Mammography Screening Preferences Among Screening-Eligible Women in Their 40s : A National U.S. Survey.

BACKGROUND: The U.S. Preventive Services Task Force (USPSTF) recently changed its recommendation for mammography screening from informed decision making to biennial screening for women aged 40 to 49 years. Although many women welcome this change, some may prefer not to be screened at age 40 years. OBJECTIVE: To conduct a national probability-based U.S. survey to investigate breast cancer screening preferences among women aged 39 to 49 years. DESIGN: Pre-post survey with a breast cancer screening decision aid (DA) intervention. (ClinicalTrials.gov: NCT05376241). SETTING: Online national U.S. survey. PARTICIPANTS: 495 women aged 39 to 49 years without a history of breast cancer or a known BRCA1/2 gene mutation. INTERVENTION: A mammography screening DA providing information about screening benefits and harms and a personalized breast cancer risk estimate. MEASUREMENTS: Screening preferences (assessed before and after the DA), 10-year Gail model risk estimate, and whether the information was surprising and different from past messages. RESULTS: Before viewing the DA, 27.0% of participants preferred to delay screening (vs. having mammography at their current age), compared with 38.5% after the DA. There was no increase in the number never wanting mammography (5.4% before the DA vs. 4.3% after the DA). Participants who preferred to delay screening had lower breast cancer risk than those who preferred not to delay. The information about overdiagnosis was surprising for 37.4% of participants versus 27.2% and 22.9% for information about false-positive results and screening benefits, respectively. LIMITATION: Respondent preferences may have been influenced by the then-current USPSTF guideline. CONCLUSION: There are women in their 40s who would prefer to have mammography at an older age, especially after being informed of the benefits and harms of screening. Women who wanted to delay screening were at lower breast cancer risk than women who wanted screening at their current age. Many found information about the benefits and harms of mammography surprising. PRIMARY FUNDING SOURCE: National Cancer Institute.

Integrating Cost into Shared Decision-Making for Heart Failure with Reduced Ejection Fraction (POCKET-COST-HF): A Trial Providing Out-of-Pocket Costs for Heart Failure Medications during Clinical Encounters.

BACKGROUND: Evidence-based medical therapy for heart failure with reduced ejection fraction (HFrEF) often entails substantial out-of-pocket costs that can vary appreciably between patients. This has raised concerns regarding financial toxicity, equity, and adherence to medical therapy. In spite of these concerns, cost discussions in the HFrEF population appear to be rare, partly because out-of-pocket costs are generally unavailable during clinical encounters. In this trial, out-of-pocket cost information is given to patients and clinicians during outpatient encounters with the aim to assess the impact of providing this information on medication discussions and decisions. HYPOTHESIS: Cost-informed decision-making will be facilitated by providing access to patient-specific out-of-pocket cost estimates at the time of clinical encounter. DESIGN: Integrating Cost into Shared Decision-Making for Heart Failure with Reduced Ejection Fraction (POCKET-COST-HF) is a multicenter trial based at Emory Healthcare and University of Colorado Health. Adapting an existing patient activation tool from the EPIC-HF trial, patients and clinicians are presented a checklist with medications approved for treatment of HFrEF with or without patient-specific out-of-pocket costs (obtained from a financial navigation firm). Clinical encounters are audio-recorded, and patients are surveyed about their experience. The trial utilizes a stepped-wedge cluster randomized design, allowing for each site to enroll control and intervention group patients while minimizing contamination of the control arm. DISCUSSION: This trial will elucidate the potential impact of robust cost disclosure efforts and key information regarding patient and clinician perspectives related to cost and cost communication. It also will reveal important challenges associated with providing out-of-pocket costs for medications during clinical encounters. Acquiring medication costs for this trial requires an involved process and outsourcing of work. In addition, costs may change throughout the year, raising questions regarding what specific information is most valuable. These data will represent an important step towards understanding the role of integrating cost discussions into heart failure care. GOV IDENTIFIER: NCT04793880.

Predictors of COVID-19 vaccine uptake: an online three-wave survey study of US adults.

BACKGROUND: To effectively promote vaccine uptake, it is important to understand which people are most and least inclined to be vaccinated and why. In this study, we examined predictors of COVID-19 vaccine uptake and reasons for non-vaccination. METHODS: We conducted an online English-language survey study in December-2020, January-2021, and March-2021. A total of 930 US respondents completed all surveys. Multiple logistic regression models were run to test whether the early vaccine eligibility, demographic factors, and psychological factors predict getting at least one dose of a COVID-19 vaccination in January-2021 and in March-2021. RESULTS: The proportion of respondents who received ≥ 1-dose of a COVID-19 vaccine increased from 18% (January) to 67% (March). Older age predicted vaccine uptake in January (OR = 2.02[95%CI = 1.14-3.78], p < .001) and March (10.92[6.76-18.05], p < .001). In January, additional predictors were higher numeracy (1.48[1.20-1.86], p < .001), COVID-19 risk perceptions (1.35[1.03-1.78], p = .029), and believing it is important adults get the COVID-19 vaccine (1.66[1.05-2.66], p = .033). In March, additional predictors of uptake were believing it is important adults get the COVID-19 vaccine (1.63[1.15-2.34], p = .006), prior COVID-19 vaccine intentions (1.37[1.10-1.72], p = .006), and belief in science (0.84[0.72-0.99], p = .041). Concerns about side effects and the development process were the most common reasons for non-vaccination. Unvaccinated respondents with no interest in getting a COVID-19 vaccine were younger (0.27[0.09-0.77], p = .016), held negative views about COVID-19 vaccines for adults (0.15[0.08-0.26], p < .001), had lower trust in healthcare (0.59[0.36-0.95], p = .032), and preferred to watch and wait in clinically ambiguous medical situations (0.66[0.48-0.89], p = .007). CONCLUSIONS: Evidence that attitudes and intentions towards COVID-19 vaccines were important predictors of uptake provides validation for studies using these measures and reinforces the need to develop strategies for addressing safety and development concerns which remain at the forefront of vaccine hesitancy.

Climate change threats to the global functional diversity of freshwater fish.

Climate change impacts on freshwater ecosystems and freshwater biodiversity show strong spatial variability, highlighting the importance of a global perspective. While previous studies on biodiversity mostly focused on species richness, functional diversity, which is a better predictor of ecosystem functioning, has received much less attention. This study aims to comprehensively assess climate change threats to the functional diversity of freshwater fish across the world, considering three complementary metrics-functional richness, evenness and divergence. We built on existing spatially explicit projections of geographical ranges for 11,425 riverine fish species as affected by changes in streamflow and water temperature extremes at four warming levels (1.5°C, 2.0°C, 3.2°C and 4.5°C). To estimate functional diversity, we considered the following four continuous, morphological and physiological traits: relative head length, relative body depth, trophic level and relative growth rate. Together, these traits cover five ecological functions. We treated missing trait values in two different ways: we either removed species with missing trait values or imputed them. Depending on the warming level, 6%-25% of the locations globally face a complete loss of functional diversity when assuming no dispersal (6%-17% when assuming maximal dispersal), with hotspots in the Amazon and Paraná River basins. The three facets of functional diversity do not always follow the same pattern. Sometimes, functional richness is not yet affected despite species loss, while functional evenness and divergence are already reducing. Other times, functional richness reduces, while functional evenness and/or divergence increase instead. The contrasting patterns of the three facets of functional diversity show their complementarity among each other and their added value compared to species richness. With increasing climate change, impacts on freshwater communities accelerate, making early mitigation critically important.

Access to Results of Patient Reported Outcome Surveys Does Not Improve Survey Response Rates.

INTRODUCTION: In this embedded substudy of a longitudinal, randomized controlled trial, we sought to evaluate the effects of patient engagement and results feedback on longitudinal patient-reported outcome (PRO) survey completion rates. METHODS: Newly diagnosed stage 0-III breast cancer patients seen at an academic breast center between June 2019 and December 2021 were invited to participate in a longitudinal PRO study. Participants were emailed the BREAST-Q survey, a validated PRO scale, preoperatively and at regular intervals during their postoperative course. Patients were randomized into the intervention group, who received survey results upon completion, or the control group, who received no feedback. The primary endpoint was postoperative survey completion rate. An intention to treat analysis was performed and a quasi-Poisson regression was used to compare rates of longitudinal survey completion between the two groups. RESULTS: Of the 253 patients offered the preoperative survey, 115 were in the intervention group and 138 were in the control group. Postoperative survey completion rate was 54% for the intervention group and 47% for the control group. There was no significant difference in longitudinal postoperative survey completion rate between the two groups (rate ratio 1.10; 95% confidence interval [CI] 0.93-1.31). CONCLUSIONS: In this prospective randomized controlled study, patients did not complete surveys at a higher rate when their survey results were shared with them, suggesting that viewing these results without appropriate clinical context does not generate significant enhancement in patient engagement. Effective interventions to improve survey response rate must be identified to better evaluate PROs.

Veterans and Nonveterans Coping With Stress During 4 Months of COVID-19.

PURPOSE: Identifying how people have been coping with stress during the COVID-19 pandemic allows us to anticipate how the population may react to similar stressors over time. In this study, we assessed patterns of coping styles among veterans and nonveterans, and stability and change in these strategies at 3 time points during the pandemic. METHODS: Using an online survey platform, we circulated a questionnaire at 3 time points during the period when COVID-19 vaccines became widely available (December 2-27, 2020; January 21-February 6, 2021; and March 8-23, 2021). The questionnaire asked participants about their extent of use of 11 coping strategies, and symptoms of anxiety and depression. RESULTS: A total of 2,085 participants (50.8% veterans) completed the questionnaire at 1 or more time points and 930 participants (62.8% veterans) completed it at all 3 time points. Cluster analysis identified 3 distinct coping styles: adaptive, distressed, and disengaged. Compared with nonveterans, veterans more commonly had adaptive and disengaged coping styles, and less commonly had a distressed coping style. The majority of the cohort (71.3%) changed coping style at least once during the study period. Participants who used the same coping style across all 3 time points reported lower levels of anxiety and depression. CONCLUSIONS: Our data demonstrate a need to better understand the dynamic nature of coping with pandemic-level stressors across time. We did not find patterns of change in coping styles, but our findings point to potential advantages of stability in coping style. It is possible that less adaptive styles that are more stable may be advantageous for mental health. This research has implications for supporting patients dealing with stress in family medicine.

Effects of Nitrogen Emissions on Fish Species Richness across the World's Freshwater Ecoregions.

The increasing application of synthetic fertilizer has tripled nitrogen (N) inputs over the 20th century. N enrichment decreases water quality and threatens aquatic species such as fish through eutrophication and toxicity. However, the impacts of N on freshwater ecosystems are typically neglected in life cycle assessment (LCA). Due to the variety of environmental conditions and species compositions, the response of species to N emissions differs among ecoregions, requiring a regionalized effect assessment. Our study tackled this issue by establishing regionalized species sensitivity distributions (SSDs) of freshwater fish against N concentrations for 367 ecoregions and 48 combinations of realms and major habitat types globally. Subsequently, effect factors (EFs) were derived for LCA to assess the effects of N on fish species richness at a 0.5 degree × 0.5 degree resolution. Results show good SSD fits for all of the ecoregions that contain sufficient data and similar patterns for average and marginal EFs. The SSDs highlight strong effects on species richness due to high N concentrations in the tropical zone and the vulnerability of cold regions. Our study revealed the regional differences in sensitivities of freshwater ecosystems against N content in great spatial detail and can be used to assess more precisely and comprehensively nutrient-induced impacts in LCA.

Offshore Wind Energy and Marine Biodiversity in the North Sea: Life Cycle Impact Assessment for Benthic Communities.

Large-scale offshore wind energy developments represent a major player in the energy transition but are likely to have (negative or positive) impacts on marine biodiversity. Wind turbine foundations and sour protection often replace soft sediment with hard substrates, creating artificial reefs for sessile dwellers. Offshore wind farm (OWF) furthermore leads to a decrease in (and even a cessation of) bottom trawling, as this activity is prohibited in many OWFs. The long-term cumulative impacts of these changes on marine biodiversity remain largely unknown. This study integrates such impacts into characterization factors for life cycle assessment based on the North Sea and illustrates its application. Our results suggest that there are no net adverse impacts during OWF operation on benthic communities inhabiting the original sand bottom within OWFs. Artificial reefs could lead to a doubling of species richness and a two-order-of-magnitude increase of species abundance. Seabed occupation will also incur in minor biodiversity losses in the soft sediment. Our results were not conclusive concerning the trawling avoidance benefits. The developed characterization factors quantifying biodiversity-related impacts from OWF operation provide a stepping stone toward a better representation of biodiversity in life cycle assessment.

Biodiversity Impact Assessment Considering Land Use Intensities and Fragmentation.

Land use is a major threat to terrestrial biodiversity. Life cycle assessment is a tool that can assess such threats and thereby support environmental decision-making. Within the Global Guidance for Life Cycle Impact Assessment (GLAM) project, the Life Cycle Initiative hosted by UN Environment aims to create a life cycle impact assessment method across multiple impact categories, including land use impacts on ecosystem quality represented by regional and global species richness. A working group of the GLAM project focused on such land use impacts and developed new characterization factors to combine the strengths of two separate recent advancements in the field: the consideration of land use intensities and land fragmentation. The data sets to parametrize the underlying model are also updated from previous models. The new characterization factors cover five species groups (plants, amphibians, birds, mammals, and reptiles) and five broad land use types (cropland, pasture, plantations, managed forests, and urban land) at three intensity levels (minimal, light, and intense). They are available at the level of terrestrial ecoregions and countries. This paper documents the development of the characterization factors, provides practical guidance for their use, and critically assesses the strengths and remaining shortcomings.

Characterization Factors to Assess Land Use Impacts on Pollinator Abundance in Life Cycle Assessment.

While wild pollinators play a key role in global food production, their assessment is currently missing from the most commonly used environmental impact assessment method, Life Cycle Assessment (LCA). This is mainly due to constraints in data availability and compatibility with LCA inventories. To target this gap, relative pollinator abundance estimates were obtained with the use of a Delphi assessment, during which 25 experts, covering 16 nationalities and 45 countries of expertise, provided scores for low, typical, and high expected abundance associated with 24 land use categories. Based on these estimates, this study presents a set of globally generic characterization factors (CFs) that allows translating land use into relative impacts to wild pollinator abundance. The associated uncertainty of the CFs is presented along with an illustrative case to demonstrate the applicability in LCA studies. The CFs based on estimates that reached consensus during the Delphi assessment are recommended as readily applicable and allow key differences among land use types to be distinguished. The resulting CFs are proposed as the first step for incorporating pollinator impacts in LCA studies, exemplifying the use of expert elicitation methods as a useful tool to fill data gaps that constrain the characterization of key environmental impacts.

Replicability, Robustness, and Reproducibility in Psychological Science.

Replication-an important, uncommon, and misunderstood practice-is gaining appreciation in psychology. Achieving replicability is important for making research progress. If findings are not replicable, then prediction and theory development are stifled. If findings are replicable, then interrogation of their meaning and validity can advance knowledge. Assessing replicability can be productive for generating and testing hypotheses by actively confronting current understandings to identify weaknesses and spur innovation. For psychology, the 2010s might be characterized as a decade of active confrontation. Systematic and multi-site replication projects assessed current understandings and observed surprising failures to replicate many published findings. Replication efforts highlighted sociocultural challenges such as disincentives to conduct replications and a tendency to frame replication as a personal attack rather than a healthy scientific practice, and they raised awareness that replication contributes to self-correction. Nevertheless, innovation in doing and understanding replication and its cousins, reproducibility and robustness, has positioned psychology to improve research practices and accelerate progress.

Biodiversity Loss from Freshwater Use for China's Electricity Generation.

Electricity generation has two major, under-investigated impacts on freshwater biodiversity due to its water use: the consumption of freshwater and thermal emissions to freshwater. Here, we analyze the spatiotemporal freshwater biodiversity impacts of China's electric power system and the driving factors for these impacts. We show that between 2008 and 2017, the freshwater consumption of electricity generation peaked in 2013 (13.6 Gm3). Meanwhile, the freshwater consumption factor of China's electricity generation decreased from 3.2 to 2.0 L/kWh. However, due to increasing thermal emissions, the biodiversity loss via freshwater use increased from 1.1 × 108 in 2008 to 1.6 × 108 PDF m3 year. The overall biodiversity loss per unit of electricity generation decreased from 3.2 × 10-5 to 2.5 × 10-5 PDF m3 year/kWh. Biodiversity loss from thermal pollution is 60% higher than that driven by water consumption. Electricity transmission results in the shifting of biodiversity impacts across regions. The results show that 15% of total biodiversity loss was embedded in transmission networks. In terms of electrical power system drivers of biodiversity loss, the total generation was the main driving factor of the increase in loss (rather than shifts in generation type, for example). Our results indicate the necessity of assessing the biodiversity impacts of electricity generation and incorporating them into energy system planning.

Global Human Consumption Threatens Key Biodiversity Areas.

Key biodiversity areas (KBAs) are critical regions for preserving global biodiversity. KBAs are identified by their importance to biodiversity rather than their legal status. As such, KBAs are often under pressure from human activities. KBAs can encompass many different land-use types (e.g., cropland, pastures) and land-use intensities. Here, we combine a global economic model with spatial mapping to estimate the biodiversity impacts of human land use in KBAs. We find that global human land use within KBAs causes disproportionate biodiversity losses. While land use within KBAs accounts for only 7% of total land use, it causes 16% of the potential global plant loss and 12% of the potential global vertebrate loss. The consumption of animal products accounts for more than half of biodiversity loss within KBAs, with housing the second largest at around 10%. Bovine meat is the largest single contributor to this loss, at around 31% of total biodiversity loss. In terms of land use, lightly grazed pasture contributes the most, accounting for around half of all potential species loss. This loss is concentrated mainly in middle- and low-income regions with rich biodiversity. International trade is an important driver of loss, accounting for 22-29% of total potential plant and vertebrate loss. Our comprehensive global, trade-linked analysis provides insights into maintaining the integrity of KBAs and global biodiversity.

The Role of Different Types of Actors In The Future of Sustainable Agriculture In a Dutch Peri-urban Area.

Peri-urban areas support a broad range of multifunctional demands for public goods. In northwest Europe, peri-urban areas tend to overlap with intensive agricultural land, resulting in conflicts between agricultural use and the public good demands of residents. Sustainable intensification (SI) of agriculture might help reconcile agricultural and well-being goals, but it is unclear how the mix of actors in a peri-urban setting can trigger or restrain SI. In a Dutch case study, we explored how SI of agriculture can contribute to making peri-urban areas more sustainable, and which actors are key enabling factors for implementing SI. We used interviews, surveys, workshops, and empirical analysis to obtain insight into the stakeholder's vision of a sustainable future for the case study area, the farming system and actor network. We integrated these insights in a Bayesian Belief Network, where we linked the actor network to implementation of three SI measures (farm-level efficiency measures, small landscape elements, and direct sales), and used sensitivity analysis to model effects of support for implementation by different groups of actors. The case study has a dense stakeholder network, where, dependent on the SI measure, farmers are triggered by all actors to implement SI, or have a stronger role in uptake themselves. The sensitivity analysis suggested that the future preferred by the stakeholders requires broad support of all actors involved, with local actors without a formal role being essential for uptake. Overall, trade-offs among public goods are almost inevitable when taking up SI measures.

Gain-loss framing and patients' decisions: a linguistic examination of information framing in physician-patient conversations.

When discussing risks and benefits with cancer patients, physicians could focus on losses such as mortality rates and cancer recurrence or, alternatively, gains such as survival rates and curing cancer. Previous research has shown that the way health information is framed influences individuals' preferences and choices. We operationalized gain-loss framing as physicians' choice of words related to gains (cancer survival), or losses (cancer mortality). In an exploratory analysis, we investigated (a) whether physicians used gain or loss words as a function of their recommendation, (b) whether physicians' choice of words was associated with patients' treatment choices. We analyzed transcribed consultations with male patients who had intermediate-risk prostate cancer. Using an iterative process of gathering and evaluating words, we created gain- and loss-dictionaries. The loss-dictionary included words related to cancer death and cancer progression. The gain-dictionary included words related to survival and cure. Using Linguistic Inquiry and Word Count software, we calculated the number of words related to gains and losses in each transcript. We found that physicians who recommended immediate cancer treatment for prostate cancer (vs. active surveillance) used slightly fewer words related to losses and significantly fewer words related specifically to death from cancer. Further analysis showed that loss words were associated with the patient's choice of immediate cancer treatment. A novel method of automated text analysis showed that physicians' use of loss words was correlated with physicians' recommendations for cancer treatment versus active surveillance. Additionally, loss words in consultations were associated with patients' choice of cancer treatment.

Adherence of Internet-Based Cancer Risk Assessment Tools to Best Practices in Risk Communication: Content Analysis.

BACKGROUND: Internet-based risk assessment tools offer a potential avenue for people to learn about their cancer risk and adopt risk-reducing behaviors. However, little is known about whether internet-based risk assessment tools adhere to scientific evidence for what constitutes good risk communication strategies. Furthermore, their quality may vary from a user experience perspective. OBJECTIVE: This study aims to understand the extent to which current best practices in risk communication have been applied to internet-based cancer risk assessment tools. METHODS: We conducted a search on August 6, 2019, to identify websites that provided personalized assessments of cancer risk or the likelihood of developing cancer. Each website (N=39) was coded according to standardized criteria and focused on 3 categories: general website characteristics, accessibility and credibility, and risk communication formats and strategies. RESULTS: Some best practices in risk communication were more frequently adhered to by websites. First, we found that undefined medical terminology was widespread, impeding comprehension for those with limited health literacy. For example, 90% (35/39) of websites included technical language that the general public may find difficult to understand, yet only 23% (9/39) indicated that medical professionals were their intended audience. Second, websites lacked sufficient information for users to determine the credibility of the risk assessment, making it difficult to judge the scientific validity of their risk. For instance, only 59% (23/39) of websites referenced the scientific model used to calculate the user's cancer risk. Third, practices known to foster unbiased risk comprehension, such as adding qualitative labels to quantitative numbers, were used by only 15% (6/39) of websites. CONCLUSIONS: Limitations in risk communication strategies used by internet-based cancer risk assessment tools were common. By observing best practices, these tools could limit confusion and cultivate understanding to help people make informed decisions and motivate people to engage in risk-reducing behaviors.

Characterizing Land Use Impacts on Functional Plant Diversity for Life Cycle Assessments.

Decision support tools such as life cycle assessment (LCA) increasingly aim to account for impacts on biodiversity. While taxonomic measures like species richness have been implemented, they do not fully grasp the impacts on ecosystem functioning. Functional diversity, derived from the species' traits, is more representative of ecosystem processes. This study provides a framework for developing characterization factors for functional diversity as affected by land use. It exploits the large databases on plant traits and species composition that have recently become available and allow bringing biodiversity impact assessment to the next level. Three functional diversity indices therein describe different aspects of functional diversity, namely richness, evenness, and divergence. Applying our framework to Germany as a proof of concept, we show significant losses in functional plant diversity when converting natural forests to agricultural land use. Consistently across different forests and agricultural systems, functional richness decreases steeply and functional divergence moderately upon occupation. In contrast, functional evenness exhibits opposite trends. The resulting characterization factors are likely to be representative of temperate regions. The framework is flexible and applicable to larger scales and other impact categories. As such, it facilitates harmonizing biodiversity impact assessments and better represents ecosystem functioning by incorporating functional diversity.

Cross-Sectional Psychological and Demographic Associations of Zika Knowledge and Conspiracy Beliefs Before and After Local Zika Transmission.

Perceptions of infectious diseases are important predictors of whether people engage in disease-specific preventive behaviors. Having accurate beliefs about a given infectious disease has been found to be a necessary condition for engaging in appropriate preventive behaviors during an infectious disease outbreak, while endorsing conspiracy beliefs can inhibit preventive behaviors. Despite their seemingly opposing natures, knowledge and conspiracy beliefs may share some of the same psychological motivations, including a relationship with perceived risk and self-efficacy (i.e., control). The 2015-2016 Zika epidemic provided an opportunity to explore this. The current research provides some exploratory tests of this topic derived from two studies with similar measures, but different primary outcomes: one study that included knowledge of Zika as a key outcome and one that included conspiracy beliefs about Zika as a key outcome. Both studies involved cross-sectional data collections that occurred during the same two periods of the Zika outbreak: one data collection prior to the first cases of local Zika transmission in the United States (March-May 2016) and one just after the first cases of local transmission (July-August). Using ordinal logistic and linear regression analyses of data from two time points in both studies, the authors show an increase in relationship strength between greater perceived risk and self-efficacy with both increased knowledge and increased conspiracy beliefs after local Zika transmission in the United States. Although these results highlight that similar psychological motivations may lead to Zika knowledge and conspiracy beliefs, there was a divergence in demographic association.

On the Usefulness of Narratives: An Interdisciplinary Review and Theoretical Model.

Background: How can we use stories from other people to promote better health experiences, improve judgments about health, and increase the quality of medical decisions without introducing bias, systematically persuading the listeners to change their attitudes, or altering behaviors in nonoptimal ways? More practically, should narratives be used in health education, promotion, or behavior change interventions? Method: In this article, we address these questions by conducting a narrative review of a diverse body of literature on narratives from several disciplines to gain a better understanding about what narratives do, including their role in communication, engagement, recall, persuasion, and health behavior change. We also review broad theories about information processing and persuasion from psychology and more specific models about narrative messaging found in the health communication and marketing literatures to provide insight into the processes by which narratives have their effect on health behavior. Results: To address major gaps in our theoretical understanding about how narratives work and what effects they will have on health behavior, we propose the Narrative Immersion Model, whose goal is to identify the parameters that predict the specific impact of a particular narrative (e.g. persuade, inform, comfort, etc.) based on the type of narrative message (e.g. process, experience, or outcome narrative). Further, the Narrative Immersion Model describes the magnitude of the effect as increasing through successive layers of engagement with the narrative: interest, identification, and immersion. Finally, the Narrative Immersion Model identifies characteristics of the narrative intervention that encourage greater immersion within a given narrative. Conclusions: We believe there are important communication gaps in areas areas of behavioral medicine that could be addressed with narratives; however, more work is needed in order to employ narrative messaging systematically. The Narrative Immersion Model advances our theoretical understanding about narrative processing and its subsequent effects on knowledge, attitudes, and behavior.

A Randomized Study of Patient Risk Perception for Incidental Renal Findings on Diagnostic Imaging Tests.

OBJECTIVE: The purpose of this study is to assess differences in patient distress, risk perception, and treatment preferences for incidental renal findings with descriptive versus combined descriptive and numeric graphical risk information. MATERIALS AND METHODS: A randomized survey study was conducted for adult patients about to undergo outpatient imaging studies at a large urban academic institution. Two survey arms contained either descriptive or a combination of descriptive and numeric graphical risk information about three hypothetical incidental renal findings at CT: 2-cm (low risk) and 5-cm (high risk) renal tumors and a 2-cm (low risk) renal artery aneurysm. The main outcomes were patient distress, perceived risk (qualitative and quantitative), treatment preference, and valuation of lesion discovery. RESULTS: Of 374 patients, 299 participated (79.9% response rate). With inclusion of numeric and graphical, rather than only descriptive, risk information about disease progression for a 2-cm renal tumor, patients reported less worry (3.56 vs 4.12 on a 5-point scale; p < 0.001) and favored surgical consultation less often (29.3% vs 46.9%; p = 0.003). The proportion choosing surgical consultation for the 2-cm renal tumor decreased to a similar level as for the renal artery aneurysm with numeric risk information (29.3% [95% CI, 21.7-36.8%] and 27.9% [95% CI, 20.5-35.3%], respectively). Patients overestimated the absolute risk of adverse events regardless of risk information type, but significantly more so when given descriptive information only, and valued the discovery of lesions regardless of risk information type (range, 4.41-4.81 on a 5-point scale). CONCLUSION: Numeric graphical risk communication for patients about incidental renal lesions may facilitate accurate risk comprehension and support patients in informed decision making.