Communicating the results of risk-based breast cancer screening through visualizations of risk: a participatory design approach

BACKGROUND

Risk-based breast cancer (BC) screening raises new questions regarding information provision and risk communication. This study aimed to: 1) investigate women's beliefs and knowledge (i.e., mental models) regarding BC risk and (risk-based) BC screening in view of implications for information development; 2) develop novel informational materials to communicate the screening result in risk-based BC screening, including risk visualizations of both quantitative and qualitative information, from a Human-Centered Design perspective.

METHODS

Phase 1: Interviews were conducted (n = 15, 40-50 years, 5 lower health literate) on women's beliefs about BC risk and (risk-based) BC screening. Phase 2: In three participatory design sessions, women (n = 4-6 across sessions, 40-50 years, 2-3 lower health literate) made assignments and created and evaluated visualizations of risk information central to the screening result. Prototypes were evaluated in two additional sessions (n = 2, 54-62 years, 0-1 lower health literate). Phase 3: Experts (n = 5) and women (n = 9, 40-74 years) evaluated the resulting materials. Two other experts were consulted throughout the development process to ensure that the content of the information materials was accurate. Interviews were transcribed literally and analysed using qualitative thematic analysis, focusing on implications for information development. Notes, assignments and materials from the participatory design sessions were summarized and main themes were identified.

RESULTS

Women in both interviews and design sessions were positive about risk-based BC screening, especially because personal risk factors would be taken into account. However, they emphasized that the rationale of risk-based screening and classification into a risk category should be clearly stated and visualized, especially for higher- and lower-risk categories (which may cause anxiety or feelings of unfairness due to a lower screening frequency). Women wanted to know their personal risk, preferably visualized in an icon array, and wanted advice on risk reduction and breast self-examination. However, most risk factors were considered modifiable by women, and the risk factor breast density was not known, implying that information should emphasize that BC risk depends on multiple factors, including breast density.

CONCLUSIONS

The information materials, including risk visualizations of both quantitative and qualitative information, developed from a Human-Centered Design perspective and a mental model approach, were positively evaluated by the target group.

Health literate-sensitive shared decision-making in maternity care: needs for support among maternity care professionals in the Netherlands

BACKGROUND

Shared decision-making (SDM) in maternity care is challenging when clients have insufficient health literacy (HL) skills. This study gained insight in how professionals apply HL-sensitive SDM in Dutch maternity care and their needs for support therein.

METHODS

Maternity care professionals (n = 30) completed a survey on SDM and the role of HL. Midwives (n = 13) were observed during simulated conversations discussing pain relief options and interviewed afterwards. The client-actors were instructed to portrait specific inadequate HL skills. Observation items focused on adapting communication to HL, and SDM (OPTION-5).

RESULTS

In the survey, professionals indicated experiencing most challenges when estimating clients' information comprehension. Observations showed that most midwives created choice awareness and informed clients about options, whereas exploring preferences and actual decision-making together with clients were observed less frequently. Their perceived HL-related obstacles and needs for support related to clients' information comprehension. In the interviews, midwives reported putting much effort into explaining available options in maternity care, but also that decisions about pain relief are often postponed until the moment of labour.

CONCLUSION

Professionals' self-reported needs focus on clients' information comprehension. However, observations indicate that it is not the stage of informing, but rather value clarification and actual decision-making that need improvement in HL-sensitive SDM.

Conditions for autonomous reproductive decision-making in prenatal screening: A mixed methods study

BACKGROUND

Pregnant women should be able to make autonomous and meaningful decisions about prenatal screening for fetal abnormalities. It remains largely unclear which circumstances facilitate or hinder such a decision-making process.

OBJECTIVE

To investigate what conditions Dutch pregnant women and professional experts consider important for autonomous reproductive decision-making in prenatal screening for fetal abnormalities, and the extent to which, according to women, those conditions are met in practice.

METHODS

A mixed methods study was conducted in the Netherlands in 2016-2017. A conceptual model was used to interview professional experts (n = 16) and pregnant women (n = 19). Thematic analysis was performed to identify important conditions. Subsequently, a questionnaire assessed the perceived importance of those conditions and the extent to which these were met, in the experience of pregnant women (n = 200).

RESULTS

Professional experts stressed the importance of information provision, and emphasized a rational decision-making model. Pregnant women differed in what information they felt was needed, and this depended on the screening decision made. Questionnaire findings showed that women prioritized discussion and consensus with partners. Information about test accuracy and miscarriage risk of invasive follow-up testing was also considered important. Two key conditions were not adequately met, in the experience of women: (1) having information about miscarriage risk; (2) not being directed by health professionals in decision-making.

CONCLUSION

According to women, discussion and consensus with partners was considered a highly important condition for an autonomous and meaningful decision-making process. Access to information about safety of testing and ensuring that women are not being directed in their decision-making by health professionals seem to be areas for improvement in prenatal care practice.

Informed Decision-Making and Capabilities in Population-based Cancer Screening

Informed decision-making (IDM) is considered an important ethical and legal requirement for population-based screening. Governments offering such screening have a duty to enable invitees to make informed decisions regarding participation. Various views exist on how to define and measure IDM in different screening programmes. In this paper we first address the question which components should be part of IDM in the context of cancer screening. Departing from two diverging interpretations of the value of autonomy-as a right and as an ideal-we describe how this value is operationalized in the practice of informed consent in medicine and translate this to IDM in population-based cancer screening. Next, we specify components of IDM, which is voluntariness and the requirements of disclosure and understanding. We argue that whereas disclosure should contain all information considered relevant in order to enable authentic IDM, understanding of basic information is sufficient for a valid IDM. In the second part of the paper we apply the capability approach in order to argue for the responsibility of the government to warrant equal and real opportunities for invitees for IDM. We argue that additional conditions beyond mere provision of information are needed in order to do so.

Particulate matter in the workplace: effects of a mental models-based folder combined with a practical assignment

BACKGROUND

With increasing knowledge on the adverse health effects of certain constituents of PM (particulate matter), such as silica, metals, insoluble ions, and black carbon, PM has been under the attention of work safety experts. Previously, we investigated the perceptions of blue-collar workers in highly exposed areas of work. Subsequently, we developed an instruction folder highlighting the most important aspects of PM risk and mitigation, and tested this folder in a digital experiment. The digital experiment yielded positive results with regards to acquired knowledge about PM, but did not on risk perception or safety behavior.

METHODS

In this study, we investigate the effects of the folder when combined with a practical assignment involving a PM exposimeter, showing the amount of particulate matter in microgram per cubic meter in real time on its display for various activities. We tested this at six workplaces of four companies in the roadwork and construction branch.

RESULTS

The results indicate that the folder itself yields an increased knowledge base in employees about PM, but the effects of the practical assignment are more contentious. Nevertheless, there is an indication that using the assignment may lead to a higher threat appraisal among employees for high exposure activities.

CONCLUSION

We recommend implementing our folder in companies with high PM exposure and focusing further research on appropriate methods of implementation.

Promoting an active choice among physically inactive adults: a randomised web-based four-arm experiment

BACKGROUND

Promoting active (i.e., conscious, autonomous, informed, and value-congruent) choices may improve the effectiveness of physical activity interventions. This web-based four-arm experimental study investigated the effect of promoting an active versus passive choice regarding physical activity on behavioural and psychological outcomes (e.g., physical activity intentions and behaviours, autonomy, commitment) among physically inactive adults.

METHODS

Dutch inactive adults were randomized into four groups: physical activity guideline only (control group G), guideline & information (GI), guideline & active choice (GA), or guideline & active choice & action planning (GA +). GA and GA + participants were stimulated to make an active choice by weighing advantages and disadvantages of physical activity, considering personal values, and identifying barriers. GA + participants additionally completed action/coping planning exercises. Passive choice groups G and GI did not receive exercises. Self-reported behavioural outcomes were assessed by a questionnaire pre-intervention (T0, n = 564) and at 2-4 weeks follow-up (T2, n = 493). Psychological outcomes were assessed post-intervention (T1, n = 564) and at follow-up. Regression analyses compared the outcomes of groups GI, GA and GA + with group G. We also conducted sensitivity analyses and a process evaluation.

RESULTS

Although promoting an active choice process (i.e., interventions GA and GA +) did not improve intention (T1) or physical activity (T2 versus T0), GA + participants reported higher commitment at T1 (β = 0.44;95%CI:0.04;0.84) and more frequently perceived an increase in physical activity between T0 and T2 (β = 2.61;95%CI:1.44;7.72). GA participants also made a more active choice at T1 (β = 0.16;95%CI:0.04;0.27). The GA and GA + intervention did not significantly increase the remaining outcomes. GI participants reported higher intention strength (β = 0.64;95%CI:0.15;1.12), autonomy (β = 0.50;95%CI:0.05;0.95), and commitment (β = 0.39;95%CI:0.04;0.74), and made a more active choice at T1 (β = 0.13;95%CI:0.02;0.24). Interestingly, gender and health condition modified the effect on several outcomes. The GA + intervention was somewhat more effective in women. The process evaluation showed that participants varied in how they perceived the intervention.

CONCLUSIONS

There is no convincing evidence of a beneficial effect of an active versus passive choice intervention on physical activity intentions and behaviours among inactive adults. Further research should determine whether and how active choice interventions that are gender-sensitized and consider health conditions can effectively increase physical activity.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04973813 . Retrospectively registered.

Dynamics in public perceptions and media coverage during an ongoing outbreak of meningococcal W disease in the Netherlands

Background

From 2015 to 2018, the Netherlands faced an outbreak of invasive meningococcal disease (IMD) caused by serogroup W. To counter the rise in infections, the government introduced a catch-up menACWY vaccination campaign for teenagers in 2018 and 2019. The outbreak situation induced substantial media attention and a run on menACWY vaccines outside the vaccination campaign. This study aimed to gain insights into the dynamics of public perceptions of and responses to the outbreak and the menACWY vaccination, and into the media coverage about the outbreak.

Methods

Three repeated surveys (N = 1110) between 2017 and 2019 were sent to parents of teenagers invited for a menACWY catch-up vaccination, other parents, and individuals with no under-age children. These surveys assessed IMD risk perceptions, attitudes towards the menACWY vaccination, trust in involved institutions, and willingness to vaccinate with the menACWY vaccine. Changes in the public perceptions and responses were studied with linear multilevel regression analyses. In addition, 103 national newspaper articles from the period 2017–2019 were thematically coded with themes about IMD and the menACWY vaccination.

Results

The survey results showed clear increases in perceived IMD severity, positive attitude towards the menACWY vaccination, and willingness to vaccinate over time. Perceived IMD vulnerability remained low across all three waves, and trust in involved institutions increased slightly. Differences between the survey groups were limited. The newspaper articles discussed the rise in infections extensively, the disease symptoms, and the possible fatal outcome of IMD. In addition, while many articles discussed the menACWY vaccine shortage, few discussed the safety or effectiveness of the vaccine.

Conclusion

The real-time insights into the interrelated dynamics of public perceptions, responses, and media coverage provide an integrated portrait of the social developments during this outbreak. The focus on IMD severity and the absence of doubt in the public discussion about vaccine safety may have played an important role in the societal response to this outbreak and the recommended vaccine.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12920-8.

Risk communication about work-related stress disorders in healthcare workers: a scoping review

Purposes

Healthcare workers are at risk of stress-related disorders. Risk communication can be an effective preventive health measure for some health risks, but is not yet common in the prevention of stress-related disorders in an occupational healthcare setting. The overall aim is to examine whether risk communication was part of interventions aimed at the prevention of stress-related disorders in healthcare workers.

Method

We performed a scoping review using the framework of Arksey and O’Malley. We searched in Medline, Web of Science and PsychInfo for studies reporting on preventive interventions of stress-related disorders in healthcare workers between 2005 and December 2020. Studies were included when the intervention reported on at least one element of risk communication and one goal. We predefined four elements of risk communication: risk perception, communication of early stress symptoms, risk factors and prevention; and three goals: inform, stimulate informed decision-making and motivate action.

Results

We included 23 studies that described 17 interventions. None of the included interventions were primarily developed as risk communication interventions, but all addressed the goals. Two interventions used all four elements of risk communication. The prominent mode of delivery was face to face, mostly delivered by researchers. Early stress symptoms and risk factors were measured by surveys.

Conclusions

Risk communication on risk factors and early signs of stress-related disorders is not that well studied and evaluated in an occupational healthcare setting. Overall, the content of the communication was not based on the risk perception of the healthcare workers, which limited the likelihood of them taking action.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00420-022-01851-x.

Testing the effects on information use by older versus younger women of modality and narration style in a hospital report card

Background

Hospital report cards (HRCs) are usually presented in a textual and factual format, likely hampering information processing.

Objective

This study aimed to investigate the effects of audiovisual and narrative information in HRCs on user responses, and to test differences between older and younger women.

Design

A 2 (modality [textual vs. audiovisual]) × 3 (narration style [factual vs. process narrative vs. experience narrative]) online experiment was conducted. Information about breast cancer care was used as a case example. Age (younger [<65] vs. older [≥65]) was included as a potential effect modifier.

Setting and Participants

A total of 631 disease‐naïve women (M_age = 56.06) completed an online survey. The outcomes were perceived cognitive load, satisfaction, comprehension, information recall and decisional conflict. Data were analysed using AN(C)OVAs.

Results

Audiovisual (vs. textual) information resulted in higher information satisfaction across age groups, but was associated with lower comprehension in older women. An experience narrative (vs. factual information) increased satisfaction with attractiveness and emotional support of the information only in older women. A three‐way interaction effect was found, suggesting that older women were most satisfied with the comprehensibility of audiovisual factual or textual process narrative information. Younger women were most satisfied with the comprehensibility of audiovisual process narrative or textual factual information.

Discussion and Conclusion

Audiovisual and narrative information in an HRC showed beneficial effects on satisfaction measures. In particular, audiovisual information could be incorporated into HRCs to increase satisfaction with information.

Public Contribution

Lay persons helped in optimizing the visuals used in the stimulus materials by checking for clarity.

Non-invasive prenatal testing (NIPT) and pregnant women's views on good motherhood: a qualitative study

Women's views on responsible motherhood influence decision-making regarding participation in prenatal screening. Previous studies showed that the probabilistic nature of the first-trimester combined test and the potential requirement for subsequent invasive diagnostics serve as legitimate reasons for women to exclude prenatal screening from their moral responsibilities. These moral barriers might now be less relevant with the introduction of the non-invasive prenatal test (NIPT) resulting in women feeling a moral duty to use NIPT screening as part of responsible motherhood. This qualitative study explores the impact of NIPT on women's moral beliefs about the meaning of prenatal screening in relation to responsible motherhood. We performed semi-structured interviews with 29 pregnant women who were offered NIPT as a first-tier screening test within a Dutch nationwide study (TRIDENT-2). Results show that the inherent uncertainty about the fetus's health despite improved accuracy and the lack of treatment for a detected disorder, combined with the possibility to obtain information about actionable anomalies through the fetal anomaly scan, support women's perspectives that NIPT is not an obligation of responsible motherhood. Acceptance of NIPT is considered to be a free decision related to the information each woman needs to be a good mother for her child and her family. Women's views may change when NIPT has expanded to include treatable or preventable conditions.

Routinization of prenatal screening with the non-invasive prenatal test: pregnant women's perspectives

Due to the favorable test characteristics of the non-invasive prenatal test (NIPT) in the screening of fetal aneuploidy, there has been a strong and growing demand for implementation. In the Netherlands, NIPT is offered within a governmentally supported screening program as a first-tier screening test for all pregnant women (TRIDENT-2 study). However, concerns have been raised that the test’s favorable characteristics might lead to uncritical use, also referred to as routinization. This study addresses women’s perspectives on prenatal screening with NIPT by evaluating three aspects related to routinization: informed choice, freedom to choose and (personal and societal) perspectives on Down syndrome. Nationwide, a questionnaire was completed by 751 pregnant women after receiving counseling for prenatal screening. Of the respondents, the majority (75.5%) made an informed choice for prenatal screening as measured by the multidimensional measure of informed choice (MMIC). Education level and religious affiliation were significant predictors of informed choice. The main reason to accept screening was “seeking reassurance” (25.5%), and the main reason to decline was “every child is welcome” (30.6%). The majority of respondents (87.7%) did not perceive societal pressure to test. Differences between test-acceptors and test-decliners in personal and societal perspectives on Down syndrome were found. Our study revealed high rates of informed decision-making and perceived freedom to choose regarding fetal aneuploidy screening, suggesting that there is little reason for concern about routinization of NIPT based on the perspectives of Dutch pregnant women. Our findings highlight the importance of responsible implementation of NIPT within a national screening program.

Information needs during an emerging outbreak of meningococcal W135 disease in the Netherlands: a study among teenagers, their parents and healthcare professionals

BACKGROUND

To counter the rise in invasive meningococcal disease (IMD) serogroup W, the Netherlands introduced a menACWY catch-up vaccination campaign for teenagers in 2018 and 2019. Teenagers and parents who have questions or who seek advice from a professional about vaccinations are likely to consult a youth healthcare professional or their general practitioner. This study aimed to appraise the ability of these healthcare professionals to meet the information needs of teenagers and their parents at the start of the vaccination campaign.

METHODS

With online surveys, we assessed information needs in teenagers (N = 1603) and parents (N = 1784) concerning IMD and the menACWY vaccination, and in healthcare professionals (N = 520) in their communication with teenagers and parents. We additionally studied healthcare professionals' expectations of the information needs of teenagers and parents.

RESULTS

We identified several information needs about IMD and the menACWY vaccination in teenagers, parents and healthcare professionals. Some important commonalities in the information needs in these three groups were found, with regard to the topics IMD prevention, vaccine effectiveness and vaccine protection duration. Healthcare professionals' expectations of the information needs of teenagers and parents were quite accurate but some important discrepancies were found.

CONCLUSION

Our results suggest that healthcare professionals might not have been optimally equipped or prepared for questions from teenagers and their parents at the beginning of the vaccination campaign. We recommend public health institutes to timely assess and meet information needs about new vaccines in healthcare professionals to optimally equip them for consultations.

Meningococcal W135 Disease Vaccination Intent, the Netherlands, 2018-2019

To control the rise in Neisseria meningitidis strain W infections, during 2018–2019, the Netherlands launched a catch-up meningococcal conjugate (MenACWY) vaccination campaign for teenagers (13–18 years of age). Applying a mental models approach, we surveyed teenagers and their parents about their knowledge and beliefs about meningococcal disease, the MenACWY vaccination, vaccinations in general, and their MenACWY vaccination intentions. Using random forest analysis, we studied predictions of vaccination intentions by knowledge and beliefs. Survey response rate was 52.8% among teenagers and 59.4% among parents. MenACWY vaccination intentions were best predicted by knowledge and beliefs about vaccinations in general, surpassing knowledge and beliefs about meningococcal disease and the MenACWY vaccination. For teenagers, their parents’ intention that the teenager be vaccinated was a strong predictor of the teenagers’ own vaccination intention. To optimize vaccination uptake during future outbreaks, we recommend that communications emphasize the effectiveness and safety of vaccines and continue to focus on parents.

Women's Participation in Decision-Making in Maternity Care: A Qualitative Exploration of Clients' Health Literacy Skills and Needs for Support

Shared decision-making requires adequate functional health literacy (HL) skills from clients to understand information, as well as interactive and critical HL skills to obtain, appraise and apply information about available options. This study aimed to explore women's HL skills and needs for support regarding shared decision-making in maternity care. In-depth interviews were held among women in Dutch maternity care who scored low (n = 10) and high (n = 13) on basic health literacy screening test(s). HL skills and perceived needs for support were identified through thematic analysis. Women appeared to be highly engaged in the decision-making process. They mentioned searching and selecting general information about pregnancy and labor, constructing their preferences based on their own pre-existing knowledge and experiences and by discussions with partners and significant others. However, women with low basic skills and primigravida perceived difficulties in finding reliable information, understanding probabilistic information, constructing preferences based on benefit/harm information and preparing for consultations. Women also emphasized dealing with uncertainties, changing circumstances of pregnancy and labor, and emotions. Maternity care professionals could further support clients by guiding them towards reliable information. To facilitate participation in decision-making, preparing women for consultations (e.g., agenda setting) and supporting them in a timely manner to understand benefit/harm information seem important.

Dynamic Public Perceptions of the Coronavirus Disease Crisis, the Netherlands, 2020

A key component of outbreak control is monitoring public perceptions and public response. To determine public perceptions and public responses during the first 3 months of the coronavirus disease (COVID-19) outbreak in the Netherlands, we conducted 6 repeated surveys of ≈3,000 persons. Generalized estimating equations analyses revealed changes over time as well as differences between groups at low and high risk. Overall, respondents perceived the risks associated with COVID-19 to be considerable, were positive about the mitigation measures, trusted the information and the measures from authorities, and adopted protective measures. Substantial increases were observed in risk perceptions and self-reported protective behavior in the first weeks of the outbreak. Individual differences were based mainly on participants’ age and health condition. We recommend that authorities constantly adjust their COVID-19 communication and mitigation strategies to fit public perceptions and public responses and that they tailor the information for different groups.

Development and usability of educational material about workplace particulate matter exposure

BACKGROUND

Particulate matter (PM) exposure is an important health risk, both in daily life and in the workplace. It causes respiratory and cardiovascular diseases and results in 800,000 premature deaths per year worldwide. In earlier research, we assessed workers' information needs regarding workplace PM exposure, the properties and effects of PM, and the rationale behind various means of protection. We also concluded that workers do not always receive appropriate risk communication tools with regards to PM, and that their PM knowledge appears to be fragmented and incomplete.

METHODS

We considered several concepts for use as an educational material based on evaluation criteria: ease of use, costs, appropriateness for target audiences and goals, interactivity, implementation issues, novelty, and speed. We decided to develop an educational folder, which can be used to inform employees about the properties, effects and prevention methods concerning PM. Furthermore, we decided on a test setup of a more interactive way of visualisation of exposure to PM by means of exposimeters. For the development of the folder, we based the information needs on our earlier mental models-based research. We adjusted the folder based on the results of ten semi-structured interviews evaluating its usability.

RESULTS

The semi-structured interviews yielded commentaries and suggestions for further improvement, which resulted in a number of alterations to the folder. However, in most cases the folder was deemed satisfactory.

CONCLUSION

Based on this study, the folder we developed is suitable for a larger-scale experiment and a practical test. Further research is needed to investigate the efficacy of the folder and the application of the exposimeter in a PM risk communication system.

Autonomous and informed decision-making: The case of colorectal cancer screening

INTRODUCTION

It is increasingly considered important that people make an autonomous and informed decision concerning colorectal cancer (CRC) screening. However, the realisation of autonomy within the concept of informed decision-making might be interpreted too narrowly. Additionally, relatively little is known about what the eligible population believes to be a 'good' screening decision. Therefore, we aimed to explore how the concepts of autonomous and informed decision-making relate to how the eligible CRC screening population makes their decision and when they believe to have made a 'good' screening decision.

METHODS

We conducted 27 semi-structured interviews with the eligible CRC screening population (eighteen CRC screening participants and nine non-participants). The general topics discussed concerned how people made their CRC screening decision, how they experienced making this decision and when they considered they had made a 'good' decision.

RESULTS

Most interviewees viewed a 'good' CRC screening decision as one based on both reasoning and feeling/intuition, and that is made freely. However, many CRC screening non-participants experienced a certain social pressure to participate. All CRC screening non-participants viewed making an informed decision as essential. This appeared to be the case to a lesser extent for CRC screening participants. For most, experiences and values were involved in their decision-making.

CONCLUSION

Our sample of the eligible CRC screening population viewed aspects related to the concepts of autonomous and informed decision-making as important for making a 'good' CRC screening decision. However, in particular the existence of a social norm may be affecting a true autonomous decision-making process. Additionally, the present concept of informed decision-making with its strong emphasis on making a fully informed and well-considered decision does not appear to be entirely reflective of the process in practice. More efforts could be made to attune to the diverse values and factors that are involved in deciding about CRC screening participation.

Choice architecture interventions to change physical activity and sedentary behavior: a systematic review of effects on intention, behavior and health outcomes during and after intervention

BACKGROUND

Choice architecture interventions, which subtly change the environment in which individuals make decisions, can be used to promote behavior change. This systematic review aimed to summarize studies on micro-environmental choice architecture interventions that encouraged physical activity or discouraged sedentary behavior in adults, and to describe the effectiveness of those interventions on these behaviors - and on related intentions or health outcomes - in presence of the intervention and after removal of the intervention (i.e. post-intervention, regardless of the time elapsed).

METHODS

We systematically searched PubMed, Embase, PsycINFO and the Cochrane Library for (quasi) experimental studies published up to December 2019 that evaluated the effect of choice architecture interventions on physical activity and sedentary behavior, as well as on intentions and health outcomes related to physical activity/sedentary behavior. Studies that combined choice architecture techniques with other behavior change techniques were excluded. All studies were screened for eligibility, relevant data was extracted and two independent reviewers assessed the methodological quality using the QualSyst tool.

RESULTS

Of the 9609 records initially identified, 88 studies met our eligibility criteria. Most studies (n = 70) were of high methodologic quality. Eighty-six studies targeted physical activity, predominantly stair use, whereas two studies targeted sedentary behavior, and one targeted both behaviors. Intervention techniques identified were prompting (n = 53), message framing (n = 24), social comparison (n = 12), feedback (n = 8), default change (n = 1) and anchoring (n = 1). In presence of the intervention, 68% of the studies reported an effect of choice architecture on behavior, whereas after removal of the intervention only 47% of the studies reported a significant effect. For all choice architecture techniques identified, except for message framing, the majority of studies reported a significant effect on behavioral intentions or behavior in presence of the intervention.

CONCLUSIONS

The results suggest that prompting can effectively encourage stair use in adults, especially in presence of a prompt. The effectiveness of the choice architecture techniques social influence, feedback, default change and anchoring cannot be assessed based on this review. More (controlled) studies are needed to assess the (sustained) effectiveness of choice architecture interventions on sedentary behavior and other types of physical activity than stair use.

Decision-making styles in the context of colorectal cancer screening

BACKGROUND

Our study examined the use of decision-making styles, as identified by Scott and Bruce (1995) (i.e. differentiating between a rational, intuitive, dependent, avoidant and spontaneous decision-making style), within the context of colorectal cancer (CRC) screening participation. In the field of cancer screening, informed decision-making is considered important, which follows the Rational Decision model. Subsequently, gaining more insight into decision-making styles being used in real life, could improve support to people when making their screening decision. In addition, we examined whether the decision-making style that people used was associated with their experienced decisional conflict.

METHODS

An online survey was carried out among a sample of first-time CRC screening invitees (1282 respondents, response rate 49%). We assessed people's decision-making styles, CRC screening participation, education level, self-reported health literacy, and decisional conflict, and examined the possible associations between them.

RESULTS

In our study, people who had to decide about CRC screening scored high on using both a rational and intuitive decision-making style. Respondents scoring higher on using a spontaneous or dependent decision-making style were more likely to have participated in CRC screening, while respondents scoring higher on using an avoidant decision-making style were more likely not to have participated in CRC screening. However, differences were small. Generally, people in our study experienced low decisional conflict.

CONCLUSION

Our eligible CRC screening population scored high on using both a rational and intuitive decision-making style. To optimise support to people, public education materials could be appealing more to the intuitive processes at hand. That being said, the current education materials aimed at informed/rational decision-making do not necessarily seem to create a problem, as people generally experienced low decisional conflict. Possible concerns regarding the use of a spontaneous, dependent or avoidant decision-making style could be that these styles might be contributing to less informed decisions. However, it is relevant to consider that the found differences are small and that any possible concern applies to a relatively small group of people.

Do people with a different goal-orientation or specific focus make different decisions about colorectal cancer-screening participation?

Objective

Previous studies have shown that having promotion-oriented goals (e.g. wanting to become healthy) or prevention-oriented goals (e.g. wanting to avoid getting ill) can affect people’s health-related decisions and behaviour by emphasising aspects and information that seem relevant in light of what they want to achieve. However, this issue has not yet been researched regarding colorectal cancer (CRC) screening. With our study, we aimed to examine the relationship between people’s goal-orientation or focus on advantages or disadvantages and their CRC screening participation, as this could provide insights for supporting people in making this complex decision.

Methods

An online survey was carried out among a sample of first-time CRC screening invitees (1282 respondents, response rate 49%). We assessed people’s goal-orientation (i.e. promotion-orientation and prevention-orientation), focus on the advantages or disadvantages of CRC screening, screening participation and main considerations (e.g. cancer is a serious illness) concerning their screening decision.

Results

Generally, CRC screening participants scored higher on both promotion-orientation and prevention-orientation than non-participants. Both CRC screening participation and non-participation were not associated with a dominant goal-orientation. CRC screening participants did show a dominant focus on the advantages of CRC screening. Mediation analysis showed support for our premise that the relationship between people’s goal-orientation or focus on advantages or disadvantages and their screening participation could be (partially) mediated by people’s main considerations concerning CRC screening.

Conclusion

CRC screening participants and non-participants differed in their goal-orientation and focus on advantages or disadvantages. CRC screening participation appears to be associated with a focus on the advantages of CRC screening, which could impede the making of an informed decision. CRC screening non-participation appears not to be associated with any clear goal-orientation or focus, or we have not yet managed to capture this, which could be either beneficial or problematic for making an informed decision.

Why are the public so positive about colorectal cancer screening?

BACKGROUND

Colorectal cancer (CRC) screening is widely recommended. Earlier research showed that the general public are positive about CRC screening, as too the eligible CRC screening population. Among the eligible CRC screening population this positive perception has been shown to be associated with their perceptions of cancer, preventive health screening and their own health. It is unclear whether these concepts are also associated with the positive perception of the general public. Knowing this can provide insight into the context in which public perception concerning CRC screening is established. The aim of our study was to examine which main perceptions are associated with the public perception concerning CRC screening.

METHODS

An online survey was carried out in a Dutch population sample (adults 18+) among 1679 respondents (response rate was 56%). We assessed the public's perceptions concerning cancer, preventive health screening, own health, and the government, and examined their possible association with public opinion concerning CRC screening.

RESULTS

The public's positive attitude towards CRC screening is associated with the public's positive attitude towards preventive health screening in general, their perceived seriousness of cancer, their belief of health being important, and their trust in the government regarding national screening programmes.

CONCLUSION

Trust in the government and perceptions regarding the seriousness of cancer, preventive health screening and the importance of one's health seem to be important factors influencing how the public view CRC screening. The public are likely to process information about CRC screening in such a way that it confirms their existing beliefs of cancer being serious and preventive screening being positive. This makes it likely that they will notice information about the possible benefits of CRC screening more than information about its possible downsides, which would also contribute to the positive perception of CRC screening.

The effects of infographics and several quantitative versus qualitative formats for cardiovascular disease risk, including heart age, on people's risk understanding

OBJECTIVE

To study how comprehension of cardiovascular disease (CVD) risk is influenced by: (1) infographics about qualitative risk information, with/without risk numbers; (2) which qualitative risk dimension is emphasized; (3) heart age vs. traditional risk format.

METHODS

For aim 1, a 2 (infographics versus text) x 2 (risk number versus no risk number) between-subjects design was used. For aim 2, three pieces of information were tested within-subjects. Aim 3 used a simple comparison group. Participants (45-65 yrs old) were recruited through an online access panel; low educated people were oversampled. They received hypothetical risk information (20%/61yrs). Primary outcomes: recall, risk appraisals, subjective/objective risk comprehension.

SECONDARY OUTCOMES

behavioral intentions, information evaluations.

RESULTS

Infographics of qualitative risk dimensions negatively affected recall, subjective risk comprehension and information evaluations. No effect of type of risk dimension was found on risk perception. Heart age influenced recall, comprehension, evaluations and affective risk appraisals.

CONCLUSION

Infographics of hypothetical CVD risk information had detrimental effects on measures related to risk perception/comprehension, but effects were mainly seen in undereducated participants. Heart age influenced perceptions/comprehension of hypothetical risk in a way that seemed to support understanding.

PRACTICE IMPLICATIONS

Heart age seems a fruitful risk communication approach in disease risk calculators.

"These Power Lines Make Me Ill": A Typology of Residents' Health Responses to a New High-Voltage Power Line

Little attention has been devoted to the potential diversity in residents' health responses when exposed to an uncertain environmental health risk. The present study explores whether subgroups of residents respond differently to a new high-voltage power line (HVPL) being put into operation. We used a quasi-experimental prospective field study design with two pretests during the construction of a new HVPL, and two posttests after it was put into operation. Residents living nearby (0-300 m, n = 229) filled out questionnaires about their health and their perception of the environment. We applied latent class growth models to investigate heterogeneity in the belief that health complaints were caused by a power line. Classes were compared on a wide range of variables relating to negative-oriented personality traits, perceived physical and mental health, and perceptions of the environment. We identified five distinct classes of residents, of which the largest (49%) could be described as emotionally stable and healthy with weak responses to the introduction of a new power line. A considerable minority (9%) responded more strongly to the new line being activated. Residents in this class had heard more about the health effects of power lines beforehand, were more aware of the activation of the new line, and reported a decrease in perceived health afterwards. Based on our findings we can conclude that there is a considerable heterogeneity in health responses to a new HVPL. Health risk perceptions appear to play an important role in this typology, which has implications for risk management.

Modeled and Perceived Exposure to Radiofrequency Electromagnetic Fields From Mobile-Phone Base Stations and the Development of Symptoms Over Time in a General Population Cohort

We assessed associations between modeled and perceived exposure to radiofrequency electromagnetic fields (RF-EMF) from mobile-phone base stations and the development of nonspecific symptoms and sleep disturbances over time. A population-based Dutch cohort study, the Occupational and Environmental Health Cohort Study (AMIGO) (n = 14,829; ages 31-65 years), was established in 2011/2012 (T0), with follow-up of a subgroup (n = 3,992 invited) in 2013 (T1; n = 2,228) and 2014 (T2; n = 1,740). We modeled far-field RF-EMF exposure from mobile-phone base stations at the home addresses of the participants using a 3-dimensional geospatial model (NISMap). Perceived exposure (0 = not at all; 6 = very much), nonspecific symptoms, and sleep disturbances were assessed by questionnaire. We performed cross-sectional and longitudinal analyses, including fixed-effects regression. We found small correlations between modeled and perceived exposure in AMIGO participants at baseline (n = 14,309; rSpearman = 0.10). For 222 follow-up participants, modeled exposure increased substantially (>0.030 mW/m2) between T0 and T1. This increase in modeled exposure was associated with an increase in perceived exposure during the same time period. In contrast to modeled RF-EMF exposure from mobile-phone base stations, perceived exposure was associated with higher symptom reporting scores in both cross-sectional and longitudinal analyses, as well as with sleep disturbances in cross-sectional analyses.

How lay people understand and make sense of personalized disease risk information

Background

Disease risk calculators are increasingly web‐based, but previous studies have shown that risk information often poses problems for lay users.

Objective

To examine how lay people understand the result derived from an online cardiometabolic risk calculator.

Design

A qualitative study was performed, using the risk calculator in the Dutch National Prevention Program for cardiometabolic diseases. The study consisted of three parts: (i) attention: completion of the risk calculator while an eye tracker registered eye movements; (ii) recall: completion of a recall task; and (iii) interpretation: participation in a semi‐structured interview.

Setting and participants

We recruited people from the target population through an advertisement in a local newspaper; 16 people participated in the study, which took place in our university laboratory.

Results

Eye‐tracking data showed that participants looked most extensively at numerical risk information. Percentages were recalled well, whereas natural frequencies and verbal labels were remembered less well. Five qualitative themes were derived from the interview data: (i) numerical information does not really sink in; (ii) the verbal categorical label made no real impact on people; (iii) people relied heavily on existing knowledge and beliefs; (iv) people zoomed in on risk factors, especially family history of diseases; and (v) people often compared their situation to that of their peers.

Discussion and conclusion

Although people paid attention to and recalled the risk information to a certain extent, they seemed to have difficulty in properly using this information for interpreting their risk.

The Dutch public are positive about the colorectal cancer-screening programme, but is this a well-informed opinion?

BACKGROUND

Population-based colorectal cancer (CRC) screening is widely recommended, and members of the eligible screening population seem to be positive about it. However, it is not well known how people outside the eligible screening population view CRC screening, and whether they are supportive of the government providing this. Public opinion may affect people's personal views and their screening decision. The aim of our study was to examine the opinion of the Dutch general public regarding the national CRC screening programme.

METHOD

An online survey was carried out in a Dutch population sample of adults aged 18 and older, assessing level of support, personal attitude, collective attitude, perceived social norm, awareness, and knowledge regarding the CRC screening programme.

RESULTS

The response rate was 56% (n = 1679/3000). Generally, the Dutch public are positive about and supportive of the CRC screening programme. We found the biggest proportion of support (86%) when people were asked directly. A smaller proportion (48%) was supportive when people had to choose between other options concerning how the government could possibly deal with CRC. People report knowing more about the benefits of CRC screening than about its possible harms and risks. Many people found it difficult to answer the knowledge questions that asked about numerical information concerning CRC screening correctly.

CONCLUSION

People were less supportive of the CRC screening programme when having to choose between other options concerning dealing with CRC, and their support may not be based on a full comprehension of what CRC screening entails. Further research is needed to establish what knowledge people need in order to form a well-founded opinion.

Treatment recommendations by clinicians in stage I non-small cell lung cancer: A study of factors that influence the likelihood of accounting for the patient's preference

OBJECTIVES

Surgery and stereotactic ablative radiotherapy (SABR) are both curative treatment options for patients with stage I non-small cell lung cancer (NSCLC). Shared decision making (SDM) has been advocated in this patient group. This study explored clinician decision making in relation to the stated treatment preferences of patients.

METHODS

In a previous study, we conducted a binary choice experiment with hypothetical cases among 126 clinicians. Secondary data analysis was performed using multilevel logistic regression models, in which random differences between clinicians' decisions were taken into account. We analyzed the influence of patient- and clinician-related characteristics, and uncertainty as experienced by clinicians about their recommendation on the clinician's decision (either in line with the patient's preference or not).

RESULTS

Significant interactions were observed between patient- and clinician-related characteristics, indicating that patient preferences were selectively taken into account, depending on clinicians' specialty, their views about the comparability of cancer-related outcomes following surgery and SABR, and the degree of uncertainty about the treatment recommendation.

CONCLUSIONS

Our findings suggest that SDM for stage I NSCLC care is largely influenced by how clinicians weigh available scientific evidence.

PRACTICE IMPLICATIONS

Clinicians should involve lung cancer patients more and ask for their preferences in making treatment recommendations.

Psychological factors associated with the intention to choose for risk-reducing mastectomy in family cancer clinic attendees

OBJECTIVES

Women seeking counseling because of familial breast cancer occurrence face difficult decisions, such as whether and when to opt for risk-reducing mastectomy (RRM) in case of BRCA1/2 mutation. Only limited research has been done to identify the psychological factors associated with the decision for RRM. This study investigated which psychological factors are related to the intention to choose for RRM.

MATERIALS & METHODS

A cohort of 486 cancer-unaffected women with a family history of breast cancer completed the following questionnaires prior to genetic counseling: the Cancer Worry Scale, Positive And Negative Affect Scale, Perceived Personal Control Scale, Hospital Anxiety and Depression Scale and State Anxiety Scale and questions regarding socio-demographic characteristics, family history, risk perception and RRM intention. Multivariate logistic regression was used to analyze the relation between psychological factors and women's intention to choose for RRM.

RESULTS

Factors associated with RRM intention were high positive affect (OR = 1.86, 95%CI = 1.12-3.08), high negative affect (OR = 2.52, 95%CI = 1.44-4.43), high cancer worry (OR = 1.65, 95%CI = 1.00-2.72), high perceived personal control (OR = 3.58, 95%CI = 2.18-5.89), high risk-perception (OR = 1.85, 95%CI = 1.15-2.95) and having children (OR = 2.06, 95%CI = 1.21-3.50).

CONCLUSION

Negative and positive affects play an important role in the intention for RRM. Furthermore, perceived personal control over the situation is associated with an intention for RRM. In addition to focusing on accurate risk communication, counseling should pay attention to the influence of perceived control and emotions to facilitate decision-making.

Nocebo responses to high-voltage power lines: Evidence from a prospective field study

BACKGROUND

Experimental studies suggest that nocebo responses might occur after exposure to equipment emitting electromagnetic fields such as high voltage power lines (HVPLs) or mobile phone base stations.

OBJECTIVES

The present study investigates to what extent health responses to a new HVPL can be explained by beliefs of residents regarding the health effects of HVPLs.

METHODS

We used a quasi-experimental prospective field study design with two pretests during the construction of a new HVPL, and two posttests after it has been put into operation. Residents living near (0-300 m, n=229; 300-500 m, n=489) and farther away (500-2000 m, n=536) filled out questionnaires about their health and their beliefs about the negative health effects of power lines. Longitudinal mediation models were applied to investigate to what extent these beliefs could explain a change in reported symptoms after the new line was put into operation.

RESULTS

Significant (p<.01) indirect effects were found for proximity on the increase in reported cognitive (R(2)=0.41) and somatic (R(2)=0.79) symptoms after the power line was put into operation through an increase in the belief that power lines causes health effects. The direct effects of proximity on an increase in reported symptoms were not significant.

CONCLUSIONS

Our findings suggest that increases in reported health complaints after a new HVPL has been put into operation can be explained by nocebo mechanisms. Future field studies are needed to know whether our findings extend to other environmental health issues in a community.

[Information is more than just the number]

In order to be able to make informed choices, it is important that patients have transparent information about the pros and cons of treatment. When using the number unnecessarily treated (NUT) as information for patients, we should take the following into account. First, patients should understand that non-effective treatment may still do harm. This might be in contradiction with their ideas about the effects of treatment. Second, as many patients have difficulties understanding numbers and probabilities, the usefulness of NUT may be limited. Third, it is very important to use the proper presentation format to make the information intuitively meaningful for patients. A natural frequency tree and not a population diagram appears to be the optimal format for this purpose. When giving patient information the premise is that the form of the message is more important than the numbers.

A patient perspective on shared decision making in stage I non-small cell lung cancer: a mixed methods study

Background

Surgery and stereotactic ablative radiotherapy (SABR) are both curative treatment options for patients with a stage I non-small cell lung cancer (NSCLC). Consequently, there is growing interest in studying the role of patients in treatment decision making. We studied how patients with stage I NSCLC perceived shared decision making (SDM) in general, and how they viewed different aspects of SDM.

Methods

A sequential mixed methods design was used, consisting of qualitative interviews (N = 11), as well as a survey study (N = 76) focusing on different SDM-related aspects. Participants were interviewed to understand their own experience with treatment decision making. In the survey study, patients rated the importance of 20 aspects of shared decision making that were identified during interviews. Descriptive analysis and explorative factor analysis were performed.

Results

We assessed six qualitative themes covering SDM aspects that were determined by patients to be important. The survey identified four SDM-related factors with sufficient internal consistency, namely (1) ‘guidance by clinician’ (α = .741), (2) ‘conduct of clinician’ (α = .774); (3) ‘preparation for treatment decision making’ (α = .864); and (4) ‘active role of patient in treatment decision making’ (α = .782). Of these, clinician guidance was rated as most important by patients (M = 3.61; SD = .44). Only 28.9 % of patients in the survey study reported that both treatment options were discussed with them.

Conclusions

Patients with a stage I NSCLC found clinician guidance to be important when making treatment decisions. Nevertheless, the majority of patients reported not being offered both treatment options, which might have influenced this finding.

Making comparative performance information more comprehensible: an experimental evaluation of the impact of formats on consumer understanding

Study objectives

We aimed to investigate how different presentation formats influence comprehension and use of comparative performance information (CPI) among consumers.

Methods

An experimental between-subjects and within-subjects design with manipulations of CPI presentation formats. We enrolled both consumers with lower socioeconomic status (SES)/cognitive skills and consumers with higher SES/cognitive skills, recruited through an online access panel. Respondents received fictitious CPI and completed questions about interpretation and information use. Between subjects, we tested (1) displaying an overall performance score (yes/no); (2) displaying a small number of quality indicators (5 vs 9); and (3) displaying different types of evaluative symbols (star ratings, coloured dots and word icons vs numbers and bar graphs). Within subjects, we tested the effect of a reduced number of healthcare providers (5 vs 20). Data were analysed using descriptive analysis, analyses of variance and paired-sampled t tests.

Results

A total of 902 (43%) respondents participated. Displaying an overall performance score and the use of coloured dots and word icons particularly enhanced consumer understanding. Importantly, respondents provided with coloured dots most often correctly selected the top three healthcare providers (84.3%), compared with word icons (76.6% correct), star ratings (70.6% correct), numbers (62.0%) and bars (54.2%) when viewing performance scores of 20 providers. Furthermore, a reduced number of healthcare providers appeared to support consumers, for example, when provided with 20 providers, 69.5% correctly selected the top three, compared with 80.2% with five providers.

Discussion

Particular presentation formats enhanced consumer understanding of CPI, most importantly the use of overall performance scores, word icons and coloured dots, and a reduced number of providers displayed. Public report efforts should use these formats to maximise impact on consumers.

Somatic symptom reports in the general population: Application of a bi-factor model to the analysis of change

OBJECTIVE

To investigate the latent structure of somatic symptom reports in the general population with a bi-factor model and apply the structure to the analysis of change in reported symptoms after the emergence of an uncertain environmental health risk.

METHODS

Somatic symptoms were assessed in two general population environmental health cohorts (AMIGO, n=14,829 & POWER, n=951) using the somatization scale of the four-dimensional symptom questionnaire (4DSQ-S). Exploratory bi-factor analysis was used to determine the factor structure in the AMIGO cohort. Multi-group and longitudinal models were applied to assess measurement invariance. For a subsample of residents living close to a newly introduced power line (n=224), we compared a uni- and multidimensional method for the analysis of change in reported symptoms after the power line was put into operation.

RESULTS

We found a good fit (RMSEA=0.03, CFI=0.98) for a bi-factor model with one general and three symptom specific factors (musculoskeletal, gastrointestinal, cardiopulmonary). The latent structure was found to be invariant between cohorts and over time. A significant increase (p<.05) was found only for musculoskeletal and gastrointestinal symptoms after the power line was put into operation.

CONCLUSIONS

In our study we found that a bi-factor structure of somatic symptoms reports was equivalent between cohorts and over time. Our findings suggest that taking this structure into account can lead to a more informative interpretation of a change in symptom reports compared to a unidimensional approach.

Barriers in using cardiometabolic risk information among consumers with low health literacy

OBJECTIVES

To identify the barriers from the perspective of consumers with low health literacy in using risk information as provided in cardiometabolic risk assessments.

DESIGN

A qualitative thematic approach using cognitive interviews was employed.

METHODS

We performed interviews with 23 people with low health literacy/health numeracy, who were recruited through (1) several organisations and snowball sampling and (2) an online access panel. Participants completed the risk test of the Dutch national cardiometabolic risk assessment and viewed the personalized information about their risk. They were asked to answer probing questions about different parts of the information. The qualitative data were analysed by identifying main themes related to barriers in using the information, using a descriptive thematic approach.

RESULTS

The four main themes identified were as follows: (1) People did not fully accept the risk message, partly because numerical information had ambiguous meaning; (2) people lacked an adequate framework for understanding their risk; (3) the purpose and setting of the risk assessment was unclear; and (4) current information tells nothing new: A need for more specific risk information.

CONCLUSIONS

The main barriers were that the current presentation seemed to provoke undervaluation of the risk number and that texts throughout the test, for example about cardiometabolic diseases, did not match people's existing knowledge, failing to provide an adequate framework for understanding cardiometabolic risk. Our findings have implications for the design of disease risk information, for example that alternative forms of communication should be explored that provide more intuitive meaning of the risk in terms of good versus bad.

STATEMENT OF CONTRIBUTION

What is already known on this subject? Online disease risk assessments have become widely available internationally. People with low SES and health literacy tend to participate less in health screening. Risk information is difficult to understand, yet little research has been carried out among people with low health literacy. What does this study add? People with low health literacy do not optimally use risk information in an online cardiometabolic risk assessment. The texts provided in the cardiometabolic risk assessment do not suit to their existing knowledge. The typical risk communication (numbers, bar graph, verbal label) seems to provoke undervaluation of risk.

Symptom reporting after the introduction of a new high-voltage power line: a prospective field study

BACKGROUND

There is public concern about the potential health effects of exposure to extremely low frequency electromagnetic fields (ELF-EMF) of high-voltage power lines (HVPLs). Some residents living near HVPLs believe ELF-EMF might cause non-specific health complaints.

OBJECTIVES

The present study is the first to prospectively investigate whether self-reported health complaints and causal beliefs increase after the construction of a new power line.

METHODS

We used a quasi-experimental design with two pretests before and two posttests after a new HVPL was put into operation. Residents living near (0-300m, n=229; 300-500m, n=489) and farther away (500-2000m, n=536) participated in the study. Linear mixed models were fitted to test whether symptom reports and beliefs that power lines caused health complaints increased more in residents living close to the new line compared to residents living farther away.

RESULTS

A significantly (p<.05) larger increase from baseline in symptom reports and causal beliefs was found in residents living within 300m from the new power line when compared to residents living farther away. While symptom reports did not differ at baseline, the belief that a power line could cause these symptoms was at baseline already stronger for residents living close compared to residents living farther away.

CONCLUSIONS

We found a negative impact of a new HVPL on health perceptions of nearby residents, even before the line was put into operation.

NIPT-based screening for Down syndrome and beyond: what do pregnant women think?

OBJECTIVE

The aim of the study is to study pregnant women's views on noninvasive prenatal testing (NIPT) for Down syndrome and the potential to test for a broader range of conditions.

METHODS

An online questionnaire available on the Dutch pregnancy fair website was completed by 381 pregnant women.

RESULTS

Of the women, 51% expressed interest in having NIPT, including 33% of women who had declined first-trimester screening. The majority (73%) thought that the uptake of screening would increase with NIPT. Most women agreed that testing for life-threatening (89%), severe physical (79%), or severe mental (76%) disorders should be offered. A minority (29%) felt that prenatal screening should also be offered for late-onset disorders. Most (41%) preferred to have a free choice from a list of disorders, 31% preferred a 'closed offer', and 26% preferred choosing between packages of disorders. Although most women (76%) thought that screening for a broad range of conditions would avoid much suffering, 39% feared that it would confront couples with choices, the implications of which would be difficult to grasp.

CONCLUSION

The results suggest that the uptake of screening will increase with NIPT. If NIPT will be offered for a broad range of conditions, it is crucial to find a way that facilitates rather than undermines well-informed decision-making.

Communicating cancer treatment information using the Web: utilizing the patient's perspective in website development

Background

Online cancer information can support patients in making treatment decisions. However, such information may not be adequately tailored to the patient’s perspective, particularly if healthcare professionals do not sufficiently engage patient groups when developing online information. We applied qualitative user testing during the development of a patient information website on stereotactic ablative radiotherapy (SABR), a new guideline-recommended curative treatment for early-stage lung cancer.

Methods

We recruited 27 participants who included patients referred for SABR and their relatives. A qualitative user test of the website was performed in 18 subjects, followed by an additional evaluation by users after website redesign (N = 9). We primarily used the ‘thinking aloud’ approach and semi-structured interviewing. Qualitative data analysis was performed to assess the main findings reported by the participants.

Results

Study participants preferred receiving different information that had been provided initially. Problems identified with the online information related to comprehending medical terminology, understanding the scientific evidence regarding SABR, and appreciating the side-effects associated with SABR. Following redesign of the website, participants reported fewer problems with understanding content, and some additional recommendations for better online information were identified.

Conclusions

Our findings indicate that input from patients and their relatives allows for a more comprehensive and usable website for providing treatment information. Such a website can facilitate improved patient participation in treatment decision-making for cancer.

Congruence between patients' preferred and perceived participation in medical decision-making: a review of the literature

Background

Patients are increasingly expected and asked to be involved in health care decisions. In this decision-making process, preferences for participation are important. In this systematic review we aim to provide an overview the literature related to the congruence between patients’ preferences and their perceived participation in medical decision-making. We also explore the direction of mismatched and outline factors associated with congruence.

Methods

A systematic review was performed on patient participation in medical decision-making. Medline, PsycINFO, CINAHL, EMBASE and the Cochrane Library databases up to September 2012, were searched and all studies were rigorously critically appraised. In total 44 papers were included, they sampled contained 52 different patient samples.

Results

Mean of congruence between preference for and perceived participation in decision-making was 60% (49 and 70 representing 25^th and 75^th percentiles). If no congruence was found, of 36 patient samples most patients preferred more involvement and of 9 patient samples most patients preferred less involvement. Factors associated with preferences the most investigated were age and educational level. Younger patients preferred more often an active or shared role as did higher educated patients.

Conclusion

This review suggests that a similar approach to all patients is not likely to meet patients’ wishes, since preferences for participation vary among patients. Health care professionals should be sensitive to patients individual preferences and communicate about patients’ participation wishes on a regular basis during their illness trajectory.

Health responses to a new high-voltage power line route: design of a quasi-experimental prospective field study in the Netherlands

Background

New high-voltage power transmission lines will be introduced due to increasing demand for reliable and renewable energy supplies. Some residents associate non-specific health complaints with exposure to electromagnetic fields from nearby power lines. This study protocol describes the design and rationale of a prospective study investigating whether the introduction of a new power line triggers health responses in residents living nearby.

Methods/Design

The study is designed as a quasi-experimental field study with two pretests during the construction of a new power line route, and two posttests after it has been put into operation. Key outcomes are self-reported non-specific somatic and cognitive health complaints, and attribution of these health complaints to a power line. The main determinant is proximity to the new power line route. One member of every household (n = 2379) residing in close proximity (0-500 meters) to the overhead parts of a new power line route in the Netherlands is invited to participate, as well as a sample of household members (n = 2382) residing farther away (500-2000 meters). Multilevel analysis will be employed to test whether an increase in key outcome measures is related to proximity to the line. Longitudinal structural equation models will be applied to test to what extent health responses are mediated by psychosocial health mechanisms and moderated by negative oriented personality traits.

Discussion

This is the first study to investigate health responses to a new power line route in a prospective manner. The results will provide theoretical insight into psychosocial mechanisms operating during the introduction of an environmental health risk, and may offer suggestions to policymakers and other stakeholders for minimizing adverse health responses when introducing new high-voltage power lines.

Using web-based familial risk information for diabetes prevention: a randomized controlled trial

Background

It has been suggested that family history information may be effective in motivating people to adopt health promoting behaviour. The aim was to determine if diabetic familial risk information by using a web-based tool leads to improved self-reported risk-reducing behaviour among individuals with a diabetic family history, without causing false reassurance among those without a family history.

Methods

An online sample of 1,174 healthy adults aged 35–65 years with a BMI ≥ 25 was randomized into two groups receiving an online diabetes risk assessment. Both arms received general tailored diabetes prevention information, whilst the intervention arm also received familial risk information after completing a detailed family history questionnaire. Separate analysis was performed for four groups (family history group: 286 control versus 288 intervention group; no family history: 269 control versus 266 intervention group). Primary outcomes were self-reported behavioural outcomes: fat intake, physical activity, and attitudes towards diabetes testing. Secondary outcomes were illness and risk perceptions.

Results

For individuals at familial risk there was no overall intervention effect on risk-reducing behaviour after three months, except for a decrease in self-reported saturated fat intake among low-educated individuals (Beta (b) -1.01, 95% CI −2.01 to 0.00). Familial risk information resulted in a decrease of diabetes risk worries (b −0.21, -0.40 to −0.03). For individuals without family history no effect was found on risk-reducing behaviour and perceived risk. A detailed family history assessment resulted in a greater percentage of individuals reporting a familial risk for diabetes compared to a simple enquiry.

Conclusions

Web-based familial risk information reduced worry related to diabetes risk and decreased saturated fat intake of those at greatest need of preventative care. However, the intervention was not effective for the total study population on improving risk-reducing behaviour. The emphasis on familial risk does not seem to result in false reassurance among individuals without family history. Additionally, a detailed family history questionnaire identifies more individuals at familial risk than a simple enquiry.

Trial registration

NTR1938

Educating health consumers about cardio-metabolic health risk: what can we learn from lay mental models of risk?

OBJECTIVE

To study lay conceptions of cardio-metabolic risk and compare them with those of experts, in order to formulate focal points for better educational risk information.

METHODS

40 Dutch lay people were interviewed about the risks of developing cardio-metabolic diseases. Following a 'mental models approach', their conceptions were qualitatively analyzed and compared to an expert model.

RESULTS

We identified four key themes representing lay conceptions: (1) "same factors, different value" (e.g. the dominance of certain factors, such as stress); (2) "superficiality and incoherence" (e.g. a focus on health and illness in general); (3) "misjudged elevated risk concept" (e.g. either being sick or not); and (4) "no concept of a link between cardio-metabolic diseases" (e.g. separate links between causes and diseases).

CONCLUSION

Potential mismatches between lay and expert conceptions do not seem to indicate a lack of basic knowledge among consumers, but rather that certain risk factors are not effectively translated into a coherent risk picture.

PRACTICE IMPLICATIONS

In improving educational materials, we could more explicitly take into account factors that lay people find important. Additionally, effort should be made to produce a more coherent risk understanding among consumers, for example through an alternative information structure.

[Indicating risks in the Dutch Cancer Society Cancer Risk Test: indicating population risks improves risk perception]

OBJECTIVE

To have the Dutch Cancer Society Cancer Risk Test (KWF-KRT) assessed by users and to determine the effect of the numerical indication of risks on the perception of cancer risks.

DESIGN

Cross-sectional questionnaire study.

METHOD

In total 612 persons from the general population were given a shortened test version of the KWF-KRT test for colon and lung cancer via the Internet. 12 different versions were tested, differing in the quantification of risks. Each participant received one version of the test for colon cancer and one for lung cancer. Before and after taking the KWF-KRT, participants were asked to complete a questionnaire.

RESULTS

Completing the KWF-KRT version without numbers improved the understanding of the relative risk of colon cancer. Beforehand, 57% of the participants underestimated their personal cancer risk for colon cancer and 38% their risk for lung cancer. Addition of quantitative information on the population risk to the standard test resulted in twice as many correct estimates of the population risk and significantly improved the estimates of personal risk. It made no difference whether the population risk was presented only in numbers or also as a population diagram. The quantification of the personal risk and risk reduction had no effect. Approximately 12% of the participants indicated that they had become more worried about the risk of cancer after completing the test. The assessment of the KWF-KRT by the participants was largely positive.

CONCLUSION

Adding quantitative information about the population risk led to a better understanding of both the population risk and the personal risk of cancer.

Parental duties and prenatal screening: does an offer of prenatal screening lead women to believe that they are morally compelled to test?

BACKGROUND

in debates around prenatal screening, it is frequently argued that responsible parenthood implies the acquisition of all available medical information about the health of a fetus, and use of this information to benefit the future child.

OBJECTIVE

to analyse whether an offer of a prenatal test leads women to believe that they are morally obliged to control the health of their fetus.

DESIGN

a substudy within a randomised controlled trial (RCT) aimed to assess the decision-making process of women when confronted with an offer of a prenatal screening test.

PARTICIPANTS

111 women participating in an RCT were retrospectively asked their views on the meaning of testing within their parental duties.

FINDINGS

testing was described as a personal option that goes beyond the normal parental responsibilities. Participants did not believe that they ought to control the health of the fetus or to avoid disability. A duty to test was only reported when the birth of a disabled child would have a negative impact on family life.

CONCLUSION

women's accounts suggest that two main factors are involved in making testing morally obligatory: (1) the woman's views on her moral duties to her family; and (2) the expected burden of a disabled child on the well-being of the family. A family-centred approach would be more suitable to assess the moral imperative character of testing than women's ethical views about their moral duties towards their unborn child.

IMPLICATIONS

a test offer should not be limited to communication of the characteristics of screening and the meaning of the test results. In helping women to assess the meaning of testing within their parental duties, counselling should include the family situation in which women have to decide, the women's expectations about living with a child with Down's syndrome or any other disability, and the women's views on their commitments towards their family.

Women's views on the moral status of nature in the context of prenatal screening decisions

Appeals to the moral authority of nature play an important role in ethical discussions about the acceptability of prenatal testing. While opponents consider testing a dangerous violation of the moral inviolable course of nature, defenders see testing as a new step in improving dominion over nature. In this study we explored the meaning of appeals to nature among pregnant women to whom a prenatal screening test was offered and the impact of these appeals on their choices regarding the acceptance of screening. Contrary to theoretical debates we found that appeals to the moral authority of nature do not prevent women from welcoming the possibilities of controlling the outcomes of pregnancy, neither do they provide prima facie justification for (not) intervening in the natural course of events. Both acceptors and decliners believed in an inherent morality in nature that must be respected. They welcome the possibility of knowing more about the health of the fetus and to make their own reproductive decisions. Concerns for the quality of their child's life and for their capacity to assure a good life for their family and disabled child appear to play a central role in the decision regarding the use of screening. Appeals to nature can be interpreted as an attempt to justify beliefs regarding suffering that must be avoided and the impact that family interests may have on the decision. These findings have significant implications for ethical guidance in debates about the acceptability and boundaries of control of offspring characteristics by prenatal testing.

Using family history information to promote healthy lifestyles and prevent diseases; a discussion of the evidence

Background

A family history, reflecting genetic susceptibility as well as shared environmental and behavioral factors, is an important risk factor for common chronic multifactorial diseases such as cardiovascular diseases, type 2 diabetes and many cancers.

Discussion

The purpose of the present paper is to discuss the evidence for the use of family history as a tool for primary prevention of common chronic diseases, in particular for tailored interventions aimed at promoting healthy lifestyles. The following questions are addressed: (1) What is the value of family history information as a determinant of personal disease risk?; (2)How can family history information be used to motivate at-risk individuals to adopt and maintain healthy lifestyles in order to prevent disease?; and (3) What additional studies are needed to assess the potential value of family history information as a tool to promote a healthy lifestyle?

Summary

In addition to risk assessment, family history information can be used to personalize health messages, which are potentially more effective in promoting healthy lifestyles than standardized health messages. More research is needed on the evidence for the effectiveness of such a tool.