Development and preliminary evaluation of a bowel cancer screening decision aid for adults with lower literacy

Perceptions of primary care patients on the use of electronic clinical decision support tools to facilitate health care: A systematic review

OBJECTIVE

Electronic clinical decision support tools (eCDSTs) are interventions designed to facilitate clinical decision-making using targeted medical knowledge and patient information. While eCDSTs have been demonstrated to improve quality of care, there is a paucity of research relating to the acceptability of eCDSTs in primary care from the patients' perspective. This study aims to summarize current evidence relating to primary care patients' perceptions and experiences on the use of eCDSTs by their clinician to provide care.

METHODS

Four databases (Medline, Embase, CINAHL and Cochrane Library) were searched for qualitative and quantitative studies with outcomes relating to patients' perceptions of the use of clinician-facing or shared-eCDSTs. Data extraction and critical appraisal using the Johanna Briggs Institute Critical Appraisal checklists were carried out independently by reviewers. Qualitative and quantitative outcomes were synthesized independently. We used Richardson et al. 'Patient Evaluation of Artificial Intelligence (AI) in Healthcare' framework for qualitative analysis.

FINDINGS

20 papers were included for synthesis. eCDSTs were generally well-regarded by patients. The key facilitators for use were promoting informed decision-making, prompting discussions, aiding clinical decision-making, and enabling information sharing. Key barriers for use were lack of holistic care, 'medicalized' language, and confidentiality concerns.

CONCLUSION

Our study identified important aspects to consider in the development of future eCDSTs. Patients were generally positive regarding the use of eCDSTs; however, patient's perspectives should be included from the conception of new eCDSTs to ensure recommendations align with the needs of patients and clinicians.

PRACTICE IMPLICATIONS

The study results contribute to ensuring the acceptability of eCDSTs for patients and their unique needs. Encouragement is given for future development to adopt and build upon these findings. Additional research focusing on patients' perceptions of using eCDSTs for specific health conditions is deemed necessary.

Use of a Linguistically Appropriate Decision Aid for Cervical Cancer Screening of South Asian Ethnic Minority Women in Hong Kong: A Pilot Randomised Controlled Trial

BACKGROUND

Decision aids have been shown to be effective in assisting the decision-making process in healthcare settings. This study aimed to examine the feasibility and acceptability of a linguistically appropriate printed decision aid for cervical cancer screening in South Asian women and to preliminarily estimate its effects on decisional conflicts, clarity of values, risk perception, the screening decision and screening uptake.

METHODS

This was a pilot randomised controlled trial. Forty-eight South Asian women aged 25 to 64 years were recruited and allocated to either the intervention group or control group. The participants in the intervention group read a linguistically appropriate printed decision aid.

RESULTS

All of the participants in the intervention group agreed that the decision aid was useful in aiding their decision-making. These participants showed significantly greater improvement in decisional conflicts, clarity of values and risk perceptions than those in the control group (all p < 0.05). The screening uptake rate was significantly higher in the intervention group than in the control group (p < 0.001).

CONCLUSIONS

The decision aid was feasible and acceptable among South Asian women, and it resulted in reduced decisional conflict and increased screening uptake compared with usual care. To improve the convenience of using decision aids, they could be developed in various forms, such as printed and mobile application forms, to meet individual requirements.

TRIAL REGISTRATION

The trial was registered at the Chinese Clinical Trial Registry on 23 October 2021 (ChiCTR2100052225).

The development of a decision aid to support Hodgkin lymphoma survivors considering lung cancer screening

BACKGROUND

Decisions aids (DA) can support patients to make informed decisions about screening tests. This study describes the development and initial evaluation of a lung cancer screening (LCS) DA targeted towards survivors of Hodgkin lymphoma (HL).

METHODS

A prototype decision aid booklet was developed and subsequently reviewed by a steering group who provided feedback. Revisions were made to produce the DA tested in this study. HL survivors were recruited to an online survey and/or focus groups. Lymphoma practitioners were invited to an interview study. In the online survey, decisional conflict scales and knowledge scales were completed before and after accessing the DA. The focus groups and interviews explored acceptability and comprehensibility and the decisional needs of stakeholders. Focus groups and interviews were audio recorded. The framework method was used to analyse qualitative data.

RESULTS

38 HL survivors completed the online survey. Following exposure to the DA, knowledge of LCS and risk factors and decisional conflict scores (total score and subscale scores) improved significantly. 11 HL survivors took part in two focus groups (n = 5 and n = 6) and 11 practitioners were interviewed. Focus group and interview results: The language, format and length were considered acceptable. Both groups felt the DA was balanced and presented a choice. Icon arrays were felt to aid comprehension of absolute risk values and for some survivors, they reduced affective risk perceptions. Among survivors, the impact of radiation risk on decision making varied according to gender and screening interval, whilst practitioners did not anticipate it to be a major concern for patients. Both groups expressed that a screening offer could mitigate anxiety about lung cancer risk. As anticipated by practitioners, survivors expressed a desire to seek advice from their clinical team. Practitioners thought the DA would meet their informational needs regarding LCS  when supporting survivors.

CONCLUSIONS

The DA is considered acceptable by HL survivors and practitioners. The DA reduces decisional conflict and improves knowledge in HL survivors, suggesting that it would support HL survivors to make informed decisions when considering LCS in a future clinical trial.

Implementation of an animated medication information tool in community pharmacies, with a special focus on patients with limited health literacy

OBJECTIVES

The animated medication information tool 'Watchyourmeds' provides information in an accessible manner through animated videos and therefore appears to be especially suitable for people with limited health literacy. This study aimed to assess the implementation of this animated medication information tool in Dutch community pharmacies, with a special focus on patients with limited health literacy.

METHODS

A cross-sectional survey based on the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework was sent to approximately 75% of the ±1900 community pharmacies in the Netherlands through email newsletters of pharmacy networks.

KEY FINDINGS

140 pharmacists (⁓10%) completed the survey and 125 of them (89%) indicated that they offered the animated medication information tool to their patients. 108 pharmacists indicated that the tool was offered to all patients, not only to patients with limited health literacy. The distribution method was primarily passive (patients were given a leaflet and were not explicitly pointed to or informed about the tool). Two frequently cited motivations for offering the tool were that it complemented other sources of information and that the health insurer provided a financial incentive. The main reasons patients refused to use the tool were that they had no access to or no affinity for the required technology.

CONCLUSIONS

This study demonstrated that the tool is used in community pharmacies and that it is offered to all patients, regardless of their presumed health literacy level. A more active method of offering the tool may be warranted to better reach patients with limited health literacy.

Providing Balanced Information about Options in Patient Decision Aids: An Update from the International Patient Decision Aid Standards

BACKGROUND

The objective of this International Patient Decision Aids Standard (IPDAS) review is to update and synthesize theoretical and empirical evidence on how balanced information can be presented and measured in patient decision aids (PtDAs).

METHODS

A multidisciplinary team conducted a scoping review using 2 search strategies in multiple electronic databases evaluating the ways investigators defined and measured the balance of information provided about options in PtDAs. The first strategy combined a search informed by the Cochrane Review of the Effectiveness of Decision Aids with a search on balanced information. The second strategy repeated the search published in the 2013 IPDAS update on balanced presentation.

RESULTS

Of 2450 unique citations reviewed, the full text of 168 articles was screened for eligibility. Sixty-four articles were included in the review, of which 13 provided definitions of balanced presentation, 8 evaluated mechanisms that may introduce bias, and 42 quantitatively measured balanced with methods consistent with the IPDAS criteria in PtDAs. The revised definition of balanced information is, "Objective, complete, salient, transparent, evidence-informed, and unbiased presentation of text and visual information about the condition and all relevant options (with important elements including the features, benefits, harms and procedures of those options) in a way that does not favor one option over another and enables individuals to focus attention on important elements and process this information."

CONCLUSIONS

Developers can increase the balance of information in PtDAs by informing their structure and design elements using the IPDAS checklist. We suggest that new PtDA components pertaining to balance be evaluated for cognitive bias with experimental methods as well by objectively evaluating patients' and content experts' beliefs from multiple perspectives.

A scoping review of the use of visual aids in health education materials for persons with low-literacy levels

OBJECTIVE

To conduct a scoping review on the literature on visual aids in health education for persons with low-literacy.

METHODS

A scoping review methodology was employed. Pre-defined selection criteria identified 47 studies for inclusion. Data were extracted in relation to: (a) definitions of low-literacy and health literacy, (b) population studied, (c) research country, (d) consent procedures, (e) visual aids used, (f) development of visual aids, and (g) targeted outcomes.

RESULTS

Visual aids developed with persons with low-literacy demonstrated statistically significant improvements in health literacy outcomes, with benefits in medication adherence and comprehension also reported. Pictograms and videos were the most effective visual aids. Only one study adapted consent procedures for low-literacy participants.

DISCUSSION

Visual aids in health education materials may benefit persons with low-literacy levels, but large gaps in the research base are evident. Experimental research in low- and middle-income countries, with a particular focus on consent for participants with low-literacy is needed.

PRACTICE IMPLICATIONS

Visual aid design needs to include stakeholders. Consent procedures and decision-making need to be specifically adapted for participants with low-literacy.

"I would not go to him": Focus groups exploring community responses to a public health campaign aimed at reducing unnecessary diagnostic imaging of low back pain

BACKGROUND

Community awareness of the harms of overdiagnosis remains low.

OBJECTIVE

To evaluate community responses to a public health campaign designed for health service waiting rooms that focuses on the harms of unnecessary diagnostic imaging for low back pain.

METHODS

We conducted two focus groups of 19 community members with or without low back pain in Sydney, Australia. This study formed the fourth and final stage of the development process of a public health campaign: (a) initial design, (b) expert review and revision, (c) online experiment and (d) community views & revision. We evaluated reactions to components of the campaign that included digital posters and an information leaflet using strong imagery and messaging about the risk of overdiagnosis. We conducted a qualitative thematic analysis to identify main themes.

RESULTS

Community members reacted with surprise, initial mistrust, and occasionally anger towards imagery and messaging that suggested diagnostic imaging tests could be unnecessary and harmful. With further reflection and discussion, and after reading longer format information about overdiagnosis, the participants found some of the messages informative and useful. Participants appeared to gain a better understanding of the concept of overdiagnosis and the importance of not rushing to imaging.

CONCLUSIONS

Public health campaigns including posters and leaflets displayed in waiting rooms could raise awareness about overuse of diagnostic imaging and the harms of overdiagnosis more broadly. However, negative reactions are possible and must be managed carefully.

PATIENT OR PUBLIC CONTRIBUTION

We involved a community participation manager who provided advice on the focus group discussion guide, participant recruitment and manuscript presentation.

Patient-centred and economic effectiveness of a decision aid for patients with age-related cataract in China: study protocol of a randomised controlled trial

INTRODUCTION

The need for cataract surgery is on the rise due to our ageing population and high demands for greater visual functioning. Although the majority of patients want to participate in a shared decision-making process, no decision aid has been available to improve the quality of decision. The present study aims to determine whether a decision aid increases informed decision about cataract surgery.

METHODS AND ANALYSIS

A parallel randomised controlled trial (772 participants) will be conducted. The decision aid will be implemented among patients with any age-related cataract in Yuexiu District, which is socioeconomically representative of a major metropolitan region in Southern China. Participants will be randomly assigned to receive either a patient decision aid or a traditional booklet, and they will complete three surveys: (1) baseline assessment before the intervention (time point (T)1), 2 weeks (T2) and 1 year (T3) after the intervention. The control group receives a traditional booklet with standard general information developed by the National Eye Institute to help patients understand cataract, whereas the intervention group receives a patient decision aid that includes not only the standard general information, but also the quantitative risk information on the possible outcomes of cataract surgery as well as value clarification exercise. The primary study outcome is the informed decision, the percentage of patients who have adequate knowledge and demonstrate consistency between attitudes and intentions. Secondary outcomes include perceived importance of cataract surgery benefits/harms, decision conflict and confidence, anticipated regret and booklet utilisation and acceptability at 2 weeks, and surgical rates and a cost-utility estimate of the decision aid at 1 year.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of Zhongshan Ophthalmic Center (reference number: 2019KYPJ090). Results will be published in peer-reviewed journals and presented at scientific meetings for academic audiences.

TRIAL REGISTRATION NUMBER

NCT03992807.

Development and preliminary evaluation of a decision aid to support informed choice among patients with age-related cataract

OBJECTIVE

Shared decision making and meaningful patient involvement are key in improving cataract treatment outcomes, but no decision aid has been formally developed and validated for this purpose. Our aims were to develop a patient decision aid to guide patients' decision about when to undergo cataract surgery, and to determine patient's comprehension and booklet's acceptability.

METHODS

The patient decision aid was developed and included evidence-based information about general cataract, its benefits, risks of treatment options, and value clarification exercise. A total of 30 patients with age-related cataract aged between 50 and 80 years were interviewed after using either the patient decision aid (n = 15) or the traditional education booklet (n = 15).

RESULTS

The patients who received the decision aid agreed that the information was new (n = 15, 100%), the length of the aid was "just about right" (n = 13, 87%), the information was clear and easy to understand (n = 13, 87%), the decision aid was helpful in making decision (n = 13, 87%) and would like to recommend this decision aid to others (n = 14, 93%).

CONCLUSIONS

The decision aid was assessed positively by patients with age-related cataract. There is a need for its further verification in the context of primary eye care setting.

Development and pilot-testing of a colorectal cancer screening decision aid for individuals with varying health literacy levels

OBJECTIVE

Making an informed decision about colorectal cancer screening requires health literacy. Our aim was to develop and pilot-test a computer-based decision aid to support informed decision making about whether or not to participate in colorectal cancer screening for individuals with varying health literacy levels in the Netherlands.

METHODS

First, we designed and adapted the decision aid prototype among 25 individuals with low (n = 15) and adequate (n = 10) health literacy. Second, we used a before/after study to assess changes in knowledge, attitude, intention, decisional conflict, deliberation, anxiety and risk perception in an online survey among 81 individuals eligible for colorectal cancer screening with low (n = 35) and adequate (n = 46) health literacy.

RESULTS

The decision aid was acceptable, comprehensible, reduced decisional conflict, increased deliberation and improved knowledge about colorectal cancer screening, but not about colorectal cancer, among individuals with adequate and low health literacy. Usability was slightly higher for participants with adequate health literacy compared to those with low health literacy.

CONCLUSION

The decision aid is promising in supporting informed decision making about colorectal cancer screening, also among individuals with lower health literacy.

PRACTICE IMPLICATIONS

Further refinement of interactive features, such as videos, animations and the values clarification exercise, is needed to increase the usability of the decision aid.

The iPrevent Online Breast Cancer Risk Assessment and Risk Management Tool: Usability and Acceptability Testing

BACKGROUND

iPrevent estimates breast cancer (BC) risk and provides tailored risk management information.

OBJECTIVE

The objective of this study was to assess the usability and acceptability of the iPrevent prototype.

METHODS

Clinicians were eligible for participation in the study if they worked in primary care, breast surgery, or genetics clinics. Female patients aged 18-70 years with no personal cancer history were eligible. Clinicians were first familiarized with iPrevent using hypothetical paper-based cases and then actor scenarios; subsequently, they used iPrevent with their patients. Clinicians and patients completed the System Usability Scale (SUS) and an Acceptability questionnaire 2 weeks after using iPrevent; patients also completed measures of BC worry, anxiety, risk perception, and knowledge pre- and 2 weeks post-iPrevent. Data were summarized using descriptive statistics.

RESULTS

The SUS and Acceptability questionnaires were completed by 19 of 20 clinicians and 37 of 43 patients. Usability was above average (SUS score >68) for 68% (13/19) clinicians and 76% (28/37) patients. The amount of information provided by iPrevent was reported as "about right" by 89% (17/19) clinicians and 89% (33/37) patients and 95% (18/19) and 97% (36/37), respectively, would recommend iPrevent to others, although 53% (10/19) clinicians and 27% (10/37) patients found it too long. Exploratory analyses suggested that iPrevent could improve risk perception, decrease frequency of BC worry, and enhance BC prevention knowledge without changing state anxiety.

CONCLUSIONS

The iPrevent prototype demonstrated good usability and acceptability. Because concerns about length could be an implementation barrier, data entry has been abbreviated in the publicly available version of iPrevent.

A low literacy targeted talking book about radiation therapy for cancer: development and acceptability

PURPOSE

To develop a low literacy talking book (written book with accompanying audio-recording) about radiation therapy and explore its acceptability with patients and caregivers.

METHOD

The talking book was developed iteratively using low literacy design principles and a multidisciplinary committee comprising consumers and experts in radiation oncology, nursing, behavioural sciences, and linguistics. It contained illustrations, photos, and information on: treatment planning, daily treatment, side effects, psychosocial health, and a glossary of medical terms. Semi-structured interviews were conducted with patients who self-reported low functional health literacy and caregivers to explore their views on the resource. Thematic analysis using a framework approach informed the analysis.

RESULTS

Participants were very satisfied with the content, illustrations, and language in the resource. Most were unfamiliar with the term 'talking book', but liked the option of different media (text and audio). The resource was seen as facilitating communication with the cancer care team by prompting question-asking and equipping patients and their families with knowledge to communicate confidently.

CONCLUSIONS

The low literacy talking book was well accepted by patients and their caregivers. The next step is to examine the effect of the resource on patients' knowledge, anxiety, concerns, and communication with the cancer care team.

Patient-rated importance of key information on screening colonoscopy in Germany: a survey of statutory health insurance members

BACKGROUND

Primary colonoscopic screening is considered to be of great benefit but also has the potential to cause severe harm. Thus, eligible subjects should be supported in making an informed choice whether to participate.

OBJECTIVES

To identify information on screening colonoscopy that colonoscopy-naïve subjects rate as particularly important for decision making.

DESIGN

Survey of German statutory health insurance members using a written questionnaire in November 2015.

STUDY POPULATION

Colonoscopy-naïve individuals aged 50 to 65 years.

MAIN OUTCOME MEASURES

Importance of key information about screening colonoscopy, including potential risks and benefits, baseline risk of colorectal cancer/polyps and practical aspects of the procedure, as well as associations between participants' characteristics and their judgement of information as to being 'very important'.

RESULTS

Of 1871 respondents (overall response rate: 31%), a subgroup of 370 colonoscopy-naïve subjects was eligible for inclusion (average age: 55 years, 47% male). Information on the risks was rated as very important by most respondents, unimportant by 6%. Information on the benefits was considered unimportant by 26%. Regression analysis showed that less educated persons regarded most items to be more often relevant than highly educated subjects. A greater proportion of women than men rated details regarding pain and practical aspects as very important. Subjects with a low educational level living alone were identified as the group with the least interest in information on risks.

CONCLUSION

Cultivating awareness around the central meaning of the (quantitative) benefits of screening in informed decision making should be focused on more in future information materials. The high requirement of less educated people to become more informed provides a strong motivation for further efforts to develop evidence-based information that adequately informs this group. Tailoring information according to gender-specific needs may be warranted in light of the observed differences in information preferences between women and men.

Can child restraint product information developed using consumer testing sustain correct use 6 months after child restraint purchase? Study protocol for a cluster randomised controlled trial

BACKGROUND

With long-standing and widespread high rates of errors in child restraint use, there is a need to identify effective methods to address this problem. Information supplied with products at the point of sale may be a potentially efficient delivery point for such a countermeasure. The aim of this study is to establish whether product materials developed using a consumer-driven approach reduce errors in restraint use among purchasers of new child restraint systems.

METHODS

A cluster randomised controlled trial (cRCT) will be conducted. Retail stores (n=22) in the greater Sydney area will be randomised into intervention sites (n=11) and control sites (n=11), stratified by geographical and socioeconomic indicators. Participants (n=836) will enter the study on purchase of a restraint. Outcome measures are errors in installation of the restraint as observed by a trained researcher during a 6-month follow-up home assessment, and adjustment checks made by the parent when the child is placed into the restraint (observed using naturalistic methods). Process evaluation measures will also be collected during the home visit. An intention-to-treat approach will be used for all analyses. Correct use and adjustment checks made by the parent will be compared between control and intervention groups using a logistic regression model. The number of installation errors between groups will be compared using Poisson regression.

DISCUSSION

This cRCT will determine the effectiveness of targeted, consumer-driven information on actual error rates in use of restraints. More broadly, it may provide a best practice model for developing safety product information.

TRIAL REGISTRATION NUMBER

ACTRN12617001252303p; Pre-results.

Common methods of measuring 'informed choice' in screening participation: Challenges and future directions

There is general agreement among public health practitioners, academics, and policymakers that people offered health screening tests should be able to make informed choices about whether to accept. Robust measures are necessary in order to gauge the extent to which informed choice is achieved in practice and whether efforts to improve it have succeeded. This review aims to add to the literature on how to improve methods of measuring informed choice. We discuss and critique commonly-used approaches and outline possible alternative methods that might address the issues identified. We explore the challenges of defining what information should be provided about screening and hence understood by service users, appraise the use of 'thresholds' to define e.g. positive attitudes towards screening, and describe problems inherent in conceptualising 'informed choice' as a single dichotomous outcome that either does or does not occur. Suggestions for future research include providing greater detail on why particular aspects of screening information were considered important, analysing knowledge and attitude measures at an ordinal or continuous level (avoiding problematic decisions about dichotomising data in order to set thresholds), and reconceptualising informed choice as a multifactorial set of outcomes, rather than a unitary one.

Effects of Design Features of Explicit Values Clarification Methods

Background. Diverse values clarification methods exist. It is important to understand which, if any, of their design features help people clarify values relevant to a health decision. Purpose. To explore the effects of design features of explicit values clarification methods on outcomes including decisional conflict, values congruence, and decisional regret. Data Sources. MEDLINE, all EBM Reviews, CINAHL, EMBASE, Google Scholar, manual search of reference lists, and expert contacts. Study Selection. Articles were included if they described the evaluation of 1 or more explicit values clarification methods. Data Extraction. We extracted details about the evaluation, whether it was conducted in the context of actual or hypothetical decisions, and the results of the evaluation. We combined these data with data from a previous review about each values clarification method’s design features. Data Synthesis. We identified 20 evaluations of values clarification methods within 19 articles. Reported outcomes were heterogeneous. Few studies reported values congruence or postdecision outcomes. The most promising design feature identified was explicitly showing people the implications of their values, for example, by displaying the extent to which each of their decision options aligns with what matters to them. Limitations. Because of the heterogeneity of outcomes, we were unable to perform a meta-analysis. Results should be interpreted with caution. Conclusions. Few values clarification methods have been evaluated experimentally. More research is needed to determine effects of different design features of values clarification methods and to establish best practices in values clarification. When feasible, evaluations should assess values congruence and postdecision measures of longer-term outcomes.

Design Features of Explicit Values Clarification Methods

Background. Values clarification is a recommended element of patient decision aids. Many different values clarification methods exist, but there is little evidence synthesis available to guide design decisions. Purpose. To describe practices in the field of explicit values clarification methods according to a taxonomy of design features. Data Sources. MEDLINE, all EBM Reviews, CINAHL, EMBASE, Google Scholar, manual search of reference lists, and expert contacts. Study Selection. Articles were included if they described 1 or more explicit values clarification methods. Data Extraction. We extracted data about decisions addressed; use of theories, frameworks, and guidelines; and 12 design features. Data Synthesis. We identified 110 articles describing 98 explicit values clarification methods. Most of these addressed decisions in cancer or reproductive health, and half addressed a decision between just 2 options. Most used neither theory nor guidelines to structure their design. “Pros and cons” was the most common type of values clarification method. Most methods did not allow users to add their own concerns. Few methods explicitly presented tradeoffs inherent in the decision, supported an iterative process of values exploration, or showed how different options aligned with users’ values. Limitations. Study selection criteria and choice of elements for the taxonomy may have excluded values clarification methods or design features. Conclusions. Explicit values clarification methods have diverse designs but can be systematically cataloged within the structure of a taxonomy. Developers of values clarification methods should carefully consider each of the design features in this taxonomy and publish adequate descriptions of their designs. More research is needed to study the effects of different design features.

Towards informed decisions on breast cancer screening: Development and pilot testing of a decision aid for Chinese women

OBJECTIVE

To pilot-test a novel, self-use breast cancer (BC) screening decision aid (DA) targeting Hong Kong (HK) Chinese women at average risk of BC.

METHODS

Women were recruited through a population-based telephone survey using random digit dialling between October 2013 and January 2014. Eligible participants completed our baseline survey and then received the DA by post. Participants (n=90) completed follow-up telephone interviews one month later.

RESULTS

Most participants thought that all/most DA content was presented clearly (86.7%), and was useful in helping women make screening-related decisions (88.9%). It also achieved its expected impact of improving informed decision-making and increasing shared-participation preference without increasing participants' anxiety levels. Participants showed a modest non-statistical increase in their screening knowledge scores. Older women rated the perceived severity of a BC diagnosis as significantly lower, and more educated women reported significantly lower perceived anxiety about the disease.

CONCLUSION

Our DA appears acceptable and feasible for self-use by HK Chinese women who need to make an informed decision about BC screening without increasing overall anxiety levels.

PRACTICE IMPLICATIONS

This study supports the potential of self-use DAs for cancer screening-related decision support in a Chinese population.

People's willingness to accept overdetection in cancer screening: population survey

OBJECTIVES

To describe the level of overdetection people would find acceptable in screening for breast, prostate, and bowel cancer and whether acceptability is influenced by the magnitude of the benefit from screening and the cancer specific harms from overdetection.

DESIGN

Online survey. Women were presented with scenarios on breast and bowel cancer, men with scenarios on prostate and bowel cancer. For each particular cancer, we presented epidemiological information and described the treatment and its consequences. Secondly, we presented two different scenarios of benefit: one indicating a 10% reduction in cancer specific mortality and the second indicating a 50% reduction.

SETTING

Online survey of the population in the United Kingdom.

PARTICIPANTS

Respondents were part of an existing panel of people who volunteer for online research and were invited by email or online marketing. We recruited 1000 respondents, representative for age and sex for the UK population.

MAIN OUTCOME MEASURES

Number of cases of overdetection people were willing to accept, ranging from 0-1000 (complete screened population) for each cancer modality and each scenario of benefit.

RESULTS

There was large variability between respondents in the level of overdetection they would find acceptable, with medians ranging from 113 to 313 cases of overdetection per 1000 people screened. Across all scenarios, 4-7% of respondents indicated they would accept no overdetection at all compared with 7-14% who thought that it would be acceptable for the entire screened population to be overdetected. Acceptability in screening for bowel cancer was significantly lower than for breast and prostate cancer. People aged 50 or over accepted significantly less overdetection, whereas people with higher education levels accepted more; 29% of respondents had heard of overdetection before.

CONCLUSIONS

Acceptability of overdetection in cancer screening is variable. Invitations for screening should include clear information on the likelihood and consequences of overdetection to allow people to make an informed choice.

Overdetection in breast cancer screening: development and preliminary evaluation of a decision aid

OBJECTIVE

To develop, pilot and refine a decision aid (ahead of a randomised trial evaluation) for women around age 50 facing their initial decision about whether to undergo mammography screening.

DESIGN

Two-stage mixed-method pilot study including qualitative interviews (n=15) and a randomised comparison using a quantitative survey (n=34).

SETTING

New South Wales, Australia.

PARTICIPANTS

Women aged 43-59 years with no personal history of breast cancer.

INTERVENTIONS

The decision aid provides evidence-based information about important outcomes of mammography screening over 20 years (breast cancer mortality reduction, overdetection and false positives) compared with no screening. The information is presented in a short booklet for women, combining text and visual formats. A control version produced for the purposes of comparison omits the overdetection-related content.

OUTCOMES

Comprehension of key decision aid content and acceptability of the materials.

RESULTS

Most women considered the decision aid clear and helpful and would recommend it to others. Nonetheless, the piloting process raised important issues that we tried to address in iterative revisions. Some participants found it hard to understand overdetection and why it is of concern, while there was often confusion about the distinction between overdetection and false positives. In a screening context, encountering balanced information rather than persuasion appears to be contrary to people's expectations, but women appreciated the opportunity to become better informed.

CONCLUSIONS

The concept of overdetection is complex and new to the public. This study highlights some key challenges for communicating about this issue. It is important to clarify that overdetection differs from false positives in terms of its more serious consequences (overtreatment and associated harms). Screening decision aids also must clearly explain their purpose of facilitating informed choice. A staged approach to development and piloting of decision aids is recommended to further improve understanding of overdetection and support informed decision-making about screening.

Communicating the benefits and harms of colorectal cancer screening needed for an informed choice: a systematic evaluation of leaflets and booklets

OBJECTIVE

Evidence-based health information (EBHI) can support informed choice regarding whether or not to attend colorectal cancer (CRC) screening. The present study aimed to assess if German leaflets and booklets appropriately inform consumers on the benefits and harms of CRC screening.

METHODS

A systematic search for print media on CRC screening was performed via email enquiry and internet search. The identified documents were assessed for the presence and correctness of information on benefits and harms by two reviewers independently using a comprehensive list of criteria.

RESULTS

Many of the 28 leaflets and 13 booklets identified presented unbalanced information on the benefits and harms of CRC screening: one-third did not provide any information on harms. Numeracy information was often lacking. Ten cross-language examples of common misinterpretations or basically false and misleading information were identified.

DISCUSSION

Most of the CRC screening leaflets and booklets in Germany do not meet current EBHI standards. After the study, the publishers of the information materials were provided feedback, including a discussion of our findings. The results can be used to revise existing information materials or to develop new materials that provide correct, balanced, quantified, understandable and unbiased information on CRC screening.

Informed choice in bowel cancer screening: a qualitative study to explore how adults with lower education use decision aids

BACKGROUND

Offering informed choice in screening is increasingly advocated, but little is known about how evidence-based information about the benefits and harms of screening influences understanding and participation in screening.

OBJECTIVE

We aimed to explore how a bowel cancer screening decision aid influenced decision making and screening behaviour among adults with lower education and literacy.

METHODS

Twenty-one men and women aged 55-64 years with lower education levels were interviewed about using a decision aid to make their screening decision. Participants were purposively selected to include those who had and had not made an informed choice.

RESULTS

Understanding the purpose of the decision aid was an important factor in whether participants made an informed choice about screening. Participants varied in how they understood and integrated quantitative risk information about the benefits and harms of screening into their decision making; some read it carefully and used it to justify their screening decision, whereas others dismissed it because they were sceptical of it or lacked confidence in their own numeracy ability. Participants' prior knowledge and beliefs about screening influenced how they made sense of the information.

DISCUSSION AND CONCLUSIONS

Participants valued information that offered them a choice in a non-directive way, but were concerned that it would deter people from screening. Healthcare providers need to be aware that people respond to screening information in diverse ways involving a range of literacy skills and cognitive processes.

A content analysis of visual cancer information: prevalence and use of photographs and illustrations in printed health materials

Researchers and practitioners have an increasing interest in visual components of health information and health communication messages. This study contributes to this evolving body of research by providing an account of the visual images and information featured in printed cancer communication materials. Using content analysis, 147 pamphlets and 858 images were examined to determine how frequently images are used in printed materials, what types of images are used, what information is conveyed visually, and whether or not current recommendations for the inclusion of visual content were being followed. Although visual messages were found to be common in printed health materials, existing recommendations about the inclusion of visual content were only partially followed. Results are discussed in terms of how relevant theoretical frameworks in the areas of behavior change and visual persuasion seem to be used in these materials, as well as how more theory-oriented research is necessary in visual messaging efforts.

The effect of information about overdetection of breast cancer on women's decision-making about mammography screening: study protocol for a randomised controlled trial

INTRODUCTION

Women are largely unaware that mammography screening can cause overdetection of inconsequential disease, leading to overdiagnosis and overtreatment of breast cancer. Evidence is lacking about how information on overdetection affects women's breast screening decisions and experiences. This study investigates the consequences of providing information about overdetection of breast cancer to women approaching the age of invitation to mammography screening.

METHODS AND ANALYSIS

This is a randomised controlled trial with an embedded longitudinal qualitative substudy. Participants are a community sample of women aged 48-50 in New South Wales, Australia, recruited in 2014. Women are randomly allocated to either quantitative only follow-up (n=904) or additional qualitative follow-up (n=66). Women in each stream are then randomised to receive either the intervention (evidence-based information booklet including overdetection, breast cancer mortality reduction and false positives) or a control information booklet (including mortality reduction and false positives only). The primary outcome is informed choice about breast screening (adequate knowledge, and consistency between attitudes and intentions) assessed via telephone interview at 2 weeks postintervention. Secondary outcomes measured at this time include decision process (decisional conflict and confidence) and psychosocial outcomes (anticipated regret, anxiety, breast cancer worry and perceived risk). Women are further followed up at 6 months, 1 and 2 years to assess self-reported screening behaviour and long-term psychosocial outcomes (decision regret, quality of life). Participants in the qualitative stream undergo additional in-depth interviews at each time point to explore the views and experiences of women who do and do not choose to have screening.

ETHICS AND DISSEMINATION

The study has ethical approval, and results will be published in peer-reviewed journals. This research will help ensure that information about overdetection may be communicated clearly and effectively, using an evidence-based approach, to women considering breast cancer screening.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry ACTRN12613001035718.

Balancing the presentation of information and options in patient decision aids: an updated review

Background

Standards for patient decision aids require that information and options be presented in a balanced manner; this requirement is based on the argument that balanced presentation is essential to foster informed decision making. If information is presented in an incomplete/non-neutral manner, it can stimulate cognitive biases that can unduly affect individuals’ knowledge, perceptions of risks and benefits, and, ultimately, preferences. However, there is little clarity about what constitutes balance, and how it can be determined and enhanced. We conducted a literature review to examine the theoretical and empirical evidence related to balancing the presentation of information and options.

Methods

A literature search related to patient decision aids and balance was conducted on Medline, using MeSH terms and PubMed; this search supplemented the 2011 Cochrane Collaboration’s review of patient decision aids trials. Only English language articles relevant to patient decision making and addressing the balance of information and options were included. All members of the team independently screened clusters of articles; uncertainties were resolved by seeking review by another member. The team then worked in sub-groups to extract and synthesise data on theory, definitions, and evidence reported in these studies.

Results

A total of 40 articles met the inclusion criteria. Of these, six explained the rationale for balancing the presentation of information and options. Twelve defined “balance”; the definition of “balance” that emerged is as follows: “The complete and unbiased presentation of the relevant options and the information about those options—in content and in format—in a way that enables individuals to process this information without bias”. Ten of the 40 articles reported assessing the balance of the relevant decision aid. All 10 did so exclusively from the users’ or patients’ perspective, using a five-point Likert-type scale. Presenting information in a side-by-side display form was associated with more respondents (ranging from 70% to 96%) judging the information as “balanced”.

Conclusion

There is a need for comparative studies investigating different ways to improve and measure balance in the presentation of information and options in patient decision aids.

A theoretical framework for measuring knowledge in screening decision aid trials

OBJECTIVE

To describe a theoretical framework for assessing knowledge about the possible outcomes of participating in bowel cancer screening for the faecal occult blood test.

METHODS

The content of the knowledge measure was based on the UK General Medical Council's screening guidelines and a theory-based approach to assessing gist knowledge (Fuzzy Trace Theory). It comprised conceptual and numeric questions to assess knowledge of the underlying construct (e.g. false positive concept) and the approximate numbers affected (e.g. likelihood of a false positive). The measure was used in a randomised controlled trial involving 530 adults with low education, to compare the impact of a bowel screening decision aid with a screening information booklet developed for the Australian Government National Bowel Cancer Screening Program.

RESULTS

The numeric knowledge scale was particularly responsive to the effects of the decision aid; at follow-up decision aid participants' numeric knowledge was significantly greater than the controls (P<0.001). This contrasts with the conceptual knowledge scale which improved significantly in both groups from baseline to follow-up (P<0.001).

CONCLUSION

Our theory-based knowledge measure was responsive to change in conceptual knowledge and to the effect on numeric knowledge of a decision aid.

PRACTICE IMPLICATIONS

This theoretical framework has the potential to guide the development of knowledge measures in other screening settings.

Testing a Spanish-language colorectal cancer screening decision aid in Latinos with limited English proficiency: results from a pre-post trial and four month follow-up survey

BACKGROUND

Compared with non-Latinos, Latinos in the US have low rates of colorectal cancer (CRC) screening and low rates of knowledge regarding CRC screening tests and guidelines. Spanish speaking Latinos have particularly low CRC screening rates and screening knowledge. Our purpose was twofold: (1) to evaluate the effect of a computer-based, Spanish-language CRC screening decision aid on screening knowledge, intent to obtain screening, and screening self-efficacy in a community sample of Latinos with limited English proficiency (LEP); and (2) to survey these decision aid viewers at four months to determine their rates of CRC discussions with a health care provider as well as their rates of screening test completion.

METHODS

We recruited 50-75 year old Latinos with LEP who were not current with CRC. Participants screening viewed a 14 minute multimedia decision aid that addresses CRC screening rationale, recommendations, and options. We conducted an uncontrolled (pre-post) study in which we assessed screening knowledge, self-efficacy, and intent at baseline and immediately after decision aid viewing. We also conducted a follow-up telephone survey of participants at four months to examine rates of patient-provider screening discussions and test completion.

RESULTS

Among n = 80 participants, knowledge scores increased from 20% (before) to 72% (after) decision aid viewing (absolute difference [95%CI]: 52% [46, 59]). The proportion with high screening self-efficacy increased from 67% to 92% (25% [13, 37]); the proportion with high screening intent increased from 63% to 95% (32% [21, 44]). We reached 68 (85%) of 80 participants eligible for the follow-up survey. Of these 36 (53%) reported discussing screening with a provider and 13 (19%) completed a test.

CONCLUSION

Viewing a Spanish-language decision aid increased CRC screening knowledge, self-efficacy, and intent among Latinos with LEP. Decision aid viewing appeared to promote both CRC screening discussions with health care providers and test completion. The decision aid may be an effective tool for promoting CRC screening and reducing screening disparities in this population.

Effects of health literacy to self-efficacy and preventive care utilization among older adults

AIM

This study examined the relationships between health literacy, self-efficacy and preventive care utilization among older adults in Taiwan.

METHODS

The data were from a longitudinal survey, "Taiwan Longitudinal Study in Aging" in 2003 and 2007. A total of 3479 participants who completed both two waves were included for analysis. Health literacy first was constructed through education, cognitive function and disease knowledge through structural equation modeling (SEM); then, the associations of health literacy to later self-efficacy and preventive care were examined.

RESULTS

The model fit of SEM was good, indicating that the construct of health literacy was appropriate. Healthy literacy showed a moderate positive effect on self-efficacy and a small positive effect on preventive care utilization.

CONCLUSIONS

Health literacy increases self-efficacy and utilization of preventive care. Promoting people's health knowledge and health literacy is suggested.

A decision aid to support informed choices about bowel cancer screening among adults with low education: randomised controlled trial

OBJECTIVE

To determine whether a decision aid designed for adults with low education and literacy can support informed choice and involvement in decisions about screening for bowel cancer.

DESIGN

Randomised controlled trial.

SETTING

Areas in New South Wales, Australia identified as socioeconomically disadvantaged (low education attainment, high unemployment, and unskilled occupations).

PARTICIPANTS

572 adults aged between 55 and 64 with low educational attainment, eligible for bowel cancer screening.

INTERVENTION

Patient decision aid comprising a paper based interactive booklet (with and without a question prompt list) and a DVD, presenting quantitative risk information on the possible outcomes of screening using faecal occult blood testing compared with no testing. The control group received standard information developed for the Australian national bowel screening programme. All materials and a faecal occult blood test kit were posted directly to people's homes.

MAIN OUTCOME MEASURES

Informed choice (adequate knowledge and consistency between attitudes and screening behaviour) and preferences for involvement in screening decisions.

RESULTS

Participants who received the decision aid showed higher levels of knowledge than the controls; the mean score (maximum score 12) for the decision aid group was 6.50 (95% confidence interval 6.15 to 6.84) and for the control group was 4.10 (3.85 to 4.36; P<0.001). Attitudes towards screening were less positive in the decision aid group, with 51% of the participants expressing favourable attitudes compared with 65% of participants in the control group (14% difference, 95% confidence interval 5% to 23%; P=0.002). The participation rate for screening was reduced in the decision aid group: completion of faecal occult blood testing was 59% v 75% in the control group (16% difference, 8% to 24%; P=0.001). The decision aid increased the proportion of participants who made an informed choice, from 12% in the control group to 34% in the decision aid group (22% difference, 15% to 29%; P<0.001). More participants in the decision aid group had no decisional conflict about the screening decision compared with the controls (51% v 38%; P=0.02). The groups did not differ for general anxiety or worry about bowel cancer.

CONCLUSIONS

Tailored decision support information can be effective in supporting informed choices and greater involvement in decisions about faecal occult blood testing among adults with low levels of education, without increasing anxiety or worry about developing bowel cancer. Using a decision aid to make an informed choice may, however, lead to lower uptake of screening. Trial registration ClinicalTrials.gov NCT00765869 and Australian New Zealand Clinical Trials Registry 12608000011381.

Australia's national bowel cancer screening program: does it work for indigenous Australians?

BACKGROUND

Despite a lower incidence of bowel cancer overall, Indigenous Australians are more likely to be diagnosed at an advanced stage when prognosis is poor. Bowel cancer screening is an effective means of reducing incidence and mortality from bowel cancer through early identification and prompt treatment. In 2006, Australia began rolling out a population-based National Bowel Cancer Screening Program (NBCSP) using the Faecal Occult Blood Test. Initial evaluation of the program revealed substantial disparities in bowel cancer screening uptake with Indigenous Australians significantly less likely to participate in screening than the non-Indigenous population.This paper critically reviews characteristics of the program which may contribute to the discrepancy in screening uptake, and includes an analysis of organisational, structural, and socio-cultural barriers that play a part in the poorer participation of Indigenous and other disadvantaged and minority groups.

METHODS

A search was undertaken of peer-reviewed journal articles, government reports, and other grey literature using electronic databases and citation snowballing. Articles were critically evaluated for relevance to themes that addressed the research questions.

RESULTS

The NBCSP is not reaching many Indigenous Australians in the target group, with factors contributing to sub-optimal participation including how participants are selected, the way the screening kit is distributed, the nature of the test and comprehensiveness of its contents, cultural perceptions of cancer and prevailing low levels of knowledge and awareness of bowel cancer and the importance of screening.

CONCLUSIONS

Our findings suggest that the population-based approach to implementing bowel cancer screening to the Australian population unintentionally excludes vulnerable minorities, particularly Indigenous and other culturally and linguistically diverse groups. This potentially contributes to exacerbating the already widening disparities in cancer outcomes that exist among Indigenous Australians. Modifications to the program are recommended to facilitate access and participation by Indigenous and other minority populations. Further research is also needed to understand the needs and social and cultural sensitivities of these groups around cancer screening and inform alternative approaches to bowel cancer screening.