Impact of Cultural Exposure and Message Framing on Oral Health Behavior The impact of numeracy on reactions to different graphic risk presentation formats: An experimental analogue study. The Role of Numeracy in Understanding the Benefit of Screening Mammography Presenting Research Risks and Benefits to Parents: Does Format Matter? Using a Drug Facts Box to Communicate Drug Benefits and Harms Two Randomized Trials Presenting the Results of Cochrane Systematic Reviews to a Consumer Audience: A Qualitative Study Communicating Benefit and Risk Information in Direct-to-Consumer Print Advertisements Effect of Tabular and Icon Fact Box Formats on Comprehension of Benefits and Harms of Prostate Cancer Screening: A Randomized Trial
Background . Health messages are more effective when framed to be congruent with recipient characteristics , and health practitioners can strategically choose message features to promote adherence to recommended behaviors . We present exposure to US culture as a moderator of the impact of gain-frame versus loss-frame messages . Since US culture emphasizes individualism and approach orientation , greater cultural exposure was expected to predict improved patient choices and memory for gain-framed messages , whereas individuals with less exposure to US culture would show these advantages for loss-framed messages . Methods . 223 participants viewed a written oral health message in 1 of 3 r and omized conditions — gain-frame , loss-frame , or no-message control—  and were given 10 flosses . Cultural exposure was measured with the proportions of life spent and parents born in the US . At baseline and 1 week later , participants completed recall tests and reported recent flossing behavior . Results . Message frame and cultural exposure interacted to predict improved patient decisions ( increased flossing ) and memory maintenance for the health message over 1 week ; for example , those with low cultural exposure who saw a loss-frame message flossed more . Incongruent messages led to the same flossing rates as no message . Memory retention did not explain the effect of message congruency on flossing . Limitations . Flossing behavior was self-reported . Cultural exposure may only have practical application in either highly individualistic or collectivistic countries . Conclusions . In health care setting s where patients are urged to follow a behavior , asking basic demographic questions could allow medical practitioners to intentionally communicate in terms of gains or losses to improve patient decision making and treatment adherence OBJECTIVES Numeracy , the ability to process basic mathematical concepts , may affect responses to graphical displays of health risk information . Displays of probabilistic risk information using grouped dots are easier to underst and than displays using dispersed dots . However , dispersed dots may better convey the r and omness with which health threats occur , so increasing perceived susceptibility . We hypothesized that low numeracy participants would better underst and risks presented using grouped dot displays , while high numeracy participants would have good underst and ing , regardless of display type . Moreover , we predicted that dispersed dot displays , in contrast to grouped dot displays , would increase risk perceptions and worry only for highly numerate individuals . DESIGN AND METHOD One hundred and forty smokers read vignettes asking them to imagine being at risk of Crohn 's disease , in a 2(display type : dispersed/grouped dots ) x 3(risk magnitude : 3%/6%/50 % ) x 2(numeracy : high/low ) design . They completed measures of risk comprehension , perceived susceptibility and worry . RESULTS More numerate participants had better objective risk comprehension , but this effect was not moderated by display type . There was marginally significant support for the predicted numeracy x display type interaction for worry about Crohn 's disease , but not for perceived susceptibility to the condition . CONCLUSIONS Dispersed dot displays somewhat increase worry in highly numerate individuals , but only numeracy influenced objective risk comprehension . The most effective display type for communicating risk information will depend on the numeracy of the population and the goal ( s ) of the communication Patients are increasingly being exposed to quantitative information about risks for disease and benefits of treatment . Many authors [ 1 - 6 ] believe that the use of such information is an important component of informed decision making ; others cl aim that only patients given such information can make truly informed choices . This position is reflected in the recent decision of the National Institutes of Health Consensus Panel not to make a recommendation about screening mammography for women aged 40 to 49 years but to advocate that these women make their own decisions about screening on the basis of their personal evaluation of risks and benefits [ 7 ] . This strategy , however , is based on the assumption that patients underst and quantitative information . Research in this area has largely focused on how simple changes in the format of numerical information can influence choices , a concept referred to as framing [ 8 - 20 ] . But just as it is premature to worry about wording before knowing whether patients can read , it may be premature to worry about framing before knowing whether patients can underst and and manipulate numbers . In fact , evidence suggests that many persons do not work well with numbers [ 21 , 22 ] . It is likely that quantitative information is only meaningful to the extent that patients have some facility with basic probability and numerical concepts , a construct called numeracy . To learn more about the role of numeracy in communicating information about risk , we studied women 's comprehension of messages about mammography . Our goal was to underst and how numeracy affects women 's ability to gauge the benefit of mammography after receiving quantitative information . We provided women with typical risk reduction expressions about mammography , framed in relative and absolute terms , to study how well they could make use of such information . We hypothesized that the ability to use quantitative risk information would be related to the level of numeracy . Methods Study Design and Sample In December 1995 , we drew a simple r and om sample of 500 women from a registry of female veterans maintained at the Department of Veterans Affairs Medical Center , White River Junction , Vermont . These women were mailed one of four question naires , which differed only in how the same information on average risk reduction with mammography was presented . Reminder letters were sent to nonrespondents after 2 weeks , and new copies of the question naire were mailed after 4 weeks . The study was closed in February 1996 . Because of errors in the registry , 26 entries in our sample were not usable ( 10 of the listed persons were deceased , and 16 either were not female veterans or were listed twice ) . Thus , our possible respondent pool totaled 474 , of which 302 ( 64 % ) returned the question naire . The returned surveys sometimes contained unanswered questions . Such blanks may represent information about the respondent 's abilities , or they may be a marker of an unmotivated respondent or one who has become fatigued from the survey burden . To remove those who were unmotivated or fatigued , we required completion of four of the five questions on the last page of the survey for inclusion in the analyses . Only 15 women did not meet this criterion . Thus , our final sample comprised 287 women , for a 61 % completion rate . Unanswered numeracy questions were considered wrong answers . Restricting the sample to women who answered these questions yielded results similar to those seen with the entire sample . Question naire Design Assessment of Numeracy Numeracy was assessed with three questions and was scored as the total number of correct responses . The first question assessed basic familiarity with probability : Imagine that we flip a fair coin 1,000 times . What is your best guess about how many times the coin would come up heads in 1,000 flips ? _ _ _ _ times out of 1,000 . The second question asked respondents to convert a percentage ( 1 % ) to a proportion ( 10 in 1000 ) : In the BIG BUCKS LOTTERY , the chance of winning a $ 10 prize is 1 % . What is your best guess about how many people would win a $ 10 prize if 1000 people each buy a single ticket to BIG BUCKS?____person(s ) out of 1,000 . The third question reversed this task , asking the respondent to convert a proportion ( 1 in 1000 ) to a percentage ( 0.1 % ) : In ACME PUBLISHING SWEEPSAKES , the chance of winning a car is 1 in 1,000 . What percent of tickets to ACME PUBLISHING SWEEPSAKES win a car?____% . Presentation of Risk Reduction Data We r and omly assigned each of the 500 women to receive one of four question naires ; the question naires differed only in how the information on risk reduction was framed ( Figure 1 ) . Risk reduction data were framed as a 33 % relative risk reduction , a 33 % relative risk reduction together with the baseline risk for death from breast cancer in the next 10 years , a 4 in 1000 absolute risk reduction , or a 4 in 1000 absolute risk reduction together with the baseline risk for death from breast cancer in the next 10 years . Figure 1 . Overview of the task presented to a woman completing the survey and our measures of her ability to accurately apply risk reduction information . Assessment of Perceived Benefit To assess their perceived risk for death from breast cancer with and without mammography  ( Figure 1 ) , women were asked to do the following : Imagine 1,000 women exactly like you . Of these women , what is your best guess about how many will die from breast cancer during the next 10 years if they are not screened every year for breast cancer by mammogram _ _ _ _ _ out of 1000 they are screened every year for breast cancer by mammogram _ _ _ _ _ out of 1000 Calculation of Accuracy To see how accurately respondents applied the risk reduction data that they were given , we compared their perceived risk for death from breast cancer with mammography with their perceived risk for death without mammography ( Figure 1 ) . Accuracy was judged by the ability to adjust perceived risk in accordance with the risk reduction data presented . Accuracy was judged solely by the change between perceived risk with mammography and perceived risk without mammography , which we calculated from the responses to these two questions . Thus , women could grossly overestimate their risk while still accurately applying the risk reduction information . In fact , many women did overestimate their perceived risk without mammography , as observed in previous work [ 23 ] . For the two groups presented with the absolute risk reduction , we subtracted each woman 's perceived risk with mammography from her perceived risk without mammography . For example , a woman who perceived her risk to be 100 out of 1000 without mammography and 96 out of 1000 with mammography indicated an absolute risk reduction of 4 out of 1000 . Because the women in these groups were told that mammography decreases the risk for death from breast cancer by 4 in 1000 , only women whose responses indicated an absolute risk reduction of 4 in 1000 were judged to be accurate . For the two groups presented with the relative risk reduction , we determined the percentage reduction between the perceived risk without mammography and the perceived risk with mammography . For example , a woman with a perceived risk of 100 out of 1000 without mammography and 67 out of 1000 with mammography indicated a 33 % risk reduction . The women in these groups were told that mammography decreases the risk for death from breast cancer by 33 % . To allow for rounding off , women whose responses indicated a relative risk reduction between 30 % and 40 % were judged to be accurate . Statistical Analysis For the assessment of both numeracy and accuracy , the percentage of the sample that had correct answers for each measure was calculated as the number of respondents with correct responses divided by the total number of respondents ( n = 287 ) . Chi-square tests and Kruskal-Wallis tests were used to compare participant characteristics across the four groups . All comparisons were two-sided and were considered statistically significant at a P value of less than 0.05 . We used multiple logistic regression to assess the relation between accuracy in applying the risk reduction information ( dependent variable ) and numeracy ( independent variable ) after adjusting for age , income , education , and the framing of the information provided . Role of the Funding Sponsor This research was funded by the Department of Veterans Affairs Fellowship Program in Ambulatory Care and the Department of Defense 's Breast Cancer Research Program . Neither department had any role in the gathering , analysis , or interpretation of the data or in deciding whether to su bmi t the report for publication . Results Study Sample Overall , the study sample consisted of older female veterans , almost all of whom had at least a high school education . Most reported having annual household incomes of less than $ 25 000 , and fewer than one fourth were currently employed ( Table 1 ) . Most reported having had at least one mammogram , and 9 % had a history of breast cancer . No significant differences were seen in any characteristic across the four groups . Table 1 . Characteristics of the Study Sample * Assessment of Numeracy Almost half of the women ( 46 % ) answered the coin-flip question ( which asked how many times a coin would come up heads in 1000 flips ) incorrectly , raising questions about basic underst and ing of probability . Incorrect answers ranged from 0 to 800 and were largely underestimates ( one third of the sample thought that 1000 flips of a fair coin would result in < 300 heads ) . The most common incorrect answers were 25 , 50 , and 250 . Women also had trouble converting between percentages and probability expressions . The difficulty was greater for the conversion of 1 in 1000 to 0.1 % than for the conversion of 1 % to 10 in 1000 . Although 46 % of 287 respondents were unable to convert 1 % to 10 in 1000 , 80 % were unable to convert 1 in 1000 to 0.1 % . The total number of correct responses to these three simple tasks were as BACKGROUND : Several studies suggest that many parents and research participants have poor underst and ing of the elements of consent , particularly the risks and benefits . However , some data suggest that the format and framing of research risks and benefits may be an important determinant of subject underst and ing . We examined the effect of tabular and graphical presentation of risks and benefits on parents ' underst and ing of a research study . METHODS : Parents of children scheduled to undergo an elective surgical procedure ( n = 408 ) were r and omized to receive information about the risks and benefits of a sham study of postoperative pain control using text , tables , or pictographs and then completed a question naire to examine their gist ( essential ) and verbatim ( actual ) underst and ing of the information . Parent demographics were recorded and their literacy and numeracy skills measured . RESULTS : Parents r and omized to receive information using tables or pictographs had significantly ( P < 0.025 ) greater gist and verbatim underst and ing than did parents who received the information using st and ard text . Tables and pictographs were also superior to text in promoting underst and ing among parents with low numeracy and literacy skills . CONCLUSIONS : Many parents and patients have difficulty in assimilating and interpreting risk/benefit information for both research and treatment . This is due , in part , to the manner in which risks and benefits are communicated and to the literacy and numeracy abilities of the individual . The results of this study suggest a simple and practical method for enhancing underst and ing of risk/benefit statistics for parents with varying numeracy and literacy skills Context Direct-to-consumer drug advertisements do not provide st and ardized information about the benefits and harms of drug therapies . Contribution These r and omized trials tested whether adding a drug facts box to consumer prescription advertisements improved consumer knowledge and judgment . The facts box showed numbers of outcomes , including adverse events , which might occur with 2 alternative drug therapies . Consumers given advertisements that included the box had more accurate perceptions of drug benefits and side effects than consumers given advertisements without the box . Implication A st and ardized table quantifying outcomes that might occur with different therapies improved consumer knowledge of drug benefits and side effects . The Editors Direct-to-consumer advertising surpasses all other efforts to alert the U.S. public about prescription drugs . Industry spent more than $ 5 billion on these ads in 2007 (1)more than twice the total U.S. Food and Drug Administration ( FDA ) budget ( 2 ) . Although the ads are often justified as serving an educational purpose , they generally fail to provide the most fundamental information consumers need to make informed decisions : data on how well the drug works . To address this problem , we developed a drug facts box , a 1-page summary of a drug 's benefit and side effects . The central information is provided in a table that shows the chance of various outcomes for people who do and do not take the drug . In previous studies , we showed that consumers underst and and value this information ( 3 , 4 ) . We performed 2 r and omized , controlled trials in nationally representative sample s of U.S. adults ( the target audience for direct-to-consumer advertising ) to test whether a drug facts box improves consumer knowledge and helps people make better choices . Methods Design We conducted 2 r and omized , controlled trials with the same basic design from October 2006 through April 2007 : the symptom drug box trial and the prevention drug box trial . We conducted a pair of trials because consumers generally face decisions about 2 categories of drugs : those taken to treat current symptoms and those taken to reduce the risk for future events ( prevention ) . In the symptom drug box trial , we used direct-to-consumer ads for drugs to treat heartburn , an outcome ( heartburn relief ) that is common and experienced directly . We chose to include a proton-pump inhibitor ( PPI ) and a histamine-2 (H2)blocker because both drugs are used to treat current symptoms of the same disease and have similar side effect profiles , but PPIs clearly outperform H2-blockers ; we could therefore assess whether the box helped consumers choose the superior drug . In the prevention drug box trial , we used advertisements for a statin and clopidogrel for secondary cardiovascular prevention . These drugs are used to reduce the risk for future events that are important but relatively rare ( heart attack and death ) , so absolute effects can only be small . The goal of this trial was to see whether the box improved the accuracy of consumers ' perceptions about drugs used to reduce cardiovascular risk . Figure 1 shows the ads used in each trial . Figure 1 . Advertisements given to trial participants . Appendix 1 and Appendix 2 provide full-size images of all 8 ads . PPI = proton-pump inhibitor . Supplement . Appendix 1 Supplement . Appendix 2 Committees for the protection of human subjects at Dartmouth Medical School and the University of Massachusetts approved the trials . Trial protocol s were registered with Clinical Trials.gov before recruitment began . Sample Selection Figure 2 summarizes participant flow into the study . Figure 2 . Study flow diagram . R and om-Digit Dialing Protocol The Center for Survey Research , University of Massachusetts ( who conducted both surveys ) , created 2 national , r and om-digit dial sample s , each with about 3000 telephone numbers . Trained interviewers used a st and ard protocol in which they called each telephone number at least 6 times ( different days , weeks , and times ) . Whenever someone answered , the interviewer explained that we are conducting an important study about how people feel about different ways to provide information about prescription drugs in advertising . English-speaking adults age 35 to 70 years in the household were invited to participate ( if > 1 adult was eligible , the computerwhich guided these screening interviewsr and omly selected one ) . R and omization and Mail Survey Protocol Participants were r and omly assigned to the drug box or control group by using a central computerized r and om-number generator ( to ensure allocation concealment ) and were mailed survey material s ( 2 drug ads , the survey , and a stamped return envelope ) plus a prepaid $ 10 incentive with a promise of an additional $ 10 upon survey completion . Participants were not told about the alternate survey form . Nonresponders received reminder postcards after 2 weeks , a replacement question naire after 4 weeks , a telephone call after 6 weeks , and a question naire after 8 weeks . Response Rates We used st and ard Association for Public Opinion Research methods to calculate overall response rates ( 5 ) . The numerator is completed surveys ( 231 symptom drug box trial participants [ 122 in the drug box group and 109 in the control group ] and 219 prevention drug box trial participants [ 111 in the drug box group and 108 in the control group ] ) . The denominator is individuals known to be eligible ( 289 in the symptom drug box trial and 290 in the prevention drug box trial ) plus an estimate of eligible individuals in households that could not be screened . In the symptom drug box trial , this number184was calculated by applying the 44.4 % eligibility fraction observed among screened households to the 414 unscreened households . The overall response rates were 49 % in the symptom drug box trial ( 231/[289 + 184 ] ) and 46 % in the prevention drug box trial ( 219/[290 + 182 ] ) . Completion rates were calculated by using completed surveys as the numerator and participants as the denominator . For the symptom drug box trial , the completion rate was 89 % ( 231/258 ) ; the drug box group had a higher completion rate than the control group ( 95 % [ 122/129 ] vs. 84 % [ 109/129 ] ; P= 0.010 ) . In the prevention drug box trial , the completion rate was 84 % ( 219/260 ) and did not differ between groups . Study Material s We modified actual drug ads by disguising the name of the drug and manufacturer to avoid preconceived notions that participants might hold . Appendix 1 and Appendix 2 include all material s. Ad Image Page All participants received the same ad image page ( the colorful front page ) . Participants in the symptom drug box trial received ads for an H2-blocker ( Amcid ) and a PPI ( Maxtor ) . In the prevention drug box trial , the ads were for a statin ( Concor ) and clopidogrel ( Pridclo ) . Second Page In both trials , the second page differed according to r and omization . For control participants , the second page was the actual ad 's brief summary : the drug label excerpt that the FDA requires in drug ads . The drug box groups received drug facts boxes . These boxes ( Figure 3 shows the Pridclo [ clopidogrel ] box ) include a descriptive section with basic drug information ( such as indications and other things to consider doing ) . The central element is a summary table of efficacy and side effects presented as the chance of various outcomes for people who do or do not take the drug . We completed the boxes by using data from individual trials because that is how the FDA approaches drug approval ; they do not use meta- analysis to judge efficacy . Figure 3 . Pridclo ( clopidogrel ) drug facts box . FDA = U.S. Food and Drug Administration . To find efficacy data for the boxes in the symptom drug box trial , we used the Cochrane Collaboration review ( 6 ) on short-term treatment of gastroesophageal reflux diseaselike symptoms to identify all placebo-controlled trials of PPIs and H2-blockers for empirical therapy . For each drug , we chose the largest of the trials with same outcome : sustained relief , which is no heartburn episodes for 3 consecutive days . To facilitate comparisons , we st and ardized the base rate of sustained relief by averaging the findings in the placebo groups of the 2 studies ( 23 % in the H2-blocker study [ 7 ] vs. 15 % in the PPI study [ 8 ] , yielding an average base rate of 19 % ) . We calculated the relative risk ( drug vs. placebo ) for sustained relief in the H2-blocker ( relative risk , 1.87 ) and PPI ( relative risk , 4.67 ) trials by using the observed findings . To get st and ardized rates , we multiplied the averaged placebo rate by each relative risk . To frame the outcome as the proportion of patients still having heartburn , we used the complement of these calculated rates . Side effect data for the drug boxes were abstract ed from the corresponding brief summaries ( given to control participants ) to ensure that both groups had access to similar information . Although many side effects are listed throughout the brief summary , the drug box includes only the most important and largest relative to placebo or other comparator ( organized into life-threatening and symptom categories ) to focus the reader 's attention and minimize cognitive burden . To find efficacy data for the boxes in the prevention drug box trial , we began with the currently approved label for clopidogrel ( 9 ) . The label cites a single trial supporting the use of clopidogrel for heart attack prevention : CAPRIE ( Clopidogrel vs. Aspirin in Patients at Risk of Ischemic Events ) ( 10 ) . To find a similar study for the statin ( in terms of sample size , high-risk population , and outcome of heart attack ) , we review ed a meta- analysis of cholesterol-lowering treatment ( 11 ) . We chose the Medical Research Council Heart Protection Study of simvastatin ( 12 ) . To facilitate comparisons , we st and ardized the base rates of heart attack and all-cause mortality by taking the average risk in the comparator groups of the 2 studies . To get the st and ardized risk in both drug groups , we multiplied the st and ardized Objective . To develop and obtain feedback about a summary format for Cochrane review s that is accessible to a consumer audience , without oversimplification or incorrect presentation . Methods . We developed 3 versions of a Plain Language Summary ( PLS ) format of a Cochrane Systematic Review .  Using a semi-structured interview guide we tested these versions among 34 members of the public in Norway , Argentina , Canada , and Australia . The authors analyzed feedback , identified problems , and generated new solutions before retesting to produce a final version of a Plain Language Summary format . Results . Participants preferred results presented as words , supplemented by numbers in a table . There was a lack of underst and ing regarding the difference between a review and an individual study , that the effect is rarely an exact number , that evidence can be of low or high quality , and that level of quality is a separate issue from intervention effect . Participants also found it difficult to move between presentations of dichotomous and continuous outcomes . Rephrasing the introduction helped participants grasp the concept of a review . Confidence intervals were largely ignored or misunderstood . Our attempts to explain them were only partially successful . Text modifiers ( ‘ ‘ probably , ’ ’ ‘ ‘ may ’ ’ ) to convey different levels of quality were only partially understood , whereas symbols with explanations were more helpful . Participants often understood individual information elements about effect size and quality of these results , but did not always actively merge these elements . Conclusion . Through testing and iteration the authors identified and addressed several problems , using explanations , rephrasing , and symbols to present scientific concepts . Other problems remain , including how best to present confidence intervals and continuous outcomes . Future research should also test information elements in combination rather than in isolation . The new Plain Language Summary format is being evaluated in a r and omized controlled trial Background : Previous research demonstrated that providing qualitative and quantitative information in a “ drug facts box ” may help individuals underst and prescription drug information in print-based direct-to-consumer advertisements . The authors sought to determine whether qualitative , quantitative , or a combination thereof best communicates benefit and risk information . Methods : To replicate and extend previous research , the authors used simple quantitative drug information . A r and omized controlled study was conducted with 5067 Internet panelists with heartburn . Participants viewed a drug facts box with benefit and risk information that varied the presence or absence of qualitative summaries and absolute frequencies , percentages , and absolute differences . Measures included knowledge of drug benefits and risks , perceptions , and intentions . Results : Providing absolute frequencies and percentages most improved participants ’ drug knowledge and affected perceptions and intentions . Conclusions : The study findings suggest that , for simple drug information , adding absolute frequencies and percentages to direct-to-consumer advertisements may benefit consumers . Absolute differences and qualitative labels may not be needed Background . Fact boxes employ evidence -based guidelines on risk communication to present benefits and harms of health interventions in a balanced and transparent format . However , little is known about their short- and long-term efficacy and whether design ing fact boxes to present multiple outcomes with icon arrays would increase their efficacy . Method . In study 1 , 120 men ( 30–75 y ) completed a lab study . Participants were r and omly assigned to 1 of 3 fact box formats on prostate cancer screening : a tabular fact box with numbers , a fact box with numbers and icon array , and a fact box with numbers , separate icon arrays , and text to describe each benefit and harm .  Comprehension of information ( while material s were present ) and short-term knowledge recall were assessed . Study 2 recruited an online sample of 244 German men ( 40–75 y ) . Participants were r and omly assigned to 1 of the 3 fact box formats or widely distributed health information , and knowledge was assessed at baseline , shortly after presentation , and at 6-mo follow-up , along with comprehension while material s were present . Results . In both studies , comprehension and knowledge-recall scores were similar when comparing tabular and icon fact boxes . In the 6-mo follow-up , this positive effect on knowledge recall disappeared . Fact boxes increased knowledge relative to baseline but did not affect decision intentions or perceptions of having complete information to make decisions . Conclusions . This study shows that fact boxes with and without icon arrays are equally effective at improving comprehension and knowledge recall over the short-term and are simple formats that can improve on current health information . Specifically , if fact boxes are used at the time or immediately before a decision is made , they promote informed decisions about prostate cancer screening
Objectives : identifying effective summary formats is fundamental to multiple fields including science communication , systematic review s , evidence -based policy and medical decision-making .
This study tested whether table or text-only formats lead to better comprehension of the potential harms and benefits of different options , here in a medical context .