Developing visual images for communicating information aboutantiretroviral side effects to a low-literate population

Brief Telephonic Motivational Interviewing for People Living with HIV with Follow-up Problems

Motivational interviewing (MI)-based interventions can be effective for people living with HIV (PLWHIV) with medical follow-up problems. This study aimed to assess the stage of motivation to attend medical appointments of PLWHIV with medical follow-up problems and to evaluate a single telephone session MI intervention directed to engage them in care. The change in stage was evaluated before and after the intervention, and attending medical appointments was monitored for six months. Thirty-nine PLWHIV participated; 51.3% were in precontemplation/contemplation and 49.7% in preparation/action stage. Most (excluding those in the action stage from the beginning) (n = 22, 71.0%) advanced to another stage after the intervention (z = - 4.235, p < .001), and most did not miss the following appointments. Brief and remote MI interventions could be useful in low-resource settings, especially for those in the early stages of change, to explore motivations related with missing medical appointments.

Comprehension of pharmaceutical pictograms in sub-Saharan migrants newly arriving in Europe: An exploratory study

BACKGROUND

Migratory pressure from sub-Saharan Africa on Europe must also be addressed from a health literacy perspective. Sub-Saharan migrants newly arriving in Europe generally have lower literacy skills compared to the host community's citizens and special learning needs. Pictograms give health professionals a means of communicating medication instructions to people with no common language or who are illiterate, or both.

OBJECTIVE

This work aimed to explore the comprehension of a set of United States Pharmacopoeia (USP) pictograms by sub-Saharan migrants newly arriving in Europe.

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 the Spanish city of Melilla (North Africa) in June 2022. The form included a selection of 10 USP pictograms to assess their comprehension. According to the International Organization for Standardization, a pictogram must receive 66.70% correct answers to be acceptable.

RESULTS

Fifty-one sub-Saharan immigrants participated in this study. None of the pictograms reached comprehensibility threshold.

CONCLUSION

Pharmaceutical pictograms are ineffective in practice when they are not designed in a culturally sensitive manner.

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.

Use of visual aids in general practice consultations: A questionnaire-based survey

Objectives

Visual aids (VAs) seem effective to improve doctor-patient communication. The objective was to describe how VAs are used in consultation and what French general practitioners (GPs) expect of them.

Methods

Cross-sectional study using a self-administered questionnaire among French GPs in 2019. Descriptive and multinominal logistic regression analyses were performed.

Results

Of the 376 respondents, 70% used VAs at least weekly and 34% daily; 94% considered VAs useful/very useful; 77% felt they did not use VAs enough. Sketches were the most used VAs and considered the most useful. Younger age was significantly associated with a higher rate of use of simple digital images. VAs were mainly used to describe anatomy and facilitate patient comprehension. Main reasons for not using VAs more often were time spent searching, lack of habit and poor quality of available VAs. Many GPs requested a database of good quality VAs.

Conclusions

GPs use VAs regularly in consultations but would like to use them more often. Informing GPs of the usefulness of VAs, training them to draw adapted sketches and creating a good quality databank are some possible strategies to increase the use of VAs.

Innovation

This study described in detail the use of VAs as tool for doctor-patient communication.

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

Background

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

Aim

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

Setting

Community centre, Makhanda, South Africa.

Methods

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

Results

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

Conclusion

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

Contribution

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

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

BACKGROUND

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

METHODOLOGY

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

RESULTS

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

CONCLUSIONS

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

Comprehensibility of a personalized medication overview compared to usual-care prescription drug labels

Poor understanding of prescription drug label (PDL) instructions can lead to medication errors, suboptimal treatment (side) effects, and non-adherence. A personalized medication hard-copy overview listing PDL instructions and visual information may support patients in their medication use. This study aimed to investigate the comprehensibility of PDL instructions on a personalized medication overview compared to usual-care PDL instructions presented on a medication box. A hypothetical-online-experiment was set up, comparing groups of respondents exposed vs not exposed to the medication overview and who received PDL instructions for three, five, or eight medications. Participants were divided randomly in six groups. Online questionnaires were sent to a stratified sample of 900 members from the Nivel Dutch Healthcare Consumer Panel. Outcome measures included comprehension of instructions for medication use, e.g. how often, dose timing, usage advice and warnings for a medication with simple use instructions (omeprazol) and more complex use instructions (levodopa/carbidopa (L/C)). To analyze differences between experimental conditions ANOVA testing was used. 604 respondents (net response 67%) completed the questionnaires. Respondents exposed (E) to the overview gave a higher proportion of correct answers compared to non-exposed (NE) respondents for usage advice (L/C: mean 0.83, SD 0.4 E; 0.03, SD 0.2 NE, p &lt; 0.001; omeprazol: mean 0.85, SD 0.4 E; 0.10, SD 0.3 NE, p &lt; 0.001). Both groups gave the same proportion of correct answers (mean 0.80, SD 0.4, p = 1.0) for dose timing of omeprazol. More NE respondents gave correct answers for how often (mean 0.85, SD 0.4 NE; mean 0.76, SD 0.4 E, p = 0.02) and dose timing (mean 0.92, SD 0.3 NE; mean 0.86, SD 0.4 E, p = 0.04) of L/C. No differences were found regarding number of medications nor were interaction effects found between the number of medications and information type. As a medication overview contains additional information, it can be a good addition in supporting patients in their medication use compared to usual-care PDLs. Future research should focus on identifying patient groups who might benefit more from a medication overview, by testing the effect of such overview on this group.

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

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

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

DISCUSSION

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

PRACTICE IMPLICATIONS

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

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.

Provision and Need for Medicine Information in Asia and Africa: A Scoping Review of the Literature

Published reviews of written medicine information (WMI) have mainly drawn on studies published in high-income countries, including very few Asian or African studies. We therefore set out to scope the research literature to determine the extent and type of studies concerning WMI for patients/consumers across these two continents. We sought empirical studies published between January 2004 and December 2019, conducted in any Asian or African country, as defined by the United Nations, in English or with an English abstract. The majority of the 923 papers identified were from high-income countries. We retained 26 papers from Africa and 99 from Asia. Most African studies (n = 20) involved patients in the development of PILs, in the assessment of the effectiveness of PILs or in surveys. In contrast, the highest proportion of Asian studies concerned the content of WMI (n = 42). WMI is desired, but needs to be in local languages, and there needs to be more use made of pre-tested pictograms. Existing WMI frequently does not meet local regulatory requirements, particularly locally manufactured products. A number of studies reported potentially positive impacts of providing WMI on knowledge and medicine use behaviours. Provision of medicine information is essential for safe use of medicines in all countries. Internationally agreed guidelines, incorporating good design principles, are needed to ensure the optimal content and design of WMI. The World Health Organization should support African and Asian regulatory bodies to share best practice in relation to WMI for patients/consumers and to develop and implement pan-continental guidelines that take into account consumer needs and preferences.

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.

Increases in HIV Incidence Following Receptive Anal Intercourse Among Women: A Systematic Review and Meta-analysis

Receptive anal intercourse (RAI) carries a greater per-act risk of HIV acquisition than receptive vaginal intercourse (RVI) and may influence HIV epidemics driven by heterosexual sex. This systematic review explores the association between RAI and incident HIV among women, globally. We searched Embase and Medline through September 2018 for longitudinal studies reporting crude (cRR) or adjusted (aRR) relative risks of HIV acquisition by RAI practice among women. Of 27,563 articles identified, 17 eligible studies were included. We pooled independent study estimates using random-effects models. Women reporting RAI were more likely to acquire HIV than women not reporting RAI (pooled cRR = 1.56 95% CI 1.03–2.38, N = 18, I² = 72%; pooled aRR = 2.23, 1.01–4.92, N = 5, I² = 70%). In subgroup analyses the association was lower for women in Africa (pooled cRR = 1.16, N = 13, I² = 21%) than outside Africa (pooled cRR = 4.10, N = 5, I² = 79%) and for high-risk (pooled aRR = 1.69, N = 4, I² = 63%) than general-risk women (pooled aRR = 8.50, N = 1). Interview method slightly influenced cRR estimates (p value = 0.04). In leave-one-out sensitivity analyses pooled estimates were generally robust to removing individual study estimates. Main limitations included poor exposure definition, incomplete adjustment for confounders, particularly condom use, and use of non-confidential interview methods. More and better data are needed to explain differences in risk by world region and risk population. Women require better counselling and greater choice in prevention modalities that are effective during RVI and RAI.

Randomized Trial of a Health Coaching Intervention to Enhance Retention in Care: California Collaborative Treatment Group 594

Poor linkage, engagement and retention remain significant barriers in achieving HIV treatment goals in the US. HIV-infected persons entering or re-entering care across three Southern California academic HIV clinics, were randomized (1:1) to an Active, Linkage, Engagement, Retention and Treatment (ALERT) specialist for outreach and health coaching, or standard of care (SOC). The primary outcome of time to loss to follow up (LTFU) was compared using Cox proportional hazards regression modeling. No differences in the median time to LTFU (81.7 for ALERT versus 93.6 weeks for SOC; HR 1.27; p = 0.40), or time to ART initiation was observed (N = 116). Although, ALERT participants demonstrated worsening depressive symptomatology from baseline to week 48 compared to SOC (p = 0.02). The ALERT intervention did not improve engagement and retention in HIV care over SOC. Further studies are needed to determine how best to apply resources to improve retention and engagement.

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 impact of illustrated side effect information on understanding and sustained retention of antiretroviral side effect knowledge

BACKGROUND

Prompt management of side effects is critical to supporting adherence to antiretroviral (ARV) medication.

OBJECTIVE

This study examines the impact of presenting side effect information using simple text combined with pictograms on sustained knowledge of ARV side effects over three months.

METHOD

Previously designed side effect pictograms, combined with simple text, were incorporated into a side effects panel within an ARV information leaflet. In a randomised controlled study, 116 limited literacy HIV patients taking ARVs were randomly allocated to either control (standard care) or intervention groups (standard care plus illustrated information). Side effect knowledge was assessed at baseline, and intervention patients received the illustrated leaflet. Knowledge was re-tested at one and three months. Interpretation of side effect pictograms was evaluated at one month.

RESULTS

In intervention patients, mean side effect knowledge increased from 45.9% (baseline) to 95.7% (three months; p<0.0001), and pictogram interpretation was good. Knowledge did not change significantly in the control group. All found the pictograms clear and useful, and endorsed their routine use.

CONCLUSIONS

Providing patients with simple written information containing pictograms on ARV side effects significantly improved side effect knowledge, sustained over time, in limited literacy, rural South African HIV patients.

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.

Assessment of information resources for people with hypodontia

Aim:

To assess the adequacy of patient information to support understanding and decision-making for people affected by hypodontia.

Methods:

1) Questionnaire to understand the provision of patient information by dentists; 2) Systematic search to identify online open-access patient information; 3) Quality assessment of written patient information.

Results:

Questionnaire response rate was 49% (319/649); 91% examined and/or treated people with hypodontia. Most general dentists referred patients to specialist services without providing written hypodontia information. The majority of dental specialists provide patient leaflets but less than a third used web-resources. Only 19% of respondents felt current resources were fit-for-purpose. Thirty-one patient resources (18 leaflets and 13 online) were assessed against quality criteria. The aim of the resource was seldom explicit, the content was often incomplete and variation in readability scores indicated high levels of literacy were required.

Discussion:

Access to, and quality of, patient information for hypodontia is inadequate. Current resources are not sufficiently comprehensive to prepare young patients to engage in shared dental care decisions with their parents and/or dental professionals.

Conclusion:

There is a need for improved access to, and provision of, information about hypodontia if dental professionals want to meet best practice guidance and involve patients in shared decision-making.

Design of instructions for evacuating disabled adults

We investigated how the design of instructions can affect performance in preparing emergency stair travel devices for the evacuation of disable individuals. We had three hypotheses: 1) Design of instructions would account for a significant portion of explained performance variance, 2) Improvements in design of instructions would reduce time on task across device type and age group, and 3) There would be a performance decrement for older adults compared to younger adults based on the slowing of older adult information processing abilities. Results showed that design of instructions does indeed account for a large portion of explained variance in the operation of emergency stair travel devices, and that improvements in design of instructions can reduce time on task across device type and age group. However, encouragingly for real-world operations, results did not indicate any significant differences between older versus younger adults. We look to explore ways that individuals with disabilities can exploit these insights to enhance the performance of emergency stair travel devices for use.

Lost in Translation: Language, Terminology, and Understanding of Penile-Anal Intercourse in an HIV Prevention Trial in South Africa, Uganda, and Zimbabwe

Despite efforts to use culturally appropriate, understandable terms for sexual behavior in HIV prevention trials, the way in which participants interpret questions is underinvestigated and not well understood. We present findings from qualitative interviews with 88 women in South Africa, Uganda, and Zimbabwe who had previously participated in an HIV prevention trial. Findings suggested that participants may have misinterpreted questions pertaining to penile-anal intercourse (PAI) to refer to vaginal sex from behind and subsequently misreported the behavior. Three key issues emerge from these findings: first, the underreporting of socially stigmatized sexual behaviors due to social desirability bias; second, the inaccurate reporting of sexual behaviors due to miscomprehension of research terms; and third, the ambiguity in vernacular terms for sexual behavior and lack of acceptable terms for PAI in some languages. These findings highlight methodological challenges around developing clear and unambiguous definitions for sexual behaviors, with implications not only for clinical trials but also for clinical practice and sexual risk assessment. We discuss the challenges in collecting accurate and reliable data on heterosexual PAI in Africa and make recommendations for improved data collection on sensitive behaviors.

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.

Older Adults with HIV/AIDS in Rural China

Although the number of older people living with HIV/AIDS (PLWHA) has increased substantially, few studies have focused on older PLWHA in developing countries. Based on a sample of 866 rural PLWHA in Henan, Anhui and Yunnan provinces in China, this study compares the characteristics of PLWHA aged 50 or older (n=185) with younger PLWHA (n=681). Most of the older PLWHA were female (n=112), illiterate, married and at the clinical stage of HIV. Over 90% of older people with HIV/AIDS lived in Henan and Anhui provinces. The severe epidemic in Henan and Anhui provinces was caused by commercial blood and plasma donation. Older PLWHA were less educated, received less social support and were more likely to live alone than younger PLWHA. The results underline the importance of developing programs and policy initiatives targeted at older people infected with HIV/AIDS. The policy and program recommendations include using a gender sensitive strategy, designing specific AIDS education and prevention programs suitable for low-literacy older adults and social support interventions for older PLWHA.