Pharmaceutical Pictograms: an opportunity for Health Literacy?
DOI:
https://doi.org/10.30827/ars.v63i3.23979Keywords:
“health education”; illustrated leaflet; “visual aid”; pictogramsAbstract
Introduction: Instructional material for the use of medicines is often unreadable by the patient, especially if he or she is poorly literate in Health. This alleviates the need for alternatives to the traditional leaflets. The aim of this work was to review the available evidence on the pictograms as a tool leading to the rational use of medicines.
Method: A search was carried out for articles that considered studies of the communicative efficacy of pharmaceutical pictograms from Scopus, Web of Science and Medline through PubMed.
Results: 24 studies were identified with the inclusion criteria applied. 10 of the 12 randomized controlled studies obtained results favorable to the inclusion of pictograms. Cross-sectional studies explored the importance of cultural or educational context. All longitudinal studies obtained positive results after follow-up, which could be explained by prior knowledge.
Conclusions: Pictograms are a simple, economical tool with a high potential to improve the use of medication.
Downloads
References
O’Toole JK, Alvarado-Little W, Ledford CJW. Communication with Diverse Patients: Addressing Culture and Language. Pediatr Clin North Am. 2019;66(4):791-804. DOI: 10.1016/j.pcl.2019.03.006
Barros IMC, Alcântara TS, Mesquita AR, Santos ACO, Paixão FP, Lyra DP. The use of pictograms in the health care: a literature review. Res Social Adm Pharm. 2014;10(5):704-19. DOI: 10.1016/j.sapharm.2013.11.002
Patel HK, Bapat SS, Bhansali AH, Sansgiry SS. Development of Prescription Drug Information Leaflets: Impact of Cognitive Effort and Patient Involvement on Prescription Medication Information Processing. Ther Innov Regul Sci. 2018;52(1):118-29. DOI: 10.1177/2168479017716714
Wittink H, Oosterhaven J. Patient education and health literacy. Musculoskelet Sci Pract. 2018;38:120-7. DOI: 10.1016/j.msksp.2018.06.004
Garcia-Retamero R, Cokely ET. Designing Visual Aids That Promote Risk Literacy: A Systematic Review of Health Research and Evidence-Based Design Heuristics. Hum Factors. 2017;59(4):582-627. DOI: 10.1177/0018720817690634
Gazmararian JA, Curran JW, Parker RM, Bernhardt JM, DeBuono BA. Public health literacy in America: an ethical imperative. Am J Prev Med. 2005;28(3):317-22. DOI: 10.1016/j.amepre.2004.11.004
Ashrafi-Rizi H, Shahrzadi L, Dehghani-Champiri Z. Identification of patients’ rights to benefit from consumer health information services: A Delphi study. J Educ Health Promot. 2019;8:102. DOI: 10.4103/jehp.jehp_18_19
Periyakoil VS. Building a Culturally Competent Workforce to Care for Diverse Older Adults: Scope of the Problem and Potential Solutions. Journal of the American Geriatrics Society. 2019;67(S2):S423-32. DOI: 10.1111/jgs.15939
Faus Dáder MJ, Amariles Muñoz P, Martínez-Martínez. Atención Farmacéutica: Conceptos, procesos y casos prácticos. Barcelona: ERGON; 2007. 208 p.
Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, et al. Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health. 2012;12:80. DOI: 10.1186/1471-2458-12-80
Lindquist LA, Go L, Fleisher J, Jain N, Friesema E, Baker DW. Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications. J Gen Intern Med. 2012;27(2):173-8. DOI: 10.1007/s11606-011-1886-3
Wali H, Hudani Z, Wali S, Mercer K, Grindrod K. A systematic review of interventions to improve medication information for low health literate populations. Res Social Adm Pharm. 2016;12(6):830-64. DOI: 10.1016/j.sapharm.2015.12.001
Mbanda N, Dada S, Bastable K, Ingalill G-B, Ralf W S. A scoping review of the use of visual aids in health education materials for persons with low-literacy levels. Patient Educ Couns. 2021;104(5):998-1017. DOI: 10.1016/j.pec.2020.11.034
Mafruhah OR, Huang Y-M, Shiyanbola OO, Shen G-L, Lin H-W. Ideal instruments used to measure health literacy related to medication use: A systematic review. Res Social Adm Pharm. 2021;S1551-7411(21)00040-1. DOI: 10.1016/j.sapharm.2021.01.017
Wolf MS, Davis TC, Curtis LM, Bailey SC, Knox JP, Bergeron A, et al. A Patient-Centered Prescription Drug Label to Promote Appropriate Medication Use and Adherence. J Gen Intern Med. 2016;31(12):1482-9. DOI: 10.1007/s11606-016-3816-x
Cohen AK, Syme SL. Education: a missed opportunity for public health intervention. Am J Public Health. 2013;103(6):997-1001. DOI: 10.2105/AJPH.2012.300993
Sigle S, Barriga P, Correa Fernández FJ, Juhra C, Härtel S, Fegeler C. Evaluating Online Consumer Medication Information Systems: Comparative Online Usability Study. JMIR Mhealth Uhealth. 2020;8(6):e16648. DOI: 10.2196/16648
WHO. Health Promotion Glossary [Internet]. Geneve: World Health Organization; 1998 p. 36. Report No.: WHO/HPR/HEP/98.1. Disponible en: https://www.who.int/healthpromotion/about/HPR%20Glossary%201998.pdf
Young A, Tordoff J, Smith A. «What do patients want?» Tailoring medicines information to meet patients’ needs. Res Social Adm Pharm. 2017;13(6):1186-90. DOI:10.1016/j.sapharm.2016.10.006
Medina-Córdoba M, Cadavid S, Pérez-Acosta AM, Amaya-Giraldo V. Factors that Facilitate and Hinder the Comprehension of Patient Information Leaflets (PILs): A Brief Scoping Review. Frontiers in Pharmacology. 2021;12. DOI: 10.1016/j.sapharm.2019.02.013
van Beusekom MM, Kerkhoven AH, Bos MJW, Guchelaar H-J, van den Broek JM. The extent and effects of patient involvement in pictogram design for written drug information: a short systematic review. Drug Discov Today. 2018;23(6):1312-8. DOI: 10.1016/j.sapharm.2019.02.013
Ciciriello S, Johnston RV, Osborne RH, Wicks I, deKroo T, Clerehan R, et al. Multimedia educational interventions for consumers about prescribed and over-the-counter medications. Cochrane Database Syst Rev. 2013;(4):CD008416. DOI: 10.1002/14651858.CD008416.pub2
Merks P, Świeczkowski D, Balcerzak M, Drelich E, Białoszewska K, Cwalina N, et al. The evaluation of pharmaceutical pictograms among elderly patients in community pharmacy settings - a multicenter pilot study. Patient Prefer Adherence. 2018;12:257-66. DOI: 10.2147/PPA.S150113
Fuchs J. Design Science with a Focus on User-Centred Evaluation of Written Information. En: Bahri P, editor. Communicating about Risks and Safe Use of Medicines: Real Life and Applied Research [Internet]. Singapore: Springer; 2020 [citado 20 de enero de 2022]. p. 333-84. Disponible en: https://doi.org/10.1007/978-981-15-3013-5_12
Wilson EAH, Wolf MS. Working memory and the design of health materials: a cognitive factors perspective. Patient Educ Couns. 2009;74(3):318-22. DOI: 10.1016/j.pec.2008.11.005
Wolpin SE, Nguyen JK, Parks JJ, Lam AY, Morisky DE, Fernando L, et al. Redesigning pictographs for patients with low health literacy and establishing preliminary steps for delivery via smart phones. Pharmacy Practice (Granada). 2016;14(2):0-0. DOI:10.18549/PharmPract.2016.02.686
Paivio A. Imagery and verbal processes. New York: Holt, Rinehart & Winston; 1971.
Ishikawa H, Yano E. Patient health literacy and participation in the health-care process. Health Expect. 2008;11(2):113-22. DOI: 10.1111/j.1369-7625.2008.00497.x
Freedman DA, Bess KD, Tucker HA, Boyd DL, Tuchman AM, Wallston KA. Public health literacy defined. Am J Prev Med. 2009;36(5):446-51. DOI: 10.1016/j.amepre.2009.02.001
Rungsriwattana V, Ngamchaliew P, Buathong N. Effects of Pharmaceutical Pictograms on Medication Adherence in Elderly Patients with Chronic Diseases at Primary Health Care Center in Hat Yai, Songkhla. Journal of the Medical Association of Thailand. 2021;104(3):482-8.
Merks P, Świeczkowski D, Balcerzak M, Drelich E, Białoszewska K, Cwalina N, et al. Patients’ Perspective And Usefulness Of Pictograms In Short-Term Antibiotic Therapy - Multicenter, Randomized Trial. Patient Prefer Adherence. 2019;13:1667-76. DOI: 10.2147/PPA.S214419
Phimarn W, Ritthiya L, Rungsoongnoen R, Pattaradulpithuk W, Saramunee K. Development and Evaluation of a Pictogram for Thai Patients with Low Literate Skills. Indian Journal of Pharmaceutical Sciences. 2019;81(1):89-98. DOI: 10.4172/pharmaceutical-sciences.1000483
Ng AWY, Chan AHS, Ho VWS. Comprehension by older people of medication information with or without supplementary pharmaceutical pictograms. Appl Ergon. enero de 2017;58:167-75. DOI: 10.1016/j.apergo.2016.06.005
Chan H-K, Hassali MA. Modified labels for long-term medications: influences on adherence, comprehension and preferences in Malaysia. Int J Clin Pharm. 2014;36(5):904-13. DOI: 10.1007/s11096-014-0003-1
Dowse R, Barford K, Browne SH. Simple, illustrated medicines information improves ARV knowledge and patient self-efficacy in limited literacy South African HIV patients. AIDS Care. 2014;26(11):1400-6. DOI: 10.1080/09540121.2014.931559
King SR, McCaffrey DJ, Bentley JP, Bouldin A, Hallam J, Wilkin NE. The influence of symbols on the short-term recall of pharmacy-generated prescription medication information in a low health literate sample. J Health Commun. 2012;17 Suppl 3:280-93. DOI: 10.1080/10810730.2012.712620
Wilby K, Marra CA, da Silva JH, Grubisic M, Harvard S, Lynd LD. Randomized controlled trial evaluating pictogram augmentation of HIV medication information. Ann Pharmacother. 2011;45(11):1378-83. DOI: 10.1345/aph.1Q091
Braich PS, Almeida DR, Hollands S, Coleman MT. Effects of pictograms in educating 3 distinct low-literacy populations on the use of postoperative cataract medication. Can J Ophthalmol. 2011;46(3):276-81. DOI: 10.1016/j.jcjo.2011.05.004
Yin HS, Dreyer BP, van Schaick L, Foltin GL, Dinglas C, Mendelsohn AL. Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among caregivers of young children. Arch Pediatr Adolesc Med. 2008;162(9):814-22. DOI: 10.1001/archpedi.162.9.814
Mansoor L, Dowse R. Written medicines information for South African HIV/AIDS patients: does it enhance understanding of co-trimoxazole therapy? Health Educ Res. 2007;22(1):37-48. DOI: 10.1093/her/cyl039
Dowse R, Ehlers M. Medicine labels incorporating pictograms: do they influence understanding and adherence? Patient Educ Couns. 2005;58(1):63-70. DOI:10.1016/j.pec.2004.06.012
Mansoor LE, Dowse R. Effect of pictograms on readability of patient information materials. Ann Pharmacother. 2003;37(7-8):1003-9. DOI: 10.1345/aph.1C449
Barros IM, Alcântara TS, Mesquita AR, Bispo ML, Rocha CE, Moreira VP, et al. Understanding of pictograms from the United States Pharmacopeia Dispensing Information (USP-DI) among elderly Brazilians. Patient Prefer Adherence. 2014;8:1493-501. DOI: 10.2147/PPA.S65301
Knapp P, Raynor DK, Jebar AH, Price SJ. Interpretation of medication pictograms by adults in the UK. Ann Pharmacother. 2005;39(7-8):1227-33. DOI: 10.1345/aph.1E483
Hämeen-Anttila K, Kemppainen K, Enlund H, Bush Patricia J, Marja A. Do pictograms improve children’s understanding of medicine leaflet information? Patient Educ Couns. 2004;55(3):371-8. DOI: 10.1016/j.pec.2003.04.006
Vaillancourt R, Giby CN, Murphy BP, Pouliot A, Trinneer A. Recall of Pharmaceutical Pictograms by Older Adults. Can J Hosp Pharm. 2019;72(6):446-54.
Almomani BA, Mokhemer E, Al-Sawalha NA, Momany SM. A novel approach of using educational pharmaceutical pictogram for improving inhaler techniques in patients with asthma. Respir Med. 2018;143:103-8. DOI: 10.1016/j.rmed.2018.09.004
Joshi Y, Kothiyal P. A pilot study to evaluate pharmaceutical pictograms in a multispecialty hospital at dehradun. J Young Pharm. 2011;3(2):163-6. DOI:10.4103/0975-1483.80306
Merks P, Świeczkowski D, Balcerzak M, Religioni U, Drelich E, Krysiński J, et al. Patient counselling service with the use of pictograms as the example of pharmacist intervention to improving compliance and medicine safety. Cardiol J. 2021;28(6):879-86. DOI:10.5603/CJ.a2021.0022
Gebreyohannes EA, Bhagavathula AS, Abegaz TM, Abebe TB, Belachew SA, Tegegn HG, et al. The effectiveness of pictogram intervention in the identification and reporting of adverse drug reactions in naïve HIV patients in Ethiopia: a cross-sectional study. HIV AIDS (Auckl). 2019;11:9-16. DOI: 10.2147/HIV.S186797
Thompson AE, Goldszmidt MA, Schwartz AJ, Bashook PG. A randomized trial of pictorial versus prose-based medication information pamphlets. Patient Educ Couns. 2010;78(3):389-93. DOI: 10.1016/j.pec.2010.01.010
Maximos M, Smith K, Harris V, McFarlane T, Blay J, Hahn K, et al. A randomized controlled trial to assess the influence of a picture-based antiemetic medication calendar on medication-taking behavior in adults receiving chemotherapy. J Oncol Pharm Pract. 2021;10781552211041680. DOI: 10.1177/10781552211041680
Merks P, Cameron J, Bilmin K, Świeczkowski D, Chmielewska-Ignatowicz T, Harężlak T, et al. Medication Adherence and the Role of Pictograms in Medication Counselling of Chronic Patients: a Review. Front Pharmacol. 2021;12:582200. DOI: 10.3389/fphar.2021.582200
Monkman H, Kushniruk AW, Borycki EM, Sheets DJ, Barnett J. Differences in Memory, Perceptions, and Preferences of Multimedia Consumer Medication Information: Experimental Performance and Self-Report Study. JMIR Hum Factors. 2020;7(4):e15913. DOI: 10.2196/15913
Montagne M. Pharmaceutical pictograms: a model for development and testing for comprehension and utility. Res Social Adm Pharm. 2013;9(5):609-20. DOI: 10.1016/j.sapharm.2013.04.003
Wrench W, Van Dyk L, Srinivas S, Dowse R. Outcome of illustrated information leaflet on correct usage of asthma-metered dose inhaler. Afr J Prim Health Care Fam Med. 2019;11(1):e1-9. DOI: 10.4102/phcfm.v11i1.2079
Park J, Zuniga J. Effectiveness of using picture-based health education for people with low health literacy: An integrative review. Lee A, editor. Cogent Medicine. 2016;3(1):1264679. DOI: 10.1080/2331205X.2016.1264679
Houts PS, Doak CC, Doak LG, Loscalzo MJ. The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence. Patient Educ Couns. 2006;61(2):173-90. DOI: 10.1016/j.pec.2005.05.004
Monkman H, Kushniruk AW, Barnett J, Borycki EM, Sheets D. We Built It, But They Are Not Coming: Exploring Deterrents to Consumer Medication Information Use. Stud Health Technol Inform. 2019;265:189-94. DOI: 10.3233/SHTI190162
Dowse R. Pharmacists, are words enough? The case for pictograms as a valuable communication tool. Res Social Adm Pharm. 2021;17(8):1518-22. DOI: 10.1016/j.sapharm.2020.10.013
Fuchs J. The Way Forward in Package Insert User Tests from a CRO’s Perspective. Drug Information Journal. 2010;44(2):119-29. DOI: 10.1177/009286151004400203
European Commission: Enterprise and Industry Decorate-General. Guideline on the readbility of the labelling and package leaflet of medicinal products for human use [Internet]. Bruselas; 2009 ene. Disponible en: https://ec.europa.eu/health//sites/health/files/files/eudralex/vol2/c/2009_01_12_readability_guideline_final_en.pdf
Getova V, Getov I. Medicine packaging pictograms in the context of the electronic product information (ePI) proposal. Eur J Hosp Pharm. 2021;ejhpharm-2021-002960. DOI: 10.1136/ejhpharm-2021-002960
Wolf A, Fuchs J, Schweim HG. Implementation of the European QRD Template in Package Leaflets of Centralized Approved Medicines. Therapeutic Innovation and Regulatory Science. 2016;50(1):106-14. DOI: 10.1177/2168479015620247
Thomacos N, Zazryn T. Enliven Organisational Health Literacy Self-assessment Resource [Internet]. Melbourne: Enliven & School of Primary Health Care, Monash University; 2013. Disponible en: https://www.hqsc.govt.nz/assets/Consumer-Engagement/Resources/Enliven-health-literacy-audit-resource-Mar-2015.pdf
van der Waarde K. Information about medicines in Europe: Considering possible principles? Information Design Journal. 2019;25(3):307-13. DOI: 10.1075/idj.25.3.08van
Málaga G, Cuba-Fuentes MS, Rojas-Mezarina L, Romero-Albino Z, Hamb A, Paz-Soldán VA. Estrategias para promover la alfabetización en salud desde la atención primaria: una perspectiva que considera las realidades de los países de ingresos medios y bajos. Anales de la Facultad de Medicina. 2019;80(3):372-8. DOI: 10.15381/anales.803.16864
Stoop AP, van’t Riet A, Berg M. Using information technology for patient education: realizing surplus value? Patient Educ Couns. 2004;54(2):187-95. DOI: 10.1016/S0738-3991(03)00211-8
van Beusekom MM, Grootens-Wiegers P, Bos MJW, Guchelaar H-J, van den Broek JM. Low literacy and written drug information: information-seeking, leaflet evaluation and preferences, and roles for images. Int J Clin Pharm. 2016;38(6):1372-9. DOI: 10.1007/s11096-016-0376-4
Mbanda N, Dada S, Bastable K, Ingalill G-B, Ralf W S. A scoping review of the use of visual aids in health education materials for persons with low-literacy levels. Patient Educ Couns. 2021;104(5):998-1017. DOI: 10.1016/j.pec.2020.11.034
Jones CA, Mawani S, King KM, Allu SO, Smith M, Mohan S, et al. Tackling health literacy: adaptation of public hypertension educational materials for an Indo-Asian population in Canada. BMC Public Health. 2011;11:24. DOI: 10.1186/1471-2458-11-24
Brown MT, Bussell JK. Medication adherence: WHO cares? Mayo Clin Proc. 2011;86(4):304-14. DOI: 10.4065/mcp.2010.0575
Dowse R. Designing and reporting pictogram research: Problems, pitfalls and lessons learnt. Res Social Adm Pharm. 2021;17(6):1208-15. DOI: 10.1016/j.sapharm.2020.08.013
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2022 Francisco Javier Ferreira Alfaya, Maria José Zarzuelo Romero
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
The articles, which are published in this journal, are subject to the following terms in relation to the rights of patrimonial or exploitation:
- The authors will keep their copyright and guarantee to the journal the right of first publication of their work, which will be distributed with a Creative Commons BY-NC-SA 4.0 license that allows third parties to reuse the work whenever its author, quote the original source and do not make commercial use of it.
b. The authors may adopt other non-exclusive licensing agreements for the distribution of the published version of the work (e.g., deposit it in an institutional telematic file or publish it in a monographic volume) provided that the original source of its publication is indicated.
c. Authors are allowed and advised to disseminate their work through the Internet (e.g. in institutional repositories or on their website) before and during the submission process, which can produce interesting exchanges and increase citations of the published work. (See The effect of open access).
