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Images: anatomy illustration style #399

Open sarawilcox opened 2 years ago

sarawilcox commented 2 years ago

One part of new imagery guidance. Rich Kelly is leading on this.

richkelly13 commented 2 years ago

Anatomical Illustrations

Use of anatomical illustration conveys medical or biological information and provide for clear communication when words alone are not adequate. It gives people positional reference to their bodies organs and biological systems.

The human organism consists of twelve organ systems, skeletal, nervous, muscular, respiratory, endocrine, immune, cardiovascular/circulatory, urinary, integumentary, reproductive, digestive systems and skin.

Illustration facilitates creating anatomical views normally hidden and enables the display of anatomy unobtainable to the human eye or the camera. For skin/dermatology related images it is advised to still use photography unless there is a requirement to conceal graphic injury.

Anatomical imagery is important because it helps people better understand their bodies organs and systems in relation to their ongoing medical history. Medical professionals can also use the imagery to further explain medical conditions and drill down to specifics in that biological system.

Illustrations are generally a preferred visual method for anatomical imagery (as opposed to photography) as they are pseudonymised, meaning illustrations lack the visual data that identifies a real life individual, removing any data/GDPR risk on imagery.

Illustrations offer a generic view of all anatomy, they are not of any one patient. This automatically removes any bias; the viewer does not question who is in the image.

Design guidance:

(Insert visual example here when we publish)

- Insert visual example

This guidance is what we currently recommend. We’ll continuously update this based on ongoing research and contributions from the NHS Digital design community.

Untitled-1 NHS website - anatomical illustration example. Pending another round of user research

richkelly13 commented 2 years ago

User Research:

A Hotjar survey was setup by UR / Mission Team 1. (September 2021)

It showed existing illustrations on the NHS website as well as new style concepts. Recommendations were then created to further iterate the illustrative style for the NHS website. Another round of testing will be done on new iterations.

Recommendations:

Do not proceed with the new illustration style until changes have been made.

Keep textual labels within the illustrations rather than using a key

Provide labels and information on all relevant parts in the illustration (e.g. this is not done within the old illustration of chiari malformation)

Keep the old style of illustrations used for upper GI anatomy

Include helpful anatomical points of reference for users (E.g. belly button)

Ensure high colour contrast is used to show the focus of the illustrations

Consider using illustrations (with arrows) for exercises and provide more than one illustration for a movement to better convey the different stages of an exercise.

Avoid gendering illustrations as much as possible.

Design Huddle feedback to take into next round/s of testing/prototyping:

The colour coding we've devised. Although an internal indication of type of image, will people create meaning from the colour coding. (we think maybe we might hone this down to just one background colour and one highlight colour, site wide).

What happens when these illustrations are viewed on a black/white screen or high contrast monitor. Doe's it still get across the same information? (something for us to explore when we prototype).

Labels - could we try both labelling in both the image and the description. This may appease those who prefer labels in the image and those who rely on it being accessible in the description. (might be messy though!?) Comments were - from an accessibility perspective no doubt people can read labels easier, but can they associate them with the image' and 'in terms of label, is having both label inside and outside test-able?'.

New design was liked by the designers ' I love how easy on the eyes they are, gives focus on what is needed'. 'I think it works really well, improvement over photos' and 'the colours are such an improvement over white b/g!'.

Overall findings:

Strong preference for labelling without a key, but instead have the illustration directly labelled with the body part / equipment as it makes it easier to quickly understand what the illustration is showing

Preference between 'more realistic' illustrations using colour and illustrations with a grey background were split and due to personal preference. Those with a preference for realism perceived them as being more detailed. It also provided a better frame of reference to understand where it may be in your own body. E.g. the belly button in the pancreas old illustration gave a helpful frame of reference to where the other organs would be in your own body. Those with a preference for the greyed out background (as in the new style) liked that it made it more abstract, thought it was more accessible to those who were colour blind / had autism and was clearer to see what the focus of the illustration was.

High colour contrast to easily show what part of the illustration people are supposed to focus on. For example, the new style illustration of the chiari malformation clearly and quickly highlighted which area of the image people should focus on. This was also highlighted as a benefit of the new illustration style of the pacemaker, as it more clearly showed where the wires went.

The new illustration style of the chiari malformation was also preferred because it labelled more fully, whereas the old illustration was not.

When demonstrating a motion, the arrows in the new illustration were helpful to understand direction and the arrows helped give more instruction. There was a demand for several images (e.g. showing the starting position and then an image of the exercise in motion). However, the jumping motion was not included within the illustration which is often why the photo was perceived to be better.

Some participants liked that it was a photo of a real person as they thought it would be easier to relate to.

A couple of participants questioned whether illustrations needed to be gendered.

A Hotjar survey was setup by UR / Mission Team 1. (November 2021)

It showed existing illustrations on the NHS website as well as new style concepts. Recommendations were then created to further iterate the illustrative style for the NHS website. Another round of testing will be done on new iterations.

Recommendations:

Examine whether it would be possible to have labels of black text on the grey/blue background and still meet colour contrast requirements. Otherwise, consider having black text on a white background box.

Keep the old style of illustrations used for upper GI anatomy

Include helpful anatomical points of reference for users (E.g. belly button, ribs)

Ensure high colour contrast is used to show the focus of the illustrations

Consider providing videos for demonstrations of motion. For exercises and motion, use photographs of people instead of illustrations. Always supply photos at each stage in the motion/exercise (rather than just one as is currently shown in the star jump).

Avoid gendering illustrations as much as possible. If this isn't possible, include a mix of female and male looking bodies.

White background of a person is better than the peach coloured background on the old pacemaker illustration (as this was perceived more often to be white skin). However, there were still a few respondents who thought that the white background suggested white skin. Consider experimenting with different background colours.

Upper GI illustrations (March 2020)

The research concluded the following changes:

Use an image of a body that is something between the two versions tested - gender neutral, showing full torso and less abstract than the body used in image 1

Label all the organs in the image

Use a different colour for each organ

Make the organ being discussed in the content the most visually prominent

Be consistent about the colour that's used to highlight the organ that's being discussed (eg on stomach cancer page use pink for stomach, on pancreatic cancer page use pink for pancreas)

Make the point where the oesophagus ends and the stomach starts clearer by using a more contrasting colour

Maternity quick wins user research (2018)

Participants really liked ‘in context’ images which will help them ‘understand what is going on in their bodies.

Journal of Biocommunication report:

http://www.jbiocommunication.org/issues/31-3/pdf/Mader-Medical_Legal_Illustrations.pdf

Page 10: When shown orientation illustrations of the injured cervical spine in the context of the human form, rendered either realistically or generically (see Figure 6), 100% (20/20) preferred the realistic rendering; 95% (19/20) thought this treatment helped to personalize the depiction of the injury to their client.

Screenshot 2021-12-20 at 12 31 42

http://www.jbiocommunication.org/issues/31-3/pdf/Mader-Medical_Legal_Illustrations.pdf

Page 11: When lawyers were shown the panels in Figure 7, 60% (12/20) of the participants preferred the orientation illustration rendered without skin tone (Panel A). They thought that the spinal anatomy stood out better. Of the 40% (8/20) who preferred the image with the skin tone, 50% (4/8) thought that the skin color added an element of realism.

Screenshot 2021-12-20 at 12 31 54

Recommendation: (Page 14)

  1. Carefully consider the use of skin tone, ensuring that it does not detract from the anatomical issues being depicted.

Recommendation (Page 14)

  1. Consider providing step-by-step animation to communicate the details of surgery or other sequential events.

Lead Illustrator at Institute of medical illustrators: A medical artist is able to create an illustration that removes unwanted graphic material within the picture, removing blood for example. This allows for a clear view of the anatomy, to bring focus to the message to be communicated within the illustration.

Illustrations offer a generic view of all anatomy, they are not of any one patient. This automatically removes any bias; the viewer does not question who is in the photograph.

Illustrations of anatomy, science subject matters can be created to a scale. Scales can be used within the illustration, for example a visible scale such a ruler included within the illustration to aid the viewers understanding. Labelling is a regular addition and is included to further enhance the illustration.

https://www.tandfonline.com/doi/full/10.1080/17453054.2019.1633237

Medical illustration, such tools allow medical professionals to convey medical information accurately, transcending language boundaries (Goodwin, 2000; Netter & Friedlaender, 2014). In this way, they can increase patients’ understanding (Ancker et al., 2006; Brotherstone, Miles, Robb, Atkin, & Wardle, 2006; Lipkus & Hollands, 1999; World Health Organization, 2009) and elicit their attention (Delp & Jones, 1996; Houts, Doak, Doak, & Loscalzo, 2006).

Some studies found illustrations to be effective in guiding those with poor health literacy, including children and individuals in developing countries (Gazmararian et al., 1999; Houts et al., 2006; Kakkilaya et al., 2011; Michielutte, Bahnson, Dignan, & Schroeder, 1992; Peregrin, 2010).

Levin (1981) reported that illustrations are better at communicating novel rather than familiar information. We therefore selected subject matter that does not normally feature in elementary school learning stages.

User needs for illustration – taken from Accentures visual recommendation report 2019

As a lower literacy user I want visual support to help understand more clearly what is being explained

I want a visual representation of an internal condition so that can I understand it more clearly

I want to know how to perform an exercise or medical action so that I’m confident I’m doing it correctly (squats, inhaler usage etc)

(Please note the JBI paper is a little dated in terms of inclusivity/accessibility best practice).

Medical Image Professional: Scenarios when illustration is chosen over photography:

A medical artists training in human anatomy facilitates creating anatomical views normally hidden and enables the display of anatomy unobtainable to the human eye or the camera.

A medical artist is able to create an illustration that removes unwanted graphic material within the picture, removing blood for example.

Medical animations are a regular tool used by pharmaceutical companies, businesses and marketing agencies that work within health care. This type of moving 2D medical illustration and 3D medical illustration format gives the customer the ability to request custom visuals of moving parts within the body, modes of action, how drugs work within the body. A camera cannot produce this type of video.

richkelly13 commented 2 years ago

Closed by accident.

paulpod commented 2 years ago

Hey, here's a bit of 111 online introducing media (images) into the triage - Show and tell from Jan 2022 https://youtu.be/nNd8OF0v-9M?t=974 We'd done a fair bit of user research with a range of media (illustrations, photo, video, sound) including using a gallery for multiples. We went live gently with two - scrotum and groin (because people who don't have English as first language don't know those words, or what precisely meant for groin). Generally media tested really well with users. Where we used some quite graphic photos, the response has been a bit negative - still helpful in a triage but a bit unpleasant to look at. Other photos have been difficult to get hold of accurate clinically sourced photographs that are also clear, so we have concentrated on images of body parts for now.

We'd evolved to this ambiguous sex outline body shape, fairly early on, but had used some less good colours - quickly moving to high contrast NHS.UK colours. I did note there isn't strict WCAG colour contrast guidance for images, the emphasis is rightly on having them correctly described in text, but for diagrams we did think it would be good to try and get AA contrast on our colours. flank-groin-on-bodymap-02

And we did look at using 3D but we wanted it simpler - to be super clear only a couple of inches in size on a phone.

image

Scrotum was pretty simple. Groin went through a lot of iteration with clinicians to correctly match the clinical intent. One of the problems we have is an image can be more precise than words - that might not be helpful, in a triage. So shaded areas to cover variations and different problems.

image

Image is live, looks like this now

image
richkelly13 commented 1 year ago

New designs for Round 4 of Anatomical Illustrations can be found below.

Design changes have been made after an NHS website design crit on some website imagery for Cervical Cancer, Womb cancer, Ovarian Cancer and Vaginal cancer.

Changes include:

Chiari-Malformation_UR4

Procedural-Model-Example-UR4

Lumbar-Puncture---Image-2

Pacemaker-Model-UR4

Upper-GI-Example-UR4

Coronary-artery-bypass-graft-sites

In round 4 of the anatomical illustration user research, we would like to test the latest illustration styles in 1:1 sessions with users.   Research participants will be purposely screened to help us answer our remaining hypotheses and key design considerations around diversity of the imagery and further define how the images perform for people who are living with access and neuro-diverse needs. Images will also be added to live-surveys on the website for broader feedback.

richkelly13 commented 1 year ago

Round 5 of User Research is now complete.

Team have completed round 5 of UR on our latest Anatomical illustration design.

Research goals: ​

The first 4 rounds were nhs.uk site surveys followed by a 5th round online survey and 1:1 sessions with people with neuro-diverse conditions.

Round 5 - Online survey and 1:1 interview sessions: 2 users with Colour blindness, ​ 2 with dyslexia, 1 with dyspraxia and 1 with severe vertigo.

UR Presentation and Show and Tell to follow on 7th February 2023.

Latest designs are here (Images pending clinical sign-off):

Chiari-Malformation_UR6-Image-1

Chiari-Malformation_UR6-Image-2 Pacemaker-Model-UR6-Image-1 Pacemaker-Model-UR6-Image-2 Pacemaker-Model-UR6-Image-3 Pacemaker-Model-UR6-Image-4

Coronary-artery-bypass-graft-sites---UR6

Procedural---Model-Example---U6-Image-1 Procedural---Model-Example---U6-Image-2 Upper-GI-Example-UR6

richkelly13 commented 1 year ago

We are pleased to share here our DRAFT NHS digital service manual guidance for accessible Anatomical illustrations.

NHS website - Anatomical illustration guidance – DRAFT.docx

Next steps are to:

richkelly13 commented 1 year ago

User Research takeaways for the new style can be found below:

NHS.UK Show and tell: 197 - 7th February 2023.pptx

Research goals:

To understand how easy the concepts represented in the image were to understand Identify user-led opportunities to improve the image To measure the accessibility of the new images

Round 4 UR: Anatomical Illustrations - Round 4 UR.docx

Round 5 UR: Anatomical Illustrations Accessibility_Survey_Oct-22.pptx

5 rounds of UR were undertaken. Team happy to supply Rounds 1-3 UR on request.