Patients can struggle to make informed medical decisions because evidence supporting the use of certain clinical preventive recommendations is rarely unequivocal, and even if it is, they may still choose to disregard that advice.
This led one team of researchers to look at how video decision aids might be used to help persuade patients to follow evidence-based guidance. Their findings(www.annfammed.org) were published in the January/February issue of Annals of Family Medicine.
The authors chose to focus on a U.S. Preventive Services Task Force (USPSTF) recommendation to individualize decisions to use mammography(www.uspreventiveservicestaskforce.org) to screen for breast cancer in women in their 40s, as well as on a second recommendation against prostate-specific antigen (PSA)-based cancer screening. (www.uspreventiveservicestaskforce.org)
AAFP member and study co-author Barry Saver, M.D., M.P.H., a faculty physician with the Swedish Family Medicine Residency at Cherry Hill in Seattle, told AAFP News the group chose to examine video as an alternative communication channel to traditional print materials because it would be accessible to the broadest possible population, including those with limited literacy. The videos were framed as doctor-patient conversations, Saver said, because stories can be more engaging and memorable than dry lists of facts.
- Researchers analyzed how video decision aids could be used to persuade patients to follow evidence-based guidance, with findings published in the January/February issue of Annals of Family Medicine.
- The authors focused on a U.S. Preventive Services Task Force recommendation to individualize decisions about screening mammography for women in their 40s, as well as on a recommendation against prostate-specific antigen-based cancer screening.
- According to one study co-author, the researchers chose to examine video as an alternative communication channel to traditional print materials because it would be accessible to the broadest possible population, including those with limited literacy.
The randomized crossover study involved 27 men ages 50-74 with no history of prostate cancer and 35 women ages 40-49 with no breast cancer history. All participants viewed a video intervention and a more traditional, paper-based decision aid intervention in random order.
"We wanted a hard test of our approach, and we felt the USPSTF recommendations about prostate cancer screening and mammography for women in their 40s would provide this, being counterintuitive to most and somewhat controversial, yet evidence-based and developed by a group we trusted to use an objective, unbiased process," said Saver.
The authors found that at baseline, 69 percent of men and 86 percent of women reported wanting screening, with none of the men and 9 percent of the women deciding against screening, and 31 percent and 6 percent, respectively, being unsure.
However, after viewing the video interventions, 33 percent of men and 49 percent of women wanted screening, while 56 percent and 29 percent, respectively, did not want screening, and 11 percent and 20 percent were unsure. In contrast, exposure to the printed decision aids from other sources had essentially no effect on screening preferences.
The order in which each intervention was viewed likewise made no difference in study outcomes.
Leveraging the Power of Persuasion
Saver said there is abundant evidence that, for preventive health care decisions, traditional decision aids that focus on presenting evidence typically yield a modest increase in knowledge and little or no change in screening choices.
He said the group found it was important to start by alerting patients there was a decision to be considered but not to immediately present recommendations that might contradict what they already believe.
Next, it was critical to "de-bias" patients by presenting information about the harms of screening and how the benefits were actually more modest than most patients assumed. After that, it was important to emphasize the trustworthiness of and lack of bias in the USPSTF recommendations.
Access Video Decision Aids on Controversial Prevention Topics
Video decision aid resources used in a recent Annals of Family Medicine study that examined the use of video as a persuasive device to help patients better understand and accept evidence-based clinical recommendations included English(www.youtube.com) and Spanish(www.youtube.com) versions of a video recapping the U.S. Preventive Services Task Force (USPSTF) 2016 mammography screening recommendations.
The researchers found that although information alone didn't seem to change screening intentions, once patients were brought to the point of reconsidering screening, they wanted to know what evidence supported the decision -- even if it was hard to understand.
"Patients rarely come into this as blank slates," Saver said. "Advocacy groups have used persuasive messages for many years. We were also aware of the power of anecdotes over facts in swaying opinions and encountered this in our patient focus groups. Many physicians similarly don't speak about evidence, but rather say something like, 'You are due for your (test name).' That is a persuasive message, not a presentation of evidence.
"So we knew that, if we wanted patients to consider the USPSTF's counterintuitive recommendations, we would need to persuade them to do so, not simply present more facts. But we also felt it was important to present recommendations of other groups (not something traditionally done by advocacy groups) so that, if we could convince patients to consider the USPSTF's recommendations, they would also know what other groups recommended and make a better-informed choice."
Saver said the researchers explained to participants why they felt the USPSTF's recommendations were more trustworthy than other recommendations presented, but they also acknowledged that depending on a patient's personal values, he or she might prefer one recommendation to another.
Using Video Decision Aids in Practice
As a result of this research, Saver said he views video as potentially being a more effective format than print for decision aids overall, but he added that the issue being addressed and the video being used must also be taken into account. In any event, each video should be evaluated carefully to make sure it's based on the most current and accurate science and is as free from bias as possible.
"In our case, we were trying to be persuasive about what we felt was an evidence-based, unbiased recommendation," Saver said. "Most messages patients receive, through the media but also often through their clinicians, are persuasive rather than being 'just the facts.' And, usually, patients want our opinions and guidance -- they come to us for our expertise."
He said the process of creating the video decision aids not only helped him discover what it took to persuade patients to consider the USPSTF recommendations, it also made him realize there is a difference between informed and shared decision-making.
"Our participants were less likely to want to discuss the issue with their primary care providers after seeing our decision aids than before," Saver said. "It seems that, once they felt they had made an informed decision, they felt less desire to share it."
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