Literature review: using pictographs in discharge instructions for older adults with low-literacy skills


Jeungok Choi, Assistant Professor, School of Nursing, University of Massachusetts Amherst, 120 Skinner Hall, 651 North Pleasant Street, Amherst, MA 01003, USA. Telephone: +1 413 545 5689.


Aims.  To evaluate current visual aids used in health education; to explore evidence regarding the use of pictographs (simple line drawings showing explicit health care actions); and to provide suggestions for uses of pictographs in discharge instructions for older adults with low-literacy skills.

Background.  Discharge instructions consist of recommended homecare actions. However, these healthcare actions are provided in text-based discharge instructions, which are often difficult for patients with low-literacy skills to follow precisely at home. Various forms of visual aids are currently used to improve health education; however, the appropriateness of these visual aids for educating discharge instructions for older adults with low-literacy skills is unknown.

Design.  A narrative literature review.

Methods.  Eligible articles were identified via electronic searches of databases. In total, 44 articles were reviewed and analysed.

Results.  Among various visual aids, pictographs using simple line drawings combined with simplified text are the most efficient and effective tool to improve discharge education. Indeed, pictographs are well suited to show a step-by-step procedure of complex and lengthy discharge instructions consisting of multiple actions, thus making an entire action sequence easier to learn.

Conclusion.  By using pictographs with simplified text, healthcare educators can improve discharge instructions for low-literate older adults. Further research is needed to develop pictographs representing explicit healthcare actions themselves rather than concepts associated with healthcare actions; and to examine the effects of pictographs on adherence and health outcomes.

Relevance to clinical practice.  Healthcare education materials using pictographs provide effective strategies in improving discharge education for low-literate older adults in acute healthcare settings where nurses have primary responsibility as a first line of healthcare providers. It can also serve as an efficient tool to improve health education for immigrants speaking English as a second language.