The effect of deadlines on cancer screening completion: a randomized controlled trial

Consumer versus expert opinions on bowel cancer screening videos: Findings from a co-design study

OBJECTIVE

To describe compare and assess expert and consumer evaluations of videos the National Bowel Cancer Screening Program in Australia to inform the future development of effective promotional materials.

METHODS

From July to November, 2022 consumers (n = 487) were randomly assigned to see 3 of 15 videos and 34 "experts" (i.e., researchers, clinicians, and health promotion specialists) viewed all 15 videos. Participants completed 22 items reflecting positive and negative perceptions and perceived efficacy in encouraging screening participation. Multiple analyses of covariance assessed mean differences in expert and consumer ratings controlling for age and gender differences.

RESULTS

Experts and consumers reported similar perceptions about videos, with no difference in the degree to which each would encourage kit completion. However, compared to those containing personal stories, experts rated instructional and informational videos significantly lower than consumers in terms of encouraging actions that facilitate kit completion.

CONCLUSIONS

Experts may underestimate the degree to which information and personal narratives resonate with consumers viewing bowel cancer screening videos.

PRACTICAL IMPLICATIONS

It is valuable to consult consumers when designing bowel cancer screening promotion and education videos as opposed to relying solely on expert opinion especially in the context of encouraging actions that lead to kit completion.

Evaluating colonoscopy quality by performing provider type

BACKGROUND

Colorectal cancer is the third most diagnosed cancer and the second leading cause of cancer death in the United States. Colonoscopy is an essential tool for screening, used as a primary approach and follow-up to an abnormal stool-based colorectal cancer screening result. Colonoscopy quality is often measured with 4 key indicators: bowel preparation, cecal intubation, mean withdrawal time, and adenoma detection. Colonoscopies are most often performed by gastroenterologists (GI), however, in rural and medically underserved areas, non-GI providers often perform colonoscopies. This study aims to evaluate the quality and safety of screening colonoscopies performed by non-GI practitioner, comparing their outcomes with those of GI providers.

METHODS

Descriptive statistics were used to characterize the study population. Results for quality indicators were stratified by provider type and compared. Statistical significance was determined using a P value of less than .05 as the threshold for all comparisons; all P values were 2-sided.

RESULTS

No statistical difference was found when comparing performance by provider type. Median performance for gastroenterologists, general surgeons, and family medicine providers ranged from 98% to 100% for cecal intubation; 97.4% to 100% for bowel preparation; 57.4% to 88.9% for male adenoma detection rate; 47.7% to 62.13% for female adenoma detection rate; and 0:12:10 to 0:20:16 for mean withdrawal time. All provider types met and exceeded the goal metric for each of the quality indicators (P < .001).

CONCLUSIONS

As a result of this analysis, we can expect non-GI practitioner to perform colonoscopies with similar quality to GI practitioner given the performance outcomes for the key quality metrics.

The Nudging Effect of a Reminder Letter to Reduce Duplicated Medications: A Randomized Controlled Trial

BACKGROUND

The increasing trend of multiple chronic conditions across the world has worsened the problem of medication duplication in health care systems without gatekeeping or referral requirement. Thus, to overcome this problem, a reminder letter has been developed in Taiwan to nudge patients to engage in medication management.

OBJECTIVE

To evaluate the effect of reminder letter on reducing duplicated medications.

RESEARCH DESIGN

A 2-arm randomized controlled trial design.

SUBJECTS

Patients with duplicated medications in the first quarter of 2019.

MEASURES

The Taiwanese single-payer National Health Insurance Administration identified the eligible patients for this study. A postal reminder letter regarding medication duplication was mailed to the patients in the study group, and no information was provided to the comparison group. Generalized estimation equation models with a difference-in-differences analysis were used to estimate the effects of the reminder letters.

RESULTS

Each group included 11,000 patients. Those who had received the reminder letter were less likely to receive duplicated medications in the subsequent 2 quarters (postintervention 1: odds ratio [OR]=0.95, 95% CI=0.87-1.03; postintervention_2: OR=0.99, 95% CI=0.90-1.08) and had fewer days of duplicated medications (postintervention 1: β=-0.115, P =0.015; postintervention 2 (β=-0.091, P =0.089) than those who had not received the reminder letter, showing marginal but significant differences.

CONCLUSIONS

A one-off reminder letter nudge could mildly decrease the occurrence of duplicated medications. Multiple nudges or nudges incorporating behavioral science insights may be further considered to improve medication safety in health systems without gatekeeping.

Screening for Colorectal Cancer: The Role of Clinical Laboratories

BACKGROUND

Colorectal cancer (CRC) is a leading cause of cancer incidence and mortality. Screening can result in reductions in incidence and mortality, but there are many challenges to uptake and follow-up.

CONTENT

Here, we will review the changing epidemiology of CRC, including increasing trends for early and later onset CRC; evidence to support current and emerging screening strategies, including noninvasive stool and blood-based tests; key challenges to ensuring uptake and high-quality screening; and the critical role that clinical laboratories can have in supporting health system and public health efforts to reduce the burden of CRC on the population.

SUMMARY

Clinical laboratories have the opportunity to play a seminal role in optimizing early detection and prevention of CRC.

Time's ticking! Effects of deadline on the utilization of health services: Evidence from a cluster-randomized controlled trial

The low utilization of health services in rural areas is an essential factor affecting the health level of rural residents. Based on insights from behavioral economics, this study evaluates the average treatment effect of imposing a deadline on vision-care vouchers (i.e., the voucher-deadline intervention) on the utilization of health services. Using the vision health as a case study, a non-masked cluster-randomized controlled trial was conducted in 13 rural schools of a county in Shaanxi Province of China during 2018-2019. Among 1270 baseline sample students with myopia, 610 students from 6 schools were randomly assigned to receive vouchers with no deadline (i.e., the Control group), and 660 students from 7 schools to receive vouchers with a 30-day deadline (i.e., the Deadline group). The results showed that the voucher-deadline intervention significantly improved the vision-center visiting rate by 13.2 percentage points within 30 days and shortened the interval between visits (i.e., increased timeliness) by 18.7 days. In comparison, the vision-center visiting rate and the interval between visits among the control group were 16.7% and 30.5 days, respectively. However, considering a longer time frame (6 months), we found that intervention only shifted students' utilization to before the voucher expires without improving overall utilization rate. The loss aversion and time pressure induced by the voucher deadline are possible explanations for the treatment effects. This study suggests insights from behavioral economics can enhance the design of public health programs to improve the utilization and the cost-effectiveness of health-service programs. TRIAL REGISTRATION: isrctn.org Identifier ISRCTN03252665.

Barriers and facilitators of colorectal cancer screening using the 5As framework: A systematic review of US studies

Despite clear evidence that regular screening reduces colorectal cancer (CRC) mortality and the availability of multiple effective screening options, CRC screening continues to be underutilized in the US. A systematic literature search of four databases - Ovid, Medline, EBSCHOhost, and Web of Science - was conducted to identify US studies published after 2017 that reported on barriers and facilitators to CRC screening adherence. Articles were extracted to categorize relevant CRC screening barriers or facilitators that were assessed against CRC screening outcomes using the 5As dimensions: Access, Affordability, Acceptance, Awareness, Activation. Sixty-one studies were included. Fifty determinants of screening within the 5As framework and two additional dimensions including Sociodemographics and Health Status were identified. The Sociodemographics, Access, and Affordability dimensions had the greatest number of studies included. The most common factor in the Access dimension was contact with healthcare systems, within the Affordability dimension was insurance, within the Awareness dimension was knowledge CRC screening, within the Acceptance dimension was health beliefs, within the Activation dimension was prompts and reminders, within the Sociodemographics dimension was race/ethnicity, and among the Health Status dimension was chronic disease history. Among all studies, contact with healthcare systems, insurance, race/ethnicity, age, and education were the most common factors identified. CRC screening barriers and facilitators were identified across individual, clinical, and sociocontextual levels. Interventions that consider multilevel strategies will most effectively increase CRC screening adherence.

Reminders, but not monetary incentives, increase COVID-19 booster uptake

Despite substantially decreasing the risk of hospitalization and death from COVID-19, COVID-19 booster vaccination rates remain low around the world. A key question for public health agencies is how to increase booster vaccination rates, particularly among high-risk groups. We conducted a large preregistered randomized controlled trial (with 57,893 study subjects) in a county health system in northern California to test the impact of personal reminder messages and small financial incentives of $25 on booster vaccination rates. We found that reminders increased booster vaccination rates within 2 wk by 0.86 percentage points (P = 0.000) or nearly 33% off the control mean of 2.65%. Monetary incentives had no additional impact on vaccination rates. The results highlight the potential of low-cost targeted messages, but not small financial incentives, to increase booster vaccination rates.

Increasing uptake of FIT colorectal screening: protocol for the TEMPO randomised controlled trial testing a suggested deadline and a planning tool

INTRODUCTION

Screening can reduce deaths from colorectal cancer (CRC). Despite high levels of public enthusiasm, participation rates in population CRC screening programmes internationally remain persistently below target levels. Simple behavioural interventions such as completion goals and planning tools may support participation among those inclined to be screened but who fail to act on their intentions. This study aims to evaluate the impact of: (a) a suggested deadline for return of the test; (b) a planning tool and (c) the combination of a deadline and planning tool on return of faecal immunochemical tests (FITs) for CRC screening.

METHODS AND ANALYSIS

A randomised controlled trial of 40 000 adults invited to participate in the Scottish Bowel Screening Programme will assess the individual and combined impact of the interventions. Trial delivery will be integrated into the existing CRC screening process. The Scottish Bowel Screening Programme mails FITs to people aged 50-74 with brief instructions for completion and return. Participants will be randomised to one of eight groups: (1) no intervention; (2) suggested deadline (1 week); (3) suggested deadline (2 weeks); (4) suggested deadline (4 weeks); (5) planning tool; (6) planning tool plus suggested deadline (1 week); (7) planning tool plus suggested deadline (2 weeks); (8) planning tool plus suggested deadline (4 weeks). The primary outcome is return of the correctly completed FIT at 3 months. To understand the cognitive and behavioural mechanisms and to explore the acceptability of both interventions, we will survey (n=2000) and interview (n=40) a subgroup of trial participants.

ETHICS AND DISSEMINATION

The study has been approved by the National Health Service South Central-Hampshire B Research Ethics Committee (ref. 19/SC/0369). The findings will be disseminated through conference presentations and publication in peer-reviewed journals. Participants can request a summary of the results.

TRIAL REGISTRATION NUMBER

clinicaltrials.govNCT05408169.

“It's cancer screening after all”. Barriers to cervical and colorectal cancer screening and attitudes to promotion of self-sampling kits upon attendance for breast cancer screening

Objectives

To explore barriers to cervical and colorectal cancer screening and attitudes to promotion of self-sampling kits upon attendance for breast cancer screening.

Methods

Interview study with women who had not responded to one or more invitations to cervical or colorectal cancer screening. A semi-structured interview guide was used and interviews were audio recorded and transcribed verbatim. Concepts from Temporal Motivation Theory were used to structure and analyse the data.

Results

Twenty-two women were interviewed. Screening was highly valued but the women perceived screening for cervical cancer and colorectal cancer as more troublesome to participate in, compared with participation in breast cancer screening. The lack of a pre-booked appointment or a suggested deadline attenuated the perceived value of cervical and colorectal cancer screening and this further increased procrastination. Promotion of self-sampling kits for cervical and colorectal cancer screening upon attendance for breast cancer screening was considered a feasible way to increase salience of both types of screening.

Conclusion

A high number of micro steps and absence of a deadline in cervical and colorectal cancer screening diverted attention away from screening participation in cervical and colorectal cancer screening. The main facilitator could be reduction of micro actions, proposing a suggested deadline, and promotion of self-sampling kits when attending breast cancer screening to increase salience and a renewed attention to all three screening programmes.

Can financial incentives and other nudges increase COVID-19 vaccinations among the vaccine hesitant? A randomized trial

Despite rapid initial uptake, COVID-19 vaccinations in the United States stalled within a few months of widespread rollout in 2021. In response, many state and local governments, employers and health systems used public health messaging, financial incentives and creative scheduling tools to increase vaccine uptake. Although these approaches drew on evidence from influenza and other vaccination efforts, they were largely untested in the context of SARS-CoV-2. In mid-2021, months after vaccines were widely available, we evaluated vaccination intentions and vaccine uptake using a randomized control trial. To do this, we recruited unvaccinated members of a Medicaid managed care plan in California (n = 2,701) and randomly assigned them to different public health messages, $10 or $50 financial incentives for vaccination, a simple vaccination appointment scheduler, or control. While messages increased vaccination intentions, none of the interventions increased vaccination rates. Estimates for financial incentives rule out even relatively small increases in vaccination rates. Small financial incentives and other behavioral nudges do not meaningfully increase COVID-19 vaccination rates amongst the vaccine hesitant.

Financial Literacy, Financial Education, and Cancer Screening Behavior: Evidence from Japan

Although Japan has a well-established cancer screening program and has implemented several initiatives to increase screening rates, levels of cancer screening can be further improved. Based on a rational decision-making framework, this study examines the role of financial literacy and financial education, which measure peoples' knowledge about investment and savings, respectively, in improving cancer screening rates in Japan. The main data were extracted from Osaka University's Preference Parameters Study for 2011. The dependent variable was the number of cancer screenings while the two main independent variables were financial literacy and financial education. Ordered probit regression models were run to test the association between financial literacy, financial education, and the number of cancer screenings. The results showed a positive relationship between financial education and cancer screening behavior in Japan, while no significant association was observed between financial literacy and screening behavior. Furthermore, according to findings stratified by three age groups, the positive association between financial education and cancer screening behavior was particularly evident in 50- to 59-year-olds, while the effects of other demographic, socioeconomic, and risky health behavior variables were not consistent. It is imperative that implementation of more financial education programs is an effective intervention to encourage cancer screening behavior in Japanese populations.