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Patient Educ Couns. 2009 Jun;75(3):358-67. doi: 10.1016/j.pec.2009.01.012. Epub 2009 Mar 9.

Development and preliminary evaluation of a bowel cancer screening decision aid for adults with lower literacy.

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Screening and Diagnostic Test Evaluation Program, Centre for Medical Psychology and Evidence Based Decision Making, School of Public Health, University of Sydney, New South Wales, NSW, Australia.



Several countries have recently implemented national bowel cancer screening programs. To ensure equal access to screening, information is needed to suit adults ranging in literacy level. Decision aids are effective in providing balanced information and have been applied in screening. However, few have been designed for populations with lower education and literacy. This article describes the development and preliminary evaluation of a bowel cancer screening decision aid for this group.


We conducted face-to-face interviews with adults of varying literacy ability, to develop the decision aid (Stage 1). We applied principles of plain language, created visual illustrations to support key textual messages, and used colour coding to direct the reader through the booklet. We then explored its acceptability and comprehension among consumers with higher and lower education (Stage 2). Participants were recruited from a community sample with lower education and a university alumni network.


A total of 75 participants were interviewed, 43 with lower educational attainment and 32 with university education. The decision aid was positively reviewed by both education groups. Results highlighted the need to clarify the purpose of the decision aid and the availability of choice in the context of screening, especially to those with lower education.


The 2 stage iterative development process identified important factors to consider in the development of decision tools for this target group, and is recommended.


Our findings have implications for how to support people with lower education and literacy make informed screening decisions.

[Indexed for MEDLINE]

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