individual, but when you see a cartoon character, you can see a piece of yourself. We don't simply observe the cartoon, but we become the cartoon, which helps us envision ourselves enacting behaviors the character is modeling (McCloud, 1993). Another distinct form of comic that has grown in popularity among children is manga, which is similar to Japanese anime. Like graphic novels, libraries have increased their circulation and their sales have rapidly increased. While estimated in 2003 to have about $100 million in annual sales, in 2004, sales increased at to $120 million (a 20% increase). They are different from western comics in that they typically have non-linear plots, have more subplots in their stories, and gender roles tend to be more flexible (Schwartz, & Rubinstein-Avila, 2006)

Another problem comics face for use in health promotion is the stigma of 'edutainment.' Children are generally drawn to comics, since they are an entertaining escape from everyday, and are fun to read. Researchers need to be cognizant that while it's important for their comic to have the health message for which they are promoting, the comic should be a fun and entertaining to read as well as be age and even gender appropriate.

While comics may be a promising strategy for health promotion, more work is needed to establish their efficacy and effectiveness. It may also be better suited for children, since they are part of the primary audience for which comics are produced. In 2004 and 2005 Wal-Mart and Marvel comics, sponsored by the 5-A-Day program created two comics, using familiar characters like the Incredible Hulk, Spiderman, Captain America and the Fantastic Four, to promote fruit and vegetable consumption among children. In addition to a hip-hop CD, Dr. Rani Whitfield, otherwise known as the 'Hip Hop Doc' created a line of comics, which targets many facets of health education, including childhood overweight, drug abuse and sexually transmitted infection prevention (http://www.h2doc.com). Recently, Marvel comics also teamed with the Elks National Drug Awareness Program, the largest volunteer program of its kind in the United States, to provide online access to a digital comic 'Hard Choices,' which discourages underage drinking among the 4th-8th grade audience (http://www.elks.org/dap/marvel.cfm). While these efforts are to be applauded, no apparent evaluation has been done to measure either of their effectiveness. A promising, but currently unpublished study from the University of Texas, School of Public Health, evaluates a comic book based obesity prevention intervention 'Time Twisters.' At the time this article was written, a manuscript for this study was not finished, however an abstract published by the authors indicate the comic book intervention was part of a multi-component school-based intervention, targeting physical activity, screen time and snacking behaviors (Agurcia, Shegog, Kelder, & Hoelsher, 2007).

There is some caution however to consider, when using comics in health promotion. As previously mentioned, comics have and still hold a stigma as a 'junk medium' meant for children. If comics were written for lower educated/lower income adult audiences, it may be challenging to get them to actually read them. They may not want to get 'caught' reading such a book, and could believe that by being caught, it projects the image that they are illiterate and are unable to read more 'sophisticated' materials (Trent, 1979). Comics have also been reported as a medium that under represents, objectifies and sex-stereotypes women, which may be why females are reluctant to read them (McGrath, 2007). In a survey of 2,838 comic readers, 94% of those who replied were men (Ujiie, et al., 1996). Therefore, it should be considered when making health-promoting comics, they may need to be targeted and tailored to the female audience. Racial minorities are also reportedly under-represented in today's comics (McGrath, 2007). This should also be considered if health-promoting comics are produced, as there should be multi-cultural, and even multi-spiritual, cast of characters, to appeal to all different types of groups.

RECOMMENDATIONS FOR FUTURE STUDIES

For future studies, a proper needs assessment should be done first, regarding the appropriateness of the comics to a given population. It might be found that sub-groups exist among the targeted population and further assessments could identify characters and stories for which the sub-groups identify with and are interested in reading about. If further efforts are pursued in this medium, evaluation will be also be critical determine there efficacy and effectiveness and to justify future development. A study design that would help evaluate the efficacy of comics as an intervention strategy would be comparing a comic using a theory-based approach compared to a comic using a non-theory based approach. Another study design that would help evaluate the effectiveness of comics as an intervention strategy would be comparing a multi-component intervention receiving a comic book compared to an intervention group not receiving a comic book. Process evaluations are also critical for such an intervention. Therefore, some type of assessment that ensures the participants read the comic is essential.

IMPLICATIONS FOR PRACTICE

It is important to consider these issues if health educators make comics for health promotion. For future practice, comics might be better geared towards children, since they are more attractive towards young readers. By exposing children early in life, we may also be able to reduce the stigma for which they are associated. It might also be beneficial to tailor comics to their readers, so not use a 'one-size fits all' mentality. For example, a young white-male might want to read different stories from a young female Asian-American. Many of today's children are also interested in superheroes. Walk into an elementary school today, and you will be sure to see children wearing clothing with Spiderman, Batman and the Incredible Hulk. Classic superheroes, such as Captain America and Superman, can also serve as positive role models to children, because they typically display traits such as integrity, honesty and courage. Therefore, comic industry should also be considered as a major partner for future development, since they hold these characters legal rights.

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Paul Branscum, MS, RD, LD, is a Graduate Assistant at Health Promotion & Education, University of Cincinnati. Manoj Sharma, PhD, MBBS, CHES, is a Professor at Health Promotion & Education, University of Cincinnati. Please address all correspondence to Paul Branscum, MS, RD, LD, Ph.D., Graduate Assistant, Health Promotion & Education, University of Cincinnati, PO Box 210068, Cincinnati, OH 45221-0068. Phone: (513) 324-9783. Fax: (513) 556-3898. E-mail: branscpw@email.uc.edu
Table 1. Summary of interventions that have used comics in
health promotion (n=9)

Study               Target Group / Purpose               Theory

Trent, & Kinlaw,    EFNEP female Homemakers              Not
1979                                                     Reported
                    Promote six concepts of food
                    and nutrition

Gillmore,           Adolescents (14-19 year olds)        Theory of
Morrison,           in urban public health clinics or    Reasoned
Richey,             juvenile detention facilities.       Action
Balassone,                                               and Social
Gutierrez, &        HIV prevention through               Cognitive
Farris, 1997        improving communication and          Theory
                    negotiation skills for condom use.
Yuan,               4th grade children in China          Not
Manderson,          where schistosomiasis is endemic     Reported
Tempongko,
Wie, & Aiguo,       Increase knowledge of
2000                schistosomiasis and discourage
                    contact with unsafe water
                    sources.

Baranowski, T.,     African American boy scouts          Social
Baranowski, J.,                                          Cognitive
Cullen, DeMoor,     Promote fruit, juice and             Theory
Rittenberry,        vegetable consumption for
Hebert, et al.,     cancer prevention
2002

El Setouhy, &       2nd and 3rd grade children in        Not
Rio, 2003           Egypt where lymphatic filariasis     Reported
                    (LF) is endemic.

                    Increase knowledge and attitudes
                    towards LF and LF patient,
                    and promote MDA as an ideal
                    prevention method.
Risi, Bindman,      South African Women (35-65           Social
Campbell, Imrie,    years old)                           Marketing
Everett, Bradley,
et al., 2004        Educate women on the cervical
                    cancer screening process
Bush, Curry,        Families with at least 1-preteen     Not
Hollis, Grothaus,   (10-12 years old)                    Reported
Ludman,
McAfee, et al,      Influence attitudes on tobacco
2005                use.
Leibman,            Immigrant farm workers and           Experiential
Juarez, Leyva, &    their families.                      Learning
Corona, 2007
                    Educate families on risks from
                    pesticide exposure

Lyzun, &            Men over 50 years old                Social
McMullen, 2009                                           Marketing
                    Promote early prostate cancer
                    screening

Study               Description of Comic

Trent, & Kinlaw,    Six comics based on the soap
1979                opera 'The Edge of Night'
                    promoting 1 of 6 food and
                    nutrition concepts per issue.

Gillmore,           A 16-page comic "Doing it
Morrison,           Smart: Scenes from Real Life",
Richey,             containing information on
Balassone,          STD's and HIV/AIDS, and
Gutierrez, &        promoting condom use
Farris, 1997

Yuan,               Comic reinforces messages
Manderson,          given during 15-minute video
Tempongko,          intervention, and follows two
Wie, & Aiguo,       boys looking for a safe
2000                place to go swimming.

Baranowski, T.,     Eight, 4-page comic books to
Baranowski, J.,     reinforce messages given
Cullen, DeMoor,     during a dietitian led,
Rittenberry,        health promotion program.
Hebert, et al.,
2002

El Setouhy, &       English language comic
Rio, 2003           to increase knowledge on
                    LF prevalence, prevention,
                    treatment and reduce stigma
                    due to disease.

Risi, Bindman,      Xhosa language comic entitled
Campbell, Imrie,    'Nokwhezi's Story' to educate
Everett, Bradley,   women on cervical cancer
et al., 2004        screening process.

Bush, Curry,        None Given
Hollis, Grothaus,
Ludman,
McAfee, et al,
2005
Leibman,            Spanish language comic given
Juarez, Leyva, &    during home or worksite
Corona, 2007        educational sessions to
                    reinforce pesticide safety.

Lyzun, &            'Prostate Man' a middle-aged
McMullen, 2009      superhero encourages men to
                    have prostate screenings.

Study               Salient Findings

Trent, & Kinlaw,    94% read the comics, and gained both
1979                knowledge and skills related to
                    target behaviors.
                    Attitudes towards comics were
                    generally favorable.
Gillmore,           Few differences were detected in
Morrison,           outcome measures for three treatment
Richey,             conditions (comic, comic + video, &
Balassone,          comic + video + group skills training).
Gutierrez, &
Farris, 1997

Yuan,               Intervention group (video and comic)
Manderson,          had significantly more knowledge on
Tempongko,          schistosomiasis prevention (p < 0.001)
Wie, & Aiguo,       compared with control group.
2000                A significant difference (p<.001) for
                    self-reported water contact was
                    observed between treatment and control
                    groups, whereby those in the intervention
                    group increased safe water and decreased
                    unsafe water practices, and the opposite
                    occurred in the control group.

Baranowski, T.,     A small, but significant difference for
Baranowski, J.,     FJV consumption for children receiving
Cullen, DeMoor,     the intervention, compared to those
Rittenberry,        who did not.
Hebert, et al.,     ~50% of the parents reported seeing
2002                the children with the comics, only
                    17% reported their child read at least 4
                    of the 8 comics and ~60% reported their
                    child never read any of the comics.
El Setouhy, &       Children reported significant changes
Rio, 2003           in: reduction of fear that LF is a
                    killer disease, increased knowledge of
                    LF, increased positive attitudes
                    towards LF patients.
                    The comic also raised awareness that
                    MDA was the ideal prevention method.

Risi, Bindman,      No difference between intervention and
Campbell, Imrie,    control comic for self-reported
Everett, Bradley,   cervical screenings.
et al., 2004

Bush, Curry,        Of youth (n=281) with > 1 positive
Hollis, Grothaus,   tobacco belief at baseline, 43%
Ludman,             reduced, 29% reported no change,
McAfee, et al,      and 28% increased their positive beliefs.
2005
Leibman,            Families reported increased knowledge for:
Juarez, Leyva, &    1.) Proper use of pesticides; 2.) Routes
Corona, 2007        of pesticide exposure; 3.) Understanding
                    why children are a vulnerable group;
                    4.) Understanding symptoms of pesticide
                    poisoning; 5.)Proper storage of pesticides
Lyzun, &            Campaign website was visited by 3,882
McMullen, 2009      guests, with > 83% of those visit
                    counts unique.

                    Average time on the website was 2:09,
                    and average time viewing online-comic
                    was 1:46.
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