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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRACTICE IMPLICATIONS

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

PROTOCOL REGISTRATION

PROSPERO ID 275022.

Psychological inoculation improves resilience against misinformation on social media

Online misinformation continues to have adverse consequences for society. Inoculation theory has been put forward as a way to reduce susceptibility to misinformation by informing people about how they might be misinformed, but its scalability has been elusive both at a theoretical level and a practical level. We developed five short videos that inoculate people against manipulation techniques commonly used in misinformation: emotionally manipulative language, incoherence, false dichotomies, scapegoating, and ad hominem attacks. In seven preregistered studies, i.e., six randomized controlled studies (n = 6464) and an ecologically valid field study on YouTube (n = 22,632), we find that these videos improve manipulation technique recognition, boost confidence in spotting these techniques, increase people's ability to discern trustworthy from untrustworthy content, and improve the quality of their sharing decisions. These effects are robust across the political spectrum and a wide variety of covariates. We show that psychological inoculation campaigns on social media are effective at improving misinformation resilience at scale.

How reported outbreak data can shape individual behavior in a social world

Agencies reporting on disease outbreaks face many choices about what to report and the scale of its dissemination. Reporting impacts an epidemic by influencing individual decisions directly, and the social network in which they are made. We simulated a dynamic multiplex network model—with coupled infection and communication layers—to examine behavioral impacts from the nature and scale of epidemiological information reporting. We explored how adherence to protective behaviors (social distancing) can be facilitated through epidemiological reporting, social construction of perceived risk, and local monitoring of direct connections, but eroded via social reassurance. We varied reported information (total active cases, daily new cases, hospitalizations, hospital capacity exceeded, or deaths) at one of two scales (population level or community level). Total active and new case reporting at the population level were the most effective approaches, relative to the other reporting approaches. Case reporting, which synergizes with test-trace-and-isolate and vaccination policies, should remain a priority throughout an epidemic.

Stability of Risk Perception Across Pandemic and Non-pandemic Situations Among Young Adults: Evaluating the Impact of Individual Differences

Previous research suggests a higher perceived risk associated with a risky behavior predicts a lower likelihood of involvement in that behavior; however, this relationship can vary based on personality characteristics such as impulsivity and behavioral activation. During the COVID-19 pandemic, individuals began to re-evaluate the level of risk associated with everyday behaviors. But what about risks associated with “typical” risk-taking behaviors? In the present study, 248 undergraduate student participants completed measures of impulsivity, behavioral activation and inhibition, propensity to take risks, numeracy, and perceptions of and involvement in both risk-taking behavior and health promoting behavior (e.g., blood donation, registering as an organ donor, vaccination). Our study revealed that higher behavioral inhibition and greater propensity to take risks predicted greater likelihood of involvement in COVID-19-related risk behaviors, even after accounting for perceived risks and benefits of the behavior. Greater likelihood of involvement in social risk behaviors was predicted by greater numeracy and risk-taking propensity. Identifying as male, a greater propensity to take risks, and greater impulsivity predicted increased health/safety risk behaviors. Younger age, lower risk-taking propensity, and lower impulsivity were associated with a greater likelihood of donating blood. For the likelihood of registering to become an organ donor, increasing risk perception, both before and during the pandemic, was associated with greater likelihood of registering, but greater risk-taking propensity was associated with a decreased likelihood of organ donation registration. For flu vaccination, a greater propensity to take risks was associated with a greater likelihood of flu vaccination during the 2020–2021 flu season. Both cognitive and personality factors can predict involvement in risk-taking and health-promotion behaviors, warranting their continued examination.

Effects of icon arrays to communicate risk in a repeated risky decision-making task

In two experiments, participants decided on each of several trials whether or not to take a risk. If they chose to take the risk, they had a relatively high probability (from 75% to 95%) of winning a small number of points and a relatively low probability (5% to 25%) of losing a large number of points. The loss amounts varied so that the expected value of taking the risk was positive on some trials, zero on others, and negative on the rest. The main independent variable was whether the probability of losing was communicated using numerical percentages or icon arrays. Both experiments included random icon arrays, in which the icons representing losses were randomly distributed throughout the array. Experiment 2 also included grouped icon arrays, in which the icons representing losses were grouped at the bottom of the array. Neither type of icon array led to better performance in the task. However, the random icon arrays led to less risk taking than the numerical percentages or the grouped icon arrays, especially at the higher loss probabilities. In a third experiment, participants made direct judgments of the percentages and probabilities represented by the icon arrays from Experiment 2. The results supported the idea that random arrays lead to less risk taking because they are perceived to represent greater loss probabilities. These results have several implications for the study of icon arrays and their use in risk communication.

Reactions to geographic data visualization of infectious disease outbreaks: an experiment on the effectiveness of data presentation format and past occurrence information

OBJECTIVES

This study intended to compare the effectiveness of thematic maps with that of tabular data in comprehension and memory of risk magnitudes, with Zika virus (ZIKV) disease outbreaks in the United States as the subject matter. The study also aimed to examine the effects of data presentation format and past occurrence information on risk perception and risk avoidance intention.

STUDY DESIGN

This study used an experiment.

METHODS

Each participant was randomly assigned to view ZIKV disease 2017 incidence data presented in one of the three formats: a choropleth map, a graduated-circle map, and a table, after which they answered questions about comprehension and memory of risk magnitudes. Each participant was then randomly assigned to view or not to view incidence data of the previous occurrence of ZIKV outbreaks in 2016, after which they answered questions about risk perception and risk avoidance intention.

RESULTS

The results revealed the effectiveness of thematic maps over tabular data in comprehension, risk perception, and risk avoidance intention. Compared to tabular data, the choropleth map led to a better comprehension of relative risk magnitudes, the graduated-circle map led to higher risk perception, and both thematic maps led to greater risk avoidance intention. In contrast, tabular data led to better recognition of absolute risk magnitudes than both thematic maps. In addition, past occurrence information enhanced risk perception and risk avoidance intention.

CONCLUSIONS

The findings reveal the importance of data presentation format in comprehension and memory of risk magnitudes. This can be attributed to the cognitive match between the information emphasized in the presentation and that required by the tasks. The findings also suggest that data presentation format and past occurrence information are important judgmental heuristics that help to form risk perception and risk avoidance intention.

Revisiting the Open Sampling format: Improving risky choices through a novel graphical representation

When making risky choices, people often fall short of the norm of expected value (EV) maximization. Previous research has shown that presenting options in the Open Sampling (OSa) format, a 10-by-10 matrix of randomly arranged outcomes, can improve choices and reduce decision times. First, the current research aims to replicate and extend the findings on the OSa format. To this end, we compare OSa to the common description-based format as well as further graphical representations, and investigate the resulting accordance with EV maximization and decision time. Second, we study whether people lower (vs. higher) in numeracy, the ability to use probabilistic and mathematical concepts, particularly benefit from a graphical representation of options. We conducted five high-powered studies (total N = 1,575) in which participants chose repeatedly between two risky gambles, using different populations and gamble-problem sets. Overall, we could not find a benefit of the OSa format in terms of EV accordance in any of the five studies. However, three studies also tested a novel variant of the OSa format with grouped outcomes and found that it consistently improved EV accordance compared with all other formats. All graphical formats led to faster decisions without harming decision quality. The effects of presentation format were not moderated by numeracy in three of the four studies that assessed numeracy. In conclusion, our research introduces a new presentation format which consistently improves risky choices and can also be used to communicate risks in applied contexts such as medical decision making.

Susceptibility to misinformation about COVID-19 around the world

Misinformation about COVID-19 is a major threat to public health. Using five national samples from the UK (n = 1050 and n = 1150), Ireland (n = 700), the USA (n = 700), Spain (n = 700) and Mexico (n = 700), we examine predictors of belief in the most common statements about the virus that contain misinformation. We also investigate the prevalence of belief in COVID-19 misinformation across different countries and the role of belief in such misinformation in predicting relevant health behaviours. We find that while public belief in misinformation about COVID-19 is not particularly common, a substantial proportion views this type of misinformation as highly reliable in each country surveyed. In addition, a small group of participants find common factual information about the virus highly unreliable. We also find that increased susceptibility to misinformation negatively affects people's self-reported compliance with public health guidance about COVID-19, as well as people's willingness to get vaccinated against the virus and to recommend the vaccine to vulnerable friends and family. Across all countries surveyed, we find that higher trust in scientists and having higher numeracy skills were associated with lower susceptibility to coronavirus-related misinformation. Taken together, these results demonstrate a clear link between susceptibility to misinformation and both vaccine hesitancy and a reduced likelihood to comply with health guidance measures, and suggest that interventions which aim to improve critical thinking and trust in science may be a promising avenue for future research.

Susceptibility to misinformation about COVID-19 around the world

Misinformation about COVID-19 is a major threat to public health. Using five national samples from the UK (n = 1050 and n = 1150), Ireland (n = 700), the USA (n = 700), Spain (n = 700) and Mexico (n = 700), we examine predictors of belief in the most common statements about the virus that contain misinformation. We also investigate the prevalence of belief in COVID-19 misinformation across different countries and the role of belief in such misinformation in predicting relevant health behaviours. We find that while public belief in misinformation about COVID-19 is not particularly common, a substantial proportion views this type of misinformation as highly reliable in each country surveyed. In addition, a small group of participants find common factual information about the virus highly unreliable. We also find that increased susceptibility to misinformation negatively affects people's self-reported compliance with public health guidance about COVID-19, as well as people's willingness to get vaccinated against the virus and to recommend the vaccine to vulnerable friends and family. Across all countries surveyed, we find that higher trust in scientists and having higher numeracy skills were associated with lower susceptibility to coronavirus-related misinformation. Taken together, these results demonstrate a clear link between susceptibility to misinformation and both vaccine hesitancy and a reduced likelihood to comply with health guidance measures, and suggest that interventions which aim to improve critical thinking and trust in science may be a promising avenue for future research.

Susceptibility to misinformation about COVID-19 around the world

Misinformation about COVID-19 is a major threat to public health. Using five national samples from the UK (n = 1050 and n = 1150), Ireland (n = 700), the USA (n = 700), Spain (n = 700) and Mexico (n = 700), we examine predictors of belief in the most common statements about the virus that contain misinformation. We also investigate the prevalence of belief in COVID-19 misinformation across different countries and the role of belief in such misinformation in predicting relevant health behaviours. We find that while public belief in misinformation about COVID-19 is not particularly common, a substantial proportion views this type of misinformation as highly reliable in each country surveyed. In addition, a small group of participants find common factual information about the virus highly unreliable. We also find that increased susceptibility to misinformation negatively affects people's self-reported compliance with public health guidance about COVID-19, as well as people's willingness to get vaccinated against the virus and to recommend the vaccine to vulnerable friends and family. Across all countries surveyed, we find that higher trust in scientists and having higher numeracy skills were associated with lower susceptibility to coronavirus-related misinformation. Taken together, these results demonstrate a clear link between susceptibility to misinformation and both vaccine hesitancy and a reduced likelihood to comply with health guidance measures, and suggest that interventions which aim to improve critical thinking and trust in science may be a promising avenue for future research.

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.

Communicating quantitative evidence of policy effectiveness and support for the policy: Three experimental studies

Increasing the prices of products that harm health is an effective intervention for changing behaviour to improve health but public support for such interventions is generally low. The current paper investigates whether communicating evidence of a policy's effectiveness at tackling the focal problem could increase support. Across three studies we develop an infographic for communicating quantitative evidence of the effectiveness of a hypothetical tax to tackle childhood obesity. We investigate first, whether communicating evidence of effectiveness increases (a) perceived effectiveness (Studies 1,2,3) and (b) support for the policy, and second, whether any increase in perceived effectiveness mediates an increase in support (Studies 1 & 3). In all three studies (combined N = 9654) communicating evidence of effectiveness for the intervention increased perceived effectiveness. In Study 1, communicating evidence did not change support for the policy. Variations of the infographic were developed in Study 2 with one emerging as clearer and easier to comprehend. This infographic was therefore used in Study 3 in which it increased support for the tax from 45% to 49%, an effect that was mediated by perceived effectiveness. The effect sizes were small but probably meaningful at a population level. The results of these three studies suggest the potential for presenting quantitative evidence of intervention effectiveness to increase public support. Much uncertainty remains about the most effective ways of presenting this evidence, whether similar effects are achieved by presenting unquantified evidence and whether larger effects might be achieved by presenting information other than effectiveness.

Impact on product appeal of labeling wine and beer with (a) lower strength alcohol verbal descriptors and (b) percent alcohol by volume (%ABV): An experimental study

Lower strength alcohol products may help reduce alcohol consumption and associated harms. This study assessed the impact of labeling wine and beer with different verbal descriptors denoting lower strength, with and without percent alcohol by volume (%ABV), on product appeal and understanding of strength. Three thousand three hundred ninety adult survey-panel members were randomized to 1 of 18 groups with 1 of 3 levels of verbal descriptor (Low vs. Super Low vs. No verbal descriptor) and 6 levels of %ABV (5 levels varying for wine and beer, and no level given). Products with verbal descriptors denoting lower strength (Low and Super Low) had lower appeal than Regular strength products. Appeal decreased as %ABV decreased. Understanding of strength was generally high across the various drinks with majority of participants correctly identifying or erring on the side of caution when estimating the units and calories in a given drink, appropriateness for consumption by children, and drinking within the driving limit. We discuss the theoretical and policy implications of these findings for public health. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Impact of low alcohol verbal descriptors on perceived strength: An experimental study

Objectives

Low alcohol labels are a set of labels that carry descriptors such as ‘low’ or ‘lighter’ to denote alcohol content in beverages. There is growing interest from policymakers and producers in lower strength alcohol products. However, there is a lack of evidence on how the general population perceives verbal descriptors of strength. The present research examines consumers’ perceptions of strength (% ABV) and appeal of alcohol products using low or high alcohol verbal descriptors.

Design

A within‐subjects experimental study in which participants rated the strength and appeal of 18 terms denoting low (nine terms), high (eight terms) and regular (one term) strengths for either (1) wine or (2) beer according to drinking preference.

Methods

Thousand six hundred adults (796 wine and 804 beer drinkers) sampled from a nationally representative UK panel.

Results

Low, Lower, Light, Lighter, and Reduced formed a cluster and were rated as denoting lower strength products than Regular, but higher strength than the cluster with intensifiers consisting of Extra Low, Super Low, Extra Light, and Super Light. Similar clustering in perceived strength was observed amongst the high verbal descriptors. Regular was the most appealing strength descriptor, with the low and high verbal descriptors using intensifiers rated least appealing.

Conclusions

The perceived strength and appeal of alcohol products diminished the more the verbal descriptors implied a deviation from Regular. The implications of these findings are discussed in terms of policy implications for lower strength alcohol labelling and associated public health outcomes.

Designing Graphs to Communicate Risks: Understanding How the Choice of Graphical Format Influences Decision Making

Previous research suggests that the choice of graphical format for communicating risk information affects both understanding of the risk magnitude and the likelihood of acting to decrease risk. However, the mechanisms through which these effects work are poorly understood. To explore these mechanisms using a real-world scenario, we examined the relative impact of two graphical displays for depicting the risk of exposure to unexploded ammunition during potential land redevelopment. One display depicted only the foreground information graphically (a bar graph of the number of people harmed), and a second depicted the foreground and background graphically (a stacked bar graph representing both the number harmed and at risk). We presented 296 participants with either the foreground-only or the foreground and background graphical display and measured a broad set of outcome variables, examining (1) the graphical display effect on each of the outcome measures and (2) the pathways by which any display effects work to influence decision making. We found that the foreground-only graphical display increased perceived likelihood and experienced fear, which produced greater worry, which in turn increased risk aversion. In addition, a positive evaluation of the communication materials increased support for policies related to land redevelopment, whether those policies were risk taking or risk mitigating. Finally, the foreground-only graphical display decreased understanding of the risk magnitude, showing that approaches to accomplish one risk communication goal (promoting risk-averse decisions) may do so at the expense of another goal (increasing understanding).

Towards an understanding of adult judgments of synergistic health benefits

OBJECTIVE

Numerous scientific studies show that certain combinations of dietary and/or lifestyle factors produce health benefits which are greater than the sum of the benefits associated with each factor alone. To address an existing knowledge gap, we assessed the extent to which individuals understand that certain combinations present these 'synergistic health benefits'.

DESIGN

Health benefit judgments were obtained from lay adults for a range of dietary and/or lifestyle combinations that have been found to present synergistic benefits. Association between these judgments and socio-cognitive characteristics such as numeracy, education, and health interest (HI) were examined.

METHODS

Three hundred and fifty-two Swiss adults were presented with a description of one of eight synergistically beneficial combinations. Each participant provided a categorical benefit judgment (i.e., subadditive, additive, or synergistic) for the combination and explained the cognitive reasoning underlying their judgment. Participants completed measures of numeracy and HI.

RESULTS

The proportion of combinations judged to present a synergistic benefit was modest for 'macro-level' combinations (e.g., diet and exercise), but low for 'micro-level' combinations (e.g., two phytochemicals). Cognitive reasoning data showed that a higher proportion of judgments for micro-level (cf. macro-level) combinations were based on greater subjective epistemic uncertainty. Higher interest in health was associated with a better understanding of synergistic benefits, but numeracy and education level were not.

CONCLUSIONS

There is considerable scope to improve the extent to which lay adults understand that specific combination of diet and lifestyle behaviours can synergistically benefit their health. Our results enable us to make informed recommendations for public health interventions.

STATEMENT OF CONTRIBUTION

What is already known on this subject? Combining certain dietary and/or lifestyle factors can result in synergistic health benefits. People could maintain/enhance their health by combining these synergistic combinations. No previous studies have assessed the extent to which people understand that certain factors produce synergistic health benefits. What does this study add? This is the first study to identify that lay awareness of synergistic health benefits could be substantially improved. Neither education level nor numeracy moderate judgments of synergistic benefits, but health interest does. Individuals better understand that broad lifestyle behaviours (cf. specific foods and phytochemicals) are synergistic.

Effects of Numerical Versus Foreground-Only Icon Displays on Understanding of Risk Magnitudes

The aim of this work is to advance knowledge of how to measure gist and verbatim understanding of risk magnitude information and to apply this knowledge to address whether graphics that focus on the number of people affected (the numerator of the risk ratio, i.e., the foreground) are effective displays for increasing (a) understanding of absolute and relative risk magnitudes and (b) risk avoidance. In 2 experiments, the authors examined the effects of a graphical display that used icons to represent the foreground information on measures of understanding (Experiments 1 and 2) and on perceived risk, affect, and risk aversion (Experiment 2). Consistent with prior findings, this foreground-only graphical display increased perceived risk and risk aversion; however, it also led to decreased understanding of absolute (although not relative) risk magnitudes. Methodologically, this work shows the importance of distinguishing understanding of absolute risk from understanding of relative risk magnitudes, and the need to assess gist knowledge of both types of risk. Substantively, this work shows that although using foreground-only graphical displays is an appealing risk communication strategy to increase risk aversion, doing so comes at the cost of decreased understanding of absolute risk magnitudes.

Message Formats, Numeracy, Risk Perceptions of Alcohol-Attributable Cancer, and Intentions for Binge Drinking Among College Students

We conducted an experiment to examine whether risk perceptions of alcohol-attributable cancer influence college students' binge-drinking intention and to explore how message formats (text, table, and graph) and numeracy influence risk perceptions of alcohol-attributable cancer. We found that a majority of participants (87%) perceive some risks of alcohol-attributable cancer. Risk messages in tabular and graphic formats are more effective in elevating risk perceptions, but there is no significant difference between these two formats. Numeracy and its interaction with message formats, however, do not predict risk perceptions. We recommend risk messages should be delivered using tabular or graphic formats to enhance risk perceptions. We also advocate the less-is-more principle in presenting risk information.

Health literacy in an orthopaedic trauma patient population: improving patient comprehension with informational intervention

OBJECTIVES

This study aims to evaluate the change in comprehension of diagnoses, treatment plans, and discharge instructions after orthopaedic trauma patients are given an informational document that includes pictorial representations at the time of discharge. It also seeks to determine if the intervention has a greater impact on patients with lower educational backgrounds.

DESIGN

Prospective comparative cohort study.

SETTING

Academic level 1 trauma center.

PATIENTS

From April to December 2011, 529 orthopaedic trauma patients with an operatively fixed isolated fracture were eligible for inclusion. Two hundred ninety-nine eligible questionnaires were collected (56.5% response rate).

INTERVENTION

Patients were administered a questionnaire regarding their treatment and discharge instructions during their first postoperative clinic visit before being seen by a physician. The questionnaire included demographic information and questions regarding: (1) which bone was fractured, (2) type of implanted fixation, (3) weight-bearing status, (4) expected recovery time, and (5) need for deep vein thrombosis prophylaxis. All patients had received verbal instructions outlining this information at postoperative hospital discharge. During the second half of the study, patients were given an additional informational sheet with both text and pictorial representations at discharge. Multivariable log-binomial regression analyses were used to examine the impact of this intervention.

RESULTS

One hundred forty-six patients were given only the standard discharge instructions, whereas 153 patients were also administered the additional information document. The mean score for patients who received the intervention was 2.90 (out of 5) compared with the mean score of 2.54 for patients who did not receive the intervention (P = 0.013). Patients who received the intervention were 1.3 times more likely to know which bone was fractured (P = 0.007) and 1.1 times more likely to be able to correctly name the medication(s) they were prescribed for deep vein thrombosis prophylaxis (P = 0.03).

CONCLUSIONS

Overall performance on comprehension questionnaires in orthopaedic trauma patients was significantly improved via a text and pictorial intervention. The intervention did not preferentially aid patients with lower education backgrounds. Future studies should evaluate long-term postoperative results to determine if improved patient comprehension has an effect on surgical outcomes and patient satisfaction.

Addressing health literacy in patient decision aids

Background

Effective use of a patient decision aid (PtDA) can be affected by the user’s health literacy and the PtDA’s characteristics. Systematic reviews of the relevant literature can guide PtDA developers to attend to the health literacy needs of patients. The reviews reported here aimed to assess:

1. a) the effects of health literacy / numeracy on selected decision-making outcomes, and b) the effects of interventions designed to mitigate the influence of lower health literacy on decision-making outcomes, and

2. the extent to which existing PtDAs a) account for health literacy, and b) are tested in lower health literacy populations.

Methods

We reviewed literature for evidence relevant to these two aims. When high-quality systematic reviews existed, we summarized their evidence. When reviews were unavailable, we conducted our own systematic reviews.

Results

Aim 1: In an existing systematic review of PtDA trials, lower health literacy was associated with lower patient health knowledge (14 of 16 eligible studies). Fourteen studies reported practical design strategies to improve knowledge for lower health literacy patients. In our own systematic review, no studies reported on values clarity per se, but in 2 lower health literacy was related to higher decisional uncertainty and regret. Lower health literacy was associated with less desire for involvement in 3 studies, less question-asking in 2, and less patient-centered communication in 4 studies; its effects on other measures of patient involvement were mixed. Only one study assessed the effects of a health literacy intervention on outcomes; it showed that using video to improve the salience of health states reduced decisional uncertainty. Aim 2: In our review of 97 trials, only 3 PtDAs overtly addressed the needs of lower health literacy users. In 90% of trials, user health literacy and readability of the PtDA were not reported. However, increases in knowledge and informed choice were reported in those studies in which health literacy needs were addressed.

Conclusion

Lower health literacy affects key decision-making outcomes, but few existing PtDAs have addressed the needs of lower health literacy users. The specific effects of PtDAs designed to mitigate the influence of low health literacy are unknown. More attention to the needs of patients with lower health literacy is indicated, to ensure that PtDAs are appropriate for lower as well as higher health literacy patients.

Blocks, ovals, or people? Icon type affects risk perceptions and recall of pictographs

BACKGROUND

Research has demonstrated that icon arrays (also called "pictographs") are an effective method of communicating risk statistics and appear particularly useful to less numerate and less graphically literate people. Yet research is very limited regarding whether icon type affects how people interpret and remember these graphs.

METHODS

1502 people age 35-75 from a demographically diverse online panel completed a cardiovascular risk calculator based on Framingham data using their actual age, weight, and other health data. Participants received their risk estimate in an icon array graphic that used 1 of 6 types of icons: rectangular blocks, filled ovals, smile/frown faces, an outline of a person's head and shoulders, male/female "restroom" person icons (gender matched), or actual head-and-shoulder photographs of people of varied races (gender matched). In each icon array, blue icons represented cardiovascular events and gray icons represented those who would not experience an event. We measured perceived risk magnitude, approximate recall, and opinions about the icon arrays, as well as subjective numeracy and an abbreviated measure of graphical literacy.

RESULTS

Risk recall was significantly higher with more anthropomorphic icons (restroom icons, head outlines, and photos) than with other icon types, and participants rated restroom icons as most preferred. However, while restroom icons resulted in the highest correlations between perceived and actual risk among more numerate/graphically literate participants, they performed no better than other icon types among less numerate/graphically literate participants.

CONCLUSIONS

Icon type influences both risk perceptions and risk recall, with restroom icons in particular resulting in improved outcomes. However, optimal icon types may depend on numeracy and/or graphical literacy skills.

Winning or losing a bet and the perception of randomness

This study examines the potential effects of random gain, loss, or neutral outcomes on individuals' judgments of randomness in life and in unpredictable life events. Based on existing evidence, we hypothesize that experiencing gain would decrease the perception of randomness, whereas loss would have the opposite effect. One-hundred and ten students participated in a random bet for academic credit required for their introductory psychology course, where they could experience gain (bonus credit), loss (no credit), or neutral (exact credit as promised) outcomes. In addition, they filled out a questionnaire on their beliefs in randomness in general and in various everyday life events, as well as their judgment of the extent to which each event was pre-determined. The results provide partial support for our hypotheses. The participants experiencing a 'neutral' result report the highest level of randomness in general and in everyday life events, as well as the highest extent to which the events were judged as pre-determined. Randomness was judged as lower in both the 'loss' and 'gain' conditions. These patterns only emerge after controlling for gender and religiosity. The results are discussed in light of existing evidence and directions for future studies.

A focus group study on breast cancer risk presentation: one format does not fit all

Identifying a strategy that would optimize both the communication and understanding of the individual breast cancer risk remains a considerable challenge. This study explored the preferences of women with a family history of breast cancer about six presentation formats of individual breast cancer risk, as calculated from a risk prediction model. Thirty-four unaffected women attending genetic counseling because of a family history of breast cancer participated in six focus groups conducted in Québec City (2), Montréal (2) and Toronto (2), Canada. Six risk formats were presented for a fictitious case involving a 35-year-old woman (1-numerical: cumulative risk probabilities by age until 80 years; 2-risk curves: probabilities expressed in a risk curve that also provided a risk curve for a woman with no family history in first-degree relatives; 3-relative risk of breast cancer by age 80 years; 4 and 5-absolute risk of breast cancer and absolute chance of not developing breast cancer in the next 20 years; 6-qualitative: color-coded figure). Participants were asked to indicate their appreciation of each format. A group discussion followed during which participants commented on each format. The most and least appreciated formats were risk curves and relative risk, respectively. Overall, participants advocated the use of formats that combine quantitative, qualitative and visual features. Using a combination of approaches to communicate individual breast cancer risks could be associated with higher satisfaction of counselees. Given the increasing use of risk prediction models, it may be relevant to consider the preferences of both the counselee and the professional.

A counselee-oriented perspective on risk communication in genetic counseling: explaining the inaccuracy of the counselees' risk perception shortly after BRCA1/2 test result disclosure

PURPOSE

Genetic counseling may help counselees understand their genetic risk of developing breast/ovarian cancer. However, many studies have shown that their perception of their risks is inaccurate. Information-oriented variables often predicted the level of accuracy, focusing on specific processes of receiving and processing risks. We examined counselee-oriented predictors about how counselees embed cancer risks in their lives. These predictors reflect the personal meaning of genetic risks and are expected to explain/mediate the impact of genetic counseling on risk-perception-accuracy.

METHOD

We analyzed 248 questionnaires of a prospective study, filled in by probands with breast/ovarian cancer and pathogenic mutations, unclassified variants, or uninformative results (n = 30, 16, and 202, respectively). Mediation regression analyses were performed to examine whether counselee predictors mediated/explained the influence of information predictors on the accuracy. Information-oriented predictors regarded presentation format, communicated information, question format, education, pedigree information, cancer experience, and cognitive processes/heuristics. Counselee-oriented predictors regarded their self/personality, life/existence, and need for certainty about DNA test result, heredity, and cancer.

RESULTS

Both information-oriented and counselee-oriented variables significantly predicted the accuracy of the counselees' risk perception, with moderate to large effect sizes. Counselee-oriented variables completely mediated/explained the effects of information-oriented variables on the accuracy.

DISCUSSION

Counselees seemed to transform objective cancer risks into personally relevant information. Only through this personal meaning of genetic information, information-oriented processes seemed to cause inaccurate perceptions. Genetic counselors are suggested to focus communication on these personal processes.

The effect of numeracy on the comprehension of information about medicines in users of a patient information website

OBJECTIVE

To investigate the relationship between numeracy and the accuracy of side effect risk estimation following the presentation of information about a medicine via the Cancer Research UK (CR-UK) patient information website.

METHODS

591 website users were presented with information in different formats about the risks of side effects from taking tamoxifen. Participants estimated the risk of each side effect, provided other subjective ratings about the information and completed a numeracy task.

RESULTS

Regardless of presentation format, numeracy was correlated with the accuracy of three side effect risk estimates. People with cancer and tamoxifen users showed stronger correlations for all side effect estimates. In addition, numeracy was positively related to the perceived influence of the information on the decision to take the medicine and was negatively related to ratings of satisfaction with the information.

CONCLUSION

People with a lower numeracy level make larger errors in interpreting medicines side effect risk information.

PRACTICE IMPLICATIONS

Pharmacists, other health professionals and patient information websites should ensure they provide clear explanations of risk, particularly to people with low numeracy, and assess their understanding of those explanations. Future research into risk communication should take account of numeracy level, to investigate the impact of different formats.

Interventions for individuals with low health literacy: a systematic review

The U.S. Department of Health and Human Services recently called for action on health literacy. An important first step is defining the current state of the literature about interventions designed to mitigate the effects of low health literacy. We performed an updated systematic review examining the effects of interventions that authors reported were specifically designed to mitigate the effects of low health literacy. We searched MEDLINE®, The Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Educational Resources Information Center (ERIC), and the Cochrane Library databases (2003 forward for health literacy; 1966 forward for numeracy). Two reviewers independently reviewed titles, abstracts, and full-text articles for inclusion and included studies that examined outcomes by health literacy level and met other pre-specified criteria. One reviewer abstracted article information into evidence tables; a second checked accuracy. Two reviewers independently rated study quality using predefined criteria. Among 38 included studies, we found multiple discrete design features that improved comprehension in one or a few studies (e.g., presenting essential information by itself or first, presenting information so that the higher number is better, adding icon arrays to numerical information, adding video to verbal narratives). In a few studies, we also found consistent, direct, fair or good-quality evidence that intensive self-management interventions reduced emergency department visits and hospitalizations; and intensive self- and disease-management interventions reduced disease severity. Evidence for the effects of interventions on other outcomes was either limited or mixed. Multiple interventions show promise for mitigating the effects of low health literacy and could be considered for use in clinical practice.

How discriminating are discriminative instruments?

The McMaster framework introduced by Kirshner & Guyatt is the dominant paradigm for the development of measures of health status and health-related quality of life (HRQL). The framework defines the functions of such instruments as evaluative, predictive or discriminative. Evaluative instruments are required to be sensitive to change (responsiveness), but there is no corresponding index of the degree to which discriminative instruments are sensitive to cross-sectional differences.

This paper argues that indices of validity and reliability are not sufficient to demonstrate that a discriminative instrument performs its function of discriminating between individuals, and that the McMaster framework would be augmented by the addition of a separate index of discrimination. The coefficient proposed by Ferguson (Delta) is easily adapted to HRQL instruments and is a direct, non-parametric index of the degree to which an instrument distinguishes between individuals. While Delta should prove useful in the development and evaluation of discriminative instruments, further research is required to elucidate the relationship between the measurement properties of discrimination, reliability and responsiveness.