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Use of metaphors may improve participation in clinical trials
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The use of metaphors for explaining randomization could ease the difficulty in recruiting patients to participate in randomized clinical trials, according to a study published in the Journal of the National Cancer Institute.
“Health literacy is an important predictor of how patients process and evaluate health information,” Janice L. Krieger, PhD, a researcher from the STEM Translational Communication Center at University of Florida, and colleagues wrote. “And while existing literature suggests that plain language approaches may be beneficial for educating patients with low health literacy, our results show that a benign metaphor was the most effective strategy for enhancing randomization comprehension among patients with the lowest level of health literacy.”
Randomized controlled trials (RCTs) remain essential to developing medical treatments for cancer and translating biomedical discoveries into evidence-based patient care. Yet in the United States, fewer than 5% of patients with cancer participate in RCTs, and those rates are lower for racial and ethnic minorities. As a result, about 75% of investigators do not meet their RCT recruitment goals.
One of the key barriers to patient participation in RCTs is how randomization is explained to patients during the informed consent stage.
Two linguistic strategies have been used to improve the process: plain language and metaphors. The plain-language approach employs shorter sentence structure and nontechnical language and has shown to be effective in increasing comprehension of cancer diagnoses and treatment options among patients with low health literacy.
Metaphors have shown to be an effective health communication tool in which a familiar concept, such as flipping a coin, is grasped more completely than an unfamiliar one, such as randomization. Personal relevance of health information also is shown to increase patient engagement in RCTs.
In their study, Krieger and colleagues collected data from 606 patients aged 18 years or older who had been diagnosed with cancer within the previous 24 months and were able to read and write in English. Patients who had participated in previous cancer clinical trials or who did not complete all dependent measures were removed prior to analysis, resulting in a final sample of 500 participants (women, n = 317).
Participants self-reported as non-Hispanic white (n = 415), non-Hispanic black or African American (n = 28), or Hispanic (n = 57). Patients ranged in age from 18 to 89 years (mean, 50.1 years; standard deviation, 17.1 years).
Researchers randomly assigned patients to one of four message conditions: control (n = 117), plain language (n = 128), gambling metaphor (n = 132) and benign metaphor (n = 123).
A plain language explanation of randomization served as a base message. A gambling metaphor compared randomization to the chance a flipped coin would land on heads and included an additional 54 words. A benign metaphor compared randomization to the chance of a pregnancy resulting in a male or female child and included an additional 55 words.
Health literacy was measured using four items that assessed if patients felt they could easily find and interpret cancer information, with response categories ranging from “strongly agree” to “strongly disagree.” Personal relevance of clinical research was assessed by asking patients how much attention they paid to clinical research and how relevant it was to them.
Krieger and colleagues reported that among all patients, comprehension was greater among those who were explained randomization via the gambling metaphor (mean difference, 0.7; 95% CI, 0.37-1.04; P < .001) and the benign metaphor (mean difference, 0.64; 95% CI, 0.3-0.98; P < .001) than those in the control group. There were no significant differences in comprehension between these two metaphors (mean difference, 0.06; 95% CI, –0.27 to 0.39), or in comparing the use of metaphors with plain language (vs. gambling mean difference, 0.12; 95% CI, –0.2 to 0.45; vs. benign mean difference, 0.06; 95% CI, –0.27 to 0.4).
At the lowest level of health literacy, only the benign metaphor resulted in statistically significantly greater comprehension of randomization compared with the control (P = .004). The plain language and gambling metaphor did not result in greater comprehension.
At higher levels of health literacy, all three forms of messaging resulted in statistically significantly greater comprehension in comparison with control. Participants in the gambling metaphor reported greater comprehension of randomization than those in the benign metaphor group.
Researchers noted that these results could be limited by the lack of specific information on the types of cancer treatment participants were undergoing.
“Patients with the highest levels of health literacy showed greater randomization comprehension when exposed to the gambling metaphor condition as compared with the benign metaphor condition,” Krieger and colleagues wrote. “Taken together, these results show that metaphors can be more useful than plain language strategies for overcoming challenges associated with health literacy.” – by Chuck Gormley
Disclosure: Researchers report no relevant financial disclosures.
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