Health Numeracy: Explaining risk in numbers patients can use

Health Numeracy: Explaining risk in numbers patients can use
Kirtly Parker Jones MD

Explaining Contraceptive Risk to Patients
Learning Objectives List three different numerical means of presenting risk Describe three graphical methods of presenting risk Identify at least 3 factors that influence patients’ perceptions of risk Talking Points At the conclusion of this presentation, participants should also be able to: Define relative, attributable & absolute risk List three different means of presenting risk; describe the advantages of each - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at

Disclosures This presentation has been created in part by the Association of Reproductive Health Professionals (ARHP – to see more you can go to arhp.org and go to CORE slide set) I like arithmetic

Arithmetic Two plus Three equals?
If there was a 50% decrease in the number of people who answered the question incorrectly, what would be the subsequent percent of people who answered the question correctly?

Weather Class….. If there is a 50% chance of rain today and a 50% chance of rain tomorrow….. What is the chance that it will rain today AND tomorrow? What is the chance that it will rain today OR tomorrow?

What do oncologists tell patients?
The 5 year survival of stage 4 ovarian cancer is 12% Aggressive chemotherapy can increase the 5 year survival of ovarian cancer by 50% What is the chance if surviving stage 4 ovarian cancer for 5 years if a patient undergoes aggressive chemotherapy? What do you think the patient hears?

Know your numbers Expressing Risk - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at

Risk Calculations Causality Weigh pros and cons Degree to which attributable Talking Points By calculating the risk associated with a particular hazard: Researchers can hypothesize about causality. Consumers and clinicians can weigh the pros and cons of treatment interventions. Epidemiologists can calculate the degree to which a disease or event is attributable to a particular hazard. Reference Hennekens CH, Buring JE. Epidemiology in Medicine. Boston: Little, Brown, and Company. 1987:77. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Hennekens CH. Epidemiology in Medicine

Associations vs. Causality
Explaining Contraceptive Risk to Patients Associations vs. Causality An association does not always mean exposure caused outcome It could be due to random chance or bias Talking Points The existence of a statistical association does not necessarily mean that the exposure caused the outcome. For example, cigarette lighters could be said to be associated with the risk of lung cancer (because they are used to smoke cigarettes), but they are not, per se, a causal factor. Reasons for an association without a true underlying causal relationship include random chance, bias, and other factors. Making a decision about causality requires that a number of criteria be met, including (among others): Strength of the association (as measured by relative risk, for example) Consistency of the association over multiple studies Temporal sequence (exposure precedes outcome) The point is that a weak association found in a single study should not be taken as concrete evidence of a cause-and-effect relationship. Reference Grimes DA, Schulz KF. Bias and causal associations in observational research. Lancet. 2002;359:248–252. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Grimes DA. Lancet

Commonly Used Risk Calculations
Explaining Contraceptive Risk to Patients Commonly Used Risk Calculations Absolute Risk Attributable Risk Relative Risk Talking Points Here are some commonly used risk calculations that you should understand: Absolute risk Attributable risk Relative risk We’ll discuss these in some detail. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at

Absolute Risk The percentage of people in a group who experience a discrete event Number of events experienced Total exposure time of people at risk Talking Points Absolute risk is the rate at which people in a group experience a discrete event. Absolute risk = the number of events divided by the total exposure time. For example, contraceptive efficacy is often expressed in woman-years, or the total number of women who experience pregnancy while using a contraceptive method over the course of 1 year. References Evidence-Based Emergency Medicine at the New York Academy of Medicine. Glossary of Terms: Absolute risk and its reduction. Available at: Accessed September 5, 2007. Misselbrook D, Armstrong D. Thinking about risk: can doctors and patients talk the same language? Fam Practice. 2002;19(1):1–2. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at New York Academy of Medicine Misselbrook D. Fam Practice

Example of Absolute Risk
Explaining Contraceptive Risk to Patients Example of Absolute Risk Of 100,000 women on third-generation OCs, 30 will develop venous thromboembolism (VTE) per year. Absolute risk 30 per 100,000 woman-years Talking Points For example: of 100,000 women taking third-generation OCs, approximately 30 will develop VTE per year. Absolute risk = 30 per 100,000 woman-years. A woman-year is a person-time unit, or the total of the units of time—whether weeks, months, or years—that people were exposed to a condition or were actively involved in a study. One person-year can represent either a single person who was exposed for 1 year or an accumulation, such as two people who were each exposed for half a year. In this example, the person-time units are woman-years. References Mills, A. Combined oral contraception and the risk of venous thromboembolism. Hum Reprod. 1997;12: Bromham D, O’Brien T. Information for health professionals further to the Committee on Safety of Medicines’ advice on the safety of oral contraceptives. [Letter, dated 18 October 1995.] Faculty of Family Planning and Reproductive Health Care and the Family Planning Association, London - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Mills A. Hum Reprod Bromham D, O’Brien T

Attributable Risk The difference in risk between those exposed and those not exposed Reflects extra risk associated with exposure Risk in unexposed Risk in exposed Talking Points Attributable risk indicates the extra risk associated with exposure. Attributable risk is the difference in the risk of the outcome in question between those who are exposed to a condition and those who are not exposed. Attributable risk = risk in those exposed minus the risk in those not exposed. Reference BMJ Collections: Comparing disease rates. Available at: Accessed September 5, 2007. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at BMJ Collections

Attributable Risk: Example 1
Explaining Contraceptive Risk to Patients Attributable Risk: Example 1 – = Risk of cancer in smokers: 100 per 100,000 Attributable risk: 90 more cancers per 100,000 in nonsmokers: 10 per 100,000 Talking Points In this example, non-smokers are expected to develop lung cancer at a rate of 10 cases per 100,000 population per year. Smokers, on the other hand, have a lung cancer rate of 100 per 100,000 per year. This is an excess risk, or attributable risk, of 90 per 100,000 per year. (Assuming of course, that the exposure is causal.) - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at

Attributable Risk: Example 2
Explaining Contraceptive Risk to Patients Attributable Risk: Example 2 Risk from 3rd-generation OCs – Risk from 2nd-generation OCs 30 VTE per 100,000 woman-years 15 VTE per 100,000 woman-years Attributable Risk: 15 more VTE per 100,000 woman-years = Talking Points As we’ve said, attributable risk measures the difference in risk from different exposures. The absolute risk of VTE for third-generation OCs users is 30 per 100,000 woman-years. Therefore, the attributable risk is the difference between the absolute risk for women taking third-generation OCs and the absolute risk for women taking second-generation OCs. Attributable risk = 30 – 15 = 15 per 100,000 woman-years. Therefore, women taking third-generation OCs have a risk that is 15 per 100,000 higher than that for women taking second-generation OCs. Reference Mills A. Combined oral contraception and the risk of venous thromboembolism. Hum Reprod. 1997;12: - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at

Relative Risk Frequency of the outcome in the exposed group divided by the frequency of the outcome in the unexposed group Frequency Exposed Unexposed  Talking Points Relative risk: Is the frequency of the outcome in the exposed group divided by the frequency of the outcome in the unexposed group Reflects the relative likelihood of developing the outcome based on exposure References Grimes DA, Schulz KF. An overview of clinical research: the lay of the land. Lancet. 2002;359:57-61. Hennekens CH, Buring JE. Epidemiology in Medicine. Boston: Little, Brown, and Company. 1987:77. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Grimes DA. Lancet Hennekens CH. Epidemiology in Medicine

Interpreting Relative Risk
Explaining Contraceptive Risk to Patients Interpreting Relative Risk Compared with unexposed group: Relative Risk = 1 No increased risk in exposed group Relative Risk > 1 Increased risk in exposed group Relative Risk < 1 Decreased risk in exposed group Talking Points To interpret relative risk: Relative risk = 1: no increase in risk in the exposed group compared with the unexposed group. Relative risk > 1: increased risk in the exposed group compared with the unexposed group. Relative risk < 1: decreased risk in exposed group compared with the unexposed group. Reference Hennekens CH, Buring JE. Epidemiology in Medicine. Boston: Little, Brown, and Company. 1987:79. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Hennekens CH. Epidemiology in Medicine

Relative Risk: Example 1
Explaining Contraceptive Risk to Patients Relative Risk: Example 1 Absolute Risk: 3rd-Generation OCs 30 per 100,000 woman-years Absolute Risk: 2nd-Generation OCs 15 per 100,000 woman-years  Relative Risk: 2 = Talking Points For example, the data that triggered the 1995 pill scare showed that women who used third-generation OCs had a risk of VTE that was 2 times greater than that of women who used second- generation OCs. Absolute risk of VTE for women taking third-generation OCs = 30 per 100,000 woman-years Absolute risk of VTE for women taking second-generation OCs = 15 per 100,000 woman-years Relative risk = 30  15 = 2 Reference Mills A. Combined oral contraception and the risk of venous thromboembolism. Hum Reprod. 1997;12:2595–2598. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Mills A. Hum Reprod

Explaining Contraceptive Risk to Patients Relative Risk: Example 2 Risk of cesarean delivery with elective induction of labor 20% Risk of cesarean delivery with spontaneous onset of labor 10% Relative risk with induction: 20% 10% Talking Points Here’s another example, this time having to do with the risk of cesarean delivery. Risk of cesarean delivery with elective induction of labor = 20% Risk of cesarean delivery with spontaneous onset of labor = 10% Therefore, the relative risk is 20 divided by 10 = 2 Reference Grimes DA, Schulz KF. An overview of clinical research: the lay of the land. Lancet. 2002;359:57–61. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Relative risk = 20  10 = 2 more… Grimes DA. Lancet

Explaining Contraceptive Risk to Patients Relative Risk: Example 3 Risk of infection after cesarean delivery with prophylactic antibiotics 6% Risk without prophylactic antibiotics: 12% Relative risk: 6% 12% = 0.5 Talking Points Risk of infection after cesarean delivery with prophylactic antibiotics = 6% Risk of infection after cesarean delivery without prophylactic antibiotics = 12% Relative risk = 6 divided by 12 = 0.5 Reference Grimes DA, Schulz KF. An overview of clinical research: the lay of the land. Lancet. 2002;359:57-61. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Relative risk = 6  12 = 0.5 more… Grimes DA. Lancet

Ridiculous Relative Risk
Chance of getting heads is 1:2 with a normal penny In two headed penny, the chance is 2:2 Relative risk is 2 But…..you are always going to get head Relative risk isn’t useful without absolute risk

Know how to communicate numbers
Explaining Contraceptive Risk to Patients Know how to communicate numbers Communicating About Risk - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at

Tools: Numerical Data Try different ways to explain numerical data: “Three of every 10 women develop nausea.”   “You have a 30% chance of having nausea.” Talking Points Here are some tips to improve understanding of numerical data. Try different ways to explain numerical data: Avoid vague statements about risk, which may be confusing. For example, try presenting both frequency statements (3 of 10) AND probabilities (30% chance). [CLICK] SAY “3 of every 10 women develop nausea.” [CLICK] ALSO SAY “You have a 30% chance of nausea with this drug.” Reference Gigerenzer G, Edwards A. Simple tools for understanding risks: from innumeracy to insight. BMJ. 2003;327:741-4. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at more… Gigerenzer G, Edwards A. BMJ

Tools: Numerical Data (continued)
Explaining Contraceptive Risk to Patients Tools: Numerical Data (continued) Avoid shifting denominators in proportions: “Headache developed in 1 of every 333 women.” Talking Points Avoid shifting denominators in proportions: Use proportions of disease per unit of population exposed instead of proportions with a numerator of one and shifting denominators. (Note that many providers will refer to 3 of every 1,000 as a rate, but in actuality, it is a proportion. Proportions are ratios in which the denominator is the total number of individuals at risk, thus including the numerator. Rates are ratios that include exposure in the denominator.) To many people, 1 in 400 may sound like more than 1 in 200. [CLICK] “Headache developed in 1 of every 333 women” is hard to grasp. [CLICK] Instead, say “Headache developed in 3 of every 1000 women.” References Gigerenzer G, Edwards A. Simple tools for understanding risks: from innumeracy to insight. BMJ. 2003;327:741-4. Grimes DA, Snively GR. Patients’ understanding of medical risks: implications for genetic counseling. Obstet Gynecol. 1999;93:910-4. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at “Headache developed in 3 of every 1,000 women.”  more… Gigerenzer G, Edwards A. BMJ Grimes DA, Snively GR. Obstet Gynecol

Tools: Numerical Data (continued)
Explaining Contraceptive Risk to Patients Tools: Numerical Data (continued) Use absolute risk: “OC use increases the risk of heart attack 2.5-fold.”  “Heart attacks occur in 4.2 of every 1 million OC users and 1.7 of every 1 million nonusers.” Talking Points Use absolute risk instead of or in addition to relative risk: For conditions with a low rate in the baseline population, relative risk alone may exaggerate the hazard. [CLICK] DO NOT SAY “OC use increases risk of heart attack 2.5-fold.” [CLICK] SAY “Of every 1 million OC users, about 4.2 develop heart attack each year. About 1.7 nonusers have heart attacks each year.” (Data are for age 30–34, nonsmokers.) References Gigerenzer G, Edwards A. Simple tools for understanding risks: from innumeracy to insight. BMJ. 2003;327:741-4. Farley TMM, Collins J, Schlesselman JJ. Hormonal contraception and risk of cardiovascular disease: an international perspective. Contraception. 1998;57: Sloman, SA, Over D, Slovak L, Stibel, JM. Frequency illusions and other fallacies. Organizational Behavior and Human Decision Processes. 2003;91: - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Gigerenzer G, Edwards A. BMJ Farley TMM, Collins J, Schlesselman JJ. Contraception Sloman SA. Organizational Behavior and Human Decision Processes

Tools: Descriptive Terms
Explaining Contraceptive Risk to Patients Tools: Descriptive Terms Risk level High <1 in 100 Moderate 1–10 in 1,000 Low 1–10 in 10,000 Very low 1–10 in 100,000 Minimal 1–10 in 1 million Talking Points Descriptive terms may be helpful because they can simplify discussions. However, these terms are not standardized and may be defined differently by different people. The slide shows an example of one proposed set of terms to describe risk. Notice that using a variable denominator may be confusing, as we discussed before. Also, at least one study has shown that people often overestimate risk when descriptive terms are used. References Calman KC. Cancer: science and society and the communication of risk. BMJ. 1996;313: Berry DC, Raynor DK, Knapp P, Bersellini E. Patients' understanding of risk associated with medication use: impact of European Commission guidelines and other risk scales. Drug Saf. 2003;26(1):1-11. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at But your patient needs to know the numbers, too Calman KC. BMJ Berry DC, et al. Drug Saf

Tools: Risk Comparisons
Explaining Contraceptive Risk to Patients Tools: Risk Comparisons Annual risk of death (per 100,000) Skydiving 100 Driving 20 Pregnancy 11.5 Riding a bicycle 0.8 Airplane crash 0.4 Using OCs* 0.06 Talking Points This slide compares the risk of death per year for a number of different activities and events. [1] [2] Such comparisons are often used to provide a sense of perspective for various risks. As mentioned, in the U.S., approximately 470 women die each year from pregnancy-related causes (11.8 per 100,000 live births). [3] However, risk comparisons can alienate and offend the listener if they include examples of risks with different characteristics—it’s important to consider the values of the listener and the dread or worry associated with the particular risk. [4] For example, comparing the risk of dying from breast cancer (involuntary and associated with considerable dread) with the risk of driving a car (voluntary and common) may miss the point. In general, it is not a good idea to use risk comparisons such as these when communicating about risks with patients. References Table adapted from Trussell J, Jordan B. Reproductive health risks in perspective. Contraception May;73(5):437-9. Harvard Center for Risk Analysis. Risk Quiz. Available at: Accessed February 1, 2006. Chang J, Elam-Evans LD, Berg CJ, et al. Pregnancy-related mortality surveillance—United States, In: Surveillance Summaries, February 21, MMWR. 2003;52(SS-2):1-8. Bennett P. Understanding responses to risk. In: Bennett P, Calman K. Risk Communication and Public Health. Oxford, England: Oxford University Press Schwingl PJ, Ory HW, Visness CM. Estimates of the risk of cardiovascular death attributable to low-dose oral contraceptives in the United States. Am J Obstet Gynecol. 1999;180(1):241–249. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at *Nonsmoker, age 15–34 Bennett P. In: Risk Communication and Public Health. 1999; Chang J, et al. MMWR Harvard Center for Risk Analysis. 2006’ Schwingl PJ, et al. Am J Obstet Gynecol Trussell J, Jordan B. Contraception

Comparative Risks of VTE
Explaining Contraceptive Risk to Patients Comparative Risks of VTE 60 40 Incidence of VTE per 100,000 woman-years 20 Talking Points When communicating about risk, it’s important to discuss and compare risks associated with relevant alternatives. Without effective contraception, a woman may risk unintended pregnancy, and pregnancy is itself associated with risk. In the U..S, approximately 470 women die each year from pregnancy-related causes (11.8 per 100,000 live births). This slide shows one of the risks associated with pregnancy: venous thromboembolism (VTE). Looking at the risk of VTE with OC use and comparing it with the risk in pregnancy is an example of providing context when communicating about risk, as we will see in the next section. References Shulman LP, Goldzieher JW. The truth about oral contraceptives and venous thromboembolism. J Reprod Med. 2003;48:930-8. Chang J, Elam-Evans LD, Berg CJ, et al. Pregnancy-related mortality surveillance—United States, 1991–1999. In: Surveillance Summaries, February 21, MMWR. 2003;52(SS-2):1-8. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Pregnancy High-dose OC Low-dose OC General Population Shulman LP. J Reprod Med Chang J. In: Surveillance Summaries

Tools: Diagrams Categories table Numbers and categories table Paling Perspective Scale Paling Palette Talking Points This is a list of some visual tools that can be used for risk communication about hormonal contraception. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at

Tools: Categories Typical Success Rate More Effective* Effective† Less Effective‡ Sterilization (male & female) Birth control pills (combined & mini pill) Barrier methods Implants Spermicide Hormone shot Natural methods Intrauterine device (hormonal) Intrauterine device (copper) Talking Points A categories table displays risks, or in this case, contraceptive effectiveness, by grouping methods with similar risk together. [This table is adapted from the Steiner article referenced below.] (Note: NO METHOD = 85% Typical Use Rate and Lowest Expected Rate) *More effective = for most users † Effective = for most users; however, more effective if used consistently and correctly. ‡Less effective = for most users; however, effective if used consistently and correctly. Reference Steiner MJ, Dalebout S, Condon S, et al. Understanding risk: a randomized controlled trial of communicating contraceptive effectiveness. Obstet Gynecol. 2003;102: - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Adapted from Steiner MJ, et al. Obstet Gynecol

Tools: Numbers and Categories
Explaining Contraceptive Risk to Patients Tools: Numbers and Categories Typical Success Rate Typical Pregnancy Rate Lowest Expected Pregnancy Rate More Effective* Sterilization (male & female) 0.5–0.15% 0.5–0.1% Implants 0.05% Hormone shot 3% 0.3% Intrauterine device (hormonal) 0.2% Intrauterine device (copper) 0.8% 0.6% Effective† Birth control pills (combined & mini pill) 8% Less Effective‡ Barrier methods 15–16% 2–6% Spermicide 29% 18% Natural methods 25% 3–5% Talking Points A numbers and categories table displays risks, or in this case, contraceptive effectiveness, by grouping methods with similar risk together, but it also provides numerical data on risk. *More effective = for most users † Effective = for most users; however, more effective if used consistently and correctly. ‡Less effective = for most users; however, effective if used consistently and correctly. References Steiner MJ, Dalebout S, Condon S, et al. Understanding risk: a randomized controlled trial of communicating contraceptive effectiveness. Obstet Gynecol. 2003;102: Trussell J. Contraceptive efficacy. In Hatcher RA, Trussell J, Nelson A, Cates W, Stewart FH, Kowal D. Contraceptive Technology. New York: Ardent Media, 2007:747–826. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Steiner MJ, et al. Obstet Gynecol Trussell J, et al. Ardent Media, 2007.

Teaching Methods Affect Knowledge
Explaining Contraceptive Risk to Patients Teaching Methods Affect Knowledge Talking Points Regardless of which tools you use, it’s important to be aware of how your presentation of risks affects patients’ perceptions and knowledge of those risks. This slide shows some interesting data from a 2003 study by Steiner and colleagues at Family Health International and the Office of Population Research at Princeton. These researchers provided women with three different tools for understanding the effectiveness of contraceptives: The FDA table with percentages A categories and numbers table from WHO that shows percentages and divides contraceptive methods into most effective for most users, effective for most users, and less effective for most users A category table that contains no numbers but just divides methods into most effective, effective, and less effective for most users. The researchers evaluated the improvement in knowledge for the relative effectiveness of the hormonal injection vs. oral contraceptives and oral contraceptives vs. condoms. To look at changes in knowledge, they examined the pre- and post- percentage of improvement in correct score by teaching method. They found that the categories-only table improved knowledge the most and was statistically better than the FDA table with percentages. The combination table with categories and percentages was no better at improving knowledge of effectiveness than percentages alone. Reference Steiner MJ, Dalebout S, Condon S, et al. Understanding risk: a randomized controlled trial of communicating contraceptive effectiveness. Obstet Gynecol. 2003; 102: - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Categories Numbers & categories (WHO) Numbers FDA Steiner MJ. Obstet Gynecol

Tools: Paling Perspective Scale
Explaining Contraceptive Risk to Patients Tools: Paling Perspective Scale Risk of death from vaccination Risk of smallpox Death from smallpox if not vaccinated post-exposure Death from smallpox if vaccinated post-exposure INCREASED RISK 1 in 2 million 1 in 100 million (or less) 1 in 1.7 billion Talking Points This chart is reproduced in detail in your handout. The Paling Perspective Scale was developed by John Paling, research director of the Risk Communication Institute in Gainesville, FL. It shows a spectrum of risk, from minimal to very high, for various activities and could be adapted for reproductive health events. In this case, the risks from smallpox, an event of low probability, are shown for the 115 million Americans over the age of 30 who have been previously vaccinated and DO NOT live in a major metropolitan area. [Note that changing denominators are used here because the risks are so small that to express them un numbers per 100,000 would result in very many decimal places.] Reference Paling J. Strategies to help patients understand risks. BMJ. 2003;327(7417): - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at 1 in 100 billion Paling J. BMJ

Tools: Paling Palette 1,000 Women
Explaining Contraceptive Risk to Patients Tools: Paling Palette 1,000 Women Talking Points This chart is reproduced in your handout. It is animated for demonstrative purposes. John Paling also created the Paling Palette. This visual tool displays most medical risks with a probability of higher than 1 in The doctor or genetic counselor fills in the relevant data while sitting besides the patient. This format shows the estimates of positive and negative outcomes simultaneously and presents unambiguous visual representations of the probabilities. The patient may take a print out home for further consideration or the form may be signed by the patient and a copy kept on file Reference Paling J. Strategies to help patients understand risks. BMJ. 2003;327:745-8. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Paling J. BMJ

Absolute Risk of Breast Cancer in the General Population
Oncology Absolute Risk of Breast Cancer in the General Population Each 50-year-old woman has approximately a 2.8% chance of developing breast cancer by age 60 years This translates to an absolute risk of 2.8 per women All Women Aged 50 Years in the General Population— Risk for Breast Cancer by Age 60 Years In 100 women, 2.8 are at risk To address patients’ confusion regarding breast cancer risk, it may be helpful to discuss a woman’s absolute risk of breast cancer, with or without ET/HT. Absolute risk is the overall incidence of a disease in a given population. For example, Feuer and colleagues estimated that a 50-year-old woman has a 2.8% chance of developing breast cancer before she turns 60. Therefore, among 100 women, 2.8 are at risk for breast cancer. American Cancer Society, Surveillance Research, Breast Cancer Facts and Figures 2001– Available at: http// American Cancer Society, Surveillance Research, Breast Cancer Facts and Figures 2001–2002. Available at: http//

Absolute Risk of Breast Cancer After 5 Years of HT
Oncology Absolute Risk of Breast Cancer After 5 Years of HT WHI results indicate an HR for breast cancer of 1.26 after 5 years of HT use (a 26% increase in risk)1 This translates into an absolute risk of 3.5 per 100 users Risk of Breast Cancer by Age 60 Years After 5 Years of HT Use (Assuming a 26% Increase in Risk) 3.5 of 100 women who are HRT users are at risk (<1 additional woman over baseline risk) Relative risk is different from absolute and attributable risk and should not be interpreted as such. Relative risk is the ratio of the risk of disease among those exposed to a risk factor to the risk among those who were not exposed and is independent of the overall incidence of disease in the population. The WHI reported that HT users was associated with an RR of breast cancer of Women using HT experienced an 26% increase in the risk of breast cancer compared with women taking placebo.1 Therefore, the absolute risk of breast cancer by age 60 years among 50-year-old women taking HT for 5.2 years is 3.5 per 100 HT users.1,2 A discussion of the attributable risk associated with ET/HT also may help patients put breast cancer risk with ET/HT into perspective. Attributable risk refers to the excess risk of disease in patients exposed to a potential risk factor, above and beyond the risk expected in patients not exposed to the potential risk factor. In cohort studies evaluating breast cancer risk and ET/HT use, attributable risk is calculated as the difference in incidence rates between users and nonusers. The attributable risk of breast cancer in HT users, or the excess risk of breast cancer in HT users versus nonusers, is the difference between the incidence rates of HT users compared with nonusers. Therefore, the attributable risk of breast cancer in HT users who are 50 years of age is 0.7 per 100 women. 1Writing Group for the Women’s Health Initiative Investigators. JAMA. 2002;288: 1Writing Group for the Women’s Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288: 2American Cancer Society, Surveillance Research, Breast Cancer Facts and Figures 2001–2002. Available at: http//

WHO Decision Aid on Contraceptive Effectiveness
Explaining Contraceptive Risk to Patients WHO Decision Aid on Contraceptive Effectiveness Most Effective ≤1 pregnancy per 100 women in 1 year Implants, female sterilization, vasectomy, IUD Injectables, lactational amenorrhea method, pills, patch, vaginal ring Male condom, female condom, diaphragm, sponge, fertility awareness–based methods Talking Points This chart shows another way to present information on the relative effectiveness of contraceptive methods. It is adapted from a World Health Organization chart comparing typical contraceptive methods. Notice that: Frequencies per 100 women per year are used, rather than percentages. A spectrum of frequencies are shown, rather than frequencies for each method. CLICK - Withdrawal requires a partner’s cooperation. Spermicides are the least effective and must be used every time one has sex. CLICK - Male and female condoms, the diaphragm, and sponge must be used every time one has sex. Fertility awareness–based (FAB) methods also require a partner’s cooperation; with FABs, a couple must abstain or use condoms on fertile days. CLICK - Injectables require repeat injections every 1, 2, or 3 months. The lactational amenorrhea method (LAM) must follow LAM instructions. Patients must take a pill, and use a patch or vaginal ring every day. CLICK - The most effective methods: implants, female sterilization, vasectomy, and IUD are one-time procedures with nothing to do or remember. Reference Adapted from World Health Organization (WHO). Comparing typical effectiveness of contraceptive methods. [Job Aid]. Geneva: World Health Organization, Available at: Accessed January 26, 2006. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at ~30 pregnancies per 100 women in 1 year Withdrawal, spermicides Least Effective Adapted from World Health Organization, 2006.

Communicating Contraceptive Effectiveness
Explaining Contraceptive Risk to Patients Communicating Contraceptive Effectiveness Given only effectiveness category information, women overestimated pregnancy risk When later shown percentage tables, majority reported rate accurately Authors recommend category tools with general range of risk shown within each category Talking Points In the Steiner 2003 study, before seeing the tables with percentages, women who were shown only the effectiveness categories tended to overestimate the risk of pregnancy for a method in any particular category. For example, before looking at the table with percentages: 70% of women thought the annual risk of pregnancy with a “very effective” method was >5%. 40% of women thought the annual risk was >15%. (WHO defines “very effective” as 0–1%.) After looking at the table with percentages, more than two-thirds correctly reported the failure rate for oral contraceptives. The authors propose that in the area of contraceptive effectiveness, it may be more important to understand relative effectiveness than absolute effectiveness. This is because the data are average failure rates, which may not reflect actual rates for subgroups with certain characteristics (e.g., high method adherence). At the same time, women provided only with category effectiveness tools may overestimate the risk of pregnancy associated with a particular effectiveness category. For these reasons, the researchers suggest using category tools with a general range of risk within each category to provide understanding of both the relative and the absolute risk of pregnancy for each contraceptive method. The authors concluded: “A combination of categories and a general range of risk for each category may provide the most accurate understanding of both relative and absolute pregnancy risk.” Reference Steiner MJ, Dalebout S, Condon S, et al. Understanding risk: a randomized controlled trial of communicating contraceptive effectiveness. Obstet Gynecol. 2003; 102: - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Steiner MJ. Obstet Gynecol

Cardiovascular Adverse Events: Screening for Risk Factors
Explaining Contraceptive Risk to Patients Cardiovascular Adverse Events: Screening for Risk Factors Deaths per million woman-years among women age 30–34 10 22 12 3 Smoker OC User 6 7 BP Checked Venous thromboembolism Ishemic stroke Hemorrhagic stroke Myocardial infarction Talking Points This slide compares the mortality of smokers who use OCs whose blood pressure was checked before OC use and those whose blood pressure wasn’t checked. Reference Farley TMM, Collins J, Schlesselman JJ. Hormonal contraception and risk of cardiovascular disease: an international perspective. Contraception. 1998;57; - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Farley TMM, Collins J, Schlesselman JJ. Contraception 1998.

Medical student attitudes toward the doctor–patient relationship
Distribution of PPOS scores by medical school year and gender © IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSION' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER. Medical Education Volume 36, Issue 6, pages , 31 MAY 2002 DOI: /j x

Attitudes re: patient centered care through medical school

Hamstra D A et al. Med Decis Making 2014;35:27-36
Overall correct response rate as a function of numeracy and graphical format. Overall correct response rate as a function of numeracy and graphical format. N = number of responses for each graphical type. Low = low numeracy (bottom 10%). High = moderate or high numeracy (from 10th–100th percentile). Values represent the mean percent correct (± standard deviation) for each subgroup. Hamstra D A et al. Med Decis Making 2014;35:27-36

Guidance Understand risk and how to communicate it Ensure a trusting environment conducive to conversation Put risks in context Remember cultural, literacy, and developmental issues Remember that discussing risk may make it salient Talking Points This slides lists some suggestions for communicating with patients about the risks associated with combined hormonal contraception. Note that these suggestions are not evidence based. Have a clear understanding of risk yourself and how to communicate it. Ensure an environment that is conducive to conversation and that you’ve built a relationship of trust. One focus group of young African-American and Latina women found that many had negative experiences with physicians, other health professionals, and hospitals. [1] Much of the negative feeling related to lack of communication and trust. Put risks in context: Life has inherent risks. Risk associated with less effective method: pregnancy Risks associated with pregnancy itself: death, stroke, VTE Absolute risk of serious events with hormonal contraceptives is small for most women Remember cultural, literacy, and developmental issues. Remember that discussing risk may make it salient; information designed to correct misperception may make risks more “conscious” for people and lead to increased perception of risk. Reference: Pro Choice Public Education Project. She Speaks: African-American and Latino Young Women on Reproductive Health and Rights. 2004:17-8. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at more… Pro Choice Public Education Project

Guidance (continued) When providing information about risk, discuss risk reduction Remember to present absolute risk Use different forms of numerical data to explain risk Be aware of framing effects Use risk comparisons with care Have multiple, complementary tools available Talking Points When providing information about risk, discuss how the woman can reduce her risk. Remember to present absolute risk. Use different forms of numerical data to explain risk. Be aware of framing effects (the message used can influence perception of risk, for example, percentage who survive vs. percentage who die). Use risk comparisons with care. Have multiple, complementary tools available. Reference: Pro Choice Public Education Project. She Speaks: African-American and Latino Young Women on Reproductive Health and Rights. 2004:17-8. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Pro Choice Public Education Project

Know Yourself and Your Patient Talking Point We’ll now start with Section 1, in which we’ll talk about how risk is perceived, and how those perceptions influence decision making. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at

Decision Aid for Risk Communication
Explaining Contraceptive Risk to Patients Decision Aid for Risk Communication Clarify situation Provide information Clarify patient’s values Talking Points This decision aid may help you to discuss the risks and benefits of hormonal contraception with your patients. [CLICK] Clarify the situation. [CLICK] Provide information on benefits and harms. [CLICK] Clarify patient values. [CLICK] Screen for implementation problems. Reference O’Connor A, Legare F, Stacey D. Risk communication in practice: the contribution of decision aids. BMJ. 2003;327: - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Screen for implementation problems O’Connor A, Legare F, Stacey D. BMJ

A misperception of risks may unnecessarily limit choices Risk perception is affected by a number of factors Clinicians should consider relevant factors and expert guidance about risk communication Several tools are available to aid risk communication - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at

Communicating Risk: How-To’s
Explaining Contraceptive Risk to Patients Communicating Risk: How-To’s What to ask: Patient needs & concerns What to consider: Relevant factors What to use: Tools What to do: Provide guidance Talking Points Now, let’s turn to how to communicate risk. You’re in your office or an exam room. A woman wants to switch contraceptive methods. What should you tell her about risks? How should you tell her? What, exactly, should you say and do? We’ll discuss four important aspects of communicating the risks associated with contraceptives: Patient needs and concerns, or “What to ask” Relevant factors, or “What to consider” Tools, or “What to use” Guidance, or “What to do” - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at

Patient Needs & Concerns
Explaining Contraceptive Risk to Patients Patient Needs & Concerns “How important is it to avoid pregnancy right now?” “Do you want (or need) your use of contraception to be private?” “Do you have concerns about a particular contraceptive?” “What side effects are you willing to accept?” Talking Points This slide lists some questions to ask your patient to better understand her needs and concerns about risk and hormonal contraception. Use the answers to guide your discussion of risk (e.g., how much detail to provide about comparative effectiveness). Questions: How important is it to avoid pregnancy right now? Do you want your use of contraception to be private? Do you have concerns about a particular contraceptive (e.g., media report, friend’s experience)? What side effects (or risk of serious adverse events) are you willing to accept? - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at “Are you comfortable with methods that require insertion in the vagina?”

Risk & Health Decisions
Explaining Contraceptive Risk to Patients Risk & Health Decisions ‘ ‘ “…Decisions about risk are not technical, but value decisions.” Talking Points Health decisions reflect a person’s values, not just his or her understanding of the technical aspects of risk. Thus, risk communication is not about providing more information or risk calculations to change risk perception. Reference Baker B. In: Bennett P, Calman K, eds. Risk Communication and Public Health. Oxford; Oxford University Press. 1999: preface, v. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Baker B. In: Risk Communication and Public Health

Mammography numbers For every 2,000 women age 50 to 70 who are screened for 10 years, one woman will be saved from dying of breast cancer, 10 will have their lives disrupted unnecessarily by overtreatment. Nordic Cochrane Center Collaborative, 2006

Mammography Numbers repeated screening starting at age 50 saves about 1.8 (overall range, 0.9–2.7) lives over 15 years for every 1000 women screened. Keen JD. BMC Medical Informatics and Decision Making 2009

Media Influence + – Widespread dispersion of reproductive health information Misperception of contraceptive risks Talking Points The media provide a means for widespread dispersion of reproductive health information. However, they also serve as a source of risk misperception for a number of reasons: Media provide incomplete information and are designed to deliver news in small portions, or “sound bites.” Media stay viable through “selling” the news, often following the philosophy “if it bleeds, it leads.” Media do not put reported risks in context. Television advertisements for hormonal contraceptives conclude with a required, but overwhelming, list of the adverse events reported in clinical trials. Reference Grimes DA. Breast cancer, the pill, and the press. In: Mann RD, ed. Oral Contraceptives and Breast Cancer. Park Ridge, NJ: The Parthenon Publishing Group. 1989: - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Grimes DA. In: Oral Contraceptives and Breast Cancer

Perception & Interpretation of Risk
Explaining Contraceptive Risk to Patients Perception & Interpretation of Risk Individual Risk Presentation Characteristics of the Risk Talking Points Three general types of factors affect a person’s perception and interpretation of risk: Those related to the individual Those related to risk presentation Those related to the characteristics of the risk - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at

Characteristics of the Risk
Explaining Contraceptive Risk to Patients Characteristics of the Risk People worry more about risks that: The individual cannot control Are involuntary Are associated with particular dread Are novel or unfamiliar Result from man-made sources Are more easily recalled Talking Points People tend to worry more about risks that The individual cannot control (airplane v. car crash) Are involuntary (air pollution) Are associated with particular dread (breast cancer) Are novel or unfamiliar (newly discovered toxin) Result from man-made sources (radiation from mobile phones) Are more easily recalled (recent media attention) References Harvard Center for Risk Statistics. Risk in Perspective. Vol. 11. June 2003. Bennett P. Understanding responses to risk. In: Bennett P, Calman K, eds. Risk Communication and Public Health. Oxford; Oxford University Press - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Harvard Center for Risk Statistics Bennett P. In: Risk Communication and Public Health

Weighing the Risks & Benefits
Explaining Contraceptive Risk to Patients Weighing the Risks & Benefits RISKS BENEFITS Talking Points It is important to understand that for most women, the benefits of combined hormonal contraceptives outweigh the potential risks. That said, smoking, hypertension, obesity, and diabetes are risk factors that must be considered when evaluating risks associated with combined hormonal contraceptives. Reference Burkman R, Schlesselman JJ, Zieman M. Safety concerns and health benefits associated with oral contraception. Am J Obstet Gynecol. 2004;190(4 Suppl):S5-22. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an unrestricted educational grant. Last reviewed/updated by the ARHP/PPFA Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May This slide is available at Burkman R. Am J Obstet Gynecol

Guidance for Risk Communication
Understand risk and how to communicate it Establish a trusting environment conducive to conversation Put risks in context Remember cultural, literacy, social, and developmental issues Remember that discussing risk may make it salient Talking Points This slides lists some suggestions for communicating with patients about the risks associated with combined hormonal contraception. Note that these suggestions are not evidence based. Have a clear understanding of risk yourself and how to communicate it. Establish an environment that is conducive to conversation and that you’ve built a relationship of trust. One focus group of young African-American and Latina women found that many had negative experiences with physicians, other health professionals, and hospitals. [2] Much of the negative feeling was related to lack of communication and trust. Put risks in context: Life has inherent risks. Risk associated with less effective method: pregnancy Risks associated with pregnancy itself: death, stroke, VTE Absolute risk of serious adverse events with hormonal contraceptives is small for most women Remember cultural, literacy, social, and developmental issues. Remember that discussing risk may make it salient; information designed to correct misperception may make risks more “conscious” for people and lead to increased perception of risk. References Lipkus IM. Numeric, verbal, and visual formats of conveying health risks: suggested best practices and future recommendations. Med Decis Making Sep-Oct;27(5): Pro Choice Public Education Project. She Speaks: African-American and Latino Young Women on Reproductive Health and Rights. 2004:17-8. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an educational grant. Updates to this slide were made possible by funding received from Bayer HealthCare Pharmaceuticals, Merck and Co., and Teva Pharmaceuticals educational grants. This slide is available at more… Lipkus IM. Med Decis Making Pro Choice Public Education Project

Guidance for Risk Communication (cont’d)
When providing information about risk, discuss risk reduction Remember to present absolute risk Use numeric, verbal, and visual formats to convey health risk Be aware of framing effects Use risk comparisons with care Have multiple, complementary tools available Talking Points When providing information about risk, discuss how the woman can reduce her risk. Remember to present absolute risk rather that attributable risk, relative risk, or odd ratio. Use different forms of numerical data to explain risk as well as verbal and visual formats to improve perception and understanding of risk. Be aware of framing effects. For example, the message can influence an individual’s perception of risk by presenting favorable rather than unfavorable outcomes such as the risk of surviving versus risk of dying. Use risk comparisons with care. Have multiple, complementary tools available. References Lipkus IM. Numeric, verbal, and visual formats of conveying health risks: suggested best practices and future recommendations. Med Decis Making Sep-Oct;27(5): Pro Choice Public Education Project. She Speaks: African-American and Latino Young Women on Reproductive Health and Rights. 2004:17-8. - - - Original content for this slide submitted by the Clinical Advisory Committee for You Decide: Making Informed Health Decisions about Hormonal Contraception in May 2006, a joint program of ARHP and Planned Parenthood® Federation of America (PPFA). Original funding received from Ortho Women’s Health and Urology through an educational grant. Updates to this slide were made possible by funding received from Bayer HealthCare Pharmaceuticals, Merck and Co., and Teva Pharmaceuticals educational grants. This slide is available at Lipkus IM. Med Decis Making Pro Choice Public Education Project

Using numbers your patient can use
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Health Numeracy: Explaining risk in numbers patients can use

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