Do pictograms improve children's understanding of medicine leaflet information?

There is a growing need for balanced drug information customized for special target groups such as children [Food and Drug Administration. Prescription Drug Product Labeling; Medication Guide Requirements; Proposed Rule. Part VII. Department of Health and Human Services, 21 CRF Part 201, et al. Federal Register 1995;60:44182-252; Dickinson D, Raynor DK, Duman M. Patient information leaflets for medicines: using consumer testing to determine the most effective design. Patient Educ Couns 2001;43:147-59]. Pictograms are one aid that may be used to make information easier to read and understand. The aim of this study was to test whether children understand pictograms developed by the United States Pharmacopeia (USP) [The United States Pharmacopeial Convention Inc. USP Pictograms. Retrieved 11 March 2002 from http://www.usp.org/], and especially, if the pictograms improve children's understanding of medicine leaflet information. Finnish elementary school children aged 7 years (n=28), 11 years (n=31) and 13 years (n=31) were interviewed and asked what they thought 15 USP pictograms mean. The two older age groups were also asked to read an "easy-to-read" leaflet for penicillin-V. Every second child was given a leaflet with a plain text and the others received the same text accompanied by pictograms. After reading the leaflet, the children were asked seven questions related to the text. Most of the children understood the meanings of the selected 15 pictograms correctly, the proportion of the correct explanations varying from 30 to 99% according to the pictogram. Even well-understood pictograms did not help the children understand the leaflet information, although they reduced the need for probing. This study shows that the context in which pictograms are tested makes a difference in the results. Testing plain pictograms without incorporating them in their real context, e.g., in the patient information leaflet may exaggerate their usefulness in leaflet information.