This study provided preliminary
evidence that the PPCA designed to educate patients about their personal need for colorectal cancer screening and to alert their providers about CRC screening status promoted patient-provider discussion, provider recommendations, and positive patient intentions to obtain screening. The intervention was designed to provide simple personalized information about need for screening in a form that was readily accessible to patients. Rather than tailoring the intervention to literacy levels we used language, concepts and visuals suitable to people with varying degrees of education and health literacy. Process data showed that the PPCA was highly acceptable to all patients, including those who were older and had less education. Similar to several other studies, the intervention appears to have facilitated a clinical situation where prepared patients and providers were more likely to engage in productive discussions of a challenging topic.36 – 38
Strengths of this pilot study included recruitment of intervention and comparison groups from five representative rural group practices. The outcome variables for the study provided evidence that the intervention stimulated higher levels of effective interaction between patient and provider, as intended, with significant effects on provider recommendations and patient intentions, two strong predictors of screening behavior. Consistent results favoring the intervention group across 5 practices provided confidence in the generalizability of results to the rural northern communities in which the intervention was tested.
The PPCA achieved its goals of engaging rural patients from a wide range of ages and educational backgrounds and providing them with personalized educational messages about CRC screening. The program was carefully developed to meet the needs of patients with lower as well as higher levels of knowledge and skills. The amount of information presented on any screen, the formats for presenting the information, and the branching pathway for question and information personalization were all carefully designed to be usable and appealing to most adults. It is possible also that success in appealing to patients with lower levels of education or low literacy was achieved by the delivery of messages through sound as well as text; process evaluation suggested that this was an appealing feature for older patients and those with less education. Nearly all participants, regardless of age or education, found the tablet program to be “very easy” to use. The efficient flexibility of the PPCA in collecting personal information and delivering these message qualities was a significant advantage, and builds upon other research with tablet computers that successfully collected patient history and risk factor information to stimulate screening behavior.21, 39
The provider component of the intervention also appeared to work well. This component consisted of a simple notice placed in the patient's chart prior to their medical visit indicating self-reported CRC screening status, intentions to be screened, and risk factors. Discussion of colonoscopy screening was reported for approximately twice as many intervention as comparison patients. Brief interviews with staff and providers at the end of the study found that this intervention was not intrusive and most providers found it useful.
The increase in likelihood of provider recommendation to obtain CRC screening and particularly a colonoscopy as a result of the intervention is notable since this factor has been found to be one of the major influences on patients' decision to be tested.3, 4, 40
Although this assessment is based solely on posttest reports, the results are consistent with the conceptual framework that focused on facilitating discussion between patient and provider about the advantages and disadvantages of this sometimes difficult decision as a step toward formation of positive intentions.25, 26
Some barriers to wider use of this type of intervention in rural primary care practices were encountered. Solo practices were not able to complete the study because there was insufficient space for a research assistant; lack of flexibility in solo practices could be an obstacle to introduction of even simple technology innovations. A related issue was encountered when practices required patients to use the PPCA in a private area rather than in the waiting room. The practices in general did not want to manage patient questions about how to operate the tablet program. These types of issues represent challenges to intervention developers to design simple, self-explanatory programs that also provide convincing patient privacy protection.
The design for this pilot
study had some features that limit confidence in the results. Although the study included a comparison group, patients were not randomly allocated to conditions, and the comparison group was systematically recruited at a slightly earlier time. The outcomes were important predictors of obtaining screening, but did not assess actual screening behaviors. The project did not have sufficient resources to conduct a complete chart review of all participants to see if screening actually occurred. Intentions to screen and actually being screened may be different. The practices were targeted for recruitment because they were representative of primary care services in a rural area but were not randomly chosen. The practices that volunteered may be different from other rural practices and may be better at influencing patient screening intentions. It should also be noted that the levels of patient reported CRC screening in these practices was relatively high. Previous studies of the accuracy of self-reported CRC screening are mixed but increase with age.41, 42
The study provided useful information about intervention effects within this demographic segment, but no information was obtained for impact on other racial/ethnic groups or non-rural patients.
Results of this study provide insights on methods for increasing participation in CRC screening among difficult to reach populations. The design of this intervention was intended to facilitate discussions about screening between patients with low levels of education or health literacy and their providers; the outcomes suggest that this goal was achieved with a positive effect on patient screening intentions. Higher levels of patient readiness to receive and act on a provider screening recommendation may increase the chances that a provider will invest the time needed to present a rationale and make a recommendation, and increase the chances that the recommendation will be followed. The general strategy of focused preparation of patients immediately prior to a medical visit could be extended to other cancer prevention and control problems. A further finding of interest is that the intensive efforts to shape the messages built into the PPCA for the needs of lower education and health literacy patients appeared to have a favorable effect for other patients; simple well-presented messages about important health issues may generally be beneficial for all patients.43
The trend of using computer tablets in health care settings as a data-gathering tool is likely to continue because of the expected efficiencies when this approach is linked with electronic health records.44
This pilot study had limited resources to take advantage of all the potential tailoring that was possible from the data collected. One of the notable benefits of using a computer tablet is that it is able to tailor messages to the individual by characteristics such as race and ethnicity, educational skill level, age, risk of a disease and by interest in obtaining and using health information.20, 45
This flexibility of data collection and presentation of personalized health information also will allow for selection of multiple languages and cultural customization for patients from diverse populations in the same setting. The next step is to test this intervention in a randomized controlled trial with a more diverse population. The next trial would continue the formative research with new populations of intended audiences and take advantage of the PPCA's ability to tailor the messages and the presentation to the individual.
A brief patient intervention prior to medical visits appeared to increase discussion of CRC screening needs at the visit, increase provider recommendations to obtain screening, and increase patients' intentions to obtain a screening test. Although the study design precluded clear cut conclusions, the consistency of the outcome and process results across multiple test sites provided encouragement for further exploration of this approach to increasing cancer screening participation.