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.

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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.]

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