title: Redesigning pictographs for patients with low health literacy and establishing preliminary steps for delivery via smart phones.
abstract: BACKGROUND
  Pictographs (or pictograms) have been widely utilized to convey medication related messages and to address nonadherence among patients with low health literacy. Yet, patients do not always interpret the intended messages on commonly used pictographs correctly and there are questions how they may be delivered on mobile devices.
  
  
  OBJECTIVE
  Our objectives are to refine a set of pictographs to use as medication reminders and to establish preliminary steps for delivery via smart phones.
  
  
  METHODS
  Card sorting was used to identify existing pictographs that focus group members found "not easy" to understand. Participants then explored improvements to these pictographs while iterations were sketched in real-time by a graphic artist. Feedback was also solicited on how selected pictographs might be delivered via smart phones in a sequential reminder message. The study was conducted at a community learning center that provides literacy services to underserved populations in Seattle, WA. Participants aged 18 years and older who met the criteria for low health literacy using S-TOFHLA were recruited.
  
  
  RESULTS
  Among the 45 participants screened for health literacy, 29 were eligible and consented to participate. Across four focus group sessions, participants examined 91 commonly used pictographs, 20 of these were ultimately refined to improve comprehensibility using participatory design approaches. All participants in the fifth focus group owned and used cell phones and provided feedback on preferred sequencing of pictographs to represent medication messages.
  
  
  CONCLUSIONS
  Low literacy adults found a substantial number of common medication label pictographs difficult to understand. Participative design processes helped generate new pictographs, as well as feedback on the sequencing of messages on cell phones, that may be evaluated in future research.
authors.affiliation: Clinical Associate Professor, Department of Biobehavorial Nursing and Health Systems, School of Nursing University of Washington . Seattle, WA ( United States ). swolpin@uw.edu.
authors.forename: Seth E
authors.identifier: 0000-0002-6385-2310
authors.initials: SE
authors.lastname: Wolpin
authors.affiliation: Project Director, Department of Biobehavorial Nursing and Health Systems, School of Nursing, University of Washington . Seattle, WA ( United States ). Julietknguyen@gmail.com.
authors.forename: Juliet K
authors.identifier: 0000-0003-3574-6278
authors.initials: JK
authors.lastname: Nguyen
authors.affiliation: Research Analyst, Department of Biobehavorial Nursing and Health Systems, School of Nursing, University of Washington . Seattle, WA ( United States ). elfrijoli8@hotmail.com.
authors.forename: Jason J
authors.identifier: 0000-0001-6829-2618
authors.initials: JJ
authors.lastname: Parks
authors.affiliation: Clinical Associate Professor, School of Pharmacy, University of Washington . Seattle, WA ( United States ). aylam@uw.edu.
authors.forename: Annie Y
authors.identifier: 0000-0001-7204-1037
authors.initials: AY
authors.lastname: Lam
authors.affiliation: Professor, Fielding School of Public Health, University of California , Los Angeles. Los Angeles, CA ( United States ). dmorisky@ucla.edu.
authors.forename: Donald E
authors.identifier: 0000-0003-1338-2231
authors.initials: DE
authors.lastname: Morisky
authors.affiliation: Research Assistant, Department of Biobehavorial Nursing and Health Systems, School of Nursing, University of Washington . Seattle, WA ( United States ). laramariefernando@gmail.com.
authors.forename: Lara
authors.identifier: 0000-0001-8884-8003
authors.initials: L
authors.lastname: Fernando
authors.affiliation: Clinical Assistant Professor, Department of Biobehavorial Nursing and Health Systems, School of Nursing, University of Washington . Seattle, WA ( United States ). adechu@uw.edu.
authors.forename: Adeline
authors.identifier: 0000-0003-4067-0773
authors.initials: A
authors.lastname: Chu
authors.affiliation: Associate Professor The Phyllis F. Cantor Center, School of Medicine, Harvard University . Boston, MA ( United States ). Donna_Berry@dfci.harvard.edu.
authors.forename: Donna L
authors.identifier: 0000-0001-7935-2807
authors.initials: DL
authors.lastname: Berry
keywords: Health Communication; Health Literacy; Medication Adherence; Patient Education as Topic; Smartphone; United States