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 Table of Contents  
ORIGINAL RESEARCH ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 2  |  Page : 125-129

Perception about use of comics in medical and nursing education among students in health professions' schools in New Delhi


1 Department of Community Medicine, North Delhi Municipal Corporation Medical College, Hindu Rao Hospital, New Delhi, India
2 Department of Community Medicine, Vardhman Mahavir Medical College, New Delhi, India
3 Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
4 Division of Clinical Oncology, National Institute of Cancer Prevention and Research, Noida, Uttar Pradesh, India

Date of Web Publication30-Nov-2018

Correspondence Address:
Tanu Anand
Department of Community Medicine, North Delhi Municipal Corporation Medical College, Hindu Rao Hospital, New Delhi - 110 007
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/efh.EfH_298_15

  Abstract 


Background: Graphic narratives can give medical and nursing students a broader concept of health and illness. However, graphic texts are not yet integrated into medical education in India. The present study was undertaken to assess the perception of medical and nursing undergraduate students about the use of comics in health professions' education. Methods: This study was an institution-based cross-sectional study conducted among 130 medical and 108 nursing students of a medical and nursing college, respectively, in Central Delhi. A pretested self-administered questionnaire containing items to assess knowledge and perception about graphic medicine in medical education was used for data collection. Data were analyzed using SPSS 16.0. Results: The mean age of students was 20.82 ± 1.51 years. Out of the 238 students, only 21.8% had heard about graphic medicine. However, 76.9% (n = 183) of students agreed that comics should be used in health professions' education. When asked about the subjects in which comic strips can be useful, the majority of medical students wanted them to be used in teaching community medicine (n = 95; 73.1%), while nursing students more often indicated their use in anatomy (n = 59; 54.6%). Overall large proportion of both nursing and medical students opined that comics aid in better understanding (58.8%) and memorization of concepts and content (57.6%). The majority of respondents felt that comic designing requires expertise (67.6%). Students also stated that comic strips on communicable diseases and reproductive and child health could be developed and used in teaching the subject of community medicine/public health. Discussion: Majority of students felt that comics should be used in medical education in India, preferably for teaching community medicine. Further, maternal and child health are important topics that can be taught using comics in public health. There is a need to explore ways for integrating graphic medicine into health professions' education.

Keywords: Comics, graphic medicine, medical education, public health


How to cite this article:
Anand T, Kishore J, Ingle GK, Grover S. Perception about use of comics in medical and nursing education among students in health professions' schools in New Delhi. Educ Health 2018;31:125-9

How to cite this URL:
Anand T, Kishore J, Ingle GK, Grover S. Perception about use of comics in medical and nursing education among students in health professions' schools in New Delhi. Educ Health [serial online] 2018 [cited 2020 Jan 25];31:125-9. Available from: http://www.educationforhealth.net/text.asp?2018/31/2/125/246751




  Background Top


Graphic medicine can be defined as the use of comics (graphic narratives) in health sciences education and patient care [Figure 1].[1] Comics offer an engaging, strong, and accessible medium of delivering illness narratives.[2] However, little attention seems to have been paid within the health professions' literature to this media. However, existing evidence supports the assertion that carefully constructed text illustrations generally enhance learners' performance on a variety of text-dependent cognitive outcomes.[3] The literature also suggests that graphic pathographies (book-length comics about illnesses) can be used to teach medical students observational and interpretive skills.[1] Graphic pathographies can provide doctors with new insights into the personal experience of illnesses of patients and their families and thus give students a broader experience of health and illness.[1] Further, graphic texts act as adjunct aids and facilitators in the learning process.[3]
Figure 1: An example of graphic medicine. Courtesy: Graphicmedicine.worldpress.com

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Medical stories in comics are not new. Hansen has studied the portrayal of notable medical figures in the true adventure comics of the 1940s in which the quest for discoveries was portrayed as a form of heroism.[4],[5] Green introduced the recognizable genre within comics: the graphic memoir of illness or trauma.[4] Most notable among these are Cancer Vixen[6] and Mom's Cancer.[7] More recent medical literature in comics has been developed by Medikidz in the form of high-quality children's comics that explain various illnesses, treatments, and procedures.[1] Although the intended audience for these graphic memoirs and pathographies is different, these help health professionals in facilitating reflection and understanding of issues that might not have been previously considered by them while treating patients.

The academic appraisal of graphic fiction is in its infancy, and its examination by academics involved in healthcare-related studies is very sparse to date.[4] The concept of graphic medicine is new in India as well. While some medical concepts are being explained through comics for lay people and the mass community, graphic texts and comics are not yet integrated into medical and nursing education in India.

The present study was undertaken to assess the perceptions of medical and nursing undergraduate students about the use of comics in education. Past evidence shows that inclusion of students' perspectives in planning and implementation phases can prove to be fruitful, particularly when introducing newer concepts and tools into the curricula.[8]


  Methods Top


Study settings and participants

A cross-sectional study was conducted of undergraduate medical students (Bachelor of Medicine and Bachelor of Surgery) in the 2nd and 3rd years, interns, and nursing students in their 2nd, 3rd, and final years at a medical and nursing college in Delhi. Every year, 250 students are admitted to the institution; therefore, there are approximately 1250 students in the medical college at any given time. A nursing college is attached to the medical college. Every year, about 39 students are admitted into to the 4-year B. Sc. (Hons) Nursing college resulting in nearly 150 nursing students studying at any time.

Due to lack of any previous work of this kind, we chose 0.50 as the safest anticipated perception or agreement among the students regarding introduction of comic strips in health professions' education. The sample was calculated to be 100 with precision of 0.1 at the 95% confidence interval. The sample was selected from classes of the different years of medical and nursing students posted in the department of community medicine. At the time of the survey, one class each from 2nd- to 3rd-year medical students, one class of interns, and one class each of 2nd-, 3rd-, and final-year nursing students were posted in the department. All the students from the selected groups were contacted; informed consent was obtained from each participant before data collection.

Study instrument

A pretested, self-administered, structured questionnaire was used for data collection. It included items on sociodemographic characteristics of the study participants and questions on knowledge of graphic medicine, perceptions about introduction of comics in health professions' education, subjects in which participants would like to read comic strips, advantages and disadvantages of comic strips in education, and topics related to public health for which students and interns would like to have comics. Due to lack of previous studies on this subject, the questionnaire was developed after thorough literature review.[1],[2],[3],[4]

The questionnaire was reviewed for suitability, relevance, and accuracy in the Indian context. After initial development, the questionnaire was sent to one medical faculty, one nursing faculty, and one expert from an arts background. There was 100% agreement on all the items between the experts. It was further pretested in the English language with ten dental students. The questionnaire required about 5 min for completion.

Key definitions related to the study

Medical illustration is the art of transforming complex clinical and pathological information into visual images that have the potential to communicate to broad audiences.[9] Comics are simple portrayals with narratives mostly meant for children.[2]

Data collection

Questionnaires were distributed to the selected students (as explained above) after obtaining written informed consent. The subjects were given between 5 and 7 min to complete the questionnaire. Responses were examined at the time of data collection, and if information was missing, students were asked again for the information to be completed.

Statistical analysis

Data were entered in Microsoft Excel and transferred into Statistical Package for the Social Sciences (Windows version 16.0, SPSS Inc, Chicago [IL], USA). for analysis. Findings were presented as group proportions and difference in proportions for a given factor, using Chi-square. Differences between the means of the two groups were compared by t-test (for normally distributed variables). A P value cutoff for statistical significance was set at <0.05.

Ethical considerations

All students participating in the study were informed about the study purpose, and full free and voluntary consent was obtained before inclusion. Each student participating in the study was free to withdraw from the study at any point in time and was ensured confidentiality of responses. The study was approved by the departmental ethics committee of the medical college.


  Results Top


Of the total 238 students who consented to participate, there were 130 medical (54.6%) and 108 nursing students (45.4%). The mean age of the study group was 20.79 ± 1.42 years (range = 18–29 years). Among the medical students, there were 63.1% (n = 82) males and 36.9% (n = 48) females. All nursing students were females. Year-wise distribution of the study participants showed that among the medical students, 42.3% (n = 55) and 46.9% (n = 61) were from the 2nd to 3rd year, respectively, while interns constituted 10.8% (n = 14) of the total. Among the nursing students, the majority consisted of 3rd-year students (n = 46; 42.6%) followed by 2nd year (n = 33; 30.6%) and final year (n = 29; 26.8).

Nearly 22% (n = 52) of the study respondents had heard of graphic medicine. There was no significant difference between the awareness levels of medical and nursing students (medical: n = 33, 25.4%; nursing: n = 19, 17.6%; χ2 = 2.2; P = 0.16). Internet was the most common source for this information (n = 31, 59.6%), followed by television (n = 7, 13.5%). Regarding perceptions about introduction of comic strips in the curricula, 83.9% of medical students (n = 109) and 68.5% of nursing students (n = 74) agreed to the use of comic strips (χ2 = 7.8; P = 0.005). Interestingly, none of the study participants disagreed to the use of comic strips in medical education. One-fifth of the students (n = 49, 20.6%) had read comics on medical topics before the survey.

Maternal and child health-related topics were the most commonly read by all in the form of comics. Regarding the medical subjects for which the students would like to read comics, a large proportion of medical students reported community medicine followed by general medicine, whereas nursing students indicated pediatrics and anatomy. The students expressed that comic strips on communicable diseases (26.9%) and reproductive and child health (21.4%) could be made and used in teaching the subject of community medicine/public health [Table 1].
Table 1: Awareness and perceptions of medical and nursing students on the introduction of graphic medicine into curricula

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The majority of medical students (n = 100, 76.9%) considered comics as a tool to make the teaching and learning process enjoyable. A large proportion of nursing students, on the other hand, stated that comics helped in better understanding of subject matter. Among the disadvantages, the majority of both nursing (n = 77, 71.3%) and medical students (n = 84, 64.6%) considered that comics in health professions' education require expertise in development [Table 2].
Table 2: Perceived advantages and disadvantages of using comic strips as a teaching tool in medical and nursing education

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A comparison of perceptions between those who had heard about graphic medicine and those who had not revealed that those who heard about graphic medicine was more likely to agree to the introduction of graphic medicine in medical and nursing education (χ2 = 13.9; P < 0.001). Further, 44.2% of those with previous knowledge had read comics in medicine (χ2 = 22.7; P < 0.001). Related to medical subjects for which the students would like to read comics, those who had heard about graphic medicine reported community medicine and pediatrics. There was no difference between the two groups with respect to topics in public health for which they would like to read comics.


  Discussion Top


Engagement with visual art as part of the learning process, to develop skills, explore practice, or reflect on experience is a not a recent phenomenon.[10] India has had a long-standing tradition of sequential pictorial narratives, dating back thousands of years. The earliest evidence of such pictorial narratives in India can be traced back to the Paleolithic age, based on cave drawings found at Bhimbetka in Madhya Pradesh.[11] However, the concept of pictorial narratives, more specifically comics in education, is very new in India.

Consequently, only one-fifth of the students in the present study had heard of the term “Graphic Medicine” at the time of the survey. Graphic medicine is a part of the medical curricula in of handful of schools in the United States and the United Kingdom.[2],[12] Thus, to propagate this teaching–learning method for enhancement of visual literacy skills of medical students and create awareness among students and faculty, we need to explore different ways for doing so. The Internet and wireless technology enable information to be widely and readily available to everybody.[13] They can be utilized for transmission of information regarding the subject called graphic medicine.

The majority of both medical and nursing students agreed to the introduction of comics in medical and nursing education. It has been shown that accompanying illustrations to voluminous texts is extremely helpful in aiding in the understanding of many health professions' subjects.[13] Bell and Evans in a study of 1st-year medical students at Brighton and Sussex Medical School reported a strong perception that art could play a role in medical education and more specifically through analyzing art to positively develop clinical observational skills.[14]

In terms of the subjects for which students would like to have comics, the majority of medical students indicated community medicine followed by general medicine. The most probable reason for this could be the fact that the traditional textbooks of these two subjects involve intensive course material with large texts and few pictures. Furthermore, they constitute two very major subjects in medicine. On the other hand, nursing students considered anatomy and pediatrics as the subjects for which they would like to have comics. The difference in perceptions regarding the subjects between medical and nursing students highlights the fact that though they may be taught the same subjects and have intersecting curricula, they represent two different models of care. Hence, the same textbooks and similar methodology of teaching may not be optimal in relation to adoption in the two fields.

Findings of this study are in line with the available evidence.[1],[2],[4] The work of Green on final-year medical students in 2013 in the US describes why this medium resonates so powerfully with medical student learners.[15] Having presented the students' perception, insight, and understanding of the advantages of this medium, there are some challenges also which raised concerns among study participants. Comics do require expertise in development. Producing reflective text whether verbal, visual, or musical requires the translation of an experience or emotion into a relevant form of language or sign system which often offers different limitations in our cognitive and emotional work.[10] There is still the question of whether this form of educational strategy develops “better physicians” in terms of understanding, communication, and interpersonal skills.[10]

Study limitations

This study was conducted with a convenience sample of medical and nursing students, limiting the generalization of findings. Other stakeholders such as faculty members, planners, and designers of medical and nursing curricula and other authorities involved in implementation of medical and nursing curricula were not interviewed.

The current study still clearly highlights the favorable perception among the undergraduate students regarding the use of comics in medical and nursing education. There is evidence to support that graphic stories are a creative and novel way to learn and teach about illness and disease.[1] Yet, integration of graphic stories into health professions' education and practice still remains a challenge. The first step in this regard is spreading awareness about the concept among doctors and nurses. Further, more research is needed, both qualitative and longitudinal, from a wide range of disciplines to examine the effectiveness of this tool.[1],[9] Graphic medicine is a relatively new and accessible medium that has immense potential to act as a textual adjunct and take the learning process to a different level.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Green MJ, Myers KR. Graphic medicine: Use of comics in medical education and patient care. BMJ 2010;340:c863.  Back to cited text no. 1
    
2.
Williams IC. Graphic Medicine: How Comics are Revolutionizing the Representation of Illness. Hektoen Int 2011;3. Available from: http//www.hektoeninternational.org/index.php?option=com_content&view=article&id=353. [Last accessed on 2015 Feb 09].  Back to cited text no. 2
    
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Carney RN, Levin JR. Pictorial illustrations still improve students' learning from text. Educ Psychol Rev 2002;14:5-26.  Back to cited text no. 3
    
4.
Williams IC. Graphic medicine: Comics as medical narrative. Med Humanit 2012;38:21-7.  Back to cited text no. 4
    
5.
Hansen B. Medical history for the masses: How American comic books celebrated heroes of medicine in the 1940s. Bull Hist Med 2004;78:148-91.  Back to cited text no. 5
    
6.
Marchetto MA. Cancer Vixen: A True Story. New York: Alfred A Knopf; 2006.  Back to cited text no. 6
    
7.
Fies B. Mom's Cancer. New York: Abrams Image; 2006.  Back to cited text no. 7
    
8.
Shah C, Parmar D, Mehta H. Perceptions of faculty about student-centered curriculum. Arch Med Health Sci 2014;2:74-9.  Back to cited text no. 8
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9.
Association of Medical Illustrators. Medical Illustration; 1995. Available from: http//www.ami.org/medical-illustration/learn-about-medical-illustration. [Last accessed on 2016 Jul 16].  Back to cited text no. 9
    
10.
Bates V, Bleakley A, Goodman S. Medicine, Health and the Arts: Approaches to the Medical Humanities. 1st ed. New York: Taylor & Francis Group; 2014.  Back to cited text no. 10
    
11.
Singanapalli S. History of Pictorial Narratives in India; 2014. Available from: http//www.dsource.in/resource/pictorial-narratives/earlypicture/index.html. [Last accessed on 2014 Jun 24].  Back to cited text no. 11
    
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Lazarus PA, Rosslyn FM. The arts in medicine: Setting up and evaluating a new special study module at Leicester Warwick Medical School. Med Educ 2003;37:553-9.  Back to cited text no. 12
    
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Hajar R. Medical illustration: Art in medical education. Heart Views 2011;12:83-91.  Back to cited text no. 13
[PUBMED]  [Full text]  
14.
Bell LT, Evans DJ. Art, anatomy, and medicine: Is there a place for art in medical education? Anat Sci Educ 2014;7:370-8.  Back to cited text no. 14
    
15.
Green MJ. Teaching with comics: A course for fourth-year medical students. J Med Humanit 2013;34:471-6.  Back to cited text no. 15
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]


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