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The modest effects of fact boxes on cancer screening

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Abstract

As health care becomes increasingly personalized to the needs and values of individual patients, informational interventions that aim to inform and debias consumer decision-making are likely to become important tools. In a randomized controlled experiment, we explore the effects of providing participants with published fact boxes on the benefits and harms of common cancer screening procedures. Female participants were surveyed about breast cancer screening by mammography, while male participants were surveyed about prostate cancer screening by prostate-specific antigen (PSA) testing. For these screening procedures, we expect consumers to have overly optimistic prior beliefs about the benefits and harms. We find that participants update their beliefs about the net benefits of screening modestly, but we observe little change in their stated preferences to seek screening. Participants who scored higher on a numeracy test updated their beliefs about screening benefits more in response to the fact boxes than did participants who scored lower on the numeracy test.

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Data availability

Data are available upon request.

Notes

  1. If, for example, we assume that \( \overrightarrow{\mathbf{s}}\sim N\left(\overrightarrow{\boldsymbol{\theta}},\Sigma \right) \) and the prior distribution is given by \( \boldsymbol{\Pi} \left(\overrightarrow{\boldsymbol{\theta}}\right)\sim N\left({\overrightarrow{\boldsymbol{m}}}_i,\Omega \right) \), then the posterior mean \( {\overrightarrow{\boldsymbol{m}}}_{i,j}^{\ast } \) for individual i who experiences the equivalent of n draws of signal \( \overrightarrow{\mathbf{s}} \) is given by the following expression (Bolstad and Curran 2016):

    $$ {\displaystyle \begin{array}{c}{\overrightarrow{\boldsymbol{m}}}_{i,j}^{\ast }={\left[{\Omega}^{-1}+n{\varSigma}^{-1}\right]}^{-1}\left({\Omega}^{-1}{\overrightarrow{\boldsymbol{m}}}_i+n{\varSigma}^{-1}\overrightarrow{\mathbf{s}}\right)\\ {}{\overrightarrow{\boldsymbol{m}}}_{i,j}^{\ast }={\left[{\Omega}^{-1}+n{\varSigma}^{-1}\right]}^{-1}{\Omega}^{-1}{\overrightarrow{\boldsymbol{m}}}_i+{\left[{\Omega}^{-1}+n{\varSigma}^{-1}\right]}^{-1}n{\varSigma}^{-1}\overrightarrow{\mathbf{s}}\end{array}} $$

    We can represent the informational content of \( \overrightarrow{\mathbf{s}} \) and \( {\overrightarrow{\boldsymbol{m}}}_i \) as ξ = nΣ−1 and γ = Ω−1 and the relative informational content of the signal compared with the prior as Ψ = γ−1ξ. The posterior then simplifies to:

    $$ {\overrightarrow{\boldsymbol{m}}}_{i,j}^{\ast }={\left[{I}_m+\Psi \right]}^{-1}\left({\overrightarrow{\boldsymbol{m}}}_i+\Psi \overrightarrow{\mathbf{s}}\right) $$

    We generalize from this result by assuming that the perceived relative information of the signal varies depending on individual- and source-specific factors.

  2. We note that this research design allows us to examine how the distributions of outcomes change across the treatment and control arms, but it cannot allow us to identify the counterfactual outcomes for a particular individual assigned to one of these groups.

  3. Subjects could provide more than one response to a question asking about their exposure to people with the cancer of interest (either breast or prostate cancer). Subjects who indicated both that they did not know anyone with the indicated cancer and that they knew certain individuals with the indicated cancer were classified as providing inconsistent responses.

  4. We note that combined (subjective and objective) numeracy scores (coefficient = −0.073; p = 0.016) and subjective numeracy scores (coefficient = −0.060; p = 0.002) but not objective numeracy scores (coefficient = −0.048; p = 0.22) predicted treatment status in multivariable analysis. These results suggest that the treatment and control groups might not have been balanced on subjective numeracy, either due to differential completion rates and/or due to the treatment affecting later responses (e.g., the provision of health risk information might have caused individuals to rate their subjective proficiency with numbers lower). Given the potential for the subjective numeracy score to have been affected by the experimental treatment, we focus on results corresponding to objective numeracy.

  5. Most or all of the 48 second difference may be explained by the 30 second pause imposed on treatment-group respondents when first viewing the fact box and the two additional questions they answered.

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Acknowledgments

Arek Avedian provided valuable input on the design of survey questions and managed survey administration. Gregory Bruich, Dae Woong Ham, Tuna Hayirli, Yuli Hsieh, Masha Kuznetsova, Anna Zink, and an anonymous referee provided helpful comments. This project was supported in part by grant number T32HS000055 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. Hammitt acknowledges funding from the French National Research Agency (ANR) under the Investments for the Future (Investissements d’Avenir) program, grant ANR-17-EURE-0010.

Code availability

Code for statistical analyses is available upon request.

Funding

This project was supported by grant number T32HS000055 from the Agency for Healthcare Research and Quality to MRE and grant ANR-17-EURE-0010 from the French National Research Agency to JKH.

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Authors and Affiliations

  1. Interfaculty Initiative in Health Policy, Harvard University, Cambridge, MA, USA

    Michael R. Eber

  2. Harvard University, Robert Walmsley University Professor, Cambridge, MA, USA

    Cass R. Sunstein

  3. Center for Risk Analysis, Harvard University, Boston, MA, USA

    James K. Hammitt

  4. Toulouse School of Economics, Université Toulouse Capitole, Toulouse, France

    James K. Hammitt

  5. Harvard Medical School, Boston, MA, USA

    Jennifer M. Yeh

  6. Boston Children’s Hospital, Boston, MA, USA

    Jennifer M. Yeh

  7. Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA

    Michael R. Eber & James K. Hammitt

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  1. Michael R. Eber
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Eber, M.R., Sunstein, C.R., Hammitt, J.K. et al. The modest effects of fact boxes on cancer screening. J Risk Uncertain 62, 29–54 (2021). https://doi.org/10.1007/s11166-021-09344-x

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