Development of Pictographs Depicting Medication Use Instructions for Low-Literacy Medical Clinic Ambulatory Patients

BACKGROUND: One approach to help elderly and low-literacy patients understand instructions for medication use is to use pictographs or pictorial diagrams. However, most of these pictographs are designed by medical professionals and may not be optimal for such patients. OBJECTIVES: To compare low-literacy patients with medical staff in dimensions of preference and comprehension of pictographs intended to illustrate medication use instructions for medical clinic ambulatory patients. METHODS: Following 2 pilot tests, the first with small samples (5 pharmacists and 5 patients) and the second with 100 patients with low literacy, a survey of pictograph understanding and preference was conducted between May and October 2008. The survey used a third version of 3 sets of pictographs in 4 medication instruction categories for 250 low-literacy patients and 250 members of the medical staff in a teaching hospital in southern Taiwan. The 4 medication instruction categories were (a) route of administration for external use; (b) time of day for medication administration; (c) medication administration before, after, or with meals; and (d) administration quantity. The measure of preference was which pictograph in each subset best described the instruction, and the measure of comprehension was the percentage of participants who understood the meaning of the pictograph. Differences between the 2 groups in pictograph choice and comprehension were calculated using Fisher's exact test. RESULTS: All patients were considered low literacy (never attended school or grade 6 education or less). The preference of pictographs was significantly different between patients and medical staff for each of the 12 sets of pictographs. Comprehension was significantly different between patients and medical staff for pictographs in the categories of medication administration time of day and medication administration associated with meals. For pictographs representing at bedtime, after meals, and with meals, the percentage of patients who chose do not understand was significantly higher than the percentage of medical staff choosing this item. The 3 patient age groups were 60 years or younger (43.2%), aged 61 to 70 years (26.4%), and aged 71 years or older (30.4%). Preference was found to be significantly different among the 3 patient age groups in pictographs for medication administration time before meals (P = 0.002), after meals (P = 0.007), with meals (P = 0.037), and in the pictographs representing half tablet (P = 0.012) in the category of administration quantity. Comprehension was found to differ among the 3 patient age groups in pictographs representing at bedtime (P = 0.040), before meal (P = 0.022), after meals (P = 0.025), and with meals (P = 0.014) and for one, two, or three tablets (P = 0.041). CONCLUSIONS: Patients and medical staff had significant differences in preference for all categories of medical instruction pictographs and had significant differences in comprehension for the pictographs in the categories of medication administration time of day and medication administration associated with meals. Patients' preferences for and comprehension of the medical instruction pictographs were age-related. For successful development of a comprehensible prescription drug label, a diverse sample of patients should be consulted to ensure that the pictographs depicting medication use instructions are useful to all individuals, including those with low literacy.