Affiliations of authors: S. H. Taplin (Department of Family Medicine) W. E. Barlow (Department of Biostatistics), S. Curry (Department of Health Services), University of Washington, Seattle, and Group Health Cooperative of Puget Sound, Center for Health Studies, Seattle; E. Ludman, R. MacLehos, D. M. Meyer, D. Seger, D. Herta, Group Health Cooperative of Puget Sound, Center for Health Studies, Seattle; C. Chin, Group Health Cooperative of Puget Sound, Center for Health Studies, and Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle.
Correspondence to: Stephen H. Taplin, M.D., M.P.H., Group Health Cooperative of Puget Sound, 1730 Minor Ave., Suite 1600, Seattle, WA 98101-1448 (e-mail: taplin.s{at}ghc.org).
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ABSTRACT |
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INTRODUCTION |
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Efforts to understand factors affecting a woman's choice to use mammography have included population surveys, community interventions, and randomized trials of reminders (5-9). A physician's recommendation is a key motivating factor, but focusing on the physician-patient interaction is not sufficient to achieve high rates of screening (5,6,10-17). Prospective trials that have tested methods of increasing physician referrals in the course of women's care (inreach) have achieved positive responses that ranged from 8% to 60% (18). Low rates occur, in part, because women in the population cared for by a practitioner may not be seen in the physician's office each year and, therefore, will not benefit from inreach (19-21). Other studies (9,13,22-28) have avoided reliance upon physician-patient interactions by contacting women directly with mailed recommendations (outreach) but have also shown disappointing levels of screening adherence (10%-72%) (21-25). Because it appeared that outreach efforts afforded the best opportunity to involve the highest proportion of women in screening, the study described here tested methods of improving outreach through mailed and telephone contact with women due for mammograms.
Prospective randomized trials demonstrated that motivational telephone calls increased screening mammography adherence. King et al. (8) built on past work (2) and tested a method of improving outreach by implementing counseling calls (subsequent to mailed recommendations) to address "barriers" to screening, such as beliefs about mammography's risks and the lack of understanding of its benefits. Addressing barriers in a telephone call tripled the odds of getting a mammogram compared with a simple reminder letter, and the positive effects have been replicated in other randomized trials (2,21,22).
These prior trials have tested both mail and telephone outreach. However, to our knowledge, they did not compare their effects among women with and without prior mammography experience (8,19,21,22,27). Effects of calls may be quite different among women in these two categories. Whether the effects are similar among women with and without prior experience is important, since intervention plans might differ in these two groups if there were differential effects (29). Women without mammography experience are the least likely to seek it when it is recommended and the most likely to have late-stage breast cancers diagnosed (30,31).
While it is appealing to believe that women's barriers to seeking mammography are being addressed in telephone calls, it may also be that the call from the health care provider offers important motivation. Prior studies (8,21,22,32) compared counseling calls with a mailed reminder card or usual care. Whether it is necessary to address barriers or simply remind women by telephone has not been tested, although it has been shown that reminder calls alone boost adherence (28). Testing the effect of a counseling call compared with a reminder call has important practical and theoretical consequences. Since motivational calls require more staff training to learn how to address barriers, as well as more telephone time to implement, their use may be limited by resource constraints. If the call itself is sufficient motivation, then a much simpler intervention may be developed that does not directly address psychologic barriers.
To better understand motivational call effects and to maximize adherence to screening recommendations, we conducted a randomized trial among women aged 50-79 years. We compared mammography use subsequent to one of three outreach interventions among nonresponders with a mailed recommendation to schedule a mammogram: 1) reminder postcards, 2) reminder telephone calls, and 3) motivational telephone calls. Women were randomly assigned to one of these three groups if they did not schedule an examination by 2 months from a mailed recommendation that they were due. We followed women for 1 year to see whether they obtained a mammogram. We hypothesized that the motivational call would be more efficacious than the reminder call, and both would be more efficacious than the reminder postcard.
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METHODS |
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This study took place within Group Health Cooperative of Puget Sound (GHCPS), Seattle, WA, a large nonprofit health maintenance organization (HMO) controlled by its consumer board for more than 50 years. Its enrollees reflect the racial mix of the surrounding community but are somewhat less likely to be in the highest and lowest income levels (33). At the time of the study, the Puget Sound region of GHCPS included more than 70 000 women over age 40 years. A centralized Breast Cancer Screening Program (BCSP) has served these women since 1986 (31,34,35). The salient characteristics of the program include regional centers for coordinated mammography, clinical breast examination, and follow-up, as well as a centralized database that tracks women's mammography use and mails a recommendation to schedule an examination when it is due (31,34,35).
This program uses a risk factor questionnaire to enroll women. Eighty-seven percent of all women who were age eligible for this study completed the questionnaire and were, therefore, enrolled in the screening program (31). All women in the program receive reminders within 2 years of their last bilateral examination. Their physician may also recommend them for mammography at any time. There is no additional cost for women recommended for mammography through their physician or the screening program.
Design and Sample
This was a prospective randomized trial to compare the effect of telephone reminder and
motivational telephone calls among women who did not schedule a mammogram by 2 months
from the
date of a mailed recommendation to do so (Fig. 1).
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There were 11 570 age-eligible women who became due for mammograms during the 15-month rolling recruitment period. These 11 570 women included 1295 with no prior mammography and 10 275 with at least one. To reach an adequate sample size, study personnel approached a total of 6147 women during the recruitment period, including 1116 (86%) of women without prior mammography (n = 1295), and a 49% random sample (n = 5031) of those women with prior mammograms (n = 10 275).
Of the 6147 eligible women approached, 703 had already scheduled a mammogram at the point of recruitment and 382 were otherwise ineligible for the study (15 were deceased, 143 were too ill, 13 were out of the United States, 153 had language/hearing restrictions, 55 had left the plan, two were sample errors, and one was involved in another study). This left 5062 eligible women.
We created a stratified random sample of 5062 women due for mammograms within the
GHCPS,
including 4099 with prior mammography and 963 without. We recruited and surveyed 3743
(74%) women before mailing a recommendation (Fig. 1). Another
968
women refused, and 351 could not be contacted by telephone to give consent. Of the 3743
women
who consented, 550 (15%) had no prior mammography examination, and the remainder
3193
had a least one. Women were mailed the program recommendation to schedule a mammography
examination after the recruitment process was complete, regardless of whether they chose to be
in the
study. Among those women who consented to the study, we conducted a telephone survey at the
time
of recruitment. The survey included measurement of demographic characteristics not available in
automated systems and assessment of factors relevant to the conceptual framework described
below.
One thousand nine hundred sixty-five women (53%) scheduled mammograms by 2
months and
therefore were not eligible for the randomized trial. Thirteen women disenrolled from GHCPS
prior to
scheduling. After 2 months, 1765 women (47%) had not scheduled a mammogram and
were
randomly assigned to one of three intervention groups: reminder postcard (n = 590),
reminder
call (n = 585), and motivational call addressing barriers (n = 590). The project
statistician used a computer program to randomize in blocks of 18 and guarantee equal-size
groups
after each block. Randomization was stratified by previous mammography experience and
implemented
by the project coordinator.
Conceptual framework and intervention. Our study was based on a heuristic
conceptual
framework that combined aspects of the theory of reasoned action, social learning theory, and the
Precede/Proceed model for planning care (Fig. 2) (36-38). Our framework includes consideration of predisposing and enabling characteristics
that
predict intention and behavior in other studies (6,8,17,39-42).
Predisposing
characteristics include 1) personal and behavioral factors, such as demographic characteristics,
perceived risk, and past health behavior (including prior mammography, use of Pap smears, and
smoking) and 2) cognitive and affective factors, such as beliefs about mammography, values,
perceptions of what others want them to do (social norm), and affect (emotional response to
mammography). Enabling characteristics of the environment include two considerations:
logistics and
health care system support. Logistics include providing information about the location of the
centers,
details regarding parking, methods of finding transportation, and help with scheduling
appointments.
Health care system support includes benefit packages, mailed recommendations, and reminders.
Once
a behavior occurs, it has an outcome for the individual that either positively or negatively
reinforces the
behavior and influences the predisposition to repeating the behavior in the future. This
conceptualization
of a continuous interaction between individuals and their environment is consistent with social
learning
theory (38).
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We used the reminder telephone call as another type of health care system support. A woman (scheduler) conducted the reminder telephone call. She was already employed within one radiology department to schedule procedures on an automated appointment log. Like the motivational callers, she was allowed up to eight attempts to call a woman during evenings and weekends but stopped if no contact was made after all attempts. According to the study protocol, the scheduler could make an appointment and answer simple questions about logistics, but she could not elicit concerns about participation in screening. If concerns arose during the call, the protocol specified that the scheduler referred the woman to the BCSP office or to her primary care physician for further discussion.
The motivational call represents a more elaborate health care system support that also was
designed to address predisposing characteristics of women and enabling factors in the
environment. We
developed the motivational call based on the framework described above and principles of
motivational
interviewing (37,43). Development and implementation of the call are
described in detail elsewhere (44). We drafted responses to expected
cognitive and affective factors regarding mammography, as well as perceived risks, and
anticipated
logistic considerations. Samples of these factors and responses are shown in Table 1.
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Statistical Methods
All analyses are two-sided, with a statistical significance level of .05. We compared randomized groups for differences in demographic characteristics and prior health experience by use of chi-squared tests and analysis of variance. We used Cox proportional hazards models to estimate the hazard ratio (HR) and 95% confidence interval (CI) for documented mammography use by 1 year (45). Such an analysis allowed us to account for loss of women during the postintervention period and to demonstrate the relationship between the intervention and the occurrence of the mammogram. The time axis was time since randomization. Randomization occurred approximately 2 months after the mailed recommendation. We used an intention-to-treat approach in this analysis and kept all women in their randomized group up to their departure from GHCPS, their death, or the end of the observation period. An observation was censored if the woman left GHCPS or died, or if follow-up exceeded the study observation period and no mammogram occurred. Following random assignment, women were followed for 10 months (12 months following the mailed recommendation). Mammograms after that period were excluded because women could have received a subsequent screening recommendation. We found a differential main effect of the interventions in analyses stratified by prior mammography experience. Therefore, in a joint model including all women, we tested for an interaction between the main effect of the intervention and mammography experience. Subsequently, we elected to perform two parallel analyses separating women by prior mammography experience. Because race, education level, and income have been shown to be associated with mammography use in other cross-sectional studies, we considered whether the interventions had differential effects across these variables by entering them in the model and testing for a main effect. If a main effect was present, we also tested for an interaction that would suggest the interventions worked differently as income and education levels increased or race varied.
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RESULTS |
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The study women (n = 3743) came from among all apparently eligible women (n = 11 570) who were randomly selected to be approached (n = 6147) and then remained study eligible (n = 5062). Among the women approached, a higher proportion of women with prior mammography (3193 [63%] of 5031) consented to the study compared with women without prior mammography (550 [49%] of 1116). Four hundred one (41%) of the 968 women who refused the study obtained a mammogram by 1 year. One thousand six hundred twenty-seven (83%) of the 1965 women who scheduled mammograms and were ineligible for the trial obtained a mammogram by 1 year after receiving the recommendation letter.
The randomized trial included 1765 women who did not schedule a mammogram by 2
months from
the mailed recommendation. Table 2 shows the demographic
characteristics
and preventive behavior of these 1765 trial women. The table shows these characteristics
categorized
by prior mammography experience. Compared with women with prior mammography, women
without
prior mammography were more likely to report low income, low education level, and less use of
Pap
smears but they did not differ in age, race, marital status, employment, and smoking status.
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Intervention Implementation
Characteristics of the reminder and motivational telephone
interventions are similar, as shown in Table 3. The
proportion of women contacted and the mean number of attempts were
nearly identical. The mean reminder call time was substantially shorter
than the motivational call by about 5 minutes. A somewhat higher
proportion of women scheduled mammography during the motivational call
compared with the reminder call.
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Table 4 shows the proportion of trial women who
obtained mammograms by 1 year subsequent to the mailed recommendation
to schedule an examination. The proportion is lower in the postcard
reminder group (35.4% [209 of 590]) compared with either the
reminder call (51.8% [303 of 585]) or the motivational telephone
call (49.8% [294 of 590]) groups and nearly identical in these
latter two groups. Eighty-two women left GHCPS without getting
mammograms before the completion of the 1-year follow-up period and,
therefore, are in the denominator but not the numerator of these proportions.
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The motivational and reminder calls (average length, 8.5 and 3.1 minutes, respectively) had
equivalent effects (HR = 0.97; 95% CI = 0.8-1.2) (not shown in Table 4). After we controlled for the intervention effect, women with prior
mammography (n = 1277) were much more likely to get a mammogram (HR =
3.4;
95% CI = 2.7-4.3) than women without prior use (n = 488). Higher income
(HR
= 1.6; 95% CI = 1.59-2.4) but not race or more education was associated
with
higher adherence (not shown in Table 4
). Tests for interactions between
income or prior mammography use and the effect of any telephone intervention were not
statistically
significant.
Table 5 shows separate models among women with and without prior
mammograms. The effects of the reminder and motivational calls are the same within each strata
of
prior mammography experience. The effect of any call (i.e., either the reminder call or the
motivational
call) appears to be larger among women without prior mammography examinations. As noted
above,
this apparent difference is not statistically significant when tested for in a joint model. Models 1,
2, and
3 in Table 5
test, respectively, for an effect of age, race, or education
level
over and above the intervention and do not show statistically significant associations. Model 4
tests for
the additional association of higher versus low income (
$15 000 per year and
>$15 000 per
year) and demonstrates a statistically significant association. Both women with and without
mammography are more likely to get a mammogram if they have higher incomes.
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DISCUSSION |
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One potential limitation of this trial is that it occurred within a staff-model HMO. Although the population of women served by this HMO is predominantly English speaking, Caucasian, and educated, historically, only 65% adhered to a mailed recommendation (31). At the baseline, many demographic factors associated with prior mammography use in other studies were also found in these women, including higher education levels, higher income, and using other preventive services such as Pap tests (6,17,39). These similarities suggest that the findings from these women may have application beyond the HMO population alone. However, other factors, such as younger age, being married, and being a nonsmoker, were not associated with mammography use in this population, although they have been elsewhere (6). Prior work has already shown that older women are more likely to schedule a mammogram when it is recommended, so the lack of an age differential among women with and without mammography here reflects the program's regular reminders (40,46). The lack of other differences may also reflect response to these reminders, but the possibility that women enrolled in HMOs differ from other women must also be considered. Replication of the trial in more diverse populations is indicated to evaluate whether simple reminder calls are efficacious. A simple intervention would have distinct advantages for groups where intervention resources may be less than those available in this HMO.
Even though the results may be best generalized to populations within HMOs, those numbers are growing. They now cover more than 140 million individuals and this number grew nearly 42% between 1992 and 1994, according to the American Association of Health Plans (47). Within managed care, there is a rising reliance on process measures to evaluate their performance (48). Mammography use is one key measure, so the findings of this trial should have a growing audience, with an increased interest. Within this growing potential audience, the findings are best generalized to Caucasians with a somewhat higher than average education level. However, this population is at somewhat increased risk for breast cancer and will benefit from promotion activities, since mammography use after a recommendation barely meets the level of the earliest randomized trial (2,31,49).
One of the advantages of using the defined population of an HMO is that we can identify who is in the study and who is not and we can measure the behavior of each. The proportion of women getting mammograms among all potentially eligible women was larger among those who consented to the study than among those who did not. There is always suspicion that people who consent to studies are different from those who do not, and these results give credence to that suspicion.
We can also see that that there was differential study enrollment among women with and without prior mammograms. Only 49% of the women without prior mammograms enrolled in the study compared with 64% with prior mammograms. However, within our study, we randomly assigned women within the strata of women with and without prior mammography experience and then conducted the analysis within those strata. The statistical significance of the relative effects of the interventions should, therefore, be valid.
It should be clear from these numbers that prior mammography experience influences future mammography experience. Knowing the proportion of women who have prior mammography experience is critical to understanding results from this and other trials. It is also apparent that women without prior mammograms are a group who have a low, but not zero, probability of getting a mammogram. Some of them may have good reason not to get mammograms. For example, 143 women who appeared eligible were actually too ill.
The overall effect of our telephone intervention was similar to that found in other studies. To our knowledge, of the three other trials (8,21,22) that tested telephone counseling, only Janz et al. (22) report that prior mammography was considered. An effect was not reported (22). The study by King et al. (8) is closest in design to ours and was conducted in the early 1990s. They used motivational calls compared with a reminder card and tripled the odds of getting a mammogram (OR = 3.0; 95% CI = 1.8-5.1) (8). We demonstrated a similar effect among women without prior mammograms, but our interventions had a somewhat lower effect among other women and we could not distinguish between the motivational and reminder calls. Since King and colleagues did not report prior mammography use, we cannot evaluate whether the magnitude of their reported effect is due to a more influential call or a higher proportion of women without mammography experience. On the basis of the results of our work, future studies of motivational calls should account for prior screening in their analyses and include a reminder call arm as a control.
For women with and without prior mammography, a brief reminder telephone call may be as effective as a motivational call to promote adherence. The relative effect of the two calls is important to evaluate for both practical and theoretic reasons. Both calls had an effect similar to the motivational call in King's earlier work. With the growing pressure to increase efficiency and productivity, use of a brief reminder call has distinct advantages over the costs and complexity of a motivational contact. Although the results may have their greatest application in managed care, the implementation of prevention in practice has become a high priority, and this simple approach may have appeal, even for physicians in small group or solo practices (50,51). From the theoretic standpoint, it is important to understand how interventions work and may, therefore, generalize to other situations. The absence of a simple reminder call in other studies makes it impossible to know whether the effect of their intervention was due to addressing barriers or simply to calling and reminding. This study suggests that calling and reminding may be as important as addressing barriers.
Although it may be that the reminder call is as effective as the motivational call, an alternative explanation is that the motivational call did not address women's barriers. This alternative is not supported by evidence from the logs kept by the counselors. Previous work and our conceptual model predict that women with prior mammography experience may be more concerned with logistical issues and that women without prior mammography may be more concerned about its risks and benefits (41,52). The counselors' notes show that they addressed beliefs about mammography more frequently among women without prior mammography. Among women with prior mammography experience, the counselors addressed facilitating conditions, such as parking and logistics (44). Although the motivational calls appear to address barriers differentially, it does not appear that this work delivered advantages over simply providing a reminder call. There is the potential that the effect of a call is larger among women without prior mammography.
Both the reminder and motivational callers had the capability to schedule appointments. It may be that this capability was the most important factor in promoting mammography. Prior studies did not have this capability, although it has now become more widely available and was included in a study by Davis et al. (53). Davis and colleagues showed a positive effect of the call compared with a birthday card reminder but only among women already contemplating getting a mammogram (OR = 3.6; 95% CI = 1.7-7.6). They did not compare their motivational call with a scheduling call, so, like our study, the independent effect of being able to schedule an appointment cannot be determined. It appears that having the capability to schedule an appointment during a call is a wise strategy but needs further testing to measure its additional effect over the reminder call alone.
There is now a strong set of studies (23,54) demonstrating that reminder mailings subsequent to a recommendation to schedule will increase mammography use. In prior work (24), we demonstrated that reminder cards increased the odds of a mammogram by 80% over usual care. This study demonstrates that telephone calls result in a higher proportion of women getting the mammogram compared with simply sending a card. One logical approach would, therefore, be to use the interventions in series. Those women who do not schedule mammography subsequent to a reminder card could be subsequently contacted for a reminder call. Such an approach may provide a cost-effective option compared with planning telephone contacts to all women.
Given the increased interest in implementing prevention and achieving high rates of mammography, simple interventions have an appeal. Even under the best circumstances where health care is covered and women are regularly reminded to seek mammography, surprisingly small proportions take advantage of the opportunity (31). This randomized trial demonstrates that higher proportions of women can be encouraged to adhere to recommendations. Reminding women to schedule a mammography appointment was as efficacious as addressing barriers, regardless of prior mammography experience. To promote adherence to screening mammography recommendations, reminding may be as important as addressing barriers. Simple interventions should be included as comparison groups in randomized trials so that we better understand more complex intervention effects. Doing the simple things first has the potential to increase the proportion of women screened.
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NOTES |
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We acknowledge the diligent attention to detail and persistence of Nancy Snell during the study and manuscript preparation.
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Manuscript received February 9, 1999; revised November 15, 1999; accepted November 22, 1999.
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