Developing visual images for communicating information aboutantiretroviral side effects to a low-literate population

The side effects of antiretroviral (ARV) therapy are linked to altered quality of life and adherence. Poor adherence has also been associated with low health-literacy skills, with an uninformed patient more likely to make ARV-related decisions that compromise the efficacy of the treatment. Low literacy skills disempower patients in interactions with healthcare providers and preclude the use of existing written patient information materials, which are generally written at a high reading level. Visual images or pictograms used as a counselling tool or included in patient information leaflets have been shown to improve patients' knowledge, particularly in low-literate groups. The objective of this study was to design visuals or pictograms illustrating various ARV side effects and to evaluate them in a low-literate South African Xhosa population. Core images were generated either from a design workshop or from posed photos or images from textbooks. The research team worked closely with a graphic artist. Initial versions of the images were discussed and assessed in group discussions, and then modified and eventually evaluated quantitatively in individual interviews with 40 participants who each had a maximum of 10 years of schooling. The familiarity of the human body, its facial expressions, postures and actions contextualised the information and contributed to the participants' understanding. Visuals that were simple, had a clear central focus and reflected familiar body experiences (e.g. vomiting) were highly successful. The introduction of abstract elements (e.g. fever) and metaphorical images (e.g. nightmares) presented problems for interpretation, particularly to those with the lowest educational levels. We recommend that such visual images should be designed in collaboration with the target population and a graphic artist, taking cognisance of the audience's literacy skills and culture, and should employ a multistage iterative process of modification and evaluation.