HLTH 2110 Week 9 Intervention Critique Example

What Each Program Assumed Was Missing: Vale la Pena's Information Theory and a Mailed-Test Program's Obstacle Theory, Read From Their Own Design Statements and Measured Against Their Own Outcomes

Student Name

Walden University

HLTH 2110: Behavioral and Cultural Issues in Healthcare

Instructor Name

Month Day, Year

What Each Program Assumed Was Missing: Vale la Pena's Information Theory and a Mailed-Test Program's Obstacle Theory, Read From Their Own Design Statements and Measured Against Their Own Outcomes

Two Programs, One Goal

Colorectal cancer screening rates are lower among Hispanic adults in the United States than among white adults, especially among those who prefer Spanish (Liss & Baker, 2014). Programs to close that gap rest on a theory, stated or not, about what is missing. Some assume that people lack information, motivation or confidence, and set out to supply them. Others assume that people face obstacles, such as cost, time or the need for an appointment, and set out to remove them. This critique compares one program of each kind, both aimed at Hispanic adults, and locates each program's assumption in its own design statements before looking at its results.

Program 1: Vale la Pena

What It Did

Vale la Pena ("It's Worth It!") was a cluster randomized trial in 24 colonias, neighborhoods along the Texas-Mexico border in the Lower Rio Grande Valley (Fernández et al., 2015). It enrolled 665 Hispanic adults aged 50 and older. Lay health workers delivered one of two interventions: a small-media print intervention, including a DVD and a flipchart, or a tailored interactive multimedia program on tablet computers. A third group received no intervention.

What It Assumed Was Missing

The program's own statement of its measures shows its theory. The study assessed screening behavior along with "self-efficacy, knowledge, and other psychosocial constructs related to CRCS and targeted through VLP" (Fernández et al., 2015, abstract). The constructs targeted were inside the person: what they knew, how confident they felt and how they thought about screening. The design assumed that if those changed, screening would follow. It did not provide a test, pay for one or schedule one.

What It Was Measured Against

The outcome was completion of colorectal cancer screening at follow-up, compared with a group that received nothing. In the intent-to-treat analysis, 13.6% of the print group, 10.2% of the multimedia group and 10.8% of the comparison group completed screening, and the differences were not statistically significant (Fernández et al., 2015).

Program 2: A Mailed-Test Program in Community Health Centers

What It Did

Baker et al. (2014) tested a program in a network of community health centers in Chicago. The 450 participants had completed a home stool test the previous year with a normal result and were due for their next annual test. Most were Latino (87%), most preferred Spanish (83%) and three in four had no insurance (77%). The intervention group received a mailed reminder letter, a free fecal immunochemical test with low-literacy instructions and a postage-paid return envelope, then automated phone and text reminders and, for those who still had not returned the test, a personal phone call.

What It Assumed Was Missing

The program's design statement locates the problem outside the person. The authors wrote that the home test "may overcome cost and access barriers," and that its value "depends on high rates of adherence to annual screening" (Baker et al., 2014, abstract). The design followed from that: the test came to the patient, at no cost, with return postage, and reminders arrived at intervals. Nothing in the intervention aimed to change what patients knew or believed about cancer.

What It Was Measured Against

The outcome was completion of the test within six months of the due date, compared with usual care. Usual care was not nothing: it already included computerized reminders, standing orders for medical assistants to hand out home tests and feedback to clinicians on screening rates. Against that stronger comparison, 82.2% of the intervention group completed screening, compared with 37.3% of the usual care group (Baker et al., 2014). Most completed the test within the first two weeks after the mailing, before any personal call.

Comparing the Two

The difference in results is large, and it points in the direction of the obstacle theory. But the comparison must be read with care. The mailed-test participants had all completed a test the year before, so they had already shown willingness to screen. Vale la Pena recruited people in their neighborhoods, many of whom may never have been screened and may not have had a health center to return a test to. The two trials therefore test their theories in different populations, and part of the difference in results may come from who was enrolled.

Even so, the design of each program limited what it could achieve. Vale la Pena could raise knowledge and confidence, but a participant who then wanted to be screened still had to find a clinician, obtain a test or a colonoscopy and, for many, pay for it. The program did not address those steps. The mailed-test program, by contrast, made the next step the easiest one available: open an envelope, use the test, mail it back.

Table 1

Two Programs Compared

The comparison is between two separate trials, not a head-to-head test, and the populations differ in ways that matter.

What the Comparison Shows About Assumptions

A program's theory of what is missing shapes what it delivers, and what it delivers limits what it can change. Vale la Pena assumed that the gap lay in knowledge and attitudes, and its evaluation measured those constructs alongside screening. If knowledge rose and screening did not, the program's own data would suggest that knowledge was not the main barrier. The mailed-test program assumed that the gap lay in access and follow-through, and it removed those barriers directly. Liss and Baker (2014) found that socioeconomic status and access explained part, though not all, of the screening gap for Spanish-preferring Hispanic adults, which is consistent with both programs having a role: information alone is unlikely to be enough, and removing obstacles reaches people who are already willing.

Conclusion

Reading each program from its own design statements shows that Vale la Pena treated the screening gap as a matter of what people knew and believed, while the mailed-test program treated it as a matter of what stood between people and a test. The first produced no significant change in screening; the second more than doubled annual screening among people who had screened before. The comparison does not prove that information never matters. It shows that a program which supplies information but leaves every obstacle in place asks participants to do the hardest part on their own.

References

Baker, D. W., Brown, T., Buchanan, D. R., Weil, J., Balsley, K., Ranalli, L., Lee, J. Y., Cameron, K. A., Ferreira, M. R., Stephens, Q., Goldman, S. N., Rademaker, A., & Wolf, M. S. (2014). Comparative effectiveness of a multifaceted intervention to improve adherence to annual colorectal cancer screening in community health centers: A randomized clinical trial. JAMA Internal Medicine, 174(8), 1235-1241. https://doi.org/10.1001/jamainternmed.2014.2352

Fernández, M. E., Savas, L. S., Carmack, C. C., Chan, W., Lairson, D. R., Byrd, T. L., Wilson, K. M., Arvey, S. R., Krasny, S., & Vernon, S. W. (2015). A randomized controlled trial of two interventions to increase colorectal cancer screening among Hispanics on the Texas-Mexico border. Cancer Causes & Control, 26(1), 1-10. https://doi.org/10.1007/s10552-014-0472-5

Liss, D. T., & Baker, D. W. (2014). Understanding current racial/ethnic disparities in colorectal cancer screening in the United States: The contribution of socioeconomic status and access to care. American Journal of Preventive Medicine, 46(3), 228-236. https://doi.org/10.1016/j.amepre.2013.10.023