Pharmaceutical indication pictograms for low literacy viewers: Health literacy and comprehension

BACKGROUND: Poor comprehension of pharmaceutical pictograms used on medicine labels or leaflets can compromise understanding of medicine-taking information, potentially causing negative health outcomes. AIM: The aim was to assess association of health literacy (HL) with comprehension of pictograms displaying indication and side effect information in a lower literacy, limited English proficiency (LEP) population. SETTING: Community centre, Makhanda, South Africa. METHODS: This was a quantitative cross-sectional study using simple random probability sampling. Ninety isiXhosa-speaking adults with a maximum of 12 years schooling, attending primary healthcare clinics were interviewed using structured interviews. Health literacy was assessed using the Health Literacy Test for Limited Literacy populations. Comprehension of 10 locally developed pictograms was evaluated. RESULTS: The mean pictogram comprehension score was 7.9/10, with 8/10 pictograms complying with the International Organization for Standardization criterion of 66.7% correct comprehension. Only 15.6% of participants had adequate HL. A significant association of HL with pictogram comprehension was established (p = 0.002). Pictogram misinterpretation was higher in those with lower HL; adequate HL was associated with superior comprehension. Pictogram comprehension was negatively associated with age (p < 0.006), and positively associated with education (p < 0.001) and English proficiency (p < 0.001). CONCLUSION: Higher HL was associated with better pictogram comprehension. Low HL, LEP and low education levels are regarded as potential indicators for possible pictogram misinterpretation. CONTRIBUTION: This study observed the potential for misinterpretation of medication pictograms. Health professionals should be aware that low HL, limited schooling and limited English proficiency could signal difficulty in fully comprehending pictogram content.