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

The validity of instruments to measure knowledge in population-based cancer screening targeting individuals at average risk - A systematic review

OBJECTIVES

Relevant knowledge is essential for informed choices about (non)participation in population-based cancer screening. Many instruments have been proposed to assess residents' knowledge about cancer screening programmes but their measurement properties are unknown. This systematic review aims to identify and critically evaluate the measurement properties of instruments to measure knowledge about cancer screening in individuals eligible for population-based screening.

METHODS

A literature search was undertaken in PubMed, PsycINFO, Embase, CINAHL, Scopus and Web of Science in August 2023. The review included any study reporting one or more measurement properties of the questionnaire or sub-scale used measuring knowledge of cancer screening including breast, colorectal and/or cervical cancer screening. Studies including males aged 45 or older and females aged 20 or older were included. Two independent reviewers screened the articles and assessed the included articles using the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN).

RESULTS

We included 24 instruments, which varied in number and characteristics of items. All instruments were assessed as having an inadequate instrument development. The results of structural validity, internal consistency, criterion validity and reliability were assessed as indeterminate, while construct validity and responsiveness were assessed as sufficient.

CONCLUSION

This systematic review identified no instruments to measure knowledge about cancer screening where the measurement properties were sufficiently evaluated. There is a lack of focus on content validity and structural validity, and further validation of the instruments is needed. The results indicate a lack of shared understanding or agreement of what constitutes relevant knowledge about cancer screening.

Qualitative Analysis of Colorectal Cancer Screening in Rural Nebraska

Compared to urban residents, rural populations are less likely to engage in colorectal cancer (CRC) screening. As part of a statewide cancer needs assessment, we aimed to elicit rural perspectives about CRC screening and resources. We conducted three focus groups with rural Nebraska cancer survivors and caregivers (N = 20) in Spring 2021 using a collective case study design. Participant awareness of and knowledge about CRC screening methods varied across focus groups; overall, 95% of participants had heard of colonoscopy. Participants were less familiar with fecal tests and had confusion about them. Colonoscopy was associated with negative perceptions regarding the time, cost, and discomfort of the preparation and procedure, but some providers did not discuss alternative methods unless the patient resisted colonoscopy. Healthcare providers played a key role educating rural communities about CRC screening recommendations (age, risk) and testing options and being persistent in those recommendations. CRC awareness campaigns should include a variety of communication channels (TV, radio, billboards, health fairs, churches, healthcare settings). Promotion of CRC screening should include education about screening age guidelines, alternative test types, and informed decision-making between provider and patient regarding preferred screening methods based on the pros and cons of each test type. Individuals with a family history of colon issues (Crohn's disease, CRC) are considered high risk and need to be aware that screening should be discussed at earlier ages.

Adaptation and Initial Psychometric Evaluation of an Informed Prostate Cancer Screening Decision Self-Efficacy Scale for African-American Men

OBJECTIVE

To evaluate whether computer-based prostate cancer screening decision aids enhance decision self-efficacy for African-American men, culturally relevant and reliable measures are needed. However, limited psychometric evidence exists on the health-related decision self-efficacy of African-American men. This study describes the development and psychometric evaluation of the 11-item Informed Prostate Cancer Screening Decision Self-Efficacy Scale among 354 African-American men.

METHODS

Exploratory factor analysis was conducted with maximum-likelihood estimation and polychoric correlations followed by Promax and Varimax rotations.

RESULTS

Exploratory factor analysis yielded a one-factor, 11-item model of the modified scale with excellent internal consistency reliability at 0.95 and factor loadings ranging from 0.70 to 0.90. Both parallel analysis and a scree plot confirmed the retention of one factor, and the standardized root mean square residual (0.06) indicated that the factor structure explained most of the correlations.

CONCLUSIONS

Findings suggest the one-factor, 11-item Informed Prostate Cancer Screening Decision Self-Efficacy Scale has excellent psychometric properties and utility in reliably measuring health-related decision self-efficacy in African-American men. Future research is needed to confirm this factor structure among socio-demographically diverse African Americans.

Development and Psychometric Properties of a Prostate Cancer Knowledge Scale for African American Men

African American men have the highest prostate cancer-related mortality nationally. In response to this disparity, targeted interventions are emerging to enhance African American men's prostate cancer (PrCA) knowledge to ensure they are equipped to make informed decisions about PrCA screening with health-care providers. African American men's PrCA knowledge has been measured inconsistently over time with limited psychometric evidence. The factor structure of this construct in African American men is relatively unknown. This study describes the development and psychometric evaluation of an 18-item Prostate Cancer Knowledge Scale among 352 African American men. Exploratory factor analysis (EFA) was conducted using weighted least square mean and variance estimation with Geomin rotation. EFA yielded three factors: PrCA Anatomy and Screening (6 items), Risk Factors (5 items), Warning Signs (7 items) with good internal consistency reliability at KR-20 = .80 for the total scale and .64, .66, and .75, respectively, for each subscale. Factor loadings ranged from .31 to .86. The standardized root mean square residual (0.08) indicated that the factor structure explained most of the correlations. The three-factor, 18-item Prostate Cancer Knowledge Scale demonstrates that PrCA knowledge is a multidimensional construct and has utility for reliably measuring PrCA knowledge among African American men. Future research is required to confirm this factor structure among socio-demographically diverse African Americans.

Development and initial psychometric evaluation of the computer-based prostate Cancer screening decision aid acceptance scale for African-American men

BACKGROUND

To reliably evaluate the acceptance and use of computer-based prostate cancer decision aids (CBDAs) for African-American men, culturally relevant measures are needed. This study describes the development and initial psychometric evaluation of the 24-item Computer-Based Prostate Cancer Screening Decision Aid Acceptance Scale among 357 African-American men.

METHODS

Exploratory factor analysis (EFA) with maximum likelihood estimation and polychoric correlations followed by Promax and Varimax rotations.

RESULTS

EFA yielded three factors: Technology Use Expectancy and Intention (16 items), Technology Use Anxiety (5 items), and Technology Use Self-Efficacy (3 items) with good to excellent internal consistency reliability at .95, .90, and .85, respectively. The standardized root mean square residual (0.035) indicated the factor structure explained most of the correlations.

CONCLUSIONS

Findings suggest the three-factor, 24-item Computer-Based Prostate Cancer Screening Decision Aid Acceptance Scale has utility in determining the acceptance and use of CBDAs among African-American men at risk for prostate cancer. Future research is needed to confirm this factor structure among socio-demographically diverse African-Americans.

Can Women Facilitate Men's Prostate Cancer Screening Informed Decision-Making? The M-PACT Trial

The M-PACT study compared an all-male with a mixed-sex intervention to increase informed decision-making for prostate cancer screening among African-American men in church settings. We recruited 262 men in 18 churches randomized to the two intervention approaches. Trained and certified lay peer community health advisors in each church led a series of four men's health workshops on informed decision-making for prostate cancer screening. African-American male workshop participants completed baseline, post-workshop, and 12-month follow-up surveys. Contrary to our expectations, including women in the workshops did not result in increased intervention efficacy for the informed decision-making outcomes as both groups showed significant improvement over time in several study outcomes including stage of decision-making for prostate cancer screening, preference for role in decision-making, prostate cancer knowledge, and self-reports of prostate specific antigen testing. Finally, men who attended multiple workshops had better informed decision-making outcomes on several indicators. The current findings suggest mixed results from including women in this men's health educational intervention. Future work should consider optimal ways of providing family support for African-American men's health promotion.

Client and practitioner perspectives on the screening mammography experience

Mammography can be painful and unpleasant, but effective interventions to improve the experience remain scarce. As a first step towards more effective interventions, we aimed to achieve a thorough, contemporary understanding of thoughts, feelings and behaviours which affect and arise from mammography experiences. Research and professional experience suggest that the interaction between client and practitioner may be paramount in determining the quality of a client's experience. Therefore, this study aimed to capture the perspectives of clients and mammography staff from UK breast screening programmes. Thematic analysis of semi-structured qualitative in-depth interviews with 22 clients and 18 staff revealed that clients had positive attitudes to breast screening and mostly low knowledge about potential harms. Staff data indicated that some women attend for breast screening under pressure from others. Pain and coping with it were prominent themes, with wide variations in pain experiences. Clients recognised differences in mammographers' abilities to put them at ease. Staff difficulties included empowering clients within the confines of a taxing technique, and maintaining compassionate care when under strain. Future intervention development should focus on the information and support needs of women prior to the appointment and on effectively training and supporting mammographers to deal with challenging encounters.

Women's experiences with cervical cancer screening in a colposcopy referral clinic in Cape Town, South Africa: a qualitative analysis

OBJECTIVE

The aim of this study was to explore and understand women's experience with cervical cancer screening and with the referral pathways for abnormal Papanicolau (Pap) smears.

DESIGN AND SETTING

Focus group discussions were conducted with first time colposcopy clinic attendees at a tertiary hospital colposcopy clinic in Cape Town, South Africa during November 2014. A thematic analysis was conducted to identify key themes. Initial coding categories were drawn from the interview guide.

PARTICIPANTS

27 women participated in 4 focus group discussions.

RESULTS

Participants mean age was 34 years, most did not complete secondary level education and were unemployed. Negative community opinions relating to Pap smears and colposcopy referral might deter women from seeking treatment. Having a gynaecological symptom was the most commonly cited reason for having a Pap smear. Fear of having a HIV test performed at the same time as Pap smear and low encouragement from peers, were factors identified as potential access barriers. Participants commented on insufficient or lack of information from primary providers on referral to the colposcopy clinic and concerns and apprehension during waiting periods between receiving results and the colposcopy appointment were discussed.

CONCLUSIONS

There is a strong and urgent need to improve current knowledge about cervical cancer and Pap smears and the necessity and benefits of timely access to screening programmes, results and treatment. Strategies such as community health education programmes and mass media interventions could be employed to disseminate cervical cancer information and address negative community perceptions. Better training and support mechanisms to equip healthcare providers with the skills to convey cervical cancer information to women are needed. The use of short message service (SMS) to deliver Pap smear results and provide patients with more information should be considered to improve waiting times for results and alleviate apprehension during waiting periods.

Common methods of measuring 'informed choice' in screening participation: Challenges and future directions

There is general agreement among public health practitioners, academics, and policymakers that people offered health screening tests should be able to make informed choices about whether to accept. Robust measures are necessary in order to gauge the extent to which informed choice is achieved in practice and whether efforts to improve it have succeeded. This review aims to add to the literature on how to improve methods of measuring informed choice. We discuss and critique commonly-used approaches and outline possible alternative methods that might address the issues identified. We explore the challenges of defining what information should be provided about screening and hence understood by service users, appraise the use of 'thresholds' to define e.g. positive attitudes towards screening, and describe problems inherent in conceptualising 'informed choice' as a single dichotomous outcome that either does or does not occur. Suggestions for future research include providing greater detail on why particular aspects of screening information were considered important, analysing knowledge and attitude measures at an ordinal or continuous level (avoiding problematic decisions about dichotomising data in order to set thresholds), and reconceptualising informed choice as a multifactorial set of outcomes, rather than a unitary one.

The associations between objective numeracy and colorectal cancer screening knowledge, attitudes and defensive processing in a deprived community sample

We examined associations between numeracy and sociocognitive factors associated with colorectal cancer screening uptake (n = 964). Nearly half (45.7%) of the respondents incorrectly answered a numeracy question (low numeracy). Low numeracy respondents were less knowledgeable about colorectal cancer (p < .001), less positive towards screening (emotional, p < .001 and practical, p = .001) and less likely to intend to participate in screening (p = .001). They also reported greater defensive processing of cancer information (p = .001). Sociocognitive factors fully mediated the relationship between numeracy and screening intention. Addressing numeracy issues may reduce inequalities in CRC screening participation, but communication strategies could be limited by the tendency process cancer information defensively.

Development and preliminary evaluation of an online educational video about whole-genome sequencing for research participants, patients, and the general public

BACKGROUND

As whole-genome sequencing (WGS) increases in availability, WGS educational aids are needed for research participants, patients, and the general public. Our aim was therefore to develop an accessible and scalable WGS educational aid.

METHODS

We engaged multiple stakeholders in an iterative process over a 1-year period culminating in the production of a novel 10-minute WGS educational animated video, "Whole Genome Sequencing and You" (https://goo.gl/HV8ezJ). We then presented the animated video to 281 online-survey respondents (the video-information group). There were also two comparison groups: a written-information group (n = 281) and a no-information group (n = 300).

RESULTS

In the video-information group, 79% reported the video was easy to understand, satisfaction scores were high (mean 4.00 on 1-5 scale, where 5 = high satisfaction), and knowledge increased significantly. There were significant differences in knowledge compared with the no-information group but few differences compared with the written-information group. Intention to receive personal results from WGS and decisional conflict in response to a hypothetical scenario did not differ between the three groups.

CONCLUSIONS

The educational animated video, "Whole Genome Sequencing and You," was well received by this sample of online-survey respondents. Further work is needed to evaluate its utility as an aid to informed decision making about WGS in other populations.Genet Med 18 5, 501-512.

Measuring informed choice in population-based reproductive genetic screening: a systematic review

Genetic screening and health-care guidelines recommend that programmes should facilitate informed choice. It is therefore important that accurate measures of informed choice are available to evaluate such programmes. This review synthesises and appraises measures used to evaluate informed choice in population-based genetic screening programmes for reproductive risk. Databases were searched for studies offering genetic screening for the purpose of establishing reproductive risk to an adult population sample, in which aspects of informed choice were measured. Studies were included if, at a minimum, measures of uptake of screening and knowledge were used. Searches identified 1462 citations and 76 studies were reviewed in full text; 34 studies met the inclusion criteria. Over 20 different measures of informed choice were used. Many measures lacked adequate validity and reliability data. This systematic review will inform future evaluation of informed choice in population genetic screening programmes.

The effect of a supplementary ('Gist-based') information leaflet on colorectal cancer knowledge and screening intention: a randomized controlled trial

Guided by Fuzzy Trace Theory, this study examined the impact of a ‘Gist-based’ leaflet on colorectal cancer screening knowledge and intentions; and tested the interaction with participants’ numerical ability. Adults aged 45–59 years from four UK general practices were randomly assigned to receive standard information (‘The Facts’, n = 2,216) versus standard information plus ‘The Gist’ leaflet (Gist + Facts, n = 2,236). Questionnaires were returned by 964/4,452 individuals (22 %). 82 % of respondents reported having read the information, but those with poor numeracy were less likely (74 vs. 88 %, p < .001). The ‘Gist + Facts’ group were more likely to reach the criterion for adequate knowledge (95 vs. 91 %; p < .01), but this was not moderated by numeracy. Most respondents (98 %) intended to participate in screening, with no group differences and no interaction with numeracy. The improved levels of knowledge and self-reported reading suggest ‘The Gist’ leaflet may increase engagement with colorectal cancer screening, but ceiling effects reduced the likelihood that screening intentions would be affected.

Use of a community-based participatory research approach to assess knowledge, attitudes, and beliefs on biospecimen research among Pacific Islanders

Objectives. The purpose of this article is to describe a community-based participatory research pilot project conducted to investigate the knowledge, attitudes, and beliefs that Pacific Islanders (PIs) hold toward biospecimen collection, use, and banking, all of which will help drive higher PI participation rates in both medical and behavioral research studies. Method. Academic and community partners worked side by side to develop a conceptual model, study measures, and study protocols. PI community partners screened, recruited, and conducted data collection, which consisted of a paper-and-pencil survey and a 1-hour semistructured interview administered by trained community workers. Results. A total of 60 PI adults representing various PI ethnic groups completed the surveys and interviews. Results showed a general support for biospecimen studies that would benefit the community, and many are willing to provide their biospecimen samples if asked. Conclusion. Due to the established level of trust, community partners were able to successfully recruit and collect data for the study. Many of those interviewed also called for more outreach and education about the importance of biospecimen research in their communities.

"Best practice" for patient-centered communication: a narrative review

BACKGROUND

Communicating with patients has long been identified as an important physician competency. More recently, there is a growing consensus regarding the components that define physician-patient communication. There continues to be emphasis on both the need to teach and to assess the communication skills of physicians.

OBJECTIVE

This narrative review aims to summarize the work that has been conducted in physician-patient communication that supports the efficacy of good communications skills. This work may also help to define the physician-patient communication skills that need to be taught and assessed.

RESULTS

A review of the literature shows it contains impressive evidence supporting positive associations between physician communication behaviors and positive patient outcomes, such as patient recall, patient understanding, and patient adherence to therapy. There is a consensus about what constitutes "best practice" for physician communication in medical encounters: (1) fostering the relationship, (2) gathering information, (3) providing information, (4) making decisions, (5) responding to emotions, and (6) enabling disease- and treatment-related behavior.

CONCLUSIONS

Evidence supports the importance of communication skills as a dimension of physician competence. Effort to enhance teaching of communication skills to medical trainees likely will require significant changes in instruction at undergraduate and graduate levels, as well as changes in assessing the developing communication skills of physicians. An added critical dimension is faculty understanding of the importance of communication skills, and their commitment to helping trainees develop those skills.

The relationship between perceived burden of chronic conditions and colorectal cancer screening among Appalachian residents

PURPOSE

As the population living with several concurrent chronic conditions or multiple morbidity (MM) increases, understanding how to effectively fit prevention efforts into disease management becomes more important, particularly among rural, underserved populations. Compared to their urban counterparts, rural residents suffer higher rates of disease, receive fewer preventive services, and often live in environments limiting access to optimal medical care. This study describes rural residents' perceived burdens of disease management and explores the relationship between these burdens, as proxies of individuals' competing demands, and colorectal cancer screening (CRCS).

METHODS

We conducted a cross-sectional study, based on telephone survey data from 1,012 Appalachian residents, ages 50-75, with 1 or more chronic conditions. Measures of perceived MM burdens were developed based on 85 pilot interviews previously undertaken with providers and patients with MM residing in Appalachian Kentucky.

RESULTS

Many participants (81%) agreed with 1 or more statements indicating perceived burdens of disease management effects on receiving CRCS. A higher percentage of rural (vs nonrural) Appalachians perceived burdens related to physician's recommendation, preparation to colonoscopy, and time management and affordability of both current diseases and screening. These differences did not modify the overall association between perceiving MM as burdensome and forgoing CRCS. The negative effect on CRCS of perceived burdens related to interaction with physician and time management was lower for participants with multiple rather than single morbidity.

CONCLUSION

Future research designed to address perceived burdens of MM and improved interaction with health care providers may enhance critical prevention efforts among vulnerable populations.

Children's skin cancer prevention: a systematic review of parents' psychosocial measures

CONTEXT

Parents' knowledge, attitudes, and beliefs may be influenced through intervention to increase children's sun protection. Little is known about measures of these psychosocial characteristics, including psychometric properties. This paper systematically reviews parents' psychosocial measures in children's skin cancer prevention studies.

EVIDENCE ACQUISITION

A search of standard databases conducted in 2008, updated in 2011, yielded 5797 unique citations. A study was eligible if (1) it was published between January 1980 and March 2011; (2) it was published in English; (3) it reported a psychosocial measure relevant to children's skin cancer prevention; and (4) the psychosocial measure was administered to parents, the majority of whom had children aged ≤12 years. Screening yielded 57 eligible studies. Data were analyzed in 2008 and 2011.

EVIDENCE SYNTHESIS

Most studies measured one (n=24) or two (n=18) psychosocial constructs; few (n=7) measured more than three. The most frequently measured constructs were knowledge (n=41); attitudes (n=22); perceived susceptibility/risk (n=11); self-efficacy (n=9); and perceived barriers (n=9). Most studies did not mention theory. Theoretic mechanisms underlying interventions were not examined. There was little description of measure validity. Reliability, usually internal consistency, was reported more often (n=19).

CONCLUSIONS

Few studies assessed more than two parent-related psychosocial constructs, so it was not possible to test theoretic models of parental influences on children's sun protection. Validated measures were lacking. There was conceptual overlap of measures because of the presence of analogous constructs across theories and assessment of multiple constructs within a single measure.

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.

Can a decision aid enable informed decisions in neonatal nursery recruitment for a fragile X newborn screening study?

PURPOSE

To determine whether a brochure based on principles of informed decision making improved attention to study materials or altered decisions made by parents invited to participate in a fragile X syndrome newborn screening study.

METHODS

A total of 1,323 families were invited to participate in a newborn screening study to identify infants with fragile X syndrome as well as premutation carrier infants. Of these families, 716 received the original project brochure and 607 were given a new decision aid brochure.

RESULTS

Families were more likely to look at the new decision aid and mothers were more likely to read it completely, but the proportion of mothers who read the entire decision aid was only 14%. Families were more likely to rate the decision aid as very helpful. Consistent with informed decision making theory and research, participants receiving the decision aid brochure were less likely to agree to participate.

CONCLUSION

The decision aid increased attention to and perceived helpfulness of educational information about the study, but most families did not read it completely. The study suggests that even well-designed study materials are not fully reviewed in the context of in-hospital postpartum study recruitment and may need to be accompanied by a research recruiter to obtain informed consent.

Development of a fragile X syndrome (FXS) knowledge scale: towards a modified multidimensional measure of informed choice for FXS population carrier screening

BACKGROUND

Genetic carrier screening is increasingly possible for many conditions, but it is important to ensure decisions are informed. The multidimensional measure of informed choice (MMIC) is a quantitative instrument developed to evaluate informed choice in prenatal screening for Down syndrome, measuring knowledge, attitudes and uptake. To apply the MMIC in other screening settings, the knowledge scale must be modified.

OBJECTIVE

To develop and validate a modified MMIC knowledge scale for use with women undergoing carrier screening for fragile X syndrome (FXS).

SETTING AND PARTICIPANTS

Responses to MMIC items were collected through questionnaires as part of a FXS carrier screening pilot study in a preconception setting in Melbourne, Australia.

DESIGN

Ten knowledge scale items were developed using a modified Delphi technique. Cronbach's alpha and factor analysis were used to validate the new FXS knowledge scale. We summarized the knowledge, attitudes and informed choice status based on the modified MMIC.

RESULTS

Two hundred and eighty-five women were recruited, 241 eligible questionnaires were complete for analysis. The FXS knowledge scale items measured one salient construct and were internally consistent (alpha = 0.70). 71% (172/241) of participants were classified as having good knowledge, 70% (169/241) had positive attitudes and 27% (65/241) made an informed choice to accept or decline screening.

DISCUSSION AND CONCLUSIONS

We present the development of a knowledge scale as part of a MMIC to evaluate informed choice in population carrier screening for FXS. This can be used as a template by other researchers to develop knowledge scales for other conditions for use in the MMIC.

Some but not all dyadic measures in shared decision making research have satisfactory psychometric properties

OBJECTIVE

To assess the psychometric properties of dyadic measures for shared decision making (SDM) research.

STUDY DESIGN AND SETTING

We conducted an observational cross-sectional study in 17 primary care clinics with physician-patient dyads. We used seven subscales to measure six elements of SDM: (1) defining the problem, presenting options, and discussing pros and cons; (2) clarifying the patient's values and preferences; (3) discussing the patient's self-efficacy; (4) drawing on the doctor's knowledge; (5) verifying the patient's understanding; and (6) assessing the patient's uncertainty. We assessed the reliability and invariance of the factorial structure and considered a measure to be dyadic if the factorial structure of the patient version was similar to that of the physician version and if there was equality of loading (no significant chi-square).

RESULTS

We analyzed data for 264 physicians and 269 patients. All measures except one showed adequate reliability (Cronbach alpha, 0.70-0.93) and factorial validity (root mean square error of approximation, 0.000-0.06). However, we found only four measures to be dyadic (P>0.05): the values clarification subscale, perceived behavioral subscale, information-verifying subscale, and uncertainty subscale.

CONCLUSION

The subscales for values clarification, perceived behavioral control, information verifying, and uncertainty are appropriate dyadic measures for SDM research and can be used to derive dyadic indices.

Design and evaluation of a decision aid for inviting parents to participate in a fragile X newborn screening pilot study

The major objectives of this project were to develop and evaluate a brochure to help parents make an informed decision about participation in a fragile X newborn screening study. We used an iterative development process that drew on principles of Informed Decision Making (IDM), stakeholder input, design expertise, and expert evaluation. A simulation study with 118 women examined response to the brochure. An independent review rated the brochure high on informational content, guidance, and values. Mothers took an average of 6.5 min to read it and scored an average of 91.1 % correct on a knowledge test. Most women rated the brochure as high quality and trustworthy. When asked to make a hypothetical decision about study participation, 61.9 % would agree to screening. Structural equation modeling showed that agreement to screening and decisional confidence were associated with perceived quality and trust in the brochure. Minority and white mothers did not differ in perceptions of quality or trust. We demonstrate the application of IDM in developing a study brochure. The brochure was highly rated by experts and consumers, met high standards for IDM, and achieved stated goals in a simulation study. The IDM provides a model for consent in research disclosing complicated genetic information of uncertain value.

Is a prostate cancer screening anxiety measure invariant across two different samples of age-appropriate men?

Background

In order to explore the influence of anxiety on decision–making processes, valid anxiety measures are needed. We evaluated a prostate cancer screening (PCS) anxiety scale that measures anxiety related to the prostate–specific antigen (PSA) test, the digital rectal examination (DRE), and the decision to undergo PCS (PCS-D) using two samples in different settings.

Methods

We assessed four psychometric properties of the scale using baseline data from a randomized, controlled decision aid trial (n = 301, private clinic; n = 149, public).

Results

The 3-factor measure had adequate internal consistency reliability, construct validity, and discriminant validity. Confirmatory factor analyses indicated that the 3–factor model did not have adequate fit. When subscales were considered separately, only the 6–item PCS-D anxiety measure had adequate fit and was invariant across clinics.

Conclusions

Our results support the use of a 6–item PCS-D anxiety measure with age-appropriate men in public and private settings. The development of unique anxiety items relating to the PSA test and DRE is still needed.

The study of human papillomavirus (HPV) vaccine uptake from a parental perspective: a systematic review of observational studies in the United States

Despite widespread information about the human papillomavirus (HPV) vaccine, uptake continues to be low (CDC, 2010). HPV vaccine uptake may be maximized by better understanding factors likely to influence parents' decisions to vaccinate their age-recommended children. Previous reviews have summarized barriers and facilitators likely to influence parents' decision to vaccinate their adolescents (mostly daughters) against HPV; however, less attention has been given to summarize and evaluate the methodology. The aim of this study is to systematically review the methodology used in observational studies of HPV vaccine uptake from a parental perspective. A systematic search of Academic Search Premier, CINAHL, ERIC, Medline and PsycInfo to obtain relevant articles after FDA vaccine approval (2006 to present) yielded 446 studies, of which 17 studies were eligible. Results showed the majority of studies were cross-sectional, with random sampling from list-assisted sources being the most common method for data collection. Most studies used convenience samples and relied on parental self-report. Also, the majority of studies explored vaccine initiation, but only a few explored regimen completion and timely completion of vaccine regimen. Given that the effectiveness of the HPV vaccine is based on established recommendations for a three dose regimen within a timely interval, studies on factors likely to influence regimen completion and timely completion of regimen are essential to maximize the effectiveness and public health benefits of the vaccine. Research with more diverse samples, better and increased use of random sampling techniques, and the use of precise and objective measures of vaccine uptake to supplement parental self-report, is necessary to reduce selection and information biases in future studies. Studies to inform on factors likely to influence parents' decisions to vaccinate their sons against HPV are also needed.

Measuring decisional control preferences in men newly diagnosed with prostate cancer

The Control Preferences Scale is widely used in decision research to measure patient preferences for participation in treatment decision making with health care providers. Following anecdotal reports of confusion with the scale the authors conducted an exploratory interview study to examine perceptions of the meaning and applicability of the Control Preferences Scale for men with localized prostate cancer seeking treatment in a multidisciplinary urology clinic. The preliminary data suggest potential validity challenges when the Control Preferences Scale is used in a multidisciplinary prostate cancer care setting, including the clinical context of localized prostate cancer and the meaning of shared decision making.

Multi-media support for informed/shared decision-making before and after a cancer diagnosis

OBJECTIVES

To define and distinguish informed decision-making (IDM) from shared decision-making (SDM) and review the evidence for technology-based interventions designed to facilitate informed decisions about cancer screening and treatment.

DATA SOURCES

Peer-reviewed research articles from Medline and other data sources accessible through pubmed.gov.

CONCLUSION

There is evidence that multi-media decision aids (DAs) or support systems can improve quality of decision-making in terms of enhancing knowledge relevant to decision-making, reducing decisional conflict, and customizing education and coaching of patients with cancer.

IMPLICATIONS FOR NURSING PRACTICE

Nurses have a key role to play in designing, deploying, monitoring, and evaluating multi-media DAs in oncology practice settings. DAs are an adjunct to interpersonal education, providing information to patients in both the clinical setting and in more familiar settings without the time constraints of clinical encounters. Nurses can adopt such DAs and support systems and work with patients to ensure that information has been comprehended, that values have been considered, and that patients play an active role in the decision-making process as they desire.

Translating medical evidence to promote informed health care decisions

OBJECTIVE

To examine the effects of a community-based intervention on decisions about prostate-specific antigen (PSA) screening using multiple measures of informed decision making (IDM).

DATA SOURCES/STUDY SETTING

Nonequivalent control group time series design collecting primary data in late 2004 and 2005.

STUDY DESIGN

We developed a multimodal intervention designed to convey the medical uncertainty about the benefits of PSA screening and early treatment and the limited predictive ability of both the PSA test and pathological specimens collected from prostate biopsy. We examined (1) patients' recognition that there is a decision to be made about PSA screening, (2) prostate cancer knowledge levels, (3) their preferred and actual levels of participation in decision making about screening at three points in time, and (4) screening decision.

DATA COLLECTION

Baseline data collection occurred in community-based organizations. These organizations served as recruiting sources and as sites for the intervention. We collected follow-up data by mail with telephone reminders.

PRINCIPAL FINDINGS

Our intervention was associated with greater recognition of the PSA test as a decision to be made, levels of knowledge, both preferred and actual levels of involvement in decision making, but did not have an impact on the screening decision.

CONCLUSIONS

Community-based interventions can influence key measures of IDM about PSA screening.

Measuring informed decision making about prostate cancer screening in primary care

PURPOSE

To measure the extent of informed decision making (IDM) about prostate cancer screening in physician-patient encounters, describe the coding process, and assess the reliability of the IDM measure.

METHODS

Audiorecoded encounters of 146 older adult men and their primary care physicians were obtained in a randomized controlled trial of mediated decision support related to prostate cancer screening. Each encounter was dual coded for the presence or absence of 9 elements that reflect several important dimensions of IDM, such as information sharing, patient empowerment, and engaging patients in preference clarification. An IDM-9 score (range = 0-9) was determined for each encounter by summing the number of elements that were coded as present. Estimates of coding reliability and internal consistency were calculated.

RESULTS

Male patients tended to be white (59%), married (70%), and between the ages of 50 and 59 (70%). Physicians tended to be white (90%), male (74%), and have more than 10 years of practice experience (74%). IDM-9 scores ranged from 0 to 7.5 (mean [SD], 2.7 [2.1]). Reliability (0.90) and internal consistency (0.81) of the IDM-9 were both high. The IDM dimension observed most frequently was information sharing (74%), whereas the dimension least frequently observed was engagement in preference clarification (3.4%).

CONCLUSIONS

In physician-patient encounters, the level of IDM concerning prostate cancer screening was low. The use of a dual-coding approach with audiorecorded encounters produced a measure of IDM that was reliable and internally consistent.

Measuring patient-centered communication in cancer care: a literature review and the development of a systematic approach

Patient-centered communication (PCC) is a critical element of patient-centered care, which the Institute of Medicine (Committee on Quality of Health Care in America, 2001) promulgates as essential to improving healthcare delivery. Consequently, the US National Cancer Institute's Strategic Plan for Leading the Nation (2006) calls for assessing the delivery of PCC in cancer care. However, no comprehensive measure of PCC exists, and stakeholders continue to embrace different conceptualizations and assumptions about how to measure it. Our approach was grounded in the PCC conceptual framework presented in a recent US National Cancer Institute monograph (Epstein & Street, 2007). In this study, we developed a comprehensive inventory of domains and subdomains for PCC by reviewing relevant literature and theories, interviewing a limited number of cancer patients, and consulting experts. The resulting measurement domains are organized under the six core functions specified in the PCC conceptual framework: exchanging information, fostering healing relationships, recognizing and responding to emotions, managing uncertainty, making decisions, and enabling patient self-management. These domains represent a promising platform for operationalizing the complicated PCC construct. Although this study focused specifically on cancer care, the PCC measurements are relevant to other clinical contexts and illnesses, given that patient-centered care is a goal across all healthcare. Finally, we discuss considerations for developing PCC measures for research, quality assessment, and surveillance purposes. United States Department of Health and Human Services, National Institutes of Health, National Cancer Institute (2006). The NCI Strategic Plan for Leading the Nation: To Eliminate the Suffering and Death Due to Cancer. NIH Publication No. 06-5773.

Helping men make an informed decision about prostate cancer screening: a pilot study of telephone counseling

OBJECTIVE

Evaluate a computer-assisted telephone counseling (CATC) decision aid for men considering a prostate specific antigen (PSA) test.

METHODS

Eligible men were invited by their primary care providers (PCPs) to participate. Those consenting received an educational booklet followed by CATC. The counselor assessed stage of readiness, reviewed booklet information, corrected knowledge deficits and helped with a values clarification exercise. The materials presented advantages and disadvantages of being screened and did not advocate for testing or for not testing. Outcome measures included changes in stage, decisional conflict, decisional satisfaction, perceived vulnerability and congruence of a PSA testing decision with a pros/cons score. Baseline and final surveys were administered by telephone.

RESULTS

There was an increase in PSA knowledge (p<0.001), and in decisional satisfaction (p<0.001), a decrease in decisional conflict (p<0.001), and a general consistency of those decisions with the man's values. Among those initially who had not made a decision, 83.1% made a decision by final survey with decisions equally for or against screening.

CONCLUSIONS

The intervention provides realistic, unbiased and effective decision support for men facing a difficult and confusing decision.

PRACTICE IMPLICATIONS

Our intervention could potentially replace a discussion of PSA testing with the PCP for most men.

Prostate cancer screening and informed decision-making: provider and patient perspectives

The objective was to determine the extent of informed decision making for prostate cancer screening in a defined population. A state-wide population based survey of men aged 50 and above (Behavioral Risk Factor Surveillance System, 2004, Washington state) and a simple random sample of primary care physicians, were conducted in the same geographic area. We examined prostate cancer screening rates among the men (defined as either PSA or digital rectal examination within the past year) and prostate cancer screening practices among the physicians. Screening rates were 56% at ages 50-64, 68% at ages 65-79 and 64% among men age 80 and older. Adjusted analyses indicated that age, income, marital status, possessing health insurance and a personal health care provider, and talking with a provider about prostate cancer screening tests were all positively associated with screening status. In the physician survey, most physicians recommend screening to their average-risk male patients. Three-fourths (74%) of physicians discussed benefits and risks of PSA testing with their patients; but few used educational tools. Only 35% discussed the side effects of prostate cancer treatment with their patients. The rates of screening reported by men were relatively high, given that current recommendations promote informed decision making rather than universal screening. The majority of physicians recommend prostate cancer screening to their patients, with few decision-making tools used. All relevant information may not be provided in the discussion. These results point to the need for increasing informed decision making about prostate cancer screening.

A randomized trial of a computer-tailored decision aid to improve prostate cancer screening decisions: results from the Take the Wheel trial

OBJECTIVE

To evaluate a decision aid (DA) designed to promote informed decision making for prostate cancer screening.

METHODS

Twelve work sites were randomly assigned to an intervention or nonintervention comparison condition. Intervention sites received access to a computer-tailored DA at the workplace. Male employees age 45 years and above (n = 625) completed surveys at baseline and at 3-month follow-up, documenting aspects of informed decision making.

RESULTS

Using an intention-to-treat analysis, men in the intervention group were significantly more likely to have made a screening decision and to have improved knowledge without increased decisional conflict, relative to men in the comparison group. These changes were observed despite the fact that only 30% of men in intervention sites used the DA. Among DA users, similar improvements were observed, although the magnitudes of changes were substantially greater, and significant improvements in decision self-efficacy were observed.

CONCLUSIONS

A DA offered in the workplace promoted decision making, improved knowledge, and increased decision self-efficacy among users, without increasing decisional conflict. However, participation was suboptimal, suggesting that better methods for engaging men in workplace interventions are needed. IMPACT STATEMENT: This trial shows the efficacy of a computer-tailored DA in promoting informed decisions about prostate cancer screening. The DA was delivered through work sites, thereby providing access to resources required to participate in informed decision making without requiring a medical appointment. However, participation rates were suboptimal, and additional strategies for engaging men are needed.

Do men make informed decisions about prostate cancer screening? Baseline results from the "take the wheel" trial

BACKGROUND

Baseline data from a randomized trial in 12 worksites were analyzed. Men aged 45+ (n = 812) completed surveys documenting screening history, screening preferences and decisions, CaP knowledge, decision self-efficacy, and decisional consistency. Psychosocial and demographic correlates of IDM were also assessed.

RESULTS

Approximately half of the sample had a prior PSA test, although only 35% reported having made an explicit screening decision. Across the sample, CaP knowledge was low (mean = 56%), although decision self-efficacy was high (mean = 78%), and the majority of men (81%) made decisions consistent with their stated values. Compared with those who were undecided, men who made an explicit screening decision had significantly higher levels of knowledge, greater decisional self-efficacy, and were more consistent in terms of making a decision in alignment with their values. They tended to be white, have high levels of income and education, and had discussed screening with their health care provider.

CONCLUSIONS

Many men undergo CaP screening without being fully informed about the decision. These findings support the need for interventions aimed at improving IDM about screening, particularly among men of color, those with lower levels of income and education, and those who have not discussed screening with their provider.

A systematic review of measures used in studies of human papillomavirus (HPV) vaccine acceptability

BACKGROUND

The recent proliferation of studies describing factors associated with HPV vaccine acceptability could inform health care providers in improving vaccine coverage and support future research. This review examined measures of HPV and HPV-vaccine knowledge, attitudes, beliefs and acceptability, described psychometric characteristics, and provided recommendations about their use.

METHODS

A systematic search of Medline, CINAHL, PsychoInfo, and ERIC through May 2008 for English language reports of quantitative data from parents, young adults or adolescents yielded 79 studies.

RESULTS

The majority of studies were cross-sectional surveys (87%), self-administered (67%), conducted before prophylactic vaccines were publicly available (67%) and utilized convenience samples (65%). Most measured knowledge (80%), general attitudes about HPV vaccination (40%), and willingness to vaccinate one's daughter (26%). Two-thirds did not report reliability or validity of measures. The majority did not specify a theoretical framework.

CONCLUSIONS

Use of a theoretical framework, consistent labeling of constructs, more rigorous validation of measures, and testing of measures in more diverse samples are needed to yield measurement instruments that will produce findings to guide practitioners in developing successful community and clinical interventions.

Developing a dyadic OPTION scale to measure perceptions of shared decision making

OBJECTIVE

Our aim was to develop a measurement which enables research into the interdependent nature of clinical encounters. The prime objective was to develop an instrument capable of assessing the extent to which patients have been involved in (shared) decision making from two viewpoints-that of the patient and the clinician.

METHODS

To develop an initial 'dyadic OPTION' instrument, the twelve original third-person items were drafted in passive, first person plural forms. Using this version initially, three rounds of cognitive debriefing interviews were held. These were audio-recorded and analysed at the end of each round and the results used to revise the dyadic OPTION scale.

RESULTS

It was possible to modify the observer OPTION instrument into an instrument for completion by both clinicians and patients after a dyadic interaction. Cognitive debriefing revealed five areas of interpretative difficulty. Each item of the observer OPTION scale underwent modification in order to develop a dyadic version of the scale.

CONCLUSIONS

The dyadic OPTION scale is acceptable and comprehensible by both clinicians and public respondents. Cognitive debriefing adapted and refined an existing scale and provided confidence that the core constructs of the scale (perceived involvement in decisions making) were understood.

PRACTICE IMPLICATIONS

Further validation of the dyadic OPTION scale is required prior to its use in research settings.

Constructing a theoretically based set of measures for liver cancer control research studies

OBJECTIVE

Measurement tools such as surveys assessing knowledge, attitudes, and behaviors need to be theoretically consistent with interventions. The purpose of this article is to describe the first steps in the process of constructing a theoretically based set of measures that is currently used in three trials to reduce liver cancer disparities.

METHODS

Guided by a common theoretical formulation-the Health Behavior Framework-we identified constructs relevant for liver cancer control research, compiled items from previous studies and constructed new items, and translated and pilot tested items in collaboration with members of the Vietnamese, Korean, and Hmong communities.

RESULTS

We constructed three questionnaires in Vietnamese, Hmong, and Korean languages that are slightly different due to cultural and language nuances but contain a core set of measures assessing identical constructs of the Health Behavior Framework. Initial research demonstrates that items are easily understood and that they are generally related to hepatitis B screening as expected.

CONCLUSIONS

Researchers are encouraged to follow a similar process for creating theory-based assessment tools. Measuring common theoretical constructs can advance liver cancer control and other health research by facilitating a more systematic comparison of findings across different populations and intervention strategies.

EXACKTE(2): exploiting the clinical consultation as a knowledge transfer and exchange environment: a study protocol

Background

While the evidence suggests that the way physicians provide information to patients is crucial in helping patients decide upon a course of action, the field of knowledge translation and exchange (KTE) is silent about how the physician and the patient influence each other during clinical interactions and decision-making. Consequently, based on a novel relationship-centered model, EXACKTE² (EXploiting the clinicAl Consultation as a Knowledge Transfer and Exchange Environment), this study proposes to assess how patients and physicians influence each other in consultations.

Methods

We will employ a cross-sectional study design involving 300 pairs of patients and family physicians from two primary care practice-based research networks. The consultation between patient and physician will be audio-taped and transcribed. Following the consultation, patients and physicians will complete a set of questionnaires based on the EXACKTE² model. All questionnaires will be similar for patients and physicians. These questionnaires will assess the key concepts of our proposed model based on the essential elements of shared decision-making (SDM): definition and explanation of problem; presentation of options; discussion of pros and cons; clarification of patient values and preferences; discussion of patient ability and self-efficacy; presentation of doctor knowledge and recommendation; and checking and clarifying understanding. Patients will be contacted by phone two weeks later and asked to complete questionnaires on decisional regret and quality of life. The analysis will be conducted to compare the key concepts in the EXACKTE² model between patients and physicians. It will also allow the assessment of how patients and physicians influence each other in consultations.

Discussion

Our proposed model, EXACKTE², is aimed at advancing the science of KTE based on a relationship process when decision-making has to take place. It fosters a new KTE paradigm by putting forward a relationship-centered perspective and has the potential to reveal unknown mechanisms that underline effective KTE in clinical contexts. This will result in better understanding of the mechanisms that may promote a new generation of knowledge transfer strategies.

Using decision aids in community-based primary care: a theory-driven evaluation with ethnically diverse patients

OBJECTIVE

To assess the effects of informational brochures and video decision aids about cancer screening on patient intention to engage in shared decision-making and its predictors in a racially diverse sample.

METHODS

Participants were recruited from 13 community-based primary care practices serving racially and ethnically diverse patients in predominately economically disadvantaged neighborhoods. Participants completed theory-based measures assessing attitudes, perceived social norms, self-efficacy and intentions for working with their physician to make a cancer screening decision after reviewing a brochure or video decision aid, but before seeing the physician. A post-questionnaire assessed screening decisions and participant knowledge.

RESULTS

Participants who reviewed a video decision aid had higher knowledge and were more likely to want to be the primary decision-maker. They reported lower perceived social norms, self-efficacy and intentions to work with their physicians than participants who reviewed a brochure. Participants who decided against cancer screening reported lower intentions to work with their physician in making a decision and were less likely to report having spoken with their physician about screening.

CONCLUSION

Participants who opted against cancer screening after reviewing a brochure or decision aid were less likely to discuss their decision with their physician. The tendency toward autonomous decision-making was stronger among participants who reviewed a video decision aid.

Appraisal of primary outcome measures used in trials of patient decision support

OBJECTIVE

To appraise instruments used as primary outcome measures in trials measuring the effectiveness of patient decision support interventions.

METHODS

Primary outcome measures were identified in trials of patient decision aids included in the 2003 Cochrane Review. Instruments were appraised for: use in calculating sample size, appropriateness, reliability, validity, responsiveness, precision, interpretability, acceptability, and feasibility.

RESULTS

Of the 35 trials, there were 35 unique primary outcome measures and 8 instruments were appraised. Actual or preferred choice was the primary outcome measure in 18 trials. Two instruments met at least 6 of 8 appraisal criteria: Control Preference Scale (n=2 trials) and Decisional Conflict Scale (n=5 trials). The Decision Conflict Scale was used to calculate sample size in 4 trials.

CONCLUSION

Decision was the most consistent outcome measure. Most publications provided inadequate detail for appraising the instruments. Four instruments (Decisional Conflict, Control Preferences, Genetic Testing Knowledge Questionnaire, and McBride's Satisfaction with Decision) measured one or more International Patient Decision Aid Standards criteria for evaluating effectiveness.

PRACTICE IMPLICATIONS

Selecting relevant and high quality outcome measures remains challenging and is an important area for further research in the field of shared decision making.

Using focus groups to adapt ethnically appropriate, information-seeking and recruitment messages for a prostate cancer screening program for men at high risk

PURPOSE

To adapt ethnically appropriate radio and newspaper messages in order to increase information-seeking and recruitment to the high-risk Prostate Cancer Risk Assessment Program (PRAP) using input from focus groups.

METHODS

We conducted four gender- and ethnic specific-focus groups composed of up to eight participants each. Group participants ranged in age from 35-69 and were either at risk for prostate cancer or were married to someone at risk. Participants evaluated both print and radio advertisements for a PRAP media recruitment campaign, and their recommendations were used to adapt the advertisements.

RESULTS

Trigger words, e.g,, "research program," were found to be a particular issue for African-American men who cited concerns about "experimentation," while the other groups cited concerns about time commitments and cost. In the print messages, familial themes garnered an overall favorable response, but Caucasian-American participants responded negatively to the use of photos of age-appropriate models.

CONCLUSION

Focus groups are useful in checking health professional assumptions about health messages prior to developing awareness or recruitment advertisements or materials. There was an implied preference for "younger" models among Caucasian Americans. Radio and print messages were adapted using the focus group recommendations, i.e., focusing on familial themes, adding race-specific risk estimates and using younger-than-target group models.

Prediction of health professionals' intention to screen for decisional conflict in clinical practice

OBJECTIVE

To identify the determinants of the intention of physicians to screen for decisional conflict in clinical practice.

BACKGROUND

Screening for decisional conflict is one of the key competencies when educating health professionals about shared decision making. Theory-based knowledge about variables predicting their intention to screen for decisional conflict in clinical practice would help design effective implementation interventions in this area.

DESIGN

Data of two cross-sectional surveys embedded within a large implementation study of the Ottawa Decision Support Framework (ODSF) in primary care.

SETTING AND PARTICIPANTS

In total, 122 health professionals from five family practice teaching units.

METHODS

Intention to screen for decisional conflict in clinical practice was defined as the intention to use the clinical version of the Decisional Conflict Scale (DCS) with patients at the end of the clinical encounter. It was assessed at the entry and the exit from this study. Both intentions were entered as a dependent variable in multivariate analyses.

MAIN RESULTS

At entry, the intention was influenced by: attitude (P < 0.001), subjective norm (P < 0.001), perceived behavioural control (P < 0.001) and clinical site (P < 0.05). On exit, it was influenced by: subjective norm (P < 0.001), perceived behavioural control (P < 0.001), clinical site (P < 0.05), international Continuing Medical Education (CME) (P < 0.05), other diplomas (P < 0.05) and intervention (P < 0.05). In post hoc analyses, there was a statistically significant difference between entry and exit in the impact of the level of exposure to the multifaceted implementation intervention on the intention (P = 0.003).

CONCLUSIONS

Variables predicting the intention of health professionals to screen for decisional conflict in clinical practice using the DCS change over time suggesting that effective implementation interventions in this area will need to be modified longitudinally.