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      Knowledge and perceptions of risk for cardiovascular disease: Findings of a qualitative investigation from a low-income peri-urban community in the Western Cape, South Africa

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          Abstract

          Background

          South Africa currently faces an increasing burden of cardiovascular disease. Although referred to clinics after community screening initiatives, few individuals who are identified to be at high risk for developing cardiovascular disease attend. Low health literacy and risk perception have been identified as possible causes. We investigated the knowledge and perceptions about risk for cardiovascular disease in a community.

          Method

          We conducted a series of focus group discussions with individuals from a low-income peri-urban community in the Western Cape, South Africa. Different methods of presenting risk were explored. The data were organised into themes and analysed to find associations between themes to provide explanations for our findings.

          Results

          Respondents’ knowledge of cardiovascular disease and its risk factors varied, but most were familiar with the terms used to describe cardiovascular disease. In contrast, understanding of the concept of risk was poor. Risk was perceived as a binary concept and evaluation of different narrative and visual methods of presenting risk was not possible.

          Conclusion

          Understanding cardiovascular disease and its risk factors requires a different set of skills from that needed to understand uncertainty and risk. The former requires knowledge of facts, whereas understanding of risk requires numerical and computational skills. Without a better understanding of risk, risk assessments for cardiovascular disease may fail in this community.

          Translated abstract

          Connaissance et perceptions des risques de maladies cardiovasculaires: résultats d’une étude qualitative dans une communauté périurbaine à faibles revenus du Western Cape, en Afrique du Sud.

          Contexte

          A l’heure actuelle, l’Afrique du Sud se trouve confrontée à une augmentation des maladies cardiovasculaires. Bien que les patients soient envoyés dans des cliniques suite à des initiatives communautaires de dépistage, peu de ceux qui sont identifiés à haut risque de contracter des maladies cardiovasculaires se présentent. La raison en est probablement les faibles connaissances en santé et en perceptions des risques. Nous avons examiné la connaissance et la perception des risques de maladies cardiovasculaires dans une communauté.

          Méthode

          Nous avons mené une série de discussions de groupes témoins avec des individus d’une communauté périurbaine à faibles revenus du Western Cape, en Afrique du Sud. Nous avons examiné différentes méthodes de présentation de risques. Les données ont été classées par thèmes et analysées pour trouver des rapports entre les thèmes afin d’expliquer nos résultats.

          Résultats

          La connaissance des personnes interrogées sur les maladies cardiovasculaires et leurs facteurs de risques différaient, mais la plupart d’entre elles connaissaient la terminologie utilisée pour décrire les maladies cardiovasculaires. Par contre, elles comprenaient mal le concept de risque. Le risque était perçu comme une idée binaire et l’évaluation des différentes méthodes narratives et visuelle de présentation des risques n’était pas possible.

          Conclusion

          Pour comprendre les maladies cardiovasculaires et leurs risques il faut avoir un ensemble de compétences différentes de celles requises pour comprendre l’incertitude et les risques. Le premier demande une connaissance des faits, alors que la compréhension des risques exige des compétences numériques et informatiques. Sans une meilleure connaissance des risques, l’évaluation des maladies cardiovasculaires peut échouer dans cette communauté.

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          Most cited references23

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          The Health Belief Model: a decade later.

          Since the last comprehensive review in 1974, the Health Belief Model (HBM) has continued to be the focus of considerable theoretical and research attention. This article presents a critical review of 29 HBM-related investigations published during the period of 1974-1984, tabulates the findings from 17 studies conducted prior to 1974, and provides a summary of the total 46 HBM studies (18 prospective, 28 retrospective). Twenty-four studies examined preventive-health behaviors (PHB), 19 explored sick-role behaviors (SRB), and three addressed clinic utilization. A "significance ratio" was constructed which divides the number of positive, statistically-significant findings for an HBM dimension by the total number of studies reporting significance levels for that dimension. Summary results provide substantial empirical support for the HBM, with findings from prospective studies at least as favorable as those obtained from retrospective research. "Perceived barriers" proved to be the most powerful of the HBM dimensions across the various study designs and behaviors. While both were important overall, "perceived susceptibility" was a stronger contributor to understanding PHB than SRB, while the reverse was true for "perceived benefits." "Perceived severity" produced the lowest overall significance ratios; however, while only weakly associated with PHB, this dimension was strongly related to SRB. On the basis of the evidence compiled, it is recommended that consideration of HBM dimensions be a part of health education programming. Suggestions are offered for further research.
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            Presenting quantitative information about decision outcomes: a risk communication primer for patient decision aid developers

            Background Making evidence-based decisions often requires comparison of two or more options. Research-based evidence may exist which quantifies how likely the outcomes are for each option. Understanding these numeric estimates improves patients’ risk perception and leads to better informed decision making. This paper summarises current “best practices” in communication of evidence-based numeric outcomes for developers of patient decision aids (PtDAs) and other health communication tools. Method An expert consensus group of fourteen researchers from North America, Europe, and Australasia identified eleven main issues in risk communication. Two experts for each issue wrote a “state of the art” summary of best evidence, drawing on the PtDA, health, psychological, and broader scientific literature. In addition, commonly used terms were defined and a set of guiding principles and key messages derived from the results. Results The eleven key components of risk communication were: 1) Presenting the chance an event will occur; 2) Presenting changes in numeric outcomes; 3) Outcome estimates for test and screening decisions; 4) Numeric estimates in context and with evaluative labels; 5) Conveying uncertainty; 6) Visual formats; 7) Tailoring estimates; 8) Formats for understanding outcomes over time; 9) Narrative methods for conveying the chance of an event; 10) Important skills for understanding numerical estimates; and 11) Interactive web-based formats. Guiding principles from the evidence summaries advise that risk communication formats should reflect the task required of the user, should always define a relevant reference class (i.e., denominator) over time, should aim to use a consistent format throughout documents, should avoid “1 in x” formats and variable denominators, consider the magnitude of numbers used and the possibility of format bias, and should take into account the numeracy and graph literacy of the audience. Conclusion A substantial and rapidly expanding evidence base exists for risk communication. Developers of tools to facilitate evidence-based decision making should apply these principles to improve the quality of risk communication in practice.
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              Decision aids for people facing health treatment or screening decisions.

              Decision aids prepare people to participate in 'close call' decisions that involve weighing benefits, harms, and scientific uncertainty. To conduct a systematic review of randomised controlled trials (RCTs) evaluating the efficacy of decision aids for people facing difficult treatment or screening decisions. We searched MEDLINE (Ovid) (1966 to July 2006); Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library; 2006, Issue 2); CINAHL (Ovid) (1982 to July 2006); EMBASE (Ovid) (1980 to July 2006); and PsycINFO (Ovid) (1806 to July 2006). We contacted researchers active in the field up to December 2006. There were no language restrictions. We included published RCTs of interventions designed to aid patients' decision making by providing information about treatment or screening options and their associated outcomes, compared to no intervention, usual care, and alternate interventions. We excluded studies in which participants were not making an active treatment or screening decision, or if the study's intervention was not available to determine that it met the minimum criteria to qualify as a patient decision aid. Two review authors independently screened abstracts for inclusion, and extracted data from included studies using standardized forms. The primary outcomes focused on the effectiveness criteria of the International Patient Decision Aid Standards (IPDAS) Collaboration: attributes of the decision and attributes of the decision process. We considered other behavioural, health, and health system effects as secondary outcomes. We pooled results of RCTs using mean differences (MD) and relative risks (RR) using a random effects model. This update added 25 new RCTs, bringing the total to 55. Thirty-eight (69%) used at least one measure that mapped onto an IPDAS effectiveness criterion: decision attributes: knowledge scores (27 trials); accurate risk perceptions (11 trials); and value congruence with chosen option (4 trials); and decision process attributes: feeling informed (15 trials) and feeling clear about values (13 trials).This review confirmed the following findings from the previous (2003) review. Decision aids performed better than usual care interventions in terms of: a) greater knowledge (MD 15.2 out of 100; 95% CI 11.7 to 18.7); b) lower decisional conflict related to feeling uninformed (MD -8.3 of 100; 95% CI -11.9 to -4.8); c) lower decisional conflict related to feeling unclear about personal values (MD -6.4; 95% CI -10.0 to -2.7); d) reduced the proportion of people who were passive in decision making (RR 0.6; 95% CI 0.5 to 0.8); and e) reduced proportion of people who remained undecided post-intervention (RR 0.5; 95% CI 0.3 to 0.8). When simpler decision aids were compared to more detailed decision aids, the relative improvement was significant in knowledge (MD 4.6 out of 100; 95% CI 3.0 to 6.2) and there was some evidence of greater agreement between values and choice.In this review, we were able to explore the use of probabilities in decision aids. Exposure to a decision aid with probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.6; 95% CI 1.4 to 1.9). The effect was stronger when probabilities were measured quantitatively (RR 1.8; 95% CI 1.4 to 2.3) versus qualitatively (RR 1.3; 95% CI 1.1 to 1.5).As in the previous review, exposure to decision aids continued to demonstrate reduced rates of: elective invasive surgery in favour of conservative options, decision aid versus usual care (RR 0.8; 95% CI 0.6 to 0.9); and use of menopausal hormones, detailed versus simple aid (RR 0.7; 95% CI 0.6 to 1.0). There is now evidence that exposure to decision aids results in reduced PSA screening, decision aid versus usual care (RR 0.8; 95% CI 0.7 to 1.0) . For other decisions, the effect on decisions remains variable.As in the previous review, decision aids are no better than comparisons in affecting satisfaction with decision making, anxiety, and health outcomes. The effects of decision aids on other outcomes (patient-practitioner communication, consultation length, continuance, resource use) were inconclusive.There were no trials evaluating the IPDAS decision process criteria relating to helping patients to recognize a decision needs to be made, understand that values affect the decision, or discuss values with the practitioner. Patient decision aids increase people's involvement and are more likely to lead to informed values-based decisions; however, the size of the effect varies across studies. Decision aids have a variable effect on decisions. They reduce the use of discretionary surgery without apparent adverse effects on health outcomes or satisfaction. The degree of detail patient decision aids require for positive effects on decision quality should be explored. The effects on continuance with chosen option, patient-practitioner communication, consultation length, and cost-effectiveness need further evaluation.
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                Author and article information

                Journal
                Afr J Prim Health Care Fam Med
                Afr J Prim Health Care Fam Med
                PHCFM
                African Journal of Primary Health Care & Family Medicine
                AOSIS OpenJournals
                2071-2928
                2071-2936
                22 October 2015
                2015
                : 7
                : 1
                : 891
                Affiliations
                [1 ]Chronic Disease Initiative for Africa, Cape Town, South Africa
                [2 ]Brigham and Women's Hospital, Harvard University, United States
                [3 ]Department of Medicine, University of Cape Town, South Africa
                Author notes
                Correspondence to: Sam Surka, Email: samsurka@ 123456gmail.com Postal address: J 47/86, Old Groote Schuur Building, Groote Schuur Hospital Observatory, Cape Town 7925, South Africa

                How to cite this article: Surka S, Steyn K, Everett-Murphy K, Gaziano TA, Gaziano TA, Levitt N. Knowledge and perceptions of risk for cardiovascular disease: Findings of a qualitative investigation from a low-income peri-urban community in the Western Cape, South Africa. Afr J Prm Health Care Fam Med. 2015;7(1), Art. #891, 8 pages. http://dx.doi.org/10.4102/phcfm.v7i1.891

                Article
                PHCFM-7-891
                10.4102/phcfm.v7i1.891
                4656922
                26842511
                b5e2d241-b514-4d7a-a72b-b616144e70ac
                © 2015. The Authors

                AOSIS OpenJournals. This work is licensed under the Creative Commons Attribution License.

                History
                : 29 May 2015
                : 10 August 2015
                Categories
                Original Research

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