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JMIR Res Protoc. 2018 Feb 16;7(2):e11. doi: 10.2196/resprot.9090.

Testing Behavior Change Techniques to Encourage Primary Care Physicians to Access Cancer Screening Audit and Feedback Reports: Protocol for a Factorial Randomized Experiment of Email Content.

Vaisson G1,2, Witteman HO2,3,4, Bouck Z5, Bravo CA6, Desveaux L5,7, Llovet D6,7, Presseau J8,9,10, Saragosa M5,11, Taljaard M8,9, Umar S6, Grimshaw JM8,12, Tinmouth J6,13,14,15, Ivers NM5,11,13,16.

Author information

Department of Epidemiology, Faculty of Medicine, Laval University, Quebec City, QC, Canada.
Office of Education and Continuing Professional Development, Faculty of Medicine, Laval University, Quebec City, QC, Canada.
Department of Family and Emergency Medicine, Faculty of Medicine, Laval University, Quebec City, QC, Canada.
Research Centre of the Centre Hospitalier Universitaire de Qu├ębec, Laval University, Quebec City, QC, Canada.
Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.
Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada.
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
School of Psychology, University of Ottawa, Ottawa, ON, Canada.
Family Practice Health Centre, Women's College Hospital, Toronto, ON, Canada.
Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.
Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
Sunnybrook Research Institute, Toronto, ON, Canada.
Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.



Cancer Care Ontario's Screening Activity Report (SAR) is an online audit and feedback tool designed to help primary care physicians in Ontario, Canada, identify patients who are overdue for cancer screening or have abnormal results requiring follow-up. Use of the SAR is associated with increased screening rates. To encourage SAR use, Cancer Care Ontario sends monthly emails to registered primary care physicians announcing that updated data are available. However, analytics reveal that 50% of email recipients do not open the email and less than 7% click the embedded link to log in to their report.


The goal of the study is to determine whether rewritten emails result in increased log-ins. This manuscript describes how different user- and theory-informed messages intended to improve the impact of the monthly emails will be experimentally tested and how a process evaluation will explore why and how any effects observed were (or were not) achieved.


A user-centered approach was used to rewrite the content of the monthly email, including messages operationalizing 3 behavior change techniques: anticipated regret, material incentive (behavior), and problem solving. A pragmatic, 2x2x2 factorial experiment within a multiphase optimization strategy will test the redesigned emails with an embedded qualitative process evaluation to understand how and why the emails may or may not have worked. Trial outcomes will be ascertained using routinely collected administrative data. Physicians will be recruited for semistructured interviews using convenience and snowball sampling.


As of April 2017, 5576 primary care physicians across the province of Ontario, Canada, had voluntarily registered for the SAR, and in so doing, signed up to receive the monthly email updates. From May to August 2017 participants received the redesigned monthly emails with content specific to their allocated experimental condition prompting use of the SAR. We have not yet begun analyses.


This study will inform how to communicate effectively with primary care providers by email and identify which behavior change techniques tested are most effective at encouraging engagement with an audit and feedback report.

TRIAL REGISTRATION: NCT03124316; (Archived by WebCite at


behavior change techniques; clinical trials as topic; early detection of cancer; electronic mail; feedback; implementation science; persuasive communication; primary health care; process evaluation

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