Lucia Savador i et al. Risk Percep tion in Heart Transplanted Patients
Life after Heart TransplantationRisk Perception in Patients and Their Medical Team
Lucia Savadori, Lorella Lotto, and Rino RumiatiUniversity of Trento, Italy
Progress in surgical technology and in postoperative therapy has remark-ably increased life expectation after heart transplantation. Nevertheless,patients still show a resistance to resume a normal life after transplanta-tion, for example, to return to work. In this study we assume that aftersurgery patients become risk averse because they achieve a positive frameof reference. Because of this propensity toward risk aversion, they with-hold from engaging in behavior that their physical condition would allowthem in principle. Coherent with this assumption we found that com-
pared to the medical team patients overestimate the degree of risk forroutine activities. The study also showed that the representation of riskby the patients could be captured by a dreadfulness factor and a volun-tariness factor. Patients’ risk judgments were strongly and specificallypredicted by the perceived degree of dreadfulness of the activity and, to alesser extent, by the perceived knowledge of the consequences. Implica-tions for patient-physician communication were explored.
The first heart transplantation was performed at CapeTown, South Africa, in 1967. In the following 15 yearsmany patients underwent surgery, but there was a highrate of mortality, due mostly to rejection of the trans-planted organ. Since 1967 much progress in surgicaltechnologies and in postoperative therapies has beenmade. The more important one was the discovery of cy-closporine, an antirejection drug that remarkably im-proved the therapy and allowed enormous increase inlife expectancy after transplantation. In the 25 yearssince the introduction of this new drug, the survivalrates have been estimated to be 90% postoperatively,81% at one year, and 69% after five years (Kriett & Kaye,1991).
From a psychological point of view, longer life ex-pectancy suggests investigations into the quality of life oftransplant patients. The purpose of psychologists whohave explored this area was to analyze the factors ac-countable for a complete and satisfying postoperativerehabilitation. Research on this issue investigated psy-chophysical parameters, considering the whole range ofthe patient’s activities as well as syncretic judgments onthe degree of well-being, satisfaction, and acceptance ofone’s own life conditions (Kaplan, 1988). For example,one indicator of rehabilitation has been the measure of
the extent to which patients returned to work after sur-gery. Most patients in fact do not feel like returning towork despite their good medical condition. Data from250 transplant patients in the United States showed thatonly 13% of the patients were diagnosed as being in un-satisfactory physical condition, but of the remaining87% that where judged to be in good medical condition,only 45% were employed, while 36% were unemployedand 6% retired (Paris et al., 1992, 1993). In Italy, among143 patients operated on within the NIT (North ItalianTransplant) area who had held a job prior to surgery,only 55 (38%) returned to work, while 88 (62%) did not(Perini & Pappalettera, 1999). In this respect, the Italiansituation is comparable to the one described in theUnited States, given that 72 of the 88 patients who did
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Lucia Savadori received her PhD in social psychology from the Uni-versity of Padua, Italy in 1999. She concluded her Post-Doc at theUniversity of Padova, Italy in 2001. Currently, she is assistant profes-sor at the University of Trento, Italy. Her research interests include riskperception, information exchange in group decision making and rea-soning heuristics.
Correspondence concerning this article should be addressed to LuciaSavadori, Laboratorio di Scienze Cognitive, Via Tartarotti 7, I-38068Rovereto (Trento), Italy (tel. +39 0464 483515, fax +39 0464483514, e-mail [email protected]).
not return to work were judged by the medical team tobe in good physical condition.
Many explanations have been given for this subop-timal rehabilitation, such as the long-lasting diseasephase before transplantation, the patient’s self-percep-tion of being physically unable to conduct a normal life,and the potential loss of health insurance and/or dis-ability income if they returned to work (Paris et al.,1992). However, despite the high degree of risk and un-certainty that accompanies the patients’ life after hearttransplantation, no study has addressed the issue froma decision-making perspective.
In a descriptive approach of judgment and deci-sion making, life after transplantation can be describedin terms of a prospect theory value function (Kahne-man & Tverky, 1979), such as the one depicted in Figure1. According to prospect theory, utility is determinedby the difference between the person’s current stateand the state to which that person had adapted (thereference point). We assume that before transplantation(see Figure 1a) the patient is in a negatively framed con-dition, feeling miserable while experiencing cardiacdisease*. At this time, the difference in value betweenthe state of disease and the state of health is very high,and the patient is therefore very motivated to engage
in a risk-taking activity that gives a chance of restoringthe state of health. The function is steeper in the nega-tive domain meaning that there is a higher utility in thisdomain for every step that moves the current state ofthe patient closer to the reference point. However, aftertransplantation the patient should be happier (see Fig-ure 1b). As a consequence, the difference in value be-tween the actual state of the posttransplanted patientand the state of health should not be appealing. Thepatient should now experience a risk-aversion conditionwhere the motivation for any further gain along thepositive line would not be valuable, whereas the possi-bility of a loss that might re-establish a pathologicalstate should be strongly threatening. Risk aversion isdefined as the tendency to prefer any sure outcome Xover any gamble with an expected value of X. In thisstate the patient should have the main goal of main-taining a stable condition for as long as possible andavoid risk.
Such a picture of the situation should imply that thepatient will experience high-risk activities as tremen-dously high because they threaten the positive statusquo; moreover, the patient will perceive the low- or zero-risk activities as also high because, on the one hand,these activities imply at least some chance of sacrificing
Cardiac disease
Reference point:Health state
Health state
Reference point:Cardiac disease
Transplanted heart
(a)
Figure 1Prospect theory value function and status and reference points before (a) and after (b) surgery.
* The terms “miserable” and “happier” are purposely used to describe the hedonic quality of an experience. Being miserable andbeing happy are, respectively, a negative and a positive value on the good/bad dimension, which describes a person’s state of being“at the highest level of integration” (Kahneman, 1999, p. 4).
one’s status quo (even if only a very small chance),while, on the other hand, they promise little improve-ment in the patient’s well-being (for example, comparedto the improvement given by drugs). A transplanted pa-tient might be well described by the image of a gamblerwho has just won a considerable amount of money andis determined to avoid any, even a small, chance of los-ing money.
In this study we attempt to explain the suboptimalrehabilitation on the assumption that the patientachieves a positive frame of reference after transplanta-tion. Because of this frame of reference, the decision onwhether or not to engage in daily activities should bedetermined by risk aversion. This explanation couldclarify why patients withhold from engaging in behav-ior that their physical conditions would allow them.
To test our assumptions, we put forward two hy-potheses. First, we expect that the patients will manifesta high perception of risk for objectively high-risk activi-ties, such as not taking antirejection drugs or skippingthe routine check-ups. Second, we expect that patientswill also show a high perception of risk for low- or zero-risk activities because they bring a scarce utility given apositive framed condition. Low- or zero-risk activitiescomprise those of daily routine, such as having an emo-
tionally involving discussion, going shopping, driving acar, climbing stairs, and not, lastly, returning to work(see Table 1 for a complete list). We therefore proceededto measure patients’ risk perception for different typesof activities varying in the degree of risk and to check forits accuracy.
In order to measure the accuracy of risk judgmentswe need to contrast patients’ judgments with an objectivemeasure of risk involved in an activity. Such an objectivemeasure of risk is statistically difficult to determine, andeven when a value is estimated, this is still highly sus-ceptible to criticism based on the different perspectivesassumed to compute it.
A risk index associated to an hazardous activity is adifficult value to compute for many reasons. For somehazards extensive statistical data are readily available(e.g., not taking antirejection drugs) and the importanceof this risk factor for rejection is highly visible and com-putable. But for many others the hazardous effects areless readily discernible, and their assessment requirescomplex epidemiological and experimental studies(e.g., smoking or experiencing emotions). For other haz-ards, risk assessment must be based on theoretical analy-ses such as fault trees because they are so new that ex-perts lack experience with them.
Table 1Mean risk judgment by patients and the medical team of each activity on a 0 to 100 scale in the three time phases.
In order to measure the accuracy of patients’ riskjudgments, we therefore chose to compare their judg-ments with those of the medical team that performedtransplantation. We assumed that the judgments of themedical team could be regarded as an “objective mea-sure” (an accurate reference point or baseline) because oftheir expertise in this field. We therefore proceeded totest our hypothesis that patients had a higher perceptionof risk than the medical team.
The Dimensions of Risk Perception
Studies of risk perception using a psychometric paradigmhave had a long tradition since the first study conductedin 1978 by Fischhoff, Slovic, Lichtenstein, Read, andCombs. The authors showed that people make risk judg-ments of hazards by taking into account several factorsother than the fatality rates, such as the severity of theconsequences following an accident caused by the haz-ard (severity of consequences), the emotional reaction tothe hazard (dreadfulness), the number of people af-fected at the same time by a potential accident (cata-strophic character), and the potential for controlling thenegative consequences (controllability).
The psychometric paradigm (Fischoff et al., 1978) usespsychophysical scaling and multivariate analysis tech-niques to produce quantitative representations or cogni-tive maps of risks perception. Studies applying this para-digm found that a similar two-factor structure accountsfor the whole range of risk dimensions, regardless of thedifferences in culture, expertise—and regardless of thetype of hazards. The first factor, Dread Risk, usually in-cludes the severity of the consequences, the dreadful-ness, the catastrophic potential, and the lack of personalcontrol dimensions. The second factor, Unknown Risk,describes the dimensions of risk unknown, new, not vol-untarily assumed, and with effects delayed in time.Some studies revealed the presence of a third factor inaddition to the two already mentioned, labeled Numberof People Exposed (Slovic et al., 1980; Goszczynska,Tyszka, & Slovic, 1991; Mullet, Duquesnoy, Raiff, Fa-hrasmane et al., 1993; Savadori et al., 1998).
Besides providing a description of the factors onwhich people base their judgments of hazards, thesestudies were useful for predicting which factors weredeterminant in explaining risk judgments of these haz-ards. In most studies the Dread Risk factor best predictedthe risk magnitude judgments. A hazard is thereforejudged as being riskier when it is dreadful, when its con-sequences are severe, when it is catastrophic, and whenwe feel we have no control over it.
If this representation also generalizes to transplantpatients, then we should find that their risk judgmentsof each activity should be based especially on howdreadful they judge that activity. A further aim of thepresent study was therefore to investigate the risk di-mensions that best predicted patients’ risk magnitudejudgments, and how these dimensions are grouped to-gether in factors of risk perception.
Time From Transplantation and Objective Risk
One factor that needs to be considered is the role playedby the time that passes from the moment of the surgeryto the risk posed by several activities. A transplantedpatient moves through what we can call a series of timephases beginning from the moment he or she is dismissedfrom the operating room. Shortly after surgery the riskof infection from certain activities, such as a lack in per-sonal hygiene or being in crowded places, is very high.As more time passes after surgery, the risk from theseactivities decreases. Other behavior, however, such asnot taking the antirejection drugs or smoking, remainvery risky throughout the rest of the patient’s life aftersurgery. The magnitude of the objective risk of some ac-tivities therefore changes over time, whereas for othersit remains the same.
The medical team was therefore questioned aboutthe critical time phases for a patient. Three time phaseswere determined: from 0 to 6 months after transplanta-tion (phase 1), from 7 to 24 months after transplantation(phase 2), more than 24 months after transplantation(phase 3). To control for this variation in time we askedthe medical team for three judgments of risk, one foreach time phase. Patients were correspondingly dividedinto three groups according to the date of their trans-plantation. Since we controlled for the “time from trans-plantation” factor to ensure the reliability of the results,we also checked whether time had any interaction withthe overestimation of risks by patients. No precise hy-pothesis was nevertheless put forward for this interac-tion.
Method
Design and Participants
Sixty patients and 12 members of the medical team at theHeart Surgery Center (HSC) of the University of Padua(Centro di Cardiochirurgia dell’Università degli Studi diPadova), Italy participated in the study. The mean age of
the patients was about 52 years, and all of them had beentransplanted at the HSC. They were divided into threegroups of 20 patients each according to the time elapsedsince transplantation. The first group included patientswho had received a new heart in the last 6 months. Thesecond group included those patients who had beentransplanted from 7 to 24 months before the time of thedata collection. The third group included those patientswho had received a new heart more than 24 months be-fore the time of the data collection.
The 12 members of the medical team included eightnurses and four surgeons. Mean age was about 34 years(33.5 for nurses, 34.5 for surgeons). Each of them had hada noteworthy experience in the context of heart trans-plantation, as testified by the number of years they spentin that ward: about 11 years for the nurses (range from 4to 28) and about 8 years for the surgeons (range from 3to 15).
Patient Questionnaire
Patients completed a questionnaire rating the degree ofrisk for 20 activities on a 0–100 scale, where 0 = not at allrisky and 100 = extremely risky. Risk was defined as“risk to a patient like you, who went through heart trans-plantation.” The item order was randomized. After thequestionnaire the patients were asked to judge each of20 activities on a set of seven risk dimensions (see Ap-pendix). The order of the dimensions was randomizedas well.
The 20 activities implied different degrees of risk.Some activities had to do with noncompliance and werefactors considered as very high risk, such as forgettingor purposely not taking the antirejection drugs, skippingmedical check-ups, disregarding physical hygiene. Oth-ers were activities that the medical team strongly recom-mended avoiding, such as smoking, eating fried, salty,or fatty foods, being in crowded places, drinking coffee,tea, or alcoholic beverages, and suntanning. Others wereactivities that the medical team said were safe to do oreven ones the patient should engage in, such as practic-ing some sport at a low pace. Included in this last groupwere activities that could be more or less physical andmore or less emotional. Such physical activities were rid-ing a bicycle, carrying heavy luggage, running up stairs.Distinctly emotional activities were having a violent dis-cussion, receiving unexpected news, watching violentscenes on TV or in reality, reading. Other activities in-cluded a mixture of physical and emotional factors, suchas, cooking, continuing working, driving a car, and go-ing shopping.
Medical Team Questionnaire
The medical team completed a questionnaire also ratingthe degree of risk for the 20 activities on a 0–100 scale,where 0 = not at all risky and 100 = extremely risky. Riskwas defined as “risk to a patient who went through hearttransplantation.” The same rating was asked three timesaccording to the three time phases considered. Hence,for the first time phase instructions were: “rate the riskfor a patient who was operated from 0 to 6 months ago,”and similarly for the other two phases.
Procedure
The patients were contacted when they attended theirroutine medical check after transplantation. The experi-menters requested the collaboration of all the patientswho showed up at the HSC until the prefixed limit of 20patients for each group was reached. The 60 patientscontacted for the study represent about the 23% of all thetransplanted patients alive at the time of the research.The patients were explained the purpose of the studyand they agreed to participate voluntarily.
The questionnaire was administered individuallyto each patient. The experimenter read the instructionsand explained the meaning of each dimension to makesure that the patient fully understood the task.
The medical team members were contacted duringtheir professional hours at the HSC. The questionnairewas self-administered.
Results
Risk Judgments
The mean judgments of risk for each activity given bythe medical team and by the patients in each time phaseare shown in Table 1.
Three aspects of the results should be considered.First, for both patients and members of the medicalteam, risk ratings varied across the entire 0 to 100 scaleused. As expected, the activities that were originallythought to be at very high risk received higher scoresthan those that were originally considered low or zerorisk. Second, concerning the time elapsed since trans-plantation, an overall decrease of the risk ratings mov-ing from the first to the third phase was observed. Asexpected, some activities that were rated very risky justafter the surgery were not rated as risky some time afterthe surgery. In this, both patients and medical team
showed the same pattern. Third, and most interesting,risk judgments by the patients were in agreement withthe judgments by the medical team only for few items.
These conclusions were confirmed by a multivariateanalysis of variance (MANOVA) carried out on the riskjudgments of the 20 items. The MANOVAby participantswas a 2 × 3 design with both factors as between subjects-factors. The factors considered were professional role (pa-tient vs. medical team member), and time from transplan-tation (0–6 months, 7–24 months, more than 24). Post-hocanalyses were conducted using Newman-Keuls test.
The analyses showed a significant effect of the rolefactor, Hotelling’s F = 8.55, p = .0001 and a significant ef-fect of the time factor, Hotelling’s F = 1.78, p = .008. Theinteraction between the two factors did not reach signifi-cance. One-way pair comparisons between medicalteam members and patients showed that the two groupsagreed on just 5 of 20 items (see Table 2, group A). Pa-tients agreed with the medical team on the objectivehigh risk associated with some activities, such as smok-
ing, eating fried, salty, and/or fatty food, and drinkingcoffee and/or tea, as well as the risks that might derivefrom being in crowded places and going shopping.**
Nevertheless, the remaining 15 items were not per-ceived in the same way by the team members and thepatients. Five of them (see Table 2 group B) were ratedmore risky by the medical team members and hence un-derestimated by the patients. These activities includedthe noncompliance factors, such as not taking the antire-jection drugs, not adhering to the medical check-upsscheduled by the medical team (for this item, we ob-served only a tendency toward significance, p = .08), in-sufficient physical hygiene, and suntanning. Includedwithin these underestimated hazards was also driving acar, which surprisingly was judged more risky by themedical team than by the patients, although both agreedthat the risk was quite low.
For the remaining 10 items an opposite pattern wasobserved (see Table 2, group C). These activities wererated significantly more risky by the patients than the
Table 2Difference in mean perceived risk by the patients and the medical team.
RoleActivities Medical team Patients F p
(2df)
Group A Smoking 94.72 93.83 .14 .709Eating fried, salty or fatty food 86.39 83.63 .50 .481Staying in crowded places 69.31 73.17 .63 .429Drinking coffee or tea 37.36 34.63 .21 .647Shopping 21.53 19.00 .27 .604
Group B Forgetting the antirejection drugs 98.33 93.25 4.39 .039Skipping routine medical checks 97.50 92.75 3.05 .084Disregarding physical hygiene 89.44 77.92 7.04 .009Suntanning 73.44 56.00 12.63 .001Car driving 32.50 21.12 4.31 .041
Group C Consuming alcoholic beverages 81.94 91.25 4.39 .039Carrying heavy weights 53.75 69.58 6.98 .010Having a violent discussion 36.81 69.00 33.83 .0001Receiving unexpected news 26.81 45.17 9.45 .003Running up the stairs 23.19 49.25 24.55 .0001Resuming working 20.28 40.83 11.11 .001Watching violent scenes 15.42 46.55 27.32 .0001Riding a bicycle 3.33 10.58 5.64 .020Cooking 0.00 14.25 15.13 .0001Reading 0.00 7.42 9.78 .002
Note. The first group of activities (group A) are those where the patients and the medical team gave an equal risk judgment. The secondgroup of activities (group B) are those where the medical team gave higher risk judgments than patients. The third group of activities(group C) are those where the medical team gave lower risk judgments than patients.
**We assume that the patients judged “going shopping” by the risk of infection when staying in a crowded place and not by theactivity per se.
medical team. We can say that for these hazards patientsshowed an overestimation of risk. Observing the meansit was evident how these activities were judged to berather safe by the medical team (with the exception ofalcohol consumption). The highest mean rating wasgiven to “carrying heavy weights,” which ranked aroundthe middle of the 0–100 scale we used (53.75). Among theother items, some activities implied physical fatigue,such as running up the stairs and continuing working,while others implied emotional experiences, such as hav-ing a violent discussion, receiving unexpected news, andwatching violent scenes on TV. Especially for these itemsthe overestimation was noteworthy. Looking at the extentto which the two groups differ, we can see that the majordifference was found on overestimation, rather than on un-derestimation of risk, and the overestimation was defi-nitely greater for two emotional experiences (violent dis-cussions and violent scenes) followed by a physical activ-ity (climbing the stairs) and a physical-emotional activity(continue working). To summarize, the greatest differ-ences between risk judgements of the two groups wasfound for those activities that involved emotional factorsand physical factors. Most of the medium-low risk activi-ties were overestimated by the patients, while medium-high risk activities were underestimated.
The time from transplantation factor was also sig-nificant. As expected, some activities were judgedequally risky in all three time phases, while other activi-ties were judged more risky in the first phases and lessrisky in the last phases. Specifically, suntanning (71.72;58.97; 56.94) was judged more risky in phase I than inphases II and III, but it was judged equally risky inphases II and III; running up stairs (47.19; 41.25; 30.00),resuming working (44.37; 32.03; 22.97), and shopping(28.91; 18.91; 12.03) were judged more risky in phase Ithan in phase III, while they were judged equally riskyin phase I compared to II and in phase II compared to III;carrying heavy weights (70.47; 67.97; 52.50) and being incrowded places (83.59; 72.50; 59.06) were judged equally
risky in phase I and II but in both phases they werejudged more risky than in phase III. In general, risk per-ception decreased as time passed since surgery. All thesedifferences were significant for p = .05 in Student-New-man Keuls post-hoc tests.
Dimensions of Risk Perception
The patients’ judgments of each of the 20 activities oneach of the seven dimensions was reduced to a meanvalue across all patients and the means were included ina 20 (risks) × 7 (dimensions) matrix. In the same way, thepatient’s risk magnitude judgment of each of the 20 ac-tivities (from 0 to 100) was reduced to a mean valueacross subjects and added to the matrix that became 20× 8. This matrix was prepared to perform the regressionanalysis and the factor analysis.
A stepwise linear multiple regression analysis wasused to estimate the strength of the effect of each of theseven dimensions of risk in predicting the risk magni-tude judgment across all 20 activities. The regressionmodel that best described the data (R2 = .992) was a mod-el including only two of the seven dimensions: dreadful-ness and personal knowledge. The regression coeffi-cients are shown in Table 3. Hazards rated more riskywere those perceived as more dreadful and less known.In line with previous research, risk ratings by transplantpatients were best predicted by the degree of dreadful-ness associated to the hazard, a characteristic that ismostly emotional in nature. Interestingly, risk ratingswere also slightly predicted by the degree of lack ofknowledge of the risks posed by the activities.
The same 20 × 7 matrix was the base for a factoranalysis on the dimensions across the 20 hazards. Thefactor analysis used the Principal component methodand Varimax rotation. A two-factor solution was ob-tained accounting for 91% of the total variance. Load-ings of the seven dimensions on the two factors areshown in Table 4. The first factor was labeled Dread riskand accounted for most of the variance (67%), the secondfactor was named Controllability of risk and accountedfor 24% of the variance.
Factorial scores for each risk were computed andrepresented in the two-factor space to obtain a cognitivemap of the risks, as shown in Figure 2. The squares in thefigure represent the 20 hazards, and the map shows howeach hazard is described by the two factors. The Dreadfactor is represented on the ordinate, the Control factoron the abscissa. As can be seen in the figure, most of theactivities are grouped around the ordinate axis, the Dreadrisk, which explains most of the variance. Risks perceived
Table 3Summary of the stepwise regression analysis for dimen-sions predicting risk magnitude judgment.
as more dreadful were those at the top of the map (e.g.,smoking, no drugs, no medical checks, etc.).The leastdreadful risks are those represented at the bottom of thefigure (e.g., reading, cooking, etc.). All the other risks areinbetween. Note that the most overestimated risks wereincluded in the medium-dreadful group.
Discussion and Conclusions
The results of this study are consistent with a prospecttheory prediction of risk-aversion propensity for heart-transplant patients. Patients and members of the medi-cal team showed several discrepancies in their ratings ofrisk from a series of activities. Among the discrepancies,the largest ones were overestimations of risk by patients,especially for activities at zero or low risk. Prospect the-
ory assumes that the motivation to engage in an activityis seen as low in utility and as high in costs because of apositive framed condition. It is noteworthy that patientsoverestimated those activities that refer to stressfulevents involving emotionally relevant experiences andthose that refer to physical labor. These are also the ac-tivities that make life more vital and certainly improvethe quality of life after an operation, a major goal of re-habilitation.
It should also be noted that the positive framingcondition might render more acute a tendency thatcould have been already present in the patients beforetransplantation. Transplant patients are, indeed, personswho have suffered from cardiac disease before decidingto undergo surgery. This does not exclude that these pa-tients still perceive and still behave in the way theylearned to cope during their previous illness. Our datashow that risk aversion could be especially high for ac-tivities that have an emotional or physical factor em-bedded within them.
Regarding the prediction of which dimensions ofthe hazards best explained the risk rating, we essentiallyfound agreement with previous research. The dreadful-ness dimension best predicted risk ratings by patients.Indeed, this is coherent with the overestimation of theemotional hazards, since dreadfulness has to do with theemotion that one experiences when thinking of an activ-ity. The association between affective reaction to stimuliand judgments of risk was previously observed in theliterature (Finuncane, Alhakami, Slovic, & Johnson,2000).
Our findings are even more remarkable if we con-sider that patients are expected to have judgmentsstrongly congruent with the medical team because oftheir privileged role in the communication flow. First,patients have a direct and face-to-face relationship withthe medical team instead of a mediated relationship.Second, patients receive advice from a unique source ofinformation—the medical team—instead of multiplesources. These aspects should have reduced the noise incommunication from the physician to the patient andheightened, rather than reduced, the congruence be-tween their judgements of risk.
Beside the incongruent, but expected, results wealso find evidence contrasting our hypotheses. We ar-gued that hazards would be overestimated, both thoseat very high risk and those at low or zero risk. Eventhough we found evidence to support the secondhypothesis, we did not find evidence in support of thefirst hypothesis. Some very highly risky activities re-garding compliance with the medical regimen were un-
Table 4Factor loading of the risk dimensions on the two factors.
derestimated by the patients. To explain this finding, weassume a self-protection motivation interpretation. Spe-cifically, patients might refrain from cognitively apprais-ing the risks of noncompliance because of the very highdegree of risk emotionally recognized in these activities.Patients in fact perceive these activities as emotionallyvery dreadful, but they rate them as implying less riskthan the medical team does. This might sound like acontradiction and could be explained by the fact thatpatients recognize a risk emotionally while rejecting thesame risk rationally. Protection motivation theory, suchas Rogers’ (1975; Maddux & Rogers, 1983), would agreewith this interpretation and assume that the patient hada coping reaction for present life state which is depend-ent on drugs and check-ups, refusing a cognitive ap-praisal of the risk.
According to prospect theory we expected thesehazards to be overestimated because patients were ex-periencing a positive frame and therefore should havebeen risk averse: Any low risk was expected to be seenas very high—and any high risk even higher. This lastprediction appears not to have been confirmed, andprobably there was a threshold over which other psy-chological mechanisms distinct from prospect theorymight have acted and of which we have no direct sup-port in our study, such as protection motivation. We con-clude that prospect theory was good in determining theoverestimation of risk for zero and low risk activities,but did not predict noncompliance.
We found evidence that patients are scared by thoseactivities that they judge as being unknown. Lack ofknowledge of the consequences of performing the ac-tivities was a significant predictor of risk magnitudejudgments in our study. This result fits coherently withthe overestimation of zero-low risks posed from emo-tional and physical activities. Patients in this study ex-perienced a lack of knowledge of the consequences ofthese activities, a second factor, after the dreadfulness, toexplain their grater concern.
We should point out that there are two limitationsof this study. First, prospect theory is used in this studyas an explanation for patients’ poor rehabilitation.Nevertheless, according to our results we cannot saythat a framing effect really affected the patient, we mayjust assume it. This study provides only indirect evi-dence of this. Further research is needed to determinepatients’ frame of reference before and after transplan-tation. Second, patients and the medical team differ notonly in their expertise, but also in subjective vs. objectivepoint of view: Patients describe themselves whereasphysicians describe someone else. To find an adequate
interpretation of our results we would need a controlgroup of nonpatients. Unfortunately, the questionsposed to patients and physicians are technical andwould make no sense to a nonpatient.
Implications for Medical Communication with Patients
From the results of our study we may derive severalimplications for medical communication with patients.The content of this communication was usually centeredaround risks. Since the medical team had direct and face-to-face contact with the patient, and since the medicalteam was the only information source for the patient, wemight have expected that the patient would show a goodcongruence in risk ratings, the content of the communi-cation. This was not the case. As we have observed, thecommunication was not effective enough to avoid a pro-pensity by the patient toward over-estimation of low-and no-risk activities—and it was not enough to avoidthe tendency to underestimate high risks. We are notsaying here that communication can suffice to avoid anyof these mechanisms; but certainly it can help one toproceed in this direction. Nevertheless, if we look at themagnitude of the discrepancies, we can observe that thediscrepancy was not alarming for noncompliance items.Major discrepancies were found for the activities that thepatient should be encouraged to do (but does not), suchas working. We conclude that a more effective commu-nication about the utility of no-risk activities might im-prove the patients’ quality of life after transplantation,thereby smoothing the effect of the positive frame con-dition. More effort should be addressed to determine thevalid contents of communication regarding the patient’sutility to engage in several routine activities.
Acknowledgments
We would like to thank the medical team of the Centerof Heart Surgery at the University of Padova, Italy, andthe patients of the same center for being extremely col-laborative during data collection.
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Appendix: The Risk Dimensions
Dread Risk
How frightened are you by the effects of the followingactivities? (1 = not at all frightened; 5 = completely terri-fied)
Personal Control
To what degree do you believe you can control the con-sequences of the following activities using your per-sonal skill? (1 = no control at all; 5 = complete control)
Personal Knowledge
Some activities have more or less negative effects for atransplant patient. To what extent you know exactly theconsequences on your health of the following activities?(1 = totally unknown; 5 = completely known)
Risks/Benefits
In your opinion, the risks are more or less than the bene-fits when you engage in the following activities? (1 = norisks, only benefits; 5 = no benefits, only risks)
Scientific Knowledge
To what degree do you believe that the surgeon knowsexactly the consequences of the following activities for aperson who has received a transplant? (1 = does notknow at all; 5 = knows all the consequences)
Social Desirability
How do you think would engaging in the following ac-tivities be appreciated by the people close to you (rela-tives, friends, etc.)? (1 = not at all appreciated; 5 = com-pletely appreciated)
Voluntary Aspect
In your opinion, can a person choose freely or is one insome way forced to engage in the following activities?(1 = not at all free to choose; 5 = completely free tochoose)
