Sociopsychological Tailoring to Address Colorectal Cancer Screening Disparities: A Randomized Controlled Trial

Anthony Jerant; Richard L. Kravitz; Nancy Sohler; Kevin Fiscella; Raquel L. Romero; Bennett Parnes; Daniel J. Tancredi; Sergio Aguilar-Gaxiola; Christina Slee; Simon Dvorak; Charles Turner; Andrew Hudnut; Francisco Prieto; Peter Franks

doi:10.1370/afm.1623

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Culturally Tailored Decision Aids to Reduce Ethnic Disparities in CRC Screening
Robert L. Rhyne

Published on: 05 August 2014
Tailoring, Access, Preference, and Navigation in CRC Screening
Ronald E. Myers

Published on: 22 May 2014
Are we over-thinking the need for tailored messages?
Micheal B. Potter

Published on: 16 May 2014

Published on: (5 August 2014)
Page navigation anchor for Culturally Tailored Decision Aids to Reduce Ethnic Disparities in CRC Screening
Culturally Tailored Decision Aids to Reduce Ethnic Disparities in CRC Screening
Robert L. Rhyne, Professor of Family and Community Medicine.
Other Contributors:
This study was designed to test an intervention tailored to the expanded health belief model (EHBM) in a population consisting of over 50% Hispanics. We disagree with the authors' conclusion that the negative results raise doubts about the utility of using culturally tailored decision aids to reduce ethnic disparities in colorectal cancer (CRC) screening. Understanding how to promote CRC screening in Hispanic populations...
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This study was designed to test an intervention tailored to the expanded health belief model (EHBM) in a population consisting of over 50% Hispanics. We disagree with the authors' conclusion that the negative results raise doubts about the utility of using culturally tailored decision aids to reduce ethnic disparities in colorectal cancer (CRC) screening. Understanding how to promote CRC screening in Hispanic populations is important due to disparities in cancer incidence, particularly in the Southwest.[1] Many factors may explain the observed negative results of this study.
As posited by the authors, the intervention probably fell short of addressing the cultural factors in the various Hispanic populations. The lack of improvement in the EHBM factors in the Hispanic Spanish speaking population (Table 3) could indicate that the tailored intervention did not reach them. They might have been uncomfortable using computers. And furthermore the tailoring was the same for all ethnic/test groups. In our experience Hispanic populations are not homogeneous and cultural factors may differ by Hispanic subpopulation. For example, Machismo may cause certain Hispanic men to avoid colonoscopy.[2] The Hispanic populations in this study were drawn from different locations all around the country; it is difficult to design one intervention that would address the cultural factors of both urban New York and Southwestern Hispanic populations.
There are "systems" issues that may have interfered with the effectiveness of the intervention. Screening was discussed in less than half of the visits, raising questions of whether the provider even knew the subject was due for screening and whether self-efficacy played any role in the outcome of screening. Relying on patients to talk with their providers after the intervention--and expecting providers with no knowledge of the intervention and with many competing demands to order tests--may be major barriers to achieving screening, independent of the intervention. Allowing delivery of screening to occur outside of the provider visits, as a direct result of the intervention, could potentially address this systems' barrier.
To better interpret the findings, we would also have liked more information on the screening process, including what tests were recommended (and covered by insurance), when were FOBT provided (at time of visit, later), the logistics of arranging diagnostic colonoscopy (and proportion of ordered tests that were actually completed).
The control group could have been "contaminated" by also viewing a CRC decision support tool, especially if the tailoring aspect of the intervention was not effective. Having the control group view a non-cancer program would have addressed this concern.
We believe that investigators should not abandon the search for innovative culturally tailored decision aids to reduce ethnic disparities in CRC screening, which are still needed to raise awareness and participation in CRC screening in Hispanic populations.[3] Hispanics are not a homogeneous population, therefore it is difficult to design one tailored intervention that will stimulate all Hispanic subpopulations to get screened.[2,3] We must continue to study culturally appropriate interventions that include decision aids, practice transformation that takes screening out of the provider visit, and navigator approaches.
1. Hoffman RM, Espey DK, Rhyne RL, Gonzales M, Rajput A, Mishra SI, Stone SN, Wiggins CL. Colorectal Cancer Incidence and Mortality Disparities in New Mexico. J Cancer Epid. 2014; http:/dx.doi.org/10.1155/2014/239619.
2. Getrich CM, Sussman AL, Helitzer DL, Hoffman RM, Warner TD, Sanchez V, Solares A, Rhyne RL. Expressions of Machismo in Colorectal Cancer Screening Among New Mexico Hispanic Subpopulations. Qualitative Health Research 2012;22(4):546-559.
3. Gonzales M, Nelson H, Rhyne RL, Stone SN, Hoffman RM. Surveillance of Colorectal Cancer Screening in New Mexico Hispanics and Non-Hispanic Whites. J Community Health 2012; published online, DOI 10.1007/s10900-012-9568-6.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (22 May 2014)
Page navigation anchor for Tailoring, Access, Preference, and Navigation in CRC Screening
Tailoring, Access, Preference, and Navigation in CRC Screening
Ronald E. Myers, Professor
Other Contributors:
While reading this interesting article, I was struck by the low CRC screening rates reported in both study groups, and by the comparability of the screening rates in the groups. The low observed screening rates may be attributed to the fact that neither stool blood test kits nor instructions to arrange colonoscopy screening were provided to study participants as part of the intervention. Rather, it appears that study partic...
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While reading this interesting article, I was struck by the low CRC screening rates reported in both study groups, and by the comparability of the screening rates in the groups. The low observed screening rates may be attributed to the fact that neither stool blood test kits nor instructions to arrange colonoscopy screening were provided to study participants as part of the intervention. Rather, it appears that study participants were encouraged to speak with their primary care physician in order to gain access to a screening test. Thus, participant access to screening may have been influenced by whether such a discussion took place, and by the outcome of this discussion, when it occurred. A surprisingly small proportion of participants in both groups reported discussing screening with a physician (Control: 35% and Tailored IMCP: 41%). Curiously, larger proportions of participants reported that their physician recommended CRC screening (Control: 50% and Tailored IMCP: 59%). Some comment on this apparent anomaly is needed. Importantly, the distribution of screening tests participants preferred at baseline is not provided. In terms of those instances where a physician screening recommendation was reported, it is not clear what screening test was recommended by the physician. Therefore, it is not clear how many participants reported at baseline that they preferred stool blood testing versus colonoscopy, or how many had an equal preference for these two tests. It is also not clear whether the participant's primary care practice/physician expressed a preference for either test, or for that matter, whether the participant's preferred test was actually made available by the practice/physician. If a participant had a preference for stool blood testing and a discussion about screening took place, it would have been problematic if the physician was only prepared to offer colonoscopy, or actively discouraged the participant from performing his/her preferred test. Some information about the nature of the physician- patient interaction related to screening would have been illuminating. Furthermore, the tailored intervention did increase participant knowledge about and favorable perceptions related to screening. Research is needed to determine if providing immediate access to preferred screening tests and supporting participant active engagement through navigation through the performance of preferred tests can help to translate such gains in knowledge and receptivity to testing into higher CRC screening rates. Finally, the fact that the tailored IMCP intervention had the greatest impact on screening among Hispanics is intriguing, especially given the disparity in CRC screening and CRC-related mortality experienced by Hispanics compared to nonHispanic whites. Further research is needed to determine if providing access to preferred screening tests along with navigation could help to attenuate these important disparities.
Competing interests: ?? None declared
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Competing Interests: None declared.
Published on: (16 May 2014)
Page navigation anchor for Are we over-thinking the need for tailored messages?
Are we over-thinking the need for tailored messages?
Micheal B. Potter, Director
This is a well-designed study with a very nicely nuanced discussion. I was surprised by the outcome and don't think we should abandon an exploration of sociocultural tailoring. Many patients may prefer socioculturally tailored materials to standard materials, and there are indications that such an approach results in better informed patients and more patient-centered care. However, as a practical matter, the study sugg...
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This is a well-designed study with a very nicely nuanced discussion. I was surprised by the outcome and don't think we should abandon an exploration of sociocultural tailoring. Many patients may prefer socioculturally tailored materials to standard materials, and there are indications that such an approach results in better informed patients and more patient-centered care. However, as a practical matter, the study suggests that sociocultural tailoring may not provide as much "bang for the buck" as one would like. This is consistent with other research showing that programs employing a few simple and minimally tailored messages (e.g. "getting screened is easy and could save your life" or "colorectal screening prevents cancer") can be successful if these messages are are delivered repeatedly and enthusiastically to all eligible patients by a well-trusted provider of care, with appropriate attention to follow up.
Competing interests: None declared
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Competing Interests: None declared.