Annie Pouliot

Evaluation, Modification, and Validation of Pictograms Depicting Medication Instructions in the Elderly

Poor health literacy has been recognized as a limiting factor in the elderly’s ability to comprehend written or verbal medication information and also to successfully adhere to medical regimens. The objective of this study was to validate a set of pictograms depicting medication instructions for use among the elderly to support health literacy. Elderly outpatients were recruited in 3 community pharmacies in Canada. One-on-one structured interviews were conducted to assess comprehension of 76 pictograms from the International Pharmaceutical Federation. Comprehension was assessed using transparency testing and pictogram translucency, or the degree to which the pictogram represents the intended message. A total of 135 participants were enrolled in this study, and 76 pictograms were assessed. A total of 50 pictograms achieved more than 67% comprehension. Pictograms depicting precautions and warnings against certain side effects were generally not well understood. Gender, age, and education level all had a significant impact on the interpretation scores of certain individual pictograms. When all pictograms were included, younger males had a significantly higher comprehension score than older females, and participants with a higher level of education provided significantly higher translucency scores. Even when pictograms reached the comprehension threshold set by the International Organization for Standardization in the general populations, only 50 of these pictograms achieved more than 67% comprehension among the elderly, confirming that validation in this subpopulation should be conducted prior to using specific pictograms. Accompanying pictograms with education about these pictograms and important counseling points remains extremely important.

Evaluation, validation, and modification of pictograms depicting potential side effects to medication

Abstract Rationale Health literacy and discordant languages are important barriers to communicating and educating patients about their treatment. Pictograms have shown to be an effective communication tool by increasing comprehension, information recall, and adherence. Objectives To evaluate, modify, and validate a set of pictograms that depict potential side effects to medication. Methods Children inpatient and outpatient were recruited at a Canadian pediatric hospital. Participants in Phase I completed a ‘guessability’ test in order to identify the best pictogram for 27 side effects. In Phase II, structured interview using ‘guessability’ and translucency questionnaires tested the comprehensibility of 28 side effects pictograms. Results Phase I: one hundred and six patients were enrolled and the best pictogram for each category was selected for Phase II. For the side effect ‘headache’, both pictograms achieved 100% of correct answer, so both of them were used in Phase II. For the pictogram ‘general pain 2’, 93.8% of the patients thought it was ‘back pain’, so we decided to use it as ‘back pain’ pictogram in Phase II. Phase II: sixty-seven patients were interviewed, we found that 11 out of 28 pictograms were not guessed correctly by 80% or more participants and six out of 28 pictograms did not achieve a score 5 or greater from 80% or more participants. We found a significant association between the comprehension of the pictogram ‘dizzy when getting up’ and taking three medications or more. Conclusion Sixteen pictograms were validated whereas 12 failed the validation. Five of them failed at both ‘guessability’ and translucency tests.

Instructions for masking the taste of medication for children: Validation of a pictogram tool

Background: Medications that taste unpleasant can be a struggle to administer to children, most often resulting in low adherence rates. Pictograms can be useful tools to improve adherence by conveying information to patients in a way that they will understand. Methods: One-on-one structured interviews were conducted with parents/guardians and with children between the ages of 9 and 17 years at a pediatric hospital. The questionnaire evaluated the comprehension of 12 pictogram sets that described how to mask the taste of medications for children. Pictograms understood by >85% of participants were considered validated. Short-term recall was assessed by asking participants to recall the meaning of each pictogram set. Results: There were 51 participants in the study—26 (51%) were children aged 9 to 17 years and 25 (49%) were parents or guardians. Most children (54%) had health literacy levels of grade 10 or higher. Most parents and guardians (92%) had at least a high school health literacy level. Six of the 12 pictogram sets (50%) were validated. Eleven of 12 pictogram sets (92%) had a median translucency score greater than 5. All 12 pictogram sets (100%) were correctly identified at short-term recall and were therefore validated. Conclusion: The addition of validated illustrations to pharmaceutical labels can be useful to instruct on how to mask the taste of medication in certain populations. Further studies are needed to assess the clinical impact of providing illustrated information to populations with low health literacy.

Defining and identifying concepts of medication literacy: An international perspective

Background: Multiple concepts to define health literacy in the context of medication use exist, such as medication literacy, pharmacotherapy literacy, pharmacy health literacy; however, no studies have looked at consensus among experts internationally. Method: A Delphi process was used to achieve consensus on the statements about medication literacy. Experts for the Delphi were selected from a review of the literature and suggestions from an international survey conducted with members of the International Pharmaceutical Federation on medication literacy. The preliminary Delphi questionnaire was built using the statements about medication literacy found in the scientific literature. Responses and comments were analyzed using a pre‐established method and communicated to the experts after each round of Delphi. Statements with an agreement of at least 80% were accepted and used to develop a definition of medication literacy. Results: The Delphi process started with 21 experts and included 4 rounds. Overall, 30 statements regarding medication literacy were accepted and divided into 4 clusters representing: (1) type of information necessary for optimal and safe use of medication, (2) skills and abilities, (3) format of information, and (4) outcomes. These statements were used to propose 2 different definitions of medication literacy. One of the definitions was preferred by 75% of the expert panel, which provided further comments for improvements. Of the 11 experts who answered the final questionnaire, nine strongly agreed with the refined definition. Conclusion: Medication literacy is the degree to which individuals can obtain, comprehend, communicate, calculate and process patient‐specific information about their medications to make informed medication and health decisions in order to safely and effectively use their medications, regardless of the mode by which the content is delivered (e.g. written, oral and visual). Future studies should focus on how this definition can be operationalized to support the role that pharmacists and other healthcare providers.

Wasted medications, wasted resource.

In Canada, almost anything can be recycled; however, medication is not currently recycled in community practice. For many years, US hospitals in some states have taken unused medication and redispensed it without an issue.1 In 2010, Canadians spent

The evaluation of pharmaceutical pictograms among elderly patients in community pharmacy settings – a multicenter pilot study

31.1 billion on drugs.2 It is estimated that 3% to 7% of medications intended for patients goes unused in the United States and that similar wastage could cost Canada approximately

Validation of a pictogram-based diabetes education tool in counselling patients with type 2 diabetes

8 billion annually.3,4 In the current economic climate, the government is searching for ways to improve and pay for public health care. Recycling medication is a solution that sacrifices neither quality nor finances. A Health Canada study from 2000 revealed that more than 10% of Canadians had no insurance, while another 10% were considered underinsured (those spending 2.5% of their gross family income for drugs are considered underinsured and those paying 4.5% are considered uninsured).5 Medications are not covered for outpatients, resulting in a situation where those who cannot afford medications have adherence issues. The lack of a publicly funded program to pay for medications for marginalized Canadians puts them at increased risk of health problems, stress and hospitalization. In 38 US states, there have been medication recycling programs in place dating as far back as 1997.3 In Tulsa, Oklahoma, alone, 6000 prescriptions were collected in 2005, which resulted in a savings of

Derivation, Evaluation, and Validation of Illustrations of Key Counselling Points for a Pediatric Eczema Action Plan

1.4 million.6 In this program, drugs were collected from nursing homes and then distributed to patients in need via a central pharmacy.1 The nursing home residents sign a consent form to release their medication to the recycling program. Those who wish to participate in the program must sign a consent form acknowledging they understand the purpose of the program and that the pharmacy, pharmacist and manufacturers are not held responsible for medications that have been donated in good faith. To ensure patient safety, all states that have legislation concerning drug recycling contain provisions: that all collected donations must have an expiration date and not be expired, that a licensed pharmacist is part of the verification and distribution process, that each patient who receives a drug must have a valid prescription and that controlled substances cannot be collected. In some states, only drugs that are packaged in unit doses and have not left the circle of care can be collected, so that the safety of the medicines can be ensured. In the 3 years that the Iowa Prescription Drug Corporation has been distributing recycled drugs, there has been no evidence that patient safety has been compromised.1 Currently, laws in most provinces prevent an initiative like this from taking place because it is professional misconduct to redispense and resell medication. These laws have been put in place to protect the public, but are we really protecting the segments of the population unable to afford medication? Canadians who lack insurance, for instance when they are unemployed or their finances are not sufficient, can be put under unnecessary stress by needing to find ways to pay for potentially lifesaving medication. Although a recycling program would not resolve access to medication as fully as universal prescription coverage, it would fill a void for those Canadians who would otherwise have to make difficult financial decisions. A Canadian recycling program, run by a not-for-profit organization to prevent double-billing, would not put added pressure on government and would save patients money and improve their health without putting them at increased risk. We need to implement a program like this in Canada to ensure that everybody who needs medication can access it. ■

Usability, Satisfaction, and Usefulness of an Illustrated Eczema Action Plan

Introduction The search for new ways to optimize the use of medications by patients has led the pharmaceutical community to promote the idea of introducing pictograms into routine practice. The main intention of pictograms is to ease patient adherence and to reduce potential risks or errors associated with the use of medications. Purpose To evaluate a series of pharmaceutical pictograms for patient comprehension. Patients and methods The study was conducted in community pharmacies within a European Union country that belongs to the professional research network. Structured interviews were used to evaluate the pictograms for patient comprehension. This consisted of an assessment of the following: the transparency and translucency of the pictograms, health literacy, and pictogram recall. Participants were also given the opportunity to provide feedback on how to improve the pictograms. The primary endpoint was pictogram comprehension. Secondary outcomes included recall of the pictograms and pictogram translucency. Results The study included 68 patients with whom face-to-face interviews were performed. Low transparency results (≤25%) and extensive patient feedback in initial interviews led to the withdrawal of certain pictograms (n=15) from the evaluation. Among the pictograms included in the final stage of our research, 22 pictograms (62.8%) obtained an acceptable transparency level ≥66%. All pictograms passed the short-term recall test with positive results. Conclusion A majority of the designed and modified pictograms reached satisfactory guess-ability scores. Feedback from patients enabled modification of the pictograms and proved that patients have an important voice in the discussion regarding the design of additional pictograms.

Increasing Public Awareness of Ebola Virus Disease Symptoms Using a Pictogram-Based Poster

Patients often struggle to understand written medication instructions and management points due to the complexity of the information.1 As shown in a study conducted at 2 urban public hospitals, approximately 42% of patients were unable to understand written medication instructions.2 Patients with type 2 diabetes mellitus are particularly susceptible to this problem, as most are on more than one medication and are also encouraged to increase their self-management of this chronic condition. Misunderstanding medications and poor compliance with diabetes management can result in unfavourable outcomes.3-5 Since patient information on diabetes is mainly available in text format, it is important to develop counselling tools to enhance patient-provider communication. Pictograms have the ability to overcome communication barriers and provide simple yet necessary information. Numerous studies have shown that pictograms may improve medication safety, medication compliance and overall health outcomes in the general public.6,7 Pictograms have also been shown to increase the short- and long-term (after 4 weeks) memory of complex medical instructions in patients, especially when the printed information is presented along with verbal information.8,9 According to Paivio’s dual coding theory,10 the verbal system and nonverbal system work in association, and the activation of one system triggers the activation of the other. This suggests that pictures have the ability to further activate the understanding of verbal information, therefore optimizing information interpretation and message recollection.10 The use of pictorial aids such as illustrations can make health education literature more accessible, while remaining interesting enough to appeal to individuals at all levels of reading ability.11 The use of pictograms in patient information leaflets is preferred by patients and significantly improves their understanding of the material presented.12 The use of pictographic counselling tools for diabetic patients is meant to supplement written and oral information for those people who are limited in their ability to read. Difficulties in processing written instructions may be attributed to age, low literacy and comorbidities such as retinopathy. Pictograms and pictographic symbols should only use those details that are most important and provide the most information. The purpose is to lead the patient in the right direction by using symbols that build on the most characteristic concepts of reality,13 just as the traffic signs seen on the roads and streets are pictorial representations of key information understood by all drivers as an essential element of road safety. The pictograms for this study were designed with the following characteristics in mind, aiming for optimal uptake from patients with minor eye diseases: use of mainly black and white or high-contrast colours; clear and simple images; avoidance of shading, coloured images or coloured backgrounds; and use of plain large font.14 This tool was designed for patients accustomed to interpreting road signs and other commonly available pictograms; in other words, the tool catered to most North Americans with a reading level of grades 6 to 7. The purpose of the study was to evaluate and validate selected components of a pictogram-based diabetes education tool for use in counselling patients with type 2 diabetes mellitus. Pictogram-associated information recall was assessed to see if the use of pictograms improved recollection of diabetes counselling points. According to the American National Standards Institute (ANSI) standard for validation of individual pictograms, pictorial symbols must reach a criterion of at least 85% correct to achieve validation in a comprehension test.15