"Symbols can express a message in a compact form, may be more noticeable in a 'busy' environment than a written message, have more impact than words and ...be understood more quickly than (written) messages. " (ISO Bulletin December 20011)
Universally recognized graphic symbols, such as traffic symbols or those used to delineate parking spaces for the physically handicapped, can be an effective tool for communicating important information to those unable to read or with limited English proficiency (LEP). Pictures or images are what make symbols useful. Universal symbols are pictograms or images that consistently enable logical associations that help communication across languages and cultures.
The testing conducted to develop the Universal Health Care Symbols is one of the most comprehensive symbol design efforts ever undertaken. This page is designed for those who are interested in learning how the health care symbols were developed and tested.
If you are ready to use the new Universal Health Care Symbols, go to Using Symbols to download symbol artwork and the ‘how to’ best practice workbook.
Health care executives and the design community need tools and methodologies to enable LEP populations to navigate in the health environment. The number of people who speak a language other than English at home has grown significantly. This segment of the population grew by 38 percent in the 1980s and by 47 percent in the 1990s2. By 2000, 47 million persons over the age of 5 spoke a language other than English in the home. Attention to federal and state laws, which require health facilities to have signage available in the language of their patients, has increased with the growth of this population. Presidential Executive Order 13166, "Improving Access to Services for Persons with Limited English Proficiency" and National Standards for Culturally and Linguistically Appropriate Services in Health Care adopted by United States Department of Health and Human Services underscore these requirements but offer no new solutions.
Symbols are visual images that represent a referent, a word or a real world object, place or concept. Long before written language, pictographs (symbols) served as a means of communication. As societies grew and written languages developed, pictographs were employed to provide information to people who were largely illiterate. However, pictographs served mainly an informal function until the 20th century. When air travel and expanding world immigration increased, universal symbols served as an international communication tool. In hospitals, universal symbols on signs are rare. Alternatives such as signs using text, in one or more languages, or letters and numbers are quite common as are symbols or landmarks specific to a facility or a hospital.
The idea of symbols for health care signage came from the subway system in Mexico City which uses cultural icons to identify destinations. Symbols have been used for more than 30 years, making the city's subway system accessible to tourists and those unable to read. To explore the idea, a call for qualifications was issued on January 2003 by Hablamos Juntos to find a consultant to help explore the use of symbols in health care signage. JRC Design , a design firm located in Scottsdale Arizona, was commissioned to prepare a white paper on the feasibility of using symbols for health care wayfinding, including recommendations for future steps. The conclusion of the white paper was not only that symbols were a viable option for wayfinding in health care, but that a set of tested symbols, publicly available, would give designers and health facilities a much-needed alternative. The report entitled Symbol Usage in Health Care Settings for People with Limited English Proficiency Part 1: Evaluation of Use of Symbol Graphics in Medical Settings was completed in April 2003. The history and usage of visual symbols as communication tools in health care settings around the world is examined and several symbols developed for health care environments are also included. None of the health symbols found, except those from a project in Australia, were tested for public recognition and comprehension. A companion report Part 2: Implementation Recommendations provided suggestions for developing a set of tested symbols for use in health care environments.
How were the symbols developed?
The testing that was conducted to develop the set of 28 universal health care symbols is one of the most comprehensive symbols design efforts ever undertaken. The multi-step process began with the selection of referents for the project. This was accomplished with a terminology survey designed to identifying the 30 most common destinations in health facilities. A team of seven graphic designers from around the country then worked with a symbols testing consultant to design and test candidate symbols using a testing method recommended by the International Organization for Standardization (ISO). See Project's Who's Who to learn about the Design Team.
Three hundred participants from four language groups: English, Spanish, Indo-European and Asian languages provided input on the comprehension value of candidate symbols. Seventeen of the 28 symbols could be understood by at least 87% of the multilingual participants.
To compare the new symbols to typical word signage, the Society for Environmental Graphic Design (SEGD) worked with a wayfinding consultant to pilot test the symbols in the wayfinding systems of four hospitals across the country. The results were impressive:
- More than 75% of people who were tested felt that the symbols were more effective than text - symbols were easier to see and understand, and preferred even by those that could read English
- More than 80% of hospital staff interviewed felt that symbols would ease the process of giving directions to patients and visitors
The research team also found that symbols were flexible and simple to implement in a variety of health care environments, including those with complex wayfinding programs using signs, print materials and internet features like informational kiosks.
The steps taken to develop the universal symbols are briefly described below. For more details on any aspect of the project go to the Archive section of this website.
Step 1: Referent Selection
The first step was to identify the top 30 referents most often used in health facilities. A survey, developed from an inventory of existing signage in health facilities located in Hablamos Juntos demonstration sites, with over 220 health care terms was used. The results of this survey led to the 28 referents for which symbols were developed.
The terminology survey (Health Care Facility Signage survey) was disseminated to health care facilities in the demonstration sites. Up to ten people, in each facility were asked to prioritize destinations in order of importance for their users. The survey was aimed at persons who frequently interact with visitors and patients to provide direction, or those who understood visitor/patient traffic patterns in their facilities such as information booth staff or volunteers, customer service representatives, discharge planning or social work staff, admitting staff managers, director/chief/head nurses and medical officers or physicians. The highest priority terms became the referents for the project. To see a sample of the survey for Round 1 click here. See Archive for more details.
Step 2: Symbol Design and Testing top
Public information symbols used on signs to help patients and visitors navigate in health care facilities have rarely been evaluated from the user’s perspective. Important component of this project are the method used to test symbols and the recruitment of multilingual participants to provide input on candidate symbols . The over-arching goal was to develop symbols that would be effective for the broadest possible group of people. This meant avoiding cultural taboos or relying on visual clues that were strictly American or Western in nature. It also meant testing the symbols with people of various cultures and ethnic backgrounds. Finally, it meant letting these people, through the results of an iterative testing process, influence the selection of the final symbols to be included in the final set.
The design team, consisting of graphic designers experienced in symbol design, met in August 2004 in the first of three Charettes, to review and collect symbols that best represented each referent. Symbols developed through this Charette were use in the first round of comprehension estimate surveys. Results from each round of comprehensibility surveys were used to guide the redesign/refinement of new symbols and to determine the final set of the health care symbols developed through this project. A total of 600 symbols were collected or created for the project.
Symbol Survey - Comprehensibility Estimation Testing
The International Organization for Standardization (ISO) recommends Comprehension Estimate testing to test public information symbol. In this project the comprehension estimate survey instrument, with 28 open-ended questions with 100-180 unique symbols (five to six symbols per referent) was used in three rounds of testing. The research question asked for each referent was “Which public information symbols for this referent is the most meaningful to users of health care facilities?”, meaning that they serve to cross language boundaries, for the user populations in the regions surveyed. For each of the 28 referents in the study, respondents were presented with 5-6 symbols. They were then asked to assign a number to each symbol representing the percent of the U.S. population that speaks their language who they think would understand a given symbol to mean a given referent. When asked through an interpreter, the question was modified to ask about “people who speak your language”.
As an example of the survey design; these circles show the symbols that were tested for the referent “Chapel” in the three rounds of testing. The first circle was used in the first round, the second in the second round and so on. To see a sample of the survey for Round 1, click here. To learn more on the testing process see the Technical Report.
Candidate symbols were tested for their comprehensibility with participants from four language groups: English, Spanish, Indo-European and Asian language. The locations of the Hablamos Juntos demonstration sites created a natural opportunity to gather a national sample of health care facility users in ten different states. Hablamos Juntos site leaders designated a survey administrator and recruited volunteers from limited English-speaking populations. This provided, for each round of testing, a non-probability convenience sample of approximately 100 accessible and cooperative adult patients or visitors who speak a variety of languages. In many cases, interpreters assisted respondents to complete the survey.
Selecting the Final Symbol Set
Designing symbols to represent objects, a procedure, complex action or to show interaction between people is more challenging than creating an image to represent an object. The team learned this early on when to their surprise they learned that many of the symbols they created for the survey did not test well in the first round. The gap between what designers and survey participants thought would work was reinforced when symbols that were rated less than 79 did not show any significant improvement in the second round. After all the testing was completed, 17 referents had at least one symbol meeting the threshold (greater than 87) from which to establish a final set, and 11 referents with no symbol reaching the required threshold.
The team met in July for a two-day final charrette in Chicago to select the final symbols set. Survey results determined the final symbols for the seventeen referents with symbols meeting the testing threshold. These images were refined to maintain consistency in figure sizes, weights, borders and to achieve a balance among the symbols as a set. When two or more symbols for a referent tested within a few points of each other, the team selected the symbol that best supported congruence in the set overall.
For the eleven referents with low scoring symbols, the design team identified elements of the image content which seemed to be present in the higher rated symbols. Symbols for these 11 referents were selected, refined or further developed based upon the lessons learned through all phases of testing. For some referents, where all symbols tested scored poorly, the refinements resulted in entirely new symbols. In this final phase, new symbols were not tested in their final design iterations.
Step 3: Pilot Testing top
To compare the new symbols to more traditional word signage, final symbol candidates were tested in the wayfinding systems in four hospitals across the country: Somerville Hospital in Massachusetts; Saint Francis Medical Center in Grand Island, Nebraska; Grady Memorial Hospital in Atlanta; and Kaiser Permanente in San Francisco. Pilot testing also helped to learn how the tested symbols can be used effectively in health facilities.
Pilot site testing took place from April through May. A symbol/referent matching test was administered to visitors and use of collateral material, such as maps and printed materials was also tested. In focus groups, staff offered insights about their current signage system and made recommendations about the use of symbols in wayfinding.
The participants – visitors and patients in the pilot site facilities – had language proficiency ranging from little or no English (an interpreter gave instructions to these participants) to sufficient English to take the test on their own. The participants were of four language groups: English, Spanish, Indo-European and Asian. Tested languages from the latter two groups varied according to the demographics of the site area and included Creole, Nuer, Hindi, Amharic, Portuguese, Loatian, Mandarin, Cantonese and Vietnamese. Besides completing the matching test, these participants were also timed in finding six destinations on the site - four with symbols signage and two with traditional work signage.
The development of a cohesive symbol system, particularly for health care, is a controversial undertaking in the design world. The paramount goal was to create a symbol set that was simple, uniform, distinctive and clearly understood that could be used in health care wayfinding systems. The symbols had to have a graphic clarity and credibility in design to make others want to use them. Using well established symbol testing methods recommended by the ISO and extensive iterative testing (which included pilot testing in hospitals across the country) makes this one of the most comprehensive symbols design efforts ever undertaken.
In the end, this work confirmed that a thoughtful and well-designed symbol system can assist English speakers as well as people from many languages and cultures. Symbols are not the panacea for a poor signage system, nor will they alone solve wayfinding issues. However, they can be a part of a viable and dynamic system to assist all people, regardless of their reading skill level, to feel more comfortable and confident within a health care facility.
The full potential of these symbols, including their usability and effectiveness in wayfinding, will be determined through implementation in real-world health care environments. This will require more than just adding these new symbols to existing signs. It will take systems designed with openness to what visitors need for wayfinding, where symbols are a part of more comprehensive solutions. In the long term, the investment of time and money should be recouped when less time, money and energy is required to physically guide people, public and staff alike, through the site.
To help facilities implement these symbols, a workbook with best practices is available on this website. The suggested practices were drawn from best practices in other fields, such as airports, parks and cities, and lessons learned in the hospital pilot sites. Because air travelers, park visitors and pedestrians in cities are different from visitors of health facilities, more work is needed to develop best practices for health care environments. SEGD is committed to helping build practices more suitable for health environments and will continue to disseminate achievements in health facilities among its designer constituency.
Universal Symbols In Health Care Workbook, Best Practices for Sign Systems. This workbook is for health and hospital administrators, facilities managers, architects and designers of wayfinding systems. It covers the importance of universal symbols, the benefits they provide to hospitals and healthcare facilities and offers practical suggestions for implementation taken from best practices in other fields that effectively use symbols as part of their wayfinding systems.
Symbol Usage In Health Care Settings for People with Limited English Proficiency - Part Three Symbols Design Technical Report. This report describes details of developing and testing health care symbols and includes tools used in the process.
Symbol Usage in Health Care Settings for People with Limited English Proficiency - Part One: Evaluation Of Use Of Symbol Graphics In Medical Settings. This is a white paper with a brief review of symbols use that looks at the feasibility of using symbols in health care. The report finds evidence of health care symbol development and use in a variety of countries, include the United States, and concludes that not only are symbols viable for health care signage, but that a set of tested health care symbols would give designers an alternative beyond multilingual signs.
Symbol Usage in Health Care Settings for People with Limited English Proficiency - Part Two: Implementation Recommendations. Part two makes suggestions for developing a set of universal symbols.
1 ISO Bulletin December 2001. Graphical Symbols
2 U.S. Census (October 2003) Language Use and English-Speaking Ability: 2000. Census 2000 Brief