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T O TA L
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I m p rove consumer satisfaction and recall of healthcare
i n f o rmation with social learning theory.
B y M a r i e L ei n e r, B l a n c a G a r c i a , a n d G i l b er t H a n da l
T
oday’s healthcare paradigm requires
warnings). The complexity of these resources is
patients to play a major role in the execu-
often overwhelming. Strategies to help consumers
tion of their healthcare services. This has
understand information have included using
dramatically changed the doctor-patient relation-
videos, computer-based programs, graphic sym-
ship, requiring patients to become knowledgeable
bols, and easy-to-read print items combined with
and active consumers of such services. Among
oral instructions. However, vital facts sometimes
the many challenging demands: Consumers are
remain confusing or incomprehensible because of
expected to digest and comprehend large amounts
individual differences and/or disinterest. For exam-
of oral and written information during a typical
ple, some consumers face tremendous communi-
doctor’s visit. They regularly receive a variety of
cation challenges because of disparities resulting
education materials, consent forms, immunization
from lower levels of literacy, language proficiency,
schedules, treatment instructions, and prescrip-
or education. Communication difficulties also
tion drug documentation (usually with long lists
increase with the complexity of information, and
of potential adverse effects, precautions, and
the quality of presentation can aggravate them.
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Social Learning Theory
Associated Processes
Stanford University (Stanford, Calif.) psychologist Albert
Bandura’s social learning theory is a promising tool for
improving healthcare communication; marketers and healthcare educators should consider it as an independent or joint
effort. Although Bandura has expanded this theory into the
more general social cognitive theory, the focus here will be
on the basic principles of the original.
Bandura states that learning would be extremely laborious if people had to solely rely on the effects of their own
actions to decide what to do. Fortunately, most people learn
human behavior through observation and the vicarious
experience that it presents: They witness the positive or
negative effects of others’ behaviors and learn from them.
Each action they view—either by watching others or by
watching a re p resentation in diverse media formats (e.g.,
movies, TV, books)—then models a behavior consequence
that is stored in their minds throughout a symbolic communication process. On later occasions, when encountering a
similar situation, this coded information serves as a guide
for action and gives meaning, form, and continuity to people’s experiences.
Social learning theory is dependent on several interrelated
processes: attention, retention, motor reproduction, and
motivation.
Attention. This means that people must notice what is
happening around them. Characteristics of the viewer’s
mental representation influence this process, and the process
includes how much a person likes or identifies with the
model. Characteristics of the viewer, such as expectations or
level of emotional arousal, also influence it. According to
Bandura, attention occurs when the presentation is simple,
distinctive, prevalent, useful, and positive.
Retention. This relates to the idea that people must be
able to remember what they paid attention to. Imagery and
language are very important during this process, because people store information—what they have seen from the model—
in the form of mental pictures or verbal descriptions. People
can later recall what they store in their minds this way, so that
they can reproduce it with their own behaviors.
Motor reproduction. This is the action to translate depicted
images or descriptions into behavior. People must be able to
reproduce the behaviors that they observe. Day-to-day situations
are much easier to reproduce than unusual single occurrences.
Motivation. This, as Bandura defines it, refers to what
impels people to imitate observed behaviors. These reasons
include self-efficacy, past reinforcement, promised reinforcement, and vicarious reinforcement. There are also negative
motivations, which present reasons not to imitate a person.
These include past punishment, promised punishment
(threats), and vicarious punishment.
Exhibit 1
Estimated marginal means of time
Group
Comic
Video
8
Educational Application
7
Social learning theory has enjoyed much success as a
model for developing marketing messages used in TV commercials. These ads usually suggest that various products
will make consumers popular and cause their peers to admire
them. In recent years, modeling has proven effective in gaining the attention of consumers. And today, consumers can
see commercials for healthcare services and medications
everywhere on TV (e.g., Life Alert, Boniva, Lipitor).
The simplicity and success of social learning theory makes
it an attractive strategy for communicating healthcare information. However, it requires a vehicle that is very appealing to
consumers. One such vehicle is the educational cartoon
booklet, more commonly known as an educational comic
book. It is ideal because it can contain several elements in a
visual presentation—including a plot, with characters who are
pleasant, funny, and engaging. Animated cartoons are another
excellent vehicle for making learning fun and entertaining.
6
5
4
3
2
Pretest
Five weeks later
Responses to questionnaire in time 1 and 2
Responses to questionnaire (eight questions about child
development) at pretest and posttest:
Pretest
Posttest
Comic
N=243
2.48
8
Video
N=231
2.5
6.7
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Standard Deviation
p
.23<.0001
1.16<.0001
Recall Experimentation
Using the social learning theory to communicate healthcare
information has generated very promising results for us.
In our first experiment with this model, we simply tested
whether parents would have better recall from viewing an
animated cartoon or reading a typical healthcare education
handout. We presented the benefits of the polio vaccine to
two groups of parents: One group watched an animated
cartoon, and the other group read material without pictures.
The findings showed that recall of polio vaccine information
was better among the first group.
In our second experiment, we supplied information on child development to two groups of
parents. We compared the use of an animated cartoon with the use of a take-home educational
comic book; both formats employed the social
learning theory. A multidisciplinary team—which
included doctors, nurses, graphic designers, and a
marketing specialist—produced these items. Each
one consisted of facts about child development milestones
and safety guidelines, and was available in English
or Spanish.
Narrative. The story begins with a mother and father
taking their baby to the pediatrician for a four-month well-
Exhibit 2
Child development education
baby visit. The proud parents ask the doctor questions about
their baby’s development. Subsequently, they share their new
knowledge with friends and relatives, as they go through good
and bad days involving the tremendous eff o rt of being pare n t s .
Afterward, the baby and parents face daily experiences of
child development, as well as life in general. The father is
The simplicity and success
of social learning theory makes it an
attractive strategy for communicating
healthcare info r m a t i o n .
somewhat happy knowing so much about the baby’s development, but wishes to do some activities other than looking
after the baby. Later, he has the opportunity to view televised
sports without the baby. The father falls asleep while watching
his favorite sports game, and in his dreams he recalls the
child development milestones that the pediatrician showed
him. He feels the need to be close to the baby upon awakening, and decides to continue watching TV along with the
baby.
Evaluation. First, we gave a questionnaire to the 623
parents to determine their baseline knowledge about child
development. Then parents in the first group watched the
animated cartoon while waiting for a doctor’s appointment
and parents in the second group received an educational
comic book after a doctor’s appointment, to take home and
read at their leisure. Approximately five weeks later, we called
all parents and could talk with 243 of the 338 parents
(71.9%) in the first group and 231 of the 285 parents
(81.1%) in the second group. With a questionnaire, we measured how well they remembered the content. We didn’t use a
control group; we knew from the first experiment that animated cartoons were better for communicating information
than typical written material was. In addition, we asked all
parents about their levels of satisfaction with the educational
items that they’d viewed.
Outcome. Our findings indicated that parents learned
from both formats (see Exhibit 1). We observed this by looking at (1) the increased score from the baseline questions and
(2) the increased score from about five weeks later.
In regard to satisfaction, parents in the first group felt that
the time spent waiting for the doctor was more pleasant.
Among many other positive comments, they stated that they
learned from the story and that their accompanying child was
quieter while watching the animated cartoon. Parents in the
second group reported that relatives, both children and
adults, also read the educational comic book. They stated
that the content was clear and enjoyable, and that they’d like
more information in that format. Moreover, they felt better
informed about their child’s development, and thought that
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the educational comic book was funny and entertaining.
There were no significant diff e rences in the amount of information that each group recalled. And there was no difference in
recall among parents of different ages, ethnicities, or education
levels. Overall, everyone stated that learning was fun!
several ways, including clear instructions, training, and modeling the desired behavior. In our healthcare education materials, we portrayed problems and a character who lacked the
desire to do some specific activity. By creating expectation,
depicting behavior changes, and solving problems, we produced an environment of success.
Meaning of Results
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We attained the attention, retention, motor reproduction,
and motivation of the parents by creating an atmosphere of
simplicity—with a story and characters who allowed them to
understand, relate to, desire, and reach an outcome similar
to the one in Exhibit 3.
Social learning theory proposes that environmental influences, personal experiences, and attributes of behavior itself
affect behavior. A central part of the theory is the concept of
self-efficacy.
A person must believe in his or her capability to reproduce
the observed behavior, and must perceive an incentive in
doing so. In addition, he or she must value the outcomes or
consequences of performing a specific behavior or action.
A person filters the expected upshot through his or her perception of being able to carry out the observed behavior.
Self-efficacy is believed to be the most important characteristic
determining a person’s behavior change.
Presentations in different formats—comic books, dramatizations in video, and so on—can increase self-efficacy in
Exhibit 3
Interrelated processes
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Advantages Abound
Animated cartoons and educational comic books have
unique benefits for communicating healthcare information.
Animated cartoons. With these, it is possible to provide
the most flexible characters and situations. Designers can create a character to have a consistent and neutral appearance:
without belonging to a certain ethnic group or gender. This
helps in developing effective cross-cultural messages. It offers
consumers a regular, friendly character and a context that
allows them to relate to it in different settings.
Healthcare organizations can present animated cartoons
in lobbies or waiting rooms, where they can reach a broader
spectrum of consumers with each viewing. And unlike educational comic books, these don’t require significant mass pro-
Exhibit 4
Hepatitis B vaccine education
duction. The costs are restricted to the number of sites that
show the animated cartoons. However, production can be
expensive—requiring the preparation of a technical script,
animation, sound and sound effects, music, and other
elements.
Educational comic books. These take-home products
naturally have a longer life. A consumer can look at the information more than once, and others can look at it after that
person is finished with it. The production costs might be
lower than that of animated cartoons, but organizations
must consider the costs of mass printing.
Consumers’ failure to comprehend information might
largely be due to inadequate modes of successfully conveying
it. The use of the social learning theory, to present healthcare
information in animated or print format, has improved
consumer satisfaction and recall. Animated cartoons and
educational comic books offer an innovative strategy for
overcoming communication barriers in healthcare. M H S
Additional Reading
Bandura, A. (1977), Social Learning Theory. New York:
General Learning Press.
Bandura, A. (1978), “Social Learning Theory of Aggression,”
Journal of Communication, 28 (3), 12-29.
Chachkes, E. and G. Christ (1996), “Cross-Cultural Issues in
Patient Education,” Patient Education and Counseling, 27 (1),
13-21.
Kinzie, M.B. (2005), “Instructional Design Strategies for
Health Behavior Change,” Patient Education and Counseling,
56 (1), 3-15.
Leiner, M., G. Handal, and D. Williams (2004), “Patient
Communication: A Multidisciplinary Approach Using
Animated Cartoons,” Journal of Health Educational Research,
19 (5), 591-595.
About the Authors
Marie Leiner is assistant professor in the pediatrics department at Texas Tech University (TTU) in El Paso. She may be
reached at [email protected]. Blanca Garcia is assistant professor at TTU and may be reached at blanca.garcia@
ttuhsc.edu. Gilbert Handal is professor and regional dean at
TTU and may be reached at [email protected].
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