Using Visuals to Communicate Medicine Information to Patients with Low Literacy

Abstract

The patient was adamant that she had taken her medicine as instructed, pointing to the visual (Visual 1) illustrating the instructions to endorse this. Via an interpreter, she communicated that she took her tablet three times during the day and once at night (which was correct), but only on those days when the sun was shining (not on cloudy days) and the moon was visible (depending on both cloud cover and phases of the moon). [ILLUSTRATION OMITTED] Another patient who had been diagnosed with a vaginal infection, and who had received a cream to be inserted vaginally, reported no improvement in her infection. On further questioning, we found out that she had been rubbing the cream on the side of her leg like the picture tells me to do (Visual 2). [ILLUSTRATION OMITTED] Are pictures a so-called universal language? Maybe, but pictures are open to interpretation and potentially disastrous outcomes, when misinterpretation influences subsequent actions such as taking medicines. This fascinating area of research and practice has continued to interest and enthrall me over the years, and just when I think I have heard it all, along comes another oh wow, how did he get that? interpretation. Using visuals has many advantages (Doak, Doak & Root, 1996). Visual presentations are more persuasive, emotions are easily stimulated via the visual sense initiating a rapid response, memory systems in the brain favor visual storage, and materials including visuals are more user-friendly. Their usefulness is even more apparent in people with poor reading skills. We proudly call South Africa the Rainbow Nation. The name speaks for itself in describing the incredible diversity of its people. We have 11 official languages and 8 different African ethnic groups, each with its own culture, language and customs, and each with its unique perception and understanding of allopathic medicine. Literacy is a major challenge in South Africa with approximately 40% of South Africans aged 15 years and over having less than 7 years of formal schooling (grade 7 is often used as a minimum education level indicator of sustainable functional literacy) and 18% having no schooling at all, with the lowest functional literacy rate occurring in the Black population (Statistics South Africa, 2001). Apart from the nursing profession, the majority of doctors and pharmacists in South Africa are of a different culture from the average public health sector patient, with language constituting the most common communication barrier. In fact, it has been estimated that cross-cultural communication occurs approximately 80% of the time in health-care consultations (Adams, 1991). Unlike developed countries, where the problems with literacy and communication often occur with minority patients groups, in South Africa the reverse situation applies. Together, all these factors constitute a real challenge to effective patient-health care provider communication. Medicine-taking behavior is complex, multi-factorial, and depends on a dynamic interaction of several factors, including cognitive, behavioral, social, environmental, and physiologic factors (World Health Organization, 2003). However, a minimum requirement for appropriate medicine taking is a basic understanding of the medication instructions, and the ability to recall this information. Studies in patients with limited reading skills have demonstrated the value of visuals in enhancing understanding and recall of written or verbal information (Mansoor & Dowse, 2003; Dowse & Ehlers, 2005; Houts, Doak, Doak, & Loscalzo, 2006), but their use is not a strategy generally accepted and adopted by health authorities. Instead, using visuals to communicate information to low-literate patients appears to be restricted to relatively small-scale local initiatives, which are often driven by one person who is passionate about their effectiveness. These initiatives are not usually sustainable in the long term. …