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

Pharmaceutical pictograms to improve textual comprehension: A systematic review

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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 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.

Comprehensibility of South African pictograms by sub-Saharan African prospective-users

OBJECTIVES

This work aimed to explore the validity of South African pictograms to be comprehended by sub-Saharan migrant populations in Spain.

METHODS

A quantitative cross-sectional study was carried out. A voluntary survey was conducted among a population ≥ 18 years of age in a Temporary Stay Centre for Immigrants located in Spain, in June 2022. The form included a culturally and linguistically validated version of the Health Literacy questionnaire (HLS-EU-Q16), a brief questionnaire of sociodemographic variables and 10 South African pictograms selected to assess the comprehension. According to the International Organization for Standardization, a pictogram must receive 66.70% correct answers to be acceptable. Mann-Whitney U or Kruskal-Wallis tests were used to assess differences between group variables. Statistical significance was set at P < 0.05.

RESULTS

55 sub-Saharan migrants who newly arrived in Europe voluntarily agreed to participate. None of the pictograms evaluated met the validity criterion. For the selected pictograms, the range of correct answers was between 52.50% and 20.00%. Neither sociodemographic variables nor Health Literacy level were significantly associated with pictogram comprehensibility.

CONCLUSION

New culturally sensitive pictograms that are easily comprehended by sub-Saharan African population are needed.

PRACTICE IMPLICATIONS

These results may serve as a starting point for future studies that aim to create and evaluate new pictograms or create new culturally adapted versions of existing pictograms involving the target population.

Exploring the Role of Pictograms in the Comprehension of Pain

Introduction

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

Methods

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

Results

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

Discussion and Conclusions

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

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.

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.

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.

Evaluation of a pharmacist-led intervention to improve medication adherence in patients initiating dabigatran treatment: a comparison with standard pharmacy practice in Poland

Backround

Dabigatran is a direct thrombin inhibitor used to treat cardiac arrhythmias, and rates of non-adherence to dabigatran in Polish populations are high. The current study examined how a pharmacist-led intervention of counselling with pictogram-enhanced medication instructions, and smartphone medication reminders, can improve adherence to dabigatran.

Methods

A 3-month pharmacist-led intervention was conducted in community pharmacies in Poland on 325 men and women filling a dabigatran prescription for the first time. Participating pharmacies were assigned into the Control Group (n = 172 patients) or the Intervention Group (n = 153 patients). The primary outcome of this prospective study was self-reported medication adherence assessed at 3 time points (day 7, day 21, and day 90) after initiation of dabigatran.

Results

Patients in the Intervention Group were significantly more adherent (mean days on Dabigatan/week) than the Control Group at 7 days (6.0 ± 0.9 vs 5.4 ± 1.1, p < 0.0001), 21 days (5.6 ± 1.0 vs 4.9 ± 1.3, p < 0.0001), and 90 days (5.5 ± 1.3 vs 4.4 ± 2.0, p < 0.0001), respectively. The percentage of patients in the Intervention Group who reported taking dabigatran twice/day as prescribed was significantly higher than the Control Group at 7 days (82.7% vs 71.4%, p = 0.0311), at 21 days (84.4% vs 58%, p < 0.0001), and at 90 days (78.4% vs 39.7%, p < 0.0001), respectively. The proportion of patients fully adherent (every day, twice/day) at 90 days was significantly higher in the Intervention Group than in the Control Group (26.1% vs 13.2%, p = 0.0145).

Conclusions

Our findings support the role for interventions in community pharmacies in Poland to improve medication adherence, thus providing evidence for the efficacy of a pharmacist-led pictogram and smartphone-based program to support optimal dabigatran treatment.

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.

Communicating with patients through pictograms and pictures - a scoping review

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

Validation of pharmaceutical pictograms among older adults with limited English proficiency

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

PRACTICE IMPLICATIONS

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

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.

Personalized and Self-Management: Systematic Search and Evaluation Quality Factors and User Preference of Drug Reference Apps in Taiwan

Background: Drug reference apps promote self-management and improve the efficiency and quality of work for physicians, nurses, pharmacists, and patients. This study aimed to describe a systematic and stepwise process to identify drug reference apps in Taiwan, assess the quality of these apps, and analyze the influential factors for user ratings. Methods: A two-step algorithm (KESS) consisting of keyword growing and systematic search was proposed. Seven independent reviewers were trained to evaluate these apps using Mobile App Rating Scale (MARS). A logistic regression model was fitted and average marginal effects (AME) were calculated to identify the effects of factors for higher user ratings. Results: A total of 23 drug reference apps in Taiwan were identified and analyzed. Generally, these drug reference apps were evaluated as acceptable quality with an average MARS score of 3.23. Higher user engagement, more functionality, better aesthetics, and more information associated with higher user ratings. Navigation is the most influential factor on higher user ratings (AME: 13.15%) followed by performance (AME: 11.03%), visual appeal (AME: 10.87%), credibility (AME: 10.67%), and quantity of information (AME: 10.42%). Conclusions: User experience and information clearly affect user ratings of drug reference apps. Five key factors should be considered when designing drug reference apps.

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.

Guessability of U.S. pharmaceutical pictograms in Iranian prospective users

Objective:

This study examined the gueassability of US pharmaceutical pictograms as well as associated demographic factors and cognitive design features among Iranian adults.

Methods:

A total of 400 participants requested to guess the meaning of 53 US pharmaceutical pictograms using the open-ended method. Moreover, the participants were asked to rate the cognitive design features of each pictorial in terms of familiarity, concreteness, simplicity, meaningfulness and semantic closeness on a scale of 0-100.

Results:

The average guessability score (standard deviation) was 66.30 (SD=24.59). Fifty-five percent of pharmaceutical pictograms understudy met the correctness criteria of 67% specified by ISO3864, while only 30% reached the criterion level of 85% set by ANSIz535.3. Low literate participants with only primary school education had substantial difficulty in the interpretation of pharmaceutical pictograms compared to those completed higher education levels. Younger adults of <30 years significantly performed better in the interpretation of pharmaceutical pictograms as compared to >31 years old participants. ‘Home patient care’ and ‘daily medication use’ had no effect on guessability performance. Concerning cognitive design features, meaningfulness better predict geussability score compared to the others.

Conclusions:

Several USP pictograms fail to be correctly interpreted by Iranian users and need to be redesigned respecting cognitive design features. Interface designers are recommended to incorporate more familiar and concrete elements into their graphics in order to create more meaningful pictorial symbols and to avoid any misinterpretation by the user. Much effective medication use is expected to be achieved by means of this approach, through the improvement of the communication property of pharmaceutical pictograms.

Applying the Model for Improvement to a Student-run Quality Improvement Project in a Refugee Center: A Pilot Study

Due to insufficient communication strategies between healthcare providers and refugees in the United States, this quality improvement project aimed to improve disparity in refugee healthcare. We chose to focus on community pharmacist counseling sessions with refugees in the city of Rochester, New York. The two refugee populations we focused on were the Burmese and Nepali. Due to illiteracy in their native language, the refugees were not receptive to a pamphlet detailing the beneficial roles a pharmacy can have in improving their health and wellbeing. We created a pictorial survey of pharmacies near a refugee center to identify the pharmacies the refugees were utilizing in the area. Once we identified these pharmacies, we created a counseling aid booklet translating common pharmacy language/terms into English, Burmese, and Nepalese languages supported by pictorial diagrams. The counseling aid booklet was evaluated by pharmacists using a satisfaction scale. Overall, the counseling aid booklet was found to be helpful for the pharmacist’s daily interaction with refugee populations. Further plans for the counseling aid booklet include adding more pharmacy counseling terms for common disease states in refugee populations, making the book more inclusive of other languages, and implementation in more community pharmacies and other diverse healthcare settings.

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.