‘A smile stands for health and a bed for illness’: Graphic cues in children’s drawings

Abstract

Objective:

The study aimed to investigate whether children use specific types of graphic cues (facial, postural, contextual) in their drawings of healthy and ill persons and whether these cues differ as a function of age.

Design:

Cross-sectional design.

Setting:

A public primary school in a medium-sized city in Greece.

Method:

A total of 200 children in the age group of 5, 7, 9 and 11 years were first asked to define the terms under investigation, and then to draw a healthy and an ill person, as well as a baseline drawing (of a person neither healthy nor ill). Human figure drawings of health and illness were compared with their baseline drawing in an attempt to detect possible alterations in the (1) face, (2) body and (3) overall context of the drawing.

Results:

From the age of 5 years onwards, children were able to use a combination of graphic cues to convey health and illness in their drawings. Moreover, children in all age groups more often (1) employed facial cues to depict illness and health, (2) used more postural and contextual cues to depict illness than health, (3) introduced a variety of contextual cues in their drawings (e.g. linguistic, nutritional, environmental, physical and medical) and (4) used more types of graphic cues as well as more categories of contextual cues to depict illness than health. Finally, it was found that the drawings of the 5-year-old children involved significantly fewer graphic cues than those of the 7- and 11-year-olds, and significantly less contextual cues than the drawings produced by the 9- and 11-year-olds.

Conclusion:

Study findings shed light on the way children perceive and represent graphically illness and health and these are discussed in relation to their implications for health education.

Keywords

Children drawings Greece perceptions of illness and health

Introduction

Children’s perceptions of illness and health have attracted researchers’ interest worldwide. A basic understanding of human biology and health is crucial for personal and social development. However, children in modern societies are reported to have restricted comprehension and ability to cope with information related to health and illness deriving from a variety of sources in everyday contexts (Reeve and Bell, 2009; Toyama, 2016; Zaloudikova, 2010). Improved health literacy is therefore central to education – both formal and informal (Bruselius-Jensen et al., 2017). In order to design, implement and evaluate appropriate health education initiatives and interventions a thorough and systematic identification of individuals’, and especially young peoples’ evolving understanding of health-related concepts is essential (Daniels et al., 2016; Piko and Bak, 2006; Reeve and Bell, 2009; Skar and Soderberg, 2016; Zaloudikova, 2010).

Studies have shown that from an early age children perceive health and illness as oppositional constructs (Schmidt and Frohling, 2000; Zaloudikova, 2010), with health being seen as permanent whereas illness as evanescent (Campbell, 1975; Natapoff, 1978, 1982). It is well established that these perceptions change with age. By the age of 5, children exhibit a preliminary understanding of illness causality, defining illness as a biomedical phenomenon (Bibace and Walsh, 1981; Bird and Podmore, 1990; Springer and Ruckel, 1992; Toyama, 2016), and health as the absence of illness (Davó-Blanes and La Parra, 2012; Reeve and Bell, 2009) or a condition that lacks symptoms (Campbell, 1975; Natapoff, 1978; Piko and Bak, 2006).

As children develop, however, they demonstrate more differentiated and detailed perceptions and, by the age of 7–8 years, conceptualise both illness and health as complex and multifaceted phenomena and define them by referring not only to their biomedical dimensions, but also to their psychological and social consequences on people’s lives (Davó-Blanes and La Parra, 2012; Koopman et al., 2004; Myant and Williams, 2005; Piko and Bak, 2006; Reeve and Bell, 2009; Schmidt and Frohling, 2000; Toyama, 2016; Zaloudikova, 2010). This evolving complexity in their understanding is more consistent with the World Health Organization (WHO) definition of health, as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (World Health Organization (WHO), n.d., para.1).

Drawings constitute a popular research method for the exploration of children’s perceptions of illness and health, since they are considered a child-friendly and non-threatening tool, which permits access to children’s knowledge, feelings and experiences (Guillemin, 2004; Jolley, 2010; Merriman and Guerin, 2006; Morrow, 2001; Picard and Lebaz, 2010; Pridmore and Lansdown, 1997). In general, drawings are considered a language-free method to assess children’s understanding of various constructs and they are often used effectively with very young children (Villarroel and Infante, 2014) or with language-impaired children (Holliday et al., 2009; Vendeville et al., 2015), who do not always have the vocabulary to define the terms under investigation. Many studies have used the ‘draw and write’ technique in which children are asked to draw a picture of illness and/or health and then give a verbal description of their drawing in order to clarify the depicted theme (McWhirter, 2014; Piko and Bak, 2006; Pridmore and Bendelow, 1995; Zaloudikova, 2010).

However, researchers have warned that the wording of the drawing instructions may provoke different representations. For example, the prompt to draw what health/illness means to the child elicits his or her experiences of the two situations, while the instruction to draw a healthy/ill person seems to tap into his or her perceptions (Lima and De Lemos, 2014; Renslow and Maupin, 2017). Irrespective of the drawing instruction, within this research tradition content analysis is generally used to describe the main thematic categories that emerge from children’s drawing representations (Mouratidi et al., 2016; Piko and Bak, 2006; Zaloudikova, 2010).

For example, Piko and Bak (2006) classified children’s drawings of health into three main categories: (1) the biomedical, which reflected biological or medical perceptions, (2) the holistic, which incorporated psychological (i.e. social and emotional) and physical perceptions and (3) the lifestyle, which referred to behavioural perceptions. Similarly, Mouratidi et al. (2016) slightly modified Piko and Bak’s (2006) coding system to identify the general themes shown in children’s drawings of illness and health. They identified three content-specific categories: (1) the biological (i.e. drawings depicting biological or medical dimensions), (2) the psychosocial (i.e. drawings depicting emotional expressions, social interactions and abstract thoughts) and (3) the personal lifestyle (i.e. depictions of healthy or unhealthy behaviours).

It has been argued that content analysis provides insight into children’s lay concepts of illness and health (Piko and Bak, 2006). Such an analysis can serve as a useful technique for describing and quantifying data, as it permits researchers to describe the phenomenon under investigation using broad categories (Elo and Kyngäs, 2008; Krippendorff, 1980). However, the attempt to classify a depiction within a specific category may oversimplify its meaning and neglect some of the depicted details, reflecting the researcher’s own bias or his or her difficulty in conceiving of the subject matter within the depicted scene.

In an attempt to overcome some of these limitations, this study adopted a different approach aiming to explore the specific measurable graphic cues children employ to represent health and illness in their human figure drawings. Taking into account the fact that the conceptualisation of the terms ‘health’ and ‘illness’ includes an emotional component (Boruchovitch and Mednick, 1997; Pridmore and Lansdown, 1997), and that children define them by referring to their associated emotions (Campbell, 1975; Davó-Blanes and La Parra, 2012; Natapoff, 1978; Schmidt and Frohling, 2000), or tend to depict health and illness as psychological phenomena associated with positive or negative emotions, respectively (Altman and Revenson, 1985; Mouratidi et al., 2016), we attempted to investigate whether children employ in their drawings of healthy and ill figures, the graphic cues used in the depiction of positive versus negative emotions. More specifically, research has shown that children employ three different types of graphic cues to convey emotions in their human figure drawings: facial, postural and contextual cues (Bonoti and Misailidi, 2015; Brechet et al., 2009). Facial cues include the modification of a human figure’s facial features (e.g. a smiling mouth to denote happiness). Postural cues refer to alterations in the placement of the limbs and body posture (e.g. arms close to the body to denote sadness). Contextual cues comprise signs added to the general context of the drawing (e.g. a ghost to signify fear).

Children’s ability to employ the aforementioned graphic cues has been associated with their understanding of the depicted themes (Brechet and Jolley, 2014; Brechet et al., 2009) and their representational drawing skills (Brechet and Jolley, 2014; Jolley, 2010; Jolley et al., 2016). Moreover, the majority of the related studies has shown that this is an age-related ability, since as they get older children are able to incorporate in their drawings a greater number and a larger variety of graphic cues (Bonoti and Misailidi, 2015; Brechet et al., 2009; Ives, 1984; Jolley et al., 2004; Misailidi and Bonoti, 2014; Picard and Gauthier, 2012; Picard et al., 2007). Specifically, it has been found that children can effectively modify facial cues to denote the meaning of their drawing by an early age (Cox, 2005; Sayil, 2001), and with increasing age, they also introduce postural and contextual cues in their depictions (Brechet et al., 2009; Golomb, 1992; Picard et al., 2007). Moreover, it has been found that the use of graphic cues is theme-specific (Brechet et al., 2009; Golomb, 1992). For example, Bonoti and Misailidi (2015) reported that in their study children used more often facial cues to denote happiness and sadness (e.g. by altering the expression of the mouth), while they preferred the use of contextual cues to express pride or shame (e.g. by adding a medal or a broken toy).

This study aimed to investigate whether similar types of graphic cues (facial, postural and contextual) are included in children’s healthy/ill human figure drawings, as well as whether the emergence of these cues varies as a function of age. To achieve this goal, we sampled children aged 5, 7, 9 and 11 years old, since within this age range children can progressively use a variety of graphic cues in their drawings (Jolley et al., 2004; Misailidi and Bonoti, 2014; Picard et al., 2007).

It was anticipated first that children would use all three types of graphic cues to depict health and illness and more specifically that they would use the facial and postural cues, as well as contextual cues which would reflect the different aspects/components of the two terms under investigation. Previous research has shown that facial cues are easier to draw and appear earlier than postural and contextual cues (Cox, 2005; Golomb, 1992; Sayil, 2001). Thus, we could anticipate that children – especially the younger ones – would use more often facial than postural or contextual cues in their healthy/ill figures, while the use of postural and contextual cues would increase with age. Second, we anticipated that children would employ different graphic cues for the depiction of illness and health (Bonoti and Misailidi, 2015; Brechet et al., 2009) and that they would use more graphic cues to depict illness than health, since previous research has reported that children display greater ease in describing or drawing illness compared with health (Mouratidi et al., 2016; Zaloudikova, 2010). Finally, we expected children would employ a larger variety of graphic cues with age, which would reflect their evolving multifaceted perceptions of illness and health (Mouratidi et al., 2016; Myant and Williams, 2005; Toyama, 2016), as well as the development of their graphomotor skills (Golomb, 1992; Jolley, 2010).

Methods

Participants

A total of 220 children were recruited to participate in the study. During data collection, 20 children (ten 5-year-olds, five 7-year-olds, three 9-year-olds and two 11-year-olds) did not seem to understand the terms ‘illness’ and ‘health’. These children were not excluded from the procedure, but their drawings were not used in subsequent analysis. Thus, the data analysed consisted of drawings produced by 200 participants (76 boys, 124 girls), divided into four age groups: 5-year-olds (n = 50, M = 5.9, SD = .7 months), 7-year-olds (n = 50, M = 7.5, SD = .5), 9-year-olds (n = 50, M = 9.6, SD = .4) and 11-year-olds (n = 50, M = 11.5, SD = .6). Participants were drawn from a public school in a medium-sized city in Greece and came from a mid-level socio-economic background. Parents and children were informed about the aim of the study; the former gave their written consent while the later were given the choice to participate or not in the study. None of the parents declined our request and none of the children invited to participate refused to do so. According to their teachers’ reports, none of the participants suffered from any obvious cognitive or psychomotor dysfunction.

Drawing task and procedure

All the children were asked to provide drawings of healthy and ill persons and were individually tested in a quiet room at their school. The researcher (F.B.) who undertook data collection explained to them that she wanted to collect a large number of children’s drawings in order to gain insight into their ideas about illness and health. She informed the children that they could cease their participation in the study at any time during the procedure if they wished to do so.

Initially, each child was asked to explain the meaning of the words, illness and health (‘Can you tell me what the word “illness/health” means?’), in order to ensure that he or she understood the two terms under investigation. Next, the children were given three white pages, a pencil, an eraser and coloured pencils and were asked to make three drawings: (1) one depicting a healthy person, (2) one depicting an ill person and (3) and one showing a person neither healthy nor ill (baseline drawing). The instructions were, ‘I am wondering how a healthy/ill person [or a person neither healthy nor ill] looks like. Please, draw an ill/healthy person [or a person neither healthy nor ill]’.

The baseline drawing was always drawn first, while the order of the other two drawings was counterbalanced across children. There was no time restriction for the completion of the drawing tasks. After completion of the tasks, the children were thanked for their participation and were praised for their effort.

Scoring of drawings

Initially, two women raters [including G.S] who were students (mean age = 21.7) in the university department of education and who had been trained in the analysis of children’s drawings, were asked to compare the drawings of the healthy/ill person with their baseline to detect any changes in the (1) face, (2) posture and (3) context of the drawn human figure. They were also asked to describe in detail each change (facial, postural, contextual) that emerged in the drawings of the healthy/ill person in order to generate a final list of the graphic cues used.

Then, the raters were asked to independently rate each drawing of healthy/ill person against its baseline for the presence of each cue included in this final list (see Table 1). Each drawing was given a score of 1 for the presence of each type (facial, postural, contextual) of graphic cues (range 0–3). Representative drawings of health and illness scored for facial, postural and contextual graphic cues are shown in Figure 1. Contextual cues were aggregated into five broader categories (linguistic, nutritional, environmental, physical and medical) and each drawing was given a score of 1 for the presence of each category of those contextual cues (range 0–5). Agreement between raters was found to be satisfactory (97% for facial, 94% for postural and 92% for contextual cues).

Table 1.

Graphic cues used for the depiction of health and illness.

	Health	Illness
Facial cues	Smiling mouth, open eyes	Downwards mouth, tears
Postural cues	Moving figure (e.g. running or jumping)	Figure lying down or seated
Contextual cues
Linguistic cues	Verbal or mathematical sign or symbol	Verbal or mathematical sign or symbol
Nutritional cues	Healthy nutrition (fruits, vegetables)	Unhealthy nutrition (candies, fatty food, fast-food, alcohol)
Environmental cues	Outdoor (courtyard, park, countryside, sun)	Indoor (home, bed, internal place of hospital or doctor’s office)
Physical cues	Play/gymnastics (ball, trampoline, gym equipment, dumbbells fitness)	Symptoms (pimples, broken arms/legs, disability, vomiting, germs, trauma sniffle)
Medical cues	Doctor, nurse, medical examination, green cross, heart, discharge letter, doctor’s office	Doctor, nurse, medical examinations, hospital, blood, medicines, injection, crutches, cardiogram, thermometer, wheelchair, serum

Figure 1.

Representative drawings of health and illness scored for facial, postural and contextual graphic cues. Reprinted with permission.

Results

The results of the study are reported in two ways: (1) via analyses of the types of graphic cues (facial, postural, contextual) used to depict health and illness and (2) using results detailing the categories of contextual (linguistic, nutritional, environmental, physical, medical) cues used to depict health and illness. Preliminary analyses did not reveal any gender differences and therefore gender was not included in subsequent analyses.

Types of graphic (facial, postural, contextual) cues used for the depiction of health and illness

The vast majority of children used all three types of graphic cues to depict health and illness in their drawings. The number of types of graphic cues employed to depict health and illness were analysed by a 4 (age group: 5, 7, 9 and 11 years) × 2 (theme: health, illness) analysis of variance (ANOVA) with repeated measures on the last factor (theme), using the number of types of graphic cues (0 = no graphic cues to 3 = all three types of graphic cues) as the dependent variable. The main effect of the age group was significant at F(3, 196) = 2.92, p < .05, while post hoc Τukey’s honestly significant difference (HSD) comparisons revealed that children in the 5-year-old age group used a significantly smaller number of graphic cues (M = 2.10 for health and M = 2.58 for illness) compared with children in the 7-year-old (M = 2.52 for health and M = 2.64 for illness) or the 11-year-old (M = 2.42 for health and M = 2.78 for illness) age group (p < .05 and p < .001, respectively). A significant main effect of theme F(1, 196) = 32.09, p < .001 was also found, showing that children differed in the amount of graphic cues used while drawing health and illness. Scores were generally higher for illness (M = 2.66) in comparison with health (M = 2.35). However, the age group × theme interaction was not statistically significant.

Table 2 presents the frequencies (and percentages) with which facial, postural and contextual cues were employed to portray health and illness in the total sample and by age group. Inspection of the frequencies in the total sample shows that children depicted health by primarily altering the facial expression of the human figure, and then the context of their drawing, while they represented illness by primarily adding contextual cues and then alterations to the facial features.

Table 2.

Frequencies (and percentages) with which facial, postural and contextual cues emerged in the healthy/ill figure by age group.

	N	Facial N (%)		Postural N (%)		Contextual N (%)
		Health	Illness	Health	Illness	Health	Illness
5 years	50	46 (92)	39 (78)	22 (44)	40 (80)	37 (74)	50 (100)
7 years	50	44 (88)	48 (96)	37 (74)	36 (72)	45 (90)	48 (96)
9 years	50	45 (90)	43 (86)	30 (60)	41 (82)	43 (86)	48 (96)
11 years	50	48 (96)	46 (92)	33 (66)	44 (88)	40 (80)	49 (98)
Total	200	183 (91.5)	176 (88)	122 (61)	161 (80.5)	165 (82.5)	195 (97.5)

Data of Table 2 were analysed using the Cochran’s Q, a non-parametric test applied for the analysis of dichotomous variables (presence or absence of cues) in repeated measures designs (drawings of health and illness). The analysis for the total sample showed that the amounts of postural, Cochran’s Q(1, N = 250) = 16.79, p < .001 and contextual cues, Cochran’s Q(1, N = 250) = 38.21, p < .001, employed to depict health and illness were significantly different. More specifically, children used more postural and contextual cues to depict illness than health. In contrast, the instances of facial cues in children’s drawings of health and illness did not differ significantly.

In order to investigate whether a similar pattern is observed across different age groups, we applied a Cochran’s Q analyses within each age group. The results confirmed that the number of facial cues used did not differ significantly in any age group. However, it was found that (1) the 5-year-olds, Cochran’s Q(1, N = 50) = 12.46, p < .001, the 9-year-olds, Cochran’s Q(1, N = 50) = 9.31, p < .05 and the 11-year-olds, Cochran’s Q(1) = 8.01, p < .05, used significantly more often postural cues to depict illness than health, while (2) the 5-year-olds, Cochran’s Q(1, N = 50) = 13.00, p < .001 and the 11-year-olds, Cochran’s Q(1, N = 50) = 9.00, p < .05 used significantly more often contextual cues to depict illness than health.

Categories of contextual cues used for the depiction of health and illness

A variety of contextual cues was used in children’s drawings depicting healthy and ill figures (see Figure 2 for representative examples). In an attempt to investigate whether the number of categories of contextual cues varied as a function of age and theme (health vs illness), data were analysed by means of a 4 (age group: 5, 7, 9, 11 years) × 2 (theme: health, illness) analysis of variance (ANOVA) with repeated measures on the last factor (theme), using the amount of contextual graphic cues (0 = no contextual cues to 5 = all categories of contextual cues) as the dependent variable. The main effect of age group was significant at F(3, 196) = 5.21, p < .05, while post hoc comparisons (Tukey’s HSD) revealed that 5-year-olds used a significantly smaller number of contextual cues (M = 1.18 for health and M = 1.54 for illness) compared with 9-year-olds (M = 1.68 for health and M = 1.92 for illness) or 11-year-olds (M = 1.50 for health and M = 2.30 for illness) p < .05 and p < .001, respectively. A significant main effect of theme, F(1, 196) = 36.87, p < .001 was also found, indicating that children used a different amount of contextual graphic cues for representing health and illness, and more specifically they used more contextual cues to denote illness (M = 1.91) than health (M = 1.44). The interaction age group × theme was not found to be significant.

Figure 2.

Representative drawings of health and illness scored for each category of contextual cues. Reprinted with permission.

Table 3 presents the frequencies (and the percentages) with which all categories of contextual cues were used to portray health and illness in the total sample and by age group. Attempting to compare the use of the various contextual cues in children’s drawings of illness and health, we conducted a series of Cochran’s Q analyses. The results showed that children (1) used more often nutritional cues to represent health than illness Cochran’s Q(1, N = 200) = 21.41, p < .001, (2) employed more often medical cues to draw illness than health, Cochran’s Q(1, N = 200) = 41.44, p < .001 and (3) used more often environmental cues to depict illness than health, Cochran’s Q(1, N = 200) = 43.12, p < .001. The amounts of linguistic and physical cues used did not differ in the drawings of health and illness.

Table 3.

Frequencies (and percentages) with which contextual cues emerged in the healthy/ill figures in the total sample and by age group.

Age group	N	Linguistic N (%)		Nutritional N (%)		Environmental N (%)		Physical N (%)		Medical N (%)
		Health	Illness	Health	Illness	Health	Illness	Health	Illness	Health	Illness
5 years	50	2 (4)	4 (8)	13 (26)	2 (4)	26 (52)	38 (76)	15 (30)	16 (32)	3 (6)	17 (34)
7 years	50	8 (16)	11 (22)	12 (24)	3 (6)	24 (48)	43 (86)	21 (42)	21 (42)	6 (12)	15 (30)
9 years	50	14 (28)	11 (22)	18 (36)	4 (8)	23 (46)	37 (74)	19 (38)	24 (48)	10 (20)	20 (40)
11 years	50	14 (28)	14 (28)	6 (12)	6 (12)	22 (44)	35 (70)	29 (58)	34 (68)	4 (8)	26 (52)
Ν	200	39 (19)	40 (20)	49 (24.5)	15 (7.5)	95 (47.5)	153 (76.5)	84 (42)	95 (47.5)	23 (11.5)	78 (39)

Subsequent Cochran’s Q analyses within each group showed that (1) the 5-year-olds, Cochran’s Q(1, N = 50) = 8.07, p < .05, the 7-year-olds, Cochran’s Q(1, N = 50) = 6.23, p < .05, and the 9-year-olds, Cochran’s Q(1, N = 50) = 12.25, p < .001, used significantly more often nutritional cues to represent health than illness, (2) the 5-year-olds, Cochran’s Q(1, N = 50) = 12.25, p < .001, the 7-year-olds, Cochran’s Q(1, N = 50) = 5.40, p < .05, the 9-year-olds, Cochran’s Q(1, N = 50) = 5.00, p < .05 and the 11-year-olds, Cochran’s Q(1, N = 50) = 22.00, p < .001 used significantly more often medical cues to depict illness than health and (3) the 5-year-olds, Cochran’s Q(1, N = 50) = 6.00, p < .05, the 7-year-olds, Cochran’s Q(1, N = 50) = 17.19, p < .001, the 9-year-olds, Cochran’s Q(1, N = 50) = 10.89, p < .001 and the 11-year-olds, Cochran’s Q(1, N = 50) = 11.27, p < .001 employed significantly more often environmental cues to depict illness than health. No statistically significant differences between drawings of health and illness were detected in any age group concerning linguistic and physical cues.

Discussion

This study aimed to investigate the specific graphic cues children employ in their drawings of a healthy/ill person. Our findings suggest that when asked to draw a healthy or an ill person, children use three types of graphic cues. More specifically, from an early age they alter the facial features of the human figure (Brechet et al., 2009; Cox, 2005; Golomb, 1992; Sayil, 2001), while they introduce a variety of contextual cues in their drawings, probably to ensure that the meaning of their depictions will be recognisable by the viewer (Bonoti and Misailidi, 2015; Brechet et al., 2009). Postural cues, although used less frequently than facial and contextual ones, still play their role, particularly for the depiction of illness.

Children in all four age groups used more often facial cues to denote illness and health. The incidence of facial cues as it was measured through the modification of the facial expression of the healthy/ill figures compared with their baseline drawn figure (e.g. by adding a smile to the healthy figure and tears and/or a downward mouth to the ill figure) may be attributed to children’s tendency to associate health and illness with happiness and sadness, respectively (Altman and Revenson, 1985; Campbell, 1975; Davó-Blanes and La Parra, 2012; Pridmore and Lansdown, 1997; Zaloudikova, 2010), and thus to reflect this association on the facial expressions (Cox, 2005; Golomb, 1992; Picard et al., 2007) of their healthy and ill figure drawings.

However, children handled differently the graphic cues under investigation in their drawings of health and illness, corroborating previous researchers supporting that the use of graphic cues is theme-specific (Bonoti and Misailidi, 2015; Golomb, 1992; Vendeville et al., 2018). The prompt to draw a situation seems to urge the child to activate those graphic cues that will better represent the theme under investigation. Thus, children used more contextual cues for the depiction of illness than health, possibly in an attempt to better describe the specific biological and medical processes accompanying illness (Schmidt and Frohling, 2000; Zaloudikova, 2010). Moreover, they used more often postural cues to depict illness than health, a finding that could be attributed to children’s difficulty to alter the posture of the figure (Brechet and Jolley, 2014; Picard et al., 2007), a skill which requires advanced drawing ability. More specifically, while the depiction of a motionless person lying on a bed does not require any particular alterations of the usual body posture, the representation of a healthy person’s action (such as running or participating in sports activities) requires the ability to efficiently change the various parts of the human figure in order to convey the intended meaning (Goodnow, 1978).

The aforementioned context-specific depiction of illness corroborates the assumption that illness can be described through more precise terms than health, which is considered as a more general and abstract concept (Altman and Revenson, 1985; Myant and Williams, 2005; Schmidt and Frohling, 2000; Zaloudikova, 2010). An additional finding consistent with this view is that children utilised more graphic – and contextual – cues to represent illness than health, which may consequently be attributed to their greater difficulty to define and/or depict health than illness (Mouratidi et al., 2016; Zaloudikova, 2010). However, this finding could also signify that children consider the healthy person as a normal/neutral person and therefore when they draw the healthy figure, they do not include a lot of modifications compared with its baseline.

The variety of contextual cues used in children’s healthy/ill figure drawings reveals that children perceive the two terms as complex and multifaceted situations (Davó-Blanes and La Parra, 2012; Myant and Williams, 2005; Reeve and Bell, 2009; Schmidt and Frohling, 2000; Wiseman et al., 2018). So far as the specific contextual cues found to be used for the depiction of health and illness, our analysis reveals that nutritional indices were more often included in the healthy figure drawings, while medical and environmental cues were more often depicted in the ill figure drawings. These findings indicate that children focus on different dimensions of the two concepts under investigation. More specifically, nutrition is considered as a fundamental dimension for the promotion and preservation of health, an important finding that supports recent findings (Wiseman et al., 2018) contradicting previous research (Mouratidi et al., 2016; Zaloudikova, 2010) and indicates that children recognise the individual’s responsibility for his or her own health (Youssef et al., 2010). However, a similar pattern was not observed in the case of illness, which is conceptualised through its consequences, that is, its medical dimensions (e.g. surgery) and the environmental restrictions (e.g. bed) it imposes on one’s life, a finding that possibly reflects children’s personal experiences of illness (Altman and Revenson, 1985). In other words, depictions of health tend to capture the importance of preventive practices, that is, to emphasise the causes, while drawings of illness mainly draw on symptoms and their treatment, that is, to identify a health condition mainly by its effects. These findings seems to support previous research which suggests that even at young ages, children have a preliminary ability of causal thinking about the two concepts (Piko and Bak, 2006; Toyama, 2016).

With respect to the effect of age on children’s ability to use the graphic cues under investigation in their drawings of healthy and ill persons, our results showed that as they get older, children incorporate more types of graphic cues in their drawings, a tendency which may reflect a more complex perception of the two terms under investigation (Koopman et al., 2004; Myant and Williams, 2005; Schmidt and Frohling, 2000; Zaloudikova, 2010). In other words, with increasing age children are able to represent health and illness as multifaceted situations, which include facial expression (happy vs sad face), postural (moving or motionless body), medical (discharge letter vs injection), nutritional (fruits vs fast-food) and environmental (outdoor vs indoor) dimensions. Furthermore, this age-related increase in the graphic cues used may also reflect children’s developing graphomotor skills (Golomb, 1992; Jolley, 2010), which enhance their representational drawing ability and allow the depiction of a variety of cues (Brechet and Jolley, 2014).

The approach adopted in this study permitted us to measure each graphic sign and prevented the loss of important information, as it is often the case when attempting to describe children’s depictions through broad – often preconstructed – categories (Mouratidi et al., 2016; Piko and Bak, 2006; Zaloudikova, 2010). It reveals the variety and multiplicity of meanings children attribute to concepts of health and illness and thus allows for a broader and more in-depth understanding of their perceptions (Faccio et al., 2017; Reeve and Bell, 2009).

Implications and limitations

Children’s early knowledge about health and illness is mostly acquired from everyday contexts and this social information is typically vague and educationally inappropriate (Faccio et al., 2017; Toyama, 2016). More specifically, parents and teachers can play a determining role in shaping children’s understanding of the two concepts by providing opportunities and acting as role models for children to develop healthy lifestyles (Daniels et al., 2016; Nyberg et al., 2011). Furthermore, previous studies (Reeve and Bell, 2009) have indicated that health curricula and teaching materials tend to underestimate pupils’ knowledge about health and illness and embrace a restricted, unidimensional and simplistic view of them, while teachers’ explanations of illness causation are often not very detailed (Toyama, 2016).

As children’s knowledge about health and illness seems to develop from the early years, and entails a considerable breadth of connotations and dimensions, age-appropriate education and health promotion programmes should explicitly take into account this conceptual multiplicity and align with their everyday interests, knowledge and activities outside school, which seem to play a particularly important role in shaping this early knowledge (Koopman et al., 2004; Wiseman et al., 2016). Only by building on children’s preexisting perceptions can health education be expected to support their development and improve health literacy to young pupils and future adolescents and adults (Brindal et al., 2012; Daniels et al., 2016; Piko and Bak, 2006; Reeve and Bell, 2009; Zaloudikova, 2010). Based on the apparent and significant development of children’s knowledge, researchers (Daniels et al., 2016; Natapoff, 1982; Wiseman et al., 2016) argue that health education programmes should start in their first years of schooling, aiming at empowering children in participating in their own healthcare. Such programmes should gradually support them towards more sophisticated and complicated knowledge and practices in order for children to be able to make informed health decisions by the age of 9 (Natapoff, 1982). Besides, enhancing positive health attitudes in the early years is easier than improving established negative ones later in students’ lives (Piko and Bak, 2006; Woods et al., 2005). In line with this, adopting bottom-up approaches that take into account children’s views and actively involving them in inquiry-based health promotion activities has been found to motivate children to act and reflect on their own experiences and interests and to increase their participation and empowerment in controlling their health (Bruselius -Jensen et al., 2017; Davó-Blanes and La Parra, 2012; Hagquist and Starrin, 1997; Jensen and Simovska, 2005; Mengwasser and Walton, 2013; Piko and Bak, 2006; WHO, 1986). Another significant implication of the findings of this study is that health education should specifically focus on enhancing children’s understanding of the concept of health, as they exhibit greater difficulty in defining and depicting it compared with the concept of illness.

Limitations

The cross-sectional design of the study can be considered a limitation as it obscures the developmental trajectories of children’s perceptions of health and illness. Moreover, the sampling procedure did not permit us to identify children who might have experienced illness or hospitalisation in order to investigate whether those children’s pictorial representations differ from those produced by children with no similar experiences. Furthermore, an analysis of children’s verbalisations, such as their definitions of the two terms under investigation, combined with reports of their personal experiences would probably provide more in-depth insight into their ideas about illness and health. Finally, as socio-economic status and other demographic characteristics (e.g. race, ethnicity) have been found to significantly differentiate children’s health-related behaviours (Chen et al., 2018; Cheung, 2017), future research could explore whether demographic characteristics are also associated with varying perceptions reflected on their drawing representations.

Conclusion

The method adopted in this study seems valuable in capturing the subtlety of children’s developing perceptions and could therefore assist in implementing health education activities consonant with children’s own ways of reasoning. Moreover, the framework of analysis of children’s drawings of health and illness proposed in this study, could serve as a valuable tool for teachers and health programme developers to identify children’s existing knowledge and use it as a starting point to design, implement and evaluate relevant activities.

Recent research by Faccio et al. (2017) signals the three-fold potential of drawings for health education programmes. First, pre-intervention drawings can help identify children’s intuitive conceptions about health and be used as starting points for the preparation of content and the design of appropriate intervention programmes. Second, when used during an intervention, drawings can support meaning-making and cognitive development, and thus they can be considered as a part of the teaching materials. Third, post-intervention drawings can provide useful insight into the level of pupils’ conceptual understanding of the taught topic; when compared with pre-intervention drawings, they can also serve as evaluation tools to assess the effectiveness of the teaching material and methods.

Footnotes

Acknowledgements

The authors thank Aspasia Mantziou for serving as a rater in the data coding process.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iDs

Fotini Bonoti

Vasilia Christidou

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