The findings from the survey and the focus groups suggest that the participants had favourable attitudes toward the use of reminder letters to maximize screening mammography. Despite these favourable opinions, a substantial number of survey respondents did not remember receiving letters, although reminders were mailed to the same addresses as the questionnaires. This is consistent with findings from a survey exploring patient attitudes toward reminders for cholesterol screening, which also found that many respondents did not recall reminders or their contents.12
Not surprisingly, the personalized reminder letters from family physicians influenced women’s decisions to have mammograms and were seen as reflecting the physicians’ support for preventive screening. Previous studies found similar results but these were based on face-to-face counseling rather than mailed letters.10,11
Respondents who did not find the reminder letters helpful might have already scheduled appointments or decided to do so before receiving the letters. Alternatively, women who did not find the letters helpful might have been the same ones who did not get mammograms.
While there is substantial evidence supporting different reminder modalities to increase the use of preventive services, there are very few studies that have examined how such proactive interventions are viewed by the patients themselves.12,15–17
Some evidence suggests that attention to the format and content of patient reminder letters will likely further enhance their effectiveness.3,12
Ornstein et al conducted focus groups in which patients were asked to evaluate the reminder letter and other preventive services reminder materials used in an earlier study. The findings from these focus groups resulted in the development of a warmer, more personal letter, sent to patients at the time of their birthdays, that included a leaflet describing the rationale for preventive services and answering common questions about prevention.15
There is also some evidence suggesting that older patients are more likely to find reminders helpful18
and that stronger patient-provider relationships, with high levels of trust, are associated with improved adherence to recommended preventive services.19
It is also important to point out that the larger demonstration project of a reminder and recall system for preventive care services, on which our study was based, sent a second reminder that included patient education leaflets to eligible women who remained unscreened after the first letter. In our survey, however, only a random sample of women who received the first reminder letter was included.
There are several limitations to our findings. First, the questionnaire might have biased the results, as it was developed by the investigators and was not assessed for validity or reliability beyond face validity. The substantial proportion of women who did not remember the reminder raises concerns about the credibility and accuracy of other responses. This was a self-administered cross-sectional survey, and the response rate, while low, is consistent with response rates for similar mailed surveys of patients in family practices.20,21
The reminder letters included a brief explanation of the rationale for screening mammography, and relatively few women were interested in additional information about mammograms. The focus group discussions revealed that women who had been screened, and therefore would have viewed videos or had the procedure explained to them before the test, felt they were adequately informed, but that women who had not yet been screened might benefit from additional information. Consequently, reminder letters should be tailored to women’s needs, and letters sent to women who are newly eligible for screening mammography should include additional educational resources.
The cumulative evidence around the use of reminder letters to increase the use of preventive services clearly establishes their effectiveness, and there is growing evidence that the patients welcome such letters. Furthermore, these reminders appear to be particularly effective when they originate from one’s own family physician, are personalized, and are coupled with relevant educational content. Eliciting patient feedback on reminder systems for preventive services can help ensure that features important to patients are included, thus further improving their acceptability and effectiveness.