Increasing screening uptake amongst those intending to be screened: the use of action plans
Introduction
People who intend to perform a health-related behaviour do not always carry out this intention. Indeed, intention usually accounts for no more than 20–30% of variance in behaviour [1]. This limits the usefulness of psychological models of behaviour, such as the theory of planned behaviour (TPB) [2], which are based on the premise that identifying cognitive predictors of intention are key to understanding planned behaviour and behaviour change. It is likely that a key aspect of successful behaviour change lies in what happens after, rather than before, an intention is formed.
Since the 1960s, studies have found that behaviour does not change merely as a result of presenting fear-inducing health messages [3], [4], [5]. However, if a threatening health message is combined with an action plan, i.e. a detailed plan as to when, where and how to carry out a recommended health behaviour within everyday activities, the likelihood of the behaviour occurring increases. In two studies, one of uptake of tetanus inoculation [3], and one of smoking cessation [4], behaviour changed in the desired direction following the combination of a threatening health message and an action plan.
It appears that thinking about future behaviour in relation to specific environmental cues of when, where and how to enact a particular behaviour increases the frequency of that behaviour. Since the 1960s, this technique of behavioural planning has been used routinely by clinical psychologists and by other professionals whose work is aimed at psychological change [6].
More recently, action plans have been studied under a different name, that of “implementation intentions” [7], [8]. Implementation intentions have the structure: “When situation x arises, I will perform response y”, with the situation being specified in time and place. Participants typically are asked to make their own plan of “when and where” they will implement a given behaviour. A meta-analysis of 15 such studies found an overall weighted average correlation of 0.33, a medium effect size [9].
Most of the studies included in this meta-analysis were of students. Most involved completing action plans in a “laboratory” or lecture theatre setting. Only two involved patients. One of these was a study of surgical patients which found that people who complied with a request to write down when and where they would resume a number of specific functional activities, such as putting on shoes and socks, reported resuming these activities more quickly than those who did not form such plans [10]. There was no difference in intention between these self-selected groups of completers and non-completers, but there was no control group in the study. There may, however, have been differences, associated with completion of action plans, such as barriers to making changes, that accounted for the difference in reported activity resumption.
The second clinical study found that women randomly allocated to completing an action plan of clinic attendance for cervical cancer screening subsequently attended more frequently than a control group [11]. Ninety-three percent of the intervention group who returned questionnaires completed an action plan. The fact that this is more than twice as high as the compliance rate reported in the study of surgical patients, discussed earlier, may reflect a bias in the cervical screening sample. Only 52% of those approached agreed to participate in this study and these women had responded more promptly to previous screening invitations than non-participants. Information about socio-economic status of the two groups was not reported.
In summary, whilst the effectiveness of action plans has been demonstrated in students and student settings, evidence for their effectiveness in changing health behaviours in clinical situations is sparse.
One clinical situation in which planning may help people to achieve their goals is that of antenatal screening for Down’s syndrome amongst pregnant women. The aim of this screening programme is to offer pregnant women an informed choice about whether or not to undergo screening [12]. An informed choice has been defined as:
one that is based on relevant knowledge, consistent with the decision-maker’s values and behaviourally implemented [13].
In an observational study of informed choice, 20% of 883 women offered serum screening for Down’s syndrome who were found to hold positive attitudes towards undergoing screening did not subsequently undergo it [14]. This sample was from a hospital in England serving a population that was mixed both in ethnic background and in socio-economic status.
The current study aims to test the hypothesis that asking pregnant women who intend to undergo serum screening to make an action plan in an antenatal clinic increases screening uptake. This also increases rates of informed choice for this group, since behaviour is more consistent with intention.
Section snippets
Method
Women were allocated to either the intervention or the control group in alternating sequence as they were recruited.
Results
Unbiased allocation was achieved in that there were no differences between the intervention and control groups in response rate, demographic characteristics, attitude towards undergoing screening and strength of intention (Table 1). Within the intervention group, there were no differences in these variables between those forming an action plan to make an appointment and those forming an action plan to attend an appointment already made. In addition, there was no difference in uptake between the
Discussion and conclusion
The study hypothesis is not supported: asking pregnant women who intend to undergo screening to make an action plan in an antenatal clinic does not increase screening uptake. Only 63% of the intervention group made an action plan. Planners were no more likely to undergo screening than the control group but were more likely to undergo screening than non-planners, even when demographic differences between the groups were controlled for. This suggests that higher uptake reflects differences
Acknowledgements
This study was funded as part of a programme grant from The Wellcome Trust entitled “Psychological and Social Implications of the New Genetics”. Susan Michie, Elizabeth Dormandy and Theresa M. Marteau are funded by The Wellcome Trust.
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