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Objective: To predict the association between demographic, psychological, and medication-specific characteristics and the level of concern about stopping medications among older adults., Design: Cross-sectional study in which participants read 6 vignettes in which a primary care provider broached the idea of stopping a medication. Medications differed in risk, regulatory status, and indication for discontinuation., Setting and Participants: National Web-based survey distributed to adults aged 65 years or older by Dynata in January 2019., Outcome Measures: Participants reported their concern about stopping each medication (7-point scale, not at all to extremely), their preferences for more versus less care (Medical Maximizer-Minimizer Scale, MMS), medication attitudes (Beliefs about Medicines Questionnaire, BMQ), demographic characteristics, and health literacy. We used a generalized estimating equations population-averaged model to examine characteristics associated with concern about stopping medications among all the vignettes and linear regressions to explore levels of concern for individual vignettes. Regressions included the MMS, BMQ, health literacy, and demographics., Results: A total of 942 individuals started the survey, and 823 were included in our analysis. Approximately one-half of participants (range: glyburide, 49.5% to aspirin, 56.0%) reported substantial concern (≥ 4 on a 1-7 scale) about stopping each medication. Characteristics that significantly increased concern about stopping medications included female gender, identifying as black or African American, higher MMS score, and higher BMQ specific score. Higher MMS score predicted increased concern about stopping medications for each of the 6 medications., Conclusion: Characteristics of older adults (e.g., medical maximizing-minimizing preferences), as opposed to medication-specific characteristics, predict concern about stopping medications., (Copyright © 2020 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Background: To the authors' knowledge, studies regarding risk perception among survivors of thyroid cancer are scarce., Methods: The authors surveyed patients who were diagnosed with differentiated thyroid cancer from the Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles County (2632 patients; 63% response rate). The analytic cohort was defined by a ≤5% risk of disease recurrence and mortality (1597 patients). Patients estimated their recurrence and mortality risks separately (increments of 10% and endpoints of ≤5% and ≥95%). Both outcomes were dichotomized between reasonably accurate estimates (risk perception of ≤5% or 10%) versus overestimation (risk perception of ≥20%). Multivariable logistic regression was used to identify factors associated with risk overestimation, and the relationships between overestimation and both worry and quality of life were evaluated., Results: In the current study sample, 24.7% of patients overestimated their recurrence risk and 12.5% overestimated their mortality risk. A lower educational level was associated with overestimating disease recurrence (≤high school diploma: odds ratio [OR], 1.64 [95% CI, 1.16-2.31]; and some college: OR, 1.36 [95% CI, 1.02-1.81]) and mortality (≤high school diploma: OR, 1.86 [95% CI, 1.18-2.93]) risk compared with those attaining at least a college degree. Hispanic ethnicity was found to be associated with overestimating recurrence risk (OR, 1.44, 95% CI 1.02-2.03) compared with their white counterparts. Worry about recurrence and death was found to be greater among patients who overestimated versus those who had a reasonably accurate estimate of their risk of disease recurrence and mortality, respectively (P < .001). Patients who overestimated mortality risk also reported a decreased physical quality of life (mean T score, 43.1; 95% CI, 41.6-44.7) compared with the general population., Conclusions: Less educated patients and Hispanic patients were more likely to report inaccurate risk perceptions, which were associated with worry and a decreased quality of life., (© 2019 American Cancer Society.)

Importance: Guidelines for colorectal cancer (CRC) screening recommend an individualized approach in older adults that is informed by consideration of life expectancy and cancer risk. However, little is known about how patients perceive individualized screening recommendations., Objective: To assess veterans' attitudes toward and comfort with cessation of low-value CRC screening (defined as screening in a patient for whom the benefit is expected to be small based on quantitative estimates from hypothetical risk calculators)., Design, Setting, and Participants: This survey study included patients older than 50 years who had undergone prior screening colonoscopy with normal results at the Veterans Affairs Ann Arbor Healthcare System. A total of 1500 surveys were mailed to potential participants from November 1, 2010, to January 1, 2012. Survey data were analyzed from January 1, 2016, to December 31, 2017., Main Outcomes and Measures: Response to the question, "If you personally had serious health problems that were likely to shorten your life and your doctor did not think screening would be of much benefit based on the calculator, how comfortable would you be with not getting any more screening colonoscopies?", Results: Of the 1500 surveys mailed, 85 were returned to sender, leaving 1415 potential respondents; 1054 of these respondents (median age range, 60-69 years; 884 [85.9%] white and 965 [94.2%] male) completed the survey (response rate, 74.5%). A total of 300 (28.7%) were not at all comfortable with cessation of low-value CRC screening, and 509 (49.3%) thought that age should never be used to decide when to stop screening. In addition, 332 (31.7%) thought it was not at all reasonable to use life expectancy calculators, and 255 (24.3%) thought it was not at all reasonable to use CRC risk calculators to guide these decisions. In ordered logistic regression analysis, factors associated with more comfort with screening cessation were (1) higher trust in physician (odds ratio [OR], 1.19; 95% CI, 1.07-1.32), (2) higher perceived health status (OR, 1.41; 95% CI, 1.23-1.61), and (3) higher barriers to screening (OR, 1.20; 95% CI, 1.11-1.30). Factors that were associated with less comfort with screening cessation included (1) greater perceived effectiveness of screening (OR, 0.86; 95% CI, 0.80-0.94) and (2) greater perceived threat of CRC (OR, 0.81; 95% CI, 0.73-0.89)., Conclusions and Relevance: The findings suggest that many veterans have strong preferences against screening cessation even when given detailed information about why the benefit may be low. Efforts to tailor screening recommendations may be met by resistance unless they are accompanied by efforts to address underlying perceptions about the benefit of screening.

Background: China has reduced incidence of vaccine-preventable diseases through its Expanded Program on Immunization (EPI). Vaccines outside of the EPI are not provided for free by the government, however. This study explored how the stated importance of different disease and vaccine-related attributes interacted with beliefs about the immune system of a child to affect Chinese parents' decision to obtain a non-EPI vaccine., Methods: Mothers and fathers of young children at immunization clinics in Shanghai, China, were interviewed about vaccine decision-making and what attributes of a disease were important when making this decision. An inductive thematic analysis explored their beliefs about disease attributes and how these related to vaccination decisions., Results: Among the 34 interviews, severity of the disease-particularly in causing long-term disability-was the most commonly cited factor influencing a parent's decision to get a vaccine for their child. Many parents believed that natural infection was preferable to vaccination, as long as disease was not severe, and many were concerned that imported vaccines were inadequate for Chinese children's physical constitutions. All these beliefs could influence the decision to vaccinate., Conclusions: Many parents do not appear to understand how and why vaccines can support development of a healthy immune system. Because severity emerged as parents' overriding concern when making decisions about vaccines, marketing for a childhood vaccine could focus on the severe condition that a vaccine can protect against.

Background: Chinese parents have access to domestic and foreign vaccines for their children. Their vaccine preferences are unclear, especially given recent pharmaceutical quality scandals and widely held beliefs deriving from Traditional Chinese Medicine (TCM). This study characterized parental beliefs about the safety and effectiveness of Chinese and foreign vaccines., Methods: In May 2014, caregivers of young children at public immunization clinics in Shanghai, China, responded to a survey on vaccine perceptions. The two outcomes (differential belief in the effectiveness and safety of foreign vs domestic vaccines) were separately regressed onto demographic predictors in multinomial logistic regression models., Results: Among 618 caregivers, 56% thought the effectiveness of domestic and foreign vaccines were comparable; 33% thought domestic were more effective and 11% foreign. Two-thirds thought foreign and domestic vaccines had similar safety; 11% thought domestic were safer and 21% thought foreign were safer. Compared to college graduates, those with a high school education or less had greater odds of believing domestic vaccines were more effective, and also had greater odds of believing imported vaccines were safer. Greater trust in TCM was not associated with differential beliefs in the effectiveness or safety of domestic vs foreign vaccines., Conclusions: Although there is no evidence that foreign and domestic vaccines differ in either effectiveness or safety, less educated caregivers in China (but not those with greater trust in TCM) appear to believe such differences exist. Further exploration of the causes of these beliefs may be necessary in order to optimize vaccine communications in China., Competing Interests: The authors have declared that no competing interests exist.

Communicating scientific uncertainty about public health threats is ethically desirable but challenging due to its tendency to promote avoidance of choice options with unknown probabilities-a phenomenon known as "ambiguity aversion." This study examined this phenomenon's potential magnitude, its responses to different communication strategies, and its mechanisms. In a factorial experiment, 2701 adult laypersons in Spain read one of three versions of a hypothetical newspaper article describing a pandemic vaccine-preventable disease (VPD), but varying in scientific uncertainty about VPD risk and vaccine effectiveness: No-Uncertainty, Uncertainty, and Normalized-Uncertainty (emphasizing its expected nature). Vaccination intentions were lower for the Uncertainty and Normalized-Uncertainty groups compared to the No-Uncertainty group, consistent with ambiguity aversion; Uncertainty and Normalized-Uncertainty groups did not differ. Ambiguity-averse responses were moderated by health literacy and mediated by perceptions of vaccine effectiveness, VPD likelihood, and VPD severity. Communicating scientific uncertainty about public health threats warrants caution and further research to elucidate its outcomes, mechanisms, and management.

Background: Several new vaccines have been introduced into China in recent years, but some parents in China have shown concerns about the scheduling of vaccinations for young infants. This study explores caregiver concerns about children receiving multiple vaccines during a single visit and about vaccine administration in infants <6months, and assesses the degree to which these concerns are associated with ratings of the importance of different sources of vaccine information in Shanghai., Methods: Caregivers of children 8months to 7years presenting at immunization clinics in Shanghai completed a survey about vaccine co-administration and vaccine administration <6months of age. Respondents provided ratings of information from different sources (Internet, family/friends, other parents) and trust in doctors. We analyzed vaccine concerns using linear regression analyses that included these information sources after adjusting for socioeconomic variables., Results: Among 618 caregivers, 64% were concerned about vaccine co-administration and 31% were concerned about vaccine administration to infants <6months of age. Higher ratings of Internet as an important source of information were associated with greater concern about co-administration (β=0.11, 95% CI: 0.00, 0.22) and concern about administration at <6months of age (β=0.17, 95% CI: 0.05, 0.28). Higher ratings given to information from other parents corresponded to 0.24 points greater concern about vaccine co-administration (95% CI: 0.04, 0.44). More trust in doctors and ratings of information from friends and family were not associated with vaccine concerns., Conclusions: Caregiver concerns about vaccine scheduling may limit China's flexibility to add vaccines to its official immunization schedule. Reporting information about vaccine safety on the Internet and bringing groups of parents together to discuss vaccines might help to ameliorate concerns about vaccine scheduling., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

To investigate determinants of the public's perceptions of disease threat, in 2015 we conducted a randomized survey experiment in the Netherlands. Adults who read a mock news article describing average +or extreme outcomes from a hypothetical influenza pandemic were more influenced by average than by extreme case information. Presenting both types of information simultaneously appeared counterproductive.

Few national studies have asked parents how to improve the childhood vaccination process. We surveyed a nationally representative online panel of parents on how to improve this process, rationales for nonstandard approaches, and alternatives to the standard schedule. Twelve percent of the 1222 respondents reported using nonstandard approaches: 3.2% used a specific schedule, 6.0% had no specific schedule, and 2.5% declined all vaccinations. The most common rationales were that too many vaccines are given at once, and discomfort with vaccine ingredients. Regarding how to improve the process, parents using the standard schedule most often said nothing could be improved (51%), or better vaccine information (22%). Those using nonstandard approaches most often would have liked more choice (40%) or better vaccine information (26%). Parents' experiences with the vaccination process could be improved by offering information prior to visits, giving more information about side effects, and allowing more flexibility about vaccine scheduling.

Background: While the association between inadequate health literacy and adverse health outcomes has been well documented, less is known about the impact of health literacy on health perceptions, such as perceptions of control over health, and preventive health behaviors., Methods: We identified a subsample of participants (N = 707) from the Health and Retirement Study (HRS), a nationally representative sample of older adults, who participated in health literacy testing. Self-reported health literacy was measured with a literacy screening question, and objective health literacy with a summed score of items from the Test of Functional Health Literacy. We compared answers on these items to those related to participation in health behaviors such as cancer screening, exercise, and tobacco use, as well as self-referencing health beliefs., Results: In logistic regression models adjusted for gender, education, race, and age, participants with adequate self-reported health literacy (compared to poorer levels of health literacy) had greater odds of participation in mammography within the last 2 years (Odds ratio [OR] = 2.215, p = 0.01) and participation in moderate exercise two or more times per week (OR = 1.512, p = 0.03). Participants with adequate objective health literacy had reduced odds of participation in monthly breast self-exams (OR = 0.369, p = 0.004) and reduced odds of current tobacco use (OR = 0.456, p = 0.03). In adjusted linear regression analyses, self-reported health literacy made a small but significant contribution to explaining perceived control of health (β 0.151, p = <0.001) and perceived social standing (β 0.112, p = 0.002)., Conclusion: In a subsample of older adult participants of the HRS, measures of health literacy were positively related to several health promoting behaviors and health-related beliefs and non-use of breast self-exams, a screening behavior of questionable benefit. These relationships varied however, between self-reported and objectively-measured health literacy. Further investigation into the specific mechanisms that lead higher literacy people to pursue health promoting actions appears clearly warranted.

Background: A growing number of parents adopt alternative vaccination schedules for their children. A better understanding of parents' rationales for these choices is needed to guide vaccine decision making., Methods: We conducted 24 semistructured telephone interviews with parents of 12- to 36-month-olds and analyzed data using an inductive approach., Results: We identified 5 alternative vaccination approaches: "Dr Sears" schedule, shot-limiting approach, selective delay or decline, visit-by-visit decisions, and refusal of all vaccines. Parents who adopted alternative approaches expressed a desire for more control of exposure to vaccine ingredients; vaccine safety, immune system burden, and perceived disease risk were articulated as concerns., Conclusions: Parents who adopt alternative vaccination schedules can be classified in defined subgroups based on their decision-making approaches, and many describe considered reasons to support their actions. Communications that acknowledge and address those reasons may be better able to engage parents and ultimately enhance the process of decision making about vaccines., (© The Author(s) 2014.)

Few studies have examined how specific emotions may affect decision-making processes. Anxiety may be especially relevant in health decisions such as those related to cancer in which thoughts of illness or death may be abundant. We examined associations between women's anxiety about developing breast cancer and variables related to their decision to take a medication that could reduce their chances of the disease. Six-hundred and thirty-two American women, who had an increased risk of breast cancer, reviewed a web-based decision aid about tamoxifen. We examined associations between their baseline, self-reported anxiety about developing the disease and post decision aid measures including knowledge about tamoxifen, attitude toward the medication, and behavioral intentions to look for more information and take the medication. Results showed that anxiety was not associated with knowledge about tamoxifen, but it was associated with attitude toward the medication such that women who were more anxious about developing breast cancer were more likely to think the benefits were worth the risks. Greater anxiety was also associated with greater behavioral intentions to look for additional information and take the medication in the next few months. Secondary analyses showed that behavioral intentions were related to knowledge of tamoxifen and attitude toward the medication only for women who were reporting low levels of anxiety. Overall, the findings suggest that anxiety about breast cancer may motivate interest in tamoxifen and not necessarily through affecting knowledge or attitudes., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

The emergence of Web 2.0 has led to more and more Web-based resources demonstrating three defining characteristics: user participation, openness and network effects. This paper discusses these characteristics in the context of the online vaccination debate, explores how they structurally alter the way people might interact with vaccination information online, and describes ways in which such characteristics support particular tendencies in human decision making processes. Specifically, user participation supports the influence of narratives and personal accounts, openness shapes expectations for greater levels of detail and movement toward models of informed decision making, and network effects demonstrate the social nature of decision making, the influence of like-minded others and thus, the pitfalls of polarization in the online vaccination debate. Web 2.0 means that concerns about vaccination information online must expand beyond simply the possibility that people might access information of varying quality to incorporate a more comprehensive understanding of how people use current Web functionality, how such usage influences expectations about information sources and decision making processes, and the implications for communication strategies about vaccination., (Copyright © 2012. Published by Elsevier Ltd.)

It is challenging to discuss the use of high-risk organs with patients, in part because of the lack of information about how patients view this topic. This study was designed to determine how patients think about organ quality and to test formats for risk communication. Semistructured interviews of 10 patients on the waiting list revealed limited understanding about the spectrum of organ quality and a reluctance to consider anything but the best organs. A computerized quantitative survey was then conducted with an interactive graph to elicit the risk of graft failure that patients would accept. Fifty-eight percent of the 95 wait-listed patients who completed the survey would accept only organs with a risk of graft failure of 25% or less at 3 years, whereas 18% would accept only organs with the lowest risk possible (19% at 3 years). Risk tolerance was increased when the organ quality was presented relative to average organs rather than the best organs and when feedback was provided about the implications for organ availability. More than three-quarters of the patients reported that they wanted an equal or dominant role in organ acceptance decisions. Men tended to prefer lower risk organs (mean acceptable risk = 29%) in comparison with women (mean acceptable risk = 35%, P = 0.04), but risk tolerance was not associated with other demographic or clinical characteristics (eg, the severity of liver disease). In summary, patients want to be involved in decisions about organ quality. Patients' risk tolerance varies widely, and their acceptance of high-risk organs can be facilitated if we present the risks of graft failure with respect to average organs and provide feedback about the implications for organ availability., (Copyright © 2011 American Association for the Study of Liver Diseases.)

Background: An important part of delivering high-quality, patient-centered care is making sure patients are informed about decisions regarding their health care. The objective was to examine whether patients' perceptions about how informed they were about common medical decisions are related to their ability to answer various knowledge questions., Methods: A cross-sectional survey was conducted November 2006 to May 2007 of a national sample of US adults identified by random-digit dialing. Participants were 2575 English-speaking US adults aged 40 and older who had made 1 of 9 medication, cancer screening, or elective surgery decisions within the previous 2 years. Participants rated how informed they felt on a scale of 0 (not at all informed) to 10 (extremely well-informed), answered decision-specific knowledge questions, and completed standard demographic questions., Results: Overall, 36% felt extremely well informed (10), 30% felt well informed (8-9), and 33% felt not at all to somewhat informed (0-7). Multivariate logistic regression analyses showed no overall relationship between knowledge scores and perceptions of being extremely well informed (odds ratio [OR] = 0.94, 95% confidence interval [CI] 0.63-1.42, P = 0.78). Three patterns emerged for decision types: a negative relationship for cancer screening decisions (OR = 0.58, CI 0.33-1.02, P = 0.06), no relationship for medication decisions (OR = 0.99, CI 0.54-1.83, P = 0.98), and a positive relationship for surgery decisions (OR = 3.07, 95% CI 0.90-10.54, P = 0.07). Trust in the doctor was associated with feeling extremely well-informed for all 3 types of decisions. Lower education and lower income were also associated with feeling extremely well informed for medication and screening decisions. Retrospective survey data are subject to recall bias, and participants may have had different perspectives or more factual knowledge closer to the time of the decision., Conclusions: Patients facing common medical decisions are not able to accurately assess how well informed they are. Clinicians need to be proactive in providing adequate information to patients and testing patients' understanding to ensure informed decisions.

Background: Patient involvement is required before patients' preferences can be reflected in the medical care they receive. Furthermore, patients are a vital link between physicians' assessments of patients' needs and actual implementation of appropriate care. Yet no study has specifically examined how and when a representative sample of patients considered, discussed, and made medical decisions., Objective: To identify decision prevalence and decision-making processes regarding 1) initiation of prescription medications for hypertension, hypercholesterolemia, or depression; 2) screening tests for colorectal, breast, or prostate cancer; and 3) surgeries for knee or hip replacement, cataracts, or lower back pain., Design: Computer-assisted telephone interview survey., Setting: Nationally representative sample of US adults in households with telephones., Participants: 3010 English-speaking adults age 40 and older identified using a stratified random sample of telephone numbers., Measurements: Estimated prevalence of medical decisions, defined as the patient having initiated medications, been screened, or had surgery within the past 2 years or having discussed these actions with a health care provider during the same interval, as well as decision-specific data regarding patient knowledge, attitudes and patient-provider interactions., Results: 82.2% of the target population reported making at least 1 medical decision in the preceding 2 years. The proportion of decisions resulting in patient action varied dramatically both across decision type (medications [61%] v. screening [83%] v. surgery [44%]; P < 0.001), and within each category (e.g., blood pressure medications [76%] v. cholesterol medications [55%] vs. depression medications [48%]; P < 0.001). Respondents reported making more decisions if they had a primary care provider or poorer health status and fewer decisions if they had lower education, were male, or were under age 50. Limitations. Retrospective self-reports may incorporate recall biases., Conclusions: Medical decisions with significant life-saving, quality of life, and cost implications are a pervasive part of life for most US adults. The DECISIONS dataset provides a rich research environment for exploring factors influencing when and how patients make common medical decisions.

Background: The rise in Internet use for seeking health information raises questions about the role the Internet may play in how patients make medical decisions., Objective: To examine Internet use and perceived importance of different sources of information by patients making 9 specific medical decisions covering prescription medication initiation, cancer screening, and elective surgery., Setting: National sample of US adults identified by random-digit dialing., Design: Cross-sectional survey conducted between November 2006 and May 2007., Participants: The final sample comprised 2575 English-speaking US adults aged 40 y and older who had either undergone 1 of 9 medical procedures or tests or talked with a health care provider about doing so during the previous 2 y., Measurements: Participants indicated if they or other family members used the Internet to seek information related to each of the specific medical decisions and rated how important the health care provider, the Internet (if used), family and friends, and the media (newspapers, magazines, and television) were in providing information to help make the medical decision., Results: Use of the Internet for information related to specific decisions among adults 40 y and older was generally low (28%) but varied across decisions, from 17% for breast cancer screening to 48% for hip/knee replacement. Internet use was higher at younger ages, rising from 14% among those aged 70 y and older to 38% for those aged 40 to 49 y. Internet users consistently rated health care providers as the most influential source of information for medical decisions, followed by the Internet, family and friends, and media., Limitations: Telephone surveys are limited by coverage and nonresponse. The authors excluded health-related Internet use not associated with the 9 target decisions., Conclusions: A minority of patients reported using the Internet to make specific common medical decisions, but use varied widely by type of decision. Perhaps reflecting perceived risk and uncertainty, use was lowest for screening decisions and highest for surgical decisions.

Background: Although many researchers have examined patient involvement and patient-provider interactions within specific clinical environments, no nationally representative data exist to characterize patient perceptions of decision making and patient-provider communications across multiple common medical decisions., Objective: To identify deficits and variations in the patient experience of making common medical decisions about initiation of prescription medications for hypertension, hypercholesterolemia, or depression; screening tests for colorectal, breast, or prostate cancer; and surgeries for knee or hip replacement, cataracts, or lower back pain, as well as to identify factors associated with patient confidence in the decisions., Setting: National sample of US adults identified by random-digit dialing., Design: Cross-sectional survey conducted from November 2006 to May 2007., Participants: Included 2473 English-speaking adults age 40 and older who reported undertaking 1 or more of the above 9 medical actions or discussing doing so with a health care provider within the past 2 years., Measurements: Patients reported who initiated discussions and made the final decisions, how much discussion of pros and cons occurred, whether they were asked about their preferences, and their confidence that the decision "was the right one.", Results: The proportion of patient-driven decisions varied significantly across decisions (range: blood pressure: 16% to knee/hip replacement: 48%). Most patients (78%-85%) reported that providers made a recommendation, and such recommendations generally favored taking medical action. Fewer patients reported that providers asked them about their preferences (range: colon cancer screening: 34% to knee/hip replacement: 80%) or discussed reasons not to take action (range: breast cancer screening: 20% to lower back surgery: 80%). Decision confidence was higher among patients who reported primarily making the decision themselves (odds ratio [OR] = 14.6, P < 0.001) or having been asked for their preference (OR = 1.32, P < 0.01) and was lower among patients whose patient-provider discussions included cons (OR = 0.74, P = 0.008)., Limitations: Recall biases may affect patients' memories of their decision-making processes., Conclusions: DECISIONS participants reported wide variations in the proportion of discussions that included a conversation about reasons not to take action or a conversation about patients' preferences about what they would like to do. These factors appear directly related to patients' confidence that the decision was "right."

Background: Racial/ethnic differences in shared decision making about cardiovascular risk-reduction therapy could affect health disparities., Objective: To investigate whether patient race/ethnicity is associated with experiences discussing cardiovascular risk-reduction therapy with health care providers., Setting: National sample of US adults identified by random-digit dialing., Design: Cross-sectional survey conducted in November 2006 to May 2007., Participants: Among participants in the National Survey of Medical Decisions (DECISIONS), a nationally representative sample of English-speaking US adults aged 40 and older, the authors analyzed respondents who reported discussing hyperlipidemia or hypertension medications with a health care provider in the previous 2 years., Measurements: In multivariate linear and logistic regressions adjusting for age, gender, income, insurance status, perceived health, and current therapy, they assessed the relation between race/ethnicity (black/Hispanic v. white) and decision making: knowledge, discussion of pros and cons of therapy, discussion of patient preference, who made the final decision, preferred involvement, and confidence in the decision., Results: Of respondents who discussed high cholesterol (N = 738) or hypertension (N = 745) medications, 88% were white, 9% black, and 4% Hispanic. Minorities had lower knowledge scores than whites for hyperlipidemia (42% v. 52%, difference -10% [95% confidence interval (CI): 15, -5], P < 0.001), but not for hypertension. For hyperlipidemia, minorities were more likely than whites to report that the health care provider made the final decision for treatment (31.7% v. 12.3% whites, difference 19.4% [95% CI: 6.9, 33.1%], P < 0.01); this was not true for hypertension., Limitations: Possible limitations include the small percentage of minorities in the sample and potential recall bias., Conclusions: Minorities considering hyperlipidemia therapy may be less informed about and less involved in the final decision-making process.

Background: To make informed decisions, patients must have adequate knowledge of key decision-relevant facts., Objective: To determine adults' knowledge about information relevant to common types of medication, screening, or surgery decisions they recently made., Setting: National sample of US adults identified by random-digit dialing., Design: Cross-sectional survey conducted between November 2006 and May 2007., Participants: A total of 2575 English-speaking adults aged 40 y or older who reported having discussed the following medical decisions with a health care provider within the previous 2 y: prescription medications for hypertension, hypercholesterolemia, or depression; screening tests for colorectal, breast, or prostate cancer; or surgeries for knee/hip replacement, cataracts, or lower back pain., Measurements: Participants answered knowledge questions and rated the importance of their health care provider, family/friends, and the media as sources of information., Results: Accuracy rates varied widely across questions and decision contexts. For example, patients considering cataract surgery were more likely to correctly estimate recovery time than those patients considering lower back pain or knee/hip replacement (78% v. 29% and 39%, P < 0.001). Similarly, participants were more knowledgeable of facts about colorectal cancer screening than those who were asked about breast or prostate cancer. Finally, respondents were consistently more knowledgeable on comparable questions about blood pressure medication than cholesterol medication or antidepressants. The impact of demographic characteristics and sources of information also varied substantially. For example, blacks had lower knowledge than whites about cancer screening decisions (odds ratio [OR] = 0.57; 95% confidence interval [CI] = 0.43, 0.75; P = 0.001) and medication (OR = 0.77; 95% CI = 0.60, 0.97; P = 0.03) even after we controlled for other demographic factors. The same was not true for surgical decisions., Limitations: The questions did not measure all knowledge relevant to informed decision making, were subject to recall biases, and may have assessed numeracy more than knowledge., Conclusions: Patient knowledge of key facts relevant to recently made medical decisions is often poor and varies systematically by decision type and patient characteristics. Improving patient knowledge about risks, benefits, and characteristics of medical procedures is essential to support informed decision making.

Objective: We sought to estimate what proportion of adults plan to stop cancer screening tests among adults who recently considered screening and to explore factors associated with these screening plans., Design: Telephone Survey, Participants: A total of 1,237 participants aged 50 and older who reported having made one or more cancer screening decisions in the past 2 years completed 1,454 cancer screening modules for breast, prostate and colorectal screening., Main Results: Of all module respondents, 9.8% reported plans to stop screening, 12.6% for breast, 6.0 % for prostate and 9.5% for colon cancer. We found no statistically significant differences in plans to stop for those ages >or=70 (8.2%) compared to those ages 50 to 69 (10.2%) (p = 0.14.) Black respondents were less likely to report plans to stop than white respondents (OR = 0.32, 95% CI 0.12, 0.87). Participation in the decision-making process was associated with plans to stop screening; those who reported they made the final decision about screening (OR 5.9, 95% CI 1.4, 24.7) or made the decision with the health care provider (OR 4.1, 95% CI 1.0, 16.8) were more likely to have plans to stop screening compared to respondents who reported that their health care provider made the final decision., Conclusions: Plans to stop screening were uncommon among participants who had recently faced a screening decision. Given the recent US Preventive Services Task Force recommendations limiting routine cancer screening for older adults, additional efforts to educate adults about the potential risks and benefits of screening may be warranted.

Tamoxifen reduces primary breast cancer incidence, yet causes serious side effects. To date, few women with increased breast cancer risk have elected to use tamoxifen for chemoprevention. The objective of the study was to determine women's knowledge of and attitudes toward tamoxifen following exposure to a tailored decision aid (DA). A total of 632 women with a 5-year risk of breast cancer > or = 1.66% (Mean = 2.56, range = 1.7-17.3) were recruited from two healthcare organizations. Participants viewed an online DA that informed them about their 5-year risk of breast cancer and presented individually tailored content depicting the risks/benefits of tamoxifen prophylaxis. Outcome measures included behavioral intentions (to seek additional information about tamoxifen, to talk to a physician about tamoxifen, and to take tamoxifen); knowledge; and perceived risks and benefits of tamoxifen. After viewing the DA, 29% of participants said they intended to seek more information or talk to their doctor about tamoxifen, and only 6% believed they would take tamoxifen. Knowledge was considerable, with 63% of women answering at least 5 of 6 knowledge questions correctly. Participants were concerned about the risks of tamoxifen, and many believed that the benefits of tamoxifen did not outweigh the risks. This study is the largest to date to test women's preferences for taking tamoxifen and one of the largest to have tested the impact of a tailored DA. After viewing the DA, women demonstrated good understanding of tamoxifen's risks and benefits, but most were not interested in taking tamoxifen for breast cancer chemoprevention.

Objective: To test whether providing comparative risk information changes risk perceptions., Methods: Two hundred and forty-nine female visitors to a hospital cafeteria were randomized to one of two conditions which differed in whether their hypothetical breast cancer risks was lower or higher than the average women's. Participants read a scenario describing a breast cancer prevention pill and indicated their: (1) likelihood of taking the pill and (2) perception of whether the pill provides breast cancer risk reduction., Results: Women told that their hypothetical risk of breast cancer was above average were more likely to endorse taking the pill (2.79 vs. 2.23, F=4.95, p=0.002) and more likely to believe that the pill provided a significant risk reduction in breast cancer (3.15 vs. 2.73, F=4.32, p=0.005), even though the risks were equivalent., Conclusions: Providing people with comparative risk information changes their risk perceptions. People who have above average risk may feel compelled to take a treatment because they are at above average risk and therefore may not thoroughly consider the trade-offs in the risks and benefits of treatment., Practice Implications: Physicians and decision aid developers must reconsider the practice of communicating "average risk" information to patients.

Objective: To summarize existing research on individual numeracy and methods for presenting risk information to patients., Methods: We selectively retrieved articles from MEDLINE and the Social Sciences Citation Index., Results: Many Americans have low numeracy skills, a deficit that impedes effective health care. Approaches to risk communication vary in current practice, but how risks are presented can significantly affect both patients' risk perceptions and their knowledge., Conclusions: Adhering to some basic principles for presenting risk information to patients can improve understanding. However, different risk-communication methods may be needed for individuals with high versus low levels of numeracy.

Counseling women about breast cancer risks has been found to decrease screening compliance. We investigated whether women's reactions to risk information are an artifact of requiring women to estimate the risk of breast cancer prior to receiving risk information. Three hundred and fifty-six women were randomized to either make or not make a risk estimate prior to receiving risk information. Outcome measures were participants' estimates of the average woman's breast cancer risk and their emotional response to the risk information. Women overestimated the lifetime risk of breast cancer (M = 46%). Women who made risk estimates felt more relieved about the risk and perceived the risk as being lower than women who did not make estimates (p's < 0.001). Asking people to estimate risks influenced their subsequent perceptions of the risk of breast cancer.