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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Figure 1
Sequence and content of tailored IMCP and nontailored control interventions for colorectal screening.

CRC = colorectal cancer; FOBT = fecal occult blood test; IMCP = interactive multimedia computer program.

Note: shaded boxes indicate keying individually tailored modules of experimental IMCP.

^aBasic structure of tailoring in each module: (1) give all users brief feedback tailored to their responses to relevant questions; (2) offer the option to view more-detailed information.
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Figure 2
Flow of participants through the trial.

CRC = colorectal cancer; IMCP = interactive multimedia computer program.
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Figure 3
Kaplan-Meier curve for receipt of colorectal cancer screening after intervention according to study group.

IMCP = interactive multimedia computer program.

Note: Screening was ascertained by medical record review.

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Table 1

Characteristics of the Participants by Study Group

Characteristics	Study Intervention Group^a
Characteristics	Control N = 569	Tailored IMCP N = 595
Patient enrollment by performance site, %
Rochester, New York	20.9	21.0
Bronx, New York	24.0	24.1
Denver and Southwestern Colorado	15.6	16.0
San Antonio, Texas	17.9	16.7
Sacramento, California	21.6	22.2
Sociodemographics
Age, mean (SD), y	57.1 (6.2)	57.0 (6.1)
Female, %	65.8	65.0
Spanish language version of software, %	23.5	23.4
Ethnicity/race category, %
Hispanic (any race)	51.5	49.7
Non-Hispanic
White	20.7	21.0
Black	23.0	24.9
Other race	4.7	4.4
Country of birth, %
United States	69.2	70.6
Argentina	9.5	7.6
Dominican Republic	7.7	9.6
Mexico	7.7	8.2
Puerto Rico	5.8	4.0
Length of time living in United States, %^b
<1 y	4.0	6.9
1–5 y	8.0	11.4
6–10 y	8.6	9.7
>10 y	79.4	72.0
Education level, %
<High school	15.8	19.0
Some high school	21.5	18.1
High school graduate	25.1	23.8
Some college	18.5	20.9
College graduate	19.0	18.3
Income level, %
<$10,000	33.2	35.0
$10,000 to <$15,000	18.9	17.8
$15,000 to <$25,000	17.8	14.7
$25,000 to <$50,000	14.5	15.3
>$50,000	15.6	17.2
Self-rated health literacy (range 1–5), mean (SD)^c	2.0 (1.2)	2.1 (1.3)
Health-related characteristics
Health status score (range 0–100), mean (SD)^d
SF-12 physical component summary	42.9 (11.1)	42.1 (11.7)
SF-12 mental component summary	45.4 (11.4)	45.5 (11.3)
Duration of current primary care clinician relationship, %
<1 y	26.3	24.6
1–2 y	18.9	16.8
3–5 y	15.6	19.9
>5 y	36.1	36.5
Unsure	3.0	2.2
Intervention factors
Software use time, mean (SD), min^e	32.5 (22.2)	33.1 (21.8)
Satisfaction with software score (range 1–5), mean (SD)^f	4.2 (0.5)	4.3 (0.5)

IMCP = interactive multimedia computer program.
↵a P >.10 for all comparisons of characteristics between groups (χ² test for categorical variables, t test for continuous variables).
↵b Calculated using data from the 350 respondents (175 control, 175 tailored IMCP, 30% of overall sample) indicating a country of birth other than the United States.
↵c Higher scores indicate lower self-assessed health literacy.
↵d Higher scores indicate better health.
↵e Based on available data from 550 control patients and 572 IMCP patients.
↵f Higher scores indicate greater satisfaction.

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Table 2

Unadjusted Expanded Health Belief Model Sociopsychological Factor Status, Patient and Provider Visit Behaviors, and Colorectal Cancer Screening by Study Group

Characteristics (N = 1,164)	Intervention Group
Characteristics (N = 1,164)	Control (N = 569)	Tailored IMCP (N = 595)
EHBM sociopsychological factors
Specific test preference, %
Previsit	62.6	64.5
Postvisit^a	76.3	83.2
Screening knowledge score, mean (SD)
Test options (score range 0–3)^b
Previsit	1.6 (0.8)	1.7 (0.8)
Postvisit^c	1.9 (0.8)	2.2 (0.8)
Harms/inconveniences (score range 0–6)^b,^d
Previsit^c	3.7 (2.1)	4.3 (2.1)
Postvisit^c	4.1 (2.3)	5.0 (2.4)
Total (score range 0–9)^b,^e
Previsit^c	5.3 (2.5)	5.9 (2.5)
Postvisit^c	6.0 (2.7)	7.2 (2.8)
Self-efficacy score (score range 1–5), mean (SD)^d,^f
Previsit^c	3.8 (0.7)	4.1 (0.7)
Postvisit^a	3.9 (0.7)	4.0 (0.6)
Barriers score (score range 1–5), mean (SD)^d,^g
FOBT
Previsit	3.5 (0.8)	3.5 (0.8)
Postvisit	3.5 (0.7)	3.5 (0.8)
Colonoscopy
Previsit	3.4 (0.7)	3.5 (0.6)
Postvisit	3.5 (0.7)	3.5 (0.7)
Stage of readiness, %^d
Precontemplation
Previsit	11.1	4.9
Postvisit	7.4	6.2
Contemplation
Previsit	63.0	62.0
Postvisit	59.5	54.5
Preparation
Previsit	25.9	33.0
Postvisit	33.0	39.4
Self-reported prior CRC screening, %^d
FOBT	26.5	26.9
Colonoscopy	13.2	15.9
Patient-reported visit behaviors, %
CRC screening discussed	34.8	41.2
Clinician recommended CRC screening	50.2	59.0
CRC screening, No. (%)^h	123 (22.1)	132 (23.0)

CRC = colorectal cancer; IMCP = interactive multimedia computer program; EHBM = expanded health belief model; FOBT = fecal occult blood testing.
↵a P <.01.
↵b Higher scores indicate greater knowledge.
↵c P <.001 for difference in scores between intervention groups (c² test for categorical variables, t test for continuous variables).
↵d In the tailored IMCP group, these questions were answered after participants had viewed some information tailored to their knowledge of colorectal cancer screening options (see Methods and Figure 1 for details).
↵e Total knowledge score is sum of scores for knowledge of screening test options and knowledge of screening harms and inconveniences scales.
↵f Higher scores indicate higher self-efficacy.
↵g Higher scores indicate fewer barriers.
↵h During 12 months of follow-up, based on review of medical records, available for 1,132 participants (575 IMCP patients, 557 controls).

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Table 3

Adjusted Effects of the Tailored Intervention (vs Control) on Postvisit Sociopsychological Factors, Visit Behaviors, and Colorectal Cancer Screening

Outcome	Entire Sample PE^a (95% CI)	Stratified by Ethnicity/Preferred Language
Outcome	Entire Sample PE^a (95% CI)	Non-Hispanic PE^a (95% CI)	Hispanic/English PE^a (95% CI)	Hispanic/Spanish PE^a (95% CI)
EHBM sociopsychological factors^b
Prefer specific test option, %	6.8 (2.2 to 11.4)^c	5.8 (−0.9 to 12.4)	11.1 (1.7 to 20.6)^d	4.3 (−3.8 to 12.5)
Screening knowledge (total)^e	1.15 (0.86 to 1.44)^f	1.46 (1.04 to 1.87)^f	1.28 (0.70 to 1.86)^f	0.39 (−0.18 to 0.95)
Screening self-efficacy	0.10 (0.03 to 0.18)^c	0.11 (0.00 to 0.22)^d	0.11 (−0.03 to 0.25)	0.07 (−0.07 to 0.21)
Perceived screening barriers
FOBT	0.03 (−0.05 to 0.12)	0.05 (−0.07 to 0.16)	0.02 (−0.14 to 0.18)	0.01 (−0.16 to 0.18)
Colonoscopy	0.02 (−0.06 to 0.09)	0.02 (−0.09 to 0.13)	−0.02 (−0.18 to 0.13)	0.07 (−0.10 to 0.24)
Stage of readiness for screening	1.32 (1.05 to 1.66)^d	1.44 (1.03 to 2.00)^d	1.69 (1.07 to 2.67)^d	0.86 (0.53 to 1.38)
Visit behaviors, %^g
Discussion CRC screening	8.6 (3.1 to 14.2)^c	9.2 (1.4 to 17.0)^d	10.5 (−0.2 to 21.2)	6.0 (−5.7 to 17.8)
Recommendation CRC screening	6.4 (1.0 to 11.8)^d	8.1% (0.4 to 15.8%)^d	8.3 (−2.0 to 18.5%)	3.1 (−7.5 to 13.7)
CRC screening, %^h	0.5 (−4.3 to 5.3)	−0.3 (−7.4 to 6.8)	−1.3 (−9.3 to 6.8)	4.3 (−6.1 to 14.6)

CRC = colorectal cancer; EHBM = expanded health belief model; FOBT = fecal occult blood testing; IMCP = interactive multimedia computer program; PE = parameter estimate; SE = self-efficacy.
↵a Parameter estimates for total knowledge (score range = 0–9) and self-efficacy (score range = 1–5) represent the amount of change in score (ie, points); parameter estimates for specific test preference, discussion and recommendation of colorectal cancer screening, and colorectal cancer screening represent percentage point increases or decreases; parameter estimate for stage of readiness represents the odds of an increase in stage.
↵b All sociopsychological factor models were adjusted for the previsit value of the dependent variable and study recruitment center; the entire sample analyses also were adjusted for ethnicity/language strata.
↵c P <.01.
↵d P <.05.
↵e Analyses examined effects on a total colorectal cancer screening knowledge scale, derived by combining the scores for the knowledge of screening test options and knowledge of screening risks and inconveniences scales.
↵f P <.001.
↵g All visit behavior models were adjusted for study recruitment center; the entire sample analyses also were adjusted for ethnicity/language strata.
↵h Based on review of medical records, available for 1,132 participants (575 IMCP patients, 557 control patients). All receipt of screening models were adjusted for study recruitment center; the entire sample analysis also was adjusted for ethnicity/language strata.

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The Article in Brief

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

Anthony Jerant , and colleagues

Background Colorectal cancer (CRC) screening is under-utilized. This study compares two CRC screening interventions delivered before office visits: an interactive multimedia computer program tailored to patients' beliefs about CRC screening and a non-tailored program providing basic CRC screening information.

What This Study Found An interactive multimedia computer program tailored to patients? specific beliefs about colorectal cancer screening was no more effective in improving colorectal cancer screening rates than a non-tailored informational program. In a multiethnic patient sample, the tailored program improved colorectal cancer screening knowledge, self-efficacy, readiness, test preference specificity, discussion and recommendation, however, in the subsequent year patients in both groups received screening at similar rates.

Implications

The findings raise doubts about the effectiveness of sociopsychological tailoring approaches in promoting CRC screening. the utility of one-time tailoring of socio-psychological factors in promoting and reducing ethnic disparities in CRC screening.