“They Need to Feel Non-Judgmental”: Results of Participatory Photovoice Research to Inform Lung Cancer Screening Imagery

Abstract

Introduction

Effective communication and messaging strategies are crucial to raise awareness and support participants' efforts to adhere to lung cancer screening (LCS) guidelines. Health messages that incorporate images are processed more efficiently, and given the stigma surrounding lung cancer and cigarette smoking, emphasis must be placed on selecting imagery that is engaging to LCS-eligible individuals. This exploratory study aimed to identify person-centered themes surrounding LCS imagery.

Materials and Methods

This qualitative study leveraged a modified photovoice approach and interviews to define descriptive themes about LCS imagery. Study participants eligible for annual LCS who had a CT scan within 12 months were asked to select three images and participate in a semi-structured interview about photo selection, likes, and dislikes. Participants were also asked their opinions about images from current LCS communications featuring matches, smoke, and cigarettes. Data were analyzed using an inductive thematic approach.

Results

Data saturation was reached after thirteen individuals completed the photovoice activity; each participant selected three pictures resulting in a total of 39 images representing LCS. Over half (54%) of images selected contained lungs and only 4 (10%) contained smoking-related elements. Five main themes emerged: 1) images should focus on good news and early detection; 2) people should be relatable; 3) pictures with lungs can dually support lung health or invoke fear; 4) opportunity for education or awareness; and 5) should not be judgmental and induce stigma.

Conclusions

These findings suggest that LCS imagery should not contain negative or stigmatizing elements but instead be relatable and educational. This information can inform communication and messaging interventions and strategies for future LCS participation, awareness, and educational research.

Keywords

lung cancer lung cancer screening photovoice stigma imagery

Introduction

Lung cancer has been the leading cause of cancer death for over 60 years in men and 30 years for women.¹ Historically, lung cancer has been primarily diagnosed in late stages due to lack of symptoms prior to metastatic spread of disease.² Lung cancer screening (LCS) with low-dose computed tomography (LDCT) has emerged as an effective method to diagnose early-stage lung cancer when eligible individuals adhere to annual screening.^3,4 Two randomized controlled trials provided evidence that LCS reduces lung cancer mortality by approximately 20% when completed annually.^3,4 Both trials reported >90% adherence to multiple rounds of screening, directly influencing the mortality reduction.^3,5

Unfortunately, participation in LCS outside of clinical trials has been limited in the United States, with only 5.8% of eligible individuals being screened,⁶ and adherence to annual screening guidelines reported to be as low as 22%.⁷ Despite this limited use and participation, LCS has already contributed to a shift toward early-stage diagnosis. In 2013, the first year the US Preventive Services Task Force (USPSTF) recommended LCS,⁸ lung cancer accounted for 27.5% of cancer deaths and had a 5-survival of 16% with only 15% of cases diagnosed as early stage.⁹ Ten years later, the percentage of cancer deaths attributable to lung cancer decreased to 20.8%, with an increased 5-year survival of 25.4%, and 21% of cases diagnosed at a localized, early stage.¹⁰

There is a crucial need to increase participation to maximize the unfulfilled individual and population benefits of LCS. Effective communication and messaging strategies are crucial to raise awareness and support participants' efforts to adhere to LCS guidelines. Research has pinpointed several factors related to low participation that can serve as starting points for targeted or tailored messaging content, including logistical barriers (e.g., transportation, taking time off from work, cost); psychosocial factors (e.g., high levels of stigma, fatalism, medical system distrust, low-risk perception); and sociodemographic factors with lower levels of participation among minority populations and individuals that currently smoke.^11-14

Health messages that incorporate images are processed more efficiently than messages with text alone and are especially important for individuals with low health literacy and/or numeracy to help explain and retain complicated medical information.^15-17 Given the pervasive public stigma surrounding lung cancer and cigarette smoking that is exacerbated by public health communications and ad campaigns,¹⁸ emphasis must be placed on selecting imagery that is engaging to individuals who are eligible for LCS but does not evoke stigma or fear. Recently, the American Cancer Society National Lung Cancer Roundtable published the Lung Cancer Stigma Communications Assessment Tool (LCS-CAT) focused on identifying and providing alternatives for stigmatizing, judgmental, and discriminating language, imagery, and context in lung cancer communications.^19,20 Specific to imagery, the LCS-CAT provides guidance that images with dark color schemes, show people as isolated or alone, negative facial expressions, and images with smoking or cigarettes contain stigmatizing qualities.^19,20 Similarly, prior qualitative research has reported that individuals at high risk for lung cancer find images of cigarettes ineffective for awareness,²¹ indicating a need to pinpoint engaging and non-judgmental imagery for LCS communications. This exploratory study aimed to identify person-centered themes surrounding LCS imagery based on photos selected by LCS-eligible individuals and to inform future LCS communications to facilitate engagement and annual adherence.

Materials and Methods

This qualitative study leveraged a modified photovoice approach where participants’ selected images that represented LCS to them and then participated in semi-structured interviews to define descriptive themes about LCS imagery. This study was approved by the Colorado Multiple Institutional Review Board at the University of Colorado Anschutz Medical Campus (study #21-3881, approved on July 14, 2021) with waivers of HIPAA and informed consent to identify eligible individuals. Additionally, a waiver of informed consent documentation was granted, with study participants agreeing to the contents of an informational sheet before initiating study procedures. Study methodology follows those described by Hirsch and Studts.²² Due to the ongoing COVID-19 pandemic, all study procedures were completed electronically using REDCap (Vanderbilt University; electronic data capture hosted at University of Colorado Anschutz Medical Campus) and Zoom. The reporting of this study conforms to COREQ guidelines.²³

Study Participants and Recruitment

Study participants included individuals who were English-speaking, eligible for LCS by current US Preventive Services Task Force or Medicare guidelines (50 – 80 years of age, a minimum of a 20 pack year smoking history, and currently smoke or quit within previous 15 years), and had completed an LCS-specific LDCT at University of Colorado Hospital, with results recommending annual follow-up (Lung-RADS 1 or 2) within 12 months prior to study invitation. Individuals that had LDCT results that recommended shorter term follow-up (Lung-RADS 3 or 4) or did not provide consent were excluded. Two methods of participant identification were used to recruit the study sample. First, eligible individuals meeting the inclusion criteria were identified from pulling lists of individuals that had been screened within the previous 12 months with a Lung-RADs 1 or 2 results from the LCS program clinical tracking database. Second, interested individuals were recruited from an interest question that was included in a survey regarding behavioral aspects of annual LCS adherence participation. Since the purpose of the survey was separate from this study about imagery no bias was expected from involving the same participants for both the survey and the imagery work. After determining eligibility the study team sent an introductory letter with details about the study purpose and procedures to eligible individuals by email or postal mail, dependent on contact information available in the electronic health record. Interested individuals were provided a link to a REDCap survey that contained an informational consent sheet; following acknowledgement of the consent, participants completed demographic and smoking history questions and were provided additional information about how to complete the photovoice activity. Investigators used purposive sampling to recruit a variable sampling population by sex, race/ethnicity, age, and smoking status (current or former). Study enrollment was limited to participants with access to a computer with video and audio capability. All individuals that provided informed consent completed all parts of the research.

Modified Photovoice Procedures and Interview Guide

Following informed consent, participants were asked to find three photos representative of LCS and then upload the photos into a REDCap database. Participants were given the choice to find images on the internet or take photos themselves and were provided with the following prompts to help them reflect about images:

- Why did you decide to be screened for lung cancer?

- What motivated you to be screened for lung cancer?

- What aspects in your life helped you decide to be screened for lung cancer?

- How did being screened for lung cancer make you feel about your life and health?

- What do you think about continuing to participate in lung cancer screening?

This modified photovoice methodology allowed participants to visually share their perceptions of LCS. Traditional photovoice is a participatory research method that gives individuals a ‘voice’ about a community or cultural phenomenon by supplying participants with a camera and then discussing captured photos in a focus group discussion.²⁴

Photovoice methodology was also used to develop the semi-structured interview guide by adapting questions from the SHOWeD technique that is commonly used to help participants discuss photos captured in photovoice studies²⁵ (Table 1). Study participants were also asked their likes and dislikes of each photo and to rate each image on a scale of 0 (I really don’t like this photo) to 10 (I really like this photo).

Table 1.

Photovoice Interview Questions Adapted From the SHOWeD Technique. This Table has Been Previously Published in²⁰ and can be Reproduced Under the Terms of Creative Commons Attribution 4.0 License.

The SHOWeD Technique	Adapted Interview Question
What do you See here?	To begin, please describe what you see when you look at this picture? What about what you feel?
What’s really Happening here?	Tell me about what you think is happening in this photo.
How does this relate to Our lives?	What does this picture mean to you?
Why does this problem, concern, or strength Exist?	Why did you select this picture to represent lung cancer screening?
What can we Do about it?	How could this help support lung cancer screening?

Interview Procedures

Interviews were conducted 1-on-1 by a female doctoral student with experience conducting qualitative interviews using the Zoom platform. Since interviews were conducted virtually, the research team had little control over the environment and presence of non-participants, however, participants were informed the interviews would be 1-on-1. The interviewer was not known to the participants prior to the interview and information about the LCS background of the interviewer, that the research was part of the interviewer’s doctoral dissertation, and aims of the study were discussed prior to initiating questions. Participants were shown the three images they picked to represent LCS (1 at a time) and asked questions from the interview guide for each photo. At the end of the interview, participants were shown three images from LCS advertisements found on a Google image search in September 2022 that featured images commonly used for LCS communications, including matches, cigarette smoke, and cigarettes. Specifically, each participant was shown the following three images (“a priori LCS images”):

1) Lungs on Fire: A pair of lungs constructed out of matches with several areas caught on fire. The color scheme included red, orange, and black.²⁶

2) Wondering Smoke: Black background with a light question mark formed from cigarette smoke.²⁷

3) Lung Ashtray: 2 ashtrays in the shape of lungs filled with burnt-out cigarettes. The background is dark brown, contrasted by white and light gray cigarettes.²⁸

Participants were asked their thoughts, likes, dislikes, and ratings of each image. In total, each participant was asked about 6 images, the three images they selected to represent LCS and the three a priori images. All interviews took place between October 2022 and February 2023, and lasted an average of 24 minutes (standard deviation = 6 minutes), with a range of 15 to 35 minutes. Interviews were audio-recorded and transcribed. Study participants were compensated with a $60 gift card upon completion of the interview.

Qualitative and Mixed Methods Analysis

An inductive thematic analysis was completed using the 6-step process outlined by Braun and Clark.^29,30 Interview transcripts were coded using ATLAS.Ti Version 22 (Scientific Software Development GmbH), with coding completed simultaneously with data collection to track data saturation. Two researchers independently coded the first three interviews to monitor for code intrareader reliability and inform initial codebook development. A second set of three interviews were coded independently by each coder to iteratively refine the codebook, with all codes determined by consensus among the study team. One coder then recoded all transcripts, with the study team meeting weekly to discuss coding, themes, and data saturation. Saturation was determined to be reached when no additional information was being discovered in interviews.³¹ The coding tree is included as Supplemental File 1.

A mixed methods analysis was completed for the three a priori LCS images (Lungs on Fire, Wondering Smoke, and Lung Ashtray) through a matrix analysis³² to compare the qualitative quotes and quantitative rating data. A matrix analysis had been intended to be completed for all theme and rating data; however, the matrix analysis was not feasible for the photovoice component with the wide variety of images selected by participants. Photo ratings were averaged across comparable components of the photovoice images (i.e., images with lungs, people, cigarettes/smoke) and for the a priori LCS pictures.

Results

Data saturation was reached after 13 interviews were completed. The majority of participants were female (62%), Non-Hispanic White (85%), had some college education (77%), formerly smoked (61%), and had completed more than 1 screening LDCT (69%) (Table 2). The sampling population included individuals from 51 – 73 years of age. Each participant selected three pictures for a total of 39 images representing LCS, described in Table 3. Most images included a medical or health setting or objects (69%), with over half containing representations of lungs (54%). Only 4 pictures (10%) contained cigarettes, smoke, or people smoking.

Table 2.

Self-Reported Characteristics of Photovoice Participants, n = 13.

Characteristic	N (%)*
Sex
Male	5 (38)
Female	8 (62)
Race/ethnicity
Non-Hispanic White	11 (85)
Other race/ethnicity	2 (15)
Age (mean ( ± SD))	64.8 ( ± 6.3)
Age (range)	51-73
	Missing n = 1
Education
Completed high school	1 (8)
Some college	4 (31)
College graduate	5 (38)
Postgraduate	1 (8)
	Missing n = 2
Smoking status
Current	4 (31)
Former	8 (61)
	Missing n = 1
LDCT quantity
1	2 (15)
2	3 (23)
3	6 (46)
	Missing n = 2

*N(%) of Non-missing Data.

Table 3.

Characteristics of Imagery Selected for the Photovoice Activity.

Photo characteristic summary n = 39
27 (69%) contained medical aspects.
• 21 (54%) included lungs
• 9 (23%) were tumors/x-rays/CT slices
• 5 (13%) contrasted healthy/diseased sides
• 3 (8%) CT scanners
13 (33%) had distinct settings
• 5 (13%) medical (physician office/radiology)
• 5 (13%) outdoors (traveling, park)
• 3 (8%) indoors (house, gym)
14 (36%) included people in the photo.
• 10 (26%) included women
• 8 (20%) showed older individuals, 3 younger, 3 indiscernible
• 6 (15%) showed smiling/laughing, none were angry
39 (100%) evaluated for color schemes.
• (51%) 20 were light (white, light shades of blue, green, pink, orange)
• (36%) 14 were dark (black, red, dark shades of blue and green)
• (13%) 5 were medium (mix of light and dark colors without 1 overpowering)
8 (20%) included words
• LCS eligibility/risk factors/awareness
• “Early detection saves lives”
4 (10%) contained cigarettes/smoke/people smoking

Inductive thematic analysis identified 5 overarching themes about content, influence, and engagement involving images that represent LCS. The first 4 themes were primarily informed by codes from images selected during the photovoice activity, while the fifth theme was informed from quotes about the three a priori LCS images. Each theme is described in detail below, with expressive quotes presented in Table 4.

Table 4.

Representative Quotes From Each Theme.

Theme	Quote number	Participant ID	Quote
Theme 1: Images should focus on positive aspects of early detection and being informed of good news	1	9	Well, yeah, because obviously I’ve already smoked and back when I think this picture was, I don’t know if this person had the same choice to get screening to prevent or to mitigate whatever potential cancer. Just like as you get older, we all have new tests that we get to go and get done. You know, your 40, you get to get your, your breast cancer testing, then your fifties, you get colono, colonoscopy or whatever the heck, colonoscopies. So you have all these steps in life, but there wasn’t for many years lung cancer screening tests. And so I see this as a real reason why there should be, and that I should welcome that. So as negative as the picture is, it also is a reminder of how fortunate I am because I get the opportunity to be screened and to potentially avoid that setting that this per person ended up in.
	2	13	Well, it means to me, and it probably pretty much all these pictures do, is that, um, you know, if you’re healthy you can, you know, travel the world and have the freedom to do that. Um, but I was a previous smoker for 35 years, so I started smoking very early and, um, quit when I was 55. And, you know, I think that’s why I get my lung cancer screening is because I want to continue to travel. I love to travel, I want to continue to love to travel.
	3	10	This one’s future looking… where I’ve worked for the, worked for them. This 1 with the buds and the flower and the.., plants are future looking to me. They always have been. Um, and I think that’s 1 of the things that flowers do for us, and especially a lemon. The scent of a lemon is intoxicating. And I think you see that here with the, the different shades that are coming off of that lemon. You can kind of almost feel the waxiness of it, and… they’re very, uh, tangible. And I think you can feel that in this picture. And there’s a hope and a future and a, um, cancer. One of the things with cancer is it can take away your timeline. This has a future.
	4	5	Discuss the results in the mail. Um, like said, you know, I should return every year, but that things look, you know, I had a little, um, mass, but that was non-cancerous and not, not expected to grow.
	5	3	It was like for me this shows good news. It’s like you’ve had this, and either, and the good news can be reflected in 2 ways, right? 1 way is like, ‘Yeah, We got the results of the screening, and there’s been no major changes in anything and everything’s looking fine. We’ll see you next year.’ Or it could be how we got it early, and we did whatever treatment. And now it’s good news… I mean, it’s the happy doctor thing.
	6	8	Well, um, I selected it because that’s basically what you need to know whether you have spots on your lung. And that is a good reminder that people who, especially those who smoke, should be tested and, and know before it's too late whether there’s an issue.
	7	9	Yeah, I, um, I think that any kind of screening, what I believe is motivating is the way that it's an opportunity to avoid something. And so I think anything with some kind of positive message as part of it and, and showing a lot of people that, you know, early detection saved my life, that kind of stuff, tho that those type of messages, especially with some kind of happy flower somewhere in the picture,
	8	1	This 1 I like, because um it it hits home. I I did quit, and it was what uh 7 years later that the cancer showed up. So just because you quit doesn’t mean that you can go ahead and think that Everything’s hunky dory. Uh: you still have to be checked. Do the screening and the necessary preventative, or your lungs will look like this.
Theme 2: People represented in LCS images should be relatable by sex, age, life, and health status.	9	3	What I just see is a senior woman that smoking but um unlike what you usually see in the media she’s not like most most media pictures are of smokers are just like ugly, horrible, like awful people. So this picture I like, because I think 1 of the questions was what you know, what led me to start my lung cancer screening, and the answer to that is of course I was a smoker for a long time. So so, I picked this picture because I was a smoker for a long time, and but i’m not an ugly person with a tracheotomy.
	10	13	What I like most that, um, it does remind me that not to start smoking again, <laugh>, um, probably what I like least is that I smoked so long, I smoke for about 35 years. And it kind of reminds me that, and, and then how unhealthy and sometimes tired you’d feel after smoking
	11	13	And probably, cause I’m an old, I’m an old blonde lady now, you know, <laugh>, that’s like my age now, most likely <laugh>, so I can relate
	12	11	And, uh, so when I saw that spot, I thought, oh, it meant a lot to me as far as, uh, my health goes because I can see a spot there. So I felt, I felt as though I felt like, um, I was actually looking at something with this, this picture.
	13	4	Well, I just think it’s, it’s, like I said, it’s clear. It gives, you know, three different categories and if, if you meet all three for sure, you should be screened, um, as opposed to negative photographs or something like that. Okay. You know? It’s not, it’s not badgering, it’s not belittling, it’s just factual.
	14	12	The body in the picture makes it more, uh, usable for that type of, uh, uh, in instance, I mean the body, uh, you know, when you’re just looking at the 1 I had before, um, it may not be as personal, both personal or relatable or have the impact that this 1 would because of the body in the picture. Okay. Um, you know, I think it makes a more powerful, um, a more powerful, uh, impact with the body in the picture.
	14	6	Only the diseased part. You know, there’s that little part and then there’s that dark circle around , it is just, you know, it just, it’s kind of a upsetting picture, you know, somebody that smokes and don’t, won’t stop. And that can happen to them.
Theme 3: Images of lungs used for LCS communication can dually evoke fear of a cancer diagnosis or support the goal of healthy lungs	16	9	Yeah, I, um, that 1, that 1 is an interesting 1 because it kind of, to me at the top of the lungs looks kind of like healthy. And then it goes down to the bottom where the smoke is kind of like staining everything, and it just is gross. So I like it because it’s gross, because it’s lung cancer and lung cancer is gross. And so that, that gives me a very aversive feeling to cigarettes.
	17	12	Uh, yeah, the red color is more like urgent more. Um, uh, I think the red color is, is uh, well like a stop sign. You know, it’s more, uh, it has more of an impact than some other colors, um, and um, so I really think that that is, um, powerful.
	18	12	It’s smoker lung compared to a normal lung. Um, and um, this 1 I think drives home. I think we’ve all seen the image of a smoker’s lung on TV or whatever and, uh, I, although some of the younger people might not, uh, know that, but there for a while. I think we all saw it on TV… in some public service commercial or whatever… I think it’s, it’s obviously smokers lung and… I think that in itself would, uh, evokes some fear and especially where it’s too next to a regular lung… and uh, for this 1, the actual cancer is not represented, but the potential and the realization that yes, this lung is not healthy, and um, it’s, you know, the 1 of these are the lungs that are going to get cancer. [Participant 12]
	19	2	I think again, I think if they were just pink lungs with saying, here’s some healthy lungs, and you know it’d be what what people are hoping for when they got to what I hope for when I got a scanned, you know. You want to know that.
	20	9	You know, you can kind of look at the veins and stuff and you can obviously see the difference between either side. So it is like captain obvious to me, and you’ve got the black circle and then you have the nice white 1 where the valves all appear to be, um, healthy
	21	9	Yeah, the picture to me is just like, um, those, the opposite kind of, you know, mirror the opposite mirror images or the simplicity of an angel and a devil kind of thing, it’s very blatant, it’s very in your face. And wow, you can have this nice pink lung or you can have this disgusting black 1 that barely breathes, you know, it’s, it’s so obvious, um, that it, it’s like a slap in the face. This is like the wake up call picture in my opinion.
	22	12	Uh, and to me, fear is the biggest motivator in getting screened. Um, you know, if there is no fear, there’s no motivation. Okay. You know, unless you’re just 1 that, um, just wants to make sure, uh, they’re doing everything they can to stay healthy and, you know, uh, but I think fear for most people is the biggest motivator.
Theme 4: Images should bring awareness and education about LCS and expectations about the screening process	23	2	These screenings don’t bother me anymore. I’ve been through several, but I think if somebody hasn’t been through 1, they want to know. What can I expect? You know? Okay. The first 1 shows you the machine. But what does that mean? Then you show someone where it’s actually being used. There’s really nothing scary about it. You just lie down and they slide you in, and that’s that’s it, that that’s what you’re going to go through. And 5 minutes later, if that you’re done and you leave, so it’s pretty simple procedure. And if if you know that, and it’s not as scary.
	24	1	It’s quick as part of if anybody’s hesitant, it’s expensive as can be if you don’t have insurance. You gotta have insurance… if you got insurance it’s painless. It’s quick. They’re very efficient at [health care facility]. You’re in and out, and um the results come later that day. It’s super efficient and it puts you at ease.
	25	4	Well, I just think it’s, it’s, like I said, it’s clear. It gives, you know, three different categories and if, if you meet all three for sure, you should be screened, um, as opposed to negative photographs or something like that. Okay. You know? It’s not, it’s not badgering, it’s not belittling, it’s just factual.
	26	7	…so again, you got a picture of lung. Um, obviously it looks like a bad part of the lung, good part of the lung, but then you’ve also got the verbiage about World’s Lung Cancer Day. I never knew, I never knew about that. Never heard of it. <laugh>. Um, so clearly there’s not enough awareness about it
	27	9	I think it’s a good photo because it is, you know, it’s something that’s being recognized and I think the more that you see things in, um, in a, in a way like this picture is, it’s red is a great color that catches my attention and it’s showing that it is a global setting. You know, it’s not just a personal issue that, that you are potentially part of something and that we’re all aware of it. And I think it takes me to the same way that like the, um, the pink ribbons in October for breast cancer awareness and you look at all the positives because of that. And so I see this as a positive that there is World Lung Cancer Day, which I didn’t even know there was until I saw this.
	28	9	I just say the disgustingness of it. You know, it’s almost like a dirty toilet. It’s just like, ew, there’s just, there’s no reason that I wanna go clean the toilet as well. I would just avoid it. So I would avoid the cigarettes based on this, but I would not be motivated to get, um, any kind of screening.
Theme 5: Images should not shame or judge as LCS-eligible individuals are aware of the consequences of cigarette smoking	29	8	I wouldn’t, I, I personally don’t think that’s effective because yes, ashtrays are gross when you let that happen, but, and I understand they’re in the shape of lungs, but it doesn’t do anything for me as far as lung cancer screening.
	30	13	Well, it’s definitely gross <laugh>, um, you know, I, you, you look at all those and think, oh my God, I smoke all those cigarettes, my lungs, my poor lungs, <laugh>. Yeah. It, it could be definitely be a, a picture that would help support lung cancer screening.
	31	10	Well, I know that, I mean, that’s nothing new. It’s, it’s, um, it’s aggressive. It’s angry. It’s, um, I, I know it would speak to some people but not me
	32	8	Well, it, it does make you stop and think. I, to me it’s like, um, people who are non-smokers would be more, have more negative feelings toward those who smoke looking at that or making snide remarks about people who smoke, just so I don’t, for, for smokers, if smokers only saw it, I think it’d be a good thing. But because there’s such negativity about people who smoke, I mean, you know, like, I smoke 4 cigarettes a day and that’s it. And so that, that doesn’t mean it’s okay. But yeah, people look down on people who smoke really big time in the last 15 years.

Theme 1: Images Should Focus on Positive Aspects of Early Detection and Being Informed of Good News

Many participants focused on the benefits of LCS and verbalized that participating in LCS was a chance to keep up with their health. One participant commented that “early detection is obviously the goal,” while others discussed the importance of LCS to their health since they had a history of cigarette smoking. Keeping up with health allowed participants to feel that they could continue to enjoy activities in their life, selecting images they enjoyed, such as traveling and exercising (Quote 2). One participant shared how the ability keep up with hobbies held the promise of a future (Quote 3).

Although there was widespread knowledge of LCS being able to detect early-stage cancer, participants also commented that good news came in annual phone calls or letters saying that no cancer was found (Quotes 4 and 5).

Theme 2: People Represented in LCS Images Should be Relatable by Sex, Age, Life, and Health Status

Participants frequently discussed the importance of connecting with the person or situation shown in the image. This notion was raised in several different ways. The most common premise was being like the person in the image by sex and age (Quotes 9 and 11), with additional dialogue that images displaying LCS eligibility criteria motivated them to be screened since they fit all the criteria (Quote 13). Another common notion was that schematic pictures of lungs should be placed within an outline of a body to make them more personable (Quote 15).

Relatability to the image setting was also raised by several interview participants, with 1 individual commenting that a picture of their house showed “…that our house is not fancy. We’re not a, you know, we’re regular people. And I think that that shows that regular people are affected by this.” Additional discussion surrounding images with a clinician and patient talking represented the shared decision-making conversation.

Theme 3: Images of Lungs Used for LCS Communication can Dually Evoke Fear of a Cancer Diagnosis or Support the Goal of Healthy Lungs

About half of images selected by study participants contained lungs, representing a combination of tumor pictures, healthy lungs, and some photos contrasting diseased and healthy sides. Participants reported 2 ways that lung images can support LCS communications. Pictures showing tumors or a diseased/damaged side usually used black, red, and yellow colors and often accompanied conversation about fear being a motivator for screening participation because it was obvious the picture showed cancer. (Quotes 17 and 18).

The second common lung image motif was how pink, healthy lungs also motivated the participant to continue yearly screening, with the overarching goal of knowing their lungs were healthy (Quote 19). Lung images that included bronchi and bronchioles were also often correlated to illustrate healthy lungs (Quote 20).

Theme 4: Images Should Bring Awareness and Education About LCS and Expectations About the Screening Process

LCS-eligible individuals included in this study reflected that images were an excellent opportunity to educate about the process, especially around knowing what the LDCT procedure encompassed. Participants felt that seeing a CT scanner in pictures made it easy to see that the procedure was not scary and may even help claustrophobic individuals (Quote 23). Moreover, participants conveyed how quick and simple the LDCT process was to complete (Quote 24).

Several participants also highlighted how they were unaware there was a Lung Cancer Awareness Day/Month until they were searching for images for the photovoice activity, with 1 participant sharing that advertising of ‘Lung Cancer Day’ may help ‘click off a light bulb in their head’ for other LCS-eligible individuals to participate in screening. Other participants voiced the notion that their friends and family with a cigarette smoking history were unaware of LCS:

Well, I have a feeling that really that the public really isn't that knowledgeable about lung cancer screening. I, cause I know, um, like I've asked a few people, like my [family member], and she's still smoking and, and some people if they've ever had lung screen, and they're like, no. And I don't think like all the doctors are bringing it up. [Participant 13]

Theme 5: Images Should Not Shame or Judge as LCS-Eligible Individuals are Aware of the Consequences of Cigarette Smoking

All participants mentioned that they were conscious of the negative effect of smoking on their health, and many viewed the Lungs on Fire, Wondering Smoke, and Lung Ashtray photos as ‘over-the-top.' While the shock value was described as attention-grabbing, some participants felt the images were potentially stigmatizing. Another common observation about images with cigarettes and smoke was that those types of pictures conveyed a message about quitting smoking better than LCS participation. One participant captures these 2 notions:

Besides, it's gross. Yeah, I can almost smell that picture I'm telling you because I smoked for so long. Um, and I'm glad I don't now, but, um, uh, yeah, that's <laugh>. Um, you know, it seems like the more things that were absurd the more it, um, gathers people's attention. And so this picture tells me that, um, it's over the top and, and then they did that to grab somebody's attention about quitting smoking. Doesn't say too much about lung screening. But it does say a lot about quitting smoking. [Participant 11]

Some participants voiced that images of cigarettes, fire, and smoke conveyed a sense of self-blame and contributed to societal stigma by portraying the message that cigarettes were the only cause of lung cancer. Another participant shared that they felt the images contributed to society thinking badly about people who smoke (Quote 32).

A Priori LCS Imagery Mixed Methods Analysis

Using a matrix analysis to compare ratings and quotes revealed mixed reactions to the Lungs on Fire, Wondering Smoke, and Lung Ashtray photos; each photo was rated a 10 (I really like this photo) or a 0 or 1 (I really don’t like this photo) by at least 1 photovoice participant. Quotes corresponding to the three highest and lowest ratings are presented in Table 5, revealing that participants who rated these images highly thought the images caught their attention and were drawn into the message. Conversely, participants who disliked the images were more likely to say they viewed the pictures as negative and did not inspire LCS participation. Furthermore, images selected for the photovoice activity were consistently rated higher than the three a priori imagery photos (Table 6). Of the photovoice images, those containing lungs were rated the highest, while images including people were rated the lowest (average ratings of 7.5 and 6.8, respectively).

Table 5.

Representative Quotes From Highest and Lowest a priori LCS Imagery Ratings.

LCS communication photo	Participant ID	Participant rating	Quote
Lungs on fire	1	9	This 1 I like, because um it it hits home. I I did quit, and it was what uh 7 years later that the cancer showed up. So just because you quit doesn’t mean that you can go ahead and think that everything’s hunky dory. Uh, you still have to be checked. Do the screening and the necessary preventative, or your lungs will look like this.
	6	10	I’m just like, is that for real? I mean, it looks scarier than any picture I showed you. You know, absolutely. It, it does. And is that adequate, can your lungs look like that?
	13	10	Well, um, I, I mean, I, I like that picture as far as a picture for lung cancer. Um, um, but yeah, it definitely tells people they need to quit and they de it definitely tells ‘em that they could still get lung cancer even if they do quit, and that would, you know, prompt me to, um, wanna get a screening.
	3	0	No, No, No, No, No. I think it’s just feeding into the guilt and shame that culture tries to put on people who smoked.
	4	0	Well, when I see it, um, I should say, why bother quitting then? Okay. I mean, that’s not motivating. That’s very badgering
	8	2	To me, I, I guess if to, to me, my first impression would be that people who don’t smoke or, uh, never smoked would think, how can people do that to themselves? To me it’s a little bit overkill. Um, but yeah, I guess it makes you stop and think.
Wondering smoke	2	10	Yeah, If you had smoked, I mean, it’s quite visual. I mean, you get the meaning right away. Wondering, and of course if anyone who smoked, or if it did, they’re wondering. Uh, I think this one’s very good, very good. It says a lot.
	7	9	Oh, it’s talking about lung cancer screening. So, I mean, this is like, this is kinda the stuff that’s like helpful for me. Like when I see something like this and it’s making me think right away, like, and there’s verbiage, I wanna read it right away and see what it, see what this is about. Um, the actual picture itself, you know, it’s a question mark of smoke, uh, with them reading about the lung cancer screening, that helps to kind of figure what this is about.
	8	10	I think that’s a, a good image. The only thing is, because I think when it says wondering, I think there should be some larger words associated with it so that people in passing will immediately know what they’re talking about… I don’t have any negative feelings about this cigarette smoke because it’s, it’s catchy.
	1	3	No, no, the smoke and the that wouldn’t do much for me, maybe for some people. But uh I, looking at the effects on your organ that’s I mean the smoke out in public, and everything is bad news, but it’s everyday stuff, the uh pictures of your lungs, and totally messed up, that it's more of a shock. This doesn’t have any shock value to me whatsoever.
	12	1	Uh, to me it doesn’t evoke fear, which I think is a primary motivator, uh, in getting people to, um, to do the screening. Uh, yes, they recognize the smoke cuz most of them were, were smokers, um, and, uh, you know, the wondering, uh, you know, I mean, that could be powerful for some people, uh, because they may be wondering if they’re going to get cancer or whatever, uh, from smoking, that could be powerful. Um, to me it doesn’t evoke fear enough. I think the fear is the big, big motivator for people
	13	3	I mean, it’s kind of say you’re, you’re wondering, but you know, what, are you really wondering quit smoking or not?… It doesn’t really support the, the screening as much. I, I don’t think.
Lung Ashtray	6	7.5	That really, it, it, it promotes, you know, that’s, I tell you, there’s a lot of ashtrays out in public that look like that. I mean, uh, somebody, this, I’m sure there’s a lot of people like me, they wanna stop, you know, and, and that’s a nasty scene. Cigarettes are nasty, you know, you smell nasty. I mean, every time I smoke, I wash my hands and chew gum and that kind of stuff,, you know, it’s a gross thing and that just looks gross. Okay. It is what it is. That’s how, that’s how people’s that smokes cigarette, uh, ashtrays loo like that and, you know, and they get used to that grossness.
	10	10	Yeah, that 1, that’s actually a really good 1. Um, that’s a lot of guilt. That’s a lot of, uh, that 1 says everything. Okay. That’s, that’s 1 of the best ones.
	13	8	Well, it’s definitely gross <laugh>, um, you know, I, you, you look at all those and think, oh my God, I smoke all those cigarettes, my lungs, my poor lungs, <laugh>. Yeah. It, it could be definitely be a, a picture that would help support lung cancer screening
	2	0	Oh, that is awful. No, that that wouldn’t do it for me that that no, I mean all it tells you, is jeez I shouldn’t smoke. I’m not going to run and get my lung scan, because looking at that picture.
	3	0	That’s ridiculous! I don’t know who who would like that picture? It’s like like people who smoke, know that it's not healthy these days. We know it’s not healthy! That’s not telling me anything except that I have ten zillion burnt out cigarettes in my lungs. I know that already. That’s not telling me anything.
	4	0.5	I, you know, I feel it’s negative again. You don’t have to tell me that. I already know that smoking was bad for me. And it doesn’t, it, I don’t think it really encourages a person to do lung cancer screening you. It doesn’t give you any positive images

Table 6.

Ratings for Selected Photovoice Images Versus Current a priori LCS Imagery.

Photovoice imagery	Average rating
Images with lungs (n = 21)	7.5
Images with lung tumors (n = 7)	7.5
Images contrasting healthy/diseased sides (n = 5)	8.2
Images with people (n = 12)	6.8
Images with awareness/educational components (n = 8)	7.9
Images with cigarettes/smoke (n = 3)	7.2
A priori LCS imagery
Lungs on fire image	5.5
Wondering smoke image	6.2
Lung ashtray image	3.7

Discussion

Imagery can be a powerful element of health communication, helping to capture the audience’s attention, communicating important information, and even evoking reactions that can motivate or hinder behavior.¹⁷ LCS communications must emphasize selecting appropriate imagery to connect with the eligible population effectively. This study involved a qualitative inquiry approach and participatory research methodology to have LCS-eligible individuals select imagery representing LCS and thematically illuminate representation of imagery in LCS communications. This is among the first studies to provide rich, qualitative data surrounding preferences for imagery informed through direct engagement with LCS-eligible individuals.

We found that images should be approachable with a preferred focus on screening benefit, such as early detection and lung health. Conversely, there were negative reactions to images of cigarettes and smoke, with many participants describing these images as stigmatizing and judgmental, potentially leading to disengagement. It is possible that using fear-arousing images of fire, matches, and cigarettes are a spillover from anti-smoking campaigns with a similar intended audience.³³ Although fear-arousing campaigns have historically been the most successful anti-smoking messaging,³³ they have also influenced societal stigma associated with smoking and lung cancer and provoked strong reactions from study participants when similar imagery was used for LCS. Moreover, the use of stigmatizing images may be harmful by triggering disgust that makes individuals apprehensive about LCS participation. Combining disgust with fear appeals has been shown to be persuasive for immediate avoidance of a behavior,³⁴ making this tactic successful for anti-smoking but not screening participation. Importantly, >60% of the images selected for the photovoice activity did not contain dark, stigmatizing colors.

While some participants described fear of a cancer diagnosis as a motivating factor, the photos selected to accompany these quotes were predominantly tumors or other lung anomalies. This suggests it may be possible to use negative emotions to promote healthy behaviors without the added elements of stigma and disgust. Tumor images were concurrently associated with early detection and cancer that has better treatment options among study participants, a finding that is inconsistent with research by Cardarelli, et al. that found images meant to portray early detection in awareness campaigns should show lung cancer survivors and be linked to family and friends.³⁵ Other lung images selected for the photovoice activity were associated with the goal of healthy lungs, a notion that has been described in earlier qualitative research about motivations to participate in LCS.³⁶

Another important finding from this study was that images should relate to the intended recipient. Health communications that are targeted with images, especially with regard to racial and cultural sensitivity, are better received and may help facilitate behavior change.⁶ The World Health Organization recommends knowing the sociodemographic and cultural characteristics of the target audience in the development of communication campaigns to increase relevance to the audience and effectiveness of the messages.³⁷ In this study, participants expressed relatability in different dimensions, including demographic characteristics, life status, and significance to the screening process, providing many approaches that can be used to make communications applicable to the LCS-eligible population.

The findings also suggest that images may be an excellent avenue to raise LCS awareness and offer education about the screening process. Reading levels for LCS websites have been reported to have a median reading level of 10^th grade,³⁸ which is concerning because adults that are more likely to smoke cigarettes (i.e., rural residence, racial/ethnic minorities, low socioeconomic status) are also more likely to have low health literacy.^39,40 Including educational components in LCS imagery offers an important opportunity to engage and share health information with populations that often have poorer health outcomes and can greatly benefit from LCS participation.

Limitations

This study does have several limitations to note. Although purposive sampling obtained a variable study sample, the final sample was primarily limited to Non-Hispanic White individuals and those with higher attained education, potentially limiting the transferability of our findings to more diverse populations. Second, this research did not focus on some sub-populations that previous research has shown benefit from targeted imagery, including individuals that identify as lesbian, gay, bisexual, transgender, or queer.⁴¹ More research is needed to understand the influence of imagery on LCS communication in diverse populations, such as differences in imagery preferences for individuals that currently and formerly smoke, men and women, high and low literacy levels, and different racial and ethnic backgrounds. Understanding such differences is especially important given the sensitivity to sociodemographic and cultural aspects of pictures and achieving equitable LCS implementation.⁴² Last, this research emphasized finding appropriate imagery for future LCS communications, specifically for annual adherence, and the study excluded individuals with LDCT findings that were potentially worrisome for lung cancer (LungRADS 3 or 4). The imagery themes identified in this study may not be generalizable to individuals with shorter and more intensive follow-up, often associated with higher levels of anxiety and distress.⁴³

Conclusion

This research provided rich, qualitative, and participatory data that offered a robust exploration of the types and uses of imagery that can be leveraged to engage and communicate with the LCS-eligible population effectively. Similar to guidance provided in the LCS-CAT,^19,20 findings from this study suggest that LCS imagery should not contain negative or stigmatizing elements but instead be relatable and educational. Table 7 provides general considerations for the use of imagery for LCS communications. Researchers and clinicians should diligently consider the intended audience, type of communication, and details of the situation when deciding on imagery that best accompanies the message being sent and conveyed. This information can inform future communication and messaging interventions and strategies for future LCS participation, awareness, and educational research.

Table 7.

Considerations for General Use of Imagery for Lung Cancer Screening Communications. The information provided in this table offer broad elements that can be considered for selecting appropriate imagery for lung cancer screening communications. Choosing imagery as a one size must fit all approach is complicated and often must balance the benefits of the image against the potential harms of the image since population subsets may respond differently to an image. More research is needed on methods and strategies to best target or tailor imagery and messaging to engage and empower the heterogeneous LCS-eligible populations.

	Dependent on Context Consider Using:	Dependent on Context Avoid Using:
Message focus	• Focus on positive perspectives, early detection of cancer.• Hope and survival.³⁵	• Stigmatizing or blaming.¹⁹• Fear-based.¹⁹
Color themes	• Bright colors (i.e., yellow, blue, green).¹⁹	• Dark colors (i.e., red, black, brown).¹⁹
Environment/setting	• Outside environment (i.e., park, participating in hobbies such as walking, swimming, riding bikes).^19,35• Medical setting (i.e., consultation with clinician).	• Messy or unhealthy scenes (i.e., people smoking, landfills).¹⁹
Educational components	• Include lung cancer screening eligibility criteria.• Include information about Lung Cancer Awareness Day/Month.• Factually accurate information about lung cancer and lung cancer screening statistics.	• Images with smoking or cigarettes.¹⁹• Inaccurate statistics about lung cancer or lung cancer screening.
Images with people	• People in picture should be relatable to audience of message (i.e., individuals 50 – 80 years of age, both men and women).• Imagery with people should be representative of all racial and ethnic backgrounds.• Showing people being supported in a group setting (i.e., spending time with family and friends, participating in group activities and supported by clinicians and/or family).^19,35• Use neutral, hopeful, empowered facial expressions.¹⁹	• Portray only 1 sex or racial/ethnic background.• Showing people feeling isolated or alone.¹⁹• Negative or sad facial expressions.¹⁹
Images with lungs	• Images of pink lungs showing bronchi and bronchioles can be used to represent healthy lungs.• Picture of lungs with tumors can help represent early detection of cancer, however, should be used cautiously as this type of image may induce fear is some individuals. Tumors should be labeled clearly as being found as early cancer because of screening.• Place images with lungs inside the outline of a body.	• Images of black lungs as a strategy to depict diseased lungs or the effects of smoking.

Supplemental Material

Supplemental Material - “They Need to Feel Non-Judgmental”: Results of Participatory Photovoice Research to Inform Lung Cancer Screening Imagery

Supplemental Material for “They Need to Feel Non-Judgmental”: Results of Participatory Photovoice Research to Inform Lung Cancer Screening Imagery, Erin A. Hirsch, Kaitlyn Hoover, and Jamie L. Studts in Cancer Control

Supplemental Material

Supplemental Material - “They Need to Feel Non-Judgmental”: Results of Participatory Photovoice Research to Inform Lung Cancer Screening Imagery

Supplemental Material

Supplemental Material - “They Need to Feel Non-Judgmental”: Results of Participatory Photovoice Research to Inform Lung Cancer Screening Imagery

Footnotes

Author Contributions

Erin A. Hirsch: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Visualization; Roles/Writing - original draft.

Kaitlyn Hoover: Formal analysis; Methodology; Resources; Writing - review & editing.

Jamie L. Studts: Conceptualization; Funding acquisition; Investigation; Methodology; Supervision; Visualization; Writing - review & editing.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Hirsch reports grants from NIH/National Cancer Institute and non-financial support from NIH/National Center for Advancing Translational Sciences, during the conduct of the study. Dr. Studts reports personal fees from Johnson & Johnson and Genentech, outside the submitted work; and Dr. Studts volunteers on the Scientific Leadership Board of GO2 for Lung Cancer and the American Cancer Society National Lung Cancer Roundtable. Dr. Studts receives grant funding from National Cancer Institute, the Bristol Myers Squibb Foundation, the American Cancer Society, the Patient-Centered Outcomes Research Institute, the Colorado Department of Public Health and Environment, and the Centers for Disease Control and Prevention, outside the submitted work. Ms. Hoover has no conflicts of interest to disclose.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by National Institutes of Health NCI F99/K00 Predoctoral to Postdoctoral Fellow Transition Award (F99CA264409, PI: Erin Hirsch), the Thoracic Oncology Research Initiative and the Population Health Shared Resource at the University of Colorado Cancer Center (P30CA046934), and NIH/NCATS Colorado CTSA Grant Number UL1 TR002535. Contents are the authors’ sole responsibility and do not necessarily represent official NIH views.

Ethical Statement

ORCID iDs

Erin A. Hirsch

Jamie L. Studts

Supplemental Material

Supplemental material for this article is available online.

Appendix

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