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For two decades, various initiatives have encouraged Americans to consider quality when choosing clinicians, both to enhance informed choice and to reduce disparities in access to high-quality providers. The literature portrays these efforts as largely ineffective. But this depiction overlooks two factors: the dramatic expansion since 2010 in the availability of patients' narratives about care and the growth of information seeking among consumers. Using surveys fielded in 2010, 2014, and 2015, we assessed the impact of these changes on consumers' awareness of quality information and sociodemographic differences. Public exposure to any quality information doubled between 2010 and 2015, while exposure to patient narratives and experience surveys tripled. Reflecting a greater propensity to seek quality metrics, minority consumers remained better informed than whites over time, albeit with differences across subgroups in the types of information encountered. An education-related gradient in quality awareness also emerged over the past decade. Public policy should respond to emerging trends in information exposure, establish standards for rigorous elicitation of narratives, and assist consumers' learning from a combination of narratives and quantified metrics on clinician quality.

POLICY POINTS: Narratives about patients’ experiences with outpatient care are essential for quality improvement because they convey ample actionable information that both elaborates on existing domains within patient experience surveys and describes multiple additional domains that are important to patients. The content of narrative feedback from patients can potentially be translated to improved quality in multiple ways: clinicians can learn from their own patients, groups of clinicians can learn from the experience of their peers’ patients, and health system administrators can identify and respond to patterns in patients’ accounts that reflect systemic challenges to quality. Consistent investment by payers and providers is required to ensure that patient narratives are rigorously collected, analyzed fully, and effectively used for quality improvement. CONTEXT: For the past 25 years, health care providers and health system administrators have sought to improve care by surveying patients about their experiences. More recently, policymakers have acted to promote this learning by deploying financial incentives tied to survey scores. This article explores the potential of systematically elicited narratives about experiences with outpatient care to enrich quality improvement. METHODS: Narratives were collected from 348 patients recruited from a nationally representative Internet panel. Drawing from the literature on health services innovation, we developed a two‐part coding schema that categorized narrative content in terms of (a) the aspects of care being described, and (b) the actionability of this information for clinicians, quality improvement staff, and health system administrators. Narratives were coded using this schema, with high levels of reliability among the coders. FINDINGS: The scope of outpatient narratives divides evenly among aspects of care currently measured by patient experience surveys (35% of content), aspects related to measured domains but not captured by existing survey questions (31%), and aspects of care that are omitted from surveys entirely (34%). Overall, the narrative data focused heavily on relational aspects of care (43%), elaborating on this aspect of experience well beyond what is captured with communication‐related questions on existing surveys. Three‐quarters of elicited narratives had some actionable content, and almost a third contained three or more separate actionable elements. CONCLUSIONS: In a health policy environment that incentivizes attention to patient experience, rigorously elicited narratives hold substantial promise for improving quality in general and patients’ experiences with care in particular. They do so in two ways: by making concrete what went wrong or right in domains covered by existing surveys, and by expanding our view of what aspects of care matter to patients as articulated in their own words and thus how care can be made more patient‐centered. Most narratives convey experiences that are potentially actionable by those committed to improving health care quality in outpatient settings.

Objective\ud Individuals are often defensive toward health messages that suggest they are putting their health at risk because such messages threaten their self-competence and integrity. Although self-affirmation can facilitate prevention behaviors in response to health messages, effects are variable. We examined whether disease prevention focus might strengthen self-affirmation’s effects in response to disease prevention messages, given that prevention-focused individuals are likeliest to be persuaded by those messages after self-affirmation attenuates defensiveness.\ud \ud Design\ud In Study 1, participants were self-affirmed before a message about sexually transmitted infections. In Studies 2 and 3, individuals were self-affirmed prior to a message about alcohol and cancer risk.\ud \ud Main Outcome Measures\ud Studies assessed intentions to use condoms, intentions to reduce alcohol, and willingness to drink alcohol in specific scenarios.\ud \ud Results\ud In Study 1, self-affirmation facilitated condom use intentions among those higher in prevention focus. In Studies 2 and 3, self-affirmation facilitated lower willingness to consume alcohol among those high in prevention focus. A meta-analysis across the three studies indicated that self-affirmation improved intentions and willingness under high, but not low, prevention focus (d = 0.20, p = .003).\ud \ud Conclusion\ud These findings demonstrate that health prevention-focus can strengthen self-affirmation’s effects, thereby improving responsiveness to health communications about behaviors that increase disease risk.

BACKGROUND: Public reports on healthcare quality typically include complex data. To lower the cognitive burden of interpreting these data, some report designers create summary, or roll-up, measures combining multiple indicators of quality into one score. Little is known about how the availability of roll-ups affects clinician choice. OBJECTIVE: To determine how presenting quality scores at different levels of aggregation affects patients’ clinician choices. DESIGN: We conducted a simulated clinician-choice experiment, randomizing participants to three versions of a public reporting website and comparing their clinician choices. One version aggregated all clinician-level quality measures into roll-ups, the second provided disaggregated (drill-down) scores only, and the third offered both roll-ups and drill-downs. PARTICIPANTS: Five hundred fifty panelists drawn from a probability-based Internet panel. MAIN MEASURES: We assessed the amount of effort participants exerted by tracking the length of time spent on the website and the number of concrete actions taken on the website (e.g., clicking items). We evaluated decision quality by measuring whether participants selected a clinician who performed more poorly than others and incongruence between participants’ stated preferences for dimensions of quality and their chosen clinician’s performance on those dimensions. KEY RESULTS: Participants seeing drill-downs alone (mean = 14.9) or with roll-ups (mean = 19.2) took more actions than those who saw roll-ups alone (mean = 10.5) (ps

OBJECTIVE: This article describes the National Institute for Occupational Safety and Health’s (NIOSH) development of a conceptual framework for worker well-being. While well-being research is growing, there is a need to translate theoretical concepts into practical models for measurement and action. METHODS: Multidisciplinary literature reviews informed development of the worker well-being framework and major domains and subdomains. An expert panel helped prioritize constructs for measurement. RESULTS: The framework includes five domains and 20 subdomains and conceptualizes worker well-being as a subjective and objective phenomenon inclusive of experiences both within and beyond work contexts. CONCLUSION: Well-being is a positive and unifying concept that captures multiple factors that contribute to workers’ health and quality of life. This work lays the foundation for larger well-being measurement efforts and will provide tools for NIOSH partners to help workers flourish.

Introduction Many service members experiencing symptoms of mental health conditions do not receive mental health care for these symptoms. The stigma associated with having a mental health condition or seeking treatment is often cited as a specific barrier to mental health care. However, study results bearing on the question of whether and how stigma may reduce treatment-seeking have been inconsistent. Methods We searched 10 databases for sources published between 2004 and 2014 that prospectively linked stigma to treatment-related outcomes (such as treatment seeking, retention, and reports of symptoms) using longitudinal data and predictive models. The searches yielded 2,409 sources. After reviewing titles and abstracts for relevance, we retained 15 sources to undergo full-text review. Results Overall, this review illustrates that evidence exploring the direct effect of stigma on treatment-related outcomes is still scant. We identified two studies whose outcomes conflict when it comes to stigma and treatment-initiation and utilization, and three studies found no relationship between stigma and treatment-initiation and utilization. One study suggested that the relationship between stigma and experience of symptoms is nuanced and may depend on the type of stigma and types of symptoms considered. Meager evidence was available to inform the relationship between stigma and treatment duration, attrition, and quality of life/functioning. The evidence was not sufficient to draw conclusions about the state of these relationships. No conclusions could be made about the direct impact of stigma on treatment-related outcomes among military service members given that only two studies explored this relationship among military service members. Conclusion Current research does not provide a true understanding of the degree to which mental illness stigma affects treatment-related outcomes for service members experiencing mental health challenges. This understanding could only be developed through a longitudinal study assessing prospectively whether stigma affects treatment-utilization in the military. Should such a study show that stigma reduces treatment-utilization, the military would need to consider whether changes to their current approaches to stigma reduction are warranted.

Rationale Regulatory focus (i.e., focus on motivation to achieve gains or avoid losses and non-gains) is used to tailor health behavior change interventions, improving efficacy, but is currently assessed by scales that are not health-specific and may capture a version of the construct that is not ideally matched to the rationale for tailoring. Objective We developed and validated a Health Regulatory Focus Scale (HRFS), which assesses tendencies to avoid negative health consequences (prevention focus) or achieve positive health outcomes (promotion focus). Methods Across four studies (and a scale development study in supplementary online materials), we established convergent, discriminant, and predictive validity for the HRFS. In studies examining predictive validity, main outcome measures were health behavior intentions, including intentions to reduce alcohol use, quit smoking, eat a healthy diet, exercise, be screened for cancer, and engage in general cancer preventive behaviors. Results The promotion and prevention sub-scales performed well in confirmatory factor analyses. Single-factor models had significantly poorer fit than models delineating promotion and prevention. The sub-scales were differentially (and only modestly) correlated with related constructs (anxiety, optimism, information avoidance, ambiguity/fatalism). Higher HRFS-Promotion focus generally corresponded with greater health behavior intentions. Conversely, higher HRFS-Prevention focus corresponded with lower health behavior intentions. Associations were largely maintained even when controlling for established regulatory focus measures, supporting the assertion that the HRFS would predict unique variance in health behavior intentions. Conclusion The HRFS has the potential to improve the precision with which framed health messages change behavior, as it may assess a version of regulatory focus that is more ideally matched to rationale for tailoring interventions.

We conducted a simulated clinician-choice experiment, comparing choices and decision-making processes of participants ( N = 688) randomized among four experimental arms: a conventional website reporting only quantitative performance information, a website reporting both qualitative (patient comments) and quantitative information, the second website augmented by a decision aid (labeling of patient comments), and the decision-aided website further augmented by the presence of a trained navigator. Introducing patient comments enhanced engagement with the quality information but led to a decline in decision quality, particularly the consistency of choices with consumers’ stated preferences. Labeling comments helped erase the decline in decision quality, although the highest percentage of preference-congruent choices was seen in the navigator arm. Engagement with the quality information and satisfaction with choices available were likewise highest in the navigator arm. Findings held for high- and low-skilled decision makers. Thus, navigator assistance may be a promising strategy for equitably promoting higher quality choices in information-rich contexts.

Patient narratives have emerged as promising vehicles for making health care more responsive by helping clinicians to better understand their patients’ expectations, perceptions, or concerns and encouraging consumers to engage with information about quality. A growing number of websites incorporate patients’ comments. But existing comments have fragmentary content, fail to represent less vocal patients, and can be manipulated to “manage” providers’ reputations. In this article, we offer the first empirical test of the proposition that patient narratives can be elicited rigorously and reliably using a five-question protocol that can be incorporated into large-scale patient experience surveys. We tested whether elicited narratives about outpatient care are complete (report all facets of patient experience), balanced (convey an accurate mix of positive and negative events), meaningful (have a coherent storyline), and representative (draw fulsome narratives from all relevant subsets of patients). The tested protocol is strong on balance and representativeness, more mixed on completeness and meaningfulness.

This study was conducted to determine the feasibility of conducting a cost–benefit evaluation of federally-funded media campaigns encouraging mental health help-seeking among United States military personnel and veterans. To calculate the necessary sample size for the evaluation, we obtained campaign costs, and determined the number of treatment seekers needed for the campaign to break even with its cost and the associated population change that an evaluation would need to detect. The sample size needed for an evaluation with 80% power was greater than the total population of U.S. military personnel and veterans. Given that the necessary sample size exceeds the population to be sampled, an appropriately powered outcome evaluation is not feasible. Other programs that would be cost effective with extremely small effect sizes should not be subject to underpowered and thus inaccurate empirical outcome evaluation.

When choosing clinicians, patients often rely on comments available on consumer websites. The authors argue that public reporting of standardized patient satisfaction surveys could be improved if they were augmented by narrative accounts of patients' experiences.

To understand the views of prominent organizations in the field of healthcare quality on the topic of reporting roll-up measures that combine indicators of multiple, often disparate, dimensions of care to consumers.This study used a semi-structured, qualitative interview design.We conducted 30- to 60-minute semi-structured telephone interviews with representatives of 10 organizations that sponsor public healthcare quality reports and 3 national alliances representing multiple stakeholder groups. We conducted a thematic analysis of interview transcriptions to identify common issues and concerns related to reporting roll-up measures.Among sponsors reporting roll-up measures, current practices for calculating and reporting these measures are diverse. The main perceived benefit of reporting roll-up measures is that they simplify large amounts of complex information for consumers. The main concern is the potential for consumers to misunderstand the measures and what associated roll-up scores communicate about provider performance. Report sponsors and national alliances feel that more guidance and research on the methods for producing and reporting scores for roll-up measures are needed.The results of the interviews elucidate the need for research focused on construction and reporting of roll-up measures. Studies are needed to determine if roll-up measures are indeed perceived by consumers as being less complex and easier to understand.

The aim of this study was to examine two under-studied factors integral to the theoretical underpinnings of contact-based mental illness stigma reduction programs: the quality of the contact and prior personal experience with persons with mental health problems. This study utilized pre- and post-survey data collected from 4122 individuals participating in a diverse set of contact-based educational programs implemented as part of California's statewide initiative to reduce mental illness stigma. Multi-level mixed regression models were used to determine whether pre-post changes in a variety of stigma-related measures varied depending on perceived quality of contact and prior personal experience with mental illness. Significant pre-post reductions in stigma were observed, but individual perceptions of contact quality strongly moderated program effects. Mean contact quality across all attendees at a presentation was rarely a moderator. Though effective for all participants, on average, contact-based educational programs were more effective for those without prior personal or family experience of mental illness. Program organizers may wish to target recruitment efforts to reach more individuals without such experience, given the greater effectiveness of contact among these individuals. More research should explore the factors underlying individual variation in perceived quality of contact-based stigma reduction programs.

Mental illness stigma disproportionately affects help seeking among youth, men, and ethnic minorities. As part of a comprehensive statewide initiative to reduce mental illness stigma and discrimination in California, a broad set of contact-based educational programs were widely disseminated. This study examined whether the effects of contact-based educational programs varied depending on the age, gender, and race-ethnicity of participants. Participants (N = 4122) attended a contact-based educational program that was delivered as part of the statewide initiative to reduce mental illness stigma and discrimination. Self-administered surveys assessing beliefs, attitudes, and intentions toward mental illnesses and treatment were conducted immediately before and after participation in contact-based educational programs. Participant age, gender, and race-ethnicity significantly moderated pre–post changes in mental illness stigma. Although all groups exhibited significant pre–post changes across most of the stigma domains assessed, young adults, females, and Asian and Latino American participants reported larger improvements compared to older adults, males, and Whites, respectively. Findings suggest that contact-based educational programs can achieve immediate reductions in mental illness stigma across a variety of sociodemographic groups and may particularly benefit young adults and racial–ethnic minorities. Further research is needed to assess whether contact-based educational programs can sustain longer-term changes and aid in the reduction of disparities in mental illness stigma and treatment.

Introduction Negative psychosocial expectancies of smoking include aspects of social disapproval and disappointment in oneself. This paper describes analyses conducted to develop and evaluate item banks for assessing psychosocial expectancies among daily and nondaily smokers. Methods Using data from a sample of daily (N = 4,201) and nondaily (N =1,183) smokers, we conducted a series of item factor analyses, item response theory analyses, and differential item functioning analyses (according to gender, age, and race/ethnicity) to arrive at a unidimensional set of psychosocial expectancies items for daily and nondaily smokers. We also evaluated performance of short forms (SFs) and computer adaptive tests (CATs) to efficiently assess psychosocial expectancies. Results A total of 21 items were included in the Psychosocial Expectancies item banks: 14 items are common across daily and nondaily smokers, 6 are unique to daily, and 1 is unique to nondaily. For both daily and nondaily smokers, the Psychosocial Expectancies item banks are strongly unidimensional, highly reliable (reliability = 0.95 and 0.93, respectively), and perform similarly across gender, age, and race/ethnicity groups. A SF common to daily and nondaily smokers consists of 6 items (reliability = 0.85). Results from simulated CATs showed that, on average, fewer than 8 items are needed to assess psychosocial expectancies with adequate precision when using the item banks. Conclusions Psychosocial expectancies of smoking can be assessed on the basis of these item banks via the SF, by using CAT, or through a tailored set of items selected for a specific research purpose.

Introduction Smokers' health-related outcome expectancies are associated with a number of important constructs in smoking research, yet there are no measures currently available that focus exclusively on this domain. This paper describes the development and evaluation of item banks for assessing the health expectancies of smoking. Methods Using data from a sample of daily (N = 4,201) and nondaily (N = 1,183) smokers, we conducted a series of item factor analyses, item response theory analyses, and differential item functioning analyses (according to gender, age, and race/ethnicity) to arrive at a unidimensional set of health expectancies items for daily and nondaily smokers. We also evaluated the performance of short forms (SFs) and computer adaptive tests (CATs) to efficiently assess health expectancies. Results A total of 24 items were included in the Health Expectancies item banks; 13 items are common across daily and nondaily smokers, 6 are unique to daily, and 5 are unique to nondaily. For both daily and nondaily smokers, the Health Expectancies item banks are unidimensional, reliable (reliability = 0.95 and 0.96, respectively), and perform similarly across gender, age, and race/ethnicity groups. A SF common to daily and nondaily smokers consists of 6 items (reliability = 0.87). Results from simulated CATs showed that health expectancies can be assessed with good precision with an average of 5-6 items adaptively selected from the item banks. Conclusions Health expectancies of smoking can be assessed on the basis of these item banks via SFs, CATs, or through a tailored set of items selected for a specific research purpose.

Objective To design a methodology for rigorously eliciting narratives about patients' experiences with clinical care that is potentially useful for public reporting and quality improvement. Data Sources/Study Setting Two rounds of experimental data (N = 48 each) collected in 2013–2014, using a nationally representative Internet panel. Study Design Our study (1) articulates and operationalizes criteria for assessing narrative elicitation protocols; (2) establishes a “gold standard” for assessment of such protocols; and (3) creates and tests a protocol for narratives about outpatient treatment experiences. Data Collection/Extraction Methods We randomized participants between telephone and web-based modalities and between protocols placed before and after a closed-ended survey. Principal Findings Elicited narratives can be assessed relative to a gold standard using four criteria: (1) meaningfulness, (2) completeness, (3) whether the narrative accurately reflects the balance of positive and negative events, and (4) representativeness, which reflects the protocol's performance across respondent subgroups. We demonstrate that a five-question protocol that has been tested and refined yields three- to sixfold increases in completeness and four- to tenfold increases in meaningfulness, compared to a single open-ended question. It performs equally well for healthy and sick patients. Conclusions Narrative elicitation protocols suitable for inclusion in extant patient experience surveys can be designed and tested against objective performance criteria, thus advancing the science of public reporting.

We examined whether self-affirmation would facilitate intentions to engage in colorectal cancer (CRC) screening among individuals who were off-schedule for CRC screening and who were categorized as unrealistically optimistic, realistic, or unrealistically pessimistic about their CRC risk. All participants received tailored risk feedback; in addition, one group received threatening social comparison information regarding their risk factors, a second received this information after a self-affirmation exercise, and a third was a no-treatment control. When participants were unrealistically optimistic about their CRC risk (determined by comparing their perceived comparative risk to calculations from a risk algorithm), they expressed greater interest in screening if they were self-affirmed (relative to controls). Non-affirmed unrealistic optimists expressed lower interest relative to controls, suggesting that they were responding defensively. Realistic participants and unrealistically pessimistic participants who were self-affirmed expressed relatively less interest in CRC screening, suggesting that self-affirmation can be helpful or hurtful depending on the accuracy of one’s risk perceptions.

Inadequate consumption of fruits and vegetables is regarded as an important behavioral risk factor for multiple types of cancer. Nevertheless, adherence with the National Cancer Institute (NCI) guidelines to eat between five and nine servings of fruits and vegetables per day is remarkably low. The current study explored the extent to which nonadherent respondents in a national survey (N = 5,625) listed fruit and vegetable consumption as a method by which to decrease their own or others' cancer risk. We sought to determine whether respondents who listed fruit and vegetable consumption as a method by which to decrease their own or others' cancer risk (hereafter referred to as "listers") differed from respondents who did not list fruit and vegetable consumption as a method by which to decrease their own or others' cancer risk (hereafter referred to as) "nonlisters" on measures of information processing and cancer cognitions. Nonlisters were more likely than listers to seek out cancer information but less likely to trust the information. The two groups did not differ in the amount of attention they paid to such information. Listers had lower absolute risk perceptions than nonlisters, but listers and nonlisters did not differ on measures of relative breast and colon cancer risk perceptions and worry for cancer in general. Female listers did perceive themselves to be at less relative risk for breast cancer than nonlisters. Respondents were more likely to list fruit and vegetable consumption as a cancer-risk reduction strategy for others than for themselves, suggesting a "double standard" in their beliefs. These findings suggest that communications designed to promote fruit and vegetable consumption need to account for biases in how nonadherent individuals respond to these communications.