Research document by Sandra Yuen

HAPPY FOLK

RESEARCH DOCUMENT Inthernship at Happy Folk

Student Name: Sandra Yuen Studentnr: 464474 Email: sandra.y32@live.com Mobile: 06 31956774 Education: HAN University of Applied Sciences Major: Communication & Multimedia Design (CMD-C) Company Name: Happy Folk Address: Nieuwe Oeverstraat 31-33, 6811 JB Arnhem Website: www.happy-folk.com Manager: Mark Tamea Email manager: mark@happy-folk.com Mobile manager: 06 14989990 University Coach: Yvonne Brinkman Email: yvonne.brinkman@han.nl Mobile: 06 28304356 Date: 18 May 2017 Verion: 2.0

TABLE OF CONTENT 1. Preface...............................................................................................................................................................................3 2. The approach..................................................................................................................................................................4 3. How can spine Advice assure the degree of understanding of patients about Orthopedic surgery?.......5 4. What content must be provided in the animation regarding the understanding of patients about Orthopedic surgery?........................................................................................................................................................10 5. Which type of animation can be used to improve patientsâ&#x20AC;&#x2122; knowledge and understanding regarding the target group?..............................................................................................................................................................14 6. How can animation improve patientâ&#x20AC;&#x2122;s knowledge and understanding?.........................................................18 7. Conclusion.....................................................................................................................................................................20 8. Appendix........................................................................................................................................................................21

1. PREFACE This document is written in conclusion for the research of the graduation project at Happy Folk conducted by Spine Advice. The graduation assignment is to create a proof of concept which could be a solution for Spine Advice’s communication and understanding of the problem for the future. Therefore, a rich research will be done before creating the proof of concept. The research result and process will be written in this document in order to support the thesis (graduation project) at /happy Folk. The main question for this research is formulated as: “How can Spine Advice improve patient’s knowledge and understanding of Orthopedic surgery through animation?” In order to answer the main question correctly, it’s better to divide it into several sub-questions which they are also going to be answered in the further chapters of this document. The following sub-questions are: a. How can Spine Advice assure the degree of understanding of patients about Orthopedic surgery? a1. What is understanding? a2. How do you know when a person has understood you correctly? b. What content must be provided in the animation regarding the understanding of patients about Orthopedic surgery? b1. What content is important for patients about Orthopedic surgery? b2. Why those contents of Orthopedic surgery are important according to patients? c. Which type of animation can be used to improve patients’ knowledge and understanding regarding the target group? d. How can animation improve patient’s knowledge and understanding?

2. THE APPROACH In order to answer the sub-questions, there are several approaches required which were are already mentioned in the previous document of Research plan. For each sub-question, there will be a method of approach in order to have a correct and accurate answer. The answers are not randomly found for this research, all answers have had their sources based on professionals and expertsâ&#x20AC;&#x2122; knowledge which is reliable and trustworthy. Down in the table below is an overview of all the sub-questions that will be answered in several approaches. Desk research Desk research is actually research on secondary data which it is already collected from others. For example, information from CBS, theories in the Multimedia/animation field and literature from CAVI course. The student will do desk research in order to answer all the sub-questions of the project, which means in every components desk research is required (Dingemanse K, 2014). For product analysis desk research is also a must in order to gather information from other competitors. From desk research, the student will find criteria and requirements from other experts which the students can use these criteria to make his/her animation successful. Field research Field research is another method to collect information outside of your workplace setting. It is also known as qualitative research, which means the research is supported by quality information. This research method can be used for the target group analysis, which takes an insight of the target group by interviewing them for their experiences and opinions. Experimental/Showroom research Experimental research/showroom research is to experiment on the created prototype (cmdmethods, n.d). In the design stage and the end stage there will be a test session to test out if the collected data is sufficient or not for the target audience. During the experiment, the student can uncover hidden values and requirements from the target audience. This kind of examination is used to determine causation.

Subquestions a. How can Spine Advice assure the degree of understanding of patients about Orthopedic surgery?

Research Desk, Field,

a1. What is understanding?

Desk

a2. How do you know when a person has understand you correctly?

Field Showroom

b. What content must be provided in the animation regarding the understanding of patients about Orthopedic surgery?

Desk, Field, Showroom

b1. What content is important for patients about Orthopedic surgery?

Field, Desk, Showroom

b2. Why are those content of Orthopedic surgery important according to patients?

Field, Showroom

c. Which type of animation can be used to improve patients' knowledge and understanding regarding the target group?

Desk, Field, Showroom Desk, Field, Showroom

d. How can animation improve patient's knowledge and understanding?

Chart 1. Research method overview per sub-question. 4

3. HOW TO ASSURE THE DEGREE OF UNDERSTANDING OF PATIENTS ABOUT ORTHOPEDIC SURGERY? In order to answer this sub-question correctly, there are several types of research required. Therefore, this sub-question is divided into two sub-sub questions, because it’s too complex to answer the sub-question by itself. The approach in order to answer this question is by doing desk research to define what the term “understanding” means. The next approach is going to be field and showroom research, which it’s going to be explained in detail how this will take place under the paragraph 3.2 The assuring of understanding. Lastly, this sub-question is going to be answered by summarizing all the research results that are found. 3.1 Defining understanding By defining understanding is necessary, because the main question is about patient’s understanding of Orthopedic surgery. According to the literature of Education and Mind in the Knowledge Age by Carl Bereiter, understanding is a psychological process. This process is related to an abstract or physical object, such as a person, situation, or message whereby one is able to think about it and use concepts to deal adequately with that object. Understanding is a relation between the knower and an object of understanding. Understanding implies abilities and dispositions with respect to an object of knowledge sufficient to support intelligent behavior (Bereiter C, 2002). Understanding is also a way of communication. The main purpose of communication is to transfer the message to others clearly. This message is not being transferred by accident, but there is a purpose of understanding. By having a communication, it takes effort from both the sender and the receiver. And it’s a process that can be fraught with error, with messages often misinterpreted by the recipient. When this isn’t detected, it can cause tremendous confusion, wasted effort and missed opportunity. In fact, communication is only successful when both the sender and the receiver understand the same information as a result of the communication. Down in the image_A1 below, you can see the communication process theory how the message is being transferred to the receiver. From the theory of “The Mathematical Theory of Communication” the receiver has to give feedback to the sender in order to confirm the understanding of the message that is being transferred.

Image_A01 Mindtools. (n.d)

According to many researchers, for greater clarity and understanding, written materials should be created in a patient-friendly manner. This means using simple words, short sentences in bulleted format, and lots of white space. Medical jargon should be avoided and simple pictures should be used when helpful. Emphasis should be on what the patient should do and unnecessary information should be avoided (Graham S, Brookey J, 2008).

During this research for this project, there is a survey created in order to have an overview of the thoughts and opinions of the target group. In the target group analysis document, it shows that the target group mostly consists out of seniors/elderly people as according to CBS (Centraal Bureau voor de Statistiek, 2014). Down in the table below of image A_02 are the statistics of patients associated with Orthopedic surgery of Hip Replacement from the year 2005 till 2010 from Central Bureau van de Statistiek. The highest frequently patients among Orthopedic Surgery Hip Replacement are being circled in the image. For both gender, as males and females, they are from 65 years old or older, which is the most common group for hip replacement surgery. This means Orthopedic surgery of Hip Replacement is more common among seniors/elders. Like all we know, when people are aging they become slow and have short-term memory declining. According to Gerontological Society of America research short-term is critical in processing complex sentences, for example, “The brown dog that I saw running away from the car yesterday sat in the rug”. The sentence is with embedded clauses. For seniors/elders, this sentence is too long and too complex in order to understand it fully. To understand the sentence fully it involves a holding number of “pieces” of information simultaneously in short-term memory. In extensive published research, it shows that seniors/elders have an extraordinarily difficult time to process sentences with multiple embedded clauses (changeagents365, n.d). In order to say a very long and complex sentence, make short and separate sentences. For example; “You have arthritis of the hip which is making it painful for you to walk and may eventually require hip replacement surgery if we cannot control your pain with medications”. To understand this sentence correctly the receiver or listener must retain the word “arthritis” in short-term memory while processing that arthritis is causing pain while walking and surgery may be necessary if medication therapy is ineffective in controlling the pain. The sentence should be divided into separate parts, which the sentence can be meaningful by its own.

Image_A02 (Statline.cbs, 2014) 6

The results of the survey from the target group analysis show that the provided information is only 55% understandable to the patients. However, 35% of the target group doesn’t understand the provided information that well. This means 35% of the target group think they have an average understanding of the provided information. These percentages point out that there are some communication and understanding problem among patients and doctors/surgeons. If the communication is good among patients and doctors/surgeons, the percentage would be 100% “Well” understandable. Review the percentage of the understandability of the provided information down in the pie-chart below in image_ A03.

Was the provided information understandable? Very 5%

Not 0%

Less 5%

Not Less

Average 35%

Average Well Very

Anxious

Well 55%

Shocking Worried Reassured Other as Not applicable 29 29 7 5

100

Image_A03

According to Susan Leigh an Altrincham Counsellor and Hypnotherapist, to help other people understand what we’re saying is to maintain a two-way conversation rather than deliver a monologue or ‘speech’. That way each stage of the discussion flows better by being inclusive. By listening, asking questions and responding to what’s being said there’s a better chance of everyone involved understanding and being on board (Leigh S, 2014). 3.2 The assuring of understanding According to AMA Foundation, the best way to know if the patient has understood the given information fully is to use the “teach-back” method. This technique is very effective in order to ensure that patients understand what the doctor/surgeon has told them. It’s a very simple method in which doctors/surgeons can ask the patient to explain to them what they have understood from the given information. From the research in the target group analysis, patients/testees are required to have a combination of interaction with the doctor/surgeon and an animation on the side. This combination of communication is very effective because the doctor can provide the patient the animation during the consultation. After watching the animation, the doctor can use the “teach-back” technique to assure if the patient understands the information correctly. In this case, if the patient cannot explain what is going to happened to them in the surgery, the doctor can explain the information again to the patient. The result should be new efforts to ensure that patients learn what they need to know (Barry, D., Weiss, MD., 2007). Furthermore, for greater clarity and understanding, written materials should be created in a patientfriendly manner. This means using simple words, short sentences in bulleted format, and lots of white space. Medical jargon should be avoided and simple pictures should be used when helpful. Emphasis should be on what the patient should do; unnecessary information should be avoided (Barry, D., Weiss, MD., 2007). 7

Guy Harris thinks confirmation is the key to ensuring people’s understanding. It’s the illusion that people accurately understand another person’s intended message based solely on the interpretation of words, tone and body language is a trap that can hinder your desire to become a truly remarkable communicator. People certainly have an interpretation of what others intended to say, people never know if others understand correctly until the information is being confirmed. Confirming mutual understanding is the feedback loop that is often missing during situations which can lead to misunderstanding and frustration (Harris G, 2012). Well phrased confirmation questions can help to assure others’ understanding by asking the following questions (Harris G, 2012): “Let me say back to you what I think you just said, so that I can be sure I understood you correctly…” “Please correct me if I am wrong. I understood you to say ________. Is that correct?” “If I hear you correctly, you are saying _____________. Is that right?” “I hear you saying ____________. Is that right?” “It sounds to me like you feel/think ____________. Did I understand you correctly?” This approach of assuring the understanding is applied to the test of the proof of concept in order to confirm the understanding of the patient. Furthermore, in the test of the proof of concept the method of “teach-me back” is also being used by asking the following questions to the patient regarding the animation. These are the questions that are made based on the “teach-me back” method for the test of the proof of concept: 1. Can you give a short summary about the animation? 2. Can you tell a story regarding the steps that have to be taken for a hip replacement surgery? 3. Can you name the medical term of the artificial hip? 4. Can you point out on your own body where the incision is going to be in order to be operated?

Proof of concept Test The animation is clear The graphic is modern The content/animation is understandable The procedure is narrated step by step Testee feels more secure after watching the animation 3D graphic is clear and clean 3D graphic gives different angle/ perspective view The animation gives an interesting feeling The animation minimize the complexity/confusion of a surgery The content covers all the headlines of a surgery The animation looks very accurate to realism

1 X X X X

X X X X X

3 X

4 X

X X

X X X X

X X X

Total 3 1 4 5 1 3 3 3 2 3 1

Checking for understandablity Testee can give a summary Testee can tell the procedure step by step Testee remembers the artificial hip name called "Prosthesis" Testee can point out the incision position on his/her body 8

X X X

X X X X

X X X

X X X X

5 4 4 4

Table_A04

The test result of the proof of concept turns out positively regarding the patient’s understanding. Hereby, the “teach-me back” method is being used, which the tester ask the testee to explain the procedure of the surgery step by step. In table 1.2 “Checking for understandability”, it shows all the testees could give a summary of what they have seen in the animation. This method allows the patient to confirm the understanding of the given information in the animation with the doctor/surgeon. Summary Understanding is a way of communication, which it’s a relation between the knower and an object of understanding. The main purpose of this communication is to transfer the message to other clearly. A successful communication requires both as sender and receiver to understand the same information. For this project, the target group is mostly patients (women) from 65 years old or older. This means most of the target group is seniors, which people are aging in this age. These patients are slow and might have short-term memory declining. Patients among these ages have difficulties to process and retain complex sentences. Therefore, it would be easier to make short sentences for them when communicating. It’s difficult to know or to assure when a person has understood the given information or message correctly. Hereby, the receiver can give feedback to the sender in order to confirm the understanding of the message that is being transferred. Another method to assure the understanding of a patient is to use the “teach-me back” method according to AMA Foundation. Doctors/surgeons can ask the patient to explain what they have understood from the given information in the animation to assure patient’s understanding. Furthermore, for greater clarity and understanding, written materials should be created in a patient-friendly manner. This means by using simple words, short sentences in bulleted format, and lots of white space. Medical jargon should be avoided and simple pictures should be used to help the patient with retaining health literacy.

4. WHAT CONTENT MUST BE PROVIDED IN THE ANIMATION REGARDING THE UNDERSTANDING OF PATIENTS ABOUT HIP REPLACMENT OF ORTHOPEDIC SURGERY? This sub-question is also divided into two other sub-questions to reduce the complexity of the question. Therefore, the first part of the sub-question is to define the most important content regarding hip replacement surgery. The second part is to find out why those contents are so important for a patient. The approach for the answer is to do desk-, field- and showroom research. Desk research is about searching online and literature information. In field research is about collecting valuable information from the target group based on surveys and interviews. As last, showroom research is about testing out the content on the target group which it is tested on a moving storyboard. The sub-question is going to be answered according to all the collected information and summarized as a concrete answer to the question. 4.1 Content requirement The content of an animation about hip replacement of Orthopedic surgery is very broad. To specify what the content is of an animation several research is made on hip replacement animation. This research is also called the product analysis. From the product analysis, it shows the content of an animation is basically the storyline or the content what the animation is about. Everything could be the content, but what is exactly the most important information that a patient requires in order to understand hip replacement surgery. There is a product analysis document created, which several animations are analyzed base on five categories, which storyline is listed as the first category. According to AMA Foundation research medical information has to be limited and focus on the most important things a patient needs to know to undergo a hip replacement surgery (Barry, D., Weiss, MD., 2007). The Ask-Me-3 is a quick, effective tool designed to improve health communication between patients and providers. This tool encourages patients and families to ask three specific questions of their providers to better understand their health conditions and what they need to do to stay healthy (National Patient Safety Foundation, n.d). These three questions are the most important questions for patients.

Image_B01 (Barry, D., Weiss, MD., 2007) The answers of these questions are exactly the most important information or content that a patient must know. The questions are shown in image_B01. From the product analysis, it shows that many hip replacement animations have a very structural storyline which the patient/viewer can follow and understand easily. The storyline of every hip replacement surgery animation is divided into three sessions. The animation will start with a brief introduction about hip replacement surgery, then follow by the procedure and as last the after procedure or recovery. In the brief introduction, the narrator will explain what the cause is for a hip replacement surgery and what has to be done in order to be healthy. In the collected data from the survey, it also shows these three sessions of information are the most common information that patients would require in order to undergo for a surgery. There is only one difference between the survey results and the product analysis result. From the survey results, patients/testers also require information of the preoperative session. The preoperative is the before operation session, which it tells how the doctor/surgeon is going to prepare the patient for the surgery. The chart results of the survey are shown in image_B02. 10

What kind of information do you think is the most important for you to feel assure about the surgery? Other

Procedure

Recovery

Artificial replacement

Medical instruments

Incisions

Pre-operative preparation

61 0

Image_B02 Not

Less

Average Well 43

Very

In the image, it shows there are three information sessions that have the highest rank of the list. The first highest percentage from the list is the recovery information with 79%. The second highest percentage Do you information from a brochure is the information about the think procedure which has 74% and lastlyisthe pre-operative preparation with interesting? 61%. All these data are leading to the answer of the sub-question about the most important content Not Very that has to be provided in a hip replacement surgery 6% animation. As for the other information which has 13% Less lower percentages doesnâ&#x20AC;&#x2122;t mean they are not important or12% unnecessary, but they are less important for a patient to feel assure about the surgery. The patient can ask for more information during his/her consultation with the doctor. The three highest percentages information sessions are the main information Not that a patient requires in order to feel assure about the surgery. Less Average

Well

26% Down in the table Well below in Table_B03 are the interview results, which it shows the most important Very are the procedure and the recovery. contents for a surgery

Interview Feelings:

1 Sad Disappointed Worried Afraid Accepted

X X

Understandable Many medical terms Understandable with sketches

X X

Surgery experienced Average 2 3 43%

Surgery non-experienced 4 5 X

X X X

Total

4 1 1 1 1

Provided information: 1 2 1

X X

Important content: Procedure Recovery

Interesting on subject Trustworthy Secure

X X X

X X

3 4

Brochure: X

3 1 2

Communication style: 3D animation Personal communication Other digital media

X X X

X X

4 2 1

Table_B03 11

Furthermore, a test session also takes place with a moving storyboard based on the content. The test is made in order to define if the content is sufficient for the patient to understand and to feel assure about the surgery. The test result turns out positively, which the content is provided in a logical order to understand. Here down below is a table with the test results of the moving storyboard. In Table_B04, it shows all testees think the content is provided clearly in order to understand. According to all the testees, the story of the moving storyboard was very clear to understand. The story is provided in a logical way, which the story is easy to follow even without a voice-over. For most of the testees the moving storyboard covers most of the headlines of the surgery. This means the most important information regarding a hip replacement surgery are given or illustrated in the moving storyboard. The provided sequence of illustrations creates a link to the story flow how the procedure is going to be held by the surgeons/doctors.

Moving storyboard results Test Story is provided in logical way Clear story to understand Pre-operative is important The animation covers most of the headlines Illustrations are clear to understand what they represent Content/illustration is specific and direct to the point Clear sequence of images to follow Graphical element enhance the understanding of illustration Animation doesn't fullfill all the needs to undergo the surgery

1 X X X X X

2 X

3 X X

4 X X

X X X X

X X

5 X X X X

Total 3 5 1 3 3 1 2 1 1

Table_B04 4.2 The reason of the important content Besides of the survey, interviews are also conducted with the target group in order to have a deeper insight into the content of the animation. In the Target group analysis document, interviewees think procedure, recovery and pre-operative are the most important information to have in the animation. From these content, they say itâ&#x20AC;&#x2122;s easier to understand and to feel assure about the surgery. Results from the interviews show many people think this information are in a logical way to understand a complex surgery. By having this information in the animation creates a flow from the beginning to the end of the procedure. The main reason that a patient requires these content is because the patient wants to know what the doctor is going to do with his/her body. Therefore, these content of having pre-operative, procedure and recovery are the headlines of a hip replacement animation. From the test result in the previous Table_A04, most testees say the provided content covers the headlines of a hip replacement surgery.

Summary The content of the animation is basically the storyline of the animation. Medical information has to be limited and focused on the most important information that a patient needs to know. According to AMA Foundation, there is a questioning method called â&#x20AC;&#x153;Ask-me-3â&#x20AC;?, which three questions are asked by the patient mostly. The three questions are actually very simple to understand that patients require knowing what is their problem, what do they have to do to be healthy and why is it important for them. Other contents are unnecessary for patients to know. Therefore, the exact content has to be defined among these three questions. From the product analysis, it shows most of the competitors have three sessions of content in their animation, such as the pre-operative, the procedure and the recovery. Also from the survey and the interviews, these three sessions of information have the highest frequency, which means the target group does agree that those are the headlines of a surgery. The collected data from above are tested in a moving storyboard. The test turns out positively which patients do think itâ&#x20AC;&#x2122;s a very logical way to understand the surgery by knowing these three sessions.

5. WHICH TYPE OF ANIMATION CAN BE USED TO IMPROVE PATIENTS’ KNOWLEDGE AND UNDERSTANDING REGARDING THE TARGET GROUP? For this sub-question, there are also several approaches in order to define the correct answer. The first approach for this sub-question is going to be desk research. The desk research is about searching for articles online, which other researchers or experts recommend which type of animation is suitable for medical animation. Field research is another approach to have a deep insight on the target group. As last show room approach is the best approach to verify all the collected data with the target group. Hereby, the target group can have a real feel about the type of the animation. Target group can give feedback about the selected type of animation on how it improves their knowledge and understanding of the surgery. There are several different types of animation, but computer animation is the most common type of animation that has been used nowadays. Computer technology revolutionized the animation world. Computer animation consists of a wide range of techniques, but in essence is any animation that is created digitally using a computer. Whilst forms of computer animation have been around since the 1960s, it came into general use in the 1990s when animators began using it alongside traditional animation. It is more controllable and faster than traditional animation like for example hand-drawn animation. This style of animation doesn’t apply to medical animation, because there will be a lot of hand drawings for each motion. However, this project is about explaining the procedure of hip replacement surgery. The objective is too complex to be hand-draw; therefore computer animation gives the possibility to visualize the complexity of the surgery in an easier way. Scientifically is proven that retention of information is higher when it is communicated using both visual and verbal communication. Using animation as a training medium offers exciting possibilities for meeting the needs of learners. The use of animation instruction can significantly enhance people learning if properly designed and implemented. There are two types of computer animation: 2D animation Digital 2D animation can be created using computer programs such as Flash, After Effects, Cel Action and TV Paint. All these programs give the possibility to turn a simple 2D image into moving figure. With a 2D animation, several layers of pictures can be used to create the motion or movement that is needed. Digital 2D animation is not used for artistic purposes as much anymore, due to the lack of depth, but is still used in advertising and desktop publishing (Turauskis F, 2016). 3D animation Digital 3D uses programs such as 3Ds Max, Maya and ZBrush to create animation with more depth. An animator will often create a very simple version (or skeleton) for a digital character (or Avar) and build up from this with digital muscles, skin, hair, pores etc. The animator will use keyframing to set the Avar’s position, just as they would in traditional animation. However, they don’t need to do it on every frame, but just key ones – the computer programs then fill in the movement between the key frames to create a full animation. Digital animation can be very realistic, and animators can be very artistically skilled to create a character. Some animators will specialize – for example facial animators just work on the facial movements and speech of a character, rather than the whole thing (Turauskis F, 2016). 3D animation software was employed to illustrate the basic anatomy of the thyroid and the larnyx; the principle of thyroidectomy was explained by visualizing the surgical procedure step by step. Finally, the possible complications that may result from the intraoperative manipulations were also visually explained.

Eighty patients entered a prospective randomization: on the day before surgery, group 1 watched the computer animation, whereas group 2 was given the identical information in a written text (= standard flyer). The evaluation included a questionnaire with scores of 1-5, rating the patients’ understanding, subjective and objective knowledge, emotional factors like anxiety and trust and the willingness to undergo an operation. In the product analysis document, there are four hip replacement animations being examined. From the four animations, three are 3D animations and one is 2D animation. Today’s 3D medical animations use cutting-edge 3D computer graphics to convey physiological, surgical and other topics with stunning clarity and remarkable detail. These dynamic animations are a step ahead of 2D medical animations — which use a series of drawings that give the illusion of movement from only one perspective at a time. (GhostProduction, 2016). According to researchers, medical animation market has been segmented on the basis of type, application, therapeutic area, and end user. On the basis of type, the medical animation market is categorized into 3D animation and 2D animation. The 3D animation segment is expected to account for the largest share of the medical animation market in 2016. This means most of the medical animations are made in 3D instead of 2D. 3D animation provides viewers a greater sense of perspective by viewing the objects at multiple angles. Such vision enables the viewer to get a true sense of volume and depth (Marketandmarket, 2016). 3D animations can be used to relay important information simply, elegantly and memorable — without making non-medical personnel (patients, prospective clients, investors, etc.) uncomfortable. Many people have difficulty watching live-action videos of procedures, because of the blood and the gruesome images. Therefore, animations can demonstrate relevant information, making the content more pleasant to the public. A surgery is a very complex procedure which in some situation is difficult to show or to visualize. With an animation, it can venture where the human eye often cannot, delving deep into microscopic realms to convey information on a microscopic scale, as needed. 3D animations offer the option to render events in slow motion or enhanced detail, compared to what’s achievable with live video. The potential to add explanatory text and graphics further enhances the effectiveness and utility of medical animation (GhostProduction, 2016). Furthermore, a survey is created in order to collect quantitative data from the target group regarding which type of animation would they require. Here down below in are the stats of the results from the survey, which it shows 3D animation has the highest score of frequency. Most of the target group think Live recording video is very unpleasant to watch, because of the blood and horrible body parts that are uncommonly viewed. How do you feel if your doctor provides you Orthopedic surgery information in a different form? 90

80 70 60 50 39

30 20 10 0

13 6

Unpleasant

8 1

1 Terrify

Sensitive

2D animation/cartoon

Live recording

Normal

3D animation

Image_C01

Interviews are also conducted based on the survey questions in order to get a deep insight on the target group. Here down in the table below is the interview results that shows most patients do require to have 3D animation than other digital media. Surgery experienced 1 2 3

Interview Feelings: Sad Disappointed Worried Afraid Accepted

X X

Understandable Many medical terms Understandable with sketches

X X

Surgery non-experienced 4 5

Total

4 1 1 1 1

X X X

Provided information: 1 2 1

X X

Important content: Procedure Recovery

Interesting on subject Trustworthy Secure

X X X

X X

3 4

Brochure: X

3 1 2

Communication style: 3D animation Personal communication Other digital media

X X

4 2 1

Table_C02

Besides of the research results, there is also a test of the proof of concept of the hip replacement surgery. The test results are given in Table_C03, which most patients think the 3D graphic is very clean and clear to see the perspective view of the surgery.

1 X X X X

X X X X X

3 X

4 X

X X

X X X X

X X X

Checking for understandablity Testee can give a summary Testee can tell the procedure step by step Testee remembers the artificial hip name called "Prosthesis" 16 Testee can point out the incision position on his/her body

Total 3 1 4 5 1 3 3 3 2 3 1

Table_C03 X X X

X X X

X X X X

X X X

X X X X

5 4 4 4

To have an overview why 3D animation is better, review the comparison of a 3D, 2D and live image from Image_C04 down below. The 3D animation offers more detail on the texture and the depth of field of the shape of the body part. Clearly, the 2D gives a flat image without any enhancement on the object or a perspective view. Not many people can watch a live video about surgery, because it can cause an uncomfortable psychological feeling. Furthermore, the view of a live recording is very limited on just one point.

Live Image_C04

Animation has been shown to be more effective than live-action as an educational tool because it gives filmmakersâ&#x20AC;&#x2122; greater control over presentation, characterization, staging and timing, making it a powerful medium for conveying symbolic theories and concepts (Communication to EARLI, 2009). Summary There are two types of animation that is available for medical use which is 2D and 3D animation. 2D animation is simple flat images that could be illustrations and pictures taken from the reality. This type of animation doesnâ&#x20AC;&#x2122;t give the depth of field compare to a 3D illustration. Therefore, 3D animation is the most common type of animation that is being used for healthcare communications. 3D animation is the most beneficial type of animation. It offers the ability to the not seen by the naked eye, which it opens up a wide scale of variety in the human body. It depicts an accurate visualization by exploring the depths and intricacies of the science that cannot be created or replicated from a 2D illustration, sketch, photography or even live-action. The target group also confirmed which 3D animation is the best choice as a communication tool regarding the understanding of a complex surgery. Other communication tools such as live recordings are too unpleasant to watch, because of the blood.

6. HOW CAN ANIMATION IMPROVE PATIENT’S KNOWLEDGE AND UNDERSTANDING? This sub-question is actually similar to the main question of the project. Therefore, all three approaches are needed in order to have a concrete answer. Desk research is the first research for the answer of this sub-question, which it’s the same method of searching related articles or literature on the internet like other previous sub-questions. Furthermore, another research is to approach the target group by conducting interviews in order to collect valuable data. The last approach is to test out how the proof of concept can improve patient’s knowledge and understanding. Also, this sub-question can be answered by combining all other sub-questions answers together. From other researchers, it shows that populations with low health research literacy are often more open to visual multimedia based information and that practitioners and health educators should make use of a wide range of traditional and novel health information resources, from static informational Webpages to information visualization tools such as online digital content and audio/video programming (George, S., Moran, E., Duran, N., M.S., Jenders, R, 2013). Researchers from AMIA Annu Symp Proc tries video-based educational in several clinics, which there are positive results on increased knowledge and satisfaction and decreased on the anxiety of patients. According to Hermann, computer animation does reduce patient’s anxiety and increase better readiness for the operation than reading a text. Animation can improve patient’s knowledge and understanding because it has the ability to convey changes over time, whereas these changes are constantly in a static illustration. Animations offer a direct visualization of the micro-steps that is the minute changes occurring in a dynamic system, which have to be inferred from a series of static graphics. Conversely, a series of simultaneously presented static graphics allows for the different states or steps within a depicted process to be consulted at any time, while an animation must be repeated as a whole. However, animations must be adequately processed in order to extract the necessary information for building a coherent mental model (Communication to EARLI, 2009). In fact, 90% of the received information to the human brain is visual. Visuals communication go directly into the long-term memory of the brain. Furthermore, the human brain remembers 80% of what is seen and only 20% of what is read (Golden F, 2015). An animation can provide more information to a learner because all the different steps are included in the mechanism are explicitly and dynamically shown. According to many researchers have been found that animated videos are very effective in providing information, especially for patients with low health literacy. An animation is commonly seen as non-threatening, familiar and accessible across any ages, cultures and literacy levels, it can hold the attention of the viewers and enhance recall. In addition, according to Champoux JE, animation has been shown to be more effective than live-action as an educational tool because it gives filmmakers’ greater control over presentation, characterization, staging and timing, making it a powerful medium for conveying symbolic theories and concepts (George, S., Moran, E., Duran, N., M.S., Jenders, R, 2013). There is a comparison studied of the effectiveness of written materials versus animation, which animation do have significantly improved post-intervention levels of knowledge and long-term retention of health information. The study addresses a gap in the existing literature regarding the acceptability of animation as a novel information tool to enhance health research literacy among minority health care consumers by making information about clinical research more accessible to them in a culturally concordant fashion (George, S., Moran, E., Duran, N., M.S., Jenders, R, 2013).

From the interview results, the animation does increase patient/viewer’s knowledge and understanding by revealing their curiosity of which the patient/viewer cannot imagine. Down in the table below are the results of the interview, which most patients do prefer to watch animation instead of reading text such as from a brochure. The text isn’t attractive to the patient. However, if the subject is relatable the patient would then browse through the text. Browsing a text doesn’t make the patient retains the important information that a patient should know. Surgery experienced 1 2 3

Interview Feelings: Sad Disappointed Worried Afraid Accepted

X X

Understandable Many medical terms Understandable with sketches

X X

Surgery non-experienced 4 5 X

X X X

Total

4 1 1 1 1

Provided information: 1 2 1

X X

Important content: Procedure Recovery

Interesting on subject Trustworthy Secure

X X X

X X

3 4

Brochure: X

3 1 2

Communication style: 3D animation Personal communication Other digital media

X X X

X X

4 2 1

Table_D01 During the test of the proof of concept, patients are being asked if they feel the animation has increased their knowledge and understanding regarding hip replacement surgery. Most of the patients do feel and agree that the animation provides them enough information because they can visualize it instead of imagining how it would be. While reading a text, humans have to convert these text into an image in order to know what it means or what it is. It is hard to imagine, especially for patients that have a lack of knowledge in medical education. In fact, images play a powerful role in their ability to retain, remember, and recall information. Without always realizing it, humans have an emotional connection to visual content, as Mike Parkinson explains in his article on The Power of Visual Communication. Visuals trigger emotions, stimulate memories and help us connect to one another. Emotions also happen to make the most powerful influence on decisions (Margalit L, 2015). Summary Most people do prefer visual multimedia as a learning tool. Visual multimedia gives a wide range of traditional and novel health information resources such as online digital content and audio/video programming. The animation does have an effect on reducing patient’s anxiety before the operation and better preparing than just reading some text. Furthermore, an animation is commonly seen as a non-threatening, familiar and accessible across any ages, cultures and literacy levels. It can hold and attract the attention of the viewers. The human brain processes 90% of the information as visuals and the brain remembers 80% of what it sees. From the interview and the test result, they show patients do want to have animation as a communication tool, because of visualizing is better than imagining health literacy.

7. CONCLUSION Animation is the process of making the illusion of motion and change by means of the rapid display of a sequence of static images that minimally differ from each other. Nowadays, animation has become a popular digital media as an educational tool. There are several types of animation, which 2D and 3D are the most common type that is been used. 3D animation is the most common type of animation that is used for medical healthcare. It provides a wide deep view into what human eyes cannot reach, especially for surgeries. It’s difficult to photograph the exact angle of the operation with all the disturbing tools, blood, muscles, etc. Therefore, 3D animation gives the possibility to enhance the missing details that cannot or impossible to be photographed. Disturbing or unnecessary elements can be removed easily from a 3D object and emphasize on the main point. A surgery is very complex, which the procedure of the surgery can be simplified by several steps through an animation. By making a medical surgery procedure animation, there are several key points that have to be concern about. First of all, the animation has to be understandable by the audience. Hereby, to define the understandability is to transform the procedure of the surgery into a storytelling. The storyline has to be written and narrated in a common level of communication, which all ages can easily understand what the animation is about. In the medical healthcare, many doctors and surgeons use medical terms to explain health literacy to their patient, which it’s difficult for non-medical patient to understand. Therefore, in the storyline of the animation, medical jargons and long sentences have to be avoided regarding the understandability of patients. The understandability can be assured by verifying and/or confirming the information that is given by the patient. Doctors can provide the animation during the consultation and afterwards assuring the understanding of a patient. Patients do feel calm and reduce anxiety by having enough information. Human brain received 90% of information in visuals and retains 80% of information visually. This means the human brain can retain more information by visuals better than text or verbally. Health literacy is very difficult to retain, because of the complexity and unimaginable verbal communication. Therefore, by creating a medical animation can fill in the unimaginable gaps in the brain and this information will be obtained in the long-term memory. The animation can be long and very short video, but what is exactly the perfect time duration of a video. Like mentioned before a surgery is very complex, therefore the most important content must be selected from the procedure. Hereby, the “Ask-me-3” questions method is very useful, because by answering these questions are exactly the information that a patient requires to know. In order to create a successful animation, the storyline can be divided into three session namely the pre-operative, procedure and the recovery. These three sessions are the most common sessions of information that a patient requires to know regarding an operation.

8. APPENDIX Aman, J. (2013, 10 April). 5 Ways To Cure Hospital Anxiety, Surgery Fear, Fear of Medicine. Consulted on 6 March 2017, from http://www.healthyplace.com/blogs/anxiety-schmanxiety/2013/04/ hospital-anxiety-surgery-fear-and-medicine-worry/ Barry, D., Weiss, MD. ( 2007, May). Health literacy and patient safety: Help patients understand. Second edition. Consulted on 27 January 2017, from https://www.umcutrecht.nl/getmedia/ baa2a19c-8c84-4956-bf9a-bd1cbac1ac13/Health-literacy-and-patient-safety-help-patients- understand.pdf.aspx Bereiter, C. (2002). Education and mind in the Knowledge Age. Consulted on 18 January 2017, from http://www.cocon.com/observetory/carlbereiter/ Boodman, S. (2011, 01 March). Helping Patients Understand Their Medical Treatment. Consulted on 21 January 2017, from http://khn.org/news/health-literacy-understanding-medical-treatment/ Centraal Bureau voor de Statistiek. (2014, 04 February). Operaties in het ziekenhuis; soort opname, leeftijd en geslacht, 1995-2010. Consulted on 17 March 2017, from http://statline. cbs.nl/Statweb/publication/?DM=SLNL&PA=80386NED&D1=0&D2=1-2&D3=1- 5&D4=19&D5=10-15&HDR=G3,G4,T&STB=G1,G2&VW=T Centraal Bureau Statistiek. (2014, 05 February). Operaties in het ziekenhuis; soort opname, leeftijd en geslacht, 1995-2010 [Image_A02]. Consulted on 17 March 2017, from http://statline.cbs.nl/Statweb/publication/?DM=SLNL&PA=80386NED&D1=0,2-5&D2=1- 2&D3=a&D4=a&D5=l&HDR=T&STB=G1,G4,G3,G2&VW=T Changeagents365. (2012). Communicating with older adults. Consulted on 24 January 2017, from https://changeagents365.org/resources/ways-to-stay-engaged/the-gerontological-society-of- america/Communicating%20with%20Older%20Adults%20Low_GSA.pdf Communication to EARLI. (2009, n.d). When and why does animation enhance learning?. Consulted on 16 February 2017, from http://tecfaetu.unige.ch/etu-maltt/oda/berneysa/Berney_ Betrancourt_09.pdf Dalisay, L. (2013, July). How 3D Medical Animation Benefits the Healthcare Industry . Consulted on 26 February 2017, from http://www.polygonmedical.com/how-3d-medical-animation-benefits- the-healthcare-industry Dingemanse, K. (2014, 08 September). How to perform desk research. Consulted on 10 November 2017, from https://www.scribbr.com/dissertation/perform-desk-research/ Fitzpatrick, V. (2010, 26 April). Effective Communication Leads to Understanding. Consulted on 19 January 2017, from http://www.sans.edu/cyber-research/management-laboratory/article/ fitzpatrick-mgt421 Flatworldsolutions. (n.d). Medical Animation Services. Consulted on 28 January 2017, from https://www. flatworldsolutions.com/healthcare/medical-animation-services.php George, S., Moran, E., Duran, N., M.S., Jenders, R. (2013, 26 November). Using Animation as an Information Tool to Advance Health Research Literacy among Minority Participants. Consulted on 20 March 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3900192/ 21

Ghost Productions. (2016, 07 June). How Your Business Or Medical Practice Can Benefit From Medical Animation. Consulted on 26 February 2017, from http://ghostproductions.com/ blog/2016/06/07/how-your-business-or-medical-practice-can-benefit-from-medical-animation/ Golden, F. (2015, 11 February). The power of visual content: Images vs Text. Consulted on 17 March 2017, from https://www.eyeqinsights.com/power-visual-content-images-vs-text/ Graham, S., Brookey, J. (2008). Do Patients Understand? Consulted on 19 January 2017, from https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3037129/ Grossman, D. (2016, 22February). A Gripping Story: The Benefits of 3D Medical Animation. Consulted on 19 January 2017, from https://medium.com/@davegrossman/a-gripping-story-the-benefits- of-3d-medical-animation-f7c10963459c#.3kmow9c10 Harper, B. (2013, 20 November). Informed Consent: How do You Assess a Patient’s Understanding? Consulted on 21 January 2017, from https://forteresearch.com/news/informed-consent-how-do- you-assess-a-patients-understanding/ Harris, G. (2012). Five Questions to Make Sure that You Understand Others Correctly. Consulted on 24 January 2017, from https://recoveringengineer.com/resolving-conflict/five-questions-to-make- sure-that-you-understand-others-correctly/ Health.gov. (n.d). Quick guide to health literacy. Consulted on 26 February 2017, from https://health. gov/communication/literacy/quickguide/factsbasic.htm Hermann, M. (2002, May). Der Chirurg. Volume 3, issue 5. Huff, C. (2011, 01 October). Does Your Patient Really Understand? Consulted on 21 January 2017, from http://www.hhnmag.com/articles/4352-does-your-patient-really-understand Leigh, S. (2014). Do People Understand What You’re Saying? Consulted on 18 January 2017, from http://www.lifestyletherapy.net/cms/do-people-understand-what-youre-saying Nucleus. (n.d). Consulted on 29 January 2017, from http://www.nucleushealth.com/about-us/faq Margalit, L. (2015, 01 May). Video vs Text: The Brain Perspective. Consulted on 17 March 2017, from https://www.psychologytoday.com/blog/behind-online-behavior/201505/video-vs-text-the- brain-perspective Marketsandmarkerts. (2016, May). Medical Animation Market by Type (3D, 2D, 4D), Therapeutic Area (Oncology, Cosmeceutical/Plastic Surgery), Application (Drug MoA, Patient Education), End User (Medical Device Manufacturers, Hospitals/ Clinics) - Forecast to 2021. Consulted on 19 January 2017, from http://www.marketsandmarkets.com/Market-Reports/ medical-animation-market-223188473.html Melissa Ip, MA, RD. (2010, May). Keys to Clear Communication — How to Improve Comprehension Among Patients With Limited Health Literacy. Consulted on 28 January 2017, from http://www. todaysdietitian.com/newarchives/050310p26.shtml Mindtools. (n.d). Understanding communication skills [Image_A01]. Consulted on 20 January 2017, from https://www.mindtools.com/CommSkll/CommunicationIntro.htm 22

National Patient Safety Foundation. (n.d). Ask Me 3: Good Questions for Your Good Health. Consulted on 29 January 2017, from http://www.npsf.org/?page=askme3 Oâ&#x20AC;&#x2122;Connor, C. (2014, 08 March 8). The power of visual storytelling. Consulted on 19 January 2017, from http://archive.boston.com/business/blogs/global-business-hub/2014/03/the_power_of_vi.html Parsons, N. (2016, 27 January). Do Visuals Really Trump Text? Consulted on 19 January 2017, from https://www.liveplan.com/blog/2016/01/scientific-reasons-why-you-should-present-your-data- visually/ Trina E. Dorrah, MD, MPH. (2016, June). Use the Teach-Back Method to Confirm Patient Understanding. Consulted on 21 January 2017, from http://www.the-hospitalist.org/hospitalist/ article/121632/use-teach-back-method-confirm-patient-understanding Turauskis, F. (2016, 27 June). 6 Different Types of Animation - An Introduction. Consulted on 20 January, from http://www.studentworldonline.com/article/6-different-types-of-animation-an- introduction/495/