Illiterate people are at high risk for inappropriate drug use. We aimed at enabling diabetic patients who were illiterate and/or migrants to understand diet and drugs prescription through the use of Icons. We evaluated two communication tools among 40 migrant patients who were unable to read and speak Italian and had to understand medical prescriptions either by being assisted by a health care provider or by looking at the study tools. Ninety-six percent subjects with study tools and 46% subjects with usual prescription plus operator’s aid understood the prescription (P<0.01). At follow up, 90% with study tools vs 60% with usual prescription were still compliant and took drugs appropriately (P<0.01). By using the pictogram, diet and drug advice was simplified, consultation time was accelerated by using pictogram and patient’s compliance was improved.

Diabetes, Diet, Drugs, Education, Ethnic minorities, Illiteracy

Communication between health professionals and patients is inherently problematic. While people at all literacy levels have problems understanding and using health information, people with limited literacy skills - and/or limited local language skills are especially in need of help. They need assistance in understanding written information and verbal instructions [1].

Providing patients with pictorial advice on illness management should be an integral part of the first consultation. Worldwide health services operators come across patients with different languages and culture barriers in their everyday work. Ad hoc interpreters, including family members, friends, untrained members of the support staff, and strangers found in waiting rooms or on the street, are commonly used in clinical encounters. But such interpreters are more likely to make errors in understanding compared to professional interpreters thus leading to adverse clinical consequences [2].

Language barriers can have deleterious effects. Patients with such barriers are likely to have an increased risk of non-compliance to medication [3]. The problem is particularly relevant in the management of chronic disease where the process of adjusting to and learning to live with chronic illness is complex [4]. Evidence is available on how low literacy does affect compliance, inappropriate use of services, drugs, and unhealthy lifestyle, simply because they did not understand [5-6]. On the face of such cultural diversity, immigrant patients and their physicians need skills and effective communication aid in order to receive and provide satisfactory health care.

In this study, we described the work of a diabetes team in collaboration with health communication experts aimed at addressing problems of literacy and language in relation to providing education for people with diabetes.

Italy, once a notable source of emigrants, has become a magnet for immigrants in the last 20 years. In Modena province (Central-North Italy) immigrants are 7.5% of the total population, hence encounters between physicians and patients are likely to be cross-cultural. In Italy, health operators are generally able to speak or understand very few words of the most frequent European languages, i.e. English, Spanish and French. Written tools are also available in other relevant languages such as Albanian, Arab, Chinese, Philippine, French, English, Polish, Russian, Spanish, Turkish, Urdu. Unfortunately, there is still a number of languages that are unknown to professional translators. Moreover, there are many people unable to read their own native language, also among the Italian patients.

When compared to text alone, pictures closely linked to written or spoken text can markedly increase attention to and recall of health education information. Pictures can also improve comprehension when they show relationships among ideas or when they show spatial relationships [1, 7].

For these reasons, we designed communicating tools to enable diabetic patients who were illiterate and/or migrants to understand diet and drugs prescription through the use of iconic language alone.

Secondarily, we wanted to improve the patient-doctor/nurse communication through the use of simple tools pertaining to diet and drugs prescription to illiterate or migrant patients.

In order to assess the effectiveness of pictogram, we developed two instruction sheets, one containing dietary advice and the other for daily drug therapy. These handouts were validated through the methodology of the Laboratory for Citizen Empowerment [8-9]. In brief, the Laboratory for Citizen Empowerment promotes empowerment through:

• Developing a shared language between the different actors for health (physician, nurse, patient, advocate, citizen, administrator, health organization).
• Educating citizens on effectiveness and appropriateness of healthcare.
• Simplifying language to improve access to health services
• Producing evidence-based easy-to-read information materials written in a comprehensible language.
• Developing a shared language with operators addressed to the targeted people.
• Implementing a network, able to promote synergy between the different actors involved in the local health plan.

The diet tool is a front-back A4 format photograph sheet (figure 1). The front page illustrates the photos of the main recommended foods, such as pasta, legume, vegetables, poultry, fish and some fruits (peach, orange, apple, and strawberry). The front page has green coloured edges and a green traffic lights symbol as a universal icon to mean ‘permitted’, ’allowed’, ‘go’.

The back page illustrates the photos of the main forbidden foods, such as white bread, sweets, cakes, fried potatoes and chips, butter, sugar, sweet drinks and juices, chestnuts, and selected fruits (grape, fig, and khaki). The back page has red coloured edges and a red traffic lights symbol as a universal icon to mean ‘forbidden’, ‘halt’.

The drug tool is a large (A3 format for desk) planning sheet for daily drug therapy and self monitoring of blood glucose (SMBG) (Figure 2). Even for this sheet we used only the iconic language. The page is divided in 4 columns representing the daily quarters, i.e. awakening, lunch, dinner, and bedtime. The four sketches were respectively the cup of hot coffee, the sun, the moon, and the bedroom. In each column three boxes are available to be filled with drug wrapping. The boxes’ icons are: 1) SMBG sticks with a drop of blood, 2) pills, and 3) a syringe. Under the 3 boxes there is a sketch with a sample meal for each daily quarter, i.e., recommended foods for breakfast, lunch, dinner, and bedtime according to Italian cooking. However, the planning is universal so any country can tailor this sheet according to the local food choices. Under the meal field there is the repeat of the 3 boxes for different type of drugs. In this way, we clearly illustrate the timings for drug administration i.e. pre- or post-prandial or bedtime. For testing purpose, these handouts were provided to doctors and dieticians. Forty migrants who were unable to read and speak Italian and had to understand medical prescriptions either by being assisted by a health care provider or by looking at the study tools, were recruited for this study. They were followed up after 30 days to check the appropriateness of drugs' consumption at home and were asked to reiterate their comprehension.

Ninety-six percent (19 out of 20) of people with study tools and 46% (9 out of 20) of people with written prescriptions plus operator’s aid correctly understood the prescription (Difference between groups -50%, 95% Interval Confidence [IC95] -74 to -26%; P<0.01). At follow up, 18 patients (90%) with study tools were still compliant and took drugs appropriately. Twelve patients (60%) with usual prescription plus operator's aid were still compliant and took drugs appropriately (Difference between groups -30%, IC95 -55 to-5; P<0.01).

Qualitative findings: a) diet and drug prescribing was simplified and speeded up, b) the patient-doctor/nurse communication was eased, c) the presence of an interpreter was unnecessary at follow-up visits.

Dietary patterns were identified by factor analysis, using standard principal component analysis method. In brief, factors were rotated with an orthogonal (varimax) rotation to improve interpretability and minimize the correlation between the factors. The number of factors retained from each food classification method was determined by eigenvalue (>1), scree plot, factor interpretability and the variance explained by each factor. Labelling of the factors was primarily descriptive and based on our interpretation of the pattern structures.

The aim of using photos not sketches was to allow illiterate people and migrants to quickly understand what to eat and what to avoid by enabling them to identify the real food seen in the photos when going to the supermarket.

The implementation of diet tools gave qualitative but relevant results: a) simple and quick method for diet and drug prescription, b) increase understanding by patient, b) reduction of errors in drug administration at home, c) facilitation of the patient-doctor/nurse communication.

The significantly improved comprehension of instructions by participants in the experimental group illustrates the valuable role played by the pictograms in enhancing understanding in low-literate patients. This is in line with literature findings [6-7, 10].

In conclusion, diet and drug advice should be simplified by using pictorial tools among illiterate patients thus avoiding the need for translators and accelerating the consultation time. We expect to reduce errors in drug administration at home, and facilitate the patient-doctor/nurse communication.

An extensive use of pictorial tools in patient’s education should be promoted among health operators involved in patient's care, i.e. physicians, dieticians, nurses, and pharmacists. Pictorial tools should be tailored to target patients in order to meet their real needs.