Individual differences in aversion to ambiguity regarding medical tests and treatments: association with cancer screening cognitions

Scientific uncertainty and perceived mammography benefits in women screened for breast cancer

PURPOSE

Personal aversion to scientific uncertainty may influence how women perceive the benefits of mammography, a breast cancer screening practice with conflicting scientific opinions and guidelines. Such associations may even exist among women who participate in screening.

METHODS

We evaluated the distribution of aversion to ambiguous medical information (AA-Med), using a 6-item scale capturing the level of agreement with statements about obtaining a cancer screening test with conflicting medical recommendations in 665 women (aged 40-60 years; 79.5% Hispanic) recruited during screening mammography appointments in New York City. We assessed the association of AA-Med with perceptions of benefits of mammography (breast cancer mortality reduction, worry reduction, early detection, treatment improvement) using multivariable logistic regression.

RESULTS

Over a quarter of participants expressed negative reactions to medical ambiguity about a cancer screening test (e.g., fear, lower trust in experts), but a majority endorsed intention to undergo screening. AA-Med was higher in women who were U.S.-born, non-Hispanic black, and had marginal to adequate health literacy, but there were no differences by clinical factors or screening experiences (e.g., family history, prior breast biopsy). Women with higher AA-Med were more likely to perceive treatment benefits from mammography (OR = 1.37, 95% CI = 0.99-1.90), but AA-Med was not associated with other perceived mammography benefits.

CONCLUSIONS

Aversion to uncertainty regarding cancer screening varies by sociodemographic characteristics but has limited associations with perceived mammography benefits in women who already participate in screening.

Perceptions and tolerance of uncertainty: relationship to trust in COVID-19 health information and vaccine hesitancy

The COVID-19 crisis has exposed the public to considerable scientific uncertainty, which may promote vaccine hesitancy among individuals with lower tolerance of uncertainty. In a national sample of US adults in May-June 2020, we examined how both perceptions of uncertainty about COVID-19 and trait-level differences in tolerance of uncertainty arising from various sources (risk, ambiguity, and complexity) are related to vaccine hesitancy-related outcomes, including trust in COVID-19 information, COVID-19 vaccine intentions, and beliefs that COVID-19 vaccines should undergo a longer testing period before being released to the public. Overall, perceptions of COVID-19 uncertainty were not associated with trust in information, vaccine intentions, or beliefs about vaccine testing. However, higher tolerance of risk was associated with lower intentions to get vaccinated, and lower tolerance of ambiguity was associated with lower intentions to get vaccinated and preferring a longer period of vaccine testing. Critically, perceptions of COVID-19 uncertainty and trait-level tolerance for uncertainty also interacted as predicted, such that greater perceived COVID-19 uncertainty was more negatively associated with trust in COVID-19 information among individuals with lower tolerance for risk and ambiguity. Thus, although perceptions of uncertainty regarding COVID-19 may not reduce trust and vaccine hesitancy for all individuals, trait-level tolerance of uncertainty arising from various sources may have both direct and moderating effects on these outcomes. These findings can inform public health communication or other interventions to increase COVID-19 vaccination uptake.

Effects of Construal Level on Responses to Ambiguous Health Information about Alcohol Consumption

Information about the health effects of alcohol consumption can be ambiguous (i.e., lacking in reliability, credibility, or adequacy) and thus may promote maladaptive health behavior. Guided by Construal Level Theory and a conceptual taxonomy of uncertainty in health care, we tested the hypothesis that manipulating construal level would promote adaptive responses to ambiguous health information. We examined the effects of ambiguous health information about alcohol on health cognitions, message responses, and intentions, as well as whether manipulating construal moderated these effects. Alcohol users (n = 135, M_age = 20.15, 68.9% female) were randomly assigned to either a high-level or low-level construal task and then to read either an ambiguous or unambiguous health communication about the health effects of alcohol. Participants responded similarly to ambiguous health information as they did to unambiguous health information and participants in a high-level construal did not generally report differences compared with those in a low-level construal. Findings suggest that ambiguous health information might not always lead to maladaptive effects. More research is needed to examine moderators of the relationship between ambiguous health information and health outcomes, as well as to understand how and when using construal manipulations are effective in different health contexts.

Promoting the Ambiguity of a Public Health Crisis Can Facilitate Adjustment: The Joint Influence of an Ambiguous Message Focus and Implicit Self-Theories

In the early stage of a novel public health crisis, such as an infectious disease, there is often uncertainty about whether the crisis will be permanent. We find that emphasizing the potential permanency of the situation surrounding the crisis can backfire, depending on the implicit self-theory held by people. Data collected during the COVID-19 outbreak showed that when the crisis situation was communicated as potentially being permanent in nature, entity theorists, who view personal qualities as fixed, were more reluctant to adjust to it than incremental theorists, who view personal qualities as malleable. The results were consistent whether implicit self-theory was measured as an individual difference factor (study 1) or manipulated (study 2). We reason that entity and incremental theorists make different inferences about what is required to adjust under the potentially permanent crisis situation: Entity theorists tend to infer that it involves substantial change in the self, whereas incremental theorists tend to infer that it involves crisis-specific behavioral changes. Importantly, we find that communicating ambiguity by leaving open the possibility of two opposing outcomes - the crisis situation may be permanent or temporary - effectively increases entity theorists' intentions to adjust by encouraging them to infer that adjusting to the crisis involves crisis-specific behavioral changes (study 2).

Association of Self-reported Primary Care Physician Tolerance for Uncertainty With Variations in Resource Use and Patient Experience

IMPORTANCE

Inappropriate variations in clinical practice are a known cause of poor quality and safety, with variations often associated with nonclinical factors, such as individual differences in cognitive processing. The differential response of physicians to uncertainty may explain some of the variations in resource use and patient experience.

OBJECTIVE

To examine the association of physician tolerance for uncertainty with variations in resource use and patient experience.

DESIGN, SETTING, AND PARTICIPANTS

This survey study linked physician survey data (May to June 2019), patient experience survey data (January 2016 to December 2019), and billing data (January 2019 to December 2019) among primary care physicians (PCPs) at Massachusetts General Hospital with at least 10 visits in 2019. The statistical analysis was performed in 2021.

MAIN OUTCOMES AND MEASURES

The analysis examined associations of PCP tolerance for uncertainty with the tendency to order diagnostic tests, the frequency of outpatient visits, hospital admissions, emergency department visits, and patient experience data (focused on physician communication and overall rating). A 2-stage hierarchical framework was used to account for clustering of patients under PCPs. Binary outcomes were modeled using a hierarchical logistic model, and count outcomes were modeled using hierarchical Poisson or negative binomial models. The analysis was adjusted for patient demographic variables (age, sex, and race and ethnicity), socioeconomic factors (payer and neighborhood income), and clinical comorbidities.

RESULTS

Of 217 included physicians, 137 (63.1%) were women, and 174 (80.2%) were adult PCPs. A total of 62 physicians (28.6%) reported low tolerance, 59 (27.2%) reported medium tolerance, and 96 (44.2%) reported high tolerance for uncertainty. Physicians with a low tolerance for uncertainty were less likely to order complete blood cell counts (odds ratio [OR], 0.66; 95% CI, 0.50-0.88), thyroid tests (OR, 0.67; 95% CI, 0.52-0.88), a basic metabolic profile (OR, 0.78; 95% CI, 0.60-1.00), and liver function tests (OR, 0.72; 95% CI, 0.53-0.99) than physicians with a high tolerance for uncertainty. Physicians who reported higher tolerance for uncertainty were more likely to receive higher patient experience scores for listening to patients carefully (OR, 0.65; 95% CI, 0.50-0.83) and higher overall ratings (OR, 0.80; 95% CI, 0.66-0.98) than physicians with medium tolerance. Conversely, no association was found between physician tolerance for uncertainty and patient outpatient visits, hospital admissions, or emergency department visits.

CONCLUSIONS AND RELEVANCE

In clinical practice, identifying and effectively managing inappropriate variations and improving patient experience have proven to be difficult, despite increased attention to these issues. This study supports the hypothesis that physicians' tolerance for uncertainty is associated with differences in resource use and patient experience. Whether enhancing physicians' tolerance for uncertainty could help reduce unwarranted practice variations, improve quality and patient safety, and improve patient's experience remains to be established.

Supporting Health and Medical Decision Making: Findings and Insights from Fuzzy-Trace Theory

HIGHLIGHTS

Fuzzy-trace theory (FTT) supports practical approaches to improving health and medicine.FTT differs in important respects from other theories of decision making, which has implications for how to help patients, providers, and health communicators.Gist mental representations emphasize categorical distinctions, reflect understanding in context, and help cue values relevant to health and patient care.Understanding the science behind theory is crucial for evidence-based medicine.

Factors Associated with Physician Tolerance of Uncertainty: an Observational Study

BACKGROUND

Physicians need to learn and work amidst a plethora of uncertainties, which may drive burnout. Understanding differences in tolerance of uncertainty is an important research area.

OBJECTIVE

To examine factors associated with tolerance of uncertainty, including well-being metrics such as burnout.

DESIGN

Online confidential survey.

SETTING

The Massachusetts General Physicians Organization (MGPO).

PARTICIPANTS

All 2172 clinically active faculty in the MGPO.

MAIN MEASURES

We examined associations for tolerance of uncertainty with demographic information, personal and professional characteristics, and physician well-being metrics.

KEY RESULTS

Two thousand twenty (93%) physicians responded. Multivariable analyses identified significant associations of lower tolerance of uncertainty with female gender (OR, 1.23; 95% CI, 1.03-1.48); primary care practice (OR, 1.56; 95% CI, 1.22-2.00); years since training (OR, 0.99; 95% CI, 0.98-0.995); and lacking a trusted advisor (OR, 1.25; 95% CI, 1.03-1.53). Adjusting for demographic and professional characteristics, physicians with low tolerance of uncertainty had higher likelihood of being burned-out (OR, 3.06; 95% CI, 2.41-3.88), were less likely to be satisfied with career (OR, 0.37; 95% CI, 0.26-0.52), and less likely to be engaged at work (RR, 0.87; 95% CI, 0.84-0.90).

CONCLUSION

At a time when concern about physician well-being is high, with much speculation about causes of burnout, we found a strong relationship between tolerance of uncertainty and physician well-being, across specialties. Particular attention likely needs to be paid to those with less experience, those in specialties with high rates of undifferentiated illness and uncertainty, such as primary care, and ensuring all physicians have access to a trusted advisor. These results generate the potential hypothesis that efforts focused in understanding and embracing uncertainty could be potentially effective for reducing burnout. This concept should be tested in prospective trials.

Inside the 'black box' of COVID-19 vaccination beliefs: Revealing the relative importance of public confidence and news consumption habits

Rationale

President Biden's goal for 70% of U.S. adults to have received at least one vaccine by July 4, 2021 was not achieved.

Objective

The aim of this research was to assess the ‘black box’ of positive COVID-19 vaccination beliefs to determine the relative importance of each factor and thus inform well-targeted and tailored health promotion efforts.

Methods

A cross-sectional survey was conducted in a sample of U.S. adults (N = 1656), assessing the influence of demographic characteristics, cognitive effects, public confidence, and news source variety and evaluation on positive COVID-19 vaccination beliefs.

Results

Overall, the strongest predictor of positive beliefs was high confidence in public health officials and political institutions to handle the COVID-19 pandemic effectively, yet negative sentiments toward COVID-19 research and science and COVID-19 vaccine ambivalence reduced the likelihood that beliefs were positive. Cognitive effects and public confidence were identified as key predictors of positive COVID-19 vaccination beliefs over and above party identification. Importantly, high levels of confidence in science and government were mostly driven by positive evaluations of liberal news sources. High levels of COVID-19 science backlash were mostly driven by positive evaluations of conservative news sources.

Conclusions

To motivate COVID-19 vaccination among hesitant or resistant groups in the population, health promotion efforts should seek to reinforce positive COVID-19 vaccination beliefs by increasing public confidence and by reducing COVID-19 science backlash, largely by choosing specific news media and social media platforms (e.g., Breitbart, Fox News, and Facebook) as channels for health promotion and health information dissemination.

Psychological Impact of Ambiguous Health Messages about COVID-19

Perceiving ambiguity in health information-that is, uncertainty elicited from believing information lacks credibility, reliability, or adequacy-is typically associated with pessimistic appraisals (e.g., high perceived disease risk) and behavioral avoidance. We examined the effect of ambiguous health information about COVID-19 on health cognitions and vaccination intentions, and tested a "normalized-uncertainty" intervention. Two studies with identical methodology (online adult sample: n = 299, undergraduate sample: n = 150) were conducted in March to April 2020. Participants were randomly assigned to read one of three health messages about COVID-19 that emphasized what was currently unknown (ambiguity condition), what was currently unknown but that scientific uncertainty is expected (intervention condition), or what was currently known (control condition). The ambiguity condition led to greater perceived ambiguity than the control condition and perceived ambiguity in the intervention condition was comparable to the ambiguity condition. There were few differences in health cognitions, and no differences in vaccination intentions, when examining pairwise comparisons across the three conditions. Correlational analyses collapsing across condition indicated evidence of pessimistic appraisal but not behavioral avoidance among individuals who perceived greater ambiguity. Future research should examine longer, more detailed normalized-uncertainty interventions.

Predictors of Women's Awareness of the Benefits and Harms of Mammography Screening and Associations with Confusion, Ambivalence, and Information Seeking

In recent years, there has been a shift toward promoting informed decision making for mammography screening for average-risk women in their 40s. Professional organizations such as the American Cancer Society and U.S. Preventive Services Task Force recommend that women weigh the potential benefits and harms of mammography prior to initiating screening. This decision-making process assumes that women are aware of both the benefits and harms of screening, yet little is known about the prevalence and antecedents of such awareness. Moreover, it is conceivable that women who are aware of both the benefits and harms may interpret this information as conflicting - which could be concerning, as researchers have documented adverse effects of exposure to conflicting health information in prior research. Using data from a population-based survey of U.S. women aged 30-59 (N = 557), the current study found that awareness of mammography's harms is relatively low compared to awareness of benefits. Health news exposure and interpersonal communication about health were associated with greater awareness of harms. In addition, women's awareness of both the benefits and harms was positively associated with confusion about breast cancer screening recommendations, ambivalence about getting a mammogram, and mammogram-related information seeking from online sources. Implications for cancer screening communication are discussed.

Differences in cancer patients' and clinicians' preferences for disclosure of uncertain genomic tumor testing results

OBJECTIVE

To compare clinicians' and patients' preferences for disclosure of genomic tumor testing (GTT) results; to determine the sensitivity of these disclosure preferences to uncertainty about the actionability of results; and to explore factors associated with disclosure preferences.

METHODS

Community-based oncology clinicians (n = 94) and patients (n = 1121) were surveyed about their preferences for disclosing GTT results with varying levels of uncertainty (Tiers 1, 2, 3). Descriptive and multivariable regression analyses were used to compare clinicians' and patients' disclosure preferences and their sensitivity to uncertainty, and to explore associations between disclosure preferences and sociodemographic, clinical, and psychological factors.

RESULTS

Relatively more patients than clinicians preferred disclosure, and their preferences were less sensitive to the uncertainty of GTT results. For patients and clinicians, lower uncertainty sensitivity was associated with positive GTT attitudes; for patients it was also associated with greater uncertainty tolerance and knowledge of uncertainty in GTT.

CONCLUSION

Relatively more cancer patients than clinicians prefer disclosure of GTT results, and their preferences are less sensitive to result uncertainty. Uncertainty sensitivity in disclosure preferences is associated with GTT-related attitudes and uncertainty tolerance.

PRACTICE IMPLICATIONS

Differences in cancer patients' and clinicians' preferences for disclosure of uncertain GTT results warrant greater attention in cancer care.

Evidence that perceptions of and tolerance for medical ambiguity are distinct constructs: An analysis of nationally representative US data

BACKGROUND

Medical information is often conflicting and consequently perceived as ambiguous. There are individual differences both in how much people perceive ambiguity and in their tolerance for such ambiguity. Little is known about how these constructs are related to each other and with other beliefs.

OBJECTIVE

To examine the association between (a) perceived medical ambiguity, (b) tolerance for medical ambiguity and (c) their associations with various medical and cancer-specific judgement and decision-making correlates.

METHOD AND PARTICIPANTS

We conducted secondary data analyses using the cross-sectional, nationally representative Health Information National Trends Survey 4, Cycle 4 (n = 3,433, 51.0% female, M_age  = 46.5). Analyses statistically controlled for age, sex, race, education and health-care coverage.

MAIN VARIABLES STUDIED

Perceived medical ambiguity, tolerance for medical ambiguity, cancer perceptions, health-care experiences and preferences, and information-seeking styles and beliefs.

RESULTS

Perceived medical ambiguity and tolerance for medical ambiguity were statistically independent. Higher perceived ambiguity was associated with lower perceived cancer preventability, lower reliance on doctors, lower perceived health and information-seeking self-efficacy, lower perceived quality of the cancer information-seeking process, and greater cancer information avoidance. Lower tolerance for ambiguity was associated with lower cancer worry, lower trust in doctors, lower likelihood of seeking health information, and lower engagement in medical research.

DISCUSSION AND CONCLUSIONS

Perceived medical ambiguity and tolerance for medical ambiguity seem to be distinct constructs. Findings have implications for how people make medical decisions when they perceive and prefer to avoid conflicting medical information.

Effects of Media Exposure to Conflicting Information About Mammography: Results From a Population-based Survey Experiment

BACKGROUND

Although there is growing theoretical and empirical support for the proposition that media exposure to conflicting health information negatively influences public understanding and behavior, few studies have causally linked exposure to conflict with undesirable outcomes. Such outcomes might be particularly likely in the context of mammography, given widespread media attention to conflicting recommendations about the age at and frequency with which average-risk women should be screened for breast cancer.

PURPOSE

The current study tests whether exposure to conflicting information about mammography negatively influences women's affective and cognitive responses and examines whether effects vary by socioeconomic position.

METHODS

We conducted an online survey experiment in 2016 with a population-based sample of U.S. women aged 35-55 (N = 1,474). Participants were randomly assigned to one of four conditions that differed in the level of conflict about mammography presented in a news story (no, low, medium, or high conflict), stratifying by poverty level.

RESULTS

Greater exposure to conflict increased women's negative emotional responses to the story they read, their confusion about and backlash toward cancer prevention recommendations and research, and their ambivalence about mammography and other types of cancer screening, though ambivalence leveled off at high levels of exposure. There was little evidence that effects varied across socioeconomic position.

CONCLUSIONS

Findings add to the growing evidence base documenting undesirable outcomes of exposure to conflicting health information. Future research should examine whether the negative affective and cognitive responses observed translate into behavior, which could have implications for both health campaigns and patient-provider communication.

U.S. women's perceived importance of the harms and benefits of mammograms and associations with screening ambivalence: Results from a national survey

The American Cancer Society and the U.S. Preventive Task Force recently recommended that women initiate routine breast cancer screening at older ages (45 and 50, respectively) than previously recommended, and both organizations emphasize the importance of weighing the harms of mammograms against the benefits in making informed decisions. However, little is known from national samples about how women perceive the harms and benefits of mammograms, and how these perceptions relate to their attitudes about getting mammograms. To fill this gap, we surveyed a nationally representative sample of 557 U.S. women aged 30-59 about their perceptions of harms and benefits and their attitudinal ambivalence toward mammograms. We found that respondents overall perceived the benefits as more important than harms, but those who were aware of recent recommendations perceived mammogram harms as more important than those who were unaware. Women who had a mammogram within one year perceived the harms as less important and the benefits as more important, compared to those who had not had a mammogram in the past year. Those who perceived the harms as important were more ambivalent about screening than those who perceived harms as less important. We conclude that if the public health goal is to prevent the population harms from overuse of mammograms (e.g., overdiagnosis, false positives), simply providing women with information about harms and benefits may not lead to this outcome, since women are likely to perceive the benefits as more important than harms, and thus make an informed choice to obtain screening.

Women's Attitudes Toward Invasive and Noninvasive Testing When Facing a High Risk of Fetal Down Syndrome

IMPORTANCE

Noninvasive prenatal testing (NIPT) using cell-free DNA in maternal blood is increasingly common compared with invasive testing (IT) in routine antenatal detection of Down syndrome (DS).

OBJECTIVE

To assess attitudes and decision making in pregnant women facing a risk of fetal DS greater than 1 in 250 as established by combined first trimester screening at 11 to 14 weeks of gestation.

DESIGN, SETTING, AND PARTICIPANTS

Survey study in which data were collected from pregnant women at high risk of fetal DS participating in a randomized clinical trial. Data were collected from April 8, 2014, to April 7, 2016, in 57 prenatal diagnosis centers in France. Data were analyzed in 2018.

INTERVENTIONS

Data on attitudes were collected prior to offering randomization between NIPT and IT, whereas data on decision making and test results were collected as part of the clinical trial.

MAIN OUTCOME AND MEASURES

The primary outcome related to attitudes. A hierarchical cluster analysis was conducted to identify clusters with contrasting attitudes. Logistic regression analyses were used to identify factors associated with attitudes.

RESULTS

All 2436 consecutive women to whom the study was proposed (mean [SD] age, 36.3 [5.0] years) answered the questionnaire: 515 (21.1%) expressed preference toward IT with complete karyotyping, whereas 1843 (75.7%) favored NIPT with almost certain but limited information. Hierarchical cluster analysis yielded 4 different clusters that mainly differed in attitudes toward risk taking and extent of information seeking. Factors likely associated with attitudes driven by risk aversion were mostly age and religious beliefs (adjusted odds ratio [aOR], 1.03; 95% CI, 1.00-1.05; P = .03 and aOR, 1.62; 95% CI, 1.29-2.04; P < .001, respectively), whereas higher nuchal translucency measurements by ultrasonography were associated with attitudes driven by ambiguity aversion (aOR, 1.67; 95% CI, 1.27-2.20; P < .001). For attitudes involving both risk and ambiguity aversion at different extents, lower education was associated with highly valuing all possibilities of getting information on pregnancy, whereas higher education was associated with highly valuing information on fetal DS as a primary concern (aOR, 0.54; 95% CI, 0.44-0.67; P < .001 and aOR, 1.44; 95% CI, 1.20-1.74; P < .001, respectively). In all, decision making was in line with attitudes.

CONCLUSIONS AND RELEVANCE

Aversion to risk of fetal loss related to IT and aversion to ambiguity generated by incomplete information from NIPT played a major role in shaping attitudes and decision making. Informed decision making should require pregnant women at high risk of DS to receive extensive information on targeted abnormalities by both tests.

Tolerance of uncertainty: A systematic review of health and healthcare-related outcomes

BACKGROUND

Uncertainty tolerance (UT) is thought to be a characteristic of individuals that influences various outcomes related to health, healthcare, and healthcare education. We undertook a systematic literature review to evaluate the state of the evidence on UT and its relationship to these outcomes.

METHODS

We conducted electronic and bibliographic searches to identify relevant studies examining associations between UT and health, healthcare, or healthcare education outcomes. We used standardized tools to assess methodological quality and analyzed the major findings of existing studies, which we organized and classified by theme.

RESULTS

Searches yielded 542 potentially relevant articles, of which 67 met inclusion criteria. Existing studies were heterogeneous in focus, setting, and measurement approach, were largely cross-sectional in design, and overall methodological quality was low. UT was associated with various trainee-centered, provider-centered, and patient-centered outcomes which were cognitive, emotional, and behavioral in nature. UT was most consistently associated with emotional well-being.

CONCLUSIONS

Uncertainty tolerance is associated with several important trainee-, provider-, and patient-centered outcomes in healthcare and healthcare education. However, low methodological quality, study design limitations, and heterogeneity in the measurement of UT limit strong inferences about its effects, and addressing these problems is a critical need for future research.

Communication of Scientific Uncertainty about a Novel Pandemic Health Threat: Ambiguity Aversion and Its Mechanisms

Communicating scientific uncertainty about public health threats is ethically desirable but challenging due to its tendency to promote avoidance of choice options with unknown probabilities-a phenomenon known as "ambiguity aversion." This study examined this phenomenon's potential magnitude, its responses to different communication strategies, and its mechanisms. In a factorial experiment, 2701 adult laypersons in Spain read one of three versions of a hypothetical newspaper article describing a pandemic vaccine-preventable disease (VPD), but varying in scientific uncertainty about VPD risk and vaccine effectiveness: No-Uncertainty, Uncertainty, and Normalized-Uncertainty (emphasizing its expected nature). Vaccination intentions were lower for the Uncertainty and Normalized-Uncertainty groups compared to the No-Uncertainty group, consistent with ambiguity aversion; Uncertainty and Normalized-Uncertainty groups did not differ. Ambiguity-averse responses were moderated by health literacy and mediated by perceptions of vaccine effectiveness, VPD likelihood, and VPD severity. Communicating scientific uncertainty about public health threats warrants caution and further research to elucidate its outcomes, mechanisms, and management.

Sex Differences in the Association of Perceived Ambiguity, Cancer Fatalism, and Health-Related Self-Efficacy with Fruit and Vegetable Consumption

Adequate fruit and vegetable (FV) consumption is promoted as a means of preventing chronic health conditions, such as cardiovascular disease and cancer. This study investigated whether perceived ambiguity about cancer prevention recommendations, fatalistic beliefs about cancer, and health-related self-efficacy were associated with FV consumption and whether sex moderated these associations. Data from the five most recent waves (spanning 2011 to 2017) of the nationally representative Health Information National Trends Survey (N = 16,965) were used. Participants reported levels of perceived ambiguity, cancer fatalism, health-related self-efficacy, and daily FV consumption. Perceived ambiguity and cancer fatalism were negatively associated with FV consumption, ps <.001, whereas health-related self-efficacy was positively associated with FV consumption, b = 0.34, p < .001. Sex moderated these associations, ps <.05. Perceived ambiguity and cancer fatalism were more strongly associated with less FV consumption for men, bs < -0.31, ps <.001, than women, bs < -0.14, ps <.01. In contrast, health-related self-efficacy was more strongly associated with more FV consumption for women, b = 0.43, p < .001, than men, b = 0.26, p < .001. These results suggest that tailoring health messaging to target sex-specific barriers may improve their effectiveness.

How Patients View Lung Cancer Screening. The Role of Uncertainty in Medical Decision Making

RATIONALE

Radiographic lung cancer screening guidelines and coverage requirements warrant a shared decision-making process. Guidance is needed regarding how to conduct shared decision making effectively. A useful organizing theme should include consideration of a patient's response to and tolerance of uncertainty associated with lung cancer screening.

OBJECTIVES

The objectives of this study are to: (1) describe how patients respond to specific categories of uncertainty in the context of lung cancer screening, and (2) inform strategies for addressing concerns about uncertainty as part of the shared decision making.

METHODS

We performed two series of structured interviews on participants in a convenience sample of current or former cigarette smokers recruited from primary care and pulmonary practices in Philadelphia. An interview guide included prompts related to benefits, harms, and responses to general and specific types of uncertainty (stochastic, statistical, and evidentiary) associated with lung cancer screening. Interviews were audio-recorded, transcribed, and independently coded by two investigators. An inductive analysis was conducted, and major themes were identified.

MEASUREMENTS AND MAIN RESULTS

Twenty-two adults participated in the study. Sixty-eight percent were men, 72% were black or African American, and 50% met U.S. Preventive Services Task Force criteria for lung cancer screening. The primary themes to emerge from our study were: (1) the desire to decrease uncertainty may motivate lung cancer screening decisions; (2) uncertainty is an attribute of health states that impacts how patients weigh benefits and harms of lung cancer screening; (3) patient understanding and tolerance of uncertainty varies across stochastic, statistical, and evidentiary uncertainty; and (4) provider-patient communication may mitigate intolerance of uncertainty in the context of lung cancer screening.

CONCLUSIONS

A systematic approach to understanding and addressing patients' concerns about uncertainty in the context of lung cancer screening can guide a patient-centered approach to shared decision making. The results of this study can inform provider-patient communication strategies regarding the decision to perform radiographic lung cancer screening.

Factors Affecting Physicians' Intentions to Communicate Personalized Prognostic Information to Cancer Patients at the End of Life: An Experimental Vignette Study

PURPOSE

To explore the effects of personalized prognostic information on physicians' intentions to communicate prognosis to cancer patients at the end of life, and to identify factors that moderate these effects.

METHODS

A factorial experiment was conducted in which 93 family medicine physicians were presented with a hypothetical vignette depicting an end-stage gastric cancer patient seeking prognostic information. Physicians' intentions to communicate prognosis were assessed before and after provision of personalized prognostic information, while emotional distress of the patient and ambiguity (imprecision) of the prognostic estimate were varied between subjects. General linear models were used to test the effects of personalized prognostic information, patient distress, and ambiguity on prognostic communication intentions, and potential moderating effects of 1) perceived patient distress, 2) perceived credibility of prognostic models, 3) physician numeracy (objective and subjective), and 4) physician aversion to risk and ambiguity.

RESULTS

Provision of personalized prognostic information increased prognostic communication intentions (P < 0.001, η(2) = 0.38), although experimentally manipulated patient distress and prognostic ambiguity had no effects. Greater change in communication intentions was positively associated with higher perceived credibility of prognostic models (P = 0.007, η(2) = 0.10), higher objective numeracy (P = 0.01, η(2) = 0.09), female sex (P = 0.01, η(2) = 0.08), and lower perceived patient distress (P = 0.02, η(2) = 0.07). Intentions to communicate available personalized prognostic information were positively associated with higher perceived credibility of prognostic models (P = 0.02, η(2) = 0.09), higher subjective numeracy (P = 0.02, η(2) = 0.08), and lower ambiguity aversion (P = 0.06, η(2) = 0.04).

CONCLUSIONS

Provision of personalized prognostic information increases physicians' prognostic communication intentions to a hypothetical end-stage cancer patient, and situational and physician characteristics moderate this effect. More research is needed to confirm these findings and elucidate the determinants of prognostic communication at the end of life.

Perceived ambiguity as a barrier to intentions to learn genome sequencing results

Many variants that could be returned from genome sequencing may be perceived as ambiguous-lacking reliability, credibility, or adequacy. Little is known about how perceived ambiguity influences thoughts about sequencing results. Participants (n = 494) in an NIH genome sequencing study completed a baseline survey before sequencing results were available. We examined how perceived ambiguity regarding sequencing results and individual differences in medical ambiguity aversion and tolerance for uncertainty were associated with cognitions and intentions concerning sequencing results. Perceiving sequencing results as more ambiguous was associated with less favorable cognitions about results and lower intentions to learn and share results. Among participants low in tolerance for uncertainty or optimism, greater perceived ambiguity was associated with lower intentions to learn results for non-medically actionable diseases; medical ambiguity aversion did not moderate any associations. Results are consistent with the phenomenon of "ambiguity aversion" and may influence whether people learn and communicate genomic information.

Temporal changes in tolerance of uncertainty among medical students: insights from an exploratory study

BACKGROUND

Physicians' tolerance of uncertainty (TU) is a trait potentially associated with desirable outcomes, and emerging evidence suggests it may change over time. Past studies of TU, however, have been cross-sectional and have not measured tolerance of the different, specific types of uncertainty that physicians confront. We addressed these limitations in a longitudinal exploratory study of medical students.

METHODS

At the end of medical school (Doctor of Medicine degree) Years 1 and 4, a cohort of 26 students at a US medical school completed measures assessing tolerance of different types of uncertainty: 1) complexity (uncertainty arising from features of information that make it difficult to comprehend); 2) risk (uncertainty arising from the indeterminacy of future outcomes); and 3) ambiguity (uncertainty arising from limitations in the reliability, credibility, or adequacy of information). Change in uncertainty-specific TU was assessed using paired t-tests.

RESULTS

Between Years 1 and 4, there was a significant decrease in tolerance of ambiguity (t=3.22, p=0.004), but no change in students' tolerance of complexity or risk.

CONCLUSIONS

Tolerance of ambiguity--but not other types of uncertainty--decreases during medical school, suggesting that TU is a multidimensional, partially mutable state. Future studies should measure tolerance of different uncertainties and examine how TU might be improved.