Numbers matter to informed patient choices: a randomized design across age and numeracy levels

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.

Information and communication priorities of patients and healthcare professionals in shared decision making regarding adjuvant systemic breast cancer treatment: A survey study

PURPOSE

To assess information and communication priorities of patients and healthcare professionals in Shared Decision Making about adjuvant systemic treatment of primary breast cancer and identify key decision-relevant information accordingly.

METHODS

Patients (N = 122) and professionals working with breast cancer patients (N = 118), of whom 38 were nurse practitioners and 32 nurses, were recruited using convenience sampling, and surveyed about information/communication aspects key to decision-making, using ranking assignments. We further posed a simple open question, questions about receiving population-based statistics versus personalized statistics concerning treatment outcomes, and their attitude and experience concerning Shared Decision Making. Data were analyzed using descriptive analysis and a qualitative analysis.

RESULTS

Both patients and professionals prioritized information about treatment outcomes (i.e., survival, recurrence) as key decision-relevant information for patients. Patients prioritized information about relatively severe treatment side-effects and late effects (e.g., blood clot, stroke), whilst professionals prioritized information about effects that occur relatively often (e.g., hair loss, fatigue). Patients specifically wanted to know if the benefit of treatment is worth the negative impact. Both groups prioritized personalized statistics over population-based statistics.

CONCLUSIONS

Some differences between patients and professionals were found in information and communication priorities, specifically related to the different side-effects. It seems worthwhile to precisely address these side-effects in Shared Decision Making concerning adjuvant systemic treatment. Furthermore, it seems important to deliberate together on the question if expected benefit of treatment is worth the potential negative impact for the individual patient.

A Practical Significance Bias in Laypeople's Evaluation of Scientific Findings

People often rely on scientific findings to help them make decisions-however, failing to report effect magnitudes might lead to a potential bias in assuming findings are practically significant. Across two online studies (Prolific; N = 800), we measured U.S. adults' endorsements of expensive interventions described in media reports that led to effects that were small, large, or of unreported magnitude between groups. Participants who viewed interventions with unreported effect magnitudes were more likely to endorse interventions compared with those who viewed interventions with small effects and were just as likely to endorse interventions as those who viewed interventions with large effects, suggesting a practical significance bias. When effect magnitudes were reported, participants on average adjusted their evaluations accordingly. However, some individuals, such as those with low numeracy skills, were more likely than others to act on small effects, even when explicitly prompted to first consider the meaningfulness of the effect.

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."

Statistical Literacy in Hand and Upper-Extremity Patients

Purpose

Statistical literacy is the ability of a patient to apply basic statistical concepts to their health care. Understanding statistics is a critical component of shared decision making. The purpose of this investigation was to define levels of statistical literacy in an upper-extremity (UE) patient population. We aimed to determine if patient demographics would be associated with statistical literacy.

Methods

An electronic survey was administered to a consecutive series of UE patients at a single institution. We recorded baseline demographics, Single Assessment Numeric Evaluation scores, the Berlin Numeracy Test (BNT), and General Health Numeracy Test. We also included a surgical risk question, which asked: "Approximately 3% of patients who get carpal tunnel surgery develop an infection. If 100 patients get this surgery, how many would you expect to develop an infection?" A covariate-controlled adjusted odds ratio reflecting the association between each statistical literacy outcome measure and patient characteristics was reported.

Results

A total 254 surveys were administered, 148 of which were completed and included. Fifty percent of respondents had a high-school education or less. For the BNT, 78% scored in the bottom quartile, and 52% incorrectly answered all questions. For the General Health Numeracy Test, 34% answered 0 or 1/6 questions correctly. For the surgical risk question, 24% of respondents answered incorrectly. Respondents who had a college or graduate degree had 2.62 times greater odds (95% confidence interval, 1.09-6.32) of achieving a BNT score in a higher quartile than patients who did not have a college or graduate degree.

Conclusions

Overall levels of statistical literacy are low for UE patients.

Clinical relevance

When engaging in management discussions and shared decision making, UE surgeons should assume low levels of statistical literacy. Consideration of alternative formats, such as frequencies, video-based materials, and pictographs, may be warranted when discussing outcomes and risks of surgical procedures.

Excluding numeric side-effect information produces lower vaccine intentions

Encouraging vaccine uptake is important to reducing the impact of infectious disease. However, negative attitudes and vaccine hesitancy, due in part to worry about side effects, are obstacles to achieving high vaccination rates. Provided vaccine information sheets typically include a list of side effects without numeric information about their likelihoods, but providing such numbers may yield benefits. We investigated the effect of providing numeric information about side-effect likelihood (e.g., "1%") and verbal labels (e.g., "uncommon") on intentions to get a hypothetical vaccine, reasons for the vaccination decision, and risk overestimation. In a diverse, online, convenience sample (N = 595), providing numeric information increased vaccine intentions-70% of those who received numeric information were predicted to be moderately or extremely likely to vaccinate compared to only 54% of those who did not receive numeric information (p<.001), controlling for age, gender, race, education, and political ideology. Participants receiving numeric information also were less likely to overestimate side-effect likelihood. Verbal labels had additional benefits when included with numeric information, particularly among the vaccine hesitant. For these participants, verbal labels increased vaccine intentions when included with numeric information (but not in its absence). Among the vaccine-hesitant, 43% of those provided numeric information and verbal labels were predicted to be moderately or extremely likely to get vaccinated vs. only 24% of those given a list of side effects (p<.001). We conclude that the standard practice of not providing numeric information about side-effect likelihood leads to a less-informed public who is less likely to vaccinate.

Measuring the Impact of Quantitative Information on Patient Understanding: Approaches for Assessing the Adequacy of Patient Knowledge about Colorectal Cancer Screening

Background. Guidelines recommend that decision aids disclose quantitative information to patients considering colorectal cancer (CRC) screening, but the impact on patient knowledge and decision making is limited. An important challenge for assessing any disclosure involves determining when an individual has “adequate knowledge” to make a decision. Methods. We analyzed data from a trial that randomized 213 patients to view a decision aid about CRC screening that contained verbal information (qualitative arm) versus one containing verbal plus quantitative information (quantitative arm). We analyzed participants’ answers to 8 “qualitative knowledge” questions, which did not cover the quantitative information, at baseline (T0) and after viewing the decision aid (T1). We introduce a novel approach that defines adequate knowledge as correctly answering all of a subset of questions that are particularly relevant because of the participant’s test choice (“Choice-Based Knowledge Assessment”). Results. Participants in the quantitative arm answered a higher mean number of knowledge questions correctly at T1 than did participants in the qualitative arm (7.3 v. 6.9, P < 0.05), and they more frequently had adequate knowledge at T1 based on a cutoff of 6 or 7 correct out of 8 (94% v. 83%, P < 0.05, and 86% v. 71%, P < 0.05, respectively). Members of the quantitative group also more frequently had adequate knowledge at T1 when assessed by Choice-Based Knowledge Assessment (87% v. 76%, P < 0.05). Conclusions. Patients who viewed quantitative information in addition to verbal information had greater qualitative knowledge and more frequently had adequate knowledge compared with those who viewed verbal information alone, according to most ways of defining adequate knowledge. Quantitative information may have helped participants better understand qualitative or gist concepts.

Trial Registration: ClinicalTrials.gov ID# NCT01415479

Highlights

Patients who viewed quantitative information in a decision aid about colorectal cancer screening were more knowledgeable about nonquantitative information and were more likely to have adequate knowledge according to a variety of approaches for assessing that, compared with individuals who viewed only qualitative information. This result supports the inclusion of quantitative information in decision aids. Researchers assessing patient understanding should consider a variety of ways to define adequate knowledge when assessing decision quality.

Evidence-based recommendations for communicating the impacts of climate change on health

Climate change poses a multifaceted, complex, and existential threat to human health and well-being, but efforts to communicate these threats to the public lag behind what we know how to do in communication research. Effective communication about climate change's health risks can improve a wide variety of individual and population health-related outcomes by: (1) helping people better make the connection between climate change and health risks and (2) empowering them to act on that newfound knowledge and understanding. The aim of this manuscript is to highlight communication methods that have received empirical support for improving knowledge uptake and/or driving higher-quality decision making and healthier behaviors and to recommend how to apply them at the intersection of climate change and health. This expert consensus about effective communication methods can be used by healthcare professionals, decision makers, governments, the general public, and other stakeholders including sectors outside of health. In particular, we argue for the use of 11 theory-based, evidence-supported communication strategies and practices. These methods range from leveraging social networks to making careful choices about the use of language, narratives, emotions, visual images, and statistics. Message testing with appropriate groups is also key. When implemented properly, these approaches are likely to improve the outcomes of climate change and health communication efforts.

Numeracy and the Motivational Mind: The Power of Numeric Self-efficacy

BACKGROUND

Objective numeracy appears to support better medical decisions and health outcomes. The more numerate generally understand and use numbers more and make better medical decisions, including more informed medical choices. Numeric self-efficacy-an aspect of subjective numeracy that is also known as numeric confidence-also relates to decision making via emotional reactions to and inferences from experienced difficulty with numbers and via persistence linked with numeric comprehension and healthier behaviors over time. Furthermore, it moderates the effects of objective numeracy on medical outcomes.

PURPOSE

We briefly review the numeracy and decision-making literature and then summarize more recent literature on 3 separable effects of numeric self-efficacy. Although dual-process theories can account for the generally superior decision making of the highly numerate, they have neglected effects of numeric self-efficacy. We discuss implications for medical decision-making (MDM) research and practice. Finally, we propose a modification to dual-process theories, adding a "motivational mind" to integrate the effects of numeric self-efficacy on decision-making processes (i.e., inferences from experienced difficulty with numbers, greater persistence, and greater use of objective-numeracy skills) important to high-quality MDM.

CONCLUSIONS

The power of numeric self-efficacy (confidence) has been little considered in MDM, but many medical decisions and behaviors require persistence to be successful over time (e.g., comprehension, medical-recommendation adherence). Including numeric self-efficacy in research and theorizing will increase understanding of MDM and promote development of better decision interventions.

HIGHLIGHTS

Research demonstrates that objective numeracy supports better medical decisions and health outcomes.The power of numeric self-efficacy (aka numeric confidence) has been little considered but appears critical to emotional reactions and inferences that patients and others make when encountering numeric information (e.g., in decision aids) and to greater persistence in medical decision-making tasks involving numbers.The present article proposes a novel modification to dual-process theory to account for newer findings and to describe how numeracy mechanisms can be better understood.Because being able to adapt interventions to improve medical decisions depends in part on having a good theory, future research should incorporate numeric self-efficacy into medical decision-making theories and interventions.

Verbal Descriptors of the Frequency of Side Effects: Implementation of EMA Recommendations in Patient Information Leaflets in Poland

Background

The European Medicines Agency (EMA) recommends a description of drug side effects based on the frequency format and the associated verbal description. Although the recommendations refer to English-speaking countries, in several non-English speaking states, official authorities have accepted the proposed recommendations on how the patient information leaflets should be designed for descriptions of side effect frequencies. The aim of the study was to examine how manufacturers of authorized medicines in Poland implement the EMA recommendations regarding the verbal descriptors of the frequency of side effects.

Methods

A qualitative study. As a first step, we identified which of the 150 pharmaceutical companies operating in Poland had the largest market share. Then, five manufacturers were selected at random from the list of the top fifteen drug manufacturers in Poland by market share of the pharmaceutical sector. Lists of medicinal products authorized for marketing in Poland were downloaded from manufacturers’ websites, and then five products from each manufacturer were selected based on random sampling. The study included only prescription medicines and excluded over-the-counter medicines and dietary supplements from the sample. Subsequently, for each of the 25 drugs relevant patient information leaflets were obtained from the manufacturers’ websites. We evaluated how information on the frequency of side effects was provided in each leaflet, including the use of EU-recommended terms (verbal descriptors such as "very common," "common," "uncommon," "rare," "very rare") and additional notes explaining their meanings.

Results

For all manufacturers, word labels of the frequencies of side effects selected for the study were the same but the additional notes explaining their meanings were different. There were various explanations of how to understand verbal descriptors of the frequency of side effects not only across different manufacturers but also across different medicines from one manufacturer.

Conclusions

There is no single standard in the Polish pharmaceutical industry for implementing the EMA recommendations into the written information about the frequency of side effects. The observed differences for an explanation of how to understand a given verbal term do not favor a uniform interpretation of the verbal frequency labels meaning by patients.

Rates and predictors of methotrexate-related adverse events in patients with early rheumatoid arthritis: results from a nationwide UK study

OBJECTIVES

To estimate prevalence rates and identify baseline predictors of adverse events (AEs) over the first year of treatment in patients with rheumatoid arthritis (RA) starting methotrexate (MTX).

METHODS

Data came from the UK Rheumatoid Arthritis Medication Study (RAMS), a prospective cohort of patients with RA starting MTX. This analysis included patients aged ≥ 18 years with physician diagnosed RA and symptom duration ≤ two years, who were commencing MTX for the first time. AEs were recorded by interviewing patients at six- and twelve-month follow-up visits. The period prevalence rates of AEs are reported for 0-6 months, 6-12 months, and 0-12 months of follow-up. The associations between baseline characteristics and AEs were assessed using multivariable logistic regression.

RESULTS

A total of 1069 patients were included in the analysis. Overall, 77.5% experienced at least one AE. The most commonly reported AEs were: gastrointestinal (42.0%), neurological (28.6%), mucocutaneous (26.0%), pulmonary (20.9%), elevated alanine transaminase (18.0%) and haematologic AEs (5.6%).Factors associated with increased odds of AEs were: women vs men (gastrointestinal, mucocutaneous, neurological), and alcohol consumption (nausea, alopecia, mucocutaneous). Older age, higher estimated Glomerular Filtration Rate (eGFR), and alcohol consumption were associated with less reporting of haematologic AEs.

CONCLUSIONS

AEs were common among patients over the first year of MTX, although most were not serious. Knowledge of the rates and factors associated with AEs occurrence are valuable when communicating risks prior to commencing MTX. This can help patients make informed decisions whether to start MTX, potentially increasing adherence to treatment.

Imprecision and Preferences in Interpretation of Verbal Probabilities in Health: a Systematic Review

INTRODUCTION

Many health providers and communicators who are concerned that patients will not understand numbers instead use verbal probabilities (e.g., terms such as "rare" or "common") to convey the gist of a health message.

OBJECTIVE

To assess patient interpretation of and preferences for verbal probability information in health contexts.

METHODS

We conducted a systematic review of literature published through September 2020. Original studies conducted in English with samples representative of lay populations were included if they assessed health-related information and elicited either (a) numerical estimates of verbal probability terms or (b) preferences for verbal vs. quantitative risk information.

RESULTS

We identified 33 original studies that referenced 145 verbal probability terms, 45 of which were included in at least two studies and 19 in three or more. Numerical interpretations of each verbal term were extremely variable. For example, average interpretations of the term "rare" ranged from 7 to 21%, and for "common," the range was 34 to 71%. In a subset of 9 studies, lay estimates of verbal probability terms were far higher than the standard interpretations established by the European Commission for drug labels. In 10 of 12 samples where preferences were elicited, most participants preferred numerical information, alone or in combination with verbal labels.

CONCLUSION

Numerical interpretation of verbal probabilities is extremely variable and does not correspond well to the numerical probabilities established by expert panels. Most patients appear to prefer quantitative risk information, alone or in combination with verbal labels. Health professionals should be aware that avoiding numeric information to describe risks may not match patient preferences, and that patients interpret verbal risk terms in a highly variable way.

Age differences in COVID-19 risk-taking, and the relationship with risk attitude and numerical ability

This study aimed to investigate age differences in risk-taking concerning the coronavirus pandemic, while disentangling the contribution of risk attitude, objective risk and numeracy. We tested (i) whether older and younger adults differed in taking coronavirus-related health risks, (ii) whether there are age differences in coronavirus risk, risk attitude and numerical ability and (iii) whether these age differences in coronavirus risk, attitude and numerical ability are related to coronavirus risk-taking. The study was observational, with measures presented to all participants in random order. A sample of 469 participants reported their coronavirus-related risk-taking behaviour, objective risk, risk attitude towards health and safety risks, numerical ability and risk perception. Our findings show that age was significantly related to coronavirus risk-taking, with younger adults taking more risk, and that this was partially mediated by higher numeracy, but not objective risk or risk attitude. Exploratory analyses suggest that risk perception for self and others partially mediated age differences in coronavirus risk-taking. The findings of this study may better our understanding of why age groups differ in their adoption of protective behaviours during a pandemic and contribute to the debate whether age differences in risk-taking occur due to decline in abilities or changes in risk attitude.

Layperson Views about the Design and Evaluation of Decision Aids: A Public Deliberation

PURPOSE

We carried out the first public deliberation to elicit lay input regarding guidelines for the design and evaluation of decision aids, focusing on the example of colorectal ("colon") cancer screening.

METHODS

A random, demographically stratified sample of 28 laypeople convened for 4 days, during which they were informed about key issues regarding colon cancer, screening tests, risk communication, and decision aids. Participants then deliberated in small and large group sessions about the following: 1) What information should be included in all decision aids for colon screening? 2) What risk information should be in a decision aid and how should risk information be presented? 3) What makes a screening decision a good one (reasonable or legitimate)? 4) What makes a decision aid and the advice it provides trustworthy? With the help of a trained facilitator, the deliberants formulated recommendations, and a vote was held on each to identify support and alternative views.

RESULTS

Twenty-one recommendations ("deliberative conclusions") were strongly supported. Some conclusions matched current recommendations, such as that decision aids should be available for use with and without providers present (conclusions 1-4) and should support informed choice (conclusion 9). Some conclusions differed from current recommendations, at least in emphasis-for example, that decision aids should disclose cost of screening (conclusion 11) and should be kept simple and understandable (conclusion 14). Deliberants recommended that decision aids should disclose the baseline risk of getting colon cancer (conclusions 15, 17).

LIMITATIONS

Single location and medical decision.

CONCLUSIONS

Guidelines for design of decision aids should consider putting a greater focus on disclosing cost and keeping decision aids simple, and they possibly should recommend disclosing less extensive amounts of quantitative information than currently recommended.

Current Best Practice for Presenting Probabilities in Patient Decision Aids: Fundamental Principles

BACKGROUND

Shared decision making requires evidence to be conveyed to the patient in a way they can easily understand and compare. Patient decision aids facilitate this process. This article reviews the current evidence for how to present numerical probabilities within patient decision aids.

METHODS

Following the 2013 review method, we assembled a group of 9 international experts on risk communication across Australia, Germany, the Netherlands, the United Kingdom, and the United States. We expanded the topics covered in the first review to reflect emerging areas of research. Groups of 2 to 3 authors reviewed the relevant literature based on their expertise and wrote each section before review by the full authorship team.

RESULTS

Of 10 topics identified, we present 5 fundamental issues in this article. Although some topics resulted in clear guidance (presenting the chance an event will occur, addressing numerical skills), other topics (context/evaluative labels, conveying uncertainty, risk over time) continue to have evolving knowledge bases. We recommend presenting numbers over a set time period with a clear denominator, using consistent formats between outcomes and interventions to enable unbiased comparisons, and interpreting the numbers for the reader to meet the needs of varying numeracy.

DISCUSSION

Understanding how different numerical formats can bias risk perception will help decision aid developers communicate risks in a balanced, comprehensible manner and avoid accidental "nudging" toward a particular option. Decisions between probability formats need to consider the available evidence and user skills. The review may be useful for other areas of science communication in which unbiased presentation of probabilities is important.

Preference for and understanding of graphs presenting health risk information. The role of age, health literacy, numeracy and graph literacy

OBJECTIVE

To investigate 1) younger (< 65) and older (> 65) adults' preference for and understanding of graph formats presenting risk information, and 2) the contribution of age, health literacy, numeracy and graph literacy in understanding information.

MATERIALS AND METHODS

To assess preferences, participants (n = 219 < 65 and n = 227>65) were exposed to a storyboard presenting six types of graphs. Understanding (verbatim and gist knowledge) was assessed in an experiment using a 6 (graphs: clock, bar, sparkplug, table, pie vs pictograph) by 2 (age: younger [<65] vs older [>65]) between-subjects design.

RESULTS

Most participants preferred clock, pie or bar chart. Pie was not well understood by both younger and older people, and clock not by older people. Bar was fairly well understood in both groups. Table yielded high knowledge scores, particularly in the older group. Lower age, higher numeracy and higher graph literacy contributed to higher verbatim knowledge scores. Higher health literacy and graph literacy were associated with higher gist knowledge.

DISCUSSION AND CONCLUSION

Although not the preferred format, tables are best understood by older adults.

PRACTICE IMPLICATIONS

Graph literacy skills are essential for both verbatim and gist understanding, and are important to take into account when developing risk information.

The Unintended Consequences of Adverse Event Information on Medicines' Risks and Label Content

Patients and prescribers need to be aware of adverse drug events to minimize the risk of their occurrence and the severity with which they appear. However, numerous studies show that being informed about adverse events can increase the possibility of suffering from them. Patients tend to overestimate the likelihood of experiencing the adverse events included in the label, and this can contribute to worsening the negative expectations which are at the root of the nocebo effect. In fact, patients can become anxious after reading the undesirable effects section of the leaflet and, in addition to suffering from the nocebo effect, might not take a drug they could benefit from due to the fear of experiencing adverse events. In addition, patients' attention can focus towards non-specific symptoms of daily living that can be misattributed to the drug and included in the labelling. This article proposes a number of suggestions to reduce the abovementioned unintended effects associated with labelling, namely, an increased focus on the excess risk of experiencing adverse events rather than crude incidence, using attribute framing to help patients to better understand the risk of experiencing adverse events, dividing the undesirable effect section of the leaflet into subsections according to the level of evidence supporting causal relationships and, finally, restricting the addition of non-specific adverse events that are also symptoms of daily living to only those where there is enough evidence to show they have been caused by the drug. More studies on how to minimize the nocebo effect induced by adverse event information should be performed, and these should be done in collaboration with health authorities, to reach a shared consensus on how to better present adverse event information in the label.

Decision experience in hyperchoice: the role of numeracy and age differences

Due to new technologies, a profusion of products is released onto store shelves and the Internet, resulting in a special choice condition termed hyperchoice. Past research on whether hyperchoice deteriorates decision experience is mixed. The present study hypothesizes the experience in the scenario of hyperchoice may be moderated by individual characteristics, including numeracy and age differences. A total of 116 older adults and 112 younger adults were recruited from Amazon Mechanical Turk. Along with the Rasch-based numeracy scale, each participant completed a consumer and a gamble choice task. In both tasks, the number of options being presented to participants was manipulated to create a hyperchoice condition (sixteen options) and a simple-choice condition (four options). Dependent variables were post-choice difficulty and satisfaction. Multiple regressions were performed with SPSS 24.0 to test the hypothesis. As a result, hyperchoice was related to greater decision difficulty in both choice tasks. Moreover, there was an interaction between numeracy and hyperchoice in the gamble task. Specifically, whereas higher numerate participants’ experienced difficulty and satisfaction were relatively stable between the two choice conditions, lower numerate participants experienced more difficulty and dissatisfaction in the hyperchoice condition than in the simple-choice condition. Additionally, compared to younger adults, older adults reported greater decision difficulty and lower decision satisfaction, regardless of choice condition. The study supported the notion that the specific effect of hyperchoice was moderated by individual factors. The study implied merchants should adopt strategies to ease decision experience and advocated for numeracy education.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Intuitive symbolic magnitude judgments and decision making under risk in adults

Performance on an intuitive symbolic number skills task-namely the number line estimation task-has previously been found to predict value function curvature in decision making under risk, using a cumulative prospect theory (CPT) model. However there has been no evidence of a similar relationship with the probability weighting function. This is surprising given that both number line estimation and probability weighting can be construed as involving proportion judgment, that is, involving estimating a number on a bounded scale based on its proportional relationship to the whole. In the present work, we re-evaluated the relationship between number line estimation and probability weighting through the lens of proportion judgment. Using a CPT model with a two-parameter probability weighting function, we found a double dissociation: number line estimation bias predicted probability weighting curvature while performance on a different number skills task, number comparison, predicted probability weighting elevation. Interestingly, while degree of bias was correlated across tasks, the direction of bias was not. The findings provide support for proportion judgment as a plausible account of the shape of the probability weighting function, and suggest directions for future work.

How is cervical cancer screening information communicated in UK websites? Cross-sectional analysis of content and quantitative presentation formats

OBJECTIVES

To investigate whether UK websites about cervical cancer screening targeted to the public include (1) information about benefits and risks of screening, possible screening results and cervical cancer statistics, (2) quantitative presentation formats recommended in the risk communication literature and (3) appeals for participation and/or informed decision-making.

DESIGN

Cross-sectional analysis of websites using a comprehensive checklist of information items on screening benefits, risks, possible results and cervical cancer statistics.

OUTCOME MEASURES

We recorded the number of websites that contained each of the information items, and the presentation format used for probabilistic information (no quantification provided, verbal quantifiers only, different types of numerical formats and/or graphs). We also recorded the number of websites containing appeals for participation and/or informed decision-making.

SETTING

Websites were identified through the most common Google search terms used in the UK to find information on cervical screening, according to GoogleTrends and a commercial internet-monitoring programme. Two additional websites were identified by the authors as relevant.

RESULTS

After applying exclusion criteria, 14 websites were evaluated, including websites of public and private health service providers, charities, a medical society and a pharmacy. The websites mentioned different benefits, risks of screening and possible results. However, specific content varied between websites. Probabilistic information was often presented using non-recommended formats, including relative risk reductions to express screening benefits, and verbal quantifiers without numbers to express risks. Appeals for participation were present in most websites, with almost half also mentioning informed decision-making.

CONCLUSIONS

UK websites about cervical cancer screening were generally balanced. However, benefits and risks were presented using different formats, potentially hindering comparisons. Additionally, recommendations from the literature to facilitate understanding of quantitative information and facilitate informed decisions were often not followed. Designing websites that adhere to existing recommendations may support informed screening uptake.

How Do Women Interpret the NHS Information Leaflet about Cervical Cancer Screening?

Background. Organized screening programs often rely on written materials to inform the public. In the United Kingdom, women invited for cervical cancer screening receive a leaflet from the National Health Service (NHS) to support screening decisions. However, information about screening may be too complex for people to understand, potentially hindering informed decision making. Objectives. We aimed to identify women's difficulties in interpreting the leaflet used in England and negative and positive responses to the leaflet. Methods. We used a sequential mixed-methods design involving 2 steps: cognitive think-aloud interviews (n = 20), followed by an England-wide survey (n = 602). Data were collected between June 2017 and December 2018, and participants included women aged 25 to 64 y with varying sociodemographics. Results. Interview results revealed misunderstandings concerning screening results, benefits, and additional tests and treatment, although participants tended to react positively to numerical information. Participants were often unfamiliar with the potential harms associated with screening (i.e., screening risks), key aspects of human papillomavirus, and complex terms (e.g., dyskaryosis). Survey results indicated that interpretation difficulties were common (M correct items = 12.5 of 23). Lower understanding was associated with lower educational level (β's >0.15, P's <0.001), lower numeracy scores (β = 0.36, P < 0.001), and nonwhite ethnicity (β = 0.10, P = 0.007). The leaflet was evaluated positively overall. Conclusions. Despite previous user testing of the leaflet, key information may be too complex for some recipients. As a consequence, they may struggle to make informed decisions about screening participation based on the information provided. We discuss implications for the improvement of communications about screening and decision support.

Improving Communication in Breast Cancer Treatment Consultation: Use of a Computer Test of Health Numeracy

Background: Communication of statistics and probability is challenging in the cancer care setting. The objectives of this study are to evaluate a novel approach to cancer communication through the use of a computer assessment of patient health numeracy. Methods: We conducted a pilot study of the Computer Adapted Test of Numeracy Understanding in Medicine Instrument (CAT-NUMi) before the cancer treatment consultation for women with stage 0-3 breast cancer. Patient outcomes included the interpersonal processes of care (IPC) and the decisional conflict scale. We evaluated clinician use of numeric information in the cancer consultation and assessed feasibility outcomes from the clinician and patient perspective. Results: Patient participants (n = 50) had a median (interquartile range) age of 51 years (46-61), 70% were English speaking, and 30% Spanish speaking. Decisional conflict was low with a mean (standard deviation [SD]) decisional conflict score of 17.4 (12.3). The lack of clarity score (range 1-5) on the IPC was low (mean, SD),1.70 (0.71), indicating clear communication. Clinicians more often used percentages in communicating prognosis among those with higher numeracy scores (median, range): high (2, 0-8), medium (1, 0-7), and low (0, 0-8); p = 0.04. The patient experience of taking the CAT-NUMi was rated as very good or excellent by 65%, fair by 33%, and poor by 2% of patients. Conclusion: Screening for health numeracy with a short computer-based test may be a feasible strategy to optimize clear communication in the cancer treatment consultation. Further studies are needed to evaluate this strategy across cancer treatment clinical settings and populations.

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

Objective:

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

Methods:

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

Results:

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

Conclusion:

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

Level of evidence:

IIb

Impact of including quantitative information in a decision aid for colorectal cancer screening: A randomized controlled trial

OBJECTIVE

Guidelines recommend that decision aids provide quantitative information about risks and benefits of available options. Impact of providing this information is unknown.

METHODS

Randomized trial comparing two decision aids about colorectal cancer (CRC) screening with colonoscopy or fecal immunochemical test (FIT). 688 primary care patients due for CRC screening viewed a decision aid that uses words only (Verbal arm) vs. one that provides quantitative information (Quantitative arm). Main outcomes included perceived CRC risk, intent to be screened, and test preference, measured before and after viewing decision aid, and screening uptake at six months. Analyses were performed with ANCOVA and logistic regression.

RESULTS

Compared to the Verbal arm, those in the Quantitative arm had a larger increase in intent to undergo FIT (p = 0.011) and were more likely to switch their preferred test from non-FIT to FIT (28% vs. 19%, p = .010). There were decreases in perceived risk in the Verbal Arm but not the Quantitative Arm (p = 0.004). There was no difference in screening uptake. Numeracy did not moderate any effects.

CONCLUSIONS

Quantitative information had relatively minor impact and no clearly negative effects, such as reducing uptake.

PRACTICE IMPLICATIONS

Quantitative information may be useful but not essential for patients viewing decision aids.

What benefits and harms are important for a decision about cervical screening? A study of the perspective of different subgroups of women

Background: In cervical screening programs, women typically receive information leaflets to support their decision about participation. However, these leaflets are often based on what experts consider important benefits and harms of screening and not what women themselves consider important to know. Objective: To identify which benefits and harms women consider important for making a decision about cervical screening. Design: Cross-sectional study. Setting and participants: Women from the Dutch target group of cervical screening (N=248; 30-60 years), recruited through an online access panel. Main variables studied: Perceived importance of different benefits and harms of cervical screening, assessed through two rating items ("How important is the information about [this harm/benefit] for your decision?" and "For me it is a [benefit/harm] that participating in the screening program leads to [the benefit/harm]"), and one ranking item ("Rank the information according to their importance for your own choice"). Results: Women overall considered the benefits of cervical screening more important than the harms or disadvantages. The most important harm according to women was the chance of false positive results (M=4.88; SD=1.75). Differences between those with lower and higher numeracy/health literacy were found regarding several aspects, e.g. for the chance of false positive results, the chance of false negative results, the chance of overtreatment. Discussion and conclusion: The results suggest that leaflets could include more explicit information about false positive results.

Effects of Probabilities, Adverse Outcomes, and Status Quo on Perceived Riskiness of Medications: Testing Explanatory Hypotheses Concerning Gist, Worry, and Numeracy

We tested predictions of fuzzy-trace theory that qualitative health status and gist representations (ordinal and categorical) of risks contribute to willingness to start medications, beyond effects of objective risk, emotion (worry), and numeracy. Adults in two experiments were given hypothetical scenarios based on actual medications, varying health status quo (acceptable or unacceptable), adverse event (pneumonia or cancer), and four levels of quantitative risk (from 1/100,000 to 1/100) between subjects. In both experiments, cancer and higher quantitative risk elicited greater worry and risk perceptions and reduced willingness to start a new medication. Willingness to start was also influenced by health status quo. After controlling for other variables, only status quo and gist representations consistently predicted willingness to start in both experiments. Results support an integrated approach to understanding and predicting perceptions of the risks of medications that encompasses numerical cognition, emotions (such as worry), and qualitative gist representations of medical information.

Potential negative impact of informing patients about medication side effects: a systematic review

Background Pharmacovigilance, as it is carried out primarily by healthcare professionals is more focused on being very objective in nature. Acknowledging the importance of the subjective experience of patients in pharmacovigilance was underpinned by its unique ability to bring about a more holistic understanding through the deep information unraveled by the patients. Medication safety-related information has to be shared with patients to allow them to be actively involved in their therapy and pharmacovigilance. Despite the advantages of sharing information, it stands to reasons whether sharing information related to possible side effects would negatively affect patients and impinge upon their treatment plan and process. Aim of the Review The purpose of this systematic review was to critically assess the potential negative impact of informing patients about medication side effects by written and/or oral information on medication compliance, occurrence/development of suspected side effects and clinical outcomes. Method A comprehensive search was conducted in PubMed, and Cochrane library to identify potential records between the year 1975 and 2017; then titles, abstracts, and full texts were screened using the inclusion criteria to filter out irrelevant studies. The data extraction, and the results were narratively synthesized and presented in tables. Results A total of 2012 articles were screened for inclusion, 32 full-text articles were assessed for eligibility and finally resulting in the inclusion of 17 randomized control studies which met the set criteria. Findings unraveled that the educational intervention did not result in increased occurrence/reporting of side effects in most of the evaluated studies; except 4 studies, and no significant impact on compliance to medications and negative clinical outcome was observed. Apprehension of negative events to medications were observed in two of the four studies which evaluated these parameters. Conclusion The present review did not find enough evidence to support the over concerns on the potential negative impact of sharing of information on the adverse effects to patients, though the influence could manifest as nocebo-effect. The various components and methods employed for this information sharing process can influence the potential impact of this activity. These concerns about the undesirable effects should not deter the active involvement of patients in pharmacovigilance activities. There is a definite need to have more studies in this area, where much of concern still does exist among the various stakeholders of drug safety information.

The effects of infographics and several quantitative versus qualitative formats for cardiovascular disease risk, including heart age, on people's risk understanding

OBJECTIVE

To study how comprehension of cardiovascular disease (CVD) risk is influenced by: (1) infographics about qualitative risk information, with/without risk numbers; (2) which qualitative risk dimension is emphasized; (3) heart age vs. traditional risk format.

METHODS

For aim 1, a 2 (infographics versus text) x 2 (risk number versus no risk number) between-subjects design was used. For aim 2, three pieces of information were tested within-subjects. Aim 3 used a simple comparison group. Participants (45-65 yrs old) were recruited through an online access panel; low educated people were oversampled. They received hypothetical risk information (20%/61yrs). Primary outcomes: recall, risk appraisals, subjective/objective risk comprehension.

SECONDARY OUTCOMES

behavioral intentions, information evaluations.

RESULTS

Infographics of qualitative risk dimensions negatively affected recall, subjective risk comprehension and information evaluations. No effect of type of risk dimension was found on risk perception. Heart age influenced recall, comprehension, evaluations and affective risk appraisals.

CONCLUSION

Infographics of hypothetical CVD risk information had detrimental effects on measures related to risk perception/comprehension, but effects were mainly seen in undereducated participants. Heart age influenced perceptions/comprehension of hypothetical risk in a way that seemed to support understanding.

PRACTICE IMPLICATIONS

Heart age seems a fruitful risk communication approach in disease risk calculators.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Combining risk communication strategies to simultaneously convey the risks of four diseases associated with physical inactivity to socio-demographically diverse populations

A single risk factor can increase the risk of developing multiple diseases, but most risk communication research has been conducted in the context of a single disease. We explored which combination of three recommended risk communication strategies is most effective in simultaneously conveying risk estimates of four diseases associated with physical inactivity: colon cancer, stroke, diabetes, and heart disease. Participants (N = 1161, 50% no college experience, 50% racial/ethnic minority) were shown hypothetical risk estimates for each of the four diseases. All four diseases were placed at varying heights on 1 of 12 vertical bar charts (i.e., "risk ladders") to indicate their respective probabilities. The risk ladders varied in a 2 (risk reduction information: present/absent) × 2 (numerical format: words/words and numbers) × 3 (social comparison information: none/somewhat higher than average/much higher than average) full factorial design. Participants were randomly assigned to view one of the risk ladders and then completed a questionnaire assessing message comprehension, message acceptance, physical activity-related risk and efficacy beliefs, and physical activity intentions. Higher message acceptance was found among (1) people who received risk reduction information versus those who did not (p = .01), and (2) people who did not receive social comparison information versus those told that they were at higher than average risk (p = .03). Further, absolute cognitive perceived risk of developing "any of the diseases shown in the picture" was higher among people who did not receive social comparison information (p = .03). No other main effects and only very few interactions with demographic variables were found. Combining recommended risk communication strategies did not improve or impair key cognitive or affective precursors of health behavior change. It might not be necessary to provide people with extensive information when communicating risk estimates of multiple diseases.

Potential patient harms from misinterpretation of publically reported surgical outcomes

OBJECTIVE

To determine how the general public interprets surgical complication rates presented from a publicly available online surgical-rating website.

SUBJECTS AND METHODS

An in-person electronic survey was administered at the local State Fair to a convenience sample. Participants were presented with a representative output from an online surgeon-rating website and were asked to choose from three statistically equivalent surgeons for a hypothetical medical decision. We then suggested that their insurance company would only cover one surgeon and probed their willingness to pay to switch surgeons for a small chance of lowering the risk of a complication (0.7%, 95% confidence interval [CI] -8.1% to 9.5%, P = 0.9). We quantified the characteristics of those willing to switch, the degree of misinterpretation, and the subsequent potential patient harms.

RESULTS

There were 343 completed responses. When presented with a hypothetical healthcare decision, most participants (n = 209, 61%) said they were willing to pay out-of-pocket expenses to switch to a statistically equivalent surgeon. Those who were willing to pay to switch surgeons were more likely to be older (odds ratio [OR] 1.02, 95% CI 1.01-1.03), poorer (OR 1.81, 95% CI 1.07-3.11), previously had cancer (OR 5.9, 95% CI 1.9-25), and misinterpreted the data (OR 3.03, 95% CI 1.87-4.96). Those who were willing to pay out-of-pocket expenses were more inaccurate in their estimation of surgeon complication rates (mean estimate 34.0% vs 8.9%, P < 0.001, correct rate = 3.6%), and on average were willing to pay $6 494 (95% CI 4 108-8 880).

CONCLUSION

Understanding of a publicly reported surgical-complication website is often prone to misinterpretation by the general population and may lead to patient harm from a financial aspect.

Correlates of healthcare and financial decision making among older adults without dementia

OBJECTIVE

Healthcare and financial decision making among older persons has been previously associated with cognition, health and financial literacy, and risk aversion; however, the manner by which these resources support decision making remains unclear, as past studies have not systematically investigated the pathways linking these resources with decision making. In the current study, we use path analysis to examine the direct and indirect pathways linking age, education, cognition, literacy, and risk aversion with decision making. We also decomposed literacy into its subcomponents, conceptual knowledge and numeracy, in order to examine their associations with decision making.

METHOD

Participants were 937 community-based older adults without dementia from the Rush Memory and Aging Project who completed a battery of cognitive tests and assessments of healthcare and financial decision making, health and financial literacy, and risk aversion.

RESULTS

Age and education exerted effects on decision making, but nearly two thirds of their effects were indirect, working mostly through cognition and literacy. Cognition exerted a strong direct effect on decision making and a robust indirect effect working primarily through literacy. Literacy also exerted a powerful direct effect on decision making, as did its subcomponents, conceptual knowledge and numeracy. The direct effect of risk aversion was comparatively weak.

CONCLUSIONS

In addition to cognition, health and financial literacy emerged as independent and primary correlates of healthcare and financial decision making. These findings suggest specific actions that might be taken to optimize healthcare and financial decision making and, by extension, improve health and well-being in advanced age. (PsycINFO Database Record

Communicating risk in dementia care: Survey of health and social care professionals

Supporting people to live at home in line with community care policies requires increasing attention to assessing, communicating and managing risks. There is a challenge in supporting client choices that include risk-taking while demonstrating professional accountability. Risk communication becomes increasingly important with the need to engage clients and families in meaningful shared decision-making. This presents particular challenges in dementia services. This survey of risk communication in dementia care was administered to all health and social care professionals in community dementia services in Northern Ireland: June-September 2016. Of 270 professionals, 70 questionnaires were fully completed, with 55 partial completions. Scores on the Berlin Numeracy Test plus Schwartz items was low-moderate (mean 2.79 out of 7). This study did not find a significant association between numeracy and accurate perceptions of risk likelihoods in practice-based scenarios. Although 86% reported using numeric information in practice (mostly from assessment tools), respondents rarely communicated themselves using numbers. As in other domains, participants' responses were widely variable on numeric estimates of verbal terms for likelihood. In relation to medication side effects, few participants provided responses that were concordant with those in the guidance of the European Union. The risks most commonly encountered in practice were (in rank order): falls, depression, poor personal hygiene, medicines mismanagement, leaving home unsupervised, financial mismanagement, malnutrition, swallowing difficulties, abuse from others, risks to others, home appliance accidents and refusing equipment. Respondents generally overestimated the likelihood of serious harmful events by approximately 10-fold (having a missing person's report filed with the police; having a fall resulting in hospitalisation) and by approximately double (being involved in a car accident; causing a home fire), and with wide variation between respondents. There is potential in icon arrays for communicating risks. Risk literacy among dementia care practitioners needs to be developed.

Effective Formats for Communicating Risks from Cigarette Smoke Chemicals

Objective

The US government requires the public display of information about toxic chemicals in cigarettes and smoke by brand in a way that is understandable and not misleading. We sought to identify risk communication formats that meet these goals.

Methods

We conducted 3 online experiments with US adult convenience samples (total N = 1866). Participants viewed a webpage displaying information about chemicals in the smoke of a cigarette brand. Experiment 1 varied the chemicals listed and format for their health effects. Experiments 2 and 3 varied the format of chemical quantities and presence/absence of a visual risk indicator. Outcomes were understandable (increasing knowledge) and not misleading (not reinforcing misperceptions).

Results

Information about chemicals and health effects increased knowledge of these topics by ~30% (p < .001) compared to no information. Quantity format and use of a risk indicator generally did not affect knowledge. The proportion of participants misled ranged from 0% to 92%, depending on measure. Findings indicated 52% would use a website to search for safer cigarettes. Risk communication formats did little to reduce being misled.

Conclusions

Some risk communication formats successfully increased knowledge of chemicals and health effects. However, the formats did little to reduce the proportion of people misled.

Investigating the Heterogeneity in Women's Preferences for Breast Screening: Does the Communication of Risk Matter?

BACKGROUND

The relative benefits and risks of screening programs for breast cancer have been extensively debated.

OBJECTIVES

To quantify and investigate heterogeneity in women's preferences for the benefits and risks of a national breast screening program (NBSP) and to understand the effect of risk communication format on these preferences.

METHODS

An online discrete choice experiment survey was designed to elicit preferences from female members of the public for an NBSP described by three attributes (probability of detecting a cancer, risk of unnecessary follow-up, and out-of-pocket screening costs). Survey respondents were randomized to one of two surveys, presenting risk either as percentages only or as icon arrays and percentages. Respondents were required to choose between two hypothetical NBSPs or no screening in 11 choice sets generated using a Bayesian D-efficient design. The trade-offs women made were analyzed using heteroskedastic conditional logit and scale-adjusted latent class models.

RESULTS

A total of 1018 women completed the discrete choice experiment (percentages-only version = 507; icon arrays and percentages version = 511). The results of the heteroskedastic conditional logit model suggested that, on average, women were willing-to-accept 1.72 (confidence interval 1.47-1.97) additional unnecessary follow-ups and willing-to-pay £79.17 (confidence interval £66.98-£91.35) for an additional cancer detected per 100 women screened. Latent class analysis indicated substantial heterogeneity in preferences with six latent classes and three scale classes providing the best fit. The risk communication format received was not a predictor of scale class or preference class membership.

CONCLUSIONS

Most women were willing to trade-off the benefits and risks of screening, but decision makers seeking to improve uptake should consider the disparate needs of women when configuring services.

Obstetricians and gynecologists' opinions about the Affordable Care Act and their expectations about how it will impact their practice

As the primary healthcare providers for women, obstetrician-gynecologists' (OB/GYNs) experiences with and opinions about the Affordable Care Act (ACA) are important to understand. An online survey was sent to 1000 randomly selected OB/GYNs who were members of the American College of Obstetricians and Gynecologists (ACOG) in 2014. Of those, 523 opened the email and 163 responded (31% participation rate). Data were collected August 2014-October 2014 and analyzed in 2015-2016. Support for the ACA was widely distributed, with the largest subset of the sample (about 21%) in the "very supportive" category. Opinions of the ACA were more supportive than they were in a previous study conducted in 2011. When given a list of possible positive and negative impacts of the ACA on their practice, roughly 1 in 5 reported that the ACA increased work-related stress (28%), decreased total profits (22%), and lowered career satisfaction (22%), whereas 8.6% reported that the ACA increased quality of care. Around half of the providers thought that their newly insured patients would have the same level of education (42%) and numeric ability (55%) as their current patients. Almost all respondents (87%) indicated that it is at least slightly important for patients to understand their numeric likelihood of risk (such as numeric risk information from medications, treatments, and other procedures you might prescribe) -31% think it is extremely important and 44% think it is moderately important.

Measuring the health literacy of the Upper Midwest

Objectives

Health literacy—the ability to obtain, process, and understand basic health information—is a major determinant of an individual’s overall health and health care utilization. In this project, the authors examined predictors of health literacy levels, including numeracy and graphic literacy, among an adult population in the Upper Midwest.

Methods

The research was conducted at the Minnesota State Fair. Three previously validated scales were used to assess health literacy: Newest Vital Sign, the General Health Numeracy Test, and questions from Galesic and Garcia-Retamero’s Graph Literacy Scale. Demographic information—such as age, educational attainment, zip code, and other potential predictors and modifiers—was collected. Multivariate linear regression was conducted to examine the independent effects of educational attainment, race, ethnicity, gender, and rural or urban location on overall health literacy and scores on each of the individual instruments.

Results

A total of 353 Upper Midwest residents completed the survey, with the majority being white, college-educated, and from an urban area. Having a graduate or professional degree or being under the age of 21 were associated with increased health literacy scores, while having a high school diploma or some high school education, being Asian American, or being American Indian/Alaska Native were associated with lower health literacy scores.

Conclusion

Advanced health literacy skills, including the ability to calculate and compare information, were problematic even in well-educated populations. Understanding numerical and graphical information was found to be particularly difficult, and more research is needed to understand these deficits and how best to address them.

The effect of public reporting presentation on patients' decision making: An experimental survey in Yunan Province, China

Public reporting of comparative performance information (PRCPI) influence patients' decision making and optimal presentation of PRCPI is urgently required for successful patients' engagement and quality improvement. This study was to explore the presentation of PRCPI impacting on consumers' decision making.This research applied a controlled design, with participants allocated randomly to 6 groups, and a total of 515 participants were recruited in Yunnan province. Five aspects of PRCPI presentations were evaluated, including display (star rating vs numeric information), and whether information was simplified, interpreted, overload, or ranked. Participants were stimulated to identify the best or worst physicians with a hypothetical scenario. Main outcome measures were correct choices rate of best/worst physicians, indicating participants fully understood and correctly used PRCPI. χ test and logistic regression were applied to assess the effect between different presentations on consumers' decision making.The correct choices rate is only 48.93%. Compared with star rating, numerical information helped participants differentiate low-performance physicians (OR = 2.573, P = .029), including low-performance physicians in antibiotics (OR = 2.974, P = .031) and low-performance physicians in injections (OR = 2.369, P = .035). Disordered information impeded participants to fully understand and correctly use PRCPI (OR = 0.519, P = .041). The effect was mainly reflected on participants differentiating low-performance physicians (OR = 0.491, P = .039) and low-performance physicians in injections (OR = 0.440, P = .016). Other aspects of PRCPI showed nonsignificant impacts on consumers' decision making.Presentation, including information display and ranking, can influence patients' correct usage of PRCPI and the effect was mainly observed when the patients were identifying poorly performing physicians. The present study demonstrated that numerical and ranked PRCPI, combined with sufficient patient education, could be most effective to facilitate patient use.

Utilization of Continuous "Spinners" to Communicate Risk

BACKGROUND

As patients become more involved in their medical care, they must consider the specific probabilities of both positive and negative outcomes associated with different treatments. Patients who are low in numeracy may be at a disadvantage when making these decisions. This study examined the use of a "spinner" to present probabilistic information compared to a numerical format and icon array.

DESIGN

Subjects ( n = 151) were asked to imagine they suffered from chronic back pain. Two equally effective medications, each with a different incidence of rare and common side effects, were described. Subjects were randomized to 1 of 3 risk presentation formats: numeric only, numeric with icon arrays, or numeric with spinners, and answered questions regarding their risk knowledge, medication preference, and how much they liked the presentation format.

RESULTS

Compared with the numeric only format, both the spinner and icon array increased risk knowledge and were rated more likeable by subjects. Subjects viewing the spinner format were also more likely to prefer the pill with the lowest side-effect burden.

LIMITATIONS

The relatively small size, convenience sample, and hypothetical scenario were limitations of this study.

CONCLUSIONS

The use of continuous spinners presents a new approach for communicating risk to patients that may aid in their decision making.

The effect of counseling on willingness to use a hypothetical medication and perceptions of medication safety

BACKGROUND

Poor medication adherence is an ongoing issue, and contributes to increased hospitalizations and healthcare costs. Although most adverse effects are rare, the perceived risk of adverse effects may contribute to low adherence rates.

OBJECTIVES

The objective of this study was to determine how adverse effect likelihood and pharmacist counseling on adverse effect prevention affects individuals': (1) willingness to use a hypothetical medication and (2) perceptions of medication safety.

METHODS

This study used a 3 × 3 experimental design. Participants (n = 601) viewed a hypothetical scenario asking them to imagine being prescribed an anti-asthma medication that could cause fungal infections of the throat. Participants were randomized to 1 of 9 scenarios that differed on: probability of developing an infection (5%, 20%, no probability mentioned) and whether they were told how to reduce the risk of infection (no prevention strategy discussed, prevention strategy discussed, prevention strategy discussed with explanation for how it works). Participants were recruited through Amazon Mechanical Turk.

RESULTS

Participants were less willing to take the medication (F = 12.86, p < 0.0001) and considered it less safe (F = 13.11, p < 0.0001) when the probability of fungal infection was presented as 20% compared to 5% or when no probability information was given. Participants were more willing to take the medication (F = 11.78, p < 0.0001) and considered it safer (F = 11.17, p < 0.0001) when a prevention strategy was given. Finally, there was a non-statistically significant interaction between the probability and prevention strategy information such that provision of prevention information reduced the effect of variation in the probability of infection on both willingness to use the medication and perceived medication safety.

CONCLUSIONS

Optimal risk communication involves more than informing patients about possible adverse effects. Pharmacists could potentially improve patient acceptance of therapeutic recommendations, and allay medication safety concerns, by counseling about strategies patients can implement to reduce the perceived risk of adverse effects.

Medication Risk Communication in Rheumatology: Where Are We and Where Do We Go from Here?

This paper reviews findings from recent research examining issues related to the risk communication process within the context of rheumatologic conditions. Five specific questions are addressed. First, to what extent do patients with rheumatic disorders exhibit adequate knowledge relevant to disease and medication risks and risk management? Second, what sources do patients use when attempting to find information about disease and medication risks and risk management? Third, what types of information about disease and medication risks and risk management do rheumatologists provide during routine office visits. Fourth, what governmental regulations attempt to increase consumer access to information about medication risks and risk management? Finally, what other educational resources are available to facilitate patient-provider communication concerning disease and medication risks and risk management? The findings reported identify gaps in patient knowledge concerning medication risks and risk management, highlight areas for improvement, and identify resources that may enhance medication risk communication.

Recurrence risk perception and quality of life following treatment of breast cancer

PURPOSE

Little is known about different ways of assessing risk of distant recurrence following cancer treatment (e.g., numeric or descriptive). We sought to evaluate the association between overestimation of risk of distant recurrence of breast cancer and key patient-reported outcomes, including quality of life and worry.

METHODS

We surveyed a weighted random sample of newly diagnosed patients with early-stage breast cancer identified through SEER registries of Los Angeles County & Georgia (2013-14) ~2 months after surgery (N = 2578, RR = 71%). Actual 10-year risk of distant recurrence after treatment was based on clinical factors for women with DCIS & low-risk invasive cancer (Stg 1A, ER+, HER2-, Gr 1-2). Women reported perceptions of their risk numerically (0-100%), with values ≥10% for DCIS & ≥20% for invasive considered overestimates. Perceptions of "moderate, high or very high" risk were considered descriptive overestimates. In our analytic sample (N = 927), we assessed factors correlated with both types of overestimation and report multivariable associations between overestimation and QoL (PROMIS physical & mental health) and frequent worry.

RESULTS

30.4% of women substantially overestimated their risk of distant recurrence numerically and 14.7% descriptively. Few factors other than family history were significantly associated with either type of overestimation. Both types of overestimation were significantly associated with frequent worry, and lower QoL.

CONCLUSIONS

Ensuring understanding of systemic recurrence risk, particularly among patients with favorable prognosis, is important. Better risk communication by clinicians may translate to better risk comprehension among patients and to improvements in QoL.

Communicating information concerning potential medication harms and benefits: What gist do numbers convey?

OBJECTIVES

Fuzzy trace theory was used to examine the effect of information concerning medication benefits and side-effects on willingness to use a hypothetical medication.

METHODS

Participants (N=999) were recruited via Amazon Mechanical Turk. Using 3×5 experimental research design, each participant viewed information about medication side effects in 1 of 3 formats and information about medication benefits in 1 of 5 formats. For both side-effects and benefits, one format presented only non-numeric information and the remaining formats presented numeric information.

RESULTS

Individuals in the non-numeric side-effect condition were less likely to take the medication than those in the numeric conditions (p<0.0001). In contrast, individuals in the non-numeric benefit condition were more likely to take the medication than those in the numeric conditions (p<0.0001).

CONCLUSIONS

Our findings suggest that non-numeric side-effect information conveys the gist that the medication can cause harm, decreasing willingness to use the medication; whereas non-numeric benefit information has the opposite effect.

PRACTICE IMPLICATIONS

Presenting side-effect and benefit information in non-numeric format appears to bias decision-making in opposite directions. Providing numeric information for both benefits and side-effects may enhance decision-making. However, providing numeric benefit information may decrease adherence, creating ethical dilemmas for providers.

Reporting Adverse Drug Reactions in Product Labels

Product labels are intended to provide health care professionals with clear and concise prescribing information that will enhance the safe and effective use of drug products. In this manuscript, we offer suggestions to improve product labels. First, we recommend that product labels that include comparator data be changed to include adjusted incidence proportions (or adjusted incidence rates when needed and appropriate) for adverse drug reactions that are somewhat common. Second, we believe that including comparator incidence in product labels is a good practice, as it gives health care providers and patients appropriate information to put the absolute risks in perspective. Finally, we recommend changing the practice of reporting extremely rare events based on the "Rule of 3" in the Summary of Product Characteristics in Europe. We recommend that these adverse drug reactions be put in a separate table from other adverse drug reactions with a note that it is difficult to reliably estimate their incidences. In exceptional circumstances, it may be possible to present an estimate of their incidence based on postmarketing data. We believe the proposed changes could help product labels to better reflect the risk of a drug relative to a comparator.

Variation in adverse drug reactions listed in product information for antidepressants and anticonvulsants, between the USA and Europe: a comparison review of paired regulatory documents

OBJECTIVE

To compare consistency of adverse drug reaction (ADR) data in publicly available product information documents for brand drugs, between the USA and Europe. To assess the usefulness of information for prescribers and patients.

DESIGN

A comparison review of product information documents for antidepressants and anticonvulsants concurrently marketed by the same pharmaceutical company in the USA and Europe.

SETTING

For each drug, data were extracted from the US Product Inserts and the European Summary of Product Characteristics documents between 09/2013 and 01/2015.

PARTICIPANTS

Individuals contributing ADR information to product information documents.

MAIN OUTCOMES MEASURES

All ADRs reported in product information sections 5 and 6 (USA), and 4·4 and 4·8 (Europe).

RESULTS

Twelve brand drugs--24 paired documents--were included. On average, there were 77 more ADRs reported in the USA compared with in the European product information document, with a median number of 201 ADRs (range: 65-425) and 114 (range: 56-265), respectively. More product information documents in the USA reported information on the source of evidence (10 vs 5) and risk (9 vs 5) for greater than 80% of ADRs included in the document. There was negligible information included regarding duration, severity, reversibility or recurrence of ADRs. On average, only 29% of ADR terms were reported in both paired documents.

CONCLUSIONS

Product information documents contained a large number of ADRs, but lacked contextual data and information important to patients and prescribers, such as duration, severity and reversibility. The ADR profile was found to be inconsistently reported between the USA and Europe, for the same drug. Identifying, selecting, summarising and presenting multidimensional harm data should be underpinned by practical evidence-based guidelines. In order for prescribers to provide considered risk-benefit advice across competing drug therapies to patients, they need access to comprehensible and reliable ADR information.

Effective presentation of health care performance information for consumer decision making: A systematic review

OBJECTIVE

This systematic review synthesizes what is known about the effective presentation of health care performance information for consumer decision making.

METHODS

Six databases were searched for articles published in English between September 2003 and April 2014. Experimental studies comparing consumers' responses to performance information when one or more presentation feature was altered were included. A thematic analysis was performed and practical guidelines derived.

RESULTS

All 31 articles retained, the majority which tested responses to various presentations of health care cost and/or quality information, found that consumers better understand and make more informed choices when the information display is less complex. Simplification can be achieved by reducing the quantity of choices, displaying results in a positive direction, using non-technical language and evaluative elements, and situating results in common contexts.

CONCLUSION

While findings do not offer a prescriptive design, this synthesis informs approaches to enhancing the presentation of health care performance information and areas that merit additional research.

PRACTICE IMPLICATIONS

Guidelines derived from these results can be used to enhance health care performance reports for consumer decision making including using recognizable, evaluative graphics and customizable formats, limiting the amount of information presented, and testing presentation formats prior to use.