Communication of benefits and harms in shared decision making with patients with limited health literacy: A systematic review of risk communication strategies

Objectives: Risk communication (RC), as part of shared decision making, is challenging with people with limited health literacy (LHL). We aim to provide an overview of strategies to communicate benefits and harms of diagnostic and treatment options to this group. Methods: We systematically searched PubMed, Embase, Cinahl and PsycInfo. We included 28 studies on RC in informed/shared decision making without restriction to a health setting or condition and using a broad conceptualization of health literacy. Two researchers independently selected studies and one researcher performed data extraction. We descriptively compared findings for people with LHL towards recommendations for RC. Results: Health literacy levels varied in the included studies. Most studies used experimental designs, primarily on visual RC. Findings show verbal RC alone should be avoided. Framing of risk information influences risk perception (less risky when positively framed, riskier when negatively framed). Most studies recommended the use of icon arrays. Graph literacy should be considered when using visual RC. Conclusions: The limited available evidence suggests that recommended RC strategies seem mainly to be valid for people with LHL, but more research is required.