Effectiveness of using picture-based health education for people with low health literacy: An integrative review

Figures & data

Figure 1. Search flow chart using http://prisma.thetacollaborative.ca.

Table 1. Characteristics of picture-based health education strategies designed for patients with low health literacy

Study	Purpose	Setting	Sample characteristics	Design	Disease focus	Literacy measures	Key findings
Choi (2011)	To develop and validate pictograph-based discharge instructions for older adults after hip replacement surgery	United States	Experts assess appropriateness, accuracy, relevance	Tool development and evaluation	Hip replacement surgery	Not appropriate	Pictographs (simple line drawings) assist engagement and are easy to understand for low-literate immigrant refugees in discharge care actions
			N = 5
			Age range: 39–51 years
			Clinical experience: 5–15 years
			2 White, 2 AA, 1 Asian
Choi (2012)	To develop breast healthcare instructions using pictographs	United States	Immigrant women with low health literacy	Pilot study	Breast health care	S-TOFHLA ≤ 22	Pictographs (black and white simple line drawings) are effective regardless of race/ethnicity
			N = 6	Tool development and evaluation
			Age range: 37–55 years
			Living in US: ≥10 years (83.3%)	Cross-sectional study
			Edu. level: high school (66.7%)
			Hispanic/Latino (66.7%)	Interviews
			Asian (16.7%)
Choi (2013)	To examine the acceptability and comprehension of instructions in 15 low-literate older adults	United States	Convenience sample N = 15 (82.4% women)	Pilot study	Hip replacement surgery	S-TOFHLA ≤ 22	Pictographs are effective for low-literate older adults’ discharge instructions in acute health care
			Mean age 68.2 years	Cross-sectional study
			Edu. level: ≤high school (80%)	Interviews
			White (73%)
			S-TOFHLA M = 19.47
Choi (2015)	To examine the effect of pictograph-based discharge instructions on comprehension & recall of older adults with low health literacy	United States	Conv. sample ≥ 65years w/LHL	RCT	Hip replacement surgery	S-TOFHLA ≤ 22	Intervention group had significant improvement in scores on comprehension, t(35) = –2.29, p = 0.02, and recall, t(35) = –2.24, p = 0.03, vs. the comparison group
			N = 42 (28 women, 66.7%)	4 weeks discharge instruction education
			Mean age 67.59 years
			Edu. level: ≤high school (83.3%)
			White (69%)	Interviews
			STOEFLA M = 17.02 (SD = 5.16)
			Intervention group N = 21
			Women (66.7%)
			White (47.6%)
			Mean age 68.3 years
			Edu. level level: ≤high school
			S-TOFHLA M = 15.95 (SD = 1.43)
			Comparison group N = 21
			Women (66.7%)
			White (90.5%)
			Mean age 66.9 years
			Edu. level: ≤high school
			S-TOFHLA M = 18.1 (SD = 7.09)
Chuang et al. (2010)	To compare low-literacy patients and medical staff for preference and comprehension of pictographs intended to illustrate medication use instructions for medical clinic ambulatory patients	South Taiwan	Convenience sample N = 500	Prospective study	Medication	Education level	Patients and medical staff had significant differences in preferences for all categories of medical instruction pictographs and had significant differences in comprehension for the pictographs’ administration associated with meals. Patients’ preferences and comprehension of the medical instruction pictographs were age related
			Patients n = 250	Cross-sectional study		≤Elementary school
			Age M ≤ 60 years (43.2%)	Survey		(Grades 1–6)
			Women (54.4%)
			Men (45.6%)
			No schooling (61.6%)
			Medical staff n = 250
			Age M ≤ 60 years (100%)
			Women (92%)
			Male (8%)
			Edu. level: college degree (86%)
			Job: Nurse (64.8%)
DeWalt et al. (2004)	Development and pilot testing of a disease management program for heart failure patients with low literacy	United States	N = 23	Tool development and pilot test	Heart failure	REALM	Heart failure management program leads to significant improvements in self-care behavior and heart-failure-related symptoms for patients with low literacy
			Mean age 60 years	Pre-post test		S-TOFHLA
			Men (60%)	Self-report		<9th grade literacy level
			AA (60%)	3 months before and after study
			Income ≤$15,000/year (74%)	1 h educational section
			Married (67%)	Supportive phone calls over six weeks
			Mean education (years): 9.6
			REALM M: 33% (5th grade)
			S-TOFHLA: 52% inadequate reading level
			M knowledge score: 67.3
			M self-efficacy score (8–32): 30%
			M MLHFQ score (0–105): 57.3%
Dowse and Ehlers (2001)	To evaluate the use of pharmaceutical pictograms in low-literate South Africans	South Africa	Xhosa ethnic group who had attended school for no more than seven years	Pre-post test	Medication	A short literacy test	Pictographs combined with text are effective for comprehension and recall
			N = 46 (35 women, 76.1%)	3 weeks		Education level ≤7 years schooling	Pictograms communicate medication information
			Age 41–65 years (56.5%)	Interviews			Participants prefer local pictograms (p < 0.05)
			Edu. level 5–7 years (55.3%)
Dowse and Ehlers (2005)	To determine the influence of medicine labels incorporating pictograms on the understanding of instructions & on adherence	South Africa	Xhosa ethnic group attending an outpatient clinic, who had been prescribed a short course of antibiotics and had attended school for no more than10 years	RCT	Medication	Education level ≤10years	Pictograms significantly increase patients’ understanding of instructions and adherence (p < 0.01)
			N = 87	Within 3–5 days intervention			Control group average for understanding, 69.5%
			Experimental	Interviews			Control group average adherence, 71.5%; experimental group, 89.6% (p < 0.01)
			(Text & pictogram labels)
			n = 46 (42 women, 91.3%)
			Age 21–40 years: 45.7%
			Edu. level 5–7 years (41.3%)
			Language: isiXhosa (80.4%),
			English (19.6%)
			Control (text only)
			n = 41 (38 women, 92.7%)
			Age 21–40 years (61%)
			Edu. level 5–7 years (19, 36.6%)
			Language: isiXhosa (70.7%), English (34.1%)
			Percentage for understanding instructions
			Experimental group: 95%
			Control group: 70%
Kalichman et al. (2013)	To test the efficacy of a pictograph-guided adherence skills building counseling intervention for adults with limited literacy living with HIV	United States	Have HIV & receiving antiretroviral therapy	RCT	HIV	TOFHLA	Interventions or adherence counseling may be required or beneficial for patients with low or marginal literacy skills regardless of their use of pictograms
			N = 446	Audio computerized self-interviews
			Pictograph guided n = 148
			Mean age 46.7 years (70% men)
			Edu. level 12years
			HIV + testing: 14 years
			HIV symptoms: 5.1 years
			Income < $10,000/year (69%)
			TOFHLA < 85% correct (58%)
			Standard adherence n = 157
			Mean age 47 years (73% men)
			Edu. level 12 years
			HIV + testing: 13.6 years
			HIV symptoms: 5 years
			Income < $10,000/year (71%)
			TOFHLA < 85% correct (53%)
			General health improvement
			n = 141 (65% men)
			Mean age 47.8 years
			Edu. level 11.9 years
			HIV + testing: 13 years
			HIV symptoms: 4.9 years
			Income < $10,000/year (75%)
			TOFHLA < 85% correct (40%)
Kripalani et al. (2007)	To describe the development, implementation, and preliminary evaluation of an illustrated medication schedule that depicts a patient’s daily medication regimen using pill images and icons	United States	N = 209	RCT	Medication	REALM	Pill card improved medication management and understanding for those with limited health literacy, low levels of education, and cognitive function impairments (p < 0.05)
			Frequent use of pill card (83%)	Pill card assessment
			AA, 191 (91.4%)	Tool development and intervention
			Women, 122 (58.4%)	3rd month interview
			Mean age 63.7 years
			Edu. level ≥ 12 years (110, 52.6%)
			REALM: 87 inadequate, 41.6%
			MMSE ≥ 24 (64.6%)
			All patients had coronary heart disease, 99% had hypertension.
			Diabetes mellitus: 46%
			Hypercholesterolemia: 87%
			Prescribed medications: 6
Mansoor and Dowse (2003)	To access the effect of incorporating pictograms on understanding in low-literate participants	South Africa	Xhosa low-literacy participants with a maximum of 7 years of formal schooling	RCT	Medication	Education level  ≤7 years schooling	Text-and-pictogram-based information creates a significantly higher level of understanding than text-only information (p = 0.05)
			N = 60 (39 women, 65%)
			Age 21–40 years (68.3%)
			Edu. level Grades 5–7th, 40 (66.7%)
			Experimental group, text and pictogram information
			n = 30 (60% women)
			Age 21–40 years (76.7%)
			Edu. level 5–7th grades (60%)
			Control, text-only information, asked to read medicine labels and patient information leaflet
			n = 30 (70% women)
			Age 21–40 years (60%)
			Edu. level 5–7th grades (73.3%)

Notes: REALM—rapid estimate of adult literacy in medicine; TOFHLA—test of functional health literacy in adults; S-TOFHLA—short test of functional health literacy in adults; AA—African American; Edu.—education; MLHFQ—minnesota living with heart failure questionnaire; MMSE—mini-mental state examination; SEAMS—self-efficacy for appropriate medication use scale.

Table 2. Study characteristics

Study	Research design	N	References^*
Descriptive	Cross-sectional	6	Choi (2011, 2012, 2013), Chuang et al. (2010), DeWalt et al. (2004), Kripalani et al. (2007)
Intervention	RCT	5	Choi (2015), Dowse and Ehlers (2005), Kalichman et al. (2013), Kripalani et al. (2007), Mansoor and Dowse (2003)
	Pre-post test	2	DeWalt et al. (2004), Dowse and Ehlers (2001)

^* References include duplicate studies.

Table 3. The analysis of study components

Feature	Articles^* (N = 11)	References^*	Participants^** (N = 1,439)
Study design
Tool development and evaluation by experts	1	Choi (2011)	5
Tool development and evaluation by patients	3	Choi (2012), DeWalt et al. (2004), Kripalani et al. (2007)	238
Only tool evaluation	7	Choi (2013, 2015), Chuang et al. (2010), Dowse and Ehlers (2001, 2005), Kalichman et al. (2013), Mansoor and Dowse (2003)	1,196
Health literacy measurement
TOFHLA	1	Kalichman et al. (2013)	446
S-TOFHLA	4	Choi (2012, 2013, 2015), DeWalt et al. (2004)	86
REALM	2	DeWalt et al. (2004), Kripalani et al. (2007)	232
Education level	5	Chuang et al. (2010), DeWalt et al. (2004), Dowse and Ehlers (2001, 2005), Mansoor and Dowse (2003)	716
Not present	1	Choi (2011)	5
Short literacy test	1	Dowse and Ehlers (2001)	46
Study setting
United States	7 (63.6%)	Choi (2011, 2012, 2013, 2015), DeWalt et al. (2004), Kalichman et al. (2013), Kripalani et al. (2007)	746
Other countries	4 (36.4%)	Chuang et al. (2010), Dowse and Ehlers (2001, 2005), Mansoor and Dowse (2003)	693
Study fields
Hip replacement surgery	3 (27.3%)	Choi (2011, 2013, 2015)	62
Breast healthcare	1 (9.1%)	Choi (2012)	6
Medication	5 (45.4%)	Chuang et al. (2010),Dowse and Ehlers (2001, 2005), Kripalani et al. (2007), Mansoor and Dowse (2003)	902
Heart failure	1 (9.1%)	DeWalt et al. (2004)	23
HIV	1 (9.1%)	Kalichman et al. (2013)	446
Health education materials format
Only text based	0	None	0
Only pictography based	0	None	0
Simple text and pictography based	11 (100%)	Choi (2011, 2012, 2013, 2015), Chuang et al. (2010), DeWalt et al. (2004), Dowse and Ehlers (2001, 2005), Kalichman et al. (2013), Kripalani et al. (2007), Mansoor and Dowse (2003)	1,439

Notes: TOFHLA—test of functional health literacy in adults; S-TOFHLA—short test.

^* References include duplicated studies.

^** Number of participants studied, whether participants were experts or patients.

Choi, J. (2011). Pictograph-based discharge instructions for low-literate older adults after hip replacement surgery: Development and validation. Journal of Gerontological Nursing, 37, 47–56. doi:10.3928/00989134-20110706-03

 Google Scholar

Choi, J. (2012). Development and pilot test of pictograph-enhanced breast health-care instructions for community-residing immigrant women. International Journal of Nursing Practice, 18, 373–378. doi:10.1111/j.1440-172X.2012.02051.x

 Google Scholar

Choi, J. (2013). Older adults’ perceptions of pictograph-based discharge instructions after hip replacement surgery. Journal of Gerontological Nursing, 39, 48–54. doi:10.3928/00989134-20130415-02

 Google Scholar

Choi, J. (2015). Effect of pictograph-based discharge instructions on older adults’ comprehension and recall: A pilot Study. Research in Gerontological Nursing, 9, 66–71. doi:10.3928/19404921-20150513-05

 Google Scholar

Chuang, M.-H., Lin, C.-L., Wang, Y.-F., & Cham, T.-M. (2010). Development of pictographs depicting medication use instructions for low-literacy medical clinic ambulatory patients. Journal of Managed Care Pharmacy, 16, 337–345.10.18553/jmcp.2010.16.5.337

 Google Scholar

DeWalt, D. A., Pignone, M., Malone, R., Rawls, C., Kosnar, M. C., George, G., … Angel, B. (2004). Development and pilot testing of a disease management program for low literacy patients with heart failure. Patient Education and Counseling, 55, 78–86. doi:10.1016/j.pec.2003.06.002

 Google Scholar

Dowse, R., & Ehlers, M. (2001). The evaluation of pharmaceutical pictograms in a low-literate South African population. Patient Education and Counseling, 45, 87–99. doi:10.1016/S0738-3991(00)00197-X

 Google Scholar

Dowse, R., & Ehlers, M. (2005). Medicine labels incorporating pictograms: Do they influence understanding and adherence? Patient Education and Counseling, 58, 63–70. doi:10.1016/j.pec.2004.06.012

 Google Scholar

Kalichman, S. C., Cherry, C., Kalichman, M. O., Amaral, C., White, D., Grebler, T., … Schinazi, R. F. (2013). Randomized clinical trial of HIV treatment adherence counseling interventions for people living with HIV and limited health literacy. JAIDS Journal of Acquired Immune Deficiency Syndromes, 63, 42–50. doi:10.1097/QAI.0b013e318286ce49

 Google Scholar

Kripalani, S., Robertson, R., Love-Ghaffari, M. H., Henderson, L. E., Praska, J., Strawder, A., … Jacobson, T. A. (2007). Development of an illustrated medication schedule as a low-literacy patient education tool. Patient Education and Counseling, 66, 368–377. doi:10.1016/j.pec.2007.01.020

 Google Scholar

Mansoor, L. E., & Dowse, R. (2003). Effect of pictograms on readability of patient information materials. The Annals of Pharmacotherapy, 37, 1003–1009. doi:10.1345/aph.1C449

 Google Scholar