Background:

In Singapore, prescription medication labels (PMLs) are predominantly dispensed in English, but many older Singaporeans cannot read English. This poses a language barrier to accessing medication information. The inclusion of pharmaceutical pictograms, depicting medication instructions, on PMLs enhances medication literacy and optimizes pharmacotherapy outcomes among older adults. While pharmaceutical pictograms are sometimes used in Singapore, they have not been validated. We aimed to validate 52 International Pharmaceutical Federation (FIP) pharmaceutical pictograms among older Singaporeans.

Methods:

The study recruited 250 older (≥60 years) Singaporeans with limited English proficiency from 5 public polyclinics. Each participant was randomly assigned 11 pictograms and ≥50 responses for each pictogram were ensured. For each assigned pictogram, first, comprehension was assessed by asking “If you see this picture on a medicine label, what do you think it means?”, without informing him/her of its intended meaning. Then, the participant was informed of the pictogram’s intended meaning and asked to provide feedback to make the pictogram more representative and culturally-appropriate. All responses were audio-recorded, transcribed and translated before grading by 3 independent coders.

Results:

Majority of the participants were female (62.4%), of Chinese ethnicity (72%) and had no formal education (48.8%). Based on the ISO-9186 criteria for graphical symbol acceptability, only 20 pictograms (38.5%) achieved ≥66.7% comprehensibility and thus were considered validated. Pictograms relating to frequency, dose and route were better understood compared to those depicting precautions and indication or side effects. On average, participants comprehended 5 pictograms correctly. Poisson regression showed that those younger, of Chinese (versus Malay) ethnicity, with higher education and with polypharmacy comprehended more pictograms.

Discussion:

Majority of FIP pictograms (61.5%) did not achieve validity (≥66.7% comprehensibility) among older Singaporeans, highlighting the need for contextual validation of pharmaceutical pictograms prior to their use. Variation in the extent of pictogram comprehension across older adult subgroups indicates the need for comprehensive counselling and education on pharmaceutical pictograms, even after validation. Pictograms that did not achieve comprehensibility are being modified based on participants’ feedback. These re-designed Singapore-specific pictograms will be re-tested in future work.