Visuals are often seen as a universal language. They are simple, fast and free from the apparent limitations of linear text. In reality, though, visual literacy is as diverse as the people who try to use it. An icon that may be instantly clear to one user may be completely confusing to another. Many of these differences in interpretation can be explained by the influence of culture.

Consider the following examples:

• A red cross meaning “medical help” in some cultures and “do not enter” in others.

  
  

• The prayer-hands emoji (🙏) may mean literally prayer, fasting, gratitude, religion in general or a high-five, depending on the culture and the context.

  
  

• The globe icon (🌐) is assumed to mean internet or global access, but in some contexts means “language settings” and in others “news” or to signal that the topic is about the environment, climate change.

  
  

• The lock icon (🔒) is assumed to mean security or privacy but is also interpreted as ‘this is restricted’, or indicates a paywall or that it cannot be changed.

  
  

• The hospital icon (🏥) is intended to mean health or emergency services, but it is not universally familiar. In some cultures, the cross is red, green or blue and this has different connotations: pharmacy, religious hospital, and so on.

  
  

• The raised hand emoji (🖐️) carries the assumed meaning of ‘stop’, ‘raise hand’, ‘request to speak’, but in some cultures it can depict a rude gesture (open palm) or be interpreted as a wave or a greeting.

These are just a random selection of examples from general contexts. In healthcare, differences in interpretation matter. Misinterpretation of a visual can be dangerous. If health communication that incorporates visuals is to be truly inclusive, we must design for diversity and not only clarity.

Visual Literacy Is Not a Fixed Trait

Visual literacy is shaped by many factors, such as:

• Culture: as illustrated in the examples above, visual symbols are never truly universal. Their interpretation is always shaped by culture. Some cultures are already more visual in orientation (Japanese, Indigenous societies), where visual literacy is embedded and comes naturally. However, others are more text-driven (Germany, UK), which can make the leap from text to visual logic more difficult.

  
  

• Language and Directionality of Script: The direction in which we read, such as left-to-right or right-to-left, affects how we interpret visual sequences. Icon flows in Arabic and Hebrew need to be mirrored to a right-to-left reading direction. For example, a sequence like:

🕒 ➝ 💊 ➝ 🍽️ (at 3pm take your medication before meal)

would need to be flipped to:

🍽️ ⬅ 💊 ⬅ 🕒 to match the right-to-left reading logic.

            Otherwise, directionality will alter the meaning of the sequence. In this case, it would imply reverse actions in a medication sequence, which has a direct impact on safety.

• Age: younger users, digital and smartphone natives can navigate emoji-rich, icon-based environments more easily than older adults, who may not readily recognise new visual metaphors, icons or emojis.

  
  

• Education and Literacy: People with low basic skills may rely more on concrete visuals and may struggle with abstract symbols (like🧬for genetics), visual metaphors (e.g. 💡 for “idea”) or visuals that are stylised or overly decorative.

  
  

• Disability: cognitive disability, such as dementia or autism, can affect the interpretation of visual sequences, especially overloaded visuals. People with low vision or a degree of sight loss may need higher contrast, alternative text or haptic or audio support.

The Problem with “Universal Design”

Often, when developers aim for universal design, it really only means designing for the average user, rather than designing for diversity. The concept of “universal” is usually just what is most familiar to the design team. This often includes Western cultural assumptions and an English-language icon order.

This might be fine for a middle-class, higher educated, tech-literate user in North America, Europe, Australia or New Zealand. But what if the user is a rural patient in Bangladesh, a 94-year-old in France or a refugee navigating a healthcare system for the first time?

The next article explores how visual communication can be universal without being uniform.

Thank you for reading,

Mark Gibson

Leeds, United Kingdom, April 2025