564018 research-article2014
HPQ0010.1177/1359105314564018Journal of Health PsychologyVallet et al.
Article
Influence of a screening navigation program on social inequalities in health beliefs about colorectal cancer screening
Journal of Health Psychology 1–11 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105314564018 hpq.sagepub.com
Fanny Vallet1, Elodie Guillaume2, Olivier Dejardin2, Lydia Guittet2, Véronique Bouvier2, Astrid Mignon1, Célia Berchi2, Agnès Salinas3, Guy Launoy2 and Véronique Christophe1,2
Abstract The aim of the study was to test whether a screening navigation program leads to more favorable health beliefs and decreases social inequalities in them. The selected 261 noncompliant participants in a screening navigation versus a usual screening program arm had to respond to health belief measures inspired by the Protection Motivation Theory. Regression analyses showed that social inequalities in perceived efficacy of screening, favorable attitude, and perceived facility were reduced in the screening navigation compared to the usual screening program. These results highlight the importance of health beliefs to understand the mechanism of screening navigation programs in reducing social inequalities.
Keywords colorectal cancer screening, health beliefs, screening navigation intervention, social inequalities
Introduction Colorectal cancer is the third most common cancer and the second cause of mortality by cancer in France (Institut National du Cancer (INCa)).1 Because treatment efficacy is better if colorectal cancer is detected at an early stage, screening is considered a major means of improving the prognosis of this cancer. In France, screening takes place via a national organized screening program, which invites people to consult their general practitioner (GP). GPs are in charge of evaluating individual risks and encouraging the use of fecal occult blood testing (FOBT) for people aged between
1Unity
of Cognitives and Affectives Sciences (URECA) Lille 3 University, France 2U1086 INSERM UCBN “Cancers & Préventions”, University Hospital of Caen, France 3EA 3918 CERReV (Centre d’Etude et de Recherche sur les Risques et les Vulnérabilités), University of Caen, France Corresponding authors: Fanny Vallet and Véronique Christophe, Unité de Recherche en Science Cognitives et Affectives (URECA), Université Lille 3, Domaine universitaire du Pont de Bois, BP 149, 59653 Villeneuve d’Ascq Cedex, France. Email: [email protected]; [email protected]; [email protected]
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2
Journal of Health Psychology
50 and 74 years with an average risk of cancer. However, despite this national program in France, as in similar western countries, screening participation is still low and unequal, and depends on socioeconomic status (Champion et al., 2014; Frederiksen et al., 2010; Javanparast et al., 2010). For instance, screening participation is higher for people living in a privileged geographical area than in a deprived geographical area (Pornet et al., 2010). In response to the need to reduce social inequalities, there are various levels of intervention for health policy-making according to the main sources of influences on health being considered. These range from general socioeconomic, cultural, and environmental conditions to individual factors (Dahlgren and Whitehead, 1991). Regarding screening, the major factors associated with low adhesion can be organizational (e.g. national recommendations for testing, insurance coverage system, provider-related variables) and individual (e.g. demographic variables, health-related behaviors, social support, stress, life difficulties, temporal orientation, language, medical mistrust, defense strategies, religiosity; Berkowitz et al., 2008; Cokkinides et al., 2003; McQueen et al., 2014; Power et al., 2008; Vernon, 1997; Wee et al., 2005). Based on an individual approach, a growing literature has pointed to the effectiveness of screening navigation programs (SNPs) in decreasing social inequalities (Lasser et al., 2011; Paskett et al., 2011; Percac-Lima et al., 2009; Wells et al., 2008). In a pro-active way, SNPs have aimed to identify and remove the remaining individual barriers to screening (Dejardin et al., 2011; Freund et al., 2008). These barriers can be logistical (e.g. transportation or financial issues, lack of discussion of screening with GPs) or linked to individual knowledge, emotions, and beliefs (e.g. need for information, explanation of the screening efficacy, and need for reassurance). SNPs have mostly been developed in the United States, while, to our knowledge, no program has been carried out in France. In this work, the mechanisms of action of a French screening navigation were investigated.
The study focused especially on perceptions about screening and colorectal cancer, that is to say health beliefs, which have previously been shown to be linked to screening participation (Gorin, 2005; Janz et al., 2003; Kiviniemi, 2011; Stanley et al., 2013) and socioeconomic status (Wardle et al., 2004; Whitaker et al., 2011). Given that SNPs act against barriers such as knowledge, emotions, and beliefs, they should lead to greater adhesion to health beliefs encouraging screening participation (e.g. perceiving oneself more vulnerable, perceiving screening as more effective). The theoretical framework of the Protection Motivation Theory—originally developed to explain fear appeal processes leading to the motivation to adopt protective behavior (Floyd et al., 2000; Rogers, 1983)—assumes that two processes lead to the motivation to protection: threatappraisal and coping-appraisal. More specifically, the threat-appraisal component refers to the perceived severity of cancer and the perceived vulnerability of having cancer. Severity and vulnerability could increase the likelihood of adopting the recommended behavior. The coping-appraisal component refers to the ability to cope by adopting the recommended response, here the screening. It comprises beliefs in the response efficacy, in self-efficacy, which increases the likelihood of adopting the recommended behavior, and in the costs that decrease this likelihood. All of these components, which are known to motivate people to protection, were assumed to be influenced by screening navigation (SN). To our knowledge, no previous study has tested the impact of an SNP on health beliefs. Assessing health beliefs is a promising way to (1) evaluate a secondary outcome of the effectiveness of an SNP that may influence further screening adherence and reduce social inequalities and (2) provide a better understanding of the mechanisms of SNP action, thus consolidating them. The research aimed to test whether SNPs (1) lead noncompliant people to adopt more health beliefs encouraging them to screen and (2) decrease social inequalities in health beliefs.
Downloaded from hpq.sagepub.com by guest on November 15, 2015
Vallet et al.
3
Method
from responding. Moreover, because the questionnaire was sent to a large variety of people selected at random, perhaps some were not willing to respond to a questionnaire, or had no time or other external conditions. It is also possible that people who did not respond did not feel concerned by the screening, and thus by the questionnaire, especially given the large proportion of nonparticipation in screening among the nonselected sample. Differences between the sample of the 261 responders and the remaining 1955 nonresponders were analyzed and are presented in section “Results.”
Participants Data were obtained from a larger study in France, a cluster randomized trial, stratified by the characteristics of the geographical unit where participants live, and comparing SN and usual screening program (USP) arms (http:// clinicaltrials.gov website ID: NCT01555450). The whole study was conducted in accordance with French law (Council for the Protection of Individuals, Advisory Council for Health Research Information, and Data Protection Authority) and with the ethical principles of the Declaration of Helsinki of 1964 revised in Seoul in 2008. Participants were those who (1) were eligible for the whole study, (2) were eligible to receive a questionnaire, and (3) returned a filled out questionnaire. First, participants selected for the whole study were those (1) eligible for the FOBT (e.g. aged between 50 and 74 years, not suffering from cancer) and (2) with a known address in the geographical units selected. Second, questionnaires were sent to participants (1) included in the study during a defined period of 6 months within the study, (2) with an available phone number, (3) with no regular screening adherence, and (4) from them, only the 2216 participants were retained who had no previous screening adherence and who had been targeted by a previous campaign encouraging them to participate (excluding primo-participants), in order to study noncompliant participants. Third, as self-report measures were of interest, responses to the questionnaire were considered. Of the 2216 questionnaires received by participants, 267 were returned. Among these, data from six participants were deleted because dissimilarities (e.g. gender, age) were detected between the self-report data and those collected by the screening management structures. Thus, the sample was constituted of 261 participants who filled at least in part the total questionnaire. There are various possible reasons for the nonparticipation, for instance, the questionnaire length may have discouraged some participants
Material Postal address was used to determine a geographical unit for each participant: the IRIS (Ilots Regroupés pour des Indicateurs Statistiques; in French, the smallest geographical area with available statistical information). The IRIS were then stratified into their rurality, determined on the basis of the population size of IRIS reference towns, and socioeconomic status. Socioeconomic status was measured by the Townsend Index (Townsend, 1987) assessing deprivation at a geographical level, with a higher positive score meaning a more deprived IRIS. This measure enabled people to be targeted based on information about their socioeconomic status, which was available for all the population selected for the screening program, even in the absence of available individual information. Inspired by the general theoretical framework and models based on the Protection Motivation Theory, components measured by one to several items, relevant in assessing health beliefs (Boer and Seydel, 1996; Milne et al., 2002; Rogers, 1983; Weinstein, 1993), were extracted from a larger questionnaire. Thus, threat-appraisal: perceived severity and perceived vulnerability; problem-solving/screening appraisal: perceived costs, perceived facility (i.e. evaluation that screening was perceived as feasible by the respondent, similarly to self-efficacy), and three measures of perceived efficacy were measured. Moreover, more general measures were added
Downloaded from hpq.sagepub.com by guest on November 15, 2015
4
Journal of Health Psychology
about the value accorded to colorectal cancer screening: overall favorable attitude and the fact that screening is not a priority among other preoccupations. Details are given in Appendix 1. For each item, the response was given on a 5-point scale from 1 to 5. Beliefs were considered favorable, that is to say as having an effect of encouraging screening, when scores were high for severity, vulnerability, perceived facility, perceived efficacy, and favorable attitude and low for perceived costs and not a priority.
Procedure The SN arm, receiving the action of the screening navigator, was distinguished from the USP arm, benefiting only from the national organized screening program. Screening management structures sent an invitation letter, followed by a reminder letter in the case of no adherence, and finally the test was sent 1 year after the first invitation letter in the case of no adherence. The main actions of the three screening navigators were to identify individual barriers to screening and to inform participants about screening and discuss it with them in order to suppress these barriers. The intervention began with a letter (for six participants the intervention was only this letter) and then screening navigators contacted each person by telephone. The questionnaires were sent at least 9 months after the invitation letter by screening management structures for each arm.
Statistical analyses First, the characteristics of participants were analyzed and compared to those of the nonselected participants in order to evaluate the specificity of the respondents. Because of the hierarchical structure of the data with 67 IRIS including the 261 participants, multilevel analyses were conducted. First, using empty models (intercept-only model), the difference between considering intercepts at random and fixed was tested. No significant differences (p > 0.30) were found when the difference of the −2 loglikelihood value between the two models was
tested with a restricted iterative generalized least squares estimation method. Because of these nonsignificant effects and for more simplicity, data were treated with multiple regression analyses. For each regression (one for each belief measure as the outcome variable to be predicted), the following predictors were introduced: SNP (−1 = USP vs 1 = SN), standardized Deprivation Index,2 and the interaction between both these variables. Moreover, analyses were carried out to test the simple effect of Deprivation for USP (0 = USP vs 1 = SN) and for SN (−1 = USP vs 0 = SN). Finally, complementary analyses were conducted that were adjusted regressions for age, gender, the geographical unit rurality, living alone or not, and whether the GP had given information about colorectal cancer screening. Using the Stevens (1984) criterion, Studentized deleted residual outliers higher than the 3.73 absolute value were examined and deleted for each analysis. Statistical Package for the Social Sciences (SPSS) version 21 statistical software was used to analyze data.
Results Participant characteristics The participant characteristics of the selected and nonselected samples are reported in Table 1. The selected sample was not exactly the same as the nonselected one, in particular because the former were mostly those who adhered to screening and those who lived in urban places.
Effect of SN and Deprivation Index on health beliefs The results are presented in detail in Table 2. They showed no significant main effect of SN on any beliefs. However, they did show significant interactions between SN and the Deprivation Index (see Figure 1) on the efficacy of the screening test to detect colorectal cancer, the efficacy of the screening to reduce colorectal cancer consequences, overall favorable attitude,
Downloaded from hpq.sagepub.com by guest on November 15, 2015
5
Vallet et al. Table 1. Participant characteristics.
Arm Screening adherence Geographical unit rurality Deprivation Index Age
Gender Living alonea Informationa given by GP
SN USP Yes No Urban Rural Negative Positive ≤55 >55 and
HPQ0010.1177/1359105314564018Journal of Health PsychologyVallet et al.
Article
Influence of a screening navigation program on social inequalities in health beliefs about colorectal cancer screening
Journal of Health Psychology 1–11 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105314564018 hpq.sagepub.com
Fanny Vallet1, Elodie Guillaume2, Olivier Dejardin2, Lydia Guittet2, Véronique Bouvier2, Astrid Mignon1, Célia Berchi2, Agnès Salinas3, Guy Launoy2 and Véronique Christophe1,2
Abstract The aim of the study was to test whether a screening navigation program leads to more favorable health beliefs and decreases social inequalities in them. The selected 261 noncompliant participants in a screening navigation versus a usual screening program arm had to respond to health belief measures inspired by the Protection Motivation Theory. Regression analyses showed that social inequalities in perceived efficacy of screening, favorable attitude, and perceived facility were reduced in the screening navigation compared to the usual screening program. These results highlight the importance of health beliefs to understand the mechanism of screening navigation programs in reducing social inequalities.
Keywords colorectal cancer screening, health beliefs, screening navigation intervention, social inequalities
Introduction Colorectal cancer is the third most common cancer and the second cause of mortality by cancer in France (Institut National du Cancer (INCa)).1 Because treatment efficacy is better if colorectal cancer is detected at an early stage, screening is considered a major means of improving the prognosis of this cancer. In France, screening takes place via a national organized screening program, which invites people to consult their general practitioner (GP). GPs are in charge of evaluating individual risks and encouraging the use of fecal occult blood testing (FOBT) for people aged between
1Unity
of Cognitives and Affectives Sciences (URECA) Lille 3 University, France 2U1086 INSERM UCBN “Cancers & Préventions”, University Hospital of Caen, France 3EA 3918 CERReV (Centre d’Etude et de Recherche sur les Risques et les Vulnérabilités), University of Caen, France Corresponding authors: Fanny Vallet and Véronique Christophe, Unité de Recherche en Science Cognitives et Affectives (URECA), Université Lille 3, Domaine universitaire du Pont de Bois, BP 149, 59653 Villeneuve d’Ascq Cedex, France. Email: [email protected]; [email protected]; [email protected]
Downloaded from hpq.sagepub.com by guest on November 15, 2015
2
Journal of Health Psychology
50 and 74 years with an average risk of cancer. However, despite this national program in France, as in similar western countries, screening participation is still low and unequal, and depends on socioeconomic status (Champion et al., 2014; Frederiksen et al., 2010; Javanparast et al., 2010). For instance, screening participation is higher for people living in a privileged geographical area than in a deprived geographical area (Pornet et al., 2010). In response to the need to reduce social inequalities, there are various levels of intervention for health policy-making according to the main sources of influences on health being considered. These range from general socioeconomic, cultural, and environmental conditions to individual factors (Dahlgren and Whitehead, 1991). Regarding screening, the major factors associated with low adhesion can be organizational (e.g. national recommendations for testing, insurance coverage system, provider-related variables) and individual (e.g. demographic variables, health-related behaviors, social support, stress, life difficulties, temporal orientation, language, medical mistrust, defense strategies, religiosity; Berkowitz et al., 2008; Cokkinides et al., 2003; McQueen et al., 2014; Power et al., 2008; Vernon, 1997; Wee et al., 2005). Based on an individual approach, a growing literature has pointed to the effectiveness of screening navigation programs (SNPs) in decreasing social inequalities (Lasser et al., 2011; Paskett et al., 2011; Percac-Lima et al., 2009; Wells et al., 2008). In a pro-active way, SNPs have aimed to identify and remove the remaining individual barriers to screening (Dejardin et al., 2011; Freund et al., 2008). These barriers can be logistical (e.g. transportation or financial issues, lack of discussion of screening with GPs) or linked to individual knowledge, emotions, and beliefs (e.g. need for information, explanation of the screening efficacy, and need for reassurance). SNPs have mostly been developed in the United States, while, to our knowledge, no program has been carried out in France. In this work, the mechanisms of action of a French screening navigation were investigated.
The study focused especially on perceptions about screening and colorectal cancer, that is to say health beliefs, which have previously been shown to be linked to screening participation (Gorin, 2005; Janz et al., 2003; Kiviniemi, 2011; Stanley et al., 2013) and socioeconomic status (Wardle et al., 2004; Whitaker et al., 2011). Given that SNPs act against barriers such as knowledge, emotions, and beliefs, they should lead to greater adhesion to health beliefs encouraging screening participation (e.g. perceiving oneself more vulnerable, perceiving screening as more effective). The theoretical framework of the Protection Motivation Theory—originally developed to explain fear appeal processes leading to the motivation to adopt protective behavior (Floyd et al., 2000; Rogers, 1983)—assumes that two processes lead to the motivation to protection: threatappraisal and coping-appraisal. More specifically, the threat-appraisal component refers to the perceived severity of cancer and the perceived vulnerability of having cancer. Severity and vulnerability could increase the likelihood of adopting the recommended behavior. The coping-appraisal component refers to the ability to cope by adopting the recommended response, here the screening. It comprises beliefs in the response efficacy, in self-efficacy, which increases the likelihood of adopting the recommended behavior, and in the costs that decrease this likelihood. All of these components, which are known to motivate people to protection, were assumed to be influenced by screening navigation (SN). To our knowledge, no previous study has tested the impact of an SNP on health beliefs. Assessing health beliefs is a promising way to (1) evaluate a secondary outcome of the effectiveness of an SNP that may influence further screening adherence and reduce social inequalities and (2) provide a better understanding of the mechanisms of SNP action, thus consolidating them. The research aimed to test whether SNPs (1) lead noncompliant people to adopt more health beliefs encouraging them to screen and (2) decrease social inequalities in health beliefs.
Downloaded from hpq.sagepub.com by guest on November 15, 2015
Vallet et al.
3
Method
from responding. Moreover, because the questionnaire was sent to a large variety of people selected at random, perhaps some were not willing to respond to a questionnaire, or had no time or other external conditions. It is also possible that people who did not respond did not feel concerned by the screening, and thus by the questionnaire, especially given the large proportion of nonparticipation in screening among the nonselected sample. Differences between the sample of the 261 responders and the remaining 1955 nonresponders were analyzed and are presented in section “Results.”
Participants Data were obtained from a larger study in France, a cluster randomized trial, stratified by the characteristics of the geographical unit where participants live, and comparing SN and usual screening program (USP) arms (http:// clinicaltrials.gov website ID: NCT01555450). The whole study was conducted in accordance with French law (Council for the Protection of Individuals, Advisory Council for Health Research Information, and Data Protection Authority) and with the ethical principles of the Declaration of Helsinki of 1964 revised in Seoul in 2008. Participants were those who (1) were eligible for the whole study, (2) were eligible to receive a questionnaire, and (3) returned a filled out questionnaire. First, participants selected for the whole study were those (1) eligible for the FOBT (e.g. aged between 50 and 74 years, not suffering from cancer) and (2) with a known address in the geographical units selected. Second, questionnaires were sent to participants (1) included in the study during a defined period of 6 months within the study, (2) with an available phone number, (3) with no regular screening adherence, and (4) from them, only the 2216 participants were retained who had no previous screening adherence and who had been targeted by a previous campaign encouraging them to participate (excluding primo-participants), in order to study noncompliant participants. Third, as self-report measures were of interest, responses to the questionnaire were considered. Of the 2216 questionnaires received by participants, 267 were returned. Among these, data from six participants were deleted because dissimilarities (e.g. gender, age) were detected between the self-report data and those collected by the screening management structures. Thus, the sample was constituted of 261 participants who filled at least in part the total questionnaire. There are various possible reasons for the nonparticipation, for instance, the questionnaire length may have discouraged some participants
Material Postal address was used to determine a geographical unit for each participant: the IRIS (Ilots Regroupés pour des Indicateurs Statistiques; in French, the smallest geographical area with available statistical information). The IRIS were then stratified into their rurality, determined on the basis of the population size of IRIS reference towns, and socioeconomic status. Socioeconomic status was measured by the Townsend Index (Townsend, 1987) assessing deprivation at a geographical level, with a higher positive score meaning a more deprived IRIS. This measure enabled people to be targeted based on information about their socioeconomic status, which was available for all the population selected for the screening program, even in the absence of available individual information. Inspired by the general theoretical framework and models based on the Protection Motivation Theory, components measured by one to several items, relevant in assessing health beliefs (Boer and Seydel, 1996; Milne et al., 2002; Rogers, 1983; Weinstein, 1993), were extracted from a larger questionnaire. Thus, threat-appraisal: perceived severity and perceived vulnerability; problem-solving/screening appraisal: perceived costs, perceived facility (i.e. evaluation that screening was perceived as feasible by the respondent, similarly to self-efficacy), and three measures of perceived efficacy were measured. Moreover, more general measures were added
Downloaded from hpq.sagepub.com by guest on November 15, 2015
4
Journal of Health Psychology
about the value accorded to colorectal cancer screening: overall favorable attitude and the fact that screening is not a priority among other preoccupations. Details are given in Appendix 1. For each item, the response was given on a 5-point scale from 1 to 5. Beliefs were considered favorable, that is to say as having an effect of encouraging screening, when scores were high for severity, vulnerability, perceived facility, perceived efficacy, and favorable attitude and low for perceived costs and not a priority.
Procedure The SN arm, receiving the action of the screening navigator, was distinguished from the USP arm, benefiting only from the national organized screening program. Screening management structures sent an invitation letter, followed by a reminder letter in the case of no adherence, and finally the test was sent 1 year after the first invitation letter in the case of no adherence. The main actions of the three screening navigators were to identify individual barriers to screening and to inform participants about screening and discuss it with them in order to suppress these barriers. The intervention began with a letter (for six participants the intervention was only this letter) and then screening navigators contacted each person by telephone. The questionnaires were sent at least 9 months after the invitation letter by screening management structures for each arm.
Statistical analyses First, the characteristics of participants were analyzed and compared to those of the nonselected participants in order to evaluate the specificity of the respondents. Because of the hierarchical structure of the data with 67 IRIS including the 261 participants, multilevel analyses were conducted. First, using empty models (intercept-only model), the difference between considering intercepts at random and fixed was tested. No significant differences (p > 0.30) were found when the difference of the −2 loglikelihood value between the two models was
tested with a restricted iterative generalized least squares estimation method. Because of these nonsignificant effects and for more simplicity, data were treated with multiple regression analyses. For each regression (one for each belief measure as the outcome variable to be predicted), the following predictors were introduced: SNP (−1 = USP vs 1 = SN), standardized Deprivation Index,2 and the interaction between both these variables. Moreover, analyses were carried out to test the simple effect of Deprivation for USP (0 = USP vs 1 = SN) and for SN (−1 = USP vs 0 = SN). Finally, complementary analyses were conducted that were adjusted regressions for age, gender, the geographical unit rurality, living alone or not, and whether the GP had given information about colorectal cancer screening. Using the Stevens (1984) criterion, Studentized deleted residual outliers higher than the 3.73 absolute value were examined and deleted for each analysis. Statistical Package for the Social Sciences (SPSS) version 21 statistical software was used to analyze data.
Results Participant characteristics The participant characteristics of the selected and nonselected samples are reported in Table 1. The selected sample was not exactly the same as the nonselected one, in particular because the former were mostly those who adhered to screening and those who lived in urban places.
Effect of SN and Deprivation Index on health beliefs The results are presented in detail in Table 2. They showed no significant main effect of SN on any beliefs. However, they did show significant interactions between SN and the Deprivation Index (see Figure 1) on the efficacy of the screening test to detect colorectal cancer, the efficacy of the screening to reduce colorectal cancer consequences, overall favorable attitude,
Downloaded from hpq.sagepub.com by guest on November 15, 2015
5
Vallet et al. Table 1. Participant characteristics.
Arm Screening adherence Geographical unit rurality Deprivation Index Age
Gender Living alonea Informationa given by GP
SN USP Yes No Urban Rural Negative Positive ≤55 >55 and
