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THE ROLE OF PICTOGRAMS IN PATIENT MEDICATION ADHERENCE …

THE ROLE OF PICTOGRAMS IN PATIENT MEDICATION ADHERENCE
Anil T M. DEPARTMENT OF PHARMACY PRACTICE, VISVESWARAPURA INSTITUTE OF PHARMACEUTICAL SCIENCES, BANGALORE

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  • 1. THE ROLE OF PICTOGRAMS IN PATIENT MEDICATION ADHERENCE By Anil T M. Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore. In partial fulfillment of the requirements for the degree of MASTER OF PHARMACY In PHARMACY PRACTICE Under the guidance of Mrs. Meera N. K. DEPARTMENT OF PHARMACY PRACTICEVISVESWARAPURA INSTITUTE OF PHARMACEUTICAL SCIENCES BANGALORE 2007 I
  • 2. Rajiv Gandhi University of Health Sciences DECLARATION BY THE CANDIDATE I hereby declare that this dissertation entitled THE ROLE OF PICTOGRAMS IN PATIENT MEDICATION ADHERENCE is a bonafide and genuine research work carried out by me under the guidance of Mrs. Meera N.K. Asst. Professor and Guide VIPS, BangaloreDate: Signature of the CandidatePlace: Anil T M. II
  • 3. CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled THE ROLE OF PICTOGRAMS IN PATIENT MEDICATION ADHERENCE is a bonafide research work done by Anil T M. in partial fulfillment of the requirement of Master of Pharmacy in Pharmacy PracticeDate: Mrs. Meera N.K.Place: Asst. Professor and Guide VIPS, Bangalore III
  • 4. ENDORSEMENT BY THE HOD AND PRINCIPAL This is to certify that the dissertation entitled THE ROLE OF PICTOGRAMS IN PATIENT MEDICATION ADHERENCE is a bonafide research work done by Anil T M. under the guidance of Mrs. Meera N.K. Asst. ProfessorSeal and Signature of the Head Seal and Signature of the PrincipalMrs. Githa Kishore Dr. KALYANI PRAKASAMAsst. Professor and Head PrincipalDepartment of Pharmacy Practice VIPS, BangaloreVIPS, BangaloreDate: Date:Place: Place: IV
  • 5. COPYRIGHT DECLARATION BY THE CANDIDATE I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka shall have the rights to preserve, use and disseminate this dissertation / thesis in print or electronic format for academic / research purpose.Date: Signature of the CandidatePlace: Anil T M. © Rajiv Gandhi University of Health Sciences V
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  • 8. ACKNOWLEDGEMENT It gives me immense pleasure to sincerely thank and convey my feelings to thegreat persons who helped me a lot to compile my work without whose help it would havebeen definitely difficult to complete the job. With the divine blessings and grace of His Holiness Lord Shiva, I would like todedicate this work at his holy divine feet. With a deep sense of gratitude, I owe my sincere thanks to my teacher and guideMrs. Meera N.K., Assistant Professor, Department of Pharmacy Practice,Visveswarapura Institute of Pharmaceutical Sciences, Bangalore for her able guidance,critical evaluation and constant encouragement, which aided in the timely completion ofthis dissertation. I am extremely thankful for her guidance and support rendered. I extend my heartfelt gratitude to Dr. Kalyani Prakasam, Principal,Visveswarapura Institute of Pharmaceutical Sciences Bangalore, for her beneficentsupport. I would like to thank Mrs. Githa Kishore, Assistant Professor & Head,Department of Pharmacy Practice, Visveswarapura Institute of Pharmaceutical SciencesBangalore for her immense suggestions, encouragement and assistance, which were veryuseful in my dissertation completion. VIII
  • 9. I would also like to appreciate the encouragement given byProf. Raju Koneri, Department of Pharmacology Visveswarapura Institute ofPharmaceutical Sciences Bangalore. I express my sincere thanks to Mr. Ravi, Graphic designer, who helped me todesign the pictograms and Mr. Tejaswi, Data analyst, for his valuable suggestions andkind cooperation during my project work. I would like to thank all the health care professionals in KIMS hospital whohelped me to collect the data. I would also like to thank all the staff of Department of Pharmacy Practice,Mr. Shekhar, Mr. Kiran and Mr. Kenneth, for their suggestions that helped me carvemy work. I express my gratitude to all teaching and non-teaching staff of VisveswarapuraInstitute of Pharmaceutical Sciences, Bangalore. I have great affection and heartful thanks to my dear friends Rajan.H., AbdulWaheed., and Ravindra Reddy, I am forever indebted.  You guys have seen methrough the highs and lows of my postgraduate life in Bangalore. I could not have done itwithout you. IX
  • 10. “Good friendship is a gift of God”. Words are insufficient and inefficient toexpress my whole hearted thanks to Kiran, Anitha, Dharani, Faisal, Jatin andGaurang for their valuable suggestion and help offered. I take great privilege to express my heartfelt thanks to all those who have directlyor indirectly helped me in getting through this project successfully. Last, but by no means the least, I am eternally grateful to my family for theirabiding love and encouragement.Date: Signature of the CandidatePlace: Anil T.M. X
  • 11. AbstractAbstractBackground and ObjectivesPoor adherence to prescribed medication therapy is regarded worldwide as a major healthproblem, as it constitutes a significant barrier to the effective treatment of many acute andchronic diseases, The consequences of poor adherence are inadequate health outcomesand increased health costs. Hence this study was taken up as an effort to prepare andevaluate the pictograms, & asses the influence of pictogram labels on adherence totherapy in discharge patients.MethodThis study was prospective randomized Case- Control study consisting of 111 patientswith cardio vascular, pulmonary disorders and diabetes mellitus, admitted to medicinewards of KIMS Hospital. Of these 53 were taken into experiment group which receivedpictogram + text labels and 58 in control group which received text only labels alongwith counseling.ResultsPictograms were evaluated by 81 volunteers. Of the total 18 pictograms, 14 pictograms,exceed the ANSI criterion of 85% and 16 were compiled with 67%.Medication adherence was measured by pill count score in 111 patients who participatedin the study. A score of 80% and above was considered as the patient’s adherence tomedication. At the end of 12 weeks, in the experimental group 48 (90%) patients wereadherent compared to 6 (10%) in control group which is significant (patient<0.001).85% of total participants in experimental group had totally recovered compared to 5% incontrol group.ConclusionHence it was concluded that, as adherence to medication increases, total recovery fromthe illness also increases and both were correlated. It also signifies that pictograms withtext improves the adherence and attains totally recovered status.Key words: Pictograms, Discharge patients, Medication adherence, Out come of thetreatment. The Role of Pictograms In Patient Medication Adherence XI
  • 12. CONTENTSSl. No. Particulars Page No. 1 Introduction 1 2 Objectives 8 3 Review of literature 9 4 Methodology 25 5 Results 32 6 Discussion 58 7 Conclusion 76 8 Summary 77 9 Limitations 79 10 Future Directions 80 11 Bibliography 81 12 Annexures 90 XII
  • 13. LIST OF TABLESTable No. Title Page No. Sex wise distribution of the volunteers in evaluation of 1 pictograms 32 2 Age wise distribution of volunteers 33 3 Education level of volunteers 34 4 Location of volunteers 35 5 Interpretation of the pictograms before the explanation 36 6 Interpretation of the pictograms after the explanation 38 7 Interpretation of the pictograms at follow up 40 8 Statistical analysis of the understanding of pictograms 42-48 9 Sex and group distribution of the patients 49 10 Education distribution of the patients with group 50 11 Location distribution of the patients with group 51 12 Control group correlations 52 13 Experimental group correlations 52 Descriptive statistics of counseling duration and number of 14 drugs 53 15 Pill count Score at week 1 54 16 Pill count Score at week 2 54 17 Pill count Score at week 4 55 18 Pill count Score at week 8 55 19 Pill count Score at week 12 55 20 Out come of the treatment at week 1 56 21 Out come of the treatment at week 2 56 22 Out come of the treatment at week 4 56 23 Out come of the treatment at week 8 57 24 Out come of the treatment at week 12 57 25 Chronic disease and medication information result 57 XIII
  • 14. LIST OF FIGURESTable No. Figures Page No. Sex wise distribution of the volunteers in evaluation of 1 pictograms 32 2 Age wise distribution of volunteers 33 3 Education level of volunteers 34 4 Location of volunteers 35 5 Interpretation of the pictograms before the explanation 37 6 Interpretation of the pictograms after the explanation 39 7 Interpretation of the pictograms at follow up 41 8 Sex and group distribution of the patients 49 9 Education distribution of the patients with group 50 10 Location distribution of the patients with group 51 XIV
  • 15. LIST OF ABBREVIATIONS USED (In alphabetical order)Sl No. Abbreviations Expansions 1 AIDS Acquired Immuno Deficiency Syndrome 2 ANSI American National Standard Institute 3 BMQ Brief Medication Adherence 4 HCP Health Care Professionals 5 HIV Human Immunodeficiency Virus 6 ISO International Standardization Organization 7 KIMS Kempegowda Institute of Medical Sciences 8 LDL-C Low Density Lipoprotein – Cholesterol 9 PIL Patient Information Leaflet 10 USPDI United States Pharmacopoeia Dispensing Information XV
  • 16. LIST OF ANNEXURESAnnex No. Title I Patient consent form II Interpretation of pictograms III Patient data collection form IV Brief medication questionnaire (BMQ 2003) V Pictograms without text VI Pictograms with text VII Pictograms in sticker sheet VIII Description of the pictograms IX Patient consent form (Kannada) X BMQ (Kannada) XI Data collection form (Kannada) XII Patient counseling Photo XVI
  • 17. Introduction1. IntroductionMedication adherence is defined by WHO as “the degree to which the person’s behaviorcorresponds with agreed recommendations from a healthcare provider1” Nicholas EnglishG defines -Adherence as a term that is often used interchangeably with compliance. Theterm adherence is preferred over compliance because it implies an interactive, 2collaborative relationship between the patient and the pharmacist. Adherence suggests 3that the patient is involved in treatment planning and implementation. Compliance isdefined as the extent to which a persons medication-taking behavior coincides with thehealthcare providers medical advice.4The implications of poor adherence are substantial at both the individual and populationlevel. Treatment benefits for patients are reduced, leading to both under treatment of theircondition and difficulties for the prescriber in assessing efficacy and appropriate dosage.Higher doses to improve treatment response can result in toxicity at times whenadherence is high. At the population level, non adherence results in increases inmorbidity, mortality and secondary health care costs, as well as medication wastage.Incompletely treated infectious conditions can result in ongoing transmission andaccelerated development of antimicrobial resistance5.The ability of clinics and pharmacies to share information on patients’ behavior regardingprescription refills has the potential to improve adherence6.The Role of Pictograms In Patient Medication Adherence___________________________________ 1
  • 18. Introduction Dimensions of adherence Five interacting dimensions affecting adherence Social and • Poverty, illiteracy, lack of social support, poor access to services, economic high cost of transport, unstable living conditions, and family factors dysfunction associated with poor adherence • Cultural beliefs • War (adverse material and psychological effects) • Degree of supervision of children and elderly patients Health care • Quality of patient provider relationship team/system • Cost of treatment factors • Reliability of medication distribution systems • Level of training and workload of healthcare providers • Capacity for education and follow up of patients • Monitoring of performance of system • Ability to establish community support and self management capacity Condition • Severity of symptoms related factors • Level of disability • Rate of progression of disease • Availability of effective treatments Therapy • Complexity of the medical regimen (esp. dose frequency) related factors • Side effects • Duration of treatment • Previous treatment failures • Availability of medical support Patient related • Knowledge and beliefs about their illness factors • Risk perception • Information and skills for self management • Motivation and self efficacy • Co morbidities (esp. depression, alcohol and drug abuse )(Adapted from “Adherence to long term therapies: evidence for action” WHO, 2003)The Role of Pictograms In Patient Medication Adherence___________________________________ 2
  • 19. IntroductionAlthough socioeconomic status has not consistently been found to be an independentpredictor of Adherence, in developing countries low socioeconomic status may putpatients in the position of having to choose between competing priorities. Such prioritiesfrequently include demands to direct the limited resources available to meet the needs ofother family members, such as children or parents for whom they care.Adherence to treatment by children and adolescents ranges from 43% to 100%, with anaverage of 58% in developed countries 7. Several studies have suggested that adolescents 8are less adherent than younger children .The adherence of infants and toddlers torecommended treatment regimens is largely determined by the ability of the parent orguardian to understand and follow through with the recommended management. As ageincreases, children have the cognitive ability to carry out treatment tasks, but continue toneed parental supervision.Many elderly patients present with multiple chronic diseases, which require complexlong-term treatment to prevent frailty and disability. Furthermore, the elderly are thegreatest consumers of prescription drugs. In developed countries, people over 60 yearsold consume approximately 50% of all prescription medicines (as much as three timesmore per capita than the general population) and are responsible for 60% of medication-related costs even though they represent only 12% to 18% of the population in thesecountries 9.The Role of Pictograms In Patient Medication Adherence___________________________________ 3
  • 20. IntroductionAdherence to treatments is essential to the well-being of elderly patients, and is thus acritically important component of care. In the elderly, failure to adhere to medicalrecommendations and treatment has been found to increase the likelihood of therapeuticfailure, and to be responsible for unnecessary complications, leading to increasedspending on health care, as well as to disability and early death 10.Patients’ knowledge and beliefs about their illness, motivation to manage it, confidence(self-efficacy) in their ability to engage in illness-management behaviors, andexpectations regarding the outcome of treatment and the consequences of poor adherence,interact in ways not yet fully understood to influence adherence behavior.Some of the patient-related factors reported to affect adherence are: forgetfulness;psychosocial stress; anxieties about possible adverse effects; low motivation; inadequateknowledge and skill in managing the disease symptoms and treatment; lack of self-perceived need for treatment; lack of perceived effect of treatment; negative beliefsregarding the efficacy of the treatment; misunderstanding and non acceptance of thedisease; disbelief in the diagnosis; lack of perception of the health risk related to thedisease; misunderstanding of treatment instructions; lack of acceptance of monitoring;low treatment expectations; low attendance at follow up, or at counseling, motivational,behavioral, or psychotherapy classes; hopelessness and negative feelings; frustration withhealth care providers; fear of dependence; anxiety over the complexity of the drugregimen, and feeling stigmatized by the disease.The Role of Pictograms In Patient Medication Adherence___________________________________ 4
  • 21. IntroductionNo single intervention or package of interventions has been shown to be effective acrossall patients, conditions and settings. Consequently, interventions that target adherencemust be tailored to the particular illness-related demands experienced by the patient. Toaccomplish this, health systems and providers need to develop means of accuratelyassessing not only adherence, but also those factors that contribute to it.More research is required in this area. New, sustainable initiatives targeting providerscould aim to impart knowledge about the broad determinants of the problem and ofspecific strategies for addressing them, in ways that can be systematically implemented in 11practice .There is a range of evidence suggesting that education of both healthcare workers andpatients about the disease, the taking of medication and the management of side effectsimproves adherence, and that the use of clear written instructions is synergistic with theuse of Fixed Dosage Combinations or unit dose of use packaging 12.The problem of non adherence has been much discussed, but has been relativelyneglected in the mainstream delivery of primary care health services. Despite anextensive knowledge base, efforts to address the problem have been fragmented, and withfew exceptions have failed to harness the potential contributions of the diverse healthdisciplines.The Role of Pictograms In Patient Medication Adherence___________________________________ 5
  • 22. IntroductionA stronger commitment to a multidisciplinary approach is needed in order to makeprogress in this area. This will require coordinated action from health professionals,researchers, health planners and policy-makers. Although socioeconomic status has notconsistently been found to be an independent predictor of Adherence, in developingcountries low socioeconomic status may put patients in the position of having to choosebetween competing priorities. Such priorities frequently include demands to direct thelimited resources available to meet the needs of other family members, such as childrenor parents for whom they care 11.Levels of the knowledge about treatment among patients discharged from hospital haveshown especially low levels of the knowledge about medication therapy. Informationabout medication includes - medication therapy, dosage scheduling, side effects andrequired life style changes. Several studies have reported that average no. of drugs perprescription is between 2-10 drugs. Patients tend to forget oral instructions and therecalling ability decreases with increase in the number of instructions.Pictograms stimulate imagination and will help recalling of medical instructions.Previous researches on pictograms suggest that ecological and cultural factors influencethe understanding and interpretation of pictograms13. However the success of usingpictograms as a communication aid depends on a comprehensive design and testingprocess in order to produce clear, culturally acceptable pictograms after which their valuedepends largely on their appropriate use by the pharmacist in conjunction with thepictogram.The Role of Pictograms In Patient Medication Adherence___________________________________ 6
  • 23. IntroductionAs per P.S Houts, Pictograms can increase short-term memory of medical instructionsand that, for many subjects, the recall rates were close to perfect. If accurate recall can beachieved by a high percent of persons for long periods of time, then pictograms could bean important tool in giving medical information and guidance to non literate patients andfamilies.14 A research done by Goldstein EB, shows that showing pictures before oralexplanation results in better recall than when they are shown afterwards.15 .As per Ros Dowse, the improvement in comprehension complements the higheradherence rate observed in the study. A contributing factor to this enhanced adherencecould be the success of the pictograms in stimulating the memory and aiding recall ofinformation over a prolonged time.16The Role of Pictograms In Patient Medication Adherence___________________________________ 7
  • 24. Objectives2. ObjectivesGeneral objective  To determine the role of Pictograms in patient medication adherenceSpecific objectives  To design the labels incorporating the Pictograms which are culturally appropriate for discharge patients  Evaluation of the Pictograms and compare these Pictogram + Text labels and Pictogram without text labels  To asses the influence of the Pictogram labels on adherence to therapy in discharge patientsThe Role of Pictograms In Patient Medication Adherence____________________________________ 8
  • 25. Review of literature3. Review of literaturePatient adherence to medication regimens is essential to achieve successful healthoutcomes. When used correctly, medications are one of the most effective methods forthe prevention and treatment of diseases. Unfortunately, prescribed medications areoften used incorrectly and sometimes not used at all. When patients fail to takemedications as prescribed, they do not achieve the benefits of drug regimens asdemonstrated in drug efficacy studies. The efficacy of any medication depends not onlyon the correct therapeutic regimen being prescribed, but also on patient adherence.Understanding how to recognize non adherence and characteristics that affect adherenceis important to the success of the interventions designed to address this public healthproblem. Pharmacists are in an excellent position to improve patient adherence toprescription drugs by educating patients about how to properly use their medications andmonitoring how well they adhere to their treatment plans. 17 18Adherence is a primary determinant of the effectiveness of treatment because poor 19adherence attenuates optimum clinical benefit . Good adherence improves theeffectiveness of interventions aimed at promoting healthy lifestyles, such as diet 20modification, increased physical activity, non-smoking and safe sexual behavior, and 18of the pharmacological-based risk-reduction interventions .The Role of Pictograms In Patient Medication Adherence____________________________________ 9
  • 26. Review of literatureThere is strong evidence to suggest that self-management programmes offered to patientswith chronic diseases improve health status and reduce utilization and drug costs. Whenself-management and adherence programmes are combined with regular treatment anddisease-specific education, significant improvements in health-promoting behaviors,cognitive symptom management, communication and disability management have beenobserved. In addition, such programmes appear to result in a reduction in the numbers ofpatients being hospitalized, days in hospital and outpatient visits. The data suggest a costto savings ratio of approximately 1:10 in some cases, and these results persisted over 3 21years . Other studies have found similarly positive results when evaluating the same oralternative interventions. Because most of the care needed for chronic conditions is based 22on patient self- management (usually requiring complex multi-therapies , the use ofmedical technology for monitoring and changes in the patient’s lifestyle, patients faceseveral potentially life-threatening risks if health recommendations are not followed asthey were prescribed23.Interventions for removing barriers to adherence must become a central component ofefforts to improve population health worldwide. Decision-makers need not be concernedthat an undesired increase in health budget will occur due to increasing consumption ofmedications, because adherence to those medicines already prescribed will result in asignificant decrease in the overall health budget due to the reduction in the need for othermore costly interventions. Rational use of medicines means good prescribing and fulladherence to the prescriptions.The Role of Pictograms In Patient Medication Adherence____________________________________ 10
  • 27. Review of literatureInterventions that promote adherence can help close the gap between the clinical efficacyof interventions and their effectiveness when used in the field, and thus increase theoverall effectiveness and efficiency of the health system.For outcomes to be improved, changes to health policy and health systems are essential.Effective treatment for chronic conditions requires a transfer of health care away from asystem that is focused on episodic care in response to acute illness towards a system thatis proactive and emphasizes health throughout a lifetime.Elderly people represent 6.4 % of the world’s population and their numbers areincreasing by 800 000 every month. They have become the fastest-growing segment ofthe population in many developing countries 24.Many elderly patients present with multiple chronic diseases, which require complexlong-term treatment to prevent frailty and disability. Furthermore, the elderly are thegreatest consumers of prescription drugs. In developed countries, people over 60 yearsold consume approximately 50% of all prescription medicines (as much as three timesmore per capita than the general population) and are responsible for 60% of medication-related costs even though they represent only 12% to 18% of the population in these 25countries .The Role of Pictograms In Patient Medication Adherence____________________________________ 11
  • 28. Review of literatureAdherence to treatments is essential to the well-being of elderly patients, and is thus acritically important component of care. In the elderly, failure to adhere to medicalrecommendations and treatment has been found to increase the likelihood of therapeuticfailure, and to be responsible for unnecessary complications, leading to increasedspending on health care, as well as to disability and early death 26.Poor adherence to prescribed regimens affects all age groups. However, the prevalence ofcognitive and functional impairments in elderly patients increases their risk of pooradherence. Multiple co-morbidities and complex medical regimens further compromiseadherence. Age-related alterations in pharmacokinetics and pharmacodynamics make thispopulation even more vulnerable to problems resulting from nonadherence27.A patient’s motivation to adhere to prescribed treatment is influenced by the value that heor she places on following the regimen (cost-benefit ratio) and the degree of confidencein being able to follow it. Building on a patient’s intrinsic motivation by increasing theperceived importance of adherence, and strengthening confidence by building self-management skills, are behavioural treatment targets that must be addressed concurrentlywith biomedical ones if overall adherence is to be improved28.The Role of Pictograms In Patient Medication Adherence____________________________________ 12
  • 29. Review of literatureWhile many interventions (e.g. education in self-management; pharmacy managementprograms; nurse, pharmacist and other non-medical health professional interventionprotocols; counseling; behavioral interventions; follow-up and reminders, among others),have been shown to be effective in significantly improving adherence rates, they havetended to be used alone. A single-factor approach might be expected to have limitedeffectiveness, if the factors determining adherence interact and potentiate each other’sinfluence as they are likely to do29.The most effective approaches have been shown to be multi-level – targeting more thanone factor with more than one intervention. Several programmes have demonstrated goodresults using multilevel team approaches. Examples include the Multiple Risk Factor 30Intervention Trial Research Group, 1982 and the Hypertension Detection and Follow- 31up Program Cooperative Group, 1979 . In fact, adequate evidence exists to support theuse of innovative, modified health care system teams rather than traditional, independentphysician practice and minimally structured systems. Although adherence interventionsdirected towards patients have typically focused on providing education to increaseknowledge, the available evidence shows that knowledge alone is not enough32.Roter et al., published a meta-analysis of adherence-enhancing interventions whichconcluded that “no single strategy or programmatic focus showed any clear advantagecompared with another and that comprehensive interventions combining cognitive,behavioural, and affective [motivational] components were more effective than single-The Role of Pictograms In Patient Medication Adherence____________________________________ 13
  • 30. Review of literaturefocus interventions”. Information alone is not enough for creating or maintaining goodadherence habits. First-line interventions to optimize adherence must go beyond theProvision of advice and prescriptions. If either the perceived value of adhering, or 33confidence, is low, the likelihood of adherence will also be low .More research is required in this area. New, sustainable initiatives targeting providerscould aim to impart knowledge about the broad determinants of the problem and ofspecific strategies for addressing them, in ways that can be systematically implemented inpractice.Increasing the impact of interventions aimed at patient-related factors is essential. Thereis a wealth of data from the behavioral sciences demonstrating the efficacy of specificstrategies. Although it is well known that education alone is a weak intervention, manyinterventions continue to rely on patient education to encourage patients to adhere to theirtreatment. Patients need to be informed, motivated and skilled in the use of cognitive andbehavioral self-regulation strategies if they are to cope effectively with the treatment-related demands imposed by their illness. For the effective provision of care for chronicconditions it is necessary to activate the patient and the community who support him orher 34.The Role of Pictograms In Patient Medication Adherence____________________________________ 14
  • 31. Review of literatureMedication non adherence is a large and complex problem that represents a significantimpact on our healthcare system. Hundreds of reports describe rates of nonadherencewith medication regimens among patients with various medical conditions. Estimates ofpatient adherence with a prescribed regimen range from 30% to 80%, varying by medicalcondition, data source and measures used. Nonadherence to long term medicationregimens is worse than non adherence to short term regimens. Most studies tend toconverge on a non adherence rate of 50% for long term pharmacologic therapy and 20%to 25% for medications prescribed for short periods of time 35. 36Systematic review by Cochrane , of interventions to improve the management ofdiabetes mellitus in primary care, conducted in outpatient and community settings,analyzed 41 heterogeneous studies of multifaceted intervention strategies. Some of thesestudies were targeted at health professionals, others at the organization of care, but mostof them targeted both. In 15 studies, patient education was added to the professional andorganizational interventions. The reviewers concluded that multifaceted professionalinterventions can enhance the performance of health professionals in managing diabeticpatients. Organizational interventions that improve regular prompted recall and review ofpatients can also improve diabetes management. In addition, the inclusion of patient-oriented interventions can lead to improved health outcomes for the patients. Nurses canplay an important role in patient-oriented interventions, through patient education andfacilitating adherence to treatment.The Role of Pictograms In Patient Medication Adherence____________________________________ 15
  • 32. Review of literatureIn patients with hypertension, adherence to treatment recommendations has a majorimpact on health outcomes and the costs of care. Some of the better recognizeddeterminants of adherence to antihypertensive therapy are related to drug treatment suchas drug tolerability and regimen complexity. Thus, reduced side-effects, fewer dailydoses of antihypertensive, monotherapies and fewer changes in antihypertensivemedications have all been associated with better adherence 37. 38In a landmark study conducted by Morisky et al. , patients were assigned to threeadherence-promoting interventions: physician counseling, family support for monitoringpill taking, group sessions with a social worker or to a control group. The 5-year analysisshowed a continuing positive effect on appointment-keeping, weight control and blood-pressure control in the intervention groups. The all time life table mortality rate was57.3% less for the experimental group than for the control group and the hypertension-related mortality rate was 53.2% less. The results from this longitudinal study provideevidence to support the use of adherence-enhancing interventions in patients withhypertension. 39Bogden et al. tested the effect of physicians and pharmacists working together as ateam on patients with uncontrolled hypertension. In a randomized, controlled trial, 95adult patients with hypertension (more than twice as many patients in the interventiongroup as in the control group) attained blood pressure control.The Role of Pictograms In Patient Medication Adherence____________________________________ 16
  • 33. Review of literaturePatient education and self-management should be integral components of any plan forlong-term control of asthma. In particular, economic appraisals of asthma self-management programs have shown them to be cost-effective both in terms of direct costs(mainly averted hospitalizations and reduced emergency department use) and in terms ofindirect costs (e.g. productivity losses and missed school days).The cost-benefit ratios arebetween 1:2.5 and 1:7. Ratios are even better in programmes directed at high-risk groupsand patients with severe asthma 40.Despite an increasing awareness of the limitations and inadequacies of current labelingpractices and written patient education materials, few efforts have been made to address 41,the problem. particularly in countries with a high prevalence of low literate patients.One way of facilitating the communication of medicine information to patients withlimited literacy is to incorporate visual aids such as pictograms on medicine labels and inpatient information leaflets. Pictograms have been shown to enhance comphrension and 42,43recall of information when used both alone and in combination with text . Howeverit is generally acknowledged that pictograms should not be used as the sole source ofcommunication as certain studies have shown that they convey insufficient detail forproper comprehension of medicine instructions. Their use should always be accompaniedby the health care provider. The interpretation of a wide range of pictograms has beenassessed in participants from a number of different South African language groups all ofwhom displayed limited reading skills. These papers include comment on practicalapplication as well as discussion on the misinterpretation of the pictograms 43.The Role of Pictograms In Patient Medication Adherence____________________________________ 17
  • 34. Review of literatureAlthough graphic material is often considered to be part of a universal language whichcan easily be recognized by all and can convey meaning with little or no dependence onlanguage or cultural background, cross-cultural testing has consistently found otherwise .This material is often designed by highly trained professionals who unfortunately lackinsight into the target culture and who tend to make assumptions about what can becommunicated using graphic material. This emphasizes the importance of designing andevaluating pictograms in collaborations with the target population. 13.The use of visual aids such as pictograms in communicating health information to lowliterate populations has been receiving increased attention over the past few years andthis is accompanied by a growing body of literature on the subject.The design and evaluation of pictograms is a complex, multistage, iterative process. Oneof the main strategies to minimize problems when designing pictograms is to identify thetarget population and to involve that population in all stages of the design and evaluationprocess. The pictograms should firstly be tested in healthy respondents from the targetpopulation and only after the completion of this stage, should the successful designs betested in practice in a patient population to monitor for the effect of pictograms on theunderstanding of instructions and on compliance.The Role of Pictograms In Patient Medication Adherence____________________________________ 18
  • 35. Review of literatureThe limited literacy skills of a large proportion of the Indian population present asignificant barrier to accessing and understanding medicines information necessary forthe degree of adherence required for a successful therapeutic outcome. The challengefacing health care professionals (HCPs) is to communicate this information in anappropriate, understandable form commensurate with the patient’s literacy skills and inaddition, to ensure that it is acceptable in terms of patient’s culture, beliefs, attitudes andexpectations. One way of addressing the low literacy problem is to use visual aids suchas Pictograms, which have been shown to enhance comprehension and recall ofinformation when used appropriately.The United States Pharmacopoeia convention defined pharmaceutical pictograms as“standardized graphic images that help convey medication instructions, precautionsand/or warnings to patients and consumers” (USPDI, 1989). The design and evaluationof these pictograms is a complex, multistage process. One of the main strategies tominimize problems in this process is to follow a basic ergonomic principle, which is toidentify the target population in all stages, and to involve that population in all stages ofthe design and evaluation process. The Pictograms should firstly be tested in healthyparticipants from the target population to monitor the effect of pictograms on theunderstanding of and adherence to medicine instructions.The Role of Pictograms In Patient Medication Adherence____________________________________ 19
  • 36. Review of literatureResearch shows that, in order to be successful, visual aids should be designed consideringfour processes: they should connect to the learner’s existing knowledge and interests, andpresent the information in a way that helps the learner the information.There are certain guidelines for designing pictograms which were listed below:  Collaborate with the target population and gain insight into their knowledge , beliefs , attitudes and expectations  Use familiar objects and symbols  Design simple, realistic pictures with limited content.  Use the whole body image, as isolated organs may cause confusion. However pictures showing the face and hands are well interpreted.  Use multiple stage pictures with caution  Use abstract symbols, symbols depicting motion and symbols conveying perspective with caution.  Use background space appropriately  If used, colors should be as realistic as possible  Use the appropriate size and magnifications  Pre test new pictograms in the target populationThe Role of Pictograms In Patient Medication Adherence____________________________________ 20
  • 37. Review of literatureThe practical application of pictograms in a low –literate population would entail explainthe meaning of the pictogram to the patient after which the subsequent role of thepictogram is to act as a stimulus to recall that information. The evaluation process shouldtherefore incorporate a follow-up stage to test for the effectiveness of the pictograms inaiding recall of information 45.The most significant international initiative for developing a set of standardpharmaceutical pictograms was coordinated by the staff of the United StatesPharmacopoeia (USP), who began working with USP advisory panels in 1987.Thisresulted in 29 pictograms being published in the 1989 issue of the USP dispensinginformation and this number increased to 91 pictograms in the 2000 issue 46.However these were developed for application in sophisticated, technologically advancedsociety, reflecting the essentially westernized base of its culture. The pictograms containmany symbols we felt would be unfamiliar to the majority of functionally illiterate peoplein India. This population group has a vastly different cultural and socio-economicbackground from that of the average North American.The Role of Pictograms In Patient Medication Adherence____________________________________ 21
  • 38. Review of literatureTo facilitate the communication of health and medicine information to people withlimited literacy skills, the material should be written in the patient’s first language at anappropriate reading level in a simple format using basic text, and it should incorporategraphic or pictorial aids such as pictograms to complement the written text.During the last decade, there has been growing awareness of the importance of patientscounseling on discharge from the hospital. Counseling thus provides the indivual withthe knowledge which will enable him/her to achieve health, coping with illness, andmanaging treatment. Informed patients are more likely to comply with drug treatmentprograms 47, may be less anxious, more secure, and better able to take charge of their ownmedication and treatment schedule. However studies that have examined levels ofknowledge about treatment among patients discharged from hospital have shownespecially low levels of knowledge about medication therapy. Information aboutmedication covers the aspects, such as purpose of the medication therapy, dosage,scheduling, side effects, and required life style changes 48. 48Gilhar and Levy found that only a small percentage of patients were of the importanceof taking their medication at appointed times, the relationship with meals, and thenecessity of taking medication for the prescribed period. Similarly, patients were notaware of the side effects that could develop as a result of their medication and somepatients were not informed as to what should be done if these side effects appeared.The Role of Pictograms In Patient Medication Adherence____________________________________ 22
  • 39. Review of literatureHaving to take an increased number of medications has been shown to adversely affectpatient’s knowledge and appropriate use of medications. The growing amount andcomplexity of knowledge required with the increase in medication can result in too much 49information for a patient to process and remember correctly .The patient can obtain knowledge and information about medication therapy from severalsources such as, counseling, written information, the Internet and so forth. Physiciansand Pharmacists tend to be the main source of this information50.In order to asses the adherence both direct and indirect methods are available. Direct andobjective methods of assessing adherence include blood level monitoring and urine assayfor the measurement of drug metabolites or marker compounds. Collecting blood orurine samples can be expensive and inconvenient for the patients, and moreover, only alimited number of drugs can be monitored in this way.Indirect methods of assessing adherence include patient interviews, pill counts, refillrecords and measurement of health outcomes. The interview method is inexpensive andallows the pharmacist to show concern for the patient and provide the immediatefeedback. A drawback of this method is that it can overestimate adherence and itsaccuracy depends on the patient’s cognitive abilities and the honesty of his or her replies, 60as well as the interviewer’s correct interpretation of responses .The Role of Pictograms In Patient Medication Adherence____________________________________ 23
  • 40. Review of literaturePill counts provide an objective measure of the quantity of the drug taken over the timeperiod. The accuracy of the pill counts may be enhanced when pill counts are carried out 61on an unannounced basis during the course of interview .More recently, electronic devise to measure the adherence have become available. Thesehave not attained a significant role in the management of adherence in clinical settings atthis time 61.The Role of Pictograms In Patient Medication Adherence____________________________________ 24
  • 41. Methodology4. Methodology4.1 Study site:This study was conducted in Inpatient department of Kempegowda Institute of MedicalSciences (KIMS) & Research centre, Bangalore. It is a 1000 bedded tertiary careteaching, super specialty hospital with 5 medicine units, and providing specializedhealthcare services to all strata of people in and around Bangalore.4.2 Study design:This study was a randomized Case- Control study consisting of 111 patients withCardiovascular, Pulmonary disorders, and Diabetes Mellitus, who are admitted toMedicine wards.The study was designed to evaluate the effect of Pictograms in medication adherence bypatients who were randomized to 53 patients in experimental group and 58 patients incontrol group.4.3 Study Period:The study was conducted from 0ctober 2006 to April 2007.4.4 Ethical approval:The complete project work was done according to permission granted by the ethicalcommittee of Visveswarapura Institute of Pharmaceutical Sciences, Bangalore.The Role of Pictograms In Patient Medication Adherence____________________________________ 25
  • 42. Methodology4.5 Study Criteria:Inclusion Criteria:The following categories of patients, admitted to medicine wards of KIMS Hospital, wereenrolled in the study  Patients aged 18 years and above  Hospitalization for at least 24 hours & discharged with prescription for medicines to community.  Patients with Cardiovascular, Pulmonary disorders & Diabetes MellitusExclusion Criteria:  Patients admitted to medicine ward with Psychiatric problem  Patients discharged to long-term care facility.4.6 Sources of Data:Patient data relevant to the study was obtained from the following sources:  Patient data collection form  Case sheets  Direct patient interview  Brief Medication Questionnaire  Pill Count ScoreThe Role of Pictograms In Patient Medication Adherence____________________________________ 26
  • 43. Methodology4.7 Study Procedure:a) Designing of Labels: Incorporating the Pictograms which are culturally appropriate to discharge patients was done with the help of a graphic designer, and having the models of Pictograms published in USPDI & South African models. Discussion session with a representative group from the target population was held and the outcome of the same incorporated for designing the labels. Special attention was paid to points regarding image design, concept familiarity and cultural relevance.b) Evaluation of Pictograms: was done by 81 healthy adult volunteers who were visiting the study site, were given the information that they would be shown some pictures concerning medicines and would be asked what they thought about the pictures. Accordingly informed consent was obtained. The evaluation consisted of these parts: First – Showing all 18 Pictograms randomly to volunteers and asking them to say what they thought the Pictograms meant. The Pictograms were shown without the regional language text (Kannada). Second- The Pictograms were explained with the help of Pictogram + regional language text (Kannada) to them. Third-They were asked again by randomly showing only Pictogram without the text and their opinion was recorded.The Role of Pictograms In Patient Medication Adherence____________________________________ 27
  • 44. Methodology Follow-up was done after one week of the interview by showing again only the Pictograms without the text and got their opinion.c) Assessment of pictograms: Assessment of the influence of pictogram labels on adherence to the therapy was carried out in discharged patients who got admitted to medicine wards of KIMS hospital. The steps involved were: i) Preparation of Labels: The Pictograms with regional language text and text only labels were printed on the sticker sheet. (Annexure VII) ii) Patient Enrollment: 120 patients were recruited who fulfilled the inclusion criteria, and were given the explanation of the purpose and importance of the study and their informed consent was obtained. They were randomized by computer generating numbers indicating P as Pictogram + Text (Experimental group) and T as Text only labels (Control group). Totally 111 patients completed the study, 53 in experimental group and 58 in Control group. iii) Counseling and individual dispensing: After the discharge summary was written and given to the patient by duty doctor, the medicine cabinet was checked and the patient was requested to buy the medicines (if necessary). Then the medicines were packed in separateThe Role of Pictograms In Patient Medication Adherence____________________________________ 28
  • 45. Methodology polyethylene re sealable covers. As per the instructions of doctors, the corresponding Pictogram label or text only label was pasted onto the cover and the patient was counseled about the disease, drug, purpose of the medication, drug usage, duration, side effects, follow up, life style modifications etc., The number of tablets and duration of therapy was written on the sticker.After the Individualized dispensing, the patients were reminded about the follow up visitand were requested to bring their medicines in the same containers. On an average 18.23minutes were spent with each patient depending upon the number of drugs, educationlevel and understanding capability of patients. However the pill count procedure was notrevealed at this stage to avoid over estimation.Collection of Data: For the evaluation of Pictograms- Volunteer’s interpretation ofPictograms were used. This included, demographic details, opinion about the pictograms,before the explanation, after the explanation, and at follow up visit.At the base line, patient details were collected through self designed, pre tested,structured data collection form (Annexure II), by patient interview and by dischargesummary. Patient’s data collection form included patients demographic details, co-morbid conditions, list of drugs at discharge time, duration of suffering from disease,etc.,The Role of Pictograms In Patient Medication Adherence____________________________________ 29
  • 46. MethodologyMeasuring of Adherence:Patient’s adherence to prescribed therapy was evaluated by using the Brief MedicationQuestionnaire (BMQ) (Annexure IV). This questionnaire included 4 screens i.e.Regimen Screen, Belief Screen, Recall Screen, and Access Screen. The score range ofthe Regimen Screen was 0 to 5 & the range of other three screens was 0 to 2. Scoringprocedure for BMQ is given in Annexure.4.8 Statistics:For the evaluation of Pictograms- In order to find out if there is any significantassociation between the time intervals and the levels of Understanding, Chi-square testwas used. If the p – values < 0.05, it was concluded that there is significant associationbetween the time intervals and the Understanding levels.Chi-square test was used to find the significance of Pictograms with text on medicationadherence which was represented by Pill Count Score.Correlation between the Pill count scores at different time intervals and screens weredone and p-value was determined. If p < 0.001, signified the association between theparameters.Outcome of the treatment and cross tabulation of Pill count score between Control andExperimental groups at 1, 2, 4, 8 & 12 weeks interval were found out. p-value wasdetermined by Chi-square test method. If p<0.001, it was concluded that significantassociation between the parameters exists.The Role of Pictograms In Patient Medication Adherence____________________________________ 30
  • 47. MethodologyCross tabulation of education, gender, locations were done and p- value was determinedby Chi-square method. With the help of descriptive statistics- correlation betweencounseling duration and Pill count scores at 12 weeks were found out and p-valueidentified.Statistical Software:The statistical software namely, SPSS 10, was used for the analysis of the data andMicrosoft Word & Excel had been used to generate graphs, tables etc.The Role of Pictograms In Patient Medication Adherence____________________________________ 31
  • 48. Results5. ResultsPart I: Evaluation of PictogramsDemographics of the volunteers in evaluation of pictogramsSex wise distribution of the volunteers in evaluation of pictogramsA total of 81 participants were enrolled in the study in which females 42(52%) werefound to be more compared to that of males 39(48%). Table 1 represents the sex wisedistribution of the volunteers in evaluation of pictograms. Table 1: Sex wise distribution of the volunteers in evaluation of pictograms Sex No of participants Percentage Male 39 48.15 Female 42 51.85 Total 81 100 Figure 1: Sex wise distribution of the volunteers in evaluation of pictograms Sex wise distribution of the volunteers in evaluation of pictograms Male, 39 Female, 42The Role of Pictograms In Patient Medication Adherence____________________________________ 32
  • 49. ResultsAge wise distribution of volunteers53% of the volunteers belonged to age group of 21-40yrs and 38% belonged to 41-60yrs.Table 2 represents Age wise distribution of volunteers. Table 2: Age wise distribution of volunteers Age group in yrs Male Female Total Percentage <21 2 0 2 2.47 21-40 21 22 43 53.09 41-60 16 15 31 38.27 >61 0 5 5 6.17 Total 39 42 81 100 Figure 2: Age wise distribution of volunteers Age wise distribution of volunteers >61 5 Age in yrs 41-60 31 21-40 43 <21 2 0 20 40 60 No. of the volunteersThe Role of Pictograms In Patient Medication Adherence____________________________________ 33
  • 50. ResultsEducation level of volunteers35% of volunteers had education up to high school, 27% with primary education and15% had no schooling at all. Table 3 represents the education level of the volunteers. Table 3: Education level of volunteers Education level No of participants Percentage Uneducated 12 14.81 Primary 22 27.16 High school 28 34.57 PUC/Diploma 9 11.11 Degree and above 10 12.35 Total 81 100 Figure 3: Education level of volunteers Education level of volunteers 10 12 Uneducated 9 Primary High school 22 PUC/Diploma 28 Degree and aboveThe Role of Pictograms In Patient Medication Adherence____________________________________ 34
  • 51. ResultsLocation of volunteers49% of the volunteers were from urban background and 51% from rural background.Table 4 represents the location of volunteers. Table 4: Location of volunteers Location No of participants Percentage Urban 40 49.38 Rural 41 50.62 Total 81 100 Figure 4: Location of volunteers Location of volunteers 40 Urban 41 RuralThe Role of Pictograms In Patient Medication Adherence____________________________________ 35
  • 52. ResultsInterpretation of the pictograms before the explanationThe percentage of the correct interpretation of individual pictograms was negligible and77-96% of the volunteers had not understood. Table 5: Interpretation of the pictograms before the explanation Completely understood Partially understood Not understood OppositePictogram 1 0 4 77 (95.06 ) 0Pictogram 2 0 3 78 (96.29) 0Pictogram 3 0 7 74 (91.35) 0Pictogram 4 0 4 74 (91.35) 3Pictogram 5 0 5 70(86.41) 6Pictogram 6 0 6 75(92.59) 0Pictogram 7 0 4 71 (87.65) 6Pictogram 8 2 4 75 (92.59) 0Pictogram 9 0 2 79 (97.53) 0Pictogram 10 4 9 68(83.95) 0Pictogram 11 0 2 79(97.53) 0Pictogram 12 8 10 63 (77.77) 0Pictogram 13 0 1 78 (96.29) 2Pictogram 14 8 10 63(77.77) 0Pictogram 15 0 0 78 (96.21) 3Pictogram 16 0 4 77(95.06) 0Pictogram 17 8 10 63(77.77) 0Pictogram 18 0 6 75 (92.59) 0The Role of Pictograms In Patient Medication Adherence____________________________________ 36
  • 53. Results Figure 5: Interpretation of the pictograms before the explanation Interpretation of the pictograms before the explanation 17 15 Pictogram numbers 13 Opposite 11 Not 9 understood 7 Partially understood 5 Completely understood 3 1 0 20 40 60 80 No. of respondentsThe Role of Pictograms In Patient Medication Adherence____________________________________ 37
  • 54. ResultsInterpretation of the pictograms after the explanationOf the total 18 pictograms evaluated 14 exceeded 85% of ANSI criteria and 16 werecomplied with 67% criterion of ISO. Table 6 represents the interpretation of thepictograms after the explanation Table 6: Interpretation of the pictograms after the explanation Completely understood Partially understood Not understood OppositePictogram 1 71 (87.65) 10 0 0Pictogram 2 73(90.12) 8 0 0Pictogram 3 72 (88.88) 9 0 0Pictogram 4 74(91.35) 7 0 0Pictogram 5 71(87.65) 10 0 0Pictogram 6 76(93.82) 5 0 0Pictogram 7 70 (86.41) 11 0 0Pictogram 8 80 (98.76) 1 0 0Pictogram 9 72 (88.88) 9 0 0Pictogram 10 79 (97.53) 2 0 0Pictogram 11 73 (90.12) 8 0 0Pictogram 12 80 (98.76) 1 0 0Pictogram 13 40 (49.38) 30 9 2Pictogram 14 81 (100) 0 0 0Pictogram 15 35 (43.2) 25 20 1Pictogram 16 65 (80.24) 16 0 0Pictogram 17 80 (98.76) 1 0 0Pictogram 18 65 (80.27) 16 0 0The Role of Pictograms In Patient Medication Adherence____________________________________ 38
  • 55. Results Figure 6: Interpretation of the pictograms after the explanation Interpretation of the pictograms after the explanation 17 15 Pictogram numbers 13 11 Opposite Not 9 understood Partially 7 understood Completely 5 understood 3 1 0 20 40 60 80 100 No. of respondentsThe Role of Pictograms In Patient Medication Adherence____________________________________ 39
  • 56. ResultsInterpretation of the pictograms at follow upThe recall rates were higher for most of the pictograms, 12 pictograms exceeded 85% ofANSI criterion and 16 met 67% criterion of ISO. Table 7: Interpretation of the pictograms at follow up Completely understood Partially understood Not understood Opposite Pictogram 1 68 13 0 0 Pictogram 2 70 11 0 0 Pictogram 3 72 9 0 0 Pictogram 4 70 11 0 0 Pictogram 5 69 12 0 0 Pictogram 6 76 5 0 0 Pictogram 7 64 17 0 0 Pictogram 8 81 0 0 0 Pictogram 9 70 11 0 0 Pictogram 10 80 1 0 0 Pictogram 11 70 11 0 0 Pictogram 12 80 1 0 0 Pictogram 13 35 28 13 5 Pictogram 14 81 0 0 0 Pictogram 15 33 29 15 4 Pictogram 16 63 18 0 0 Pictogram 17 81 0 0 0 Pictogram 18 62 19 0 0The Role of Pictograms In Patient Medication Adherence____________________________________ 40
  • 57. Results Figure 7: Interpretation of the pictograms at follow up Interpretation of the pictograms at follow up 17 15 Pictogram numbers 13 Opposite 11 Not 9 understood Partially 7 understood Completely 5 understood 3 1 0 20 40 60 80 100 No. of respondentsThe Role of Pictograms In Patient Medication Adherence____________________________________ 41
  • 58. The Role of Pictograms In Patient Medication Adherence____________________________________ STATISTICAL ANALYSIS OF THE UNDERSTANDING OF PICTOGRAMS In order to find out if there was any significant association between the time intervals and the level of understanding, chi –square test was used. If P<0.05, it was concluded that there is significant association between the time intervals and understanding levels We conclude that there is a significant association between the time intervals and the level of understanding. It was observed that, there is a change in the level of understanding before and after the explanation and follow uptime interval which is statistically significant. Table 8: STATISTICAL ANALYSIS OF THE UNDERSTANDING OF PICTOGRAMS Before After Follow-up P-value Pictogram 1 Completely understood 0 71 68 Partially understood 4 10 13 Not understood 77 0 0 <0.001 Opposite 0 0 042 Results
  • 59. The Role of Pictograms In Patient Medication Adherence____________________________________ P-value Before After Follow-up Pictogram 2 Completely understood 0 73 70 Partially understood 3 8 11 Not understood 78 0 0 <0.001 Opposite 0 0 0 Before After Follow-up P-value Pictogram 3 Completely understood 0 72 72 Partially understood 7 9 9 Not understood 74 0 0 <0.001 Opposite 0 0 0 Before After Follow-up P-value Pictogram 4 Completely understood 0 74 70 Partially understood 4 7 11 Not understood 74 0 0 <0.001 Opposite 3 0 043 Results
  • 60. Before After Follow-up P-value The Role of Pictograms In Patient Medication Adherence____________________________________ Pictogram 5 Completely understood 0 71 69 Partially understood 5 10 12 Not understood 70 0 0 <0.001 Opposite 6 0 0 Before After Follow-up P-value Pictogram 6 Completely understood 0 76 76 Partially understood 6 5 5 Not understood 75 0 0 <0.001 Opposite 0 0 0 Before After Follow-up P-value Pictogram 7 Completely understood 0 70 64 Partially understood 4 11 17 Not understood 71 0 0 <0.001 Opposite 6 0 044 Results
  • 61. The Role of Pictograms In Patient Medication Adherence____________________________________ Before After Follow-up P-value Pictogram 8 Completely understood 2 80 81 Partially understood 4 1 0 Not understood 75 0 0 <0.001 Opposite 0 0 0 Before After Follow-up P-value Pictogram 9 Completely understood 0 72 70 Partially understood 2 9 11 Not understood 79 0 0 <0.001 Opposite 0 0 0 Before After Follow-up P-value Pictogram 10 Completely understood 4 79 80 Partially understood 9 2 1 Not understood 68 0 0 <0.00145 Results Opposite 0 0 0
  • 62. The Role of Pictograms In Patient Medication Adherence____________________________________ Before After Follow-up P-value Pictogram 11 Completely understood 0 73 70 Partially understood 2 8 11 Not understood 79 0 0 <0.001 Opposite 0 0 0 Before After Follow-up P-value Pictogram 12 Completely understood 8 80 80 Partially unders tood 10 1 1 Not understood 63 0 0 <0.001 Opposite 0 0 0 Before After Follow-up P-value Pictogram 13 Completely understood 0 40 35 Partially understood 1 30 28 Not understood 78 9 13 <0.00146 Opposite 2 2 5 Results
  • 63. The Role of Pictograms In Patient Medication Adherence____________________________________ Before After Follow-up P-value Pictogram 14 Completely understood 8 81 81 Partially understood 10 0 0 Not understood 63 0 0 <0.001 Opposite 0 0 0 Before After Follow-up P-value Pictogram 15 Completely understood 0 35 33 Partially understood 0 25 29 Not understood 78 20 15 <0.001 Opposite 3 1 4 Before After Follow-up P-value Pictogram 16 Completely understood 0 65 63 Partially understood 4 16 18 Not understood 77 0 0 <0.00147 Results Opposite 0 0 0
  • 64. The Role of Pictograms In Patient Medication Adherence____________________________________ Before After Follow-up P-value Pictogram 17 Completely understood 8 80 81 Partially understood 10 1 0 Not understood 63 0 0 <0.001 Opposite 0 0 0 Before After Follow-up P-value Pictogram 18 Completely understood 0 65 62 Partially understood 6 16 19 Not understood 75 0 0 <0.001 Opposite 0 0 048 Results
  • 65. ResultsPart II: Role of Pictograms In Patient Medication AdherenceDemographics of the patientsAll together 111 patients completed the study, 53 patients belonged to experimentalgroup and 58 to control group. Table 9 represents the Table 9: Sex and group distribution of the patients Group Gender Total Experimental Control Male 28 36 64 Female 25 22 47 Total 53 58 111 Figure 8: Sex and group distribution of the patients Gender 22 Female 25 Gender Control 36 Experimental M ale 28 0 5 10 15 20 25 30 35 40 No. of patientsThe Role of Pictograms In Patient Medication Adherence____________________________________ 49
  • 66. ResultsEducation distribution of the patients with group Table 10: Education distribution of the patients with group Group Education Total Experimental Control Uneducated 7 15 22 Primary education 20 14 34 High school 10 17 27 PUC/Diploma 12 7 19 Degree and above 4 5 9 Total 53 58 111 Figure 9: Education distribution of the patients with group Education Degree and 5 above 4 7 Education level PUC/Diploma 12 17 High school 10 Control Primary 14 Experimental education 20 15 Uneducated 7 0 5 10 15 20 No. of patientsThe Role of Pictograms In Patient Medication Adherence____________________________________ 50
  • 67. ResultsLocation distribution of the patients with group Table 11: Location distribution of the patients with group Group Location Experimental Control Total Urban 31 25 56 Rural 22 33 55 Total 53 58 111 Figure 10: Location distribution of the patients with group Location 33 Rural 22 Location Control 25 Experimental Urban 31 0 5 10 15 20 25 30 35 No. of patientsThe Role of Pictograms In Patient Medication Adherence____________________________________ 51
  • 68. ResultsPart IIICorrelations between the pill count scores at different time intervals and 4 screensControl group correlationsThe control group correlation between different screens and pill count score at 1,2,4,8and 12 weeks were tabulated and were found to be significant (p < 0.001) Table 12: Control group correlations Regimen screen Belief screen Recall screen Access screen p-valueWeek 1 -0.768 -0.735 0.653 -0.715 0.000Week 2 -0.71 -0.548 0.634 -0.125 0.000Week 4 -0.739 -0.749 0.638 -0.791 0.000Week 8 -0.804 -0.726 0.659 -0.689 0.000Week 12 -0.773 -0.649 0.705 -0.706 0.000Experimental group correlationsThe experimental group correlations between different screens and pill count score at1,2,4,8 and 12 weeks were tabulated and were found to be significant (p < 0.001) Table 13: Experimental group correlations Regimen screen Belief screen Recall screen Access screen p-valueWeek 1 -0.856 -0.515 0.642 -0.738 0.000Week 2 -0.894 -0.778 0.902 -0.701 0.000Week 4 -0.676 -0.518 0.676 -0.685 0.000Week 8 -0.919 -0.701 0.837 -0.81 0.000Week 12 -0.948 -0.786 0.934 -0.864 0.000The Role of Pictograms In Patient Medication Adherence____________________________________ 52
  • 69. ResultsCorrelation between counseling duration and No. of drugs at discharge Table 14: Descriptive statistics of counseling duration and number of drugs 2 Descriptive statistics Mean std. Deviation r p Counseling duration (in minutes) 18.23 6.23 0.847 <0.001 No. of drugs at discharge 5.54 2.24The Role of Pictograms In Patient Medication Adherence____________________________________ 53
  • 70. ResultsPart IVMedication adherencePill count scores in control and experimental groups Table 15: Pill count Score at week 1 Group Pill count Score p-value Experimental Control >80% 29 2 61-80% 19 10 41-60% 3 27 0.000 21-40% 2 19 Total 53 58 Table 16: Pill count Score at week 2 Group Pill count Score p-value Experimental Control >80% 41 3 61-80% 8 8 41-60% 2 26 0.000 21-40% 2 21 Total 53 58The Role of Pictograms In Patient Medication Adherence____________________________________ 54
  • 71. Results Table 17: Pill count Score at week 4 Group Pill count Score p-value Experimental Control >80% 45 5 61-80% 3 8 41-60% 2 22 21-40% 2 23 0.000 <=20% 1 0 Total 53 58 Table 18: Pill count Score at week 8 Group Pill count Score p-value Experimental Control >80% 45 6 61-80% 4 7 41-60% 2 24 0.000 21-40% 2 21 Total 53 58 Table 19: Pill count Score at week 12 Group Pill count Score p-value Experimental Control >80% 48 6 61-80% 1 7 41-60% 3 30 0.000 21-40% 1 15 Total 53 58The Role of Pictograms In Patient Medication Adherence____________________________________ 55
  • 72. ResultsPart VOut come of the treatment at different time intervals Table 20: Out come of the treatment at week 1 Group Out come of the treatment Experimental Control p-value Totally recovered 1 0 Moderately recovered 48 20 Poorly recovered 4 28 0.000 Not recovered 0 10 Total 53 58 Table 21: Out come of the treatment at week 2 Group Out come of the treatment Experimental Control p-value Totally recovered 3 0 Moderately recovered 46 16 Poorly recovered 4 32 0.000 Not recovered 0 10 Total 53 58 Table 22: Out come of the treatment at week 4 Group Out come of the treatment Experimental Control p-value Totally recovered 13 0 Moderately recovered 37 18 Poorly recovered 3 30 0.000 Not recovered 0 10 Total 53 58The Role of Pictograms In Patient Medication Adherence____________________________________ 56
  • 73. Results Table 23: Out come of the treatment at week 8 Group Out come of the treatment Experimental Control p-value Totally recovered 33 2 Moderately recovered 18 24 Poorly recovered 2 22 0.000 Not recovered 0 10 Total 53 58 Table 24: Out come of the treatment at week 12 Group Out come of the treatment Experimental Control p-value Totally recovered 45 3 Moderately recovered 6 31 Poorly recovered 2 16 0.000 Not recovered 0 8 Total 53 58 Table 25: Chronic disease and medication information result Chronic Received any information disease Total Yes No < 1 yr 9 45 54 1yr-<5yrs 6 21 27 5yr-<10yrs 4 14 18 10yr-<20yrs 0 10 10 >=20yrs 0 2 2The Role of Pictograms In Patient Medication Adherence____________________________________ 57
  • 74. Discussion6. DiscussionGiven the potentially important role of pictorial symbols in communicating hazards,national and international standards have been established to evaluate theircomprehensibility, including the American National Standard Institute’s ANSI Z535.3,and the Organization for International Standardization’s ISO 3864. ANSI and ISO advisethat, in a comprehension test, symbols must reach a criterion of at least 85% or 67%correct respectively, in order to be considered acceptable.Evaluation of pictograms in healthy volunteers:Demographic CharacteristicsParticipants were all Kannada speaking adults and their demographic details arepresented in the table1, 2,3and 4. Females were in majority, 42 (52%) than males (48%).53% belonged to the age group of 21-40 years and 38% belongs to 41-60 years agegroup. 35% of participants had education up to high school, 27% with Primary educationand 15% had no schooling at all. 40 participants were from urban area and 41 were fromrural area.In the study done by R.Dowse, females constituted 70% and 90% of them were betweenthe ages of 21-65 years old. All the participants had attended school for a maximum of 7years. In the study done by M. Ehlers, 76% of respondents were females, 57% werebetween the ages of 41-65 years old, and 55% of them have completed 5 to 7 years of 16schooling. So, this study correlates with the other studies in demographic parameters.The Role of Pictograms In Patient Medication Adherence____________________________________ 58
  • 75. DiscussionInterpretation of pictograms18 pictograms were used in the study and understanding of each of the pictograms wasdone at 3 intervals – Before the explanation, after the explanation and at follow up. Thelevel of understanding was also classified into 4 categories- Completely Understood,Partially Understood, Not Understood, and Opposite. Thus, for each pictogram, 3intervals and 4 understanding levels were obtained.All the 18 pictograms used in this study are illustrated in the AnnexureV, VI, VII andVIII. Table5 shows the number of respondents who gave the correct interpretation of theindividual pictograms. The percentage of correct interpretation of individual pictogramson testing during the first interview (Before the explanation) was negligible (4%), whereas 77% to 96% of the respondents were into the category of not understood. None of thepictograms exceeded the 85% criterion for the ANSI.After the explanation was given with the help of pictograms + Kannada text, the level ofunderstanding improved which is significant (p – value < 0.001). Of the total 18pictograms evaluated, 14 exceeded the 85% of ANSI criterion and 16 were complied with67% criterion. An example: Pictogram 8 – Do not drink alcohol along with medicineswas interpreted correctly by 2 participants before and, correctly by 80 (99%) participants(P<0.001) after the explanation.The Role of Pictograms In Patient Medication Adherence____________________________________ 59
  • 76. DiscussionPictogram 14- Not to smoke while taking medicine, was interpreted correctly by allparticipants (100%) and pictograms 8,12 & 17 depicting Do not drink alcohol whiletaking medicine , take the medicine one hour before the meals and take the medicine onehour after of the meals, respectively had been interpreted by 99% respondents.After the one week follow up the recall rates were higher for most of the pictograms.Pictogram 8, 14 & 17 were interpreted correctly by 100% participants (P<0.001). Out of18 pictograms evaluated 12 exceeded 85% of ANSI criterion and 16 met 67% criterion.Pictogram 13- “Complete the full course” had less correct interpretations (43%) andmaximum number (5) of opposite answers. It was misinterpreted as “Take 4 times aday”, and as “discard the tablets daily”.Pictogram 15- “Shake well before use” gave 40% of correct answers and 4 respondentshad opposite answers. It was misinterpreted as “take the whole bottle at a time”.In order to find out if there was any significant association between the time intervals andthe level of understanding. Chi-Square test was used. The p-values arrived after carryingout the test is also given. If p<0.05, it was concluded that there is significant associationbetween the time intervals and understanding level.The Role of Pictograms In Patient Medication Adherence____________________________________ 60
  • 77. DiscussionStandard of education had a significant influence on the initial interpretation of individualpictograms in only 5 cases; pictograms 8, 10, 12, 14 & 17. When considering all thepictograms collectively, an increasing trend could be observed in the successfulinterpretation of all 18 pictograms as education level increased.In the study conducted by R.dowse , the percentage of correct interpretation for indivualpictograms on first interview ranged from 37 % to 100%. Of the total 9 pictogramsevaluated, 5 exceed the 85% ANSI criterion and 7 complied the 67%. In the follow upinterview 4 pictograms were evaluated, with 3 of these being correctly interpreted by100% of the participants. seven (30%) of the pictograms were complied with the 85%criterion of ANSI comprehension. This improved substantially in the follow up 16interview, in which 20 pictograms performed at or above 85% comprehension.In a study done by Katri Hameen-Anttila 65, et al it was observed that, some pictograms,yielded several wrong and opposite answers. Especially the pictogram “take until gone”,was found problematic and was understood correctly only by 30% of respondents. Out ofthe 15 USP pictograms, most of the participants understood them correctly. Theproportion of correct answers varied between 30and 99% and the proportion of wronganswers between 0 and 34%. Seven pictograms yielded opposite explanations comparedto correct ones.The Role of Pictograms In Patient Medication Adherence____________________________________ 61
  • 78. DiscussionAcceptability of PictogramsIn testing new pictograms, assessing patient acceptability is as important as establishingpatient understanding, as it provides us with a convenient, and powerful tool foridentifying problem areas and improving consumer ability to use the informationeffectively.In this study, every participant reacted positively to the idea of having pictograms ontheir medicine and they all felt that pictograms could play a valuable role in helping themremember how to take their medicine.The design and evaluation of pharmaceutical pictograms has not been extensivelyinvestigated and reported. Researchers have expressed surprise and alarm at some of thegross errors in the interpretation of pictograms, which could have potentially serious 51effects on health outcomes . The importance of using country specific, culturallyappropriate pictorial material to relay information, particularly to the low-literate 44populations, has been well documented.In this study, respondents were shown a total of 18 pictograms in a relatively short spaceof time, a process which was potentially tiring and confusing, particularly for thoserespondents with underdeveloped visual literacy skills. These respondents were exposedto a large number of new images which required learning. This process was an intensiveThe Role of Pictograms In Patient Medication Adherence____________________________________ 62
  • 79. Discussionexplaining /learning one, with much information being offered and processed and itcalled for a sustained high degree of concentration from the respondent. This opinion also 45has been expressed by M.ehlers where they used 46 pictograms in the study.In a study done in South India, where USPDI pictograms were evaluated, only 11pictograms were correctly interpreted by 90% of the participants and this emphasized theneed for pictograms which are culturally oriented to the target population to convey themessage properly66. In this study, we have taken care of opinion of the target populationand able to design the pictograms.Health care providers have given their feedback that extra time is required to explainpictogram labels. However, these pictorial labels could serve as a valuable aid toexpedite the communication process. Research has also shown that medicine labels andpatient information incorporating pictograms are preferred over text only labels.Role of pictograms in medication adherenceA total of 120 patients met the criteria for inclusion and agreed to take part in the study.Nine patients (7.5%) dropped out due to various reasons like shifting of the places,unable to come for follow up even after repeated telephone call reminders etc., Alltogether 111 patients completed the study. 53 patients belonged to experimental groupand 58 to control group.The Role of Pictograms In Patient Medication Adherence____________________________________ 63
  • 80. DiscussionDemographic detailsThe detailed demographic details are presented in table 9,10and 11. The average age ofthe participants was 53.54 years. Men constituted 58% and women 42% of thoserecruited. 31% of participants had completed the Primary education, 24% completed theHigh school education & 20% of participants had no schooling at all. 50% of participantswere from urban and another 50% from rural areas.There was no significant baseline differences observed (chi-square test) between theexperimental and control groups on age, sex, education location, etc. This confirms thatthe randomization has taken care of these parameters to avoid bias.As a general guide, studies with a single intervention group and control group wouldneed to include at least 60 participants per group if they are to have at least 80% power todetect an absolute difference of 25% in the proportion of patients judged to have adequateadherence52.Hana Kerzaman found that similar demographic profile of participants where the averageage was 66 years and men constituted 58% and women 42%.The mean average number of drugs prescribed at discharge was 5.54 with standarddeviation of 2.24. It ranged from 3 drugs to a maximum of 13 drugs. The mean averagecounseling duration was 18.23 minutes with standard deviation of 6.23 minutes. It wasnoticed that a strong correlation between the counseling duration and the number of 2drugs at discharge (r = 0.847) was present and was highly significant (p<0.001).The Role of Pictograms In Patient Medication Adherence____________________________________ 64
  • 81. DiscussionOut of the total participants, 54(49%) were suffering from the diseases which werediagnosed at less than one year period but only 9 (19%) patients had received thecounseling on medication usage. 45 (40%) of the participants were suffering from thediseases which were diagnosed between one year to ten year period but only 12 (22%)patients had received the counseling on medication usage.12 (11%) of the participantswere suffering from the diseases which were diagnosed at from 10 years to 22 yearsperiod but unfortunately none of them had received any medication counseling.Hence it is evident that only 17% of the total participants received the counseling onmedication which was provided by Physicians. Clinical pharmacist can play a vital rolein providing the medication counseling to the patients and to help them in medicationadherence.Brief medication questionnaireBrief medication questionnaire (BMQ) is a new self report tool for screening adherenceand barriers to adherence. The tool includes a 5 item regimen screen that asks thepatients how they took each medication in the past week, a two item belief screen thatasks about drug effects and bothersome features, and a 2 item recall screen aboutpotential difficulties in remembering. The BMQ appears more sensitive than existing 63tools and may be useful in identifying and diagnosing adherence problems .It has beenshown in the annexure and the scoring procedure is given.The Role of Pictograms In Patient Medication Adherence____________________________________ 65
  • 82. DiscussionRegimen Screen: has the scoring procedure of 0 to 1 for each question and includes 5questions. Each correct answer regarding the drug regimen will get 0 point and 1 pointfor wrong answer. The total score of 0 to 1 gives the interpretation that patient has thefull knowledge about the regimen, where as scores more than 1 indicates barrier in drugregimen schedule.Belief Screen: has the scoring procedure of 0 to 1 and has 2 questions. The total scoreof 0 to 1 gives the indication of positive belief regarding drug therapy, where as score of>1, establishes the negative belief.Recall Screen: has the scoring procedure of 0 to 1 and has 2 questions. Each answer ofYes gets 1 score and No gets 0 score. Total score of 0 to 1 indicates tough recall andscores >1, establishes easy recall.Access screen: Has 2 questions which deal with refilling of prescriptions and availabilityof drugs. It carries the scoring procedure of 0 to 1. Total points of 0 to1 gives theinformation that patient had easy access and scores of >2, establishes the tough accesstowards drugs.The Role of Pictograms In Patient Medication Adherence____________________________________ 66
  • 83. DiscussionIt is evident that, when Regimen, Belief, and Access screens have lowest scores, Pillcount scores will be higher; it has been denoted by negative sign. On the contrary, inrecall screen, the higher the score, pill count score is also higher which is denoted bypositive sign.Correlations between the pill count scores at different time intervals and 4 screensControl group:Correlation between different screens and pill count score at 1,2,4,8 and 12 weeks weretabulated and found significant (p<0.001).The r values of Regimen screen at different time intervals was ranged from -0.710 to -0.804 and has p value of 0.000 which is significant.The r values of Belief screen at different time intervals ranged from -0.548 to -0.749 andhave p value of 0.000 which is significant.The r values of Recall screen at different time intervals ranged from +0.634 to +0.705and have p value of 0.000 which is significant.The Role of Pictograms In Patient Medication Adherence____________________________________ 67
  • 84. DiscussionThe r values of Access screen at different time intervals ranged from -0.125 to -0.791 andhave p value of 0.000 which is significant.Experimental group:Correlation between different screens and pill count score at 1,2,4,8 and 12 weeks weretabulated and found significant ( p<0.001).The r values of Regimen screen at different time intervals ranged from -0.676 to -0.948and has p value of 0.000 which is significant.The r values of Belief screen at different time intervals ranged from -0.515 to -0.786 andhave p value of 0.000 which is significant.The r values of Recall screen at different time intervals ranged from +0.642to +0.934 and have p value of 0.000 which is significant.The r values of Access screen at different time intervals ranged from -0.701 to -0.864and have p value of 0.000 which is significant.In this study, we can observe that the r value has been improved in the experimentalgroup comparatively with control group.The Role of Pictograms In Patient Medication Adherence____________________________________ 68
  • 85. DiscussionMedication adherenceIt is measured by pill count score, which is calculated by dividing the number of dosestaken by number of doses prescribed and is represented by percentage The score of80% and above was considered as the patients adherence to medications.In our study, the pill count score was calculated and cross tabulated to get the results, chi-square test was applied to get p-value.At week 1, Experimental group had 29 (54%) patients who could be classified asAdherent compared to 2 (3.4%) patients in control group, which is significant (p<0.001)in nature.At week 2, Experimental group had 41 (77%) patients who could be classified asAdherent compared to 3 (5.1%) patients in control group, which is significant (p<0.001)in nature.At week 4, Experimental group had 45 (85%) patients who could be classified asAdherent compared to 5 (8.6%) patients in control group, which is significant (P<0.001)in nature.At week 8, Experimental group had 45 (85%) patients who could be classified asAdherent compared to 6 (10.3%) patients in control group, which is significant (p<0.001)in nature.The Role of Pictograms In Patient Medication Adherence____________________________________ 69
  • 86. DiscussionAt week 12, Experimental group had 48 (90%) patients who could be classified asAdherent compared to 6 (10.3%) patients in control group, which is significant (p<0.001)in nature.In this study it can be noted that , the medication adherence progressed with time in theexperimental group. This can be due to ability to recall the instructions and not missingthe doses because of pictograms with text labels.Even if the patient is uneducated, the care giver can get the information by seeing thelabels which are pasted on the covers and can guide the patients appropriately or thepatient will become familiar with the pictograms and can adhere to therapy which is notpossible with text only labels.Hence we can conclude that, 90% of the participants are adherent to medication in theexperimental group, where as 10% were adherent in Control group. 53In a study by Al-Eidan added counseling from a hospital pharmacist and a follow upphone call after three days of therapy in the intervention group,(including mentioningpossible side effects) for H-pylori eradication. The control patients were given only astandard advice sheet and referral to their family physician that prescribed the samemedication. Both compliance (pill count) and H-pylori eradication were improved in theintervention group with the control group.The Role of Pictograms In Patient Medication Adherence____________________________________ 70
  • 87. Discussion 54Piette evaluated the effect of biweekly automated telephone assessment and self careeducation calls with follow up on the management of diabetes. Compared with usualcare, patients in the intervention group reported fewer problems with medicationadherence (p<0.003). Patients in the intervention group also had lower glycatedhemoglobin levels, lower serum glucose levels and fewer diabetic symptoms than thosein the control group.A study in hypertensive patients done by Friedman 55 tested a telephone linked computersystem for monitoring and counseling patients. The patients in experimental group,showed greater medication adherence (p<0.05) and controlled diastolic blood pressure(p<0.05) than those receiving usual care.In a study where the objective of the study was to asses the impact of medicinesinformation on adherence to chronic co-trimoxazole therapy in low literate HIV/AIDSpatients, participants were randomly allocated to a control group (receiving no PatientInformation leaflets (PIL), group A (receiving complex PIL) and group B (receivingsimple PIL incorporating pictograms). In a follow up interview adherence to therapy wasassessed using two methods; Self report and tablet count. The medicines informationmaterials incorporating simple text and pictograms resulted in significantly improvedadherence to therapy in the short term (76.3%), where as non- significant increase inadherence was associated with the availability of the more complex information (43.3%).This was shown by both self reported adherence and as well as tablet count62.The Role of Pictograms In Patient Medication Adherence____________________________________ 71
  • 88. DiscussionOutcome of the treatment in the present study:The participants were asked about the recovery status classified into 4 categories- Totallyrecovered, moderately recovered, poorly recovered, and not recovered. The results werecross tabulated and chi-square test was applied to get p value.At week 1, experimental group had only one patient who was totally recovered comparedto none in control group and had 48 (91%) patients moderately recovered compared to20 (34%) in control group which is significant in nature (p < 0.001).At week 2, experimental group had three patients who were totally recovered comparedto none in control group and had 46 (87%) patients moderately recovered compared to 16(28%) in control group which is significant in nature (p < 0.001).At week 4, experimental group had 13 (25%) patients who were totally recoveredcompared to none in control group and had 37 (70%) patients moderately recoveredcompared to 18 (31%) in control group which is significant in nature (p < 0.001).At week 8, experimental group had 33(62%) patients who were totally recoveredcompared to 2 (3%) in control group and had 18 (34%) patients moderately recoveredcompared to 24 (41%) in control group which is significant in nature (p < 0.001).The Role of Pictograms In Patient Medication Adherence____________________________________ 72
  • 89. DiscussionAt week 12, experimental group had 45(85%) patients who were totally recoveredcompared to 3(5%) in control group and had 6 (11%) patients were moderatelyrecovered compared to 31 (53%) in control group which is significant in nature (p <0.001).Since p<0.001, we conclude that, 85% of the total participants in experimental group hadbeen recovered totally compared to 5% in control group which is significant in nature.Hence, we conclude that, as adherence to medication increases, total recovery from theillness also increases and both were correlated. It also signifies that, Pictograms with textimproves the adherence and attains totally recovered status. 51In a study by S.A Al-Rasheed et al, improved health care events were maintainedbetween two visits with compliance significantly increasing in experimental group from48% to 70%. It highlights the potential of a pharmacist to counsel each elderly patient,prior to discharge.The Role of Pictograms In Patient Medication Adherence____________________________________ 73
  • 90. Discussion 56Levy and colleagues reported that intervention involving asthma education fromhospital based specialist asthma nurses improved adherence and clinical outcomes inasthmatic patients. Self reported compliance was significantly higher in the interventiongroup for use of inhaled topical steroids and rescue medication for severe asthmaticattacks. In terms of clinical outcomes, intervention patients had significantly higher peakexpiratory flow values and significantly fewer symptoms at six months than patients inthe control group. 57,Volume et al’s study patients in the intervention group, age>65 years old, and usingthree or more medications, received a comprehensive pharmaceutical care bypharmacists. Control group receives the usual services of pharmacy. No difference inadherence or clinical outcome was observed over the year of the study. 58Coull et al investigated the role of pharmacist in older people with ischemic heartdisease. The intervention group was provided the pharmaceutical care by pharmacist andcontrol group continued to receive standard care. The intervention group reportedsignificantly more adherence with medication (measured by self report) than the controlgroup but there was no improvement in the treatment outcome. 59Marquez Contreas et al reported a significant difference in compliance and treatmentoutcome between two study groups. The control group of 63 patients received the usualmedical treatment, which included oral information about hypercholesterolemia, adviceabout its control, brochures about dietary recommendations, 3 month long prescriptionsfor cholesterol lowering medication, and titration of that medication if indicated at 3The Role of Pictograms In Patient Medication Adherence____________________________________ 74
  • 91. Discussionmonths. The intervention group of 63 patients received this care and in addition, receiveda telephone call at 7-10 days, 2 months, and 4 months. The telephone interventionimproved the percentage of patients complying with lipemia treatment according to pillcounts, produced a larger mean decrease in total cholesterol and low density lipoproteincholesterol (LDL-C) over six months of treatment and resulted in more patients reachinggoals for their overall cholesterol profile and LDL-C.In a study which asses the effects of pharmacist giving advice to meet patient’s need afterstarting a new medicine for chronic condition. 500 patients were randomized toexperimental group who receives pharmacist delivered intervention and control groupwho had not received the counseling. At a 4 week follow up, non adherence issignificantly lower in the intervention group compared to the control (9% versus 16%,p=0.032) and intervention group patients also had more positive beliefs about their new 64medicines .The results of adherence and positive belief in this study matches with the present studyand reinforces the role of pictograms in medication adherence.The Role of Pictograms In Patient Medication Adherence____________________________________ 75
  • 92. Conclusion7. ConclusionAdherence to pharmacotherapy is essential for optimal therapeutic outcomes. The pivotalrole of the pharmacist in optimizing adherence encompasses many actions: assessing theadherence problem, identifying predisposing factors, providing comprehensivecounseling and recommending specific adherence strategies targeted to patient’s need.Low literate patients comprise a patient population with special needs who are at a higherrisk of experiencing poor health.In this study, pictograms + text labels along with patient counseling, was associated withsubstantial and sustained improvements in medication adherence among dischargedpatients receiving complex regimens.When used appropriately, with time being taken by the healthcare provider to explain themeaning, pictograms have proven to be most successful in stimulating recall of medicineinformation. This study had also shown their positive influence on patient education andcompliance.Our efforts are likely to bring the most benefit to the patients at highest risk of adherenceproblems and issues like, patients being newly introduced to a treatment or patients withprevious problems with adherence in chronic diseases. By providing them aneducational, behavioral and emotional support to manage their disease, we have probablyfulfilled our professional role in promoting adherence.The Role of Pictograms In Patient Medication Adherence____________________________________ 76
  • 93. Summary8. SummaryMedication adherence is defined by WHO as “the degree to which the person’s behaviorcorresponds with agreed recommendations from a healthcare provider.”Patient adherence to medication regimens is essential to achieve successful healthoutcomes. When used correctly, medications are one of the most – effective methods forthe prevention and treatment of diseases.Pictograms stimulate imagination and will help recalling of medical instructions. Thepractical application of pictograms in low literate population would entail explaining themeaning of the pictogram and act as a stimulus to recall the information.Objective of this study was to design and evaluate the pictograms which are culturallyappropriate for discharge patients and asses the influence of the pictogram labels onadherence to therapy in discharge patients.18 pictograms were prepared with the help of a graphic designer incorporating thesuggestions given by representative group from the target population.Pictograms were evaluated by 81 volunteers at 3 intervals- Before the explanation, afterthe explanation and at follow up. The level of understanding is also classified into 4categories – completely understood, partially understood, not understood and opposite.The Role of Pictograms In Patient Medication Adherence____________________________________ 77
  • 94. SummaryAfter the explanation was given, the level of understanding had been improved which issignificant (p<0.001). 14 pictograms exceeded the 85% of ANSI criterion and 16complied with 67% criterion of ISO.Influence of the pictograms on medication adherence was conducted in the medicinewards of KIMS hospital and Research center, Bangalore during October 2006 to April2007. It was a prospective, randomized case control study consisting of 111 patients withcardio vascular, pulmonary disorders and diabetes mellitus, admitted to medicine wards.53 patients were assigned to experiment group, received the pictogram + text labels and58 patients in the control group received the text only labels along with counseling.90% of the participants in experiment group have been classified as adherent compared to10% in control group which is significant (p<0.001). As the adherence increases, totalrecovery from the illness also increases and both were correlated. It has been concludedthat pictograms + text labels improves the medication adherence and attains totalrecovery status.The Role of Pictograms In Patient Medication Adherence____________________________________ 78
  • 95. Limitations9. LimitationsThe generalisability of the findings is limited only to hospitalized people and not to thegeneral population. Other segments of the population may posses a greater amount ofadherence to medication.In this study, patients who received the usual discharge procedure was not included.The duration of the study was small, and long term follow up is required for assessingmedication adherence in chronic disease conditions.The Role of Pictograms In Patient Medication Adherence____________________________________ 79
  • 96. Future directions10. Future directions  The pictograms prepared is only 18, there is a lot of scope to prepare new set of pictograms which could cater to the needs of patients.  The pictograms can be printed in color & asses the influence.  The text can be printed in other languages like Hindi, Telugu, Tamil etc., and used in different regions of the country.  The pictograms can be used in patient information leaflets, package inserts, and can assess the influence on adherence.  The same study can be done by adding another group consisting of patients who receive the usual discharge procedure and asses their medication adherence.  Medication adherence can be evaluated by plasma level monitoring and urine assay for the measurement of drug metabolites or marker compounds done randomly, improves the sensitivity of detecting non adherence.  Electronic pill bottle monitors can be used in measuring of adherence.  Further research is required to establish whether pictograms can be effective clinical tool which is suitable for the whole population and their meaning can be taught to children at school.  The challenge lying ahead is to influence and convince health authorities of the need for this type of intervention, introduce pictograms into routine practice and monitor the outcomes of such an initiative.The Role of Pictograms In Patient Medication Adherence____________________________________ 80
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  • 102. Bibliography 40. Taggart VS et al. You can control asthma: evaluation of an asthma education program for hospitalized inner city children. Patient education & counseling , 1991, 17: 35-47. 41. Moyniham M , Mukherjee U. Visual communication with non literates: a review of current knowledge including research in northern India. Int J Health Educ 1981; 24: 251-262. 42. Dunn M , Buckwalter K Weinstein L, palti H. Teaching the illiterate does not have to be problem. Fam Community Health 1985;8: 76-80. 43. Sexton T. Visual materials: how can we communicate? . Int Journal Health Educ 1970; 13:88-90. 44. Ngoh LN, Sheperd MD, Design, development and evaluation of visual aids for communicating prescription drugs to non literate patients in rural Cameroon. Patient Educ Couns 1977: 30: 245-61. 45. Dowse R, Ehlers MS. Pictograms in pharmacy. Int J Pharm Pract 1998;6:109-18. 46. United States Pharmacopiea dispensing Information, vol.II Rockville, (MD) :Micromedex Inc., 2000. 47. L. Esposito, The effects of medicatin education ob adherence to medication regimens in an elderly population. JAN 21 (1995) , pp 935-943.The Role of Pictograms In Patient Medication Adherence____________________________________ 86
  • 103. Bibliography 48. D. Gilhar and M. Levy , patients knowledge of medication prescribed on discharge from hospital. Harefuah 112 (1987) pp 488-490. 49. J.L. King , J.C.Schommer and R.G. wirsching , Patient’s Knowledge of medication care plans after hospital discharge. Am.J. Health System. Pharm 55 (1998), pp 1389-1393. 50. S. wolfe and V. Schrim, Medication Counseling for the elderly: effects of knowledge and compliance after hospital discharge. Geriatric Nurse 13 (1992), pp 134-139. 51. Irwin Nazareth et al. A pharmacy discharge plan for hospitalized elderly patients – a randomized controlled trial. Age and Ageing 2001;30:33-40. 52. Haynes RB et al. Interventions for enhancing medication adherence. Cochrane Database of Systematic reviews 2005, Issue 4. 53. Al-Eidan et al. Management of H.Pylori eradication – the influence of structured counseling and follw up. British Journal Cllinical Pharmacolgy 2002 ; 53 (2) 163-71. 54. Piette JD et al. Do automated calls with nurse follow up improve self care and glycemic control among the vulnerable patients with diabetes. The American Journal of Emergency Medicine 2000 ; 108: 20-7.The Role of Pictograms In Patient Medication Adherence____________________________________ 87
  • 104. Bibliography 55. Friedman RH. et al. A telecommunications system for monitoring and counseling patients with hypertension. Impact on medication adherence and blood pressure conrol. American Journal of Respiratory and critical Care Medicine 1999; 9:285- 92. 56. Levy ML et al . A randomized controlled evaluation of specialist nurse education following accident and emergency department attendance for acute asthma. 57. Volume CI et al. Pharmaceutical care research and education project: patient outcomes. Journal of the American Pharmaceutical Association 2001; 41(3): 411- 20. 58. Coull AJ et al. A randomized controlled trial of senior lay health mentoring in old people with ischemic heart disease. The Brave heart project. Age and Ageing 2004; 33:348-54. 59. Loren G. et al . Measuring adherence to anti retroviral medications in clinical trials. HIV clinical trials2000;1(1): 36-46. 60. G. Nicolas E. Sylvia porer. Optimizing Adhernece to Pharmaceutical care plans. J. Am. Pharm Assoc 2000;40(4): 465-458 61. Clyde B. Schenecter . Improving adherence to diabetes self management recommendations. Diabetes Spectrum Volume 15, 2002: 170-175.The Role of Pictograms In Patient Medication Adherence____________________________________ 88
  • 105. Bibliography 62. Mansoor LE, Dowse R. Medicine information and adherence to HIV/AIDS patients. J.clin.pharm.ther. 2006;31(1): 7-15. 63. Svarstad BL et al . The Brief Medication Questionnaire: a tool for screening patient adherence and barriers to adherence. Patient Educ couns. 1999; 37 (2): 113-24. 64. Clifford S, et al. Patient centered advice is effective in improving adherence to medicines. Pharm world sci. 2006; 28(3) : 165-70. 65. Katri Hameen Antilla et al. Do pictograms improve children’s understanding of medicine leaflet information. Medscape. 2004;pp-78-88. 66. Shekar H.S .Evaluation of pharmaceutical pictograms by south Indian population. IJHP May-june 2005;24-9.The Role of Pictograms In Patient Medication Adherence____________________________________ 89
  • 106. Annexures Annexure I Patient consent formI, ----------------------------------------- have been explained by the investigators Mrs. N KMeera or Mr. Anil T. M. about the nature and the effect of the research entitled “The Role of Pictograms in Patient Medication Adherence”I have been provided with information about the study and I have understood the same. Iunderstood the study involves following procedures.  I will be asked to answer a questionnaire for the study related to adherence to the therapy  I will be educated about my disease, diet and medication  I will be educated about the importance of the adherence to the therapyI have understood the study and satisfied with the explanation given by the investigatorsor their representatives and I hereby give my consent to participate in the study.I also understand that if I am not interested for further participation in the study, I havethe option of withdrawing from the study at any time without giving reason. Signature of the patientThe Role of Pictograms In Patient Medication Adherence____________________________________ I
  • 107. Annexures Annexure II Interpretation of pictogramsName: Age:Address: Sex:Phone No:Education Qualification: Religion:Marital Status:Occupation: Before the explanation Completely Partially Not Opposite understood understood understood Pictogram 1 Pictogram 2 Pictogram 3 Pictogram 4 Pictogram 5 Pictogram 6 Pictogram 7 Pictogram 8 Pictogram 9 Pictogram 10 Pictogram 11 Pictogram 12 Pictogram 13 Pictogram 14 Pictogram 15 Pictogram 16 Pictogram 17 Pictogram 18The Role of Pictograms In Patient Medication Adherence____________________________________ II
  • 108. Annexures After the explanation Completely Partially Not Opposite understood understood understood Pictogram 1 Pictogram 2 Pictogram 3 Pictogram 4 Pictogram 5 Pictogram 6 Pictogram 7 Pictogram 8 Pictogram 9 Pictogram 10 Pictogram 11 Pictogram 12 Pictogram 13 Pictogram 14 Pictogram 15 Pictogram 16 Pictogram 17 Pictogram 18The Role of Pictograms In Patient Medication Adherence____________________________________ III
  • 109. Annexures At follow up Completely Partially Not Opposite understood understood understood Pictogram 1 Pictogram 2 Pictogram 3 Pictogram 4 Pictogram 5 Pictogram 6 Pictogram 7 Pictogram 8 Pictogram 9 Pictogram 10 Pictogram 11 Pictogram 12 Pictogram 13 Pictogram 14 Pictogram 15 Pictogram 16 Pictogram 17 Pictogram 18The Role of Pictograms In Patient Medication Adherence____________________________________ IV
  • 110. Annexures Annexure III Patient data collection form Randomisation no:Name: Age:Address: Sex: M  F I.P.No:Phone No: Unit:Education Qualification: Religion:Marital Status: D.O.A:Occupation: D.O.D:Provisional Diagnosis: Sl No. Name of the Drug Duration Dosage 1 2 3 4 5 6 7 8 9 10 11 12Cost of the prescription: Rs……………...The Role of Pictograms In Patient Medication Adherence____________________________________ V
  • 111. AnnexuresSince how long you are suffering from this disease?Have you received any information on medication? Yes  No I f yes, by whom: Doctor  Nurse  Pharmacist  OthersHave you understood the present instructions? Yes  No How do you feel the individual dispensing? Very Useful  Useful  Not useful Knowledge about the use of medicines after a week:1. Excellent ( Use of medicines, i.e. Dose, Frequency, Route, ADR, when to come back)2. Good (Use of all medicines.)3. Average (Use of some medicines)4. Poor ( Doesn’t know completely)Outcome of the treatment: a. Totally recovered  b. Moderately recovered  c. Poorly recovered  d. Not recovered Patient satisfaction for indivualized dispensing: a. Very Useful  b. Useful  c. Not useful Knowledge about the use of medicines after two weeks: a. Excellent ( Use of medicines, i.e. Dose, Frequency, Route, ADR, When to come back) b. Good (Use of all medicines.) c. Average (Use of some medicines) d. Poor ( Doesn’t know completely)The Role of Pictograms In Patient Medication Adherence____________________________________ VI
  • 112. AnnexuresOutcome of the treatment: a. Totally recovered  b. Moderately recovered  c. Poorly recovered  d. Not recovered Patient satisfaction for indivualized dispensing: a. Very Useful  b. Useful  c. Not useful Knowledge about the use of medicines after four weeks:a. Excellent ( Use of medicines, i.e. Dose, Frequency, Route, ADR, When to come back)b. Good (Use of all medicines.)c. Average (Use of some medicines)d. Poor ( Doesn’t know completely)Outcome of the treatment: a. Totally recovered  b. Moderately recovered  c. Poorly recovered  d. Not recovered Patient satisfaction for indivualized dispensing: a. Very Useful  b. Useful  c. Not useful Knowledge about the use of medicines after 8 weeks: a. Excellent ( Use of medicines, i.e. Dose, Frequency, Route, ADR, When to come back) b. Good (Use of all medicines.) c. Average (Use of some medicines) d. Poor ( Doesn’t know completely)The Role of Pictograms In Patient Medication Adherence____________________________________ VII
  • 113. AnnexuresOutcome of the treatment: a. Totally recovered  b. Moderately recovered  c. Poorly recovered  d. Not recovered Patient satisfaction for indivualized dispensing: a. Very Useful  b. Useful  c. Not useful Knowledge about the use of medicines after 12 weeks: a. Excellent ( Use of medicines, i.e. Dose, Frequency, Route, ADR, when to come back) b. Good (Use of all medicines.) c. Average (Use of some medicines) d. Poor ( Doesn’t know completely)Outcome of the treatment: a. Totally recovered  b. Moderately recovered  c. Poorly recovered  d. Not recovered Patient satisfaction for indivualized dispensing: a. Very Useful  b. Useful  c. Not useful The Role of Pictograms In Patient Medication Adherence____________________________________ VIII
  • 114. Annexures Annexure IV Brief medication questionnaire (BMQ 2003)1. Please list below all the medications you took in the past week. For each medication you list, please answer each of the questions in the boxes below. (Use additional pages if necessary.) b. How c. How d. How e. How f. For g. How your a. Medication many days many many many what medicine is name Did you take Times per tablet did times did reason working? it? day did you you take you miss were you 1=Very take it? each time? the dose? Taking good it? 2=Somewhat 3=Not at all 4=Don’t know 2. Do any of your medications affect you in any way? Yes  No IF Yes, please name the medication and explain how it bothers you. 3. Do you have any problem in the following areas? a. Some of my medication will cause side effects: Yes  No b. It is hard to remember all the doses: Yes  No c. It is difficult to pay for the medication: Yes  No d. It is difficult to get my refill on time: Yes  No e. The dosage timings are inconvenient : Yes  NoThe Role of Pictograms In Patient Medication Adherence____________________________________ IX
  • 115. Annexures Scoring procedure for BMQRegimen screen: 1a Mentions prescribed drug without prompting 0-yes 1-no 1b-e Knows and follows current regimen without deviation 0-yes 1-no Score ≥ indicates positive screen regarding regimen non adherence. 1=Belief screen: 1g Beliefs that medications works well 0-yes 1-no 2a Beliefs that medication bothers at least a little 0-yes 1-no Score ≥ indicates positive screen regarding belief barriers. 1=Recall screen: 1c Has multiple dosage regimen 0-no 1- yes 3d Has problem remembering all the pills 0-no 1- yes Score ≥ indicates positive screen regarding recall barrier. 1=Access screen: 3d Has problem getting refills in time 0-no 1- yes 3c Has problem paying for medication 0-no 1- yes Score ≥ indicates positive screen regarding access barrier. 1=The Role of Pictograms In Patient Medication Adherence____________________________________ X
  • 116. Annexures Annexure V Pictograms without textThe Role of Pictograms In Patient Medication Adherence____________________________________ XI
  • 117. AnnexuresThe Role of Pictograms In Patient Medication Adherence____________________________________ XII
  • 118. Annexures Annexure VI Pictograms with textThe Role of Pictograms In Patient Medication Adherence____________________________________ XIII
  • 119. AnnexuresThe Role of Pictograms In Patient Medication Adherence____________________________________ XIV
  • 120. Annexures Annexure VII Pictograms in sticker sheetThe Role of Pictograms In Patient Medication Adherence____________________________________ XV
  • 121. AnnexuresThe Role of Pictograms In Patient Medication Adherence____________________________________ XVI
  • 122. Annexures Annexure VIII Description of the pictograms Description Pictogram 1 Take every day in the morning Pictogram 2 Take every day in the afternoon Pictogram 3 Take every day in the morning with break fast Pictogram 4 Take every day in the afternoon with lunch Pictogram 5 Take every day in the morning with break fast and night at dinner Pictogram 6 Take every day in the morning with break fast and afternoon and night with meals Pictogram 7 Take every day in the night Pictogram 8 Don’t drink alcohol Pictogram 9 Take every day in the night with dinner Pictogram 10 Don’t drive the vehicle Pictogram 11 Take every day in the morning, afternoon, evening and night along with meals Pictogram 12 Take one hour before the meals Pictogram 13 Complete the course Pictogram 14 Don’t smoke Pictogram 15 Shake well before use Pictogram 16 Take every day in the evening Pictogram 17 Take one hour after the food Pictogram 18 Take every day in the evening with snacksThe Role of Pictograms In Patient Medication Adherence____________________________________ XVII
  • 123. Annexures Annexure IX Patient consent form (Kannada) gÉÆÃVAiÀÄ M¦àUÉ ¥ÀvÀæ __________________________ DzÀ £À£ÀUÉ ¸ÀA±ÉÆÃzsÀPÀgÁzÀ²æêÀÄw «ÄÃgÁ CxÀªÁ CªÀgÀ ¥Àæw¤¢ü ²æà n.JA. C¤¯ï F¸ÀA±ÉÆÃzsÀ£ÉAiÀÄ «ªÀgÀ ªÀÄvÀÄÛ G¥ÀAiÉÆÃUÀzÀ §UÉÎ w½¹gÀÄvÁÛgÉ.F ¸ÀA±ÉÆÃzsÀ£ÉAiÀÄ ºÉ¸ÀgÀÄ, "OµÀzÉÆÃ¥ÀZÁgÀzÀ°è¦PÉÆÖÃUÁæªÀiïUÀ¼À ¥ÁvÀæ" F §UÉÎ £À£ÀUÉ J¯Áè ªÀiÁ»wAiÀÄ£ÀÄß CªÀgÀÄ ¤ÃrgÀÄvÁÛgÉ. F ¸ÀA±ÉÆÃzsÀ£ÉAiÀÄ PɼÀPÀAqÀ «µÀAiÀÄUÀ¼À£ÀÄßM¼ÀUÉÆArgÀÄvÀÛzÉ.  OµÀzÉÆÃ¥ÀZÁgÀzÀ §UÉÎ ªÀiÁ»w ¤ÃqÀ¯ÁUÀĪÀÅzÀÄ.  OµÀzÉÆÃ¥ÀZÁgÀzÀ §UÉÎ PÉüÀ¯ÁUÀĪÀ ¥Àæ±ÉßUÀ½UÉ £Á£ÀÄ GvÀÛj¸À¨ÉÃPÁUÀĪÀÅzÀÄ. £Á£ÀÄ J¯Áè «µÀAiÀÄUÀ¼À£ÀÄß CxÀð ªÀiÁ¢PÉÆArzÀÄÝ. F ªÀÄÆ®PÀ¸ÀA±ÉÆÃzsÀ£ÉAiÀÄ°è ¥Á¯ÉÆμÀî®Ä M¦àUÉ ¤ÃqÀÄwÛzÉÝãÉ. £Á£ÀÄ F ¸ÀA±ÉÆÃzsÀ£ÉAiÀÄ°è ªÀÄÄAzÀĪÀgÉAiÀÄ®Ä EaÒ¸À¢zÀÝ°è.F ¸ÀA±ÉÆÃzsÀ£É¬ÄAzÀ »AzÉ ¸ÀjAiÀÄ®Ä ªÀÄÄPÀÛ CªÀPÁ±À«zÉAiÉÄAzÀÄ£À£ÀUÉ w½¢zÉ. ¸À»/-The Role of Pictograms In Patient Medication Adherence____________________________________ XVIII
  • 124. Annexures Annexure X BMQ (Kannada) OµÀzÉÆÃ¥ÀZÁgÀzÀ §UÉÎ1. ¤ÃªÀÅ PÀ¼ÉzÀªÁgÀ ¸Éë¹zÀ OµÀ¢üUÀ¼À §UÉÎ :OµÀ¢üAiÀ OµÀ¢üAiÀÄ ¢£ÀzÀ°è ¥Àæw ¨Áj JµÀÄÖ ¤ÃªÀÅ JµÀÄÖ OµÀ¢ü ¤ÃªÀÅ AiÀiÁªÀ ¤ÃªÀÅ ¸Éë¸ÀÄwÛgÀĪÀÄ ºÉ¸ÀgÀÄ £ÀÄß JµÀÄÖ ¨Áj ªÀiÁvÉæAiÀÄ£ÀÄß ¸Éë¸ÀĪÀÅzÀ£ÀÄß PÁgÀtPÉÌ OµÀ¢ü AiÀiÁªÀ jÃw PÉ®¸À JµÀÄÖ ¢£À ¸Éë¸ÀÄwÛ ¸Éë¸ÀÄwÛÃj ªÀÄgÉw¢ÝÃj OµÀ¢üAiÀÄ£ÀÄß ªÀiÁqÀÄwÛzÉ ¸Éë¹¢ÝÃj Ãj ¸Éë¸ÀÄwÛ¢ÝÃj 1. ZÉ£ÁßV 2. ¸ÀĪÀiÁgÁV 3. J£ÀÆ E®è 4. UÉÆwÛ®è2) ¤ÃªÀÅ ¸Éë¸ÀÄwÛgÀĪÀ OµÀ¢ü ¤ªÀÄUÉ K£ÁzÀgÀÆ vÉÆAzÀgÉ (zÀĵÀàjuÁªÀÄUÀ¼ÀÄ) GAlÄ ªÀiÁqÀÄwÛzÉAiÉÄà ? ºËzÀÄ E®è ºËzÁzÀgÉ – OµÀ¢üAiÀÄ ºÉ¸ÀgÀÄ : ¤ªÀÄUÉ OµÀ¢¬ÄAzÀ DzÀ zÀĵÀàjuÁªÀÄUÀ¼ÀÄ :3) ¤ÃªÀÅ PɼÀUÉ w½¹gÀĪÀ «µÀAiÀÄUÀ¼À°è AiÀiÁªÀ vÉÆAzÀgÉUÀ¼À£ÀÄß C£ÀĨsÀ«¸ÀÄwÛgÀÄ«j. ºËzÀÄ E®èC) £Á£ÀÄ ¸Éë¸ÀÄwÛgÀĪÀ PÉ®ªÀÅ OµÀ¢üUÀ¼ÀÄ zÀĵÀàjuÁªÀĪÀ£ÀÄß GAlĪÀiÁqÀÄwÛzÉ.D) J®è OµÀ¢üUÀ¼À ¥ÀæªÀiÁtªÀÅ £É£À¦£À°è EgÀĪÀÅ¢®è.E) J®è OµÀ¢üAiÀÄ£ÀÄß Rjâ¸À®Ä ¸ÁzsÀåªÁUÀĪÀÅ¢®è.F) OµÀ¢üAiÀÄ£ÀÄß ªÀÄvÉÛ ªÀÄvÉÛ Rjâ¸À®Ä ¸ÁzsÀåªÁUÀĪÀÅ¢®è.G) OµÀ¢üAiÀÄ£ÀÄß vÉUÉzÀÄPÉƼÀÄîªÀ ¸ÀªÀÄAiÀĪÀÅ C£ÀÄPÀÆ®PÀgÀªÁV®è.The Role of Pictograms In Patient Medication Adherence____________________________________ XIX
  • 125. Annexures Annexure XI Data collection form (Kannada)ªÀiÁ»w ¸ÀAUÀæºÀt £ÀªÀÄÆ£É.ºÉ¸ÀgÀÄ: ªÀAiÀĸÀÄì:«¼Á¸À: °AUÀ : UÀAqÀÄ ºÉtÄÚzÀÆgÀªÁt ¸ÀASÉå: M¼ÀgÉÆÃV ¸ÀASÉå :«zÁåºÀðvÉ : «¨sÁUÀ :ªÉʪÁ»PÀ fêÀ£À : ¸ÉÃjzÀ ¢£ÁAPÀ :PÉ®¸À ©qÀÄUÀqÉ ¢£ÁAPÀ :AiÀiÁªÀ gÉÆÃUÀ¢AzÀ §¼À®ÄwÛzÁÝgÉ :PÀæ.¸À OµÀ¢üAiÀÄ ºÉ¸ÀgÀÄ JµÀÄÖ PÁ® JµÀÄÖ ¨Áj A. 1. F gÉÆÃUÀ¢AzÀ JµÀÄÖ PÁ®¢AzÀ §¼À®ÄwÛ¢ÝÃgÁ ? 2. F ªÀÄÄAZÉ AiÀiÁªÁUÀ¯ÁzÀgÀÆ OµÀzsÉÆÃ¥ÁZÁgÀzÀ §UÉÎ ªÀiÁ»w zÉÆgÀQvÉÛ ? ºËzÀÄ E®è ºËzÉAzÁzÀgÉ : AiÀiÁjAzÀ ªÉÊzÀågÀÄ £À¸ïð ¥sÁªÀÄð¹¸ïÖ EvÀgÉ 3. FUÀ PÉÆnÖgÀĪÀ ªÀiÁ»w DxÀðªÁVzÉAiÉÄà ? ºËzÀÄ E®è 4. ¥Àæw OµÀ¢üAiÀÄ£ÀÄß ¨ÉÃgÉ ¨ÉÃgÉAiÀiÁV ¤ÃqÀÄwÛgÀĪÀ F «zsÁ£ÀzÀ §UÉÎ ¤ªÀÄä C©ü¥ÁæAiÀĪÉãÀÄ ? CvÀÄåvÀÛªÀÄ GvÀÛªÀÄ GvÀÛªÀĪÁV®èThe Role of Pictograms In Patient Medication Adherence____________________________________ XX
  • 126. AnnexuresMAzÀÄ ªÁgÀzÀ £ÀAvÀgÀ 5. OµÀzÉÆÃ¥ÀZÁgÀzÀ §UÉÎ w½¢gÀĪÀ ªÀiÁ»w : 1. CvÀÄåvÀÛªÀÄ (OµÀ¢üUÀ¼À §¼ÀPÉ, ¥ÀæªÀiÁt, JµÀÄÖ ¨Áj, vÉUÉzÀÄPÉƼÀÄîªÀ «zsÁ£À, K£ÁzÀgÀÆ vÉÆAzÀgÉ DVzÀÝgÉ, ªÀÄÄA¢£À ¨sÉÃn) 2. GvÀÛªÀÄ (J®è OµÀ¢üUÀ¼À §¼ÀPÉ) 3. ªÀÄzsÀåªÀÄ (PÉ®ªÀÅ OµÀ¢üUÀ¼À §¼ÀPÉ) 4. K£ÀÆ w½¢®è. 6. OµÀzÉÆÃ¥ÀZÁgÀzÀ £ÀAvÀgÀzÀ ¥ÀjuÁªÀÄ 1) ¥ÀÇwð UÀÄtªÀÄÄR 2) §ºÀ¼ÀµÀÄÖ UÀÄtªÀÄÄR 3) ¸ÁzsÁgÀt UÀÄtªÀÄÄR 4) UÀÄtªÀÄÄRgÁV®è 7. ªÉÊAiÀÄÄQÛPÀªÁV ¤ÃqÀ¯ÁUÀÄwÛgÀĪÀ F «zsÁ£À ºÉÃVzÉ ? CvÀÄåvÀÛªÀÄ GvÀÛªÀÄ GvÀÛªÀĪÁV®è 8. OµÀ¢üUÀ¼À C£ÀÄPÀæªÀÄ «ªÀgÀuÉAiÀÄ CAPÀ : 9. £ÀA©PÉ §UÉÎ CAPÀ : 10. £É£À¥ÀÅ ªÀiÁrPÉƼÀÄîªÀÅzÀgÀ §UÉÎ CAPÀ : 11. OµÀ¢üUÀ¼À ®¨sÀåvÉ §UÉÎ CAPÀ :JgÀqÀÄ ªÁgÀzÀ £ÀAvÀgÀ 12. OµÀzÉÆÃ¥ÀZÁgÀzÀ §UÉÎ w½¢gÀĪÀ ªÀiÁ»w : 1. CvÀÄåvÀÛªÀÄ (OµÀ¢üUÀ¼À §¼ÀPÉ, ¥ÀæªÀiÁt, JµÀÄÖ ¨Áj, vÉUÉzÀÄPÉƼÀÄîªÀ «zsÁ£À, K£ÁzÀgÀÆ vÉÆAzÀgÉ DVzÀÝgÉ, ªÀÄÄA¢£À ¨sÉÃn) 2. GvÀÛªÀÄ (J®è OµÀ¢üUÀ¼À §¼ÀPÉ) 3. ªÀÄzsÀåªÀÄ (PÉ®ªÀÅ OµÀ¢üUÀ¼À §¼ÀPÉ) 4. K£ÀÆ w½¢®è. 13. OµÀzÉÆÃ¥ÀZÁgÀzÀ £ÀAvÀgÀzÀ ¥ÀjuÁªÀÄ 1) ¥ÀÇwð UÀÄtªÀÄÄR 2) §ºÀ¼ÀµÀÄÖ UÀÄtªÀÄÄR 3) ¸ÁzsÁgÀt UÀÄtªÀÄÄR 4) UÀÄtªÀÄÄRgÁV®è 14. ªÉÊAiÀÄÄQÛPÀªÁV ¤ÃqÀ¯ÁUÀÄwÛgÀĪÀ F «zsÁ£À ºÉÃVzÉ ? CvÀÄåvÀÛªÀÄ GvÀÛªÀÄ GvÀÛªÀĪÁV®èThe Role of Pictograms In Patient Medication Adherence____________________________________ XXI
  • 127. Annexures 15. OµÀ¢üUÀ¼À C£ÀÄPÀæªÀÄ «ªÀgÀuÉAiÀÄ CAPÀ : 16. £ÀA©PÉ §UÉÎ CAPÀ : 17. £É£À¥ÀÅ ªÀiÁrPÉƼÀÄîªÀÅzÀgÀ §UÉÎ CAPÀ : 18. OµÀ¢üUÀ¼À ®¨sÀåvÉ §UÉÎ CAPÀ :£Á®ÄÌ ªÁgÀzÀ £ÀAvÀgÀ 19. OµÀzÉÆÃ¥ÀZÁgÀzÀ §UÉÎ w½¢gÀĪÀ ªÀiÁ»w : 1. CvÀÄåvÀÛªÀÄ (OµÀ¢üUÀ¼À §¼ÀPÉ, ¥ÀæªÀiÁt, JµÀÄÖ ¨Áj, vÉUÉzÀÄPÉƼÀÄîªÀ «zsÁ£À, K£ÁzÀgÀÆ vÉÆAzÀgÉ DVzÀÝgÉ, ªÀÄÄA¢£À ¨sÉÃn) 2. GvÀÛªÀÄ (J®è OµÀ¢üUÀ¼À §¼ÀPÉ) 3. ªÀÄzsÀåªÀÄ (PÉ®ªÀÅ OµÀ¢üUÀ¼À §¼ÀPÉ) 4. K£ÀÆ w½¢®è. 20. OµÀzÉÆÃ¥ÀZÁgÀzÀ £ÀAvÀgÀzÀ ¥ÀjuÁªÀÄ 1) ¥ÀÇwð UÀÄtªÀÄÄR 2) §ºÀ¼ÀµÀÄÖ UÀÄtªÀÄÄR 3) ¸ÁzsÁgÀt UÀÄtªÀÄÄR 4) UÀÄtªÀÄÄRgÁV®è 21. ªÉÊAiÀÄÄQÛPÀªÁV ¤ÃqÀ¯ÁUÀÄwÛgÀĪÀ F «zsÁ£À ºÉÃVzÉ ? CvÀÄåvÀÛªÀÄ GvÀÛªÀÄ GvÀÛªÀĪÁV®è 22. OµÀ¢üUÀ¼À C£ÀÄPÀæªÀÄ «ªÀgÀuÉAiÀÄ CAPÀ : 23. £ÀA©PÉ §UÉÎ CAPÀ : 24. £É£À¥ÀÅ ªÀiÁrPÉƼÀÄîªÀÅzÀgÀ §UÉÎ CAPÀ : 25. OµÀ¢üUÀ¼À ®¨sÀåvÉ §UÉÎ CAPÀ :JAlÄ ªÁgÀzÀ £ÀAvÀgÀ 26. OµÀzÉÆÃ¥ÀZÁgÀzÀ §UÉÎ w½¢gÀĪÀ ªÀiÁ»w : 1. CvÀÄåvÀÛªÀÄ (OµÀ¢üUÀ¼À §¼ÀPÉ, ¥ÀæªÀiÁt, JµÀÄÖ ¨Áj, vÉUÉzÀÄPÉƼÀÄîªÀ «zsÁ£À, K£ÁzÀgÀÆ vÉÆAzÀgÉ DVzÀÝgÉ, ªÀÄÄA¢£À ¨sÉÃn)The Role of Pictograms In Patient Medication Adherence____________________________________ XXII
  • 128. Annexures 2. GvÀÛªÀÄ (J®è OµÀ¢üUÀ¼À §¼ÀPÉ) 3. ªÀÄzsÀåªÀÄ (PÉ®ªÀÅ OµÀ¢üUÀ¼À §¼ÀPÉ) 4. K£ÀÆ w½¢®è. 27. OµÀzÉÆÃ¥ÀZÁgÀzÀ £ÀAvÀgÀzÀ ¥ÀjuÁªÀÄ 1) ¥ÀÇwð UÀÄtªÀÄÄR 2) §ºÀ¼ÀµÀÄÖ UÀÄtªÀÄÄR 3) ¸ÁzsÁgÀt UÀÄtªÀÄÄR 4) UÀÄtªÀÄÄRgÁV®è 28. ªÉÊAiÀÄÄQÛPÀªÁV ¤ÃqÀ¯ÁUÀÄwÛgÀĪÀ F «zsÁ£À ºÉÃVzÉ ? CvÀÄåvÀÛªÀÄ GvÀÛªÀÄ GvÀÛªÀĪÁV®è 29. OµÀ¢üUÀ¼À C£ÀÄPÀæªÀÄ «ªÀgÀuÉAiÀÄ CAPÀ : 30. £ÀA©PÉ §UÉÎ CAPÀ : 31. £É£À¥ÀÅ ªÀiÁrPÉƼÀÄîªÀÅzÀgÀ §UÉÎ CAPÀ : 32. OµÀ¢üUÀ¼À ®¨sÀåvÉ §UÉÎ CAPÀ :ºÀ£ÉßgÀqÀÄ ªÁgÀzÀ £ÀAvÀgÀ 33. OµÀzÉÆÃ¥ÀZÁgÀzÀ §UÉÎ w½¢gÀĪÀ ªÀiÁ»w : 1. CvÀÄåvÀÛªÀÄ (OµÀ¢üUÀ¼À §¼ÀPÉ, ¥ÀæªÀiÁt, JµÀÄÖ ¨Áj, vÉUÉzÀÄPÉƼÀÄîªÀ «zsÁ£À, K£ÁzÀgÀÆ vÉÆAzÀgÉ DVzÀÝgÉ, ªÀÄÄA¢£À ¨sÉÃn) 2. GvÀÛªÀÄ (J®è OµÀ¢üUÀ¼À §¼ÀPÉ) 3. ªÀÄzsÀåªÀÄ (PÉ®ªÀÅ OµÀ¢üUÀ¼À §¼ÀPÉ) 4. K£ÀÆ w½¢®è. 34. OµÀzÉÆÃ¥ÀZÁgÀzÀ £ÀAvÀgÀzÀ ¥ÀjuÁªÀÄ 1) ¥ÀÇwð UÀÄtªÀÄÄR 2) §ºÀ¼ÀµÀÄÖ UÀÄtªÀÄÄR 3) ¸ÁzsÁgÀt UÀÄtªÀÄÄR 4) UÀÄtªÀÄÄRgÁV®è 35. ªÉÊAiÀÄÄQÛPÀªÁV ¤ÃqÀ¯ÁUÀÄwÛgÀĪÀ F «zsÁ£À ºÉÃVzÉ ? CvÀÄåvÀÛªÀÄ GvÀÛªÀÄ GvÀÛªÀĪÁV®è 36. OµÀ¢üUÀ¼À C£ÀÄPÀæªÀÄ «ªÀgÀuÉAiÀÄ CAPÀ : 37. £ÀA©PÉ §UÉÎ CAPÀ : 38. £É£À¥ÀÅ ªÀiÁrPÉƼÀÄîªÀÅzÀgÀ §UÉÎ CAPÀ : 39. OµÀ¢üUÀ¼À ®¨sÀåvÉ §UÉÎ CAPÀ : Annexure XIIThe Role of Pictograms In Patient Medication Adherence____________________________________ XXIII
  • 129. Annexures Patient counseling PhotoThe Role of Pictograms In Patient Medication Adherence____________________________________ XXIV