Breast cancer patients' treatment expectations after exposure to the decision aid program adjuvant online: the influence of numeracy

Evaluation of the Implementation of the Dutch Breast Cancer Surveillance Decision Aid including Personalized Risk Estimates in the SHOUT-BC Study: A Mixed Methods Approach

BACKGROUND

To improve Shared decision-making (SDM) regarding personalized post-treatment surveillance, the Breast Cancer Surveillance Decision Aid (BCS-PtDA), integrating personalized risk information, was developed and implemented in eight hospitals. The aim of this mixed-methods study was to (1) assess the implementation and participation rates, (2) identify facilitators and barriers for use by health care professionals (HCPs), (3) quantify the observed level of SDM, and (4) evaluate risk communication and SDM application in consultations.

METHODS

Implementation and participation rates and patients' BCS-PtDA use were calculated using hospital registry data and BCS-PtDA log data. HCPs' perspective on facilitators and barriers were collected using the MIDI framework. Observed SDM levels in consultation transcripts were quantified using the OPTION-5 scale. Thematic analysis was performed to assess consultation content.

RESULTS

The average PtDA implementation and participation rates were, respectively, 26% and 61%. HCPs reported that the PtDA supported choice awareness. Reported barriers for implementation were mainly increased workload and a lack of perceived benefits. The consultation analysis (n = 64) showed patients were offered a choice, but deliberation was lacking. Risk communication was generally adequate.

DISCUSSION

When the BCS-PtDA was used, patients were clearly given a choice regarding their post-treatment surveillance, but information provision and SDM application can be improved.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRACTICE IMPLICATIONS

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

PROTOCOL REGISTRATION

PROSPERO ID 275022.

Fact boxes that inform individual decisions may contribute to a more positive evaluation of COVID-19 vaccinations at the population level

Objective

For an effective control of the SARS-CoV-2 pandemic with vaccines, most people in a population need to be vaccinated. It is thus important to know how to inform the public with reference to individual preferences–while also acknowledging the societal preference to encourage vaccinations. According to the health care standard of informed decision-making, a comparison of the benefits and harms of (not) having the vaccination would be required to inform undecided and skeptical people. To test evidence-based fact boxes, an established risk communication format, and to inform their development, we investigated their contribution to knowledge and evaluations of COVID-19 vaccines.

Methods

We conducted four studies (1, 2, and 4 were population-wide surveys with N = 1,942 to N = 6,056): Study 1 assessed the relationship between vaccination knowledge and intentions in Germany over three months. Study 2 assessed respective information gaps and needs of the population in Germany. In parallel, an experiment (Study 3) with a mixed design (presentation formats; pre-post-comparison) assessed the effect of fact boxes on risk perceptions and fear, using a convenience sample (N = 719). Study 4 examined how effective two fact box formats are for informing vaccination intentions, with a mixed experimental design: between-subjects (presentation formats) and within-subjects (pre-post-comparison).

Results

Study 1 showed that vaccination knowledge and vaccination intentions increased between November 2020 and February 2021. Study 2 revealed objective information requirements and subjective information needs. Study 3 showed that the fact box format is effective in adjusting risk perceptions concerning COVID-19. Based on those results, fact boxes were revised and implemented with the help of a national health authority in Germany. Study 4 showed that simple fact boxes increase vaccination knowledge and positive evaluations in skeptics and undecideds.

Conclusion

Fact boxes can inform COVID-19 vaccination intentions of undecided and skeptical people without threatening societal vaccination goals of the population.

Excluding numeric side-effect information produces lower vaccine intentions

Encouraging vaccine uptake is important to reducing the impact of infectious disease. However, negative attitudes and vaccine hesitancy, due in part to worry about side effects, are obstacles to achieving high vaccination rates. Provided vaccine information sheets typically include a list of side effects without numeric information about their likelihoods, but providing such numbers may yield benefits. We investigated the effect of providing numeric information about side-effect likelihood (e.g., "1%") and verbal labels (e.g., "uncommon") on intentions to get a hypothetical vaccine, reasons for the vaccination decision, and risk overestimation. In a diverse, online, convenience sample (N = 595), providing numeric information increased vaccine intentions-70% of those who received numeric information were predicted to be moderately or extremely likely to vaccinate compared to only 54% of those who did not receive numeric information (p<.001), controlling for age, gender, race, education, and political ideology. Participants receiving numeric information also were less likely to overestimate side-effect likelihood. Verbal labels had additional benefits when included with numeric information, particularly among the vaccine hesitant. For these participants, verbal labels increased vaccine intentions when included with numeric information (but not in its absence). Among the vaccine-hesitant, 43% of those provided numeric information and verbal labels were predicted to be moderately or extremely likely to get vaccinated vs. only 24% of those given a list of side effects (p<.001). We conclude that the standard practice of not providing numeric information about side-effect likelihood leads to a less-informed public who is less likely to vaccinate.

Cocreation with Dutch patients of decision-relevant information to support shared decision-making about adjuvant treatment in breast cancer care

Background

To support patients in shared decision‐making about treatment options, patient decision aids (PtDAs) usually provide benefit/harm information and value clarification methods (VCMs). Recently, personalized risk information from prediction models is also being integrated into PtDAs. This study aimed to design decision‐relevant information (i.e., personalized survival rates, harm information and VCMs) about adjuvant breast cancer treatment in cocreation with patients, in a way that suits their needs and is easily understandable.

Methods

Three cocreation sessions with breast cancer patients (N = 7–10; of whom N = 5 low health literate) were performed. Participants completed creative assignments and evaluated prototypes of benefit/harm information and VCMs. Prototypes were further explored through user testing with patients (N = 10) and healthcare providers (N = 10). The researchers interpreted the collected data, for example, creative and homework assignments, and participants' presentations, to identify key themes. User tests were transcribed and analysed using ATLAS.ti to assess the understanding of the prototypes.

Results

Important information needs were: (a) need for overview/structure of information directly after diagnosis and; (b) need for transparent benefit/harm information for all treatment options, including detailed harm information. Regarding VCMs, patients stressed the importance of a summary/conclusion. A bar graph seemed the most appropriate way of displaying personalized survival rates; the impact of most other formats was perceived as too distressful. The concept of ‘personalization’ was not understood by multiple patients.

Conclusions

A PtDA about adjuvant breast cancer treatment should provide patients with an overview of the steps and treatment options, with layers for detailed information. Transparent information about the likelihood of benefits and harm should be provided. Given the current lack of information on the likelihood of side effects/late effects, efforts should be made to collect and share these data with patients. Further quantitative studies are needed to validate the results and to investigate how the concept of ‘personalization’ can be communicated.

Patient or Public Contribution

Ten breast cancer patients participated in three cocreation sessions to develop decision‐relevant information. Subsequent user testing included 10 patients. The Dutch Breast Cancer Association (BVN) was involved as an advisor in the general study design.

Clinician-Created Educational Video Resources for Shared Decision-making in the Outpatient Management of Chronic Disease: Development and Evaluation Study

Background

The provision of reliable patient education is essential for shared decision-making. However, many clinicians are reluctant to use commonly available resources, as they are generic and may contain information of insufficient quality. Clinician-created educational materials, accessed during the waiting time prior to consultation, can potentially benefit clinical practice if developed in a time- and resource-efficient manner.

Objective

The aim of this study is to evaluate the utility of educational videos in improving patient decision-making, as well as consultation satisfaction and anxiety, within the outpatient management of chronic disease (represented by atrial fibrillation). The approach involves clinicians creating audiovisual patient education in a time- and resource-efficient manner for opportunistic delivery, using mobile smart devices with internet access, during waiting time before consultation.

Methods

We implemented this educational approach in outpatient clinics and collected patient responses through an electronic survey. The educational module was a web-based combination of 4 short videos viewed sequentially, followed by a patient experience survey using 5-point Likert scales and 0-100 visual analogue scales. The clinician developed the audiovisual module over a 2-day span while performing usual clinical tasks, using existing hardware and software resources (laptop and tablet). Patients presenting for the outpatient management of atrial fibrillation accessed the module during waiting time before their consultation using either a URL or Quick Response (QR) code on a provided tablet or their own mobile smart devices. The primary outcome of the study was the module’s utility in improving patient decision-making ability, as measured on a 0-100 visual analogue scale. Secondary outcomes were the level of patient satisfaction with the videos, measured with 5-point Likert scales, in addition to the patient’s value for clinician narration and the module’s utility in improving anxiety and long-term treatment adherence, as represented on 0-100 visual analogue scales.

Results

This study enrolled 116 patients presenting for the outpatient management of atrial fibrillation. The proportion of responses that were “very satisfied” with the educational video content across the 4 videos ranged from 93% (86/92) to 96.3% (104/108) and this was between 98% (90/92) and 99.1% (107/108) for “satisfied” or “very satisfied.” There were no reports of dissatisfaction for the first 3 videos, and only 1% (1/92) of responders reported dissatisfaction for the fourth video. The median reported scores (on 0-100 visual analogue scales) were 90 (IQR 82.5-97) for improving patient decision-making, 89 (IQR 81-95) for reducing consultation anxiety, 90 (IQR 81-97) for improving treatment adherence, and 82 (IQR 70-90) for the clinician’s narration adding benefit to the patient experience.

Conclusions

Clinician-created educational videos for chronic disease management resulted in improvements in patient-reported informed decision-making ability and expected long-term treatment adherence, as well as anxiety reduction. This form of patient education was also time efficient as it used the sunk time cost of waiting time to provide education without requiring additional clinician input.

The Modest Effects of Fact Boxes on Cancer Screening

As health care becomes increasingly personalized to the needs and values of individual patients, informational interventions that aim to inform and debias consumer decision-making are likely to become important tools. In a randomized controlled experiment, we explore the effects of providing participants with published fact boxes on the benefits and harms of common cancer screening procedures. Female participants were surveyed about breast cancer screening by mammography, while male participants were surveyed about prostate cancer screening by prostate-specific antigen (PSA) testing. For these screening procedures, we expect consumers to have overly optimistic prior beliefs about the benefits and harms. We find that participants update their beliefs about the net benefits of screening modestly, but we observe little change in their stated preferences to seek screening. Participants who scored higher on a numeracy test updated their beliefs about screening benefits more in response to the fact boxes than did participants who scored lower on the numeracy test.

Numeracy and memory for risk probabilities and risk outcomes depicted on cigarette warning labels

OBJECTIVE

Greater numeracy is associated with higher likelihood to quit smoking. We examined whether numeracy supports learning of numeric health-risk information and, in turn, greater risk perceptions and quit intentions.

METHOD

Adult smokers (N = 696) viewed text warnings with numeric risk information four times each in one of three warning-label types (text-only, low-emotion pictorial [i.e., with image], high-emotion pictorial). They completed posttest measures immediately or 6 weeks later. Emotional reactions to warnings were reported the second time participants viewed the warnings. Numeracy, memory for risk probabilities and risk outcomes, risk perceptions, and quit intentions were assessed postexposures.

RESULTS

Memory for risk probabilities and risk outcomes depended on warning-label type and posttest timing. Consistent with memory-consolidation theory, memory for high- versus low-emotion labels was lower immediately, but declined less for high-than low-emotion labels. Label memory was similar between conditions at 6 weeks. Numeracy predicted overall superior memory (especially for risk probabilities) controlling for health literacy and education. It also indirectly predicted greater risk perceptions and quit intentions via memory. In exploratory analyses, however, the superior recall of risk probabilities of smoking among those higher in numeracy was associated with lower risk perceptions.

CONCLUSIONS

Numeracy is associated with superior risk memory, which relates to greater risk perceptions and quit intentions. More numerate and educated smokers may be better able to quit due to their superior learning of smoking's risks. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Disparities in risk perception of thyroid cancer recurrence and death

BACKGROUND

To the authors' knowledge, studies regarding risk perception among survivors of thyroid cancer are scarce.

METHODS

The authors surveyed patients who were diagnosed with differentiated thyroid cancer from the Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles County (2632 patients; 63% response rate). The analytic cohort was defined by a ≤5% risk of disease recurrence and mortality (1597 patients). Patients estimated their recurrence and mortality risks separately (increments of 10% and endpoints of ≤5% and ≥95%). Both outcomes were dichotomized between reasonably accurate estimates (risk perception of ≤5% or 10%) versus overestimation (risk perception of ≥20%). Multivariable logistic regression was used to identify factors associated with risk overestimation, and the relationships between overestimation and both worry and quality of life were evaluated.

RESULTS

In the current study sample, 24.7% of patients overestimated their recurrence risk and 12.5% overestimated their mortality risk. A lower educational level was associated with overestimating disease recurrence (≤high school diploma: odds ratio [OR], 1.64 [95% CI, 1.16-2.31]; and some college: OR, 1.36 [95% CI, 1.02-1.81]) and mortality (≤high school diploma: OR, 1.86 [95% CI, 1.18-2.93]) risk compared with those attaining at least a college degree. Hispanic ethnicity was found to be associated with overestimating recurrence risk (OR, 1.44, 95% CI 1.02-2.03) compared with their white counterparts. Worry about recurrence and death was found to be greater among patients who overestimated versus those who had a reasonably accurate estimate of their risk of disease recurrence and mortality, respectively (P < .001). Patients who overestimated mortality risk also reported a decreased physical quality of life (mean T score, 43.1; 95% CI, 41.6-44.7) compared with the general population.

CONCLUSIONS

Less educated patients and Hispanic patients were more likely to report inaccurate risk perceptions, which were associated with worry and a decreased quality of life.

Understanding Health Risk Comprehension: The Role of Math Anxiety, Subjective Numeracy, and Objective Numeracy

Background. Numeracy skills are important for medical decision making as lower numeracy is associated with misinterpreting statistical health risks. Math anxiety, characterized by negative emotions about numerical tasks, and lower subjective numeracy (i.e., self-assessments of numerical competence) are also associated with poor risk comprehension. Objective. To explore independent and mediated associations of math anxiety, numerical ability, and subjective numeracy with risk comprehension and to ascertain whether their associations are specific to the health domain. Methods. Objective numeracy was measured with a 14-item test. Math anxiety and subjective numeracy were assessed with self-report scales. Risk comprehension was measured with a 12-item test. In experiment 1, risk comprehension items were limited to scenarios in the health domain. In experiment 2, participants were randomly assigned to receive numerically equivalent risk comprehension items in either a health or nonhealth domain. Results. Linear regression analyses revealed that individuals with higher objective numeracy were more likely to respond correctly to the risk comprehension items, as were individuals with higher subjective numeracy. Higher math anxiety was associated with a lower likelihood of correct responding when controlling for objective numeracy but not when controlling for subjective numeracy. Mediation analyses indicated that math anxiety may undermine risk comprehension in 3 ways, including through 1) objective numeracy, 2) subjective numeracy, and 3) objective and subjective numeracy in serial, with subjective numeracy mediating the association between objective numeracy and risk comprehension. Findings did not differ by domain. Conclusions. Math anxiety, objective numeracy, and subjective numeracy are associated with risk comprehension through unique pathways. Education initiatives for improving health risk comprehension may be most effective if jointly aimed at tackling numerical ability as well as negative emotions and self-evaluations related to numeracy.

Health literacy of adults with and without arterial hypertension

OBJECTIVE

Assess the level of health literacy of adults, with and without hypertension, treated in three basic health units (UBS) in Picos, Piauí.

METHODS

Cross-sectional study conducted with 357 adults. Data were collected using a questionnaire with sociodemographic variables, and literacy was assessed by the Test of Functional Literacy in Adults. Descriptive analysis was performed followed by the association between literacy and exposure variables with Pearson's chi-squared (X2) test and Mann-Whitney U test.

RESULTS

Inadequate or marginal health literacy was found in three units investigated (71.5%; 77.8% and 85.2%);. Age and the years of schooling were factors associated with inadequate literacy in adults with hypertension (p<0.0001).

CONCLUSION

Inadequate literacy was found in more than 70% of the hypertensive patients investigated. This finding reinforces the need to improve the self-care skills of hypertensive patients, especially the older ones and those with few years of schooling.

Talking about risk in the context of genomic tests (TARGET): development and evaluation of an educational program for clinicians

Purpose

Gene expression profiling (GEP) test scores calculate risks of recurrence and likely benefit of adjuvant chemotherapy in ER-positive, HER2-negative, early-stage breast cancer. As health literacy and numeracy skills in the general population are poor, healthcare professionals (HCPs) require a wide repertoire of communication skills to explain clearly risk of recurrence scores (RSs) and uncertainty. We developed and evaluated an educational program for HCPs discussing GEP test results and adjuvant treatment.

Methods

Eight-hour workshops contained elements aimed at improving knowledge, communication skills and self-awareness; these included the science underpinning GEP tests, an interactive risk psychology lecture, exercises and facilitated group discussions regarding seven filmed scenarios involving discussions about high, intermediate and low RSs. Attendees were recorded explaining RSs with patient simulators pre and post workshop. Researchers, blinded to time point, analysed recordings using a study-specific scoring system. Primary objective outcomes were improvements post workshop in HCPs’ competence and confidence when communicating 17 pre-specified key information areas. We estimated odds ratios (OR) using conditional logistic regression to compare pre- and post-workshop scores.

Results

65 HCPs attended. Objective analyses revealed significant positive shifts post workshop which included explaining GEP tests (OR 2.98; 95% CI 1.38–6.42; P = .001), recurrence RSs (OR 3.99; 95% CI 1.72–9.25; P < .001), benefits of chemotherapy (OR 3.99; 95% CI 1.82–8.75; P < .001; and harms OR 2.31; 95% CI 1.37–3.92; P < .001) using jargon free language (OR 5.29; 95% CI 2.27–12.35; P < .001). Patient simulator assessments also showed significant improvements as did HCPs’ self-assessments and ratings of their self-confidence when discussing different GEP tests with diverse patient types (P < .001).

Conclusion

These short, intensive, interactive TARGET workshops significantly improved HCPs’ communication about GEP results in ways likely to promote more informed decision-making by patients about chemotherapy.

Electronic supplementary material

The online version of this article (10.1007/s10549-019-05316-7) contains supplementary material, which is available to authorised users.

Multilevel Influences on Patient-Oncologist Communication about Genomic Test Results: Oncologist Perspectives

Thousands of women with early-stage breast cancer receive gene-expression profile (GEP) tests to guide chemotherapy decisions. However, many patients report a poor understanding of how their test results inform treatment decision-making. We applied models of patient-centered communication and informed decision-making to assess which variables oncologists' perceive as most influential to effective communication with their patients about GEP results and intervention modalities and approaches that could support more effective conversations about treatment decisions in routine clinical care. Medical oncologists who were part of a practice group in the mid-Atlantic US completed an online, cross-sectional survey in 2016. These data were merged with de-identified electronic patient and practice data. Of the 83 oncologists contacted, 29 completed the survey (35% response rate, representing 52% of the test-eligible patients in the practice network). There were no significant differences between survey responders and nonresponders. Oncologists reported patient-related variables as most influential, including performance status (65.5%), pretesting preferences for chemotherapy (55.2%), and comprehension of complex test results (55.2%). Oncologists endorsed their experience with testing (58.6%) and their own confidence in using the test results (48.3%) as influential as well. They indicated that a clinical decision support tool incorporating patient comorbidities, age, and potential benefits from chemotherapy would support their own practice and that they could share these results and other means of communication support using print materials (79.3%) with their patients in clinic (72.4%). These preferred intervention characteristics could be integrated into routine care, ultimately facilitating more effective communication about genomic testing (such as GEP) and its role in treatment selection.

Approximate Number Processing Skills Contribute to Decision Making Under Objective Risk: Interactions With Executive Functions and Objective Numeracy

Research on the cognitive abilities involved in decision making has shown that, under objective risk conditions (i.e., when explicit information about possible outcomes and risks is available), superior decisions are especially predicted by executive functions and exact number processing skills, also referred to as objective numeracy. So far, decision-making research has mainly focused on exact number processing skills, such as performing calculations or transformations of symbolic numbers. There is evidence that such exact numeric skills are based on approximate number processing (ANP) skills, which enable quick and accurate processing of non-symbolic numbers (e.g., Chen and Li, 2014). Very few studies, however, have investigated ANP skills in the context of risky decision making and have analyzed direct associations among the aforementioned sub functions. Possible interactions between the closely related skills have not been considered. The current study (N = 128) examines interactions of ANP skills with executive functions and objective numeracy, in predicting risky choice behavior. ANP skills are represented by the accuracy in a dot-comparison task. Decision making is measured by two versions of the Game of Dice Task (GDT), which place different emphases on the reflection of potential risks. The results show two-way as well as three-way interactions between the measures of ANP skills, executive functions, and objective numeracy in predicting risky decisions in both GDT versions. The riskiest decisions were most frequently made in case of low scores in all of the three competencies, while good performance in any one of them resulted in significant reductions of disadvantageous decisions. The findings indicate that high ANP skills can positively affect choice behavior in individuals who have weaknesses in reflectively attributed skills, namely executive functions and objective numeracy. Potential compensatory effects and mechanisms of ANP in decision making are discussed.

Designing Graphs that Promote Both Risk Understanding and Behavior Change

Graphs show promise for improving communications about different types of risks, including health risks, financial risks, and climate risks. However, graph designs that are effective at meeting one important risk communication goal (promoting risk-avoidant behaviors) can at the same time compromise another key goal (improving risk understanding). We developed and tested simple bar graphs aimed at accomplishing these two goals simultaneously. We manipulated two design features in graphs, namely, whether graphs depicted the number of people affected by a risk and those at risk of harm ("foreground+background") versus only those affected ("foreground-only"), and the presence versus absence of simple numerical labels above bars. Foreground-only displays were associated with larger risk perceptions and risk-avoidant behavior (i.e., willingness to take a drug for heart attack prevention) than foreground+background displays, regardless of the presence of labels. Foreground-only graphs also hindered risk understanding when labels were not present. However, the presence of labels significantly improved understanding, eliminating the detrimental effect of foreground-only displays. Labels also led to more positive user evaluations of the graphs, but did not affect risk-avoidant behavior. Using process modeling we identified mediators (risk perceptions, understanding, user evaluations) that explained the effect of display type on risk-avoidant behavior. Our findings contribute new evidence to the graph design literature: unlike what was previously feared, we demonstrate that it is possible to design foreground-only graphs that promote intentions for behavior change without a detrimental effect on risk understanding. Implications for the design of graphical risk communications and decision support are discussed.

Understanding clinical and non-clinical decisions under uncertainty: a scenario-based survey

BACKGROUND

Prospect theory suggests that when faced with an uncertain outcome, people display loss aversion by preferring to risk a greater loss rather than incurring certain, lesser cost. Providing probability information improves decision making towards the economically optimal choice in these situations. Clinicians frequently make decisions when the outcome is uncertain, and loss aversion may influence choices. This study explores the extent to which prospect theory, loss aversion, and probability information in a non-clinical domain explains clinical decision making under uncertainty.

METHODS

Four hundred sixty two participants (n = 117 non-medical undergraduates, n = 113 medical students, n = 117 resident trainees, and n = 115 medical/surgical faculty) completed a three-part online task. First, participants completed an iced-road salting task using temperature forecasts with or without explicit probability information. Second, participants chose between less or more risk-averse ("defensive medicine") decisions in standardized scenarios. Last, participants chose between recommending therapy with certain outcomes or risking additional years gained or lost.

RESULTS

In the road salting task, the mean expected value for decisions made by clinicians was better than for non-clinicians(-$1,022 vs -$1,061; <0.001). Probability information improved decision making for all participants, but non-clinicians improved more (mean improvement of $64 versus $33; p = 0.027). Mean defensive decisions decreased across training level (medical students 2.1 ± 0.9, residents 1.6 ± 0.8, faculty1.6 ± 1.1; p-trend < 0.001) and prospect-theory-concordant decisions increased (25.4%, 33.9%, and 40.7%;p-trend = 0.016). There was no relationship identified between road salting choices with defensive medicine and prospect-theory-concordant decisions.

CONCLUSIONS

All participants made more economically-rational decisions when provided explicit probability information in a non-clinical domain. However, choices in the non-clinical domain were not related to prospect-theory concordant decision making and risk aversion tendencies in the clinical domain. Recognizing this discordance may be important when applying prospect theory to interventions aimed at improving clinical care.

Effects of a risk-based online mammography intervention on accuracy of perceived risk and mammography intentions

OBJECTIVE

This experiment tested the effects of an individualized risk-based online mammography decision intervention. The intervention employs exemplification theory and the Elaboration Likelihood Model of persuasion to improve the match between breast cancer risk and mammography intentions.

METHODS

2918 women ages 35-49 were stratified into two levels of 10-year breast cancer risk (<1.5%; ≥1.5%) then randomly assigned to one of eight conditions: two comparison conditions and six risk-based intervention conditions that varied according to a 2 (amount of content: brief vs. extended) x 3 (format: expository vs. untailored exemplar [example case] vs. tailored exemplar) design. Outcomes included mammography intentions and accuracy of perceived breast cancer risk.

RESULTS

Risk-based intervention conditions improved the match between objective risk estimates and perceived risk, especially for high-numeracy women with a 10-year breast cancer risk ≤1.5%. For women with a risk≤1.5%, exemplars improved accuracy of perceived risk and all risk-based interventions increased intentions to wait until age 50 to screen.

CONCLUSION

A risk-based mammography intervention improved accuracy of perceived risk and the match between objective risk estimates and mammography intentions.

PRACTICE IMPLICATIONS

Interventions could be applied in online or clinical settings to help women understand risk and make mammography decisions.

Empirical relationships between numeracy and treatment decision making: A scoping review of the literature

OBJECTIVES

To determine what is known from the existing literature about empirical relationships between numeracy and the three stages of the treatment decision making process (information exchange, deliberation, and deciding on the treatment to implement). We also examined if, and how, numeracy was mentioned in relation to health literacy.

METHODS

A search of four databases returned 2772 records. After de-duplication and three levels of relevance screening, 38 primary studies were included in this review.

RESULTS

Relationships between numeracy and the information exchange stage have received greater attention than relationships between numeracy and the deliberation and deciding on the treatment to implement stages. The lack of overlap in the empirical relationships examined in studies, the measure(s) of numeracy used, and the characteristics of study populations, made findings difficult to compare. Multiple knowledge gaps and measurement-related problems were identified. Numeracy and health literacy have largely been treated as separate concepts.

CONCLUSION

More research is needed to better understand the importance of numeracy and health literacy to treatment decision making.

PRACTICE IMPLICATIONS

Decision aids designed for patients with different levels of health literacy may not meet the needs of patients with different levels of numeracy. The numeracy skills of health professionals require attention.

A systematic review of decision aids for patients making a decision about treatment for early breast cancer

Several complex treatment decisions may be offered to women with early stage breast cancer, about a range of treatments from different modalities including surgery, radiotherapy, and endocrine and chemotherapy. Decision aids can facilitate shared decision-making and improve decision-related outcomes. We aimed to systematically identify, describe and appraise the literature on treatment decision aids for women with early breast cancer, synthesise the data and identify breast cancer decisions that lack a decision aid. A prospectively developed search strategy was applied to MEDLINE, the Cochrane databases, EMBASE, PsycINFO, Web of Science and abstract databases from major conferences. Data were extracted into a pre-piloted form. Quality and risk of bias were measured using Qualsyst criteria. Results were synthesised into narrative format. Thirty-three eligible articles were identified, evaluating 23 individual treatment decision aids, comprising 13 randomised controlled trial reports, seven non-randomised comparative studies, eight single-arm pre-post studies and five cross-sectional studies. The decisions addressed by these decision aids were: breast conserving surgery versus mastectomy (+/- reconstruction); use of chemotherapy and/or endocrine therapy; radiotherapy; and fertility preservation. Outcome measures were heterogeneous, precluding meta-analysis. Decisional conflict decreased, and knowledge and satisfaction increased, without any change in anxiety or depression, in most studies. No studies were identified that evaluated decision aids for neoadjuvant systemic therapy, or contralateral prophylactic mastectomy. Decision aids are available and improved decision-related outcomes for many breast cancer treatment decisions including surgery, radiotherapy, and endocrine and chemotherapy. Decision aids for neoadjuvant systemic therapy and contralateral prophylactic mastectomy could not be found, and may be warranted.

Predicting prostate cancer treatment choices: The role of numeracy, time discounting, and risk attitudes

Prostate cancer is the most common cancer among males in the United States, and there is lack of consensus as to whether active surveillance or radical prostatectomy is the best course of treatment. In this study, we examined the role of numeracy, time discounting, and risk taking on decision-making about prostate cancer treatment-in 279 men over age 50 without a prior prostate cancer diagnosis. Results showed that active surveillance was the most chosen option and its preference was predicted by numeracy and time discounting. However, radical prostatectomy was significantly predicted by participants' propensity to take risks.

Can I Count on Getting Better? Association between Math Anxiety and Poorer Understanding of Medical Risk Reductions

BACKGROUND

Lower numerical ability is associated with poorer understanding of health statistics, such as risk reductions of medical treatment. For many people, despite good numeracy skills, math provokes anxiety that impedes an ability to evaluate numerical information. Math-anxious individuals also report less confidence in their ability to perform math tasks. We hypothesized that, independent of objective numeracy, math anxiety would be associated with poorer responding and lower confidence when calculating risk reductions of medical treatments.

METHODS

Objective numeracy was assessed using an 11-item objective numeracy scale. A 13-item self-report scale was used to assess math anxiety. In experiment 1, participants were asked to interpret the baseline risk of disease and risk reductions associated with treatment options. Participants in experiment 2 were additionally provided a graphical display designed to facilitate the processing of math information and alleviate effects of math anxiety. Confidence ratings were provided on a 7-point scale.

RESULTS

Individuals of higher objective numeracy were more likely to respond correctly to baseline risks and risk reductions associated with treatment options and were more confident in their interpretations. Individuals who scored high in math anxiety were instead less likely to correctly interpret the baseline risks and risk reductions and were less confident in their risk calculations as well as in their assessments of the effectiveness of treatment options. Math anxiety predicted confidence levels but not correct responding when controlling for objective numeracy. The graphical display was most effective in increasing confidence among math-anxious individuals.

CONCLUSIONS

The findings suggest that math anxiety is associated with poorer medical risk interpretation but is more strongly related to confidence in interpretations.

Why Breast Cancer Risk by the Numbers Is Not Enough: Evaluation of a Decision Aid in Multi-Ethnic, Low-Numerate Women

Background

Breast cancer risk assessment including genetic testing can be used to classify people into different risk groups with screening and preventive interventions tailored to the needs of each group, yet the implementation of risk-stratified breast cancer prevention in primary care settings is complex.

Objective

To address barriers to breast cancer risk assessment, risk communication, and prevention strategies in primary care settings, we developed a Web-based decision aid, RealRisks, that aims to improve preference-based decision-making for breast cancer prevention, particularly in low-numerate women.

Methods

RealRisks incorporates experience-based dynamic interfaces to communicate risk aimed at reducing inaccurate risk perceptions, with modules on breast cancer risk, genetic testing, and chemoprevention that are tailored. To begin, participants learn about risk by interacting with two games of experience-based risk interfaces, demonstrating average 5-year and lifetime breast cancer risk. We conducted four focus groups in English-speaking women (age ≥18 years), a questionnaire completed before and after interacting with the decision aid, and a semistructured group discussion. We employed a mixed-methods approach to assess accuracy of perceived breast cancer risk and acceptability of RealRisks. The qualitative analysis of the semistructured discussions assessed understanding of risk, risk models, and risk appropriate prevention strategies.

Results

Among 34 participants, mean age was 53.4 years, 62% (21/34) were Hispanic, and 41% (14/34) demonstrated low numeracy. According to the Gail breast cancer risk assessment tool (BCRAT), the mean 5-year and lifetime breast cancer risk were 1.11% (SD 0.77) and 7.46% (SD 2.87), respectively. After interacting with RealRisks, the difference in perceived and estimated breast cancer risk according to BCRAT improved for 5-year risk (P=.008). In the qualitative analysis, we identified potential barriers to adopting risk-appropriate breast cancer prevention strategies, including uncertainty about breast cancer risk and risk models, distrust toward the health care system, and perception that risk assessment to pre-screen women for eligibility for genetic testing may be viewed as rationing access to care.

Conclusions

In a multi-ethnic population, we demonstrated a significant improvement in accuracy of perceived breast cancer risk after exposure to RealRisks. However, we identified potential barriers that suggest that accurate risk perceptions will not suffice as the sole basis to support informed decision making and the acceptance of risk-appropriate prevention strategies. Findings will inform the iterative design of the RealRisks decision aid.

Willingness to test for BRCA1/2 in high risk women: Influenced by risk perception and family experience, rather than by objective or subjective numeracy?

Genetic testing for breast and ovarian cancer can help target prevention programs, and possibly reduce morbidity and mortality. A positive result of BRCA1/2 is a substantial risk factor for breast and ovarian cancer, and its detection often leads to risk reduction interventions such as increased screening, prophylactic mastectomy and oophorectomy. We examined predictors of the decision to undergo cancer related genetic testing: perceived risk, family risk of breast or ovarian cancer, and numeracy as predictors of the decision to test among women at high risk of breast cancer. Stepwise regression analysis of survey responses from 459 women registered in the Cancer Genetics Network revealed greater likelihood to test for women with more family history, higher perceived risk of mutation, or Ashkenazi descent. Neither subjective nor objective numeracy was associated with the decision to test, although we replicated an earlier finding that subjective numeracy predicted willingness to pay for testing. Findings underscore the need for genetic counselling that disentangles risk perception from objective information to promote better decision-making in the context of genetic testing. Highlighting these factors is crucial for public health campaigns, as well as to clinic-based testing and direct-to-consumer testing.

Decision making and cancer

We review decision making along the cancer continuum in the contemporary context of informed and shared decision making in which patients are encouraged to take a more active role in their health care. We discuss challenges to achieving informed and shared decision making, including cognitive limitations and emotional factors, but argue that understanding the mechanisms of decision making offers hope for improving decision support. Theoretical approaches to decision making that explain cognition, emotion, and their interaction are described, including classical psychophysical approaches, dual-process approaches that focus on conflicts between emotion versus cognition (or reason), and modern integrative approaches such as fuzzy-trace theory. In contrast to the earlier emphasis on rote use of numerical detail, modern approaches emphasize understanding the bottom-line gist of options (which encompasses emotion and other influences on meaning) and retrieving relevant social and moral values to apply to those gist representations. Finally, research on interventions to support better decision making in clinical settings is reviewed, drawing out implications for future research on decision making and cancer.

How can we best respect patient autonomy in breast cancer treatment decisions?

Helping patients to maximize their autonomy in breast cancer decision-making is an important aspect of patient-centered care. Shared decision-making is a strategy that aims to maximize patient autonomy by integrating the values and preferences of the patient with the biomedical expertise of the physician. Application of this approach in breast cancer decision-making has not been uniform across cancer-specific interventions (e.g., surgery, chemotherapy), and in some circumstances may present challenges to evidence-based care delivery. Increasingly precise estimates of individual patients' risk of recurrence and commensurate predicted benefit from certain therapies hold significant promise in helping patients exercise autonomous decision-making for their breast cancer care, yet will also likely complicate decision-making for certain subgroups of patients.

The role of ANS acuity and numeracy for the calibration and the coherence of subjective probability judgments

The purpose of the study was to investigate how numeracy and acuity of the approximate number system (ANS) relate to the calibration and coherence of probability judgments. Based on the literature on number cognition, a first hypothesis was that those with lower numeracy would maintain a less linear use of the probability scale, contributing to overconfidence and nonlinear calibration curves. A second hypothesis was that also poorer acuity of the ANS would be associated with overconfidence and non-linearity. A third hypothesis, in line with dual-systems theory (e.g., Kahneman and Frederick, 2002) was that people higher in numeracy should have better access to the normative probability rules, allowing them to decrease the rate of conjunction fallacies. Data from 213 participants sampled from the Swedish population showed that: (i) in line with the first hypothesis, overconfidence and the linearity of the calibration curves were related to numeracy, where people higher in numeracy were well calibrated with zero overconfidence. (ii) ANS was not associated with overconfidence and non-linearity, disconfirming the second hypothesis. (iii) The rate of conjunction fallacies was slightly, but to a statistically significant degree decreased by numeracy, but still high at all numeracy levels. An unexpected finding was that participants with better ANS acuity gave more realistic estimates of their performance relative to others.

Provider perspectives on presenting risk information and managing worry about recurrence among breast cancer survivors

BACKGROUND

Although worry about recurrence is a persistent concern among breast cancer survivors, little is known about physicians' confidence about presenting recurrence risk information, identifying women with considerable worry, and helping women manage worry.

METHODS

Between January and June 2012, we surveyed 750 surgeons and 750 medical oncologists randomly sampled from the American Medical Association Physician Masterfile. We tested differences between surgeons and medical oncologists on confidence of presenting risk, identifying and managing worry using chi-square statistic and Student's t-tests and developed multiple variable logistic regression models to explain odds regarding confidence and use of different strategies for managing worry.

RESULTS

The analytic sample included 403 surgeons and 363 medical oncologists (n = 766; response rate = 60%). Compared with surgeons, medical oncologists were significantly more likely to report confidence in: presenting risk information (87.5% vs 73.2%), identifying women who are worried (74.1% vs 63.9%), and managing worry (66.9% vs 52.4%). Confidence in managing worry was associated with more regular inquiry about worry (p = 0.009). Models of the likelihood of using different management strategies varied by provider type (e.g., surgeons more likely than medical oncologists to recommend support group or online resources, oncologists more likely to refer to psychologist or use medications, all p < 0.05).

CONCLUSION

Cancer providers, particularly surgeons, may benefit from educational training to raise confidence in identifying women with high levels of worry and managing women with considerable worry. Communication between specialties and primary care physicians on efforts to manage worry is necessary for coordinated, quality care for women with breast cancer.

Numbers matter to informed patient choices: a randomized design across age and numeracy levels

BACKGROUND

How drug adverse events (AEs) are communicated in the United States may mislead consumers and result in low adherence. Requiring written information to include numeric AE-likelihood information might lessen these effects, but providing numbers may disadvantage less skilled populations. The objective was to determine risk comprehension and willingness to use a medication when presented with numeric or nonnumeric AE-likelihood information across age, numeracy, and cholesterol-lowering drug-use groups.

METHODS

In a cross-sectional Internet survey (N = 905; American Life Panel, 15 May 2008 to 18 June 2008), respondents were presented with a hypothetical prescription medication for high cholesterol. AE likelihoods were described using 1 of 6 formats (nonnumeric: consumer medication information (CMI)-like list, risk labels; numeric: percentage, frequency, risk labels + percentage, risk labels + frequency). Main outcome measures were risk comprehension (recoded to indicate presence/absence of risk overestimation and underestimation), willingness to use the medication (7-point scale; not likely = 0, very likely = 6), and main reason for willingness (chosen from 8 predefined reasons).

RESULTS

Individuals given nonnumeric information were more likely to overestimate risk, were less willing to take the medication, and gave different reasons than those provided numeric information across numeracy and age groups (e.g., among the less numerate, 69% and 18% overestimated risks in nonnumeric and numeric formats, respectively; among the more numerate, these same proportions were 66% and 6%). Less numerate middle-aged and older adults, however, showed less influence of numeric format on willingness to take the medication. It is unclear whether differences are clinically meaningful, although some differences are large.

CONCLUSIONS

Providing numeric AE-likelihood information (compared with nonnumeric) is likely to increase risk comprehension across numeracy and age levels. Its effects on uptake and adherence of prescribed drugs should be similar across the population, except perhaps in older, less numerate individuals.

Real-life decision making in college students. I: Consistency across specific decisions

First-year undergraduates participated in a short-term longitudinal study of real-life decision making over their first 14 months of college. They were surveyed about 7 different decisions: choosing courses for an upcoming term (3 different terms), choosing an academic major (twice), planning for the upcoming summer, and planning for sophomore-year housing. Participants showed moderate levels of consistency in the options they considered and in the criteria they used to decide between options, with about half of the options or criteria being used at 2 different points on the decision repeatedly studied. Participants varied somewhat in structural consistency, the tendency to consider the same number of options or criteria across decisions. They also varied in the way they integrated information across decision-making tasks. We suggest that people attempt to keep the information demands of the task within workable limits, sometimes sacrificing consistency as a result.

Experiences and attitudes toward risk of recurrence testing in women with breast cancer: a systematic review

Recurrence tests, such as Adjuvant! Online and Oncotype DX, can be used to determine an individual's risk of developing recurrent cancer. These technologies are useful for helping health care practitioners make treatment recommendations. With increasing use, it is necessary to consider patients' experience with and attitudes toward risk of recurrence testing. Factors such as anxiety, influence on decision making, confidence in results, and satisfaction with testing are important to consider. To understand experiences and attitudes toward risk of recurrence testing, from the perspective of women who have used these technologies following a breast cancer diagnosis. A systematic review was completed. Eight multidisciplinary electronic databases, including MEDLINE, PsycINFO, CINAHL, and ERIC, were searched from 1950 to December 17, 2012. Abstracts and full-text papers were screened for inclusion, in duplicate, based on established criteria. Recurrent themes and key concepts were identified and analyzed. One-thousand and twenty-two abstracts were retrieved, and fifty-one proceeded to full-text review. Ten studies reporting on eight populations were included in this review. Key themes that emerged from the literature include: experience with the testing process; influence testing has on treatment; and comprehension of results. The literature suggests that testing for breast cancer recurrence can have a negative impact on women; poor comprehension of test results, and anxiety/distress were the most frequently cited reasons for a negative experience. Despite these drawbacks, women consistently reported that they would recommend testing to others. The literature on this topic is limited, and heterogeneous. The available literature suggests that women are generally satisfied with risk of recurrence testing for breast cancer. Potential drawbacks of risk of recurrence testing include anxiety and comprehension of test results. Additional high-quality research on women's experiences with risk of recurrence testing for breast cancer would improve the evidence base, and would allow stronger conclusions to be drawn.

Presenting quantitative information about decision outcomes: a risk communication primer for patient decision aid developers

BACKGROUND

Making evidence-based decisions often requires comparison of two or more options. Research-based evidence may exist which quantifies how likely the outcomes are for each option. Understanding these numeric estimates improves patients' risk perception and leads to better informed decision making. This paper summarises current "best practices" in communication of evidence-based numeric outcomes for developers of patient decision aids (PtDAs) and other health communication tools.

METHOD

An expert consensus group of fourteen researchers from North America, Europe, and Australasia identified eleven main issues in risk communication. Two experts for each issue wrote a "state of the art" summary of best evidence, drawing on the PtDA, health, psychological, and broader scientific literature. In addition, commonly used terms were defined and a set of guiding principles and key messages derived from the results.

RESULTS

The eleven key components of risk communication were: 1) Presenting the chance an event will occur; 2) Presenting changes in numeric outcomes; 3) Outcome estimates for test and screening decisions; 4) Numeric estimates in context and with evaluative labels; 5) Conveying uncertainty; 6) Visual formats; 7) Tailoring estimates; 8) Formats for understanding outcomes over time; 9) Narrative methods for conveying the chance of an event; 10) Important skills for understanding numerical estimates; and 11) Interactive web-based formats. Guiding principles from the evidence summaries advise that risk communication formats should reflect the task required of the user, should always define a relevant reference class (i.e., denominator) over time, should aim to use a consistent format throughout documents, should avoid "1 in x" formats and variable denominators, consider the magnitude of numbers used and the possibility of format bias, and should take into account the numeracy and graph literacy of the audience.

CONCLUSION

A substantial and rapidly expanding evidence base exists for risk communication. Developers of tools to facilitate evidence-based decision making should apply these principles to improve the quality of risk communication in practice.

Critical research gaps and translational priorities for the successful prevention and treatment of breast cancer

INTRODUCTION

Breast cancer remains a significant scientific, clinical and societal challenge. This gap analysis has reviewed and critically assessed enduring issues and new challenges emerging from recent research, and proposes strategies for translating solutions into practice.

METHODS

More than 100 internationally recognised specialist breast cancer scientists, clinicians and healthcare professionals collaborated to address nine thematic areas: genetics, epigenetics and epidemiology; molecular pathology and cell biology; hormonal influences and endocrine therapy; imaging, detection and screening; current/novel therapies and biomarkers; drug resistance; metastasis, angiogenesis, circulating tumour cells, cancer 'stem' cells; risk and prevention; living with and managing breast cancer and its treatment. The groups developed summary papers through an iterative process which, following further appraisal from experts and patients, were melded into this summary account.

RESULTS

The 10 major gaps identified were: (1) understanding the functions and contextual interactions of genetic and epigenetic changes in normal breast development and during malignant transformation; (2) how to implement sustainable lifestyle changes (diet, exercise and weight) and chemopreventive strategies; (3) the need for tailored screening approaches including clinically actionable tests; (4) enhancing knowledge of molecular drivers behind breast cancer subtypes, progression and metastasis; (5) understanding the molecular mechanisms of tumour heterogeneity, dormancy, de novo or acquired resistance and how to target key nodes in these dynamic processes; (6) developing validated markers for chemosensitivity and radiosensitivity; (7) understanding the optimal duration, sequencing and rational combinations of treatment for improved personalised therapy; (8) validating multimodality imaging biomarkers for minimally invasive diagnosis and monitoring of responses in primary and metastatic disease; (9) developing interventions and support to improve the survivorship experience; (10) a continuing need for clinical material for translational research derived from normal breast, blood, primary, relapsed, metastatic and drug-resistant cancers with expert bioinformatics support to maximise its utility. The proposed infrastructural enablers include enhanced resources to support clinically relevant in vitro and in vivo tumour models; improved access to appropriate, fully annotated clinical samples; extended biomarker discovery, validation and standardisation; and facilitated cross-discipline working.

CONCLUSIONS

With resources to conduct further high-quality targeted research focusing on the gaps identified, increased knowledge translating into improved clinical care should be achievable within five years.

The value of personalised risk information: a qualitative study of the perceptions of patients with prostate cancer

OBJECTIVE

To explore the experiences of patients with prostate cancer with risk information and their perceptions of the value of personalised risk information in treatment decisions.

DESIGN

A qualitative study was conducted using focus groups. Semistructured interviews explored participants' experiences with using risk information, and their perceptions of the potential value of personalised risk information produced by clinical prediction models.

PARTICIPANTS

English-speaking patients, ages 54-82, diagnosed with prostate cancer within the past 3 years, residing in rural and non-rural geographic locations in Maine (USA), and attending prostate cancer patient support groups.

SETTING

6 focus groups were conducted with 27 patients; separate groups were held for patients with low-risk, medium-risk and high-risk disease defined by National Comprehensive Cancer Network guidelines.

RESULTS

Several participants reported receiving risk information that was imprecise rather than precise, qualitative rather than quantitative, indirect rather than direct and focused on biomarker values rather than clinical outcomes. Some participants felt that personalised risk information could be useful in helping them make better informed decisions, but expressed scepticism about its value. Many participants favoured decision-making strategies that were heuristic-based and intuitive rather than risk-based and deliberative, and perceived other forms of evidence-emotions, recommendations of trusted physicians, personal narratives-as more reliable and valuable in treatment decisions.

CONCLUSIONS

Patients with prostate cancer appear to have little experience using personalised risk information, may favour heuristic-based over risk-based decision-making strategies and may perceive personalised risk information as less valuable than other types of evidence. These decision-making approaches and perceptions represent potential barriers to the clinical use of personalised risk information. Overcoming these barriers will require providing patients with greater exposure to risk information, education about the nature and value of personalised risk information and training in deliberative decision-making strategies. More research is needed to confirm these findings and address these needs.

Subjective numeracy scale as a tool for assessing statistical numeracy in older adult populations

BACKGROUND

Statistical numeracy, necessary for making informed medical decisions, is reduced among older adults who make more decisions about their medical care and treatment than at any other stage of life. Objective numeracy scales are a source of anxiety among patients, heightened among older adults.

OBJECTIVE

We investigate the subjective numeracy scale as an alternative tool for measuring statistical numeracy with older adult samples.

METHODS

Numeracy was assessed using objective measures for 526 adults ranging in age from 18 to 93 years, and all participants provided subjective numeracy ratings.

RESULTS

Subjective numeracy correlated highly with objective measurements among oldest adults (70+ years; r = 0.51, 95% CI 0.32, 0.66), and for younger age groups. Subjective numeracy explained 33.2% of age differences in objective numeracy.

CONCLUSION

The subjective numeracy scale provides an effective tool for assessing statistical numeracy for broad age ranges and circumvents problems associated with objective numeracy measures.

Using decision aids to improve treatment choices for women with breast cancer

SUMMARY Breast cancer is the most frequently diagnosed cancer in women worldwide and decision-making regarding treatment options can be complex; however, patients often desire to be involved in health-related decisions. There has been a growing body of research into decision-support tools such as decision aids (DAs). Generally, DAs outperform standard care over a range of decision-making outcomes and there are some that have been developed for use with breast cancer patients across the treatment trajectory, which have been evaluated for use in practice. There is scope for developing additional DAs for cancer patients, however, there are some limitations and barriers that need to be overcome as part of the implementation process. Consideration for the mechanisms for maintaining relevancy of materials and ease of accessibility is also needed.

Protective measures, personal experience, and the affective psychology of time

We examined the role of time and affect in intentions to purchase a risk-protective measure (Studies 1 and 2) and explored participant abilities to factor time into the likelihood judgments that presumably underlie such intentions (Study 3). Participants worried more about losing their possessions and were more likely to purchase a protective measure given a longer term lease than a short-term lease, but only if their belongings were described in affect-poor terms. If described instead as being particularly special and affect-rich, participants neglected time and were about equally likely to purchase a risk-protective measure for shorter and longer term leases. However, and consistent with prior literature, the cognitive mechanism underlying this time-neglect-with-affect-richness effect seemed to be the greater use of the affect heuristic in the shorter term than the longer term. Study 2 results demonstrated that prior experience with having been burglarized amplified the interactive effect of time and affect. Greater deliberation did not attenuate this effect as hypothesized whether deliberation was measured through numeracy or manipulated through instructions. The results of Study 3 indicated that few participants are able to calculate correctly the risk numbers necessary to take time into account. Two possible solutions to encourage more purchases of protective measures in the long term are discussed.

Health numeracy in Japan: measures of basic numeracy account for framing bias in a highly numerate population

BACKGROUND

Health numeracy is an important factor in how well people make decisions based on medical risk information. However, in many countries, including Japan, numeracy studies have been limited.

METHODS

To fill this gap, we evaluated health numeracy levels in a sample of Japanese adults by translating two well-known scales that objectively measure basic understanding of math and probability: the 3-item numeracy scale developed by Schwartz and colleagues (the Schwartz scale) and its expanded version, the 11-item numeracy scale developed by Lipkus and colleagues (the Lipkus scale).

RESULTS

Participants' performances (n = 300) on the scales were much higher than in original studies conducted in the United States (80% average item-wise correct response rate for Schwartz-J, and 87% for Lipkus-J). This high performance resulted in a ceiling effect on the distributions of both scores, which made it difficult to apply parametric statistical analysis, and limited the interpretation of statistical results. Nevertheless, the data provided some evidence for the reliability and validity of these scales: The reliability of the Japanese versions (Schwartz-J and Lipkus-J) was comparable to the original in terms of their internal consistency (Cronbach's α = 0.53 for Schwartz-J and 0.72 for Lipkus-J). Convergent validity was suggested by positive correlations with an existing Japanese health literacy measure (the Test for Ability to Interpret Medical Information developed by Takahashi and colleagues) that contains some items relevant to numeracy. Furthermore, as shown in the previous studies, health numeracy was still associated with framing bias with individuals whose Lipkus-J performance was below the median being significantly influenced by how probability was framed when they rated surgical risks. A significant association was also found using Schwartz-J, which consisted of only three items.

CONCLUSIONS

Despite relatively high levels of health numeracy according to these scales, numeracy measures are still important determinants underlying susceptibility to framing bias. This suggests that it is important in Japan to identify individuals with low numeracy skills so that risk information can be presented in a way that enables them to correctly understand it. Further investigation is required on effective numeracy measures for such an intervention in Japan.

Risk perception and the economic crisis: a longitudinal study of the trajectory of perceived risk

We conducted a longitudinal survey of public response to the economic crisis to understand the trajectory of risk perception amidst an ongoing crisis. A nation-wide panel responded to seven surveys beginning in late September 2008 at the peak of the crisis and concluded in October 2009. At least 600 respondents participated in each survey, with 413 completing all seven surveys. Our online survey focused on perceptions of risk (savings, investments, retirement, job), negative emotions toward the financial crisis (sadness, anxiety, fear, anger, worry, stress), confidence in national leaders to manage the crisis (President Obama, Congress, Treasury Secretary, business leaders), and belief in one's ability to realize personal objectives despite the crisis. We employed latent growth curve modeling to analyze change in risk perception throughout the crisis. Our results suggest that, in general, people's perceptions of risk appear to decrease most rapidly during the initial phase of a crisis and then begin to level off. Negative emotion about the crisis was the most predictive of increased risk perception, supporting the notion of risk as feelings. Belief in one's ability to realize personal objectives was also predictive. Confidence in national leaders, however, was not predictive of perceived risk. Finally, our results demonstrate that groups may experience a crisis differently depending on a combination of personal characteristics such as gender, income, numeracy, and political attitude. Risk management and communication should work in sync with these mechanisms and differences across groups.

Development and Testing of an Abbreviated Numeracy Scale: A Rasch Analysis Approach

Research has demonstrated that individual differences in numeracy may have important consequences for decision making. In the present paper, we develop a shorter, psychometrically improved measure of numeracy—the ability to understand, manipulate, and use numerical information, including probabilities. Across two large independent samples that varied widely in age and educational level, participants completed 18 items from existing numeracy measures. In Study 1, we conducted a Rasch analysis on the item pool and created an eight‐item numeracy scale that assesses a broader range of difficulty than previous scales. In Study 2, we replicated this eight‐item scale in a separate Rasch analysis using data from an independent sample. We also found that the new Rasch‐based numeracy scale, compared with previous measures, could predict decision‐making preferences obtained in past studies, supporting its predictive validity. In Study, 3, we further established the predictive validity of the Rasch‐based numeracy scale. Specifically, we examined the associations between numeracy and risk judgments, compared with previous scales. Overall, we found that the Rasch‐based scale was a better linear predictor of risk judgments than prior measures. Moreover, this study is the first to present the psychometric properties of several popular numeracy measures across a diverse sample of ages and educational level. We discuss the usefulness and the advantages of the new scale, which we feel can be used in a wide range of subject populations, allowing for a more clear understanding of how numeracy is associated with decision processes. Copyright © 2012 John Wiley & Sons, Ltd.

Beyond Comprehension

When making decisions, people must frequently take into account numerical information, but not all individuals have the ability to understand and use numbers. Less numerate individuals comprehend less numerical information; but numeracy goes beyond comprehension, relating systematically to psychological mechanisms. In particular, greater numeracy has been associated with reduced susceptibility to framing effects, less influence of nonnumerical information such as mood states, and greater sensitivity to different levels of numerical risk. This greater number sensitivity has been linked with number-related affective reactions reported by the highly numerate. I briefly discuss methods to increase number use in decisions and policy implications of numeracy research.

Measuring Risk Literacy: The Berlin Numeracy Test

We introduce the Berlin Numeracy Test, a new psychometrically sound instrument that quickly assesses statistical numeracy and risk literacy. We present 21 studies (n=5336) showing robust psychometric discriminability across 15 countries (e.g., Germany, Pakistan, Japan, USA) and diverse samples (e.g., medical professionals, general populations, Mechanical Turk web panels). Analyses demonstrate desirable patterns of convergent validity (e.g., numeracy, general cognitive abilities), discriminant validity (e.g., personality, motivation), and criterion validity (e.g., numerical and non-numerical questions about risk). The Berlin Numeracy Test was found to be the strongest predictor of comprehension of everyday risks (e.g., evaluating claims about products and treatments; interpreting forecasts), doubling the predictive power of other numeracy instruments and accounting for unique variance beyond other cognitive tests (e.g., cognitive reflection, working memory, intelligence). The Berlin Numeracy Test typically takes about three minutes to complete and is available in multiple languages and formats, including a computer adaptive test that automatically scores and reports data to researchers (http://www.riskliteracy.org). The online forum also provides interactive content for public outreach and education, and offers a recommendation system for test format selection. Discussion centers on construct validity of numeracy for risk literacy, underlying cognitive mechanisms, and applications in adaptive decision support.

Risk communication with pictographs: The role of numeracy and graph processing

We conducted three studies to investigate how well pictographs communicate medical screening information to persons with higher and lower numeracy skills. In Study 1, we conducted a 2 (probability level: higher vs. lower) × 2 (reference information: yes vs. no) × 2 (subjective numeracy: higher vs. lower) between-subjects design. Persons with higher numeracy skills were influenced by probability level but not by reference information. Persons with lower numeracy tended to differentiate between a higher and a lower probability when there was no reference information. Study 2 consisted of interviews about the mental processing of pictographs. Higher numeracy was associated with counting the icons and relying on numbers depicted in the graph. Study 3 was an experiment with the same design as in Study 1, but, rather than using reference information, we varied the sequence of task type (counting first vs. non-counting first) to explore the role of the focus on numerical information. Persons with lower numeracy differentiated between higher and lower risk only when they were in the non-counting first condition. Task sequence did not influence the risk perceptions of persons with higher numeracy. In sum, our results suggest that pictographs may be useful for persons with higher and lower numeracy. However, these groups seem to process the graph differently. Persons with higher numeracy rely more on the numerical information depicted in the graph, whereas persons with lower numeracy seem to be confused when they are guided towards these numbers.

The association of understanding of medical statistics with health information seeking and health provider interaction in a national sample of young adults

Numeracy, or, "the ability to use and understand numbers in daily life" is a critical component of health literacy. However, little research has focused on numeracy in young adults (ages 18-29). We used a national sample to examine how health-information seeking, trust in sources, and interactions with health care providers differ for young adults with lower and higher numeracy. We included respondents ages 18 to 29 (n = 661) from the latest administration (2008) of the Health Information National Trends Survey (HINTS). There were no significant differences between those with lower and higher numeracy for most sociodemographic variables, nor did numeracy predict trust in health information sources. However, there were several differences for health-information seeking and health-provider interactions. Those with lower numeracy were significantly more likely to say their most recent search took a lot of effort (46% vs. 24%, p = .0008) and was frustrating (45% vs. 22%, p = .0038). Those in the lower numeracy group also reported more negative interactions with health providers, including feeling less able to rely on their provider (62% vs. 86%, p < .0001), and less likely to say their provider made sure they understood information (70% vs. 88%, p = .0001) and helped with any uncertainty (51% vs. 75%, p < .0001), even when adjusting for other variables. Our data suggest that limited comfort with numbers and statistics can influence a variety of health-related factors for young adults. More research is needed to understand how health literacy skills--including numeracy--influence health-information seeking, patient-provider relationships, and health outcomes, for young adults.

Informing Patients

Background. Given the importance of effective patient communication, findings about influences on risk perception in nonmedical domains need replication in medical domains. Objective. To examine whether numeracy influences risk perceptions when different information frames and number formats are used to present medication risks. Methods. The authors manipulated the frame and number format of risk information in a 3 (frame: positive, negative, combined) × 2 (number format: frequency, percentage) design. Participants from an Internet sample ( N = 298), randomly assigned to condition, responded to a single, hypothetical scenario. The main effects and interactions of numeracy, framing, and number format on risk perception were measured. Results. Participants given the positive frame perceived the medication as less risky than those given the negative frame. Mean risk perceptions for the combined frame fell between the positive and negative frames. Numeracy did not moderate these framing effects. Risk perceptions also varied by number format and numeracy, with less-numerate participants given risk information in a percentage format perceiving the medication as less risky than when given risk information in a frequency format; highly numerate participants perceived similar risks in both formats. The generalizability of the findings is limited due to the use of non-patients, presented a hypothetical scenario. Given the design, one cannot know whether observed differences would translate into clinically significant differences in patient behaviors. Conclusions. Frequency formats appear to increase risk perceptions over percentage formats for less-numerate respondents. Health communicators need to be aware that different formats generate different risk perceptions among patients varying in numeracy.