RE: Improving illiterate patients understanding and adherence to discharge medications.

Regis Vaillancourt, Director of Pharmacy,

Other Contributors:

October 22, 2015

Dear Editor:

We read Clayton's report published in the BMJ with great interest. Clayton and his team's quality improvement project demonstrated how the use of symbols and pictures at Lahore, Pakistan, help increase patient adherence.

The International Pharmaceutical Federation (FIP) and the Children's Hospital of Eastern Ontario (CHEO) research group have been studying the use of pictograms for many years. We agree with the author regarding the use of pictures as a supplemental aid to verbal and written directions to enhance patient understanding of medication regimens. However, it is important to state that there are other factors affecting the interpretation and preference of pictograms that must be considered. These factors are: culture-specific pictograms, provision of verbal instructions, and education levels.

Culture influences the comprehension and acceptability of pictograms. Our previous publications include focus group discussions, structured guessibility interviews and an online survey, which all indicate the need for culture-specific pictograms to maximize the effectiveness of health information communication.(1,2,3) A First Nations focus group, built of community members and health care professionals, discussed pictogram modifications to reduce interpretation errors based on cultural characteristics.(1) A consensus was made to include additional components to pictograms relating to food, alcohol and time of day at which the drug is administered.(1) Subsequently, we conducted another study evaluating pictogram interpretation in non-European cultures (Chinese, Somali, East Indian). A notable difference was shown in the distribution of interpretation errors amongst these cultures, specifically for route of administration and auxiliary instruction pictograms.(2) Lastly, we created an online survey to asses the preference between multiple pictograms representing distinct medical instructions in populations worldwide: Africa, Asia, Europe, Latin America, Northern America, and Oceania.(3) Differences in pictogram preference arose between the different world regions.(3) Based on the assessments of these publications, we can conclude that culture-specific pictograms are necessary to assure proper understanding of medical instructions in target populations.

Furthermore, another study conducted at our hospital analyzed the extent that education level affects the preference and interpretation of pictograms.(4) A significant difference in image preference was observed between participants of various education levels.(4) Also, the study analyzing pictogram interpretation in non-European cultures demonstrated a strong correlation between the individual's level of education and their ability to accurately interpret a pictogram.(2) The greatest difference was found between patients with no formal schooling and those with a minimum of an elementary level education.(2) Overall, the levels of formal education significantly affect the interpretation, comprehension, and preference of medication pictograms.

As mentioned in Clayton's report, pictures should be used in conjunction to written or spoken words. Such action will increase attention and recall of medication instructions, resulting in better patient adherence. According to the FIP guidelines for the labels of prescribed medicines, the use of pictures to convey medical directives should not be used single-handedly and should always be combined with written instructions.(5) In order to enhance patient understanding and adherence to medical directives, the use of pictograms as a supplemental aid to verbal and written directions should not be underestimated.

We encourage you to visit the FIP website for more information on pictograms ( A pictogram software, entitled The Prescription Architect (Beta Version), is now available as a tool for practice.


1. Grenier, S., Vaillancourt, R.,Pynn, D., et al. Design and development of culture-specific pictograms for the labelling of medication for first nation communities. Journal of Communication in Healthcare. 2011;4(4): doi: 10.1179/1753807611Y.0000000007

2. Kassam, R., Vaillancourt, R., Collins, J.B. Pictographic instructions for medications: do different cultures interpret them accurately? International Journal of Pharmacy Practice. 2004:12;199-209: doi: 10.1211/0022357044698

3. Wilson, E. Vaillancourt, R., Pascuet, E., et al. Seeking international consensus in the use of icons for medication instructions.

4.Richler, M., Vaillancourt, R., Celetti, S.J., et al. The use of pictograms to convey health information regarding side effects and/or indications of medications. Journal of Communication in Healthcare. 2012;0(0):doi:10.1179/1753807612Y.0000000012

5. International Pharmaceutical Federation. FIP Guidelines for the labels of prescribed medicines. The Hage, The Netherlands. 2001. Available from:

Conflict of Interest:

Dr. Regis Vaillancourt is responsible for the FIP Pictogram Project. No other competing interests.

Conflict of Interest

None declared