Gender differences in symptom misattribution for coronary heart disease symptoms and intentions to seek health care.

Women are more likely to delay seeking care for coronary heart disease (CHD) symptoms than men. We tested whether this was because they are more likely to misattribute CHD symptoms. Data were collected in December 2016. Participants were 714 Amazon's Mechanical Turk (crowdsourcing marketplace) workers with US Internet Protocol (IP) addresses; 52% female (ages 35-77 years) made judgments about patients of their same gender described in vignettes. We used adjusted multivariable logistic, ordinal, and linear regression to test our hypotheses. Women had a higher odds of misattributing the symptoms of the target in the vignettes to non-cardiac causes than men (adjusted odds ratio [AOR] = 2.08, p < .001), despite having higher mean knowledge scores about CHD (4.49 vs. 4.03, p < .001) and rating their CHD risk as higher (25% more likely to get CHD vs. 19%, p = .025) than men. Women were also less likely than men to intend to seek care at an emergency department (b = -0.33, p = .024), and if they did intend to seek care, they were more likely to intend to wait to seek care (AOR = 2.37, p = .003). Symptom misattribution may partially account for women's lower likelihood of intending to seek care from an emergency department, which would be especially critical in emergency situations.

Lay beliefs about risk: relation to risk behaviors and to probabilistic risk perceptions.

Lay illness risk beliefs are commonly held philosophies about how risk works. These include beliefs that one's personal illness risk is unknowable and beliefs that thinking about one's risk can actually increase that risk. Beliefs about risk may impact risk behaviors and thereby subsequent health status. However, limited research examines the relation between lay risk beliefs and health behavior. This paper explores this possible relation. A nationally representative sample of adults (N = 1005) recruited from an internet panel were surveyed about lay risk beliefs and risk perceptions regarding diabetes and colorectal cancer, psychosocial factors (i.e., health literacy, need for cognition, locus of control), demographics, and current health behaviors (i.e., cigarette smoking, red meat intake, physical activity). In separate sets of regressions controlling for either demographics, psychosocial factors, or risk perceptions, lay risk beliefs remained significantly related to health behaviors. It may be important to consider how to address lay risk beliefs in intervention content and targeting in order to increase adaptive health behaviors and thereby prevent chronic disease.

Worse Urinary, Sexual and Bowel Function Cause Emotional Distress and Vice Versa in Men Treated for Prostate Cancer.

PURPOSE: Definitive therapy for prostate cancer (eg surgery or radiotherapy) often has side effects, including urinary, sexual and bowel dysfunction. The purpose of this study was to test whether urinary, sexual and bowel functions contribute to emotional distress during the first 2 years after treatment and whether distress may in turn decrease function. MATERIALS AND METHODS: The study participants were 1,148 men diagnosed with clinically localized disease who were treated with surgery (63%) or radiotherapy (37%). Urinary, sexual and bowel functions were assessed with EPIC (Expanded Prostate Cancer Index Composite). Emotional distress was assessed with the NCCN® (National Comprehensive Cancer Network®) Distress Thermometer. Assessment time points were before treatment, and 6 weeks, and 6, 12, 18 and 24 months after treatment. We used time lagged multilevel models to test whether physical function predicted emotional distress and vice versa. RESULTS: Men with worse urinary, bowel and sexual functions reported more emotional distress than others at subsequent time points. The relationships were bidirectional. Men who reported worse distress also reported worse urinary, bowel and sexual functions at subsequent time points. CONCLUSIONS: Clinicians supported by practice and payer policies should screen for and facilitate the treatment of side effects and heightened emotional distress to improve well-being in survivors of prostate cancer. These interventions may be cost-effective, given that emotional distress can negatively impact functioning across life domains.

Examining the Interrelations Among Objective and Subjective Health Literacy and Numeracy and Their Associations with Health Knowledge.

BACKGROUND: Health literacy and numeracy influence many health-related behaviors and outcomes. Health literacy and numeracy have been assessed objectively and subjectively, but interrelationships among the measures and the consistency of their association with health knowledge have not been examined. OBJECTIVE: To increase understanding of the structure and interrelations among objective and subjective health literacy and numeracy and how these constructs relate to knowledge of risk factors of two major diseases. DESIGN: Secondary analysis of cross-sectional survey data, weighted to be representative of the general US population of non-institutionalized adults. PARTICIPANTS: Participants (N = 1005, 55.2% response rate) were recruited from GfK KnowledgePanel. The unweighted sample included 52% women, 26% racial/ethnic minorities, and 37% with no college experience. MAIN MEASURES: Objective health literacy, subjective health literacy, objective numeracy, subjective numeracy. Objective and perceived knowledge of diabetes and colon cancer risk factors were also assessed. KEY RESULTS: Confirmatory factor analyses indicated that a model with correlated (r = 0.16-0.56) but separate factors for each of the four literacy/numeracy constructs best fit the data (RMSEA = 0.055 (95% CI 0.049-0.061), CFI = 0.94). Consistency between measures in classifying people as having adequate or limited health literacy or numeracy was 60.9-77.1%, depending on the combination of measures. All four literacy/numeracy constructs were independently associated with objective diabetes knowledge and objective colon cancer knowledge (all ps < .04). Subjective (but not objective) literacy and numeracy measures were associated with diabetes perceived knowledge (all ps < .02). No literacy/numeracy measures were associated with perceived colon cancer knowledge. CONCLUSIONS: We identified objective and subjective health literacy and numeracy as four distinct but related concepts. We also found that each construct accounts for unique variance in objective (but not subjective) disease knowledge. Until research uncovers what psychological processes drive subjective measures (e.g., motivation, self-efficacy), research investigating the relationship between health literacy and health outcomes should consider assessing all four measures.

Health Literacy and Use and Trust in Health Information.

There is a need to investigate which health information sources are used and trusted by people with limited health literacy to help identify strategies for addressing knowledge gaps that can contribute to preventable illness. We examined whether health literacy was associated with people's use of and trust in a range of potential health information sources. Six hundred participants from a GfK Internet survey panel completed an online survey. We assessed health literacy using the Newest Vital Sign, the sources participants used to get health information, and the extent to which participants trusted health information from these sources. We performed multivariable regressions, controlling for demographic characteristics. Lower health literacy was associated with lower odds of using medical websites for health information and with higher odds of using television, social media, and blogs or celebrity webpages. People with lower health literacy were less likely to trust health information from specialist doctors and dentists, but more likely to trust television, social media, blogs/celebrity webpages, friends, and pharmaceutical companies. People with limited health literacy had higher rates of using and trusting sources such as social media and blogs, which might contain lower quality health information compared to information from healthcare professionals. Thus, it might be necessary to enhance the public's ability to evaluate the quality of health information sources. The results of this study could be used to improve the reach of high-quality health information among people with limited health literacy and thereby increase the effectiveness of health communication programs and campaigns.

Emotional Distress Increases the Likelihood of Undergoing Surgery among Men with Localized Prostate Cancer.

PURPOSE: We determined whether among men with clinically localized prostate cancer, particularly men with low risk disease, greater emotional distress increases the likelihood of undergoing surgery vs radiation or active surveillance. MATERIALS AND METHODS: Participants were 1,531 patients recruited from 2 academic and 3 community facilities (nonHispanic white 83%, nonHispanic black 11% and Hispanic 6%; low risk 36%, intermediate risk 49% and high risk 15%; choice of active surveillance 24%, radiation 27% and surgery 48%). Emotional distress was assessed shortly after diagnosis and after men made a treatment decision with the Distress Thermometer. We used multinomial logistic regression with robust standard errors to test if emotional distress at either point predicted treatment choice in the sample as a whole and after stratifying by D'Amico risk score. RESULTS: In the sample as a whole the participants who were more emotionally distressed at diagnosis were more likely to choose surgery over active surveillance (RRR 1.07; 95% CI 1.01, 1.14; p=0.02). Men who were more distressed close to the time they made a treatment choice were more likely to have chosen surgery over active surveillance (RRR 1.16; 95% CI 1.09, 1.24; p <0.001) or surgery over radiation (RRR 1.12; 95% CI 1.05, 1.19; p=0.001). This pattern was also found in men with low risk disease. CONCLUSIONS: Emotional distress may motivate men with low risk prostate cancer to choose more aggressive treatment. Addressing emotional distress before and during treatment decision making may reduce a barrier to the uptake of active surveillance.

Causes and consequences of uncertainty about illness risk perceptions.

We identified determinants of uncertainty about perceived risk judgments and demonstrated that uncertainty is associated with lower engagement in risk-reducing behavior. We found that people likely have metacognitive awareness of when their judgments are overly pessimistic, resulting in uncertainty and that question context (more constraints) and people's time orientation (future orientation) are associated with lower uncertainty. Uncertainty about conditioned risk judgments was associated with lower engagement in exercising and eating a healthy diet in order to reduce risk for heart disease. As a potential determinant of behavior, uncertainty about risk judgments merits further consideration for integration into theories of health behavior.

Gender bias in clinical decision making emerges when patients with coronary heart disease symptoms also have psychological symptoms.

BACKGROUND: Delayed treatment may contribute to women's relatively higher morbidity and mortality from coronary heart disease (CHD). We tested whether disparities in treatment may be due to bias in diagnosis and treatment recommendations for women with psychological symptoms. METHODS: Fourth year medical students (N = 225) from 13 U.S. medical schools were randomly assigned to make clinical decisions (CHD risk judgments, diagnosis, treatment recommendations) about one of four experimental vignette patients (male or female; with symptoms of depression and anxiety or without). Vignettes were presented as text via an online survey platform. RESULTS: The female patient with psychological symptoms was perceived to be at lowest risk for CHD. Perceptions of risk partly mediated lower likelihood of recommending the female patient with psychological symptoms be seen in an emergency department, take medication, or receive nutrition or exercise advice relative to the male patient with psychological symptoms. CONCLUSIONS: There was a gender bias in CHD clinical decision-making when patients had concurrent psychological symptoms.

Racial or Ethnic and Socioeconomic Disparities in Prostate Cancer Survivors' Prostate-specific Quality of Life.

OBJECTIVE: To conduct a prospective study to examine whether there are pretreatment and post-treatment disparities in urinary, sexual, and bowel quality of life (QOL) by race or ethnicity, education, or income in men with clinically localized prostate cancer (PCa.) METHODS: Participants (N = 1508; 81% white; 12% black; 7% Hispanic; 50% surgery; 27% radiotherapy; 23% active surveillance) completed the Expanded Prostate Cancer Index Composite measure of PCa-specific QOL prior to treatment, 6 weeks, 6, 12, 18, and 24 months after treatment. We analyzed pretreatment differences in QOL with multivariable linear regression and post-treatment differences with generalized estimating equation models. RESULTS: Blacks and Hispanics (compared with whites) and men with lower income had worse pretreatment urinary function; poorer and less educated men had worse pretreatment sexual function (P < .05). In adjusted models, among men treated surgically, blacks and Hispanics had worse bowel function compared with whites, and men with lower income experienced more sexual bother and slower recovery in urinary function. Not all racial or ethnic differences favored whites; blacks had higher sexual function than whites prior to surgery and improved faster after surgery. Blacks receiving radiotherapy had lower post-treatment bowel bother than whites (P < .05). CONCLUSION: Controlling for baseline QOL, there were some post-treatment disparities in urinary and sexual QOL that suggest the need to investigate whether treatment quality and access to follow-up care is equitable. However, survivorship disparities may, to a greater extent, reflect disadvantages in baseline health that exacerbate QOL issues after treatment.

Low Health Literacy and Health Information Avoidance but Not Satisficing Help Explain "Don't Know" Responses to Questions Assessing Perceived Risk.

BACKGROUND: People who say they don't know (DK) their disease risk are less likely to engage in protective behavior. PURPOSE: This study examined possible mechanisms underlying not knowing one's risk for common diseases. METHODS: Participants were a nationally representative sample of 1005 members of a standing probability-based survey panel who answered questions about their comparative and absolute perceived risk for diabetes and colon cancer, health literacy, risk factor knowledge and health information avoidance, and beliefs about illness unpredictability. Survey satisficing was a composite assessment of not following survey instructions, nondifferentiation of responses, haphazard responding, and speeding. The primary outcomes were whether a person selected DK when asked absolute and comparative risk perception questions about diabetes or colon cancer. Base structural equation modeling path models with pathways from information avoidance and health literacy/knowledge to DK responding for each DK outcome were compared to models that also included pathways from satisficing or unpredictability beliefs. RESULTS: Base models contained significant indirect effects of health literacy (odds ratios [ORs] = 0.94 to 0.97, all P < 0.02) and avoidance (ORs = 1.05 to 1.15, all P < 0.01) on DK responding through risk factor knowledge and a direct effect of avoidance (ORs = 1.21 to 1.28, all P < 0.02). Adding the direct effect for satisficing to models resulted in poor fit (for all outcomes, residual mean square error estimates >0.17, all weighted root mean square residuals >3.2, all Comparative Fit Index <0.47, all Tucker-Lewis Index <0.49), indicating that satisficing was not associated with DK responding. Unpredictability was associated with not knowing one's diabetes risk (OR = 1.01, P < 0.01). LIMITATIONS: The data were cross-sectional; therefore, directionality of the pathways cannot be assumed. CONCLUSIONS: DK responders may need more health information, but it needs to be delivered differently. Interventions might include targeting messages for lower health literacy audiences and disrupting defensive avoidance of threatening health information.

Experiences of Uncertainty in Men With an Elevated PSA.

A significant proportion of men, ages 50 to 70 years, have, and continue to receive prostate specific antigen (PSA) tests to screen for prostate cancer (PCa). Approximately 70% of men with an elevated PSA level will not subsequently be diagnosed with PCa. Semistructured interviews were conducted with 13 men with an elevated PSA level who had not been diagnosed with PCa. Uncertainty was prominent in men's reactions to the PSA results, stemming from unanswered questions about the PSA test, PCa risk, and confusion about their management plan. Uncertainty was exacerbated or reduced depending on whether health care providers communicated in lay and empathetic ways, and provided opportunities for question asking. To manage uncertainty, men engaged in information and health care seeking, self-monitoring, and defensive cognition. Results inform strategies for meeting informational needs of men with an elevated PSA and confirm the primary importance of physician communication behavior for open information exchange and uncertainty reduction.

What Is a "Good" Treatment Decision? Decisional Control, Knowledge, Treatment Decision Making, and Quality of Life in Men with Clinically Localized Prostate Cancer.

OBJECTIVE: We explored whether active patient involvement in decision making and greater patient knowledge are associated with better treatment decision-making experiences and better quality of life (QOL) among men with clinically localized prostate cancer. Localized prostate cancer treatment decision making is an advantageous model for studying patient treatment decision-making dynamics because there are multiple treatment options and a lack of empirical evidence to recommend one over the other; consequently, it is recommended that patients be fully involved in making the decision. METHODS: Men with newly diagnosed clinically localized prostate cancer (N = 1529) completed measures of decisional control, prostate cancer knowledge, and decision-making experiences (decisional conflict and decision-making satisfaction and difficulty) shortly after they made their treatment decision. Prostate cancer-specific QOL was assessed at 6 months after treatment. RESULTS: More active involvement in decision making and greater knowledge were associated with lower decisional conflict and higher decision-making satisfaction but greater decision-making difficulty. An interaction between decisional control and knowledge revealed that greater knowledge was only associated with greater difficulty for men actively involved in making the decision (67% of sample). Greater knowledge, but not decisional control, predicted better QOL 6 months after treatment. CONCLUSIONS: Although men who are actively involved in decision making and more knowledgeable may make more informed decisions, they could benefit from decisional support (e.g., decision-making aids, emotional support from providers, strategies for reducing emotional distress) to make the process easier. Men who were more knowledgeable about prostate cancer and treatment side effects at the time that they made their treatment decision may have appraised their QOL as higher because they had realistic expectations about side effects.