Pharmaceutical pictograms can be valuable in reinforcing information given to patients by other means, but they need to be culture-specific and carefully explained, according to speakers at an oral communications session of the International Pharmaceutical Federation's pharmacy information section on September 10 .
Dr MARTINA EHLERS (faculty of pharmacy, Rhodes university, South Africa) described research into whether pharmaceutical pictograms improved compliance in antibiotic therapy in the functionally illiterate.
The research had involved prescriptions for amoxicillin. It had used five pictograms adapted for local use from designs issued by the United States Pharmacopeial Convention. Three had indicated the frequency of dosage, the need to take the medicine on an empty stomach and the need to complete the course. The other two, used only on paediatric liquid formulations, had indicated the need to shake the bottle and the need to store the dispensed medicine in a cool place.
A control group of patients had received traditional labelling only and an experimental group had received traditional labelling plus pictograms. All patients had been counselled by the pharmacist, aided by an interpreter where necessary. The meaning of each pictogram had been explained to those in the experimental group.
All the patients had been visited at home without warning within five days of dispensing and assessed for their understanding of the dosage instructions, recall and compliance. All of those who had been given the pictograms had met a comprehension standard drawn up by the International Standards Organisation, compared with fewer than two-thirds of the control group. More than 80 per cent of the experimental group had met a standard for comprehension established by the American National Standards Institute, compared with fewer than 40 per cent of the control group.
Of those given the pictograms, more than 70 per cent had had a complete understanding of the information, compared with fewer than 20 per cent of the control group. Forty per cent of the pictogram group had achieved 100 per cent compliance, but none in the control group had done so.
Dr Ehlers concluded that pharmaceutical pictograms were valuable if used in an appropriate manner, ie, in combination with verbal and written reinforcement.
Dr ROS DOWSE, a colleague of Dr Ehlers, described research which had examined comprehension of a range of USPC pictograms, comparing them with local adaptations. She said that devising suitable pictograms required a good insight into, and good co-operation with, the target culture.
Looking at specific USPC pictograms, Dr Dowse said that only 58 per cent of respondents had correctly understood the "store in refrigerator" pictogram. The main problem had been the image's failure to convey clearly the idea of a refrigerator rather than just a cupboard. The food in the illustration had led some respondents to interpret it as an instruction to take the medicine before, with or after a meal. The Rx symbol, well known in the US, was not recognised at all.
The "take at bedtime" pictogram had been interpreted "correctly" by 88 per cent of respondents. However, it had not always conveyed the concept of night, and interpretations had included "take and lie down in a cool place" (ie, out of the sun). Some had seen the moon and star as an Islamic emblem. A revised version for local use omitted the star and used a black background to reinforce the concept of night-time.
Seventy-five per cent of respondents had "correctly" interpreted the USP pictogram for "take with meals", which showed a westernised place setting. Because it included an empty plate, one interpretation had been that one should not eat when taking the medicine. "Correct" interpretation had reached 94 per cent when the image was changed to an edge-on view of a heaped plate with a spoon.
The USP pictogram for "Do not drink alcohol while taking this medicine" was "correctly" interpreted by only 51 per cent of respondents. Correct interpretation had increased to 85 per cent with a redesign which included replacing the wine and beer glasses with bottles and a cardboard carton (the commonest container for beer sales in the communities surveyed).
Concluding, Dr Dowse said that the research had shown the need for pictograms to be adapted to the local culture. Only three out of 23 USP pictograms had met the ANSI standard. In contrast, 13 of the locally adapted versions had met the standard.
Work on the development of a symbolic (non-text) language for patients with literacy problems was described to the session by Mr MICHAEL MONTAGNE (Massachusetts college of pharmacy, United States). He said that the researchers (who had used the words "icon" rather than "pictogram") had developed and tested about 500 individual icons and about 50 icon sequences.
The research had involved individual testing and focus group feedback. Each icon had been classed as having high, moderate or low comprehension, with the standard for high comprehension being "correct" recognition by at least 85 per cent of respondents with no more than 5 per cent being critically confused. The researchers had found that very few icons scored high comprehension.
With icons for dosage form, only those for solid dosage achieved high comprehension. Others only met the moderate standard. Similar results were achieved with icons indicating quantity.
For route of administration, only oral route icons achieved a high level of comprehension. Others scored moderate or low.
In the case of warning messages, the only icons achieving a high level of comprehension were those that indicated dangers such as poisoning. Warnings about taking with liquids or avoiding alcohol achieved only moderate comprehension levels. Some side side effect warnings scored low.
Icons concerned with the timing of dosage were generally not well understood. Those indicating the frequency of dosage achieved moderate comprehension, but those indicating time of administration or duration of therapy were poorly understood.
The researchers found that sequences of icons were often more easily understood than single icons. The icon order could assist in comprehension, with preceding icons providing prompts or clues, particularly for familiar directions and phrases.
Suggestions for future work included pictogram testing in pharmacies with actual patients and the use of pictograms in pharmacist-guided counselling interventions.