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2. Global distribution of HIV
3. Background Approx 5.2 million people in South Africa are HIV positive
? 920 000 patients are currently taking antiretrovirals (ARVs)
Pravin Gordhan, Budget Speech 2010, “…by 2012/13, SA Govt is budgeting to have ZAR 2.1 billion on ARVs.”
“South Africa’s understaffed public health system and the ballooning cost of treating millions of people for life will pose daunting challenges to the government’s ambitious goals.”
South Africa redoubles efforts against AIDS
New York Times, May 2010
4. Medicine-taking behaviour ARVs demand > 95% adherence
Non adherence may be due to:
poor comprehension of the medicine instructions
complexity of the therapy
inadequate health literacy
…. a host of other factors…
Patient information leaflets (PIL) are widely used to convey health information
Use in South Africa? Comprehension..?
5. Literacy : South Africa Literacy in South Africa:
6. Literacy : Eastern Cape Literacy in South Africa, Eastern Cape:
7. Visuals as communication aids
present more information in a given space
simplify complex concepts
increase the speed of message transfer
increase learning retention and enhance recall
are superior to text & verbal communication (40-80% of verbal info provided by HCPs is forgotten almost immediately)
8. Health-related pictorial information
9. Ways to represent an object
10. Interpretation of visuals 3 interpretation techniques:
symptomatic – create meaning based on everyday experiences
e.g. laughing faces associated with happiness
iconic – higher order interpretation e.g. thought balloons
symbolic – the heart as a convention-based metaphor for love
Interpretation by low-literate viewers:
failure to find central focus
failure to understand abstract elements and conventions (actions lines)
literal interpretation (directional arrow as stick)
failure to integrate elements to create story
create own stories based on personal experiences
11. What are these trying to “say”?
12. Side effects, ARVs, patients Side effects:
high prevalence, short and long term toxicity
frequency and severity linked to poor adherence
significantly impact HRQOL
early detection essential for management
Patients inadequately informed about side effects
SA – no written information provided despite legal requirements
13. Objectives To design simple, culturally sensitive pictograms to communicate antiretroviral side effect information
To rigorously evaluate the pictograms in a low-literate South African population
14. Method : Qualitative study Design workshops with ? 130 Pharmacy students
Rough sketches refined in consultation with graphic designer.
Pictograms printed on cards as both large and small images.
Group discussions with the target population and health care providers.
Pictograms iteratively modified.
15. Method : Quantitative study 11 pictograms tested in 80 Xhosa participants who were at least 18 years old with maximum of 10 years schooling
Individual interviews with interpreters to collect demographics ; interpretation and acceptability of pictograms
Data analysis: frequency data, chi-square and ANOVA to determine influence of age, gender and education on interpretation at 5% level of significance
16. Results : Demographics
58 (72%) were unemployed
22. Correct interpretation of pictograms
23. Correct interpretation of pictograms
25. Conclusions Interpretation involves significant cognitive load
Familiar experiences best interpreted e.g. vomiting.
Body posture and facial expressions important.
Education, age and sex did not significantly influence interpretation.
Design process for successful pictograms:
conducted in collaboration with target population
27. Information design: objectives To develop patient information leaflets (PILs) for ARV Regimens 1a, 1b, 1c and 1d
To investigate, in HIV/AIDS patients on ARVs, the influence of illustrated information materials on knowledge and understanding of HIV/AIDS and of ARV-related information
To investigate the influence of age, gender and educational level on knowledge
28. Illustrated labels Stage 1 : Materials development - labels
Medicine labels were designed for regimens 1a, 1b, 1c and 1d
31. Results Overall knowledge score
Control group (standard care)
Experimental group (Illustrated labels and PIL)
Significance : p<0.001
32. Association with knowledge
33. Conclusions Illustrated materials improved knowledge
General HIV/AIDS information: knowledge good
ARV related information: variable
Side effect information: poor
Patients and healthcare providers enthusiastic about labels and PILs
A definite need identified for well designed information for public sector HIV/AIDS patients
34. Where to from here? Pictograms: possible applications
Include in leaflets for patients?
Ask opinion of HIV patients on ARVs ?
Group sessions with patients at clinics?
Community health worker education ?
Leaflets: introduce into more clinics at local, district, provincial and national level
35. Acknowledgements Funding
Center for AIDS Research, University of California, San Diego.
Susan Abraham, graphic artist, for drawing the pictograms.
Prof Sarah Radloff for statistical assistance.
Our participants for their valuable input.