The short-term impact of tailored mammography decision-making interventions

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017.

OBJECTIVES

To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach.

SEARCH METHODS

We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022.

SELECTION CRITERIA

We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence.

MAIN RESULTS

This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015.

AUTHORS' CONCLUSIONS

Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.

Public Health Messaging during the COVID-19 Pandemic and Beyond: Lessons from Communication Science

The COVID-19 pandemic has made it clear that effective public health messaging is an indispensable component of a robust pandemic response system. In this article, we review decades of research from the interdisciplinary field of communication science and provide evidence-based recommendations for COVID-19 public health messaging. We take a principled approach by systematically examining the communication process, focusing on decisions about what to say in a message (i.e., message content) and how to say it (i.e., message executions), and how these decisions impact message persuasiveness. Following a synthesis of each major line of literature, we discuss how science-based principles of message design can be used in COVID-19 public health messaging. Additionally, we identify emerging challenges for public health messaging during the COVID-19 pandemic and discuss possible remedies. We conclude that communication science offers promising public health messaging strategies for combatting COVID-19 and future pandemics.

Decision coaching for people making healthcare decisions

BACKGROUND

Decision coaching is non-directive support delivered by a healthcare provider to help patients prepare to actively participate in making a health decision. 'Healthcare providers' are considered to be all people who are engaged in actions whose primary intent is to protect and improve health (e.g. nurses, doctors, pharmacists, social workers, health support workers such as peer health workers). Little is known about the effectiveness of decision coaching.

OBJECTIVES

To determine the effects of decision coaching (I) for people facing healthcare decisions for themselves or a family member (P) compared to (C) usual care or evidence-based intervention only, on outcomes (O) related to preparation for decision making, decisional needs and potential adverse effects.

SEARCH METHODS

We searched the Cochrane Library (Wiley), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (Ebsco), Nursing and Allied Health Source (ProQuest), and Web of Science from database inception to June 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) where the intervention was provided to adults or children preparing to make a treatment or screening healthcare decision for themselves or a family member. Decision coaching was defined as: a) delivered individually by a healthcare provider who is trained or using a protocol; and b) providing non-directive support and preparing an adult or child to participate in a healthcare decision. Comparisons included usual care or an alternate intervention. There were no language restrictions.

DATA COLLECTION AND ANALYSIS

Two authors independently screened citations, assessed risk of bias, and extracted data on characteristics of the intervention(s) and outcomes. Any disagreements were resolved by discussion to reach consensus. We used the standardised mean difference (SMD) with 95% confidence intervals (CI) as the measures of treatment effect and, where possible, synthesised results using a random-effects model. If more than one study measured the same outcome using different tools, we used a random-effects model to calculate the standardised mean difference (SMD) and 95% CI. We presented outcomes in summary of findings tables and applied GRADE methods to rate the certainty of the evidence.

MAIN RESULTS

Out of 12,984 citations screened, we included 28 studies of decision coaching interventions alone or in combination with evidence-based information, involving 5509 adult participants (aged 18 to 85 years; 64% female, 52% white, 33% African-American/Black; 68% post-secondary education). The studies evaluated decision coaching used for a range of healthcare decisions (e.g. treatment decisions for cancer, menopause, mental illness, advancing kidney disease; screening decisions for cancer, genetic testing). Four of the 28 studies included three comparator arms.  For decision coaching compared with usual care (n = 4 studies), we are uncertain if decision coaching compared with usual care improves any outcomes (i.e. preparation for decision making, decision self-confidence, knowledge, decision regret, anxiety) as the certainty of the evidence was very low.  For decision coaching compared with evidence-based information only (n = 4 studies), there is low certainty-evidence that participants exposed to decision coaching may have little or no change in knowledge (SMD -0.23, 95% CI: -0.50 to 0.04; 3 studies, 406 participants). There is low certainty-evidence that participants exposed to decision coaching may have little or no change in anxiety, compared with evidence-based information. We are uncertain if decision coaching compared with evidence-based information improves other outcomes (i.e. decision self-confidence, feeling uninformed) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with usual care (n = 17 studies), there is low certainty-evidence that participants may have improved knowledge (SMD 9.3, 95% CI: 6.6 to 12.1; 5 studies, 1073 participants). We are uncertain if decision coaching plus evidence-based information compared with usual care improves other outcomes (i.e. preparation for decision making, decision self-confidence, feeling uninformed, unclear values, feeling unsupported, decision regret, anxiety) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with evidence-based information only (n = 7 studies), we are uncertain if decision coaching plus evidence-based information compared with evidence-based information only improves any outcomes (i.e. feeling uninformed, unclear values, feeling unsupported, knowledge, anxiety) as the certainty of the evidence was very low.

AUTHORS' CONCLUSIONS

Decision coaching may improve participants' knowledge when used with evidence-based information. Our findings do not indicate any significant adverse effects (e.g. decision regret, anxiety) with the use of decision coaching. It is not possible to establish strong conclusions for other outcomes. It is unclear if decision coaching always needs to be paired with evidence-informed information. Further research is needed to establish the effectiveness of decision coaching for a broader range of outcomes.

A systematic review of decision aids for mammography screening: Focus on outcomes and characteristics

PURPOSE

Decision Aid systems (DAs) provide information on the pros and cons of mammography. This study aimed to review the research on mammography DAs, synthesize the findings related to their outcomes and characteristics, and address the existed research gap.

METHODS

Relevant studies were identified through a comprehensive search on some e-databases, including PubMed, EMBASE, Scopus, and Web of Science in August 2020; by searching the keywords of "Breast cancer", "Screening", and "Decision aid systems" as well as their synonyms in the titles and abstracts of the papers with no time limits. Among the selected English journal papers with the interventional study design, those measuring outcome values of using mammography DAs were recognized as eligible for being included in this review.

RESULTS

The systematic search results in 16 DAs regarding mammography that were designed and then evaluated from 18 selected studies. The results showed that DAs provide improvements in knowledge and informed choice, the decreased decisional conflicts and decisional confidence, almost without changing any attitude towards mammography, mammography participation rates, psychological issues, anticipated regret, and perceived risk of breast cancer. The DAs' effects on women's inclination to screening were divergent. In other words, the DAs affect individuals' inclination in rare cases; however, on occasion, they could affect women's decision to undergo screening.

CONCLUSION

DAs could correct the bias attached to the existing knowledge on mammography and breast cancer in women so that they are more likely to make a precise decision. Additionally, it might be of central importance in shared decision-making and assisting health providers, in order to promote the quality of care. Accordingly, performing more studies is needed to develop more professional DAs in various countries with different facilities, cultures, and languages.

Framing the Clinical Encounter: Shared Decision-Making, Mammography Screening, and Decision Satisfaction

The study examines whether physicians' framing of clinical interactions is related to patient shared decision-making (SDM) satisfaction when using a clinical decision support tool (CDST) concerning mammographic screening. To answer this question, we combined (a) system log data from a CDST, (b) content coding of the physicians' message framing while using the CDST, and (c) a post-visit patient survey to assess SDM satisfaction concerning screening mammography. Results suggest that two types of message frames - consequence frames and numerical frames - moderated the relationship of the CDST on SDM satisfaction. When the CDST displayed low risk of breast cancer for a patient, physicians were able to improve the cognitive aspects of SDM satisfaction by framing the consequences of mammography screening in positive terms. However, when the physician delivered the numerical information in relative, rather than absolute terms, the patient's SDM satisfaction was reduced. Our study advances previous message framing effect research in health communication from experimental settings to clinical encounters. It also discusses the importance of delivering risk-congruent frames in clinical settings.

Quality of decision aids developed for women at average risk of breast cancer eligible for mammographic screening: Systematic review and assessment according to the International Patient Decision Aid Standards instrument

Mammographic screening contributes to a reduction in specific mortality, but it has disadvantages. Decision aids are tools designed to support people's decisions. Because these aids influence patient choice, their quality is crucial. The objective of the current study was to conduct a systematic review of decision aids developed for women eligible for mammographic screening who have an average breast cancer risk and to assess the quality of these aids. The systematic review included articles published between January 1, 1997, and August 1, 2019, in the PubMed, Embase, Cochrane, and PsycInfo databases. The studies were reviewed independently by 2 reviewers. Any study containing a decision aid for women eligible for mammographic screening with an average breast cancer risk was included. Two double-blind reviewers assessed the quality of the selected decision aids using the International Patient Decision Aid Standards instrument, version 3 (IPDASi). Twenty-three decision aids were extracted. Classification of decision aid quality using the IPDASi demonstrated large variations among the decision aids (maximum IPDASi score, 188; mean ± SD score, 132.6 ± 23.8; range, 85-172). Three decision aids had high overall scores. The 3 best-rated dimensions were disclosure (maximum score, 8; mean score, 6.8), focusing on transparency; information (maximum score, 32; mean score, 26.1), focusing on the provision of sufficient details; and probabilities (maximum score, 32; mean score 25), focusing on the presentation of probabilities. The 3 lowest-rated dimensions were decision support technology evaluation (maximum score, 8; mean score, 4.3), focusing on the effectiveness of the decision aid; development (maximum score, 24; mean score, 12.6), evaluating the development process; and plain language (maximum score, 4; mean score, 1.9), assessing appropriateness for patients with low literacy. The results of this review identified 3 high-quality decision aids for breast cancer screening.

The Effect of Educational Intervention Based on the Theory of Planned Behavior on Mammography Screening in Iranian Women

Mammography is the most special screening method for early diagnosis of breast cancer. The purpose of present research is investigating the effect of educational intervention based on theory of planned behavior on mammography screening of women in Fasa city, Fars province, Iran. In this quasi-experimental study, 400 subjects (200 subjects for experimental group and 200 subjects for control group) were selected in 2017-2018. Educational intervention for the experimental group included 8 educational sessions. A questionnaire used for evaluating demographic information and constructs of theory of planned behavior (knowledge, perceived behavioral control, subjective norms, and attitude) investigated mammography performance of women before and 6 months after intervention. Data were analyzed by using SPSS 22 through chi-square test, McNemar's test, and Wilcoxon-Mann-Whitney test at significance level of P < 0.05. The average age of subjects was 45.52 ± 6.76 years in the experimental group and 45.12 ± 6.64 years in the control group. Six months after intervention, the experimental group showed significant increase in knowledge, perceived behavioral control, subjective norms, and attitude compared to the control group and 174 people (78%) of the experimental group had intention for doing mammography and 148 people (74%) of the experimental group performed mammography. Also, 6 months after educational intervention, 38 people (19%) of the control group had intention for performing mammography and 14 people (7%) of the control group performed mammography.

Effectiveness of the Theory-Based Educational Interventions on Screening of Breast Cancer in Women: A Systematic Review and Meta-Analysis

Screening plays an essential role in the reduction of mortality and morbidity of breast cancer, which is one of the most common cancers in women worldwide. The aim of this study was to find out whether the use of health education model and theory-based behavioral interventions is effective in women’s breast cancer screening behavior. Applying different search strategies, we searched electronic databases including PubMed, ScienceDirect, Web of Science, and Scopus without time limit from January 12 to March 11, 2017. Keywords included “Breast neoplasm,” Screening,” “Women,” and “Health Education.” First, screening was conducted based on title, abstract, and full text. Then, the studies were screened according to the selection criteria of our study. The relevant and eligible studies were critically appraised by Delphi checklist. In addition, a meta-analysis of eligible studies was conducted with the random-effect approach. Twenty-six of 8,620 initial studies (with sample size of 10,681 in the intervention group and 8,854 in the control group) were included in the final analysis. The results of the meta-analysis showed that the probability of screening behavior in the intervention group is 1.4 times of that in the control group. Furthermore, subgroup analysis by the type of screening behavior indicates that the probabilities of conducting breast self-examination and mammography in the intervention group are 1.9 and 1.4 times of those in the control group. The health education program has a significant impact on breast cancer screening behaviors, particularly breast self-examination. Thus, given the positive effects of the educational screening programs in women, it is suggested that these programs must be continuously pursued with long-term follow-up and increasing rates of screening behaviors should be monitored.

Promoting Breast Cancer Surveillance: The EMPOWER Study, a Randomized Clinical Trial in the Childhood Cancer Survivor Study

PURPOSE

The aim of the current study was to increase the uptake of screening mammography among high-risk women who were treated for a childhood cancer with chest radiotherapy.

PATIENTS AND METHODS

Two hundred four female survivors in the Childhood Cancer Survivor Study who were treated with chest radiotherapy with 20 Gy or greater, age 25 to 50 years, and without breast imaging in the past 24 months were randomly assigned 2:1 to receive a mailed informational packet followed by a tailored telephone-delivered brief motivational interview (intervention) versus an attention control. Primary outcome was the difference in the proportion of participants who completed a screening mammogram by 12 months as evaluated in an intent-to-treat analysis. Stratum-adjusted relative risk (RR) and 95% CI were estimated using the Cochran-Mantel-Haenszel method. Secondary outcomes included the completion of screening breast magnetic resonance imaging (MRI) and barriers to screening and moderating factors.

RESULTS

Women in the intervention group were significantly more likely than those in the control group to report a mammogram (45 [33.1%] of 136 v 12 [17.6%] of 68; RR, 1.9; 95% CI, 1.1 to 3.3). The intervention was more successful among women age 25 to 39 years (RR, 2.2; 95% CI, 1.1 to 4.7) than among those age 40 to 50 years (RR, 1.4; 95% CI, 0.6 to 3.2). The proportion of women who reported a breast MRI at 12 months was similar between the two groups: 16.2% (intervention) compared with 13.2% (control; RR, 1.2; 95% CI, 0.6 to 2.5). Primary barriers to completing a screening mammogram and/or breast MRI included lack of physician recommendation, deferred action by survivor, cost, and absence of symptoms.

CONCLUSION

Use of mailed materials followed by telephone-delivered counseling increased mammography screening rates in survivors at high risk for breast cancer; however, this approach did not increase the rate of breast MRI. Cost of imaging and physician recommendation were important barriers that should be addressed in future studies.

Explaining the effects of a decision intervention on mammography intentions: The roles of worry, fear and perceived susceptibility to breast cancer

OBJECTIVE

This study examines the effects of a mammography decision intervention on perceived susceptibility to breast cancer (PSBC) and emotion and investigates how these outcomes predict mammography intentions.

DESIGN

Randomised between-subjects online experiment. Participants were stratified into two levels of risk. Within each stratum, conditions included a basic information condition and six decision intervention conditions that included personalised risk estimates and varied according to a 2 (amount of information: brief vs. extended) × 3 (format: expository vs. untailored exemplar vs. tailored exemplar) design. Participants included 2465 US women ages 35-49.

MAIN OUTCOME MEASURES

PSBC as a percentage, PSBC as a frequency, worry, fear and mammography intentions.

RESULTS

The intervention resulted in significant reductions in PSBC as a percentage for women in both strata and significant increases in worry and fear for women in the upper risk stratum. Of the possible mediators examined, only PSBC as a percentage was a consistent mediator of the effect of the intervention on mammography intentions.

CONCLUSION

The results provide insight into the mechanism of action of the intervention by showing that PSBC mediated the effects of the intervention on mammography intentions.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Decision aids are interventions that support patients by making their decisions explicit, providing information about options and associated benefits/harms, and helping clarify congruence between decisions and personal values.

OBJECTIVES

To assess the effects of decision aids in people facing treatment or screening decisions.

SEARCH METHODS

Updated search (2012 to April 2015) in CENTRAL; MEDLINE; Embase; PsycINFO; and grey literature; includes CINAHL to September 2008.

SELECTION CRITERIA

We included published randomized controlled trials comparing decision aids to usual care and/or alternative interventions. For this update, we excluded studies comparing detailed versus simple decision aids.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened citations for inclusion, extracted data, and assessed risk of bias. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made and the decision-making process.Secondary outcomes were behavioural, health, and health system effects.We pooled results using mean differences (MDs) and risk ratios (RRs), applying a random-effects model. We conducted a subgroup analysis of studies that used the patient decision aid to prepare for the consultation and of those that used it in the consultation. We used GRADE to assess the strength of the evidence.

MAIN RESULTS

We included 105 studies involving 31,043 participants. This update added 18 studies and removed 28 previously included studies comparing detailed versus simple decision aids. During the 'Risk of bias' assessment, we rated two items (selective reporting and blinding of participants/personnel) as mostly unclear due to inadequate reporting. Twelve of 105 studies were at high risk of bias.With regard to the attributes of the choice made, decision aids increased participants' knowledge (MD 13.27/100; 95% confidence interval (CI) 11.32 to 15.23; 52 studies; N = 13,316; high-quality evidence), accuracy of risk perceptions (RR 2.10; 95% CI 1.66 to 2.66; 17 studies; N = 5096; moderate-quality evidence), and congruency between informed values and care choices (RR 2.06; 95% CI 1.46 to 2.91; 10 studies; N = 4626; low-quality evidence) compared to usual care.Regarding attributes related to the decision-making process and compared to usual care, decision aids decreased decisional conflict related to feeling uninformed (MD -9.28/100; 95% CI -12.20 to -6.36; 27 studies; N = 5707; high-quality evidence), indecision about personal values (MD -8.81/100; 95% CI -11.99 to -5.63; 23 studies; N = 5068; high-quality evidence), and the proportion of people who were passive in decision making (RR 0.68; 95% CI 0.55 to 0.83; 16 studies; N = 3180; moderate-quality evidence).Decision aids reduced the proportion of undecided participants and appeared to have a positive effect on patient-clinician communication. Moreover, those exposed to a decision aid were either equally or more satisfied with their decision, the decision-making process, and/or the preparation for decision making compared to usual care.Decision aids also reduced the number of people choosing major elective invasive surgery in favour of more conservative options (RR 0.86; 95% CI 0.75 to 1.00; 18 studies; N = 3844), but this reduction reached statistical significance only after removing the study on prophylactic mastectomy for breast cancer gene carriers (RR 0.84; 95% CI 0.73 to 0.97; 17 studies; N = 3108). Compared to usual care, decision aids reduced the number of people choosing prostate-specific antigen screening (RR 0.88; 95% CI 0.80 to 0.98; 10 studies; N = 3996) and increased those choosing to start new medications for diabetes (RR 1.65; 95% CI 1.06 to 2.56; 4 studies; N = 447). For other testing and screening choices, mostly there were no differences between decision aids and usual care.The median effect of decision aids on length of consultation was 2.6 minutes longer (24 versus 21; 7.5% increase). The costs of the decision aid group were lower in two studies and similar to usual care in four studies. People receiving decision aids do not appear to differ from those receiving usual care in terms of anxiety, general health outcomes, and condition-specific health outcomes. Studies did not report adverse events associated with the use of decision aids.In subgroup analysis, we compared results for decision aids used in preparation for the consultation versus during the consultation, finding similar improvements in pooled analysis for knowledge and accurate risk perception. For other outcomes, we could not conduct formal subgroup analyses because there were too few studies in each subgroup.

AUTHORS' CONCLUSIONS

Compared to usual care across a wide variety of decision contexts, people exposed to decision aids feel more knowledgeable, better informed, and clearer about their values, and they probably have a more active role in decision making and more accurate risk perceptions. There is growing evidence that decision aids may improve values-congruent choices. There are no adverse effects on health outcomes or satisfaction. New for this updated is evidence indicating improved knowledge and accurate risk perceptions when decision aids are used either within or in preparation for the consultation. Further research is needed on the effects on adherence with the chosen option, cost-effectiveness, and use with lower literacy populations.

Effects of a risk-based online mammography intervention on accuracy of perceived risk and mammography intentions

OBJECTIVE

This experiment tested the effects of an individualized risk-based online mammography decision intervention. The intervention employs exemplification theory and the Elaboration Likelihood Model of persuasion to improve the match between breast cancer risk and mammography intentions.

METHODS

2918 women ages 35-49 were stratified into two levels of 10-year breast cancer risk (<1.5%; ≥1.5%) then randomly assigned to one of eight conditions: two comparison conditions and six risk-based intervention conditions that varied according to a 2 (amount of content: brief vs. extended) x 3 (format: expository vs. untailored exemplar [example case] vs. tailored exemplar) design. Outcomes included mammography intentions and accuracy of perceived breast cancer risk.

RESULTS

Risk-based intervention conditions improved the match between objective risk estimates and perceived risk, especially for high-numeracy women with a 10-year breast cancer risk ≤1.5%. For women with a risk≤1.5%, exemplars improved accuracy of perceived risk and all risk-based interventions increased intentions to wait until age 50 to screen.

CONCLUSION

A risk-based mammography intervention improved accuracy of perceived risk and the match between objective risk estimates and mammography intentions.

PRACTICE IMPLICATIONS

Interventions could be applied in online or clinical settings to help women understand risk and make mammography decisions.

A Breast Cancer Fear Scale: Psychometric Development

Fear of breast cancer has been inversely associated with participation in screening. However, investigators have generally used only one item or global scales to measure fear. This report describes development of a fear scale specific to breast cancer. Data from a large study involving mammography adherence were used to test the breast cancer fear scale for validity and reliability. Construct validity was verified through factor analysis and regression analysis predicting mammography. All items loaded on a single factor and theoretical relationships were verified by linear and logistic regression. The Cronbach alpha for the scale was .91.

Taking the Transtheoretical Model Into the Field: A Curriculum for Lay Health Advisors

The transtheoretical model (TTM) is a commonly applied theoretical perspective for understanding mammography behaviors and improving the effectiveness of one-on-one counseling. The North Carolina Breast Cancer Screening Program (NC-BCSP) developed a training curriculum to incorporate TTM into the advising practices of lay health advisors (LHAs). The TTM helped “natural helper” LHAs understand that women in their rural North Carolina communities were likely to be in different stages for mammography screening and hence required different messages. NC-BCSP staff believed that by combining an understanding of TTM with LHAs’ natural helping abilities we potentially increased the effectiveness of LHA advising. Our limited evaluation, based on LHA feedback, suggests the curriculum is a useful training tool, even for those unfamiliar with behavior change models. Our TTM curriculum serves as an example of a health behavior theory successfully operationalized outside academia for use in the field by lay people.

Design Features of Explicit Values Clarification Methods

Background. Values clarification is a recommended element of patient decision aids. Many different values clarification methods exist, but there is little evidence synthesis available to guide design decisions. Purpose. To describe practices in the field of explicit values clarification methods according to a taxonomy of design features. Data Sources. MEDLINE, all EBM Reviews, CINAHL, EMBASE, Google Scholar, manual search of reference lists, and expert contacts. Study Selection. Articles were included if they described 1 or more explicit values clarification methods. Data Extraction. We extracted data about decisions addressed; use of theories, frameworks, and guidelines; and 12 design features. Data Synthesis. We identified 110 articles describing 98 explicit values clarification methods. Most of these addressed decisions in cancer or reproductive health, and half addressed a decision between just 2 options. Most used neither theory nor guidelines to structure their design. “Pros and cons” was the most common type of values clarification method. Most methods did not allow users to add their own concerns. Few methods explicitly presented tradeoffs inherent in the decision, supported an iterative process of values exploration, or showed how different options aligned with users’ values. Limitations. Study selection criteria and choice of elements for the taxonomy may have excluded values clarification methods or design features. Conclusions. Explicit values clarification methods have diverse designs but can be systematically cataloged within the structure of a taxonomy. Developers of values clarification methods should carefully consider each of the design features in this taxonomy and publish adequate descriptions of their designs. More research is needed to study the effects of different design features.

Developing an Atrial Fibrillation Guideline Support Tool (AFGuST) for shared decision making

OBJECTIVE

Patient values and preferences are an important component to decision making when tradeoffs exist that impact quality of life, such as tradeoffs between stroke prevention and hemorrhage in patients with atrial fibrillation (AF) contemplating anticoagulant therapy. Our objective is to describe the development of an Atrial Fibrillation Guideline Support Tool (AFGuST) to assist the process of integrating patients' preferences into this decision.

MATERIALS AND METHODS

CHA2DS2VASc and HAS-BLED were used to calculate risks for stroke and hemorrhage. We developed a Markov decision analytic model as a computational engine to integrate patient-specific risk for stroke and hemorrhage and individual patient values for relevant outcomes in decisions about anticoagulant therapy.

RESULTS

Individual patient preferences for health-related outcomes may have greater or lesser impact on the choice of optimal antithrombotic therapy, depending upon the balance of patient-specific risks for ischemic stroke and major bleeding. These factors have been incorporated into patient-tailored booklets which, along with an informational video, were developed through an iterative process with clinicians and patient focus groups.

KEY LIMITATIONS

Current risk prediction models for hemorrhage, such as the HAS-BLED, used in the AFGuST, do not incorporate all potentially significant risk factors. Novel oral anticoagulant agents recently approved for use in the United States, Canada, and Europe have not been included in the AFGuST. Rather, warfarin has been used as a conservative proxy for all oral anticoagulant therapy.

CONCLUSIONS

We present a proof of concept that a patient-tailored decision-support tool could bridge the gap between guidelines and practice by incorporating individual patient's stroke and bleeding risks and their values for major bleeding events and stroke to facilitate a shared decision making process. If effective, the AFGuST could be used as an adjunct to published guidelines to enhance patient-centered conversations about the anticoagulation management.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Decision aids are intended to help people participate in decisions that involve weighing the benefits and harms of treatment options often with scientific uncertainty.

OBJECTIVES

To assess the effects of decision aids for people facing treatment or screening decisions.

SEARCH METHODS

For this update, we searched from 2009 to June 2012 in MEDLINE; CENTRAL; EMBASE; PsycINFO; and grey literature. Cumulatively, we have searched each database since its start date including CINAHL (to September 2008).

SELECTION CRITERIA

We included published randomized controlled trials of decision aids, which are interventions designed to support patients' decision making by making explicit the decision, providing information about treatment or screening options and their associated outcomes, compared to usual care and/or alternative interventions. We excluded studies of participants making hypothetical decisions.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. The primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were:A) 'choice made' attributes;B) 'decision-making process' attributes.Secondary outcomes were behavioral, health, and health-system effects. We pooled results using mean differences (MD) and relative risks (RR), applying a random-effects model.

MAIN RESULTS

This update includes 33 new studies for a total of 115 studies involving 34,444 participants. For risk of bias, selective outcome reporting and blinding of participants and personnel were mostly rated as unclear due to inadequate reporting. Based on 7 items, 8 of 115 studies had high risk of bias for 1 or 2 items each.Of 115 included studies, 88 (76.5%) used at least one of the IPDAS effectiveness criteria: A) 'choice made' attributes criteria: knowledge scores (76 studies); accurate risk perceptions (25 studies); and informed value-based choice (20 studies); and B) 'decision-making process' attributes criteria: feeling informed (34 studies) and feeling clear about values (29 studies).A) Criteria involving 'choice made' attributes:Compared to usual care, decision aids increased knowledge (MD 13.34 out of 100; 95% confidence interval (CI) 11.17 to 15.51; n = 42). When more detailed decision aids were compared to simple decision aids, the relative improvement in knowledge was significant (MD 5.52 out of 100; 95% CI 3.90 to 7.15; n = 19). Exposure to a decision aid with expressed probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.82; 95% CI 1.52 to 2.16; n = 19). Exposure to a decision aid with explicit values clarification resulted in a higher proportion of patients choosing an option congruent with their values (RR 1.51; 95% CI 1.17 to 1.96; n = 13).B) Criteria involving 'decision-making process' attributes:Decision aids compared to usual care interventions resulted in:a) lower decisional conflict related to feeling uninformed (MD -7.26 of 100; 95% CI -9.73 to -4.78; n = 22) and feeling unclear about personal values (MD -6.09; 95% CI -8.50 to -3.67; n = 18);b) reduced proportions of people who were passive in decision making (RR 0.66; 95% CI 0.53 to 0.81; n = 14); andc) reduced proportions of people who remained undecided post-intervention (RR 0.59; 95% CI 0.47 to 0.72; n = 18).Decision aids appeared to have a positive effect on patient-practitioner communication in all nine studies that measured this outcome. For satisfaction with the decision (n = 20), decision-making process (n = 17), and/or preparation for decision making (n = 3), those exposed to a decision aid were either more satisfied, or there was no difference between the decision aid versus comparison interventions. No studies evaluated decision-making process attributes for helping patients to recognize that a decision needs to be made, or understanding that values affect the choice.C) Secondary outcomes Exposure to decision aids compared to usual care reduced the number of people of choosing major elective invasive surgery in favour of more conservative options (RR 0.79; 95% CI 0.68 to 0.93; n = 15). Exposure to decision aids compared to usual care reduced the number of people choosing to have prostate-specific antigen screening (RR 0.87; 95% CI 0.77 to 0.98; n = 9). When detailed compared to simple decision aids were used, fewer people chose menopausal hormone therapy (RR 0.73; 95% CI 0.55 to 0.98; n = 3). For other decisions, the effect on choices was variable.The effect of decision aids on length of consultation varied from 8 minutes shorter to 23 minutes longer (median 2.55 minutes longer) with 2 studies indicating statistically-significantly longer, 1 study shorter, and 6 studies reporting no difference in consultation length. Groups of patients receiving decision aids do not appear to differ from comparison groups in terms of anxiety (n = 30), general health outcomes (n = 11), and condition-specific health outcomes (n = 11). The effects of decision aids on other outcomes (adherence to the decision, costs/resource use) were inconclusive.

AUTHORS' CONCLUSIONS

There is high-quality evidence that decision aids compared to usual care improve people's knowledge regarding options, and reduce their decisional conflict related to feeling uninformed and unclear about their personal values. There is moderate-quality evidence that decision aids compared to usual care stimulate people to take a more active role in decision making, and improve accurate risk perceptions when probabilities are included in decision aids, compared to not being included. There is low-quality evidence that decision aids improve congruence between the chosen option and the patient's values.New for this updated review is further evidence indicating more informed, values-based choices, and improved patient-practitioner communication. There is a variable effect of decision aids on length of consultation. Consistent with findings from the previous review, decision aids have a variable effect on choices. They reduce the number of people choosing discretionary surgery and have no apparent adverse effects on health outcomes or satisfaction. The effects on adherence with the chosen option, cost-effectiveness, use with lower literacy populations, and level of detail needed in decision aids need further evaluation. Little is known about the degree of detail that decision aids need in order to have a positive effect on attributes of the choice made, or the decision-making process.

Enhancing informed choice to undergo health screening: a systematic review

OBJECTIVE

To assess the effectiveness of health screening interventions aimed at enhancing informed choice.

METHODS

Studies were selected if (1) they were randomized controlled trials conducted between January 1, 2000, and March 30, 2010, (2) participants in one arm underwent a prescreening intervention aimed at improving informed choice, and (3) informed choice was the primary outcome.

RESULTS

Eight studies that met the inclusion criteria involved screening for prostate, colorectal and breast cancer, and diabetes. Five of the 8 prescreening interventions led to greater informed choice.

CONCLUSIONS

With researchers mindful of the limited number of studies, findings were encouraging, but conclusions regarding the most effective ways of facilitating informed choice for screening are at best tentative.

What is lacking in current decision aids on cancer screening?

Recent guidelines on cancer screening have provided not only more screening options but also conflicting recommendations. Thus, patients, with their clinicians' support, must decide whether to get screened, which modality to use, and how often to undergo screening. Decision aids could potentially lead to better shared decision-making regarding screening between the patient and the clinician. A total of 73 decision aids concerning screening for breast, cervical, colorectal, and prostate cancers were reviewed. The goal of this review was to assess the effectiveness of such decision aids, examine areas in need of more research, and determine how the decision aids can be currently applied in the real-world setting. Most studies used sound study designs. Significant variation existed in the setting, theoretical framework, and measured outcomes. Just over one-third of the decision aids included an explicit values clarification. Other than knowledge, little consistency was noted with regard to which patient attributes were measured as outcomes. Few studies actually measured shared decision-making. Little information was available regarding the feasibility and outcomes of integrating decision aids into practice. In this review, the implications for future research, as well as what clinicians can do now to incorporate decision aids into their practice, are discussed.

Personalised risk communication for informed decision making about taking screening tests

BACKGROUND

There is a trend towards greater patient involvement in healthcare decisions. Although screening is usually perceived as good for the health of the population, there are risks associated with the tests involved. Achieving both adequate involvement of consumers and informed decision making are now seen as important goals for screening programmes. Personalised risk estimates have been shown to be effective methods of risk communication.

OBJECTIVES

To assess the effects of personalised risk communication on informed decision making by individuals taking screening tests. We also assess individual components that constitute informed decisions.

SEARCH METHODS

Two authors searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2012), MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL (EbscoHOST) and PsycINFO (OvidSP) without language restrictions. We searched from 2006 to March 2012. The date ranges for the previous searches were from 1989 to December 2005 for PsycINFO and from 1985 to December 2005 for other databases. For the original version of this review, we also searched CancerLit  and Science Citation Index (March 2001). We also reviewed the reference lists and conducted citation searches of included studies and other systematic reviews in the field, to identify any studies missed during the initial search.

SELECTION CRITERIA

Randomised controlled trials incorporating an intervention with a 'personalised risk communication element' for individuals undergoing screening procedures, and reporting measures of informed decisions and also cognitive, affective, or behavioural outcomes addressing the decision by such individuals, of whether or not to undergo screening.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed each included trial for risk of bias, and extracted data. We extracted data about the nature and setting of interventions, and relevant outcome data. We used standard statistical methods to combine data using RevMan version 5, including analysis according to different levels of detail of personalised risk communication, different conditions for screening, and studies based only on high-risk participants rather than people at 'average' risk. 

MAIN RESULTS

We included 41 studies involving 28,700 people. Nineteen new studies were identified in this update, adding to the 22 studies included in the previous two iterations of the review. Three studies measured informed decision with regard to the uptake of screening following personalised risk communication as a part of their intervention. All of these three studies were at low risk of bias and there was strong evidence that the interventions enhanced informed decision making, although with heterogeneous results. Overall 45.2% (592/1309) of participants who received personalised risk information made informed choices, compared to 20.2% (229/1135) of participants who received generic risk information. The overall odds ratios (ORs) for informed decision were 4.48 (95% confidence interval (CI) 3.62 to 5.53 for fixed effect) and 3.65 (95% CI 2.13 to 6.23 for random effects). Nine studies measured increase in knowledge, using different scales. All of these studies showed an increase in knowledge with personalised risk communication. In three studies the interventions showed a trend towards more accurate risk perception, but the evidence was of poor quality. Four out of six studies reported non-significant changes in anxiety following personalised risk communication to the participants. Overall there was a small non-significant decrease in the anxiety scores. Most studies (32/41) measured the uptake of screening tests following interventions. Our results (OR 1.15 (95% CI 1.02 to 1.29)) constitute low quality evidence, consistent with a small effect, that personalised risk communication in which a risk score was provided (6 studies) or the participants were given their categorised risk (6 studies), increases uptake of screening tests. 

AUTHORS' CONCLUSIONS

There is strong evidence from three trials that personalised risk estimates incorporated within communication interventions for screening programmes enhance informed choices. However the evidence for increasing the uptake of such screening tests with similar interventions is weak, and it is not clear if this increase is associated with informed choices. Studies included a diverse range of screening programmes. Therefore, data from this review do not allow us to draw conclusions about the best interventions to deliver personalised risk communication for enhancing informed decisions. The results are dominated by findings from the topic area of mammography and colorectal cancer. Caution is therefore required in generalising from these results, and particularly for clinical topics other than mammography and colorectal cancer screening.

Health-related quality of life improvement via telemedicine for epilepsy: printed versus SMS-based education intervention

BACKGROUND

Improving health-related quality of life (HRQoL) among people with epilepsy (PWE) has become the focus of various treatment programmes and behavioural interventions which continue to be challenging to both patients and healthcare professionals.

AIMS AND OBJECTIVES

To investigate the impact of SMS-based epilepsy education programme on PWE's HRQoL status and to determine the predictors for good HRQoL.

METHODS

Eligible epilepsy out-patients from three public hospitals in East Coast Peninsular Malaysia were randomized into two groups: intervention (IG) and control (CG). Patients in the CG were supplied with only printed epilepsy educational module, while those in the IG additionally received short message service (SMS) from the Mobile Epilepsy Educational System (MEES). The Malay Quality of Life in Epilepsy Inventory-30 (MQOLIE-30) was utilized for HRQoL assessment. Descriptive statistics, paired t test, analysis of covariance and multiple logistic regression were employed for data analyses (SPSS 16).

RESULTS

One hundred and forty-four PWE were recruited for the study (age = 30.5 ± 11.8; unmarried = 60.4 %; education level ≤ SPM/Cambridge O' level = 76.4 %; illness duration > 5 years = 51.1 %). After controlling for possible confounders, IG exhibited positive changes in HRQoL profile compared to CG particularly in Seizure Worry, Overall Quality of Life, Emotional Well-Being, Social Functioning and Overall Score (p < 0.05). After adjusting for covariates, being employed and receiving additional SMS-based epilepsy education programme emerged as the significant predictors of good HRQoL among PWE.

CONCLUSION

Receiving continuous SMS-based epilepsy information from the MEES seemed to generate positive impacts on PWE's overall HRQoL. This study has provided a basis for future innovations to inspire efforts in ensuring the welfare and HRQoL of PWE and their families.

Using animated computer-generated text and graphics to depict the risks and benefits of medical treatment

OBJECTIVE

Conventional print materials for presenting risks and benefits of treatment are often difficult to understand. This study was undertaken to evaluate and compare subjects' understanding and perceptions of risks and benefits presented using animated computerized text and graphics.

METHODS

Adult subjects were randomized to receive identical risk/benefit information regarding taking statins that was presented on an iPad (Apple Corp, Cupertino, Calif) in 1 of 4 different animated formats: text/numbers, pie chart, bar graph, and pictograph. Subjects completed a questionnaire regarding their preferences and perceptions of the message delivery together with their understanding of the information. Health literacy, numeracy, and need for cognition were measured using validated instruments.

RESULTS

There were no differences in subject understanding based on the different formats. However, significantly more subjects preferred graphs (82.5%) compared with text (17.5%, P<.001). Specifically, subjects preferred pictographs (32.0%) and bar graphs (31.0%) over pie charts (19.5%) and text (17.5%). Subjects whose preference for message delivery matched their randomly assigned format (preference match) had significantly greater understanding and satisfaction compared with those assigned to something other than their preference.

CONCLUSIONS

Results showed that computer-animated depictions of risks and benefits offer an effective means to describe medical risk/benefit statistics. That understanding and satisfaction were significantly better when the format matched the individual's preference for message delivery is important and reinforces the value of "tailoring" information to the individual's needs and preferences.

Rethinking Communication in the E-health Era

There is substantial epidemiological evidence that widespread adoption of specific behavior changes can significantly improve population health. Yet, health communication efforts, while well intentioned, have often failed to engage people to change behavior within the complex contexts of their lives. `E-health communication', health promotion efforts that are mediated by computers and other digital technologies, may have great potential to promote desired behavior changes through unique features such as mass customization, interactivity and convenience. There is growing initial evidence that e-health communication can improve behavioral outcomes. However, we have much to learn about whether the technical promise of e-health communication will be effective within the social reality of how diverse people communicate and change in the modern world. This article examines current evidence concerning e-health communication and evaluates opportunities for e-health applications.

Clustering very low-income, insured women's mammography screening barriers into potentially functional subgroups

BACKGROUND

Mammography screening is essential for early detection of breast cancer and increased survival rates. Women, particularly those of low socioeconomic status, face barriers that impede their screening adherence. Although many studies have sought to identify these barriers, more research is needed on to address these obstacles in practice. The objective of this study is to divide mammography screening barriers into functional clusters using empirical evidence, which may guide the development of effective mammography screening promotion messages.

METHODS

A sample of 173 low-income White and Black women randomly selected from a managed care organization rated each of 21 potential mammography barriers on a scale ranging from "strongly agree" to "strongly disagree." A maximum clustering similarity method was used to identify relevant clusters of screening barriers.

RESULTS

Five clusters were derived, with a high similarity index (0.881). Each cluster was named to reflect the shared theme of the barriers within it: Perceived Lack of Value in Health Care, Lack of Information, Mistrust/Skepticism, Medical Delay Behavior, and Anxiety/No Control. A dominant barrier within each cluster was identified, and bivariate correlation coefficients were reported.

CONCLUSION

Cluster analysis yielded five distinct subgroups of mammography screening barriers.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Decision aids prepare people to participate in decisions that involve weighing benefits, harms, and scientific uncertainty.

OBJECTIVES

To evaluate the effectiveness of decision aids for people facing treatment or screening decisions.

SEARCH STRATEGY

For this update, we searched from January 2006 to December 2009 in MEDLINE (Ovid); Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, issue 4 2009); CINAHL (Ovid) (to September 2008 only); EMBASE (Ovid); PsycINFO (Ovid); and grey literature. Cumulatively, we have searched each database since its start date.

SELECTION CRITERIA

We included published randomised controlled trials (RCTs) of decision aids, which are interventions designed to support patients' decision making by providing information about treatment or screening options and their associated outcomes, compared to usual care and/or alternative interventions. We excluded studies in which participants were not making an active treatment or screening decision.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts for inclusion, extracted data, and assessed potential risk of bias. The primary outcomes, based on the International Patient Decision Aid Standards, were:A) decision attributes;B) decision making process attributes.Secondary outcomes were behavioral, health, and health system effects. We pooled results of RCTs using mean differences (MD) and relative risks (RR), applying a random effects model.

MAIN RESULTS

Of 34,316 unique citations, 86 studies involving 20,209 participants met the eligibility criteria and were included. Thirty-one of these studies are new in this update. Twenty-nine trials are ongoing. There was variability in potential risk of bias across studies. The two criteria that were most problematic were lack of blinding and the potential for selective outcome reporting, given that most of the earlier trials were not registered.Of 86 included studies, 63 (73%) used at least one measure that mapped onto an IPDAS effectiveness criterion: A) criteria involving decision attributes: knowledge scores (51 studies); accurate risk perceptions (16 studies); and informed value-based choice (12 studies); and B) criteria involving decision process attributes: feeling informed (30 studies) and feeling clear about values (18 studies).A) Criteria involving decision attributes:Decision aids performed better than usual care interventions by increasing knowledge (MD 13.77 out of 100; 95% confidence interval (CI) 11.40 to 16.15; n = 26). When more detailed decision aids were compared to simpler decision aids, the relative improvement in knowledge was significant (MD 4.97 out of 100; 95% CI 3.22 to 6.72; n = 15). Exposure to a decision aid with expressed probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.74; 95% CI 1.46 to 2.08; n = 14). The effect was stronger when probabilities were expressed in numbers (RR 1.93; 95% CI 1.58 to 2.37; n = 11) rather than words (RR 1.27; 95% CI 1.09 to 1.48; n = 3). Exposure to a decision aid with explicit values clarification compared to those without explicit values clarification resulted in a higher proportion of patients achieving decisions that were informed and consistent with their values (RR 1.25; 95% CI 1.03 to 1.52; n = 8).B) Criteria involving decision process attributes:Decision aids compared to usual care interventions resulted in: a) lower decisional conflict related to feeling uninformed (MD -6.43 of 100; 95% CI -9.16 to -3.70; n = 17); b) lower decisional conflict related to feeling unclear about personal values (MD -4.81; 95% CI -7.23 to -2.40; n = 14); c) reduced the proportions of people who were passive in decision making (RR 0.61; 95% CI 0.49 to 0.77; n = 11); and d) reduced proportions of people who remained undecided post-intervention (RR 0.57; 95% CI 0.44 to 0.74; n = 9). Decision aids appear to have a positive effect on patient-practitioner communication in the four studies that measured this outcome. For satisfaction with the decision (n = 12) and/or the decision making process (n = 12), those exposed to a decision aid were either more satisfied or there was no difference between the decision aid versus comparison interventions. There were no studies evaluating the decision process attributes relating to helping patients to recognize that a decision needs to be made or understand that values affect the choice.C) Secondary outcomesExposure to decision aids compared to usual care continued to demonstrate reduced choice of: major elective invasive surgery in favour of conservative options (RR 0.80; 95% CI 0.64 to 1.00; n = 11). Exposure to decision aids compared to usual care also resulted in reduced choice of PSA screening (RR 0.85; 95% CI 0.74 to 0.98; n = 7). When detailed compared to simple decision aids were used, there was reduced choice of menopausal hormones (RR 0.73; 95% CI 0.55 to 0.98; n = 3). For other decisions, the effect on choices was variable. The effect of decision aids on length of consultation varied from -8 minutes to +23 minutes (median 2.5 minutes). Decision aids do not appear to be different from comparisons in terms of anxiety (n = 20), and general health outcomes (n = 7), and condition specific health outcomes (n = 9). The effects of decision aids on other outcomes (adherence to the decision, costs/resource use) were inconclusive.

AUTHORS' CONCLUSIONS

New for this updated review is evidence that: decision aids with explicit values clarification exercises improve informed values-based choices; decision aids appear to have a positive effect on patient-practitioner communication; and decision aids have a variable effect on length of consultation.Consistent with findings from the previous review, which had included studies up to 2006: decision aids increase people's involvement, and improve knowledge and realistic perception of outcomes; however, the size of the effect varies across studies. Decision aids have a variable effect on choices. They reduce the choice of discretionary surgery and have no apparent adverse effects on health outcomes or satisfaction. The effects on adherence with the chosen option, patient-practitioner communication, cost-effectiveness, and use with developing and/or lower literacy populations need further evaluation. Little is known about the degree of detail that decision aids need in order to have positive effects on attributes of the decision or decision-making process.

Design and methods for a randomized clinical trial comparing three outreach efforts to improve screening mammography adherence

Background

Despite the demonstrated need to increase screening mammography utilization and strong evidence that mail and telephone outreach to women can increase screening, most managed care organizations have not adopted comprehensive outreach programs. The uncertainty about optimum strategies and cost effectiveness have retarded widespread acceptance. While 70% of women report getting a mammogram within the prior 2 years, repeat mammography rates are less than 50%. This 5-year study is conducted though a Central Massachusetts healthcare plan and affiliated clinic. All womenhave adequate health insurance to cover the test.

Methods/Design

This randomized study compares 3 arms: reminder letter alone; reminder letter plus reminder call; reminder letter plus a second reminder and booklet plus a counselor call. All calls provide women with the opportunity to schedule a mammogram in a reasonable time. The invention period will span 4 years and include repeat attempts. The counselor arm is designed to educate, motivate and counsel women in an effort to alleviate PCP burden.

All women who have been in the healthcare plan for 24 months and who have a current primary care provider (PCP) and who are aged 51-84 are randomized to 1 of 3 arms. Interventions are limited to women who become ≥18 months from a prior mammogram. Women and their physicians may opt out of the intervention study.

Measurement of completed mammograms will use plan billing records and clinic electronic records. The primary outcome is the proportion of women continuously enrolled for ≥24 months who have had ≥1 mammogram in the last 24 months. Secondary outcomes include the number of women who need repeat interventions. The cost effectiveness analysis will measure all costs from the provider perspective.

Discussion

So far, 18,509 women aged 51-84 have been enrolled into our tracking database and were randomized into one of three arms. At baseline, 5,223 women were eligible for an intervention. We anticipate that the outcome will provide firm data about the maximal effectiveness as well as the cost effectiveness of the interventions both for increasing the mammography rate and the repeat mammography rate.

Trial registration

http://clinicaltrials.gov/NCT01332032

A meta-analysis of computer-tailored interventions for health behavior change

OBJECTIVE

Computer-tailored interventions have become increasingly common for facilitating improvement in behaviors related to chronic disease and health promotion. A sufficient number of outcome studies from these interventions are now available to facilitate the quantitative analysis of effect sizes, permitting moderator analyses that were not possible with previous systematic reviews.

METHOD

The present study employs meta-analytic techniques to assess the mean effect for 88 computer-tailored interventions published between 1988 and 2009 focusing on four health behaviors: smoking cessation, physical activity, eating a healthy diet, and receiving regular mammography screening. Effect sizes were calculated using Hedges g. Study, tailoring, and demographic moderators were examined by analyzing between-group variance and meta-regression.

RESULTS

Clinically and statistically significant overall effect sizes were found across each of the four behaviors. While effect sizes decreased after intervention completion, dynamically tailored interventions were found to have increased efficacy over time as compared with tailored interventions based on one assessment only. Study effects did not differ across communication channels nor decline when up to three behaviors were identified for intervention simultaneously.

CONCLUSION

This study demonstrates that computer-tailored interventions have the potential to improve health behaviors and suggests strategies that may lead to greater effectiveness of these techniques.

Healthy colon, healthy life: a novel colorectal cancer screening intervention

BACKGROUND

Colorectal cancer (CRC) screening rates are increasing, but they are still low, particularly in ethnic minority groups. In many resource-poor settings, fecal occult blood test (FOBT) is the main screening option.

INTERVENTION

Culturally tailored telephone counseling by community health advisors employed by a community-based organization, culturally tailored brochures, and customized FOBT kits.

DESIGN

RCT. Participants were randomized to (1) basic intervention: culturally tailored brochure plus FOBT kit (n=765); (2) enhanced intervention: brochure, FOBT plus telephone counseling (n=768); or (3) usual care (n=256).

SETTING/PARTICIPANTS

Latino and Vietnamese primary care patients at a large public hospital.

MAIN OUTCOME MEASURES

Self-reported receipt of FOBT or any CRC screening at 1-year follow-up.

RESULTS

1358 individuals (718 Latinos and 640 Vietnamese) completed the follow-up survey. Self-reported FOBT screening rates increased by 7.8% in the control group, by 15.1% in the brochure group, and by 25.1% in the brochure/telephone counseling group (p<0.01 for differences between each intervention and usual care and for the difference between brochure/telephone counseling and brochure alone). For any CRC screening, rates increased by 4.1% in the usual care group, by 11.9% in the FOBT/brochure group, and by 21.4% in the brochure/telephone counseling group (p<0.01 for differences between each intervention and usual care and for the difference between the basic and the enhanced intervention).

CONCLUSIONS

An intervention that included culturally tailored brochures and tailored telephone counseling increased CRC screening in Latinos and the Vietnamese. Brochure and telephone counseling together had the greatest impact. Future research should address replication and dissemination of this model for Latinos and Vietnamese in other communities, and adaptation of the model for other groups.

Effects of a tailored web-based educational intervention on women's perceptions of and intentions to obtain mammography

AIMS AND OBJECTIVES

Breast cancer is the fourth leading cause of death in Taiwanese women. Mammography has been recognised as a powerful tool for breast cancer detection. This study compared the effectiveness of a web-based tailored educational intervention based on Transtheoretical Model concepts with currently available educational information for improving Taiwanese women's perceptions and intentions to obtain mammography.

BACKGROUND

Despite the wide use of the Internet for health information dissemination, health information found on the web frequently is very general and not individualised or tailored to meet specific individual needs. This has produced unsatisfactory outcomes such as little to no increase in individuals' knowledge or behaviour changes.

DESIGN

A pretest-posttest study. Tailored intervention was hypothesised to be significantly different from standard intervention in perceptions of and intentions for Taiwanese women to receive mammography.

METHODS

One hundred and twenty-eight Taiwanese women were randomly assigned to one of two groups: tailored intervention or standard intervention. The tailored intervention group received a variety of educational programme tailored to the precontemplation stage for mammography based on Transtheoretical Model concepts. The standard intervention group obtained standardised mammography brochures. Interventions were given online and online questionnaires were completed by subjects at baseline and completion of interventions.

RESULTS

The tailored intervention group had significantly more positive perceptions of mammography and significantly more intention to obtain mammography than the standard intervention group postintervention.

CONCLUSIONS

This study contributes to our knowledge of how a health education website can enhance women's mammography-related positive perceptions and intentions if tailored to their readiness for change.

RELEVANCE TO CLINICAL PRACTICE

Increasingly, people get their health information from the web. If that education is also tailored to individual needs, it can have a greater impact on their health care decisions.

Tailored information about cancer risk and screening: a systematic review

OBJECTIVE

To study interventions that provide people with information about cancer risk and about screening that is tailored to their personal characteristics. We assess the tailoring characteristics, theory base and effects on risk perception, knowledge and screening behavior of these interventions.

METHODS

A systematic literature review in this field was performed. PubMed, EMBASE, PsychINFO, CINAHL and Cochrane databases were searched. Forty studies fulfilled all inclusion criteria. Methodological quality was assessed and a best evidence synthesis conducted for the 28 randomized controlled trials without co-intervention or with similar co-intervention in intervention and control group.

RESULTS

Most included studies evaluated an intervention aiming to promote cancer screening. The majority of articles (30) evaluated information that was tailored based on variables related to behavior change, sometimes combined with cancer risk factors. Ten other articles described an intervention that tailored information based on risk factors only.

CONCLUSION

Information that was tailored based on behavior change variables increased realistic perception of cancer risks and knowledge of cancer compared to generic information. Also, information tailored to individuals' risk factors increased realistic risk perception compared to generic information.

PRACTICE IMPLICATIONS

To improve cancer risk perception and knowledge health providers could better give patients information about cancer risk and screening that is tailored to their personal characteristics than generic information.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Decision aids prepare people to participate in 'close call' decisions that involve weighing benefits, harms, and scientific uncertainty.

OBJECTIVES

To conduct a systematic review of randomised controlled trials (RCTs) evaluating the efficacy of decision aids for people facing difficult treatment or screening decisions.

SEARCH STRATEGY

We searched MEDLINE (Ovid) (1966 to July 2006); Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library; 2006, Issue 2); CINAHL (Ovid) (1982 to July 2006); EMBASE (Ovid) (1980 to July 2006); and PsycINFO (Ovid) (1806 to July 2006). We contacted researchers active in the field up to December 2006. There were no language restrictions.

SELECTION CRITERIA

We included published RCTs of interventions designed to aid patients' decision making by providing information about treatment or screening options and their associated outcomes, compared to no intervention, usual care, and alternate interventions. We excluded studies in which participants were not making an active treatment or screening decision, or if the study's intervention was not available to determine that it met the minimum criteria to qualify as a patient decision aid.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts for inclusion, and extracted data from included studies using standardized forms. The primary outcomes focused on the effectiveness criteria of the International Patient Decision Aid Standards (IPDAS) Collaboration: attributes of the decision and attributes of the decision process. We considered other behavioural, health, and health system effects as secondary outcomes. We pooled results of RCTs using mean differences (MD) and relative risks (RR) using a random effects model.

MAIN RESULTS

This update added 25 new RCTs, bringing the total to 55. Thirty-eight (69%) used at least one measure that mapped onto an IPDAS effectiveness criterion: decision attributes: knowledge scores (27 trials); accurate risk perceptions (11 trials); and value congruence with chosen option (4 trials); and decision process attributes: feeling informed (15 trials) and feeling clear about values (13 trials).This review confirmed the following findings from the previous (2003) review. Decision aids performed better than usual care interventions in terms of: a) greater knowledge (MD 15.2 out of 100; 95% CI 11.7 to 18.7); b) lower decisional conflict related to feeling uninformed (MD -8.3 of 100; 95% CI -11.9 to -4.8); c) lower decisional conflict related to feeling unclear about personal values (MD -6.4; 95% CI -10.0 to -2.7); d) reduced the proportion of people who were passive in decision making (RR 0.6; 95% CI 0.5 to 0.8); and e) reduced proportion of people who remained undecided post-intervention (RR 0.5; 95% CI 0.3 to 0.8). When simpler decision aids were compared to more detailed decision aids, the relative improvement was significant in knowledge (MD 4.6 out of 100; 95% CI 3.0 to 6.2) and there was some evidence of greater agreement between values and choice.In this review, we were able to explore the use of probabilities in decision aids. Exposure to a decision aid with probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.6; 95% CI 1.4 to 1.9). The effect was stronger when probabilities were measured quantitatively (RR 1.8; 95% CI 1.4 to 2.3) versus qualitatively (RR 1.3; 95% CI 1.1 to 1.5).As in the previous review, exposure to decision aids continued to demonstrate reduced rates of: elective invasive surgery in favour of conservative options, decision aid versus usual care (RR 0.8; 95% CI 0.6 to 0.9); and use of menopausal hormones, detailed versus simple aid (RR 0.7; 95% CI 0.6 to 1.0). There is now evidence that exposure to decision aids results in reduced PSA screening, decision aid versus usual care (RR 0.8; 95% CI 0.7 to 1.0) . For other decisions, the effect on decisions remains variable.As in the previous review, decision aids are no better than comparisons in affecting satisfaction with decision making, anxiety, and health outcomes. The effects of decision aids on other outcomes (patient-practitioner communication, consultation length, continuance, resource use) were inconclusive.There were no trials evaluating the IPDAS decision process criteria relating to helping patients to recognize a decision needs to be made, understand that values affect the decision, or discuss values with the practitioner.

AUTHORS' CONCLUSIONS

Patient decision aids increase people's involvement and are more likely to lead to informed values-based decisions; however, the size of the effect varies across studies. Decision aids have a variable effect on decisions. They reduce the use of discretionary surgery without apparent adverse effects on health outcomes or satisfaction. The degree of detail patient decision aids require for positive effects on decision quality should be explored. The effects on continuance with chosen option, patient-practitioner communication, consultation length, and cost-effectiveness need further evaluation.

Factors associated with annual-interval mammography for women in their 40s

BACKGROUND

Evidence is mounting that annual mammography for women in their 40s may be the optimal schedule to reduce morbidity and mortality from breast cancer. Few studies have assessed predictors of repeat mammography on an annual interval among these women.

METHODS

We assessed mammography screening status among 596 insured Black and Non-Hispanic white women ages 43-49. Adherence was defined as having a second mammogram 10-14 months after a previous mammogram. We examined socio-demographic, medical and healthcare-related variables on receipt of annual-interval repeat mammograms. We also assessed barriers associated with screening.

RESULTS

44.8% of the sample were adherent to annual-interval mammography. A history of self-reported abnormal mammograms, family history of breast cancer and never having smoked were associated with adherence. Saying they had not received mammography reminders and reporting barriers to mammography were associated with non-adherence. Four barrier categories were associated with women's non-adherence: lack of knowledge/not thinking mammograms are needed, cost, being too busy, and forgetting to make/keep appointments.

CONCLUSIONS

Barriers we identified are similar to those found in other studies. Health professionals may need to take extra care in discussing mammography screening risk and benefits due to ambiguity about screening guidelines for women in their 40s, especially for women without family histories of breast cancer or histories of abnormal mammograms. Reminders are important in promoting mammography and should be coupled with other strategies to help women maintain adherence to regular mammography.

Lessons learned from developing a tailored print intervention: a guide for practitioners and researchers new to tailoring

Although some "how-to" guides have been written on tailored messaging, we found no reports on lessons learned from the process of developing a tailored intervention. Such lessons may be useful for practitioners and researchers who are new to tailored intervention development. The authors describe lessons gleaned from the process of developing a repeat mammography tailored print intervention. Lessons learned include the following: Selection of determinants appropriate for tailoring should be based on a theoretic framework and refined through assessment of the target population; researchers should anticipate threats to fidelity of intervention delivery because of incomplete or illogical survey data; fingerprinting enables assessment of intervention dose and how it relates to effectiveness of the tailored intervention; and a systematic process for conducting a systems test is needed to check for inconsistencies and errors before final tailored letter production. These lessons are discussed in the context of challenges and possible solutions for tailored health communication.

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.

Reconciling population benefits and women's individual autonomy in mammographic screening: in-depth interviews to explore women's views about ‘informed choice’

OBJECTIVE

To explore women's reactions to 'informed choice' in mammographic screening.

SETTING AND METHODS

Telephone interviews with a convenience sample of 106 women aged 45-70 years recruited from general practices in Sydney.

RESULTS

Many (42%) women preferred an active role in decision-making. Respondents had low scores for 'uncertainty' and 'factors contributing to uncertainty' in response to explicit questions about the decision to have mammographic screening. Yet respondents indicated significantly greater willingness to have a test when the benefit of a 'new' screening test for breast cancer was expressed as relative risk reduction (RRR) (88%) than either absolute risk reduction (ARR) (78%) (McNemar's test: chi(2)1=7.14, p=0.013) or all-cause mortality (53%) (McNemar's test: chi(2)1=35.1, p<0.01). Significantly more respondents considered information about ARR 'new' to them (65%) compared with RRR information (30%) (McNemar's test: chi(2)1=25.83, p<0.01).

CONCLUSIONS

As mammographic screening exposes well women to potential harms for an overall population benefit, it is challenging to ensure 'informed choice'. Our results suggest women will likely appreciate individual consultations as the context in which to share complex information that women in our study agreed they need to know about mammographic screening. Our results also demonstrate that women's willingness as individuals to participate in mammographic screening is influenced by 'framing effect'. Hence, the quantitative content of decision aids to promote 'informed choice' must be comprehensive and balanced.

Mammography Stage of Adoption and Decision Balance Among Asian Indian and Filipino American Women

Cancer is the leading cause of death among Asian American women, and the death rate has increased almost 200% since 1990. Previous research has applied the transtheoretical model constructs to examine cancer screening behavior; however, to our knowledge, this is the first such investigation to examine relationships between stages of mammography adoption and decision balance among Asian American women. This article presents study findings from a convenience sample of 228 women aged 40 to 81 years (mean = 55.0, SD = 9.6) residing in southeastern Michigan. The current study demonstrates excellent support for the psychometric properties of a pros and cons measure, with promising Cronbach alphas above .70. Results from confirmatory factor analysis also support the factor structure derived from exploratory factor analysis with good model fit indices. This study also provides some support on transtheoretical model-hypothesized relationships in this sample of Asian American women that, as the stages of adoption of mammography proceeded from earlier to later ones, the decisional balance would become more favorable. The specific beliefs (both positive and negative) associated with the various stages of mammography adoption have implications for health professionals in developing stage-matched interventions to motivate women in adopting regular mammography.

Is there a role for decision aids in cancer-related decisions?

Cancer-related decisions are challenging, requiring patients to evaluate associated medical and psychological outcomes within the context of their personal values. In response, a number of decisional support tools have been developed. Clinical decision aids are decisional support tools designed to facilitate patient-driven decision-making by providing relevant information on the options while eliciting and incorporating patient preferences; they have been designed to support decision-making in the prevention, screening, and treatment of cancer. The development begins with identification of an appropriate clinical problem, followed by needs assessment to determine content and optimal methods of data presentation. Because implementation of a decision aid requires time and financial commitment, its efficacy in improving the quality of patients' decisions must be evaluated. In randomized controlled trials, cancer-related decision aids have been shown to increase patients' knowledge regarding their disease, and may facilitate patients playing a more active role in decision-making. Some studies suggest less decisional conflict and improved satisfaction with decision-making as a result. Whether use of a decision aid impacts the actual decisions made by patients, however, is less evident.

Measures used in studies of informed decision making about cancer screening: a systematic review

Interventions to promote informed decision making (IDM) for cancer screening are increasingly common. The resulting body of literature provides an opportunity for a systematic review of measures in use. We searched standard databases for intervention trials and other studies of screening decisions and decision aids, finding 2,110 unique citations (most with abstracts) that we reduced to 104 full-text articles; 36 studies met inclusion criteria (prostate = 20, colorectal = 9, breast = 6, cervical = 1). Two independent coders abstracted data on study characteristics, constructs, and measures. Our findings revealed that most studies measured screening (or intention) and knowledge; fewer measured recommended IDM-related constructs and none measured all outcomes proposed for evaluating IDM interventions. Validity and reliability of measures received inadequate attention in study reports, and conceptual overlap exists among measures. Few IDM measures have been developed/carefully adapted from treatment measures and tested for cancer screening or in diverse populations. We recommend that new and in-progress studies emphasize outcomes beyond knowledge-participation in decision making according to personal preference, satisfaction with the process, and consistency between decisions and values. Also needed is better use of theory to guide conceptualization and operationalization of measures, greater attention to reliability and validity (particularly in diverse populations), more thorough reporting of sources and operating characteristics of measures, and increased emphasis and resources focused on these issues by funders, researchers, and journal editors.

Theoretical foundations for interventions designed to promote informed decision making for cancer screening

BACKGROUND

Decision aids are currently being developed and evaluated for use in cancer-screening decisional settings.

PURPOSE

The purpose of this article is to review and discuss the theoretical basis of interventions to promote informed decision making in cancer screening.

METHODS

We reviewed interventions cited in Briss et al. and Rimer et al. to identify their theoretical basis, intervention content, measurement strategies, and outcomes.

RESULTS

Few interventions had a strong, decision-oriented conceptual basis. This was apparent in their intervention content, the measurement strategy, and the choice of outcomes for the study.

CONCLUSIONS

We recommend that more research occur into the basis of decision making in cancer screening and that future interventions use this research to rigorously design and evaluate decision aids to help people make choices about cancer screening.

The effect of telephone versus print tailoring for mammography adherence

OBJECTIVE

The purpose of this intervention was to increase mammography adherence in women who had not had a mammogram in the last 15 months.

METHODS

A prospective randomized intervention trial used four groups: (1) usual care, (2) tailored telephone counseling, (3) tailored print, (4) tailored telephone counseling and print. Participants included a total of 1244 women from two sites-a general medicine clinic setting serving predominately low-income clientele and a Health Maintenance Organization (HMO). Computer-tailored interventions addressed each woman's perceived risk of breast cancer, benefits and/or barriers and self-efficacy related to mammography screening comparing delivery by telephone and mail.

RESULTS

Compared to usual care all intervention groups increased mammography adherence significantly (odds ratio 1.60-1.91) when the entire sample was included.

CONCLUSIONS

All interventions groups demonstrated efficacy in increasing mammography adherence as compared to a usual care group. When the intervention analysis considered baseline stage, pre contemplators (women who did not intend to get a mammogram) did not significantly increase in mammography adherence as compared to usual care.

PRACTICE IMPLICATIONS

Women who are in pre contemplation stage may need a more intensive intervention.

A systematic review of information in decision aids

OBJECTIVE

We completed a systematic review of information reported as included in decision aids (DAs) for adult patients, to determine if it is complete, balanced and accurate.

SEARCH STRATEGY

DAs were identified using the Cochrane Database of DAs and searches of four electronic databases using the terms: 'decision aid'; shared decision making' and 'patients'; 'multimedia or leaflets or pamphlets or videos and patients and decision making'. Additionally, publications reporting DA development and actual DAs that were reported as publicly available on the Internet were consulted. Publications were included up to May 2006.

DATA EXTRACTION

Data were extracted on the following variables: external groups consulted in development of the DA, type of study used, categories of information, inclusion of probabilities, use of citation lists and inclusion of patient experiences.

MAIN RESULTS

68 treatment DAs and 30 screening DAs were identified. 17% of treatment DAs and 47% of screening DAs did not report any external consultation and, of those that did, DA producers tended to rely more heavily on medical experts than on patients' guidance. Content evaluations showed that (i) treatment DAs frequently omit describing the procedure(s) involved in treatment options and (ii) screening DAs frequently focus on false positives but not false negatives. About 1/2 treatment DAs reported probabilities with a greater emphasis on potential benefits than harms. Similarly, screening DAs were more likely to provide false-positive than false-negative rates.

CONCLUSIONS

The review led us to be concerned about completeness, balance and accuracy of information included in DAs.

Tailored interventions for screening mammography among a sample of initially non-adherent women: when is a booster dose important?

OBJECTIVE

To assess added value of a booster dose of a tailored mammography intervention.

METHODS

Participants, non-adherent at baseline, were randomly assigned to usual care or one of three tailored interventions. Intervention group members (n=657) were further randomly assigned to receive/not receive a booster intervention dose. Electronic record mammography data were collected following initial intervention and at 6 and 15 months post-booster.

RESULTS

Booster had no effect among women not screened after first intervention dose (n=337). Among women screened after initial dose (n=320), booster predicted re-screening at 6 but not 15 months. A boosterxrace interaction showed a booster effect at 6 months for African Americans (OR=4.66, p=.0005) but not Caucasians (OR=0.74, p=.44).

CONCLUSIONS

Findings suggest if a first-dose intervention does not facilitate screening, neither will a booster dose. However, among women for whom a first dose is effective, boosters can facilitate timely repeat adherence, especially among African Americans. At 6 months booster recipients were less likely to be off-schedule but, by 15 months, the groups were similar.

PRACTICE IMPLICATIONS

Boosters may effect when, but not whether, women continue screening.

Personalised risk communication for informed decision making about taking screening tests

BACKGROUND

There is a trend towards greater patient involvement in healthcare decisions. Adequate discussion of the risks and benefits associated with different choices is often required if involvement is to be genuine and effective. Achieving both the adequate involvement of consumers and informed decision making are now seen as important goals for any screening programme. Personalised risk estimates have been shown to be effective methods of risk communication in general, but the effectiveness of different strategies has not previously been examined.

OBJECTIVES

To assess the effects of different types of personalised risk communication for consumers making decisions about taking screening tests.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2004), MEDLINE (1985 to December 2005), EMBASE (1985 to December 2005), CINAHL (1985 to December 2005), and PsycINFO (1989 to December 2005). Follow-up searches involved hand searching Preventive Medicine, citation searches on seven authors, and searching reference lists of articles. For the original version of this review (Edwards 2003c) we also searched CancerLit (1985 to 2001) and Science Citation Index Expanded (searched March 2002).

SELECTION CRITERIA

Randomised controlled trials addressing the decision by consumers of whether or not to undergo screening, incorporating an intervention with a 'personalised risk communication element' and reporting cognitive, affective, or behavioural outcomes. A 'personalised risk communication element' is based on the individual's own risk factors for a condition (such as age or family history). It may be calculated from an individual's risk factors using formulae derived from epidemiological data, and presented as an absolute or relative risk or as a risk score, or it may be categorised into, for example, high, medium or low risk groups. It may be less detailed still, involving a listing, for example, of a consumer's risk factors as a focus for discussion and intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed each trial for quality and extracted data. We extracted data about the nature and setting of the intervention, and relevant outcome data, along with items relating to methodological quality. We then used standard statistical methods of the Consumers and Communication Review Group to combine data using MetaView, including analysis according to different levels of detail of personalised risk communication, different condition for screening, and studies based only on high risk participants rather than people at 'average' risk.

MAIN RESULTS

Twenty-two studies were included, nine of which were added in the 2006 update of this review. There was weak evidence, consistent with a small effect, that personalised risk communication (whether written, spoken or visually presented) increases uptake of screening tests (odds ratio (OR) 1.31 (random effects, 95% confidence interval (CI) 0.98 to 1.77). In three studies the interventions showed a trend towards more accurate risk perception (OR 1.65 (95% CI 0.96 to 2.81), and three other trials with heterogenous outcome measures showed improvements in knowledge with personalised risk interventions. There was little other evidence from these studies that the interventions promoted or achieved informed decision making by consumers about participation in screening. More detailed personalised risk communication may be associated with a smaller increase in uptake of tests. That is, for personalised risk communication which used and presented numerical calculations of risk, the OR for test uptake was 0.82 (95% CI 0.65 to 1.03). For risk estimates or calculations which were categorised into high, medium or low strata of risk, the OR was 1.42 (95% CI 1.07 to 1.89). For risk communication that simply listed personal risk factors the OR was 1.42 (95% CI 0.95 to 2.12). Over half of the included studies assessed interventions in the context of mammography. These studies showed similar effects to the overall dataset. The five studies examining risk communication in high risk individuals (individuals at higher risk due to, for example, a family history of breast cancer or other conditions) showed larger odds ratios for uptake of tests than the other studies (random effects OR 1.74; 95% CI 1.05 to 2.88). There were insufficient data from the included studies to report odds ratios on other key outcomes such as: intention to take tests, anxiety, satisfaction with decisions, decisional conflict, knowledge and resource use.

AUTHORS' CONCLUSIONS

Personalised risk communication (as currently implemented in the included studies) may have a small effect on increasing uptake of screening tests, and there is only limited evidence that the interventions have promoted or achieved informed decision making by consumers.

Mobile eHealth interventions for obesity: a timely opportunity to leverage convergence trends

Obesity is often cited as the most prevalent chronic health condition and highest priority public health problem in the United States. There is a limited but growing body of evidence suggesting that mobile eHealth behavioral interventions, if properly designed, may be effective in promoting and sustaining successful weight loss and weight maintenance behavior changes. This paper reviews the current literature on the successes and failures of public health, provider-administered, and self-managed behavioral health interventions for weight loss. The prevailing theories of health behavior change are discussed from the perspective of how this knowledge can serve as an evidence base to inform the design of mobile eHealth weight loss interventions. Tailored informational interventions, which, in recent years, have proven to be the most effective form of conventional health behavior intervention for weight loss, are discussed. Lessons learned from the success of conventional tailored informational interventions and the early successes of desktop computer-assisted self-help weight management interventions are presented, as are design principles suggested by Social Cognitive Theory and the Social Marketing Model. Relevant computing and communications technology convergence trends are also discussed. The recent trends in rapid advancement, convergence, and public adoption of Web-enabled cellular telephone and wireless personal digital assistant (PDA) devices provide timely opportunities to deliver the mass customization capabilities, reach, and interactivity required for the development, administration, and adoption of effective population-level eHealth tailored informational interventions for obesity.

Public Education and Cancer Control

OBJECTIVES

To provide an overview of public education efforts in tobacco, obesity, environmental health, and cancer screening.

DATA SOURCES

Cochrane, AHRQ, the CDC's Guide to Community Preventive Services, and other reviews.

CONCLUSION

Major changes in rates of smoking and cancer screening attest to the effectiveness of public education efforts. Diet and physical activity have more resistant behaviors. Communication technologies offer possibilities for connecting people with the education they need.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can play important roles in public education by helping to overcome people's misperceptions and biases related to cancer. There also may be an important role for nurses as information brokers.

Tailored interventions to enhance osteoporosis prevention in women

PURPOSE

The purpose of this pilot study was to determine if tailored nursing interventions based on personal knowledge of bone mineral density from a dual-energy x-ray absorptiometry cause increases in knowledge of osteoporosis, health beliefs, or osteoporosis-prevention behaviors in postmenopausal women 50-65 years of age, 6 months after the intervention.

METHOD

The design for this pilot study was a two group quasi-experimental design. The treatment group received a tailored intervention; the control group did not. Outcome data were gathered at 6 months after dual-energy x-ray absorptiometry. The tailored intervention was designed and given to each woman via telephone using her dual-energy x-ray absorptiometry results and osteoporosis questionnaire data that addressed her knowledge of osteoporosis and osteoporosis-prevention behaviors of calcium intake, exercise, smoking, and alcohol use. A written mailed copy of the intervention followed the telephone interview. Six months after the intervention, the women were mailed another osteoporosis questionnaire to determine if the tailored intervention made a difference in the outcome variables.

SAMPLE

A total 124 women between the ages of 50 and 65 (101 control, 23 treatment) comprised the sample.

RESULTS

There was no difference in knowledge between groups. On the average, there were significantly more perceived barriers to calcium in the tailored group (mean = 13.48) than in the nontailored group (mean = 11.55) (t = 2.147; df = 122; p = .034). There were significantly more perceived barriers to exercise in the tailored group (mean = 14.39) than in the nontailored group (mean = 12.21) (t = .144; df = 122; p = .034). Daily calcium intake increased in both the tailored and the nontailored groups. The tailored intervention increased women's daily calcium intake from 614.28 to 1039.10 mg (t = -2.896; df = 22; p = .008). The nontailored group daily calcium intake increased from 587.91 to 916.30 mg (t = -3.541; df = 100; p = .001); there was no significant difference between the groups. Weight-bearing exercise behaviors decreased from 96.04 minutes to 59.2 minutes in the tailored group but increased slightly in the nontailored group from 81.47 to 87.26 minutes of exercise.

CONCLUSION

Tailored interventions increased women's perceived barriers to calcium and exercise. Both groups increased calcium intake. The mixed findings of increased perception of barriers to calcium and exercise and decreased exercise behaviors indicate the need for further study. This important intervention has implications for orthopaedic nurses and healthcare professionals involved in health promotion and prevention of osteoporosis.

A cost-effectiveness comparison of three tailored interventions to increase mammography screening

BACKGROUND

Mammography is the primary method used for breast cancer screening. However, adherence to recommended screening practices is still below acceptable levels. This study examined the cost-effectiveness of three combinations of tailored telephone and mailed intervention strategies for increasing adherence to mammography.

METHODS

There were 1044 participants who were randomly assigned to one of four groups. A logistic regression model with adherence as the dependent variable and group as the independent variable was used to test for significant differences, and a ratio of cost/improvement in mammogram adherence evaluated the cost-effectiveness.

RESULTS

All three of the interventions (tailored telephone, tailored mail, and tailored telephone and mail) had significantly better adherence rates compared with the control group (usual care). However, when also considering costs, one emerged as the superior strategy. The cost-effectiveness ratios for the three interventions show that the tailored mail (letter) was the most cost-effective strategy, achieving 43.3% mammography adherence at a marginal cost of dollar 0.39 per 1% increase in women screened. The tailored mail plus telephone achieved greater adherence (49.4%), but at a higher cost (dollar 0.56 per 1% increase in women screened).

CONCLUSIONS

A tailored mail reminder is an effective and economical intervention to increase mammography adherence. Future research should confirm this finding and address its applicability to practice in other settings.

The efficacy of tailored print materials in promoting colorectal cancer screening: results from a randomized trial involving callers to the National Cancer Institute's Cancer Information Service

In this large randomized trial among callers to the Cancer Information Service (CIS), tailored print materials were tested for efficacy in promoting colorectal cancer (CRC) screening (fecal occult blood test [FOBT], flexible sigmoidoscopy, or colonoscopy). All participants completed baseline interviews at the end of their usual service calls to the CIS, as well as short-term (6-month) and longer-term (14-month) telephone follow-up interviews. The study sample (n = 4,014) was restricted to English-speaking CIS callers 50 + years of age, who would be eligible for CRC screening at 14 months follow-up and did not call the CIS about CRC or CRC screening. Four experimental conditions were compared: a single untailored (SU) mailout of print material (the control condition); a single tailored (ST) mailout of print material; four (multiple) tailored (MT) mailouts of print materials spanning 12 months, all of which were tailored to information obtained at baseline; and four (multiple) retailored (MRT) mailouts also spanning 12 months, with retailoring of the print materials (mailouts 2, 3, and 4) based on updated information obtained from the 6-month follow-up interviews. Consistent with the main hypothesis of this trial, a significant linear trend across the SU, ST, MT, and MRT groups was found at 14 months (42%, 44%, 51%, and 48%, respectively, p = 0.05). Only for MT was there a significant difference compared with SU (p = 0.03) for the sample as a whole, while no differences were found for MT vs. MRT at 14 months. Significant moderator effects in the predicted direction were found among females, younger participants, and among those with a history of CRC screening, all of which involved the SU vs. MT MRT comparisons. Only among younger participants (ages 50-59) was there a difference between SU vs. ST at 14 months. Given these results, we conclude from this trial the following: (1) the MRT intervention failed to show added benefit beyond the MT intervention, (2) the significant intervention effects involving the MT and MRT conditions can be explained by tailoring and/or the longitudinal nature of both interventions, and (3) the most compelling evidence in support of tailoring was found for the ST condition among younger participants, where a significant need for interventions exists at the national level. Directions for future research are discussed in light of the results summarized above.

Informed decision making: what is its role in cancer screening?

Interest in informed decision making (IDM) has grown in recent years. Greater patient involvement in decision making is consistent with recommendations to improve health care quality. This report provides an overview of IDM; clarifies the differences between IDM, shared decision making (SDM), and informed consent; and reviews the evidence to date about IDM for cancer screening. The authors also make recommendations for research. We define IDM as occurring when an individual understands the disease or condition being addressed and comprehends what the clinical service involves, including its benefits, risks, limitations, alternatives, and uncertainties; has considered his or her preferences and makes a decision consistent with them; and believes he or she has participated in decision making at the level desired. IDM interventions are used to facilitate informed decisions. The authors reviewed the evidence to date for IDM and cancer screening based primarily on published meta-analyses and a recent report for the Centers for Disease Control and Prevention's Guide to Community Preventive Services. IDM and SDM interventions, such as decision aids, result in improved knowledge, beliefs, risk perceptions, and combinations of these. Little or no evidence exists, however, regarding whether these interventions result in 1) participation in decision making at a level consistent with patient preferences or 2) effects on patient satisfaction with the decision-making process. These variables generally either were not assessed or were not reported in the articles reviewed. Results of interventions on uptake of screening were variable. After exposure to IDM/SDM interventions, most studies showed small decreases in prostate cancer screening, whereas four studies on breast and colorectal cancer screening showed small increases. Few data are available by which to evaluate current practices in cancer screening IDM. Patient participation in IDM should be facilitated for those who prefer it. More research is needed to assess the benefits of IDM/SDM interventions and to tailor interventions to individuals who are most likely to desire and benefit from them. There are many system barriers to IDM/SDM and few tools. More work is needed in this area as well. In addition, research is needed to learn how to incorporate IDM into ongoing clinical practice and to determine whether there are unintended negative consequences of IDM.