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Validation of a pictogram-based diabetes education tool in counselling patients with type 2 diabetes

Patients often struggle to understand written medication instructions and management points due to the complexity of the information.1 As shown in a study conducted at 2 urban public hospitals, approximately 42% of patients were unable to understand written medication instructions.2 Patients with type 2 diabetes mellitus are particularly susceptible to this problem, as most are on more than one medication and are also encouraged to increase their self-management of this chronic condition. Misunderstanding medications and poor compliance with diabetes management can result in unfavourable outcomes.3-5 
 
Since patient information on diabetes is mainly available in text format, it is important to develop counselling tools to enhance patient-provider communication. Pictograms have the ability to overcome communication barriers and provide simple yet necessary information. Numerous studies have shown that pictograms may improve medication safety, medication compliance and overall health outcomes in the general public.6,7 
 
Pictograms have also been shown to increase the short- and long-term (after 4 weeks) memory of complex medical instructions in patients, especially when the printed information is presented along with verbal information.8,9 According to Paivio’s dual coding theory,10 the verbal system and nonverbal system work in association, and the activation of one system triggers the activation of the other. This suggests that pictures have the ability to further activate the understanding of verbal information, therefore optimizing information interpretation and message recollection.10 The use of pictorial aids such as illustrations can make health education literature more accessible, while remaining interesting enough to appeal to individuals at all levels of reading ability.11 The use of pictograms in patient information leaflets is preferred by patients and significantly improves their understanding of the material presented.12 
 
The use of pictographic counselling tools for diabetic patients is meant to supplement written and oral information for those people who are limited in their ability to read. Difficulties in processing written instructions may be attributed to age, low literacy and comorbidities such as retinopathy. Pictograms and pictographic symbols should only use those details that are most important and provide the most information. The purpose is to lead the patient in the right direction by using symbols that build on the most characteristic concepts of reality,13 just as the traffic signs seen on the roads and streets are pictorial representations of key information understood by all drivers as an essential element of road safety. The pictograms for this study were designed with the following characteristics in mind, aiming for optimal uptake from patients with minor eye diseases: use of mainly black and white or high-contrast colours; clear and simple images; avoidance of shading, coloured images or coloured backgrounds; and use of plain large font.14 This tool was designed for patients accustomed to interpreting road signs and other commonly available pictograms; in other words, the tool catered to most North Americans with a reading level of grades 6 to 7. 
 
The purpose of the study was to evaluate and validate selected components of a pictogram-based diabetes education tool for use in counselling patients with type 2 diabetes mellitus. Pictogram-associated information recall was assessed to see if the use of pictograms improved recollection of diabetes counselling points. According to the American National Standards Institute (ANSI) standard for validation of individual pictograms, pictorial symbols must reach a criterion of at least 85% correct to achieve validation in a comprehension test.15