3 Development and testing of pictograms for the symptoms of pre-eclampsia in Ogun State, Nigeria

Introduction According to the World Health Organization, there were an estimated 45,000 maternal deaths in Nigeria in 2015; where pre-eclampsia was one of the leading causes. Pregnant women, families and the wider communities frequently show inadequate health knowledge of pregnancy complications which may contribute to high rates of mortality and morbidity. Poor knowledge of complex conditions such as pre-eclampsia is of particular concern. There are no universally recognized pictorial aides for the danger signs in pregnancy. To address this gap, pre-eclampsia specific pictograms were developed for use in the Community Level Interventions for Pre-eclampsia (CLIP) project. These were designed to educate pregnant women and relevant community decision-makers regarding these danger symptoms. Objectives 1. To develop culturally-relevant pictograms of the symptoms of pre-eclampsia. 2. To evaluate the appropriateness and understanding of these pictograms amongst pregnant women of south-western Nigeria. Methods Twelve pictograms were designed to represent the danger symptoms of pre-eclampsia: abdominal pain, chest pain, nausea, vomiting, seizure, stroke, unconsciousness, vaginal bleeding, visual disturbances, headache, and finally two images to represent shortness of breath. Symptoms were selected based on those shown to be predictive of adverse maternal outcomes as well the consequences of pre-eclampsia. Pictograms were developed from literature review and consultation with clinical experts, January–June 2012. Evaluation of pictograms was conducted in Ogun State, Nigeria in September, 2012. Two focus groups and seventeen interviews were conducted with pregnant women in Nigeria to beta-test the twelve draft images and subsequently updated based on the feedback of the 41 participants. Results Pregnant women had difficulty interpreting most pictograms when asked in the absence of additional information: 23(56%) misinterpreted the image for abdominal pain, 34(83%) and 27(66%) for the two images depicting shortness of breath, 22(54%) for the image of chest pain, 26(63%) for the image of nausea, 26(63%) for the image of seizures, 18(44%) for the image of stroke, 31(76%) for the image of unconsciousness, 15(37%) for the image of visual disturbances, 8(20%) for the image of vaginal bleeding. However, all participants correctly identified the symptoms depicted in pictograms for headache and vomiting. Participants provided recommendations that were implemented to improve the pictograms, such as changes in facial expression and the placement of hands. Conclusion These findings suggest that women understood only a few of the tested pictograms when shown in the absence of health information. Some pictograms were revised to improve understanding of the complications of pre-eclampsia. In addition, pregnant women should be provided these pictorial aides in conjunction with basic health teaching related to pregnancy and its complications.