Communication of benefits and harms in shared decision making with patients with limited health literacy: A systematic review of risk communication strategies.

OBJECTIVES: Risk communication (RC), as part of shared decision making, is challenging with people with limited health literacy (LHL). We aim to provide an overview of strategies to communicate benefits and harms of diagnostic and treatment options to this group. METHODS: We systematically searched PubMed, Embase, Cinahl and PsycInfo. We included 28 studies on RC in informed/shared decision making without restriction to a health setting or condition and using a broad conceptualization of health literacy. Two researchers independently selected studies and one researcher performed data extraction. We descriptively compared findings for people with LHL towards recommendations for RC. RESULTS: Health literacy levels varied in the included studies. Most studies used experimental designs, primarily on visual RC. Findings show verbal RC alone should be avoided. Framing of risk information influences risk perception (less risky when positively framed, riskier when negatively framed). Most studies recommended the use of icon arrays. Graph literacy should be considered when using visual RC. CONCLUSIONS: The limited available evidence suggests that recommended RC strategies seem mainly to be valid for people with LHL, but more research is required. PRACTICE IMPLICATIONS: More qualitative research involving people with LHL is needed to gain further in-depth insights into optimal RC strategies. PROTOCOL REGISTRATION: PROSPERO ID 275022.

A qualitative exploration of clinicians' strategies to communicate risks to patients in the complex reality of clinical practice.

BACKGROUND: Risk communication, situated in the model of shared decision making (SDM), is an essential element in daily clinical practice. The scientific literature makes a number of generic recommendations. Yet the application of risk communication remains a challenge in patient-clinician encounters. How clinicians actually communicate risk during consultations is not well understood. We aimed to explore the risk communication strategies used by clinicians and extract narratives and visualizations of those strategies to help inform medical education. METHODS: In this qualitative descriptive study, we interviewed fifteen purposely sampled clinicians from several medical disciplines, who were familiar with the concept of SDM. Deductive and inductive content analysis was used during an iterative data collection and analyses process. RESULTS: Our study identified various strategies reported to be used by clinicians to address the complexities of risk communication such as dealing with uncertainty. These included verbal, numerical and visual risk communication and framing. Clinicians were familiar with recommended risk formats such as natural frequencies and population pictograms. However, it became clear that clinicians' expertise and communication goals also play an important role in the risk talk. Clinicians try to lay a foundation for balanced decision-making and to incorporate patient preferences while faced with several challenges such as the dilemma of raising awareness but triggering anxiety or fan fear in patients. Consequently, they also use communication goals such as influencing mindset and reassuring patients. Additionally, clinicians frequently have to account for the illusion of certainty in the risk talk. CONCLUSION: Risk communication is a multi-faceted construct that cannot be dealt with in isolation from the clinical context. For future research we recommend considering a more practical framework within the clinical setting and to take a goal-directed approach into account when investigating and teaching the topic. The patient perspective should also be addressed in further research.

Global Diversification Dynamics Since the Jurassic: Low Dispersal and Habitat-Dependent Evolution Explain Hotspots of Diversity and Shell Disparity in River Snails (Viviparidae).

The Viviparidae, commonly known as River Snails, is a dominant group of freshwater snails with a nearly worldwide distribution that reaches its highest taxonomic and morphological diversity in Southeast Asia. The rich fossil record is indicative of a probable Middle Jurassic origin on the Laurasian supercontinent where the group started to diversify during the Cretaceous. However, it remains uncertain when and how the biodiversity hotspot in Southeast Asia was formed. Here, we used a comprehensive genetic data set containing both mitochondrial and nuclear markers and comprising species representing 24 out of 28 genera from throughout the range of the family. To reconstruct the spatiotemporal evolution of viviparids on a global scale, we reconstructed a fossil-calibrated phylogeny. We further assessed the roles of cladogenetic and anagenetic events in range evolution. Finally, we reconstructed the evolution of shell features by estimating ancestral character states to assess whether the appearance of sculptured shell morphologies was driven by major habitat shifts. The molecular phylogeny supports the monophyly of the three subfamilies, the Bellamyinae, Lioplacinae, and Viviparinae, but challenges the currently accepted genus-level classification in several cases. The almost global distribution of River Snails has been influenced both by comparatively ancient vicariance and more recent founder events. In Southeast Asia, Miocene dispersal was a main factor in shaping the modern species distributions. A recurrent theme across different viviparid taxa is that many species living in lentic waters exhibit sculptured shells, whereas only one strongly sculptured species is known from lotic environments. We show that such shell sculpture is habitat-dependent and indeed evolved several times independently in lentic River Snails. Considerably high transition rates between shell types in lentic habitats probably caused the co-occurrence of morphologically distinct shell types in several lakes. In contrast, directional evolution toward smooth shells in lotic habitats, as identified in the present analyses, explains why sculptured shells are rarely found in these habitats. However, the specific factors that promoted changes in shell morphology require further work. [biogeographical analyses; fossil-calibrated phylogeny; fossil-constrained analyses; Southeast Asia; stochastic character mapping.].