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Helping Your Patients Decide: Making Informed Health Choices About Hormonal Contraception

(Published June 2006)

Tools for Communicating Risk About Hormonal Contraceptives

Communication tools provide patients with a variety of means for understanding risk. There are two basic types of tools:

  • written or oral tools, including numerical data, descriptive terms, and analogies and comparisons
  • visual tools

Different tools may be more effective with particular groups of patients, such as those with lower literacy skills. Use of a variety of tools also may help some women better understand a specific risk. A provider can present several tools, explaining that “Some women understand this information better when it’s shown in a picture; others prefer to read words and numbers, and others gain best understanding with words, numbers and pictures.”

In addition, tools that can accommodate very different levels of risk may be useful for discussing events with different degrees of risk. Tools for communicating only about rare events, such as stroke, may not be helpful for communicating about events that are more common, such as contraceptive failure or side effects. A better tool might combine both levels of risk into a single, comparable graphic or presentation.

Numerical Data

Numerical data, such as risk calculations, can be essential for explaining a particular health risk. However, such data can introduce confusion, depending on the presentation. Several techniques can improve understanding of numerical data:

  • It can be helpful to present numerical data in different ways. For example, presenting data on risk as a frequency statement (“Three of every 10 women develop nausea”) and as a probability (“You have a 30 percent chance of nausea”) can aid understanding.
  • Presenting numerical data with a shifting denominator can be confusing. To many people, 1 in 400 may sound like a greater risk than 1 in 200. A better practice is to present data with a static denominator, such as 1,000 or 10,000. For example, it is better to say “Headache developed in 3 of every 1,000 women” than “Headache developed in 1 of every 333 women.”
  • The use of relative risk alone can exaggerate the hazard for conditions with a low rate in the baseline population. To provide context, providers can present the absolute risk instead of, or in addition to, relative risk.1 For example, rather than saying “Oral contraceptive use increases the risk of heart attack about 2 fold,” providers can say, “Of every one million OC users, about 4 experience a heart attack each year. For comparison, about 2 nonusers have heart attacks each year.”2 (Note that these data are for nonsmoking women of 30–34 years old.)

Descriptive Terms

Descriptive terms are phrases that divide risk into categories. Table 3 shows one proposed set of descriptive terms. Use of these terms can simplify risk discussions, but there are several caveats:

  • Because the terms are not standard, they may be defined differently by different people.
  • Use of a variable denominator may be confusing, as previously mentioned.
  • At least one study has shown that people often overestimate risk when descriptive terms are used.3

Analogies and Comparisons

An analogy is a type of comparison that is used to show a similarity between two or more things. One analogy for risk reduction involves stairs in a building.5 A provider can describe the effects of risks and risk reduction behaviors by comparing them to stories in a building, as follows:

“A healthy woman taking OCs leaves the house by the door. A woman taking OCs who has high blood pressure jumps from the first floor. A woman taking OCs who smokes and has high blood pressure jumps from the second floor. A woman taking OCs who has a history of blood clots, smokes, and has high blood pressure jumps from the roof.”

Using this analogy, the provider can explain that decreasing the risks that can be changed is like walking down the stairs in the building.

Another type of comparison that can be used when communicating about risk is the presentation of the risk of death for different activities and events (see Figure 12). Such comparisons are used to provide a sense of perspective for various risks. Notice, for example, that the use of OCs by nonsmoking women less than 35 years old is associated with an annual risk of death lower than that associated with pregnancy or bicycle riding.

Despite the potential advantage of providing a sense of perspective, risk comparisons must be used with caution. As previously mentioned, they can alienate, confuse, or offend the listener if they include examples of activities or events with different characteristics. For this reason, it’s important for providers to consider the values of the listener and the dread or worry associated with the particular risk.9 For example, comparing the risk of dying from breast cancer, which is involuntary and associated with considerable dread, with the risk of driving a car, which is voluntary and common, may generate distrust or confusion instead of improved understanding.

For hormonal contraceptives, it may be more useful to compare the risks with those associated with a relevant alternative (e.g., not using effective contraception) than with those connected with life events. Overall, the risk of pregnancy from a single act of intercourse is 3 percent.10 However, as shown in Figure 13, the risk rises to almost 10 percent just before ovulation in women with regular cycles.10 Over the course of a year, the risk of pregnancy without contraception is 85 percent, leading to a high probability of experiencing the risks of pregnancy or abortion, along with other costs and benefits of pregnancy and childbearing.11

Visual Tools

Visual tools can be very helpful for communicating the risks associated with hormonal contraceptives. Use of tables, diagrams, and scales can help women put risks into perspective and make a better-informed health decision. Tables may include numerical data, risk categories, or both. Tables 4 and 5 show a categories table and a numbers and categories table. The categories table displays risks (or in this case, contraceptive effectiveness) by grouping items with similar risk. The numbers and categories table displays risks by grouping items but also provides numerical data.

 

Diagrams also can help women better understand the risks associated with hormonal contraceptives. One especially innovative diagram was created by researchers working with commercial sex workers in Cambodia.13 The researchers needed to design an easily understood consent form for participation in a study. They divided women into groups and asked them to draw petals and thorns onto an image of a flower—a petal for each benefit and a thorn for each risk associated with participating in the study. The women listed on the petals items such as “Get new information” and “Learn about women in other brothels” and on the thorns, “Loss of leisure time” and “Loss of time with clients.” The researchers found that the exercise helped the women understand the risks being discussed and engaged their interest in the project.

 Various visual scales have been developed to help people understand risk; some of these scales can be used to explain risks of hormonal contraceptives. A researcher in risk communication, John Paling, created a visual scale that shows a spectrum of risk, from minimal to very high, for various activities.14 The scale, shown in Figure 14, could be adapted for reproductive health events, such as risk of VTE.

Paling also created a visual tool that displays the risk of particular events through the use of human icons, as shown in Figure 15. Using images with enough icons to discuss all relevant risks (e.g., 1,000 or 10,000) can help provide context for the discussion, based on the magnitude of the risks. If icons are grouped into larger sets, as in Paling’s tool, discussions of high-probability events such as contraceptive effectiveness can focus on shaded groups of 10 or 100; discussion of less common risks, such as stroke, can focus on a few shaded icons.

References

  1. Gigerenzer G, Edwards A. Simple tools for understanding risks: from innumeracy to insight. BMJ. 2003;327:741-4.
  2. Farley TM, Collins J, Schlesselman JJ. Hormonal contraception and risk of cardiovascular disease: An international perspective. Contraception. 1998;57;211-30.
  3. 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.
  4. Calman KC. Cancer: science and society and the communication of risk. BMJ. 1996;313:799-802.
  5. Edwards E. Communicating risks through analogies. [letter] BMJ. 2003;327:749.
  6. Trussell J, Jordan B. Reproductive health risk in perspective. Contraception. In press.
  7. Harvard Center for Risk Statistics. Risk quiz. Available at: http://www.hcra.harvard.edu/. Accessed May 10, 2006.
  8. Chang J, Elam-Evans LD, Berg CJ, et al. Pregnancy-related mortality surveillance—United States, 1991-1999. In: Surveillance Summaries, February 21, 2003. MMWR. 2003;52(SS-2):1-8.
  9. Bennett P, Calman K. Risk Communication and Public Health. Oxford, England: Oxford University Press; 1999.
  10. Wilcox AJ, Dunson DB, Weinberg CR, Trussell J, Baird DD. Likelihood of conception with a single act of intercourse: providing benchmark rates for assessment of post-coital contraceptives. Contraception. 2001;63:211-15.
  11. Trussell J. The essentials of contraception: Efficacy, safety, and personal considerations. In: Hatcher RA, Trussell J, Stewart FH, Nelson AL, Cates W, Jr, Guest F, et al., editors. Contraceptive Technology. 18th ed. New York: Ardent Media, Inc.; 2004. pp. 221-52.
  12. Steiner MJ, Dalebout S, et al. Understanding risk: a randomized controlled tiral of communicating contraceptive effectiveness. Obstet Gynecol. 2003;102:709-17.
  13. Population Council. Informed consent: From good intentions to sound practices. Available at: http://www.popcouncil.org/pdfs/ebert/informedconsent.pdf. Accessed October 12, 2005.
  14. Paling J. Strategies to help patients understand risks. BMJ. 2003;327:745-8.