Comprehensibility of Fact Sheets Addressing Benefits and Risks of Preventive Interventions: A Cross-Sectional Evaluation Study

Abstract

Background:

Preventive tests and procedures (PTPs) help to reduce disease burden. However, patient expectations often differ from current guidelines, resulting in overuse or underuse of PTPs. Shared decision making can bridge this gap but requires clear, evidence-based information. This study aimed to develop and conduct an initial evaluation of prototype fact sheets designed to support informed decisions about PTPs.

Methods:

We selected 11 PTPs based on their potential for over- or underuse. For each, we developed a fact sheet following guideline recommendations. These summarised key benefits, risks and relevance using verbal, numerical and graphical formats. User experience and comprehensibility were assessed through a survey among a university population. Participants rated comprehensibility, content and design on a 5-point scale. Approval was defined as the proportion of ‘very good’ or ‘rather good’ ratings. Participants giving poor ratings were invited to provide free-text comments. Subgroup analyses were performed by age and educational level.

Results:

A total of 2,082 individuals answered all relevant questions to fact sheets. The median fact sheet approval score was 77% (interquartile range: 55%, 91%). Six of the 11 fact sheets received an approval of greater than 80% for comprehensibility in general. Lower approval was reported for risk descriptions, usefulness in doctor–patient conversations and visuals. Cancer screening sheets scored the lowest. Subgroup analyses showed lower approval in younger age groups and among individuals with higher levels of education.

Conclusions:

Initial user testing of the fact sheets showed generally positive ratings regarding comprehensibility and user experience. However, the presentation of specific risks and the use of visuals needed to be adapted, especially for cancer-related topics. The findings highlighted the importance of tailoring informational materials to effectively support shared decision making.

Keywords

prevention shared decision making risk communication formats decision aids evidence-based medicine primary care

Highlights

Evidence-based fact sheets can support informed patient decisions about preventive tests and procedures.

Communicating the risks and benefits remains a challenge, particularly in the context of cancer screenings.

People with lower education levels found the materials easier to understand than highly educated participants did.

These findings provide guidance for further refinement; additional evaluation in intended patient populations is required before clinical implementation.

Introduction

Prevention is considered a fundamental aspect of modern health care, contributing to improved public health outcomes and to reduced long-term health care costs.¹ In Switzerland, a wide range of preventive tests and procedures (PTPs) are offered, including cancer screening tests (such as mammography or colorectal cancer screening), cardiovascular risk assessments and behavioural counselling interventions (eg, smoking cessation support). While this variety may be beneficial for personalised care, it also presents challenges: patients and physicians must navigate through complex information to determine which preventive measures are truly beneficial. Although evidence-based guidelines on PTPs provide physicians with structured recommendations, patient-oriented information materials are often inconsistent in quality and may lack clarity, accessibility or credibility.² Patients’ expectations, defined as population-level perceptions regarding the usefulness of or demand for preventive interventions, often differ from the guidelines set by clinicians, influencing health care decisions that may diverge from current best practices.³

This misalignment is particularly relevant in the context of shared decision making (SDM), which is defined as a collaborative process in which patients and physicians work together to make informed choices based on clinical evidence and personal values.^4,5 SDM is fundamental across all areas of health care but presents distinct challenges in preventive care⁶ because interventions are offered to individuals without symptoms. In such circumstances, balancing potential benefits and harms is more complex as it is often preference sensitive, with decisions influenced by both clinical factors and patient values. However, many patients tend to overestimate the benefits of PTPs⁷ while underestimating their potential harms,⁸ often due to optimistic portrayals in the media⁹ but also due to sparse information (ie, lack of potential harms) and not-evidence-based services of checkup providers,¹⁰ limited health literacy,¹¹ or a strong belief in the power of medical technology.³ These perceptions can lead to the overuse of certain interventions, such as cancer screenings in low-risk populations, while evidence-based, guideline recommended (high-value) PTPs may be underused simply because their importance is not well understood.³

The consequences of these misconceptions are substantial. In this context, low-value interventions refer to preventive measures for which the potential harms outweigh the expected benefits or whose use exceeds evidence-based guideline recommendations. The overuse of such interventions¹² has been shown to result in unnecessary testing, overdiagnosis and psychological distress,¹³ among other adverse consequences. Conversely, the underuse of interventions can potentially lead to delays in diagnosis or the progression of preventable conditions.³ At a systemic level, both patterns contribute to inefficiencies and the waste of resources, resulting in rising health care costs.^13,14 Consequently, improving the quality of patient information is a key strategy for reducing the inappropriate use of PTPs and aligning public expectations with medical evidence.

To address this discrepancy, there is an increasing need for concise, reliable and user-friendly materials that support informed decision making. Such materials should communicate benefits and harms in a balanced and transparent manner and facilitate dialogue between patients and health care providers. While evidence-based formats such as fact boxes exist for selected preventive topics,¹⁵ structured and practice-oriented materials are not consistently available across a broader range of PTPs. This study represents an initial step within an iterative development process and focuses on early-stage user evaluation rather than definitive implementation testing. We aimed to develop a standardised set of fact sheets covering multiple PTPs, combining verbal, numerical and visual formats within a unified framework designed for integration into routine primary care workflows. We further sought to systematically evaluate their perceived clarity, acceptability and user experience.

Methods

Fact Sheet Development

Selection of topics

The topics selected for the fact sheets were chosen based on the current evidence related to Swiss residents’ expectations regarding checkup examinations.³ Following a thorough analysis, out of 32 initially considered PTPs, 11 topics were identified as being prone to overuse or underuse (Supplemental Table 1). For the purposes of this project, underuse was defined as low public expectation (less than 50%, according to Diaz Hernandez et al³) of preventive services that are strongly or moderately recommended by the Swiss EviPrev (Evidence-Based Preventive Medicine) program¹⁶ and/or the United States Preventive Services Task Force (USPSTF).¹⁷ Overuse was defined as high public expectation (≥50%) of services that are not recommended (USPSTF grade D) or for which the evidence is insufficient or conflicting (USPSTF grade I).

In selecting topics, we considered whether detailed individual-level information (eg, health history) would be required to determine eligibility for a given PTP. Interventions necessitating extensive prescreening, sensitive personal information or complex clinical background knowledge were excluded to maintain feasibility, limit questionnaire length and enhance participant adherence. Accordingly, topics such as alcohol consumption or sexual behaviour were not included. The final topics for the development of fact sheets were categorised based on potential underuse and overuse. Potential underuse included counselling for tobacco smoking, counselling for physical activity, screening for hypertension, screening for depression and screening for abdominal aortic aneurysm. Potential overuse included screening for breast cancer, screening for prostate cancer, screening for lung cancer (low-dose computed tomography), resting electrocardiography, lung radiography (chest X-ray) and unspecific laboratory analyses.

All fact sheets, including both the initial and the revised final versions, are provided in the Supplementary Material (Supplemental Figures 1–32).

Selection of information presentation formats

A literature search was conducted to identify existing fact sheets and assess their applicability to our national context. The search was performed in PubMed and complemented by a structured internet search to capture a broader range of formats. Rather than extracting specific content, the identified materials served primarily as inspiration for graphical design and modes of information presentation. Current recommendations were reviewed from national and international sources, such as EviPrev,¹⁶ the USPSTF,¹⁷ Choosing Wisely,¹⁸ and the Canadian Task Force on Preventive Health Care.¹⁹ The development of the fact sheets was informed by established principles of risk communication and evidence-based patient information.^20–22 We aimed to present benefits and harms in a balanced way, use absolute risks where possible, avoid relative risks and apply clear numerical and visual formats to improve transparency and comparability. These principles guided the structure and content of the fact sheets while allowing adaptation to a practice-oriented format.

Fact sheets were developed using a standardised template combining verbal, numeric and visual information. Each included a target-audience header, a key-message title, background on the condition and PTP and a graphic on benefits and risks. A summary reinforced key points, footnotes clarified terms and references supported credibility. This structure was applied consistently across all sheets.

Fact Sheet Evaluation Procedure

An open, cross-sectional online survey was conducted in German using REDCap study software (version 15.2.1).^23,24 The full survey instrument, including all items and response options, is provided in Supplemental Table 2. The survey was disseminated via a single, university-wide e-mail to students and staff at the University of Zurich, as this method of communication was deemed to be the most accessible. The university-based sampling strategy was expected to yield a younger, more highly educated and potentially more health-literate sample than typical primary care populations. It was chosen to allow rapid feedback within an iterative development process and to obtain input from a population expected to critically appraise content and presentation. This early evaluation was not intended to provide population-representative estimates but to identify areas for refinement prior to testing in primary care settings. Participation was incentivised through a lottery for shopping vouchers and took place from February 18, 2025, to March 5, 2025. No reminder e-mails were sent. Informed consent for the collection and analysis of anonymised data was obtained via a checkbox on the first page.

Fact sheets were assigned based on age, sex and smoking status, using randomisation where possible, with each participant receiving 2 sheets. Smokers received a smoking-related sheet: those >40 y of age received a sex-specific screening sheet plus 1 random topic; nonsmokers <40 y received 2 random topics (excluding smoking and sex-specific screenings). This ensured relevance without overload (see Supplementary Material, Figure 33). Ratings of the fact sheets were obtained using 5-point Likert scales that followed an identical response structure but differed slightly in wording according to the specific evaluation context (eg, ranging from very good to very bad or very clear to very unclear). Responses marked ‘no answer’ were treated as missing and excluded from the Likert scale analyses. Low ratings triggered open-ended feedback. Participants also reported native language and education.

Key Dimensions of the Evaluation

The evaluation of the user experience with the fact sheets was based on Peter Morville’s User Experience Honeycomb,²⁵ adapted by Rosenbaum²⁶ and Busert et al.²⁷ The key dimensions assessed were comprehensibility, communication of benefits and risks, design and other evaluations such as preferences regarding distribution and graphic presentation.

Comprehensibility

Comprehensibility was defined as the ease with which the material could be understood.²⁸ Participants were asked to evaluate the clarity of the general text and of specific sections, including headers, titles, text segments, figures and footnotes.

Benefit and risk communication

Participants were asked to assess their level of understanding of the information to determine whether they felt adequately equipped to make an informed personal decision regarding a PTP. For fact sheets presenting both benefits and risks, the clarity of each aspect was assessed, including whether the importance of weighing them up was conveyed. Where only benefits or risks were presented, the clarity of the presented information was still rated, and participants also indicated how useful they thought the fact sheet would be in discussions with a physician.

Design

The design assessment covered 2 main areas: layout and formatting. The former involved evaluating elements such as the balance of text and graphics, visual hierarchy and colour utilisation. The latter focused on aspects including font size, readability and typography.

Additional evaluations for future implementation

Two further aspects were assessed to help plan the future distribution of the fact sheets: 1) preferred distribution channels: participants were invited to select multiple preferred settings for receiving the fact sheets (eg, in the waiting room of a doctor’s office, from the physician in person, on the internet). Open-text responses invited further suggestions. 2) Graphic preferences regarding icon arrays used for visualizing risks in screening for breast, prostate and lung cancer and in lung radiography fact sheets. These arrays represent an at-risk population and display both the predicted number of events and nonevents.²⁹ In general, participants evaluated 2 fact sheets assigned according to the allocation procedure described above. For selected screening topics, participants were additionally shown 2 alternative versions of the same fact sheet that differed only in the icon array denominator (100 vs 1,000 reference persons). They were asked to compare the 2 versions and indicate which visual format they perceived as more effective.

Due to the specific context of each fact sheet, slight variations in the phrasing of the questions were used in the survey. Text-based readability was assessed using the Flesch Reading Ease Score for the English translations and the Wiener Sachtext–Formel for the German versions.

Approval Metrics

We defined 3 types of approval outcome based on the 5-point Likert scale items included in the survey: 1) Item approval, defined as the percentage of participants who gave a positive evaluation of an item (ie, when their response fell into the 2 most favorable rating categories, such as ‘very understandable’ or ‘rather understandable’, ‘very useful’ or ‘rather useful’, and analogous top 2 categories depending on the item wording). 2) Fact sheet approval score, defined as a measure of the overall positive evaluation of each fact sheet, calculated as the percentage of all assessed items on that fact sheet that received a response within the 2 most favorable rating categories. 3) Comprehensibility approval score, defined as the average rating of the item ‘comprehensibility in general’ across all fact sheets. This score provided a general measure of perceived comprehensibility, independent of the content of individual fact sheets. An average comprehensibility approval score >80% was considered as high.

Data Analysis

Statistical analyses were conducted using R (version 4.1).³⁰ The analyses were carried out at the level of the individual fact sheet evaluations. Any fact sheet that was fully evaluated, according to the key dimensions, was included in the analysis.

Descriptive analyses were performed for each fact sheet evaluation. The basic characteristics of the participants were also reported. The results were presented as numbers and percentages, n (%), for categorical or binary variables and as means (standard deviations) or medians (interquartile ranges; IQRs), as appropriate, for continuous variables. Available case analysis was performed, and the number of nonmissing responses was reported for other participants’ characteristics that were not required for the allocation of the fact sheets or for their evaluation, such as native language and educational background. For group comparisons, the chi-squared test was used for categorical or binary variables, and t test or Wilcoxon rank-sum test was used for continuous variables, as appropriate. A P value of ≤0.05 was used to determine statistical significance. The absolute value of the effect size r was reported and classified as small (r ≥ 0.1 and r < 0.3), medium (r ≥ 0.3 and r < 0.5) or large (≥0.5), following Cohen’s thresholds.³¹

Open-text feedback was systematically reviewed by 1 team member (B.H.), who grouped responses thematically and identified recurring patterns. A descriptive summary of the most frequent and/or substantively relevant themes was prepared and subsequently discussed within the study team. No formal qualitative content analysis with predefined coding schemes or interrater reliability assessment was conducted.³² This pragmatic approach shares characteristics with rapid qualitative analysis methods that aim to efficiently identify actionable themes in applied health research and iterative intervention development. Adaptations to the materials were considered when comments 1) recurred across participants, 2) indicated potential misunderstandings or ambiguities in the presentation of benefits and harms or 3) identified structural or visual elements with clear implications for comprehensibility or decision support.

Subgroup Analyses

Group comparisons were performed by age (<40 vs ≥40 y), by education level (low: compulsory school or vocational education vs high: all higher educational levels) and by native language (German vs other). The age cutoff of 40 y was chosen for clinical contextual reasons, as most cancer screenings in Switzerland are generally recommended from age 50 y onward, making this threshold a pragmatic distinction between lower-risk younger adults and those approaching screening-relevant age. These analyses aimed to identify differences in user experience that are relevant to the target audience of general practice. Comparisons were conducted per fact sheet and across all materials.

Adaptation of Fact Sheets

After evaluation of the survey, the fact sheets were adapted based on participants’ feedback. Approval of ≥80% was considered satisfactory and not requiring further improvement. Any fact sheet and/or individual item with an approval of less than 80% was discussed within the research group, taking into account the specific free-text responses. Decisions regarding adaptation were made on a case-by-case basis. Further analysis and evaluation were not carried out on the postadaptation fact sheets.

Ethics and Reporting

The CHERRIES checklist for internet-based surveys³³ and the STROBE checklist for reporting cross-sectional studies³⁴ are provided in Supplementary Table 3 and 4, respectively.

Results

Survey Data and Participants

The online survey was distributed to 36,143 potential participants. Of these, 2,735 opened the survey and 2,618 answered at least 1 question (participation rate: 7.2%). The survey was completed by 1,951 participants (response rate: 5.4%), answering all questions, including those not relevant to the evaluation of the fact sheet. A total of 2,082 participants answered all questions relative to the fact sheet evaluation: 1,963 answered all the questions on the 2 fact sheets, and 119 participants answered all the questions on 1 fact sheet, for a total of 4,045 fact sheet evaluations.

Most participants were younger than 40 y (73.0%) and female (71.3%). Furthermore, 61.3% of the participants had obtained a university degree. Detailed demographic data are presented in Table 1.

Table 1.

Basic Characteristics of Survey Participants (N = 2,082).

Demographics	n (%)
Age, y (median [IQR])	28.00 [23.00, 41.00]
<40	1,520 (73.0)
≥40	562 (27.0)
Sex
Male	598 (28.7)
Female	1,484 (71.3)
Smoking status
Active smoker	178 (8.5)
Nonsmoker	1,904 (91.5)
Highest educational qualification^a
Compulsory school	7 (0.4)
Vocational education	96 (4.9)
Maturity certificate, professional/specialised maturity certificate	547 (28.0)
Higher specialised and vocational education	106 (5.4)
University, bachelor’s degree	413 (21.2)
University, master’s degree	481 (24.7)
Doctorate/professorship	301 (15.4)
Native language^a
German	1,678 (86.0)
Other language	273 (14.0)

IQR, interquartile range.

Note. Unless otherwise stated, figures are absolute and percentages (in brackets).

Missing n = 131.

Fact Sheet Evaluation

The median fact sheet approval score was 77% (IQR [55%, 91%]). Across the 3 assessed domains, the highest approval levels were observed for items related to comprehensibility. Detailed analysis of approval for each fact sheet is reported in Table 2.

Table 2.

Approval Analysis of Fact Sheets Completed in Full.

Fact Sheets	Screening for Breast Cancer	Screening for Prostate Cancer	Screening for Lung Cancer (Low-Dose CT Scan)	Screening for Abdominal Aortic Aneurysm	Counselling for Tobacco Smoking	Counselling for Physical Activity	Screening for Depression	Screening for Hypertension	Resting Electrocardiography (ECG)	Lung Radiography (X-Ray)	Unspecific Laboratory Analysis
Analysed Fact Sheets, n = 4,045	349	161	125	56	156	624	512	510	534	512	506
Comprehensibility
In general^a	85%	63%	60%	79%	90%	82%	95%	94%	77%	76%	86%
Header	94%	91%	77%	86%	90%	88%	90%	90%	91%	92%	89%
Title	94%	87%	70%	89%	86%	75%	88%	88%	92%	90%	85%
First information text	91%	83%	74%	86%	90%	88%	85%	90%	82%	69%	82%
Figure	69%	30%	38%	68%	79%	58%	72%	75%	60%	63%	70%
Second information text	82%	67%	71%	82%	86%	70%	88%	88%	80%	86%	76%
Footnotes	77%	62%	61%	66%	68%	64%	65%	72%	73%	n.a.	76%
Benefit and risk communication
Clarity that PTP has benefits	65%	49%	65%	88%	83%^b	66%^b	89%^b	86%	n.a.	n.a.	n.a.
Clarity that PTP has no benefits	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	84%	83%	77%
Clarity that PTP has risks	75%	60%	65%	32%	n.a.	n.a.	n.a.	n.a.	n.a.	36%	68%
Clarity of the importance to weigh up benefits and risks	67%	55%	57%	38%	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.
Feeling well informed to make a decision	62%	50%	50%	57%	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.
Usefulness for discussion with physician	n.a.	n.a.	n.a.	n.a.	46%	43%	59%	66%	38%	42%	59%
Design
Layout	47%	36%	46%	64%	55%	52%	47%	64%	62%	50%	63%
Formatting	55%	58%	54%	68%	63%	64%	60%	69%	73%	66%	75%
Factsheet approval score^c	77% [62%, 92%]	62% [38%, 85%	62% [38%, 85%	69% [60% 85%]	82% [64%, 91%]	73% [55%, 91%]	82% [64%, 91%]	82% [73%, 91%]	82% [64%, 91%]	73% [55%, 91%]	82% [64%, 91%]

CT, computed tomography; PTP, preventive tests and procedures.

Note. This table presents the proportion of responses falling into the 2 most favorable rating categories for each item (on a 5-item Likert scale). Blue: approval <80%; yellow: approval ≥80%. Not available (n.a.) was used to denote elements that were not requested for evaluation in the specific fact sheet.

Comprehensibility approval score (average rating across all fact sheets) is 81%.

Survey included the question as to whether it is clear that the PTP is part of a preventive counselling.

Percentage of all items on a fact sheet that received responses in the 2 most favorable rating categories. Numbers reported as median [interquartile range].

Comprehensibility

The general comprehensibility of the fact sheets was satisfactory. The comprehensibility approval score was 81%, and 6 of the 11 fact sheets attained the ≥80% approval threshold on the item comprehensibility in general. The fact sheets on prostate cancer screening and lung cancer screening received the lowest comprehensibility ratings. Headers, titles and main texts were generally well understood, while figures and footnotes showed lower approval (figures: 30%–79%; footnotes: 61%–77%).

Benefit and risk communication

The clarity of the benefits, risks and the importance of weighing both to support informed decision making varied by topic. In the case of cancer screenings, approval for benefit–risk communication was found to be 49% to 75%, compared with 32% to 89% for other topics. Participants often perceived the benefits as ambiguous and the risks as not being explained well enough, as reflected in the free-text feedback:

The benefits are presented, but the risks are not made clear enough. What are the consequences of a false positive result? What are the risks of overdiagnosis? (Male, 63 y old; prostate cancer fact sheet)

It is absolutely not mentioned that someone should weigh up the positives and negatives to make their decision. (Female, 33 y old; lung cancer fact sheet)

Compared with cancer screenings, noncancer screenings and lifestyle counselling received higher ratings for benefit clarity (mostly ≥80%). Ratings for the usefulness of the fact sheet for discussion with a physician were 38% to 66%. Free-text comments indicated a lack of guidance or unclear next steps. One comment, for example, expressed uncertainty about how to start a conversation with a physician about the subject:

There is no call to action. I see the statistic and know that if I check more often, the risk of serious consequences is lower. But what should I do after reading the fact sheet? (Male, 24 y old; hypertension fact sheet)

Design

The evaluation of design elements revealed mixed ratings. Approval for layout ranged from 36% to 64%, while that for formatting (font size, typography) ranged from 54% to 75%. Criticism in open-text feedback focused on text density, small font size and lack of visual hierarchy:

Too much text for an info sheet—no one has time for that. (Male, 25 y old; counselling for physical activity fact sheet)

The graphics take up too much space that could be used for more information. (Female, 24 y old; lung radiography fact sheet)

Additional evaluations

Results on the preferred distribution channels are shown in Table 3. The most common choice was for materials to be made available in the waiting room of a general practice (79%), with counselling centres (eg, national cancer league, 62.7%) and distribution over the internet (58.4%) being the next most popular options. Preferences varied slightly by topic, with specialist settings (eg, gynaecologists for breast cancer, pulmonologists for lung cancer, 48.7%) also commonly selected. In contrast, commercial providers (36.5%) were found to be less favoured, and only a small proportion of participants indicated a preference for other channels (6.4%). The importance of trusted environments, particularly primary care settings, in the dissemination of such materials was emphasised by the participants.

Table 3.

Distribution Preferences.

Preferred Way of Receiving Fact Sheets	n (%); N = 4,045 Fact Sheets Evaluations Completed
In the waiting room of a GP’s office	3,204 (79.0)
At counselling centres (eg, national cancer league)	2,536 (62.7)
On the internet	2,364 (58.4)
From a specialist (eg, gynaecologist)	1,972 (48.7)
Handed out personally by GP	1,652 (40.8)
From commercial providers (eg, commercial check-up centres)	1,477 (36.5)
At the reception desk of a GP’s office	1,309 (32.4)
Other^a	259 (6.4)

GP, general practitioner.

Note. Participants could select multiple answers. Unless otherwise stated, figures are absolute and percentages (in brackets).

Free text. Examples: social media, advertising space, health insurance, hospital.

Preferred visual variants

When comparing icon arrays referencing 100 versus 1,000 individuals, most participants selected the 1,000-person variant. This preference was consistent across all the screening topics that were examined, including lung radiography (67.4%), breast cancer (64.8%), prostate cancer (64.6%) and lung cancer (57.6%). The rationale for this preference was multifaceted, with participants citing that ‘whole numbers are easier to read’ (female, 48 y old; breast cancer screening fact sheet; as the 100-person variant necessitated decimal places, eg, 1.6 vs 16), ‘decimal numbers for a person count are hard to interpret’ (female, 53 y old; breast cancer screening fact sheet), and the 1,000-person variant ‘better illustrates proportions’ (male, 44 y old; lung cancer screening fact sheet) and ‘reflects the rarity of the events’ (female, 43 yold; breast cancer screening fact sheet).

Subgroup Analyses

Results of the subgroup analysis are shown in Figure 1a and b and in Supplemental Table 5.

Figure 1.

Subgroup analysis according to age (a) and education (b).

Fact sheets rated by participants younger than 40 y (n = 2,966, 73.3%) had a median fact sheet approval score of 73%, while those rated by participants aged 40 y or older (n = 1,079) scored higher (median: 82%; P = 0.025, small effect size r = 0.035). However, no significant age-related differences were found for 6 of 9 fact sheets, indicating broad suitability across age groups.

Fact sheets rated by participants with a lower level of education (n = 206, 5%) had a higher median fact sheet approval score, 85%, than those rated by participants with a higher level of education (n = 3,839; median: 73%; P < 0.001, small effect size r = 0.077). A significant difference was identified for 6 of the 11 fact sheets.

No statistically significant differences were observed in fact sheet evaluations when stratified by native language.

Adaptation of Fact Sheets

Fact sheets with approval less than 80% were adapted according to the most important criticism points of participants. Figure 2 illustrates an example fact sheet before and after modifications. An overview of the most common criticisms and the corresponding adjustments can be found in Table 4.

Figure 2.

Comparison of the original (left) and revised (right) versions of a fact sheet.

Table 4.

Evaluation Dimensions, Key Feedback Themes and Implemented Revisions of the Fact Sheets.

Dimension	Criticism Point	Adaptation Made
Comprehensibility	Low comprehensibility of graphics	Revision of all graphics, complete renewal of 4/11 graphics
	Low comprehensibility of footnotes	Improvement of the readability of footnotes by highlighting individual terms in bold
	Unclear next steps after reading	Integration of a bolded call for action: ‘Talk to your doctor for more information’ to facilitate integration into clinical conversations
Benefit and Risk communication	Unclear risks and resulting consequences	Additional clarification of the terms ‘overdiagnosis’ and ‘false positive’ with the note ‘often associated with further examinations and anxiety’
	Lack of awareness of benefits and risks	Naming benefits and risks as such
	Missing call to weigh up the options	Incorporation of a standardised sentence across all relevant topics to explicitly encourage individual reflection: ‘Consider what the benefits and risks mean for you personally and whether or not you would like to make use of (the PTP)’; this was undertaken to support value-sensitive decision making and to make the balancing of potential benefits and harms more tangible
Design	Textual overload	Reduced text density and volume for enhanced readability
Additional	Icon array	Replacement of the visuals with 1,000-person variants

The adaptations focused on 4 main dimensions: comprehensibility, benefit–risk communication, design and additional elements such as icon arrays. Changes included revisions to graphics and footnotes, clarification of benefits and risks, incorporation of standardised prompts to encourage individual reflection, reductions in text volume and updates to visual elements. These adjustments were guided directly by participant feedback to enhance usability, clarity and support for value-sensitive decision making.

The design of the fact sheets was identified as a significant area for improvement. Participants specifically criticised small font sizes, lack of visual hierarchy and dense presentation of information. In response, the adapted fact sheets featured reduced text volume, a clearer structure and typographic improvements. Although only moderate design adaptations were implemented, these changes aimed to reduce perceived information overload and improve navigability.

The Flesch Reading Ease Score for the final English versions ranged from 37 to 56, indicating moderate difficulty, while the Wiener Sachtext–Formel for the German versions categorised the texts as ‘mittelschwer’ (moderately difficult) (Supplemental Table 6). The values for the initial fact sheets prior to revision ranged from 39 to 63. However, these text-based readability scores do not account for the visual elements (eg, icons, graphs) that contribute significantly to the overall comprehensibility of the fact sheets.

Discussion

This study aimed to develop and evaluate evidence-based fact sheets on PTPs to support informed decision making in primary care and represents an initial evaluation of prototype materials. Most of the fact sheets were found to be highly comprehensible by the participants across a range of topics, although notable differences emerged in the presentation of numerical and visual information. Cancer screening topics posed particular challenges, primarily due to the complex nature of benefit–risk evaluations and visualisations requiring probabilistic reasoning.

Fact Sheet Evaluation

Benefit–risk communication was identified as one of the most challenging areas, particularly with regard to cancer screening. Participants often mentioned that the risks were not clearly explained. This finding is consistent with research indicating that patient-facing cancer screening materials often underrepresent risks or adopt a benefit-focused approach because increasing participation is prioritised over providing a balanced view of potential harms.³⁵ A recent study confirms that many people are unfamiliar with the concept of overuse and, even if they are familiar with it, do not associate it with harm but rather with costs.³⁶ While the potential value of increased screening uptake in certain contexts should be acknowledged, it is important to recognise that this may also lead to unrealistic patient expectations and unnecessary procedures, particularly when the actual benefit is minimal.³⁷ In response to these concerns, the adapted fact sheets included an improved explanation of the risks and a standard prompt encouraging personal reflection on the implications of benefits and harms. This formulation reflects best practice in value-sensitive decision aids and is designed to foster deliberation rather than persuasion.³⁸

To promote transparency and avoid misinterpretation, our fact sheets consistently used absolute risks instead of relative risks, which are known to exaggerate perceived benefits.³⁹ As an exception, the adapted fact sheet on smoking cessation showed a relative risk reduction, as survey participants found the absolute risk reduction on the original fact sheet not convincing enough to quit smoking. This approach contrasts with the common practice of presenting benefits as large relative risk reductions and harms as smaller absolute risks in patient-targeted materials.^40–42 This can lead to biased medical decisions.⁴³

Survey responses regarding our fact sheets showed considerable variation and relatively low levels of agreement in the categories ‘clarity of the importance to weigh up benefits and risks’ and ‘feeling well informed to make a decision’. These findings highlight the challenges involved in designing decision aids, particularly the need to balance informational completeness with cognitive accessibility.⁴⁴ Previous research has shown that individuals presented with poorly structured or imbalanced materials, such as emotional anecdotes alongside statistical information, may rely more on anecdotal evidence than statistical reasoning. This can impair the quality of medical decisions.⁴⁵ The effective design of patient materials relies not only on aesthetic clarity but also on cognitive ergonomics. Design elements such as chunking of information, consistent layout patterns and prominent headings are recommended by established design guidelines such as the US Centers for Disease Control and Prevention Clear Communication Index.⁴⁶

Participants expressed a strong preference for fact sheets to be distributed within clinical environments, particularly by general practitioners or in waiting rooms, settings associated with high levels of trust. This preference reflects the central role of primary care in initiating preventive health discussions.⁴⁷ Conversely, commercial providers were met with scepticism, underscoring the importance of source credibility.

Adaptations were made to the fact sheets based on feedback from participants, including changes in the icon array formats, the way to present risks and text phrasing. These adaptations were made to align the materials with the latest best practices in patient-centred communication.

Subgroup Analysis

In contrast to the general Swiss population (median age: 43.9 y for women, 41.8 y for men⁴⁸; tertiary education (defined as higher specialised and vocational education and above⁴⁹): 43.8%⁵⁰), the survey population was younger and better educated. The age-based analysis examined potential generational differences in comprehension and engagement. However, the predominantly academic sample may have been more critical and better able to interpret written and numerical information than the general population. As such, the findings are not directly transferable to more heterogeneous primary care populations. Validation in general practice settings is needed to assess performance in more diverse and clinically relevant groups.

Implications for Practice, Policy and Research

Evidence-based and user-tested fact sheets offer a simple way of supporting informed decision making. Following further evaluation of their effectiveness, the fact sheets are intended to be made accessible to patients and general practitioners to support evidence-based consultations and promote informed decision making in primary care. Integrating these materials into routine clinical workflows, for example, by providing them as printed handouts or digital links during consultations, could frame preventive health discussions and foster patient autonomy. Consistent with existing literature showing that patients prefer health information from trusted sources,⁵¹ our findings support embedding such fact sheets within primary care pathways to enhance their practical uptake and integration into SDM processes.

Future iterations should enhance accessibility and inclusivity by incorporating multilingual and visually adaptive formats and by actively involving underrepresented groups in the design process. Further testing in intended populations is required. The fact sheets will be evaluated in general practice settings to assess usability, comprehension and contextual fit across diverse patient populations. Future studies should complement subjective ratings with objective outcome measures, such as standardised knowledge questions and risk interpretation tasks, to better determine whether the materials improve informed decision making beyond perceived clarity. In addition, research should examine longer-term outcomes, including the quality of decisions and the uptake of screening procedures. Exploring interactive or tailored formats may further strengthen personalised risk communication.

Strengths and Limitations

Key strengths of this study include the subgroup analyses by age and educational levels, which provided nuanced insights into the differential reception of the fact sheets. In addition, the comparison of 2 icon array formats provided targeted evidence on the impact of visual design on user comprehension. Lastly, we presented a combination of risk communication formats to participants rather than a specific single format. This approach is recommended by other researchers⁵² as a ‘best practice’ for risk communication, offering optimal comprehensibility.

This study has several important limitations. First, the evaluation was conducted in a university-based convenience sample that was not representative of the general population, thereby limiting external validity. The findings from the university-based population cannot be directly generalised to general practice populations, particularly older individuals, those with lower health literacy or linguistically diverse groups. The predominantly younger and more highly educated cohort may have influenced perceptions of the materials, and no additional data were collected from nonuniversity or primary care populations. Validation in older, more socioeconomically and linguistically diverse groups remains a necessary next step.

Comprehensibility was assessed subjectively, which reflects user acceptance but not actual understanding, risk literacy or informed decision making. Thus, no conclusions can be drawn regarding objective comprehension. The study cannot determine effects on knowledge or appropriate use of preventive care. Future research should include objective measures of comprehension, such as knowledge-based assessments, to determine whether perceived comprehensibility translates into actual understanding and examine behavioural or decision-related outcomes.

Third, the overall response rate was low, although a large number of participants completed the evaluation. The prevalence of smoking in the sample was lower than in the general population (8.5% vs 23.9%),⁵³ resulting in fewer evaluations of smoking-related fact sheets.

Fourth, readability was assessed using text-based indices, which do not capture the contribution of visual elements and layout to overall comprehensibility and may therefore not fully reflect the accessibility of the multimodal fact sheets.

Finally, the fact sheets were not developed through a formal participatory co-design process involving patients or underrepresented populations. Incorporating user-centred design approaches, particularly with individuals with lower health literacy, will be important to enhance inclusivity and accessibility in future iterations.

Conclusion

Evaluating fact sheets that present a combination of various formats to communicate the risks and benefits of different PTPs demonstrated high overall approval. However, elements like the communication of specific risks and visual elements needed to be adapted, especially in cancer-related topics. The findings of this study highlighted the importance of tailoring informational materials such as fact sheets, focusing on clarity of content and presentation, in order to effectively support SDM. Additional research in intended end-user populations and using objective outcome measures is required before clinical implementation.

Supplemental Material

sj-pdf-1-mpp-10.1177_23814683261462594 – Supplemental material for Comprehensibility of Fact Sheets Addressing Benefits and Risks of Preventive Interventions: A Cross-Sectional Evaluation Study

Supplemental material, sj-pdf-1-mpp-10.1177_23814683261462594 for Comprehensibility of Fact Sheets Addressing Benefits and Risks of Preventive Interventions: A Cross-Sectional Evaluation Study by Bigna Hut, Stefania Di Gangi, Giuseppe Pichierri, Oliver Senn, Stefan Neuner-Jehle and Andreas Plate in MDM Policy & Practice

Footnotes

Acknowledgements

We thank all participants for their participation in the study and for providing valuable feedback.

ORCID iDs

Bigna Hut

Stefania Di Gangi

Giuseppe Pichierri

Andreas Plate

Ethical Considerations

As the survey was fully anonymous, it was not required to be approved under the Federal Act on Research Involving Human Beings. The local ethics committee of the Canton of Zurich waived approval.

Consent to Participate

Participants received study information on the survey’s first page and provided electronic informed consent before proceeding.

Consent for Publication

Participants were informed that anonymised data would be published and gave electronic consent on the survey’s first page.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Data Availability

According to the informed consent, participants were assured that their data would be processed exclusively by the study team and would not be shared with any third parties. In line with this commitment, the datasets generated and analysed in the study cannot be made available to external parties.

Supplemental Material

Supplemental material for this article is available online.

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