The influence of education on the interpretation of pharmaceutical pictograms for communicating medicine instructions

Objective: To assess the influence of formal education on the interpretation of pharmaceutical pictograms. Method: A total of 46 pictograms were used: 23 were extracted directly from the USP-DI, and 23 with corresponding meanings were designed in accordance with the local culture (local pictograms). One hundred and thirty Xhosa respondents, who ranged from having no formal education to tertiary level education, were interviewed with the aid of an interpreter. Demographic data were collected, a literacy test was conducted and respondents were tested for their interpretation of all 46 pictograms. Preference for either the USP-DI or the local pictogram was determined. Setting: Respondents were interviewed in primary health care clinics, a variety of work settings or in their homes in Grahamstown, South Africa. Key findings: Standard of education had a significant influence on the interpretation of 24 of the 46 pictograms. Generally, significant differences in interpretation were apparent between those with only primary school education and those who had completed at least some senior school education (P<0.05). The group with tertiary education was significantly better than the other groups (P<0.05). Only 15 of the 46 pictograms met the American National Standards Institute (ANSI) 85% correct criterion. Conclusion: Interpretation was dependent on education and the development of visual literacy skills, but potential for misinterpretation in all educational groups was noted. These results suggest that pictograms should only be used as a communication aid in combination with text or verbal information from the health care provider.