Does narrative information bias individual's decision making? A systematic review☆
Introduction
Patients are encouraged to participate in the decision making and management of their healthcare (The NHS plan, 2000). Many medical decisions are complicated and can be difficult to make especially when the decision is emotive, involves risk, is time pressured (Bekker et al., 1999, O'Connor, Stacey et al., 2003), and/or when the decision is ‘preference sensitive’, and there is no single best medical treatment option available (O'Connor, Légaré et al., 2003, Wennberg et al., 2002).
Decision aids are interventions designed to help patients make deliberate choices between two or more treatment options (O'Connor, Stacey, et al., 2003). There is evidence for the effectiveness of decision aid interventions to facilitate patient decision making (Bekker et al., 1999, O'Connor, Stacey et al., 2003). Typically decision aids include accurate and up to date treatment information and techniques to encourage patients to assimilate this information with their own values and preferences (Bekker et al., 1999, O'Connor, Stacey et al., 2003). However, there is considerable variation in the content of these complex interventions and it remains unclear what components of the decision aid are the ‘active ingredients’ in facilitating patient decision making (Bekker et al., 2003, Bekker et al., 1999, Charles et al., 2005, Elwyn et al., 2006).
Increasingly treatment information in decision aids is being presented as patient narrative rather than as factual information (Elwyn et al., 2006, Feldman-Stewart et al., 2006). Reviews of the content of decision aids found that anywhere between 20 and 74% of decision aids contain examples of other patient's experience of having the health condition and/or choosing treatment options, in the form of testimonials or accounts presented in the first and third person (Feldman-Stewart et al., 2006, O'Connor, Stacey et al., 2003). The patient experience, and use of narratives, is an established part of medical training and clinical skills acquisition (Chisholm and Askham, 2006, Ubel et al., 2001). In addition, patient narratives may help people make sense of and cope with their (ill) health (Herxheimer & Ziebland, 2004). What is unclear is the appropriateness of patient narratives in interventions designed to help patients make good decisions about treatment options and illness management. At present there is considerable variation in the length, breadth and content of narratives included in decision aids, and it is unclear how narratives are balanced to provide an appropriate range of the patient's experience (Khangura, Bennett, Stacey, & O'Connor, 2008).
Decision aids work, in part, by presenting balanced information about the advantages and disadvantages of all the treatment options in a way that enables individuals to process this information without bias. Decision aids encourage patients to evaluate systematically more of the decision-relevant information in accord with their own beliefs and emotions, compared to those making the same decision unaided (Bekker et al., 2003). The use of narratives within decision aids may reduce the effectiveness of decision aids to facilitate informed decision making by a) biasing the presentation of information, and b) discouraging individuals to evaluate systematically the decision-relevant information (Beyerstein, 2001). When patient narratives are used, it is unlikely that all the possible consequences of the decision alternatives are represented by the story (Butow, Fowler, & Ziebland, 2005). Decision aids are more likely to include narratives where the patient is satisfied with their decision (Khangura et al., 2008). Presenting more information about one type of consequence is directive (Kessler, 1992). In addition, it is likely that patient narratives encourage the use of heuristic processing. Processing information heuristically relies on the use of ‘rules of thumb’ based on an individual's past experiences and observations (Chaiken, 1980). In such circumstances, the context of the message, such as who is delivering the information, is more influential in decision making than the message content, such as information about the risks and benefits of treatment options (Chaiken, 1980). Individuals may well be persuaded by others' stories because of a characteristic of the narrator rather than the content of the message, although this is an empirical question.
Section snippets
Defining narrative information
Most research exploring the role of narratives in persuasion and decision making has been carried out with student populations (Morman, 2000) in non-medical contexts such as consumer research (Dickson, 1982). Several terms for the same phenomenon are used including narratives (Green & Brock, 2000), exemplars (Brosius, 1999), anecdotal evidence (Slater & Rouner, 1996), testimonial evidence (Ubel et al., 2001) and case histories (Dickson, 1982). Further, there is no clear definition and/or
Previous summaries of narrative-based empirical research
Scoping the literature identified three previous reviews of the primary empirical evidence assessing the persuasive effects of narrative information on decision making: Allen and Preiss, 1997, Reinard, 1988, and Taylor and Thompson (1982). The aims of the reviews were to compare the effect of information presented as narratives compared to other forms of evidence, e.g. statistics, in a range of contexts on individual's judgment. There appear to be discrepancies between the reviews' conclusions
Design
A survey of primary empirical research employing a systematic review method.
Search strategy
Two search strategies were developed with reference to the review aims, CRD (2001) guidelines, keywords of target articles, and the University of Leeds librarians' expertise to identify articles from a) medical and psychological, and b) communications-based websites electronic databases. The search strategies included the following terms: [decision making – decision, persuasion, judgment] + [narrative type – testimonial,
Results
Seventeen studies were included in the review; 41% included first person, 59% third person (Table 1, Table 2). Most were carried out in North America, employed an experimental design, a student sample, referred to a theory, and included third-person narratives; all were in the context of medicine and health, and almost two-thirds presented hypothetical decisions scenarios (Table 1, Table 2). In total five studies demonstrated an effect of narratives on individual's preferences and/or decision
Discussion
This review of 17 studies investigated the effect of narrative information on individual's decision making; 41% included first person, 59% third person. The synthesis of results suggests only limited evidence for the influence of narratives on individual's decision making (5/17 studies) compared to the provision of no additional information and/or statistically based information. Studies using first person narratives were more than twice as likely to find an effect as those using third-person
Conclusions
It seems likely that narrative information does affect the individual's decision making processes and outcomes, in both health and other decision contexts. Approximately a third of the studies (5/17) found that narrative information affected the individual's decision making process and outcomes. Similar studies carried out in non-medical settings suggest evidence for the biasing effect of narrative on decision making. At present, it is unclear why narratives affect the decision making process,
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Financial support for this study was provided partly by a PhD studentship (Economic and Social Research Council and Baxter's Pharmaceuticals). The funding agreement ensured the author's (AW) independence in designing the study, interpreting the data, writing, and publishing the report.
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* Indicates study included in the systematic review.