Systematic reviews can be beautiful when seen through the eyes of a comic strip artist

I recently illustrated key parts of a Cochrane systematic review on selective versus routine episiotomies. See the illustration in full on my website. Jani Ruotsalainen, who was unfortunate enough to see early versions of it (and even commented them to everyone’s great benefit), told me that others could be interested by further details on how and why I made this illustration. Hopefully by following his suggestion people who actually know something about illustration and research can swiftly bury my work and replace it with something good.

selective-episiotomy-focus-on-methods-sample

A snippet of the illustration explaining the systematic review process.

First, I’d like to begin with what I believe is most important about this illustration:

I HAVE NO IDEA IF IT IS MORE CONFUSING THAT HELPFUL.

Yes you read that right and maybe that’s not the best thing I should say about my work but I don’t intend on only saying positive things about it.

Indeed, every single panel of my illustration can be interpreted in many different ways by different readers (or by the same reader on different occasions, me included)*. Not all panels are as straightforward as I want them to be and there are a number of things that could be improved or done differently (such as involving end-users in the creation process, offering the review author’s perspective, regular updates or actually telling a story of how the systematic review emerged and how it fits with current knowledge). While uncertainties are entirely normal when testing non-standard approaches to research dissemination, I think it should be emphasized with this illustration. Epidemiology is a serious domain (even if I keep making jokes about it) and associated misunderstandings can have large consequences.

sample university hospitals.png

Some readers may think all 5 studies took place in the same hospital or that studies took place in single hospitals. Others may think they were only written in university hospitals. Many may see something else than a hospital (a factory perhaps?).

Now…Why did I go ahead and spend two days drawing non-stop (a pretty bad idea, I am aware, but motivation can come and go very fast) and over 35+ hours** working on an illustration of a systematic review?

Well, there are plenty of reasons.

The first one is that I did it so that I could have more friends who can fake understanding what I talk about***. The main reason I illustrated a systematic review is that I care about people being able to live happy and fulfilling lives and this has led me to health research, epidemiology, Cochrane and systematic reviews. Many healthcare guidelines and decisions are now based on systematic reviews and I find it critical that people understand some of their key elements. While I had already seen some graphical representations of systematic reviews. I felt they were still too abstract. I wanted to make it slightly more real and wanted to point out that illustrating a systematic review was entirely feasible. Finally, it was a personal challenge (am I crazy enough to do it?) and a way to (hopefully) get better at illustrating scientific studies (then maybe one day we can end up with more user-friendly epidemiology textbooks?).

As a bit of context and disclaimer, I also draw French comic strips (sometimes translated to English) on health research, all of which can be read online for free. While I try to keep things as simple as possible (or so I fool myself to believe) for anyone interested, the comics are primarily aimed at health professionals, with an educational intent and so was this illustration. In my opinion it is an illustration of parts of a systematic review and I would not call it something else.

So how did I do it?

I read a systematic review, summarized it, made some drawings, published it and gracefully accepted being praised for my heroic work.

I followed these specific steps:

  1. Search for and identify a key study (ideally a systematic review)
  2. Read, appraise the study and summarize its key points
  3. Send written summary to study authors for feedback
    • Update/modify if/as needed
  4. Illustrate the written summary with drawings
  5. Send illustration to study authors for feedback
    • Update/modify if/as needed
  6. Publish
  7. Review & update the illustration (in a perfect world)

Let us now examine each of these steps in a little more detail. Please feel free to emulate my recommendations/suggestions however you see fit. This process shouldn’t be set in stone and unchangeable.

1. Search for and identify a key study

The first step involves finding a study to illustrate. There are many ways to do this but I usually find ideas of systematic reviews to illustrate through a specialized alert system or by browsing the titles of recently published Cochrane reviews in the Cochrane Library. The selection process is highly subjective; as I try to choose the systematic reviews that I believe are sufficiently simple to require limited background explanations and that seem relevant to a broad audience (a decision which unfortunately means rare diseases are unlikely to be represented).

cochrane current issue.png

The current (February 2018) issue of Cochrane reviews. Found [here].

Consequently systematic reviews that are not Open Access (OA) are excluded. This is partly for legal reasons (copyright) but also because I want those reading my illustration to be able to check what my work is based on and because I strongly value OA science. Besides, I hope to encourage researchers to publish their work OA by mainly illustrating their studies. I know this makes no difference but I choose to believe a different narrative.

2. Read the study and summarize its key points

I then read the systematic review I found to check if my initial assessment was appropriate and I assess how rigorously it was done by using the AMSTAR II checklist.  This tells me if the authors followed good practices or not and to what extent. Systematic reviews with too low AMSTAR II scores or that lack a key AMSTAR II element are excluded (I said the selection was highly subjective). Again, I don’t want to illustrate studies that have been poorly done and that could be unreliable (unless the whole point is to show what probably shouldn’t be done) and I hope illustrating good ones encourages good practices (more delusions?).

I then briefly summarize the systematic review with 42 or so sentences with <30 words (I’m not drawing a book after all). This summary must, if possible, use the least amount of jargon (although I do include some by design and also by forgetting what is jargon and what is not) and either offer a visual or a verbal explanation otherwise. There must be some details about the context of the review, the methods used, when the searches were done, the results (I often select some of them or the primary outcome for brevity), conflicts of interest & financial sources and a link to the study.  Depending on my intentions, the summary may be more focused on some aspects of the study than others. In the selective episiotomy illustration my focus was on the methods and PICO framework, not the outcomes.

selective-episiotomy-written-summary-sample

An early draft of the selective episiotomy systematic review. Note the subtle changes in wording with the final illustration and the removal of some contents.

3. Send written summary to study authors for feedback

I then send an email to the corresponding author(s) of the review with the written summary included, along with some explanation of what I’m doing. If I get no answer whatsoever in the following month (as is often the case) I usually drop the project for fear of making momentous mistakes. If I get comments I try to update or modify my written summary accordingly (although I’m open to disagreeing). This can go on for some time (months or more) depending on the availability of authors, how frequently they answer/read their emails, how specific the comments are (and how easy the modifications) and how fast I make changes. I don’t know how much time the review authors spend looking at my illustrations. Although contact with the authors is an important step I follow to ensure fidelity of the illustration with the study, I am aware they may end up biasing it.

4. Illustrate the written summary with drawings

Here is a 5-minute video which may be more explicit than any explanation I may offer:

[Brief description of the CookieScience comic strip creation process (January 2018)]

Briefly put: I launch Photoshop CS3, open a premade template, add rows of squares to have similar spacing between sentences and drawings (the original intention was to make it easier if one day my drawings were to be printed, but I think those spaces are actually useless). I then type the sentences (either one or two per “row” depending on their length and what space I estimate they will require) and I directly draw one of the visual representation alternatives that comes to my mind when I read and think about the sentence. On rare occasions, I may look for some pictures on Google (such as on mediolateral episiotomies) for reference so that I stay accurate. I’m using a cheap Wacom Intuos Comic pen to simulate using a pencil (which is highly unreliable and requires me to restart my laptop 50% of the time to make it work…).

Photo1107.jpg

I may occasionnally draw outside. Unpractical, but I could hardly find something better than combining comics, health research and nature.

I then add some color where I find that it makes sense (again, a subjective decision) to make some elements stand out more (such as countries or studies with a randomized design) or to distinguish them (episiotomies in grey, selective episiotomies in white). The only rule is that colors must be kept simple (besides, doing this reasonably well would take me ages).

selective-episiotomy-with-and-without-color-sample

Some may find it easier to understand the process by manipulating the raw files, which can be found here.

5. & 6. Send illustration to study authors for feedback and publish

Finally, I send an email to the corresponding author(s) of the review with the illustration attached for feedback. As before, I then make changes where needed. Once the authors are satisfied with my changes I tell them when I will publish the illustration on my website and give them its URL link. All that is left once published is to send a tweet from my Twitter account.

I rarely promote my illustrations any further (I hate advertising as I have a hard time saying things I draw are any good and consider that if my drawings aren’t shared they weren’t that great to begin with****).

Some thoughts for the future

If I had to think about what to do next with this illustration, I would start by asking a sample of health professionals and non-health professionals what they think of it (while keeping in mind that some may find it difficult to understand combining illustrations/comics and scientific research) and collect suggestions for improvements/changes (especially those lovely criticisms!). I would then create three new versions (or actually I would ask actual artists to make them), make them into leaflets and compare them with a different leaflet (as similar as possible but with less or no drawings) in a trial. Important outcomes would also have to be defined together with end-users and stakeholders. Should these consist of: comprehension, dissemination of leaflets, contents remembered six months later, percent of the leaflet read, satisfaction, health outcomes, understanding of risks/benefits, or some combination of the above?

A more detailed documentation of the creation process (such as how the systematic review was selected and appraised, why some outcomes were shown and others not, etc.) may at some point end up being required for increased transparency and to help distinguish illustrations done following a rigorous process from those that may arise from less rigorous authors but this is likely to increase production costs and the time required to create the illustrations. I am also concerned this could stifle creativity and make it very difficult to illustrate studies. But this concern is likely premature because standards for scientific illustrations and tools to appraise them just aren’t available yet.

Assuming early results show positive and sufficiently important results (a threshold which may be up for debate) I would then love to see international collaborations of artists, non-health-professionals and researchers working on illustrations of research studies and their findings. Or competitions where the goal is to produce an illustration or a single drawing (with a CC-BY license!) which aims to explain a scientific concept/result/study that as many people as possible can understand and remember. I would also be curious to see speed-painting methods applied to illustrations of research studies and further derivatives such as: interactive illustrations, illustrations where the contents change depending on the users, living comic strips explaining the current state of research on a specific topic, etc…

But there is no need to rush; I am not keen to see illustrations of systematic reviews end up on a list of practices widely adopted yet later shown ineffective or harmful due to excessive early hype.

Acknowledgments

I would like to specifically thank the authors and Jani for their comments on my illustration as it is fairly uncommon for authors to answer my requests for feedback. I realize it may take some (valuable) time to check for inaccuracies or offer feedback and there are plenty of other more important things to do. Thanks a lot! Your help was well appreciated.

About the author

Martin Vuillème received very limited formal training in epidemiology and didn’t believe much of what his teachers taught him anyway. He received no funding for this illustration or previous ones. He hopes commercial, academic and personal interests never end up plaguing scientific illustrations and actually doesn’t like cookies that much. He is aware of novelty effects.

*Some could say words alone are also equally subject to interpretations.

** Many of which could be avoided with automation, extra tea and templates.

***Actually there may be more than an ounce of truth in this statement.

****If I get too attached to my work I could risk ignoring its critics and failures.

 

Comments from the editor (Jani)

Wow. Double wow. What the hell, let’s up the stakes straight away with triple wow with extra whipped cream and sugar on top! I mean not only does this guy understand our Cochrane cryptic secret language of systematic reviews but he can: 1) translate the essence of our complicated scientific product into something that doesn’t lull the reader to sleep within minutes, 2) draw elegantly, 3) explain in writing what he does for the benefit of others, and 4) sprinkle all of the above with a hefty wallop of humour! I bet he’s also good looking and plays Mozart on the grand piano from memory whilst blindfolded. I hate the bastard already. But seriously, this is just what the doctor ordered we need in Cochrane. If only we could foster more talents like his by organizing a practical workshop in which he could share his particular brand of magic live to inspire others. No wait. We can! Let’s invite the guy to the Cochrane Colloquium in Edinburgh in September 2018 and organize a workshop!

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Tweet, tweet + blogshot, or tweet + picture: results from a Twitter pilot study

I was once tasked with designing a qualitative study that asked administrators, nurses, and doctors about their accountability. Not an easy thing to do, as this subject is very complex and each group would see accountability very differently. In the end, having the interview participant draw out a diagram or edit a prepared one greatly helped (more here and here). Diagrams work well as a data collection method because they sit between the open-endedness of a visual and the linear flow of text (more here and here) and borrow the benefits (and disadvantages) of both sides. Cochrane Blogshots, which consist of a few lines of text summing up a Cochrane Review’s Plain Language Summary and an image, seemed to me to also sit on a spectrum between text on one side and the visual on the other.

When looking at the impact of blogshots on Twitter, it seemed reasonable to compare them to the two opposite sides of the spectrum, i.e. just text and just an image. Looking at engagement on Twitter, some say that tweets with images get up to 150% more retweets and 89% more favorites and infographics being 40 times more likely to share on social networks. So where would blogshots fit into this? Would blogshots borrow the benefits of text and pictures and be ‘better’ than both? Or would they borrow both the benefits and disadvantages of both and be in the middle?

Tasked with a quarter to look into blogshots deeper, we set up a pilot study to test how well blogshots performed. The long term plan was to hand off a tried and tested concept to other Cochrane groups to scale-up.  We had five data sets each with a tweet with just text, a tweet containing a blogshot, and a tweet containing a picture. We controlled for a variety of things:

  • Order of presentation: Perhaps the audience responds more favourable to the first tweet they see. Hence we changed the order of the three tweets for each dataset.
  • Time of day: All tweets were be sent at the same time: 9pm AEST, which is 12noon BST and 7am EDT.
  • Day of the week: Traffic varies depending on the day of the week. All tweets from the same data set were sent on the same day of the week.
  • Content of tweet: standardized wording and standard #cochraneevidence hashtag were used. We did not use any topic-based hashtags or tag any Twitter account.
  • Link to Review: We used a new and different link for each of the 15 tweets so that we could track who is clicking through to the review.
  • Accompanied material: Each of the five data sets were tweeted without an image, with a picture, and with a blogshot. The picture used was the same one used in the blogshot.
  • Topic: Interest in a tweet/picture/blogshot may be mostly driven if someone is interested in the subject matter. Working with Cochrane UK, we selected general interest reviews from their Evidence for Everyday Health Choices blogshot series to maximize general appeal.
  • Blogshot quality: Cochrane UK has taken the lead in blogshot production. We used only blogshots created by Cochrane UK to ensure an equal quality standard.
  • Only English: Blogshots are translated into many languages. Given the scale of this study we focused on English blogshots.

And so out went 15 tweets on the main Cochrane twitter account: five with just text, five with text and an image, and five with text and a blogshot.

blogshot

Here are the results (highest scores highlighted):

blogshot-study-results-clearer

C: clicks, L: likes, RT: retweets

Our small-scale study suggests that sharing a blogshot on average almost doubles the click-throughs, likes, and retweets that you get over a text-only tweet. However, sharing a related picture with text in a tweet on average triples the click-throughs and likes, and doubles retweets.

We hope that the Cochrane Community views this as a ‘proof of concept’ or ‘pilot stage’ study on which to base larger studies. This may be done by several people or groups working together and combining evidence, or several smaller studies done separately. Ideally it would also be good to have a sample of non-English tweets and perhaps a sample from a specialized audience, like a particular Review Group or Field.

It should also be noted that these measures really only look at engagement i.e. that people took notice of the tweets and then performed an action which makes them visible to us. It is hard to know if people understood the information within them or if they did something with that information offline. Unpacking the difference between engagement versus uptake and how it relates to impact is definitely a whole blog post in itself!

Overall I think the lesson is that presenting Cochrane visually is important. Every Cochrane-related post on social media should have an image accompanying it. This can be a photo or a blogshot, but the important thing is to include something other than just text. This should be standard practice across all Cochrane accounts.

CEAD looks forward to hearing from you on your thoughts about this pilot study and other plans to share Cochrane evidence visually.

Muriah Umoquit
Cochrane Internal Communications and Content Officer

Infographic Abstracts

“To abstract is to draw out the essence of a matter. To abstract in art is to separate certain fundamentals from irrelevant material which surrounds them.”  ― Ben Shahn

Abstracts are arguably the most important part of any publication, particularly a systematic review or guideline.  The most important because often that is all most readers read or have access to. In today’s world where most new science is behind a paywall, abstracts are currently the only truly open access conduit for new findings. Therefore abstracts should present data in the most user-friendly of form, meaning infographics.

forest-plot-of-trees_laurel-grahamThis is not an argument for pine tree icons instead of forest plots:  this is an argument for infographic summaries in PubMed and really every database that provides abstracts of clinical publications.

Visualized data will capture readers’ attention when they would otherwise just skim over text and miss salient outcomes. A big red bar across a prescription bottle or a 3-D pie chart with dead rats on a slice sends a clear message: “Don’t feed your rats pills!”

As the old adage goes: “Images speak louder than words”, wait that’s actions….

No matter. Messaging must be direct, correct, succinct, and graphic. Especially in this age of social media, short attention spans, and economizing.

optimal-feeding-for-rats_laurel-graham

In a world where emoticons and text messages impart vital information, science is at a disadvantage. When findings might as well be written in hieroglyphics, infographics can be the 21st century’s Rosetta stone decoding the results for all. For all because it has been discovered that researchers often rely on bits and pieces of data just like the public rather than finding and reading all of the relevant data.

Nicholas et al.’s study reported on a survey of more than 1,000 transaction logs (equalling 17, 000 sessions) in ScienceDirect. Results showed 20% of researchers only read abstracts. Apparently, they were relying on only the abstract’s data to determine suitability. This is particularly disconcerting because ScienceDirect provides links to full-text, dependent on the subscriptions of the institution the researcher is affiliated with. Even worse is the fact that many abstracts do not include measures of absolute effect. A study by King et al. found that in 96 Cochrane and 94 non-Cochrane reviews only 34 (22.5%) reported absolute measures. Sadly Agarwal et al. found that authors seldom report the most patient-important outcomes and absolute effect measures in systematic review abstracts. As King et al remind us, Peer-reviewed reporting checklists of studies, CONSORT and STROBE, recommend publishing both absolute and relative measures of effect whenever possible. The Cochrane Handbook also reminds us that absolute measures are useful when determining an intervention’s likely benefits and likely harms.

Jo Weldon, research coordinator for the Cochrane Oral Health Group, began the discussion of standards in her blog post; she recommended infographics feature: central outcome (does the intervention work?), indicating overall risk, strength of evidence, the publishing Cochrane Review Group’s logo,  and shortened URLs.

A next step could be reviewing PRISMA’s abstract reporting standards and translating those to universal symbols for example. All areas reported in an abstract cannot and do not need to be represented in an infographic, but many can and should be.

Laurel Graham, Evidence-based Dentistry Manager at American Academy of Pediatric Dentistry, Cochrane Innovations
Follow me on Twitter: @forestplot

 

Quo Vadis Cochrane visualisation?

September 2016 will mark the first anniversary of this blog – yay! Without better ideas regarding what to post next and there being no need to beat back eager volunteers throwing manuscripts at me with a stick, I thought it was high time we look back at what we’ve achieved thus far and where we might be headed next.

In my first post I envisaged recruiting like-minded individuals to take a crack at putting together some Cochrane infographics. I believe we can safely agree that this goal has been reached most spectacularly. My own feeble doodles were followed first by thoughts by Jo Weldon from Cochrane Oral Health on things to consider when putting together an infographic and then the first professional-looking product published on this here blog was by Carlos Cuello from McMaster on probiotics to prevent enterocolitis in preterm babies.

Then Jo Anthony and Holly Millward from Cochrane Comms heaped on more advice about what tools to use and what bits to include with helpful links. Next I jumped in again with something a little different, a GIF animation I made together with our institute’s graphic designer (have you seen the improved version?) about blunt vs. sharp needles to prevent needle stick injuries in surgical staff. Then Helen West from Cochrane Pregnancy and Childbirth broke the bank with truly exquisite examples of well thought out infographics about turning babies to reduce problems at childbirth that incorporated the official colour scheme and everything. Wow. The bar was set pretty high but then Paul Beirne from University College in Cork went beyond the static image with an animated video (Needle size for vaccination procedures in children and adolescents) equipped with a snazzy soundtrack featuring himself playing the guitar! Crikey! So clearly we’ve amassed a troop of eager volunteers willing to explain their thoughts and the production process behind the imagery they created. First point thoroughly ticked.

Secondly I hoped there would be something to present in Vienna once I got this ball rolling. There was. I managed to coax our institute’s graphic designer to put together that very convincing GIF animation I mentioned earlier. I subjected many fellow cochranites to it in Vienna and many kindly retweeted when I shared it on social media. But then the actual infographics meeting we managed to organise at the Colloquium was all rather ad hoc and more of an occasion to affirm the need for infographics and that there were people keen to put some together without being forced, threatened or even financially incentivised. Nonetheless, I declare the second point ticked as well. Even if we didn’t get our own session at a CochraneTech symposium or David McCandless giving a talk. I suppose one can’t have too much of a good thing.

My third and most ambitious point was to design and conduct an experiment to see if all the effort to visualise Cochrane review results actually pays off in that the end result is easier to understand and recall than, say, the abstract or PLS. Of course it’s fun and interesting as it is to us visually inclined nerds getting our jollies just by making infographics because it’s interesting. However, I’m sure none us would argue against it being even better if we could also achieve actual benefits outside our little coven with its secret handshake. Any success in this department? None whatsoever. Maybe I put off Shaun Treweek by mentioning him by name. I don’t know. But I still think it’s a great idea. So that’s the only agenda point I will be pushing in Seoul. What’s more, I’ve scribbled an infographic of sorts to illustrate what I mean. OK, it’s actually a poster but this will have to do for now.

Infographics RCT

This is what I want to do. Actually I think it would be rather silly not to since here we have an intervention that we would hope would have tangible effects, if not directly as health improvements but indirectly as increased knowledge. Does it? We’re not sure. How do we find out? We’re scientists so we conduct an experiment. How about any other avenues of development? How can we keep going forward with Cochrane infographics?

Here is my humble vision. 1) Let’s put together a training webinar accompanied by a Handbook of sorts. Miranda Cumpston and friends from Cochrane Training can surely help. 2) Let’s rig up a funding mechanism by which sufficiently well fleshed out ideas could be outsourced to paid designers. I discussed this with Julie Wood in Vienna and she was generally positive about the CEU setting aside something like GBP 5000 per annum. But then we didn’t manage to put anything on paper. This of course begs the questions of what is well fleshed out and who decides? Maybe there’s enough material there for a another post.

Now though I shake off the office dust for a spot of well-earned holiday. Should this experiment idea tickle your fancy please get in touch after I ooze back to the bureau on August 8th.

Cheerio!
Jani Ruotsalainen

Creating an animated video summary of a Cochrane review

After reading Jani’s blog post on creating Cochrane infographics I thought I would try and produce one for our most recent review: Needle size for vaccination procedures in children and adolescents. I soon encountered several obstacles created by the complexities of the review which involved:

  • multiple comparisons (long versus short needles, wide versus narrow needles)
  • multiple patient-relevant outcomes (immune response, pain, crying, local reactions, other adverse events after vaccination)
  • varying quality of evidence (GRADE) ratings across outcomes.

My attempts to address these issues resulted in a messy infographic that contained too many images and an excessive amount of explanatory text. I eventually abandoned the infographic and decided to create a video that would incorporate a voice-over to deliver additional information that could not be communicated by a static combination of images and text alone. You can have a look at the finished product below:

I developed the video in four stages:

Stage 1: Drafting the voice-over (narration) script for the video

I used the Plain Language Summary (PLS) of the review as a template for the voice-over script which I divided into four sections:

1) Introduction/Background
2) Review questions
3) Study characteristics and quality of the evidence
4) Key findings.

I drew up a table for each section that contained a draft of the voice-over script and an outline of appropriate visuals that could be used to communicate the key messages. It is essential to plan the narration and visuals for the video simultaneously because you will need to deliver the voice-over at a pace that will allow sufficient time for any accompanying images and text to appear on the screen. An extract from the table that I used for the Introduction/Background section is illustrated below:

pbeirnetablefinal

Once I had completed a Table for each section, I then read the entire voice-over script aloud from start to finish several times. Reading aloud is a great way to identify words and phrases that don’t ‘sound right’ and can also help to identify transitions from one sentence to the next that are not as smooth as they should be. After multiple edits I finally had a workable voice-over script for the video of about six minutes in duration.

Stage 2: Recording the voice-over script

I recorded the voice-over on my office PC using a basic USB microphone and Audacity® – a free software programme for sound recording and editing. During the recording I read the script at a relatively slow pace and tried to ensure that there were appropriate pauses where I intended new images or text to appear on the video. I carried out some basic post-recording editing using Audacity® to remove unwanted background noise (including the annoying ‘hum’ from the air-conditioning in the office). I saved the final voice-over as a WAV (Waveform Audio) file.

Stage 3: Making the video

I used Camtasia® screen capture and video-editing software to create the video. I have been using Camtasia® for several years and have found it one of the easiest video-creating tools to navigate and work creatively with (I should mention at this point that I have no vested interests to declare in relation to any products mentioned in this post!).

The first step in making the video involved importing the voice-over audio file and all of the images that I intended to use into Camtasia®. I obtained the images from multiple sources including creative commons license images located using Google images and free clip art sites such as clker.com. I also purchased some royalty-free images via subscriptions to shutterstock and PresenterMedia. I customised some of the images in PowerPoint (e.g. I ‘cropped’ some images to remove unwanted parts) before finally importing into Camtasia®.

Once the importation process was completed, I added the audio file to a ‘track’ on the ‘timeline’ (see below). I then added images to different tracks and positioned them on the timeline to ensure that they were appropriately synchronised with the voice-over. This process was very time-consuming but it was not technically difficult to do – Camtasia® has an intuitive, easy-to-use interface and the product website also includes numerous tutorials that show you how to navigate the various settings and use basic and advanced video editing techniques.

Paul Beirne's pic1

Deciding how to present the key findings of the review was one of the most challenging aspects of creating the video. I opted for a modified version of a Summary of Findings Table (see below) that contained details of the outcomes, the GRADE quality of evidence ratings and a narrative summary of the key findings. For simplicity, and in keeping with the presentation of results in the Plain Language Summary of our review, I did not include any numerical data in the table. I used Source Sans Pro typeface for the text in accordance with Cochrane branding guidelines.

Paul Beirne's pic2

Stage 4: Adding the finishing touches and producing the video

Having synchronised all images and accompanying text with the voice-over, I used editing tools in Camtasia® to add some visual effects, including ‘transitions’ to create a smoother flow between different sections of the video. I also inserted arrows and highlighted text at selected time points to draw the viewer’s attention to specific parts of the screen. At the beginning and end of the video I added a ‘handwriting effect’ created using the whiteboard software VideoScribe®. I saved the handwriting effect as a Quick Time Movie (.mov) file and then imported it into Camtasia®. Finally, to remove any ‘awkward silences’ at the start and finish of the video, I added a repetitive guitar riff which I played on my acoustic guitar and recorded directly into Camtasia®.

With the finishing touches added, I was now ready to produce and share the video. Camtasia® allows you to you to upload your video immediately on YouTube, Vimeo and Screencast.com, provided that you have already registered with these sites. You can also use Camtasia® to produce the file in several formats including MP4, WMV (Windows Media video), MOV (QuickTime movie), AVI (Audio Video Interleave video file), M4V (iPod, iPhone, iTunes compatible video) and GIF (animation file). I chose MP4 format as this offers a good quality video with a relatively small file size and it plays on most desktop browsers, smartphones and tablets.

Conclusion

The findings of some Cochrane reviews may be challenging to present in an infographic. As a previous contributor to Visually Cochrane has noted: “where there are multiple comparisons, lots of outcomes or no clear findings it becomes much more difficult to summarise the review visually.” In these circumstances an alternative approach is to consider combining images with narration in a video format. I hope this post has given you some useful hints regarding how to develop such a video. Other helpful tips for producing a Cochrane animated video can be found in another blog post in the Cochrane Community Archive.

Good luck in your creative endeavours!

Paul Beirne

Paul is a Cochrane review author and teaches epidemiology to public health students at University College Cork, Ireland.

Visualising data in a Cochrane infographic

I took up the challenge of producing an infographic for a Cochrane review, and decided to use the recently updated review: External cephalic version for breech presentation at term. My aim was to produce a visual outline of the summary of findings table and plain language summary for a lay audience. In this blogpost, I will focus on the process of creating meaningful visualisation of the data. This is the area that I found most challenging when producing the infographic, and I would like to explore how it can be done effectively. It’s difficult to strike the balance between simple communication and research complexity: It’s impossible to include every detail of a review in an infographic, but removing too much detail can distort the message of the original review beyond recognition.

Developing the infographic

The raw materials you start with are critical to the quality and clarity of the infographic you’re able to produce. The review I chose had an excellent plain language summary, written by Dr Elizabeth Wager. The review had clear conclusions that could be represented visually: two outcomes in the summary of findings table showed differences that could be turned into pictographs (vaginal cephalic birth not achieved and caesarean section), the other outcomes showed no difference between groups so could be summarised briefly (Apgar score <7 at 5 minutes, umbilical vein pH < 7.20, neonatal admission, and perinatal death). Where there are multiple comparisons, lots of outcomes, or no clear findings it becomes much more difficult to summarise the review visually. I was lucky that this review fitted the format of an infographic!

I used Piktochart, a free online tool, to product the infographic. Piktochart allows users to input data and produce graphs and charts. This function was very useful for producing the arrays of babies and women for a pictograph, which could be easily edited. I was mindful of sticking to the Cochrane brand guidelines, and keeping the layout clean and uncluttered. The design was influenced by Carlos Cuello’s infographic Probiotics and necrotizing enterocolitis in preterm babies, presented on this blog in September.

The infographic of ECV at term

ecv-at-term

Challenges in data visualisation

I faced two major issues with turning the review data on mode of delivery into a pictograph: How to accurately present meta-analysis in frequencies, and how to communicate uncertainty in the results. The review presents “vaginal cephalic birth not achieved” (phrased negatively to fit the conventions of RevMan). However, from a pregnant woman’s perspective “head first vaginal birth” is probably a more important and interesting outcome. Logically “not head-first vaginal birth” and “head-first vaginal birth” should add up to all births…. As all babies are born either by caesarean section, vaginal head-first delivery, or vaginal breech delivery, the neatest way to present the results of the review would be as a single grid for “type of birth” comparing these outcomes. Again, logically the three types of birth should add up to all births… However, my numbers didn’t add to up 100 out of 100 babies, as illustrated below: blog example (1)

After checking the numbers (several times!), I worked out why they didn’t add up. In a meta-analysis, the weighting assigned to studies is affected by the number of events for an outcome, as well as the size of the study. Therefore, switching an outcome around can completely change the weighting, and the final relative effect.

I wanted to present the outcomes that pregnant women would be most interested in, but also for the infographic to be consistent with the review. I decided to show the outcomes presented in the review as two separate outcomes (caesarean section and head first vaginal birth not achieved). I used colour to highlight the positive outcome “head first vaginal birth” in magenta, against light grey for “not head first vaginal birth” from the review, and framing the outcome both ways in the text (for example. “79 babies out of 100 did not have a head-first vaginal birth” and “21 babies out of 100 had a head-first vaginal birth”). To differentiate between the outcomes caesarean section and head first vaginal birth not achieved I used women icons in the caesarean pictograph, and baby icons in the head-first delivery pictograph.

I wasn’t sure whether and how to include confidence intervals on the infographic. Confidence intervals are important in the reporting of review findings, and affect our certainty in the result. However, they may not be well understood by the public and it’s not easy to present them visually without over-complicating the message of the infographic. I experimented with a few options, but decided to take the same approach as Carlos Cuello, including the confidence interval in the text and relating it to the role of chance.

Helen West, Cochrane Pregnancy and Childbirth

I’d welcome feedback on this infographic. In particular, I’d like to hear your views on the issues relating to data visualisation:
• how to get the right balance between simple communication and research complexity;
• how to accurately present meta-analysis in frequencies;
• how (and if) to include confidence intervals.

[Helen West is supported by an National Institute for Health Research (NIHR) Cochrane programme Grant (13/89/05) and Cochrane infrastructure funding to Cochrane Pregnancy and Childbirth. The views and opinions expressed herein are those of the author and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Health.]

Beyond rules and regulations

In the previous post Holly and Jo went a little deeper into what Cochrane infographics can be like and how you might go about creating your own. Their post provides guiding questions on the what and the how, i.e. the contents (pictures and text) and the tools with which to put them together.

However, I’m a little scared that all this helpful advice is seen more like stiff regulation that will be enforced with almighty force. Ye shall include the Cochrane logo, the correct font, colour scheme, punctuation, hyphenation, etc., etc. or thou shalt incur the wrath and furious vengeance of Cochrane! Sounds ominous, right? Well, thankfully Cochrane is not actually eager to smite anyone with stone tablets of truth or any other instruments. Biblical or otherwise. There is still plenty of room to play around and to try what might work as a Cochrane infographic. To illustrate the point, I attach here a proof of concept I put together with my colleagues Ella Smeds and Matti Gröhn from FIOH.

Blunt needles improved

This is an animated GIF explaining the main result of Cochrane Work review Blunt versus sharp suture needles for preventing percutaneous exposure incidents in surgical staff and its relevance. Not too shabby, eh?

What it still admittedly needs is GRADE (high quality evidence) and an explanation of the kinds of operations in which the intervention has been tried and tested successfully (abdominal operations, vaginal repair and hip replacement). Also a link to the actual review wouldn’t hurt either. However, even with its present imperfections it is quite formidable in lodging a simple message into the viewer’s mind. The gif is also small enough to be attached to a tweet. So, if Ella, Matti and I were to provide a word of advice, we would chisel these points on our stone tablets:

  • Come up with arresting imagery that grabs the viewer’s attention. Moving pictures are more effective than static ones.
  • Emphasize your facts and main message!
  • Keep your infographic small enough so it can piggyback on a tweet.
  • Work iteratively and, if possible, with people who have totally different backgrounds and sensibilities than yourself.
  • Forget all advice you’ve read and heard (especially if listed as bullet points) and just try out something!

I often describe Cochrane as a global semi-anarchistic network (i.e. not just anarchy in the UK). The great thing about such a loose network is that it has tremendous amounts of talent and potential sprinkled all over the world. We just need to tease it out and tap into it. Thankfully Cochrane has already made great headway in leveraging its members’ skills further with new tools like Task Exchange. Hopefully we can put it to good use also in connecting skills and ideas when it comes to Cochrane infographics. The sky (i.e. not heaven) really is the limit here.

Jani Ruotsalainen, Cochrane Work, FIOH
With the kind help of Ella Smeds and Matti Gröhn, FIOH