A decision aid for women considering hormone therapy after ...

Patient Education and Counseling 33 (1998) 267–279 

A decision aid for women considering hormone therapy after 

menopause: decision support framework and evaluation 

a,b,c, b,c b,c b 

Annette M. O’Connor * , Peter Tugwell , George A. Wells , Tom Elmslie , 

b b b a c 

Elaine Jolly , Garry Hollingworth , Ruth McPherson , Helen Bunn , Ian Graham , 

a,c 

Elizabeth Drake 

a University of Ottawa, School of Nursing, Ottawa, Ontario, Canada 

b University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada 

c Clinical Epidemiology Unit, Ottawa Civic Hospital Loeb Research Institute, 1053 Carling Ave, Ottawa, Ontario, K1Y 4E9, Canada 

Abstract 

Received 30 July 1997; received in revised form 20 October 1997; accepted 10 November 1997 

Although postmenopausal women are advised to consider their values when deliberating about potential benefits and risks 

of hormone therapy (HRT), feasible, effective methods of decision support in primary care have yet to be established. Using 

an explicit decision support framework, we developed a self-administered HRT decision aid and evaluated it in a 

before/after study of 94 women from six family practices. An audiotape guided women through an illustrated booklet 

including: detailed information about HRT benefits and risks tailored to a woman’s clinical risk, and a values clarification 

exercise to promote informed decision making consistent with personal values. After using the decision aid participants: had 

better general knowledge and more realistic personal expectations of HRT benefits and risks; and, felt more certain, 

informed, clear about values, and supported in decision making. Women’s values elicited in the clarification exercise were 

84% accurate in discriminating between decisions. Women with polarized preferences at baseline did not change their minds, 

but were better informed. Changes in preferences occurred in the uncertain group, with equal numbers accepting or declining 

HRT. Most participants found the decision aid comprehensible, acceptable in length and pace, and balanced. Decision aids 

are useful in preparing women for decision making about this complex, personal issue. © 1998 Elsevier Science Ireland 

Ltd. 

Keywords: Decision making; Women’s health; Choice behavior; Informed consent; Decision support techniques; Patient 

education; Patient participation; Health education; Consumer satisfaction; Hormone replacement therapy (HRT); Menopause 

Practice guidelines [1,2] suggest that post- only after learning about the probable benefits and 

menopausal women consider long-term hormone risks and judging their personal value. Implementing 

therapy (HRT) to protect the heart and bones, but these guidelines is challenging in primary care, given 

the complexity of judging the benefits and risks, the 

* size of the post-menopausal population, and the 

Corresponding author. Tel.: (1-613) 798-5555; fax: (1-613) 

761-5492; e-mail: aoconnor@civich.ottawa.on.ca limited resources to support women’s decision mak- 

0738-3991/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. 

PII S0738-3991(98)00026-3

268 A.M. O’Connor et al. / Patient Education and Counseling 33 (1998) 267 –279 

ing. General educational materials are limited in stance, diagnosis, or developmental transition; (2) 

helping women to judge the personal likelihood and require careful deliberation because of the uncertain 

personal value of HRT benefits and risks. Therefore, and/or value-sensitive nature of the benefits and 

‘decision aids’ are being developed as an adjunct to risks; and (3) need relatively more effort during the 

counseling [3–6]. Decision aids differ from usual deliberation phase than the implementation phase. 

patient education materials by: focusing on alter- Therefore the DSF is less useful for decisions: (1) 

natives, benefits, and risks tailored to a woman’s with no immediate stimulus for deliberation; (2) 

clinical risk profile; providing detailed descriptions whose key challenge is implementing and maintainof 

the benefits and risks in functional terms; using ing the decision; or (3) that are rapid, repetitive, 

explicit probabilities to describe the likelihood of automatic, impulsive or deferential to authority. 

benefits and risks; including values clarification to As shown in Fig. 1, the DSF is organized accordencourage 

evaluation of the personal importance of ing to: (1) determinants of decisions; (2) decision 

the benefits and risks; and emphasizing choice and support interventions which address the determinants 

shared decision making [7]. In the case of the HRT to improve the quality of the decision making 

decision, benefits and risks need to be tailored to a process and the decision; and (3) evaluation to 

woman’s hysterectomy status and risk of coronary ascertain the success of the decision support on the 

heart disease (CHD), osteoporosis, and breast cancer quality of the decision process, decision, and out- 

[1]. Moreover, a woman needs to consider her values comes of decisions. The concepts apply to both the 

[1] in balancing the potential benefits of protection client (individual, couple, or group) and the pracfrom 

CHD and osteoporosis and relief of menopausal titioner, although the empirical focus in this paper is 

symptoms against the endometrial cancer risk, the on the client. 

uncertain risk of breast cancer, the side effects of 

HRT, and her attitudes toward preventive medication 1.1. Determinants of decisions 

for a natural aging process. 

HRT decision aids are in the early developmental Essential inputs into decisions include the client’s 

stages. There is little evidence of their efficacy. and practitioner’s: demographic, clinical, and prac- 

Some lack an explicit conceptual framework and tice characteristics; perceptions of the decision; 

some are unsuitable for administration in primary perceptions of important others involved in the 

care settings with limited personnel, time, space, or decision; and personal and external resources to 

technology. Our study objective was to develop and make and implement a choice. These are defined in 

evaluate a portable, self-administered decision aid, Table 1. According to the theories underlying the 

based on an explicit framework of decision support, DSF, the selection of one alternative over another 

which a women could use at home to prepare her for depends not only on the client and practitioner 

structured counseling with her practitioner. We de- characteristics, but also on whether they are knowveloped 

a decision aid delivered via a take-home ledgeable about the issues, expect the alternative will 

booklet and audiotape and then evaluated it in a likely lead to outcomes they most value; are reasonbefore/after 

study in 6 family practices. This paper ably certain this is the best alternative; perceive that 

presents the decision support framework we used to important others agree with and are supportive of 

develop the decision aid and the results of this the alternative; and have the necessary personal and 

preliminary evaluation. external resources to make and implement the 

choice. 

1. Decision support framework 1.2. Decision support 

Our decision support framework (DSF) is based Decision support involves preparing the client and 

on expectancy value, decisional conflict, and social the practitioner for decision making and structuring 

support theories [8–15]. It was developed for health follow-up counseling. The goal is to improve the 

decisions that: (1) are stimulated by a new circum- quality of decision making by addressing the modifi-

A.M. O’Connor et al. / Patient Education and Counseling 33 (1998) 267 –279 269 

Fig. 1. Decision Support Framework (DSF). 

able determinants of decisions that are suboptimal: likelihood of benefits and risks. Decision aids may 

inadequate knowledge; unrealistic expectations; un- also clarify personal values by either implicitly or 

clear values; unclear norms; unwanted pressure; explicitly asking individuals to consider the personal 

inadequate support; and inadequate personal and importance they place on each benefit and risk and to 

external resources to make the decision. Since these identify the tradeoffs they will need to make in 

factors also contribute to decisional conflict [16], choosing one alternative. As a consequence, there 

high decisional conflict or uncertainty which results may be better congruence between a person’s values 

in decision delay can also be addressed. Decision and their choice. 

support includes providing tailored information, Another potential mechanism for creating realistic 

clarifying values, and augmenting self-help skills in expectations and clarifying values lies in the detailed 

decision making and implementation. The mecha- descriptions of benefits and risks depicting their 

nisms whereby each of these interventions addresses impact on physical, emotional, and social function. 

the suboptimal determinants [16,7] are described Decision makers tend to judge the likelihood of an 

below. outcome [14] in accordance with: (a) the ease with 

Decision aids include information about the prob- which they can imagine it (availability heuristic); and 

lem, alternatives, and benefits and risks to improve (b) their belief that they represent the type of person 

knowledge of the decision. Probabilities tailored to who would normally experience the outcome (reprethe 

client’s clinical risk are included to create more sentativeness heuristic). They are also better able to 

realistic expectations or subjective judgements of the form an opinion about the value of an outcome when


Table 1 

Definitions of determinants of decisions in the decision support framework 

(1) Client’s and practitioner’s sociodemographic and clinical characteristics 

Client: age, gender, education, ethnicity, occupation, locale, diagnosis and duration of condition, health status (physical, emotional, 

cognitive, social) 

Practitioner: age, gender, ethnicity, clinical education and specialty, practice locale, years of experience 

(2) Client’s and practitioner’s perceptions of the decision 

Knowledge Cognizance of the clinical problem, alternatives and rationale, consequences (benefits, risks) 

Expectations Perceived likelihood or probability of benefits and risks 

Values Desirability or personal importance of benefits and risks; under conditions of uncertainty, utilities become 

values which incorporate not only desirability but also attitude toward risk 

Decisional conflict Uncertainty about course of action to take arising from factors inherent in the decision (uncertainty of outcomes, 

or the need to make value tradeoffs between benefits and risks) and modifiable factors (inadequate knowledge, 

unrealistic expectations, unclear values and norms, unwanted social pressure, inadequate social support, lack of 

other resources). 

(3) Client’s and practitioner’s perceptions of important others regarding the decision 

Norms Perceptions of what important others think is the appropriate choice. For the client, important others may 

include their spouse, family, peers, and practitioner(s). For the practitioners, it may include the client, 

professional peers, and personal network. 

Pressure Perception of persuasion, influence, coercion from important others to select one alternative 

Support Informational, emotional, and tangible help from important others to bolster and sustain decision making 

Decision participation Actual practice and preferences for participation in decision making (client controlled, shared with practitioner, 

roles practitioner controlled, other controlled) 

(4) Client’s and practitioner’s resources to make the decision 

Personal resources 

Experience Previous exposure to the clinical problem, alternatives, consequences, decision making process 

Self-efficacy Confidence in one’s abilities in decision making, including shared decision making 

Motivation Readiness and interest in decision making, including shared decision making 

Skills Abilities in making and implementing a decision 

Other Instrumental and financial capabilities to implement choices 

External resources (assets from others that are required to make and implement the decision) 

Type Access to information, advice, emotional support, instrumental help, financial assistance, and health and social 

services 

Source Social networks, professional networks, support groups, voluntary agencies, and the formal health care, 

education, and social sectors 

it is familiar, simple, and directly experienced [15]. menting decisions and managing their consequences. 

The detailed scenarios in decision aids may translate The acquisition or re-enforcement of self-help skills 

an outcome into familiar, vivid functional descrip- may reduce decision delay and improve implementations 

with which clients can identify and may tion of decisions. 

provide vicarious experience from which to better Other mechanisms of decision support may imjudge 

the likelihood and value of each benefit and prove the quality of decision making. Helping inrisk 

for them. dividuals to actively consider a decision in the 

To address the problem of unclear norms, a context of their own clinical risks and values may 

decision aid may provide information on experts’ enhance a person’s: perceived relevance of the 

and other clients’ opinions and practices and the issues; engagement in the process; self-efficacy, and 

underlying rationale for diverging opinions. Deci- sense of mastery and control [17]. These in turn may 

sions aids or follow-up counseling may also address increase satisfaction with the decision process, the 

unwanted pressure, inadequate support and resources decision, and increase implementation of the deciby 

enhancing self-help skills in handling pressure, sion. 

seeking social support and external resources, imple- Decision support should also address other deter-


minants in the DSF (practitioner and client charac- the objectives, content, and decision support methteristics, 

preferences for decision participation). For ods. 

example, a woman’s decision aid needs to be gender We structured the content of the decision aid 

sensitive and appropriate for the age, education, and according to the ACP counseling guidelines [1] and 

ethnicity of the population. It needs to be flexible to delivered it using a self-administered, self-paced 

clients’ preferences for participation in decision booklet and audiotape. It was designed to be used by 

making. Shared decision making is preferred more a woman at home in preparation for a follow-up visit 

frequently among female, younger, and better edu- to discuss the issue with her practitioner. The 40 min 

cated clients [18,19], but the aid should accommo- audiotape guided a woman through a 32-page illusdate 

all women’s preferences. Women perceive risks trated booklet including: 

differently from men [20]; therefore the method of 

presenting risk information should be acceptable to 2.1. General information 

them. 

1. CHD, osteoporosis, endometrial cancer, and 

1.3. Evaluating decision support breast cancer including definition, incidence, median 

age of onset, mortality rates, and the phys- 

The DSF distinguishes between quality decision ical, emotional and social impact of these dismaking 

and quality outcomes, because good deci- eases; and major risk factors; 

sions can still result in bad outcomes, due to the 2. prevention and early detection strategies; 

stochastic nature of clinical events. Since decisions 3. HRT regimens; benefits and risks including efthat 

depend on client’s values cannot be judged as fects on CHD, osteoporosis, menopausal sympright 

or wrong, the DSF defines a high quality toms, endometrial cancer, breast cancer, side 

decision as informed, consistent with personal val- effects, contraindications, and other concerns 

ues, and acted upon, and in which decision makers women express about taking HRT; 

express satisfaction with the decision making process 4. probabilities of disease with and without HRT 

and the decision [6,16]. Indicators of quality decision according to risk of disease and hysterectomy 

making may include: adequate knowledge; realistic status; 

expectations; clear values, congruence between values 

and one’s choice; low decisional conflict; deci- 2.2. Steps in weighing her own benefits and risks 

sion implementation, and satisfaction with the decision 

and decision making process [6,16]. Improving Guidance was provided in completing a Personal 

the quality of decision making may impact favourab- Worksheet to: 

ly on clients’ outcomes such as: (a) persistence with 

the decision [21]; (b) health related quality of life, 1. identify her personal lifetime benefits and risks of 

which is derived, in part, from values; (c) reduced HRT tailored to her hysterectomy status, and risk 

distress from consequences [22,23]; (d) reduced of CHD, osteoporosis and breast cancer; review 

regret; (e) appropriate and efficient use of resources; her menopausal symptoms status and menstrual 

and (f) long-term satisfaction with care. history; and consider other issues important in the 

decision; 

2. clarify her values using a ‘weigh scale’ to rate her 

2. The HRT decision aid perceived importance of each benefit and risk; 

3. identify her current health practices in promoting 

The early prototypes of the HRT decision aid were healthy bones, heart, and breasts; 

developed using an iterative process with the re- 4. list her questions; 

search team and panels of clients, medical and 5. identify her preference for participation in decinursing 

practitioners, and educators. These groups sion making; and 

guided its development using criteria such as need, 6. indicate her predisposition or ‘leaning’ toward 

feasibility, and appropriateness and acceptability of taking HRT.


2.3. Suggested steps for a follow-up visit with her questionnaire. The timing of our post-decision aid 

practitioner assessment was planned to capture women’s knowledge 

and perceptions at what would normally be 

The completed Personal Worksheet provided a considered the time of decision making. However, 

focus for discussion for the woman to: for the current evaluation, there was no planned 

follow-up to discuss the issue with the woman’s 

1. review possible benefits and risks with her prac- family physician. 

titioner to verify and fill in gaps; 

2. discuss personal values by showing the prac- 3.2. Sample 

titioner her weigh scale; 

3. make a decision considering benefits, risks, per- We recruited 94 women including never users, 

sonal values, and preference for decision partici- former users, and current users of HRT. Inclusion 

pation; and criteria were: age 50–60 years; at least 2 years 

4. plan the next steps. postmenopausal; and, able to read English. Exclusion 

criteria were: HRT use less than 2 years; previous 

The booklet included illustrative icons to represent discontinuation of HRT due to intolerable side 

each concept. The text was adjusted to a Grade 8 effects; osteoporosis-associated fractures; and absoreading 

level, but was comprehensible to those with lute contra-indications to HRT [2]. Our inclusion and 

less than Grade 8 reading because of the accompany- exclusion criteria were designed to reflect the usual 

ing audiotape and illustrations. The data describing group of women deciding about HRT: current users 

lifetime risks and benefits were those used in the to determine how long they want to take it; former 

ACP guidelines from the overview of Grady et al. users for menopausal symptom relief who may not 

[24]. A woman used the aid in a self-paced, active want to consider it for preventive purposes, and 

way, responding to checklists and writing in her never users who may wish to consider it for prevenopinions. 

In order to familiarize herself with the tive purposes. 

steps in weighing the benefits and risks, she was The study received approval from the local ethics 

shown how four other women completed the steps review committee. 

before being asked to complete her own assessment. 

The four different cases also reinforced the notion 3.3. Measures 

that decision making is variable and can be individualized 

according to a woman’s health history, Our sources of data included: a recruitment 

values, current health practices, and preferences for screening questionnaire; baseline and post-decision 

decision participation. aid questionnaires; and, responses completed by 

participants in the decision aid group. The following 

client variables from the DSF were elicited: socio- 

3. Evaluation methods demographic and clinical variables; perceptions of 

the decision (knowledge, expectations, values, deci- 

3.1. Before/after study design sional conflict); and perceptions of others (pressure, 

support, and decision participation preferences). Ac- 

Participants were screened and recruited over six ceptability of the intervention was also elicited in the 

months from 6 family practices in downtown Ot- post-decision aid questionnaire. 

tawa, Canada. Following a routine office visit, the Client characteristics included age, education, 

participants completed a baseline questionnaire menstrual and hormonal history, hysterectomy status 

eliciting their knowledge, personal expectations and and clinical risks for CHD, osteoporosis, and breast 

importance ratings of HRT benefits and risks, current cancer. 

leaning toward taking HRT, and decisional conflict. Knowledge of HRT benefits, risks and side effects 

At the next office visit, before seeing their physician, as described in the decision aid was determined with 

participants completed the decision aid and another a 21-item questionnaire using a true/false/unsure


response format. Expectations of HRT benefits and tic if they were in the appropriate quartile of 

risks were elicited as perceived lifetime probabilities probability (excluding the extremes of 0% or 100%) 

of CHD, hip fracture, and breast cancer with and as described in the decision aid. 

without HRT. Expectations were classified as realis- Values or importance ratings of HRT benefits and 

Fig. 2. Relationship between women’s values and their decisions to take HRT.


risks were assessed: (1) using a scale anchored by 0 decisional conflict scores were found, we planned 

(not at all important to me) and 10 (extremely post hoc analysis of the subscales. To improve the 

important to me); and from the values clarification clinical interpretation of changes in scores of the 

exercise (Fig. 2) in which women shaded a portion expectations and decisional conflict measures, we 

of each benefit and risk box on the weigh scale to described each item in the scale. For each item in the 

indicate how important it was to them (no shading 5 decisional conflict scale, we described the percentage 

not at all important to me; completely shaded 5 of respondents whose score fell within the norm of 

extremely important to me). Values were quantified groups who make decisions (2.0 or less 5 

as the proportion of the height of the box that was agreement/strong agreement with positively worded 

shaded; the measurements were stable on retest items or disagreement/strong disagreement with 

(Pearson r 5 0.70–0.89) and were 95% accurate in negatively worded items). 

discriminating between those who accepted or de- The sample size of 94 participants was selected to 

clined HRT [5]. Value congruence with the decision detect an effect size of at least 0.40 on the DCS with 

was calculated as: the multiple correlation between Type I error of 0.05 and Type II error of 0.20. This 

women’s values and their decision; and the accuracy effect size was judged clinically important because 

of the values in discriminating between those who effect sizes observed between those who make and 

made different decisions. delay decisions have ranged between 0.43 and 0.82 

Decisional conflict or uncertainty was measured [16,25]. 

with a Decisional Conflict Scale (DCS) which 

elicits: uncertainty about choosing among alterna- 3.5. Limitations 

tives; modifiable factors contributing to uncertainty 

such as feeling uninformed, unclear about values and The lack of a control group precluded controlling 

unsupported in decision making; and perceived for repeated measurement and co-interventions. Reeffective 

decision making. The scale has satisfactory sults are generalizable to women with comparable 

reliability and discriminates between those who characteristics including an interest in HRT and 

make and delay decisions [16,25]. willingness to participate in a study. We measured 

Two items in the DCS were also used to elicit only a subset of variables in the DSF; the impact on 

perceived pressure and support from others. Accep- the remaining variables especially decision imtability 

of the decision aid was assessed in terms of: plementation, long-term persistence, and satisfaction 

(1) comprehensibility of each component of the with the decision cannot be ascertained. The interdecision 

aid on a 100 mm visual analogue scale vention did not include follow-up with a practitioner; 

anchored by ‘poor’ to ‘excellent’; and (2) the length, therefore, some participants may have only been 

pace, amount of information, and balance using making a hypothetical decision. 

structured response categories. Decisions were assessed: 

(1) as a ‘leaning’ toward taking HRT on a 

15-point scale anchored by ‘yes hormones’ and ‘no 4. Results 

hormones’ with ‘unsure’ at the mid-point; and (2) as 

a choice (yes, no, unsure). The test–retest Pearson r Demographic and clinical characteristics (summacoefficients 

for each approach were 0.95 and 0.91, rized in Table 2) show that participants were approxrespectively 

[5]. imately equally distributed in terms of their age 

group, current use of HRT, and hysterectomy status. 

3.4. Analysis plan and sample size The majority of participants: had at least some post 

secondary education; preferred to share decision 

After describing the characteristics of our sample making with their practitioner; had at least one risk 

and their decision participation preferences, we factor for CHD; and did not report having low bone 

evaluated the expected changes in the following DSF density or a first degree relative with breast cancer. 

variables using paired t-tests: decisional conflict, The characteristics of the sample were comparable to 

knowledge; and, expectations. If changes in the total regional census and survey data except for propor-


Table 2 

Demographic and clinical characteristics of the participants 

Variable Study participants n 5 94 

a 

Regional data 

% (95% Confidence Interval) % (95% Confidence Interval) 

Age 

50–55 51 (41,61) 50 

56–60 

Highest education level 

49 (41,61) 50 

, High school diploma 20 (13,29) 25 

High school diploma 17 (10,26) 18 

Some post-secondary 32 (23,41) 40 

University degree 

HRT use 

31 (22,41) 17 

Current use 47 (37,60) 35 (29,41) 

Previous use 16 (10,24) 15 (11,20) 

Never use 

HRT decision participation preferences 

37 (28,47) 50 (44,56) 

Woman decides after opinion from practitioner 21 

Shared 63 

Practitioner decides 5 

Unsure 11 

Hysterectomy 

CHD (Coronary Heart Disease) risk factors 

46 

Early family history 39 

Hypertension 25 

Smokers 17 

High cholesterol 14 

Diabetes 11 

At least 1 risk factor 54 

Low bone density 7 

Mother or sister has breast cancer 14 

a Education data is from the regional census. Clinical data is from regional surveys. 

tion with university degrees, which was higher in the using the decision aid are summarized in Table 4. 

study sample. There were statistically significant improvements in 

Changes in Decisional Conflict after using the knowledge ( p 5 0.001) with respondents having 

decision aid are summarized in Table 3. There was a approximately half of the test items correct before 

statistically significant decline in total decisional the decision aid and three quarters correct after the 

conflict scores ( p 5 0.001). When each subscale was decision aid. Expectation scores also improved ( p 5 

examined, the 95% confidence limits of the differ- 0.001) with respondents having approximately a 

ences between group means had no overlap with zero third of their expectations realistic before the decifor 

the subscales of feeling uncertain, uninformed, sion aid and slightly over half after the decision aid. 

unclear about values, and unsupported in decision There were improvements in all expectations, most 

making. There was overlap with zero for the sub- notably in women’s expectations of outcomes with 

scale of perceiving one has made an ineffective HRT (32% to 46%). When unrealistic expectations 

decision. When individual scale items were ex- were classified as high or low for each outcome, 

amined, there were improvements in all but one scale (data not shown), we found that participants with 

item, with improvements ranging from 2% to 36%. unrealistic expectations of outcomes without any 

Changes in Knowledge and Expectations after HRT consistently underestimated their risk of CHD


Table 3 

Post-decision aid changes in decisional conflict (n 5 94) 

Before aid After aid 

Mean (S.D.) Mean (S.D.) t statistic p value 

a 

(1) Total DCS score 2.5 (0.7) 2.2 (0.5) 3.9 0.001 

(2) Subscore Mean (S.D.) Mean (S.D.) Difference 95% CL 

(a) Uncertainty 2.9 (1.2) 2.5 (1.1) 0.1 (0.5,0.1) 

(b) Uninformed 2.5 (1.0) 1.9 (0.6) 0.2 (0.5, 0.8) 

(c) Unclear values 2.6 (0.8) 2.2 (0.6) 0.3 (0.6, 0.2) 

(d) Unsupported 2.8 (0.7) 2.6 (0.7) 0.2 (0.4, 0.07) 

(e) Ineffective choice 2.2 (0.6) 2.1 (0.6) 0.2 (0.3,-0.05) 

b 

(3) Percentage expressing no problems with each DCS item (score 2 or less ) 

% % Difference 

(a) 

55 1E2asy choice 43 

Sure what to do 43 68 25 

Clear best choice 

(b) 

57 65 8 

89 1K8 now alternatives 71 

Know HRT benefits 54 85 31 

Know HRT risks 

(c) 

47 83 36 

Aware importance of ben- 

89 1efi6ts 73 

Aware importance of risks 72 92 20 

Sure which more important 

(d) 

30 49 19 

Feel no pressure from 

83 o0thers 83 

Have enough support 48 50 2 

Have enough advice 

(e) 

13 34 21 

78 1I2nformed choice 66 

Reflects values 83 87 4 

Will stick with 68 70 2 

Satisfied with 74 78 4 

a 

DCS scores are calculated by summing each item (ranging from 1 to 5) and dividing by the number of items. Scores theoretically range 

from 1 (low decisional conflict) to 5 (high decisional conflict). According to the scale norms, groups who delay choices have average 

decisional conflict scores above 2.5; those who make choices have average scores of 2 or less. 

b 

To score 2 or less on one single item, a respondent agrees or strongly agrees with a positively worded item or disagrees/strongly disagrees 

with a negatively worded item. 

S.D. 5 standard deviation. 

and overestimated their risk of breast cancer. Virtual- importance ratings, the multiple correlation coeffily 

all of the women’s unrealistic expectations with cients were 0.40 before the decision aid and 0.56 

HRT were in the direction of overestimating the after the decision aid. When we used discriminant 

positive effects on CHD and osteoporosis and also function analysis to examine congruence between 

overestimating the negative effect on breast cancer. decisions after using the aid and importance ratings 

When change in value congruence with the deci- from the weigh scale in the decision aid, women’s 

sion was assessed by examining the multiple correla- values were 84% accurate in discriminating between 

tion coefficients between leaning toward HRT and choices. As shown in Fig. 2, those choosing HRT


Table 4 

Post-decision aid changes in knowledge and realistic expectations (n 5 94) 

Before aid After aid 

a 

(1) Knowledge score Mean (S.D.) Mean (S.D.) Mean diff. (S.D.) p value 

54 (19) 75 (21) 21 (20) 0.001 

b 

(2) Realistic expectations score Mean (S.D.) Mean (S.D.) Mean diff. (S.D.) p value 

32 (19) 55 (28) 23 (22) 0.001 

(3) Percentage realistic expectations % % Difference 

CHD without HRT 29% 39% 10% 

Hip fracture without HRT 34% 44% 10% 

Breast cancer without HRT 41% 51% 10% 

CHD with HRT 22% 57% 35% 

Hip fracture with HRT 14% 57% 46% 

Breast cancer with HRT 43% 75% 32% 

a Knowledge score calculated as the percentage items correct. 

b Realistic defined as a response within the correct quartile on a probability scale ranging from 0% to 100%, excluding the extremes of 100% 

and 0%. Total score calculated as the percentage of expectations measured that were realistic. 

S.D. 5 standard deviation. 

Table 5 

Change in women’s predisposition to take HRT after exposure to a decision aid (n 5 94) 

Before decision aid After decision aid 

Leaning ‘Yes’ Unsure Leaning ‘No’ 

(n 5 52) (n 5 19) (n 5 23) 

Leaning ‘Yes’ (n 5 47) 44 3 0 

Unsure (n 5 28) 7 15 6 

Leaning ‘No’ (n 5 19) 1 1 17 

placed more importance on the benefits compared to 5. Discussion 

the risks; those declining HRT placed more importance 

on the risks. For those who were unsure, the This before/after study demonstrated that the 

importance they placed on the benefits was compar- decision aid performed according to the predictions 

able to those placed on the risks. Moreover, the of the DSF: reducing uncertainty, increasing knowlbenefit 

side of the scale was similar to those choos- edge, creating realistic expectations, clarifying valing 

HRT; on the risk side, it was similar to those ues, and supporting decision making. It is promising 

declining HRT. that over half of the women exposed to a decision 

Changes in the participants’ predisposition to aid had good general knowledge and realistic extaking 

HRT are presented in Table 5. There was little pectations, and felt they had enough advice to make 

change in the groups whose baseline predispositions a decision. Considering the large numbers of women 

were strongly polarized either toward choosing or who will reach menopausal age over the next decade, 

toward declining HRT. Most of the change took the self-administered decision aid has the potential to 

place in the group who were unsure at baseline, with streamline follow-up counseling with their practitionroughly 

equal numbers of the unsure group choosing ers. It provides the clinician with a summary of the 

to accept or decline HRT after using the decision aid. woman’s benefit/risk profile, values, questions and


predispositions, and may facilitate triaging according practitioners for shared decision making, the decision 

to the type and level of counseling required. aid’s impact on the client–practitioner interaction; 

One of the clear benefits of decision aids is to and long-term efficacy and efficiency. Are decision 

create more realistic expectations of benefits and aids superior to usual approaches in primary care? 

risks by providing detailed probabilistic information What else is needed besides the women’s decision 

according to the woman’s clinical risk profile. With- aid to prepare practitioners for shared decision 

out this information, women underestimate their risk making? What are the effects of the decision aid 

of heart disease, overestimate their risk of breast after women discuss HRT with their practitioners at 

cancer, and overestimate the potential benefits and follow-up visits? Does the aid streamline the process, 

risks from HRT. It remains to be seen if the re- improve women’s and practitioners’ satisfaction with 

alignment of expectations will have positive effects their interaction, reduce remaining decisional conon 

outcomes such as fear, regret, and decision flict, and improve satisfaction with the choice that is 

persistence. eventually made? What are the effects of the deci- 

The improved clarity of values from using the sion aid on long-term persistence with the decision, 

decision aid may have been due to the weigh scale distress from HRT side effects, and post-decisional 

exercise. By leading women through a series of regret? Such questions are currently being evaluated 

different examples of how other women have judged in our randomized controlled trial which includes 

the personal importance of the benefits and risks, preparatory materials for practitioners as well as 

they learned how values contribute to a decision and women, analysis of client–practitioner interactions, 

were prepared to perform the exercise for them- and longer-term follow-up. 

selves. A second explanation is that respondents In conclusion, our decision aid prepared women 

were better able to form an opinion about the value for decision making about HRT. By individualizing 

of an outcome [15] because of the detailed descrip- the decision according to their clinical risk profiles 

tions of how CHD, osteoporosis, and breast cancer and values, women had less uncertainty, better 

affects women’s lives. knowledge, more realistic expectations, clearer val- 

Although the decision aid had a favourable impact ues, and felt more supported in their decision. Future 

on women’s comfort with the process used to arrive evaluations are required to examine their effects 

at their choice, it had little impact on their decision relative to usual care and on practitioner–client 

per se. However, these results were confounded by 

two factors: (1) women’s previous experience with 

decision making about HRT, which may have en- 

interactions and long-term behaviour. 

trenched their views; and (2) the rather hypothetical 

nature of the decision making which did not involve 

Acknowledgements 

planned follow-up with their physicians. Future 

evaluations should focus on women who are actually 

considering the issue for the first time with their 

This project was supported by the Institute of 

Clinical Evaluative Sciences in Ontario, Toronto, 

Ontario, Canada and the Medical Research Council 

practitioners and changes should be monitored after 

of Canada. 

reviewing the decision aid and after counseling by 

their practitioners. 

The lack of difference in the DCS effective 

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