Violence risk assessment and risk communication: the effects of using actual cases, providing instruction, and employing probability versus frequency formats

"They are saying it's high, but I think it's quite low": exploring cardiovascular disease risk communication in NHS health checks through video-stimulated recall interviews with patients - a qualitative study

BACKGROUND

NHS Health Check (NHSHC) is a national cardiovascular disease (CVD) risk identification and management programme. However, evidence suggests a limited understanding of the most used metric to communicate CVD risk with patients (10-year percentage risk). This study used novel application of video-stimulated recall interviews to understand patient perceptions and understanding of CVD risk following an NHSHC that used one of two different CVD risk calculators.

METHODS

Qualitative, semi-structured video-stimulated recall interviews were conducted with patients (n = 40) who had attended an NHSHC using either the QRISK2 10-year risk calculator (n = 19) or JBS3 lifetime CVD risk calculator (n = 21). Interviews were transcribed and analysed using reflexive thematic analysis.

RESULTS

Analysis resulted in the development of four themes: variability in understanding, relief about personal risk, perceived changeability of CVD risk, and positive impact of visual displays. The first three themes were evident across the two patient groups, regardless of risk calculator; the latter related to JBS3 only. Patients felt relieved about their CVD risk, yet there were differences in understanding between calculators. Heart age within JBS3 prompted more accessible risk appraisal, yet mixed understanding was evident for both calculators. Event-free survival age also resulted in misunderstanding. QRISK2 patients tended to question the ability for CVD risk to change, while risk manipulation through JBS3 facilitated this understanding. Displaying information visually also appeared to enhance understanding.

CONCLUSIONS

Effective communication of CVD risk within NHSHC remains challenging, and lifetime risk metrics still lead to mixed levels of understanding in patients. However, visual presentation of information, alongside risk manipulation during NHSHCs can help to increase understanding and prompt risk-reducing lifestyle changes.

TRIAL REGISTRATION

ISRCTN10443908. Registered 7th February 2017.

Political ideology shapes risk and benefit judgments of COVID-19 vaccines

In April 2021, the use of the Johnson & Johnson COVID-19 vaccine was paused to investigate whether it had caused serious blood clots to a small number of women (six out of 6.8 million Americans who had been administered that vaccine). As these events were unfolding, we surveyed a sample of Americans (N = 625) to assess their reactions to this news, whether they supported the pausing of the vaccine, and potential psychological factors underlying their decision. In addition, we employed automated text analyses as a supporting method to more classical quantitative measures. Results showed that political ideology influenced the support for the pausing of the vaccine; liberals were more likely to oppose it than conservatives. In addition, the effect of political ideology was mediated by the difference between perceived benefit and risk and the language style used to produce reasons in support (or against) the decision to pause the vaccine. Liberals perceived the benefit of vaccines higher than the risk, used a more analytic language style when stating their reasons, and had a more positive attitude toward the vaccine. We discuss the implications of our findings considering vaccine hesitancy and risk perception during the COVID-19 pandemic.

Effects of media portrayal on perceived cruise risk, image, and intentions

This research examines how news media portrayal of Covid-19 cases on cruise ships can produce decision biases. Two experiments were conducted in which news stories were varied according to format, base rate, framing and number size. The results demonstrate that prior cruise experience increases travel intentions and cruise image and lowers perceptions of cruise risk. Perceived risk is higher when the number of cases is presented in concrete numbers versus abstract percentages. Negative framing increases perceptions of cruise risk versus positive framing, especially when expressed in small numbers. The results extend beyond Covid-19 by demonstrating that sensationalism in the news media can result in decision biases that over- emphasize negative outcomes and increases risk perceptions in the minds of consumers. The findings suggest travel companies should work together with news media outlets when crisis situations arise to shift away from sensationalism and provide concrete information that is useful for consumers.

Calibrating violence risk assessments for uncertainty

Psychiatrists and other mental health clinicians are often tasked with assessing patients' risk of violence. Approaches to this vary and include both unstructured (based on individual clinicians' judgement) and structured methods (based on formalised scoring and algorithms with varying scope for clinicians' judgement). The end result is usually a categorisation of risk, which may, in turn, reference a probability estimate of violence over a certain time period. Research over recent decades has made considerable improvements in refining structured approaches and categorising patients' risk classifications at a group level. The ability, however, to apply these findings clinically to predict the outcomes of individual patients remains contested. In this article, we review methods of assessing violence risk and empirical findings on their predictive validity. We note, in particular, limitations in calibration (accuracy at predicting absolute risk) as distinct from discrimination (accuracy at separating patients by outcome). We also consider clinical applications of these findings, including challenges applying statistics to individual patients, and broader conceptual issues in distinguishing risk and uncertainty. Based on this, we argue that there remain significant limits to assessing violence risk for individuals and that this requires careful consideration in clinical and legal contexts.

Maximizers' Susceptibility to the Effect of Frequency vs. Percentage Format in Risk Representation

The present study explored the susceptibility of maximizers to the effect of the specific information format-frequency vs. percentage-in a risk assessment task. One-hundred and fourteen participants were randomized into two experimental conditions: a frequency format and a percentage format. In both conditions, participants had to rate the level of risk that a mental patient would harm someone after his discharge from a mental health facility, based on the information reported in the psychologist's assessment for that patient. In the frequency condition, the information was presented in terms of frequencies, whereas in the percentage condition the same information was presented in terms of percentage. Our experiment showed that resolute maximizers are less affected by the specific format of the task than fearful maximizers. Thus, we conclude that resolute maximizers are more normative decision-makers. Theoretical and practical implications are discussed.

Optimism bias and its relation to scenario valence, gender, sociality, and insecure attachment

Optimism bias refers to the tendency to display unjustified high/low expectations of future positive/negative events. This study asked 202 participants to estimate the likelihood of 96 different events. We investigated optimism biases for both oneself and the general population, and how these biases are influenced by gender, valence of the event, sociality of the event, as well as attachment anxiety and attachment avoidance. We found that sociality interacted with gender, with the difference in optimism bias for social vs. alone events being larger among women than among men. Attachment anxiety mainly reduced the optimism bias among men deliberating over future alone situations, while attachment avoidance primarily reduced optimism bias among female respondents deliberating over future social interactions. These results may have implications for the well-being and motivation of differently attached men and women and ultimately inspire psychotherapy interventions.

The Individuals’ Willingness to Get the Vaccine for COVID-19 during the Third Wave: A Study on Trust in Mainstream Information Sources, Attitudes and Framing Effect

Different inner and external determinants might explain an individual’s willingness to get the vaccine for COVID-19. The current study aims at evaluating the effects of trust in mainstream information sources on individuals’ willingness to get the vaccine and the moderator role of the message framing. Six hundred and thirty-four participants (68.5% females and 31.5% males) were enrolled in an online survey. Participants filled out a questionnaire assessing: trust in mainstream information sources and vaccinal attitude (trust in vaccine benefit, worries over unforeseen future effects, concerns about commercial profiteering, and preference for natural immunity). In addition, participants were randomly exposed to one of four conditions of framing information about the vaccine (gain-probability; gain-frequency; loss-probability; loss-frequency). Results showed that trust in vaccine benefit (b = 9.90; 95% CI: 8.97, 11.73) and concerns about commercial profiteering (b = −4.70; 95% CI: −6.58, −2.81) had a significant effect on the intention to get the vaccine. Further, a significant interaction was observed between loss-gain and trust in vaccine benefit and between frequency-probability and concerns about commercial profiteering. Future vaccination campaigns should consider the individuals’ concerns about vaccine benefit and economic profits to efficaciously deliver frequency-framed or probability-framed information.

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.

Augmenting Password Strength Meter Design Using the Elaboration Likelihood Model: Evidence from Randomized Experiments

In this research, we study an effective method to encourage users to generate stronger passwords. Specifically, we propose a novel design of password strength meters that incorporates contextual information to help users digest the message generated by the password strength meter. We evaluate our design by leveraging three independent and complementary methods: a survey-based experiment using students to evaluate the saliency of our conceptual design (proof of concept), a controlled laboratory experiment conducted on Amazon Mechanical Turk to test the effectiveness of the proposed design (proof of value), and a randomized field experiment conducted in collaboration with an online forum in Asia to establish proof of use. In each study, we observe that users exposed to the proposed password strength meter are more likely to change their passwords, leading to a new password that is significantly stronger. Our findings suggest that the proposed design of augmented password strength meters is an effective method for promoting secure password behavior among end users. Our design also requires minimal computational resources and technical capabilities.

Effects of icon arrays to communicate risk in a repeated risky decision-making task

In two experiments, participants decided on each of several trials whether or not to take a risk. If they chose to take the risk, they had a relatively high probability (from 75% to 95%) of winning a small number of points and a relatively low probability (5% to 25%) of losing a large number of points. The loss amounts varied so that the expected value of taking the risk was positive on some trials, zero on others, and negative on the rest. The main independent variable was whether the probability of losing was communicated using numerical percentages or icon arrays. Both experiments included random icon arrays, in which the icons representing losses were randomly distributed throughout the array. Experiment 2 also included grouped icon arrays, in which the icons representing losses were grouped at the bottom of the array. Neither type of icon array led to better performance in the task. However, the random icon arrays led to less risk taking than the numerical percentages or the grouped icon arrays, especially at the higher loss probabilities. In a third experiment, participants made direct judgments of the percentages and probabilities represented by the icon arrays from Experiment 2. The results supported the idea that random arrays lead to less risk taking because they are perceived to represent greater loss probabilities. These results have several implications for the study of icon arrays and their use in risk communication.

Frequency or total number? A comparison of different presentation formats on risk perception during COVID-19

Curbing the COVID-19 pandemic remains an ongoing global challenge. Institutions often release information about confirmed COVID-19 cases by citing the total number of cases (e.g., 100,000), their (relative) frequency (e.g., 100 per 1,000,000), or occasionally their proportion (e.g., 0.0001) in a region. I compared the effect of these three presentation formats — total cases, frequency, and proportion — on people’s perceived risk. I found people perceived a higher risk of COVID-19 from a total-cases format than from frequency formats when the denominators are relatively small, and the lowest risk from a proportion format. Correspondingly, people underestimated total infections when given frequency and overestimated frequency when given total number of cases. Additional comparisons were made among mathematically equivalent variations of frequency formats (e.g., 1 in 100, 10 in 1,000, 1,000 in 10,000, etc.). The results provided qualified support for denominator neglect, which seems to occur in bins into which denominators are grouped (e.g., 1–1000, 10000–100000), such that only across bins could participants perceive differences. Finally, a mixed format of proportion and total cases reduced perceived risks from total cases alone, while a mixed format of frequency and total cases failed to produce similar results. I conclude by providing concrete suggestions regarding COVID-19 information releases.

Low numeracy is associated with poor financial well-being around the world

Numeracy refers to the ability to use numbers, including converting percentages (e.g., 10%) into absolute frequencies (e.g., 1 in 10). Studies have suggested that numeracy is correlated to financial outcomes, suggesting its relevance to financial decisions. However, almost all research on numeracy has been conducted in high-income countries in Europe and North America. Our analyses suggest that low numeracy is much more common in low-income countries, thus potentially threatening the financial well-being of the world’s poorest. We analyzed data from the Lloyd’s Register Foundation World Risk Poll, which assessed basic numeracy in 141 countries, including 21 low-income, 34 lower middle income, 43 upper middle income, and 43 high-income countries. Numeracy was associated with being among the poorest 20% of one’s country, and with difficulty living on one’s income, even after accounting for income, education, and demographics. These findings underscore the importance of worldwide numeracy education.

How do People Judge Risk? Availability may Upstage Affect in the Construction of Risk Judgments

When making risk judgments, people rely on availability and affect as convenient heuristics. The two heuristics share many similarities and yet there have been no or few attempts to ascertain their causal impact on risk judgments. We present an experiment (N = 143) where we varied availability-by-recall (thinking of less or more occurrences of someone from one's social network dying) and the affective impact of certain risks (using images). We found that availability-by-recall had a stronger impact in constructing risk judgments. Asking people to think of more occurrences led to higher judgments of mortality and higher values placed on a single life, irrespective of changes in affect, risk media coverage, and retrieval time. Affect, however, was not disregarded. Our data suggest a causal mechanism where the retrieval of occurrences leads to changes in affect, which in turn, impact risk judgments. These findings increase understanding of how risk judgments are constructed with the potential to impact risk communication through direct manipulations of availability and affect. We discuss these and other implications of our findings.

Cardiovascular disease risk communication in NHS Health Checks: a qualitative video-stimulated recall interview study with practitioners

BACKGROUND

NHS Health Check (NHSHC) is a national programme to identify and manage cardiovascular disease (CVD) risk. Practitioners delivering the programme should be competent in discussing CVD risk, but there is evidence of limited understanding of the recommended 10-year percentage CVD risk scores. Lifetime CVD risk calculators might improve understanding and communication of risk.

AIM

To explore practitioner understanding, perceptions, and experiences of CVD risk communication in NHSHCs when using two different CVD risk calculators.

DESIGN & SETTING

Qualitative video-stimulated recall (VSR) study with NHSHC practitioners in the West Midlands.

METHOD

VSR interviews were conducted with practitioners who delivered NHSHCs using either the QRISK2 10-year risk calculator (n = 7) or JBS3 lifetime CVD risk calculator (n = 8). Data were analysed using reflexive thematic analysis.

RESULTS

In total, nine healthcare assistants (HCAs) and six general practice nurses (GPNs) were interviewed. There was limited understanding and confidence of 10-year risk, which was used to guide clinical decisions through determining low-, medium-, or high-risk thresholds, rather than as a risk communication tool. Potential benefits of some JBS3 functions were evident, particularly heart age, risk manipulation, and visual presentation of risk.

CONCLUSION

There is a gap between the expectation and reality of practitioners' understanding, competencies, and training in CVD risk communication for NHSHCs. Practitioners would welcome heart age and risk manipulation functions of JBS3 to promote patient understanding of CVD risk, but there is a more fundamental need for practitioner training in CVD risk communication.

Cardiovascular disease risk communication in NHS Health Checks using QRISK®2 and JBS3 risk calculators: the RICO qualitative and quantitative study

BACKGROUND

The NHS Health Check is a national cardiovascular disease prevention programme. There is a lack of evidence on how health checks are conducted, how cardiovascular disease risk is communicated to foster risk-reducing intentions or behaviour, and the impact on communication of using different cardiovascular disease risk calculators.

OBJECTIVES

RIsk COmmunication in Health Check (RICO) study aimed to explore practitioner and patient understanding of cardiovascular disease risk, the associated advice or treatment offered by the practitioner, and the response of the patients in health checks supported by either the QRISK^®2 or the JBS3 lifetime risk calculator.

DESIGN

This was a qualitative study with quantitative process evaluation.

SETTING

Twelve general practices in the West Midlands of England, stratified on deprivation of the local area (bottom 50% vs. top 50%), and with matched pairs randomly allocated to use QRISK2 or JBS3 during health checks.

PARTICIPANTS

A total of 173 patients eligible for NHS Health Check and 15 practitioners.

INTERVENTIONS

The health check was delivered using either the QRISK2 10-year risk calculator (usual practice) or the JBS3 lifetime risk calculator, with heart age, event-free survival age and risk score manipulation (intervention).

RESULTS

Video-recorded health checks were analysed quantitatively (n = 173; JBS3, n = 100; QRISK2, n = 73) and qualitatively (n = 128; n = 64 per group), and video-stimulated recall interviews were undertaken with 40 patients and 15 practitioners, with 10 in-depth case studies. The duration of the health check varied (6.8-38 minutes), but most health checks were short (60% lasting < 20 minutes), with little cardiovascular disease risk discussion (average < 2 minutes). The use of JBS3 was associated with more cardiovascular disease risk discussion and fewer practitioner-dominated consultations than the use of QRISK2. Heart age and visual representations of risk, as used in JBS3, appeared to be better understood by patients than 10-year risk (QRISK2) and, as a result, the use of JBS3 was more likely to lead to discussion of risk factors and their management. Event-free survival age was not well understood by practitioners or patients. However, a lack of effective cardiovascular disease risk discussion in both groups increased the likelihood of a maladaptive coping response (i.e. no risk-reducing behaviour change). In both groups, practitioners often missed opportunities to check patient understanding and to tailor information on cardiovascular disease risk and its management during health checks, confirming apparent practitioner verbal dominance.

LIMITATIONS

The main limitations were under-recruitment in some general practices and the resulting imbalance between groups.

CONCLUSIONS

Communication of cardiovascular disease risk during health checks was brief, particularly when using QRISK2. Patient understanding of and responses to cardiovascular disease risk information were limited. Practitioners need to better engage patients in discussion of and action-planning for their cardiovascular disease risk to reduce misunderstandings. The use of heart age, visual representation of risk and risk score manipulation was generally seen to be a useful way of doing this. Future work could focus on more fundamental issues of practitioner training and time allocation within health check consultations.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN10443908.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 50. See the NIHR Journals Library website for further project information.

The communication of uncertainty in health: A scoping review

OBJECTIVE

To conduct a scoping review of existing studies that examine communication strategies that address uncertainty in health and categorize them using the taxonomy of uncertainty.

METHODS

Relevant articles retrieved from ten databases were categorized according to the dimensions of the taxonomy of uncertainty, and study characteristics were extracted from each article.

RESULTS

All articles (n = 63) explored uncertainty in the context of probabilistic risk and related to scientific issues (n = 63; 100%). The majority focused on complexity (n = 24; 38.1%) and uncertainty experienced by patients (n = 52; 82.5%). Most utilized quantitative methods (n = 46; 73.0%), hypothetical scenarios (n = 49; 77.8%), and focused on cancer (n = 20; 31.7%). Theory guided messages and study design in fewer than half (n = 27; 42.9%).

CONCLUSIONS

Heterogeneity in terminology used to refer to different types of uncertainties preclude a unified research agenda on uncertainty communication. Research predominately focuses on probability as the source of uncertainty, uncertainties related to scientific issues, and uncertainty experienced by patients.

PRACTICE IMPLICATIONS

Additional efforts are needed to understand providers' experience of uncertainty, and to identify strategies to address ambiguity. Future studies should use consistent terminology to allow for coherence and advancement of uncertainty communication scholarship. Continued efforts to refine the existing taxonomy should be undertaken.

Hindsight Bias and Electoral Outcomes: Satisfaction Counts More Than Winner-Loser Status

The tendency to perceive outcomes as more foreseeable once they are available is a well-known phenomenon. However, research on the cognitive and motivational factors that induce individuals to overestimate the foreseeability of an electoral outcome has yielded inconsistent findings. In three studies based on large-scale electoral surveys (ITANES, Italian National Election Studies), we argued that the tendency to perceive an electoral outcome as foreseeable is positively and consistently associated with satisfaction with the outcome. Across all studies, satisfaction with the outcome was significantly and positively associated with retrospective foreseeability, above and beyond voters’ preference for a “winning” or “losing” party. In Study 3, a measure of memory distortion of pre-electoral forecasts was included, which was only weakly associated with retrospective foreseeability, but not with satisfaction for the outcome, supporting the notion of different levels of hindsight bias associated with different cognitive and motivational factors.

A qualitative exploration of two risk calculators using video-recorded NHS health check consultations

BACKGROUND

The aim of the study was to explore practitioner-patient interactions and patient responses when using QRISK®2 or JBS3 cardiovascular disease (CVD) risk calculators. Data were from video-recorded NHS Health Check (NHSHC) consultations captured as part of the UK RIsk COmmunication (RICO) study; a qualitative study of video-recorded NHSHC consultations from 12 general practices in the West Midlands, UK. Participants were those eligible for NHSHC based on national criteria (40-74 years old, no existing diagnoses for cardiovascular-related conditions, not on statins), and practitioners, who delivered the NHSHC.

METHOD

NHSHCs were video-recorded. One hundred twenty-eight consultations were transcribed and analysed using deductive thematic analysis and coded using a template based around Protection Motivation Theory.

RESULTS

Key themes used to frame the analysis were Cognitive Appraisal (Threat Appraisal, and Coping Appraisal), and Coping Modes (Adaptive, and Maladaptive). Analysis showed little evidence of CVD risk communication, particularly in consultations using QRISK®2. Practitioners often missed opportunities to check patient understanding and encourage risk- reducing behaviour, regardless of the risk calculator used resulting in practitioner verbal dominance. JBS3 appeared to better promote opportunities to initiate risk-factor discussion, and Heart Age and visual representation of risk were more easily understood and impactful than 10-year percentage risk. However, a lack of effective CVD risk discussion in both risk calculator groups increased the likelihood of a maladaptive coping response.

CONCLUSIONS

The analysis demonstrates the importance of effective, shared practitioner-patient discussion to enable adaptive coping responses to CVD risk information, and highlights a need for effective and evidence-based practitioner training.

TRIAL REGISTRATION

ISRCTN ISRCTN10443908 . Registered 7th February 2017.

Quantitative examination of video-recorded NHS Health Checks: comparison of the use of QRISK2 versus JBS3 cardiovascular risk calculators

OBJECTIVES

Quantitatively examine the content of National Health Service Health Check (NHSHC), patient-practitioner communication balance and differences when using QRISK2 versus JBS3 cardiovascular disease (CVD) risk calculators.

DESIGN

RIsk COmmunication in NHSHC was a qualitative study with quantitative process evaluation, comparing NHSHC using QRISK2 or JBS3. We present data from the quantitative process evaluation.

SETTING AND PARTICIPANTS

Twelve general practices in the West Midlands (England) conducted NHSHC using JBS3 or QRISK2 (6/group). Patients were eligible for NHSHC based on national criteria (aged 40-74, no existing cardiovascular-related diagnoses, not taking statins). Recruitment was stratified by patients' age, gender and ethnicity.

METHODS

Video recordings of NHSHC were coded, second-by-second, to quantify who was speaking and what was being discussed. Outcomes included consultation duration, practitioner verbal dominance (ratio of practitioner:patient speaking time (pr:pt ratio)) and proportion of time discussing CVD risk, risk factors and risk management.

RESULTS

173 video-recorded NHSHC were analysed (73 QRISK, 100 JBS3). The sample was 51% women, 83% white British, with approximately equal proportions across age groups. NHSHC duration varied greatly (6.8-38.0 min). Most (60%) lasted less than 20 min. On average, CVD risk was discussed for less than 2 min (9.06%±4.30% of consultation time). There were indications that, compared with NHSHC using JBS3, those with QRISK2 involved less CVD risk discussion (JBS3 M=10.24%, CI: 8.01-12.48 vs QRISK2 M=7.44%, CI: 5.29-9.58) and were more verbally dominated by practitioners (pr:pt ratio JBS3 M=3.21%, CI: 2.44-3.97 vs QRISK2=2.35%, CI: 1.89-2.81). The largest proportion of NHSHC time was spent discussing causal risk factors (M=37.54%, CI: 32.92-42.17).

CONCLUSIONS

There was wide variation in NHSHC duration. Many were short and practitioner-dominated, with little time discussing CVD risk. JBS3 appears to extend CVD risk discussion and patient contribution. Qualitative examination of how it is used is necessary to fully understand the potential benefits of these differences.

TRIAL REGISTRATION NUMBER

ISRCTN10443908.

Forensic Source Conclusions

Abstract. Forensic science evidence may be the most powerful weapon in the arsenal of law enforcement officials and prosecutors. As such, it is important to be aware of factors that threaten the validity of forensic source conclusions (e.g., “This bullet was fired from that gun”). This paper identifies 20 threats to the validity of forensic source conclusions including threats that spring from (a) the evidentiary samples themselves, (b) forensic examiners and the procedures they use, (c) features of the law, and (d) cognitive limitations of jurors and others who must weigh forensic science source claims.

Risk perception and response toward climate change for higher education students in Taiwan

The effects of climate change have already begun to threaten biological diversity and human societies, and these effects will continue to grow over time. To face the challenges related to mitigation and adaptation will require an educated and motivated citizenry. From the perspective of green education, providing knowledge related to climate change and promoting pro-environmental behaviors is imperative. In this study, we assess current levels of knowledge, risk perception and types of pro-environmental behaviors. We administered a questionnaire to 1118 university students in Taiwan evaluating climate change knowledge (15 items), risk perception (23 items), and attitudes toward behavioral change (33 items). Factor analyses were conducted to identify the underlying latent variables for risk perception and obstacles to behavioral change, and ANOVA tests were performed to identify significant associations between three different levels of climate change knowledge and responses to the risk perception and obstacles-to-change items. We found that higher levels of knowledge significantly predicted greater perceptions of risk related to biodiversity threats and increased public costs. In terms of behavior, students with lower levels of knowledge were significantly more likely to find uncertainties related to climate change to be a greater obstacle to engaging in pro-environmental behaviors. Higher levels of knowledge clearly allow individuals to better assess the threats posed by climate change and reduces the perceived level of uncertainty related to climate change and the impact of pro-environmental behaviors. Our results suggest that Taiwan's efforts to implement climate change related information in the public schools and in the university system have been effective and that such efforts should be broadened to reach the public as a whole.

Numeracy and memory for risk probabilities and risk outcomes depicted on cigarette warning labels

OBJECTIVE

Greater numeracy is associated with higher likelihood to quit smoking. We examined whether numeracy supports learning of numeric health-risk information and, in turn, greater risk perceptions and quit intentions.

METHOD

Adult smokers (N = 696) viewed text warnings with numeric risk information four times each in one of three warning-label types (text-only, low-emotion pictorial [i.e., with image], high-emotion pictorial). They completed posttest measures immediately or 6 weeks later. Emotional reactions to warnings were reported the second time participants viewed the warnings. Numeracy, memory for risk probabilities and risk outcomes, risk perceptions, and quit intentions were assessed postexposures.

RESULTS

Memory for risk probabilities and risk outcomes depended on warning-label type and posttest timing. Consistent with memory-consolidation theory, memory for high- versus low-emotion labels was lower immediately, but declined less for high-than low-emotion labels. Label memory was similar between conditions at 6 weeks. Numeracy predicted overall superior memory (especially for risk probabilities) controlling for health literacy and education. It also indirectly predicted greater risk perceptions and quit intentions via memory. In exploratory analyses, however, the superior recall of risk probabilities of smoking among those higher in numeracy was associated with lower risk perceptions.

CONCLUSIONS

Numeracy is associated with superior risk memory, which relates to greater risk perceptions and quit intentions. More numerate and educated smokers may be better able to quit due to their superior learning of smoking's risks. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Landscape of Risk Communication Research: A Scientometric Analysis

Risk communication is a significant research domain with practical importance in supporting societal risk governance and informed private decision making. In this article, a high-level analysis of the risk communication research domain is performed using scientometrics methods and visualization tools. Output trends and geographical patterns are identified, and patterns in scientific categories determined. A journal distribution analysis provides insights into dominant journals and the domain's intellectual base. Thematic clusters and temporal evolution of focus topics are obtained using a terms analysis, and a co-citation analysis provides insights into the evolution of research fronts and key documents. The results indicate that the research volume grows exponentially, with by far most contributions originating from Western countries. The domain is highly interdisciplinary, rooted in psychology and social sciences, and branching mainly into medicine and environmental sciences. Narrative themes focus on risk communication in medical and societal risk governance contexts. The domain originated from public health and environmental concerns, with subsequent research fronts addressing risk communication concepts and models. Applied research fronts are associated with environmental hazards, public health, medical risks, nuclear power, and emergency response to various natural hazards. Based on the results, various avenues for future research are described.

41st Annual North American Meeting of the Society for Medical Decision Making; October 21, 2019; Portland, Oregon Keynote Address The More Who Die, the Less We Care: Confronting the Deadly Arithmetic of Compassion

In this keynote address delivered at the 41st Annual North American Meeting of the Society for Medical Decision Making, I discuss the psychology behind valuing human lives. Research confirms what we experience in our daily lives. We are inconsistent and sometimes incoherent in our valuation of human life. We value individual lives greatly, but these lives lose their value when they become part of a larger crisis. As a result, we do too little to protect human lives in the face of catastrophic threats from violence, natural disasters, and other causes. In medicine, this may pose difficult choices when treating individual patients with expensive therapies that keep hope alive but are not cost-effective for the population, for example, with end of life. Lifesaving judgments and decisions are highly context-dependent, subject to many forms of response mode and framing effects and affective biases. This has implications for risk communication and the concept of shared decision making. Slower, more introspective decision making may reduce some of the biases associated with fast, intuitive decisions. But slow thinking can also introduce serious biases. Understanding the strengths and weaknesses of fast and slow thinking is a necessary first step toward valuing lives humanely and improving decisions.

41st Annual North American Meeting of the Society for Medical Decision Making; October 21, 2019; Portland, Oregon Keynote Address The More Who Die, the Less We Care: Confronting the Deadly Arithmetic of Compassion

In this keynote address delivered at the 41st Annual North American Meeting of the Society for Medical Decision Making, I discuss the psychology behind valuing human lives. Research confirms what we experience in our daily lives. We are inconsistent and sometimes incoherent in our valuation of human life. We value individual lives greatly, but these lives lose their value when they become part of a larger crisis. As a result, we do too little to protect human lives in the face of catastrophic threats from violence, natural disasters, and other causes. In medicine, this may pose difficult choices when treating individual patients with expensive therapies that keep hope alive but are not cost-effective for the population, for example, with end of life. Lifesaving judgments and decisions are highly context-dependent, subject to many forms of response mode and framing effects and affective biases. This has implications for risk communication and the concept of shared decision making. Slower, more introspective decision making may reduce some of the biases associated with fast, intuitive decisions. But slow thinking can also introduce serious biases. Understanding the strengths and weaknesses of fast and slow thinking is a necessary first step toward valuing lives humanely and improving decisions.

Protecting consumers from fraudulent health claims: A taxonomy of psychological drivers, interventions, barriers, and treatments

OBJECTIVE

Fraudulent health claims-false or misleading claims used to promote health remedies that are untested, ineffective, and often harmful-cause extensive and persistent harm to consumers. To address this problem, novel interventions are needed that address the underlying cognitive mechanisms that render consumers susceptible to fraudulent health claims. However, there is currently no single framework of relevant psychological insights to design interventions for this purpose. The current review aims to address this gap.

METHOD

An integrative theoretical review was conducted across several relevant disciplines including criminology; behavioural economics; and cognitive, health, and social psychology.

RESULTS

The current review presents a novel taxonomy that aims to serve as an agenda for future research to systematically design and compare interventions based on empirical evidence. Specifically, this taxonomy identifies (i) the psychological drivers that make consumers susceptible to fraudulent health claims, (ii) the psychological barriers that may prevent successful application of interventions, and (iii) proposes evidence-informed treatments to overcome those barriers.

CONCLUSIONS

The resulting framework integrates behavioural insights from several hitherto distinct disciplines and structures promising interventions according to five underlying psychological drivers: Visceral influence, Affect, Nescience, Misinformation, and Norms (VANMaN). The taxonomy presents an integrative and accessible theoretical framework for designing evidence-informed interventions to protect consumers from fraudulent health claims. This review has broad implications for numerous topical issues including the design and evaluation of anti-fraud campaigns, efforts to address the growing problem of health-related misinformation, and for countering the polarisation of politically sensitive health issues.

Improving cardiovascular disease risk communication in the UK national health service health check programme

OBJECTIVE

To develop and test training to improve practitioners' confidence and perceived understanding when communicating cardiovascular disease (CVD) risk using novel tools and metrics.

METHODS

A CVD risk communication training workshop was developed through interviews with patients and practitioners delivering Health Checks, a literature review, NICE guidance and the UK Health Check competency framework. It was pilot-tested with practitioners delivering Health Checks in the UK. Perceived practitioner understanding and confidence were measured before and up to 10 weeks after the workshop, and changes were compared with those in a control group (who received no intervention). Perceived impact was also explored through semi-structured interviews.

RESULTS

Sixty-two practitioners (34 intervention, 28 control) took part. Perceived practitioner understanding (p = .030) and perceived patient understanding (p = .007) improved significantly for those delivering Health Checks in the training group compared with controls. Practitioner confidence also improved significantly more in practitioners who attended the training (p = .001). Findings were supported by interviews with a sub-sample of practitioners (n = 13).

CONCLUSION

The training workshop improved practitioners' confidence and perceived understanding of CVD risk in Health Checks.

PRACTICE IMPLICATIONS

The training is an important step to improving practitioner understanding of CVD risk in Health Checks and should be implemented on a wider scale.

The Classification of Violence Risk

(Reprinted with permission from Behav. Sci. Law 24: 721-730, 2006).

Flash Flood Risk Perception by the Population of Mindelo, S. Vicente (Cape Verde)

São Vicente Island (Republic of Cape Verde) lies within the Sahelian zone and faces several natural hazards, one of which is flash flooding. With the purpose of understanding what factors determine flash flood risk perception, a questionnaire entitled Flash Flood Hazard Perception in Cape Verde was applied to 199 subjects. Analysis of variance (ANOVA) was performed to identify the primary factors associated with the perception of flash flood risk. Differences between different groups under the same impact factor were also compared. The results indicated that certain socio-demographic characteristics of the respondents (gender, level of education, and type of housing) and prior experience correlated with flash flood risk perception. The study also shows statistical differences between the groups. In general, males and the respondents with a high level of education, homeowners, and people with prior experience have better perception of the flash flood risk. These findings can help decision makers to improve effective flash flood risk communication policies and flood risk reduction strategies.

"The median isn't the message": How to communicate the uncertainties of survival prognoses to cancer patients in a realistic and hopeful way

This study investigated how doctors communicate the uncertainties of survival prognoses to patients recently diagnosed with life‐threatening cancer, and suggests ways to improve this communication. Two hundred thirty‐eight Norwegian oncologists and general practitioners (GPs) participated in Study 1. The study included both a scenario and a survey. The scenario asked participants to respond to a hypothetical patient who wanted to know how long (s)he could be expected to live. There were marked differences in responses within both groups, but few differences between the GPs and oncologists. There was a strong reluctance among doctors to provide patients with a prognosis. Even when they were presented with a statistically well‐founded right‐skewed survival curve, only a small minority provided hope by communicating the variation in survival time. In Study 2, 177 healthy students rated their preferences for different ways of receiving information regarding the uncertainty of a survival prognosis. Participants who received an explicitly described right‐skewed survival curve believed that they would feel more hopeful. These participants also obtained a more realistic understanding of the variation in survival than those who did not receive this information. Based on the findings of the two studies and on extant psychological research, the author suggests much‐needed guidelines for communicating survival prognoses in a realistic and optimistic way to patients recently diagnosed with life‐threatening cancer. In particular, the guidelines emphasise that the doctor explains the often strongly right‐skewed variation in survival time, and thereby providing the patient with realistic hope.

A qualitative study of cardiovascular disease risk communication in NHS Health Check using different risk calculators: protocol for the RIsk COmmunication in NHS Health Check (RICO) study

BACKGROUND

NHS Health Check is a national cardiovascular disease (CVD) risk assessment programme for 40-74 year olds in England, in which practitioners should assess and communicate CVD risk, supported by appropriate risk-management advice and goal-setting. This requires effective communication, to equip patients with knowledge and intention to act. Currently, the QRISK®2 10-year CVD risk score is most common way in which CVD risk is estimated. Newer tools, such as JBS3, allow manipulation of risk factors and can demonstrate the impact of positive actions. However, the use, and relative value, of these tools within CVD risk communication is unknown. We will explore practitioner and patient CVD risk perceptions when using QRISK®2 or JBS3, the associated advice or treatment offered by the practitioner, and patients' responses.

METHODS

RIsk COmmunication in NHS Health Check (RICO) is a qualitative study with quantitative process evaluation. Twelve general practices in the West Midlands of England will be randomised to one of two groups: usual practice, in which practitioners use QRISK®2 to assess and communicate CVD risk; intervention, in which practitioners use JBS3. Twenty Health Checks per practice will be video-recorded (n = 240, 120 per group), with patients stratified by age, gender and ethnicity. Post-Health Check, video-stimulated recall (VSR) interviews will be conducted with 48 patients (n = 24 per group) and all practitioners (n = 12-18), using video excerpts to enhance participant recall/reflection. Patient medical record reviews will detect health-protective actions in the first 12-weeks following a Health Check (e.g., lifestyle referrals, statin prescription). Risk communication, patient response and intentions for health-protective behaviours in each group will be explored through thematic analysis of video-recorded Health Checks (using Protection Motivation Theory as a framework) and VSR interviews. Process evaluation will include between-group comparisons of quantitatively coded Health Check content and post-Health Check patient outcomes. Finally, 10 patients with the most positive intentions or behaviours will be selected for case study analysis (using all data sources).

DISCUSSION

This study will produce novel insights about the utility of QRISK®2 and JBS3 to promote patient and practitioner understanding and perception of CVD risk and associated implications for patient intentions with respect to health-protective behaviours (and underlying mechanisms). Recommendations for practice will be developed.

TRIAL REGISTRATION

ISRCTN ISRCTN10443908 . Registered 7th February 2017.

How emergency managers (mis?)interpret forecasts

Emergency managers who work on floods and other weather-related hazards constitute critical frontline responders to disasters. Yet, while these professionals operate in a realm rife with uncertainty related to forecasts and other unknowns, the influence of uncertainty on their decision-making is poorly understood. Consequently, a national-level survey of county emergency managers in the United States was administered to examine how they interpret forecast information, using hypothetical climate, flood, and weather scenarios to simulate their responses to uncertain information. The study revealed that even emergency managers with substantial experience take decision shortcuts and make biased choices, just as do members of the general population. Their choices vary depending on such features as the format in which probabilistic forecasts are presented and whether outcomes are represented as gains or losses. In sum, forecast producers who consider these decision processes when developing and communicating forecasts could help to improve flood preparation and potentially reduce disaster losses.

BUILDING RISK COMMUNICATION CAPABILITIES AMONG PROFESSIONALS: SEVEN ESSENTIAL CHARACTERISTICS OF RISK COMMUNICATION

Since the Fukushima disaster, medical professionals have been involved in risk communication with residents affected. This is an urgent issue, and an important aspect of global disaster preparedness is defining the essential characteristics of professional risk communication, and training medical professionals and students to conduct effective risk communication. Using a narrative of risk trade-offs between radionuclides in the diet and traffic accidents as an example, we introduce the seven essential characteristics required by medical professionals and authorities involved in risk communication: (1) risk assessment, (2) differentiating between risk acceptance and risk trade-offs, (3) understanding differences in risk quality, (4) understanding how to frame information given residents' values, (5) giving attention to coping with too-high risk, (6) building trust and (7) fully considering how information is provided. Furthermore, we introduce an example of lectures at which participants can voluntarily learn the seven essential characteristics of risk communication through group discussions.

Bad News Has Wings: Dread Risk Mediates Social Amplification in Risk Communication

Social diffusion of information amplifies risk through processes of birth, death, and distortion of message content. Dread risk-involving uncontrollable, fatal, involuntary, and catastrophic outcomes (e.g., terrorist attacks and nuclear accidents)-may be particularly susceptible to amplification because of the psychological biases inherent in dread risk avoidance. To test this, initially balanced information about high or low dread topics was given to a set of individuals who then communicated this information through diffusion chains, each person passing a message to the next. A subset of these chains were also reexposed to the original information. We measured prior knowledge, perceived risk before and after transmission, and, at each link, number of positive and negative statements. Results showed that the more a message was transmitted the more negative statements it contained. This was highest for the high dread topic. Increased perceived risk and production of negative messages was closely related to the amount of negative information that was received, with domain knowledge mitigating this effect. Reexposure to the initial information was ineffectual in reducing bias, demonstrating the enhanced danger of socially transmitted information.

Risk assessment communication difficulties: An empirical examination of the effects of categorical versus probabilistic risk communication in sexually violent predator decisions

Expert testimony concerning risk and its communication to the trier of fact has important implications for some of the most significant legal decisions. In a simulated sexual violent predator hearing, we examined how mock jurors interpret and use recidivism risk expert testimony communicated either categorically, using verbal labels, or probabilistically, using numeric values. Based upon the STATIC-99R, we compared mock jurors' decision-making and verdicts when we manipulated the style of risk communication across four different risk levels. In terms of verdict decisions, we found that higher risk levels were associated with more commitment decisions, but that this relationship only existed for the categorical risk-communication format. We also replicated previous research demonstrating that participants overestimate recidivism risk in general, especially when higher risk is communicated categorically. Finally, our participants did not differentiate well between the four levels of risk offered, instead apparently employing a more simplistic dichotomy between "low" or "high" risk for both their verdict decisions and their thresholds for commitment. The legal and policy implications of our findings are discussed, as well as suggestions for more effective presentation of expert risk testimony.

The case against categorical risk estimates

Risk estimates can be communicated in a variety of forms, including numeric and categorical formats. An example of the latter is "low/medium/high risk." The categorical format is preferred by judges and practitioners alike, and is mandated by the most commonly utilized forensic risk assessment instruments (the HCR-20 and the Static-99). This article argues against the practice of communicating risk in categorical terms on empirical and normative grounds. Empirically, there is no consensus about what level of risk corresponds to a particular category, such as "high risk." Moreover, recent studies indicate that categorizing an otherwise continuous risk estimate does not add incremental predictive validity to the risk estimate. Normatively, categorization obscures what is fundamentally a value judgment about the relative costs and benefits of correct (e.g., true positive) and incorrect (e.g., false positive) outcomes. Such a judgment is inherently non-scientific and invades the province of the jury. Indeed, categorical risk estimates are in principle no different than "dangerousness predictions," which are simply binary and which have been denounced by the field. The fact that alternative risk communication formats have limitations does not justify continuing the pervasive practice of communicating categorical risk estimates.

Sex Offender Risk Assessment: Where Are We and Where Are We Going?

PURPOSE OF REVIEW

Risk assessment is one of the most ubiquitous tasks in the criminal justice system, informing virtually every decision made about offenders. This review, intended for researchers and practitioners, outlines some of the most important recent advances, emerging issues, and recommendations in sex offender risk assessment.

RECENT FINDINGS

The underlying nature and purpose of risk scales is reviewed, with implications for how we should evaluate them. Limits of recidivism probability estimates are discussed, and efforts to advance a common language for describing risk levels are highlighted. Advances in risk communication and field validity are summarized. The utility of protective risk factors in risk assessments is debated. Emerging areas in assessing offender change and assessments with child pornography offenders are discussed. Despite critical advances in the last few years, there are still important gaps in knowledge, particularly for risk communication, field implementation, offender change, and child pornography offenders.

Good (or bad) vibrations: clinical intuition in violence risk assessment

Assessment and management of the risk of violence in psychiatry inevitably and appropriately draws on emotionally laden ‘intuitive’ modes of thought, as well as deliberative analytic thinking. This article discusses the concept of ‘intuition’ and proposes a brief set of guidelines, derived from work by the cognitive psychologist Robin Hogarth, by which intuitive thinking may be applied by clinicians when undertaking risk assessment work. The guidelines are: consider the learning structure relevant to the risk assessment task; use your own emotions as a source of data; impose ‘circuit breakers' such as cost–benefit analyses and validated structured risk assessment tools; and use a narrative approach to develop formulations. The guidelines are intended to provide a framework for ongoing reflective practice in assessing and managing risk.

How to make good-enough risk decisions

Making decisions in the context of risk is an integral part of psychiatric work. Despite this, decision-making skills are rarely systematically taught and the processes behind decisions are rarely made explicit. This article attempts to apply contemporary evidence from cognitive and social psychology to common dilemmas faced by psychiatrists when assessing and managing risk. It argues that clinical decision-making should acknowledge both the value and limitations of intuitive approaches in dealing with complex dilemmas. After discussing the various ways in which clinical decision-making is commonly derailed, the article outlines a framework that accommodates both rational and intuitive modes of thinking, with the aim of optimising decision-making in high-risk situations.

Communicating Conservation Status: How Different Statistical Assessment Criteria Affect Perceptions of Extinction Risk

Although alternative forms of statistical and verbal information are routinely used to convey species' extinction risk to policymakers and the public, little is known about their effects on audience information processing and risk perceptions. To address this gap in literature, we report on an experiment that was designed to explore how perceptions of extinction risk differ as a function of five different assessment benchmarks (Criteria A-E) used by scientists to classify species within IUCN Red List risk levels (e.g., Critically Endangered, Vulnerable), as well as the role of key individual differences in these effects (e.g., rational and experiential thinking styles, environmental concern). Despite their normative equivalence within the IUCN classification system, results revealed divergent effects of specific assessment criteria: on average, describing extinction risk in terms of proportional population decline over time (Criterion A) and number of remaining individuals (Criterion D) evoked the highest level of perceived risk, whereas the single-event probability of a species becoming extinct (Criterion E) engendered the least perceived risk. Furthermore, participants scoring high in rationality (analytic thinking) were less prone to exhibit these biases compared to those low in rationality. Our findings suggest that despite their equivalence in the eyes of scientific experts, IUCN criteria are indeed capable of engendering different levels of risk perception among lay audiences, effects that carry direct and important implications for those tasked with communicating about conservation status to diverse publics.