The use of pictograms in the health care: A literature review

Enhancing patient acceptance of ICD implantation through structured shared decision making: conversation is key

BACKGROUND

Implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy defibrillators (CRT-D) are lifesaving treatments for patients at risk for sudden cardiac death. Effective physician-patient communication during the shared decision-making process is essential. Electrophysiologist-patient conversations were targeted to obtain objective data on the interaction, understand the conversation framework, and uncover opportunities for improved communication.

METHODS

Individuals previously identified as requiring an ICD/CRT-D but declined implantation were recruited for this four-stage interview and survey-based study. Quantitative analysis of surveys and AI analysis of conversation videos was conducted to evaluate patient participant expectations, analyze feedback about the conversations with study physicians, and gauge willingness for device implantation.

RESULTS

The study included 27 patients (mean age 51 years, 51.9% female) and 9 study physicians. Patients were significantly more willing to undergo ICD/CRT-D implantation after conversing with study physicians compared to their own physicians and pre-conversation surveys (mean scores: 5.0, 3.1, and 4.4 out of 7, respectively; p < 0.001). Patient participants had higher satisfaction with the study conversation, rating study physicians higher in effectiveness of explanations, responsiveness to questions, and overall quality of the conversation compared to their own physicians (all p < 0.001).

CONCLUSIONS

In a cohort of patients who previously declined ICD/CRT-D implantation, patient satisfaction and willingness to undergo implantation of a guideline-directed device therapy increased significantly following a structured conversation with study physicians. Identified key elements could be integrated into user-friendly tools and educational materials to facilitate these conversations, improving patient engagement with the decision-making process and enhancing informed acceptance of indicated device therapies.

The preferences of people in Australia to respond and engage with advertisements to promote reproductive health: Results of a discrete choice experiment

Objectives

The health of people prior to pregnancy impacts pregnancy outcomes and childhood health, making the preconception period an important time to optimise health behaviours. Low awareness of the importance of this issue is a recognised barrier to achieving good preconception health. Public health messaging can help to address this barrier.

Methods

A discrete choice experiment to assess the preferences of people of reproductive age for a health promotion advertisement for preconception health was conducted. Attributes of the advertisement image, title, additional text content and positioning, and the location of advertisement were assessed by fitting a mixed logit model to the choices made.

Results

Three hundred and thirty-four responses were obtained, from people of reproductive age, both planning and not planning a pregnancy, in Australia. Participants placed most importance on the image, and the location in which they saw the advertisement. An image of adult and baby hands was preferred to adult hands only, and healthcare settings were preferred to more general media locations such as advertising online or on public transport. Preference was also given to the advertisement title of "Healthy you, Healthy baby", closely followed by "Are you ready for pregnancy?". The location and content of additional text did not significantly impact engagement with the advertisement.

Conclusion

The image and title on the advertisement, and the locations in which they are placed were the most significant features to impact engagement with a health promotion advertisement for preconception health. This can inform health promotion efforts for preconception health.

Pharmaceutical pictograms to improve textual comprehension: A systematic review

INTRODUCTION

Written instructive information for the patient is key in pharmaceutical care. However, the preexisting literature agrees on the discordance between the readability of written medication messages intended for patients. The aim of our work was to systematically review the available evidence on the effect of pharmaceutical pictograms as elements that facilitate understanding of the text in primary or secondary medication packaging.

METHODS

A parallel systematic search was conducted of the literature covering evidence of the effect of including pictograms in primary or secondary packaging on comprehension by potential users or caregivers up to April 9, 2023. The databases consulted were Scopus, MEDLINE and Web of Science. Only randomized controlled studies, whose main outcome measure was comprehension, were included.

RESULTS

Only 8 papers met our search criteria. In most of the included studies, the intervention of including pictograms improved participants' performance in comprehending instructions. A debatable methodological quality, and differences in the target population, textual complexity of the materials or the cultural affinity of the pictograms with the target population in each study, could have had a decisive influence on the results.

CONCLUSION

The heterogeneity in the design of each study poses a significant barrier to establishing commonalities and generalizing the results. This heterogeneity also prevented us from conclusively confirming the usefulness of pictograms complementary to instructional text in improving the comprehension of instructions for the rational use of medicines.

Development of pictogram-based content of self-management health information for Korean patients with chronic obstructive pulmonary disease

BACKGROUND

Adherence to self-management greatly impacts patients with chronic obstructive pulmonary disease (COPD) patients. However, most patients with COPD have a limitation in understanding text-based self-management plans owing to low health literacy. Thus, strategies to improve self-management in patients with COPD should be developed.

OBJECTIVES

This study aimed to develop pictogram-based content comprising self-management health information for patients with COPD.

METHODS

Items for COPD self-management health information were selected based on in-depth interviews with patients and text network analysis conducted in our previous study and a systematic literature review to develop preliminary pictogram-based content. Then, 30 patients with COPD and 10 healthcare professionals (HCPs) were recruited to evaluate the preliminary content using a client satisfaction questionnaire with a maximum score of 32.

RESULTS

Content was developed with one item related to disease knowledge while the other 20 concerned self-management. Patients (28.70 ± 2.94) and HCPs (27.40 ± 2.84) evaluated the content as high quality with adjustments made to increase the size of the letters and shorten the number of items for readability. Twenty-one items were collated in the final booklet, while 14 of the 21 items were incorporated into a poster.

CONCLUSIONS

This study indicates that the pictogram-based content was sufficiently well designed and received good evaluations from both patients with COPD and HCPs. Therefore, it may have prospects for enhancing self-management in patients with COPD. However, the effect of the content on the outcomes of older patients with COPD and low health literacy will need to be validated in future research.

Pharmaceutical pictograms: User-centred redesign, selection and validation

Objective

In an earlier study, several tested International Pharmaceutical Federation (FIP) pictograms did not achieve validity among older adults in Singapore. In this study, for 27 unvalidated FIP pictograms, we (1) developed variants of each pictogram, (2) elicited the most-preferred variant, and (3) assessed the validity of the most-preferred variant among older Singaporeans.

Methods

In phase 1, up to three variants of the 27 pictograms were developed, based on older adults' feedback from a previous study. In phase 2, the most-preferred variant of 26 pictograms, which had two or three variants, was selected by 100 older participants. In phase 3, the 27 most-preferred variants (including the pictogram with only one variant) were assessed for validity - transparency and translucency - among 278 older participants (10 pictograms per participant). To evaluate transparency, participants were first asked: "If you see this picture on a medicine label, what do you think it means?" for each assigned pictogram. If they responded, they were asked, "How do you know?", and if not, they were told, "Tell me everything you see in this picture". Then, participants were shown their assigned pictograms again, one by one, and the pictogram's intended meaning was revealed to evaluate translucency. Pictograms were classified as valid (≥66% participants interpreted its intended meaning correctly [transparency criterion] and ≥85% participants rated its representativeness as ≥ 5 [translucency criterion]), partially valid (only transparency criterion fulfilled) or not valid.

Results

In phase 1, 77 variants of the 27 pictograms were developed. In phase 2, a majority of the most-preferred variants were selected by >50% participants. In phase 3, 10 (37.0%) of the 27 pictograms tested were considered valid, and five (18.5%) were partially valid. A higher proportion of pictograms portraying dose and route of administration and precautions were valid or partially valid, versus those depicting indications or side effects.

Conclusion

Contextual redesigning and selection of pharmaceutical pictograms, which initially failed to achieve validity in a population, contributed to their validation.

Innovation

The redesigned validated pictograms from this study can be incorporated into relevant patient information materials in clinical practice.

Comprehension of prescription orders with and without pictograms: tool validation and comparative assessment among a sample of participants from a developing country

BACKGROUND

Medication errors can often occur due to the patient's inability to comprehend written or verbal medication orders. This study aimed to develop pictograms of selected medication orders and to validate the comprehension of prescription orders index and compare the comprehension scores with and without pictograms. In addition to determine the predictors that could be associated with a better or worse comprehension of prescription orders with pictograms versus that of their written counterparts.

METHODS

A cross-sectional study was conducted using a snowball sampling technique. Six pictograms were developed to depict specific medication orders. The comprehension of prescription orders index was constructed and validated. The study then compared the comprehension scores of prescription orders with and without pictograms, and identified the predicting factors score difference.

RESULTS

A total of 1848 participants were included in the study. The structure of the comprehension of prescription orders index was validated over a solution of four factors, with an adequate Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy of 0.711 and a significant Bartlett's test of sphericity (P < 0.001). The construct validity of the index was further confirmed by highly significant correlations between each item and the full index (P < 0.001). The study also found a significant association between the difference in comprehension scores for prescription orders with and without pictograms and several factors, including age, level of education, area of residence, number of children, and smoking status with the difference of comprehension scores (P < 0.001).

CONCLUSION

Pictogram-based instructions of medication orders were better understood by the Lebanese population than written instructions, making the incorporation of pictograms in pharmacy practice paramount to optimize medication use by the patient and thus yielding better health outcomes.

Exploring the Role of Pictograms in the Comprehension of Pain

Introduction

Pain is both difficult to see and to articulate and this is challenging for both patients and clinicians. The aim of this study was to develop and test pictograms to describe different pain qualities.

Methods

22 pictograms were developed for evaluation based on pain qualities of the short form McGill Pain Questionnaire, version 2 (SF-MPQ-2). An online matching survey was conducted and disseminated via social media in 2021.

Results

An overall matching of 66% or higher between pictogram and pain qualities descriptors was considered a proper matching. This study was carried out internationally (males = 57, age=41y.o. ±16; females = 155, age=41y.o.±17) and in Poland (males=49, age =35y.o.±17; females = 164, age=35y.o.±16). There were 14 pictograms that did not achieve 66% matching in any country. 8 pictograms mutually in all subgroups achieved a matching score of ≥66% regardless of geographic location, sex, income, or education level.

Discussion and Conclusions

These 8 pictograms can be used clinically once they have been redrawn to improve consistency, and future research in the design of pictograms representing pain qualities of the SF-MPQ-2 should focus on design improvements for the remaining 14 pain qualities with poor comprehensibility.

Do Pictograms on Medication Packages Cause People to Consult Package Inserts Less Often? If so, With What Consequences?

Overall, pharmaceutical pictograms seem to improve medication adherence. However, little is known about how warning pictograms (e.g., "do not drive after taking") on medication packages influence patients' information-seeking strategies such as consulting the package insert (PI) to determine other features such as the correct dosage. In this online study, participants (358 students) were presented with three fictitious scenarios (e.g., headache after alcohol consumption; factor scenario) in which medication use would be contraindicated. Each scenario was accompanied by a visual presentation of a medication package that could contain three possible pictogram selections or arrangements (factor warning); some arrangements contained pictograms relevant to the situation represented by the scenario, while others did not. Participants had to decide which dosage of the represented medication they were allowed to take in the given scenario. In making this decision, they could consult the PI or not. Overall, in two out of the three scenarios (driving and pregnancy), medication packages with relevant pictograms resulted in fewer PI consultations but led to more correct dosage decisions ("no pill") than packages with irrelevant pictograms. Pictograms generally played no role in either the review of the PI consultation or dosage decisions in the alcohol scenario. Providing warning-relevant pictograms on medication packages can help people know when they should not take medication even without reading the PI.

Improving wound swab collection in paediatric patients: a quality improvement project

Microbiology sample swabs may be unsuccessful or rejected for a variety of reasons. Typically, errors occur in the preanalytical phase of sample collection. Errors with collection, handling and transport can lead to the need to repeat specimen collection. Unsuccessful specimens contribute to delays in diagnosis, increased patient stress and increased healthcare costs. An audit of sample swabs from London Health Sciences Centre Children's Hospital from August through October 2021 yielded complete success rates of 100% for ear and eye culture swabs, 98.1% for methicillin-resistant Staphylococcus aureus swabs and 88.9% for wound swabs. This project aimed to improve wound swab success to 95% on the paediatric inpatient and paediatric emergency departments by May 2022.Stakeholders from paediatric clinical services including physicians, nurses and the laboratory medicine team at our centre were engaged to guide quality improvement interventions to improve specimen success rate. Based on feedback, we implemented visual aids to our electronic laboratory test information guide. Additionally, visual reminders of correct sample collection equipment were placed in high traffic areas for nursing staff.After the interventions were implemented, a three-month follow-up showed that wound swab success rate rose to 95.3%. This study achieved its aim of improving wound swab success rate to 95%. It adds to the growing pool of evidence that preanalytical phase intervention such as visual aids can increase swab success rates, in healthcare settings.

Methodology of an approach for modifying pictograms showing medication side effects or indication

BACKGROUND

Pictograms may improve user-friendliness and comprehension of written or verbal health information. This paper describes a method to modify pictograms to improve their visual clarity, appeal and overall interpretive complexity in order to reduce the cognitive load on the viewer during comprehension.

METHODOLOGY

Nine pictograms previously tested for comprehension were selected for modification. In phase 1, two participatory design workshops were conducted with (a) three limited literacy, first-language isiXhosa-speaking participants and (b) four university students. Opinions and ideas for improving interpretation were discussed. In phase 2, revised visuals were generated by the graphic artist and subsequently modified in an intensive, multistage, iterative process.

RESULTS

As no guidelines for pictogram modification exist, a modification schema was developed based on the process described in this study. Adopting a participatory approach combined with a systematic, intensive modification process enabled the opinions and preferences of the end-users to be heard, ensuring cultural relevance and contextual familiarity of the final product. Careful scrutiny of all individual visual elements of each pictogram, considerations of space, and thickness of lines all contributed to improving the legibility of visuals.

CONCLUSIONS

The methodology for designing and modifying existing pictograms using a participatory process resulted in nine final pictograms that were approved by all design team members and considered good candidates for subsequent comprehension testing. The methodological schema presented in this paper provides guidance to researchers intending to design or modify pictograms.

Guessability of standard pharmaceutical pictograms in members of the Nigerian public

Background

Pharmaceutical pictograms are standardized images used to visually convey medication instructions. Very little is known about the ability of Africans to interpret these images.

Objectives

Thus, the aim of this study was to assess the guessability (ability to correctly guess meaning) of selected International Pharmaceutical Federation (FIP) and United States Pharmacopoeia (USP) pictograms in members of the Nigerian public.

Methods

A cross-sectional survey was carried out between May and August 2021 on 400 randomly sampled members of Nigerian public. Selected pictograms (24 FIP and 22 USP pictograms) were grouped and printed on A3 sheets of paper which were used to interview members of the public who fulfilled the study's' eligibility criteria. Respondents were asked to guess the meanings of either the FIP or USP pictograms, and their answers written down verbatim. Descriptive and inferential statistics were used to report the data collected.

Results

Four hundred respondents were interviewed, with 200 respondents each assessing the guessability of the FIP and USP pictograms. The guessability of assessed FIP pictograms ranged between 3.5 and 95%, while that for the USP pictograms was 27.5-97%. Eleven FIP and Thirteen USP pictograms respectively achieved the International Organization for Standardization (ISO) comprehensibility cutoff point of 67%. Guessing performance (the total number of pictograms correctly guessed by an individual) of respondents that assessed the FIP pictograms was significantly associated with their age (p = 0.044) and highest level of education completed (p = 0.003). For the USP pictograms, guessing performance was only significantly associated with the highest educational level completed (p < 0.001).

Conclusions

Guessability of both pictogram types varied widely, but the guessability of the USP pictograms was generally better than that for the FIP pictograms. Many of the tested pictograms may however need to be redesigned before they can be correctly interpreted by members of the Nigerian public.

Challenges encountered by pharmacy staff in using prescription medication labels during medication counselling with older adults and solutions employed: A mixed-methods study

Background

Prescription medication labels (PMLs) predominantly dispensed in English, are an important adjunct to medication counselling. PMLs are routinely used by pharmacy staff to counsel older adults about their medications. This study sought to identify challenges that pharmacy staff observe older adults face in using their PMLs, and to identify and quantify solutions employed by pharmacy staff during medication counselling to address such challenges.

Methods

Ten in-depth interviews were done with primary care pharmacy staff to gather the range of challenges and solutions. Subsequently, a quantitative survey, informed by the qualitative findings, was administered to 121 pharmacy staff to assess if the reported solutions were commonly used.

Results

The two main challenges were incongruity between PML language (English) and older adults' language proficiency, and poor PML legibility. The solutions, classified under three themes, were simplifying medication information on PMLs, supplementing PMLs with additional medication information and mitigating poor readability.

Conclusions

Pharmacy staff observed challenges faced by older adults in using PMLs during medication counselling. Ad-hoc improvisations by pharmacy staff to PMLs were pervasive. System-level PML improvements, such as provision of legible bilingual medication instructions, pharmaceutical pictograms and additional medication information, through patient information leaflets or using quick response (QR) codes on PMLs, should be considered. This will facilitate patient-provider communication, especially in settings with language dissonance between PMLs and patients.

Pictograms to aid laypeople in identifying the addictiveness of gambling products (PictoGRRed study)

The structural addictive characteristics of gambling products are important targets for prevention, but can be unintuitive to laypeople. In the PictoGRRed (Pictograms for Gambling Risk Reduction) study, we aimed to develop pictograms that illustrate the main addictive characteristics of gambling products and to assess their impact on identifying the addictiveness of gambling products by laypeople. We conducted a three-step study: (1) use of a Delphi consensus method among 56 experts from 13 countries to reach a consensus on the 10 structural addictive characteristics of gambling products to be illustrated by pictograms and their associated definitions, (2) development of 10 pictograms and their definitions, and (3) study in the general population to assess the impact of exposure to the pictograms and their definitions (n = 900). French-speaking experts from the panel assessed the addictiveness of gambling products (n = 25), in which the mean of expert's ratings was considered as the true value. Participants were randomly provided with the pictograms and their definitions, or with a standard slogan, or with neither (control group). We considered the control group as representing the baseline ability of laypeople to assess the addictiveness of gambling products. Each group and the French-speaking experts rated the addictiveness of 14 gambling products. The judgment criterion was the intraclass coefficients (ICCs) between the mean ratings of each group and the experts, reflecting the level of agreement between each group and the experts. Exposure to the pictograms and their definition doubled the ability of laypeople to assess the addictiveness of gambling products compared with that of the group that read a slogan or the control group (ICC = 0.28 vs. 0.14 (Slogan) and 0.14 (Control)). Laypeople have limited awareness of the addictive characteristics of gambling products. The pictograms developed herein represent an innovative tool for universally empowering prevention and for selective prevention.

Development of Self-Management Pictorial Health Information and Comparison of Korean Patients' With Chronic Obstructive Pulmonary Disease and Health Care Professionals' Perceptions

The current study aimed to evaluate pictorial health information (HI) in chronic obstructive pulmonary disease (COPD) patient self-management. Each of 14 literal examples of COPD HI was transformed into three pictorials. The preliminary pictorial COPD HI was validated by 10 experts. In total, 60 patients with COPD and 50 health care professionals (HCPs) were selected to perceive the intended meanings in the pictorial HI. All 42 pictures scored ≥0.8 on the content validity index. Patients chose pictorial HI with descriptions of subjective expressions or those that reflected a patient's actual life, whereas HCPs selected HI that was described in simple, direct, and abstract expressions. Results indicate that HCPs are better suited to provide real life-friendly pictorial HI to patients with COPD. Therefore, it is expected that developing pictograms with patients with COPD could help convey intended meanings. [Journal of Gerontological Nursing, 48(10), 41-46.].

Comprehension of Pictograms Demonstrating the Risk of Medication Use During Pregnancy: A Systematic Review

OBJECTIVE

This study aimed to summarize the comprehension of a pictogram about the risk of medication use during pregnancy.

METHODS

A systematic review was performed using the PRISMA checklist of the PubMed, Embase, Cochrane Central Register of Controlled Trials, CINAHL, PsycInfo, LILACS, Academic Search Premier, Scopus, and Web of Science databases, grey literature (Google Scholar and OpenAIRE), ClinicalTrials.gov website, and design journals and congresses. The search was performed since the database inception, without language or year of publication restrictions.

RESULTS

Twelve studies met the inclusion criteria for this review, 2 of which were randomized clinical trials. The pictograms and methods used varied widely among studies. The comprehension of the pregnancy pictograms had a complex communication outcome with a variation of 21-96%.

CONCLUSIONS FOR PRACTICE

The lack of a standard pictogram and uniform methods to evaluate the comprehension of the pregnancy pictogram made it challenging to reach a conclusion with the studies available to date on the safety and efficacy of the pregnancy pictogram to alert the risk of medication use.

Feasibility of supported self-management with a pictorial action plan to improve asthma control

Supported self-management reduces asthma-related morbidity and mortality. This paper is on a feasibility study, and observing the change in clinical and cost outcomes of pictorial action plan use is part of assessing feasibility as it will help us decide on outcome measures for a fully powered RCT. We conducted a pre-post feasibility study among adults with physician-diagnosed asthma on inhaled corticosteroids at a public primary-care clinic in Malaysia. We adapted an existing pictorial asthma action plan. The primary outcome was asthma control, assessed at 1, 3 and 6 months. Secondary outcomes included reliever use, controller medication adherence, asthma exacerbations, emergency visits, hospitalisations, days lost from work/daily activities and action plan use. We estimated potential cost savings on asthma-related care following plan use. About 84% (n = 59/70) completed the 6-months follow-up. The proportion achieving good asthma control increased from 18 (30.4%) at baseline to 38 (64.4%) at 6-month follow-up. The proportion of at least one acute exacerbation (3 months: % difference -19.7; 95% CI -34.7 to -3.1; 6 months: % difference -20.3; 95% CI -5.8 to -3.2), one or more emergency visit (1 month: % difference -28.6; 95% CI -41.2 to -15.5; 3 months: % difference -18.0; 95% CI -32.2 to -3.0; 6 months: % difference -20.3; 95% CI -34.9 to -4.6), and one or more asthma admission (1 month: % difference -14.3; 95% CI -25.2 to -5.3; 6 months: % difference -11.9; 95% CI -23.2 to -1.8) improved over time. Estimated savings for the 59 patients at 6-months follow-up and for each patient over the 6 months were RM 15,866.22 (USD3755.36) and RM268.92 (USD63.65), respectively. Supported self-management with a pictorial asthma action plan was associated with an improvement in asthma control and potential cost savings in Malaysian primary-care patients.Trial registration number: ISRCTN87128530; prospectively registered: September 5, 2019, http://www.isrctn.com/ISRCTN87128530 .

Communicating with patients through pictograms and pictures - a scoping review

BackgroundCommunication between patients and Health Care Workers (HCW) may on occasion be challenged by disparities in cultural background, age and educational level. Written educational material is commonly used to reduce the risk of miscommunication. However, literacy among patients may also differ and it is therefore speculated that the use of pictograms may improve patients' understanding and adherence.ObjectiveTo evaluate the scientific literature and investigate the effect and practical utility of pictograms in medical settings with focus on dermatological patients.Materials and methodsPubmed, EMBASE, and Cochrane Library were searched July 2021 for studies regarding use of pictograms in medical settings and dermatology.ResultsThe use of pictograms in dermatology is not well characterized, but studies in other fields of medicine report a positive effect of using pictograms in communication. Pictograms have a significant positive effect when presented alongside verbal or written explanations.ConclusionThe quality of the development process is important to ensure the utility of any pictogram. Involving the target population in the design and validation of the pictograms may be critical. In the validation process, testing of transparency and translucency may benefit from international recommendations.

Validation of pharmaceutical pictograms among older adults with limited English proficiency

OBJECTIVE

Pictograms on prescription medication labels enhance medication literacy and medication adherence. However, pictograms need to be contextually validated. We assessed the validity of 52 International Pharmaceutical Federation pictograms among 250 older Singaporeans with limited English proficiency.

METHODS

Participants were randomly assigned 11 pictograms each. For each pictogram, participants were first asked its intended meaning. Then, they were told the intended meaning and asked to rate how well the pictogram represented the meaning, on a scale of 1-7. Pictograms were classified as valid (≥66% participants assigned the pictogram interpreted its intended meaning correctly [transparency criterion] and ≥85% participants rated its representativeness as ≥5 [translucency criterion]), partially valid (only transparency criterion was fulfilled) or not valid. Open-ended questions gathered feedback to improve pictograms.

RESULTS

14 pictograms (26.9%) achieved validity and 6 pictograms (11.5%) achieved partial validity. A greater proportion of pictograms for dose and route of administration, and dosage frequency achieved validity or partial validity versus those depicting precautions, indications or side effects.

CONCLUSION

Majority (61.5%) of the assessed pictograms did not achieve validity or partial validity, highlighting the importance of contextual validation.

PRACTICE IMPLICATIONS

Low pictogram comprehension emphasizes the importance of facilitating pictogram understanding during medication counseling.

Visual aids in ambulatory clinical practice: Experiences, perceptions and needs of patients and healthcare professionals

This study aims to explore how visual aids (VA) are used in ambulatory medical practice. Our research group (two doctors, one graphic designer and one sociologist) have led a qualitative study based on Focus Groups. A semi-structured guide and examples of VA were used to stimulate discussions. Participants were healthcare professionals (HP) working in ambulatory practice in Geneva and French-speaking outpatients. After inductive thematic analysis, the coding process was analyzed and modified to eventually reach consensus. Six focus groups gathered twenty-one HP and fifteen patients. Our study underlines the variety of purposes of use of VA and the different contexts of use allowing the distinction between “stand-alone” VA used out of consultation by patients alone and “interactive” VA used during a consultation enriched by the interaction between HP and patients. HP described that VA can take the form of useful tools for education and communication during consultation. They have questioned the quality of available VA and complained about restricted access to them. Patients expressed concern about the impact of VA on the interaction with HP. Participants agreed on the beneficial role of VA to supplement verbal explanation and text. Our study emphasizes the need to classify available VA, guarantee their quality, facilitate their access and deliver pertinent instructions for use.

The effect of the Original MethOd at pharmacy To ENhAnce Support for Health Improvement in the limited Japanese proficiency patients visiting local community pharmacy: A randomized controlled trial

OBJECTIVES

With an increase in globalization, the number of non-native-speaking citizens and tourists visiting local pharmacies is rapidly growing worldwide, creating linguistic and sociological problems. The aim of this study is to compare the effect of adding our original method, Original MethOd at pharmacy To ENhAnce Support for Health Improvement (OMOTENASHI), to the conventional medication counselling method (CMC) when counselling non-Japanese patients at the pharmacy.

METHODS

The OMOTENASHI consists of tools written in multiple languages and illustrations to clarify the effects and side effects, and to confirm patients' understanding. 71 non-Japanese patients were recruited and randomly assigned to the OMOTENASHI or to the CMC in a 1:1 ratio. Comprehension and satisfaction level were evaluated.

RESULTS

The overall comprehension level was significantly higher in the OMOTENASHI than in the CMC (75% vs 38%, p = 0.002), with a prominent difference in the recognition of the name, effects, side effects, precautions, and how to deal with side effects of the prescribed medication.

CONCLUSION

The OMOTENASHI to be a helpful tool in providing essential information to non-native-speaking patients.

PRACTICE IMPLICATION

The study highlighted the need to ensure every patient's safety and interests, and to avoid disadvantages caused by limited language proficiency in the globalization era.

The Development of Schematics to Illustrate Women's Experiences with Adjuvant Hormone Therapy in the Treatment of Breast Cancer

OBJECTIVE

Non-adherence to adjuvant hormone therapy prescribed orally in the treatment of breast cancer is complex as the literature has shown. Many women find it hard to adhere to the hormonal medicines they are prescribed and expected to take for at least 5 years following the initial management of their breast cancer. Arguably, communicating other women's 'trials, tribulations, and triumphs' with medication-taking could help newly-diagnosed patients to better prepare for the journey ahead. Our objective was to visually represent women's experiences with these medicines using data synthesized in the literature.

METHODS

Three schematics were drawn for each phase of medication-taking, namely, starting out, adherence, and cessation. The schematics were validated by interviewing a panel of healthcare professionals (n=10) and calculating a Content Validity Index (CVI). The edited drawings were discussed with a separate panel of breast cancer survivors (n=14) whose responses were elicited qualitatively in one-to-one interviews.

RESULTS

A total of 76 individual pictograms were drawn across the three schematics. The 13 pictograms that had an item-level CVI<0.8 were modified according to feedback resulting in three final schematics with an overall CVI of 87%, 87% and 80%, respectively.

CONCLUSION

Synthesised summaries of women's experiences with oral hormone therapy for breast cancer were visualised via three validated schematics. The schematics could aid patient-professional communication to help anticipate and tackle negative experiences and support decisions to take hormone medication in breast cancer.

Clinician Use of HIV-Related Infographics During Clinic Visits in the Dominican Republic is Associated with Lower Viral Load and Other Improvements in Health Outcomes

We designed an infographic intervention to help clinicians provide health information to persons living with HIV. In this study, we assessed the extent to which our intervention may improve objectively and subjectively measured health outcomes (CD4 count, viral load, and engagement with clinician among others) when integrated into routine visits in the Dominican Republic. In this pretest-posttest study, we followed participants for 9 months at 3-month intervals. Physicians administered the intervention during participants' first 3 visits. Outcome measures, selected using a conceptual model, were assessed at 4 time points. We assessed changes in outcomes over time with general linear regressions and Wilcoxon Signed-Rank tests. Participants (N = 50) were mostly female (56%) and had been living with HIV for a mean of 6.3 years (SD = 6.1). All outcomes, except CD4 count, demonstrated statistically significant improvements by study end. This provides preliminary evidence our intervention may improve outcomes, but further testing is needed.

Pictorial versus written asthma action plans for youth: initial impact on regimen knowledge, medication adherence, symptom control, and family satisfaction

OBJECTIVE

Asthma action plans (AAP) are recommended to guide asthma management. Written AAPs (WAAPs) are under-utilized and can be difficult to understand. Our study designed and tested a simplified pictorial AAP (PAAP). We hypothesized that better outcomes would be obtained for youth with the PAAP.

METHODS

One hundred and sixty-nine (169) youth (aged 8-17; AAP-naïve) were screened for this pilot, 2-arm randomized controlled trial. Feasibility, usability and preliminary efficacy of PAAP compared to a WAAP, for improving outcomes (inhaled corticosteroid (ICS) adherence, symptom control, AAP knowledge, AAP satisfaction) were assessed quantitatively. Youth received an AAP from their physician after completing baseline measures and completed measures at three additional time points (1-, 3-, and 6-month).

RESULTS

Forty-five youth were recruited (PAAP = 22; WAAP = 23). Youth AAP knowledge was higher for the PAAP group compared to the WAAP group (p = .017). ICS adherence did not differ between groups, over time, or based on prescribed dosing; however, for WAAP participants, adherence was lower with a higher daily prescription (4 puffs) relative to a lower dose (p = .006). Symptom control improved with both AAPs, but the change was not statistically significant. Lung function did not change significantly by AAP type or time, and literacy variables were not related significantly to outcomes. Youth satisfaction with AAP improved significantly for the PAAP group compared to the WAAP group (p = .03).

CONCLUSIONS

Higher AAP knowledge and satisfaction among youth in the PAAP group suggests that structured education from a physician using a PAAP is beneficial. Intervention and study design insights gained will guide future research.

Regular soft contact lens wearers' comprehension of graphical symbols labelled on multipurpose solutions

CLINICAL RELEVANCE

Symbols are commonly used to represent information of health care products included multipurpose solutions (MPSs) for contact lens (CL) care.

BACKGROUND

Little knowledge is available about recognition and comprehension by regular soft CL wearers of commonly used symbols in the instructions of CL MPSs marketed worldwide.

METHODS

CL wearers from the UK and Spain were invited to answer an anonymous on-line questionnaire (distributed though Facebook and Twitter) concerning the recognition and comprehension of seven common symbols (ISO 15223:2017 and EN 980:2008) included in MPS package instructions.

RESULTS

Answers of one hundred-ten soft CL wearers who use MPS (27 in the UK and 83 in Spain) were analysed showing low recognition and comprehension of the surveyed symbols even in wearers with > 5 years of CL wear (71.8%). The CE marked was the most recognised (96% in the UK and 88% in Spain, P = 0.29) and understood (78% in the UK and 85% in Spain, P = 0.25) symbol, but other important symbols, such as 'Caution' and 'Do not reuse', were under recognised (22% in the UK and 19% in Spain, P = 0.78 and 11% in the UK and 6% in Spain, P = 0.40 respectively) and understood (close to 30% in both countries P > 0.15). Participants with > 5 years of experience, showed slightly higher comprehension (P < 0.05) in some symbols ('Sterilised'; 'Do not reuse'; 'Use by date' and 'CE marked').

CONCLUSION

These results suggest an insufficient comprehension of seven common symbols included in MPS instructions among regular CL wearers in the UK and Spain without high impact of CL wear experience. Improving the education and symbol comprehension of regular CL wearers could help to get better patients' behaviour and safe use of MPS in soft CLs care.

Ergonomic analysis and design intervention in symbols used in hospitals in central India

People visiting different Government Hospitals at Jabalpur in central India, were facing problems in comprehending different symbols. One of such hospital authority approached the research team for developing new symbols which could be easily comprehended by the users. Based on this, the current study was conducted, which included two experiments. The first experiment dealt with the ergonomic evaluation and identification of problems associated with the existing symbols. New concepts were then developed based on Ergonomic principles and users' feedback. The second experiment focused upon testing of the new concepts on the target users. Results of Experiment 1 indicated that the mean comprehension level was 22.3% for all the existing symbols (n = 41). Low scores (on a scale of 1-10) were found for the existing symbol for ergonomic principles (mean value was 1.9 for Compatibility, 2.1 for Familiarity, and 2.0 for Standardisation). Redesigned concepts of the symbols were tested on the target users, the result indicated an improvement in comprehensibility of newly designed symbols. The mean comprehension level for 53 new/redesigned symbols was 70.2%, which included redesign of 41 orignal and inclusion of 12 new symbols. High scores (on a scale of 1-10) were received for all the new symbols for ergonomic principles (the mean value was 8.4 for Compatibility, 8.5 for Familiarity, and 8.5 for Standardisation). Findings of this study may be helpful for the researchers working in the domain of information ergonomics in space related to healthcare sector or similar areas.

The effectiveness of using text and pictograms on oral rehydration, dry-mixture sachet labels

Background

Medication labels are often the only information available to patients after obtaining medication from a healthcare practitioner. Pictograms are graphic symbols that have shown to increase understanding of medicine use instructions.

Aim

To compare the accuracy of the interpretation of medicine use instructions from two different oral rehydration (OR) dry-mixture sachet labels – the control ‘routine textonly’ label and an experimental label with ‘text-and-pictograms’.

Setting

Participants were recruited from waiting rooms in public primary health care (PHC) facilities in Cape Town.

Method

Each participant was required to answer six questions about OR preparation. Response accuracy was determined by comparing the participant’s answer to the actual information written on the relevant label. Afterwards, participants could offer their opinion about the label and ways to improve their understanding.

Results

Of the 132 participants who were recruited, 67 were allocated to the experimental group and 65 to the control group. Only the significant difference between the experimental and control groups for the six questions regarding the label, was recorded for the answer that could be read from a single pictogram (p = 0.00) on the experimental group’s label. When asked about this question, more control participants (15/65) found the dosing instruction difficult to understand when compared to the experimental group (1/67). A third of the control participants (22/65) indicated that they could not see or locate instructions on the label.

Conclusion

Text and pictograms on written medicine labels may be an effective tool to aid understanding of medicine use instructions amongst patients attending PHC facilities.

Perceptions of the International Symbol of Accessibility among nondisabled university students in Hong Kong

The present experimental study involved 346 university students without self-reported disability and investigated the perceived symbolic meanings of the International Symbol of Accessibility (ISA) along with its associations with stereotypes toward wheelchair users and the perceived inclusiveness of the social climate. Participants were randomized into four groups with exposure to either the ISA, Motion-symbol, Universal-Design-symbol, or all-symbols. The results showed that different symbols were associated with different patterns of perceived symbolic meanings. Exposure to the Universal-Design-symbol, which emphasizes equality (but not the Motion-symbol, which emphasizes autonomy), was significantly and indirectly associated with relatively lower stereotypes toward wheelchair users (and perceived less inclusive social climate) through associating the Universal-Design-symbol with relatively lower perceived symbolic meanings of "Passive" and "Labeling" (and "Passive") compared to exposure to the ISA. Recommendations for a contextual-dependent replacement of symbol, the methodology of implicit association tests, and the usage of symbols of access in cartography were discussed.

Effectiveness of pictographs in improving patient education outcomes: a systematic review

The objective of this review was to investigate process of pictograph development and the effectiveness of pictographs in patient education. We conducted searches in Medline/PubMed, CINAHL with full text, PsycInfo, ERIC and Cochrane Library with keywords: (pictograph or pictorial) AND (patient education) NOT (children or adolescent or youth or child or teenagers). After excluding manuscripts that did not meet inclusion criteria, 56 articles were included between the time of the last review on this topic (January 2008) and May 2019. There are 17 descriptive studies, 27 randomized control trial studies, 9 quasi-experimental studies and 2 unique literatures in the systematic review. Major goals of the studies are pictograph development or validation. The majority of manuscripts (n = 48) supported the approach. However, six studies did not find significant differences in the outcome. Differences in patient population, pictograph designs and author-developed outcome measurements made it difficult to compare the findings. There is a lack of evidence on validating information outcome measurements. This review demonstrated that implementing pictographs into patient education is a promising approach for better information understanding and health management. Pictographic interventions need to be carefully developed and validated with both the targeted patient population and the clinical experts.

MASCC/ISOO clinical practice guidelines for the management of mucositis: sub-analysis of current interventions for the management of oral mucositis in pediatric cancer patients

OBJECTIVE

The aim of this sub-analysis was to highlight the MASCC/ISOO clinical practice guidelines for the management of oral mucositis (OM) in pediatric patients and to present unique considerations in this patient population.

METHODS

This sub-analysis of the pediatric patient population is based on the systematic review conducted by the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISSO) published in 2019/2020. Studies were scored and assigned a level of evidence based on previously published criteria. Data regarding adverse effects and compliance was collected from the original publications.

RESULTS

A total of 45 papers were included and assessed in this sub-analysis, including 21 randomized controlled trials (RCTs). Chewing gum was demonstrated to be not effective in preventing OM in pediatric cancer patients in 2 RCTs. The efficacy of all other interventions could not be determined based on the available literature.

CONCLUSION

There is limited or conflicting evidence about interventions for the management of OM in pediatric cancer patients, except for chewing gum which was ineffective for prevention. Therefore, currently, data from adult studies may need to be extrapolated for the management of pediatric patients. Honey and photobiomodulation therapy in this patient population had encouraging potential. Implementation of a basic oral care protocol is advised amid lack of high level of evidence studies.

Pharmacists, are words enough? The case for pictograms as a valuable communication tool

Despite living in a visually saturated world, with visual content permeating seemingly every aspect of our lives, an area in which visuals are still under-represented is health communication. Written health information, including medicines information, has generally been reported as being reader-unfriendly, offering challenges and barriers to even the most literate of readers with its often lengthy, detailed documents, use of medical jargon, and densely packed small text. The inclusion of visual content in the form of pictograms offers the potential to enhance the attractiveness and reader-friendliness of the information as well as improving comprehension and recall of medicines and general health information. This commentary presents the case of pictograms as a valuable tool in medicines information, urging pharmacists to consider their adoption in practice, but also sounding a note of caution when using pictograms.

Using pictures to convey health information: A systematic review and meta-analysis of the effects on patient and consumer health behaviors and outcomes

OBJECTIVE

Assess the effect of pictorial health information on patients' and consumers' health behaviors and outcomes, evaluate these effects in lower health literacy populations, and examine the attributes of the interventions.

METHODS

We included randomized controlled trials (RCTs) that assessed the effect of pictorial health information on patient and consumer health behaviors and outcomes. We conducted a meta-analysis of RCTs that assessed knowledge/understanding, recall, or adherence, and a subgroup analysis of those outcomes on lower health literacy populations. We narratively reviewed characteristics of pictorial health interventions that significantly improved outcomes for lower health literacy populations.

RESULTS

From 4160 records, we included 54 RCTs (42 in meta-analysis). Pictorial health information moderately improved knowledge/understanding and recall overall, but largely increased knowledge/understanding for lower health literacy populations (n = 13), all with substantial heterogeneity. Icons with few words may be most helpful in conveying health information.

CONCLUSION

Our results support including pictures in health communication to improve patient knowledge. Our results should be interpreted with caution considering the significant heterogeneity of the meta-analysis outcomes.

PRACTICE IMPLICATIONS

Future research should assess which types and characteristics of pictures that best convey health information and are most useful and the implementation and sustainability in healthcare contexts.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018084743.

The Effectiveness of Pictorial Discharge Advice Versus Standard Advice Following Discharge From the Emergency Department: A Systematic Review and Meta-Analysis

INTRODUCTION

Failure to provide adequate discharge advice to patients on leaving the emergency department can lead to poor understanding of and noncompliance with discharge instructions and consequently postdischarge complications or hospital readmissions. The use of pictographs to complement discharge advice has the potential to enhance patient recall and comprehension. The purpose of this paper was to determine the effectiveness of pictorial discharge advice compared with standard discharge advice in the emergency department.

METHODS

A systematic review and meta-analysis was conducted. CINAHL, MEDLINE, ASSIA, and EMBASE were searched from inception to March 1, 2020, combining terms related to the emergency room, pictogram, and randomized trials as appropriate. Randomized trials reporting on the use of pictorial discharge advice in the emergency department were eligible for inclusion. Outcome measures were comprehension, compliance with advice, satisfaction with advice and the ED visit, and reattendance rates. The Cochrane risk of bias tool was used to assess bias in the included studies.

RESULTS

Four studies were identified as eligible and included in the review. Pictorial discharge advice improved comprehension, compliance, and patient satisfaction with the advice, but not satisfaction with the ED visit when compared with standard discharge advice. None of the included studies measured reattendance rates.

DISCUSSION

The results of this systematic review support the use of pictorial discharge advice. However, few studies exist; none had a low risk of bias overall, and 3 were published over 12 years ago. This finding highlights a need for further research to inform evidence-based best practices on optimal methods for providing quality discharge advice in the emergency department.

Assessing health professionals' perception of health literacy in Rhode Island community health centers: a qualitative study

Background

Limited health literacy is linked with poor health behaviors, limited health care access, and poor health outcomes. Improving individual and population health outcomes requires understanding and addressing barriers to promoting health literacy.

Methods

Using the socio-ecological model as a guiding framework, this qualitative study (Phase 1 of a larger ongoing project) explored the interpersonal and organizational levels that may impact the health literacy levels of patients seeking care at federally qualified community health centers (FQCHCs) in Rhode Island. Focus groups were conducted with FQCHC employees (n = 37) to explore their perceptions of the health literacy skills of their patients, health literacy barriers patients encounter, and possible strategies to increase health literacy. The focus groups were audio-recorded and transcribed, and transcripts were coded using a process of open, axial, and selective coding. Codes were grouped into categories, and the constant comparative approach was used to identify themes.

Results

Eight unique themes centered on health literacy, sources of health information, organizational culture’s impact, challenges from limited health literacy, and suggestions to ameliorate the impact of limited health literacy. All focus group participants were versed in health literacy and viewed health literacy as impacting patients’ health status. Participants perceived that some patients at their FQCHC have limited health literacy. Participants spoke of themselves and of their FQCHC addressing health literacy through organizational- and provider-level strategies. They also identified additional strategies (e.g., training staff and providers on health literacy, providing patients with information that includes graphics) that could be adopted or expanded upon to address and promote health literacy.

Conclusions

Study findings suggest that strategies may need to be implemented at the organizational-, provider-, and patient- level to advance health literacy. The intervention phase of this project will explore intervention strategies informed by study results, and could include offering health literacy training to providers and staff to increase their understanding of health literacy to include motivation to make and act on healthy decisions and strategies to address health literacy, including the use of visual aids.

User-Centered Design and Evaluation of a Web-Based Decision Aid for Older Adults Living With Mild Cognitive Impairment and Their Health Care Providers: Mixed Methods Study

Background

Mild cognitive impairment (MCI) is often considered a transitional state between normal and pathologic (eg, dementia) cognitive aging. Although its prognosis varies largely, the diagnosis carries the risk of causing uncertainty and overtreatment of older adults with MCI who may never progress to dementia. Decision aids help people become better informed and more involved in decision making by providing evidence-based information about options and possible outcomes and by assisting them in clarifying their personal values in relation to the decision to be made.

Objective

This study aimed to incorporate features that best support values clarification and adjust the level of detail of a web-based decision aid for individuals with MCI.

Methods

We conducted a rapid review to identify options to maintain or improve cognitive functions in individuals with MCI. The evidence was structured into a novel web-based decision aid designed in collaboration with digital specialists and graphic designers. Qualitative and user-centered evaluations were used to draw on users’ knowledge, clarify values, and inform potential adoption in routine clinical practice. We invited clinicians, older adults with MCI, and their caregivers to evaluate the decision aid in 6 consecutive rounds, with new participants in each round. Quantitative data were collected using the Values Clarity and Informed subscales of the Decisional Conflict Scale, the System Usability Scale, the Ottawa Acceptability questionnaire, and a 5-point satisfaction rating scale. We verified their comprehension using a teach-back method and recorded usability issues. We recorded the audio and computer screen during the session. An inductive thematic qualitative analysis approach was used to identify and describe the issues that arose. After each round, an expert panel met to prioritize and find solutions to mitigate the issues. An integrated analysis was conducted to confirm our choices.

Results

A total of 7 clinicians (social workers, nurses, family physicians, psychologists) and 12 older (≥60 years) community-dwelling individuals with MCI, half of them women, with education levels going from none to university diploma, were recruited and completed testing. The thematic analysis revealed 3 major issues. First, the user should be guided through the decision-making process by tailoring the presentation of options to users’ priorities using the values clarification exercise. Second, its content should be simple, but not simplistic, notably by using information layering, plain language, and pictograms. Third, the interface should be intuitive and user friendly, utilize pop-up windows and information tips, avoid drop-down menus, and limit the need to scroll down. The quantitative assessments corroborated the qualitative findings.

Conclusions

This project resulted in a promising web-based decision aid that can support decision making for MCI intervention, based on the personal values and preferences of the users. Further ongoing research will allow its implementation to be tested in clinical settings.

To Develop Health Education Tools for Nasogastric Tube Home Caring Through Participatory Action Research

Medical institutions provide guidance on caring skills for home caregivers. Oral teaching is combined with graphical tools in a method that has been proved to be an effective way of quickly mastering home caring skills and promotes effective learning for home caregivers. The graphic design and operation contents of this method are constantly revised through interviews and observations, and by carrying out home care application graphics it forms a spiral structure of Plan-Do-Study-Act (PDSA) participatory action research (PAR). In the three cycles of the operation of PDSA PAR, the designers accurately create graphics of the caring details based on the nurses' demonstrations and develop health education tools that are suitable to provide continuous assistance and services in real-life situations. PAR combined with PDSA, in each of the three cycles of the operation-design personnel, medical personnel and home caregiver personnel, respectively-as the lead roles, guide the planning decisions for PAR. This study is a reference for the improvement and development of medical graphics for health education tools to improve accuracy.

Prenatal consults with illustrated literature (PnCIL): a RCT studying visual aids during prenatal consults

OBJECTIVE

We hypothesize that addition of illustrated handouts during prenatal consultations decreases maternal anxiety and improves maternal knowledge.

STUDY DESIGN

Inpatient gravid women at 25 0/7-34 6/7 weeks gestation were randomized to Standard or Illustrated consults, verbal consults supplemented with a visual handout. Post consult surveys were administered assessing maternal anxiety and knowledge acquisition.

RESULT

We enrolled 82 women; 54 to Standard Consult, 28 to Illustrated Consult. Consult duration was the same across arms. Anxiety and knowledge were not impacted by the intervention overall. We found higher mean knowledge by 17% for consults ≥31 min (P = 0.006; 95% CI 0.67-3.82), and 13% in primigravids (P = 0.032; 95% CI 0.15-3.21) in the intervention arm.

CONCLUSIONS

Using illustrated handouts is feasible and does not increase duration of prenatal consults. It may improve knowledge acquisition in long consults and in primigravida women, although it does not impact anxiety and knowledge overall.

Exploring Pictorial Health Education Tools for Long-Term Home Care: A Qualitative Perspective

Regarding long-term home care needs, nurses need to communicate effectively and reasonably when teaching home caregivers. Designers can assist medical staff and develop pictorial tools to enhance communication. The purpose of this study is to explore a theoretical basis from the perspective of designers, patients’ home caregivers, and medical staff to construct a theoretical framework that can jointly develop pictorial health education tools and healthcare system. The qualitative methods, including in-depth interview and observation, are applied to this study; ground theory sets out to construct a framework from the verbatim transcript of the interviews. Based on interview results, six axial codes were extracted: (1) the method of interdisciplinary cooperation; (2) medical research ethics; (3) communication methods; (4) forms of health education tools; (5) development of health education tools; (6) home care intubation procedure. Eight groups of home caregivers offered suggestions from their experiences. The designers need to assist medical staff to solve real problems, pay attention to professional norms, and forms of cooperation. Health education tools need to meet the needs of medical staff and home caregivers and designers should pay attention to the processes of communication. This study can also assist in interdisciplinary cooperation to explore the theoretical basis of pictorial health education tools for nurses in the context of long-term care at home.

Impact of pictograms on medication adherence: A systematic literature review

OBJECTIVE

The aim of this systematic review was to investigate the potential effect of pictograms on patient adherence to medication therapies.

METHOD

PubMed, MEDLINE, Embase, CINAHL, and CENTRAL were searched for relevant articles. Experimental studies testing the use of pictograms in patient counselling regarding medication therapy, which quantitatively measured adherence, were included.

RESULTS

Seventeen studies were identified that fulfilled our inclusion criteria. These were heterogeneous with respect to study setting, population size, and the medication regimen tested. All the studies had methodological quality limitations. The pictogram interventions differed with respect to complexity, intervention length, and the measured adherence outcome. Ten studies (58.8 %) reported a statistically significant effect, of the pictogram intervention in question, on patient adherence to medication therapies. Of these, 80 % involved populations at elevated risk for non-adherence.

CONCLUSION AND PRACTICE IMPLICATIONS

Pictograms used in combination with written and/or oral information can have a positive impact on patient populations that are highly at risk for non-adherence when counselled on the proper use of medicines.

Comprehensibility of pharmaceutical pictograms: Effect of prospective-user factors and cognitive sign design features

BACKGROUND

The people's comprehensibility regarding the meaning of internationally recommended pictograms is an important factor in the correct usage of medications.

OBJECTIVE

To investigate the relationship between the guessability of the pharmaceutical pictograms, the cognitive sign features, and prospective-user factors.

METHODS

A total of 351 Iranian people participated in this study. Two questionnaires were used to measure guessability and cognitive design features regarding the pharmaceutical pictograms. A single-sheet questionnaire was also developed to collect demographic data.

RESULTS

According to the 67% correctness criterion suggested by ISO 3864:P3, 18 pictograms were understandable by the participants. Moreover, of the five cognitive features, "semantic closeness" and "meaningfulness" had the most correlation with the guessability score. In terms of personal factors, understanding of the pictograms' meaning was negatively correlated with age, while it had no association with the occupation.

CONCLUSIONS

Some pharmaceutical pictograms developed by reliable international organizations can be used in a community only after redesigning and testing among the prospective users. The findings indicated that some pharmaceutical pictograms were not comprehensible for most participants. It is therefore expected that using a combination of pictograms with written messages and training could help in conveying the messages by pharmaceutical pictograms.

Burns in Nepal: a participatory, community survey of burn cases and knowledge, attitudes and practices to burn care and prevention in three rural municipalities

OBJECTIVES

As part of an ongoing, long-term project to co-create burn prevention strategies in Nepal, we collected baseline data to share and discuss with the local community, use as a basis for a co-created prevention strategy and then monitor changes over time. This paper reports on the method and outcomes of the baseline survey and demonstrates how the data are presented back to the community.

DESIGN

A community-based survey.

SETTING

Community based in three rural municipalities in Nepal.

PARTICIPANTS

1305 households were approached: the head of 1279 households participated, giving a response rate of 98%. In 90.3% of cases, the head of the household was male.

RESULTS

We found that 2.7% (CI 1.8 to 3.7) of 1279 households, from three representative municipalities, reported at least one serious burn in the previous 12 months: a serious burn was defined as one requiring medical attention and/or inability to work or do normal activities for 24 hours. While only 4 paediatric and 10 adult cases in the previous 12 months reached hospital care, the impact on the lives of those involved was profound. Only one patient was referred on from primary to secondary/tertiary care; the average length of hospital stay for those presenting directly to secondary/tertiary care was 21 days. A range of first-aid behaviours were used, many of which are appropriate for the local context while a few may be potentially harmful (eg, the use of dung).

CONCLUSION

The participatory approach used in this study ensured a high response rate. We have demonstrated that infographics can link the pathway for each of the cases observed from initial incident to final location of care.

Public Health Implications of Image-Based Social Media: A Systematic Review of Instagram, Pinterest, Tumblr, and Flickr

INTRODUCTION

Image-based social media Instagram, Pinterest, Tumblr, and Flickr have become sources of health-related information and tools for health communication. No known systematic review exists that summarizes the existing research and its health implications.

METHODS

We searched EBSCOhost Academic Search Complete, PubMed, and Web of Science in January 2016, April 2017, and November 2017, with the following keywords: Pinterest, Instagram, Tumblr, or Flickr. Only public health-related, peer-reviewed research articles were included (excluding surveys of self-reported social media use).

RESULTS

Sixty-six research articles were included. All 12 experimental studies used Instagram. Of the 54 observational studies, 38 studied Instagram; 12, Pinterest; 7, Tumblr; and 6, Flickr; some studies investigated more than 1 platform. More than half of the included articles were related to mental health and substance abuse (n = 39, 59%). Other topics included chronic diseases, infectious diseases, surgery, injury prevention, pharmacovigilance, sexual and reproductive health, and adolescent psychology with functional magnetic resonance imaging.

DISCUSSION

Public health-oriented research on Instagram, Pinterest, Tumblr, and Flickr is increasing. Most observational studies investigated questions ranging from public perception of diseases or interventions (vaccination) and undesirable media exposure ("echo chamber," distorted body image, underage substance use, and pro-suicide messages) to information dissemination and online engagement (likes and comments). A few studies attempted to use image-based social media as intervention tools, but the results were mainly exploratory.

CONCLUSION

More research is needed to study how social media users discuss health through sharing images online, and how public health professionals can communicate effectively using image-sharing social media.

The art of consent: visual materials help adult patients make informed choices about surgical care

Supporting patients in making informed healthcare decisions is a cornerstone of ethical medical practice. Surgeons frequently draw for and show images to patients when consenting them for operations but the value of this practice in informed decision-making is unclear. An audit was conducted in a General Surgery Department. 244 patients completed questionnaires on the value of visual materials when giving consent for surgery. The complexity of the operations was classified into "simple", "moderate" or "complex". 100% of patients felt they had given informed consent to surgery. 62% of patients received at least one form of visual material during the consenting process. All patients who received a drawing, and 99% of those provided with other images, valued these resources. Visual materials were considered more useful to patients when giving consent for moderate or complex operations than simple ones. Approximately one third of patients who did not receive visual materials would have appreciated these when making an informed decision. This research highlights the value of surgeons drawing for, and providing other visual resources to, their patients as part of the consent process. There is a role for further research and training materials in drawing skills for surgeons.

Effect of a Japanese drug alert pictogram on medication-taking/driving behavior

Objective: This study aimed to determine the usefulness and effects of a pictogram for alerting patients about drugs that affect driving in order to prevent traffic injury and maintain good adherence.Method: The participants comprised 600 men and 600 women aged 20-79 (49.58 ± 16.21) years, registered with an Internet research company. All were licensed to drive a car and were taking prescribed medication. The outcome measures were: 1) awareness of existing pictogram, 2) perceived driving risk after viewing the pictogram, 3) usefulness of the pictogram, and 4) medication-taking and driving behavior after viewing the pictogram.Results: Few respondents (5.4%) were aware of the Japanese pictogram issued by the Council for Appropriate Drug Use. Participants evaluated their driving risk as moderate-to-high (3.51 ± 0.69) after viewing the pictogram, and risk perception was higher among respondents in their 50 s and 60 s than among those in their 20 s. Across all respondents, the pictogram was rated as follows (on a 5-point Likert scale): effective for warning, 3.79 ± 0.90; informative, 3.75 ± 0.84; understandable meaning (comprehensibility), 3.90 ± 0.96; simplicity, 3.71 ± 0.95; and eye-catching, 3.60 ± 0.98. We defined the following as positive behavior: taking medication according to the instructions of a medical professional (good compliance), stopping driving, and consulting medical professionals. The positive behavior rate was 63.2%. Being shown the pictogram might lead to more positive medication-taking and driving behavior among respondents who are female and have lower driving frequency, higher levels of risk perception, and higher evaluation of the pictogram compared to their counterparts.Conclusion: A pictogram is a potentially useful and effective tool for communicating risk and supporting decision-making by supplying drivers with tailored information. However, we assume that some people who drive frequently must drive for work, go to the hospital, etc. It is essential, in these cases, for medical professionals to be more deeply involved with the patients and to maintain lines of communication by listening to patients' descriptions of their everyday life. By adding these pictograms to the labeling of potentially driver-impairing medications (such as by putting them on the outer packaging, package inserts, and inner medicine containers), it is expected that they can better inform users regarding safe behavior and promote medication adherence.

Comprehension of Safety Pictograms Affixed to Agricultural Machinery among Pakistani Migrant Farmworkers in Italy

Objectives: Safety pictograms are important graphic elements that are useful for rapidly conveying messages in workplaces. The purpose of this study was to investigate the comprehension of safety pictograms affixed to agricultural machinery among a group of Pakistani migrant farmworkers employed in Italy. Methods: Interviews about the meanings attributed to four standardized safety pictograms affixed to agricultural machinery depicting the most frequent causes of farm accidents were administered to 29 Pakistani migrant farmworkers employed on Italian farms. Results: There was high variability in pictogram comprehension. None of the participants interpreted all the pictograms in accordance with the definitions provided by the international standards. Higher comprehension rates were reported for pictograms related to the risks of tractor rollover and foot injury, while pictograms referring to the need to consult a technical manual and the risk of entanglement yielded lower comprehension scores. Previous farming experience in the country of origin and the number of years of education were significantly associated with comprehension scores. Conclusion: A discussion of pictogram features that may be critical for comprehension is provided, and (re)design suggestions are given to improve the cross-cultural comprehension of these safety signs.

Developing Infographics to Facilitate HIV-Related Patient-Provider Communication in a Limited-Resource Setting

BACKGROUND

Productive patient-provider communication is a recognized component of high-quality health care that leads to better health outcomes. Well-designed infographics can facilitate effective communication, especially when culture, language, or literacy differences are present.

OBJECTIVES

This study aimed to rigorously develop infographics to improve human immunodeficiency virus (HIV)-related patient-provider communication in a limited-resource setting. A secondary purpose was to establish through participant feedback that infographics convey intended meaning in this clinical and cultural context.

METHODS

We adapted a participatory design methodology, developed in a high-resource setting, for use in the Dominican Republic. Initially, content to include was established using a data-triangulation method. Then, infographics were iteratively generated and refined during five phases of design sessions with three stakeholder groups: (1) 25 persons living with HIV, (2) 8 health care providers, and (3) 5 domain experts. Suggestions for improvement were incorporated between design sessions and questions to confirm interpretability of infographics were included at the end of each session.

RESULTS

Each participant group focused on different aspects of infographic designs. Providers drew on past experiences with patients and offered clinically and contextually relevant recommendations of symbols and images to include. Domain experts focused on technical design considerations and interpretations of infographics. While it was difficult for patient participants to provide concrete suggestions, they provided feedback on the meaning of infographics and responded clearly to direct questions regarding possible changes. Fifteen final infographics were developed and all participant groups qualitatively confirmed that they displayed the intended content in a culturally appropriate and clinically meaningful way.

CONCLUSION

Incorporating perspectives from various stakeholders led to the evolution of designs over time and generated design recommendations that will be useful to others creating infographics for use in similar populations. Next steps are to assess the feasibility of using infographics to improve clinical communication and patient outcomes.

Comparing Written Versus Pictorial Asthma Action Plans to Improve Asthma Management and Health Outcomes Among Children and Adolescents: Protocol of a Pilot and Feasibility Randomized Controlled Trial

Background

Asthma is an important focus for pediatric health research as management of asthma symptoms is a significant challenge, and morbidity and mortality among youths with asthma remain prevalent. Treatment guidelines for asthma recommend a written asthma action plan (WAAP) that summarizes individualized instructions for daily medication use. However, WAAPs are typically written at a seventh- to ninth-grade reading level, which can be a barrier to young people in understanding their treatment, having confidence in using a WAAP, and engaging with asthma education.

Objective

Utilizing a feasibility and pilot randomized controlled trial (RCT) design, the objective of the Take Action for Asthma Control study is to test a symptom-based, computer-generated pictorial asthma action plan (PAAP) in comparison with a standard WAAP and assess the feasibility and acceptability of the asthma action plan (AAP) intervention and study procedures. The study has 3 aims: (1) estimate the effect sizes of PAAPs compared with WAAPs on outcomes (eg, AAP knowledge and medication adherence), (2) evaluate feasibility and acceptability of AAP intervention and RCT procedures from the perspectives of key stakeholders, and (3) establish whether parent and youth literacy levels are associated with treatment outcomes.

Methods

This feasibility and pilot RCT is a block randomized, 2-arm, parallel-group clinical trial, lasting 6 months in duration. At baseline, participants will be randomly assigned to receive a PAAP or WAAP generated for them and reviewed with them by their asthma physician. Study procedures will take place over 4 separate time points: a baseline clinic appointment, 1-month telephone follow-up, and 3- and 6-month clinic-based follow-ups. At each time point, data will be collected related to the main outcomes: AAP knowledge, AAP satisfaction, asthma control, pulmonary function, and adherence to daily asthma medication. A sample size of up to 60 participants (aged 8-17 years) will be recruited. Feasibility and acceptability data will be collected via one-to-one qualitative interviews with providers involved in the study and a subgroup of families that participate in the study.

Results

Recruitment and data collection began in May 2017 and were completed in October 2018.

Conclusions

This pilot and feasibility study will test the potential efficacy, feasibility, and acceptability of an AAP intervention and study procedures. The findings will inform the design and delivery of a future definitive trial to assess the efficacy of PAAPs versus WAAPs in supporting asthma self-management among children and adolescents.

International Registered Report Identifier (IRRID)

DERR1-10.2196/11733

Patients' Perspective And Usefulness Of Pictograms In Short-Term Antibiotic Therapy - Multicenter, Randomized Trial

PURPOSE

To evaluate the practical utility of pharmaceutical pictograms in routine practice in community pharmacy. The primary outcome (composite endpoint) consisted of three elements: i) complete use of the whole package of medication, ii) taking the recommended dose twice a day, and iii) subjective assessment of patients' perspective on medical information about antibiotic therapy obtained during the pharmacy consultation measured by Net Promoter Score in scale from 1 to 10 where 1 is the lowest and 10 the highest possible rating.

PATIENTS AND METHODS

A multicenter, randomized controlled study was conducted. Community pharmacies (n = 64) which agreed to participate in the study were assigned to one of two groups: i) study - providing an antibiotic with pictograms placed on the external packaging of the medicinal product containing information about drug regimen (n = 32); or ii) control - providing an antibiotic according to usual pharmacy practice (n = 32). Two semi-structured interviews were performed. Data were collected from 199 patients with a mean age ± SD of 45.5 ± 17.0 years.

RESULTS

In the control group, 15.7% of participants discontinued therapy before using the whole package compared with 13.4% of participants in the study group. In the control group, 81.3% of patients reported that they always took the medication twice a day as recommended by their healthcare providers compared with 80.4% of patients in the study group. The Net Promoter Score was higher for pharmacy practice with than without pictograms (71.3% vs 51.5%, respectively, p<0.005). The chance that a patient was an advocate of pharmaceutical services (scores 9 and 10) was twice as likely in the case of pharmaceutical practice supported by pictograms (p<0.02). The composite endpoint was achieved more frequently in the population using pictograms, however this difference was not statistically significant (p<0.34).

CONCLUSION

The pharmaceutical pictograms are readily accepted by patients and could prove to be a valuable support for pharmacists in conducting pharmaceutical care. Further representative research is needed to evaluate the true effectiveness of this solution.

Visualized nutrition education and dietary behavioral change: A systematic review and meta-analysis

Effectiveness of using visual approaches in health education and its influential factors were still in debate. This study aimed to asess the effects of visualized nutrition education on dietary knowledge and behavioral changes, and factors influencing them. A comprehensive search of PubMed, EMBASE, Scopus, and Cochrane Library was conducted. Eligible studies were trials assessed effects of visualized nutrition education on dietary knowledge or behavior changes, compared with non-visualized or no education group. Fourteen studies (n = 7,259) were qualitatively analyzed and 7 of them were included in the meta-analysis. We found a higher fiber intake in both short term (1.59 g/1000 kcals, 95% CI 0.90-2.27) and long term (1.36 g/1000 kcals, 95% CI 0.64-2.09). A marginal advantage was shown in short-term fruits and vegetables consumption (F&V consumption) (standardized mean difference [SMD] = 0.08, 95% CI -0.00 to 0.16). The education effects were more pronounced when education was delivered in series (SMD_{F&V consumption} = 0.09, 95% CI 0.00-0.17), avoiding loss-framing (SMD_{Fat intake} = 0.31, 95% CI 0.10-0.51) and video modeling (SMD_{F&V consumption} = 0.23, 95% CI 0.03-0.43), with short length plus cultural adaptation. Visualized nutrition education was overall promising in improving dietary behaviors. Delivering in series, short in length, with cultural adaptation were features tended to enlarge the benefits of visualized education while loss-framing and video modeling might be avoided.