Tailored messages, external barriers, and women's utilization of professional breast cancer screening over time

Research Guided by the Theory of Care-Seeking Behavior: A Scoping Review

BACKGROUND

A particular Theory of Care-Seeking Behavior was developed to explain care-seeking behavior with psychosocial concepts, external conditions, and clinical and demographic factors. Having a careful review of studies based on this theory could guide future research on care-seeking behaviors.

OBJECTIVES

With a scoping review: describe characteristics of studies guided by a Theory of Care-Seeking Behavior, summarize support for the relationships of proposed, explanatory variables with care-seeking behaviors, and examine support for propositions in the theory.

METHOD

Searching 5 electronic databases, we sought studies that were: full-text, peer-reviewed, in English, data-based, guided by the theory, and published from January 1, 1992, to January 1, 2022.

RESULTS

Across 18 identified articles, the behaviors studied included: symptomatic screening (n = 8), asymptomatic screening (n = 7), and care-seeking behaviors for either screening or symptoms (n = 3). A total of 3328 adults participated in the studies. In 16 studies, all participants were female. In 60% to 83% of studies, researchers had reported findings that supported the relationships of explanatory concepts with care-seeking behavior. Among the 7 studies that tested the 2 propositions of theory, all 7 tests failed to support the proposition that clinical and demographic factors influence care-seeking behavior indirectly through psychosocial variables. Six tests supported the proposition that psychosocial variables influence behavior conditionally, on external conditions.

CONCLUSIONS

Relationships of these explanatory variables with care-seeking behaviors were supported, as was 1 of 2 propositions. The Theory of Care-Seeking Behavior can be applied to new clinical situations to continue to build knowledge of the theory and understanding of care-seeking behaviors.

Factors Associated with Screening Mammogram Uptake among Women Attending an Urban University Primary Care Clinic in Malaysia

Screening mammograms have resulted in a reduction in breast cancer mortality, yet the uptake in Malaysia was low. This study aimed to determine the prevalence and factors associated with screening mammogram uptake among women attending a Malaysian primary care clinic. A cross-sectional study was conducted among 200 women aged 40 to 74 attending the clinic. The data was collected using questionnaires assessing sociodemographic, clinical characteristics, knowledge and health beliefs. Multiple logistic regression was used to identify factors associated with mammogram uptake. The prevalence of screening mammograms was 46.0%. About 45.5% of women with high breast cancer risk had never undergone a mammogram. Older participants, aged 50 to 74 (OR = 2.57, 95% CI: 1.05, 6.29, p-value = 0.039) and those who received a physician’s recommendation (OR = 7.61, 95% CI: 3.81, 15.20, p-value < 0.001) were more likely to undergo screening mammography. Significant health beliefs associated with mammogram uptake were perceived barriers (OR = 0.81, 95% CI: 0.67, 0.97, p-value = 0.019) and cues to action (OR = 1.30, 95% CI: 1.06, 1.59, p-value = 0.012). Approximately half of the participants and those in the high-risk group had never undergone a mammogram. Older age, physician recommendation, perceived barriers and cues to action were significantly associated with mammogram uptake. Physicians need to play an active role in promoting breast cancer screening and addressing the barriers.

Rainbow of KIBOU project: Effectiveness of invitation materials for improving cancer screening rate using social marketing and behavioral economics approaches

Studies to date have shown that individual invitation (call) and re-invitation (recall) are effective in improving cancer screening rate. Also, by dividing subjects into segments and sending unique messages to each segment, the cancer screening rate is further improved. However, this approach is not realistic in the local governments due to limited resources, so we used social marketing and nudge techniques to develop cancer screening recommendation materials that do not need to send separately. This study therefore aimed to verify the effect of these materials in the real world. We compared the cancer screening rates in municipalities within Japan that used the invitation materials we developed (colorectal, breast, lung, cervical and stomach cancer), with those from the previous year. In addition, the usefulness of the materials in the real world was examined multilaterally using RE-AIM framework (Reach, Effectiveness, Adaption, Implementation, Maintenance). From 2015 to 2018, 4.3 million residents (Reach) from 787 municipalities (Adaption) were sent invitation materials for cancer screening. Of 167 municipalities that were compared, 141 (83%) showed an increase in screening rate when our materials were used. Overall, the screening rate improved by 2.6% or 1.44 fold (p < 0.001) (Effectiveness). However, the screening rate varied greatly depending on how screening is provided. Of the four years studied, 75 municipalities used the same materials for two or more years (Implementation). The material developed in this study improved the cancer screening rate in the real world, and it may be possible to further improve the screening rate if the number of opportunities for screening and its capacity is increased at the timing of sending materials. The materials can be found on the website (http://rokproject.jp/kenshin/) and free electronic files are available to municipalities wishing to use them.

Effects of nurse-led interventions on early detection of cancer: A systematic review and meta-analysis

BACKGROUND

Early detection of cancer serves an important strategy for cancer control, but its uptake rate remains relatively limited. Nurse-led interventions may have potential benefits for the early detection of cancer, but the evidence remains unclear.

OBJECTIVES

Synthesise the evidence on the impact of nurse-led interventions on early cancer detection. The primary outcome was early cancer detection uptake rate. Secondary outcomes were cancer knowledge, early detection beliefs, diagnosed precancerous lesions and early-stage cancers.

DESIGN

A systematic review and meta-analysis of randomised controlled trails.

DATA SOURCES

Eight English language databases (British Nursing Index, Cochrane Central Register of Controlled Trials, CINAHL Complete, EMBASE, Ovid Emcare, Medline, Scopus, Web of Science Core Collection) and three Chinese language databases (Chinese Biomedical Literature Databases, China Journal Net, and Wanfang Data) were searched from inception date to September 2019. Grey literature and reference lists of included studies were also examined.

REVIEW METHODS

Two reviewers independently assessed eligibility, extracted data and evaluated methodological quality using the Cochrane risk of bias (RoB 2.0) tool. Meta-analyses and descriptive analyses were used. Subgroup analyses were conducted for study settings and intervention types.

RESULTS

Ten studies examined the effects of nurse-led interventions, including education, patient reminders, counselling, and patient navigation, on early detection of breast or cervical cancer, colorectal cancer, and lung cancer. Nurse-led interventions improved the uptake rates of mammography [risk ratio (RR) = 1.97; 95% confidence interval (CI): 1.17-3.33; p = 0.01], clinical breast examination (RR = 2.16; 95% CI: 1.02-4.59; p = 0.05), regular breast self-examination (RR = 2.01; 95% CI: 1.54-2.63; p < 0.001), and colonoscopy (RR = 1.90; 95% CI: 1.57-2.30; p < 0.001), but not of faecal blood occult tests. Subgroup analyses showed significantly improved mammography and clinical breast examination uptake rates for interventions conducted at health centres, and that patient navigation had better effects on improving colonoscopy uptake rates than did counselling. The intervention also improved cancer knowledge, early detection beliefs, and cases of detected precancerous lesions.

CONCLUSIONS

Nurse-led interventions may improve early cancer detection uptake rates, cancer knowledge, early detection beliefs, and cases of detected precancerous lesions. The effects of nurse-led interventions conducted in home settings on improving mammography and clinical breast examination uptake rates may need further exploration. Patient navigation may be superior to counselling in improving colonoscopy uptake rates. Social media may be an option for delivering early cancer detection guidance, but needs to be further explored. Tweetable abstract: Nurse-led interventions have potential effects on promoting early detection of cancer.

Breast Cancer Screening in Women With Schizophrenia: A Systematic Review and Meta-Analysis

OBJECTIVE

Women with schizophrenia appear to receive breast cancer diagnoses at later stages of the disease compared with the general population. To study this disparity, this report reviewed and quantified the differences in rates of mammography screening for women with schizophrenia and other psychotic disorders compared with the general population.

METHODS

A systematic literature search was conducted in PubMed, Embase, Web of Science, and PsycINFO databases. Each database was searched from inception to September 14, 2018. The search strategy included search terms for breast cancer, mammography, schizophrenia, and psychosis. Two reviewers independently screened and evaluated eligible studies. The main outcome measure was the rate of mammography screening among women with schizophrenia and psychotic disorders versus a comparable population of women without these diagnoses. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for abstracting data, and the Newcastle-Ottawa Scale was used for assessing data quality. A meta-analysis with a random-effects model was performed.

RESULTS

From a total of 304 abstracts reviewed, 11 studies met the inclusion criteria, representing 25,447 women with diagnoses of schizophrenia or psychosis across four countries. The meta-analysis showed that women with schizophrenia were less likely than women without schizophrenia to receive mammography screening (pooled OR=0.50, 95% confidence interval=0.38-0.64, p<0.001). In subgroup analysis, this association was not significantly affected by quality of the study.

CONCLUSIONS

Women with schizophrenia and other psychotic disorders were about half as likely as the general population to receive mammography screening. Further research is needed to determine causes of this disparity.

Using Facebook to communicate mammography messages to rural audiences

OBJECTIVE

The purpose of this scholarly project was to answer the following question: What is the highest level of engagement achieved with a mammography campaign on Facebook?

DESIGN AND SAMPLE

An Idaho public health department implemented a tailored message mammography campaign on Facebook during Breast Cancer Awareness Month. Target sample for the Facebook campaign were women and men over the age of 40 in rural Idaho.

MEASURES

Data collected from Facebook were used to measure and stratify engagement into a hierarchy of six levels, with intent to get a mammogram representing the highest level of engagement. A survey measuring women's intent to a get a mammogram was distributed via an online link.

RESULTS

The posts reached 48,503 Facebook users-11,147 of the total reach were unique users. Intent to get a mammogram, the highest level of engagement, was stated both in Facebook comments and on the online survey. Forty-nine women completed the survey, and 82% of women expressed intent to get a mammogram in the next year.

CONCLUSION

This project conducted as a program evaluation demonstrates how public health nurses can develop, implement, and evaluate Facebook mammography campaigns in the future.

How Could Nurse Researchers Apply Theory to Generate Knowledge More Efficiently?

BACKGROUND

Reports of nursing research often do not provide adequate information about whether, and how, researchers applied theory when conducting their studies. Unfortunately, the lack of adequate application and explication of theory in research impedes development of knowledge to guide nursing practice.

OBJECTIVES

To clarify and exemplify how to apply theory in research.

METHODS

First we describe how researchers can apply theory in phases of research. Then we share examples of how three research teams applied one theory to these phases of research in three different studies of preventive behaviors.

CONCLUSIONS

Nurse researchers can review and refine ways in which they apply theory in guiding research and writing publications. Scholars can appreciate how one theory can guide researchers in building knowledge about a given condition such as preventive behaviors. Clinicians and researchers can collaborate to apply and examine the usefulness of theory.

CLINICAL RELEVANCE

If nurses had improved understanding of theory-guided research, they could better assess, select, and apply theory-guided interventions in their practices.

Consumer Health Informatics: Promoting Patient Self-care Management of Illnesses and Health

Consumer health informatics (CHI) is propelling important changes for medical providers and the lives of patients through information and communications technology. Independently, medical consumers seek, collect, and use health information for decision making. However, when constructing a CHI-based medical platform, high technology must be applied in a fully understandable and usable format for both health care providers and consumers. This study examines the present status of CHI and its effect on medical consumers. For the development of CHI, we discuss the need for tailored health communications and capacity building with chronic patients at the medical center. First, empowerment is a key characteristic needed for medical consumer health care management. However, promoting patient self-care management of illnesses and health is necessary to create conjugation where cooperation with medical service providers is possible. Also, establishing a health care delivery system that will support cooperation is necessary. Second, tailored health communications can uniquely construct the health information of patients, which prevents unnecessary or excessive information from leading patients to confused and inappropriate decisions. Ultimately, through the present environment of health communication, the innovation of a consumer health care information system has become the tide of the times and the positive effect of improved health can be expected.

Health Behavioural Theories and Their Application to Women's Participation in Mammography Screening

The most effective method of detecting breast cancer among asymptomatic women is by mammography screening. Most countries have this preventive measure in place for women within their society; however, most of these programs struggle with attendance. This article discusses four health behavioural theories and models in relation to mammography screening that may explain the factors affecting women's participation, including the health belief model, theory of planned behaviour, trans-theoretical model, and the theory of care seeking behaviour. In summary, analysis of these theories indicates that the theory of care seeking behaviour has value for exploring these factors because of its sensitivity to socioeconomic differences that exist among women in society and because it has a broader construct (such as habit and external factors) compared to the other health behavioural theories.

Exploring the relationship between patients' information preference style and knowledge acquisition process in a computerized patient decision aid randomized controlled trial

Background

We have shown in a randomized controlled trial that a computerized patient decision aid (P-DA) improves medical knowledge and reduces decisional conflict, in early stage papillary thyroid cancer patients considering adjuvant radioactive iodine treatment. Our objectives were to examine the relationship between participants’ baseline information preference style and the following: 1) quantity of detailed information obtained within the P-DA, and 2) medical knowledge.

Methods

We randomized participants to exposure to a one-time viewing of a computerized P-DA (with usual care) or usual care alone. In pre-planned secondary analyses, we examined the relationship between information preference style (Miller Behavioural Style Scale, including respective monitoring [information seeking preference] and blunting [information avoidance preference] subscale scores) and the following: 1) the quantity of detailed information obtained from the P-DA (number of supplemental information clicks), and 2) medical knowledge. Spearman correlation values were calculated to quantify relationships, in the entire study population and respective study arms.

Results

In the 37 P-DA users, high monitoring information preference was moderately positively correlated with higher frequency of detailed information acquisition in the P-DA (r = 0.414, p = 0.011). The monitoring subscale score weakly correlated with increased medical knowledge in the entire study population (r = 0.268, p = 0.021, N = 74), but not in the respective study arms. There were no significant associations with the blunting subscale score.

Conclusions

Individual variability in information preferences may affect the process of information acquisition from computerized P-DA’s. More research is needed to understand how individual information preferences may impact medical knowledge acquisition and decision-making.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-015-0168-0) contains supplementary material, which is available to authorized users.

Developing and evaluating an individually tailored intervention to increase mammography adherence among Chinese American women

BACKGROUND

Breast cancer consistently is the most commonly diagnosed cancer and the second most common cause of cancer mortality among Asian Americans in the United States. The incidence of breast cancer in Asian American women has been increasing at a much higher rate than in white women.

OBJECTIVES

A randomized control single-blind study was conducted comparing the efficacy of an individually tailored telephone counseling and National Cancer Institute brochure.

METHODS

The sample consisted of 193 Chinese American women with no breast cancer history. The participants were randomly assigned to either an intervention or a control group. Self-reported data that included demographic variables, knowledge, beliefs, and screening behaviors were collected at baseline and 4 months.

RESULTS

The intervention group had increased screening to 40% compared with 33% for the control group at 4 months; the difference was not statistically significant. When the subanalyses were performed, the intervention is effective in certain demographic groups (ie, elderly women aged ≥65 years and recent immigrants). The study intervention was well accepted by participants and perceived as feasible and culturally appropriate based on process evaluation.

CONCLUSIONS

The study also demonstrates the feasibility of recruiting and retaining eligible women to participate, and the results show that both study intervention and printed materials increase awareness of the importance of breast cancer screening and screening behaviors for Chinese American women.

IMPLICATIONS FOR PRACTICE

Oncology nurses and advanced practice nurses can play critical roles on this medically underserved population that experiences disparities in breast cancer mortality by providing culturally appropriate counseling to promote screening adherence.

[Barriers in the breast cancer screening and the role of nursing: an integrative review]

Mammographic breast cancer screening is a fact in developed countries. Nursing acts in different ways in this process, having an important role in the barriers related to non-adherence to screening, but its effectiveness is little proven, with limited number of clinical trials about this topic. An integrative review of the literature in PubMed and LILACS (Latin American Literature) was conducted, aiming to evaluate controlled clinical trials about nurse's role in breast cancer screening. It was used the key words breast cancer screening, clinical trials and nurse. From 110 publications in PubMed, 18 were clinical trials and showed the nurse's role in breast cancer screening. None publication was observed in LILACS database. This review shows the effectiveness of nursing in breast cancer screening, presenting new nurse's role in the multidisciplinary team that qualify actions related to women's health.

Online anonymous discussion between service users and health professionals to ascertain stakeholder concerns in using e-health services in mental health

Implementation of e-health in mental health services requires that we are aware of stakeholders' concerns. We ascertained the views of mental health professionals and mental health service users through the (1) development of 12 topics based on the research literature, (2) presentation to 31 participants (19 mental health professionals and 12 mental health service users) and discussion in three 1-week programmes, (3) thematic analysis of transcripts, and (4) comparison with the literature to identify areas requiring attention in e-health implementation. This method of engaging mental health service users and mental health professionals was effective. We identified areas that (1) should be the first to implement (e.g. discussion forums, email, and Skype), (2) where further education and engagement are necessary before e-health methods could be used (e.g. unsupported computerised cognitive behavioural therapy, computer-patient interviewing, and patient access to online medical records), and (3) for further research (e.g. the impact of bad online experiences).

Young women's reasons to seek sexually transmitted infection screening

OBJECTIVES

To describe young women's reasons to seek and not to seek sexually transmitted infection (STI) screening; to explore whether reasons differed by age and STI screening history.

DESIGN AND SAMPLE

Cross-sectional, descriptive. Female students (N = 216) at a university in the Midwestern United States.

MEASURES

An anonymous online survey was designed based on the Theory of Care Seeking Behavior and literature regarding STI screening among young women.

RESULTS

The most common reason to seek STI screening was to start treatment promptly (85%); the most common reason not to seek screening was being asymptomatic (54%). Participants' reasons differed by age and screening history. Women under 25 were more likely than women 25 and older to seek screening because of encouragement from female role models (p < .01). Women who had never been screened were more likely than women who had been screened to avoid screening because of embarrassment (p < .05). Novel findings included seeking STI screening because it "should be done" if sexually active and because of encouragement from female role models.

CONCLUSIONS

Health care and public health professionals can use these findings to develop strategies to improve STI screening rates among young women.

Understanding Hmong women's beliefs, feelings, norms, and external conditions about breast and cervical cancer screening

OBJECTIVES

To describe the beliefs, feelings, norms, and external conditions regarding breast and cervical cancer screening in a sample of Hmong women.

DESIGN AND SAMPLE

In a descriptive design, female Hmong researchers recruited 16 Hmong women (ages 24-73) at a community center. Guided by the Theory of Care Seeking Behavior (TCSB), researchers asked participants semi-structured questions about their beliefs, feelings, norms, and external conditions in a group setting. Researchers documented responses in writing and audio recordings. Guided by theory, we used directed content analysis to categorize responses.

RESULTS

Participants' beliefs' about screening included uncertainty about causes of breast and cervical cancer, uncertainty about Western forms of treatments, and terminal illness as outcomes of such cancer. Many felt embarrassed about breast and cervical cancer screening. Their cultural norms about undressing for an exam and listening to authority figures were different from Western norms. External conditions that influenced participants' for screenings included difficulties in communicating with interpreters and clinicians.

CONCLUSIONS

Consistent with the TCSB, Hmong women's beliefs, affect, cultural norms and external conditions helped to understand their use of breast and cervical screening. Findings could guide nursing and public health interventions to improve culturally sensitive, cancer screening for Hmong women.

Impact of a health communication intervention to improve glaucoma treatment adherence. Results of the interactive study to increase glaucoma adherence to treatment trial

OBJECTIVE

To determine the efficacy of an automated, interactive, telephone-based health communication intervention for improving glaucoma treatment adherence among patients in 2 hospital-based eye clinics.

METHOD

A total of 312 patients with glaucoma (18-80 years of age) were enrolled in a randomized controlled trial at 2 eye clinics located in hospitals in the southeastern United States. These patients were considered nonadherent because they did not take their medication, refill their medication, and/or keep their appointments. The treatment group received an automated, interactive, tailored, telephone-based health communication intervention and tailored print materials. The control group received usual care.

MAIN OUTCOME MEASURES

Adherence with medication taking, prescription refills, and appointment keeping measured by interviews, medical charts, appointment records, and pharmacy data.

RESULTS

A statistically significant increase was found for all adherence measures in both the intervention and control groups. Interactive telephone calls and tailored print materials did not significantly improve adherence measures compared with controls.

CONCLUSIONS

During the study period, patient adherence to glaucoma treatment and appointment keeping improved in both study arms. Participation in the study and interviews may have contributed. Strategies that address individuals' barriers and facilitators may increase the impact of telephone calls, especially for appointment keeping and prescription refills.

APPLICATION TO CLINICAL PRACTICE

Glaucoma patient care should include reminders about consistent use of medication and the importance of keeping appointments. More frequent, and personalized, telephone contact may be helpful to patients who are known to be nonadherent.

TRIAL REGISTRATION

clinicaltrials.gov Identifier:NCT00794170.

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.

It's the amount of thought that counts: when ambivalence contributes to mammography screening delay

PURPOSE

This study examines whether ambivalence toward mammography screening, as moderated by total amount of thought given to the reasons for and against getting mammograms at recommended intervals, predicts greater delay in obtaining subsequent screening mammograms.

METHODS

A sample of 3,430 insured women with recent (within the last 8-9 months) screening mammograms completed telephone interviews as part of a 5-year intervention study to achieve sustained adherence to annual-interval mammography. Delay was assessed by the number of days between mammograms.

RESULTS

Controlling for demographic factors and perceived screening barriers, days between mammograms increased as ambivalence and thought increased. Thought moderated ambivalence: Among women who were most ambivalent, women obtained mammograms 1 month earlier for each unit increase in thought.

CONCLUSION

Future studies should test innovative ways to resolve ambivalence and increase thought about consequences of getting mammograms as a strategy to promote mammography screening adherence.

Staffing time required to increase cancer-screening rates through telephone support

We describe the staff time required by the prevention care manager-tailored telephone support intervention, which significantly increased breast, cervical, and colorectal cancer-screening rates among female patients of Community Health Centers in New York City. For a sample of 38 women whose intervention was timed, prevention care managers spent an average of 99 minutes per woman on the phone and on related follow-up tasks over 18 months, or 248 minutes for each additional cancer-screening test obtained. Potential modifications to decrease the time required include automation of common tasks and the use of administrative data to further tailor outreach calls.

Mammography facilities are accessible, so why is utilization so low?

OBJECTIVE

This study examines new socio-ecological variables reflecting community context as predictors of mammography use.

METHODS

The conceptual model is a hybrid of traditional health-behavioral and socio-ecological constructs with an emphasis on spatial interaction among women and their environments, differentiating between several levels of influence for community context. Multilevel probability models of mammography use are estimated. The study sample includes 70,129 women with traditional Medicare fee-for-service coverage for inpatient and outpatient services, drawn from the SEER-Medicare linked data. The study population lives in heterogeneous California, where mammography facilities are dense but utilization rates are low.

RESULTS

Several contextual effects have large significant impacts on the probability of mammography use. Women living in areas with higher proportions of elderly in poverty are 33% less likely to use mammography. However, dually eligible women living in these poor areas are 2% more likely to use mammography than those without extra assistance living in these areas. Living in areas with higher commuter intensity, higher violent crime rates, greater land use mix (urbanicity), or more segregated Hispanic communities exhibit -14%, -1%, -6%, and -3% (lower) probability of use, respectively. Women living in segregated American Indian communities or in communities where more elderly women live alone exhibit 16% and 12% (higher) probability of use, respectively. Minority women living in more segregated communities by their minority are more likely to use mammography, suggesting social support, but this is significant for Native Americans only. Women with disability as their original reason for entitlement are found 40% more likely to use mammography when they reside in communities with high commuter intensity, suggesting greater ease of transportation for them in these environments.

CONCLUSIONS

Socio-ecological variables reflecting community context are important predictors of mammography use in insured elderly populations, often with larger magnitudes of effect than personal characteristics such as race or ethnicity (-3% to -7%), age (-2%), recent address change (-7%), disability (-5%) or dual eligibility status (-1%). Better understanding of community factors can enhance cancer control efforts.

A randomized trial of a tailored barriers intervention for Cancer Information Service (CIS) callers in pain

Cancer pain management can be improved by overcoming patients' attitudinal barriers to reporting pain and using analgesics. A simple cost-effective barriers intervention designed to reach a large number of persons with cancer has not yet been tested. Such an intervention should be tested against barriers' assessment-alone, as well as no-treatment control. The purpose of this study was to test the efficacy and the cost effectiveness of a tailored barriers intervention (TBI), an educational intervention tailored to participants' attitudinal barriers toward reporting pain and using analgesics. This was a randomized three-group (TBI, assessment-alone, or control) trial with measures at baseline and 28 days later conducted at the NorthCentral and Heartland offices of the Cancer Information Service (CIS), an NCI program that provides information to persons seeking answers to cancer-related questions. Participants (1256 adult CIS callers diagnosed with cancer with moderate to severe pain in the past week) joined the study and were randomized. Of these participants, 970 (77.23%) provided follow-up data. The TBI consisted of educational messages tailored to each participant's attitudinal barriers, delivered orally over the telephone, followed by a printed mailed copy. The outcome measures were attitudinal barriers to pain management, as well as pain outcomes (duration, severity, and interference with life activities). At follow-up the TBI group had significantly lower attitudinal barriers scores compared to assessment-alone and control, but the groups did not differ on the pain outcome variables. TBI and assessment-alone had similar cost effectiveness. The TBI needs to be strengthened to achieve reductions in pain severity.

Effects of program exposure and engagement with tailored prevention communication on sun protection by young adolescents

Few family-based interventions to increase sun safe behavior among adolescents have been evaluated. The present study tested an intervention that included tailored and nontailored print communications delivered by mail to adolescents (age 11 to 15) and their parents who were also participating in an evaluation of an in-school intervention. The use of sunscreen, protective clothing, and avoidance of the sun were promoted, and family communication and environmental change strategies were fostered. Adolescents and their parents were pretested in May of 2002 and posttested from August to October. Adolescents (N = 599) were stratified on experimental condition in the in-school study (in-school intervention vs control) and randomly were assigned from within strata to receive (N = 288) or not receive (N = 311) the summer intervention materials. No statistically significant effects were found for adolescents between the randomized experimental conditions. Parents' had increased knowledge (F = 5.52, p < .05) and propensity to have their child wear sunglasses (F = 4.07, p < .05). Greater program exposure/engagement led to enhanced sun protection behavior (e.g., fewer sunburns) and psychosocial factors among adolescents and parents. Greater exposure/engagement led to improvements in family interaction and home environment (e.g., shade audit completed). Future research is needed on exposure/engagement with family-based health messaging and on family-based sun safety programs for adolescents.

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

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, either regularly or, in some cases, ever. This report presents the results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of interventions designed to increase screening for breast, cervical, and colorectal cancers by increasing community demand for these services. Evidence from these reviews indicates that screening for breast cancer (mammography) and cervical cancer (Pap test) has been effectively increased by use of client reminders, small media, and one-on-one education. Screening for colorectal cancer by fecal occult blood test has been increased effectively by use of client reminders and small media. Additional research is needed to determine whether client incentives, group education, and mass media are effective in increasing use of any of the three screening tests; whether one-on-one education increases screening for colorectal cancer; and whether any demand-enhancing interventions are effective in increasing the use of other colorectal cancer screening procedures (i.e., flexible sigmoidoscopy, colonoscopy, double contrast barium enema). Specific areas for further research are also suggested in this report.

Tailored interventions to promote mammography screening: a meta-analytic review

OBJECTIVE

To evaluate the effectiveness of tailored interventions, designed to reach one specific person based on her unique characteristics, for promoting mammography use.

METHOD

This systematic review used meta-analytic techniques to aggregate the effect size of 28 studies published from 1997 through 2005. Potential study-level moderators of outcomes (sample, intervention, and methodological characteristics) were also examined.

RESULTS

A small but significant aggregate odds ratio effect size of 1.42 indicated that women exposed to tailored interventions were significantly more likely to get a mammogram (p<0.001). The type of population recruited and participants' pre-intervention level of mammography adherence did not significantly influence this effect. Tailored interventions that used the Health Belief Model and included a physician recommendation produced the strongest effects. Interventions delivered in person, by telephone, or in print were similarly effective. Finally, defining adherence as a single recent mammogram as opposed to regular or repeated mammograms yielded higher effect sizes.

CONCLUSION

Tailored interventions, particularly those that employ the Health Belief Model and use a physician recommendation, are effective in promoting mammography screening. Future investigations should strive to use more standardized definitions of tailoring and assessments of mammography outcomes.

Comparison of three methods to increase knowledge about breast cancer and breast cancer screening in screening mammography patients

RATIONALE AND OBJECTIVES

The specific aim of the study was to determine which of several cost-effective interventions is best able to improve the breast cancer knowledge of women who present for screening mammography.

MATERIALS AND METHODS

A total of 198 English-speaking women, with no personal or family history of breast cancer, were recruited and randomized to four groups when they presented to the clinic for a screening mammogram. All women filled in a demographic data form and answered a questionnaire containing nine questions about breast cancer, risk, and screening to assess their knowledge and perception. Three educational interventions were tested in this study. The first consisted of a brochure, which provided answers to the questionnaire items and addressed the issues in more depth. The second intervention was an educational conversation with a specially trained mammography technologist. She reviewed the subject's answers to the questionnaire items correcting and/or clarifying them. The third intervention consisted of the brochure together with the conversation with a trained technologist. There was also a control group that just filled in the study questionnaire but did not receive an educational intervention. The same questionnaire was administered by telephone 4 to 6 weeks after the screening experience to all study subjects. Changes in their knowledge and perceptions of breast cancer were measured and compared.

RESULTS

A statistically significant increase in knowledge was found in all of the three investigated groups compared to the control group. There were no statistically significant differences in the amount of increase between women who underwent different interventions.

CONCLUSIONS

All three interventions resulted in increased knowledge about breast cancer and screening. No differences in the amount of knowledge increase were found between three interventions tested. The educational brochure seems to represent the most convenient and least costly method to increase knowledge about breast cancer and screening among women who present for screening mammography.

A systematic review of mammography educational interventions for low-income women

OBJECTIVE

We conducted a systematic review to examine the effectiveness of educational interventions in increasing mammography screening among low-income women.

DATA SOURCES

Bibliographic databases, including MEDLINE, The Cochrane Central Register of Controlled Trials, The Cochrane Database of Systematic Reviews, and the ISI Web of Science, were searched for relevant articles.

STUDY INCLUSION AND EXCLUSION CRITERIA

Randomized, community-based trials targeting low-income women and published between January 1980 and March 2003 were included.

DATA EXTRACTION

The search yielded 242 studies; 24 met all inclusion criteria.

DATA SYNTHESIS

Three studies used mammography vans, three used low-cost vouchers or provided free mammograms, three used home visits, one used community education alone, one provided referrals, five incorporated multiple intervention strategies, two used phone calls, one used videos and print material, and five used primarily print material.

RESULTS

Of nine studies that reduced barriers to care via mammography vans, cost vouchers, or home visits, eight showed statistically significant increases in mammography screening. Seven of the eight studies that used peer educators had significant increases in screening, as did four of the five studies that used multiple (intervention) components.

CONCLUSIONS

Interventions that used peer educators, incorporated multiple intervention strategies, or provided easy access via vans, cost vouchers, or home visits were effective in increasing screenings. Mailed letter or telephone reminders were not effective in trials involving low-income women, which is contrary to findings from middle/upper-income studies.

Randomized controlled trial of a repeat mammography intervention: effect of adherence definitions on results

BACKGROUND

As overall mammography rates approach national goals, mammography promotion efforts must increasingly focus on repeat adherence. This randomized controlled trial examined the effect of two interventions on repeat mammography utilization using various adherence definitions.

METHODS

1,558 women aged 40-63 receiving a mammogram through a federally funded screening program were randomized to three groups: mailed reminder (minimum group); mailed thank you card, newsletters, and reminder (maximum group); no mailings (control). The primary outcome (repeat mammogram) was assessed 13, 15, 18, and 24 months after the qualifying mammogram using administrative data.

RESULTS

The proportions receiving a repeat mammogram within 13 months were 0.28, 0.30, and 0.32 for control, minimum, and maximum groups, respectively. The corresponding proportions were 0.38, 0.43, and 0.45 at 15 months; 0.43, 0.49, and 0.51 at 18 months; and 0.47, 0.52, and 0.54 at 24 months. There were no significant differences across study groups at 13 months. The differences between control and maximum subjects at 15, 18, and 24 months were statistically significant. The differences between control and minimum subjects were significant only at 18 months.

CONCLUSIONS

The two low-cost mailed interventions evaluated modestly increased repeat mammography utilization. However, effects were not visible until at least 15 months after the qualifying mammogram.

Long-term results from a randomized controlled trial to increase cancer screening among attendees of community health centers

PURPOSE

We assessed whether increased cancer screening rates that were observed with Cancer Screening Office Systems (Cancer SOS) could be maintained at 24 months' follow-up, a period in which clinics were expected to be largely self-sufficient in maintaining the intervention.

METHODS

Eight primary care clinics serving disadvantaged populations in Hills-borough County, Fla, agreed to take part in a cluster-randomized experimental trial. Charts of independent samples of established patients aged 50 to 75 years were abstracted, with data collected at baseline (n = 1,196) and at 24 months' follow-up (n = 1,296). Papanicolaou (Pap) smears, mammography, and fecal occult blood testing were assessed.

RESULTS

At 24 months of follow-up, intervention patients had received a greater number of cancer screening tests (mean 1.17 tests vs 0.94 tests, t test = 4.42, P <.0001). In multivariate analysis that controlled for baseline screening rates, secular trends, and other patient and clinic characteristics, the intervention increased the odds of mammograms slightly (odds ratio [OR]) = 1.26; 95% confidence interval [CI], 1.02-1.55; P = .03) but had no effect on fecal occult blood tests (OR = 1.17; 95% CI, 0.92-1.48; P =0.19) or Pap smears (OR = 0.88; 95% CI, 0.0.68-1.15; P = .34).

CONCLUSIONS

The Cancer SOS intervention had persistent, although modest, effects on screening at 24 months' follow-up, an effect that had clearly diminished from results reported at 12 months' follow-up. Further study is needed to develop successful intervention strategies that are either self-sustaining or that are able to produce long-term changes in screening behavior.

Patient-Centered Interventions

BACKGROUND

Nurse researchers in incontinence have focused on testing the effects of standardized interventions; however, nurses in practice usually customize interventions with patients. Patient-centered interventions promise to bring research and practice closer together.Tailored interventions, one kind of patient-centered intervention, have been associated with improved health outcomes and can guide research interventions regarding incontinence.

OBJECTIVES

To define the concept "patient-centered," discuss four kinds of patient-centered interventions, offer examples of tailored interventions, and suggest ideas for future incontinence research.

METHODS

Existing literature on patient-centered interventions was analyzed to generate a plan for future research.

RESULTS

Research is needed to demonstrate the efficacy of patient-centered interventions in outcomes, to determine bio-psycho-social factors of subgroups (race, gender, ethnicity) in order to more accurately describe prevalence rates and create effective interventions, and to find common variables among successful interventions.

CONCLUSIONS

Developing and testing patient-centered interventions regarding incontinence promises to advance knowledge about more effective interventions, conditions under which they are more or less effective, and how they are effective.

Psychosocial Variables, External Barriers, and Stage of Mammography Adoption

Guided by H. Triandis's (1980) theory of behavior and the transtheoretical model, the study purpose was to examine differences in psychosocial variables and external conditions by stage of mammography adoption. Sampled from a statewide population, participants (N=509) were women aged 51-80. They had been contacted by telephone, screened for eligibility (e.g., no history of cancer or recent mammogram), and interviewed 3-6 months later. Higher utility beliefs, social influences, and practitioner interactions about mammography were associated with improved stage of adoption, as were lower negative affect and external barriers regarding mammography. Higher decisional balance scores, with and without negative affect toward mammography were associated with improved stage. Controlling for variables reflecting pros and cons, negative affect toward mammography further distinguished among stages. A richer set of pros and cons measures could explain screening more fully.