Research in Social and

Administrative Pharmacy 10 (2014) 704–719

Review Article
The use of pictograms in the health care:
A literature review
Izadora M.C. Barros, M.Sc., Ph.D. Student.,
Thaciana S. Alcântara, M.Sc. Student.,
Alessandra R. Mesquita, M.Sc., Ph.D. Student.,
Anne Caroline O. Santos, M.Sc.,
Felipe P. Paixão, Pharmacy Student., Divaldo P. Lyra Jr., Ph.D.*
Laboratory of Teaching and Research in Social Pharmacy (LEPFS), Federal University of Sergipe, Cidade Universitária
“Prof. José Aloı´sio Campos,” Jardim Rosa Elze, São Cristóvão, Sergipe CEP: 49100-000, Brazil

Abstract
Background: The ability of patients to understand pharmacotherapy information is critical to the successful
use of medications. One of the risk factors that may predispose the patient to non-adherence is the low
retention of verbal information. Thereby, one way to facilitate the understanding of patients regarding
prescribed pharmacotherapy is to incorporate pictograms to transmit information in a clear, expeditious,
and simple manner.
Objective: To evaluate literature on the use of pictograms for health professionals and assess their impact
on helping patients increase the understanding of and compliance with medical instructions.
Methods: Searches were conducted from February to March 2012. We searched articles in databases, using
the keywords: “pictograms,” “health,” “health care professionals,” “medication” and “pictorial represen-
tation.” After this step, we performed a manual sorting, evaluating titles and abstracts. The articles were
carefully examined according to the following variables: (1) geographic location and setting of the studies;
(2) study design; (3) number of pictograms used; (4) education; (5) sample size; (6) age of participants; (7)
function of pictograms; (8) limitations described in the literature evaluated.
Results: The research identified 136 published studies. After the exclusion process, 24 studies met inclusion
criteria and from those, 50% were conducted in Africa, and 51.4% were considered effective. In the
evaluation of the function of the pictograms, to verify their utility, 23 studies used to educate patients on
the use of medications. The translation and cultural adaptation of pictograms was performed in five
studies, and one study considered this process as validation.
Conclusion: In this review, the literature contained only a few studies employing pictograms by health
professionals, and most of these were meant for the use of medications. Moreover, the specific results reinforce
the need for more studies in this area to provide a more complete approach about pictograms in the heath care.
Ó 2014 Elsevier Inc. All rights reserved.

Keywords: Pictograms; Health care; Health professionals

* Corresponding author. Tel./fax: þ55 2107991925577.

E-mail address: lyra_jr@hotmail.com (D.P. Lyra).

1551-7411/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.sapharm.2013.11.002
 Barros et al. / Research in Social and Administrative Pharmacy 10 (2014) 704–719
Introduction
The understanding of pharmacotherapy adop-
ted is an essential factor for treatment adherence
and elimination or reduction of risks, especially
for patients with limited understanding.1 One of
the risk factors that may predispose patients to
non-adherence is the low retention of verbal infor-
mation.2 Studies show that 40–80% of the infor-
mation provided by health professionals is
forgotten immediately, because patients tend to
focus more on information about clinical diag-
nosis and often fail to retain information about
the medication treatment.3,4 This situation be-
comes worse when there is a low literacy in
health.5
Health literacy has been defined as the degree to
which individuals have the capacity to obtain
process and understand basic information and
services needed to make appropriated decisions
regarding their health.6 People with low health lit-
eracy are likely to have even more difficulties with
language/instructions utilized in specifically in
health care (prescriptions, leaflets, educational ma-
terials etc.).7 Thus, several studies have reported an
association between inadequate literacy and prob-
lems related to the proper use of medication.8–11
One way to facilitate the understanding of
patients about prescribed pharmacotherapy is to
incorporate visual tools on the guidance provided
by health professionals, through the use of labels
and patient education pamphlet.11 Among the
possible tools, stand out illustrations and picto-
grams. The illustrations (drawings, paintings,
photographs) are pictorial images used to enhance
readability and comprehension of a text, also used
in photonovelas.12 The pictograms (indicative,
signaling, and informative graphic symbols)
involve figures and concepts and can be used to
transmit information in a clear, expeditious, and
simple manner.13
Studies show that in practice the pictograms are
used for better understanding and recall of infor-
mation and should be used accompanied of verbal
guidance provided by health professionals.14–16
The use of pictograms has been receiving progres-
sive attention in recent years, possibly because of
the awareness of health professionals about the
need to provide adequate information to patients
with comprehension difficulties about their treat-
ment, for example, elderly, children and people
with low literacy.8,17,18
In this regard, since 2010, the International
Pharmaceutical Federation (FIP) has reinforced
705
the importance of pictograms as a way of commu-
nication to provide fundamental information on
the use of medication.19 The FIP is the global
federation of national associations of pharmacists
and pharmaceutical scientists and is in official re-
lations with the World Health Organization
(WHO). The Military and Emergency Pharmacy
Section (MEPS) of FIP is working to develop
culturally sensitive pictograms in both general
and in low-literacy populations.19
The FIP emphasizes the need to validate and
culturally adapt the pictograms for counseling
patients. Therefore, pictograms should be devel-
oped in accordance with the culture, beliefs, atti-
tudes and expectations of the target population and
should be carefully explained, thus to increasing the
degree of accountability and participation of pa-
tients so that they participate actively in their
treatment.20 Moreover, there are few studies that
show the feasibility and use of pictograms in health
care. As such, the aim of this review was to evaluate
the use of pictograms for health professionals and
to verify if these could help increase the understand-
ing and compliance of instructions.
Methods
This review was performed in seven steps,
adapting the recommendations of the Cochrane
Handbook: (1) formulation of the question, in
which were defined patients, disease and thera-
peutic intervention; (2) location and selection of
studies; (3) critical appraisal of the studies; (4)
data collection; (5) analysis and presentation of
data; (6) interpreting the results; and (7) upgrad-
ing and updating.
In this context, an active data search was
performed in the following databases: EBSCO,
Embase, LILACS, Pubmed, Scopus, SciELO and
PsycINFO. This study used a free search; that is,
the keywords were determined by the authors,
drawing upon their expert knowledge. Thus, was
used the following keywords: “pictograms,”
“health,” “health care professionals,” “medica-
tion” and “pictorial representation” with this
associations: “pictograms,” “health,” “health care
professionals”/“pictograms,” “health,” “medica-
tion”/“pictograms,” “health care professionals,”
“medication”/“pictograms,” “health care profes-
sionals,” “pictorial representation”/“pictograms,”
“health,” “pictorial representation”/“pictograms,”
“medication,” “pictorial representation.”
After this step, there was a manual sorting,
evaluating titles and abstracts. Inclusion criteria
706 Barros et al. / Research in Social and Administrative Pharmacy 10 (2014) 704–719
were: (1) articles published from January 1960 to
March 2009 in English, Portuguese and Spanish;
(2) complete articles available in databases; and
(3) studies related to the use of pictograms for
health professionals in patient education. The
studies analyzed in this review used pictograms
exclusively for patient education and were not
included studies that used professional labeling
documents. It is noteworthy that the articles
indexed repeatedly in 2 or more databases were
considered only once. Reviews, letters to the
editor, case study and conference proceedings
also were excluded from this study.
The above-named languages were chosen for
the following reasons: traditionally, international
databases provide the descriptors in English, so
the search strategy should necessarily be in that
language. Additionally, the publishing language
of the journals is predominantly English. Despite
this, articles in Portuguese or Spanish languages
were also included in the study due to the authors’
familiarity with these languages, making possible
the analysis of the articles.
The images that were described as pictograms
by authors of the articles were analyzed by two
reviewers and health professionals. However, the
images that have generated doubts were evalu-
ated by a graphic artist (designer) to determine if
they were pictograms or other types of pictorial
images, for example, drawings, paintings or
photographs that were used to enhance interest
in reading as well as to complement and
strengthen information.
The analysis of the selected articles was per-
formed by 2 independent reviewers. The degree of
agreement in the assessment of titles and abstracts
was measured using the Kappa considering a
confidence interval of 95%. Discrepancies ob-
served in analysis of the articles were resolved by
consensus between reviewers.
For the final evaluation, the articles were
carefully examined according to the following
variables: (1) geographic location and setting of
the studies; (2) study design; (3) number of
pictograms used; (4) education; (5) sample size;
(6) age of participants; (7) function of the picto-
grams; and (8) limitations described in the
literature evaluated. The studies analyzed in
this review of the literature used pictograms
exclusively for patient education and were not
included in the studies that used professional
labeling documents.
The present review was written in partial
accordance with criteria of the declaration of
PRISMA (Preferred Reporting Items for System-
atic Reviews and Meta-Analyses), which provides
essential information on the methodology and
conduct of systematic reviews, serving 51.85% (1,
3, 4, 6, 9, 10, 11, 17, 18, 20, 24, 25, 26 and 27) of
the criteria recommended.21
Results
An initial screening was used to identify 341
eligible titles (Fig. 1). After eliminating duplica-
tion, the search identified 136 published studies.
In the selection of titles, 62 additional titles were
excluded because they did not use pictograms.
Thereby, 74 were considered potentially relevant
to the analysis. With respect to the Kappa index,
it showed substantial agreement among the raters
(K ¼ 0.752: titles, and K ¼ 0.732: abstracts) and
was considered statistically significant (P ! 0.001).
After reading the abstracts, 46 papers were
pre-selected for the evaluation of the full text. Of
these, 22 were excluded: 6 because the full-text
version was not available in the databases, and 16
were not in agreement with the inclusion criteria.
At the end of the article selection process, 24 met
the specific inclusion criteria 22 were in English,
one in Spanish, and one in Portuguese.
With regard to the geographic location, 50%8–10,
13,16,20,22–27
were conducted in Africa, and the main
setting in which the pictograms were used were as
follows: hospital,5,23,26–29 outpatient24,30 and health
units.8,16,20,24 Regarding the methodological
design, most studies (66.6%)8–10,13,15,16,20,22–25,31,32
did not describe the methodology used. With regard
to the effectiveness, 54.1%5,8,10,14,16,20,23,24,27–29,32,33
were considered effective because the articles
described that the pictograms stimulated recall of
information previously provided, increased under-
standing or adherence of prescribed pharmaco-
therapy and 29.1%9,13,22,25,26,34,35 did not report
in the study on the effectiveness. Table 1 describes
the general characteristics of the selected studies.
In verifying the utility of the pictograms, 235,8–10,
13–16,20,22–29,31–36
studies aimed to educate patients
on the use of medications and only one study30
applied pictograms to perform prognostic and diag-
nostic tests. The amount of pictograms ranged from
three16 to 100,30 and two9,25 studies highlighted the
large amount of pictograms as the main limitation.
Concerning the form of presentation of the picto-
grams, 41.6%5,8,10,14,16,20,24,27,28,31 used a patient
education pamphlet.
Regarding the type of pictogram used, 54.1%8,
10–12,15,16,20,23,27,29,30,32,33
used local pictograms,
 Barros et al. / Research in Social and Administrative Pharmacy 10 (2014) 704–719
Fig. 1. Flowchart of progressive selection of studies (based on PRISMA, 2009).
which means pictograms developed and adapted ac-
cording to education, culture, beliefs, attitudes and
expectations of research participants; 20.8%24,
26,31,34,36
used United States Pharmacopeia –
Dispensing Information (USP-DI) pictograms; and
16.6%9,22,25,35 used both. With respect to compre-
hensibility, the symbols among these pictograms
were evaluated according to the guidelines recom-
mended by international standards, which recom-
mend a minimum percentage of understanding. In
this review, the studies used the following standards.
According to International Organization for Stan-
dardization (ISO) the images are considered under-
standable when at least 67% of them are observed
as correct. The European Commission suggests a
minimum percentage of 80%, and the American
National Standards Institute recommends a mini-
mum value of the comprehensibility is 85%.
The evaluated studies had an average compre-
hensibility of 70.6%, which were evaluated accord-
ing to the studies that described the percentage of
707
understanding of pictograms. The translation and
cultural adaptation of pictograms was performed
in 59,15,22,25,33 studies and 133 study considered this
process as validation. Table 2 provides detailed in-
formation of the pictograms evaluated in this
review.
In the analyzed studies, the pictograms were
presented to participants who were six31 to 9635
years of age. The literacy level of the participants
ranged from illiterate to much higher, and in
66.6%8–10,14,16,20,22–25,27,30,31,33,34 of the studies, a
higher proportion of participants had either
completed or were still in elementary school, and
only two22,26 studies reported the use of pictograms
with illiterate (Table 3).
Discussion
Communication with the patient has as its main
purpose the guidance and education regarding the
correct use of medications (improving effectiveness,
Table 1

708
General characteristics of studies (n ¼ 24) included in the systematic review
Authors Geographic location Setting Study design Limitations Effectiveness Outcome effectiveness
Goel (2010) Africa Hospital NR No explanation was given NR –
to the participants before
the presentation of the

Barros et al. / Research in Social and Administrative Pharmacy 10 (2014) 704–719

pictograms, making the
process confusing
Thompson et al (2010) NR NR Randomized trial Included individuals who Yes This study found benefit in
were not actually free recall, cued recall, or
prescribed the drug comprehension through
methotrexate, which may the addition of
have caused the decrease pictograms to a simple
in motivation to read prose-based medication
pamphlet
Sorfleet et al (2009) Africa Humanitarian mission NR The language used by health NR –
care providers was
French. However, many
(43%) elderly patients
could not communicate
in that language. Did not
include procedures to
assess patients’ adherence
to therapy
Yin et al (2008) North America Hospital Randomized trial Unable to maintain the Yes A plain language,
study blind, because the pictogram-based
participants often intervention used as a
reported their part of medication
randomization group in counseling resulted in
the follow-up evaluations decreased medication
dosing errors and
improved adherence
Mwingira et al (2007) Africa NR NR The sample size was Yes The patient information
relatively small and only leaflet designed for this
included participants study was shown to be
from one country and one effective in
language group in East communicating
Africa information about
antiretroviral
Mansoor et al (2006) (1) Africa Health units NR NR Yes This study reinforces the
value of providing
patients with an
appropriately designed
patient information
leaflet to inform

Barros et al. / Research in Social and Administrative Pharmacy 10 (2014) 704–719

appropriate medicine
taking behavior
Mansoor et al (2006) (2) Africa Health units NR NR Yes The medicines information
materials incorporating
simple text and
pictograms resulted in
significantly improved
adherence to therapy in
the short term
Dowse et al (2005) Africa Outpatient NR NR Yes A high adherence of greater
than 90% was found for
54% of the experimental
group (text þ pictogram
labels), compared with
only 2% of the control
group (text-only labels)
Hameen-Anttilaa et al Europe School NR NR No –
(2004)
Mansoor et al (2003) Africa Health units NR NR Yes The pictograms were
significantly improved the
understanding of
instructions in both the
nystatin suspension test
materials
Dowse et al (2002) Africa Sectors of the local black NR The process of NR –
community interpretation has
become tiresome, because
of large amount of images
Dowse et al (2001) Africa Sectors of the local black NR The process of NR –
community interpretation has
become tiresome, because
of large amount of images

709
(continued)
Table 1(continued )

710
Authors Geographic location Setting Study design Limitations Effectiveness Outcome effectiveness
Dowse et al (2011) Africa Health unit or residence NR NR Yes Majority (87.2%)
enthusiastically endorsed
the inclusion of
pictograms, both for

Barros et al. / Research in Social and Administrative Pharmacy 10 (2014) 704–719

enhancing readability and
as an aid to
understanding and
recalling information
Wilby et al (2011) North America Hospital Randomized trial NR Yes Pictograms improve the
recall of targeted
medication information
among patients receiving
antiretroviral therapy for
HIV management
Braich et al (2011) Asia Hospital Randomized trial NR Yes Taking the pictograms
home proved to be the
most effective way to
educate patients who had
low literacy levels, and it
increased adherence to
regimens by 28 days or
more
Joshi et al (2011) Africa Hospital NR NR NR –
Marques et al (2009) South America NR NR NR NR –
Knapp et al (2005) Europe NR Crossover trial Small number of NR –
Randomized trial participants, which limits
its generalizability.
Kassam et al (2004) North America NR NR NR No –
Mbuagbaw et al (2012) Africa Hospital Crossover trial NR Yes Majority (40.7%) of
participants preferred
pictograms to the
comprehension of
frequently used
prescription patterns
Kasper et al (2011) Europe Outpatient Randomized trial NR No –
 Barros et al. / Research in Social and Administrative Pharmacy 10 (2014) 704–719 711

well accepted and assisted reducing risks and promoting adherence to treat-
The pictograms used in the
dispensing process were

in transmission the of ment).37 According to the literature, the communi-

pictograms helpful in
considered the use of
cation has been conceptualized as a process of

finding the needed

Majority (74.3%) information transmission, in which occurs the
issue, receipt and understanding of the messages,
information

information
which can be verbal (written and spoken) and
nonverbal.38
The use of nonverbal messages, such as picto-
grams, has been receiving greater attention in
–

recent years, possibly due to the awareness of

health professionals about the need to strengthen
the guidance on pharmacotherapy used by the
patient.16 The use of pictograms in health care can
Some patients reported that Yes

Yes

No

be seen in two contexts: the professional context,

in which the pictograms serve to signal the equip-
ment used in different practices and public
identifying the image
they had difficulty

context, observed in environmental signals in hos-

pitals and clinics; and the communication of in-
formation in the materials for health promotion,
e.g., pamphlets, labels and leaflets about medica-
tions use.39
NR

NR

Local studies
Most studies in this review were held in Africa
Crossover trial

where there are many people with low health

literacy.40 People with low health literacy are
more likely to have difficulties with the type of
NR

NR

reading required in health care services, usually

provided in written form, such as prescriptions,
leaflets and educational materials.7 Consequently,
the low literacy can be considered as a significant
barrier to understanding the use of medicines and
achieving positive health outcomes.
Another important aspect is the deficit of
Community
Pharmacy

Pharmacy

cognitive abilities. The low reading comprehen-

sion and the deficits in cognitive abilities are the
factors related to low health literacy, which can
promote implications in communication of the
health professional with the patient.41 Therefore,
it is necessary to overcome learning barriers repre-
North America
South America

sented by these implications through the use of

written materials simplified and visuals as illustra-
Europe

tions and pictograms.15,42

Influence of age
In the elderly population, the complexity reduces
Bernardini et al (2000)

NR, not reported.

Galato F et al (2006)

the ability to correctly interpret the instructions of

Grenier et al (2011)

pharmacotherapeutic regimens.43 Consequently,

there are the commitment of adherence to treat-
ment, the worsening of the disease diagnosed, the
development of morbidity and mortality of pa-
tients, increased rates of hospitalization and costs
of health systems.44 Furthermore, when there is
Table 2

712
Characteristics of pictograms evaluated in the studies included in systematic review
Authors Function of the Number of Type of Form of % Mean Validation of Transcultural
pictograms pictograms pictogram used presentation comprehensibility pictograms adaptation
of the pictograms
Goel (2010) Medication 8 USP-DI and local Not used patient Between the pictograms No Yes

Barros et al. / Research in Social and Administrative Pharmacy 10 (2014) 704–719

pictograms education pamphlet analyzed in this study,
nor label, presented in the understanding of
random participants ranged
from 0% to 84%.
Thompson et al (2010) Medication NR Local pictograms Patient education 80% No No
pamphlet
Sorfleet et al (2009) Medication 13 Local pictograms Storyboard 10 pictograms O80% No No
Yin et al (2008) Medication NR NR Patient education NR No No
pamphlet
Mwingira et al (2007) Medication 6 Local pictograms Patient education 95% No No
pamphlet
Mansoor et al (2006) (1) Medication 3 Local pictograms Patient education 76.3% No No
pamphlet
Mansoor et al (2006) (2) Medication NR Local pictograms Patient education NR No No
pamphlet
Dowse et al (2005) Medication NR Local pictograms Label 95.2% No No
Hameen-Anttilaa et al Medication 15 USP-DI Patient education 30–99% No No
(2004) pamphlet
Mansoor et al (2003) Medication 15 USP-DI Patient education O80% No No
pamphlet
Dowse et al (2002) Medication 46 USP-DI and local Not used patient 21.7% USP and 43.4% No Yes
pictograms education pamphlet local pictograms
nor label, presented in O85%
random
Dowse et al (2001) Medication 46 USP-DI and local Not used patient 1 Interview: No Yes
pictograms education pamphlet 30.0% Local pictograms
nor label, presented in and 8.7% USP
random O85%
Follow up:
87.0% local pictograms
and 47.8% USP
O85%
Dowse et al (2011) Medication 20 Local pictograms Patient education 60.4% No No
pamphlet
Wilby et al (2011) Medication NR Local pictograms NR 88.0% No No
Braich et al (2011) Medication NR NR Patient education NR No No
pamphlet
Joshi et al (2011) Medication 10 USP-DI Not used patient 9.5% No No
education pamphlet
nor label, presented in

Barros et al. / Research in Social and Administrative Pharmacy 10 (2014) 704–719

random
Marques et al (2009) Medication 14 USP-DI Not used patient NR No No
education pamphlet
nor label, presented in
random
Knapp et al (2005) Medication 20 USP-DI and local Not used patient 15% No No
pictograms education pamphlet
nor label, presented in
random
Kassam et al (2004) Medication 16 USP-DI NR 25% No No
Mbuagbaw et al (2012) Medication NR Local pictograms Patient education 75.9% No No
pamphlet
Kasper et al (2011) Prognosis 100 Local pictograms NR NR No No
and diagnosis
clinical
Galato et al (2006) Medication 6 Local pictograms Not used patient 67% Yes Yes
education pamphlet
nor label, presented in
random
Bernardini et al (2000) Medication NR Local pictograms Questionnaire NR No No
Grenier et al (2011) Medication 21 Local pictograms Via web NR No Yes
NR, not reported.

713
Table 3
General characteristics of participants included in the systematic review
Authors
Goel (2010)
Thompson et al (2010)
Sorfleet et al (2009)
Yin et al (2008)
Mwingira et al 2007
Mansoor et al (2006) (1)
Mansoor et al (2006) (2)
Dowse et al (2005)
Hameen-Anttilaa et al (2004)
Mansoor et al (2003)
Dowse et al (2002)
Dowse et al (2001)
714
Number of participants Type of participants Age (mean) Level of literacy
100 NR 25–55 20% illiterate and 23% had graduated
100 People with less than high school 18–65 People who have not completed high
education but understand English school
Barros et al. / Research in Social and Administrative Pharmacy 10 (2014) 704–719
and have no prior knowledge of the
drug methotrexate
525 NR 9: O61 NR
245 Parents who had at least one child NR NR
aged 30 days to 8 years, which was
prescribed a liquid medication
60 HIV-positive patients who were not 21–40 The majority (60%): 511 years of
chronically treated with schooling
cotrimoxazole
120 People who were between 0 and 10 26–40 The majority (44.2%): 8–12 years of
years of formal schooling and had schooling
been prescribed one of these
antibiotics: Amoxicillin (capsules
and suspension),
phenoxymethylpenicillin and
cotrimoxazole tablet
120 Black people with HIV positive who 26–40 The majority (44.2%): 8–12 years of
were using the pill cotrimoxazole schooling
87 People who were between 0 and 10 The majority (82%): 21–65 0–10 years of schooling
years of formal schooling and had
been prescribed one of these
antibiotics: amoxicillin (capsules
and suspension),
phenoxymethylpenicillin and
cotrimoxazole tablet
90 Children 6–13 First, fifth and seventh grade
39 People who had 0–7 years of schooling 68%: 21–40 0–7 years of schooling
130 People unemployed, unskilled, manual The majority: 21–65 0 to O12 years of schooling
workers, teachers, undergraduates
and graduate with the Xhosa
mother tongue
46 Black people of the Xhosa group, all 57%: 41–65 The majority (55%): 5–7 years of
with schooling less than 7 years schooling
Dowse et al (2011) 39
Wilby et al (2011) 82
Braich et al (2011) 225
Joshi et al (2011) 200
Marques et al (2009) 55
Knapp et al (2005) 227
Kassam et al (2004) 39
Mbuagbaw et al (2012) 204
Kasper et al (2011) 100
Galato et al (2006) 73
Bernardini et al (2000) 1004
Grenier et al (2011) 66
NR, not reported.
Adults with the mother tongue O18 !10 years of schooling
isiXhosa had not received any
guidance on HIV/AIDS and used
ARVs
HIV-positive patients receiving O19 NR
antiretroviral drugs, who had 19
Barros et al. / Research in Social and Administrative Pharmacy 10 (2014) 704–719
years or more
Patients of primary school NR Below the level of elementary school
Illiterate patients 40–49 Illiterate
NR 18–84 43.64%: mean education
Persons aged greater than or equal to Part 1: 17–83 No educational qualifications (n ¼ 59),
16, who were not registered as Part 2: 65–96 professional qualifications or school
visually impaired (n ¼ 47), current college student or
graduate (n ¼ 54).
People who were unable to read or 44%: O60 The majority (44%): basic education
understand English, French or
Spanish
NR 45,6%: 21–30 The majority (48%): elementary
school
Adults who had multiple sclerosis and 18–70 0 to O12 years of schooling
can speak German
Patients and/or drug users (general 14–70 The majority (48%): elementary
population, health professionals and school
community health workers)
NR 84.6%: O50 The majority (56.7%): no schooling
NR NR NR
715
716 Barros et al. / Research in Social and Administrative Pharmacy 10 (2014) 704–719
low literacy and decline in cognitive abilities and
memory, this problem becomes even more serious,
because it hinders the knowledge of basic informa-
tion about health in this population.45
In this context, the use of pictograms can assist
in the care of the elderly, minimizing risks arising
from cognitive or educational deficits.46 Further-
more, pictograms cannot be used as the sole
source of communication, because they do not
transmit levels of detail sufficient to be a proper
understanding of the information.35 In a Hanson
and Hartzema study (1995) on the application of
pictograms without verbal guidance in elderly pa-
tients with low literacy, these were not considered
beneficial for acquiring and understanding infor-
mation about using medications.47 Therefore,
the guidance of elderly patients with low literacy
should be clear and always accompanied by verbal
instructions or supplementary texts.
Function of pictograms in health
The lack of instructions understanding about
the use of medications has been recognized as a
significant health problem, resulting in the loss of
effectiveness of the medications, prolongation
of therapy, worsening of symptoms or even death
of the patient.48 In this review almost all studies
used pictograms for instructions on the use of
medications. On the other hand, in other areas of
health, as in medicine, the illustrations are used
more often than the pictograms to explain mainly
the clinical diagnosis for patients.49–51 Research
also shows that pictograms and illustrations facil-
itate communication between health professionals
and patients, encouraging the retention of infor-
mation provided previously.10,24,26 Thus, it is the
role of health professionals to provide adequate
patient counseling by using these visual tools,
considering their age and level of literacy.
Types of pictograms used
The pictograms are generally better understood
when compared with the culture of the target
population. In this review, most of the studies
used local pictograms for guidance on the correct
use of medicines. Sampaio and colleagues (2008),
for example, reported in their study that local and
cultural factors are important for the interpretation
of the pictograms and these can have a clear
meaning in a country or culture, but be incompre-
hensible in another location.52
In short, the studies that compared the un-
derstanding and acceptance of pictograms of the
USP-DI and the local pictograms showed that
patients not only prefer, but are also more likely
to correctly interpret local pictograms, since they
reflect their beliefs and cultural aspects.15,22,36,53
Faced with the above, pictograms should be
adjusted in accordance with the culture, beliefs,
attitudes and expectations and are carefully ex-
plained, thus increasing the degree of account-
ability of the patient, so that it participates
actively in their treatment.
Effectiveness of pictograms
Pictograms may have an important role in
increasing the understanding and hence in promot-
ing adherence to prescribed pharmacotherapy.13
Regarding the effectiveness of pictograms, most
studies considered positive the use of pictograms
for patient education. In Mansoor and colleagues’
(2006) study, for example, the information mate-
rials about the use of medications that incorporated
pictograms resulted in significant improvement in
adherence to treatment in the short term.20
According to Watson and McKinstry (2009),
pictograms can serve as specific tools of visual
communication, in which health professionals can
use to improve the oral and written instructions
about the medications dispensed to the patient,
increasing knowledge and promoting adherence to
treatment.54 Therefore, it is important to invest in
the introduction and use of pictograms as a com-
plementary system of guidance provided by health
professionals.
Validation of pictograms
Pictograms must be developed from the target
population and undergo a rigorous evaluation.9
According to the FIP, two different concepts will
be examined to determine the pictograms compre-
hension by using a validated method: transpar-
ency and translucency. Transparency is “the
guessability of the meaning” of a picture or image
when the signification is unknown by partici-
pants.55–57 Translucency is the degree to which a
participant believes that the image represents
what it is supposed to portray after being told
the meaning of the pictogram.19,57
For the process of validation, the analysis of
the understanding of pictograms (transparency)
should follow recommendations of three major
organizations: the International Organization for
Standardization (ISO), the European Commission
(EC) and the American National Standards Insti-
tute (ANSI).
 Barros et al. / Research in Social and Administrative Pharmacy 10 (2014) 704–719
Galato and colleagues study (2006) used
“transparency” to verify the understanding and
culturally adapted of 4 local pictograms in Brazil,
being the only one to consider this process as
“validation of pictograms.”33 However, other
studies performed the same process, but not
named with this terminology, being regarded as
“cultural adaptation.”9,15,22,25,33 Therefore, vali-
dation of the pictograms is necessary to perform
the two processes (transparency and translu-
cency).19 Nevertheless, if the pictograms do not
reach the level of understanding previously estab-
lished by international standards, these can be
adapted to the local culture.
The cross-cultural adaptation and validation
of the pictograms are important because they
allow interchangeability of data in the world.
Conversely, these processes suffer from influences
in the perception and interpretation by patients
and vary with the patient education, culture,
values and experience.33,58 Based on these data it
appears necessary to develop more specific studies
in order to validate and adapt the pictograms in
accordance with the culture of each country and
to provide reliable results.
Suggestions for future studies
Longitudinal studies are needed to understand
the aspects that influence the understanding and
effectiveness of pictograms. In these studies it is
possible to test the pictograms in the same
population and those who are not considered
understandable can be redesigned and tested
again until they get a positive result. Therefore,
it is possible to more deeply understand the
relationships among the factors observed, for
example, between the educational and cultural
aspects with the understanding of pictograms.
Furthermore, longitudinal studies can analyze
changes in characteristics of the individual over
a period of time. For example, it is possible to
verify the adherence before and after the appli-
cation of the pictograms.
Another proposal is the development of
research on the design of pictograms with the
participation of graphic artists. Several factors
can affect the understanding of the pictograms,
such as the size of the pictogram, color and
transmission of multiple types of information.23
Thus, if the pictogram is not well designed, it
can cause confusion and harm to the attention,
comprehension, recall and adherence of the in-
structions provided. Thereby, it is important the
717
participation of graphic artists (designers) in the
development of the pictograms.
One suggestion for future research also em-
phasizes the need to conduct studies on the use of
pictograms in other areas of health. As previously
reported, there are few studies of other areas that
used pictograms to guide patients. For example,
nursing, physiotherapy, and nutrition could use
information materials with pictograms as guides
for patient education to explain the anatomy,
tests, treatments, tips and others important health
information.59 Therefore, the use of these educa-
tional materials may increase the liability of the
patients, so that they participate in the decision-
making process.
Limitations
This study had some limitations. The authors
did not assess whether the pictograms were used
with or without verbal guidance. The number of
key terms used in the search was limited because
of the primary purpose of the review. This may
restrict the findings; moreover, the investigators
used a free search for keywords; that is, the
keywords were determined by the authors based
on their knowledge of the literature because the
terms are not listed as descriptors in MeSH.
Moreover, the process of article selection was
not fully validated.
Conclusion
Pictograms can serve as communication tools
to enhance visual attention, comprehension, recall
and adherence of the instructions provided. In this
review, were found few articles on the use of
pictograms by health professionals in the literature
and almost all are meant for the use of medica-
tions. Moreover, the specific results showed that
most of the studies were conducted in Africa and
were considered effective for patient education.
Furthermore, it is suggested that future research
employ longitudinal study designs and involve
graphic artists in creating the pictograms. Gaps
in the literature underscore the need for more
research in this area to provide a more compre-
hensive approach about pictograms in health care.
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