Persuasive Interventions for Controversial Cancer Screening Recommendations: Testing a Novel Approach to Help Patients Make Evidence-Based Decisions

Abstract

PURPOSE We wanted to evaluate novel decision aids designed to help patients trust and accept the controversial, evidence-based, US Preventive Services Task Force recommendations about prostate cancer screening (from 2012) and mammography screening for women aged 40 to 49 years (from 2009). METHODSWe created recorded vignettes of physician-patient discussions about prostate cancer screening and mammography, accompanied by illustrative slides, based on principles derived from preceding qualitative work and behavioral science literature. We conducted a randomized crossover study with repeated measures with 27 men aged 50 to 74 years and 35 women aged 40 to 49 years. All participants saw a video intervention and a more traditional, paper-based decision aid intervention in random order. At entry and after seeing each intervention, they were surveyed about screening intentions, perceptions of benefits and harm, and decisional conflict.RESULTS Changes in screening intentions were analyzed without regard to order of intervention after an initial analyses showed no evidence of an order effect. At baseline, 69% of men and 86% of women reported wanting screening, with 31% and 6%, respectively, unsure. Mean change on a 3-point, yes, unsure, no scale was -0.93 (P = <.001) for men and -0.50 (P = <.001) for women after seeing the video interventions vs 0.0 and -0.06 (P = .75) after seeing the print interventions. At the study end, 33% of men and 49% of women wanted screening, and 11% and 20%, respectively, were unsure. CONCLUSIONS Our novel, persuasive video interventions significantly changed the screening intentions of substantial proportions of viewers. Our approach needs further testing but may provide a model for helping patients to consider and accept evidence-based, counterintuitive recommendations. 2017;15:48-55. https://doi.org/10.1370/afm.1996. Ann Fam Med INTRODUCTIONP atients face many medical decisions, and rarely is the evidence about the balance of benefits and harms so unequivocal that it can be assumed all patients would make the same choice if adequately informed. Evidence can be complicated and incomplete, and experts' recommendations may conflict. Even when there is an evidence-based recommendation for a specific medical decision, patients' values might lead to a different choice. Patients are exposed to social norms, media campaigns, and powerful anecdotes regarding testing.1,2 Furthermore, human decision making rarely fits the idealized model of a rational, informed process. 3,4 Order of presentation, loss-vs gain-based framing, anchor effects, and perceived norms can introduce biases, 5-10 and adding information can make decisions more difficult.11-14 Shortcuts (heuristics) used to simplify decisions often lead to suboptimal choices. 15,16 Thus, the ideal of the informed decision is difficult to achieve in practice. Charles et al note, "Patient preferences for information do not necesBarry G. Saver, MD 18 A Cochrane review of decision aids for treatment and screening decisions concluded there was...

Keeping the patient in the center: Common challenges in the practice of shared decision making

“…In these cases, "persuasive messaging" to encourage patients to fully consider alternatives may be "normatively correct." In a trial of "persuasive decision aids," more participants changed their minds about mammography and prostate cancer screening preferences after viewing a persuasive decision aid, as compared to more traditional, knowledge-focused materials [33]. The implications of these findings for SDM might seem controversial; however, in practice, many patients will need persuasion simply to engage with a decision or to consider a recommendation to weigh the options and make a personal choice.…”

Nudging in screening: Literature review and ethical guidance

“…Another form of nudging is working with the default bias, e.g., predetermined appointments [49,86,87], as well as screening kits sent by mail (reduction of the "hassle factor/friction cost") [49]. Personalized letters, educational phone calls and videos [42], as well as telephone reminders (availability heuristics) [49], persuasion [88], and GP's signature (authority bias) [49] are also discussed. Minor monetary incentives [89], appeals to fear, and the use of threats have also been discussed [90].…”

Behavioral Economics Interventions in Clinical Decision Support Systems

“…The 12 selected articles reported on 10 distinct studies. Among these studies, three addressed monitoring and individual feedback [32][33][34], two compared framed presentations [35,36], two addressed heuristics [37,38] and [39], one was about social norms [40], one addressed the ordering effect [41], and one used a combination of overconfidence, risk aversion, and herding [42,43]. Figure 1 presents the flowchart of this systematic review.…”

“…One randomized study [39] noted that patients who do not have clearly defined values or preferences when asked to make decisions may construct preferences to justify their choices. Novel persuasive video interventions with recorded vignettes were used to help patients trust and accept controversial, evidence-based screening medical recommendations, and produced significant changes in the screening intentions.…”