1-in-X" bias: "1-in-X" format causes overestimation of health-related risks

According to the "1-in-X" effect, "1-in-X" ratios (e.g., 1 in 12) trigger a higher subjective probability than numerically equivalent "N-in-X*N" ratios (e.g., 3 in 36). Here we tested: (i) the effect on objective measures, (ii) its consequences for decision-making, (iii) whether this effect is a form of bias by measuring probability accuracy, and (iv) its amplification in people with lower health literacy and numeracy. In parallel-designed experiments, 975 participants from the general adult population participated in one of five experiments following a 2(format: "1-in-X" or "N-in-X*N") × 4(scenarios) mixed design. Participants assessed the risk of contracting a disease on either a verbal probability scale (Exp. 1), or a numerical probability/frequency scale with immediate (Exp. 2-3) or delayed presentation (Exp. 4-5). Participants also made a health-related decision and completed a health literacy and numeracy scale. The "1-in-X" ratios yielded higher probability perceptions than the "N-in-X*N" ratios and affected relevant decisions. Critically, the "1-in-X" ratios led to a larger objective overestimation of numerical probabilities than the "N-in-X*N" ratios. People with lower levels of health literacy and numeracy were not more sensitive to the bias. Health professionals should use "1-in-X" ratios with great caution when communicating to patients, because they overestimate health risks.