Numeric, Verbal, and Visual Formats of Conveying Health Risks: Suggested Best Practices and Future Recommendations
TL;DR: Best practices for conveying magnitude of health risks using numeric, verbal, and visual formats are offered and several recommendations are suggested for enhancing precision in perception of risk by presenting risk magnitudes numerically and visually.
Abstract: Perception of health risk can affect medical decisions and health behavior change Yet the concept of risk is a difficult one for the public to grasp Whether perceptions of risk affect decisions and behaviors often relies on how messages of risk magnitudes (ie, likelihood) are conveyed Based on expert opinion, this article offers, when possible, best practices for conveying magnitude of health risks using numeric, verbal, and visual formats This expert opinion is based on existing empirical evidence, review of papers and books, and consultations with experts in risk communication This article also discusses formats to use pertaining to unique risk communication challenges (eg, conveying small-probability events, interactions) Several recommendations are suggested for enhancing precision in perception of risk by presenting risk magnitudes numerically and visually Overall, there are little data to suggest best practices for verbal communication of risk magnitudes Across the 3 formats, few overall recommendations could be suggested because of 1) lack of consistency in testing formats using the same outcomes in the domain of interest, 2) lack of critical tests using randomized controlled studies pitting formats against one another, and 3) lack of theoretical progress detailing and testing mechanisms why one format should be more efficacious in a specific context to affect risk magnitudes than others Areas of future research are provided that it is hoped will help illuminate future best practices
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TL;DR: Clinicians and patients should maximize the therapeutic effects of communication by explicitly orienting communication to achieve intermediate outcomes associated with improved health.
1,780 citations
Cites background from "Numeric, Verbal, and Visual Formats..."
...Clinical evidence is typically in the form of probabilities applicable to populations, not individual patients [41]....
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TL;DR: In this paper, the authors discuss the importance of teaching statistical thinking and transparent representations in primary and secondary education as well as in medical school, and recommend using frequency statements instead of single-event probabilities, absolute risks instead of relative risks, mortality rates instead of survival rates, and natural frequencies instead of conditional probabilities.
Abstract: Many doctors, patients, journalists, and politicians alike do not understand what health statistics mean or draw wrong conclusions without noticing. Collective statistical illiteracy refers to the widespread inability to understand the meaning of numbers. For instance, many citizens are unaware that higher survival rates with cancer screening do not imply longer life, or that the statement that mammography screening reduces the risk of dying from breast cancer by 25% in fact means that 1 less woman out of 1,000 will die of the disease. We provide evidence that statistical illiteracy (a) is common to patients, journalists, and physicians; (b) is created by nontransparent framing of information that is sometimes an unintentional result of lack of understanding but can also be a result of intentional efforts to manipulate or persuade people; and (c) can have serious consequences for health. The causes of statistical illiteracy should not be attributed to cognitive biases alone, but to the emotional nature of the doctor-patient relationship and conflicts of interest in the healthcare system. The classic doctor-patient relation is based on (the physician's) paternalism and (the patient's) trust in authority, which make statistical literacy seem unnecessary; so does the traditional combination of determinism (physicians who seek causes, not chances) and the illusion of certainty (patients who seek certainty when there is none). We show that information pamphlets, Web sites, leaflets distributed to doctors by the pharmaceutical industry, and even medical journals often report evidence in nontransparent forms that suggest big benefits of featured interventions and small harms. Without understanding the numbers involved, the public is susceptible to political and commercial manipulation of their anxieties and hopes, which undermines the goals of informed consent and shared decision making. What can be done? We discuss the importance of teaching statistical thinking and transparent representations in primary and secondary education as well as in medical school. Yet this requires familiarizing children early on with the concept of probability and teaching statistical literacy as the art of solving real-world problems rather than applying formulas to toy problems about coins and dice. A major precondition for statistical literacy is transparent risk communication. We recommend using frequency statements instead of single-event probabilities, absolute risks instead of relative risks, mortality rates instead of survival rates, and natural frequencies instead of conditional probabilities. Psychological research on transparent visual and numerical forms of risk communication, as well as training of physicians in their use, is called for. Statistical literacy is a necessary precondition for an educated citizenship in a technological democracy. Understanding risks and asking critical questions can also shape the emotional climate in a society so that hopes and anxieties are no longer as easily manipulated from outside and citizens can develop a better-informed and more relaxed attitude toward their health.
967 citations
01 Mar 2011
TL;DR: Differences in health literacy level were consistently associated with increased hospitalizations, greater emergency care use, lower use of mammography, lower receipt of influenza vaccine, poorer ability to demonstrate taking medications appropriately, poorer able to interpret labels and health messages, and, among seniors, poorer overall health status and higher mortality.
Abstract: Objectives To update a 2004 systematic review of health care service use and health outcomes related to differences in health literacy level and interventions designed to improve these outcomes for individuals with low health literacy. Disparities in health outcomes and effectiveness of interventions among different sociodemographic groups were also examined. Data sources We searched MEDLINE®, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, PsychINFO, and the Educational Resources Information Center. For health literacy, we searched using a variety of terms, limited to English and studies published from 2003 to May 25, 2010. For numeracy, we searched from 1966 to May 25, 2010. Review methods We used standard Evidence-based Practice Center methods of dual review of abstracts, full-text articles, abstractions, quality ratings, and strength of evidence grading. We resolved disagreements by consensus. We evaluated whether newer literature was available for answering key questions, so we broadened our definition of health literacy to include numeracy and oral (spoken) health literacy. We excluded intervention studies that did not measure health literacy directly and updated our approach to evaluate individual study risk of bias and to grade strength of evidence. Results We included good- and fair-quality studies: 81 studies addressing health outcomes (reported in 95 articles including 86 measuring health literacy and 16 measuring numeracy, of which 7 measure both) and 42 studies (reported in 45 articles) addressing interventions. Differences in health literacy level were consistently associated with increased hospitalizations, greater emergency care use, lower use of mammography, lower receipt of influenza vaccine, poorer ability to demonstrate taking medications appropriately, poorer ability to interpret labels and health messages, and, among seniors, poorer overall health status and higher mortality. Health literacy level potentially mediates disparities between blacks and whites. The strength of evidence of numeracy studies was insufficient to low, limiting conclusions about the influence of numeracy on health care service use or health outcomes. Two studies suggested numeracy may mediate the effect of disparities on health outcomes. We found no evidence concerning oral health literacy and outcomes. Among intervention studies (27 randomized controlled trials [RCTs], 2 cluster RCTs, and 13 quasi-experimental designs), the strength of evidence for specific design features was low or insufficient. However, several specific features seemed to improve comprehension in one or a few studies. The strength of evidence was moderate for the effect of mixed interventions on health care service use; the effect of intensive self-management inventions on behavior; and the effect of disease-management interventions on disease prevalence/severity. The effects of other mixed interventions on other health outcomes, including knowledge, self-efficacy, adherence, and quality of life, and costs were mixed; thus, the strength of evidence was insufficient. Conclusions The field of health literacy has advanced since the 2004 report. Future research priorities include justifying appropriate cutoffs for health literacy levels prior to conducting studies; developing tools that measure additional related skills, particularly oral (spoken) health literacy; and examining mediators and moderators of the effect of health literacy. Priorities in advancing the design features of interventions include testing novel approaches to increase motivation, techniques for delivering information orally or numerically, "work around" interventions such as patient advocates; determining the effective components of already-tested interventions; determining the cost-effectiveness of programs; and determining the effect of policy and practice interventions.
952 citations
Additional excerpts
..., <9th grade level) Eligibility criteria: Included: ≥ 18 years-old On antiretroviral therapy for ≥ 3 months Receiving treatment from 1 of 2 U- Penn HIV clinics Excluded: NR Sampling strategy: Pharmacy records examined for those recruited sequentially on arrival for regular clinic appointments Sample size: 87 Age, median (IQR): <95% adherence: 44 (37-48) ≥95% adherence: 46 (37-53) Gender, %: Females: <95% adherence: 24 ≥95% adherence: 27 Race/Ethnicity, %: <95% adherence: Black: 88 White: 12 ≥95% adherence: Black: 69 White: 31 Income, %: <$10,0000: <95% adherence: 64 ≥95% adherence: 47 Insurance status: NR Education, %: High school <95% adherence: 60 ≥95% adherence: 69 Other characteristics: Median CD4 count (interquartile range) <95% adherence: 303 cells/cm3 (163-537) ≥95% adherence: 363 cells/cm3 (248-470) Undetectable viral load (<50 c/ml), %: <95% adherence: 45 ≥95% adherence: 73 Health literacy/numeracy levels: NR...
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01 Jan 2010
TL;DR: Evidence is provided that statistical illiteracy is common to patients, journalists, and physicians and that information pamphlets, Web sites, leaflets distributed by the pharmaceutical industry, and even medical journals often report evidence in nontransparent forms that suggest big benefits of featured interventions and small harms.
822 citations
Cites background or methods from "Numeric, Verbal, and Visual Formats..."
...Neurath’s isotypes have not yet been adapted to health statistics, but various graphic representations are in use (Elmore & Gigerenzer, 2005; Galesic, Garcia-Retamero, & Gigerenzer, in press; Paling, 2003; Kurz-Milcke et al., 2008; Lipkus, 2007; Schapira, Nattinger, & McHorney, 2001)....
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...Neurath’s isotopes have not yet been adapted to health statistics, but various graphic representations are in use (Galesic, Garcia-Retamero, & Gigerenzer, in press; Paling, 2003; Kurz-Milcke et al., 2008; Lipkus, 2007; Schapira, Nattinger, & McHorney, 2001)....
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TL;DR: Evidence-based medicine progressed to recognise limitations of evidence alone, and has increasingly stressed the need to combine critical appraisal of the evidence with patient's values and preferences through shared decision making.
557 citations
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27,773 citations
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TL;DR: It is shown that emotional reactions to risky situations often diverge from cognitive assessments of those risks, and when such divergence occurs, emotional reactions often drive behavior.
Abstract: Virtually all current theories of choice under risk or uncertainty are cognitive and consequentialist. They assume that people assess the desirability and likelihood of possible outcomes of choice alternatives and integrate this information through some type of expectation-based calculus to arrive at decision. The authors propose an alternative theoretical perspective, the risk-as-feelings hypothesis, that highlights the role of affect experienced at the moment of decision making. Drawing on research from clinical, physiological, and other subfield of psychology, they show that emotional reactions to risky situations often drive behavior. The risk-as-feelings hypothesis is shown to explain a wide range of phenomena that have resisted interpretation in cognitive-consequentialist terms.
4,901 citations
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TL;DR: This article proposed the risk-as-feelings hypothesis, which highlights the role of affect experienced at the moment of decision making, and showed that emotional reactions to risky situations often diverge from cognitive assessments of those risks.
Abstract: Virtually all current theories of choice under risk or uncertainty are cognitive and consequentialist. They assume that people assess the desirability and likelihood of possible outcomes of choice alternatives and integrate this information through some type of expectation-based calculus to arrive at a decision. The authors propose an alternative theoretical perspective, the risk-as-feelings hypothesis, that highlights the role of affect experienced at the moment of decision making. Drawing on research from clinical, physiological, and other subfields of psychology, they show that emotional reactions to risky situations often diverge from cognitive assessments of those risks. When such divergence occurs, emotional reactions often drive behavior. The risk-as-feelings hypothesis is shown to explain a wide range of phenomena that have resisted interpretation in cognitive-consequentialist terms.
4,647 citations
TL;DR: The idea that people's preferences are often constructed in the process of elicitation is derived from studies demonstrating that normatively equivalent elicitation (e.g., choice and pricing) give rise to systematically different responses.
Abstract: Dowe really knowwhatwewant?Ormustwe sometimes construct our preferences on the spot, using whatever cues are available – even when these cues lead us astray? One of the main themes that has emerged from behavioral decision research during the past three decades is the view that people’s preferences are often constructed in the process of elicitation. This idea is derived from studies demonstrating that normatively equivalent methods of elicitation (e.g., choice and pricing) give rise to systematically different responses. These preference reversals violate the principle of procedure invariance that is fundamental to all theories of rational choice. If different elicitation procedures produce different orderings of options, how can preferences be defined and in what sense do they exist? This book shows not only the historical roots of preference construction but also the blossoming of the conceptwithin psychology, law,marketing, philosophy, environmental policy, and economics. Decision making is now understood to be a highly contingent form of information processing, sensitive to task complexity, time pressure, response mode, framing, reference points, and other contextual factors.
2,164 citations
"Numeric, Verbal, and Visual Formats..." refers background in this paper
...Formats used for conveying risk information are critical because individuals often do not have a priori and stable opinions about risk magnitudes; as such, their beliefs and feelings about risk are likely to be influenced by format.(156) Although this review was about communicating probabilistic information because of its central role in most risk communications, it should be noted that probabilistic data may not be the most important dimension of risk people desire or use....
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TL;DR: By analyzing several thousand solutions to Bayesian problems, the authors found that when information was presented in frequency formats, statistically naive participants derived up to 50% of all inferences by Bayesian algorithms.
Abstract: Is the mind, by design, predisposed against performing Bayesian inference? Previous research on base rate neglect suggests that the mind lacks the appropriate cognitive algorithms. However, any claim against the existence of an algorithm, Bayesian or otherwise, is impossible to evaluate unless one specifies the information format in which it is designed to operate. The authors show that Bayesian algorithms are computationally simpler in frequency formats than in the probability formats used in previous research. Frequency formats correspond to the sequential way information is acquired in natural sampling, from animal foraging to neural networks. By analyzing several thousand solutions to Bayesian problems, the authors found that when information was presented in frequency formats, statistically naive participants derived up to 50% of all inferences by Bayesian algorithms. Non-Bayesian algorithms included simple versions of Fisherian and Neyman-Pearsonian inference. Is the mind, by design, predisposed against performing Bayesian inference? The classical probabilists of the Enlightenment, including Condorcet, Poisson, and Laplace, equated probability theory with the common sense of educated people, who were known then as "hommes eclaires." Laplace (1814/ 1951) declared that "the theory of probability is at bottom nothing more than good sense reduced to a calculus which evaluates that which good minds know by a sort of instinct, without being able to explain how with precision" (p. 196). The available mathematical tools, in particular the theorems of Bayes and Bernoulli, were seen as descriptions of actual human judgment (Daston, 1981,1988). However, the years of political upheaval during the French Revolution prompted Laplace, unlike earlier writers such as Condorcet, to issue repeated disclaimers that probability theory, because of the interference of passion and desire, could not account for all relevant factors in human judgment. The Enlightenment view—that the laws of probability are the laws of the mind—moderated as it was through the French Revolution, had a profound influence on 19th- and 20th-century science. This view became the starting point for seminal contributions to mathematics, as when George Boole
1,873 citations