Communication Research Behind the #knowyourlemons Campaign

 
 

Whether you are a doctor in a clinic, a public health director or an activist looking for creative ways to educate those around you about breast cancer, our education campaign is designed for everyone.

We are aware, but we are not educated

Only two in five people (42%) are confident about recognising the changes to their breasts that could be a sign of cancer, according to a new survey of 19,000 respondents by Avon Products, Inc.

The survey also found despite 73% of respondents saying they look out for changes to the appearance of their breasts, many report that they aren't confident recognising the early signs of breast cancer. A quarter (25%) think that a lump is the only sign of breast cancer that can be identified without medical equipment.  When asked to identify 10 common symptoms of breast cancer, only 2% managed to select all 10 correctly.

We found similar problems as we developed our materials. We conducted a survey asking a simple question, "What does a cancerous lump feel like?" Only 49% could give a correct answer (n=255).

That makes it pretty difficult to do a self-exam if you don't know what you are feeling for.

But for those that saw our materials, knowledge greatly improved:

Want to dive into the research? Take a look at the PhD Thesis that started this campaign, from the British Library online archive. 

Want to dive into the research? Take a look at the PhD Thesis that started this campaign, from the British Library online archive

Self-Exam Survey

In a survey of 80 women, our initial findings are:

  • 4% self-exam regularly
  • 71% feel guilty for not doing it more often
  • 44% wish they understood self-exams better

The takeaway from this is that we need to find a better approach to self-exams. It should be a quick and simple part of our health routine, but we tend to forget about it. Yet 39% of us are the ones to discover a symptom, so it's not something to let fall off our radar completely.

So what are the 3 barriers to breast cancer education?

We have the only global breast cancer education campaign, knowyourlemons.com, that works across barriers of literacy, taboo and fear around the world.

 

CHALLENGE #1: LITERACY

Most health messages are still communicated through text, often using medical terminology that challenges even the educated patient. In the USA, it’s estimated that 1 in 5 patients have low literacy. On a global scale, literacy is a much bigger problem. To save lives, we need to be able to communicate beyond text.

 

CHALLENGE #2: TABOO

Because breasts are usually associated with sex, images of them are often censored in public. This makes it difficult to “show” breast cancer to a large audience, especially in certain cultures or settings. To save lives and reach more people, we need to show breasts in a way that can be displayed in public.

 

CHALLENGE #3: FEAR

Talking about cancer can be scary. Some just don’t want to talk about it. Fear of the unknown can also stop women from telling someone about a symptom during a stage when it can be treated. In developing countries, more than half of women diagnosed with breast cancer are diagnosed as terminal, compared to just 10% in developed countries. To save lives, we need to approach the topic in a more friendly and familiar way.

 

SO HOW DO THE LEMONS WORK SO WELL?

 

Separate the tie between   breasts = sex  +   cancer = death
by using a more family-friendly visual substitute.

 

Explain what a cancerous lump can feel like
by using an object they have already felt.

 

 

Visualize the steps of diagnosis, in such a way that they can picture themselves in the detection process.

How do patients know what to expect if there’s no road map to see the way ahead?

 

A new way to educate without censorship or embarrassment

Breast cancer is associated with some pretty strong taboos that can make a public campaign difficult. First, “breast” is often associated with sex, and displaying images of breasts can be a problem. Second, “cancer” is often associated with death, making it a topic that for many is difficult to talk about, leaving many people avoiding it altogether. These materials remove the “sex” and “death” from the message of breast cancer through using a visual metaphor of a lemon to represent the breast. Because it is similar in appearance but separate from the body, it can be a powerful tool for illustrating signs of breast cancer in a very specific way, while avoiding censorship. This is a completely new way of educating the public about breast cancer, that makes it possible to reach more people than ever before. It also reaches those who may have difficulties with reading or are embarrassed about the topic.

So how does one show something that can’t be displayed in public? Simple! Find a friendly, familiar substitute—the lemon.

More than just a friendly looking fruit, lemons resemble the shape of a breast on the outside and resemble the anatomy of a breast on the inside. And amazingly, a cancerous lump often feels hard and immovable—just like a lemon seed. Have a look at just how similar it is in the image below:

 

 
 

Why visuals are critical in educational materials

Words are usually the way that the public is educated about health messages. However, this is a problem for a few reasons:

  • It’s estimated that 1 in 5 patients have literacy issues (1), making reading difficult.
  • Most wordy educational materials are never read (Beaumont PhD, p. 249).
  • The information is in one language which is a problem for educating multicultural audiences.

Images can communicate to people of any language, are more engaging and can communicate information in a specific way that words cannot (imagine navigating a new town without a map, or building a house without blueprints). However, getting the right image can be difficult. And when most health materials are developed without designers, with limited budgets and lack of time, words are the easier way of communicating. In fact, in a review of over 100 breast cancer detection materials and websites, less than 10% of them used educational images at all. Despite this, 89% of patients prefer visual materials to non-graphic material.

The only materials that tell the whole story

In a comprehensive review of breast cancer detection materials in print and online, no single resource provided all of the key information necessary for a patient to be fully aware of the detection process. Information like, “What does a lump feel like?” “What does breast cancer look like?” “What steps do I take to detect breast cancer?” were often not answered. By testing the message and materials with patients, it was possible to create a simple two-page leaflet that delivered these key messages in a single resource in a powerful and memorable way. The only one of its kind. Get the leaflet here.

 

Tested with hundreds of patients 

Most health materials are rarely tested with their audiences to determine if they work before the money is spent on printing. To make sure that the these Worldwide Breast Cancer materials were done right, several studies were done to get the visuals and the messages just right. Here are some results from those studies.

Designing began by doing a general survey of the public, to find where the gaps in education were and what the materials needed to inform the public about. Over 200 people took part in this survey.

It was found that half of patients didn’t know what a cancerous lump felt like. So a poster illustrating what the anatomy of a breast felt like was designed. This poster was tested alongside a traditional line drawing of anatomy which was common in education materials. The results were dramatic:

Interestingly, most people didn’t read the text in the second poster. Their knowledge was based mostly on looking at the images.

“Does seeing breast anatomy in this visual way improve your understanding
of what to feel for when you are doing a breast self-exam?”

97% said yes.
65% said it also made them feel more confident in their ability to recognize breast cancer.

It was also discovered that many people didn’t know that breast cancer could be presented in other ways besides a lump. A poster was designed to illustrate these signs. One study with 67 people looked at how accurately they could interpret the symptoms without any text. This would determine if this poster could communicate to more people across the world despite language differences.

Early version of the image was tested without text labels. This showed which visuals were dependent on text descriptions and images were modified.

Early version of the image was tested without text labels. This showed which visuals were dependent on text descriptions and images were modified.

 

Testing revealed that people could identify most of the signs by appearance alone. This led to improvements in the appearance of the images to increase their ability to communicate accurately. It also identified which symptoms needed a simple text label to help them interpret what they saw more accurately.

After improvements to the image were made, another patient group was used to test the text labels with the image, bringing the interpretation of the signs of breast cancer to near perfect levels, resulting in the finished poster:

“Would you be able to recognize these signs on yourself better now that you’ve seen this image?” 
89% said yes.

ANOTHER EARLY VERSION OF THE IMAGE (2011).

ANOTHER EARLY VERSION OF THE IMAGE (2011).

Help patients see the “big picture view” of their patient pathway

To understand the process of detection, the designer went through the full detection process herself. She acted as a patient in several clinics, got a mammogram, and interviewed several healthcare professionals in the US and UK in their environments to compare different systems. This was done to understand how to communicate the process to patients in a way that was simple yet specific enough to help patients participate in the process and catch errors when certain steps or options weren’t offered.

An example of this is demonstrated in the design of a patient pathway chart below, with the top one using text and lines, and the bottom one using images of people in a simple step-by-step view:

By illustrating the steps of breast cancer detection as a series of interactions with people and results, it provides the patient with a “big picture” view of the whole process. This helps them understand where they currently are in the process and the options that are available to them. When patients clearly understand the detection journey, they are more likely to participate in it and anxiety over the unknown in reduced—all through the help of good design!

 

A figure that most women can relate to

The woman figure, known as “The Mayor”, used to illustrate breast cancer events and act as a source of the friendly, approachable voice in the materials, is a unique concept and contribution in breast cancer detection materials to date. The Mayor has been found to be a relatable female image for most patients spanning across a range of nationalities as the campaign as been used in over 70 countries. When people were asked, “Could this woman be seen as someone from you country?” 98% of respondents, representing countries such as Columbia, USA, Britain, South Africa and the Middle East, said yes.

When tested with women in Qatar, one participate wrote: “I love the idea that the woman has no features and black hair, which could make her Indian, Pakistani, Asian or Arab.”

So why is this important? Often in materials, a woman is needed to illustrate a breast cancer event, such as getting a mammogram. If the materials are to be used in a variety of countries, it’s important for the reader to feel that the woman standing at the mammography machine is representing her, instead of representing a foreigner. If a patient makes a connection with the woman in the materials, they are more likely to visualize themselves participating in screening and seeing the information as being relevant to them, in their time. Here is an example of why using an illustrated figure is a benefit over using photographs:

 

Turn patient exams into teaching moments

These materials are designed to promote collaboration between patient and physician. Through using these materials developed by Worldwide Breast Cancer in the health environment, patient–physician encounters can become teaching moments as well as diagnostic events. In particular, the risk assessment form allows a physician and patient to understand their risk while at the same time developing a screening plan. A copy can then be made for the patient chart that records the patient’s risk level and screening plan. The other copy is for the patient to take home as a reminder of that conversation.

Health practitioners can use these materials in each point of the patient journey to increase the effectiveness of screening and diagnostic events. Worldwide Breast Cancer makes it easy to improve the patient experience through well-designed information. Learn how to get the materials here.

 

Still curious why we don't use breasts? Take a look here, but be warned, it's a graphic image.