Social Norms in Cervical Cancer Screening

Cancer screening aims to check the body for cancer before symptoms develop. Social norms theory suggests people falsely perceive the attitudes and/or behaviours of similar others to be different from their own and correcting these perceptions can lead to behaviour change. Across two studies, we tested if women underestimate peer levels of cervical screening behaviour and whether a social norms manipulation increases intention to attend cervical cancer screening. In study 1, participants completed a survey on cervical cancer screening norms. In study 2, participants were randomised to receive no norm information, norm information, or norm information plus statement on value of norms in decision making. In study 1, participant estimates of peer level of cervical screening behaviour were significantly lower than nationally reported levels. In study 2, a social norm plus value statement intervention led to stronger intentions to attend screening. This effect was consistent across demographic factors and screening status. Participants significantly underestimate rates of cervical screening behaviour in their peers. A brief, online social norms plus values manipulation increased intentions to attend cervical cancer screening across all groups.

A randomised controlled trial of volitional and motivational interventions to improve cervical cancer screening uptake

OBJECTIVE

Cervical cancer is the fourth most common cancer to occur in women worldwide. In the UK, the NHS cervical screening programme invites eligible individuals to take part in screening every 3-5 years. At present, around 70% of individuals attend screening when invited. The present study aimed to test the effectiveness of a volitional and a motivational intervention alone and in combination on screening uptake at 16-week follow up.

METHODS

14,536 participants were recruited from the list of eligible participants invited for screening in Yorkshire, Humber and the North East regions of England in December 2021. They were randomised to a social norm-based motivational intervention (SNA); implementation intention-based Volitional Help Sheet (VHS); combined intervention (SNA + VHS); or treatment as usual control. The primary outcome was screening uptake measured via patient screening records at 16 weeks.

RESULTS

Of the 14,466 participants with eligible data for analysis, 5793 (40.0%) attended for cervical cancer screening in the 16 weeks after the intervention mailing. Both age and deprivation influenced screening uptake, with lower uptake in the youngest individuals and those from more deprived areas. Compared to control, there was no evidence of any benefit from the VHS implementation intervention alone (Adj.OR = 0.99, 95% CI 0.90 to 1.10), the SNA motivational intervention alone (Adj.OR = 0.89; 95% CI: 0.80 to 0.99), or the combined intervention (Adj.OR = 0.96, 95% CI 0.86 to 1.06).

CONCLUSION

The study did not support any benefit of either VHS or SNA interventions alone or in combination on cervical cancer screening uptake. It did demonstrate alarmingly low levels of screening uptake at 16 weeks which were well below the average rate. Future research needs to urgently investigate and understand the barriers to uptake following on from the COVID-19 pandemic.

The Effect of Social Norms on Physicians’ Intentions to Use Liver Cancer Screening: A Cross-Sectional Study Using Extended Theory of Planned Behavior

Background

Liver cancer is a globally acknowledged threat to public health, and there is a critical and urgent need to determine factors associated with the use of liver cancer screening and to further promote its use.

Purpose

To examine whether the extended theory of planned behavior (TPB) incorporating social norms predicts physicians’ intentions to use liver cancer screening and to identify the associated factors quantitatively, using contrast-enhanced ultrasound (CEUS) as an example.

Methods

A research framework was established by adding social norms to the TPB, based on which the questionnaire for this study was developed. Through multistage random sampling, a cross-sectional questionnaire survey was conducted among 292 physicians in Fujian and Jiangxi provinces. Due to the multicollinearity problem of the data, ridge regression was applied to determine the influencing factors of physicians’ intentions to use CEUS.

Results

Most participants (87.30%) reported that they were willing to use liver cancer screening in their clinical practice. The scores of TPB variables were generally higher than those of social norms variables. Ridge regression results indicated that the proposed model was explanatory, which has accounted for 73.5% of the total variance in physicians’ intentions. Analyses also illustrated the significant role of TPB variables (attitude and perceived behavioral control) and social norms variables (personal norms, organizational norms, and industrial norms) on physicians’ intentions to use CEUS.

Conclusion

The study extended the TPB by including the concepts of social norms, which is not only conducive to expanding the knowledge of factors associated with physicians’ intentions to use liver cancer screening, but also provides implications for developing strategies to promote the use of certain health services or products, such as playing the role of core members, holding panel meetings, and establishing information push systems.

Testing messages from behavioral economics to improve participation in a population-based colorectal cancer screening program in Cyprus: Results from two randomized controlled trials

•Behavioral economic-based interventions have been suggested to increase uptake in CRC screening programmes.•This study tested the effectiveness of six behavioral economic-based messages in two field trials.•None of the messages increased screening participation.

Attributing Blame to Robots: I. The Influence of Robot Autonomy

OBJECTIVE

The research examined how humans attribute blame to humans, nonautonomous robots, autonomous robots, or environmental factors for scenarios in which errors occur.

BACKGROUND

When robots and humans serve on teams, human perception of their technological team members can be a critical component of successful cooperation, especially when task completion fails.

METHODS

Participants read a set of scenarios that described human-robot team task failures. Separate scenarios were written to emphasize the role of the human, the robot, or environmental factors in producing the task failure. After reading each scenario, the participants allocated blame for the failure among the human, robot, and environmental factors.

RESULTS

In general, the order of amount of blame was humans, robots, and environmental factors. If the scenario described the robot as nonautonomous, the participants attributed almost as little blame to them as to the environmental factors; in contrast, if the scenario described the robot as autonomous, the participants attributed almost as much blame to them as to the human.

CONCLUSION

We suggest that humans use a hierarchy of blame in which robots are seen as partial social actors, with the degree to which people view them as social actors depending on the degree of autonomy.

APPLICATION

The acceptance of robots by human co-workers will be a function of the attribution of blame when errors occur in the workplace. The present research suggests that greater autonomy for the robot will result in greater attribution of blame in work tasks.

Behavioral economics informed message content in text message reminders to improve cervical screening participation: Two pragmatic randomized controlled trials

The objective of the reported research was to assess the impact of text message (SMS) reminders and their content on cervical screening rates. Women invited for cervical screening in Northwest London from February-October 2015 were eligible. 3133 women aged 24-29 (Study 1) were randomized (1, 1) to 'no SMS' (control), or a primary care physician (PCP) endorsed SMS (SMS-PCP). 11,405 women aged 30-64 (Study 2), were randomized (1, 1:1:1:1:1:1) to either: no SMS, an SMS without manipulation (SMS), the SMS-PCP, an SMS with a total or proportionate social norm (SMS-SNT or SMS-SNP), or an SMS with a gain-framed or loss-framed message (SMS-GF and SMS-LF). The primary outcome was participation at 18 weeks. In Study 1 participation was significantly higher in the SMS-PCP arm (31.4%) compared to control (26.4%, aOR, 1.29, 95%CI: 1.09-1·51; p = 0.002). In Study 2 participation was highest in the SMS-PCP (38.4%) and SMS (38.1%) arms compared to control (34.4%), (aOR: 1.19, 95%CI: 1.03-1.38; p = 0.02 and aOR: 1.18, 95%CI: 1.02-1.37; p = 0.03, respectively). The results demonstrate that behavioral SMSs improve cervical screening participation. The message content plays an important role in the impact of SMS. The results from this trial have already been used to designing effective policy for cervical cancer screening. The NHS Cervical Screening Programme started running a London-wide screening SMS campaign which was based on the cervical screening trial described here. According to figures published by Public Health England, after six months attendance increased by 4.8%, which is the equivalent of 13,400 more women being screened at 18 weeks.

When More Is Not Better: Three Common Mistakes in Health Messaging Interventions

Health messaging interventions frequently make three well-intentioned but mistaken choices in their communications strategies. To increase their persuasiveness, these messages frequently call attention to the greatest possible numbers of people engaging in undesirable behavior, victims of this behavior, and reasons why one should change the behavior. We raise recent research suggesting how and why the intuitively attractive more-is-better heuristic can be unproductive, and suggest ways to overcome these pitfalls.

The Role of Health Literacy in Explaining the Relation between Educational Level and Decision Making about Colorectal Cancer Screening

Little is known about why educational inequalities exist in informed decision making in colorectal cancer (CRC) screening. Insight into the role and impact of health literacy is essential for intervention development. This study investigates associations between health literacy and informed decision making in CRC screening and explores to what extent health literacy mediates the association between education and informed decision making in CRC screening. In total, 696 individuals eligible for CRC screening (55–75 years of age) were recruited from online panels and filled in an online questionnaire at T0 (n = 696), T1 (n = 407) and T2 (n = 327). A hypothetical mediation model was tested using structural equation modelling. Outcomes included CRC knowledge, CRC screening knowledge, attitude, injunctive norm, descriptive norm, risk perception, self-efficacy, decisional conflict and decisional certainty. Health literacy domains included Comprehension, Application, Numeracy and Communication. Comprehension, Application and Numeracy, were found to mediate the association between education and knowledge about CRC and CRC screening, injunctive norm, descriptive norm, decisional conflict and decisional certainty. In light of these findings, targeting multiple health literacy domains in decision-support interventions is essential for facilitating informed decision making in CRC screening.

Don't forget the group! The importance of social norms and empathy for shaping donation behaviour

Feelings of empathy and the influence of social descriptive norms are related to intentions to donate. People are more likely to help and donate to others when they empathise with them, and when they perceive descriptive norms to encourage such behaviour. However, previous work has not considered the potential interplay between empathy and descriptive norms. Across two surveys in two different national settings (Ns = 1300 and 144), we assessed the interplay between empathy and social descriptive norms on frequency of donation (Study 1) and on willingness to donate (Study 2). Consistent with our main hypotheses, in Studies 1 and 2, norms and empathy were positive predictors of frequency of donation and willingness to donate. Importantly, a consistent interaction between norms and empathy was found in both studies. Empathy was a stronger predictor of donation behaviour and disposition when norms were low. Theoretical and applied implications of these findings are discussed.

The impact of descriptive norms on motivation to participate in cancer screening - Evidence from online experiments

OBJECTIVE

The current study tested in two online experiments whether manipulating normative beliefs about cancer screening uptake increases intention to attend colorectal screening among previously disinclined individuals.

METHODS

2461 men and women from an Internet panel (Experiment 1 N = 1032; Experiment 2, N = 1423) who initially stated that they did not intend to take up screening were asked to guess how many men and women they believe to get screened for colorectal cancer. Across participants, we varied the presence/absence of feedback on the participant's estimate, as well as the stated proportion of men and women doing the screening test.

RESULTS

Across the two experiments, we found that receiving one of the experimental messages stating that uptake is higher than estimated significantly increased the proportion of disinclined men and women becoming intenders. While, we found a positive relationship between the communicated uptake and screening intentions, we did not find evidence that providing feedback on the estimate has an added benefit.

CONCLUSION

Screening intention can be effectively manipulated through a high uptake message.

PRACTICE IMPLICATIONS

Communication of high screening uptake is an easy and effective way to motivate disinclined individuals to engage in colorectal cancer screening.

Testing verbal quantifiers for social norms messages in cancer screening: evidence from an online experiment

BACKGROUND

Studies have shown that presenting correct information about group norms to correct misperceptions of norms can influence health behaviours. In two online studies we investigated how different ways of communicating the current uptake of 43% of the English Bowel Scope Screening (BSS) programme affects intention among disinclined men and women.

METHODS

In the first study, 202 participants were asked to interpret eight quantifiers for 43% uptake ('few', 'many', 'a considerable number', 'a large number', 'a great number', 'a lot', 'numerous' and 'nearly half') and to indicate how misleading they perceived each of them to be. In the second study, with 1245 participants, we compared the motivational impact of two quantifiers ('a large number' and 'nearly half' which were associated with the highest perceived uptake (48.9%) and considered least misleading in study 1 respectively) with a control message that did not contain any information on uptake, and a message which communicated actual uptake as a proportion (43%).

RESULTS

While we found that both verbal quantifiers increased screening intentions compared with the control group (from 7.8 to 12.5%, aOR 1.72; 95%CI 1.00-2.96 in the case of 'a large number' and 14.3%, aOR 2.02; 95%CI 1.20-3.38 for 'nearly half'), simply communicating that 43% do the test, however, had no impact on intentions (9.9% vs. 7.8% aOR 1.25; 95%CI 0.73-2.16).

CONCLUSION

Verbal quantifiers can be used to improve the perception of low uptake figures and avoid a demotivating effect.

Primary Drivers of Willingness to Continue to Participate in Community-Based Health Screening for Chronic Diseases

Background: As the average age of the population continues to rise in the 21st century, chronic illnesses have become the most prominent threats to human health. Research has shown that early screenings for chronic diseases are an effective way of lowering incidence and mortality rates. However, low participation rates for health screening is one of the main challenges for preventive medicine. The objective of this study was to determine the primary drivers which: (1) first motivate people to participate in community-based health screening for chronic diseases; and (2) increase their willingness to continue to participate. Methods: A total of 440 individuals between 30 and 75 years of age were invited to undergo a health screening and then complete an interview questionnaire. Screenings and interviews were conducted in four regions in northern Taiwan. The questionnaire was separated into three sections, which explored sociodemographic differences, drivers of willingness to participate, and willingness to continue to participate respectively. Raw data was analyzed using the statistical software package SPSS (SPSS Inc., Chicago, IL, USA). Main Outcome Measures: Effects of sociodemographic factors on health screening participation rate, drivers of willingness to participate, and willingness to continue to participate. Results: Seventy-three percent of participants responded that they would be willing to continue to join in future health screenings. Notably, elderly people and married people were respectively more likely to participate in preventive health screening than were younger people and people who were single, divorced, separated, or widowed. Level of education was another key driver of willingness to participate in health screening for chronic diseases, as were the concern of relatives/friends and the provision of participation incentives. Discussion: Some of our findings, such as the key drivers of willingness to continue to participate in health screening that we identified, were different from findings of many previous studies conducted in other countries. The current study also found that a higher percentage of participants would be willing to join a similar health screening in the future if the service design is considered in advance and is well-implemented.

"Don't Drink Too Much!" Reactance Among Young Men Following Health-Related Social Control

This study investigated conditions under which young men responded with reactance to the suggestion to reduce their alcohol consumption. In an experimental study, 84 young men (university students, mean age: 24 years) listened to a recorded telephone call and were asked to imagine that they themselves were the recipients of this call. In this call, either a girlfriend or a male friend suggested that the recipient of the call should reduce his alcohol intake that evening. In one condition, the suggestion was highly restrictive; in the other condition, the suggestion was framed in a nonrestrictive way. Perceived threat, negative thoughts, and feelings of anger after listening to the call were assessed. Further outcome variables were intention and perceived probability of complying with the suggestion. Participants felt more anger after hearing the highly restrictive suggestion and more threatened by the suggestion made by the girlfriend. Interaction effects emerged. Participants reported more negative thoughts and lower intention and perceived probability to comply when a highly restrictive suggestion was made by the girlfriend. The male friend’s highly restrictive suggestion resulted in a perceived probability of complying (54%) that was similar to the probability of the girlfriend’s nonrestrictive suggestion (55%). Women’s efforts to reduce their male partners’ alcohol consumption can result in boomerang effects. Male peers might be more effective in motivating other men to behave in a healthier way. These results support recent findings with regard to the potential of peer positive social control.

To rest or not to rest-Health care professionals' attitude toward recommending physical activity to their cancer patients

OBJECTIVE

While in the past cancer patients were advised to rest, recent research revealed various beneficial effects of physical activity, including increased treatment tolerability during cancer treatment and prolonged survival, which has led to a paradigm shift in relevant guidelines. This study examined if this paradigm shift from rest to activity has been consolidated in health care professionals' (HCP') attitude. It was investigated if the two dimensions of attitude (rest and activity) are endorsed empirically within the theory of planned behavior (TPB). Differences between physicians and nurses were examined.

METHODS

Five hundred forty seven physicians and 398 nurses treating breast, prostate, or colorectal cancer patients completed a cross-sectional questionnaire. To assess attitude toward physical activity during cancer treatment, we developed a 15-item scale, which included original statements of HCP. TPB variables were assessed.

RESULTS

A factor analysis revealed the proposed distinction of attitude into two dimensions. The activity-paradigm was stronger represented in HCP' attitude compared with rest-paradigm (M_{activity-paradigm}  = 4.1 versus M_{rest-paradigm}  = 2.7, p < 0.001). Additionally, the activity-paradigm had higher exploratory power in explaining intention to recommend physical activity in cancer patients. However, the rest-paradigm was able to explain intention to recommend physical activity over and above activity-paradigm (ΔR²  = 0.05). Nurses had higher scores on the rest-paradigm than physicians.

CONCLUSIONS

The activity-paradigm has already been consolidated in HCP' minds. However, the rest-paradigm is still present in the daily routine of oncology physicians and nurses. Addressing concerns and insecurities related to supporting cancer patients in maintaining or building up a physically active lifestyle is a very important educational task.

Are healthcare professionals being left in the lurch? The role of structural barriers and information resources to promote physical activity to cancer patients

PURPOSE

Although many cancer patients benefit from physical activity (PA), healthcare professionals (HCP) still do not promote it routinely. Including different groups of HCP, this study aimed to examine how structural barriers are perceived as impeding by HCP for promoting PA to cancer patients, how the perceptions of structural barriers are associated with promoting PA, and how HCP react to information resources.

METHODS

A total of 287 physicians in outpatient care, 242 physicians in inpatient care, and 388 oncology nurses completed our questionnaire (paper-pencil or online). Participants assessed nine different structural barriers (on a 4-point Likert Scale) and reported their PA promotion frequency. Further, they could request three different kinds of information resources about PA in oncological settings.

RESULTS

Across professional groups, more than 70% of HCP indicated that they promoted PA to their cancer patients often or routinely. Oncology nurses indicated that they were more impeded in promoting PA by six structural barriers than physicians (all p < .01). "Not enough time per patient" and "lack of an expert contact person" were associated with a reduced PA promotion in two professional groups (all p < .05). Information resources were requested by 69.5% of the participants: mostly physicians working in outpatient care and especially by those perceiving structural barriers.

CONCLUSIONS

Although a big proportion of HCP reported that they frequently promoted PA, our findings suggest that HCP still perceive structural barriers. The perception and influence of structural barriers differed between professional groups, pointing to the importance of profession specific guidance.

Behavioral economics: "nudging" underserved populations to be screened for cancer

Persistent disparities in cancer screening by race/ethnicity and socioeconomic status require innovative prevention tools and techniques. Behavioral economics provides tools to potentially reduce disparities by informing strategies and systems to increase prevention of breast, cervical, and colorectal cancers. With an emphasis on the predictable, but sometimes flawed, mental shortcuts (heuristics) people use to make decisions, behavioral economics offers insights that practitioners can use to enhance evidence-based cancer screening interventions that rely on judgments about the probability of developing and detecting cancer, decisions about competing screening options, and the optimal presentation of complex choices (choice architecture). In the area of judgment, we describe ways practitioners can use the availability and representativeness of heuristics and the tendency toward unrealistic optimism to increase perceptions of risk and highlight benefits of screening. We describe how several behavioral economic principles involved in decision-making can influence screening attitudes, including how framing and context effects can be manipulated to highlight personally salient features of cancer screening tests. Finally, we offer suggestions about ways practitioners can apply principles related to choice architecture to health care systems in which cancer screening takes place. These recommendations include the use of incentives to increase screening, introduction of default options, appropriate feedback throughout the decision-making and behavior completion process, and clear presentation of complex choices, particularly in the context of colorectal cancer screening. We conclude by noting gaps in knowledge and propose future research questions to guide this promising area of research and practice.

How norms work: self-identification, attitude, and self-efficacy mediate the relation between descriptive social norms and vegetable intake

BACKGROUND

The current studies aim to show that descriptive social norms influence vegetable intake and to investigate three potentially underlying processes (self-identification, attitude, and self-efficacy).

METHODS

In two studies, descriptive social norms regarding vegetable intake were manipulated (majority vs. minority norm). Study 1 investigated both the relation between baseline vegetable intake and self-identification, attitude, and self-efficacy, as well as the effect of the norm manipulation on vegetable intake over a one-week period. Study 2 investigated potential mediation of the effect of the manipulation on vegetable intake intentions through self-identification, attitude, and self-efficacy.

RESULTS

Study 1 showed that the proposed mediators were related to a baseline measure of vegetable intake. Moreover, in participants identifying strongly with the norm referent group, majority norms led to higher vegetable consumption than minority norms. Study 2 showed that the direct effect of the social norm manipulation on vegetable intake intentions was partly mediated by self-identification, attitude, and self-efficacy.

CONCLUSIONS

These studies shed first light on processes underlying the effect of descriptive social norms on health behavior. A norm describing the behavior of a salient social group leads people to identify more with, have more positive attitudes toward, and feel more self-efficacious regarding that behavior.

Who makes use of Internet-delivered health information? The role of gender role self-concept in young men and women

This study examined the contribution of gender role self-concept (expressiveness and instrumentality) on active interest in and use of Internet-delivered health information among young men and women. Four hundred and twenty university students reported health behaviours and perceived personal vulnerability regarding five diseases. We analysed active interest in receiving health-related information concerning these diseases (providing email address to receive a link to health-related websites) and actual use of provided websites two weeks afterwards. Usage of health-related information via the Internet was objectively assessed by recording log-ins on the website and obtaining individual click counts. In both sexes, higher expressiveness was independently associated with being more likely to show active interest in health-related information. Additionally, expressiveness was positively associated with website use in men independent of age, personal vulnerability and reported health behaviours. Thus, an expressive self-concept facilitates the use of health-related information, especially among men.

Social influences on eating: implications for nutritional interventions

We review recent research on the effect of social context on food intake and food choice and assess the implications for nutritional interventions. We focus on studies of modelling of eating behaviour and the impact of perceived eating norms on the amounts and types of food that individuals eat. We suggest that social context influences eating via multiple mechanisms, including identity signalling and self-presentation concerns. However, building on existing theoretical models, we propose that social factors may be particularly influential on nutrition because following the behaviour of others is adaptive and social norms inform individuals about behaviours that are likely to be optimal (‘if everyone else is doing it, I probably should be’). Guided by understanding of the potential underlying mechanisms, we discuss how social norms might be used to promote healthier nutrition.

What makes African American health disparities newsworthy? An experiment among journalists about story framing

News stories reporting race-specific health information commonly emphasize disparities between racial groups. But recent research suggests this focus on disparities has unintended effects on African American audiences, generating negative emotions and less interest in preventive behaviors (Nicholson RA, Kreuter MW, Lapka C et al. Unintended effects of emphasizing disparities in cancer communication to African-Americans. Cancer Epidemiol Biomarkers Prev 2008; 17: 2946-52). They found that black adults are more interested in cancer screening after reading about the progress African Americans have made in fighting cancer than after reading stories emphasizing disparities between blacks and whites. This study builds on past findings by (i) examining how health journalists judge the newsworthiness of stories that report race-specific health information by emphasizing disparities versus progress and (ii) determining whether these judgments can be changed by informing journalists of audience reactions to disparity versus progress framing. In a double-blind-randomized experiment, 175 health journalists read either a disparity- or progress-framed story on colon cancer, preceded by either an inoculation about audience effects of such framing or an unrelated (i.e. control) information stimuli. Journalists rated the disparity-frame story more favorably than the progress-frame story in every category of news values. However, the inoculation significantly increased positive reactions to the progress-frame story. Informing journalists of audience reactions to race-specific health information could influence how health news stories are framed.