Real-world effectiveness of a social-psychological intervention translated from controlled trials to classrooms.

Social-psychological interventions have raised the learning and performance of students in rigorous efficacy trials. Yet, after they are distributed "in the wild" for students to self-administer, there has been little research following up on their translational effectiveness. We used cutting-edge educational technology to tailor, scale up, and track a previously-validated Strategic Resource Use intervention among 12,065 college students in 14 STEM and Economics classes. Students who self-administered this "Exam Playbook" benefitted by an average of 2.17 percentage points (i.e., a standardized effect size of 0.18), compared to non-users. This effect size was 1.65 percentage points when controlling for college entrance exam scores and 1.75 [-1.88] for adding [dropping] the Exam Playbook in stratified matching analyses. Average benefits differed in magnitude by the conduciveness of the class climate (including peer norms and incentives), gender, first-generation status, as well as how often and how early they used the intervention. These findings on how, when, and who naturally adopts these resources address a need to improve prediction, translation, and scalability of social-psychological intervention benefits.

Adapting an in-person patient-caregiver communication intervention to a tailored web-based format.

BACKGROUND: Interventions that target cancer patients and their caregivers have been shown to improve patient-caregiver communication, support, and emotional well-being. OBJECTIVE: To adapt an in-person communication intervention for cancer patients and caregivers to a web-based format, and to examine the usability and acceptability of the web-based program among representative users. METHODS: A tailored, interactive web-based communication program for cancer patients and their family caregivers was developed based on an existing in-person, nurse-delivered intervention. The development process involved: (1) building a multidisciplinary team of content and web design experts, (2) combining key components of the in-person intervention with the unique tailoring and interactive features of a web-based platform, and (3) conducting focus groups and usability testing to obtain feedback from representative program users at multiple time points. RESULTS: Four focus groups with 2-3 patient-caregiver pairs per group (n = 22 total participants) and two iterations of usability testing with four patient-caregiver pairs per session (n = 16 total participants) were conducted. Response to the program's structure, design, and content was favorable, even among users who were older or had limited computer and Internet experience. The program received high ratings for ease of use and overall usability (mean System Usability Score of 89.5 out of 100). CONCLUSIONS: Many elements of a nurse-delivered patient-caregiver intervention can be successfully adapted to a web-based format. A multidisciplinary design team and an iterative evaluation process with representative users were instrumental in the development of a usable and well-received web-based program.

OMG do not say LOL: obese adolescents' perspectives on the content of text messages to enhance weight loss efforts.

Adolescents participating in weight loss programs experience difficulty adhering to behavior change recommendations. Communications technology provides a low cost means to increase the frequency of contact with adolescents which can improve their engagement and also lead to behavior change. Within a larger project on the development of tailored text messages for adolescents enrolled in an existing multidisciplinary weight management program, this study explored participants' perspectives about message content. A library of messages was developed focused on topics central to weight management. Four focus groups were conducted with a total of 24 participants from the weight management program to gage their reactions to the messages. Detailed notes from the focus groups were analyzed to assess the acceptability of individual messages and to identify overriding themes. Results indicate that participants were very enthusiastic about receiving text messages. They preferred messages that provided recipe ideas, included successful weight loss strategies used by peers, and requested feedback regarding their progress. They preferred positive, encouraging, and direct messages. They were unanimous that messages should include encouraging symbols (e.g., exclamation points and "smiley faces") as often as possible. They emphasized that any mention of unhealthy foods or behaviors would trigger them to eat those foods or engage in those behaviors. Text messaging acronyms (e.g., LOL) were considered too informal for messages from healthcare providers. This study suggests that including text messages in obesity interventions is acceptable to obese adolescents as a means of supporting their weight loss efforts, and it highlights the need for such messages to be carefully constructed.

The distinct role of comparative risk perceptions in a breast cancer prevention program.

BACKGROUND: Comparative risk perceptions may rival other types of information in terms of effects on health behavior decisions. PURPOSE: We examined associations between comparative risk perceptions, affect, and behavior while controlling for absolute risk perceptions and actual risk. METHODS: Women at an increased risk of breast cancer participated in a program to learn about tamoxifen which can reduce the risk of breast cancer. They reported comparative risk perceptions of breast cancer and completed measures of anxiety, knowledge, and tamoxifen-related behavior intentions. Three months later, the women reported their behavior. RESULTS: Comparative risk perceptions were positively correlated with anxiety, knowledge, intentions, and behavior 3 months later. After controlling for participants' actual risk of breast cancer and absolute risk perceptions, comparative risk perceptions predicted anxiety and knowledge, but not intentions or behavior. CONCLUSIONS: Comparative risk perceptions can affect patient outcomes like anxiety and knowledge independently of absolute risk perceptions and actual risk information.

Women's decisions regarding tamoxifen for breast cancer prevention: responses to a tailored decision aid.

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.

Testing whether decision aids introduce cognitive biases: results of a randomized trial.

OBJECTIVE: Women at high risk of breast cancer face a difficult decision whether to take medications like tamoxifen to prevent a first breast cancer diagnosis. Decision aids (DAs) offer a promising method of helping them make this decision. But concern lingers that DAs might introduce cognitive biases. METHODS: We recruited 663 women at high risk of breast cancer and presented them with a DA designed to experimentally test potential methods of identifying and reducing cognitive biases that could influence this decision, by varying specific aspects of the DA across participants in a factorial design. RESULTS: Participants were susceptible to a cognitive bias - an order effect - such that those who learned first about the risks of tamoxifen thought more favorably of the drug than women who learned first about the benefits. This order effect was eliminated among women who received additional information about competing health risks. CONCLUSION: We discovered that the order of risk/benefit information influenced women's perceptions of tamoxifen. This bias was eliminated by providing contextual information about competing health risks. PRACTICE IMPLICATIONS: We have demonstrated the feasibility of using factorial experimental designs to test whether DAs introduce cognitive biases, and whether specific elements of DAs can reduce such biases.

Communicating side effect risks in a tamoxifen prophylaxis decision aid: the debiasing influence of pictographs.

OBJECTIVE: To experimentally test whether using pictographs (image matrices), incremental risk formats, and varied risk denominators would influence perceptions and comprehension of side effect risks in an online decision aid about prophylactic use of tamoxifen to prevent primary breast cancers. METHODS: We recruited 631 women with elevated breast cancer risk from two healthcare organizations. Participants saw tailored estimates of the risks of 5 side effects: endometrial cancer, blood clotting, cataracts, hormonal symptoms, and sexual problems. Presentation format was randomly varied in a three factor design: (A) risk information was displayed either in pictographs or numeric text; (B) presentations either reported total risks with and without tamoxifen or highlighted the incremental risk most relevant for decision making; and (C) risk estimates used 100 or 1000 person denominators. Primary outcome measures included risk perceptions and gist knowledge. RESULTS: Incremental risk formats consistently lowered perceived risk of side effects but resulted in low knowledge when displayed by numeric text only. Adding pictographs, however, produced significantly higher comprehension levels. CONCLUSIONS: Pictographs make risk statistics easier to interpret, reducing biases associated with incremental risk presentations. PRACTICE IMPLICATIONS: Including graphs in risk communications is essential to support an informed treatment decision-making process.

Alternate methods of framing information about medication side effects: incremental risk versus total risk of occurrence.

Communications of treatment risk, such as medication package inserts, commonly report total rates of adverse reactions (e.g., 4% get heartburn with placebo, 9% with medication). This approach, however, requires mental arithmetic to distinguish the incremental risk caused by medication (here, 5%) from the total post-treatment risk. In two Internet-administered survey experiments (N = 2,012 and 1,393), we tested whether explicitly reporting the incremental risk and framing it as the "additional risk" of complications influenced people's impressions of adverse event risks. Study 1 compared side-by-side displays of total risks against sequential presentations that highlighted the incremental risk, using both text and graphical formats. Results showed that incremental risk formats significantly lowered participants' worry about complications and reduced biases caused by varying the risk denominator. Study 2 unpacked this factor and showed that its effect on both perceived likelihood and worry derives primarily from the incremental risk framing rather than from sequential presentation. Explicitly reporting incremental risk statistics appears to facilitate recognition of how much risk already exists at baseline. Presenting adverse reaction risks in this manner may improve patient comprehension of the effects of treatment decisions and support effective risk communication.

Measuring numeracy without a math test: development of the Subjective Numeracy Scale.

BACKGROUND: Basic numeracy skills are necessary before patients can understand the risks of medical treatments. Previous research has used objective measures, similar to mathematics tests, to evaluate numeracy. OBJECTIVES: To design a subjective measure (i.e., self-assessment) of quantitative ability that distinguishes low- and high-numerate individuals yet is less aversive, quicker to administer, and more usable for telephone and Internet surveys than existing numeracy measures. RESEARCH DESIGN: Paper-and-pencil questionnaires. SUBJECTS: The general public (N = 703) surveyed at 2 hospitals. MEASURES: Forty-nine subjective numeracy questions were compared to measures of objective numeracy. RESULTS: An 8-item measure, the Subjective Numeracy Scale (SNS), was developed through several rounds of testing. Four items measure people's beliefs about their skill in performing various mathematical operations, and 4 measure people's preferences regarding the presentation of numerical information. The SNS was significantly correlated with Lipkus and others' objective numeracy scale (correlations: 0.63-0.68) yet was completed in less time (24 s/item v. 31 s/item, P < 0.05) and was perceived as less stressful (1.62 v. 2.69, P < 0.01) and less frustrating (1.92 v. 2.88, P < 0.01). Fifty percent of participants who completed the SNS volunteered to participate in another study, whereas only 8% of those who completed the Lipkus and others scale similarly volunteered (odds ratio = 11.00, 95% confidence interval = 2.14-56.65). CONCLUSIONS: The SNS correlates well with mathematical test measures of objective numeracy but can be administered in less time and with less burden. In addition, it is much more likely to leave participants willing to participate in additional research and shows much lower rates of missing or incomplete data.

Deaf persons and computer use.

Deaf person's computer use was studied (N = 227). Respondents self-administered a survey in their preferred language (voice, American Sign Language, captions, or printed English). A small nonparticipant sample was also recruited. Demographics were consistent with those in other studies of deaf people: 63% of respondents reported computer use, mostly at home; 50% of nonparticipants reported computer use. Subjects with hearing loss due to meningitis were less likely to use computers (p = .0004). Computer use was associated with English usage at home (p = .008), with hearing persons (p = .002), and with physicians and nurses (p = .00001). It was also associated with the use of Signed English as a child to communicate (p = .02), teacher use of Signed English (p = .04), and teacher use of ASL (p = .03). Two thirds of respondents reported using computers, though nonresponder data suggested less use among all deaf persons. Computer use was associated with English use and inversely associated with hearing loss due to meningitis.

The development of an Alzheimer's disease channel for the Michigan Interactive Health Kiosk Project.

The overall objective of this article is to describe the development and implementation of an Alzheimer's disease (AD) module for the Michigan Interactive Health Kiosk Project. This project provides access to health information via 100 kiosks located in public places throughout the state (e.g., churches, senior centers, schools, shopping malls, grocery stores, hospitals) using interactive multimedia software. Because the kiosk screen was designed to resemble a television set, program modules are referred to as "channels." The AD channel is designed to increase knowledge and awareness of the disease among the general public. After an overview of the overall project, the steps involved in developing the AD channel and strategies designed to monitor its use are described, including touch-screen usage data and an on-line user survey. Finally, marketing and promotion of the channel and the implications of this initiative for disseminating information about AD are discussed.

Adolescents searching for health information on the Internet: an observational study.

BACKGROUND: Adolescents' access to health information on the Internet is partly a function of their ability to search for and find answers to their health-related questions. Adolescents may have unique health and computer literacy needs. Although many surveys, interviews, and focus groups have been utilized to understand the information-seeking and information-retrieval behavior of adolescents looking for health information online, we were unable to locate observations of individual adolescents that have been conducted in this context. OBJECTIVE: This study was designed to understand how adolescents search for health information using the Internet and what implications this may have on access to health information. METHODS: A convenience sample of 12 students (age 12-17 years) from 1 middle school and 2 high schools in southeast Michigan were provided with 6 health-related questions and asked to look for answers using the Internet. Researchers recorded 68 specific searches using software that captured screen images as well as synchronized audio recordings. Recordings were reviewed later and specific search techniques and strategies were coded. A qualitative review of the verbal communication was also performed. RESULTS: Out of 68 observed searches, 47 (69%) were successful in that the adolescent found a correct and useful answer to the health question. The majority of sites that students attempted to access were retrieved directly from search engine results (77%) or a search engine's recommended links (10%); only a small percentage were directly accessed (5%) or linked from another site (7%). The majority (83%) of followed links from search engine results came from the first 9 results. Incorrect spelling (30 of 132 search terms), number of pages visited within a site (ranging from 1-15), and overall search strategy (eg, using a search engine versus directly accessing a site), were each important determinants of success. Qualitative analysis revealed that participants used a trial-and-error approach to formulate search strings, scanned pages randomly instead of systematically, and did not consider the source of the content when searching for health information. CONCLUSIONS: This study provides a useful snapshot of current adolescent searching patterns. The results have implications for constructing realistic simulations of adolescent search behavior, improving distribution and usefulness of Web sites with health information relevant to adolescents, and enhancing educators' knowledge of what specific pitfalls students are likely to encounter.

Does pornography-blocking software block access to health information on the Internet?

CONTEXT: The Internet has become an important tool for finding health information, especially among adolescents. Many computers have software designed to block access to Internet pornography. Because pornography-blocking software cannot perfectly discriminate between pornographic and nonpornographic Web sites, such products may block access to health information sites, particularly those related to sexuality. OBJECTIVE: To quantify the extent to which pornography-blocking software used in schools and libraries limits access to health information Web sites. DESIGN AND SETTING: In a simulation of adolescent Internet searching, we compiled search results from 24 health information searches (n = 3206) and 6 pornography searches (n = 781). We then classified the content of each site as either health information (n = 2467), pornography (n = 516), or other (n = 1004). We also compiled a list of top teen health information sites (n = 586). We then tested 6 blocking products commonly used in schools and libraries and 1 blocking product used on home computers, each at 2 or 3 levels of blocking restrictiveness. MAIN OUTCOME MEASURE: Rates of health information and pornography blocking. RESULTS: At the least restrictive blocking setting, configured to block only pornography, the products blocked a mean of only 1.4% of health information sites. The differences between blocking products was small (range, 0.6%-2.3%). However, about 10% of health sites found using some search terms related to sexuality (eg, safe sex, condoms) and homosexuality (eg, gay) were blocked. The mean pornography blocking rate was 87% (range, 84%-90%). At moderate settings, the mean blocking rate was 5% for health information and 90% for pornography. At the most restrictive settings, health information blocking increased substantially (24%), but pornography blocking was only slightly higher (91%). CONCLUSIONS: Blocking settings have a greater impact than choice of blocking product on frequency of health information blocking. At their least restrictive settings, overblocking of general health information poses a relatively minor impediment. However, searches on some terms related to sexuality led to substantially more health information blocking. More restrictive blocking configurations blocked pornography only slightly more, but substantially increased blocking of health information sites.