Like many have already stated, symbols and graphic depictions only work if the meaning is clear. 

We have universal symbols for many things already.  You'd think there'd be some standard symbols for depicting time and for medical terms/actions. 

So I did a little research. The first place I went to was the ISO (International Organization for Standardization). This is "the world's largest developer and publisher of International Standards."  http://www.iso.org/iso/home.htm

They have a lot of information on the development and use of universal symbols. I specifically looked for symbols that measure time, and any that had to do with the medical field. I found these:

ISO 80000-3:2006  Quantities and units -- Part 3: Space and time
(Gives names, symbols and definitions for quantities and units of space and time. Where appropriate, conversion factors are also given.)

ISO 15223-1:2006  Medical devices -- Symbols to be used with medical device labels, labelling and information to be supplied 
(Identifies requirements for the development and use of symbols that may be used to convey information on the safe and effective use of medical devices.)

Doing a search for just "symbols" provided 215 separate publications. Unfortunately, you have to purchase them to see and use them. And to make things confusing, all of the prices are listed using Swedish francs. I used a currency converter and found that some of these publications range between $70.00-120.00 (kinda steep!)


Some less expensive alternatives:  


Symbol Sourcebook: An Authoritative Guide to International Graphic Symbols
by Henry Dreyfuss

Famed industrial designer Henry Dreyfuss recognized the importance of symbols in communicating more quickly and effectively; for many years he and his staff collected and codified graphic symbols as they are used in all walks of life throughout the world. The result is this "dictionary" of universally used graphic symbols.

I looked it up on Amazon and could view the index. It looks like there are at least 5 pages of medical symbols included in the book. 



Global Graphics: Symbols - Designing with Symbols for an International Market
by Anistatia R. Miller, Jared M. Brown, Cheryl Dangel Cullen

This guidebook covers everything designers need to know about the national and international meanings of various traditional and not-so traditional cultural symbols. 


Hablamos Juntos

Hablamos Juntos, an initiative of The Robert Wood Johnson Foundation, was launched to eliminate language barriers and improve the quality of health care for people with Limited English Proficiency (LEP). They worked to develop 28 symbols that can be used for signage in health care settings. http://www.hablamosjuntos.org/signage/PDF/SymbolPosterB.pdf

On their website (http://www.hablamosjuntos.org/) you can download information about developing and using universal symbols in health care. I think many of the recommendations and guidelines can be applied to creating or choosing graphics for something like a "pill card" or other similar educational tools.

Symbol Usage in Health Care Settings for People with Limited English Proficiency - Part One: Evaluation Of Use Of Symbol Graphics In Medical Settings. This is a white paper with a brief review of symbols use that looks at the feasibility of using symbols in health care. The report finds evidence of health care symbol development and use in a variety of countries, include the United States, and concludes that not only are symbols viable for health care signage, but that a set of tested health care symbols would give designers an alternative beyond multilingual signs.

Symbol Usage in Health Care Settings for People with Limited English Proficiency - Part Two: Implementation Recommendations. Part two makes suggestions for developing a set of universal symbols. 

Symbol Usage In Health Care Settings for People with Limited English Proficiency - Part Three: Symbols Design Technical Report. This report describes details of developing and testing health care symbols and includes tools used in the process. 


I hope this information is helpful.

Doug Seubert
Guideline Editor
Quality Improvement & Care Management
Marshfield Clinic
www.marshfieldclinic.org
1000 N Oak Avenue
Marshfield, WI 54449
(715) 387-5096 (1-800-782-8581 ext. 75096)
seubert.douglas at marshfieldclinic.org

------Original Message------
From:	"Dickerson, Robert" <DICKERR2 at ihs.org>
Date:	Thu Feb 28, 2008 -- 01:09:27 PM
To:	healthliteracy at nifl.gov
Subject:	[HealthLiteracy 1798] Re: pill card

While this tool appears to be a step in the right direction I also agree
with and share the concerns of both Laurie Anson and Marcia. Some of the
other graphics I saw on the site I would not necessarily equate with the
terms they are supposed to signify. For example the graphic that I
believe is supposed be a bag of sugar to represent diabetes did not
connect for me until I realized is was supposed to represent a bag of
sugar. I just saw a bag of something???

Of course making the connection between the graphic and intended meaning
may be influenced by context and the patient's medical conditions (the
sugar bag may make more sense to a diabetic than a non-diabetic). I'm
curious if there are truly universal graphics, symbols, pictures or
visuals that are understood by a majority of people. Of course unique
cultural difference may make even "universal" graphics meaningless in
some cases. In this event alternatives should be made available.

I'm also curious if the graphics in this application were used because
they are conveniently available clip art or if they have truly been
studied and shown effective for a variety of patient populations.

Thanks,
Bob Dickerson, MSHSA, RRT
Quality Improvement Coordinator, Clinical Quality
Iowa Health - Des Moines
Des Moines, Iowa
Phone: (515) 263-5792
Fax: (515) 263-5415
E-mail: DICKERR2 at ihs.org
Website: www.ihsdesmoines.org


-----Original Message-----
From: healthliteracy-bounces at nifl.gov
[mailto:healthliteracy-bounces at nifl.gov] On Behalf Of Trenter, Marcia L
Sent: Wednesday, February 27, 2008 5:11 PM
To: The Health and Literacy Discussion List
Subject: [HealthLiteracy 1795] Re: pill card


I agree with Ms. Anson. Considering culture/understanding ethnicity will
help us understand others' interpretations of graphics. We live in a
multi-cultural society. We need to accept that "one size does not fit
all"; one presentation will rarely be interpreted universally. Thus,
strategic targeting of visuals, cultural awareness, focus testing, and
hopefully teach-back orientation.  Here's a graphic challenge for all.

What graphic(s) would depict the following.

3x daily without food. 

Graphics for:	Morning
			Mid-afternoon
			Bedtime

3x daily with food.

Graphics for:	Breakfast
			Lunch
			Dinner

We used a rising sun with a rooster to depict "morning" and several
focus participants thought it meant, "breakfast with chicken". 

I will be very interested to hear your response and grateful.

Thanks,
Marcia

___________________
Marcia L. Trenter
Special Assistant to the Office Director Office of Training and
Communications Center for Drug Evaluation and Research U.S. Food and
Drug Administration Rm 2436, Bldg. 51
10903 New Hampshire Avenue
Silver Spring, MD 20993-0002
301-796-3172
Fax 301-847-8718
E-mail marcia.trenter at fda.hhs.gov
______________________


-----Original Message-----
From: healthliteracy-bounces at nifl.gov
[mailto:healthliteracy-bounces at nifl.gov] On Behalf Of Laurie Anson
Sent: Wednesday, February 27, 2008 5:03 PM
To: The Health and Literacy Discussion List
Subject: [HealthLiteracy 1794] pill card

To the List -

As an RN, I recall having heard of the use of pill cards similar to the
one shown. As I remember, there were some difficulties with the symbols
used (sunrise, sunset, moon) across cultural lines. I think the use of
pill cards is an excellent idea, as long as great care is taken to
explain the symbols to the client. For instance, if there is no "sunset"
to compare to "sunrise", then there might be some confusion about the
significance of that particular symbol.


Laurie Anson
ansons at epix.net



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