Increasing informed uptake and non-uptake of screening: evidence from a systematic review

Finding the PSA-based screening stopping age using prostate cancer risk

BACKGROUND

Prostate Cancer screening was not rational for people who were suffered from other serious diseases and had a low quality of life. Biopsy and Prostate-Specific Antigen based screening also had imperfect information, pain, and costs. Finding the Prostate Cancer screening stopping age was important because after an age, Prostate-Specific Antigen test was not recommended and patients should not perform subsequent procedures. It could reduce the economic burden of Prostate Cancer. In this study, we modeled the effects of Prostate Cancer risk and comorbidities on the Prostate Cancer screening stopping age.

METHODS

first, using a Markov model for PC progression, we provided a model for optimal Prostate Cancer screening stopping age. Second, we explored the relationship between comorbidities effects, Prostate Cancer risk and the stopping age.

RESULTS

Our results suggest that the stopping age was an increasing function of PC risk and comorbidities effects. Screening should be stopped before 70 years. Finding showed that for men with diseases such as stroke or heart diseases, screening should not be performed at any age.

CONCLUSIONS

Personalizing PC screening through paying more attention to PC risk can improve efficiency of screening. The role of personal characteristics such as race, family history, and previous PSA in PC screening decision-making was highlighted by stratifying men in different PC risk groups to find their stopping age. Incorporating comorbidity effects shows that severity of comorbidity was a crucial factor in PC screening stopping age decision-making process.

Recruitment strategies and interventions to increase participation in lung cancer screening programmes: a systematic review protocol

INTRODUCTION

Despite strong evidence for the efficacy of low-radiation dose CT (LDCT) in reducing lung cancer (LC) mortality, implementing LC screening (LCS) programmes remains a challenge. We aim to systematically review the evidence on the strategies used to recruit the adult population at risk of LC to LDCT within LCS programmes and to estimate the effectiveness of interventions identified, used to reach the potentially eligible population, increase participation and informed choice, and ensure equitable access.

METHODS AND ANALYSIS

This sequential systematic literature review will consist of three steps: (1) a scoping review of existing strategies and organisational models for LCS; (2) selecting papers reporting relevant outcomes (test coverage, screening participation and informed choice) and comparing results among different models; (3) a systematic review of interventions implemented to increase participation in LCS programmes. Each step will follow the methodological guidelines provided by the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data sources include electronic databases such as Medline (PubMed version), Embase, CINAHL (Ebsco version), Scopus and Cochrane CENTRAL. The search will be limited to studies published from January 2000 to March 2023 in English, Italian, French, Spanish, Serbian and Croatian language. Findings will be synthesised quantitatively and qualitatively as appropriate. Risk of bias assessment will be only applied to studies selected in the second and third steps. The quality of evidence will be summarised for each outcome using the Grading Recommendation Assessment, Development and Evaluation methodology.

ETHICS AND DISSEMINATION

Given that this is a review of existing literature, ethics approval is not required. The results will be published in peer-reviewed scientific journals and presented at relevant conferences. The findings of this review will help guide health authorities in organising LCS programmes and developing recommendations, policies, and actions at national and regional levels.

PROSPERO REGISTRATION NUMBER

CRD42023408357.

Cancer Prevention Sense Making and Metaphors in Young Women’s Invented Stories

Despite the proven effectiveness of cancer prevention, the literature highlights numerous obstacles to the adoption of screening, even at a young age. In cancer discourse, the metaphor of war is omnipresent and reflects an imperative demand to win the war against disease. From the psychodynamic perspective, the risk of cancer forecasts an emotionally critical experience for which it is important to study mental representations concerning illness and health care. Through the creation of an invented story that offers a framework for imagination, our aim is to understand what the relationship with preventive practices in oncology means for young women and how this relationship is revealed by their metaphors. A total of 58 young women voluntarily participated in the present research, answering a narrative prompt. The stories written by the participants were analyzed using qualitative methodology to identify construct, themes and metaphors. Our findings identify four constructs: the construction of a defense: youth as protection; the attribution of blame about cancer risk; learning from experience as a prevention activator; and from inaccessibility to access to preventive practices: the creation of engagement. The construction of an invented story allows us to promote a process of prefiguration on the bodily, affective and thought planes invested in preventive practice and brings out the use of metaphors to represent cancer risk and self-care. The results allow us to think about the construction of interventions to promote engagement processes in prevention from an early age.

Improvements in the Effectiveness of Early Detection in Colorectal Cancer with Open-Label Randomised Study

Introduction: The general objective of this research is to improve the quality of colorectal cancer screening (CRC) by assessing, as an indicator of effectiveness, the ability of colonoscopy to detect more advanced adenomas in the exposed group than in the control group. Material and Methods: The present work is designed as an open-label randomized study on cancer screening, using two groups based on their exposure to the protocol: an exposed to intervention group (EIG, 167), and a control group (CG, 167), without the intervention of the protocol and by 1:1 matching. Results: In 167 patients in the GEI, 449 polyps are visualized and 274 are adenomas (80.58%), of which 100 (36.49%) are advanced adenomas. In the CG (n = 174), there are 321 polyps and 152 adenomas (82.60%). The variables significantly associated by logistic regression to the detection of adenomas are the male sex with an OR of 2.52. The variable time to withdrawal, ≥9 min, is significant at 99% confidence (p = 0.002/OR 34.67) and the fractional dose is significant at 99% (p = 0.009, OR 7.81). Conclusion: Based on the observations made, our study suggests that the intervention in collaboration between primary care and hospital care is effective from a preventive point of view and achieves the objective of effectiveness and quality of the PCCR.

Next-Generation Sequencing in Newborn Screening: A Review of Current State

Newborn screening was first introduced at the beginning of the 1960s with the successful implementation of the first phenylketonuria screening programs. Early expansion of the included disorders was slow because each additional disorder screened required a separate test. Subsequently, the technological advancements of biochemical methodology enabled the scaling-up of newborn screening, most notably with the implementation of tandem mass spectrometry. In recent years, we have witnessed a remarkable progression of high-throughput sequencing technologies, which has resulted in a continuous decrease of both cost and time required for genetic analysis. This has enabled more widespread use of the massive multiparallel sequencing. Genomic sequencing is now frequently used in clinical applications, and its implementation in newborn screening has been intensively advocated. The expansion of newborn screening has raised many clinical, ethical, legal, psychological, sociological, and technological concerns over time. This review provides an overview of the current state of next-generation sequencing regarding newborn screening including current recommendations and potential challenges for the use of such technologies in newborn screening.

"I wish that there was more info": characterizing the uncertainty experienced by carriers of pathogenic ATM and/or CHEK2 variants

Little is known about what uncertainties patients experience after being identified to carry a pathogenic variant in a moderate-risk cancer gene as a result of undergoing multigene panel testing for cancer susceptibility. Data regarding cancer risk estimates and effectiveness of risk management strategies for these variants continues to evolve, which has the potential to evoke uncertainty. Acknowledging uncertainty during pre- and post-test discussions is imperative to helping individuals to adapt to their results. A better understanding of this population's experience of uncertainty is needed to facilitate such discussions and is the aim of the current study. Semi-structured interviews (30-60 min in length), informed by Han and colleagues' taxonomy of uncertainty in clinical genomic sequencing, were conducted to assess motivations to pursue genetic testing, areas of perceived uncertainty, and strategies for managing uncertainty among 20 carriers of pathogenic variants in two moderate-risk genes, ATM and CHEK2. We found that participants pursue genetic testing with the expectation that results will clarify cancer risks and approaches to management. Participants experience uncertainties aligning with Han's taxonomy relating to the ambiguity of specific cancer risk estimates and effectiveness of certain risk management strategies. These uncertainties influenced decisions around the uptake of risk management strategies, which were additionally impacted by clinicians' uncertainty towards such strategies. Participants employ a variety of uncertainty management approaches to cope with their anxieties. Clinicians may wish to use these findings to facilitate patient adaptation to the implications of multigene panel testing for cancer susceptibility during both pre- and post-test counseling sessions.

Randomised controlled trial comparing uptake of NHS Health Check in response to standard letters, risk-personalised letters and telephone invitations

Background

NHS Health Check is a primary prevention programme offering cardiovascular disease (CVD) risk assessment to adults in England aged 40–74. Uptake remains a challenge and invitation method is a strong predictor of uptake. There is evidence of low uptake when using invitation letters. Telephone invitations might increase uptake, but are not widely used. We explored the potential to improve uptake through personalising letters to patient’s CVD risk, and to compare this with generic letters and telephone invitations.

Methods

HEalth Check TRial (HECTR) was a three-arm randomised controlled trial in nine general practices in Staffordshire (UK). Eligible patients were randomised to be invited to a NHS Health Check using one of three methods: standard letter (control); telephone invitation; letter personalised to the patient’s CVD risk. The primary outcome was attendance/non-attendance. Data were collected on a range of patient- and practice-level factors (e.g., patient socio-demographics, CVD risk, practice size, Health Checks outside usual working hours). Multi-level logistic regression estimated the marginal effects to explore whether invitation method predicted attendance. Invitation costs were collated from practices to estimate cost benefit.

Results

In total, 4614 patients were included in analysis (mean age 50.2 ± 8.0 yr.; 52.4% female). Compared with patients invited by standard letter (30.9%), uptake was significantly higher in those invited by telephone (47.6%, P < .001), but not personalised letter (31.3%, p = .812). In multi-level analysis, compared with the standard letter arm, likelihood of attendance was 18 percentage points higher in the telephone arm and 4 percentage points higher in the personalised letter arm. The effect of telephone calls appeared strongest in patients who were younger and had lower CVD risk. We estimated per 1000 patients invited, risk-personalised letters could result in 40 additional attended Health Checks (at no extra cost) and telephone invitations could result in 180 additional Health Checks at an additional cost of £240.

Conclusions

Telephone invitations should be advocated to address the substantial deficit between current and required levels of NHS uptake, and could be targeted at younger and lower CVD risk adults. Risk-personalised letters should be explored further in a larger sample of high risk individuals.

Trial registration

Registration number: ISRCTN15840751 date of registration: 24/10/2017.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6540-8) contains supplementary material, which is available to authorized users.

An Individualized Approach to Cancer Screening Decisions in Older Adults: A Multilevel Framework

Guidelines for optimal cancer screening in older adults remain unclear, particularly for adults over the age of 75. While cancer screening in older adults may benefit some in good health, it may cause unnecessary burdens in others with limited life expectancy. Thus, a systematic approach to enable individualized cancer screening decisions in older adults is needed. We suggest a framework that guides such decisions through evidence-based approaches from multiple interactions, and that involves the patient, clinician, and healthcare system. An individualized approach considers differences in disease risk rather than the chronological age of the patient. This paper presents a comprehensive framework that depicts the independent and converging levels of influences on individualized cancer screening decisions in older adults. This Individualized Decisions for Screening (IDS) framework recognizes the reality of these interrelationships, including the tensions that arise when behaviors and outcomes are valued differently at the patient, clinician, and healthcare organization levels. Person-centered approaches are essential to advancing multilevel research of individualized cancer screening decisions among older adults.

Whole-genome sequencing in newborn screening? A statement on the continued importance of targeted approaches in newborn screening programmes

The advent and refinement of sequencing technologies has resulted in a decrease in both the cost and time needed to generate data on the entire sequence of the human genome. This has increased the accessibility of using whole-genome sequencing and whole-exome sequencing approaches for analysis in both the research and clinical contexts. The expectation is that more services based on these and other high-throughput technologies will become available to patients and the wider population. Some authors predict that sequencing will be performed once in a lifetime, namely, shortly after birth. The Public and Professional Policy Committee of the European Society of Human Genetics, the Human Genome Organisation Committee on Ethics, Law and Society, the PHG Foundation and the P3G International Paediatric Platform address herein the important issues and challenges surrounding the potential use of sequencing technologies in publicly funded newborn screening (NBS) programmes. This statement presents the relevant issues and culminates in a set of recommendations to help inform and guide scientists and clinicians, as well as policy makers regarding the necessary considerations for the use of genome sequencing technologies and approaches in NBS programmes. The primary objective of NBS should be the targeted analysis and identification of gene variants conferring a high risk of preventable or treatable conditions, for which treatment has to start in the newborn period or in early childhood.

The expanding role of primary care in cancer control

The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise—from epidemiologists, psychologists, policy makers, and cancer specialists—has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.

Effectiveness of three interventions in improving adherence to cervical cancer screening

In countries where cervical cancer screening programmes are conducted on an opportunistic basis, an active search for women at risk should be made to increase coverage. The objective of our study was to assess the effectiveness of three primary care interventions consisting of providing written, telephone and face-to-face information to increase screening participation among women over the age of 25 years. A randomized experimental study with only one post-test control group was conducted on women aged 25-70 years. A total of 1676 women were randomly distributed into four groups and the following interventions were implemented: written briefing; telephone briefing; an invitation to attend a group meeting and no briefing (control group). The women were evaluated 2 years after the intervention. The outcome variable was participation or nonparticipation in cervical cancer screening. It proved possible to interview a total of 1122 women. Among the groups, homogeneity was tested in terms of sociodemographic characteristics and health-related variables. Women who had undergone cytological testing in the 2 years preceding evaluation had a lower mean age (P<0.001) than women who had not done so (45.5±11.0 vs. 48.8±13.0 years). The proportion of women who had participated in screening was as follows: 35.3% in the written information group [95% confidence interval (CI) 29.8-40.9]; 38.4% in the telephone information group (95% CI 32.5-44.2); 29.3% in the face-to-face information group (95% CI 22.8-35.7) and 26.1% in the control group (95% CI 21.2-30.9), with this difference proving statistically significant (P=0.005). Logistic regression showed that only the interventions based on written or telephone briefing were effective vis-à-vis the control group. In conclusion, both written and telephone information can serve to improve women's participation in opportunistic cervical cancer screening. Current preventive strategies could be optimized by means of simple interventions within the scope of health professionals.

A qualitative investigation of non-response in NHS health checks

Background

Improving uptake of NHS Health Checks has become a priority in England, but there is a lack of data on the perceptions of programme non-attenders. This study aimed to explore how non-attenders of NHS Health Checks perceive the programme, identify reasons for non-attendance and inform strategies to improve uptake.

Method

This qualitative study involved individuals registered at four general practices in Stoke-on-Trent, UK, who had not taken up their invitation to a NHS Health Check. Semi-structured face-to-face and telephone interviews were audio-recorded and transcribed verbatim for Thematic Analysis.

Results

Interviews were completed with 19 males and 22 females (mean age 52.9 ± 8.5 years), who were socio-demographically representative of the non-attender population. Four main themes identified related to: the positive perception of the Health Check concept among non-attenders; the perceived lack of personal relevance; ineffective invitation method and appointment inconvenience were common barriers; previous experience of primary care can influence uptake.

Conclusions

Fundamental requirements for improving uptake are that individuals recognise the personal relevance of Health Checks and that attendance is convenient. Incorporating more sophisticated and personalised risk communication as part of the invitation could increase impact and promote candidacy. Flexibility and convenience of appointments should be considered by participating general practices.

Considering consent: a structural equation modelling analysis of factors influencing decisional quality when accepting newborn screening

INTRODUCTION

Newborn bloodspot screening (NBS) programs generate an ethical tension between promoting the uptake of effective public health measures and facilitating informed consent from individuals.

AIM

To explore the factors that affect parental perceptions of decision quality when accepting NBS METHODS: Survey of parents with children screened in 2008 (n = 154, 32% response rate). Questions were based on previous research and existing measures. The primary outcome was decision quality. Predictors were latent constructs of Attitudes to medicine, Perceived knowledge, Attitudes to screening, and Perceived choice. Responses were analysed using structural equation modelling.

RESULTS

Increases in perceived choice and positive attitudes towards screening improved decision quality. Perceived knowledge had a significant and positive relationship with attitudes to screening (0.375, p < 0.01) as did perceived choice on perceived knowledge (0.806, p < 0.01). Attitudes to screening were also significantly influenced by attitudes to medicine, although less so than the effect of perceived knowledge. The model had good fit on all indices (χ(2) = 61.396, df = 48, p = 0.093; CFI = 0.979; RMSEA = 0.043).

CONCLUSIONS

Our results implicate the presentation of screening as a key determinant of decision quality both in terms of the immediate information regarding the potential benefits and risks, but also the way in which consent processes are managed. If we want to better understand parent decision-making we need to go beyond analyses of information content, or parental recall of this, but consider the context in which screening is provided.

Parental decision-making and acceptance of newborn bloodspot screening: an exploratory study

Objective

Newborn bloodspot screening is an internationally established public health measure. Despite this, there is a paucity of information relating to the decision-making process that parents go through when accepting newborn screening. This is important as screening panels are expanding; potentially leading to an increasing amount of complex information. This study sought to understand the factors that influence parental decisions and roles they play in the decision-making process.

Patients and Methods

Qualitative thematic evaluation of semi structured interviews with parents whose children had recently undergone newborn screening in the Merseyside and Cheshire region of England, UK.

Results

Eighteen interviews with first time parents (n = 12) and those with previous children (n = 6). Seven factors were identified as being either explicitly or implicitly related to parental decision-making: Experience, Attitudes to medicine, Information-seeking behaviour, Perceived knowledge, Attitudes to screening, and Perceived choice, all of which ultimately impact on Perceived decisional quality.

Conclusions

These results indicate that while content is important, other contextual factors such as personal experience, perceived choice, and general attitudes toward medicine, are also highly influential. In particular, relationships with key healthcare professionals are central to information collection, attitudes toward screening, and the level of deliberation that is invested in decisions to accept newborn bloodspot screening.

National evidence on the use of shared decision making in prostate-specific antigen screening

PURPOSE

Recent clinical practice guidelines on prostate cancer screening using the prostate-specific antigen (PSA) test (PSA screening) have recommended that clinicians practice shared decision making-a process involving clinician-patient discussion of the pros, cons, and uncertainties of screening. We undertook a study to determine the prevalence of shared decision making in both PSA screening and nonscreening, as well as patient characteristics associated with shared decision making.

METHODS

A nationally representative sample of 3,427 men aged 50 to 74 years participating in the 2010 National Health Interview Survey responded to questions on the extent of shared decision making (past physician-patient discussion of advantages, disadvantages, and scientific uncertainty associated with PSA screening), PSA screening intensity (tests in past 5 years), and sociodemographic and health-related characteristics.

RESULTS

Nearly two-thirds (64.3%) of men reported no past physician-patient discussion of advantages, disadvantages, or scientific uncertainty (no shared decision making); 27.8% reported discussion of 1 to 2 elements only (partial shared decision making); 8.0% reported discussion of all 3 elements (full shared decision making). Nearly one-half (44.2%) reported no PSA screening, 27.8% reported low-intensity (less-than-annual) screening, and 25.1% reported high-intensity (nearly annual) screening. Absence of shared decision making was more prevalent in men who were not screened; 88% (95% CI, 86.2%-90.1%) of nonscreened men reported no shared decision making compared with 39% (95% CI, 35.0%-43.3%) of men undergoing high-intensity screening. Extent of shared decision making was associated with black race, Hispanic ethnicity, higher education, health insurance, and physician recommendation. Screening intensity was associated with older age, higher education, usual source of medical care, and physician recommendation, as well as with partial vs no or full shared decision making.

CONCLUSIONS

Most US men report little shared decision making in PSA screening, and the lack of shared decision making is more prevalent in nonscreened than in screened men. Screening intensity is greatest with partial shared decision making, and different elements of shared decision making are associated with distinct patient characteristics. Shared decision making needs to be improved in decisions for and against PSA screening.

Enhancing informed choice to undergo health screening: a systematic review

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evaluation of Informed Choice for contraceptive methods among women attending a family planning program: conceptual development; a case study in Chile

OBJECTIVE

To generate and validate a scale to measure the Informed Choice of contraceptive methods among women attending a family health care service in Chile.

STUDY DESIGN AND SETTING

The study follows a multimethod design that combined expert opinions from 13 physicians, 3 focus groups of 21 women each, and a sample survey of 1,446 women. Data analysis consisted of a qualitative text analysis of group interviews, a factor analysis for construct validity, and kappa statistic and Cronbach alpha to assess scale reliability.

RESULTS

The instrument comprises 25 items grouped into six categories: information and orientation, quality of treatment, communication, participation in decision making, expression of reproductive rights, and method access and availability. Internal consistency measured with Cronbach alpha ranged from 0.75 to 0.89 for all subscales (kappa, 0.62; standard deviation, 0.06), and construct validity was demonstrated from the testing of several hypotheses.

CONCLUSIONS

The use of mixed methods contributed to developing a scale of Informed Choice that was culturally appropriate for assessing the women who participated in the family planning program.

Decision Support and the Effectiveness of Web-based Delivery and Information Tailoring for Bowel Cancer Screening: An Exploratory Study

Background

Colorectal cancer (CRC) is the third most commonly diagnosed cancer in males and the second in females throughout the developed world. Population screening using fecal occult blood tests (FOBTs) facilitates early detection and greater chance of survival, but participation rates are low. We developed a Web-based decision tool to provide information tailored to an individual’s decision stage for CRC screening and attitude toward screening utilizing the Preventive Health Model (PHM) and Precaution Adoption Process Model (PAPM) as theoretical frameworks for screening behavior. We describe the practical steps employed in the tool’s design and the subsequent conduct of an exploratory study.

Objective

To design a decision tool for CRC screening and conduct an exploratory study among average-risk men and women to (1) test the impact of message type (tailored vs non-tailored) and message delivery modality (Web-based vs paper-based) on attitudes toward screening and screening uptake, and (2) investigate the acceptability of the decision tool and relevance of materials.

Methods

Participants (n = 100), recruited from a population sample of men and women aged 50-76 residing in urban Adelaide, Australia, were randomly assigned to a control group or one of 4 interventions: (1) Web-based and tailored information, (2) paper-based and tailored information, (3) Web-based and non-tailored (generic) information, or (4) paper-based and non-tailored information. Participation was augmented by snowball recruitment (n = 19). Questionnaires based on PHM variables were administered pre- and post-intervention. Participants were given the opportunity to request an FOBT. Following the intervention, participants discussed the acceptability of the tool.

Results

Full data were available for 87.4% (104/119) of participants. Post-intervention, perceived susceptibility scores for individuals receiving tailored information increased from mean 10.6 (SD 2.1) to mean 11.8 (SD 2.2). Scores on self-efficacy increased in the tailored group from mean 11.7 (SD 2.0) to mean 12.6 (SD 1.8). There were significant time x modality x message effects for social influence and salience and coherence, reflecting an increase in these scores for tailored Web-based participants only; social influence scores increased from mean 11.7 (SD 2.6) to mean 14.9 (SD 2.3), and salience and coherence scores increased from mean 16.0 (SD 2.2) to mean 17.7 (SD 2.1). There was no greater influence of modality or message type on movement toward a decision to screen or screening uptake, indicating that neither tailored messages nor a Web modality had superior effect. Overall, participants regarded tailored messages positively, but thought that the Web tool lacked “media richness.”

Conclusions

This exploratory study confirms that tailoring on PHM predictors of CRC screening has the potential to positively address attitudes toward screening. However, tailoring on these variables did not result in significantly increased screening uptake. Future research should consider other possible psychosocial influences. Mode of delivery did not affect outcomes, but as a delivery medium, the Web has economic and logistical advantages over paper.

The impact of different communication and organizational strategies on mammography screening uptake in women aged 40-45 years

BACKGROUND

Several factors can influence access to population breast cancer screening. The aim of the study was to evaluate the impact of different information approaches, women's socio-demographic characteristics and organizational factors on mammography screening uptake.

METHODS

We selected 5744 women aged 40-45 years who were randomly assigned to be given letters with: (i) a pre-fixed appointment plus standard leaflet (Group 1); (ii) a pre-fixed appointment plus a more comprehensive booklet (Group 2); (iii) point (ii) plus the offer of a counselling session (Group 3); and (iv) an invitation to contact the centre to get information and arrange participation (Group 4).

RESULTS

Ninety-five women were excluded before the invitation and 5649 were randomized. After excluding undelivered letters (n = 41) and women reporting an exclusion criterion following our invitation (n = 248), the final eligible population was 5360 women. Participation rates following the first contact were 36.5, 39.9, 35.8 and 16.5% for Groups 1-4, respectively. The rates increased to 40.9, 43.6, 40.1 and 35.1% after the reminder letters. Women receiving more complete information had a higher uptake (Group 2), although not statistically significant. Differences among the four groups were maintained by controlling the effect of socio-demographic and attendance determinants. Regardless of intervention, participation was higher among married, higher educated, white-collared women, those born in northern Italy, living closer to the screening unit and with a female-collaborative doctor.

CONCLUSION

Invitation letters with a fixed appointment correlate with a higher attendance rate. Providing women with more information on procedures, risks and benefits of mammography screening does not modify their participation.

Impact of informed-choice invitations on diabetes screening knowledge, attitude and intentions: an analogue study

Background

Despite concerns that facilitating informed choice would decrease diabetes screening uptake, 'informed choice' invitations that increased knowledge did not affect attendance (the DICISION trial). We explored possible reasons using data from an experimental analogue study undertaken to develop the invitations. We tested a model of the impact on knowledge, attitude and intentions of a diabetes screening invitation designed to facilitate informed choices.

Methods

417 men and women aged 40-69 recruited from town centres in the UK were randomised to receive either an invitation for diabetes screening designed to facilitate informed choice or a standard type of invitation. Knowledge of the invitation, attitude towards diabetes screening, and intention to attend for diabetes screening were assessed two weeks later.

Results

Attitude was a strong predictor of screening intentions (β = .64, p = .001). Knowledge added to the model but was a weak predictor of intentions (β = .13, p = .005). However, invitation type did not predict attitudes towards screening but did predict knowledge (β = -.45, p = .001), which mediated a small effect of invitation type on intention (indirect β = -.06, p = .017).

Conclusions

These findings may explain why information about the benefits and harms of screening did not reduce diabetes screening attendance in the DICISION trial.

Helping women make choices about mammography screening: an online randomized trial of a decision aid for 40-year-old women

OBJECTIVE

To evaluate the effect of a decision aid (DA) on women's knowledge of the benefits and harms of screening and on their ability to make an informed decision.

METHODS

An online randomized controlled trial among 321 women aged 38-45 years was conducted. Participants were randomized to either immediate or delayed access to the online DA which (i) explained the benefits and harms, (ii) included a values clarification exercise and a worksheet to support decision making. The primary outcome, knowledge of benefits and harms of screening, and secondary outcomes, informed choice (composite of knowledge, values and intention), anxiety and acceptability of the DA were measured using online questionnaires.

RESULTS

Women in the intervention group were more knowledgeable (mean score out of 10, 7.35 vs 6.27, p<0.001) and were more likely to have made a decision (82% vs 61% p<0.001). Of those who made a decision, women in the intervention group were less likely to start screening now (52% vs 65% p=0.05). There was no significant difference in the proportion of women who made an informed choice (71% intervention group vs 64% control group, p=0.24). The DA was helpful, balanced and clear, and did not make women anxious.

CONCLUSIONS

The DA increased knowledge and reduced indecision, without increasing feelings of anxiety.

PRACTICE IMPLICATIONS

This decision aid is easy to access online and could be an inexpensive way of supporting women aged 40 who are considering whether to start screening now, or wait until they are 50. The results of this study demonstrate the potential of DAs to help inform women about both the benefits and risks of screening at this age and to support women and clinicians in this decision making process.

Impact of information about risks and benefits of cancer screening on intended participation

BACKGROUND

Providing comprehensive information about the risks and benefits of cancer screening is ethically necessary, but information about risks may decrease participation. This study explored the impact of information on intended participation using a randomised factorial design.

METHODS

We conducted a mail survey of 2333 adults living in Geneva, Switzerland. Each participant was given one randomly chosen version of a scenario that described a hypothetical cancer screening test, and was asked whether he or she would accept to undergo screening. The versions varied in terms of the amount of information about risks and benefits.

RESULTS

Respondents who received information about risks associated with screening were more likely to refuse participation (odds ratio 2.6 (95% confidence interval (CI) 2.0-3.5)) than those who received minimal information. In contrast, information about benefits had no impact on intended participation (odds ratio 1.0 (95% CI 0.8-1.2)). The impact of information about risks was significantly stronger in women than in men, in respondents who were in poorer health, who have had a doctor visit in the past 6months, those who have had a cancer screening test in the past 3years, and those who reported a high desire for autonomy in medical decisions.

CONCLUSIONS

Informing potential participants about the risks of screening may reduce participation rates. Enhanced information about the benefits of screening does not counterbalance this effect.

Aversion to ambiguity regarding medical tests and treatments: measurement, prevalence, and relationship to sociodemographic factors

Aversion to "ambiguity"-uncertainty about the reliability, credibility, or adequacy of risk-related information-is an important problem that may influence judgments and decisions about medical interventions. Ambiguity aversion (AA) varies among individuals, however, and has been understudied in the health domain. To explore this phenomenon further, we developed a new theory-based measure of aversion to ambiguity regarding medical tests and treatments, and examined the prevalence and association of AA with sociodemographic factors. The "AA-Med" scale was developed using a large survey sample of the U.S. public (n = 4,398), and scale psychometric properties and the population distribution of AA were evaluated. The scale demonstrated acceptable reliability (alpha = .73) and validity as ascertained by association with respondents' interest in a hypothetical ambiguous cancer screening test. Ambiguity aversion (AA) was associated with older age, non-White race, lower education and income, and female sex. The AA-Med scale is a promising new measure, and AA is associated with several sociodemographic factors. We discuss implications of these findings and potential applications of the scale for future research.

Laypersons' responses to the communication of uncertainty regarding cancer risk estimates

OBJECTIVE

To explore laypersons' responses to the communication of uncertainty associated with individualized cancer risk estimates and to identify reasons for individual differences in these responses.

DESIGN

A qualitative study was conducted using focus groups. Participants were informed about a new colorectal cancer risk prediction model, and presented with hypothetical individualized risk estimates using presentation formats varying in expressed uncertainty (range v. point estimate). Semistructured interviews explored participants' responses to this information.

PARTICIPANTS AND SETTING

Eight focus groups were conducted with 48 adults aged 50 to 74 residing in 2 major US metropolitan areas, Chicago, IL and Washington, DC. Purposive sampling was used to recruit participants with a high school or greater education, some familiarity with information technology, and no personal or immediate family history of cancer.

RESULTS

Participants identified several sources of uncertainty regarding cancer risk estimates, including missing data, limitations in accuracy and source credibility, and conflicting information. In comparing presentation formats, most participants reported greater worry and perceived risk with the range than with the point estimate, consistent with the phenomenon of "ambiguity aversion.'' However, others reported the opposite effect or else indifference between formats. Reasons suggested by participants' responses included individual differences in optimism and motivations to reduce feelings of vulnerability and personal lack of control. Perceptions of source credibility and risk mutability emerged as potential mediating factors.

CONCLUSIONS

Laypersons' responses to the communication of uncertainty regarding cancer risk estimates differ, and include both heightened and diminished risk perceptions. These differences may be attributable to personality, cognitive, and motivational factors.

Informed decision making before initiating screening mammography: does it occur and does it make a difference?

OBJECTIVE

Informed decision making regarding screening mammography is recommended for women under age 50. To what extent it occurs in clinical settings is unclear.

METHODS

Using a mailed instrument, we surveyed women aged 40-44 prior to their first screening mammogram. All women were members of a large health maintenance organization and received care at a large medical practice in the Greater Boston area. The survey measured informed decision making, decisional conflict, satisfaction, and screening mammography knowledge and intentions to undergo screening.

RESULTS

Ninety-six women responded to the survey (response rate 47%). Overall, women reported limited informed decision making regarding screening mammography, both with respect to information exchange and involvement in the decision process. Less than half (47%) reported discussing the benefits of screening; 23% the uncertainties; and only 7% the harms. About 30% reported discussing the nature of the decision or clinical issue; and 29% reported their provider elicited their preferred role in the decision; 38% their preferences; and 24% their understanding of the information. Women who were uninformed had higher decisional conflict (2.37 vs. 1.83, P=0.005) about screening mammography and were more likely to be dissatisfied with the information and involvement. Women's screening mammography knowledge was limited in most areas; however being presented with information did not diminish their intentions to undergo screening.

CONCLUSION

Informed decision making before initiating screening mammography is limited in this setting. There appears to be little indication that information about the benefits and harms decreases women's intentions to undergo screening. Methods to communicate information to women before initiating screening mammography are needed.

Effectiveness of Decision Aids

Increased interest in health care consumerism has created an environment conducive to growth in the use of decision aids (DAs) to support patient decision making. The authors review the research literature published within the past 5 years that assesses the effects of DAs in the areas of screening and treatment. Multiple measures are used to evaluate the effectiveness of DAs, with mixed evidence of impacts. To date, most evidence from screening studies suggests that DAs are effective in increasing knowledge and are acceptable to patients, but patient uptake of screening has been mixed. Among treatment studies, there is some, but limited, evidence showing impact of DAs on immediate and long-term decisional conflict, patient satisfaction, and quality of life. Few studies provide assessment of impact on health outcomes, quality of care, utilization, or costs, all areas likely to be of growing interest to private purchasers, insurers, and public programs.

A systematic review of decision support needs of parents making child health decisions

OBJECTIVE

To identify the decision support needs of parents attempting to make an informed health decision on behalf of a child.

CONTEXT

The first step towards implementing patient decision support is to assess patients' information and decision-making needs.

SEARCH STRATEGY

A systematic search of key bibliographic databases for decision support studies was performed in 2005. Reference lists of relevant review articles and key authors were searched. Three relevant journals were hand searched.

INCLUSION CRITERIA

Non-intervention studies containing data on decision support needs of parents making child health decisions.

DATA EXTRACTION AND SYNTHESIS

Data were extracted on study characteristics, decision focus and decision support needs. Studies were quality assessed using a pre-defined set of criteria. Data synthesis used the UK Evidence for Policy and Practice Information and Co-ordinating Centre approach.

MAIN RESULTS

One-hundred and forty nine studies were included across various child health decisions, settings and study designs. Thematic analysis of decision support needs indicated three key issues: (i) information (including suggestions about the content, delivery, source, timing); (ii) talking to others (including concerns about pressure from others); and (iii) feeling a sense of control over the process that could be influenced by emotionally charged decisions, the consultation process, and structural or service barriers. These were consistent across decision type, study design and whether or not the study focused on informed decision making.

Improving the quality of communication in organised cervical cancer screening programmes

OBJECTIVE

To provide health professionals involved in cervical cancer screening with an insight into the complex issues relating to communication about screening and to provide a framework for a more effective communication strategy.

METHODS

This paper has been compiled by a multidisciplinary pan-European group of health professionals and cancer advocates from several European screening programmes. European surveys on screening communication, literature reviews and group discussion were used for this purpose.

RESULTS

Information on cervical screening must be accessible, relevant, comprehensible, comprehensive, client-centred, phase-specific and multilevel. An effective communication strategy should consider health professionals' screening knowledge and their communication skills, consumers' health literacy skills and the communication needs of specific sub-groups in the target population. Co-operation between screening professionals, advocacy groups and journalists should be promoted.

CONCLUSION

To communicate effectively and appropriately is a complex task which can be influenced by a number of factors. Screening workers need better information themselves and must take into account the needs and characteristics of the target population.

PRACTICE IMPLICATIONS

This document should provide a useful tool to help screening professionals in designing and developing good quality and effective communication strategies.

Nonattendance in a cervical cancer screening program - what happens if women's requirements are met?

In this study we focus on women who have no registered cervical smear during the previous 5 years, their requirements for attendance, and promotive efforts performed. Of the 400 women randomly selected to answer a telephone-based questionnaire about future attendance at cervical cancer screening (CCS), 120 would consider having a cervical smear taken, and 50 of them wanted help to accomplish that. When meeting the women's requirements, such as being assured friendly treatment and a suitable appointment time, the numbers of registered cervical smears were higher for the study group compared with a control group. Still, the most highly resistant women did not attend.

Should a colon cancer screening decision aid include the option of no testing? A comparative trial of two decision aids

Background

An important question in the development of decision aids about colon cancer (CRC) screening is whether to include an explicit discussion of the option of not being screened. We examined the effect of including or not including an explicit discussion of the option of deciding not to be screened in a CRC screening decision aid on subjective measures of decision aid content; interest in screening; and knowledge.

Methods

Adults ages 50–85 were assigned to view one of two versions of the decision aid. The two versions differed only in the inclusion of video segments of two men, one of whom decided against being screened. Participants completed questionnaires before and after viewing the decision aid to compare subjective measures of content, screening interest and intent, and knowledge between groups. Likert response categories (5-point) were used for subjective measures of content (eg. clarity, balance in favor/against screening, and overall rating), and screening interest. Knowledge was measured with a three item index and individual questions. Higher scores indicated favorable responses for subjective measures, greater interest, and better knowledge. For the subjective balance, lower numbers were associated with the impression of the decision aid favoring CRC screening.

Results

57 viewed the "with" version which included the two segments and 49 viewed the "without" version. After viewing, participants found the "without" version to have better subjective clarity about benefits of screening ("with" 3.4, "without" 4.1, p < 0.01), and to have greater clarity about downsides of screening ("with" 3.2, "without" 3.6, p = 0.03). The "with" version was considered to be less strongly balanced in favor of screening. ("with" 1.8, "without" 1.6, p = 0.05); but the "without" version received a better overall rating ("with" 3.5, "without" 3.8, p = 0.03). Groups did not differ in screening interest after viewing a decision aid or knowledge.

Conclusion

A decision aid with the explicit discussion of the option of deciding not to be screened appears to increase the impression that the program was not as strongly in favor of screening, but decreases the impression of clarity and resulted in a lower overall rating. We did not observe clinically important or statistically significant differences in interest in screening or knowledge.

The effect of offering different numbers of colorectal cancer screening test options in a decision aid: a pilot randomized trial

Background

Decision aids can improve decision making processes, but the amount and type of information that they should attempt to communicate is controversial. We sought to compare, in a pilot randomized trial, two colorectal cancer (CRC) screening decision aids that differed in the number of screening options presented.

Methods

Adults ages 48–75 not currently up to date with screening were recruited from the community and randomized to view one of two versions of our previously tested CRC screening decision aid. The first version included five screening options: fecal occult blood test (FOBT), sigmoidoscopy, a combination of FOBT and sigmoidoscopy, colonoscopy, and barium enema. The second discussed only the two most frequently selected screening options, FOBT and colonoscopy. Main outcomes were differences in screening interest and test preferences between groups after decision aid viewing. Patient test preference was elicited first without any associated out-of-pocket costs (OPC), and then with the following costs: FOBT-$10, sigmoidoscopy-$50, barium enema-$50, and colonoscopy-$200.

Results

62 adults participated: 25 viewed the 5-option decision aid, and 37 viewed the 2-option version. Mean age was 54 (range 48–72), 58% were women, 71% were White, 24% African-American; 58% had completed at least a 4-year college degree. Comparing participants that viewed the 5-option version with participants who viewed the 2-option version, there were no differences in screening interest after viewing (1.8 vs. 1.9, t-test p = 0.76). Those viewing the 2-option version were somewhat more likely to choose colonoscopy than those viewing the 5-option version when no out of pocket costs were assumed (68% vs. 46%, p = 0.11), but not when such costs were imposed (41% vs. 42%, p = 1.00).

Conclusion

The number of screening options available does not appear to have a large effect on interest in colorectal cancer screening. The effect of offering differing numbers of options may affect test choice when out-of-pocket costs are not considered.

Audio-visual presentation of information for informed consent for participation in clinical trials

BACKGROUND

Informed consent is a critical component of clinical research. Different methods of presenting information to potential participants of clinical trials may improve the informed consent process. Audio-visual interventions (presented for example on the Internet, DVD, or video cassette) are one such method.

OBJECTIVES

To assess the effects of providing audio-visual information alone, or in conjunction with standard forms of information provision, to potential clinical trial participants in the informed consent process, in terms of their satisfaction, understanding and recall of information about the study, level of anxiety and their decision whether or not to participate.

SEARCH STRATEGY

We searched: the Cochrane Consumers and Communication Review Group Specialised Register (searched 20 June 2006); the Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library, issue 2, 2006; MEDLINE (Ovid) (1966 to June week 1 2006); EMBASE (Ovid) (1988 to 2006 week 24); and other databases. We also searched reference lists of included studies and relevant review articles, and contacted study authors and experts. There were no language restrictions.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing audio-visual information alone, or in conjunction with standard forms of information provision (such as written or oral information as usually employed in the particular service setting), with standard forms of information provision alone, in the informed consent process for clinical trials. Trials involved individuals or their guardians asked to participate in a real (not hypothetical) clinical study.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion and extracted data. Due to heterogeneity no meta-analysis was possible; we present the findings in a narrative review.

MAIN RESULTS

We included 4 trials involving data from 511 people. Studies were set in the USA and Canada. Three were randomised controlled trials (RCTs) and the fourth a quasi-randomised trial. Their quality was mixed and results should be interpreted with caution. Considerable uncertainty remains about the effects of audio-visual interventions, compared with standard forms of information provision (such as written or oral information normally used in the particular setting), for use in the process of obtaining informed consent for clinical trials. Audio-visual interventions did not consistently increase participants' levels of knowledge/understanding (assessed in four studies), although one study showed better retention of knowledge amongst intervention recipients. An audio-visual intervention may transiently increase people's willingness to participate in trials (one study), but this was not sustained at two to four weeks post-intervention. Perceived worth of the trial did not appear to be influenced by an audio-visual intervention (one study), but another study suggested that the quality of information disclosed may be enhanced by an audio-visual intervention. Many relevant outcomes including harms were not measured. The heterogeneity in results may reflect the differences in intervention design, content and delivery, the populations studied and the diverse methods of outcome assessment in included studies.

AUTHORS' CONCLUSIONS

The value of audio-visual interventions for people considering participating in clinical trials remains unclear. Evidence is mixed as to whether audio-visual interventions enhance people's knowledge of the trial they are considering entering, and/or the health condition the trial is designed to address; one study showed improved retention of knowledge amongst intervention recipients. The intervention may also have small positive effects on the quality of information disclosed, and may increase willingness to participate in the short-term; however the evidence is weak. There were no data for several primary outcomes, including harms. In the absence of clear results, triallists should continue to explore innovative methods of providing information to potential trial participants. Further research should take the form of high-quality randomised controlled trials, with clear reporting of methods. Studies should conduct content assessment of audio-visual and other innovative interventions for people of differing levels of understanding and education; also for different age and cultural groups. Researchers should assess systematically the effects of different intervention components and delivery characteristics, and should involve consumers in intervention development. Studies should assess additional outcomes relevant to individuals' decisional capacity, using validated tools, including satisfaction; anxiety; and adherence to the subsequent trial protocol.

Perceived ambiguity about cancer prevention recommendations: associations with cancer-related perceptions and behaviours in a US population survey

BACKGROUND

Health information reaching the public today is often characterized by what decision theorists have termed 'ambiguity'- i.e. uncertainty regarding the information's reliability, credibility or adequacy. This is a critical problem, as growing research suggests that ambiguity has important effects-promoting pessimistic judgments about risks and potential outcomes of risk-reducing behaviours, and lowering adoption of these behaviours. However, little is known about the public's perceptions of ambiguity in the health information domain, the effects of these perceptions, and the factors that influence these effects.

OBJECTIVE

To examine associations between perceived ambiguity regarding cancer prevention recommendations and prevention-related perceptions and behaviours, and to explore how these associations differ by cancer type.

STUDY DESIGN AND PARTICIPANTS

Cross-sectional analysis of data on 4,070 adults participating in the 2005 US Health Information National Trends Survey. MAIN VARIABLES AND OUTCOME MEASURES: We examined associations between perceived ambiguity about colon, skin and lung cancer prevention recommendations and two main outcome variables: (i) risk-related cognitions (perceived cancer risk and preventability, cancer-related worry) and (ii) risk-modifying behaviours (colon cancer screening, sunscreen use and smoking abstinence).

RESULTS

Perceived ambiguity was inversely associated with perceptions of the preventability of all three cancers, and with cancer-specific risk-modifying behaviours including sigmoidoscopy-colonoscopy testing, sunscreen use and smoking abstinence. Relationships with cancer risk perceptions and worry varied across different cancer types.

CONCLUSIONS

Perceived ambiguity about cancer prevention recommendations has significant and predictable associations with cancer prevention-related cognitions and behaviours, and some associations differ by cancer type. These findings have implications for future research and communication efforts.

Perceived ambiguity about screening mammography recommendations: association with future mammography uptake and perceptions

Conflicting expert recommendations regarding cancer screening and prevention are growing in number, visibility, and importance, but their impact are not well understood. In this study, we examined the impact of conflicting recommendations about mammography screening on women's mammography behavior and perceptions. We conducted a secondary analysis of longitudinal data from the 1995 Maximizing Mammography Participation Trial, a large randomized interventional trial examining the effectiveness of patient reminders in increasing mammography utilization among women ages 50 to 79. Using the decision theory concept of "ambiguity" as an analytic framework, we tested several predictions about the effects of conflicting recommendations regarding mammography recommendations on behavior, cognitions, and emotions related to mammography screening. We found high perceived ambiguity about mammography recommendations to be associated with both diminished uptake of mammography over time [odds ratio (OR), 0.42; 95% confidence interval (95% CI), 0.23-0.76; P < 0.0001] and lower intentions for future mammography (OR, 0.34; 95% CI, 0.20-0.55; P < 0.0001). High perceived ambiguity also predicted greater mammography-related worry over time (OR, 2.60; 95% CI, 1.79-3.78; P < 0.0001). These findings suggest that conflicting recommendations regarding cancer screening and prevention have important effects, and we discuss the implications of these findings for future research.

Do pregnant women in Greece make informed choices about antenatal screening for Down's syndrome? A questionnaire survey

OBJECTIVE

to investigate the knowledge and attitudes towards Down's syndrome screening among pregnant women presenting for prenatal screening in Greece, in order to explore whether Greek women are able to make informed choices.

DESIGN

survey using self-administered questionnaires.

SETTING

public hospital in Athens, Greece.

PARTICIPANTS

135 pregnant women with a gestational age of between 11 and 20 weeks, just before antenatal screening for Down's syndrome.

FINDINGS

a total of 96% of women had a positive attitude towards screening and 45% had a good level of knowledge concerning the screening process for Down's syndrome. A standard measure of informed choice was used, which was validated for use in Greek. We found that 44% of women made an informed choice and 56% of women made an uninformed choice. This was because of the low percentage of women with a good level of knowledge. It was also found that knowledge and attitudes were not associated and seemed to be independent of each other. A higher level of informed choice was associated with a higher level of educational achievement and income, time of decision-making and the satisfaction with the decision.

CONCLUSIONS

health professionals should ensure that all women receive appropriate and intelligible information about antenatal screening for Down's syndrome. This information should be suited to women's learning ability in order to increase their knowledge before undergoing screening. Health professionals should educate and increase women's knowledge, and also give women a chance to explore their attitudes and discuss the issues involved.

IMPLICATIONS FOR PRACTICE

on the basis of the current measure of informed choice, we found that knowledge is a weak determinant of uptake of screening. However, the measure focuses on knowledge regarding the screening process, rather than on the condition itself. In addition, informed choice is a far broader concept than the issues covered by the measurement tool. Therefore, it could be concluded that attempts to increase attitude-behaviour consistency (i.e. to increase uptake for women with positive attitudes towards screening and to decrease uptake for women with negative attitudes) could be more successful in increasing informed choice in screening for Down's syndrome in Greece.

Are pregnant Australian women well informed about prenatal genetic screening? A systematic investigation using the Multidimensional Measure of Informed Choice

BACKGROUND

Ethical practice requires that decisions to participate in medical care be well informed. Investigations into prenatal genetic screening for Down syndrome have assessed women's knowledge but have not examined whether being well informed about the potential consequences of screening, such as subsequent diagnostic testing, diagnosis and termination, is associated with psychological distress for women.

AIMS

To assess informed choice to participate in second trimester maternal serum screening (2MSS) in pregnant women using a validated measure and to compare anxiety levels in women who were well informed versus poorly informed.

METHODS

A prospective cohort study where pregnant women completed the Multidimensional Measure of Informed Choice and the Hospital Anxiety and Depression Scale immediately prior to the offer of 2MSS. Follow-up questionnaires assessing psychological symptomatology were completed at 20 and 30 weeks gestation.

RESULTS

Only 37% of decisions were informed; those who participated in screening were more likely to have made an informed decision than those who did not (P = 0.01); 31% did not know that miscarriage was a possible consequence of diagnostic testing subsequent to an increased risk screening result and only 62% correctly identified that termination of pregnancy would be offered if Down syndrome were to be diagnosed. Short-term anxiety levels in those who were well informed were not significantly different from those who were poorly informed (P = 0.14).

CONCLUSIONS

Health promotion strategies, which are readily applicable in clinical settings and address diverse learning needs and attitudes of pregnant women, are needed. The impact of antenatal screening on other dimensions of pregnancy psychology remains to be investigated.

Communicating with women about mammography

BACKGROUND/METHODS

We report survey results of the types of tools used to communicate with women about breast cancer screening and the content areas included in each tool for member countries of the International Breast Cancer Screening Network (IBSN).

RESULTS

In addition to using pamphlets and invitation letters, new technologies are being used such as the Internet which allows for easy updating of information and can provide interactive modules. Several countries have addressed the needs of specific populations such as indigenous populations or blind women. All countries provide basic information, although they do not provide all the same information.

CONCLUSION

More research is needed to understand what women need to make an informed decision about mammography and to learn what the best modalities are to provide this information.

Informed choice in screening programmes: Do leaflets help? A critical literature review

BACKGROUND

Screening programmes aim to maximise population benefit by maximizing uptake but must also allow informed choice about participation. Many programmes provide potential participants with information leaflets. This article reviews studies of the effectiveness of leaflets in promoting informed choice in screening.

METHODS

I searched 15 electronic databases and the websites of UK screening programmes, searched the bibliographies of identified studies and contacted experts in the field. Randomized controlled trials (RCTs) and controlled clinical trials where an attempt had been made to determine the contribution of leaflets to the exercise of informed choice in screening decisions were included.

RESULTS

I identified nine trials from various screening programmes. Outcome measures included knowledge, attitudes to screening, intention to be screened, uptake, anxiety, satisfaction with decision-making, discussions about screening with care providers and agreement that enough information had been provided to allow informed choice. Most studies demonstrated that providing written information increased knowledge, but evidence that this promoted informed choice was poor.

CONCLUSIONS

Research into informed choice in screening is hampered by the lack of agreement about its definition and measurement. The most effective way for screening programmes to achieve informed choice is unclear. Programmes should not rely solely on providing written information but should explore additional ways to promote informed choice.

Older adults' attitudes about continuing cancer screening later in life: a pilot study interviewing residents of two continuing care communities

Background

Individualized decision making has been recommended for cancer screening decisions in older adults. Because older adults' preferences are central to individualized decisions, we assessed older adults' perspectives about continuing cancer screening later in life.

Methods

Face to face interviews with 116 residents age 70 or over from two long-term care retirement communities. Interview content included questions about whether participants had discussed cancer screening with their physicians since turning age 70, their attitudes about information important for individualized decisions, and their attitudes about continuing cancer screening later in life.

Results

Forty-nine percent of participants reported that they had an opportunity to discuss cancer screening with their physician since turning age 70; 89% would have preferred to have had these discussions. Sixty-two percent believed their own life expectancy was not important for decision making, and 48% preferred not to discuss life expectancy. Attitudes about continuing cancer screening were favorable. Most participants reported that they would continue screening throughout their lives and 43% would consider getting screened even if their doctors recommended against it. Only 13% thought that they would not live long enough to benefit from cancer screening tests. Factors important to consider stopping include: age, deteriorating or poor health, concerns about the effectiveness of the tests, and doctors recommendations.

Conclusion

This select group of older adults held positive attitudes about continuing cancer screening later in life, and many may have had unrealistic expectations. Individualized decision making could help clarify how life expectancy affects the potential survival benefits of cancer screening. Future research is needed to determine whether educating older adults about the importance of longevity in screening decisions would be acceptable, affect older adults' attitudes about screening, or change their screening behavior.

Decision making in prostate-specific antigen screening National Health Interview Survey, 2000

BACKGROUND

The net benefits and harms of prostate cancer screening with the prostate-specific antigen (PSA) test are uncertain, and professional organizations recommend that physicians discuss these uncertainties with patients before initiating screening. Using a nationally representative sample of men reporting past PSA screening, we aimed to determine the extent to which screening was initiated by physicians and preceded by physician-patient discussions.

METHODS

Cross-sectional analysis of data from the 2000 National Health Interview Survey; 2,676 men aged 40 and older underwent PSA screening and met study inclusion criteria. We analyzed the proportions of men for whom PSA screening was (1) was initiated by the physician versus the patient, and (2) preceded by discussions about the test's advantages and disadvantages.

RESULTS

Overall, 74% (95% CI=71.8-76.0) of recipients reported that PSA screening was initiated by their physician, and the proportion increased with advancing age, declining health status, lack of family history of prostate cancer, presence of a usual source of medical care, and non-Hispanic ethnicity. Sixty-five percent (95% CI=63.1-67.1) of screening recipients reported prescreening discussions with their physicians. Discussions were more common with physician-initiated screening than with patient-initiated screening, and among patients reporting a usual source of medical care, non-blue-collar occupation, and black race.

CONCLUSIONS

Among U.S. men receiving PSA screening, screening is usually initiated by physicians, frequently in men relatively less likely to benefit from it, and often without prior discussion of the test's advantages and disadvantages. Further examination of the PSA decision-making process among screened and unscreened men is warranted.

Men considering a hypothetical treatment for prostate cancer: a comparison to patients

BACKGROUND

In facilitating informed decision making about PSA screening, men are often asked to consider the potential consequences of the test, including a diagnosis of prostate cancer and how they would want to be treated. However, there is no empirical evidence thus far demonstrating that men are able to consider this hypothetical situation in a realistic manner.

PURPOSE

To compare the features (attributes) of treatments that are important to non-patient men considering a hypothetical diagnosis of prostate cancer with those deemed important to men actually diagnosed with early-stage disease.

METHODS

Two groups of men went through a decision aid interview to help them choose between treatment options for early-stage prostate cancer: non-patient men who imagined themselves to be diagnosed with the disease, and newly diagnosed patients. During the interview participants identified features of the treatment and disease that were important to their decisions.

RESULTS

The percentage of non-patients and patients that thought particular attributes were important was correlated: r (33) = 0.77, p < 0.01. The effects on bladder and bowel functioning were considered important to >or=50% of each group. In addition to the 22 attributes initially presented, 49% of non-patients and 67% of patients identified additional attributes as being important to their decision. Eight (42%) of the 19 additional attributes were identified by non-patients and patients alike.

CONCLUSIONS

The group of non-patient men provided a close approximation to the group of newly diagnosed men with respect to the attributes identified as being important to their treatment decisions for early-stage prostate cancer, suggesting that the consideration of what is important to the decision by non-patient men is realistic.