13-5-10 Communicating Through Pic to Grams Dowse

8/6/2019 13-5-10 Communicating Through Pic to Grams Dowse

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ROS DOWSEAssociate Professor : PharmaceuticsFaculty of Pharmacy, Rhodes University,GrahamstownSouth Africa

COMMUNICATING WITH PATIENTS:the barrier of low literacy


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Global distribution of HIV


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B ackground

Approx 5.2 million people in South Africa are HIV positive

b 920 000 patients are currently taking antiretrovirals (ARVs)

Pravin Gordhan, Budget Speech 2010, by 2012/13, SA Govt is

budgeting to have ZAR 2.1 b illion on ARVs.

South Africa s understaffed public health system and the

ballooning cost of treating millions of people for life will posedaunting challenges to the government s ambitious goals. South Africa redou b les efforts against AIDS

New York Times, May 2010(


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Literacy : South Africa

L iteracy in South Africa:

18%

16%

7%

31%

20%

8%No Schooling

Some primary

Completed primary

Some secondary

Completed secondary

Tertiary


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Literacy : Eastern Cape

L iteracy in South Africa, Eastern Cape:

23%

20%

7%

30%

14%

6%

No Schooling

Some primary

Completed primary

Some secondary

Completed secondary

Tertiary


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Visuals as communication aids

Visualsattract attentionpresent more information in a given spacesimplify complex conceptsincrease the speed of message transferincrease learning retention and enhance recall

are superior to text & verbal communication(40-80% of verbal info provided by HCPs is forgottenalmost immediately)


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Health-related pictorial information


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W ays to represent an object


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Interpretation of visuals

3 interpretation techniques:symptomatic create meaning based on everyday experiences

e.g. laughing faces associated with happinessiconic higher order interpretation e.g. thought balloons

symbolic the heart as a convention-based metaphor for love

Interpretation by low-literate viewers:failure to find central focusfailure to understand abstract elements and conventions(actions lines)literal interpretation (directional arrow as stick)failure to integrate elements to create storycreate own stories based on personal experiences


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W hat are these trying to say?


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Side effects, ARVs, patients

Side effects:high prevalence, short and long term toxicity

frequency and severity linked to poor adherence

significantly impact HRQO L

early detection essential for management

Patients inadequately informed about side effects

SA no written information provided despitelegal requirements


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Objectives

To design simple, culturally sensitive pictograms tocommunicate antiretroviral side effect information

To rigorously evaluate the pictograms in a low-literateSouth African population


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M ethod : Qualitative study

Design workshops with 1 30 Pharmacy students

Rough sketches refined in consultation with graphicdesigner.

Pictograms printed on cards as both large and smallimages.

Group discussions with the target population and

health care providers.Pictograms iteratively modified.


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M ethod : Quantitative study

11 pictograms tested in 80 Xhosa participants who wereat least 1 8 years old with maximum of 1 0 yearsschooling

Individual interviews with interpreters to collectdemographics ; interpretation and acceptability of pictograms

Data analysis: frequency data, chi-square and ANOVA todetermine influence of age, gender and education oninterpretation at 5% level of significance


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Results : Demographics

58 (72%) were unemployed

Gender Age Education

M ale 33 (4 1 %)Female 47 (59%)

1 8-29 5 (6%)30-39 1 6 (20%)40-50 27 (34%)> 50 32 (40%)

Grade 3 2 1 (26%)Grade 4-7 32 (40%)Grade 8- 1 0 27 (34%)


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Nausea and vomiting

Initial


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Nausea and vomiting cont

Final


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Peripheral neuropathy cont

Final


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Nightmares and hallucinations

Final

Initial


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Nausea andvomiting(early)

1 00%

Abdominal pain(early) 98%

Headache(early)

95%

Diarrhoea(early)

93%

Correct interpretation of pictograms


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Skin rash(early)

93%

L ipoatrophy(early)

83%

L ipodystrophy(late)

80%



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Fever(early / late) 73%

Peripheral

neuropathy(late)

73%

Dizziness(early)

65%

Nightmare(early)

48%



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ConclusionsInterpretation involves significant cognitive load

Familiar experiences best interpreted e.g. vomiting.B ody posture and facial expressions important.

Education, age and sex did not significantly influenceinterpretation.

Design process for successful pictograms:multi-stage, iterativeculturally sensitiveconducted in collaboration with target population


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Information design: o bjectives

To develop patient information leaflets (PILs) for ARVRegimens 1a, 1 b , 1c and 1d

To investigate, in HIV/AIDS patients on ARVs, theinfluence of illustrated information materials onknowledge and understanding of HIV/AIDS and of ARV-related information

To investigate the influence of age, gender andeducational level on knowledge


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Illustrated la bels

Stage 1 : Materials development - la bels

Medicine la bels were designed for regimens 1a, 1 b , 1c and 1d

Stavudine (d4T)

Lamivudine (3TC) Nevirapine (NVP) Zidovudine (AZT) EFV


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Results

Ov erall knowledge score

C ontrol group (standard care)68. 9%

Experimental group (Illustrated labels and PIL)

86.1%

Significance : p


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Association with knowledge

C ontrol(p v alue)

Experimental(p v alue)

Age 0.028 0.004

Education 0.008 than 50 years


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Conclusions

Illustrated materials improved knowledgeGeneral HIV/AIDS information: knowledge goodARV related information: varia b leSide effect information: poor

Patients and healthcare providers enthusiasticabout la bels and PILsA definite need identified for well designedinformation for pu b lic sector HIV/AIDS patients


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W here to from here?

Pictograms: possi b le applicationsInclude in leaflets for patients?Ask opinion of HIV patients on ARVs ?Group sessions with patients at clinics?Nurse education?Community health worker education ?

Leaflets: introduce into more clinics at local,district, provincial and national level


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Acknowledgements

FundingRhodes UniversityCenter for AIDS Research, University of California, San Diego.

Susan Abraham, graphic artist, for drawing the pictograms.

Prof Sarah Radloff for statistical assistance.Our participants for their valuable input.


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13-5-10 Communicating Through Pic to Grams Dowse

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