An Overview of Pictogram: Need in Healthcare System

A pictogram is a stylized figurative illustration meant to grab the viewer's attention and provide information in order to communicate quickly and effectively without the need of words or language. The majority of the literature on health-related pictograms dates back about 30 years. Educational institutions, community pharmacies, hospital pharmacies, discharge or outpatient clinics, primary care clinics, and different medical departments (pediatrics, pulmonology, cardiovascular medicine, internal medicine, geriatrics, gastroenterology, and ophthalmology) are among the settings where health pictogram research has been carried out.

Studies have also been conducted in graphic design, visual communication and systems engineering departments. Lühnen et al.'s 2019 systematic review highlights the insufficiency of the design process and suggests that "... studies assessing the value of pharmaceutical pictograms would benefit from establishing best practices in the design and use of the pictograms themselves."[4]

Objectives

• Enhancing Patient Comprehension: Pictograms help patients, especially those with low literacy levels, understand medical instructions more easily. They improve recall and comprehension of health instructions, which are essential for effective treatment adherence.
• Improving Medication Adherence: By clearly illustrating how and when to take medications, pictograms can enhance patients' adherence to prescribed regimens, leading to better health outcomes.
• Overcoming Language Barriers: In multicultural settings, pictograms transcend language differences, ensuring that patients from diverse linguistic backgrounds receive consistent and accurate information.
• Facilitating Health Education: Pictograms serve as effective tools in health education materials, aiding in the communication of complex medical information in an accessible manner.
• Enhancing Safety Protocols: In clinical environments, pictograms can depict safety procedures, reducing the risk of errors and enhancing overall patient safety.[5]

Common Uses of Pictograms

• Public Signage: Airport signs, restroom symbols, and road signs.
• Safety Instructions: Hazard symbols, emergency exits, and fire safety signs.
• Data Representation: Graphs, charts, and statistical icons.
• User Interfaces: Mobile app icons, website navigation, and buttons

Some examples of commonly used Pictograms are given below:

• Case -1 [ Visual hallucinations due to long term usage of metoprolol]

In the reports of Jonathan A Goldner with the topic of Metoprolol-induced visual hallucinations: a case series in the JOURNAL OF MEDICAL CASE REPORTS, He stated that the Caucasian patients who suffered from heart related diseases specially hypertension and were under the medication of metoprolol, patients had experienced visual hallucinations; while sleeping they hallucinated that people were seating on chair and staring at them. On physical examination and laboratory evaluation, physician observed that they had no history of alcohol consumption and any kind of psychiatric disorder and after discontinuation of metoprolol, the patient's visual hallucination completely stopped.

So, such side effects could be avoided by representing pictorially to avoid long term usage of Anti-Hypertensive drugs like Metoprolol.[6]

• Case -2 [Sunburn due to Transdermal Fentanyl patches]

In the reports of Katia Sindali, with the topic of Life-threatening coma and full-thickness sunburn in a patient treated with transdermal fentanyl patches: a case report, he stated that the Caucasian women suffered from respiratory depression miosis and a Glasgow Coma Scale (GCS) of 3/ 15 due to sun exposure and her body temperature was 41⁰ C, while she was using fentanyl patches for chronic back pain. On full clinical examination she had wide spread erythema covering the majority of anterior surface of her body as well as blistering on her abdomen and lower limbs.

Fig. Images showing full thickness sunburn due to Fentanyl Patches

As we can see the effect of fentanyl in this case report is life threatening. So we can overcome such consequences by pictorial representation of conditions to be avoided while taking a particular medication. We have also designed a pictogram for this specific case which is presented below.

Fig- pictogram created for instructing not to use fentanyl patches under sunlight.

• Case -3 [Accidental IV administration of epinephrine instead of midazolam at colonoscopy]

In the reports of Ahmed Gado with the topic of Accidental IV administration of epinephrine instead of midazolam at colonoscopy, in this the accidental administration of epinephrin instead of pethidine (50 mg) and midazolam (5 mg) happened. This mistake was committed due to similar appearance of midazolam and epinephrine ampoules.

Fig. Similar appearance ampoules

So such errors occurring due to similar resemblance of ampoules, can be overcome by some pictorial representation.[7] These are few case reports many more are there, considering the problems in each situation unawareness or ignorance about the instruction or guidelines may be the reason behind the crisis. PICTOGRAM: instruction in picture or vector format will be the helping tool as solution to such crisis.

5. Steps for survey

1. Collection of problem statements

This was our first step of the complete survey, in which we came up with the google form which we circulated in public domain with the point of view of collecting the views of people regarding Pictogram. https://forms.gle/CpMvUfQCZChRgroF6eri

Fig- Specimen of online form for problem statement finding

Fig- graphical representation of online form responses

Fig- Graphical representations of google form questionnaire

Q-1 Do you ever face any kind of problems while dealing with any medicine?

Q-2 Precautions on label should be mentioned in which form?

Q-3 Have you ever faced any side effects of medicine?

Q-4 Have you observed any issues after prolong use of a particular medicine?

2. Screening of problem statements (intellectual)

This was our second step of survey, so in this we found some common problems which people are facing while administering and using the different medications.

The problem statements we observed during our survey are listed below: -

• Sometimes we neglect the warnings so it should be mentioned in picture format
• Some drugs are contraindicated in pregnancy so it should be mentioned on label
• The tip of the drops should not be touch with bare hands
• Some of the instructions like don’t take it with milk or don’t drive
• Side effects of antibiotics should be mentioned on label.
• Storage conditions for vaccine and parenteral should be mentioned.
• Language barrier- instructions in unfamiliar languages.
• Misinterpretation.
• Nasal drops, ear drops, and other drops precautions should be given in picture form.
• Instructions for dispersible tablets should be mentioned on label.
• Instructions for ENO that it should be firstly dissolved in water and then consumed.
• Disposal of sanitary napkins should be done with care to avoid environmental pollution.
• Some drugs are contraindicated in pregnancy.
• Amoxicillin causes red patches on bodies cause irritation to persist for 2-3 days.
• Sometimes I am unable to understand the precaution if it nis pictorially shown we can easily understand the precautions and carefully use it.
• After taking NSAIDs inflammation in stomach.
• Complex terminology.
• Do not touch eyes when you are applying preparations.
• How to open seal of ointments and drops.
• Instructions for teratogenic action of drugs.
• Insertion methods for suppository

After analysing the above problem statements, we came up with a few pictograms, which are presented in this google form.

3. Identification of problem statements

So, from above data we saw few problems that were commonly faced by most of the population while using a drug.

1. Drugs that are not safe during pregnancy
2. Drugs that are safe in pregnancy
3. Directions for the use of ophthalmic preparation
4. Direction for the administration of dispersible tablet
5. Method to dispose sanitary napkins
6. Do not touch eyes with bare hands
7. Directions for the route of administration
8. Shake well before use for preparations like suspension 

4) Creation of pictogram

From the collected problem statements, we came up with the few pictograms.

Do not touch tip of eyedrop

For parenteral ue

Do not eat orally

Safe in Pregnancy

Do not expose patch in sunlight

Do not touch eyes

Shake well before use

Do not use in Pregnancy

Dispersible tablet

Dissolve granules in water

Directions for the use of eyedrop

Directions for the disposal of sanitary napkin

5. Screening of pictogram (public responses)  https://forms.gle/HVuNxzZSLiTaNTZ99

6)  Rectification of unidentified pictogram

So, after analysing the responses we found that some of the pictograms were not correctly identified by responders. So we focused on why those pictograms were not identified, and then we realize that some changes were required in those pictograms.  So, we came up with the modification in those pictograms. Those pictograms are shown in this google form.

Directions for the use of eyedrop

Safe in Pregnancy

Do not expose patch in sunlight

7. Rescreening of unidentified pictogram

This was the second last step of our survey. In this we analyse the pictogram analysis-1 google form. And from that we identified problematic pictograms that were not identified by the public, then we modified those pictograms and created another google form as pictogram analysis-2. Then we circulated the google form in public domain again and collected responses.  This time the pictograms were successfully identified by the responders. So we finalize those pictograms.

https://forms.gle/xipKu477FCZwabQFA

After some corrections, the pictograms were correctly identified by the responders.

8. Finalization of pictogram

This step completes our survey, we have set a criteria of 75% for finalisation of pictograms. Initially our some pictograms didn’t pass our criteria, so we rectified them and came up with some modifications in them. Then our all pictograms passed it. So from this we finalized the pictogram survey.

Do not touch tip of eyedrops

For parenteral use

Do not eat orally

Safe in Pregnancy

Do not expose patch in sunlight

Do not touch eyes

Shake well before use

Do not use in Pregnancy

Dispersible tablet

Directions for the eyedrop

Dissolve granules in water

Directions for the disposal of sanitary napkin