Personal approach boosts mammograms

Women respond to targeted letters

The National Committee for Quality Assurance in Washington, DC, wants health maintenance organizations (HMOs) to increase the number of women who have routine mammograms. One good way to get a woman into the mammogram habit is to address her individual concerns, say researchers at Brown University in Providence, RI.

In a randomized clinical trial of nearly 1,400 women members of a New England HMO, a personal approach encouraged more women to get a repeat mammogram than did generic advice, breast cancer screening, or no intervention, says William Rakowski, PhD, associate professor of medical science at Brown University School of Medicine.

Women in the four-year screening project were randomly assigned to three groups. All of the women were interviewed four times to assess their breast cancer screening history, concerns, and actions. After each of the first two interviews, women in one group received computer-generated personalized letters and additional education materials tailored to their survey responses. Another group received standard mammography information. The third group received nothing.

The personalized messages were created to custom-fit each woman's readiness to change her health behavior regarding routine mammograms, explains Beverly Ehrich, MPH, project director of the Mammography Education Partnership at the Center for Gerontology and Health Care Research at Brown University. Trained interviewers scored women's readiness and placed them in one of five readiness stages:

o Precontemplation. A woman is not having routine mammograms and is not intending to start.

o Contemplation. She is not having routine mammograms but is considering starting.

o Action. She has started having routine mammograms.

o Maintenance. She has had at least two mammograms on schedule.

o Relapse risk. She has had routine mammograms on schedule but is now off schedule and has no plans to have a mammogram in the near future.

The Mammography Education Partnership based its interventions on the Transtheoretical Model of Behavior Change, which proposes that people differ in their readiness to adopt a health-related behavior and must go through stages of readiness. "At each stage, there are various behaviors associated with making the desired behavior change," says Ehrich. Researchers found women who received personalized materials were 10% more likely to get a repeat mammogram than those who didn't. "We match the materials with the person with the objective of nudging them one step further, rather than asking them to make a full-fledged change right away," says Rakowski.

Are you ready?

"If we know a woman's stage of readiness, we know which messages are more likely to influence her to implement the desired behavior," Ehrich says. "The stages represent a continuum of change. It's a circular model. Women can be in the maintenance stage and go back to contemplation stage."

"We've found that sending generalized messages to all women about mammography doesn't work," Ehrich adds. "If a woman is absolutely not ready - she's precontemplative - what you want to do is raise her understanding of breast cancer and breast cancer screening. It doesn't do any good to tell her the mammography center down the street has Saturday hours. She hasn't even thought about the significance of cancer screening to her health. She's not ready for a discussion of logistics and cost."

Rakowski says most HMOs could adapt the Brown breast cancer screening model to encourage other health behavior changes without much difficulty. "We could easily run our system off a standard PC. We are printing our own project materials on a standard ink jet printer. If you had a simple survey, and you knew exactly what you wanted to ask, you could hand a patient a two-page questionnaire during a primary care visit. You could pop the answers into the computer and customize materials to encourage positive health behaviors."

[Examples of the expert system letters and tip sheets are available from Beverly Ehrich, Center for Gerontology and Health Care Research, Brown University, Box G-H3, Providence, RI 02912. Fax: (401) 863-9219. See also: Ehrich B, Clark M, Rakowski W, Allison S. Implementing a computer-based mammography education project in a man -aged care setting. Medicine and Health/Rhode Island 1998; 81:79-82.] n