Lung cancer is now widely recognized as a serious global threat to human life and health, which is the leading cause of cancer death for many years. The age-standardized 5-year relative survival rate of lung cancer in China increased slightly from 2003 to 2015 but did not exceed 20.0%. However, studies have confirmed that early surgical intervention for lung cancer can achieve a 5-year survival rate of more than 90%. Since the survival time of lung cancer patients is closely related to the timing of clinical treatment, lung cancer screening has increasingly become an important means to prevent lung cancer.
Recently, low-dose computerized tomography (LDCT), which is characterized by its reasonable price and high accessibility, has been used as the main method in lung cancer screening.[5,6] During this process, a class of lesions that radiographically present as ground-glass opacities (GGOs) have increasingly been found. In 1989, Gamsu et al. were the first to describe such increased-density lesions as ground-glass attenuation on lung high-resolution CT. Many studies have shown that GGOs can be an early stage of lung cancer.[9,10]
With the growing understanding of GGOs, recent studies have shown that the standardized management of the early detection of GGOs, such as through more rigorous follow-up and selective surgery, can offer benefits for patients.[11,12] The 5-year survival rate for pure GGOs after surgical treatment has approached 100%. Now, with the gradual popularization of lung cancer screening, the positive rate of GGOs in China has skyrocketed. For some people, it is possible that if they were not screened, they might not have been diagnosed with cancer in their lifetimes, which reduces public cooperation in screening. These contradictions, to a large extent, indicate that the public still lacks a scientific and reasonable understanding of the treatment strategies for GGOs (such as follow-up or surgery), which greatly exacerbates the anxiety of public about personal health. Therefore, it is urgent to improve the public’s health awareness and reduce the fear of the emergence of GGOs through positive health communication.
Health communication is defined as communication methods and strategies used to inform individuals abouthealth care facts and best practices, with the aim of improving patient health outcomes and enriching personal and community behaviors and public health practices.[17,18] Research on health communication combines post-positivism with social psychology and aims to explore the relationship among information, cognition, attitude, and behavior by constructing variables. Publicity measures for screening lung cancer can be adjusted by examining the effects of different forms of persuasion or dissemination of information.
To study this interaction, an approach based on eye-movement data was used to capture the intrinsic cognitive processes underlying reading. It was reported that different types of information materials may trigger different reading responses and thus lead to different cognitive responses. Characteristics such as the type and style of information can be reflected in the eye movement patterns of individuals when reading these materials. Thus, the eye-tracking experiment is an effective method that has been used in neuroscience and psychology research. The development of eye-tracking devices, it have been successfully combined with mathematical models to provide an objective assessment of where an individual’s gaze fixates on an image.[23,24]
According to different information modalities, we established 3 forms of medical education in this study: text, graphic, and video materials. A modality refers to the way that human beings interact with the external environment (such as people, machines, objects, and animals) through their senses (such as vision and hearing). If two or more modalities are involved in an interactive activity, the information presented is called multimodal information. Video is a typical multimodal material, while text and graphic materials belong to unimodal media. Each kind of media is unique in its ability to convey certain information content, so the appropriateness of the selected media has an important impact on the effect of health communication. Therefore, we should explore which media model can better transmit health information to improve health awareness. In addition, the vulnerability of transmission targets is identified to make public health interventions.
This study designed unimodal (text and graph) and multimodal (video) materials about GGO-related knowledge. Furthermore, to objectively identify the factors that affect the quality of health education, we recorded participants’ visual information through an eye-tracking system. With these data and the results of a knowledge test about lung cancer, the aim was to find out a better propaganda and education plan for the popularization of information about GGO-related lung cancer screening.
MATERIALS AND METHODS
Volunteers were recruited at Beijing Jiaotong University. Participants had to have no relevant medical background and had to be able to fully cooperate throughout the entire trial process. Ethical approval was obtained from the ethics committee of Beijing Jiaotong University, and informed consent were obtained from all participants to publish details of this study. The first group of volunteers served as a control group and were tested on their lung cancer knowledge before receiving health education. In contrast, the second group of volunteers, as the experimental group, took the same knowledge test after receiving the health education. They were required to have corrected visual acuity above 1.0 and normal color vision, to be right-handed, and to meet the basic conditions of the eye-tracking experiment. It should be noted that all the subjects under 40 years old had a bachelor’s degree or above, and all the subjects over 40 years old had a middle school degree or below. According to the different information forms they were exposed to, the experimental group was further divided into text, graphic, and video groups. An eye-tracking system was performed to record eye-tracking data synchronously. Specifical experimental procedure of this study was shown in Supplementary Table S1.
In this study, there were 3 types of presentation, namely, text, graphic, and video materials, to test the comprehension effect of the subjects. The text and graph were considered unimodal information, while the video was multimodal information. All content for the 3 types of materials was focused on GGO-related expertise, as selected by three doctors of thoracic surgery. The text [Supplementary Figure S1] and graphic [Supplementary Figure S2] materials were further compiled and produced by our research group and were classified as unimodal media. The video material was a recording of a professor’s presentation of similar texts, images, and charts. And it was not captioned. A knowledge test about GGO-related lung cancer with a total of 7 questions was designed by three doctors.
Equipment and setting
The experiment was conducted in the laboratory of the School of Language and Communication, Beijing Jiaotong University, and it was completed in 3 working days. A Tobii Pro Spectrum screen-based eye-tracking camera (Tobii, Danderyd, Sweden) and Tobii Studio software (Tobii, Danderyd, Sweden) were installed on a laptop computer to collect eye-tracking data at a sampling of 1200 Hz. Another computer was also set up to show the display of the participant’s computer to allow the researchers to monitor the whole test. The light source in the room remained constant and suitable. The experimental room was in a windowless closed environment to minimize interference from the outside world.
SPSS 26.0 software was used for the statistical analysis of the data. Enumeration data are expressed as the number of cases and percentage. Measurement data are expressed as the mean and standard deviation. The skewness distribution data are expressed as the median. Furthermore, the inter-subject effect test and the posthoc multiple comparison tests were performed under Bonferroni correction. Besides, the Kruskal–Wallis test (nonparametric test) was performed for each group with different types of eye-tracking metrics. The posthoc multiple comparisons was performed using the Mann-Whitney U test. Spearman correlation analysis was conducted with eye movement data to examine awareness of the GGO survival rate in the different research groups. P <0.05 was considered statistically significant.
A total of 126 participants were enrolled in this study, including 71 males (56.35%) and 55 females (43.65%). There were 37 participants aged 20-39 years (39.37%), 79 participants aged 40-59 years (62.70%), and 10 participants over 60 years (7.94%). As shown in Supplementary Table S2, the data of the different groups were comparable, with no significant differences in age or sex among these 4 groups (P = 0.559).
Test scores for GGO-related lung cancer knowledge
After taking sufficient time to review the materials about GGO-related lung cancer, participants took a knowledge test with a total of 7 questions. The overall average score was 4.09 ± 1.76. The scores of the control group, text group, graphic group, and video group were 2.77 ± 1.14, 5.16 ± 1.11, 4.89 ± 1.45, and 4.88 ± 1.21, separately [Figure 1]. The data across groups met the homogeneity of variance (F (3,122) =1.373, P = 0.254). We tested the scores between the 4 groups using one-way ANOVA and found a significant difference (F (3,122) =44.845, P < .001). Further multiple comparisons between groups (Bonferroni correction) showed that the scores of each experimental group were significantly higher than those of the control group, while there was no significant difference among the 3 experimental groups (P > 0.05, Supplementary Table S3).
Correct rate for each question
The rates of correct answers for each question on the test are shown in Table 1. Only the correct rate of question 7, ‘What are the five-year survival rates for GGO-related early-stage lung cancer and stage III lung cancer, respectively?’ (hereafter referred to as the Cancer Survival Rate), was significantly different among the experimental groups (P = 0.038). Specifically, the Mann-Whitney U test showed that the correct rate of the graphic group was significantly higher than that of the video group (Z = -2.053, P = 0.040), but did not differ from the text group (Z = -0.610, P = 0.542). There was no significant difference in the accuracy of other questions among the experimental groups (P > 0.05).
Eye-tracking data in different groups
Information on fixations
The Kruskal–Wallis test (nonparametric) of 3 independent samples showed that there were significant differences in interval duration, total duration of whole fixations, the average duration of whole fixations, and a number of whole fixations (P < 0.001). Specifically, the interval duration, total duration of whole fixations, and a number of whole fixations of the graphic group were significantly lower than those of the other two groups by the Mann-Whitney U test (P < 0.05). In contrast, the video group had the highest values for these variables [Table 2].
Information on saccades
The Kruskal–Wallis test (nonparametric) showed that there were significant differences in the number of saccades, average peak velocity of saccades, and amplitude of saccades among the 3 groups (P < 0.001). The graphic group had the lowest average peak velocity of saccades, while the text group had the lowest average saccade amplitude. The video group had significantly higher speed and amplitude than the other two groups by the Mann-Whitney U test (P < 0.05) [Table 3].
Information on the first saccade
The Kruskal–Wallis test (nonparametric test) showed that the 3 groups had statistically significant differences in the time to the first saccade (P < 0.001) and direction of the first saccade (P = 0.046). Interestingly, the graphic group had significantly higher values for these variables than the other two groups by the Mann-Whitney U test (P < 0.05) [Table 4].
Correlation between different groups and accuracy of the cancer survival rate
To further explore the reasons for the differences in the knowledge of the cancer survival rate among the groups, we combined the eye-tracking data of each group and the Cancer Survival Rate accuracy to conduct A Spearman correlation analysis. The results showed that the minimum amplitude of saccades was negatively correlated with the Cancer Survival Rate accuracy in the video group (R = -0.385, P = 0.029). Notably, the number of saccades in the text group was negatively correlated with the correct rate for the cancer survival rate (R = -0.436, P = 0.029). Meanwhile, the time to the first saccade in the graphic group was negatively correlated with the correct rate for the cancer survival rate (R = -0.544, P = 0.003), while the maximum peak velocity of saccades was positively correlated with the correct rate (R = 0.415, P = 0.028). Considering the lowest fixation time of the graphic group shown in Table 2 the results suggested that the graphic material could obtain a higher accuracy rate in a shorter time [Supplementary Table S4].
Health has both physical and mental aspects. In addition to the disease being cured through concrete means, education should also be used to promote a positive and accurate mental state. Raising public awareness of lung cancer through health communication, such as by promoting early screening and improving standard treatment, are of great importance to individuals and society. Some studies have shown that improved health awareness enables people to not only actively cooperate with screening but also correctly face screening results and make reasonable treatment choices.[30,31] In terms of practical applications, the better public awareness of the importance of lung cancer screening is, the better public cooperation and long-term prognosis.
Content with high media richness usually attracts the audience’s attention and leads to interactive behavior more than unimodal media. However, compared with a single medium, mixed media with higher richness does not always achieve a better persuasive effect. This suggests that the simplicity of media may be better for healthy communication. Especially in the medical field, too many professional concepts and terms may increase the cognitive burden on the audience. Unimodal or multimodal media perhaps have different propagation effects, and not all concepts can be effectively propagated through multimodal fusion.
The results of our study found that a satisfactory improvement in the accuracy rate could be obtained, as long as each experimental group was given enough time to review the material. Although there were no significant differences in the test scores of the 3 experimental groups, the overall score of the text group was slightly higher, and the scores of the video and graphic groups were similar. This may be due to the small sample size. The video group scored significantly lower on the question, of the Cancer Survival Rate, than the other two groups. However, in clinical practice, this is what patients and their families are most concerned about. A careful analysis of participants’ eye-tracking information revealed that the video group had the highest number of fixations and the longest fixation time but the shortest average fixation time. The number of fixations can be understood as indicating the subject’s interest in the material. The higher the number of fixations is, the greater the subjects pay attention to the material and the greater the interest in understanding the material itself.[34,35] The average fixation duration was mainly used to measure the cognitive effort and processing difficulty required to understand the materials. The longer the average fixation time, the better the concentration of the participant’s attention.
A previous study defined attention as the process of allocating limited information processing capacity. The development of attention theory holds that individual cognitive ability is limited and that attention is a selective process. Because an individual’s ability to process many visual stimuli is limited, people can choose to focus only on certain parts. The video group was likely to be distracted by multiple pieces of information. As a result, they could not allocate enough attention to the key information. In addition to the information about lung cancer, the narrator’s voice, appearance, and even tone also attracted the attention of participants. The excessive information sources also explained the high fixation frequency and long fixation duration in the video group. That is the participants in this group needed to spend more time compensating for the lack of attention distribution. This suggests that video materials actually decrease the quality of knowledge acquisition and reduce efficiency in the process of health communication. This conclusion can also be supported by the finding that the video group had higher values than the other two groups for every indicator of saccade information.
Moreover, the total duration and number of fixations in the graphic group were the lowest, and the average fixation time was moderate. The use of graphic materials seems to be a promising way of disseminating key information more quickly while ensuring the quality of knowledge acquisition. Some researchers believe that attention is influenced by both the amount of information and the significance. A stimulus will receive more attention when it is both informative and significant. Attention, in turn, influences individual preferences, memories, and choices. Charts are an easy way to highlight key points with sufficient information.
From a macroscopic perspective, the development of technology has made it easier for people to obtain information. On the one hand, social media enhanced the freedom and enthusiasm of the public for sharing information. Increasing content production and sharing may promote more complex and diversified health discourse networks. On the other hand, the massive amount of information available to the public also means that this access can easily spiral out of their control. People need to distinguish the value of health information that relates to life safety. Diversified health education models help improve patients’ health literacy and self-management abilities.[41,42] However, dissemination through multimodal and information-rich media decrease the speed at which audiences obtain information. In fact, although the video material was more able to attract people’s attention, it reduced the efficiency of popularizing knowledge about GGO-related lung cancer in this study. In terms of specific operations, unimodal media, such as text and charts, were easier to produce, cost less, and did not require special hardware equipment.
A limitation of this study is that the groups were not divided based on their education levels, economic levels, or other factors. Relevant studies have shown that older age, low education level and concerns about cost constitute barriers to lung cancer screening.[16,43] However, being a former smoker, having respiratory symptoms, having lower FEV1, having chronic obstructive pulmonary disease, and having a family history of lung cancer were associated with higher perceived risk, which was positively correlated with calculated risk in a screening population.[44,45]
In a word, we believe that the legibility and authenticity of the content and the simplicity of the form of its dissemination are the key points for strengthening health education. Notably, it was on the unimodal information, such as text and graphics, that people can spend less time and cost to achieve effective acquisition of lung cancer screening knowledge. What is more important is to combine the ease of information transmission of unimodal media with the attractiveness of multimodal media to improve lung cancer health awareness among the public.
Financial support and sponsorship
This research was funded by Beijing Hope Run Special Fund of Cancer Foundation of China, Grant/Award Number: LC2021A02.
Conflicts of interest
There are no conflicts of interest.
We thank all volunteers from Beijing Jiaotong University for their participation in this study.
1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020:GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2021;71:209–49.
2. Zeng H, Chen W, Zheng R, Zhang S, Ji JS, Zou X, et al. Changing cancer survival in China during 2003-15:A pooled analysis of 17 population-based cancer registries. Lancet Glob Health 2018;6:e555–67.
3. Bao F, Ye P, Yang Y, Wang L, Zhang C, Lv X, et al. Segmentectomy or lobectomy for early stage lung cancer:A meta-analysis. Eur J Cardiothorac Surg 2014;46:1–7.
4. Poonia DR, Sehrawat A, Gupta MK. Lung cancer screening
:An unending tale. J Cancer Res Ther 2021;17:1289–93.
5. Zhang P, Liu JM, Zhang YY, Hua R, Xia FF, Shi YB. Computed tomography-guided lung biopsy:A meta-analysis of low-dose and standard-dose protocols. J Cancer Res Ther 2021;17:695–701.
6. National Lung Screening Trial Research Team. Lung Cancer Incidence and Mortality with Extended Follow-up in the National Lung Screening Trialxs J Thorac Oncol 2019;14:1732–42.
7. Zhang Y, Jheon S, Li H, Zhang H, Xie Y, Qian B, et al. Results of low-dose computed tomography as a regular health examination among Chinese hospital employees. J Thorac Cardiovasc Surg 2020;160:824–31.
8. Gamsu G, Klein JS. High resolution computed tomography of diffuse lung disease. Clin Radiol 1989;40:554–6.
9. Kuriyama K, Seto M, Kasugai T, Higashiyama M, Kido S, Sawai Y, et al. Ground-glass opacity on thin-section CT:Value in differentiating subtypes of adenocarcinoma of the lung. AJR Am J Roentgenol 1999;173:465–9.
10. Scholten ET, de Jong PA, de Hoop B, van Klaveren R, van Amelsvoort-van DVS, Oudkerk M, et al. Towards a close computed tomography monitoring approach for screen detected subsolid pulmonary nodules?. Eur Respir J 2015;45:765–73.
11. Fu F, Zhang Y, Wang S, Li Y, Wang Z, Hu H, et al. Computed tomography density is not associated with pathological tumor invasion for pure ground-glass nodules. J Thorac Cardiovasc Surg 2021;162:451–9.
12. Ye T, Deng L, Xiang J, Zhang Y, Hu H, Sun Y, et al. Predictors of pathologic tumor invasion and prognosis for ground glass opacity featured lung adenocarcinoma. Ann Thorac Surg 2018;106:1682–90.
13. Sagawa M, Oizumi H, Suzuki H, Uramoto H, Usuda K, Sakurada A, et al. A prospective 5-year follow-up study after limited resection for lung cancer with ground-glass opacity. Eur J Cardiothorac Surg 2018;53:849–56.
14. Yang W, Qian F, Teng J, Wang H, Manegold C, Pilz LR, et al. Community-based lung cancer screening
with low-dose CT in China:Results of the baseline screening. Lung Cancer 2018;117:20–6.
15. Paci E, Duffy S. Overdiagnosis and overtreatment of breast cancer:Overdiagnosis and overtreatment in service screening. Breast Cancer Res 2005;7:266–70.
16. Lillie SE, Fu SS, Fabbrini AE, Rice KL, Clothier B, Nelson DB, et al. What factors do patients consider most important in making lung cancer screening
decisions?Findings from a demonstration project conducted in the Veterans Health Administration. Lung Cancer 2017;104:38–44.
17. Rogers EM. The field of health communication today:An up-to-date report. J Health Commun 1996;1:15–23.
18. Freimuth VS, Quinn SC. The contributions of health communication to eliminating health disparities. Am J Public Health 2004;94:2053–5.
19. Zoller HM, Kline KN. Theoretical contributions of interpretive and critical research in health communication. Ann Int Commun Assoc 2008;32:89–135.
20. Torres D, Sena WR, Carmona HA, Moreira AA, Makse HA, Andrade JS Jr. Eye-tracking as a proxy for coherence and complexity of texts. PLoS One 2021;16:e260236.
21. Clifton C Jr, Ferreira F, Henderson JM, Inhoff AW, Liversedge SP, Reichle ED, et al. Eye movements in reading and information processing:Keith Rayner's 40 year legacy. J MEM LANG 2016;86:1–19.
22. Celine G, Cho V, Kogan A, Anthonappa R, King N. Eye-tracking in dentistry:What do children notice in the dentist?. J Dent 2018;78:72–5.
23. Amor TA, Lukovic M, Herrmann HJ, Andrade JS Jr. Influence of scene structure and content on visual search strategies. J R Soc Interface 2017;14:20170406.
24. Dahl AC, Carlson SE, Renken M, McCarthy KS, Reynolds E. Materials matter:An exploration of text complexity and its effects on middle school readers'comprehension processing. Lang Speech Hear Serv Sch 2021;52:702–16.
25. Mollet GA. Fundamentals of Human Neuropsychology 6th J Undergrad Neurosci Educ 2008;6:R3–4.
26. Ku B, Case L, Sung MC. Pro?moting parent–teacher communication within adapted physical education using the media richness theory.
27. Dutta MJ. Communicating about culture and health:Theorizing culture-centered and cultural sensitivity approaches. Commun Theor 2010;17:304–28.
28. Bitzer EM, Sporhase U. [Health Literacy and patient education in medical rehabilitation]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2015;58:983–8 [German}.
29. Hornik RC. Public Health Communication:Evidence for Behavior Change Mahwah, N. J. L. Erlbaum Associates 2002.
30. Hansberry DR, White MD, D'Angelo M, Prabhu AV, Kamel S, Lakhani P, et al. Lung cancer screening
guidelines:How readable are internet-based patient education resources?. AJR Am J Roentgenol 2018;211:W42–6.
31. Williams LB, Looney SW, Joshua T, McCall A, Tingen MS. Promoting community awareness of lung cancer screening
among disparate populations:Results of the cancer-community awareness access research and education project. Cancer Nurs 2021;44:89–97.
32. Kock N. Media richness or media naturalness?The evolution of our biological communication apparatus and its influence on our behavior toward E-communication tools. IEEE T Prof Commun 2005;48:117–30.
33. Xiao H, Zhang Z, Zhang L. An investigation on information quality, media richness, and social media fatigue during the disruptions of COVID-19 pandemic. Curr Psychol 2021 1–12 doi:10.1007/s12144-021-02253-x.
34. Muñoz CP. The role of age and proficiency in subtitle reading. An eye-tracking study. System 2017 S346251X–S16301038X.
35. Szarkowska A, Gerber-Morón O. Two or three lines:A mixed-methods study on subtitle processing and preferences. Perspect Stud Transl 2018;27:1–21.
36. Bisson M, Heuven WJBV, Conklin K, Tunney RJ. Processing of native and foreign language subtitles in films:An eye tracking study. Appl Psycholinguist 2012;35:399–418.
37. Walker C, Federici FM. Eye Tracking and Multidisciplinary Studies on Translation. Amsterdam:John Benjamins Publishing Company 2018 295.
38. Lans Ralf VD, Pieters R, Wedel M. Competitive brand salience. Market Sci 2008;27:922–31.
39. Moorhead SA, Hazlett DE, Harrison L, Carroll JK, Irwin A, Hoving C. A new dimension of health care:Systematic review of the uses, benefits, and limitations of social media for health communication. J Med Internet Res 2013;15:e85.
40. Wynia MK, Osborn CY. Health literacy and communication quality in health care organizations. J Health Commun 2010;15;Suppl 2;102–15.
41. Whitehead D. A stage planning programme model for health education/health promotion practice. J Adv Nurs 2001;36:311–20.
42. Peluso MJ, Hafler JP, Sipsma H, Cherlin E. Global health education programming as a model for inter-institutional collaboration in interprofessional health education. J Interprof Care 2014;28:371–3.
43. Jonnalagadda S, Bergamo C, Lin JJ, Lurslurchachai L, Diefenbach M, Smith C, et al. Beliefs and attitudes about lung cancer screening
among smokers. Lung Cancer 2012;77:526–31.
44. Turner J, Pond GR, Tremblay A, Johnston M, Goss G, Nicholas G, et al. Risk perception among a lung cancer screening
population. Chest 2021;160:718–30.
45. Sari O, Uysal B, Yilmaz TE, Ceti AG, Beyzadeoglu M. The effect of cancer diagnosis in first-degree relatives on participation of healthy individuals in cancer screening programs and on their attitudes towards healthy lifestyle changes. J Cancer Res Ther 2022;18:103–8.
46. Szmuda T, Ozdemir C, Ali S, Singh A, Syed MT, Sloniewski P. Readability of online patient education material for the novel coronavirus disease (COVID-19):A cross-sectional health literacy study. Public Health 2020;185:21–5.