Measuring numeracy without a math test: development of the Subjective Numeracy Scale

Does counting change what counts? Quantification fixation biases decision-making

People often rely on numeric metrics to make decisions and form judgments. Numbers can be difficult to process, leading to their underutilization, but they are also uniquely suited to making comparisons. Do people decide differently when some dimensions of a choice are quantified and others are not? We explore this question across 21 preregistered experiments (8 in the main text, N = 9,303; 13 in supplement, N = 13,936) involving managerial, policy, and consumer decisions. Participants face choices that involve tradeoffs (e.g., choosing between employees, one of whom has a higher likelihood of advancement but lower likelihood of retention), and we randomize which dimension of each tradeoff is presented numerically and which is presented qualitatively (using verbal estimates, discrete visualizations, or continuous visualizations). We show that people systematically shift their preferences toward options that dominate on tradeoff dimensions conveyed numerically-a pattern we dub "quantification fixation." Further, we show that quantification fixation has financial consequences-it emerges in incentive-compatible hiring tasks and in charitable donation decisions. We identify one key mechanism that underlies quantification fixation and moderates its strength: When making comparative judgments, which are essential to tradeoff decisions, numeric information is more fluent than non-numeric information. Our findings suggest that when we count, we change what counts.

Design of patient-facing immunization visualizations affects task performance: an experimental comparison of 4 electronic visualizations

OBJECTIVE

This study experimentally evaluated how well lay individuals could interpret and use 4 types of electronic health record (EHR) patient-facing immunization visualizations.

MATERIALS AND METHODS

Participants (n = 69) completed the study using a secure online survey platform. Participants viewed the same immunization information in 1 of 4 EHR-based immunization visualizations: 2 different patient portals (Epic MyChart and eClinicWorks), a downloadable EHR record, and a clinic-generated electronic letter (eLetter). Participants completed a common task, created a standard vaccine schedule form, and answered questions about their perceived workload, subjective numeracy and health literacy, demographic variables, and familiarity with the task.

RESULTS

The design of the immunization visualization significantly affected both task performance measures (time taken to complete the task and number of correct dates). In particular, those using Epic MyChart took significantly longer to complete the task than those using eLetter or eClinicWorks. Those using Epic MyChart entered fewer correct dates than those using the eLetter or eClinicWorks. There were no systematic statistically significant differences in task performance measures based on the numeracy, health literacy, demographic, and experience-related questions we asked.

DISCUSSION

The 4 immunization visualizations had unique design elements that likely contributed to these performance differences.

CONCLUSION

Based on our findings, we provide practical guidance for the design of immunization visualizations, and future studies. Future research should focus on understanding the contexts of use and design elements that make tables an effective type of health data visualization.

Pilot study of a decision aid on BRCA1/2 genetic testing among Orthodox Jewish women

INTRODUCTION

Orthodox Jewish women face unique social, cultural, and religious factors that may influence uptake of BRCA1/2 genetic testing. We examined the impact of a web-based decision aid (DA) on BRCA1/2 genetic testing intention/completion among Orthodox Jewish women. We conducted a single-arm pilot study among 50 Orthodox Jewish women who were given access to a web-based DA entitled RealRisks and administered serial surveys at baseline and 1 and 6 months after exposure to the DA. Descriptive statistics were conducted for baseline characteristics and study measures. Comparisons were made to assess changes in study measures over time. Fifty Orthodox Jewish women enrolled in the study with a mean age of 43.9 years (standard deviation [SD] 14.6), 70% Modern Orthodox, 2% with personal history of breast cancer, and 68% and 16% with a family history of breast or ovarian cancer, respectively. At baseline, 27 (54%) participants intended to complete genetic testing. Forty-three participants (86%) completed RealRisks and the 1-month survey and 38 (76%) completed the 6-month survey. There was a significant improvement in BRCA1/2 genetic testing knowledge and decrease in decisional conflict after exposure to the DA. At 1 month, only 20 (46.5%) completed or intended to complete genetic testing (p = 0.473 compared to baseline). While the DA improved genetic testing knowledge and reduced decisional conflict, genetic testing intention/completion did not increase over time. Future interventions should directly address barriers to BRCA1/2 genetic testing uptake and include input from leaders in the Orthodox Jewish community.

CLINICALTRIALS

GOV ID

NCT03624088 (8/7/18).

Clinical and demographic factors determining patient fracture risk decision point (FRDP): The improving risk communication in osteoporosis (RICO) project

This study aims to understand how osteoporosis medication acceptance varies across countries with differing guidance on treatment threshold and influence of clinical and demographic factors. A total of 79.2% accepted treatment at a fracture probability at or below the treatment threshold. Fracture history and age did not strongly impact acceptance, suggesting a need for improved fracture risk communication.

PURPOSE

This part of the Improving Risk Communication in Osteoporosis (RICO) study aims to understand patients' willingness to initiate osteoporosis treatment given a hypothetical fracture probability-derived from the FRAX® Risk Assessment Tool-and how age, fracture history, and numeric literacy may influence this.

METHODS

In 2022-2023, 332 postmenopausal women at risk of fracture were interviewed from nine countries to determine participants' Fracture Risk Decision Point (FRDP), the lowest probability of major osteoporotic fracture at which they would accept an osteoporosis medication. Participants' FRDP was evaluated given eight hypothetical 10-year FRAX scores.

RESULTS

In countries with FRAX-based treatment thresholds, over half of the participants per country reported an FRDP that was below the threshold. Collectively, 79.2% demonstrated FRDPs at or below their respective threshold. Age and fracture history did not have a strong influence on FRDP; however, those who demonstrated higher levels of numeric literacy reported a significantly higher median FRDP (10%) compared to those who showed lower levels (5%, p < 0.001).

CONCLUSIONS

Most patients were willing to accept an osteoporosis medication prescription at a hypothetical FRAX probability that was even lower than that of their nationally recommended treatment threshold. Literacy scores had a significant influence on FRDP whereas age and fracture history did not.

Impact of gist intervention on automated system interpretability and user decision making

As they become more common, automated systems are also becoming increasingly opaque, challenging their users' abilities to explain and interpret their outputs. In this study, we test the predictions of fuzzy-trace theory-a leading theory of how people interpret quantitative information-on user decision making after interacting with an online decision aid. We recruited a sample of 205 online crowdworkers and asked them to use a system that was designed to detect URLs that were part of coordinated misinformation campaigns. We examined how user endorsements of system interpretability covaried with performance on this coordinated misinformation detection task and found that subjects who endorsed system interpretability displayed enhanced discernment. This interpretability was, in turn, associated with both objective mathematical ability and mathematical self-confidence. Beyond these individual differences, we evaluated the impact of a theoretically motivated intervention that was designed to promote sensemaking of system output. Participants provided with a "gist" version of system output, expressing the bottom-line meaning of that output, were better able to identify URLs that might have been part of a coordinated misinformation campaign, compared to users given the same information presented as verbatim quantitative metrics. This work highlights the importance of enabling users to grasp the essential, gist meaning of the information they receive from automated systems, which benefits users regardless of individual differences.

It is, uh, very likely? The impact of prosodic uncertainty cues on the perception and interpretation of spoken verbal probability phrases

People typically use verbal probability phrases when discussing risks ("It is likely that this treatment will work"), both in written and spoken communication. When speakers are uncertain about risks, they can nonverbally signal this uncertainty by using prosodic cues, such as a rising, question-like intonation or a filled pause ("uh"). We experimentally studied the effects of these two prosodic cues on the listener's perceived speaker certainty and numerical interpretation of spoken verbal probability phrases. Participants (N = 115) listened to various verbal probability phrases that were uttered with a rising or falling global intonation and with or without a filled pause before the probability phrase. For each phrase, they gave a point estimate of their numerical interpretation in percentages and indicated how certain they thought the speaker was about the correctness of the probability phrase. Speakers were perceived as least certain when the verbal probability phrases were spoken with both prosodic uncertainty cues. Interpretation of verbal probability phrases varied widely across participants, especially when rising intonation was produced by the speaker. Overall, high probability phrases (e.g., "very likely") were estimated as lower (and low probability phrases, such as "unlikely," as higher) when they were uttered with a rising intonation. The effects of filled pauses were less pronounced, as were the uncertainty effects for medium probability phrases (e.g., "probable"). These results stress the importance of nonverbal communication when verbally communicating risks and probabilities to people, for example, in the context of doctor-patient communication.

Patient Perceptions of Standardized Risk Language Used in ACR Prostate MRI PI-RADS Scores

INTRODUCTION

Prostate MRI reports use standardized language to describe risk of clinically significant prostate cancer (csPCa) from "equivocal" (Prostate Imaging Reporting and Data System [PI-RADS] 3), "likely" (PI-RADS 4), to "highly likely" (PI-RADS 5). These terms correspond to risks of 11%, 37%, and 70% according to American Urological Association guidelines, respectively. We assessed how men perceive risk associated with standardized PI-RADS language.

METHODOLOGY

We conducted a crowdsourced survey of 1,204 men matching a US prostate cancer demographic. We queried participants' risk perception associated with standardized PI-RADS language across increasing contexts: words only, PI-RADS sentence, full report, and full report with numeric estimate. Median perceived risk (interquartile range) and absolute under/overestimation compared with American Urological Association standards were reported. Multivariable linear mixed-effects analysis identified factors associated with accuracy of risk perception.

RESULTS

Median perceived risks of csPCa (interquartile range) for the word-only context were "equivocal" 50% (50%-74%), "likely" 75% (68%-85%), and "highly likely" 87% (78%-92%), corresponding to +39%, +38%, and +17% overestimation, respectively. Median perceived risks for the PI-RADS-sentence context were 50% (50%-50%), 75% (68%-81%), and 90% (80%-94%) for PI-RADS 3, 4, and 5, corresponding to +39%, +38%, and +20% overestimation, respectively. Median perceived risks for the full-report context were 50% (35%-70%), 72% (50%-80%), and 84% (54%-91%) for PI-RADS 3, 4, and 5, corresponding to +39%, +35%, and +14% overestimation, respectively. For the full-report-with-numeric-estimate context describing a PI-RADS 4 lesion, median perceived risk was 70% (50%-%80), corresponding to +33% overestimation. Including numeric estimates increased correct perception of risk from 3% to 11% (P < .001), driven by men with higher numeracy (odds ratio 1.24, P = .04).

CONCLUSION

Men overestimate risk of csPCa associated with standardized PI-RADS language regardless of context, especially for PI-RADS 3 and 4 lesions. Changes to PI-RADS language or data-sharing policies for imaging reports should be considered.

Preferences for Tapering Biologic Disease-Modifying Antirheumatic Drugs Among People With Rheumatoid Arthritis: A Discrete Choice Experiment

OBJECTIVE

Little is known about the preferences of people with rheumatoid arthritis (RA) regarding tapering of biologic disease-modifying antirheumatic drugs (bDMARDs). The aim of this study was to assess the preferences of people with RA in relation to potential treatment-related benefits and risks of bDMARD tapering and the health care service-related attributes that affect tapering.

METHODS

Participants with RA who had experience taking a bDMARD completed an online discrete choice experiment. Participants were asked their preferences when given three hypothetical treatment scenarios in which varying the frequency of treatment might alter their chance of adverse effects, of regaining disease control, and of other health care service-related effects. Preference weights were estimated using a multinomial logit model.

RESULTS

There were 142 complete responses. Reduced dosing frequency of bDMARD treatment had the largest impact on preference (mean 1.0, 95% confidence interval [CI] 0.8-1.2), followed by chance of disease flare (mean 0.7, 95% CI 0.6-0.9). Participants were willing to accept an increased risk of flare between 10.6% (95% CI 3.2-17.9) and 60.6% (95% CI 48.1-72.9) in exchange for benefits associated with tapering bDMARDs. Participants with better quality of life were more likely to choose to remain on current treatment. The predicted uptake of bDMARD tapering was high among people with RA, suggesting bDMARD tapering was a favored option.

CONCLUSION

For individuals with RA, making decisions about tapering bDMARDs involves considering several factors, with the most important determinants identified as dosing frequency and the risk of disease flare. Understanding patient perspectives of bDMARD tapering may enable physicians to make patient-focused shared health care decisions.

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.

Associations between subjective social status and predictors of interest in genetic testing among women diagnosed with breast cancer at a young age

PURPOSE

Genetic testing for gene mutations which elevate risk for breast cancer is particularly important for women diagnosed at a young age. Differences remain in access and utilization to testing across social groups, and research on the predictors of interest in genetic testing for women diagnosed at a young age is limited.

METHODS

We examined the relationships between subjective social status (SSS) and variables previously identified as possible predictors of genetic testing, including genome sequencing knowledge, genetic worry, cancer worry, health consciousness, decision-making preferences, genetic self-efficacy, genetic-related beliefs, and subjective numeracy, among a cohort of women who were diagnosed with breast cancer at a young age.

RESULTS

In this sample (n = 1,076), those who had higher SSS had significantly higher knowledge about the limitations of genome sequencing (Odds Ratio (OR) = 1.11; 95% CI = 1.01-1.21) and significantly higher informational norms (OR = 1.93; 95% CI = 1.19-3.14) than those with lower SSS. Similarly, education (OR = 2.75; 95% CI = 1.79-4.22), health status (OR = 2.18; 95% CI = 1.44-3.31) were significant predictors among higher SSS women compared to lower SSS women in our multivariate analysis. Lower SSS women with low self-reported income (OR = 0.13; 95% CI = 0.08-0.20) had lower odds of genetic testing interest. Our results are consistent with some prior research utilizing proxy indicators for socioeconomic status, but our research adds the importance of using a multidimensional indicator such as SSS to examine cancer and genetic testing predictor outcomes.

CONCLUSION

To develop interventions to improve genetic knowledge, researchers should consider the social status and contexts of women diagnosed with breast cancer at a young age (or before 40 years old) to ensure equity in the distribution of genetic testing benefits.

Using Separate Single-Outcome Risk Presentations Instead of Integrated Multioutcome Formats Improves Comprehension in Discrete Choice Experiments

INTRODUCTION

Despite decades of research on risk-communication approaches, questions remain about the optimal methods for conveying risks for different outcomes across multiple time points, which can be necessary in applications such as discrete choice experiments (DCEs). We sought to compare the effects of 3 design factors: 1) separated versus integrated presentations of the risks for different outcomes, 2) use or omission of icon arrays, and 3) vertical versus horizontal orientation of the time dimension.

METHODS

We conducted a randomized study among a demographically diverse sample of 2,242 US adults recruited from an online panel (mean age 59.8 y, s = 10.4 y; 21.9% African American) that compared risk-communication approaches that varied in the 3 factors noted above. The primary outcome was the number of correct responses to 12 multiple-choice questions asking survey respondents to identify specific numbers, contrast options to recognize dominance (larger v. smaller risks), and compute differences. We used linear regression to test the effects of the 3 design factors, controlling for health literacy, graph literacy, and numeracy. We also measured choice consistency in a subsequent DCE choice module.

RESULTS

Mean comprehension varied significantly across versions (P < 0.001), with higher comprehension in the 3 versions that provided separated risk information for each risk. In the multivariable regression, separated risk presentation was associated with 0.58 more correct responses (P < 0.001; 95% confidence interval: 0.39, 0.77) compared with integrated risk information. Neither providing icon arrays nor using vertical versus horizontal time formats affected comprehension rates, although participant understanding did correlate with DCE choice consistency.

CONCLUSIONS

In presentations of multiple risks over multiple time points, presenting risk information separately for each health outcome appears to increase understanding.

HIGHLIGHTS

When conveying information about risks of different outcomes at multiple time points, separate presentations of single-outcome risks resulted in higher comprehension than presentations that combined risk information for different outcomes.We also observed benefits of presenting single-outcome risks separately among respondents with lower numeracy and graph literacy.Study participants who scored higher on risk understanding were more internally consistent in their responses to a discrete choice experiment.

Icon Arrays for Medical Risk Communication: Do Icon Type and Color Influence Cardiovascular Risk Perception and Recall?

BACKGROUND

Icon arrays have been shown to be an effective method for communicating medical risk information. However, in practice, icon arrays used to visualize personal risks often differ in the type and color of the icons. The aim of this study was to examine the influence of icon type and color on the perception and recall of cardiovascular risk, as little is known about how color affects the perception of icon arrays.

METHODS

A total of 866 participants aged 40 to 90 years representative of the German population in terms of gender and age completed an online experiment. Using a 2 × 2 between-subjects design, participants were randomly assigned to 1 of 4 experimental groups. They received their hypothetical 10-year cardiovascular risk using an icon array that varied by icon type (smiley v. person) and color (black/white v. red/yellow). We measured risk perception, emotional response, intentions of taking action to reduce the risk (e.g., increasing one's physical activity), risk recall, and graph evaluation/trustworthiness, as well as numeracy and graphical literacy.

RESULTS

Icon arrays using person icons were evaluated more positively. There was no effect of icons or color on risk perception, emotional response, intentions of taking action to reduce the risk, or trustworthiness of the graph. While more numerate/graphical literate participants were more likely to correctly recall the presented risk estimate, icon type and color did not influence the probability of correct recall.

CONCLUSIONS

Differences in the perception of the tested icon arrays were rather small, suggesting that they may be equally suitable for communicating medical risks. Further research on the robustness of these results across other colors, icons, and risk domains could add to guidelines on the design of visual aids.

HIGHLIGHTS

The use of different icons and colors did not influence the perception and the probability of recalling the 10-year cardiovascular risk, the emotional response, or the intentions to reduce the presented risk.Icon arrays with person icons were evaluated more positively.There was no evidence to suggest that the effectiveness of the studied icon arrays varied based on individuals' levels of numerical or graphical literacy, nor did it differ between people with or without a history of CVD or on medication for an increased CVD risk.

Numeric social-media posts engage people with climate science

Innumeracy (lack of math skills) among nonscientists often leads climate scientists and others to avoid communicating numbers due to concerns that the public will not understand them and may disengage. However, people often report preferring to receive numbers; providing them also can improve decisions. Here, we demonstrated that the presence vs. absence of at least one Arabic integer in climate-related social-media posts increased sharing up to 31.7% but, counter to hypothesis, decreased liking of messages 5.2% in two preregistered observational studies (climate scientists on Twitter, N  > 8 million Tweets; climate subreddit, N  > 17,000 posts and comments). We speculated that the decreased liking was due, not to reduced engagement, but to more negative feelings towards climate-related content described with numeric precision. A preregistered within-participant experiment (N = 212) then varied whether climate consequences were described using Arabic integers (e.g. "90%") or another format (e.g. verbal terms, "almost all"). The presence of Arabic integers about consequences led to more sharing, wanting to find out more, and greater trust and perceptions of an expert messenger; perceived trust and expertise appeared to mediate effects on sharing and wanting to find out more. Arabic integers about consequences again led to more negative feelings about the Tweets as if numbers clarified the dismaying magnitude of climate threats. Our results indicate that harnessing the power of numbers could increase public trust and concern regarding this defining issue of our time. Communicators, however, should also consider counteracting associated negative feelings-that could halt action-by providing feasible solutions to increase people's self-efficacy.

Effects of a Patient Portal Intervention to Address Diabetes Care Gaps: Protocol for a Pragmatic Randomized Controlled Trial

BACKGROUND

Despite the potential to significantly reduce complications, many patients do not consistently receive diabetes preventive care. Our research team recently applied user-centered design sprint methodology to develop a patient portal intervention empowering patients to address selected diabetes care gaps (eg, no diabetes eye examination in last 12 months).

OBJECTIVE

This study aims to evaluate the effect of our novel diabetes care gap intervention on completion of selected evidence-based diabetes preventive care services and secondary outcomes.

METHODS

We are conducting a pragmatic randomized controlled trial of the effect of the intervention on diabetes care gaps. Adult patients with diabetes mellitus (DM) are recruited from primary care clinics affiliated with Vanderbilt University Medical Center. Participants are eligible if they have type 1 or 2 DM, can read in English, are aged 18-75 years, have a current patient portal account, and have reliable access to a mobile device with internet access. We exclude patients with medical conditions that prevent them from using a mobile device, severe difficulty seeing, pregnant women or women who plan to become pregnant during the study period, and patients on dialysis. Participants will be randomly assigned to the intervention or usual care. The primary outcome measure will be the number of diabetes care gaps among 4 DM preventive care services (diabetes eye examination, pneumococcal vaccination, hemoglobin A1c, and urine microalbumin) at 12 months after randomization. Secondary outcomes will include diabetes self-efficacy, confidence managing diabetes in general, understanding of diabetes preventive care, diabetes distress, patient portal satisfaction, and patient-initiated orders at baseline, 3 months, 6 months, and 12 months after randomization. An ordinal logistic regression model will be used to quantify the effect of the intervention on the number of diabetes care gaps at the 12-month follow-up. For dichotomous secondary outcomes, a logistic regression model will be used with random effects for the clinic and provider variables as needed. For continuous secondary outcomes, a regression model will be used.

RESULTS

This study is ongoing. Recruitment was closed in February 2022; a total of 433 patients were randomized. Of those randomized, most (n=288, 66.5%) were non-Hispanic White, 33.5% (n=145) were racial or ethnic minorities, 33.9% (n=147) were aged 65 years or older, and 30.7% (n=133) indicated limited health literacy.

CONCLUSIONS

The study directly tests the hypothesis that a patient portal intervention-alerting patients about selected diabetes care gaps, fostering understanding of their significance, and allowing patients to initiate care-will reduce diabetes care gaps compared with usual care. The insights gained from this study may have broad implications for developing future interventions to address various care gaps, such as gaps in cancer screening, and contribute to the development of effective, scalable, and sustainable approaches to engage patients in chronic disease management and prevention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04894903; https://classic.clinicaltrials.gov/ct2/show/NCT04894903.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56123.

Performance of aging consumers in an e-commerce product choice task: The role of working memory and decision strategies

Over the past two decades, there has been a growing interest in research on aging and the decision-making behavior of older consumers. The subject of this article is multi-attribute decisions made using product comparison, a widely used functionality of many e-commerce stores. Studies on cognitive aging have established a negative relationship between age and accuracy in multi-attribute choice tasks; however, works in informatics (Human-Computer Interaction, UX research) have not accounted for how individual user differences affect the optimality of users' product comparison decisions. Our work attempts to bridge this gap between the disciplines of psychology of aging and informatics. We predicted and confirmed, in an online study simulating e-commerce shopping, the strong limitations of older adults in product comparison tasks. In subsequent modeling, other individual characteristics, such as visual working memory, were predicted and shown to be a reliable mediator of the relationship between age and decision accuracy. Popular product comparison tables are not sufficient for older consumers. Despite following UX guidelines for designing product comparison tables, overall correctness of consumer decisions in our study ranged from 90% to as little as 30%, depending on the difficulty of the task and the age of the consumer. These findings have important practical implications for UX design of e-commerce Websites.

Patient-reported predictors of postdischarge mortality after cardiac hospitalization

BACKGROUND

Adults hospitalized for cardiovascular events are at high risk for postdischarge mortality. Screening of psychosocial risk is prioritized by the Joint Commission. We tested whether key patient-reported psychosocial and behavioral measures could predict posthospitalization mortality in a cohort of adults hospitalized for a cardiovascular event.

METHODS

We conducted a prospective cohort study to test the prognostic utility of validated patient-reported measures, including health literacy, social support, health behaviors and disease management, and socioeconomic status. Cox survival analyses of mortality were conducted over a median of 3.5 years.

RESULTS

Among 2977 adults hospitalized for either acute coronary syndrome or acute decompensated heart failure, the mean age was 53 years, and 60% were male. After adjusting for demographic, clinical, and other psychosocial factors, mortality risk was greatest among patients who reported being unemployed (hazard ratio [HR]: 1.99, 95% confidence interval [CI]): 1.30-3.06), retired (HR: 2.14, 95% CI: 1.60-2.87), or unable to work due to disability (HR: 2.36, 95% CI: 1.73-3.21), as compared to those who were employed. Patient-reported perceived health competence (PHCS-2) and exercise frequency were also associated with mortality risk after adjusting for all other variables (HR: 0.86, 95% CI: 0.73-1.00 per four-point increase in PHCS-2; HR: 0.86, 95% CI: 0.77-0.96 per 3-day increase in exercise frequency, respectively).

CONCLUSIONS

Patient-reported measures of employment status, perceived health competence, and exercise frequency independently predict mortality after a cardiac hospitalization. Incorporating these brief, valid measures into hospital-based screening may help with prognostication and targeting patients for resources during post-discharge transitions of care.

Treatment Preferences of Adolescents and Young Adults with Depressive Symptoms: A Discrete Choice Experiment

BACKGROUND

Depression in adolescents and young adults is common and causes considerable disease burden while hampering their development, leading to adverse consequences in later life. Although treatment is available, young people are a vulnerable group regarding uptake and completion of treatment. To improve this, insight into youth's preferences for treatment is essential.

OBJECTIVE

The aim of this study was to investigate patient preferences for depression treatment in a Dutch sample aged 16-24 years using a discrete choice experiment (DCE).

METHODS

The study was conducted in The Netherlands between October 2018 and June 2019, and included 236 adolescents and young adults with current depressive symptoms or previous treatment. The DCE included five attributes (treatment type, frequency of appointment, waiting time, effectiveness, evaluation of therapeutic alliance) with corresponding levels. Results were analysed using latent class analysis.

RESULTS

Results show a general preference for individual psychotherapy, treatment with high frequency, high effectiveness, short waiting time and a standard evaluation of the therapeutic alliance ('click' with the therapist) early in treatment. Latent class analysis revealed three different patterns of preferences regarding treatment type and willingness to engage in therapy. The first class showed a strong preference for individual therapy. The second class, including relatively older, higher educated and treatment-experienced participants, preferred high frequency treatment and was more open to different forms of therapy. The third class, including lower educated, younger and treatment-naïve adolescents showed reluctance to engage in therapy overall and in group therapy specifically.

CONCLUSION

In this DCE, three classes could be identified that share similar preferences regarding treatment effectiveness, waiting time and evaluation of the therapeutic alliance, but varied considerably in their preference for treatment type (individual, group, or combined psychotherapy) and their willingness to engage. The results from this study may inform mental health care providers and institutions and help optimize professional care for adolescents and young adults with depressive symptoms, improving engagement in this vulnerable group.

Collective overclaiming is related to collective narcissism and numeracy

When asked to estimate how much their state or nation has contributed to history, people typically provide unreasonably large estimates, claiming that their group has contributed much more to history than nongroup members would estimate, demonstrating collective overclaiming. Why does such overclaiming occur? In the current study we examined factors that might predict collective overclaiming. Participants from 12 U.S. states estimated how much their home state contributed to U.S. history, completed measures of collective narcissism and numeracy, and rated the importance of 60 specific historical events. There was a positive relationship between collective overclaiming and collective narcissism, a negative relationship between collective overclaiming and numeracy, and a positive relationship between collective overclaiming and the importance ratings of the specific events. Together, these results indicate that overclaiming is partially and positively related to collective narcissism and negatively related to people's ability to work with numbers. We conclude that collective overclaiming is likely determined by several factors, including the availability heuristic and ego protection mechanisms, in addition to collective narcissism and relative innumeracy.

Patient Risk-Benefit Preferences for Transcatheter Versus Surgical Mitral Valve Repair

BACKGROUND

Transcatheter edge-to-edge repair (TEER) of mitral regurgitation is less invasive than surgery but has greater 5-year mortality and reintervention risks, and leads to smaller improvements in physical functioning. The study objective was to quantify patient preferences for risk-benefit trade-offs associated with TEER and surgery.

METHODS AND RESULTS

A discrete choice experiment survey was administered to patients with mitral regurgitation. Attributes included procedure type; 30-day mortality risk; 5-year mortality risk and physical functioning for 5 years; number of hospitalizations in the next 5 years; and risk of additional surgery in the next 5 years. A mixed-logit regression model was fit to estimate preference weights. Two hundred one individuals completed the survey: 63% were female and mean age was 74 years. On average, respondents preferred TEER over surgery. To undergo a less invasive procedure (ie, TEER), respondents would accept up to a 13.3% (95% CI, 8.7%-18.5%) increase in reintervention risk above a baseline of 10%, 4.6 (95% CI, 3.1-6.2) more hospitalizations above a baseline of 1, a 10.7% (95% CI, 6.5%-14.5%) increase in 5-year mortality risk above a baseline of 20%, or more limited physical functioning representing nearly 1 New York Heart Association class (0.7 [95% CI, 0.4-1.1]) over 5 years.

CONCLUSIONS

Patients in general preferred TEER over surgery. When holding constant all other factors, a functional improvement from New York Heart Association class III to class I maintained over 5 years would be needed, on average, for patients to prefer surgery over TEER.

Predictors of COVID-19 vaccine uptake: an online three-wave survey study of US adults

BACKGROUND

To effectively promote vaccine uptake, it is important to understand which people are most and least inclined to be vaccinated and why. In this study, we examined predictors of COVID-19 vaccine uptake and reasons for non-vaccination.

METHODS

We conducted an online English-language survey study in December-2020, January-2021, and March-2021. A total of 930 US respondents completed all surveys. Multiple logistic regression models were run to test whether the early vaccine eligibility, demographic factors, and psychological factors predict getting at least one dose of a COVID-19 vaccination in January-2021 and in March-2021.

RESULTS

The proportion of respondents who received ≥ 1-dose of a COVID-19 vaccine increased from 18% (January) to 67% (March). Older age predicted vaccine uptake in January (OR = 2.02[95%CI = 1.14-3.78], p < .001) and March (10.92[6.76-18.05], p < .001). In January, additional predictors were higher numeracy (1.48[1.20-1.86], p < .001), COVID-19 risk perceptions (1.35[1.03-1.78], p = .029), and believing it is important adults get the COVID-19 vaccine (1.66[1.05-2.66], p = .033). In March, additional predictors of uptake were believing it is important adults get the COVID-19 vaccine (1.63[1.15-2.34], p = .006), prior COVID-19 vaccine intentions (1.37[1.10-1.72], p = .006), and belief in science (0.84[0.72-0.99], p = .041). Concerns about side effects and the development process were the most common reasons for non-vaccination. Unvaccinated respondents with no interest in getting a COVID-19 vaccine were younger (0.27[0.09-0.77], p = .016), held negative views about COVID-19 vaccines for adults (0.15[0.08-0.26], p < .001), had lower trust in healthcare (0.59[0.36-0.95], p = .032), and preferred to watch and wait in clinically ambiguous medical situations (0.66[0.48-0.89], p = .007).

CONCLUSIONS

Evidence that attitudes and intentions towards COVID-19 vaccines were important predictors of uptake provides validation for studies using these measures and reinforces the need to develop strategies for addressing safety and development concerns which remain at the forefront of vaccine hesitancy.

Patients' preferences for fracture risk communication: the Risk Communication in Osteoporosis (RICO) study

The RICO study indicated that most patients would like to receive information regarding their fracture risk but that only a small majority have actually received it. Patients globally preferred a visual presentation of fracture risk and were interested in an online tool showing the risk.

PURPOSE

The aim of the Risk Communication in Osteoporosis (RICO) study was to assess patients' preferences regarding fracture risk communication.

METHODS

To assess patients' preferences for fracture risk communication, structured interviews with women with osteoporosis or who were at risk for fracture were conducted in 11 sites around the world, namely in Argentina, Belgium, Canada at Hamilton and with participants from the Osteoporosis Canada Canadian Osteoporosis Patient Network (COPN), Japan, Mexico, Spain, the Netherlands, the UK, and the USA in California and Washington state. The interviews used to collect data were designed on the basis of a systematic review and a qualitative pilot study involving 26 participants at risk of fracture.

RESULTS

A total of 332 women (mean age 67.5 ± 8.0 years, 48% with a history of fracture) were included in the study. Although the participants considered it important to receive information about their fracture risk (mean importance of 6.2 ± 1.4 on a 7-point Likert scale), only 56% (i.e. 185/332) had already received such information. Globally, participants preferred a visual presentation with a traffic-light type of coloured graph of their FRAX® fracture risk probability, compared to a verbal or written presentation. Almost all participants considered it important to discuss their fracture risk and the consequences of fractures with their healthcare professionals in addition to receiving information in a printed format or access to an online website showing their fracture risk.

CONCLUSIONS

There is a significant communication gap between healthcare professionals and patients when discussing osteoporosis fracture risk. The RICO study provides insight into preferred approaches to rectify this communication gap.

An item response theory analysis of the matrix reasoning item bank (MaRs-IB)

Matrix reasoning tasks are among the most widely used measures of cognitive ability in the behavioral sciences, but the lack of matrix reasoning tests in the public domain complicates their use. Here, we present an extensive investigation and psychometric validation of the matrix reasoning item bank (MaRs-IB), an open-access set of matrix reasoning items. In a first study, we calibrate the psychometric functioning of the items in the MaRs-IB in a large sample of adult participants (N = 1501). Using additive multilevel item structure models, we establish that the MaRs-IB has many desirable psychometric properties: its items span a wide range of difficulty, possess medium-to-large levels of discrimination, and exhibit robust associations between item complexity and difficulty. However, we also find that item clones are not always psychometrically equivalent and cannot be assumed to be exchangeable. In a second study, we demonstrate how experimenters can use the estimated item parameters to design new matrix reasoning tests using optimal item assembly. Specifically, we design and validate two new sets of test forms in an independent sample of adults (N = 600). We find these new tests possess good reliability and convergent validity with an established measure of matrix reasoning. We hope that the materials and results made available here will encourage experimenters to use the MaRs-IB in their research.

Clearing the air: evaluating institutions' social media health messaging on wildfire and smoke risks in the US Pacific Northwest

BACKGROUND

Wildfire smoke contributes substantially to the global disease burden and is a major cause of air pollution in the US states of Oregon and Washington. Climate change is expected to bring more wildfires to this region. Social media is a popular platform for health promotion and a need exists for effective communication about smoke risks and mitigation measures to educate citizens and safeguard public health.

METHODS

Using a sample of 1,287 Tweets from 2022, we aimed to analyze temporal Tweeting patterns in relation to potential smoke exposure and evaluate and compare institutions' use of social media communication best practices which include (i) encouraging adoption of smoke-protective actions; (ii) leveraging numeric, verbal, and Air Quality Index risk information; and (iii) promoting community-building. Tweets were characterized using keyword searches and the Linguistic Inquiry and Word Count (LIWC) software. Descriptive and inferential statistics were carried out.

RESULTS

44% of Tweets in our sample were authored between January-August 2022, prior to peak wildfire smoke levels, whereas 54% of Tweets were authored during the two-month peak in smoke (September-October). Institutional accounts used Twitter (or X) to encourage the adoption of smoke-related protective actions (82% of Tweets), more than they used it to disseminate wildfire smoke risk information (25%) or promote community-building (47%). Only 10% of Tweets discussed populations vulnerable to wildfire smoke health effects, and 14% mentioned smoke mitigation measures. Tweets from Washington-based accounts used significantly more verbal and numeric risk information to discuss wildfire smoke than Oregon-based accounts (p = 0.042 and p = 0.003, respectively); however, Tweets from Oregon-based accounts on average contained a higher percentage of words associated with community-building language (p < 0.001).

CONCLUSIONS

This research provides practical recommendations for public health practitioners and researchers communicating wildfire smoke risks on social media. As exposures to wildfire smoke rise due to climate change, reducing the environmental disease burden requires health officials to leverage popular communication platforms, distribute necessary health-related messaging rapidly, and get the message right. Timely, evidence-based, and theory-driven messaging is critical for educating and empowering individuals to make informed decisions about protecting themselves from harmful exposures. Thus, proactive and sustained communications about wildfire smoke should be prioritized even during wildfire "off-seasons."

Stated-Preference Survey Design and Testing in Health Applications

Following the conceptualization of a well-formulated and relevant research question, selection of an appropriate stated-preference method, and related methodological issues, researchers are tasked with developing a survey instrument. A major goal of designing a stated-preference survey for health applications is to elicit high-quality data that reflect thoughtful responses from well-informed respondents. Achieving this goal requires researchers to design engaging surveys that maximize response rates, minimize hypothetical bias, and collect all the necessary information needed to answer the research question. Designing such a survey requires researchers to make numerous interrelated decisions that build upon the decision context, selection of attributes, and experimental design. Such decisions include considering the setting(s) and study population in which the survey will be administered, the format and mode of administration, and types of contextual information to collect. Development of a survey is an interactive process in which feedback from respondents should be collected and documented through qualitative pre-test interviews and pilot testing. This paper describes important issues to consider across all major steps required to design and test a stated-choice survey to elicit patient preferences for health preference research.

Variability in conceptualizations and measurement of genetic literacy

Objective

To examine definitions and measures for genetic literacy in the published literature, and the associations between commonly utilized measures.

Methods

We completed a systematic review searching eight databases for empirical articles containing quantitative measures of genetic literacy. Articles were assessed for study properties, definitions, and measure characteristics. An online survey was then completed by 531 U.S. adults to examine correlations between frequently used genetic literacy measures.

Results

92 articles met inclusion criteria for the systematic review. Articles rarely defined genetic literacy, and existing definitions showed inconsistencies in the knowledge and cognitive domains that comprise genetic literacy. Definitions frequently included objective conceptual knowledge, comprehension, and applied knowledge, however most measures only assessed objective or subjective knowledge. Genetic literacy measures were infrequently assessed for psychometric properties and the content domains assessed by measures varied considerably. Correlation analyses showed weak to moderate relationships between genetic literacy measures.

Conclusion

A comprehensive and consistent definition of genetic literacy and its cognitive and conceptual domains should be implemented to inform the development of concordant measurement tools and improve research and clinical care in genetics.

Innovation

We examine and compare definitions and measures of genetic literacy, suggest a more comprehensive definition, and recommendations for research development.

Investigation of interest in and timing preference for cancer predisposition testing and expanded carrier screening among women of reproductive age

Objective

To examine cognitive, relational, and social predictors of interest in and timing preference for cancer predisposition testing (CPT) and expanded carrier screening (ECS) offered in routine gynecologic care for women of reproductive age.

Methods

Women between 20 and 35 years old who were currently pregnant or had a prior pregnancy (N = 351) completed an online survey. Bivariate and multivariable analyses were used to identify significant predictors of women's interest in and timing preference for CPT and ECS.

Results

Most respondents reported high interest in CPT and ECS and preferred to have them when planning for a pregnancy. Perceived importance of genetic information and negative attitude towards uncertainty predicted interest in CPT and ECS in multivariable models. Genetic knowledge predicted preference for CPT or ECS when planning for a pregnancy.

Conclusion

Educational and decision support tools should be developed to enhance women's knowledge and awareness of CPT and ECS and to provide them with strategies to manage uncertainty.

Innovation

We examined women's timing preference for CPT and ECS and the impact of partner support and trust with gynecologist. A context-specific attitudes toward uncertainty scale was used to investigate women's particular perceptions of uncertainty in genetic testing.

Perceptions of Income Inequality and Women's Intrasexual Competition

Income inequality has been empirically linked to interpersonal competition and risk-taking behaviors, but a separate line of findings consistently shows that individuals have inaccurate perceptions of the actual levels of income inequality in society. How can inequality be both consistently misperceived and yet a reliable predictor of behavior? The present study extends both these lines of research by evaluating if the scope of input used to assess income inequality (i.e., at the national, state, county, or postal code level) can account for perception discrepancies and if actual/perceived inequality is associated with female intrasexual competition. Female participants recruited online from the general US population (n = 691) provided demographic information, measures of perceived income inequality, and measures of intrasexual competition attitudes and behavior. Actual and perceived income inequality (at any level) did not predict negative attitudes toward other women or female weighting of physical appearance as a desirable trait. Perceived income inequality and actual county-level inequality was, however, predictive of female competition in the form of self-sexualization clothing choice. Further analyses found that age and importance placed on physical attractiveness also predicted women's clothing choices. Perceptions of income inequality were predicted not by actual Gini indices, but by beliefs about the levels of poverty and income gaps. These results highlight the importance of better understanding the proximate cues by which people perceive environmental features such as inequality, and how those cues are used to adjust interpersonal behaviors.

Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Goals-of-Care and Family/Surrogate Decision-Maker Data

BACKGROUND

To facilitate comparative research, it is essential for the fields of neurocritical care and rehabilitation to establish common data elements (CDEs) for disorders of consciousness (DoC). Our objective was to identify CDEs related to goals-of-care decisions and family/surrogate decision-making for patients with DoC.

METHODS

To achieve this, we formed nine CDE working groups as part of the Neurocritical Care Society's Curing Coma Campaign. Our working group focused on goals-of-care decisions and family/surrogate decision-makers created five subgroups: (1) clinical variables of surrogates, (2) psychological distress of surrogates, (3) decision-making quality, (4) quality of communication, and (5) quality of end-of-life care. Each subgroup searched for existing relevant CDEs in the National Institutes of Health/CDE catalog and conducted an extensive literature search for additional relevant study instruments to be recommended. We classified each CDE according to the standard definitions of "core", "basic", "exploratory", or "supplemental", as well as their use for studying the acute or chronic phase of DoC, or both.

RESULTS

We identified 32 relevant preexisting National Institutes of Health CDEs across all subgroups. A total of 34 new instruments were added across all subgroups. Only one CDE was recommended as disease core, the "mode of death" of the patient from the clinical variables subgroup.

CONCLUSIONS

Our findings provide valuable CDEs specific to goals-of-care decisions and family/surrogate decision-making for patients with DoC that can be used to standardize studies to generate high-quality and reproducible research in this area.

Prevalence and predictors of shared decision-making in goals-of-care clinician-family meetings for critically ill neurologic patients: a multi-center mixed-methods study

BACKGROUND

Shared decision-making is a joint process where patients, or their surrogates, and clinicians make health choices based on evidence and preferences. We aimed to determine the extent and predictors of shared decision-making for goals-of-care discussions for critically ill neurological patients, which is crucial for patient-goal-concordant care but currently unknown.

METHODS

We analyzed 72 audio-recorded routine clinician-family meetings during which goals-of-care were discussed from seven US hospitals. These occurred for 67 patients with 72 surrogates and 29 clinicians; one hospital provided 49/72 (68%) of the recordings. Using a previously validated 10-element shared decision-making instrument, we quantified the extent of shared decision-making in each meeting. We measured clinicians' and surrogates' characteristics and prognostic estimates for the patient's hospital survival and 6-month independent function using post-meeting questionnaires. We calculated clinician-family prognostic discordance, defined as ≥ 20% absolute difference between the clinician's and surrogate's estimates. We applied mixed-effects regression to identify independent associations with greater shared decision-making.

RESULTS

The median shared decision-making score was 7 (IQR 5-8). Only 6% of meetings contained all 10 shared decision-making elements. The most common elements were "discussing uncertainty"(89%) and "assessing family understanding"(86%); least frequent elements were "assessing the need for input from others"(36%) and "eliciting the context of the decision"(33%). Clinician-family prognostic discordance was present in 60% for hospital survival and 45% for 6-month independent function. Univariate analyses indicated associations between greater shared decision-making and younger clinician age, fewer years in practice, specialty (medical-surgical critical care > internal medicine > neurocritical care > other > trauma surgery), and higher clinician-family prognostic discordance for hospital survival. After adjustment, only higher clinician-family prognostic discordance for hospital survival remained independently associated with greater shared decision-making (p = 0.029).

CONCLUSION

Fewer than 1 in 10 goals-of-care clinician-family meetings for critically ill neurological patients contained all shared decision-making elements. Our findings highlight gaps in shared decision-making. Interventions promoting shared decision-making for high-stakes decisions in these patients may increase patient-value congruent care; future studies should also examine whether they will affect decision quality and surrogates' health outcomes.

Information Avoidance: Past Perspectives and Future Directions

In the present age of unprecedented access to information, it is important to understand how and why people avoid information. Multiple definitions of "information avoidance" exist, and key aspects of these definitions deserve attention, such as distinguishing information avoidance from (lack of) information seeking, considering the intentionality and temporal nature of information avoidance, and considering the personal relevance of the information. In this review, we provide a cross-disciplinary historical account of theories and empirical research on information avoidance and seeking, drawing from research in multiple fields. We provide a framework of antecedents of information avoidance, categorized into beliefs about the information (e.g., risk perceptions), beliefs about oneself (e.g., coping resources), and social and situational factors (e.g., social norms), noting that constructs across categories overlap and are intertwined. We suggest that research is needed on both positive and negative consequences of information avoidance and on interventions to reduce information avoidance (when appropriate). Research is also needed to better understand temporal dynamics of information avoidance and how it manifests in everyday life. Finally, comprehensive theoretical models are needed that differentiate avoidance from seeking. Research on information avoidance is quickly expanding, and the topic will only grow in importance.

Patient-reported predictors of post-discharge mortality after cardiac hospitalization

Background

Adults hospitalized for cardiovascular events are at high risk for post-discharge mortality. Hospital-based screening of health-related psychosocial risk factors is now prioritized by the Joint Commission and the National Quality Forum to achieve equitable, high-quality care. We tested our hypothesis that key patient-reported psychosocial and behavioral measures could predict post-hospitalization mortality in a cohort of adults hospitalized for a cardiovascular event.

Methods

This was a prospective cohort of adults hospitalized at Vanderbilt University Medical Center. Validated patient-reported measures of health literacy, social support, disease self-management, and socioeconomic status were used as predictors of interest. Cox survival analyses of mortality were conducted over a median 3.5-year follow-up (range: 1.25 - 5.5 years).

Results

Among 2,977 adults, 1,874 (63%) were hospitalized for acute coronary syndrome and 1,103 (37%) were hospitalized for acute decompensated heart failure; 60% were male; and the mean age was 53 years. After adjusting for demographic, clinical, and other psychosocial factors, mortality risk was greatest among patients who reported being unable to work due to disability (Hazard Ratio (HR) 2.36, 95% Confidence Interval (CI): 1.73-3.21), who were retired (HR 2.14, 95% CI 1.60-2.87), and who reported unemployment (HR 1.99, 95% CI 1.30-3.06) as compared to those who were employed. Patient-reported measures of disease self-management, perceived health competence and exercise frequency, were also associated with mortality risk after full covariate adjustment (HR 0.86, 95% CI 0.73-1.00 per four-point increase), (HR 0.86, 95% CI 0.77-0.96 per three-day change), respectively.

Conclusions

Patient-reported measures of employment status independently predict post-discharge mortality after a cardiac hospitalization. Measure of disease self-management also have prognostic modest utility. Hospital-based screening of psychosocial risk is increasingly prioritized in legislative policy. Incorporating brief, valid measures of employment status and disease self-management factors may help target patients for psychosocial, financial, and rehabilitative resources during post-discharge transitions of care.

Genetic counseling and testing for females at elevated risk for breast cancer: Protocol for the randomized controlled trial of the Know Your Risk intervention

BACKGROUND

Genetic counseling and testing have an important role in the care of patients at elevated risk for breast cancer. However, conventional pre- and post-test genetic counseling is labor and time intensive, less accessible for patients living outside major urban centers, and impractical on a large scale. A patient-driven approach to genetic counseling and testing may increase access, improve patients' experiences, affect efficiency of clinical practice, and help meet workforce demand. The objective of this 2-arm randomized controlled trial is to determine the efficacy of Know Your Risk (KYR), a genetic counseling patient preference intervention.

METHODS

Females (n = 1000) at elevated risk (>20% lifetime) for breast cancer will be randomized to the KYR intervention or conventional genetic counseling. The study will provide comprehensive assessment of breast cancer risk by multigene panel testing and validated polygenic risk score. Primary outcome is adherence to National Comprehensive Cancer Network guidelines for a clinical encounter every 6-12 months and an annual mammogram (breast MRI if recommended) determined by medical record review. Secondary outcomes include adherence to other recommended cancer screening tests determined by medical record review and changes in breast cancer knowledge, perception of risk, post-test/counseling distress, and satisfaction with counseling by completion of three surveys during the study. Study aims will be evaluated for non-inferiority of the KYR intervention compared to conventional genetic counseling.

CONCLUSION

If efficacious, the KYR intervention has the potential to improve patients' experience and may change how genetic counseling is delivered, inform best practices, and reduce workforce burden.

TRIAL REGISTRATION

ClinicalTrials.govNCT05325151.

How Do People Process Different Representations of Statistical Information? Insights into Cognitive Effort, Representational Inconsistencies, and Individual Differences

BACKGROUND

Graphical representation formats (e.g., icon arrays) have been shown to lead to better understanding of the benefits and risks of treatments compared to numbers. We investigate the cognitive processes underlying the effects of format on understanding: how much cognitive effort is required to process numerical and graphical representations, how people process inconsistent representations, and how numeracy and graph literacy affect information processing.

METHODS

In a preregistered between-participants experiment, 665 participants answered questions about the relative frequencies of benefits and side effects of 6 medications. First, we manipulated whether the medical information was represented numerically, graphically (as icon arrays), or inconsistently (numerically for 3 medications and graphically for the other 3). Second, to examine cognitive effort, we manipulated whether there was time pressure or not. In an additional intervention condition, participants translated graphical information into numerical information before answering questions. We also assessed numeracy and graph literacy.

RESULTS

Processing icon arrays was more strongly affected by time pressure than processing numbers, suggesting that graphical formats required more cognitive effort. Understanding was lower when information was represented inconsistently (v. consistently) but not if there was a preceding intervention. Decisions based on inconsistent representations were biased toward graphically represented options. People with higher numeracy processed quantitative information more efficiently than people with lower numeracy did. Graph literacy was not related to processing efficiency.

LIMITATIONS

Our study was conducted with a nonpatient sample, and the medical information was hypothetical.

CONCLUSIONS

Although graphical (v. numerical) formats have previously been found to lead to better understanding, they may require more cognitive effort. Therefore, the goal of risk communication may play an important role when choosing how to communicate medical information.

HIGHLIGHTS

This article investigates the cognitive processes underlying the effects of representation format on the understanding of statistical information and individual differences therein.Processing icon arrays required more cognitive effort than processing numbers did.When information was represented inconsistently (i.e., partly numerically and partly graphically), understanding was lower than with consistent representation, and decisions were biased toward the graphically represented options.People with higher numeracy processed quantitative information more efficiently than people with lower numeracy did.

Eliciting preferences for cancer screening tests: Comparison of a discrete choice experiment and the threshold technique

OBJECTIVE

To compare results of three preference elicitation methods for a cancer screening test.

METHODS

Participants (undergraduate students) completed a discrete choice experiment (DCE) and a threshold technique (TT) task. Accuracy (false positives, false negatives), benefits (lives saved), and cost for a cancer screening test were used as attributes in the DCE and branching logic for the TT. Participants were also asked a direct elicitation question regarding a hypothetical screening test for breast (women) or prostate (men) cancer without mortality benefit. Correlations assessed the relationship between DCE and TT thresholds. Thresholds were standardized and ranked for both methods to compare. A logistic regression used the thresholds to predict results of the direct elicitation.

RESULTS

DCE and TT estimates were not meaningfully correlated (max ρ = 0.17). Participant rankings of attributes matched only 20% of the time (58/292). Neither method predicted preference for being screened (ps > 0.21).

CONCLUSIONS

The DCE and TT yielded different preference estimates (and rank orderings) for the same participant. Neither method predicted patients' desires for a screening test.

PRACTICE IMPLICATIONS

Clinicians, patients, policy makers, and researchers should be aware that patient preference results may be sensitive to the method of eliciting preferences.

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.

Assessing and Understanding Reactance, Self-Exemption, Disbelief, Source Derogation and Information Conflict in Reaction to Overdiagnosis in Mammography Screening: Scale Development and Preliminary Validation

PURPOSE

Overdiagnosis is a concept central to making informed breast cancer screening decisions, and yet some people may react to overdiagnosis with doubt and skepticism. The present research assessed 4 related reactions to overdiagnosis: reactance, self-exemption, disbelief, and source derogation (REDS). The degree to which the concept of overdiagnosis conflicts with participants' prior beliefs and health messages (information conflict) was also assessed as a potential antecedent of REDS. We developed a scale to assess these reactions, evaluated how those reactions are related, and identified their potential implications for screening decision making.

METHODS

Female participants aged 39 to 49 years read information about overdiagnosis in mammography screening and completed survey questions assessing their reactions to that information. We used a multidimensional theoretical framework to assess dimensionality and overall domain-specific internal consistency of the REDS and Information Conflict questions. Exploratory and confirmatory factor analyses were performed using data randomly split into a training set and test set. Correlations between REDS, screening intentions, and other outcomes were evaluated.

RESULTS

Five-hundred twenty-five participants completed an online survey. Exploratory and confirmatory factor analyses identified that Reactance, Self Exemption, Disbelief, Source Derogation, and Information Conflict represent unique constructs. A reduced 20-item scale was created by selecting 4 items per construct, which showed good model fit. Reactance, Disbelief, and Source Derogation were associated with lower intent to use information about overdiagnosis in decision making and the belief that informing people about overdiagnosis is unimportant.

CONCLUSIONS

REDS and Information Conflict are distinct but correlated constructs that are common reactions to overdiagnosis. Some of these reactions may have negative implications for making informed screening decisions.

HIGHLIGHTS

Overdiagnosis is a concept central to making informed breast cancer screening decisions, and yet when provided information about overdiagnosis, some people are skeptical.This research developed a measure that assessed different ways in which people might express skepticism about overdiagnosis (reactance, self-exemption, disbelief, source derogation) and also the perception that overdiagnosis conflicts with prior knowledge and health messages (information conflict).These different reactions are distinct but correlated and are common reactions when people learn about overdiagnosis.Reactance, disbelief, and source derogation are associated with lower intent to use information about overdiagnosis in decision making as well as the belief that informing people about overdiagnosis is unimportant.

Differences in decisions affected by cognitive biases: examining human values, need for cognition, and numeracy

A better understanding of factors that can affect preferences and choices may contribute to more accurate decision-making. Several studies have investigated the effects of cognitive biases on decision-making and their relationship with cognitive abilities and thinking dispositions. While studies on behaviour, attitude, personality, and health worries have examined their relationship with human values, research on cognitive bias has not investigated its relationship to individual differences in human values. The purpose of this study was to explore individual differences in biased choices, examining the relationships of the human values self-direction, conformity, power, and universalism with the anchoring effect, the framing effect, the certainty effect, and the outcome bias, as well as the mediation of need for cognition and the moderation of numeracy in these relationships. We measured individual differences and within-participant effects with an online questionnaire completed by 409 Brazilian participants, with an age range from 18 to 80 years, 56.7% female, and 43.3% male. The cognitive biases studied consistently influenced choices and preferences. However, the biases showed distinct relationships with the individual differences investigated, indicating the involvement of diverse psychological mechanisms. For example, people who value more self-direction were less affected only by anchoring. Hence, people more susceptible to one bias were not similarly susceptible to another. This can help in research on how to weaken or strengthen cognitive biases and heuristics.

Numerical and Visual Representations of Uncertainty Lead to Different Patterns of Decision Making

Although visualizations are a useful tool for helping people to understand information, they can also have unintended effects on human cognition. This is especially true for uncertain information, which is difficult for people to understand. Prior work has found that different methods of visualizing uncertain information can produce different patterns of decision making from users. However, uncertainty can also be represented via text or numerical information, and few studies have systematically compared these types of representations to visualizations of uncertainty. We present two experiments that compared visual representations of risk (icon arrays) to numerical representations (natural frequencies) in a wildfire evacuation task. Like prior studies, we found that different types of visual cues led to different patterns of decision making. In addition, our comparison of visual and numerical representations of risk found that people were more likely to evacuate when they saw visualizations than when they saw numerical representations. These experiments reinforce the idea that design choices are not neutral: seemingly minor differences in how information is represented can have important impacts on human risk perception and decision making.

Social Influences on Similarity Judgments and Intertemporal Choice

Discounting models are commonly applied to understand intertemporal choices. Similarity models provide an alternative, attribute-based approach where people compare the similarity of reward amounts and time delays for options and decide based on dissimilarity. Knowledge of other people's similarity judgments may affect an individual's similarity judgments, which can in turn affect subsequent intertemporal choices. We investigated the potential effects of social influence across three studies by having participants make similarity judgments and intertemporal choices before and after viewing other people's similarity judgments. We found that participants preferred larger but delayed intertemporal choice options more after they viewed similarity judgments that suggested a preference for larger, later rewards. Additionally, this change in preference seemed to result from a shift in participants' personal similarity judgments for reward amount and time delay pairs to match the social information. Our findings suggest that social information about similarity judgments can shape intertemporal choices, which can potentially be used to help increase people's preferences for options that benefit them in the long term.

Genetic Testing and Other Healthcare Use by Black and White Individuals in a Genomic Sequencing Study

INTRODUCTION

Early adopters play a critical role in the diffusion of medical innovations by spreading awareness, increasing acceptability, and driving demand. Understanding the role of race in the context of other characteristics of potential early adopters can shed light on disparities seen in the early implementation of genomic medicine. We aimed to understand the association between self-identified race and individual experience with genetic testing outside of the research context.

METHODS

We assessed factors associated with the odds of having ever received genetic testing prior to enrollment in a genomic sequencing study among 674 self-identified white and 407 self-identified African, African American, or Afro-Caribbean ("Black") individuals.

RESULTS

Controlling for individual determinants of healthcare use (demographics, personality traits, knowledge and attitudes, and health status), identifying as Black was associated with lower odds of prior genetic testing (OR = 0.43, 95% CI [0.27-0.68], p < 0.001). In contrast, self-identified race was not associated with the use of non-genetic clinical screening tests (e.g., echocardiogram, colonoscopy). Black and white individuals were similar on self-reported personality traits tied to early adoption but differed by sociodemographic and resource facilitators of early adoption.

CONCLUSION

Persistent racial disparities among early adopters may represent especially-entrenched disparities in access to and knowledge of genomic technologies in clinical settings.

Thyroid Cancer Risk Communication in Patients with Thyroid Nodules

The objective of this study is to evaluate thyroid cancer risk clinician-patient communication among patients receiving usual counseling and counseling enhanced by a conversation aid. A secondary analysis of clinical visit recordings and post-visit surveys obtained during a trial assessing the impact of a conversation aid for patients with thyroid nodules was conducted. We assessed how thyroid cancer risk was communicated, different risk communication strategies between groups, and predictors of accurate cancer risk perception. Fifty-nine patients were analyzed. Most were women (90%) and middle-aged (median 57 years). A verbal description of thyroid cancer risk was present most frequently (83%) and was more frequent in the conversation aid than the usual care group (100% vs. 63%, p < 0.001). A numerical description using percentages was present in 41% of visits and was more frequent in the conversation aid group (59% vs. 19%, p = 0.012). Natural frequencies (7%) and positive/negative framing (10%) were utilized less commonly. Uncertainty about risks was not discussed. No predictors of accurate risk perception were identified. Clinicians most commonly present a verbal description of thyroid cancer risk. Less commonly, natural frequencies, negative/positive framing, or uncertainty is discussed. Clinicians caring for patients with thyroid nodules should be aware of different strategies for communicating thyroid cancer risk.

Patient Perception of Skin Cancer Reduction by Nicotinamide Correlates With Use

Introduction Nicotinamide (Vitamin B3) has been shown to reduce the rate of non-melanoma skin cancers by 23%, yet most patients do not know that this supplement reduces skin cancer. Understanding patient beliefs about skin cancer reduction attributed to nicotinamide is important to appropriately counsel patients on oral supplement use and ultimately to prevent non-melanoma skin cancers. Objective The objective of this study was to determine the association between nicotinamide use and perceived efficacy in skin cancer reduction. Methods Patients who underwent Mohs surgery in 2019 were sent an online survey assessing nicotinamide use, efficacy compared to sunscreen, and perceived skin cancer risk reduction. Results Data from 50 surveys revealed a perceived risk reduction attributed to nicotinamide of 31.2% for basal cell carcinoma (BCC), 30.2% for squamous cell carcinoma (SCC), and 24.3% for melanoma. In the subset of respondents taking nicotinamide, the perceived risk reduction was significantly higher at 41.2% for BCC and 38.3% for SCC (p<0.05) and positively correlated with reported nicotinamide use (p<0.05). The perceived risk reduction of melanoma was not significantly increased in patients taking nicotinamide (31.6%); however, the perceived risk reduction was correlated with nicotinamide use (p<0.05). In addition, 15.6% of respondents believed that nicotinamide was more effective than sunscreen at preventing skin cancer. Conclusion A larger perceived reduction of non-melanoma skin cancers attributed to nicotinamide is associated with increased oral nicotinamide use. Better patient education regarding the reduction of skin cancers with oral nicotinamide will need to be implemented to change patients' perceptions of the value of nicotinamide.

Parents' Psychological and Decision-Making Outcomes following Prenatal Diagnosis with Complex Congenital Heart Defect: An Exploratory Study

Background. Parents with a fetus diagnosed with a complex congenital heart defect (CHD) are at high risk of negative psychological outcomes. Purpose. To explore whether parents' psychological and decision-making outcomes differed based on their treatment decision and fetus/neonate survival status. Methods. We prospectively enrolled parents with a fetus diagnosed with a complex, life-threatening CHD from September 2018 to December 2020. We tested whether parents' psychological and decision-making outcomes 3 months posttreatment differed by treatment choice and survival status. Results. Our sample included 23 parents (average Age[years]: 27 ± 4, range = 21-37). Most were women (n = 18), non-Hispanic White (n = 20), and married (n = 21). Most parents chose surgery (n = 16), with 11 children surviving to the time of the survey; remaining parents (n = 7) chose comfort-directed care. Parents who chose comfort-directed care reported higher distress (x ¯  = 1.51, s = 0.75 v. x ¯  = 0.74, s = 0.55; Mdifference = 0.77, 95% confidence interval [CI], 0.05-1.48) and perinatal grief (x ¯  = 91.86, s = 22.96 v. x ¯  = 63.38, s = 20.15; Mdifference = 27.18, 95% CI, 6.20-48.16) than parents who chose surgery, regardless of survival status. Parents who chose comfort-directed care reported higher depression (x ¯  = 1.64, s = 0.95 v. x ¯  = 0.65, s = 0.49; Mdifference = 0.99, 95% CI, 0.10-1.88) than parents whose child survived following surgery. Parents choosing comfort-directed care reported higher regret (x ¯  = 26.43, s = 8.02 v. x ¯  = 5.00, s = 7.07; Mdifference = 21.43, 95% CI, 11.59-31.27) and decisional conflict (x ¯  = 20.98, s = 10.00 v. x ¯  = 3.44, s = 4.74; Mdifference = 17.54, 95% CI; 7.75-27.34) than parents whose child had not survived following surgery. Parents whose child survived following surgery reported lower grief (Mdifference = -19.71; 95% CI, -39.41 to -0.01) than parents whose child had not. Conclusions. The results highlight the potential for interventions and care tailored to parents' treatment decisions and outcomes to support parental coping and well-being.

Highlights

Question: Do the psychological and decision-making outcomes of parents differ based on their treatment decision and survival outcome following prenatal diagnosis with complex CHD?Findings: In this exploratory study, parents who decided to pursue comfort-directed care after a prenatal diagnosis reported higher levels of psychological distress and grief as well as higher decisional conflict and regret than parents who decided to pursue surgery.Meaning: The findings from this exploratory study highlight potential differences in parents' psychological and decision-making outcomes following a diagnosis of complex CHD for their fetus, which appear to relate to the treatment approach and the treatment outcome and may require tailoring of psychological and decision support.

Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Goals-of-care and Family/Surrogate Decision-Maker Data

INTRODUCTION

In order to facilitate comparative research, it is essential for the fields of neurocritical care and rehabilitation to establish common data elements (CDE) for disorders of consciousness (DoC). Our objective was to identify CDEs related to goals-of-care decisions and family/surrogate decision-making for patients with DoC.

METHODS

To achieve this, we formed nine CDE working groups as part of the Neurocritical Care Society's Curing Coma Campaign. Our working group focused on goals-of-care decisions and family/surrogate decision-makers created five subgroups: (1) clinical variables of surrogates, (2) psychological distress of surrogates, (3) decision-making quality, (4) quality of communication, and (5) quality of end-of-life care. Each subgroup searched for existing relevant CDEs in the NIH/CDE catalog and conducted an extensive literature search for additional relevant study instruments to be recommended. We classified each CDE according to the standard definitions of "core," "basic," "exploratory," or "supplemental," as well as their utility for studying the acute or chronic phase of DoC, or both.

RESULTS

We identified 32 relevant pre-existing NIH CDEs across all subgroups. A total of 34 new instruments were added across all subgroups. Only one CDE was recommended as disease core, the "mode of death" of the patient from the clinical variables subgroup.

CONCLUSIONS

Our findings provide valuable CDEs specific to goals-of-care decisions and family/surrogate decision-making for patients with DoC that can be used to standardize studies to generate high-quality and reproducible research in this area.

The effect of numeric information about the likelihood of receiving a false negative or false positive result on people's attitudes towards colorectal cancer screening using faecal immunochemical testing (FIT)

OBJECTIVE

To examine the impact of numeric risk information about false negative (FN) and false positive (FP) rates in fecal immunochemical testing (FIT) on attitudes towards screening.

METHODS

102 people aged 45-55, living in the UK, read 6 hypothetical vignettes presented online about the use of FIT kits to detect colorectal cancer, in which information about FN and FP rates was systematically varied.

RESULTS

Numeric FN risk information reduced people's interest in screening, perception of screening effectiveness and lowered trust in screening compared to verbal FN information. Verbal FN information reduced perceptions of screening effectiveness and trust compared to no FN information. People with high subjective numeracy reported lower trust in screening following the provision of numeric FN information but numeracy did not moderate any other associations. FP information did not affect attitudes towards FIT testing.

CONCLUSION

Numeric FN risk information decreased people's perceptions of screening effectiveness and trust in the results of screening. While it influenced people's interest in screening, the effect was small.

PRACTICE IMPLICATIONS

Numeric FN information has a small effect on interest in screening and could promote informed decision making without affecting screening uptake.

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).

Numeracy, gist, literal thinking and the value of nothing in decision making

The onus on the average person is greater than ever before to make sense of large amounts of readily accessible quantitative information, but the ability and confidence to do so are frequently lacking. Many people lack practical mathematical skills that are essential for evaluating risks, probabilities and numerical outcomes such as survival rates for medical treatments, income from retirement savings plans or monetary damages in civil trials. In this Review, we integrate research on objective and subjective numeracy, focusing on cognitive and metacognitive factors that distort human perceptions and foment systematic biases in judgement and decision making. Paradoxically, an important implication of this research is that a literal focus on objective numbers and mechanical number crunching is misguided. Numbers can be a matter of life and death but a person who uses rote strategies (verbatim representations) cannot take advantage of the information contained in the numbers because 'rote' strategies are, by definition, processing without meaning. Verbatim representations (verbatim is only surface form, not meaning) treat numbers as data as opposed to information. We highlight a contrasting approach of gist extraction: organizing numbers meaningfully, interpreting them qualitatively and making meaningful inferences about them. Efforts to improve numerical cognition and its practical applications can benefit from emphasizing the qualitative meaning of numbers in context - the gist - building on the strengths of humans as intuitive mathematicians. Thus, we conclude by reviewing evidence that gist training facilitates transfer to new contexts and, because it is more durable, longer-lasting improvements in decision making.

Demographic, structural, and psychological predictors of risk-increasing and mask wearing behaviors among US adults between December 2020-March 2021

OBJECTIVES

To assess demographic, structural, and psychological predictors of risk-increasing and risk-decreasing behaviors METHODS: This study used data from an online longitudinal, three-wave COVID-19 survey (12/20-03/21) regarding the behaviors, attitudes, and experiences of US Veteran (n = 584) and non-Veteran (n = 346) adults.

RESULTS

Inability to get groceries delivered emerged as the strongest predictor of more frequent risk-increasing behavior across all timepoints. Other consistent predictors of more frequent risk-increasing behavior and less frequent mask wearing included less worry about getting COVID-19, disbelief in science, belief in COVID-19 conspiracies, and negative perceptions of the state response. No demographic factor consistently predicted risk-increasing behavior or mask wearing, though different demographic predictors emerged for more frequent risk-increasing behaviors (e.g., lower health literacy) and mask-wearing (e.g., older age and urban residence) at certain timepoints. The most frequently endorsed reasons for having contact with others concerned health-related (food, medical care, and exercise) and social needs (seeing friends/family and boredom).

CONCLUSIONS

These findings highlight key individual-level determinants of risk-increasing behaviors and mask wearing which encompass demographic, structural, and psychological factors.

PRACTICE IMPLICATIONS

Findings can support public health experts and health communicators promote engagement with risk-reducing behaviors and address key barriers to engaging in these behaviors.

Communicating health information with visual displays

Well-designed visual displays have the power to convey health messages in clear, effective ways to non-experts, including journalists, patients and policymakers. Poorly designed visual displays, however, can confuse and alienate recipients, undermining health messages. In this Perspective, we propose a structured framework for effective visual communication of health information, using case examples of three common communication tasks: comparing treatment options, interpreting test results, and evaluating risk scenarios. We also show simple, practical ways to evaluate a design's success and guide improvements. The proposed framework is grounded in research on health risk communication, visualization and decision science, as well as our experience in communicating health data.

Using User-Centered Design to Facilitate Adherence to Annual Lung Cancer Screening: Protocol for a Mixed Methods Study for Intervention Development

BACKGROUND

Lung cancer is the leading cause of cancer-related death in the United States, with the majority of lung cancer occurrence diagnosed after the disease has already metastasized. Lung cancer screening (LCS) with low-dose computed tomography can diagnose early-stage disease, especially when eligible individuals participate in screening on a yearly basis. Unfortunately, annual adherence has emerged as a challenge for academic and community screening programs, endangering the individual and population health benefits of LCS. Reminder messages have effectively increased adherence rates in breast, colorectal, and cervical cancer screenings but have not been tested with LCS participants who experience unique barriers to screening associated with the stigma of smoking and social determinants of health.

OBJECTIVE

This research aims to use a theory-informed, multiphase, and mixed methods approach with LCS experts and participants to develop a set of clear and engaging reminder messages to support LCS annual adherence.

METHODS

In aim 1, survey data informed by the Cognitive-Social Health Information Processing model will be collected to assess how LCS participants process health information aimed at health protective behavior to develop content for reminder messages and pinpoint options for message targeting and tailoring. Aim 2 focuses on identifying themes for message imagery through a modified photovoice activity that asks participants to identify 3 images that represent LCS and then participate in an interview about the selection, likes, and dislikes of each photo. A pool of candidate messages for multiple delivery platforms will be developed in aim 3, using results from aim 1 for message content and aim 2 for imagery selection. The refinement of message content and imagery combinations will be completed through iterative feedback from LCS experts and participants.

RESULTS

Data collection began in July 2022 and will be completed by May 2023. The final reminder message candidates are expected to be completed by June 2023.

CONCLUSIONS

This project proposes a novel approach to facilitate adherence to annual LCS through the development of reminder messages that embrace content and imagery representative of the target population directly in the design process. Developing effective strategies to increase LCS adherence is instrumental in achieving optimal LCS outcomes at individual and population health levels.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46657.