Pictograms: A Bridge Between Pharmaceutical Professionals and Patients

Lipi Gupta

One of the important and
foremost aims of the pharmacy professional is to counsel the patient
appropriately at right time providing complete information about the proper
dose, dosing schedule and dosing regimen of the prescribed medication.
Pictograms play a vital role in the accomplishment of this task.

It has been
proved through various theories put forward by researchers that effective
utilization of pictograms bridges the communication gap between the patients
and the health care providers. Pictograms should be designed in such a way that
they are able to establish a good communication with the patient and at the
same time the relevant message should be conveyed in an effective manner to the
communicatee/user. Pictograms have proved themselves as effective tools for
educating the illiterate patients and thus can be helpful to prevent
incompatibilities because this matter is concerned with the health of human
beings. 

Introduction:

Communication between pharmaceutical professionals and a patient proves
to be very problematic. Patients, even those with well developed language
skills, find it difficult to process medical information because they are
unfamiliar with medical terminology, are preoccupied with their symptoms, and
because they are upset which makes concentration difficult. People with limited
literacy skills are especially in need of help. They need help in understanding
written information because they place more reliance on spoken explanations.
There are much information, direction to use, precautions and preventions that
a pharmaceutical expert likes to suggest to a patient, which can be done only
through direct conversation, but is not possible.

So there are many approaches made in
this direction to overcome the problem. One of such approaches is the ‘

USE OF PICTOGRAMS’

. 

Pharmaceutical
Pictograms: What they are?

Pharmaceutical
Pictograms are pictorial representation of information about doses, medication
and warnings.  It
is hypothesized that using visual concept maps aid the patients in
understanding and remembering how to take their medications. An individualized
medication concept map, in conjunction with patient counseling, may be a tool
that could be used to communicate critical medication information.

Combining
pictures with spoken or written text affects health communication very much.
Four aspects of health communication influenced by pictograms are:

(1)  Drawing
attention to the materials or message,

(2)  Helping
people comprehend the information being  
presented,

(3)  Increasing
recall of the message, and

(4)  Increasing
the likelihood that people will act in accordance with the message (adherence).

This paper reviews research on how
pictures can contribute to health education and pictures combined with text can
influence the understanding of people.

This is
closely related to McGuire’s
information processing theory [1] in which he proposed a
matrix explaining the communication/persuasion process. His matrix consists of
five input variables (source, message characteristics, channel, receiver and
response target) and thirteen output variables. Pictures fall within McGuire’s
second input variable ‘‘message characteristics,’’ McGuire’s model is a useful
conceptual framework for our literature review because it positions pictures
within the persuasion process. It also suggests directions for future research
on how pictures can contribute to health education.

This
paper aims to:

(1)  Make
a review of research on the relationship of pharmaceutical experts and people
through pictograms,

(2)  Make
recommendations for how health educators can make optimal use of pictures in
combination with text to add to this relationship.

(3)  Elaborate
the facilitation provided through pictograms in enhancing attention,
comprehension, recall and adherence of people.

Pharmaceutical
Pictograms
: Effective Means to Promote Attention for Future Research

Findings
in the Delp and Jones study [2]
as well as research on student preferences
suggest that the addition of pictures to health education text will increase
the likelihood that the text will be read. The simple and effective design of
the Delp and Jones study shows that it is feasible to conduct such research in
clinical settings. Health education researchers should, therefore, include, in
their evaluations of health education materials, questions on whether the
materials were read or attended to by patients and their family care givers and
investigate the kinds of pictures that are most effective in drawing attention
to the materials.

Pharmaceutical Pictograms:  Making People to Notice and read a Health
Message

Not
all health communications are read by the people, which could benefit. Racks of
informational brochures in doctors’ offices are often ignored and, even when
health professionals give brochures to patients, not all are read. Patients or
families do not always attend even spoken instructions by health professionals
because they are stressed, distracted, or confused. One contribution of
pictures to health education is to attract the attention of patients and
families and to stimulate them to attend to the information. The pictures
attract the attention of people and bring it to the piece of information that
has to be conveyed.

Pharmaceutical Pictograms
: Helping Hand in
Understanding a Message

Patients sometimes have difficulty
understanding health care information. Studies by Ley [3] and others have shown
that health information is often unfamiliar to patients and contains complex
concepts and words. This is, in part, caused by the tendency of health
professionals to use the same technical terminology and complex sentence
structures in communicating with patients that they use in communicating with
their professional peers. Another reason is the inherent complexity and
uncertainties involved in the topics being discussed. As a result, health
professionals may qualify statements and speak in broad generalizations to
patients who want specific information that applies to them, personally. At the
same time, patients are in a stressful environment where there is a power
imbalance, educational imbalance, and where they are fearful of appearing
stupid and fearful of rejection or abandonment. As a result, they are hesitant
to admit that they do not understand directions or the reasons for medical
interventions.

The World Health Organization estimates that, even among
industrialized countries, there are large numbers of people with low literacy
skills. Comprehension problems can be especially acute for people with low
literacy skills.

Pharmaceutical Pictograms
: Vital Role in Comprehending the Health Education Materials

Comprehension
is the process of interpreting the meaning of words or pictures to understand
their collective meaning. It is different from recall, which is the process of
retrieving individual words or picture elements from memory. People may
remember information without, necessarily, understanding it.

Where
Austin et al. [4], Mansoor and Dowse [5] and Michielutte et al. [6], using an
experimental design similar to Delp and Jones, which showed that pictures had
significantly more correct responses, assessed the effects of incorporating
pictures on understanding medication instructions on adults, Hammeen-Anttila et
al. [7] studied the effect on children’s understanding of medicine leaflet.

According
to the authors’ conclusion, the data support the hypothesis, the effect of
pictures with text on comprehension of health information was that it really
enhanced the understanding of people about the text. Not even the adults but
also it helps children to understand the basic idea what the leaflets are meant
to convey.

Pharmaceutical Pictograms
Vs Facilitation of Comprehension

Moll
[9] and Readance and Moore [8] investigated the effects of different kinds
drawings seem to facilitate comprehension more than do shaded drawings or
photographs and color photographs seem to have a greater effect than black and
white pictures.

Both papers suggest that simple
drawings are most effective in facilitating comprehension. The advantage of
simple drawings over more complex pictures may be due to their minimizing
distracting details. Research has shown that people are more likely to attend
to irrelevant details in illustrations instead of the actual information on
which less emphasis is laid [10].

Captions: Role in
Facilitating the Comprehension
.

Pictures
can often be interpreted in multiple ways. The text that accompanies the
picture usually guides the interpretation but people with limited reading
skills may by-pass the text and try to understand a message by guessing the
meaning of the pictures. In addition, when the text includes abstract language,
pictures may be interpreted differently. One way to deal with this problem is
to include captions that explain the intended meaning of the picture and/or
prompts within pictures such as labels or arrows within the pictures.  Levie and Lentz [11] cite studies showing
that instructing students on what to look for in a picture increased
comprehension. Pettersson [12] showed that pictures typically generate a great
variety of associations. They concluded that the pictures used in information
and instructional materials should always have captions to guide the
understanding of the content.

Pharmaceutical Pictograms
: Contribution in maximizing the  Comprehension of Health-Related Information
.

The
complexity of research on comprehension suggests that studies in and outside of
health education can be an important source of hypotheses for health educators
rather than a source of conclusions that can be applied directly to health
education for adults.

Researches by Moll [9] as well as Readance
and

Moore

’s
review of education research [8] suggest that simple line drawings will
maximize comprehension of health information.

Dowse and Ehler’s research [13] and
Levie’s literature review suggest that culturally relevant pictures will
facilitate comprehension more than pictures that are not culturally relevant to
the viewing audience. It is likely that this will be especially important for
people in cultures that have had little contact with western medicine.

Levie
and Lentz’s literature review of research in education [11] suggests that close
proximity of pictures and related text or the use of captions with pictures
will facilitate comprehension. Levie and Lentz’s review [11] also suggests that
pictures are frequently and effectively used to show much information like the
steps in giving an injection or using an inhaler or where the liver is located
in the body, and do so more easily and efficiently than words alone. However,
words are still important in explaining the implications of the pictures and in
explaining what is happening in the pictures. So, for example, to understand a
series of pictures showing steps in using an inhaler requires prior
understanding of what an inhaler is and what it is used for.

Fig: Pictogram depicting instructions to
how to use inhaler

Pharmaceutical Pictograms
: Do They Enhance the Remembrance of Health Education Materials?

Once a health message is understood, people must
remember the message in order to use it. Health professionals frequently give
important information by speaking, but usually only once.

And
even with written instructions, most people read them only once and then rely
on their memories when taking health actions.     Recall
can be assessed in two ways: as ‘‘free recall’’ or as ‘‘cued recall. In the
context of health education, free recall occurs when a patient reads or hears
information about a health problem and, later, without any pictures or cues,
remembers that information in deciding what actions to take or to tell to other
people. Cued recall occurs when a patient reads or hears health information
with an accompanying picture and later views the same picture to help remember
the information.

The
pictorial superiority effect has been demonstrated with a wide range of
populations and, while the addition of pictures to written or spoken text
enhances recall of diverse groups, it does not make their recall equal. These
findings support Sojourner and Wogalter’s [14] conclusion that pictorial
superiority occurs. Studies have also shown that the pictorial superiority
effect is especially prominent with recall over a longer period of time [16,18]
and there is some research suggesting that people who are more adept at
visually representing their experiences will show a greater recall effect of
pairing pictures with text [17].

In cued recall, pictures are present during both learning
and recall. A clinical example would be a health professional telling a patient
or family caregiver how to treat a bed sore while viewing matching pictures and
then giving them copies of the pictures to take home to serve as reminders of
what was said. This use of pictures could be especially helpful to patients.

Will Pictures Influence People’s
Intentions and Behavior in Response to Medical Instructions?

Research on relationships between pictures and behavior
suggests a complex relationship. Behavior or ‘‘adherence’’ is the final and
most important outcome for health education. It is not enough to notice, understand,
and remember a message. The person must carry out the recommended actions.           Adherence involves two steps:
accepting the message as something the person should act on and then actually
carrying out the recommended actions. The addition of pictures to health
education materials will change both intention and behavior, but whether the
change is positive or negative depends on the audience’s emotional response to
the picture. Positive emotional responses will increase the target behavior
while negative responses will decrease the behavior.

Studies
by Dowse and Ehlers [13] and Roter [15] showing the importance of cultural
sensitivity suggest that pictures of people who are similar to the viewer will
have a greater effect on behavior than pictures of unfamiliar, different
people.

The Delp
and Jones study [2] suggests that the addition of pictures will have a greater
effect on the behavior of people who have difficulty reading. Such people may
be more influenced by material with pictures because they are accustomed to
making inferences from pictures and because they are unable and/or
uncomfortable reading

Conclusion:

This paper shows that adding pictures to written and
spoken language can increase patient attention, comprehension, recall and
adherence. In many cases these benefits were large. The effectiveness of health
communications can be significantly increased by including pictures in the
design of new health education materials. 
Our review also suggests that pictures can be especially helpful to
patients in understanding, recalling and adhering to health instructions.

McGuire’s
communication/persuasion theory [1] is helpful in providing a framework for
identifying important future research directions. McGuire’s theory also calls
attention to possible interactions among output variables. For example,
realistic photographs may be effective in drawing attention, but because the
camera captures so many details, the details may interfere with comprehension.

Effective
use of pictures builds on a foundation of clear language. Pictures will be more
easily understood when the accompanying text is clear.

Captions
that describe what is happening in a picture can often be written at a low
literacy level thereby helping people with limited reading skills understand
the intended meaning of the pictures.

It
is likely that cultural sensitivity will play a role in whether people attend
to education materials as well. Cultural sensitivity includes using familiar
objects and symbols, as recommended by Dowse and Ehlers in their review of
pictograms in pharmacy [19].

Health
professionals should explain the intended message to the artists as well as the
outcomes they desire. It is a mistake to ask artists, who do not have the
background to fully understand the intended message, to create images without
guidance from professionals who do have that understanding.

References:

[1] McGuire MJ. Constructing social psychology: creative
and critical processes.

Cambridge

University

Press; 1999.

[2] Delp C, Jones J. Communicating information to
patients: the use of cartoon illustrations to improve comprehension of
instructions. Acad Emerg Med 1996;3:264–70.

[3] Ley P. Satisfaction, compliance and communication. Br
J Clin Psychol 1982;21:241–54.

[4] Austin PE, Matlack R, Dunn KA, Kosler C, Brown CK.
Discharge instructions: do illustrations help our patients understand them? Ann
Emerg Med 1995;25:317–20.

[5] Mansoor LE, Dowse R. Effect of pictograms on
readability of patient information materials. Ann Pharmacother 2003;37:1003–9.

[6] Michielutte R, Bahnson J,

Digman

MB

,
Schroeder E. The use of illustrations and narrative text style to improve
readability of a health education brochure. J Cancer Educ 1992;7:251–60.

[7] Hameen-Antila K, Kemppainen K, Enlund H, Patricia JB,
Marja A. Do pictograms improve children’s understanding of medicine leaflet
information? Patient Educ Couns 2004;55:371–8.

[8] Readance JE,MooreDW.Ameta-analytic reviewof the effect
of adjunct pictures on reading comprehension. Psychol Sch 1981;18:218–24.

[9] Moll JM.
Doctor–patient communication in rheumatology: studies of visual and verbal
perception using educational booklets and other graphic material. Ann Rheum Dis
1986;45:198–209.

[10] Fillippatou D, Pumfrey PD.
Pictures, titles, reading accuracy and reading comprehension: a research review
(1973–95). Educ Res 1996;38:259–91.

[11] Levie WH, Lentz R. Effects of text illustrations: a
review of research. ECTJ 1982;30:195–232.

[12] Pettersson
R.In: Associations from pictures in imagery and visual literacy: selected
readings from the annual conference of the international visual literacy
association; 1994.

[13] Dowse R, Ehlers MS. The evaluation of pharmaceutical
pictograms in a low-literate South 
African population. Patient Educ Couns 2001;

45:87–99.

[14] Sojourner RJ, Wogalter MS. The influence of
pictorials on the comprehension and recall of pharmaceutical safety and warning
information. Int J Cogn Ergon 1998;2:93–106.

[15] Roter DL, Rudd RE, Keogh J, Robinson B. Worker
produced health education material for the construction trades. Intl Quart
Community Health Educ 1987;7:109–21.

[16] Hosey GM, Stracqualursi F. Designing and evaluating
diabetes education materials for American Indians. Diab Educator 1990;16:407–8.

[17] Carney RN, Levin JR. Pictorial illustrations still
improve students’ learning from text. Educ Psychol Rev 2002;14:5–26.

[18]

Gardner

MP, Houston MJ.
The effects of verbal and visual components of retail communications. J Retail
1986;62:1–15.

[19] Dowse R, Ehlers MS. Pictograms in pharmacy. Int J
Pharm Pract 1998;6:109–18.

About Author:

Lipi Gupta

An undergraduate pharmacy student having excellent written
and oral communication skills and flair for writing willing to engulf in depth
subject knowledge while studying.

Correspondence: Lipi Gupta, D.J.College of Pharmacy, Niwari Road , Modinagar (U.P.)-201204.

e-mail : pharmacistlipi@gmail.com, kamalpharmacist@gmail.com

Kamal Dua

Presently working in the capacity of Lecturer, Department of
Pharmaceutics, DJCOP, Modinagar and having professional working experience of
three years.

Vijay.Kumar.Sharma

Presently working in the capacity of Assistant Professor,
Department of Pharmaceutical Chemistry, DJCOP, Modinagar and having
professional working experience of fifteen years.

Dr.U.V.Singh Sara

Presently working in the capacity of Director and Head,
Department of Pharmaceutics, DJCOP, Modinagar and having professional working
experience of more than fifteen years.

Aditi Vats

An undergraduate pharmacy student having flair for writing.
Enjoys reading and writing pharmacy related relevant articles.