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Lung cancer screening is a US Preventive Services Task Force Grade B recommendation that has been shown to decrease lung cancer-related mortality by approximately 20%. However, making the decision to screen, or not, for lung cancer is a complex decision because there are potential risks (eg, false positive results, overdiagnosis). Shared decision making was incorporated into the lung cancer screening guideline and, for the first time, is a requirement for reimbursement of a cancer screening test from Medicare. Awareness of lung cancer screening remains low in both the general and screening-eligible populations. When a screening-eligible person visits their clinician never having heard about lung cancer screening, engaging in shared decision making to arrive at an informed decision can be a challenge. Methods to effectively prepare patients for these clinical encounters and support both patients and clinicians to engage in these important discussions are needed.
The aim of the study was to estimate the effects of a computer-tailored decision support tool that meets the certification criteria of the International Patient Decision Aid Standards that will prepare individuals and support shared decision making in lung cancer screening decisions.
A pilot randomized controlled trial with a community-based sample of 60 screening-eligible participants who have never been screened for lung cancer was conducted. Approximately half of the participants (n=31) were randomized to view LungTalk—a web-based tailored computer program—while the other half (n=29) viewed generic information about lung cancer screening from the American Cancer Society. The outcomes that were compared included lung cancer and screening knowledge, lung cancer screening health beliefs (perceived risk, perceived benefits, perceived barriers, and self-efficacy), and perception of being prepared to engage in a discussion about lung cancer screening with their clinician.
Knowledge scores increased significantly for both groups with greater improvement noted in the group receiving LungTalk (2.33 vs 1.14 mean change). Perceived self-efficacy and perceived benefits improved in the theoretically expected directions.
LungTalk goes beyond other decision tools by addressing lung health broadly, in the context of performing a low-dose computed tomography of the chest that has the potential to uncover other conditions of concern beyond lung cancer, to more comprehensively educate the individual, and extends the work of nontailored decision aids in the field by introducing tailoring algorithms and message framing based upon smoking status in order to determine what components of the intervention drive behavior change when an individual is informed and makes the decision whether to be screened or not to be screened for lung cancer.
RR2-10.2196/resprot.8694
Lung cancer screening is recommended by the US Preventive Services Task Force (USPSTF) with a Grade B recommendation and offers the potential to detect lung cancer via low-dose computed tomography of the chest at an earlier stage when more treatment options exist [
Knowledge and awareness about lung cancer screening among the general population is extremely low [
In this paper, the results of a community-based, pilot randomized controlled trial to compare the effects of LungTalk to those of a nontailored lung screening information sheet in a sample of screening-eligible individuals are presented. LungTalk was developed using the USPSTF Lung Cancer Screening Guidelines as well as qualifying and certification criteria of the International Patient Decision Aid Standards instrument [
Are there changes in knowledge of lung cancer risk and screening, and lung cancer screening health beliefs (perceived risk, perceived benefits, perceived barriers, self-efficacy) between patients who received LungTalk and those who received the nontailored lung screening information sheet?
Are there changes in participants’ perceptions of being prepared to engage in a discussion with their clinician about lung cancer screening between patients who received LungTalk and those who received the nontailored lung screening information sheet?
Are there changes in self-reported patient-clinician discussions about lung cancer screening and receipt of a lung cancer screening recommendation between patients who received LungTalk and those who received the nontailored lung screening information sheet?
Participants (n=60), both men and women, who were eligible for lung cancer screening were recruited using Facebook-targeted advertisement. (Facebook has the ability to “target” an advertisement by demographics and keywords listed in each individual Facebook user’s profile or interest list.) Using this technique, we were able to purposively sample people aged 55 years and older who indicated smoking as an interest or like in their profile. Frandsen et al [
LungTalk is a computer-tailored decision support tool that is theoretically grounded in the Conceptual Model on Lung Cancer Screening Participation [
LungTalk includes audio, video, and animation segments with tailoring algorithms for scripts presented from a master content library. In addition, LungTalk offers the option of saving or printing a tailored summary (at program completion) that individuals can use to guide a discussion with their clinician. This summary highlights key points related to lung health and screening tailored by smoking status, offers questions the user can ask to initiate a discussion with their clinician, and includes specific questions identified by the user that they wish to discuss with their clinician. Content in LungTalk is visually presented with text written at an eighth grade reading level. To meet the needs of people with low literacy and auditory preference learning styles, all content is narrated as well as shown as written text on screens (see
The control group viewed a nontailored lung screening information sheet online that contained information compiled from lung cancer screening information developed by the American Cancer Society. The reading level of this written material was at an eighth grade level.
Data collected between January 2017 and February 2017 from participants in the state of Indiana. Data were collected via online surveys completed by participants (baseline only) and telephone interviews conducted by trained research staff. The follow-up surveys were developed in REDCap, a secure web-based application to build and manage online surveys and databases. Participants completed a 20-minute baseline survey prior to randomization. Follow-up surveys were then completed 1 week and 3 months postintervention.
The baseline survey collected data on sociodemographic and health status characteristics, lung cancer and screening knowledge, lung cancer screening health beliefs (perceived risk of lung cancer, perceived benefits of, perceived barriers to, and self-efficacy for lung cancer screening) [
A follow-up telephone interview was conducted within 1 week of the participant completing the intervention. The interview included items to assess lung cancer and screening knowledge, lung cancer screening health beliefs (perceived risk, perceived benefits, perceived barriers, and self-efficacy) [
Guided by the Conceptual Model on Lung Cancer Screening Participation, valid and reliable instruments were used to measure knowledge of lung cancer risk and screening, lung cancer screening health beliefs (perceived risk of lung cancer, perceived benefits of, perceived barriers to, and self-efficacy for lung cancer screening), health care clinician recommendation, perception of preparation to engage in a patient-clinician discussion about lung cancer screening, and stage of adoption for lung cancer screening participation. Stage of adoption was measured using an algorithm that is theoretically based upon the Precaution Adoption Process model [
Deidentified data collected via REDCap were exported for analyses. Data completeness was assessed through descriptive analyses. Means and standard deviations or frequency distributions were examined to check for coding errors and out-of-range values.
Our first goal was to evaluate the feasibility of study procedures. Therefore, we calculated study participation rates and rates of completion and retention of participants at baseline (T1), 1-week postintervention (T2), and 3 months postintervention (T3). For each, we calculated the proportion of people who were recruited initially and retained at each data collection timepoint (see
Participant recruitment flowchart.
Analysis of covariance models (ANCOVAs) were performed to determine if there were significant differences in change scores between groups, adjusted for the value at T1. Using the model result’s means and standard error, we calculated the pooled model-based standard deviation and Cohen
Participants ranged in age from 55 to 74 years (mean 62.4, SD 5.2) with fairly equal numbers of men (29/60, 48%) and women (31/60, 52%). The majority were White (48/60, 80%). Participant sociodemographic and health status characteristics are shown by intervention group in
Demographics and smoking characteristics at baseline.
Characteristic | Overall (n=60) | LungTalk (n=31) | Nontailored lung screening information sheet (n=29) | ||
Age (years), mean (SD) | 62.2 (5.2) | 61.2 (4.8) | 63.2 (5.5) | .13a | |
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.07b | |
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55-64 | 38 (63) | 23 (74) | 15 (52) |
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65+ | 22 (37) | 8 (26) | 14 (48) |
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.99b | |
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Male | 29 (48) | 15 (48) | 14 (48) |
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Female | 31 (52) | 16 (52) | 15 (52) |
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.86c | |
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White | 48 (80) | 24 (77) | 24 (83) |
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Black | 10 (17) | 6 (19) | 4 (14) |
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Other | 2 (3) | 1 (3) | 1 (3) |
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.73c | |
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Yes | 10 (17) | 6 (19) | 4 (14) |
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No | 50 (83) | 25 (81) | 25 (86) |
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.78b | |
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Former | 28 (46.7) | 15 (48.4) | 13 (44.8) |
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Current | 32 (53.3) | 16 (51.6) | 16 (55.2) |
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.23c | |
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<High school | 1 (2) | 1 (3) | 0 (0) |
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High school/GED | 19 (32) | 10 (32) | 9 (31) |
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Some college | 19 (32) | 12 (39) | 7 (24) |
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College graduate | 21 (35) | 8 (26) | 13 (45) |
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<$25,000 | 25 (42) | 14 (45) | 11 (39) | .94b |
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$25,000-$50,000 | 20 (34) | 9 (29) | 11 (39) |
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>$50,000 | 14 (24) | 8 (26) | 6 (21) |
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.33c | |
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Medicare | 14 (24) | 9 (30) | 5 (18) |
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Medicaid | 8 (14) | 4 (13) | 4 (14) |
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Private | 18 (31) | 11 (37) | 7 (25) |
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Medicare+supplement | 8 (14) | 2 (7) | 6 (21) |
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Other | 2 (3.5) | 0 (0) | 2 (7) |
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Multiple | 8 (14) | 4 (13) | 4 (14) |
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Pack-years tobacco smoking, mean (SD) | 48.7 (19.5) | 47.6 (21.9) | 49.9 (16.6) | .29a | |
Packs smoked daily, mean (SD) | 1.3 (0.5) | 1.4 (0.5) | 1.3 (0.5) | .97a | |
Years smoked, mean (SD) | 36.6 (8.3) | 35.4 (9.3) | 37.9 (7.0) | .10a | |
Years since quitting, mean (SD) | 6.3 (5.0) | 6.7 (5.7) | 5.8 (4.4) | .77a |
aWilcoxon rank-sum test.
bChi-square test.
cFisher exact test.
Mean scores, standard deviations, and change scores for knowledge and beliefs are shown in
While
Because knowledge was significantly higher for those who received LungTalk, we examined group differences on individual knowledge items to see where specific improvements were made (
Scores at baseline (T1) and 1-week postintervention (T2) and within-group tests.
Variable | Lung Talk, mean (SD) |
Nontailored lung screening information sheet, mean (SD) | |
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T1 | 3.90 (1.47) | 3.66 (1.47) |
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T2 | 6.27 (1.26) | 4.79 (1.32) |
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Change | 2.33 (1.54) | 1.14 (1.16) |
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SRMa | 1.51 | 0.98 |
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<.01 | <.01 | |
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T1 | 13.74 (2.66) | 13.69 (1.95) |
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T2 | 13.43 (2.40) | 14.28 (2.36) |
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Change | –0.27 (2.13) | 0.59 (1.96) |
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SRM | –0.13 | 0.30 |
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.50 | .12 | |
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T1 | 17.55 (1.88) | 18.34 (2.70) |
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T2 | 18.70 (3.10) | 18.07 (2.89) |
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Change | 1.17 (2.85) | –0.28 (2.00) |
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SRM | 0.41 | –0.14 |
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.03 | .46 | |
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T1 | 34.10 (7.15) | 33.03 (6.48) |
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T2 | 33.20 (7.43) | 30.90 (7.24) |
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Change | –0.90 (5.86) | –2.14 (6.49) |
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SRM | –0.15 | –0.33 |
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.41 | .09 | |
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T1 | 27.45 (5.08) | 28.38 (4.87) |
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T2 | 28.97 (4.55) | 30.38 (4.16) |
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Change | 1.53 (3.30) | 2.00 (3.56) |
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SRM | 0.46 | 0.56 |
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.02 | .01 |
aSRM: standardized response mean = mean change / SD of change.
b2-sided paired test.
Effect sizes.
Variable | Scale range | Adjusted mean (SE) change | Comparison | ||||
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LungTalk | Nontailored lung screening information sheet | Mean difference (95% CI) | Cohen |
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Total knowledge | 0-6 | 2.41 (0.20) | 1.06 (0.21) | 21.5 (1, 56) | <.01 | 1.35 (0.77, 1.93) | 0.8482 |
Total perceived risk | 3-12 | –0.26 (0.34) | 0.58 (0.35) | 3.03 (1, 56) | .09 | –0.85 (–1.83, 0.13) | –0.3179 |
Total perceived benefits | 6-24 | 1.07 (0.45) | –0.18 (0.45) | 3.79 (1, 56) | .06 | 1.25 (–0.04, 2.54) | 0.3555 |
Total perceived barriers | 17-68 | –0.72 (1.06) | –2.32 (1.07) | 1.12 (1, 56) | .29 | 1.60 (–1.43, 4.62) | 0.1931 |
Total self-efficacy | 9-36 | 1.37 (0.54) | 2.17 (0.55) | 1.08 (1, 56) | .30 | –0.80 (–2.35, 0.75) | –0.1896 |
aPositive effect size indicates greater increase from T1 to T2 for LungTalk than for InfoSheet. Negative effect size indicates greater increase from T1 to T2 for InfoSheet than for LungTalk.
Individual knowledge items by within-group change.
Knowledge item | LungTalk |
Nontailored lung screening information sheet | ||||
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Baseline, |
T2, |
Baseline, |
T2, |
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Who is more likely to get lung cancer? (a person who has smoked cigarettes for a long time) | 27 (87.1) | 28 (93.3) | .41 | 26 (89.7) | 27 (93.1) | .56 |
What is the most common symptom of lung cancer? (chronic cough) | 25 (80.7) | 25 (83.3) | .56 | 24 (82.8) | 27 (93.1) | .18 |
Which test is currently recommended for lung cancer screening? (low-dose CTb scan) | 8 (25.8) | 25 (83.3) | <.001 | 9 (31.0) | 24 (82.8) | .001 |
Compared to a chest x-ray, how much radiation does a lung scan expose you to? (about the same as a chest x-ray) | 6 (19.4) | 11 (36.7) | .06 | 6 (20.7) | 8 (27.6) | .41 |
What should a person do before being screened for lung cancer? (talk with their health care provider about low-dose CT screening) | 21 (67.7) | 29 (96.7) | .01 | 20 (69.0) | 24 (82.8) | .10 |
If you choose to have a lung scan to screen for lung cancer and everything is normal, when will you need to have your next one? (in 1 year) | 17 (54.8) | 25 (83.3) | .007 | 8 (27.6) | 7 (24.1) | .71 |
Who is currently recommended to have a lung scan to screen for lung cancer? (only current and former smokers) | 10 (32.3) | 21 (70.0) | .004 | 6 (20.7) | 13 (44.8) | .008 |
At what age is it recommended that people start to screen for lung cancer? (55) | 7 (22.6) | 24 (80.0) | <.001 | 7 (24.1) | 9 (31.0) | .48 |
a2-sided McNemar test of paired proportions.
bCT: computed tomography.
As shown in
User satisfaction, clinician recommendation, shared decision-making discussion by group.
Variable | Lung Talk (n=31) | Nontailored lung screening information sheet (n=29) | |||||
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.002 | ||||
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Not at all satisfied | 0 (0) | 1 (3) |
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Somewhat satisfied | 1 (3) | 4 (14) |
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Satisfied | 7 (23) | 16 (55) |
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Very satisfied | 22 (73) | 8 (28) |
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.52 | ||||
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Somewhat prepared | 4 (13) | 6 (21) |
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Prepared | 10 (33) | 6 (21) |
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Very prepared | 16 (53) | 17 (59) |
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.33 | ||||
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Yes | 8 (28) | 4 (15) |
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No | 22 (72) | 25 (85) |
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.23 | |||||
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Yes | 10 (34) | 5 (19) |
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No | 20 (66) | 24 (81) |
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a2-sided Fisher exact test.
P-value is from two-sided Fisher’s exact Test.
At 6 months, though the number of participants who reported that they had a discussion with their clinician in the LungTalk group (10/31, 34.5%) was double that in the nontailored lung screening information sheet group (5/29, 18.5%), this difference was not significant (
It is still relatively early on in the development of decision support tools for lung cancer screening. Most have focused on calculating personal risk for the development of lung cancer and subsequent recommendations to screen are based upon calculated risk status [
Similar to other patient decision aids [
As an intervention, individuals using LungTalk felt equally prepared to engage in a discussion with their clinician about lung cancer screening as they did with the nontailored lung screening information sheet. From the patient perspective, being prepared to engage in a shared discussion about lung cancer screening is essential to successfully involving the patient in the dyadic communication clinical context of this patient-clinician equitable engagement; however, participants were significantly more satisfied with LungTalk (
Consistent with other types of cancer screening, knowledge and health beliefs have been shown to be associated with lung cancer screening behavior [
With regard to health beliefs, even though LungTalk improved perceived benefits and self-efficacy in expected directions, changes were not significantly different compared those of the lung screening information sheet. LungTalk fell short in reducing perceived barriers to lung cancer screening, an important variable that often predicts cancer screening behaviors. The impact of these interventions on perceived risk of lung cancer was not observed and highlights a critical gap in the tailored messaging component of the intervention. Moving forward, it is important that tailored messages be further refined to target specific barriers to lung cancer screening as well as perceived risk as it relates to lung cancer for the target patient population in order to improve the efficacy of LungTalk as both a health communication and decision support tool.
As a pilot study, we had adequate power for estimating effect sizes and detecting large effect sizes. For example, 26 participants in each group were required for 80% power to detect a large Cohen
As with all studies, this study is not without limitations. Our recruitment methods may have influenced who participated in this study. Targeted Facebook advertisement allowed us to purposively sample people aged 55 years and older who indicated smoking as an interest on their Facebook page. People who use Facebook and who indicate smoking as an interest may constitute unique sample. Our sample demographics, however, indicate that we successfully recruited a racially diverse, national sample with equal numbers of men and women. Randomization also was effective; no differences between groups were observed at baseline. Our nonsignificant group differences in change scores on health belief variables were likely due to inadequate integration of content and tailored messages in LungTalk that would impact health belief constructs. Future versions of LungTalk need to address these constructs specifically in content and tailored messages if we are to change health beliefs in the directions that promote patient-clinician discussions about lung cancer screening and shared decisions.
Preliminary results indicate LungTalk is a helpful communication tool for individuals who are considering the option of lung cancer screening. Specifically, LungTalk can help enhance the shared decision-making process by priming individuals with essential baseline knowledge to support an informed discussion with a health care clinician about potential risks and benefits related to lung cancer screening.
Screenshots - LungTalk.
standardized response mean
US Preventive Services Task Force
This work has been supported by the Indiana University Purdue University at Indianapolis Developing Diverse Researchers with Investigative Expertise Pilot Grant, American Cancer Society Institutional Research Grant, and Indiana University School of Nursing Pilot Grant.
LCH and SMR conceived of the study and sought funding and ethical approval. LCH and SMR are responsible for the development phase with the Community Advisory Board. LCH, EV, and RSC are responsible for the usability testing phase of the study. LCH and SMR are responsible for the pilot randomized controlled trial phase and planned statistical analysis. LCH, EV, SMR, and RSC assisted in the development of LungTalk and subsequent iterations. NH and DPC provided feedback on the concept of LungTalk at key points in development. EV has assisted with data collection in all phases of the testing. All authors have been involved in drafting and revising the manuscript and approved the final version.
None declared.