Who profits from visual aids: overcoming challenges in people's understanding of risks [corrected]

Probability overestimation induced by icon arrays

In decision making under risk, where the consequences of choices vary depending on specific probabilities, a proper interpretation of the presented probabilities is essential. However, because people are not good at evaluating numerical values, such as percentages, efforts have been made to accurately convey presented probabilities using visual aids represented by icon arrays. However, previous studies have suggested that icon arrays produce an overestimation of probabilities under specific conditions. Especially, (a) the arrangement of highlighted icons and (b) the severity of the outcomes represented by highlighted icons can lead to an overestimation of probabilities. By considering the absolute estimation of probabilities indicated by icon arrays and manipulating the aforementioned factors, this study investigated whether these factors could elicit an overestimation of probabilities in an additive manner or whether they have interactive effects. Two studies (total N = 1171) consistently showed that the arrangement of highlighted icons and the outcome severity they indicate induced a perceptual bias in the estimation of the probabilities presented in icon arrays in an additive manner. When the highlighted icons were random and the outcomes they indicate were severe, the probabilities presented by the icon arrays were overestimated. Accordingly, the study not only confirms the robustness of the findings of previous studies but also expand our understanding of the probability overestimation caused by icon arrays. Here, we discuss our findings in terms of the impact of risk-related communication.

"R" you getting this? Factors contributing to the public's understanding, evaluation, and use of basic reproduction numbers for infectious diseases

BACKGROUND

We (1) examined the effects of evaluative labels and visual aids on people's understanding, evaluation, and use of the COVID-19 reproduction number (or "r-number"), (2) examined whether people's perceived susceptibility and (intended) adherence to preventive measures changed after being exposed to the r-number, and (3) explored whether these effects and changes depended on people's numeracy skills.

METHODS

In an online experiment, participants from a large Dutch representative sample (N = 1,168) received information about the COVID-19 r-number displayed on the corona dashboard of the Dutch Ministry of Health, Welfare and Sport. The r-number was either presented with or without a categorical line display (i.e., evaluative label) and with or without an icon-based tree diagram (i.e., visual aid) explaining how the number works. Regarding people's use of the statistic, we measured perceived susceptibility to COVID-19 and adherence (intention) to five preventive measures before and after exposure to the r-number. After exposure, we also measured participants' understanding, perceived usefulness, affective and cognitive evaluation, and objective numeracy.

RESULTS

About 56% of participants correctly interpreted the r-number, with highly numerate people having better understanding than less numerate people. Information about the r-number was perceived as more useful when presented with a visual aid. There were no differences across experimental conditions in people's understanding, affective, and cognitive evaluations. Finally, independent of experimental conditions, intention to adhere to preventive measures was higher after seeing the r-number, but only among highly numerate people.

CONCLUSIONS

Although evaluative labels and visual aids did not facilitate people's understanding and evaluation of the r-number, our results show that the statistic is perceived as useful and may be used to stimulate adherence to preventive measures. Policy makers and public health communicators are advised to clearly explain why they are giving these numbers to - especially - the less numerate people, but also how people could use them for behavior change to combat the spread of virus during a pandemic.

Communicating the results of risk-based breast cancer screening through visualizations of risk: a participatory design approach

BACKGROUND

Risk-based breast cancer (BC) screening raises new questions regarding information provision and risk communication. This study aimed to: 1) investigate women's beliefs and knowledge (i.e., mental models) regarding BC risk and (risk-based) BC screening in view of implications for information development; 2) develop novel informational materials to communicate the screening result in risk-based BC screening, including risk visualizations of both quantitative and qualitative information, from a Human-Centered Design perspective.

METHODS

Phase 1: Interviews were conducted (n = 15, 40-50 years, 5 lower health literate) on women's beliefs about BC risk and (risk-based) BC screening. Phase 2: In three participatory design sessions, women (n = 4-6 across sessions, 40-50 years, 2-3 lower health literate) made assignments and created and evaluated visualizations of risk information central to the screening result. Prototypes were evaluated in two additional sessions (n = 2, 54-62 years, 0-1 lower health literate). Phase 3: Experts (n = 5) and women (n = 9, 40-74 years) evaluated the resulting materials. Two other experts were consulted throughout the development process to ensure that the content of the information materials was accurate. Interviews were transcribed literally and analysed using qualitative thematic analysis, focusing on implications for information development. Notes, assignments and materials from the participatory design sessions were summarized and main themes were identified.

RESULTS

Women in both interviews and design sessions were positive about risk-based BC screening, especially because personal risk factors would be taken into account. However, they emphasized that the rationale of risk-based screening and classification into a risk category should be clearly stated and visualized, especially for higher- and lower-risk categories (which may cause anxiety or feelings of unfairness due to a lower screening frequency). Women wanted to know their personal risk, preferably visualized in an icon array, and wanted advice on risk reduction and breast self-examination. However, most risk factors were considered modifiable by women, and the risk factor breast density was not known, implying that information should emphasize that BC risk depends on multiple factors, including breast density.

CONCLUSIONS

The information materials, including risk visualizations of both quantitative and qualitative information, developed from a Human-Centered Design perspective and a mental model approach, were positively evaluated by the target group.

Telephone versus in-person genetic counseling for hereditary cancer risk: Patient predictors of differential outcomes

PURPOSE

Telegenetics has become the predominant mode of cancer genetic counseling during the COVID-19 pandemic. We sought to identify potential patient-level contraindicators for telegenetic genetic counseling.

METHODS

We analyzed post-counseling (pre-result disclosure) follow-up data from a randomized noninferiority trial of a telephone genetic counseling versus usual care genetic counseling. Among 669 randomized participants, 600 completed pre-test counseling and 568 completed a 2-week follow-up assessment before receiving test results. In this analysis, we focused on genetic counseling outcomes (knowledge, decisional conflict, and distress). In multivariate models controlling for bivariate predictors of these outcomes, we tested our a priori hypotheses that pre-counseling numeracy, perceived stress, and race/ethnicity would moderate the outcomes of telephone genetic counseling versus usual care.

RESULTS

Only numeracy significantly moderated associations between mode of genetic counseling and outcomes. Higher numeracy was associated with higher post-counseling knowledge following telephone genetic counseling (p < 0.001), but not usual care (p = 0.450). Higher numeracy was also associated with lower distress following telephone genetic counseling (p = 0.009) but not usual care (p = 0.16). Neither perceived stress nor race/ethnicity exhibited differential impacts on telephone genetic counseling versus usual care (ps > 0.20).

CONCLUSION

Although high numeracy was associated with higher levels of knowledge following telegenetic counseling, we did not identify any clinically significant patient-level contraindicators for telegenetic counseling. These results lend further confidence to the broad use of telegenetics.

Picture this: Evaluating the efficacy of genetic counseling visual aids

Visual aids have been validated as effective tools for educating patients in a variety of medical settings. However, research exploring the efficacy and potential benefit of genetic counseling visual aids is lacking. To begin to address this gap, this study assessed participant knowledge of genetic counseling concepts after viewing either visual or non-visual educational content. Participants were recruited from the general population using the crowdsourcing platform Mechanical Turk. Wilcoxon rank-sum tests were carried out to evaluate differences in knowledge survey scores between the visual and non-visual groups, and Poisson regression models were fitted to evaluate these differences across a variety of demographic backgrounds. The visual group had equal or higher scores than the non-visual group across all analyses. The difference in group scores was statistically significant for autosomal recessive inheritance knowledge scores (p < 0.05). In addition, this difference was approaching significance for higher-level knowledge scores (p = 0.05) and total knowledge scores in individuals who have not completed post-secondary education (p = 0.05). These results indicate that visual aids improve knowledge of specific genetic counseling concepts such as inheritance patterns; the education of which is often integral to genetic counseling. These results also indicate that visual aids may facilitate a deeper understanding of genetic counseling concepts and may be particularly valuable for individuals with lower educational backgrounds. Together, the results of this study support the inclusion of visual aids in genetic counseling education to help improve patient understanding and the accessibility of genetic healthcare information.

Use of visual aids in general practice consultations: A questionnaire-based survey

Objectives

Visual aids (VAs) seem effective to improve doctor-patient communication. The objective was to describe how VAs are used in consultation and what French general practitioners (GPs) expect of them.

Methods

Cross-sectional study using a self-administered questionnaire among French GPs in 2019. Descriptive and multinominal logistic regression analyses were performed.

Results

Of the 376 respondents, 70% used VAs at least weekly and 34% daily; 94% considered VAs useful/very useful; 77% felt they did not use VAs enough. Sketches were the most used VAs and considered the most useful. Younger age was significantly associated with a higher rate of use of simple digital images. VAs were mainly used to describe anatomy and facilitate patient comprehension. Main reasons for not using VAs more often were time spent searching, lack of habit and poor quality of available VAs. Many GPs requested a database of good quality VAs.

Conclusions

GPs use VAs regularly in consultations but would like to use them more often. Informing GPs of the usefulness of VAs, training them to draw adapted sketches and creating a good quality databank are some possible strategies to increase the use of VAs.

Innovation

This study described in detail the use of VAs as tool for doctor-patient communication.

Communication of benefits and harms in shared decision making with patients with limited health literacy: A systematic review of risk communication strategies

OBJECTIVES

Risk communication (RC), as part of shared decision making, is challenging with people with limited health literacy (LHL). We aim to provide an overview of strategies to communicate benefits and harms of diagnostic and treatment options to this group.

METHODS

We systematically searched PubMed, Embase, Cinahl and PsycInfo. We included 28 studies on RC in informed/shared decision making without restriction to a health setting or condition and using a broad conceptualization of health literacy. Two researchers independently selected studies and one researcher performed data extraction. We descriptively compared findings for people with LHL towards recommendations for RC.

RESULTS

Health literacy levels varied in the included studies. Most studies used experimental designs, primarily on visual RC. Findings show verbal RC alone should be avoided. Framing of risk information influences risk perception (less risky when positively framed, riskier when negatively framed). Most studies recommended the use of icon arrays. Graph literacy should be considered when using visual RC.

CONCLUSIONS

The limited available evidence suggests that recommended RC strategies seem mainly to be valid for people with LHL, but more research is required.

PRACTICE IMPLICATIONS

More qualitative research involving people with LHL is needed to gain further in-depth insights into optimal RC strategies.

PROTOCOL REGISTRATION

PROSPERO ID 275022.

The Lure of Beauty: People Select Representations of Statistical Information Largely Based on Attractiveness, Not Comprehensibility

OBJECTIVE

People differ in whether they understand graphical or numerical representations of statistical information better. However, assessing these skills is often not feasible when deciding which representation to select or use. This study investigates whether people choose the representation they understand better, whether this choice can improve risk comprehension, and whether results are influenced by participants' skills (graph literacy and numeracy).

METHODS

In an experiment, 160 participants received information about the benefits and side effects of painkillers using either a numerical or a graphical representation. In the "no choice" condition, the representation was randomly assigned to each participant. In the "choice" condition, participants could select the representation they would like to receive. The study assessed gist and verbatim knowledge (immediate comprehension and recall), accessibility of the information, attractiveness of the representation, as well as graph literacy and numeracy.

RESULTS

In the "choice" condition, most (62.5%) chose the graphical format, yet there was no difference in graph literacy or numeracy (nor age or gender) between people who chose the graphical or the numerical format. Whereas choice slightly increased verbatim knowledge, it did not improve gist or overall knowledge compared with random assignment. However, participants who chose a representation rated the representation as more attractive, and those who chose graphs rated them as more accessible than those without a choice.

LIMITATIONS

The sample consisted of highly educated undergraduate students with higher graph literacy than the general population. The task was inconsequential for participants in terms of their health.

CONCLUSIONS

When people can choose between representations, they fail to identify what they comprehend better but largely base that choice on how attractive the representation is for them.

HIGHLIGHTS

People differ systematically in whether they understand graphical or numerical representations of statistical information better. However, assessing these underlying skills to get the right representation to the right people is not feasible in practice. A simple and efficient method to achieve this could be to let people choose among representations themselves.However, our study showed that allowing participants to choose a representation (numerical v. graphical) did not improve overall or gist knowledge compared with determining the representation randomly, even though it did slightly improve verbatim knowledge.Rather, participants largely chose the representation they found more attractive. Most preferred the graphical representation, including those with low graph literacy.It would therefore be important to develop graphical representations that are not only attractive but also comprehensible even for people with low graph literacy.

Effect of different visual presentations on the public's comprehension of prognostic information using acute and chronic condition scenarios: two online randomised controlled trials

OBJECTIVES

To assess the effectiveness of bar graph, pictograph and line graph compared with text-only, and to each other, for communicating prognosis to the public.

DESIGN

Two online four-arm parallel-group randomised controlled trials. Statistical significance was set at p<0.016 to allow for three-primary comparisons.

PARTICIPANTS AND SETTING

Two Australian samples were recruited from members registered at Dynata online survey company. In trial A: 470 participants were randomised to one of the four arms, 417 were included in the analysis. In trial B: 499 were randomised and 433 were analysed.

INTERVENTIONS

In each trial four visual presentations were tested: bar graph, pictograph, line graph and text-only. Trial A communicated prognostic information about an acute condition (acute otitis media) and trial B about a chronic condition (lateral epicondylitis). Both conditions are typically managed in primary care where 'wait and see' is a legitimate option.

MAIN OUTCOME

Comprehension of information (scored 0-6).

SECONDARY OUTCOMES

Decision intention, presentation satisfaction and preferences.

RESULTS

In both trials, the mean comprehension score was 3.7 for the text-only group. None of the visual presentations were superior to text-only. In trial A, the adjusted mean difference (MD) compared with text-only was: 0.19 (95% CI -0.16 to 0.55) for bar graph, 0.4 (0.04 to 0.76) for pictograph and 0.06 (-0.32 to 0.44) for line graph. In trial B, the adjusted MD was: 0.1 (-0.27 to 0.47) for bar graph), 0.38 (0.01 to 0.74) for pictograph and 0.1 (-0.27 to 0.48) for line graph. Pairwise comparisons between the three graphs showed all were clinically equivalent (95% CIs between -1.0 and 1.0). In both trials, bar graph was the most preferred presentation (chosen by 32.9% of trial A participants and 35.6% in trial B).

CONCLUSIONS

Any of the four visual presentations tested may be suitable to use when discussing quantitative prognostic information.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12621001305819).

Using Icon Arrays to Communicate Gambling Information Reduces the Appeal of Scratch Card Games

Past work has demonstrated that presenting statistical information in a foreground-background icon array can improve risk understanding, reduce decision-making biases, and decrease the salience of low-probability risks. In the present study, we assess whether presenting readily available gambling information within a foreground-background icon array influences individuals' gambling-related judgments (e.g., their perceived likelihood of winning a prize). Across two experiments (N = 1151), we find that using icon arrays to present gambling information reduces the appeal of scratch card games. That is, participants presented with gambling information in a foreground-background icon array, as opposed to a non-graphical numerical format, reported feeling less likely to win a prize, less excitement to play, and less urge to gamble on a scratch card game presented in a hypothetical gambling task. Overall, we conclude that presenting gambling information in an icon array format represents a simple yet promising tool for correcting gamblers' often overly-optimistic perceptions and reducing the appeal of negative expected value scratch card games.

Beyond High-Income Countries: Low Numeracy Is Associated with Older Adult Age around the World

Background

Numeracy, or the ability to understand and use numbers, has been associated with obtaining better health and financial outcomes. Studies in high-income countries suggest that low numeracy is associated with older age-perhaps especially among individuals with lower education. Here, we examined whether findings generalize to the rest of the world.

Methods

Gallup surveyed >150,000 participants for the 2019 Lloyd's Register Foundation World Risk Poll, from 21 low-income, 34 lower-middle income, 42 upper-middle income, and 43 high-income countries. Low numeracy was operationalized as failing to correctly answer, "Is 10% bigger than 1 out of 10, smaller than 1 out of 10, or the same as 1 out of 10?"

Results

Regressions controlling for participants' education, income, and other characteristics found that, worldwide, low numeracy was associated with older age, lower education, and their interaction. Findings held in each country-income category, although low numeracy was more common in low-income countries than in high-income countries.

Limitations

Age differences may reflect cohort effects and life span-developmental changes.

Discussion

Low numeracy is more common among people who are older and less educated. We discuss the need for education and interventions outside of the classroom.

Highlights

We analyzed a global survey conducted in 21 low-income, 34 lower-middle income, 42 upper-middle income, and 43 high-income countries.Low numeracy was associated with older adult age, even after accounting for age differences in education.Low numeracy was more common in older people with lower education.

Probablement, Wahrscheinlich, Likely? A Cross-Language Study of How People Verbalize Probabilities in Icon Array Visualizations

Visualizations today are used across a wide range of languages and cultures. Yet the extent to which language impacts how we reason about data and visualizations remains unclear. In this paper, we explore the intersection of visualization and language through a cross-language study on estimative probability tasks with icon-array visualizations. Across Arabic, English, French, German, and Mandarin, n=50 participants per language both chose probability expressions - e.g. likely, probable - to describe icon-array visualizations (Vis-to-Expression), and drew icon-array visualizations to match a given expression (Expression-to-Vis). Results suggest that there is no clear one-to-one mapping of probability expressions and associated visual ranges between languages. Several translated expressions fell significantly above or below the range of the corresponding English expressions. Compared to other languages, French and German respondents appear to exhibit high levels of consistency between the visualizations they drew and the words they chose. Participants across languages used similar words when describing scenarios above 80% chance, with more variance in expressions targeting mid-range and lower values. We discuss how these results suggest potential differences in the expressiveness of language as it relates to visualization interpretation and design goals, as well as practical implications for translation efforts and future studies at the intersection of languages, culture, and visualization. Experiment data, source code, and analysis scripts are available at the following repository: https://osf.io/g5d4r/.

Designing With Pictographs: Envision Topics Without Sacrificing Understanding

Past studies have shown that when a visualization uses pictographs to encode data, they have a positive effect on memory, engagement, and assessment of risk. However, little is known about how pictographs affect one's ability to understand a visualization, beyond memory for values and trends. We conducted two crowdsourced experiments to compare the effectiveness of using pictographs when showing part-to-whole relationships. In Experiment 1, we compared pictograph arrays to more traditional bar and pie charts. We tested participants' ability to generate high-level insights following Bloom's taxonomy of educational objectives via 6 free-response questions. We found that accuracy for extracting information and generating insights did not differ overall between the two versions. To explore the motivating differences between the designs, we conducted a second experiment where participants compared charts containing pictograph arrays to more traditional charts on 5 metrics and explained their reasoning. We found that some participants preferred the way that pictographs allowed them to envision the topic more easily, while others preferred traditional bar and pie charts because they seem less cluttered and faster to read. These results suggest that, at least in simple visualizations depicting part-to-whole relationships, the choice of using pictographs has little influence on sensemaking and insight extraction. When deciding whether to use pictograph arrays, designers should consider visual appeal, perceived comprehension time, ease of envisioning the topic, and clutteredness.

Investigating the presentation of uncertainty in an icon array: A randomized trial

BACKGROUND

Clinicians are often advised to use pictographs to communicate risk, but whether they offer benefits when communicating risk imprecision (e.g., 65%-79%) is unknown.

PURPOSE

To test whether any of three approaches to visualizing imprecision would more effectively communicate breast and ovarian cancer risk for BRCA1 pathogenic variant carriers.

METHODS

1,300 UK residents were presented with a genetic report with information about BRCA1-related risks, with random assignment to one of four formats: no visualization (text alone), or a pictograph using shaded icons, a gradient, or arrows marking range endpoints. We also tested pictographs in two layouts. Analysis of variance (ANOVA) and regression was employed.

RESULTS

There was no effect of format. Participants shown pictographs vs. text alone had better uptake of breast cancer risk messages (p < .05, η ² = 0.003). Pictographs facilitated memory for the specific amount of risk (p < 0.001, η ² = 0.019), as did the tabular layout. Individuals not having completed upper secondary education may benefit most.

CONCLUSIONS

We found weak evidence in favor of using simple pictographs with ranges to communicate BRCA risk (versus text alone), and of the tabular layout.

INNOVATION

Testing different ways of communicating imprecision within pictographs is a novel and promising line of research.

Do Messages Matter? Investigating the Combined Effects of Framing, Outcome Uncertainty, and Number Format on COVID-19 Vaccination Attitudes and Intention

Guided by prospect theory, the current study aims to explore Chinese adults' attitudes and intention to get vaccinated against COVID-19 and investigate the effects of message frames (gain vs. loss), outcome uncertainty (certain vs. uncertain), and number format (frequency vs. percentage) on vaccination attitudes and intention. Participants (n = 413) were randomly assigned to one of the eight experimental conditions and participated in the online experiment. The results showed that Chinese adults' attitudes toward COVID-19 vaccination were highly favorable, and the vaccination intention was high; age and education were positively correlated with attitudes and intention. The results also showed that message frames, outcome uncertainty, and number format did not have significant main or interaction effects on vaccination attitudes and intention. The discussion focused on how Chinese culture and contextual factors may have influenced the results of the study, as well as the implications and suggestions for future studies.

Text-Based vs. Graphical Information Formats in Sepsis Prevention and Early Detection: A Randomized Controlled Trial on Informed Choice

Sepsis is associated with 11 million global deaths annually. Although serious consequences of sepsis can generally be avoided with prevention and early detection, research has not yet addressed the efficacy of evidence-based health information formats for different risk groups. This study examines whether two evidence-based health information formats—text based and graphical—differ in how well they foster informed choice and risk and health literacy and in how well they support different sepsis risk groups. Based on a systematic literature review, two one-page educative formats on sepsis prevention and early detection were designed—one text based and one graphical. A sample of 500 German participants was randomly shown one of the two formats; they were then assessed on whether they made informed choices and on their risk and health literacy. For both formats, >70% of participants made informed choices for sepsis prevention and >75% for early detection. Compared with the graphical format, the text-based format was associated with higher degrees of informed choice (p = 0.012, OR = 1.818) and risk and health literacy (p = 0.032, OR = 1.710). Both formats can foster informed choices and risk and health literacy on sepsis prevention and early detection, but the text-based format appears to be more effective.

Icon arrays reduce concern over COVID-19 vaccine side effects: a randomized control study

On April 13, 2021, the CDC announced that the administration of Johnson and Johnson's COVID-19 vaccine would be paused due to a rare blood clotting side effect in ~ 0.0001% of people given the vaccine. Most people who are hesitant to get a COVID-19 vaccine list potential side effects as their main concern (PEW, 2021); thus, it is likely that this announcement increased vaccine hesitancy among the American public. Two days after the CDC's announcement, we administered a survey to a group of 2,046 Americans to assess their changes in attitudes toward COVID-19 vaccines. The aim of this study was to investigate whether viewing icon arrays of side effect risk would prevent increases in COVID-19 vaccine hesitancy due to the announcement. We found that using icon arrays to illustrate the small chance of experiencing the blood clotting side effect significantly prevented increases in aversion toward the Johnson and Johnson vaccine as well as all other COVID-19 vaccines.

Reference Dependence in Bayesian Reasoning: Value Selection Bias, Congruence Effects, and Response Prompt Sensitivity

This work examines the influence of reference dependence, including value selection bias and congruence effects, on diagnostic reasoning. Across two studies, we explored how dependence on the initial problem structure influences the ability to solve simplified precursors to the more traditional Bayesian reasoning problems. Analyses evaluated accuracy and types of response errors as a function of congruence between the problem presentation and question of interest, amount of information, need for computation, and individual differences in numerical abilities. Across all problem variations, there was consistent and strong evidence of a value selection bias in that incorrect responses almost always conformed to values that were provided in the problem rather than other errors including those related to computation. The most consistent and unexpected error across all conditions in the first experiment was that people were often more likely to utilize the superordinate value (N) as part of their solution rather than the anticipated reference class values. This resulted in a weakened effect of congruence, with relatively low accuracy even in congruent conditions, and a dominant response error of the superordinate value. Experiment 2 confirmed that the introduction of a new sample drew attention away from the provided reference class, increasing reliance on the overall sample size. This superordinate preference error, along with the benefit of repeating the PPV reference class within the question, demonstrated the importance of reference dependence based on the salience of information within the response prompt. Throughout, higher numerical skills were generally associated with higher accuracy, whether calculations were required or not.

Harmonization and Visualization of Data from a Transnational Multi-Sensor Personal Exposure Campaign

Use of a multi-sensor approach can provide citizens with holistic insights into the air quality of their immediate surroundings and their personal exposure to urban stressors. Our work, as part of the ICARUS H2020 project, which included over 600 participants from seven European cities, discusses the data fusion and harmonization of a diverse set of multi-sensor data streams to provide a comprehensive and understandable report for participants. Harmonizing the data streams identified issues with the sensor devices and protocols, such as non-uniform timestamps, data gaps, difficult data retrieval from commercial devices, and coarse activity data logging. Our process of data fusion and harmonization allowed us to automate visualizations and reports, and consequently provide each participant with a detailed individualized report. Results showed that a key solution was to streamline the code and speed up the process, which necessitated certain compromises in visualizing the data. A thought-out process of data fusion and harmonization of a diverse set of multi-sensor data streams considerably improved the quality and quantity of distilled data that a research participant received. Though automation considerably accelerated the production of the reports, manual and structured double checks are strongly recommended.

Determinants of information diffusion in online communication on vaccination: The benefits of visual displays

OBJECTIVE

Social media are an increasingly important source of information on the benefits and risks of vaccinations, but the high prevalence of misinformation provides challenges for informed vaccination decisions. It is therefore important to understand which messages are likely to diffuse online and why, and how relevant aspects-such as scientific facts on vaccination effectiveness-can be made more comprehensible and more likely to be shared. In two studies, we (i) explore which characteristics of messages on flu vaccination facilitate their diffusion in online communication, and (ii) whether visual displays (i.e., icon arrays) facilitate the comprehension and diffusion of scientific effectiveness information.

METHODS

In Study 1, 208 participants each rated a random sample of 15 out of 63 messages on comprehensibility, trustworthiness, persuasiveness, familiarity, informativeness, valence, and arousal, and then reported which information they would share with subsequent study participants. In Study 2 (N = 758), we employed the same rating procedure for a selected set of 9 messages and experimentally manipulated how scientific effectiveness information was displayed.

RESULTS

Study 1 illustrated that scientific effectiveness information was difficult to understand and thus did not diffuse well. Study 2 demonstrated that visual displays improved the understanding of this information, which could, in turn, increase its social impact.

CONCLUSIONS

The comprehensibility of scientific information is an important prerequisite for its diffusion. Visual displays can facilitate informed vaccination decisions by rendering important information on vaccination effectiveness more transparent and increasing the willingness to share this information.

Does choice change preferences? An incentivized test of the mere choice effect

Widespread evidence from psychology and neuroscience documents that previous choices unconditionally increase the later desirability of chosen objects, even if those choices were uninformative. This is problematic for economists who use choice data to estimate latent preferences, demand functions, and social welfare. The evidence on this mere choice effect, however, exhibits serious shortcomings which prevent evaluating its possible relevance for economics. In this paper, we present a novel, parsimonious experimental design to test for the economic validity of the mere choice effect addressing these shortcomings. Our design uses well-defined, monetary lotteries, all decisions are incentivized, and we effectively randomize participants' initial choices without relying on deception. Results from a large, pre-registered online experiment find no support for the mere choice effect. Our results challenge conventional wisdom outside economics. The mere choice effect does not seem to be a concern for economics, at least in the domain of decision making under risk.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10683-021-09728-5.

A Review of Chronic Comorbidities in Adults Living With HIV: State of the Science

ABSTRACT

People living with HIV are living longer, high-quality lives; however, as they age, this population is at increased risk for developing chronic comorbidities, including cardiovascular disease, certain types of cancer (e.g., lung, anal, and liver), and diabetes mellitus. The purpose of this state-of-the-science review is to provide an evidence-based summary on common physical comorbidities experienced by people living and aging with HIV. We focus on those chronic conditions that are prevalent and growing and share behavioral risk factors that are common in people living with HIV. We will discuss the current evidence on the epidemiology, physiology, prevention strategies, screening, and treatment options for people living with HIV across resource settings.

Visualizing Uncertainty for Non-Expert End Users: The Challenge of the Deterministic Construal Error

There is a growing body of evidence that numerical uncertainty expressions can be used by non-experts to improve decision quality. Moreover, there is some evidence that similar advantages extend to graphic expressions of uncertainty. However, visualizing uncertainty introduces challenges as well. Here, we discuss key misunderstandings that may arise from uncertainty visualizations, in particular the evidence that users sometimes fail to realize that the graphic depicts uncertainty. Instead they have a tendency to interpret the image as representing some deterministic quantity. We refer to this as the deterministic construal error. Although there is now growing evidence for the deterministic construal error, few studies are designed to detect it directly because they inform participants upfront that the visualization expresses uncertainty. In a natural setting such cues would be absent, perhaps making the deterministic assumption more likely. Here we discuss the psychological roots of this key but underappreciated misunderstanding as well as possible solutions. This is a critical question because it is now clear that members of the public understand that predictions involve uncertainty and have greater trust when uncertainty is included. Moreover, they can understand and use uncertainty predictions to tailor decisions to their own risk tolerance, as long as they are carefully expressed, taking into account the cognitive processes involved.

An Exploratory Study of the Development and Pilot Testing of an Interactive Visual Tool of Neuropsychological Test Results in Memory Clinics

Background:

Neuropsychological feedback is an important part of the neuropsychological assessment process. However, patients have difficulties remembering this information.

Objective:

The aim of this study was to develop a web-based visual tool to improve the understanding of neuropsychological results, information retention, and psychologist-patient communication.

Methods:

The visual tool was developed and optimized using an iterative three-phase stepwise approach to determine its usability, technology acceptance, and feasibility in a memory clinic population. Feedback from different user perspectives (patients, family members, and psychologists) was obtained in each phase using a multimethod approach (e.g. a multidisciplinary brainstorm session, think-aloud sessions, focus groups). The prototype was subsequently tested in a pilot study.

Results:

The first phases offered insights that led to optimization of the prototype. On a scale ranging from 0 to 100, psychologists evaluated the usability as high [88.1±7.6,70–87]. During the pilot study, both patients and significant others gave positive feedback, but information retention in patients remained low. All participants thought the benefits of the visual tool included seeing cognitive strengths and weaknesses with a translation to daily life all at one glance and receiving feedback on paper to take home. Important barriers were mentioned by psychologists, such as a limited set of tests included and no integration with hospital systems.

Conclusion:

Overall, patients, family members, and psychologists reported that a visual display of the cognitive profile with insights into daily life had added value to clinical practice. Feedback from the pilot study was adopted in the tool for future implementation purposes.

Interpersonal factors contributing to tension in the Chinese doctor-patient-family relationship: a qualitative study in Hunan Province

OBJECTIVE

To identify actionable barriers to communication that contribute to tension in the Chinese doctor-patient-family relationship (DPFR) among surgeons, surgical patients and their family members.

DESIGN

We employed qualitative research methods using in-depth, semistructured interviews in Mandarin and English and conducted preoperatively and postoperatively. Interviews were audio recorded, transcribed and translated into English. Data were analysed using thematic analysis.

SETTING

An urban, tertiary-level teaching hospital in Hunan Province, China.

PARTICIPANTS

We recruited a purposive sample of 11 inpatients undergoing the same minor surgery, 9 of their family members and 9 surgeons between June and August 2015.

RESULTS

We identified three emergent themes. First, trust degradation occurred before and during the healthcare experience. Second, the healthcare-seeking experience for patients and family members was marked by unmet expectations for achieving a basic understanding of the illness as well as powerlessness over their situation. Third, societal pressures on doctors contributed to a state of learned helplessness.

CONCLUSIONS

Our findings suggest that tension in the DPFR is associated with interpersonal and structural challenges, with communication playing an important role. Reforms at all levels are needed to promote a more patient-centred experience while ensuring the well-being and security of providers.

Communicating tailored risk information of cancer treatment side effects: Only words or also numbers?

BACKGROUND

The increased availability of patient reported outcome data makes it feasible to provide patients tailored risk information of cancer treatment side effects. However, it is unclear how such information influences patients' risk interpretations compared to generic population-based risks, and which message format should be used to communicate such individualized statistics.

METHODS

A web-based experiment was conducted in which participants (n = 141) read a hypothetical treatment decision-making scenario about four side effect risks of adjuvant chemotherapy for advanced colon cancer. Participants were cancer patients or survivors who were recruited from an online Dutch cancer patient panel. All participants received two tailored risks (of which the reference class was based on their age, gender and tumor stage) and two generic risks conveying the likelihood of experiencing the side effects. The risks were presented either in words-only ('common' and 'very common'), or in a combination of words and corresponding numerical estimates ('common, 10 out of 100' and 'very common, 40 out of 100'). Participants' estimation of the probability, accuracy of their estimation, and perceived likelihood of occurrence were primary outcomes. Perceived personal relevance and perceived uncertainty were secondary outcomes.

RESULTS

Tailored risks were estimated as higher and less accurate than generic risks, but only when they were presented in words; Such differences were not found in the verbal and numerical combined condition. Although tailoring risks did not impact participants' perceived likelihood of occurrence, tailored risks were perceived as more personally relevant than generic risks in both message formats. Finally, tailored risks were perceived as less uncertain than generic risks, but only in the verbal-only condition.

CONCLUSIONS

Considering current interest in the use of personalized decision aids for improving shared decision-making in oncology, it is important that clinicians consider how tailored risks of treatment side effects should be communicated to patients. We recommend both clinicians who communicate probability information during consultations, and decision aid developers, that verbal descriptors of tailored risks should be supported by numerical estimates of risks levels, to avoid overestimation of risks.

User-Centered Design and Evaluation of a Web-Based Decision Aid for Older Adults Living With Mild Cognitive Impairment and Their Health Care Providers: Mixed Methods Study

Background

Mild cognitive impairment (MCI) is often considered a transitional state between normal and pathologic (eg, dementia) cognitive aging. Although its prognosis varies largely, the diagnosis carries the risk of causing uncertainty and overtreatment of older adults with MCI who may never progress to dementia. Decision aids help people become better informed and more involved in decision making by providing evidence-based information about options and possible outcomes and by assisting them in clarifying their personal values in relation to the decision to be made.

Objective

This study aimed to incorporate features that best support values clarification and adjust the level of detail of a web-based decision aid for individuals with MCI.

Methods

We conducted a rapid review to identify options to maintain or improve cognitive functions in individuals with MCI. The evidence was structured into a novel web-based decision aid designed in collaboration with digital specialists and graphic designers. Qualitative and user-centered evaluations were used to draw on users’ knowledge, clarify values, and inform potential adoption in routine clinical practice. We invited clinicians, older adults with MCI, and their caregivers to evaluate the decision aid in 6 consecutive rounds, with new participants in each round. Quantitative data were collected using the Values Clarity and Informed subscales of the Decisional Conflict Scale, the System Usability Scale, the Ottawa Acceptability questionnaire, and a 5-point satisfaction rating scale. We verified their comprehension using a teach-back method and recorded usability issues. We recorded the audio and computer screen during the session. An inductive thematic qualitative analysis approach was used to identify and describe the issues that arose. After each round, an expert panel met to prioritize and find solutions to mitigate the issues. An integrated analysis was conducted to confirm our choices.

Results

A total of 7 clinicians (social workers, nurses, family physicians, psychologists) and 12 older (≥60 years) community-dwelling individuals with MCI, half of them women, with education levels going from none to university diploma, were recruited and completed testing. The thematic analysis revealed 3 major issues. First, the user should be guided through the decision-making process by tailoring the presentation of options to users’ priorities using the values clarification exercise. Second, its content should be simple, but not simplistic, notably by using information layering, plain language, and pictograms. Third, the interface should be intuitive and user friendly, utilize pop-up windows and information tips, avoid drop-down menus, and limit the need to scroll down. The quantitative assessments corroborated the qualitative findings.

Conclusions

This project resulted in a promising web-based decision aid that can support decision making for MCI intervention, based on the personal values and preferences of the users. Further ongoing research will allow its implementation to be tested in clinical settings.

Tackling the outcome bias related to the effectiveness of antibiotics against the common cold: results of a randomized controlled trial applying the Solomon four-group design

In recent years, antimicrobial resistance (AMR) has become an international public health priority. In the area of human medicine, the mis- and overuse of antibiotics is an important contributor to the development of AMR. Such a non-prudent use of antibiotics is especially prevalent in the treatment of viral infections such as the common cold. The present study aims to address the misconception, also known as outcome bias, that antibiotics may be an effective treatment against the common cold by providing a "debiasing" risk communication intervention. It aims at conveying the non-existence of a cause-effect relationship between antibiotics and the reduction of cold-related symptoms through a visual aid and simple explanatory text. A Solomon four-group design was employed to test for within- and between-subjects effects of the intervention as well as potential sensitization effects of the repeated measurement. A total of 311 participants residing in Germany were randomly assigned to receiving (1) a pretest, the debiasing intervention and post-test (2), a pretest, a control stimulus and post-test (3), the debiasing intervention and post-test, or (4) the post-test only. Outcome measures included knowledge about the effectiveness of antibiotics, the attitude toward using it as treatment against the common cold and the evaluation of a scenario describing an irresponsible use of antibiotics. Within-subjects comparisons found that participants receiving the pre- and post-test and intervention showed improved knowledge (t(77) = -2.53, p = .014), attitude (t(77) = -2.09, p = .040), and evaluation measures (t(77) = -2.23, p = .028). The pretest might, however, have caused a sensitization of participants for knowledge-related questions (t(77) = 2.207, p = .029). Between-subjects comparisons found differences in knowledge levels between the post-test only group and both groups receiving the intervention (F(3, 307) = 5.63, p = .001, η2p = .05]. There were no differences between the intervention and control groups with regard to attitude and evaluation of the scenario. While the risk communication intervention led to an increase in knowledge, the outcomes related to attitude and evaluation of a scenario were only affected positively in one group. Therefore, it seems that communication interventions based on visual aids are a simple method to promote the understanding of the true relationship between antibiotic treatment and the decrease of cold-related symptoms. Variables such as attitude and evaluation of a scenario presenting the irresponsible use of antibiotics require, however, additional interventions facilitating a translation of accurate understanding into respective attitudes and judgments.

Probability Size Matters: The Effect of Foreground-Only versus Foreground+Background Graphs on Risk Aversion Diminishes with Larger Probabilities

Graphs are increasingly recommended for improving decision-making and promoting risk-avoidant behaviors. Graphs that depict only the number of people affected by a risk ("foreground-only" displays) tend to increase perceived risk and risk aversion (e.g., willingness to get vaccinated), as compared to graphs that also depict the number of people at risk for harm ("foreground+background" displays). However, previous research examining these "foreground-only effects" has focused on relatively low-probability risks (<10%), limiting generalizability to communications about larger risks. In two experiments, we systematically investigated the moderating role of probability size on foreground-only effects, using a wide range of probability sizes (from 0.1% to 40%). Additionally, we examined the moderating role of the size of the risk reduction, that is, the extent to which a protective behavior reduces the risk. Across both experiments, foreground-only effects on perceived risk and risk aversion were weaker for larger probabilities. Experiment 2 also revealed that foreground-only effects were weaker for smaller risk reductions, while foreground-only displays decreased understanding of absolute risk magnitudes independently of probability size. These findings suggest that the greater effectiveness of foreground-only versus foreground+background displays for increasing perceived risk and risk aversion diminishes with larger probability sizes and smaller risk reductions. Moreover, if the goal is to promote understanding of absolute risk magnitudes, foreground+background displays should be used rather than foreground-only displays regardless of probability size. Our findings also help to refine and extend existing theoretical accounts of foreground-only effects to situations involving a wide range of probability sizes.

When Does the Incremental Risk Format Aid Informed Medical Decisions? The Role of Learning, Feedback, and Number of Treatment Options

Background. Informed medical decisions require understanding the benefits and risks of treatments. This entails comparing treatment outcomes to a control group. The incremental risk format has been recommended as it directly visualizes the differences between treatment and control group in 1 graph, whereas they have to be calculated from 2 separate graphs in the total risk format. We investigated when the incremental risk format aids understanding. Methods. In 2 experiments, participants received information about medical treatments, either as incremental or total risk format. We assessed verbatim knowledge (precise quantitative knowledge), gist knowledge (knowledge of essential meaning), and evaluations of the formats. Study 1 (N = 99) consisted of only 1 trial with medical information and also assessed recall. Study 2 (N = 222) assessed learning across multiple trials and also varied the presence of feedback and the number of treatment options. Results. In study 1, the incremental risk format (v. total risk format) led to worse knowledge, recall, and evaluations. In study 2, participants learned to understand the incremental risk format over time, resulting in comparable verbatim knowledge and evaluations as in the total risk format, as well as in even better gist knowledge. Feedback and number of treatment options did not moderate the effect of risk format. Limitations. The studies were conducted with nonpatient samples, and study 2 employed hypothetical treatments. Conclusions. The incremental risk format was initially less understandable than the total risk format. After a short learning period, however, the incremental risk format resulted in better gist knowledge and was comparable otherwise, which suggests that participants had to get used to that format. This has important implications for the study of new formats.

Do Preferred Risk Formats Lead to Better Understanding? A Multicenter Controlled Trial on Communicating Familial Breast Cancer Risks Using Different Risk Formats

PURPOSE

Counselees' preferences are considered important for the choice of risk communication format and for improving patient-centered care. We here report on counselees' preferences for how risks are presented in familial breast cancer counseling and the impact of this preferred format on their understanding of risk.

PATIENTS AND METHODS

As part of a practice-based randomized controlled trial, 326 unaffected women with a family history of breast cancer received their lifetime risk in one of five presentation formats after standard genetic counseling in three Dutch familial cancer clinics: 1) in percentages, 2) in frequencies ("X out of 100"), 3) in frequencies plus graphical format (10×10 human icons), 4) in frequencies and 10-year age-related risk and 5) in frequencies and 10-year age-related risk plus graphical format. Format preferences and risk understanding (accuracy) were assessed at 2-week follow-up by a questionnaire, completed by 279/326 women.

RESULTS

The most preferred risk communication formats were numbers combined with verbal descriptions (37%) and numbers only (26%). Of the numerical formats, most (55%) women preferred percentages. The majority (73%) preferred to be informed about both lifetime and 10-year age-related risk. Women who had received a graphical display were more likely to choose a graphical display as their preferred format. There was no significant effect between the intervention groups with regard to risk accuracy. Overall, women given risk estimates in their preferred format had a slightly better understanding of risk.

CONCLUSION

The results suggest that the accuracy of breast cancer risk estimation is slightly better for women who had received this information in their preferred format, but the risk format used had no effect on women's risk accuracy. To meet the most frequent preference, counselors should consider providing a time frame of reference (eg, risk in the next 10 years) in a numerical format, in addition to lifetime risk.

Heuristics for designing user-centric drug products: Lessons learned from Human Factors and Ergonomics

Even the most effective drug product may be used improperly and thus ultimately prove ineffective if it does not meet the perceptual, motor and cognitive capacities of its target users. Currently, no comprehensive guideline for systematically designing user‐centric drug products that would help prevent such limitations exists. We have compiled a list of approximate but nonetheless useful strategies—heuristics—for implementing a user‐centric design of drug products and drug product portfolios. First, we present a general heuristic for user‐centric design based on the framework of Human Factors and Ergonomics (HF/E). Then we demonstrate how to implement this general heuristic for older drug users (i.e., patients and caregivers aged 65 years and older) and with respect to three specific challenges (use‐cases) of medication management: (A) knowing what drug product to take/administer, (B) knowing how and when to take/administer it, and (C) actually taking/administering it. The presented heuristics can be applied prospectively to include existing knowledge about user‐centric design at every step during drug discovery, pharmaceutical drug development, and pre‐clinical and clinical trials. After a product has been released to the market, the heuristics may guide a retrospective analysis of medication errors and barriers to product usage as a basis for iteratively optimizing both the drug product and its portfolio over their life cycle.

Benefits and harms of selective oestrogen receptor modulators (SERMs) to reduce breast cancer risk: a cross-sectional study of methods to communicate risk in primary care

BACKGROUND

In Australia, evidence-based guidelines recommend that women consider taking selective oestrogen receptor modulators (SERMs) to reduce their risk of breast cancer. In practice, this requires effective methods for communicating the harms and benefits of taking SERMs so women can make an informed choice.

AIM

To evaluate how different risk presentations influence women's decisions to consider taking SERMs.

DESIGN AND SETTING

Cross-sectional, correlational study of Australian women in general practice.

METHOD

Three risk communication formats were developed that included graphics, numbers, and text to explain the reduction in breast cancer risk and risk of side effects for women taking SERMs (raloxifene or tamoxifen). Women aged 40-74 years in two general practices were shown the risk formats using vignettes of hypothetical women at moderate or high risk of breast cancer and asked to choose 'If this was you, would you consider taking a SERM?' Descriptive statistics and predictors (risk format, level of risk, and type of SERM) of choosing SERMs were determined by logistic regression.

RESULTS

A total of 288 women were recruited (an 88% response rate) between March and May 2017. The risk formats that showed a government statement and an icon array were associated with a greater likelihood of considering SERMs relative to one that showed a novel expected frequency tree. Risk formats for raloxifene and for the high-risk vignettes were also more strongly associated with choosing to consider SERMs. No associations were found with any patient demographics.

CONCLUSION

Specific risk formats may lead to more women considering taking SERMs to reduce breast cancer risk, especially if they are at high risk of the condition. Raloxifene may be a more acceptable SERM to patients.

Presenting time-based risks of stroke and death for Patients facing carotid stenosis treatment options: Patients prefer pie charts over icon arrays

OBJECTIVE

To user-test graphical display formats (icon arrays, pie, bar, and line charts) to identify preferred formats and metrics ('probability of death or stroke' or 'proportion of time lived without death or stroke') in order to display time-dependent risks of stroke or death for three carotid stenosis treatments: endarterectomy (surgery), stenting, and medical therapy.

METHODS

Iterative cycles of semi-structured interviews with patients recruited from a Vascular Clinic.

RESULTS

A total of 27 patients (mean age = 68; range: 50-85) were interviewed over four cycles. Patients strongly preferred the pie chart over icon arrays, and over bar or line graphs. The preference was based on patient recognition of the time-based increase in risk for stroke or death for treatment options. Patients preferred data presented as probabilities instead of the proportion of time lived. We did not assess patients' understanding.

CONCLUSION

Patients preferred the pie chart formats and reported better realization that risks increase with time for each option and that tradeoffs exist when surgery has a higher short-term risk than medical therapy.

PRACTICE IMPLICATIONS

There remains debate on how best to convey time-dependent risk information to patients, especially where low literacy and numeracy might exist.

Effect of Tabular and Icon Fact Box Formats on Comprehension of Benefits and Harms of Prostate Cancer Screening: A Randomized Trial

BACKGROUND

Fact boxes employ evidence-based guidelines on risk communication to present benefits and harms of health interventions in a balanced and transparent format. However, little is known about their short- and long-term efficacy and whether designing fact boxes to present multiple outcomes with icon arrays would increase their efficacy.

METHOD

In study 1, 120 men (30-75 y) completed a lab study. Participants were randomly assigned to 1 of 3 fact box formats on prostate cancer screening: a tabular fact box with numbers, a fact box with numbers and icon array, and a fact box with numbers, separate icon arrays, and text to describe each benefit and harm. Comprehension of information (while materials were present) and short-term knowledge recall were assessed. Study 2 recruited an online sample of 244 German men (40-75 y). Participants were randomly assigned to 1 of the 3 fact box formats or widely distributed health information, and knowledge was assessed at baseline, shortly after presentation, and at 6-mo follow-up, along with comprehension while materials were present.

RESULTS

In both studies, comprehension and knowledge-recall scores were similar when comparing tabular and icon fact boxes. In the 6-mo follow-up, this positive effect on knowledge recall disappeared. Fact boxes increased knowledge relative to baseline but did not affect decision intentions or perceptions of having complete information to make decisions.

CONCLUSIONS

This study shows that fact boxes with and without icon arrays are equally effective at improving comprehension and knowledge recall over the short-term and are simple formats that can improve on current health information. Specifically, if fact boxes are used at the time or immediately before a decision is made, they promote informed decisions about prostate cancer screening.

Task-Based Effectiveness of Basic Visualizations

Visualizations of tabular data are widely used; understanding their effectiveness in different task and data contexts is fundamental to scaling their impact. However, little is known about how basic tabular data visualizations perform across varying data analysis tasks. In this paper, we report results from a crowdsourced experiment to evaluate the effectiveness of five small scale (5-34 data points) two-dimensional visualization types-Table, Line Chart, Bar Chart, Scatterplot, and Pie Chart-across ten common data analysis tasks using two datasets. We find the effectiveness of these visualization types significantly varies across task, suggesting that visualization design would benefit from considering context-dependent effectiveness. Based on our findings, we derive recommendations on which visualizations to choose based on different tasks. We finally train a decision tree on the data we collected to drive a recommender, showcasing how to effectively engineer experimental user data into practical visualization systems.

Misinterpretation of online surgical outcomes: The British Association of Urological Surgeons Surgical Outcomes Audit

Objective:

The purpose of this study was to evaluate whether the information presented in the British Association of Urological Surgeons Surgical Outcomes Audit is comprehended by the general population.

Methods:

An in-person electronic survey was administered at the local state fair in 2016. Participants were presented with an representative output from the British Association of Urological Surgeons Surgical Outcomes Audit and were asked to estimate the complication rate and make a hypothetical healthcare decision. The primary output depicted a complication rate of 6.7% which was above the 99th percentile. The degree of misinterpretation and the risk of making an inappropriate healthcare decision was evaluated.

Results:

Of the 350 completed responses, only 142 (40.6%) correctly estimated the surgeons’ complication rate. Individuals who were not college educated (odds ratio 3.02, 95% confidence interval 1.88–4.95) were more likely to misinterpret the information. Only 7.6% recognized that the surgeon’s complication rate was above the 99th percentile. Despite the high complication rate, 16.6% decided to continue with the surgery as planned and not ask the surgeon about their rates, seek a second opinion or change surgeons. Misinterpreters had a higher risk of making an inappropriate hypothetical decision (odds ratio 2.75, 95% confidence interval 1.42–5.62).

Conclusion:

The general population have difficulty in interpreting the data presented by The British Association of Urological Surgeons Surgical Outcomes Audit and are thus vulnerable to making poor healthcare decisions or decisions which are inconsistent with their goals of care.

Level of evidence:

IIb

Communicative aspects of decision aids for localized prostate cancer treatment - A systematic review

CONTEXT

Despite increasing interest in the development and use of decision aids (DAs) for patients with localized prostate cancer (LPC), little attention has been paid to communicative aspects (CAs) of such tools.

OBJECTIVE

To identify DAs for LPC treatment, and review these tools for various CAs.

MATERIALS AND METHODS

DAs were identified through both published literature (MEDLINE, Embase, CINAHL, CENTRAL, and PsycINFO; 1990-2018) and online sources, in compliance with the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Identified DAs were reviewed for the International Patient Decision Aid Standards criteria, and analyzed on CAs, including information presentation, personalization, interaction, information control, accessibility, suitability, and source of information. Nineteen DAs were identified.

RESULTS

International Patient Decision Aid Standards scores varied greatly among DAs. Crucially, substantial variations in use of CAs by DAs were identified: (1) few DAs used visual aids to communicate statistical information, (2) none were personalized in terms of outcome probabilities or mode of communication, (3) a minority used interactive methods to elicit patients' values and preferences, (4) most included biased cross tables to compare treatment options, and (5) issues were observed in suitability and accessibility that could hinder implementation in clinical practice.

CONCLUSIONS

Our review suggests that DAs for LPC treatment could be further improved by adding CAs such as personalized outcome predictions and interaction methods to the DAs. Clinicians who are using or developing such tools might therefore consider these CAs in order to enhance patient participation in treatment decision-making.

Using the Short Graph Literacy Scale to Predict Precursors of Health Behavior Change

BACKGROUND

Visual displays can facilitate risk communication and promote better health choices. Their effectiveness in improving risk comprehension is influenced by graph literacy. However, the construct of graph literacy is still insufficiently understood, partially because existing objective measures of graph literacy are either too difficult or too long.

OBJECTIVES

We constructed a new 4-item Short Graph Literacy (SGL) scale and examined how SGL scores relate to key cognitive, affective, and conative precursors of health behavior change described in common health behavior theories.

METHODS

We performed secondary analyses to adapt the SGL scale from an existing 13-item scale. The initial construction was based on data collected in a laboratory setting in Germany ( n = 51). The scale was then validated using data from nationally representative samples in Germany ( n = 495) and the United States ( n = 492). To examine how SGL scores relate to precursors of health behavior change, we performed secondary analyses of a third study involving a nationwide US sample with 47% participants belonging to racial/ethnic minorities and 46% with limited formal education ( n = 835).

RESULTS

Graph literacy was significantly associated with cognitive precursors in theoretically expected ways (e.g., positive associations with risk comprehension and response efficacy and a negative association with cognitive risk perception). Patterns for affective precursors generally mirrored those for cognitive precursors, although numeracy was a stronger predictor than graph literacy for some affective factors (e.g., feelings of risk). Graph literacy had predictive value for most cognitive and affective precursors beyond numeracy. In addition, graph literacy (but not numeracy) predicted key conative precursors such as defensive processing.

CONCLUSIONS

Our data suggest that the SGL scale is a fast and psychometrically valid method for measuring objective graph literacy. Our findings also highlight the theoretical and practical relevance of graph literacy.

A Scoping Review of Health Literacy Measurement Tools in the Context of Cardiovascular Health

Background. Despite the strong link between health literacy and cardiovascular health outcomes, health literacy measurements remain flawed and fragmented. There exists a gap in the knowledge when formulating a valid measurement to capture the broad concept of health literacy. The existence of various tools for health literacy measurement also hampers the availability of health literacy data. Additionally, little research is available on a valid measurement tool for cardiovascular health literacy. Objective. This study aims to provide an overview of the health literacy measurement tools used in the context of cardiovascular health. Method. A scoping review was conducted. Two electronic databases, Medline and Embase, were searched to identify studies that described a tool for the measurement of health literacy in the context of cardiovascular health. Results. After reviewing the available studies, 53 studies met the inclusion criteria. A total of 26 health literacy measurement tools were identified in the studies. Among the 26 tools, 16 used an objective measurement approach, 9 adopted a subjective approach, and 1 employed a mixed approach. Additionally, 28 studies used tools to measure print literacy, 15 studies measured print literacy and numeracy, and 5 studies measured print literacy, oral literacy, and numeracy. Conclusions. STOFHLA, TOFHLA, and REALM were the mostly commonly used tools in the selected studies. The majority of tools were based heavily on reading skills and word recognition. Researchers should focus on the development of more comprehensive and reliable health literacy measurement tool(s) specific to cardiovascular health to assist health care providers to more efficiently and accurately identify people with cardiovascular problems who have inadequate health literacy.

The experience-based format of probability improves probability estimates: The moderating role of individual differences in numeracy

People with low statistical numeracy have difficulties understanding numerical information. For instance, they often misunderstand the probability of experiencing side effects, which could reduce adherence to medical treatments. We investigated whether presenting information about probability using a method based on the direct experience of events influences the accuracy of probability estimates compared to viewing a static numerical description of the same information. Participants completed a numeracy test and were randomly assigned to one of two conditions. In the description-based probability condition, participants were presented with 24 binomial distributions consisting of a target stimulus "X" and a distractor stimulus "·" in the form of odds (the distribution "7 × 13 ·" is an example of a 35% probability: here the target [distractor] stimulus was present 7[13] times in a 20-stimulus distribution). In the experience-based probability condition, participants observed the same information but the stimuli were randomly arranged and displayed sequentially. Participants in both conditions estimated the probability of the target stimulus in each trial. In the experience-based format participants with low numeracy made more accurate probability estimates in comparison to the description-based format. In contrast, accuracy in participants with high numeracy was similar in the two formats.

Evidence on the effectiveness of health literacy interventions in the EU: a systematic review

BACKGROUND

In the last decade, the attention for health literacy has increased in the European Union. This is due to three main reasons. First, reviews have shown that inadequate health literacy is associated with worse health outcomes, higher health care use and expenditure. Second, in all European countries the population is aging and the number of chronically ill people is rising. Improving health literacy in this group can offer greater opportunities to take an active part in society, be independent and improve quality of life. Third, since most research on health literacy has been conducted outside Europe and relatively little is known about the development of health literacy interventions and its effects on outcome measures in European countries. The aim of this systematic review was to assess the evidence on the effectiveness of health literacy interventions in the European Union published between 1995 and 2018.

METHODS

Searches have been performed in Medline, PubMed, EMBASE, CINAHL, Cochrane library, PsychINFO, ERIC, Web of Science and SCOPUS for publications on health literacy intervention studies in European Union countries. Studies were included if the research was conducted in one or more Member States of the European Union, the publication described an intervention study, the intervention was aimed at health literacy, the publication described an outcome measure related to health literacy and the publication was written in English, French or German.

RESULTS

A total of 23 studies were included. Three types of interventions were identified; aimed at improving health literacy, tailored to different health literacy levels and aimed at improving health outcomes in general that differentiated in effects for people with different health literacy levels. Most interventions identified in the review focus on the functional level of health literacy or numeracy. The strength of evidence from the European health literacy intervention studies was low and there was a huge heterogeneity in study design, measurement tools and outcomes measured.

CONCLUSIONS

Promising interventions were tailored to the needs of patients, addressing functional, interactive and critical skills and use not difficult animated spoken text. Future research should focus on the development and assessment of such interventions and use stronger designs.

Judging risk magnitude: walking to the left and base jumping to the right

When thinking about quantifiable domains such as numbers, pitch, and size, they are implicitly mapped on to representational space with small/low/less and large/high/more of the respective domain represented on the left and right sides of representational space, respectively. Recent research has also demonstrated that more abstract domains (colours, language, political party names) are also mapped in the same way. This study investigated a new abstract domain, risk, to examine if this same pattern of effects is apparent (left = low risk/right = high risk) to get a better understanding of how risk magnitudes are processed. Experiment 1 (n = 26) presented objective, statistically calculated risk stimuli (micromorts) to participants, who indicated if the stimuli had lower or higher risks than a referent, with their left and right hands. Experiment 2 (n = 25) utilised the same task, but the risk stimuli were generated by the participants themselves. Both experiments found the expected association of risk with space-indicated by faster left-hand responses to low-risk stimuli and faster right-hand responses to high-risk stimuli. Risks appear to fit onto a standard left-right spatial association; however, the effect sizes for all analyses were small. The results of this study are not only in line with the idea of a generalised magnitude processing system, but might also inform best practices in effective communications of risks.

Online Decision Support Tool for Personalized Cancer Symptom Checking in the Community (REACT): Acceptability, Feasibility, and Usability Study

Background

Improving cancer survival in the UK, despite recent significant gains, remains a huge challenge. This can be attributed to, at least in part, patient and diagnostic delays, when patients are unaware they are suffering from a cancerous symptom and therefore do not visit a general practitioner promptly and/or when general practitioners fail to investigate the symptom or refer promptly. To raise awareness of symptoms that may potentially be indicative of underlying cancer among members of the public a symptom-based risk assessment model (developed for medical practitioner use and currently only used by some UK general practitioners) was utilized to develop a risk assessment tool to be offered to the public in community settings. Such a tool could help individuals recognize a symptom, which may potentially indicate cancer, faster and reduce the time taken to visit to their general practitioner. In this paper we report results about the design and development of the REACT (Risk Estimation for Additional Cancer Testing) website, a tool to be used in a community setting allowing users to complete an online questionnaire and obtain personalized cancer symptom-based risk estimation.

Objective

The objectives of this study are to evaluate (1) the acceptability of REACT among the public and health care practitioners, (2) the usability of the REACT website, (3) the presentation of personalized cancer risk on the website, and (4) potential approaches to adopt REACT into community health care services in the UK.

Methods

Our research consisted of multiple stages involving members of the public (n=39) and health care practitioners (n=20) in the UK. Data were collected between June 2017 and January 2018. User views were collected by (1) the “think-aloud” approach when participants using the website were asked to talk about their perceptions and feelings in relation to the website, and (2) self-reporting of website experiences through open-ended questionnaires. Data collection and data analysis continued simultaneously, allowing for website iterations between different points of data collection.

Results

The results demonstrate the need for such a tool. Participants suggest the best way to offer REACT is through a guided approach, with a health care practitioner (eg, pharmacist or National Health Service Health Check nurse) present during the process of risk evaluation. User feedback, which was generally consistent across members of public and health care practitioners, has been used to inform the development of the website. The most important aspects were: simplicity, ability to evaluate multiple cancers, content emphasizing an inviting community “feel,” use (when possible) of layperson language in the symptom screening questionnaire, and a robust and positive approach to cancer communication relying on visual risk representation both with affected individuals and the entire population at risk.

Conclusions

This study illustrates the benefits of involving public and stakeholders in developing and implementing a simple cancer symptom check tool within community. It also offers insights and design suggestions for user-friendly interfaces of similar health care Web-based services, especially those involving personalized risk estimation.

The Value of a Photobook in Informing Families About the Cosmetic Results of Surgery in Craniosynostosis

This paper outlines the development and evaluation of a photobook resource to support parents' decision making regarding potential craniofacial surgery for their child. The photobook was developed at a UK Craniofacial Unit and consisted of preoperative and postoperative photographs of patients with craniosynostosis. It was intended to act as a visual adjunct to detailed verbal discussion of surgical treatment options. No changes in the uptake rate of surgery were detected following the introduction of the photobook. An evaluation of parents' views of the photobook indicates that families generally welcomed the resource and did not report any adverse responses. Ethical considerations of the use of such a resource cannot be discounted, and careful presentation of such a resource in the context of a specialist team is recommended.

Use of feedback to improve mental number line representations in primary care clinics

BACKGROUND

As patients become more engaged in decisions regarding their medical care, they must weigh the potential benefits and harms of different treatments. Patients who are low in numeracy may be at a disadvantage when making these decisions, as low numeracy is correlated with less precise representations of numerical magnitude. The current study looks at the feasibility of improving number representations. The aim of this study was to evaluate whether providing a small amount of feedback to adult subjects could improve performance on a number line placement task and to determine characteristics of those individuals who respond best to this feedback.

METHODS

Subjects from two outpatient clinic waiting rooms participated in a three phase number line task. Participants were asked to place numbers on a computerized number line ranging from 0 to 1000 in pre-test, feedback, and post-test phases. Generalized estimating equations were used to model log-transformed scores and to test whether 1) performance improved after feedback, and 2) the degree of improvement was associated with age, education level or subjective numeracy.

RESULTS

There was an overall improvement in task performance following the feedback. The average percent absolute error was 7.32% (SD: 6.00) for the pre-test and 5.63% (SD: 3.71) for the post-test. There was a significant interaction between college education and post-test improvement. Only subjects without some college education improved with feedback.

CONCLUSIONS

Adults who do not have higher levels of education improve significantly on a number line task when given feedback.

The effect of a new lifetime-cardiovascular-risk display on patients' motivation to participate in shared decision-making

BACKGROUND

This study investigated the effects of three different risk displays used in a cardiovascular risk calculator on patients' motivation for shared decision-making (SDM). We compared a newly developed time-to-event (TTE) display with two established absolute risk displays (i.e. emoticons and bar charts). The accessibility, that is, how understandable, helpful, and trustworthy patients found each display, was also investigated.

METHODS

We analysed a sample of 353 patients recruited in general practices. After giving consent, patients were introduced to one of three fictional vignettes with low, medium or high cardiovascular risk. All three risk displays were shown in a randomized order. Patients were asked to rate each display with regard to motivation for SDM and accessibility. Two-factorial repeated measures analyses of variance were conducted to compare the displays and investigate possible interactions with age.

RESULTS

Regarding motivation for SDM, the TTE elicited the highest motivation, followed by the emoticons and bar chart (p < .001). The displays had no differential influence on the age groups (p = .445). While the TTE was generally rated more accessible than the emoticons and bar chart (p < .001), the emoticons were only superior to the bar chart in the younger subsample. However, this was only to a small effect (interaction between display and age, p < .01, η 2  = 0.018).

CONCLUSIONS

Using fictional case vignettes, the novel TTE display was superior regarding motivation for SDM and accessibility when compared to established displays using emoticons and a bar chart. If future research can replicate these results in real-life consultations, the TTE display will be a valuable addition to current risk calculators and decision aids by improving patients' participation.