The role of inadequate health literacy skills in colorectal cancer screening

An exploratory study of older adults' comprehension of printed cancer information: is readability a key factor?

Printed cancer information often is written at or beyond high school reading levels, despite lower average literacy abilities of the public. The objectives of this exploratory study were twofold: (1) to evaluate older adults' comprehension of breast (BC), prostate (PC), and colorectal (CC) cancer information; and (2) to determine if comprehension of BC, PC, and CC information varies according to text readability. Comprehension of printed cancer resources was evaluated with 44 community-dwelling older adults using the Cloze procedure and recall questions. Participants' comprehension scores were compared with Simple Measure of Gobbledegook (SMOG) readability scores (<grade 13 vs. grade 13+). Overall, older adults had satisfactory comprehension of cancer information as measured by Cloze (.86 +/- .01) and recall (.71 +/- .02). For CC information written at grade 13, however, a significant negative correlation between readability and Cloze comprehension was found (r(s) = -.44, SE = .17, p = .019), indicating poorer participant comprehension at higher readability levels. Comprehension of BC or PC information did not vary by readability level. Though readability plays a role in older adults' understanding of cancer information, cancer type and content are also important factors that influence comprehension. Use of plain language is recommended for CC resources.

The Case for Development of a New Test of Health Literacy

PURPOSE/OBJECTIVES

To review the need for reading assessments for patients with cancer, review existing reading assessment tools, and make a case for a new tool specific to patients with cancer.

DATA SOURCES

Published articles, experiences, and discussions with published authors in the field of literacy.

DATA SYNTHESIS

Valid and reliable tools that assess word recognition and comprehension exist for general use in health care. Word-recognition tests do not always predict comprehension, and a commonly used comprehension test has sections assessing only very low, second year of high school, and graduate-level skills.

CONCLUSIONS

A new tool, developed specifically for patients with cancer, may better capture reading ability and comprehension. It is being evaluated for use in a clinical setting.

IMPLICATIONS FOR NURSING

If nurses know their patients' reading levels, they can plan more effectively for teaching self-care and discussing decision making. Outcomes related to health and satisfaction may improve if poor readers are given materials they can understand.

Health literacy weakly but consistently predicts primary care patient dissatisfaction

OBJECTIVES

To study relationships between health literacy and multiple satisfaction domains. Health literacy is related to some domains of patient satisfaction such as communication and understanding, but little is known about relationships of health literacy with other satisfaction domains. Moreover, the importance of health literacy in predicting satisfaction compared with other patient sociodemographics is underexplored.

DESIGN

Cross-sectional survey.

SETTING

Primary care waiting areas with a Veterans Administration Medical Center and a university health system.

PARTICIPANTS

One thousand five hundred and twenty-eight primary care patients.

MAIN OUTCOME MEASURES

A brief demographics questionnaire, the Rapid Estimate of Adult Literacy in Medicine, the Veterans Affairs ambulatory care patient satisfaction survey, and an adaptation of the Charlson Comorbidity Index.

RESULTS

In unadjusted regression analyses, lower health literacy level was a significant predictor of worse satisfaction in 7 of 10 domains (P < 0.01). When adjusting for patient sociodemographics, predicted relationships remained significant in six of the seven domains (P < 0.05), with each unit change in the 4-stage literacy classification associated with a 3-6 point decrease in dissatisfaction scores (0-100 scale). Health literacy did not predict overall dissatisfaction (P = 0.55).

CONCLUSIONS

These results suggest that health literacy, as assessed through a pronunciation exercise that is closely related to more comprehensive measures of literacy, has a consistent, albeit weak relationship with patient satisfaction. Future work is needed to clarify if patients with lower literacy are really receiving different care than those with higher literacy and to pinpoint the sources of their more negative responses.

CDC-funded intervention research aimed at promoting colorectal cancer screening in communities

BACKGROUND

Although strong scientific evidence has shown that screening for colorectal cancer saves lives, most U.S. adults who are at the recommended age are not being screened. Prior studies suggest that barriers to routine screening vary by race, ethnicity, socioeconomic status, urban/rural residence, health insurance status, and factors related to health care providers and the health care environment. Relatively few studies, however, have identified and tested intervention approaches to promote routine colorectal cancer screening among diverse populations.

METHODS

The Division of Cancer Prevention and Control at CDC has funded ongoing projects to develop and test interventions to promote routine colorectal cancer screening among medically underserved populations in Appalachia, the Lower Rio Grande Valley in Texas, the High Plains region of Colorado, and other U.S. communities.

RESULTS

This article provides an overview of colorectal cancer screening intervention studies currently funded by CDC that focus on a wide range of populations, including medically underserved persons who live in predominately rural areas, Hispanic and non-Hispanic persons, urban African Americans, persons with low health literacy, and persons enrolled in managed care organizations.

CONCLUSIONS

These CDC-funded intervention research projects are likely to contribute importantly to evidence about what works to promote colorectal cancer screening in diverse U.S. communities. .

Colorectal cancer testing among patients cared for by Iowa family physicians

BACKGROUND

Colorectal cancer (CRC) can be largely prevented or effectively treated, yet about half of eligible Americans have not been screened. The purpose of this study was to examine patient and physician factors associated with documented CRC testing according to national guidelines.

METHODS

Cross-sectional study where 511 randomly selected rural patients aged 55 to 80 years of 16 board-certified Iowa family physicians were enrolled in 2004. Patient survey and medical record information were linked with physician surveys. Predictors of CRC testing were examined using a regression procedure that accommodated random physician effects (2005-2006).

RESULTS

Forty-six percent of patients were up-to-date with CRC testing in accordance with national guidelines. This percentage varied from 5% to 75% by physician (p < 0.0001). Of the patients who were up-to-date, 89% had colonoscopy, and 62% had symptoms prior to testing that could indicate CRC. The strongest univariate predictors other than symptoms were patient recollection of physician recommendation (odds ratio [OR] = 6.4, 95% confidence interval [CI] = 4.2-9.6) and physician documentation of recommendation (OR = 14.1, CI = 8.5-23.3). A multivariable regression model showed testing in accordance with guidelines significantly increased with government insurance (OR = 1.6, CI = 1.2-2.3), having a health maintenance visit in the preceding 26 months (OR = 2.4, CI = 1.4-4.1), family history of CRC (OR = 3.1, CI = 1.6-5.8), number of medical conditions (OR = 1.2 for each additional condition, CI = 1.1-1.3), high importance of screening to patient (OR = 2.6, CI = 1.5-4.5), patient satisfaction with doctor's discussions (OR = 3.3, CI = 2.2-4.8), physician trained in flexible sigmoidoscopy (OR = 2.3, CI = 1.6-3.4), and physician report of trying to follow American Cancer Society (ACS) guidelines (OR = 1.7, CI = 1.2-2.5). After excluding patients who had symptoms prior to screening, most of the ORs in the logistic regression analysis increased except that the number of medical conditions and physician trying to follow ACS guidelines became nonsignificant.

CONCLUSIONS

Fewer than half of rural patients received CRC testing, and most of those tested had symptoms. Physician recommendations and the manner of presenting the recommendations greatly influenced whether patients were tested.

Development of a Smiling Touchscreen multimedia program for HRQoL assessment in subjects with varying levels of literacy

OBJECTIVE

As low literacy affects the assessment of health-related quality of life (HRQoL) in several ways (e.g., subject eligibility and cost of administration), better approaches to HRQoL assessment in subjects with varying literacy levels are needed.

METHODS

We developed a multimedia touchscreen program (the Smiling Touchscreen, ST) to administer HRQoL instruments to subjects with varying levels of Chinese language and computer literacy, using an iterative process where patients' input on design, clarity of instructions, and user-friendliness were repeatedly gathered and incorporated in development. The ST thus has several user-friendly features for low-literacy subjects (e.g., presentation of individual items using visual and auditory stimuli, voice-text synchronization, and visual analog scale with a touch and drag function), which we evaluated using qualitative and quantitative methods.

RESULTS

The ST was well accepted by subjects (n = 66, 76% female, median [interquartile] age: 49.0 [40.0, 56.0]) with high (n = 43) or low (n = 23) literacy, 98% of whom found it easy or very easy to use, and 85% found the voice-text synchronization feature useful. In low-literacy subjects without computer experience (30%), none reported any difficulties using the ST. The median (interquartile) time spent to complete the ST (four Instruction and Practice screens, 24 questions, one visual analog scale) for high- and low-literacy groups was 13.9 (9.6, 23.9) and 23.2 (15.8, 26.5) minutes, respectively. Among subjects expressing a preference (n = 47), 21 (47%) favored the ST over interviewer- or self-administration.

CONCLUSION

The ST is well accepted by subjects with varying literacy levels, including those without computer experience. It is thus a promising new approach for HRQoL assessment among subjects with varying literacy levels.

Literacy and health outcomes: a cross-sectional study in 1002 adults with diabetes

Background

Inconsistent findings reported in the literature contribute to the lack of complete understanding of the association of literacy with health outcomes. We evaluated the association between literacy, physiologic control and diabetes complications among adults with diabetes.

Methods

A cross-sectional study of 1,002 English speaking adults with diabetes, randomly selected from the Vermont Diabetes Information System, a cluster-randomized trial of a diabetes decision support system in a region-wide sample of primary care practices was conducted between July 2003 and March 2005. Literacy was assessed by the Short-Test of Functional Health Literacy in Adults. Outcome measures included glycated hemoglobin, low density lipoprotein, blood pressure and self-reported complications.

Results

After adjusting for sociodemographic characteristics, duration of diabetes, diabetes education, depression, alcohol use, and medication use we did not find a significant association between literacy and glycemic control (beta coefficent,+ 0.001; 95% confidence interval [CI], -0.01 to +0.01; P = .88), systolic blood pressure (beta coefficent, +0.08; 95% CI, -0.10 to +0.26; P = .39), diastolic blood pressure (beta coefficent, -0.03; 95% CI, -0.12 to +0.07, P = .59), or low density lipoprotein (beta coefficent, +0.04; 95% CI, -0.27 to +0.36, P = .77. We found no association between literacy and report of diabetes complications.

Conclusion

These findings suggest that literacy, as measured by the S-TOFHLA, is not associated with glycated hemoglobin, blood pressure, lipid levels or self-reported diabetes complications in a cross-sectional study of older adults with diabetes under relatively good glycemic control. Additional studies to examine the optimal measurement of health literacy and its relationship to health outcomes over time are needed.

Recommendations for effective newborn screening communication: results of focus groups with parents, providers, and experts

OBJECTIVES

The aims of this study were to determine parent and provider knowledge and awareness of newborn screening; to gather opinions from parents, providers, and newborn screening professionals about the content and timing of newborn screening education; and to use consensus data to formulate recommendations and to develop educational materials for parents and providers.

METHODS

We conducted 22 focus groups and 3 individual interviews between October 2003 and May 2004, with English- and Spanish-speaking parents of infants <1 year of age who had experience with initial testing, retesting, or false-positive screenings; health professionals who provide prenatal care or health care for newborns; and state newborn screening program health professionals.

RESULTS

Parents and providers had limited knowledge and awareness about newborn screening practices. Parents wanted brief to-the-point information on newborn screening and its benefits, including the possible need for retesting and the importance of returning promptly for retesting if initial results are abnormal. Parents wanted the information orally from the primary care provider. Parents, providers, and newborn screening professionals all thought that an accompanying concise, easy-to-read brochure with contact information would be helpful. All focus group participants thought that parents should receive this information before the birth of the infant, preferably in the third trimester of pregnancy. Providers wanted a brief checklist of information and resources to prepare them to educate parents effectively.

CONCLUSIONS

We recommend prenatal and primary care providers be more involved in educating parents about newborn screening. Professional societies and state health officials should work together to encourage parent and provider education. User-friendly patient and provider education materials, such as those we developed, could form the basis for this educational approach.

The Single Item Literacy Screener: evaluation of a brief instrument to identify limited reading ability

Background

Reading skills are important for accessing health information, using health care services, managing one's health and achieving desirable health outcomes. Our objective was to assess the diagnostic accuracy of the Single Item Literacy Screener (SILS) to identify limited reading ability, one component of health literacy, as measured by the S-TOFHLA.

Methods

Cross-sectional interview with 999 adults with diabetes residing in Vermont and bordering states. Participants were randomly recruited from Primary Care practices in the Vermont Diabetes Information System June 2003 – December 2004. The main outcome was limited reading ability. The primary predictor was the SILS.

Results

Of the 999 persons screened, 169 (17%) had limited reading ability. The sensitivity of the SILS in detecting limited reading ability was 54% [95% CI: 47%, 61%] and the specificity was 83% [95% CI: 81%, 86%] with an area under the Receiver Operating Characteristics Curve (ROC) of 0.73 [95% CI: 0.69, 0.78]. Seven hundred seventy (77%) screened negative on the SILS and 692 of these subjects had adequate reading skills (negative predictive value = 0.90 [95% CI: 0.88, 0.92]). Of the 229 who scored positive on the SILS, 92 had limited reading ability (positive predictive value = 0.4 [95% CI: 0.34, 0.47]).

Conclusion

The SILS is a simple instrument designed to identify patients with limited reading ability who need help reading health-related materials. The SILS performs moderately well at ruling out limited reading ability in adults and allows providers to target additional assessment of health literacy skills to those most in need. Further study of the use of the SILS in clinical settings and with more diverse populations is warranted.

The roles of low literacy and social support in predicting the preventability of hospital admission

BACKGROUND

Prior studies found higher hospitalization rates among patients with low literacy, but did not determine the preventability of these admissions or consider other determinants of hospitalization, such as social support. This study evaluated whether low literacy was a predictor for preventability of hospitalization when considered in the context of social support, sociodemographics, health status, and risk behaviors.

METHODS

A convenience sample of 400 patients, admitted to general medicine wards in a university-affiliated Veterans Affairs hospital between August 1, 2001 and April 1, 2003, completed a face-to-face interview to assess literacy, sociodemographics, social support, health status, and risk behaviors. Two Board-certified Internists independently assessed preventability of hospitalization and determined the primary preventable cause through blinded medical chart reviews.

RESULTS

Neither low literacy (<seventh grade) nor very low literacy (<fourth grade) was significantly associated with preventability of hospitalization. In multivariable analysis, significant predictors of having a preventable cause of hospitalization included binge alcohol drinking (P< or =.001), lower social support for medical care (P<.04), < or =3 annual clinic visits (P<.005), and > or =12 people talked to weekly (P<.023). Among nonbinge drinkers with lower social support for medical care, larger social networks were predictive of preventability of hospitalization. Among nonbinge drinkers with higher support for medical care, lower outpatient utilization was predictive of the preventability of hospitalization.

CONCLUSIONS

While low literacy was not predictive of admission preventability, the formal assessment of alcohol binge drinking, social support for medical care, social network size, and prior outpatient utilization may enhance our ability to predict the preventability of hospitalizations and develop targeted interventions.

Knowledge of colon cancer screening in a national probability sample in the United States

This study examined colon cancer screening knowledge and potential covariates (demographic, health, health care, and cancer information seeking) among adults of at least 45 years of age. Data were analyzed from the 2003 National Cancer Institute's (NCI's) Health Information National Trends Survey (HINTS 2003), a U.S. random-digit dial study. Our sample consisted of 3,131 adults (53.6% female, 77.9% White). The colon cancer screening knowledge questions assessed whether participants had heard of the fecal occult blood test (FOBT; 73.7%), knew the recommended start age (26.1%), knew the frequency of FOBT (39.5%), had heard of flexible sigmoidoscopy or colonoscopy (84.3%), knew the start age (39.6%), and knew the frequency with which to test (12.8%). Factors associated with lower knowledge (all equal to p < .05 in a multivariate analysis) included being younger (45 to 49 years old) or older (70 years old or more), African American or non-Hispanic other, unmarried; had lower educational attainment; had not visited a health care provider in the past year; had not previously undergone FOBT; and had never looked for cancer information. This study documents low rates of colon cancer screening knowledge in the general population, and identifies subgroups where health communication interventions are most warranted.

Quick assessment of literacy in primary care: the newest vital sign

PURPOSE

Current health literacy screening instruments for health care settings are either too long for routine use or available only in English. Our objective was to develop a quick and accurate screening test for limited literacy available in English and Spanish.

METHODS

We administered candidate items for the new instrument and also the Test of Functional Health Literacy in Adults (TOFHLA) to English-speaking and Spanish-speaking primary care patients. We measured internal consistency with Cronbach's alpha and assessed criterion validity by measuring correlations with TOFHLA scores. Using TOFLHA scores <75 to define limited literacy, we plotted receiver-operating characteristics (ROC) curves and calculated likelihood ratios for cutoff scores on the new instrument.

RESULTS

The final instrument, the Newest Vital Sign (NVS), is a nutrition label that is accompanied by 6 questions and requires 3 minutes for administration. It is reliable (Cronbach alpha >0.76 in English and 0.69 in Spanish) and correlates with the TOFHLA. Area under the ROC curve is 0.88 for English and 0.72 for Spanish versions. Patients with more than 4 correct responses are unlikely to have low literacy, whereas fewer than 4 correct answers indicate the possibility of limited literacy.

CONCLUSION

NVS is suitable for use as a quick screening test for limited literacy in primary health care settings.

Literacy and knowledge, attitudes, and behavior about colorectal cancer screening

This cross-sectional survey explored the association between functional health literacy and knowledge of, beliefs and attitudes about, and reported usage of colorectal cancer screening tests. The results indicate that functional health literacy, as assessed by the Short Test of Functional Health Literacy in Adults (STOFHLA), is not an independent predictor of colorectal cancer screening knowledge, beliefs, attitudes, or behavior. Latino ethnicity and education, however, often predicted screening responses, suggesting that efforts to improve communication about colorectal cancer screening with Latino patients and patients with low education clearly are needed to reduce the disparities in awareness and utilization of colorectal cancer screening tests. This study also explored influences on intended screening behavior. Physician recommendation was found to be a powerful motivator of intention to undergo colorectal cancer screening regardless of literacy level, indicating that interventions aimed at increasing physician recommendation of colorectal cancer screening may be an effective way of increasing screening rates.

Modeling Pathways to Affective Barriers on Colorectal Cancer Screening Among Japanese Americans

The study aimed to identify the mechanisms through which colorectal cancer (CRC)-specific affective barriers, including fear of finding CRC, embarrassment, and concerns for screening discomfort, can be reduced to guide the development of interventions aimed at the secondary prevention of CRC. A model explaining these affective barriers was developed and tested among a random sample of 305 asymptomatic Japanese Americans using a path analysis. The model suggested that affective barriers could be reduced by increasing CRC-related knowledge, which could be enhanced by acculturation, social support, and physician recommendation. Interventions that focus on increasing CRC-related knowledge could reduce affective barriers to CRC screening for this population when taking the enhancement of communication skills and interpersonal interactions into account.

Health care provider-directed intervention to increase colorectal cancer screening among veterans: results of a randomized controlled trial

PURPOSE

Colorectal cancer screening is the most underused cancer screening tool in the United States. The purpose of this study was to test whether a health care provider-directed intervention increased colorectal cancer screening rates.

PATIENTS AND METHODS

The study was a randomized controlled trial conducted at two clinic firms at a Veterans Affairs Medical Center. The records of 5,711 patients were reviewed; 1,978 patients were eligible. Eligible patients were men aged 50 years and older who had no personal or family history of colorectal cancer or polyps, had not received colorectal cancer screening, and had at least one visit to the clinic during the study period. Health care providers in the intervention firm attended a workshop on colorectal cancer screening. Every 4 to 6 months, they attended quality improvement workshops where they received group screening rates, individualized confidential feedback, and training on improving communication with patients with limited literacy skills. Medical records were reviewed for colorectal cancer screening recommendations and completion. Literacy level was assessed in a subset of patients.

RESULTS

Colorectal cancer screening was recommended for 76.0% of patients in the intervention firm and for 69.4% of controls (P = .02). Screening tests were completed by 41.3% of patients in the intervention group versus 32.4% of controls (P = .003). Among patients with health literacy skills less than ninth grade, screening was completed by 55.7% of patients in the intervention group versus 30% of controls (P < .01).

CONCLUSION

A provider-directed intervention with feedback on individual and firm-specific screening rates significantly increased both recommendations and colorectal cancer screening completion rates among veterans.

Promoting health literacy

This report reviews some of the extensive literature in health literacy, much of it focused on the intersection of low literacy and the understanding of basic health care information. Several articles describe methods for assessing health literacy as well as methods for assessing the readability of texts, although generally these latter have not been developed with health materials in mind. Other studies have looked more closely at the mismatch between patients' literacy levels and the readability of materials intended for use by those patients. A number of studies have investigated the phenomenon of literacy from the perspective of patients' interactions in the health care setting, the disenfranchisement of some patients because of their low literacy skills, the difficulty some patients have in navigating the health care system, the quality of the communication between doctors and their patients including the cultural overlay of such exchanges, and ultimately the effect of low literacy on health outcomes. Finally, the impact of new information technologies has been studied by a number of investigators. There remain many opportunities for conducting further research to gain a better understanding of the complex interactions between general literacy, health literacy, information technologies, and the existing health care infrastructure.

Colorectal cancer screening knowledge, attitudes, and beliefs among veterans: does literacy make a difference?

PURPOSE

To evaluate whether lower literacy is associated with poorer knowledge and more negative attitudes and beliefs toward colorectal cancer screening among veterans without recent colorectal cancer screening.

PATIENTS AND METHODS

Three hundred seventy-seven male veterans, age 50 years and older, who had not undergone recent colorectal cancer screening, were surveyed about their knowledge, attitudes, and beliefs regarding colorectal cancer screening. Patients' literacy was assessed with the Rapid Estimate of Adult Literacy in Medicine, an individually administered screening test for reading.

RESULTS

Thirty-six percent of the 377 men had an eighth grade literacy level or higher. Men with lower literacy were 3.5 times as likely not to have heard about colorectal cancer (8.8% v 2.5%; P =.006), 1.5 times as likely not to know about screening tests (58.4% v 40.9%; P =.0001), and were more likely to have negative attitudes about fecal occult blood testing (FOBT), but not about flexible sigmoidoscopy. Specifically, men with lower literacy skills were two times as likely to be worried that FOBT was messy (26.7% v 13.3%; P =.008), 1.5 times as likely to feel that FOBT was inconvenient (28.7% v 18%; P =.05), and four times as likely to state they would not use an FOBT kit even if their physician recommended it (17.9% v 4.0%; P =.02).

CONCLUSION

Limited literacy may be an overlooked barrier in colorectal cancer screening among veterans.

Association of socioeconomic status and receipt of colorectal cancer investigations: a population-based retrospective cohort study

BACKGROUND

Although the Canadian health care system was designed to ensure equal access, inequities persist. It is not known if inequities exist for receipt of investigations used to screen for colorectal cancer (CRC). We examined the association between socioeconomic status and receipt of colorectal investigation in Ontario.

METHODS

People aged 50 to 70 years living in Ontario on Jan. 1, 1997, who did not have a history of CRC, inflammatory bowel disease or colorectal investigation within the previous 5 years were followed until death or Dec. 31, 2001. Receipt of any colorectal investigation between 1997 and 2001 inclusive was determined by means of linked administrative databases. Income was imputed as the mean household income of the person's census enumeration area. Multivariate analysis was performed to evaluate the relationship between the receipt of any colorectal investigation and income.

RESULTS

Of the study cohort of 1,664,188 people, 21.2% received a colorectal investigation in 1997-2001. Multivariate analysis demonstrated a significant association between receipt of any colorectal investigation and income (p < 0.001); people in the highest-income quintile had higher odds of receiving any colorectal investigation (adjusted odds ratio [OR] 1.38; 95% confidence interval [CI] 1.36-1.40) and of receiving colonoscopy (adjusted OR 1.50; 95% CI 1.48-1.53).

INTERPRETATION

Socioeconomic status is associated with receipt of colorectal investigations in Ontario. Only one-fifth of people in the screening-eligible age group received any colorectal investigation. Further work is needed to determine the reason for this low rate and to explore whether it affects CRC mortality.

Views and preferences of low-literate Hispanics regarding diabetes education: results of formative research

Hispanics are twice as likely as non-Hispanic Whites to have diabetes and are also at higher risk for diabetes-related complications and poorer outcomes. The prevalence of diabetes is inversely related to educational status. Low literacy is common, especially among older Hispanics. Little literature exists on formative research to create diabetes education materials for this audience. Two focus groups assessed views and preferences for diabetes education of low-literate, low-income, non-English-speaking urban Caribbean and Central American Hispanics with diabetes, as well as utility of materials developed specifically for this population, as part of the preliminary work for a pilot study of a diabetes intervention. Implications for practitioners and researchers are discussed.

Patient and provider barriers to colorectal cancer screening in the primary care safety-net

OBJECTIVES

This study examines patient and provider barriers to screening for colorectal cancer among low-income uninsured African-Americans aged 50 years or older in an urban safety-net primary care clinic, with the goal of informing a future intervention.

METHODS

Four focus groups were conducted among 40 patients from, or living in the immediate neighborhood of, a primary care clinic for uninsured residents of Washington, DC. An additional focus group was conducted among primary care providers from the same clinic. Using semistructured open-ended questions, moderators elicited perceptions of barriers and promoters of colorectal cancer screening and suggestions to improve adherence to screening guidelines. The focus groups were audio-taped and transcribed verbatim. The transcripts were independently coded by two reviewers using established qualitative methodology.

RESULTS

Patient and provider comments from the five focus groups fell into one of eight content areas: primary care characteristics (36% of comments), procedural issues related to screening (16% of comments), knowledge (14% of comments), cost/insurance coverage (13%), ordering of priorities (12%), attitudes (5%), information sources (2%), and perceptions of discrimination (2%). Involving various members of the primary care team in colorectal cancer screening processes, and using reminders with feedback, were identified as promising avenues for future interventions in the safety-net setting. Patients and providers cited the lack of referral sources for colonoscopy for follow-up of abnormal fecal occult blood tests (FOBT), and lack of treatment sources as major barriers to the initiation of colorectal cancer screening in uninsured populations.

CONCLUSIONS

Organizational level interventions, such as a team approach to colorectal cancer screening, are important areas identified for future colorectal cancer screening interventions in the safety-net primary care setting. Larger policy efforts to provide coverage for screening, diagnosis, and treatment among the uninsured are critical to implementing adequate colorectal cancer screening for this population.

Perspectives on colorectal cancer screening: a focus group study

OBJECTIVE

To assess attitudes and acceptability of Ontario consumers and doctors towards colorectal screening with faecal occult blood testing (FOBT) and colonoscopy.

DESIGN, SETTING AND PARTICIPANTS

Focus groups with gender-specific samples of the population, high-risk gastroenterology patients and family doctors.

METHOD

Semi-structured interview guides used by facilitator to lead groups through knowledge of risk factors and prevention of colorectal cancer, the screening modalities, requirements for implementing screening programmes, barriers to screening and preferences towards screening.

MAIN FINDINGS

There were low levels of knowledge about colorectal cancer and its prevention in the general population. FOBT was an acceptable screening modality, but considerable education about its use and benefits would be necessary to implement a screening programme. Colonoscopy was not perceived to be a good choice for a primary screen in the general population. The high-risk group supported use of FOBT in the general population and emphasized the need for education. The doctors were more reluctant about screening, requesting clear guidelines. They also identified the time and resources that would be required if a screening programme were initiated.

CONCLUSION

While colorectal screening is acceptable in this sample, information and decision aids are required to enable consumers and providers to make effective decisions. Implementation of colorectal screening programmes requires substantial educational efforts for both consumers and doctors.

Patient and physician factors predict patients' comprehension of health information

While patients frequently do not comprehend health information, little is known about patient and physician factors that influence lack of comprehension. To assess effectiveness of health information exchange, 19 physicians and 145 patients were given post-encounter questionnaires to evaluate the preceding visit. We analyzed differences in beliefs between patients who comprehended health information and patients who did not, and whether physicians' attitudes and self-assessment of their educational abilities influenced this comprehension. Patients with insufficient comprehension were more likely to have schooling below college and cited language as a barrier. Physicians who believed health information delivery to be important had fewer patients with comprehension difficulties, while physicians who assessed themselves as very effective educators had significantly more patients with lack of comprehension, compared with physicians who did not feel as effective. Patients' comprehension of health information was associated not only with patient factors but also with physicians' attitude and self-assessment.

The association of health literacy with cervical cancer prevention knowledge and health behaviors in a multiethnic cohort of women

OBJECTIVE

Our purpose was to describe the relationship between health literacy, ethnicity, and cervical cancer screening practices and to evaluate physician recognition of low literacy.

STUDY DESIGN

We studied a prospective cohort of English-speaking patients > or =18 years (n = 529) in ambulatory women's clinics. Univariate and multivariate analyses were used to evaluate demographics, health practices and beliefs, and knowledge regarding cervical cancer screening and prevention. Physicians' assessments of patient reading skills were obtained.

RESULTS

Low health literacy (<9th grade) was found among 40% of participants. Minority women were half as likely to know the purpose of the Papanicolaou test (9% vs 21%; P <.03) and were significantly more likely to have low literacy levels compared with white women (46% vs 15%; P <.05). Literacy was the only factor independently associated with knowledge related to cervical cancer screening (adjusted odds ratio, 2.25; 95% CI, 1.05-4.80). Physicians detected only 20% of the lowest readers.

CONCLUSION

Poor health literacy was a better predictor of cervical cancer screening knowledge than ethnicity or education, yet physicians infrequently recognized low literacy. Improved physician awareness and development of low literacy interventions may improve cervical cancer screening, particularly for the most vulnerable women.

Implementation of colorectal cancer screening: the challenge

Colorectal cancer is the second leading cause of cancer death among men and women in the United States, and its incidence is increasing in other developed countries throughout the world. Efficacious and cost-effectiveness screening measures exist for colorectal cancer, but successful implementation at a community level remains challenging. This article is a summary of recently published information on cost-effectiveness of colorectal screening, attempts to enhance acceptance and compliance by physicians and the public, and legislative efforts to ensure access to screening.