How Many Words Does a Picture Really Tell? Cross-sectional Descriptive Study of Pictogram Evaluation by Youth.

BACKGROUND Communicating health-related instructions with pictograms is useful, but such graphics can be interpreted in different ways. It is crucial to understand which pictogram components are best for accurate communication. OBJECTIVES To catalogue pictograms used to label drugs in clinical practice; to identify the common graphic elements for defined categories of pictograms, by performing a semiotic analysis (studying how signs are perceived and how they should be designed); to identify the key graphic elements common to pictograms preferred by users; and to develop suggestions for future pictogram design on the basis of users' input. METHODS Literature and Internet searches were performed to identify pictograms and pictogram categories. A call for pictograms was also circulated through the International Pharmaceutical Federation (FIP). Youth at a Canadian pediatric hospital were asked to rate pictograms (including storyboards and prescription labels generated by FIP pictogram software) in terms of how best they represented their intended meanings. Pictograms for which at least 80% of participants "somewhat agreed", "agreed", or "strongly agreed" that the graphic conveyed the intended meaning were designated as "preferred" and were selected for analysis. Elements appearing in at least 50% of these preferred pictograms were highlighted as key graphic elements for design of future pictograms. RESULTS In total, 21 categories were identified for pictograms used in clinical practice, and a total of 204 pictograms were analyzed. Eighty-six participants took part in the survey. For each pictogram category, certain elements were identified as "preferred" and as "key graphic elements", whereas other elements met neither designation. For all 21 pictogram categories, at least 80% of survey respondents agreed that the FIP storyboard conveyed the intended meaning. CONCLUSIONS Certain key, preferred graphic elements are required for pharmaceutical pictograms to convey their intended meaning. The overlap between preferred and key pictogram elements indicates that both must be considered in development of future pictograms. Redesign of existing pictograms with consideration of the best semiotic elements is in progress.