Communication preference moderates the effect of a tailored intervention to increase colorectal cancer screening among African Americans

How Message-Evoked Emotions Undermine Persuasion: The Mediating Role of Fear and Anger in Health Message Effects Among Older Adults

Guided by literature on framing, this study explored how the presence of age labels in different message frames influenced message-evoked fear and anger responses, particularly for older adults with different levels of need for autonomy (NFA), which ultimately affected their physical activity intentions. The results of a three-factor between-subjects experiment, with message frame (gain versus loss) and age label (present versus absent) as manipulated variables and NFA (low versus medium versus high) as quasi-experiment variable (N = 237) revealed that loss-framed message evoked higher levels of fear and anger as compared to gain-framed message. Furthermore, the anger elicited by loss-framing was more pronounced when age labels were present, especially among older adults with low NFA. The moderated mediation analysis revealed that, among older adults with low NFA, loss-framed messages decreased physical activity intentions through message-evoked anger. Notably, this mediating effect was more pronounced when age labels were present.

The health communication orientations scale: Development and two-country validation of a questionnaire that measures health communication style preferences

OBJECTIVE

Self-Determination Theory posits that everyone has a basic need for autonomy that needs to be fulfilled to establish autonomous motivation for health behavior (change). Regardless, individual differences exist in health communication style preferences. This paper outlines the development and validation of the Health Communication Orientations Scale (HCOS), a new measure to assess these preferences.

METHODS

Nationally representative online panels from the US (n = 603) and the Netherlands (n = 737) completed a survey containing the HCOS, established motivational measures, and demographic questions.

RESULTS

Factor analyses identified five subscales valid for both populations: HCOS (1) Expert, (2) Others, (3) Self, (4) Oppositional, and (5) Internet. Scores for Expert and Internet were higher in the US sample; Others, Self, and Oppositional were higher in the Dutch sample. Internal reliability for the five factors was high across samples (range 0.84-0.91). Many significant correlations with established measures were observed in both samples indicating the construct validity of the scale.

CONCLUSION

The HCOS subscales have strong psychometric properties.

PRACTICE IMPLICATIONS

The HCOS represents a novel approach to assessing communication style preferences for general and patient populations. Further investigation in how the HCOS may be used to tailor health messaging is warranted.

Cultural Sensitivity and Cultural Tailoring: Lessons Learned and Refinements After Two Decades of Incorporating Culture in Health Communication Research

In this article, we examine progress and challenges in designing, implementing, and evaluating culturally sensitive behavioral interventions by tailoring health communication to groups or individuals. After defining common tailoring constructs (i.e., culture, race, and ethnicity), cultural sensitivity, and cultural tailoring, we examine when it is useful to culturally tailor and address cultural sensitivity in health communication by group tailoring or individual tailoring and when tailoring health communication may not be necessary or appropriate for achieving behavior change. After reviewing selected approaches to cultural tailoring, we critique the quality of research in this domain with a focus on the internal validity of empirical findings. Then we explore the ways in which cultural sensitivity, group targeting, and individual tailoring have incorporated culture in health promotion and health communication. We conclude by articulating yet unanswered questions and suggesting future directions to move the field forward.

Prevalence and predictors of colorectal cancer screening in the United States: evidence from the HINTS database 2018 to 2020

BACKGROUND

The incidence of colorectal cancer (CRC) and CRC-related mortality among young adults (< 50 years) has been on the rise. The American Cancer Society (ACS) reduced the CRC screening age to 45 in 2018. Few studies have examined the barriers to CRC screening among young adults.

METHODS

Analyses were conducted using data from 7,505 adults aged 45-75 years who completed the 2018 to 2020 Health Information National Trends Survey. We examined the sociodemographic characteristics associated with CRC screening overall and by age group using separate multivariable logistic regression models.

RESULTS

76% of eligible adults had received screening for CRC. Increasing age, Black racial group [OR 1.45; 95% CI (1.07, 1.97)], having some college experience, a college degree or higher [OR 1.69; 95% CI (1.24, 2.29)], health insurance coverage [OR 4.48; 95% CI (2.96, 6.76)], primary care provider access [OR 2.48; 95% CI (1.91, 3.22)] and presence of a comorbid illness [OR 1.39; 95% CI (1.12, 1.73)] were independent predictors of CRC screening. Current smokers were less likely to undergo CRC screening [OR 0.59; 95% CI (0.40, 0.87)]. Among adults aged 50-64 years, being of Hispanic origin [OR 0.60; 95% CI (0.39, 0.92)] was associated with a lower likelihood of CRC screening.

CONCLUSION

CRC screening rates among adults 45-49 years are low but are increasing steadily. Odds of CRC screening among Blacks is high which is encouraging while the odds among current smokers is low and concerning given their increased risk of developing CRC.

Systematic review of randomised controlled trials on interventions aimed at promoting colorectal cancer screening amongst ethnic minorities

OBJECTIVES

Significant disparities exist between different ethnic groups when it comes to participation in colorectal cancer (CRC) screening programmes. A variety of interventions have been proposed to improve participation rates of ethnic minorities for CRC screening. This systematic review aims to appraise the evidence available from published randomised controlled trials (RCTs) and to identify effective interventions aimed at promoting CRC screening amongst underserved ethnic minorities.

DESIGN

We searched EmBASE, Medline, PsychInfo, Scopus and CINAHL for RCTs that analysed interventions to promote CRC screening in all ethnic minorities. CRC screening was measured as documented or self-reported screening rates. The protocol of this study was registered prospectively on PROSPERO with the registration number CRD42020216384.

RESULTS

We identified 42 relevant RCT articles, out of 1805 articles highlighted by the initial search. All except one were conducted in the US. The most frequently studied ethnic groups were African-Americans (33%), East Asians (30%), and Hispanics/Latinos (23%). In total, 7/42 (16%) RCTs had multiple arms. Interventions mainly intended to educate (52%), provide patient navigation services (21%), or provide a combination of these interventions (19%). We demonstrate that combination methods are most effective.

CONCLUSION

Many RCTs, mostly in the US, have trialed interventions aimed to increase CRC screening uptake amongst ethnic minorities to varying success. We conclude that using a combination of methods with patient navigation, education, and cultural tailoring is most effective at increasing CRC screening uptake amongst ethnic minorities. This highlights that multiple factors may hinder CRC screening and finding a one-size-fits-all solution that can be reliably implemented among different cultures and countries may be complex.

Shared Decision Making in Health Care: Theoretical Perspectives for Why It Works and For Whom

Applying both theoretical perspectives and empirical evidence, we address 2 key questions regarding shared decision making (SDM): 1) When should SDM be more patient driven, and when should it be more provider driven? and 2) Should health care providers match their SDM style/strategy to patient needs and preferences? Self-determination theory, for example, posits a distinction between autonomy and independence. A patient may autonomously seek their health care provider's input and guidance, perhaps due to low perceived competence, low coping resources, or high emotional arousal. Given their need state, they may autonomously require nonindependence. In this case, it may be more patient centered and need supportive to provide more provider-driven care. We discuss how other patient characteristics such as personality attributes, motivational state, and the course of illness and other parameters such as time available for an encounter may inform optimal provider decision-making style and strategy. We conclude that for some types of patients and clinical circumstances, a more provider-driven approach to decision making may be more practical, ethical, and efficacious. Thus, while all decision making should be patient centered (i.e., it should consider patient needs and preferences), it does not always have to be patient driven. We propose a flexible model of SDM whereby practitioners are encouraged to tailor their decision making behaviors to patient needs, preferences, and other attributes. Studies are needed to test whether matching decision-making behavior based on patient states and traits (i.e., achieving concordance) is more effective than simply providing all patients with the same type of decision making, which could be tested using matching/mismatching designs.

Opportunities and Challenges When Using the Electronic Health Record for Practice-Integrated Patient-Facing Interventions: The e-Assist Colon Health Randomized Trial

Background

Even after a physician recommendation, many people remain unscreened for colorectal cancer (CRC). The proliferation of electronic health records (EHRs) and tethered online portals may afford new opportunities to embed patient-facing interventions within clinic workflows and engage patients following a physician recommendation for care. We evaluated the effectiveness of a patient-facing intervention designed to complement physician office-based recommendations for CRC screening.

Design

Using a 2-arm pragmatic, randomized clinical trial, we evaluated the intervention’s effect on CRC screening use as documented in the EHR (primary outcome) and the extent to which the intervention reached the target population. Trial participants were insured, aged 50 to 75 y, with a physician recommendation for CRC screening. Typical EHR functionalities, including patient registries, health maintenance flags, best practice alerts, and secure messaging, were used to support research-related activities and deliver the intervention to enrolled patients.

Results

A total of 1,825 adults consented to trial participation, of whom 78% completed a baseline survey and were exposed to the intervention. Most trial participants (>80%) indicated an intent to be screened on the baseline survey, and 65% were screened at follow-up, with no significant differences by study arm. One-third of eligible patients were sent a secure message. Among those, more than three-quarters accessed study material.

Conclusions

By leveraging common EHR functionalities, we integrated a patient-facing intervention within clinic workflows. Despite practice integration, the intervention did not improve screening use, likely in part due to portal-based interventions not reaching those for whom the intervention may be most effective.

Implications

Embedding patient-facing interventions within the EHR enabled practice integration but may minimize program effectiveness by missing important segments of the patient population.

Highlights

Communicating risk to promote colorectal cancer screening: a multi-method study to test tailored versus targeted message strategies

Colorectal cancer (CRC) screening rates are suboptimal, partly due to poor communication about CRC risk. More effective methods are needed to educate patients, but little research has examined best practices for communicating CRC risk. This multi-method study tests whether tailoring CRC risk information increases screening intentions. Participants (N = 738) were randomized with a 2:2:1 allocation to tailored, targeted, and control message conditions. The primary outcome was intention to screen for CRC (yes/no). Additional variables include perceived message relevance, perceived susceptibility to CRC, and free-text comments evaluating the intervention. A chi-square test determined differences in the proportion of participants who intended to complete CRC screening by condition. A logistic-based path analysis explored mediation. Free-text comments were analyzed using advanced topic modeling analysis. CRC screening intentions were highest in the tailored intervention and significantly greater than control (P = 0.006). The tailored message condition significantly increased message relevance compared with control (P = 0.027) and targeted conditions (P = 0.002). The tailored condition also increased susceptibility (P < 0.001) compared with control, which mediated the relationship between the tailored condition and intention to screen (b = 0.04, SE = 0.02, 95% confidence interval = 0.02, 0.09). The qualitative data reflect similar trends. The theoretical mechanisms and practical implications of tailoring health education materials about CRC risk are discussed.

Effect of Patient-Directed Messaging on Colorectal Cancer Screening: A Randomized Clinical Trial

IMPORTANCE

Colorectal cancer (CRC) screening is underused in the US. Tailored message interventions have shown benefit for increasing screening uptake of mammography and Papanicolaou testing, but their role in CRC screening is less clear.

OBJECTIVE

To evaluate the effectiveness of a tailored message telephone intervention prior to scheduling of a screening or surveillance colonoscopy and its effect on CRC screening completion rates.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted from July 2017 through August 2018 at the University of Pennsylvania Health System (UPHS), an urban academic medical center. Participants were asymptomatic patients aged 50 to 75 years who were eligible for CRC screening or surveillance, had been referred for colonoscopy, and did not have a scheduled colonoscopy appointment. Data analysis was conducted from January to September 2019.

INTERVENTIONS

Patients underwent block randomization in a 1:1:1 ratio to 1 of 3 study arms. Participants in the usual care group were contacted via a mailed letter and instructed to call to schedule a colonoscopy. In the generic message group, participants were contacted by telephone, completed an assessment, and received a uniform, nontailored message encouraging colonoscopy scheduling. Participants in the tailored message group were contacted by telephone, completed an assessment, and received a tailored message encouraging colonoscopy scheduling based on their identified assessment cohort.

MAIN OUTCOMES AND MEASURES

The primary outcome was colonoscopy completion rate within 120 days of enrollment. The secondary outcome was colonoscopy scheduling rate appointment within 120 days of enrollment.

RESULTS

A total of 600 participants (median [IQR] age, 56 [51-63] years; 373 women [62.2%]) were enrolled, including 200 participants randomized to usual care, 200 participants randomized to the generic message, and 200 participants randomized to the tailored message. The total sample included 12 Asian participants (2.0%), 324 Black participants (54.0%), and 227 White participants (37.8%), and 9 participants (1.5%) were of Latino or Hispanic ethnicity. Colonoscopy completion was significantly higher for both the tailored message group (69 participants [34.5%]) and the generic message group (64 participants [32.0%]) compared with the usual care group (37 participants [18.5%]) (P < .001 and P = .002, respectively). Scheduling rates were also significantly higher in both groups, with 106 participants (53.0%) in the tailored message group and 105 participants (52.5%) in the generic message group scheduling appointments, compared with 54 participants (27.0%) in the usual care arm (P < .001 for both).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial among individuals whose CRC screening was not up to date, both a tailored message intervention and a generic message intervention were significantly more effective at increasing colonoscopy scheduling and completion rates compared with usual care. These findings suggest that individualized health communications can increase individual motivation to obtain CRC screening.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03310892.

The Relationship between Future Anxiety Due to COVID-19 and Vigilance: The Role of Message Fatigue and Autonomy Satisfaction

How does future anxiety caused by the COVID-19 pandemic relate to people’s willingness to remain vigilant and adhere to preventive measures? We examined the mediating role of message fatigue and the moderating role of autonomy satisfaction in the relationship between future anxiety due to COVID-19 and willingness to remain vigilant. A cross-sectional online survey was conducted with adults residing in the United States in June 2021 when numerous U.S. states re-opened following the CDC’s relaxed guidelines for fully vaccinated individuals. Our data showed that message fatigue mediated the relationship between future anxiety due to the pandemic and willingness to remain vigilant. The data further revealed that autonomy satisfaction significantly moderated the mediation. Namely, the role of message fatigue in the indirect relationship between future anxiety and willingness to remain vigilant was significant only among people low to moderate in autonomy satisfaction; its role in the indirect path was not significant for those high in autonomy satisfaction. Notably, independent of the mechanism involving message fatigue, future anxiety was directly and positively associated with willingness to remain vigilant regardless of the levels of autonomy satisfaction. Implications of these findings are discussed in light of psychological and behavioral responses to the current pandemic and policy directions.

Message Frame-Tailoring in Digital Health Communication: Intervention Redesign and Usability Testing (Preprint)

Background

Message frame–tailoring based on the need for autonomy is a promising strategy to improve the effectiveness of digital health communication interventions. An example of a digital health communication intervention is Personal Advice in Stopping smoking (PAS), a web-based content-tailored smoking cessation program. PAS was effective in improving cessation success rates, but its effect sizes were small and disappeared after 6 months. Therefore, investigating whether message frame–tailoring based on the individual’s need for autonomy might improve effect rates is worthwhile. However, to our knowledge, this has not been studied previously.

Objective

To investigate whether adding message frame–tailoring based on the need for autonomy increases the effectiveness of content-tailored interventions, the PAS program was redesigned to incorporate message frame–tailoring also. This paper described the process of redesigning the PAS program to include message frame–tailoring, providing smokers with autonomy-supportive or controlling message frames—depending on their individual need for autonomy. Therefore, we aimed to extend framing theory, tailoring theory, and self-determination theory.

Methods

Extension of the framing theory, tailoring theory, and self-determination theory by redesigning the PAS program to include message frame–tailoring was conducted in close collaboration with scientific and nonscientific smoking cessation experts (n=10), smokers (n=816), and communication science students (n=19). Various methods were used to redesign the PAS program to include message frame–tailoring with optimal usability: usability testing, think-aloud methodology, heuristic evaluations, and a web-based experiment.

Results

The most autonomy-supportive and controlling message frames were identified, the cutoff point for the need for autonomy to distinguish between people with high and those with low need for autonomy was determined, and the usability was optimized.

Conclusions

This resulted in a redesigned digital health communication intervention that included message frame–tailoring and had optimal usability. A detailed description of the redesigning process of the PAS program is provided.

Trial Registration

Netherlands Trial Register NL6512 (NRT6700); https://www.trialregister.nl/trial/6512

Interventions for increasing colorectal cancer screening uptake among African-American men: A systematic review and meta-analysis

BACKGROUND

African-American men have the lowest 5-year survival rate in the U.S. for colorectal cancer (CRC) of any racial group, which may partly stem from low screening adherence. It is imperative to synthesize the literature evaluating the effectiveness of interventions on CRC screening uptake in this population.

MATERIALS AND METHODS

In this systematic review and meta-analysis, Medline, CINAHL, Embase, and Cochrane CENTRAL were searched for U.S.-based interventions that: were published after 1998-January 2020; included African-American men; and evaluated CRC screening uptake explicitly. Checklist by Cochrane Collaboration and Joanna Brigg were utilized to assess risk of bias, and meta-regression and sensitivity analyses were employed to identify the most effective interventions.

RESULTS

Our final sample comprised 41 studies with 2 focused exclusively on African-American men. The most frequently adopted interventions were educational materials (39%), stool-based screening kits (14%), and patient navigation (11%). Most randomized controlled trials failed to provide details about the blinding of the participant recruitment method, allocation concealment method, and/or the outcome assessment. Due to high heterogeneity, meta-analysis was conducted among 17 eligible studies. Interventions utilizing stool-based kits or patient navigation were most effective at increasing CRC screening completion, with odds ratios of 9.60 (95% CI 2.89-31.82, p = 0.0002) and 2.84 (95% CI 1.23-6.49, p = 0.01). No evidence of publication bias was present for this study registered with the International Prospective Registry of Systematic Reviews (PROSPERO 2019 CRD42019119510).

CONCLUSIONS

Additional research is warranted to uncover effective, affordable interventions focused on increasing CRC screening completion among African-American men. When designing and implementing future multicomponent interventions, employing 4 or fewer interventions types may reduce bias risk. Since only 5% of the interventions solely focused on African-American men, future theory-driven interventions should consider recruiting samples comprised solely of this population.

A smoker's choice? Identifying the most autonomy-supportive message frame in an online computer-tailored smoking cessation intervention

OBJECTIVE

To test the effect of autonomy-supportive message framing on people's perceived autonomy-support while considering the individual need for autonomy as a moderator. Also, to test whether autonomy-supportive message frames - through increased perceived autonomy-support - lead to more self-determined motivation, and increased intention to quit smoking.

DESIGN

An online 2(autonomy-supportive; controlling language) × 2(choice; no choice) between-subjects design with control condition (generic advice) with adult smokers intending to quit (N = 626).

MAIN OUTCOME

Intention to quit smoking (Theory of Planned Behaviour).

MEASURES

Perceived autonomy-support (Virtual Climate Care Questionnaire), need for autonomy (Health Causality Orientations Scale), self-determined motivation (Treatment Self-Regulation Questionnaire), attitudes, social influence, self-efficacy (I-Change Model).

RESULTS

Structural equation modelling revealed no significant effect of autonomy-supportive-message frames on perceived autonomy-support or self-determined motivation, neither did the need for autonomy moderate these effects. Self-determined motivation had a positive, significant effect on intention to quit, mediated by attitudes, social influence, and self-efficacy.

CONCLUSION

Although message frames did not affect perceived autonomy-support or self-determined motivation, higher self-determined motivation increased intention to quit via attitudes, social influence, and self-efficacy. Before drawing the conclusion that message framing has no effect, we recommend to replicate this study in a real-life setting with smokers more likely to read and process the message frames more attentively.

Effectiveness of Message Frame-Tailoring in a Web-Based Smoking Cessation Program: Randomized Controlled Trial

Background

The content of online computer-tailored interventions is often determined to match an individual’s characteristics, beliefs, and behavioral factors. These content-tailored interventions lead to better message processing and a higher likelihood of behavior change such as smoking cessation. However, a meta-analysis of online computer-tailored interventions showed that effect sizes, albeit positive, remain small, suggesting room for improvement. A promising strategy to enhance the effectiveness of online computer-tailored interventions is to tailor the message frame (ie, how a message is communicated) based on the preferred communication style of the user in addition to content-tailoring. One factor that determines an individual’s communication style preference is the need for autonomy; some individuals prefer an autonomy-supportive communication style (offering choice and use of suggestive language), whereas others might prefer a directive communication style, which is replete with imperatives and does not provide choice. Tailoring how messages are presented (eg, based on the need for autonomy) is called message frame-tailoring.

Objective

The aim of the present study was to test the effectiveness of message frame-tailoring based on the need for autonomy, in isolation and in combination with content-tailoring, within the context of an online computer-tailored smoking cessation intervention. The primary outcome measure was the 7-day point-prevalence of smoking abstinence. Secondary outcomes were perceived message relevance, self-determined motivation to quit smoking, and sociocognitive beliefs.

Methods

A randomized controlled trial with a 2 (message frame-tailoring vs no message frame-tailoring) by 2 (content-tailoring vs no content-tailoring) design was conducted among adult smokers intending to quit smoking (N=273).

Results

Structural equation modeling revealed that the content-tailored condition increased smoking abstinence rates 1 month after the start of the intervention (beta=.57, P=.02). However, neither message frame-tailoring nor its interaction with content-tailoring significantly predicted smoking abstinence. In our model, message frame-tailoring, content-tailoring, as well as their interaction significantly predicted perceived relevance of the smoking cessation messages, which consequently predicted self-determined motivation. In turn, self-determined motivation positively affected attitudes and self-efficacy for smoking cessation, but only self-efficacy consequently predicted smoking abstinence. Participants in the control condition perceived the highest level of message relevance (mean 4.78, SD 1.27). However, messages that were frame-tailored for individuals with a high need for autonomy in combination with content-tailored messages led to significantly higher levels of perceived message relevance (mean 4.83, SD 1.03) compared to those receiving content-tailored messages only (mean 4.24, SD 1.05, P=.003).

Conclusions

Message frame-tailoring based on the need for autonomy seems to be an effective addition to conventional content-tailoring techniques in online smoking cessation interventions for people with a high need for autonomy; however, this is not effective in its current form for people with a low need for autonomy.

Trial Registration

Dutch Trial Register (NL6512/NRT-6700); https://www.trialregister.nl/trial/6512

Race moderates the effects of Motivational Interviewing on smoking cessation induction

OBJECTIVE

Health disparities necessitate exploration of how race moderates response to smoking cessation treatment. Data from a randomized clinical trial of Motivational Interviewing (MI) for smoking cessation induction were used to explore differential treatment response between African American (AA) vs Non-Black (NB) smokers.

METHODS

Adult tobacco smokers (138 AA vs 66 NB) with low desire to quit were randomly assigned to four sessions of MI or health education (HE). Outcomes (e.g., quit attempts) were assessed 3- and 6-months.

RESULTS

There was evidence of a Race by Treatment interaction such that MI was less effective than HE in AA smokers. Mean Cohen's d for the interaction effect was -0.32 (95% CI [-0.44, -0.20]). However, the race interaction could be accounted for by controlling for baseline relationship status and communication preference (wants directive approach).

CONCLUSIONS

MI may be less effective for smoking cessation induction in AA vs NB smokers when compared to another active and more directive therapy. The differential response between races may be explained by psychosocial variables.

PRACTICE IMPLICATIONS

MI may not be an ideal choice for all African American smokers. Patients' relationship status and preference for a directive counseling approach might explain disparities in response to MI treatment.

Customization in mobile health apps: explaining effects on physical activity intentions by the need for autonomy

Given the widespread adoption and technical possibilities of mobile technology, mobile health apps could be potentially effective tools to intervene in people’s daily routines and stimulate physical activity. Self-determination theory and the motivational technology model both suggest that mobile technology can promote health behaviour change by allowing users to customize their online experience when using mobile health apps. However, we know very little about why and for whom customization is most effective. Using a between-subjects experimental design, we tested the effects of customization in mobile health apps among a convenience sample (N = 203). We assessed the effects of customization on perceived active control over mobile health apps, autonomous motivation to use mobile health apps, and intention to engage in physical activity, and tested the moderating role of need for autonomy. Structural equation modelling showed that customization in mobile health apps does not increase perceived active control, autonomous motivation, or the intention to engage in physical activity. However, an interaction effect between customization and need for autonomy showed that customization in mobile health apps leads to higher intentions to engage in physical activity for those with a greater need for autonomy, but not for those with a lesser need for autonomy. The implications for theory and practice are discussed.

Identifying the Most Autonomy-Supportive Message Frame in Digital Health Communication: A 2x2 Between-Subjects Experiment

Background

The effectiveness of digital health communication may be increased by enhancing autonomy supportiveness.

Objective

This study aimed to identify the most autonomy-supportive message frame within an intervention for increasing vegetable intake by testing the effect of the following 2 strategies: (1) using autonomy-supportive language and (2) providing choice.

Methods

A Web-based 2 (autonomy-supportive vs controlling language)×2 (choice vs no choice) experiment was conducted among 526 participants, recruited via a research panel. The main outcome measures were perceived autonomy support (measured using the Virtual Care Climate Questionnaire, answered with scores 1 to 5), perceived relevance (measured with one question, answered with scores 1 to 5), and overall evaluation of the intervention (measured with 1 open-ended question, answered with scores 1 to 10).

Results

Choice had a significant positive effect on the overall evaluation of the intervention (b=.12; P=.003), whereas for participants with a high need for autonomy, there was a significant positive effect on perceived relevance (b=.13; P=.02). The positive effect of choice on perceived autonomy support approached significance (b=.07; P=.07). No significant effects on any of the three outcomes were observed for language.

Conclusions

Results suggest that provision of choice rather than the use of autonomy-supportive language can be an easy-to-implement strategy to increase the effectiveness of digital forms of health communication, especially for people with a high need for autonomy.

Invitation to Screening Colonoscopy in the Population at Familial Risk for Colorectal Cancer

BACKGROUND

Screening colonoscopy can lower the incidence of colorectal cancer (CRC), yet participation rates are low even in groups at high risk. The goal of this study was to double the rate of participation in screening colonoscopy among persons at familial risk and then to determine the frequency of neoplasia in this risk group.

METHODS

In a nationwide, cluster-randomized, multicenter study, first-degree relatives (FDR) of patients with CRC across Germany received written informational materials concerning the familial risk of CRC, along with an invitation to undergo colonoscopy. Participants in the intervention group were additionally counseled by nurses over the telephone. The primary endpoint of the study was colonoscopy uptake within 30 days.

RESULTS

The participants' mean age was 50.8 years. The colonoscopy uptake rates were 99/125 (79%) in the intervention group and 97/136 (71%) in the control group (RR = 1.11; 95% confidence interval [0.97; 1.28]). A polypectomy was performed in 72 of 196 asymptomatic persons (37%). In 13 cases (7%), an advanced neoplasia was detected; two of these persons had colon cancer (stages T0 and T1). 42% of the participants expressed barriers against colonoscopy. 22 reported mild side effects; there were no serious side effects.

CONCLUSION

Additional counseling by nurses over the telephone does not increase the participation rate. Approaching patients who have CRC is an opportunity to increase the participation of their first-degree relatives in screening colonoscopy. The frequency of neoplasia that was found in this study underscores the need to screen relatives even before they reach the usual age threshold for screening.

Should or could? Testing the use of autonomy-supportive language and the provision of choice in online computer-tailored alcohol reduction communication

Individuals can feel more motivated to change health behaviour when perceiving autonomy-support, as induced through non-pressuring message phrasing and the provision of choice: autonomy-supportive message framing. Additionally, controlling message phrasing – commands that do not provide choice – can thwart autonomy and lead to reactance, which is detrimental to the persuasiveness of health messages. Many health messages have not been formulated in an autonomy-supportive manner and therefore could arouse reactance, resulting in reduced intervention effectiveness. We aimed to test the effects of autonomy-supportive vs. controlling alcohol reduction message frames on individuals’ perceived autonomy-support from these messages; and their reactance towards the message while considering the individual need for autonomy in the context of an online computer-tailored alcohol reduction intervention. A 2 (autonomy-supportive language vs. controlling language) × 2 (choice vs. no choice) between-subjects experiment (N = 521) was conducted using an online computer-tailored alcohol reduction intervention. Outcome measures were perceived autonomy-support and reactance and we investigated whether an individual’s need for autonomy moderated the effect of autonomy-supportive and controlling message frames on those outcome variables. Multiple linear regression analyses showed that neither autonomy-supportive nor controlling message frames had significant effects on perceived autonomy-support or reactance, and there was no moderation from the need for autonomy. Overall, participants evaluated the intervention as positive and perceived high levels of autonomy-support, regardless of the message frame used. Future research needs to test whether the positive intervention evaluation is due to content tailoring, and whether more distinguishable manipulations of message frames could be effective.

Implementation and Evaluation of a Novel Colorectal Cancer Decision Aid Using a Centralized Delivery Strategy

BACKGROUND

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States; however, CRC screening reduces both incidence and mortality rates. Patient decision aids (DAs) are an evidence-based strategy to support patients making health-related decisions. CRC screening DAs can be unsuccessful due to provider preferences for colonoscopy and lack of effective DA implementation strategies within clinical settings.

METHODS

A hybrid implementation-effectiveness study was conducted testing the feasibility of using an existing centralized preventive health screening outreach infrastructure to implement a novel CRC DA across a health care system. Participants included primary care patients at one of three study clinics. Implementation was assessed by determining whether patients remembered receiving the DA and were aware of CRC screening options. Effectiveness was measured by comparing overall screening rates between the control and intervention groups.

RESULTS

Using a centralized delivery system was a feasible and efficient method for implementing DAs to a large academic health system. More than 90% of the intervention group remembered receiving the DA, and 80% found it helpful in their decision-making process. The DA was successful in improving CRC screening knowledge; however, overall CRC screening rates significantly decreased between the control and intervention periods (50.8% vs. 39.2%, respectively; p = 0.03).

CONCLUSION

Centralized delivery is a feasible method for DA implementation. Although DAs increase knowledge, the true effectiveness of CRC DAs in clinical settings is unknown, as a result of the number in screening tests, diversity in DA format, and the variability in dissemination and implementation practices.

Socioeconomic and ethnic inequities within organised colorectal cancer screening programmes worldwide

OBJECTIVE

Colorectal cancer (CRC) screening programmes can reduce CRC mortality. However, the implementation of a screening programme may create or exacerbate socioeconomic and ethnic health inequities if participation varies by subgroup. We determined which organised programmes characterise participation inequities by socioeconomic and ethnic subgroups, and assessed the variation in subgroup participation among programmes collecting group-specific data.

DESIGN

Employing a literature review and survey among leaders of national or regional screening programmes, this study identified published and unpublished data on participation by socioeconomic status and ethnicity. We assessed programmes offering faecal occult blood tests (FOBT) for screening. Primary outcome was screening participation rate.

RESULTS

Across 24 organised FOBT-screening programmes meeting the inclusion criteria, participation rates ranged from 21% to 73%. Most programmes (13/24, 54%) did not collect data on participation by socioeconomic status and ethnicity. Among the 11 programmes with data on participation by socioeconomic status, 90% (28/31 publications) reported lower participation among lower socioeconomic groups. Differences across socioeconomic gradients were moderate (66% vs 71%) to severe (35% vs 61%). Only six programmes reported participation results by ethnicity. Ethnic differences were moderate, though only limited data were available for evaluation.

CONCLUSIONS

Across organised CRC screening programmes worldwide, variation in participation by socioeconomic status and ethnicity is often not assessed. However, when measured, marked disparities in participation by socioeconomic status have been observed. Limited data were available to assess inequities by ethnicity. To avoid exacerbating health inequities, screening programmes should systematically monitor participation by socioeconomic status and ethnicity, and investigate and address determinants of low participation.

Colorectal cancer screening: Associations between information provision, attitudes and intended participation

OBJECTIVE

Properly informing target audiences is crucial in population-based screening programs. We aimed to evaluate the impact of information about CRC screening on attitudes and intended participation in a screening-naive population.

METHODS

614 persons (aged 55-75 years) received a survey. Information on CRC and screening was provided piece by piece, and per piece its impact on attitudes and intended participation was assessed. All persons received the same information content, but the sequence of information differed per condition: information on the high mortality rate of colorectal cancer was presented in the first or the second piece. Educational levels, the extent people considered future consequences, and value concordance between attitudes and intentions were assessed.

RESULTS

436 persons (response 71%) completed the survey. Overall most respondents reported positive attitudes towards CRC screening (78%) and intentions to participate in CRC screening (83%), independent of sequence of information provision. Intentions about participation were value concordant in the majority (88%). Results were similar in low educated groups.

CONCLUSION

Providing balanced information about CRC screening (also addressing negative effects) did not impede value concordance and high rates of intended participation.

PRACTICE IMPLICATIONS

High rates of screening intentions are possible without omitting threatening health information in communication materials.

Cultural adaptations to augment health and mental health services: a systematic review

BACKGROUND

Membership in diverse racial, ethnic, and cultural groups is often associated with inequitable health and mental health outcomes for diverse populations. Yet, little is known about how cultural adaptations of standard services affect health and mental health outcomes for service recipients. This systematic review identified extant themes in the research regarding cultural adaptations across a broad range of health and mental health services and synthesized the most rigorous experimental research available to isolate and evaluate potential efficacy gains of cultural adaptations to service delivery.

METHODS

MEDLINE, PsycINFO, CINAHL, EMBASE, and grey literature sources were searched for English-language studies published between January 1955 and January 2015. Cultural adaptations to any aspect of a service delivery were considered. Outcomes of interest included changes in service provider behavior or changes in the behavioral, medical, or self-reported experience of recipients.

RESULTS

Thirty-one studies met the inclusion criteria. The most frequently tested adaptation occurred in preventive services and consisted of modifying the content of materials or services delivered. None of the included studies focused on making changes in the provider's behavior. Many different populations were studied but most research was concerned with the experiences and outcomes of African Americans. Seventeen of the 31 retained studies observed at least one significant effect in favor of a culturally adapted service. However there were also findings that favored the control group or showed no difference. Researchers did not find consistent evidence supporting implementation of any specific type of adaptation nor increased efficacy with any particular cultural group.

CONCLUSIONS

Conceptual frameworks to classify cultural adaptations and their resultant health/mental health outcomes were developed and applied in a variety of ways. This review synthesizes the most rigorous research in the field and identifies implications for policy, practice, and research, including individualization, cost considerations, and patient or client satisfaction, among others.

Cultural challenges to engaging patients in shared decision making

OBJECTIVE

Engaging patients in their health care through shared decision-making is a priority embraced by several national and international groups. Missing from these initiatives is an understanding of the challenges involved in engaging patients from diverse backgrounds in shared decision-making. In this commentary, we summarize some of the challenges and pose points for consideration regarding how to move toward more culturally appropriate shared decision-making.

DISCUSSION

The past decade has seen repeated calls for health policies, research projects and interventions that more actively include patients in decision making. Yet research has shown that patients from different racial/ethnic and cultural backgrounds appraise their decision making process less positively than do white, U.S.-born patients who are the current demographic majority.

CONCLUSION

While preliminary conceptual frameworks have been proposed for considering the role of race/ethnicity and culture in healthcare utilization, we maintain that more foundational and empirical work is necessary. We offer recommendations for how to best involve patients early in treatment and how to maximize decision making in the way most meaningful to patients. Innovative and sustained efforts are needed to educate and train providers to communicate effectively in engaging patients in informed, shared decision-making and to provide culturally competent health care.

Effectiveness of three interventions to improve participation in colorectal cancer screening

BACKGROUND AND OBJECTIVE

Participation in colorectal cancer (CRC) screening varies widely among different countries and different socio-demographic groups. Our objective was to assess the effectiveness of three primary-care interventions to increase CRC screening participation among persons over the age of 50 years and to identify the health and socio-demographic-related factors that determine greater participation.

METHODS

We conducted a randomized experimental study with only one post-test control group. A total of 1,690 subjects were randomly distributed into four groups: written briefing; telephone briefing; an invitation to attend a group meeting; and no briefing. Subjects were evaluated 2 years post-intervention, with the outcome variable being participation in CRC screening.

RESULTS

A total of 1,129 subjects were interviewed. Within the groups, homogeneity was tested in terms of socio-demographic characteristics and health-related variables. The proportion of subjects who participated in screening was: 15.4% in the written information group (95% confidence interval [CI]: 11.2-19.7); 28.8% in the telephone information group (95% CI: 23.6-33.9); 8.1% in the face-to-face information group (95% CI: 4.5-11.7); and 5.9% in the control group (95% CI: 2.9-9.0), with this difference proving statistically significant (p < 0.001). Logistic regression showed that only interventions based on written or telephone briefing were effective. Apart from type of intervention, number of reported health problems and place of residence remained in the regression model.

CONCLUSIONS

Both written and telephone information can serve to improve participation in CRC screening. This preventive activity could be optimized by means of simple interventions coming within the scope of primary health-care professionals.

Correlates of Health Communication Preferences in a Multiethnic Population of Pregnant Women and Mothers of Young Children

BACKGROUND

As posited in multiple health communication theories, it is vital to understand modern health communication preferences among communities in order to develop tailored interventions to reduce Infant Mortality (IM). Literature suggests that health communication inequalities play an important role in infant health knowledge gaps, thus contributing to the disparate IM rates. We sought to understand preferred methods of communication among expectant or mothers of young children of varying sociodemographics. We hypothesized that methods of communication would vary by sociodemographics.

METHODS

A bilingual questionnaire, developed using community based participatory research principles was offered at pre-selected women's health agencies in the Shenandoah Valley of Virginia. Participants chose from a researched list of 22 methods of communication and also designated their "top three choices." Communication methods were compared across sociodemographics using chi-squared statistical tests.

RESULTS

A total of 292 participants completed the questionnaire at the various sites. Participants were predominantly White (60%) or Hispanic/Latina (30%), and lived in Frederick county/Winchester city (77%). Of the 22 communication methods, the five most prevalent were: talking with a healthcare provider (91%), family or friends (85-87%), using internet (84%), and handouts/booklets (80%). Communication methods most frequently chosen as a "top three choice" were: internet (46%), talking with healthcare providers (33%), and talking with family (32%). A higher preference for talking with a healthcare provider was noted among higher income individuals (100%) compared to lower income (82%; p-value=0.0062), a higher preference for call-in hotlines among Hispanic (49%) vs. non-Hispanic women (15%; p-value<0.0001), and a higher preference for placemats at fast-food restaurants among older women (42%) compared to younger (16%, p-value=0.0361).

CONCLUSION

Results suggest the incorporation of multiple methods may be a practical approach to reaching different segments of the population including those identified as most vulnerable for infant mortality.