Clinical Trial Details
— Status: Completed
Administrative data
| NCT number |
NCT04683068 |
| Other study ID # |
R1249/20-IEO1314 |
| Secondary ID |
|
| Status |
Completed |
| Phase |
N/A
|
| First received |
|
| Last updated |
|
| Start date |
January 10, 2021 |
| Est. completion date |
December 31, 2021 |
Study information
| Verified date |
May 2022 |
| Source |
European Institute of Oncology |
| Contact |
n/a |
| Is FDA regulated |
No |
| Health authority |
|
| Study type |
Interventional
|
Clinical Trial Summary
BRCA1- and BRCA2-associated Hereditary Breast and Ovarian Cancer Syndrome (HBOC) increases
the relative and absolute risk of developing breast and ovarian cancer and, to a lesser
extent, prostate and pancreatic cancer. Men face BRCA-related cancer risks as women do,
although with a different magnitude, and they may also transmit the mutations to their
children. Notwithstanding, men have not received much attention since now. They are
under-tested compared to women and the communication is not tailored on their needs. Research
on the psychological determinants of men's informed decision-making is particularly lacking
as well as experimental evidence on the efficacy of tailored messages on men's needs.
Applying principles of the Health Action Process Approach (HAPA), the present protocol
proposes a study with the aim to test psychological variables influencing men's
decision-making. Moreover, the proposed research intends to test the efficacy of two messages
through a randomized experimental study. A total of 264 participants will be involved, among
the men's relatives of women with verified germline mutations. The study entails a pre- post-
evaluation with randomization of the participants in two conditions corresponding to the two
messages. The expected results provide answers related to the impact of action self-efficacy,
outcome expectancy (personal or familiar), risk perception, health risk aversion, intolerance
of uncertainty, perceived barriers, and coping self-efficacy on informed decision-making.
Data gathered from this study may inform health care providers, policymakers, and public
health managers about the communication strategy for men and about the psychological
variables influencing decision-making.
Description:
Background As for other pathogenic gene mutations [1,2], germline mutations in BRCA1- and
BRCA2 genes (BReast CAncer 1 gene and BReast CAncer 2 gene) predispose carriers to an
increased suscepti-bility in developing breast and ovarian cancer [3] but also prostate,
pancreatic cancer and mela-noma [4]. BRCA1 and BRCA2 germline mutations are inherited in an
autosomal dominant manner; this means that offspring of an individual with a BRCA1 or BRCA2
germline mutation have a 50% chance of inheriting the variant [5,6], and the same probability
of passing it to the progeny. BRCA1/2 mutations have no gender distinction [7], both men and
women can inherit the mutation, although it exposes them to different risks.
Men with BRCA1/2 mutations can incur a lifetime risk of up to 6.8 percent for breast cancer,
and between 6 and 15 percent for prostate cancer [6,8]. These risks are particularly higher
when BRCA2 gene is involved. However, men do not receive the same attention as women [9]. In
particular, women can be tested to search BRCA1 or BRCA2 unknown germline mutations,
especially when suffering from breast and/or ovarian cancer, or to search known BRCA1/2
germline mutations previously identified in the family (i.e., cascade screening). Instead,
men are mainly involved in cascade screening and, rarely, they are tested for BRCA1/2
germline mutations [10]. Very recently, the guidelines of the National Comprehensive Cancer
Network [11] have suggested to con-sider patients with pancreatic and prostatic cancers as
eligible for genetic testing for BRCA germline mutations. However, such a recommendation is
not yet routine for the test proposal.
Some socio-cultural aspects have been related to the men's attitude toward BRCA1/2 mutations
and genetic testing. For example, Pritchard [12] suggested that BRCA 1/2 mutations are
generally associated with female gender. He also pointed out that the name of the associated
Hereditary Breast and Ovarian Cancer Syndrome (HBOC) creates a confusion since breast and
ovarian cancers are considered a 'female matter' by layperson [18]. Similarly, others [13,14]
have found that fear of stigmatization is one obstacle for the men's decision-making. To
date, there are no studies, applying a strong theoretical rationale, that have systematically
tested which are the psychological variables influencing men's informed decisions for genetic
testing, when facing BRCA-related mutations. Moreover, to the best of our knowledge, there
are no studies testing what is the better communication strategy to inform men's
decision-making. Therefore, the present study aims to fill these gaps with an experimental
study with a longitudinal component. First, applying principles of the Health Action Process
Approach (HAPA), a motivational inclined theory that explains changes in behaviors, will be
tested what psychological determinants influence the decision to undergo a genetic test for a
germline BRCA mutations. The role of intolerance to the uncertainty and the health risk
attitudes will be explored. The HAPA model has been chosen because it is an evolution of the
first stadial models of health psychology [15] and it assumes that individuals pass through
qualitatively different stages of psychological elaboration when they have to adopt new
health behaviors. The other aim the proposed study is to test two different narrative
messages in order to understand which is the most efficient in informing men's
decision-making.
Principles of the Health Action Process Approach (HAPA) According to the Health Action
Process Approach [16] there are several variables involved in the implementation of new
health behaviors. Specifically, it is possible to identify risk perception, outcome
expectancies and action self-efficacy as predisposing factors that have an impact on the
informed decision; this is considered the motivation phase, in which subjects begin to form
an intention. In this model, the intention to perform a specific health behavior is
considered as a middle-level mediator between the variables considered in the motivation
phase and those in the volition phase.
Furthermore, according to this model, volition factors involve planning that is further
specified as coping and action planning, and coping self-efficacy. Volition factors are
considered as be-ing influential in the subsequent phase and they are the most proximal
predictors to actual behavior decisions. This second phase (i.e., the volition phase) should
be subdivided in pre-action phase, in which the previous mentioned coping and action
planning, and coping self-efficacy take place, and action phase, ending with a behavior.
This model was tested in several health contexts [17,18], in particular for smoking behavior
[16,19,20], physical activity [21,22], dietary [23,24] and also in cancer-related screening
behavior [25]. Those studies demonstrated the efficacy of the theory in explaining the
initiation and maintenance of such health preventive behaviors. Together with the principles
of the HAPA model, the present study aims to understand whether other psychological factors
may explain men's decision making regarding genetic testing for BRCA1/2 germline mutations.
For this reason, two attitudinal factors are examined: intolerance of uncertainty and health
risk attitudes.
When people face with a potential threat for their health, one key element affecting their
subsequent decisions and behaviors is how much they feel certain or uncertain regarding the
threat. In our case, a man who is considering the possibility to undergo a genetic test for
BRCA germline mutations is facing with two different types of uncertainty. The first one is
the proximal uncertain-ty due to the result of the genetic test itself. The second one is the
distal uncertainty depending on the risk to develop a cancer if a germline mutation would be
found. The intention to undergo a genetic test for a germline mutation may be, therefore,
determined by the way in which the individual manages the uncertainty due to the discovery of
a possible negative result (i.e., the presence of a mutation) and to the future consequences
of the germline mutation.
Intolerance of Uncertainty (IU) is a trait characteristic of individuals who are not able to
tolerate the aversive reactions triggered by a perceived lack of sufficient information or by
an is-sue that can have more than one solution [26]. Individuals with low tolerance for
uncertainty tend to perceive the threat as a source of discomfort and to react negatively to
it [27]. Some studies investigated the relationship between intolerance of uncertainty (IU)
and the attitude to undergo health monitoring, in particular cancer-related screening
[28,29]. In particular Tan and colleagues showed that intolerance of uncertainty may function
as an important determinant of anxiety among men pursuing active surveillance for prostate
cancer [28]. One qualitative study in lung cancer screening decision-making showed that some
participants sought to decrease uncertainty through lung cancer screening and, if needed,
with additional testing; others declined the screening in order to avoid the uncertainty
associated with undefined results [30]. Indeed intolerance of uncertainty consists of two
dimensions: the first one, the desire for predictability, is an active strategy to manage the
uncertainty that is perceived as intolerable, and leads to search for as much information as
possible about the threat to restore a balance. Rosen and colleagues [31] showed that high
levels of IU were associated with an increase in health monitoring and screening; other
studies suggested that searching for threat-related information may be driven by the desire
to reduce uncertainty [32,33]. The second one, called uncertainty paralysis, is configured as
an avoidance strategy and leads to inability to act because of the uncertainty [26].
Another construct related to the previous one, at least in the health framework, is the
attitude toward health risk. In order to contrast the perception of significant uncertainty,
people choose responses and act in a certain way, and this is defined as the personal
attitude toward health risk. In fact, people differ in their attitude towards health risks,
and this affects decision making regarding preventive behaviors (e.g., screening, physical
activity), and risky behaviors (e.g., surgery) [34]. Taken together all this evidence suggest
that IU and health risk attitudes may play a role when a man is facing with the decision to
undergo a genetic test to detect BRCA germline mutation because there are similar mutations
in the family. Since men with BRCA-related cancer risks deal with probabilistic and complex
information [35,36], both of these attitudinal factors can have an effect on the
implementation of health behaviors and therefore can influence the informed decision to
undergo cascade screening for BRCA1/2 mutations.
How to inform men's decision making for BRCA1/2 germline mutations genetic testing The other
aim is to investigate how to inform men's decision-making. Low levels of men's knowledge
regarding BRCA1/2 germline mutations is found as one of the most important problems in this
field [37]. Therefore, one main research achievement may be to find the right way to
correctly inform them. The present study aims to test two different messages tailored to
men's specific needs and to understand what is the best way to inform them. Although
narrative approaches showed efficacy in promoting health behavioral intentions [38], and in
increasing adherence to cancer screening [39] in particular, its utility for improving men's
BRCA cascade screen-ing remains unexplored. The present research intends to explore whether
narrative messages can be effective in informing men's decision-making.
In particular, two features are fundamental in narrative strategies context: the narrative
perspective and the framing. The first one is a fundamental story feature and changes how
information is delivered to the audience; researchers identified that first-person narrative
messages are able to increase self-identity and to promote the assimilation of the theme
better than third-person narratives [40]. Therefore, the present study chooses to create
narrative messages with a first-person feature. Regarding the framing, messages can either
emphasize negative consequences (losses) or positive outcomes (gains) of a given action.
Prospect theory [41] posits that, in general, people are more likely to take risks when
presented with a loss-framed message, and the contrary for a gain-framed message. But
regarding disease prevention behaviors, like smoking cessation [61] and skin cancer
prevention [42], researchers have suggested an advantage, albeit small, of a gain frame over
a loss frame [43]. Therefore, the present study chooses to create narrative messages oriented
to a gain frame.
Furthermore, applying the Uncertainty Management Theory [44], a social psychological approach
to uncertainty, Rauscher et al. [13] investigated how men with increased BRCA-related cancer
risk approach the individual and familial uncertainty related to that pathogenic variant.
Those qualitative results showed that men's primary concern when managing BRCA-related cancer
risks is the aversive consequences of the discovery of a germline mutation for their family
[45]. Their focus on familial uncertainty management is maybe due to the difficulties
encountered in the management of their own risk due to the lack of information and management
options. In the end, the authors suggested that genetic counseling would benefit from a
family focus. Also Hallowell and colleagues [46] highlighted the role of family member
(mother, partner or children) in men's decision-making about BRCA testing. In particular,
they showed how men's decision to have genetic testing was influenced by the obligations
perceived from family members, primarily their children.
Based on these premises, this study proposes to test the effectiveness of two first-person
gain-framed messages, one narrating a self-referred story and the other a family-referred
story. The effectiveness will be measured in terms of one or both messages' ability to
predict the intention to undergo genetic screening.
Objectives
We hypothesize the following relationships (figure 1 shows the tested model):
1. HP1: higher risk perception, positive outcome expectations, and action self-efficacy
longitudinally predict the intention and the action to undergo a genetic test for BRCA
germline mutations.
2. HP2: higher health risk attitude and low intolerance to uncertainty have a longitudinal
influence on predicted higher intention, planning, and action initiation.
3. HP3: higher intention and coping self-efficacy longitudinally predict higher planning.
4. HP4: higher planning (i.e., action planning, coping planning) and coping self-efficacy
longitudinally predict higher action initiation.
5. Based on results by Rauscher et al. [13] and Hallowell and colleagues [46], we
formulated a research question: (RQ1) is there any difference between personal outcome
expectations and family outcome expectations in their association with intention?
6. HP5: family-referred narrative gain-framed message (vs. self-referred narrative
gain-framed message) will produce greater intention and action to undergo genetic
testing for BRCA 1/2 germline mutations in at-risk men.
Method Design The research will involve three phases, with results from each phase
informing the next phase (see Figure 2). In the first phase, a literature review will be
performed to identify other psychological variables influencing individuals' adherence
to evidence based guidelines on BRCA1/2 germline genetic testing. Subsequently, a pilot
survey will be created in order to test its feasibility and un-derstandability for
participants.
The third and final phase entails a RCT with participants receiving one of the two
conditions (i.e., self-referred narrative framed message, family-referred narrative
framed message) and it tests the main hypotheses and research question of the study.
Participants will answer to several questions before and after the message exposure.
Participants and study setting Participants are 264 males, relatives of women with BRCA1
and/or BRCA2 germline mutations who are patients of the Division of Cancer Prevention
and Genetics at the European Institute of Oncology (IEO) in Milan. The IEO is a
specialized Hospital and an internationally recognized Cancer Center located in Italy
working on research, prevention, diagnosis, and treatment of cancer.
Sample size and power calculation The sample size is determined through an a priori
power analysis using GPower 4.0 [47]. Among the imputed parameters it was chosen to
include partial η2 = .05, alpha lower than .05, power d (1-B) = .70. Considering that
Luszczynska et al. [48] found a η2 = .01, η2 = .05 is a prudential choice. Two groups,
corresponding to the two experimental conditions of the study, and 7 covariates were
included. The final estimated number of participants is 264, 132 in each group. It
should be noted that changing the number of covariates does not change the total number
of participants.
Recruitment According to the registry of the Division of Cancer Prevention and Genetics
(IEO), all women with BRCA1 and/or BRCA2 germline mutations with at least a male
relative will be reached by a phone call and/or an email. During the first contact, a
member of the research team informs the female patients about the research purposes and
the procedure. The researcher will then ask the women to share the information with
their male relative(s) and to invite him (them) to participate in the research. All the
information about the research, including an invitation letter, an information sheet,
and the consent form, will be also sent by email to the women. If those relatives want
to be contacted to participate in the study, a researcher calls them and shares with
them the information sheet, the informed consent, and the link to the online survey.
Participants will sign the informed consent before starting to fill the survey and data
collection will be done through an online survey via the use of an identifier. In order
to promote participant retention and complete follow-up, participants will be prompted
to respond, calling them by phone or contacting them by email.
Randomization Participants who meet the study inclusion criteria will be randomly
assigned to receive one of the two conditions. Randomization will occur during T1,
immediately after the data collection of psychological measures. The participants will
not be informed of the condition to which they have been allocated until the message
itself will be shown.
Time 1 assessment All participants will complete the T1 assessment, via an online survey
which will be available for a two-week period. The T1 measures will include demographic,
health status, risk perception, health risk aversion, and intolerance of uncertainty.
After this evaluation, participants will be ran-domized and exposed to one message. A
manipulation check, the evaluation of the perceived qual-ity of the information
presented on the messages, positive outcome expectations, action self-efficacy, benefit
for genetic test will be then collected.
Intervention Time 2 assessment Two weeks later, via an online survey, participants reply
to questions on the intention to undergo germline genetic testing, coping self-efficacy,
action planning, and coping planning.
Time 3 assessment Starting from the end of T2 until 3 months later, data on action
initiation will be collected (i.e., genet-ic test for BRCA1/2 gene germline mutations).
Measures T1 measures Before the randomization, all participants answer several
questions, as follows.
Demographic. Self-reported age, education, occupation, degree of relationship with the
woman with BRCA1/2 genes germline mutation, household composition.
Health Status. Self-reported general health and existing diagnosis for the chronic
disease will be investigated with a single item each [49]. Response options for general
health conditions will be on a 5-point Likert scale. The response options for the item
on the existing chronic disease will be binary coded (no - yes, specify).
Risk perception. Relative risk perception regarding the possibility to develop breast,
prostatic, and pancreatic cancer will be investigated with one item each [50,51].
Response options are on a 7-point Likert scale.
Health Risk aversion. The six items of the Health Risk Attitude [52] will be
administered to assess how a person would resolve risky health decisions. Response
options are on a 7-point Likert scale.
Intolerance of Uncertainty. The items of the Intolerance of Uncertainty Scale-12 [53]
will be applied to measure two dimensions of the intolerance of ambiguity, which are the
desire of predictability and uncertainty paralysis. Response options are on a 5-point
Likert scale.
T2 measures After the message exposure, participants reply to several questions, as
follows.
Manipulation check. Two items created ad hoc evaluate whether participants have read and
understood the message content. Multiple-choice answers are used with one correct answer
and two incorrect answers as distractors. Participants who fail to answer those
questions will be excluded from the analyses.
Perceived Quality of the Message. Three items evaluate whether the message is credible,
convincing, and persuasive. Response options are on a 7-point Likert scale.
Positive Outcome Expectation. Eight items will be created ad hoc for this research
evaluating positive outcome expectations regarding the participant himself (4 items) and
his family members (4 items). The response option will be on a 5-point Likert scale.
Action Self-Efficacy. According to Schwarzer & Luszczynska's [16] indications,
self-efficacy will be assessed through three items as the capability of keeping up with
the behavior, by implementing coping strategies. Response option will be on a 5-point
Likert scale.
Benefit for Genetic Test. A 5-digit semantic differential will be applied to measure the
perceived benefit for genetic tests. Examples of the proposed adjectives are important,
relevant, useful, benefit.
Intention to undergo genetic testing. Coping Self-efficacy. Three items created ad hoc
for the present research evaluate whether the individual feels to be capable of tackling
the possible obstacles and difficulties that could make it difficult to undergo genetic
screening. Response options are on a 5-point Likert scale.
Action planning. Three items developed ad hoc for the present research will ask if the
participant has planned when, how, and where to undergo the genetic test for BRCA1/2
mutations. The response option will be on a 4-point Likert scale.
Coping Planning. Four items developed ad hoc for the present research will ask how much
the participant thinks to encounter in planning the action. The response option will be
on a 5-point Likert scale.
T3 measures Action. Information on the action initiation (i.e., a genetic test for
BRCA1/2 germline mutations) will be collected when the participant takes the appointment
for the genetic test and receives the test.
References
1. Corso G, Montagna G, Figueiredo J, Vecchia C La, Romario UF, Fernandes MS, et al.
Heredi-tary gastric and breast cancer syndromes related to CDH1 germline mutation:
A multidisciplinary clinical review. Cancers (Basel). MDPI AG; 2020. p. 1-25.
2. Corso G, Bonanni B, Veronesi P, Galimberti V. Mutual exclusion of CDH1 and BRCA
germline mutations in the pathway of hereditary breast cancer. Arch. Gynecol.
Obstet. Springer Verlag; 2018. p. 1067-8.
3. Corso G, Feroce I, Intra M, Toesca A, Magnoni F, Sargenti M, et al. BRCA1/2
germline mis-sense mutations: A systematic review. Eur. J. Cancer Prev. Lippincott
Williams and Wilkins; 2018. p. 279-86.
4. Nyberg T, Frost D, Barrowdale D, Evans DG, Bancroft E, Adlard J, et al. Prostate
Cancer Risks for Male BRCA1 and BRCA2 Mutation Carriers: A Prospective Cohort
Study. Eur Urol. Elsevier B.V.; 2020;77:24-35.
5. Kuchenbaecker KB, Hopper JL, Barnes DR, Phillips KA, Mooij TM, Roos-Blom MJ, et al.
Risks of breast, ovarian, and contralateral breast cancer for BRCA1 and BRCA2
mutation carriers. JAMA - J Am Med Assoc. American Medical Association;
2017;317:2402-16.
6. Petrucelli N, Daly MB, Pal T. BRCA1- and BRCA2-Associated Hereditary Breast and
Ovarian Cancer. GeneReviews®. University of Washington, Seattle; 1993.
7. Silvestri V, Leslie G, Barnes DR, Agnarsson BA, Aittomäki K, Alducci E, et al.
Characteriza-tion of the Cancer Spectrum in Men with Germline BRCA1 and BRCA2
Pathogenic Variants: Re-sults from the Consortium of Investigators of Modifiers of
BRCA1/2 (CIMBA). JAMA Oncol. American Medical Association; 2020;6.
8. Oh M, Alkhushaym N, Fallatah S, Althagafi A, Aljadeed R, Alsowaida Y, et al. The
association of BRCA1 and BRCA2 mutations with prostate cancer risk, frequency, and
mortality: A meta-analysis. Prostate. John Wiley and Sons Inc.; 2019;79:880-95.
9. da Silva TL. Male breast cancer: Medical and psychological management in comparison
to fe-male breast cancer. A review. Cancer Treat. Commun. Elsevier Ltd; 2016. p.
23-34.
10. Marabelli M, Calvello M, Bonanni B. Test more men for BRCA genes. Nature.
2019;573:346.
11. Daly MB, Pilarski R, Yurgelun MB, Berry MP, Buys SS, Dickson P, et al.
Genetic/familial high-risk assessment: Breast, ovarian, and pancreatic, version
1.2020 featured updates to the NCCN guidelines. JNCCN J Natl Compr Cancer Netw.
Harborside Press; 2020;18:380-91.
12. Pritchard CC. New name for breast-cancer syndrome could help to save lives. Nature.
Nature Research; 2019. p. 27-9.
13. Rauscher EA, Dean M, Campbell-Salome G, Barbour JB. "How do we rally around the one
who was positive?" Familial uncertainty management in the context of men managing
BRCA-related cancer risks. Soc Sci Med. Elsevier Ltd; 2019;242:112592.
14. Strømsvik N, Råheim M, Yen N, Gjengedal E. Men in the women's world of hereditary
breast and ovarian cancer-a systematic review. Fam Cancer. Springer; 2009;8:221-9.
15. Prochaska JO, Di Clemente CC. Transtheoretical therapy: Toward a more integrative
model of change. Psychotherapy. American Psychological Association (APA);
1982;19:276-88.
16. Schwarzer R, Luszczynska & A. The Health Action Process Approach. Eur Psychol.
2008;13:141-51.
17. Zhang CQ, Zhang R, Schwarzer R, Hagger MS. A Meta-Analysis of the Health Action
Process Approach. Heal Psychol. 2019;
18. Mohammadi Zeidi I, morshedi H, shokohi abdolah. Application of the Health Action
Process Approach (HAPA) Model to Determine Factors Affecting Physical Activity in
Hypertensive Pa-tients. J Jiroft Univ Med Sci. Journal of Jiroft University of
Medical Sciences; 2020;7:349-60.
19. Radtke T, Scholz U, Keller R, Hornung R. Smoking is ok as long as I eat healthily:
Compensa-tory Health Beliefs and their role for intentions and smoking within the
Health Action Process Ap-proach. Psychol Heal. 2012;27:91-107.
20. Scholz U, Nagy G, Göhner W, Luszczynska A, Kliegel M. Changes in self-regulatory
cogni-tions as predictors of changes in smoking and nutrition behaviour. Psychol
Heal. 2009;24:545-61.
21. Barg CJ, Latimer AE, Pomery EA, Rivers SE, Rench TA, Prapavessis H, et al.
Examining pre-dictors of physical activity among inactive middle-aged women: An
application of the health ac-tion process approach. Psychol Heal. Routledge ;
2012;27:829-45.
22. Parschau L, Barz M, Richert J, Knoll N, Lippke S, Schwarzer R. Physical activity
among adults with obesity: Testing the health action process approach. Rehabil
Psychol. American Psychologi-cal Association Inc.; 2014;59:42-9.
23. Steca P, Pancani L, Greco A, D'Addario M, Magrin ME, Miglioretti M, et al. Changes
in Die-tary Behavior among Coronary and Hypertensive Patients: A Longitudinal
Investigation Using the Health Action Process Approach. Appl Psychol Heal
Well-Being. Wiley-Blackwell; 2015;7:316-39.
24. Chiu C-Y, Lynch RT, Chan F, Rose L. The Health Action Process Approach as a
Motivational Model of Dietary Self-Management for People With Multiple Sclerosis.
Rehabil Couns Bull. SAGE PublicationsSage CA: Los Angeles, CA; 2012;56:48-61.
25. Daniel AO, Omorogieva Enoma I, Omobude-Idiado SN. Application of Protection
Motivation Theory (PMT) and Health Action Process Approach (HAPA) in promoting
women's adaptive en-gagement towards breast self examination. Acad Res Int.
2014;5:291.
26. Carleton RN. Fear of the unknown: One fear to rule them all? J. Anxiety Disord.
Elsevier Ltd; 2016. p. 5-21.
27. Buhr K, Dugas MJ. Investigating the construct validity of intolerance of
uncertainty and its unique relationship with worry. J Anxiety Disord. J Anxiety
Disord; 2006;20:222-36.
28. Tan H-J, Marks LS, Hoyt MA, Kwan L, Filson CP, Macairan M, et al. The Relationship
be-tween Intolerance of Uncertainty and Anxiety in Men on Active Surveillance for
Prostate Cancer. J Urol. Elsevier Inc.; 2016;195:1724-30.
29. Taber JM, Klein WMP, Ferrer RA, Han PKJ, Lewis KL, Biesecker LG, et al. Perceived
ambi-guity as a barrier to intentions to learn genome sequencing results. J Behav
Med. Springer New York LLC; 2015;38:715-26.
30. Schapira MM, Aggarwal C, Akers S, Aysola J, Imbert D, Langer C, et al. How patients
view lung cancer screening: The role of uncertainty in medical decision making. Ann
Am Thorac Soc. American Thoracic Society; 2016;13:1969-76.
31. Rosen NO, Knäuper B, Sammut J. Do individual differences in intolerance of
uncertainty af-fect health monitoring? Psychol Heal. Routledge ; 2007;22:413-30.
32. Hock M, Krohne HW, Kaiser J. Coping Dispositions and the Processing of Ambiguous
Stimuli. J Pers Soc Psychol. American Psychological Association Inc.;
1996;70:1052-66.
33. Krohne HW. Vigilance and cognitive avoidance as concepts in coping research. Atten
Avoid Strateg coping with aversiveness. 1993.
34. Van Osch SMC, Stiggelbout AM. The development of the Health-Risk Attitude Scale.
2007.
35. Oliveri S, Pravettoni G. Capturing how individuals perceive genetic risk
information: a phe-nomenological perspective. J Risk Res. Routledge;
2018;21:259-67.
36. Oliveri S, Scotto L, Ongaro G, Triberti S, Guiddi P, Pravettoni G. "You do not get
cancer by chance": Communicating the role of environmental causes in cancer
diseases and the risk of a "guilt rhetoric." Psychooncology. John Wiley and Sons
Ltd; 2019;28:2422-4.
37. Skop M, Lorentz J, Jassi M, Vesprini D, Einstein G. "Guys Don't Have Breasts": The
Lived Experience of Men Who Have BRCA Gene Mutations and Are at Risk for Male
Breast Cancer. Am J Mens Health. SAGE Publications Inc.; 2018;12:961-72.
38. Braddock K, Dillard JP. Meta-analytic evidence for the persuasive effect of
narratives on be-liefs, attitudes, intentions, and behaviors. Commun Monogr.
Routledge; 2016;83:446-67.
39. Jensen JD, King AJ, Carcioppolo N, Krakow M, Samadder NJ, Morgan S. Comparing
tailored and narrative worksite interventions at increasing colonoscopy adherence
in adults 50-75: A ran-domized controlled trial. Soc Sci Med. 2014;104:31-40.
40. van Peer W, Maat HP. Narrative perspective and the interpretation of characters'
motives. Lang Lit Int J Stylist. SAGE Publications Ltd; 2001;10:229-41.
41. Kahneman D, Tversky A. Prospect Theory: An Analysis of Decision Under Risk. 2013.
p. 99-127.
42. O'Keefe DJ, Jensen JD. The relative persuasiveness of gain-framed and loss-framed
messages for encouraging disease prevention behaviors: A meta-analytic review. J.
Health Commun. Taylor & Francis Group ; 2007. p. 623-44.
43. Kim HK, Lee TK. Conditional Effects of Gain-Loss-Framed Narratives among Current
Smok-ers at Different Stages of Change. J Health Commun. Taylor and Francis Inc.;
2017;22:990-8.
44. Brashers DE. Communication and Uncertainty Management. J Commun. Oxford University
Press (OUP); 2001;51:477-97.
45. Hesse-Biber S, An C. Within-Gender Differences in Medical Decision Making Among
Male Carriers of the BRCA Genetic Mutation for Hereditary Breast Cancer. Am J Mens
Health. SAGE Publications Inc.; 2017;11:1444-59.
46. Hallowell N, Ardern-Jones A, Eeles R, Foster C, Lucassen A, Moynihan C, et al.
Men's Deci-sion-Making About Predictive BRCA1/2 Testing: The Role of Family. J
Genet Couns. John Wiley & Sons, Ltd; 2005;14:207-17.
47. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: A flexible statistical power
analysis program for the social, behavioral, and biomedical sciences. Behav Res
Methods. Psychonomic Society Inc.; 2007. p. 175-91.
48. Luszczynska A, Schwarzer R, Lippke S, Mazurkiewicz M. Self-efficacy as a moderator
of the planning-behaviour relationship in interventions designed to promote
physical activity. Psychol Heal. Psychol Health; 2011;26:151-66.
49. Shim M, Kelly B, Hornik R. Cancer information scanning and seeking behavior is
associated with knowledge, lifestyle choices, and screening. J Health Commun. J
Health Commun; 2006;11:157-72.
50. Renner B. Hindsight bias after receiving self-relevant health risk information: A
motivational perspective. Memory. Taylor & Francis Group ; 2003;11:455-72.
51. Renner B. Biased Reasoning: Adaptive Responses to Health Risk Feedback. Personal
Soc Psy-chol Bull. Pers Soc Psychol Bull; 2004;30:384-96.
52. Dieteren CM, Brouwer WBF, Van Exel J. How do combinations of unhealthy behaviors
relate to attitudinal factors and subjective health among the adult population in
the Netherlands? BMC Public Health. BioMed Central Ltd.; 2020;20:441.
53. Bottesi G, Ghisi M, Novara C, Bertocchi J, e Ilaria MB, Dominicis D, et al.
Intolerance of un-certainty scale (IUS-27 e IUS-12): Due studi preliminari.
Psicoter Cogn e Comport. 2015;21:345-65.
