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

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

Biasing and debiasing health decisions with bar graphs: Costs and benefits of graph literacy

Bar graphs can improve risk communication in medicine and health. Unfortunately, recent research has revealed that bar graphs are associated with a robust bias that can lead to systematic judgement and decision-making errors. When people view bar graphs representing means, they tend to believe that data points located within bars are more likely to be part of the underlying distributions than equidistant points outside bars. In three experiments, we investigated potential consequences, key cognitive mechanisms, and generalisability of the within-the-bar bias in the medical domain. We also investigated the effectiveness of different interventions to reduce the effect of this bias and protect people from errors. Results revealed that the within-the-bar bias systematically affected participants’ judgements and decisions concerning treatments for controlling blood glucose, as well as their interpretations of ecological graphs designed to guide health policy decisions. Interestingly, individuals with higher graph literacy showed the largest biases. However, the use of dot plots to replace bars improved the accuracy of interpretations. Perceptual mechanisms underlying the within-the-bar bias and prescriptive implications for graph design are discussed.

Designing Visual Aids That Promote Risk Literacy: A Systematic Review of Health Research and Evidence-Based Design Heuristics

Background Effective risk communication is essential for informed decision making. Unfortunately, many people struggle to understand typical risk communications because they lack essential decision-making skills. Objective The aim of this study was to review the literature on the effect of numeracy on risk literacy, decision making, and health outcomes, and to evaluate the benefits of visual aids in risk communication. Method We present a conceptual framework describing the influence of numeracy on risk literacy, decision making, and health outcomes, followed by a systematic review of the benefits of visual aids in risk communication for people with different levels of numeracy and graph literacy. The systematic review covers scientific research published between January 1995 and April 2016, drawn from the following databases: Web of Science, PubMed, PsycINFO, ERIC, Medline, and Google Scholar. Inclusion criteria were investigation of the effect of numeracy and/or graph literacy, and investigation of the effect of visual aids or comparison of their effect with that of numerical information. Thirty-six publications met the criteria, providing data on 27,885 diverse participants from 60 countries. Results Transparent visual aids robustly improved risk understanding in diverse individuals by encouraging thorough deliberation, enhancing cognitive self-assessment, and reducing conceptual biases in memory. Improvements in risk understanding consistently produced beneficial changes in attitudes, behavioral intentions, trust, and healthy behaviors. Visual aids were found to be particularly beneficial for vulnerable and less skilled individuals. Conclusion Well-designed visual aids tend to be highly effective tools for improving informed decision making among diverse decision makers. We identify five categories of practical, evidence-based guidelines for heuristic evaluation and design of effective visual aids.

Improving risk literacy in surgeons

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRACTICE IMPLICATIONS

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

Measuring Graph Literacy without a Test: A Brief Subjective Assessment

BACKGROUND

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

OBJECTIVES

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

PARTICIPANTS

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

DESIGN

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

MEASURES

Psychometric properties of the scale.

RESULTS

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

CONCLUSIONS

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

Brief Messages to Promote Prevention and Detection of Sexually Transmitted Infections

We review the results of our research program investigating the effects of brief risk awareness interventions for sexually active young adults—the age group most at-risk for sexually transmitted infections (STIs). Our review examines the influence of framed messages, individual differences, and visual aids on key attitudes, behavioral intentions, and health outcomes in three extensive longitudinal studies. Our first study showed that health messages can promote self-reported condom use (screening for STIs) when the messages were framed in positive (negative) terms. This study also showed that adding visual aids to the positive and negative framed messages made them equally and highly effective for promoting self-reported behavior. Visual aids increased self-reported behavior by eliminating the effect of framing on attitudes and behavioral intentions, which in turn influenced self-reported behavior. Our second study showed that visual aids were especially helpful for reducing the effect of message framing among young adults with low numeracy and high graph literacy. Our third study showed that visual aids influenced key attitudes, behavioral intentions, and self-reported behavior as much as a validated 8-hour educational program. Overall, our research suggests that well-constructed visual aids provide simple, effective ways of communicating quantitative information about STIs to at-risk young adults. Theoretical mechanisms, public policy implications, and open questions are discussed.

Injury Risk Estimation Expertise: Interdisciplinary Differences in Performance on the ACL Injury Risk Estimation Quiz

Background:

Simple observational assessment of movement is a potentially low-cost method for anterior cruciate ligament (ACL) injury screening and prevention. Although many individuals utilize some form of observational assessment of movement, there are currently no substantial data on group skill differences in observational screening of ACL injury risk.

Purpose/Hypothesis:

The purpose of this study was to compare various groups’ abilities to visually assess ACL injury risk as well as the associated strategies and ACL knowledge levels. The hypothesis was that sports medicine professionals would perform better than coaches and exercise science academics/students and that these subgroups would all perform better than parents and other general population members.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A total of 428 individuals, including physicians, physical therapists, athletic trainers, strength and conditioning coaches, exercise science researchers/students, athletes, parents, and members of the general public participated in the study. Participants completed the ACL Injury Risk Estimation Quiz (ACL-IQ) and answered questions related to assessment strategy and ACL knowledge.

Results:

Strength and conditioning coaches, athletic trainers, physical therapists, and exercise science students exhibited consistently superior ACL injury risk estimation ability (+2 SD) as compared with sport coaches, parents of athletes, and members of the general public. The performance of a substantial number of individuals in the exercise sciences/sports medicines (approximately 40%) was similar to or exceeded clinical instrument-based biomechanical assessment methods (eg, ACL nomogram). Parents, sport coaches, and the general public had lower ACL-IQ, likely due to their lower ACL knowledge and to rating the importance of knee/thigh motion lower and weight and jump height higher.

Conclusion:

Substantial cross-professional/group differences in visual ACL injury risk estimation exist. The relatively profound differences in injury risk estimation accuracy and their potential implications for risk screening suggest the need for additional training and outreach (see http://www.ACL-IQ.org).

Clinical Relevance:

Parents and sport coaches would likely benefit from training or use of decision support tools such as the ACL nomogram to assess ACL injury risk. In addition, physicians and other sports medicine professionals may also benefit from improving risk estimation performance to reach clinical biomechanical standards.

Visual aids improve diagnostic inferences and metacognitive judgment calibration

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

Injury Risk Estimation Expertise: Assessing the ACL Injury Risk Estimation Quiz

BACKGROUND

Available methods for screening anterior cruciate ligament (ACL) injury risk are effective but limited in application as they generally rely on expensive and time-consuming biomechanical movement analysis. A potentially efficient alternative to biomechanical screening is skilled movement analysis via visual inspection (ie, having experts estimate injury risk factors based on observations of athletes' movements).

PURPOSE

To develop a brief, valid psychometric assessment of ACL injury risk factor estimation skill: the ACL Injury Risk Estimation Quiz (ACL-IQ).

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

A total of 660 individuals participated in various stages of the study, including athletes, physicians, physical therapists, athletic trainers, exercise science researchers/students, and members of the general public in the United States. The ACL-IQ was fully computerized and made available online (www.ACL-IQ.org). Item sampling/reduction, reliability analysis, cross-validation, and convergent/discriminant validity analyses were conducted to refine the efficiency and validity of the assessment.

RESULTS

Psychometric optimization techniques identified a short (mean time, 2 min 24 s), robust, 5-item assessment with high reliability (test-retest: r = 0.90) and high test sensitivity (average difference of exercise science professionals vs general population: Cohen d = 2). Exercise science professionals and individuals from the general population scored 74% and 53% correct, respectively. Convergent and discriminant validity was demonstrated. Scores on the ACL-IQ were best predicted by ACL knowledge and specific judgment strategies (ie, cue use) and were largely unrelated to domain-general spatial/decision-making ability, personality, or other demographic variables. Overall, 23% of the total sample (40% of exercise science professionals; 6% of general population) performed better than or equal to the ACL nomogram.

CONCLUSION

This study presents the results of a systematic approach to assess individual differences in ACL injury risk factor estimation skill; the assessment approach is efficient (ie, it can be completed in <3 min) and psychometrically robust. The results provide evidence that some individuals have the ability to visually estimate ACL injury risk factors more accurately than other instrument-based ACL risk estimation methods (ie, ACL nomogram). The ACL-IQ provides the foundation for assessing the efficacy of observational ACL injury risk factor assessment (ie, does simple skilled visual inspection reduce ACL injuries?). The ACL-IQ can also be used to increase our understanding of the perceptual-cognitive mechanisms underlying injury risk assessment expertise, which can be leveraged to accelerate learning and improve performance.

Understanding the Harms and Benefits of Cancer Screening

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

Injury Risk Estimation Expertise: Cognitive-Perceptual Mechanisms of ACL-IQ

Instrument-based biomechanical movement analysis is an effective injury screening method but relies on expensive equipment and time-consuming analysis. Screening methods that rely on visual inspection and perceptual skill for prognosticating injury risk provide an alternative approach that can significantly reduce cost and time. However, substantial individual differences exist in skill when estimating injury risk performance via observation. The underlying perceptual-cognitive mechanisms of injury risk identification were explored to better understand the nature of this skill and provide a foundation for improving performance. Quantitative structural and process modeling of risk estimation indicated that superior performance was largely mediated by specific strategies and skills (e.g., irrelevant information reduction), and independent of domain-general cognitive abilities (e.g., mental rotation, general decision skill). These cognitive models suggest that injury prediction expertise (i.e., ACL-IQ) is a trainable skill, and provide a foundation for future research and applications in training, decision support, and ultimately clinical screening investigations.

Improving risk understanding across ability levels: Encouraging active processing with dynamic icon arrays

Icon arrays have been found to improve risk understanding and reduce judgment biases across a wide range of studies. Unfortunately, individuals with low graph literacy experience only limited benefits from such displays. To enhance the efficacy and reach of these decision aids, the authors developed and tested 3 types of dynamic design features--that is, computerized display features that unfold over time. Specifically, the authors manipulated the sequential presentation of the different elements of icon arrays, the presence of explanatory labels indicating what was depicted in the different regions of the arrays, and the use of a reflective question followed by accuracy feedback. The first 2 features were designed to promote specific cognitive processes involved in graph comprehension, whereas the 3rd feature was designed to promote a more active, elaborative processing of risk information. Explanatory labels were effective in improving risk understanding among less graph-literate participants, whereas reflective questions resulted in large and robust performance benefits among participants with both low and high graph literacy. Theoretical and prescriptive implications are discussed. (PsycINFO Database Record

Factors predicting surgeons' preferred and actual roles in interactions with their patients

BACKGROUND

Although shared decision making offers clinical benefits, there is a lack of research investigating physicians' roles in interactions with their patients. Research examining what characterizes physicians who involve patients in decision making is also limited. The authors investigated surgeons' preferred and usual roles in interactions with patients, and whether these roles are influenced by their gender, experience, area of expertise, numeracy, and cultural background.

METHODS AND RESULTS

Participants were a diverse sample of 292 surgeons from 60 countries. Surgeons completed a survey about their usual and preferred roles in medical decision making. They also completed the Berlin Numeracy Test-a brief instrument designed to measure numeracy in culturally diverse educated individuals. Most surgeons preferred to share decision making with patients, but very few reported having a collaborative role in typical interactions. Female surgeons showed a stronger preference for collaborative decision making than their male counterparts (OR = 2.08). However, female surgeons more often played an active role in medical decision making, involving patients less often (OR = 5.39). Surgeons with low numeracy (OR = 3.83), less experienced surgeons (OR = 3.15), and surgeons from individualistic countries (OR = 1.82) rarely involved patients in decision making.

CONCLUSIONS

Most surgeons reported that shared decision making was their preferred method for medical decision making. Unfortunately, many of them were insufficiently equipped to take a more collaborative role in interactions with patients. Gender, numeracy, length of experience, and cultural background limited their willingness to collaborate. Future research should identify effective interventions that help overcome barriers to shared decision making.

Communicating Health Risks With Visual Aids

Informed decision making requires that people understand health risks. Unfortunately, many people are not risk literate and are biased by common risk communication practices. In this article, we review a collection of studies investigating the benefits of visual aids for communicating health risks to diverse vulnerable people (e.g., varying in abilities, ages, risk characteristics, and cultural backgrounds). These studies show that appropriately designed visual aids are often highly effective, transparent, and ethically desirable tools for improving decision making, changing attitudes, and reducing risky behavior. Theoretical mechanisms, open questions, and emerging applications are discussed.

Simple but powerful health messages for increasing condom use in young adults

In a large longitudinal study involving young adults, we conducted an eight-hour STD educational intervention and examined the impact of the intervention on the efficacy of a message for promoting condom use. The message was framed in positive or negative terms and was presented visually or in numbers (percentages or frequencies). Results indicated that the numerical positive-framed message increased condom use among young adults who did not receive the intervention, whereas the numerical negative-framed message did not. Attitudes toward condom use along with changes in intentions to use condoms mediated this framing effect. In contrast, the positive-framed and negative-framed messages were equally and highly effective for promoting condom use when the messages were presented visually or when young adults received the STD educational intervention before reading the message, suggesting that the simple brochures featuring visual aids were as effective in changing attitudes and behavioral intentions as the extensive intervention. These findings add to a growing body of evidence detailing the mechanisms that allow well-constructed visual aids to be among the most effective, transparent, memorable, and ethically desirable means of risk communication. Clinical and public health implications are discussed.

Communicating and Distorting Risks with Graphs: An Eye-Tracking Study

Graphs can represent complex information in accessible ways. Unfortunately, many graphs are poorly designed and lead to errors in judgment and decision-making. Here, we examine the influence of distorted graphs used by advertisers and major news organizations to communicate risks. Results indicated that the distorted graphs were associated with large judgment errors and that cognitive abilities (e.g., numeracy, graph literacy, cognitive reflection) predicted differences in error rates. Eye-tracking results revealed a strong link between elaborative information search and stimuli-memory, which mediated the ability-judgment relationship. Discussion focuses on cognitive mechanisms (e.g., elaborative encoding), implications for HFES graph design guidelines, and emerging opportunities for personalized decision support.

Using visual aids to improve communication of risks about health: a review

Recent research has shown that patients frequently experience difficulties understanding health-relevant numerical concepts. A prominent example is denominator neglect, or the tendency to pay too much attention to numerators in ratios (e.g., number of treated patients who died) with insufficient attention to denominators (e.g., overall number of treated patients). Denominator neglect can lead to inaccurate assessments of treatment risk reduction and thus can have important consequences for decisions about health. Here, we reviewed a series of studies investigating (1) different factors that can influence patients' susceptibility to denominator neglect in medical decision making—including numerical or language-related abilities; (2) the extent to which denominator neglect can be attenuated by using visual aids; and (3) a factor that moderates the effectiveness of such aids (i.e., graph literacy). The review spans probabilistic national U.S. and German samples, as well as immigrant (i.e., Polish people living in the United Kingdom) and undergraduate samples in Spain. Theoretical and prescriptive implications are discussed.

Effective communication of risks to young adults: using message framing and visual aids to increase condom use and STD screening

Sexually Transmitted Diseases (STDs)-including HIV/AIDS-are among the most common infectious diseases in young adults. How can we effectively promote prevention and detection of STDs in this high risk population? In a two-phase longitudinal experiment we examined the effects of a brief risk awareness intervention (i.e., a sexual health information brochure) in a large sample of sexually active young adults (n = 744). We assessed the influence of gain- and loss-framed messages, and visual aids, on affective reactions, risk perceptions, attitudes, behavioral intentions, and reported behaviors relating to the prevention and detection of STDs. Results indicate that gain-framed messages induced greater adherence for prevention behaviors (e.g., condom use), whereas loss-framed messages were more effective in promoting illness-detecting behaviors (e.g., making an appointment with a doctor to discuss about STD screening). The influence of the framed messages on prevention and detection of STDs was mediated by changes in participants' attitudes toward the health behaviors along with changes in their behavioral intentions. Moreover, when visual aids were added to the health information, both the gain- and loss-framed messages became equally and highly effective in promoting health behaviors. These results converge with other data indicating that well-constructed visual aids are often among the most highly effective, transparent, fast, memorable, and ethically desirable means of risk communication. Theoretical, economic, and public policy implications of these results are discussed.

The making of an expert

Popular lore tells us that genius is born, not made. Scientific research, on the other hand, reveals that true expertise is mainly the product of years of intense practice and dedicated coaching. Ordinary practice is not enough: To reach elite levels of performance, you need to constantly push yourself beyond your abilities and comfort level. Such discipline is the key to becoming an expert in all domains, including management and leadership. Those are the conclusions reached by Ericsson, a professor of psychology at Florida State University; Prietula, a professor at the Goizueta Business School; and Cokely, a research fellow at the Max Planck Institute for Human Development, who together studied data on the behavior of experts, gathered by more than 100 scientists. What consistently distinguished elite surgeons, chess players, writers, athletes, pianists, and other experts was the habit of engaging in "deliberate" practice--a sustained focus on tasks that they couldn't do before. Experts continually analyzed what they did wrong, adjusted their techniques, and worked arduously to correct their errors. Even such traits as charisma can be developed using this technique. Working with a drama school, the authors created a set of acting exercises for managers that remarkably enhanced executives' powers of charm and persuasion. Through deliberate practice, leaders can improve their ability to win over their employees, their peers, or their board of directors. The journey to elite performance is not for the impatient or the faint of heart. It takes at least a decade and requires the guidance of an expert teacher to provide tough, often painful feedback. It also demands would-be experts to develop their "inner coach" and eventually drive their own progress.

Sources of individual differences in working memory: contributions of strategy to capacity

Some research on attentional control in working memory has emphasized theoretical capacity differences. However, strategic behavior, which has been relatively unexplored, can also influence attentional control and its relationship to cognitive performance. In two experiments, we examined the relationship between attentional control (measured with operation span) and interference in a part-list cuing paradigm. Paradoxically, the results indicated that superior attentional control was related to increased interference. This relationship reflected the participants' use of more complex encoding strategies, rather than superior interference control at retrieval, and was eliminated following brief encoding strategy training. The results suggest that complex span measures sometimes predict individual differences in task strategies related to interference control and that these strategies may be amenable to training. The implications for working memory research and the roles of strategies in basic memory and attention paradigms are briefly discussed.