Influence Screening Uptake Research Articles

Implementation of hereditary cancer risk assessment in primary care: Intervention strategies and proximal outcomes.

279 Background: Family history-based risk assessment for hereditary breast and ovarian cancer and Lynch syndrome is guideline recommended and has strong evidence supporting its implementation into clinical practice, especially primary care. Yet, adoption has been impeded by limited awareness of genetic evaluation guidelines among primary care providers (PCPs), time constraints in screening during appointments, and limited resources for follow-up within primary care. To close this gap, we implemented a hereditary cancer risk assessment program that addresses these barriers and evaluated proximal implementation outcomes. Methods: We used intervention mapping for adaptation (IM-Adapt), a modified version of Intervention Mapping to guide the adaptation and implementation of the evidence-based 7-question family history screening (FHS-7) at a primary care clinic within an academic medical center. FHS-7 was adapted for administration via electronic patient portal prior to PCP visit or in-person at PCP visit. All clinic patients were offered screening and follow-up genetic counseling and testing per guidelines. Administrative, programmatic, and electronic medical record data were analyzed for program evaluation. Results: Between February 2023 and March 2024, 4,540 primary care patients were offered hereditary cancer risk assessment and 3,497 (77%) completed screening. Patient portals were used to complete screening more frequently than in-person at the clinic (86.6% vs 13.4%). Among patients with qualifying family history of cancer (n=1,267, 36%), 1,117 (88%) were eligible for navigation as they completed their primary care appointment and did not undergo genetic counseling within the last 5 years. Of the eligible patients, 62% were successfully contacted by a navigator and offered genetic counseling. Program implementation was facilitated by key personnel (clinical champion, informatics staff, genetic patient navigator) and adaptations to fit the implementation setting (adapting FHS7 for patient self-report rather than administration by PCP, patient population with high patient-portal adoption rate and in-house genetic service resources). Conclusions: We demonstrate the feasibility of hereditary cancer risk assessment within primary care and describe actionable aspects of the implementation context that influence screening uptake that can be incorporated into the design of future implementation for maximum impact. Findings advance the state of science in identification of unaffected individuals with inherited cancer susceptibility and genetic service delivery.

Systems mapping: a novel approach to national lung cancer screening implementation in Australia.

Lung cancer screening with low-dose computed tomography has been started in some high-income countries and is being considered in others. In many settings uptake remains low. Optimal strategies to increase uptake, including for high-risk subgroups, have not been elucidated. This study used a system dynamics approach based on expert consensus to identify (I) the likely determinants of screening uptake and (II) interactions between these determinants that may affect screening uptake. Consensus data on key factors influencing screening uptake were developed from existing literature and through two stakeholder workshops involving clinical and consumer experts. These factors were used to develop a causal loop diagram (CLD) of lung cancer screening uptake. The CLD comprised three main perspectives of importance for a lung cancer screening program: participant, primary care, and health system. Eight key drivers in the system were identified within these perspectives that will likely influence screening uptake: (I) patient stigma; (II) patient fear of having lung cancer; (III) patient health literacy; (IV) patient waiting time for a scan appointment; (V) general practitioner (GP) capacity; (VI) GP clarity on next steps after an abnormal computed tomography (CT); (VII) specialist capacity to accept referrals and undertake evaluation; and (VIII) healthcare capacity for scanning and reporting. Five key system leverage points to optimise screening uptake were also identified: (I) patient stigma influencing willingness to receive a scan; (II) GP capacity for referral to scans; (III) GP capacity to increase patients' health literacy; (IV) specialist capacity to connect patients with timely treatment; and (V) healthcare capacity to reduce scanning waiting times. This novel approach to investigation of lung cancer screening implementation, based on Australian expert stakeholder consensus, provides a system-wide view of critical factors that may either limit or promote screening uptake.

Association between Socioecological Status, Nutrient Intake, and Cancer Screening Behaviors in Adults Aged 40 and Over: Insights from the Eighth Korea National Health and Nutrition Examination Survey (KNHANES, 2019).

Cancer screening is pivotal for early detection and improved survival rates. While socio-ecological factors are known to influence screening uptake, the role of lifestyle, dietary habits, and general health in shaping these decisions remains underexplored. Utilizing the 2019 Korea National Health and Nutrition Examination Survey (KNHANES), this study examined the myriad of factors impacting cancer screening utilization. Data from 274,872 adults aged 40 years or older were scrutinized, highlighting demographics, income, lifestyle behaviors, health-related variables, nutrient intake, and dietary quality. A combination of descriptive statistics and logistic regression helped us ascertain influential determinants. Higher educational attainment and income quartiles were positively correlated with cancer screening rates. Regular walkers, those engaged in moderate physical activity, and individuals with a previous cancer diagnosis were more likely to get screened. High-risk drinkers and smokers were less inclined towards screening. Dietary habits also influenced screening decisions. Notably, participants with healthier eating behaviors, indicated by factors such as regular breakfasts and fewer meals out, were more likely to undergo screening. Additionally, nutrient intake analysis revealed that those who had undergone screening consumed greater quantities of most nutrients, bar a few exceptions. For individuals aged 50-64, nutritional assessment indicators highlighted a higher mean adequacy ratio (MAR) and index of nutritional quality (INQ) value among those who participated in screening, suggesting better nutritional quality. This study elucidates the complex socio-ecological and nutritional landscape influencing cancer screening decisions. The results underscore the importance of a holistic approach, emphasizing lifestyle, dietary habits, and socio-economic considerations. It provides a roadmap for policymakers to craft more inclusive screening programs, ensuring equal access and promoting early detection.

Pap Smear Screening: Deterrents among the At-Risk Population in Trinidad

Cervical cancer is a condition that affects many women globally. The WHO recommends Papanicolaou (Pap) smear screening, a method by which abnormal cervical cells can be detected and aid in preventing malignant progression. However, despite the availability of this test, uptake remains low among many Caribbean countries, including Trinidad. Objective: A literature review on cervical cancer screening and barriers to getting tested in Trinidad. Study Design: The study design chosen was a narrative literature review. This paper sought to assess available literature centered around reasons for lack of screening and how it may contribute to the current prevalence rates of cervical cancer. Methods: Data was obtained from online articles via Google Scholar, Pubmed, ScienceDirect, and Scopus from 1987 to 2022. The focus was on publications detailing lifestyle and factors influencing Pap smear testing and follow-up. Results: Results showed that personal understanding, accessibility, physician perception, and socioeconomic disadvantages can deter pap smear screening. Conclusions: Addressing these issues and how they can influence screening uptake is key to increasing detection and decreasing cervical cancer deaths.

Effect of Perceived Self-Vulnerability on Prostate Cancer Screening Uptake and Associated Factors: A Cross-Sectional Study of Public Health Facilities in Western Kenya.

Background:Perceived self-vulnerability to prostate cancer is known to influence screening uptake among men in the general population. However, knowledge gap persists on the influence of perceived self-vulnerability to prostate cancer on uptake of screening among male health workers; a demographic that has health insurance and is assumed to have knowledge of screening services for prostate cancer.Objective:This study aimed to assess the effect of perceived self-vulnerability to prostate cancer on screening uptake among male health workers in Kisumu County, western Kenya.Methods:This was a hospital-based cross-sectional study with a descriptive and analytical design. A modified self-administered questionnaire on self-vulnerability was issued to 197 male health workers who were randomly sampled from a study population of 336 eligible participants. The study was conducted at purposively selected public health facilities.Findings:Level of self-reported screening uptake was 27%. Rural residence (AOR = 0.71: 95% CI, 0.32–1.57, p = 0.019), education level (AOR = 5.01; 95% CI, 1.2–20.86, p = 0.027), participant’s lack of knowledge about screening services covered by health insurance schemes of which they are members (AOR = 0.2, 95% CI, 0.08–0.5, p = 0.001), good perception of health status (AOR = 4; 95% CI: 1.52–10.53, p = 005) were determinants of screening uptake for prostate cancer. Perceived self-vulnerability to prostate cancer didn’t influence screening uptake of participants (p < 0.05). Participants from rural set-up had a higher likelihood of perceiving themselves to be at risk of prostate cancer (AOR = 2.35, 95% CI, 1.17–4.72, p < 0.05) compared to those form urban settings. Old age of 60 years and above (AOR = 3.5, 95% CI: 0.3–40.98, p < 0.002) was predictive of perceived self-vulnerability.Conclusion:Findings from this study showed low uptake of screening and low perceived self-vulnerability to prostate cancer. Perceived self-vulnerability did not influence screening uptake for prostate cancer. Screening knowledge of prostate cancer as covered by health insurance, good perception of health status and level of education should be integrated in screening programs that are individualized on the basis of personal preferences and informed decision making regarding the uncertainty of benefit and the associated harms of screening.

Factors influencing screening uptake rate in healthcare institutions in Poland

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)

Wide variability in colorectal cancer screening uptake by general practitioner: Cross-sectional study.

Despite several interventions, colorectal cancer (CRC) screening uptake remains below acceptable levels in Italy. Among the potential determinants of screening uptake, only a few studies analysed the role of general practitioners (GPs). The aim was to evaluate the variation in screening uptake of the clusters of subjects assisted by single GPs. Ancona province, Central Italy. Cross-sectional study, including all residents aged 50-69 years, who were offered the public screening programme with biannual faecal immunochemical tests. Demographic (of all GPs) and screening data (of all eligible residents) for years 2018-2019 were collected from the official electronic datasets of the Ancona Local Health Unit. The potential predictors of acceptable screening uptake, including GP's gender, age, and number of registered subjects, were evaluated using random-effect logistic regression, with geographical area as the cluster unit. The final sample consisted of 332 GP clusters, including 120,178 eligible subjects. The overall province uptake was 38.0% ± 10.7%. The uptake was lower than 30% in one-fifth of the GP clusters, and higher than 45% in another fifth. At multivariable analysis, the significant predictors of uptake were younger GP age (p = 0.010) and lower number of registered subjects (p < 0.001). None of the GP clusters with 500 subjects or more showed an uptake ≥45%. The wide variation across GPs suggests they might substantially influence screening uptake, highlighting a potential need to increase their commitment to CRC screening. Further research is needed to confirm the role of the number of registered subjects.

The health belief model and colorectal cancer screening in the general population: A systematic review.

Colorectal cancer screening saves lives and is cost-effective. It allows early detection of the pathology, and enables earlier medical intervention. Despite clinical practice guidelines promoting screening for average risk individuals, uptake remains suboptimal in many populations. Few studies have examined how sociobehavioural factors influence screening uptake in the context of behaviour change theories such as the health belief model. This systematic review therefore examines how the health belief model’s constructs are associated with colorectal cancer screening.Four databases were systematically searched from inception to September 2019. Quantitative observational studies that used the health belief model to examine colorectal screening history, intention or behaviour were included.A total of 30 studies met the criteria for review; all were of cross-sectional design. Perceived susceptibility, benefits and cues to action were directly associated with screening history or intention. Perceived barriers inversely associated with screening history or intention. The studies included also found other modifying factors including sociodemographic and cultural norms. Self-report of screening history, intention or behaviour, convenience sampling and lack of temporality among factors were common limitations across studies.The health belief model’s associations with colorectal cancer screening uptake was consistent with preventive health behaviours in general. Future studies should examine how theory-based behavioural interventions can be tailored to account for the influence of socioecological factors.

Improving Abdominal Aortic Aneurysm (AAA) Screening Uptake through Patient Engagement—Analysis and Outcomes of Strategies to Improve Uptake at a Regional Program Level

To identify areas of health inequality that adversely affect patient engagement at a regional level within the National Abdominal Aortic Aneurysm Screening Program (NAAASP). Patient-reported improvements to services were implemented and analysis of subsequent uptake undertaken. A prospective study of 390 men who failed to attend their AAA screening invitation. Nonattendees were contacted by post and telephone. Patients were analyzed as per ethnicity, working status, and Index of Multiple Deprivation quintile. Patient-suggested improvements to the service were recorded, analyzed, and implemented. Uptake data were then collected for the subsequent two years. The Screening Management and Referral Tracking system used by NAAASP is 97% accurate in holding patient contact details, and nonattenders are four times more likely to respond to telephone contact. Reasons for failing to attend screening invitations include factors that can be addressed at a regional level such as: inconvenient timings/locations of screening clinics and a lack of awareness or understanding of what AAA screening means as well as language/literacy barriers. The incidence of AAAs in the nonattendee group was almost 3 times that of our general (attending) population. Afro-Caribbean men were disproportionately less likely to attend for screening. After implementing patient-suggested improvements to the service, screening uptake increased from 75.2% (2015-16 screening year) to 81.3% (2017-2018). To date, no other studies have gone on to assess the effectiveness of interventions targeted at reducing inequalities in NAAASP attendance, but we show an increase in local screening uptake of 6% in a 2-year period after implementing improvement strategies. This article adds to existing literature by confirming external factors such as social deprivation adversely influence screening uptake and that AAAs are more prevalent in socially deprived groups. It reinforces the importance of regional attempts to contact and engage nonattenders as they may be most at risk of developing AAAs.

The Effects of Health Disparities on Perceptions About Lung Cancer Screening (LCS): Survey Results of a Patient Sample.

Lung cancer screening (LCS) is currently advocated in a subset of current or former smokers with a thirty pack-year smoking history or higher. Studies report that few patients meeting the criteria for screening are undergoing LCS. We conducted a survey to assess if barriers to LCS (race, ethnicity, and socioeconomic status) affect the perceptions about LCS that could influence screening uptake. We did not detect different perceptions based on race, ethnicity, or socioeconomic status; however, our survey found that fewer barriers and more benefits to LCS may be perceived in patients who undergo other types of health screening and more benefits for those with internet capable devices.

Transforming Screening Uptake in Low-resource and Underinformed Populations: A Preliminary Study of Factors Influencing Women's Decisions to Uptake Screening

ObjectivesThe objective of this study was to assess the factors influencing women's decision to uptake screening mammography in an underinformed population. Study DesignThe study is a cross-sectional survey of factors influencing screening uptake. MethodsA modified breast cancer awareness measure was used to assess women's knowledge of breast cancer, mammography, and factors that influence screening uptake. A second questionnaire investigated health professionals' (HPs') attitude to screening and the criteria for screening recommendation. Descriptive statistics were used to assess women's breast cancer awareness, factors that influence screening uptake, and HPs' attitude to breast cancer education and mammography recommendation. We ranked HPs' responses pertaining to criteria for screening recommendation using a Kendall's W test. ResultsSixty-nine percent (n = 180) of women were aware of breast cancer, and half of them had performed breast self-examination (n = 131). About 53% (n = 138) of women were not aware of mammography, and only 15.4% (n = 40) of them have had a screening mammogram. Women's awareness of breast cancer risk factors and symptoms was poor. Many women would consider having a screening mammogram if instructed to do so by their husbands (87.7%; n = 228), HPs (96.2%; n = 250), and if government-funded screening programmes are available (90%; n = 234). Less than 40% (n = 21) of HPs had referred at least one woman for screening mammography within the last 6 months. Family history, age, and reproductive factors ranked as the highest criteria for screening recommendation. ConclusionsSpouses and HPs may be crucial to changing the current status quo around screening utilisation and government-funded screening programmes may increase screening uptake.

Abstract B65: Barriers to recommended screening among U.S. immigrants: A literature review

Abstract Purpose/Objectives: Maximizing cancer screening uptake has been a high public health priority in the United States, particularly for three prevalent and high-mortality cancers which benefit from early detection: breast, cervical, and colorectal cancers. However, screening rates for these cancers remain very low for US immigrants. Immigrants face unique barriers in accessing preventative healthcare that may or may not be specific to particular cultural and socioeconomic backgrounds. This review aims to synthesize literature on barriers to cancer screening among US immigrants in order to help design interventions that aim to increase screening in these diverse populations. Methods: We conducted a comprehensive search in Ovid Medline using Medical Subject Headings to capture articles discussing broadly defined barriers to screening for breast, cervical, or colorectal cancer in any immigrant communities in the United States. An initial 1148 articles was reduced to a final sample of 90 based on the following inclusion criteria: (1) population-based studies that were not evaluating an intervention (2) at least 80% of the study population immigrants or refugees to the United States (3) focus on uptake or receipt of any screening procedure for one or more of the three cancers of interest (4) study population did not include cancer patients or survivors (5) outcomes included factors influencing screening uptake (studies showing a disparity in screening but not seeking to explain it were excluded) and (6) publication year of 2000 or later. Results: Of the 90 studies included in the analysis, 26 (28.8%) were qualitative in design while the rest were quantitative survey studies. Men and women from most major immigrant groups in the United States were represented. Studies reported a large range but generally reported higher rates of having ever been screened (25-96%), and low rates of regular screening for all cancers (20-60%). Studies identified a wide-range of barriers including structural barriers such as insurance/cost (n=61), not having a regular provider or not receiving screening recommendation (n=47), language barriers (n=40), discrimination (n=18), navigating health systems (n=11) work/family responsibilities (n=9), and transportation (n=7). Fear and stigma of cancer and screening, concerns about pain, modesty, embarrassment, and lack of knowledge about availability or reason for screening were also identified. Some groups expressed fatalistic conceptions of health, or cultural/religious barriers, however many expressed interest in prevention. General themes important for increasing screening among US immigrants emerged: (1) It is important to disaggregate immigrant groups from racial categories and (2) it is equally important to understand communities' unique cultural or religious concerns. (3) The effects of cultural or psychosocial barriers were less inhibitory than structural barriers. (4) Structural and language barriers, socioeconomic status, and time in the US, were most important for predicting screening uptake. Conclusions: There is no one-size-fits-all solution for increasing cancer screening among all US immigrants. Results suggest the importance of providers taking time to counsel all patients but perhaps especially those who were raised in cultures with differing conceptions of health. Community-based educational and motivational programs in conjunction with programs to increase structural access may help to increase screening uptake. For providers, identifying community members and/or friends and relatives of patients who can be motivators to screening is likely an effective method to improve screening rates. Targeted interventions that address both individual and structural barriers may be most effective in increasing cancer screening in immigrant communities. Citation Format: Elizabeth M. Allen, John O. Loftus. Barriers to recommended screening among U.S. immigrants: A literature review. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B65.

Cancer screening behaviours among South Asian immigrants in the UK, US and Canada: a scoping study.

South Asian (SA) immigrants settled in the United Kingdom (UK) and North America [United States (US) and Canada] have low screening rates for breast, cervical and colorectal cancers. Incidence rates of these cancers increase among SA immigrants after migration, becoming similar to rates in non-Asian native populations. However, there are disparities in cancer screening, with low cancer screening uptake in this population. We conducted a scoping study using Arksey & O'Malley's framework to examine cancer screening literature on SA immigrants residing in the UK, US and Canada. Eight electronic databases, key journals and reference lists were searched for English language studies and reports. Of 1465 identified references, 70 studies from 1994 to November 2014 were included: 63% on breast or cervical cancer screening or both; 10% examined colorectal cancer screening only; 16% explored health promotion/service provision; 8% studied breast, cervical and colorectal cancer screening; and 3% examined breast and colorectal cancer screening. A thematic analysis uncovered four dominant themes: (i) beliefs and attitudes towards cancer and screening included centrality of family, holistic healthcare, fatalism, screening as unnecessary and emotion-laden perceptions; (ii) lack of knowledge of cancer and screening related to not having heard about cancer and its causes, or lack of awareness of screening, its rationale and/or how to access services; (iii) barriers to access including individual and structural barriers; and (iv) gender differences in screening uptake and their associated factors. Findings offer insights that can be used to develop culturally sensitive interventions to minimise barriers and increase cancer screening uptake in these communities, while recognising the diversity within the SA culture. Further research is required to address the gap in colorectal cancer screening literature to more fully understand SA immigrants' perspectives, as well as research to better understand gender-specific factors that influence screening uptake.

Awareness of ovarian cancer risk factors among women in Malaysia: a preliminary study.

Ovarian cancer is recognized as the fourth leading cancer in Malaysia. However, women do not always seek help in a timely manner and gaps in awareness may influence screening uptake and presentation. The purpose of this study was to determine levels of awareness of ovarian cancer risk factors in female population in Penang, Malaysia. A cross-sectional study was conducted in Penang, Malaysia from January until February 2014. Eighty-seven women were selected by convenient sampling. Awareness of risk factors of ovarian cancer was assessed using a self-administered questionnaire. Data were analyzed using statistical package for the social sciences (SPSS) version 20.0 for descriptive statistics and Pearson chi-square test for the association between socio-demographic data and awareness. A p value ≤0.05 was considered statistically significant. In all, 74.7% of participants answered correctly for the risk factor of increasing age, although 94.3% were unaware of increased risk of tall women. A majority, 71.3%, had a low level of awareness of ovarian cancer risk factors. There was a significant association between age and knowledge (p=0.047). Additionally, there was a significant association between higher education level and level of awareness of ovarian cancer risk factors (p=0.039). This study revealed that awareness of ovarian cancer risk factors among Malaysian women is low. The results show a need for improved public understanding about ovarian cancer risks and provision of important information for health professionals about initiatives needed for future awareness, prevention and screening programs.

Nonmedical Costs of Colorectal Cancer Screening Using CT Colonography

Nonmedical costs are important because they may influence screening uptake and the results of cost-effectiveness analyses of colorectal cancer (CRC) screening. Although the nonmedical costs of CRC screening are known for fecal occult blood testing, flexible sigmoidoscopy, and colonoscopy, they are unknown for CT colonography (CTC). The purpose of this study was to determine the nonmedical costs of CTC. Four hundred eighty-one consecutive individuals presenting for CRC screening using CTC were approached at a radiology clinic in Calgary, Alberta, Canada, to participate in the study. Of these, 197 agreed to have a questionnaire mailed to them. Subjects completed the questionnaire, including items on time off work, both for the subject and any accompanying caregiver; travel details; and direct out-of-pocket expenses. Time costs were valued at government of Canada wage rates. Travel costs included estimated costs for travel by car and actual parking costs and taxi and public transportation fares. Car user's costs were calculated using a Canadian Automobile Association estimate of motoring costs per kilometer. Costs are reported in 2010 Canadian dollars. One hundred thirty-two subjects returned the questionnaire (mean age, 57 years; 65% men; 67% employed). Ten subjects traveled >200 km for their CTC. The nonmedical costs (subject with or without caregiver) for the 122 subjects who resided within 200 km of the clinic averaged $101. The nonmedical costs of CRC screening using CTC are significant but lower than those of colonoscopy. Patients should be aware of these differential costs, and they should be incorporated into economic analyses of CRC screening.

Factors that influence the patient uptake of diabetic retinopathy screening

To assess whether patients were receiving regular diabetic retinopathy screening and to examine factors influencing screening uptake. A questionnaire covering demographics, diabetic medical history and the knowledge of and attitudes to diabetic retinopathy was administered to all adults who were due to attend diabetes clinics in two centres in Dublin, Ireland over two months in 2001/2002. Of the 209 people who completed the questionaire, 169 (81%) had a dilated fundal examination within the last year. The most significant predictor for receiving screening was a previous physician recommendation about the necessity of a regular eye examination. The main barriers to receiving adequate screening were lack of knowledge regarding the need for ocular examination and the effect of mydriasis in prohibiting driving. It is essential that patients are fully aware of the need for a regular eye examination. Once a physician recommends this the screening rate improves.

Nonmedical Costs of Colorectal Cancer Screening With the Fecal Occult Blood Test and Colonoscopy

The nonmedical costs of colorectal cancer screening are unknown. However, they might influence screening uptake and impact the cost-effectiveness of colorectal cancer screening modalities. Consecutive individuals presenting for colorectal cancer screening in the Calgary Health Region were recruited from 4 community laboratory collection sites (fecal occult blood test) and 2 endoscopy units (colonoscopy). Subjects completed a questionnaire including items on time off work for the subject and any accompanying caregiver, travel details, and direct out-of-pocket expenses (bowel prep). Time costs were valued at Government of Canada wage rates. Travel costs included estimated costs for travel by car and actual parking costs and taxi and public transportation fares. Car users' costs were calculated by using a Canadian Automobile Association estimate of motoring costs per kilometer. Costs are in 2006 Canadian dollars. The final sample included 604 subjects who underwent fecal occult blood test (mean age, 62 years; 51% male; 43% employed) and 723 who underwent colonoscopy (mean age, 56; 49% male; 66% employed). Eighty percent of colonoscopy subjects required an accompanying caregiver, compared with only 5% for fecal occult blood test. The nonmedical costs (subject +/- caregiver) averaged $308 for colonoscopy and $36 for fecal occult blood test. The nonmedical costs of colorectal cancer screening are substantial, especially for colonoscopy. However, the costs are similar with repeated fecal occult blood tests. These costs might be one factor accounting for low colorectal cancer screening uptake rates. Nonmedical costs should be incorporated into economic analyses of colorectal cancer screening.

Presenting Risk Information A Review of the Effects of Framing and other Manipulations on Patient Outcomes

Discussing risks and benefits of treatments or care options is becoming an increas ingly important part of modern health care. This paper reviews the literature about manipulations of risk and benefit information in the clinical setting. There is a paucity of evidence in this field, particularly when examining specific manipulations. Only three categories of manipulation had three or more studies. The available evidence shows that the way information is presented can have significant effects on decisions made. The largest effects are evident when relative risk information is presented, as compared with absolute risk data. In addition, "loss framing" is more effective in influencing screening uptake behaviors than "gain framing" (odds ratio 1.18 [95% confidence interval 1.01-1.38]). There is also a pattern of evidence from studies comparing simpler with more complex information, more data with less, and those comparing numerical with verbal descriptions of risks. These studies suggest that providing more information, and which is more understandable to the patient, is associated with improved patient knowledge and a greater wariness to take treat ments or participate in trials. These findings can contribute to efforts to improve communication between professionals and patients.