• Jaffna study notes need to educate diabetic patients on hypoglycaemic symptoms

Pictograms developed regarding lifestyle modifications and medication use by patients with diabetes could be used to effectively convey relevant information pertaining to the same, a local study found. 

This observation, along with the need to educate diabetic patients on hypoglycaemic symptoms was made in a short communication on the "Development of pictograms for patients with diabetes at a teaching hospital in Northern Sri Lanka – A pilot study" which was authored by S. Thuvaragan and J. Rakshana (both attached to the Jaffna University's Allied Health Sciences Faculty's Pharmacy Department) and R. Surenthirakumaran (attached to the same University's Medical Faculty) and published in the Pharmaceutical Journal of Sri Lanka's 12th Volume's First Issue in December, 2022.

M.K. Cavaghan, D.A. Ehrmann and K.S. Polonsky's "Interactions between insulin resistance and insulin secretion in the development of glucose intolerance" explains that diabetes is a chronic metabolic disease characterised by the low secretion of insulin and the development of insulin resistance. In Sri Lanka, there has been a rapid increase in diabetic patients over the past 20 years. P. Katulanda, G.R. Constantine, J.G. Mahesh, R. Sheriff, R.D.A. Seneviratne, S. Wijeratne, M. Wijesuriya, M.I. McCarthy, A.I. Adler and D.R. Matthews's "Prevalence and projections of diabetes and pre-diabetes in adults in Sri Lanka – Sri Lanka Diabetes, Cardiovascular Study" conducted between 2005 and 2006 found the prevalence of diabetes to be 10.3% among the adult population. S.P. Borse, A.S. Chhipa, V. Sharma, D.P. Singh and M. Nivsarkar's "Management of type 2 diabetes: Current strategies, unfocused aspects, challenges, and alternatives" noted that the pharmacological approach is partly effective in the management of diabetes. L. Chen, J.H. Pei, J. Kuang, H.M. Chen, Z. Chen, Z.W. Li and H.Z. Yang's "Effect of lifestyle intervention in patients with type 2 diabetes: A meta-analysis" pointed out that lifestyle related characteristics are important factors that influence the progression of the disease. 

J.A. Cramer's "A systematic review of adherence with medications for diabetes" emphasised that lifestyle modification along with the pharmacological approach is crucial for the effective management of diabetes.

The global health literacy-related crisis affects both developing and developed nations. P. Merks, J. Cameron, K. Bilmin, D. Świeczkowski, T. Chmielewska-Ignatowicz, T. Harężlak, K. Białoszewska, K.F. Sola, M.J. Jaguszewski and R. Vaillancourt's "Medication adherence and the role of pictograms in medication counselling of chronic patients: A review" concluded that poor health literacy has been associated with poor treatment adherence among patients with chronic diseases. S.C. Bailey, A.G. Brega, T.M. Crutchfield, T. Elasy, H. Herr, K. Kaphingst, A.J. Karter, S. Moreland-Russell, C.Y. Osborn, M. Pignone, R. Rothman and D. Schillinger's "Update on health literacy and diabetes" elaborated that low health literacy among diabetic patients has been associated with poor glycaemic control. 

A United Kingdom study observed that pictograms can be an effective alternative to written information for patients with low literacy. A United States pharmacopoeia defined pharmaceutical pictograms as standardised graphic images that help convey medication instructions, precautions and/or warnings to patients and consumers. R. Dowse and L.E. Mansoor's "Design and evaluation of a new pharmaceutical pictogram sequence to convey medicine usage" observed that pictograms are useful for persons who cannot read printed verbal messages because of inadequate reading skills or unfamiliarity with the language used in the message. 

Thuvaragan et al.'s study aimed to develop and evaluate the comprehension level of culturally specific pictograms among patients with diabetes attending a teaching hospital in Northern Sri Lanka. A mixed method study was conducted through two phases which included the Delphi technique (per C-C. Hsu and B.A. Sandford's "The Delphi technique: Making sense of consensus", it is utilised as an iterative technique which was designed with group communication sessions and in this instance, it was conducted as a focus group brainstorming discussion phase with selected experts including undergraduate pharmacy students, pharmacy academics, hospital pharmacists, general physicians, an endocrinologist, a community physician and expert patients with diabetes, to develop the first draft of pictograms and subsequently as a refinement phase in which the pictograms were finalised) and a pilot study (conducted among patients with diabetes attending the diabetic centre in a teaching hospital in Northern Sri Lanka from November, 2020, to November, 2021).

The 19 pictograms were on the following: eating a healthy diet, avoiding smoking, avoiding the intake of alcohol, drinking soft drinks with less sugar content, avoiding eating junk food, avoiding the excess use of social media, following one's monthly or regular check-ups, monitoring one's blood glucose concentration/level by oneself, monitoring one's blood pressure by oneself, checking one's eyes regularly, doing yoga regularly, doing exercise regularly, protecting one's feet with care, preventing a hypoglycaemic attack, taking one's medicines regularly on time, keeping the insulin vial in the fridge, keeping the insulin vial in the pot, administering one's insulin properly and regarding insulin injection sites.

A pilot evaluation of the pictograms was conducted among diabetic patients at the diabetic clinic at the Teaching Hospital, Jaffna. A systematic sampling technique was performed to collect the data from diabetic patients who were attending the said diabetic clinic. Around 30 patients attend the diabetic clinic per day. The total number of clinic days was five per week. One patient among the first two patients selected randomly was assigned as the first patient. Then, every second patient was included in the study. The patients were asked to interpret the meaning of the pictograms developed. The American National Standards Institute's "Standard Criteria for Safety Symbols" was used to assess the comprehension level of the pictograms. 

The brainstorming discussions additionally identified stress management for pictograms regarding lifestyle changes.

A total of 288 patients responded to the study. More than 80% of the participants correctly interpreted 13 pictograms out of 14 which were related to lifestyle modification while over 80% of the participants achieved a correct interpretation of all five pictograms for the improvement of medication use. The percentage of comprehension of pictograms regarding the prevention of a hypoglycaemic attack was very low among patients (11.8%).

Culturally specific pictograms are important in order to improve the comprehension level of patients and thus information could be effectively conveyed to patients with low literacy so as to manage their disease. 

Out of the 19 pictograms, 18 were correctly comprehended by patients with diabetes. Only one pictogram related to the symptoms of hypoglycaemic attacks was not interpreted by most of the patients. It could be due to the unawareness of the patients regarding the symptoms of hypoglycaemia. M.K. Wijesinghe, K.D. Liyanarachchi and N.P. Somasundaram's "Knowledge of patients with type 2 diabetes mellitus about their condition – A descriptive analysis" found that more than half of the patients were not aware of hypoglycaemic symptoms. Pictograms regarding diet and exercise were comprehended by all the patients. P. Ranasinghe, A.S. Pigera, M.H. Ishara, L.M. Jayasekara, R. Jayawardena and P. Katulanda's "Knowledge and perceptions about diet and physical activity among Sri Lankan adults with diabetes mellitus: A qualitative study" revealed that most of the patients knew the importance of diet and exercise.

M. Montagne's "Pharmaceutical pictograms: A model for development and testing for comprehension and utility" points out that pictograms alone did not improve the knowledge of diabetes management and that therefore, educational training is also needed for patients in order to understand the pictograms. The proper counselling of patients with the aid of pictograms could improve patients’ knowledge on pharmacological and non-pharmacological therapies of diabetes and their effective control. H. Sletvold, L.A.B. Sagmo and E.A. Torheim's "Impact of pictograms on medication adherence: A systematic literature review" pointed out that the usage of pictograms along with written or oral information could improve the adherence to medications especially in patients with a high risk of non-adherence. 

According to the findings of Thuvaragan et al., more attention should be paid to educate the patients on hypoglycaemic symptoms which could increase the risk of admission to hospitals and mortality. Also, it revealed that first educating the patients regarding the management of diabetes and then using pictograms will be helpful in order to improve the comprehension level of patients concerning pictograms.

Eighteen pictograms developed regarding lifestyle modifications and medication use was well comprehended by patients with diabetes in Northern Sri Lanka.