The evaluation of pharmaceutical pictograms in a low-literate South African population
Introduction
Pharmaceutical care is a philosophy of practice that is being adopted by many pharmacists world-wide and is described as a practice in which the pharmacist takes responsibility for a patient’s drug-related needs and is held accountable for this commitment [1]. An integral part of this process involves educating and counselling patients in order to prepare and motivate them to adhere to their medication regimens [2]. The quality and form of this information must, however, be appropriate to the patient’s level of education and must also take into account his culture, beliefs, attitudes and expectations [3], [4].
In many parts of the developed world, literacy is taken for granted and health care professionals assume that they are dealing with a reading patient population [4], [5], [6], [7]. However, this assumption has been shown to be seriously misleading, as is illustrated by a number of studies and anecdotal reports in which non-adherence to medication regimens was found to be due to an inability to read and understand the medication directions [8], [9], [10], [11], [12], [13]. Health care systems generally require that patients possess a wide range of literacy skills in order to function effectively within a health care environment [4], [14], [15] and a distinct link between poor reading skills and poor health has been reported [4], [16], [17], [18], [19].
In considering literacy within the health care system, Williams et al. [5] have defined functional health literacy as a range of basic skills necessary to function in the health care environment. Several studies conducted in developed countries have shown that the mean reading ability of patients was far below the readability level of most of the written materials tested, and these studies identified a high prevalence of inadequate functional health literacy [5], [14], [20], [21], [22], [23], [24], [25], [26]. This problem is exacerbated in developing countries where the illiteracy rates are significantly higher. In South Africa it is estimated that only 30% of the black adult population is literate, with 25% being semi-literate and 45% illiterate [27].
This presents an enormous challenge to health care professionals all over the world to identify patients with inadequate literacy skills, to tailor any written information according to the estimated reading ability of the patient, and to investigate additional methods of facilitating the provision of information if the patient is illiterate. One way of communicating medication information to illiterate patients is to use visual aids such as pictograms which stimulate the imagination and offer an alternative means of recalling instructions without involving the written word. However, the success of using pictograms as a communication aid depends on a comprehensive design and testing process in order to produce clear, culturally acceptable pictograms, after which their value depends largely on their appropriate use by the health care professional who must provide verbal reinforcement in conjunction with the pictograms [28].
Visual images or symbols are a ubiquitous part of modern life and are often successful at communicating information to an international population, but their success is determined to a large extent by constant exposure to this type of graphic material which stimulates the learning process. Its accurate interpretation requires learning the conventions of representing three-dimensional reality on a two-dimensional surface [29]. In the absence of this learning process, visual images that effectively communicate a message to one population may prove meaningless to another.
Research indicates that the environment, both ecological and cultural, can exert a significant influence on the ability of the individual to perceive, as well as on what he perceives [29]. Although graphic material is often considered to be part of a universal language which can easily be recognised by all and can convey meaning with little or no dependence on language or cultural background [30], cross-cultural testing has consistently found otherwise [29], [31], [32], [33]. This material is often designed by highly trained professionals who unfortunately lack insight into the target culture and who tend to make assumptions about what can be communicated using graphic material. This emphasises the importance of designing and evaluating pictograms in collaboration with the target population [28], [29], [31], [34], [35], [36], [37], [38], [39], [40].
The use of visual aids such as pictograms in communicating health information to low-literate populations has been receiving increased attention over the past few years and this is accompanied by a growing body of literature on the subject. Although a detailed discussion is beyond the scope of this article, a review on the topic is available [28]. The review also examines the role of pictograms as an aid to compliance with medication regimens by various patient populations including illiterate patients, the elderly, the visually impaired and people unfamiliar with the native language such as tourists and immigrants.
The design and evaluation of pictograms is a complex, multistage, iterative process. One of the main strategies to minimise problems when designing pictograms is to identify the target population and to involve that population in all stages of the design and evaluation process. The pictograms should firstly be tested in healthy respondents from the target population and only after the completion of this stage, should the successful designs be tested in practice in a patient population to monitor for the effect of pictograms on the understanding of instructions and on compliance.
In deciding on the acceptability of a pictogram, researchers are guided by international standards which have been established for evaluating the comprehensibility of pictorial symbols. The American National Standard’s Institute (ANSI Z535.3) [41] and the International Standards Organisation’s (ISO 3864) [42] advise that, in a comprehension test, pictorial symbols must reach at least a criterion of 85 or 67% correct, respectively. These standards may be considered arbitrary, but given the importance of understanding the correct medication instructions in order to use a medicine safely, comprehension should be above the 85% level if possible.
The practical application of pictograms in a low-literate population would entail explaining the meaning of the pictogram to the patient after which the subsequent role of the pictogram is to act as a stimulus to recall that information. The evaluation process should therefore incorporate a follow-up stage to test for the effectiveness of pictograms in aiding recall of information [28]. This follow-up test should not be conducted during the same encounter as the initial testing as this would not simulate the real-life situation, but should rather be conducted after a suitable period of time has elapsed [37].
The most significant international initiative for developing a set of standard pharmaceutical pictograms was co-ordinated by the staff of the United States Pharmacopeia (USP), who began working with USP advisory panels in 1987. This resulted in 29 pictograms being published in the 1989 issue of the USP dispensing information [43] and this number increased to 91 pictograms in the 2000 issue [44]. However these were developed for application in a sophisticated, technologically advanced society, reflecting the essentially westernised base of its culture. The pictograms contain many symbols we felt would be unfamiliar to the majority of functionally illiterate people in South Africa who are found mainly in the black population. This population group has a vastly different cultural and socio-economic background from that of the average North American.
The objectives of this study were to evaluate and compare locally developed, culturally appropriate pharmaceutical pictograms with pictograms appearing in the 1991 edition of the USP-DI in a black, low-literate population. A further objective was to investigate the effectiveness of pictograms in stimulating recall of medication instructions.
Section snippets
Study site and sample
There are eight black ethnic groups in South Africa, each with its own language and ethnic culture. This study was conducted in the Eastern Cape, one of nine provinces in South Africa incorporating a large rural area which is mainly underdeveloped and economically poor, and which has an extremely high unemployment rate. The majority of the Local black population belongs to the Xhosa ethnic group and all our respondents were drawn from this group.
Preparation of Local and USP pictogram sets
Details of the multistage, iterative design
Demographic data
Demographic data are displayed in Table 1. Females constituted the majority (76%) of our respondents. One of the reasons for the low number of males is that the interviews were conducted during working hours and males were more likely to have employment. We felt that this was acceptable for our assessment as it reflects the actual situation commonly found at the outpatient clinics where the majority of attendees are females, as paediatric patients are usually brought in either by their mothers
Discussion
There has been a recent increase in the number of papers reporting the development and testing of pharmaceutical pictograms [9], [38], [39], [40], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64]. These vary in usefulness, with some being of little value due to a variety of reasons such as lack of information on the design process, use of a population other than the target population to test the pictograms, not showing the
Practical implications
Low-literate patients comprise a patient population with special needs who are at a higher risk of experiencing poor health. This study has shown that pictograms can be successful in communicating medication information to such a population, particularly if they are developed in collaboration with the target community and cultural influences are acknowledged. When used appropriately, with time being taken by the health care provider to explain their meaning, they have been proven to be most
Acknowledgements
The authors would like to acknowledge Rhodes University for financial assistance, Professor Sarah Radloff for statistical assistance, Miss Nontutuzelo Faku for acting as our interpreter and all the respondents who willingly participated and offered their opinions.
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