Reliability and validity of a questionnaire to measure colorectal cancer screening behaviors: does mode of survey administration matter?

Protocol to measure validity and reliability of colorectal, breast, cervical and lung cancer screening questions from the 2021 National Health Interview Survey: Methodology and design

Previous studies demonstrate that self-reports of mammography screening for breast cancer and colonoscopy screening for colorectal cancer demonstrate concordance, based on adherence to screening guidelines, with electronic medical records (EMRs) in over 90% of those interviewed, as well as high sensitivity and specificity, and can be used for monitoring our Healthy People goals. However, for screening tests for cervical and lung cancers, and for various sub-populations, concordance between self-report and EMRs has been noticeably lower with poor sensitivity or specificity. This study aims to test the validity and reliability of lung, colorectal, cervical, and breast cancer screening questions from the 2021 and 2022 National Health Interview Survey (NHIS). We present the protocol for a study designed to measure the validity and reliability of the NHIS cancer screening questions compared to EMRs from four US-based healthcare systems. We planned a randomized trial of a phone- vs web-based survey with NHIS questions that were previously revised based on extensive cognitive interviewing. Our planned sample size will be 1576 validity interviews, and 1260 interviews randomly assigned at 1 or 3 months after the initial interview. We are enrolling people eligible for cancer screening based on age, sex, and smoking history per US Preventive Services Task Force recommendations. We will evaluate question validity using concordance, sensitivity, specificity, positive predictive value, negative predictive value, and report-to-records ratio. We further are randomizing participants to complete a second survey 1 vs 3 months later to assess question reliability. We suggest that typical measures of concordance may need to be reconsidered in evaluating cancer screening questions.

Changes in uptake of stool-based colorectal cancer screening during the Covid-19 pandemic

PURPOSE

Colorectal cancer (CRC) screening is underutilized and endoscopic colon screening includes a number of barriers that were exacerbated by the Covid-19 pandemic. At-home stool-based screening (SBS) increased during the pandemic and potentially reached eligible adults hesitant to be screened by endoscopy. The purpose of this analysis was to examine the change in uptake of SBS during the pandemic among adults not screened within guidelines by endoscopy.

METHODS

We used data from the 2019 and 2021 National Health Interview Surveys to estimate uptake of SBS among adults aged 50-75 years, without a previous diagnosis of CRC and without guideline-concordant endoscopic screening. We also examined provider recommendations for screening tests. To examine if changes in uptake differed during the pandemic by demographic and health characteristics, we combined survey years and ran logistic regression models with an interaction term for each factor and survey year.

RESULTS

In our study population, SBS increased 74% overall from 2019 to 2021 (8.7% to 15.1%; p < 0.001), with the largest percent increase among those aged 50-52 years (3.5% to 9.9%; p < 0.001). Among those aged 50-52 years, the ratio of endoscopy to SBS changed from 83%/17% in 2019 to 55%/45% in 2021. Cologuard was the only screening test where recommendations by healthcare providers significantly increased from 2019 (10.6% to 16.1%; p = 0.002).

CONCLUSIONS

Use and recommendations for SBS increased substantially during the pandemic. Increased awareness among patients could potentially improve future CRC screening rates if uptake of SBS occurs among those unable or unwilling to be screened by endoscopy.

Breast, cervical, and colorectal cancer screening test use in the US territories of Guam, Puerto Rico, and the US Virgin Islands

BACKGROUND

The United States Preventive Services Task Force (USPSTF) recommends breast, cervical, and colorectal cancer screening among eligible adults, but information on screening use in the US territories is limited.

METHODS

To estimate the proportion of adults up-to-date with breast, cervical, and colorectal cancer screening based on USPSTF recommendations, we analyzed Behavioral Risk Factor Surveillance System data from 2016, 2018, and 2020 for the 50 US states and DC (US) and US territories of Guam and Puerto Rico and from 2016 for the US Virgin Islands. Age-standardized weighted proportions for up-to-date cancer screening were examined overall and by select characteristics for each jurisdiction.

RESULTS

Overall, 67.2% (95% CI: 60.6-73.3) of women aged 50-74 years in the US Virgin Islands, 74.8% (70.9-78.3) in Guam, 83.4% (81.7-84.9) in Puerto Rico, and 78.3% (77.9-78.6) in the US were up-to-date with breast cancer screening. For cervical cancer screening, 71.1% (67.6-74.3) of women aged 21-65 years in Guam, 81.3% (74.6-86.5) in the US Virgin Islands, 83.0% (81.7-84.3) in Puerto Rico, and 84.5% (84.3-84.8) in the US were up-to-date. For colorectal cancer screening, 45.2% (40.0-50.5) of adults aged 50-75 years in the US Virgin Islands, 47.3% (43.6-51.0) in Guam, 61.2% (59.5-62.8) in Puerto Rico, and 69.0% (68.7-69.3) in the US were up-to-date. Adults without health care coverage reported low test use for all three cancers in all jurisdictions. In most jurisdictions, test use was lower among adults with less than a high school degree and an annual household income of < $25,000.

CONCLUSION

Cancer screening test use varied between the US territories, highlighting the importance of understanding and addressing territory-specific barriers. Test use was lower among groups without health care coverage and with lower income and education levels, suggesting the need for targeted evidence-based interventions.

Factors associated with the accurate self-report of cancer screening behaviors among women living in the rural Midwest region of the United States

This study examines the accuracy of the self-report of up-to-date cancer screening behaviors (Mammography, Papanicolaou (Pap)/Human Papillomavirus (HPV) tests, Fecal Occult Blood Test (FOBT)/Fecal Immunochemical Test (FIT), Colonoscopy) compared to medical record documentation prior to eligibility determination and enrollment in a randomized controlled trial of an intervention to increase cancer screening among women living in rural counties of Indiana and Ohio. Women (n = 1,641) completed surveys and returned a medical record release form from November 2016-June 2019. We compared self-report to medical records for up-to-date cancer screening behaviors to determine the validity of self-report. Logistic regression models identified variables associated with accurate reporting. Women were up-to-date for mammography (75 %), Pap/HPV test (54 %), colonoscopy (53 %), and FOBT/FIT (6 %) by medical record. Although 39.6 % of women reported being up-to-date for all three anatomic sites (breast, cervix, and colon), only 31.8 % were up to date by medical records. Correlates of accurate reporting of up-to-date cancer screening varied by screening test. Approximately-one-third of women in rural counties in the Midwest are up-to-date for all three anatomic sites and correlates of the accurate reporting of screening varied by test. Although most investigators use medical records to verify completion of cancer screening behaviors as the primary outcome of intervention trials, they do not usually use medical records for the routine verification of study eligibility. Study results suggest that future research should use medical record documentation of cancer screening behaviors to determine eligibility for trials evaluating interventions to increase cancer screening.

Cancer Screening Test Use-U.S., 2019

INTRODUCTION

The U.S. Preventive Services Task Force recommends breast, cervical, and colorectal cancer screening to reduce mortality from these cancers, but screening use has been below national targets. The purpose of this study is to examine the proportion of screening-eligible adults who are up to date with these screenings and how screening use compares with Healthy People 2020 targets.

METHODS

Data from the 2019 National Health Interview Survey were used to examine the percentages of adults up to date with breast cancer screening among women aged 50‒74 years without previous breast cancer, cervical cancer screening among women aged 21‒65 years without previous cervical cancer or hysterectomy, and colorectal cancer screening among adults aged 50‒75 years without previous colorectal cancer. Estimates are presented by sociodemographic characteristics and healthcare access factors. Analyses were conducted in 2021.

RESULTS

Percentages of adults up to date were 76.2% (95% CI= 75.0, 77.5) for breast cancer screening, 76.4% (95% CI= 75.2, 77.6) for cervical cancer screening, and 68.3% (95% CI= 67.3, 69.3) for colorectal cancer screening. Although some population subgroups met breast and colorectal cancer screening targets (81.1% and 70.5%, respectively), many did not, and cervical cancer screening was below the target for all examined subgroups. Lower education and income, nonmetropolitan county of residence (which included rural counties), no usual source of care or health insurance coverage, and Medicaid coverage were associated with lower screening test use.

CONCLUSIONS

Estimated use of breast, cervical, and colorectal cancer screening tests based on the 2019 National Health Interview Survey were below national targets. Continued monitoring may allow for examination of screening trends, inform interventions, and track progress in eliminating disparities.

Screening for Colorectal Cancer in the United States: Correlates and Time Trends by Type of Test

BACKGROUND

It is strongly recommended that adults aged 50-75 years be screened for colorectal cancer. Recommended screening options include colonoscopy, sigmoidoscopy, CT colonography, guaiac fecal occult blood testing (FOBT), fecal immunochemical testing (FIT), or the more recently introduced FIT-DNA (FIT in combination with a stool DNA test). Colorectal cancer screening programs can benefit from knowledge of patterns of use by test type and within population subgroups.

METHODS

Using 2018 National Health Interview Survey (NHIS) data, we examined colorectal cancer screening test use for adults aged 50-75 years (N = 10,595). We also examined time trends in colorectal cancer screening test use from 2010-2018.

RESULTS

In 2018, an estimated 66.9% of U.S. adults aged 50-75 years had a colorectal cancer screening test within recommended time intervals. However, the prevalence was less than 50% among those aged 50-54 years, those without a usual source of health care, those with no doctor visits in the past year, and those who were uninsured. The test types most commonly used within recommended time intervals were colonoscopy within 10 years (61.1%), FOBT or FIT in the past year (8.8%), and FIT-DNA within 3 years (2.7%). After age-standardization to the 2010 census population, the percentage up-to-date with CRC screening increased from 61.2% in 2015 to 65.3% in 2018, driven by increased use of stool testing, including FIT-DNA.

CONCLUSIONS

These results show some progress, driven by a modest increase in stool testing. However, colorectal cancer testing remains low in many population subgroups.

IMPACT

These results can inform efforts to achieve population colorectal cancer screening goals.

A stepped randomized trial to promote colorectal cancer screening in a nationwide sample of U.S. Veterans

BACKGROUND

Colorectal cancer (CRC) screening (CRCS) facilitates early detection and lowers CRC mortality.

OBJECTIVES

To increase CRCS in a randomized trial of stepped interventions. Step 1 compared three modes of delivery of theory-informed minimal cue interventions. Step 2 was designed to more intensively engage those not completing CRCS after Step 1.

METHODS

Recruitment packets (60,332) were mailed to a random sample of individuals with a record of U.S. military service during the Vietnam-era. Respondents not up-to-date with CRCS were randomized to one of four Step 1 groups: automated telephone, telephone, letter, or survey-only control. Those not completing screening after Step 1 were randomized to one of three Step 2 groups: automated motivational interviewing (MI) call, counselor-delivered MI call, or Step 2 control. Intention-to-treat (ITT) analyses assessed CRCS on follow-up surveys mailed after each step.

RESULTS

After Step 1 (n = 1784), CRCS was higher in the letter, telephone, and automated telephone groups (by 1%, 5%, 7%) than in survey-only controls (43%), although differences were not statistically significant. After Step 2 (n = 516), there were nonsignificant increases in CRCS in the two intervention groups compared with the controls. CRCS following any combination of stepped interventions overall was 7% higher (P = 0.024) than in survey-only controls (55.6%).

CONCLUSIONS

In a nationwide study of Veterans, CRCS after each of two stepped interventions of varying modes of delivery did not differ significantly from that in controls. However, combined overall, the sequence of stepped interventions significantly increased CRCS.

Rationale and design of the validation of bladder health instrument for evaluation in women (VIEW) protocol

Background

Bladder health is an understudied state and difficult to measure due to lack of valid and reliable instruments. While condition specific questionnaires assess presence, severity and degree of bother from lower urinary tract symptoms, the absence of symptoms is insufficient to assume bladder health. This study describes the methodology used to validate a novel bladder health instrument to measure the spectrum of bladder health from very healthy to very unhealthy in population based and clinical research.

Methods

Three samples of women are being recruited: a sample from a nationally representative general population and two locally recruited clinical center samples—women with a targeted range of symptom severity and type, and a postpartum group. The general population sample includes 694 women, 18 years or older, randomly selected from a US Postal delivery sequence file. Participants are randomly assigned to electronic or paper versions of the bladder health instrument along with a battery of criterion questionnaires and a demographic survey; followed by a retest or a two-day voiding symptom diary. A total of 354 women around 7 clinical centers are being recruited across a spectrum of self-reported symptoms and randomized to mode of completion. They complete the two-day voiding symptom diary as well as a one-day frequency volume diary prior to an in-person evaluation with a standardized cough stress test, non-invasive urine flowmetry, chemical urine analysis and post void residual measurement. Independent judge ratings of bladder health are obtained by interview with a qualified health care provider. A total of 154 postpartum women recruited around 6 of the centers are completing similar assessments within 6–12 weeks postpartum. Dimensional validity will be evaluated using factor analysis and principal components analysis with varimax rotation, and internal consistency with Cronbach’s alpha. Criterion validity will be assessed using multitrait-multimethod matrix including correlations across multiple data sources and multiple types of measures.

Discussion

We aim to validate a bladder health instrument to measure the degree of bladder health within the general population and among women (including postpartum) recruited from local clinical centers.

Trial registration NCT04016298 Posted July 11, 2019 (https://www.clinicaltrials.gov/ct2/show/NCT04016298?cond=bladder+health&draw=2&rank=1).

Sex differences in the impact of Affordable Care Act Medicaid expansion on colorectal cancer screening

Access to care varies by sex such that interactions with insurance status result in mixed patterns of preventive services utilization. We examined sex-specific effects of ACA Medicaid expansions on receipt of CRC screening. We used Behavioral Risk Factor Surveillance System data (2008-2016) for adults aged 50-64 years with household income ≤138% of federal poverty level to examine self-reported lifetime use of guideline-recommended CRC screening services overall and by screening modality. We employed difference-in-difference models comparing changes in CRC screening in 20 Medicaid expansion states before and after the ACA to changes in 18 states that did not expand Medicaid during our study period. We divided the expansion period into implementation (2014) and post-expansion (2016) periods to account for possible lagged effects. We observed time-varying effects of Medicaid expansion that revealed relative increases in CRC screening occurring during the post-expansion period. Heterogeneous effects by sex and by screening modality were also observed: there was a significant relative increase of 16.2 percentage points (95% CI [2.2, 30.2]; p-value = 0.023) in lifetime colonoscopy use among women in expansion states relative to non-expansion states in the post-expansion period. There were no significant effects of Medicaid expansion among men. Health insurance expansion had a lagged but significant effect on CRC screening among low-income non-elderly women in Medicaid expansion states, but no effect for men. The observed increase in CRC screening among women suggests that barriers to CRC screening may differ by sex, and tailored interventions to increase CRC screening improve outcomes.

Evaluating Lung Cancer Screening Uptake, Outcomes, and Costs in the United States: Challenges With Existing Data and Recommendations for Improvement

The National Lung Screening Trial (NLST) reported substantial reduction in lung cancer mortality among high-risk individuals screened annually with low-dose helical computed tomography (LDCT). As a result, the US Preventive Services Task Force issued a B recommendation for annual LDCT in high-risk individuals, which requires private insurers to cover it without cost-sharing. The Medicare program also covers LDCT for high-risk beneficiaries without cost-sharing. However, the NLST findings may not be generalizable to the community setting because of differences in patients, providers, and practices participating in the NLST. Thus, examining uptake of LDCT screening in community practice is critical, as is evaluating the immediate and downstream outcomes of screening, including false-positive scans, follow-up examinations and adverse events, costs, stage of disease at diagnosis, and survival. This commentary presents an overview of the landscape of the data resources currently available to evaluate the uptake, outcomes, and costs of LDCT screening in the United States. We describe the strengths and limitations of existing data sources, including administrative databases, surveys, and registries. Thereafter, we provide recommendations for improving the data infrastructure pertaining to three overarching research areas: receipt of guideline-consistent screening and follow-up, weighing benefits and harms of screening, and costs of screening.

Differences in colorectal cancer screening rates across income strata by levels of urbanization: results from the Canadian Community Health Survey (2013/2014)

OBJECTIVE

Canadian colorectal cancer screening rates differ across income strata. In the United States, disparities across income strata worsen in rural areas. In Canada, differences in screening across income strata have not been explored by levels of urbanization. This project aimed to estimate up-to-date colorectal cancer (UTD-CRC) screening across income strata by levels of urbanization.

METHODS

Data from the Canadian Community Health Survey (2013/2014) were used to estimate the prevalence of UTD-CRC screening by income quintiles for Canadians aged 50-74 years. UTD-CRC screening was defined as fecal occult blood testing within 2 years or colonoscopy/sigmoidoscopy within 10 years before the survey. Levels of urbanization were defined per Statistics Canada Metropolitan Influenced Zone classifications. Weighted proportions of UTD-CRC screening were calculated and logistic regression was used to assess the effect of income by levels of urbanization.

RESULTS

Self-reported UTD-CRC screening prevalence among Canadians was 52.0%. UTD-CRC screening rates by income ranged from 47.8% (Q1-low) to 54.0% (Q5-high). Across all levels of urbanization, higher income was associated with increased odds of UTD-CRC screening compared to the lowest income quintile (Urban-OR_Q5 = 1.49, 95% CI 1.17-1.89; Rural-OR_Q5 = 1.42, 95% CI 1.02-1.99; Remote-OR_Q5 = 1.54, 95% CI 1.02-2.31). Higher education (OR_{post-secondary} = 1.30, 95% CI 1.14-1.49), increasing age (OR_70-74 = 2.88, 95% CI 2.39-3.47), and not identifying as an immigrant (OR = 1.45, 95% CI 1.19-1.75) were associated with an increased odds of UTD-CRC screening.

DISCUSSION

Half of Canadians report UTD-CRC screening but across levels of urbanization, higher income was associated with higher screening rates. Efforts are needed to understand and address inequities, particularly among low-income populations.

The association between long-term conditions and uptake of population-based screening for colorectal cancer: results from two English cohort studies

Introduction

Uptake of screening for colorectal cancer (CRC) can reduce mortality, and population-based screening is offered in England. To date, there is little evidence on the association between having a long-term condition (LTC) and CRC screening uptake. The objective of this study was to examine the association between having an LTC and uptake of CRC screening in England with the guaiac fecal occult blood test, with a particular focus on common mental disorders.

Methods

The study was a preregistered secondary analysis of two cohorts: first, a linked data set between the regional Yorkshire Health Study (YHS) and the National Health Service National Bowel Cancer Screening Program (BCSP, years 2006–2014); second, the national English Longitudinal Study of Ageing (ELSA, years 2014–2015). Individuals eligible for BCSP screening who participated in either the YHS (7,142) or ELSA Wave 7 (4,099) were included. Study registration: ClinicalTrials.gov, number NCT02503969.

Results

In both the cohorts, diabetes was associated with lower uptake (YHS odds ratio [OR] for non-uptake 1.35, 95% CI 1.03–1.78; ELSA 1.33, 1.03–1.72) and osteoarthritis was associated with increased uptake (YHS 0.75, 0.57–0.99; ELSA 0.76, 0.62–0.93). After controlling for broader determinants of health, there was no evidence of significantly different uptake for individuals with common mental disorders.

Conclusion

Two large independent cohorts provided evidence that uptake of CRC screening is lower among individuals with diabetes and higher among individuals with osteoarthritis. Further work should compare barriers and facilitators to screening among individuals with either of these conditions. This study also demonstrates the benefits of data linkage for improving clinical decision-making.

Designing a randomized controlled trial to evaluate a community-based narrative intervention for improving colorectal cancer screening for African Americans

OBJECTIVE

To describe the methodology of a 2-arm randomized controlled trial that compared the effects of a narrative and didactic version of the Witness CARES (Community Awareness, Reach, & Empowerment for Screening) intervention on colorectal cancer screening behavior among African Americans, as well as the cognitive and affective determinants of screening.

METHODS

Witness CARES targeted cognitive and affective predictors of screening using a culturally competent, community-based, narrative or didactic communication approach. New and existing community partners were recruited in two New York sites. Group randomization allocated programs to the narrative or didactic arm. Five phases of data collection were conducted: baseline, post-intervention, three-month, six-month, and qualitative interviews. The primary outcome was screening behavior; secondary outcomes included cognitive and affective determinants of screening.

RESULTS

A total of 183 programs were conducted for 2655 attendees. Of these attendees, 19.4% (N=516) across 158 programs (50% narrative; 50% didactic) were study-eligible and consented to participate. Half (45.6%) of the programs were delivered to new community partners and 34.8% were delivered at faith-based organizations. Mean age of the total sample was 64.7years and 75.4% were female.

CONCLUSION

The planned number of programs was delivered, but the proportion of study-eligible attendees was lower than predicted. This community-based participatory research approach was largely successful in involving the community served in the development and implementation of the intervention and study.

Physician Intervention and Chinese Americans' Colorectal Cancer Screening

OBJECTIVE

We conducted a cluster-randomized trial evaluating an intervention that trained Chinese-American primary care physicians to increase their Chinese patients' colorectal cancer (CRC) screening.

METHODS

Twenty-five physicians (13 randomized to the intervention arm and 12 to the control arm) and 479 of their patients (aged 50-75 and nonadherent to CRC screening guidelines) were enrolled. The intervention, guided by Social Cognitive Theory, included a communication guide and 2 in-office training sessions to enhance physicians' efficacy in com- municating CRC screening with patients. Patients' CRC screening rates (trial outcome) and rating of physician communication before intervention and at 12-month follow-up were assessed. Intention-to-treat analysis for outcome evaluation was conducted.

RESULTS

Screening rates were slightly higher in the intervention vs. the control arm (24.4% vs. 17.7%, p = .24). In post hoc analyses, intervention arm patients who perceived better communication were more likely to be screened than those who did not (OR = 1.09, 95% CI: 1.03, 1.15). This relationship was not seen in the control arm.

CONCLUSIONS

This physician-focused intervention had small, non-significant effects in increasing Chinese patients' CRC screening rates. Physician communication appeared to explain intervention efficacy. More intensive interventions are needed to enhance Chinese patients' CRC screening.

Comparing cancer screening estimates: Behavioral Risk Factor Surveillance System and National Health Interview Survey

Cancer screening prevalence from the Behavioral Risk Factor Surveillance System (BRFSS), designed to provide state-level estimates, and the National Health Interview Survey (NHIS), designed to provide national estimates, are used to measure progress in cancer control. A detailed description of the extent to which recent cancer screening estimates vary by key demographic characteristics has not been previously described. We examined national prevalence estimates for recommended breast, cervical, and colorectal cancer screening using data from the 2012 and 2014 BRFSS and the 2010 and 2013 NHIS. Treating the NHIS estimates as the reference, direct differences (DD) were calculated by subtracting NHIS estimates from BRFSS estimates. Relative differences were computed by dividing the DD by the NHIS estimates. Two-sample t-tests (2-tails), were performed to test for statistically significant differences. BRFSS screening estimates were higher than those from NHIS for breast (78.4% versus 72.5%; DD=5.9%, p<0.0001); colorectal (65.5% versus 57.6%; DD=7.9%, p<0.0001); and cervical (83.4% versus 81.8%; DD=1.6%, p<0.0001) cancers. DDs were generally higher in racial/ethnic minorities than whites, in the least educated than most educated persons, and in uninsured than insured persons. For example, the colorectal cancer screening DD for whites was 7.3% compared to ≥8.9% for blacks and Hispanics. Despite higher prevalence estimates in BRFSS compared to NHIS, each survey has a unique and important role in providing information to track cancer screening utilization among various populations. Awareness of these differences and their potential causes is important when comparing the surveys and determining the best application for each data source.

Influence of the mode of administration on the results of medication adherence questionnaires

INTRODUCTION AND OBJECTIVES

Adherence to medication regimen is commonly assessed through questionnaires, some of which are validated via self-administration. The inadequate health literacy of elderly people pushes researchers to the use of interviews as a method of administration. The aims of this study were to compare the results obtained with an interviewer-administered and a self-administered medication adherence questionnaire and to evaluate the consequences of the adherence status classification of individuals.

METHODS

A cross-sectional study was performed in which the Medida de Adesão aos Tratamentos adherence questionnaire was administered to adult patients who were taking at least 1 antihypertensive drug. The data were collected in 7 community pharmacies in central Portugal between March 2014 and September 2015 in 2 different phases: in the first phase, the questionnaire was applied during a healthcare professional interview, and the second phase involved a self-report administration. A confirmatory factor analysis was conducted, and the measurement and structural invariances across the application methods were examined.

RESULTS

A sample of 425 patients with a mean age of 68.21 ± 10.56 years participated in the study. The confirmatory factor analysis revealed that both the interview and self-report had a good fit with the original model, although the self-report results exhibited a better fit. In the interview administration, we obtained lower values for skewness and higher levels of kurtosis. The patients subjected to the interview administration presented with a 9.7% higher tendency to answer "never" when compared with the self-administered application, which overestimated adherence.

CONCLUSIONS

The interview administration method induced bias that led to a higher percentage of "never" answers and a subsequent overestimation of adherence levels. Self-report administration should be preferred in the application of medication adherence questionnaires.

Differences between husbands and wives in colonoscopy use: Results from a national sample of married couples

Marriage is linked to improved colorectal cancer-related health, likely in part through preventive health behaviors, but it is unclear what role spouses play in colorectal cancer screening. We therefore determine whether self-reported colonoscopy rates are correlated within married couples and the characteristics of spouses associated with colonoscopy use in each partner. We use US nationally-representative 2010 data which includes 804 male-female married couples drawn from a total sample of 3137 community-dwelling adults aged 55-90years old. Using a logistic regression model in the full sample (N=3137), we first find married men have higher adjusted colonoscopy rates than unmarried men (61% versus 52%, p=0.023), but women's rates do not differ by marital status. In the couples' sample (N=804 couples), we use a bivariate probit regression model to estimate multiple regression equations for the two spouses simultaneously as a function of individual and spousal covariates, as well as the adjusted correlation within couples. We find that individuals are nearly twice as likely to receive a colonoscopy if their spouse recently has had one (OR=1.94, 95% CI: 1.39, 2.67, p<0.001). Additionally, we find that husbands have higher adjusted colonoscopy rates whose wives are: 1) happier with the marital relationship (65% vs 51%, p=0.020); 2) more highly educated (72% vs 51%, p=0.020), and 3) viewed as more supportive (65% vs 52%, p=0.020). Recognizing the role of marital status, relationship quality, and spousal characteristics on colonoscopy uptake, particularly in men, could help physicians increase guideline adherence.

Comparison of Patient-Reported Quality-of-Life and Complications in Men With Prostate Cancer, Between Two Modes of Administration

INTRODUCTION

Our purpose was to: (1) assess the level of consistency between the quality-of-life (QOL) scores of men with prostate cancer for urinary/bowel/sexual bother, collected via telephone versus self-administered survey; (2) determine factors associated with variation in level of agreement; and (3) assess the efficacy of telephone interview as a mode of administration against the "gold standard" tool, EPIC-26.

METHODS

Cohen's Kappa coefficients were calculated to investigate test-retest reliability across modes of administration. Logistic regression models explored patients' characteristics associated with the magnitude of urinary/bowel/sexual problem. Sensitivities and specificities of the telephone mode in reference to "gold standard" were further measured.

RESULTS

From 221 men who agreed to participate in the study, 168 (76.0%) returned completed surveys. Kappa-linear model resulted in a moderate agreement across the urinary/bowel/sexual bother scores for both modes of administration; with greatest concordance recorded for bowel bother (90%). Patient's age (<75 years), disease risk, and active treatment type determined a moderate-to-good level of agreement between administration modalities with a Kappa varying between 0.44 and 0.73; χ(2), 8.18; P = .042. Sensitivity tests revealed that 68% of men with a moderate/big problem during the phone interviews would respond to suffering from a moderate/big sexual problem.

CONCLUSION

Results of this pilot study revealed that QOL outcomes from this registry will likely underestimate the true bother experienced by men. More research is required to determine the differences between self-administered and telephone interviews in men with prostate cancer.

Cluster Randomized Trial of a Church-Based Peer Counselor and Tailored Newsletter Intervention to Promote Colorectal Cancer Screening and Physical Activity Among Older African Americans

Action Through Churches in Time to Save Lives (ACTS) of Wellness was a cluster randomized controlled trial developed to promote colorectal cancer screening and physical activity (PA) within urban African American churches. Churches were recruited from North Carolina (n = 12) and Michigan (n = 7) and were randomized to intervention (n = 10) or comparison (n = 9). Intervention participants received three mailed tailored newsletters addressing colorectal cancer screening and PA behaviors over approximately 6 months. Individuals who were not up-to-date for screening at baseline could also receive motivational calls from a peer counselor. The main outcomes were up-to-date colorectal cancer screening and Metabolic Equivalency Task (MET)-hours/week of moderate-vigorous PA. Multivariate analyses examined changes in the main outcomes controlling for church cluster, gender, marital status, weight, and baseline values. Baseline screening was high in both intervention (75.9%, n = 374) and comparison groups (73.7%, n = 338). Screening increased at follow-up: +6.4 and +4.7 percentage points for intervention and comparison, respectively (p = .25). Baseline MET-hours/week of PA was 7.8 (95% confidence interval [6.8, 8.7]) for intervention and 8.7 (95% confidence interval [7.6, 9.8]) for the comparison group. There were no significant changes (p = .15) in PA for intervention (-0.30 MET-hours/week) compared with the comparison (-0.05 MET-hours/week). Among intervention participants, PA increased more for those who participated in church exercise programs, and screening improved more for those who spoke with a peer counselor or recalled the newsletters. Overall, the intervention did not improve PA or screening in an urban church population. These findings support previous research indicating that structured PA opportunities are necessary to promote change in PA and churches need more support to initiate effective peer counselor programs.

Recent trends in breast, cervical, and colorectal cancer screening test utilization in Canada, using self-reported data from 2008 and 2012

In Canada, self-reported data from the Canadian Community Health Survey 2008 and 2012 provide an opportunity to examine overall utilization of breast, cervical, and colorectal cancer screening tests for both programmatic and opportunistic screening. Among women 50-74 years of age, utilization of screening mammography was stable (62.0% in 2008 and 63.0% in 2012). Pap test utilization for women 25-69 years of age remained high and stable across Canada in 2008 and 2012 (78.9% in 2012). The percentage of individuals 50-74 years of age who reporting having at least 1 fecal test within the preceding 2 years increased in 2012 (to 23.0% from 16.9% in 2008), but remains low. Stable rates of screening mammography utilization (about 30%) were reported in 2008 and 2012 among women 40-49 years of age, a group for which population-based screening is not recommended. Although declining over time, cervical cancer screening rates were high for women less than 25 years of age (for whom screening is not recommended). Interestingly, an increased percentage of women 70-74 years of age reported having a Pap test. In 2012, a smaller percentage of women 50-69 years of age reported having no screening test (5.9% vs. 8.5% in 2008), and more women reported having the three types of cancer screening tests (19.0% vs. 13.2%). Efforts to encourage use of screening within the recommended average-risk age groups are needed, and education for stakeholders about the possible harms of screening outside those age groups has to continue.

Randomized controlled trial of storytelling compared to a personal risk tool intervention on colorectal cancer screening in low-income patients

PURPOSE

Screening rates for colorectal cancer (CRC) lag for low-income, minority populations, contributing to poorer survival rates. A model of storytelling as culture-centric health promotion was tested for promoting CRC screening.

DESIGN

A two-group parallel randomized controlled trial.

SETTING

Primary care, safety-net clinics.

SUBJECTS

Low-income patients due for CRC screening, ages 50 to 75 years, speaking English or Spanish.

INTERVENTION

Patients were exposed to either a video created from personal stories composited into a drama about "Papa" receiving CRC screening, or an instrument estimating level of personal cancer risk. Patients received a health care provider referral for CRC screening and were followed up for 3 months to document adherence.

MEASURES

Behavioral factors related to the narrative model (identification and engagement) and theory of planned behavior.

ANALYSIS

Main effects of the interventions on screening were tested, controlling for attrition factors, and demographic factor associations were assessed. Path analysis with model variables was used to test the direct effects and multiple mediator models.

RESULTS

Main effects on CRC screening (roughly half stool-based tests, half colonoscopy) did not indicate significant differences (37% and 42% screened for storytelling and risk-based messages, respectively; n = 539; 33.6% male; 62% Hispanic). Factors positively associated with CRC screening included being female, Hispanic, married or living with a partner, speaking Spanish, having a primary care provider, lower income, and no health insurance. Engagement, working through positive attitudes toward the behavior, predicted CRC screening.

CONCLUSION

A storytelling and a personalized risk-tool intervention achieved similar levels of screening among unscreened/underscreened, low-income patients. Factors usually associated with lower rates of screening (e.g., no insurance, being Hispanic) were related to more adherence. Both interventions' engagement factor facilitated positive attitudes about CRC screening associated with behavior change.

Screening polypectomy rates below quality benchmarks: A prospective study

AIM: To estimate and compare sex-specific screening polypectomy rates to quality benchmarks of 40% in men and 30% in women.

METHODS: A prospective cohort study was undertaken of patients aged 50-75, scheduled for colonoscopy, and covered by the Québec universal health insurance plan. Endoscopist and patient questionnaires were used to obtain screening and non-screening colonoscopy indications. Patient self-report was used to obtain history of gastrointestinal conditions/symptoms and prior colonoscopy. Sex-specific polypectomy rates (PRs) and 95%CI were calculated using Bayesian hierarchical logistic regression.

RESULTS: In total, 45 endoscopists and 2134 (mean age = 61, 50% female) of their patients participated. According to patients, screening PRs in males and females were 32.4% (95%CI: 23.8-41.8) and 19.4% (95%CI: 13.1-25.4), respectively. According to endoscopists, screening PRs in males and females were 30.2% (95%CI: 27.0-41.9) and 16.6% (95%CI: 16.3-28.6), respectively. Sex-specific PRs did not meet quality benchmarks at all ages except for: males aged 65-69 (patient screening indication), and males aged 70-74 (endoscopist screening indication). For all patients aged 50-54, none of the CI included the quality benchmarks.

CONCLUSION: Most sex-specific screening PRs in Québec were below quality benchmarks; PRs were especially low for all 50-54 year olds.

Identifying key variables in African American adherence to colorectal cancer screening: the application of data mining

BACKGROUND

This paper reports on an effort to identify a streamlined set of issues important for colorectal cancer communication and interventions with older African Americans.

METHODS

African American (N = 1,021), 683 women and 338 men, 50 to 75 years completed a telephone survey addressing demographics, colorectal cancer screening, cancer attitudes, and cancer related cultural attitudes. Several data analytics methods were applied and evaluated. Among them, results from associative data mining identified key variables and logistic regression was used to confirm associations to screening adherence.

RESULTS

Sets of co-occurring variables identified by associative data mining methods are extracted to further study differences between adherent and non-adherent groups. Logistic regressions suggested four variables were significantly associated with adherence: healthcare provider colonoscopy recommendation, prevention services at the place health care is usually sought, a history of colitis, and a history of polyps.

CONCLUSIONS

The findings suggest a streamlined set of issues and concerns that may be used by providers advising patients or developing colorectal cancer intervention strategies for older African Americans. The data suggest the continued importance of healthcare provider recommendation to screen. It is important that providers give a clear recommendation to screen regardless of the test ultimately selected and should advise all patients that family history and the absence of symptoms or colitis do not eliminate the value of screening.

Colorectal cancer among Koreans living in South Korea versus California: incidence, mortality, and screening rates

OBJECTIVES

This study compared trends in colorectal cancer (CRC) incidence and mortality rates among Koreans in South Korea and Korean Americans and non-Hispanic whites in California between 1999 and 2009, and examined CRC screening rates and socio-demographic correlates of CRC screening in the two Korean populations.

DESIGN

Age-standardized CRC incidence and mortality rates of Koreans in South Korea and Korean Americans and non-Hispanic whites in California for the years 1999-2009 were obtained from annual reports of cancer statistics and modeled using joinpoint regression. Using 2009 data from the Korean National Health and Nutrition Examination Survey and the California Health Interview Survey, we estimated and compared CRC screening rates and test modalities. We used multiple logistic regression to examine socio-demographic correlates of completion of CRC screening according to the guidelines among the two Korean populations.

RESULTS

CRC incidence and mortality rates among South Koreans increased during 1999-2009 but more slowly during the late 2000s. In California, CRC incidence increased among Korean American females but decreased among non-Hispanic whites. About 37% of South Koreans and 60% of Korean Americans reported completion of CRC screening according to guidelines in 2009. Among South Koreans, married status, higher income, and private health insurance were associated with CRC screening, adjusting for other factors. Among Korean Americans, having health insurance was associated with CRC screening.

CONCLUSION

Despite almost identical CRC screening guidelines in South Korea and the USA and substantially higher screening rates among Korean Americans as compared to South Koreans, disparities remain in both populations with respect to CRC statistics. Thus, efforts to promote primary and secondary prevention of CRC in both Korean populations are critically important in both countries.

Validating self-reported mammography use in vulnerable communities: findings and recommendations

BACKGROUND

Most health surveys ask women whether they have had a recent mammogram, all of which report mammography use (past 2 years) at about 70% to 80% regardless of race or residence. We examined the potential extent of overreporting of mammography use in low income African-American and Latina women, and whether self-report inaccuracies might bias estimated associations between patient characteristics and mammography use.

METHODS

Using venue-based sampling in two poor communities on the west side of Chicago, we asked eligible women living in two west side communities of Chicago to complete a survey about breast health (n = 2,200) and to provide consent to view their medical record. Of the 1,909 women who screened eligible for medical record review, 1,566 consented (82%). We obtained medical records of all women who provided both permission and a valid local mammography facility (n = 1,221). We compared the self-reported responses from the survey with the imaging reports found in the medical record (documented). To account for missing data, we conducted multiple imputations for key demographic variables and report standard measures of accuracy.

RESULTS

Although 73% of women self-reported a mammogram in the last 2 years, only 44% of self-reports were documented. Overreporting of mammography use was observed for all three ethnic groups.

CONCLUSIONS

These results suggest considerable overestimation of prevalence of use in these vulnerable populations.

IMPACT

Relying on known faulty self-reported mammography data as a measure of mammography use provides an overly optimistic picture of utilization, a problem that may be exacerbated in vulnerable minority communities.

Promoting colorectal cancer screening through group education in community-based settings

National colonoscopy adherence rates near 65% and New York City (NYC) colonoscopy rates approach 69%. Despite an overall increase in national colorectal cancer (CRC) screening rates, rates of CRC screening among Blacks and Latinos are lower than non-Latino Whites. We developed two group level, culturally targeted educational programs about CRC for Blacks and Latinos. One hour programs included education about screening, peer testimony given by a colonoscopy-adherent person, and pre- and post-knowledge assessment. From 2010 to 2012, we conducted 66 education programs in NYC, reaching 1,065 participants, 62.7% of whom were 50 years of age or older identified as Black or Latino and provided information about colonoscopy history (N = 668). Colonoscopy adherence in the sample was 69.3%. There was a significant increase in mean knowledge score about CRC and CRC screening from pretest to posttest. Sixty-eight percent of attendees without prior colonoscopy reported intent to schedule a colonoscopy as a result of attending the program. Culturally targeted education programs with peer testimony are a valuable way to raise awareness about CRC and colonoscopy and can influence intent to screen among nonadherent persons. Additional research is needed to establish group level education as an effective means of promoting CRC screening.

Agreement between self-reported and registered colorectal cancer screening: a meta-analysis

This random-effects meta-analysis investigates the accuracy of self-reported colorectal cancer screening history as a function of screening mode (colonoscopy, flexible sigmoidoscopy, faecal occult blood testing - FOBT, double-contrast barium enema - DCBE) and survey mode (written, telephone, face-to-face). Summary estimates of sensitivity, specificity, positive predictive value (PPV) and area under the receiver operating characteristic curve (AUC) were calculated. Medical record data were used as reference. We included 23 studies comprising 11,592 subjects. Colonoscopy yielded higher AUC [0.948, 95% confidence interval (CI) = 0.918, 0.968] than flexible sigmoidoscopy (0.883, 95% CI = 0.849, 0.911) and FOBT (0.869, 95% CI = 0.833, 0.898). Colonoscopy showed the highest sensitivity (0.888, 95% CI = 0.835, 0.931), whereas specificity was comparable between screening modes (ranging from 0.802 for FOBT to 0.904 for DCBE). AUC was not significantly different between survey modes. Prevalence of screening history correlated positively with sensitivity and negatively with specificity, possibly because of errors in the medical records. In conclusion, the accuracy of self-reported cancer screening is generally moderate, and higher for colonoscopy than for sigmoidoscopy and FOBT.

Limited health literacy is a barrier to colorectal cancer screening in England: evidence from the English Longitudinal Study of Ageing

OBJECTIVE

To determine the association between health literacy and participation in publicly available colorectal cancer (CRC) screening in England using data from the English Longitudinal Study of Ageing (ELSA).

METHODS

ELSA is a population-based study of English adults aged ≥ 50 years. Health literacy, participation in the national CRC screening programme, and covariates were interview-assessed in 2010-11. All those age-eligible for screening from 2006 to 11 were included in the present analysis (n=3087). The association between health literacy and screening was estimated using multivariable-adjusted logistic regression.

RESULTS

73% of participants had adequate health literacy skills. Screening uptake was 58% among those with adequate and 48% among those with limited health literacy skills. Having adequate health literacy was associated with greater odds of CRC screening (multivariable adjusted OR=1.20; 95% CI: 1.00-1.44), independent of other predictors of screening: age (OR=0.92; 95% CI: 0.91-0.94 per one year increase), female sex (OR=1.31; 95% CI: 1.11-1.54), and being in a higher wealth quintile (OR=1.88; 95% CI: 1.43-2.49).

CONCLUSIONS

Limited health literacy is a barrier to participation in England's national, publicly available CRC screening programme. Interventions should include appropriate design of information materials, provision of alternative support, and increased one-on-one interaction with health care professionals.

Decision Aid to Technologically Enhance Shared decision making (DATES): study protocol for a randomized controlled trial

BACKGROUND

Clinicians face challenges in promoting colorectal cancer screening due to multiple competing demands. A decision aid that clarifies patient preferences and improves decision quality can aid shared decision making and be effective at increasing colorectal cancer screening rates. However, exactly how such an intervention improves shared decision making is unclear. This study, funded by the National Cancer Institute, seeks to provide detailed understanding of how an interactive decision aid that elicits patient's risks and preferences impacts patient-clinician communication and shared decision making, and ultimately colorectal cancer screening adherence.

METHODS/DESIGN

This is a two-armed single-blinded randomized controlled trial with the target of 300 patients per arm. The setting is eleven community and three academic primary care practices in Metro Detroit. Patients are men and women aged between 50 and 75 years who are not up to date on colorectal cancer screening. ColoDATES Web (intervention arm), a decision aid that incorporates interactive personal risk assessment and preference clarification tools, is compared to a non-interactive website that matches ColoDATES Web in content but does not contain interactive tools (control arm). Primary outcomes are patient uptake of colorectal cancer screening; patient decision quality (knowledge, preference clarification, intent); clinician's degree of shared decision making; and patient-clinician concordance in the screening test chosen. Secondary outcome incorporates a Structural Equation Modeling approach to understand the mechanism of the causal pathway and test the validity of the proposed conceptual model based on Theory of Planned Behavior. Clinicians and those performing the analysis are blinded to arms.

DISCUSSION

The central hypothesis is that ColoDATES Web will improve colorectal cancer screening adherence through improvement in patient behavioral factors, shared decision making between the patient and the clinician, and concordance between the patient's and clinician's preferred colorectal cancer screening test. The results of this study will be among the first to examine the effect of a real-time preference assessment exercise on colorectal cancer screening and mediators, and, in doing so, will shed light on the patient-clinician communication and shared decision making 'black box' that currently exists between the delivery of decision aids to patients and subsequent patient behavior.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT01514786.

Determinants of adherence to screening by colonoscopy in individuals with a family history of colorectal cancer

OBJECTIVE

Although first-degree relatives (FDRs) of colorectal cancer (CRC) patients, as a high-risk population, have the most to gain from colonoscopy screening, their adherence is suboptimal. Thus, an assessment of the determinants of adherence to screening is of potential importance.

METHODS

A cross-sectional study was conducted among 318 FDRs of 164 CRC patients treated at Tel-Aviv Sourasky Medical Center. Interviews were conducted with a questionnaire using I-Change Model.

RESULTS

Adherence to interval colonoscopy was low with only 73 FDRs (23.0%). Greater adherence was associated with socio-demographic variables (older age, siblings, having spouse, higher level of education and income) and behavioral variables (healthier lifestyle, utilization of preventive health services). Family physicians and kin were identified as the most influential figures on uptake. Intention, affective barriers, positive attitudes, social support, cues to action, age, and health maintenance were the strongest determinants of participation in CRC screening.

CONCLUSION

Adherence to colonoscopy is determined by multiple variables. Medical staff can play a key role in increasing adherence to colonoscopy.

PRACTICE IMPLICATIONS

Future interventions should focus on fostering positive attitudes, overcoming barriers, enhancing social support and providing a medical recommendation. Special efforts should be invested in young FDRs, those of low socio-economic status and those who underutilize preventive medicine.

Screening for colorectal cancer: using data to set prevention priorities

INTRODUCTION

Adherence to colorectal cancer screening recommendations is known to vary by state, but less information is available about within-state variability. In the current study, we assess county-level screening rates for Missouri, with the goal of better targeting public health efforts to increase screening.

METHODS

Prevalence of colorectal cancer screening among Missouri adults between the ages of 50 and 74 was obtained from 2008 and 2010 Behavioral Risk Factor Surveillance System data. We used multilevel logistic regression to generate county-specific estimates. After excluding 77 counties with fewer than 30 respondents, information was available about 3,739 individuals in 37 counties, representing 78.5 % of the state population.

RESULTS

Across counties, the prevalence of being up-to-date with recommended colorectal cancer screening ranged from 25 to 70 %.

CONCLUSION

State-level information about colorectal cancer screening masks substantial within-state variability. Assessing and monitoring county-level disparities in screening can guide public health efforts to increase screening and reduce colorectal cancer mortality. More complete population survey data will make such analysis possible.

Exploring opportunities for colorectal cancer screening and prevention in the context of diabetes self-management: an analysis of the 2010 National Health Interview Survey

Because diabetes is associated with increased colorectal cancer (CRC) risk, it is important that people with diabetes receive CRC screenings according to guidelines. In addition, many diabetes self-care recommendations are associated with a reduced risk of CRC. This study aims to identify potential opportunities for enhancing CRC prevention within the context of diabetes management. Using data from 1,730 adults with diabetes aged 50-75 years who responded to the 2010 National Health Interview Survey, we calculated population estimates of behaviors consistent with US Preventive Services Task Force guidelines for CRC screening and American Diabetes Association recommendations for diabetes care. We examined bivariate associations between CRC screening and selected diabetes self-care behaviors associated with CRC risk. Results were stratified by demographic characteristics. Thirty-nine percent of adults with diagnosed diabetes were not up-to-date with CRC screenings. Sixteen percent smoked and 2 % exceeded alcohol intake recommendations. Among those capable of exercise, 69 and 90 % did not meet aerobic exercise and resistance training recommendations, respectively. CRC screening was generally not associated with diabetes self-care behaviors. Among some demographic groups, CRC screening was associated with adequate aerobic activity, not smoking, and being overweight or obese. Many adults with diabetes do not follow guidelines for CRC screening or recommendations for diabetes care that may also reduce CRC risk. Thus, opportunities may exist to jointly promote CRC screening and prevention and diabetes self-management among adults with diabetes.

Effectiveness of a theory-based intervention to increase colorectal cancer screening among Iranian health club members: a randomized trial

Colorectal cancer is the third most commonly diagnosed cancer and the fourth leading cause of death in the world. There are few published studies that have used theory-based interventions designed to increase colorectal cancer screening in community lay health organizations. The present study was guided by the theoretical concepts of the preventive health model. Twelve health clubs of a municipal district in Tehran were randomized to two study groups with equal ratio. The control group received usual services throughout the study while the intervention group also received a theory-based educational program on colorectal cancer screening plus a reminder call. Screening behavior, the main outcome, was assessed 4 months after randomization. A total of 360 members aged 50 and older from 12 health clubs completed a baseline survey. Participants in the intervention group reported increased knowledge of colorectal cancer and screening tests at 4 months follow-up (p's < .001). Moreover, exposure to the theory-based intervention significantly improved self-efficacy, perceived susceptibility, efficacy of screening, social support, and intention to be screened for colorectal cancer, from baseline to 4 months follow-up (p's < .001). The screening rate for colorectal cancer was significantly higher in the intervention group compared to the control group (odds ratio = 15.93, 95% CI = 5.57, 45.53). Our theory-based intervention was found to have a significant effect on colorectal cancer screening use as measured by self-report. The findings could have implications for colorectal cancer screening program development and implementation in primary health care settings and through other community organizations.

The utility of cancer-related cultural constructs to understand colorectal cancer screening among african americans

BACKGROUND

Data suggest that colorectal cancer could be cut by approximately 60% if all people aged 50 years or older received regular screening. Studies have identified socio-cultural attitudes that might inform cancer education and screening promotion campaigns. This article applies item response theory (IRT) to a set of survey items selected to assess sociocultural attitudes in order to determine how current measures may affect what we know about how these attitudes affect colorectal cancer screening (CRCS).

DESIGN AND METHODS

A survey of colorectal cancer screening, screening attitudes and cultural beliefs was administered to 1021 African Americans - 683 women and 338 men, ages 50 to 75. Eligibility criteria for participation included being born in the United States, self-identified African American male or female, age 50 to 75 years. The IRT analysis was performed on 655 individuals with complete data for the 43 observed variables.

RESULTS

Twenty-nine items comprise the Multi-construct African American Cultural Survey (MAACS) that addresses seven cultural constructs: mistrust/distrust, privacy, ethnic identity, collectivism, empowerment, and male gender roles. The items provide adequate information about the attitudes of the population across most levels of the constructs assessed. Among the sociocultural variables considered, empowerment (OR=1.078; 95% CI: 1.008, 1.151) had the strongest association with CRCS adherence and privacy showed promise.

CONCLUSIONS

The MAACS provides a fixed length questionnaire to assess African American CRCS attitudes, two new constructs that might assist in CRCS promotion, and a suggested focus for identification of additional constructs of interest. Significance for public healthThe 29 items of the Multi-construct African American Cultural Survey, identified through IRT analyses, can be used by community health researchers interested in determining the relevance of cultural constructs in the design and implementation of colorectal cancer screening programs in the African American community. With appropriate identification of sociocultural concerns, CRC health education materials and promotion strategies may avoid unnecessary conflicts with community beliefs and values. Avoiding conflicts between beliefs and values increases the likelihood that evidence and the recommended behaviours are considered for adoption. In addition, the short survey, as well as the broader item set, may be useful as a starting point for surveys to be used with other cancer sites. The application of IRT analysis to measures of cultural constructs to facilitate the development of accurate and efficient measures may prove useful in other racial/ethnic communities where cultural concerns may be relevant for health education and promotion.

Validation of self-reported colorectal cancer screening behaviors among Appalachian residents

OBJECTIVES

We determined the validity of self-reported colorectal cancer (CRC) screening data provided by Appalachian Ohio residents and identified correlates of providing accurate data.

DESIGN AND SAMPLE

We conducted cross-sectional telephone interviews between September 2009 and April 2010. Our study included Appalachian Ohio residents (n = 721) ages 51-75 years.

MEASURES

We compared self-reported CRC screening data to medical records to determine validity. Multivariable logistic regression was used to identify correlates of providing accurate self-reported screening data.

RESULTS

About 68% of participants self-reported having any CRC screening test within recommended guidelines, whereas medical records indicated that only 49% were within guidelines (concordance = 0.76). Concordance was higher for flexible sigmoidoscopy and fecal occult blood test compared with colonoscopy, although sensitivity and positive predictive value were much higher for colonoscopy. Participants overreported CRC screening behaviors for all tests. Participants who had a regular checkup in the last 2 years (OR = 2.78, 95% CI: 1.15-6.73), or who self-rated their health as good or better (OR = 1.88, 95% CI: 1.12-3.16) were more likely to provide accurate screening data.

CONCLUSIONS

Many participants failed to provide accurate CRC screening data, and validity varied greatly across individual CRC screening tests. Future CRC screening studies among Appalachian residents should use medical records, if possible, to determine screening histories.

Online narratives and peer support for colorectal cancer screening: a pilot randomized trial

BACKGROUND

Delivering personal narratives and peer support for CRC screening in an online weight-loss community could be an efficient approach to engaging individuals at increased risk, because obesity is associated with excess colorectal cancer (CRC) mortality and lower screening rates.

PURPOSE

Evaluate user engagement and impact of narratives and peer support for promoting CRC screening in an online weight-loss community.

DESIGN

Pilot randomized trial.

SETTING/PARTICIPANTS

Members of an online weight-loss community who were not up-to-date with CRC screening were enrolled in the study in 2011.

INTERVENTION

Basic and Enhanced groups (n=153 each) both received education. The Enhanced group also received narratives and peer support for CRC screening in online forums.

MAIN OUTCOME MEASURES

The main measures were user engagement, psychosocial outcomes, and self-report CRC screening at 6 months. Analyses were conducted with (1) the full sample of participants and (2) a minimum dose sample of those who participated in their assigned intervention to a minimum degree. Analyses were completed in 2012.

RESULTS

Participants were mostly female (92%) with a mean age of 56 years. More than 90% in both groups viewed the educational information. Only 57% in the Enhanced group joined the online team. The Enhanced group had greater improvement in motivation for screening than the Basic group at 1 month (p=0.03). In the full sample, there was no difference in CRC screening at 6 months (Enhanced 19% vs Basic 16%, adjusted OR=1.33, 95% CI=0.73, 2.42). In the minimum dose sample, fecal occult blood testing was higher in the Enhanced (14%) vs Basic (7%) group (adjusted OR=2.49, 95% CI=1.01, 6.17).

CONCLUSIONS

Although no between-group differences in CRC screening were seen at 6 months, this study did demonstrate that it is feasible to deploy a narrative and peer support intervention for CRC screening in a randomized trial among members of an online community. However, modifications are needed to improve user engagement.

TRIAL REGISTRATION

This study is registered at ClinicalTrials.gov NCT01411826.

Systems intervention to promote colon cancer screening in safety net settings: protocol for a community-based participatory randomized controlled trial

BACKGROUND

Colorectal cancer is a leading cause of cancer mortality. Screening can be effective but is underutilized. System- or multi-level interventions could be effective at increasing screening, but most have been implemented and evaluated in higher-resource settings such as health maintenance organizations. Given the disparities evident for colorectal cancer and the potential for screening to improve outcomes, there is a need to expand this work to include diverse settings, including those who treat economically disadvantaged patients. This paper describes the study protocol for a trial designed to increase colorectal cancer screening in those 'safety-net' health centers that serve underinsured and uninsured patients. This trial was designed and is being implemented using a community-based participatory approach.

METHODS/DESIGN

We developed a practical clinical cluster-randomized controlled trial. We will recruit 16 community health centers to this trial. This systems-level intervention consists of a menu of evidence-based implementation strategies for increasing colorectal cancer screening. Health centers in the intervention arm then collaborate with the study team to tailor strategies to their own setting in order to maximize fit and acceptability. Data are collected at the organizational level through interviews, and at the provider and patient levels through surveys. Patients complete a survey about their healthcare and screening utilization at baseline, six months, and twelve months.

OUTCOMES

The primary outcome is colorectal cancer screening by patient self-report, supplemented by a chart-audit in a subsample of patients. Implementation outcomes informed by the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) conceptual framework will be measured at patient, provider, and practice levels.

DISCUSSION

Our study is one of the first to integrate community participatory strategies to a randomized controlled trial in a healthcare setting. The multi-level approach will support the ability of the intervention to affect screening through multiple avenues. The participatory approach will strengthen the chance that implementation strategies will be maintained after study completion and, supports external validity by increasing health center interest and willingness to participate.

TRIAL REGISTRATION

NCT01299493.

Correlates of self-reported colorectal cancer screening accuracy in a multi-specialty medical group practice

PURPOSE

We assessed whether accuracy of self-reported screening for colorectal cancer (CRC) varied by respondent characteristics or healthcare utilization.

METHODS

From 2005 to 2007, 857 respondents aged 51 - 74 were recruited from a multi-specialty medical group practice to answer a questionnaire about their CRC screening (CRCS) behaviors. Self-reports were compared with administrative and medical records to assess concordance, sensitivity, specificity, and report-to-records ratios for overall CRCS (fecal occult blood test, sigmoidoscopy, and/or colonoscopy).

RESULTS

Concordance was good (≥0.8 to <0.9) or fair (≥0.7 to <0.8) for most subgroups; respondents with >5 visits outside the clinic had poor (<0.7) concordance. Sensitivity estimates were mostly excellent (≥0.9) or good but poor for respondents whose healthcare provider did not advise a specific CRCS test. Specificity was poor for the following respondents: 65+ years, males, college graduates, family history of CRC, >5 visits outside of the clinic, or whose healthcare provider advised a specific CRCS test. Respondents 65+ years and with >5 outside visits over-reported CRCS.

CONCLUSIONS

With few exceptions, self-reports of CRCS in an insured population is reasonably accurate across subgroups. More work is needed to replicate these findings in diverse settings and populations to better understand subgroup differences and improve measures of CRCS.

Comparison of breast cancer screening rates between Korean women in America versus Korea

BACKGROUND

Breast cancer is the most commonly diagnosed cancer among Korean American women and among Korean women in Korea. However, many Asian women are not aware of the importance of screening mammography. This study compares breast cancer screening in Korean women in California and in Korea.

METHODS

The 2005 California Health Interview Survey (CHIS) and 2005 Korean National Cancer Screening Survey (KNCSS) were used to examine breast cancer screening and related factors. The sample included 252 Korean American women in California and 889 Korean women aged > or = 40 years. Logistic regression was used to predict the odds of having had a screening mammography in the past 2 years. For CHIS data, SUDAAN software (Research Triangle Institute, Research Triangle Park, NC) was used to take into account the design of the complex and multistage samples.

RESULTS

Korean women reported a lower rate than Korean American women of ever having had a screening mammography (50.8% vs. 77.8%). Korean women also had lower rates of having had a screening mammography in the past 2 years than Korean American women (39.5% vs. 57.2%). Korean Americans were less likely to undergo screening mammography if they were older. Korean women were less likely to undergo screening mammography if they were older, unemployed, lacked private cancer insurance, lacked health checkups, did not exercise, had poor health status, or currently smoked.

CONCLUSIONS

We found significant differences in cancer screening behavior in Korean women depending on where they lived. These differences may indicate an important influence of social factors on preventive health behavior.

Factors associated with participation in colorectal cancer screening in Korea: the Fourth Korean National Health and Nutrition Examination Survey (KNHANES IV)

PURPOSE

Despite the Government's National Cancer Screening Program for colorectal cancer (CRC), the number of individuals participating in screening in Korea is low. Therefore, the aim of this study was to identify associations between relevant risk factors and the uptake of screening in Korea.

METHODS

The Health Interview Survey sub-dataset derived from the Fourth Korean National Health and Nutrition Examination Survey (KNHANES IV) was used to evaluate participation in CRC screening and factors associated with attendance in individuals aged ≥50. Those that completed the questionnaire and not previously diagnosed with CRC were enrolled (8,042 subjects). Multi-dimensional covariates were considered as potential predictors for CRC screening in multivariate analyses.

RESULTS

A total of 33.2% complied with the CRC screening recommendations. The following were associated with participation: age (aged 70 or older [ref], aged 70 or over; odds ratio (OR) 1.81, 95% confidence interval (CI) 1.54-2.14), marital status (OR 1.43, 95%CI 1.23-1.66), urban-dwelling (OR 1.16, 95%CI 1.02-1.32), education level (elementary school or less [ref], high school (OR 1.29, 95%CI 1.09-1.53), university or higher (OR 1.53, 95%CI 1.23-1.91)), household income (fourth quartile [ref], first quartile (OR 1.29, 95%CI 1.07-1.56)), private health insurance (OR 1.38, 95%CI 1.21-1.58), smoking (OR 1.35, 95%CI 1.43-1.60), self-reported depression (OR 0.79, 95%CI 0.68-0.92), and number of chronic diseases (0-3 [ref], ≥4 (OR 1.41, 95%CI 1.22-1.62)).

CONCLUSION

To improve participation in CRC screening, appropriate strategies must be directed toward vulnerable populations, such as those with low socioeconomic status.

Implementation and process evaluation of a workplace colorectal cancer screening program in eastern Washington

Colorectal cancer screening is a life-saving intervention, but screening rates are low. The authors implemented and evaluated the Spokane Colorectal Cancer Screening Program-a novel worksite intervention to promote colorectal cancer screening that used a combination of evidence-based strategies recommended by the Guide to Community Preventive Services, as well as additional strategies. Over a period of approximately 3 months, participating worksites held one or more physician-led seminars about colorectal cancer screening for employees. They also distributed free fecal immunochemical tests at the worksite to employees 50 years and older, and they provided test results to employees and their primary care physician. The authors measured attendance at seminars, test kits taken and returned, employee awareness of the program, and colorectal cancer screening rates in participating and comparison worksites. It is estimated that 9% of eligible employees received kits at the worksite, and 4% were screened with these kits. The Spokane Colorectal Cancer Screening Program was a promising pilot test of an innovative worksite screening program that successfully translated evidence-based strategies into practical use in a brief period of time, and it merits a larger study to be able to test its effects more rigorously.

Colorectal cancer screening and physical activity promotion among obese women: an online evaluation of targeted messages

Obese women are at higher risk for several cancers, but are less likely than normal weight women to engage in cancer prevention behaviors such as screening and physical activity. Targeted health messages may help increase healthy behaviors among vulnerable groups such as obese women. Using findings from focus groups with obese women, the authors created targeted messages to promote colorectal cancer screening and physical activity among obese women. The messages addressed psychosocial constructs, such as benefits and barriers to colorectal cancer screening and exercise, which were relevant to the target population. Messages were tested online with women age 50 years and older (N = 181). Participants were stratified by weight (obese vs. nonobese) and randomized to review either 10 targeted (intervention) or 10 generic (control) messages. Study outcomes included elaboration about the messages, message relevance and trustworthiness, and behavioral intentions. The authors used moderation and subgroup analyses to determine whether the intervention messages were better received by certain women. They found no differences in elaboration, behavioral intentions, relevance, or trustworthiness between intervention and control for either weight group. However, exercise intentions increased more (p = .06) among inactive obese women who received intervention messages (+2.9) compared with those who were in the control group (+1.2). Intervention messages also produced more elaboration among women who viewed their weight as a barrier to screening or exercise. Tailoring intervention messages for obese women on the basis of behavior and barriers may improve outcomes more than giving the same messages to all obese women.

The prevalence of chronic pain with an analysis of countries with a Human Development Index less than 0.9: a systematic review without meta-analysis

BACKGROUND

To date, there are no systematic reviews of epidemiological studies of chronic pain in the developing world.

AIM

To estimate the prevalence of chronic pain worldwide paying particular attention to data from countries with a Human Development Index (HDI) of less than 0.9.

METHODS

A literature search was conducted for cross-sectional surveys of chronic pain (≥3 months) in the adult general population using Medline, Embase, CINAHL, SportDiscus, Sciencedirect, CAS ILLUMINA, Academic search complete, PsycINFO and AMED. Forty-eight studies were identified and 29 of these were excluded because they surveyed children, the elderly or were longitudinal studies.

RESULTS

Weighted mean ± SD prevalence of chronic pain worldwide was 30.3% ± 11.7% (19 studies, 65 surveys, 34 countries, 182,019 respondents). There was no correlation between HDI and prevalence. In countries with a HDI < 0.9 prevalence was 33.9% ± 14.5% and significantly higher than prevalence in countries with a HDI of ≥0.9 (29.9% ± 12.7%), although removal of a large study that may have included a sample of individuals with comorbidities reduced the worldwide estimate to 28.0% ± 11.8% (47 surveys, 33 countries, 139,770 participants). Interestingly, the estimate of countries with a HDI < 0.9 to 24.8% ± 8.9% (7 surveys, 7 countries, 6122 participants) became significantly lower than the estimate of countries with a HDI ≥ 0.9 which was 28.1% ± 11.6% (40 surveys, 21 countries, 133,648 participants).

CONCLUSION

The review provides further evidence that the prevalence of chronic pain in the general population is high. However, there was insufficient reliable data to estimate with any certainty the prevalence of chronic pain in countries with an HDI < 0.9 with variability in estimates between surveys being of concern. Subtle differences in review and survey methodology appeared to impact markedly on estimates. There is a need for epidemiological studies that estimate the prevalence of chronic pain in developing countries to determine the scale of the problem.

Cancer screening patterns by weight group and gender for urban African American church members

Obese white women have lower rates of cancer screening compared to non-obese women. This study will determine if a relationship exists between weight and adherence to cancer screening guidelines among African Americans. We used multivariate logistic regression to examine the relationship between being up-to-date with cancer screening (colorectal, breast, cervical, and prostate) and weight group (normal, overweight, obese I, obese II+) using data from older (age 50+) members (N = 955) of 20 African American churches in Michigan and North Carolina. CRC testing rates were examined using multiple definitions to account for differences in screening rates vs. polyp surveillance rates. After adjusting for confounders, we found relationships between weight group and up-to-date CRC (P = 0.04) and PSA (P = 0.004) testing for men and mammography (P = 0.03) for women. Compared to normal-weight men, obese I men were more likely to be up-to-date with CRC (OR 2.35, 95%CI 1.02-5.40) and PSA (OR 4.24 95%CI 1.77-10.17) testing. CRC screening rates were lower when individuals with polyps were excluded from the analysis; however, patterns by weight remained the same. Contrary to previous research, we did not find lower rates of cancer screening among obese African Americans. Instead, we found that normal-weight African American men had lower screening rates than any other group. As we did not consistently find lower screening rates among obese African Americans, targeting this group for increased screening promotion may not be the most effective way to reduce weight-related cancer disparities.

Acceptability of narratives to promote colorectal cancer screening in an online community

OBJECTIVE

To assess the acceptability of narratives to promote colorectal cancer (CRC) screening among members of an online weight loss community.

METHOD

Members of online weight loss community completed an Internet survey in 2010. Multiple logistic regression models examined demographic and attitudinal correlates of interest in sharing and receiving CRC screening narratives.

RESULTS

Participants (n=2386) were 92% female with mean (SD) age 58 (6) years; 68% were up-to-date with CRC screening. Among those who were up-to-date, 39% were interested in sharing their narratives with other members. African-Americans were more likely than other racial groups to be interested in sharing narratives (adjusted OR 2.02, 95% CI 1.14-3.57). Older, married members and those with greater CRC screening worries were less likely to be interested in sharing narratives. Among those not up-to-date, 63% were interested in receiving narratives from online community members, and those with higher perceived salience of CRC screening were more likely to be interested in receiving narratives (adjusted OR 1.86, 95% CI 1.31-2.65).

CONCLUSIONS

Members of this online weight loss community expressed interest in sharing and receiving narratives for CRC screening promotion. Attitudes and demographic characteristics may predict successful recruitment of those who would share and receive narratives.

Patterns of colorectal cancer test use, including CT colonography, in the 2010 National Health Interview Survey

BACKGROUND

Recommended colorectal cancer (CRC) screening tests for adults ages 50 to 75 years include home fecal occult blood tests (FOBT), sigmoidoscopy with FOBT, and colonoscopy. A newer test, computed tomographic (CT) colonography, has been recommended by some, but not all, national organizations.

METHODS

We analyzed 2010 National Health Interview Survey data, including new CT colonography questions, from respondents ages 50 to 75 years (N = 8,952). We (i) assessed prevalence of CRC test use overall, by test type, and by sociodemographic and health care access factors and (ii) assessed reported reasons for not having a CRC test.

RESULTS

The age-standardized percentage of respondents reporting FOBT, sigmoidoscopy, or colonoscopy within recommended time intervals was 58.3% [95% confidence interval (CI), 57.0-59.6]. Colonoscopy was the most commonly reported test [within past 10 years: 54.6% (95% CI, 53.2-55.9)]. Home FOBT and sigmoidoscopy with FOBT were less frequently used [FOBT within past year: 8.8% (95% CI, 8.1-9.6); sigmoidoscopy within past 5 years with FOBT within past 3 years: 1.3% (95% CI, 1.0-1.6)]. CT colonography was rare: 1.3% (95% CI, 1.0-1.7). Increasing age, education, income, having health care insurance, and having a usual source of health care were associated with higher CRC test use. Test use within recommended time intervals was particularly low among individuals ages 50 to 64 years without health care insurance [21.2% (95% CI, 18.3-24.4)]. The most common reason for nonuse was "no reason or never thought about it."

CONCLUSIONS

About 40% of Americans ages 50 to 75 years do not meet the recommendations for having CRC screening tests.

IMPACT

Expanded health care coverage and greater awareness of CRC screening are needed to further decrease CRC mortality.

Overutilization of endoscopic surveillance in nondysplastic Barrett's esophagus: a multicenter study

BACKGROUND

Guidelines suggest that patients with nondysplastic Barrett's esophagus (BE) undergo endoscopic surveillance every 3 to 5 years, but actual use of surveillance endoscopy and the determinants of variation in surveillance intervals are not known.

OBJECTIVE

To measure use of surveillance endoscopy and its variation in patients with nondysplastic BE.

DESIGN

Multicenter, cross-sectional study.

SETTING

Three sites in Arizona, Minnesota, and North Carolina.

PATIENTS

This study involved patients who had prevalent BE without a history of high-grade dysplasia or esophageal adenocarcinoma.

INTERVENTION

Participants were given validated measures of quality of life, numeracy, and cancer risk perception, and the total number of prior endoscopic surveillance examinations was measured.

MAIN OUTCOME MEASUREMENTS

Oversurveillance was defined as >1 surveillance examination per 3-year period.

RESULTS

Among 235 patients with nondysplastic BE, 76% were male and 94% were white. The average (± standard deviation [SD]) duration of BE was 6.5 ± 5.9 years. The mean (± SD) number of endoscopies per 3-year period was 2.7 ± 2.6. Oversurveillance was present in 65% of participants, resulting in a mean of 2.3 excess endoscopies per patient. Neither numeracy skills nor patient perception of cancer risk were associated with oversurveillance.

LIMITATIONS

Endoscopies were measured by patient report, which is subject to error. Results may be generalizable only to patients seen in academic centers.

CONCLUSION

Most patients with nondysplastic BE had more surveillance endoscopic examinations than is recommended by published guidelines. Patient factors did not predict oversurveillance, indicating that other factors may influence decisions about the interval and frequency of surveillance examinations.

Analysis of the efficacy of screening tests in colorectal cancer by faecal occult blood test--own experience

Screening of the colon cancer seems to be important to improve the results of the surgical treatment. There are different screening programs, the most common use the fecal occult blood (FOB) tests or colonoscopy.

THE AIM OF THE STUDY

was to evaluate the results of the colon cancer screening based on the FOB test and perform the algorhytm improving the effectiveness of the screening.

MATERIAL AND METHODS

941 patients with the positive results of the FOB (immunochromatographic method) test were investigated. In all cases the rectosigmoidoscopy for the detection of the lower GI tract pathology was done. 312 patients were qualified to colonoscopy.

RESULTS

Adenomatous polyps and adenocarcinomas were detected in 116 patients. There was no correlation between clinical symptoms and the colorectal cancer. The colorectal cancer was recognized statistically more common at the patients with previous detected neoplasia, in the colon and other organs, with hereditary nonpolyposis colorectal cancer and with inflammatory bowel diseases.

CONCLUSIONS

The colorectal cancer screening based on the FOB can be effective in the early recognition of the bowel malignancy. The previous questionnaire can eliminate from the FOB screening the patients without indications (previously done colonoscopy or barium enema) or with directly indications for colonoscopy.