In a world that is increasingly global, visual communication is often seen as a universal shortcut. It is a way to transcend language barriers with a single image. Yet visuals, just like words, are interpreted through the lens of culture, experience and literacy. Therefore, the challenge is this: How can we design visuals that are localised to diverse audiences without losing clarity or structural integrity?

The answer lies in designing, or building, visuals with intention, not just in what they look like, but in how they are used, how they are interpreted and how they work together.

Building a Visual Grammar Framework

Just as language follows grammar rules, so too effective visual communication follows a logic – a visual grammar. A common useful structure is Time ➝ Action ➝ Condition, a sequence that mirrors how many health instructions are presented.

For example:

•             In English (left-to-right): 🕖 ➝ 💊 ➝ 🍽️ = “Take this medicine at 7 o’clock, with food.”

•             In Arabic (right-to-left): 🍽️ ⬅️ 💊 ⬅️ 🕖 = Same meaning, different direction.

While the icons and reading direction may change, the deep structure, i.e. the sentence logic, the underlying grammar, remains intact.

This is one way that visuals can keep consistency across cultures.

Localise the Visual Vocabulary, but Not the Syntax

When localising, rather than altering the whole visual system, the icon vocabulary could be adapted to fit local norms. For example:

•             Swap 🍽️ for 🍜 in East Asia, where a bowl of noodles may better represent a meal.

•             Use 🧴 instead of 🧼 in places where bar soap is unfamiliar.

•             Be mindful that icons like 💉 can signal vaccination in one region but evoke fear or danger in another. What if you do not wish to convey any of that and the syringe simply means ‘for intravenous use’?

Making culturally appropriate adaptations makes the visuals culturally relevant, while preserving the core design rule: One icon = one idea.

If visuals are used in a sequence to denote a medical instruction, such as ‘take one pill before a meal’, or ‘if you continue to feel pain, please contact your doctor.’, then the ‘grammar’ of the sequence matters and must be used consistently. This is particularly so for modifiers like 🚫 (do not), 🔁 (continuation, persistence), ❗ (caution, warning). These must be used in the same way on every occasion.

Co-Design with Local Audiences

Designers must never assume that the interpretations of emojis are universal. It is vital for visuals to be tested with real people. A strategy for iterative testing could be as follows:

·       Comprehension testing with users from diverse linguistic and cultural backgrounds.

·       Involve people from the target community, e.g. health workers, elders, patients in feedback loops, so that the visuals are co-designed and validated by real users.

Combining both strands encourages genuine usability.

Visual Literacy is a Public Health Skill

If health organisations have invested anything in improving communication with patients, they tended to focus solely on text readability. But visual literacy, which is the ability to interpret images and icon sequences, also deserves attention, especially for populations facing language, age or educational barriers.

Visual literacy in health contexts can be supported in the following ways:

·       Include Visual Glossaries: tools like digital apps can include simple icon indexes, e.g. 💊 = Medication; 🍽️ = with food, and so on.

·       Public Health Campaigns: posters, videos and digital ads could introduce common icon sequences through exposure and repetition, such as ‘How to take your medicines’ and broken down visually, step by step.

·       Enable Learning: digital tools or eCOAs could include tooltips, voiceover explanations, pop-up or hover-over information that explains the visual. This would enable people to gain fluency over time and save them from guessing, possibly incorrectly.

·       Offer Personalisation: users could choose between simplified or detailed icon sets (a parallel could be the difference between Traditional versus Simplified Chinese characters), or there could be audio explanations in their language (easy to achieve with AI translation and text-to-speech – with human oversight, of course), AI could also detect user confusion or misinterpretation and could then trigger adaptive support.

If we allow them, digital tools can also become teachers. Imagine a digital symptom tracker that is to be used in a hyper-multilingual society such as India. Pictograms could replace the need for translating symptoms like cough, fever, appetite, and these pictograms would have undergone iterative testing in the communities in question. There could be audio accompaniment in the local language. This is surely better than a traditional text-based tool, whether electronic or paper-based.

Clarity Comes Through Cultural Respect

Visuals do not necessarily have to be the same for everyone, they just need to be understood by everyone. The goal should not be to chase a perfect, one-size-fits-all icon. It should be to develop a visual system that is:

·       Structurally consistent: The visual system has its own grammar.

·       Culturally adaptable: the ‘vocabulary’ can be customised because the underlying grammar holds the structure in place.

·       Repeated and reinforced: exposure and repetition encourage users to become visually literate.

·       Tested with real users in the spirit of formative, iterative design, with summative validation at the end of the development process.

·       Designed for easy learning, not clumsy guessing.

Approaching visual design in this way is a stride towards creating a shared language, one that crosses borders, ages and abilities. In fact, it is more than that: it is also a leap closer to health tools and systems that are accessible and usable to the people they are meant to serve.

Thank you for reading,

Mark Gibson

Leeds, United Kingdom, April 2025