There’s a hole in my bucket: The Circularity of Discussions Around Pictograms
Article by Mark Gibbson
The use of pictograms to convey drug-specific or health-specific information to lay patients has interested me for many years. This article is really just a ‘doodle’ of my thoughts around this subject and the potentialimpasse that we find ourselves in when discussing it at industry and regulatory level. This is of the first of a series of articles on the subject of pictogram design and testing.
In theory, pictograms can serve to provide vital information to people:
· Who have low literacy skills (up to 20% of the UK population are unable to read or have low literacy skills)
· Who may have limited competence in English (in the UK, up to 8% of the population speak a first language other than English)
· Who would be classed as ‘hard-to-reach’, such as people with a learning disability
· Who are in multilingual environments in extreme circumstances, such as disaster relief.
An inability to access written text can impair an individual’s ability to follow instructions regarding important life issues, such as medicine taking. Alternative methods of provision include recorded spoken information and pictograms. Pictograms in medicine have been developed and deployed around the world, the best known studies having taken place in the USA and South Africa. However, there is evidence that the understanding of pictograms is culture dependent. Other than a handful of isolated pilot studies (with no apparent follow up), there does not seem to have been any significant study in the area of pictogram use and interpretation across cultures.
This is in spite of the fact that the pictogram development is an important issue in the pharmaceutical, medical and surgical device industries, where pictograms are frequently used to convey complex information, such a when to take a medicine or how to administer it.
In fact, in all the discussed about pictograms I have been involved in the UK, France and wider Europe, I have become acquainted with circularity of how pictogram development is treated, as illustrated below:
‘There’s a hole in my bucket’:
i) Notionally, pictograms are a good idea, so…
ii) The realisation that sometimes pictograms may not be interpreted as intended and culture might colour users’ interpretation…
iii) The realisation that poor interpretation of pictograms might be down to poor design…
iv) And we can’t understand why because our marketing department and graphic designers are really good, but…
i) Pictograms are still notionally a good idea (back to the original idea).
I think the industry can break away from the roundabout discussions in this otherwise important area by discussing the following issues:
· Pictograms must convey simple information, on a one pictogram – one concept basis
· For pictograms in EU Patient Information Leaflets, they must also be usability tested as part of the readability test, since they are equally as important to the general message as the written instructions· As a code for communicating ideas, pictograms that are new and unfamiliar to users must be intuitively understood or easy to learn. For example, we all had to learn that ‘■’ = ‘stop’ or ‘◄◄’ = ‘rewind’ on a DVD player· As far as possible, pictograms must be culturally neutral. For example, to convey ‘take at mealtimes’, would a pictogram such as this: be intuitively understood by native speakers of Somali, or if a product is to be sold in India or the whole of southern and eastern Asia?
· Where complex information is being depicted, should photography rather than artistry ought to be considered?
· Discussion about pictograms in a pharmacy and medical device context ought to be brought back into the field of semiotics, the parent discipline of pictogram communication. Virtually no published research discussing pictograms with a health application displays any awareness of or references to semiotics as the core discipline of this area, yet there is a whole ocean of published pictogram research in semiotics
To answer the following questions:
· Is it possible to have universally understood pictograms to convey information that could be understood clearly and unequivocally in potentially stressful situations, such as disaster relief?
· If there are cross-cultural problems in the understanding of pictograms used in patient education materials, is the problem due to the fact that pictograms have largely been the domain of Anglo-Saxon developers, i.e. viewing the world through Anglo-Saxon eyes? What would Indian, Chinese or African developers of pictograms do differently?
· Do we know for sure that some pictograms, such as those depicting mealtimes could cause problems of interpretation cross-culturally, or are we simply making this (potentially patronising) assumption, based on a dominant Anglo-Saxon worldview?
· Presenting pictograms to illustrate how to take an asthma inhaler is one thing, but what about conveying potentially complex information, such as about when and how to take medicines or learning about and managing a newly diagnosed health condition?
· With the right design, can anything be conveyed in pictogram form? What about other abstract concepts, such as information about energy consumption, carbon footprinting, paying taxes? Can these concepts be represented in pictogram form for people with a cognitive disability, for example?
References
Abdullah R, Huebner R, Pictograms, Icons & Signs: A Guide to Information Graphics, Thames and Hudson, 2006
Dowse R, Ehlers M, Pictograms for conveying medicine instructions: comprehension in various South African language groups, South African Journal of Science 100, November/December 2004
Dowse R and Ehlers MS, The evaluation of pharmaceutical pictograms in a low-literate South African population. Patient Educational and Counseling 2001; 45: 87-99
Dowse, R, Ehlers, MS, Pictograms in pharmacy. International Journal of Pharmacy Practice 1998; 6: 109-18
Price S, Raynor DK, Knapp P, Developing effective medicine pictograms for the UK, HSRPP Conference, Leeds, March 2003
‘There’s a hole in my bucket’ [URL: http://en.wikipedia.org/wiki/There’s_a_Hole_in_My_Bucket]
United States Pharmacopoeia. [URL: http://www.usp.org/information/programs/pgrams/describe.htm]
Damien Bové is THE Drug Development and Regulatory Consultant (pharmaceutical or biotechnology), I work with my clients to define a drug development target, define a drug development strategy, define a regulatory strategy or define a commercial strategy. Our clients are generally raising funds or looking to license out their technology and we help them achieve it. If you want to know more don’t hesitate to get in touch.
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