Redesigning pictographs for patients with low health literacy and establishing preliminary steps for delivery via smart phones

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Medication Adherence, Health Literacy, Smartphone, Patient Education as Topic, Health Communication, United States


Background: Pictographs (or pictograms) have been widely utilized to convey medication related messages and to address nonadherence among patients with low health literacy. Yet, patients do not always interpret the intended messages on commonly used pictographs correctly and there are questions how they may be delivered on mobile devices.

Objective: Our objectives are to refine a set of pictographs to use as medication reminders and to establish preliminary steps for delivery via smart phones.

Methods: Card sorting was used to identify existing pictographs that focus group members found “not easy” to understand. Participants then explored improvements to these pictographs while iterations were sketched in real-time by a graphic artist. Feedback was also solicited on how selected pictographs might be delivered via smart phones in a sequential reminder message. The study was conducted at a community learning center that provides literacy services to underserved populations in Seattle, WA. Participants aged 18 years and older who met the criteria for low health literacy using S-TOFHLA were recruited.

Results: Among the 45 participants screened for health literacy, 29 were eligible and consented to participate. Across four focus group sessions, participants examined 91 commonly used pictographs, 20 of these were ultimately refined to improve comprehensibility using participatory design approaches. All participants in the fifth focus group owned and used cell phones and provided feedback on preferred sequencing of pictographs to represent medication messages.

Conclusion: Low literacy adults found a substantial number of common medication label pictographs difficult to understand. Participative design processes helped generate new pictographs, as well as feedback on the sequencing of messages on cell phones, that may be evaluated in future research.

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1. Jones CM, Mack KA, Paulozzi LJ. Pharmaceutical overdose deaths, United States, 2010. JAMA. 2013;309(7):657-659. doi: 10.1001/jama.2013.272

2. Meichenbaum D, Turk DC. Facilitating Treatment Adherence. A Practitioner's Guidebook; 1987. ISBN-13: 978-1468453614

3. Bauer AM, Schillinger D, Parker MM, Katon W, Adler N, Adams AS, Moffet HH, Karter AJ. Health literacy and antidepressant medication adherence among adults with diabetes: the diabetes study of Northern California (DISTANCE). J Gen Intern Med. 2013;28(9):1181-1187. doi: 10.1007/s11606-013-2402-8

4. Chisolm DJ. Capsule commentary on Bauer et Al., health literacy and antidepressant adherence among adults with diabetes: implications for future research. J Gen Intern Med. 2013;28(9):1223. doi: 10.1007/s11606-013-2437-x

5. Selden C, Zorn M, Ratzan S, Parker R. National Library of Medicine Current Bibliographies in Medicine: Health Literacy. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services; 2000.

6. Advani AA, Lopez J, Jones J, Patel S. The Role of Pictograms for Enhancement of Patient Prescription Medication Information in the US. J Pharm Technol 2013;29(1):40-45. doi: 10.1177/875512251302900107

7. Ngoh LN, Shepherd MD. Design, development, and evaluation of visual aids for communicating prescription drug instructions to nonliterate patients in rural Cameroon. Patient Educ Couns. 1997;31(3):245-261.

8. Barlow Magumo A, Kohake JR. Iterative Test and Development of Pharmaceutical Pictorials” IEA: Volume 4: Ergonomics and Design. 1994:360-362.

9. Chan H-K, Hassali M. Modified labels for long-term medications: influences on adherence, comprehension and preferences in Malaysia. Int J Clin Pharm. 2014;36(5):904-913. doi: 10.1007/s11096-014-0003-1

10. Choi J. Pictograph-based discharge instructions for low-literate older adults after hip replacement surgery: development and validation. J Gerontol Nurs. 2011;37(11):47-56. doi: 10.3928/00989134-20110706-03

11. Moynihan M, Mukherjee U. Visual communication with non-literates: a review of current knowledge including research in northern India. Int J Health Educ. 1981;24(4):251-262.

12. AHRQ Pharmacy Health Literacy Center. Agency for Healthcare Research and Quality. Available at (accessed December 1, 2014).

13. Paivio A. Imagery and verbal processes. New York, New York: Holt, Rinehart, and Winston.; 1971.

14. Dual Coding and Common Coding Theories of Memory. 2014. Available at (accessed February 14, 2016).

15. United States Pharmacopeial Convention (USPC) Pictograms. 1997.

16. Development, references and publications. 2015. Available at (accessed January 15, 2016).

17. Wolf MS, Davis TC, Bass PF, Curtis LM, Lindquist LA, Webb JA, Bocchini MV, Bailey SC, Parker RM. Improving prescription drug warnings to promote patient comprehension. Arch Intern Med. 2010;170(1):50-56. doi: 10.1001/archinternmed.2009.454

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

19. Dowse R, Mansoor LE. Design and evaluation of a new pharmaceutical pictogram sequence to convey medicine usage. Ergonomics 2004;16:29-41.

20. Montagne M. Pharmaceutical pictograms: A model for development and testing for comprehension and utility. Res Social Adm Pharm. 2013;9(5):609-620. doi: 10.1016/j.sapharm.2013.04.003

21. Kheir N, Awaisu A, Radoui A, El Badawi A, Jean L, Dowse R. Development and evaluation of pictograms on medication labels for patients with limited literacy skills in a culturally diverse multiethnic population. Res Social Adm Pharm. 2014;10(5):720-730. doi: 10.1016/j.sapharm.2013.11.003

22. Kripalani S, Robertson R, Love-Ghaffari MH, Henderson LE, Praska J, Strawder A, Katz MG, Jacobson TA. Development of an illustrated medication schedule as a low-literacy patient education tool. Patient Educ Couns. 2007;66(3):368-377.

23. Langer Research Associates. Medication Adherence in America A National Report Card. New York, NY: National Community Pharmacists Association (NCPA); 2013.

24. Strandbygaard U, Thomsen SF, Backer V. A daily SMS reminder increases adherence to asthma treatment: a three-month follow-up study. Respir Med. 2010;104(2):166-171. doi: 10.1016/j.rmed.2009.10.003

25. Pop-Eleches C, Thirumurthy H, Habyarimana JP, Zivin JG, Goldstein MP, de Walque D, MacKeen L, Haberer J, Kimaiyo S, Sidle J, Ngare D, Bangsberg DR. Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders. AIDS. 2011;25(6):825-834. doi: 10.1097/QAD.0b013e32834380c1

26. Mall S, Sibeko G, Temmingh H, Stein DJ, Milligan P, Lund C. Using a treatment partner and text messaging to improve adherence to psychotropic medication: a qualitative formative study of service users and caregivers in Cape Town, South Africa. Afr J Psychiatry (Johannesbg). 2013;16(5):364-370. doi: 10.4314/ajpsy.v16i5.49

27. Spinuzzi C. The methodology of participatory design. Technical Communication 2005;52(2):163-174.

28. Zargarzadeh AH, Law AV. Design and test of preference for a new prescription medication label. Int J Clin Pharm. 2011;33(2):252-259. doi: 10.1007/s11096-011-9488-z

29. Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test to measure functional health literacy. Patient Educ Couns. 1999;38(1):33-42.

30. Helmholz A. Number, and Reading Levels, for Students Served by the Literacy Source. In: Wolpin S, ed. Seattle; 2010.

31. Morgan D. Planning Focus groups - Focus group kit 2. Thousand Oaks, CA: Sage; 1998.

32. Crabtree B, Miller, W. Doing qualitative research; 1999.

33. Kitzinger J. Qualitative research. Introducing focus groups. BMJ. 1995;311(7000):299-302.

34. Krueger R. Developing Questions for Focus Groups - Focus Group Kit 3. Thousand Oaks, CA: Sage; 1998.

35. Krueger RA. Moderating Focus Groups - Focus Group Kit 4. Thousand Oaks, CA: Sage; 1998.

36. Fern E. Advanced Focus Group Research: Sage; 2001.

37. Wogalter MS, Clayton Silver N. Warning Symbols In: Handbook of Warnings. 2006: ISBN 9780805847246

38. Abdullah RRH. Pictograms, Icons & Signs: A Guide to Information Graphics. New York: Thames & Hudson 2006.

39. Bertin J. Semiology of Graphics. University of Wisconsin; 1983. ISBN-13: 978-1589482616

40. Cowgill J, Bolek J. Symbol Usage In Health Care Settings for People with Limited English Proficiency. Part Two: Implementaion Recommendations. Scottsdale: JRC; 2003.

41. Dreyfuss H. Symbol Sourcebook: An Authoritative Guide to International Graphic Symbols. Wiley: New York; 1984:28. ISBN-13: 978-0471288725

42. Bliss CK. Semantography: One Writing for One World. Blissymbolics; 1965.

43. Perri S, Argo L, Kuang J, Buia D, Hillab B, Brayac B, Treitler-Zenga Q. A picture's meaning: The design and evaluation of pictographs illustrating patient discharge instructions. J Commun Healthcare 2015;8(4):335-350. doi: 10.1080/17538068.2016.1145877

44. Korenevsky A, Vaillancourt R, Pouliot A, Revol M, Steed E, Besançon L, Wahrendorf MS, Patel JR. How many words does a picture really tell? cross-sectional descriptive study of pictogram evaluation by youth. Can J Hosp Pharm. 2013;66(4):219-226.

45. The role of in the conveying of consumer safety information. Department of Trade and Industry, 1997. Available at (accessed 3/12/2016)

46. Tait AR, Voepel-Lewis T, Brennan-Martinez C, McGonegal M, Levine R. Using animated computer-generated text and graphics to depict the risks and benefits of medical treatment. Am J Med. 2012;125(11):1103-1110. doi: 10.1016/j.amjmed.2012.04.040

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