Journal of Cancer Education

, Volume 27, Issue 4, pp 752–758 | Cite as

Influence of Framing and Graphic Format on Comprehension of Risk Information among American Indian Tribal College Students

  • Debra Sprague
  • Joan E. Russo
  • Donna L. LaVallie
  • Dedra S. Buchwald


We evaluated methods for presenting risk information by administering six versions of an anonymous survey to 489 American Indian tribal college students. All surveys presented identical numeric information, but framing varied. Half expressed prevention benefits as relative risk reduction, half as absolute risk reduction. One third of surveys used text to describe prevention benefits; one third used text plus bar graph; one third used text plus modified bar graph incorporating a culturally tailored image. The odds ratio (OR) for correct risk interpretation for absolute risk framing vs. relative risk framing was 1.40 (95 % CI = 1.01, 1.93). The OR for correct interpretation of text plus bar graph vs. text only was 2.16 (95 % CI = 1.46, 3.19); OR for text plus culturally tailored bar graph vs. text only was 1.72 (95 % CI = 1.14, 2.60). Risk information including a bar graph was better understood than text-only information; a culturally tailored graph was no more effective than a standard graph.


Risk information Health communication American Indian/Alaska Native American Indian students Tribal college 


  1. 1.
    Montori VM, Rothman RL (2005) Weakness in numbers. The challenge of numeracy in health care. J Gen Intern Med 20:1071–1072PubMedCrossRefGoogle Scholar
  2. 2.
    Ancker JS, Senathirajah Y, Kukafka R, Starren JB (2006) Design features of graphs in health risk communication: a systematic review. JAMA 13:608–618Google Scholar
  3. 3.
    Kirsch IS, Jungeblut A, Jenkins L, Kolstad A (2002) Adult literacy in America: A first look at the findings of the National Adult Literacy Survey, 3rd edn. US Dept of Education, Office of Educational Research and Improvement, National Center for Educational Statistics, Washington, DCGoogle Scholar
  4. 4.
    Paasche-Orlow MK, Parker RM, Gazmararian JA, Nielsen-Bohlman LT, Rudd RR (2005) The prevalence of limited health literacy. J Gen Intern Med 20:75–184CrossRefGoogle Scholar
  5. 5.
    Malenka DJ, Baron JA, Johansen S, Wahrenberger JW, Ross JM (1993) The framing effect of relative and absolute risk. J Gen Intern Med 8:543–548PubMedCrossRefGoogle Scholar
  6. 6.
    Hux JE, Naylor CD (1995) Communicating the benefits of chronic preventive therapy: does the format of efficacy data determine patients’ acceptance of treatment? Med Decis Making 15:152–157PubMedCrossRefGoogle Scholar
  7. 7.
    Cranney M, Walley T (1996) Same information, different decisions: the influence of evidence on the management of hypertension in the elderly. Br J Gen Pract 46:661–663PubMedGoogle Scholar
  8. 8.
    Misselbrook D, Armstrong D (2001) Patients’ responses to risk information about the benefits of treating hypertension. Br J Gen Pract 51:276–279PubMedGoogle Scholar
  9. 9.
    Gigerenzer G (2003) Why does framing influence judgment? J Gen Intern Med 18:960–961PubMedCrossRefGoogle Scholar
  10. 10.
    Sheridan SL, Pignone MP, Lewis CL (2003) A randomized comparison of patients’ understanding of number needed to treat and other common risk reduction formats. J Gen Intern Med 18:884–892PubMedCrossRefGoogle Scholar
  11. 11.
    Waters EA, Weinstein ND, Colditz GA, Emmons K (2006) Formats for improving risk communication in medical tradeoff decisions. J Health Commun 11:167–182PubMedCrossRefGoogle Scholar
  12. 12.
    Lipkus IM (2007) Numeric, verbal, and visual formats of conveying health risks: suggested best practices and future recommendations. Med Decis Making 27:696–713PubMedCrossRefGoogle Scholar
  13. 13.
    Feldman-Stewart D, Kocovski N, McConnell BA, Brundage MD, Mackillop WJ (2000) Perception of quantitative information for treatment decisions. Med Decis Making 20:228–238PubMedCrossRefGoogle Scholar
  14. 14.
    Brundage M, Feldman-Stewart D, Leis A, Bezjak A, Degner L, Velji K, Zetes-Zanatta L, Tu D, Ritvo P, Pater J (2005) Communicating quality of life information to cancer patients: a study of six presentation formats. J Clin Oncol 23:6949–6956PubMedCrossRefGoogle Scholar
  15. 15.
    Zikmund-Fisher BJ, Ubel PA, Smith DM, Derry HA, McClure JB, Stark A, Pitsch RK, Fagerlin A (2008) Communicating side effect risks in a tamoxifen prophylaxis decision aid: the debiasing influence of pictographs. Patient Educ Couns 73:209–214PubMedCrossRefGoogle Scholar
  16. 16.
    Mazur DJ, Merz JF (1993) How the manner of presentation of data influences older patients in determining their treatment preferences. J Am Geriatr Soc 41:223–228PubMedGoogle Scholar
  17. 17.
    Elting LS, Martin CG, Cantor SB, Rubenstein EB (1999) Influence of data display formats on physician investigators’ decisions to stop clinical trials: prospective trial with repeated measures. BMJ 318:1527–1531PubMedCrossRefGoogle Scholar
  18. 18.
    Sprague D, LaVallie DL, Wolf FM, Jacobsen C, Sayson K, Buchwald D (2011) Influence of graphic format on comprehension of risk information among American Indians. Med Decis Making 31:437–443Google Scholar
  19. 19.
    LaVallie DL, Wolf FM, Jacobsen C, Sprague D, Buchwald D (2011) Health numeracy and understanding of risk among older American Indians and Alaska Natives. J Health Commun Dec. 21 [Epub ahead of print]Google Scholar
  20. 20.
    Noe T, Manson SM, Croy C, McGough H, Henderson JA, Buchwald DS (2005) In their own voices: American Indian decisions to participate in health research. In: Trimble J, Fisher C (eds) Handbook of ethical research with ethnocultural populations and communities. Sage, Thousand Oaks, CA, pp 93–116Google Scholar
  21. 21.
    Buchwald D, Mendoza-Jenkins V, Croy C, McGough H, Bezdek M, Spicer P (2006) Attitudes of urban American Indians and Alaska Natives regarding participation in research. J Gen Intern Med 21:648–651PubMedCrossRefGoogle Scholar
  22. 22.
    Student Body (2010) Available from: Accessed April 16, 2010
  23. 23.
    Student Enrollment Demographics (2010) Available from: Accessed April 16, 2010
  24. 24.
    Schapira MM, Nattinger AB, McHorney CA (2001) Frequency or probability? A qualitative study of risk communication formats used in health care. Med Decis Making 21:459–467PubMedGoogle Scholar
  25. 25.
    Stone ER, Sieck WR, Bull BE, Yates JF, Parks SC, Rush CJ (2003) Foreground: background salience: explaining the effects of graphical displays on risk avoidance. Organ Behav Hum Decis Process 90(1):19–36CrossRefGoogle Scholar
  26. 26.
    Hodge FS, Itty TL, Cadogan MP, Martinez F (2011) “Weaving Balance into Life”: development and cultural adaptation of a cancer symptom management toolkit for Southwest American Indians. J Cancer Surviv Dec 11 [Epub ahead of print]Google Scholar
  27. 27.
    Schwartz LM, Woloshin S, Black WC, Welch HG (1997) The role of numeracy in understanding the benefit of screening mammography. Ann Intern Med 127:966–972PubMedGoogle Scholar
  28. 28.
    Cuite CL, Weinstein ND, Emmons K, Colditz G (2008) A test of numeric formats for communicating risk probabilities. Med Decis Making 28:377–384PubMedCrossRefGoogle Scholar
  29. 29.
    Clegg LX, Li FP, Hankey BF, Chu K, Edwards BK (2002) Cancer survival among US whites and minorities: a SEER (Surveillance, Epidemiology, and End Results) Program population-based study. Arch Intern Med 162:1985–1993PubMedCrossRefGoogle Scholar
  30. 30.
    Ward E, Jemal A, Cokkinides V, Singh GK, Cardinez C, Ghafoor A, Thun M (2004) Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer J Clin 54:78–93PubMedCrossRefGoogle Scholar
  31. 31.
    Espey DK, Wu XC, Swan J, Wiggins C, Jim MA, Ward E, Wingo PA, Howe HL, Ries LA, Miller BA, Jemal A, Ahmed F, Cobb N, Kaur JS, Edwards BK (2007) Annual report to the nation on the status of cancer, 1975–2004, featuring cancer in American Indians and Alaska Natives. Cancer 110:2119–2152PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Debra Sprague
    • 1
    • 2
  • Joan E. Russo
    • 3
  • Donna L. LaVallie
    • 1
    • 4
  • Dedra S. Buchwald
    • 1
    • 2
  1. 1.Partnerships for Native HealthUniversity of WashingtonSeattleUSA
  2. 2.General Internal MedicineUniversity of WashingtonSeattleUSA
  3. 3.Department of Psychiatry and Behavioral SciencesUniversity of WashingtonSeattleUSA
  4. 4.Medical Education and Biomedical InformaticsUniversity of WashingtonSeattleUSA

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