Patient Education and Counseling 63 (2006) 328–335 www.elsevier.com/locate/pateducou The impact of illustrations on public understanding of the aim of cancer screening Hannah Brotherstone a, Anne Miles a,*, Kathryn A. Robb a, Wendy Atkin b, Jane Wardle a a Health Behaviour Unit, Department of Epidemiology and Public Health, University College London, London WC1E 6BT, UK b Colorectal Cancer Unit, St Mark’s Hospital, UK Received 17 January 2006; received in revised form 13 March 2006; accepted 27 March 2006 Abstract Objective: To study the effectiveness of visual illustrations in improving people’s understanding of the preventive aim of flexible sigmoidoscopy (FS) screening. Methods: Three-hundred and eighteen people aged 60–64 were offered an appointment to attend FS screening and randomly allocated to receive either written information alone or written information plus illustrations. The illustrations showed the adenoma–carcinoma sequence and how it can be interrupted by removing polyps found during FS. Telephone interviews were conducted with a randomly selected sub-set of people prior to their screening appointment to assess their knowledge and understanding of the test (n = 65). The interviews were tape- recorded, transcribed and content analysed by researchers blind to the condition people had been allocated to. Results: In the written information only group, 57% understood that the test was looking for polyps rather than just cancer, whilst in the group who received written information and illustrations, 84% understood this. Logistic regression analyses confirmed that addition of illustrations resulted in significantly better understanding (OR = 3.75; CI: 1.16–12.09; p = 0.027), and this remained significant controlling for age, gender and Townsend scores (an area-based measure of deprivation) (OR = 10.85; CI: 1.72–68.43; p = 0.01). Conclusion: Illustrations improved understanding of the preventive aim of FS screening. Practice implications: Pictoral illustrations could be used to facilitate patient understanding of screening. # 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Screening; Colorectal; Illustrations; Comprehension; Recall; Patient education; Pictures 1. Introduction screening that need to be conveyed; one of which is that some types of cancer screening (e.g. cervical screening) do Informed decision-making about cancer screening more than identify cancer early; they can actually prevent it requires people to understand its potential costs and benefits. by detecting and removing pre-cancerous lesions. Recent evidence indicates that the public overestimate the The limited evidence available indicates that the concept benefits of screening and are largely unaware of its short- of a pre-cancerous lesion is poorly understood. Knowledge comings or potential for adverse effects [1,2]. As a result, of pre-cancerous states for oral and cervical cancers is poor efforts to promote informed decision-making have concen- [5–7], and the terms ‘pre-cancer’ and ‘cancer’ are often trated on providing information to clarify the limitations of assumed to be synonymous. Although cervical screening is screening [3,4]. However, there are positive aspects of well-established in Britain, a survey of first time attenders at a colposcopy clinic for the treatment of cervical abnorm- alities found that 10% of women thought an abnormal smear * Corresponding author at: Health Behaviour Unit, Department of Epi- demiology and Public Health, University College London, Gower Street, meant early-stage cancer [7]. London WC1E 6BT, UK. Tel.: +44 20 7679 1749; fax: +44 20 7813 2848. Like cervical screening, flexible sigmoidoscopy (FS) E-mail address: [email protected] (A. Miles). screening has the potential to prevent cancer by detecting 0738-3991/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2006.03.016 H. Brotherstone et al. / Patient Education and Counseling 63 (2006) 328–335 329 and removing the pre-cancerous lesions (adenomatous The leaflet was based on materials that had been polyps), and thereby interrupting the ademoma–carcinoma extensively piloted and were used in the UK FS Trial sequence [8]. Few people are likely to be aware that colorectal [19]. It contained comprehensive information about FS cancer can be prevented through screening because knowl- screening including risk factors for bowel (colorectal) edge of this type of cancer is poor [9,10]. This is important in cancer, how screening works, what the test involves, what the UK, because colorectal cancer screening will be offered as happens if pre-cancers are found, whether there are risks part of the nationwide screening program from 2006, and associated with having the test, and the reliability of the test. effective ways of informing all sectors of the community The leaflet also explained that bowel cancer developed from about screening need to be developed. benign polyps, and that the screening tests aimed to detect Written leaflets are often used to convey the benefits and and remove polyps and therefore prevent the development of harms of screening, but they have limitations. People may cancer. The illustrations represented the polyp-cancer not be attracted to written materials, some will find the process and the removal of polyps. The text accompanying content difficult to understand either because of the use of the illustrations also repeated the name used for the test technical language in the document or their own literacy (Flexi-Scope) and the fact that a nurse would be conducting level, and the material may be hard to remember. the procedure. The link between colorectal cancer devel- Surprisingly, simplifying written information has been opment and increasing age was also emphasized because the found to be more beneficial to good readers than poor illustrations showed polyps developing in a 50–60 year old. readers [11]. One possible alternative approach is to use We predicted that people sent the illustrations would have illustrations to supplement the text. Research into the value a better understanding of the preventive aim of FS screening, of illustrations in enhancing health communications has be more likely to remember the name of the test and that it been scant, but a recent review [12] concluded that visual would be carried out by a nurse, and be more likely to displays of information alongside text can make a useful mention older age as a risk factor. No specific predictions contribution. Illustrations make written information more were made about whether the illustrations would improve attractive [13,14], and increase the likelihood that the text knowledge of the material contained only in the written will be read [15], understood [14] and remembered [15,16]. leaflet. Data on attendance at screening were collected from Illustrations may be particularly beneficial for people with the screening centre, but the study was not designed or low levels of literacy who are both least knowledgeable powered to examine screening attendance and the primary about cancer [17] and least likely to benefit from written outcome was awareness of the preventive aim of FS information. There is also evidence that illustrations screening. improve comprehension more among people with lower A sample of 123 of the 318 people to whom the literacy or fewer years of education [14,18]. information was sent were selected at random for a We hypothesized that visual illustrations of the devel- telephone interview within two to four weeks of the opment of adenomas and their removal during FS screening information materials being sent out. The interviewer would clarify written information and help people under- explained that because FS screening was new to Britain, stand that FS is intended to prevent colorectal cancer. The we wanted to understand what people thought about it, and present study compared people’s understanding of the what they thought of the information materials that they had preventive aim of FS screening following written material been sent. Respondents were asked if they were willing to be alone or written material accompanied with illustrations. interviewed and permission was sought to record the interview with assurances that the information collected would be confidential. 2. Methods 2.2. The interview 2.1. Participants and procedures The interviewer asked first if the respondent had received Three-hundred and eighteen people, aged 60–64, any information about bowel screening and whether they registered at GP practices in Harrow (London, UK), and remembered anything about it. This was followed by eight eligible for screening (e.g. had not had an endoscopic bowel questions, five of which related to the screening procedure investigation in the last 2 years) were invited to participate in (do you remember what the test is looking for, how long the an ongoing feasibility study into population-based FS test takes, how often people need to have the test, who screening, and were sent a timed, dated screening performs the test, and the name of the test). Three questions appointment. They were randomized either to be sent a were about bowel cancer (whether it is common, and written leaflet alone (n = 151) or a written leaflet along with whether age and gender are associated with increased a set of illustrations showing the development of cancer from likelihood of getting the disease). polyps and removal of polyps during flexible sigmoidoscopy The interviews were recorded and transcribed, and coded (n = 167). The illustrations are shown in Fig. 1 and the by two independent raters who were blind to condition written information leaflet in Appendix A. (leaflet only or leaflet and illustrations). The raters began by 330 H. Brotherstone et al. / Patient Education and Counseling 63 (2006) 328–335 Fig. 1. Illustrations showing the adenoma-carcinoma sequence and how flexible sigmoidoscopy screening can prevent cancer through ‘polyp’ removal. examining five transcripts to gauge the range of response polyps can be benign and develop into cancer. Some options to the question about the aim of the test. The examples are given in Table 1.