This article describes the rationale and empirical testing of an instrument to measure laypeople’s epistemic beliefs about medicine (EBAM).
Why are laypeople’s epistemic beliefs about medicine important and of interest for health psychology issues? For shared decision making and for patients’ treatment adherence, it is necessary for patients to understand the complexity and, at times, uncertainty of medical knowledge [1
]. Imagine a male patient diagnosed with high cholesterol. His general practitioner has made clear that he should avoid eating butter and red meat and that it might be of value to take some medication to lower the cholesterol level. The patient will probably search for additional information on what to do on the Internet [3
] (Google finds about 104.000.000 results for the keyword “cholesterol”). There, he will come across web pages with statements on the dangerousness as well as on the harmlessness of eating butter. He will find web pages that advertise a specific drug to lower cholesterol and Internet forums where patients describe (adventurous) alternative ways in how they control high cholesterol. In other words, he will be confronted with a plenitude of information and a multitude of opinions on a specific health-related problem. As a result, forming a conclusion about his future behavior will be quite difficult and the treatment of cholesterol may in his view be a complex and ill-structured problem (which it might also be in experts’ view [4
]). The patient will have to undertake the task to assess which information is more important and valid than other information, how conflicts between various perspectives of knowledge can be solved, and how conflicting evidence could be integrated into a viable framework of personal understanding and decision making. He will have to cope with the fact that there are alternative treatments, differing interpretations of symptoms or even several interpretations of the underlying pathophysiological explanations of illnesses and risks. How the patient assesses the controversies (both on his own and in the next consultation with the doctor), in how far he accepts that people disagree on what is the best solution, how he reconciles his own ideas with those of experts and whether he takes advice from his doctor is influenced by the beliefs he holds about the nature of medical knowledge and knowing, called epistemic beliefs.
Of course, whether the patient will take advice from his doctor and in how far he is willing to participate in the decision making process, is not only influenced by epistemic beliefs but also by many other factors, e.g. the patients’ degree of anxiety, age or even their numeracy skills [5
]. Furthermore, various characteristics of the doctor will play a role, e.g. his general consultation skills [6
] but also in how far he appears to be trustworthy and competent [7
] (and this evaluation of trustworthiness and competence might again be influenced by epistemic beliefs, see below).
Most problems patients are confronted with in medical decision making require knowledge and expertise which goes far beyond laypeople’s understanding. That is, patients depend on experts' explanations and advice and are not able to acquire the knowledge and skills which would be necessary to directly assess the experts' knowledge claims. However, patients will probably have a more general idea about what constitutes trustworthy and reliable knowledge claims, how one can obtain knowledge, or how to identify credible sources for (medical) information. That is, patients can refer to their epistemic beliefs when they need to reflect critically about medical information, evaluate what to believe, and which knowledge claim to support [8
]. Epistemic beliefs are furthermore seen to function as an “apprehension structure” [10
]: they allow for an anticipation of the knowledge to be learnt or to be dealt with, which includes for example an expectation of the complexity of a topic and of how much is already known about a topic.
As outlined above, medical problem solving often does not result in one clear solution, and the lack of relevant information for the problem-solving process is common [11
]. Because many health-related problems are contentious and lack clear-cut solutions, they can be described as ill-structured problems, that is, “problems about which reasonable people reasonably disagree” [13
]. Research in non-medical disciplines suggests that epistemic beliefs play an important role in dealing with such problems [8
]. Therefore, assessing laypeople’s epistemic beliefs about medicine is important.
As a result, patients’ epistemic beliefs play an important role in medical decision making. They can be seen as a “must” for the exercise of patient rights, as they can guide their medical decision making even though patients do not have a conceptual understanding of the problem at hand. However, also in the case that patients prefer a rather paternalistic decision making model, their epistemic beliefs will still play a role insofar as that they may guide the choice of the expert to be trusted.
Therefore, laypeople’s epistemic beliefs about medicine should become a topic for research in health psychology. Psychological research on epistemic beliefs provides a profound background for this target.
Research on epistemic beliefs
During the last two decades, epistemic beliefs have become a target of increased research interest in developmental and educational psychology [14
]. Epistemology as one cornerstone of philosophy embodies questions about the processes by which human knowledge is justified as well as questions about the nature of knowledge [17
]. This leads to the most often used definition of the construct epistemic beliefs which distinguishes between the nature of knowledge and the nature (or process) of knowing as the two core sets of concerns [18
]. How one conceptualizes knowledge and how it changes over time are seen as aspects of the nature of knowledge, while considerations about where knowledge comes from and how to make justifications refer to beliefs about the nature of knowing. Epistemic beliefs range from a less advanced view to more advanced epistemologies and develop through life and from educational experiences [19
]. Whereas a less advanced view includes beliefs such as that knowledge is certain and stable, either true or false, and can be handed down by an authority, a more advanced view is characterized by beliefs that knowledge is rather complex and relativistic, by accepting the uncertainty and changeability of truth, and acknowledging that knowledge is construed individually.
It is assumed that people possess both discipline-general and discipline-specific epistemic beliefs (beliefs about specific academic fields) concurrently [21
]. Discipline-specific beliefs are presumed to play a predominant role when working on a discipline-specific problem, while discipline-general beliefs influence motivation and engagement [17
For example, studies reveal the important role of epistemic beliefs in dealing with (scientific) controversies [25
]. An exemplary study [26
] investigated the influence of high school students’ epistemic understanding on the critical interpretation of a dual-position text. In this study, an initial test of epistemic understanding asked participants to indicate for pairs of contrasting statements whether they think that only one of the views described is right or whether both views could have some rightness and – depending on the response to this question (“if both could be right”) –whether one view could be better than the other. According to this initial test, participants were assigned to three groups of different epistemic positions: participants primarily holding a less advanced (seeing knowledge as absolute and either right or wrong), moderate (seeing knowledge as idiosyncratic, so that all positions are equally right), or more advanced view (seeing knowledge as derived from reason, so that some positions are more justified and sustainable than others). All participants read a scientific text about genetically modified food, introducing both the position in favor and against such food. After reading the text, participants were asked to write a conclusion to the text. Findings showed that students with more advanced and with moderate epistemic understanding reflected better on the inconclusive nature of the debate on transgenic food than students with less advanced beliefs.
Epistemic beliefs about medicine
To date, epistemic beliefs about medicine have rarely been considered in psychological or medical research [28
]. This is in sharp contrast to the assumed importance of such beliefs (outlined above). Evidence-based medicine comes along with the need for advanced epistemic beliefs [29
]. Epistemic beliefs about medicine should play a quite prominent role in everyday life, not least because “the life of every individual is ripe with opportunities for applying health related knowledge” [31
After a thorough review of the literature, few studies explicitly assessed beliefs about the nature of medical knowledge and knowing, and these studies did not deal with laypeople. In one study [29
], conceptions of medical knowledge in an exploratory interview study on second-year medical students were considered. Results show that most students started medical school with rather simplistic beliefs, for example, stating that if uncertainty existed in some aspects of medical knowledge, this uncertainty would only be temporary. Within their first two years in medical school, most students changed their understanding of medical knowledge with regard to its certainty and considered medical knowledge open to change or adaptation. That is, the experience that medical knowledge less black or white than assumed led students to question their former way of thinking about medical knowledge.
Another study [32
] attempted to elicit and analyze general practice trainees’ and trainers’ beliefs about medical knowledge and knowing in a focus-group approach. It concluded that people’s epistemic beliefs are probably influential in the solution of medical problems.
In sum, the nature of medical knowledge and knowing is not yet well researched, especially with regard to laypeople’s beliefs. One first attempt to assess laypeople’s epistemic beliefs about medicine is to develop an instrument to survey such beliefs. However, no such medicine-specific instrument exists. To date, research on laypeople’s views on knowledge about medicine has only considered laypeople’s subjective theories of illnesses [33
]. Therefore, the objective of the study described in the following is to develop an instrument to survey laypeople’s epistemic beliefs about medicine. More specifically, we aimed for an instrument that assesses different aspects of laypeople’s epistemic beliefs about medicine and that explicitly focuses on the appearance of medical knowledge in everyday life. Items should especially consider that laypeople must rely on others to justify their beliefs and particularly take into account the trustworthiness of different sources.