Patient Education for Colon Cancer Screening: A Randomized Trial of a Video Mailed before a Physical Examination

Context Many patients who might benefit from colorectal cancer screening do not get screening. Time pressure may prevent physicians from fully educating their patients about colorectal cancer screening. Contribution In this randomized, controlled trial, an educational video about colorectal cancer screening mailed to patients before a primary care visit did not increase the rate of screening compared with usual care. Cautions The video focused on sigmoidoscopy rather than colonoscopy, and the study sample had a higher than average baseline rate of colorectal cancer screening. Colorectal cancer is a major cause of cancer death (1). Evidence about screening test effectiveness (2) continues to mount, and guidelines from many organizations promote several screening options (3-7). Rates of screening, however, remain lower than rates of other preventive services (8-10). Barriers to screening are numerous. Physicians report inadequate time to educate patients and facilitate decision making (11, 12). Contributing factors include competing demands placed on clinicians (13) and the need to manage acute problems (12, 14). Prominent patient barriers include lack of knowledge about colorectal cancer and fears of cancer and screening tests (15, 16). Interventions to increase screening have generally focused on individual providers and clinical systems. Provider education programs, use of support staff, on-site sigmoidoscopy services, and reminder systems have all increased testing (11, 16-23). Patient-focused interventions have used education, reminders, and cost reduction to increase use of fecal occult blood testing (17-19) and sigmoidoscopy (20, 21). This study examined the effectiveness of an educational video designed to increase colorectal cancer screening, particularly via sigmoidoscopy; the video was mailed to patients' homes before a scheduled periodic health examination. We studied the effectiveness of this patient education video for several reasons. First, the information that patients need for colorectal cancer screening is complex and voluminous because of the multiple screening options and the increased emphasis on informed decision making and informed consent (22-26). Clinicians view time demands and competing medical needs as screening barriers (27-29). The video contains considerable information, and thus clinicians can spend less time explaining the information to patients. Second, video assures standardized content that is not subject to providers' individual opinions or weak communication skills. Video overcomes some weaknesses of mass media health messages: brevity, superficial rendering of complex issues, and lack of opportunity for review (30). Third, the public is more oriented toward viewing than reading, and video is particularly attractive to populations with low literacy (31, 32). Last, to our knowledge no other study has evaluated the effect of a mailed video (an aspect that solves in-clinic logistic problems) independent of other systems changes (21). Methods Study Overview We used a randomized, controlled design to assess the effectiveness of a video intended to encourage discussion of colorectal cancer screening with the primary care provider and increase use of screening, particularly by sigmoidoscopy. Standardized telephone interviews were conducted twice. Participants completed the baseline interview several weeks before their scheduled visit and were then randomly assigned within age and sex strata to the experimental or the control group. Follow-up assessment was completed 4 to 6 months after the periodic examination. Study Sites Participants were recruited from 5 sites in central Massachusetts. Most were patients in internal medicine and family medicine clinics of an academic medical center (university practice). Other sites were a suburban clinic of a staff-model health maintenance organization (HMO); 3 university-affiliated, community-based practices; a rural practice; and 2 suburban practices, which were combined for analyses because of small sample sizes and similar patient populations (community practices). The Committee for the Protection of Human Subjects of the University of Massachusetts Medical School and the Institutional Review Board of Fallon Community Health Plan reviewed and approved the study. Participant Recruitment Eligible participants were patients 50 to 74 years of age who had an upcoming periodic health assessment and were eligible for sigmoidoscopy according to screening guidelines (no sigmoidoscopy within 5 years or colonoscopy within 10 years). A computerized appointment system identified potentially eligible participants because appointments are coded by type, including appointments for physical examinations, and by appointment length ( 30 minutes). Records used to determine previous tests varied by site and included patient information systems, medical records, and a log of completed procedures. To assure sex and age representation (men age 50 to 64 years, men age 65 to 74 years, women age 50 to 64 years, and women age 65 to 74 years), we determined that a sample size of 225 in each of the younger agesex groups and a sample size of 100 in each of the older agesex groups would assure 80% power to detect significant differences (at an level of 0.05) ranging from 7% to 16% depending on the outcome in the comparison group overall. Patients were enrolled from February 1999 through December 2000. We sent 1883 eligible patients an invitation letter several weeks before their appointment. Of the 1788 who were contacted by telephone, 1575 (88%) consented to participate. Consenting persons were screened for additional eligibility criteria. Those excluded reported recent (n= 339) or planned (n= 26) tests; did not undergo scheduled sigmoidoscopy in the past 10 months (n= 3); reported a colorectal cancer diagnosis or related symptoms (n= 30); canceled their periodic examination appointment (n= 41); could not participate because of illness, death, disability, or dementia or because they were institutionalized (n= 69); did not speak English (n= 35); had a spouse enrolled in the study (n= 17); had moved out of the area (n= 12); or were older than 74 years of age (n= 2). The baseline sample consisted of 1001 persons. After the baseline interview was completed, we sorted consenting participants into the 4 sexage groups. A computer-generated random-number table determined assignment in each group. The project director, who was not located at any clinical site, allocated enrollees to the intervention or control group using the computer-generated assignment, tracked group assignment, and mailed intervention materials. The project director was the only individual with knowledge of or access to group or individual assignment. The interviewer was blinded to group assignment at both baseline (conducted before randomization) and follow-up interviews. Subsequently, 63 patients were not eligible: 50 did not keep an index appointment, and 13 could not participate because of death, poor health, or decline in cognitive inability. Of the 938 persons eligible for follow-up (97.9%), 926 were contacted by an interviewer who was blinded to group assignment, and 918 completed the follow-up interview. Intervention The objective of the video was to encourage patients to discuss colorectal cancer screening, particularly using sigmoidoscopy, with their physician at their upcoming appointment. This intervention builds on the promising literature about the effectiveness of video to improve health behavior (30, 33-35), increase patient knowledge (36-40), reduce anxiety (41, 42), and provide role modeling (43). The intervention consisted of a 15-minute video titled Say Yes to the Test. Development was guided by the PRECEDE/PROCEED model for health promotion planning (44) and the behavioral model of utilization (45), incorporating elements of social cognitive theory (46, 47). We were also interested in testing a mailed outreach strategy. Showing videos in busy clinics is logistically difficult, presenting time, equipment, noise, space, and privacy problems. Friedman and colleagues (48) found that episodic technical difficulties hindered video education in the clinic setting. Mead and colleagues (49) reported that patient education materials (video, pamphlets, posters) placed in clinic waiting rooms did not increase use of preventive services. Of note, widespread ownership of video players and affordable per-unit cost make a mail-out approach feasible. The video, hosted by a nationally known actress who has had colorectal cancer, described screening by using graphics, footage of physicians discussing screening importance, and footage of a patient undergoing sigmoidoscopy. It addressed benefits and barriers to sigmoidoscopy, primarily with clips of several patients who had screening-detected colorectal cancer, and featured patients discussing sigmoidoscopy experiences (50). Barriers included minimal knowledge of colorectal cancer, lack of screening information, low perceived risk, fear of cancer, and expectation of pain and embarrassment (16, 20, 51-60). Videos were mailed to each participant's home before the scheduled physical examination; each package contained a letter, signed by the primary care physician, encouraging the participant to view the video. Participants in the control group received usual care with no special materials. Data Collection and Measures Fifteen- to 20-minute telephone surveys were conducted at baseline and 4 to 6 months after the primary care appointment. The timing of the follow-up survey allowed all recommended tests to be scheduled and completed. We developed survey items by using our previous work (50, 61) and other studies (62). The survey described all tests: For example, a fecal occult blood test was defined as a test taken at home, with cards mailed back. The follow-up survey also covered the intervention group's experience with the video. Colorectal Cancer Screening a