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Refining teratogen warning symbols for diverse populations
Abstract
The current research reports on efforts to refine the design of recently developed teratogen warning symbols and to examine their interpretation by different populations such as those with low health literacy, adolescents, and individuals who are not fluent in English.
Alternative symbols identified as most successful in an earlier study were further refined through the use of multiple focus groups and expert review. Six symbols emerged as potential candidates to replace the current symbol. A nationally distributed field trial (n = 700) examined these six alternate teratogen warnings in addition to the symbol presently in use.
Five of the alternate warning symbols exceeded the level of correct interpretation elicited by the current symbol. No symbol exceeded the ANSI limit of 5% critical confusion. Two symbols consistently elicited the most accurate responses in terms of message interpretation, target audience, intended action, and perceived consequences of ignoring the warning.
This effort produced at least two viable alternative symbols that appear to be more effective than the current symbol at communicating both the instruction to not take while pregnant and the consequence that exposure could cause birth defects. Several results varied by participant characteristics. Understanding how members of diverse subpopulations might interact with these warnings should be informative to healthcare professionals.
... Some studies used the pictogram by Daniel et al. (2001), which was presented as a symbol in use in the USA to represent a prohibition on pregnancy. However, it does not demonstrate the action of taking medicine or the consequences of its use (Goldsworthy & Kaplan, 2006;Goldsworthy et al., 2008;Mayhorn & Goldsworthy, 2007). ...
... In other studies, pictograms were created by the authors to demonstrate, in different ways, the risk of medication use during pregnancy (Goldsworthy & Kaplan, 2006;Goldsworthy et al., 2008;Mayhorn & Goldsworthy, 2007van Beusekon et al., 2016). The meanings of the created pictograms show, in an individualized or integrated way, the prohibition during pregnancy, the prohibition of taking something during pregnancy, and fetal death or injury. ...
... The meanings of the created pictograms show, in an individualized or integrated way, the prohibition during pregnancy, the prohibition of taking something during pregnancy, and fetal death or injury. The tested pictograms are shown in Fig. 2. (Daniel et al., 2001;Goldsworthy & Kaplan, 2006;Goldsworthy et al., 2008;Kim et al., 2016;Knapp et al., 2005;Mayhorn & Goldsworthy, 2007;Mayhorn & Goldsworthy, 2009;van Beusekon et al., 2016;Wolf et al., 2010;You et al., 2011). Other questions formats, such as matching up warning phrases with the corresponding icons, are less reliable than an open-ended question because the range of potential answers is limited by the experimenter (Wolff & Wogalter, 1998). ...
Objective
This study aimed to summarize the comprehension of a pictogram about the risk of medication use during pregnancy.
Methods
A systematic review was performed using the PRISMA checklist of the PubMed, Embase, Cochrane Central Register of Controlled Trials, CINAHL, PsycInfo, LILACS, Academic Search Premier, Scopus, and Web of Science databases, grey literature (Google Scholar and OpenAIRE), ClinicalTrials.gov website, and design journals and congresses. The search was performed since the database inception, without language or year of publication restrictions.
Results
Twelve studies met the inclusion criteria for this review, 2 of which were randomized clinical trials. The pictograms and methods used varied widely among studies. The comprehension of the pregnancy pictograms had a complex communication outcome with a variation of 21–96%.
Conclusions for Practice
The lack of a standard pictogram and uniform methods to evaluate the comprehension of the pregnancy pictogram made it challenging to reach a conclusion with the studies available to date on the safety and efficacy of the pregnancy pictogram to alert the risk of medication use.
... BACKGROUND: Several birth defects warning symbols identified as most successful in an earlier study (Mayhorn and Goldsworthy, 2007) were further modified and then evaluated within a nationally distributed field trial (n 5 2773). The purpose for the current research was to determine whether symbol warning components could be improved further, whether the addition of text enhanced comprehension uniformly across symbols, and whether results varied by the application of different interpretation standards (coding schemes). ...
... These initial findings were promising because they revealed that participants' abilities to correctly interpret the meanings of several of the alternate warnings exceeded that of the existing warning, with several candidates emerging as viable alternatives to the existing warning. The candidates were further refined based on the results and a second, larger scale field study (n 5 700) conducted to further validate these alternative warnings (Mayhorn and Goldsworthy, 2007). Results indicated that two of the alternate symbols met the ANSI criterion of 85%, and none exceeded the ANSI limit of 5% critical confusion. ...
... Although these efforts have been informative in terms of highlighting a number of design and methodological issues, further questions remain. For instance, previous efforts by Goldsworthy and Kaplan (2006a) and Mayhorn and Goldsworthy (2007) focused on the enhancement of the symbol component of the teratogen warning: that is, how effective can the symbol be made by modifying the symbol itself. This is a reasonable approach given the well-documented benefits of including a symbol component in warnings, including the ability to attract attention (Kalsher et al., 1996;Sojourner and Wogalter, 1998) and to cue people to perform necessary safety behavior to avoid a hazard (Leonard et al., 1999). ...
Several birth defects warning symbols identified as most successful in an earlier study (Mayhorn & Goldsworthy, 2007) were further modified and then evaluated within a nationally distributed field trial (n = 2773). A total of 11 warning labels were examined: 4 new symbols plus the existing baseline symbol, each in versions with and without text, plus a text-only condition. Participant interpretation accuracy and preferences were assessed. For symbol-only conditions, several candidate symbols outperformed the existing symbol, one substantially so. The effect of adding text to symbols varied significantly by symbol. Symbol+text and text-only conditions performed equivalently, generally exceeded symbol-only conditions, and often surpassed the ANSI benchmark of 85% accurate interpretation. Implications are drawn from the process and outcomes in relation to warning design, warning evaluation, and future research.
... These initial findings were promising because they revealed that participants' abilities to correctly interpret the meanings of several of the alternate warnings exceeded that of the existing warning, with several candidates emerging as viable alternatives to the existing warning. The candidates were further refined based on the results and a second, larger scale field study (n 5 700) conducted to further validate these alternative warnings (Mayhorn and Goldsworthy, 2007). Results indicated that two of the alternate symbols met the ANSI criterion of 85%, and none exceeded the ANSI limit of 5% critical confusion. ...
... Although these efforts have been informative in terms of highlighting a number of design and methodological issues, further questions remain. For instance, previous efforts by Goldsworthy and Kaplan (2006a) and Mayhorn and Goldsworthy (2007) focused on the enhancement of the symbol component of the teratogen warning: that is, how effective can the symbol be made by modifying the symbol itself. This is a reasonable approach given the well-documented benefits of including a symbol component in warnings, including the ability to attract attention (Kalsher et al., 1996; Sojourner and Wogalter, 1998) and to cue people to perform necessary safety behavior to avoid a hazard (Leonard et al., 1999). ...
... This is a reasonable approach given the well-documented benefits of including a symbol component in warnings, including the ability to attract attention (Kalsher et al., 1996; Sojourner and Wogalter, 1998) and to cue people to perform necessary safety behavior to avoid a hazard (Leonard et al., 1999). However, Mayhorn and Goldsworthy (2007) noted that such refinement, for this particular message and within the design limitations, may be closing in on a ''performance plateau,'' a level of observed outcomes whereby large gains are no longer possible and incremental gains become increasingly ...
Several birth defects warning symbols identified as most successful in an earlier study (Mayhorn and Goldsworthy, 2007) were further modified and then evaluated within a nationally distributed field trial (n = 2773). The purpose for the current research was to determine whether symbol warning components could be improved further, whether the addition of text enhanced comprehension uniformly across symbols, and whether results varied by the application of different interpretation standards (coding schemes).
A total of 11 warning labels were examined: four new symbols plus the existing baseline symbol, each in versions with and without text, plus a text-only condition. Participant interpretation accuracy and preferences were assessed during face-to-face interview sessions.
For symbol-only conditions, several candidate symbols outperformed the existing symbol, one substantially so. The effect of adding text to symbols varied significantly by symbol. Symbol plus text and text-only conditions performed equivalently, generally exceeded symbol-only conditions, and often surpassed the American National Standards Institute benchmark of 85% accurate interpretation.
The research effort has identified a teratogen symbol and warning that outperforms the one currently in use. The effort has also identified important pragmatic and conceptual issues that should inform future work to improve medication labeling and other hazard communication.
... Other warnings may be directed to a very specific audience. Warnings about the risk of birth defects associated with taking a prescription medication would be directed primarily to women of child bearing age; although others such as spouses or parents might also receive the warning (Mayhorn and Goldsworthy, 2007). Likewise, as noted above, healthcare professionals such as physicians or pharmacists should receive the warnings regarding potential birth defects when treating patients who are or may become pregnant. ...
... According to the ANSI (2006) Z535.3 standard, an acceptable symbol must have less than 5% critical confusions (opposite meaning or a meaning that would produce unsafe behavior). Research by Mayhorn and Goldsworthy (2007) illustrates an example of a misinterpretation of a pictorial that was part of a warning for the drug Accutane. This drug is used for severe acne, but causes birth defects in babies of women taking the drug during pregnancy. ...
... Other warnings may be dir~cted to_a very specific audience. Warnings about the nsk of btrth defects associated with taking a prescription medication would be directed primarily to wome n of child-bearing age; although others such as spouses or parents might also receive the warning (Mayhorn and Goldsworthy, 2007). Likewise, as noted above, health care professionals such as physicians or pharmacists should recei ve ~e w~ings regarding potential birth defects when treatrng pattents who are or may become pregnant. ...
... According to the ANSI (2006) Z535.3 standard, an acceptable symbol must have less than 5% critical confusions ( opposite meaning or a meaning that would produce un safe behavior). Research by Mayhorn and Goldsworthy (2007) illustrates an example of a misinterpretation of a pictorial that was prut of a warning for the drug Accutane. This drug is used for severe acne but causes birth defects in babies of women taking the drug during pregnancy. ...
... For instance, risk perceptions associated with pesticide warning labels appear to vary by ethnicity such that the likelihood of warn-ing compliance is higher for European-American farm workers than for Latino farm workers (Smith-Jackson, Wogalter, & Quintela, 2008). Similarly, in a study that examined several possible birth defect warning labels among a diverse group of women of child-bearing age, both accuracy of warning interpretation and warning preference-the warning participants thought would be most effective-varied significantly by participant characteristics (Goldsworthy & Kaplan, 2006a;Mayhorn & Goldsworthy, 2007). These analyses typically examine common audience characteristics, such as age, gender, and/or ethnicity, by using a relatively unsophisticated statistical analytical tool, such as chisquare or Fisher's Exact Test, to determine whether "correctness" or rates of particular responses vary by those demographic characteristics. ...
... Age of participants was restricted to those 12 to 44 years because these data were collected in conjunction with another project (reported in Mayhorn & Goldsworthy, 2007) that assessed the comprehensibility of birth defects warnings; thus, consistent with previous research in that particular domain, the age of the sample was restricted to those of child-bearing age. Seventy-three percent of the participants were female. ...
Hazard mitigation, including warning development, validation, and dissemination, is an important aspect of product safety and workplace and consumer protection. Understanding our audiences—workers and consumers—is an especially important, often overlooked, aspect of risk and harm reduction efforts. In this article, particular attention is paid to audience analysis in hazard communication and warning messaging, with a focus on the potential role of latent class analysis (LCA). We provide an example of using LCA to analyze a hazardous behavior: prescription medicine sharing and borrowing. Four distinct groups of people—ranging from abstainers to at-risk sharers—are identified and discussed. Building better warnings and risk communication techniques is essential to promoting occupational and consumer safety. Audience analysis is a vital component of these efforts. LCA appears to be a worthwhile addition to our analytical toolbox by allowing risk reduction and hazard-mitigation efforts to tailor interventions to a diverse target audience. © 2010 Wiley Periodicals, Inc.
... Unfortunately, the safety symbol research literature also indicates that symbols may not be understood by members of the atrisk population at levels expected by the symbol designers (Laux et al., 1989;Mayhorn and Goldsworthy, 2007). It is important, therefore, that comprehension testing be conducted to determine the effectiveness of proposed symbols before they are widely implemented. ...
... Some limitations of this study should be noted: the sample for the leaflet evaluation was small, which could limit the results' generalization; the evaluation used web-based questionnaires; and the participants' perceptions were assessed through scales. Therefore, further development and evaluation are required, for example, ask more/ different questions, and the use of the open-ended formal compression test should be applied in order to obtain compression scores, as well as the participants' inputs for improving the solutions (e.g., Mayhorn & Goldsworthy, 2007). Also, other methods for evaluating the pictograms' quality should be used to test other topics beyond comprehension, such as legibility, memorization and actual compliance. ...
The Health Care-Associated Infections (HCAIs) are a serious health problem, having contributed to high morbidity and mortality rates, as well as an increase in associated costs. Together with a set of good practices, hand hygiene is considered one of the key measures of preventing and controlling the spread of HCAIs. However, compliance with hand hygiene is relatively low. Therefore, there is a well-recognized need for measures that increase compliance rates. This paper describes the development and evaluation of a set of pictograms that illustrate the "Five Moments for Hand Hygiene”. The pictograms depict the key moments where hand hygiene is a mandatory obligation to healthcare workers. In the design and validation of the pictograms, a user-centered design approach was adopted, involving the participation of health care workers through methods such as focus group sessions, the comprehensibility judgment test and the perceived adequacy, effectiveness and preference assessment questionnaire. The gathered results could serve to improve the effectiveness of the present campaigns, which are intended to promote hand hygiene compliance among healthcare workers.
... Another common intervention is the addition of pictorial representations, and many studies have had success in using this intervention to improve patient comprehension. 4,[9][10][11][12][13][14][15][16][17] A study by Galesic et al 11 showed that adding pictographs to numerical information increased understanding by 23% in 3 hypothetical treatment scenarios, with greater improvements among those with low literacy. Similarly, a study by Garcia-Retamero and Galesic 12 showed that adding icon arrays to information about risk reductions decreased misunderstanding among low numeracy participants from 74% to 42% and from 26% to 15% among participants with high numeracy. ...
This study aims to evaluate the change in comprehension of diagnoses, treatment plans, and discharge instructions after orthopaedic trauma patients are given an informational document that includes pictorial representations at the time of discharge. It also seeks to determine if the intervention has a greater impact on patients with lower educational backgrounds.
Prospective comparative cohort study.
Academic Level 1 trauma center.
From April to December 2011, 529 orthopaedic trauma patients with an operatively fixed isolated fracture were eligible for inclusion. 299 eligible questionnaires were collected (56.5% response rate).
Patients were administered a questionnaire regarding their treatment and discharge instructions during their first postoperative clinic visit prior to being seen by a physician. The questionnaire included demographic information and questions regarding: (1) which bone was fractured; (2) type of implanted fixation; (3) weight-bearing status; (4) expected recovery time; and (5) need for DVT prophylaxis. All patients had received verbal instructions outlining this information at postoperative hospital discharge. During the second half of the study, patients were given an additional informational sheet with both text and pictorial representations at discharge. Multivariable log-binomial regression analyses were used to examine the impact of this intervention.
146 patients were given only the standard discharge instructions, while 153 patients were also administered the additional information document. The mean score for patients who received the intervention was 2.90 (out of 5) compared to the mean score of 2.54 for patients who did not receive the intervention (p=0.013). Patients who received the intervention were 1.3 times more likely to know which bone was fractured (p=0.007) and 1.1 times more likely to be able to correctly name the medication(s) they were prescribed for DVT prophylaxis (p=0.03).
Overall performance on comprehension questionnaires in orthopaedic trauma patients was significantly improved via a text and pictorial intervention. The intervention did not preferentially aid patients with lower education backgrounds. Future studies should evaluate long-term postoperative results to determine if improved patient comprehension has an effect on surgical outcomes and patient satisfaction.
... Unfortunately, the safety symbol research literature also indicates that symbols may not be understood by members of the atrisk population at levels expected by the symbol designers (Laux et al., 1989;Mayhorn and Goldsworthy, 2007). It is important, therefore, that comprehension testing be conducted to determine the effectiveness of proposed symbols before they are widely implemented. ...
... Another common intervention is the addition of pictorial representations, and many studies have had success in using this intervention to improve patient comprehension. 4,[9][10][11][12][13][14][15][16][17] A study by Galesic et al 11 showed that adding pictographs to numerical information increased understanding by 23% in 3 hypothetical treatment scenarios, with greater improvements among those with low literacy. Similarly, a study by Garcia-Retamero and Galesic 12 showed that adding icon arrays to information about risk reductions decreased misunderstanding among low numeracy participants from 74% to 42% and from 26% to 15% among participants with high numeracy. ...
Objectives:
The aim of this study was to evaluate the level of comprehension in an orthopedic trauma patient population regarding injury, surgery, and postoperative instructions and to determine if educational background is associated with inadequate comprehension.
Design:
This involved a prospective observational cohort.
Setting:
The study was conducted at an Academic Level 1 trauma center.
Patients:
From April to June 2011, 248 orthopedic trauma patients with an operatively fixed isolated fracture were found to be eligible for inclusion. One hundred forty-six eligible questionnaires were collected (58.9% response rate).
Intervention:
The patients were administered a questionnaire during their first postoperative visit before being seen by a physician. The questionnaire included demographic information and questions regarding (1) which bone was fractured; (2) the type of implanted fixation; (3) weight-bearing status; (4) expected recovery time; and (5) need for deep vein thrombosis (DVT) prophylaxis. Multivariable logistic regression analyses were used to examine the association between educational level and questions regarding surgical procedure and discharge instructions.
Results:
The overall mean score of all the patients on the patient comprehension portion was 2.54 ± 1.27 correct responses out of 5. Only 47.9% of patients knew the bone they fractured, and 18.5% knew their expected healing time. Of the patients, 66.4% knew the type of implanted fixation, and 45.2% knew their weight-bearing status. The patients (74.0%) knew their DVT prophylaxis medication(s). The mean score for patients in the group ≤ HS (high-school education or less) was 2.26, whereas the mean score for patients in the group > HS (more than high-school education) was 3.00 (P = 0.0009). The patients in the group > HS were 2.54 times more likely to know the bone they fractured (P = 0.01), 3.82 times more likely to know the recovery time (P = 0.004), and 2.79 times more likely to know their DVT prophylaxis medication(s) than patients in the group ≤ HS.
Conclusions:
Orthopedic trauma patients demonstrated limited comprehension of their injuries, surgeries, and postoperative instructions. Patients with lower educational levels did significantly worse on the questionnaire than those with higher educational levels. The results of the study highlight a lack of comprehension within this patient population and suggest that an increased focus on patient communication by orthopedic providers may be necessary.
... Two research assistants independently coded all participant responses. The three interpretation questions (meaning, target audience, and intended action) were coded according to a three-tier codebook based on previous work by the authors [4,5,18]. For the first tier, the unit of analysis was each individual idea mentioned by a participant. ...
We interviewed 594 adolescents throughout the United States. One in five reported sharing prescription medication. Of these, less than half received instructions, many delayed professional care, few informed providers, and a third reported experiencing side effects. Efforts to reduce medication sharing prevalence and risks among adolescents may be justified.
... Two research assistants independently coded all participant responses. The three interpretation questions (meaning, target audience, and intended action) were coded according to a three-tier codebook based on previous work by the authors [4,5,18]. For the first tier, the unit of analysis was each individual idea mentioned by a participant. ...
Warnings are an important component of pharmaceutical risk mitigation efforts, yet very little research attention has been directed toward adolescent interpretation of such warnings. This study examined adolescents' interpretations of and preferences for warning symbols and statements related to pharmaceuticals with teratogenic properties.
A total of 200 adolescents interpreted one of four warning symbols and four warning statements. Responses were coded using an established three-tier coding system. Symbol preferences were elicited. Interpretation accuracy and symbol preferences were analyzed by symbol and statement.
The symbol in use on medication labels at the time of the study elicited nearly goal levels of interpretation accuracy; however it exceeded allowable levels of critical confusion. An alternative symbol elicited more fully correct responses than the existing symbol and was preferred to the existing symbol by a margin of 2 to 1. Yet another symbol was most preferred despite eliciting fewer correct interpretations. The impact of warning statements on overall warning interpretation varied by statement and statement-symbol combinations. At least one statement appeared to lessen the overall message of caution, and few adolescents expressed an awareness of risk if one "may become pregnant" until explicitly informed of this risk.
Comprehension of medical warning symbols and statements among adolescents is an important public health issue. Those involved in adolescent health education and research have considerable theoretical and practical tools for approaching the development and evaluation of such warning messages. Understanding how warnings are interpreted can lead to more effective communication efforts and reduce risk.
Warnings are safety communications used to inform people about hazards and to provide instructions to avoid or minimize undesirable consequences such as injury or death. Warnings are used in a variety of contexts to address environmental and product-related hazards. In the broad field of safety, particularly injury prevention, there is the concept of hazard control. Hazard control involves a set of methods that differ in reliability and effectiveness, and thus preference and priority, yielding a hierarchy of hazard control. The hazards could be those in the public environment, in over-the-counter products in a drugstore, or on a shelf of a hardware store. Warnings located close to the hazard both physically and in time will increase the likelihood of attention switch. Auditory warnings are frequently used to attract attention. Visual warnings formatted to be aesthetically pleasing are more likely to hold attention than a single chunk of very dense text.
Introduction:
Low health literacy (HL) is an obstacle to therapeutic patient education (TPE), especially for people in a vulnerable situation, who are also at greater risk of chronic illnesses and their complications. It therefore seems essential to rethink TPE programmes in order to ensure greater equity based on analysis of the characteristics of HL interventions and their possible relationships with TPE.
Methods:
A scoping review of the literature was performed from November 2014 to January 2016 using the following search engines: MEDLINE/PubMed, EMBASE, PsycINFO, ERIC, OpenGrey, SUDOC, thèses.fr and BDSP and the following search terms: ?health literacy?, ?Littératie en santé?, ?literacy?, ?Littératie?, ?numeracy?, ?numératie?, ?compétence en santé? combined with the keywords: ?programme?, ?program?, ?intervention?, ?méthode?, ?method?, ?technique?, ?outil?, ?tool?.
Results:
After selecting forty out of 206 studies, interventions were classified into two main types of specific interventions to promote comprehension of resources intended for patients and generally complex interventions designed to support and improve HL skills.
Discussion:
While the level of health literacy has an impact on TPE programme accessibility, TPE programmes need to be made more accessible and TPE must constitute an opportunity to address health literacy needs via its own specific modalities. Creating partnerships between social/educational and health settings might be an effective strategy to strengthen the interrelationships between HL and TPE, as might training that prepares caregivers-educators to improve patient HL.
Conclusion:
Interrelationships between HL and TPE are possible. Research should question the pedagogical modalities to be used to adapt TPE programs to the HL.
In order to keep subscribers up-to-date with the latest developments in their field, John Wiley & Sons are providing a current awareness service in each issue of the journal. The bibliography contains newly published material in the field of pharmacoepidemiology and drug safety. Each bibliography is divided into 20 sections: 1 Books, Reviews & Symposia; 2 General; 3 Anti-infective Agents; 4 Cardiovascular System Agents; 5 CNS Depressive Agents; 6 Non-steroidal Anti-inflammatory Agents; 7 CNS Agents; 8 Anti-neoplastic Agents; 9 Haematological Agents; 10 Neuroregulator-Blocking Agents; 11 Dermatological Agents; 12 Immunosuppressive Agents; 13 Autonomic Agents; 14 Respiratory System Agents; 15 Neuromuscular Agents; 16 Reproductive System Agents; 17 Gastrointestinal System Agents; 18 Anti-inflammatory Agents - Steroidal; 19 Teratogens/fetal exposure; 20 Others. Within each section, articles are listed in alphabetical order with respect to author. If, in the preceding period, no publications are located relevant to any one of these headings, that section will be omitted.
Despite scientific advances in clinical teratology, exposures during pregnancy still cause great anxiety and misunderstanding. Patients and health care providers are frequently called upon to determine the health implications of scientific studies, which may involve limited and contradictory data. These findings are often conveyed numerically, which is a particularly difficult form of information for both patients and their health providers to understand and interpret. Almost half of the general population (and a substantial minority of physicians) have difficulty with numeracy. Patients with low numeracy tend to interpret information in an absolute manner and ignore uncertainty, have more difficulty using numeric information to inform their choices, and are more easily influenced by emotion and the format used in presenting information. Formats involved in conveying probability include positive or negative framing, use of relative versus absolute risk, and ratios and percentages. Health providers should communicate risk analysis in a fashion that facilitates comprehension and results in informed behavior. This is more likely to be achieved when risks are conceptualized as more than just numbers, and are considered in the context of individuals' life circumstances and values. Most teratogen risk communication is done over the telephone; this presents both advantages and challenges. Strategies are suggested to improve risk communication. These include avoiding the use of relative risk, using a consistent denominator, framing the information in a variety of ways (positive vs. negative), using verbal qualifiers judiciously, and employing visual aids.
Because icons, signs, and symbols are now widely used to communicate information, it is essential for system designers to know what makes them easy to use and interpret. The authors report a series of studies that examine characteristics considered central to icon usability. After quantifying the properties of icon concreteness, complexity, and discriminability, the authors assessed each property's effects on user performance when user experience, task demands, and presentation context were systematically varied. Findings indicated that the effects of icon concreteness were primarily associated with the initial grasp of meaning, whereas complexity effects were found to persist longer and to be associated with search efficacy. The effects of icon distinctiveness were complex, but distinctiveness was enhanced by using both semantic and visual contrasts. The implications of these findings for interface design are discussed.
The appropriate use of pharmaceuticals, as well as their hazards, are not commonly known to most people. In fact, the only information available to consumers is usually the material found on the product label. Unfortunately, for some consumers this method of communicating instructions and risks may be ineffective, and potentially dangerous. People may have difficulty with the labels because the print on the label is too small for them to read. Two alternative (tag and fold-out) designs were developed to increase the available surface area for information printed on a fictitious prescription drug label. The alternative label designs were compared to a standard controllahel. The presence versus the absence of pictorials visually depicting several instructions and warnings was also examined. Participants rated the labels on ease of reading the labels, likelihood of noticing the warnings, likelihood of reading the warnings, preference for each of the labels, and likelihood that they would recommend each label for use by a friend or family member. The results showed that participants (n = 84) preferred the alternative label designs, especially the tag labels, and those with illustrative pictorials. Implications of these results and recommendations for future research in this area are discussed.
Self-reports of behaviors and attitudes are strongly influenced by features of the research instrument, including question wording, format, and context. Recent research has addressed the underlying cognitive and communicative processes, which are systematic and increasingly well- understood. I review what has been learned, focusing on issues of question comprehension, behavioral frequency reports, and the emergence of context effects in attitude measurement. The accumulating knowledge about the processes underlying self-reports promises to improve questionnaire design and data quality.
Surveys are perhaps the most used, and sometimes misused, methodological tool among academic researchers. Self-administered survey questionnaires (and guided interviews) allow us to elicit behav-iors, attributes, beliefs, and attitudes among populations. Data gathered from poorly designed instru-mentation is suspect and investigators are disappointed when research involving the use of attitude scales is viewed unfavorably by peer reviewers. Summated rating scales may be commonly used to elicit feelings or attitudes from students, faculty members, administrators, and others. Investigators must be conscious of the referent object and the research objectives when constructing items compris-ing a summated ratings scale. Items should be gathered from careful review of the literature and consultation with experts. Pilot testing a survey instrument and its component attitude scale are critical to success. Adherence to a few basic tenets will help to ensure that responses to the scale are valid and reliable. There are a number of means by which a scale's validity and reliability can be determined. While ordinal in nature, data gathered from summated rating scales may be analyzed with robust, parametric statistics that allow investigators to tackle the multivariate nature of many problems in social, administrative, and clinical research. Novices in questionnaire survey design and analysis are encouraged to consult with a number of sources who may be helpful to them, including survey methodologists and statisticians.
The appropriate use of pharmaceuticals, as well as their hazards, are not commonly known to most people. In fact, the only information available to consumers at the time of consumption is usually the material found on the product label. Unfortunately, people often have difficulty with the labels because the print on the label is too small for them to read. Two alternative (tag and fold-out) designs were developed to increase the available surface area on a fictitious prescription drug label. The alternative label designs, with and without pictorials depicting instructions and warnings, were compared to a standard control label. In Expt. l, 84 undergraduates rated the labels on several preference dimensions, including: ease of reading the labels, likelihood of noticing the warnings, likelihood of reading the warnings, preference for each of the labels, and likelihood that they would recommend each label for use by a friend or family member. Across all dimensions, undergraduates preferred the alternative labels, especially the tag labels, and labels with pictorials. In Expt. 2, the ratings of 58 older adults (mean age = 73 years) showed a similar pattern of results. Implications of these results and recommendations for future research in this area are discussed.
Organizing theoretical framework: a consolidated communication-human information processing (C-HIP) Model -- Intermediate processing stages: methodological considerations for research on warnings -- Methodological techniques for evaluating behavioral intentions and compliance -- Source -- Channel -- Attention capture and maintenance -- Comprehension and memory -- Attitudes and beliefs -- Motivation -- Behavior -- Standards and government regulations in the USA -- Practical considerations regarding the design and evaluation of product warnings -- The law relating to warnings -- The expert witness
Because icons, signs, and symbols are now widely used to communicate information, it is essential for system designers to know what makes them easy to use and interpret. The authors report a series of studies that examine characteristics considered central to icon usability. After quantifying the properties of icon concreteness, complexity, and discriminability, the authors assessed each property's effects on user performance when user experience, task demands, and presentation context were systematically varied. Findings indicated that the effects of icon concreteness were primarily associated with the initial grasp of meaning, whereas complexity effects were found to persist longer and to be associated with search efficacy. The effects of icon distinctiveness were complex, but distinctiveness was enhanced by using both semantic and visual contrasts. The implications of these findings for interface design are discussed.
Warning symbols are used on teratogenic medications to communicate the message that women should (1) not take that medication if they may already be pregnant, and (2) not get pregnant while taking that medication. Communications research indicates that people interpret symbols or pictures in different ways. Other studies have shown that patients do not always receive education materials that are part of prescription protocol. Researchers at the Centers for Disease Control and Prevention (CDC) tested the interpretation of the teratogen warning symbol and its ability to convey the correct information without accompanying education.
A teratogen warning symbol currently printed on some medication packaging uses graphics and text warning the user not to get pregnant. Researchers interviewed women of childbearing age about their interpretation of the warning symbol and its meaning. Ninety-seven women were interviewed in a variety of locations, including public health clinics, literacy and job training offices, health clubs, and malls.
Only 21% of women interpreted correctly without prompting that they should either not take the medication if they are pregnant or not get pregnant while taking the medication. Twenty-seven percent of women first thought the symbol meant the package contained birth control medication, and 24% said it simply indicated the package contained drugs or medicine. An additional 7% said they did not know what the symbol was supposed to mean; 39% of respondents offered circumstances in which prescription medications might be shared.
Misinterpretation of warning symbols can result in serious consequences. This research should serve as an urgent call for mandating education for all patients receiving drugs with teratogenic properties, and careful pretesting and modification of warning symbols before they are used on medications with teratogenic effects. Published 2001 Wiley-Liss, Inc.
A conceptual framework employing the distinction between stimulus-centered and subject-centered scales is presented as a basis for reviewing 80 years of literature on the optimal number of response alternatives for a scale. Concepts and research from information theory and the absolute judgment paradigm of psychophysics are used. The author reviews the major factors influencing the quality of scaled information, points out areas in particular need of additional research, and makes some recommendations for the applied researcher.
A conceptual framework employing the distinction between stimulus-centered and subject-centered scales is presented as a basis for reviewing 80 years of literature on the optimal number of response alternatives for a scale. Concepts and research from information theory and the absolute judgment paradigm of psychophysics are used. The author reviews the major factors influencing the quality of scaled information, points out areas in particular need of additional research, and makes some recommendations for the applied researcher.
Pictorial development and testing can be a costly and inefficient process. The process of designing and testing pictorial symbols could benefit from a precursor test to determine the likelihood that a concept will permit the design of a successful symbol (according to subsequent comprehension testing). This study examines whether ratings of the concepts of to-be-designed symbols could be useful in the prediction of comprehension of the ensuing symbols for those concepts. Participants rated 50 text descriptions (referent plus further verbal context) on: (1) how concrete is this concept? (2) how easy is it to visualize this concept?; and (3) how effective would a simple picture be in conveying this concept? These ratings served as predictors of the population estimates and open-ended comprehension scores obtained from previous research by Young and Wogalter (2001). Results showed that there was a high correlation between the measures used in this study with both population estimates and open-ended comprehension scores. Ease of visualization of a concept had the highest predictive value with concreteness, being the second highest predictor. Measures of the ease of visualization or imaging a concept may be useful preliminary tools for pictorial designers.
Self-reports of behaviors and attitudes are strongly influenced by features of the research instrument, including question wording, format, and context. Recent research has addressed the underlying cognitive and communicative processes, which are systematic and increasingly well-understood. The author reviews what has been learned, focusing on issues of question comprehension, behavioral frequency reports, and the emergence of context effect in attitude measurement. The accumulating knowledge about the processes underlying self-reports promises to improve the questionnaire design and data quality. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Includes bibliographical references, index
This study was conducted to validate a shortened version of the Rapid Estimate of Adult Literacy in Medicine (REALM). This screening instrument is designed to be used in public health and primary care settings to identify patients with low reading levels. It provides reading grade estimates for patients who read below a ninth-grade level. The REALM can be administered in one to two minutes by personnel with minimal training.
Two hundred and three patients in four university hospital clinics (internal medicine, family practice, ambulatory care, and obstetrics/gynecology) were given the REALM and three other standardized reading tests: the reading recognition section of the Peabody Individual Achievement Test-Revised (PIAT-R), the Wide Range Achievement Test-Revised (WRAT-R), and the Slosson Oral Reading Test-Revised (SORT-R). One hundred inmates at a state prison were also given the REALM twice, one week apart, to determine test-retest reliability.
The REALM correlated well with the three other tests. (Correlation coefficients were 0.97 [PIAT-R], 0.96 [SORT-R], and 0.88 [WRAT-R].) All correlations were significant at P < .0001. Test-retest reliability was 0.99 (P < .001).
The REALM provides an estimate of patient reading ability, displays excellent concurrent validity with standardized reading tests, and is a practical instrument for busy primary care settings.
Low literacy is a pervasive and underrecognized problem in health care Approximately 21% of American adults are functionally illiterate, and another 27% have marginal literacy skills. Such patients may have difficulty reading and understanding discharge instructions, medication labels, patient education materials, consent forms, or health surveys. Properly assessing the literacy level of individual patients or groups may avoid problems in clinical care and research. This article reviews the use of literacy assessments, discusses their application in a variety of health care settings, and cites issues providers need to consider before testing. The authors describe informal and formal methods of screening for reading and comprehension in English and Spanish including the Rapid Estimate of Adult Literacy in Medicine, the Wide Range Achievement Test-3, the Cloze procedure, the Test of Functional Health Literacy in Adults, and others. Practical implications and recommendations for specific use are made.
Previous research has noted potential inadequacies in the warning labels and symbols used with some teratogenic medications. A clear teratogen warning symbol represents an important component of risk mitigation for accidental teratogen exposure.
Several teratogen warning symbols were developed through rapid prototyping and focus groups. A nationally distributed field trial (n = 300) examined the relative effectiveness of 6 candidate symbols, including the symbol in use at the time of the study. Measures included open-ended interpretation, closed-ended preference, and demographic surveys. Each participant was shown a single symbol and asked what it meant, to whom it applied, and what that person should do. Text statements were added to the symbol and participants were asked to reinterpret the warning. Participants were told the intended message of the warning, shown all 6 symbols, and asked to choose the most effective symbol.
Four of 6 symbols achieved levels of correct interpretation close to or exceeding the American National Standards Institute (ANSI) benchmark of 85% and none exceeded the ANSI limit of 5% critical confusion. Symbols elicited varying conceptual responses. Respondents considered 1 symbol to be the most effective, by a 4 to 1 margin. Several outcomes varied by age and by ethnicity.
Several symbols emerged as viable alternatives to the current symbol; however, no 1 symbol was clearly found to be the most effective. Instead, the symbol considered "best" depends on the messages that are considered most essential to the warning. Additionally, it appears a symbol without the addition of text can convey most, but possibly not all, of the meaning required of the warning label. Next steps should include further symbol refinement, closer examination of text additions to symbols, and validation of the candidate symbols and warnings through a large-scale field trial.
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System to manage Accutane related teratogenic-ity Guide to best practices Human factors in engineering and design, 7 th Edition
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Phrase gen-eration and symbol comprehension for 40 safety symbols Human Factors and Ergo-nomics Society Self-reports: How the questions shape the answers
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Design and evaluation of public information symbols Visual information for everyday use: Design and research perspectives
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On the prediction of pictorial comprehension
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- Wogalter