Meaningful Communication but not Superficial Anthropomorphism Facilitates Human-Automation Trust Calibration: The Human-Automation Trust Expectation Model (HATEM).

OBJECTIVE: The objective was to demonstrate anthropomorphism needs to communicate contextually useful information to increase user confidence and accurately calibrate human trust in automation. BACKGROUND: Anthropomorphism is believed to improve human-automation trust but supporting evidence remains equivocal. We test the Human-Automation Trust Expectation Model (HATEM) that predicts improvements to trust calibration and confidence in accepted advice arising from anthropomorphism will be weak unless it aids naturalistic communication of contextually useful information to facilitate prediction of automation failures. METHOD: Ninety-eight undergraduates used a submarine periscope simulator to classify ships, aided by the Ship Automated Modelling (SAM) system that was 50% reliable. A between-subjects 2 × 3 design compared SAM appearance (anthropomorphic avatar vs. camera eye) and voice inflection (monotone vs. meaningless vs. meaningful), with the meaningful inflections communicating contextually useful information about automated advice regarding certainty and uncertainty. RESULTS: Avatar SAM appearance was rated as more anthropomorphic than camera eye, and meaningless and meaningful inflections were both rated more anthropomorphic than monotone. However, for subjective trust, trust calibration, and confidence in accepting SAM advice, there was no evidence of anthropomorphic appearance having any impact, while there was decisive evidence that meaningful inflections yielded better outcomes on these trust measures than monotone and meaningless inflections. CONCLUSION: Anthropomorphism had negligible impact on human-automation trust unless its execution enhanced communication of relevant information that allowed participants to better calibrate expectations of automation performance. APPLICATION: Designers using anthropomorphism to calibrate trust need to consider what contextually useful information will be communicated via anthropomorphic features.

Effects of Low- Versus High-Fidelity Simulations on the Cognitive Burden and Performance of Entry-Level Paramedicine Students: A Mixed-Methods Comparison Trial Using Eye-Tracking, Continuous Heart Rate, Difficulty Rating Scales, Video Observation and Interviews.

INTRODUCTION: High-fidelity simulation-based training is often avoided for early-stage students because of the assumption that while practicing newly learned skills, they are ill suited to processing multiple demands, which can lead to "cognitive overload" and poorer learning outcomes. We tested this assumption using a mixed-methods experimental design manipulating psychological immersion. METHODS: Thirty-nine randomly assigned first-year paramedicine students completed low- or high-environmental fidelity simulations [low-environmental fidelity simulations (LF(en)S) vs. high-environmental fidelity simulation (HF(en)S)] involving a manikin with obstructed airway (SimMan3G). Psychological immersion and cognitive burden were determined via continuous heart rate, eye tracking, self-report questionnaire (National Aeronautics and Space Administration Task Load Index), independent observation, and postsimulation interviews. Performance was assessed by successful location of obstruction and time-to-termination. RESULTS: Eye tracking confirmed that students attended to multiple, concurrent stimuli in HF(en)S and interviews consistently suggested that they experienced greater psychological immersion and cognitive burden than their LF(en)S counterparts. This was confirmed by significantly higher mean heart rate (P < 0.001) and National Aeronautics and Space Administration Task Load Index mental demand (P < 0.05). Although group allocation did not influence the proportion of students who ultimately revived the patient (58% vs. 30%, P < 0.10), the HF(en)S students did so significantly more quickly (P < 0.01). The LF(en)S students had low immersion resulting in greater assessment anxiety. CONCLUSIONS: High-environmental fidelity simulation engendered immersion and a sense of urgency in students, whereas LF(en)S created assessment anxiety and slower performance. We conclude that once early-stage students have learned the basics of a clinical skill, throwing them in the "deep end" of high-fidelity simulation creates significant additional cognitive burden but this has considerable educational merit.

Assessing simulation-based clinical training: comparing the concurrent validity of students' self-reported satisfaction and confidence measures against objective clinical examinations.

Introduction: Simulation-based education (SBE) literature is replete with student satisfaction and confidence measures to infer educational outcomes. This research aims to test how well students' satisfaction and confidence measures correlate with expert assessments of students' improvements in competence following SBE activities. Methods: N=85 paramedic students (mean age 23.7 years, SD=6.5; 48.2% female) undertook a 3-day SBE workshop. Students' baseline competence was assessed via practical scenario simulation assessments (PSSAs) administered by expert paramedics and confidence via a questionnaire. Postworkshop competence and confidence plus self-reported students' satisfaction were remeasured. Results: PSSA scores increased significantly between baseline and post workshop (35.7%→53.4%, p<0.001), as did students' confidence (55.7%→60.5%, p<0.001), and their workshop satisfaction was high (71.0%). Satisfaction and postworkshop confidence measures were moderately correlated (r=0.377, p=0.001). However, competence improvements were not significantly correlated with either satisfaction (r=-0.107 p=0.344) or change in confidence (r=-0.187 p=0.102). Discussion: Students' self-reported satisfaction and confidence measures bore little relation to expert paramedics' judgements of their educational improvements. Satisfaction and confidence measures appear to be dubious indicators of SBE learning outcomes.

Clinical Placement Before or After Simulated Learning Environments?: A Naturalistic Study of Clinical Skills Acquisition Among Early-Stage Paramedicine Students.

BACKGROUND: There is conflicting evidence surrounding the merit of clinical placements (CPs) for early-stage health-profession students. Some contend that early-stage CPs facilitate contextualization of a subsequently learned theory. Others argue that training in simulated-learning experiences (SLEs) should occur before CP to ensure that students possess at least basic competency. We sought to investigate both claims. METHODS: First-year paramedicine students (n = 85) undertook 3 days of CP and SLEs as part of course requirements. Students undertook CP either before or after participation in SLEs creating 2 groups (Clin → Sim/Sim → Clin). Clinical skills acquisition was measured via direct scenario-based clinical assessments with expert observers conducted at 4 intervals during the semester. Perceptions of difficulty of CP and SLE were measured via the National Aeronautics and Space Administration Task Load Index. RESULTS: Students' clinical assessment scores in both groups improved significantly from beginning to end of semester (P < 0.001). However, at semester's end, clinical assessment scores for the Sim → Clin group were statistically significantly greater than those of the Clin → Sim group (P = 0.021). Both groups found SLEs more demanding than CP (P < 0.001). However, compared with the Sim → Clin group, the Clin → Sim group rated SLE as substantially more time-demanding than CP (P = 0.003). CONCLUSIONS: Differences in temporal demand suggest that the Clin → Sim students had fewer opportunities to practice clinical skills during CP than the Sim → Clin students due to a more limited scope of practice. The Sim → Clin students contextualized SLE within subsequent CP resulting in greater improvement in clinical competency by semester's end in comparison with the Clin → Sim students who were forced to contextualize skills retrospectively.

Quantification of opportunities for early-stage paramedicine students to practice clinical skills during clinical placements compared with an equal dose of simulation-based workshops.

Introduction: A reported advantage of simulation-based learning environments (SLE) over clinical placements (CPs) is that the former can provide a greater number and breadth of opportunities to practice level-appropriate clinical skills compared with the random patient presentations provided during the latter. Although logical and widely accepted as fact, we find no published evidence to demonstrate the magnitude, nor indeed veracity, of this assumption. We therefore sought to quantify the clinical skills practiced by entry-level paramedicine students attending a well-selected CP compared with an equal dosage of SLE. Methods: N=37 first-year paramedicine students completed activity diaries during 3 days of CP and 3 days of SLE. Opportunities to practice clinical skills were quantified and coded as either: level-appropriate, beyond-level or of non-discipline relevance. Results: During SLE, the average student was exposed 226 times to 11 level-appropriate clinical procedures. During CP the average student was exposed 48 times to 24 clinical procedures, the majority relevant to paramedicine (63%), but a minority level-appropriate (38%). Students' opportunities for supervised, 'hands on' practice represented only 10% of exposures in either SLE or CP but in terms of raw numbers of level-appropriate opportunities, SLE provided more than CP (n=23 vs 2). Discussion: Our results confirm that SLE provides substantially more opportunities than CP for students to practice level-appropriate skills and is therefore more appropriate for repetitive practice. However, CP is likely to remain useful to students for practicing interpersonal skills and contextualisation of knowledge within the broader health system. Educators should therefore carefully articulate learning objectives before choosing between SLE and CP.

Impact of a point-of-sale tobacco display ban on smokers' spontaneous purchases: comparisons from postpurchase interviews before and after the ban in Western Australia.

OBJECTIVE: To assess the impact of the Western Australian tobacco point-of-sale display ban on spontaneous purchase behaviours. METHODS: Daily adult smokers (n=402) observed purchasing cigarettes were recruited via exit interviews either 2 months before or after the implementation of the display ban. Smokers were asked if they had intended to purchase cigarettes before entering the store to assess spontaneous purchase behaviours. Whether smokers had noticed the displays before their purchase and the extent to which this influenced their purchase decision was also assessed via non-prompting questions. RESULTS: When compared with before the ban, fewer smokers after the ban noticed the displays (27.1% vs 1.1%, p<0.001), fewer reported making spontaneous purchases (28.2% vs 19.8%, p<0.05) and fewer claimed the displays influenced their purchase decisions (free recall 5.0% vs 1.1%, p<0.05; cued recall 22.1% vs 3.8%, p<0.001). Before the ban, spontaneous purchasers were more likely than planned purchasers to suggest the displays influenced their purchase decisions (free recall 9.7% vs 3.2%, p<0.05; cued recall 40.0% vs 17.9%, p<0.01). After the ban, spontaneous purchasers nominating the influence of displays fell substantially (free recall 9.7% vs 5.6%, p=NS; cued recall 40.0% vs 11.1%, p<0.01) as it did for planned purchasers (free recall 3.2% vs 0.0%, p<0.05; cued recall 17.9% vs 2.1%, p<0.01). CONCLUSIONS: We observed a 30% reduction in smokers making spontaneous tobacco purchases after implementation of the Western Australian tobacco display ban and between a fivefold and sixfold reduction in the proportion suggesting displays influenced their decision to purchase cigarettes. These data are consistent with previous research suggesting tobacco displays encourage spontaneous purchases and their removal corresponds to reductions in the same.

Measuring the effect of cigarette plain packaging on transaction times and selection errors in a simulation experiment.

INTRODUCTION: Australia has introduced legislation to force all cigarette packaging to be generic from 2012 onwards. The tobacco retail industry estimates this will result in transaction times increasing by 15-45 s per pack and is spending at least $A10 million of tobacco industry funds on an advertising campaigns claiming that the increased time and errors associated with plain packaging will ultimately cost small businesses $A 461 million per annum and endanger 15,000 jobs. We undertook an objective experiment to test these claims. METHODOLOGY: Participants (n=52) were randomly assigned to stand in front of a display of either 50 plain or coloured cigarette packets and then were read a randomly ordered list of cigarette brands. The time participants took to locate each packet was recorded and all selection errors were noted. After 50 'transactions', participants repeated the entire experiment with the alternative plain/coloured packs. Afterwards, participants were asked in an open-ended manner whether plain or coloured packaging was easier to locate and why. RESULTS: The average transaction was significantly quicker for plain compared with coloured packs (2.92 vs 3.17 s; p=0.040). One or more mistakes were made by 40.4% of participants when selecting coloured packaging compared with only 17.3% for plain packaging (p=0.011). Qualitative results suggested that the colours and inconsistent location of brand names often served to distract when participants scanned for brands. CONCLUSION: Rather than plain packaging requiring an additional 45 s per transaction, our results suggest that it will, if anything, modestly decrease transaction times and selection errors.

Using viral e-mails to distribute tobacco control advertisements: an experimental investigation.

The authors' objective was to conduct a trial of viral e-mail marketing as a distribution method for tobacco control advertisements. University students (n = 200) in the state of Western Australia were randomly allocated to receive 1 of 2 e-mails with hyperlinks to tobacco control advertisements ("Toilet" and "Rubbish") emphasizing the disgusting nature of smoking. Recipients followed a hyperlink to a Web page playing Toilet or Rubbish on endless loop. Viewers were encouraged to forward the e-mail to their friends and invited to complete an online survey about the advertisement. Unique downloads for each advertisement were identified by internet provider (IP) location and tallied by date and geographical location to assess subsequent dissemination beyond the initial 200 students. There were 826 unique viewings of the advertisements averaging 26.9 viewings per day for the first fortnight, followed by a lower average of 4.1 hits per day for the next 3.5 months. IP addresses identified hits from 3 other Australian states and 7 other countries. Online surveys were completed by 103 respondents (12.5% of total hits) but included few smokers (n = 9). Significantly more respondents rated Toilet as "funny" compared with Rubbish (40% vs. 11%; p < .05), likely explaining why the former accounted for significantly more viewings than the latter (487 vs. 339; p < .001). There was a greater than fourfold return in dissemination for each initial e-mail sent but daily hits rapidly deteriorated over time. Entertainment appears to facilitate viral e-mails being forwarded onwards but only exceptionally compelling tobacco control materials are ever likely to become self-perpetuating.

Children's understanding of the selling versus persuasive intent of junk food advertising: implications for regulation.

Evidence suggests that until 8 years of age most children are cognitively incapable of appreciating the commercial purpose of television advertising and are particularly vulnerable to its persuasive techniques. After this age most children begin to describe the 'selling' intent of advertising and it is widely assumed this equips them with sufficient cognitive defences to protect against advertisers' persuasion attempts. However, much of the previous literature has been criticised for failing to differentiate between children's awareness of 'selling' versus 'persuasive' intent, the latter representing a more sophisticated understanding and superior cognitive defence. Unfortunately there is little literature to suggest at what age awareness of 'persuasive intent' emerges; our aim was to address this important issue. Children (n = 594) were recruited from each grade from Pre-primary (4-5 years) to Grade 7 (11-12 years) from ten primary schools in Perth, Western Australia and exposed to a McDonald's television advertisement. Understanding the purpose of television advertising was assessed both nonverbally (picture indication) and verbally (small discussion groups of 3-4), with particular distinction made between selling versus persuasive intent. Consistent with previous literature, a majority of children described the 'selling' intent of television advertising by 7-8 years both nonverbally and verbally, increasing to 90% by 11-12 years. Awareness of 'persuasive' intent emerged slowly as a function of age but even by our oldest age-group was only 40%. Vulnerability to television advertising may persist until children are far older than previously thought. These findings have important implications regarding the debate surrounding regulation of junk food (and other) advertising aimed at children.

'We're not told why--we're just told': qualitative reflections about the Western Australian Go for 2&5® fruit and vegetable campaign.

OBJECTIVE: To explore why there is a lack of acceptance among Western Australian (WA) adults of the Go for 2&5® fruit and vegetable social marketing message to consume at least five servings of vegetables per day. DESIGN: A series of focus group discussions comprised of homogeneous groups varied by sex and age, until saturation of themes was achieved, followed by thematic analysis. SETTING: Part of qualitative research for the Go for 2&5® fruit and vegetable social marketing campaign in WA (2009 population: 2.2 million). SUBJECTS: WA adults stratified by sex and age groups (18-29 and 30-55 years) drawn from the second and third quartiles of socio-economic disadvantage. RESULTS: Familiarity with the Go for 2&5® message was excellent. Understanding of what constitutes 'two servings of fruit' was excellent and regarded by participants as highly achievable. Understanding of what constitutes 'five servings of vegetables' was suboptimal with widespread overestimation contributing to the belief that it is unrealistic. Participants did not know how the 2&5 recommendation was formulated and believed that daily consumption of two servings of fruit and five of vegetables would confer no greater health benefit than one of fruit and three of vegetables. Participants assumed that the 2&5 recommendation was 'aspirational' in the sense that it was purposely exaggerated to simply encourage greater overall consumption. CONCLUSIONS: A convincing case needs to be presented to WA adults as to why they should consume five servings of vegetables per day. Continuing efforts to educate incorporating what constitutes a serving will assist perceptions that the recommendation is realistic.

Impact of smoking images in magazines on the smoking attitudes and intentions of youth: an experimental investigation.

OBJECTIVE: To determine the effect of magazine incidental smoking imagery on youths' smoking intentions. METHODS: A magazine was developed incorporating photographs of smokers (Smoking Magazine). A second version of the magazine (Non-smoking Magazine) included these photographs with the tobacco paraphernalia digitally erased. Equal numbers of smokers and non-smokers aged 14-17 years (n = 357) were randomly assigned to look through one version of the magazine and then asked a series of questions. RESULTS: Smokers made more unprompted mention of smoking imagery than non-smokers after viewing Smoking Magazine (52% vs 34%; p<0.05). Smokers viewing Smoking Magazine were more likely to report an urge to smoke (54% vs 40%; p<0.05). Female non-smokers who viewed Smoking Magazine were more likely than those who viewed Non-smoking Magazine to state a future intention to smoke (13% vs 0%; p<0.05). Female smokers were more attracted to the male models appearing in Smoking Magazine than Non-smoking Magazine (49% vs 24%; p<0.05) and the opposite was true for female non-smokers (28% vs 52%; p<0.05). Female smokers were also marginally more likely to desire looking like the female models in Smoking Magazine (64% vs 46%; p = 0.06) but no difference was observed in the non-smoking females (46% vs 46%). Male smokers and non-smokers did not differ in their responses by magazine type. CONCLUSIONS: Incidental positive smoking imagery in magazines can generate the same sorts of consumer effects attributed to advertising in general, including tobacco advertising. Sex specific results of our study may be explained by the choice of smoking images used.

Public (Mis)understanding of the UV Index.

The ultraviolet index (UVI) has been regularly reported in Australia for a decade but utilisation remains extremely low ( approximately 5%). Blunden, Lower, and Slevin, in a 2004 Journal of Health communication article, suggest that Australians' understanding of the UVI is "good," and education to increase awareness of the index is therefore no longer warranted. To test this position, focus groups were conducted followed by an intercept survey of 404 residents of Perth, Western Australia, aged 16-44 years, to explore understanding and familiarity with the UVI. Results suggested that far from being "good," the familiarity and understanding of the UVI of at least half of Australians is poor. This was exemplified by the following: mean estimations of average UVI values in summer and winter being highly exaggerated (19.8 and 11.8, respectively); 61.2% not appreciating that the UVI is independent of temperature; at least 55.0% not appreciating that UV conditions peak at solar noon; and 23.3% of 22-44 year olds confusing the UVI with a "burn-time" measure. People who do not understand the UVI are unlikely to utilise it effectively. It therefore remains possible that utilisation of the UVI remains low because understanding is poor. Future efforts to improve utilisation of the UVI, particularly among those looking at new display formats, may therefore be ineffective, unless they also incorporate strategies to facilitate understanding of the measure.

People's perceptions of cancer survivability: implications for oncologists.

Individuals typically overestimate survival for lung cancer and underestimate it for melanoma. However, reporting of results generally masks the extent of disagreement between people on survival rates. Most methods used to question individuals are of little use and are not comparable across studies. The topic of people's perceptions of survival for various cancers is under-researched. A clearer definition is needed of survivability, as is a standard way to measure it and then present the information. We have undertaken a review of studies reporting public perceptions of cancer survival rates and compared the results, where possible, with actual survival rates. We also investigate some potential implications of people's underestimation or overestimation of survival for screening and prevention behaviours and delineate implications for oncologists.

The weighty issue of Australian television food advertising and childhood obesity.

ISSUE ADDRESSED: The aim of this paper is to provide an accessible overview of research literature on the link between childhood obesity and food advertising on Australian television. METHODS: A systematic review of current medical, public health, psychological and marketing research literature surrounding the topics of childhood obesity and television food advertising, with emphasis on Australian data. RESULTS: Childhood obesity rates have tripled since 1985, mirrored by increases in consumption of energy-dense foods. Energy-dense food advertising is ubiquitous in children's television programming, but children's ability to perceive the commercial intent of advertisements only emerges gradually as a function of age. Until such time, children are trusting, and hence vulnerable, to food advertising, influencing their desires and purchase requests to parents. There is robust evidence to suggest that television viewing and childhood obesity are related. However, the direction of causation and specific contribution of food advertising remains equivocal. Moreover, the link between television and childhood obesity is surprisingly weak, with only a small independent effect size (approximately 1%). CONCLUSIONS: Television food advertising seems to have only a very small, indirect link to childhood obesity.

Western Australians' perceptions of the survivability of different cancers: implications for public education campaigns.

ISSUE ADDRESSED: People's decisions about whether to participate in cancer screening and to seek treatment are related to their perceptions of the survivability of cancer. However, there is little empirical evidence to suggest people's awareness of the survivability of different cancers. The object of the present study was to determine people's estimates of the survivability of 10 cancers. METHODS: In 2001, data were collected via computer-assisted telephone interviews with 1,501 randomly selected metropolitan and rural Western Australian adults. Participants were presented with a list of 10 cancers. Half the sample was asked to nominate the three most survivable, and half was asked to nominate the three least survivable cancers. RESULTS: Participants' rankings of the 10 cancers in terms of perceived survivability were consistent with cancer registry data, with the exception of bone cancer which was underrated. Respondents' average estimates of five-year survival rates were also accurate (+/- 2-6%) for cancers with relatively high survival rates such as breast, cervical, prostate, and other skin cancers, with the exception of melanoma, which was underestimated (20%). However, average estimated survival rates for cancers with low survivability, such as leukaemia, lung, and stomach cancers, were substantially overestimated, being 31%, 38% and 43% higher respectively. CONCLUSIONS: Western Australians appear to have a reasonable understanding of the relative survivability of various cancers but a poorer appreciation of actual survival rates.

Changes in beliefs about cancer in Western Australia, 1964-2001.

OBJECTIVE: To assess changes in people's knowledge and beliefs about cancer between 1964 and 2001. DESIGN: Questions in a 1964 survey of beliefs about cancer (randomly selected households) were replicated in a 2001 telephone survey (random-digit dialing). SETTING: Perth, Western Australia. PARTICIPANTS: 984 and 491 participants aged 20 years or older in the 1964 and 2001 surveys, respectively (response rates, 86.8% and 47.0%). MAIN OUTCOME MEASURES: Changes in knowledge and beliefs about cancer. RESULTS: Between 1964 and 2001, there were major improvements in knowledge about the causes of cancer, with several myths dispelled. In 1964, the proportion of Perth residents surveyed who believed that cancer is contagious was 20% (95% CI, 18%-22%), compared with 3% (95% CI, 2%-4%) in 2001. Similarly, the proportion who believed cancer is caused by "a knock" was 25% (95% CI, 22%-28%) in 1964, compared with 1% (95% CI, 0-2%) in 2001. Cancer screening participation rates also greatly improved, from 18% (95% CI, 16%-20%) in 1964 to 77% (95% CI, 73%-81%) in 2001. Changes in participants' sources of knowledge about cancer were also evident, with family members and television increasing markedly as sources of information. CONCLUSIONS: Improved education of the public in health matters over the past four decades appears to have had a major and positive impact on knowledge about cancer.