Can informed choice invitations lead to inequities in intentions to make lifestyle changes among participants in a primary care diabetes screening programme? Evidence from a randomized trial.
Public Health (2011)
- PubMed: 21764087
Available from www.ncbi.nlm.nih.gov
or
Abstract
To test whether information about benefits and harms of screening for type 2 diabetes increases intentions to make lifestyle changes amongst attenders, predominantly among the socially advantaged and those with a strong future time orientation.
Available from www.ncbi.nlm.nih.gov
Page 1
Can informed choice invitations lead to inequities in intentions to make lifestyle changes among participants in a primary care diabetes screening programme? Evidence from a randomized trial.
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Page 2
Original Research
Can informed choice invitations lead to inequities in
intentions to make lifestyle changes among participants in
a primary care diabetes screening programme? Evidence from
a randomized trial
I. Kellar*, E. Mann, A.L. Kinmonth, A.T. Prevost, S. Sutton, T.M. Marteau
General Practice & Primary Care Research Unit, University of Cambridge, Institute of Public Health, Forvie Site, Robinson Way,
Cambridge CB2 2SR, UK
a r t i c l e i n f o
Article history:
Received 25 May 2010
Received in revised form
28 February 2011
Accepted 26 May 2011
Available online xxx
Keywords:
Informed choice
Screening
Behaviour change
s u m m a r y
Objective: To test whether information about benefits and harms of screening for type 2
diabetes increases intentions to make lifestyle changes amongst attenders, predominantly
among the socially advantaged and those with a strong future time orientation.
Study design: Planned subgroup analysis of attenders for screening participating in
a randomized controlled trial of an informed choice invitation vs a standard invitation to
attend for type 2 diabetes screening.
Methods: Potentially eligible participants were identified from practice registers using
routine data which were used to calculate risk scores for diabetes for all aged 40e69 years
without known type 2 diabetes and area deprivation based on post code. In total, 1272
individuals in the top 25% risk category were randomized to receive one of two invitations
to attend their practices for screening: an informed choice invitation or a standard invi-
tation. The subsequent attenders completed self-report measures of future time orienta-
tion and deprivation immediately before undergoing a screening test.
Results: Individual-level deprivation demonstrated a significant moderator effect [F
(4,635) ¼ 4.32, P ¼ 0.002]: individuals who were high in deprivation had lower intentions to
engage in lifestyle change following receipt of the informed choice invitation. However,
intentionswere not patterned by deprivationwhen itwas assessed at the area-level using the
Index of Multiple Deprivation 2007. The hypothesized moderating effect of future time
orientation on invitation type was also supported [F(14,613)¼ 2.46, P¼ 0.002): individuals low
in future time orientation had markedly lower intentions to engage in lifestyle change
following receipt of an informed choice invitation compared with a standard invitation for
screening.
Conclusion: Efforts to enhance informed choice where the implications of diagnosis are
a requirement for lifestyle change may require that the immediate benefits are commu-
nicated, and efforts to address the apparent barriers to diabetes self-care are made, if the
potential for inequity is to be avoided.
ª 2011 Published by Elsevier Ltd on behalf of The Royal Society for Public Health.
* Corresponding author. Tel.: þ44 (0) 1223 330456; fax: þ44 (0) 1223 762515.
E-mail address: ik261@medschl.cam.ac.uk (I. Kellar).
avai lable at www.sciencedirect .com
Public Health
journal homepage: www.elsevier .com/puhe
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p u b l i c h e a l t h x x x ( 2 0 1 1 ) 1e8
PUHE1488_proof ■ 11 June 2011 ■ 1/8
Please cite this article in press as: Kellar I, et al., Can informed choice invitations lead to inequities in intentions to make
lifestyle changes among participants in a primary care diabetes screening programme? Evidence from a randomized trial,
Public Health (2011), doi:10.1016/j.puhe.2011.05.010
0033-3506/$ e see front matter ª 2011 Published by Elsevier Ltd on behalf of The Royal Society for Public Health.
doi:10.1016/j.puhe.2011.05.010
Can informed choice invitations lead to inequities in
intentions to make lifestyle changes among participants in
a primary care diabetes screening programme? Evidence from
a randomized trial
I. Kellar*, E. Mann, A.L. Kinmonth, A.T. Prevost, S. Sutton, T.M. Marteau
General Practice & Primary Care Research Unit, University of Cambridge, Institute of Public Health, Forvie Site, Robinson Way,
Cambridge CB2 2SR, UK
a r t i c l e i n f o
Article history:
Received 25 May 2010
Received in revised form
28 February 2011
Accepted 26 May 2011
Available online xxx
Keywords:
Informed choice
Screening
Behaviour change
s u m m a r y
Objective: To test whether information about benefits and harms of screening for type 2
diabetes increases intentions to make lifestyle changes amongst attenders, predominantly
among the socially advantaged and those with a strong future time orientation.
Study design: Planned subgroup analysis of attenders for screening participating in
a randomized controlled trial of an informed choice invitation vs a standard invitation to
attend for type 2 diabetes screening.
Methods: Potentially eligible participants were identified from practice registers using
routine data which were used to calculate risk scores for diabetes for all aged 40e69 years
without known type 2 diabetes and area deprivation based on post code. In total, 1272
individuals in the top 25% risk category were randomized to receive one of two invitations
to attend their practices for screening: an informed choice invitation or a standard invi-
tation. The subsequent attenders completed self-report measures of future time orienta-
tion and deprivation immediately before undergoing a screening test.
Results: Individual-level deprivation demonstrated a significant moderator effect [F
(4,635) ¼ 4.32, P ¼ 0.002]: individuals who were high in deprivation had lower intentions to
engage in lifestyle change following receipt of the informed choice invitation. However,
intentionswere not patterned by deprivationwhen itwas assessed at the area-level using the
Index of Multiple Deprivation 2007. The hypothesized moderating effect of future time
orientation on invitation type was also supported [F(14,613)¼ 2.46, P¼ 0.002): individuals low
in future time orientation had markedly lower intentions to engage in lifestyle change
following receipt of an informed choice invitation compared with a standard invitation for
screening.
Conclusion: Efforts to enhance informed choice where the implications of diagnosis are
a requirement for lifestyle change may require that the immediate benefits are commu-
nicated, and efforts to address the apparent barriers to diabetes self-care are made, if the
potential for inequity is to be avoided.
ª 2011 Published by Elsevier Ltd on behalf of The Royal Society for Public Health.
* Corresponding author. Tel.: þ44 (0) 1223 330456; fax: þ44 (0) 1223 762515.
E-mail address: ik261@medschl.cam.ac.uk (I. Kellar).
avai lable at www.sciencedirect .com
Public Health
journal homepage: www.elsevier .com/puhe
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PUHE1488_proof ■ 11 June 2011 ■ 1/8
Please cite this article in press as: Kellar I, et al., Can informed choice invitations lead to inequities in intentions to make
lifestyle changes among participants in a primary care diabetes screening programme? Evidence from a randomized trial,
Public Health (2011), doi:10.1016/j.puhe.2011.05.010
0033-3506/$ e see front matter ª 2011 Published by Elsevier Ltd on behalf of The Royal Society for Public Health.
doi:10.1016/j.puhe.2011.05.010
Page 3
Introduction
Type 2 diabetes is a chronic condition that meets many of the
criteria for screening.1 Undiagnosed diabetes is commonplace
and typically asymptomatic, but is associated with significant
morbidity and premature mortality. Between one-third and
one-half of people with type 2 diabetes are undiagnosed, and
up to 30% exhibit evidence of diabetic complications at diag-
nosis.2 Existing evidence suggests that the adverse conse-
quences of screening are minimal,3,4 that intensive treatment
of clinically diagnosed patients is beneficial,5 and that inten-
sive treatment of screen-detected patients is also likely to be
beneficial.6
Providing equal access for all is a key policy target for the
UK Department of Health.7 It has been suggested that facili-
tating patient informed choice will help address social
inequalities.8 Informed choice can be defined as ‘one that is
based on relevant knowledge, consistent with the decision
maker’s values and behaviourally implemented’.9 Provision of
relevant information is a key element in decision aids for
health treatments and screening,10 albeit one that may be
unrelated to uptake.11 In Choosing Health,7 it is proposed that
differential access to information is one reason for social
patterning in health care uptake, with a dearth of appropriate
information for more deprived individuals resulting in less
motivation to engage in health protective behaviours. It has
been suggested that if thiswere addressed, these patientsmay
make healthier choices and be more committed to the choices
that they make.7 However, it has also been suggested that
such information will be primarily acted upon by the most
advantaged in society, and exacerbate health inequality.
Facilitating informed choices means promoting
uptake,9,12e14 and there may be tension between the aim of
informing patients and the potential for avoiding harms.11
There is concern that people may feel less positive about
screening and decide not to attend after receiving information
about the limited individual benefits and possible harms of
screening,9,15 and that there may be a differential effect on
attendance across social groups resulting in even lower
uptake amongst themore socially deprived; an example of the
‘inverse care law’.16 This group is more likely to include those
in poorest health, and hence those for whom the benefits of
screening might be greatest.17
In a recent pragmatic trial,18 participants were assigned at
random to receive one of two invitations to screening: a short,
standard invitation, or an extended invitation designed to
facilitate informed choice. Attendance at screening was very
similar between groups: 58% and 56%, respectively. Among
attenders, intentions to change behaviour were not affected
by invitation type; therefore, no evidence of conflictwas found
between efforts to achieve informed choice, attendance and
engagement in this practice-based screening programme.
However, socially deprived groups, who are most vulnerable
to disease, remained least likely to attend. Attendance was
47% for the highest tertile of deprivation and 64% for the
lowest tertile (P < 0.001).
An association between socio-economic status and access
to health care has been found in many settings and among
many groups.19,20 A negative association with socio-economic
status has been demonstrated with morbidity among diabetic
clinic attendees,21,22 and with diabetic control and insulin
use.23,24 Socio-economic status is inversely associated with
type 2 diabetes, and cardiovascular disease and ischaemic
heart disease are more common among people with diabetes
in low socio-economic groups.23e25 The relative risk of all-
cause mortality among those with diabetes compared with
those without is 2.34 among the top Townsend fifth of mate-
rial deprivation and 1.30 among the lowest fifth.25
Research questions
Type 2 diabetes is a condition for which behaviour change is
a cornerstone of treatment.5 In a recent trial,18 those who
attended for screening after receiving an informed choice
invitation were expected to do so with a stronger awareness
for, and hence intentions to engage in, lifestyle change if they
were found to have diabetes compared with those receiving
a standard invitation. Intention to engage in lifestyle change
was operationalized as a measure of intentions to take
medication as prescribed, reduce fat intake and increase
physical activity if diabetes was diagnosed. Intentions
summarize an individual’s motivation to perform a behav-
iour,26 and all goal theories propose it as a key determinant of
behaviour.27
Contrary to prediction, amongst those who attended for
screening, the invitationdesigned to support informedchoices
did not increase lifestyle change intentions. Given the afore-
mentioned associations between deprivation and health-
related measures, a cross-over interaction, such that that the
effect is polarized between socio-economic subgroups,may be
occurring, therebymasking any effect when testing for amain
effect. This poses the following research question (RQ1): does
deprivation at individual or area-level interact with invitation
type to affect intentions to change behaviour?
It is anticipated that the interaction will operate such that
where deprivation is high, receipt of an informed choice
invitation is associated with lower intentions to change
behaviour compared with those who receive the standard
invitation. This effect of deprivation will be examined at
individual-level (RQ1a) and area-level (RQ1b).
Time orientation refers to the extent to which an individ-
ual’s mindset is focused upon present or future goals.28,29
Individuals who are low in future time orientation have
a poorer sense of the implications of current actions on future
outcomes.30 It has been found to be related to physical activity
and healthy eating,31 as well as processing of screening-
related risk information32 and intentions to participate in
screening.32,33 Intentions to change one’s lifestyle in response
to a diagnosis of diabetes is reliant on an appreciation of the
future outcomes.32 In the present context, where the impli-
cations of diagnosis are a requirement for lifestyle change,
with long-term benefits to prognosis being a key message, the
following research question is posed (RQ2): does future
orientation interact with invitation type to affect individuals’
intentions to change lifestyle if a diagnosis of diabetes were to
be made?
It is anticipated that the interaction will operate such that
among people who are low in future orientation, receipt of an
p u b l i c h e a l t h x x x ( 2 0 1 1 ) 1e82
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PUHE1488_proof ■ 11 June 2011 ■ 2/8
Please cite this article in press as: Kellar I, et al., Can informed choice invitations lead to inequities in intentions to make
lifestyle changes among participants in a primary care diabetes screening programme? Evidence from a randomized trial,
Public Health (2011), doi:10.1016/j.puhe.2011.05.010
Type 2 diabetes is a chronic condition that meets many of the
criteria for screening.1 Undiagnosed diabetes is commonplace
and typically asymptomatic, but is associated with significant
morbidity and premature mortality. Between one-third and
one-half of people with type 2 diabetes are undiagnosed, and
up to 30% exhibit evidence of diabetic complications at diag-
nosis.2 Existing evidence suggests that the adverse conse-
quences of screening are minimal,3,4 that intensive treatment
of clinically diagnosed patients is beneficial,5 and that inten-
sive treatment of screen-detected patients is also likely to be
beneficial.6
Providing equal access for all is a key policy target for the
UK Department of Health.7 It has been suggested that facili-
tating patient informed choice will help address social
inequalities.8 Informed choice can be defined as ‘one that is
based on relevant knowledge, consistent with the decision
maker’s values and behaviourally implemented’.9 Provision of
relevant information is a key element in decision aids for
health treatments and screening,10 albeit one that may be
unrelated to uptake.11 In Choosing Health,7 it is proposed that
differential access to information is one reason for social
patterning in health care uptake, with a dearth of appropriate
information for more deprived individuals resulting in less
motivation to engage in health protective behaviours. It has
been suggested that if thiswere addressed, these patientsmay
make healthier choices and be more committed to the choices
that they make.7 However, it has also been suggested that
such information will be primarily acted upon by the most
advantaged in society, and exacerbate health inequality.
Facilitating informed choices means promoting
uptake,9,12e14 and there may be tension between the aim of
informing patients and the potential for avoiding harms.11
There is concern that people may feel less positive about
screening and decide not to attend after receiving information
about the limited individual benefits and possible harms of
screening,9,15 and that there may be a differential effect on
attendance across social groups resulting in even lower
uptake amongst themore socially deprived; an example of the
‘inverse care law’.16 This group is more likely to include those
in poorest health, and hence those for whom the benefits of
screening might be greatest.17
In a recent pragmatic trial,18 participants were assigned at
random to receive one of two invitations to screening: a short,
standard invitation, or an extended invitation designed to
facilitate informed choice. Attendance at screening was very
similar between groups: 58% and 56%, respectively. Among
attenders, intentions to change behaviour were not affected
by invitation type; therefore, no evidence of conflictwas found
between efforts to achieve informed choice, attendance and
engagement in this practice-based screening programme.
However, socially deprived groups, who are most vulnerable
to disease, remained least likely to attend. Attendance was
47% for the highest tertile of deprivation and 64% for the
lowest tertile (P < 0.001).
An association between socio-economic status and access
to health care has been found in many settings and among
many groups.19,20 A negative association with socio-economic
status has been demonstrated with morbidity among diabetic
clinic attendees,21,22 and with diabetic control and insulin
use.23,24 Socio-economic status is inversely associated with
type 2 diabetes, and cardiovascular disease and ischaemic
heart disease are more common among people with diabetes
in low socio-economic groups.23e25 The relative risk of all-
cause mortality among those with diabetes compared with
those without is 2.34 among the top Townsend fifth of mate-
rial deprivation and 1.30 among the lowest fifth.25
Research questions
Type 2 diabetes is a condition for which behaviour change is
a cornerstone of treatment.5 In a recent trial,18 those who
attended for screening after receiving an informed choice
invitation were expected to do so with a stronger awareness
for, and hence intentions to engage in, lifestyle change if they
were found to have diabetes compared with those receiving
a standard invitation. Intention to engage in lifestyle change
was operationalized as a measure of intentions to take
medication as prescribed, reduce fat intake and increase
physical activity if diabetes was diagnosed. Intentions
summarize an individual’s motivation to perform a behav-
iour,26 and all goal theories propose it as a key determinant of
behaviour.27
Contrary to prediction, amongst those who attended for
screening, the invitationdesigned to support informedchoices
did not increase lifestyle change intentions. Given the afore-
mentioned associations between deprivation and health-
related measures, a cross-over interaction, such that that the
effect is polarized between socio-economic subgroups,may be
occurring, therebymasking any effect when testing for amain
effect. This poses the following research question (RQ1): does
deprivation at individual or area-level interact with invitation
type to affect intentions to change behaviour?
It is anticipated that the interaction will operate such that
where deprivation is high, receipt of an informed choice
invitation is associated with lower intentions to change
behaviour compared with those who receive the standard
invitation. This effect of deprivation will be examined at
individual-level (RQ1a) and area-level (RQ1b).
Time orientation refers to the extent to which an individ-
ual’s mindset is focused upon present or future goals.28,29
Individuals who are low in future time orientation have
a poorer sense of the implications of current actions on future
outcomes.30 It has been found to be related to physical activity
and healthy eating,31 as well as processing of screening-
related risk information32 and intentions to participate in
screening.32,33 Intentions to change one’s lifestyle in response
to a diagnosis of diabetes is reliant on an appreciation of the
future outcomes.32 In the present context, where the impli-
cations of diagnosis are a requirement for lifestyle change,
with long-term benefits to prognosis being a key message, the
following research question is posed (RQ2): does future
orientation interact with invitation type to affect individuals’
intentions to change lifestyle if a diagnosis of diabetes were to
be made?
It is anticipated that the interaction will operate such that
among people who are low in future orientation, receipt of an
p u b l i c h e a l t h x x x ( 2 0 1 1 ) 1e82
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PUHE1488_proof ■ 11 June 2011 ■ 2/8
Please cite this article in press as: Kellar I, et al., Can informed choice invitations lead to inequities in intentions to make
lifestyle changes among participants in a primary care diabetes screening programme? Evidence from a randomized trial,
Public Health (2011), doi:10.1016/j.puhe.2011.05.010
Page 4
informed choice invitation is associated with lower intentions
to change behaviour if they are found to have diabetes
following screening compared with those who receive the
standard invitation.
Methods
Design
This study employed a planned subgroup analysis of
attenders for screening in a randomized controlled trial of an
informed choice invitation vs a standard invitation to attend
for type 2 diabetes screening (see Fig. 1). Randomization was
undertaken from a central site by the study statistician
following stratification of participants by practice and
household. Clinical and trial staff taking measurements and
entering data were unaware of the groups to which individ-
uals had been assigned. Fifty-six participants did not receive
an invitation (see Fig. 1). Seven hundred and twenty-one
participants attended screening: 353 received the informed
choice invitation and 368 received the standard invitation.
Individuals from the same householdwere assigned to receive
the same type of invitation (mean cluster size 1.14).
Procedure, setting and recruitment
Participants were screening appointment attendees from
a randomized controlled trial which undertook randomiza-
tion of individuals by household clusters, testing the impact of
an invitation designed to facilitate informed choice vs a stan-
dard invitation on uptake of type 2 diabetes screening (see
Fig. 1). Invitees were identified from the registers of four
general practices. Two practices with above-average area
deprivation scores [Index of Multiple Deprivation (IMD) 2007]
and two practices in relatively affluent areas took part.
Previously validated diabetes risk scores were calculated, and
the sample of 1500 was selected by randomly sampling
household clusters with adults aged 40e69 years in the top
25% of the risk score distribution.34 In one practice which was
Randomized
n=1272
Excluded n=228
- Criteria not met n=43
- Opted-out n=183
- Opt-out undelivered n=2
Invitation not sent
n=32
- Died n=1
- Record unavailable n=3
- Left practice n=13
- Unknown n=15
Invitation not sent
n=21
- Died n=3
- Record unavailable n=1
- Left practice n=9
- Late GP exclusion or
inclusion n=2
- Unknown n=6
Sent informed
choice invitation
n=601
Assessed for eligibility
n=1500
Did not attend
n=246
Invitation
returned
undelivered
n=1
Did not attend
n=249
Invitation
returned
undelivered
n=2
Sent standard
invitation
n=618
Allocated to receive standard
invitation
n=639
Allocated to receive
informed choice invitation
n=633
Informed choice
Invitation
attendees
n=353
Standard
invitation
attendees
n=368
Fig. 1 e Trial procedure and participant flow.<reproduce 14 m cm wide>.
p u b l i c h e a l t h x x x ( 2 0 1 1 ) 1e8 3
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PUHE1488_proof ■ 11 June 2011 ■ 3/8
Please cite this article in press as: Kellar I, et al., Can informed choice invitations lead to inequities in intentions to make
lifestyle changes among participants in a primary care diabetes screening programme? Evidence from a randomized trial,
Public Health (2011), doi:10.1016/j.puhe.2011.05.010
to change behaviour if they are found to have diabetes
following screening compared with those who receive the
standard invitation.
Methods
Design
This study employed a planned subgroup analysis of
attenders for screening in a randomized controlled trial of an
informed choice invitation vs a standard invitation to attend
for type 2 diabetes screening (see Fig. 1). Randomization was
undertaken from a central site by the study statistician
following stratification of participants by practice and
household. Clinical and trial staff taking measurements and
entering data were unaware of the groups to which individ-
uals had been assigned. Fifty-six participants did not receive
an invitation (see Fig. 1). Seven hundred and twenty-one
participants attended screening: 353 received the informed
choice invitation and 368 received the standard invitation.
Individuals from the same householdwere assigned to receive
the same type of invitation (mean cluster size 1.14).
Procedure, setting and recruitment
Participants were screening appointment attendees from
a randomized controlled trial which undertook randomiza-
tion of individuals by household clusters, testing the impact of
an invitation designed to facilitate informed choice vs a stan-
dard invitation on uptake of type 2 diabetes screening (see
Fig. 1). Invitees were identified from the registers of four
general practices. Two practices with above-average area
deprivation scores [Index of Multiple Deprivation (IMD) 2007]
and two practices in relatively affluent areas took part.
Previously validated diabetes risk scores were calculated, and
the sample of 1500 was selected by randomly sampling
household clusters with adults aged 40e69 years in the top
25% of the risk score distribution.34 In one practice which was
Randomized
n=1272
Excluded n=228
- Criteria not met n=43
- Opted-out n=183
- Opt-out undelivered n=2
Invitation not sent
n=32
- Died n=1
- Record unavailable n=3
- Left practice n=13
- Unknown n=15
Invitation not sent
n=21
- Died n=3
- Record unavailable n=1
- Left practice n=9
- Late GP exclusion or
inclusion n=2
- Unknown n=6
Sent informed
choice invitation
n=601
Assessed for eligibility
n=1500
Did not attend
n=246
Invitation
returned
undelivered
n=1
Did not attend
n=249
Invitation
returned
undelivered
n=2
Sent standard
invitation
n=618
Allocated to receive standard
invitation
n=639
Allocated to receive
informed choice invitation
n=633
Informed choice
Invitation
attendees
n=353
Standard
invitation
attendees
n=368
Fig. 1 e Trial procedure and participant flow.<reproduce 14 m cm wide>.
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PUHE1488_proof ■ 11 June 2011 ■ 3/8
Please cite this article in press as: Kellar I, et al., Can informed choice invitations lead to inequities in intentions to make
lifestyle changes among participants in a primary care diabetes screening programme? Evidence from a randomized trial,
Public Health (2011), doi:10.1016/j.puhe.2011.05.010
Page 5
in the most deprived area, only body mass index (BMI) was
available to identify high risk individuals. High BMI (top
quartile) is a good proxy measure of diabetes risk.34 Patients
meeting the following criteria were excluded from the trial:
diagnosed with diabetes since the patient search was per-
formed; pregnant or breast-feeding; diagnosed with
a psychotic illness, such as schizophrenia, hypomania, major
depression or manic depression; or diagnosed with an illness
with a likely prognosis of less than 1 year to death. Consent
was sought prior to commencement of the study. The consent
process is reported in full in Mann et al.35 Questionnaires were
administered at the screening appointment, prior to
screening.
Recruitment
Of 1500 individuals identified, 43were excluded on the basis of
known diabetes, pregnancy, breast-feeding, a psychotic
illness or a life-threatening illness. The remaining individuals
were sent a letter from their general practitioners asking them
to return a reply-paid opt-out form to their practices within 28
days if they did not wish to receive an invitation for screening.
One hundred and eighty-three patients opted-out and
a further two patients were excluded because invitation
letters were returned undelivered. In total, 1272 participants
were assigned at random to receive one of two invitations to
screening: an extended invitation designed to facilitate
informed choice, or a short, standard invitation.
Intervention materials
Standard invitation
The standard invitation was based on invitations commonly
used to invite people for diabetes and coronary heart disease
screening.36,37 The text stated that screening was offered
because the participant had a high risk of type 2 diabetes, and
that diabetes has serious long-term consequences. The text
was designed to be comprehensible to those with a reading
age of 11 years or above, based on reading formulae.38
Informed choice invitation
The informed choice invitation contained the same informa-
tion as the standard invitation, and also contained informa-
tion about diabetes risk and the consequences of screening
and treatment, based on the UK General Medical Council
(GMC) guidelines for consent.39 These recommend that the
following information should be presented in obtaining
consent for screening: the purpose of screening, details of
diagnosis and prognosis with and without treatment, proba-
bility of benefits and risks, and an emphasis on patient
choice.a Participants were encouraged to make a choice that
reflected their values using a decisional balance sheet adapted
from Wankel et al.40 The text was estimated from reading
formulae to be comprehensible to those with a reading age
above 11 years.38
These invitations were developed and evaluated in
a formal pilot study38 in which 417 adults without known
diabetes were randomized to receive one of the two types of
invitation. Levels of informed choice were significantly higher
2 weeks following receipt of the informed choice invitation
compared with the standard invitation (42.9% vs 11.2%;
difference ¼ 31.7%, 95% confidence interval 22.5e40.5%). This
difference was largely attributable to higher levels of knowl-
edge following receipt of the informed choice invitation.
Measures
Intentions to change lifestyle if diabetes was diagnosed
This measure is a behavioural expectation of actual lifestyle
change. The scale was the mean of three intention items:
intention to take medication as prescribed; intention to
reduce fat intake; and intention to increase physical activity
over the subsequent 3 months. For example, ‘How likely is it
that you will increase the amount of physical activity that you
do over the next 3 months’ (1 ¼ extremely unlikely,
7 ¼ extremely likely). Cronbach’s alpha was 0.58.
Deprivation
Deprivation was measured at the individual and area-level.
The individual-level measure of deprivation was a five-point
scale from 0 to 4, calculated from self-reported demographic
information. A participant scored 1 for each of the following
criteria that was true of them: (a) do not own a car, (b) do not
own their own home, (c) do not have post-16 level educational
qualifications, and (d) do not have any formal qualifications.41
The area-level measure of deprivation was the IMD2007,
published by the UK Deputy Prime Minister’s Office.
Geographical areas (approximate population 1500 per area)
are rated on seven indicators of deprivation: (a) income; (b)
employment; (c) health, deprivation and disability; (d)
education, skills and training; (e) barriers to housing and
services; (f) crime; and (g) living environment. The scores are
weighted, summed and transformed resulting in a score from
0 to 100 where a score >50 is the cut-off for the 10 most
deprived areas. Patient postcodes were used to identify
a deprivation score for the area in which they live.
Future time orientation
Future time orientation was measured using the four item
scale from the brief ZTPI-R 33. Each item was measured on
a five-point scale from 1 (very uncharacteristic of me) to 5
(very characteristic of me). The four items are: thinking about
the future is pleasant to me; when I want to achieve some-
thing, I set goals and consider specific means of reaching
those goals; meeting tomorrow’s deadlines and doing other
necessary work comes before tonight’s play; and it seems to
me that my future plans are pretty well laid out.
Participant characteristics
Table 1 shows that participants in the two invitation groups
were similar in terms of study characteristics. There were no
significant differences between the groups for any of themean
scores on the study variables. Overall, the participants were
characterized by strong intentions, low future orientation,
modest levels of individual deprivation, and low levels of area-
level deprivation.
a Study materials and documents described in this protocol are
available from the Corresponding author. on request.
p u b l i c h e a l t h x x x ( 2 0 1 1 ) 1e84
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PUHE1488_proof ■ 11 June 2011 ■ 4/8
Please cite this article in press as: Kellar I, et al., Can informed choice invitations lead to inequities in intentions to make
lifestyle changes among participants in a primary care diabetes screening programme? Evidence from a randomized trial,
Public Health (2011), doi:10.1016/j.puhe.2011.05.010
available to identify high risk individuals. High BMI (top
quartile) is a good proxy measure of diabetes risk.34 Patients
meeting the following criteria were excluded from the trial:
diagnosed with diabetes since the patient search was per-
formed; pregnant or breast-feeding; diagnosed with
a psychotic illness, such as schizophrenia, hypomania, major
depression or manic depression; or diagnosed with an illness
with a likely prognosis of less than 1 year to death. Consent
was sought prior to commencement of the study. The consent
process is reported in full in Mann et al.35 Questionnaires were
administered at the screening appointment, prior to
screening.
Recruitment
Of 1500 individuals identified, 43were excluded on the basis of
known diabetes, pregnancy, breast-feeding, a psychotic
illness or a life-threatening illness. The remaining individuals
were sent a letter from their general practitioners asking them
to return a reply-paid opt-out form to their practices within 28
days if they did not wish to receive an invitation for screening.
One hundred and eighty-three patients opted-out and
a further two patients were excluded because invitation
letters were returned undelivered. In total, 1272 participants
were assigned at random to receive one of two invitations to
screening: an extended invitation designed to facilitate
informed choice, or a short, standard invitation.
Intervention materials
Standard invitation
The standard invitation was based on invitations commonly
used to invite people for diabetes and coronary heart disease
screening.36,37 The text stated that screening was offered
because the participant had a high risk of type 2 diabetes, and
that diabetes has serious long-term consequences. The text
was designed to be comprehensible to those with a reading
age of 11 years or above, based on reading formulae.38
Informed choice invitation
The informed choice invitation contained the same informa-
tion as the standard invitation, and also contained informa-
tion about diabetes risk and the consequences of screening
and treatment, based on the UK General Medical Council
(GMC) guidelines for consent.39 These recommend that the
following information should be presented in obtaining
consent for screening: the purpose of screening, details of
diagnosis and prognosis with and without treatment, proba-
bility of benefits and risks, and an emphasis on patient
choice.a Participants were encouraged to make a choice that
reflected their values using a decisional balance sheet adapted
from Wankel et al.40 The text was estimated from reading
formulae to be comprehensible to those with a reading age
above 11 years.38
These invitations were developed and evaluated in
a formal pilot study38 in which 417 adults without known
diabetes were randomized to receive one of the two types of
invitation. Levels of informed choice were significantly higher
2 weeks following receipt of the informed choice invitation
compared with the standard invitation (42.9% vs 11.2%;
difference ¼ 31.7%, 95% confidence interval 22.5e40.5%). This
difference was largely attributable to higher levels of knowl-
edge following receipt of the informed choice invitation.
Measures
Intentions to change lifestyle if diabetes was diagnosed
This measure is a behavioural expectation of actual lifestyle
change. The scale was the mean of three intention items:
intention to take medication as prescribed; intention to
reduce fat intake; and intention to increase physical activity
over the subsequent 3 months. For example, ‘How likely is it
that you will increase the amount of physical activity that you
do over the next 3 months’ (1 ¼ extremely unlikely,
7 ¼ extremely likely). Cronbach’s alpha was 0.58.
Deprivation
Deprivation was measured at the individual and area-level.
The individual-level measure of deprivation was a five-point
scale from 0 to 4, calculated from self-reported demographic
information. A participant scored 1 for each of the following
criteria that was true of them: (a) do not own a car, (b) do not
own their own home, (c) do not have post-16 level educational
qualifications, and (d) do not have any formal qualifications.41
The area-level measure of deprivation was the IMD2007,
published by the UK Deputy Prime Minister’s Office.
Geographical areas (approximate population 1500 per area)
are rated on seven indicators of deprivation: (a) income; (b)
employment; (c) health, deprivation and disability; (d)
education, skills and training; (e) barriers to housing and
services; (f) crime; and (g) living environment. The scores are
weighted, summed and transformed resulting in a score from
0 to 100 where a score >50 is the cut-off for the 10 most
deprived areas. Patient postcodes were used to identify
a deprivation score for the area in which they live.
Future time orientation
Future time orientation was measured using the four item
scale from the brief ZTPI-R 33. Each item was measured on
a five-point scale from 1 (very uncharacteristic of me) to 5
(very characteristic of me). The four items are: thinking about
the future is pleasant to me; when I want to achieve some-
thing, I set goals and consider specific means of reaching
those goals; meeting tomorrow’s deadlines and doing other
necessary work comes before tonight’s play; and it seems to
me that my future plans are pretty well laid out.
Participant characteristics
Table 1 shows that participants in the two invitation groups
were similar in terms of study characteristics. There were no
significant differences between the groups for any of themean
scores on the study variables. Overall, the participants were
characterized by strong intentions, low future orientation,
modest levels of individual deprivation, and low levels of area-
level deprivation.
a Study materials and documents described in this protocol are
available from the Corresponding author. on request.
p u b l i c h e a l t h x x x ( 2 0 1 1 ) 1e84
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PUHE1488_proof ■ 11 June 2011 ■ 4/8
Please cite this article in press as: Kellar I, et al., Can informed choice invitations lead to inequities in intentions to make
lifestyle changes among participants in a primary care diabetes screening programme? Evidence from a randomized trial,
Public Health (2011), doi:10.1016/j.puhe.2011.05.010
Page 6
Hypothesis H1a was supported; individual-level depriva-
tion had a significant moderating effect on the relationship
between invitation type and lifestyle change intentions
[F(4,638) ¼ 4.11, P ¼ 0.003; partial h2 ¼ 0.03] in broadly the pre-
dicted direction (see Fig. 2). In contrast, RQ1b was not sup-
ported; area-level deprivation did not significantly moderate
the effect of invitation type upon intention to change behav-
iour [F(57,509)¼1.14,P¼0.239].RQ2wassupported; future time
orientation significantly moderated the effect of invitation
type upon lifestyle change intentions [F(14,636) ¼ 2.18,
P¼ 0.006; partial h2¼ 0.05] in the predicted direction (see Fig. 3).
Table 2 presents the means and standard deviations for
lifestyle change intentions at three levels of future time
orientation and individual deprivation. This demonstrates
that, for those who are high in future time orientation, invi-
tation type is unlikely to impact intentions to change behav-
iour, whereas for those low in future time orientation, the
receipt of the informed choice invitation is likely to result in
lower intentions to change behaviour than receipt of the
standard invitation. Examining the effect of individual depri-
vation (Table 2), invitation type is unlikely to impact inten-
tions to change behaviour for those who score low on
individual deprivation, whereas for those who score highly on
individual deprivation, the receipt of the informed choice
invitation is likely to result in lower intentions to change
behaviour.
Discussion
RQ1a and RQ2 were supported. Individuals rated as highly
deprived, using an individual-level measure, reported lower
intentions to change their behaviour following a diagnosis for
diabetes after the informed choice invitation compared with
the standard invitation (H1a). However, this was not the case
when an area-level measure of deprivationwas used (H1b); no
significant moderating effect was detected. Similarly, indi-
viduals with low future orientation reported lower intentions
to engage in health protective behaviours in the event of
a diagnosis for diabetes after the informed choice invitation
compared with the standard invitation (H2).
In the pilot study, general population attitudes towards
attending for diabetes screening were positive regardless of
deprivation.38 This replicates findings in the context of other
screening programmes.42,43 When considering the effect of
individual deprivation upon screening attendance across both
invitations,44 it was concluded that it is not people’s negative
attitudes to screening that are responsible for this example of
Table 1e Participants’ means and standard deviations on
study variables.
Measure Informed choice
(n ¼ 353)
Standard
(n ¼ 368)
Total
(n ¼ 721)
Intention 5.84 5.84 5.84
(SD/n) (1.09/328) (1.03/340) (1.06/668)
Future orientation 3.84 3.84 3.84
(SD/n) (0.73/333) (0.75/346) (0.74/679)
Individual deprivation 1.16 1.14 1.15
(SD/n) (1.07/3.22) (1.03/336) (1.05/658)
IMD2007 19.07 18.63 18.84
(SD/n) (10.15/353) (9.72/368) (9.93/721)
SD, standard deviation.
4
5
6
7
- 1 S D 0 S D + 1 S D
Individual-level deprivation
n o i t n e t n I
Informed
Standard
Fig. 2 e Effect of individual-level deprivation on the
relationship between invitation type and intentions to
change lifestyle if diabetes was diagnosed.<reproduce
12 cm wide, need to ensure the reader can distinguish
between the lines when printed in black and white>.
4
5
6
7
-1 SD 0 SD +1 SD
Future time orientation
noitnetnI
Informed
Standard
Fig. 3 e Effect of future time orientation on the relationship
between invitation type and intentions to change lifestyle
if diabetes was diagnosed.<reproduce 12 cm wide, need
to ensure the reader can distinguish between the lines
when printed in black and white>.
Table 2 e Means and standard deviations for lifestyle
change intentions at three levels of significant
moderating variables.
<-1 SD
(low)
0 SD
(moderate)
>1 SD
(high)
Individual
deprivation
Standard 5.83 5.90 5.57
(SD/n) (1.09/120) (1.01/181) (1.01/29)
Informed 6.01 5.90 4.93
(SD/n) (0.95/118) (0.97/165) (1.58/35)
Difference 0.18 0.00 0.64
Future time
orientation
Standard 5.46 5.86 6.18
(SD/n) (1.13/54) (1.00/237) (0.97/49)
Informed 5.01 5.94 6.17
Difference (1.48/46) (0.92/236) (1.12/46)
(SD/n) 0.45 0.08 0.01
SD, standard deviation.
p u b l i c h e a l t h x x x ( 2 0 1 1 ) 1e8 5
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PUHE1488_proof ■ 11 June 2011 ■ 5/8
Please cite this article in press as: Kellar I, et al., Can informed choice invitations lead to inequities in intentions to make
lifestyle changes among participants in a primary care diabetes screening programme? Evidence from a randomized trial,
Public Health (2011), doi:10.1016/j.puhe.2011.05.010
tion had a significant moderating effect on the relationship
between invitation type and lifestyle change intentions
[F(4,638) ¼ 4.11, P ¼ 0.003; partial h2 ¼ 0.03] in broadly the pre-
dicted direction (see Fig. 2). In contrast, RQ1b was not sup-
ported; area-level deprivation did not significantly moderate
the effect of invitation type upon intention to change behav-
iour [F(57,509)¼1.14,P¼0.239].RQ2wassupported; future time
orientation significantly moderated the effect of invitation
type upon lifestyle change intentions [F(14,636) ¼ 2.18,
P¼ 0.006; partial h2¼ 0.05] in the predicted direction (see Fig. 3).
Table 2 presents the means and standard deviations for
lifestyle change intentions at three levels of future time
orientation and individual deprivation. This demonstrates
that, for those who are high in future time orientation, invi-
tation type is unlikely to impact intentions to change behav-
iour, whereas for those low in future time orientation, the
receipt of the informed choice invitation is likely to result in
lower intentions to change behaviour than receipt of the
standard invitation. Examining the effect of individual depri-
vation (Table 2), invitation type is unlikely to impact inten-
tions to change behaviour for those who score low on
individual deprivation, whereas for those who score highly on
individual deprivation, the receipt of the informed choice
invitation is likely to result in lower intentions to change
behaviour.
Discussion
RQ1a and RQ2 were supported. Individuals rated as highly
deprived, using an individual-level measure, reported lower
intentions to change their behaviour following a diagnosis for
diabetes after the informed choice invitation compared with
the standard invitation (H1a). However, this was not the case
when an area-level measure of deprivationwas used (H1b); no
significant moderating effect was detected. Similarly, indi-
viduals with low future orientation reported lower intentions
to engage in health protective behaviours in the event of
a diagnosis for diabetes after the informed choice invitation
compared with the standard invitation (H2).
In the pilot study, general population attitudes towards
attending for diabetes screening were positive regardless of
deprivation.38 This replicates findings in the context of other
screening programmes.42,43 When considering the effect of
individual deprivation upon screening attendance across both
invitations,44 it was concluded that it is not people’s negative
attitudes to screening that are responsible for this example of
Table 1e Participants’ means and standard deviations on
study variables.
Measure Informed choice
(n ¼ 353)
Standard
(n ¼ 368)
Total
(n ¼ 721)
Intention 5.84 5.84 5.84
(SD/n) (1.09/328) (1.03/340) (1.06/668)
Future orientation 3.84 3.84 3.84
(SD/n) (0.73/333) (0.75/346) (0.74/679)
Individual deprivation 1.16 1.14 1.15
(SD/n) (1.07/3.22) (1.03/336) (1.05/658)
IMD2007 19.07 18.63 18.84
(SD/n) (10.15/353) (9.72/368) (9.93/721)
SD, standard deviation.
4
5
6
7
- 1 S D 0 S D + 1 S D
Individual-level deprivation
n o i t n e t n I
Informed
Standard
Fig. 2 e Effect of individual-level deprivation on the
relationship between invitation type and intentions to
change lifestyle if diabetes was diagnosed.<reproduce
12 cm wide, need to ensure the reader can distinguish
between the lines when printed in black and white>.
4
5
6
7
-1 SD 0 SD +1 SD
Future time orientation
noitnetnI
Informed
Standard
Fig. 3 e Effect of future time orientation on the relationship
between invitation type and intentions to change lifestyle
if diabetes was diagnosed.<reproduce 12 cm wide, need
to ensure the reader can distinguish between the lines
when printed in black and white>.
Table 2 e Means and standard deviations for lifestyle
change intentions at three levels of significant
moderating variables.
<-1 SD
(low)
0 SD
(moderate)
>1 SD
(high)
Individual
deprivation
Standard 5.83 5.90 5.57
(SD/n) (1.09/120) (1.01/181) (1.01/29)
Informed 6.01 5.90 4.93
(SD/n) (0.95/118) (0.97/165) (1.58/35)
Difference 0.18 0.00 0.64
Future time
orientation
Standard 5.46 5.86 6.18
(SD/n) (1.13/54) (1.00/237) (0.97/49)
Informed 5.01 5.94 6.17
Difference (1.48/46) (0.92/236) (1.12/46)
(SD/n) 0.45 0.08 0.01
SD, standard deviation.
p u b l i c h e a l t h x x x ( 2 0 1 1 ) 1e8 5
521
522
523
524
525
526
527
528
529
530
531
532
533
534
535
536
537
538
539
540
541
542
543
544
545
546
547
548
549
550
551
552
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554
555
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557
558
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564
565
566
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569
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583
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650
PUHE1488_proof ■ 11 June 2011 ■ 5/8
Please cite this article in press as: Kellar I, et al., Can informed choice invitations lead to inequities in intentions to make
lifestyle changes among participants in a primary care diabetes screening programme? Evidence from a randomized trial,
Public Health (2011), doi:10.1016/j.puhe.2011.05.010
Page 7
the inverse care law,45 but rather a difference in the enact-
ment of positive intentions, perhaps reflecting practical
barriers to keeping non-urgent appointments. However, in the
case of intentions to change lifestyle amongst those who did
attend, a modest effect was found whereby individual depri-
vation moderated the effect of invitation type, with this
affecting the most deprived such that those who received the
informed choice invitation reported the lowest intentions to
engage in health protective behaviours of any of the
subgroups analysed. Data on attitudes to lifestyle changewere
not collected, so the possibility that these determine the
difference in intention cannot be ruled out. However, others
have proposed that lack of access to transport, limited access
to childcare and limited financial resources may form barriers
to diabetes self-management among deprived groups.46 A
recentmeta-analysis of interventions to promote lifestyle and
physical activity found that increasing awareness of barriers
resulted in significantly reduced self-efficacy to undertake
physical activity, even when combined with subsequent
problem solving.47 As such, the expectation of encountering
these barriers inhibits intentions to engage in lifestyle change,
much as it inhibits the health behaviours themselves.
Consequently, information that does address the expectation
of encountering these barriers, such as that which was
provided in the informed choice invitation, has the potential
to exacerbate further health inequity.
The reasons underlying the finding that area-level depri-
vation in the form of IMD2007 did not demonstrate a similar
effect are difficult to disentangle. Comparing the individual-
level measure with the area-level measure, there were fewer
individuals scoring highly on area- rather than individual-
level deprivation measure, and there were few recruits in
the most deprived 10% of the distribution of the IMD. It has
been suggested that aggregated deprivation measures of
relatively large areas, such as IMD2007, do not give access to
the heterogeneity beneath the super output area-level, and
that lifestyle measures are more up to date than the neces-
sarily dated area aggregated measures from sources that are
not specifically tied to a particular study. These can include
a greater income component48 that may be the primary
source of the effects of deprivation.49 Whilst the authors are
not aware of other studies demonstrating differential
patterns of response to public health interventions between
individual- and area-level deprivation, it is interesting to
note that the relationship between individuals’ socio-
economic status and physical activity is long estab-
lished,50,51 whereas there appear to be limited data available
at the area-level, and indeed some data showing no associ-
ation.52 Still, despite the questions raised regarding the
usefulness of these measures in explaining the effects of
deprivation,48,53 further research is required to understand
this difference in patterning.
The treatment of screen-detected diabetes includes
immediate efforts to change lifestyle in return for the hope of
future benefits. The GMC guidelines on which the informed
choice materials were based recommend inclusion of details
of the likely experience of treatment including side effects;
and details of benefits and harms, including potential lifestyle
changes. The informed choice invitation included information
on the potential for immediate modest practical and
psychological inconvenience from screening, and described
the limited possibility of avoiding poor health outcomes
within 10 years with treatment if diabetes was found. In
contrast, the standard invitation gave no information of the
temporal placement of any consequences.
Future orientation is associated with a clear sense of the
future and the implication of current actions on that future,30
thus it is consistent that intentions to engage in lifestyle
change is greater for thosewho aremore future orientedwhen
information regarding future health gains is emphasized, even
when the possibility of those gains occurring are relatively
meagre. Studies have already demonstrated that future
orientation is associatedwith engaging inphysical activity and
healthy eating,31 choosing to attend screening,54 delaying first
sexual intercourse,30 not engaging in risky driving55 as well as
a willingness to expend effort for future gain more gener-
ally.56,57 Whilst avoiding the present inconveniences of
screening may seem to be in the rational self-interest of indi-
viduals low in future orientation, this may not be a decision
that people will remain satisfied with over the life course. As
such, the finding of a modest moderating effect of future
orientation on the effect of invitation type upon lifestyle
change intentions suggests that information about the
outcome of screening programmes should include, where
available, any benefits of early diagnosis and treatment, and
not simply longer-termbenefitswhichmayhave littlemeaning
to those with a present orientation.
This study has a number of limitations. The authors did not
recruit many participants in the most deprived 10% of the
distribution in area-level deprivation. Despite this, it was
possible to demonstrate moderating effects across levels of
individual deprivation, albeit the effect was not manifested
among those low in deprivation or high in future time orien-
tation. Additionally, the study was not powered to examine
whether there were three-way moderating effects when
looking at future time orientation and deprivation together.
Also, the use of lifestyle change intentions as a proxy for
lifestyle behaviour change begs future studies that should
seek to replicate the findings reported here with a behavioural
outcome. Still, in terms of the component constructs used to
index the decision, a recent meta-analysis of studies that
applied the Theory of Planned Behaviour to screening15 found
that the correlation between screening intentions and
screening behaviour was 0.42 (k¼ 19, n¼ 8148, 95% confidence
interval 0.40e0.44). As such, it is likely to be a reliable
account.58,59 Finally, the generalizability of the findings to
other screening programmes is unknown. The harms that can
arise from screening for diabetes were described in the invi-
tation as comprising worry and false reassurance, which may
not be considered serious by participants. In contrast, partic-
ipation in other screening programmes can entail serious
physical harms from subsequent invasive testing (e.g. colo-
noscopy) or treatment (e.g. prostatectomy). As such, variation
in the nature of the harms presented, particularly where the
unwanted outcomes vary in terms of their immediacy, are
likely to result in different effects to those described here.
Studies are needed that compare the impact of presenting
uncertainty about individual benefit and harm across
screening programmes with different types and levels of
benefit and harm.
p u b l i c h e a l t h x x x ( 2 0 1 1 ) 1e86
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PUHE1488_proof ■ 11 June 2011 ■ 6/8
Please cite this article in press as: Kellar I, et al., Can informed choice invitations lead to inequities in intentions to make
lifestyle changes among participants in a primary care diabetes screening programme? Evidence from a randomized trial,
Public Health (2011), doi:10.1016/j.puhe.2011.05.010
ment of positive intentions, perhaps reflecting practical
barriers to keeping non-urgent appointments. However, in the
case of intentions to change lifestyle amongst those who did
attend, a modest effect was found whereby individual depri-
vation moderated the effect of invitation type, with this
affecting the most deprived such that those who received the
informed choice invitation reported the lowest intentions to
engage in health protective behaviours of any of the
subgroups analysed. Data on attitudes to lifestyle changewere
not collected, so the possibility that these determine the
difference in intention cannot be ruled out. However, others
have proposed that lack of access to transport, limited access
to childcare and limited financial resources may form barriers
to diabetes self-management among deprived groups.46 A
recentmeta-analysis of interventions to promote lifestyle and
physical activity found that increasing awareness of barriers
resulted in significantly reduced self-efficacy to undertake
physical activity, even when combined with subsequent
problem solving.47 As such, the expectation of encountering
these barriers inhibits intentions to engage in lifestyle change,
much as it inhibits the health behaviours themselves.
Consequently, information that does address the expectation
of encountering these barriers, such as that which was
provided in the informed choice invitation, has the potential
to exacerbate further health inequity.
The reasons underlying the finding that area-level depri-
vation in the form of IMD2007 did not demonstrate a similar
effect are difficult to disentangle. Comparing the individual-
level measure with the area-level measure, there were fewer
individuals scoring highly on area- rather than individual-
level deprivation measure, and there were few recruits in
the most deprived 10% of the distribution of the IMD. It has
been suggested that aggregated deprivation measures of
relatively large areas, such as IMD2007, do not give access to
the heterogeneity beneath the super output area-level, and
that lifestyle measures are more up to date than the neces-
sarily dated area aggregated measures from sources that are
not specifically tied to a particular study. These can include
a greater income component48 that may be the primary
source of the effects of deprivation.49 Whilst the authors are
not aware of other studies demonstrating differential
patterns of response to public health interventions between
individual- and area-level deprivation, it is interesting to
note that the relationship between individuals’ socio-
economic status and physical activity is long estab-
lished,50,51 whereas there appear to be limited data available
at the area-level, and indeed some data showing no associ-
ation.52 Still, despite the questions raised regarding the
usefulness of these measures in explaining the effects of
deprivation,48,53 further research is required to understand
this difference in patterning.
The treatment of screen-detected diabetes includes
immediate efforts to change lifestyle in return for the hope of
future benefits. The GMC guidelines on which the informed
choice materials were based recommend inclusion of details
of the likely experience of treatment including side effects;
and details of benefits and harms, including potential lifestyle
changes. The informed choice invitation included information
on the potential for immediate modest practical and
psychological inconvenience from screening, and described
the limited possibility of avoiding poor health outcomes
within 10 years with treatment if diabetes was found. In
contrast, the standard invitation gave no information of the
temporal placement of any consequences.
Future orientation is associated with a clear sense of the
future and the implication of current actions on that future,30
thus it is consistent that intentions to engage in lifestyle
change is greater for thosewho aremore future orientedwhen
information regarding future health gains is emphasized, even
when the possibility of those gains occurring are relatively
meagre. Studies have already demonstrated that future
orientation is associatedwith engaging inphysical activity and
healthy eating,31 choosing to attend screening,54 delaying first
sexual intercourse,30 not engaging in risky driving55 as well as
a willingness to expend effort for future gain more gener-
ally.56,57 Whilst avoiding the present inconveniences of
screening may seem to be in the rational self-interest of indi-
viduals low in future orientation, this may not be a decision
that people will remain satisfied with over the life course. As
such, the finding of a modest moderating effect of future
orientation on the effect of invitation type upon lifestyle
change intentions suggests that information about the
outcome of screening programmes should include, where
available, any benefits of early diagnosis and treatment, and
not simply longer-termbenefitswhichmayhave littlemeaning
to those with a present orientation.
This study has a number of limitations. The authors did not
recruit many participants in the most deprived 10% of the
distribution in area-level deprivation. Despite this, it was
possible to demonstrate moderating effects across levels of
individual deprivation, albeit the effect was not manifested
among those low in deprivation or high in future time orien-
tation. Additionally, the study was not powered to examine
whether there were three-way moderating effects when
looking at future time orientation and deprivation together.
Also, the use of lifestyle change intentions as a proxy for
lifestyle behaviour change begs future studies that should
seek to replicate the findings reported here with a behavioural
outcome. Still, in terms of the component constructs used to
index the decision, a recent meta-analysis of studies that
applied the Theory of Planned Behaviour to screening15 found
that the correlation between screening intentions and
screening behaviour was 0.42 (k¼ 19, n¼ 8148, 95% confidence
interval 0.40e0.44). As such, it is likely to be a reliable
account.58,59 Finally, the generalizability of the findings to
other screening programmes is unknown. The harms that can
arise from screening for diabetes were described in the invi-
tation as comprising worry and false reassurance, which may
not be considered serious by participants. In contrast, partic-
ipation in other screening programmes can entail serious
physical harms from subsequent invasive testing (e.g. colo-
noscopy) or treatment (e.g. prostatectomy). As such, variation
in the nature of the harms presented, particularly where the
unwanted outcomes vary in terms of their immediacy, are
likely to result in different effects to those described here.
Studies are needed that compare the impact of presenting
uncertainty about individual benefit and harm across
screening programmes with different types and levels of
benefit and harm.
p u b l i c h e a l t h x x x ( 2 0 1 1 ) 1e86
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652
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664
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PUHE1488_proof ■ 11 June 2011 ■ 6/8
Please cite this article in press as: Kellar I, et al., Can informed choice invitations lead to inequities in intentions to make
lifestyle changes among participants in a primary care diabetes screening programme? Evidence from a randomized trial,
Public Health (2011), doi:10.1016/j.puhe.2011.05.010
Page 8
Conclusion
Given the findings of moderating effects of individual-level
deprivation, manifested among the most deprived, and
future time orientation,manifested among those low in future
orientation, subsequent studies examining the effects of
promoting informed choice on subsequent health protective
behaviours should consider the effect that these variables
may have on patients’ intentions to take up the treatments
they are offered if these groups are not to be disadvantaged.
Notwithstanding the limitation regarding the use of intention
as the outcome variable, this study suggests that if they are
not to result in subsequent inequalities, attempts to enhance
informed choice in the context of screening invitations where
the implications of diagnosis are lifestyle change should draw
on efforts to address the apparent barriers to lifestyle change.
Information that emphasizes the immediate benefits of
a healthy diet, regular physical activity and medication
adherence should be paired with descriptions of lifestyle
change treatments that include barrier-reducing measures.
Lastly, in terms of evaluating whom the promotion of
informed choices benefits and harms, this study suggests that
the inclusion of individual-level deprivation and future time
orientation measures is warranted.
Ethical approval
Ethical approval was granted by COREC (Cambridgeshire 1: 06/
Q0104/17). This study is registered as ISRCTN73125647.
Funding
This trial was funded by the Wellcome Trust (Grant No
076838). The sponsor had no role in the study design; in the
collection, analysis and interpretation of data; in the writing
of themanuscript; or in the decision to submit themanuscript
for publication. The General Practice and Primary Care
Research Unit is supported by NIHR funds. IK was supported
by a NIHR Programme Grant for Applied Research (RP-PG-
0606-1259).
Competing interests
None declared.
Acknowledgments
The authors wish to thank the study participants and the staff
at BrettonMedical Practice, Peterborough; Old Fletton Surgery,
Peterborough; The Rookery Medical Centre, Newmarket; and
Thorney Medical Practice, Peterborough; the nurses who
conducted the screening clinics led by Marian Bosman; the
MRC Field Epidemiology team; Nicola Popplewell, Helen
Morris, Kate Williams and Rachel Crockett for their contribu-
tion to the development of the study and the materials; and
IrwinNazareth, GrahamWatt andDanMason for contribution
to discussion of the results. ALK, TM and SS are members of
the NIHR School for Primary Care Research.
r e f e r e n c e s
1. Wareham NJ, Griffin SJ. Should we screen for type 2 diabetes?
Evaluation against National Screening Committee criteria.
BMJ 2001;322:986e8.
2. UK Prospective Diabetes Study Group. UK Prospective
Diabetes Study 6. Complications in newly diagnosed type 2
diabetic patients and their association with different clinical
and biochemical risk factors. Diabetes Res 1990;13:1e11.
3. Adriaanse MC, Snoek FJ. The psychological impact of
screening for type 2 diabetes. Diabetes Metab Res Rev 2006;22:
20e5.
4. Eborall HC, Griffin SJ, Prevost AT, Kinmonth AL, French DP,
Sutton S. Psychological impact of screening for type 2
diabetes: controlled trial and comparative study embedded in
the ADDITION (Cambridge) randomised controlled trial. BMJ
2007;335:486.
5. UK Prospective Diabetes Study Group. Tight blood pressure
control and risk of macrovascular and microvascular
complications in type 2 diabetes: UKPDS 38. BMJ 1998;317:
703e13.
6. Echouffo-Tcheugui JB, Sargeant LA, Prevost AT,
Williams KM, Barling RS, Butler R, et al. How much might
cardiovascular disease risk be reduced by intensive therapy
in people with screen-detected diabetes? Diabet Med 2008;25:
1433e9.
7. Department of Health. Choosing health: making healthy choices
easier. London: Crown; 2004.
8. Dormandy E, Michie S, Hooper R, Marteau TM. Low uptake of
prenatal screening for Down syndrome in minority ethnic
groups and socially deprived groups: a reflection of women’s
attitudes or a failure to facilitate informed choices? Int J
Epidemiol 2005;34:346e52.
9. Marteau TM, Kinmonth AL. Screening for cardiovascular risk:
public health imperative or matter for individual informed
choice? BMJ 2002;325:78e80.
10. O’Connor AM, Bennett CL, Stacey D, Barry M, Col NF, Eden KB,
et al. Decision aids for people facing health treatment or
screening decisions. Cochrane Database Syst Rev 2009;3:
CD001431.
11. Bekker HL. Decision aids and uptake of screening. BMJ 2010;
341:c5407.
12. Barr DA, Fenton L, Blane D. The claim for patient choice and
equity. J Med Ethics 2008;34:271e4.
13. Fox R. Informed choice in screening programmes: do leaflets
help? a critical literature review. J Public Health (Oxf) 2006;28:
309e17.
14. Jepson RG, Forbes CA, Sowden AJ, Lewis RA. Increasing
informed uptake and non-uptake of screening: evidence from
a systematic review. Health Expect 2001;4:116e26.
15. Cooke R, French DP. How well do the theory of reasoned
action and theory of planned behaviour predict intentions
and attendance at screening programmes? a meta-analysis.
PsycholHealth 2008;23:745e65.
16. Tudor Hart J. Commentary: three decades of the inverse care
law. BMJ 2000;320:18e9.
17. Raffle AE. Information about screening e is it to achieve high
uptake or to ensure informed choice? Health Expect 2001;4:
92e8.
18. Mann E, Prevost AT, Griffin S, Kellar I, Sutton S, Parker M,
et al. Impact of an informed choice invitation on uptake of
screening for diabetes in primary care (DICISION): trial
Protocol. BMC Public Health; 2009.
19. van der Meer JB, van den Bos J, Mackenbach JP.
Socioeconomic differences in the utilization of health
services in a Dutch population: the contribution of health
status. Health Policy 1996;37:1e18.
p u b l i c h e a l t h x x x ( 2 0 1 1 ) 1e8 7
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822
823
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827
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837
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839
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844
845
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848
849
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PUHE1488_proof ■ 11 June 2011 ■ 7/8
Please cite this article in press as: Kellar I, et al., Can informed choice invitations lead to inequities in intentions to make
lifestyle changes among participants in a primary care diabetes screening programme? Evidence from a randomized trial,
Public Health (2011), doi:10.1016/j.puhe.2011.05.010
Given the findings of moderating effects of individual-level
deprivation, manifested among the most deprived, and
future time orientation,manifested among those low in future
orientation, subsequent studies examining the effects of
promoting informed choice on subsequent health protective
behaviours should consider the effect that these variables
may have on patients’ intentions to take up the treatments
they are offered if these groups are not to be disadvantaged.
Notwithstanding the limitation regarding the use of intention
as the outcome variable, this study suggests that if they are
not to result in subsequent inequalities, attempts to enhance
informed choice in the context of screening invitations where
the implications of diagnosis are lifestyle change should draw
on efforts to address the apparent barriers to lifestyle change.
Information that emphasizes the immediate benefits of
a healthy diet, regular physical activity and medication
adherence should be paired with descriptions of lifestyle
change treatments that include barrier-reducing measures.
Lastly, in terms of evaluating whom the promotion of
informed choices benefits and harms, this study suggests that
the inclusion of individual-level deprivation and future time
orientation measures is warranted.
Ethical approval
Ethical approval was granted by COREC (Cambridgeshire 1: 06/
Q0104/17). This study is registered as ISRCTN73125647.
Funding
This trial was funded by the Wellcome Trust (Grant No
076838). The sponsor had no role in the study design; in the
collection, analysis and interpretation of data; in the writing
of themanuscript; or in the decision to submit themanuscript
for publication. The General Practice and Primary Care
Research Unit is supported by NIHR funds. IK was supported
by a NIHR Programme Grant for Applied Research (RP-PG-
0606-1259).
Competing interests
None declared.
Acknowledgments
The authors wish to thank the study participants and the staff
at BrettonMedical Practice, Peterborough; Old Fletton Surgery,
Peterborough; The Rookery Medical Centre, Newmarket; and
Thorney Medical Practice, Peterborough; the nurses who
conducted the screening clinics led by Marian Bosman; the
MRC Field Epidemiology team; Nicola Popplewell, Helen
Morris, Kate Williams and Rachel Crockett for their contribu-
tion to the development of the study and the materials; and
IrwinNazareth, GrahamWatt andDanMason for contribution
to discussion of the results. ALK, TM and SS are members of
the NIHR School for Primary Care Research.
r e f e r e n c e s
1. Wareham NJ, Griffin SJ. Should we screen for type 2 diabetes?
Evaluation against National Screening Committee criteria.
BMJ 2001;322:986e8.
2. UK Prospective Diabetes Study Group. UK Prospective
Diabetes Study 6. Complications in newly diagnosed type 2
diabetic patients and their association with different clinical
and biochemical risk factors. Diabetes Res 1990;13:1e11.
3. Adriaanse MC, Snoek FJ. The psychological impact of
screening for type 2 diabetes. Diabetes Metab Res Rev 2006;22:
20e5.
4. Eborall HC, Griffin SJ, Prevost AT, Kinmonth AL, French DP,
Sutton S. Psychological impact of screening for type 2
diabetes: controlled trial and comparative study embedded in
the ADDITION (Cambridge) randomised controlled trial. BMJ
2007;335:486.
5. UK Prospective Diabetes Study Group. Tight blood pressure
control and risk of macrovascular and microvascular
complications in type 2 diabetes: UKPDS 38. BMJ 1998;317:
703e13.
6. Echouffo-Tcheugui JB, Sargeant LA, Prevost AT,
Williams KM, Barling RS, Butler R, et al. How much might
cardiovascular disease risk be reduced by intensive therapy
in people with screen-detected diabetes? Diabet Med 2008;25:
1433e9.
7. Department of Health. Choosing health: making healthy choices
easier. London: Crown; 2004.
8. Dormandy E, Michie S, Hooper R, Marteau TM. Low uptake of
prenatal screening for Down syndrome in minority ethnic
groups and socially deprived groups: a reflection of women’s
attitudes or a failure to facilitate informed choices? Int J
Epidemiol 2005;34:346e52.
9. Marteau TM, Kinmonth AL. Screening for cardiovascular risk:
public health imperative or matter for individual informed
choice? BMJ 2002;325:78e80.
10. O’Connor AM, Bennett CL, Stacey D, Barry M, Col NF, Eden KB,
et al. Decision aids for people facing health treatment or
screening decisions. Cochrane Database Syst Rev 2009;3:
CD001431.
11. Bekker HL. Decision aids and uptake of screening. BMJ 2010;
341:c5407.
12. Barr DA, Fenton L, Blane D. The claim for patient choice and
equity. J Med Ethics 2008;34:271e4.
13. Fox R. Informed choice in screening programmes: do leaflets
help? a critical literature review. J Public Health (Oxf) 2006;28:
309e17.
14. Jepson RG, Forbes CA, Sowden AJ, Lewis RA. Increasing
informed uptake and non-uptake of screening: evidence from
a systematic review. Health Expect 2001;4:116e26.
15. Cooke R, French DP. How well do the theory of reasoned
action and theory of planned behaviour predict intentions
and attendance at screening programmes? a meta-analysis.
PsycholHealth 2008;23:745e65.
16. Tudor Hart J. Commentary: three decades of the inverse care
law. BMJ 2000;320:18e9.
17. Raffle AE. Information about screening e is it to achieve high
uptake or to ensure informed choice? Health Expect 2001;4:
92e8.
18. Mann E, Prevost AT, Griffin S, Kellar I, Sutton S, Parker M,
et al. Impact of an informed choice invitation on uptake of
screening for diabetes in primary care (DICISION): trial
Protocol. BMC Public Health; 2009.
19. van der Meer JB, van den Bos J, Mackenbach JP.
Socioeconomic differences in the utilization of health
services in a Dutch population: the contribution of health
status. Health Policy 1996;37:1e18.
p u b l i c h e a l t h x x x ( 2 0 1 1 ) 1e8 7
781
782
783
784
785
786
787
788
789
790
791
792
793
794
795
796
797
798
799
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801
802
803
804
805
806
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808
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811
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815
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899
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904
905
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908
909
910
PUHE1488_proof ■ 11 June 2011 ■ 7/8
Please cite this article in press as: Kellar I, et al., Can informed choice invitations lead to inequities in intentions to make
lifestyle changes among participants in a primary care diabetes screening programme? Evidence from a randomized trial,
Public Health (2011), doi:10.1016/j.puhe.2011.05.010
Page 9
20. Goddard M, Smith P. Equity of access to health care. York: Centre
for Reviews and Dissemination; 1998.
21. Kelly WF, Mahmood R, Kelly MJ, Turner S, Elliott K. Influence
of social deprivation on illness in diabetic patients. BMJ 1993;
307:1115e6.
22. Connolly VM, Kesson CM. Socioeconomic status and
clustering of cardiovascular disease risk factors in diabetic
patients. Diabetes Care 1996;19:419e22.
23. Chaturvedi N, Stephenson JM, Fuller JH. The relationship
between socioeconomic status and diabetes control and
complications in the EURODIAB IDDM Complications Study.
Diabetes Care 1996;19:423e30.
24. Kelly WF, Mahmood R, Turner S, Elliott K. Geographical
mapping of diabetic patients from the deprived inner city
shows less insulin therapy and more hyperglycaemia. Diabet
Med 1994;11:344e8.
25. Roper NA, Bilous RW, Kelly WF, Unwin NC, Connolly VM.
Excess mortality in a population with diabetes and the impact
of material deprivation: longitudinal, population based study.
BMJ 2001;322:1389e93.
26. Ajzen I. The theory of planned behavior. Organiz Behav Hum
Decis Processes 1991;50:179e211.
27. Webb TL, Sheeran P. Does changing behavioral intentions
engender behavior change? a meta-analysis of the
experimental evidence. Psychol Bull 2006;132:249e68.
28. Petrocelli JV. Factor validation of the consideration of future
consequences scale: evidence for a short version. J Soc Psychol
2003;143:405e13.
29. Strathman S, Gleicher F, Boninger DS, Edwards CS. The
consideration of future consequences: weighing immediate
and distant outcomes of behaviour. J Personality Soc Psychol
1994;66:742e52.
30. Rothspan S, Read SJ. Present versus future time perspective
and HIV risk among heterosexual college students. Health
Psychol 1996;15:131e4.
31. Luszczynska A, Gibbons FX, Piko BF, Tekozel M. Self-
regulatory cognitions, social comparison, and perceived
peers’ behaviors as predictors of nutrition and physical
activity: a comparison among adolescents in Hungary,
Poland, Turkey, and USA. Psychol Health 2004;19:577e93.
32. Orbell S, Perugini M, Rakow T. Individual differences in
sensitivity to health communications: consideration of future
consequences. Health Psychol 2004;23:388e96.
33. Crockett R, Wilkinson TM, Marteau TM. Social patterning of
screening uptake and the impact of facilitating informed
choices: psychological and ethical analyses. Health Care Anal
2008;16:17e30.
34. Griffin SJ, Little PS, Hales CN, Kinmonth AL, Wareham NJ.
Diabetes risk score: towards earlier detection of type 2 diabetes
in general practice. Diabet Metab Res Rev 2000;16:164e71.
35. Mann E, Prevost AT, Griffin S, Kellar I, Sutton S, Parker M,
et al. Impact of an informed choice invitation on uptake of
screening for diabetes in primary care (DICISION): trial
protocol. BMC Public Health 2009;9:63.
36. Muir J, Mant D, Jones L, Yudkin D. Effectiveness of health
checks conducted by nurses in primary care: results of the
OXCHECK study after one year. Imperial Cancer Research
Fund OXCHECK Study Group. BMJ 1994;308:308e12.
37. Wood DA, Kinmonth AL, Davies GA, Yarwood J,
Thompson SD, Pyke SDM, et al. Randomised controlled trial
evaluating cardiovascular screening and intervention in
general practice: principal results of British family heart
study. BMJ 1994;308:313e20.
38. Kellar I, Sutton S, Griffin S, Prevost AT, Kinmonth AL,
Marteau TM. Evaluation of an informed choice invitation for
type 2 diabetes screening. Patient Educ Counsel 2008;72:232e8.
39. General Medical Council. Seeking patients’ consent: the ethical
considerations. London: GMC; 1998.
40. Wankel LM, Yardley JK, Graham J. The effects of motivational
interventions upon the exercise adherence of high and low
self-motivated adults. Can J Appl Sport Sci 1985;10:147e55.
41. Sutton S, Gilbert H. Effectiveness of individually tailored
smoking cessation advice letters as an adjunct to telephone
counselling and generic self-help materials: randomized
controlled trial. Addiction 2007;102:994e1000.
42. Cockburn J, Redman S, Hill D, Henry E. Public understanding
of medical screening. J Med Screen 1995;2:224.
43. Dormandy E, Michie S, Hooper R, Marteau T. Informed choice
in antenatal Down syndrome screening: a cluster-
randomised trial of combined versus separate visit testing.
Patient Educ Counsel 2006;61:56e64.
44. Marteau TM, Mann E, Prevost AT, Vasconcelos J, Kellar I,
Sanderson S, et al. Impact of an informed choice invitation on
uptake of screening for diabetes in primary care (DICISION):
a randomised trial. BMJ, in press.
Q1
45. Tudor Hart J. The inverse care law. Lancet 1971;1:405e12.
46. Eakin EG, Bull SS, Glasgow RE, Mason M. Reaching those most
in need: a review of diabetes self-management interventions
in disadvantaged populations. Diabetes Metab Res Rev 2002;18:
26e35.
47. Ashford S, Edmunds J, French DP. What is the best way to
change self-efficacy to promote lifestyle and recreational
physical activity? a systematic review with meta-analysis.
Br J Health Psychol 2010;15:265e88.
48. Harris RJ, Longley PA. Creating small area measures of urban
deprivation. Environ Plann A 2002;34:1073e93.
49. Hall P, Pfeiffer U. Urban future 21: a global agenda for twenty-first
century cities. London: Spon; 2000.
50. Ford ES, Merritt RK, Heath GW, Powell KE, Washburn RA,
Kriska A, et al. Physical activity behaviors in lower and higher
socioeconomic status populations. Am J Epidemiol 1991;133:
1246e56.
51. Reisig V, Reitmeir P, Doring A, Rathmann W, Mielck A. Social
inequalities and outcomes in type 2 diabetes in the German
region of Augsburg. A cross-sectional survey. Int J Public Health
2007;52:158e65.
52. Sowden SL, Breeze E, Barber J, Raine R. Do general practices
provide equitable access to physical activity interventions? Br
J Gen Pract 2008;58:e1e8.
53. Longley PA, Harris RJ. Towards a new digital data
infrastructure for urban analysis and modelling. Environ Plann
B Plann Design 1999;26:855e78.
54. Orbell S, Hagger M. Temporal framing and the decision to
take part in type 2 diabetes screening: effects of individual
differences in consideration of future consequences on
persuasion. Health Psychol 2006;25:537e48.
55. Zimbardo PG, Keough KA, Boyd JN. Present time perspective
as a predictor of risky driving. Personality Indiv Differ 1997;23:
1007e23.
56. Brown WT, Jones JM. The substance of things hoped for:
a study of the future orientation, minority status perceptions,
academic engagement, and academic performance of black
high school students. J Black Psychol 2004;30:248e73.
57. D’Alessio M, Guarino A, De Pascalis V, Zimbardo PG. Testing
Zimbardo’s Stanford time perspective Inventory (STPI) -Short
form: an Italian study. Time Soc; 2003::333e47.
58. Armitage CJ, Conner M. Efficacy of the theory of planned
behaviour: a meta-analytic review. Br J Soc Psychol 2001;40:
471e500.
59. Godin G, Kok G. The theory of planned behavior: a review of
its applications to health-related behaviors. Am J Health
Promot 1996;11:87e98.
p u b l i c h e a l t h x x x ( 2 0 1 1 ) 1e88
911
912
913
914
915
916
917
918
919
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921
922
923
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925
926
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1001
1002
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1016
1017
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1021
1022
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1024
1025
1026
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1032
1033
1034
1035
1036
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1038
1039
1040
1041
1042
PUHE1488_proof ■ 11 June 2011 ■ 8/8
Please cite this article in press as: Kellar I, et al., Can informed choice invitations lead to inequities in intentions to make
lifestyle changes among participants in a primary care diabetes screening programme? Evidence from a randomized trial,
Public Health (2011), doi:10.1016/j.puhe.2011.05.010
for Reviews and Dissemination; 1998.
21. Kelly WF, Mahmood R, Kelly MJ, Turner S, Elliott K. Influence
of social deprivation on illness in diabetic patients. BMJ 1993;
307:1115e6.
22. Connolly VM, Kesson CM. Socioeconomic status and
clustering of cardiovascular disease risk factors in diabetic
patients. Diabetes Care 1996;19:419e22.
23. Chaturvedi N, Stephenson JM, Fuller JH. The relationship
between socioeconomic status and diabetes control and
complications in the EURODIAB IDDM Complications Study.
Diabetes Care 1996;19:423e30.
24. Kelly WF, Mahmood R, Turner S, Elliott K. Geographical
mapping of diabetic patients from the deprived inner city
shows less insulin therapy and more hyperglycaemia. Diabet
Med 1994;11:344e8.
25. Roper NA, Bilous RW, Kelly WF, Unwin NC, Connolly VM.
Excess mortality in a population with diabetes and the impact
of material deprivation: longitudinal, population based study.
BMJ 2001;322:1389e93.
26. Ajzen I. The theory of planned behavior. Organiz Behav Hum
Decis Processes 1991;50:179e211.
27. Webb TL, Sheeran P. Does changing behavioral intentions
engender behavior change? a meta-analysis of the
experimental evidence. Psychol Bull 2006;132:249e68.
28. Petrocelli JV. Factor validation of the consideration of future
consequences scale: evidence for a short version. J Soc Psychol
2003;143:405e13.
29. Strathman S, Gleicher F, Boninger DS, Edwards CS. The
consideration of future consequences: weighing immediate
and distant outcomes of behaviour. J Personality Soc Psychol
1994;66:742e52.
30. Rothspan S, Read SJ. Present versus future time perspective
and HIV risk among heterosexual college students. Health
Psychol 1996;15:131e4.
31. Luszczynska A, Gibbons FX, Piko BF, Tekozel M. Self-
regulatory cognitions, social comparison, and perceived
peers’ behaviors as predictors of nutrition and physical
activity: a comparison among adolescents in Hungary,
Poland, Turkey, and USA. Psychol Health 2004;19:577e93.
32. Orbell S, Perugini M, Rakow T. Individual differences in
sensitivity to health communications: consideration of future
consequences. Health Psychol 2004;23:388e96.
33. Crockett R, Wilkinson TM, Marteau TM. Social patterning of
screening uptake and the impact of facilitating informed
choices: psychological and ethical analyses. Health Care Anal
2008;16:17e30.
34. Griffin SJ, Little PS, Hales CN, Kinmonth AL, Wareham NJ.
Diabetes risk score: towards earlier detection of type 2 diabetes
in general practice. Diabet Metab Res Rev 2000;16:164e71.
35. Mann E, Prevost AT, Griffin S, Kellar I, Sutton S, Parker M,
et al. Impact of an informed choice invitation on uptake of
screening for diabetes in primary care (DICISION): trial
protocol. BMC Public Health 2009;9:63.
36. Muir J, Mant D, Jones L, Yudkin D. Effectiveness of health
checks conducted by nurses in primary care: results of the
OXCHECK study after one year. Imperial Cancer Research
Fund OXCHECK Study Group. BMJ 1994;308:308e12.
37. Wood DA, Kinmonth AL, Davies GA, Yarwood J,
Thompson SD, Pyke SDM, et al. Randomised controlled trial
evaluating cardiovascular screening and intervention in
general practice: principal results of British family heart
study. BMJ 1994;308:313e20.
38. Kellar I, Sutton S, Griffin S, Prevost AT, Kinmonth AL,
Marteau TM. Evaluation of an informed choice invitation for
type 2 diabetes screening. Patient Educ Counsel 2008;72:232e8.
39. General Medical Council. Seeking patients’ consent: the ethical
considerations. London: GMC; 1998.
40. Wankel LM, Yardley JK, Graham J. The effects of motivational
interventions upon the exercise adherence of high and low
self-motivated adults. Can J Appl Sport Sci 1985;10:147e55.
41. Sutton S, Gilbert H. Effectiveness of individually tailored
smoking cessation advice letters as an adjunct to telephone
counselling and generic self-help materials: randomized
controlled trial. Addiction 2007;102:994e1000.
42. Cockburn J, Redman S, Hill D, Henry E. Public understanding
of medical screening. J Med Screen 1995;2:224.
43. Dormandy E, Michie S, Hooper R, Marteau T. Informed choice
in antenatal Down syndrome screening: a cluster-
randomised trial of combined versus separate visit testing.
Patient Educ Counsel 2006;61:56e64.
44. Marteau TM, Mann E, Prevost AT, Vasconcelos J, Kellar I,
Sanderson S, et al. Impact of an informed choice invitation on
uptake of screening for diabetes in primary care (DICISION):
a randomised trial. BMJ, in press.
Q1
45. Tudor Hart J. The inverse care law. Lancet 1971;1:405e12.
46. Eakin EG, Bull SS, Glasgow RE, Mason M. Reaching those most
in need: a review of diabetes self-management interventions
in disadvantaged populations. Diabetes Metab Res Rev 2002;18:
26e35.
47. Ashford S, Edmunds J, French DP. What is the best way to
change self-efficacy to promote lifestyle and recreational
physical activity? a systematic review with meta-analysis.
Br J Health Psychol 2010;15:265e88.
48. Harris RJ, Longley PA. Creating small area measures of urban
deprivation. Environ Plann A 2002;34:1073e93.
49. Hall P, Pfeiffer U. Urban future 21: a global agenda for twenty-first
century cities. London: Spon; 2000.
50. Ford ES, Merritt RK, Heath GW, Powell KE, Washburn RA,
Kriska A, et al. Physical activity behaviors in lower and higher
socioeconomic status populations. Am J Epidemiol 1991;133:
1246e56.
51. Reisig V, Reitmeir P, Doring A, Rathmann W, Mielck A. Social
inequalities and outcomes in type 2 diabetes in the German
region of Augsburg. A cross-sectional survey. Int J Public Health
2007;52:158e65.
52. Sowden SL, Breeze E, Barber J, Raine R. Do general practices
provide equitable access to physical activity interventions? Br
J Gen Pract 2008;58:e1e8.
53. Longley PA, Harris RJ. Towards a new digital data
infrastructure for urban analysis and modelling. Environ Plann
B Plann Design 1999;26:855e78.
54. Orbell S, Hagger M. Temporal framing and the decision to
take part in type 2 diabetes screening: effects of individual
differences in consideration of future consequences on
persuasion. Health Psychol 2006;25:537e48.
55. Zimbardo PG, Keough KA, Boyd JN. Present time perspective
as a predictor of risky driving. Personality Indiv Differ 1997;23:
1007e23.
56. Brown WT, Jones JM. The substance of things hoped for:
a study of the future orientation, minority status perceptions,
academic engagement, and academic performance of black
high school students. J Black Psychol 2004;30:248e73.
57. D’Alessio M, Guarino A, De Pascalis V, Zimbardo PG. Testing
Zimbardo’s Stanford time perspective Inventory (STPI) -Short
form: an Italian study. Time Soc; 2003::333e47.
58. Armitage CJ, Conner M. Efficacy of the theory of planned
behaviour: a meta-analytic review. Br J Soc Psychol 2001;40:
471e500.
59. Godin G, Kok G. The theory of planned behavior: a review of
its applications to health-related behaviors. Am J Health
Promot 1996;11:87e98.
p u b l i c h e a l t h x x x ( 2 0 1 1 ) 1e88
911
912
913
914
915
916
917
918
919
920
921
922
923
924
925
926
927
928
929
930
931
932
933
934
935
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937
938
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991
992
993
994
995
996
997
998
999
1000
1001
1002
1003
1004
1005
1006
1007
1008
1009
1010
1011
1012
1013
1014
1015
1016
1017
1018
1019
1020
1021
1022
1023
1024
1025
1026
1027
1028
1029
1030
1031
1032
1033
1034
1035
1036
1037
1038
1039
1040
1041
1042
PUHE1488_proof ■ 11 June 2011 ■ 8/8
Please cite this article in press as: Kellar I, et al., Can informed choice invitations lead to inequities in intentions to make
lifestyle changes among participants in a primary care diabetes screening programme? Evidence from a randomized trial,
Public Health (2011), doi:10.1016/j.puhe.2011.05.010
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