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Breast reconstruction (BR) improves women's health-related quality of life (HRQOL) following mastectomy for breast cancer, yet factors contributing to improved HRQOL remain unclear. This study aimed to explore the overall impact of mastectomy with or without BR on participants' perceptions of HRQOL over time in a cohort of women with high-risk breast cancer; to examine differences in mean HRQOL scores between immediate BR, delayed BR and no BR groups; to assess the influence of patient characteristics potentially associated with HRQOL scores; and to determine the feasibility of long-term collection of patient-reported outcome measures in clinical settings. A prospective, longitudinal study of 100 women with high-risk breast cancer who underwent mastectomy with or without breast reconstruction and were likely to require post-mastectomy radiotherapy. Four validated patient-reported questionnaires, comprising 21 outcome measures relating to HRQOL, administered at baseline and up to 4 years post-mastectomy. Demographic, clinical and surgical data extracted from patient medical records. Consistently significant declines in perceptions of future health and arm symptoms, consistently significant improvements in treatment side effects, breast symptoms and fatigue, as well as significant improvements, compared to baseline, in social functioning and financial difficulties at 48 months. No significant differences in mean HRQOL scores between women given a choice of reconstructive options. Similar trajectories of HRQOL scores were found in women with high-risk breast cancer who were offered a choice of BR. Informed choice may be an independent contributing factor in long-term maintenance of most HRQOL indicators at their pre-mastectomy levels. • Reconstruction following mastectomy improves women's health-related quality of life • No quality of life differences found between women with or without reconstruction • Type or timing of reconstruction was also not significant • Factors contributing to improved quality of life after four years remain unclear • Informed choice may be a key factor in women maintaining their quality of life [ABSTRACT FROM AUTHOR]

• Intention is most predictive for second trimester Tdap vaccine acceptance. • Second vs third trimester Tdap vaccine acceptance yields comparable predictors. • Rejection of maternal vaccination as opposed to acceptance remains hard to predict. A maternal tetanus-diphtheria-and-acellular-pertussis (Tdap) vaccine is offered to all pregnant women in the Netherlands in their second trimester since December 2019. However, former studies solely investigated the socio-psychological factors that influence vaccine acceptance among pregnant women in the third trimester. We identified predicting factors for attitude, intention and acceptance of maternal Tdap vaccination during the second trimester of pregnancy. As part of a large prospective cohort study, women early in pregnancy completed a questionnaire on determinants regarding acceptance of maternal Tdap vaccination between 20 and 24w of gestation. The vaccine was offered after completion of the questionnaire. A random forest model and Receiver Operating Characteristics (ROC) analyses were carried out to identify the factors most predictive for vaccine acceptance on the whole data set, and also in sensitivity analysis on a subset reflecting the annual nationwide 70% vaccination uptake. Among 1158 participants who were offered a Tdap vaccination between 20 and 24w of gestation, 1098 (94.8%) accepted and 60 (5.2%) rejected the vaccine. Random forest analyses identified intention as most predictive for acceptance, followed by attitude towards vaccination, beliefs regarding safety, risk perception of severity of side effects, moral responsibility, beliefs regarding effectiveness and risk perception of susceptibility of side effects, with a sensitivity of 100% and a specificity of 40%, for which this combination could be improved by the ROC analysis to 82% and 67%, respectively. The sensitivity analysis yielded an order of predictors that generally corresponded with the initial model. Intention, attitude, beliefs on safety and effectiveness, risk perception of side effects and moral responsibility were most predictive for maternal Tdap vaccine acceptance during the second trimester of pregnancy, in accordance with studies regarding third trimester vaccination. These should be discussed by healthcare professionals early in pregnancy to provide an informed choice towards vaccine acceptance. [ABSTRACT FROM AUTHOR]

Objectives: To explore informed choice in reproductive genetic carrier screening (RGCS).Methods: Women visiting a gynaecologist practice in Flanders (Belgium) were asked to consider participation in a study where RGCS was offered for free to them and their male partner. A modified Multidimensional Measure of Informed Choice was used to determine whether couples who opted for RGCS made an informed choice. In addition, we assessed risk perception, feelings towards RGCS, anxiety and decisional conflict.Results: Most participants (82 %, n = 63/77) made an informed choice with regard to RGCS according to our modified MMIC. Thirteen participants made an uninformed choice due to insufficient knowledge and one participant because of insufficient knowledge and value-inconsistency. Anxiety scores were elevated for three participants. Two participants presented with decisional conflict.Conclusion: Our results show high rates of informed choice among non-pregnant couples who were offered RGCS in a research study and received up to 30 min of pre-test counseling.Practice Implications: Limited resources outside a research context may impact informed choice. Pre-test counselling initiatives for RGCS should ideally be organized in such a way that information can be provided at multiple time points to avoid information overload and to allow for a reflection period. [ABSTRACT FROM AUTHOR]

This study aimed to investigate the perspectives of international experts and Danish citizens on relevant knowledge about population-based breast, colorectal and cervical cancer screening. This was a qualitative interview study with focus group interviews with experts and Danish citizens eligible for breast, colorectal and/or cervical cancer screening. Data were collected using semi-structured interview guides, audio-recorded and transcribed verbatim. A thematic analysis was conducted. Participants were nine international experts from Germany, Canada, the USA, Sweden, the Netherlands and Australia, and 54 citizens from Denmark. Most citizens had 'adequate' or 'problematic' levels of health literacy. Themes that experts and citizens agreed on were: knowledge about the disease and symptoms, practical information about screening, benefits of screening, the option of non-participation and the importance of having numeric information of possible screening outcomes. Experts agreed on the importance of knowledge about the harms of screening, but only a minority of citizens considered this important. The experts and citizens disagreed on the relevance of knowledge about harms of screening and agreed on other relevant knowledge. What experts and citizens find important may not align when making informed decisions. Therefore, experts and citizens needs to be involved when developing questionnaires. • Knowledge about benefits of screening was important for both experts and citizens. • Experts emphasised the need for knowledge about the harms of screening. • Experts and citizens disagreed on importance of knowledge of harms of screening. [ABSTRACT FROM AUTHOR]

Objective: To provide a systematic review of self-administered decision aids (DAs) for citizens invited to participate in colorectal cancer screening synthesizing the effectiveness of self-administered DAs on informed choice or the components hereof; knowledge, attitudes, and participation.Methods: The literature search was undertaken in PubMed, CINAHL, PsycINFO, Embase and Scopus and last updated 19 March 2021. Results were presented by narrative synthesis, meta-analyses and vote counting based on direction of effect.Results: Fourteen studies of fair methodological quality were included. One study reported on informed choice and 13 studies reported on the components. Self-administered DAs increased participation and knowledge whereas it was inconclusive with regard to attitudes towards screening. The studies were very heterogeneous with different comparators, outcomes and means of measurement.Conclusion: This systematic review showed a potential for self-administered DAs to support informed choice in colorectal cancer screening, especially by increasing knowledge.Practice Implications: It seems reasonable to consider informed choice to be one of the main outcomes of self-administered DAs. Yet there is a need for consensus on how to measure informed choice in cancer screening, especially a validated measurement of knowledge defining what constitutes 'adequate knowledge'. [ABSTRACT FROM AUTHOR]

Objective: To assess the effect of a patient decision aid on the quality of decision-making for patients with age-related cataracts.Methods: 773 patients with cataracts aged 50-80 years were randomly assigned to receive either the intervention decision aid (including standard information, quantitative information on the possible outcomes of cataract surgery and a value clarification exercise) or the control booklet (including standard information). The primary outcome was informed choice (defined as adequate knowledge and congruency between attitudes and surgical intentions), which was assessed at 2 weeks after intervention via a telephone interview.Results: The decision aid increased the proportion of participants making an informed choice, from 5.68 % in the control group to 27.7 % in the intervention group (P < 0.001). Compared with controls, more participants in the intervention group had adequate overall knowledge about cataract surgery (36.8 % vs. 8.79 % in controls; P < 0.001), and fewer participants intended to undergo surgery (22.5 % vs. 34.1 % in controls; P < 0.001).Conclusion: Use of the patient decision aid may increase the proportion of patients making informed choices. Importantly, it might also reduce the acceptance of operations.Practice Implications: Patient decision aids represent a simple and low-cost tool to facilitate informed choice among patients with cataracts. [ABSTRACT FROM AUTHOR]

Objective: To describe the development of a web-based, patient-facing decision aid to support patients and research participants to make an informed, values-based decision about whether to receive additional results from genomic sequencing.Methods: We developed the decision aid following the multi-step process described in the International Patient Decision Aids Standards. This utilized literature review, focus groups, and alpha testing with research participants undergoing clinical genomic sequencing.Results: The decision aid, the Optional Results Choice Aid (ORCA), includes a seven-question "values clarification exercise," illustrative patient quotes, and summative guidance for the user. The decision aid was found to be highly readable, acceptable and relevant in alpha testing.Conclusion: We developed a decision aid to support informed, values-based decision making for patients and research participants considering whether to receive additional results from genomic sequencing. ORCA is being implemented in the NHGRI-funded Cancer Health Assessment Reaching Many (CHARM) study, where we are measuring informed values-choice congruence.Practice Implications: ORCA was designed to support patients and research participants to make an informed, values-based decision about whether to receive additional results from genomic sequencing. [ABSTRACT FROM AUTHOR]

Objective: To assess the choice and attitude of pregnant women regarding CMV serological screening and CMV prevention behaviors in pregnancy.Study Design: In this cross-sectional study, pregnant women were recruited in a single center during routine prenatal screening tests at 11-16 weeks. Participants filled out a questionnaire assessing knowledge about congenital CMV (cCMV) infection, risk perception and willingness to have CMV serological screening as well as their attitude toward CMV prevention behaviors.Results: Among 234 pregnant women, 74.4 % (95 % confidence interval: 68.8-80.0 %) wanted CMV serological screening in pregnancy. The factors significantly associated with the desire for screening were perceived risk and perceived severity of cCMV. An informed choice regarding CMV screening (value-consistent, based on good knowledge and deliberated) was performed by 54 % of women who chose the screening and 30 % of women who declined the screening (p = 0.039). The median scores regarding attitudes toward CMV prevention behaviors were 3.7/5 for avoiding sharing behaviors and 4.0/5 for not kissing a child on the lips.Conclusion: The majority of pregnant women want to have CMV serological screening once informed about congenital CMV infection. New tools need to be developed to allow for informed choice regarding CMV serological screening in pregnancy. [ABSTRACT FROM AUTHOR]

A midwife's ability to fully support women's autonomy and self-determination with respect to midwifery care is often challenging. This is particularly true of water immersion for labour and birth. However, the woman's agency over what happens to her body and that of her unborn baby should be key considerations for maternity care provision. A three phased mixed-methods study was undertaken to examine how water immersion policies and guidelines are informed. Phase three of this study captured the knowledge and experiences of Australian midwives, their support for water immersion and their experiences of using policies and guidelines to inform and facilitate the practice. Critical, post structural, interpretive interactionism was used to examine more than 300 responses to three open-ended questions included in a survey of 233 midwives. Comment data were analysed to provide further insight, context and meaning to previously reported results. Findings demonstrated a complex, multidimensional interplay of factors that impacted on both the midwife's ability to offer and the woman's decision to use water immersion under the themes 'the reality of the system', 'the authoritative 'others" and 'the pseudo decision-makers'. Multiple scaffolded levels were identified, each influenced by the wider macro-socio-political landscape of Australian midwifery care. The insight gained from examining midwives' views and opinions of water for labour and birth, has aided in contextualising previously reported results. Such insight highlights the importance of qualitative research in challenging the status quo and working towards woman-centred practice and policy. [ABSTRACT FROM AUTHOR]

Maternal Pertussis Vaccination (MPV) during pregnancy became part of the National Immunization Program in the Netherlands late 2019. This study aims to identify social-psychological factors associated with MPV acceptance among Dutch women to add to the current understanding of vaccine hesitancy worldwide, and to inform the development of communication and information campaigns about MPV. We conducted a cross-sectional study using an online survey among 611 women (174 pregnant women, 205 women who had given birth in the past two years and 232 women of 20–35 years old). The primary and secondary outcomes were vaccination intention and attitude towards MPV, respectively. Pearson's correlation and regression analyses were used to examine social-psychological and socio-demographic determinants of the outcomes. Vaccination intention was most explained by attitudes towards MPV, beliefs about safety, moral norm and the belief about the effectiveness of MPV (R2 = 0.79). Other factors associated were injunctive norm, anticipated regret of vaccinating, and decisional certainty. Attitudes towards MPV were further explained by descriptive norm, risk perceptions of side effects, and risk perceptions of the baby getting pertussis when not vaccinating, and fear of MPV and of the disease (R2 = 0.76). Finally, pregnant women had a significantly lower intention and less positive attitude towards MPV than non-pregnant women. Communication about MPV should address the most important determinants of MPV intention and attitude, i.e. beliefs about safety and effectiveness and moral norms. Furthermore, such information may benefit from taking into account affective feelings of pregnant women such as anticipated regret and fear towards MPV. Further research could explore this. The timing of communication about MPV can be important as determinants of MPV acceptance may vary depending on pregnancy status. [ABSTRACT FROM AUTHOR]

Long-acting reversible contraception (LARC) initiation has been well-studied and intervened upon. Because LARC requires provider intervention for initiation and removal, it is critical to measure informed choice at the time of desired discontinuation as well. We examined perceptions of access to LARC discontinuation among women at two sites in Burkina Faso, where LARC is the dominant method in the contraceptive mix. We analyzed data from a 2017–2018 population-based, cross-sectional survey of 281 implant users and 55 intrauterine device users at two sites in Burkina Faso. We measured perceptions of access to LARC discontinuation through survey items assessing whether participants (1) were informed on how to discontinue the method, (2) believed they could have LARC removed without a lot of difficulty, (3) believed cost would be a barrier to discontinuation, (4) had ever attempted to have a provider remove LARC, and (5) successfully had LARC removed. The distribution of these measures was examined in the population and for differences by gravida, parity, domestic partnership, fertility desires, and recency of last childbirth. Thirty-eight (11%) of current LARC users reported that they were not informed on how to discontinue, 56 (17%) believed having their device removed would be difficult, and 54 (16%) believed cost would be a barrier to removal. Of women who attempted removal, providers did not immediately remove LARC on request for 10 (28%). Findings indicate that LARC uptake is an insufficient measure of reproductive access or choice. Future studies should include patient-centered measures that span the full duration of contraceptive use. This paper finds that a sizable proportion of LARC users lack information about method discontinuation and perceive or experience barriers to method removal. These findings call for a reconsideration of free and informed contraceptive choice to include the entire duration of contraceptive use, not only the time of method provision. [ABSTRACT FROM AUTHOR]

To gain a deeper understanding of women's thoughts and experiences regarding informed choices during childbirth. A qualitative approach with individual in-depth interviews was chosen for data collection. Ten women were interviewed three to four weeks after the birth of their first child. The transcribed interviews were analysed using systematic text condensation. Two main themes emerged based on the analysis: "women's resources and coping abilities" and "women's abilities to make informed choices during birth". Women's resources and coping abilities influenced how they retrieved information and made their own choices. Their abilities to make informed choices during birth were influenced by the course of the birth process and the fact that they were patients and submitted to the hospitals' routines. Instead of using the term "informed choice", women in this study discussed involvement, participation and being heard and seen as individuals. How receptive women are to information during birth varies, and midwives play an important role during pregnancy in informing and encouraging them. The relationship between women and midwives influences women's abilities to make informed choices during birth. Women need individual care and should be encouraged to have realistic expectations and to gain knowledge and confidence in their ability to give birth. A model of care in which women experience greater continuity will have an impact on their expectations, decision-making and experience of birth. [ABSTRACT FROM AUTHOR]

Alongside midwifery units (AMUs) are managed by midwives and proximate to obstetric units (OUs), offering a home-like birth environment for women with straightforward pregnancies. They support physiological birth, with fast access to medical care if needed. AMUs have good perinatal outcomes and lower rates of interventions than OUs. In England, uptake remains lower than potential use, despite recent changes in policy to support their use. This article reports on experiences of access from a broader study that investigated AMU organisation and care. Organisational case studies in four National Health Service (NHS) Trusts in England, selected for variation geographically and in features of their midwifery units. Fieldwork (December 2011 to October 2012) included observations (>100 h); semi-structured interviews with staff, managers and stakeholders (n = 89) and with postnatal women and partners (n = 47), on which this paper reports. Data were analysed thematically using NVivo10 software. Women, partners and families felt welcome and valued in the AMU. They were drawn to the AMUs' environment, philosophy and approach to technology, including pain management. Access for some was hindered by inconsistent information about the existence, environment and safety of AMUs, and barriers to admission in early labour. Key barriers to AMUs arise through inequitable information and challenges with admission in early labour. Most women still give birth in obstetric units and despite increases in the numbers of women birthing on AMUs since 2010, addressing these barriers will be essential to future scale-up. [ABSTRACT FROM AUTHOR]

Objective: We aimed to assess to what extent men make informed choices in the context of prostate cancer screening and how written material contributes to that process.Methods: We developed a leaflet describing prostate cancer screening, and a questionnaire consisting of knowledge, attitude, and intended screening uptake components to assess informed decision-making. The leaflet and questionnaire were pilot-tested among men of the target population, adapted accordingly, and sent to 761 members of an online research panel. We operationalized whether the leaflet was read as spending one minute on the leaflet page and by a self-reported answer of respondents.Results: The response rate was 66% (501/761). The group who read the leaflet (n = 342) correctly answered a knowledge item significantly more often (10.9 versus 8.8; p < 0.001) than those who did not read the leaflet (n = 159), and made more informed choices (73% versus 56%; p = 0.001). There were no significant differences in attitude and intended screening uptake between both groups.Conclusion: Having read the leaflet could be one of the factors associated with increased levels of knowledge and informed decision-making.Practical Implications: The results of this study showed that increasing knowledge and supporting informed decision-making with written material are feasible in prostate cancer screening. [ABSTRACT FROM AUTHOR]

Highlights • Among 105 people who attempted to stop taking antipsychotic medication, less than half consulted a doctor in preparation and approximately a third used a gradual withdrawal method. • Just over half described successfully stopping and half reported no current use. • Unwanted withdrawal effects were reported by 61.9% of the group and spanned emotional, cognitive, physical, and functional domains. • Withdrawing gradually across more than one month showed significant, positive associations with self-described success and no current use. Abstract Few studies explore subjective experiences of attempting to discontinue antipsychotic medication, the withdrawal methods people use, or how their efforts affect their outcomes. People who take antipsychotics for off-label purposes are poorly represented in the literature. This study investigates experiences of attempting to discontinue antipsychotics in a cross-sectional sample and explores potential associations between withdrawal methods, relapse, and success. An anonymous online survey was completed by 105 adults who had taken antipsychotics for any reason and had attempted discontinuation at least once. A mixed methods approach was used to interpret the responses. Just over half (55.2%) described successfully stopping for varying lengths of time. Half (50.5%) reported no current use. People across diagnostic groups reported unwanted withdrawal effects, but these were not universal. Withdrawing gradually across more than one month was positively associated, and relapse was negatively associated with both self-defined successful discontinuation and no current use. Gradual withdrawal was negatively associated with relapse during withdrawal. We conclude it is possible to successfully discontinue antipsychotic medication, relapse during withdrawal presents a major obstacle to successfully stopping AMs, and people who withdraw gradually across more than one month may be more likely to stop and to avoid relapse during withdrawal. [ABSTRACT FROM AUTHOR]

Abstract Objective To explore women's experiences of the concept of informed choice during pregnancy and childbirth. Methods A three-phase action research approach. In the second phase of the study (reported in this paper), 15 women were interviewed to establish their experiences of informed choice. Setting Dublin, Ireland in a large maternity hospital. Findings We found that multiple factors influence how women experience informed choice including; their sense of self and the quality of their relationships with maternity care professionals. Women's experiences as expressed through their sense of self reveal that informed choice, is not only defined by but contingent on the quality of women's relationships with their caregiver and their ability to engage in a process of shared decision-making with them. Key conclusions Informed choice is experienced as a relational construct women's relationships with maternity care professionals can influence their perceptions of their sense of self following childbirth. Supportive relationships are key to supporting the concept of informed choice. [ABSTRACT FROM AUTHOR]

Objective: Properly informing target audiences is crucial in population-based screening programs. We aimed to evaluate the impact of information about CRC screening on attitudes and intended participation in a screening-naive population.Methods: 614 persons (aged 55-75 years) received a survey. Information on CRC and screening was provided piece by piece, and per piece its impact on attitudes and intended participation was assessed. All persons received the same information content, but the sequence of information differed per condition: information on the high mortality rate of colorectal cancer was presented in the first or the second piece. Educational levels, the extent people considered future consequences, and value concordance between attitudes and intentions were assessed.Results: 436 persons (response 71%) completed the survey. Overall most respondents reported positive attitudes towards CRC screening (78%) and intentions to participate in CRC screening (83%), independent of sequence of information provision. Intentions about participation were value concordant in the majority (88%). Results were similar in low educated groups.Conclusion: Providing balanced information about CRC screening (also addressing negative effects) did not impede value concordance and high rates of intended participation.Practice Implications: High rates of screening intentions are possible without omitting threatening health information in communication materials. [ABSTRACT FROM AUTHOR]

The majority of individuals in the UK opting to terminate a pregnancy complicated by fetal anomaly have a medical rather than a surgical termination. This study provides context, understanding and evidence of the value that they attach to having the option to choose a termination method following a diagnosis of fetal anomaly. Ten women attending a fetal medicine unit participated in qualitative interviews by telephone and in person, explaining decision-making processes for their choice of method, their views on having this choice, and their perception of the value and acceptability of this choice. Important factors included the opportunity to confirm the fetal anomaly, hospitalisation, waiting time, and duration of the process. The emotional effort of carrying the pregnancy was foremost for many women, as was the need for self-preservation from birth trauma. Choice of termination method was felt to be a right for an individual facing a fetal anomaly. • Individuals should be offered a choice of termination method for fetal anomaly and supported to make an informed choice • Individuals require support during the time between the decision to terminate and the procedure, and directly afterwards. • Options for pain management for a medical termination and the choice not to have sight of the fetus should be offered. [ABSTRACT FROM AUTHOR]

Background Risk knowledge is relevant to make informed decisions in multiple sclerosis (MS). The risk knowledge questionnaire for relapsing-remitting MS (RIKNO 1.0) was developed and piloted in Germany. Objective To produce a revised RIKNO 2.0 questionnaire using mixed methodology in a European setting. Methods The questionnaire was translated in seven languages. MS patient and health professional (HP) expert feedback was obtained from Germany, Italy, Estonia, Serbia, and the UK. A German web-based survey of RIKNO 2.0 compared the tool with the MS Knowledge Questionnaire (MSKQ), each one used with two versions (with/without a “don’t know” DN option). Results While RIKNO 2.0 was considered difficult, it was rated as highly educational. One item was reframed, and two new items were added. The web-based German survey (n = 708 completers) showed that the DN version did not increase participation rate and did not produce significantly higher scores. Internal consistency (Cronbach alpha) without SN response was 0.73. RIKNO 2.0 scores showed normality distribution irrespective of the answering format. Item difficulty was high ranging from 0.07 to 0.79. Less than 50% of questions were answered correctly (mean 8.9) compared to 80.4% in the MSKQ (mean 20.1). Higher numeracy competency and education were significantly, albeit weakly, associated to higher scores for both RIKNO 2.0 and MSKQ. Conclusion Including “don’t know” options in knowledge questionnaires does not increase percentage of correct replies. RIKNO 2.0 is a complex questionnaire to be used in an educational context and studies on patient information. The tool is now available in seven languages. [ABSTRACT FROM AUTHOR]

Question How happy we are depends partly on how we live our life and part of our way of life is the commute between home and work. In this context we are faced with the question of how much time spent on commuting is optimal happiness wise, and what means of transportation. Since our personal experience is limited, it is helpful to draw on the experience of other people, of people like us in particular. Earlier research Several cross-sectional studies have found lower subjective wellbeing among long-distance commuters and among users of public transportation. Yet these differences could be due to selection effects, such as unhappy people ending up more often in distant jobs without having a car. Still another limitation is that earlier research has focused on the average effect of commuting, rather than specifying what is optimal for whom. Method Data of the Dutch ‘GeluksWijzer’ (Happiness Indicator) study were analyzed, in the context of which 5000 participants recorded both what they had done in the previous day and how happy they had felt during these activities. This data allows comparison between how the same person feels at home and during their commute. The number of participants is large enough to allow a split-up between different kinds of people, in particular among the many well-educated women who participated in this study. Results People feel typically less well when commuting than at home, and this negative difference is largest when commuting using public transportation and smallest when commuting by bike. It is not per se the commuting time that depresses mood, but specific combinations of commuting time and commuting mode. Increasing commuting times can even lead to an uplift of mood when the commute is by bike or foot. Split-up by different kinds of people shows considerable differences, especially with regard to the different modes and company when travelling. Optimal ways of commuting for different kinds of people are presented in a summary table, from which individuals can read what will fit them best. The differences illustrate that research focusing on averages will not help individuals to make a more informed choice with respect to commuting mode. [ABSTRACT FROM AUTHOR]

Objectives: To explore levels and patterns in contraceptive use since the introduction of informed choice in reproductive health services in China since 1994, and to assess the implications of reproductive health service needs among married women of reproductive age in China.Material and Methods: Data from Chinese nationwide surveys of family planning and reproductive health undertaken in 1988, 1997, 2001, and 2006 were analyzed to assess levels and trends in patterns of contraceptive use among married women by age, residence, and number of children. Contraceptive methods were classified into two categories: provider-controlled and user-dependent methods.Results: The provider-controlled pattern for contraceptive use was predominant regardless of whether women were free to choose their own contraceptives. Older, rural women, and those with more than one child preferred provider-controlled contraceptive methods; this trend has changed little after 1997. In contrast, the user-controlled methods were preferred by young, urban women, strikingly with no or only one child, and geographically in more affluent areas in north or southwest China.Conclusion: A preference for user-dependent methods is noted in the urban areas but inclination towards provider-controlled contraceptive methods is still prevalent in rural areas in China. [ABSTRACT FROM AUTHOR]

Objective to explore women's understandings and definitions of the concept of informed choice during pregnancy and childbirth. Methods a three-phase action research approach. In the first phase of the study (reported in this paper), fifteen women were interviewed to establish their understandings and experiences of informed choice. Setting Dublin, Ireland in a large maternity hospital. Participants fifteen postnatal women who gave birth to a live healthy infant, women attended obstetric or midwifery-led care. Findings we found that multiple factors influence how women define informed choice including; their expectations of exercising choice, their sense of responsibility towards their infant, their sense of self and the quality of their relationships with maternity care professionals. The interdependence of the mother-baby relationship deems that in the context of pregnancy and childbirth, women's definitions, perceptions and experiences of informed choice should be considered to be relational. Women consider that informed choice means more than just the provision of information; rather it requires an in-depth discussion with a professional who is known to them. Women's understandings reveal that informed choice, is not only defined by but contingent on the quality of women's relationships with their caregiver and their ability to engage in a process of shared decision-making with them. Key conclusion Informed choice is defined and experienced as a relational construct, the support provided by maternity care professionals to women in contemporary maternity care must reflect this. [ABSTRACT FROM AUTHOR]

Air transport Greenhouse Gas (GHG) emissions estimates differ greatly, depending on the calculation method employed. Among the IPCC, ICAO, DEFRA, and BrighterPlanet calculation methods, the largest estimate may be up to 4.5 times larger than the smallest. Such heterogeneity – and ambiguity over the true estimate – confuses the consumer, undermining the credibility of emissions estimates in general. Consequently, GHG emissions estimates do not currently appear on the front page of flight search-engine results. Even where there are differences between alternative flights’ emissions, this information is unavailable to consumers at the point of choice. When external considerations rule out alternative travel-modes, the relative ranking of flight options’ GHG emissions is sufficient to inform consumers’ decision making. Whereas widespread agreement on a gold standard remains elusive, the present study shows that the principal GHG emissions calculation methods produce consistent rankings within specific route-structure classes . Hence, for many consumers, the flight identified as most GHG efficient is not sensitive to the specific calculation method employed. But unless GHG emissions information is displayed at the point of decision, it cannot enter into consumers’ decision making. A credible and ambiguity-free alternative would thus be to display GHG ranking information on the front page of flight search-engine results. [ABSTRACT FROM AUTHOR]

Objective: this paper explores unexpected findings about how to "do risk talk" which emerged during a broader research project on of the application and misapplication of evidence-based practice in Canada. Design: the study used qualitative methods such as semi-structured interviews and thematic analysis of inter-professional maternity care conference presentations. Setting: Canada Participants: fifty Canadian midwives, doctors and nurses involved in maternity care were interviewed to uncover the "how and whys" of differing interpretations and uneven application of evidence. Results: care providers described a "lean to technology" as an unexpected result of using evidence in their discussions with pregnant women. They perceived risk talk as undermining low intervention approaches and reassurance about the safety of birth. Across professional groups, interviewees described how they attempted to mitigate this unwanted effect. Their strategies to put risk in perspective include finding comparable everyday risks, using words and pictures to describe numbers and using absolute risk and numbers needed to treat rather than relative risk. They warned about the need to balance a culture of fear combined with maternal altruism. Time, reassurance, awareness and humility were seen as key tools. Key conclusions and implications for practice: midwives and other maternity care providers can use a variety of techniques to put risk into perspective. It is important to discuss evidence and risk with an awareness that the process itself can exaggerate risk. Care providers in all professional groups were motivated to avoid contributing to a culture of fear about childbirth and increasing rates of intervention. [ABSTRACT FROM AUTHOR]

Objectives: in the context of a rising caesarean section (CS) rate in Japan, the objectives of this study were; to investigate the national situation for women's birth options after primary CS; to explore characteristics of institutions accepting planned vaginal birth after caesarean (VBAC); to identify the timing and type of information given to women about their birth options by health professionals. Design: a national census study using a self-administered postal survey of nursing managers within obstetric departments in Japanese hospitals and clinics was conducted. Data were analyzed to explore characteristics of institutions accepting or not accepting VBAC and information given to women about planned VBAC and planned repeat CS. Setting: institutions included hospitals and clinics providing childbirth services throughout Japan. Participants: nursing managers from hospitals (n=303) and clinics (n = 196) completed surveys about their institutional policies and practices around birth after CS. Findings: only 154 (30.9%) of 499 institutions examined, accepted planned vaginal birth as an option for birth after CS. The success rate of VBAC was 77.0% in these institutions. Availability of transport services for institutional transfer and existence of a Maternal Fetal Intensive Care Unit (MFICU) were significantly associated with acceptance of VBAC (OR=5.39,p< 0.001; OR=2.96,p=0.04). Information about options for birth method was mostly provided in the form of consent documents, and doctors were the sole provider of information about method of childbirth in 55.7% of institutions. Nursing managers described challenges in caring for women who strongly desire VBAC when women did not have access to information or if institutional policies conflicted with women's wishes. They recommended evidence-based information for women regarding birth choices after CS and recognised the necessity of emotional support for women faced with decision dilemmas. Key conclusions: institutional policies and practices for birth after CS vary widely in Japan, with evidence of limited opportunities for women to make informed choices about planned VBAC. It was difficult for nurse managers to support women to choose VBAC when institutional policy conflicted with this choice and when women did not have consistent or balanced information. Implications for practice: strategies are needed to support women as well as pregnancy care providers to support women to consider VBAC as a possible birth option after CS and to expand the use of shared decision making in pregnancy care settings in Japan. [ABSTRACT FROM AUTHOR]

Objectives: To examine the 'nanny state' arguments used by tobacco companies, explore the cognitive biases that impede smokers' ability to make fully informed choices, and analyse the implications for those working to limit the harmful effects of other risk products. Study design: A critical analysis of the practices engaged in by the tobacco industry, the logic on which they relied, and the extent to which their work has informed approaches used by other industries. Results: The tobacco industry's deliberate strategy of challenging scientific evidence undermines smokers' ability to understand the harms smoking poses and questions arguments that smoking is an informed choice. Cognitive biases predispose smokers to discount risk information, particularly when this evidence is disputed and framed as uncertain. Only state intervention has held the tobacco industry to account and begun ameliorating the effects of their sustained duplicity. Evidence other industries are now adopting similar tactics, particularly use of 'nanny state' claims to oppose proportionate interventions, is concerning. Conclusions: Some marketing strategies have deliberately mis-informed consumers thus directly contributing to many public health problems. Far from removing free choice, government policies that restrain commercial communications and stimuli are pre-requisites necessary to promote free choice. [ABSTRACT FROM AUTHOR]

Abstract: Background: Informed choice is often lacking in women's decisions about prenatal screening. Aim: The aim of this study is to evaluate how well midwives in Ontario, Canada are facilitating informed choice in this area. Methods: An Internet-based survey was used to investigate 171 midwifery clients’ knowledge, attitude towards and experience of prenatal genetic screening tests, and to determine the proportion of study participants who made an informed choice about prenatal screening. Findings: All participants demonstrated adequate knowledge of prenatal screening. The vast majority (93.0%) of participants made an informed choice. Participants who chose to screen had lower knowledge scores than those who opted out of screening. Client satisfaction rates in regard to care received in this area ranged from 97% to 100%. Conclusions: Results of this study suggest that Ontario midwives are effective in conveying information on prenatal genetic screening, contributing to high levels of client knowledge and satisfaction in comparison to similar studies in other jurisdictions. [Copyright &y& Elsevier]

Objective: to explore midwives' perceptions of their role as facilitators of informed choice in antenatal screening. Design: qualitative. Setting: community midwives, Yorkshire and Humber region, UK. Participants: community midwives offering antenatal screening (n=5). Method: semi-structured interviews analysed using Thematic Analysis. Findings: to facilitate informed choice, midwives highlighted both the importance and challenges of engaging in discussion with women, remaining non-directive, within tight timeframes, sometimes with women unable to communicate in English or with complex social needs. Conclusion: midwives varied in the degree to which they believed it was their role to (1) discuss rather than just provide information and (2) to check women's understanding of the information provided. Midwives were concerned about the constraints imposed by first trimester combined screening in terms of the limited time in which they had to facilitate informed choice and the women had to make a decision about screening. To ensure that women understand the options available to them and are able to exercise an informed choice, clinical guidelines are needed that set out how midwives can actively facilitate informed screening choices without compromising patient autonomy. This is especially important given the small 'window of opportunity' within which combined first trimester screening is a viable option. [ABSTRACT FROM AUTHOR]

Objective: To generate and validate a scale to measure the Informed Choice of contraceptive methods among women attending a family health care service in Chile. Study Design and Setting: The study follows a multimethod design that combined expert opinions from 13 physicians, 3 focus groups of 21 women each, and a sample survey of 1,446 women. Data analysis consisted of a qualitative text analysis of group interviews, a factor analysis for construct validity, and kappa statistic and Cronbach alpha to assess scale reliability. Results: The instrument comprises 25 items grouped into six categories: information and orientation, quality of treatment, communication, participation in decision making, expression of reproductive rights, and method access and availability. Internal consistency measured with Cronbach alpha ranged from 0.75 to 0.89 for all subscales (kappa, 0.62; standard deviation, 0.06), and construct validity was demonstrated from the testing of several hypotheses. Conclusions: The use of mixed methods contributed to developing a scale of Informed Choice that was culturally appropriate for assessing the women who participated in the family planning program. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To determine the level of informed choice in women invited for breast cancer screening for the first time. Methods: To determine the content of decision-relevant knowledge, 16 experts were asked to judge whether each of 51 topics represented essential information to enable informed choices. To assess the level of informed choices, a questionnaire was then sent to all 460 invited women in the south-western part of the Netherlands who turned 50 in August 2008. Results: Of all 229 respondents, 95% were deemed to have sufficient knowledge as they answered at least 8 out of 13 items correctly. In 90% there was consistency between intention (not) to participate and attitude. As a result, 88% made an informed choice. Sixty-eight percent of women responded correctly on the item of over-diagnosis. Even if all non-respondents were assumed to have no knowledge, 50% of the total group invited to participate still had sufficient knowledge. Conclusions: Women were deemed to have sufficient relevant knowledge of the benefits and harms if they answered at least half of the items correctly. Practice implications: To further increase informed choices in breast cancer screening, information on some of the possible harms merits further attention. [Copyright &y& Elsevier]

Abstract: Objective: To describe a theoretical framework for assessing knowledge about the possible outcomes of participating in bowel cancer screening for the faecal occult blood test. Methods: The content of the knowledge measure was based on the UK General Medical Council''s screening guidelines and a theory-based approach to assessing gist knowledge (Fuzzy Trace Theory). It comprised conceptual and numeric questions to assess knowledge of the underlying construct (e.g. false positive concept) and the approximate numbers affected (e.g. likelihood of a false positive). The measure was used in a randomised controlled trial involving 530 adults with low education, to compare the impact of a bowel screening decision aid with a screening information booklet developed for the Australian Government National Bowel Cancer Screening Program. Results: The numeric knowledge scale was particularly responsive to the effects of the decision aid; at follow-up decision aid participants’ numeric knowledge was significantly greater than the controls (P <0.001). This contrasts with the conceptual knowledge scale which improved significantly in both groups from baseline to follow-up (P <0.001). Conclusion: Our theory-based knowledge measure was responsive to change in conceptual knowledge and to the effect on numeric knowledge of a decision aid. Practice implications: This theoretical framework has the potential to guide the development of knowledge measures in other screening settings. [Copyright &y& Elsevier]

Abstract: As health professionals and patients are moving toward shared models of decision making, there is a growing need for integrated decision support tools that facilitate uptake of best evidence in routine clinical practice in a patient-centered manner. This article charts the landscape of clinical practice guidelines (CPGs) and patient decision aids. Decision support tools for medical practice can be mapped on two dimensions. (1) The target user and his or her level of decision making; either for groups of patients or for an individual patient and (2) the level of uncertainty: either supporting more directive decision making (behavior support) in the case of strong recommendations with a single best option or supporting dialog (deliberation support) on the pros and cons of different options in the case of conditional (or weak) recommendations. We conclude that it is important to establish closer links between CPGs and patient decision aids, through collaborative development of both. Such collaboration will encourage the design of decision support tools for professionals and patients who share the same evidence and the aim to increase the quality of decision making between doctor and patient. This could facilitate the implementation of CPGs and shared decision making in clinical practice. [Copyright &y& Elsevier]

Abstract: Informed choice is internationally recognised and accepted as an important aspect of ethical healthcare. In the UK, NHS antenatal screening policies state that their primary aim is to facilitate reproductive informed choices. These policies, implemented within a multiethnic population, are largely guided by the ethical principle of autonomy. This study was carried out in 2009 in the UK and used Q-methodology to explore diversity in the value attached to autonomous informed choice in antenatal screening for genetic disorders and similarities and differences in this value in women from different ethnic origins. Ninety-eight participants of African, British White, Caribbean, Chinese and Pakistani origin completed a 41-statement Q-sort in English, French, Mandarin or Urdu. Q-Factor analysis produced five statistically independent viewpoints of the value of informed choice: choice as an individual right; choice informed by religious values; choice as a shared responsibility; choice advised by health professionals; and choice within the family context. The findings show that women hold a variety of views on the nature of informed choice, and that, contradictory to policies of autonomous informed choice, many women seek and value the advice of health professionals. The findings have implications for the role of health professionals in facilitating informed choice, quality of care and equity of access. [Copyright &y& Elsevier]

Abstract: Objective: To evaluate the effects of an information film on making an informed choice regarding Down syndrome screening, and women''s knowledge and experiences of information. Methods: Randomized controlled trial including 184 women in the intervention group and 206 controls recruited from maternity units in Stockholm, Sweden. The intervention was an information film presented as a complement to written and verbal information. Data were collected via a questionnaire in gestational week 27. Three different measures were combined to measure informed choice: attitudes towards Down syndrome screening, knowledge about Down syndrome and Down syndrome screening, and uptake of CUB (combined ultrasound and biochemical screening). Results: In the intervention group 71.5% made an informed choice versus 62.4% in the control group. Women in the intervention group had significantly increased knowledge, and to a greater extent than the control group, experienced the information as being sufficient, comprehensible, and correct. Conclusions: An information film tended to increase the number of women who made an informed choice about Down syndrome screening. Participants were more satisfied with the information received. Practice implications: Access to correct, nondirective, and sufficient information is essential when making a choice about prenatal diagnostics. It is essential with equivalent information to all women. [Copyright &y& Elsevier]

Abstract: Objective: To explore how effectively information presentation formats used in a patient decision aid communicated the ability of a disease modifying anti-rheumatic drug to slow the rate of progression of rheumatoid arthritis related structural joint damage (SJD). Methods: 91 first year psychology students and 91 RA patients participated in a prospective randomized, single blind, factorial experimental design evaluating the effect of four information formats on: satisfaction with risk communication, verbatim and gist recall of a hypothetical anti-rheumatic drug''s ability to slow the rate of progression of SJD. Results: Both groups underestimated the hypothetical drug''s ability to slow SJD. Formats that supported the narrative statement with a reinforcing graphic element resulted in recall closer to the true value. Comparison of the results from testing of RA patients and college students were remarkably similar across formats. Conclusion: Rate of progression as communicated by narrative statement plus a graphic element (i.e. speedometer metaphor or pictograph) aided recall better than a narrative statement alone. Our results suggest that testing decision aid components with non-patients may provide data generalizable to patient populations. Practice implications: Graphics must be used carefully in patient decision aids as they can enhance recall, but may also introduce unintended recall bias. [Copyright &y& Elsevier]

Abstract: Aim: To determine longer term health outcome in a cohort of UK service personnel who received the anthrax vaccination. Method: We conducted a three year follow up of UK service personnel all of whom were in the Armed Forces at the start of the Iraq War. 3206 had been offered the anthrax vaccination as part of preparations for the 2003 invasion of Iraq. A further 1190 individuals who did not deploy to Iraq in 2003 were subsequently offered the vaccination as part of later deployments, and in whom we therefore had prospective pre-exposure data. Results: There was no overall adverse health effect following receipt of the anthrax vaccination, with follow up data ranging from three to six years following vaccination. The previous retrospective association between making an uninformed choice to receive the anthrax vaccination and increased symptom reporting was replicated within a longitudinal sample where pre-vaccination health was known. Conclusions: Anthrax vaccination was not associated with long term adverse health problems. However, symptoms were associated with making an uninformed choice to undergo the vaccination. The results are important both for the safety of the vaccine and for future policies should anthrax vaccination be required in either military or non military populations. [Copyright &y& Elsevier]

Abstract: Background: Adequate knowledge is essential for making informed decisions. We attempted to determine the level of knowledge about mechanisms of action of birth control methods in five representative samples of European women. Study Design: Randomly selected women, aged 18–49 years, completed an anonymous survey in Germany, France, the UK, Sweden and Romania (N=1137). Participants were asked about how contraceptive methods work and if providers should inform them about this issue. Multiple linear regression was used to evaluate women''s characteristics associated with their knowledge of mechanisms of action. Results: The majority of women identified the unequivocal mode of action of condoms, sterilization and abortion. Fewer than 2% identified all possible mechanisms of action of hormonal contraceptives and intrauterine devices. Highly educated women correctly identified the mechanism or mechanisms of action of more methods than less educated women (β=0.22, 95% confidence interval 0.01–0.43). Regardless of their sociodemographic characteristics and their belief about when human life begins, most women (75%) stated that the provider should inform them about possible postfertilization effects. Conclusions: European women have low knowledge about mechanisms of action of several contraceptive methods. The majority want to be informed about possible postfertilization effects. Since adequate knowledge is essential for making informed decisions, providers are encouraged to inform women about all possible mechanisms of action of contraceptives. [Copyright &y& Elsevier]

Abstract: Background: The choice of a birth control method is influenced by sociocultural and personal factors. We explored the perceived influences in women''s choice of a birth control method in five European countries (Germany, France, the UK, Romania and Sweden), where contraception is widely used. Study Design: This is a cross-sectional study of 1137 randomly selected women aged 18–49 years. An anonymous, 31-item questionnaire related to birth control methods was used. Logistic regression was used to identify variables associated with partner participation in choice of a contraceptive. Results: Oral contraceptives were mainly used in Germany (54.3%), France (50.5%) and Sweden (34.6%) and condoms in the UK (29.6%) and Romania (22.9%). Sweden showed the highest use of intrauterine devices (IUD, 19%). Romania had the lowest use of contraception. Oral contraceptives and IUDs use were frequently suggested by providers instead of by women. Choosing the method with the partner was associated with age [odds ratio (OR)=0.97, 95% confidence interval (CI) 0.94–0.99], being a university graduate (OR=1.59, 95% CI 1.01–2.29), married (OR=1.52, 95% CI 1.01–2.29) and with using a method that requires partner''s cooperation (OR=8.18, 95% CI 5.46–12.27). Conclusions: Hormonal contraceptives and IUDs are commonly recommended by providers rather than requested by women. Partner preferences are taken into account when his cooperation in the use of the method is needed. As fertility care is a male and female issue, there is still more room for actively involving both women and men in their choice of a birth control method. [Copyright &y& Elsevier]

Objective: To test whether information about benefits and harms of screening for type 2 diabetes increases intentions to make lifestyle changes amongst attenders, predominantly among the socially advantaged and those with a strong future time orientation. Study design: Planned subgroup analysis of attenders for screening participating in a randomized controlled trial of an informed choice invitation vs a standard invitation to attend for type 2 diabetes screening. Methods: Potentially eligible participants were identified from practice registers using routine data which were used to calculate risk scores for diabetes for all aged 40-69 years without known type 2 diabetes and area deprivation based on post code. In total, 1272 individuals in the top 25% risk category were randomized to receive one of two invitations to attend their practices for screening: an informed choice invitation or a standard invitation. The subsequent attenders completed self-report measures of future time orientation and deprivation immediately before undergoing a screening test. Results: Individual-level deprivation demonstrated a significant moderator effect [F (4,635) = 4.32, P = 0.002]: individuals who were high in deprivation had lower intentions to engage in lifestyle change following receipt of the informed choice invitation. However, intentions were not patterned by deprivation when it was assessed at the area-level using the Index of Multiple Deprivation 2007. The hypothesized moderating effect of future time orientation on invitation type was also supported [P(14,613) 2.46, P = 0.002): individuals low in future time orientation had markedly lower intentions to engage in lifestyle change following receipt of an informed choice invitation compared with a standard invitation for screening. Conclusion: Efforts to enhance informed choice where the implications of diagnosis are a requirement for lifestyle change may require that the immediate benefits are communicated, and efforts to address the apparent barriers to diabetes self-care are made, if the potential for inequity is to be avoided. [ABSTRACT FROM AUTHOR]

Objective: To determine the content of decision-relevant knowledge needed for informed decision-making about (non-) participation in prenatal screening for Down's syndrome (DS), in order to develop a knowledge questionnaire for routine application in large-scale programme evaluations. Methods: A generic list of content domains for knowledge about screening was extracted from the literature. Items reflecting specific knowledge domains were constructed. An expert group of professionals and pregnant women expressed whether domains and items represented decision-relevant information. Results: All presented domains were scored as (very) important. Options when receiving an ‘increased probability for DS’ test result, the meaning of this result, the aim of the screening, and voluntary nature of the test were scored as most important. The condition being screened for, prevalence, and the screening procedure were scored as relatively less important, with a high amount of expert consensus. Conclusion: A knowledge measure for prenatal screening for DS was developed, based on domains and items acquired by expert consensus. Practice implications: This measure of decision-relevant knowledge can be used in routine, large-scale evaluations of the procedure for offering information about prenatal screening for DS. [Copyright &y& Elsevier]

Abstract: Objective: to explore routinisation and constraints on informed choice in a one-stop clinic offering first trimester antenatal chromosomal screening for Down’s syndrome. Design: recordings of booking appointments and pre-screening consultations in both a community and a hospital clinic setting. Setting: one antenatal clinic site in the UK offering first trimester nuchal translucency screening in combination with maternal serum screening. Participants: 57 taped clinical consultations involving pregnant women and midwives and health-care assistants (HCAs). Findings: midwives and HCAs expected women to make informed decisions about screening for Down’s syndrome. However, midwives’ attempts to maintain the normality of pregnancy and avoid discussions about potential scenarios, as well as their emphasis on the high accuracy rate of first trimester screening have routinised first trimester antenatal screening for Down’s syndrome. Also, a general expectation in the clinic to take up screening and the constrained service context in which midwives and HCAs work had implications for women’s informed choices. Key conclusions: directive information combined with lack of purposeful dialogue with pregnant women have constrained the process of information-giving about antenatal screening for Down’s syndrome. Implications: the provision of information about antenatal screening for Down’s syndrome is a challenging role for midwives. Changes in midwifery practice resulting from continuing education as well as less constraining service contexts could improve the quality of information about antenatal screening for Down’s syndrome. [Copyright &y& Elsevier]

Abstract: For patients with multiple sclerosis (MS) involvement in treatment decisions becomes ever more imperative. Recently new therapeutic options have become available for the treatment of MS and more will be licensed in the near future. Although more efficacious and easier to administer, the new drugs pose increased risks of severe side effects. Also, new diagnostic criteria lead to more and earlier MS diagnoses. Facing increasingly complex decisions, patients need up-to-date evidence-based information and decision support systems in order to make informed decision together with physicians based on their autonomy preferences. This article summarizes recently terminated and ongoing trials on MS patient education and decision aids conducted by the authors'' study groups. Programs on relapse management, immunotherapy, and for patients with suspected and early MS have been developed and evaluated in randomized controlled clinical trials. It could be shown that the programs successfully increase knowledge and allow patients to make informed decisions based on their preferences. For the near future, we aim to develop a modular program for all relevant decisions in MS to increase patients'' self-management and empower patients to develop their individual approach with the disease. Faced by a disease with many uncertainties, this should enhance patients'' sense of control. Still, it remains a challenge to adequately assess decision quality. Therefore, a study in six European and one Australian centers will start soon aiming to establish adequate tools to assess decision-making quality. [Copyright &y& Elsevier]

Abstract: This paper reports on a qualitative study examining everyday practices of healthy living (HL). Forty-four semi-structured interviews were undertaken with Canadian and UK citizens, aged 45 – 70, in April–May 2010. The research sits within the now substantial literature concerned with how health information is mediated, both by people and technologies, and employed in the context of ‘good’ health citizenship. Throughout this work, notions of ‘choice’ and ‘empowerment’ have been interrogated, theoretically and empirically, to reveal both the knowledge/power relationships integral to ‘informing’ processes and the shifting relationship between information and care in contemporary health encounters. In this paper, we analyse how people make sense of what it means to live healthily and how they know if they are doing so by focussing on three ways in which study participants become informed about healthy living: through their engagement with universal HL messages, through their own information searches, and through their attempts to measure their ‘healthiness’. Following critique of the “logic of choice” in contemporary healthcare, we understand healthy living as a “situation of choice” where complex problems are framed as simple matters of choice and where information and technologies are understood as neutral aids to decision-making in support of ‘correct’ choices. Our analysis builds on and extends Mol’s work by exploring how participants negotiate between this “logic of choice” and her alternative “logic of care” in their accounts of everyday HL informing practices and how the two logics “interfere” with one another. These accounts show resistance to the logic of choice through ‘calls for care’ but they also show clearly how the disciplining logic of choice works to (re)present such calls for care as failed attempts at healthy living, undermining the very practices the logic of choice seeks to encourage. [Copyright &y& Elsevier]

Abstract: Objective: to translate the original English version of the Multidimensional Measure of Informed Choice (MMIC) into Greek, to adapt it culturally to Greece, and to determine its psychometric properties for the assessment of informed choice in antenatal screening for Down syndrome. Design: survey using self-administrated questionnaires. Setting: public hospital in Athens, Greece. Participants: 135 pregnant women with gestational age between 11th and 20th week just prior to having antenatal screening for Down syndrome. Findings: 96% of women had a positive attitude towards screening and 45% had a good level of knowledge concerning the screening process for Down syndrome. Using a standard measure of informed choice, validated for use in Greek, it was found that 44% of women made an informed choice, and thus 56% of women made an uninformed choice. The internal consistency of the scales was good; Cronbach''s alpha was found to be 0.76 for the attitude scale and 0.64 for the knowledge scale, suggesting that all items were appropriate to measure. The performed factor analysis of the attitude scale indicated three factors with an eigenvalue over 1.0. Those factors were responsible for 87% of the variance. Key conclusions: this study indicates that the Greek version of the MMIC appears to be a reliable and valid tool for measuring informed choice in antenatal screening for Down syndrome. Due to its short length and consumption of time, it seems to be a practical instrument for use in Greek antenatal clinics. [Copyright &y& Elsevier]

Abstract: Background: antenatal screening for fetal abnormalities is now offered to all pregnant women in many countries in Europe. Previous studies have shown that women and their partners may not make informed choices about screening. Objectives: to investigate knowledge of screening in both prospective parents and professionals offering screening in England, and to identify the ways in which pregnant women and their partners could be supported to make informed decisions about antenatal screening. Design: cross-sectional survey design. Data were collected from July 2007 to January 2008 using two self-completion questionnaires. Setting and participants: questionnaires were completed by: (i) pregnant women (n=100) and their partners (n=11), and (ii) midwives involved in offering antenatal screening (n=78). Measurements: demographic data and survey responses were analysed using descriptive statistics and cross-tabulations. Findings: some midwives lack accurate knowledge about screening and the conditions for which screening is offered. Parents wish to have information about screening at an earlier stage and would like the prospective father to be included in screening discussions. There is evidence that many parents do not perceive the second trimester ultrasound scan as a method of screening. Balanced information about the lives of people with Down syndrome would be seen as helpful by many parents. Key conclusions: further efforts need to be made to educate midwives more fully so that pregnant women and their partners are able to make informed choices about screening. Balanced information about the lives of people with Down syndrome should be available to prospective parents to support their decision making. [Copyright &y& Elsevier]

Abstract: Background: The ‘Next Birth After Caesarean’ (NBAC) clinic is a dedicated service for women who have had a previous caesarean section. The midwifery-led clinic commenced at a tertiary hospital in Western Australia in 2008. As part of this service, access to a midwife via telephone is available. Aim: This paper aims to provide maternity health care providers with an increased understanding of, and insight into, the different information needs of this specific group of maternity care consumers. Methods: A qualitative descriptive approach was used to analyse the content of 170 telephone calls made by women to the NBAC clinic over a period of 16 months (July 2008–November 2009). Results: Six distinct categories of calls were elicited from the analysis process with the majority of calls related to women seeking information and support about the option of vaginal birth after caesarean (VBAC). These were labeled: ‘Wanting and seeking a VBAC’; ‘Is VBAC a possiblility?’; ‘Seeking clarification and cross-checking information in the face of opposition’; ‘Existing NBAC clients checking in/checking out’; ‘Feeling distressed and disappointed; wanting to talk’ and ‘Professional inquiry about NBAC service’. Discussion: It is acknowledged that women require access to non-biased information to be able to make informed decisions about birth after caesarean. However there remains limited evidence on the precise informational needs of these women. It appears from our findings that this particular group of maternity service consumers requires opportunities to discuss their particular needs within the context of their individual childbearing experiences. Conclusion: Preliminary evidence is provided that a telephone service led by midwives may be one effective strategy to meet women''s informational needs and address decisional conflict in relation to options for birth after a caesarean section. [Copyright &y& Elsevier]

Abstract: Objective: Some methods of family planning, such as oral contraceptives, emergency pill or intrauterine device, may occasionally work after fertilization. These effects may be important to some women. We explored Spanish women''s attitudes towards contraceptive choices that may have occasional post-fertilization mechanisms of action. Study design: Cross-sectional study in a Spanish representative sample of 848 potentially fertile women, aged 18–49. Data were collected using a 30-item questionnaire about family planning. Logistic regression was used to identify variables associated with women''s attitudes towards post-fertilization effects. Results: The majority of women were married, had completed high school and had at least one child. Forty-five percent of women would not consider using a method that may work after fertilization and 57% would not consider using one that may work after implantation. Forty-eight percent of the sample would stop using a method if they learned that it sometimes works after fertilization, increasing to 63% when referring to a method that sometimes works after implantation. Women who believe that human life begins at fertilization, those who believe it is important to distinguish between spontaneous and induced embryo losses and women who report having a religion were less likely to consider the use of a method with some post-fertilization effects. Conclusion: The possibility of post-fertilization effects may influence Spanish women''s choice of a family planning method. Information about mechanisms of action of birth control methods should be disclosed to women so that they can make informed choices. [Copyright &y& Elsevier]

: Objective: To discuss whether using the International Patient Decision Aids Standards (IPDAS) Collaboration checklist as a gold standard to judge interventions’ quality is premature and potentially detrimental to the validity of resources designed to help patients make treatment choices. Methods: Conceptual review integrating the science behind individuals’ decision making with the demands of designing complex, healthcare interventions. Results: Patient decision aids are promoted as interventions to help professionals engage in shared and/or patient-centred care. The IPDAS domains were informed by experts’ opinions of best practice. Decision scientists study how individuals make decisions, what biases their choices and how best to support decisions. There is debate from decision scientists about which component parts are the active ingredients that help people make decisions. Conclusions: Interventions to help patients make choices have different purposes, component parts and outcomes to those facilitating professional–patient communications. The IPDAS checklist will change to respond to new evidence from the decision sciences. Practice implications: Adhering uncritically to the IPDAS checklist may reduce service variation but is not sufficient to ensure interventions enable good patient decision making. Developers must be encouraged to reason about the IPDAS checklist to identify those component parts that do (not) meet their intervention''s purpose. [Copyright &y& Elsevier]

Objective: To survey quality criteria for evidence-based patient information (EBPI) and to compile the evidence for the identified criteria. Methods: Databases PubMed, Cochrane Library, PsycINFO, PSYNDEX and Education Research Information Center (ERIC) were searched to update the pool of criteria for EBPI. A subsequent search aimed to identify evidence for each criterion. Only studies on health issues with cognitive outcome measures were included. Evidence for each criterion is presented using descriptive methods. Results: 3 systematic reviews, 24 randomized-controlled studies and 1 non-systematic review were included. Presentation of numerical data, verbal presentation of risks and diagrams, graphics and charts are based on good evidence. Content of information and meta-information, loss- and gain-framing and patient-oriented outcome measures are based on ethical guidelines. There is a lack of studies on quality of evidence, pictures and drawings, patient narratives, cultural aspects, layout, language and development process. Conclusion: The results of this review allow specification of EBPI and may help to advance the discourse among related disciplines. Research gaps are highlighted. Practice implications: Findings outline the type and extent of content of EBPI, guide the presentation of information and describe the development process. [Copyright &y& Elsevier]

Abstract: Background: Population-based screening for prostate cancer (PCa) remains controversial. To help men making informed decisions about prostate specific antigen (PSA) screening a risk indicator (www.uroweb.org) was developed. This risk indicator is embedded in a leaflet that informs men about the pros and cons of PCa screening and enables calculation of the individual risk of having a biopsy detectable PCa. Aim: To assess the effect of providing a leaflet including individualized risk estimation on informed decision making of men, i.e. knowledge about PCa and PSA screening, attitude towards undergoing a PSA test and intention to have a PSA test. Methods: An intervention study among 2000 men, aged 55–65years, randomly selected from the population registry of the city of Dordrecht, the Netherlands, in 2008. Men were sent a questionnaire on knowledge of PCa, attitude and intention to have a PSA test. Men without a history of (screening for) PCa were sent the leaflet and Questionnaire 2 within 2weeks after returning Questionnaire 1. Validated health and anxiety measures were used. Results: One thousand and twenty seven of 2000 men completed Questionnaire 1 (51%), of whom 298 were excluded due to a history of (screening for) PCa. Of the 729 remaining men, 601 completed Questionnaire 2 as well. At the second assessment significantly more men met the requirements of informed decision making (15% versus 33%, p <0.001), more men had relevant knowledge (284/601, 50% versus 420/601, 77%, p <0.001) and the intention to have a PSA test had increased (p <0.001). Conclusions: Providing information on PCa screening combined with individualized risk estimation enhanced informed decision making and may be used for shared decision making on PSA screening of physicians and patients. [Copyright &y& Elsevier]