Presenting research risks and benefits to parents: does format matter?

Numerical versus graphical aids for decision-making in a multi-cue signal identification task

Decision aids are commonly used in tactical decision-making environments to help humans integrate base-rate and multi-cue information. However, it is important that users appropriately trust and rely on aids. Decision aids can be presented in many ways, but the literature lacks clarity over the conditions surrounding their effectiveness. This research aims to determine whether a numerical or graphical aid more effectively supports human performance, and explores the relationships between aid presentation, trust, and workload. Participants (N = 30) completed a signal-identification task that required integration of readings from a set of three dynamic gauges. Participants experienced three conditions: unaided, using a numerical aid, and using a graphical aid. The aids combined gauge and base-rate information in a statistically-optimal fashion. Participants also indicated how much they trusted the system and how hard they worked during the task. Analyses explored the impact of aid condition on sensitivity, response bias, response time, trust, and workload. Both the numerical and graphical aids produced significant increases in sensitivity and trust, and significant decreases in workload in comparison to the unaided condition. The difference in response time between the graphical and unaided conditions approached significance, with participants responding faster using the graphical aid without decrements in sensitivity. Significant interactions between aid and signal type indicated that both aided conditions promoted faster responding to non-hostile signals, with larger mean differences in the graphical aid condition. Practically, graphical aids in which suggestions are more salient to users may promote faster responding in tactical environments, with negligible cost of accuracy.

Are interactive and tailored data visualizations effective in promoting flu vaccination among the elderly? Evidence from a randomized experiment

OBJECTIVE

Although interactive data visualizations are increasingly popular for health communication, it remains to be seen what design features improve psychological and behavioral targets. This study experimentally tested how interactivity and descriptive titles may influence perceived susceptibility to the flu, intention to vaccinate, and information recall, particularly among older adults.

MATERIALS AND METHODS

We created data visualization dashboards on flu vaccinations, tested in a 2 (explanatory text vs none) × 3 (interactive + tailored, static + tailored, static + nontailored) + questionnaire-only control randomized between-participant online experiment (N   = 1378).

RESULTS

The flu dashboards significantly increased perceived susceptibility to the flu compared to the control: static+nontailored dashboard, b = 0.14, P = .049; static-tailored, b = 0.16, P = .028; and interactive+tailored, b = 0.15, P = .039. Interactive dashboards potentially decreased recall particularly among the elderly (moderation by age: b = -0.03, P = .073). The benefits of descriptive text on recall were larger among the elderly (interaction effects: b = 0.03, P = .025).

DISCUSSION

Interactive dashboards with complex statistics and limited textual information are widely used in health and public health but may be suboptimal for older individuals. We experimentally showed that adding explanatory text on visualizations can increase information recall particularly for older populations.

CONCLUSION

We did not find evidence to support the effectiveness of interactivity in data visualizations on flu vaccination intentions or on information recall. Future research should examine what types of explanatory text can best support improved health outcomes and intentions in other contexts. Practitioners should consider whether interactivity is optimal in data visualization dashboards for their populations.

Probability and informed consent

In this paper, we illustrate some serious difficulties involved in conveying information about uncertain risks and securing informed consent for risky interventions in a clinical setting. We argue that in order to secure informed consent for a medical intervention, physicians often need to do more than report a bare, numerical probability value. When probabilities are given, securing informed consent generally requires communicating how probability expressions are to be interpreted and communicating something about the quality and quantity of the evidence for the probabilities reported. Patients may also require guidance on how probability claims may or may not be relevant to their decisions, and physicians should be ready to help patients understand these issues.

Virtual Reality for Patient Education about Hypertension: A Randomized Pilot Study

BACKGROUND

Hypertension challenges arise in part from poor adherence due to inadequate patient education. VR offers immersive learning to improve hypertension knowledge.

OBJECTIVE

To compare VR education with traditional verbal education to improve hypertension knowledge.

METHODS

In this randomised trial, 182 patients with hypertension were assigned to receive either traditional physician-led education (n = 88) or VR education (n = 94) with equivalent content. The VR group experienced a 3D video using Oculus Quest 2 headsets. Knowledge was assessed post-intervention using a 29-item questionnaire. The primary outcome was the objective score. Subjective satisfaction and responder characteristics were secondary outcomes.

RESULTS

Median objective scores were significantly higher for VR (14, IQR 3) versus traditional education (10, IQR 5), p < 0.001, indicating superior hypertension knowledge acquisition with VR. Subjective satisfaction was high in both groups. Participants were categorized into low (first quartile) and medium-high (second to fourth quartiles) responders based on their scores. Low responders had a significantly higher prevalence of older women than medium-high responders (57% vs. 40% female, p = 0.024; 68 vs. 65 years), p = 0.036).

CONCLUSIONS

VR outperforms traditional education. Tailoring to groups such as older women can optimise learning.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

HIGHLIGHTS

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

The Lure of Beauty: People Select Representations of Statistical Information Largely Based on Attractiveness, Not Comprehensibility

OBJECTIVE

People differ in whether they understand graphical or numerical representations of statistical information better. However, assessing these skills is often not feasible when deciding which representation to select or use. This study investigates whether people choose the representation they understand better, whether this choice can improve risk comprehension, and whether results are influenced by participants' skills (graph literacy and numeracy).

METHODS

In an experiment, 160 participants received information about the benefits and side effects of painkillers using either a numerical or a graphical representation. In the "no choice" condition, the representation was randomly assigned to each participant. In the "choice" condition, participants could select the representation they would like to receive. The study assessed gist and verbatim knowledge (immediate comprehension and recall), accessibility of the information, attractiveness of the representation, as well as graph literacy and numeracy.

RESULTS

In the "choice" condition, most (62.5%) chose the graphical format, yet there was no difference in graph literacy or numeracy (nor age or gender) between people who chose the graphical or the numerical format. Whereas choice slightly increased verbatim knowledge, it did not improve gist or overall knowledge compared with random assignment. However, participants who chose a representation rated the representation as more attractive, and those who chose graphs rated them as more accessible than those without a choice.

LIMITATIONS

The sample consisted of highly educated undergraduate students with higher graph literacy than the general population. The task was inconsequential for participants in terms of their health.

CONCLUSIONS

When people can choose between representations, they fail to identify what they comprehend better but largely base that choice on how attractive the representation is for them.

HIGHLIGHTS

People differ systematically in whether they understand graphical or numerical representations of statistical information better. However, assessing these underlying skills to get the right representation to the right people is not feasible in practice. A simple and efficient method to achieve this could be to let people choose among representations themselves.However, our study showed that allowing participants to choose a representation (numerical v. graphical) did not improve overall or gist knowledge compared with determining the representation randomly, even though it did slightly improve verbatim knowledge.Rather, participants largely chose the representation they found more attractive. Most preferred the graphical representation, including those with low graph literacy.It would therefore be important to develop graphical representations that are not only attractive but also comprehensible even for people with low graph literacy.

Designing for patient decision-making: Design challenges generated by patients with atrial fibrillation during evaluation of a decision aid prototype

Shared decision-making (SDM) empowers patients and care teams to determine the best treatment plan in alignment with the patient's preferences and goals. Decision aids are proven tools to support high quality SDM. Patients with atrial fibrillation (AF), the most common cardiac arrhythmia, struggle to identify optimal rhythm and symptom management strategies and could benefit from a decision aid. In this Brief Research Report, we describe the development and preliminary evaluation of an interactive decision-making aid for patients with AF. We employed an iterative, user-centered design method to develop prototypes of the decision aid. Here, we describe multiple iterations of the decision aid, informed by the literature, expert feedback, and mixed-methods design sessions with AF patients. Results highlight unique design requirements for this population, but overall indicate that an interactive decision aid with visualizations has the potential to assist patients in making AF treatment decisions. Future work can build upon these design requirements to create and evaluate a decision aid for AF rhythm and symptom management.

Comparison Conundrum and the Chamber of Visualizations: An Exploration of How Language Influences Visual Design

The language for expressing comparisons is often complex and nuanced, making supporting natural language-based visual comparison a non-trivial task. To better understand how people reason about comparisons in natural language, we explore a design space of utterances for comparing data entities. We identified different parameters of comparison utterances that indicate what is being compared (i.e., data variables and attributes) as well as how these parameters are specified (i.e., explicitly or implicitly). We conducted a user study with sixteen data visualization experts and non-experts to investigate how they designed visualizations for comparisons in our design space. Based on the rich set of visualization techniques observed, we extracted key design features from the visualizations and synthesized them into a subset of sixteen representative visualization designs. We then conducted a follow-up study to validate user preferences for the sixteen representative visualizations corresponding to utterances in our design space. Findings from these studies suggest guidelines and future directions for designing natural language interfaces and recommendation tools to better support natural language comparisons in visual analytics.

Investigating the presentation of uncertainty in an icon array: A randomized trial

BACKGROUND

Clinicians are often advised to use pictographs to communicate risk, but whether they offer benefits when communicating risk imprecision (e.g., 65%-79%) is unknown.

PURPOSE

To test whether any of three approaches to visualizing imprecision would more effectively communicate breast and ovarian cancer risk for BRCA1 pathogenic variant carriers.

METHODS

1,300 UK residents were presented with a genetic report with information about BRCA1-related risks, with random assignment to one of four formats: no visualization (text alone), or a pictograph using shaded icons, a gradient, or arrows marking range endpoints. We also tested pictographs in two layouts. Analysis of variance (ANOVA) and regression was employed.

RESULTS

There was no effect of format. Participants shown pictographs vs. text alone had better uptake of breast cancer risk messages (p < .05, η ² = 0.003). Pictographs facilitated memory for the specific amount of risk (p < 0.001, η ² = 0.019), as did the tabular layout. Individuals not having completed upper secondary education may benefit most.

CONCLUSIONS

We found weak evidence in favor of using simple pictographs with ranges to communicate BRCA risk (versus text alone), and of the tabular layout.

INNOVATION

Testing different ways of communicating imprecision within pictographs is a novel and promising line of research.

Communicating With Diverse Patients About Participating in a Biobank: A Randomized Multisite Study Comparing Electronic and Face-to-Face Informed Consent Processes

Some individuals' understanding of informed consent (IC) information may improve with electronic delivery, but others may benefit from face-to-face (F2F). This randomized, multisite study explores how individuals from diverse backgrounds understand electronic IC documents versus F2F, their confidence in understanding, and enrollment in research. A total of 501 patients at two U.S. biobanks with diverse populations participated. There were no overall differences between electronic and F2F understanding, but F2F predicted higher confidence in understanding and enrollment. Ethnicity and a higher educational level predicted higher understanding and confidence. Study findings suggest that electronic consent may lead to better understanding for non-Hispanic patients of higher socioeconomic status. F2F processes may lead to better understanding and higher enrollment of patients from Hispanic and lower socioeconomic levels. Researchers should carefully consider how they implement electronic IC processes and whether to maintain an F2F process to better address the needs and limitations of some populations.

Visual Arrangements of Bar Charts Influence Comparisons in Viewer Takeaways

Well-designed data visualizations can lead to more powerful and intuitive processing by a viewer. To help a viewer intuitively compare values to quickly generate key takeaways, visualization designers can manipulate how data values are arranged in a chart to afford particular comparisons. Using simple bar charts as a case study, we empirically tested the comparison affordances of four common arrangements: vertically juxtaposed, horizontally juxtaposed, overlaid, and stacked. We asked participants to type out what patterns they perceived in a chart and we coded their takeaways into types of comparisons. In a second study, we asked data visualization design experts to predict which arrangement they would use to afford each type of comparison and found both alignments and mismatches with our findings. These results provide concrete guidelines for how both human designers and automatic chart recommendation systems can make visualizations that help viewers extract the "right" takeaway.

The effects of quality of evidence communication on perception of public health information about COVID-19: Two randomised controlled trials

BACKGROUND

The quality of evidence about the effectiveness of non-pharmaceutical health interventions is often low, but little is known about the effects of communicating indications of evidence quality to the public.

METHODS

In two blinded, randomised, controlled, online experiments, US participants (total n = 2140) were shown one of several versions of an infographic illustrating the effectiveness of eye protection in reducing COVID-19 transmission. Their trust in the information, understanding, feelings of effectiveness of eye protection, and the likelihood of them adopting it were measured.

FINDINGS

Compared to those given no quality cues, participants who were told the quality of the evidence on eye protection was 'low', rated the evidence less trustworthy (p = .001, d = 0.25), and rated it as subjectively less effective (p = .018, d = 0.19). The same effects emerged compared to those who were told the quality of the evidence was 'high', and in one of the two studies, those shown 'low' quality of evidence said they were less likely to use eye protection (p = .005, d = 0.18). Participants who were told the quality of the evidence was 'high' showed no statistically significant differences on these measures compared to those given no information about evidence quality.

CONCLUSIONS

Without quality of evidence cues, participants responded to the evidence about the public health intervention as if it was high quality and this affected their subjective perceptions of its efficacy and trust in the provided information. This raises the ethical dilemma of weighing the importance of transparently stating when the evidence base is actually low quality against evidence that providing such information can decrease trust, perception of intervention efficacy, and likelihood of adopting it.

Effectiveness of pictographs in improving patient education outcomes: a systematic review

The objective of this review was to investigate process of pictograph development and the effectiveness of pictographs in patient education. We conducted searches in Medline/PubMed, CINAHL with full text, PsycInfo, ERIC and Cochrane Library with keywords: (pictograph or pictorial) AND (patient education) NOT (children or adolescent or youth or child or teenagers). After excluding manuscripts that did not meet inclusion criteria, 56 articles were included between the time of the last review on this topic (January 2008) and May 2019. There are 17 descriptive studies, 27 randomized control trial studies, 9 quasi-experimental studies and 2 unique literatures in the systematic review. Major goals of the studies are pictograph development or validation. The majority of manuscripts (n = 48) supported the approach. However, six studies did not find significant differences in the outcome. Differences in patient population, pictograph designs and author-developed outcome measurements made it difficult to compare the findings. There is a lack of evidence on validating information outcome measurements. This review demonstrated that implementing pictographs into patient education is a promising approach for better information understanding and health management. Pictographic interventions need to be carefully developed and validated with both the targeted patient population and the clinical experts.

Parents'/Patients' Perception of the Informed Consent Process and Surgeons Accountability in Corrective Surgery for Adolescent Idiopathic Scoliosis: A Prospective Study

STUDY DESIGN

Prospective study.

OBJECTIVE

To determine the parents'/patients' perception on the informed consent process prior to posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) patients.

SUMMARY OF BACKGROUND DATA

Understanding parents/patients perspective on the process is important in order to achieve the goal of consent and prevent medico-legal implications.

METHODS

Fifty AIS patients operated between August 2019 and November 2019 were prospectively recruited. Parents'/patients' perceptions on three sections were evaluated: the process of the informed consent, specific operative risk which they were most concerned with and the accountability of surgeons for the surgical risks. These data were ranked and scored using a 5-point Likert Scale. Preferences were reported in mean and standard deviation. Differences in terms of preferences were studied using One-way analysis of variance (ANOVA) analysis and deemed significant when P < 0.05.

RESULTS

There were 30 females (60.0%) and 20 males (40.0%) with a mean age of 41.8 ± 10.6 years. Majority of parents/patients preferred the inform consent to be explained more than once (P = 0.021), once during clinic consultation and once during admission (4.2 ± 1.0). Consent taking by both attending surgeons was preferred (4.5 ± 0.6) compared with other healthcare providers, P < 0.001. Death (60.0%) and neurological deficit (30.0%) were the two most concerned surgical risks. Parents/patients would still hold the surgeon accountable for any complications despite signing the informed consent and they felt that surgeons were directly responsible for screw-related injuries (3.9 ± 0.9), neurological injury (3.8 ± 0.9), and intraoperative bleeding (3.7 ± 0.9).

CONCLUSION

Parents/patients preferred the attending surgeons to personally explain the informed consent, more than once with the use of visual aid. They would still hold the surgeons accountable when complications occur despite acceptance of the informed consent.

LEVEL OF EVIDENCE

2.

Health Numeracy and Relative Risk Comprehension in Perioperative Patients and Physicians

BACKGROUND

Helping patients to understand relative risks is challenging. In discussions with patients, physicians often use numbers to describe hazards, make comparisons, and establish relevance. Patients with a poor understanding of numbers-poor "health numeracy"-also have difficulty making decisions and coping with chronic conditions. Although the importance of "health literacy" in perioperative populations is recognized, health numeracy has not been well studied. Our aim was to compare understanding of numbers, risk, and risk modification between a patient population awaiting surgery under general anesthesia and attending physicians at the same center.

METHODS

We performed a single-center cross-sectional survey study to compare patients' and physicians' health numeracy. The study instrument was based on the Schwartz-Lipkus survey and included 3 simple health numeracy questions and 2 risk reduction questions in the anesthesiology domain. The survey was mailed to patients over the age of 18 scheduled for elective surgery under general anesthesia between June and September 2019, as well as attending physicians at the study center.

RESULTS

Two hundred thirteen of 502 (42%) patient surveys sent and 268 of 506 (53%) physician surveys sent were returned. Median patient score was 4 of 5, but 32% had a score of ≤3. Patients significantly overestimated their total scores by an average of 0.5 points (estimated [mean ± standard deviation (SD)] = 4.3 ± 1.2 vs actual 3.8 ± 1.3; P < .001). Health numeracy was significantly associated with higher educational level (gamma = 0.351; P < .001) and higher-income level (gamma = 0.397; P < .001). Physicians' health numeracy was significantly higher than the patients' (median [interquartile range {IQR}] = 5 [4-5] vs 4 [3-5]; P < .001). There was no significant difference between physicians' self-estimated and actual total numeracy score (mean ± SD = 4.8 ± 0.6 vs 4.7 ± 0.6; P = .372). Simple health numeracy (questions 1-3) was predictive of correct risk reduction responses (questions 4, 5) for both patients (gamma = 0.586; P < .001) and physicians (gamma = 0.558; P = .006).

CONCLUSIONS

Patients had poor health numeracy compared to physicians and tended to overrate their abilities. A small proportion of physicians also had poor numeracy. Poor health numeracy was associated with incomprehension of risk modification, suggesting that some patients may not understand treatment efficacy. These disparities suggest a need for further inquiry into how to improve patient comprehension of risk modification.

A systematic review of factors associated with side-effect expectations from medical interventions

BACKGROUND

Fear of side-effects can result in non-adherence to medical interventions, such as medication and chemotherapy. Side-effect expectations have been identified as strong predictors of later perception of side-effects. However, research investigating predictors of side-effect expectations is disparate.

OBJECTIVE

To identify factors associated with side-effect expectations.

SEARCH STRATEGY

We systematically searched Embase, Ovid MEDLINE, Global Health, PsycARTICLES, PsycINFO, Web of Science and Scopus.

INCLUSION CRITERIA

Studies were included if they investigated associations between any predictive factor and expectations of side-effects from any medical intervention.

DATA EXTRACTION AND SYNTHESIS

We extracted information about participant characteristics, medication, rates of side-effects expected and predictors of side-effect expectations. Data were narratively synthesized.

MAIN RESULTS

We identified sixty-four citations, reporting on seventy-two studies. Predictors fell into five categories: personal characteristics, clinical characteristics, psychological traits and state, presentation format of information, and information sources used. Using verbal risk descriptors (eg 'common') compared to numerical descriptors (eg percentages), having lower quality of life or well-being, and currently experiencing symptoms were associated with increased side-effect expectations.

DISCUSSION AND CONCLUSIONS

Decreasing unrealistic side-effect expectations may lead to decreased experience of side-effects and increased adherence to medical interventions. Widespread communications about medical interventions should describe the incidence of side-effects numerically. Evidence suggests that clinicians should take particular care with patients with lower quality of life, who are currently experiencing symptoms and who have previously experienced symptoms from treatment. Further research should investigate different clinical populations and aim to quantify the impact of the media and social media on side-effect expectations.

Risk communication in tables versus text: a registered report randomized trial on 'fact boxes'

OBJECTIVES

identifying effective summary formats is fundamental to multiple fields including science communication, systematic reviews, evidence-based policy and medical decision-making. This study tested whether table or text-only formats lead to better comprehension of the potential harms and benefits of different options, here in a medical context.

DESIGN

pre-registered, longitudinal experiment: between-subjects factorial 2 (message format) × 2 topic (therapeutic or preventative intervention) on comprehension and later recall (CONSORT-SPI 2018).

SETTING

longitudinal online survey experiment.

PARTICIPANTS

2305 census-matched UK residents recruited through the survey panel firm YouGov.

PRIMARY OUTCOME MEASURE

comprehension of harms and benefits and knowledge recall after six weeks.

RESULTS

fact boxes-simple tabular messages-led to more comprehension (d = 0.39) and slightly more knowledge recall after six weeks (d = 0.12) compared to the same information in text. These patterns of results were consistent between the two medical topics and across all levels of objective numeracy and education. Fact boxes were rated as more engaging than text, and there were no differences between formats in treatment decisions, feeling informed or trust.

CONCLUSIONS

the brief table format of the fact box improved the comprehension of harms and benefits relative to the text-only control. Effective communication supports informed consent and decision-making and brings ethical and practical advantages. Fact boxes and other summary formats may be effective in a wide range of communication contexts.

When Does the Incremental Risk Format Aid Informed Medical Decisions? The Role of Learning, Feedback, and Number of Treatment Options

Background. Informed medical decisions require understanding the benefits and risks of treatments. This entails comparing treatment outcomes to a control group. The incremental risk format has been recommended as it directly visualizes the differences between treatment and control group in 1 graph, whereas they have to be calculated from 2 separate graphs in the total risk format. We investigated when the incremental risk format aids understanding. Methods. In 2 experiments, participants received information about medical treatments, either as incremental or total risk format. We assessed verbatim knowledge (precise quantitative knowledge), gist knowledge (knowledge of essential meaning), and evaluations of the formats. Study 1 (N = 99) consisted of only 1 trial with medical information and also assessed recall. Study 2 (N = 222) assessed learning across multiple trials and also varied the presence of feedback and the number of treatment options. Results. In study 1, the incremental risk format (v. total risk format) led to worse knowledge, recall, and evaluations. In study 2, participants learned to understand the incremental risk format over time, resulting in comparable verbatim knowledge and evaluations as in the total risk format, as well as in even better gist knowledge. Feedback and number of treatment options did not moderate the effect of risk format. Limitations. The studies were conducted with nonpatient samples, and study 2 employed hypothetical treatments. Conclusions. The incremental risk format was initially less understandable than the total risk format. After a short learning period, however, the incremental risk format resulted in better gist knowledge and was comparable otherwise, which suggests that participants had to get used to that format. This has important implications for the study of new formats.

Do Preferred Risk Formats Lead to Better Understanding? A Multicenter Controlled Trial on Communicating Familial Breast Cancer Risks Using Different Risk Formats

PURPOSE

Counselees' preferences are considered important for the choice of risk communication format and for improving patient-centered care. We here report on counselees' preferences for how risks are presented in familial breast cancer counseling and the impact of this preferred format on their understanding of risk.

PATIENTS AND METHODS

As part of a practice-based randomized controlled trial, 326 unaffected women with a family history of breast cancer received their lifetime risk in one of five presentation formats after standard genetic counseling in three Dutch familial cancer clinics: 1) in percentages, 2) in frequencies ("X out of 100"), 3) in frequencies plus graphical format (10×10 human icons), 4) in frequencies and 10-year age-related risk and 5) in frequencies and 10-year age-related risk plus graphical format. Format preferences and risk understanding (accuracy) were assessed at 2-week follow-up by a questionnaire, completed by 279/326 women.

RESULTS

The most preferred risk communication formats were numbers combined with verbal descriptions (37%) and numbers only (26%). Of the numerical formats, most (55%) women preferred percentages. The majority (73%) preferred to be informed about both lifetime and 10-year age-related risk. Women who had received a graphical display were more likely to choose a graphical display as their preferred format. There was no significant effect between the intervention groups with regard to risk accuracy. Overall, women given risk estimates in their preferred format had a slightly better understanding of risk.

CONCLUSION

The results suggest that the accuracy of breast cancer risk estimation is slightly better for women who had received this information in their preferred format, but the risk format used had no effect on women's risk accuracy. To meet the most frequent preference, counselors should consider providing a time frame of reference (eg, risk in the next 10 years) in a numerical format, in addition to lifetime risk.

Preferences for centralised emergency medical services: discrete choice experiment

OBJECTIVES

It is desirable that public preferences are established and incorporated in emergency healthcare reforms. The aim of this study was to investigate preferences for local versus centralised provision of all emergency medical services (EMS) and explore what individuals think are important considerations for EMS delivery.

DESIGN

A discrete choice experiment was conducted. The attributes used in the choice scenarios were: travel time to the hospital, waiting time to be seen, length of stay in the hospital, risks of dying, readmission and opportunity for outpatient care after emergency treatment at a local hospital.

SETTING

North East England.

PARTICIPANTS

Participants were a randomly sampled general population, aged 16 years or above recruited from Healthwatch Northumberland network database of lay members and from clinical contact with Northumbria Healthcare National Health Service Foundation Trust via Patient Experience Team.

PRIMARY AND SECONDARY OUTCOME MEASURES

Analysis used logistic regression modelling techniques to determine the preference of each attribute. Marginal rates of substitution between attributes were estimated to understand the trade-offs individuals were willing to make.

RESULTS

Responses were obtained from 148 people (62 completed a web and 86 a postal version). Respondents preferred shorter travel time to hospital, shorter waiting time, fewer number of days in hospital, low risk of death, low risk of readmission and outpatient follow-up care in their local hospital. However, individuals were willing to trade off increased travel time and waiting time for high-quality centralised care. Individuals were willing to travel 9 min more for a 1-day reduction in length of stay in the hospital, 38 min for a 1% reduction in risk of death and 112 min for having outpatient follow-up care at their local hospital.

CONCLUSIONS

People value centralised EMS if it provides higher quality care and are willing to travel further and wait longer.

Benefits and harms of selective oestrogen receptor modulators (SERMs) to reduce breast cancer risk: a cross-sectional study of methods to communicate risk in primary care

BACKGROUND

In Australia, evidence-based guidelines recommend that women consider taking selective oestrogen receptor modulators (SERMs) to reduce their risk of breast cancer. In practice, this requires effective methods for communicating the harms and benefits of taking SERMs so women can make an informed choice.

AIM

To evaluate how different risk presentations influence women's decisions to consider taking SERMs.

DESIGN AND SETTING

Cross-sectional, correlational study of Australian women in general practice.

METHOD

Three risk communication formats were developed that included graphics, numbers, and text to explain the reduction in breast cancer risk and risk of side effects for women taking SERMs (raloxifene or tamoxifen). Women aged 40-74 years in two general practices were shown the risk formats using vignettes of hypothetical women at moderate or high risk of breast cancer and asked to choose 'If this was you, would you consider taking a SERM?' Descriptive statistics and predictors (risk format, level of risk, and type of SERM) of choosing SERMs were determined by logistic regression.

RESULTS

A total of 288 women were recruited (an 88% response rate) between March and May 2017. The risk formats that showed a government statement and an icon array were associated with a greater likelihood of considering SERMs relative to one that showed a novel expected frequency tree. Risk formats for raloxifene and for the high-risk vignettes were also more strongly associated with choosing to consider SERMs. No associations were found with any patient demographics.

CONCLUSION

Specific risk formats may lead to more women considering taking SERMs to reduce breast cancer risk, especially if they are at high risk of the condition. Raloxifene may be a more acceptable SERM to patients.

Effect of Tabular and Icon Fact Box Formats on Comprehension of Benefits and Harms of Prostate Cancer Screening: A Randomized Trial

BACKGROUND

Fact boxes employ evidence-based guidelines on risk communication to present benefits and harms of health interventions in a balanced and transparent format. However, little is known about their short- and long-term efficacy and whether designing fact boxes to present multiple outcomes with icon arrays would increase their efficacy.

METHOD

In study 1, 120 men (30-75 y) completed a lab study. Participants were randomly assigned to 1 of 3 fact box formats on prostate cancer screening: a tabular fact box with numbers, a fact box with numbers and icon array, and a fact box with numbers, separate icon arrays, and text to describe each benefit and harm. Comprehension of information (while materials were present) and short-term knowledge recall were assessed. Study 2 recruited an online sample of 244 German men (40-75 y). Participants were randomly assigned to 1 of the 3 fact box formats or widely distributed health information, and knowledge was assessed at baseline, shortly after presentation, and at 6-mo follow-up, along with comprehension while materials were present.

RESULTS

In both studies, comprehension and knowledge-recall scores were similar when comparing tabular and icon fact boxes. In the 6-mo follow-up, this positive effect on knowledge recall disappeared. Fact boxes increased knowledge relative to baseline but did not affect decision intentions or perceptions of having complete information to make decisions.

CONCLUSIONS

This study shows that fact boxes with and without icon arrays are equally effective at improving comprehension and knowledge recall over the short-term and are simple formats that can improve on current health information. Specifically, if fact boxes are used at the time or immediately before a decision is made, they promote informed decisions about prostate cancer screening.

Facilitating the transition of young people with long-term conditions through health services from childhood to adulthood: the Transition research programme

Background

As young people with long-term conditions move from childhood to adulthood, their health may deteriorate and their social participation may reduce. ‘Transition’ is the ‘process’ that addresses the medical, psychosocial and educational needs of young people during this time. ‘Transfer’ is the ‘event’ when medical care moves from children’s to adults’ services. In a typical NHS Trust serving a population of 270,000, approximately 100 young people with long-term conditions requiring secondary care reach the age of 16 years each year. As transition extends over about 7 years, the number in transition at any time is approximately 700.

Objectives

Purpose – to promote the health and well-being of young people with long-term conditions by generating evidence to enable NHS commissioners and providers to facilitate successful health-care transition. Objectives – (1) to work with young people to determine what is important in their transitional health care, (2) to identify the effective and efficient features of transitional health care and (3) to determine how transitional health care should be commissioned and provided.

Design, settings and participants

Three work packages addressed each objective. Objective 1. (i) A young people’s advisory group met monthly throughout the programme. (ii) It explored the usefulness of patient-held health information. (iii) A ‘Q-sort’ study examined how young people approached transitional health care. Objective 2. (i) We followed, for 3 years, 374 young people with type 1 diabetes mellitus (150 from five sites in England), autism spectrum disorder (118 from four sites in England) or cerebral palsy (106 from 18 sites in England and Northern Ireland). We assessed whether or not nine proposed beneficial features (PBFs) of transitional health care predicted better outcomes. (ii) We interviewed a subset of 13 young people about their transition. (iii) We undertook a discrete choice experiment and examined the efficiency of illustrative models of transition. Objective 3. (i) We interviewed staff and observed meetings in three trusts to identify the facilitators of and barriers to introducing developmentally appropriate health care (DAH). We developed a toolkit to assist the introduction of DAH. (ii) We undertook a literature review, interviews and site visits to identify the facilitators of and barriers to commissioning transitional health care. (iii) We synthesised learning on ‘what’ and ‘how’ to commission, drawing on meetings with commissioners.

Main outcome measures

Participation in life situations, mental well-being, satisfaction with services and condition-specific outcomes.

Strengths

This was a longitudinal study with a large sample; the conditions chosen were representative; non-participation and attrition appeared unlikely to introduce bias; the research on commissioning was novel; and a young person’s group was involved.

Limitations

There is uncertainty about whether or not the regions and trusts in the longitudinal study were representative; however, we recruited from 27 trusts widely spread over England and Northern Ireland, which varied greatly in the number and variety of the PBFs they offered. The quality of delivery of each PBF was not assessed. Owing to the nature of the data, only exploratory rather than strict economic modelling was undertaken.

Results and conclusions

(1) Commissioners and providers regarded transition as the responsibility of children’s services. This is inappropriate, given that transition extends to approximately the age of 24 years. Our findings indicate an important role for commissioners of adults’ services to commission transitional health care, in addition to commissioners of children’s services with whom responsibility for transitional health care currently lies. (2) DAH is a crucial aspect of transitional health care. Our findings indicate the importance of health services being commissioned to ensure that providers deliver DAH across all health-care services, and that this will be facilitated by commitment from senior provider and commissioner leaders. (3) Good practice led by enthusiasts rarely generalised to other specialties or to adults’ services. This indicates the importance of NHS Trusts adopting a trust-wide approach to implementation of transitional health care. (4) Adults’ and children’s services were often not joined up. This indicates the importance of adults’ clinicians, children’s clinicians and general practitioners planning transition procedures together. (5) Young people adopted one of four broad interaction styles during transition: ‘laid back’, ‘anxious’, ‘wanting autonomy’ or ‘socially oriented’. Identifying a young person’s style would help personalise communication with them. (6) Three PBFs of transitional health care were significantly associated with better outcomes: ‘parental involvement, suiting parent and young person’, ‘promotion of a young person’s confidence in managing their health’ and ‘meeting the adult team before transfer’. (7) Maximal service uptake would be achieved by services encouraging appropriate parental involvement with young people to make decisions about their care. A service involving ‘appropriate parental involvement’ and ‘promotion of confidence in managing one’s health’ may offer good value for money.

Future work

How might the programme’s findings be implemented by commissioners and health-care providers? What are the most effective ways for primary health care to assist transition and support young people after transfer?

Study registration

This study is registered as UKCRN 12201, UKCRN 12980, UKCRN 12731 and UKCRN 15160.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Older Teens' Understanding and Perceptions of Risks in Studies With Genetic Testing: A Pilot Study

Background: The consent process used in clinical research today falls markedly short of the ideal process envisioned nearly 30 years ago. Critics have suggested that the informed consent process has become challenging, formalistic, and incompletely understood by researchers and participants alike. Hence, the purpose of this pilot study was to identify and characterize important aspects of the informed consent process that teens believe impact their understanding of risks of participation in studies with genetic testing. Methods: The personal research experiences of 15 teens regarding consent/assent and research participation in studies with genetic testing were solicited through focus-group interviews. All participants had enrolled in at least one research study involving genetic testing in the prior 2 years. All groups were facilitated by the same experienced focus-group moderator. Themes and subthemes were identified, summarized, and interpreted using conventional qualitative content analysis. Results: Three overarching themes emerged from the interviews: fear of what could happen, need for additional information regarding risks, and need for autonomy and decision-making control throughout the consent process. Conclusion: Results of this pilot study provide preliminary evidence that teens can identify and characterize key issues in the informed consent/assent process when it comes to the risks of research participation. These findings are consistent with other research regarding teens' perceptions and recommendations for genetic testing research.

[Association between life space and health literacy in community-dwelling older adults]

AIM

To examine the association between health literacy (HL) and life space in community-dwelling older adults.

METHODS

In this cross-sectional study, we analyzed 210 community-dwelling older adults (mean age: 74.6 years, women: 63.8%). Health literacy was measured using the 14-item Health Literacy Scale (HLS-14). The 14 items consist of 5 items for functional HL (FHL), 5 items for interactive HL (CHL), and 4 items for critical HL (IHL). We calculated the total score, FHL score, CHL score, and IHL score. Life space was measured using the life-space assessment (LSA). A linear regression model was used to analyze the association between the HLS-14 score and LSA score. We adjusted for variables associated with the LSA score.

RESULTS

The FHL score was significantly associated with the LSA score (crude model: β = 1.40, p < 0.01, adjusted model: β = 1.11, p = 0.01). However, the total score, IHL, and CHL were not significantly associated with the LSA score.

CONCLUSIONS

A higher FHL is significantly associated with a greater larger life space in community-dwelling older adults. This finding may help elderly people maintain a greater life space which will help them to improve their HL while also making it possible for them to obtain easy-to-understand information.

Improved pregnant women's understanding of research information by an enhanced informed consent form: a randomised controlled study nested in neonatal research

OBJECTIVE

This study aimed to test the applicability and effectiveness of the enhanced informed consent form (ICF) methodology, proposed by the Strategic Initiative for Developing Capacity in Ethical Review (SIDCER), in neonatal research requiring maternal consent.

DESIGN

A single-centre open-label randomised controlled study.

SETTING

Antenatal care clinics at Phramongkutklao Hospital, Thailand.

PATIENTS

234 pregnant women who were at risk of preterm labour were enrolled; 232 individuals completed the study.

INTERVENTIONS

The participants were randomly assigned to read either the SIDCER ICF or the conventional ICF.

MAIN OUTCOME MEASURES

The participants' understanding of essential trial-related information was assessed using 25 closed-ended questions. The primary endpoint was the proportion of the participants who obtained the satisfactory level of understanding at 80% (score of ≥20/25).

RESULTS

72.5% (87/120) of the participants in the SIDCER ICF group and 59.8% (67/112) of the conventional ICF group achieved the primary endpoint (relative risk (RR)=1.212, 95% CI 1.005 to 1.462, p=0.041). The superiority of the SIDCER ICF over the conventional ICF was significant, particularly among the participants whose education was at the high school level or below (63.5% vs 44.1%, RR=1.441, 95% CI 1.022 to 2.030, p=0.031).

CONCLUSIONS

The SIDCER ICF methodology is applicable to neonatal research requiring maternal consent. The SIDCER ICF significantly improved the understanding of pregnant women, particularly among those with lower levels of education. The present study confirms the value of the SIDCER ICF methodology in research involving individuals with a limited academic background.

Discussing Death as a Possible Outcome of PICU Care

OBJECTIVES

To describe practical considerations related to discussions about death or possible death of a critically ill child.

DATA SOURCES

Personal experience and reflection. Published English language literature.

STUDY SELECTION

Selected illustrative studies.

DATA EXTRACTION

Not available.

DATA SYNTHESIS

Narrative and experiential review were used to describe the following areas benefits and potential adverse consequences of conversations about risk of death and the timing of, preparation for, and conduct of conversations about risk of death.

CONCLUSIONS

Timely conversations about death as a possible outcome of PICU care are an important part of high-quality ICU care. Not all patients "require" these conversations; however, identifying patients for whom conversations are indicated should be an active process. Informed conversations require preparation to provide the best available objective information. Information should include distillation of local experience, incorporate the patients' clinical trajectory, the potential impact(s) of alternate treatments, describe possible modes of death, and acknowledge the extent of uncertainty. We suggest the more factual understanding of risk of death should be initially separated from the more inherent value-laden treatment recommendations and decisions. Gathering and sharing of collective knowledge, conduct of additional investigations, and time can increase the factual content of risk of death discussions. Timely and sensitive delivery of this best available knowledge then provides foundation for high-quality treatment recommendations and decision-making.

Effect of different formats for information on side effects regarding medicine users' understanding: A randomized controlled trial

OBJECTIVE

The objective of this randomized controlled trial was to evaluate the efficacy of presenting information on the risks of side effects from a medicine, presented in different formats.

METHODS

A randomized, parallel-group, single-center controlled trial was conducted among adult users of a training pharmacy. The information was categorized into the following groups: verbal descriptors+percentage range, percentage range and absolute percentage. The main outcomes were gist understanding and verbatim understanding, classified either as adequate or inadequate. The analyses were performed using ANOVA and Pearson's chi-square test.

RESULTS

A total of 393 participants were recruited from June to October 2015. Adequate levels of gist understanding and verbatim understanding were respectively 65.6% and 53.9% for the verbal descriptors+percentage range (n=128), 63.4% and 44.3% for percentage range (n=131), and 62.3% and 48.5% for absolute percentage (n=131), with no statistically significant difference between the groups (p=0.852 and p=0.299, respectively).

CONCLUSION

The understanding of the information was similar in all three formats, but the percentages of adequate understanding were low.

PRACTICAL IMPLICATIONS

The percentage of inadequate understanding demonstrated in this study indicates that alternative formats for reporting adverse reactions need to be evaluated.

Consent and recruitment: the reporting of paediatric trials published in 2012

OBJECTIVES

We evaluated 300 paediatric trials to determine: the consent and recruitment strategies used, who trial information was targeted to, how incentives were used and if they achieved their recruitment targets.

METHODS

For this cross-sectional evaluation, we searched the Cochrane Central Register of Controlled Trials for paediatric trials published in 2012 and randomly selected 300 that reported on outcomes for participants aged ≤21 years. We collected data on consent and recruitment procedures for each trial and undertook descriptive analyses in SPSS statistics V.23.

RESULTS

All but one trial (99.7%) used a standard recruitment strategy. Most (92%) trials reported that consent was obtained but only 13% reported who obtained consent. Two-thirds (65%) of trials included school-aged participants, and of these 68% reported obtaining assent. Half (50%) of the trials reported who the trial information was targeted to. Most trials (75%) of school-aged participants targeted information towards children or children and their parents. Fourteen per cent of trials reported using incentives, half (50%) of which were in the form of compensation. Only 48% of trials reported sufficient data to determine if their recruitment targets were achieved. Of these, 70% achieved their targets.

CONCLUSIONS

Notable reporting shortcomings included: how families were recruited into the trial, who obtained consent and/or assent and how, who trial information was directed to, whether incentives were used and sufficient data to determine if the recruitment target was achieved. Forthcoming paediatric-specific reporting standards may improve reporting in this priority area. Our data provide a baseline for ongoing monitoring of the state of the research.

Communicating infectious disease prevalence through graphics: Results from an international survey

•

The impact of graphics to inform the general public on health knowledge is unknown.

•

Heat maps were evaluated as superior to dot maps or picto-trendlines.

•

Heat maps are a viable option to widely disseminate information about infectious diseases.

Background

Graphics are increasingly used to represent the spread of infectious diseases (e.g., influenza, Zika, Ebola); however, the impact of using graphics to adequately inform the general population is unknown.

Objective

To examine whether three ways of visually presenting data (heat map, dot map, or picto-trendline)—all depicting the same information regarding the spread of a hypothetical outbreak of influenza—influence intent to vaccinate, risk perception, and knowledge.

Design

Survey with participants randomized to receive a simulated news article accompanied by one of the three graphics that communicated prevalence of influenza and number of influenza-related deaths.

Setting

International online survey.

Participants

16,510 adults living in 11 countries selected using stratified random sampling based on age and gender.

Measurements

After reading the article and viewing the presented graphic, participants completed a survey that measured interest in vaccination, perceived risk of contracting disease, knowledge gained, interest in additional information about the disease, and perception of the graphic.

Results

Heat maps and picto-trendlines were evaluated more positively than dot maps. Heat maps were more effective than picto-trendlines and no different from dot maps at increasing interest in vaccination, perceived risk of contracting disease, and interest in additional information about the disease. Heat maps and picto-trendlines were more successful at conveying knowledge than dot maps. Overall, heat maps were the only graphic to be superior in every outcome.

Limitations

Results are based on a hypothetical scenario.

Conclusion

Heat maps are a viable option to promote interest in and concern about infectious diseases.

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.

Does Iconicity in Pictographs Matter? The Influence of Iconicity and Numeracy on Information Processing, Decision Making, and Liking in an Eye-Tracking Study

Researchers recommend the use of pictographs in medical risk communication to improve people's risk comprehension and decision making. However, it is not yet clear whether the iconicity used in pictographs to convey risk information influences individuals' information processing and comprehension. In an eye-tracking experiment with participants from the general population (N = 188), we examined whether specific types of pictograph icons influence the processing strategy viewers use to extract numerical information. In addition, we examined the effect of iconicity and numeracy on probability estimation, recall, and icon liking. This experiment used a 2 (iconicity: blocks vs. restroom icons) × 2 (scenario: medical vs. nonmedical) between-subject design. Numeracy had a significant effect on information processing strategy, but we found no effect of iconicity or scenario. Results indicated that both icon types enabled high and low numerates to use their default way of processing and extracting the gist of the message from the pictorial risk communication format: high numerates counted icons, whereas low numerates used large-area processing. There was no effect of iconicity in the probability estimation. However, people who saw restroom icons had a higher probability of correctly recalling the exact risk level. Iconicity had no effect on icon liking. Although the effects are small, our findings suggest that person-like restroom icons in pictographs seem to have some advantages for risk communication. Specifically, in nonpersonalized prevention brochures, person-like restroom icons may maintain reader motivation for processing the risk information.

Improved participants' understanding of research information in real settings using the SIDCER informed consent form: a randomized-controlled informed consent study nested with eight clinical trials

PURPOSE

This study aimed to test the applicability and effectiveness of the principles and informed consent form (ICF) template proposed by the Strategic Initiative for Developing Capacity in Ethical Review (SIDCER) across multiple clinical trials involving Thai research participants with various conditions.

METHODS

A single-center, randomized-controlled study nested with eight clinical trials was conducted at Thammasat University Hospital, Thailand. A total of 258 participants from any of the eight clinical trials were enrolled and randomly assigned to read either the SIDCER ICF (n = 130) or the conventional ICF (n = 128) of the respective trial. Their understanding of necessary information was assessed using the post-test questionnaire; they were allowed to consult a given ICF while completing the questionnaire. The primary endpoint was the proportion of the participants who had the post-test score of ≥80%, and the secondary endpoint was the total score of the post-test.

RESULTS

The proportion of the participants in the SIDCER ICF group who achieved the primary endpoint was significantly higher than that of the conventional ICF group (60.8 vs. 41.4%, p = 0.002). The total score of the post-test was also significantly higher among the participants who read the SIDCER ICF than those who read the conventional ICF (83.3 vs. 76.0%, p < 0.001).

CONCLUSIONS

The present study demonstrated that the SIDCER ICF was applicable and effective to improve Thai research participants' understanding of research information in diverse clinical trials. Using the SIDCER ICF methodology, clinical researchers can improve the quality of ICFs for their trials.

High Numerates Count Icons and Low Numerates Process Large Areas in Pictographs: Results of an Eye-Tracking Study

In two experiments, we investigated the influence of numeracy on individuals' information processing of pictographs depending on numeracy via an eye-tracker. In two conditions, participants from the general population were presented with a scenario depicting the risk of having cancer and were asked to indicate their perceived risk. The risk level was high (63%) in experiment 1 (N = 70) and low (6%) in experiment 2 (N = 69). In the default condition, participants were free to use their default strategy for information processing. In the guiding-toward-the-number condition, they were prompted to count icons in the pictograph by answering with an explicit number. We used eye-tracking parameters related to the distance between sequential fixations to analyze participants' strategies for processing numerical information. In the default condition, the higher the numeracy was, the shorter the distances traversed in the pictograph were, indicating that participants counted the icons. People lower in numeracy performed increased large-area processing by comparing highlighted and nonhighlighted parts of the pictograph. In the guiding-toward-the-number condition, participants used short distances regardless of their numeracy, supporting the notion that short distances represent counting. Despite the different default processing strategies, participants processed the pictograph with a similar depth and derived similar risk perceptions. The results show that pictographs are beneficial for communicating medical risk. Pictographs make the gist salient by making the part-to-whole relationship visually available, and they facilitate low numerates' non-numeric processing of numerical information. Contemporaneously, pictographs allow high numerates to numerically process and rely on the number depicted in the pictograph.

Visual assessment of the similarity between a patient and trial population: Is This Clinical Trial Applicable to My Patient?

BACKGROUND

A critical consideration when applying the results of a clinical trial to a particular patient is the degree of similarity of the patient to the trial population. However, similarity assessment rarely is practical in the clinical setting. Here, we explore means to support similarity assessment by clinicians.

METHODS

A scale chart was developed to represent the distribution of reported clinical and demographic characteristics of clinical trial participant populations. Constructed for an individual patient, the scale chart shows the patient's similarity to the study populations in a graphical manner. A pilot test case was conducted using case vignettes assessed by clinicians. Two pairs of clinical trials were used, each addressing a similar clinical question. Scale charts were manually constructed for each simulated patient. Clinicians were asked to estimate the degree of similarity of each patient to the populations of a pair of trials. Assessors relied on either the scale chart, a summary table (aligning characteristics of 2 trial populations), or original trial reports. Assessment time and between-assessor agreement were compared. Population characteristics considered important by assessors were recorded.

RESULTS

Six assessors evaluated 6 cases each. Using a visual scale chart, agreement between physicians was higher and the time required for similarity assessment was comparable.

CONCLUSION

We suggest that further research is warranted to explore visual tools facilitating the choice of the most applicable clinical trial to a specific patient. Automating patient and trial population characteristics extraction is key to support this effort.

Strategies for Disseminating Information on Biomedical Research on Autism to Hispanic Parents

Low income Hispanic families experience multiple barriers to accessing evidence-based information on Autism Spectrum Disorders (ASD). This study utilized a mixed-strategy intervention to create access to information in published bio-medical research articles on ASD by distilling the content into parent-friendly English- and Spanish-language ASD Science Briefs and presenting them to participants using two socially-oriented dissemination methods. There was a main effect for short-term knowledge gains associated with the Science Briefs but no effect for the dissemination method. After 5 months, participants reported utilizing the information learned and 90% wanted to read more Science Briefs. These preliminary findings highlight the potential benefits of distilling biomedical research articles on ASD into parent-friendly educational products for currently underserved Hispanic parents.

Clinical Trial Decisions in Difficult Circumstances: Parental Consent Under Time Pressure

Treatments and interventions used to care for children in emergencies should be based on strong evidence. Well-designed clinical trials investigating these interventions for children are therefore indispensable. Parental informed consent is a key ethical requirement for the enrollment of children in such studies. However, if time is limited because of an urgent need for intervention, there are additional ethical challenges to adequately support the informed consent process. The acute situation and associated psychological impact may compromise the ability of parents to give informed consent. Little evidence exists to guide the process of consent seeking for a child's research participation when time is limited. It is also unclear in what circumstances alternatives to prospective informed consent could be applied. This article describes possible options to manage the informed consent process in an appropriate, practical, and, we believe, ethical way when time is limited.

Recommendations and evidence for reporting items in pediatric clinical trial protocols and reports: two systematic reviews

BACKGROUND

Complete and transparent reporting of clinical trial protocols and reports ensures that these documents are useful to all stakeholders, that bias is minimized, and that the research is not wasted. However, current studies repeatedly conclude that pediatric trial protocols and reports are not appropriately reported. Guidelines like SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) and CONSORT (Consolidated Standards of Reporting Trials) may improve reporting, but do not offer guidance on issues unique to pediatric trials. This paper reports two systematic reviews conducted to build the evidence base for the development of pediatric reporting guideline extensions: 1) SPIRIT-Children (SPIRIT-C) for pediatric trial protocols, and 2) CONSORT-Children (CONSORT-C) for pediatric trial reports.

METHOD

MEDLINE, the Cochrane Methodology Register, and reference lists of included studies were searched. Publications of any type were eligible if they included explicit recommendations or empirical evidence for the reporting of potential items in a pediatric protocol (SPIRIT-C systematic review) or trial report (CONSORT-C systematic review). Study characteristics, recommendations and evidence for pediatric extension items were extracted. Recurrent themes in the recommendations and evidence were identified and synthesized. All steps were conducted by two reviewers.

RESULTS

For the SPIRIT-C and CONSORT-C systematic reviews 366 and 429 publications were included, respectively. Recommendations were identified for 48 of 50 original reporting items and sub-items from SPIRIT, 15 of 20 potential SPIRIT-C reporting items, all 37 original CONSORT items and sub-items, and 16 of 22 potential CONSORT-C reporting items. The following overarching themes of evidence to support or refute the utility of reporting items were identified: transparency; reproducibility; interpretability; usefulness; internal validity; external validity; reporting bias; publication bias; accountability; scientific soundness; and research ethics.

CONCLUSION

These systematic reviews are the first to systematically gather evidence and recommendations for the reporting of specific items in pediatric protocols and trials. They provide useful and translatable evidence on which to build pediatric extensions to the SPIRIT and CONSORT reporting guidelines. The resulting SPIRIT-C and CONSORT-C will provide guidance to the authors of pediatric protocols and reports, respectively, helping to alleviate concerns of inappropriate and inconsistent reporting, and reduce research waste.

Design and Focus Test of a Preconsultation Decision Aid for Breast Cancer Reconstruction Patients: A Quality Improvement Initiative

OBJECTIVE

To design, develop, and evaluate via focus group a preconsultation decision aid to improve patient satisfaction for breast reconstruction.

METHODS

The design of the decision aid was based on perceived patient needs, literature, existing decision aids, and current standard of breast cancer reconstruction treatment and consultation at Stanford. Our decision aid was designed to (1) reducing fear of the unknown in patients via providing a knowledge base that they can rely on, (2) helping patients identify their key breast reconstruction concerns, (3) addressing common patient concerns, (4) providing a framework to help patients identify the treatment option that may be right for them, and (5) promoting shared decision making. Physicians were consulted on the decision aid, following which a focus group was conducted for patient feedback.

RESULTS

Interviewed patients (n = 12) were supportive of the decision aid initiative. Participants were especially pleased with the side-by-side comparison of surgical options and the parsimonious way information was represented. All patients before undergoing reconstruction (n = 3) requested the decision guide to reference at home. All interviewed patients believed information level was "about right."

CONCLUSIONS

Decision aid was well received by patients in the focus group. As the initiative is for quality improvement, we saw no need to further delay the distribution of the decision aid. A pilot study will be conducted to evaluate whether our decision aid has an effect on patients' decision regret, stress, and anxiety.

[Guideline for the Development of Evidence-based Patient Information: insights into the methods and implementation of evidence-based health information]

The "Guideline for the Development of Evidence-based Patient Information" project is a novelty. The aim of this project is to enhance the quality of health information. The development and implementation process is guided by national and international standards. Involvement of health information developers plays an essential role. This article provides an insight into the guideline's underlying methodology, using graphics as an example. In addition, the results of a qualitative study exploring the competencies of health information developers are presented. These results will guide the implementation of the guideline. We conducted systematic literature searches (until June 2014), critical appraisal and descriptive analyses applying GRADE for two selected guideline questions. Out of 3,287 hits 11 RCTs were included in the analysis. The evidence has been rated to be of low to moderate quality. Additional graphics may have a positive effect on cognitive outcomes. However, the relevance of the results is questionable. For graphics, we found some indication that especially pictograms but also bar graphs have a positive effect on cognitive outcomes and meet patients' preferences. In order to prepare for the implementation of the guideline, we conducted a qualitative study to explore the competencies of health information developers using expert interviews. Four telephone interviews were conducted, audio recorded, transcribed and analysed according to Grounded Theory. Six categories were identified: literature search, development of health information, participation of target groups, continuing education and further training of health information developers, cooperation with different institutions, essential competencies. Levels of competencies regarding the methods of evidence-based medicine and evidence-based health information vary considerably and indicate a need for training. These results have informed the development of a training programme that will support the implementation.

Use of mobile devices and the internet for multimedia informed consent delivery and data entry in a pediatric asthma trial: Study design and rationale

INTRODUCTION

Phase III/IV clinical trials are expensive and time consuming and often suffer from poor enrollment and retention rates. Pediatric trials are particularly difficult because scheduling around the parent, participant and potentially other sibling schedules can be burdensome. We are evaluating using the internet and mobile devices to conduct the consent process and study visits in a streamlined pediatric asthma trial. Our hypothesis is that these study processes will be non-inferior and will be less expensive compared to a traditional pediatric asthma trial.

MATERIALS/METHODS

Parents and participants, aged 12 through 17 years, complete the informed consent process by viewing a multi-media website containing a consent video and study material in the streamlined trial. Participants are provided an iPad with WiFi and EasyOne spirometer for use during FaceTime visits and online twice daily symptom reporting during an 8-week run-in followed by a 12-week study period. Outcomes are compared with participants completing a similarly designed traditional trial comparing the same treatments within the same pediatric health-system. After 8 weeks of open-label Advair 250/50 twice daily, participants in both trial types are randomized to Advair 250/50, Flovent 250, or Advair 100/50 given 1 inhalation twice daily. Study staff track time spent to determine study costs.

RESULTS

Participants have been enrolled in the streamlined and traditional trials and recruitment is ongoing.

CONCLUSIONS

This project will provide important information on both clinical and economic outcomes for a novel method of conducting clinical trials. The results will be broadly applicable to trials of other diseases.

Empirical relationships between health literacy and treatment decision making: a scoping review of the literature

OBJECTIVES

This study asked: What is known from the existing literature about the empirical relationships between health literacy (HL) and the three stages of the treatment decision making (TDM) process: information exchange, deliberation, and deciding on the treatment to implement?

METHODS

A scoping review of the literature was conducted. Four databases were searched and a total of 2772 records were returned. After de-duplication and three levels of relevance screening, 41 primary studies were included.

RESULTS

Relationships between HL and information exchange were studied more often than relationships between HL and deliberation and deciding on the treatment to implement. Across the 41 studies, there was little overlap in terms the measure(s) of HL adopted, the aspect of TDM considered, and the characteristics of the study populations--making comparisons of the findings difficult. Multiple knowledge gaps and measurement-related problems were identified; including, the possibility that the process of TDM influences HL.

CONCLUSION

The importance of HL to the three stages of TDM is unclear because of the knowledge gaps and measurement-related problems that exist.

PRACTICE IMPLICATIONS

There are many uncertainties about how TDM, or the design and use of patient decision aids, should respond to patients with different levels of HL.

The effect of a supplementary ('Gist-based') information leaflet on colorectal cancer knowledge and screening intention: a randomized controlled trial

Guided by Fuzzy Trace Theory, this study examined the impact of a ‘Gist-based’ leaflet on colorectal cancer screening knowledge and intentions; and tested the interaction with participants’ numerical ability. Adults aged 45–59 years from four UK general practices were randomly assigned to receive standard information (‘The Facts’, n = 2,216) versus standard information plus ‘The Gist’ leaflet (Gist + Facts, n = 2,236). Questionnaires were returned by 964/4,452 individuals (22 %). 82 % of respondents reported having read the information, but those with poor numeracy were less likely (74 vs. 88 %, p < .001). The ‘Gist + Facts’ group were more likely to reach the criterion for adequate knowledge (95 vs. 91 %; p < .01), but this was not moderated by numeracy. Most respondents (98 %) intended to participate in screening, with no group differences and no interaction with numeracy. The improved levels of knowledge and self-reported reading suggest ‘The Gist’ leaflet may increase engagement with colorectal cancer screening, but ceiling effects reduced the likelihood that screening intentions would be affected.

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.

Participant comprehension of research for which they volunteer: a systematic review

PURPOSE

Evidence indicates that research participants often do not fully understand the studies for which they have volunteered. The aim of this systematic review was to examine the relationship between the process of obtaining informed consent for research and participant comprehension and satisfaction with the research.

DESIGN

Systematic review of published research on informed consent and participant comprehension of research for which they volunteer using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Statement as a guide.

METHODS

PubMed, Cumulative Index for Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trails, and Cochrane Database of Systematic Reviews were used to search the literature for studies meeting the following inclusion criteria: (a) published between January 1, 2006, and December 31, 2013, (b) interventional or descriptive quantitative design, (c) published in a peer-reviewed journal, (d) written in English, and (e) assessed participant comprehension or satisfaction with the research process. Studies were assessed for quality using seven indicators: sampling method, use of controls or comparison groups, response rate, description of intervention, description of outcome, statistical method, and health literacy assessment.

FINDINGS

Of 176 studies identified, 27 met inclusion criteria: 13 (48%) were randomized interventional designs and 14 (52%) were descriptive. Three categories of studies included projects assessing (a) enhanced consent process or form, (b) multimedia methods, and (c) education to improve participant understanding. Most (78%) used investigator-developed tools to assess participant comprehension, did not assess participant health literacy (74%), or did not assess the readability level of the consent form (89%). Researchers found participants lacked basic understanding of research elements: randomization, placebo, risks, and therapeutic misconception.

CONCLUSIONS

Findings indicate (a) inconsistent assessment of participant reading or health literacy level, (b) measurement variation associated with use of nonstandardized tools, and (c) continued therapeutic misconception and lack of understanding among research participants of randomization, placebo, benefit, and risk. While the Agency for Healthcare and Quality and National Quality Forum have published informed consent and authorization toolkits, previously published validated tools are underutilized.

CLINICAL RELEVANCE

Informed consent requires the assessment of health literacy, reading level, and comprehension of research participants using validated assessment tools and methods.

Exploring consumer opinions on the presentation of side-effects information in Australian Consumer Medicine Information leaflets

Background

Consumer Medicine Information (CMI) is a brand‐specific and standardized source of written medicine information available in Australia for all prescription medicines. Side‐effect information is poorly presented in CMI and may not adequately address consumer information needs.

Objective

To explore consumer opinions on (i) the presentation of side‐effect information in existing Australian CMI leaflets and alternative study‐designed CMIs and (ii) side‐effect risk information and its impact on treatment decision making.

Design

Fuzzy trace, affect heuristic, frequency hypothesis and cognitive‐experiential theories were applied when revising existing CMI side‐effects sections. Together with good information design, functional linguistics and medicine information expertise, alternative ramipril and clopidogrel CMI versions were proposed. Focus groups were then conducted to address the study objectives.

Participants and setting

Three focus groups (n = 18) were conducted in Sydney, Australia. Mean consumer age was 58 years (range 50–65 years), with equal number of males and females.

Results

All consumers preferred the alternative CMIs developed as part of the study, with unequivocal preference for the side‐effects presented in a simple tabular format, as it allowed quick and easy access to information. Consumer misunderstandings reflected literacy and numeracy issues inherent in consumer risk appraisal. Many preferred no numerical information and a large proportion preferred natural frequencies.

Conclusions

One single method of risk presentation in CMI is unable to cater for all consumers. Consumer misunderstandings are indicative of possible health literacy and numeracy factors that influence consumer risk appraisal, which should be explored further.

Animated randomness, avatars, movement, and personalization in risk graphics

Background

Risk communication involves conveying two inherently difficult concepts about the nature of risk: the underlying random distribution of outcomes and how a population-based proportion applies to an individual.

Objective

The objective of this study was to test whether 4 design factors in icon arrays—animated random dispersal of risk events, avatars to represent an individual, personalization (operationalized as choosing the avatar’s color), and a moving avatar—might help convey randomness and how a given risk applies to an individual, thereby better aligning risk perceptions with risk estimates.

Methods

A diverse sample of 3630 adults with no previous heart disease or stroke completed an online nested factorial experiment in which they entered personal health data into a risk calculator that estimated 10-year risk of cardiovascular disease based on a robust and validated model. We randomly assigned them to view their results in 1 of 10 risk graphics that used different combinations of the 4 design factors. We measured participants’ risk perceptions as our primary outcome, as well as behavioral intentions and recall of the risk estimate. We also assessed subjective numeracy, whether or not participants knew anyone who had died of cardiovascular causes, and whether or not they knew their blood pressure and cholesterol as potential moderators.

Results

Animated randomness was associated with better alignment between risk estimates and risk perceptions (F_1,3576=6.12, P=.01); however, it also led to lower scores on healthy lifestyle intentions (F_1,3572=11.1, P<.001). Using an avatar increased risk perceptions overall (F_1,3576=4.61, P=.03) and most significantly increased risk perceptions among those who did not know a particular person who had experienced the grave outcomes of cardiovascular disease (F_1,3576=5.88, P=.02). Using an avatar also better aligned actual risk estimates with intentions to see a doctor (F_1,3556=6.38, P=.01). No design factors had main effects on recall, but animated randomness was associated with better recall for those at lower risk and worse recall for those at higher risk (F_1,3544=7.06, P=.01).

Conclusions

Animated randomness may help people better understand the random nature of risk. However, in the context of cardiovascular risk, such understanding may result in lower healthy lifestyle intentions. Therefore, whether or not to display randomness may depend on whether one’s goal is to persuade or to inform. Avatars show promise for helping people grasp how population-based statistics map to an individual case.