Mike Zender

Bio: Mike Zender is an academic researcher from University of Cincinnati. The author has contributed to research in topics: Icon design & Icon. The author has an hindex of 5, co-authored 14 publications receiving 191 citations.

Shared decision-making to improve attention-deficit hyperactivity disorder care.

Abstract: Objective To examine the effect of a shared decision-making intervention with parents of children newly diagnosed with attention-deficit/hyperactivity disorder. Methods Seven pediatricians participated in a pre/post open trial of decision aids for use before and during the office visit to discuss diagnosis and develop a treatment plan. Encounters pre- (n = 21, control group) and post-intervention implementation (n = 33, intervention group) were compared. We video-recorded encounters and surveyed parents. Results Compared to controls, intervention group parents were more involved in shared decision-making (31.2 vs. 43.8 on OPTION score, p Conclusions Our intervention increased shared decision-making with parents. Parents were better informed about treatment options without increasing visit duration. Practice implications Interventions are available to prepare parents for visits and enable physicians to elicit parent preferences and involvement in decision-making.

User Interface Design Principles for Interaction Design

Abstract: In recent years, the number of computationally-based devices has grown rapidly, and with them the number of interfaces we encounter. Often, the face for today’s product or service is, at first touch, an interface. While the pervasiveness of the interface might present a minor challenge for the majority, for those with little previous knowledge or accessibility limitations the challenge can be insurmountable. In many cases, the way we access and use, and even the degree to which we rely on technology, may be vastly different from generation to generation. As the number of interfaces and the diversity of users grow, the need for effective interface design increases. Clocks on VCRs and DVD players flash at users insistently demanding to be reset, a mute testimony to the failure of the interface. Designers commonly mimic standard interface design elements such as icons and metaphors, or create flashy interfaces that may appeal visually, but often at the expense of user understanding and functionality. Despite mimicry, creativity, new technology, and a steadily growing need, interfaces are mired in paradigms established decades ago at a time when user interface was more a computer novelty than a part of everyday life. Thus far, pundits, consultants, and authors have attempted to improve interface design primarily by exploring and analyzing existing patterns of interface design, or by defining desirable enduser experiences. One example of a detailed analysis of an existing pattern is the Nielsen Norman Group’s 106-page report, “Site Map Usability.”1 A site map is a means for quickly gaining an overview of a Web site. The report mentions a principle in the first sentence of the executive summary: “Help users understand where they are”; then analyzes in great detail a specific means or pattern for meeting that need such as “Web site maps,” delivering twenty-eight guidelines “to improve site map usability.” Another recent example is Duyne, Landay, and Hong’s book The Design of Sites,2 which focuses on using existing patterns to improve Web interface design. As helpful as such approaches are, the examination of an existing pattern such as the site map, and a detailed recipe for the execution of that pattern, is not designed to stimulate innovation. 1 Nielsen Norman Group, Site Map Usability (Fremont, CA, 1998). 2 Douglas K. van Duyne, James A. Landay, and Jason I Hong, The Design of Sites (Boston: Addison-Wesley, 2003).

Improving Icon Design: Through Focus on the Role of Individual Symbols in the Construction of Meaning

Abstract: Despite the fact that icons are widely relied upon for communication, designers have few principles to guide icon design. This paper reports a study of the role individual symbols play on the construction of meaning from icons. An experiment compared two sets of four icons, each made of a different set of discrete symbols. It finds that the interaction of the right number of symbols for the referent, and a more apt combination of individual symbols for the referent, can significantly improve the construction of an icon that communicates what was intended. The rules of thumb proposed here are applicable to construction of any visual communication that uses symbols.cons today are ubiquitous and utilitarian. They shimmy on iPhones, bounce on computer screens, spin on cable TV's, and hang out on restroom doors. Icons are useful because they facilitate succinct communication. While their form is simple, their comprehension can be extensive. Indeed, nearly all communication happens through the interaction of symbols. Icons, ancestors of the earliest known forms of writing, have been a functional part of daily life since the pyramids were built so why study them now?A sufficient reason would be that many icons are not understood as intended. The ISO (2007) and ANSI (2007) recommend 85% correct comprehension for all warning symbols. A 2010 USA Today article titled "One third of drivers can't recognize this idiot light" (Woodyard, 2010) reported that a tire inflation pressure warning icon mandated by law, was not understood by 60% of drivers: 46% couldn't even identify the symbol as a tire! Our own icon comprehension studies show depressingly similar results. Only eight of a set of 54 medical icons that were carefully designed to cross language and cultural barriers achieve 85% comprehension by subjects in the USA, and just 3 of those icons were comprehended at the 85% level by subjects in Tanzania. Indeed, fewer than 1 in 10 Tanzanians, many of whom had advanced medical training, could correctly identify 19 of the 54 medical icons. That's a failure rate of 90%.Despite the common failure of icons, little is written about how they work from either a theoretical or a practical 'how-to' perspective. Beginning with Dreyfuss' Symbol Sourcebook (Dreyfuss, 1972) there has been steady parade of books that exhibit the latest symbols and icons, but few if any of these tomes explain how visual symbols work or how they might be made to work better. That is the gap our icon research seeks to fill. This paper describes a research study that measured the impact different combinations of symbols have on the comprehension of four icons. Based on this we identify some patterns, sketch some initial hypotheses for how people construct meaning from symbols, and propose some how-to rules of thumb to guide the design of more effective icons.symbols and iConsBesides being ubiquitous and utilitarian, icons are significant objects of study. Icons have simplicity of form compared with many other communication materials whose visual forms are much more complex. Icon's lean visual form reduces interpretive complexity. Icons also tend to have a very definite intended meaning: the referent...This gives icons an established measure of comprehension success. Icons are typically created in a consistent graphic style. Since standardization efforts in the 1970's, notably the US Department of Transportation's commission of the AIGA to produce a standard symbol set, icons for a wide range of referents have followed the highly abstract round head and mitten hands familiar on restroom doors. Thus a wide variety of subject matter is available in a consistent visual style, facilitating study. While we are aware of one study that explores the effectiveness of this common style (Marom-Tock & Goldschmidt, 2011), similarity of style -however effective - has the benefit of reducing the number of variables in comprehension testing. …

Advancing Icon Design for Global Non Verbal Communication: Or What Does the Word Bow Mean?

Abstract: Written language is limited in effectiveness to those who can read. Verbal language is effective only for those who understand the particular language being spoken. But everyone, except those with obvious visual impairment, can effectively perceive images without regard for literacy or language. For decades these realities have suggested the promise of a universal visual language but with little real result. The occasional Olympic event sign or restroom door sign are state of the art for global non-verbal communication. While icon design has evolved little since the 1970's, the world has moved on. Increasing economic globalization and the expansion of global communication networks have made it easier to deliver messages and more important to do so, while science has advanced understanding of perception and cognition establishing principles only speculated about in the 1970's. The dream of using images to greatly facilitate global communication persists. Unfortunately, image based communication is not currently well enough informed by principles of effectiveness to attempt such a project. To address this problem a team of researchers assembled at the University of Cincinnati to explore the development of advanced techniques for global non-verbal or image based communication. The team explored novel approaches and identified several principles designed to expand icon based communication so that it can communicate more complex messages and more abstract concepts with greater specificity than previously. bow What does the word "bow"mean? Several things, but the most accurate answer is it depends on the context. To illustrate: shoe | bow ship | bow arrow | bow rain | bow take a | bow bow | down IN EACH OF THE ABOVE PAIRS SOMETHING SPARKS a different meaning for the single typographic sign: "bow." That something is simply another sign, a context. In some pairs the context sparks a meaning that is only subtly different, no doubt in homage to the vagaries of linguistic etymology, but in other instances the context spotlights a meaning that is a different part of speech altogether, a verb instead of a noun for example. In each case context is what illumines the meaning (Wittgenstein. 1961 [1921]). This is as true for sentences and stories as it is for words (Wright, 1992). Unfortunately, written language though rich in context is limited in effectiveness to those who can read. Even verbal language is effective only for those who understand the particular language being spoken. But everyone, except those with obvious visual impairment, can understand images without regard for literacy or language. Donis A. Dondis even goes so far as to claim "Among illiterate constituencies, visual communi cation's effectiveness is undisputed"(Dondis, 1973). From street signs to Olympic venues, images communicate where words fail. What exactly does the icon of a man mean? Again, it appears to depend in part on the context: street sign I human icon park sign I human icon airport door sign I human icon (left to right Figure 1 below) The visual changes in the human icons are minimal and fairly subtle yet, in their context, viewers from all over the world have 'read' these icons as meaning specific and very different things: a crosswalk, a hiking trail, a restroom. In a park context adding two additional strokes to the man icon suggests a backpack and walking stick. The park context combined with two immediate iconic clues redefine the 'crosswalk' icon to a hiking trail icon. Like words, the overall context of the human icon changes its meaning. This is an impressive transformation accomplished with an economy of means. However, as successful as these icons are in their contexts, they are not as comprehensive or as definitive as words. The system from which the hiking icon came has no icon for 'pleasant hiking trail' or 'difficult hiking trail' or even 'dangerous hiking trail. …

(Mis)understanding: Icon Comprehension in Different Cultural Contexts

Abstract: Icons are frequently used in contexts where comprehension needs to be consistent across cultural and linguistic barriers. This paper reports on a study comparing the comprehension of 54 universal medical icons in rural Tanzania and the United States of America. It finds that most of the icons were not understood cross-culturally. The premise of the study was that this misunderstanding might have two causes: cultural distinctions and lack of knowledge. To test the premise we studied icon comprehension by those in two different cultures with two levels of medical knowledge: 'standard' and 'advanced'. The results show that most (33 of 47) poorly comprehended icons failed due to lack of medical knowledge or unfamiliarity with technology, while few (5 of 47) poorly comprehended icons failed due to cultural differences. Analysis of icons that failed due to cultural differences suggests that the primary drivers of cultural misunderstanding were the use of culturally sensitive metaphor and the incorporation of learned signs (non-representational symbols such as words) in icon design. Awareness of these causes of poor comprehension across cultures might help designers design effective universal icons by incorporating into the design process research methods that identify disparities of specific knowledge in the target people group and by avoiding use of metaphor and learned signs. These findings empower calls for cultural sensitivity in visual communication with guidance for implementation.KEY WORDSicon; pictogram; medical communication; culture; comprehensionINTRODUCTIONIcons are often relied upon to communicate where words fail. They race through Olympic venues, plod through international airports, and glow on smartphones. Icons are useful in these international contexts because they visually represent what they symbolize, bypassing language by connecting with our shared visual experience of the world. Icons can cross cultures and eras. Hieroglyphs in ancient Egyptian tombs still speak without words across accumulated millennia of changing technology and culture.Icons still speak today, but often unclearly. Recent studies show that contemporary icons may not be as widely understood as we assume. Only 60% of people can correctly identify the tire inflation 'idiot light' icon in cars. (Woodyard, 2010) There are several complicating factors to communicating well with icons. Image-based icons must be designed to connect with familiar objects. Poor drawing, or not drawing an object from the commonly seen point of view such as a tire in Woodyard's example, is one factor that can result in misunderstanding. Another factor is disparity in familiarity with various technologies across the globe. For example, Magnetic Resonance Imaging now seems to be available everywhere in the USA but may not be available anywhere in some African countries. Someone who does not know that an MRI exists will not understand an icon of an MRI, no matter how well drawn. As James Mangan said, "correct interpretation of these signs requires exposure to what they signify." (Mangan, 1978, p. 256) A further factor is the use of metaphor to communicate which may draw upon cultural norms like using children's toys to communicate a children's hospital ward. Such cultural norms differ. What is a toy in one culture may not be a toy in another, leading to failure to understand both the metaphor and the icon based on it.Some studies verify that cultural differences may impact the ability to correctly comprehend medication instruction icons in Africa, (Knapp, Raynor, Jebar, & Price, 2005), while others find little or no difference across culture but instead find greater difference in comprehension due to educational level. (Kassam, Vaillancourt, & Collins, 2004) The Kassam article, which tested three language people groups living in Canada, exposes the issue of what specific features such as language and praxis should define one cultural from another. …

Interventions for increasing the use of shared decision making by healthcare professionals

Abstract: Background Shared decision making (SDM) is a process by which a healthcare choice is made by the patient, significant others, or both with one or more healthcare professionals. However, it has not yet been widely adopted in practice. This is the second update of this Cochrane review. Objectives To determine the effectiveness of interventions for increasing the use of SDM by healthcare professionals. We considered interventions targeting patients, interventions targeting healthcare professionals, and interventions targeting both. Search methods We searched CENTRAL, MEDLINE, Embase and five other databases on 15 June 2017. We also searched two clinical trials registries and proceedings of relevant conferences. We checked reference lists and contacted study authors to identify additional studies. Selection criteria Randomized and non-randomized trials, controlled before-after studies and interrupted time series studies evaluating interventions for increasing the use of SDM in which the primary outcomes were evaluated using observer-based or patient-reported measures. Data collection and analysis We used standard methodological procedures expected by Cochrane.We used GRADE to assess the certainty of the evidence. Main results We included 87 studies (45,641 patients and 3113 healthcare professionals) conducted mainly in the USA, Germany, Canada and the Netherlands. Risk of bias was high or unclear for protection against contamination, low for differences in the baseline characteristics of patients, and unclear for other domains.Forty-four studies evaluated interventions targeting patients. They included decision aids, patient activation, question prompt lists and training for patients among others and were administered alone (single intervention) or in combination (multifaceted intervention). The certainty of the evidence was very low. It is uncertain if interventions targeting patients when compared with usual care increase SDM whether measured by observation (standardized mean difference (SMD) 0.54, 95% confidence interval (CI) -0.13 to 1.22; 4 studies; N = 424) or reported by patients (SMD 0.32, 95% CI 0.16 to 0.48; 9 studies; N = 1386; risk difference (RD) -0.09, 95% CI -0.19 to 0.01; 6 studies; N = 754), reduce decision regret (SMD -0.10, 95% CI -0.39 to 0.19; 1 study; N = 212), improve physical (SMD 0.00, 95% CI -0.36 to 0.36; 1 study; N = 116) or mental health-related quality of life (QOL) (SMD 0.10, 95% CI -0.26 to 0.46; 1 study; N = 116), affect consultation length (SMD 0.10, 95% CI -0.39 to 0.58; 2 studies; N = 224) or cost (SMD 0.82, 95% CI 0.42 to 1.22; 1 study; N = 105).It is uncertain if interventions targeting patients when compared with interventions of the same type increase SDM whether measured by observation (SMD 0.88, 95% CI 0.39 to 1.37; 3 studies; N = 271) or reported by patients (SMD 0.03, 95% CI -0.18 to 0.24; 11 studies; N = 1906); (RD 0.03, 95% CI -0.02 to 0.08; 10 studies; N = 2272); affect consultation length (SMD -0.65, 95% CI -1.29 to -0.00; 1 study; N = 39) or costs. No data were reported for decision regret, physical or mental health-related QOL.Fifteen studies evaluated interventions targeting healthcare professionals. They included educational meetings, educational material, educational outreach visits and reminders among others. The certainty of evidence is very low. It is uncertain if these interventions when compared with usual care increase SDM whether measured by observation (SMD 0.70, 95% CI 0.21 to 1.19; 6 studies; N = 479) or reported by patients (SMD 0.03, 95% CI -0.15 to 0.20; 5 studies; N = 5772); (RD 0.01, 95%C: -0.03 to 0.06; 2 studies; N = 6303); reduce decision regret (SMD 0.29, 95% CI 0.07 to 0.51; 1 study; N = 326), affect consultation length (SMD 0.51, 95% CI 0.21 to 0.81; 1 study, N = 175), cost (no data available) or physical health-related QOL (SMD 0.16, 95% CI -0.05 to 0.36; 1 study; N = 359). Mental health-related QOL may slightly improve (SMD 0.28, 95% CI 0.07 to 0.49; 1 study, N = 359; low-certainty evidence).It is uncertain if interventions targeting healthcare professionals compared to interventions of the same type increase SDM whether measured by observation (SMD -0.30, 95% CI -1.19 to 0.59; 1 study; N = 20) or reported by patients (SMD 0.24, 95% CI -0.10 to 0.58; 2 studies; N = 1459) as the certainty of the evidence is very low. There was insufficient information to determine the effect on decision regret, physical or mental health-related QOL, consultation length or costs.Twenty-eight studies targeted both patients and healthcare professionals. The interventions used a combination of patient-mediated and healthcare professional directed interventions. Based on low certainty evidence, it is uncertain whether these interventions, when compared with usual care, increase SDM whether measured by observation (SMD 1.10, 95% CI 0.42 to 1.79; 6 studies; N = 1270) or reported by patients (SMD 0.13, 95% CI -0.02 to 0.28; 7 studies; N = 1479); (RD -0.01, 95% CI -0.20 to 0.19; 2 studies; N = 266); improve physical (SMD 0.08, -0.37 to 0.54; 1 study; N = 75) or mental health-related QOL (SMD 0.01, -0.44 to 0.46; 1 study; N = 75), affect consultation length (SMD 3.72, 95% CI 3.44 to 4.01; 1 study; N = 36) or costs (no data available) and may make little or no difference to decision regret (SMD 0.13, 95% CI -0.08 to 0.33; 1 study; low-certainty evidence).It is uncertain whether interventions targeting both patients and healthcare professionals compared to interventions of the same type increase SDM whether measured by observation (SMD -0.29, 95% CI -1.17 to 0.60; 1 study; N = 20); (RD -0.04, 95% CI -0.13 to 0.04; 1 study; N = 134) or reported by patients (SMD 0.00, 95% CI -0.32 to 0.32; 1 study; N = 150 ) as the certainty of the evidence was very low. There was insuffient information to determine the effects on decision regret, physical or mental health-related quality of life, or consultation length or costs. Authors' conclusions It is uncertain whether any interventions for increasing the use of SDM by healthcare professionals are effective because the certainty of the evidence is low or very low.

Shared Decision Making in Pediatrics: A Systematic Review and Meta-analysis

Abstract: Background Little is known about the impact of interventions to support shared decision making (SDM) with pediatric patients. Objectives To summarize the efficacy of SDM interventions in pediatrics on patient-centered outcomes. Data Sources We searched Ovid Medline, Ovid Embase, Ovid Cochrane Library, Web of Science, Scopus, and Ovid PsycInfo from database inception to December 30, 2013, and performed an environmental scan. Study Eligibility Criteria We included interventions designed to engage pediatric patients, parents, or both in a medical decision, regardless of study design or reported outcomes. Study Appraisal and Synthesis Methods We reviewed all studies in duplicate for inclusion, data extraction, and risk of bias assessment. Meta-analysis was performed on 3 outcomes: knowledge, decisional conflict, and satisfaction. Results Sixty-one citations describing 54 interventions met eligibility criteria. Fifteen studies reported outcomes such that they were eligible for inclusion in meta-analysis. Heterogeneity across studies was high. Meta-analysis revealed SDM interventions significantly improved knowledge (standardized mean difference [SMD] 1.21, 95% confidence interval [CI] 0.26 to 2.17, P = .01) and reduced decisional conflict (SMD −1.20, 95% CI −2.01 to −0.40, P = .003). Interventions showed a nonsignificant trend toward increased satisfaction (SMD 0.37, 95% CI −0.04 to 0.78, P = .08). Limitations Included studies were heterogeneous in nature, including their conceptions of SDM. Conclusions and Implications of Key Findings A limited evidence base suggests that pediatric SDM interventions improve knowledge and decisional conflict, but their impact on other outcomes is unclear. Systematic Review Registration Number PROSPERO CRD42013004761 (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42013004761).

Physicians' Shared Decision-Making Behaviors in Depression Care. Commentary

Abstract: Background: Although shared decision making (SDM) has been reported to facilitate quality care, few studies have explored the extent to which SDM is implemented in primary care and factors that influence its application. This study assesses the extent to which physicians enact SDM behaviors and describes factors associated with physicians' SDM behaviors within the context of depression care. Methods: In a secondary analysis of data from a randomized experiment, we coded 287 audiorecorded interactions between physicians and standardized patients (SPs) using the Observing Patient Involvement (OPTION) system to assess physician SDM behaviors. We performed a series of generalized linear mixed model analyses to examine physician and patient characteristics associated with SDM behavior. Results: The mean (SD) OPTION score was 11.4 (3.3) of 48 possible points. Older physicians (partial correlation coefficient=-0.29; β=-0.09; P<.01) and physicians who practiced in a health maintenance organization setting (β=-1.60; P<.01) performed fewer SDM behaviors. Longer visit duration was associated with more SDM behaviors (partial correlation coefficient=0.31; β=0.08; P<.01). In addition, physicians enacted more SDM behaviors with SPs who made general (β=2.46; P <.01) and brand-specific (β=2.21; P<.01) medication requests compared with those who made no request. Conclusions: In the context of new visits for depressive symptoms, primary care physicians performed few SDM behaviors. However, physician SDM behaviors are influenced by practice setting and patient-initiated requests for medication. Additional research is needed to identify interventions that encourage SDM when indicated.

The impact and utility of encounter patient decision aids: Systematic review, meta-analysis and narrative synthesis.

Abstract: Objective To determine the effect of encounter patient decision aids (PDAs) as evaluated in randomized controlled trials (RCTs) and conduct a narrative synthesis of non-randomized studies assessing feasibility, utility and their integration into clinical workflows. Methods Databases were systematically searched for RCTs of encounter PDAs to enable the conduct of a meta-analysis. We used a framework analysis approach to conduct a narrative synthesis of non-randomized studies. Results We included 23 RCTs and 30 non-randomized studies. Encounter PDAs significantly increased knowledge (SMD = 0.42; 95% CI 0.30, 0.55), lowered decisional conflict (SMD= -0.33; 95% CI -0.56, -0.09), increased observational-based assessment of shared decision making (SMD = 0.94; 95% CI 0.40, 1.48) and satisfaction with the decision-making process (OR = 1.78; 95% CI 1.19, 2.66) without increasing visit durations (SMD= -0.06; 95% CI -0.29, 0.16). The narrative synthesis showed that encounter tools have high utility for patients and clinicians, yet important barriers to implementation exist (i.e. time constraints) at the clinical and organizational level. Conclusion Encounter PDAs have a positive impact on patient-clinician collaboration, despite facing implementation barriers. Practical implications The potential utility of encounter PDAs requires addressing the systemic and structural barriers that prevent adoption in clinical practice.

Conveying Safety Messages on Agricultural Machinery: The Comprehension of Safety Pictorials in a Group of Migrant Farmworkers in Italy.

Abstract: The comprehension of safety signs affixed to agricultural machinery is fundamental to warning users about the residual risks which cannot be eliminated with machinery design and the adoption of protections. This is particularly relevant for the migrant workforce, which may encounter some language barriers with written safety communication. The present study aimed to investigate the comprehension of safety signs affixed to agricultural machinery in a group of migrants from both European and non-European countries employed in Italian agriculture. Thirty-seven migrant farmworkers (12 Indians, 17 Pakistanis, and eight Romanians) were individually interviewed to test the comprehension of four safety signs referring to the main causes of fatal and non-fatal injuries caused by interactions with farm machinery. Romanians obtained the highest comprehension performance (68.8% of correct answers), followed by Indians (35.4%), with Pakistanis being last (32.4%). The nationality and the previous experience as a farmworker significantly affected the comprehension of safety signs. The results pointed out the importance of adequately training migrants on the meaning of safety signs. Beside this, the study suggests a redesign of the signs, considering some signs’ features to enhance pictorials’ cross-cultural comprehension.