Cancer Detection and Prevention 27 (2003) 442–450 A randomized trial of telephone counseling to promote screening mammography in two HMOs Roger Luckmann, MD, MPH a,∗ , Judith A. Savageau, MPH a , Lynn Clemow, PhD b , Anne M. Stoddard, ScD c , Mary E. Costanza, MD a a University of Massachusetts Medical School, Worcester, MA, USA b Robert Wood Johnson School of Medicine, New Brunswick, NJ, USA c University of Massachusetts School of Public Health, Amherst, MA, USA Accepted 11 September 2003 Abstract Tailored telephone counseling (TTC) is effective in increasing utilization of screening mammography, but has received limited testing on a large scale in a contemporary HMO setting in which most eligible women get regular screening. We conducted a randomized controlled trial comparing TTC to an active control (mailed reminders) among women aged 50–80 enrolled in two HMOs in New England (n = 12,905). Over a 1-year period counselors attempted to contact women in the intervention arm who had not had a mammogram within the last 15 months. The absolute increase in mammography use due to the intervention was 4.9% (OR 1.3, 95% CI 1.0–1.6) in one HMO and 3.1% (OR 1.2, 95% CI 1.0–1.3) in the other. We estimated that one additional woman was screened for each 10.9 women eligible for counseling. An intervention process analysis documented a high level of acceptance of TTC and identified subgroups that could be targeted for counseling to improve the efficiency of TTC. © 2003 International Society for Preventive Oncology. Published by Elsevier Ltd. All rights reserved. Keywords: Screening mammography; Breast cancer prevention; Telephone counseling; Randomized controlled trial; Health behavior 1. Introduction Over the last 10 years a national effort to promote regular mammography screening for breast cancer among women aged 50 and older has provided the impetus for dozens of descriptive studies of screening knowledge, attitudes, and beliefs and numerous trials of a wide variety of interven- tions aimed at increasing the use of mammography [1,2]. Interventions have targeted individual women, communities, medical care providers and their office staff. Some early studies of tailored telephone counseling (TTC) to promote mammography showed that brief, scripted coun- seling calls focused on a woman’s barriers to getting a mam- mogram could substantially increase utilization [3]. Several other studies of similar tailored telephone interventions that followed also showed promising results, although the con- tent and duration of counseling and the study populations varied considerably across studies [4–6]. Recent studies of TTC targeting underusers of mammography, have found that TTC was most effective among women who were sporadic ∗ Corresponding author. Tel.: +1-508-856-4150; fax: +1-508-856-1212. E-mail address: luckmanr@ummhc.org (R. Luckmann). users of mammography and least effective among those who had never had a mammogram [7–11]. Overall, the magnitude of the effect of TTC among underusers studied recently was lower than the effect size among unselected women studied during the early phases of adoption of screening mammog- raphy in the United States. Costanza et al. have suggested that the effectiveness of TTC for mammography may have declined over time, as increasing numbers of women have become regular mammography users [7]. They postulate that TTC may be most effective during the early and middle phases of adoption of a screening test, when most individ- uals have not yet had the test, and there are few compet- ing promotional efforts. Once most individuals have adopted regular screening habits, and reminders for repeat screening are being regularly provided by preventive care systems, the pool of people who become overdue for screening becomes increasingly dominated by individuals who are highly resis- tant to the adoption of the test. These resistant individuals are not likely to respond to brief TTC. According to the 1995 behavioral risk factor surveillance survey [12], the percent of US women with a self-reported mammogram within the past 2 years by age group was 76.8% (age 50–59), 74.3% (age 60–69), and 64.9% (age ≥70). These high rates of 0361-090X/$30.00 © 2003 International Society for Preventive Oncology. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.cdp.2003.09.003