Elsevier

Preventive Medicine

Volume 38, Issue 6, June 2004, Pages 694-703
Preventive Medicine

Short- and long-term effects of tailored information versus general information on determinants and intentions related to early detection of cancer

https://doi.org/10.1016/j.ypmed.2003.12.016Get rights and content

Abstract

Background. Since it is widely accepted that the earlier cancer is detected, the better the chances of treatment and survival, people should be encouraged to create positive intentions toward early detection of several types of cancer, for instance, skin cancer, breast cancer, and colon cancer. This can be done by being alert to the warning signs of cancer and seeking help once a cancer symptom is detected.

Methods. A randomized controlled study (n = 1,500) assessed the effects of computer-tailored information and general information on determinants and intentions to engage in early detection behaviors (i.e., passive detection and help seeking) compared with those in a control group. Possible negative side effects, like increased chronic fear of cancer and more fatalistic attitudes toward cancer, were studied as well.

Results. Shortly after the intervention, differences between the study groups were found in intention, several social psychological determinants, and knowledge. Six months after the intervention, there were still differences between the tailored information group and the control group in intentions toward help seeking. Neither of the interventions resulted in increased chronic fear nor more fatalistic attitudes toward cancer.

Conclusions. It is concluded that there were positive effects of the tailored intervention on determinants, passive detection, and help-seeking intentions in the short-term, but additional research is needed to assess ways of maintaining these effects in the long-term.

Introduction

It is widely accepted that the earlier cancer is detected, the better the chances of treatment and survival [1]. In practice, however, cancer detection and diagnosis are often subject to delays [2], [3], [4], [5], [6]. Therefore, people should be encouraged to engage in early detection behaviors, such as being attentive to cancer symptoms (see Table 1), self-examination, seeking medical help when symptoms are detected, and participating in screening programs. According to Qin et al. [7], cancer can be divided into three anatomical categories: (1) cancers of the superficial organs, such as skin, breast, and testis, which can be detected by looking for lumps, ulcerations or moles, or by palpation; (2) cancers of the hollow organs, such as urinary bladder, lungs, etc., which can be detected by, for instance, blood loss; and (3) cancer of deep, solid organs, which does not give any signals in the early development of the cancer and which cannot be detected by palpation. Malignancies of these organs rarely give symptoms in the early stages, and can only be detected by medical tests, such as X-ray, CT scans, and blood tests. The focus of the present study is therefore on types of cancer included in the first two categories.

Many programs have been developed to stimulate people to perform breast self-examination (BSE) or testicular self-examination (TSE) and to participate in screening programs for breast and cervical cancer (e.g., [8], [9], [10], [11], [12], [13], [14]). Far less has been done to enhance attentiveness to general cancer symptoms and to seeking help for these symptoms. A study in Sweden attempted to shorten patient delay by informing patients by letter about the symptoms of common forms of cancer. Patients were invited to visit health centers if the symptoms mentioned in the letter were observed [15]. This resulted in 234 visits and the detection of 15 cancers, of which 13 were localized. Another study was undertaken to improve specifically the prognosis of melanoma by providing the public with information on features of early melanoma, and to encourage people to consult a physician if they recognized such lesions on their skin [5]. Very promising results were obtained within a period of 6 months after the intervention: the proportion of patients diagnosed with ‘good prognosis’ had increased from 38% to 62%, while the proportion of patients with ‘poor prognosis’ had decreased from 34% to 15%. Unfortunately, no control groups were included in either of these studies, so the value of the conclusions on patient delay or prognosis was limited. In The Netherlands, the Dutch Cancer Society has developed several brochures informing the general public about early detection of cancer, including the ‘warning signs of cancer’, BSE, TSE, and participating in screening programs. Furthermore, in 1997, a mass media campaign was launched within the framework of the European Week Against Cancer, attempting to get people to pay attention to symptoms of forms of cancer common among men [16]. Unfortunately, these interventions were not evaluated for their effects.

It is often questioned whether interventions on early detection of cancer may cause fear, or that certain information may result in unnecessary worries about a particular complaint or a particular diagnosis. Fear may lead to different coping styles, for instance, by avoiding the threatening situation [17]. This might mean that people who cannot cope with the fear associated with the detection of cancer, and who have little trust in the effectiveness of medical treatment, respond with fatalistic opinions toward cancer, such as, ‘if you find a cancer symptom, it's too late to do anything about it anyway,’ and hence do not engage in early detection behaviors [18]. In the Swedish study, the information did not cause anxiety [15], and the same was found in studies providing information about breast self-examination, testicular cancer, and testicular self-examination [8], [19], [20]. Nevertheless, in developing health education interventions on early detection of cancer, the undesirable side effect of fear and unnecessary worries should be very carefully taken into consideration.

A promising and relatively new approach in health education is computerized tailoring, which adapts health education messages to the characteristics, needs, and interests of the recipient [21], [22], [23]. This leads to more personally relevant information, which is more likely to be thoughtfully considered [24], and is therefore thought to be more effective in changing determinants and behaviors than generic information. Computerized tailoring has been shown to change intentions and behaviors, such as reducing fat intake and stimulating fruit and vegetable intake [25], [26], smoking cessation [27], [28], losing weight [29], promoting physical activity [30], participating in mammography screening [10], [11] and PAP test [14]. Computerized tailoring focuses on individuals. Messages are based on individual self-reported behavior and beliefs [31].

If the goal of an intervention is to encourage healthy behavior, it is necessary to know what the underlying factors are, which decide whether a person will engage or not engage in that particular behavior [32]. We used the Attitude–Social Influence–Self Efficacy (ASE) model [33], [34], which can be regarded as an extended version of the Theory of Planned Behavior [35]. This model distinguishes three determinants influencing people's motivation to perform a particular behavior. Intention, on its turn, influences actual behavior (Fig. 1). The three main determinants have an impact on behavior through the influence on intention. The first determinant, attitude, refers to a person's beliefs about the behavior, for instance, the advantages or disadvantages he or she expects from performing the behavior. The attitude concept has recently been supplemented with two affective components [36]. The first is anticipated regret, which is the feeling of regret someone expects to experience afterwards if he or she chooses not to perform the behavior. The second is moral obligation, which refers to a personal belief about what ought to be done. Behavior or intentions toward behavior are also influenced by what important people in someone's environment do or think, which refers to the second determinant, social influence. The third determinant is self-efficacy, that is, someone's belief in his or her own capability to perform the behavior. There are several differences between the ASE model and the TPB in the constructs and the way they are measured. First, the ASE model added anticipated regret and moral obligation. These factors have proven to be significant predictors of early detection behaviors [36], [37], [38]. Second, in the TPB, social influence is assessed by the social norm (i.e., what other people think you should do). In the ASE model, as additional aspects of social influence, the modeling concept and social support/pressure were added. Third, the self-efficacy concept of Bandura was included in the ASE model, while TPB measured perceived behavioral control. The models differ from each other in the way constructs are measured, whereas TPB uses multiplicative functions to assess attitudes (belief, evaluation), social norm (norm, motivation to comply), and self-efficacy (control beliefs, perceived power); ASE does not. The ASE has proven to be a useful model in predicting several behaviors related to the primary prevention of cancer and coronary heart disease [39], [40], [41], [42], and also to the secondary prevention of cancer [36], [37], [38]. By including these additional concepts, we expect a valuable contribution of the ASE model in the present study.

So far, no tailored interventions have been developed or evaluated to motivate asymptomatic people to engage in early cancer detection behaviors, except for those stimulating women to have a mammography. Therefore, a randomized controlled study with a pretest and two post-tests was conducted to test two different interventions: a computerized tailored intervention and the standard general information currently provided by the Dutch Cancer Society to encourage the Dutch adult population to form positive intentions. We studied the effects of the two interventions on intentions, social psychological determinants, and knowledge, immediately after the intervention and after 6 months, and compared these with the same parameters in a control group that received no information. Intention was chosen as an outcome measure, since 6 months is too short to assess actual detection of possible cancer symptoms in a general population and their response once a symptom is detected. The intention toward two behaviors was distinguished: (1) passive detection, which may be described as becoming aware of cancer symptoms, but does not require any concrete action to be undertaken, and (2) consulting a physician once a possible cancer symptom was detected. If a possible cancer symptom is not followed up by medical consultation, the detection is in fact useless and the cancer detection process will be delayed. It was hypothesized that the changes in social psychological determinants and intentions would be significantly more positive for the recipients of the tailored information. Furthermore, we hypothesized that the tailored information would not increase chronic fear of cancer or fatalistic attitudes toward cancer.

Section snippets

Study design and procedures

A randomized controlled study with a pretest and two post-tests to evaluate the impact of a computerized tailored intervention on early detection of cancer was conducted among 1,855 Dutch adults. Subjects were recruited in January 1999 by a short announcement in local door-to-door newspapers throughout The Netherlands, and in one national newspaper. Those interested in participation were asked to register by telephone or e-mail and they were told that they were participating in a study on the

Respondents

Of the initial 1,855 volunteer subjects, 1,500 met the criteria for being approached for the telephone questionnaire at T2 (i.e., having completed the written questionnaires at T0 and T1, not having cancer at T0, having a telephone, and having indicated at T0 that they were willing to participate in the telephone questionnaire). A total of 1,358 (73%) subjects completed the telephone questionnaire, equally distributed across the tailored information group (32%), the general information group

Discussion

The present study tested the impact of a computer-tailored intervention in encouraging people to form positive intentions toward early detection behaviors. Short-term effects showed that the tailored information group had more knowledge of cancer symptoms, more positive expectations of the advantages of early detection behaviors, and higher self-efficacy expectations toward passive detection than the control group and/or the general information group. Additionally, the recipients of the

Acknowledgements

This study was supported by a grant from the Dutch Cancer Society.

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