New directions for risk communication research: a discussion with additional suggestions

Perceived intrafamily melanoma risk communication

Melanoma is a skin cancer that can be deadly. Members of families with a strong history of melanoma have a high risk of melanoma occurrence or recurrence. Enhanced survival in these family members could be influenced by their knowledge of melanoma risk and by simple behaviors to decrease their risk or detect melanoma in its early, most curable, stage. Yet, there is minimal exploration on communication of risk or risk-modifying behaviors in melanoma at-risk families. In this study, we describe perceived intrafamily communication of melanoma risk. Using a qualitative descriptive approach, we examined in-depth interviews with 22 members of 8 families having 2 or more cases of melanoma. We identified 4 major themes: (1) awareness and understanding of risk, (2) families facilitate and hinder communication, (3) promoting melanoma prevention and detection in the family, and (4) an obligation to tell others. We discuss these findings in the context of extant knowledge of cancer risk communication in families at high risk for other cancers, impediments to cancer risk communication, remaining gaps in knowledge of this phenomenon, suggestions for hypothesis-driven research, and clinical implications that are applicable to these and other at-risk families.

Screening in the dark: ethical considerations of providing screening tests to individuals when evidence is insufficient to support screening populations

During the past decade, screening tests using computed tomography (CT) have disseminated into practice and been marketed to patients despite neither conclusive evidence nor professional agreement about their efficacy and cost-effectiveness at the population level. This phenomenon raises questions about physicians' professional roles and responsibilities within the setting of medical innovation, as well as the appropriate scope of patient autonomy and access to unproven screening technology. This article explores how physicians ought to respond when new screening examinations that lack conclusive evidence of overall population benefit emerge in the marketplace and are requested by individual patients. To this end, the article considers the nature of evidence and how it influences decision-making for screening at both the public policy and individual patient levels. We distinguish medical and ethical differences between screening recommended for a population and screening considered on an individual patient basis. Finally, we discuss specific cases to explore how evidence, patient risk factors and preferences, and physician judgment ought to balance when making individual patient screening decisions.

Predictors of decision making in families at risk for inherited breast/ovarian cancer

OBJECTIVE

The purpose of this study was to identify factors associated with decision making about inherited cancer risk information within families and determine the interdependence between survivors' and relatives' decision making.

DESIGN

A descriptive, cross-sectional design using a population-based sample of 146 dyads (N = 292) was used. Analyses included multilevel modeling using the Actor-Partner-Interdependence Model.

MAIN OUTCOME MEASURES

Decision making regarding inherited cancer risk information.

RESULTS

Several individual and family factors contributed toward survivors' and female relatives' decision making about inherited cancer risk information. Individual factors included the individual's perceptions of their family communication and cancer history. Family factors included survivors' and family members' age, communication and coping style that influenced the decision making of the other member of the dyad. Cancer worries and a monitoring coping style affected both seeking and avoiding decision making for survivors and relatives.

CONCLUSIONS

In view of the importance of genetic information upon family health outcomes, it is critical to address both individual and family factors that may influence decision making about cancer risk information and surveillance options for all members within the family.

Communication and decision-making about seeking inherited cancer risk information: findings from female survivor-relative focus groups

Dramatic advances in cancer genetics and identification of germline mutations in cancer genes such as BRCA1 and BRCA2 have led to new options in genetic risk assessment for families with histories of breast and ovarian cancer. However, little research has been carried out with individuals and their families regarding how cancer risk information is communicated within families and factors that may affect individuals and family members making informed decisions about their health. This study explored participants' knowledge of cancer risk, their perceptions and concerns regarding inherited cancer risk information, family communication patterns, and factors that may affect their decision to learn about inherited cancer risk in their families. Nine focus groups of family dyads were conducted (N=39) consisting of breast or ovarian cancer patients and close female relatives. All transcribed interviews were analyzed using qualitative software. Key findings showed diversity in how families communicated and made decisions about their health, persistent worry for their families, lack of knowledge about inherited cancer, vigilance in watching their health, and barriers present in communicating about genetic risk. Results from this study support inclusion of family members in addressing inherited cancer risk information and contextual family factors critical to consider in potentially high risk families.

"Why take it if you don't have anything?" breast cancer risk perceptions and prevention choices at a public hospital

BACKGROUND

Despite advances in breast cancer risk assessment and risk reduction technologies, little is still known about how high-risk women make sense of their risk and assess prevention options, particularly among minority and low-income women. Qualitative methods explore the complex meanings and logics of risk and prevention that quantitative approaches overlook.

OBJECTIVE

This study examined how women attending a high risk breast cancer clinic at a public hospital conceptualize their breast cancer risk and think about the prevention options available to them.

METHODS

Semi-structured interviews were used to gather data from 33 high-risk women (75% African American) between May and August 2004. Interview transcripts were analyzed for recurrent themes and patterns.

RESULTS

Despite general awareness of their objective risk status, many women in this study reported they did not feel "high risk" because they lacked signs and symptoms of cancer. Risk was described as an experienced acute problem rather than a statistical possibility. Women also frequently stated that thinking about cancer might cause it to happen and so it is better not to "dwell on it." While screening was welcomed, women were generally skeptical about primary prevention. In particular, preventive therapies were perceived to cause problems and were only acceptable as treatment options for a disease.

CONCLUSIONS

The body of ideas about risk and prevention expressed by this population differ from the medical model. These findings have implications for risk perception research as well as for the efficacy of risk communication and prevention counseling in clinical contexts.

Does worry about breast cancer predict screening behaviors? A meta-analysis of the prospective evidence

OBJECTIVE

Many women worry about the possibility of developing breast cancer, but there is conflicting evidence concerning whether cancer worry acts as a facilitator or inhibitor of breast cancer screening.

METHOD

We conducted a meta-analysis of 12 prospective studies that measured worry about breast cancer at baseline and subsequent breast self-examination (BSE) or mammography utilization among 3342 high-risk and general population women.

RESULTS

The data consistently show that breast cancer worry has a small but reliable (r = 0.12) association with breast cancer screening behavior, such that greater worry predicts a greater likelihood of screening. We also found that the means for breast cancer worry were consistently in the lower third of the scales, despite differences in measurement approaches, sample utilization, or the date that the study was conducted.

CONCLUSION

The meta-analysis supports the contention that breast cancer worry may motivate screening behavior, and that high levels of breast cancer worry are uncommon.

Research issues in genetic testing of adolescents for obesity

Obesity is often established in adolescence, and advances are being made in identifying its genetic underpinnings. We examine issues related to the eventual likelihood of genetic tests for obesity targeted to adolescents: family involvement; comprehension of the test's meaning; how knowledge of genetic status may affect psychological adaptation; minors' ability to control events; parental/child autonomy; ability to make informed medical decisions; self-esteem; unclear distinctions between early/late onset for this condition; and social stigmatization. The public health arena will be important in educating families about possible future genetic tests for obesity.

Randomized trial of a tailored nutrition education CD-ROM program for women receiving food assistance

OBJECTIVE

This article describes the development and randomized evaluation of a tailored nutrition education CD-ROM program for participants in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in North Carolina.

DESIGN

After randomization to intervention or control groups, participants completed a baseline survey and were resurveyed immediately after program use and 1 to 2 months postintervention.

SETTING

Two WIC clinics in central North Carolina.

PARTICIPANTS

A total of 307 respondents to the follow-up survey (response rate 74.8%) comprised the study sample. Participants were female (96%), 20% were pregnant, and 50% were minorities (African American and other).

INTERVENTION

The interactive CD-ROM consisted of a targeted video soap opera, dietary assessment, and individually tailored dietary feedback and strategies for change.

MAIN OUTCOME MEASURES

Measures included total fat and fruit and vegetable intake, knowledge of low-fat and infant feeding choices, self-efficacy, and stages of change.

ANALYSIS

Descriptive statistics assessed baseline comparability of study groups; analysis of covariance and F tests were used to assess program effects at follow-up.

RESULTS

INTERVENTION group members increased self-efficacy (P <.01) and scored significantly higher (P <.05) on both low-fat and infant feeding knowledge compared with controls. No differential effect was observed for dietary intake variables.

CONCLUSIONS AND IMPLICATIONS

The findings suggest that one dose of an interactive CD-ROM program can impact mediators of dietary change but may be insufficient to change behavior.

Patient comprehension of information for shared treatment decision making: state of the art and future directions

How does the way that information is presented potentially influence patients' consent for health treatments, in a shared decision making process? The goal of this paper is to present an overview of selected recent literature concerning patient health information presentation/use for treatment decision making. Recent work with patient populations has begun to extend early cognitive psychological work showing systematic biases in thinking. Key research findings are organized by type of format (probability, graphic, and qualitative/quantitative dimensions). The applied literature on this topic is amenable to only limited integration in regard to key findings, and relatively few novel approaches to improving information comprehension have been described in the health literature. Promising approaches being proposed, developed, and tested are described, such as enhanced-access computerized patient choice modules, "debiasing" techniques, and tailoring of information. Additional theoretical and practical issues are discussed, as well as selected policy implications of current knowledge.

Pediatric advocacy

Advocacy is part of the job description of a pediatrician. There is a long history of pediatrician involvement in civil society. Like other skills in pediatrics, the skills required for advocacy activities are learnable. Anyone who can learn the Krebs cycle can learn how to be a child advocate. Being a child advocate is not always easy, but it is rewarding. The 1995 Nobel Prize in Chemistry was awarded to Rowland et al for their work in the description of the destruction of stratospheric ozone by chlorofluorocarbons. Having done the groundbreaking research, Rowland and Molina spent much time working to ban chlorofluorocarbons. When asked why they, as bench scientists, ventured out of the laboratory as advocates, Rowland stated, "If not me, who? If not now, when?" (personal communication, December 7, 2000).