The Influence of Skills, Message Frame, and Visual Aids on Prevention of Sexually Transmitted Diseases

Interventions Promoting Condom Use Among Youth: A Systematic Review

In many European and other high-income, Western countries, condom use has been decreasing among youth. A variety of promotional strategies to increase condom use exists. Our systematic review aimed to identify effective elements in interventions aimed at increasing condom use in youth. We searched databases (2010-2021) for intervention studies promoting condom use among youth in Western, high-income countries. The primary outcome was condom use; the secondary outcome was sexually transmitted infection (STI) diagnoses. Effectiveness per intervention was defined based on the percentage of comparisons that showed significant increases in condom use and significant decreases in STIs. We compared the effectiveness of interventions for different participant-, intervention- and methodological characteristics. We included 74 papers describing 85 interventions in the review. Overall, the median intervention effectiveness was 33.3% (interquartile range = 0%-66.7%) for condom use and 0% (interquartile range = 0%-100%) for STI diagnoses. Intervention effectiveness for condom use was significantly higher in interventions tailored towards females and males specifically, compared with interventions applied to both sexes combined. Our findings show the difficulty in designing effective interventions to increase condom use among youth. Interventions aimed at either females or males were more effective in increasing condom use.

Measuring feelings about choices and risks: The Berlin Emotional Responses to Risk Instrument (BERRI)

We introduce a brief instrument specifically validated for measuring positive and negative feelings about risks-the Berlin Emotional Responses to Risk Instrument (BERRI). Based on seven studies involving diverse adults from three countries (n = 2120), the BERRI was found to robustly estimate anticipatory affective reactions derived from subjective evaluations of positive (i.e., assured, hopeful, and relieved) and negative emotions (i.e., anxious, afraid, and worried). The brief BERRI outperformed a 14-item assessment, uniquely tracking costs/benefits associated with cancer screening among men and women (Studies 1 and 2). Predictive validity was further documented in paradigmatic risky choice studies wherein options varied over probabilities and severities across six contexts (health, social, financial, technological, ethical, and environmental; Study 3). Studies 4-6, conducted during the Ebola epidemic and COVID-19 pandemic, indicated BERRI responses were sensitive to subtle effects caused by emotion-related framing manipulations presented in different cultures and languages (the United States, Spain, and Poland). Study 7 indicated BERRI responses remained stable for 2 weeks. Although the BERRI can provide an estimate of overall affect, choices were generally better explained by the unique influences of positive and negative affect. Overall, results suggest the novel, brief instrument can be an efficient tool for high-stakes research on decision making and risk communication.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Probability Size Matters: The Effect of Foreground-Only versus Foreground+Background Graphs on Risk Aversion Diminishes with Larger Probabilities

Graphs are increasingly recommended for improving decision-making and promoting risk-avoidant behaviors. Graphs that depict only the number of people affected by a risk ("foreground-only" displays) tend to increase perceived risk and risk aversion (e.g., willingness to get vaccinated), as compared to graphs that also depict the number of people at risk for harm ("foreground+background" displays). However, previous research examining these "foreground-only effects" has focused on relatively low-probability risks (<10%), limiting generalizability to communications about larger risks. In two experiments, we systematically investigated the moderating role of probability size on foreground-only effects, using a wide range of probability sizes (from 0.1% to 40%). Additionally, we examined the moderating role of the size of the risk reduction, that is, the extent to which a protective behavior reduces the risk. Across both experiments, foreground-only effects on perceived risk and risk aversion were weaker for larger probabilities. Experiment 2 also revealed that foreground-only effects were weaker for smaller risk reductions, while foreground-only displays decreased understanding of absolute risk magnitudes independently of probability size. These findings suggest that the greater effectiveness of foreground-only versus foreground+background displays for increasing perceived risk and risk aversion diminishes with larger probability sizes and smaller risk reductions. Moreover, if the goal is to promote understanding of absolute risk magnitudes, foreground+background displays should be used rather than foreground-only displays regardless of probability size. Our findings also help to refine and extend existing theoretical accounts of foreground-only effects to situations involving a wide range of probability sizes.

Using the Short Graph Literacy Scale to Predict Precursors of Health Behavior Change

BACKGROUND

Visual displays can facilitate risk communication and promote better health choices. Their effectiveness in improving risk comprehension is influenced by graph literacy. However, the construct of graph literacy is still insufficiently understood, partially because existing objective measures of graph literacy are either too difficult or too long.

OBJECTIVES

We constructed a new 4-item Short Graph Literacy (SGL) scale and examined how SGL scores relate to key cognitive, affective, and conative precursors of health behavior change described in common health behavior theories.

METHODS

We performed secondary analyses to adapt the SGL scale from an existing 13-item scale. The initial construction was based on data collected in a laboratory setting in Germany ( n = 51). The scale was then validated using data from nationally representative samples in Germany ( n = 495) and the United States ( n = 492). To examine how SGL scores relate to precursors of health behavior change, we performed secondary analyses of a third study involving a nationwide US sample with 47% participants belonging to racial/ethnic minorities and 46% with limited formal education ( n = 835).

RESULTS

Graph literacy was significantly associated with cognitive precursors in theoretically expected ways (e.g., positive associations with risk comprehension and response efficacy and a negative association with cognitive risk perception). Patterns for affective precursors generally mirrored those for cognitive precursors, although numeracy was a stronger predictor than graph literacy for some affective factors (e.g., feelings of risk). Graph literacy had predictive value for most cognitive and affective precursors beyond numeracy. In addition, graph literacy (but not numeracy) predicted key conative precursors such as defensive processing.

CONCLUSIONS

Our data suggest that the SGL scale is a fast and psychometrically valid method for measuring objective graph literacy. Our findings also highlight the theoretical and practical relevance of graph literacy.

Numeracy and Risk Literacy: What Have We Learned so Far?

Numerical skills are essential to make informed decisions in our daily life. Unfortunately, many people lack basic numeracy, which limits their ability to accurately interpret risks (i.e., risk literacy). In this paper, we provide an overview of research investigating the role of numeracy in two prominent domains, where most research was concentrated, health and finance. We summarize what has been learned so far in these domains and suggest promising venues for future research. We conclude that it is important to conduct interventions to improve numeracy in less numerate individuals and to help them make informed decisions and achieve better life outcomes.

Numeracy Predicts Risk of Pre-Hospital Decision Delay: a Retrospective Study of Acute Coronary Syndrome Survival

BACKGROUND

Many patients delay seeking medical attention during acute coronary syndromes (ACS), profoundly increasing their risk for death and major disability. Although research has identified several risk factors, efforts to improve patient decision making have generally been unsuccessful, prompting a call for more research into psychological factors.

PURPOSE

The purpose of this study is to estimate the relationship between ACS decision delay and numeracy, a factor closely related to general decision making skill and risk literacy.

METHODS

About 5 days after experiencing ACS, 102 survivors (mean age = 58, 32-74) completed a questionnaire including measures of numeracy, decision delay, and other relevant factors (e.g., anxiety, depression, symptom severity, knowledge, demographics).

RESULTS

Low patient numeracy was related to longer decision delay, OR = 0.64 [95 % confidence interval (CI) 0.44, 0.92], which was in turn related to higher odds of positive troponin on arrival at the hospital, OR = 1.37 [95 % CI 1.01, 2.01]. Independent of the influence of all other assessed factors, a patient with high (vs. low) numeracy was about four times more likely to seek medical attention within the critical first hour after symptom onset (i.e., OR_high-low = 3.84 [1.127, 11.65]).

CONCLUSIONS

Numeracy may be one of the largest decision delay risk factors identified to date. Results accord with theories emphasizing potentially pivotal roles of patient deliberation, denial, and outcome understanding during decision making. Findings suggest that brief numeracy assessments may predict which patients are at greater risk for life-threatening decision delay and may also facilitate the design of risk communications that are appropriate for diverse patients who vary in risk literacy.

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.

Improving risk literacy in surgeons

OBJECTIVE

To effectively practice evidence-based medicine, surgeons need to understand and be able to communicate health-relevant numerical information. We present the first study examining risk literacy in surgeons by assessing numeracy and surgical risk comprehension. Our study also investigated whether visual aids improve risk comprehension in surgeons with limited numeracy.

METHODS

Participants were 292 surgeons from 60 countries who completed an instrument measuring numeracy and evaluated the results of a randomized controlled trial including post-surgical side-effects. Half of the surgeons received this information in numbers. The other half received the information represented visually. Accuracy of risk estimation, reading latency, and estimate latency (i.e., deliberation) were assessed.

RESULTS

Some surgeons have low numeracy and could not correctly interpret surgical risks without additional support. Visual aids made risks transparent and eliminated differences in risk understanding between more and less numerate surgeons, increasing the amount of time that less numerate surgeons spent deliberating about risks.

CONCLUSIONS

Visual aids can be an efficient and inexpensive means of improving risk comprehension and clinical judgement in surgeons with low numerical and statistical skills.

PRACTICE IMPLICATIONS

Programs designed to help professionals represent and communicate health-relevant numerical information in simple transparent graphs may unobtrusively promote informed decision making.

Measuring Graph Literacy without a Test: A Brief Subjective Assessment

BACKGROUND

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

OBJECTIVES

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

PARTICIPANTS

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

DESIGN

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

MEASURES

Psychometric properties of the scale.

RESULTS

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

CONCLUSIONS

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

Is patients' numeracy related to physical and mental health?

OBJECTIVE

There is compelling evidence showing that health literacy influences health outcomes. However, there is a dearth of research investigating this issue in the vast literature on numeracy-the ability to accurately interpret numerical information about risk, a skill that is only moderately correlated with health literacy. In a cross-sectional study, we investigated whether objective and subjective numeracy is related to objective and subjective health outcomes. Objective (subjective) numeracy is actual (self-reported) numerical competence. Objective outcomes include prevalence of comorbidity and prescribed medications. Subjective outcomes include perceptions of physical and mental health.

METHODS

A convenience sample of 502 male individuals receiving outpatient care at a Veterans Affairs Medical Center reported their demographics and answered a survey measuring objective and subjective numeracy, trust in physicians, satisfaction with role in medical decision making, perceptions of physical and mental health, and risky habits. We computed patients' body mass index (BMI) and their age-adjusted Charlson index-an extensively studied comorbidity index for predicting mortality in clinical research. We retrieved number of prescribed medications from medical records.

RESULTS

Compared with patients who had high objective numeracy, patients with low objective numeracy showed higher prevalence of comorbidities and took more prescribed medications. Compared with patients who had high subjective numeracy, patients with low subjective numeracy had more negative perceptions of their physical and mental health. These conclusions held after controlling for the effect of demographics, risky habits, BMI, trust in physicians, and satisfaction with role in decision making, suggesting that numeracy has a unique, significant contribution to health outcomes beyond the effect of these factors.

CONCLUSIONS

Our research documents for the first time that self-reported numeracy is related to perceptions of health, whereas objective numeracy is related to actual health, laying the groundwork for future research on the effect of numeracy on health outcomes.

Visual aids improve diagnostic inferences and metacognitive judgment calibration

Visual aids can improve comprehension of risks associated with medical treatments, screenings, and lifestyles. Do visual aids also help decision makers accurately assess their risk comprehension? That is, do visual aids help them become well calibrated? To address these questions, we investigated the benefits of visual aids displaying numerical information and measured accuracy of self-assessment of diagnostic inferences (i.e., metacognitive judgment calibration) controlling for individual differences in numeracy. Participants included 108 patients who made diagnostic inferences about three medical tests on the basis of information about the sensitivity and false-positive rate of the tests and disease prevalence. Half of the patients received the information in numbers without a visual aid, while the other half received numbers along with a grid representing the numerical information. In the numerical condition, many patients–especially those with low numeracy–misinterpreted the predictive value of the tests and profoundly overestimated the accuracy of their inferences. Metacognitive judgment calibration mediated the relationship between numeracy and accuracy of diagnostic inferences. In contrast, in the visual aid condition, patients at all levels of numeracy showed high-levels of inferential accuracy and metacognitive judgment calibration. Results indicate that accurate metacognitive assessment may explain the beneficial effects of visual aids and numeracy–a result that accords with theory suggesting that metacognition is an essential part of risk literacy. We conclude that well-designed risk communications can inform patients about healthrelevant numerical information while helping them assess the quality of their own risk comprehension.

Understanding the Harms and Benefits of Cancer Screening

Objective. Decisions about cancer screenings often involve the consideration of complex and counterintuitive evidence. We investigated psychological factors that promote the comprehension of benefits and harms associated with common cancer screenings and their influence on shared decision making. Methods. In experiment 1, 256 men received information about PSA-based prostate cancer screening. In experiment 2, 355 women received information about mammography-based breast cancer screening. In both studies, information about potential screening outcomes was provided in 1 of 3 formats: text, a fact box, or a visual aid (e.g., mortality with and without screening and rate of overdiagnosis). We modeled the interplay of comprehension, perceived risks and benefits, intention to participate in screening, and desire for shared decision making. Results. Generally, visual aids were the most effective format, increasing comprehension by up to 18%. Improved comprehension was associated with 1) superior decision making (e.g., fewer intentions to participate in screening when it offered no benefit) and 2) more desire to share in decision making. However, comprehension of the evidence had a limited effect on experienced emotions, risk perceptions, and decision making among those participants who felt that the consequences of cancer were extremely severe. Conclusions. Even when information is counterintuitive and requires the integration of complex harms and benefits, user-friendly risk communications can facilitate comprehension, improve high-stakes decisions, and promote shared decision making. However, previous beliefs about the effectiveness of screening or strong fears about specific cancers may interfere with comprehension and informed decision making.

Primary care patients' perspectives of barriers and enablers of primary prevention and health promotion-a meta-ethnographic synthesis

Background

Primary care (PC) patients have difficulties in committing to and incorporating primary prevention and health promotion (PP&HP) activities into their long-term care. We aimed to re-interpret, for the first time, qualitative findings regarding factors affecting PC patients' acceptance of PP&HP activities.

Methods and Findings

A meta-ethnographic synthesis was generated following electronic and manual searches that retrieved 29 articles. Papers were reviewed and translated to produce a re-interpretation of the extracted concepts. The factors affecting PC patients' receptiveness to PP&HP activities were framed in a four-level ecological model (intrapersonal, interpersonal, institutional and environment and society). Intrapersonal factors (patients' beliefs/attitudes, knowledge, skills, self-concept, motivation and resources) were the most numerous, with almost 25 different factors. Public health education to modify erroneous beliefs and values regarding PP&HP could encourage a transition to healthier lifestyles. Health care professionals' abilities to communicate and involve patients in the decision-making process can act as facilitators. Biopsychosocial training (with emphasis on communication skills) for health professionals must start with undergraduates. Increased consultation time, the use of reminders, follow-up visits and tools for communicating risk and motivating patients could be applied at the intrapersonal level. Collaborative care involving other health professionals (nutritionists or psychotherapists) and family and community stakeholders (teachers or gym trainers) was important in developing healthier habits. Patients also cited barriers related to the built environment and socioeconomic difficulties that highlighted the need for policies promoting social justice and equity. Encouraging PP&HP using social marketing strategies and regulating media to control its impact on health were also cited. Only the perspectives of PC patients in the context of chronic conditions were considered thus limiting extrapolation to other contexts.

Conclusions

Several factors affect PP&HP. This must be taken into account when designing PP&HP activities if they are to be successfully implemented and maintained in routine practice.

The moderating role of objective and subjective numeracy in attribute framing

Previous research has found that objective numeracy moderates framing effects: People who are less numerate were found to be more susceptible to goal-framing and attribute-framing effects than people who are highly numerate. This study examined the possibility that subjective numeracy likewise moderates attribute framing in contexts where participants are presented with percentages of success or failure. The results show that compared with highly numerate participants, less numerate participants were more susceptible to the effect of attribute framing. Interestingly, this moderating effect was revealed only when using objective numeracy measures, and not when subjective numeracy measures were used. Future research is suggested to replicate these findings, to establish the generalizability of numeracy as a moderator of other cognitive biases, and to examine several possible theoretical explanations for the differential moderation of attribute-framing bias.