Pictograms in pharmacy

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.

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.

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.

How Do Patients Understand Questions about Lower Urinary Tract Symptoms? A Qualitative Study of Problems in Completing Urological Questionnaires

Lower urinary tract symptoms are common complaints in ageing people. For a urological evaluation of such complaints in men, the International Prostate Symptom Score (IPSS) is used worldwide. Previous quantitative studies have revealed serious problems in completing this questionnaire. In order to gain insight into the nature and causes of these problems, we conducted a qualitative study. Not only the purely verbal IPSS was studied but also two alternatives, including pictograms: the Visual Prostate Symptom Score (VPSS) and the Score Visuel Prostatique en Image (SVPI). Men aged 40 years and over with an inadequate level of health literacy (IHL; n = 18) or an adequate level of health literacy (AHL; n = 47) participated. Each participant filled out one of the three questionnaires while thinking aloud. The analysis of their utterances revealed problems in both health literacy groups with form-filling tasks and subtasks for all three questionnaires. Most noticeable were the problems with the IPSS; the terminology and layout of this form led to difficulties. In the VPSS and SVPI, the pictograms sometimes raised problems. As in previous research on form-filling behavior, an overestimation by form designers of form fillers' knowledge and skills seems to be an important explanation for the problems observed.

Evaluation of pharmaceutical pictogram comprehension among adults in the Philippines

Background

The use of pharmaceutical pictograms to enhance patients’ understanding of drug regimens has been proven effective in many countries. There are two reference systems for pictograms generally used in pharmacy: the United States Pharmacopeia (USP) and International Pharmacy Federation (FIP). This study aimed to evaluate the effectiveness of USP and FIP pictograms among adults in the Philippines by identifying how many pictograms would pass the American National Standards Institute (ANSI) criterion of 85% comprehension, and to describe the factors affecting pictograms’ comprehension.

Methods

A descriptive cross-sectional research using a face-to-face interview was performed to evaluate 108 pictograms in 52 Filipino adults enrolled through quota sampling. Descriptive statistics, Mann–Whitney U test (Wilcoxon rank-sum test), univariate linear regression, and multiple linear regression were used to statistically analyze the data collected.

Results

Only 17 (16 USP and 1 FIP) out of the 108 pictograms (15.74%) passed the ANSI criterion. The median score of Filipinos was 71 out of 108 pictograms (Interquartile range: 10–96). The multivariate model (R² = 0.5645, F (4,47) = 15.23) suggested that the score was lower by 5.85 points if the user was female, 21.58 points lower if the participant was below Grade 12 education level, and 1.20 points lower if the patient was greater than 46 years old. Education level was identified as the significant predictor (p-value < 0.0000*, power = 99.98%). The participant with greater than Grade 12 has a higher comprehension score of rank-sum 952.5 (Expected = 689) compared to only 425.5 (Expected = 689).

Conclusions

Since only 17 pictograms passed as stand-alone tool for patient information material, the researchers recommend the use of verbal and written instructions to complement pictograms to enhance comprehension. Furthermore, the government should consider the inclusion of health pictograms in basic health education.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40545-022-00426-y.

Impact of a Dental Storybook on Parents' Knowledge of Children's Oral Health: A Randomized Controlled Trial

PURPOSE

To evaluate the effectiveness of a dental storybook on parents' knowledge about oral health of their children and to assess their perception of its effect in reducing dental anxiety levels among their children, as well as improving their oral health knowledge.

PATIENTS AND METHODS

This was a two-arm parallel, single-blind, randomized controlled trial (RCT) which was performed at the pediatric dental clinics in the Dental University Hospital, King Saud University, Riyadh, Saudi Arabia. Parents of 88 children (6-8 years old) were included in the present study. Parents and their children were randomly divided into two groups as follows: the intervention group (received the storybook and verbal oral hygiene instructions) and the control group (only received verbal oral hygiene instructions; same information included in the book). Three dental visits, including screening, examination/cleaning and treatment, were provided for each child. In the screening visit, baseline parental oral health knowledge was evaluated for all parents. Afterward, parental oral health knowledge was re-evaluated in the examination visit. In the treatment visit, a parental perception questionnaire was administered to parents following treatment to evaluate their satisfaction regarding the use of the storybook in reducing anxiety levels among their children.

RESULTS

There was a significant improvement in the total knowledge score at the follow-up visit in the intervention group compared to the control group (P<0.0001). Overall, the majority of parents perceived the storybook as a useful source of information, and they found it to be effective in reducing dental anxiety levels among their children.

CONCLUSION

The dental storybook is an effective educational tool that can help parents become more knowledgeable about their children's oral health. Moreover, parents perceived the storybook as an effective tool for enhancing their oral health knowledge and lowering their children's dental anxiety.

Medication Adherence and the Role of Pictograms in Medication Counselling of Chronic Patients: a Review

Pharmaceutical care requires a patient-centered approach, focusing on the ability of patients to understand drug-related information and follow the instructions delivered by pharmacists as well as other health-care providers included in the circle of care. With the goal of ensuring the prescribed use of medications, called medication adherence, health-care providers have to consider many risk factors such as geography (culture), social economic status, age, and low literacy that may predispose patients to non-adherence, and considerations have to be made for chronic patients living with life-long disease states. The aim of this review is to provide a balanced and comprehensive review outlining a number of different medication counselling and education approaches that have been used to try to improve medication adherence and health outcomes with the use of clear and concise graphic illustrations—called pictograms. By highlighting the current landscape of the general use and efficacy of pharmaceutical pictograms to aid in the knowledge and recall of drug-related information, as well as outlining specific medication adherence outcomes with pharmaceutical pictograms in chronic patients, the current review describes the need for health-care providers to move beyond the traditional didactic methods of oral and verbal communication with patients regarding medication-taking behavior.

Evaluation of pharmaceutical pictograms by older "turkers": A cross-sectional crowdsourced study

BACKGROUND

Well-designed pharmaceutical pictograms may improve patients' understanding of medication instructions. However, the iterative participatory design process required to produce effective pictograms can be costly in terms of money, time, and effort. Crowdsourcing has been applied to bring down the costs of the participatory design process, but the feasibility of using this approach with older adults remains largely unknown.

OBJECTIVES

To evaluate the feasibility of using Amazon Mechanical Turk (MTurk), a leading crowdsourcing platform, for participatory pictogram evaluation with older adults (55+) and to evaluate the comprehensibility of USP pictogram, identify common misinterpretations, and explore the relationship between selected participant characteristics and their pictogram comprehension performance.

METHODS

108 older adults (56.5% female; 57-80 years of age) were recruited via MTurk to complete a cross-sectional online survey that asked them to interpret 15 USP pictograms and answer questions about their health and health literacy.

RESULTS

It was feasible to perform pictogram evaluation with older adults on MTurk, as shown by ease of recruitment and high data quality. Of the 15 pictograms tested, seven (46.7%) resulted in a comprehensibility score below the threshold established by the American National Standards Institute (ANSI), eight (53.3%) elicited common misinterpretations, and two (13.3%) resulted in ANSI-defined "critical confusion." Age (P = 0.04) was associated with pictogram comprehension performance. Certain issues with the pictogram subtitles emerged during the evaluation.

CONCLUSIONS

MTurk is a feasible platform for participatory pictogram evaluation, even for a sole target of older adults. The USP should develop a pictogram user manual, redesign pictograms confusing to older adults, and establish policies and procedures to ensure that pictogram subtitles conform to evidence-based best practices and standards for patient-centered written drug information.

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.

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.

Literature review of medication administration problems in paediatrics by parent/caregiver and the role of health literacy

OBJECTIVE

To identify studies that highlighted medication administration problems experienced by parents and children, which also looked at health literacy aspect using a validated tool to assess for literacy.

STUDY DESIGN

Ten electronic databases were systematically searched and supplemented by hand searching through reference lists using the following search terms: (1) paediatric, (2) medication error including dosing error, medication administration error, medication safety and medication optimisation and (3) health literacy.

RESULTS

Of the (1230) records screened, 14 studies were eligible for inclusion. Three analytical themes emerged from the synthesis. The review highlighted that frequencies and magnitudes of dosing errors vary by the measurement tools used, the dose prescribed and by the administration instruction provided. Parent's sociodemographic, such as health literacy and language, is a key factor to be considered when designing an intervention aimed at averting medication administration errors at home. The review summarised some potential strategies that could help in reducing medication administration errors among children at home. Among these recommendations is to show the prescribed dose to the parents or young people along with the verbal instructions, as well as to match the prescribed dose with the measuring tool dispensed, to provide an explicit dose intervals and pictographic dosing instructions.

CONCLUSION

The findings suggest that in order to optimise medication use by parents, further work is needed to address the nature of these issues at home. Counselling, medication administration instructions and measurement tools are some of the areas in addition to the sociodemographic characteristics of parents and young people that need to be considered when designing any future potential intervention aimed at reducing medication errors among children and young people at home.

Community Healthcare and Technology to Enhance Communication in Pediatric Obesity Care

Childhood obesity continues to be a critical healthcare issue and a paradigm of a pervasive chronic disease affecting even our youngest children. When considered within the context of the socioecological model, the factors that influence weight status, including the social determinants of health, limit the impact of multidisciplinary care that occurs solely within the medical setting. Coordinated care that incorporates communication between the healthcare and community sectors is necessary to more effectively prevent and treat obesity. In this article, the Expert Exchange authors, with input from providers convened at an international pediatric meeting, provide recommendations to address this critical issue. These recommendations draw upon examples from the management of other chronic conditions that might be applied to the treatment of obesity, such as the use of care plans and health assessment forms to allow weight management specialists and community personnel (e.g., school counselors) to communicate about treatment recommendations and responses. To facilitate communication across the healthcare and community sectors, practical considerations regarding the development and/or evaluation of communication tools are presented. In addition, the use of technology to enhance healthcare-community communication is explored as a means to decrease the barriers to collaboration and to create a web of connection between the community and healthcare providers that promote wellness and a healthy weight status.

An illustrated booklet for reinforcing community health worker knowledge of tuberculosis and facilitating patient counselling

Background

Community health workers (CHWs) have facilitated the move to decentralise tuberculosis (TB) management, but lack access to information appropriate both for personal use and in patient interaction and education.

Aim

To explore the impact of a pictorial-based TB booklet on reinforcing CHW knowledge and facilitating patient counselling.

Setting

This study was conducted in local primary health care clinics and the Hospice in Grahamstown, Eastern Cape Province in South Africa.

Methods

Quantitative and qualitative methods were used. A simple, 17-page, A5 booklet containing pictograms and simple text was designed in collaboration with CHWs who advised on preferred content. Its influence on knowledge was assessed in 31 CHWs using a 17-item questionnaire in a before-and-after study. The experiences of CHWs using the booklet were qualitatively explored using focus group discussions (FGD) and semi-structured interviews.

Results

Overall knowledge increased significantly from 70.6% to 85.3% (p < 0.001) with 8 of 17 questions significantly better answered at follow-up. These addressed meaning of side effects and side effect advice for patients, cause and prevention of TB, action if a dose is forgotten, timing of dose in relation to food intake and the possibility that not all patients are cured. Community health workers reported using the booklet during patient interactions, commenting that it enhanced their confidence in their own TB-related knowledge, improved recall of information and reduced uncertainty. They appreciated the simplicity of the text and its user-friendliness because of the inclusion of pictograms. The booklet was perceived to be valuable as a tool for both patient education as well as improved communication with patients.

Conclusion

A simple, user-friendly TB booklet containing pictograms improved CHW knowledge and acted as a valuable tool in patient communication and education.

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.

Pharmaceutical pictograms for low-literate patients: Understanding, risk of false confidence, and evidence-based design strategies

OBJECTIVE

This study aims to (1) evaluate ten pharmaceutical pictograms for low-literate patients on understandability, (2) assess the risk of false confidence in understanding, and (3) identify how the design can be improved to increase understandability.

METHODS

Interviews were conducted with n=197 pharmacy visitors in the Netherlands. Additional qualitative discussions were held with n=30 adequately and n=25 low-literate participants (assessed with REALM-D). Qualitative data were analysed using the Thematic Framework approach.

RESULTS

Half of the pictograms reached 67% understanding (31.0%-98.5%); two did in the low-literate group. Three pictograms showed a risk for false confidence. Pictograms appeared to be most effective when people were familiar with their visual elements and messages.

CONCLUSION

Low-literate people have more difficulty understanding pictograms than people with adequate literacy. While the risk of false confidence is low, for critical safety information, 67% understanding might not be sufficient. Design strategies for pharmaceutical pictograms should focus on familiarity, simplicity, and showing the intake and effect of medicine.

PRACTICE IMPLICATIONS

Health professionals should go over the meaning of pictograms when providing drug information to patients to increase patients' familiarity with the message and to ensure that all pictograms are sufficiently understood.

Optimising adherence to childhood pneumonia treatment: the design and development of patient instructions and a job aid for amoxicillin dispersible tablets

INTRODUCTION

Pneumonia is the leading cause of death from infection in children worldwide. Despite global treatment recommendations that call for children with pneumonia to receive amoxicillin dispersible tablets, only one-third of children with pneumonia receive any antibiotics and many do not complete the full course of treatment. Poor adherence to antibiotics may be driven in part by a lack of user-friendly treatment instructions.

OBJECTIVE

In order to optimise childhood pneumonia treatment adherence at the community level, we developed a user-friendly product presentation for caregivers and a job aid for healthcare providers (HCPs). This paper aims to document the development process and offers a model for future health communication tools.

METHODS

We employed an iterative design process that included document review, key stakeholder interviews, engagement with a graphic designer and pre-testing design concepts among target users in India and Kenya. The consolidated criteria for reporting qualitative research were used in the description of results.

RESULTS

Though resources for pneumonia treatment are available in some countries, their content is incomplete and inconsistent with global recommendations. Document review and stakeholder interviews provided the information necessary to convey to caregivers and recommendations for how to present this information. Target users in India and Kenya confirmed the need to support better treatment adherence, recommended specific modifications to design concepts and suggested the development of a companion job aid. There was a consensus among caregivers and HCPs that these tools would be helpful and improve adherence behaviours.

CONCLUSIONS

The development of user-friendly instructions for medications for use in low-resource settings is a critically important but time-intensive and resource-intensive process that should involve engagement with target audiences.

Patients' preferences for visuals: differences in the preferred level of detail, type of background and type of frame of icons depicting organs between literate and low-literate people

OBJECTIVE

To evaluate icons of organs with systematic variations in design to provide directions for the development of pictograms that support patient leaflets targeted at a low-literate audience.

METHODS

In interview questionnaires, 191 pharmacy visitors (IJsselstein, The Netherlands), indicated for four organs in which image the organ was represented most clearly. The icons vary in level of detail of the depicted organ, in the organs that are shown in the background, and in how much of the body is shown as frame. Participants' literacy was determined through the Dutch Rapid Estimate of Adult Literacy in Medicine (REALM-D).

RESULTS

For the three internal organs, the intestines, lungs and kidneys, low-literate participants were more likely than literate participants to opt for less context in the form of the frame of the body.

CONCLUSION

When the meaning of the visual is given, low-literate people prefer organ icons with less context of the body over a depiction of the whole body.

PRACTICE IMPLICATIONS

Since literate and low-literate people differ in perceptual preferences, continued involvement of people with limited literacy skills in the design process is essential to target the visuals to their needs.

Is easy read information really easier to read?

BACKGROUND

Producing accessible information regarding health issues is very important in order to ensure that people with intellectual disabilities (ID) have equal access to services and can make informed decisions about their treatment.

METHOD

This study examined whether an Easy Read leaflet improved service users' comprehension and compared the efficacy of two different modalities of presenting information: 'text and pictures' or 'pictures only'. Participants' knowledge was assessed at baseline and immediately after the leaflet.

RESULTS

Our findings indicate that the use of the leaflet improved knowledge but neither modality of presenting information was significantly more effective at making the document easier to understand. Contrary to expectation, people with milder ID may find pictures more effective in the absence of text.

CONCLUSIONS

Although pictures were not found to be detrimental, our results do not favour the use of pictures as well as text when giving information, particularly to people with milder disabilities. The generalised use of text and picture formats for all people with ID in spite of the scant evidence supporting its effectiveness is concerning.

A proposed disaster literacy model

Although numerous government, nonprofit, and relief organizations have endeavored to educate and prepare the American public for disasters, adults with physical, mental, and educational disabilities remain among the most vulnerable and least prepared subgroups of the population. The lack of alignment between the literacy demands of existing disaster preparedness and recovery materials and the literacy skills of many vulnerable subgroups limits their ability to understand and effectively use potentially life-saving information. We review the literature on literacy and vulnerable populations, propose a new model for disaster literacy, and describe opportunities for incorporating best practices into planning and preparedness activities. Disaster literacy is defined here as an individual's ability to read, understand, and use information to make informed decisions and follow instructions in the context of mitigating, preparing, responding, and recovering from a disaster. Recommendations are made for developing and evaluating disaster communication materials for vulnerable populations. To meet and improve the disaster literacy of vulnerable populations we suggest pilot-testing and evaluation be routinely used to inform selection of media type, message, and point of contact.

The effect of age and educational level on the cognitive processes used to comprehend the meaning of pictograms

BACKGROUND AND AIMS

Pictograms, designed to be a universal communication system, are often created from several concrete and easily recognizable drawings. Does understanding depend on a logical approach? Or is it the ability to inhibit the concrete sense of each picture that allows access to a higher level of comprehension? (ability to abstract). These executive functions are sensitive to the effects of aging and educational level. The aim of our study was to evaluate the nature of the cognitive processes underlying the meaning of pictograms and to test the effect of aging and educational level.

METHODS

We enrolled 19 older adults (60-69 years old) and 63 young adults (20-29 years old). Of these 63 young adults, 43 had a high educational level (Young-High participants), and 20 had a lower educational level (Young-Low participants). Each participant was asked the meaning of 20 pictograms and underwent an assessment of abstraction and logical abilities with WAIS-III test.

RESULTS

Older adults had lower pictogram assessment scores and abstraction and logical abilities when compared with young adults. In both groups, abstraction and logical abilities were correlated with the interpretation of pictograms but only abstraction ability remains strongly correlated with pictogram comprehension in the older group after adjustment of sex, age and educational level. Consequently, the poorer performances of older adults to determine the meaning of pictograms could be explained by the decline of abstraction ability in elderly.

CONCLUSIONS

Pictograms are not the universal communication system as we formerly thought. Age and educational level may influence the performance in determining the meaning of pictograms.

Teach back and pictorial image educational strategies on knowledge about diabetes and medication/dietary adherence among low health literate patients with type 2 diabetes

AIMS

To explore the impact of pictorial image and teach back educational strategies on knowledge, adherence to medication and diet among patients with type 2 diabetes and low health literacy in Saqqez, Iran.

METHODS

In this randomized controlled trial, 127 patients with type 2 diabetes who had low health literacy were randomly allocated into three arms of the study (pictorial image, teach back, and control groups). The two intervention groups received education within three weekly sessions, each lasting 20 min. The level of functional health literacy in adults (TOFHLA), diabetes knowledge, and adherence to medication and diet were measured and compared in the three groups before and six weeks after the interventions. We used intention to treat analysis. Data were analyzed using ANOVA and Paired t test.

RESULTS

Mean scores of knowledge, adherence to medication and diet revealed significant differences between two intervention groups and control group (P<0/001) six weeks after intervention.

CONCLUSIONS

Both educational strategies increased knowledge, as well as adherence to medications and diet among patients with type 2 diabetes and low health literacy. Both educational strategies seem to be effective for patients with low health literacy and are recommended to be used according to patients' conditions.

Effects of prospective-user factors and sign design features on guessability of pharmaceutical pictograms

OBJECTIVE

To examine the associations between the guessing performance of 25 pharmaceutical pictograms and five sign features for naïve participants. The effect of prospective-user factors on guessing performance was also investigated.

METHODS

A total of 160 Hong Kong Chinese people, drawn largely from a young student population, guessed the meanings of 25 pharmaceutical pictograms that were generally not familiar to them. Participants then completed a questionnaire about their drug buying and drug label reading habits, and their demographics and medication history. Finally they rated five features (familiarity, concreteness, complexity, meaningfulness, and semantic distance) of the pharmaceutical pictograms using 0-100 scales.

RESULTS

For all pharmaceutical pictograms, mean and standard deviation of guessability score were 64.8 and 17.1, respectively. Prospective-user factors of 'occupation', 'age' and 'education level' significantly affected guessing performance. For sign features, semantic closeness was the best predictor of guessability score, followed by simplicity, concreteness, meaningfulness and familiarity.

CONCLUSION

User characteristics and sign features are critical for pharmaceutical pictograms. To be effective, pharmaceutical pictograms should have obvious and direct connections with familiar things and it is recommended that pharmaceutical pictograms should be designed with consideration of the five sign features investigated here.

PRACTICE IMPLICATIONS

This study provides useful information and recommendations to assist interface designers to create and evaluate icons for pharmaceutical products and to design more user-friendly pharmaceutical pictograms. However, further work is needed to see how older people respond to such pharmaceutical pictograms.

'I can't relate it to teeth': a qualitative approach to evaluate oral health education materials for preschool children in New South Wales, Australia

BACKGROUND

Early Childhood Caries is a significant public health issue worldwide. Although much is known about the aetiology of dental caries, there is limited evidence on the understanding of caregivers on readily available early childhood oral health education materials.

AIM

The purpose of this study was to record how parents cope with dental health education materials for preschool children commonly available in New South Wales, Australia.

DESIGN

This qualitative study was nested within a large cohort study in South Western Sydney. English-speaking mothers (n = 24) with young children were approached for a face-to-face, semi-structured interview at their homes. Two dental leaflets designed by NSW Health to give advice on monitoring young children's oral health were sent to mothers prior to the interview. Interviews were recorded and subsequently transcribed verbatim. Transcripts were analysed by interview debriefing and a thematic coding.

RESULTS

Mothers generally reported that the leaflets were easy to read but noted that the information pertaining to bottle feeding was confusing. Furthermore, they were unable to understand terms such as 'fluoride' and 'fissure sealants'. Early childhood nutrition and infant teething were inadequately addressed, and mothers preferred pictorial presentations to improve their understanding of oral health.

CONCLUSIONS

Producers of health education leaflets should keep the messages simple and straightforward, avoid the use of medical jargon, and use pictorial aids to improve communication with parents.

A pilot study to evaluate pharmaceutical pictograms in a multispecialty hospital at dehradun

Pharmaceutical pictograms have the potential to play an important role in optimizing compliance in the illiterate patient population. Pictograms may improve warning comprehension for those with visual or literacy difficulties and can sometimes be recognized and recalled far better than words. The main purpose of this study is to determine whether these pictograms can be effectively understood by illiterate patients, who otherwise cannot read the instructions given on their prescription order. In this study, 10 pharmaceutical pictograms were evaluated in patients attending the outpatient department of the Shri Mahant Indresh Hospital, a multispecialty, referral hospital in Dehradun (Uttarakhand). Understanding of pictograms by patients before and after interpretation was noted and follow-up interpretation was also noted. Results of the study showed that prior to explanation, the majority of the patients were unable to interpret the pictograms correctly but after explanation of their meaning, interpretation by them showed a marked improvement, indicating the need of using pictograms along with verbal reinforcement. The study also highlighted poor patient follow-up, a major cause of patient non-compliance, often leading to a poor therapeutic outcome of the prescribed medication order. Such problems can be taken care of by an active participation by healthcare professionals.

A randomized trial of pictorial versus prose-based medication information pamphlets

OBJECTIVE

The goal of this study was to compare prose and pictorial-based information pamphlets about the medication methotrexate in the domains of free recall, cued recall, comprehension and utility.

METHODS

A single blind, randomized trial of picture versus prose-based information pamphlets including 100 participants aged 18-65 years of age, who had not completed high school, could read English, and had no prior knowledge about methotrexate. Superiority of pamphlet type was assessed using immediate free recall, cued recall and comprehension.

RESULTS

There were no differences between picture and prose pamphlets in free recall, cued recall, and comprehension either immediately or after a 1-week interval. Immediate free recall of important information was 17-26%; free recall fell even lower to 7-16% after 1 week. The pictorial pamphlet was preferred over the prose-based pamphlet.

CONCLUSION

This study found no benefit in free recall, cued recall, or comprehension through the addition of pictograms to a simple prose-based medication pamphlet.

PRACTICE IMPLICATIONS

In order for them to be effective in clinical practice, even simple medication information pamphlets that have been assessed for patients' ability to comprehend them cannot be used as the sole means for conveying important medication-related information to patients.

The influence of education on the interpretation of pharmaceutical pictograms for communicating medicine instructions

Objective

To assess the influence of formal education on the interpretation of pharmaceutical pictograms.

Method

A total of 46 pictograms were used: 23 were extracted directly from the USP-DI, and 23 with corresponding meanings were designed in accordance with the local culture (local pictograms). One hundred and thirty Xhosa respondents, who ranged from having no formal education to tertiary level education, were interviewed with the aid of an interpreter. Demographic data were collected, a literacy test was conducted and respondents were tested for their interpretation of all 46 pictograms. Preference for either the USP-DI or the local pictogram was determined.

Setting

Respondents were interviewed in primary health care clinics, a variety of work settings or in their homes in Grahamstown, South Africa.

Key findings

Standard of education had a significant influence on the interpretation of 24 of the 46 pictograms. Generally, significant differences in interpretation were apparent between those with only primary school education and those who had completed at least some senior school education (P &lt; 0.05). The group with tertiary education was significantly better than the other groups (P &lt; 0.05). Only 15 of the 46 pictograms met the American National Standards Institute (ANSI) 85% correct criterion.

Conclusion

Interpretation was dependent on education and the development of visual literacy skills, but potential for misinterpretation in all educational groups was noted. These results suggest that pictograms should only be used as a communication aid in combination with text or verbal information from the health care provider.

Pictographic instructions for medications: do different cultures interpret them accurately?

Objective

(1) To determine whether a range of linguistically diverse individuals of non-European descent could understand the meaning of predeveloped pictograms without any additional aids such as verbal explanations; (2) to identify appropriate modifications to the pictograms to diminish errors of interpretation; and (3) to test the notion that central pictogram elements have the same meaning irrespective of language or culture.

Setting

The study was conducted in Vancouver, Canada.

Method

This study tested a set of 16 predeveloped pictograms to determine whether they accurately communicated the intended medication administration directions to participants who neither speak nor read English, French or Spanish. Both qualitative and quantitative methods evaluated the pictograms' interpretability among 39 participants from three language groups, Cantonese, Somali and Punjabi. Standard analysis of variance tested for differences due to language groups and other demographics.

Key findings

Only four of the 16 initial pictograms tested were interpreted correctly by 70% of participants. Relaxing the criterion from 70% to 50% included seven more. Modifications of problem elements within the pictograms further improved interpretation accuracy levels by 22%, to a final accuracy of 67.15%. Quantity errors were twice as common as timing, administration route or auxiliary instruction errors.

Conclusions

Participants could identify particular pictographic symbols they found confusing or ambiguous. Basic education and time since immigration predicted interpretation accuracy better than first language or any other demographic characteristic.

Use of pictorial aids in medication instructions: a review of the literature

PURPOSE

The effects of pictorial aids in medication instructions on medication recall, comprehension, and adherence are reviewed.

SUMMARY

Many patients depend on medication labels and patient information leaflets for pertinent drug information, but these materials are often difficult for patients to understand. Research in psychology and marketing indicates that humans have a cognitive preference for picture-based, rather than text-based, information. Studies have shown that pictorial aids improve recall, comprehension, and adherence and are particularly useful for conveying timing of doses, instructions on when to take medicine, and the importance of completing a course of therapy. Other research has compared various techniques for using picture-based information and supports the use of integrative instructions, a combination of textual, oral, and pictorial communication, to promote comprehension and adherence. While pictures have generally proven useful for improving patient comprehension and adherence, not all picture-based interventions have produced successful results. Some icons, particularly clock icons, have been found to be too complex to enhance understanding and could not overcome the advantage provided by the familiarity of the textbased format, suggesting that patients be trained to use pictorial medication information before they are expected to use icons as an aid for medication administration. In addition to enhancing understanding, pictorial aids have been found to improve patients' satisfaction with medication instructions.

CONCLUSION

The use of pictorial aids enhances patients' understanding of how they should take their medications, particularly when pictures are used in combination with written or oral instructions.

Medicines information and adherence in HIV/AIDS patients

BACKGROUND

Providing written medicines information is being legislated in an increasing number of countries worldwide, with the patient information leaflet (PIL) being the most widely used method for conveying health information. The impact of providing such information on adherence to therapy is reportedly unpredictable. Therapy for human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and related opportunistic infections usually involves polytherapy and complex regimens, both of which are risk factors for non-adherence. The objective of this study was to assess the impact of medicines information on adherence to chronic co-trimoxazole therapy in low-literate HIV/AIDS patients.

METHODS

Two different PILs were designed for co-trimoxazole tablets and were available in both English and isiXhosa. Participants were randomly allocated to a control group (receiving no PIL), group A (receiving a "complex PIL") and group B (receiving a "simple PIL" incorporating pictograms). At the first interview, demographic data were collected and the time, date and day that the participant would take his/her first tablet of the month's course was also documented. In a follow-up interview adherence to therapy was assessed using two methods; self-report and tablet count.

RESULTS

The medicines information materials incorporating simple text and pictograms resulted in significantly improved adherence to therapy in the short term, whereas a non-significant increase in adherence was associated with the availability of the more complex information. This was shown by both the self-reported assessment as well as the tablet count.

CONCLUSION

This research suggests that appropriately designed written material can have a positive impact in improving adherence and, together with verbal consultation, are essential for enabling patients to make appropriate decisions about their medicine taking.

The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence

OBJECTIVE

To assess the effects of pictures on health communications.

METHOD

Peer reviewed studies in health education, psychology, education, and marketing journals were reviewed. There was no limit placed on the time periods searched.

RESULTS

Pictures closely linked to written or spoken text can, when compared to text alone, markedly increase attention to and recall of health education information. Pictures can also improve comprehension when they show relationships among ideas or when they show spatial relationships. Pictures can change adherence to health instructions, but emotional response to pictures affects whether they increase or decrease target behaviors. All patients can benefit, but patients with low literacy skills are especially likely to benefit. Patients with very low literacy skills can be helped by spoken directions plus pictures to take home as reminders or by pictures plus very simply worded captions.

PRACTICE IMPLICATIONS

Educators should: (1) ask "how can I use pictures to support key points?", (2) minimize distracting details in pictures, (3) use simple language in conjunction with pictures, (4) closely link pictures to text and/or captions, (5) include people from the intended audience in designing pictures, (6) have health professionals plan the pictures, not artists, and (7) evaluate pictures' effects by comparing response to materials with and without pictures.

Interpretation of Medication Pictograms by Adults in the UK

BACKGROUND

Patients' ability to understand information about medication is crucial for safety and effectiveness. Rates of illiteracy worldwide indicate that written information alone cannot meet many patients' needs. Medication pictograms are an alternative, but may be culturally sensitive. Previous testing has used large pictograms, which are impractical for conventional drug information formats.

OBJECTIVE

To compare 2 sets of pictograms for instructions or warnings (from the US and South Africa) for understandability by adults in the UK and examine the effects of pictogram size and repeat presentation on understandability among older adults.

METHODS

In the first part of the study, 160 adults (aged 17–83 y) reviewed and interpreted 10 pictograms. In the second, 67 older adults (aged 65–96 y) were randomly assigned to review 10 small or large pictograms. After giving their interpretation, they were informed of the correct meaning. One week later, they were shown the same pictograms and gave their interpretation.

RESULTS

The pictograms for the 10 different instructions and warnings showed great variation in interpretation rates (7.5–90%), with few significant differences between the US and South African versions. Only 3 were understood by ≥85% of the population. Pictograms performed significantly better if they were larger and at the second presentation.

CONCLUSIONS

Pictograms have the potential to help patients understand information on drug therapy. This study shows that some existing pictograms are not easily interpreted and that testing is needed before their implementation. A reduction in their size to allow incorporation into conventional written formats may cause additional problems for patients.

Do pictograms improve children's understanding of medicine leaflet information?

There is a growing need for balanced drug information customized for special target groups such as children [Food and Drug Administration. Prescription Drug Product Labeling; Medication Guide Requirements; Proposed Rule. Part VII. Department of Health and Human Services, 21 CRF Part 201, et al. Federal Register 1995;60:44182-252; Dickinson D, Raynor DK, Duman M. Patient information leaflets for medicines: using consumer testing to determine the most effective design. Patient Educ Couns 2001;43:147-59]. Pictograms are one aid that may be used to make information easier to read and understand. The aim of this study was to test whether children understand pictograms developed by the United States Pharmacopeia (USP) [The United States Pharmacopeial Convention Inc. USP Pictograms. Retrieved 11 March 2002 from http://www.usp.org/], and especially, if the pictograms improve children's understanding of medicine leaflet information. Finnish elementary school children aged 7 years (n=28), 11 years (n=31) and 13 years (n=31) were interviewed and asked what they thought 15 USP pictograms mean. The two older age groups were also asked to read an "easy-to-read" leaflet for penicillin-V. Every second child was given a leaflet with a plain text and the others received the same text accompanied by pictograms. After reading the leaflet, the children were asked seven questions related to the text. Most of the children understood the meanings of the selected 15 pictograms correctly, the proportion of the correct explanations varying from 30 to 99% according to the pictogram. Even well-understood pictograms did not help the children understand the leaflet information, although they reduced the need for probing. This study shows that the context in which pictograms are tested makes a difference in the results. Testing plain pictograms without incorporating them in their real context, e.g., in the patient information leaflet may exaggerate their usefulness in leaflet information.

Effect of pictograms on readability of patient information materials

OBJECTIVE

To design, develop, and evaluate a simple, understandable medicine label and patient information leaflet (PIL) for nystatin suspension, and to assess the effect of incorporating pictograms on understanding in low-literate participants.

METHODS

Patient information materials were designed and pretested in a pilot study (n = 20), and were subjected to the Fry's readability test. The final evaluation was conducted with 60 low-literate participants who had a maximum of 7 years of formal schooling and for whom English was their second language. Demographic data were collected. Participants were randomly allocated to a control (text-only information) or experimental (text + pictogram information) group, shown the medicine label and PIL, and asked to read them. A series of questions was asked about the instructions and an understanding level was calculated in each case. A second series of questions assessed patient acceptability of the materials. Differences in understanding were determined by chi(2) tests.

RESULTS

Both sets of these simple written materials were generally well understood. However, the presence of pictograms was shown to improve the comprehension of more complex information, resulting in significantly more participants in the experimental group obtaining a score for understanding >80% for both the medicine label and PIL. A clear preference for the materials incorporating pictograms was expressed.

CONCLUSIONS

The presence of pictograms had a positive effect in the acquisition and comprehension of drug information.

The evaluation of pharmaceutical pictograms in a low-literate South African population

An inability to read and understand written medication instructions may be a major contributory factor to non-compliance in certain patient populations, particularly in countries with a high illiteracy rate such as South Africa. Twenty three pictograms from the USP-DI and a corresponding set of 23 locally developed, culturally sensitive pictograms for conveying medication instructions were evaluated in 46 Xhosa respondents who had attended school for a maximum of 7 years. Respondents were tested for their interpretation of all 46 pictograms at the first interview and again 3 weeks later. The correct meaning of each pictogram was explained at the end of the first interview. Preference for either the Local or USP pictograms was determined. At the follow-up interview, 20 of the Local pictograms complied with the ANSI criterion of >/=85% comprehension, compared with 11 of the USP pictograms. Respondents indicated an overwhelming preference for the Local pictograms.