As the world becomes more and more digital, visuals are rapidly replacing text as the preferred mode of communication. Healthcare is no exception to this. From mobile health apps and electronic Clinical Outcome Assessments (eCOAs) to medication labels and patient portals, icons and pictograms have a prominent position. The goals of visuals are simple:

·       To reduce the cognitive burden of readers

·       To improve clarity and comprehension

·       To reach diverse audiences, including people with low literacy or limited language proficiency.

But are icons really universal?

The assumption has been that icons transcend language and culture is optimistic. While visuals can indeed bridge communication gaps, they can also open the door to misunderstanding, especially when it comes to communication about health. It is vital to scrutinize how icons are interpreted and understood across different populations.

The Appeal of Icons in Healthcare

Icons certainly offer advantages in patient communication:

·       They are quick to process

·       They can clarify complex instructions

·       They can overcome language and literacy barriers

·       They can visually reinforce key actions or steps.

In eCOAs, icons are often used for actions like “next”, “submit”, “back” or to indicate the level of pain or mood. In medication labels, a sun icon might be used to indicate morning dosing or a moon to signal bedtime. These symbols are a clear improvement over dense paragraphs of text.

How often do we really test whether patients actually understand what the symbols mean?

Could the Universality of Icons be a Myth?

Icons are not inherently universal. Their meaning is shaped by culture, context, exposure and age. A simple example is the tick mark (checkmark in North America - ✔️). In Western cultures, this means “correct” or “complete”. In other cultures, such as Japan, it can indicate an error. A red ‘X’ might mean ‘incorrect’ or ‘cancel’ to one user but “danger” to others. The thumbs-up emoji is a friendly gesture in many cultures, but deeply offensive in others. These are not trivial differences. In health communication, they can have real consequences.

Facial icons used to assess mood or pain, such as the sad and smiley faces often used in paediatric assessments, might also be misread due to cultural norms around emotion expression. A grimace could be interpreted as a smile. A ‘worried’ face might be interpreted as neutral or even happy in another region.

I wonder if any attention is paid to these during cognitive debriefing processes or even before that during the iterative development phase of a COA?

Other examples from our experience of testing visuals include:

·       A wine glass with a cross icon to mean ‘do not take with alcohol’ was interpreted by some patients as ‘take with wine’.

·       A warning icon to denote ‘serious side effect’ was interpreted as ‘urgent medication’.

·       Children under 5 or 6 years old may not be able to distinguish between mood faces without adult explanation

·       If icons are to be presented in a sequence, be sure to reverse this sequence in right-to-left reading contexts. Unbelievably, this is sometimes overlooked, and the users interpret it in exactly the opposite way as intended. Read that again: this is something we have encountered when testing translated materials several times.

Icons, in many respects, are very much like words, particularly in how they are acquired. A few icons for concrete objects may be intuitively interpreted, a bit like how onomatopoeic words sound like the word it describes – although this is very much culturally bound (compare the English ‘cock-a-doodle-do’ with the Kurdish ‘koko-ri-ko-kok’). The majority of icons, just like words, require learning and context, especially when dealing with abstract concepts.

What Factors Can Influence Icon Understanding

Several key variables shape how icons are interpreted:

·       Cultural background: How signs are read vary widely. What has meaning in one culture can be confusing or even inappropriate in another.

·       Age and Generation: Older adults with less exposure to technology may interpret icons differently or rely more on the text that accompanies it.

·       Digital Literacy: people with limited experience in app-based navigation may not understand visual options and shortcuts, such as hamburger menus or sliders.

·       Visual Literacy: Just as with other literacies, the ability to interpret visual information is not evenly distributed and this is often overlooked in the design of health communication.

·       Language Priming: people tend to interpret visuals based on their language, environment and culture.

Why Does This Matter?

In clinical research, even when an eCOA might be perfectly understood and usable, a clumsy visual could act as a trip-wire: if a study participant does not fully understand an icon, their responses could be inaccurate. Take the pain scale with facial expressions, for example. If the faces do not align with the patient’s norms and expectations, they may select a rating that does not accurately reflect their experience.

How to Improve Icon Clarity and Cross-Cultural Usability

As with any other aspect of user-centred design, icons need to be validated, rather than developers assuming universality. Beyond the development phase, cognitive debriefing offers a unique opportunity to gain user feedback across a wide range of cultures about how visuals in an eCOA are interpreted. Failure to do so is not only a shame, but an act of negligence.

Standardisation of Icons in Health

There is growing momentum around the development of shared sets of visual standards, such as:

·       WHO pictograms for medication safety

·       ISO 7001 for public information symbols

·       HL7 FHIR interface design guidelines.

However, adoption is uneven, as many healthcare apps rely on their own custom visual metaphors, which can be confusing. A truly global icon library would require collaboration across regulatory bodies, design communities and patient advocacy groups. This would require regular testing, updating and cultural vetting.

Great Promise, but Not a Magic Bullet

Icons can make patient communication more accessible, but only when they are used carefully. The idea that visuals speak a universal language is attractive, but it is also misleading. In health communication, assumption creates and magnifies risk.

Icons need to be tested, validated and contextualised for the populations that they have been designed to serve. Only then can we design icons that are not just functional, but inclusive too.

Thank you for reading,

Mark Gibson

Leeds, United Kingdom, March 2025