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National Cancer Institute

Centers of Excellence in Cancer Communication Research at University of Michigan Center for Health Communications Research

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Website : http://chcr.umich.eduExit Disclaimer

Overview: The purpose of the University Of Michigan Center for Health Communications Research (CHCR), a Center Of Excellence in Cancer Communication Research (CECCR), is to continue expanding the scientific foundation of interactive health communication (IHC) interventions for health promotion, disease prevention, risk communication, and informed decisionmaking. A better understanding of the efficacy, reach, costs, and benefits of IHC interventions has already resulted in marked improvements and rapid advances in real world IHC dissemination. With rapid advances in digital communication technologies (e.g., smart phones), IHC interventions have become increasingly relevant and powerful. For the past decade, CHCR has studied the “black box” of IHC interventions. Using theoretical perspectives from the fields of health behavior and communication, the CHCR has identified important active ingredients of IHC interventions and relevant individual characteristics that moderate the impact of such interventions. Results from CHCR research have been adopted in health care, employer, pharmaceutical, and government settings throughout the world. The University of Michigan CHCR participated in the first iteration of CECCR; for more information about their first set of projects see the CECCR Archive.

Primary research and goals:

  1. Extend our tailoring research beyond prevention to the broader cancer care continuum; including early detection, treatment, and long-term survival.
  2. Extend our tailoring research to new clinical and post-treatment settings.
  3. Deepen our understanding of the key psychosocial and communication components identified in CECCR I, including motivation, ethnic identity, risk perception, and cognitive processing.
  4. Explore methods of tailoring to patient preferences for shared decision making.
  5. Develop new social and cognitive neuroscience strategies for identifying immediate impact and mechanisms of health communication messages.
  6. Develop new interdisciplinary collaborations with scientists and research institutions.
  7. Train a new generation of health communication scientists and practitioners.
  8. Disseminate the scientific and practical results of our research efforts.
  9. Woven through our CECCR II research are crosscutting interests related to:
    1. Tailoring and relevant communications channels.
    2. Reaching underserved populations through more relevant and easier-to-process content.
    3. Physiological mechanisms of communication effect.
    4. Methodological issues of design, data collection, and measurement.

Key partnerships and collaborations:

  1. New York State Department of Health
  2. Roswell Park Cancer Center
  3. Research Triangle Institute
  4. University of Massachusetts
  5. Cancer Council Victoria, Australia
  6. West Coast Screen Writers Guild
  7. Henry Ford Health System
  8. Commonwealth of Virginia University
  9. University of North Carolina
  10. Ann Arbor VA Medical Center
  11. University of Michigan Hospital
  12. Duke University
  13. Michigan State University

Photo of Dr. Victor J. Strecher, Ph.D., M.P.H.Principal investigator: Dr. Victor J. Strecher, Ph.D., M.P.H. is a professor in the Department of Health Behavior and Health Education, School of Public Health at the University of Michigan. He is also director of the Health Media Research Laboratory and director of Cancer Prevention and Control at the School of Medicine at the University of Michigan. Most recently, he became president and CEO of HealthMedia Inc. in Ann Arbor.

Dr. Strecher founded the University of Michigan’s Health Media Research Laboratory (HMRL), a multidisciplinary team of behavioral scientists, health educators, instructional designers, computer engineers, graphic artists, project managers, and students from a wide variety of disciplines (public health, epidemiology, psychology, computer engineering, information science, art, music, and others). The HMRL, along with Dr. Strecher's previous laboratory, the Health Communications Research Laboratory at the University of North Carolina, has conducted research studies and demonstration projects of computer-tailoring and interactive multimedia programs for the past 8 years.

Dr. Strecher’s academic interests include evaluative research of interactive health communications and health behavior change interventions. He has been principal investigator on over $10 million in research grants, many of which have been in the area of interactive health communication research. Grant-funded studies have included, among others, several computer-tailored print interventions, including tailored materials to callers of the National Cancer Institute’s Cancer Information Service (CIS); tailored materials for cigarette smoking cessation, mammography, and dietary fat reduction; tailored materials for injury victims in the emergency room; and tailored materials to HMO members based on a comprehensive health risk appraisal. Computer-based interactive multimedia interventions include a program for genetic counseling on BRCA1 and BRCA2 and programs to teach women about their risks of breast cancer. Dr. Strecher received his Ph.D. from the University of North Carolina-Chapel Hill.

Contact Information:
Victor J. Strecher
STRECHER@UMICH.EDU

Co-investigators:

Photo of Co-investigator Lawrence C. An, M.D.
Lawrence C. An, M.D.
Photo of Co-investigator Kenneth A. Resnicow, Ph.D.
Kenneth A. Resnicow, Ph.D.
Photo of Co-investigator Angela Fagerlin, Ph.D.
Angela Fagerlin, Ph.D.

Primary projects

  1. Evaluating media and cessation components of a statewide Web-based cessation Program
    1. Lead researcher: Lawrence C. An, M.D.
    2. Overview: This project aims to improve two fundamental aspects of population-based smoking cessation programming: reach through a media campaign encouraging the use of a Web-based cessation intervention and efficacy of the Web-based smoking cessation intervention.
    3. Implications for cancer prevention and control: Although reportedly used by millions of smokers, the Internet currently offers a mixed, largely untested, set of cessation options. A greater understanding of both reach and efficacy is essential to the dissemination of this intervention modality to other states and countries, a long-term goal of this research.
  2. Increasing colorectal cancer screening in African Americans using tailoring and MI
    1. Lead researcher: Kenneth A. Resnicow, Ph.D.
    2. Overview: This randomized trial tests two increasingly intensive interventions to increase colorectal cancer (CRC) screening among African American members of an integrated health care system:
      1. The Electronic Medical Record (EMR) Tailoring group will receive up to two CRC-related newsletters tailored on the EMR variables of name, age, gender, history of prior CRC screening, and history of health maintenance exams
      2. The Enhanced Tailoring group will receive up to two CRC-related newsletters tailored on EMR variables, plus additional variables such as screening test preferences, barriers to screening, preference for autonomy vs. expert direction, racial salience, and motivations for screening.
    3. Implications for cancer prevention and control: CRC mortality rates are 43 percent higher among African Americans than whites and account for approximately 12 percent of all cancer deaths among African Americans. One strategy to reduce this disparity is to increase early detection. Ethnic differences exist in the determinants of screening behavior.
    Figure 1: Cover of Inside Health newsletterFigure 1: Cover of Inside Health, an individually tailored newsletter to increase colorectal cancer screening among African Americans.
    Figure 2: Secondary page of Inside Health newsletterFigure 2: Tailored testimonials and content to reduce barriers to colorectal cancer screening.
  3. Promoting shared decisionmaking through a tailored decision aid
    1. Lead researcher: Angela Fagerlin, Ph.D.
    2. Overview: The goal of this study is to help patients with localized prostate cancer recognize the importance of their preferences when making a treatment decision and to find ways to help patients communicate such preferences to their urologist. The CHCR is testing whether a race-tailored DVD can increase patient perception of the salience of their preferences, increase concordance between patient preferences and subsequent decisions, and improve doctor-patient communication. To achieve these goals, prostate cancer patients are recruited at their biopsy appointment and randomized to receive or not receive the DVD that will teach them communication skills. All subjects receive educational materials.
    3. Implications for cancer prevention and control: We currently do not know the best ways to help patients take information they learn from decision aids and make those outcomes salient in their lives, nor how to make sure they recognize that their own values will play a crucial role in determining the best health care alternative. It is no longer enough to provide information to patients; we now need to teach patients how to use this information in their communication with physicians.
    Figure 1: Cover of Discussing the Choice DVDFigure 1: Cover of Discussing the Choice interactive DVD, a tool to help early-stage prostate cancer patients communicate treatment preferences to their urologist.
    Screenshot from Discussing the Choice DVDFigure 2: A screenshot from Discussing the Choice, where a doctor and patient illustrate good communication techniques.

Secondary projects

  1. Web-based support of the cancer patient in transition
    1. Lead researcher: Jennifer J. Griggs, M.D., M.P.
    2. Overview: The CHCR proposes an intervention for patients completing multimodality breast cancer treatment as a novel model of care for breast cancer survivors. The intervention, which will include a dedicated “transition visit” and tailored Web-based support, will be designed to provide informational support and strategies for self-management of the long-term effects of cancer and its treatment to patients following their completion of multimodality breast cancer treatment.
    3. Implications for cancer prevention and control: After the completion of surgery, chemotherapy, and radiation therapy, patient information needs focus on the long-term side effects of treatment, risk of recurrence, and the risk of breast cancer in family members. Coincident with the need for new information is a decrease in the availability of medical resources for addressing these needs. Many cancer specialists are not able to provide survivorship information and care because of time constraints and lack of expertise regarding care of the survivor.
    Screenshot of The Survivorship Resource Room home pageFigure 1: The Survivorship Resource Room homepage is individually tailored for each breast cancer patient.
    Screenshot of The Survivorship Resource Room broken down to show how to get answersFigure 2: Sections of the Survivorship Resource Room Website provide tailored information concerning symptoms, coping strategies, questions to ask the doctor, upcoming appointments, and summaries of treatment and care plans.
  2. Increasing human papillomavirus vaccination among adolescents
    1. Lead researcher: Amanda F. Dempsey, M.D., M.P.H.
    2. Overview: The broad objective of this application is to develop and pilot test an intervention that uses individually-tailored educational messages about HPV and the HPV vaccine to counteract mothers’ negative beliefs about the vaccine for their adolescent daughters. The CHCR hypothesizes that providing this intervention to HPV vaccine-reluctant mothers will increase their intention of utilizing the HPV vaccination for their daughters and that this increased intention will result in an increase of daughters initiating the HPV vaccine series.
    3. Implications for cancer prevention and control: Decreases in the population-level burden of cervical (and other HPV-related) cancers will not be realized if HPV vaccine utilization continues to be low. Mechanisms to increase adolescent HPV vaccine uptake could have substantial impacts on population health.
    Screenshot of content-specific brochuresFigure 1: Examples of educational brochures for HPV-vaccine-hesitant mothers (shows 1 side of a 2-sided brochure). Content of the brochure is tailored based on the top 3 barriers to HPV vaccination identified by each mother. Red circles and highlights indicate additional areas of message tailoring.
    Table 1: Control Intervention
    Average Intention Pre 2.21 1.66
    Average Intention Post 3.54 3.81
    Mean Intentional Change 1.33 2.14
    Range 0-4
    Standard Deviation
    Comparison of mothers in the control and intervention groups. Table 1 shows the mean change in HPV vaccination intention (0-11 point scale) among mothers before (pre) and after (post) viewing tailored (intervention) or untailored educational brochures. Range of intentional change and standard deviation (S.D.) are also shown.
  3. Developing a Web-based portal to improve chemotherapy dose selection
    1. Lead researcher: Tunghi May Pini, M.D., M.P.H.
    2. Overview: The purpose of this project is to develop and pilot a Web-based intervention to:
      1. Investigate the knowledge, attitudes, and beliefs of oncologists with regard to reduced vs. full weight-based chemotherapy dosing, using physician survey
      2. Provide specific feedback about optimal dosing of adjuvant chemotherapy for breast cancer
      3. Assess changes in prescribing patterns after the feedback intervention is implemented.
    3. Implications for cancer prevention and control: Dose reductions in overweight and obese patients may account for poorer cancer survival rates among heavy patients with breast and other cancers. Furthermore, given the higher prevalence of obesity among minority patients and among patients of lower socioeconomic status, dose reductions may also account for racial and social disparities in cancer outcomes.
    Screenshot of online survey from ChemoDoseSelect.orgFigure 1: Online survey of oncologist knowledge, attitudes, and beliefs concerning chemotherapy dosing.
    Screenshot of tailored feedback from ChemoDoseSelect.orgFigure 2: Tailored feedback on optimal dosing of adjuvant chemotherapy for breast cancer.
  4. Development of a patient-specific tool to communicate recurrence risk for men with rising PSA following radiation therapy for prostate cancer
    1. Lead researcher: Daniel A. Hamstra, M.D, Ph.D.
    2. Overview: To make the decision of when to start androgen deprivation therapy (ADT) as salvage treatment following definitive radiation treatment (RT) for localized prostate cancer, men need to have an understanding of how their PSA values and likelihood of recurrence will change over time. This center has developed a novel computer model based on 2,386 previously treated patients that will provide these two pieces of numerical information. The goal of this project is to develop and test methods of communicating this information to patients and to determine how patients use it in their treatment decisions.
    3. Implications for cancer prevention and control: Currently the decision to start ADT after radiation therapy is driven more by patient anxiety than factual information about risk. The proposed intervention will provide a patient-specific tailored risk assessment, which may help overcome some of this anxiety and aid in insuring that treatment decisions are more risk based and clinically grounded.
  5. A dissemination and implementation (D&I) narrative video library for researchers and practitioners
    1. Lead researcher: Borsika A. Rabin, Ph.D., Pharm.D., M.P.H.
    2. Overview: The purpose of this project is to develop version 1.0 of a freely accessible online library containing video vignettes for researchers and practitioners who are interested in disseminating and implementing evidence-based practices, programs, and tools for cancer prevention and care. A video vignette is a brief visually encoded digital file that communicates “how-to” knowledge in a narrative form that models a solution to a particular problem. Each video vignette in this collection will highlight a discussion with a leading researcher or practitioner who will describe one problem in the process of dissemination and implementation (D&I) and show viewers how he/she solved this problem.
    3. Implications for cancer prevention and control: A growing number of researchers and practitioners believe that the key to effective D&I of interventions is to design for D&I. The D&I Narrative Video Library will provide support to researchers and practitioners who seek to design for D&I and hence has the potential to heighten the impact of effective cancer prevention and control interventions.
    4. Acknowledgements: Funding for this research was provided through the CHCR and the Cancer Research Network’s Cancer Communication Research Center.

Publications:

  1. Amsterlaw, J., Zikmund-Fisher, B.J., Fagerlin, A., & Ubel, P.A. (2006). Can avoidance of complications lead to biased healthcare decisions? Judgement and Decision Making, 1(1), 64-75.
  2. Bhavnani, S.K., Bichakjian, C.K., Johnson, T.M., Little, R.J., Peck, F.A., Schwartz, J.L., & Strecher, V.J. (2006). Strategy hubs: Domain portals to help find comprehensive information. Journal of the American Society for Information Science and Technology, 57(1), 4-24.
  3. Bhavnani, S.K & Peck, F.A. (2010). Scatter matters: Regularities and implications for the scatter of healthcare information on the web. Journal of the American Society for Information Science and Technology,61(4), 659-676.
  4. Buis, L.R., Janney, A.W., Hess, M.L., Culver, S.A., & Richardson, C.R. (2009). Barriers encountered during enrollment in an internet-mediated randomized controlled trial. Trials, 10, 76.
  5. Chakrabarti, B., Collins, L.M., Murphy, S.A., Narir, V., & Strecher, V. (2005). A comparison of randomized trials and multi-phase optitmization strategy for behavioral interventions. University of Michigan: Department of Statistics.
  6. Chakraborty, B., Collins, L.M., Strecher, V.J., & Murphy, S.A. (2009). Developing multicomponent interventions using fractional factorial designs. Statistics in Medicine, 28(21), 2687-2708.
  7. Chakraborty, B., Murphy, S., & Strecher, V. (2009). Inference for non-regular parameters in optimal dynamic treatment regimes. Statistical Methods in Medical Research, 19 (3), 317-343.
  8. Chua, H.F., Liberzon, I., Welsh, R.C., & Strecher, V.J. (2009). Neural correlates of message tailoring and self-relatedness in smoking cessation programming. Biological Psychiatry, 65(2), 165-168.
  9. Chua, H.F., Polk, T., Welsh, R., Liberzon, I., & Strecher, V. (2009). Neural responses to elements of a web-based smoking cessation program. Studies in Health Technolology and Informatics, 144, 174-178.
  10. Collins, L.M., Chakraborty, B., Murphy, S.A., & Strecher, V. (2009). Comparison of a phased experimental approach and a single randomized clinical trial for developing multicomponent behavioral interventions. Clinical Trials, 6(1), 5-15.
  11. Collins, L.M., Murphy, S.A., Nair, V.N., & Strecher, V.J. (2005). A strategy for optimizing and evaluating behavioral interventions. Annals of Behavioral Medicine, 30(1), 65-73.
  12. Collins, L.M., Murphy, S.A., & Strecher, V. (2007). The multiphase optimization strategy (MOST) and the sequential multiple assignment randomized trial (SMART): New methods for more potent eHealth interventions. American Journal of Preventive Medicine, 32(5 Suppl), S112-118.
  13. Couper, M., Peytchev, A., Strecher, V., Rothert, K., & Anderson, J. (2005). Combining information from multiple modes to reduce nonresponse bias. Paper presented at Proceedings of the Joint Statistical Meetings.
  14. Couper, M.P., Alexander, G.L., Zhang, N., Little, R.J., Maddy, N., Nowak, M.A., & Cole Johnson, C. (2010). Engagement and retention: measuring breadth and depth of participant use of an online intervention. Journal of Medical Internet Research, 12(4), e52.
  15. Couper, M.P., Peytchev, A., Strecher, V.J., Rothert, K., & Anderson, J. (2007). Following up nonrespondents to an online weight management intervention: randomized trial comparing mail versus telephone. Journal of Medical Internet Research, 9(2), e16.
  16. Davis, R.E., Alexander, G., Calvi, J., Wiese, C., Greene, S., Nowak, M., & Resnicow, K. (2010). A new audience segmentation tool for African Americans: the black identity classification scale. Journal of Health Communication, 15(5), 532-554.
  17. Davis, R.E., Couper, M.P., Janz, N.K., Caldwell, C.H., & Resnicow, K. (2010). Interviewer effects in public health surveys. Health Education Research, 25(1), 14-26.
  18. Fagerlin, A., Ubel, P.A., Smith, D.M., & Zikmund-Fisher, B.J. (2007). Making numbers matter: Present and future research in risk communication. American Journal of Health Behavior, 31, S47-56.
  19. Fagerlin, A., Zikmund-Fisher, B.J., Nair, V., Derry, H.A., McClure, J. B., Greene, S., & Ubel, P.A. (2010). Women's decisions regarding tamoxifen for breast cancer prevention: responses to a tailored decision aid. Breast Cancer Research and Treatment, 119(3), 613-620.
  20. Fagerlin, A., Zikmund-Fisher, B.J., & Ubel, P.A. (2005). How making a risk estimate can change the feel of that risk: Shifting attitudes toward breast cancer risk in a general public survey. Patient Education and Counseling, 57(3), 294-299.
  21. Fagerlin, A., Zikmund-Fisher, B.J., Ubel, P.A., Jankovic, A., Derry, H.A., & Smith, DM. (2007). Measuring numeracy without a math test: Development of the Subjective Numeracy Scale. Medical Decision Making, 27(5), 672-680.
  22. Glasgow, R.E., Nelson, C.C., Kearney, K.A., Reid, R., Ritzwoller, D. P., Strecher, V. J., & Wildenhause, K. (2007). Reach, engagement, and retention in an Internet-based weight loss program in a multi-site randomized controlled trial. Journal of Medical Internet Research, 9(2), e11.
  23. Keeton, K., Zikmund-Fisher, B.J., Ubel, P.A., Fenner, D.E., & Fagerlin, A. (2008). The accuracy of predicting parity as a prerequisite for cesarean delivery on maternal request. Obstetrics and Gynecology, 112(2 Pt 1), 285-289.
  24. Langford, A.T., Resnicow, K., Davis, R.E., Alexander, G.L., Calvi, J., Weise, C., & Tolsma, D. (2010). Ethnic identity predicts loss-to-follow-up in a health promotion trial. Contemporary Clinical Trials, 31(5), 414-418.
  25. Little, R. & An, H.G. (2004). Robust likelihood-based analysis of multivariate data with missing values. Statistica Sinica, 14(3), 949-968.
  26. McClure, J.B., Greene, S.M., Wiese, C., Johnson, K.E., Alexander, G., Strecher, V. (2006). Interest in an online smoking cessation program and effective recruitment strategies: Results from Project Quit. Journal of Medical Internet Research, 8(3), e14.
  27. Nair, V., Strecher, V., Fagerlin, A., Ubel, P., Resnicow, K., Murphy, S., & Zhang, A. (2008). Screening experiments and the use of fractional factorial designs in behavioral intervention research. American Journal of Public Health, 98(8), 1354-1359.
  28. Resnick, P.J., Janney, A.W., Buis, L.R., & Richardson, C.R. (2010). Adding an online community to an internet-mediated walking program. Part 2: strategies for encouraging community participation. Journal of Medical Internet Research, 12(4), e72.
  29. Resnicow, K., Strecher, V., Couper, M., Chua, H., Little, R., Nair, V., & Atienza, A.A. (2010). Methodologic and design issues in patient-centered e-health research. American Journal of Preventive Medicine, 38(1), 98-102.
  30. Richardson, C.R., Buis, L.R., Janney, A.W., Goodrich, D.E., Sen, A., Hess, M.L., & Piette, J.D. (2010). An online community improves adherence in an internet-mediated walking program. Part 1: Results of a randomized controlled trial. Journal of Medical Internet Research, 12(4), e71.
  31. Rothert, K., Strecher, V.J., Doyle, L.A., Caplan, W.M., Joyce, J.S., Jimison, H.B.,& Roth, M.A. (2006). Web-based weight management programs in an integrated health care setting: A randomized, controlled trial. Obesity (Silver Spring), 14(2), 266-272.
  32. Strecher, V. (2007). Internet methods for delivering behavioral and health-related interventions (eHealth). Annual Review of Clinical Psychology, 3, 53-76.
  33. Strecher, V & McPheeters, M. (2006), The potential role of tailored messaging. Behavioral Healthcare, 26(10), 24-26.
  34. Strecher, V.J., McClure, J.B., Alexander, G.L., Chakraborty, B., Nair, V.N., Konkel, J.M., & Pomerleau, O.F. (2008). Web-based smoking-cessation programs: Results of a randomized trial. American Journal of Preventive Medicine, 34(5), 373-381.
  35. Strecher, V.J., Shiffman, S., & West, R. (2005). Randomized controlled trial of a web-based computer-tailored smoking cessation program as a supplement to nicotine patch therapy. Addiction, 100(5), 682-688.
  36. Strecher, V.J., Shiffman, S., & West, R. (2006). Moderators and mediators of a web-based computer-tailored smoking cessation program among nicotine patch users. Nicotine & Tobacco Research, 8, S95-101.
  37. Tolsma, D., Calvi, J., Davis, R.E., Greene, S.M., Resnicow, K., Anderson, J., & Alexander, G. (2009). Challenges in researching racially sensitive topics in HMOs. Health Psychology, 28(4), 389-390.
  38. Ubel PA, Smith DM, Zikmund-Fisher BJ, Derry, H.A., McClure, J., Stark, A., & Fagerlin, A. (2010). Testing whether decision aids introduce cognitive biases: Results of a randomized trial. Patient Education and Counseling, 80(2), 158-163.
  39. Williams, G.C., McGregor, H., Borrelli, B., Jordan, P.J., & Strecher, V.J. (2005). Measuring tobacco dependence treatment outcomes: A perspective from the behavior change consortium. Annals of Behavioral Medicine, 29, 11-19.
  40. Zahuranec, D.B., Morgenstern, L.B., Sanchez, B.N., Resnicow, K., White, D.B., & Hemphill, J.C. (2010). Do-not-resuscitate orders and predictive models after intracerebral hemorrhage. Neurology, 75(7), 626-633.
  41. Zhang, G, Little, R.J. (2005). Extensions of the penalized spline propensity prediction method of imputation. Paper presented at the Proceedings of the Joint Statistical Meetings.
  42. Zhang, G.Y. & Little, R. (2009). Extensions of the penalized spline of propensity prediction method of imputation. Biometrics, 65(3), 911-918.
  43. Zikmund-Fisher, B.J., Fagerlin, A., Roberts, T.R., Derry, H.A., & Ubel, P.A. (2008). Alternate methods of framing information about medication side effects: Incremental risk versus total risk of occurrence. Journal of Health Communication, 13(2), 107-124.
  44. Zikmund-Fisher, B.J., Fagerlin, A., & Ubel, P.A. (2005). What's time got to do with it‌ Inattention to duration in interpretation of survival graphs. Risk Analysis, 25(3), 589-595.
  45. Zikmund-Fisher, B.J., Fagerlin, A., & Ubel, P.A. (2008). Improving understanding of adjuvant therapy options by using simpler risk graphics. Cancer, 113(12), 3382-3390.
  46. Zikmund-Fisher, B.J., Fagerlin, A., & Ubel, P.A. Risky feelings: Why a 6 percent risk of cancer does not always feel like 6 percent . Patient Education and Counseling, 81, S87-93.
  47. Zikmund-Fisher, B.J., Sarr, B., Fagerlin, A., & Ubel, P.A. (2006). A matter of perspective: Choosing for others differs from choosing for yourself in making treatment decisions. Journal of General Internal Medicine, 21(6), 618-622.
  48. Zikmund-Fisher, B.J., Smith, D.M., Ubel, P.A., & Fagerlin, A. (2007). Validation of the Subjective Numeracy Scale: Effects of low numeracy on comprehension of risk communications and utility elicitations. Medical Decision Making, 27(5), 663-671.
  49. Zikmund-Fisher, B.J., Ubel, P.A., Smith, D.M., Derry, H.A., McClure, J.B., Stark, A., & Fagerlin, A. (2008). Communicating side effect risks in a tamoxifen prophylaxis decision aid: The debiasing influence of pictographs. Patient Education and Counseling, 73(2), 209-214.