Estructura de la capacitación integral para los docentes

The following is a description of the factors that were considered in the design of the gist leaflet. Versions of the leaflet can be found in studies 2, 3 and 4.

5.1.3.1 Numerical information

As discussed above, there is evidence to suggest that attempts to encourage further understanding of risk information through the provision of numbers may be misguided. The empirical evidence to support the provision of numerical information for improving medical decision-making is scarce. Furthermore, it is possible that the provision of excessive numerical information can ‘hurt rather than help’ this process (Hibbard & Peters, 2003; Peters et al., 2007, 2013; Reyna & Brainerd, 1991; Schwartz, 2011; Zikmund-Fisher et al., 2010). Specifically, in a CRC screening context it has been shown to increase the prevalence of negative attitudes about CRC screening (Miles, Rodrigues, & Sevdalis, in press). At the same time, it is important that information is not so oversimplified that it is no longer accurate or fails to enable people to make an informed decision about screening (Ramirez & Forbes, 2012). Concerns that simplifying health information might disadvantage certain

groups are alleviated by the finding that low literacy messages can improve knowledge even among more educated samples (S. W. Smith et al., 2013).

To overcome difficulties with processing numerical information, I attempted to encourage gist-based processing by providing a verbal description of the number which provides an evaluative label (i.e. gist) of the number (e.g. ‘most people [98 out of 100]’). This approach has been used successfully in previous research (Berry & Hochhauser, 2006; Knapp, Gardner, Raynor, Woolf, & McMillan, 2010; Zikmund- Fisher, Fagerlin, Keeton, & Ubel, 2007). Broadly, findings indicate that comprehension of the information is improved, particularly for people with low numeracy (Peters et al., 2009). Furthermore, the same study suggested evaluative categories can increase deliberative processing of the numerical information. Numerical descriptors may also increase perceptions of risk, and as a result be more effective at altering behaviour than numerical information is isolation (Zikmund-Fisher et al., 2007). In line with current evidence, natural frequencies with the same denominator were used to present key numerical information (Galesic & Garcia-Retamero, 2010).

5.1.3.2 Reduction of concepts

In keeping ith the ‘less-is-more’ approach, the leaflet was designed to encourage gist-based processing by removing specific concepts which were deemed ambiguous in the think-aloud study (Chapter 4). This resulted in four pages of text being used for the gist leaflet, compared ith 15 pages in ‘The Facts’ booklet. An example of information that was streamlined was the role of FOB screening in preventing CRC (by removing polyps detected at follow-up colonoscopy). This was justified because of the unconvincing evidence that FOB-based screening reduces CRC incidence (Scholefield et al., 2012). The leaflet therefore focused on the primary mechanism by which FOB screening works; the early detection of colorectal adenomas. A further example of streamlining was the removal of academic references from within the text to accommodate the preferences of people with low health literacy (S. K. Smith et al., 2008).

After consultation with the expert panel, a decision was reached to remove any mention of ‘unclear’ results. This decision as made as it as considered confusing to the reader in the think-aloud study, without any additional benefit by its inclusion.

Its removal also fits with providing information in the most simple gist format (i.e. nominal), without overlapping categories (Reyna, 2008).

5.1.3.3 Navigation

Guidelines on the layout of health information designed for groups with low health literacy suggest providing essential information at the beginning of the text (McCaffery et al., 2012). This has been shown to improve comprehension and decision-making (Peters et al., 2007). To identify what was considered to be essential information, I searched the relevant literature to identify aspects of screening that are considered essential to make an informed decision (General Medical Council, 2008; S. K. Smith, et al., 2012). Interviews with the SSPs were also important to this process.

Information that was deemed essential to making a screening decision was presented on the front page. This included: i) the prevalence of the cancer; ii) how the test works iii) the efficacy of the test and iv) who is invited. To avoid the front page becoming too dense with information, additional essential information that could not be explained succinctly (i.e. in a single sentence) was contained in subsequent pages. This information included: i) the disadvantages of screening; ii) the possible outcomes iii) practical aspects of screening and iv) where more information can be found.

After providing the essential information on page 1, we aimed to improve the navigability of the information by providing ‘sign-posting’ to direct the reader to the location in the leaflet where more detailed information could be found (i.e. pages 2 and 3) (Dickinson, Raynor, & Duman, 2001). Page 4 as devoted to ‘sign-post’ other information sources (i.e. Bowel Cancer Screening: The Facts). As such, the booklet was designed to be a cascade of information formats ranging from the simplest gist-based information through to more detailed information for those that wanted it.

5.1.3.4 Language

Health literacy, EU and NHS guidelines suggest vernacular rather than formal language should be used where possible in cancer communication materials (Austoker et al., 2012; DeWalt et al., 2010; Plain English Campaign, 2011; Ramirez

& Forbes, 2012) (see Table 5-3 for examples that were implemented here). The use of words with multiple definitions (e.g. spot) may be confusing for the reader. However, this was accounted for by testing the comprehensibility of the leaflet (study 2). These guidelines also recommend that information should be written in short sentences and bullet point lists. Evidence from cognitive psychology suggests this reduces the cognitive burden of information by enabling participants to ‘chunk’ information and retain more in short-term memory (Wilson et al., 2010; Wolf et al., 2009). This is particularly important for people with poor basic skills due to the strong association between health literacy and cognitive ability (Wolf et al., 2012). Importantly, reducing the cognitive burden of information can increase subsequent recall and this is apparent for all health literacy groups (Freed et al., 2013).

Table 5-3 Comparison between formal and vernacular language

Word used in ‘The Facts’ Vernacular equivalent

Colorectal Bowel

Detect Spot

Faeces/waste matter/stool/bowel motions Poo

Colonoscopy Further testing

Reduces Lowers

5.1.3.5 Aesthetic appeal

The EU guidelines suggest that information materials should be appealing to the recipient (Austoker et al., 2012). The aim of this is to encourage engagement and processing of the information, and reduce immediate defensive reactions such as avoidance. In response to the guidelines, a blue background was used because experimental evidence has demonstrated that it invokes a lower disgust response (Curtis, Aunger, & Rabie, 2004), a frequently cited barrier to CRC and CRC screening participation (Chapple et al., 2008; Dolan et al., 2004; Reynolds et al., 2013; von Wagner et al., 2012).

Conclusion

In conclusion, this project is among the first to use empirical evidence behind FTT to create new health information. Mindful of the constraints of the National Health

Service Bowel Cancer Screening Programme (NHS BCSP) and the movement towards informed decision-making in healthcare, I demonstrated how gist-based information could be operationalised within the constraints of an organised healthcare system. This approach was deemed feasible by a multidisciplinary group of experts, including SSPs working in the programme and hub directors. The process was iterative and included multiple face-to-face meetings, e-mail contact and telephone calls with collaborators.

At all stages of the process, the latest empirical evidence from the fields of information design, cognitive psychology and health literacy were incorporated to create the gist leaflet. The information was largely based on ‘The Facts’ booklet, and did not provide any additional information beyond this. However, only essential information was used and presented to accommodate preference for gist-based processing. Care was taken to ensure that the leaflet met principles of IDM.

A strength of the design process was the involvement of academics and clinicians from a wide range of disciplines. Lay involvement was provided by two members of the public who were present at the advisory group meeting and they were named as collaborators on the NIHR Programme grant in which the project is based. Although this process used appropriate guidelines, the judgments regarding the design and content were largely made by me and the research team. To address this limitation, the leaflet must be evaluated to ensure it is readable, comprehensible and effective at communicating its message (Garner et al., 2012).

Chapter 6. Evaluating the readability and comprehensibility