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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRACTICE IMPLICATIONS

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

PROTOCOL REGISTRATION

PROSPERO ID 275022.

Medical decision-making with tables and graphs: The role of cognition, emotions, and analytic thinking

The shift from one-way to two-way communication in healthcare decision-making has heightened the need to understand the role of display formats including tables and graphs as decision aids. In this paper, we investigate cognitive and affective influences on decision-making involving display formats. We find that a display format's impact on decision quality is mediated by two distinct components of cognition (verbatim and gist knowledge), and that tables compared to bar graphs improve decision quality. We also find evidence that analytic thinking and lower negative affect can improve decision quality. Implications for marketers, better engaging patients, and encouraging improved decision-making are discussed.

Effect of linguistic framing and information provision on attitudes towards induced seismicity and seismicity regulation

Shale gas is an expanding energy source worldwide, yet ‘fracking’ remains controversial. Amongst public concerns is induced seismicity (tremors). The UK had the most stringent induced seismicity regulations in the world, prior to instating a moratorium on shale gas development. The Government cited induced seismicity as the key rationale for its November 2019 English moratorium. Yet, little is known about how the public perceives induced seismicity, whether they support regulatory change, or how framing and information provision affect perceptions. Across three waves of a longitudinal experimental UK survey (N = 2777; 1858; 1439), we tested whether framing of induced seismicity influences support for changing regulations. The surveys compared (1) quantitative versus qualitative framings, (2) information provision about regulatory limits in other countries and (3) seismicity from other industries, and (4) framing a seismic event as an ‘earthquake’ or something else. We find low support for changing current policy, and that framing and information provision made little difference to this. The one strong influence on perceptions of seismic events came from the type of activity causing the event; shale gas extraction clearly led to the most negative reactions. We discuss implications for future UK policy on shale gas and geothermal energy in an evolving energy landscape.

Factors associated with the risk perception of COVID-19 infection and severe illness: A cross-sectional study in Japan

Understanding COVID-19 risk perception may help inform public health messaging aimed at encouraging preventive measures and improving countermeasures against the pandemic. We conducted an online survey of 29,708 Japanese adults in February 2021 and estimated the associations between COVID-19 risk perception and a broad array of individual factors. Two logistic regressions were constructed to estimate factors associated with the risk perception of COVID-19 (defined as responding that one might become infected within the next 6 months), and of severe illness among those who responded that they might become infected (defined as responding that one would become severely ill). After adjusting for covariates, those with a higher perceived risk of the COVID-19 vaccine had higher odds of risk perception for both infection and severe illness. Interestingly, those with higher odds of risk perception of being infected were more likely to report obtaining their information from healthcare workers whereas those with lower odds were more likely to report obtaining their information from the Internet or the government; those with lower odds of risk perception of being severely ill were more likely to report obtaining their information from the Internet. The higher the trust level in the government as a COVID-19 information source, the lower the odds of both risk perception of being infected and becoming severely ill. The higher the trust levels in social networking services as a COVID-19 information source, the higher the odds of risk perception of becoming severely ill. Public health messaging should address the factors identified in our study.

Persuasive communication in medical decision-making during consultations with patients with limited health literacy in hospital-based palliative care

OBJECTIVE

Both patients in the palliative phase of their disease and patients with limited health literacy (LHL) have an increased risk of being influenced by healthcare providers (HCPs) when making decisions. This study aims to explore to what extent persuasive communication occurs during shared decision-making (SDM) by (1) providing an overview of persuasive communication behaviours relevant for medical decision-making and (2) exemplifying these using real-life outpatient consultations.

METHODS

An exploratory qualitative design was applied: (1) brief literature review; (2) analysis of verbatim extracts from outpatient consultations and stimulated recall sessions with HCPs; and (3) stakeholder meetings.

RESULTS

24 different persuasive communication behaviours were identified, which can be divided in seven categories: biased presentation of information, authoritative framing, probability framing, illusion of decisional control, normative framing, making assumptions and using emotions or feelings.

CONCLUSIONS

Persuasive communication is multi-faceted in outpatient consultations. Although undesirable, it may prove useful in specific situations making it necessary to study the phenomenon more in depth and deepen our understanding of its mechanisms and impact.

PRACTICE IMPLICATIONS

Awareness among HCPs about the use of persuasive communication needs to be created through training and education. Also, HCPs need help in providing balanced information.

Comparison of the accuracy of residents, senior physicians and surrogate decision-makers for predicting hospital mortality of critically ill patients

OBJECTIVE

To compare the predictive performance of residents, senior intensive care unit physicians and surrogates early during intensive care unit stays and to evaluate whether different presentations of prognostic data (probability of survival versus probability of death) influenced their performance.

METHODS

We questioned surrogates and physicians in charge of critically ill patients during the first 48 hours of intensive care unit admission on the patient's probability of hospital outcome. The question framing (i.e., probability of survival versus probability of death during hospitalization) was randomized. To evaluate the predictive performance, we compared the areas under the ROC curves (AUCs) for hospital outcome between surrogates and physicians' categories. We also stratified the results according to randomized question framing.

RESULTS

We interviewed surrogates and physicians on the hospital outcomes of 118 patients. The predictive performance of surrogate decisionmakers was significantly lower than that of physicians (AUC of 0.63 for surrogates, 0.82 for residents, 0.80 for intensive care unit fellows and 0.81 for intensive care unit senior physicians). There was no increase in predictive performance related to physicians' experience (i.e., senior physicians did not predict outcomes better than junior physicians). Surrogate decisionmakers worsened their prediction performance when they were asked about probability of death instead of probability of survival, but there was no difference for physicians.

CONCLUSION

Different predictive performance was observed when comparing surrogate decision-makers and physicians, with no effect of experience on health care professionals' prediction. Question framing affected the predictive performance of surrogates but not of physicians.

Numeracy and COVID-19: examining interrelationships between numeracy, health numeracy and behaviour

During the COVID-19 pandemic, people across the globe have been exposed to large amounts of statistical data. Previous studies have shown that individuals' mathematical understanding of health-related information affects their attitudes and behaviours. Here, we investigate the relation between (i) basic numeracy, (ii) COVID-19 health numeracy, and (iii) COVID-19 health-related attitudes and behaviours. An online survey measuring these three variables was distributed in Canada, the United States (US) and the United Kingdom (UK) (n = 2032). In line with predictions, basic numeracy was positively related to COVID-19 health numeracy. However, predictions, neither basic numeracy nor COVID-19 health numeracy was related to COVID-19 health-related attitudes and behaviours (e.g. follow experts' recommendations on social distancing, wearing masks etc.). Multi-group analysis was used to investigate mean differences and differences in the strength of the correlation across countries. Results indicate there were no between-country differences in the correlations between the main constructs but there were between-country differences in latent means. Overall, results suggest that while basic numeracy is related to one's understanding of data about COVID-19, better numeracy alone is not enough to influence a population's health-related attitudes about disease severity and to increase the likelihood of following public health advice.

Effective communication regarding risk of fracture for individuals at risk of fragility fracture: a scoping review

Two scoping reviews were conducted to review recommendations and guidelines for communication regarding general health risk, and to investigate communication strategies regarding risk of fracture. Healthcare professionals are invited to apply these recommendations to optimize a patient-centered approach to reducing risk of fracture.

INTRODUCTION

To conduct a scoping review of the medical literature regarding recommendations and tools for effective communication between healthcare professionals and patients regarding general health risk and risk of fracture.

METHODS

The scoping review was divided into two parts to search for (1) studies presenting recommendations and guidelines for communication regarding general health risk; (2) studies investigating communication regarding risk of fracture for individuals at risk for fractures. Medline was searched in April 2020 to identify relevant studies.

RESULTS

The scoping review included 43 studies on communication with regard to general health risk and 25 studies about communication regarding risk of fracture. Recommendations for effective communication with regard to risk are presented. Communication of numeric data on risk should be adapted to the literacy and numeracy levels of the individual patient. Patient understanding of numerical data can be enhanced with appropriate use of visual aids (e.g., pie charts, icon arrays, bar charts, pictograms). The FRAX® tool is the most recommended and most used tool for assessing risk of fracture. Communication sent as individualized letters to patients following DXA scans has been studied, although patient understanding of their risk of fracture is often reported as low using this technique. Use of visual aids may improve patient understanding.

CONCLUSION

Healthcare professionals are encouraged to apply recommendations presented in this scoping review in their clinical practice. Patient understanding of risk of fracture should be confirmed by making sure that patients feel free to ask questions and express their concerns. This will contribute to an optimal patient-centered approach. Developing online tools to convert the probability of fracture into patient-friendly visual presentations could facilitate communication between healthcare professionals and patients about risk of fracture.

Psychological Factors Affecting Risk Perception of COVID-19: Evidence from Peru and China

COVID-19 has spread around the world, causing a global pandemic, and to date is impacting in various ways in both developed and developing countries. We know that the spread of this virus is through people’s behavior despite the perceived risks. Risk perception plays an important role in decision-making to prevent infection. Using data from the online survey of participants in Peru and China (N = 1594), data were collected between 8 July 31 and August 2020. We found that levels of risk perception are relatively moderate, but higher in Peru compared to China. In both countries, anxiety, threat perception, self-confidence, and sex were found to be significant predictors of risk perception; however, trust in the information received by government and experts was significant only in Peru, whereas self-confidence had a significant negative effect only for China. Risk communication should be implemented through information programs aimed at reducing anxiety and improving self-confidence, taking into consideration gender differences. In addition, the information generated by the government should be based on empirical sources. Finally, the implications for effective risk communication and its impacts on the health field are discussed.

Testing a best practices risk result format to communicate genetic risks

OBJECTIVE

To investigate the effect of a genetic report format using risk communication "best-practices" on risk perceptions, in part to reduce risk overestimates.

METHODS

Adults (N = 470) from the Coriell Personalized Medicine Collaborative (CPMC) were randomized to a 2 × 2 experimental design to receive a hypothetical "personalized" genetic risk result for leukemia (relative risk = 1.5 or 2.5) through either the standard CPMC report (N = 232) or an enriched report informed by best practices (N = 238). A one-time, online survey assessed numeracy and risk perceptions including "feelings of risk" and a numerical estimate.

RESULTS

Regardless of numeracy, participants who received the enriched report had fewer overestimates of their lifetime risk estimate (LRE; odds ratio = 0.19, p < .001) and lower feelings of risk on two of three measures (p < .001). Participants with higher numeracy scores had fewer overestimates of LRE (OR = 0.66, p < .001) and lower feelings of risk on two out of three measures (p ≤ .01); the interaction between numeracy and report format was non-significant.

CONCLUSION

The enriched report produced more accurate LRE and lower risk perceptions regardless of numeracy level, suggesting the enriched format was helpful to individuals irrespective of numeracy ability.

PRACTICE IMPLICATIONS

Best practice elements in risk reports may help individuals form more accurate risk perceptions.

Communicating personalized risks from COVID-19: guidelines from an empirical study

As increasing amounts of data accumulate on the effects of the novel coronavirus SARS-CoV-2 and the risk factors that lead to poor outcomes, it is possible to produce personalized estimates of the risks faced by groups of people with different characteristics. The challenge of how to communicate these then becomes apparent. Based on empirical work (total n = 5520, UK) supported by in-person interviews with the public and physicians, we make recommendations on the presentation of such information. These include: using predominantly percentages when communicating the absolute risk, but also providing, for balance, a format which conveys a contrasting (higher) perception of risk (expected frequency out of 10 000); using a visual linear scale cut at an appropriate point to illustrate the maximum risk, explained through an illustrative 'persona' who might face that highest level of risk; and providing context to the absolute risk through presenting a range of other 'personas' illustrating people who would face risks of a wide range of different levels. These 'personas' should have their major risk factors (age, existing health conditions) described. By contrast, giving people absolute likelihoods of other risks they face in an attempt to add context was considered less helpful. We note that observed effect sizes generally were small. However, even small effects are meaningful and relevant when scaled up to population levels.

Current Challenges When Using Numbers in Patient Decision Aids: Advanced Concepts

BACKGROUND

Decision aid developers have to convey complex task-specific numeric information in a way that minimizes bias and promotes understanding of the options available within a particular decision. Whereas our companion paper summarizes fundamental issues, this article focuses on more complex, task-specific aspects of presenting numeric information in patient decision aids.

METHODS

As part of the International Patient Decision Aids Standards third evidence update, we gathered an expert panel of 9 international experts who revised and expanded the topics covered in the 2013 review working in groups of 2 to 3 to update the evidence, based on their expertise and targeted searches of the literature. The full panel then reviewed and provided additional revisions, reaching consensus on the final version.

RESULTS

Five of the 10 topics addressed more complex task-specific issues. We found strong evidence for using independent event rates and/or incremental absolute risk differences for the effect size of test and screening outcomes. Simple visual formats can help to reduce common judgment biases and enhance comprehension but can be misleading if not well designed. Graph literacy can moderate the effectiveness of visual formats and hence should be considered in tool design. There is less evidence supporting the inclusion of personalized and interactive risk estimates.

DISCUSSION

More complex numeric information. such as the size of the benefits and harms for decision options, can be better understood by using incremental absolute risk differences alongside well-designed visual formats that consider the graph literacy of the intended audience. More research is needed into when and how to use personalized and/or interactive risk estimates because their complexity and accessibility may affect their feasibility in clinical practice.

Risk Ladder, Table, or Bulleted List? Identifying Formats That Effectively Communicate Personalized Risk and Risk Reduction Information for Multiple Diseases

BACKGROUND

Personalized medicine may increase the amount of probabilistic information patients encounter. Little guidance exists about communicating risk for multiple diseases simultaneously or about communicating how changes in risk factors affect risk (hereafter "risk reduction").

PURPOSE

To determine how to communicate personalized risk and risk reduction information for up to 5 diseases associated with insufficient physical activity in a way laypeople can understand and that increases intentions.

METHODS

We recruited 500 participants with <150 min weekly of physical activity from community settings. Participants completed risk assessments for diabetes, heart disease, stroke, colon cancer, and breast cancer (women only) on a smartphone. Then, they were randomly assigned to view personalized risk and risk reduction information organized as a bulleted list, a simplified table, or a specialized vertical bar graph ("risk ladder"). Last, they completed a questionnaire assessing outcomes. Personalized risk and risk reduction information was presented as categories (e.g., "very low"). Our analytic sample (N = 372) included 41.3% individuals from underrepresented racial/ethnic backgrounds, 15.9% with vocational-technical training or less, 84.7% women, 43.8% aged 50 to 64 y, and 71.8% who were overweight/obese.

RESULTS

Analyses of covariance with post hoc comparisons showed that the risk ladder elicited higher gist comprehension than the bulleted list (P = 0.01). There were no significant main effects on verbatim comprehension or physical activity intentions and no moderation by sex, race/ethnicity, education, numeracy, or graph literacy (P > 0.05). Sequential mediation analyses revealed a small beneficial indirect effect of risk ladder versus list on intentions through gist comprehension and then through perceived risk (b_{IndirectEffect} = 0.02, 95% confidence interval: 0.00, 0.04).

CONCLUSION

Risk ladders can communicate the gist meaning of multiple pieces of risk information to individuals from many sociodemographic backgrounds and with varying levels of facility with numbers and graphs.

The Network Structure of Decision-Making Competence in Chinese Adults

Decision-making competence refers to the ability to make better decisions, as defined by decision-making principles posited by models of rational choice. The adult decision-making competence (A-DMC) scale is a relatively mature evaluation tool used for decision-making competence. However, the A-DMC is yet far from other mature psychological evaluation tools, and especially the structure of A-DMC remains unclear. In the current study, we estimated a regularized partial correlation network of decision-making competence in a Chinese sample consisting of 339 adults who were evaluated by the A-DMC, and then the centrality indicators were calculated. The results revealed that all nodes of the decision-making competence networks are positively associated, except for the association of resistance to framing (RF) and resistance to sunk costs (SC). The strongest edge was between RF and applying decision rules (DR; regularized partial correlation = 0.37). The centrality indicators of RF and applying DR were highest, revealing that these two variables may play important roles in the decision-making competence network. Our study conceptualizes the decision-making competence from network perspectives, so as to provide some insights for future researches.

A qualitative exploration of clinicians' strategies to communicate risks to patients in the complex reality of clinical practice

BACKGROUND

Risk communication, situated in the model of shared decision making (SDM), is an essential element in daily clinical practice. The scientific literature makes a number of generic recommendations. Yet the application of risk communication remains a challenge in patient-clinician encounters. How clinicians actually communicate risk during consultations is not well understood. We aimed to explore the risk communication strategies used by clinicians and extract narratives and visualizations of those strategies to help inform medical education.

METHODS

In this qualitative descriptive study, we interviewed fifteen purposely sampled clinicians from several medical disciplines, who were familiar with the concept of SDM. Deductive and inductive content analysis was used during an iterative data collection and analyses process.

RESULTS

Our study identified various strategies reported to be used by clinicians to address the complexities of risk communication such as dealing with uncertainty. These included verbal, numerical and visual risk communication and framing. Clinicians were familiar with recommended risk formats such as natural frequencies and population pictograms. However, it became clear that clinicians' expertise and communication goals also play an important role in the risk talk. Clinicians try to lay a foundation for balanced decision-making and to incorporate patient preferences while faced with several challenges such as the dilemma of raising awareness but triggering anxiety or fan fear in patients. Consequently, they also use communication goals such as influencing mindset and reassuring patients. Additionally, clinicians frequently have to account for the illusion of certainty in the risk talk.

CONCLUSION

Risk communication is a multi-faceted construct that cannot be dealt with in isolation from the clinical context. For future research we recommend considering a more practical framework within the clinical setting and to take a goal-directed approach into account when investigating and teaching the topic. The patient perspective should also be addressed in further research.

Effect of interventions including provision of personalised cancer risk information on accuracy of risk perception and psychological responses: A systematic review and meta-analysis

OBJECTIVE

To synthesize the literature on the effect of provision of personalised cancer risk information to individuals at population level risk on accuracy of risk perception and psychological responses.

METHODS

A systematic review and random effects meta-analysis of articles published from 01/01/2000 to 01/07/2017.

RESULTS

We included 23 studies. Immediately after provision of risk information 87% of individuals were able to recall the absolute risk estimate. Less than half believed that to be their risk, with up to 71% believing their risk to be higher than the estimate. Provision of risk information increased accuracy of perceived absolute risk immediately after risk information compared with no information (pooled RR 4.16 (95%CI 1.28-13.49), 3 studies). There was no significant effect on comparative risk accuracy (pooled RR 1.39 (0.72-2.69), 2 studies) and either no change or a reduction in cancer worry, anxiety and fear.

CONCLUSION

These findings highlight the complex cognitive processes involved in the conceptualisation of risk.

PRACTICE IMPLICATIONS

Individuals who appear to understand and are able to recall risk information most likely do not believe it reflects their own risk.

The impact of artificial intelligence on the current and future practice of clinical cancer genomics

Artificial intelligence (AI) is one of the most significant fields of development in the current digital age. Rapid advancements have raised speculation as to its potential benefits in a wide range of fields, with healthcare often at the forefront. However, amidst this optimism, apprehension and opposition continue to strongly persist. Oft-cited concerns include the threat of unemployment, harm to the doctor–patient relationship and questions of safety and accuracy. In this article, we review both the current and future medical applications of AI within the sub-speciality of cancer genomics.

The Influence of Health Numeracy and Health Warning Label Type on Smoking Myths and Quit-Related Reactions

INTRODUCTION

Health numeracy helps individuals understand risk information, but limited data exist concerning numeracy's role in reactions to varying types of health warning labels (HWLs) for cigarettes.

METHODS

A nationally representative online panel of adult current smokers received two exposures (1 week apart) to nine HWLs with either text-only or pictorial images with identical mandated text. Following the second exposure, participants (n = 594) rated their beliefs in smoking myths (eg, health-promoting behaviors can undo the risks of smoking) and how much the warnings made them want to quit smoking. Generalized estimating equation regression examined the relation of objective health numeracy and its interaction with HWL type to smoking-myth beliefs and quit-related reactions.

RESULTS

Health numeracy was not significantly associated with smoking-myth beliefs; the interaction with HWL type was also nonsignificant. Adult smokers with lower health numeracy had higher quit-related reactions than those with higher numeracy following exposure to HWLs. The type of HWL significantly modified numeracy's associations with quit-related reactions; no significant association existed between text-only HWLs and quit-related reactions, whereas among those who viewed the pictorial warnings, lower numeracy was associated with greater quit-related reactions (β = -.23; p < .001).

CONCLUSIONS

Lower as compared to higher health numeracy was significantly associated with higher quit-related reactions to HWLs and especially with pictorial HWLs. Health numeracy and HWL type were not associated with the endorsement of smoking myths. The role of health numeracy in effectively communicating risks to smokers warrants thoughtful consideration in the development of tobacco HWLs.

IMPLICATIONS

Health numeracy plays an important role in an individual's ability to understand and respond to health risks. Smokers with lower health numeracy had greater quit-related reactions to pictorial health warnings than those who viewed text-only warning labels. Development and testing of health warning labels should consider health numeracy to most effectively communicate risk to US smokers.

How Well Do COP22 Attendees Understand Graphs on Climate Change Health Impacts from the Fifth IPCC Assessment Report?

Graphs are prevalent in the reports of the Intergovernmental Panel on Climate Change (IPCC), often depicting key points and major results. However, the popularity of graphs in the IPCC reports contrasts with a neglect of empirical tests of their understandability. Here we put the understandability of three graphs taken from the Health chapter of the Fifth Assessment Report to an empirical test. We present a pilot study where we evaluate objective understanding (mean accuracy in multiple-choice questions) and subjective understanding (self-assessed confidence in accuracy) in a sample of attendees of the United Nations Climate Change Conference in Marrakesh, 2016 (COP22), and a student sample. Results show a mean objective understanding of M = 0.33 for the COP sample, and M = 0.38 for the student sample. Subjective and objective understanding were unrelated for the COP22 sample, but associated for the student sample. These results suggest that (i) understandability of the IPCC health chapter graphs is insufficient, and that (ii) particularly COP22 attendees lacked insight into which graphs they did, and which they did not understand. Implications for the construction of graphs to communicate health impacts of climate change to decision-makers are discussed.

Communicating Low-Probability High-Consequence Risk, Uncertainty and Expert Confidence: Induced Seismicity of Deep Geothermal Energy and Shale Gas

Subsurface energy activities entail the risk of induced seismicity including low-probability high-consequence (LPHC) events. For designing respective risk communication, the scientific literature lacks empirical evidence of how the public reacts to different written risk communication formats about such LPHC events and to related uncertainty or expert confidence. This study presents findings from an online experiment (N = 590) that empirically tested the public's responses to risk communication about induced seismicity and to different technology frames, namely deep geothermal energy (DGE) and shale gas (between-subject design). Three incrementally different formats of written risk communication were tested: (i) qualitative, (ii) qualitative and quantitative, and (iii) qualitative and quantitative with risk comparison. Respondents found the latter two the easiest to understand, the most exact, and liked them the most. Adding uncertainty and expert confidence statements made the risk communication less clear, less easy to understand and increased concern. Above all, the technology for which risks are communicated and its acceptance mattered strongly: respondents in the shale gas condition found the identical risk communication less trustworthy and more concerning than in the DGE conditions. They also liked the risk communication overall less. For practitioners in DGE or shale gas projects, the study shows that the public would appreciate efforts in describing LPHC risks with numbers and optionally risk comparisons. However, there seems to be a trade-off between aiming for transparency by disclosing uncertainty and limited expert confidence, and thereby decreasing clarity and increasing concern in the view of the public.

Prenatal diagnosis tests and women's risk perception: a cross-sectional study

OBJECTIVE

To investigate women's decision to undergo non-invasive and/or invasive tests for prenatal diagnosis depending on the procedure-related risk and the risk of carrying a foetus with Down syndrome (DS). Both risks are rated in terms of numerical relevance and acceptability.

METHOD

A sample of 448 consecutive women with low-risk pregnancies were interviewed to collect social and clinical variables and to determine their perceptions of the risks of invasive procedure-related miscarriage and carrying a foetus with DS. The risks were scored numerically in terms of their relevance and acceptability using a 10-point rating scale.

RESULTS

The factors related to the use of non-invasive tests were age ≥35 years, not being treated at a public service, rating the risk of carrying a foetus with DS as having high numerical relevance and low acceptability, and rating the risk of miscarriage as having high acceptability. These relationships were still present when the use of invasive tests was considered, except in terms of the numerical relevance of the risk of carrying a foetus with DS.

CONCLUSION

Perceived acceptability affects the interpretation of a given risk more than the numerical relevance of the risk.

Risk Prioritization in the Food Domain Using Deliberative and Survey Methods: Differences between Experts and Laypeople

This study examined how experts and laypeople using both a deliberative and a survey method prioritized 28 hazards related to food and everyday items. To enable them to make deliberative decisions, participants received detailed descriptions of the hazards. The participants prioritized the hazards before and after a group discussion, in which the group's average prioritization was discussed. The rankings of the hazards before and after the group discussion were highly correlated. However, laypeople and experts differed significantly in their rankings for 18 of the 28 hazards. Trust and confidence were important predictors for laypeople's risk rankings. To test the influence of the deliberative method (e.g., providing detailed information about each hazard), data from a second group of laypeople were collected with a no-information survey. This group did not receive specific information about the hazards. The risk rankings of the laypeople who received information were highly correlated with the risk rankings of laypeople who did not receive information. Overall, the results suggest that deliberative methods of risk-ranking or no-information survey methods with no information about hazards provide similar results among laypeople. The conclusion is that government agencies should not only base their risk prioritization on evidence from risk assessments but also need to consider laypeople's hazard rankings. This procedure may result in an efficient and publicly accepted risk management strategy.

Information about first-trimester screening and self-reported distress among pregnant women and partners - comparing two methods of information giving in Sweden

INTRODUCTION

Balanced information before prenatal diagnosis (PND) aims to help expectant parents to make an informed choice. However, it is important that the information does not increase the expectant parents' psychological distress. The aim was to examine psychological distress among expectant parents, before and after receiving information about PND, to evaluate the possible differences between two different procedures of information giving, and to evaluate the association between satisfaction with the information and psychological distress.

MATERIAL AND METHODS

A longitudinal design, based on questionnaire data from 380 expectant parents from four counties in Sweden. The measurement points; T1, before the information about PND was given and T2, 2 weeks after the prenatal screening or 15 weeks of gestation. The Hospital Anxiety and Depression Scale (HADS) and the Swedish version of the Cambridge Worrying Scale (CWS) measured psychological distress. The Satisfaction with Genetic Counseling Scale (SCS) measured satisfaction with information about PND.

RESULTS

The rate of psychological distress was stable among the pregnant women, but decreased among their partners, after the information was received. General anxiety and the social-medical dimension of pregnancy-related worry decreased among the participants who received information, using the more distinct two-stage process (group A), but was unchanged in group B (less distinct two-stage process). Health-related worry decreased in both groups, whereas relational worry and level of depressive symptoms were unchanged in both groups.

CONCLUSION

Information about PND does not increase the psychological distress among expectant parents. A more distinct two-stage process of information giving might even decrease their anxiety.

Designing Visual Aids That Promote Risk Literacy: A Systematic Review of Health Research and Evidence-Based Design Heuristics

Background Effective risk communication is essential for informed decision making. Unfortunately, many people struggle to understand typical risk communications because they lack essential decision-making skills. Objective The aim of this study was to review the literature on the effect of numeracy on risk literacy, decision making, and health outcomes, and to evaluate the benefits of visual aids in risk communication. Method We present a conceptual framework describing the influence of numeracy on risk literacy, decision making, and health outcomes, followed by a systematic review of the benefits of visual aids in risk communication for people with different levels of numeracy and graph literacy. The systematic review covers scientific research published between January 1995 and April 2016, drawn from the following databases: Web of Science, PubMed, PsycINFO, ERIC, Medline, and Google Scholar. Inclusion criteria were investigation of the effect of numeracy and/or graph literacy, and investigation of the effect of visual aids or comparison of their effect with that of numerical information. Thirty-six publications met the criteria, providing data on 27,885 diverse participants from 60 countries. Results Transparent visual aids robustly improved risk understanding in diverse individuals by encouraging thorough deliberation, enhancing cognitive self-assessment, and reducing conceptual biases in memory. Improvements in risk understanding consistently produced beneficial changes in attitudes, behavioral intentions, trust, and healthy behaviors. Visual aids were found to be particularly beneficial for vulnerable and less skilled individuals. Conclusion Well-designed visual aids tend to be highly effective tools for improving informed decision making among diverse decision makers. We identify five categories of practical, evidence-based guidelines for heuristic evaluation and design of effective visual aids.

Knowledge and Attitudes Regarding Non-Invasive Prenatal Testing (NIPT) and Preferences for Risk Information among High School Students in Sweden

Non-invasive prenatal testing (NIPT) was recently introduced for prenatal testing of genetic disorders. Cell-free fetal DNA is present in maternal blood during pregnancy and enables detection of fetal chromosome aberrations in a maternal blood sample. The public perspective to this new, simple method has not been illuminated. The views of young people (i.e. future parents) are important to develop suitable counseling strategies regarding prenatal testing. The aim was to explore Swedish high school students’ attitudes, knowledge and preferences regarding NIPT. A questionnaire was completed by 305 students recruited from one high school in Stockholm, November and December 2014. Most students (80 %) considered prenatal testing as good. The majority (65 %) was positive or very positive towards NIPT and 62 % stated that they potentially would like to undergo the test if they or their partner was pregnant. The vast majority (94 %) requested further information about NIPT. Most students (61 %) preferred verbal information, whereas 20 % preferred information via the Internet. The majority of the high school students was positive towards prenatal testing and most was positive towards NIPT. Further, information was requested by the vast majority before making a decision about NIPT. Most of the students preferred verbal information and to a lesser extent information via the Internet. The attitudes, knowledge and preferences for risk information concerning NIPT in young adults are important, in order to increase knowledge on how to educate and inform future parents.

Socioeconomic Differences in Informed Decisions About Down Syndrome Screening: A Systematic Review and Research Agenda

Supporting pregnant women to make informed choices about Down syndrome screening is widely endorsed. We reviewed the literature on: (a) the association between socioeconomic position and informed choices and decision-making about Down syndrome screening, and (b) the possible mediating variables (e.g., health literacy, numeracy skills, behavioral and communication variables) that might explain the relationship. EMBASE, MEDLINE, PubMed, CINAHL, and PsycINFO were searched from January 1999 to September 2014. The methodological quality of studies was determined by predefined criteria regarding the research aims, study design, study population and setting, measurement tools, and statistical analysis. A total of 33 studies met the inclusion criteria. Women from lower socioeconomic groups experience greater difficulties making informed choices about Down syndrome screening compared to women from higher socioeconomic groups. Most studies focus on individual dimensions of informed decision-making rather than assessing elements in conjunction with one another. Few studies have explored why there are socioeconomic differences in women's ability to make informed screening decisions. Future work is needed to identify mediating variables in this pathway. Systematic evidence-based intervention development to improve communication, understanding, and decision-making about Down syndrome screening is needed to ensure that women have an equal opportunity to make an informed choice about screening regardless of their socioeconomic position.

Measuring Graph Literacy without a Test: A Brief Subjective Assessment

BACKGROUND

Visual aids tend to help diverse and vulnerable individuals understand risk communications, as long as these individuals have a basic understanding of graphs (i.e., graph literacy). Tests of objective graph literacy (OGL) can effectively identify individuals with limited skills, highlighting vulnerabilities and facilitating custom-tailored risk communication. However, the administration of these tests can be time-consuming and may evoke negative emotional reactions (e.g., anxiety).

OBJECTIVES

To evaluate a brief and easy-to-use assessment of subjective graph literacy (SGL) (i.e., self-reported ability to process and use graphically presented information) and to estimate the robustness and validity of the SGL scale and compare it with the leading OGL scale in diverse samples from different cultures.

PARTICIPANTS

Demographically diverse residents (n = 470) of the United States, young adults (n = 172) and patients (n = 175) from Spain, and surgeons (n = 175) from 48 countries.

DESIGN

A focus group and 4 studies for instrument development and initial validation (study 1), reliability and convergent and discriminant validity evaluation (study 2), and predictive validity estimation (studies 3 and 4).

MEASURES

Psychometric properties of the scale.

RESULTS

In about 1 minute, the SGL scale provides a reliable, robust, and valid assessment of skills and risk communication preferences and evokes fewer negative emotional reactions than the OGL scale.

CONCLUSIONS

The SGL scale can be suitable for use in clinical research and may be useful as a communication aid in clinical practice. Theoretical mechanisms involved in SGL, emerging applications, limitations, and open questions are discussed.

Positive Attitudes towards Non-Invasive Prenatal Testing (NIPT) in a Swedish Cohort of 1,003 Pregnant Women

Objective

The clinical utilization of non-invasive prenatal testing (NIPT) for identification of fetal aneuploidies is expanding worldwide. The aim of this study was to gain an increased understanding of pregnant women’s awareness, attitudes, preferences for risk information and decision-making concerning prenatal examinations with emphasis on NIPT, before its introduction into Swedish healthcare.

Method

Pregnant women were recruited to fill in a questionnaire, including multiple-choice questions and Likert scales, at nine maternity clinics located in different areas of Stockholm, Sweden.

Results

In total, 1,003 women participated in the study (86% consent rate). The vast majority (90.7%) considered examinations aiming to detect fetal abnormalities to be good. Regarding NIPT, 59.8% stated that they had heard about the method previously, yet 74.0% would like to use the test if available. The main factor affecting the women’s decision to undergo prenatal chromosomal screening was worry about the baby’s health (82.5%), followed by the urge to have as much information as possible about the fetus (54.5%). Most women (79.9%) preferred to receive NIPT information orally.

Conclusion

The overwhelming majority of a cohort of 1,003 pregnant women considered prenatal examinations good. Moreover, the majority had a positive attitude towards NIPT and would like to use the test if available.

Visual presentations of efficacy data in direct-to-consumer prescription drug print and television advertisements: A randomized study

OBJECTIVE

To determine whether visual aids help people recall quantitative efficacy information in direct-to-consumer (DTC) prescription drug advertisements, and if so, which types of visual aids are most helpful.

METHODS

Individuals diagnosed with high cholesterol (n=2504) were randomized to view a fictional DTC print or television advertisement with no visual aid or one of four visual aids (pie chart, bar chart, table, or pictograph) depicting drug efficacy. We measured drug efficacy and risk recall, drug perceptions and attitudes, and behavioral intentions.

RESULTS

For print advertisements, a bar chart or table, compared with no visual aid, elicited more accurate drug efficacy recall. The bar chart was better at this than the pictograph and the table was better than the pie chart. For television advertisements, any visual aid, compared with no visual aid, elicited more accurate drug efficacy recall. The bar chart was better at this than the pictograph or the table.

CONCLUSION

Visual aids depicting quantitative efficacy information in DTC print and television advertisements increased drug efficacy recall, which may help people make informed decisions about prescription drugs.

PRACTICE IMPLICATIONS

Adding visual aids to DTC advertising may increase the public's knowledge of how well prescription drugs work.

Empirical relationships between numeracy and treatment decision making: A scoping review of the literature

OBJECTIVES

To determine what is known from the existing literature about empirical relationships between numeracy and the three stages of the treatment decision making process (information exchange, deliberation, and deciding on the treatment to implement). We also examined if, and how, numeracy was mentioned in relation to health literacy.

METHODS

A search of four databases returned 2772 records. After de-duplication and three levels of relevance screening, 38 primary studies were included in this review.

RESULTS

Relationships between numeracy and the information exchange stage have received greater attention than relationships between numeracy and the deliberation and deciding on the treatment to implement stages. The lack of overlap in the empirical relationships examined in studies, the measure(s) of numeracy used, and the characteristics of study populations, made findings difficult to compare. Multiple knowledge gaps and measurement-related problems were identified. Numeracy and health literacy have largely been treated as separate concepts.

CONCLUSION

More research is needed to better understand the importance of numeracy and health literacy to treatment decision making.

PRACTICE IMPLICATIONS

Decision aids designed for patients with different levels of health literacy may not meet the needs of patients with different levels of numeracy. The numeracy skills of health professionals require attention.

Public preferences for communicating personal genomic risk information: a focus group study

Background

Personalized genomic risk information has the potential to motivate behaviour change and promote population health, but the success of this will depend upon effective risk communication strategies.

Objective

To determine preferences for different graphical and written risk communication formats, and the delivery of genomic risk information including the mode of communication and the role of health professionals.

Design

Focus groups, transcribed and analysed thematically.

Participants

Thirty‐four participants from the public.

Methods

Participants were provided with, and invited to discuss, a hypothetical scenario giving an individual's personalized genomic risk of melanoma displayed in several graphical formats.

Results

Participants preferred risk formats that were familiar and easy to understand, such as a ‘double pie chart’ and ‘100 person diagram’ (pictograph). The 100 person diagram was considered persuasive because it humanized and personalized the risk information. People described the pie chart format as resembling bank data and food (such as cake and pizza). Participants thought that email, web‐based platforms and postal mail were viable options for communicating genomic risk information. However, they felt that it was important that a health professional (either a genetic counsellor or ‘informed’ general practitioner) be available for discussion at the time of receiving the risk information, to minimize potential negative emotional responses and misunderstanding. Face‐to‐face or telephone delivery was preferred for delivery of high‐risk results.

Conclusions

These public preferences for communication strategies for genomic risk information will help to guide translation of genome‐based knowledge into improved population health.

Women's Experiences of Publicly Funded Non-Invasive Prenatal Testing in Ontario, Canada: Considerations for Health Technology Policy-Making

Non-invasive prenatal testing (NIPT) via fetal DNA in maternal blood has been publicly funded in Ontario, Canada, for high-risk women since 2014. We solicited women's experiences and values related to this new health technology to describe how this test is currently being used in Ontario and to provide information about patient priorities to inform future policy decisions about the use of NIPT. Guided by constructivist grounded theory methodology, we interviewed 38 women who had diverse personal experiences with NIPT. Participants' accounts of their values for decision making about NIPT heavily relied on three mutually modulating factors: timing, accuracy, and risk. The values expressed by women conflict with the way that publicly funded NIPT has typically been implemented in Ontario. We offer recommendations for how NIPT might be integrated into prenatal care pathways in a way more consistent with women's values.

Ethical persuasion: the rhetoric of communication in critical care

This article reviews the ethics of rhetoric in critical care. Rational appeals in critical care fail to move patients or surrogates to a better course of action. Appeals to their emotions are considered illegitimate because they may preclude autonomous choice. This article discusses whether it is always unethical to change someone's beliefs, whether persuasive communication is inherently harmful and whether it leaves no space for voluntariness. To answer these questions, the article engages with Aristotle's work, Rhetoric. In considering whether there is a place for emotionally charged messages in a patient-provider relationship, the article intends to delineate the nature of this relationship and describe the duties this relationship implies. The article presents examples of persuasive communication used in critical care and discusses whether providers may have a duty to persuade patients. This duty is supported by the fact that doctors often influence patients' and families' choices by framing presented options. Doctors should assume responsibility in recognizing these personal and contextual influences that may influence the medical choices of their patients. They should attempt to modify these contextual factors and biases in a way that would assist patients and families in reaching the desired outcomes. The opening sections surveyed a number of definitions found in relevant literature and outlined some of the concepts included in the proposed definition. This definition helps to distinguish instances of persuasion from cases of manipulation, coercion and deception. Considering the fact that patients and families often make irrational decisions and the fact that doctors inadvertently influence their choices, the article suggested that persuasion can be a positive tool in medical communication. When patients or families clearly do not understand the risks or make decisions that contradict their long-term goals, persuasion can be used as a positive influence.

Recommendations for malaria prevention in moderate to low risk areas: travellers' choice and risk perception

Background

The considerable malaria decline in several countries challenges the strategy of chemoprophylaxis for travellers visiting moderate- to low-risk areas. An international consensus on the best strategy is lacking. It is essential to include travellers’ opinions in the decision process. The preference of travellers regarding malaria prevention for moderate- to low-risk areas, related to their risk perception, as well as the reasons for their choices were investigated.

Methods

Prior to pre-travel consultation in the Travel Clinic, a self-administered questionnaire was given to travellers visiting moderate- to low-risk malaria areas. Four preventive options were proposed to the traveller, i.e., bite prevention only, chemoprophylaxis, stand-by emergency treatment alone, and stand-by emergency treatment with rapid diagnostic test. The information was accompanied by a risk scale for incidence of malaria, anti-malarial adverse drug reactions and other travel-related risks, inspired by Paling palettes from the Risk Communication Institute.

Results

A total of 391 travellers were included from December 2012 to December 2013. Fifty-nine (15%) opted for chemoprophylaxis, 116 (30%) for stand-by emergency treatment, 112 (29%) for stand-by emergency treatment with rapid diagnostic test, 100 (26%) for bite prevention only, and four (1%) for other choices. Travellers choosing chemoprophylaxis justified their choice for security reasons (42%), better preventive action (29%), higher efficacy (15%) and easiness (15%). The reasons for choosing stand-by treatment or bite prevention only were less medication consumed (29%), less adverse drug reactions (23%) and lower price (9%). Those who chose chemoprophylaxis were more likely to have used it in the past (OR = 3.0 (CI 1.7-5.44)), but were not different in terms of demographic, travel characteristics or risk behaviour.

Conclusions

When travelling to moderate- to low-risk malaria areas, 85% of interviewees chose not to take chemoprophylaxis as malaria prevention, although most guidelines recommend it. They had coherent reasons for their choice. New recommendations should include shared decision-making to take into account travellers’ preferences.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-015-0654-y) contains supplementary material, which is available to authorized users.

The effect of different graphical and numerical likelihood formats on perception of likelihood and choice

BACKGROUND

Quantitative risk information plays an important role in decision making about health. This study focuses on commonly used numerical and graphical formats and examines their effect on perception of different likelihoods and choice preferences.

METHODS

An experimental study was conducted with 192 participants, who evaluated 2 sets of 4 lotteries. Numerical formats to describe likelihood varied systematically between participants (X%, X-in-100, or 1-in-X). The effect of graphic formats (bar charts, icon charts) was assessed as a within-subjects factor. Dependent measures included perceived likelihood, choice preferences about participating in the lottery, and processing times.

RESULTS

Numerical likelihoods presented as 1-in-X were processed fastest and were perceived as conveying larger likelihoods than the X-in-100 and percentages formats (mean response times in seconds: 5.65 v. 7.31 and 6.50; mean rating on a 1-9 scale: 4.38 v. 3.30 and 3.31, respectively). The 1-in-X format also evoked a stronger willingness to participate in a lottery than the 2 other numerical formats. The effect of adding graphs on perceived likelihood was moderated by numerical aptitude. Graphs reduced ratings of perceived likelihood of participants with lower numeracy, while there was no overall effect for participants with higher numeracy.

CONCLUSION

Perception of likelihood differs significantly depending on the numerical format used. The 1-in-X format yields higher perceived likelihoods and it appears to be the easiest format to interpret. Graphs primarily affect perception of likelihood of people with lower numerical aptitude. These effects should be taken into account when discussing medical risks with patients.

Communicating the risk of violent and offending behavior: review and introduction to this special issue

How to communicate risk of recidivism in correctional and forensic contexts has been a subject of scholarly discussion for two decades. This emerging literature, however, is sparse compared with studies on the assessment of risk for violent and offending behavior. In this special issue of Behavioral Sciences and the Law, we have gathered together empirical and review papers exemplifying promising directions and methodologies. We begin with a review of the state of the field, and lessons that can be drawn from research into medical risk assessment and risk communication, finding that many of the same principles apply to the forensic context. How risks are framed, and how numerate assessors are, affects how risk information is understood and applied. We discuss the existing research bearing on these issues, as well as the conceptual, practical, empirical, and legal implications of communicating risk using numerical or categorical risk terms. Along with the seven articles in this volume, we suggest directions for future research on measuring and communicating change, understanding and managing the statistical literacy of those who use and communicate risk assessments, and developing a theoretical framework for forensic risk communication research. We hope this volume will help integrate and invigorate research into forensic risk communication.

The effect of prognostic data presentation format on perceived risk among surrogate decision makers of critically ill patients: a randomized comparative trial

PURPOSE

The purpose of this study is to determine whether varying the format used to present prognostic data alters the perception of risk among surrogate decision makers in the intensive care unit (ICU).

METHODS

This was a prospective randomized comparative trial conducted in a 23-bed adult tertiary ICU. Enrolled surrogate decision makers were randomized to 1 of 2 questionnaires, which presented hypothetical ICU scenarios, identical other than the format in which prognostic data were presented (eg, frequencies vs percentages). Participants were asked to rate the risk associated with each prognostic statement.

RESULTS

We enrolled 141 surrogate decision makers. The perception of risk varied significantly dependent on the presentation format. For "quantitative data," risks were consistently perceived as higher, when presented as frequencies (eg, 1 in 50) compared with equivalent percentages (eg, 2%). Framing "qualitative data" in terms of chance of "death" rather than "survival" led to a statistically significant increase in perceived risks. Framing "quantitative" data in this way did not significantly affect risk perception.

CONCLUSION

Data format had a significant effect on how surrogate decision makers interpreted risk. Qualitative statements are interpreted widely and affected by framing. Where possible, multiple quantitative formats should be used for presenting prognostic information.

Striking a balance in communicating pharmacogenetic test results: promoting comprehension and minimizing adverse psychological and behavioral response

OBJECTIVE

Pharmacogenetic (PGx) testing can provide information about a patient's likelihood to respond to a medication or experience an adverse event, and be used to inform medication selection and/or dosing. Promoting patient comprehension of PGx test results will be important to improving engagement and understanding of treatment decisions.

METHODS

The discussion in this paper is based on our experiences and the literature on communication of genetic test results for disease risk and broad risk communication strategies.

RESULTS

Clinical laboratory reports often describe PGx test results using standard terminology such as 'poor metabolizer' or 'ultra-rapid metabolizer.' While this type of terminology may promote patient recall with its simple, yet descriptive nature, it may be difficult for some patients to comprehend and/or cause adverse psychological or behavioral responses.

CONCLUSION

The language used to communicate results and their significance to patients will be important to consider in order to minimize confusion and potential psychological consequences such as increased anxiety that can adversely impact medication-taking behaviors.

PRACTICE IMPLICATIONS

Due to patients' unfamiliarity with PGx testing and the potential for confusion, adverse psychological effects, and decreased medication adherence, health providers need to be cognizant of the language used in discussing PGx test results with patients.

Numeric and graphic risk information processing of high and low numerates in the intuitive and deliberative decision modes: An eye-tracker study

The influence of numeracy on information processing of two risk communication formats (percentage and pictograph) was examined using an eye tracker. A sample from the general population (N = 159) was used. In intuitive and deliberative decision conditions, the participants were presented with a hypothetical scenario presenting a test result. The participants indicated their feelings and their perceived risk, evoked by a 17% risk level. In the intuitive decision condition, a significant correlation (r = .30) between numeracy and the order of information processing was found: the higher the numeracy, the earlier the processing of the percentage, and the lower the numeracy, the earlier the processing of the pictograph. This intuitive, initial focus on a format prevailed over the first half of the intuitive decision-making process. In the deliberative decision condition, the correlation between numeracy and order of information processing was not significant. In both decision conditions, high and low numerates processed pictograph and percentage formats with similar depths and derived similar meanings from them in terms of feelings and perceived risk. In both conditions numeracy had no effects on the degree of attention on the percentage or the pictograph (number of fixations on formats and transitions between them). The results suggest that pictographs attract low numerates’ attention, and percentages attract high numerates’ attention in the first, intuitive, phase of numeric information processing. Pictographs thus ensure low numerates’ further elaboration on numeric risk information, which is an important precondition of risk understanding and decision making.

The Role of Public Trust During Pandemics

The present review examined the importance of trust when preparing for and during a pandemic. The reviewed literature suggests that trust in health agencies positively influenced people’s willingness to adopt recommended behavior. Most of these studies are atheoretical, and due to the lack of a common framework for trust and its antecedents, finding commonalities among the studies may seem difficult. The trust, confidence, and cooperation model was used to uncover the commonalities among the various studies on trust. This framework suggests that a distinction between values and past performance may be helpful to better understand the impact of trust on risk perception and behavior. Based on the reviewed literature, the following five recommendations relevant for crisis communication during pandemics were identified: A diverse set of experts should be used as communicators, medical personnel need to model the recommended behavior, a transparent information strategy should be used, the focus should be not only on trust but also on confidence, and establishing trust in health authorities before a pandemic occurs is important. Furthermore, research gaps were identified that should be addressed to better understand the role of trust when dealing with pandemics.

Development and validation of the numeracy understanding in Medicine Instrument short form

Health numeracy can be defined as the ability to understand and use numeric information and quantitative concepts in the context of health. The authors previously reported the development of the Numeracy Understanding in Medicine Instrument (NUMi), a 20-item test developed using item response theory. The authors now report the development and validation of a short form of the NUMi. Item statistics were used to identify a subset of 8 items representing a range of difficulty and content areas. Internal reliability was evaluated with Cronbach's alpha. Divergent and convergent validity was assessed by comparing scores of the S-NUMI with existing measures of education, print and numeric health literacy, mathematic achievement, cognitive reasoning, and the original NUMi. The 8-item scale had adequate reliability (α=.72) and was strongly correlated to the 20-item NUMi (α=.92). S-NUMi scores were strongly correlated with the Lipkus Expanded Health Numeracy Scale (α=.62), the Wide Range of Achievement Test-Mathematics (α=.72), and the Wonderlic Cognitive Ability Test (α=.76). Moderate correlation was found with education level (α=.58) and print literacy as measured by the Test of Functional Health Literacy in Adults (α=.49). Results show that the short form of the NUMi is a reliable and valid measure of health numeracy feasible for use in clinical and research settings.

Communicating Health Risks With Visual Aids

Informed decision making requires that people understand health risks. Unfortunately, many people are not risk literate and are biased by common risk communication practices. In this article, we review a collection of studies investigating the benefits of visual aids for communicating health risks to diverse vulnerable people (e.g., varying in abilities, ages, risk characteristics, and cultural backgrounds). These studies show that appropriately designed visual aids are often highly effective, transparent, and ethically desirable tools for improving decision making, changing attitudes, and reducing risky behavior. Theoretical mechanisms, open questions, and emerging applications are discussed.