Pictograms: a continuous quality improvement initiative

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Pictograms a continuous quality improvement
initiative

• Presented by L Col R Vaillancourt BPharm, Pharm
  D, FCSHP, O.M.M.
• Directorate of Medical Policy, Pharmacy Policies
  and Standards, Canadian Forces Health Services,
  Ottawa, ON

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Background

• The Disaster Response Team (DART) of the Canadian
  Armed Forces deploys personnel on mission of
  humanitarian relief
• DART is often deployed to areas of the world with
  low literacy rates and lack of a common language
  (ie) French, English, or Spanish.

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Background

• Lack of a common language and low literacy pose a
  problem for healthcare professional trying to
  care for the subject population.
• In order to address these issues, pictographic
  instructions are used to address 4 areas key to
  proper compliance to pharmacotherapy

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Components of Pictograms

• The 4 components necessary for successful
  pharmacotherapeutic treatment are
• Timing
• Route of administration
• Quantity
• Auxiliary directions

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Studies

• The CF has completed two studies to assess the
  comprehension of pictographic instructions
• Pre-testing of pictograms used in medicines
  dispensed in missions of humanitarian relief1 (in
  collaboration with the University of Otago, New
  Zealand)
• Pictographic Instructions for Medications Do
  Other Cultures Interpret Them Accurately?2(in
  collaboration with the University of British
  Columbia)

• 1 Regis Vaillancourt, Kath Ryan, Gordon Beckett,
  Sulakshi de Silva
• 2 Regis Vaillancourt, Rosemin Kassam

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Pictographic Instructions for MedicationsDo
Other Cultures Interpret Them Accurately?
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Objectives

• To determine whether ethnically diverse
  individuals could understand the pictogram
  meanings without additional aids such as verbal
  instructions or explanations
• To identify appropriate modifications to the
  pictograms to reduce interpretation errors

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Study Design

• A structured individual-interview process was
  used to evaluate how respondents from three
  different ethnic groups
• Chinese
• East Indian
• Somalian
• Low literacy skills in English, French or Spanish
  would interpret a set of 16 pictograms prepared
  by DART

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Illustration of how the pictograms were
distributed for testing
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Modification of Pictograms
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13 correct
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5 ml
75 correct
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8 correct
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25 correct
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50 (12)
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50 (12)
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94 (16)
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27
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50
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82
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92
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2
2
76
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89
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Pre-testing of pictograms used in medicines
dispensed in missions of humanitarian relief
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Objectives

• To assess the effectiveness and comprehensibility
  of medication label pictograms among non-English
  speaking people
• To determine the cultural appropriateness of the
  images used in such pictograms

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Study Design

• For each of three different ethnic populations
• Khmer
• Korean
• Kurdish
• Each focus group consisted of 6-8 participants
  with a diverse range of education, literacy, and
  occupations
• Discussion was facilitated by and interpreter

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Pictograms

• Images representing proper ways to take or store
  medication
• Other important information about medication that
  the healthcare provider should provide to his/her
  patient

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How were the pictograms presented to the
participants ?
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Interviews

• Phase 1 Individual Interviews
• The individuals understanding of the pictogram

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• Phase 2 Focus Group Interviews
• How the community perceived the pictogram
• Cultural relevance

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• Picture misinterpreted
• Curtain
• Sink
• Brush
• Mortar and pestle
• Do not have noodles after taking this medication
• Other problems
• Arabs read from right to left

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Quantitative analysis

• The Study broke down a number of pictograms
  into the basic concepts in order to understand
  where interpretation errors may arise

• Take the medication four hourly
• Take four times a day ( with face)
• Take four times a day (without face)
• Take three times daily.
• Take twice daily.
• Take one tablet.
• Take two tablets.
• Take with food

• Do not consume alcohol while taking this
  medication.
• Gargle
• Measure out 5ml using the dropper
• Use a spoon to take this medication
• Take two capsules each time
• Take one drop using a dropper
• Inhale the medication using an inhaler

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Results
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Quantitative Analysis

• The pictograms were also tested in their entirety
  in order to see how the concepts when put
  together to form the pictographic instructions
  were understood
• For each pictogram, the errors made by each
  participant were determined using the degree of
  success scale

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Degree of Success results
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Results

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Results

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• After tabulating the qualitative analysis, it was
  found that there were several pictograms that
  were not well understood or caused confusion
• Some of the main reasons were
• The picture was not seen clearly
• The symbol was not culturally relevant
• The symbol was perceived by the participant but
  was misinterpreted

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Pictograms A Pharmacists perspectiveWorkshop
Moderated by LCol Regis Vaillancourt (Canada)
and Mrs Jane Dawson (New Zealand)
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Question 1

• What are some of the problems with using
  pictographic instructions for medications in
  regions with low levels of literacy and no
  comprehension of the language used by the service
  provider?

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Question 2

• What type of cultural/ethnic considerations are
  there either in your country or in the regions
  near you?

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Question 3

• What are some ways to improve the delivery of
  pharmaceutical care during humanitarian relief
  missions?

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Evaluation/Comprehension of Pictograms
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1 tablet 2 times a day w/food
Version 1
Version 2
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2 puffs 4 times daily
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Gargle 5 ml 4 times daily
Version 1
Version 2
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1 tsp every 4 hours
Version 1
Version 2
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1 tsp 4 times daily
Version 1
Version 2
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2 tablets twice dailyDo not take with alcohol
Version 1
Version 2