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Gavaruzzi, Teresa (2010) On Context Effects in Medical Decision Making: When the Way Information is Presented Affects Patients' Decisions. [Tesi di dottorato]

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Abstract (inglese)

Decision making is pervasive in our daily life. Sometimes we face decisions that are very important, such as the decision about what medical treatment to undergo. But how can we be sure that we are making the right decision? Or even more subtly, how can we be sure that our decision would be the same, no matter what the circumstances? The answer from the research that has been conducted in the field of medical judgment and decision making is “you can’t be sure.” Indeed, the context has a great impact on what patients decide. In this dissertation, I show some examples of the effects of contextual information on decision making. Specifically, three studies address the effect of different variables that influence judgments and decisions without the decision maker being aware of them. In the first study, I examine the role played by three factors on the decision between a risky and a safe alternative: the decision domain (the medical vs. financial domain); the decision maker’s purpose (utilitarian vs. hedonic); and the type of information provided (generic vs. detailed). The results suggest that when the information is generic and the purpose is hedonic (i.e., not essential), the risk attitude is opposite in the two domains, thus suggesting that when people’s life or health is at stake, they are more cautious, whereas they are more willing to play with their money for hedonic purposes. The second study investigates several potential explanations for an unusual finding. Indeed, while people generally prefer harms of omission to harms of commission (i.e., omission bias), for cancer they prefer active treatments over undergoing regular check-ups without treatment. On one hand, the results highlight that this finding depends on how the inactive option is conceived and described. On the other hand, they also point out that the instance of a malignant tumor which has already been diagnosed is a peculiar case relative to other kinds of illnesses. Finally, the third study is a demonstration that physicians are also affected by context factors that should not affect their choices. Specifically, they are influenced both by how many options are available and by information about patients that is irrelevant to the decision.
Thus, when we as patients or physicians are making decisions which impact either our own health or someone else’s health, we are subject to biases and we are affected by contextual information. But what if we were health communicators? How would we use this knowledge? Knowing that patients may make differing choices depending on the way information is presented is certainly important, but how health communicators and policy decision makers apply this knowledge is just as central to medical decision making. Possible approaches that can be taken can be visualized along a continuum. At one extreme, the paternalist approach sees the doctor as an apprehensive father, and, thus, it is the doctor who makes the decision with little or no input from the patient. At the other extreme, with the informed decision making approach, it is the patient who, after being fully informed about all the options available and their consequences, makes the decision with little or no input from the doctor.
Depending on the approach that is chosen, health messages also can take different forms. When they are aimed at persuading people to engage in a given behavior, such as dieting or undergoing a screening test. When informing a patient about the options available (in the informed or shared approach), the message should not be designed to influence the patient’s decision other than providing information, i.e., it should be neutral relative to the decision. The other three studies presented in the dissertation investigate cancer screening decision making within these two approaches. The first two of these studies investigate the effect of the way in which information is presented on participants’ prostate cancer screening decisions. The first study takes an informed approach, while the second one considers the same topic from the paternalistic approach, by using prospect theory as reference. The last study, also using a paternalistic approach, but applied to the decision whether or not to undergo colon cancer screening, assesses the real screening behavior of patients. Our findings allow us to discuss in a critical manner the results of a recent meta-analysis that disconfirmed the effect of framing, as proposed and interpreted in prospect theory. Indeed, we have tested and confirmed one possible reason for this result, not considered in the meta-analysis and which could have, therefore, biased its conclusion. Specifically, the lexical valence of the terms used to describe the consequences seems to be a relevant factor in the effectiveness of the message. To our knowledge, this factor was considered neither in previous studies nor in the more recent meta-analysis. To summarize, I first investigated some of the contextual factors that affect medical judgments and decisions from an experimental perspective. Then, I studied more specifically context effects in messages promoting cancer screening behaviors, highlighting some practical implications and theoretical consequences.

Abstract (italiano)

Le decisioni sono molto comuni nella nostra vita quotidiana. Spesso si tratta di decisioni banali, altre volte ci confrontiamo con scelte molto importanti, come ad esempio quelle che coinvolgono la nostra salute. Potremmo, ad esempio, essere chiamati a decidere se sottoporci o meno ad un certo trattamento medico, oppure potremmo trovarci a dover scegliere tra due o più alternative di trattamento. Ma come potremmo essere sicuri che la nostra scelta sia davvero la scelta giusta, o comunque la migliore per noi? E, ancora, come potremmo essere sicuri che quella sarebbe in qualsiasi caso la nostra decisione? La risposta della ricerca condotta nell’ambito delle decisioni mediche è “non possiamo esserne sicuri”. Numerosi effetti di contesto influenzano, infatti, le decisioni dei pazienti. In questa tesi illustro alcuni esempi che mostrano come le informazioni contestuali possano avere un effetto sulla presa di decisione. Nello specifico, tre studi indagano l’effetto di diverse variabili che influenzano i giudizi e le decisioni senza che i decisori stessi ne siano consapevoli. Nel primo studio mostro come la scelta tra un’alternativa rischiosa e un’alternativa sicura possa essere influenzata da tre fattori: l’ambito della decisione (medico vs. finanziario); l’obiettivo del decisore (necessario vs. futile); e l’informazione fornita (generica vs. dettagliata). I risultati suggeriscono che quando l’informazione è generica e l’obiettivo è futile, l’atteggiamento nei confronti del rischio è l’opposto nei due ambiti, suggerendo quindi che quando è la vita delle persone ad essere in gioco, esse si mostrano più caute, mentre risultano maggiormente disposte ad azzardare con il denaro, quando l’obiettivo è futile. Il secondo studio indaga numerose potenziali spiegazioni per un risultato riportato recentemente in letteratura che sembra andare in direzione opposta a quelli riportati negli studi che lo hanno preceduto. Infatti, sebbene generalmente le persone preferiscano opzioni i cui danni derivanti dalla mancata azione sono maggiori rispetto ai danni provocati dalla commissione di un’azione (“omission bias”), nel caso di una diagnosi di cancro sembra preferiscano trattamenti attivi rispetto alla possibilità di effettuare controlli regolari, senza trattamenti. Da una parte, i risultati del mio studio evidenziano che questo risultato dipende da come è concepita e descritta l’opzione di omissione dell’azione. Dall’altra, evidenziano anche che una diagnosi di tumore maligno è un caso particolare, rispetto ad altri tipi di diagnosi. ll terzo studio, infine, è una dimostrazione del fatto che anche gli studenti di medicina sono influenzati da fattori di contesto che, auspicabilmente, non dovrebbero invece influire sulle loro scelte. In particolare, sono influenzati sia dal numero di alternative a disposizione, sia da informazioni che, pur essendo relative alla storia clinica del paziente, dovrebbero essere irrilevanti per la decisione.
Quindi, l’essere pazienti o medici che decidono per la propria o l’altrui salute non ci esime dall’essere soggetti a distorsioni e, tutti, siamo vittime di trappole cognitve e siamo influenzati da informazioni contestuali. Ma cosa succederebbe se fossimo esperti in comunicazione sulla salute? Come useremmo questa conoscenza? Sapere che i pazienti possono prendere decisioni diverse a seconda del modo in cui le informazioni sono presentate loro è certamente importante, ma anche l’uso che gli esperti in comunicazione sulla salute e coloro che attuano le decisioni a livello comunitario fanno di questa conoscenza è centrale nella presa di decisione in ambito medico. I diversi approcci possono essere collocati lungo un continuum. Ad un estremo, l’approccio paternalistico vede il medico come un padre apprensivo: in questo caso, è il medico a prendere la decisione, con poche o nessuna indicazione da parte del paziente. All’altro estremo, secondo l’approccio informato alle decisioni mediche, è il paziente che, dopo essere completamente informato su tutte le opzioni disponibili e sulle loro conseguenze, prende la decisione, con poche o nessuna indicazione da parte del medico.
A seconda dell’approccio adottato, gli stessi messaggi per la salute possono avere forme diverse. Quando si promuove un comportamento salutista usando un approccio paternalistico, il messaggio dovrebbe cercare di convincere le persone ad attuare il comportamento desiderato, come ad esempio mettersi a dieta o effettuare un test di screening. Quando invece si informa il paziente sulle opzioni disponibili (approccio informato o condiviso), il messaggio non dovrebbe essere formulato in modo da influenzare la decisione del paziente, dovrebbe cioè essere neutro rispetto alla decisione. Gli altri tre studi presentati nella tesi indagano la decisione di sottoporsi a screening oncologici nell’ottica di questi due approcci. I primi due di questi studi indagano l’effetto del modo in cui sono presentate le informazioni relativamente allo screening per il cancro alla prostata. Il primo studio assume un approccio informato, mentre il secondo considera lo stesso argomento con un approccio paternalistico, prendendo la teoria del prospetto come riferimento. L’ultimo studio, anch’esso in una prospettiva paternalista, ma applicata allo screening per il cancro del colon, confronta diversi tipi di messaggio e valuta, anziché le intenzioni dei pazienti, il comportamento effettivo di adesione dei pazienti all’esame proposto.
I dati ottenuti ci consentono di discutere in modo critico i risultati di una recente meta-analisi che ha confutato l’effetto framing, così come proposto dalla teoria del prospetto. Abbiamo preso in considerazione e testato un possibile aspetto, non valutato nella meta-analisi, che potrebbe aver contribuito a distorcere i risultati e la conclusione. In particolare, la nostra ipotesi è che la valenza lessicale dei termini usati per descrivere le conseguenze del comportamento sia un fattore rilevante nel determinare l’efficacia del messaggio. Per quanto ne sappiamo, questo fattore non è stato considerato né negli studi precedenti, né nella più recente meta-analisi.
Per riassumere, i primi studi presentati in questa tesi hanno indagato alcuni dei fattori di contesto che influenzano i giudizi e le decisioni da una prospettiva sperimentale. Nelle ricerche successive, ho studiato più specificamente gli effetti del contesto nei messaggi che promuovono comportamenti di screening per tumori, mettendo in luce possibili approfondimenti teorici e alcune implicazioni pratiche.

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Tipo di EPrint:Tesi di dottorato
Relatore:Lotto, Lorella
Dottorato (corsi e scuole):Ciclo 22 > Scuole per il 22simo ciclo > SCIENZE PSICOLOGICHE > SCIENZE COGNITIVE
Data di deposito della tesi:NON SPECIFICATO
Anno di Pubblicazione:01 Febbraio 2010
Parole chiave (italiano / inglese):medical decision making; context effects; framing effect; paternalistic approach; informed decision making; cancer screening
Settori scientifico-disciplinari MIUR:Area 11 - Scienze storiche, filosofiche, pedagogiche e psicologiche > M-PSI/01 Psicologia generale
Struttura di riferimento:Dipartimenti > Dipartimento di Psicologia dello Sviluppo e della Socializzazione
Codice ID:2985
Depositato il:28 Ott 2010 14:11
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