A Scoping Review of Animated Video’s Effect on Individual Health Knowledge

  

    
Ref #
    
Author

      Year

      Country
    
Healthcare area
    
Video design

      theory

      User input
    
Population
    
Video

      (Location)

      [Device]
    
Video duration

      (number)

      [views]
    
Sample Size
    
Outcomes1
  
  

    
22
    
Al Owaifeer

      2011

      Saudi Arabia
    
Glaucoma general information
    
2D

      -

      No
    
-

      29% illiterate

      56 years

      55% male
    
(Clinic)

      [Computer]
    
3m

      (1 video)

      [1 view]
    
196: animation
    
Knowledge (+)
  
  

    
16
    
Wang

      2014

      US
    
Prostate health terminology
    
2D & 3D

      MMLT

      No
    
91% Black

      77% = 2° Ed

      54 years

      100% male
    
(Clinic)

      [Computer]
    
16m

      -

      -
    
56: animation
    
Knowledge (+)
  
  

    
17
    
Axelrod

      2017

      US
    
Kidney transplantation process and donor choices
    
2D

      -

      No
    
26% Black

      25% Asian

      15% Hispanic

      80% 2° Ed

      52 years

      51% male
    
(Clinic)

      [Tablet]
    
3m

      (13 videos)

      [= 1 view]
    
81: animation
    
Knowledge (+)

      Interest in nonstandard kidney (=)

      Interest in living donor kidney (+)

      Informed decision-making (+)
  
  

    
13
    
Kayler

      2019

      US
    
Kidney transplantation allocation
    
2D

      MMLT

      Yes2
    
50% Black

      86% 2° Ed

      53 years

      65% male
    
(Clinic)

      [Computer]
    
2m

      -1

      [1 view]
    
40: animation
    
Knowledge (+)

      Decisional self-efficacy (+)

      Beliefs3 (+)
  
  

    
Note: US:    United States; 2D: Two-Dimensional; 3D: Three-Dimensional; 2o Ed:    Secondary Education; MMLT: Multimedia Learning Theory; m: Minutes; s:    Seconds.

      1(+)    significant positive change; (-) significant negative change; (=)    non-significant change.

      2Patient    representatives; 50% African American.

      3Beliefs about kidney allocation fairness. 
  

Table 3: Pre/Post Studies of Standalone Animated Educational Video.

Five studies assessed knowledge change in diverse subgroups [11,13,14,20,21]. Increasing age was associated with lower knowledge gains in one RCT [20]. In contrast, a pre-post study and an RCT found similar effect size increases in knowledge between older and younger persons [13,14]. Low literacy learners exposed to animated video learned the same amount of information [13,14,17] or more [21] than their higher health literate counterparts in 4 studies: a between-group study [21] that measured health literacy with the Short Assessment of Health Literacy in Dutch, and an RCT [14] and 2 pre-post studies [13,17] that all measured health literacy with 2 screener questions [25]. Regarding other subgroups, knowledge scores increased significantly or similarly among individuals who were Black [13,14,17], Hispanic [17], low income [13,14], or had low technology access [13,14,17] relative to White, higher income, and those with higher technology ownership, respectively.

Impact of standalone animated video on secondary outcomes

A total of 30 secondary outcomes were reported and can be categorized into 5 outcome domains. The most frequently studied domain was (1) perceived understanding or decision-making, followed by (2) attitudes, (3) anxiety, (4) care delivery, and (5) satisfaction with education.

Perceived understanding/Decision making: Measures of selfreported understanding and decision-making were reported in 5 studies - perceived understanding of inner ear anatomy [18], genomic testing [11], kidney allocation [13,14], and live kidney donation [17] were higher with animation compared to usual care [14,18], no information [11], and baseline [13,17]. Three studies found improved decision-making about (1) choosing kidney offers compared to usual education [14]; (2) individual timing of joining the kidney waiting list compared to baseline [13]; and (3) live donor kidney transplantation compared to baseline [17]. Two studies assessing hypothetical decision-making and decisional conflict found similar results compared to no information [11], text [11], and realistic video [19].

Attitudes: Five studies evaluated change in attitudes about undergoing procedures or kidney transplants from different types of donors [13,14,17,19,21]. Positive attitudes were found toward colorectal cancer screening compared to other educational materials [21], toward fairness of organ allocation compared to baseline [13], and toward receiving a transplant with a non-standard kidney compared to usual care in one study [14] but not in another compared to baseline [17]. Attitudes about hypothetical orthopedic surgery were unchanged between animation and realistic video conditions [19].

Anxiety/Affect: Affective outcomes were measured in 4 studies among participants undergoing or considering invasive procedures. Using the State and Trait Anxiety Inventory [20,23,24], 2 trials showed that state anxiety levels about colorectal surgery [24] and coronary angiography [23] were significantly reduced. One trial found no differences in anesthesia anxiety between the animation and usual care [20]. In a between-group study, animation decreased fear and disgust of hypothetical orthopedic surgery compared to realistic video [19].

Care delivery/Behavior: Four out of 15 studies reported data about care delivery or behavioral intention. Compared to usual education, animation groups had shorter time to obtain consent for anesthesia [20] but non-significant differences in length of hospital stay after colorectal surgery [24] and vital signs during coronary angiography [23]. Intention to participate in genome sequencing was unchanged between animation, no information, and written information groups [11].

Usefulness/Satisfaction: Only one study reported a substantive usefulness/satisfaction measure. Animation was reported to be more useful for learning about Meniere’s disease compared to usual care [18]. One additional study reported greater satisfaction with the informed consent visit that used animation compared to usual care [20].

Discussion

This scoping review of 8 RCTs and 7 non-RCTs conducted in adults found that standalone animation improved knowledge in the majority of studies for health procedures, including kidney transplantation, general anesthesia, surgery, and various health conditions. Animated video used as an isolated education strategy generally increased knowledge compared to standard care and compared to other strategies that did not blend moving schematic images with audio. Some studies that looked at diverse communities also found that standalone animated video yielded superior knowledge change across age, race, and literacy level compared to control conditions. The vast majority of animated video interventions were focused on single viewing clinic delivery of brief videos. Some studies also showed promise in decreasing learner anxiety and improving attitudes toward health behaviors.

Knowledge

This scoping review highlights the effectiveness of animation to increase knowledge compared to other teaching formats such as text, oral, real video, audiobook, static cartoon, and silent captioned animation. The powerful learning effect of animation has been attributed to the use of audiovisual formats, which allows for dual channels of processing audio and visual information separately and concurrently [26], and also the use of signaling and schematic images that reinforce verbal messages [27]. Information, therefore, can be processed by learners more easily [28]. Ease of learning with animation allows for content to be presented in shorter duration, making animation more efficient. Efficient education may be important for patients’ learning since attention spans are known to decline after 10 minutes [29]. The duration of the animations included in this scoping review ranged between 2 and 16 minutes, and the majority were 3 minutes or less. This is in contrast to standalone real video interventions that average 36 minutes [30]. Regarding kidney transplantation, easy and efficient education strategies, like animation, may be useful to impact the ESKD population, who tend to be an older population [31] and have cognitive decline related to uremia, comorbidities, and age [32]. Easy and efficient education may also be useful to impact learning of social network members, who are highly important to enhance a patient’s access to transplantation through social support and donating kidneys [2] but who may not have had the benefit of meeting with and learning from providers.

Other outcomes

Secondary outcome data of this scoping review serve to build the profile of the animation effect. A promising effect was on anxiety reduction. Learner anxiety might arise when the content is difficult to learn and in relation to the procedure itself. Ease of learning with animation [28] may help to resolve anxiety of learning difficult content and further enable learning of complex topics. Anxiety reduction may also be due to the fact that the animations, especially cartoons, may be appealing or amusing to viewers [33] and may focus on positive framing of information, resulting in enjoyment of learning and less fear of the procedure. This is underscored by one of the papers in this scoping review, in which live action video increased fear and disgust compared to animation. Animation may therefore be promising for reducing anxiety related to learning about and undergoing procedures beneficial to ESKD patients’ health, like kidney transplantation and donation.

Behavioral outcomes

It is important to note that none of the studies in this scoping review measured the effect of animation on individual-level behavior. One relevant paper that was excluded against review criteria (i.e., lack of knowledge outcome) may be useful to inform this discussion. Jones et al. [34] found that myocardial infarction patients who viewed a 15-minute educational animated video delivered in the hospital before discharge reported greater exercise and faster return to normal activities compared to usual care at 7-weeks post-baseline. Adherence to secondary prevention was attributed to increased confidence that their heart disease was under control, through lower reported levels of avoidance and reduced anxiety about exertion, and increased patient perceptions of their ability to exercise and return to their normal activities. Although behavior change was not assessed in any of the studies that were included in this scoping review, the effectiveness of standalone “real” video education in changing health behaviors has been previously described. A systematic review of studies using a real video [30] found that behaviors such as cancer screening, treatment adherence, and self-care were increased using a single real video as the sole educational tool compared to various control conditions, supporting the potential utility of standalone animated video to enhance behaviors and potentially kidney transplant-seeking and donating.

Intervention design

Unfortunately, there was a paucity of evidence relevant to design features of the animations. The majority of the animations evaluated in this scoping review were 2D animations with a duration of 3 minutes or less. Only a few studies provided some guiding principles used in the development of the educational animation [13,14,16,21,23]. For instance, Schnellinger et al. [10] used animated characters to demonstrate proper pediatric antibiotic usage to parents. This strategy, known as modeling, refers to active and visual demonstrations of desired behaviors [30]. Video modeling has been found to increase self-care behaviors in numerous studies [30]. Another strategy used in 3 studies [11,13,14] is editing the animation in response to learner feedback. Editing is easier with digital mediums than film and allows an iterative process to meet users’ needs and for optimal communication of health messages [33]. It is notable that of 4 studies showing knowledge gains in at-risk groups, 2 had iterated the video in response to patient input, suggesting the potential importance of responding to learner feedback when creating animations for difficult to educate populations. Examination of the studies that did not differentially increase knowledge may provide insights. For example, one study [15] aimed to teach probabilistic information using animation. While there is some evidence that using a written approach may be more appropriate for this type of education, teaching probabilities may be difficult to achieve, regardless of the medium. In another study [18], 3D animation was not effective to increase knowledge. Motion sickness during viewing is a known limitation of 3D media, which might affect learning [35]. In 2 studies, the lack of difference may be due to low sample size, possibly indicative of insufficient power to find associations [18,24].

Intervention delivery

We found little, if any, technological integration to enhance access to learning materials or sharing of information. Most of the animations were viewed by participants on computers and were not available to patients or the healthcare community after initial exposure. Digital health interventions offer the potential to promote health education and behaviors in a way that gives users flexible and convenient access, but the full potential of current technological offerings has not been realized. As such, we were unable to glean insights of facilitators or barriers with respect to implementing standalone animated video remote from the clinical setting.

Our scoping review is limited by the design of many of the studies; only eight were RCTs. As quality assessment is not a requirement of scoping reviews, articles were not excluded on this basis; this may be a source of bias in this review [36]. The reporting of animated video development methods varied considerably in their completeness across the literature, and, as such, our data are limited by the details described in the studies. For example, most papers described the type of animation produced but did not provide details on the use of theory or key informants to develop the intervention. Incomplete reporting of outcomes may be due to the exclusion of 3 studies that did not measure knowledge change. Also, our limited selection to English language studies removes many innovative international models for this intervention. Lastly, our group published 2 of the studies included in this scoping review. An initial review of the studies was initiated prior to our video development and evaluation and this scoping review was later completed by a pre-doctoral student towards her dissertation.

Conclusion

Current patient educational methods about kidney transplantation have limitations to reach vulnerable populations and to empower patient sharing of education with salient others. There is a need for innovative strategies, such as standalone animated video, which offers ease and efficiency of learning and potentially sharing information.

Practice implications

The primary aim of this scoping review was to assess the effect of standalone animated video to increase knowledge among adults within any healthcare context. Our finding that this single medium may be a powerful format for instruction advocates for its usefulness in future educational interventions, including in diverse populations with challenges of age, literacy, and technology access, such as in individuals who could benefit from kidney transplantation or who may consider donating a kidney.

Funding Acknowledgements

This study is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number R39OT31887 as part of an award totaling $1.2M with no percentage financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

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