Child:

Original Article
care, health and development
doi:10.1111/j.1365-2214.2010.01138.x

Children’s understanding of cancer and views on

health-related behaviour: a ‘draw and write’ study cch_1138 289..299

K. Knighting,* N. Rowa-Dewar,† C. Malcolm,† N. Kearney‡ and F. Gibson§

*Nursing, Midwifery and Social Work Department, University of Manchester, Manchester
†Cancer Care Research Centre Department of Nursing & Midwifery, Department of Nursing and Midwifery, University of Stirling,
Stirling
‡School of Nursing and Midwifery, University of Dundee, Dundee, and
§Clinical Professor of Children and Young People’s Cancer Care, Great Ormond Street Hospital for Children and London South Bank
University, London, UK

Accepted for publication 23 May 2010

Keywords
cancer, children’s views,
health beliefs, health
promotion
Correspondence:
Katherine Knighting,
Nursing, Midwifery and
Social Work Department,
University of Manchester,
Manchester M13 9PL, UK
E-mail:
katherine.knighting@
manchester.ac.uk
Abstract
Background Few studies have explored young children’s understanding of cancer and health-
related behaviours yet this is essential to develop health promotion initiatives that build on young
children’s current knowledge levels and awareness.
Method An exploratory descriptive design using the ‘draw and write’ technique was used to
investigate children’s views of cancer and health behaviours. The sample included 195 children
aged eight to 11 years from five schools in deprived, affluent and rural locations in Scotland.
Results When asked about cancer children demonstrated a good level of awareness by
responding with text and drawings about the what they understood cancer to be; types of cancer;
causes of cancer; what happens to people who have cancer; their personal experience of cancer
and the emotions they associated with cancer. Older children, and children attending affluent
schools, have more defined ideas about the causes of cancer and awareness of broader issues such
as the risk of passive smoking or the potential impact on the family. Factors such as alcohol and
illegal drugs were only reported by children attending schools in deprived locations. Children
demonstrated considerable knowledge about healthy and unhealthy lifestyle behaviours; however,
it is not clear whether this knowledge translates into their behaviours or the choices offered within
their home environment.
Conclusions Children view cancer in a negative way from an early age, even without personal
experience. There is a need to demystify cancer in terms of its causes, how to recognize it, how it is
treated and to publicize improved survival rates. There is a need for targeted and developmentally
appropriate approaches to be taken to health education in schools, with an awareness of the
influence of the media on children’s information. Strategies should take into consideration the
socio-economic and cultural contexts of children’s lives which influence their choices and
behaviours.

during their lifetime [Information Services Division (ISD)

Introduction
2008]. The number of new cancer cases is estimated to rise
Cancer is one of the most significant health problems in Scot- globally by 50% by 2020 (WHO 2003). Scotland experiences
land with one in three people developing some form of cancer higher incidence and mortality rates of cancer compared with

© 2010 Blackwell Publishing Ltd 289

290 K. Knighting et al.
other western European countries [Scottish Executive Health
Department (SEHD) 2001]. A key factor in reversing this trend
will be raising awareness of both cancer prevention and early
detection with the Scottish public.
Establishing healthy lifestyles from childhood may prevent
many chronic health problems, such as cancer, in later life
(Franks et al. 2007). The National Healthy Schools programme
[Department of Health (DH) and Department for Education
and Employment (DEE) 1999], The National Fruit Scheme (DH
2001) and The National Child Measurement Programme (DH
2007a) are examples of policy schemes to improve the health
of children. As a result, both health surveillance and health
promotion are highlighted in national standards such as healthy
eating, exercise and citizenship. Health education that builds on
an accurate understanding of the beliefs and knowledge about
health in the target group is thought to be more effective than
strategies which lack this foundation (Tones 1990).
Understandings of health and illness differ and develop
across the life-span (Backett & Davidson 1992) and there is a
growing body of literature exploring children and young peo-
ple’s understanding. While children and young people tend to
emphasize psychosocial and sports activity criteria in their defi-
nitions of health, middle-aged and older adults tend to define
health more according to conditions which may limit it (Piko
2000). Cognitive competence plays a role in children’s concepts
of health and illness with younger children’s understandings
more likely to be based on their own experiences. Hence, con-
tamination and contagious agents frequently appear in younger
children’s accounts (Goldman et al. 1991; Solomon & Cassima-
tis 1999). Pre-adolescent children are a particularly interesting
group for health promotion programmes as they, with increas-
ing experience and knowledge, often have an understanding
of health behaviours and already show negative attitudes to
risk behaviours. These negative attitudes and their awareness
of health education messages can then potentially be reinforced
by age-appropriate health improvement initiatives (Piko & Bak
2006).
Despite its significance, few studies have explored children’s
views of cancer specifically. One exception is a key study by
Oakley et al. (1995). This study explored issues about health and
cancer prevention with children (9–10 years) using an interview
schedule with a draw and write technique, and with young
people (15–16 years) using a questionnaire. The results revealed
that young people had limited knowledge about cancer gener-
ally, often simply referring to death and smoking. Considerable
knowledge about the factors that contribute to good and bad
health were evident, with a healthy diet, exercise and sport,
hygiene, not smoking, and sleep depicted as key healthy behav-
© 2010 Blackwell Publishing Ltd, Child: care, health and development, 37, 2, 289–299
iours. Unhealthy behaviours included smoking, an unhealthy
diet (such as sugar, fast food and chocolate), the environment
and alcohol. Children also suggested other causes of poor
health, such as violence, hygiene and some medicines. This
study demonstrated that children and young people were aware
of the predominant health education messages yet many were
thought to lead less than healthy lifestyles. The role of health
education in informing children was considered by
the authors to be overshadowed by the role of television and
other media.
Since 1995 information and communication technologies
have opened up new possibilities in the field of health educa-
tion, encouraging both children and adults to take responsibil-
ity for the choices they make regarding their health (DH 2005,
2007b). Much has changed in terms of healthy messages, where
health education and informing the general public about the
risks and prevention of cancer has increased (see NHS choices
http://www.nhs.uk/Pages/HomePage.aspx). There has also been
a considerable body of literature published which has looked at
the importance of children’s health beliefs and behaviours in
relation to lifestyle issues (e.g. Gosling et al. 2008) and particu-
lar health topics such as smoking (Woods et al. 2005) and sun
protection (McWhirter et al. 2000). However, there have not
been any papers which have explored children’s understanding
of cancer and cancer care in Scotland so the time is therefore
ripe to undertake a study similar to Oakley et al. (1995) to
improve our understanding of the knowledge and beliefs
of children in Scotland today in order to consider
recommendations for age-appropriate health improvement
initiatives.
Methods
Design
The findings presented in this paper are drawn from a larger
qualitative study which aimed to establish what people living in
Scotland think about cancer and cancer care (Rowa-Dewar et al.
2008). While not wholly representative of the views of the
people of Scotland, it is the largest scale study of a cross-section
of the Scottish population to date and the findings have impor-
tant implications for health promotion initiatives. This paper
presents data focusing exclusively on the children’s accounts of
cancer and health using the draw and write technique (Prid-
more & Bendelow 1995). Because children may know more than
they are able to say, using children’s drawings combined with
their writing can potentially be a powerful way of accessing their
accounts (Pridmore & Bendelow 1995; Piko & Bak 2006). This

paper will report the views from children from different socio-
economic communities across Scotland in order to understand
what children’s knowledge and beliefs are in relation to health
and cancer. It will also compare the findings of this study with
the findings of the Oakley et al. paper to explore whether there
has been any change in the way children are writing or drawing
about health behaviours and cancer.
Sample and setting
Data were collected from a total of 195 children attending five
schools in socio-economically deprived (n = 2), affluent (n = 2)
and rural communities (n = 1). They were selected using a
census-based DepCat score system (Carstairs & Morris 1991).
The Carstairs and Morris Index of Deprivation is often used as
a measure of quantifying relative socio-economic deprivation
or affluence in different localities across Scotland. The Depri-
vation scores are derived by combining four census variables
which best indicate material disadvantage for each postcode
sector in Scotland. The variables used are proportion of house-
holds with male unemployment, lack of car ownership, over-
crowded housing and the head of the household being in social
class IV or V. There are seven deprivation scores (DepCat) with
DepCat 1 being the most affluent and DepCat 7 being the most
deprived. The study included 90 Primary 4 children aged eight
to 9 years and 105 Primary 6 children aged 10 to 11 years. There
were 90 children attending schools in deprived areas and 96
children attending schools in affluent areas (Table 1). Because of
their small number the children from the rural school have not
been included in the socio-economic analysis. Any differences
found for this group because of their remote location have been
discussed in the paper, however, in order to highlight potential
differences in the experience of children who live in the large
remote locations across Scotland.
All primary schools invited to take part in the study agreed
to participate. Access was negotiated with head teachers. A letter
and an information sheet which described the study and
emphasized its voluntary nature were sent home with the chil-
dren. The research team were guided by the head teacher in each
Table 1. School sample by DepCat rating and age category
School DepCat rating Primary 4 Primary 6
School 1 Deprived 26 26
School 2 Deprived 13 25
School 3 Rural 5 4
School 4 Affluent 24 25
School 5 Affluent 22 25
Total 90 105
© 2010 Blackwell Publishing Ltd, Child: care, health and development, 37, 2, 289–299
Children’s understanding of cancer and health behaviours 291
school in relation to whether an ‘opt-in’ slip was required from
parents. Only one school chose to ask parents to sign the letter
and return it if they wanted their child to participate. All other
schools were happy to be verbally notified by parents if they did
not want their child to participate. Children’s verbal consent to
participate was also ascertained at the start of data collection.
Eighteen families asked for their children not to be included
across the schools in the study, and three children chose to leave
the classroom after the session had been explained.
Data collection and procedure
The draw and write technique (Pridmore & Bendelow 1995) is
becoming increasingly popular as a method of eliciting chil-
dren’s views within health care (Oakley et al. 1995; Horstman &
Bradding 2002; Woods et al. 2005; Driessnack 2006; Franck
et al. 2008). It is considered non-threatening to children, as
virtually all school-age children are familiar with producing
drawings and writing about themselves (Horstman et al. 2008).
In each of the five schools the research team were given
access to the children for 1 hour. Presence of teachers/helpers
in the class varied depending on their preference, with teachers
being present in three out of the five schools. After the research
team introduced themselves they explained the purpose of the
study, what was expected from the children, that the activities
were not a test, that their drawing or writing would not be
identified by their name and the voluntary nature of the study.
Sufficient time was allowed for children to ask questions and
make a decision on whether to leave the room or stay. Children
were observed closely by teaching and research staff to pick up
on any overt signs of worry or distress. The two activities were
outlined separately and children were asked to: ‘please write
or draw anything you know about cancer’ (Task 1), and ‘please
write or draw what keeps you healthy and what makes you not
healthy’ (Task 2). Children worked individually while sitting at
their usual tables with three to six other children, depending
on the size of the class. The research team members supported
the children by clarifying their questions and checking
meaning of drawings, while encouraging the children to draw
or write their own views and not copy from other children on
their table.
Following the completion of data collection, the researchers
responded to any questions the children had about the session
and encouraged the children to talk to their teacher or parents if
they had any further questions. Schools were given cards from
the charity Cancerbackup with contact details in case further
information was needed and were also reassured that they could
292 K. Knighting et al.
contact the research team if any significant issues arose from the
sessions that would require a second visit.
Data analysis
Techniques of thematic content analysis (Coffey & Atkinson
1996; Elo & Kyngäs 2007) were applied to the booklets from one
school for both Primary 4 and Primary 6 by two independent
researchers in order to develop an initial list of codes. These
codes were then discussed and once there was agreement on the
codes and their definitions a random selection of drawings and
writings from schools were coded as an intercoder agreement
exercise. The level of intercoder agreement was 98% which
demonstrated a high level of agreement (MacQueen et al. 2008).
The codes were then systematically applied to the remaining
data by two researchers working independently and then
checked for consistency. New codes were developed and agreed
as required. During the final stage of analysis the individual
codes were collapsed into themes. Quantitative data for the
number of items for each code, age and school community type
were entered into a computer database and simple statistical
tests of significance (mainly c2) used to examine any differences
in relation to age and school community.
Results
Data from both tasks are presented below using tally counts to
indicate the frequency of specific factors in the text or drawings.
Most of the children provided more than one factor in their
drawings or writings so the written and drawn responses have
been collapsed together to generate the final number of factors
for each code in order to provide an overview of the frequency
of each code. Any differences in style of response between the
schools are highlighted in the sections below.
Task 1: what do you know about cancer?
When the children were asked to ‘write or draw anything you
know about cancer’ six main themes were identified in their
responses.
Theme 1: what is cancer?
There were only 39 responses in this theme (20%) suggesting
that their understanding of cancer itself was difficult for chil-
dren to visualize or communicate. Only one child in Primary
6 attending a school in a deprived community provided a
response in this theme. The Primary 4 children attending
© 2010 Blackwell Publishing Ltd, Child: care, health and development, 37, 2, 289–299
schools in affluent communities wrote that cancer was a
‘disease’ (n = 6) or drew pictures of balls with the text ‘balls of
gas’ (n = 2). The older children in Primary 6 who responded
mainly described cancer as a medical disease or illness (n = 29),
and wrote the word such as ‘lumps’ (n = 1). One child from this
group also drew a picture of a cell suggesting a more biological
view (n = 1).
Theme 2: types of cancer
Almost half of the children responded with some type of
cancer in their responses (n = 93, 47%). Most of the responses
consisted of lists of body areas where children thought it was
possible to have cancer. Some children provided drawings of
people next to the lists. The type of cancer most frequently
reported by both groups of children was breast cancer (n = 26).
Lung cancer was the second most frequently reported
cancer, although it was only reported by children in Primary
6 (n = 14). Five children from both age groups simply wrote
‘different types’ (n = 10) suggesting they knew that there were
several types of cancer but did not have sufficient knowledge
to provide details.
The younger children in Primary 4 listed six areas of the body
that could have cancer (breast, tongue, kidney, heart, mouth,
skin) and the older children in Primary 6 listed 19 areas (breast,
lung, penis, testicular, heart, mouth, eye, brain, throat, bowel, leg,
bone, ear, arm, hand, skin, liver, stomach, head). Some of
the body areas were well-known types of cancer such as lung,
testicular and skin cancer. Other body areas listed are rare cancers
and may have been listed by some children as body parts, such as
ear, eye, arm and tongue, rather than demonstrating knowledge
of areas where people can develop cancer. Upon questioning
some of the children told the researchers that they were showing
they were aware that cancer could develop anywhere in the body.
There were no statistical differences between the school com-
munities or age but it was noted that the largest number of body
areas was provided by children in Primary 4 attending schools
in deprived communities and children in Primary 6 attending
schools in affluent communities.
Theme 3: causes of cancer
The two main behaviours reported by children in both age
groups as causing cancer were smoking cigarettes (n = 106) and
exposure to the sun or sun beds (n = 25). The majority of
children drew cigarettes or smoking, the no smoking symbol,
the sun and sun beds. A few written responses were provided
about the link between smoking and cancer, passive smoking

causing cancer and smoking making people vulnerable but
these tended to be only the odd word included with drawings.
Other responses from both age groups included illness (asthma
and eczema, n = 10), drugs (hash and pills, n = 7) and environ-
mental factors (car pollution, breathing in gas, microwaves, tele-
vision, fires and mobile phone, n = 6). The older children in
Primary 6 demonstrated a greater awareness of potential causes
reporting additional items of alcohol (n = 14), a diet high in
sugar (n = 4) and lack of exercise (n = 1). Other additional
Figure 1. Example of a drawing in the ‘causes
of cancer’ theme.
© 2010 Blackwell Publishing Ltd, Child: care, health and development, 37, 2, 289–299
Children’s understanding of cancer and health behaviours 293
responses from the older children included plastic surgery
(n = 1) and sex (n = 1).
There were no statistically significant differences between the
school communities but some factors were only reported by
distinct groups of children. Children in Primary 6 from schools
in affluent communities reported an awareness of passive
smoking as a cause of cancer and children across both age
groups from schools in deprived communities reported alcohol
and illegal drugs as causes of cancer.
294 K. Knighting et al.

Some children provided longer statements about the causes

of cancer which are detailed below:
To me cancer is a seriously bad disease. I think a main
reason for that is you can get cancer anywhere on your
body. I also think though that it is silly to smoke, or to do
any other things like – that makes the risk a lot higher.
(P6, School 4, Affluent)
Cancer I think is shocking I think the main reason people
get cancer is because of passive smoking and smoking.
Another reason people get cancer is because of fires and
the smoking. (P6, School 4, Affluent)
Dunk a cigarette in the ashtray, and say goodbye, KILL +
it causes Kancer. (P4, School 1, Deprived)
The longer statements provided by older children from
schools in affluent communities and their larger number of
responses demonstrates an increasing awareness of causes of
cancer and the element of risk in behaviours. Only one child
from the younger age group at a school from a deprived com-
munity provided a written statement (Fig. 1).
Theme 4: what happens to people who have cancer?
The children’s’ responses in this theme consisted of drawings or
writing about the physical things that people with cancer may
experience such as immobility (e.g. drawings of people in
wheelchairs, in bed or on crutches, n = 30); hair loss (n = 29);
and spending time in hospital (e.g. drawings of people in a
bed attached to a drip, n = 11). Children also associated death
(n = 25) with having cancer writing statements such as ‘it
kills you’ and ‘die’. Several responses related to the potential for
treatment with drawings of syringes, tablets and bottles (n = 2),
surgery (n = 2) and stoma bag (n = 1). There were some positive
responses relating to cure (n = 3) with text such as ‘might be able
to stop it’.
There were no statistical differences between school commu-
nities but only children from schools in affluent communities
included pain in their responses (n = 2) and they provided a
higher number of responses about treatment, surgery and being
in hospital demonstrating a greater awareness of what may
happen to people who have cancer. It was interesting to note

Figure 2. Example of a drawing in the ‘what

happens to people who have cancer’ theme.

© 2010 Blackwell Publishing Ltd, Child: care, health and development, 37, 2, 289–299
 Children’s understanding of cancer and health behaviours 295

that only one of the children who lived in the rural community
had ever been in a hospital when they were an inpatient. None
of the other children had visited a hospital despite family
members having been in hospital as the hospitals were on the
mainland not the island where they lived. These children told
the researchers that their knowledge of what it was like to be in
hospital was gathered from television programmes and books
(Fig. 2).
Theme 5: personal experiences of cancer
Only 14 (7%) children reported having any personal experience
of cancer. Typically this was a family member, such as a grand-
parent or family pet, who had died of cancer. There were no
personal stories of anyone surviving cancer. For many of the
children their only experience of knowing someone who had
cancer was hearing about celebrities who were diagnosed with
cancer on the news.
Theme 6: emotions associated with cancer
Only 15 (8%) of children provided responses relating to emo-
tions. All the responses were provided by children from schools
in affluent communities. Younger children in Primary 4 drew
sad faces (n = 4) or wrote that they would be ‘sorry for the
person’ (n = 1). The older children wrote emotive words to
describe cancer as a ‘bad’ or ‘nasty’ things (n = 9), or express
their feelings of sadness (n = 5) or sympathy (n = 1) for people
with cancer. For example one child wrote:
made to watch a family member fight it. Out of all the
types of cancer breast cancer is the worst to me. (P6,
School 4, Affluent)
Task 2: what keeps us healthy or makes us unhealthy
There were no statistically significant differences between age
groups or school communities for this task so the responses have
been reported for the total sample. The responses to this task
were categorized into five main categories. The largest category
associated with health was diet consisting of examples of healthy
food (n = 253) followed by healthy drinks (n = 80). The third
largest category was exercise behaviour with taking exercise be-
ing seen as healthy (n = 116). The fourth category for health was
not smoking (n = 4), followed by use of medicines such as vita-
mins and antibiotics (n = 13). Other miscellaneous healthy items
were ‘sleep’, ‘rest’, ‘being clean’ and ‘playing computer games’.
The largest category associated with unhealthy behaviour was
diet consisting of unhealthy food such as fast food and choco-
late (n = 207) followed by unhealthy drinks such as fizzy pop
(n = 69). The third largest category after diet-related factors was
smoking (n = 59). The fourth category was inactivity and being
lazy (n = 32), followed by taking drugs such as illegal drugs (n =
21). Miscellaneous unhealthy items were ‘not getting fresh air’,
‘mobile phones’, ‘bed sores’, ‘being unclean’ and ‘not washing’
(Table 2).
In addition to drawing pictures, some of the children wrote
statements explaining their thoughts about healthy and
unhealthy behaviours:

Cancer to me is like a disease, it tears familys apart, break- Do lots of exercise and running playing sports makes you
ing bonds. Causing pain and fear to all familys who were fit and healthy. (P6, School 5, Affluent)

Table 2. Main categories in text and drawings

Primary 4 Primary 6 Total
of healthy and unhealthy behaviours by class
Category items (n) items (n) items (n)
group*
Diet
Healthy food (e.g. vegetables, fruit, fish) 117 136 253
Unhealthy food (e.g. fast food, chocolate) 118 89 207
Drinks
Health drinks (e.g. water, milk) 32 48 80
Unhealthy drink (e.g. fizzy drinks) 20 49 69
Exercise behaviours
Taking exercise (healthy) 60 56 116
Inactivity/lazy (unhealthy) 10 22 32
Smoking behaviours
Not smoking (healthy) 3 1 4
Smoking (unhealthy) 20 39 59
Use of medicines or drugs
Medicines (healthy) (e.g. vitamins, antibiotics) 7 6 13
Drugs (unhealthy) (e.g. pills, illegal drugs) 6 15 21

*There were no statistically significant differences between age groups or school communities for this task
(c2, P < 0.05).

© 2010 Blackwell Publishing Ltd, Child: care, health and development, 37, 2, 289–299
296 K. Knighting et al.
Sweetys are not good for you and chocolate is not good
for you. If you are fat it is not really helfy for you. (P6,
School 2, Deprived)
Frout like appls and bnannas kepe you helthey. . . . bad
things like smoking, sogars, drugs, burgus. (P4, School 5,
Affluent)
During the session in the classroom, it was clear, however,
that awareness of healthy and unhealthy factors, such as eating
a good diet, did not necessarily translate into the children’s
actual lifestyle choices, or those offered to them within their
© 2010 Blackwell Publishing Ltd, Child: care, health and development, 37, 2, 289–299
Figure 3. Example of a drawing in the ‘healthy
and unhealthy behaviours’ task.
living conditions, particularly in children attending the schools
in deprived communities, for example one child told research-
ers ‘I like broccoli but my mum never buys it’ (Fig. 3).
Discussion
Although children may have some of the same responses as
adults to serious diseases like cancer, such as thoughts of death
and dying, children can also have a unique outlook and hence
should be supported to express their perspectives on matters
that affect their lives. The questions we asked children mirrored

the questions asked of the adult population in the larger public
involvement project, ensuring that the views of all members of
the public were included and valued (Rowa-Dewar et al. 2008).
Both age groups demonstrated awareness of the most
common cancers, their potential causes and key healthy and
unhealthy behaviours across the two tasks. As may have been
anticipated the older children provided more drawings and
tended to used both drawing and text in more of their
responses. The older children also had more defined ideas about
the causes of cancer and awareness of broader issues, such as the
risk of passive smoking, which was not found with the younger
children.
Looking across the school communities, the main differences
were that children attending affluent schools tended to demon-
strate a greater level of awareness or knowledge of current
lifestyle issues, and only children attending deprived schools
included factors such as alcohol abuse and illegal drugs as causes
of cancer. The social conditions in which children live can exert
an influence on their health but less is known about how socio-
economic and cultural contexts of children’s lifestyles shape
children’s perspectives of health (Backett-Milburn et al. 2003;
Irwin et al. 2006). This is an area that requires further study,
particularly in relation to how children perceive and manage
everyday health relevant behaviours.
When comparing the findings of task one with those in the
Oakley et al. (1995) study these children were able to demon-
strate a similar awareness of cancer, its potential causes and its
impact on the individual and family. A key difference in the
drawings of the children in this study, however, was the greater
awareness of what happens when you get cancer, such as the
need for treatment and spending a lot of time in hospital. This
was surprising given the low number of children who reported
having any direct experience with someone who has cancer in
this study (14 of 199) compared with the higher proportion of
children in the Oakley study (54 of 100 aged 9–10 year olds),
and lack of experience of hospitals in the children from the rural
community. As the children reported in the classroom this high-
lights the impact of the media on children’s knowledge and
perceptions, particularly in the absence of experience. More
recently, we have seen an increase, and interest, in reporting
personal experiences of diseases, particularly those that are
more harrowing and ‘news worthy’ and recent stories during the
period of data collection were discussed by the children. The
low number of children who reported any personal experience
of cancer may have been due to no direct question about per-
sonal experience being asked in the study or that the children
may have been protected by family members because of their
age.
© 2010 Blackwell Publishing Ltd, Child: care, health and development, 37, 2, 289–299
Children’s understanding of cancer and health behaviours 297
Another difference was the low number of children who
mentioned any positive impact of treatment such as a cure in
this study (3) compared with the three quarters of older chil-
dren in the Oakley et al. study (1995) who thought that cancer
could be cured and the significant level of awareness in the
younger children of the Oakley study who felt that cancer was
not necessarily incurable or fatal (reported in follow up paper
Bendelow et al. 1996). It is possible that those children with less
personal experience of cancer will be less aware of the survival
rates of treatment.
While children have clearly assimilated some ideas of health
promotion and disease prevention, they also reported ideas
which are not connected with increased risk for developing
cancer, such as violence. It is notable that Oakley et al.’s (1995)
study also reported factors such as violence as causes of cancer.
This perhaps points to a continued need to reinforce the differ-
ence between what might be considered ‘bad’ behaviour (vio-
lence) from behaviours which might be considered ‘bad’ for your
health or contribute to the development of ‘cancer’.
When comparing the findings for task two, children in this
study had considerable knowledge about healthy and unhealthy
lifestyle factors just like those in the Oakley paper. Many of their
responses demonstrated awareness of individually based health
promotion messages, such as ‘five portions of fruit and veg is
good for you’ and an understanding of both environmental
factors and risk behaviours. It is not possible to say how well
children’s health beliefs are reflected in their actual behaviour
based on the data collected. However, we do know that chil-
dren’s fruit/vegetable intake is still below recommended levels
(DH 2000; Mangunkusumo et al. 2007), and poor school meal
provision and personal taste preferences for fast food have been
identified as barriers to healthy eating (Shepherd et al. 2006).
The link between perceptions of health and sport activities
identified in the literature was also evident in the children’s
views of healthy and unhealthy behaviours with the third largest
category associated with health being related to physical exer-
cise. These findings suggest that we need to continue to build on
children’s beliefs and their appreciation of risk behaviours with
age-appropriate health improvement initiatives that tackle indi-
vidual behaviour but also consider the social world of children,
both in school and at home. In order to do this we must con-
tinue to listen to the views of children, drawing on research
methods such as ethnography, to explore the social worlds
of children (Emond 2005) and evaluate the impact of any
initiatives.
It could be argued that the older children from affluent
school communities performed better on both tasks because
of being better able to express themselves. It should be noted,
298 K. Knighting et al.
however, that their responses were more focused and appropri-
ate, demonstrating a greater awareness and knowledge about
cancer and lifestyle factors.
Children reported that television, magazines and the internet
were their main sources of health information, suggesting that
health education had a limited role in their responses. The
importance of the media on children’s beliefs has been reported
elsewhere (Food Standards Agency 2007) highlighting the need
for parents and educators to be aware of its strong influence of
media on children’s health beliefs.
The draw and write technique allowed the research team to
engage with children using a non-threatening and open-ended
method to tap into children’s perceptions by inviting children
to use their own communication skills freely. Similar to others,
we would suggest that this combination of writing and drawing
can elicit more information from children than either compo-
nent alone (Pion et al. 1997; Horstman et al. 2008). One limi-
tation to the using this technique within the typical classroom
setting was the opportunity for children to copy from each other
rather than work independently. The researchers watched the
children carefully to discourage copying of each other work-
books but it is unlikely that no instances occurred. However,
given that the main responses were found at different tables
across the different schools it is likely that the key factors and
themes identified would have arisen independently in most
children and were not related purely to copying each other.
Conclusions
Despite the huge investments in health promotion in schools
this study suggests that the knowledge of children on health and
unhealthy behaviours, cancer and cancer care have not changed
greatly since the Oakley et al. (1995) study. Children can recite
health messages but still prefer unhealthy food, and the differ-
ences identified between schools in affluent and deprived com-
munities suggest that there are some important issues to be
considered for health inequalities. It also highlights the need for
targeted and developmentally appropriate approaches to be
taken to health education in schools in different communities,
particularly in the deprived areas which may require a more
joined-up approach which will impact on the community and
families in order to have a lasting impact on children’s health.
This study has found that like the adult population of the
larger study children view cancer in very negative terms from an
early age, even without personal experience. There is nothing
unusual in viewing a serious disease like cancer in a negative
way but in order to promote prevention behaviours and early
detection professionals in health, social care and education have
© 2010 Blackwell Publishing Ltd, Child: care, health and development, 37, 2, 289–299
an important role in changing people’s approach to cancer.
There is still a need to demystify cancer by maximizing oppor-
tunities available to present more positive images of cancer care,
treatment and survival rates through general health awareness
strategies. With reference to our study, we would suggest that
any strategies need to take into consideration the socio-
economic and cultural contexts of children’s lives which can
influence their choices and behaviour. In addition, these find-
ings are highly relevant and have wider implications, both
nationally and internationally, for advancing health promotion
in the childhood population.
Key messages
• Children between eight and 11 years of age have well-
formed views on cancer, and a good awareness of healthy
and unhealthy lifestyle choices and behaviours.
• There are differences in the level of understanding and
awareness between children from schools in affluent and
deprived areas.
• Despite being able to recite key health promotion messages
it is unclear whether this knowledge translates into chil-
dren’s actual behaviour and choices available in their
living environment.
• Children reported a very negative view of cancer from an
early age which suggests a need to demystify cancer and
publicize improved survival rates.
• There is a need for targeted and developmentally appro-
priate approaches to health promotion in schools and
wider interventions which take into account the socio-
economic and cultural contexts that impact on children’s
lives and choices for a healthy lifestyle.
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