Personal approach boosts mammograms
Personal approach boosts mammograms
Women respond to targeted letters
The National Committee for Quality Assurance in Washington, DC, wants health maintenance organizations (HMOs) to increase the number of women who have routine mammograms. One good way to get a woman into the mammogram habit is to address her individual concerns, say researchers at Brown University in Providence, RI.
In a randomized clinical trial of nearly 1,400 women members of a New England HMO, a personal approach encouraged more women to get a repeat mammogram than did generic advice or breast cancer screening or no intervention, says William Rakowski, PhD, associate professor of medical science at Brown University School of Medicine.
Women in the four-year screening project were randomly assigned to three groups. All women were interviewed four times to assess their breast cancer screening history, concerns, and actions. After each of the first two interviews, women in one group received computer-generated personalized letters and additional education materials tailored to their survey responses. Another group received standard mammography educational information. The third group received nothing.
A perfect fit
The messages were created to custom fit each woman's readiness to change her health behavior surrounding routine mammograms, explains Beverly Ehrich, MPH, project director of the Mammography Education Partnership at the Center for Gerontology and Health Care Research at Brown University. Trained interviewers scored women's readiness and placed them in one of five readiness stages. Those are:
· Precontemplation. Woman is currently not having routine mammograms and not intending to start.
· Contemplation. Woman is not having routine mammograms but is considering starting.
· Action. Woman has started getting routine mammograms.
· Maintenance. Woman has had at least two mammograms on schedule.
· Relapse risk. Woman has had routine mammograms on schedule but is now off schedule and has no plans to have a mammogram in the near future.
The Mammography Education Partnership based its interventions on the Transtheoretical Model of Behavior Change which proposes that people differ in their readiness to adopt a health-related behavior and must go through stages of readiness. (For more on the behavior change model, see p. 96.)
"At each stage, there are various behaviors associated with making the desired behavior change," Ehrich says.
Researchers found that women who received personalized materials were 10% more likely to get a repeat mammogram than those who received none. "We match the materials with the person with the objective of nudging them one step further, rather than asking them to make a full-fledged change right away," Rakowski says. (For samples of targeted messages, see p. 108.)
Are you ready?
"If we know a woman's stage of readiness, we know which messages are more likely to influence her to implement the desired behavior," Ehrich says. "The stages represent a continuum of change. It's a circular model. Women can be in the maintenance stage and go back to the contemplation stage."
"We've found that sending generalized messages to all women about mammography doesn't work," Ehrich adds. "If a woman is absolutely not ready - she's precontemplative - what you want to do is raise her understanding of breast cancer and breast cancer screening. It doesn't do any good to tell her the mammography center down the street has Saturday hours. She hasn't even thought about the significance of cancer screening to her health. She's not ready for a discussion of logistics and cost."
Rakowski says most HMOs could adapt the Brown University breast cancer screening model to encourage other health behavior changes without too much difficulty. "We could easily run our system off a standard PC," he says. "We are printing our own project materials on a standard ink jet printer. If you had a simple survey, and you knew exactly what you wanted to ask, you could hand a patient a two-page questionnaire during a primary care visit. You could pop the answers into the computer and customize materials to encourage positive health behaviors."
It's even possible for case managers and physicians to gauge readiness with a few simple questions asked during a routine office visit or a telephone interview, Rakowski says. "All you have to ask are questions about intention." He says those questions might include:
· Do you want to change?
· Do you feel confident you can change?
· Do you intend to try to change in the next six months?
"We don't always have to measure things with such long scales that both patients and clinical staff get overwhelmed. Even simple tools can yield useful information," he says.
[Editor's note: Examples of the expert system letters and tip sheets are available from Beverly Ehrich, Center for Gerontology and Health Care Research, Brown University, Box G-H3, Providence, RI 02912. Fax: (401) 863-9219.]
Suggested reading
Ehrich B, Clark M, Rakowski W, Allison S. Implementing a computer-based mammography education project in a managed care setting. Med and Health/Rhode Island 1998; 81:79-82.
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