Lea Hagoel

Risk communication strategies: state of the art and effectiveness in the context of cancer genetic services.

The objective of this paper is first to describe the different strategies used to communicate risks to patients in the field of cancer or genetics, to review their effectiveness, and to summarise the state of the art of this practice in particular, in cancer genetics. The target audience is health care professionals involved in the communication of cancer risks, and genetic risks of breast/ovarian or colorectal cancer in particular. The methods include a review of the literature (Medline, Pascal, PsycInfo, Embase) by a panel of researchers and clinicians (cancer geneticists, epidemiologists, health psychologists, sociologists) in the context of a European Project on risk communication. We highlight practices that have been shown to be effective in the context of health psychology research and those being still under consideration for use in routine practice. In conclusion, this paper adds clinical relevance to the research evidence. We propose specific steps that could be integrated in standard clinical practice based on current evidence for their usefulness/effectiveness.

Screening with faecal occult blood test FOBT for colorectal cancer: assessment of two methods that attempt to improve compliance

Screening with the faecal occult blood test (FOBT) has been shown in randomized control trials to be effective in reducing mortality from colorectal cancer. Compliance to this test recommendation, however, by the general population is usually low. To evaluate different methods of increasing compliance with FOBT, using mailed test kits or order cards, with or without information leaflets, subjects were randomly assigned to receive a test kit or a kit request card. An information leaflet was included in half of the mailings. All participants were contacted for interview. Compliance was evaluated through the central computer system of the studys FOBT laboratory. Self‐initiated compliance with FOBT in the year preceding the study was 0.6% of the study participants. The overall compliance rate with the programme invitation was 17.9%, with a somewhat higher, though non‐significant response to the mailed kit (19.9%) over the kit request card (15.9%). Women complied with the test significantly more than men, older participants more than younger. Compliance to FOBT is low among the Israeli population aged 50–74 who receive a formal invitation to carry out this screening. Mailing a kit request card within the framework of a screening programme can achieve a substantial increase (to 17.9%) in the level of compliance for the relatively low cost of postage. More effort is needed to study additional means of convincing the non‐responders to take part in this potentially life saving activity.

Participation rates for organized colorectal cancer screening programmes: an international comparison.

Objective Participation, an indicator of screening programme acceptance and effectiveness, varies widely in clinical trials and population-based colorectal cancer (CRC) screening programmes. We aimed to assess whether CRC screening participation rates can be compared across organized guaiac fecal occult blood test (G-FOBT)/fecal immunochemical test (FIT)-based programmes, and what factors influence these rates. Methods Programme representatives from countries participating in the International Cancer Screening Network were surveyed to describe their G-FOBT/FIT-based CRC screening programmes, how screening participation is defined and measured, and to provide participation data for their most recent completed screening round. Results Information was obtained from 15 programmes in 12 countries. Programmes varied in size, reach, maturity, target age groups, exclusions, type of test kit, method of providing test kits and use, and frequency of reminders. Coverage by invitation ranged from 30–100%, coverage by the screening programme from 7–67.7%, overall uptake/participation rate from 7–67.7%, and first invitation participation from 7–64.3%. Participation rates generally increased with age and were higher among women than men and for subsequent compared with first invitation participation. Conclusion Comparisons among CRC screening programmes should be made cautiously, given differences in organization, target populations, and interpretation of indicators. More meaningful comparisons are possible if rates are calculated across a uniform age range, by gender, and separately for people invited for the first time vs. previously.

The gradient in mammography screening behavior: a lifestyle marker

The study reports a gradient in adhering to a recommended health behavior-mammography screening. Data were collected on 951 Israeli women, aged 50-74, who were mailed an invitation to a prescheduled mammography screening appointment and were later phone interviewed about their background, their other health behaviors and their health perceptions related to cancer, mammography and self-rated health. The main finding that emerged was a gradient consisting of three groups defined by their adherence to mammography screening: women who declined the invitation to undergo screening (nonattenders, 32%), women who attended a screening upon encouragement (attenders, 45%) and women who initiated the test on their own (self-screenees, 23%). This gradient was shown to be related to structural/background variables (e.g. SES, age, education, ethnicity), other health behaviors and perceptual variables related to health in general and to cancer. For example, self-screenees were of a higher SES, engaged in more health behaviors and were closer to other women who performed a mammography. An analysis carried out to discern where the difference between the three groups lied showed that it was more apparent between the self-screenees and attenders, and that the attenders and nonattenders were more similar to each other. These findings are discussed in terms of health behavior as a discrete phenomenon vs. reflecting a lifestyle. Suggestions for intervention possibilities are presented in light of the finer ranking proposed above (as opposed to the dichotomy of engaging/not engaging in a health behavior).

The public prefers fecal occult blood test over colonoscopy for colorectal cancer screening

The acceptability of colorectal cancer (CRC) screening tests to the population influences adherence. Population preferences between fecal occult blood test (FOBT) and colonoscopy for CRC screening were examined by previous test experience. The study population was a random sample of 413 members of Israels largest Health Maintenance Organization (HMO) aged 48–68 years. In a telephone interview, an explanation was provided regarding FOBT and colonoscopy. Participants were asked which they preferred and their degree (1–6) of agreement with each of eight test characteristics. Overall Attitude Scores toward FOBT and colonoscopy were compared. Predictors of colonoscopy preference and of refusal to undergo screening were examined using a logistic regression model. FOBT was preferred as a screening test by 70.2% of the participants, colonoscopy by 9.3%, 7.4% were indecisive, and 13.1% were not interested in screening. FOBT and colonoscopy similarly scored highly as life saving (5.2 vs. 5.1, respectively), with colonoscopy scoring significantly higher as time consuming (3.8 vs. 1.3, P<0.0001), disturbing (4.6 vs. 1.8, P<0.0001), painful (4.1 vs. 1.0, P<0.0001), annoying (4.8 vs. 1.9, P<0.0001), and involving risk (3.2 vs. 1.0, P<0.0001). In a logistic multivariate analysis, preference of colonoscopy was associated with the perception of being at CRC risk [odds ratio (OR): 3.1 (95% confidence interval (CI): 1.3–7.6)], with more positive attitude scores towards this test [OR: 2.2 (95% CI: 1.6–3.0)], and with a more negative one toward FOBT [OR: 0.4 (95% CI: 0.3–0.7)]. Target population preferences for CRC screening supports a policy of FOBT screening for an average risk population and colonoscopy for high-risk individuals.

Clustering Women’s Health Behaviors

This study attempts to characterize health lifestyles by subgrouping women with similar behavior patterns. Data on background, health behaviors, and perceptions were collected via phone interview from 1,075 Israeli women aged 50 to 74. From a cluster analysis conducted on health behaviors, three clusters emerged: a “health promoting” cluster (44.1%), women adhering to recommended behaviors; an “inactive” cluster (40.3%), women engaging in neither health-promoting nor compromising behaviors; and an “ambivalent” cluster (15.4%), women engaging somewhat in both health-promoting and compromising behaviors. Clustering was cross-tabulated by demographic and perceptual variables, further validating the subgrouping. The cluster solution was also validated by predicting another health behavior (mammography screening) for which there was an external validating source. Findings are discussed in comparison to published cluster solutions, culminating in suggestions for intervention alternatives. The concept of lifestyle was deemed appropriate to summarize the clustering of these behavioral, perceptual, and structural variables.

Cancer genetics service provision: a comparison of seven European centres.

Objective: To conduct a survey in seven European cancer genetics centres to compare service provision, organisation and practices for familial breast and colon cancer consultations and testing. Information was obtained on aspects of services both nationally and locally. Methods: A detailed survey questionnaire was adapted collaboratively to obtain the required information. Initial survey data were collected within each centre and interim results were discussed at two European Workshops. Where differences in practice existed, details were clarified to ensure accuracy and adequacy of information. Participating centres were Haifa (Israel), Hannover (Germany), Leiden (The Netherlands), Leuven (Belgium), Manchester (UK), Marseille (France) and Milan (Italy), representing countries with populations ranging from 6.5 to 80 million. Results: The European countries diverged in regard to the number of cancer genetics centres nationally (from 8 in Belgium to 37 in France), and the average population served by each centre (from 0.59 million in Israel to 3.32 million in Italy). All centres offered free care at the point of access, but referral to specialist care varied according to national health care provision. At a centre level, staff roles varied due to differences in training and health care provision. The annual number of counsellees seen in each participating centre ranged from 200 to over 1,700. Access to breast surveillance or bowel screening varied between countries, again reflecting differences in medical care pathways. These countries converged in regard to the wide availability of professional bodies and published guidelines promoting aspects of service provision. Similarities between centres included provision of a multidisciplinary team, with access to psychological support, albeit with varying degrees of integration. All services were dominated (70–90%) by referrals from families with an increased risk of breast cancer despite wide variation in referral patterns. Collection of pedigree data and risk assessment strategies were broadly similar, and centres used comparable genetic testing protocols. Average consultation times ranged between 45 and 90 min. All centres had access to a laboratory offering DNA testing for breast and bowel cancer-predisposing genes, although testing rates varied, reflecting the stage of service development and the type of population. Israel offered the highest number of genetic tests for breast cancer susceptibility because of the existence of specific founder mutations, in part explaining why the cancer genetics service in Haifa differed most from the other six. Conclusion: Despite considerable differences in service organisation, there were broad similarities in the provision of cancer genetic services in the centres surveyed.

Crossing Borders: Toward a trans-disciplinary scientific identity

For several decades, researchers have addressed the topic of disciplines: how they come into existence, how they are institutionalized, and how they change over time. These discussions have focused on new disciplines and shifting paradigms in the natural and the social sciences, as well as in the humanities. Many of the shifts seem to require increasing reliance on what has been called interdisciplinary research--research carried out in teams whose members are experts in different fields. This article examines how a disciplinary shift was brought about in a single individual. The impetus for the shift is social and organizational, the process is undergone in a bureaucratic context, and the outcome is a kind of scientific identity that has not been explored specifically, that of a transdisciplinary identity in which competencies in the social and the life sciences are interwoven in daily practices.

Psychosocial and medical factors in pregnancy outcomes: A case study of Israeli women

Building on a body of research which confirms that psychosocial factors have an important influence on health in general and on pregnancy outcomes in particular, we carried out a prospective study of pregnant women in Israel. We hypothesized that medical pregnancy and delivery outcomes are mediated by psychosocial coping resources and risks. Resources were defined as social ties, and risks as life events self-reported as stressful. The population studied included 233 women who responded to questionnaires after the second trimester of pregnancy. Medical data on the delivery were collected from hospital archives. The questionnaire measured biomedical risks, including general medical and obstetrical history, as well as health behaviours, social ties, and perceived stress. Pregnancy outcomes were classified according to medical measures of abnormalities in mother and child at birth. Our findings show that resources such as the variety of social ties (family, friends, neighbours and colleagues) interacted significantly with biomedical risk. It was found that low scores for social ties anticipated 3.6 times higher negative medical outcome in otherwise healthy women than in those with higher scores for social ties. The findings of the study are discussed in terms of their implications for relating to social competence as a determining element in health and health behaviour.

An evaluation of an education programme, for prevention and early diagnosis of malignancy in Israel.

A community-wide health education programme for the prevention and early detection of cancer was performed in the Krayot municipalities, north of Haifa, Israel, during the years 1985–86. In order to assess its effectiveness, an evaluation programme was conducted. The knowledge, attitudes and behaviour of women who had been exposed to the education programme and of a control group, were compared before the programme started and 2.5 years later, after it ended. The programme was conducted in five clinics and included changes in the functioning of the clinics and their teams to be used in the interaction with the insured women. A piloted questionnaire was used to evaluate knowledge, attitudes and behaviour of these women. Emphasis was placed on smoking, sun tanning, self-examination of breast and other aspects of possible early detection of cancer. The education programme was ineffective not only with regard to behaviour but also in relation to knowledge on the relationship between health behaviour and cancer. The need for the establishment of more effective means for health education is eminent. If health education programmes are to succeed, we must understand what motivates or prevents compliance with recommended health behaviour.