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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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

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