Impact of Game-Inspired Infographics on User Engagement and Information Processing in an eHealth Program

Background

Online interventions providing individual health behavior assessment should deliver feedback in a way that is both understandable and engaging. This study focused on the potential for infographics inspired by the aesthetics of game design to contribute to these goals.

Objective

We conducted formative research to test game-inspired infographics against more traditional displays (eg, text-only, column chart) for conveying a behavioral goal and an individual’s behavior relative to the goal. We explored the extent to which the display type would influence levels of engagement and information processing.

Methods

Between-participants experiments compared game-inspired infographics with traditional formats in terms of outcomes related to information processing (eg, comprehension, cognitive load) and engagement (eg, attitudes toward the information, emotional tone). We randomly assigned participants (N=1162) to an experiment in 1 of 6 modules (tobacco use, alcohol use, vegetable consumption, fruit consumption, physical activity, and weight management).

Results

In the tobacco module, a game-inspired format (scorecard) was compared with text-only; there were no differences in attitudes and emotional tone, but the scorecard outperformed text-only on comprehension (P=.004) and decreased cognitive load (P=.006). For the other behaviors, we tested 2 game-inspired formats (scorecard, progress bar) and a traditional column chart; there were no differences in comprehension, but the progress bar outperformed the other formats on attitudes and emotional tone (P<.001 for all contrasts).

Conclusions

Across modules, a game-inspired infographic showed potential to outperform a traditional format for some study outcomes while not underperforming on other outcomes. Overall, findings support the use of game-inspired infographics in behavioral assessment feedback to enhance comprehension and engagement, which may lead to greater behavior change.

What Factors Moderate Self-Other Discrepancies in Decision Making? Results from a Vaccination Scenario

When we make risky decisions for others, we tend to follow social norms about risks. This often results in making different decisions for others than we would make for ourselves in a similar situation (i.e., self-other discrepancies). In an experiment, we investigated self-other discrepancies in young adults' decisions to purchase a vaccine against a sexually-transmitted virus for themselves or for another person (i.e., the target of the decision). When the target's preferences were in line with social norms, surrogates showed large self-other discrepancies in line with these norms. When the target's preferences were contrary to social norms, surrogates did not show self-other discrepancies in line with these preferences; instead they still followed social norms, F(1, 140) = 21.45, p < .001, η p 2 = .13. Surrogates with lower numeracy, F(2, 128) = 3.44, p = .035, η p 2 = .05, and higher empathy, F(2, 128) = 3.72, p = .027, η p 2 = .06, showed self-other discrepancies more in line with the target's preferences, even when these were contrary to the norm. Surrogates whose own risk attitudes were contrary to social norms showed larger self-other discrepancies, F(1, 128) = 5.38, p = .022, η p 2 = .04. These results demonstrate that perceived social norms about risk can predict self-other discrepancies in risky decisions, even when the target's preferences are known and at odds with the social norm. Further, the surrogates' numeracy, empathy, and propensity to take risks influence the extent to which risky decisions for others resemble risky decisions for oneself.

High Numerates Count Icons and Low Numerates Process Large Areas in Pictographs: Results of an Eye-Tracking Study

In two experiments, we investigated the influence of numeracy on individuals' information processing of pictographs depending on numeracy via an eye-tracker. In two conditions, participants from the general population were presented with a scenario depicting the risk of having cancer and were asked to indicate their perceived risk. The risk level was high (63%) in experiment 1 (N = 70) and low (6%) in experiment 2 (N = 69). In the default condition, participants were free to use their default strategy for information processing. In the guiding-toward-the-number condition, they were prompted to count icons in the pictograph by answering with an explicit number. We used eye-tracking parameters related to the distance between sequential fixations to analyze participants' strategies for processing numerical information. In the default condition, the higher the numeracy was, the shorter the distances traversed in the pictograph were, indicating that participants counted the icons. People lower in numeracy performed increased large-area processing by comparing highlighted and nonhighlighted parts of the pictograph. In the guiding-toward-the-number condition, participants used short distances regardless of their numeracy, supporting the notion that short distances represent counting. Despite the different default processing strategies, participants processed the pictograph with a similar depth and derived similar risk perceptions. The results show that pictographs are beneficial for communicating medical risk. Pictographs make the gist salient by making the part-to-whole relationship visually available, and they facilitate low numerates' non-numeric processing of numerical information. Contemporaneously, pictographs allow high numerates to numerically process and rely on the number depicted in the pictograph.

A Simple Tool for Communicating the Benefits and Harms of Health Interventions: A Guide for Creating a Fact Box

One of the major hurdles to promoting informed decision making in health is the continued use of poor risk presentation formats. This article offers a guide to develop a Fact Box, a simple decision tool to present data about the benefits and harms of treatments that has been demonstrated to improve understanding of health risks, an important part of risk literacy. The article offers guidance about how to determine the evidence basis for a health topic, select outcomes to report, extract and present numbers or outcomes, and design the layout. The guide also addresses potential challenges for summarizing evidence and provides alternatives for addressing issues related to missing, insufficient, imprecise, or conflicting evidence and for dealing with issues related to statistical and clinical significance. The guide concludes with details on how to document the development of the Fact Box for the purpose of transparency and reproducibility. Fact Boxes are an efficient tool to promote risk literacy and should be available in every physician's office.

Improving risk literacy in surgeons

OBJECTIVE

To effectively practice evidence-based medicine, surgeons need to understand and be able to communicate health-relevant numerical information. We present the first study examining risk literacy in surgeons by assessing numeracy and surgical risk comprehension. Our study also investigated whether visual aids improve risk comprehension in surgeons with limited numeracy.

METHODS

Participants were 292 surgeons from 60 countries who completed an instrument measuring numeracy and evaluated the results of a randomized controlled trial including post-surgical side-effects. Half of the surgeons received this information in numbers. The other half received the information represented visually. Accuracy of risk estimation, reading latency, and estimate latency (i.e., deliberation) were assessed.

RESULTS

Some surgeons have low numeracy and could not correctly interpret surgical risks without additional support. Visual aids made risks transparent and eliminated differences in risk understanding between more and less numerate surgeons, increasing the amount of time that less numerate surgeons spent deliberating about risks.

CONCLUSIONS

Visual aids can be an efficient and inexpensive means of improving risk comprehension and clinical judgement in surgeons with low numerical and statistical skills.

PRACTICE IMPLICATIONS

Programs designed to help professionals represent and communicate health-relevant numerical information in simple transparent graphs may unobtrusively promote informed decision making.

Measuring Graph Literacy without a Test: A Brief Subjective Assessment

BACKGROUND

Visual aids tend to help diverse and vulnerable individuals understand risk communications, as long as these individuals have a basic understanding of graphs (i.e., graph literacy). Tests of objective graph literacy (OGL) can effectively identify individuals with limited skills, highlighting vulnerabilities and facilitating custom-tailored risk communication. However, the administration of these tests can be time-consuming and may evoke negative emotional reactions (e.g., anxiety).

OBJECTIVES

To evaluate a brief and easy-to-use assessment of subjective graph literacy (SGL) (i.e., self-reported ability to process and use graphically presented information) and to estimate the robustness and validity of the SGL scale and compare it with the leading OGL scale in diverse samples from different cultures.

PARTICIPANTS

Demographically diverse residents (n = 470) of the United States, young adults (n = 172) and patients (n = 175) from Spain, and surgeons (n = 175) from 48 countries.

DESIGN

A focus group and 4 studies for instrument development and initial validation (study 1), reliability and convergent and discriminant validity evaluation (study 2), and predictive validity estimation (studies 3 and 4).

MEASURES

Psychometric properties of the scale.

RESULTS

In about 1 minute, the SGL scale provides a reliable, robust, and valid assessment of skills and risk communication preferences and evokes fewer negative emotional reactions than the OGL scale.

CONCLUSIONS

The SGL scale can be suitable for use in clinical research and may be useful as a communication aid in clinical practice. Theoretical mechanisms involved in SGL, emerging applications, limitations, and open questions are discussed.

Visual presentations of efficacy data in direct-to-consumer prescription drug print and television advertisements: A randomized study

OBJECTIVE

To determine whether visual aids help people recall quantitative efficacy information in direct-to-consumer (DTC) prescription drug advertisements, and if so, which types of visual aids are most helpful.

METHODS

Individuals diagnosed with high cholesterol (n=2504) were randomized to view a fictional DTC print or television advertisement with no visual aid or one of four visual aids (pie chart, bar chart, table, or pictograph) depicting drug efficacy. We measured drug efficacy and risk recall, drug perceptions and attitudes, and behavioral intentions.

RESULTS

For print advertisements, a bar chart or table, compared with no visual aid, elicited more accurate drug efficacy recall. The bar chart was better at this than the pictograph and the table was better than the pie chart. For television advertisements, any visual aid, compared with no visual aid, elicited more accurate drug efficacy recall. The bar chart was better at this than the pictograph or the table.

CONCLUSION

Visual aids depicting quantitative efficacy information in DTC print and television advertisements increased drug efficacy recall, which may help people make informed decisions about prescription drugs.

PRACTICE IMPLICATIONS

Adding visual aids to DTC advertising may increase the public's knowledge of how well prescription drugs work.

Is patients' numeracy related to physical and mental health?

OBJECTIVE

There is compelling evidence showing that health literacy influences health outcomes. However, there is a dearth of research investigating this issue in the vast literature on numeracy-the ability to accurately interpret numerical information about risk, a skill that is only moderately correlated with health literacy. In a cross-sectional study, we investigated whether objective and subjective numeracy is related to objective and subjective health outcomes. Objective (subjective) numeracy is actual (self-reported) numerical competence. Objective outcomes include prevalence of comorbidity and prescribed medications. Subjective outcomes include perceptions of physical and mental health.

METHODS

A convenience sample of 502 male individuals receiving outpatient care at a Veterans Affairs Medical Center reported their demographics and answered a survey measuring objective and subjective numeracy, trust in physicians, satisfaction with role in medical decision making, perceptions of physical and mental health, and risky habits. We computed patients' body mass index (BMI) and their age-adjusted Charlson index-an extensively studied comorbidity index for predicting mortality in clinical research. We retrieved number of prescribed medications from medical records.

RESULTS

Compared with patients who had high objective numeracy, patients with low objective numeracy showed higher prevalence of comorbidities and took more prescribed medications. Compared with patients who had high subjective numeracy, patients with low subjective numeracy had more negative perceptions of their physical and mental health. These conclusions held after controlling for the effect of demographics, risky habits, BMI, trust in physicians, and satisfaction with role in decision making, suggesting that numeracy has a unique, significant contribution to health outcomes beyond the effect of these factors.

CONCLUSIONS

Our research documents for the first time that self-reported numeracy is related to perceptions of health, whereas objective numeracy is related to actual health, laying the groundwork for future research on the effect of numeracy on health outcomes.

Development of a Donor-Centered Approach to Risk Assessment: Rebalancing Nonmaleficence and Autonomy

Living kidney donors are often excluded from the shared decision making and patient-centered models that are advocated in medical practice. Thresholds for acceptable risk vary between transplant centers, and between clinicians and donors. Although donor selection committees commonly focus on medical risks, potential donors also consider nonmedical risks and burdens, which may alter their assessment of an acceptable level of medical risk. Thus, transplant centers may encounter ethical tensions between nonmaleficence and respect for donor autonomy. A donor-centered model of risk assessment and risk reconciliation would integrate the donor's values and preferences in a shared decision about their eligibility to donate. This paper argues for shifting to a donor-centered model of risk assessment, and presents a research agenda to facilitate the greater participation of donors in their own evaluation and approval processes.

Comprehension and computation in Bayesian problem solving

Humans have long been characterized as poor probabilistic reasoners when presented with explicit numerical information. Bayesian word problems provide a well-known example of this, where even highly educated and cognitively skilled individuals fail to adhere to mathematical norms. It is widely agreed that natural frequencies can facilitate Bayesian inferences relative to normalized formats (e.g., probabilities, percentages), both by clarifying logical set-subset relations and by simplifying numerical calculations. Nevertheless, between-study performance on "transparent" Bayesian problems varies widely, and generally remains rather unimpressive. We suggest there has been an over-focus on this representational facilitator (i.e., transparent problem structures) at the expense of the specific logical and numerical processing requirements and the corresponding individual abilities and skills necessary for providing Bayesian-like output given specific verbal and numerical input. We further suggest that understanding this task-individual pair could benefit from considerations from the literature on mathematical cognition, which emphasizes text comprehension and problem solving, along with contributions of online executive working memory, metacognitive regulation, and relevant stored knowledge and skills. We conclude by offering avenues for future research aimed at identifying the stages in problem solving at which correct vs. incorrect reasoners depart, and how individual differences might influence this time point.

Visual aids improve diagnostic inferences and metacognitive judgment calibration

Visual aids can improve comprehension of risks associated with medical treatments, screenings, and lifestyles. Do visual aids also help decision makers accurately assess their risk comprehension? That is, do visual aids help them become well calibrated? To address these questions, we investigated the benefits of visual aids displaying numerical information and measured accuracy of self-assessment of diagnostic inferences (i.e., metacognitive judgment calibration) controlling for individual differences in numeracy. Participants included 108 patients who made diagnostic inferences about three medical tests on the basis of information about the sensitivity and false-positive rate of the tests and disease prevalence. Half of the patients received the information in numbers without a visual aid, while the other half received numbers along with a grid representing the numerical information. In the numerical condition, many patients–especially those with low numeracy–misinterpreted the predictive value of the tests and profoundly overestimated the accuracy of their inferences. Metacognitive judgment calibration mediated the relationship between numeracy and accuracy of diagnostic inferences. In contrast, in the visual aid condition, patients at all levels of numeracy showed high-levels of inferential accuracy and metacognitive judgment calibration. Results indicate that accurate metacognitive assessment may explain the beneficial effects of visual aids and numeracy–a result that accords with theory suggesting that metacognition is an essential part of risk literacy. We conclude that well-designed risk communications can inform patients about healthrelevant numerical information while helping them assess the quality of their own risk comprehension.

Effects of Numerical Versus Foreground-Only Icon Displays on Understanding of Risk Magnitudes

The aim of this work is to advance knowledge of how to measure gist and verbatim understanding of risk magnitude information and to apply this knowledge to address whether graphics that focus on the number of people affected (the numerator of the risk ratio, i.e., the foreground) are effective displays for increasing (a) understanding of absolute and relative risk magnitudes and (b) risk avoidance. In 2 experiments, the authors examined the effects of a graphical display that used icons to represent the foreground information on measures of understanding (Experiments 1 and 2) and on perceived risk, affect, and risk aversion (Experiment 2). Consistent with prior findings, this foreground-only graphical display increased perceived risk and risk aversion; however, it also led to decreased understanding of absolute (although not relative) risk magnitudes. Methodologically, this work shows the importance of distinguishing understanding of absolute risk from understanding of relative risk magnitudes, and the need to assess gist knowledge of both types of risk. Substantively, this work shows that although using foreground-only graphical displays is an appealing risk communication strategy to increase risk aversion, doing so comes at the cost of decreased understanding of absolute risk magnitudes.

Emotionality Differences Between a Native and Foreign Language

A growing literature examines how affective processing may be weaker in a foreign language than in a native language. This article reviews mechanisms that could underlie this effect and then delves into practical implications. The most common category of explanations is that emotional resonances in the discourse context accrue to utterances because human memory is inherently associative. One application concerns forensic investigations. Compared to emotional phrases in a native language, emotional phrases heard or read in a foreign language elicit weaker skin-conductance responses (SCRs). In one study involving a mock crime, SCRs elicited by a foreign language were high and insensitive to emotionality, suggesting a stress response. A second application is decision making, given recent findings that judgments in a foreign language are influenced by emotional content. This raises the question of how to assess the real-world importance of this provocative laboratory finding. A third application is the emotional and logical appeal of advertising slogans. In multilingual regions, marketers could direct appeals to consumers in their native language to sell luxury items. In contrast, ads using a less proficient or foreign language may be most effective for selling items that will increase work productivity.

Understanding the Harms and Benefits of Cancer Screening

Objective. Decisions about cancer screenings often involve the consideration of complex and counterintuitive evidence. We investigated psychological factors that promote the comprehension of benefits and harms associated with common cancer screenings and their influence on shared decision making. Methods. In experiment 1, 256 men received information about PSA-based prostate cancer screening. In experiment 2, 355 women received information about mammography-based breast cancer screening. In both studies, information about potential screening outcomes was provided in 1 of 3 formats: text, a fact box, or a visual aid (e.g., mortality with and without screening and rate of overdiagnosis). We modeled the interplay of comprehension, perceived risks and benefits, intention to participate in screening, and desire for shared decision making. Results. Generally, visual aids were the most effective format, increasing comprehension by up to 18%. Improved comprehension was associated with 1) superior decision making (e.g., fewer intentions to participate in screening when it offered no benefit) and 2) more desire to share in decision making. However, comprehension of the evidence had a limited effect on experienced emotions, risk perceptions, and decision making among those participants who felt that the consequences of cancer were extremely severe. Conclusions. Even when information is counterintuitive and requires the integration of complex harms and benefits, user-friendly risk communications can facilitate comprehension, improve high-stakes decisions, and promote shared decision making. However, previous beliefs about the effectiveness of screening or strong fears about specific cancers may interfere with comprehension and informed decision making.

Communicating the risk of violent and offending behavior: review and introduction to this special issue

How to communicate risk of recidivism in correctional and forensic contexts has been a subject of scholarly discussion for two decades. This emerging literature, however, is sparse compared with studies on the assessment of risk for violent and offending behavior. In this special issue of Behavioral Sciences and the Law, we have gathered together empirical and review papers exemplifying promising directions and methodologies. We begin with a review of the state of the field, and lessons that can be drawn from research into medical risk assessment and risk communication, finding that many of the same principles apply to the forensic context. How risks are framed, and how numerate assessors are, affects how risk information is understood and applied. We discuss the existing research bearing on these issues, as well as the conceptual, practical, empirical, and legal implications of communicating risk using numerical or categorical risk terms. Along with the seven articles in this volume, we suggest directions for future research on measuring and communicating change, understanding and managing the statistical literacy of those who use and communicate risk assessments, and developing a theoretical framework for forensic risk communication research. We hope this volume will help integrate and invigorate research into forensic risk communication.

Numeric and graphic risk information processing of high and low numerates in the intuitive and deliberative decision modes: An eye-tracker study

The influence of numeracy on information processing of two risk communication formats (percentage and pictograph) was examined using an eye tracker. A sample from the general population (N = 159) was used. In intuitive and deliberative decision conditions, the participants were presented with a hypothetical scenario presenting a test result. The participants indicated their feelings and their perceived risk, evoked by a 17% risk level. In the intuitive decision condition, a significant correlation (r = .30) between numeracy and the order of information processing was found: the higher the numeracy, the earlier the processing of the percentage, and the lower the numeracy, the earlier the processing of the pictograph. This intuitive, initial focus on a format prevailed over the first half of the intuitive decision-making process. In the deliberative decision condition, the correlation between numeracy and order of information processing was not significant. In both decision conditions, high and low numerates processed pictograph and percentage formats with similar depths and derived similar meanings from them in terms of feelings and perceived risk. In both conditions numeracy had no effects on the degree of attention on the percentage or the pictograph (number of fixations on formats and transitions between them). The results suggest that pictographs attract low numerates’ attention, and percentages attract high numerates’ attention in the first, intuitive, phase of numeric information processing. Pictographs thus ensure low numerates’ further elaboration on numeric risk information, which is an important precondition of risk understanding and decision making.

Predicting biases in very highly educated samples: Numeracy and metacognition

We investigated the relations between numeracy and superior judgment and decision making in two large community outreach studies in Holland (n=5408). In these very highly educated samples (e.g., 30–50% held graduate degrees), the Berlin Numeracy Test was a robust predictor of financial, medical, and metacognitive task performance (i.e., lotteries, intertemporal choice, denominator neglect, and confidence judgments), independent of education, gender, age, and another numeracy assessment. Metacognitive processes partially mediated the link between numeracy and superior performance. More numerate participants performed better because they deliberated more during decision making and more accurately evaluated their judgments (e.g., less overconfidence). Results suggest that well-designed numeracy tests tend to be robust predictors of superior judgment and decision making because they simultaneously assess (1) mathematical competency and (2) metacognitive and self-regulated learning skills.