Research-based guidelines for warning design and evaluation

Impact of tobacco-related health warning labels across socioeconomic, race and ethnic groups: results from a randomized web-based experiment

BACKGROUND

The U.S. Family Smoking Prevention and Tobacco Control Act of 2009 requires updating of the existing text-only health warning labels on tobacco packaging with nine new warning statements accompanied by pictorial images. Survey and experimental research in the U.S. and other countries supports the effectiveness of pictorial health warning labels compared with text-only warnings for informing smokers about the risks of smoking and encouraging cessation. Yet very little research has examined differences in reactions to warning labels by race/ethnicity, education or income despite evidence that population subgroups may differ in their ability to process health information. The purpose of the present study was to evaluate the potential impact of pictorial warning labels compared with text-only labels among U.S. adult smokers from diverse racial/ethnic and socioeconomic subgroups.

METHODS/FINDINGS

Participants were adult smokers recruited from two online research panels (n = 3,371) into a web-based experimental study to view either the new pictorial warnings or text-only warnings. Participants viewed the labels and reported their reactions. Adjusted regression models demonstrated significantly stronger reactions for the pictorial condition for each outcome salience (b = 0.62, p<.001); perceived impact (b = 0.44, p<.001); credibility (OR = 1.41, 95% CI = 1.22-1.62), and intention to quit (OR = 1.30, 95% CI = 1.10-1.53). No significant results were found for interactions between condition and race/ethnicity, education, or income. The only exception concerned the intention to quit outcome, where the condition-by-education interaction was nearly significant (p = 0.057).

CONCLUSIONS

Findings suggest that the greater impact of the pictorial warning label compared to the text-only warning is consistent across diverse racial/ethnic and socioeconomic populations. Given their great reach, pictorial health warning labels may be one of the few tobacco control policies that have the potential to reduce communication inequalities across groups. Policies that establish strong pictorial warning labels on tobacco packaging may be instrumental in reducing the toll of the tobacco epidemic, particularly within vulnerable communities.

The Spanish pictogram on medicines and driving: The population's comprehension of and attitudes towards its use on medication packaging

The Spanish pictogram on medicines and driving is legally binding since 2011. We have evaluated patients' comprehension, change in driving frequency and the perceived usefulness, information, comprehensibility, and simplicity of this pictogram on 1385 Spaniards users of the National Health Service (pharmacies, primary care and hospital centres). Most, 85.7%, correctly related the symbol with the possible effects of the medicine on driving and the 83.9% of the drivers would reduce the frequency with which they drive when prescribed a medicine with such pictogram. The pictogram was found, in a 10-point Likert, useful (8.3±1.7), informative (7.7±1.9), comprehensible (7.8±1.9) and simple (7.8±1.9). The Spanish pictogram on medicines and driving is understood by the great majority of those interviewed; is well considered by the users of the National Health Service; and offers good prospects for reinforce the awareness of health care professionals and patients on the effects of medicines on driving.

Consumer perceptions of medication warnings about driving: a comparison of French and Australian labels

OBJECTIVE

Little research has examined user perceptions of medication warnings about driving. Consumer perceptions of the Australian national approach to medication warnings about driving are examined. The Australian approach to warning presentation is compared with an alternative approach used in France. Visual characteristics of the warnings and overall warning readability are investigated. Risk perceptions and behavioral intentions associated with the warnings are also examined.

METHOD

Surveys were conducted with 358 public hospital outpatients in Queensland, Australia. Extending this investigation is a supplementary comparison study of French hospital outpatients (n = 75).

RESULTS

The results suggest that the Australian warning approach of using a combination of visual characteristics is important for consumers but that the use of a pictogram could enhance effects. Significantly higher levels of risk perception were found among the sample for the French highest severity label compared to the analogous mandatory Australian warning, with a similar trend evident in the French study results. The results also indicated that the French label was associated with more cautious behavioral intentions.

CONCLUSION

The results are potentially important for the Australian approach to medication warnings about driving impairment. The research contributes practical findings that can be used to enhance the effectiveness of warnings and develop countermeasures in this area. Hospital pharmacy patients should include persons with the highest level of likelihood of knowledge and awareness of medication warning labeling. Even in this context it appears that a review of the Australian warning system would be useful particularly in the context of increasing evidence relating to associated driving risks. Reviewing text size and readability of messages including the addition of pictograms, as well as clarifying the importance of potential risk in a general community context, is recommended for consideration and further research.

Equating Perceived Urgency Across Auditory, Visual, and Tactile Signals

Determining the most effective modality to use to draw an operator’s attention to a specific situation has been a topic of recent interest. Making this determination requires ensuring that the signals being compared have been equated for saliency and perceived urgency. We conducted an experiment to examine how perceptions of urgency and annoyance change with changes in physical parameters across auditory, visual, and tactile modalities. While urgency ratings in the low, medium, and high range were found in each modality, parameters such as interpulse interval had a greater impact on perceived urgency than annoyance in the auditory and tactile modality, while having relatively little impact in the visual modality. Results can be used to facilitate the design of alerts and warnings with pre-specified urgency levels while minimizing annoyance and have implications for both research and interface design.

Health literacy assessment of labeling of pediatric nonprescription medications: examination of characteristics that may impair parent understanding

OBJECTIVE

Poor quality and variability of medication labeling have been cited as key contributors to medication misuse. We assessed the format and content of labels and materials packaged with common pediatric liquid nonprescription medications.

METHODS

Descriptive study. A total of 200 top-selling pediatric oral liquid nonprescription medications (during the 52 weeks ending October 30, 2009) categorized as analgesic, cough/cold, allergy, and gastrointestinal products, with dosing information for children <12 years (representing 99% of U.S. market for these products) were reviewed. The principal display panel (PDP) and FDA Drug Facts panel (side panel) of each bottle, and associated box, if present, were independently examined by 2 abstractors. Outcome measures were content and format of active ingredient information and dosing instructions of the principal display panel and Drug Facts panel.

RESULTS

Although almost all products listed active ingredients on the Drug Facts panel (side panel), nearly 1 in 5 (37 [18.5%]) did not list active ingredients on the PDP. When present, mean (SD) font size for PDP active ingredients was 10.7 (5.0), smaller than product brand name (32.1 [15.0]) and flavor (13.1 [4.8]); P < .001. Most products included directions in chart form (bottle: 167 [83.5%], box: 148 [96.1%], P < .001); mean (SD) font size: 5.5 (0.9; bottle), 6.5 (0.5; box), P < .001. Few products expressed dosing instructions in pictographic form: 4 (2.6%) boxes and 0 bottles. Nearly all products included the Food and Drug Administration-mandated sections.

CONCLUSIONS

The format and content of labels for nonprescription pediatric liquid medications could be improved to facilitate parent understanding of key medication information, including active ingredient information and dosing instructions.

Developing safety signs for children on board trains

Every year a number of young children are injured as a result of accidents that occur on board trains in Great Britain. These accidents range from being caught in internal doors, through to injuries caused by using seats. We describe our efforts to design a new set of safety signs in order to help prevent the occurrence of these types of accident. The research was funded under a Rail Safety and Standards Board (RSSB) managed UK Department for Transport research programme and was carried out in collaboration with Loughborough University. The study involved analysis of industry accident incidence data and running a set of classroom discussions with young school children (aged 5-10, n=210). The classroom discussions initially involved showing them examples of a new design prototype sign alongside existing train signs and gathering the requirements for new designs. A second set of classroom discussions with these children was used to evaluate the new signs based on the outcomes from earlier discussions. We describe our findings alongside a set of outline guidelines for the design of safety signs for young children. A final section considers the main methodological and other lessons learnt from the study, alongside study limitations and possibilities for future research.

Relevance of health warnings on cigarette packs: a psycholinguistic investigation

Although most research on the effect of tobacco warnings has been focused on attitude changes following the presentation of tobacco warnings, this paper takes a somewhat new perspective by investigating cognitive processing of tobacco warnings by adolescents of different ages (i.e., 14-, 16-, and 18-year-olds). More specifically, this paper investigates the way adolescents encode different textual elements presented in tobacco warnings. By means of a standard psycholinguist paradigm (i.e., sentence evaluation paradigm), we evaluated tobacco warnings differing along three variables: (1) severity, (2) time consequence and (3) target (health vs. others). Our main result demonstrated noticeable differences between the age groups and between smoking experiences in the cognitive processing of tobacco warnings. Our experimental paradigm represents an important step in identifying the mechanisms through which certain types of written warnings are cognitively processed, which in turn may well set a critical base for understanding decision makers' responses to risky behaviors such as smoking and for constructing adequate health warnings.

Electronic gaming machine warning messages: information versus self-evaluation

Regulators have extensively used warning signs in many health domains to enhance knowledge and shift attitudes and behaviors to reduce associated harm. The effectiveness of these signs is influenced by their physical attributes and content. Gambling warning signs traditionally focus on the following: informing individuals of the potentially risky outcomes of gambling and the odds of winning, encouraging gambling within affordable limits, and advertising counseling services. The limited evidence suggests that warning signs for gambling attract attention and improve knowledge but are generally ineffective in modifying players' thoughts and behaviors. Therefore, the authors aimed to determine the optimal content of messages that would enhance responsible gambling practices. The authors conclude that, in contrast with signs displaying probabilities or informing players of the risks associated with gambling, signs designed to encourage players to reflect on, appraise, evaluate, and self-regulate their actions have greater theoretical and empirical support. The authors comment that warning signs should promote the application of self-appraisal and self-regulation skills rather than the simple provision of information on odds and probabilities to maximize their effectiveness as a public health tool.

Information Technology Exception Messages

Users of information technology (IT) frequently encounter “exception messages” during their interactions with computing systems. Exception messages are important points of communication with users of IT and are similar in principle to compliance and warning messages that appear on consumer products and equipment (e.g., cigarettes, power tools, etc.), in various environments (e.g., around machinery), and on chemicals. This study reviews the normative elements and information that are included in product, chemical, and environment compliance and warning messages and combines these with recommendations in the IT literature to propose that five elements and information should be included in IT exception messages with a standard format. It is argued that including these elements in the proposed format will improve the consistency and effectiveness of exception messages. Also reported are the results of an investigation of a sample of actual exception messages to determine their degree of conformity with the proposed elements. Results indicate that IT exception messages lack descriptive content.

The effect of graphics on environmental health risk beliefs, emotions, behavioral intentions, and recall

Lay people have difficulty understanding the meaning of environmental health risk information. Visual images can use features that leverage visual perception capabilities and semiotic conventions to promote meaningful comprehension. Such evidence-based features were employed to develop two images of a color-coded visual scale to convey drinking water test results. The effect of these images and a typical alphanumeric (AN) lab report were explored in a repeated measures randomized trial among 261 undergraduates. Outcome measures included risk beliefs, emotions, personal safety threshold, mitigation intentions, the durability of beliefs and intentions over time, and test result recall. The plain image conveyed the strongest risk message overall, likely due to increased visual salience. The more detailed graded image conveyed a stronger message than the AN format only for females. Images only prompted meaningful risk reduction intentions among participants with optimistically biased safety threshold beliefs. Fuzzy trace theory supported some findings as follow. Images appeared to promote the consolidation of beliefs over time from an initial meaning of safety to an integrated meaning of safety and health risk; emotion potentially shaped this process. Although the AN report fostered more accurate recall, images were related to more appropriate beliefs and intentions at both time points. Findings hinted at the potential for images to prompt appropriate beliefs independent of accurate factual knowledge. Overall, results indicate that images facilitated meaningful comprehension of environmental health risk information and suggest foci for further research.

Do Warning Signs on Electronic Gaming Machines Influence Irrational Cognitions?

Electronic gaming machines are popular among problem gamblers; in response, governments have introduced “responsible gaming” legislation incorporating the mandatory display of warning signs on or near electronic gaming machines. These signs are designed to correct irrational and erroneous beliefs through the provision of accurate information on probabilities of winning and the concept of randomness. There is minimal empirical data evaluating the effectiveness of such signs. In this study, 93 undergraduate students were randomly allocated to standard and informative messages displayed on an electronic gaming machine during play in a laboratory setting. Results revealed that a majority of participants incorrectly estimated gambling odds and reported irrational gambling-related cognitions prior to play. In addition, there were no significant between-group differences, and few participants recalled the content of messages or modified their gambling-related cognitions. Signs placed on electronic gaming machines may not modify irrational beliefs or alter gambling behaviour.

Views on chemical safety information and influences on chemical disposal behaviour in the UK

This study examined how groups representing four tiers in the chemical supply chain (manufacturers, vendors, workers and consumers) understood safety information, and the factors that influenced disposal behaviour. Data from seven, semi-structured, focus groups was analysed both qualitatively (textual analysis) and quantitatively (network analysis). Such combined analytical methods enabled us to achieve both detailed insights into perceptions and behaviour and an objective understanding of the prevailing opinions that occurred within and between the focus group discussions. We found issues around awareness, trust, access and disposal behaviours differed between groups within the supply chain. Participants from the lower tiers perceived chemical safety information to be largely inaccessible. Labels were the main source of information on chemical risks for the middle and bottom tiers of the supply chain. Almost all of the participants were aware of the St Andrew's Cross and skull and crossbones symbols but few were familiar with the Volatile Organic Compound logo or the fish and tree symbol. Both the network and thematic analysis demonstrated that whilst frequent references to health risks associated with chemicals were made environmental risks were usually only articulated after prompting. It is clear that the issues surrounding public understanding of chemical safety labels are highly complex and this is compounded by inconsistencies in the cognitive profiles of chemical users. Substantially different cognitive profiles are likely to contribute towards communication difficulties between different tiers of the supply chain. Further research is needed to examine the most effective ways of communicating chemical hazards information to the public. The findings demonstrate a need to improve and simplify disposal guidance to members of the public, to raise public awareness of the graphic symbols in the CHIP 3.1, 2005 regulations and to improve access to disposal guidance.

Visualizing seismic risk and uncertainty: a review of related research

Government agencies and other authorities often communicate earthquake risks using maps derived from geographic information systems. Yet, little is known about the effects of these maps on risk perceptions. While mental models research and other approaches are available to inform risk communication text design, similar empirically derived guidance is lacking for visual risk communications, such as maps, which are likely to trump text in their impact and appeal. This paper reviews the empirical research that might inform such guidance. Research on graphs, spatial and visual perception, and map design suggests that graphics increase risk avoidance over numerical risk representations, and countable visuals, like dots, can increase the accuracy of perceived risks, but not always. Cartographic design features, such as color, animation, interactivity, and depth cues, are all candidates to represent risk and uncertainty and to influence risk perception. While there are robust known effects of color (e.g., red = danger), with some cultural variability, animation can increase the salience of otherwise obscure features but is not uniformly effective. Depth cues, dimensionality, and the extent to which a representation depicts versus symbolizes a scene will influence the viewer's perspective and perception, depending on the viewer's familiarity with the scene; their effects on risk perception remain unclear. The translation and representation of technical information about risk and uncertainty is critical to risk communication effectiveness. Our review suggests a handful of candidate criteria for evaluating the effects of risk visualizations, short of changes in behavior: accuracy, accessibility, retention, and perceived risk and usefulness.

Exploratory research on reading cognition and escape-route planning using building evacuation plan diagrams

The purpose of evacuation plan diagrams is for readers to comprehend and then plan an evacuation route. However, comprehending such diagrams involves complex issues that have yet to be addressed by research. This study aims to investigate how Taiwanese people interpret evacuation plan diagrams in their buildings. Issues of interest include the amount of time that it takes for a member of the general public to read a diagram and the time that they spend planning their escape route. Correlated and influencing factors are analyzed. The floor plan of an actual department store was used as the diagram for cognitive testing. A method of stimulated measurement was conducted over the Internet. The results of the experiment showed that the time it takes to plan an escape route is about 1.1 to 2 times longer than its reading time. This indicates that there is a significant time difference between diagram interpretation and stimulated planning. It was found that the longer it takes to read a diagram, the longer it takes to plan an escape route. In addition, to understand the difference between interpretations by the general public versus those with an architectural background, an analysis showed that the general public takes two to three times longer than architectural professionals to read a diagram and plan an escape route. Consequently, improvements in reading diagrams could help in the planning of a more efficient escape route. Furthermore, through our analysis, we found that the design of diagram symbols must satisfy conventional use and also that diagrams must avoid the use of metaphorical and abstract symbols. Diagrams that follow our guidelines will generally result in more effective and efficient conveyance of the intended message, thereby assisting in an emergency.

Risk factors and prevention for spinal cord injury from diving in swimming pools and natural sites in Quebec, Canada: a 44-year study

BACKGROUND

Diving is the most frequent cause of spinal cord injury (SCI) from recreation and sport in Canada. This study was done to identify risk factors for SCI from diving in the province of Quebec.

METHODS

An interview survey was done for a target population of 203 subjects with a SCI from diving treated in the two specialized rehabilitation centers in Quebec during 1961-2004. Telephone interviews of consenting individuals were used to collect pertinent personal, equipment, and environmental factors for each incident.

RESULTS

Response was 44% (89/203); 92% were male and 85% <35 years old. Only 37% were aware prior to injury of the risk of SCI from diving, and only 33% had received water safety training. Swimming pools were the site of 51% (n=45) and natural bodies of water for 49% (n=44). 87% (n=39) of pools were single-unit home pools and 57% (n=26) above-ground. Depth indicators were absent for 100% of above-ground and 74% of in-ground pools. For SCI in in-ground pools, 63% resulted from striking the up-slope between deep and shallow ends. For dives at natural sites, a dock or wharf was the most frequent location, 36% (n=16). In 52% of pools and 79% of natural sites, depth was <1.4m (4.6ft). Signs prohibiting diving were absent in 96% of above-ground and 89% of in-ground pools. Alcohol was reported in 47% of SCIs.

INTERPRETATION

The target for prevention of diving SCI is male youths and young adults. Above-ground pools are too shallow and small for diving. Deep ends of many in-ground pools are excessively shallow and short since many SCIs resulted from striking the up-slope. Prevention of SCI from diving needs to focus on education of potential victims, pool vendors and manufacturers, and regulations for safety norms in private pools. Water safety should highlight diving as a high-risk activity, and emphasize that most home pools and natural sites are unsafe. Safer evidence-based pool designs and more effective warnings need to be implemented.

Recall of electronic gaming machine signs: A static versus a dynamic mode of presentation

This study compared differences in rates of free and cued recall for messages displayed on electronic gaming machines (EGMs) delivered in one of two display modes: static or dynamic. Rates of recall were investigated in a laboratory setting using 92 university students (75.0% female) with a mean age of 19.3 years (SD = 2.4 years). The static mode consisted of a fixed government-mandated message placed on the frame of an EGM directly next to the gaming buttons. In the dynamic mode, an identical message was presented in the form of a translucent display scrolling across the screen during play. Results showed that significantly more of the information presented in dynamic mode was recalled, and with greater accuracy, in both free recall and cued recall conditions compared with static government-mandated messages. It was concluded that the method of displaying signs influences awareness and recall of harm minimization messages.