Using pictographs to enhance recall of spoken medical instructions II.

The first study in this series [Houts PS, Bachrach R, Witmer JT, Tringali CA, Bucher JA, Localio RA. Patient Educ. Couns. 1998;35:83-8] found that recall of spoken medical instructions averaged 14% but that, when pictographs (drawings representing the instructions) accompanied the spoken instructions and were present during recall, 85% of medical instructions were remembered correctly. Those findings suggested that spoken instructions plus pictographs may be a way to give people with low literacy skills access to medical information that is normally available only in written form. However, there were three important limitations to that study: (1) the subjects were literate and perhaps literate people remember pictograph meanings better than people with low literacy skills; (2) only short term recall was tested and, for medical information to be useful clinically, it must be remembered for significant periods of time and (3) a maximum of 50 instructions were shown in pictographs, whereas managing complex illnesses may require remembering several hundred instructions. This study addresses those limitations by investigating 4-week recall of 236 medical instructions accompanied by pictographs by people with low literacy skills. Subjects were 21 adult clients of an inner city job training program who had less than fifth grade reading skills. Results showed 85% mean correct recall of pictograph meanings immediately after training (range from 63 to 99%) and 71% after 4 weeks (range from 33 to 94%). These results indicate that people with low literacy skills can, with the help of pictographs, recall large amounts of medical information for significant periods of time. The impact of pictographs on symptom management and patient quality of life remains to be studied.

Mixed reference frames for dynamic inhibition of return.

Reference frames mediating inhibition of return (IOR) in dynamic displays were investigated by comparing the effects of a cue in simple versus extended objects. Experiment 1 replicated S. P. Tipper, B. Weaver, L. M. Jerreat, and A. L. Burak's (1994) finding of location- and object-based IOR for boxes rotating about fixation. In Experiments 2 and 3, the boxes were replaced by two boomerang-shaped objects. Response times were slowed to all target locations across a cued object. They were also slowed to locations vacated by the uncued region of the cued object-evidence for a representation the authors call the "perceptual footprint." Whereas an object served as the medium for location-based IOR for B. S. Gibson and H. Egeth (1994), the environment served as the medium for object- and location-based IOR in Experiments 2 and 3. This suggests that (a) frames of reference may be considered hierarchically and (b) nesting of frames is context dependent.

On the distinction between visual salience and stimulus-driven attentional capture.

It is often assumed that the efficient detection of salient visual objects in search reflects stimulus-driven attentional capture. Evidence for this assumption, however, comes from tasks in which the salient object is task relevant and therefore may elicit a deliberate deployment of attention. In 9 experiments, participants searched for a nonsalient target (vertical among tilted bars). In each display, 1 bar was highly salient in a different dimension (e.g., color or motion). When the target and salient elements coincided only rarely, reducing the incentive to attend deliberately to the salient stimuli, response times depended little on whether the target was salient, although some interesting exceptions were observed. It is concluded that efficient selection of an element in visual search does not constitute evidence that the element captures attention in a purely stimulus-driven fashion.

How does feature-based attention affect visual processing?

Five experiments are reported from which it is concluded that attending on the basis of a stimulus feature (e.g., red) does not directly affect the sensory quality of stimuli that possess that feature. Feature-based attention was manipulated in a visual search task by providing information about the probability that the target would possess a given feature (e.g., "The target has a 1.0 probability of being red when present.") Feature-based attention failed to aid performance under "data-limited" conditions (i.e., those under which performance was primarily affected by the quality of the stimulus) but did affect performance under conditions that were not data limited (Experiments 1-3). If attending to a feature had affected the sensory quality of stimuli, performance should have been aided under all conditions. Experiments 4 and 5 provided converging support for this conclusion.

Goal-directed and stimulus-driven attention in cross-dimensional texture segregation.

Goal-directed and stimulus-driven control of attention was examined in a visual texture segregation task. Recent published reports have debated the existence and efficiency of goal-directed guidance of attention. Some of this research has focused on the apparent stimulus-driven attentional priority given to salient distractors, even when they are known to be irrelevant to the task. In the present study, subjects searched a texture array for targets defined along one dimension. These displays also included distractors created by variation in an irrelevant dimension. Targets were of three different overall shapes. On each trial, distractors could be the same shape as the target or one of the other two shapes. In two experiments subjects were informed of the overall shape of the target prior to stimulus presentation. In these experiments, distractors that did not match the overall shape of the target caused less interference than distractors that matched the target's shape. In the third experiment, subjects were not informed of the overall shape of the target. In this experiment all distractors caused roughly equal interference. The results of these experiments demonstrate that if subjects are given information about the overall shape of the target, they are able to use this information to reduce interference from distractors that do not match the overall target shape. While acknowledging some stimulus-driven interference, this illustrates a previously unexplored source of goal-directed guidance that can reduce interfering effects of even salient distractors and argues against purely stimulus-driven control of attention.

Goal-directed guidance of attention: evidence from conjunctive visual search.

Conjunctive visual search is most difficult when distractor types are in equal proportions and gets easier as the proportions diverge (e.g., E. Zohary & S. Hochstein, 1989). This may reflect restriction of search to the feature shared by the target and the less-frequent distractor. Alternatively, such effects could reflect target salience, which varies with distractor ratio. In 2 experiments, 60 participants searched 64-element displays for a conjunctive target among distractors of 2 types in various proportions. Participants were correctly informed (Experiment 1) or misinformed (Experiment 2) about which distractor type would be less frequent on most trials. In both experiments, the distractor-ratio effect was significantly influenced by the information provided to participants. These findings demonstrate the efficacy of top-down information in guiding attention and show that it can be applied flexibly, weighted toward particular target features.

Perception without attention: evidence of grouping under conditions of inattention.

Many theories of visual perception assume that before attention is allocated within a scene, visual information is parsed according to the Gestalt principles of organization. This assumption has been challenged by experiments in which participants were unable to identify what Gestalt grouping patterns had occurred in the background of primary-task displays (A. Mack, B. Tang, R. Tuma, S. Kahn, & I. Rock, 1992). In the present study, participants reported which of 2 horizontal lines was longer. Dots in the background, if grouped, formed displays similar to the Ponzo illusion (Experiments 1 and 2) or the Müller-Lyer illusion (Experiment 3). Despite inaccurate reports of what the patterns were, participants' responses on the line-length discrimination task were clearly affected by the 2 illusions. These results suggest that Gestalt grouping does occur without attention but that the patterns thus formed may not be encoded in memory without attention.

Beyond similarity: masking of the target is sufficient to cause the attentional blink.

When subjects are asked to identify a letter target embedded in a rapid serial visual presentation stream, the detection of a subsequent letter probe is briefly impaired. This transient deficit in probe detection, termed the "attentional blink," depends on the type of item that immediately follows the letter target (Raymond, Shapiro, & Arnell, 1995). Two models have been proposed to account for this effect. The interference model of the attentional blink predicts that visual similarity between the probe and item immediately following the target (+1 item) causes the attentional blink, whereas the two-stage model is based on the notion that increased time needed to process the target letter causes the attentional blink. In order to test between these two possibilities, the masking properties of the +1 item and its similarity to the probe were varied. We found the attentional blink when the +1 item acted as a mask of the target, even though the +1 item and the probe were visually dissimilar. This pattern of results supports the two-stage model of the attentional blink.

Visual attention: control, representation, and time course.

Three central problems in the recent literature on visual attention are reviewed. The first concerns the control of attention by top-down (or goal-directed) and bottom-up (or stimulus-driven) processes. The second concerns the representational basis for visual selection, including how much attention can be said to be location- or object-based. Finally, we consider the time course of attention as it is directed to one stimulus after another.

Are attentional dwell times inconsistent with serial visual search?

Duncan, Ward, and Shapiro (1994) estimated that attention must remain focused on an object for several hundred milliseconds before being shifted to another object, and they referred to this period as theattentional dwell time. An important implication of these long estimates of the dwell time for models of visual search is that the search process must not involve an item-by-item serial scanning mechanism. If it did, then searching through an array of items would require enormous amounts of time, which-based on data from visual search experiments-it does not. The present report, however, provides evidence that the long estimates of attentional dwell time were caused, at least in part, by the use of masked targets. Implications of these variable estimates of the attentional dwell time for models of visual search are discussed.

Inhibition and disinhibition of return: evidence from temporal order judgments.

In the present study the temporal order judgment (TOJ) task was used to investigate whether or not inhibition of return (IOR) affects perceptual processing. Previous failures to obtain IOR in the TOJ task have been taken to suggest that IOR does not affect perceptual processing (e.g., Maylor, 1985). The present study showed that IOR is modulated by the temporal disparity between successive targets as well as the relative order in which they appear at cued and uncued locations. Consequently, IOR affects TOJs in some conditions but not in others. The selective occurrence of IOR in the TOJ task provides converging support for the notion that IOR does affect perceptual processing, and also accounts for the previous failures to observe IOR in the TOJ task. Moreover, these and other results suggest that inhibitory processing at the cued location can be disinhibited when stimulation occurs at other locations.

Overriding stimulus-driven attentional capture.

Theeuwes (1992) found a distracting effect of irrelevant-dimension singletons in a task involving search for a known target. He argued from this that selectivity is determined solely by stimulus salience; the parallel stage of visual processing cannot provide top-down guidance to the attentive stage sufficient to permit completely selective use of task-relevant information. We argue that in the task used by Theeuwes, subjects may have adopted the strategy of searching for an odd form even though the specific target form was known. In Experiment 1, we replicated Theeuwes's findings. Search for a circle target among diamond nontargets was disrupted by the presence of a diamond nontarget that was uniquely colored. In two subsequent experiments, we discouraged the singleton detection strategy, forcing subjects to search for the target feature. There was no distracting effect of a color singleton in these experiments, even with displays physically identical to those of Experiment 1, demonstrating that top-down selectivity is indeed possible during visual search. We conclude that goal-directed selection of a specific known featural identity may override stimulus-driven capture by salient featural singletons.

Inhibition of return to object-based and environment-based locations.

Inhibition of return (IOR) has been described in terms of two functional components. The location-based component is associated with descriptions of spatially fixed, environmental locations; the object-based component is associated with more abstract descriptions of spatially invariant objects. In the present study, we hypothesized that the location-based component may also be associated with descriptions of spatially invariant objects because, like environment-based descriptions, object-based descriptions have an intrinsic spatial structure. To test this hypothesis, we employed a computer-generated depiction of a brick that rotated in depth between the presentations of cue and target. The results of four experiments showed that IOR accrued to locations that remained fixed with respect to the brick as well as the environment, suggesting that both object-based and environment-based descriptions can influence location-based IOR.

Nucleus basalis magnocellularis and attention: effects of muscimol infusions.

The basal forebrain is important in cognitive processing. Most studies have focused on the importance of this area in mnemonic processing. However, the nucleus basalis magnocellularis (NBM), which is a major component of the basal forebrain, may also be involved in attentional processes. Attention can influence the sensitivity of perceptual processes, as assessed by discriminability, or the selection of response strategies, as assessed by bias. This experiment examined whether temporary inactivation of the NBM, using the GABA agonist muscimol, would interfere with attention. Each rat was tested in a 2-choice reaction time (RT) task in which stimulus frequency was varied. RT and error rate increased, and discriminability decreased following muscimol infusions into the NBM. Bias was unchanged. The pattern of results provides evidence that the NBM is important in attention, and this influence of the NBM acts primarily on perceptual aspects of attention.

Response time and accuracy revisited: converging support for the interactive race model.

The interactive race model embodies 2 central claims: that divided attention is best described as a race between separately processed codes and that the 2 types of design contingency to which the model is sensitive affect different processing stages. Previous support for the model has come from a series of redundant-target tasks examining reaction time (RT) (J.T. Mordkoff & S. Yantis, 1991). We tested both central claims using near-threshold, accuracy tasks. This approach capitalizes on a known difference between RT and accuracy measures: that (in simple tasks) accuracy is sensitive only to perceptual manipulations, whereas RT is affected by both perceptual and postperceptual factors (J.L. Santee & H.E. Egeth, 1982). The results from 3 experiments provide converging support for the proposed loci of the 2 contingency-sensitive mechanisms within the interactive race model, as well as additional evidence concerning the differential sensitivities of RT and accuracy measures.

Expectancy and stimulus frequency: a comparative analysis in rats and humans.

We examined whether expectancy, one of several factors influencing attention, is similarly affected in rats and humans by manipulation of relative stimulus frequency. A two-choice reaction time (RT) task was developed for rats, and an analogous task was used for humans. Errors, RTs, discriminability, and response bias were measured. Both rats and humans shifted their response bias to the more frequent stimulus, with no change in overall discriminability. As stimulus probability or stimulus repetition increased, RTs and errors decreased. These results illustrate the similarity of expectancy in rats and humans. This two-choice RT task for rats can be used in future studies to examine the neuronal mechanisms of expectancy and attention.

Consequences of allocating attention to locations and to other attributes.

Simple reaction time to a light target may be lengthened when the light is preceded by a noninformative stimulus at the same location. This is known as inhibition of return. Does inhibition of return result if the relation between successive stimuli is defined in terms of color or orientation? Subjects pressed a key when a small square was displayed. In Experiments 1-3, location and color of the square were manipulated; there was inhibition of return based on location, but not on color. In Experiments 4-5, a confounding of color and luminance was eliminated, with no change in results. In Experiments 6-7, the background was composed of vertical stripes and the squares were composed of left- or right-oriented diagonal stripes. There was evidence of inhibition of return based on location, but not on orientation. These data support the idea that location is processed differently from other features.

Further evidence for a time-independent shift of the focus of attention.

The separation between stimuli was manipulated in a same-different matching task. In Experiment 1, stimuli were upright Ts and/or Ls, whereas in Experiment 2, they were rotated Ts and/or Ls. In both experiments, mean reaction time (RT) for the same-different judgment did not increase as a function of interletter separation, suggesting either that the time needed to relocate attention was independent of distance, or that the stimuli were processed in parallel. These alternatives were tested in a third experiment, with a diagnostic for parallel processing proposed by Egeth and Dagenbach (1991). The diagnostic indicated that the rotated Ts and Ls in Experiment 2 were processed serially. If serial processing implies the utilization of attention, then the results of Experiment 2 suggest that relocation of attention is time-invariant with respect to distance.

Parallel versus serial processing in visual search: further evidence from subadditive effects of visual quality.

The authors propose a diagnostic for distinguishing between serial and parallel processing in visual search; it is based on testing for subadditive effects of a within-trial visual quality manipulation on target-absent trials. It was evaluated in 2 experiments wherein parallel and serial processing might be expected on the basis of previous work and was then applied to a more uncertain situation in a third experiment. The diagnostic indicates parallel processing of stimuli that differ from each other on a featural basis (Xs and Os) and canonical letters that differ in line arrangement (Ts and Ls) but serial processing when Ts and Ls are randomly rotated. These results form a coherent pattern that is understandable in terms of the literature on visual search, and thus they suggest that the diagnostic may be a useful addition to the methodology used to distinguish between serial and parallel processes.

Local processes in preattentive feature detection.

Sagi and Julesz (1987) claimed that for a target to be detected preattentively, it must be within some small critical distance of a nontarget. The independent effects of separation and display size, which were confounded in the Sagi and Julesz experiments, were examined. Experiments 1 and 2 revealed that in tasks requiring search for a color-defined target, target-nontarget separation had no effect on reaction time (RT). Display size, however, was inversely related to RT. Experiment 3 ruled out the possibility that the decreasing function of RT with display size was due to arousal caused by higher display luminance. When nontarget grouping was inhibited, (Exp. 4) it was found that RT no longer decreased with increasing display size. This suggests that nontarget grouping may have been the cause of the improved performance at larger display sizes. Experiments 5 and 6 extended the results to line segments, the stimuli used by Sagi and Julesz.