Would pictures help patients understand prescriptions?

Handing out a prescription How easy is it to understand instructions on medicine labels and leaflets?

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In a hospital in Lahore, Pakistan, patients use simple pictures of the sun rising over the mountains and the moon and stars at night to help them understand when to take their medication and how long to take it for.

With about half of patients at the hospital unable to read or write, written instructions on prescriptions and medicine labels are virtually useless.

Start Quote

There are many elderly patients who find the writing in small font... on medicines difficult to read.”

End Quote Dr Mike Smith Patients Association

In the UK, where about one in six people is thought to be "functionally illiterate" - defined as being unable to pass an English GCSE - could pictures and symbols improve patient understanding too?

Taking the wrong dose of medicine can be dangerous. It can put patients' lives at risk.

According to the Patients Association, their helpline receives many calls from patients concerned about whether they have taken the right quantity of medicine at the right time.

Dr Mike Smith, chairman of the association, says labelling is a patient safety issue.

"There are many elderly patients who may find the writing in small font on the coloured labels on bottles and packets of medicines difficult to read."

The instructions are usually typed, first by the GP on the prescription form, then re-typed and added to by a pharmacist who attaches them to the medicine bottle and box itself.

So could using pictures make things easier?

Example of symbols used on prescriptions in Pakistan to help illiterate patients take their medicine The redesigned picture-based prescription improved the understanding of patients in Lahore

"Using pictures and clarity of labels will certainly help the adherence to medications, which in turn will reduce the need to seek help from emergency services due to medication errors," Dr Smith says.

He adds that the use of pictures on labels could also help patients with mild learning difficulties or dementia.

Target groups

At Services Hospital in Lahore, Dr Matthew Clayton and colleagues designed the new prescription form for patients, based on pictures rather than words (see image above). It also requires the pharmacists to write the number for each medication, as it appears on the form, on to the corresponding box of tablets.

His report on the experiment, published by the BMJ this week, describes an approximate 20% increase in illiterate patients' understanding when using the new form.

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Pictures sound like a really easy answer - but they can cause more problems than they solve.”

End Quote Prof Theo Raynor University of Leeds

Literacy levels are much higher in the UK, but there are still many groups who could potentially benefit.

Dr Mobasher Butt, clinical lead at BMJ Learning and Quality Improvement, and a GP in London, says patients with visual impairments, learning disabilities, mental health problems and those taking lots of different medications could all be helped by a picture-based approach.

He said: "Given the diversity of population we look after, symbols could certainly help reinforce verbal messages.

"When we give patients a prescription we normally explain when to take the medicine and how often, then that message is reiterated by the pharmacist.

"But if the patient has the added advantage of picture and symbols to go on, that would really help."

However, not everyone agrees.

Woman reading patient information for her medicine The patient information leaflet (PIL) tends to focus on the harms and side-effects of drugs
'Not simple'

Theo Raynor, professor of pharmacy practice at the University of Leeds, and an expert on the information provided with medicines in primary care, says pictures can be confusing and give patients completely the wrong idea.

Because most people in the UK can read and write to some degree, the priority should be to make information on prescriptions and labels "as clear and simple as possible".

He cites the example of a symbol featuring a baby with a cross through it, meaning "keep out of the reach of children".

"Some people thought it meant 'don't take if pregnant', others thought it meant 'this medicine is a contraceptive' and others 'don't give to children'.

"Pictures sound like a really easy answer - but they can cause more problems than they solve."

Prof Raynor says pictures have to be tested on patients and then patients should be taught how to interpret them, otherwise they are anything but simple.

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There's too much about the harms and side-effects of medicines.”

End Quote Prof Theo Raynor

Where he thinks attention should really be focused is on the patient information leaflets (PILs) that come inside the medicine box.

At present, they are text-heavy and complicated.

Better balance

"There's too much about the harms and side-effects of medicines. The information needs to be more balanced," Prof Raynor says.

"People like to have that leaflet, so there should be more about how they can benefit from the medication."

Dr Butt agrees that the information in the PIL can be "overwhelming" for patients and sometimes it contradicts what the GP has recommended.

Between the patient's name, date of birth and details of the medication, there is evidently little room for instructions on a label, which is why the Medicines and Healthcare Products Regulatory Agency guidelines stress the need for healthcare professionals and pharmaceutical companies to "use simple words of few syllables".

The use of pictures on prescriptions in Lahore did not completely solve the problem for illiterate patients, so there is obviously still work to do on a perfect solution.


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  • rate this

    Comment number 35.

    Nobody here seems to have grasped the idea that some older people or maybe even people with learning difficulties would benefit from being told. take these medicines in the morning, or at night,

    its not just about Literacy and grasp of the Queens English,

  • rate this

    Comment number 23.

    I bet there are a few more than one in six people in the UK who wouldn't pass a GCSE, I've seen one of the papers and I wouldn't stand a hope. God knows how the kids manage to learn it all.
    I wouldn't think you need GCSE English to read instructions though, I'm not that slow, but could do with bigger writing so you don't need a magnifier.

  • rate this

    Comment number 22.

    It is quite common in pharmacies to pass around completed labels to colleagues and ask "does this make sense?" Often the answer is no - and we're familiar with such instructions. The warning label system was recently reworded after it was found that warnings such as "avoid alcoholic drink" had very different interpretations. People make a stab at understanding but ambiguity is a safety issue.

  • rate this

    Comment number 12.

    As a UK-based pharmacist who has had lectures on health literacy, it is definitely not just people who are completely illiterate or have English as a foreign language who struggle with medication wording. It can get a lot more complicated than "take one daily". See for example this Irish trial, where small changes drastically improved understanding: http://www.ncbi.nlm.nih.gov/pubmed/22127619

  • rate this

    Comment number 10.

    Yes, pictures say a thousand words


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