Personalised risk communication for informed decision making about entering screening programs

Nephrologists' perspectives on cancer screening in patients with chronic kidney disease: An interview study

AIM

Patients with chronic kidney disease (CKD) have an increased risk of cancer compared with the general population. Despite this, there is considerable variability in cancer screening practices among nephrologists that may reflect uncertainties about the benefits and harms of screening, the additional costs, and competing priorities among the complex issues that patients are confronted with. We aimed to describe nephrologists' perspectives and approaches to cancer screening in CKD.

METHODS

Semi-structured interviews were conducted with 29 nephrologists from 15 units across Australia and New Zealand. Interviews were transcribed and thematically analyzed.

RESULTS

Five themes were identified: empowering patients to make informed decisions (respecting patient preferences, communicating evidence-based recommendations, creating awareness of consequences, preparing for transplantation); justifiable risk taking (avoiding undue consequences in vulnerable populations, balancing the costs and benefits, warranted by long term immunosuppression, assurance of reasonable survival gains); ambiguity of evidence in supporting decisions (absence of standardized recommendations, limited transferability of population-based data); depending on a shared multidisciplinary approach (collaboration with primary health care, access to coordinated skin cancer clinics); and prioritizing current or imminent complications.

CONCLUSION

Nephrologists approach decisions about cancer screening in patients with CKD based on patient preferences, assessment of risk, justifiable survival gains, and current health priorities. Evidence-based guidelines, communication frameworks and specialist clinics may support informed and shared decision making about cancer screening in CKD.

Reactions to online colorectal cancer risk estimates among a nationally representative sample of adults who have never been screened

Data on the public's reactions to online tailored colorectal cancer (CRC) risk estimates are sparse. We assessed among 560 men and women aged 50-75 with no CRC screening history reactions to online tailored CRC estimated comparative risk (i.e., self vs. other their age and sex). Assessed were reactions to estimate (i.e., repeating back estimate, match between perceived comparative risk and estimate, accuracy and usefulness of estimate, emotional reactions), risk appraisals and screening intentions. 73% of the sample accurately repeated back their estimate; the match between perceived comparative risk and the estimate was lowest among those informed of being at higher risk. Higher estimates were viewed as less useful and evoked more negative emotions. Viewing the estimate as more useful and experiencing more negative emotions were related with higher risk appraisals and, in turn, screening intentions. These data indicate that adults at higher comparative risk resist accepting a higher risk status.

Toward Optimal Decision Making among Vulnerable Patients Referred for Cardiac Surgery: A Qualitative Analysis of Patient and Provider Perspectives

OBJECTIVES

Comprehension of risks, benefits, and alternative treatment options has been shown to be poor among patients referred for cardiac interventions. Patients' values and preferences are rarely explicitly sought. An increasing proportion of frail and older patients are undergoing complex cardiac surgical procedures with increased risk of both mortality and prolonged institutional care. We sought input from patients and caregivers to determine the optimal approach to decision making in this vulnerable patient population.

METHODS

Focus groups were held with both providers and former patients. Three focus groups were convened for Coronary Artery Bypass Graft (CABG), Valve, or CABG +Valve patients ≥ 70 y old (2-y post-op, ≤ 8-wk post-op, complicated post-op course) (n = 15). Three focus groups were convened for Intermediate Medical Care Unit (IMCU) nurses, Intensive Care Unit (ICU) nurses, surgeons, anesthesiologists and cardiac intensivists (n = 20). We used a semi-structured interview format to ask questions surrounding the informed consent process. Transcribed audio data was analyzed to develop consistent and comprehensive themes.

RESULTS

We identified 5 main themes that influence the decision making process: educational barriers, educational facilitators, patient autonomy and perceived autonomy, patient and family expectations of care, and decision making advocates. All themes were influenced by time constraints experienced in the current consent process. Patient groups expressed a desire to receive information earlier in their care to allow time to identify personal values and preferences in developing plans for treatment. Both groups strongly supported a formal approach for shared decision making with a decisional coach to provide information and facilitate communication with the care team.

CONCLUSIONS

Identifying the barriers and facilitators to patient and caretaker engagement in decision making is a key step in the development of a structured, patient-centered SDM approach. Intervention early in the decision process, the use of individualized decision aids that employ graphic risk presentations, and a dedicated decisional coach were identified by patients and providers as approaches with a high potential for success. The impact of such a formalized shared decision making process in cardiac surgery on decisional quality will need to be formally assessed. Given the trend toward older and frail patients referred for complex cardiac procedures, the need for an effective shared decision making process is compelling.

WITHDRAWN: Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases

This review is now out of date although it is correct as of the date of publication [Issue 2, 2008]. The authors are developing a new protocol which will replace this review. Publication of the protocol is expected in 2014, and serves to update the existing review and incorporate the latest evidence into a new Cochrane Review. The latest version of this review (available in 'Other versions' tab on The Cochrane Library) may still be useful to readers until the new review is published.

In 2016, the replacement review titled 'Non‐pharmacological interventions for breathlessness in advanced stages of malignant and non‐malignant diseases' was deregistered and split into four separate reviews of individual interventions: Respiratory interventions for breathlessness in adults with advanced diseases; Physical interventions for breathlessness in adults with advanced diseases; Cognitive‐emotional interventions for breathlessness in adults with advanced diseases; Multi‐dimensional interventions for breathlessness in adults with advanced diseases.

At September 2020, these replacement titles were deregistered (Multi‐dimensional interventions) or the protocols withdrawn (Cognitive‐emotional interventions; Multi‐dimensional interventions; Respiratory interventions) as they did not meet Cochrane standards or expectations.

The editorial group responsible for this previously published document have withdrawn it from publication.

Predictors of risk-based medical follow-up: a report from the Childhood Cancer Survivor Study

PURPOSE

The purpose of this study is to conduct an intervention study designed to assess the effectiveness of using a newsletter to increase medical follow-up in pediatric cancer survivors at risk of selected treatment complications.

METHODS

Survivors participating in the Childhood Cancer Survivor Study who were at least 25 years of age and at risk of cardiovascular disease, breast cancer, or osteoporosis related to previous cancer treatment were randomly assigned to receive a newsletter featuring brief health risk information or a newsletter including an insert providing more comprehensive health risk information. A follow-up survey distributed 24 months after the newsletter intervention assessed predictors of medical follow-up.

RESULTS

Overall, there were no differences found among the groups in terms of access to a treatment summary, medical follow-up, discussion of childhood cancer health risks, and medical screening for the targeted health behaviors. One exception, indicating borderline significance was that women at risk for osteoporosis who received the newsletter insert were more likely to have discussed their risk with a doctor than those who only received the brief information (10.1 % vs. 4.0 % p = 0.05). Discussion of breast cancer (OR = 2.15; 95 % CI = 1.74-2.66), heart disease (OR = 5.54; 95 % CI = 4.67-6.57) and osteoporosis (OR = 10.6; 95 % CI = 8.34-13.47) risk with physician significantly predicted report of undergoing screening for targeted behavior in previous 2 years as did physician access to treatment summary.

CONCLUSIONS

More detailed content in a newsletter had minimal effect on recommended screening. However, survivor's discussion of cancer-related risks with one's doctor significantly influenced participation in health screening. These results highlight the integral role of communication in health behavior.

IMPLICATIONS FOR CANCER SURVIVORS

This study is designed to assess communication strategies that increase medical follow-up in pediatric cancer survivors at risk of selected treatment complications. The results are of great importance not only to the pediatric oncology community but also the broad range of adult oncology medical specialties who are directly involved in the long-term medical care of this ever increasing population of cancer survivors.

Personalised risk communication for informed decision making about taking screening tests

BACKGROUND

There is a trend towards greater patient involvement in healthcare decisions. Although screening is usually perceived as good for the health of the population, there are risks associated with the tests involved. Achieving both adequate involvement of consumers and informed decision making are now seen as important goals for screening programmes. Personalised risk estimates have been shown to be effective methods of risk communication.

OBJECTIVES

To assess the effects of personalised risk communication on informed decision making by individuals taking screening tests. We also assess individual components that constitute informed decisions.

SEARCH METHODS

Two authors searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2012), MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL (EbscoHOST) and PsycINFO (OvidSP) without language restrictions. We searched from 2006 to March 2012. The date ranges for the previous searches were from 1989 to December 2005 for PsycINFO and from 1985 to December 2005 for other databases. For the original version of this review, we also searched CancerLit  and Science Citation Index (March 2001). We also reviewed the reference lists and conducted citation searches of included studies and other systematic reviews in the field, to identify any studies missed during the initial search.

SELECTION CRITERIA

Randomised controlled trials incorporating an intervention with a 'personalised risk communication element' for individuals undergoing screening procedures, and reporting measures of informed decisions and also cognitive, affective, or behavioural outcomes addressing the decision by such individuals, of whether or not to undergo screening.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed each included trial for risk of bias, and extracted data. We extracted data about the nature and setting of interventions, and relevant outcome data. We used standard statistical methods to combine data using RevMan version 5, including analysis according to different levels of detail of personalised risk communication, different conditions for screening, and studies based only on high-risk participants rather than people at 'average' risk. 

MAIN RESULTS

We included 41 studies involving 28,700 people. Nineteen new studies were identified in this update, adding to the 22 studies included in the previous two iterations of the review. Three studies measured informed decision with regard to the uptake of screening following personalised risk communication as a part of their intervention. All of these three studies were at low risk of bias and there was strong evidence that the interventions enhanced informed decision making, although with heterogeneous results. Overall 45.2% (592/1309) of participants who received personalised risk information made informed choices, compared to 20.2% (229/1135) of participants who received generic risk information. The overall odds ratios (ORs) for informed decision were 4.48 (95% confidence interval (CI) 3.62 to 5.53 for fixed effect) and 3.65 (95% CI 2.13 to 6.23 for random effects). Nine studies measured increase in knowledge, using different scales. All of these studies showed an increase in knowledge with personalised risk communication. In three studies the interventions showed a trend towards more accurate risk perception, but the evidence was of poor quality. Four out of six studies reported non-significant changes in anxiety following personalised risk communication to the participants. Overall there was a small non-significant decrease in the anxiety scores. Most studies (32/41) measured the uptake of screening tests following interventions. Our results (OR 1.15 (95% CI 1.02 to 1.29)) constitute low quality evidence, consistent with a small effect, that personalised risk communication in which a risk score was provided (6 studies) or the participants were given their categorised risk (6 studies), increases uptake of screening tests. 

AUTHORS' CONCLUSIONS

There is strong evidence from three trials that personalised risk estimates incorporated within communication interventions for screening programmes enhance informed choices. However the evidence for increasing the uptake of such screening tests with similar interventions is weak, and it is not clear if this increase is associated with informed choices. Studies included a diverse range of screening programmes. Therefore, data from this review do not allow us to draw conclusions about the best interventions to deliver personalised risk communication for enhancing informed decisions. The results are dominated by findings from the topic area of mammography and colorectal cancer. Caution is therefore required in generalising from these results, and particularly for clinical topics other than mammography and colorectal cancer screening.

Aid-assisted decision making and colorectal cancer screening: a randomized controlled trial

BACKGROUND

Shared decision making (SDM) is a widely recommended yet unproven strategy for increasing colorectal cancer (CRC) screening uptake. Previous trials of decision aids to increase SDM and CRC screening uptake have yielded mixed results.

PURPOSE

To assess the impact of decision aid-assisted SDM on CRC screening uptake.

DESIGN

RCT.

SETTING/PARTICIPANTS

The study was conducted at an urban, academic safety-net hospital and community health center between 2005 and 2010. Participants were asymptomatic, average-risk patients aged 50-75 years due for CRC screening.

INTERVENTION

Study participants (n=825) were randomized to one of two intervention arms (decision aid plus personalized risk assessment or decision aid alone) or control arm. The interventions took place just prior to a routine office visit with their primary care providers.

MAIN OUTCOME MEASURES

The primary outcome was completion of a CRC screening test within 12 months of the study visit. Logistic regression was used to identify predictors of test completion and mediators of the intervention effect. Analysis was completed in 2011.

RESULTS

Patients in the decision-aid group were more likely to complete a screening test than control patients (43.1% vs 34.8%, p=0.046) within 12 months of the study visit; conversely, test uptake for the decision aid and decision aid plus personalized risk assessment arms was similar (43.1% vs 37.1%, p=0.15). Assignment to the decision-aid arm (AOR=1.48, 95% CI=1.04, 2.10), black race (AOR=1.52, 95% CI=1.12, 2.06) and a preference for a patient-dominant decision-making approach (AOR=1.55, 95% CI=1.02, 2.35) were independent determinants of test completion. Activation of the screening discussion and enhanced screening intentions mediated the intervention effect.

CONCLUSIONS

Decision aid-assisted SDM has a modest impact on CRC screening uptake. A decision aid plus personalized risk assessment tool is no more effective than a decision aid alone.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.govNCT00251862.

Using the word 'cancer' in communication about an abnormal Pap test: finding common ground with patient-provider communication

OBJECTIVE

To investigate provider and patient views about communication regarding cervical cancer screening follow-up.

METHODS

Using qualitative analysis, we interviewed 20 providers and 10 patients from two urban clinics that serve low-income African American and Hispanic women. Semi-structured interviews and focus groups assessed familiarity with National Cancer Institute's Cancer Information Service (CIS) and reactions to a letter asking women with abnormal Pap test to telephone CIS. The letter suggested questions to ask prior to receiving follow-up.

RESULTS

No patient or provider was familiar with CIS. Providers but not patients expressed discomfort with use of the word 'cancer' in the letter and in CIS's name. Providers feared that reference to cancer would provoke fatalism and impede timely follow-up, whereas patients felt information about cancer risk was needed to prompt timely follow-up. Information providers found necessary to convey in order to accurately explain abnormal Pap tests surpassed patients' literacy levels.

CONCLUSION

Qualitative data suggest important gaps in perspective between providers and patients. There is a need to bridge the gap and overcome communication challenges to promote timely medical follow-up and have better health outcomes.

PRACTICE IMPLICATIONS

Implications and strategies for improving patient-provider education and communication about abnormal Pap test are discussed.

Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults

BACKGROUND

Breathlessness is one of the most common symptoms experienced in the advanced stages of malignant and non-malignant disease. Benzodiazepines are widely used for the relief of breathlessness in advanced diseases and are regularly recommended in the literature. However, the evidence for their use for this symptom is unclear.

OBJECTIVES

To determine the efficacy of benzodiazepines for the relief of breathlessness in patients with advanced disease.

SEARCH STRATEGY

We searched 14 electronic databases up to September 2009. We checked the reference lists of all relevant studies, key textbooks, reviews, and websites. We contacted investigators and specialists in palliative care for unpublished data.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and controlled clinical trials (CCTs) assessing the effect of benzodiazepines in relieving breathlessness in patients with advanced stages of cancer, chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), motor neurone disease (MND), and idiopathic pulmonary fibrosis (IPF).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed identified titles and abstracts. Three independent review authors performed assessment of all potentially relevant studies (full text), data extraction, and assessment of methodological quality. We carried out meta-analysis where appropriate.

MAIN RESULTS

Seven studies were identified, including 200 analysed participants with advanced cancer and COPD. Analysis of all seven studies (including a meta-analysis of six out of seven studies) did not show a beneficial effect of benzodiazepines for the relief of breathlessness in patients with advanced cancer and COPD. Furthermore, no significant effect could be observed in the prevention of breakthrough dyspnoea in cancer patients. Sensitivity analysis demonstrated no significant differences regarding type of benzodiazepine, dose, route and frequency of delivery, duration of treatment, or type of control.

AUTHORS' CONCLUSIONS

There is no evidence for a beneficial effect of benzodiazepines for the relief of breathlessness in patients with advanced cancer and COPD. There is a slight but non-significant trend towards a beneficial effect but the overall effect size is small. Benzodiazepines caused more drowsiness as an adverse effect compared to placebo, but less compared to morphine. These results justify considering benzodiazepines as a second or third-line treatment within an individual therapeutic trial, when opioids and non-pharmacological measures have failed to control breathlessness. Although a few good quality studies were included in this review, there is still a further need for well-conducted and adequately powered studies.

Involving patients in cardiovascular risk management with nurse-led clinics: a cluster randomized controlled trial

BACKGROUND

Preventive guidelines on cardiovascular risk management recommend lifestyle changes. Support for lifestyle changes may be a useful task for practice nurses, but the effect of such interventions in primary prevention is not clear. We examined the effect of involving patients in nurse-led cardiovascular risk management on lifestyle adherence and cardiovascular risk.

METHODS

We performed a cluster randomized controlled trial in 25 practices that included 615 patients. The intervention consisted of nurse-led cardiovascular risk management, including risk assessment, risk communication, a decision aid and adapted motivational interviewing. The control group received a minimal nurse-led intervention. The self-reported outcome measures at one year were smoking, alcohol use, diet and physical activity. Nurses assessed 10-year cardiovascular mortality risk after one year.

RESULTS

There were no significant differences between the intervention groups. The effect of the intervention on the consumption of vegetables and physical activity was small, and some differences were only significant for subgroups. The effects of the intervention on the intake of fat, fruit and alcohol and smoking were not significant. We found no effect between the groups for cardiovascular 10-year risk.

INTERPRETATION

Nurse-led risk communication, use of a decision aid and adapted motivational interviewing did not lead to relevant differences between the groups in terms of lifestyle changes or cardiovascular risk, despite significant within-group differences.

Conceptual problems in laypersons' understanding of individualized cancer risk: a qualitative study

OBJECTIVE

To explore laypersons' understanding of individualized cancer risk estimates, and to identify conceptual problems that may limit this understanding.

BACKGROUND

Risk prediction models are increasingly used to provide people with information about their individual risk of cancer and other diseases. However, laypersons may have difficulty understanding individualized risk information, because of conceptual as well as computational problems.

DESIGN

A qualitative study was conducted using focus groups. Semi-structured interviews explored participants' understandings of the concept of risk, and their interpretations of a hypothetical individualized colorectal cancer risk estimate.

SETTING AND PARTICIPANTS

Eight focus groups were conducted with 48 adults aged 50-74 years residing in two major US metropolitan areas. Participants had high school or greater education, some familiarity with information technology, and no personal or family history of cancer.

RESULTS

Several important conceptual problems were identified. Most participants thought of risk not as a neutral statistical concept, but as signifying danger and emotional threat, and viewed cancer risk in terms of concrete risk factors rather than mathematical probabilities. Participants had difficulty acknowledging uncertainty implicit to the concept of risk, and judging the numerical significance of individualized risk estimates. The most challenging conceptual problems related to conflict between subjective and objective understandings of risk, and difficulties translating aggregate-level objective risk estimates to the individual level.

CONCLUSIONS

Several conceptual problems limit laypersons' understanding of individualized cancer risk information. These problems have implications for future research on health numeracy, and for the application of risk prediction models in clinical and public health settings.

Making diabetes self-management education culturally relevant for Filipino Americans in Hawaii

PURPOSE

The purpose of this study was to identify the cultural values, traditions, and perceptions of diabetes risk and self-care among Filipino Americans in Hawaii with type 2 diabetes that facilitate or impede engagement in diabetes self-management behaviors and education classes.

METHODS

This qualitative study used 2 rounds of semistructured focus groups and interviews. Participants included 15 patients with type 2 diabetes recruited from a large health-maintenance organization in Hawaii and 7 health care and cultural experts recruited from the community. The taped and transcribed focus groups and interviews were coded thematically. Participants evaluated example materials for diabetes self-management education (DSME) with Filipino Americans.

RESULTS

Several aspects of Filipino American culture were identified as central to understanding the challenges of engaging in self-management behaviors and DSME: (1) undertaking self-management while prioritizing the family and maintaining social relationships, (2) modifying diet while upholding valued symbolic and social meanings of food, (3) participating in storytelling in the face of stigma associated with diabetes, and (4) reconciling spiritual and biomedical interpretations of disease causality and its management. Respondents also emphasized the role of several qualitative aspects of perceived risk (eg, dread, control) in moderating their behaviors. Participants suggested ways to make DSME culturally relevant.

CONCLUSIONS

Awareness of cultural values and qualitative aspects of perceived risk that influence Filipino Americans' engagement in diabetes self-care behaviors and classes may help to improve teaching methods, materials, and recruitment strategies.

A systematic review of decision support needs of parents making child health decisions

OBJECTIVE

To identify the decision support needs of parents attempting to make an informed health decision on behalf of a child.

CONTEXT

The first step towards implementing patient decision support is to assess patients' information and decision-making needs.

SEARCH STRATEGY

A systematic search of key bibliographic databases for decision support studies was performed in 2005. Reference lists of relevant review articles and key authors were searched. Three relevant journals were hand searched.

INCLUSION CRITERIA

Non-intervention studies containing data on decision support needs of parents making child health decisions.

DATA EXTRACTION AND SYNTHESIS

Data were extracted on study characteristics, decision focus and decision support needs. Studies were quality assessed using a pre-defined set of criteria. Data synthesis used the UK Evidence for Policy and Practice Information and Co-ordinating Centre approach.

MAIN RESULTS

One-hundred and forty nine studies were included across various child health decisions, settings and study designs. Thematic analysis of decision support needs indicated three key issues: (i) information (including suggestions about the content, delivery, source, timing); (ii) talking to others (including concerns about pressure from others); and (iii) feeling a sense of control over the process that could be influenced by emotionally charged decisions, the consultation process, and structural or service barriers. These were consistent across decision type, study design and whether or not the study focused on informed decision making.

Systematic review of implementation strategies for risk tables in the prevention of cardiovascular diseases

Background

Cardiovascular disease prevention is guided by so-called risk tables for calculating individual’s risk numbers. However, they are not widely used in routine practice and it is important to understand the conditions for their use.

Objectives

Systematic review of the literature on professionals’ performance regarding cardiovascular risk tables, in order to develop effective implementation strategies.

Selection criteria

Studies were eligible for inclusion if they reported quantitative empirical data on the effect of professional, financial, organizational or regulatory strategies on the implementation of cardiovascular risk tables. Participants were physicians or nurses.

Outcome measure

Primary: professionals’ self-reported performance related to actual use of cardiovascular risk tables. Secondary: patients’ cardiovascular risk reduction.

Data collection and analysis

An extensive strategy was used to search MEDLINE, EMBASE, CINAHL, and PSYCHINFO from database inception to February 2007.

Main results

The review included 9 studies, covering 3 types of implementation strategies (or combinations). Reported effects were moderate, sometimes conflicting and contradictory. Although no clear relation was observed between a particular type of strategy and success or failure of the implementation, promising strategies for patient selection and risk assessment seem to be teamwork, nurse led-clinics and integrated IT support.

Conclusions

Implementation strategies for cardiovascular risk tables have been sparsely studied. Future research on implementation of cardiovascular risk tables needs better embedding in the systematic and problem-based approaches developed in implementation science.

Psychological interventions for women with metastatic breast cancer

BACKGROUND

Systematic reviews of psychological interventions for patients with cancer are conflicting, some showing benefits for patients and others not. One early study appeared to show significant survival and psychological benefits from a psychological intervention given to women with metastatic breast cancer. Subsequent studies have however demonstrated conflicting results.

OBJECTIVES

To assess the effects of psychological interventions (educational, individual cognitive behavioural or psychotherapeutic, or group support) on psychological and survival outcomes for women with metastatic breast cancer.

SEARCH STRATEGY

For this update, the Cochrane Breast Cancer Group Specialised Register was searched (September 2007). Also searched were MEDLINE (1966-September 2006), CINAHL (1982-September 2006), PsycInfo (1974-September 2006), and SIGLE (1980-September 2006).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of psychological interventions for women with metastatic breast cancer. Studies which were not t 'intention to treat' were included owing to the nature of the patient group under study and the likely high loss of follow-up data.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers. Data about the nature and setting of the intervention, relevant outcome data and items relating to methodological quality were extracted.

MAIN RESULTS

Five primary studies (511 women) were identified all group psychological interventions. Two of these were cognitive behavioural interventions and three evaluated support-expressive group therapy. The five studies of group psychological therapies showed very limited evidence of benefit arising from these interventions. Although there was evidence of short-term benefit for some psychological outcomes, in general these were not sustained at follow-up. A clearer pattern of psychological outcomes could not be discerned as a wide variety of outcome measures and durations of follow-up were used in the included studies. The possible longer survival times in women allocated to receive psychological intervention in the early study have not been replicated in the subsequent four studies (including one by members of the first study group), and overall the effects of these interventions on survival are not statistically significant (for example, odds ratio for 5 year survival 0.83 (95% confidence interval [CI] 0.53 - 1.28).

AUTHORS' CONCLUSIONS

There is insufficient evidence to advocate that group psychological therapies (either cognitive behavioural or supportive-expressive) should be made available to all women diagnosed with metastatic breast cancer. Any benefits of the interventions are only evident for some of the psychological outcomes and in the short term. The possibility of the interventions causing harm is not ruled out by the available data.

The impact of different time frames of risk communication on Type 2 diabetes patients' understanding and memory for risk of coronary heart disease and stroke

AIMS

We examined the impact of communicating risk of coronary heart disease (CHD) and stroke, using three time frames (1, 5 or 10 years), on Type 2 diabetic (T2D) patients' understanding of risk of CHD/stroke and their memory for these risks.

METHODS

Patients (N = 95) estimated their risk of developing CHD/having a stroke as a result of diabetes, in one of three time frames. Using the United Kingdom Prospective Diabetes Study Risk Engine and the same time frame, patients were then given individualized, objective risk estimates of developing CHD/stroke. Following explanation of these risks, patients' risk understanding was examined by asking them to report again their risk of developing CHD/stroke. Six weeks later we assessed patient memory for these risks by asking them to recall their actual risk estimates for CHD/stroke.

RESULTS

In all time frames, we successfully reduced participants' originally inflated risk perceptions of CHD (F(1,92) = 73.01, P < 0.001) and stroke (F(1,91) = 119.05, P < 0.001), although the 10-year risk group was the most resistant to correction for both CHD (F(1,90) = 9.32, P < 0.001) and stroke (F(2,88) = 3.97, P < 0.02). Participants' recall of their stroke risk at 6 weeks regressed towards original, inflated risk perceptions for the 10-year group only (F(4,176) = 4.73, P < 0.001).

CONCLUSION

Patients' inflated perceptions of CHD/stroke risk can be easily corrected using shorter (1- or 5-year) risk communication time frames.

Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases

BACKGROUND

Breathlessness is a common and distressing symptom in the advanced stages of malignant and non-malignant diseases. Appropriate management requires both pharmacological and non-pharmacological interventions.

OBJECTIVES

The primary objective was to determine the effectiveness of non-pharmacological and non-invasive interventions to relieve breathlessness in participants suffering from the five most common conditions causing breathlessness in advanced disease.

SEARCH STRATEGY

We searched the following databases: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, British Nursing Index, PsycINFO, Science Citation Index Expanded, AMED, The Cochrane Pain, Palliative and Supportive Care Trials Register, The Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effectiveness in June 2007. We also searched various websites and reference lists of relevant articles and textbooks.

SELECTION CRITERIA

We included randomised controlled and controlled clinical trials assessing the effects of non-pharmacological and non-invasive interventions to relieve breathlessness in participants described as suffering from breathlessness due to advanced stages of cancer, chronic obstructive pulmonary disease (COPD), interstitial lung disease, chronic heart failure or motor neurone disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed relevant studies for inclusion. Data extraction and quality assessment was performed by three review authors and checked by two other review authors. Meta-analysis was not attempted due to heterogeneity of studies.

MAIN RESULTS

Forty-seven studies were included (2532 participants) and categorised as follows: single component interventions with subcategories of walking aids (n = 7), distractive auditory stimuli (music) (n = 6), chest wall vibration (CWV, n = 5), acupuncture/acupressure (n = 5), relaxation (n = 4), neuro-electrical muscle stimulation (NMES, n = 3) and fan (n = 2). Multi-component interventions were categorised in to counselling and support (n = 5), breathing training (n = 3), counselling and support with breathing-relaxation training (n = 2), case management (n = 2) and psychotherapy (n = 2). There was a high strength of evidence that NMES and CWV could relieve breathlessness and moderate strength for the use of walking aids and breathing training. There is a low strength of evidence that acupuncture/acupressure is helpful. There is not enough data to judge the evidence for distractive auditory stimuli (music), relaxation, fan, counselling and support, counselling and support with breathing-relaxation training, case management and psychotherapy. Most studies have been conducted in COPD patients, only a few studies included participants with other conditions.

AUTHORS' CONCLUSIONS

Breathing training, walking aids, NMES and CWV appear to be effective non-pharmacological interventions for relieving breathlessness in advanced stages of disease.

Health literacy and the information needs and dilemmas of first-time mothers over 35 years

AIM AND OBJECTIVES

This paper aims to highlight the information-based dilemmas of a particular group of healthcare patients, first-time mothers over 35 years.

BACKGROUND

In recent years, there has been a proliferation of health-related information and a move towards greater public access to health information as an important step towards patient education and empowerment. Information technologies, such as the Internet, have added considerable momentum to this trend. Many health professionals now consider the provision of detailed health information to patients as requisite for informed decision making. Within the literature there is some emphasis on the importance of patient understanding of information received; however, to date, few studies have considered information over-consumption as problematic.

METHODS

Using in-depth interviews, a sample of 22 first-time mothers over 35 years was interviewed over three junctures: 35 weeks gestation, 10-14 days postpartum and six to eight months postpartum. Three focus group interviews of midwives and maternal and child health nurses were also conducted. This paper was undertaken as part of a larger project to evaluate the experience of first mothering over 35 years.

RESULTS

Mothers in this study were found to have access to large volumes of health information. This tendency was driven by both the women and the health professionals who cared for them. Midwives and maternal and child health nurses revealed a tendency to provide older first-time mothers with considerable health information of a medical orientation, understanding that this is what the women required. However, despite common perceptions of empowerment, the consumption of medical-type information proved frightening and many mothers described feeling overwhelmed by 'knowing too much'.

CONCLUSION

This study contributes to the limited understanding of the information needs of a growing group of childbearing women, first-time mothers over 35 years. By providing an insight into the 'downside' of extensive health information, nursing staff, in particular, may consider the amount and type of information they distribute. Some suggestions are offered to health professionals to ameliorate the information-based dilemmas of these women.

RELEVANCE TO CLINICAL PRACTICE

As the number of childbearing women over 35 years continues to grow, it is important for health professionals to understand the particular needs of this group. In doing so, doctors, midwives and maternal and child health nurses may be in a position to provide more meaningful maternal support.

Numeracy skill and the communication, comprehension, and use of risk-benefit information

Current health care policy emphasizes improving health outcomes and the efficacy of health care delivery by supporting informed consumer choices. At the same time, health information often involves uncertainty, and many people may lack the skills and knowledge to process this information, manage their health and health care, and make informed choices. Innumeracy, an element of poor health literacy, is associated with the comprehension and use of important health information. We review this literature and examine what can be done to help less numerate people act more effectively and take charge of their health.

Risk assessment in diabetes management: how do general practitioners estimate risks due to diabetes?

OBJECTIVES

To evaluate the ability of general practitioners (GPs) in Germany to estimate the risk of patients with diabetes developing complications.

METHODS

An interview study using a structured questionnaire to estimate risks of four case vignettes having diabetes-specific complications within the next 10 years, risk reduction and life expectancy potential. A representative random sample of 584 GPs has been drawn, of which 150 could be interviewed. We compared GPs' estimates among each other (intraclass correlation coefficient (ICC) and Cohen's (multirater-) kappa) and with risks for long-term complications generated by the multifactor disease model "Mellibase", which is a knowledge-based support system for medical decision management.

RESULTS

The risk estimates by GPs varied widely (ICC 0.21 95% CI (0.13 to 0.36)). The average level of potential risk reduction was between 47% and 70%. Compared with Mellibase values, on average, the GPs overestimated the risk threefold. Mean estimates of potential prolongation of life expectancy were close to 10 years for each patient, whereas the Mellibase calculations ranged from 3 to 10 years.

CONCLUSIONS

Overestimation could lead to unnecessary care and waste of resources.

An Evaluation of Internet Websites Provided by Radiotherapy Departments

The research identifies and evaluates the content and readability of Websites of all radiotherapy departments that provide a Website. As more patients are being referred for radiotherapy treatment each year, the information needs of the public on this subject is growing. Fifty-two per cent of radiotherapy departments within the United Kingdom (UK) and Ireland were identified as providing a Website. These Websites were evaluated, over a period of 2 weeks, using an adapted Website evaluation tool. Five criteria – content, authority, navigation, design and technical aspects – were identified as important aspects of a Website. For each criterion a number of statements were listed and using a Likert scale were marked. Flesch–Kincaid readability tests were used to analyse the readability level of the Websites. Data analysis resulted in the ranking of the Websites. Evaluation scores varied greatly and the readability tests showed 92% of the Websites were written at a level too high for the public. This shows the varying quality of radiotherapy department Websites with scores ranging from 48 to 115, and the varying readability level of these Websites. The research makes suggestions for the improvement of radiotherapy department Websites including the provision of a dedicated Website team within the department, educated in Website design.

Informed choice in screening programmes: Do leaflets help? A critical literature review

BACKGROUND

Screening programmes aim to maximise population benefit by maximizing uptake but must also allow informed choice about participation. Many programmes provide potential participants with information leaflets. This article reviews studies of the effectiveness of leaflets in promoting informed choice in screening.

METHODS

I searched 15 electronic databases and the websites of UK screening programmes, searched the bibliographies of identified studies and contacted experts in the field. Randomized controlled trials (RCTs) and controlled clinical trials where an attempt had been made to determine the contribution of leaflets to the exercise of informed choice in screening decisions were included.

RESULTS

I identified nine trials from various screening programmes. Outcome measures included knowledge, attitudes to screening, intention to be screened, uptake, anxiety, satisfaction with decision-making, discussions about screening with care providers and agreement that enough information had been provided to allow informed choice. Most studies demonstrated that providing written information increased knowledge, but evidence that this promoted informed choice was poor.

CONCLUSIONS

Research into informed choice in screening is hampered by the lack of agreement about its definition and measurement. The most effective way for screening programmes to achieve informed choice is unclear. Programmes should not rely solely on providing written information but should explore additional ways to promote informed choice.

Personalised risk communication for informed decision making about taking screening tests

BACKGROUND

There is a trend towards greater patient involvement in healthcare decisions. Adequate discussion of the risks and benefits associated with different choices is often required if involvement is to be genuine and effective. Achieving both the adequate involvement of consumers and informed decision making are now seen as important goals for any screening programme. Personalised risk estimates have been shown to be effective methods of risk communication in general, but the effectiveness of different strategies has not previously been examined.

OBJECTIVES

To assess the effects of different types of personalised risk communication for consumers making decisions about taking screening tests.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2004), MEDLINE (1985 to December 2005), EMBASE (1985 to December 2005), CINAHL (1985 to December 2005), and PsycINFO (1989 to December 2005). Follow-up searches involved hand searching Preventive Medicine, citation searches on seven authors, and searching reference lists of articles. For the original version of this review (Edwards 2003c) we also searched CancerLit (1985 to 2001) and Science Citation Index Expanded (searched March 2002).

SELECTION CRITERIA

Randomised controlled trials addressing the decision by consumers of whether or not to undergo screening, incorporating an intervention with a 'personalised risk communication element' and reporting cognitive, affective, or behavioural outcomes. A 'personalised risk communication element' is based on the individual's own risk factors for a condition (such as age or family history). It may be calculated from an individual's risk factors using formulae derived from epidemiological data, and presented as an absolute or relative risk or as a risk score, or it may be categorised into, for example, high, medium or low risk groups. It may be less detailed still, involving a listing, for example, of a consumer's risk factors as a focus for discussion and intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed each trial for quality and extracted data. We extracted data about the nature and setting of the intervention, and relevant outcome data, along with items relating to methodological quality. We then used standard statistical methods of the Consumers and Communication Review Group to combine data using MetaView, including analysis according to different levels of detail of personalised risk communication, different condition for screening, and studies based only on high risk participants rather than people at 'average' risk.

MAIN RESULTS

Twenty-two studies were included, nine of which were added in the 2006 update of this review. There was weak evidence, consistent with a small effect, that personalised risk communication (whether written, spoken or visually presented) increases uptake of screening tests (odds ratio (OR) 1.31 (random effects, 95% confidence interval (CI) 0.98 to 1.77). In three studies the interventions showed a trend towards more accurate risk perception (OR 1.65 (95% CI 0.96 to 2.81), and three other trials with heterogenous outcome measures showed improvements in knowledge with personalised risk interventions. There was little other evidence from these studies that the interventions promoted or achieved informed decision making by consumers about participation in screening. More detailed personalised risk communication may be associated with a smaller increase in uptake of tests. That is, for personalised risk communication which used and presented numerical calculations of risk, the OR for test uptake was 0.82 (95% CI 0.65 to 1.03). For risk estimates or calculations which were categorised into high, medium or low strata of risk, the OR was 1.42 (95% CI 1.07 to 1.89). For risk communication that simply listed personal risk factors the OR was 1.42 (95% CI 0.95 to 2.12). Over half of the included studies assessed interventions in the context of mammography. These studies showed similar effects to the overall dataset. The five studies examining risk communication in high risk individuals (individuals at higher risk due to, for example, a family history of breast cancer or other conditions) showed larger odds ratios for uptake of tests than the other studies (random effects OR 1.74; 95% CI 1.05 to 2.88). There were insufficient data from the included studies to report odds ratios on other key outcomes such as: intention to take tests, anxiety, satisfaction with decisions, decisional conflict, knowledge and resource use.

AUTHORS' CONCLUSIONS

Personalised risk communication (as currently implemented in the included studies) may have a small effect on increasing uptake of screening tests, and there is only limited evidence that the interventions have promoted or achieved informed decision making by consumers.

Print information to inform decisions about mammography screening participation in 16 countries with population-based programs

OBJECTIVE

To profile and compare the content and presentation of written communications related to informed decision-making about mammography.

METHODS

Materials from 16 screening programs organized at the national or regional level were analyzed according to five major information domains suggested by the international literature.

RESULTS

A majority of countries provided information on the program (interval, cost and quality). There was considerable variability in comprehensiveness of elements in the domains, e.g., test characteristics (false positive/negative) and pros and cons of screening. The majority noted the likelihood of recall for further tests, few commented on the risks of additional tests or finding unimportant tumors. The audit also found variation in presentation (words and pictures).

CONCLUSIONS

Presentation of comprehensive, but balanced information on screening benefits and risks is complex and daunting. Issues such as framing effects, coupled with debate about screening efficacy are challenging to the design of effective information tools. The objective of increasing screening prevalence at the population level must be balanced with objectively presenting complete and clear information. Additional research is needed on how information (and mode of presentation) impact screening decisions.

PRACTICE IMPLICATIONS

Public health officials need to articulate their objectives and review written communication according to important decision-making domains.

Efficacy of a simple, low-cost educational intervention in improving knowledge about risks and benefits of screening mammography

OBJECTIVES

To assess the efficacy of a minimal cost and involvement educational intervention in improving women's knowledge about screening mammography and to explore patient perceptions of the educational intervention.

PARTICIPANTS AND METHODS

During the study period (March 10, 2005, to July 1, 2005), 1446 participants in the Mayo Mammography Health Study scheduled for a mammogram within 4 weeks at the Mayo Clinic in Rochester, Minn, were randomized to 2 study groups and mailed surveys about mammograms. The 2 groups received separate surveys; both surveys contained knowledge-based questions about mammography, but the educational intervention group survey also contained qualitative questions that assessed the educational pamphlets.

RESULTS

Of the 668 surveys returned (responders), 248 (34.4%) were from the control group, and 420 (58.3%) were from the intervention group. Approximately 80% of responders had had more than 7 prior mammograms. Significant increases in knowledge about mammography were found in the educational intervention compared with the control group on questions regarding age to begin screening mammography (67.9% vs 54.4%; P < .001), recommended frequency of mammograms (86.4% vs 75.4%; P < .001), overall reduction in mortality due to screening mammography (55.2% vs 8.9%; P < .001), and proportions of women who required follow-up mammograms (35.5% vs 14.9%; P < .001) or biopsy (59.5% vs 13.3%; P < .001). Qualitative data results indicated that most women who received the educational intervention found the pamphlets helpful and informative despite having had many previous mammograms.

CONCLUSION

The results suggest that providing women scheduled for screening mammograms with physician-approved educational material before their appointment significantly increases knowledge about screening mammography, risks and benefits, and possible follow-up.

An evaluation of the Decisional Conflict Scale for measuring the quality of end-of-life decision making

OBJECTIVE

Researchers and clinicians acknowledge the complexity of planning for future medical treatment desired in the event of incapacitation. Unfortunately, many attempts to evaluate the quality of such difficult planning have been stymied by the lack of measures that can be shown to have validity. This study examines the psychometric characteristics of the Decisional Conflict Scale (DCS) when used as a measure of patients' evaluation of their end-of-life decision-making process.

METHODS

This evaluation used the combined data from two independent samples in which 59 outpatients with a life-threatening illness and their surrogate decision makers were assigned to receive, a decision aid intervention, the patient-centered advance care planning (PcACP), or usual care only.

RESULTS

Internal consistency for the DCS in the end-of-life decision-making context was high. The DCS demonstrated convergent, construct, and discriminant validity based on the total scale scores.

CONCLUSION

The DCS appears to be a viable research instrument for measuring the quality of end-of-life decision making. However, the uncertainty subscale showed a weak discriminating ability and lack of association with the two other subscales, the modifiable factors contributing to uncertainty and the effectiveness of the decision making.

PRACTICE IMPLICATIONS

The findings of the study can be useful for measuring decisional conflict in individuals with serious illness facing end-of-life decision making.

Reduction in uptake of PSA tests following decision aids: systematic review of current aids and their evaluations

A man's decision to have a prostate-specific antigen (PSA) test should be an informed one. We undertook a systematic review to identify and appraise PSA decision aids and evaluations. We searched 15 electronic databases and hand-searched key journals. We also contacted key authors and organisations. All decision aids and evaluations that discussed PSA were included, with meta-analyses performed on two outcomes from the evaluations: PSA testing and patient knowledge of PSA and related issues. Seven decision aids and 11 evaluations were included. The meta-analysis showed a significantly reduced probability in PSA testing after a decision aid: -3.5% (95% confidence interval: 0.0 to 7.2%; P = 0.050). There were significant improvements in knowledge within 2 weeks after a decision aid: 19.5% (95% confidence interval: 14.2 to 24.8%; P < 0.001). The effect on knowledge was less pronounced within 12-18 months after a decision aid: 3.4% (95% confidence interval: -0.7 to 7.4%; P = 0.10). PSA decision aids improve knowledge about PSA testing, at least in the short term. Men given these decision aids seem to be less likely to have the PSA test.

A qualitative study of women's decision-making at the end of IVF treatment

BACKGROUND

The decision not to pursue further in vitro fertilization (IVF) after one or more unsuccessful attempts is an important and often difficult one for couples. Relatively little is known about the woman's perception of this decision-making process. The aim of this study was to examine patients' perspectives of decision-making, including circumstances influencing it and satisfaction with the decision-making process.

METHODS

Semi-structured interviews were conducted with a purposive sample of 25 women who had decided to end treatment after unsuccessful IVF treatment. Interviews were tape-recorded and transcribed by means of thematic analysis using the open coding technique.

RESULTS

Women experienced difficulty in accepting that their infertility would remain unresolved. Many felt that they had started with unrealistic expectations of treatment success and felt vulnerable to the pressures of both the media and society. Although the decision to end treatment was difficult, it offered many women a way out of the emotional distress caused by IVF; however, the process of decision-making created a sense of 'confrontation' for the women in which they had to address issues they had previously avoided. Adoptive parents perceived less societal pressure than those who remained childless.

CONCLUSIONS

Efforts to improve the psychological preparation of couples who decide to end IVF treatment should be directed towards examination of the existing system of consultation, which has certain limitations in terms of the quality of communication and the provision of post-treatment support. Further efforts to develop strategies, which facilitate the decision-making process, should be considered.

A critical dialogue: communicating with type 2 diabetes patients about cardiovascular risk

Patients with type 2 diabetes mellitus (DM) are at increased risk for cardiovascular disease (CVD), and many patients are inadequately treated for risk factors such as hyperglycemia, hyperlipidemia, hypertension, and smoking. Providing individualized risk information in a clear and engaging manner may serve to encourage both patients and their physicians to intensify risk-reducing behaviors and therapies. This review outlines simple and effective methods for making CVD risk information understandable to persons of all levels of literacy and mathematical ability. To allow the patient to understand what might happen and how, personal risk factors should be clearly communicated and the potential consequences of a CVD event should be presented in a graphic but factual manner. Risk calculation software can provide CVD risk estimates, and the resulting information can be made understandable by assigning risk severity (eg, "high") by comparing clinical parameters with accepted treatment targets and by comparing the individual's risk with that of the "average" person. Patients must also be informed about how they might reduce their CVD risk and be supported in these efforts. Thoughtful risk communication using these techniques can improve access to health information for individuals of low literacy, especially when interactive computer technology is employed. Research is needed to find the best methods for communicating risk in daily clinical practice.

Affect, risk, and decision making

Risk is perceived and acted on in 2 fundamental ways. Risk as feelings refers to individuals' fast, instinctive, and intuitive reactions to danger. Risk as analysis brings logic, reason, and scientific deliberation to bear on risk management. Reliance on risk as feelings is described with "the affect heuristic." The authors trace the development of this heuristic across a variety of research paths. The authors also discuss some of the important practical implications resulting from ways that this heuristic impacts how people perceive and evaluate risk, and, more generally, how it influences all human decision making. Finally, some important implications of the affect heuristic for communication and decision making pertaining to cancer prevention and treatment are briefly discussed.

Psychological interventions for women with metastatic breast cancer

BACKGROUND

There have been conflicting results from systematic reviews of psychological interventions for patients with cancer, some showing benefits for patients and others not. One early study appeared to show significant survival benefits as well as psychological benefits from a psychological intervention given to women with metastatic breast cancer. Some further studies have been undertaken, again with conflicting results.

OBJECTIVES

To assess the effects of psychological interventions (educational, individual cognitive behavioural or psychotherapeutic, or group support) on psychological and survival outcomes for women with metastatic breast cancer.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group Trials Register (September 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2003), MEDLINE (1966-October 2003), CancerLit (1983-2000), CINAHL (1982-October 2003), PsycInfo (1974-November 2003), and SIGLE (1980-November 2003).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of psychological interventions for women with metastatic breast cancer. Studies were included even if they were not 'intention to treat', owing to the nature of the patient group under study and the likely high loss of follow-up data.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers. Data about the nature and setting of the intervention, and the relevant outcome data were extracted, along with items relating to methodological quality.

MAIN RESULTS

Five primary studies were identified, all group psychological interventions. Two of these were cognitive behavioural interventions and three evaluated support-expressive group therapy. The five studies of group psychological therapies for women with metastatic breast cancer showed very limited evidence of benefit arising from these interventions. Although there was evidence of short-term benefit for some psychological outcomes, in general these were not sustained at follow-up. A clearer pattern of psychological outcomes could not be discerned as a wide variety of outcome measures and durations of follow-up were used in the included studies. The possible longer survival times in women allocated to receive psychological intervention in the early study have not been replicated in the subsequent four studies (including one by members of the first study group), and overall the effects of these interventions on survival are not statistically significant (for example, odds ratio for 5 year survival 0.83 (95% confidence interval [CI] 0.53 - 1.28).

REVIEWERS' CONCLUSIONS

There is insufficient evidence to advocate that group psychological therapies (either cognitive behavioural or supportive-expressive) should be made available to all women diagnosed with metastatic breast cancer. Any benefits of the interventions are only evident for some of the psychological outcomes and in the short term. The possibility of the interventions causing harm is not ruled out by the available data.

Women need better information about routine mammography

Scientists continue to argue about the benefits of breast screening, but ultimately decisions about screening should be made by women themselves. To make this decision, however, women need to fully understand both the benefits and the potential harms