Comparing tailored and narrative worksite interventions at increasing colonoscopy adherence in adults 50–75: A randomized controlled trial
Introduction
Colorectal cancer (CRC) is the third most common cancer in men and women, and accounts for almost ten percent of cancer deaths in the United States (Siegel, Naishadham, & Jemal, 2013). These rates have been declining for two decades, due in part to increased utilization of CRC screening (Smith, Brookes, Cokkinides, Saslow, & Brawley, 2013). CRC screening has been advocated for adults aged 50–75 since the early 1980s (Vernon et al., 2011), but adherence is under 60% nationally (Smith et al., 2013). Given the health benefits of CRC screening – and its inclusion as a national public health objective – identifying strategies to increase participation in screening is a priority.
One communication strategy that has increased CRC screening adherence is tailoring (e.g., Manne et al., 2009). Tailoring is the personalization of information based on user characteristics (Kreuter, Farrell, Olevitch, & Brennan, 2000). Instead of crafting a message for everyone (stock messages) or for a particular group or demographic (targeted messages), tailoring involves the creation of unique messages for each individual (Rimer & Kreuter, 2006). For example, a targeted message might be designed for Hispanic men in general whereas a tailored message would address the attitudes, beliefs, and risk factors of a particular Hispanic man. Thus, tailoring provides information relevant to the individual rather than the group. Meta-analyses have revealed that tailored messages are more effective than untailored messages at increasing adherence to cancer screening recommendations, though the typical effect is small (r = .08, 95% CI: .06, .09) and most studies have relied on self-report measures of screening (e.g., Krebs et al., 2010, Noar et al., 2007).
An alternative strategy is to use narratives to increase CRC screening adherence (Green, 2006). Narratives are also called stories and include characters and a string of connected events (Kreuter et al., 2007). CRC screening narratives often depict individuals grieving lost loved ones, overcoming challenges, benefitting from behaviors, or using services (Dillard, Fagerlin, Dal Cin, Zikmund-Fisher, & Ubel, 2010). Narratives may be effective at changing behavior because people enjoy stories, become absorbed in the plot, and may be less likely to reject (or even notice) counter-attitudinal information (Dal Cin et al., 2004, Moyer-Gusé and Nabi, 2010, Slater and Rouner, 2002). Narratives are also effective vehicles for conveying information that is culturally aligned or centered (Larkey & Hecht, 2010). Communication researchers have noted that narratives are a promising strategy for increasing cancer screening participation, and these approaches are being used more frequently in promoting health and wellness (Kreuter et al., 2007).
To compare tailoring and narrative communication strategies, a randomized controlled trial (RCT) was developed and carried out at eight worksites. In the RCT, adults were randomly assigned to receive one of four pamphlets about CRC screening: stock, narrative, tailored, or tailored narrative. In the latter, the pamphlet was personalized to participants' characteristics and included a narrative with a protagonist from the same gender and racial/ethnic demographic. The main outcome of interest in this study was CRC screening behavior. To measure this outcome, insurance claims data were collected 18 months after the intervention for each participant to track CRC screening. Thus, the current study examines the effectiveness of two different strategies (alone and in combination) and utilizes a more objective measure of behavior (insurance claims data) than many previous studies.
Section snippets
Tailoring
Tailored messages were originally crafted by hand and evaluated via tailored letter interventions or tailored counseling (Kreuter, Strecher, & Glassman, 1999). Innovations in communication technology have facilitated tailoring efforts by replacing hand tailoring with computerized algorithms (e.g., Jensen, King, Carcioppolo, & Davis, 2012). Computerized, algorithmic-based tailoring can provide people with personalized information quickly and makes this approach more sustainable for interventions
Study design
A 2 (stock vs. tailored) × 2 (no narrative vs. narrative) message intervention was carried out in eight Indiana worksites (six hospitals and two manufacturing plants). Participants completed a pretest on a computer (Time 1) and then were randomly assigned by the computer to one of four intervention conditions: stock (no narrative, no tailoring), narrative (narrative, no tailoring), tailored (no narrative, tailored), or tailored narrative (narrative, tailored). The message intervention was
Results
Three hierarchical logistic regressions were utilized to evaluate the effectiveness of tailored and narrative message approaches. The regression was not significant for FOBT claims, Cox & Snell R2 = .09, −2 Log Likelihood = 41.86, χ2 = 19.18, df = 15, p = .206, and it was only significant at the second block for the combined category, Cox & Snell R2 = .07, −2 Log Likelihood = 133.05, χ2 = 4.26, df = 1, p = .039. Individuals with greater CIO were less likely to file a CRC cancer screening claim,
Discussion
Researchers from a number of fields have examined strategies for increasing CRC screening adherence. These efforts have yet to identify a cost-effective strategy that consistently increases screening adherence. Vernon et al. (2011) noted this following the failure of another randomized controlled trial:
To date, as a research community, we have yet to identify an intervention approach for CRC screening that is consistently more effective than usual care or minimal cues despite using the best
Acknowledgments
Jakob D. Jensen (Ph.D., University of Illinois, 2007) is an Assistant Professor in the Department of Communication and the Department of Health Promotion and Education at the University of Utah. Andy J. King is an Assistant Professor in the Department of Public Relations at Texas Tech University. Nick Carcioppolo is an Assistant Professor in the Department of Communication at the University of Miami. Melinda Krakow is a doctoral student in the Department of Communication at the University of
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