The effect of a tailored communication intervention for increasing uptake of colonoscopy among Chinese first-degree relatives of people with colorectal cancer

Ph.D.BackgroundColorectal cancer (CRC) ranks third most commonly diagnosed cancer and the second cause of cancer death in the world. Positive family history of CRC among first-degree relatives (FDRs) is consistently identified as one of the most important risk factors for developing the disease. Colonoscopy is the best screening choice for persons at increased risk as it offers prevention by removal of pre-neoplastic lesions rather than early detection. Nevertheless, the screening rates of colonoscopy among FDRs in CRC patients is low. The aim of this study was to develop an evidence-based tailored communication intervention to promote uptake of colonoscopy among FDRs of people with colorectal cancer and examined its effectiveness.MethodsThis study comprised of four phases. Phase I was a systematic review and meta-analysis to summarize existing evidence of the effectiveness of tailored communication interventions to promote colonoscopy screening rates in FDRs of people with CRC. Phase II was psychometric testing of Revised Colorectal Cancer Perception and Screening (RCRCPS) and Self-efficacy Questionnaire instruments used for secondary outcome measures and intervention development. The findings of the systematic review and the instruments validated in Phase II were used to guide the development of the evidence-based tailored communication (Phase III). After adaption based on the pilot study that aimed to test the feasibility and acceptability of the intervention, the main study was applied in Phase IV with the design of RCT (n=188). Eligible FDRs were recruited and randomly allocated to receive tailored communication intervention or usual care. The primary outcome was the uptake of colonoscopy. Secondary outcomes were psychosocial variables (perceived susceptibility, severity, benefits, barriers, self-efficacy and cues to action) derived from the Health Belief Model (HBM). The effect of tailored communication intervention on uptake of colonoscopy was tested using logistic regression. Generalized estimating equation (GEE) models were used to examine the effects of tailored communication intervention on HBM variables at different time points. Finally, the process of implementing the intervention was also evaluated.ResultsIn phase I, four studies that adopted tailored communication interventions to increase screening rates of colonoscopy were identified. Pooled analysis showed that tailored communication had a beneficial effect on improving colonoscopy screening rate [Odds ratio (OR): 2.21, 95% confidential interval (CI): 1.71-2.85, p < 0.001]. Furthermore, subgroup analysis showed that repeated tailored communication delivered both written and verbal information had a beneficial effect on increasing screening rates of colonoscopy (OR: 2.39, 95% CI: 1.78–3.21, p < 0.001).In Phase II, 197 FDRs of people with CRC were recruited. The results indicated that the RCRCPS had acceptable psychometric properties, with internal consistency (Cronbach’ alpha=0.74–0.87) and test-retest reliability in a 4-week interval (intraclass coefficient=0.59-0.84). Confirmatory factor analysis revealed that the RCRCPS (simplified Chinese version) conformed to the four-factor model suggested by the original version (the chi-square/degree of freedom=1.326, root-mean-square error of approximation=0.041, comparative fit index=0.904, Tucker Lewis index =0.896 and standardized root mean square residual=0.684). Self-efficacy Questionnaire was also demonstrated acceptable reliability with a Cronbach’s alpha of 0.77 and an intraclass coefficient of 0.53.In Phase III, the tailoring decision rules were developed by using the score of each HBM variables assessed by the instruments validated in Phase II. The decision rules, as well as the recent guidelines from authorized organizations, such as CRC screening guidelines from the Chinese Center for Disease Control and Prevention and American Cancer Society, were used to develop the tailored messages. After two rounds of panel review, the Item-Content Validity of each rule and messages reached 1.0. All five invited FDRs of CRC patients reported they could understand the messages easily. Based on the suggestions from the systematic review in Phase I, WeChat was applied as the channel to deliver all three sessions of the tailored communication intervention, including 2 written message sessions and 1 voice call counselling session.In the final phase, the logistic regression showed that tailored communication intervention significantly increased uptake of colonoscopy (OR: 2.752, 95% CI: 1.428–5.303, p<0.01) respectively. The GEE models supported the efficacy of tailored communication intervention on perceived susceptibility, barriers, and cues to action. For process evaluation, the intervention was delivered according to the protocol. Besides, high rates of the dosage received and high satisfaction rates were achieved in this study.ConclusionThis study demonstrates the effectiveness of tailored communication interventions delivered through WeChat. The feasibility and acceptability of tailored communication interventions utilized novel channels were also demonstrated. The findings underscore the importance of tailored communication for individuals with a positive family history of CRC and should be considered to be adopted to promote screening in health care and public health settings.研究背景大腸癌是世界上第三大常見癌症和第二大癌症死亡原因。腸癌家族史一直被認為是腸癌患者的直系親屬發展該病的最重要風險因素之一。 結腸鏡檢查是高危人群的最佳篩查選擇，因為它不僅可以及早發現，還可以同時去除腫瘤前病變。 然而，腸癌患者直系親屬的結腸鏡篩查率仍然很低。因此這項研究的目的是構建基於證據的定制溝通干預措施，以促進結腸直腸鏡檢查在大腸癌患者直系親屬中的使用，並研究其有效性和成本效益。研究方法這個研究主要包括四個階段。第一個階段是系統評價和薈萃分析，旨在總結現有定制溝通干預方式對提升腸癌患者直系親屬的腸鏡篩查率的有效性的證據。第二階段是問卷的信效度檢。問卷將用於次要結果的測量和干預的構建。第一階段系統綜述的結果以及第二階段確定的測量工具被用來構建本研究所使用的定制溝通干預（第三階段）。在根據旨在測試干預措施的可行性和可接受性的初步研究結果進行調整後，隨機對照試驗（N = 188）被應用於第四階段，也是本研究中的主要研究階段。本研究招募了符合納入排除標準的直系親屬後隨機分配都接受量身定制交流干預組或常規護理組。主要結果是是否接受腸鏡檢查。次要結果是源自健康信念模型的社會心理變數（感知風險，嚴重性，益處，障礙，自我效能感和行動線索）。使用邏輯回歸對兩組的結腸鏡檢查情況進行比較。使用廣義估計方程模型來檢查量身定制溝通干預在不同時間點對社會心理變數的影響。最後，還評估了實施干預措施的過程進行了評價。研究結果在第一階段，系統綜述共納入4項研究。薈萃分析結果顯示，定制式溝通干預方式能夠有效提升腸鏡篩查率（標準化平均差異: 2.21, 95% 置信區間: 1.71–2.85, p值 < 0.001）。另外亞組分析顯示，重複的且包括語音和文字資訊的定制溝通干預方式的具有更好的效果（標準化平均差異: 2.39, 95% 置信區間: 1.78–3.21, p < 0.001）。研究第二階段招募了197名直系親屬進行信效度檢驗。結果顯示修改版腸癌及篩查健康新年量表（RCRCPS） 具有可接受的內部一致性（0.74–0.87）和四星期重測信度（0.59–0.84）。驗證性因數分析顯示RCRCPS 符合原版本問卷構建所應用的健康信念4因數模型。自我效能量表的內部一致性係數為0.77及4星期重測信度為 0.53。在第三階段中，通過使用在第二階段中驗證的測量工具評估的變數分數來制定決策規則。 決策規則以及授權組織的最新指南，例如中國疾病預防控制中心和美國癌症協會的腸癌篩查指南，均被用於開發量身定制的資訊。 經過兩輪小組審查，每條規則和定制消息的內容有效性達到1.0。 5名受邀請的腸癌患者直系親屬報告他們可以輕鬆理解這些資訊。 根據第一階段系統綜述的建議，微信被用作提供量身定制的交流干預的所有三個模組的管道，包括2個文字資訊模組和1個語音資訊模組。在最後階段，邏輯回歸表明，量身定制的交流干預措施顯著提高了結腸鏡檢查的篩查率(比值比: 2.752, 95% 置信區間: 1.428, 5.303, p