Development, references and publications
The evidence supporting using pictograms together with written information for patients is very strong [Houts PS, Bachrach R, Witmer JT, et. al. Using pictographs to enhance recall of spoken medical instructions. Patient Educ Couns, 1998;35(2):83-88; Houts PS, Witmer JT, Egeth HE et. al. Using pictographs to enhance recall of spoken medical instructions II. Patient Educ Couns, 2001;43(3):231-242]. Studies have shown that using pictographic instructions in conjunction with written and oral instructions increases patient comprehension. Pictograms have been shown to increase short-term and long-term (after 4 weeks) memory of complex medical instructions in patients who had less than fifth grade reading skills [Houts PS, Witmer JT, Egeth HE et. al. Using pictographs to enhance recall of spoken medical instructions II. Patient Educ Couns, 2001;43(3):231-242].
Using pictures and graphics to support written material greatly improves comprehension, understanding and recall of health information. Studies show that the less education someone has, the more combining written instructions with pictures will improve their understanding of health information [Houts PS, Witmer JT, Egeth HE et. al. Using pictographs to enhance recall of spoken medical instructions II. Patient Educ Couns, 2001;43(3):231-242].
In addition, there is currently some data suggesting that although some pictograms are universal, others may have some cultural specificity. For certain, local languages must be used as much as possible to maximize the benefits of the written and visual health information [Ngoh LN, Shepherd MD. Design, development and evaluation of visual aids for communicating prescription drug evaluations to nonliterate patients in rural Cameroon, Patient Educ Couns. 1997;31(3):245-61]. This is why the FIP is collaborating with as many different countries as possible to translate the pictogram software into local languages.
How the pictograms were developed
The FIP Military and Emergency Pharmacy Section convened to develop a practical approach to the use of pictograms during humanitarian medical missions. The following process needs to be undertaken in order to develop a set of pictograms:
- Determine what other pictograms are required to effectively instruct your target group in the appropriate administration of their medicines.
- Gather together a small group of individuals from the culture that you are targeting. Determine what items/practices are appropriate to design into the culturally specific pictograms that you require.
- Consult more widely with members of the cultural community to discuss the ideas generated.
- Submit the ideas to the MEPS project coordinators.
- MEPS got the graphic artists to generate the new designs. (It was important that the designs were done in a consistent style to reduce variability, inconsistencies and possible confusion).
- The culturally specific designs were returned for validation within the culture. The processes involved in the validation stage varied depending on location and circumstances.
After the pictograms were finalized, they were tested in field with people from different cultures. Methods of evaluation that have been used include open-ended questions in which respondents are shown a pictogram and asked to interpret its meaning. According to international standards for the evaluation of the comprehensibility of pictorial symbols, a pictogram must be correctly guessed by a majority of individuals.
Tools for Practice
- Software – [http://www.fip.org/pictogramsoftware/]
- Downloadable pictograms:
- Download the offline pictograms program for North America [8Mb] (last update: June 2009)
(This is the version which prints on Letter (US) size paper)
- Download the offline pictograms program for the rest of the World [8Mb] (last update: June 2009)
(This is the version which prints on A4 size paper)
If you don't have Microsoft Access on your computer, you will also have to download Access Runtime (free download) on Microsoft website: click here
Click here to download the instructions of use
Components of Pictograms
1. Cultural sensitivity
These pictograms have been tested in a North American/European population and we do not know how other cultures will interpret some pictograms. Specifically, instructions that relate to frequency and auxiliary labels are particularly culture sensitive. For example the pictogram take three times daily could be misinterpreted by a patient who may not take their medication on a cloudy day or where the sun doesn’t set during certain months.
Take with food:
This pictogram on the left was used in a country like Haiti where the meals are mainly composed of fish and cereals. While the pictogram on the right is used in Haiti where the typical diet contains chicken and rice.
2. Size of pictograms
A study of the visually impaired elderly population showed the large pictograms to be significantly better interpreted than the small ones [Knapp P, Raynor DK, Jebar AH. Interpretation and Recall of Different Sizes of Pictograms by Older People. Peer Reviewed Proceedings of the 13th International Social Pharmacy Workshop, Malta, 19-23 July 2004 - groupe de 2 b. http://ipac.kacst.edu.sa/eDoc/2006/159954_1.pdf].
How to use pictograms
Pictograms give health professionals a means of communicating medication instructions to people who do not share their language and / or who may be illiterate. Pictograms may also be used for those who have a slight cognitive impairment or difficulties seeing, such as the elderly. To help improve communication, various formats of the medication instructions can be printed (see below):
- A label with customizable size
- A medication information sheet for one medication
- A prescription calendar that combines all medicines
- A storyboard of a medication
To ensure that the pictograms would be as easy to use, a storyboard concept was developed, as opposed to creating one large pictogram to represent information.
The storyboard consists of one vertical column containing an outline of the human body (where the health care provider could depict the indication for the medication) and three horizontal rows (see below): one each for dose / route of administration (first row), frequency (second row) and auxiliary instructions (third row).
The storyboard concept also has an option for liquids to measure a spoon:
A medication calendar:
A medication information sheet:
Medication instructions included:
- Medication name
- Route and quantity of medicines per dose
Optional instructions to include on information sheets:
- The picture of the medication
- Reason(s)for use
- Side effects (up to 2)
Refer to the website and follow instructions in the user manual.
Languages that the pictogram program is available in:
More information regarding the use of pictograms
Kassam R, Vaillancourt R, Collins JB. Pictographic instructions for medications: do different cultures interpret them accurately? International Journal of Pharmacy Practice. 2004; 12: 199-209. Abstract
Ryan K, de Silva S, Becket G, Vaillancourt R. Lessons Learned from Pre-testing Pictograms with Non-English Speaking Peoples in Peer Reviewed Proceedings of the 13th International Social Pharmacy Workshop, Malta, 19–23 July 2004. Pharmacy Education. 2004 Sep-Dec; 4(3/4): 191-264. Document
Pictograms used to facilitate communication.
- Validation of culture-specific pictograms for type II diabetes management in the Mexican community. Abstract
- Validation of culture-specific pictograms for the labeling of medication in a Mexican community.
- Validation of a set of asthma illustrations in children with chronic asthma in the emergency department. Abstract; Poster.
- The evaluation of key visual elements of pictograms to label medication. Abstract; Poster.
- Design, development, and evaluation of culture-sensitive pictographic instructions for dispensing medications. Abstract; Poster.
- Development of culture specific pictograms for the labeling of medication for first nation communities. Abstract; Poster.
- Development of culture-specific pictograms for type II diabetes patient counseling. Abstract; Poster.
Assessment of the level of the understanding of pictograms has been carried out in two university based studies:
- Pre-testing of pictograms used in medicines dispensed in missions of humanitarian relief (in collaboration with the University of Otago, New Zealand).
- Pictographic Instructions for Medications: Do Other Cultures Interpret Them Accurately? (in collaboration with the University of British Columbia, Canada).
In April 2005, a researcher went on a humanitarian mission to Gabon to trial a set of culturally specific pictograms. The aim of the trial was to:
- To design, develop and evaluate a pictogram storyboard concept and individual pictograms in an operational context.
- To assess patient comprehension of the pictogram elements and storyboard concept both at the time of dispensing and upon short term follow-up.
The aim of this study was to pre-test these pictograms. Interviews were conducted, via an interpreter, with Kurdish, Khmer and Korean participants who were unable to read or speak English, Spanish or French.