Evaluation, Modification, and Validation of Pictograms Depicting Medication Instructions in the Elderly

Transparency and translucency indices for 1,525 pictograms from the Aragonese Portal of Augmentative and Alternative Communication

This study investigated the transparency and translucency of 1,525 pictograms from the Aragonese Portal of Augmentative and Alternative Communication (ARASAAC). A total of 521 participants took part in tasks that involved providing the word that best described the meaning of a pictogram or rating the relationship between a pictogram and a verbal label. This process allowed us to obtain indices of transparency (the quality of pictograms that makes their meaning easily "guessable" in the absence of their referent) and translucency (the degree of perceived relationship between the pictogram and its referent when the latter is present) which were further analyzed to assess their reliability and comparability with similar studies. Additionally, the relationship of those indices with various visual and psycholinguistic characteristics was explored, particularly focusing on the match between the original ARASAAC pictogram names and the most frequently provided names by the participants (modal names) for the pictograms. Results showed relatively low levels of transparency, as well as high levels of translucency, with nouns displaying the highest values in both metrics. For transparency and translucency, word imageability and concreteness were the most correlated factors, and, together with age of acquisition, they were the most important features related to the name matching with ARASAAC. The norms derived from this study enhance our understanding of pictogram perception, empowering stakeholders to leverage data-driven insights for the development and implementation of pictographic systems, thus improving cognitive accessibility.

Investigating medication adherence among Taiwanese patient with hypertension, hyperlipidemia, and diabetes: A pilot study using the Chinese version of a Two-Part Medication Nonadherence Scale and the NHI MediCloud system

BACKGROUND

This pilot study aimed to investigate medication nonadherence among Taiwanese patients with diabetes, hypertension, and hyperlipidemia using the Chinese version of the Two-Part Medication Nonadherence Scale (C-TPMNS) and the National Health Insurance (NHI) Medicloud system. The study revealed insights into the factors contributing to nonadherence and the implications for improving patient adherence to medications for chronic conditions. However, the small sample size limits the generalizability of the findings. Additionally, the study identified the need for further research with larger and more diverse samples to validate the preliminary findings.

METHODS

The study conducted surveys individuals in central Taiwan who received three-high medications and those who returned expired medications from chain pharmacies. A structured questionnaire including the C-TPMNS was administered, and additional data on medical history and HbA1c, LDL, and blood pressure levels were collected from the NHI Medicloud system. Data analysis was performed using multiple ordered logistic regression and Wald test methods. Setting interpretation cutoff point to determine medication nonadherence.

RESULTS

The study found that 25.8% of participants were non-adherent to prescribed medications. Non-adherent individuals had significantly higher systolic blood pressure (SBP ≥ 140 mmHg) than adherent participants. Non-adherence was also associated with factors such as lower education, single status, living alone, abnormal glucose postprandial concentration, and triglyceride levels. The C-TPMNS demonstrated good reliability (Cronbach's alpha = 0.816) and validity (area under the ROC curve = 0.72).

CONCLUSION

The study highlighted the complexity of medication nonadherence with diverse determinants and emphasized the importance of tailored interventions. The findings underscored the need for region-specific research to comprehensively address medication nonadherence, especially focusing on adherence to medications for hypertension, hyperlipidemia, and diabetes. The study also identified the need for larger, more diverse studies to validate and expand upon the initial findings and emphasized the importance of pharmacist interventions and patient empowerment in managing chronic conditions and improving overall health outcomes.

Comprehension of US Pharmacopeia and South African pictograms by sub-Saharan migrants who newly arrived in Europe

BACKGROUND

Patient understanding of health information is crucial for successful pharmaceutical care. Pharmaceutical pictograms enable communication of medication instructions to patients who may not share a common language or are illiterate. However, cultural factors can impact the accurate interpretation of these visual aids.

OBJECTIVES

This study aimed to assess and compare the comprehensibility of two sets of pictograms from different cultural backgrounds among sub-Saharan migrants recently arrived in Europe.

METHODS

In June 2022, a cross-sectional survey was conducted at the Migrant Temporary Stay Center in Melilla, Spain. Participants were randomly assigned to interpret 10 pictograms from either the U.S. Pharmacopeia or South African counterparts, with a minimum of 50 participants per group. Following the International Organization for Standardization's testing comprehensibility criterion, pictograms achieving a 66.7% correct interpretation rate were considered acceptable. Health literacy was measured using a culturally validated sub-Saharan version of the European Health Literacy Survey Questionnaire (HLS-EU-Q16). Data analysis included Fisher's exact test or chi-square test (for qualitative variables) and the Mann-Whitney test (for quantitative variables).

RESULTS

A total of 106 participants were included (51 in the U.S. pharmacopeia group and 55 in the South African group). None of the assessed pictograms met the comprehensibility criterion, and both groups exhibited high nonresponse rates. The South African pictograms were better understood than the American ones for all intended messages, with a statistically significant difference in overall comprehension (p = 0.002). Additionally, the participants' country of birth was a statistically significant factor for comprehension (p = 0.019).

CONCLUSIONS

Our findings indicate that evaluated pharmaceutical pictograms cannot be validly used in newly arrived sub-Saharan immigrants in Europe. However, the significantly better comprehension of South African pictograms compared to North American ones highlights the importance of cultural alignment between pictograms and their prospective users for effective comprehensibility.

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.

Pharmaceutical indication pictograms for low literacy viewers: Health literacy and comprehension

Background

Poor comprehension of pharmaceutical pictograms used on medicine labels or leaflets can compromise understanding of medicine-taking information, potentially causing negative health outcomes.

Aim

The aim was to assess association of health literacy (HL) with comprehension of pictograms displaying indication and side effect information in a lower literacy, limited English proficiency (LEP) population.

Setting

Community centre, Makhanda, South Africa.

Methods

This was a quantitative cross-sectional study using simple random probability sampling. Ninety isiXhosa-speaking adults with a maximum of 12 years schooling, attending primary healthcare clinics were interviewed using structured interviews. Health literacy was assessed using the Health Literacy Test for Limited Literacy populations. Comprehension of 10 locally developed pictograms was evaluated.

Results

The mean pictogram comprehension score was 7.9/10, with 8/10 pictograms complying with the International Organization for Standardization criterion of 66.7% correct comprehension. Only 15.6% of participants had adequate HL. A significant association of HL with pictogram comprehension was established (p = 0.002). Pictogram misinterpretation was higher in those with lower HL; adequate HL was associated with superior comprehension. Pictogram comprehension was negatively associated with age (p < 0.006), and positively associated with education (p < 0.001) and English proficiency (p < 0.001).

Conclusion

Higher HL was associated with better pictogram comprehension. Low HL, LEP and low education levels are regarded as potential indicators for possible pictogram misinterpretation.

Contribution

This study observed the potential for misinterpretation of medication pictograms. Health professionals should be aware that low HL, limited schooling and limited English proficiency could signal difficulty in fully comprehending pictogram content.

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.

Factors influencing medication adherence in multi-ethnic Asian patients with chronic diseases in Singapore: A qualitative study

Background: Poor medication adherence can lead to adverse health outcomes and increased healthcare costs. Although reasons for medication adherence have been widely studied, less is explored about factors affecting medication adherence for patients in non-Western healthcare setting and from Asian cultures. This study aimed to explore cultural perspectives on factors influencing medication adherence among patients with chronic diseases in a multi-ethnic Asian healthcare setting.

Methods: We conducted a qualitative study involving in-depth interviews with patients with chronic conditions purposively recruited from a community hospital in Singapore until data saturation was achieved. A total of 25 patients participated in this study. Interviews were transcribed and thematically analyzed. Themes were subsequently mapped into the World Health Organization (WHO) Framework of Medication Adherence.

Results: Participants commonly perceived that sides effects (therapy-related dimension), poor understanding of medication (patient-related dimension), limited knowledge of condition (patient-related dimension), forgetfulness (patient-related dimension) and language issues within a multi-ethnic healthcare context (healthcare team and system-related dimension) as the main factors contributing to medication adherence. Importantly, medication adherence was influenced by cultural beliefs such as the notion of modern medicines as harms and fatalistic orientations towards escalation of doses and polypharmacy (patient-related dimension). Participants made various suggestions to foster adherence, including improved patient-physician communication, enhanced care coordination across providers, use of language familiar to patients, patient education and empowerment on the benefits of medication and medication adjustment.

Conclusion: A wide range of factors influenced medication adherence, with therapy- and patient-related dimensions more pronounced compared to other dimensions. Findings demonstrated the importance of cultural beliefs that may influence medication adherence. Future efforts to improve medication adherence should consider a person-centered approach to foster more positive health expectations and self-efficacy on medication adherence, supplemented with routine reviews, development of pictograms and cultural competence training for healthcare professionals.

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.

Exploring the Use of Pictograms in Privacy Agreements to Facilitate Communication Between Users and Data Collecting Entities: Randomized Controlled Trial

BACKGROUND

Privacy agreements can foster trust between users and data collecting entities by reducing the fear of data sharing. Users typically identify concerns with their data privacy settings, but due to the complexity and length of privacy agreements, users opt to quickly consent and agree to the terms without fully understanding them.

OBJECTIVE

This study explores the use of pictograms as potential elements to assist in improving the transparency and explanation of privacy agreements.

METHODS

During the development of the pictograms, the Double Diamond design process was applied for 3 instances of user interactions and 3 iterations of pictograms. The testing was done by performing a comparative study between a control group, which received no pictograms, and an experimental group, which received pictograms. The pictograms were individually tested to assess their efficacy by using an estimated comprehension of information symbols test.

RESULTS

A total of 57 participants were recruited for the pictogram evaluation phase. With the addition of pictograms, the overall understanding improved by 13% (P=.001), and the average time spent answering the questions decreased by 57.33 seconds. A 9% decrease in perceived user frustration was also reported by users, but the difference was not significant (χ²₄=4.80; P=.31). Additionally, none of the pictograms passed the estimated comprehension of information symbols test, with 7 being discarded immediately and 5 requiring further testing to assess their efficacy.

CONCLUSIONS

The addition of pictograms appeared to improve users' understanding of the privacy agreements, despite the pictograms needing further changes to be more understandable. This proves that with the aid of pictographic images, it is possible to make privacy agreements more accessible, thereby allowing trust and open communication to be fostered between users and data collecting entities.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05631210; https://clinicaltrials.gov/ct2/show/NCT05631210.

Proceso de evaluación de pictogramas: Catálogo de señalización accesible andaluz

Todas las personas necesitan apoyarse en elementos del contexto para desenvolverse por los entornos de manera autónoma. Esta necesidad se concreta en apoyos específicos cuando las personas tienen dificultades en comprensión permanentes o circunstanciales. Para que un contexto sea accesible universal y cognitivamente se emplean pictogramas para identificar los entornos. Estos pictogramas constituyen una señalética que debe ser validada por procesos estandarizados como describe la Normativa ISO-9186. El objetivo del estudio fue ampliar la base de pictogramas disponibles para la señalización de edificios y evaluar su diseño accesible. Los datos se recogieron por entrevista online y por formulario autocompletado online, en dos fases, la evaluación de la comprensibilidad y la translucidez, así como la calidad perceptual de los pictogramas. Un total de 1462 personas evaluaron la comprensión de los pictogramas y 270 su calidad perceptiva. Dicha muestra incluye participantes de diferentes colectivos y perfiles cognitivos. Se evaluaron 151 pictogramas y fueron 55 los seleccionados por cumplir criterios de comprensión, translucidez y calidad perceptiva. Este resultado supone una contribución relevante a las bases de pictogramas de uso público y privado existentes y aporta recursos señaléticos validados que pueden beneficiar a todas las personas facilitando la accesibilidad cognitiva en los espacios.

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.

Well-designed medical pictograms accelerate search

Two types of newly designed pharmaceutical pictograms (with and without context) were compared with an existing type of certified pictograms regarding their search efficiency. Each of the 30 participants had to search a total of 1'090 "fictitious" medical shelves for a certain box defined by the amount and type of medical instructions given (memory size) and presented among a variable number of other boxes (set size). The boxes contained the different types of pictograms mentioned above. Calculated factorial analyses on reaction time data, among others, showed that the two newly designed pictogram types make search more efficient compared to existing types of pictograms (i.e., flatter reaction time x set size slopes). Furthermore, regardless of the type of pictogram, this set size effect became more pronounced with larger memory sizes. Overall, the newly designed pictograms need fewer attentional resources and therefore might help to increase patient adherence.

Health Literacy Level and Comprehension of Prescription and Nonprescription Drug Information

The aim of this study was to investigate the level of misunderstanding of medication information in Korean adults after stratifying by level of health literacy and to identify the factors influencing the misunderstanding of medication information and reading amounts of information on OTC drug labels. A cross-sectional survey was performed with 375 adult participants using the survey instrument. Multiple linear regression analyses were performed to identify factors which influence misunderstanding of medication information. Participants misunderstood 20% of words on OTC drug labels, 9% of prescription drug instructions, and 9% of pictograms. Participants on average read 59% of the overall contents of the OTC drug labels. As prescription drugs’ dosing regimens became more complicated, the level of misunderstanding instructions increased. The level of misunderstanding words on OTC drug labels significantly decreased as participants had adequate health literacy (β = −18.11, p < 0.001) and higher education levels (β = −6.83, p < 0.001), after adjusting for the study variables. The level of misunderstanding instructions for prescription drugs increased as participants became older (β = 8.81, p < 0.001) and had lower education levels (β = −5.05, p < 0.001), after adjusting for the study variables. The level of misunderstanding pictograms was similar to that of misunderstanding instructions for prescription drug labels. The amount of reading information on OTC drug labels significantly increased as respondents had adequate health literacy (β = 9.27, p < 0.001), were older (β = 12.49, p < 0.001), or had chronic diseases (β = 7.49, p = 0.007). Individuals’ health literacy level, reading behaviors, and complexity of medication instructions are associated with misunderstanding of medication information. Appropriate word choices in drug labels and an improved format of medication instructions could increase understanding of medication information and prevent adverse drug reactions.

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.

A scoping review of the use of visual aids in health education materials for persons with low-literacy levels

OBJECTIVE

To conduct a scoping review on the literature on visual aids in health education for persons with low-literacy.

METHODS

A scoping review methodology was employed. Pre-defined selection criteria identified 47 studies for inclusion. Data were extracted in relation to: (a) definitions of low-literacy and health literacy, (b) population studied, (c) research country, (d) consent procedures, (e) visual aids used, (f) development of visual aids, and (g) targeted outcomes.

RESULTS

Visual aids developed with persons with low-literacy demonstrated statistically significant improvements in health literacy outcomes, with benefits in medication adherence and comprehension also reported. Pictograms and videos were the most effective visual aids. Only one study adapted consent procedures for low-literacy participants.

DISCUSSION

Visual aids in health education materials may benefit persons with low-literacy levels, but large gaps in the research base are evident. Experimental research in low- and middle-income countries, with a particular focus on consent for participants with low-literacy is needed.

PRACTICE IMPLICATIONS

Visual aid design needs to include stakeholders. Consent procedures and decision-making need to be specifically adapted for participants with low-literacy.

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.

Recall of Pharmaceutical Pictograms by Older Adults

BACKGROUND

Low health literacy and high medication burden in the older adult population are contributing factors to the misunderstanding of medication instructions, leading to an increased risk of poor adherence and adverse events in this group of patients.

OBJECTIVE

To evaluate the ability of older adults to recall the meaning of 13 pharmaceutical pictograms 4 weeks after receipt of feedback on pictogram meaning.

METHODS

Older adults (aged 65 or older) were recruited from one community pharmacy in Canada. One-on-one structured interviews were conducted to assess the comprehensibility of 13 pharmaceutical pictograms from the International Pharmaceutical Federation's database of pictograms. Each participant was then told the meaning of each pictogram. Recall was assessed 4 weeks later.

RESULTS

A total of 58 participants met the inclusion criteria and agreed to participate. The number of pictograms meeting the ISO threshold for comprehensibility of symbols increased from 10 at the initial comprehensibility assessment to 13 at the recall assessment. Analysis of demographic data showed no associations between initial comprehensibility of the pictograms and age, sex, education level, or number of medications taken.

CONCLUSIONS

The results of this study indicate that after being informed of the meaning of pharmaceutical pictograms, older adults were able to recall the pictogram meanings for at least 4 weeks.

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.

The extent and effects of patient involvement in pictogram design for written drug information: a short systematic review

This short review provides insight into the extent and effectiveness of patient involvement in the design and evaluation of pictograms to support patient drug information. Pubmed, CINAHL, Cochrane Library, Embase, PsycINFO, Academic Search Premier and Web of Science were searched systematically; the 73 included articles were evaluated with the MMAT. We see that, usually, non-patient end-users are involved in the design of pharmaceutical pictograms - patients are more commonly involved in the final evaluation of pictogram success. Repeated involvement of (non-)patients aids the design of effective pharmaceutical pictograms, although there is limited evidence for such effects on patient perception of drug information or health behaviour.

The evaluation of pharmaceutical pictograms among elderly patients in community pharmacy settings - a multicenter pilot study

INTRODUCTION

The search for new ways to optimize the use of medications by patients has led the pharmaceutical community to promote the idea of introducing pictograms into routine practice. The main intention of pictograms is to ease patient adherence and to reduce potential risks or errors associated with the use of medications.

PURPOSE

To evaluate a series of pharmaceutical pictograms for patient comprehension.

PATIENTS AND METHODS

The study was conducted in community pharmacies within a European Union country that belongs to the professional research network. Structured interviews were used to evaluate the pictograms for patient comprehension. This consisted of an assessment of the following: the transparency and translucency of the pictograms, health literacy, and pictogram recall. Participants were also given the opportunity to provide feedback on how to improve the pictograms. The primary endpoint was pictogram comprehension. Secondary outcomes included recall of the pictograms and pictogram translucency.

RESULTS

The study included 68 patients with whom face-to-face interviews were performed. Low transparency results (≤25%) and extensive patient feedback in initial interviews led to the withdrawal of certain pictograms (n=15) from the evaluation. Among the pictograms included in the final stage of our research, 22 pictograms (62.8%) obtained an acceptable transparency level ≥66%. All pictograms passed the short-term recall test with positive results.

CONCLUSION

A majority of the designed and modified pictograms reached satisfactory guess-ability scores. Feedback from patients enabled modification of the pictograms and proved that patients have an important voice in the discussion regarding the design of additional pictograms.

Comprehensibility of selected United States Pharmacopeia pictograms by illiterate and literate Farsi speakers: The first experience in Iran - Part II

Background:

Conveying information to patients on how to use medications at the dispensing sessions and retention of this information by the patients is essential to the good pharmaceutical care. The aim of our study was to examine the comprehensibility of the selected three potentially usable pictograms by five groups of subjects who had different levels of literacy in both before and after mini educational sessions.

Materials and Methods:

Nine experienced pharmacists selected three potentially usable pictograms in Isfahan pharmacies: Pictograms D through F representing respectively: “do not take medication during pregnancy,” “keep medication in the refrigerator,” and “take medication with plenty of water.” Then, graduate students of two major universities (Groups 1 and 2), low-literate and illiterate individuals (Groups 3 and 4), and walk – in patients in the pharmacies affiliated to the Isfahan School of Pharmacy (Group 5) were asked about the comprehensibility of these pictograms before and after mini-education sessions. The American National Standard Institute and International Organization for Standardization standards were used for comparisons.

Results:

In the pre-follow-up period, D and E pictograms were most understandable (87.4%, 87.2%). In the post-follow-up, E and D pictograms were understood most (98.0%, 95.3%), followed by F (92.9%). Among the improvements measured in post-follow-up, pictogram F showed the biggest improvement (P = 0.0).

Conclusion:

Pictograms depicting the use of medications during pregnancy (D) and storing medication in the refrigerator (E) was easier to understand by our study population. The groups with the high level of literacy interpreted the pictograms better than those with lower levels of literacy.