Pictograms From the Developing World

There is a lot to learn from the developing world when it comes to communicating with patients. A lot of the developing world has difficulty with multiple languages and much of the population has low health literacy. In a number of studies, visual aids such as pictograms have been found to aid recall, comprehension and medications adherence which can be effective in enhancing understanding of post discharge instructions, particularly among low-literate patients [1-4]. Given the evidence, countries around the world have adopted pictograms to help improve their discharge processes.

At the Kasturba Hospital in Manipal, India, a group of researchers used pictograms to communicate information about the adverse effects of antiretroviral (ARV) therapy, particularly among the illiterate group. The team designed a set of 20 simple, culturally sensitive pictograms of adverse drug reactions (ADRs) to highly active antiretroviral therapy (HAART). They interviewed 50 hospitalized human immunodeficiency virus (HIV) positive patients on the ARV therapy who ranged from having no schooling to college level education. Results from their study suggest that the use of pictograms can be effective as a counseling tool to improve patient’s knowledge towards the side effects of ARV therapy, particularly among the illiterate and low-literate populations, as well as improve self-efficacy to deal with the challenges associated with adherence to their ARV management [5].

In South Africa, pictograms for prescription medication instructions been have been designed, developed and evaluated in areas with low-literate populations. In one study, the researchers adopted a multistage, iterative process to design a set of local pictograms to communicate medication information among the low-literate Xhosa population in the Eastern Cape--an economically poor region with low literacy rate. The concept of using pictograms to convey medication instructions to patients who could not read was explained. The team surveyed 46 black Xhosa respondents after and found that the use of pictograms were more successful over written text drug labels when communicating medication information. Participants demonstrated lower comprehension of their medication instructions when presented with the text labels. On the other hand, the use of pictograms increased accuracy in the interpretations of the medication instructions and also enhanced better recall among the respondents. The study concluded that the use of pictograms can be effective, particularly if they are developed in collaboration with the target population and cultural influences are taken into consideration [6].

The impacts of low health literacy affecting accurate interpretation and adherence to discharge medication prescriptions were also recognized as major challenges at the Services Hospital in Lahore, Pakistan—where nearly half (48%) of its patients were identified as being illiterate. In the paper, the study team found that an overwhelmingly majority (88% to 95%) of these illiterate patients struggled to interpret the written discharge prescriptions after leaving the hospital. The team redesigned the discharge medication prescription using pictographic images and symbols to convey the information. To evaluate the impacts of the redesigned pictorial discharge prescription, the team conducted a pre/post survey with 100 illiterate patients. Findings showed that the redesigned pictorial prescription instructions demonstrated large relative increases in patients’ comprehension of their medication discharge. Specifically, results indicated that 23%-35% of the participants (depending on the level of counselling given) understood their medication discharge instructions in comparison to 5%-12% of the group when they were given the text written discharge prescription [7].

Here are some existing pictograms of medication and follow up instructions. Let us know what you think of them. Should we use them? Should we change them? Share your thoughts with us!

How can we learn from this? How can we apply this to PODS? Share your thoughts with us!

[1] Dowse R, Ehlers M. Medicine labels incorporating pictograms: do they influence understanding and adherence? Patient Educ Couns. 2005; 58:63-70.

[2] Mansoor LE, Dowse R. Effect of pictograms on readability of patient information materials. Ann Pharmacother. 2003; 37:1003-9.

[3] Morrow DG, Hier CM, Menard WE et al. Icons improve older and younger adults’ comprehension of medication information. J Gerontol B Psychol Sci Soc Sci. 1998; 53B:P240-54.

[4]. Patel V, Eisemon T, Arocha J. Comprehending instructions for using pharmaceutical products in rural Kenya. Instr Sci.1990; 19:71-84.

[5] Dowse R, Ehlers MS. The evaluation of pharmaceutical pictograms in a low-literate South African population. Patient Educ Couns. 2001 Nov; 45(2):87-99.

[6] Rajesh, R, Vidyasagar, S, Varma, M et al. Design And Evaluation of Pictograms for Communicating Information about Adverse Drug reactions to Antiretroviral Therapy in Indian human Immunodeficiency Virus positive patients. Journal of Pharmaceutical and Biomedical Sciences. 2012; 16(10):1-11.

[7] Clayton M, Syed F, Rashid A, Fayyaz U. Improving illiterate patients understanding and adherence to discharge medications. BMJ Qual Improv Report 2012; 1:1 u496.w167.