Pictogram Project

Action Plans using pictograms

Asthma Action Plan

A written action plan is an important part of asthma self-management. However, these document are often text-heavy and may be difficult to comprehend for certain users, specifically children and parents/adults of low health literacy 4,5. The addition of pictures alongside patient health information is an effective means of improving comprehension, recall and treatment adherence.

CHEO developed an Asthma Action Plan (AAPP). Building upon asthma action plans, this new tool combine pediatric-specific pictograms and written directions in order to help children to improve their disease self-management and monitoring.

All pictograms were validated in children and have been used in an Asthma Action Plan at CHEO Emergency Department since then.

PDF version>>

Development stages


1. Pascuet E, Vaillancourt R, Collins M, Moore A, Scoular D, Gaboury I, et al. Visual Thematic Analysis of Childrens Illustrations to Improve Receptiveness to Pictorial Asthma Action Plans. Journal of Pharmacy Practice and Research.2010;40(2):92-96 POSTER

2. Tulloch J, Vaillancourt R, Irwin D, Pascuet E. Evaluation, modification and validation of a set of asthma illustrations in children with chronic asthma in the emergency department. Can Respir J.2012;19(1):26-31 POSTER

3. Stulberg E, Irwin D, Vaillancourt R, Zemek R, Farion K, Rohde K. Community Pharmacist Perception and Utilization of a Pediatric Emergency Department Asthma Action Plan & Prescription. Can J Hosp Pharm.2015;68(4):356 POSTER

4. Mansoor LE, Dowse R. Effect of Pictograms on Readability of Patient Information Materials. Ann Pharmacother. 2003;37:1003-1009.

5. Ducharme F, Bhogal S. The role of written action plans in childhood asthma. Curr Opin Allergy Clin Immunol. 2008;8:177-88.


Diabetes Action Plan

FIP Action Plan

Pictograms Development For Canadian First Nations

Diabetes Mellitus is currently a growing epidemic among Canadian First Nations, especially those living on reserves (17.2% compared with 10.3% for First Nations living off reserves and 5.0% of the general Canadian population) 1. Pictograms developed to improve communication regarding diabetes self-care can be especially helpful in the First Nations populations given the language and health literacy barriers that exist2.

This Canadian project resulted in the development of 33 pictograms to support diabetes education of First Nations communities on the British Columbia West Coast1.

Using these pictograms, six patient infographics explaining conditions that can result from poor diabetes management were created and validated1.

Pictogram can help patients to understand & recall information

Blood Sugar Control

Blood pressure control

Urine testing

See pictograms developed for Diabetes 

Blood Sugar Control (pdf)

Eye Problems (pdf)

Heart Disease (pdf)

Infection (pdf)

Kidney Disease (pdf)

Nerve Damage (pdf)

Other Diabetes Action Plan

Health Literacy and Outcomes

The health literacy of diabetics is related to the way health care professionals provide medical information. Unfortunately, in case of low literacy, patients can experience difficulties with communication4.

Among patients with Type 2 Diabetes, inadequate health literacy is associated with less disease related knowledge which may limit self-interpretation of test results. This can lead to less effective self-care and worse glycemic control5,6,7, which is associated with increased risk of complications8.


  • age ≤60 years
  • having postsecondary schooling
  • low knowledge score
  • being depressed (PHQ-2: ≥2)


In one study examining health literacy in the USA, subjects with inadequate functional health literacy were found to be less knowledgeable about chronic10.


A Brazilian study in elderly Type 2 diabetics found poorer glycemic control in patients with inadequate functional health literacy. 31.0% had HbA1C > 8.0 compared to 16.1% in those with adequate functional health literacy5.



More than 70% of health care professionals think that using pictograms is an effective means to improve health literacy while less than 50% used them routinely11. The FIP pictogram software can help reduce this gap.

Download FIP pictogram software>>


A 2017 study, described another way to improve medication adherence in patients on oral diabetic medication. Researchers developed flashcards and QR-codes that provided patients with easy way to access educational videos12.


A recent systematic review from the USA found that there is controversy in evidence linking low health literacy with more negative outcomes of diabetes care13.

Good quality evidence is still lacking, and low health literacy remains a significant barrier to improving diabetic outcomes.


1. Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a public health perspective. Ottawa, 2011. phac-aspc.gc.ca/cd-mc/publications/diabetes-diabete/facts-figures-faits-chiffres-2011/highlights-saillants-eng.php#chp6. Accessed October 29, 2018.

2. Cloutier M, Vaillancourt R, Pynn D, Wade J, Preston C, Turpin P, Hansra A. Design and Development of Culture-Specific Pictograms for Type 2 Diabetes Mellitus Education Councelling. Canadian Journal of Diabetes.2014;38(6):379-392 POSTER

3. Doucette D, Vaillancourt R, Berthenet M, Pouliot A. Validation of a pictogram-based diabetes education tool in counselling patients with type 2 diabetes. Canadian Pharmacists Journal / Revue Des Pharmaciens Du Canada.2014;147(60):340-344 POSTER

4. Howe CJ, Cipher DJ, LeFlore J, Lipman TH. Parent Health Literacy and Communication With Diabetes Educators in a Pediatric Diabetes Clinic: A Mixed Methods Approach. Journal of Health Communication. 2015;20(2):50-59

5. Souza JG, Apolinario D, Magaldi RM, Busse AL, Campora F, Jacob-Filho W. Functional health literacy and glycaemic control in older adults with type 2 diabetes: a cross-sectional study. BMJ Open. 2014 Feb 12; 4(2):e004180

6. Bailey SC, Brega AG, Crutchfield TM, Elasy T, Herr H, Kaphingst K, Karter AJ, Moreland-Russell S, Osborn CY, Pignone M, Rothman R, Schillinger D. Update on health literacy and diabetes. Diabetes Educ. 2014; 40(5):581-604

7. Pathways of empowerment perceptions, health literacy, self-efficacy, and self-care behaviors to glycemic control in patients with type 2 diabetes mellitus. 2016 Open the poster (PDF version )

8. Al Sayah F, Majumdar SR, Williams B, Robertson S, Johnson JA.Health Literacy and health Outcomes in Diabetes: A Systematic Review.2013;28(3):444-452

9. Maneze D, Everett B, Astorga C, Yogendran D, Salamonson Y. The Influence of Health Literacy and depression on Diabetes self-management: a cross-sectional study. J Diabetes Res.2016(1):1-8

10. Gazmararian JA, Williams MV, Peel J, Baker DW. Health literacy and knowledge of chronic disease. Patient EducCouns. 2003 Nov; 51(3):267-75

11. Howe CJ, Walker D, Watts J.Use of Recommended Communication Techniques by Diabetes Educators.HLRP.2017;1(4):145-152

12. Yeung DL, Alvarez KS, Quinones ME, Clark CA, Oliver GH, Alvarez CA, et al. Low-health literacy flashcards & mobile video reinforcement to improve medication adherence in patients on oral diabetes, heart failure, and hypertension medications. J Am Pharm Assoc. 2017;57(1):30-37

13. Fatima Al Sayah, Sumit R. Majumdar, Beverly Williams, Sandy Robertson, Jeffrey A. Johnson. Health Literacy and Health Outcomes in Diabetes: A Systematic Review. J Gen Intern Med. 2013 Mar; 28(3):444–452


Eczema Action Plan

In recent years, there has been growing interest in using an Eczema Action Plan to improve Atopic Dermatitis self-management1,2,3. Eczema treatment plans are often complex4,5,6 with poor compliance.

Eczema Action Plan (EAP) was designed and validated to achieving acceptable transparency, translucency, and recall. Input was received from pediatric patients and a multidisciplinary medical team. The incorporation of validated illustrations into EAP was proven to be beneficial to patients with limited health literacy7.

The use of illustrations, graphics and attractive layout plays a key role in improving the readability of Eczema Action Plans8 and improve the understanding of written instructions9.


  • Clarify which medications to use during a flare6
  • Enhance patients’ understanding of Atopic Dermatitis10,11 and their treatment plans5
  • Increase treatment adherence10
  • Simplified treatment adjustments depending on symptoms severity5
  • Decrease in parental anxiety5
  • Increase confidence regarding self-management 5,6
  • Improve clinical outcomes5
  • Improve symptom recognition and prevention1


1. Sauder MB, Mc Evoy A, Sampson M, Kanigsberg N, Vaillancourt R, Ramien ML, et al. The Effectiveness of Written Action Plans in Atopic Dermatitis. Pediatric Dermatol.2016;33(2):151-3

2. Gilliam AE, Madden N, Sendowski M, Mioduszewski M, Duderstadt KG. Use of Eczema Action Plans (EAPs) to improve parental understanding of treatment regimens in pediatric atopic dermatitis (AD): A randomized controlled trial. J AM Acad Dermatol. 2016.74(2):375-7

3. Ntuen E, Taylor SL, Kinney M, O’Neill JL, Krowchuck DP, Feldman SR. Physicians’ perceptions of an eczema action plan for atopic dermatitis. J Dermatolog Treat.2010;21(1):28-33

4. Snyder A, Farhangian M, Feldman SR. A review of patient adherence to topical therapies for treatment of atopic dermatitis. Curtis. 2015;96(6):397-401

5. Shi VY, Nanda S, Lee K, Armstrong AW, Lio PA. Improving patient education with an eczema action plan: a randomized controlled trial. JAMA Dermatol. 2013;149(4):481-3

6. Rork JF, Sheehan WJ, Gaffin JM, Timmons KG, Sidbury R, Schneider LC, et al. Parental response to written eczema action plans in children with eczema. Arch Dermatol. 2012;148(3):391-2

7. McDonald K, Suter P, Pouliot A, Zemek R, Mc Evoy A, Vaillancourt Regis. Usability, Satisfaction and Comprehension of an Illustrated Eczema Action Plan in Practice by Pediatric Patients. Journal of Cutaneous Maedicine and Surgery. 2017;22(2):147-153 POSTER

8. Stringer T, Yin HS, Gittler J, Curtiss P, Schneider A, Oza VS. The readability, suitability, and content features of eczema action plans in the United States. Pediatr Dermatol.2018;35(6):800-807

9. Sansgiry SS, Cady PS, Adamciok BA. Consumer comprehension of information on over-the-counter medication labels: effects of picture superiority and individual differences based on age. Journal of Pharmaceutical Marketing & Management.1994;11(3):63-76

10. Chisolm SS, Taylor SL, Balkrishnan R, Feldman SR. Written action plans: potential for improving outcomes in children with atopic dermatitis. J Am Acad Dermatol.2008;59(4):677-83

11. Brown J, Weitz NW, Liang A, Stockwell MS, Friedman S. Does an Eczema Action Plan Improve Atopic Dermatitis? A Single-Site Randomized Controlled Trial. Clin Pediatr. 2018;57(14):1624-1629


Anaphylaxis Action Plan

An Anaphylaxis Action Plan (AAP) with pictorial aids was developed and validated based on the images’ guessability, translucency and recall scores. The AAP has since been used by health care professionals working in emergency and urgent care setting for patient education and future self-management.

PDF version>>


Garrick M, Vaillancourt R, Irwin Danica, Wrong A, Zemek R, Alqurashi W. Design and validation of pictograms in a pediatric anaphylaxis action plan. Pediatr Allergy Immunol.2015;26:223-233


Make medication taste better

Medications that taste unpleasant can be a struggle to administer to children, most often resulting in low adherence rates.

Structured interviews with children 9 to 17 years old and/or their guardians were conducted to evaluate the comprehension of 12 pictogram sets that described how to mask the taste of medications for children.

All 12 pictogram sets were correctly identified at short-term recall and were therefore validated.

PDF version>>




PDF version>>


Vaillancourt, R., Truong, Y., Karmali, S., Kraft, A., Manji, S., Villarreal, G., & Pouliot, A. (2017). Instructions for masking the taste of medication for children. Canadian Pharmacists Journal / Revue Des Pharmaciens Du Canada, 150(1), 52-59. doi:10.1177/1715163516669383