Validation of pharmaceutical pictograms among older adults with limited English proficiency

Objective: Pictograms on prescription medication labels enhance medication literacy and medication adherence. However, pictograms need to be contextually validated. We assessed the validity of 52 International Pharmaceutical Federation pictograms among 250 older Singaporeans with limited English proficiency. Methods: Participants were randomly assigned 11 pictograms each. For each pictogram, participants were first asked its intended meaning. Then, they were told the intended meaning and asked to rate how well the pictogram represented the meaning, on a scale of 1-7. Pictograms were classified as valid (>-66% participants assigned the pictogram interpreted its intended meaning correctly [transparency criterion] and >-85% participants rated its representativeness as >-5 [translucency criterion]), partially valid (only transparency criterion was fulfilled) or not valid. Open-ended questions gathered feedback to improve pictograms. Results: 14 pictograms (26.9%) achieved validity and 6 pictograms (11.5%) achieved partial validity. A greater proportion of pictograms for dose and route of administration, and dosage frequency achieved validity or partial validity versus those depicting precautions, indications or side effects. Conclusion: Majority (61.5%) of the assessed pictograms did not achieve validity or partial validity, highlighting the importance of contextual validation. Practice implications: Low pictogram comprehension emphasizes the importance of facilitating pictogram understanding during medication counseling. (c) 2021 Elsevier B.V. All rights reserved.