From ideas to action – The story behind one Cochrane infographic

I feel lucky living in an era in which I can easily find people with whom I share common interests and who also get excited about ideas that I have always found fascinating. That’s how I got to know about this project. It is not hard to see its value and potential for translating evidence (knowledge) to patients and practically anyone who wants to understand evidence and our work in Cochrane. In my opinion Cochrane infographics is a perfect opportunity to help achieve the knowledge-to-action process or the “knowledge translation cycle”, as it is also known. This project implies integrating the right amount of science, technology, and art, so what’s not to like?

With a few paragraphs I would like to illustrate some of my experiences with drafting infographics for communicating evidence.

WHY?

I’ve always thought that one of the biggest challenges in healthcare is the adequate, ethically sound, responsible, and efficient communication of research evidence to consumers (patients, families, carers), policy-makers, and other stakeholders and decision-makers. Efforts like Cochrane training for consumers and Testing Treatments are just two examples that show how the public can and want to learn about how treatments work and how all kinds of interventions and diagnostic procedures are tested.

Visualization is a critical part of many learning processes involved in many daily life situations. Unfortunately we tend to forget the information we read, and also (and possibly worse) sometimes we tend to have erroneous perceptions about our own knowledge. We also suffer from cognitive biases such as illusory superiority, mistakenly assessing our ability to be much higher than is accurate. The anti-vaccination movement is a perfect example of this. It is deceptively easy to believe one has sufficient competence to gather all relevant information and synthesize it without letting one’s own biases affect the result. So I usually think of this not only as a problem of quantity but also of the quality of the knowledge being transmitted. What we have here with this blog is a good opportunity to give infographics a chance as an add-on for knowledge dissemination, so I decided to draft my first infographic.

DRAFTING MY INFOGRAPHIC

Although there is no unique guidance on this, in my opinion and in general terms it would be advisable to choose a topic that it is both relevant and newsworthy. What I mean is picking a “hot” topic currently discussed on the news, blogs, or one that in your opinion (or from the perspective of experts and other stakeholders) would require wider attention and adequate explanation to change things and reach better health outcomes.

I am a paediatrician, so on this occasion coming up with interesting subject matter was an easy choice. I decided to communicate to my peers and patients what is the evidence on the use of probiotics for the prevention of necrotizing enterocolitis (NEC), a condition that affects preterm babies’ bowels and can be potentially dangerous. I’ve been listening and reading about the use of probiotics for preventing this condition and saving lives so I decided it would be a good idea to recap the evidence in a user-friendly way. A recent Cochrane review was available so I directed my attention to what the review would say to a lay person about the condition (the “what” and “why”), the methods (the “how”), and results. This can easily be obtained from the plain language summary, which is basically a friendly summary explaining the condition and the results from the review. With an eye on what the reader should get out of it, I tried to complete the picture by making use of the summary of findings tables and the rest of the review to have a better understanding of the whole body of evidence.

One of the most important things to share is our confidence in the estimate (quality of the evidence) based on the GRADE assessment. This gives a sense of how confident we are that the research estimate we obtained is true. Also it is advisable to present absolute numbers using a pictographic representation with figures that are intuitive and easy to remember.

Putting the infographic together took about three hours of my time spread over several days (while sitting in the cafeteria, during a flight, or whilst having a coffee-break). I am a Mac user (no conflict of interest to declare) and my choice of tool for drafting infographics or designing figures for my Blog or other work is Keynote®. I’ve found this presentation software both powerful and flexible for those of us who cannot or will not go into the depths of designing using Adobe® Photoshop or other more professional tools. Please remember that this is only a draft! On Keynote you can throw in images in any format and it will grab them with ease and flexibility. You can use many types of fonts and tweaks with visually amazing results. I always use it for my presentations. You can even supercharge the software with other supplementary applications like Infographics®, which is an application with lots of pre-fabricated designs with which you can create your own. There are tons of other applications that you can find to practice your skills if you want, like visual.ly, Piktochart, easel.ly, among many others. However, none of these tools are actually compulsory. As many blog posts have already stated, a draft infographic draft can be easily created by using a pen and a piece of paper!

This is an exciting time as we can forget about committees and simply leverage the power of the crowd or hive mind to find and implement incremental improvements together. Now it is your chance to tell us what you think and what do you recommend. All comments and critique are more than welcome. Let’s do this together. Click the link below to open a pdf of my infographic.

Carlos Cuello (mucked about by Jani Ruotsalainen)

probiotics_NEC_infographicprobiotics_NEC_infographic

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Some ideas for further development…

Exciting times are ahead for Cochrane, and the launch of an infographics product ties in perfectly with the recent rebranding. We are a world-leader in publishing independent, quality research for healthcare decision-making, and yet we’ve (so far!) struggled to become a household name synonymous with evidence patients can trust.

Working alongside Wikipedia to enhance and ensure healthcare pages reflect up-to-date evidence will certainly assist moving Cochrane in to the mainstream and away from the notion of dusty tomes that only clinicians and policymakers can make sense of, but creating infographics could potentially be the vehicle that places the headlines from our Cochrane reviews directly in the hands of those suffering from the conditions we study.

We need to define what are the key elements in Cochrane infographics that will assist decision-making while incorporating these very same elements in to a ‘sexy’ design that encourages people to share them. We should also consider what an efficient infographic production process might look like to get the evidence out there, and provide guidance for what an efficient dissemination strategy might look like.

Let’s break that down with a few ideas for further discussion…

Key elements

In terms of headlines, there needs to be the core outcome obviously (does the intervention work?), but we also need to be able to come up with a way of succinctly indicating overall risk. We could perhaps build on the Cochrane Risk of Bias threshold system where green indicates low risk of bias (i.e. everything A-OK), yellow means unclear (i.e. something iffy going on), and red means high risk of bias (i.e. serious problems). The result is a nice traffic light graph giving an overall impression of the included studies (see example below).

RoB summary example from Handbook

I’d particularly love to see the strength of evidence reflected in there too such as number of trials, number of participants, etc. It’s not only the right thing to do, as it acknowledges the contribution of all the patients who contributed to being able to determine whether the treatment works, but it also provides a more holistic view of the review process. To put this in context, would you personally trust the findings of a review with five studies conducted with 100 included patients as much as you would a review with 40 included studies and thousands of patients for making a decision about your own treatment?

We should be offering the public the opportunity to see this information clearly in the context of the headlines, and it also provides a talking point too. Furthermore, it’s also a nice way to clearly demonstrate the degree of work that has gone in to enormous reviews, and subtly indicate why the update hasn’t perhaps been published as soon as the public/clinicians/policymakers would have liked!

Design

Aside from adhering to the new brand guidelines, I imagine the infographics to be clean and bold, with the secondary colour (and incremental variant shades of it) drawn from the originating CRG’s own selected logo choice (cyan, green, magenta, orange, red, or teal).

Further to this, it’d be quite nice if the CRG’s logo was used perhaps rather than the generic Cochrane logo, as it’d be a good way to build each CRG’s public presence to encourage consumers under their scope to engage with them directly, and would reflect each logo used by individual CRG’s on their own social media accounts (the route many will ideally use to field queries relating to the reviews) and get conversation started all the quicker. Infographics may well be an ideal way for us to break down the barriers on the way of people accessing our research. They can also help the public connect who it was that produced which review, instead of assigning the credit to a rather faceless enormous global network.

I’ll come up with some visuals of alternative infographic layouts in the next couple of weeks (after a holiday first!), so that we can drive the conversation forward a bit more about what we do (and definitely don’t!) want to see reflected on infographics to accompany our reviews.

Production

It depends how people want to do this. Cochrane Review Groups are all unique with a degree of autonomy in their operation.

Considering this history of a DIY attitude, it would certainly be possible to produce a low-tech generic Word document template that MEs could enter the most salient details from a review in to predefined and preformatted fields that is then saved to PDF and converted (with clear instructions!) to JPEG for sharing as an image (the infographic).

Alternatively, I envisage the potential for Cochrane formulating a centralised team (working remotely, just like the copy editing team, and a named role in Archie to be incorporated in to the workflow system) of existing Cochranites with sufficient design skills to be drip fed reviews (supplied with the core content for inclusion in the infographic) at the point they’re sent for copy editing so that the infographic is ready at the point of publication.

This way, each review sent to the team would lead to an infographic with its own individual identity – looking distinct, whilst still coherent with the Cochrane brand – thereby increasing the likelihood of being shared repeatedly. Whereas the downside of the low-tech version would be to have fairly bland uniform visuals and a significant reliance on text to convey the message.

To assist in the efficiency of the production process, it’s probable that much of the iconography would be replicable across multiple reviews (e.g. blood droplets, syringes, anatomy sections [hand, heart, mouth etc.]) and therefore could be easily collated in a centralised repository to allow for quicker infographic composition.

Stylistically, if there are multiple audiences age-wise specific reviews want to appeal to, we could also look at a Cochrane Kids infographic product that is softer aesthetically (particularly in the choice of typeface and iconography) that parents can use to talk about healthcare with their children.

Dissemination

Shortened URLs are instrumental in delivering concise messages that users can reliably and quickly enter in their browser or share in a post (e.g. http://tiny.cc/triclosan); and would ideally be typed at the bottom of each infographic so that the address was embedded when shared.

Obviously, the more our reviews are linked to and read will inherently affect each Group’s potential to bump up their Impact Factor (and other metrics). Ideally, we would have our own shortened URL domain rather than relying on another company, and perhaps for simplicity the URL would reflect the Cochrane Database number for ID purposes.

A further benefit in doing this would be that when new iterations of the review are published, although a revised infographic would be issued the previous version would still link to the most up-to-date evidence should the review’s conclusions have changed at update.

Huge communities set up for sharing content already exist and it’s up to us to make sure we get our research out there, with undiluted and accurate headlines that are less likely to be spun by parties with competing interests or those simply looking to sensationalise for their own profit.

In addition to the usual heavy hitters (Twitter and Facebook), other social media communities have been building serious traction for some time too (Pinterest, Instagram, etc. [the list could go on and on…]), and once accounts have been set up, distribution to each of these could easily be managed from a single platform like Hootsuite.

Away from social media, MailChimp’s new photo campaign product Snap seems like the kind of email distribution vehicle editorial bases can make use of for little or no cost to approach other online communities.


Hopefully this post has provided some food for thought about the possibilities and direction Cochrane infographics could take. I’d love to hear your thoughts if you want to comment on the post.

Jo Weldon
Research Coordinator, Cochrane Oral Health Group

(with a little tinkering by Jani)

Introducing the start of Cochrane infographics

Let’s begin at the beginning

Infographics in Cochrane – what’s that supposed to mean? Well, it’s an idea. I could claim it as my own but I’m sure that there are many others who have had similar Heureka-moments years ago. For example, see this poster presented in Hyderabad. Also infographics as a whole have been around for centuries already. Especially when it comes to health issues, one has to mention Florence Nightingale’s elegant creation depicting causes of death in the Crimean war. So I stay well clear of declaring any originality in that department. What then is all the fuss about? My idea, or vision, or inspiring mental itch if you will, is that it would be really cool to have a visual format for presenting results of Cochrane reviews, something like an intuitive pictorial Plain Language Summary. As there aren’t ready off-the-shelf solutions, it is up to us cochranites to roll our sleeves and put something together ourselves. So, the second half of my idea is to leverage the enthusiasm of individuals, to lure likeminded people together and see what happens with a loosely defined target. Pretty much the same way Cochrane began in the first place.

Why should I keep reading?

I propose embracing a bravely anarchist approach where anyone can participate according to their interests and, to some degree, skills. This means no committees and only the bare minimum of steering. Wikipedia is perhaps the best living proof of the power of the hive mind. Why not try a similar model? Talking of proposals, who the hell am I anyway to be making any? Am I a designer? No. Am I journalist? No. I’m just an Average Joe Managing Editor plagued by curiosity. I harbor no delusions of joining the pantheon of design gods like David MacCandless who can do wonders already (see for yourself). I just want to see what we can come up with for Cochrane. Can we formulate some kinds of templates or iconography that Cochrane groups can then easily use to put together their own infographics? That’s what I want to find out.

Who exactly is doing what here?

To help me in this quest I’ve enlisted a number of Cochrane colleagues including CochraneTech (the propeller-heads) and the communications people (can’t think of a fitting stereotype to illustrate). Next I welcome YOU to join us. What we have agreed in our little coven so far is that we set up this blog as a sandbox, a common playground where any interested party can join in by commenting on posts and by posting their own improved versions. We now kick things off with a little something we put together earlier. I made a rough sketch and Jacob Riis from CochraneTech kindly made it look pretty. It tries to depict the main result of this Cochrane review and some supporting facts to better convince the reader. What do you think? Does it have the right things in it? Can you visualize risk in some better way? Should we stick to just the results? Please jump in and enter your comments below.
Visually Cochrane 1st draft infographic blunt needles-page-001Blunt-needles

Is there a method in this madness?

The long term vision here is to push a few drafts through this anarchistic unplanned development process to be able to present the results at the annual Cochrane Colloquium in Vienna. Then later we can even run an experiment to compare PLS, podcasts and whatever visual delights we manage to whip up in terms of how people understand and recall their contents. There’s already similar project afoot in Aberdeen by Shaun Treweek and friends. It will be interesting to see if we can get similar results. And so, without further ado, join me and together we will rule the galaxy… erm…sorry… I mean we will make some cool infographics! Woohoo!

Jani Ruotsalainen
Managing Editor, Cochrane Work