A randomized trial comparing the effect of two phone-based interventions on colorectal cancer screening adherence

Interventions to Improve Endoscopic Screening Adherence of Cancer in High-Risk Populations: A Scoping Review

Background

Colorectal, and gastric cancers have the second, and fourth mortality rates worldwide, respectively. Endoscopic screening is a crucial diagnostic tool for colorectal, and gastric cancers. Effective interventions can improve adherence to endoscopic screening in high-risk populations, which is important for cancer prevention and mortality reduction. This study aimed to identify interventions that could improve adherence to endoscopic screening for cancer in high-risk populations.

Methods

Combination keywords including colorectal cancer, gastric cancer, screening adherence, and interventions were used to search for articles in PubMed, Web of Science, Cochrane Library, and MEDLINE Complete. The review methodology was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-SCR).

Results

A total of 12 articles were included in this review: 9 randomized controlled trials(RCT) and 3 quasi-experimental studies(QEDs). Among the extracted studies, 11 were about colorectal cancer, and 1 was about gastric cancer. Most studies used lecture-based or Information Technology-based health education interventions. Narrative interventions have proven to be novel and effective approaches for promoting adherence to endoscopic screening. Health education interventions included cancer epidemiology, cancer risk factors, warning symptoms, and screening methods.

Conclusion

All interventions involved were effective in increasing individual knowledge of cancer-related endoscopic screening, willingness to undergo screening, and screening behaviors. These findings provide a reference for designing endoscopy-related cancer screening interventions.

Are behavioral economics interventions effective in increasing colorectal cancer screening uptake: A systematic review of evidence and meta-analysis?

Various interventions have been investigated to improve the uptake of colorectal cancer screening. In this paper, the authors have attempted to provide a pooled estimate of the effect size of the BE interventions running a systematic review based meta-analysis. In this study, all the published literatures between 2000 and 2022 have been reviewed. Searches were performed in PubMed, Scopus and Cochrane databases. The main outcome was the demanding the one of the colorectal cancer screening tests. The quality assessment was done by two people so that each person evaluated the studies separately and independently based on the individual participant data the modified Jadad scale. Pooled effect size (odds ratio) was estimated using random effects model at 95% confidence interval. Galbraith, Forrest and Funnel plots were used in data analysis. Publication bias was also investigated through Egger's test. All the analysis was done in STATA 15. From the initial 1966 records, 38 were included in the final analysis in which 72612 cases and 71493 controls have been studied. About 72% have been conducted in the USA. The heterogeneity of the studies was high based on the variation in OR (I2 = 94.6%, heterogeneity X2 = 670.01 (d.f. = 36), p < 0.01). The random effect pooled odds ratio (POR) of behavioral economics (BE) interventions was calculated as 1.26 (95% CI: 1.26 to 1.43). The bias coefficient is noteworthy (3.15) and statistically significant (p< 0.01). According to the results of this meta-analysis, health policy and decision makers can improve the efficiency and cost effectiveness of policies to control this type of cancer by using various behavioral economics interventions. It's noteworthy that due to the impossibility of categorizing behavioral economics interventions; we could not perform by group analysis.

A randomized controlled trial of a tailored navigation intervention to promote breast and cervical cancer screening among intergenerational Southeast Asian women

Background

Cancer is the leading cause of death for Southeast Asian women in the U.S. Southeast Asian women have significantly high rates of breast and cervical cancers, yet are least likely to obtain regular mammography and Pap testing of all racial/ethnic groups in the U.S.

Objectives

The purpose of this study is to compare a tailored navigation intervention delivered by bilingual and bicultural Community Health Advisors to information and reminder only to increase age-appropriate breast and cervical cancer screening completion among Southeast Asian women.

Methods

The Southeast Asian Women's Health Project study will enroll 232 Cambodian, Filipino, Lao, and Vietnamese women who are not up to date with their breast and cervical cancer screenings. Women randomized to navigation will receive the intervention for 10 weeks. Women in the information group will be mailed information on mammography and Pap testing only. All participants will be contacted post-enrollment to assess screening completion.

Discussion

We will examine intervention efficacy, predictors of each intervention group, and the influence of intergenerational exchange of breast and cervical cancer screening information between mothers and daughters. We will disseminate study results locally to the community, nationally at conferences, and through peer-reviewed journals.

Recruitment Challenges of a Colorectal Cancer Screening Dissemination Study

BACKGROUND

Dissemination strategies to reach underserved and minority populations to promote screening for colorectal cancer (CRC) are key to reducing disparities. We conducted a study to examine a tailored messaging approach to navigate individuals from communities (i.e., lower income, less access to care, and underscreened) to clinics to receive CRC screening. We encountered several political, demographic, and secular trend issues that required reconsideration and redesign of implementation strategies.

OBJECTIVES

Through study implementation from 2012 to 2017, changes in medical reimbursement and immigration policies-at the state level and later at the national level-affected healthcare delivery systems that had initially committed to supporting the study and our recruitment methods. Although our selected zip codes and sites had previously yielded high rates of CRC screening nonadherence, within a few years, these sites showed substantially higher screening adherence rates-yielding limited numbers of eligible participants. In addition, state immigration policy trends created mistrust and fear, leading to lower participation rates than anticipated. This report documents and provides valuable insights on how we and the community network developed creative strategies to overcome these challenges.

METHODS

New relationships with community partners were extended to tap advisory board input to meet the challenges. Criteria for clinic participation widened from originally selected Federally Qualified Health Centers (FQHCs) to various nonprofit, hybrid, and privately insured reimbursement types. Recruitment site options were creatively redefined to reach community participants where they live, work, and receive services.

RESULTS

Strategies that engage community members in identifying alternative healthcare delivery structures and that link recruitment efforts to community-based service organizations were found to be critical to recapturing community trust in the face of unfavorable political environments. Widening the type of clinic partners from FQHCs to stand-alone nonprofits and private clinics and identifying unusual types of recruitment sites provided alternative solutions for successful study implementation.

DISCUSSION

In prevention-based studies that face unplanned system and political barriers to recruitment, embedding the study in the community may aid in reestablishing trust levels to improve engagement and recruitment of clinic partners and eligible participants.

A Motivational Interviewing Intervention to Improve Adherence to ACEIs/ARBs among Nonadherent Older Adults with Comorbid Hypertension and Diabetes

BACKGROUND

Hypertension and diabetes mellitus are independent risk factors for cardiovascular diseases. Due to the cardioprotective nature of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs), they are recommended for patients with comorbid hypertension and diabetes. However, poor adherence to ACEIs/ARBs among older adults is a major public health concern. This study aimed to assess the effectiveness of a telephonic motivational interviewing (MI) intervention conducted by pharmacy students among a nonadherent older population (≥ 65 years old) with diabetes and hypertension.

METHODS

Patients continuously enrolled in a Medicare Advantage Plan who received an ACEI/ARB prescription between July 2017 and December 2017 were identified. Group-based trajectory modeling (GBTM) was used to identify distinct patterns of ACEI/ARB adherence during the 1-year baseline period: adherent, gaps in adherence, gradual decline, and rapid decline in adherence. Patients from the three nonadherent trajectories were randomized into MI intervention or control group. The intervention consisted of an initial call and five follow-up calls administered by MI-trained pharmacy students and tailored to the baseline ACEI/ARB adherence trajectories. The primary outcome was adherence to ACEI/ARB during the 6- and 12-month periods post-MI implementation. The secondary outcome was discontinuation, defined as no refills for ACEI/ARB during the 6- and 12-month periods post-MI implementation. Multivariable regression analyses examined the impact of MI intervention on ACEI/ARB adherence and discontinuation while adjusting for baseline covariates.

RESULTS

A total of 240 patients in the intervention group and 480 patients as randomly selected controls were included in this study. At 6 months, patients receiving the MI intervention had significantly better adherence (β = 0.06; p = 0.03) compared with the controls. Linear and logistic regression models also showed patients in the intervention group were more likely to be adherent than controls within 12 months of intervention implementation (β = 0.06; p = 0.02 and OR: 1.46; 95% CI 1.05-2.04, respectively). MI intervention did not have any significant impact on the ACEI/ARB discontinuation.

CONCLUSION

Patients who received the MI intervention were more likely to be adherent at 6 and 12 months following the intervention initiation, despite gaps in the follow-up calls due to COVID-19. Pharmacist-led MI intervention is an effective behavioral strategy to improve medication adherence among older adults and tailoring the intervention to past adherence patterns may enhance the intervention effectiveness. This study was registered with the United States National Institutes of Health (ClinicalTrials.gov identifier NCT03985098).

Motivational Interviewing to Improve the Uptake of Colorectal Cancer Screening: A Systematic Review and Meta-Analysis

Introduction

Colorectal cancer screening when done early can significantly reduce mortality. However, screening compliance is still lower than expected even in countries with established screening programs. Motivational interviewing is an approach that has been explored to promote behavioral change including screening compliance. This review synthesizes the efficacy of motivational interviewing in promoting uptake of colorectal screening modalities and is the only review so far that examines motivational interviewing for colorectal cancer screening alone.

Methods

A systematic review and meta-analysis was conducted to examine the effects of motivational interviewing for colorectal cancer screening. PubMed, EMBASE, CENTRAL, PsycINFO, and CINAHL were searched to identify eligible studies from inception to June 2021 and selection criteria was defined. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool. The DerSimonian and Laird random effects model was used in the statistical analysis for studies included in the meta-analysis.

Results

Fourteen studies from 14 randomized-controlled trials with a low to moderate risk of bias were analyzed. 8 studies in the systematic review showed that motivational interviewing is superior to a control group. Meta-analysis was conducted on 11 studies and showed that motivational interviewing is statistically significant in increasing colorectal cancer screening rates in both intention-to-treat and per-protocol analysis. Timing of data collection of colorectal cancer screening rates did not make a significant difference to the efficacy of motivational interviewing. Studies that offered and accepted a mixture of colorectal screening modalities such as colonoscopy and fecal immunochemical tests were significantly more likely to have favorable colorectal screening outcomes. Heterogeneity in intervention was noted between studies, specifically differences in the training of interventionists, intervention delivery and comparator components.

Conclusion

Motivational interviewing is a tailored intervention demonstrating mixed evidence in improving colorectal cancer screening attendance amongst individuals. More research is needed to rigorously compare the effect of motivational interviewing alone vs. in combination with other screening promotion strategies to enhance colorectal cancer screening compliance.

Adaptation of colorectal cancer screening tailored navigation content for American Indian communities and early results using the intervention

BACKGROUND

American Indians (AI) experience major colorectal cancer (CRC) screening disparities with commensurate inequity in CRC mortality and other outcomes. The purpose of this report is to describe the methods and early results of adapting a previously successful intervention for the AI community.

METHODS

The educational content and delivery strategy of the parent intervention were adapted for AIs guided by an adaptation framework and cultural consultations with the community and clinicians. As part of the environmental scanning, we identified the need to substantively revise our data entry, collection, and tracking system and develop a REDCap database for this purpose. In this study, we staggered the implementation of the intervention in each facility to inform the process from one clinic to the next, and assess both the clinical outcomes of the tailored intervention and the implementation processes across two clinic settings, Facilities A and B.

RESULTS

The REDCap database is an indispensable asset, and without it we would not have been able to obtain reliable aggregate screening data while improvements to facility electronic health records are in progress. Approximately 8% (n = 678) of screening-eligible patients have been exposed to the navigator intervention. Of those exposed to the navigator intervention, 37% completed screening.

CONCLUSIONS

With the small numbers of patients exposed so far to the intervention, it would be premature to draw any broad conclusions yet about intervention effects. However, early screening completion rates are substantial advances on existing rates, and we have demonstrated that a tailored navigator intervention for facilitating CRC screening was readily adapted with provider and community input for application to AIs. A REDCap database for tracking of CRC screening by navigators using tablets or laptops on- or offline is easy to use and allows for generation of aggregate, anonymized screening data.

TRIAL REGISTRATION

There was no health intervention meeting the criteria of a clinical trial. The University of Arizona Institutional Review Board granted exemption from obtaining informed consent from patients undergoing CRC screening after administration of the tailored navigation intervention as usual care.

Cost-Effectiveness of Community-to-Clinic Tailored Navigation for Colorectal Cancer Screening in an Underserved Population: Economic Evaluation Alongside a Group-Randomized Trial

PURPOSE

Although screening for colorectal cancer (CRC) lowers mortality and morbidity and is generally cost-effective, little is known about the cost-effectiveness of screening promotion.

DESIGN

Cost-effectiveness analysis alongside a group-randomized trial. Setting: Multicultural, underinsured communities in the Phoenix, Arizona, area.

SUBJECTS

English- or Spanish-speaking adults who were out of compliance for CRC screening guidelines.

INTERVENTION

All participants received community-based group education (GE), and the intervention group also received tailored community-to-clinic navigation (GE+TN).

MEASURES

Number of participants screened and costs of tailored navigation, clinic visits, and CRC screening tests.

ANALYSIS

Incremental cost per additional person screened from the perspective of the healthcare system with bootstrapped confidence intervals.

RESULTS

Community sites were recruited and randomized to GE (n = 120) and GE + TN (n = 119). Across these sites 1154 individuals were screened, 504 were eligible, and 345 attended the group education class (n = 134 GE; n = 211 GE + TN). Screening rates (26.5% GE + TN; 10.4% GE; 16.1% increase 95% CI: 7%, 23%) and costs per participant ($271 GE + TN; $167 GE; a net cost increase of $104 95% CI: $1, $189) were significantly higher in the intervention group. Incremental cost-effectiveness was $646 (95% CI: -$68, $953) per additional person screened.

CONCLUSION

Depending on the value placed on an additional person screened, the addition of community-to-clinic tailored navigation to a community-based CRC screening promotion program may be highly cost-effective.

IMProving care After inherited Cancer Testing (IMPACT) study: protocol of a randomized trial evaluating the efficacy of two interventions designed to improve cancer risk management and family communication of genetic test results

BACKGROUND

Implementing genetic testing for inherited cancer predisposition into routine clinical care offers a tremendous opportunity for cancer prevention and early detection. However, genetic testing itself does not improve outcomes; rather, outcomes depend on implemented follow-up care. The IMPACT study is a hybrid type I randomized effectiveness-implementation trial to simultaneously evaluate the effectiveness of two interventions for individuals with inherited cancer predisposition focused on: 1) increasing family communication (FC) of genetic test results; and 2) improving engagement with guideline-based cancer risk management (CRM).

METHODS

This prospective study will recruit a racially, geographically, and socioeconomically diverse population of individuals with a documented pathogenic/likely pathogenic (P/LP) variant in an inherited cancer gene. Eligible participants will be asked to complete an initial trial survey and randomly assigned to one of three arms: A) GeneSHARE, a website designed to increase FC of genetic test results; B) My Gene Counsel's Living Lab Report, a digital tool designed to improve understanding of genetic test results and next steps, including CRM guidelines; or C) a control arm in which participants continue receiving standard care. Follow-up surveys will be conducted at 1, 3, and 12 months following randomization. These surveys include single-item measures, scales, and indices related to: 1) FC and CRM behaviors and behavioral factors following the COM-B theoretical framework (i.e., capability, opportunity, and motivation); 2) implementation outcomes (i.e., acceptability, appropriateness, exposure, and reach); and 3) other contextual factors (i.e., sociodemographic and clinical factors, and uncertainty, distress, and positive aspects of genetic test results). The primary outcomes are an increase in FC of genetic test results (Arm A) and improved engagement with guideline-based CRM without overtreatment or undertreatment (Arm B) by the 12-month follow-up survey.

DISCUSSION

Our interventions are designed to shift the paradigm by which individuals with P/LP variants in inherited cancer genes are provided with information to enhance FC of genetic test results and engagement with guideline-based CRM. The information gathered through evaluating the effectiveness and implementation of these real-world approaches is needed to modify and scale up adaptive, stepped interventions that have the potential to maximize FC and CRM.

TRIAL REGISTRATION

This study is registered at Clinicaltrials.gov (NCT04763915, date registered: February 21, 2021).

PROTOCOL VERSION

September 17th, 2021 Amendment Number 04.

Outcomes from a pilot genetic counseling intervention using motivational interviewing and the extended parallel process model to increase cascade cholesterol screening

Familial hypercholesterolemia (FH) is an inherited condition resulting in increased risk of premature cardiovascular disease. This risk can be reduced with early diagnosis and treatment, but it can be challenging to identify individuals with FH. Cascade screening, the most efficient and cost-effective identification method, requires FH patients to communicate with their at-risk family and encourage them to pursue screening. Beyond FH, patients with conditions increasing disease risk to family members report barriers to the communication process such as insufficient knowledge of the condition and discomfort informing relatives. We conducted a pilot study of a genetic counseling intervention incorporating behavior-change principles from motivational interviewing (MI) and the extended parallel process model (EPPM) to help parents of children with FH overcome these barriers and improve cascade screening rates for FH. Of the 13 participants who completed the intervention and post-intervention surveys, 6 reported contacting and/or screening additional relatives. A large effect size in increasing communication and screening was observed (η²  = 0.20), with the mean percent of at-risk relatives contacted rising from 33% to 45%, and the mean percent screened rising from 32% to 42%. On average, 2.23 new relatives were contacted and 2.46 were screened, per participant, by the end of the study. Direct content analysis revealed that despite the open-ended nature of the goal-setting process, participant goals fell into two categories including those who set goals focused on communicating with and screening family members (n = 9) and those who set goals only focused on managing FH (n = 4). Overall, the communication and screening rates reported after the intervention were higher than previous observations in adult FH populations. These results suggest this EPPM/MI genetic counseling intervention could be a useful tool for increasing communication and cascade screening for FH. With further research on goal-setting techniques, the intervention could be refined and replicated to identify more individuals affected by FH or modified for use with other actionable genetic conditions.

Psychosocial Determinants of Vegetable Intake Among Nepalese Young Adults: An Exploratory Survey

Background: Adequate intake of vegetables facilitates a healthy lifestyle. However, the majority of Nepalese young adults consume inadequate amount of vegetables per day. Objectives: We explored psychosocial determinants of daily intake of two or more servings of vegetables among Nepalese young adults using attitude, social influence, and self-efficacy (ASE) as a theoretical framework, extended with measures of habit and self-identity as additional constructs. Methods/Participants: A cross-sectional study through a web-based questionnaire survey was conducted among 461 Nepalese young adults aged 18-35 years old. Participants were recruited through convenience (snowball) sampling. A factor-based partial least square structural equation modelling was used for analysis. Results: The findings indicated that attitudes (β = 0.09, p = 0.029), social influence (β = 0.17, p < 0.001), habit (β = 0.24, p < 0.001) and self-identity (β = 0.30, p < 0.001) were significant factors influencing intention to eat two or more servings of vegetables per day. Further, self-efficacy (β = 0.10, p = 0.011), habit (β = 0.08, p = 0.034), diet (β = -0.10, p = 0.014), and place of residence (β = 0.11, p = 0.007) significantly influenced behaviour to eat two or more servings of vegetables per day. However, self-efficacy (β = 0.07, p = 0.062) did not significantly influence intention and self-identity (β = 0.06, p = 0.083), age (β = -0.02, p = 0.328), gender (β = 0.02, p = 0.350), and body mass index (β = -0.04, p = 0.209) did not significantly influence behaviour to eat two or more servings of vegetables per day. Conclusion: The study shows that attitudes, social influence, habit, and self-identity were significant factors influencing intention to eat two or more servings of vegetables per day. Further, self-efficacy and habit significantly influenced behaviour to eat two or more servings of vegetables per day. However, self-efficacy did not significantly influence intention and self-identity did not significantly influence behaviour to eat two or more servings of vegetables per day.

Effects of a Community-to-Clinic Navigation Intervention on Colorectal Cancer Screening Among Underserved People

BACKGROUND

Colorectal cancer screening remains suboptimal among poor and underserved people.

PURPOSE

We tested the effectiveness of a community-to-clinic navigator intervention to guide multicultural, underinsured individuals into primary care clinics to complete colorectal cancer screening.

METHODS

This two-phase behavioral intervention study was conducted in Phoenix, Arizona (2012-2018). Community sites were randomized to group education or group education plus tailored navigation to increase attendance at primary care clinics (Phase I). Individuals who completed a clinic appointment received the tailored navigation in person or via phone (Phase II).

RESULTS

In Phase I (N = 345), 37.9% of the intervention group scheduled a clinic appointment versus 19.4% of the comparison group. In Phase II, 26.5% of the original intervention group were screened versus only 10.4% of the original comparison group. Those in the intervention group were 3.84 times more likely to be screened than were those in the comparison group (odds ratio = 3.84; 95% confidence interval = 1.81-6.92).

CONCLUSIONS

Translation of an efficacious tailored navigation intervention for colorectal cancer screening to a community-to-clinic context is associated with significantly increased rates of colorectal cancer screening. Navigation assistance to address barriers to screening may serve as the most important component of any educational program to increase individual adherence to colorectal cancer screening.

From participation to diagnostic assessment: a systematic scoping review of the role of the primary healthcare sector in the National Bowel Cancer Screening Program

Primary health care (PHC) plays a vital support role in organised colorectal cancer (CRC) screening programs by encouraging patient participation and ensuring timely referral for diagnostic assessment follow up. A systematic scoping review of the current evidence was conducted to inform strategies that better engage the PHC sector in organised CRC screening programs. Articles published from 2005 to November 2019 were searched across five databases. Evidence was synthesised and interventions that specifically require PHC involvement were mapped to stages of the CRC screening pathway. Fifty-seven unique studies were identified in which patient, provider and system-level interventions align with defined stages of the CRC screening pathway: namely, identifying/reminding patients who have not responded to CRC screening (non-adherence) (n=46) and follow up of a positive screen referral (n=11). Self-management support initiatives (patient level) and improvement initiatives (system level) demonstrate consistent benefits along the CRC screening pathway. Interventions evaluated as part of a quality-improvement process tended to report effectiveness; however, the variation in reporting makes it difficult to determine which elements contributed to the overall study outcomes. To maximise the benefits of population-based screening programs, better integration into existing primary care services can be achieved through targeting preventive and quality care interventions along the entire screening pathway.

Startup and implementation costs of a colorectal cancer screening tailored navigation research study

BACKGROUND

Colorectal cancer (CRC) is the third leading cause of cancer-related death in the United States. Despite improvements in screening, testing for CRC is underutilized in some populations, suggesting a need to identify efficient test promotion strategies.

METHODS

Our intervention guided individuals from low-income, underserved communities into primary care clinics to receive CRC screening referrals. Community sites were randomized to education or education plus navigation. The Phase I community-to-clinic navigation outcome was clinic attendance; the Phase II clinic-to-screening navigation outcome was screening completion. We used micro-costing to determine costs necessary to replicate our project in a similar, non-research setting.

RESULTS

Over the 4-year project, startup costs tended to decrease as implementation costs increased. The largest component of startup costs (32 % of total) was community site recruitment. Implementation costs per class attendee were higher in the navigation group ($1084) than control ($798). But costs per participant who made a clinic appointment ($3573 versus $6292) and per participant who completed screening ($4083 versus $7640) were lower in the navigation group.

CONCLUSIONS

Our description of startup and implementation costs for this intervention provides decision makers with information needed to plan and budget for a similar project to guide individuals from community into clinics.

Randomized Controlled Trial of Personalized Colorectal Cancer Risk Assessment vs Education to Promote Screening Uptake

INTRODUCTION

Risk stratification has been proposed as a strategy to improve participation in colorectal cancer (CRC) screening, but evidence is lacking. We performed a randomized controlled trial of risk stratification using the National Cancer Institute's Colorectal Cancer Risk Assessment Tool (CCRAT) on screening intent and completion.

METHODS

A total of 230 primary care patients eligible for first-time CRC screening were randomized to risk assessment via CCRAT or education control. Follow-up of screening intent and completion was performed by record review and phone at 6 and 12 months. We analyzed change in intent after intervention, time to screening, overall screening completion rates, and screening completion by CCRAT risk score tertile.

RESULTS

Of the patients, 61.7% of patients were aged <60 years, 58.7% female, and 94.3% with college or higher education. Time to screening did not differ between arms (hazard ratio 0.78 [95% confidence interval (CI) 0.52-1.18], P = 0.24). At 12 months, screening completion was 38.6% with CCRAT vs 44.0% with education (odds ratio [OR] 0.80 [95% CI 0.47-1.37], P = 0.41). Changes in screening intent did not differ between the risk assessment and education arms (precontemplation to contemplation: OR 1.52 [95% CI 0.81-2.86], P = 0.19; contemplation to precontemplation: OR 1.93 [95% CI 0.45-8.34], P = 0.38). There were higher screening completion rates at 12 months in the top CCRAT risk tertile (52.6%) vs the bottom (32.4%) and middle (31.6%) tertiles (P = 0.10).

DISCUSSION

CCRAT risk assessment did not increase screening participation or intent. Risk stratification might motivate persons classified as higher CRC risk to complete screening, but unintentionally discourage screening among persons not identified as higher risk.

Motives for non-adherence to colonoscopy advice after a positive colorectal cancer screening test result: a qualitative study

SETTING

Participants with a positive faecal immunochemical test (FIT) in screening programs for colorectal cancer (CRC) have a high risk for colorectal cancer and advanced adenomas. They are therefore recommended follow-up by colonoscopy. However, more than ten percent of positively screened persons do not adhere to this advice.

OBJECTIVE

To investigate FIT-positive individuals' motives for non-adherence to colonoscopy advice in the Dutch CRC screening program.

SUBJECTS

Non-adherent FIT-positive participants of the Dutch CRC screening program.

DESIGN

We conducted semi structured in-depth interviews with 17 persons who did not undergo colonoscopy within 6 months after a positive FIT. Interviews were undertaken face-to-face and data were analysed thematically with open coding and constant comparison.

RESULTS

All participants had multifactorial motives for non-adherence. A preference for more personalised care was described with the following themes: aversion against the design of the screening program, expectations of personalised care, emotions associated with experiences of impersonal care and a desire for counselling where options other than colonoscopy could be discussed. Furthermore, intrinsic motives were: having a perception of low risk for CRC (described by all participants), aversion and fear of colonoscopy, distrust, reluctant attitude to the treatment of cancer and cancer fatalism. Extrinsic motives were: having other health issues or priorities, practical barriers, advice from a general practitioner (GP) and financial reasons.

CONCLUSION

Personalised screening counselling might have helped to improve the interviewees' experiences with the screening program as well as their knowledge on CRC and CRC screening. Future studies should explore whether personalised screening counselling also has potential to increase adherence rates. Key points Participants with a positive FIT in two-step colorectal cancer (CRC) screening programs are at high risk for colorectal cancer and advanced adenomas. Non-adherence after an unfavourable screening result happens in all CRC programs worldwide with the consequence that many of the participants do not undergo colonoscopy for the definitive assessment of the presence of colorectal cancer. Little qualitative research has been done to study the reasons why individuals participate in the first step of the screening but not in the second step. We found a preference for more personalised care, which was not reported in previous literature on this subject. Furthermore, intrinsic factors, such as a low risk perception and distrust, and extrinsic factors, such as the presence of other health issues and GP advice, may also play a role in non-adherence. A person-centred approach in the form of a screening counselling session may be beneficial for this group of CRC screening participants.

A Motivational Interviewing Intervention to Promote CRC Screening: A Pilot Study

BACKGROUND

Appalachian Kentuckians suffer a disproportionate incidence and mortality from colorectal cancer (CRC) and are screened at lower rates (35%) compared with 47% of Kentuckians.

OBJECTIVE

The aim of this study was to evaluate the efficacy of a motivational interviewing intervention delivered by trained Lay Health Advisors on CRC screening.

METHOD

Eligible participants recruited from an emergency department (ED) completed a baseline survey and were randomized to either the control or the motivational interviewing intervention provided by Lay Health Advisors. Follow-up surveys were administered 3 and 6 months after baseline. To evaluate potential differences in treatment and control groups, t tests, χ, and Mann-Whitney U tests were used.

RESULTS

At either the 3- or 6-month assessment, there was no difference in the CRC screening by group (χ = 0.13, P = .72). There was a significant main effect for the study group in the susceptibility to CRC model; regardless of time, those in the intervention group reported approximately 1-point higher perceived susceptibility to CRC, compared with controls (est. b = 0.68, P = .038). Age and financial adequacy had a significant effect related to CRC screening. Older participants (est. b = 0.09, P = .014) and those who reported financial inadequacy (est. b = 2.34, P = .002) reported more screening barriers.

CONCLUSION

This pilot study elucidated important factors influencing the uptake of CRC for an ED transient population and this may be useful in the design of future interventions using motivational interviewing in EDs.

IMPLICATIONS FOR PRACTICE

Nurses can provide information about CRC screening guidelines and provide referrals to appropriate screening resources in the community.

Effectiveness of motivational interviewing in enhancing cancer screening uptake amongst average-risk individuals: A systematic review

BACKGROUND

Although cancer is a worldwide public health problem, it can be detected early and prevented through cancer screening. Recommendations for screening methods and screening intervals are currently available for several types of cancer. However, not all average-risk individuals are motivated to undergo cancer screening.

OBJECTIVES

To examine the effectiveness of motivational interviewing that targets average-risk individuals regarding their cancer screening intention and uptake and to provide recommendations for the content and format of motivational interviewing based on the existing evidence.

METHODS

A systematic literature search was performed using four databases and a manual search. A combination of keywords including 'motivational interviewing', 'cancer screening', 'screening intention' and 'screening uptake' were used to identify relevant articles. Only randomised controlled trials that examined the effects of motivational interviewing amongst average-risk individuals were included in the review. The Cochrane Risk of Bias Tool was used to appraise the methodological quality of the selected articles. The findings were summarised in narrative and tabular formats.

RESULTS

Six randomised controlled trials that used motivational interviewing to enhance cancer screening uptake or intention were included in the review. The findings show that motivational interviewing that used a face-to-face and telephone-based approach or were used together with a tailored or reminder letter enhanced the participants' uptake of breast and cervical cancer screening and their intention to undergo future cervical cancer screening. Mixed results were observed in the effectiveness of single-contact motivational interviewing on colorectal cancer screening.

CONCLUSIONS

The use of motivational interviewing has demonstrated improvements in the uptake of breast and cervical cancer screening. However, more research is warranted in view of the inconclusive findings noted for colorectal cancer screening. Further studies with more rigorous methods are needed to identify the most effective interventions and to test the feasibility and efficiency of the use of Internet-based information communication technology to deliver motivational interviewing.

An RCT to Increase Breast and Colorectal Cancer Screening

INTRODUCTION

Adherence to breast and colorectal cancer screenings reduce mortality from these cancers, yet screening rates remain suboptimal. This 2 × 2 RCT compared 3 theory-based interventions to usual care to simultaneously increase breast and colon cancer screening in women who were nonadherent to both screenings at study entry.

DESIGN

RCT.

SETTING/PARTICIPANTS

Women (n=692) who were nonadherent to both breast and colon cancer screenings and aged 51-75 years were recruited. Enrollment, intervention delivery, and data collection were completed between 2013 and 2017, and data analyzed in 2018.

INTERVENTION

The randomized intervention included the following 4 groups: 3 intervention arms (personally tailored messages using a web-based intervention, phone delivery by a trained navigator, or both) compared with usual care. Women at an average risk for colon cancer were allowed to select either colonoscopy or stool test as their preferred colon cancer screening. Mammography was promoted for breast cancer screening.

MAIN OUTCOME MEASURES

Outcome data at 6 months included self-report and medical records for screening activity.

RESULTS

All intervention arms significantly increased receipt of either a mammogram or stool test compared with control (web: p<0.0249, phone: p<0.0001, web + phone: p<0.0001). When considering receipt of both mammogram and stool test, all intervention arms were significantly different from usual care (web: p<0.0249, phone: p<0.0003, web + phone: p<0.0001). In addition, women who were adherent to mammography had a 4.5 times greater odds of becoming adherent to colonoscopy.

CONCLUSIONS

The tailored intervention simultaneously supporting both breast and colon cancer screenings significantly improved rates of obtaining one of the screenings and increased receipt of both tests.

TRIAL REGISTRATION

This study is registered with the clinical trials identifier NCT03279198 at www.clinicaltrials.gov.

Proven Strategies for Increasing Adherence to Colorectal Cancer Screening

Although colorectal cancer (CRC) can be prevented or detected early through screening and surveillance, barriers that lower adherence to screening significantly limit its effectiveness. Therefore, implementation of interventions that address and overcome adherence barriers is critical to efforts to decrease morbidity and mortality from CRC. This article reviews the current available evidence about interventions to increase adherence to CRC screening.

Effectiveness of a brief phone intervention to increase participation in a population-based colorectal cancer screening programme: a randomized controlled trial

AIM

Although colorectal cancer (CRC) screening reduces mortality and morbidity the uptake in target populations is suboptimal. The aim was to assess whether adding a brief phone intervention to the usual invitation process increases participation in a CRC screening programme based in Catalonia.

METHOD

This was a non-blinded prospective randomized control study of patients eligible for their first CRC screening test (immunochemical faecal occult blood test). Between March and December 2017, 512 invitees (age range 50-69 years) were randomized to receiving either a brief informative phone call prior to receiving the standard screening invitation (letter and informative brochure) or the standard screening invitation alone. The primary outcome was participation in the screening programme at 6 months.

RESULTS

In all, 492/512 patients (54.7% women; 45.3% men) could be analysed (239/256 intervention group; 253/256 control group). On an intention to treat basis, the intervention group (55% women; 45% men) saw an 11% increase in the participation rate (51.05% vs 40.32%, P = 0.017). The intervention was more effective in male patients (50.93% vs 33.91%, P = 0.01) and those patients aged between 50 and 54 years (54.32% vs 37.77%, P = 0.03). After adjusting for sex, age and geographic area, the benefit of the intervention remained statistically significant (adjusted OR 1.54, 95% CI 1.07-2.20).

CONCLUSION

Our data suggest that a brief, informative intervention by phone in addition to the usual invitation process is effective in increasing participation in a CRC screening programme. It may be a useful strategy to improve uptake in groups which are less likely to participate in CRC screening (clinicaltrials.gov NCT03082911).

Precision health research and implementation reviewed through the conNECT framework

BACKGROUND

Precision health is a population-based approach that incorporates big-data strategies to understand the complex interactions between biological, environmental, lifestyle, and psychosocial factors that influence health.

PURPOSE

A promising tool to facilitate precision health research and its dissemination is the ConNECT Framework.

METHODS

Here, we discuss the relationship of the five broad and synergistic principles within the ConNECT Framework as they may apply to nursing science research: (1) Integrating Context, (2) Fostering a Norm of Inclusion, (3) Ensuring Equitable Diffusion of Innovations, (4) Harnessing Communication Technology, and (5) Prioritizing Specialized Training.

DISCUSSION/CONCLUSION

The principles within this framework can be used by nurse scientists and educators to guide and disseminate precision health research.

A 4-year randomized trial comparing three outreach interventions to promote screening mammograms

As population health has become a focus of health care payers and providers, interest has grown in mail, phone, and other forms of outreach for improving population rates of cancer screening. Translational research is needed to compare the effectiveness and cost of low- and high-intensity behavioral outreach interventions for promoting cancer screening. The purpose of the article is to compare the effectiveness in promoting biannual mammograms of three interventions delivered over 4 years to a primary care population with a high baseline mammography adherence of 83.3%. We randomized women aged 40-84 to reminder letter only (LO arm), letter + reminder call (RC arm), and two letters + counseling call (CC arm) involving tailored education and motivational interviewing. Mammography adherence (≥1 mammogram in the previous 24 months) at four time points was determined from insurance claims records. Over 4 years, 30,162 women were randomized. At the end of 4 years, adherence was highest in the RC arm (83.0%) compared with CC (80.8%) and LO (80.8%) arms (p = .03). Only 23.5% of women in the CC arm were reached and accepted full counseling. The incremental cost per additional mammogram for RC arm women was $30.45 over the LO arm cost. A simple reminder call can increase screening mammogram adherence even when baseline adherence is high. Some more complex behavioral interventions delivered by mail and phone as in this study may be less effective, due to limited participation of patients, a focus on ambivalence, lack of follow-up, and other factors.

Colorectal Cancer: A Collaborative Approach to Improve Education and Screening in a Rural Population

BACKGROUND

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and second leading cause of cancer death for men and women in the United States. Although early detection and diagnosis greatly affect survival rates, only about half of the U.S. population participates in screening.
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OBJECTIVES

The purpose of this project was to implement community-based CRC education and screening. Outcomes included CRC knowledge, CRC screening kit return rate, and rate of positive screening results. 
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METHODS

Partnering with a community hospital, CRC educational sessions and free screening opportunities were provided for 193 local city government employees. CRC knowledge was assessed before and after education with the Knowledge Assessment Survey. A paired t test indicated significant improvement in mean CRC knowledge.
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FINDINGS

More than half of the participants elected to take home fecal immunochemical test kits. Of the 29 participants who submitted their screening kits for evaluation, eight had positive results and received referral recommendations. All participants were notified of their screening results. The community-based CRC project was effective in improving CRC knowledge and screening participation.

Evaluation of Interventions Intended to Increase Colorectal Cancer Screening Rates in the United States: A Systematic Review and Meta-analysis

IMPORTANCE

Colorectal cancer screening (CRC) is recommended by all major US medical organizations but remains underused.

OBJECTIVE

To identify interventions associated with increasing CRC screening rates and their effect sizes.

DATA SOURCES

PubMed, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, and ClinicalTrials.gov were searched from January 1, 1996, to August 31, 2017. Key search terms included colorectal cancer and screening.

STUDY SELECTION

Randomized clinical trials of US-based interventions in clinical settings designed to improve CRC screening test completion in average-risk adults.

DATA EXTRACTION AND SYNTHESIS

At least 2 investigators independently extracted data and appraised each study's risk of bias. Where sufficient data were available, random-effects meta-analysis was used to obtain either a pooled risk ratio (RR) or risk difference (RD) for screening completion for each type of intervention.

MAIN OUTCOMES AND MEASURES

The main outcome was completion of CRC screening. Examination included interventions to increase completion of (1) initial CRC screening by any recommended modality, (2) colonoscopy after an abnormal initial screening test result, and (3) continued rounds of annual fecal blood tests (FBTs).

RESULTS

The main review included 73 randomized clinical trials comprising 366 766 patients at low or medium risk of bias. Interventions that were associated with increased CRC screening completion rates compared with usual care included FBT outreach (RR, 2.26; 95% CI, 1.81-2.81; RD, 22%; 95% CI, 17%-27%), patient navigation (RR, 2.01; 95% CI, 1.64-2.46; RD, 18%; 95% CI, 13%-23%), patient education (RR, 1.20; 95% CI, 1.06-1.36; RD, 4%; 95% CI, 1%-6%), patient reminders (RR, 1.20; 95% CI, 1.02-1.41; RD, 3%; 95% CI, 0%-5%), clinician interventions of academic detailing (RD, 10%; 95% CI, 3%-17%), and clinician reminders (RD, 13%; 95% CI, 8%-19%). Combinations of interventions (clinician interventions or navigation added to FBT outreach) were associated with greater increases than single components (RR, 1.18; 95% CI, 1.09-1.29; RD, 7%; 95% CI, 3%-11%). Repeated mailed FBTs with navigation were associated with increased annual FBT completion (RR, 2.09; 95% CI, 1.91-2.29; RD, 39%; 95% CI, 29%-49%). Patient navigation was not associated with colonoscopy completion after an initial abnormal screening test result (RR, 1.21; 95% CI, 0.92-1.60; RD, 14%; 95% CI, 0%-29%).

CONCLUSIONS AND RELEVANCE

Fecal blood test outreach and patient navigation, particularly in the context of multicomponent interventions, were associated with increased CRC screening rates in US trials. Fecal blood test outreach should be incorporated into population-based screening programs. More research is needed on interventions to increase adherence to continued FBTs, follow-up of abnormal initial screening test results, and cost-effectiveness and other implementation barriers for more intensive interventions, such as navigation.

A learning community approach to identifying interventions in health systems to reduce colorectal cancer screening disparities

Although colorectal cancer (CRC) screening in the United States has been increasing, screening rates are not optimal, and there are persistent disparities in CRC screening and mortality, particularly among minority patients. As most CRC screening takes place in primary care, health systems are well-positioned to address this important population health problem. However, most health systems have not actively engaged in identifying and implementing effective evidence-based intervention strategies that can raise CRC screening rates and reduce disparities. Drawing on the Collective Impact Model and the Interactive Systems Framework for Dissemination and Implementation, our project team applied a learning community strategy to help two health systems in southeastern Pennsylvania identify evidence-based CRC screening interventions for primary care patients. Initially, this approach involved activating a coordinating team, steering committee (health system leadership and stakeholder organizations), and patient and stakeholder advisory committee to identify candidate CRC screening intervention strategies. The coordinating team guided the steering committee through a scoping review to identify seven randomized trials that identified interventions that addressed CRC screening disparities. Subsequently, the coordinating team and steering committee applied a screening intervention classification typology to select an intervention strategy that involved using an outreach strategy to provide minority patients with access to both stool blood test and colonoscopy screening. Finally, the coordinating team and steering committee engaged the health system patient and stakeholder advisory committee in planning for intervention implementation, thus taking up the challenge of reducing and important health disparity in patient populations served by the two health systems.

Patient-mediated interventions to improve professional practice

BACKGROUND

Healthcare professionals are important contributors to healthcare quality and patient safety, but their performance does not always follow recommended clinical practice. There are many approaches to influencing practice among healthcare professionals. These approaches include audit and feedback, reminders, educational materials, educational outreach visits, educational meetings or conferences, use of local opinion leaders, financial incentives, and organisational interventions. In this review, we evaluated the effectiveness of patient-mediated interventions. These interventions are aimed at changing the performance of healthcare professionals through interactions with patients, or through information provided by or to patients. Examples of patient-mediated interventions include 1) patient-reported health information, 2) patient information, 3) patient education, 4) patient feedback about clinical practice, 5) patient decision aids, 6) patients, or patient representatives, being members of a committee or board, and 7) patient-led training or education of healthcare professionals.

OBJECTIVES

To assess the effectiveness of patient-mediated interventions on healthcare professionals' performance (adherence to clinical practice guidelines or recommendations for clinical practice).

SEARCH METHODS

We searched MEDLINE, Ovid in March 2018, Cochrane Central Register of Controlled Trials (CENTRAL) in March 2017, and ClinicalTrials.gov and the International Clinical Trials Registry (ICTRP) in September 2017, and OpenGrey, the Grey Literature Report and Google Scholar in October 2017. We also screened the reference lists of included studies and conducted cited reference searches for all included studies in October 2017.

SELECTION CRITERIA

Randomised studies comparing patient-mediated interventions to either usual care or other interventions to improve professional practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data and assessed risk of bias. We calculated the risk ratio (RR) for dichotomous outcomes using Mantel-Haenszel statistics and the random-effects model. For continuous outcomes, we calculated the mean difference (MD) using inverse variance statistics. Two review authors independently assessed the certainty of the evidence (GRADE).

MAIN RESULTS

We included 25 studies with a total of 12,268 patients. The number of healthcare professionals included in the studies ranged from 12 to 167 where this was reported. The included studies evaluated four types of patient-mediated interventions: 1) patient-reported health information interventions (for instance information obtained from patients about patients' own health, concerns or needs before a clinical encounter), 2) patient information interventions (for instance, where patients are informed about, or reminded to attend recommended care), 3) patient education interventions (intended to increase patients' knowledge about their condition and options of care, for instance), and 4) patient decision aids (where the patient is provided with information about treatment options including risks and benefits). For each type of patient-mediated intervention a separate meta-analysis was produced.Patient-reported health information interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We found that for every 100 patients consulted or treated, 26 (95% CI 23 to 30) are in accordance with recommended clinical practice compared to 17 per 100 in the comparison group (no intervention or usual care). We are uncertain about the effect of patient-reported health information interventions on desirable patient health outcomes and patient satisfaction (very low-certainty evidence). Undesirable patient health outcomes and adverse events were not reported in the included studies and resource use was poorly reported.Patient information interventions may improve healthcare professionals' adherence to recommended clinical practice (low-certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 42) are in accordance with recommended clinical practice compared to 20 per 100 in the comparison group (no intervention or usual care). Patient information interventions may have little or no effect on desirable patient health outcomes and patient satisfaction (low-certainty evidence). We are uncertain about the effect of patient information interventions on undesirable patient health outcomes because the certainty of the evidence is very low. Adverse events and resource use were not reported in the included studies.Patient education interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We found that for every 100 patients consulted or treated, 46 (95% CI 39 to 54) are in accordance with recommended clinical practice compared to 35 per 100 in the comparison group (no intervention or usual care). Patient education interventions may slightly increase the number of patients with desirable health outcomes (low-certainty evidence). Undesirable patient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies.Patient decision aid interventions may have little or no effect on healthcare professionals' adherence to recommended clinical practice (low-certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 43) are in accordance with recommended clinical practice compared to 37 per 100 in the comparison group (usual care). Patient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies.

AUTHORS' CONCLUSIONS

We found that two types of patient-mediated interventions, patient-reported health information and patient education, probably improve professional practice by increasing healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We consider the effect to be small to moderate. Other patient-mediated interventions, such as patient information may also improve professional practice (low-certainty evidence). Patient decision aids may make little or no difference to the number of healthcare professionals' adhering to recommended clinical practice (low-certainty evidence).The impact of these interventions on patient health and satisfaction, adverse events and resource use, is more uncertain mostly due to very low certainty evidence or lack of evidence.

A Randomized Trial to Compare a Tailored Web-Based Intervention and Tailored Phone Counseling to Usual Care for Increasing Colorectal Cancer Screening

BACKGROUND

Colorectal cancer mortality could be decreased with risk-appropriate cancer screening. We examined the efficacy of three tailored interventions compared with usual care for increasing screening adherence.

METHODS

Women (n = 1,196) ages 51 to 74, from primary care networks and nonadherent to colorectal cancer guidelines, were randomized to (1) usual care, (2) tailored Web intervention, (3) tailored phone intervention, or (4) tailored Web + phone intervention. Average-risk women could select either stool test or colonoscopy, whereas women considered at higher than average risk received an intervention that supported colonoscopy. Outcome data were collected at 6 months by self-report, followed by medical record confirmation (attrition of 23%). Stage of change for colorectal cancer screening (precontemplation or contemplation) was assessed at baseline and 6 months.

RESULTS

The phone (41.7%, P < 0.0001) and combined Web + phone (35.8%, P < 0.001) interventions significantly increased colorectal cancer screening by stool test compared with usual care (11.1%), with ORs ranging from 5.4 to 6.8 in models adjusted for covariates. Colonoscopy completion did not differ between groups except that phone significantly increased colonoscopy completion compared with usual care for participants in the highest tertile of self-reported fear of cancer.

CONCLUSIONS

A tailored phone with or without a Web component significantly increased colorectal cancer screening compared with usual care, primarily through stool testing, and phone significantly increased colonoscopy compared with usual care but only among those with the highest levels of baseline fear.

IMPACT

This study supports tailored phone counseling with or without a Web program for increasing colorectal cancer screening in average-risk women.

Effectiveness of reminder strategies on cancer screening adherence: a randomised controlled trial

BACKGROUND

Few randomised controlled trials (RCTs) have evaluated the different recalling approaches for enhancing adherence to faecal immunochemical test (FIT)-based screening.

AIM

The authors evaluated the effectiveness of two telecommunication strategies on improving adherence to yearly FIT screening.

DESIGN AND SETTING

A randomised, parallel group trial was performed in a primary care screening practice.

METHOD

The authors recruited 629 asymptomatic individuals aged 40-70 years with a negative FIT in 2015 to a population-based screening programme. On participation, they were invited to repeat their second round of FIT in 2016, 12 months after the first test. Each participant was randomly assigned to either interactive telephone reminder (n = 207), short message service reminder (SMS, n = 212), or control, where no additional interventions were delivered after the findings of their first FIT was communicated to the participants (n = 210). Reminders in the intervention groups were delivered 1 month before subjects' expected return. Additional telephone reminders were delivered 2 months after the expected return date to all subjects who defaulted specimen return. The outcomes included rates of FIT collection and specimen return up to 6 months after their expected return.

RESULTS

At 6 months, the cumulative FIT collection rate was 95.1%, 90.4%, and 86.5%, respectively, for the telephone, SMS, and control groups (P = 0.010). The corresponding specimen return rate was 94.1%, 90.0%, and 86.0% (P = 0.022). When compared with the control, only subjects in the telephone group were significantly more likely to collect FIT tubes (adjusted odds ratio [AOR] 3.18, 95% confidence interval [CI] = 1.50 to 6.75, P = 0.003) and return completed specimens (AOR = 2.73, 95% CI = 1.35 to 5.53, P = 0.005).

CONCLUSION

Interactive telephone reminders are effective at securing previously screened subjects to repeat screening 1 year after a negative finding.

Motivational interviewing-based training vs traditional training on the uptake of cervical screening: a quasi-experimental study

OBJECTIVES

Cervical cancer, a major health issue affecting women, is preventable and can be successfully treated. It is essential that measures are taken to improve the uptake of screening for this cancer. The aim of this study was to compare the effects of motivational interviewing (MI)-based training and traditional training on the frequency of cervical cancer screening tests in a group of working female teachers.

STUDY DESIGN

This is a quasi-experimental study.

METHODS

This research was conducted in 2017 among 134 teachers (aged 30-60 years) working in southeastern Iran. The participants were selected from among the eligible individuals and subsequently divided into MI-based training and traditional training groups (n = 67 for each group). Each group received a three-session training program, and 20 weeks after the end of the last training session, the information obtained from cervical cancer screening tests was documented. To analyze the data, independent t-test and Chi-squared test were run in SPSS, version 21.

RESULTS

There was no significant difference between the two groups in terms of demographic characteristics such as age, age at the first pregnancy, age of marriage, the number of parities, and educational level. Twenty weeks after intervention, 20.9% of the MI-based training group underwent Pap smear screening test, while 9% of the women in the traditional training group took the test, indicating a statistically significant difference between the two groups (P < 0.0.5).

CONCLUSION

MI-based training has a significant positive effect on women's compliance with cervical cancer screening tests. Therefore, it is recommended that this technique be adopted in women's health centers.

TRIAL REGISTRATION NUMBER

IRCT2017100729954N4.

Toward an Emerging Role for Motivational Interviewing in Primary Care

PURPOSE OF REVIEW

Implementing Motivational Interviewing (MI) in primary care settings has been problematic due in part to persistent gaps in knowledge. Examples include poor understanding of how to effectively train persons to conduct MI, or of which aspects of MI-related communication are associated with better outcomes for patients. This review describes how recent research findings addressing the knowledge gaps support a growing role for MI in primary care.

RECENT FINDINGS

Two trials of MI training combined classroom time with ongoing coaching and feedback, resulting in enhanced MI ability relative to a control arm where PCPs received minimal or no MI training. A third MI training trial excluded coaching and feedback, failing to increase use of MI. Adding to a growing list of behavioral health-related problems for which MI training has shown some effectiveness, a trial of training PCPs to use MI with depressed patients was associated with significantly improved depressive symptoms. Moreover, aspects of the PCPs' MI-related language and patients' arguments for positive behavior changes, "change talk," appeared to explain the positive effects of MI training on depression outcome. MI-training approaches have improved such that PCPs and possibly other clinic staff may want to consider MI training as a way to more effectively support their patients as they address behavioral health-related problems (e.g., tobacco use). MI training should focus on eliciting "change talk" from patients. Researchers and funding agencies might collaborate to continue closing knowledge gaps in the MI literature.

A Motivational Interviewing Intervention by Pharmacy Students to Improve Medication Adherence

BACKGROUND

Diabetes mellitus (DM) patients with comorbid hypertension (HTN) are at a higher risk of developing microvascular and macrovascular DM complications. Through guideline-driven recommendations, angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are highly recommended for these patients. Unfortunately, medication adherence to these products, though crucial to achieving therapeutic benefit, is frequently suboptimal. Motivational interviewing (MI) is a patient-centered collaborative communication style that is used to strengthen internal motivation for change that may prove effective in enhancing adherence.

OBJECTIVE

To examine the effect of an MI telephone intervention conducted by pharmacy students in improving adherence to ACEIs/ARBs among Medicare Advantage Plan (MAP) patients with both DM and HTN.

METHODS

A prospective study was conducted among patients enrolled in a Texas MAP. Medical claims data were used to identify patients with DM and HTN, and pharmacy claims were observed to recognize those who filled either an ACEI or an ARB during June 2014. Patients with a 6-month proportion of days covered (PDC) < 0.80 in the previous 6 months were determined nonadherent, and 75% of those were randomly selected to serve as potential subjects for the intervention, while 25% were randomly selected to serve as potential subjects for the control group. The intervention was a telephone call by a pharmacy student on rotation at the health plan, and 5 monthly follow-up calls. Before implementing calls, participating students attended a 3-day MI training course, where their proficiency for MI skills was evaluated. Refill data during the 6-month postintervention were evaluated to examine the intervention effect measured on 3 outcomes: PDC; PDC ≥ 0.80 versus < 0.80; and discontinuation versus continuation. Multivariate linear and logistic regression models were constructed to adjust for any imbalances in baseline characteristics, including age, gender, number of other medications, regimen complexity, health low-income subsidy status, prescriber specialty, comorbidities, 6-month previous hospitalization, baseline 6-month PDC, and Centers for Medicare & Medicaid Services risk score.

RESULTS

A total of 11 students participated in the intervention implementation. Patients receiving calls were randomly selected from those potential subjects for the intervention arm until a target of 250 was reached; 500 controls were randomly selected from the potential subjects for the control arm. The final cohort included in multivariate models consisted of 743 patients. Patients completing the initial call and at least 2 follow-ups were less likely to discontinue (OR = 0.29; 95% CI = 0.15-0.54; P < 0.001) and more likely to be adherent in the linear regression model (β = 0.0604, P < 0.001) and the logistic regression model (OR = 1.53; 95% CI = 1.02-2.28; P = 0.009). Other factors significantly associated with better adherence included higher baseline PDC and number of medications. Depression status was significantly associated with lower adherence.

CONCLUSIONS

Patients receiving 2 or more calls had significantly better adherence and less discontinuation during the 6 months following initial calls compared with those who did not receive calls. This finding indicates that an MI-based telephone intervention by pharmacy students may be a promising intervention to improve adherence. Future research should examine the sustainability of the intervention effect for longer time periods and its influence on associated clinical outcomes.

DISCLOSURES

This project was supported by the Pharmaceutical Research and Manufacturers of America Foundation (PhRMA). The content is solely the responsibility of the authors and does not necessarily represent the official views of PhRMA. The funding agency was not involved in research design, analysis, or reporting results. Funding was obtained by Abughosh. Holstad provided a consultation regarding the MI guide and provided the MI training. Study concept and design were contributed by Abughosh and Fleming, along with Serna, Esse, and Holstad. Serna, Esse, Mann, Holstad, and Masilamani collected the data, and data interpretation was performed by Abughosh, Wong, and Esse. The manuscript was written by Abughosh, Wong, and Esse and revised by Masilamani and Holstad, along with the other authors.

Increasing Colorectal Cancer Screening Using a Quality Improvement Approach in a Nurse-Managed Primary Care Clinic

According to the American Cancer Society, 1 in 23 Americans will be diagnosed with colorectal cancer (CRC) in their lifetime. Screening for CRC is an effective, yet underused preventive approach. This is especially true in rural areas, where only 35% of patients were found to be up to date on their screenings in 2014. Increasing CRC screening can produce positive patient outcomes by early recognition and removal of precancerous polyps. The purpose of this project was to use quality improvement (QI) interventions to increase CRC screening rates at a nurse-managed clinic in rural Indiana. Using Deming's Plan-Do-Study-Act QI model, multiple interventions were implemented which resulted in a 37% increase in the number of screenings ordered on eligible patients and an overall increase of 28% in the completion of the screenings. This project contributes to healthcare quality knowledge by also suggesting that the fundamental principles of encouraging staff feedback to gain buy-in, improving processes informed by patient data, and valuing frequent performance feedback to staff, strengthened this QI project and ensured adoption and sustainability of these results.

Knowledge and Beliefs Regarding Breast and Cervical Cancer Screening Among Mexican-Heritage Latinas

BACKGROUND

Lower participation rates in mammography and Papanicolaou test are common among Latinas compared with other ethnic groups. Suboptimal screening rates are attributed to lack of knowledge, access to services, and cultural influences.

OBJECTIVE

The purpose of this study is to qualitatively examine an alternative framework for examining cultural influences on Mexican-heritage Latinas' understandings of breast and cervical cancer screening and how to leverage their beliefs to positively influence screening practices.

METHODS

The study is based on the analysis of 4 focus groups with 47 Latinas residing in greater Phoenix, Arizona.

RESULTS

Iterative qualitative analyses identified 5 major themes: (1) knowledge and beliefs about cancer cause and risk in general, (2) knowledge and beliefs specific to breast and cervical cancer screening, (3) experiences with breast and cervical cancer screening, (4) facilitators and barriers to breast and cervical screening, and (5) desired information about cancer and screening.

CONCLUSIONS

Rather than focusing on Latinas' knowledge and/or misconceptions of breast and cervical cancer in screening-related education, researchers must examine what Latinas believe and leverage those convictions to expand their perceptions and behaviors related to breast and cervical cancer prevention practices.

IMPLICATIONS FOR PRACTICE

Practitioners should recognize that Latinas may differ in beliefs from other minorities, and that even within-group, there may be cultural differences that influence cancer screening behaviors.

Mobile health application for remote oral cancer surveillance

BACKGROUND

To determine the effectiveness of a mobile phone-based remote oral cancer surveillance program (Oncogrid) connecting primary care dental practitioners and frontline health care workers (FHW) with oral cancer specialists.

METHODS

The study population (N = 3,440) included a targeted cohort (n = 2,000) and an opportunistic cohort (n = 1,440) screened by FHW and dental professionals, respectively. The authors compared the screening efficacy in both groups, with specialist diagnosis considered the reference standard. The outcomes measured were lesion detection and capture of interpretable images of the oral cavity.

RESULTS

In the targeted cohort, among 51 of 81 (61%) interpretable images, 23 of 51 (45%) of the lesions were confirmed by specialists, while the opportunistic cohort showed 100% concordance with the specialists (106 of 106). Sixty-two of 129 (48%) of the recommended patients underwent biopsy; 1 of 23 (4%) were in the targeted cohort, and 61 of 106 (57%) were in the opportunistic cohort. Ninety percent of the lesions were confirmed to be malignant or potentially malignant.

CONCLUSIONS

The mobile health-based approach adopted in this study aided remote early detection of oral cancer by primary care dental practitioners in a resource-constrained setting. Further optimization of this program is required to adopt the system for FHW. Evaluation of its efficacy in a larger population is also warranted.

PRACTICAL IMPLICATIONS

The increased efficiency of early detection by dentists, when assisted by a remote mobile health-based approach, is a step toward a more effective oral cancer screening program.

Randomized controlled dissemination study of community-to-clinic navigation to promote CRC screening: Study design and implications

INTRODUCTION

Regular screening facilitates early diagnosis of colorectal cancer (CRC) and reduction of CRC morbidity and mortality. Screening rates for minorities and low-income populations remain suboptimal. Provider referral for CRC screening is one of the strongest predictors of adherence, but referrals are unlikely among those who have no clinic home (common among poor and minority populations).

METHODS/STUDY DESIGN

This group randomized controlled study will test the effectiveness of an evidence based tailored messaging intervention in a community-to-clinic navigation context compared to no navigation. Multicultural, underinsured individuals from community sites will be randomized (by site) to receive CRC screening education only, or education plus navigation. In Phase I, those randomized to education plus navigation will be guided to make a clinic appointment to receive a provider referral for CRC screening. Patients attending clinic appointments will continue to receive navigation until screened (Phase II) regardless of initial arm assignment. We hypothesize that those receiving education plus navigation will be more likely to attend clinic appointments (H1) and show higher rates of screening (H2) compared to those receiving education only. Phase I group assignment will be used as a control variable in analysis of screening follow-through in Phase II. Costs per screening achieved will be evaluated for each condition and the RE-AIM framework will be used to examine dissemination results.

CONCLUSION

The novelty of our study design is the translational dissemination model that will allow us to assess the real-world application of an efficacious intervention previously tested in a randomized controlled trial.

Motivational interviewing to improve health screening uptake: A systematic review

OBJECTIVE

Health screenings, physical tests that diagnose disease, are underutilized. Motivational interviewing (MI) may increase health screening rates. This paper systematically reviewed the published articles that examined the efficacy of MI for improving health screening uptake.

METHODS

Articles published before April 28, 2015 were reviewed from PubMed, PsycINFO, and CINAHL. Study methodology, participant demographics, outcomes and quality were extracted from each article.

RESULTS

Of the 1573 abstracts, 13 met inclusion criteria. Of the 13 studies, 6 found MI more efficacious than a control, 2 found MI more efficacious than a weak control yet equivalent to an active control, and 3 found MI was not significantly better than a control. Two single arm studies reported improvements in health screening rates following an MI intervention.

CONCLUSIONS

MI shows promise for improving health screening uptake. However, given the mixed results, the variability amongst the studies and the limited number of randomized trials, it is difficult to discern the exact impact of MI on health screening uptake.

PRACTICE IMPLICATIONS

Future research is needed to better understand the impact of MI in this context. Such research would determine whether MI should be integrated into standard clinical practice for improving health screening uptake.

Family Ties: The Role of Family Context in Family Health History Communication About Cancer

Family health history about cancer is an important prevention and health promotion tool. Yet few studies have identified family context factors that promote such discussions. We explored relations among family context (cohesion, flexibility, and openness), self-efficacy, and cancer communication (gathering family history, sharing cancer risk information, and frequency) in a diverse group of women enrolled in a randomized control trial. Baseline survey data for 472 women were analyzed. The women's average age was 34 years, 59% identified as Black, 31% had graduated high school, and 75% reported a family history of any cancer. Results showed that greater family cohesion and flexibility were related to higher communication frequency and sharing cancer information. Women who reported greater self-efficacy were more likely to have gathered family history, shared cancer risk information, and communicated more frequently with relatives. Openness was not associated with communication but was related to greater family cohesion and flexibility. Adjusting for demographic variables, self-efficacy, and family cohesion significantly predicted communication frequency. Women with higher self-efficacy were also more likely to have gathered family health history about cancer and shared cancer risk information. Future research may benefit from considering family organization and self-efficacy when developing psychosocial theories that in turn inform cancer prevention interventions.

Predictors of stage of adoption for colorectal cancer screening among African American primary care patients

BACKGROUND

Compared with other racial groups, African Americans have the highest colorectal cancer (CRC) incidence and mortality rates coupled with lower screening rates.

OBJECTIVE

Our study examined the predictors of stage of adoption for fecal occult blood testing (FOBT) and colonoscopy among African American primary care patients who were nonadherent to published screening guidelines.

METHODS

Baseline data (N = 815) in a randomized clinical trial were analyzed. Participants were categorized into precontemplation, contemplation, and preparation stages for FOBT and colonoscopy. Predictor variables were demographics, clinical variables, CRC health beliefs and knowledge, and social support. Hierarchical modeling was to identify significant predictors of stage of adoption.

RESULTS

Older, male, Veterans Affairs participants and those with higher perceived self-efficacy, family/friend encouragement, and a provider recommendation had higher odds of being at a more advanced stage of adoption for FOBT. Patients with a history of cancer and higher perceived barriers had higher odds of being at an earlier stage of adoption for FOBT. Predictors of more advanced stage of adoption for colonoscopy included higher perceived benefits, higher perceived self-efficacy, family/friend encouragement, and a provider recommendation for colonoscopy. Higher income (>30 000 vs <15 000) was predictive of earlier stage of adoption for colonoscopy.

CONCLUSIONS

Enhancing self-efficacy, encouragement from family and friends, and provider recommendations are important components of interventions to promote CRC screening.

IMPLICATIONS FOR PRACTICE

Nurses can use knowledge of the characteristics associated with stage of adoption to educate and motivate their African American primary care patients to complete CRC screening tests.

A Multistate Asian-Language Tobacco Quitline: Addressing a Disparity in Access to Care

OBJECTIVES

We conducted a dissemination and implementation study to translate an intervention protocol for Asian-language smokers from an efficacy trial into an effective and sustainable multistate service.

METHODS

Three state tobacco programs (in California, Colorado, and Hawaii) promoted a multistate cessation quitline to 3 Asian-language-speaking communities: Chinese, Korean, and Vietnamese. The California quitline provided counseling centrally to facilitate implementation. Three more states joined the program during the study period (January 2010-July 2012). We assessed the provision of counseling, quitting outcomes, and dissemination of the program.

RESULTS

A total of 2004 smokers called for the service, with 88.3% opting for counseling. Among those opting for counseling, the 6-month abstinence rate (18.8%) was similar to results of the earlier efficacy trial (16.4%).

CONCLUSIONS

The intervention protocol, based on an efficacy trial, was successfully translated into a multistate service and further disseminated. This project paved the way for the establishment of a national quitline for Asian-language speakers, which serves as an important strategy to address disparities in access to care.

Impact of Risk Assessment and Tailored versus Nontailored Risk Information on Colorectal Cancer Testing in Primary Care: A Randomized Controlled Trial

BACKGROUND

Colorectal cancer screening is effective but underused. Guidelines for which tests are recommended and at what intervals depend on specific risks. We developed a tablet-based Cancer Risk Intake System (CRIS) that asks questions about risk prior to appointments and generates tailored printouts for patients and physicians summarizing and matching risk factors with guideline-based recommendations.

METHODS

Randomized controlled trial among patients who: (i) used CRIS and they and their physicians received tailored printouts; (ii) used CRIS to answer questions but received standard information about cancer screening while their physicians received a standard electronic chart prompt indicating they were age-eligible but not currently adherent for colorectal cancer screening; or (iii) comprised a no-contact group that neither used CRIS nor received any information while their physicians received the standard prompt. Participation in testing was assessed via electronic medical record at 12 months.

RESULTS

Participation in any colorectal cancer testing was three times higher for those who used the CRIS and received any printed materials, compared with no-contact controls (47% vs. 16%; P < 0.0001). Among CRIS users ages 50 and older, participation in any testing was higher in the tailored group (53% vs. 44%, P = 0.023).

CONCLUSION

Use of CRIS and receipt of any information facilitated participation in testing. There was more testing participation in the CRIS-tailored than nontailored group.

IMPACT

Asking patients questions about their specific risk factors and giving them and their providers information just prior to an appointment may increase participation in colorectal cancer testing. Tailoring the information has some added benefit.

Tailored telephone counseling increases colorectal cancer screening

To compare the efficacy of two interventions to promote colorectal cancer screening participation and forward stage movement of colorectal cancer screening adoption among first-degree relatives of individuals diagnosed with adenomatous polyps. One hundred fifty-eight first-degree relatives of individuals diagnosed with adenomatous polyps were randomly assigned to receive one of two interventions to promote colorectal cancer screening. Participants received either a tailored telephone counseling plus brochures intervention or a non-tailored print brochures intervention. Data were collected at baseline and 3 months post-baseline. Group differences and the effect of the interventions on adherence and stage movement for colorectal cancer screening were examined using t-tests, chi-square tests, and logistic regression. Individuals in the tailored telephone counseling plus brochures group were significantly more likely to complete colorectal cancer screening and to move forward on stage of change for fecal occult blood test, any colorectal cancer test stage and stage of the risk-appropriate test compared with individuals in the non-tailored brochure group at 3 months post-baseline. A tailored telephone counseling plus brochures intervention successfully promoted forward stage movement and colorectal cancer screening adherence among first-degree relatives of individuals diagnosed with adenomatous polyps.

A framework for evaluating the cost-effectiveness of patient decision aids: A case study using colorectal cancer screening

OBJECTIVE

Patient decision aids are important tools for facilitating balanced, evidence-based decision making. However, the potential of decision aids to lower health care utilization and costs is uncertain; few studies have investigated the cost-effectiveness of decision aids that change patient behavior. Using an example of a decision aid for colorectal cancer screening, we provide a framework for analyzing the cost-effectiveness of decision aids.

METHODS

A decision-analytic model with two strategies (decision aid or no decision aid) was used to calculate expected costs in U.S. dollars and benefits measured in life-years saved (LYS). Data from a systematic review of ten studies about decision aid effectiveness was used to calculate the percentage increase in the number of people choosing screening instead of no screening. We then calculated the incremental cost per LYS with the use of the decision aid.

RESULTS

The no decision aid strategy had an expected cost of $3023 and yielded 18.19 LYS. The decision aid strategy cost $3249 and yielded 18.20 LYS. The incremental cost-effectiveness ratio for the decision aid strategy was $36,126 per LYS. Results were sensitive to the cost of the decision aid and the percentage change in behavior caused by the decision aid.

CONCLUSIONS

This study provides proof-of-concept evidence for future studies examining the cost-effectiveness of decision aids. The results suggest that decision aids can be beneficial and cost-effective.

Optimising colorectal cancer screening acceptance: a review

The study aims to review available evidence concerning effective interventions to increase colorectal cancer (CRC) screening acceptance. We performed a literature search of randomised trials designed to increase individuals' use of CRC screening on PubMed, Embase, Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects. Small (≤ 100 subjects per arm) studies and those reporting results of interventions implemented before publication of the large faecal occult blood test trials were excluded. Interventions were categorised following the Continuum of Cancer Care and the PRECEDE-PROCEED models and studies were grouped by screening model (opportunistic vs organised). Multifactor interventions targeting multiple levels of care and considering factors outside the individual clinician control, represent the most effective strategy to enhance CRC screening acceptance. Removing financial barriers, implementing methods allowing a systematic contact of the whole target population, using personal invitation letters, preferably signed by the reference care provider, and reminders mailed to all non-attendees are highly effective in enhancing CRC screening acceptance. Physician reminders may support the diffusion of screening, but they can be effective only for individuals who have access to and make use of healthcare services. Educational interventions for patients and providers are effective, but the implementation of organisational measures may be necessary to favour their impact. Available evidence indicates that organised programmes allow to achieve an extensive coverage and to enhance equity of access, while maximising the health impact of screening. They provide at the same time an infrastructure allowing to achieve a more favourable cost-effectiveness profile of potentially effective strategies, which would not be sustainable in opportunistic settings.

Randomized controlled trial of storytelling compared to a personal risk tool intervention on colorectal cancer screening in low-income patients

PURPOSE

Screening rates for colorectal cancer (CRC) lag for low-income, minority populations, contributing to poorer survival rates. A model of storytelling as culture-centric health promotion was tested for promoting CRC screening.

DESIGN

A two-group parallel randomized controlled trial.

SETTING

Primary care, safety-net clinics.

SUBJECTS

Low-income patients due for CRC screening, ages 50 to 75 years, speaking English or Spanish.

INTERVENTION

Patients were exposed to either a video created from personal stories composited into a drama about "Papa" receiving CRC screening, or an instrument estimating level of personal cancer risk. Patients received a health care provider referral for CRC screening and were followed up for 3 months to document adherence.

MEASURES

Behavioral factors related to the narrative model (identification and engagement) and theory of planned behavior.

ANALYSIS

Main effects of the interventions on screening were tested, controlling for attrition factors, and demographic factor associations were assessed. Path analysis with model variables was used to test the direct effects and multiple mediator models.

RESULTS

Main effects on CRC screening (roughly half stool-based tests, half colonoscopy) did not indicate significant differences (37% and 42% screened for storytelling and risk-based messages, respectively; n = 539; 33.6% male; 62% Hispanic). Factors positively associated with CRC screening included being female, Hispanic, married or living with a partner, speaking Spanish, having a primary care provider, lower income, and no health insurance. Engagement, working through positive attitudes toward the behavior, predicted CRC screening.

CONCLUSION

A storytelling and a personalized risk-tool intervention achieved similar levels of screening among unscreened/underscreened, low-income patients. Factors usually associated with lower rates of screening (e.g., no insurance, being Hispanic) were related to more adherence. Both interventions' engagement factor facilitated positive attitudes about CRC screening associated with behavior change.

Reducing inequities in colorectal cancer screening in North America

Colorectal cancer (CRC) is an important cause of mortality and morbidity in North America. Screening using a fecal occult blood test, flexible sigmoidoscopy, or colonoscopy reduces CRC mortality through the detection and treatment of precancerous polyps and early stage CRC. Although CRC screening participation has increased in recent years, large inequities still exist. Minorities, new immigrants, and those with lower levels of education or income are much less likely to be screened. This review provides an overview of the commonly used tests for CRC screening, disparities in CRC screening, and promising methods at the individual, provider, and system levels to reduce these disparities. Overall, to achieve high CRC participation rates and reduce the burden of CRC in the population, a multi-faceted approach that uses strategies at all levels to reduce CRC screening disparities is urgently required.

Motivational interviewing with primary care populations: a systematic review and meta-analysis

This meta-analysis synthesized the findings from randomized controlled trials (RCTs) of motivational interviewing (MI) for health behavior outcomes within primary care populations. Published and unpublished RCTs were identified using databases and online listservs. Studies were synthesized by outcome subgroup and meta-regression analyses were conducted to determine potential moderators accounting for heterogeneity within samples. Mean effect sizes ranged from .07 to .47; significant effect sizes were found for the adherence subgroup of studies (p = .04) and all outcomes combined (p = .02). Professional credentials of intervention deliverer were found to significantly moderate the association between MI and effect size in substance use subgroup (p = .0005) and all outcomes combined (p = .004). Mean effect sizes were largest in outcomes related to weight loss, blood pressure, and substance use. MI appears to be useful in clinical settings and as few as 1 MI session may be effective in enhancing readiness to change and action directed towards reaching health behavior-change goals.