Aims To design pictogram stickers to help overcome communication barriers in identifying medicines.
Method A Pharmacy Patient Forum Group was set up and involved in delivering an improved pharmacy service.
Results Pictogram stickers have been designed for cardiology, indigestion, and pain medication.
Conclusion A pictorial approach is a simple, novel and innovative way to identify indications of medicines.
Walsall Healthcare NHS Trust provides local, general hospital and community services to around 270,000 people in Walsall and the surrounding areas.1 There has been a significant demographical shift in Walsall over the past decade.
Figure 1 shows a snapshot of the Borough summary of the Census Report for 2011:2
- ‘White British’ remains the largest single group population, while the number of residents from a minority ethnic group has risen to almost one in four from the previous census
- The largest increase is in people of Asian background, within this group; those of Pakistani background have increased the most.
The census results highlight the prevalence of poor literacy in this population:
- In 3.3% of households, no one speaks English as their main language
- There are more than 6000 residents who cannot speak English well, of whom 1200 cannot speak the language at all.
Compared with the national picture, Walsall has a high proportion of residents over 16 with no qualifications or low qualifications (at level 1). One in three Walsall adults has no formal qualifications – which equates to over 71,800 people (33.7%) compared with a national figure of 22.7%. In addition, a further 14.6% of residents only have level 1 qualifications compared with 13.3% in England and Wales. This indicates almost half of Walsall’s adult population do not have qualifications equivalent to five passes at GCSE (level 2), which highlights the issue of limited literacy in this population.
The Pharmacy Department at Walsall Healthcare NHS Trust has set up a Pharmacy Patient Forum Group (PPFG). The main aim of the PPFG is to engage patients in the co-design of innovative ideas to enhance patient safety and experience. This would support in delivery of the Trust’s objective to become best-in-class for patient experience.
The main project to date has been designing pictogram stickers that illustrate the indications of medicines in an attempt to overcome communication barriers in identifying medicines. The treatment of long-term illnesses usually includes long-term use of medicines. Although guidelines and research provides information that these combinations of medicines are effective, their full benefit is often not achieved as up to 50% of patients do not take their medicines as prescribed.3 Following our work with the PPFG, there are currently four approved pictogram stickers.
Public members we recruited by invitation, using a database held by the Trust. All members on the database were sent a letter to express interest in participating in the PPFG. These members were invited to attend an initial meeting and ‘signed up’. Meetings are arranged approximately every six weeks and attended by:
- The Trust membership and engagement manager
- Pharmacy staff – senior pharmacist and ward-based services technical manager
- Trust members – who may also be involved in volunteering work around the Trust
Initially, all members of the PPFG were given a complementary tour of the pharmacy department where they could see the workforce in action and appreciate the workload of the team. The tour included:
- Aseptic unit
- Out-of-hours medication area
- Admissions ward, where they saw the ward-based pharmacy team in action.
Positive feedback was obtained from Trust Members regarding the ‘special insight’ into how pharmacy teams work behind the scenes. Feedback from the Members included:
- Having these meetings has enabled us to see and understand the problems faced so we now understand the complicated working system of a hospital pharmacy supplying all areas with medicines including emergency departments and the Chemotherapy unit
- As a group we have seen first-hand the daily problems experienced by pharmacists and doctors and understand the necessary checks that are being undertaken. We are all agreed that it would not be possible to prevent all delays without compromising patients’ safety.
Several projects are being carried out simultaneously. The main project arose when Trust members raised concerns about correctly identifying indications of medicines due to polypharmacy on discharge.
In an attempt to relieve some of the problems related to polypharmacy and possibly miscommunication, that is, through language barriers, we decided to create pictogram stickers for indications of medications that would be placed alongside the standard direction labels. A pictorial approach has been shown to be simple, novel and innovative way to identify indications of medicines.4
We have designed and developed the following universal pictogram stickers to enable patients to identify indications when faced with language barriers, some disabilities or minor vision problems (Figure 2). We gained approval for the pictograms from:
- Specialist teams – cardiology, pain and gastro teams
- 100% of patients, relatives, carers recognised the pictograms as the correct indication
- Peer review.
We have recently involved a local school to support the PPFG in developing a pictogram sticker for antibiotics. This was initiated by means of a competition where the children were asked to design an image that was representative of antibiotics. We have finalised the design and it is currently with the printing team for final amendments. The competition has strengthened local community relations and raised awareness of the projects and, more importantly, of antibiotic awareness.
Showcasing the work
To increase awareness of the project, we showcased our work at the following:
- Poster presentation at Hospital Pharmacy Europe Live event in 2016 and 2018
- Article published in the local newspapers advertising the innovative and collaborative work carried out by the pharmacy team and PPFG in April 2017
- Articles published in Membership Connect Magazine and the Pharmaceutical Journal (www.pharmaceutical-journal.com/opinion/correspondence/obtaining-patient-feedback-via-a-forum-group/20201596.article), and Trust Connect Magazine
- Presentation given to Friends of Expert Patients Programme
- Article submitted to West Midlands Innovation Day
- The pharmacy team and the PPFG were honoured to receive the Excellence in Hospital Pharmacy Practice Award at the Clinical Pharmacy Congress in 2018.
- Recently, in February 2019, the project has been accepted for a poster presentation at the Royal Pharmaceutical Society (RPS) Science and research Summit 2019, in London, and the prestigious 5th Qatar International Pharmacy Conference (QIPC) 2019, Qatar.
The project has generated huge interest at both events. This has given both the pharmacy team and Trust members the determination to continue with the innovative project and improve patient safety and compliance to medicines.
Designing pictogram stickers for indications of medicines is a lengthy process. The group initially design images which then have to be amended till the correct indication is represented. This is then validated via an in-house audit and the patients’ and representatives’ views taken on board. This is followed by ratification by the design company, which is responsible for printing the pictogram to a ‘printer friendly’ version. The research work is carried out alongside our NHS duties so delays on working on the project are inevitable. Currently we have three stickers in use and two stickers in the validation process (antibiotics and anticoagulation). After these have been rolled out, we will start looking at the next category, which is yet to be decided.
- Walsall NHS Heatlhcare Trust. www.walsallhealthcare.nhs.uk/about-us/ (accessed January 2018).
- 2011 Census reports. Key statistics for Walsall: Borough summary. https://go.walsall.gov.uk/Portals/0/images/importeddocuments/walsall_census_2011_
summary_report_v1.0.pdf (accessed January 2018).
- Brown M, Bussell K. Medication adherence: WHO cares? Mayo Clin Proc 2011;86(4):304–14.
- Kheir N et al. Development and evaluation of pictograms on medication labels for patients with limited literacy skills in a culturally diverse multiethnic population. Res Social Adm Pharm 2014;10(5):720–30.