ROS DOWSE Associate Professor : Pharmaceutics Faculty of Pharmacy, Rhodes University, Grahamstown South Africa

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 Visuals� attract attention 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: multi-stage, iterative culturally sensitive 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) 68.9% Experimental group (Illustrated labels and PIL) 86.1% 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? Nurse education? Community health worker education ? Leaflets: introduce into more clinics at local, district, provincial and national level

35. Acknowledgements Funding Rhodes University 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.