TABLE 1

Comparison of Features of the Low-Literacy Pictogram- and Photograph-Based Action Plan and Standard Action Plan

Low-Literacy Action PlanStandard Action Plan
FeaturesSupporting Evidence
Overall structureThree color zones used to divide information about everyday care (green section) from information about when the child is starting to get sick (yellow; rescue medicine needed) and when the child is very sick (red; emergency help needed).
GeneralSymptom-based information for asthma management.Evidence suggests that symptom-based action plans are superior to peak flow–based plans with respect to prevention of acute care visits.37,38Symptom-based information for asthma management and areas where providers can fill in peak flow–based information, a typical feature of US action plans.9
Presentation of medication instructions: Misunderstanding of asthma medication instructions is a contributor to the high rate of parent and patient nonadherence to prescribed asthma medication regimens24; misunderstandings relate to timing and frequency of medications, as well as mix-ups between which inhaler to take for emergencies and which inhaler is for everyday use.11Times of day used (eg, “morning” and “night”).Use of medication instructions relating to particular times per day (eg, morning, noon, evening, bedtime) has been found to improve patient understanding, especially with complex regimens,39,40 and is part of new evidence-based medication labeling standards issued by the US Pharmacopoeia.41No guidance for provider given about how to present times of day; most commonly, providers presented instructions in times per day (eg, “2×/day”).
Morning and night pictograms emphasize times of day.Incorporation of pictograms in medication instructions has been found to improve medication self-management.42No morning and night pictograms.
Shading used to “chunk,” or cluster, information about morning and night medication regimens.Chunking of information helps cluster similar information, which is easier for the brain to process.43No shading used to chunk information about morning and night regimens.
Photographs of inhalers included to help parents differentiate between their everyday and rescue inhalers; color of each inhaler evident from photographs (Flovent, orange; Albuterol, blue).Use of color is a strategy used to help support understanding of key concepts; in this case, presenting inhaler color provides valuable information to help parents act on medication instructions.43No colors of inhalers indicated. Providers can choose to write in inhaler colors.
Presentation of spacer information: Use of a spacer with inhaled asthma medications is considered to be essential for maximal delivery of medication to the lungs, improving medication efficacy.12Spacer use reinforced through repetition of this concept each time inhaler information is provided on action plan. For each medication:Repetition of key concepts13 encourages providers to reinforce the information and supports parent understanding.No spacer use mentioned in text. Provider can choose to write in need for spacer.
Spacer use mentioned in text (eg, “2 puffs with spacer”).Pictograms are particularly effective for visually reinforcing concepts,19,2124,42 in this case, the importance of spacer use. No images of spacer shown.
Spacer is shown in pictograms (eg, line drawing of child using an inhaler with a mask and spacer).
Reinforcement of need for everyday preventive medications, even when sick: For asthmatics with persistent asthma, use of daily controller medications has been shown to be the best way to prevent asthma exacerbations, and they work best if taken every day, regardless of whether the child is sick or well.14 Those with low HL have been found to be more likely to underuse inhaled steroids10 and are more likely to believe that medications work better if not used all the time.44Need for everyday preventive medicine addressed in the top banner of green zone.Repetition of key concepts encourages providers to reinforce the information and supports parent understanding.13Need for everyday preventive medicine addressed in text in green zone (not emphasized with color).
Concept reiterated in yellow zone.Effective use of layout, including allocation of adequate space to particularly important concepts, can help highlight key concepts.9,43Concept reiterated in text in yellow zone (not emphasized with color).
Concept mentioned in text, along the top banner.
“Snapshot” of the pictographic and photographic green zone medication information in the yellow zone section (which shows images of both Flovent and Singular).
Presentation of symptoms of serious exacerbation (red zone): Difficulty recognizing symptoms of a serious asthma exacerbation can result in lack of appropriate intensification, or escalation, of treatment.15,16Inclusion of predominantly explicit symptoms along the left column of the action plan (eg, “ribs show when breathing,” “can’t stop coughing,” “neck pulls in”).Presentation of explicit symptoms is helpful in providing clarity about what parents should look for, making the instructions more actionable.43Inclusion of predominantly general, subjective symptoms along the left side of the action plan (eg, “difficulty breathing,” “coughing,” “wheezing”).
Symptoms presented 1 at a time in bullet format.Symptoms presented 1 at a time are easier to read than when unrelated symptoms are clustered together.22Multiple symptoms sometimes grouped under 1 bullet.