Psychosocial influences on older adults' interest in participating in bowel cancer screening

Public awareness of gastric cancer risk factors and screening behaviours in Shijiazhuang, China: A community-based survey

BACKGROUND

Reducing exposure to risk factors and screening represent 2 major approaches to gastric cancer (GC) prevention, but public knowledge GC risk factors and screening behaviour remain unknown. We aimed to investigate public awareness of GC risk factors, adherence to screening, and barriers hindering screening practices in China.

METHODS

This community-based household survey was conducted within Shijiazhuang, China, and 1490 residents were recruited through a multistage stratified cluster random sampling approach. A self-administered questionnaire was completed which consisted of three sections: demographics, awareness of GC risk factors, and personal screening behaviours. Factors associated with knowledge of risk factors and screening behaviours were evaluated using binary logistic regression analysis.

RESULTS

The mean risk factor awareness score of 12 (7, 15) revealed insufficient knowledge in 51.1% of participants. Dietary lifestyle factors were better understood than physical activity and weight-related factors. Marital status (OR 1.967; 95% CI 1.415 to 2.734), higher income (OR 1.197; 95% CI 1.010 to 1.418), and a history of upper gastrointestinal problems (OR 0.048; 95% CI 1.002 to 1.311) were associated with higher awareness. Merely 21.5% underwent GC screening, with higher rates linked to older age (OR 1.642; 95% CI 1.418 to 1.902), higher education (OR 1.398; 95% CI 1.176 to 1.662), a history of upper gastrointestinal problems (OR 3.842; 95% CI 2.833 to 5.209), and moderate (OR 2.077; 95% CI 1.352 to 3.191) and high (OR 2.529; 95% CI 1.311 to 4.878) perceived GC risk. Notably, participants commonly refused gastroscopy due to the absence of symptoms or signs.

CONCLUSIONS

In Shijiazhuang, more than half of participants demonstrated inadequate knowledge of GC risk factors, and screening participation rates were remarkably low. This emphasizes the need for targeted interventions to enhance GC awareness and significantly improve screening rates.

Psychological distress and bowel cancer screening participation

OBJECTIVE

To better understand barriers to participation in mail-out bowel cancer screening programs, two survey studies tested the relationship between psychological distress and self-reported bowel cancer screening.

METHODS

First, a nationally representative sample of Australians N = 5421 completed measures of bowel cancer screening and psychological distress (using the Kessler Psychological Distress Scale; K10). Second, N = 479 completed a survey measuring participation in the National Bowel Cancer Screening Program (NBCSP) and psychological distress using the Depression, Anxiety and Stress Scale. In both studies, logistic regressions were conducted to test relationships between psychological distress and self-reported screening participation.

RESULTS

Study one found that psychological distress had a significant quadratic effect on having ever screened for bowel cancer, where screening rates were similar for those with low, moderate, or high levels of distress, but were lower for those with very high levels of distress. In study two, depression scores had a negative linear relationship with NBCSP participation (higher depression levels were associated with lower screening participation), and anxiety had a quadratic effect whereby NBCSP participation rates were higher with increasing levels of anxiety except in the severe category, where participation was significantly lower.

CONCLUSIONS

Findings indicate that psychological distress has a complex relationship with screening, and those with extreme levels of distress consistently show lower participation rates. Special efforts to encourage screening may be required for those experiencing extreme psychological distress and mental health disorders.

Patient attitudes towards changes in colorectal cancer surveillance: An application of the Health Belief Model

OBJECTIVE

This is to determine whether health beliefs regarding colorectal cancer (CRC) screening could predict discomfort with a change to CRC surveillance proposing regular faecal immunochemical tests (FIT) instead of colonoscopy.

METHODS

Eight hundred individuals enrolled in a South Australian colonoscopy surveillance programme were invited to complete a survey on surveillance preferences. Responses were analysed using binary logistic regression predicting discomfort with a hypothetical FIT-based surveillance change. Predictor variables included constructs based on the Health Belief Model: perceived threat of CRC, perceived confidence to complete FIT and colonoscopy (self-efficacy), perceived benefits from current surveillance and perceived barriers to FIT and colonoscopy.

RESULTS

A total of 408 participants (51%) returned the survey (complete data n = 303; mean age 62 years, 52% male). Most participants (72%) were uncomfortable with FIT-based surveillance reducing colonoscopy frequency. This attitude was predicted by a higher perceived threat of CRC (OR = 1.03 [95% CI 1.01-1.04]), higher colonoscopy self-efficacy (OR = 1.34 [95% CI 1.13-1.59]) and lower perceived barriers to colonoscopy (OR = 0.92 [95% CI 0.86-0.99]).

CONCLUSIONS

Health beliefs regarding colonoscopy and perceived threat of CRC may be important to consider when changing CRC surveillance protocols. If guideline changes were introduced, these factors should be addressed to provide patients reassurance concerning the efficacy of the alternative protocol.

What are common barriers and helpful solutions to colorectal cancer screening? A cross-sectional survey to develop intervention content for a planning support tool

OBJECTIVE

Colorectal screening using faecal immunochemical tests (FITs) can save lives if the people invited participate. In Scotland, most people intend to complete a FIT but this is not reflected in uptake rates. Planning interventions can bridge this intention-behaviour gap. To develop a tool supporting people willing to do colorectal screening with planning to complete a FIT, this study aimed to identify frequently experienced barriers and solutions to these barriers.

DESIGN

This is a cross-sectional study.

SETTING

Participants were recruited through the Scottish Bowel Screening Programme to complete a mailed questionnaire.

PARTICIPANTS

The study included 2387 participants who had completed a FIT (mean age 65 years, 40% female) and 359 participants who had not completed a FIT but were inclined to do so (mean age 63 years, 39% female).

OUTCOME MEASURES

The questionnaire assessed frequency of endorsement of colorectal screening barriers and solutions.

RESULTS

Participants who had not completed a FIT endorsed significantly more barriers than those who had completed a FIT, when demographic, health and behavioural covariates were held constant (F(1,2053)=13.40, p<0.001, partial η2=0.01). Participants who completed a FIT endorsed significantly more solutions than those who did not (U=301 585.50, z=-3.21, p<0.001, r=0.06). This difference became insignificant when covariates were controlled. Participants agreed on the most common barriers and solutions regardless of screening history. Barriers included procrastination, forgetting, fear of the test result, screening anxiety, disgust and low self-efficacy. Solutions included hand-washing, doing the FIT in private, reading the FIT instructions, benefit of early detection, feelings of responsibility, high self-efficacy and seeing oneself as a person who looks after one's health.

CONCLUSION

This survey identified six barriers and seven solutions as key content to include in the development of a planning tool for colorectal screening using the FIT. Participatory research is required to codesign an engaging and accessible planning tool.

Likely uptake of a future a lung cancer screening programme in Hodgkin lymphoma survivors: a questionnaire study

Background

Many Hodgkin lymphoma (HL) survivors are at increased risk of subsequent malignant neoplasms (SMN), including lung cancer, due to previous treatment for HL. Lung cancer screening (LCS) detects early-stage lung cancers in ever smokers but HL survivors without a heavy smoking history are ineligible for screening. There is a rationale to develop a targeted LCS. The aim of this study was to investigate levels of willingness to undergo LCS in HL survivors, and to identify the psycho-social factors associated with screening hesitancy.

Methods

A postal questionnaire was sent to 281 HL survivors registered in a long-term follow-up database and at increased risk of SMNs. Demographic, lung cancer risk factors, psycho-social and LCS belief variables were measured. Multivariable logistic regression analysis was performed to determine the factors associated with lung cancer screening hesitancy, defined as those who would ‘probably’ or ‘probably not’ participate.

Results

The response rate to the questionnaire was 58% (n = 165). Participants were more likely to be female, older and living in a less deprived area than non-participants. Uptake (at any time) of breast and bowel cancer screening among those previously invited was 99% and 77% respectively. 159 participants were at excess risk of lung cancer. The following results refer to these 159. Around half perceived themselves to be at greater risk of lung cancer than their peers. Only 6% were eligible for lung cancer screening pilots aimed at ever smokers in the UK. 98% indicated they would probably or definitely participate in LCS were it available. Psycho-social variables associated with LCS hesitancy on multivariable analysis were male gender (OR 5.94 CI 1.64–21.44, p < 0.01), living in an area with a high index of multiple deprivation decile (deciles 6–10) (OR 8.22 CI 1.59–42.58, p < 0.05) and lower levels of self-efficacy (OR 1.64 CI 1.30–2.08 p < 0.01).

Conclusion

HL survivors responding to this survey were willing to participate in a future LCS programme but there was some hesitancy. A future LCS trial for HL survivors should consider the factors associated with screening hesitancy in order to minimise barriers to participation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01959-3.

Cancer Worry Distribution and Willingness to Undergo Colonoscopy at Three Levels of Hypothetical Cancer Risk—A Population-Based Survey in Sweden

Simple Summary

Cancer worry is a known health concern in cancer patients and people with a genetic predisposition to cancer. We measured how worried people, in general, are about developing cancer to describe levels in non-affected individuals. In total, 943 respondents completed a survey containing the Cancer Worry Scale (CWS) and hypothetical questions asking if they would attend a colonoscopy screening at a 5, 10, or 70 percent lifetime risk of developing bowel cancer. Unaffected individuals scored a mean of 9.46 on the six-item CWS. Women scored significantly higher than men (9.91 vs. 9.06). Women and parents had higher cancer worry than men and people without children when ruling out differences in education, age, and country of birth. People who worried more were also more inclined to undergo a colonoscopy screening, and intention increased with higher levels of hypothetical risk. These data may be helpful in future work on cancer worry and cancer prevention.

Abstract

Purpose: We describe levels of cancer worry in the general population as measured with the Cancer Worry Scale (CWS) and investigate the association with colonoscopy screening intentions in three colorectal cancer risk scenarios. Methods: The data were sourced through a population-based survey. Respondents (n = 943) completed an eight-item CWS and questions on colonoscopy screening interest at three hypothetical risk levels. Results: Respondents without a personal cancer history (n = 853) scored 9.46 on the six-item CWS (mean, SD 2.72). Mean scores were significantly higher in women (9.91, SD 2.89) as compared to men (9.06, SD 2.49, p < 0.001). Linear regression showed higher cancer worry in women and those with children when controlling for education, age group, and country of birth. High cancer worry (six-item CWS mean >12) was identified in 25% of women and in 17% of men. Among those, 71% would attend a colonoscopy screening compared to 52% of those with low cancer worry (p < 0.001, 5% CRC-risk). Conclusions: The distribution of cancer worry in a general population sample showed higher mean scores in women, and levels overlapped with earlier findings in cancer-affected samples. Respondents with high cancer worry were more inclined to undergo a colonoscopy screening, and intention increased with higher levels of hypothetical risk.

Can targeting women with behavioural science 'nudges' help black men to find out more about their high risk of contracting prostate cancer?

OBJECTIVE

Prostate cancer is now deadlier than breast cancer in the UK, with more than 12,000 men dying from it in the country in 2018. Black men are nearly three times more likely to suffer prostate cancer, with one in four contracting the disease in their lifetime. Despite being a high risk group very few black men aged 45 and over visit their GP to discuss the pros and cons of screening. This is a problem as early onset of the disease presents no symptoms and when symptoms do appear, such as urinary problems, and men do visit a doctor it is often too late to reverse the cancer's spread. This study investigates using the strong social norm of wives and girlfriends being the guardian of black men's health as a way of influencing their behaviour.

METHODS

Using a historically controlled study via email we tested the social norm nudge in the field with 13 Afro-Caribbean organisations across the UK.

RESULTS

The trial found the social norm nudge produced a 15.5 per cent click-through rate, which was significantly higher than the historical controls. Meanwhile, the messenger effect saw a click-through rate of 38.5 per cent on men.

CONCLUSION

At a national level the social norm nudge would equate to 37,315 black women taking positive action to find out more information about their husband or boyfriend's high risk of contracting prostate cancer.

PRACTICE IMPLICATIONS

Use clinicians as messengers in correspondence to promote engagement with information about prostate cancer screening.

Disparities in the participation and adherence of older adults in lifestyle-based multidomain dementia prevention and the motivational role of perceived disease risk and intervention benefits: an observational ancillary study to a randomised controlled trial

Background

Preventive interventions for dementia are urgently needed and must be tested in randomised controlled trials (RCTs). Selection (volunteer) bias may limit efficacy, particularly in trials testing multidomain interventions and may also be indicative of disparities in intervention uptake in real-world settings. We identified factors associated with participation and adherence in a 3-year RCT of multidomain lifestyle intervention and/or omega-3 supplementation for prevention of cognitive decline and explored reasons for (non-) participation.

Methods

Ancillary study during recruitment and follow-up of the 3-year Multidomain Alzheimer Preventive Trial (MAPT) conducted in in 13 memory centres in France and Monaco, involving 1630 community-dwelling dementia-free individuals aged ≥ 70 who were pre-screened for MAPT (1270 participated in MAPT; 360 declined to participate).

Results

Response rates were 76% amongst MAPT participants and 53% amongst non-participants. Older individuals (odds ratio 0.94 [95% confidence interval 0.91–0.98] and those with higher anxiety (0.61 [0.47–0.79]) were less likely to participate in the trial. Those with higher income (4.42 [2.12–9.19]) and family history (1.60 [1.10–2.32]) or greater fear (1.73 [1.30–2.29]) of dementia were more likely to participate, as were those recruited via an intermediary (e.g. pension funds, local Alzheimer’s associations, University of the 3rd Age, sports clubs) (2.15 [1.45–3.20]). MAPT participants living in larger towns (0.71 [0.55–0.92]) and with higher depressive symptoms (0.94 [0.90–0.99]) were less likely to adhere to the interventions. Greater perceived social support (1.21 [1.03–1.43]) and cognitive function (1.37 [1.13–1.67]) predicted better adherence. Descriptively, the most frequent reasons for accepting and refusing to participate were, respectively, altruism and logistical constraints, but underlying motivations mainly related to (lack of) perceived benefits.

Conclusions

Disparities in uptake of health interventions persist in older age. Those most at risk of dementia may not participate in or adhere to preventive interventions. Barriers to implementing lifestyle changes for dementia prevention include lack of knowledge about potential benefits, lack of support networks, and (perceived) financial costs.

Trial registration

NCT00672685 (ClinicalTrials.gov)

Supplementary Information

The online version contains supplementary material available at 10.1186/s13195-021-00904-6.

The integrated screening action model (I-SAM): A theory-based approach to inform intervention development

Screening can reduce deaths if the people invited participate. However, good uptake is hard to achieve, and our current approaches are failing to engage the most vulnerable. A coherent model of screening behaviour to guide our understanding and intervention development is yet to be established. The present aim was to propose an Integrated Screening Action Model (I-SAM) to improve screening access. The I-SAM synthesises existing models of health behaviour and empirical evidence. The I-SAM was developed following: i) an appraisal of the predominant models used within the screening literature; ii) the integration of the latest knowledge on behaviour change; with iii) the empirical literature, to inform the development of a theory-based approach to intervention development. There are three key aspects to the I-SAM: i) a sequence of stages that people pass through in engaging in screening behaviour (based on the Precaution Adoption Process Model); ii) screening behaviour is shaped by the interaction between participant and environmental influences (drawing from the Access Framework); and iii) targets for intervention should focus on the sources of behaviour - 'capability', 'opportunity', and 'motivation' (based on the COM-B Model). The I-SAM proposes an integrated model to support our understanding of screening behaviour and to identify targets for intervention. It will be an iterative process to test and refine the I-SAM and establish its value in supporting effective interventions to improve screening for all.

Justice beliefs buffer against perceived barriers to colorectal cancer screening among African Americans

OBJECTIVES

African Americans develop and die from colorectal cancer (CRC) more than any other racial group in the United States. Perceived barriers to screening (e.g. embarrassment and financial costs) likely exacerbate these disparities. Identifying psychological factors that can reduce the impact of perceived barriers and encourage CRC screening is therefore critical. This study explored whether believing the world is fairer for oneself than in general (personal justice ascendancy) would moderate the impact that perceived barriers have on receptivity to CRC screening.

METHOD

Four-hundred fifty-seven screening eligible African Americans completed measures of beliefs about justice for self and others, as well as perceived barriers to CRC screening. Participants also completed theory of planned behaviour (TPB) measures of screening receptivity (attitudes, norms, perceived behavioural control and intentions).

RESULTS

Perceived barriers and justice beliefs interacted to predict perceived behavioural control over screening. Perceived barriers were associated with less perceived behavioural control only when personal justice beliefs were low. In turn, perceived behavioural control predicted stronger intentions to obtain CRC screening.

CONCLUSIONS

Interactive effects with perceived barriers highlight that strong personal justice beliefs play an important role in CRC screening and could aid in addressing CRC screening disparities among African Americans.

Factors Associated with Knowledge, Attitudes, and Practice towards Colorectal Cancer and Its Screening among People Aged 50-75 Years

Background: Colorectal cancer (CRC) screening is effective for early detection of CRC, particularly for males aged 50 or above. However, the rate of participation in the screening program is still low. This study was to examine knowledge, attitudes, and practice toward CRC and its screening and explored their associated factors. Methods: A descriptive cross-sectional study was conducted in a convenience sample of adults aged 50–75 years without cognitive problems, who were recruited at multi-elderly centers in Hong Kong. A questionnaire was used to measure knowledge, attitudes, and practice (KAP) towards CRC and its screening. Results: The total of 300 Chinese people included 147 (49.0%) males with a mean age of 58.72 (SD 6.91) years old. This study population had good knowledge and practice, as well as very good attitudes toward CRC and its screening. The multivariate regression results showed that receiving insurance coverage was the most significant factor positively associated with knowledge, attitudes, and practice. Other than this, lower educational level had significant negative association with knowledge and practice. Having self-sufficient financial support and receiving screening program information had positive associations with knowledge. Conclusion: People who are receiving insurance coverage have better KAP towards CRC and its screening. This indicates that they can receive adequate information about the screening procedure from their insurance agents and receive financial support under their insurance coverage. Therefore, they are more willing to participate in the screening program. Other factors, including having good self-sufficient financial support and receiving adequate information about CRC and its screening, significantly enhance knowledge. Based on the relationships among KAP, knowledge enhancement can improve attitude and practice in participating in the CRC screening program. Those who attained lower education should receive more attention. In this sense, adequate financial support from health insurance or subsidies from the government can increase an individual’s willingness to participate in the CRC screening, particularly those at a low socioeconomic level. Educational programs should be promoted to enhance knowledge about CRC and its screening, especially to those who attained lower education levels.

Randomized Controlled Trial of Personalized Colorectal Cancer Risk Assessment vs Education to Promote Screening Uptake

INTRODUCTION

Risk stratification has been proposed as a strategy to improve participation in colorectal cancer (CRC) screening, but evidence is lacking. We performed a randomized controlled trial of risk stratification using the National Cancer Institute's Colorectal Cancer Risk Assessment Tool (CCRAT) on screening intent and completion.

METHODS

A total of 230 primary care patients eligible for first-time CRC screening were randomized to risk assessment via CCRAT or education control. Follow-up of screening intent and completion was performed by record review and phone at 6 and 12 months. We analyzed change in intent after intervention, time to screening, overall screening completion rates, and screening completion by CCRAT risk score tertile.

RESULTS

Of the patients, 61.7% of patients were aged <60 years, 58.7% female, and 94.3% with college or higher education. Time to screening did not differ between arms (hazard ratio 0.78 [95% confidence interval (CI) 0.52-1.18], P = 0.24). At 12 months, screening completion was 38.6% with CCRAT vs 44.0% with education (odds ratio [OR] 0.80 [95% CI 0.47-1.37], P = 0.41). Changes in screening intent did not differ between the risk assessment and education arms (precontemplation to contemplation: OR 1.52 [95% CI 0.81-2.86], P = 0.19; contemplation to precontemplation: OR 1.93 [95% CI 0.45-8.34], P = 0.38). There were higher screening completion rates at 12 months in the top CCRAT risk tertile (52.6%) vs the bottom (32.4%) and middle (31.6%) tertiles (P = 0.10).

DISCUSSION

CCRAT risk assessment did not increase screening participation or intent. Risk stratification might motivate persons classified as higher CRC risk to complete screening, but unintentionally discourage screening among persons not identified as higher risk.

Motives for non-adherence to colonoscopy advice after a positive colorectal cancer screening test result: a qualitative study

SETTING

Participants with a positive faecal immunochemical test (FIT) in screening programs for colorectal cancer (CRC) have a high risk for colorectal cancer and advanced adenomas. They are therefore recommended follow-up by colonoscopy. However, more than ten percent of positively screened persons do not adhere to this advice.

OBJECTIVE

To investigate FIT-positive individuals' motives for non-adherence to colonoscopy advice in the Dutch CRC screening program.

SUBJECTS

Non-adherent FIT-positive participants of the Dutch CRC screening program.

DESIGN

We conducted semi structured in-depth interviews with 17 persons who did not undergo colonoscopy within 6 months after a positive FIT. Interviews were undertaken face-to-face and data were analysed thematically with open coding and constant comparison.

RESULTS

All participants had multifactorial motives for non-adherence. A preference for more personalised care was described with the following themes: aversion against the design of the screening program, expectations of personalised care, emotions associated with experiences of impersonal care and a desire for counselling where options other than colonoscopy could be discussed. Furthermore, intrinsic motives were: having a perception of low risk for CRC (described by all participants), aversion and fear of colonoscopy, distrust, reluctant attitude to the treatment of cancer and cancer fatalism. Extrinsic motives were: having other health issues or priorities, practical barriers, advice from a general practitioner (GP) and financial reasons.

CONCLUSION

Personalised screening counselling might have helped to improve the interviewees' experiences with the screening program as well as their knowledge on CRC and CRC screening. Future studies should explore whether personalised screening counselling also has potential to increase adherence rates. Key points Participants with a positive FIT in two-step colorectal cancer (CRC) screening programs are at high risk for colorectal cancer and advanced adenomas. Non-adherence after an unfavourable screening result happens in all CRC programs worldwide with the consequence that many of the participants do not undergo colonoscopy for the definitive assessment of the presence of colorectal cancer. Little qualitative research has been done to study the reasons why individuals participate in the first step of the screening but not in the second step. We found a preference for more personalised care, which was not reported in previous literature on this subject. Furthermore, intrinsic factors, such as a low risk perception and distrust, and extrinsic factors, such as the presence of other health issues and GP advice, may also play a role in non-adherence. A person-centred approach in the form of a screening counselling session may be beneficial for this group of CRC screening participants.

Trends and Predictors for the Uptake of Colon Cancer Screening Using the Fecal Occult Blood Test in Spain from 2011 to 2017

Background: In Spain, colorectal cancer screening using the fecal occult blood test, targeted towards the 50–69 age bracket, was implemented on different dates. We aim to assess the temporal trend of colorectal cancer (CRC) screening uptake according to the year of screening implementation in each region and to identify predictors for the uptake of CRC screening. Methods: A cross-sectional study with 12,657 participants from the Spanish National Health Surveys 2011 and 2017 was used. Uptake rates were analyzed according to the date that the screening program was implemented. Results: For regions with programs implemented before 2011, the uptake rate increased 3.34-fold from 2011 to 2017 (9.8% vs. 32.7%; p < 0.001). For regions that implemented screening within the 2011–2016 period, the uptake rose from 4.3% to 13.2% (3.07-fold; p < 0.001), and for regions that implemented screening after 2016, the uptake increased from 3.4% to 8.8% (2.59-fold; p < 0.001). For the entire Spanish population, the uptake increased 3.21-fold (6.8% vs. 21.8%; p < 0.001). Positive predictors for uptake were older age, Spanish nationality, middle-to-high educational level, suffering chronic diseases, non-smoking and living in regions where screening programs were implemented earlier. Conclusions: The different periods for the implementation of CRC screening as well as sociodemographic and health inequalities may have limited the improvement in the screening uptake from 2011 to 2017 in Spain.

Perceived life expectancy and colorectal cancer screening intentions and behaviour: A population-based UK study

The relationships between perceived life expectancy (PLE), cancer screening intentions and behaviour are not well understood, despite the importance of remaining life expectancy for the early diagnosis benefits of screening. This study investigates the relationships between PLE and each of: the intention to complete faecal occult blood test (FOBt) screening, ‘ever’ uptake of FOBt screening, and repeat uptake of FOBt screening for colorectal cancer. Data were from the population-representative Attitudes, Behaviour and Cancer UK Survey II (ABACUS II) in England in 2015. Eligible respondents for the present analysis were aged 60–70 years (FOBt eligible age range), who completed the survey question on perceived life expectancy (N = 824). We used logistic regression models to estimate the associations between PLE and the intention to complete screening, ‘ever’ uptake of screening, and repeat uptake of screening, with adjustment for age, gender, occupation-based social grade, marital status, ethnicity, and smoking status. PLE was positively associated with repeated uptake of FOBt (adjusted OR = 2.55; 95% CI: 1.04–6.30 for expecting to live to ≥90 years versus <80 years). Older adults may base decisions to continually participate in cancer screening on their expectations of remaining life expectancy. Future research should investigate the feasibility and acceptability of individualised cancer screening recommendations that take life expectancy into account.

Low participation in organized colorectal cancer screening in France: underlying ethical issues

International studies have shown a significant reduction in colorectal cancer (CRC) mortality following the implementation of organized screening programs, given a sufficient participation rate and adequate follow-up. The French national CRC screening program has been generalized since 2008 and targets 18 million men and women aged 50-74 years. Despite broad recommendations, the participation rate remains low (29.8%), questioning the efficiency of the program. A panel of experts was appointed by the French National Cancer Institute to critically examine the place of autonomy and efficiency in CRC screening and propose recommendations. In this paper, we explore the ethical significance of a public health intervention that falls short of its objectives owing to low take-up by the population targeted. First, we analyze the reasons for the low CRC screening participation. Second, we examine the models that can be proposed for public health actions, reconciling respect for the individual and the collective good. Our expert panel explored possible ways to enhance take-up of CRC screening within the bounds of individual autonomy, adapting awareness campaigns, and new educational approaches that take into account knowledge and analysis of sociocultural hurdles. Although public health actions must be universal, target actions should nonetheless be developed for nonparticipating population subgroups.

Comparison of prognostic models to predict the occurrence of colorectal cancer in asymptomatic individuals: a systematic literature review and external validation in the EPIC and UK Biobank prospective cohort studies

OBJECTIVE

To systematically identify and validate published colorectal cancer risk prediction models that do not require invasive testing in two large population-based prospective cohorts.

DESIGN

Models were identified through an update of a published systematic review and validated in the European Prospective Investigation into Cancer and Nutrition (EPIC) and the UK Biobank. The performance of the models to predict the occurrence of colorectal cancer within 5 or 10 years after study enrolment was assessed by discrimination (C-statistic) and calibration (plots of observed vs predicted probability).

RESULTS

The systematic review and its update identified 16 models from 8 publications (8 colorectal, 5 colon and 3 rectal). The number of participants included in each model validation ranged from 41 587 to 396 515, and the number of cases ranged from 115 to 1781. Eligible and ineligible participants across the models were largely comparable. Calibration of the models, where assessable, was very good and further improved by recalibration. The C-statistics of the models were largely similar between validation cohorts with the highest values achieved being 0.70 (95% CI 0.68 to 0.72) in the UK Biobank and 0.71 (95% CI 0.67 to 0.74) in EPIC.

CONCLUSION

Several of these non-invasive models exhibited good calibration and discrimination within both external validation populations and are therefore potentially suitable candidates for the facilitation of risk stratification in population-based colorectal screening programmes. Future work should both evaluate this potential, through modelling and impact studies, and ascertain if further enhancement in their performance can be obtained.

Communication of cancer screening results by letter, telephone or in person: A mixed methods systematic review of the effect on attendee anxiety, understanding and preferences

Attending and receiving a result from screening can be an anxious process. Using an appropriate method to deliver screening results could improve communication and reduce negative outcomes for screening attendees. Screening programmes are increasingly communicating results by letter or telephone rather than in-person. We investigated the impact of communication methods on attendees. We systematically reviewed the literature on the communication methods used to deliver results in cancer screening programmes for women, focusing on screening attendee anxiety, understanding of results and preferences for results communication. We included qualitative and quantitative research. We searched MEDLINE, PsycINFO, CINAHL, Cochrane Library and Embase. Results were analysed using framework synthesis. 10,558 papers were identified with seven studies meeting the inclusion criteria. Several key ideas emerged from the synthesis including speed, accuracy of results, visual support, ability to ask questions, privacy of results location and managing expectations. Verbal communication methods (telephone and in-person) were preferred and facilitated greater understanding than written methods, although there was considerable variability in attendee preferences. Findings for anxiety were mixed, with no clear consensus on which method of communication might minimise attendee anxiety. The low number of identified studies and generally low quality evidence suggest we do not know the most appropriate communication methods in the delivery of cancer screening results. More research is needed to directly compare methods of results communication, focusing on what impact each method may have on screening attendees.

Cancer worries and uptake of breast, cervical, and colorectal cancer screening: A population-based survey in England

OBJECTIVE

Some degree of general worry about cancer may facilitate screening participation, but specific worries about the potential consequences (e.g. treatment, death) may act as deterrents. No studies have examined these associations in the same sample. We assessed associations between general versus specific cancer worries and cancer screening participation.

METHODS

In 2016, a population-based cross-sectional survey of adults living in England was carried out. This paper reports analyses of a subsample (n = 1694). Measures included (i) frequency of general cancer worry, (ii) specific worries about the emotional and physical consequences of a cancer diagnosis, and (iii) specific worries about the social consequences of a cancer diagnosis. Logistic regression analyses examined their association with self-reported screening uptake among participants eligible for cervical (n = 671), breast (n = 323), and colorectal (n = 368) cancer screening.

RESULTS

Frequency of general cancer worry was not associated with screening participation. Specific worry about the emotional and physical consequences increased the odds of participants reporting regular uptake of colorectal screening (OR 1.41, 95% CI 1.04-1.90). Specific worry about the social consequences of diagnosis was negatively associated with regular attendance for cervical and breast screening in unadjusted analyses only. In adjusted models, the associations were no longer statistically significant for cervical (OR 0.82, 95% CI 0.65-1.03) or breast (OR 0.69, 95% CI 0.45-1.04) screening.

CONCLUSIONS

Specific worries about cancer may be differentially associated with participation across screening programmes. Further research is needed, as interventions to optimise informed participation may be improved if the specific worries associated with low participation in each programme are understood.

Attitudes towards lung cancer screening in a population sample

Background

Lung cancer is the leading cause of cancer death worldwide. Routine UK lung cancer screening is not yet available, thus understanding barriers to participation in lung screening could help maximize effectiveness if introduced.

Methods

Population‐based survey of 1007 adults aged 16 and over in Wales using random quota sampling. Computer‐assisted face‐to‐face interviews included demographic variables (age, gender, smoking, social group), four lung cancer belief statements and three lung screening attitudinal items. Determinants of lung screening attitudes were examined using multivariable regression adjusted for age, gender, social group and previous exposure to lung campaign messages.

Results

Avoidance of lung screening due to fear of what might be found was statistically significantly associated with negative lung cancer beliefs including fatalism (aOR = 8.8, 95% CI = 5.6‐13.9, P ≤ 0.001), low perceived value of symptomatic presentation (aOR = 2.4, 95% CI = 1.5‐3.9, P ≤ 0.001) and low treatment efficacy (aOR = 0.3, CI = 0.2‐0.7, P ≤ 0.01).

Low perceived effectiveness of lung screening was significantly associated with fatalism (aOR = 6.4, 95% CI = 3.5‐11.7, P ≤ 0.001), low perceived value of symptom presentation (aOR = 4.9, 95% CI = 2.7‐8.9, P ≤ 0.001) and low treatment efficacy (aOR = 0.1, 95% CI = 0.1‐0.3, P ≤ 0.001). In contrast, respondents who thought lung screening could reduce cancer deaths had positive beliefs about lung cancer (aOR = 0.4, 95% CI = 0.2‐0.7, P ≤ 0.001) and its treatment (aOR = 6.1, 95% CI = 3.0‐12.6, P ≤ 0.001).

Conclusion

People with negative beliefs about lung cancer may be more likely to avoid lung screening. Alongside the introduction of effective early detection strategies, interventions are needed to modify public perceptions of lung cancer, particularly for fatalism.

Understanding Cancer Worry Among Patients in a Community Clinic-Based Colorectal Cancer Screening Intervention Study

BACKGROUND

To reduce colorectal cancer (CRC) screening disparities, it is important to understand correlates of different types of cancer worry among ethnically diverse individuals.

OBJECTIVES

The current study examined the prevalence of three types of cancer worry (i.e., general cancer worry, CRC-specific worry, and worry about CRC test results) as well as sociodemographic and health-related predictors for each type of cancer worry.

METHODS

Participants were aged 50-75, at average CRC risk, nonadherent to CRC screening guidelines, and enrolled in a randomized controlled trial to increase CRC screening. Participants completed a baseline questionnaire assessing sociodemographics, health beliefs, healthcare experiences, and three cancer worry measures. Associations between study variables were examined with separate univariate and multivariable logistic regression models.

RESULTS

Responses from a total of 416 participants were used. Of these, 47% reported experiencing moderate-to-high levels of general cancer worry. Predictors of general cancer worry were salience and coherence (aOR = 1.1, 95% CI [1.0, 1.3]), perceived susceptibility (aOR = 1.2, 95% CI [1.1, 1.3), and social influence (aOR = 1.1, 95% CI [1.0, 0.1]). Fewer (23%) reported moderate-to-high levels of CRC-specific worry or CRC test worry (35%). Predictors of CRC worry were perceived susceptibility (aOR = 1.4, 95% CI [1.3, 1.6]) and social influence (aOR = 1.1, 95% CI [1.0, 1.2]); predictors of CRC test result worry were perceived susceptibility (aOR = 1.2, 95% CI [1.1, 1.3) and marital status (aOR = 2.0, 95% CI [1.1, 3.7] for married/partnered vs. single and aOR = 2.3, 95% CI [1.3, 4.1] for divorced/widowed vs. single).

DISCUSSION

Perceived susceptibility consistently predicted the three types of cancer worry, whereas other predictors varied between cancer worry types and in magnitude of association. The three types of cancer worry were generally predicted by health beliefs, suggesting potential malleability. Future research should include multiple measures of cancer worry and clear definitions of how cancer worry is measured.

Differences in Dementia Beliefs between Non-Demented Public Screeners and In-Home Screeners and Their Potential Impact on Future Dementia Screening Intention: The Nakajima Study

In many cohort studies of dementia, while differences in sociodemographic characters between responders and non-responders of dementia screening have been reported, differences in dementia beliefs have been relatively less known. The aims of this study were to clarify dementia beliefs and to explore potential impacts on an intention to attend a future dementia screening in public screeners and in-home screeners, respectively. We performed a cross-sectional population-based study using a question about an intention to attend a future dementia screening and a questionnaire on dementia beliefs. Subjects were all residents aged 65 years or older in the north area of Nakajima, Japan (n = 385). All subjects were asked to attend a public dementia screening first. An in-home dementia screening was subsequently conducted in subjects with non-responders to a public screening. The questionnaire consisted of four dementia beliefs: "perceived susceptibility," "perceived severity," "perceived barriers," and "perceived benefits." Public screeners significantly expressed an intention to attend a future dementia screening more than in-home screeners (p = 0.002). In in-home screeners, low "perceived severity" were significantly associated with an intention to attend a future dementia screening [adjusted OR (95% CI) = 0.51 (0.32-0.80)]. In both public and in-home screeners, high "perceived benefits" were significantly associated with an intention to attend a future dementia screening [adjusted OR (95% CI) = 2.13 (1.46-3.10); adjusted OR (95% CI) = 2.56 (1.22-5.35), respectively]. It is necessary to reduce "perceived severity" among in-home screeners to increase dementia screening participants.

Cancer Mortality, Early Detection and Treatment among Adult New Zealanders: Changes in Perceptions between 2001 and 2014/5

Background:

Beliefs about cancer risk and experience of early detection and treatment can impact on willingness to engage with these initiatives. This study describes changes in perceptions of cancer mortality, early detection and treatment among adult New Zealanders (NZ) between two cross-sectional studies conducted in 2001 and 2014/5.

Methods:

Data was collected via telephone interviews conducted by trained interviewers in 2001 (231 females and 207 males, 64% response rate) and 2014/5 (588 females and 476 males, 64% response rate). Participants were asked to identify the most common three causes of cancer mortality among women and then men. They were also asked to note their agreement or otherwise with statements about early detection and treatment of cancer.

Results:

There was an increase in proportions of men who correctly identified prostate cancer as one of the top three causes of cancer mortality among men, and also an increase among women who correctly identified bowel cancer as one of the top three. Most participants agreed that there were benefits from early detection for cancer outcomes. Over time, there was a significant decline in proportions which felt that most cancer treatment is “so terrible it is worse than death” and that alternative therapy has an “equal or better chance of curing cancer.”

Conclusion:

Internationally, there is little information available about changes in cancer perceptions over time, these findings suggest some changes in perceptions of treatment and awareness of types of cancer with the highest mortality in NZ, which should support timely engagement with early detection and treatment services.

The role of self-efficacy, self-esteem and optimism for using routine health check-ups in a population-based sample. A longitudinal perspective

While several cross-sectional studies have shown that self-efficacy, self-esteem and optimism are associated with the use of routine health check-ups, little is known about this relationship based on longitudinal studies. Consequently, the purpose of this study was to examine whether these factors are associated with routine health check-ups longitudinally. Data were retrieved from a population-based longitudinal study of individuals (≥40years of age) residing in private households in Germany (two waves: 2008 and 2011). Widely established scales were used to quantify self-efficacy, self-esteem, and optimism. Respondents reported whether they used a health check-up in the last two years. Conditional fixed-effects logistic regressions were used (n=1504), adjusting for socio-demographic, lifestyle and health-related variables. After adjusting for various potential confounders, regression analysis revealed that the use of routine health check-ups increased with self-efficacy [OR: 1.71 (95%-CI: 1.14-2.55)], self-esteem [OR: 1.78 (1.16-2.73)], and optimism [OR: 1.37 (1.01-1.86)]. Furthermore, the use of routine health check-ups increased with changes from employment to retirement [OR: 2.60 (1.34-5.03)], whereas it was not associated with changes in age, marital status, smoking status, the number of physical illnesses, self-rated health and body-mass index. The current study stresses the importance of an association between screening behavior and self-efficacy, self-esteem and optimism longitudinally. Interventions aiming at modifying these psychological factors might help to increase the use of routine health check-ups.

Colorectal Cancer Screening: What Is the Population's Opinion

Background

Colorectal cancer (CRC) is the first cause of death by cancer in Portugal and mortality has been increasing in the last 30 years.

Materials and Methods

During a raising awareness campaign performed by our Gastroenterology Department, in Setúbal, Portugal, an anonymous written questionnaire was developed and presented in order to evaluate the population's knowledge and attitude regarding CRC screening.

Results

The following results were reported: 140 persons; mean age 54.6 years; 61.4% women; 22.1% had a family history of colorectal cancer. The main risk factors mentioned by the respondents were family history of CRC, previous history of intestinal polyps, and intestinal infection. Screening was considered useful by all respondents. About 60% of the respondents had been counselled, at least, on one screening technique, mainly by their general practitioner: colonoscopy in 31, fecal occult blood test in 44, and flexible sigmoidoscopy in 9. Most of the respondents had had the appropriate screening test, according to their age and family history. Fourteen of the respondents had not undergone the recommended screening. Their answers showed that this was due to fear of pain/discovering a disease as well as embarrassment.

Conclusion

Although the majority of the respondents were aware of the importance of CRC screening, results show that there are still several misconceptions about risk factors, fear, and reluctance concerning the screening techniques. Awareness actions are useful to clarify possible questions and inform the population in order to increase compliance with screening.

The role of general psychosocial factors for the use of cancer screening-Findings of a population-based observational study among older adults in Germany

Within the framework of the health‐belief model, some studies exist investigating the association between illness‐specific psychosocial factors and the use of cancer screenings. However, studies investigating the association between general psychosocial factors and the use of cancer screenings are missing. Thus, this study aimed at examining the association between well‐established general psychosocial factors and the use of cancer screenings. Data were gathered from a large, population‐based sample of community‐dwelling individuals aged 40 and above in Germany (n = 7673; in 2014). Loneliness, cognitive well‐being, affective well‐being (negative and positive affect), optimism, self‐efficacy, self‐esteem, self‐regulation, perceived autonomy, perceived stress, and perceived social exclusion were used as general psychosocial factors. Furthermore, individuals were asked whether they regularly underwent early cancer screening in the past years (yes; no). A total of 65.6% of the individuals used cancer screening. Adjusting for sociodemographic factors, self‐rated health, morbidity and lifestyle factors, multiple logistic regressions revealed that the use of cancer screening is positively associated with decreased loneliness, cognitive well‐being, optimism, self‐efficacy, self‐esteem, self‐regulation, perceived autonomy, decreased perceived stress, decreased perceived social exclusion, and positive affect, while it is not associated with negative affect. This study stresses the strong association between general psychosocial factors and the use of cancer screening. This knowledge might be fruitful to address individuals at risk for underuse.

Does psychosocial stress exacerbate avoidant responses to cancer information in those who are afraid of cancer? A population-based survey among older adults in England

OBJECTIVE

Communication of cancer information is an important element of cancer control, but cancer fear may lead to information avoidance, especially when coping is low. We examined the association between cancer fear and cancer information avoidance, and tested whether this was exacerbated by psychosocial stress.

DESIGN

Cross-sectional survey of 1258 population-based adults (58-70 years) in England.

MAIN OUTCOME MEASURES

Cancer fear (intensity and frequency), perceived psychosocial stress and cancer information avoidance. Control variables were age, gender, ethnicity, marital status and education.

RESULTS

A quarter (24%) of respondents avoided cancer information. Ordinal logistic regression analyses showed main effects of psychosocial stress (OR = 1.17, 95% CI 1.07-1.29) and cancer fear: cancer information avoidance was lowest in those with no cancer fear (13%), followed by those with moderate (24%; OR = 2.15, 95% CI: 1.49-3.12), and high cancer fear (35%; OR = 3.90, 95% CI: 2.65-5.73). In the adjusted model, the interaction between cancer fear and stress was significant (OR = 1.14, 95% CI 1.004-1.29, p < .05): 40% of those with high fear/high stress avoided cancer information compared with 29% with high fear/low stress.

CONCLUSION

Cancer fear and psychosocial stress interact to produce disengagement with cancer-related information, highlighting the importance of affective processes to cancer control efforts.

Pilot study on use of home telephoning to identify and recruit high-risk individuals for lung cancer screening

Widespread lung cancer screening with low-dose computed tomography is urgently needed in Europe to identify lung cancers early and reduce lung cancer deaths. The most effective method of identifying high-risk individuals and recruiting them for screening has not been determined. In the present pilot study we investigated direct telephoning to families as a way of identifying high risk individuals and recruiting them to a screening/smoking cessation program, that avoided the selection bias of voluntary screening. Families in the province of Milan, Italy, were contacted by telephone at their homes and asked about family members over 50 years who were heavy smokers (30 or more pack-years). Persons meeting these criteria were contacted and asked to participate in the program. Those who agreed were given an appointment to undergo screening and receive smoking cessation counseling. Among the 1000 contacted families, involving 2300 persons, 44 (1.9%) were eligible for LDCT screening, and 12 (27%) of these participated in the program. The cost of this recruitment strategy pilot study was around 150 euro per screened subject. We obtained useful information on the proportion of the general population eligible for lung cancer screening and the proportion of those who responded. However the cost of home telephone calling is probably too high to be practicable as a method of recruiting high risk persons for screening. Alternative recruitment methods, possibly involving family physicians practitioners, need to be investigated.

Exploring the Potential of Anticipated Regret as an Emotional Cue to Improve Bowel Cancer Screening Uptake

Objective. Bowel cancer is currently the second leading cause of cancer-related death in Australia and screening participation is suboptimal. This study examined the role of emotion in the form of anticipated regret (AR) and its relationship to screening intentions. Methods. N = 173 persons aged 45 to 80 years completed a survey measuring demographic variables, readiness to screen, relative importance of health by comparison to other life priorities, satisfaction with current health, and AR if not participating in future bowel cancer screening. Results. AR was a significant predictor of future screening intentions. Those with higher levels of AR were seven times more likely (OR = 7.18) to intend to screen in the future compared to those with lower AR. This relationship was not compromised when controlling for other variables including gender and satisfaction with one's health. AR levels were significantly lower in people who had been screened previously and in those with full health insurance. Conclusions. These results demonstrate that AR is uniquely related to future bowel cancer screening intentions. Future studies should continue to consider this as a useful target for behavioural interventions and identify new ways of delivering these interventions to improve their reach.

Concerns, perceived need and competing priorities: a qualitative exploration of decision-making and non-participation in a population-based flexible sigmoidoscopy screening programme to prevent colorectal cancer

OBJECTIVE

Optimising uptake of colorectal cancer (CRC) screening is important to achieve projected health outcomes. Population-based screening by flexible sigmoidoscopy (FS) was introduced in England in 2013 (NHS Bowel scope screening). Little is known about reactions to the invitation to participate in FS screening, as offered within the context of the Bowel scope programme. We aimed to investigate responses to the screening invitation to inform understanding of decision-making, particularly in relation to non-participation in screening.

DESIGN

Qualitative analysis of semistructured in-depth interviews and written accounts.

PARTICIPANTS AND SETTING

People from 31 general practices in the North East and East of England invited to attend FS screening as part of NHS Bowel scope screening programme were sent invitations to take part in the study. We purposively sampled interviewees to ensure a range of accounts in terms of beliefs, screening attendance, sex and geographical location.

RESULTS

20 screeners and 25 non-screeners were interviewed. Written responses describing reasons for, and circumstances surrounding, non-participation from a further 28 non-screeners were included in the analysis. Thematic analysis identified a range of reactions to the screening invitation, decision-making processes and barriers to participation. These include a perceived or actual lack of need; inability to attend; anxiety and fear about bowel preparation, procedures or hospital; inability or reluctance to self-administer an enema; beliefs about low susceptibility to bowel cancer or treatment and understanding of harm and benefits. The strength, rather than presence, of concerns about the test and perceived need for reassurance were important in the decision to participate for screeners and non-screeners. Decision-making occurs within the context of previous experiences and day-to-day life.

CONCLUSIONS

Understanding the reasons for non-participation in FS screening can help inform strategies to improve uptake and may be transferable to other screening programmes.

What do people fear about cancer? A systematic review and meta-synthesis of cancer fears in the general population

Background

Cancer has long inspired fear, but the effect of fear is not well understood; it seems both to facilitate and to deter early diagnosis behaviours. To elucidate fear's behavioural effects, we systematically reviewed and synthesised qualitative literature to explore what people fear about cancer.

Methods

We searched Medline, Embase, PsycInfo, Web of Science, AnthroSource, and Anthrobase for studies on cancer fear in breast, cervical, and colorectal cancer screening and analysed 102 studies from 26 countries using thematic synthesis.

Results

Fears of cancer emanated from a core view of cancer as a vicious, unpredictable, and indestructible enemy, evoking fears about its proximity, the (lack of) strategies to keep it at bay, the personal and social implications of succumbing, and fear of dying from cancer.

Conclusions

This view of cancer as ‘an enemy’ reprises the media's ‘war on cancer’ theme and may affect the acceptance of cancer early detection and prevention messages, since cancer's characteristics influenced whether ‘fight’ or ‘flight’ was considered appropriate.

Using Specialist Screening Practitioners (SSPs) to increase uptake of the Bowel Scope (Flexible Sigmoidoscopy) Screening Programme: a study protocol for a feasibility single-stage phase II trial

Background

The NHS Bowel Scope Screening (BSS) programme offers men and women aged 55 years a once-only flexible sigmoidoscopy (FS), a test that can help reduce colorectal cancer (CRC) incidence and mortality. However, the benefits of BSS are contingent on uptake. This National Institute for Health Research-funded single-stage phase II trial will test the feasibility of using patient navigation (PN), an intervention that offers support to patients to overcome barriers to healthcare, to increase BSS uptake within a socially deprived area of England.

Methods/design

All individuals invited for BSS at South Tyneside NHS Foundation Trust during the 6-month recruitment period will be invited to take part in the study. Consenting participants will be randomised to receive PN or usual care in a 2:1 ratio. PN involves non-attenders receiving a phone call from a Specialist Screening Practitioner (SSP) who will elicit reasons for non-attendance and offer educational, practical, and emotional support as needed. If requested by the patient, another appointment for BSS will then be arranged. We anticipate 30 % of participants will be non-attenders. Using A’Hern single-stage design, with 20 % significance level and 80 % power, at least 35 participants who receive PN need to subsequently attend for PN to be considered worthy of further investigation in a definitive trial. The primary outcome measure will be the number of participants in the PN group who re-book and attend their BSS appointment. A qualitative analysis of the PN transcripts, and interviews with the SSPs, will also be conducted, alongside a quantitative analysis of completed patient-reported experience questionnaires. An economic analysis will calculate the costs of delivering PN.

Discussion

This feasibility study will be instrumental in deciding whether to conduct the first definitive trial of PN in BSS in England. If PN is subsequently shown to be cost-effective at increasing uptake of BSS, NHS policies could be modified to implement PN as a standard service. The results will be disseminated in peer-reviewed journals and at scientific conferences.

Trial registration

International Standard Randomised Controlled Trial Number, ISRCTN13314752

Electronic supplementary material

The online version of this article (doi:10.1186/s40814-016-0093-8) contains supplementary material, which is available to authorized users.

Rural-Urban Differences in Colorectal Cancer Screening Barriers in Nebraska

Nebraska ranks 36th nationally in colorectal cancer screening. Despite recent increases in CRC screening rates, rural areas in Nebraska have consistently shown lower rates of CRC screening uptake, compared to urban areas. The objective of this study was to investigate reasons for lower CRC screening rates among Nebraska residents, especially among rural residents. We developed a questionnaire based on Health Belief Model (HBM) constructs to identify factors associated with the use of CRC screening. The questionnaire was mailed in 2014 to adults aged 50-75 years in an urban community in the east and a rural community in the west regions of the state. Multiple logistic regression models were created to assess the effects of HBM constructs, rural residence, and demographic factors on CRC screening use. Of the 1200 surveys mailed, 393 were returned (rural n = 200, urban n = 193). Rural respondents were more likely to perceive screening cost as a barrier. Rural residents were also more likely to report that CRC cannot be prevented and it would change their whole life. In multiple regression models, rural residence, perceived embarrassment, and perceived unpleasantness about screening were significantly associated with reduced odds of receiving colonoscopy. Older age (62 years and older), having a personal doctor, and perceived risk of getting CRC were significantly associated with increased odds of receiving colonoscopy. Interventions to increase uptake of colorectal cancer screening in rural residents should be tailored to acknowledge unique perceptions of screening methods and barriers to screening.

The UK Lung Cancer Screening Trial: a pilot randomised controlled trial of low-dose computed tomography screening for the early detection of lung cancer

BACKGROUND

Lung cancer kills more people than any other cancer in the UK (5-year survival < 13%). Early diagnosis can save lives. The USA-based National Lung Cancer Screening Trial reported a 20% relative reduction in lung cancer mortality and 6.7% all-cause mortality in low-dose computed tomography (LDCT)-screened subjects.

OBJECTIVES

To (1) analyse LDCT lung cancer screening in a high-risk UK population, determine optimum recruitment, screening, reading and care pathway strategies; and (2) assess the psychological consequences and the health-economic implications of screening.

DESIGN

A pilot randomised controlled trial comparing intervention with usual care. A population-based risk questionnaire identified individuals who were at high risk of developing lung cancer (≥ 5% over 5 years).

SETTING

Thoracic centres with expertise in lung cancer imaging, respiratory medicine, pathology and surgery: Liverpool Heart & Chest Hospital, Merseyside, and Papworth Hospital, Cambridgeshire.

PARTICIPANTS

Individuals aged 50-75 years, at high risk of lung cancer, in the primary care trusts adjacent to the centres.

INTERVENTIONS

A thoracic LDCT scan. Follow-up computed tomography (CT) scans as per protocol. Referral to multidisciplinary team clinics was determined by nodule size criteria.

MAIN OUTCOME MEASURES

Population-based recruitment based on risk stratification; management of the trial through web-based database; optimal characteristics of CT scan readers (radiologists vs. radiographers); characterisation of CT-detected nodules utilising volumetric analysis; prevalence of lung cancer at baseline; sociodemographic factors affecting participation; psychosocial measures (cancer distress, anxiety, depression, decision satisfaction); and cost-effectiveness modelling.

RESULTS

A total of 247,354 individuals were approached to take part in the trial; 30.7% responded positively to the screening invitation. Recruitment of participants resulted in 2028 in the CT arm and 2027 in the control arm. A total of 1994 participants underwent CT scanning: 42 participants (2.1%) were diagnosed with lung cancer; 36 out of 42 (85.7%) of the screen-detected cancers were identified as stage 1 or 2, and 35 (83.3%) underwent surgical resection as their primary treatment. Lung cancer was more common in the lowest socioeconomic group. Short-term adverse psychosocial consequences were observed in participants who were randomised to the intervention arm and in those who had a major lung abnormality detected, but these differences were modest and temporary. Rollout of screening as a service or design of a full trial would need to address issues of outreach. The health-economic analysis suggests that the intervention could be cost-effective but this needs to be confirmed using data on actual lung cancer mortality.

CONCLUSIONS

The UK Lung Cancer Screening (UKLS) pilot was successfully undertaken with 4055 randomised individuals. The data from the UKLS provide evidence that adds to existing data to suggest that lung cancer screening in the UK could potentially be implemented in the 60-75 years age group, selected via the Liverpool Lung Project risk model version 2 and using CT volumetry-based management protocols.

FUTURE WORK

The UKLS data will be pooled with the NELSON (Nederlands Leuvens Longkanker Screenings Onderzoek: Dutch-Belgian Randomised Lung Cancer Screening Trial) and other European Union trials in 2017 which will provide European mortality and cost-effectiveness data. For now, there is a clear need for mortality results from other trials and further research to identify optimal methods of implementation and delivery. Strategies for increasing uptake and providing support for underserved groups will be key to implementation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN78513845.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 40. See the NIHR Journals Library website for further project information.

Barriers to uptake among high-risk individuals declining participation in lung cancer screening: a mixed methods analysis of the UK Lung Cancer Screening (UKLS) trial

OBJECTIVE

The current study aimed to identify the barriers to participation among high-risk individuals in the UK Lung Cancer Screening (UKLS) pilot trial.

SETTING

The UKLS pilot trial is a randomised controlled trial of low-dose CT (LDCT) screening that has recruited high-risk people using a population approach in the Cambridge and Liverpool areas.

PARTICIPANTS

High-risk individuals aged 50-75 years were invited to participate in UKLS. Individuals were excluded if a LDCT scan was performed within the last year, if they were unable to provide consent, or if LDCT screening was unable to be carried out due to coexisting comorbidities.

OUTCOME MEASURES

Statistical associations between individual characteristics and UKLS uptake were examined using multivariable regression modelling. In those who completed a non-participation questionnaire (NPQ), thematic analysis of free-text data was undertaken to identify reasons for not taking part, with subsequent exploratory linkage of key themes to risk factors for non-uptake.

RESULTS

Comparative data were available from 4061 high-risk individuals who consented to participate in the trial and 2756 who declined participation. Of those declining participation, 748 (27.1%) completed a NPQ. Factors associated with non-uptake included: female gender (OR=0.64, p<0.001), older age (OR=0.73, p<0.001), current smoking (OR=0.70, p<0.001), lower socioeconomic group (OR=0.56, p<0.001) and higher affective risk perception (OR=0.52, p<0.001). Among non-participants who provided a reason, two main themes emerged reflecting practical and emotional barriers. Smokers were more likely to report emotional barriers to participation.

CONCLUSIONS

A profile of risk factors for non-participation in lung screening has emerged, with underlying reasons largely relating to practical and emotional barriers. Strategies for engaging high-risk, hard-to-reach groups are critical for the equitable uptake of a potential future lung cancer screening programme.

TRIAL REGISTRATION NUMBER

The UKLS trial was registered with the International Standard Randomised Controlled Trial Register under the reference 78513845.

Factors affecting the uptake of vaccination by the elderly in Western society

OBJECTIVE

To present the results of a literature review on factors related to vaccine uptake by elderly persons.

METHODS

A systematic literature search was performed using Medline, Embase, and SciSearch to collect all publications available on factors related to vaccine uptake from 1966 until October 2012 for West European and North American societies. In total, 1001 articles were identified and 60 were included in the review.

RESULTS

We identified six main themes that influence the willingness to be vaccinated: 1) attitudes and beliefs regarding vaccination in general including positive and negative attitudes and beliefs; 2) perceived risk and severity including knowledge, perceived susceptibility and severity and personal experience; 3) vaccine characteristics including side-effects, effectiveness, content of the vaccine and knowledge; 4) advice and information including influence of the healthcare worker and relatives and the information source and format; 5) general health-related behavior including previous vaccinations, visiting GP or senior center and other preventive behaviors; and 6) accessibility and affordability including logistics, combinations of vaccines and costs.

CONCLUSION

The most important factors related to vaccine uptake are people's attitudes and beliefs regarding vaccination (especially their negative attitudes), recommendations of healthcare workers, side effects and effectiveness of the vaccine, and perceived susceptibility.

Self-reported participation and beliefs about bowel cancer screening in New South Wales, Australia

ISSUE ADDRESSED

To describe self-reported bowel cancer screening participation, beliefs and attitudes in a sample of New South Wales (NSW) adults, and to identify beliefs and demographic factors associated with self-reported bowel cancer screening participation.

METHODS

This study used data from the International Cancer Benchmarking Partnership Module 2, a representative population-based telephone survey. Self-reported participation in and beliefs about bowel cancer screening were measured using the Awareness and Beliefs about Cancer survey of people aged 50 years and over living in NSW, Australia (n=2001). Logistic regression modelling was used to identify explanatory variables associated with bowel cancer screening participation.

RESULTS

Half of all women (54.1%, 95% CI: 50.8-57.4%) and two-thirds of men (65.7%, 95% CI: 61.5-69.9%) reported screening for bowel cancer within the previous 5 years. Believing that screening was only necessary when experiencing symptoms was more likely to be endorsed by people aged 65 years and over (25.5%, 95% CI: 22.2-28.7%) rather than younger (50-64 years; 16.7%, 95% CI: 13.8-19.7%), non-English-speaking migrants (35.4%, 95% CI: 26.7-44.1%) versus others (18.6%, 95% CI: 16.4-20.7%), and people in metropolitan (23.3%, 95% CI: 20.4-26.1%) versus non-metropolitan areas (16.4%, 95% CI: 12.8-20%). People who disagreed that screening was only necessary when experiencing symptoms were four times more likely to report screening participation (OR 3.96, 95% CI: 3.11-5.03).

CONCLUSIONS

Community education about bowel cancer screening is needed to correct misperceptions regarding screening in the absence of symptoms. Tailored strategies for older, migrant and urban communities may be beneficial. SO WHAT? Education strategies that promote the need for screening in the absence of symptoms and correct misconceptions about bowel cancer screening amongst subgroups of the NSW population may improve screening rates and decrease the burden of bowel cancer in NSW.

The structure and demographic correlates of cancer fear

Background

Cancer is often described as the ‘number one’ health fear, but little is known about whether this affects quality of life by translating into high levels of worry or distress in everyday life, or which population groups are most affected. This study examined the prevalence of three components of cancer fear in a large community sample in the UK and explored associations with demographic characteristics.

Methods

Questions on cancer fear were included in a survey mailed to a community sample of adults (n = 13,351; 55–64 years). Three items from a standard measure of cancer fear assessed: i) whether cancer was feared more than other diseases, ii) whether thinking about cancer caused discomfort, and iii) whether cancer worry was experienced frequently. Gender, marital status, education, and ethnicity were assessed with simple questions. Anxiety was assessed with the brief STAI and a standard measure of self-rated health was included.

Results

Questionnaire return rate was 60% (7,971/13,351). The majority of respondents agreed or strongly agreed that they feared cancer more than other diseases (59%), and felt uncomfortable thinking about it (52%), and a quarter (25%) worried a lot about cancer. All items were significantly inter-correlated (r = .35 to .42, p’s < .001), and correlated with general anxiety (r = .16 to .28, p’s < .001) and self-rated health (r = -.07 to -.16, p’s < .001). In multivariable analyses including anxiety and general health, all cancer fear indicators were significantly higher in women (ORs between 1.15 and 1.48), respondents with lower education (ORs between 1.40 and 1.66), and those with higher general anxiety (ORs between 1.50 and 2.11). Ethnic minority respondents (n = 285; 4.4%) reported more worry (OR: 1.85).

Conclusions

More than half of this older adult sample in the UK had cancer as greatest health fear and this was associated with feeling uncomfortable thinking about it and worrying more about it. Women and respondents with less education or from ethnic minority backgrounds were disproportionately affected by cancer fear. General anxiety and poor health were associated with cancer fear but did not explain the demographic differences.

No association between colorectal cancer worry and screening uptake in Appalachian Ohio

BACKGROUND

Limited data are available on the association between colorectal cancer (CRC) worry and CRC screening uptake, particularly in rural and underserved populations where there is an excess burden of CRC.

METHODS

Between September 2009 and March 2010, we conducted a cross-sectional study among a randomly selected sample of Appalachian Ohio residents aged 51-75 years (n= 1084). We also reviewed their medical records. Multivariable-adjusted models examined the association between CRC worry and screening by medical record review, assessed effect modification by CRC worry and determined the correlates of higher CRC worry.

RESULTS

Approximately 50% of participants were adherent to CRC screening guidelines. There was no significant association between higher CRC worry and screening adherence [odds ratio (OR) = 1.32, 95% confidence interval (CI): 0.86-2.02]. CRC worry did not modify the association between any covariate and screening adherence. Participants who were unemployed/disabled (OR = 2.15, 95% CI: 1.34-3.45) and had higher CRC risk perception (OR = 3.49, 95% CI: 2.19-5.56) had higher odds of moderate-to-extreme worry.

CONCLUSIONS

These findings highlight the need for meaningful exploration of why higher CRC worry is not associated with adherence to CRC screening, particularly in rural, medically underserved populations. Development and implementation of interventions to increase CRC screening in such areas is a significant public health priority.

Colorectal cancer prevention in Europe: burden of disease and status of screening programs

Colorectal cancer is a major public health challenge worldwide. In Europe it is the first malignancy in terms of incidence and the second in terms of mortality in both genders. Despite evidence indicating that removal of premalignant and early-stage cancer lesion scan greatly reduce mortality, remarkable differences are still found among countries both in terms of organized screening programs and of the tests used. In 2003 the European Council recommended that priority be given to activation of organized cancer screening programs, and various states have been making significant efforts to adopt effective prevention programs with international quality standards and centralizing screening organization and result evaluation. After a 2008 European Union report on the state of screening program, activation highlighted that little more than 50% (12/22) of Member States had colorectal cancer screening programs, Screening programs have been adopted or earlier pilot projects have been extended nationwide. This paper examines the state of activation and the screening strategies of colorectal cancer screening programs in EU States as of July 2013.

Public stated preferences and predicted uptake for genome-based colorectal cancer screening

Background

Emerging developments in nanomedicine allow the development of genome-based technologies for non-invasive and individualised screening for diseases such as colorectal cancer. The main objective of this study was to measure user preferences for colorectal cancer screening using a nanopill.

Methods

A discrete choice experiment was used to estimate the preferences for five competing diagnostic techniques including the nanopill and iFOBT. Alternative screening scenarios were described using five attributes namely: preparation involved, sensitivity, specificity, complication rate and testing frequency. Fourteen random and two fixed choice tasks, each consisting of three alternatives, were offered to 2225 individuals. Data were analysed using the McFadden conditional logit model.

Results

Thirteen hundred and fifty-six respondents completed the questionnaire. The most important attributes (and preferred levels) were the screening technique (nanopill), sensitivity (100%) and preparation (no preparation). Stated screening uptake for the nanopill was 79%, compared to 76% for iFOBT. In the case of screening with the nanopill, the percentage of people preferring not to be screened would be reduced from 19.2% (iFOBT) to 16.7%.

Conclusions

Although the expected benefits of nanotechnology based colorectal cancer screening are improved screening uptake, assuming more accurate test results and less preparation involved, the relative preference of the nanopill is only slightly higher than the iFOBT. Estimating user preferences during the development of diagnostic technologies could be used to identify relative performance, including perceived benefits and harms compared to competitors allowing for significant changes to be made throughout the process of development.

Public awareness of colorectal cancer screening: knowledge, attitudes, and interventions for increasing screening uptake

Colorectal cancer ranks as one of the most incidental and death malignancies worldwide. Colorectal cancer screening has proven its benefit in terms of incidence and mortality reduction in randomized controlled trials. In fact, it has been recommended by medical organizations either in average-risk or family-risk populations. Success of a screening campaign highly depends on how compliant the target population is. Several factors influence colorectal cancer screening uptake including sociodemographics, provider and healthcare system factors, and psychosocial factors. Awareness of the target population of colorectal cancer and screening is crucial in order to increase screening participation rates. Knowledge about this disease and its prevention has been used across studies as a measurement of public awareness. Some studies found a positive relationship between knowledge about colorectal cancer, risk perception, and attitudes (perceived benefits and barriers against screening) and willingness to participate in a colorectal cancer screening campaign. The mentioned factors are modifiable and therefore susceptible of intervention. In fact, interventional studies focused on average-risk population have tried to increase colorectal cancer screening uptake by improving public knowledge and modifying attitudes. In the present paper, we reviewed the factors impacting adherence to colorectal cancer screening and interventions targeting participants for increasing screening uptake.

Do high risk patients alter their lifestyle to reduce risk of colorectal cancer?

BACKGROUND

Colorectal cancer (CRC) may be reduced by healthy lifestyle behaviours. We determined the extent of self-reported lifestyle changes in people at increased risk of CRC, and the association of these reports with anxiety, risk and knowledge-based variables.

METHODS

We randomly selected 250 participants who had undergone surveillance colonoscopy for family history of CRC. A telephone interview was conducted, recording demographics and family history. Self-reported lifestyle change due to thoughts about CRC across a range of dietary and lifestyle variables was assessed on a four-point scale. Participants' perceptions of the following were recorded: risk factor knowledge, personal risk, and worry due to family history. General anxiety was assessed using the GAD-7 scale. Ordinal logistic regression was used to calculate adjusted results.

RESULTS

There were 148 participants (69% response). 79.7% reported at least one healthy change. Change in diet and physical activity were most frequently reported (fiber, 63%; fruit and vegetables, 54%; red meat, 47%; physical activity, 45%), with consumption of tobacco, alcohol, and body weight less likely (tobacco, 25%; alcohol, 26%; weight 31%). People were more likely to report healthy change with lower levels of generalized anxiety, higher worry due to family history, or greater perceived knowledge of CRC risk factors. Risk perception and risk due to family history were not associated with healthy changes.

CONCLUSIONS

Self-reported lifestyle changes due to thoughts about CRC were common. Lower general anxiety levels, worries due to family history, and perceived knowledge of risk factors may stimulate healthy changes.

The UK Lung Screen (UKLS): demographic profile of first 88,897 approaches provides recommendations for population screening

The UK Lung Cancer Screening trial (UKLS) aims to evaluate low-dose computed tomography (LDCT) lung cancer population screening in the United Kingdom. In UKLS, a large population sample ages 50 to 75 years is approached with a questionnaire to determine lung cancer risk. Those with an estimated risk of at least 5% of developing lung cancer in the next 5 years (using the Liverpool Lung project risk model) are invited to participate in the trial. Here, we present demographic, risk, and response rate data from the first 88,897 individuals approached. Of note, 23,794 individuals (26.8% of all approached) responded positively to the initial questionnaire; 12% of these were high risk. Higher socioeconomic status correlated positively with response, but inversely with risk (P < 0.001). The 50- to 55-year age group was least likely to participate, and at lowest cancer risk. Only 5% of clinic attendees were ages ≤60 years (compared with 47% of all 88,897 approached); this has implications for cost effectiveness. Among positive responders, there were more ex-smokers than expected from population figures (40% vs. 33%), and fewer current smokers (14% vs. 17.5%). Of note, 32.7% of current smokers and 18.4% of ex-smokers were designated as high risk. Overall, 1,452 of 23,794 positive responders (6.1%) were deemed high risk and attended a recruitment clinic. UKLS is the first LDCT population screening trial, selecting high-risk subjects using a validated individual risk prediction model.

KEY FINDINGS

(i) better recruitment from ex- rather than current smokers, (ii) few clinic attendees ages early 50s, and (iii) representative number of socioeconomically deprived people recruited, despite lower response rates.

Integrating men's health and masculinity theories to explain colorectal cancer screening behavior

Colorectal cancer (CRC) is the third most common cause of cancer deaths among men in the United States. Although CRC screening has been found to reduce CRC incidence and mortality, current screening rates among men are suboptimal due to various practical and psychosocial barriers. One potential barrier to CRC screening identified in qualitative studies with men is the threat to masculinity that endoscopic screening methods pose. Indeed, beliefs about masculinity have been predictive of other preventive health behaviors among men. In this review article, we propose a novel conceptual framework to explain men's CRC screening behavior that integrates masculinity norms, gender role conflict, men's health care experiences, behaviors, and beliefs, and social and background variables. This framework has the potential to guide future research on men's CRC screening behaviors and other health behaviors and may inform gender-sensitive interventions that target masculinity beliefs to increase preventive health behaviors.

Attitudes and beliefs of non-participants in a population-based screening programme for colorectal cancer

BACKGROUND

Uptake of colorectal cancer screening programmes needs to be improved or at least maintained in order to achieve projected reductions in mortality and morbidity. Understanding the origins of non-participation in screening is therefore important.

OBJECTIVE

To explore the beliefs and experiences of individuals who had not responded either to their screening invitation or reminder.

DESIGN

A qualitative study using in-depth interviews with non-participants from England's population-based colorectal cancer screening programme. Data collection and analysis were carried out using a grounded theory approach, with an emphasis on the constant comparison method, and continued until saturation (27 interviews).

FINDINGS

The interviews provided an in-depth understanding of a range of reasons and circumstances surrounding non-participation in screening, including contextual and environmental influences as well as factors specific to the screening test. Non-participation in screening was not necessarily associated with negative attitudes towards screening or a decision to not return a kit. Reasons for non-participation in screening included not feeling that participation is personally necessary, avoiding or delaying decision making, and having some degree of intention to take part but failing to do so because of practicalities, conflicting priorities or external circumstances. Beliefs, awareness and intention change over time.

DISCUSSION AND CONCLUSIONS

A range of approaches may be required to improve screening uptake. Some non-participants may already have a degree of intention to take part in screening in the future, and this group may be more responsive to interventions based on professional endorsement, repeat invitations, reminders and aids to making the test more practical.

The effect of information about false negative and false positive rates on people's attitudes towards colorectal cancer screening using faecal occult blood testing (FOBt)

OBJECTIVE

To examine the impact of numeric risk information about false negative (FN) and false positive (FP) rates in faecal occult blood testing (FOBt) on attitudes towards screening.

METHODS

95 people aged 45-59, living in England, read 6 hypothetical vignettes presented online about the use of FOB testing to detect bowel cancer, in which information about FN and FP rates was systematically varied.

RESULTS

Both verbal and numeric FN risk information reduced people's interest in screening compared with no FN information. Numeric FN risk information reduced people's perceptions of screening effectiveness and lowered perceived trust in the results of screening compared with both verbal FN information and no FN information. FP information did not affect attitudes towards FOB testing. There was limited evidence that FN information reduced interest and perceptions of screening effectiveness more in educated groups.

CONCLUSION

Numeric FN risk information decreased people's perceptions of screening effectiveness and trust in the results of screening but did not affect people's interest in screening anymore than verbal FN risk information.

PRACTICE IMPLICATIONS

Numeric FN information could be added to patient information without affecting interest in screening, although this needs to be replicated in a larger, more representative sample.

Associations among family history of cancer, cancer screening and lifestyle behaviors: a population-based study

PURPOSE

Some cancers are largely preventable through modification of certain behavioral risk factors and preventive screening, even among those with a family history of cancer. This study examined the associations between (1) family cancer history and cancer screening, (2) family history and cancer preventive lifestyle behaviors, and (3) cancer screening and lifestyle behaviors.

METHODS

Data were from the 2009 California Health Interview Survey (n = 12,603). Outcomes included screening for breast cancer (BC) and colorectal cancer (CRC) and six cancer preventive lifestyle behaviors, based on World Cancer Research Fund recommendations. Multivariate logistic regression analyses, stratified by gender and race-ethnicity, examined associations. Predicted probabilities of cancer screening by family cancer history, race-ethnicity, and sex were computed.

RESULTS

Family history of site-specific cancer-CRC for men and women, and BC for women-was associated with higher probability of cancer screening for most groups, especially for CRC, but was largely unrelated to other lifestyle behaviors. In the few cases in which family history was significantly associated with lifestyle-for example, physical activity among White and Latino males, smoking among White and Asian females-individuals with a family history had lower odds of adherence to recommendations than those with no family history. Greater overall adherence to lifestyle recommendations was associated with higher odds of up-to-date CRC screening among White and Asian males, and lower odds among Asian females (no significant association with BC screening); this relationship did not vary by family cancer history.

CONCLUSION

The fact that family history of cancer is not associated with better lifestyle behaviors may reflect shared behavioral risks within families, or the lack of knowledge about how certain lifestyle behaviors impact personal cancer risk. Findings can inform interventions aimed at lifestyle behavioral modification for individuals at increased cancer risk due to family history.

Shared decision-making about colorectal cancer screening: a conceptual framework to guide research

OBJECTIVE

To develop a conceptual framework to guide research on shared decision-making about colorectal cancer (CRC) screening among persons at average risk and their providers.

METHODS

Based upon a comprehensive review of empirical literature and relevant theories, a conceptual framework was developed that incorporated patient characteristics, cultural beliefs, provider/health care system variables, health belief/knowledge/stage of adoption variables, and shared decision-making between patients and providers that may predict behavior. Relationships among concepts in the framework, shared decision-making process and outcomes, and CRC screening behavior were proposed. Directions for future research were presented.

RESULTS

Many of the concepts in the proposed framework have been examined in prior research. However, these elements have not been combined previously to explain shared decision-making about CRC screening.

CONCLUSION

Research is needed to test the proposed relationships and hypotheses and to refine the framework.

PRACTICE IMPLICATIONS

Findings from future research guided by the proposed framework may inform clinical practice to facilitate shared decision-making about CRC screening.