Effects of Interactive Pictorial Education on Community Dwelling Older Adult's Self Efficacy and Knowledge for Safe Medication

Korean older adults living in communities often experience chronic illness and take multiple medications, such as over-the-counter (OTC) medicines, nutritional supplements, and prescription medicines. Therefore, they are potentially at high risk of adverse drug interactions (Ministry of Health and Welfare, 2009). According to the Korean Elderly Survey conducted by the Ministry of Health and Welfare, 84.5% of people older than 65 years take over-the-counter (OTC) medicines, nutritional supplements, or prescription medicines. In addition, 27.5% of them take more than three types of medicines. Adverse drug interactions resulting from polypharmacy raise major concerns for the optimal health of older adults. Thus, medication complexity and adverse effects resulting from polypharmacy have been associated with increased number of hospital admissions (Han, 2007).

The administration of medications and the monitoring of their effects in elderly patients are important nursing roles and nurses have to demonstrate professional knowledge, skills and increased responsibility (Neafsey et al., 2009). Several studies in Korea have highlighted the role of the nurse in educating or assisting the elderly clients to develop appropriate knowledge and behaviors required for self medication. When the elderly clients were provided with both verbal and written instructions, in group or at individual level, knowledge and compliance behaviors improved (Katz, Kripalani, & Weiss, 2006). However, education on self management of medication is typically delivered with written and verbal information and may not be fully understandable by all older adults, who have different literacy levels and expectations (Lee & Park, 2007; Shin, Kim, Kim, & Yi, 2005). Low functional health literacy has been found to be an important factor of medication non-adherence, leading to poor health outcomes (Lee & Kang, 2008; Lee & Park, 2010). People with low health literacy will have difficulty learning information from many written medical materials, including medication instructions (Dimateo, 2004). The limited literacy skills of a large proportion of the Korean elderly present a significant barrier to accessing and understanding medicine information necessary for the degree of adherence required for a successful health outcome (Lee & Park, 2010). The challenge facing healthcare providers is to communicate health information in an understandable form, which is appropriate for the literacy skills, culture, and expectations of the target population.

Research has shown that visual aids can increase the patient's understanding. Furthermore, visual cues accompanied by oral instructions have increased the patient's recall more than oral instructions alone (Houts, Doak, Doak, & Loscalzo, 2006). Interactive pictorials are visual tools designed to be used in small, interactive group or individual education, where participants can learn about specific topics (Mansoor & Dowse, 2004). A pictorial is a graphic tool used to create, manage, and exchange information and knowledge. The use of interactive pictorial education may increase the patient's understanding of medication instructions. Especially, the pictorial map represents information and knowledge via the spatial organization of concepts/topics, ideas, words, or other items, linked to and arranged in an ordinal pattern according to the education contents. Visual mapping diagrams of ideas and concepts are widely acknowledged as a very powerful and fun learning tool (Sojourner & Wogalter, 1998).

The pictorial map and cards can incorporate meaningful pictograms to present the flow of ideas. As graphic knowledge representation tools, they provide written, visual, and spatial information and this combination is more likely to be retrievable from memory than written information alone. An interactive pictorial detailing the education contents may be a useful tool to communicate critical medication information to low literate elderly patients and the education provider and the receiver can interact like in a game. Pictorial aids used with verbal education and written materials can further the patients' understanding of safe medication and, therefore, can potentially improve their medication adherence and health outcomes (Hill, 2004).

The concept of self-efficacy, as a major factor in behavioral changes, was proposed by Bandura (1986) and refers to the belief or confidence that one can successfully perform a specific action required to attain a desired outcome, and is an important predictor of medication adherence (Molassiotis et al., 2002). Previous research suggests that self-efficacy is a strong predictor of treatment adherence, and that it serves as a useful basis for interventions (Molassiotis et al.; Scherer & Bruce, 2001).

In addition, knowledge for appropriate medication is an important factor to improve the patients' medication adherence and safe medication. Data from previous studies reported that older adults with inappropriate knowledge of medication are at risk of medication misuse and abuse (Park, 2008).

Therefore, this study examined in older adults living in the community the effectiveness of interactive pictorial education as education strategy to reduce medication misuse and non-adherence, thus improving self-efficacy and knowledge towards safe medication.

This study evaluated the effects of interactive pictorial education on self-efficacy and knowledge towards safe medication of community dwelling older adults in Korea. Data from this study support all study hypotheses. The recipients of the interactive pictorial education plus information booklet showed greater self-efficacy and knowledge of safe medication than both the group receiving the conventional education only with the information booklet and the control subjects who received no information. The improvement in self-efficacy and knowledge with the intervention suggests that older adults benefit from visual aids tailored to their learning style and aging characteristics. This study tested an innovative approach that is different from the previous studies using the pictorial map and cards to facilitate older adults' participation and comprehension of education.

At baseline, the overall initial self-efficacy score was medium and knowledge towards safe medication score was relatively low, indicating that Korean older adults in the community need an educational intervention to improve their medication self-efficacy and knowledge. Data from previous studies reported that older adults typically take multiple medications and are at high risk of adverse drug interactions (Fialova et al., 2005). In addition, their knowledge concerning potential interactions arising from self medication and the self-efficacy to avoid such incidents was low (Kripalani et al., 2007; Neafsey, Strickler, Shellman, & Padula, 2001).

The experimental group showed significant increase of self-efficacy and knowledge compared to those of the information booklet group and the control group. Mild to moderate improvement in self-efficacy was reported in previous studies using pictorial aids with interaction (Kripalani et al., 2007; Neafsey et al., 2009). This demonstrated that the use of an educational aid, such as visual materials with active interaction, allowed older adults to use medication appropriately and increased their confidence. Research in psychology and education indicates that human subjects have a cognitive preference for picture-based, rather than text-based, information (Katz, Kripalani, & Weiss, 2006). In this way, medication-related pictorial aids, that describe appropriate medication-taking behaviors, can help patients to reduce their medication misuse and overuse behavior. In this study, pictorial aids with written information booklet were used in the experimental group. The findings of this study supported previous studies. Several studies emphasized the importance of using pictures in conjunction with either written or oral instructions to avoid misinterpretation of picture only instructions. Dowse and Ehlers (2005) assessed both comprehension and adherence to treatment using either text-only (control) or text-plus-pictogram (experimental) information for prescribed antibiotics in a mostly female population with low literacy level. The text-plus-pictogram group showed higher comprehension and medication adherence (95% and 90%, respectively) than those in the text only group (70% and 72%, respectively). Sojourner and Wogalter (1998) assessed the effect of pictures on patients' comprehension of simulated medication schedules. Participants recalled significantly more medication information when presented with the redundant text and pictures than with text alone, pictures alone, and text with only some pictures. Patients found pictures most helpful for obtaining information about medication name, daily dose, and times to take the medication, but found them less useful for showing drug interactions.

Research indicates that visual aids have been an effective aid to both comprehension and recall of information, if combined with text and verbal interaction in small group education (Andrus & Roth, 2002; Lee & Park, 2007). In this study, we delivered the small group based education, allowing active interaction between the instructor and the participants. This small group approach allowed enough time for the older adults with different literacy levels to understand the education contents and facilitate the interaction. The problem in older adults with low literacy level is their inability to read the text. Therefore, we consider that in this population, pictorial aids should always be used in conjunction with verbal instructions. Older adults with low literacy level comprise a population with special needs, who are at higher risk of experiencing poor health. Compared to traditional education methods, interactive pictorial education focuses on participant-directed discussions and on shared problem-solving with self medication (Sawhney & Reicherter, 2005).

This study has also shown that the pictorial education can be successful in communicating medication information, particularly if they are developed in collaboration with the target population. Previous studies recommended that pictorial aids needed to be developed based on the target user's culture level and learning style. In this study, the researcher developed the pictorial aids while working with the focus group of older adults in a formative manner, during the development phase (Neafsey et al., 2001). The revision of the contents and designs was made based on the opinions from the focus group such as use of easy terminology, big size of text, use of simple graphics and familiar subjects and so on.

The findings from the studies of pictorial memory suggested a large storage capacity for visual information and good retention of pictures over time (Dowse & Ehlers, 2005; Mansoor & Dowse, 2004). They also reinforced the importance of incorporating a follow-up phase in the testing process and demonstrated that the pictorial aids were easily learned and subsequently recalled over a prolonged time. This study tested only the difference between the pre- and post-test effects; therefore future study is needed to test the long term effects.

This study had several limitations and these limitations can be addressed through future research. First, the education contents used in this study involved simulated usage instructions, usually for a single treatment, rather than one or more real drugs prescribed in the study participants. Because older adults with chronic disease usually take multiple medications, we need to explore the effects of individualized education, according to the older adults' health state and medication-related characteristics. Second, the outcome variables in this study were self-efficacy and knowledge of medication. Additional research is needed to measure other clinical outcome data, such as medication adherence behavior, biological markers, and health related quality of life.

The interactive pictorial education is an innovative approach that provides a mean for older adults to learn the appropriate medication use for improving their own health. It empowers older adults with different literacy levels to enhance their self-efficacy and knowledge for the safe use of medication. The results from this study demonstrate that the study sample of older adults benefited significantly from this innovative approach of health education. Moreover, augmentation of conventional (written) health education via an interactive visual concept map provided participants with the significant overall advantage of increased knowledge and self-efficacy.

Future studies, using subjects with lower education levels, are needed to confirm whether the interactive pictorial approach can help remove the barriers of advanced age and limited education in health literacy efforts.

The sample used for this study was recruited from senior centers in a single metropolitan city. Consequently, the results of this study cannot be generalized to the entire population of older adults in Korea. Data from future studies will help to determine if the interactive pictorial education is equally effective with the older adults in both rural and urban areas. Moreover, future research will include study of a sample population in home care settings or clinical settings, to support the efficacy of the approach across various settings, as well.

In this study, the effectiveness of the intervention was measured at pre- and post-test points. Prospective long term studies may ultimately reveal that health education presented in this manner benefits older adults in the assimilation of knowledge and self-efficacy necessary to avoid costly medication interactions and their consequent adverse health effects.

The implications for future practice are related to the delivery of various health information to older adults via interactive visual aids. In the community setting, interactive pictorial education can be adapted to cover broader topics, related to both health promotion and disease management. In addition, the computer assisted pictorial education has the potential to revolutionize health education for older adults. Computer assisted interactive pictorial education can be provided to older adults as a self-education method. Additionally, computer assisted interactive pictorial education may provide both timely and appropriate individualized interventions and evaluations for older adults with various diseases and health information needs. Personalized health education for older adults, based on this innovative approach, could promote meaningful continuity of care and could amend any potential gaps between the clinical and the home care settings.