Client-directed interventions to increase community demand for breast, cervical, and colorectal cancer screening a systematic review

Using concept mapping in the knowledge-to-action process to compare stakeholder opinions on barriers to use of cancer screening among South Asians

BACKGROUND

Using the knowledge-to-action (KTA) process, this study examined barriers to use of evidence-based interventions to improve early detection of cancer among South Asians from the perspective of multiple stakeholders.

METHODS

In 2011, we used concept mapping with South Asian residents, and representatives from health service and community service organizations in the region of Peel Ontario. As part of concept mapping procedures, brainstorming sessions were conducted with stakeholders (n = 53) to identify barriers to cancer screening among South Asians. Participants (n = 46) sorted barriers into groups, and rated barriers from lowest (1) to highest (6) in terms of importance for use of mammograms, Pap tests and fecal occult blood tests, and how feasible it would be to address them. Multi-dimensional scaling, cluster analysis, and descriptive statistics were used to analyze the data.

RESULTS

A total of 45 unique barriers to use of mammograms, Pap tests, and fecal occult blood tests among South Asians were classified into seven clusters using concept mapping procedures: patient's beliefs, fears, lack of social support; health system; limited knowledge among residents; limited knowledge among physicians; health education programs; ethno-cultural discordance with the health system; and cost. Overall, the top three ranked clusters of barriers were 'limited knowledge among residents,' 'ethno-cultural discordance,' and 'health education programs' across surveys. Only residents ranked 'cost' second in importance for fecal occult blood testing, and stakeholders from health service organizations ranked 'limited knowledge among physicians' third for the feasibility survey. Stakeholders from health services organizations ranked 'limited knowledge among physicians' fourth for all other surveys, but this cluster consistently ranked lowest among residents.

CONCLUSION

The limited reach of cancer control programs to racial and ethnic minority groups is a critical implementation issue that requires attention. Opinions of community service and health service organizations on why this deficit in implementation occurs are fundamental to understanding the solutions because these are the settings in which evidence-based interventions are implemented. Using concept mapping within a KTA process can facilitate the engagement of multiple stakeholders in the utilization of study results and in identifying next steps for action.

An automated intervention with stepped increases in support to increase uptake of colorectal cancer screening: a randomized trial

BACKGROUND

Screening decreases colorectal cancer (CRC) incidence and mortality, yet almost half of age-eligible patients are not screened at recommended intervals.

OBJECTIVE

To determine whether interventions using electronic health records (EHRs), automated mailings, and stepped increases in support improve CRC screening adherence over 2 years.

DESIGN

4-group, parallel-design, randomized, controlled comparative effectiveness trial with concealed allocation and blinded outcome assessments. (ClinicalTrials.gov: NCT00697047)

SETTING

21 primary care medical centers.

PATIENTS

4675 adults aged 50 to 73 years not current for CRC screening.

INTERVENTION

Usual care, EHR-linked mailings ("automated"), automated plus telephone assistance ("assisted"), or automated and assisted plus nurse navigation to testing completion or refusal ("navigated"). Interventions were repeated in year 2.

MEASUREMENTS

The proportion of participants current for screening in both years, defined as colonoscopy or sigmoidoscopy (year 1) or fecal occult blood testing (FOBT) in year 1 and FOBT, colonoscopy, or sigmoidoscopy (year 2).

RESULTS

Compared with those in the usual care group, participants in the intervention groups were more likely to be current for CRC screening for both years with significant increases by intensity (usual care, 26.3% [95% CI, 23.4% to 29.2%]; automated, 50.8% [CI, 47.3% to 54.4%]; assisted, 57.5% [CI, 54.5% to 60.6%]; and navigated, 64.7% [CI, 62.5% to 67.0%]; P < 0.001 for all pair-wise comparisons). Increases in screening were primarily due to increased uptake of FOBT being completed in both years (usual care, 3.9% [CI, 2.8% to 5.1%]; automated, 27.5% [CI, 24.9% to 30.0%]; assisted, 30.5% [CI, 27.9% to 33.2%]; and navigated, 35.8% [CI, 33.1% to 38.6%]).

LIMITATION

Participants were required to provide verbal consent and were more likely to be white and to participate in other types of cancer screening, limiting generalizability.

CONCLUSION

Compared with usual care, a centralized, EHR-linked, mailed CRC screening program led to twice as many persons being current for screening over 2 years. Assisted and navigated interventions led to smaller but significant stepped increases compared with the automated intervention only. The rapid growth of EHRs provides opportunities for spreading this model broadly.

The association between chronic disease and physical disability among female Medicaid beneficiaries 18-64 years of age

BACKGROUND

Rates of physical disability are higher in women than in men, and economically disadvantaged women are at greater risk for physical disability than women with higher incomes. Chronic diseases increase the risk of physical disability, and people with physical disability experience some added risks of secondary conditions including chronic disease. Yet, little is known about the prevalence of chronic disease among women living with a physical disability who use Medicaid, a particularly disadvantaged population.

OBJECTIVE

This study described the prevalence of chronic disease among adult (18-64 years), female, Florida Medicaid beneficiaries living with a physical disability between 2001 and 2005.

METHODS

Using Medicaid eligibility and claims files, we extracted ICD-9 codes for physically-disabling conditions and Current Procedure Terminology codes for mobility-assistive devices to define three levels of physical disability.

RESULTS

Participants appeared to be at high risk for both physical disability and chronic diseases. Close to half of the women had been diagnosed with one or more physically-disabling conditions, and 5.3% used mobility devices. One-third of the women had hypertension and sizeable proportions had other chronic diseases. Women with physical disability were more likely to have co-morbid chronic diseases than their able-bodied counterparts.

DISCUSSION

Our findings support the need for improved chronic disease prevention among female Medicaid beneficiaries, particularly those with physical disability. Strategies to improve prevention, screening and treatment in this population may mitigate the trends toward higher physical disability rates in the low-income, working-age population and may prevent high Medicare and Medicaid costs in the long-run.

Increasing the use of preventative health services to promote healthy eating, physical activity and weight management: the acceptability and potential effectiveness of a proactive telemarketing approach

BACKGROUND

Telephone based interventions are effective in promoting health behaviours. The use of telephone based support services to promote healthy eating, activity or weight loss, however, are currently under-utilised. The aim of this study was to assess the acceptability and potential effectiveness of a telemarketing approach in increasing community use of proactive services to encourage healthy eating, physical activity and weight loss.

METHODS

The study employed a cross sectional design. Eligible consenting participants completed a 15 minute telephone survey conducted by trained telephone interviewers using computer assisted telephone interviewing technology.

RESULTS

Overall, 87% of participants considered it acceptable for a health service to contact people by telephone to offer assistance to help them lose weight, eat healthily or be more physically active. Among participants with inadequate fruit and vegetable intake, physical activity or who were overweight, 64%, 54% and 61% respectively reported that they would use one or more of the proactive support services offered. Females and those from non -English speaking households who did not eat sufficient serves were significantly more likely to report that they would use support services.

CONCLUSIONS

The findings suggest that proactive telemarketing of health services to facilitate healthy eating, physical activity or weight loss is considered highly acceptable and may be effective in encouraging service use by more than half of all adults with these behavioural risks.

Relationship between colorectal cancer screening adherence and knowledge among vulnerable rural residents of Appalachian Kentucky

BACKGROUND

Colorectal cancer (CRC) is 1 of the leading causes of cancer-related deaths among residents of rural Appalachia. Rates of guideline-consistent CRC screening in Appalachian Kentucky are suboptimal.

OBJECTIVE

This study sought to determine the relationship between CRC screening knowledge, specifically regarding recommended screening intervals, and receipt of screening among residents of rural Appalachian Kentucky.

METHODS

Residents of Appalachian Kentucky (n = 1096) between the ages of 50 and 76 years completed a telephone survey including questions on demographics, health history, and knowledge about CRC screening between November 20, 2009, and April 22, 2010.

RESULTS

Although 67% of respondents indicated receiving screenings according to guidelines, respondents also demonstrated significant knowledge deficiencies about screening recommendations. Nearly half of respondents were unable to identify the recommended screening frequency for any of the CRC screening modalities. Accuracy about the recommended frequency of screening was positively associated with screening adherence.

CONCLUSIONS

Enhanced educational approaches have the potential to increase CRC screening adherence in this population and reduce cancer mortality in this underserved region.

IMPLICATIONS FOR PRACTICE

Nurses play a critical role in patient education, which ultimately may increase screening rates. To fulfill this role, nurses should incorporate current recommendation about CRC screening into educational sessions. Advanced practices nurses in rural settings should also be aware of the increased vulnerability of their patient population and develop strategies to enhance awareness about CRC and the accompanying screening tests.

Factors influencing adherence to mammography screening guidelines in Appalachian women participating in a mobile mammography program

The objectives of this study were to evaluate the characteristics (demographic, access to care, health-related behavioral, self and family medical history, psychosocial) of women age 40 years and above who participated in a mobile mammography screening program conducted throughout West Virginia (WV) to determine the factors influencing their self-reported adherence to mammography screening guidelines. Data were analyzed using the Andersen Behavioral Model of Healthcare Utilization framework to determine the factors associated with adherence to mammography screening guidelines in these women. Of the 686 women included in the analysis, 46.2% reported having had a mammogram in the past 2 years. Bivariate analyses showed predisposing factors such as older age and unemployed status, visit to a obstetrician/gynecologist (OB/GYN) in the past year (an enabling factor) and need-related factors such as having a family history of breast cancer (BC), having had breast problems in the past, having had breast biopsy in the past, having had a Pap test in past 2 years, and having had all the screenings for cholesterol, blood glucose, bone mineral density and high blood pressure in past 2 years to be significant predictors of self-reported adherence to mammography guidelines. In the final model, being above 50 years (OR=2.132), being morbidly obese (OR=2.358), having BC-related events and low knowledge about mammography were significant predictors of self-reported adherence. Breast cancer related events seem to be associated with mammography screening adherence in this rural Appalachian population. Increasing adherence to mammography screening may require targeted, community-based educational interventions that precede and complement visits by the mobile mammography unit.

Implementation and process evaluation of a workplace colorectal cancer screening program in eastern Washington

Colorectal cancer screening is a life-saving intervention, but screening rates are low. The authors implemented and evaluated the Spokane Colorectal Cancer Screening Program-a novel worksite intervention to promote colorectal cancer screening that used a combination of evidence-based strategies recommended by the Guide to Community Preventive Services, as well as additional strategies. Over a period of approximately 3 months, participating worksites held one or more physician-led seminars about colorectal cancer screening for employees. They also distributed free fecal immunochemical tests at the worksite to employees 50 years and older, and they provided test results to employees and their primary care physician. The authors measured attendance at seminars, test kits taken and returned, employee awareness of the program, and colorectal cancer screening rates in participating and comparison worksites. It is estimated that 9% of eligible employees received kits at the worksite, and 4% were screened with these kits. The Spokane Colorectal Cancer Screening Program was a promising pilot test of an innovative worksite screening program that successfully translated evidence-based strategies into practical use in a brief period of time, and it merits a larger study to be able to test its effects more rigorously.

Interventions to improve screening and follow-up in primary care: a systematic review of the evidence

BACKGROUND

The American Academy of Pediatrics and other organizations recommend several screening tests as part of preventive care. The proportion of children who are appropriately screened and who receive follow-up care is low.

OBJECTIVE

To conduct a systematic review of the evidence for practice-based interventions to increase the proportion of patients receiving recommended screening and follow-up services in pediatric primary care.

DATA SOURCE

Medline database of journal citations.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

We developed a strategy to search MEDLINE to identify relevant articles. We selected search terms to capture categories of conditions (eg, developmental disabilities, obesity), screening tests, specific interventions (eg, quality improvement initiatives, electronic records enhancements), and primary care. We searched references of selected articles and reviewed articles suggested by experts. We included all studies with a distinct, primary care-based intervention and post-intervention screening data, and studies that focused on children and young adults (≤21 years of age). We excluded studies of newborn screening.

STUDY APPRAISAL AND SYNTHESIS METHODS

Abstracts were screened by 2 reviewers and articles with relevant abstracts received full text review and were evaluated for inclusion criteria. A structured tool was used to abstract data from selected articles. Because of heterogeneous interventions and outcomes, we did not attempt a meta-analysis.

RESULTS

From 2547 returned titles and abstracts, 23 articles were reviewed. Nine were pre-post comparisons, 5 were randomized trials, 3 were postintervention comparisons with a control group, 3 were postintervention cross-sectional analyses only, and 3 reported time series data. Of 14 articles with preintervention or control group data and significance testing, 12 reported increases in the proportion of patients appropriately screened. Interventions were heterogeneous and often multifaceted, and several types of interventions, such as provider/staff training, electronic medical record templates/prompts, and learning collaboratives, appeared effective in improving screening quality. Few articles described interventions to track screening results or referral completion for those with abnormal tests. Data were often limited by single-site, nonrandomized design.

CONCLUSIONS

Several feasible, practice- and provider-level interventions appear to increase the quality of screening in pediatric primary care. Evidence for interventions to improve follow-up of screening tests is scant. Future research should focus on which specific interventions are most effective, whether effects are sustained over time, and what interventions improve follow-up of abnormal screening tests.

Effectiveness of interventions to increase screening for breast, cervical, and colorectal cancers: nine updated systematic reviews for the guide to community preventive services

CONTEXT

Screening reduces mortality from breast, cervical, and colorectal cancers. The Guide to Community Preventive Services previously conducted systematic reviews on the effectiveness of 11 interventions to increase screening for these cancers. This article presents results of updated systematic reviews for nine of these interventions.

EVIDENCE ACQUISITION

Five databases were searched for studies published during January 2004-October 2008. Studies had to (1) be a primary investigation of one or more intervention category; (2) be conducted in a country with a high-income economy; (3) provide information on at least one cancer screening outcome of interest; and (4) include screening use prior to intervention implementation or a concurrent group unexposed to the intervention category of interest. Forty-five studies were included in the reviews.

EVIDENCE SYNTHESIS

Recommendations were added for one-on-one education to increase screening with fecal occult blood testing (FOBT) and group education to increase mammography screening. Strength of evidence for client reminder interventions to increase FOBT screening was upgraded from sufficient to strong. Previous findings and recommendations for reducing out-of-pocket costs (breast cancer screening); provider assessment and feedback (breast, cervical, and FOBT screening); one-on-one education and client reminders (breast and cervical cancer screening); and reducing structural barriers (breast cancer and FOBT screening) were reaffirmed or unchanged. Evidence remains insufficient to determine effectiveness for the remaining screening tests and intervention categories.

CONCLUSIONS

Findings indicate new and reaffirmed interventions effective in promoting recommended cancer screening, including colorectal cancer screening. Findings can be used in community and healthcare settings to promote recommended care. Important research gaps also are described.

The SUCCEED Legacy Grant program: enhancing community capacity to implement evidence-based interventions in breast and cervical cancer

The Southeastern U.S. Collaborative Center of Excellence in the Elimination of Disparities Legacy Grant Program provides funding to increase community-based organizations' capacity to implement evidence-based breast and cervical cancer interventions for African American women. This article describes the development of the grant process, summarizes Legacy grantee outcomes, and discusses lessons learned.

Recruitment for the National Breast and Cervical Cancer Early Detection Program

BACKGROUND

To reduce disparities in breast and cervical cancer in the U.S., it is essential that programs such as CDC's National Breast and Cervical Cancer Early Detection Program (NBCCEDP) use evidence-based strategies. Recommendations for interventions to increase breast and cervical cancer screening have been disseminated by national public health organizations. To increase screening, cancer control planners would benefit from use of evidence-based strategies for recruitment of participants in their communities.

PURPOSE

The purpose of the study was to inventory recruitment activities for cancer screening within NBCCEDP programs and assess if activities used to increase cancer screening are evidence-based.

METHODS

Interviews were conducted with 61 recruitment coordinators in 2008 to elicit their recruitment activities, use of evidence-based resources, and barriers to using evidence-based interventions (EBIs). Study data were analyzed in 2009.

RESULTS

Of the 340 activities reported, many were categorized as educational materials, one-on-one education, mass media, group education, and special events. Two thirds of inventoried activities matched an EBI. Coordinators reported that colleagues and the CDC are their primary sources of information about EBIs and few coordinators had used evidence-based resources. Lack of money or funding, questionable applicability to priority populations, limited staffing or staff time, and insufficient evidence-based research were the most important barriers to EBI use.

CONCLUSIONS

Although the majority of NBCCEDP recruitment activities were evidence-based, one third were not. Additional training and technical assistance are recommended to help public health agencies adopt the use of these strategies.

The Italian health surveillance (SiVeAS) prioritization approach to reduce chronic disease risk factors

OBJECTIVE

Because public health funds are limited, programs need to be prioritized.

METHODS

We used data on 15 risk factors from Italy's public health surveillance to inform prioritization of programs. We ranked risk factors using a score based on the product of six criteria: deaths attributable to risk factors; prevalence of risk factors; risk factor prevalence trend; disparity based on the ratio of risk factor prevalence between low and high education attainment; level of intervention effectiveness; and cost of the intervention.

RESULTS

We identified seven priorities: physical inactivity; cigarette smoking (current smoking); ever told had hypertension; not having blood pressure screening; ever told had high cholesterol; alcohol (heavy drinking); not eating five fruits and vegetables a day; and not having a fecal occult blood test.

CONCLUSIONS

This prioritization method should be used as a tool for planning and decision making.

A web-based patient tool for preventive health: preliminary report

BACKGROUND

The Internet is a promising medium for engaging the community in preventive care and health promotion, particularly among those who do not routinely access health care.

OBJECTIVE

The authors pilot-tested a novel website that translates evidence-based preventive health guidelines into a patient health education tool. The web-based tool allows individuals to enter their health risk factors and receive a tailored checklist of recommended preventive health services based on up-to-date guidelines from the US Preventive Services Task Force and the Advisory Committee on Immunization Practices.

METHODS

The authors conducted surveys and in-depth interviews among a purposive sample of adults from an urban African American community who pilot-tested the website in a standardized setting. Interviews were designed to assess the usability, navigability, and content of the website and capture patient perceptions about its educational value and usefulness. Each interview was audiotaped, transcribed, and examined using the constant comparative method.

RESULTS

Twenty-five participants piloted the tool: 96% found it easy to use and 64% reported learning something new. Many participants reported that, in addition to improving clinical preventive care (the intended purpose), the website could serve as a stand-alone tool to improve self-awareness and motivate behavior change.

CONCLUSIONS

A web-based tool designed to translate preventive health guidelines for the community may serve the dual purpose of improving the delivery of preventive health care and encouraging health promotion. The website developed here is publicly available for use by practitioners and the community.

Integrating primary care and public health: learning from the Brazilian way

After a long history of vertical programming, specialisation and disintegration, general practitioners are now being urged to take on wider commissioning and public health responsibilities. The support structures are not in place, and integration of primary care with good public health practice is new territory. Innovation can be found in unlikely places. The Brazilian government has a 20-year history of a nationwide, integrated, comprehensive, community health programme that seamlessly bridges two important interfaces - between the community and primary care, and between primary care and public health. Some elements of this approach could be translated into the UK and would likely bring about improved clinical care, cost savings, improved understanding of local epidemiological variations and therefore commissioning. Understanding this approach is the first step to a new way of integrated commissioning, spanning and not reinforcing traditional clinical domains.

Systems strategies to support cancer screening in U.S. primary care practice

BACKGROUND

Although systems strategies are effective in improving health care delivery, little is known about their use for cancer screening in U.S. primary care practice.

METHODS

We assessed primary care physicians' (N = 2,475) use of systems strategies for breast, cervical, and colorectal cancer (CRC) screening in a national survey conducted in 2007. Systems strategies included patient and physician screening reminders, performance reports of screening rates, electronic medical records, implementation of in-practice guidelines, and use of nurse practitioners/physician assistants. We evaluated use of both patient and physician screening reminders with other strategies in separate models by screening type, adjusted for the effects of physician and practice characteristics with multivariate logistic regression.

RESULTS

Fewer than 10% of physicians used a comprehensive set of systems strategies to support cancer screening; use was greater for mammography and Pap testing than for CRC screening. In adjusted analyses, performance reports of cancer screening rates, medical record type, and in-practice guidelines were associated with use of both patient and physician screening reminders for mammography, Pap testing, and CRC screening (P < 0.05).

CONCLUSION

Despite evidence supporting use of systems strategies in primary care, few physicians report using a comprehensive set of strategies to support cancer screening.

IMPACT

Current health policy initiatives underscore the importance of increased implementation of systems strategies in primary care to improve the use and quality of cancer screening in the United States.

The effect of two types of sms-texts on the uptake of screening mammogram: a randomized controlled trial

OBJECTIVE

To compare the effect of two different types of short text message service (SMS-text) reminders on the uptake of screening mammogram.

METHODS

A randomized controlled trial was conducted in 2010 among females aged between 40 and 75, benefiting from the Health Insurance Plan at the American University of Beirut, whose cell phone numbers were available in their electronic medical records, and who did not do a mammogram in the past 2 years. The sample (n=385) was randomly divided into two subgroups. The first subgroup (n1=192) received a general SMS-text inviting its members to do a mammogram while the second subgroup (n2=193) received an additional informative SMS-text informing them about the benefits of mammogram screening.

RESULTS

30.7% (59) of subgroup 1 and 31.6% (61) of subgroup 2 underwent a mammogram screening test during the 6 months follow up interval post-intervention (Chi-square test, p-value ≥ 0.05). There was no difference between the response rates in the two subgroups.

CONCLUSION

A brief invitation SMS-text message for screening mammogram was found to be as effective as a detailed informative one.

Telephone counseling and attendance in a national mammography-screening program a randomized controlled trial

BACKGROUND

In Germany, a mammography-screening program (MSP) was implemented on a national level. It complies with all criteria of the European guidelines for quality assurance in screening mammography; however, the attendance rate is 54%, falling short of the target attendance rate of 70%. The aim of this study was to investigate whether additional telephone counseling improves attendance among nonresponders and the level of satisfaction with telephone counseling.

DESIGN

In a prospective RCT, women identified as nonresponders in the MSP were randomized to a control group that received written reminders or to an intervention group that additionally received telephone counseling. In a follow-up, a subset of the intervention group was contacted by telephone regarding their satisfaction with telephone counseling.

SETTING/PARTICIPANTS

In 2008, a total of 5477 women aged 50-69 years who were eligible for the German MSP but had not participated up to 6 weeks after the first invitation were included in the study.

INTERVENTIONS

Individual telephone counseling consisted of scripted calls from a trained counselor who provided information on MSP and answered the woman's questions.

MAIN OUTCOME MEASURES

Report of mammography use provided by the screening unit 3 months after the reminder was sent.

RESULTS

Analysis was conducted in 2009. Comparison of screening attendance revealed a significantly higher attendance rate in the intervention group compared with controls (29.7% vs 26.1%, p=0.0035). When only women for whom telephone numbers were available were analyzed, attendance was even better (35.5% vs 29.7%, p=0.0004). In the follow-up, 278 of 404 women were actually surveyed. Of those, 33% stated that telephone counseling had influenced their decision, 56% stated that they had undergone screening mammography, and 77% agreed that personal telephone counseling should be used routinely to encourage nonresponders to go for screening.

CONCLUSIONS

Individual telephone counseling for nonresponders to a national program for breast cancer screening was well accepted by participants and effective.

TRIAL REGISTRATION

This study is registered at the Australian New Zealand Clinical Trials Registry ACTRN12611000645954.

Effective interventions to facilitate the uptake of breast, cervical and colorectal cancer screening: an implementation guideline

BACKGROUND

Appropriate screening may reduce the mortality and morbidity of colorectal, breast, and cervical cancers. Several high-quality systematic reviews and practice guidelines exist to inform the most effective screening options. However, effective implementation strategies are warranted if the full benefits of screening are to be realized. We developed an implementation guideline to answer the question: What interventions have been shown to increase the uptake of cancer screening by individuals, specifically for breast, cervical, and colorectal cancers?

METHODS

A guideline panel was established as part of Cancer Care Ontario's Program in Evidence-based Care, and a systematic review of the published literature was conducted. It yielded three foundational systematic reviews and an existing guidance document. We conducted updates of these reviews and searched the literature published between 2004 and 2010. A draft guideline was written that went through two rounds of review. Revisions were made resulting in a final set of guideline recommendations.

RESULTS

Sixty-six new studies reflecting 74 comparisons met eligibility criteria. They were generally of poor to moderate quality. Using these and the foundational documents, the panel developed a draft guideline. The draft report was well received in the two rounds of review with mean quality scores above four (on a five-point scale) for each of the items. For most of the interventions considered, there was insufficient evidence to support or refute their effectiveness. However, client reminders, reduction of structural barriers, and provision of provider assessment and feedback were recommended interventions to increase screening for at least two of three cancer sites studied. The final guidelines also provide advice on how the recommendations can be used and future areas for research.

CONCLUSION

Using established guideline development methodologies and the AGREE II as our methodological frameworks, we developed an implementation guideline to advise on interventions to increase the rate of breast, cervical and colorectal cancer screening. While advancements have been made in these areas of implementation science, more investigations are warranted.

What implementation interventions increase cancer screening rates? a systematic review

BACKGROUND

Appropriate screening may reduce the mortality and morbidity of colorectal, breast, and cervical cancers. However, effective implementation strategies are warranted if the full benefits of screening are to be realized. As part of a larger agenda to create an implementation guideline, we conducted a systematic review to evaluate interventions designed to increase the rate of breast, cervical, and colorectal cancer (CRC) screening. The interventions considered were: client reminders, client incentives, mass media, small media, group education, one-on-one education, reduction in structural barriers, reduction in out-of-pocket costs, provider assessment and feedback interventions, and provider incentives. Our primary outcome, screening completion, was calculated as the overall median post-intervention absolute percentage point (PP) change in completed screening tests.

METHODS

Our first step was to conduct an iterative scoping review in the research area. This yielded three relevant high-quality systematic reviews. Serving as our evidentiary foundation, we conducted a formal update. Randomized controlled trials and cluster randomized controlled trials, published between 2004 and 2010, were searched in MEDLINE, EMBASE and PSYCHinfo.

RESULTS

The update yielded 66 studies new eligible studies with 74 comparisons. The new studies ranged considerably in quality. Client reminders, small media, and provider audit and feedback appear to be effective interventions to increase the uptake of screening for three cancers. One-on-one education and reduction of structural barriers also appears effective, but their roles with CRC and cervical screening, respectively, are less established. More study is required to assess client incentives, mass media, group education, reduction of out-of-pocket costs, and provider incentive interventions.

CONCLUSION

The new evidence generally aligns with the evidence and conclusions from the original systematic reviews. This review served as the evidentiary foundation for an implementation guideline. Poor reporting, lack of precision and consistency in defining operational elements, and insufficient consideration of context and differences among populations are areas for additional research.

A randomized controlled trial of a tailored interactive computer-delivered intervention to promote colorectal cancer screening: sometimes more is just the same

BACKGROUND

There have been few studies of tailored interventions to promote colorectal cancer (CRC) screening.

PURPOSE

We conducted a randomized trial of a tailored, interactive intervention to increase CRC screening.

METHODS

Patients 50-70 years completed a baseline survey, were randomized to one of three groups, and attended a wellness exam after being exposed to a tailored intervention about CRC screening (tailored group), a public web site about CRC screening (web site group), or no intervention (survey-only group). The primary outcome was completion of any recommended CRC screening by 6 months.

RESULTS

There was no statistically significant difference in screening by 6 months: 30%, 31%, and 28% of the survey-only, web site, and tailored groups were screened. Exposure to the tailored intervention was associated with increased knowledge and CRC screening self-efficacy at 2 weeks and 6 months. Family history, prior screening, stage of change, and physician recommendation moderated the intervention effects.

CONCLUSIONS

A tailored intervention was not more effective at increasing screening than a public web site or only being surveyed.

Do community health worker interventions improve rates of screening mammography in the United States? A systematic review

BACKGROUND

Community health workers (CHW) are lay individuals who are trained to serve as liaisons between members of their communities and health care providers and services.

METHODS

A systematic review was conducted to synthesize evidence from all prospective controlled studies on effectiveness of CHW programs in improving screening mammography rates. Studies reported in English and conducted in the United States were included if they: (i) evaluated a CHW intervention designed to increase screening mammography rates in women 40 years of age or older without a history of breast cancer; (ii) were a randomized controlled trial (RCT), case-controlled study, or quasi-experimental study; and (iii) evaluated a CHW intervention outside of a hospital setting.

RESULTS

Participation in a CHW intervention was associated with a statistically significant increase in receipt of screening mammography [risk ratio (RR): 1.06 (favoring intervention); 95% CI: 1.02-1.11, P = 0.003]. The effect remained when pooled data from only RCTs were included in meta-analysis (RR: 1.07; 95% CI: 1.03-1.12, P = 0.0005) but was not present using pooled data from only quasi-experimental studies (RR: 1.03; 95% CI: 0.89-1.18, P = 0.71). In RCTs, participants recruited from medical settings (RR: 1.41; 95% CI: 1.09-1.82, P = 0.008), programs conducted in urban settings (RR: 1.23; 95% CI: 1.09, 1.39, P = 0.001), and programs where CHWs were matched to intervention participants on race or ethnicity (RR: 1.58, 95% CI: 1.29-1.93, P = 0.0001) showed stronger effects on increasing mammography screening rates.

CONCLUSIONS

CHW interventions are effective for increasing screening mammography in certain settings and populations.

IMPACT

CHW interventions are especially associated with improvements in rate of screening mammography in medical settings, urban settings, and in participants who are racially or ethnically concordant with the CHW.

Reactions to a targeted intervention to increase fecal occult blood testing among average-risk adults waiting for screening colonoscopy

BACKGROUND

Increasing demand combined with limited capacity has resulted in long wait times for average-risk adults referred for screening colonoscopy for colorectal cancer. Management of patients on these growing wait lists is an emerging clinical issue.

OBJECTIVE

To inform the content and design of a mailed targeted invitation for patients to undergo annual fecal occult blood testing (FOBT) while awaiting colonoscopy.

METHODS

Focus groups (FGs) with average-risk patients on a wait list for screening colonoscopy at a high-throughput academic outpatient colonoscopy facility were conducted. During each FG session, feedback regarding a range of materials under consideration for the planned intervention was elicited using a semistructured facilitator guide. The FG sessions were recorded and transcribed verbatim, and analyzed using the constant comparative method to identify key themes.

RESULTS

Findings from the three FGs (n=28) suggested that average risk patients on a wait list for screening colonoscopy would be receptive to a targeted intervention recommending they undergo FOBT while waiting. Participants indicated that the invitation to undergo FOBT was an important acknowledgement that they were on an actively managed list, and that a mechanism to ensure that they were correctly triaged while waiting was in place. Several specific suggestions to improve the design of the targeted intervention were obtained.

CONCLUSIONS

Results of the present study provide useful information for developing effective strategies to manage average-risk individuals facing long wait times for screening colonoscopy.

Use of evidence-based strategies to promote mammography among medically underserved women

BACKGROUND

Several web-based resources recommend effective intervention strategies to promote use of mammography but there is limited information on whether the strategies are used, particularly by organizations that serve medically underserved women.

PURPOSE

In 2010, data collected by the Avon Breast Health Outreach Program (BHOP) were analyzed to examine the diffusion of evidence-based intervention strategies among funded organizations.

METHODS

Data on intervention strategies were obtained from a 2009 survey of Avon BHOP organizations funded during 2006-2009. Self-reported use of mammography was reported from annual intake forms administered to medically underserved women aged ≥40 years, excluding those with a history of breast cancer or initial enrollees not exposed to the strategies. Strategies reflected interventions reviewed in the Guide to Community Preventive Services. Those recommended to increase demand and use of mammography included (1) client reminders; (2) small media; (3) one-to-one education; (4) removal of structural barriers to rescreening; and (5) group education-and one that lacked sufficient evidence to warrant a recommendation (6) client incentives.

RESULTS

Among 86 organizations, 96% used three or more intervention strategies. The most common strategies were group education (91%) and client reminders (83%). The overall crude-percentage of recent mammography use was 84%. This percentage was similar for clinical sites and nonclinical sites, despite the disproportionate enrollment of medically underserved women in nonclinical sites.

CONCLUSIONS

The wide use of evidence-based strategies among Avon BHOP-funded organizations and high percentage of recent mammography use among women exposed to the strategies suggests that medically underserved women are benefiting from effective interventions to increase use of mammography.

Physicians' colorectal cancer screening discussion and recommendation patterns

BACKGROUND

Primary care physician (PCP) actions are pivotal to colorectal cancer (CRC) screening performance, and guidelines recommend discussion with patients about test options and potential benefits and harms. This article profiles patterns of discussion about and recommendations for screening and explores potential associations with multilevel factors (patient, clinician, practice, and environment).

METHODS

In 2009, we analyzed data from 1,266 physicians responding to the 2006-2007 National Survey of Primary Care Physicians' Recommendations and Practices for Breast, Cervical, Colorectal, and Lung Cancer Screening (absolute response rate=69.3%; cooperation rate=75.0%). Descriptive statistics examined physicians' reports of discussion and recommendations. Multivariate analyses assessed the associations of these practices with multilevel factors.

RESULTS

Although few respondents reported discussion of all options, 46% usually discuss more than one option; the vast majority of these respondents discuss fecal occult blood testing (FOBT) and colonoscopy (49%) or FOBT, sigmoidoscopy, and colonoscopy (32%). Of physicians who discuss more than one option, a majority reported usually recommending one or more test options, most commonly colonoscopy alone (43%) and FOBT and colonoscopy (43%). Several personal characteristics (specialty), perceived patient characteristics (prefer physician to decide), practice characteristics (geographic location), and community barriers (specialist availability) were independently associated with discussion and/or recommendation patterns.

CONCLUSIONS

PCPs do not discuss the full menu of test options, but many report selecting one or two options for discussion and recommendation. To ensure that patients' perspectives and concerns are elicited and considered, patient decision-making approaches should be considered.

IMPACT

Attention to informed decision making in CRC screening will be important for enhancing patient-centered quality care.

Cancer Screening Behaviors of African American Women Enrolled in a Community-Based Cancer Prevention Trial

Background: African American women have increased mortality rates for cervical, breast, and colorectal cancers, yet not all receive the recommended screening tests for these cancers. We characterized the cancer screening behaviors of African American women enrolled in a community-based cancer prevention trial. Methods: We examined cross-sectional data from 1123 African American customers aged ≥18 years from 37 beauty salons in North Carolina who completed the North Carolina BEAUTY and Health Project baseline survey. Mixed logistic regression models were used to identify correlates of receiving cervical, breast, and colorectal cancer screening tests within recommended screening guidelines. Results: Overall, 94% (1026 of 1089) of women aged ≥18 years reported receiving a Pap smear test within the last 3 years, 70% (298 of 425) of women aged ≥40 years reported receiving a mammography within the last year, and 64% (116 of 180) of women aged ≥50 years were considered to be within recommended screening guidelines for colorectal cancer. Age was correlated with recent Pap smear testing and mammography. Women who reported receiving a recent Pap smear test were more likely to report a mammogram in the last year, and women with a recent mammogram were more likely to be within recommended screening guidelines for colorectal cancer. Many women reported multiple barriers to getting recommended cancer screening tests. Conclusions: Almost all women reported receiving a Pap smear test within the last 3 years. Future interventions should focus on increasing breast and colorectal cancer screening among African American women.

Effectiveness of a patient and practice-level colorectal cancer screening intervention in health plan members: the CHOICE trial

BACKGROUND

Colorectal cancer (CRC) screening reduces CRC incidence and mortality but is underused. Effective interventions to increase screening that can be implemented broadly are needed.

METHODS

A controlled trial was conducted to evaluate a patient-level and practice-level intervention to increase the use of recommended CRC screening tests among health plan members. The patient-level intervention was a patient decision aid and included stage-targeted brochures that were mailed to health plan members. Intervention practices received academic detailing to prepare practices to facilitate CRC testing once patients were activated by the decision aid. We used patient surveys and claims data to assess CRC test completion.

RESULTS

Among 443 active participants, 75.8% were ages 52 to 59 years, 80.9% were white, 62.1% were women, and 46.4% had college degrees or greater education. Among 380 active participants with known screening status at 12 months based on survey results, 39% in the intervention group reported receiving CRC screening compared with 32.2% in the usual care group (unadjusted odds ratio [OR], 1.34; 95% confidence interval; [CI], 0.88-2.05; P = .17). After adjusting for baseline differences and accounting for clustering, the effect was somewhat larger (OR, 1.64; 95% CI, 0.98-2.73; P = .06). Claims analysis produced similar effects for active participants. The intervention was more effective in those who had incomes >$50,000 (OR, 2.16; 95% CI, 1.07-4.35) than in those who had lower incomes (OR, 1.25; 95% CI, 0.53-2.94; P = .03 for interaction).

CONCLUSIONS

Interventions combining a patient-directed decision aid and practice-directed academic detailing had a modest but statistically nonsignificant effect on CRC screening rates among active participants.

Women's cognitive and affective reactions to breast cancer survivor stories: a structural equation analysis

OBJECTIVE

Compare the immediate affective and cognitive reactions to cancer survivor stories about mammography and breast cancer vs. a didactic, informational approach.

METHODS

Participants (N=489) were African American women age 40 years and older (mean=61). Most had ≤high school education (67%), annual household income ≤$20,000 (77%), and a prior mammogram (89%). Participants completed surveys before and after watching the narrative or informational video. We used structural equation modeling to examine the large number of inter-related latent constructs.

RESULTS

Women who watched the narrative video experienced more positive and negative emotions, found it easier to understand the video, had more positive evaluations of the video, reported stronger identification with the message source (i.e., perceived similarity, trust, liking), and were more engaged with the video.

CONCLUSION

Narratives elicited immediate reactions consistent with theorized pathways of how communication affects behavior. Future studies should examine whether and how these immediate outcomes act as mediators of the longer term effects of narratives on affect, cognitions, and behavior.

PRACTICE IMPLICATIONS

Stories of other women's experiences may be more powerful than a didactic presentation when encouraging African American women to get a mammogram.

Using intervention mapping to promote the receipt of clinical preventive services among women with physical disabilities

This article describes the development of Promoting Access to Health Services (PATHS), an intervention to promote regular use of clinical preventive services by women with physical disabilities. The intervention was developed using intervention mapping (IM), a theory-based logical process that incorporates the six steps of assessment of need, preparation of matrices, selection of theoretical methods and strategies, program design, program implementation, and evaluation. The development process used methods and strategies aligned with the social cognitive theory and the health belief model. PATHS was adapted from the workbook Making Preventive Health Care Work for You, developed by a disability advocate, and was informed by participant input at five points: at inception through consultation by the workbook author, in conceptualization through a town hall meeting, in pilot testing with feedback, in revision of the curriculum through an advisory group, and in implementation by trainers with disabilities. The resulting PATHS program is a 90-min participatory small-group workshop, followed by structured telephone support for 6 months.

Results of a community-based randomized trial to increase colorectal cancer screening among Filipino Americans

OBJECTIVES

We conducted 1 of the first community-based trials to develop a multicomponent intervention that would increase colorectal cancer screening among an Asian American population.

METHODS

Filipino Americans (n = 548) nonadherent to colorectal cancer (CRC) screening guidelines were randomized into an intervention group that received an education session on CRC screening and free fecal occult blood test (FOBT) kits; a second intervention group that received an education session but no free FOBT kits; and a control group that received an education session on the health benefits of physical activity.

RESULTS

Self-reported CRC screening rates during the 6-month follow-up period were 30%, 25%, and 9% for participants assigned to intervention with FOBT kit, intervention without the kit, and control group, respectively. Participants in either of the 2 intervention groups were significantly more likely to report screening at follow-up than were participants in the control group.

CONCLUSIONS

A multicomponent intervention that includes an educational group session in a community setting can significantly increase CRC screening among Filipino Americans, even when no free FOBT kits are distributed.

Use of mass media campaigns to change health behaviour

Mass media campaigns are widely used to expose high proportions of large populations to messages through routine uses of existing media, such as television, radio, and newspapers. Exposure to such messages is, therefore, generally passive. Such campaigns are frequently competing with factors, such as pervasive product marketing, powerful social norms, and behaviours driven by addiction or habit. In this Review we discuss the outcomes of mass media campaigns in the context of various health-risk behaviours (eg, use of tobacco, alcohol, and other drugs, heart disease risk factors, sex-related behaviours, road safety, cancer screening and prevention, child survival, and organ or blood donation). We conclude that mass media campaigns can produce positive changes or prevent negative changes in health-related behaviours across large populations. We assess what contributes to these outcomes, such as concurrent availability of required services and products, availability of community-based programmes, and policies that support behaviour change. Finally, we propose areas for improvement, such as investment in longer better-funded campaigns to achieve adequate population exposure to media messages.

Finding the minimal intervention needed for sustained mammography adherence

BACKGROUND

Regular adherence to mammography screening saves lives, yet few women receive regular mammograms.

DESIGN

RCT.

SETTING/PARTICIPANTS

Participants were recruited through a state employee health plan. All were women aged 40-75 years and had recent mammograms prior to enrollment (n=3547). Data were collected from 2004 to 2009.

INTERVENTION

Trial tested efficacy of a two-step adaptively-designed intervention to increase mammography adherence over 4 years. The first intervention step consisted of three reminder types: enhanced usual care reminders (EUCR); enhanced letter reminders (ELR); both delivered by mail, and automated telephone reminders (ATR). After delivery of reminders, women who became off-schedule in any of the 4 years received a second step of supplemental interventions. Three supplemental intervention arms contained priming letters and telephone counseling: barriers only (BarriCall); barriers plus positive consequences of getting mammograms (BarriConCall+); and barriers plus negative consequences of not getting mammograms (BarriConCall-).

MAIN OUTCOME MEASURES

Average cumulative number of days non-adherent to mammography over 4 years based on annual screening guidelines (analyses conducted in 2009).

RESULTS

All reminders performed equally well in reducing number of days of non-adherence. Women randomized to receive supplemental interventions had significantly fewer days of non-adherence compared to women who received EUCR (p=0.0003). BarrConCall+ and BarrConCall- conditions did not significantly differ in days non-adherent compared to women in the barriers-only condition (BarriCon).

CONCLUSIONS

The minimal intervention needed for sustained mammography use is a combination of a reminder followed by a priming letter and barrier-specific telephone counseling for women who become off-schedule. Additional costs associated with supplemental interventions should be considered by organizations deciding which interventions to use.

TRIAL REGISTRATION NUMBER

NCT01148875.

Breast cancer screening interventions in selected counties across US regions

OBJECTIVES

To determine the types of, and the populations targeted by interventions implemented to increase breast cancer screening rates in counties with large African American populations across different US regions.

METHODS

A brief questionnaire was administered by e-mail to county representatives from 33 states from October 2008 through March 2009. Responses were obtained from 33% of 203 targeted counties.

RESULTS

Most counties (>80%) reported interventions for African American women and for women with low income. Women were exposed to different kinds of interventions depending on where they lived. Most counties in the Northeast (93%), Southwest (82%), and Midwest (100%) implemented interventions that provided free or low cost mammograms. Counties in the Southeast (83%) were more likely to report education interventions. Counties from the Southwest reported using a variety of interventions to encourage breast cancer screening.

CONCLUSION

In this selected group of counties, different types of interventions were used to increase breast cancer screening in minority and disadvantaged women. Interventions implemented were similar to those shown in the literature to be effective in increasing screening rates in specific populations. Future research should examine the use of screening interventions in a larger sample of US counties.

Pilot test of a peer-led small-group video intervention to promote mammography screening among Chinese American immigrants

This study evaluated the feasibility, acceptability, and potential effect of a small-group video intervention led by trained Chinese American lay educators who recruited Chinese American women not up to date on mammography screening. Nine lay educators conducted 14 Breast Health Tea Time Workshops in community settings and private homes that started with watching a culturally tailored video promoting screening followed by a question-and-answer session and distribution of print materials. Many group attendees did not have health insurance or a regular doctor, had low levels of income, and were not proficient in English. Forty-four percent of the attendees reported receipt of a mammogram within 6 months after the small-group session, with higher odds of screening among women who had lived in the United States less than 10% of their lifetime. Four of the educators were very interested in conducting another group session in the next 6 months.

Fecal occult blood testing beliefs and practices of U.S. primary care physicians: serious deviations from evidence-based recommendations

BACKGROUND

Fecal occult blood testing (FOBT) is an important option for colorectal cancer screening that should be available in order to achieve high population screening coverage. However, results from a national survey of clinical practice in 1999-2000 indicated that many primary care physicians used inadequate methods to implement FOBT screening and follow-up.

OBJECTIVE

To determine whether methods to screen for fecal occult blood have improved, including the use of newer more sensitive stool tests.

DESIGN

Cross-sectional national survey of primary care physicians.

PARTICIPANTS

Participants consisted of 1,134 primary care physicians who reported ordering or performing FOBT in the 2006-2007 National Survey of Primary Care Physicians' Recommendations and Practices for Cancer Screening.

MAIN MEASURES

Self-reported data on details of FOBT implementation and follow-up of positive results.

RESULTS

Most physicians report using standard guaiac tests; higher sensitivity guaiac tests and immunochemical tests were reported by only 22.0% and 8.9%, respectively. In-office testing, that is, testing of a single specimen collected during a digital rectal examination in the office, is still widely used although inappropriate for screening: 24.9% of physicians report using only in-office tests and another 52.9% report using both in-office and home tests. Recommendations improved for follow-up after a positive test: fewer physicians recommend repeating the FOBT (17.8%) or using tests other than colonoscopy for the diagnostic work-up (6.6%). Only 44.3% of physicians who use home tests have reminder systems to ensure test completion and return.

CONCLUSIONS

Many physicians continue to use inappropriate methods to screen for fecal occult blood. Intensified efforts to inform physicians of recommended technique and promote the use of tracking systems are needed.

Interventions to promote repeat breast cancer screening with mammography: a systematic review and meta-analysis

BACKGROUND

Various interventions to promote repeat use of mammography have been evaluated, but the efficacy of such interventions is not well understood.

METHODS

We searched electronic databases through August 15, 2009, and extracted data to calculate unadjusted effect estimates (odds ratios [ORs] and 95% confidence intervals [CIs]). Eligible studies were those that reported estimates of repeat screening for intervention and control groups. We tested homogeneity and computed summary odds ratios. To explore possible causes of heterogeneity, we performed stratified analyses, examined meta-regression models for 15 a priori explanatory variables, and conducted influence analyses. We used funnel plots and asymmetry tests to assess publication bias. Statistical tests were two-sided.

RESULTS

The 25 eligible studies (27 effect estimates) were statistically significantly heterogeneous (Q = 69.5, I(2) = 63%, P < .001). Although there were homogeneous subgroups in some categories of the 15 explanatory variables, heterogeneity persisted after stratification. For all but one explanatory variable, subgroup summary odds ratios were similar with overlapping confidence intervals. The summary odds ratio for the eight heterogeneous reminder-only studies was the largest observed (OR = 1.79, 95% CI = 1.41 to 2.29) and was statistically significantly greater than the summary odds ratio (P(diff) = .008) for the homogeneous group of 17 studies that used the more intensive strategies of education/motivation or counseling (OR = 1.27, 95% CI = 1.17 to 1.37). However, reminder-only studies remained statistically significantly heterogeneous, whereas the studies classified as education/motivation or counseling were homogeneous. Similarly, in meta-regression modeling, the only statistically significant predictor of the intervention effect size was intervention strategy (reminder-only vs the other two combined as the referent). Publication bias was not apparent.

CONCLUSIONS

The observed heterogeneity precludes a summary effect estimate. We also cannot conclude that reminder-only intervention strategies are more effective than alternate strategies. Additional studies are needed to identify methods or strategies that could increase repeat mammography.

Randomized controlled trial of mammography intervention in insured very low-income women

BACKGROUND

The expectation that insurance coverage mitigates health disparities and equalizes use of healthcare assumes that services are equally accessed; however, the insured low-income target population in this research had a mammography rate of 23.4%, well below the general population. Our objective was to determine the most effective intervention to improve mammography use in low-income women insured by a managed care organization (MCO).

METHODS

The study was a randomized controlled trial. Participants were 2,357 women noncompliant with screening mammography randomly assigned to one of three groups: control (n = 786) received usual care; simple intervention (n = 785) received prompt letter from the MCO medical director; and stepwise intervention (n = 786) received the same prompt letter from the MCO; if noncompliant, a second prompt letter from their primary care physician and, if still noncompliant, counseling from lay health workers. Outcome was completion of screening mammography extracted from medical records.

RESULTS

Screening rates were 13.4% for the control, 16.1% for the simple intervention, and 27.1% for the stepwise intervention. Compared with the control, the primary care physician letter in the stepwise intervention increased the likelihood of screening by 80% [Relative Risk (RR) = 1.80; P < 0.001], and counseling tripled the likelihood of screening (RR = 3.11; P < 0.001).

CONCLUSIONS

Compared with the control and simple intervention, a stepwise intervention to increase mammography is effective in a target population of hard-to-reach, low-income, insured women.

IMPACT

The research provides evidence for the impact of stepwise interventions to improve cancer screening in low-income insured populations, although the screening rates remain well below those of the general population.

The role of behavioral science theory in development and implementation of public health interventions

Increasing evidence suggests that public health and health-promotion interventions that are based on social and behavioral science theories are more effective than those lacking a theoretical base. This article provides an overview of the state of the science of theory use for designing and conducting health-promotion interventions. Influential contemporary perspectives stress the multiple determinants and multiple levels of determinants of health and health behavior. We describe key types of theory and selected often-used theories and their key concepts, including the health belief model, the transtheoretical model, social cognitive theory, and the ecological model. This summary is followed by a review of the evidence about patterns and effects of theory use in health behavior intervention research. Examples of applied theories in three large public health programs illustrate the feasibility, utility, and challenges of using theory-based interventions. This review concludes by identifying cross-cutting themes and important future directions for bridging the divides between theory, practice, and research.

Longitudinal predictors of nonadherence to maintenance of mammography

BACKGROUND

Regular adherence to screening mammography, also known as maintenance of mammography, reduces breast cancer morbidity and mortality. However, mammography maintenance is uncommon and little is known about why women do not maintain regular screening schedules. We investigated longitudinal predictors of women not maintaining adherence.

METHODS

Participants were insured women enrolled in an intervention trial who had screening mammograms 8 to 9 months before study enrollment (n = 1,493). Data were collected from 2003 to 2008. We used discrete event history analysis to model nonadherence to mammography maintenance over three successive annual screening intervals (+ 2 months).

RESULTS

Most (54%) women did not maintain screening adherence over 3 years. Women who did not maintain adherence were more likely to be ages 40 to 49 years, rate their health fair or poor, be less satisfied with their last mammography experiences, report one or more barriers to getting mammograms, be less than completely confident about getting their next mammograms (lower self-efficacy), or have weaker behavioral intentions. The odds of not maintaining adherence decreased over time.

DISCUSSION

Although great strides have been achieved in increasing the proportion of women who have received mammograms, most women still are not maintaining regular mammography use over time. Our findings provide insights into targets for future mammography maintenance interventions.

Optimization of preventive health care facility locations

BACKGROUND

Preventive health care programs can save lives and contribute to a better quality of life by diagnosing serious medical conditions early. The Preventive Health Care Facility Location (PHCFL) problem is to identify optimal locations for preventive health care facilities so as to maximize participation. When identifying locations for preventive health care facilities, we need to consider the characteristics of the preventive health care services. First, people should have more flexibility to select service locations. Second, each preventive health care facility needs to have a minimum number of clients in order to retain accreditation.

RESULTS

This paper presents a new methodology for solving the PHCFL problem. In order to capture the characteristics of preventive health care services, we define a new accessibility measurement that combines the two-step floating catchment area method, distance factor, and the Huff-based competitive model. We assume that the accessibility of preventive health care services is a major determinant for participation in the service. Based on the new accessibility measurement, the PHCFL problem is formalized as a bi-objective model based on efficiency and coverage. The bi-objective model is solved using the Interchange algorithm. In order to accelerate the solving process, we implement the Interchange algorithm by building two new data structures, which captures the spatial structure of the PHCFL problem. In addition, in order to measure the spatial barrier between clients and preventive health care facilities accurately and dynamically, this paper estimates travelling distance and travelling time by calling the Google Maps Application Programming Interface (API).

CONCLUSIONS

Experiments based on a real application for the Alberta breast cancer screening program show that our work can increase the accessibility of breast cancer screening services in the province.

Breast and cervical cancer screening specific effects of depression and obesity

BACKGROUND

Obesity and depression may each be associated with lower rates of cervical and breast cancer screening. Studies have examined obesity or depression alone, but not together, despite the established link between them.

PURPOSE

This article aims to disentangle the effects of depression and obesity on receipt of breast and cervical cancer screening.

METHODS

A stratified sampling design was used to recruit women aged 40-65 years with information on BMI from an integrated health plan in Washington State in 2003-2005. A telephone survey included the Patient Health Questionnaire-9 for depression, weight, and height. Automated data assessed Paps for 3097 women over a 3-year period and screening mammograms over a 2-year period for 2163 women aged > or =51 years. Logistic regression models (conducted in 2008) examined the association between obesity and depression and receipt of screening tests.

RESULTS

In univariate logistic regression models, women were less likely to receive a Pap if they were obese (OR=0.53, 95% CI=0.41, 0.69) or depressed (OR=0.60, 95% CI=0.42, 0.87). Further, women were less likely to receive a screening mammogram if they were depressed (OR=0.45, 95% CI=0.30, 0.67). In multivariable models, only obesity remained significantly associated with a lower likelihood of Pap screening (OR=0.67, 95% CI=0.0.49, 0.93), and only depression remained significantly associated with lower rates of screening mammography (OR=0.49, 95% CI=0.31, 0.76). Obesity and depression did not interact significantly in either model.

CONCLUSIONS

Obesity and depression appear to have specific effects on receipt of different cancer-screening tests.

Uptake of colorectal cancer screening: system, provider and individual factors and strategies to improve participation

Colorectal cancer (CRC) accounts for 9% of all new cancer cases worldwide and affects over 1 million people each year. Screening can reduce the mortality associated with the disease, yet participation rates are suboptimal. Compliers with CRC screening are less deprived; they have higher education than noncompliers and tend to be male, white and married. Likely reasons for nonparticipation encompass several 'modifiable' factors that could be targeted in interventions aimed at increasing participation rates. Successful intervention strategies include organizational changes, such as increasing access to fecal occult blood test (FOBT) kits, providing reminders to healthcare providers or users about screening opportunities, and educational strategies to improve awareness and attitudes towards CRC screening. Multifactor interventions that target more than one level of the screening process are likely to have larger effects. The biggest challenge for future research will be to reduce inequalities related to socio-economic position and ethnicity in the uptake of screening.

Factors in quality care--the case of follow-up to abnormal cancer screening tests--problems in the steps and interfaces of care

To achieve the benefit of cancer screening, appropriate follow-up of abnormal screening test results must occur. Such follow-up requires traversing the transition between screening detection and diagnosis, including several steps and interfaces in care. This article reviews factors and interventions associated with follow-up of abnormal tests for cervical, breast and colorectal cancers. We synthesized 12 reviews of descriptive and intervention studies published between 1980 and 2008. There was wide variability in definition of follow-up, setting, study population, and reported prevalence rates. Correlates of follow-up included patient characteristics (eg, knowledge and age), social support, provider characteristics, practice (eg, having reminders systems), community and professional norms (eg, quality measures), and policy (eg, federal programs). Effective interventions included patient education and support; delivery systems design changes, such as navigation; and information system changes, most notably patient tracking and physician reminders. Few studies focused explicitly on interfaces and steps of care, such as communication between primary care and specialists, or simultaneously targeted the multilevel factors that affect care. Future practice and research priorities should include development of clear operational definitions of the steps and interfaces related to patients, providers, and organizations; reflect evolving guidelines and new technologies; determine priorities for intervention testing; and improve measures and apply appropriate study designs.

Intervention to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers a systematic review of provider reminders

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet, not all people who should be screened are screened regularly or, in some cases, ever. This report presents results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of provider reminder/recall interventions to increase screening for breast, cervical, and colorectal cancers. These interventions involve using systems to inform healthcare providers when individual clients are due (reminder) or overdue (recall) for specific cancer screening tests. Evidence in this review of studies published from 1986 through 2004 indicates that reminder/recall systems can effectively increase screening with mammography, Pap, fecal occult blood tests, and flexible sigmoidoscopy. Additional research is needed to determine if provider reminder/recall systems are effective in increasing colorectal cancer screening by colonoscopy. Specific areas for further research are also suggested.

Organizational factors and the cancer screening process

Cancer screening is a process of care consisting of several steps and interfaces. This article reviews what is known about the association between organizational factors and cancer screening rates and examines how organizational strategies can address the steps and interfaces of cancer screening in the context of both intraorganizational and interorganizational processes. We reviewed 79 studies assessing the relationship between organizational factors and cancer screening. Screening rates are largely driven by strategies to 1) limit the number of interfaces across organizational boundaries; 2) recruit patients, promote referrals, and facilitate appointment scheduling; and 3) promote continuous patient care. Optimal screening rates can be achieved when health-care organizations tailor strategies to the steps and interfaces in the cancer screening process that are most critical for their organizations, the providers who work within them, and the patients they serve.

Behavioral theory in the context of applied cancer screening research

The U.S. health care system is indeed challenged to provide effective, equitable, and efficient care for its citizens (Aday, Begley, Lairson, & Balkrishnan, 2004 ). The past decades have witnessed profound concern about the quality of care Americans receive, the equality of care across racial ethnic communities, and the escalating costs of private and public coverage. These concerns apply to the cancer care continuum, including screening. This commentary reflects on the methods, findings, and implications of the articles from the Behavioral Constructs and Culture in Cancer Screening (3Cs) in this Health Education & Behavior supplement. This commentary considers several important themes for consideration in applied screening research, including the (a) focus on population diversity in a cultural context, (b) domains of social context and their importance, and (c) contributions of an interdisciplinary team and mixed methods to research productivity. Although the articles focus on breast cancer screening, the methods, observations, and recommendations are relevant to other screening tests.

Impact of mailed and automated telephone reminders on receipt of repeat mammograms: a randomized controlled trial

BACKGROUND

This study compares the efficacy of three types of reminders in promoting annual repeat mammography screening.

DESIGN

RCT.

SETTING AND PARTICIPANTS

Study recruitment occurred in 2004-2005. Participants were recruited through the North Carolina State Health Plan for Teachers and State Employees. All were aged 40-75 years and had a screening mammogram prior to study enrollment. A total of 3547 women completed baseline telephone interviews.

INTERVENTION

Prior to study recruitment, women were assigned randomly to one of three reminder groups: (1) printed enhanced usual care reminders (EUCRs); (2) automated telephone reminders (ATRs) identical in content to EUCRs; or (3) enhanced letter reminders that included additional information guided by behavioral theory. Interventions were delivered 2-3 months prior to women's mammography due dates.

MAIN OUTCOME MEASURES

Repeat mammography adherence, defined as having a mammogram no sooner than 10 months and no later than 14 months after the enrollment mammogram.

RESULTS

Each intervention produced adherence proportions that ranged from 72% to 76%. Post-intervention adherence rates increased by an absolute 17.8% from baseline. Women assigned to ATRs were significantly more likely to have had mammograms than women assigned to EUCRs (p=0.014). Comparisons of reminder efficacy did not vary across key subgroups.

CONCLUSIONS

Although all reminders were effective in promoting repeat mammography adherence, ATRs were the most effective and lowest in cost. Health organizations should consider using ATRs to maximize proportions of members who receive mammograms at annual intervals.