Designing, Developing, and Validating a Set of Standardized Pictograms to Support Pediatric-Reported Gastroduodenal Symptoms

OBJECTIVE

To develop and validate a set of static and animated gastroduodenal symptom pictograms for children.

STUDY DESIGN

There were 3 study phases: 1: cocreation using experience design methods to develop pediatric gastroduodenal symptom pictograms (static and animated); 2: an online survey to assess acceptability, as well as face and content validity; and 3: a preference study. Phases 2 and 3 compared the novel pediatric pictograms with existing pictograms used with adult patients.

RESULTS

Eight children aged 6-15 years (5 female) participated in phase 1, and 69 children in phase 2 (median age 13 years: IQR 9-15); an additional 49 participants were included in phase 3 (median age 15: IQR 12-17). Face and content validity were higher for the pediatric static and animated pictogram sets compared with pre-existing adult pictograms (78% vs 78% vs 61%). Participants with worse gastric symptoms had superior comprehension of the pediatric pictograms (χ2 [8, N = 118] P < .001). All participants preferred the pediatric static pictogram set was over both the animated and adult sets (χ2 [2, N = 118] P < .001).

CONCLUSIONS

The cocreation phase resulted in the symptom concept confirmation and design of 10 acceptable static and animated gastroduodenal pictograms with high face and content validity when evaluated with children aged 6-18. Validity was superior when children reported more problematic symptoms. Therefore, these pictograms could be used in clinical and research practice to enable standardized symptom reporting for children with gastroduodenal disorders.

The Use of Pictograms in the Evaluation of Functional Abdominal Pain Disorders in Children

OBJECTIVE

To evaluate whether the use of pictograms improves symptom evaluation for children with functional abdominal pain disorders (FAPDs).

STUDY DESIGN

This survey study was conducted in 2 academic centers and included patients aged 8-18 years visiting the outpatient clinic for FAPD symptom evaluation. Patients were randomized to fill out the questionnaire without or with accompanying pictograms to assess gastrointestinal symptoms. Afterwards, patients underwent clinical health assessment by the healthcare professional (HCP). Subsequently, the HCP filled out the same questionnaire without pictograms, while blinded to the questionnaire completed by the patient. Primary outcome was the level of agreement between identified symptoms as assessed by patients and HCP.

RESULTS

We included 144 children (questionnaire without accompanying pictograms [n = 82] and with accompanying pictograms [n = 62]). Overall agreements rates were not significantly different (without pictograms median, 70% vs with pictograms median, 70%). Accompanying pictograms did not significantly improve the assessment of abdominal pain symptoms. Accompanying pictograms were beneficial for concordance rates for nausea and vomiting symptoms (without pictograms median, 67% vs with pictograms median, 100%; P = .047). Subgroup analyses for children aged 8-12 years of age revealed similar results (concordance on the presence of nausea and vomiting without pictograms median, 67% vs with pictograms median, 100%; P = .015). Subgroup analyses for children ages 12-18 years showed no significant differences in concordance rates.

CONCLUSIONS

Pictograms do not seem to improve the assessment of FAPDs. However, the use of pictograms improves the evaluation of nausea and vomiting, especially for children aged 8-12 years. Therefore, HCPs could consider using pictograms in that setting during consultations.

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.

Pharmacy students' opinion of the routine use of pharmaceutical pictograms on a health care train serving rural limited literacy patients

OBJECTIVES

To assess pharmacy student opinion of the routine use of pictograms for counselling and communicating medicine-related information.

METHODS

A Google Forms survey was sent to co-ordinators at five Pharmacy Schools who distributed the link to 152 students following their 5-day work placement. The survey included Likert Scale and open questions on prior pictogram exposure, their usefulness in practice and their design.

KEY FINDINGS

Opinion of pictogram usefulness in facilitating communication with patients was positive, with 104 (95.4%) rating their usefulness as good/excellent. Students noted language and low literacy as communication barriers which pictograms helped to mitigate. Only 24.8% (N = 27) reported that using pictograms required extra time during the dispensing process. Most students reported that patients liked the pictograms and found it easy to teach patients the pictogram meaning to clarify verbal and written medicine-related information. Pictograms were regarded by most students as simple, clear, culturally acceptable and able to communicate their core message clearly. A third agreed that they should have additional detail and be more realistic, some offered suggestions for modification. Many suggested expanding pictogram use to primary care clinics and hospitals.

CONCLUSIONS

This study presents unique finding relating to the role and value of pictograms in practice. Opinion of routine pictogram use was largely positive, particularly given significant language and literacy barriers in this rural population. The extra time taken using pictograms was generally not regarded as a barrier to their adoption. Pictogram quality and design were considered to be good, with expanded use of pictograms suggested.

Pictograms to assess bloating and distension symptoms in the general population in Mexico: Results of The Rome Foundation Global Epidemiology Study

BACKGROUND

There is no term for bloating in Spanish and distension is a very technical word. "Inflammation"/"swelling" are the most frequently used expressions for bloating/distension in Mexico, and pictograms are more effective than verbal descriptors (VDs) for bloating/distension in general GI and Rome III-IBS patients. However, their effectiveness in the general population and in subjects with Rome IV-DGBI is unknown. We analyzed the use of pictograms for assessing bloating/distension in the general population in Mexico.

METHODS

The Rome Foundation Global Epidemiology Study (RFGES) in Mexico (n = 2001) included questions about the presence of VDs "inflammation"/"swelling" and abdominal distension, their comprehension, and pictograms (normal, bloating, distension, both). We compared the pictograms with the Rome IV question about the frequency of experiencing bloating/distension, and with the VDs.

KEY RESULTS

"Inflammation"/"swelling" was reported by 51.5% and distension by 23.8% of the entire study population; while 1.2% and 25.3% did not comprehend "Inflammation"/"swelling" or distension, respectively. Subjects without (31.8%) or not comprehending "inflammation"/"swelling"/distension (68.4%) reported bloating/distension by pictograms. Bloating and/or distension by the pictograms were much more frequent in those with DGBI: 38.3% (95%CI: 31.7-44.9) vs. without: 14.5% (12.0-17.0); and in subjects with distension by VDs: 29.4% (25.4-33.3) vs. without: 17.2% (14.9-19.5). Among subjects with bowel disorders, those with IBS reported bloating/distension by pictograms the most (93.8%) and those with functional diarrhea the least (71.4%).

CONCLUSIONS & INFERENCES

Pictograms are more effective than VDs for assessing the presence of bloating/distension in Spanish Mexico. Therefore, they should be used to study these symptoms in epidemiological research.

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.

Pictograms are more effective than verbal descriptors in Spanish for bloating and distension

BACKGROUND

There is no translation for bloating in Spanish, and distension is very technical.

AIMS

To evaluate pictograms for assessing bloating/distension in patients with general gastroenterology (Study 1, n = 88) and in those with irritable bowel syndrome [IBS] (Study 2: n = 144), and to correlate them with verbal descriptors (VDs) and physician's diagnosis (PDx).

METHODS

Patients answered the Rome III Questionnaire with VDs and pictograms, and were consulted by two gastroenterology fellows (PDx). Correlations were conducted with Cohen's kappa, and ROC curves were used to contrast pictograms and VDs with PDx.

RESULTS

"Inflammation" was the most frequent VDs, while distension was commonly interpreted as a sensation ("inflammation") and/or increased abdominal girth. In patients not reporting bloating/distension with VDs, pictograms detected these symptoms in (Study 1 and Study 2) 82.2 and 89.6% of patients. In addition, pictograms showed a positive agreement with PDx, kappa: 0.63 (p < 0.0001) and 0.8 (p < 0.0001); and a negative agreement with VD, kappa: -0.45 (p = 0.05) and -0.1 (p = 0.2), respectively, in studies 1 and 2. Pictograms were more sensitive and specific than VDs (Study 1: ROC = 0.90 (95% CI: 0.80-0.96), p < 0.0001 versus 0.74 (0.62-0.88), p < 0.0001; Study 2: 0.99 (0.98-1.00), p = 0.004 versus 0.32 (0.10-0.54), p = 0.294).

CONCLUSIONS

Pictograms are more effective than Spanish VDs for bloating/distension in patients consulting for gastroenterology problems and those with IBS, supporting their usefulness in the clinic and research studies.

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.

Farmers' behavior in reading and using risk information displayed on pesticide labels: a test with the theory of planned behavior

BACKGROUND

Labels are the first source of information for the safe use of pesticides, but farmers rarely read labels before pesticide use. Using data from a sample of 300 orchard farmers in Meshginshar County, Iran, this study examined farmers' intention and behavior in reading and using risk information displayed on pesticide labels, using the theory of planned behavior (TPB).

RESULTS

Only 26% of the respondents mentioned that they read pesticide labels. Most farmers showed a low tendency towards reading pesticide labels due to low education, advanced age, and label-related problems, i.e., use of too technical language and unclear texts with small and illegible fonts. From the three basic variables of the TPB, subjective norms and perceived behavioral control (PBC) showed a significant impact on intention, while attitudes showed no significant impact. The three main variables of the TPB explained 90.2% of the variance in farmers' intention to read and use the labels. Furthermore, PBC and intention significantly affected farmers' actual behavior in reading and using the labels, explaining 78.5% of the variance in farmers' actual behavior. Age, experience in farming, and experience in spraying were negatively correlated with all variables of the TPB.

CONCLUSION

Findings provide new insights into farmers' behavior in reading pesticide labels by using for the first time the TPB. Pesticide manufacturers should consider the special conditions of subsistence farmers (low education and advanced age) when preparing pesticide labels and the extension services could use those findings to improve farmers' training in the use of pesticide labels. © 2021 Society of Chemical Industry.

Investigation of Radiation Safety Pictogram Recognition in Daily Life

After the Fukushima Daiichi nuclear accident of 2011, interest regarding radiation safety in everyday life has increased considerably. This study investigates the general public’s current level of awareness of six warning pictograms in regard to medical and natural radiation safety utilized under ISO 7010, as per Korea industrial regulations. Namely, it tests whether survey respondents can recognize pictograms related to radiation safety according to their purpose, as their inability to do so poses a serious safety problem. The empirical analysis results regarding the awareness levels for radiation safety pictograms are as follows. First, 63.3% of the respondents were unable to correctly identify the pictograms; that is, their level of understandings of the six pictograms related to everyday radiation were low. Second, the mean score for the correct responses to the question of what the six pictograms indicated in relation to everyday radiation safety was also relatively low, with a mean score of 2.79 and a standard deviation of 1.447. The primary reasons for the low awareness and understanding levels were identified to be insufficient education related to radiation safety in schools. Additionally, it is necessary to revise and rectify current warning pictograms established by the Korea Industrial Standards and ISO 7010. This study is thus significant in that it identifies the level of understanding of the pictograms and suggests the need for improvement as a diversified effort toward improving everyday radiation safety.

Factors associated with serious vehicular accidents: A cross-sectional study in hospital emergency rooms

AIMS

Pictograms on medicine boxes warn of potential drug-related driving hazard; we studied their association with serious accidents.

METHODS

Prospective study in emergency departments of the hospitals in Bordeaux and Périgueux (France), of drivers with serious (admitted at least 24 hours) or nonserious vehicular accidents. Minors, passengers, pedestrians or subjects incapable of answering an interview were excluded. Interviews ascertained driver and accident characteristics, use of drugs with or without pictograms, use of alcohol and abuse substances, sleepiness, distractions, and mind wandering at the time of the accident, RESULTS: Between 18 October 2016 and 26 December 2018, 1200 of the 6212 drivers admitted to the hospital emergency rooms, 741 nonserious, 459 serious, were interviewed. Serious accidents were associated with male sex (odds ratio 1.89, 95% confidence interval [1.36-2.64]), age above 60 years (3.64 [2.21-6.00]), driving on local roads (3.34 [2.34-4.76]), driving a motorcycle (3.39 [2.29-5.00]), having drunk alcohol within 6 hours (2.89 [1.85-4.51]) and using a drug with a pictogram during the 24 hours previous to the accident (1.57 [1.06-2.32]). From 207 police reports, 101 drivers were not responsible, and 106 were responsible, associated with age below 40 years, driving in overcast or rainy weather (2.62 [1.29-5.33]), on local roads (3.89 [1.90-7.95]), and use of at least 1 pictogram drug in the previous week (3.12 [1.31-7.41]).

CONCLUSION

The known risks of alcohol and pictogram drugs, of riding motorcycles and using local roads were confirmed. As measured, behavioural sleepiness did not predict accidents.

Outcome of illustrated information leaflet on correct usage of asthma-metered dose inhaler

Background

Research globally has shown that metered dose inhaler (MDI) technique is poor, with patient education and regular demonstration critical in maintaining correct use of inhalers. Patient information containing pictorial aids improves understanding of medicine usage; however, manufacturer leaflets illustrating MDI use may not be easily understood by low-literacy asthma patients.

Aim

To develop and evaluate the outcome of a tailored, simplified leaflet on correct MDI technique in asthma patients with limited literacy skills.

Setting

A rural primary health care clinic in the Eastern Cape, South Africa.

Methods

Pictograms illustrating MDI steps were designed to ensure cultural relevance. The design process of the leaflet was iterative and consultative involving a range of health care professionals as well as patients. Fifty-five rural asthma patients were recruited for the pre-post design educational intervention study. Metered dose inhaler technique was assessed using a checklist, and patients were then educated using the study leaflet. The principal researcher then demonstrated correct MDI technique. This process was repeated at follow-up 4 weeks later.

Results

The number of correct steps increased significantly post intervention from 4.6 ± 2.2 at baseline to 7.9 ± 2.7 at follow-up (p < 0.05). Statistically significant improvement of correct technique was established for 10 of the 12 steps. Patients liked the pictograms and preferred the study leaflet over the manufacturer leaflet.

Conclusion

The tailored, simple, illustrated study leaflet accompanied by a demonstration of MDI technique significantly increased correct MDI technique in low-literacy patients. Patients approved of the illustrated, simple text leaflet, and noted its usefulness in helping them improve their MDI technique.

Emergency, Pictogram-Based Augmented Reality Medical Communicator Prototype Using Precise Eye-Tracking Technology

This article details the process involved in the development of a new and revolutionary solution for medical communication. Our solution precisely tracks head and eye movement and allows the user to interact with an intuitive, pictogram-based interface. Around the world, many people rely on written instruction and verbal or nonverbal communication to accompany medication or provide additional information on a patient's symptoms. However, poor language skills and a host of health problems, psychological disorders, and trauma can limit a person's ability to speak or move. Our solution could drastically improve the quality of life of patients suffering from brain injury, hearing loss, and many other communication disorders and disabilities. They can begin to communicate with greater ease and fluency, feel connected to the world, and experience better and more accurate medical care. The potential applications have many incredible advantages, ranging from improved communication with family to emergency medical uses that can save the life of an affected individual. The use of augmented reality in our solution, as well as the secondary camera to improve accuracy in eye tracking, makes this solution for more accuracy, whereas the inclusion of a pictogram-based interface makes it a practical solution that cuts down on the error margins of traditional accessibility devices and makes it equally accessible to children and speakers of foreign languages. According to the data gathered, we confirm that the solution we propose has many possible practical applications in improving the health, safety, and quality of life of the user.

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.

Validation of Pictograms for Safer Handling of Medications: Comprehension and Recall among Pharmacy Students

BACKGROUND

Medication preparation and administration are higher-risk steps in the medication management process. Therefore, medication management strategies, such as warnings and education about medication safety, are essential in preventing errors and improving the safe handling of medications by health care workers.

OBJECTIVES

To validate comprehension of 9 pictograms designed to improve medication safety, and to assess long-term recall of these pictograms in a sample of pharmacy students.

METHODS

First- and second-year pharmacy students were recruited as participants. The study was divided into 2 phases: comprehension (Phase 1) and long-term recall (Phase 2). In Phase 1, a slideshow of the 9 pictograms was presented to participants, who were asked to write the meaning of and required action for each pictogram. The intended meaning of each pictogram was then presented to the participants. Four weeks later, long-term recall was assessed in Phase 2 of the study using the same method. The meaning and required action that participants provided for each pictogram were reviewed by 3 independent raters. A pictogram was considered to be validated in the pharmacy student population if at least 67% of participants identified the correct meaning or required action during the recall phase.

RESULTS

A total of 101 pharmacy students participated in Phase 1 and 67 in Phase 2. In Phase 1, 4 pictograms met the 67% threshold for comprehension. In Phase 2, after training, 7 of the 9 pictograms were validated.

CONCLUSIONS

Given the results obtained with pharmacy students, redesign may be necessary for 2 of the pictograms. The use of validated medication safety pictograms on medication labels and other identifiers may prevent errors during medication handling and administration; this is an important avenue of investigation for future studies.

Development of Pictograms to Enhance Medication Safety Practices of Health Care Workers and International Preferences

BACKGROUND

A panel of medication management experts previously identified 9 key medication safety issues and high-alert drug classes as representing the most pressing medication-handling issues in health care.

OBJECTIVE

To develop medication safety pictograms depicting medication safety issues and high-alert drug classes that represent medication-handling risks for health care personnel.

METHODS

An iterative design process, including activities such as semiotic analysis, design/redesign, and evaluation, was used to develop medication safety pictograms. Nurses, physicians, pharmacists, and students listed and drew graphic elements to depict each of the 9 key medication safety issues. Graduate students in graphic design developed the preliminary pictograms for the study. A Delphi survey was then conducted with experts recruited from the International Pharmaceutical Federation to reach consensus on the pictograms and provide feedback to the graphic designers. Health care providers from around the world were invited to participate in a survey to determine a preferred pictogram for each safety warning.

RESULTS

For each medication safety issue, 3 to 5 pictograms were developed on the basis of graphic elements suggested by 52 health care providers. These pictograms were then presented to 58 experts in 2 rounds of a Delphi process. For each medication safety issue, consensus on the 2 best pictograms was reached and feedback provided. A total of 799 participants from 61 countries responded to the international preference survey. Most of the participants (n = 536, 67.1%) were Canadian, and of those, 385 (71.8%) were pharmacists. In 8 categories, consensus on the preferred pictogram was reached across the health care professions; however, a difference in preference was apparent for the pictogram representing "neuromuscular blocking agent", with nurses' preferred pictogram differing from the preference of other participants.

CONCLUSION

This project produced pictograms to illustrate 9 important medication safety issues, which can now be validated through comprehension and recall assessments. Further study can also determine their potential to reduce medication administration errors.

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

Background:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

Creating a better picture of chronic pain: improving pain pictogram designs through systematic evaluation of user responses

This article discusses the challenges of visually representing pain qualities in pictogram design. An existing set of 12 pictograms designed for people with literacy problems was evaluated to understand more about misunderstandings of pictogram interpretation. Two sets of university students from different disciplines were asked to interpret the pictograms, and a novel classification system was developed to categorise answer types, as 'location', 'affective', temporal' or 'literal'. Several design recommendations are made as a result that will help improve the design of pain pictograms as a whole as well as guide designers of related pictogram work. We demonstrate how, through the robust classification of incorrect responses, it is possible to extract useful comprehension error patterns to inform future design.

Design and validation of pictograms in a pediatric anaphylaxis action plan

BACKGROUND

Current anaphylaxis action plans (AAPs) are based on written instructions without inclusion of pictograms.

OBJECTIVES

To develop an AAP with pictorial aids and to prospectively validate the pictogram components of this plan.

METHODS

Participants recruited from the emergency department and allergy clinic participated in a questionnaire to validate pictograms depicting key counseling points of an anaphylactic reaction. Children ≥ 10 years of age and caregivers of children < 10 years with acute anaphylaxis or who carried epinephrine auto-injector for confirmed allergy were eligible. Guessability, translucency, and recall were assessed for 11 pictogram designs. Pictograms identified as correct or partially correct by at least 85% of participants were considered valid. Three independent reviewers assessed these outcome measures.

RESULTS

Of the 115 total participants, 73 (63%) were female, 76 (66%) were parents/guardians, and 39 (34%) were children aged 10-17. Overall, 10 pictograms (91%) reached ≥ 85% for correct guessability, translucency, and recall. Four pictograms were redesigned to reach the preset validation target. One pictogram depicting symptom management (5-min wait time after first epinephrine treatment) reached 82% translucency after redesign. However, it reached 98% and 100% of correct guessability and recall, respectively.

CONCLUSIONS

We prospectively designed and validated a set of pictograms to be included in an AAP. The incorporation of validated pictograms into an AAP may potentially increase comprehension of the triggers, signs and symptoms, and management of an anaphylactic reaction.

Simple, illustrated medicines information improves ARV knowledge and patient self-efficacy in limited literacy South African HIV patients

Few studies have investigated antiretroviral (ARV) knowledge and self-efficacy in limited literacy patients. Using a randomized controlled study design, we investigated the influence of a simple pre-tested patient information leaflet (PIL) containing both text and illustrations on HIV- and ARV-related knowledge and on self-efficacy over six months in a limited literacy African population. The recruited patients were randomly allocated to either control (standard care) or intervention group (standard care plus illustrated PIL). HIV and medicines-related knowledge was evaluated with a 22-question test at baseline, one, three, and six months. Self-efficacy was assessed using a modified version of the HIV Treatment Adherence Self-Efficacy Scale. Two-thirds of the patients were female, mean age was 39.0 ± 9.6 years and mean education was 7.3 ± 2.8 years. Patients who received the PIL showed a significant knowledge increase over the six-month period (62.0-94.4%), with improvement at each subsequent interview whereas the control group showed no improvement. At baseline, side effect knowledge was the lowest (50-56%) but increased in the intervention group to 92%. Similarly, other medicine-related knowledge at baseline (57-67%) improved significantly (93%) and was sustained over six months. Cohen's d values post-baseline ranged between 1.36 and 2.18, indicating a large intervention effect. Self-efficacy improved significantly over six months in intervention but not control patients. At baseline, patients with ≤ 3 years of education had lower knowledge and self-efficacy but this was not observed post-intervention, which we attribute to the PIL mitigating the effect of limited education. Knowledge and self-efficacy were significantly correlated in the intervention group. In conclusion, a low-cost intervention of a well-designed, pre-tested, simple, illustrated PIL significantly increased both ARV knowledge and self-efficacy in HIV patients with limited education.

Understanding of pictograms from the United States Pharmacopeia Dispensing Information (USP-DI) among elderly Brazilians

OBJECTIVE

To assess the understanding and cultural acceptability of the United States Pharmacopeia Dispensing Information (USP-DI) in a group of elderly Brazilians.

METHODS

The study participants were individuals between 60 and 90 years old, of both sexes, with different levels of education and income. Fifteen of 81 pictograms from the USP-DI were presented to the elderly subjects, individually, without subtitles and in random order, so that the participants' understanding of the pictograms could be evaluated.

RESULTS

The study included 116 participants. Only one of the selected pictograms reached the comprehension criterion established by the International Organization for Standardization 3864. With regard to the relationship between understanding and sociodemographic characteristics, age, wage income, and level of education were all found to be significantly associated with participants' understanding of some of the pictograms.

CONCLUSION

Most of the USP-DI pictograms evaluated were not well understood by the elderly Brazilians. This finding indicates that such pictograms need to be culturally adapted for the Brazilian context if they are to serve their purpose effectively in this country.

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.