Background

Up to 25% of the UK population cannot read or have low literacy skills. This may seriously affect their ability to follow instructions on medicine-taking. Alternative methods of provision include enhanced verbal information (oral or taped) and pictograms. Medicine pictograms have been developed and testing around the world, notably two series in the US¹ and South Africa². However, there is evidence that the understanding of pictograms is significantly culture dependent³ and there has been little UK work. This study evaluated the interpretation by UK patients of selected pictograms from the US and South Africa.

Method

10 pairs of pictograms which depicted common medicine instructions were selected from both the US and South African series and presented to 160 adult attenders at a general practice (mean age 43 years (range 17-84), 63% women). Each viewed 5 pictograms, all from the same series, and gave their interpretation of each pictogram's meaning. The selection and order of presentation was randomly pre-determined to control for effects of order or combination. The 10 pictograms were: Complete the course; This medicine may make you drowsy; Take 4 times a day; Do not take if pregnant; Do not brake or crush capsules or tablets; Take with meals; Store in the fridge; Do not take with milk or other dairy products; Do not take with meals; Do not drink alcohol while taking this medicine.

Results

There was considerable variation in the ability of the pictograms to convey their message effectively (range 19% to 86% of patients). The best understood were those relating to pregnancy (86% correct) and alcohol (85%). The worst were pictograms for drowsiness (19%) and take with meals (23%). Correct interpretation was more likely from men (p=0.02) while participants aged 65 or over were significantly less likely to interpret the pictograms correctly (p<0.001). Only two of the pictogram pairs were significantly different in terms of level of interpretation (p<0.05): milk and dairy products and drowsiness pictograms. Overall, lower educational attainment was significantly associated with lower scoring.

Discussion

Some pictograms were particularly weak in their ability to convey their meaning. This may be due to their design or because the message was too complex. The best scoring pictograms were those that conveyed simple messages, e.g. Do not take if pregnant.

As most medicines are used by older people, it is of concern that they were less successful in interpreting the pictograms. The effect of education attainment mirrors work on testing the understanding of information leaflets⁴. Further testing is required for the use of pictograms on medicines for UK populations. In particular, research should examine how complementing verbal information with the pictogram might impact on subsequent understanding.

References

1 United States Pharmacopoeia. URL: http://www.usp.org/information/programs/pgrams/describe.htm [3rd November 2002]

2 Dowse R and Ehlers MS. The evaluation of pharmaceutical pictograms in a low-literate South African population. Pat Educ Counsel 2001; 45: 87-99

3 Dowse, R, Ehlers, MS. Pictograms in pharmacy. Int J Pharm Prac 1998; 6: 109-18

4 Woodland M, Cloherty M, P Knapp, Raynor DK User testing for information leaflets - is it more than just a good idea?. HSR & Pharmacy Practice Conference, Leeds, April 2002