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Risk Talk: On Communicating Benefits and Harms in Health Care
Linköping University, Department of Medicine and Health Sciences, Clinical Pharmacology . Linköping University, Faculty of Health Sciences.
2006 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

One of the most critical elements in empowering the patient, and ensuring concordance, is communication of the possible benefits and harms of different actions in health care. Risk assessment is a complex task due both to the different interpretations of the concept of risk, and the common lack of hard facts. Hormone, or hormone replacement, therapy (HT) is used by many women in, and after, the menopause. The benefits and possible harms associated with short and long term treatment with HT have been extensively discussed the last decade and the use of HT has decreased dramatically internationally the last few years.

The aims of this thesis were to study the interaction between patient and physician when discussing risks and benefits of different treatment alternatives, and to suggest strategies to improve risk communication in clinical practice. The studies have focused on how risks and benefits with HT were communicated between women and physicians during firsttime consultations in 1999- 2000 on this subject (20 women, 5 gynaecologists), and through questionnaires how attitudes towards HT have changed between 1999 (n=1,760) and 2003 (n=1,733) among women entering the menopause (53-54 years).

Through a qualitative analysis of the risk communication in the consultations a system was constructed to classify how risk is communicated in relation to benefits. This was used to assess and present differences in risk communication in the consultations. Different rhetorical strategies by the physicians were identified and the dominating tendency was a move from the woman’s current problems to the long-term effects of HT.

The questionnaires showed a marked difference in attitudes towards HT between the years. In 2003 women perceived HT to be associated with higher risk and less benefits than in 1999. This correlated to a drastic reduction in the use of HT over the same period. Media was the most frequent source of information about HT during the last twelve months before the questionnaire in 2003.

Possible explanations for the different attitudes towards HT between women entering the menopause and gynaecologist; how this difference might have influenced the results; and how they may have implications for future communication strategies are discussed. This thesis illustrates the importance of a deeper understanding in health care of the concept of risk in order to achieve an adequate communication of risk. This is important both in consultations and in campaigns to educate and inform the public.

Place, publisher, year, edition, pages
Institutionen för medicin och vård , 2006.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 933
Keyword [en]
risk, communication, menopause, hormone replacement therapy, physician-patient relations
National Category
Pharmacology and Toxicology
Identifiers
URN: urn:nbn:se:liu:diva-7338ISBN: 91-85497-68-1 (print)OAI: oai:DiVA.org:liu-7338DiVA: diva2:22357
Public defence
2006-01-26, Berzeliussalen,, Campus US, Linköpings universitet, Linköping, 13:00 (English)
Opponent
Supervisors
Note
Reprinted figure 1 on page 32 with permission from Science Ref # 05-17260-Revised. Copyright 2006 AAAS.Available from: 2006-09-19 Created: 2006-09-19 Last updated: 2009-08-22
List of papers
1. Hormone replacement therapy in the menopause - structure and content of risk talk
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2005 (English)In: Maturitas, ISSN 0378-5122, E-ISSN 1873-4111, Vol. 50, no 1, 8-18 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To investigate how risks and benefits of hormone replacement therapy (HRT) are communicated to women in clinical practice. To evaluate the usefulness of a risk classification based on context framing, i.e. whether the risk is discussed for one or several alternative treatments, and/or in the same context as possible benefits.

Design: Analysis of structure and content of transcribed consultations (n=20) from first-time visits for discussion of climacteric discomfort and/or HRT with five physicians at three different out-patient clinics of gynecology.

Results: All women received a prescription of HRT. An alternative to HRT was discussed in seven of the consultations. No decision aids were used. Risk discussion was dominated by the physicians giving information about long-time risk and benefits. The decision to prescribe was made either before the risk discussion was initiated, or before it was finished, in 8 of the 18 consultations where risk discussion was present. Risk classification according to context framing was performed and indicated use of different communication strategies by the physicians.

Conclusions: The perspective of the physicians was mainly on prevention while the women were more focused on symptom alleviation. Each physician had a strategy of his/her own for the risk discussion. Thus, the major differences found between the consultations were between physicians, and not between the women. Risk discussion seemed to be aimed at motivating the woman to follow the physician’s decision rather than to help her participate in the decision-making process.

Keyword
Hormone replacement therapy, Risk, Communication, Patient participation, Patient compliance, Concordance
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13970 (URN)10.1016/j.maturitas.2004.03.014 (DOI)
Available from: 2006-09-19 Created: 2006-09-19 Last updated: 2017-12-13Bibliographically approved
2. Risk communication in consultations about hormone therapy in the menopause – concordance in risk assessment and framing due to the context
Open this publication in new window or tab >>Risk communication in consultations about hormone therapy in the menopause – concordance in risk assessment and framing due to the context
2006 (English)In: Climacteric, ISSN 1369-7137, E-ISSN 1473-0804, Vol. 9, no 5, 347-354 p.Article in journal (Refereed) Published
Abstract [en]

Background

It is important for the physician and the patient to have a mutual understanding of the possible consequences of different treatment alternatives in order to achieve a partnership in decision making.

Objective

The aim of this study was to explore to which degree first-time consultations for discussion of climacteric discomfort achieved shared understanding of the risks and benefits associated with hormone therapy in the menopausal transition (HT).

Methods

Analysis of structure and content of transcribed consultations (n=20), and follow-up interviews of the women (n=19 pairs of consultations and interviews), from first-time visits for discussion of climacteric discomfort and/or HT with five physicians at three different out-patient clinics of gynaecology in Sweden.

Results

Four distinctively different interpretations of risk, depending on whether or not benefits were discussed in the same context, emerged from the analysis. On average 5 advantages (range 0-11) and 2 (0-3) disadvantages were mentioned during the consultations. In the interviews the women expressed on average 4 advantages (0-7) and 1 disadvantage (0-3). There were major variations between advantages and disadvantages expressed in the consultation and the following interview.

Conclusion

Even though the consultations scored high in patient involvement, the information in most consultations was not structured in a way that made it possible to achieve a shared or an informed decision making.

Keyword
Risk, Risk assessment, Communication, Physician-Patient Relations, Professional-Patient Relations
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-11692 (URN)10.1080/13697130600870220 (DOI)
Note
Original publication: Hoffmann M, Hammar M, Kjellgren K I, Lindh-Åstrand L and Ahlner J, Risk communication in consultations about hormone therapy in the menopause – concordance in risk assessment and framing due to the context, 2006, Climacteric, (9), 5, 347-354. http://dx.doi.org/10.1080/13697130600870220. Copyright © Taylor & Francis Group, an informa businessAvailable from: 2008-10-13 Created: 2008-10-13 Last updated: 2017-12-13Bibliographically approved
3. Risk talk: rhetorical strategies in consultations on hormone replacement therap
Open this publication in new window or tab >>Risk talk: rhetorical strategies in consultations on hormone replacement therap
2005 (English)In: Health, Risk and Society, ISSN 1369-8575, E-ISSN 1469-8331, Vol. 5, no 2, 139-154 p.Article in journal (Refereed) Published
Abstract [en]

When analysing risk discussions in medical settings it is important to consider the specific activity type. In this qualitative study 20 first-time consultations by healthy women regarding hormone replacement therapy (HRT) in the menopause the risk discussion is asymmetrical with the doctors dominating. Despite being set up as a specific opportunity for women in the menopause to discuss problems and risks, it comes forth as a decision-making activity in a traditional medical setting. The consultations fulfil to a high extent the demands for informed decision making, but the risk discussions are recontextualised into a cost-benefit discourse with a typical implicit quantitative bias. The doctors use several different rhetorical strategies such as positive introduction of HRT, embedding drawbacks in positive introductions and/or exits thereby diminishing them. The word risk is avoided to a considerable extent and the term 'drawbacks' is used instead. The most obvious strategy is to move from the woman's symptoms to aspects of prevention, thus changing the discussion from the menopause and different strategies to cope with menopausal problems into a medically oriented discussion of pharmacological treatment alternatives. The 'change of life' in these talks is entirely conceptualised within a 'medical model'.

Place, publisher, year, edition, pages
Hants, UK: Carfax Publishing, 2005
Keyword
Risk, Communication, Menopause, Hormone Replacement Therapy, Physician-patient Relations
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13972 (URN)10.1080/1369857031000123920 (DOI)000184127500003 ()
Available from: 2006-09-19 Created: 2006-09-19 Last updated: 2017-12-13
4. Changes in women’s attitudes towards and use of hormone therapy after HERS and WHI
Open this publication in new window or tab >>Changes in women’s attitudes towards and use of hormone therapy after HERS and WHI
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2005 (English)In: Maturitas, ISSN 0378-5122, E-ISSN 1873-4111, Vol. 52, no 1, 11-17 p.Article in journal (Refereed) Published
Abstract [en]

Objectives:

To assess changes in women's attitudes towards risk and benefits of, and use of hormone treatment in the menopausal transition (HT) before and after Heart and Estrogen/Progestin Replacement Study (HERS) and the oestrogen and progestin trial of Women's Health Initiative (WHI).

Methods:

Postal questionnaires to all women 53 and 54 years of age in a Swedish community in 1999 (n = 1.760) and 2003 (n = 1.733). Data on sales of HT were collected from the database of the National Corporation of Swedish Pharmacies.

Results:

The fraction of women reporting current use of HT fell from 40.5 to 25.3% (p < 0.001, χ2-test) both by fewer women starting and more women discontinuing treatment. This corresponded to a decrease in dispensation of HT in Linköping and nationwide for the same age group. The fraction of women who had tried complementary treatment for climacteric discomfort, increased from 9.6 to 18.1% for natural remedies (p < 0.001, χ2-test).

Women perceived HT as more risky and less beneficial in 2003 as compared with 1999 (both p < 0.001, χ2-test). The most frequent source of information about HT during the last year before the 2003 questionnaire were newspaper or magazines (43.8%) and television or radio (31.7%).

Conclusions:

The decreased use of HT in the community correlated with pronounced changes in the attitudes towards HT. Media were a more frequent source of information than health care personnel. This indicates that media reports about major clinical studies might have influenced the use of HT among women.

Place, publisher, year, edition, pages
Elsevier, 2005
Keyword
Hormone replacement therapy, Risk, Communication, Communications media/mass media, Concordance (patient compliance)
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13973 (URN)10.1016/j.maturitas.2005.06.003 (DOI)
Available from: 2006-09-19 Created: 2006-09-19 Last updated: 2017-12-13Bibliographically approved

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