Using illustrated narratives to increase knowledge of COVID-19 testing and prevention behaviors: A randomized experiment of an online learning module

Alexis Marsh, LMSW1, Victoria De La Vega, MPH1, Amy McQueen, PhD1, Charlene Caburnay, PhD, MPH1, Jennifer M. Wolff, PhD1, Penina Acayo Laker, MFA2, Aayesha Ejaz, BA2 and Matthew Kreuter, PhD, MPH1, (1)Health Communication Research Laboratory, Brown School, Washington University in St. Louis, St. Louis, MO, (2)Sam Fox School of Design & Visual Arts, Washington University in St. Louis, St. Louis, MO

Theoretical Background and research questions/hypothesis:

This study aimed to identify culturally appropriate health communication strategies to help underserved populations make informed decisions about COVID-19 testing and prevention behaviors. During the COVID-19 pandemic, callers to 211 helplines sought assistance with health needs like COVID-19 testing and vaccine information. Research shows that stories have distinctive capabilities to help people understand and use health information. An online learning module featuring four hand-drawn illustrated narratives with accompanying questions and plain language feedback on responses was created and evaluated among callers to 211. We hypothesized that participants who received the learning module would score higher on knowledge outcomes in a post-test compared to participants who did not receive the module.


298 adults were recruited from individuals who called 211 from September to December 2022 in CT, NC, and NE. With participant consent, 211s shared potential participants’ contact information with the study team. These individuals were sent a text message via Qualtrics with a link to an online informed consent document and project description. Those who consented were randomly assigned to immediately proceed to one of two versions of an online survey. The learning module, which contained questions about testing and isolation guidelines, was embedded in one version. Both surveys included identical post-test questions assessing information covered in the module. After completion, all participants received a downloadable information sheet with up-to-date COVID-19 guidelines and state-specific information to access COVID-19 tests.


A Wilcoxon-Mann-Whitney test (used due to a non-normal distribution) indicated that participants receiving the learning module scored, on average, significantly higher on post-test knowledge than those who did not receive it (W= 16040, r= .40, p<.001). Within the experimental group, 71.4% of participants showed an improvement in COVID-19 prevention knowledge in the post-test. There was a significant difference between groups such that those in the experimental group had higher odds of a correct response on 7 out of 10 post-test items. The largest differences were observed on questions that assessed the best time to take a COVID-19 test after exposure, testing before visiting an unvaccinated individual, and knowing how long someone can test positive after infection. Eighty-four percent of all respondents correctly answered that COVID-19 self-tests are a good choice for someone experiencing COVID-19 symptoms, while only 45% correctly answered when to take a second self-test after first getting a negative result.


In a randomized study with 298 adult callers to a resource helpline, a learning module featuring hand-drawn illustrated narratives with accompanying questions and plain language feedback on participant responses significantly increased knowledge about COVID-19 testing and prevention behaviors. Participants exposed to the learning module were more likely to correctly answer post-test questions assessing prevention and self-test behaviors compared to a control group that did not receive the module.

Implications for research and/or practice:

Illustrated narratives embedded in an online learning module can help increase knowledge for COVID-19 testing and prevention behaviors. Results support that this is a promising approach to improve access to complex health information among vulnerable populations.