Duke-NUS Launches Pictograms to Enhance Clarity in Medication Instructions

In a significant advancement aimed at improving patient care, Duke-NUS Medical School has unveiled a set of visual aids, or pictograms, designed to clarify medication instructions. This initiative seeks to make medication-taking easier and safer, particularly for elderly patients who often struggle with complex prescription labels.

The launch includes 35 specially designed pictograms, developed by Duke-NUS researchers in collaboration with various public healthcare institutions and pharmacies. The goal is to encourage widespread adoption of these visual aids, ensuring that seniors and other patients can better understand their medication instructions. Given the varied healthcare services across different institutions in Singapore, these pictograms aim to standardize medication-related visuals, enhancing clarity across the board.

These pictograms can be printed or affixed to prescription medication packets and bottles, supplementing the existing labels provided by hospitals, polyclinics, GP clinics, and pharmacies. The pictograms convey crucial information such as medication names and dosing instructions, which are often presented in a format that is difficult for some patients to comprehend. Testing with patient groups indicated that the pictograms are easily understood, making them a valuable resource in clinical settings.

Currently, prescription medication bottles typically come with labels containing instructions primarily in English. However, many patients, particularly seniors, face challenges in understanding these instructions. In Singapore, over half (53%) of individuals aged 65 and older cannot read English, which complicates medication management for this demographic. A study conducted in 2020 revealed that 50% of older adults surveyed reported difficulty understanding medication labels, leading to confusion regarding when and how often to take their prescribed medications. This confusion can result in medication non-adherence, where patients do not follow their healthcare provider's instructions, potentially jeopardizing their health.

In response to these challenges, pharmacists often resort to personalized strategies, such as providing handwritten medication information in the patient's preferred language or larger print, or even sketching diagrams to facilitate understanding. Some healthcare institutions have taken it a step further by incorporating their own sets of pictograms into medication labels. 

To standardize and enhance this approach, Duke-NUS researchers collaborated with SingHealth Polyclinics, National Healthcare Group Polyclinics (NHGP), NHG Pharmacy, and the National Institute of Education to curate and validate a comprehensive set of 35 pictograms. The initiative, named "Prescription Medication Label Improvement for Singaporean Elderly" (PROMISE), reflects a concerted effort to tailor these tools to the specific cultural context of Singapore.

Of the 35 pictograms, 20 were developed by the International Pharmaceutical Federation (FIP) Foundation for Education and Research, a non-governmental organization focused on improving medication safety. The remaining 15 were specifically designed by Duke-NUS researchers to cater to local needs and cultural nuances. 

The effectiveness of the pictograms was evaluated through two studies conducted from March 2019 to February 2021, which involved more than 600 participants. These studies focused on older adults aged 60 and above, many of whom had limited proficiency in English. The results were promising, showing that all 35 pictograms were valid for use without the need for further testing or modifications. Notably, over 66% of participants correctly interpreted the pictograms, and more than 85% rated them as accurately representing their intended meanings.

Associate Professor Rahul Malhotra, Deputy Director of Duke-NUS Centre for Ageing Research and Education (CARE) and Principal Investigator of the PROMISE project, emphasized the critical role of clear medication instructions for older patients. "Older patients rely heavily on medication labels as a source of information due to a higher prevalence of chronic diseases and medication intake," he stated. "There is an urgent need to improve existing medication labels to help older adults take their medication safely and adhere to their treatment plans. In our studies, we collaborated closely with patients and pharmacists to redesign and test the pictograms, ensuring their needs were effectively addressed."

Kevin Ben Laurence, Director of the FIP Foundation for Education and Research (Singapore/Indonesia), expressed optimism about the project's impact. "The FIP Foundation pictogram project in Singapore is designed to make medication use safer by providing health professionals with effective tools to communicate medication instructions, especially to older patients who may not be proficient in English. We are pleased to see institutions around the world recognizing the utility of our pictograms and hope for their widespread adoption in Singapore."

One of the first public healthcare institutions to implement the new pictograms is Woodlands Health’s Urgent Care Centre @ Admiralty. Since April 2024, healthcare staff at the center have begun using selected pictograms relevant to their patient population. Ms. Yong Pei Chean, Chief of Pharmacy at Woodlands Health, emphasized the institution's commitment to patient empowerment and safety. "The adoption of pictograms will aid patients who have difficulty reading, enhancing their understanding of medication instructions. Additionally, it allows our staff to overcome language barriers when explaining medication to patients. We have identified several pictograms pertinent to common conditions and will incorporate them into our pharmacies for the benefit of a broader audience."

Duke-NUS remains dedicated to enhancing patient care through innovative biomedical research and health services. The insights gained from this study will contribute to a more resilient and future-ready healthcare system that empowers individuals to maintain healthier lives for longer. The PROMISE initiative is funded by Singapore's Ministry of Health, underscoring the government’s commitment to improving healthcare accessibility and effectiveness for its aging population.