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Sending men the message about preventive care: an evaluation of communication strategies.

The purpose of this study was to evaluate the effectiveness of patient and/or physician communication interventions to increase men's utilization of preventive healthcare services. The study focused on men between the ages of 40 and 60 who were enrolled in a large southeastern insurance company's health maintenance organization (HMO) and point of service (POS) products. Eligible men were randomized to receive various forms of preventive care reminders. Results showed that personalized communications that included health education for men combined with a patient-specific reminder system for providers led to a significant improvement in the number of men who received preventive health care screenings. Results also showed that communicating with the man's loved ones in the home combined with a patient-specific reminder system for providers was significantly associated with improvement in preventive healthcare screenings. Further research should continue to evaluate the best methods for engaging men in the healthcare system.

Keywords: men's health, men, preventive care, communication, health education, patient-specific provider reminder tools, prostate cancer screening, cholesterol screening, loved one

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In the past 15 to 20 years, the vast majority of gender-related health research has focused on women's health, and appropriately so. However, the need for preventive care for men is becoming better recognized. Various studies have compared men's healthcare behaviors to women's and found significant differences with regard to life expectancy, preventive care utilization, and rates of chronic disease (Courtenay, 1999, 2000a; Sandman, Simantov, & An, 2000). For instance, in 2001, men's life expectancy was five years shorter than women's (Kochanek, Murphy, Anderson, & Scott, 2004). As compared to women, men are about 1.5 times more likely to die of heart disease, cancer, and chronic lower respiratory diseases (Kochanek et al., 2004). Regular medical exams are a critical component of the early detection of many potentially fatal diseases; however, on average, men see doctors 28 percent less often than women (National Center for Health Statistics, 2001). Given these statistics, new efforts need to be made to influence men's health behavior. Routine medical exams are critical for detecting and treating potentially fatal disease. Because men do not receive regular and timely health screenings, by the time they do see a doctor with a health problem, their condition is often serious (Courtenay, 2000a).

To our knowledge, there have been few educational campaigns directed toward men about their general preventive healthcare needs. Much of the current literature on men's health focuses on identifying men's underutilization of preventive care, some of the causes of this underutilization (Williams, 2003), and how their health-related beliefs and behaviors contribute to this underutilization (Courtenay, 1999, 20000a, 2000b). There has also been a great deal of literature studying the positive relationship between having a usual source of care and receiving preventive care (CDC, 1998; DeVoe, Fryer, Phillips, & Green, 2003; Seeff et al., 2004; Xu, 2002). While there has not been much research on interventions designed to encourage men to obtain general preventive care, significant work has been done related to men and prostate cancer screenings (Partin et al., 2004; Schapira & VanRuiswyk, 2000; Volk, Spann, Cass, & Halwley, 2003; Weller et al., 2003; Wilt, Murdoch, Nelson, Nugent, & Rubins, 2001) as well as colorectal cancer screening (Beeker, Kraft, Southwell, & Jorgensen, 2000; Lipkus, Crawford, Fenn, Biradavoul, & Binder, 1999; Pignone, Harris, & Kinsinger, 2000; Stone et al., 2002).

Most major medical organizations, including the American Academy of Family Physicians and the U.S. Preventive Services Task Force (USPSTF) recommend periodic health assessment including height, weight, and blood pressure readings and regular cholesterol screenings (every five years, if normal) for men ages 40 years and older. In addition to those screenings, colorectal cancer screening is also recommended for men 50 and older. In the past, annual prostate cancer screening was strongly encouraged for men 50 and older, but this recommendation has recently been changed to annual prostate cancer counseling for men over the age of 50 years. Despite these specific recommendations, the majority of men are not getting the preventive services they need.

The following study was conducted by a single-state health insurance plan in the southeastern United States. The plan's claims data related to preventive health service utilization by members was consistent with published literature and revealed that its male members were significantly underutilizing preventive care services. This information inspired the creation of various materials for communicating the importance of preventive care to this population. The materials were designed to improve this group's utilization of recommended preventive health care services: specifically, annual health assessments, colorectal cancer screenings (for men over the age of 50), prostate cancer screenings, and cholesterol screenings. The purpose of this study was to test various mailed educational methods for improving men's preventive screening rates. Materials were developed based on member preference surveys as well as information found in general health education literature. Using a controlled study design, this research attempted to answer the following questions:

* Can men's health screening behavior be improved through mailed member and provider information?

* Which educational materials are most effective for increasing the number of men's health screenings?

* Which screenings are members most likely to receive as a result of these mailings?

METHOD

POPULATION

Using claims data from May 2001 through April 2003, the health plan identified men who were enrolled in a managed-care product (HMO and point of service) who had seen a primary care provider but had not received any preventive health screenings in the past two years. The study was limited to men who saw a provider in the previous two years because the health plan was an open-access design and did not require its members to identify a primary healthcare provider that would handle all of their care. Without a medical claim, the plan would not be able to identify a provider to send information to.

Over half of the men who did not have a preventive health screening within the past two years were between the ages of 40 and 60. According to health plan underwriting statistics for males under the age of 65, men between 55 and 64 had the highest total per member monthly costs, the highest number of inpatient hospital stays, and the highest number and cost of prescriptions per member per month (Blue Cross and Blue Shield of North Carolina, 2002b). In order to help alleviate some of these costs, the plan focused on men between the ages of 40 and 60 to promote preventive care earlier in life before major health problems start to appear.

IMPLEMENTATION

To inform providers of their patients who needed some preventive screenings and provide them with a reminder tool, men's health chart stickers were created. These stickers were prepopulated with the member's name, date of birth, and the date the stickers were sent. During development, the health plan used member and provider input to create these personalized reminder tools for providers. The stickers included check boxes for a routine health assessment including blood pressure, height, weight, and lifestyle counseling; a cholesterol screening; a colorectal cancer screening; and a prostate cancer screening. The stickers were bright yellow and contained an adhesive that allowed for easy removal without tearing the medical chart.

To study whether educating a female member of the household about men's health would increase men's preventive healthcare behaviors, a postcard was developed that was directed to any female member of the household. The postcard was addressed "To Someone Who Loves [member's name]" and included a list of preventive screenings recommended for men between the ages of 40 and 60.

To communicate directly with the targeted male, two personalized letters were created, one directed to men between the ages of 40 and 49, the other directed at men 50 and older. These letters were created and focused on the recommended preventive health screenings necessary for men in that age range. The letters also indicated the importance of establishing a relationship with a doctor and how to find a doctor near where they live or work. These letters bore the signature of a male medical director who was an employee of the health plan.

STUDY DESIGN

The study population was randomly assigned to two groups, a group of members whose provider would be receiving chart stickers, and one whose provider would not receive chart stickers. These two groups were further divided by randomly assigning members to four other groups: No Other Mailing, Letter and Pamphlet, Letter and Pamphlet followed by a Postcard, and Postcard Only. The control group of 1,000 members received no interventions during the study period. However, these members did receive materials once the study was completed. A randomly selected group of men who received a letter and pamphlet but no screening by the six-month analysis received a follow-up loved-one postcard. The project design is illustrated in Figure 1.

[FIGURE 1 OMITTED]

In June of 2003, 991 primary care providers were identified through claims analysis as the most recent provider the men had seen for any sort of medical visit in the past two years. The providers were sent prepopulated chart stickers as well as a survey to determine how they would utilize the chart stickers and what other types of information they would and would not like to receive in the future.

In July of 2003, the health plan sent personalized letters and pamphlets to 2,339 men (1,396 between the ages of 40 and 49 and 943 between the ages of 50 and 60), reminding them about the importance of preventive care, what screenings were needed for what age groups, and instructions for finding a primary care provider if they did not already have one. Also in July, 2,338 were sent the loved-one postcard targeted to any woman living in the home. These members received only this postcard and no other member intervention.

In January of 2004, a six-month post-intervention claims analysis was done to determine whether any of the men in the study had received a preventive health screening. If the men in the letter and pamphlet groups had not received a preventive-care screening by the six-month analysis, a random sample of these men were sent a loved-one postcard. Another claims analysis was conducted six months later to determine whether the men who received this follow-up loved-one postcard were more likely to receive a preventive-care screening than the men who were not sent the follow-up loved-one postcard. An analysis was done for each intervention group in the study matrix (Table 1).

A claims analysis was conducted six months after the interventions were mailed. This time period was considered sufficient to allow the men to receive the information and schedule a preventive-care appointment with a primary healthcare provider. These visits, often termed "well visits," tend to have longer appointment waiting periods than appointments made to see a doctor when the patient is sick. In addition to allowing enough time for an appointment and a subsequent visit, a sixmonth delay between the interventions and analysis allowed for any claims lag that might have occurred between the preventive healthcare visit and when the claim arrived and was paid by the health plan. The authors felt that any screening occurring six months beyond the mailing of the interventions could not reliably be attributed to the intervention itself.

The claims analysis identified whether an individual obtained any preventive health-screening claims after the intervention(s) was/were received. A preventive health screening was defined as receiving one or more of the following: general preventive health visit, cholesterol screening, colorectal cancer screening, or prostate cancer screening. There were no major claims or coding changes between the initial data collection and the outcomes claims analysis in January 2004. For members who left the plan between the original data collection and the outcomes analysis, only their claims that accrued between the original data collection and their termination data were analyzed. The rates were examined to determine which communication method best encouraged men to see their provider for a preventive health screening. Statistical significance was assessed using a z-test at a significance level of .05.

FINDINGS

The key outcome measures for the study were the number of colorectal cancer screenings, cholesterol screenings, prostate cancer screenings, and preventive health-care office visits performed. In addition, receipt of any preventive care services was tabulated. The effects of provider, member, and provider and member interventions were assessed. Results also examined the effect of prepopulated chart stickers alone. Finally, the receipt of any preventive-care services was examined by age. Preventive care services were not examined by race and socioeconomic status. This information is not routinely collected by the health plan and would not be present in the claims database being used for study analysis.

PREVENTIVE HEALTHCARE OFFICE VISIT

A member was considered to have had a preventive healthcare office visit if the claims analysis found evidence of a preventive healthcare office visit that did not result in an actual screening test. Of the 5,677 members who received interventions, 17.8 percent (1,012/5,677) received a preventive-care office visit, regardless of intervention type. When examined by intervention type, three of the five interventions (chart sticker only, personalized letter/pamphlet and chart sticker, personalized letter/pamphlet only, loved-one postcard and chart sticker, or loved-one postcard only), letter/pamphlet and chart sticker (p = .001), letter/pamphlet only (p = .038), and postcard and chart sticker (p = .004), resulted in significant improvements (p [less than or equal to] .05) over the control group. The control group contains members who received no intervention and whose provider received no chart sticker for them. Of the interventions, the personalized letter and chart sticker resulted in the highest percentage (20.60%, 242/1,170) of members receiving a preventive-healthcare office visit. The loved-one postcard and chart sticker intervention resulted in a 19.1 percent (223/1,169) screening rate. When the interventions were compared to one another, the personalized letter/pamphlet combined with a provider chart sticker resulted in a statistically significantly higher percentage of preventive-healthcare office visits as compared to a chart sticker only (p [less than or equal to] .05) or a postcard only (p [less than or equal to] .01). However, the letter/pamphlet and chart sticker were about equally as effective as the postcard and chart sticker.

To determine whether a combination of member-directed mailings and loved-one postcards significantly improved the percentage of men who received any preventive-healthcare screening, a sample of men in the letter/pamphlet group (both with and without provider chart stickers) who had not received any preventive care after six months were sent the loved-one postcard. Of the 457 men who received a personalized letter/pamphlet followed by a loved-one postcard and whose provider received a chart sticker, 91.9 percent (420/457) had a preventive-healthcare office visit within the next six months as compared to 31.9 percent (93/292) of those who did not receive the follow-up postcard. This was a statistically significant improvement (p <.001). Of the 459 men who received a personalized letter and pamphlet followed by a loved-one postcard and whose provider did not receive a chart sticker, 91.3 percent (419/459) had a preventive-healthcare office visit within the next six months as compared to 32.3 percent (109/337) of those who did not receive the follow-up postcard. This, too, was a statistically significant improvement (p <.001).

COLORECTAL CANCER SCREENING

A member was considered to have had a colorectal cancer screening if the claims analysis found evidence of a fecal occult blood test (FOBT), sigmoidoscopy, colonoscopy, or double-contrast barium enema. Of men 50 and older who received interventions, 8.5 percent (201/2341) received a colorectal cancer screening. When examined by intervention type, none of the interventions showed a significant improvement over the control group. In fact, the control group had a significantly higher percentage (11.4%, 47/413) of members who received a colorectal cancer screening. Of the intervention groups, the personalized letter/pamphlet and chart sticker resulted in the highest percentage of members getting a colorectal cancer screening (10.7%, 51/478). Based on these results, further analysis was not deemed necessary.

CHOLESTEROL SCREENING

A member was considered to have had a cholesterol screening if the claims analysis found evidence of a cholesterol screening claim. Of the 5,677 members who received interventions, 24.4 percent (1,386/5,677) received a cholesterol screening, regardless of intervention type. When examined by intervention type, all the interventions resulted in significant improvements (p [less than or equal to].05) over the control group. Of the interventions, the personalized letter/pamphlet and chart sticker resulted in the highest percentage (25.9%, 304/1,170) of members receiving a cholesterol screening. The loved-one postcard and chart-sticker intervention resulted in a 24.8 percent (290/1,169) screening rate. When the interventions were compared to one another, none of the interventions was significantly better than the others in increasing the number of cholesterol screenings.

When a loved-one postcard in conjunction with a personalized letter/pamphlet was examined, of the 457 men who received a personalized letter/pamphlet followed by a loved-one postcard and whose provider did not receive a chart sticker, 15.5 percent (71/459) received a cholesterol screening as compared to 8.3 percent (28/337) of the group that received no follow-up loved-one postcard. This was a statistically significant improvement (p [less than or equal to] .01). There was no statistically significant improvement for men who received a personalized letter/pamphlet followed by a loved-one postcard and whose provider received a chart sticker.

PROSTATE CANCER SCREENING

A member was considered to have had a prostate cancer screening if the claims analysis found coding indicating a prostate-specific antigen (PSA) test or a digital rectal exam. Of the 5,677 members who received interventions, 12.2 percent (694/5,677) received a prostate cancer screening, regardless of intervention type. When examined by intervention type, two of the five interventions, personalized letter/pamphlet and chart sticker (p = .001) and loved-one postcard and chart sticker (p = .039), resulted in a significant improvement (p [less than or equal to] .05) over the control group. Of the interventions, the personalized letter/pamphlet and chart sticker resulted in the highest percentage (14.9%, 175/1,170) of members receiving a prostate cancer screening. The loved-one postcard and chart-sticker intervention resulted in a 12.4 percent (145/1,169) screening rate. When the interventions were compared to one another, the personalized letter/pamphlet combined with a provider chart sticker resulted in a statistically significantly higher percentage of prostate cancer screenings as compared to any other intervention (p [less than or equal to] 05).

When a loved-one postcard in conjunction with a personalized mailing was examined, of the 459 men who received a personalized letter and pamphlet followed by a loved-one postcard and whose provider did not receive a chart sticker, 9.4 percent (43/459) received a prostate cancer screening, as compared to 4.7 percent (16/337) of the group that received no follow-up loved-one postcard. This was a statistically significant improvement (p [less than or equal to] .01). There was no statistically significant improvement for men who received a personalized letter and pamphlet followed by a loved- one postcard and whose provider received a chart sticker.

ANY PREVENTIVE CARE

A claims analysis was done to determine whether the member had received any preventive screening after the interventions were sent. Of the 5,677 members who received interventions, 32.7 percent (1,856/5,677) received some preventive screening, regardless of intervention type. This was a statistically significant improvement over the control group (p = .001). When examined by intervention type, each of the five interventions (chart sticker only, personalize letter/pamphlet and chart sticker, personalized letter/pamphlet only, loved-one postcard and chart sticker, or loved-one postcard only) showed a significant improvement (p [less than or equal to].05) over the control group. The personalized letter/pamphlet and chart sticker resulted in the highest percentage (36.0%, 421/1170) of members receiving at least one preventive-healthcare screening. When the interventions were compared to one another, the personalized letter/pamphlet combined with a provider chart sticker resulted in a statistically significantly higher percentage of preventive health screenings as compared to the other interventions (p [less than or equal to].05).

When a loved-one postcard in conjunction with a personalized letter/pamphlet was examined, of the 457 men who received a personalized letter/pamphlet followed by a loved-one postcard and whose provider received a chart sticker, 21.89 percent (100/457) received a preventive-healthcare screening as compared to 14.7 percent (43/292) of the group that received no follow-up loved-one postcard. This was a statistically significant improvement (p [less than or equal to]. 01). Of the 459 men who received a personalized letter/pamphlet followed by a loved-one postcard and whose provider did not receive a chart sticker, 22.2 percent (102/459) received a preventive-healthcare screening within the next six months as compared to 13.1 percent (44/337) of those who did not receive the follow-up postcard. This, too, was a statistically significant improvement (p [less than or equal to]. 01). In both instances, the follow-up postcard sent to a loved one living in the home resulted in a significant improvement in the number of men who received a preventive-healthcare screening.

Tables 1 and 2 provide summaries of the impact of interventions on screening rates and the p values associated with them. Positive, significant improvements are in bold.

PREPOPULATED CHART STICKERS

When chart-sticker interventions alone were examined, members whose provider received a prepopulated chart sticker were significantly more likely to receive any preventive-care screening (p < 0.01) or a cholesterol screening (p < 0.01). Chart stickers alone did not have a significant impact on the number of prostate cancer screenings, colorectal cancer screenings, or routine preventive-healthcare office visits.

PROVIDER SURVEY

Providers responded positively to the prepopulated men's health-chart stickers. Provider surveys were mailed to 991 provider offices with 12% response rate (118/991). Almost three-quarters (74.0%) of respondents indicated that they would apply the chart stickers and use them as reminders for preventive care. About half (48.4%) of the respondents who said they would not use the stickers stated that they had electronic medical records. Other than the survey, which had a low response rate, no other process validation was conducted to determine whether the physicians who received chart stickers used them. However, the outcomes analysis does suggest that including a provider reminder component does in some cases significantly increase the percentage of men who receive a preventive care screening.

AGE AND INTERVENTION TYPE

The only relevant collectable demographic variable on this population other than gender was age. Two age ranges were compared, 40 to 49 and 50 to 59. There were too few men ages 60 and older to make any reliable conclusions.

Regardless of intervention type, men in both age ranges who received any intervention were significantly more likely to receive a preventive-healthcare screening than men in the same age ranges who received no interventions (40-49,p <. 001; 50-59, p < .01). When examined by intervention type, the intervention that resulted in the highest percentage of men being screened in both age ranges was the letter/pamphlet and chart sticker (40-49, 30.8%; 50-59, 43.3%). Of men between the ages of 40 and 49, 31.2 percent (1,040/3,336) received a preventive-healthcare screening after receiving any of the interventions. This is a significant improvement over men ages 40 to 49 in the control group (p < .001). While the letter and chart sticker intervention resulted in the highest percentage of these men receiving a preventive-healthcare screening, the intervention was only significantly more effective than receiving no intervention or receiving the chart sticker only. There were no significant differences between the letter and chart sticker and the other intervention types.

Of men between the ages of 50 and 59, 43.0 percent (933/2,169) received a preventive-healthcare screening after receiving any of the interventions. This is a significant improvement over the men ages 50 to 59 in the control group (p < .01). While the letter and chart sticker intervention resulted in the highest percentage of men between the ages of 50 and 59 getting a preventive-healthcare screening, the intervention was only significantly more effective than receiving no intervention. There were no significant differences between the letter/pamphlet and chart sticker and the other intervention types for men in this age range.

DISCUSSION

Given the national underutilization trends for men cited in the introduction, the health plan performed an analysis of its members' utilization to determine whether similar utilization patterns of healthcare and health outcomes for men were present. General utilization-monitoring and needs-assessment data revealed significant underuse trends for the plan's male member population. According to claims data, women were six times as likely as men to receive a preventive health screening in 2002 (BCBSNC, 2002a). Annual physicals provide physicians opportunities to identify chronic diseases at an early stage and to counsel members on healthy lifestyle choices, particularly around preventing heart disease. Medical costs for the plan's older male population were higher than any other group. According to 2002 health plan underwriting data of men ages 19 to 64, men between the ages of 55 and 64 had the highest total per member monthly costs, the highest number of inpatient hospital stays, and the highest number and cost of prescriptions per member per month (BCBSNC, 2002b). More than three-quarters of plan members hospitalized for a heart attack and three-quarters of members hospitalized for other chronic ischemic heart disease in 2002 were men (BCBSNC, 2002a). By improving men's preventive healthcare service utilization at a younger age, the health plan hoped to improve the health of its male member population and help reduce the medical costs of these men as they get older.

The 2003 Men's Health program provided insight into the most effective means to communicate preventive health messages to men and to provide a preventive care reminder system for physicians. The materials were developed based on literature as well as member preference surveys done by the health plan between 2001 and 2002. Four types of communication were tested: (a) a personalized letter combined with an educational health pamphlet; (b) a loved one postcard; (c) a personalized letter combined with an educational health pamphlet, followed by a loved one postcard; and (d) a prepopulated chart sticker sent to physicians. The personalized letter and educational pamphlets were designed to educate the member about the importance of preventive care screenings and to inform them about the specific screenings they need. A separate letter was created for men ages 40-49 and 50 and older to differentiate between their different screening needs. Both letters included information on age-appropriate preventive health screenings, instructions for finding a participating provider in their area, and an educational men's health pamphlet. Results from plan focus groups held in 2000 as well as results from some prostate cancer literature suggested that men preferred to receive personalized health education materials, with the preferred source being their personal physician (BCBSNC, 2000; Reich et al., 1997). While it was not feasible to ask each member's personal provider to send the letter, a male plan medical director, a licensed physician, signed all letters. The effectiveness of educational health pamphlets has been discussed in various studies, particularly regarding prostate cancer screening (Partin et al., 2004; Schapira & VanRuiswyk, 2000; Wilt et al., 2001). The pamphlets that were used in this study had been evaluated in previous men's health mailings. The pamphlet's contents included information on nutrition, exercise, routine health screenings, colon cancer, prostate and testicular cancer, and sexually transmitted diseases.

While some studies illustrate the importance of female spousal support and influence on health behaviors and decisions, to our knowledge there have been few interventions targeting loved ones to help improve the preventive health behavior of men. Literature shows that one of the most cited reasons men go to the doctor is the insistence of a female loved one (Courtenay, 2000a; Sandman et al., 2000). Married men may benefit from having a concerned spouse and from women's greater propensity to seek healthcare for themselves and for their families. Men who live alone are less likely than those living with spouses or partners to see a physician, receive preventive care, or come in contact with the healthcare system (Sandman et al., 2000). Furthermore, the health of many men is monitored by their wives, girlfriends, and mothers, who often schedule any medical appointments they may need (Courtenay, 2000). A study by Pierce, Hong, Franks, and Ketterer (2002) demonstrated that wives' expectations for their husband's health as well as their role in maintaining the health of their family motivate women to promote their husbands' positive healthy lifestyle. This data is corroborated by comments made during the plan's 2001 focus groups in which participants cited their significant others/wives as the impetus for their seeing a physician (BCBSNC, 2001). Due to evidence in the literature and the feedback from the focus group, the health plan's Men's Health program included a postcard designed to use the influence of female loved ones living in the home to help convince men to get their necessary preventive health screenings. The postcard was addressed to "Someone who loves [Member's name]" and lists the recommended preventive screenings by age.

Various studies show that a physician's recommendation is a strong predictor for patients obtaining preventive healthcare screenings (Bindman, Grumbach, Osmond, Vranizan, & Stewart, 1996; DeVoe, Fryer, Phillips, & Green, 2003; Ettner, 1999). While other health insurance organizations have implemented chart stickers as reminder tools for their providers, the health plan in this study personalized these stickers to the member they represented. These stickers were prepopulated with the member's name, date of birth, and the date the stickers were sent. The stickers included check boxes for a routine health assessment including blood pressure, height, weight, lifestyle counseling, a cholesterol screening, a colorectal cancer screening, and a prostate cancer screening. The stickers were bright yellow and contained an adhesive that allowed for easy removal without damaging the medical record.

Compared to the control group, the men in either the provider and/or member intervention groups were more likely to receive preventive healthcare office visits, cholesterol screenings, and prostate cancer screenings. The study shows that intervening with men either alone or in combination with their provider can have a significant improvement on their preventive health behavior in terms of obtaining preventive healthcare office visits, cholesterol screenings, and prostate cancer screenings. Chart stickers, when used with either the personalized letter/pamphlet or the loved-one postcard, contributed to a higher percentage of men screened than did letters/pamphlets, chart stickers, or postcards alone. The study shows that personalized letters/pamphlets sent to the male patient as well as a reminder system sent to the provider's office yielded the highest percentage of men receiving their preventive health screenings. This study also documents that communicating with the female spouse of the male patient can lead to significant improvements in obtaining cholesterol screenings when the postcard is sent on its own and contribute to significant improvement in obtaining preventive-healthcare office visits, cholesterol screenings, and prostate cancer screenings when combined with a provider reminder system. When the loved-one postcard was sent as a follow-up to the personalized letter/pamphlet, the loved one postcard contributed to significant increases in the number of men receiving preventive-healthcare screenings, whether their provider received a chart sticker or not. Specifically, men who had received a personalized letter/pamphlet, yet had not received a preventive-care screening after six months, and whose loved one received a postcard were significantly more likely to receive a prostate cancer screening, cholesterol screening, and a preventive-healthcare office visit. In fact, almost 92 percent of men whose loved one received a follow-up postcard received a preventive-healthcare office visit.

None of the interventions had a significant impact on the number of men who received their colorectal cancer screenings. However, studies on colorectal cancer screening show that there are specific and unique barriers to this screenings, not the least of which are the invasiveness, discomfort, and expense of the screenings. Literature shows that interventions designed to improve colorectal cancer screening rates need to only address colorectal cancer screening, and focus on these barriers, as well as the perceived risk and doctor recommendation (Beeker, Craft, Southwell, & Jorgensen, 2000; Codori, Petersen, Miglioretti, & Boyd, 2001; Lipkus et al., 1999; Lipkus, Green, & Marcus, 2003; Walsh & Terdiman, 2003).

Due to considerable debate around the effectiveness of prostate cancer screening, in 2004 the plan began recommending prostate cancer counseling instead of screening, as recommended by the U.S. Preventive Services Task Force. A recent study from researchers at Stanford University argues that the PSA is no longer a useful diagnostic marker of prostate cancer and has led to overtreatment of the disease (Stamey, Caldwell, McNeal, Nolley, Hemenez, & Downs, 2004). The health plan will continue to promote annual prostate cancer screening counseling and/or prostate cancer screening annually for men over the age of 50. This study showed that personalized letters/chart stickers as well as loved-one postcards and chart stickers can lead to a significant increase in the number of men screened for prostate cancer.

When the interventions and screening results were examined by age, men in their fifties received a significantly higher percentage of preventive healthcare screenings after receiving any intervention as compared to men in their forties. However, the only screening that resulted in a statistically significant improvement in screening over the control group for men in their fifties was the letter/pamphlet and chart stickers. Intervening with the letter/pamphlet and chart sticker resulted in a seven percentage point increase in the number of men screened as compared to no intervention at all.

For men in their forties, the letter/pamphlet and chart stickers were also the most effective intervention. However, unlike men in their fifties, all interventions sent to men in their forties resulted in a significantly higher percentage of men receiving a preventive-healthcare screening as compared to no intervention at all. While the letter/pamphlet and chart stickers were the most effective intervention as compared to no intervention at all, it was also significantly more effective when compared to other intervention types. Men in their forties were very responsive to the reminders and educational information about preventive healthcare presented in this study. If these men receive preventive healthcare while in their forties, hopefully they will be able to treat or prevent chronic conditions earlier and enjoy better health in their fifties and older.

Throughout this analysis, the intervention that has led to the highest percentage of both aggregate and specific screenings is the combination of the provider chart sticker and personalized member letter and pamphlet. For all screenings except for colorectal cancer screenings and cholesterol screenings, the personalized letter/pamphlet combined with the chart sticker was significantly more effective than the control or most other intervention groups. The letter/pamphlet and chart sticker and the postcard and chart sticker were almost equally as effective in increasing the number of men who received a preventive-healthcare office visit. With regards to cholesterol screenings, all of the interventions resulted in significantly improving the number of men receiving their screening as compared to the control group, but none of the interventions were more effective than the other. This could be the result of cholesterol screening being the most widely accepted, affordable, and least controversial of the screenings recommended.

As with any study, there were limitations that might have affected the results. First, due to considerable debate regarding the effectiveness of the PSA test, doctors and patients could have decided not to have the recommended PSA screening, resulting in lower prostate cancer screening results. Also, due to unreliable marital status membership data, the loved-one postcards were sent to men's homes regardless of whether data existed indicating there was a female loved one in the home. Therefore, the number of men receiving a screening due to the loved-one postcard might not always be a result of the influence of a female in the home. When analyzing the data on the loved-one postcards sent six months after the personalized letter/pamphlet, it must be considered that the increased screenings resulted from a follow-up mailing (a second contact) rather than the influence of the female loved one. Also, due to claims and coding accuracy, claims lag, and claims loss, preventive services may be misreported and impact results.

CONCLUSION

This study evaluates the effectiveness of various communication interventions to encourage men to seek preventive-healthcare screenings. The findings suggest that any of the proposed interventions increased the percentage of men receiving a cholesterol screening, prostate cancer screening, or general preventive health visit. The most effective intervention for encouraging men to seek preventive healthcare was a personalized approach that included health education for men combined with a patient-specific reminder system for providers. Involving a loved one in the home by sending her a general men's health preventive care reminder postcard combined with sending a patient-specific reminder to the provider was also significantly associated with an increase in cholesterol and prostate screenings as well as general preventive healthcare visits. Following a personalized male intervention with a loved one communication also led to significant improvements in prostate cancer screenings, cholesterol screenings, and preventive-healthcare office visits. None of the evaluated interventions were successful in increasing the proportion of men who received their colorectal cancer screenings. Further research on communication strategies for improving men's health preventive care service utilization is warranted to help health plans and other healthcare agencies engage men in the healthcare system. It is also important to note that these interventions worked well for an insured population. Future research should be conducted to determine how best to increase the preventive healthcare behavior of those men who are not insured and to help these men find affordable preventive healthcare.

This project was supported by a grant provided by Pfizer, Incorporated.

Correspondence concerning this article should be addressed to Denise J. Holland, MHA, Program Innovation Manager, Blue Cross and Blue Shield of North Carolina, P.O. Box 2291, Durham, NC 27702-2291. Electronic mail: denise.holland@bcbsnc.com

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DENISE J. HOLLAND

DON W. BRADLEY

Blue Cross and Blue Shield of North Carolina

JOSEPH M. KHOURY

Men's Health Institute of North Carolina
Table 1
Intervention Matrix

 Loved-
 Letter/ One
 No mailing Pamphlet Postcard

Chart Sticker 1,000 1,170 1,169
No Chart Sticker 1,000 1,169 1,169
Chart Sticker
No Chart Sticker

 After
 Six-Month
 Analysis
 Letter/ Letter/
 Pamphlet, Pamphlet,
 Follow-up No Follow-up
 Loved-One Loved One
 Postcard Postcard

Chart Sticker
No Chart Sticker
Chart Sticker 457 292
No Chart Sticker 459 337

Table 2
Summary of Screening Impacts as Compared to Control

 p value
Screening Intervention Group Percent (< .05)

Any Screening Chart Sticker Only 31.70% 0.014
(Colorectal cancer, Letter and Chart Sticker 36.00% 0.001
prostate cancer, Letter Only 32.00% 0.008
cholesterol, Postcard and Chart Sticker 32.20% 0.005
general health visit) Postcard Only 31.40% 0.015

Prostate Cancer Chart Sticker Only 10.00% 0.500
Screening Letter and Chart Sticker 14.95% 0.001
 Letter Only 11.89% 0.080
 Postcard and Chart Sticker 12.40% 0.039
 Postcard Only 11.54% 0.125

Cholesterol Chart Sticker Only 24.00% 0.005
Screening Letter and Chart Sticker 25.90% 0.001
 Letter Only 23.60% 0.008
 Postcard and Chart Sticker 24.80% 0.001
 Postcard Only 23.30%

Colorectal Cancer Chart Sticker Only 7.93% 0.046
Screening Letter and Chart Sticker 10.67% 0.370
 Letter Only 8.17% 0.054
 Postcard and Chart Sticker 7.94% 0.040
 Postcard Only 8.15% 0.050

Preventive Care Chart Sticker Only 16.20% 0.195
Office Visit Letter and Chart Sticker 20.60% 0.001
 Letter Only 17.60% 0.038
 Postcard and Chart Sticker 19.07% 0.004
 Postcard Only 15.30% 0.371

Table 3
Summary of Screening Impacts of Follow-Up Loved-One
Postcard on Men Who Were Not Screened after Six Months

 p value
Screening Intervention Group Percent (< .05)

Any Screening Chart Sticker Only 31.70% 0.019
(Colorectal cancer, Letter Only 32.00% 0.018
prostate cancer, Postcard and Chart Sticker 32.20% 0.029
cholesterol, general Postcard Only 31.40% 0.011
health visit) Letter and Chart Sticker 14.95% NA
Prostate Cancer Chart Sticker Only 10.00% 0.010
Screening Letter Only 11.89% 0.015
 Postcard and Chart Sticker 12.40% 0.036
 Postcard Only 11.54% 0.008

Cholesterol Letter and Chart Sticker 25.90% NA
Screening Chart Sticker Only 24.00% 0.171
 Letter Only 23.60% 0.100
 Postcard and Chart Sticker 24.80% 0.258
 Postcard Only 23.30% 0.071

Preventive Care Letter and Chart Sticker 20.60% NA
Office Visit Chart Sticker Only 16.20% 0.003
 Letter Only 17.60% 0.030
 Postcard and Chart Sticker 19.07% 0.166
 Postcard Only 15.30% 0.001
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Author:Khoury, Joseph M.
Publication:International Journal of Men's Health
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Date:Jun 22, 2005
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