• breast health-care instructions;
  • immigrant women;
  • low literacy;
  • pictographs;
  • visual aids

Current written text-based health-care instructions are not suitable for presenting lengthy, complex breast health-care instructions and are difficult for immigrant women with limited literacy skills. The aims of this study were to develop breast health-care instructions enhanced by pictographs (simple line drawings representing health-care actions) and pilot test the instructions in a sample of six immigrant women with limited literacy skills. Based on the Mayer's Cognitive Theory of Multimedia Learning, pictographs were developed in addition to low-literacy text. The text and the pictographs were then pilot tested with six immigrant women in community health centres for clarity, comprehension and acceptability through face-to-face interviews. Participants perceived that the drawings were engaging and enhanced clarity of the intended health-care messages. The black and white simple line drawings were well received by participants of varying race and ethnicity. The pictograph-based approach might be an effective tool in developing health-care instructions for immigrant women with limited literacy skills. Future research is needed to compare the effect of pictograph-enhanced instructions with written text-based instructions on adherence to instructions and health outcomes.