Background: Sepsis is a leading cause of mortality worldwide, yet sepsis knowledge remains poor and preventive strategies underused. We assessed the impact of the awareness campaign “SepsisWissen” (SepWiss) on vaccination coverage among German adult at-risk groups. Methods: Controlled before-after study (intervention vs. control regions). Primary outcome was vaccination coverage for seasonal Influenza, pneumococcal, meningococcal vaccines, and incidence for Haemophilus influenzae type b (Hib) vaccines among at-risk groups. Intervention effects were estimated using difference-in-differences generalized linear models with negative binomial distribution. Secondary outcomes were sepsis knowledge, emergency recognition, vaccination attitudes, assessed via longitudinal surveys and analyzed using multi-group structural equation models adjusted for baseline covariates. Findings: There was no evidence of a consistent intervention effect on vaccination uptake. Small positive effects were observed for influenza (age18–59; ratio of rate ratios (RRR) 1·031, 95%CI 1·02–1·04) and pneumococcal vaccination (age<18; RRR 1·15, 95%CI 1·09–1·22); small negative effects for pneumococcal (age60–69; RRR 0·90 95%CI 0·865–0·937) and meningococcal vaccination (age18–59; RRR 0·915 95%CI 0·857–0·977).In the post-campaign survey (n=260), self-reported campaign contact was higher in the intervention region (20·0% vs. 1·5%). We found no significant regional difference in sepsis knowledge after the campaign. In a planned subgroup analysis, participants reporting campaign contact showed higher sepsis knowledge (average treatment effect (ATE) = 3·02, p<0·01), and more positive attitudes toward influenza (ATE=0·16, p=0·04) and COVID-19 vaccination (ATE=0·38, p<0·01). Interpretation: Improvements among exposed individuals suggest that evidence-based sepsis communication can be effective when received. Sustainable impact liekly requires broader, sustained public messaging linked to actionable prevention pathways, for example through primary-care reminders and targeted insurer communication.

BACKGROUND:The Coronavirus disease 2019 (COVID-19) pandemic highlighted the importance of public adherence to pandemic management measures. Contempt for these measures could undermine compliance in future pandemics. This study explored associations between self-reported COVID-19 experiences and contemptuous beliefs about COVID-19 pandemic management. METHODS:A cross-sectional online survey study was conducted in September 2024 with 964 German citizens and 423 healthcare professionals from respondi panels (Cologne, Germany). Respondents reported their attitudes toward eight contemptuous statements regarding COVID-19 pandemic management and their personal COVID-19 experiences, including infection, vaccine side effects, long COVID, and patient care (for professionals). Associations were analyzed using logistic regression and Mann-Whitney U tests. RESULTS:Citizens with self-reported experience of COVID-19 infections were less likely to hold contemptuous beliefs (OR: 0.58; 95% CI: 0.39-0.85; P = .005), while those with experience of vaccine side effects were considerably more likely (OR: 1.50; 95% CI: 1.10-1.92; P = .009). Long COVID had no significant effect. Among professionals, not having cared for COVID-19 patients doubled the likelihood of contempt (OR: 2.10; 95% CI: 1.28-3.45; P = .003). CONCLUSION:Findings suggest that experiential factors may contribute to belief formation-an area with limited empirical attention but potential relevance for addressing societal polarization.

Postoperative delirium (POD) is a frequent and serious complication associated with increased morbidity and mortality. Although predictive models for POD exist, they are rarely implemented in routine clinical practice, partly due to their complexity and data requirements. Simple and interpretable tools based on routinely available data may improve clinical applicability. In this retrospective cohort study, we evaluated Fast-and-Frugal Trees (FFTrees) for predicting POD using routine electronic health record data from 61,150 surgical patients treated between 2017 and 2020 at a large German university hospital. We assessed the transferability of previously developed FFTrees and compared their performance with logistic regression, classification and regression trees, random forests, and support vector machines. Updated FFTrees were derived for pre- and peri-operative prediction. Previously published FFTrees showed reduced performance in routine data but improved after recalibration. Updated FFTrees achieved balanced accuracies of 58% (pre-operative) and 60% (peri-operative), with performance comparable to more complex models. Although predictive accuracy was moderate across all models, FFTrees offer advantages in simplicity, transparency, and ease of implementation. As easily memorized decision rules, they can help clinicians organize familiar cues in an optimal order, supporting delirium risk assessment in routine practice where more complex tools are rarely used.

Background Acceptance of containment measures during a pandemic depends not only on perceived effectiveness but also on personal experience, individual beliefs, and transparent public health communication. Objective To assess the perceived usefulness of 15 non-pharmaceutical interventions (NPIs) to contain the spread of COVID-19, the association with personal experience, temporal perspective, individual beliefs, and public demands for accountability for politicians and scientists. Methods In a cross-sectional online survey, 5116 adults in Germany rated the perceived usefulness of 15 pandemic NPIs across 3 points in time (temporal change). COVID-19-related experiences and agreement with eight contemptuous beliefs about pandemic management were assessed. Associations between temporal change, contemptuous beliefs, personal experience, and perceived usefulness of NPIs were investigated. Open questions were analysed using inductive content analysis. Results Perceived usefulness of NPIs varied, with indoor mask mandates evaluated as most useful and nightly curfews as least. Temporal perspectives and personal experiences with COVID-19 infection or with Long-Covid showed small effects. Vaccination yielded the strongest group differences: vaccinated individuals rated the NPIs more useful than unvaccinated participants. Low perceived usefulness of NPIs was associated with stronger endorsement of contemptuous beliefs. Nearly half of participants supported accountability demands, primarily for politicians. Conclusion Evaluations of NPIs were strongly shaped by personal experiences with the COVID-19 pandemic, especially vaccination status. Perceptions that NPIs were useless or that rationales were not communicated transparently were strongly associated with negative evaluations and higher contempt. To sustain trust and compliance in future crises, policymakers should engage early with public concerns while acknowledging uncertainty.

BackgroundTime-to-event outcomes from randomized controlled trials (RCTs) are often communicated without clearly conveying how treatment effects evolve over time. This can limit clinicians' ability to interpret results and support patient decision making.MethodsWe conducted an online experiment with 250 German general practitioners in April 2024. Participants evaluated treatment effects presented in 4 common formats: hazard ratios, prolongation of life, restricted mean survival time (RMST), and absolute risk reduction. We assessed 1) understanding, defined as the ability to correctly compare effect sizes (small, medium, large), and 2) acceptability of each format. We also tested whether providing baseline risk information (control group outcomes) improved performance.ResultsParticipants' effectiveness ratings did not differ between small, medium, and large treatment effects in any format. RMST presentations were judged less effective but more acceptable than the other formats. Providing baseline risk information did not influence effectiveness ratings or acceptance.LimitationsThe use of a convenience sample may limit generalizability.ConclusionsGeneral practitioners struggled to interpret time-to-event treatment effects across all formats. Although RMST was preferred, no format supported accurate understanding of effect size.ImplicationsCurrent approaches may not adequately support communication of time-to-event outcomes in clinical practice. More effective strategies are needed, likely combining absolute time-based measures with clear contextual information such as baseline risk.Registration:OSF 10.17605/OSF.IO/U69YMHighlightsTime-to-event outcomes from randomized trials are difficult for clinicians to interpret.General practitioners were unable to distinguish between small, medium, and large treatment effects across formats.Restricted mean survival time was preferred but did not improve understanding of time-to-event effects.Current formats do not support communication of time-to-event outcomes in clinical decision making.

BACKGROUND:In Germany, long-term prescribing of benzodiazepines and Z drugs remains common even though their use for no more than 30 days is recommended in the guidelines because of risks including dependence, cognitive impairment, and falling. In this randomized controlled trial, we studied whether social norm feedback can reduce non-guideline-compliant prescribing in outpatient practices. METHODS:Using routine prescribing data that we obtained from the Rhineland-Palatinate Association of Statutory Health Insurance Physicians (KV RLP) for the third and fourth quarters of 2022, we identified 1258 outpatient primary care practices that had issued non-guideline-compliant benzodiazepine or Z-drug prescriptions (≥30 days). These practices were randomized (1:1) to receive either social norm feedback or no feedback (629 practices in each group). The practices in the intervention group were sent a letter in June 2023 containing their prescribing percentile rank relative to other practices in the same specialty, as well as guideline recommendations; those in the control group were not contacted. The primary outcome was the change in defined daily doses (DDD) of non-guideline-compliant prescriptions per 1000 patients from Q3/Q4 2022 to Q3/Q4 2023. The data were analyzed by the intention-to-treat principle. 108 practices were lost to follow-up. RESULTS:The intervention group displayed a larger reduction in DDD of non-guideline-compliant prescriptions per 1000 patients (-6.5%, from 408.97 to 382.40) than the control group (-3.0%, from 401.38 to 389.30; p = 0.006), as well as in the percentage of patients receiving inappropriate prescriptions (-20.2% vs -6.6%; p < 0.001). The strongest effect was seen among practices that had been below the 65th percentile of non-compliant prescribing at baseline. CONCLUSION:This first randomized controlled trial on social norm feedback in Germany demonstrates that a simple, low-cost social norm intervention can reduce inappropriate benzodiazepine and Z-drug prescribing and help address an ongoing public health concern.

BACKGROUND:In 1962, the idea emerged that medical students' tolerance of uncertainty could determine their specialty choice. While some studies supported this claim, others refuted it, often using independently developed instruments. We explored whether the reported link between specialty choice and uncertainty tolerance is more myth than evidence by employing established instruments to investigate whether specialty choice could be explained by variance in uncertainty tolerance. METHOD:We conducted a cross-sectional online survey at two periods of time. From February to June 2023, we queried 563 final-year medical students from 34 German medical universities (1) on their uncertainty tolerance using three validated tools (the modified tolerance for ambiguity scale, the physicians' reaction to uncertainty scale and the uncertainty intolerance scenario method) and (2) on their intended specialty choice. In a follow-up 1 year later (May to June 2024), 263 of those medical students responded to our query on their final specialty choice and again on their uncertainty tolerance. RESULTS:Participants' (N = 563) median age was 26.0 years (mean: 27.2; SD = 3.8), and 70% (n = 396) were female. Originally reported differences and rank orders in uncertainty tolerance among medical students with different intended specialty choices could not be replicated for any of the three scales. Instead, our results suggest different rank orders of uncertainty tolerance by different tools, as well as nonsignificant differences between intended medical specialties. Intercorrelation coefficient analyses demonstrated that, depending on the scale, only 0.3% to 1.5% of the variance in uncertainty tolerance could be attributed to specialty choice. Follow-up data using actual instead of intended medical choices left findings unchanged. DISCUSSION:Our findings suggest that the presumed link between uncertainty tolerance and specialty choice is more myth than evidence. Instead of teaching this link or using it as an admissions criterion, medical schools should equip students with the skills needed to navigate uncertainty across their careers.

Lay perceptions of risks are often at odds with their empirical assessments, particularly regarding risks of peers. Going beyond only considering perceived peer risks, this study explored whether the actual social environment of a person informs their individual COVID risk perception. A cohort of Psychology freshmen (N = 88; academic year 2021/22) was surveyed about their COVID infection status in the past year, prevalence estimates within their cohort, and their social relationships. They were further queried on their expected susceptibility for a COVID infection within the forthcoming month and the potential severity of such an infection. Average student estimation of 1-year prevalence rates (71.8%) were in line with the self-reported prevalence of the cohort (69.8%, p = .110) and took infection prevalence in their social circle into account (β = 0.24, p = .025). This social circle prevalence also contributed to the individual assessment of COVID susceptibility (β = 0.24, p = .031), but not the severity of the disease (β = 0.05, p = .671). These results indicate that the perception of prevalence among peers is not necessarily biased and that social cues of prevalence in the environment are considered when estimating individual susceptibility.

Background: Postoperative delirium (POD) is a critical and distressing condition, making identification of high-risk patients essential. Yet, complexity of existing predictive models limits their practical use. This study evaluates fast-and-frugal decision trees (FFTrees)—simple binary prediction algorithms—and compares them to complex algorithms using routine clinical data from a large German hospital.Objectives: To evaluate the utility of FFTrees in predicting POD and compare performance against complex algorithms.Design: Retrospective cohort study.Setting: Routine clinical data from three campuses of a German hospital.Participants: 61,150 patients who underwent surgery between 2017 and 2020.Interventions: Two FFTrees—previously established for pre- and peri-operative settings using research data—were tested, compared against complex algorithms (logistic regression, classification and regression trees, random forests, support vector machines), and two novel FFTrees were developed for the clinical dataset.Main Outcome Measures: Predictive performance assessed by balanced accuracy (mean of sensitivity and specificity).Results: Established FFTrees achieved balanced accuracies of 54% pre-operatively and 59% peri-operatively after thresholds were adjusted to the routine clinical dataset. FFTrees outperformed complex comparators in the pre- and peri-operative setting. The novel pre-operative FFTree identified age, American Society of Anesthesiologists status, and type of surgery as key predictors, achieving a balanced accuracy of 58%. The novel peri-operative FFTree highlighted age, anesthesia duration, and pre-existing conditions as key predictors, achieving a balanced accuracy of 60%.Conclusion: FFTrees serve as practical diagnostic tools for adhering to POD risk assessment guidelines and offer a feasible alternative to more complex models in routine clinical practice.

Background: Despite clear recommendations from evidence-based guidelines to restrict tonsillectomies for adult patients with infrequent tonsillitis, adoption among German otolaryngologists remains limited. Social influences, including opinion leaders and perceived social norms across peers, may shape practitioners’ adherence to these guidelines. Purpose: This study examined how German otolaryngologists perceive peer social norms and opinion leaders regarding tonsillectomy guidelines, and how these perceptions relate to their own guideline adherence. Methods: In a cross-sectional online survey (N = 100), otolaryngologists reported their tonsillectomy practices, attitudes toward relevant guidelines, and perceptions of both peer and opinion leader behaviors. Guideline adherence was assessed via self-reported clinical decisions. Social influences were analyzed using ordinal logistic regression. Results: While most otolaryngologists reported guideline-consistent attitudes and behavior, many perceived their peers and opinion leaders as less adherent. Guideline adherence was significantly associated with individual tonsillectomy attitudes (OR = 0.18, p &lt; .001) and perceived opinion leader attitudes (OR = 0.33, p = .013), but not with perceptions of the general peer group or demographics. Conclusions: Otolaryngologists’ perceptions of opinion leaders are significantly associated with their adherence to tonsillectomy guidelines, even beyond their own attitudes. Misperceptions about peer and leader practices may hinder guideline diffusion. Interventions targeting opinion leaders and correcting misperceptions may accelerate guideline adoption in clinical practice.

To make reasonable future medical decisions, medical students need to be sufficiently educated to interpret diagnostic tests. Natural frequencies are considered the gold standard for understanding single diagnostic test results. However, they may be less suitable in situations involving sequential diagnostic testing. We test whether odds and likelihood ratios (odds/LR) may serve as a viable alternative in these situations. In our preregistered randomized-controlled crossover trial, we recruited 167 medical students and 162 psychology students. The proportion of correctly calculated positive predictive values of a single (PPV) and two sequential diagnostic tests (sPPV) was the primary, the subjective comprehensibility of the information the secondary outcome. The proportion of correct PPVs was significantly higher in the natural frequency (36.2 https://doi.org/10.17605/OSF.IO/F3297 .

Effective communication of health risks in the news media is essential for enabling informed decision-making among the public. To this end, health reporting should present baseline risks alongside the potential benefits and harms of interventions, using transparent numerical formats such as absolute risks and well-defined reference classes. Public concern over unclear risk communication during the COVID-19 pandemic highlights the need to assess reporting practices and identify areas for improvement. In this study, we analyzed 1,397 news articles from three major German outlets covering pandemic-related topics. Our findings indicate that while reports on mask-wearing rarely included numbers, articles on COVID-19-related mortality and vaccination frequently did —though often in nontransparent ways. The baseline risk of mortality was often reported as raw frequencies without standardized reference classes. Additionally, articles tended to emphasize either benefits or harms of vaccination, with benefits often framed as relative risks and harms as absolute risks, complicating direct comparison. These practices may hinder readers’ ability to accurately assess risks and make informed decisions. To enhance transparency and improve public understanding, journalists need targeted training and access to tools that support evidence-based risk communication. Supporting these practices could foster more informed choices and help strengthen public trust in health reporting.

BackgroundOveruse of medical care is a pervasive problem. Studies using hypothetical scenarios suggest that physicians’ risk literacy influences medical decisions; real-world correlations, however, are lacking. We sought to determine the association between physicians’ risk literacy and their real-world prescriptions of potentially hazardous drugs, accounting for conflicts of interest and perceptions of benefit–harm ratios in low-value prescribing scenarios.Setting and sampleCross-sectional study—conducted online between June and October 2023 via field panels of Sermo (Hamburg, Germany)—with a convenience sample of 304 English general practitioners (GPs).MethodsGPs’ survey responses on their treatment-related risk literacy, conflicts of interest and perceptions of the benefit–harm ratio in low-value prescribing scenarios were matched to their UK National Health Service records of prescribing volumes for antibiotics, opioids, gabapentin and benzodiazepines and analysed for differences.Results204 GPs (67.1%) worked in practices with ≥6 practising GPs and 226 (76.0%) reported 10–39 years of experience. Compared with GPs demonstrating low risk literacy, GPs with high literacy prescribed fewer opioids (mean (M): 60.60 vs 43.88 prescribed volumes/1000 patients/6 months, p=0.016), less gabapentin (M: 23.84 vs 18.34 prescribed volumes/1000 patients/6 months, p=0.023), and fewer benzodiazepines (M: 17.23 vs 13.58 prescribed volumes/1000 patients/6 months, p=0.037), but comparable volumes of antibiotics (M: 48.84 vs 40.61 prescribed volumes/1000 patients/6 months, p=0.076). High-risk literacy was associated with lower conflicts of interest (ϕ = 0.12, p=0.031) and higher perception of harms outweighing benefits in low-value prescribing scenarios (p=0.007). Conflicts of interest and benefit–harm perceptions were not independently associated with prescribing behaviour (all ps >0.05).Conclusions and relevanceThe observed association between GPs with higher risk literacy and the prescription of fewer hazardous drugs suggests the importance of risk literacy in enhancing patient safety and quality of care.

BackgroundAlthough transparency is crucial for building public trust, public health communication during the COVID-19 pandemic was often nontransparent.MethodsIn a cross-sectional online study with COVID-19 vaccine-hesitant German residents (N = 763), we explored the impact of COVID-19 public health communication on the attitudes of vaccine-hesitant individuals toward vaccines as well as their perceptions of incomprehensible and incomplete information. We also investigated whether specific formats of public health messaging were perceived as more trustworthy.ResultsOf the 763 participants, 90 (11.8%) said they had become more open-minded toward vaccines in general, 408 (53.5%) reported no change, and 265 (34.7%) said they had become more skeptical as a result of public health communication on COVID-19 vaccines. These subgroups differed in how incomprehensible they found public health communication and whether they thought information had been missing. Participants’ ranking of trustworthy public health messaging did not provide clear-cut results: the fully transparent message, which reported the benefit and harms in terms of absolute risk, and the nontransparent message, which reported only the benefit in terms of relative risk were both considered equally trustworthy (p = 0.848).DiscussionIncreased skepticism about vaccines during the COVID-19 pandemic may have partly been fueled by subpar public health communication. Given the importance of public trust for coping with future health crises, public health communicators should ensure that their messaging is clear and transparent.

BACKGROUND:Sepsis is a life-threatening organ dysfunction due to a dysregulated host response to infection. Annually, sepsis leads to approx. 90.000 deaths in Germany. Risk factors include amongst others older age (>60), innate or acquired dysfunction of the immune system, and underlying chronic diseases of the lung, heart, liver, or kidneys. The manifestation of sepsis is a medical emergency, and patient outcomes depend on timely diagnosis and immediate treatment. In addition, vaccinations e.g., against pneumococci or influenza virus, are a highly effective public health tool to prevent the most common underlying infections that may lead to sepsis. However, a lack of public awareness for the relevance of vaccination and detecting sepsis as an emergency underlines the need for public health interventions that address these issues. SepWiss aims to evaluate the effects of a multimodal information campaign designed to address this lack of awareness among the risk population in Germany. METHODS:SepWiss is an intervention at state level, consisting of a multimodal information campaign targeting risk groups in the German federal states of Berlin and Brandenburg (intervention region). Based on available evidence, various information formats were developed and implemented by outdoor advertising, social media, educational formats and through stakeholders' platforms, starting in August 2021. The control region comprises of the remaining 14 German federal states. We will analyze vaccination coverage (primary outcome), and sepsis knowledge, the ability to detect sepsis as an emergency, and attitude towards vaccination (secondary outcomes) amongst the risk population in a controlled before-after comparison. The implementation is accompanied by a mixed-method process evaluation. DISCUSSION:SepWiss is the first project of its kind to evaluate a complex multi-faceted evidence-based information campaign with regards to the topics of vaccination coverage, and the importance of sepsis detection and prevention for the most vulnerable populations in Germany. Results will be valuable for informing further nationwide campaigns. TRIAL REGISTRATION:German Registry for Clinical Trials: DRKS00024475. Registered February 24th, 2021.

Die aktuelle & ouml;ffentliche Gesundheitskommunikation entspricht oft nicht den Bedingungen, die f & uuml;r eine informierte Entscheidungsfindung erforderlich sind. Im Gegenteil: Die & Ouml;ffentlichkeit erh & auml;lt h & auml;ufig unvollst & auml;ndige, intransparente und zum Teil irref & uuml;hrende Gesundheitsinformationen. Um das Vertrauen in die & ouml;ffentliche Gesund-heitskommunikation zu verbessern, fordern Forschergemeinschaften zunehmend die ausf & uuml;hrliche und transparente Darstellung aller relevanten Informationen, darunter auch das Ausma ss wissenschaftlicher Unsicherheit und die potenziellen Grenzen von Pr & auml;ventionsma ss nahmen. Current public health communication often does not meet the requirements neces-sary for informed decision-making. On the contrary: the general public often receives incomplete, intransparent and to some extent misleading health information. In order to foster trust in public health communication, research communities are increas-ingly calling for full and transparent disclosure of all relevant information, which includes the extent of scientific uncertainty and the potential limitations of preven-tive interventions.

Misrepresentation of peer behavior has often been observed in college students and may lead to over-expression of alcohol consumption and under-expression of studying. While social norm feedback approaches have had mixed success in addressing these misrepresentations and altering behavior, they may have been too unspecific to be effective and did not directly assess individual perception accuracy. We thus investigated how specific, one-time feedback on the behavioral distribution of alcohol consumption or study time of a clearly defined, individually-adjusted social circle would affect the respective norm estimations and behavior of a class of Psychology students (n = 89 in January) across their first year of study. Students overestimated alcohol consumption and partially underestimated studying norms. While social circle feedback on alcohol consumption did not clearly affect both individual estimation accuracy and alcohol consumption, feedback on peers' studying time increased studying with no clear effect on estimation accuracy. This indicates that social circle norm feedback may be suitable to evoke behavioral effects. The correction of the detected inaccuracies did not appear to be a precondition for the feedback to be effective.