Following a rigorous method is essential to create pictograms. Many factors may disrupt a clear understanding of illustrations by patients. Conducting a semiotic analysis is an effective way to develop pictograms adapted to the target population.1
Semiotic of graphics
The semiology of graphics is a set of rules that can be used to transform verbal or written information into an illustration. 2
When looking at an image, our eyes are free to examine the overall picture, only one element within the picture, or any combination of elements. The eyes have a unique ability of seeing all the possible subsets of an image almost instantaneously and automatically. 3
Therefore, it is important to determine the elements, as well as the combination of elements that will be best understood by the target population.
According to the Cambridge Dictionary, semiotics is “the study of signs and symbols, what they mean, and how they are used”. Semiotic analysis aims to highlight the key graphic elements of a drawing that helps to recognize the subject. To achieve this, a detailed study of a set of illustrations has to be done.
In the context of the Asthma Action Plan (link), children were asked to draw how they feel when their asthma is under control and during an attack. Each drawing was analyzed and key graphic elements (open mouth, worried eyebrows…) were listed. Lastly, frequencies of occurrence were calculated for each graphic element (cough, dizziness, etc.).
Thus, drawings are a good way to target the subject of future pictograms and to create illustrations close to children’s representations.
From the list of graphic elements (closes eyes, leaning forward etc.) obtained via the semiotic analysis and their frequencies of occurrence, key details were identified. These elements must be included in the final pictogram design.
To validate pictograms, two parameters should be assessed:
- Translucency 1,4,5,6
- Guessability 1,7
International Standards Organization (ISO) =67%4
American National Standards Institute (ANSI) =85%4,8
It is possible to test:
- short-term recall (there must be a distraction phase to ensure the test is measuring memory storage rather than working memory11)
- long-term recall11,12
Methods to assess patient’s memory:
- Show the pictogram to patients and ask them what they think it represent => evaluation of guessability (has to be >85%)13
After a while (5 minutes: short-term recall / one or two mouths: long-term recall), repeat the same test and compare the first rate to the second. (guessability has to be >85%)
If at least one of the parameters (translucency, guessability, recall) is not validated, the pictogram has to be redesigned.
The modified pictogram will be reevaluated.
Recall refers to the ability of patients to remember the knowledge gained due to the use of illustrations and/or written information.10
1.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
2.Marc Emery. La sémiologie graphique. Entretien avec J. Bertin. Communication et langages.1975;28:33-43
3.Jacques Bertin. Semiology of Graphics: Diagrams, Networks, Maps.2010
4.International Organization for Standardization [Internet]. ISO 9186-1:2014.[updated 2014 March]. Accessed December,7, 2018. Available from: https://www.iso.org/standard/59226.html
5.Katz MG, Kripalani S, Weiss BD. Use of pictorial aids in medication instructions: a review of the literature. Am J Health Syst Pharm.2006;63(23):2391-7
6.Bloomberg K, Karlan GR, Lloyd L. The Comparative Translucency of Initial Lexical Items Represented in Five Graphic Symbol Systems and Sets. Journal of Speech, Language, and Hearing.1990;33(4):717-725
7.Chan AHS, Chan KWL. Effects of prospective-user factors and sign design features on guessability of pharmaceutical pictograms. Patient Education and Counceling.2013;90(2):268-275
8.Barros I, Alcantara T, Mesquita A, Santos AC, Paixão FP, Lyra DP. The use of pictograms in the health care: A literature review.2014;10(5):704-719
9. ANSI[Internet]. ANSI/NEMA Z535.1-2006 (R2011) Safety colors Z535.1 sets forth the technical definitions, color standards, and color tolerances for the ANSI Z535 safety colors. Accessed December 7,2018. Available from: http://webstore.ansi.org/RecordDetail.aspx?sku=ANSI%2fNEMA+Z535.1-2006+(R2011)&source=mRNAs_article
10.. Houts PS, Bachrach R, Witmer JT, Tringali CA, Bucher JA, Localio RA. Using pictographs to enhance recall of spoken medical instructions. Patient Educ Couns 1998: 35: 83–8.
11. King SR, McCaffrey DJ III, Bentley JP, Bouldin A, Hallam J, Wilkin NE. The influence of symbols on the short‐term recall of pharmacy‐generated prescription medication information in a low health literate sample. J Health Mass Commun 2012: 17(Suppl 3): 280–93.
12. Del Re L, Vaillancourt R, Villarreal G, Pouliot A. Pictograms: Can they help patients recall medication safety instructions? Visible Language.2016;50(1):127-151
13. Mok Garrick, Vaillancourt R, Irwin D, Wong A, Zemek Roger, Alqurashi A. Design and validation of pictograms in pediatric anaphylaxis action plan. 2015