Using Pictographs and Pictograms for Patient Education

Posted by NoTime_author in Featured Articles, News on Aug 15th, 2010 | one response

Recently Joint Commission released Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals (2010). This monograph offers recommendations to help hospitals address unique patient needs, meet the new patient-centered communication standards, and comply with existing Joint Commission requirements. These include the expectation that hospitals:
— Provide patient education that meets patient needs.
— Support the patient’s ability to understand and act on health information.
— Integrate health literacy strategies into patient discussions and materials.

One way some organizations are trying to communicate with people with low functional health literacy skills is to use pictographs or pictograms in their printed materials. These are pictorial symbols for words or phrases, or statistics in a chart or graph.

Weiss (2007) states that “using pictures, including cartoons or pictographs with verbal explanations and use of models, can greatly increase patient understanding and retention of information” (page 40).

A study by Yin, Dreyer, van Schaick, Foltin, Dinglas, & Mendelsohn (2008) concluded a plain language, pictogram-based intervention used as part of medication counseling decreased medication dosing errors and improved adherence among multiethnic, low socioeconomic status caregivers whose children were treated at an urban pediatric emergency department.

Zeng-Treitler, Kim, & Hunter, (2008) supplemented discharge instructions with free texts with pictographs, and tested them on 13 healthy volunteers. They found the pictograph enhancement resulted in statistically significant better recall rates (p<0.001).

But before you add pictographs and pictograms into your printed materials, test them with your patient populations. Doak, Doak, & Root (1996) warned that when staff tested some computer graphic pictograms with focus groups, patients found them to be cold and unclear. They recommended you use visuals that give a sense of realism and the patient see the action recommended.

Chuang, Lin, Wang, & Cham (2010) discovered pictographs designed by medical professionals may not be optimal for elderly and low-literacy patients. They offered choices of 12 sets of pictographs and found the preference of patients and medical staff was significantly different. Comprehension was significantly different between patients and medical staff for several pictographs.

So yes, pictograms and pictographs can help your patients with low functional health literacy skills understand your printed instructions. But be sure to test them on your patient population. What may seem clear to you may make no sense to your patient. And what may work for your population may not work for each individual patient. Always evaluate understanding with teach back. After explaining to your patient what needs to be done, have your patient teach the content back to you to be sure he or she understands. This gives you the opportunity to correct misunderstandings before they become medical errors.

If you want to learn more:

Chuang, M. H., Lin, C. L., Wang, Y. F., & Cham, T. M. (2010). Development of pictographs depicting medication use instructions for low-literacy medical clinic ambulatory patients. J Manag Care Pharm, 16(5), 337-345.
http://www.amcp.org/data/jmcp/337-345.pdf

Doak, C. C., Doak, L. G., & Root, J. H. (1996). Teaching patients with low literacy skills (2nd ed.). Philadelphia: J. B. Lippincott Company. http://www.hsph.harvard.edu/healthliteracy/doak.html

Hill, L. H., & Roslan, M. M. (2004). Using visual concept mapping to communicate medication information to chronic disease patients with low health literacy. Paper presented at the Concept Maps: Theory, Methodology, Technology. Proceedings of the First International Conference on Concept Mapping, Pamplona. Spain.

The Joint Commission. (2010). Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. Oakbrook Terrace, IL:: The Joint Commission. http://www.jointcommission.org/PatientSafety/HLC/

Weiss, B. D. (2007). Manual for clinicians: Health literacy and patient safety: Help patients understand. 2nd. http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf

Yin, H. S., Dreyer, B. P., van Schaick, L., Foltin, G. L., Dinglas, C., & Mendelsohn, A. L. (2008). Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among caregivers of young children. Arch Pediatr Adolesc Med, 162(9), 814-822. http://archpedi.ama-assn.org/cgi/content/full/162/9/814

Zeng-Treitler, Q., Kim, H., & Hunter, M. (2008). Improving patient comprehension and recall of discharge instructions by supplementing free texts with pictographs. AMIA Annu Symp Proc, 849-853.