title: 'Much clearer with pictures': using community-based participatory research to design and test a Picture Option Grid for underserved patients with breast cancer.
abstract: OBJECTIVE
  Women of low socioeconomic status (SES) diagnosed with early stage breast cancer experience decision-making, treatment and outcome disparities. Evidence suggests that decision aids can benefit underserved patients, when tailored to their needs. Our aim was to develop and test the usability, acceptability and accessibility of a pictorial encounter decision aid targeted at women of low SES diagnosed with early stage breast cancer.
  
  
  METHODS
  Community-based participatory research (CBPR) using think-aloud protocols (phases 1 and 2) and semistructured interviews (phase 3).
  
  
  METHODS
  Underserved community settings (eg, knitting groups, bingo halls, senior centres) and breast clinics.
  
  
  METHODS
  In phase 1, we recruited a convenience sample of clinicians and academics. In phase 2, we targeted women over 40 years of age, of low SES, regardless of breast cancer history, and in phase 3, women of low SES, recently diagnosed with breast cancer.
  
  
  METHODS
  The pictorial encounter decision aid was derived from an evidence-based table comparing treatment options for breast cancer (http://www.optiongrid.org).
  
  
  METHODS
  We assessed the usability, acceptability and accessibility of the pictorial decision aid prototypes using the think-aloud protocol and semistructured interviews.
  
  
  RESULTS
  After initial testing of the first prototype with 18 academics and health professionals, new versions were developed and tested with 53 lay individuals in community settings. Usability was high. In response to feedback indicating that the use of cartoon characters was considered insensitive, a picture-only version was developed and tested with 23 lay people in phase 2, and 10 target users in phase 3.
  
  
  CONCLUSIONS
  Using CBPR methods and iterative user testing cycles improved usability and accessibility, and led to the development of the Picture Option Grid, entirely guided by multiple stakeholder feedback. All women of low SES recently diagnosed with early stage breast cancer found the Picture Option Grid usable, acceptable and accessible.
authors.affiliation: The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA The Dartmouth Center for Health Care Delivery Science, Dartmouth College, Hanover, New Hampshire, USA.
authors.forename: Marie-Anne
authors.initials: MA
authors.lastname: Durand
authors.affiliation: The Dartmouth Center for Health Care Delivery Science, Dartmouth College, Hanover, New Hampshire, USA.
authors.forename: Shama
authors.initials: S
authors.lastname: Alam
authors.affiliation: The Dartmouth Center for Health Care Delivery Science, Dartmouth College, Hanover, New Hampshire, USA.
authors.forename: Stuart W
authors.initials: SW
authors.lastname: Grande
authors.affiliation: The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA The Dartmouth Center for Health Care Delivery Science, Dartmouth College, Hanover, New Hampshire, USA.
authors.forename: Glyn
authors.initials: G
authors.lastname: Elwyn
mesh_terms: D000328:Adult; D000368:Aged; D001296:Audiovisual Aids; D001943:Breast Neoplasms / Q000628:therapy*; D055812:Community-Based Participatory Research; D003657:Decision Making; D003661:Decision Support Techniques; D005240:Feasibility Studies; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D012923:Social Class; D035862:Vulnerable Populations
keywords: Low socioeconomic status; breast cancer disparities; decision support techniques; encounter decision aids; pictorial superiority; usability
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