Preferences for More or Less Health Care and Association With Health Literacy of Men Eligible for Prostate-Specific Antigen Screening in Australia
Authors: Kristen Pickles, Laura D. Scherer, Erin Cvejic, Jolyn Hersch, Alexandra Barratt, Kirsten J. McCaffery
Journal: JAMA Network Open (2021)

<h3>Importance</h3> Understanding personal factors that influence diverse responses to health care information, such as preferences for more or less health care, might be beneficial to more effective communication and better involvement in health care choices. <h3>Objective</h3> To determine whether individuals' preferences for more or less health care are associated with informed choice and understanding of overdiagnosis in routine prostate cancer screening and to examine associations among preferences, educational status, and health literacy. <h3>Design, Setting, and Participants</h3> This survey study included a community-based sample of men in Australia aged 45 to 60 years eligible for prostate-specific antigen (PSA) screening, recruited via an international social research company. Survey data were collected online from June 27 to July 26, 2018. Data were analyzed in April 2020. <h3>Exposures</h3> Participants were randomized to 1 of 2 versions of an online decision aid (full-length or abbreviated) about PSA screening and completed an online survey that included a measure of preference for more or less health care, the Medical Maximizer-Minimizer Scale (MMS), in which higher score indicates preference for more health care. <h3>Main Outcomes and Measures</h3> The primary outcome was informed choice; knowledge, attitudes, and intentions about screening for prostate cancer were also measured. <h3>Results</h3> Of 3722 participants who began the survey, 2993 (80.4%) completed it (mean [SD] age, 52.15 [6.65] years). Stronger preferences for more heath care were observed in those without tertiary education (mean difference, 0.15; 95% CI, 0.09-0.22;<i>P</i> &lt; .001) and with inadequate health literacy (mean difference, 0.16; 95% CI, 0.09-0.22;<i>P</i> &lt; .001). After controlling for health and demographic variables, a 1-unit increase in MMS score was associated with reduced relative risk (RR) of making an informed choice (RR, 0.78; 95% CI, 0.74-0.82;<i>P</i> &lt; .001) and of having adequate conceptual knowledge (RR, 0.87; 95% CI, 0.84-0.90;<i>P</i> &lt; .001), correct numerical knowledge (RR, 0.93; 95% CI, 0.89-0.97;<i>P</i> = .001), and correct understanding of overdiagnosis (RR, 0.84; 95% CI, 0.79-0.90;<i>P</i> &lt; .001). A 1-unit increase in MMS score was associated with a more positive attitude toward screening (RR, 1.18; 95% CI, 1.15-1.21;<i>P</i> &lt; .001) and more positive intention to screen (RR, 1.20; 95% CI, 1.16-1.25;<i>P</i> &lt; .001) after adjusting for control variables. <h3>Conclusions and Relevance</h3> This survey study examined associations between preferences for more or less health care and knowledge about overdiagnosis and informed choice among men in Australia. These results may motivate clinicians to elicit individual patient preferences to facilitate tailored discussions with patients about low-value care, such as prostate cancer screening, for which benefit is uncertain.