Posted on May 26, 2014

A novel strategy adapted by Qatar University (QU) researchers and external collaborators to use pictograms to match common labeling instructions on medicines was found to be of considerable benefit to migrant workers with low literacy skills who make up the majority of the manual labor workforce in Qatar.

The study entitled “Development and evaluation of pictograms on medication labels for patients with limited literacy skills in a culturally-diverse multiethnic population” was funded by Qatar National Research Fund (QNRF) under its Undergraduate Research Experience Program (UREP). It was conducted by QU College of Pharmacy (CPH) faculty and Principal Investigator Dr Nadir Kheir, CPH faculty Dr Ahmed Awaisu, pharmacy graduates Amina Radoui and Aya Elbadawi, Ms Linda Jean from Qatar Petroleum (QP) Medical Services, and Dr Ros Dowse from Rhodes University, South Africa.

In the study, the research team considered the low literacy level of foreign workers in Doha and their lack of English and Arabic language skills which ultimately present a challenge for healthcare professionals. Its core objective was to address the oftentimes inappropriate use of prescribed medications due to patients’ low literacy or lack of understanding of usage instructions, resulting in serious consequences worldwide which were largely preventable. 

As medicine labels in Qatar are typically in Arabic and English, they are poorly understood by many of the country’s migrant workers. Additionally, verbal explanations of the written label also posed a similar challenge both for the healthcare professional and the migrant worker/patient. Pharmacists in Qatar expressed a feeling of frustration in trying to explain instructions related to medication to patients who cannot speak or understand English or Arabic, and invariably have to limit their verbal communication to the most basic of instructions such as frequency of dosage.

The research team developed pictograms (simple drawings or cartoons depicting the dosage instructions or precautions) for selected medicine labels, and evaluated comprehension of them by foreign workers of low literacy level in Doha, in tandem with their comprehension of conventional text supported by verbal instructions, and of pictogram-only labels.

QU collaborative research study-  Pictograms1[].jpg

The study was conducted in a primary health care facility within QP which has a large population of foreign workers. The company has four primary health care clinics distributed across Qatar each with a dedicated outpatient pharmacy. A total of 123 participants (18-65yrs) took part in the study which involved a consultative approach with input from the researchers, a local graphic artist, and members of the target population. Of the participants, around 70% had a poor level of English, and almost 95% a poor level of Arabic.

Eleven common labeling instructions were selected out of 23 that were screened, and pictograms were developed using visual concepts and ideas from the literature. Participants were randomized in 3 groups for comprehension testing -- written text plus verbal instructions; pictogram-only labels; and pictogram with verbal instructions. The researchers found that the group tested on pictogram plus verbal instructions achieved better results in comprehension and interpretation than the group tested on written text plus verbal instructions in a language the participants did not understand. Comprehension of pictogram-only labels ranked lowest among the selected group.

The findings revealed that the best interpreted pictograms with verbal instructions included: “Take two tablets three times a day”, “Take one tablet in the morning and one tablet at night”, and “Instill one drop in the eye”. The worst interpreted pictograms with verbal instructions were: “Do not take with dairy products” and “Do not use by mouth”. It was also found that some pictograms were difficult to interpret even when accompanied by verbal instructions, suggesting the need to thoroughly pilot them among users prior to implementation.

Dr Kheir noted that studies have shown the growing attention being paid to supporting patients’ ability to read and understand health information by improving the quality of medicine labeling. “In light of this, this study is extremely vital for Qatar and by extension the Gulf region where migrant workers are a huge and growing population who should be provided the facility to avail of healthcare services that recognize the workers’ limitations in being responsible for taking the medication prescribed due to their low language and literacy skills”, he said.

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