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

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

HIGHLIGHTS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

HIGHLIGHTS

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

Integrating participant feedback and concerns to improve community and individual level chemical exposure assessment reports

BACKGROUND

As exposure assessment has shifted towards community-engaged research there has been an increasing trend towards reporting results to participants. Reports aim to increase environmental health literacy, but this can be challenging due to the many unknowns regarding chemical exposure and human health effects. This includes when reports encompass a wide-range of chemicals, limited reference or health standards exist for those chemicals, and/or incompatibility of data generated from exposure assessment tools with published reference values (e.g., comparing a wristband concentration to an oral reference dose).

METHODS

Houston Hurricane Harvey Health (Houston-3H) participants wore silicone wristbands that were analyzed for 1,530 organic compounds at two time-points surrounding Hurricane Harvey. Three focus groups were conducted in separate neighborhoods in the Houston metropolitan area to evaluate response to prototype community and individual level report-backs. Participants (n = 31) evaluated prototype drafts using Likert scales and discussion prompts. Focus groups were audio-recorded, and transcripts were analyzed using a qualitative data analysis program for common themes, and quantitative data (ranking, Likert scales) were statistically analyzed.

RESULTS

Four main themes emerged from analysis of the transcripts: (1) views on the report layout; (2) expression of concern over how chemicals might impact their individual or community health; (3) participants emotional response towards the researchers; and (4) participants ability to comprehend and evaluate environmental health information. Evaluation of the report and key concerns differed across the three focus groups. However, there was agreement amongst the focus groups about the desire to obtain personal exposure results despite the uncertainty of what the participant results meant.

CONCLUSIONS

The report-back of research results (RBRR) for community and individual level exposure assessment data should keep the following key principles in mind: materials should be accessible (language level, data visualization options, graph literacy), identify known information vs unknown (e.g., provide context for what exposure assessment data means, acknowledge lack of current health standards or guidelines), recognize and respect community knowledge and history, and set participant expectations for what they can expect from the report.

Numeracy, gist, literal thinking and the value of nothing in decision making

The onus on the average person is greater than ever before to make sense of large amounts of readily accessible quantitative information, but the ability and confidence to do so are frequently lacking. Many people lack practical mathematical skills that are essential for evaluating risks, probabilities and numerical outcomes such as survival rates for medical treatments, income from retirement savings plans or monetary damages in civil trials. In this Review, we integrate research on objective and subjective numeracy, focusing on cognitive and metacognitive factors that distort human perceptions and foment systematic biases in judgement and decision making. Paradoxically, an important implication of this research is that a literal focus on objective numbers and mechanical number crunching is misguided. Numbers can be a matter of life and death but a person who uses rote strategies (verbatim representations) cannot take advantage of the information contained in the numbers because 'rote' strategies are, by definition, processing without meaning. Verbatim representations (verbatim is only surface form, not meaning) treat numbers as data as opposed to information. We highlight a contrasting approach of gist extraction: organizing numbers meaningfully, interpreting them qualitatively and making meaningful inferences about them. Efforts to improve numerical cognition and its practical applications can benefit from emphasizing the qualitative meaning of numbers in context - the gist - building on the strengths of humans as intuitive mathematicians. Thus, we conclude by reviewing evidence that gist training facilitates transfer to new contexts and, because it is more durable, longer-lasting improvements in decision making.

Health Literacy of Surrogates and Communication Issues in Palliative Care Conversations in Critical Care: An Integrative Review

Worldwide, 56.8 million persons are estimated to require palliative care. Critically ill patients benefit from palliative care by improving their quality of life through symptom management. Resistance to palliative care exists from surrogate decision-makers because of low health literacy and communication issues with providers. This research reviewed the literature to identify how health literacy and health care communication influenced palliative care conversations with decision-making surrogates and health outcomes of critically ill patients. The review included articles between 2011 and 2022 using the terms communication, health literacy, palliative care, critical care, intensive care, ICU, surrogate decision maker, family, and caregiver in PubMed, CINAHL, and Google Scholar. Fourteen articles were included. Quality was assessed through Joanna Briggs Institute appraisal tools. Health literacy of surrogates was not found to be significant for patient outcomes. However, there were significant differences between clinician and surrogate communication influenced by surrogates' previous health care experiences. Early communication about prognosis was important for surrogates. Structured communication approaches were preferred by surrogates. Limitations of the review included primarily White participants, small variability of research sites, and a few number of articles. Future research needs to study the effects of surrogate health literacy of critically ill patients on willingness to accept palliative care.

Understanding quality data correctly: a randomized comparison of presentation formats among cancer patients and relatives

Background: Patient representatives are increasingly engaged in quality in health care, and even though quality data are publicly available, correct interpretation may be challenging. We designed a randomized study with the primary aim to examine the association between preferred data presentation format and the interpretation of quality data among cancer patients and relatives.Material and methods: Surveys were distributed to the Danish Cancer Society Citizens' Panel between 31 March and 14 April 2019 and 55% completed the survey (N = 464) including six storyboards that presented authentic quality data in table format, league table and point estimates. The storyboards were randomized to expose participants to the data in the three different formats and in varying presentation order. Logistic regression models were used to calculate Odds Ratios (ORs) and 95% confidence intervals (CIs) for the association between preferred presentation format, health literacy, education and cohabitation status as exposures and interpretation of quality data as outcome.Results: The majority of participants (97%) had high literacy and 57% had a medium or long higher education. A total of 60% found the questions difficult or very difficult and 33% were not able to correctly interpret at least one format. Correct interpretation was associated with preferred league table (OR = 1.62; 95% CI = 1.04-5.52) and if the data was presented in the preferred format. Medium and long education were associated with correct interpretation of at least one format (OR = 1.93; 95% CI = 1.16-3.21 and OR = 3.89; 95% CI = 1.90-7.95, respectively) while health literacy and cohabitation status were not.Conclusions: More than one third of the participants were not able to correctly interpret the data and the understanding of quality data improved with longer education and if the data was presented in the preferred format. Decision-makers should carefully consider displaying quality data according to preferred presentation format and to guide interpretation for individuals with short education.

Health Literacy and eHealth: Challenges and Strategies

Given the impact of health literacy (HL) on patients' outcomes, limited health literacy is a major barrier to improve cancer care globally. HL refers to the degree in which an individual is able to acquire, process, and comprehend information in a way to be actively involved in their health decisions. Previous research found that almost half of the population in developed countries have difficulties in understanding health-related information. With the gradual shift toward the shared decision making process and digital transformation in oncology, the need for addressing low HL issues is crucial. Decision making in oncology is often accompanied by considerable consequences on patients' lives, which requires patients to understand complex information and be able to compare treatment methods by considering their own values. How health information is perceived by patients is influenced by various factors including patients' characteristics and the way information is presented to patients. Currently, identifying patients with low HL and simple data visualizations are the best practice to help patients and clinicians in dealing with limited health literacy. Furthermore, using eHealth, as well as involving HL mediators, supports patients to make sense of complex information.

Comprehension, utility, and preferences of prostate cancer survivors for visual timelines of patient-reported outcomes co-designed for limited graph literacy: meters and emojis over comics

OBJECTIVE

Visual timelines of patient-reported outcomes (PRO) can help prostate cancer survivors manage longitudinal data, compare with population averages, and consider future trajectories. PRO visualizations are most effective when designed with deliberate consideration of users. Yet, graph literacy is often overlooked as a design constraint, particularly when users with limited graph literacy are not engaged in their development. We conducted user testing to assess comprehension, utility, and preference of longitudinal PRO visualizations designed for prostate cancer survivors with limited literacy.

MATERIALS AND METHODS

Building upon our prior work co-designing longitudinal PRO visualizations with survivors, we engaged 18 prostate cancer survivors in a user study to assess 4 prototypes: Meter, Words, Comic, and Emoji. During remote sessions, we collected data on prototype comprehension (gist and verbatim), utility, and preference.

RESULTS

Participants were aged 61-77 (M = 69), of whom half were African American. The majority of participants had less than a college degree (95%), had inadequate health literacy (78%), and low graph literacy (89%). Among the 4 prototypes, Meter had the best gist comprehension and was preferred. Emoji was also preferred, had the highest verbatim comprehension, and highest rated utility, including helpfulness, confidence, and satisfaction. Meter and Words both rated mid-range for utility, and Words scored lower than Emoji and Meter for comprehension. Comic had the poorest comprehension, lowest utility, and was least preferred.

DISCUSSION

Findings identify design considerations for PRO visualizations, contributing to the knowledge base for visualization best practices. We describe our process to meaningfully engage patients from diverse and hard-to-reach groups for remote user testing, an important endeavor for health equity in biomedical informatics.

CONCLUSION

Graph literacy is an important design consideration for PRO visualizations. Biomedical informatics researchers should be intentional in understanding user needs by involving diverse and representative individuals during development.

Need for numbers: assessing cancer survivors' needs for personalized and generic statistical information

Background

Statistical information (e.g., on long-term survival or side effects) may be valuable for healthcare providers to share with their patients to facilitate shared decision making on treatment options. In this pre-registered study, we assessed cancer survivors’ need for generic (population-based) versus personalized (tailored towards patient/tumor characteristics) statistical information after their diagnosis. We examined how information coping style, subjective numeracy, and anxiety levels of survivors relate to these needs and identified statistical need profiles. Additionally, we qualitatively explored survivors’ considerations for (not) wanting statistical information.

Methods

Cancer survivors’ need for statistics regarding incidence, survival, recurrence, side effects and quality of life were assessed with an online questionnaire. For each of these topics, survivors were asked to think back to their first cancer diagnosis and to indicate their need for generic and personalized statistics on a 4-point scale (‘not at all’- ‘very much’). Associations between information coping style, subjective numeracy, and anxiety with need for generic and personalized statistics were examined with Pearson’s correlations. Statistical need profiles were identified using latent class analysis. Considerations for (not) wanting statistics were analyzed qualitatively.

Results

Overall, cancer survivors (n = 174) had a higher need for personalized than for generic statistics (p < .001, d = 0.74). Need for personalized statistics was associated with higher subjective numeracy (r = .29) and an information-seeking coping style (r = .41). Three statistical need profiles were identified (1) a strong need for both generic and personalized statistics (34%), (2) a stronger need for personalized than for generic statistics (55%), and (3) a little need for both generic and personalized statistics (11%). Considerations for wanting personalized cancer statistics ranged from feelings of being in control to making better informed decisions about treatment. Considerations for not wanting statistics related to negative experience with statistics and to the unpredictability of future events for individual patients.

Conclusions

In light of the increased possibilities for using personalized statistics in clinical practice and decision aids, it appears that most cancer survivors want personalized statistical information during treatment decision-making. Subjective numeracy and information coping style seem important factors influencing this need. We encourage further development and implementation of data-driven personalized decision support technologies in oncological care to support patients in treatment decision making.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-02005-2.

Medical decision-making with tables and graphs: The role of cognition, emotions, and analytic thinking

The shift from one-way to two-way communication in healthcare decision-making has heightened the need to understand the role of display formats including tables and graphs as decision aids. In this paper, we investigate cognitive and affective influences on decision-making involving display formats. We find that a display format's impact on decision quality is mediated by two distinct components of cognition (verbatim and gist knowledge), and that tables compared to bar graphs improve decision quality. We also find evidence that analytic thinking and lower negative affect can improve decision quality. Implications for marketers, better engaging patients, and encouraging improved decision-making are discussed.

Shared decision-making in the Netherlands: Progress is made, but not for all. Time to become inclusive to patients

Dutch initiatives targeting shared decision-making (SDM) are still growing, supported by the government, the Federation of Patients' Organisations, professional bodies and healthcare insurers. The large majority of patients prefers the SDM model. The Dutch are working hard to realise improvement in the application of SDM in daily clinical practice, resulting in glimpses of success with objectified improvement on observed behavior. Nevertheless, the culture shift is still ongoing. Large-scale uptake of SDM behavior is still a challenge. We haven't yet fully reached the patients' needs, given disappointing research data on patients' experiences and professional behavior. In all Dutch implementation projects, early adopters, believers or higher-educated persons have been overrepresented, while patients with limited health literacy have been underrepresented. This is a huge problem as 25% of the Dutch adult population have limited health literacy. To further enhance SDM there are issues to be addressed: We need to make physicians conscious about their limited application of SDM in daily practice, especially regarding preference and decision talk. We need to reward clinicians for the extra work that comes with SDM. We need to be inclusive to patients with limited health literacy, who are less often actually involved in decision-making and at the same time more likely to regret their chosen treatment compared to patients with higher health literacy.

How People Understand Risk Matrices, and How Matrix Design Can Improve their Use: Findings from Randomized Controlled Studies

Risk matrices are a common way to communicate the likelihood and potential impacts of a variety of risks. Until now, there has been little empirical work on their effectiveness in supporting understanding and decision making, and on how different design choices affect these. In this pair of online experiments (total n = 2699), we show that risk matrices are not always superior to text for the presentation of risk information, and that a nonlinear/geometric labeling scheme helps matrix comprehension (when the likelihood/impact scales are nonlinear). To a lesser degree, results suggested that changing the shape of the matrix so that cells increase in size nonlinearly facilitates comprehension as compared to text alone, and that comprehension might be enhanced by integrating further details about the likelihood and impact onto the axes of the matrix rather than putting them in a separate key. These changes did not affect participants' preference for reducing impact over reducing likelihood when making decisions about risk mitigation. We recommend that designers of risk matrices consider these changes to facilitate better understanding of relationships among risks.

Effective Communication of Personalized Risks and Patient Preferences During Surgical Informed Consent Using Data Visualization: Qualitative Semistructured Interview Study With Patients After Surgery

Background

There is no consensus on which risks to communicate to a prospective surgical patient during informed consent or how. Complicating the process, patient preferences may diverge from clinical assumptions and are often not considered for discussion. Such discrepancies can lead to confusion and resentment, raising the potential for legal action. To overcome these issues, we propose a visual consent tool that incorporates patient preferences and communicates personalized risks to patients using data visualization. We used this platform to identify key effective visual elements to communicate personalized surgical risks.

Objective

Our main focus is to understand how to best communicate personalized risks using data visualization. To contextualize patient responses to the main question, we examine how patients perceive risks before surgery (research question 1), how suitably the visual consent tool is able to present personalized surgical risks (research question 2), how well our visualizations convey those personalized surgical risks (research question 3), and how the visual consent tool could improve the informed consent process and how it can be used (research question 4).

Methods

We designed a visual consent tool to meet the objectives of our study. To calculate and list personalized surgical risks, we used the American College of Surgeons risk calculator. We created multiple visualization mock-ups using visual elements previously determined to be well-received for risk communication. Semistructured interviews were conducted with patients after surgery, and each of the mock-ups was presented and evaluated independently and in the context of our visual consent tool design. The interviews were transcribed, and thematic analysis was performed to identify major themes. We also applied a quantitative approach to the analysis to assess the prevalence of different perceptions of the visualizations presented in our tool.

Results

In total, 20 patients were interviewed, with a median age of 59 (range 29-87) years. Thematic analysis revealed factors that influenced the perception of risk (the surgical procedure, the cognitive capacity of the patient, and the timing of consent; research question 1); factors that influenced the perceived value of risk visualizations (preference for rare event communication, preference for risk visualization, and usefulness of comparison with the average; research question 3); and perceived usefulness and use cases of the visual consent tool (research questions 2 and 4). Most importantly, we found that patients preferred the visual consent tool to current text-based documents and had no unified preferences for risk visualization. Furthermore, our findings suggest that patient concerns were not often represented in existing risk calculators.

Conclusions

We identified key elements that influence effective visual risk communication in the perioperative setting and pointed out the limitations of the existing calculators in addressing patient concerns. Patient preference is highly variable and should influence choices regarding risk presentation and visualization.

Differences in Data Trustworthiness and Risk Perception between Bar Graphs and Pictograms

We investigated whether differences in presentation style affect risk perception, understanding, preference, and trust toward data. One hundred and sixty Fukushima Medical University students were shown the lifetime probability of breast cancer incidence for a 50-year-old woman, presented in both a pictogram and a horizontal bar graph format. Participants rated each of the following on a five-point scale by looking at each figure: risk perception, perceived truth of data, and comparative risk perception. The perceived truth of data was high for pictograms, especially among men and among those defined as having lower health literacy. Women correctly perceived the risk of breast cancer as higher than that of dying in a car accident when the data were presented on a pictogram. There was no difference in risk perception, perceived truth of data, or comparative risk perception arising from being shown the bar graphs and the pictograms in a particular order. There was a 50/50 split on which type of graph was perceived as easier to understand, but the preference was for the pictogram format. It is important to devise a visual method of health communication that considers the purpose of the information and characteristics of the target audience.

The Patient Navigator: Can a systematically developed online health information tool improve patient participation and outcomes related to the consultation in older patients newly diagnosed with colorectal cancer?

BACKGROUND

Older cancer patients may search for health information online to prepare for their consultations. However, seeking information online can have negative effects, for instance increased anxiety due to finding incorrect or unclear information. In addition, existing online cancer information is not necessarily adapted to the needs of older patients, even though cancer is a disease often found in older individuals.

OBJECTIVE

The aim of this study was to systematically develop, implement and evaluate an online health information tool for older cancer patients, the Patient Navigator, providing information that complements the consultation with healthcare providers.

METHOD

For the development and evaluation of the Patient Navigator, the four phases of the MRC framework were used. In the first and second phase the Patient Navigator was developed and pilot tested based on previous research and sub-studies. During the third phase the Patient Navigator was implemented in four Dutch hospitals. In the last phase, a pilot RCT was conducted to evaluate the Patient Navigator in terms of usage (observational tracking data), user experience (self-reported satisfaction, involvement, cognitive load, active control, perceived relevance of the tool), patient participation (observational data during consultation), and patient outcomes related to the consultation (questionnaire data regarding anxiety, satisfaction, and information recall). Recently diagnosed colorectal cancer patients (N = 45) were randomly assigned to the control condition (usual care) or the experimental condition (usual care + Patient Navigator).

RESULTS

The Patient Navigator was well used and evaluated positively. Patients who received the Patient Navigator contributed less during the consultation by using less words than patients in the control condition and experienced less anxiety two days after the consultation than patients in the control condition.

CONCLUSION

Since the Patient Navigator was evaluated positively and decreased anxiety after the consultation, this tool is potentially a valuable addition to the consultation for patients. Usage of the Patient Navigator resulted in patients using less words during consultations, without impairing patients' satisfaction, possibly because information needs might be fulfilled by usage of the Patient Navigator. This could create the possibility to personalize communication during consultations and respond to other patient needs.

Exploring Cancer Survivor Needs and Preferences for Communicating Personalized Cancer Statistics From Registry Data: Qualitative Multimethod Study

Background

Disclosure of cancer statistics (eg, survival or incidence rates) based on a representative group of patients can help increase cancer survivors’ understanding of their own diagnostic and prognostic situation, and care planning. More recently, there has been an increasing interest in the use of cancer registry data for disclosing and communicating personalized cancer statistics (tailored toward personal and clinical characteristics) to cancer survivors and relatives.

Objective

The aim of this study was to explore breast cancer (BCa) and prostate cancer (PCa) survivor needs and preferences for disclosing (what) and presenting (how) personalized statistics from a large Dutch population-based data set, the Netherlands Cancer Registry (NCR).

Methods

To elicit survivor needs and preferences for communicating personalized NCR statistics, we created different (non)interactive tools visualizing hypothetical scenarios and adopted a qualitative multimethod study design. We first conducted 2 focus groups (study 1; n=13) for collecting group data on BCa and PCa survivor needs and preferences, using noninteractive sketches of what a tool for communicating personalized statistics might look like. Based on these insights, we designed a revised interactive tool, which was used to further explore the needs and preferences of another group of cancer survivors during individual think-aloud observations and semistructured interviews (study 2; n=11). All sessions were audio-recorded, transcribed verbatim, analyzed using thematic (focus groups) and content analysis (think-aloud observations), and reported in compliance with qualitative research reporting criteria.

Results

In both studies, cancer survivors expressed the need to receive personalized statistics from a representative source, with especially a need for survival and conditional survival rates (ie, survival rate for those who have already survived for a certain period). Personalized statistics adjusted toward personal and clinical factors were deemed more relevant and useful to know than generic or average-based statistics. Participants also needed support for correctly interpreting the personalized statistics and putting them into perspective, for instance by adding contextual or comparative information. Furthermore, while thinking aloud, participants experienced a mix of positive (sense of hope) and negative emotions (feelings of distress) while viewing the personalized survival data. Overall, participants preferred simplicity and conciseness, and the ability to tailor the type of visualization and amount of (detailed) statistical information.

Conclusions

The majority of our sample of cancer survivors wanted to receive personalized statistics from the NCR. Given the variation in patient needs and preferences for presenting personalized statistics, designers of similar information tools may consider potential tailoring strategies on multiple levels, as well as effective ways for providing supporting information to make sure that the personalized statistics are properly understood. This is encouraging for cancer registries to address this unmet need, but also for those who are developing or implementing personalized data-driven information tools for patients and relatives.

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.

Gender, education, and digital generations as determinants of attitudes toward health information for health workers in West Java, Indonesia

Health information is a commodity heavily sought by Indonesians because of the increasing consciousness of a healthy lifestyle. However, the circulation of health information is consistently disrupted by misinformation and disinformation, particularly on social media and chatting platforms such as WhatsApp. Identified misinformation and disinformation can be found on the official web page run by the Ministry of Communication and Information (https://trustpositif.kominfo.go.id/). Digital information exchange often involves health care workers; they are considered a credible source of health information. The purpose of this study was to delineate the attitudes of health care workers toward health information, determined by gender, educational attainment, and age differences. Health information in this study was information circulated on WhatsApp. We divided the age differences into four digital generations: baby boomers and Generations X, Y, and Z. We used the t-test and analysis of education and age differences when using the analysis of variance to demonstrate the differences among determinants factors of respondents—617 health care workers in West Java—in using WhatsApp when receiving and sharing health information. The results support that attitudes toward health information are determined by education attainment and differences in generation and that gender differences have no effect.