Jessica S. Ancker

Design features of graphs in health risk communication: a systematic review.

This review describes recent experimental and focus group research on graphics as a method of communication about quantitative health risks. Some of the studies discussed in this review assessed effect of graphs on quantitative reasoning, others assessed effects on behavior or behavioral intentions, and still others assessed viewers likes and dislikes. Graphical features that improve the accuracy of quantitative reasoning appear to differ from the features most likely to alter behavior or intentions. For example, graphs that make part-to-whole relationships available visually may help people attend to the relationship between the numerator (the number of people affected by a hazard) and the denominator (the entire population at risk), whereas graphs that show only the numerator appear to inflate the perceived risk and may induce risk-averse behavior. Viewers often preferred design features such as visual simplicity and familiarity that were not associated with accurate quantitative judgments. Communicators should not assume that all graphics are more intuitive than text; many of the studies found that patients interpretations of the graphics were dependent upon expertise or instruction. Potentially useful directions for continuing research include interactions with educational level and numeracy and successful ways to communicate uncertainty about risk.

Rethinking Health Numeracy: A Multidisciplinary Literature Review

The purpose of this review is to organize various published conceptions of health numeracy and to discuss how health numeracy contributes to the productive use of quantitative information for health. We define health numeracy as the individual-level skills needed to understand and use quantitative health information, including basic computation skills, ability to use information in documents and non-text formats such as graphs, and ability to communicate orally. We also identify two other factors affecting whether a consumer can use quantitative health information: design of documents and other information artifacts, and health-care providers communication skills. We draw upon the distributed cognition perspective to argue that essential ingredients for the productive use of quantitative health information include not only health numeracy but also good provider communication skills, as well as documents and devices that are designed to enhance comprehension and cognition.

Redesigning electronic health record systems to support public health

Current electronic health record systems are primarily clinical in focus, designed to provide patient-level data and provider-level decision support. Adapting EHR systems to serve public health needs provides the possibility of enormous advances for public health practice and policy. In this review, we evaluate EHR functionality and map it to the three core functions of public health: assessment, policy development, and assurance. In doing so, we identify and discuss important design, implementation, and methodological issues with current systems. For example, in order to support public healths traditional focus on preventive health and socio-behavioral factors, EHR data models would need to be expanded to incorporate environmental, psychosocial, and other non-medical data elements, and workflow would have to be examined to determine the optimal way of collecting these data. We also argue that redesigning EHR systems to support public health offers benefits not only to the public health system but also to consumers, health-care institutions, and individual providers.

Peer-to-Peer Communication, Cancer Prevention, and the Internet

Online communication among patients and consumers through support groups, discussion boards, and knowledge resources is becoming more common. In this article, the summary of a workgroup discussion, we discuss key methods through which such web-based peer-to-peer communication may affect health promotion and disease prevention behavior (exchanges of information, emotional and instrumental support, and establishment of group norms and models). We also discuss several theoretical models for studying online peer communication, including social theory, health communication models, and health behavior models. Although online peer communication about health and disease is very common, research evaluating effects on health behaviors, mediators, and outcomes is still relatively sparse. We suggest that future research in this field should include formative evaluation and studies of effects on mediators of behavior change, behaviors, and outcomes. It also will be important to examine spontaneously emerging peer communication efforts to see how they can be integrated with theory-based efforts initiated by researchers.

Interactive Graphics for Expressing Health Risks: Development and Qualitative Evaluation

Recent findings suggest that interactive game-like graphics might be useful in communicating probabilities. We developed a prototype for a risk communication module, focusing on eliciting users preferences for different interactive graphics and assessing usability and user interpretations. Feedback from five focus groups was used to design the graphics. The final version displayed a matrix of square buttons; clicking on any button allowed the user to see whether the stick figure underneath was affected by the health outcome. When participants used this interaction to learn about a risk, they expressed more emotional responses, both positive and negative, than when viewing any static graphic or numerical description of a risk. Their responses included relief about small risks and concern about large risks. The groups also commented on static graphics: arranging the figures affected by disease randomly throughout a group of figures made it more difficult to judge the proportion affected but often was described as more realistic. Interactive graphics appear to have potential for expressing risk magnitude as well as the feeling of risk. This affective impact could be useful in increasing perceived threat of high risks, calming fears about low risks, or comparing risks. Quantitative studies are planned to assess the effect on perceived risks and estimated risk magnitudes.

Effects of Game-Like Interactive Graphics on Risk Perceptions and Decisions

Background. Many patients have difficulty interpreting risks described in statistical terms as percentages. Computer game technology offers the opportunity to experience how often an event occurs, rather than simply read about its frequency. Objective. To assess effects of interactive graphics on risk perceptions and decisions. Design. Electronic questionnaire. Participants and setting. Respondents (n = 165) recruited online or at an urban hospital. Intervention. Health risks were illustrated by either static graphics or interactive game-like graphics. The interactive search graphic was a grid of squares, which, when clicked, revealed stick figures underneath. Respondents had to click until they found a figure affected by the disease. Measurements. Risk feelings, risk estimates, intention to take preventive action. Results. Different graphics did not affect mean risk estimates, risk feelings, or intention. Low-numeracy participants reported significantly higher risk feelings than high-numeracy ones except with the interactive search graphic. Unexpectedly, respondents reported stronger intentions to take preventive action when the intention question followed questions about efficacy and disease severity than when it followed perceived risk questions (65% v. 34%; P < 0.001). When respondents reported risk feelings immediately after using the search graphic, the interaction affected perceived risk (the longer the search to find affected stick figures, the higher the risk feeling: ρ = 0.57; P = 0.009). Limitations. The authors used hypothetical decisions. Conclusions. A game-like graphic that allowed consumers to search for stick figures affected by disease had no main effect on risk perception but reduced differences based on numeracy. In one condition, the game-like graphic increased concern about rare risks. Intentions for preventive action were stronger with a question order that focused first on efficacy and disease severity than with one that focused first on perceived risk.

Effect of Arrangement of Stick Figures on Estimates of Proportion in Risk Graphics

Background. Health risks are sometimes illustrated with stick figures, with a certain proportion colored to indicate they are affected by the disease. Perception of these graphics may be affected by whether the affected stick figures are scattered randomly throughout the group or arranged in a block. Objective. To assess the effects of stick-figure arrangement on first impressions of estimates of proportion, under a 10-s deadline. Design. Questionnaire. Participants and Setting. Respondents recruited online (n = 100) or in waiting rooms at an urban hospital (n = 65). Intervention. Participants were asked to estimate the proportion represented in 6 unlabeled graphics, half randomly arranged and half sequentially arranged. Measurements. Estimated proportions. Results. Although average estimates were fairly good, the variability of estimates was high. Overestimates of random graphics were larger than overestimates of sequential ones, except when the proportion was near 50%; variability was also higher with random graphics. Although the average inaccuracy was modest, it was large enough that more than one quarter of respondents confused 2 graphics depicting proportions that differed by 11 percentage points. Low numeracy and educational level were associated with inaccuracy. Limitations. Participants estimated proportions but did not report perceived risk. Conclusions. Randomly arranged arrays of stick figures should be used with care because viewers’ ability to estimate the proportion in these graphics is so poor that moderate differences between risks may not be visible. In addition, random arrangements may create an initial impression that proportions, especially large ones, are larger than they are.

Health care system approaches for cancer patient communication.

Cancer patient communication is always embedded in a complex background of inter-related parts, that is, a system. Cancer patients specifically are exposed to a health care system. Considering this context, this article summarizes the insights from a roundtable discussion involving behavioral medicine and oncology experts convened at the 2008 Annual Meeting of the Society of Behavioral Medicine as part of an annual preconference course entitled “Interpersonal Communication and Cancer Control: Emerging Themes.” In this article we summarize the communication-relevant components of health care systems, focusing on the macro level. Next, we review existing theoretical frameworks for systems-based communication, the unique aspects of “systems thinking,” and the emerging systems tools that can be integrated in cancer communication. Finally, we propose a research agenda for successful system approaches for patient-centered cancer communication.

Towards a Taxonomy of Modes of Moral Decision-Making

Sunstein advocates a more systematic approach to the study of moral decision-making, namely the heuristics-and-biases paradigm. We offer two concerns and suggest that a focus on decision processes can add value. Recent research on decision modes suggest that it is useful to distinguish between the qualitative differences in the ways in which moral decisions can be made when they are not made by reflective, consequentialist reasoning.