Catharine Wang

Reducing the Influence of Anecdotal Reasoning on People’s Health Care Decisions: Is a Picture Worth a Thousand Statistics?:

Background . People’s treatment decisions are often influenced by anecdotal rather than statistical information. This can lead to patients making decisions based on others’ experiences rather than on evidence-based medicine. Objective . To test whether the use of a quiz or pictograph decreases people’s reliance on anecdotal information. Design . Two cross-sectional survey studies using hypothetical scenarios. Participants read a scenario describing angina and indicated a preference for either bypass surgery or balloon angioplasty. The cure rate of both treatments was presented using prose, a pictograph, a quiz, or a pictograph and quiz combination. Participants read anecdotes from hypothetical patients who described the outcome of their treatment; the number of successful anecdotes was either representative or unrepresentative of the cure rates. Setting and Participants . Prospective jurors at the Philadelphia County Courthouse and travelers at the Detroit-Wayne County Metropolitan Airport. Measurements . Proportion of respondents preferring bypass over balloon angioplasty. Results . In study 1, when statistical information was presented in prose, treatment choices were influenced by anecdotes, with 41% of participants choosing bypass when the anecdotes were representative and only 20% choosing it when the anecdotes were unrepresentative (x2 = 14.40, P < 0.001). When statistics were reinforced with the pictograph and quiz, anecdotes had no significant influence on treatment decisions (38% choosing bypass when anecdotes were representative v. 44% when unrepresentative, x2 = 1.08, P > 0.20). In study 2, the tradeoff quiz did not reduce the impact of the anecdotes (27% v. 28% choosing bypass after receiving or not receiving the quiz, x2 < 1, P > 0.20). However, the pictograph significantly reduced the impact of anecdotes, with 27% choosing bypass after receiving no pictograph and 40% choosing bypass after receiving a pictograph (x2 = 6.44, P < 0.001). Conclusions . Presenting statistical information using a pictograph can reduce the undue influence of anecdotal reasoning on treatment choices.

Effect of Preventive Messages Tailored to Family History on Health Behaviors: The Family Healthware Impact Trial

PURPOSE We wanted to determine the impact of automated family history assessment and tailored messages for coronary heart disease, stroke, diabetes, colorectal, breast, and ovarian cancer on preventive behaviors compared with a standard preventive message. METHODS The study was a cluster-randomized clinical trial that included 41 primary care practices, the majority in the Midwest, using Family Healthware, a self-administered, Web-based tool that assesses familial risk for the diseases and provides personalized risk-tailored messages. Patients in the control group received an age- and sex-specific health message related to lifestyle and screening. Smoking cessation, fruit and vegetable intake, physical activity, aspirin use, blood pressure, and cholesterol and blood glucose screening were assessed at baseline and 6 months after the intervention. RESULTS Of 4,248 participants, 3,344 (78%) completed the study. Participants were white (91%), female (70%), and insured (97%), and had a mean age of 50.6 years (range 35–65 years). Intervention participants were more likely to increase daily fruit and vegetable consumption from 5 or fewer servings a day to 5 or more servings a day (OR = 1.29; 95% confidence interval [CI], 1.05–1.58) and to increase physical activity (OR = 1.47; 95% CI, 1.08–1.98) to 5 to 6 times a week for 30 minutes or more a week. The absolute differences in proportion were 3% and 4%, respectively. Intervention participants were less likely to move from not having cholesterol screening in the last 5 years to having their cholesterol measured within 5 years (OR = 0.34; 95% CI, 0.17–0.67), with an absolute difference of 15%. CONCLUSIONS Messages tailored to an individual’s familial risk for 6 common diseases modestly increased self-reported physical activity and fruit and vegetable intake but reduced the likelihood of receiving cholesterol screening.

Familial risk for common diseases in primary care: the Family Healthware Impact Trial.

CONTEXT Family history is a risk factor for many common chronic diseases, yet it remains underutilized in primary care practice. BACKGROUND Family Healthware is a self-administered, web-based tool that assesses familial risk for CHD; stroke; diabetes; and colorectal, breast, and ovarian cancer, and provides a personalized prevention plan based on familial risk. The Family Healthware Impact Trial evaluated the tool. DESIGN In this cluster RCT, participants completed baseline and 6-month follow-up surveys. The intervention group used Family Healthware directly after the baseline survey. Controls used the tool after completing the follow-up survey. SETTING/PARTICIPANTS Patients aged 35-65 years with no known diagnosis of these six diseases were enrolled from 41 primary care practices. MAIN OUTCOME MEASURES The prevalence of family-history-based risk for coronary heart disease (CHD); stroke; diabetes; and colorectal, breast, and ovarian cancer was determined in a primary care population. RESULTS From 2005 to 2007, 3786 participants enrolled. Data analysis was undertaken from September 2007 to March 2008. Participants had a mean age of 50.6 years and were primarily white (91%) women (70%). Of the 3585 participants who completed the risk assessment tool, 82% had a strong or moderate familial risk for at least one of the diseases: CHD (strong=33%, moderate=26%); stroke (strong=15%, moderate=34%); diabetes (strong=11%, moderate=26%); colorectal cancer (strong=3%, moderate=11%); breast cancer (strong=10%, moderate=12%); and ovarian cancer (strong=4%, moderate=6%). Women had a significantly (p<0.04) higher familial risk than men for all diseases except colorectal and ovarian cancer. Overweight participants were significantly (p<or=0.02) more likely to have a strong family history for CHD, stroke, and diabetes. Older participants were significantly (p<or=0.02) more likely to report a strong family history for CHD and stroke as well as colorectal and breast cancer. CONCLUSIONS This self-administered, online tool delineated a substantial burden of family-history-based risk for these chronic diseases in an adult, primary care population. TRIAL REGISTRATION NCT00164658.

Comparison of risk perceptions and beliefs across common chronic diseases.

OBJECTIVES Few studies have compared perceptions of risk, worry, severity and control across multiple diseases. This paper examines how these perceptions vary for heart disease, diabetes, stroke, and colon, breast, and ovarian cancers. METHODS The data for this study came from the Family Healthware Impact Trial (FHITr), conducted in the United States from 2005 to 2007. Healthy adults (N=2362) from primary care practices recorded their perceptions at baseline for each disease. Analyses were conducted controlling for study site and personal risk factors. RESULTS Perceived risk was significantly higher for cancers than for other diseases. Men worried most about getting heart disease; women worried most about getting breast cancer, followed by heart disease. Diabetes was perceived to be the least severe condition. Heart disease was perceived to be the most controllable compared to cancers, which were perceived to be the least controllable. Women had higher perceived risk and worry ratings compared to men for several diseases. CONCLUSIONS These data highlight how individuals comparatively view chronic diseases. Addressing prior disease perceptions when communicating multiple disease risks may facilitate an accurate understanding of risk for diseases, and help individuals to effectively identify and engage in relevant behaviors to reduce their risk.

Clinical utility of family history for cancer screening and referral in primary care: A report from the Family Healthware Impact Trial

Purpose: To assess the effectiveness of computerized familial risk assessment and tailored messages for identifying individuals for targeted cancer prevention strategies and motivating behavior change.Methods: We conducted a randomized clinical trial in primary care patients aged 35–65 years using Family Healthware, a self-administered, internet-based tool that collects family history for six common diseases including breast cancer, colon cancer, and ovarian cancer, stratifies risk into three tiers, and provides tailored prevention messages. Cancer screening adherence and consultation were measured at baseline and 6-month follow-up.Results: Of 3283 participants, 34% were at strong or moderate risk of at least one of the cancers. Family Healthware identified additional participants for whom earlier screening (colon cancer, 4.4%; breast cancer, women ages: 35–39 years, 9%) or genetic assessment (colon cancer, 2.5%; breast cancer, 10%; and ovarian cancer, 4%) may be indicated. Fewer than half were already adherent with risk-based screening. Screening adherence improved for all risk categories with no difference between intervention and control groups. Consultation with specialists did not differ between groups.Conclusion: Family Healthware identified patients for intensified cancer prevention. Engagement of clinicians and patients, integration with clinical decision support, and inclusion of nonfamilial risk factors may be necessary to achieve the full potential of computerized risk assessment.

Research and Practice Opportunities at the Intersection of Health Education, Health Behavior, and Genomics:

Researchers and practitioners in health behavior and health education (HBHE) can play a pivotal leadership role in the integration of genomic advances to improve the public’s health. The purpose of this article is to outline research and practice opportunities at the intersection of genomics and HBHE. We begin this article by briefly summarizing the existing evidence in the literature pertaining to the public’s use of genetic services, the effectiveness of genetic counseling, and the impact of genetic testing. Following this, we outline and expand on several areas that we believe are ripe for further exploration, understanding, and public health application:(a) public understanding of genetic information, (b) interventions for health behavior change, and (c) public health assurance and advocacy. This analysis has identified the need to consider potential application efforts in genomics and HBHE from an ecological perspective, with an emphasis on multiple levels of intervention and analysis.

Consumer Perceptions of Interactions With Primary Care Providers After Direct-to-Consumer Personal Genomic Testing

BACKGROUND Direct-to-consumer (DTC) personal genomic testing (PGT) allows individuals to learn about their genetic makeup without going through a physician, but some consumers share their results with their primary care provider (PCP). OBJECTIVE To describe the characteristics and perceptions of DTC PGT consumers who discuss their results with their PCP. DESIGN Longitudinal, prospective cohort study. SETTING Online survey before and 6 months after results. PARTICIPANTS DTC PGT consumers. MEASUREMENTS Consumer satisfaction with the DTC PGT experience; whether and, if so, how many results could be used to improve health; how many results were not understood; and beliefs about the PCPs understanding of genetics. Participants were asked with whom they had discussed their results. Genetic reports were linked to survey responses. RESULTS Among 1026 respondents, 63% planned to share their results with a PCP. At 6-month follow-up, 27% reported having done so, and 8% reported sharing with another health care provider only. Common reasons for not sharing results with a health care provider were that the results were not important enough (40%) or that the participant did not have time to do so (37%). Among participants who discussed results with their PCP, 35% were very satisfied with the encounter, and 18% were not at all satisfied. Frequently identified themes in participant descriptions of these encounters were actionability of the results or use in care (32%), PCP engagement or interest (25%), and lack of PCP engagement or interest (22%). LIMITATION Participants may not be representative of all DTC PGT consumers. CONCLUSION A comprehensive picture of DTC PGT consumers who shared their results with a health care provider is presented. The proportion that shares results is expected to increase with time after testing as consumers find opportunities for discussion at later appointments or if results become relevant as medical needs evolve. PRIMARY FUNDING SOURCE National Institutes of Health.

Celebrity disclosures and information seeking: the case of Angelina Jolie

Purpose:On 14 May 2013, actress Angelina Jolie disclosed that she had a BRCA1 mutation and underwent a prophylactic bilateral mastectomy. This study documents the impact of her disclosure on information-seeking behavior, specifically that regarding online genetics and risk reduction resources available from the National Cancer Institute.Methods:Using Adobe Analytics, daily page views for 11 resources were tracked from 23 April 2013 through 25 June 2013. Usage data were also obtained for four resources over a 2-year period (2012–2013). Source of referral that viewers used to locate a specific resource was also examined.Results:There was a dramatic and immediate increase in traffic to the National Cancer Institute’s online resources. The Preventive Mastectomy fact sheet received 69,225 page views on May 14, representing a 795-fold increase as compared with the previous Tuesday. A fivefold increase in page views was observed for the PDQ Genetics of Breast and Ovarian Cancer summary in the same time frame. A substantial increase, from 0 to 49%, was seen in referrals from news outlets to four resources from 7 May to 14 May.Conclusion:Celebrity disclosures can dramatically influence online information-seeking behaviors. Efforts to capitalize on these disclosures to ensure easy access to accurate information are warranted.Genet Med 17 7, 545–553.

Current Research Promises and Challenges in Behavioral Oncology: Report from the American Society of Preventive Oncology Annual Meeting, 2002

The Behavioral Oncology Interest Group of the American Society of Preventive Oncology held a Roundtable session on March 10, 2002, at the American Society of Preventive Oncology annual meeting in Bethesda, Maryland, to discuss the current state-of-the-science in behavioral approaches to cancer prevention and control and to delineate priorities for additional research. Four key areas were considered: (a) behavioral approaches to cancer genetic risk assessment and testing; (b) biological mechanisms of psychosocial effects on cancer; (c) the role of risk perceptions in cancer screening adherence; and (d) the impact of tailored and targeted interventions on cancer prevention and control research. The evidence reviewed indicates that behavioral approaches have made significant contributions to cancer prevention and control research. At the same time, there is a need to more closely link future investigations to the underlying base of behavioral science principles and paradigms that guide them. To successfully bridge the gap between the availability of effective new cancer prevention and control technologies and the participants they are meant to serve will require the development of more integrative conceptual models, the incorporation of more rigorous methodological designs, and more precise identification of the individual and group characteristics of the groups under study.

Literacy Assessment of Family Health History Tools for Public Health Prevention

Objectives: This study aimed to systematically identify and evaluate the readability and document complexity of currently available family history tools for the general public. Methods: Three steps were undertaken to identify family history tools for evaluation: (a) Internet searches, (b) expert consultation, and (c) literature searches. Tools identified were assessed for readability using the Simple Measure of Gobbledygook (SMOG) readability formula. The complexity of documents (i.e., forms collecting family history information) was assessed using the PMOSE/IKIRSCH document readability formula. Results: A total of 78 tools were identified, 47 of which met the criteria for inclusion. SMOG reading grade levels for multimedia-based tools ranged from 10.1 to 18.3, with an average score of 13.6. For print-based tools, SMOG ranged from 8.7 to 14.1, with an average score of 12.0. Document complexity ranged from very low complexity (level 1 proficiency) to high complexity (level 4 proficiency). Conclusion: The majority of tools are written at a reading grade level that is beyond the 8th grade average reading level in the United States. The lack of family history tools that are easy to read or use may compromise their potential effectiveness in identifying individuals at increased risk for chronic diseases in the general population.