Sociopsychological tailoring to address colorectal cancer screening disparities: a randomized controlled trial

Interventions for improving health literacy in migrants

BACKGROUND

Health literacy (HL) is a determinant of health and important for autonomous decision-making. Migrants are at high risk for limited HL. Improving HL is important for equitable promotion of migrants' health.

OBJECTIVES

To assess the effectiveness of interventions for improving HL in migrants. To assess whether female or male migrants respond differently to the identified interventions.

SEARCH METHODS

We ran electronic searches to 2 February 2022 in CENTRAL, MEDLINE, Embase, PsycInfo and CINAHL. We also searched trial registries. We used a study filter for randomised controlled trials (RCTs) (RCT classifier).

SELECTION CRITERIA

We included RCTs and cluster-RCTs addressing HL either as a concept or its components (access, understand, appraise, apply health information).

DATA COLLECTION AND ANALYSIS

We used the methodological procedures recommended by Cochrane and followed the PRISMA-E guidelines. Outcome categories were: a) HL, b) quality of life (QoL), c) knowledge, d) health outcomes, e) health behaviour, f) self-efficacy, g) health service use and h) adverse events. We conducted meta-analysis where possible, and reported the remaining results as a narrative synthesis.

MAIN RESULTS

We included 28 RCTs and six cluster-RCTs (8249 participants), all conducted in high-income countries. Participants were migrants with a wide range of conditions. All interventions were adapted to culture, language and literacy. We did not find evidence that HL interventions cause harm, but only two studies assessed adverse events (e.g. anxiety). Many studies reported results for short-term assessments (less than six weeks after total programme completion), reported here. For several comparisons, there were also findings at later time points, which are presented in the review text. Compared with no HL intervention (standard care/no intervention) or an unrelated HL intervention (similar intervention but different information topic) Self-management programmes (SMP) probably improve self-efficacy slightly (standardised mean difference (SMD) 0.28, 95% confidence interval (CI) 0.06 to 0.50; 2 studies, 333 participants; moderate certainty). SMP may improve HIV-related HL (understanding (mean difference (MD) 4.25, 95% CI 1.32 to 7.18); recognition of HIV terms (MD 3.32, 95% CI 1.28 to 5.36)) (1 study, 69 participants). SMP may slightly improve health behaviours (3 studies, 514 participants), but may have little or no effect on knowledge (2 studies, 321 participants) or subjective health status (MD 0.38, 95% CI -0.13 to 0.89; 1 study, 69 participants) (low certainty). We are uncertain of the effects of SMP on QoL, health service use or adverse events due to a lack of evidence. HL skills building courses (HLSBC) may improve knowledge (MD 10.87, 95% CI 5.69 to 16.06; 2 studies, 111 participants) and any generic HL (SMD 0.48, 95% CI 0.20 to 0.75; 2 studies, 229 participants), but may have little or no effect on depression literacy (MD 0.17, 95% CI -1.28 to 1.62) or any health behaviour (2 studies, 229 participants) (low certainty). We are uncertain if HLSBC improve QoL, health outcomes, health service use, self-efficacy or adverse events, due to very low-certainty or a lack of evidence. Audio-/visual education without personal feedback (AVE) probably improves depression literacy (MD 8.62, 95% CI 7.51 to 9.73; 1 study, 202 participants) and health service use (MD -0.59, 95% CI -1.11 to -0.07; 1 study, 157 participants), but probably has little or no effect on health behaviour (risk ratio (RR) 1.07, 95% CI 0.91 to 1.25; 1 study, 135 participants) (moderate certainty). AVE may improve self-efficacy (MD 3.51, 95% CI 2.53 to 4.49; 1 study, 133 participants) and may slightly improve knowledge (MD 8.44, 95% CI -2.56 to 19.44; 2 studies, 293 participants) and intention to seek depression treatment (MD 1.8, 95% CI 0.43 to 3.17), with little or no effect on depression (SMD -0.15, 95% CI -0.40 to 0.10) (low certainty). No evidence was found for QoL and adverse events. Adapted medical instruction may improve understanding of health information (3 studies, 478 participants), with little or no effect on medication adherence (MD 0.5, 95% CI -0.1 to 1.1; 1 study, 200 participants) (low certainty). No evidence was found for QoL, health outcomes, knowledge, health service use, self-efficacy or adverse events. Compared with written information on the same topic SMP probably improves health numeracy slightly (MD 0.7, 95% CI 0.15 to 1.25) and probably improves print literacy (MD 9, 95% CI 2.9 to 15.1; 1 study, 209 participants) and self-efficacy (SMD 0.47, 95% CI 0.3 to 0.64; 4 studies, 552 participants) (moderate certainty). SMP may improve any disease-specific HL (SMD 0.67, 95% CI 0.27 to 1.07; 4 studies, 955 participants), knowledge (MD 11.45, 95% CI 4.75 to 18.15; 6 studies, 1101 participants) and some health behaviours (4 studies, 797 participants), with little or no effect on health information appraisal (MD 1.15, 95% CI -0.23 to 2.53; 1 study, 329 participants) (low certainty). We are uncertain whether SMP improves QoL, health outcomes, health service use or adverse events, due to a lack of evidence or low/very low-certainty evidence. AVE probably has little or no effect on diabetes HL (MD 2, 95% CI -0.15 to 4.15; 1 study, 240 participants), but probably improves information appraisal (MD -9.88, 95% CI -12.87 to -6.89) and application (RR 1.51, 95% CI 1.29 to 1.77) (1 study, 608 participants; moderate certainty). AVE may slightly improve knowledge (MD 8.35, 95% CI -0.32 to 17.02; low certainty). No short-term evidence was found for QoL, depression, health behaviour, self-efficacy, health service use or adverse events. AVE compared with another AVE We are uncertain whether narrative videos are superior to factual knowledge videos as the evidence is of very low certainty. Gender differences Female migrants' diabetes HL may improve slightly more than that of males, when receiving AVE (MD 5.00, 95% CI 0.62 to 9.38; 1 study, 118 participants), but we do not know whether female or male migrants benefit differently from other interventions due to very low-certainty or a lack of evidence.

AUTHORS' CONCLUSIONS

Adequately powered studies measuring long-term effects (more than six months) of HL interventions in female and male migrants are needed, using well-validated tools and representing various healthcare systems.

Mobile Health (mHealth) Interventions to Increase Cancer Screening Rates in Hispanic/Latinx Populations: A Scoping Review

Hispanic/Latinx persons have disproportionately lower breast, cervical, and colorectal cancer screening rates than non-Hispanic White (NHW) persons. This low participation in cancer screening results in late-stage cancer diagnosis among Hispanic persons compared to NHW persons. Mobile health (mHealth) interventions effectively improve cancer screening rates in the general population; however, few reviews about mHealth interventions are tailored to Hispanic populations. This is important to investigate given that Hispanic persons differ from NHW persons with regard to culture, language, and health care utilization. Therefore, in this study, we investigated: (a) What types of mHealth interventions have been undertaken to increase cancer screening rates among Hispanic persons in the United States? (b) How effective have these interventions been? and (c) What features of these interventions help increase cancer screening rates? Searches conducted during December 2020 identified 10 articles published between January 2017 and December 2020 that met our inclusion criteria. The review revealed that mHealth interventions mainly provided education about cancer and cancer screening using videos, PowerPoint slides, and interactive multimedia. mHealth interventions that effectively improved screening behavior were mainly for easy-to-screen cancers like skin and cervical cancer. Finally, reviewed studies did not provide details on how cultural adaptations were made, and it is unclear what specific features of mHealth interventions increase cancer screening rates among Hispanic persons. Future research should identify and evaluate the effects of different components of culturally tailored interventions on cancer screening. Public health practitioners and health care providers should tailor mHealth approaches to their clients or patients and practice environment.

Psychosocial Risk Profiles and Colorectal Cancer Screening: A Latent Profile Analysis in a Colorectal Cancer Screening Intervention Setting

Health behavior theories have identified predictors of colorectal cancer screening. This study aimed to determine the psychosocial profiles of a predominantly Hispanic population of primarily Mexican origin receiving a colorectal cancer screening intervention and whether a specific combination of psychosocial profiles modified the effect of colorectal cancer screening intervention on colorectal cancer screening uptake.A total of 467 participants aged 50 to 75 years due for colorectal cancer screening received an educational intervention. Latent profile analysis (LPA) was performed on baseline psychosocial constructs to identify the homogenous clustering of individuals with similar psychosocial constructs. In addition, colorectal cancer screening rates and changes in psychosocial scores between the latent groups were compared.Three psychosocial profiles, including a low benefit and high susceptibility group (LBHS), a high benefit and low susceptibility group (HBLS), and a high barrier and high susceptibility group (HBHS), were identified in this study. The HBLS group had the lowest susceptibility, with no improvement in benefits and barriers. This group had the lowest screening rate (80.85%) compared with 88.8% in LBHS and 86.3% in HBHS following the intervention. Finally, the intervention effect size on psychosocial score changes was smaller in HBLS than in other groups.This subgroup analysis suggests that colorectal cancer educational interventions should be tailored to improve the benefits and barriers among individuals with high susceptibility scores.

PREVENTION RELEVANCE

This LPA analysis provides some direction for tailoring colorectal cancer educational interventions to improve the benefits and barriers among individuals with high susceptibility scores in hard-to-screen populations such as our border population.

Video Interventions for Reducing Health Inequity in Cancer Screening Programmes: a Systematic Review

BACKGROUND

Health equity can lead to disparities in cancer screening, treatment, and mortality. This systematic review aims to identify and describe interventions that used video or DVD formats to reduce health inequity in cancer screening and review the effectiveness of such interventions in increasing screening rates compared to usual care conditions.

METHODS

We searched PubMed, Web of Science, Embase, and Cochrane databases for randomized control trials (RCTs) published until 18/01/2023 that compared intervention versus usual care control groups, with the percentage of cancer screening uptake during follow-up as an outcome. The risk of Bias was assessed with the Cochrane Collaboration tool.

RESULTS

After screening 4201 abstracts, 192 full texts were assessed for eligibility and 18 were included that focused on colorectal (n = 9), cervical (n = 5), breast (n = 5), and prostate (n = 1) cancer screening. All were based in the USA except one and most focused on ethnicity/race, while some included low-income populations. Most of the video interventions used to increase cervical cancer screening reported positive results. Studies aimed at increasing mammography uptake were mostly effective only in specific groups of participants, such as low-income or less-educated African American women. Results for colorectal cancer screening were conflicting. Videos that were culturally tailored or used emotive format were generally more effective than information-only videos.

CONCLUSIONS

Video interventions to increase cancer screening among populations with low screening uptake show some positive effects, though results are mixed. Interventions that use individual and cultural tailoring of the educational material should be further developed and investigated outside of the USA.

Interactive or tailored digital interventions to increase uptake in cervical, breast, and colorectal cancer screening to reduce health inequity: a systematic review

BACKGROUND AND OBJECTIVES

Significant health inequities exist in screening uptake for certain types of cancer. The review question was to identify and describe interactive, tailored digital, computer, and web-based interventions to reduce health inequity in cancer screening and review the effectiveness of such interventions in increasing screening rates versus usual care.

METHODS

We searched four medical literature databases for randomized control trials (RCTs) published until 12 January 2023 that evaluated interventions aimed at increasing the percentage of breast, prostate, cervical, or colorectal cancer screening uptake. Meta-analysis was not conducted due to heterogeneity among studies.

RESULTS

After screening 4200 titles and abstracts, 17 studies were included. Studies focused on colorectal ( n  = 10), breast ( n  = 4), cervical ( n  = 2), and prostate ( n  = 1) cancer screening. All were based in the USA except two. Most studies focused on ethnicity/race, while some included low-income populations. Intervention types were heterogeneous and used computer programs, apps, or web-based methods to provide tailored or interactive information to participants about screening risks and options. Some studies found positive effects for increasing cancer screening uptake in the intervention groups compared to usual care, but results were heterogeneous.

CONCLUSION

Interventions that use individual and cultural tailoring of cancer screening educational material should be further developed and investigated outside of the USA. Designing effective digital intervention strategies, with components that can be adapted to remote delivery may be an important strategy for reducing health inequities in cancer screening during the coronavirus disease 2019 pandemic.

Utilization of Hepatocellular Carcinoma Surveillance Programs in Patients With Cirrhosis: A Systematic Review and Meta-Analysis

Patients with cirrhosis are advised to undergo hepatocellular carcinoma (HCC) surveillance every 6 months. Routine surveillance is associated with early tumor detection and improved survival. However, surveillance is underutilized. We aimed to characterize the uptake of HCC surveillance in cirrhotic patients following the implementation of interventional programs. We performed a comprehensive literature search of major databases (from inception to October 2020). Surveillance was defined as having an abdominal sonogram every 6 months. Nine studies were included for meta-analysis which involved 4550 patients. The etiology of liver cirrhosis was largely due to hepatitis C or B (n=2023), followed by alcohol (n=857), and nonalcoholic steatohepatitis (n=432). Patients enrolled in surveillance programs were 6 times more likely to undergo abdominal sonography when compared with standard of care (odds ratio=6.00; 95% confidence interval: 3.35-10.77). On subgroup analysis, clinical reminders were associated with a 4 times higher rate of HCC surveillance compared with standard of care (odds ratio=3.80; 95% confidence interval: 2.25-6.39). Interventional programs significantly improve the rate of HCC surveillance. This is clinically impactful and should be considered as a means for improving surveillance rates.

Interventions to reduce cancer screening inequities: the perspective and role of patients, advocacy groups, and empowerment organizations

BACKGROUND

Health inequities lead to low rates of cancer screening in certain populations, such as low-income and ethnic minority groups. Different interventions to address this have been developed with mixed results. However, interventions are not always developed in collaboration with the people they target. The aim of our article is to present the viewpoint of patients, survivors, advocates, and lay persons on interventions to increase cancer screening from a health inequity perspective.

METHODS

We prepared talking points to guide discussions between coauthors, who included representatives from nine patient and survivor advocacy groups, organizations working for citizen/patient empowerment, and health equity experts. Perspectives and opinions were first collected through video conferencing meetings and a first draft of the paper was prepared. All authors, read through, revised, and discussed the contents to reach an agreement on the final perspectives to be presented.

RESULTS

Several themes were identified: it is important to not view screening as a discrete event; barriers underlying an individual's access and willingness to undergo screening span across a continuum; individually tailored interventions are likely to be more effective than a one-size fits-all approach because they may better accommodate the person's personal beliefs, knowledge, behaviors, and preferences; targeting people who are unknown to medical services and largely unreachable is a major challenge; including professional patient advocacy groups and relevant lay persons in the cocreation of interventions at all stages of design, implementation, and evaluation is essential along with relevant stakeholders (healthcare professionals, researchers, local government and community organizations etc).

CONCLUSIONS

Interventions to address cancer screening inequity currently do not adequately solve the issue, especially from the viewpoint of patients, survivors, and lay persons. Several core pathways should be focused on when designing and implementing interventions: advancing individually tailored interventions; digital tools and social media; peer-based approaches; empowerment; addressing policy and system barriers; better design of interventions; and collaboration, including the involvement of patients and patient advocacy organizations.

Testing the Effectiveness of an Animated Decision Aid to Improve Recruitment of Control Participants in a Case-Control Study: Web-Based Experiment

BACKGROUND

Participation in case-control studies is crucial in epidemiological research. The self-sampling bias, low response rate, and poor recruitment of population representative controls are often reported as limitations of case-control studies with limited strategies to improve participation. With greater use of web-based methods in health research, there is a further need to understand the effectiveness of different tools to enhance informed decision-making and willingness to take part in research.

OBJECTIVE

This study tests whether the inclusion of an animated decision aid in the recruitment page of a study website can increase participants' intentions to volunteer as controls.

METHODS

A total of 1425 women were included in a web-based experiment and randomized to one of two experimental conditions: one in which they were exposed to a simulated website that included the animation (animation; n=693, 48.6%), and one in which they were exposed to the simulated website without the animation (control; n=732, 51.4%). The simulated website was adapted from a real website for a case-control study, which invites people to consider taking part in a study that investigates differences in purchasing behaviors between women with and without ovarian cancer and share their loyalty card data collected through 2 high street retailers with the researchers. After exposure to the experimental manipulation, participants were asked to state (1) their intention to take part in the case-control study, (2) whether they would be willing to share their loyalty card for research, and (3) their willingness to be redirected to the real website after completing the survey. Data were assessed using ordinal and binary logistic regression, reported in percentages (%), adjusted odds ratio (AOR), and 95% confidence intervals.

RESULTS

Including the animation in the simulated website did not increase intentions to participate in the study (AOR 1.09; 95% CI 0.88-1.35) or willingness to visit the real study website after the survey (control 50.5% vs animation 52.6%, AOR 1.08; 95% CI 0.85-1.37). The animation, however, increased the participants' intentions to share the data from their loyalty cards for research in general (control 17.9% vs animation 26%; AOR 1.64; 95% CI 1.23-2.18).

CONCLUSIONS

While the results of this study indicate that the animated decision aid did not lead to greater intention to take part in our web-based case-control study, they show that they can be effective in increasing people's willingness to share sensitive data for health research.

Coping Strategies in Elderly Colorectal Cancer Patients

Simple Summary

Coping strategies help to mitigate the impact of a situation on an individual’s life. Elderly patients that undergo the stressful situation of going through colorectal cancer are no exception. This systematic review describes the improvement of the quality of life of patients who applied coping strategies to their situation. The results expose that coping strategies helped these patients to adapt and overcome the disease’s stressful scenarios.

Abstract

In Spain, 34,331 new cases of colorectal cancer were diagnosed in 2018 and 15,923 individuals died from this disease in the same year. The highest incidence of colorectal cancer is among individuals aged 65–75 years and the physiological consequences of aging, alongside the effects of the disease and its treatment, can exacerbate their physical deterioration and cognitive impairment and reduce their social relationships. The learning of coping strategies may help to improve the quality of life of patients after cancer diagnosis. To test the hypothesis that the utilization of coping strategies can improve the quality of life of elderly patients with colorectal cancer, PubMed and EBSCO databases were searched, up to 2021, using the following terms: “coping strategies and colorectal cancer” with “anxiety”, “quality of life”, “depression”, “unmet needs”, “optimism”, “intimacy”, “distress”, “self-efficacy” and “self-esteem” with Boolean operators “AND”, “OR”. The literature search retrieved 641 titles/abstracts written in English. After an exhaustive analysis, only 7 studies met the inclusion criteria. Randomized evidence was scant and was reported only in 3/7 of the studies analyzed. Data from available randomized evidence support that patients improved on their depression and quality of life and felt more prepared to deal with their cancer. Coping strategies in patients with colorectal cancer were effective in improving patient adaptation to their new situation. Healthcare professionals working with these patients should receive training in this complementary treatment, to be able to conduct comprehensive care in order to improve the quality of life of these patients.

Mediators of screening uptake in a colorectal cancer screening intervention among Hispanics

Background

Colorectal cancer (CRC) is the second leading cause of cancer deaths in the USA. Although a number of CRC screening tests have been established as being effective for CRC prevention and early detection, rates of CRC screening test completion in the US population remain suboptimal, especially among the uninsured, recent immigrants and Hispanics. In this study, we used a structural equation modelling approach to identify factors influencing screening test completion in a successful CRC screening program that was implemented in an uninsured Hispanic population. This information will enhance our understanding of influences on CRC screening among historically underscreened populations.

Methods

We used generalized structural equation models (SEM) utilizing participant reported information collected through a series of surveys. We identified direct and indirect pathways through which cofactors, CRC knowledge and individual Health Belief Model constructs (perceived benefits, barriers, susceptibility, fatalism and self-efficacy) and a latent psychosocial health construct mediated screening in an effective prospective randomized CRC screening intervention that was tailored for uninsured Hispanic Americans.

Results

Seven hundred twenty-three participants were eligible for inclusion; mean age was 56 years, 79.7% were female, and 98.9% were Hispanic. The total intervention effect was comparable in both models, with both having a direct and indirect effect on screening completion (n = 715, Model 1: RC = 2.46 [95% CI: 2.20, 2.71, p < 0.001]; n = 699, Model 2 RC =2.45, [95% CI: 2.18, 2.72, p < 0.001]. In Model 1, 32% of the overall effect was mediated by the latent psychosocial health construct (RC = 0.79, p < 0.001) that was in turn mainly influenced by self-efficacy, perceived benefits and fatalism. In Model 2, the most important individual mediators were self-efficacy (RC = 0.24, p = 0.013), and fatalism (RC = 0.07, p = 0.033).

Conclusion

This study contributes to our understanding of mediators of CRC screening and suggests that targeting self-efficacy, perceived benefits and fatalism could maximize the effectiveness of CRC screening interventions particularly in Hispanic populations.

From participation to diagnostic assessment: a systematic scoping review of the role of the primary healthcare sector in the National Bowel Cancer Screening Program

Primary health care (PHC) plays a vital support role in organised colorectal cancer (CRC) screening programs by encouraging patient participation and ensuring timely referral for diagnostic assessment follow up. A systematic scoping review of the current evidence was conducted to inform strategies that better engage the PHC sector in organised CRC screening programs. Articles published from 2005 to November 2019 were searched across five databases. Evidence was synthesised and interventions that specifically require PHC involvement were mapped to stages of the CRC screening pathway. Fifty-seven unique studies were identified in which patient, provider and system-level interventions align with defined stages of the CRC screening pathway: namely, identifying/reminding patients who have not responded to CRC screening (non-adherence) (n=46) and follow up of a positive screen referral (n=11). Self-management support initiatives (patient level) and improvement initiatives (system level) demonstrate consistent benefits along the CRC screening pathway. Interventions evaluated as part of a quality-improvement process tended to report effectiveness; however, the variation in reporting makes it difficult to determine which elements contributed to the overall study outcomes. To maximise the benefits of population-based screening programs, better integration into existing primary care services can be achieved through targeting preventive and quality care interventions along the entire screening pathway.

Evaluation of Interventions Intended to Increase Colorectal Cancer Screening Rates in the United States: A Systematic Review and Meta-analysis

IMPORTANCE

Colorectal cancer screening (CRC) is recommended by all major US medical organizations but remains underused.

OBJECTIVE

To identify interventions associated with increasing CRC screening rates and their effect sizes.

DATA SOURCES

PubMed, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, and ClinicalTrials.gov were searched from January 1, 1996, to August 31, 2017. Key search terms included colorectal cancer and screening.

STUDY SELECTION

Randomized clinical trials of US-based interventions in clinical settings designed to improve CRC screening test completion in average-risk adults.

DATA EXTRACTION AND SYNTHESIS

At least 2 investigators independently extracted data and appraised each study's risk of bias. Where sufficient data were available, random-effects meta-analysis was used to obtain either a pooled risk ratio (RR) or risk difference (RD) for screening completion for each type of intervention.

MAIN OUTCOMES AND MEASURES

The main outcome was completion of CRC screening. Examination included interventions to increase completion of (1) initial CRC screening by any recommended modality, (2) colonoscopy after an abnormal initial screening test result, and (3) continued rounds of annual fecal blood tests (FBTs).

RESULTS

The main review included 73 randomized clinical trials comprising 366 766 patients at low or medium risk of bias. Interventions that were associated with increased CRC screening completion rates compared with usual care included FBT outreach (RR, 2.26; 95% CI, 1.81-2.81; RD, 22%; 95% CI, 17%-27%), patient navigation (RR, 2.01; 95% CI, 1.64-2.46; RD, 18%; 95% CI, 13%-23%), patient education (RR, 1.20; 95% CI, 1.06-1.36; RD, 4%; 95% CI, 1%-6%), patient reminders (RR, 1.20; 95% CI, 1.02-1.41; RD, 3%; 95% CI, 0%-5%), clinician interventions of academic detailing (RD, 10%; 95% CI, 3%-17%), and clinician reminders (RD, 13%; 95% CI, 8%-19%). Combinations of interventions (clinician interventions or navigation added to FBT outreach) were associated with greater increases than single components (RR, 1.18; 95% CI, 1.09-1.29; RD, 7%; 95% CI, 3%-11%). Repeated mailed FBTs with navigation were associated with increased annual FBT completion (RR, 2.09; 95% CI, 1.91-2.29; RD, 39%; 95% CI, 29%-49%). Patient navigation was not associated with colonoscopy completion after an initial abnormal screening test result (RR, 1.21; 95% CI, 0.92-1.60; RD, 14%; 95% CI, 0%-29%).

CONCLUSIONS AND RELEVANCE

Fecal blood test outreach and patient navigation, particularly in the context of multicomponent interventions, were associated with increased CRC screening rates in US trials. Fecal blood test outreach should be incorporated into population-based screening programs. More research is needed on interventions to increase adherence to continued FBTs, follow-up of abnormal initial screening test results, and cost-effectiveness and other implementation barriers for more intensive interventions, such as navigation.

Colorectal cancer screening use among insured adults: Is out-of-pocket cost a barrier to routine screening?

AIM

To describe the characteristics of adults who needed to see a doctor in the past year but could not due to the extra cost and assess the impact of limited financial resources on the receipt of routine fecal occult blood test, sigmoidoscopy, or colonoscopy for colon cancer screening among insured patients.

METHODS

Data obtained from the 2012 Behavioral Risk Factor Surveillance System included 215436 insured adults age 50-75 years. We computed frequencies, adjusted odds ratios (aORs), and 95%CIs using SAS v9.3 software.

RESULTS

Nine percent of the study population needed to see a doctor in the past year but could not because of cost. The numbers were significantly higher among those aged 50-64 (P < 0.0001), Non-Hispanic Whites (P < 0.0001), and those with a primary care physician (P < 0.0001) among other factors. Adjusting for possible confounders, aORs for not seeing the doctor in the past year because of cost were: stool occult blood test within last year aOR = 0.88; 95%CI: 0.76-1.02, sigmoidoscopy within last year aOR = 0.72; 95%CI: 0.48-1.07, colonoscopy within the last year aOR = 0.91; 95%CI: 0.81-1.02.

CONCLUSION

We found that the limited financial resources within the past 12 mo were significantly associated with colorectal cancer (CRC) non-screening. Patients with risk factors identified in this study should adhere to CRC guidelines and should receive financial help if needed.

Colorectal cancer screening use among insured adults: Is out-of-pocket cost a barrier to routine screening?

AIM

To describe the characteristics of adults who needed to see a doctor in the past year but could not due to the extra cost and assess the impact of limited financial resources on the receipt of routine fecal occult blood test, sigmoidoscopy, or colonoscopy for colon cancer screening among insured patients.

METHODS

Data obtained from the 2012 Behavioral Risk Factor Surveillance System included 215436 insured adults age 50-75 years. We computed frequencies, adjusted odds ratios (aORs), and 95%CIs using SAS v9.3 software.

RESULTS

Nine percent of the study population needed to see a doctor in the past year but could not because of cost. The numbers were significantly higher among those aged 50-64 (P < 0.0001), Non-Hispanic Whites (P < 0.0001), and those with a primary care physician (P < 0.0001) among other factors. Adjusting for possible confounders, aORs for not seeing the doctor in the past year because of cost were: stool occult blood test within last year aOR = 0.88; 95%CI: 0.76-1.02, sigmoidoscopy within last year aOR = 0.72; 95%CI: 0.48-1.07, colonoscopy within the last year aOR = 0.91; 95%CI: 0.81-1.02.

CONCLUSION

We found that the limited financial resources within the past 12 mo were significantly associated with colorectal cancer (CRC) non-screening. Patients with risk factors identified in this study should adhere to CRC guidelines and should receive financial help if needed.

Interventions Promoting Colorectal Cancer Screening Among Latino Men: A Systematic Review

Introduction

Colorectal cancer, the second leading cause of cancer death in the United States, is also among the most preventable cancers. However, Latino men are less likely than non-Latino men to engage in preventive screening. Compared with 60% of non-Latino white men and women, only 42% of Latino men are up to date with colorectal cancer screening guidelines, which may result in diagnosis at advanced disease stages and increased deaths. We evaluated the literature on colorectal cancer screening interventions among Latino men to characterize intervention components effective in increasing colorectal cancer screening.

Methods

Two independent reviewers searched MEDLINE, CINAHL, and PsycINFO to identify articles on intervention studies that promote colorectal cancer screening among Latino men. Inclusion criteria were randomized controlled or comparative effectiveness trials, an outcome of any colorectal cancer screening test, published in English, US-based, results published from January 2004 through December 2016, Latino or Spanish-speaking male participants, and a minimum of one patient-level component. Two other reviewers independently assessed article quality and conducted data abstraction.

Results

Forty-four studies met the inclusion criteria; only 7 studies with 20% or more Latinos and 39% or more men were included in the final analyses. The most common intervention strategies included one-on-one interactions with a patient navigator and reducing structural barriers (eg, providing fecal occult blood tests). Interventions using small media produced mixed results.

Conclusion

Although intervention studies focused on colorectal cancer screening among men of racial/ethnic minorities are scarce, our findings highlight promising strategies that were effective at increasing colorectal cancer screening among Latino men. Additional research in the area of Latino men’s health is needed, especially to further develop and test theoretically grounded interventions that promote colorectal cancer screening with larger samples of men and across diverse geographic areas in the United States.

Taxonomy for colorectal cancer screening promotion: Lessons from recent randomized controlled trials

OBJECTIVE

To derive a taxonomy for colorectal cancer screening that advances Randomized Controlled Trials (RCTs) and screening uptake.

DESIGN

Detailed publication review, multiple interviews with principal investigators (PIs) and collaboration with PIs as co-authors produced a CRCS intervention taxonomy. Semi-structured interview questions with PIs (Drs. Inadomi, Myers, Green, Gupta, Jerant and Ritvo) yielded details about trial conduct. Interview comparisons led to an iterative process informing serial interviews until a consensus was obtained on final taxonomy structure.

RESULTS

These taxonomy headings (Engagement Sponsor, Population Targeted, Alternative Screening Tests, Delivery Methods, and Support for Test Performance (EPADS)) were used to compare studies. Exemplary insights emphasized: 1) direct test delivery to patients; 2) linguistic-ethnic matching of staff to minority subjects; and 3) authorization of navigators to schedule or refer for colonoscopies and/or distribute stool blood tests during screening promotion.

CONCLUSION

PIs of key RCTs (2012-2015) derived a CRCS taxonomy useful in detailed examination of CRCS promotion and design of future RCTs.

A randomized controlled trial of a multicomponent, targeted, low-literacy educational intervention compared with a nontargeted intervention to boost colorectal cancer screening with fecal immunochemical testing in community clinics

BACKGROUND

The objective of the current study was to improve colorectal cancer (CRC) screening uptake with the fecal immunochemical test (FIT). The current study investigated the differential impact of a multicomponent, targeted, low-literacy educational intervention compared with a standard, nontargeted educational intervention.

METHODS

Patients aged 50 to 75 years who were of average CRC risk and not up-to-date with CRC screening were recruited from either a federally qualified health center or a primary care community health clinic. Patients were randomized to the intervention condition (targeted photonovella booklet/DVD plus FIT kit) or comparison condition (standard Centers for Disease Control and Prevention brochure plus FIT kit). The main outcome was screening with FIT within 180 days of delivery of the intervention.

RESULTS

Of the 416 participants, 54% were female; the participants were racially and ethnically diverse (66% white, 10% Hispanic, and 28% African American), predominantly of low income, and insured (the majority had county health insurance). Overall, the FIT completion rate was 81%, with 78.1% of participants in the intervention versus 83.5% of those in the comparison condition completing FIT (P =  .17). In multivariate analysis, having health insurance was found to be the primary factor predicting a lack of FIT screening (adjusted odds ratio, 2.10; 95% confidence interval, 1.04-4.26 [P =  .04]).

CONCLUSIONS

The multicomponent, targeted, low-literacy materials were not found to be significantly different or more effective in increasing FIT uptake compared with the nontargeted materials. Provision of a FIT test plus education may provide a key impetus to improve the completion of CRC screening. The type of educational material (targeted vs nontargeted) may matter less. The findings of the current study provide a unique opportunity for clinics to adopt FIT and to choose the type of patient education materials based on clinic, provider, and patient preferences. Cancer 2017;123:1390-1400. © 2016 American Cancer Society.

Randomized Trial of a Computerized Touch Screen Decision Aid to Increase Acceptance of Colonoscopy Screening in an African American Population with Limited Literacy

The goal of this study was to assess the effectiveness of a touch screen decision aid to increase acceptance of colonoscopy screening among African American patients with low literacy, developed and tailored using perceptual mapping methods grounded in Illness Self-Regulation and Information-Communication Theories. The pilot randomized controlled trial investigated the effects of a theory-based intervention on patients' acceptance of screening, including their perceptions of educational value, feelings about colonoscopy, likelihood to undergo screening, and decisional conflict about colonoscopy screening. Sixty-one African American patients with low literacy, aged 50-70 years, with no history of colonoscopy, were randomly assigned to receive a computerized touch screen decision aid (CDA; n = 33) or a literacy appropriate print tool (PT; n = 28) immediately before a primary care appointment in an urban, university-affiliated general internal medicine clinic. Patients rated the CDA significantly higher than the PT on all indicators of acceptance, including the helpfulness of the information for making a screening decision, and reported positive feelings about colonoscopy, greater likelihood to be screened, and lower decisional conflict. Results showed that a touch screen decision tool is acceptable to African American patients with low iteracy and, by increasing intent to screen, may increase rates of colonoscopy screening.

Spanish-Language Consumer Health Information Technology Interventions: A Systematic Review

Background

As consumer health information technology (IT) becomes more thoroughly integrated into patient care, it is critical that these tools are appropriate for the diverse patient populations whom they are intended to serve. Cultural differences associated with ethnicity are one aspect of diversity that may play a role in user-technology interactions.

Objective

Our aim was to evaluate the current scope of consumer health IT interventions targeted to the US Spanish-speaking Latino population and to characterize these interventions in terms of technological attributes, health domains, cultural tailoring, and evaluation metrics.

Methods

A narrative synthesis was conducted of existing Spanish-language consumer health IT interventions indexed within health and computer science databases. Database searches were limited to English-language articles published between January 1990 and September 2015. Studies were included if they detailed an assessment of a patient-centered electronic technology intervention targeting health within the US Spanish-speaking Latino population. Included studies were required to have a majority Latino population sample. The following were extracted from articles: first author’s last name, publication year, population characteristics, journal domain, health domain, technology platform and functionality, available languages of intervention, US region, cultural tailoring, intervention delivery location, study design, and evaluation metrics.

Results

We included 42 studies in the review. Most of the studies were published between 2009 and 2015 and had a majority percentage of female study participants. The mean age of participants ranged from 15 to 68. Interventions most commonly focused on urban population centers and within the western region of the United States. Of articles specifying a technology domain, computer was found to be most common; however, a fairly even distribution across all technologies was noted. Cancer, diabetes, and child, infant, or maternal health were the most common health domains targeted by consumer health IT interventions. More than half of the interventions were culturally tailored. The most frequently used evaluation metric was behavior/attitude change, followed by usability and knowledge retention.

Conclusions

This study characterizes the existing body of research exploring consumer health IT interventions for the US Spanish-speaking Latino population. In doing so, it reveals three primary needs within the field. First, while the increase in studies targeting the Latino population in the last decade is a promising advancement, future research is needed that focuses on Latino subpopulations previously overlooked. Second, preliminary steps have been taken to culturally tailor consumer health IT interventions for the US Spanish-speaking Latino population; however, focus must expand beyond intervention content. Finally, the field should work to promote long-term evaluation of technology efficacy, moving beyond intermediary measures toward measures of health outcomes.

Does patient time spent viewing computer-tailored colorectal cancer screening materials predict patient-reported discussion of screening with providers?

The main aim is to examine whether patients' viewing time on information about colorectal cancer (CRC) screening before a primary care physician (PCP) visit is associated with discussion of screening options during the visit. We analyzed data from a multi-center randomized controlled trial of a tailored interactive multimedia computer program (IMCP) to activate patients to undergo CRC screening, deployed in primary care offices immediately before a visit. We employed usage time information stored in the IMCP to examine the association of patient time spent using the program with patient-reported discussion of screening during the visit, adjusting for previous CRC screening recommendation and reading speed.On average, patients spent 33 minutes on the program. In adjusted analyses, 30 minutes spent using the program was associated with a 41% increase in the odds of the patient having a discussion with their PCP (1.04, 1.59, 95% CI). In a separate analysis of the tailoring modules; the modules encouraging adherence to the tailored screening recommendation and discussion with the patient's PCP yielded significant results. Other predictors of screening discussion included better self-reported physical health and increased patient activation. Time spent on the program predicted greater patient-physician discussion of screening during a linked visit.Usage time information gathered automatically by IMCPs offers promise for objectively assessing patient engagement around a topic and predicting likelihood of discussion between patients and their clinician.

Development of a Practical Model for Targeting Patient Decision Support Interventions to Promote Colorectal Cancer Screening in Vulnerable Populations

We sought to develop a practical model for predicting probability of colorectal cancer (CRC) screening completion in a diverse safety-net population and a subsequent framework for targeting screening promotion interventions. Data used to construct the models was prospectively collected from a CRC screening intervention. Models were cross-validated by randomly splitting the data into training and validation samples. The predicted probabilities of screening completion from the final model were trichotomized into framework groups and cross-validated by defining cut-points in the training sample, applying them to the validation sample, and comparing across samples for homogeneity. The final model included demographic and simple psychosocial measures and predicted screening behavior adequately (AUROC=0.63). The framework groups (cut-points 0.62 (low), 0.74 (medium), and 1.0 (high)) were homogeneous across the two samples. The model and framework may be useful for designing and delivering targeted interventions to promote CRC screening. Future research should validate the framework groups.

Poor knowledge of colorectal cancer in Brunei Darussalam

BACKGROUND

Colorectal cancer (CRC) is the most common gastrointestinal cancer and the incidence is increasing in many developing countries. While it can be detected early and even prevented through screening and removal of premalignant lesions, there are barriers to screening which include low level of knowledge and awareness of CRC. This study assessed the level of knowledge of CRC in Brunei Darussalam.

MATERIALS AND METHODS

A total of 431 (262 male and 161 female) subjects participated in this questionnaire study. Subjects were scored on their knowledge of signs/symptoms (maximum 10 correct answers) and known risk factors for CRC (maximum 10 correct answers) and were categorised into poor (0-2), moderate (3-4) and satisfactory (5-10). Comparisons were made between the various patient factors.

RESULTS

Overall, 54.1% could not name any CRC signs/symptoms or associated risk factors. Most were not aware of any screening modalities. The overall scores for CRC signs/symptoms and risk factors were 1.3±1.39 (range 0-6) and 0.6±1.05 (range 0-5) respectively. Overall, the breakdown of scores was: poor (78.1%), moderate (20.3%) and satisfactory (6.2%) for signs/symptoms and poor (93.2%), moderate (6.2%) and satisfactory (0.7%) for risk factors. Higher level of education, female gender and non-Malay race were associated with higher scores for both signs/symptoms and knowledge of screening modality; however the overall scores were low.

CONCLUSIONS

Our study showed that the general knowledge of CRC in Brunei Darussalam is poor. Being female, with higher levels of education and non-Malay race were associated with higher scores, but they were still generally poor. More needs to be done to increase the public knowledge and awareness of CRC.

Urinary and sexual dysfunction rates and risk factors following rectal cancer surgery

OBJECTIVE

The aim of this study was to express the effects of demographic characteristics, the type of the surgery, tumour characteristics and adjuvant therapy on urinary and sexual dysfunctions.

MATERIALS AND METHOD

Pre-operational urinary and sexual dysfunctions of the patients were evaluated by using the surveys prepared according to International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF) in men and Index of Female Sexual Function (IFSF) in women.

FINDINGS

A total of 56 patients were included in the study; 20 of them were women and 36 of them were men. The mean age was 56. Abdominoperineal resection (APR) was performed on 11 patients, and low anterior resection (LAR) was performed on 45. The post-treatment IPSS classes were worsened at a rate of 12.7 % compared to the pre-treatment. The mean post-treatment sexual dysfunction score of both men and women were decreased by 27.5 and 17.8 %, respectively. Rectal tumours located in the lower part resulted in more sexual dysfunction.

CONCLUSION

The tumour in the 1/3 lower part of the rectal area was determined to be the most effective factor that caused both urinary and sexual dysfunction. Patients should be informed about the urinary and sexual dysfunctions in the pre-operative consultations.

Socio-psychological factors in the Expanded Health Belief Model and subsequent colorectal cancer screening

OBJECTIVE

CRC screening interventions tailored to the Expanded Health Belief Model (EHBM) socio-psychological factors have been developed, but the contributions of individual factors to screening outcomes are unclear.

METHODS

In observational analyses of data from a randomized intervention trial, we examined the independent associations of five EHBM factors - CRC screening knowledge, self-efficacy, stage of readiness, barriers, and discussion with a provider - with objectively measured CRC screening after one year.

RESULTS

When all five factors were added simultaneously to a base model including other patient and visit characteristics, three of the factors were associated with CRC screening: self-efficacy (OR=1.32, p=0.001), readiness (OR=2.72, p<0.001), and discussion of screening with a provider (OR=1.59, p=0.009). Knowledge and barriers were not independently associated with screening. Adding the five socio-psychological factors to the base model improved prediction of CRC screening (area under the curve) by 7.7%.

CONCLUSION

Patient CRC screening self-efficacy, readiness, and discussion with a provider each independently predicted subsequent screening.

PRACTICE IMPLICATIONS

Self-efficacy and readiness measures might be helpful in parsimoniously predicting which patients are most likely to engage in CRC screening. The importance of screening discussion with a provider suggests the potential value of augmenting patient-focused EHBM-tailored interventions with provider-focused elements.

How can we boost colorectal and hepatocellular cancer screening among underserved populations?

Colorectal cancer (CRC) and hepatocellular carcinoma (HCC) are common causes of cancer incidence and mortality in the USA, particularly among underserved populations such as racial/ethnic minorities, the under-/uninsured, and individuals with low socioeconomic status. Although screening can reduce cancer-related mortality, participation is suboptimal among underserved populations, likely serving as the largest contributor to observed inequities in HCC and CRC outcomes among US populations. In this narrative review, we highlight inequities across populations in the USA with respect to incidence and mortality for CRC and HCC and highlight potential causes, with a focus on screening rates. In addition, drawing from the recent literature, we highlight promising strategies for increasing screening for HCC and CRC and propose future research and policy solutions to optimize screening rates. With focused implementation of screening strategies and novel research, the burden of HCC and CRC can be reduced among underserved populations.

Testing Interventions to Motivate and Educate (TIME): A multi-level intervention to improve colorectal cancer screening

Objective

To test the effectiveness of a colorectal cancer (CRC) screening intervention directed at three levels (clinic, provider, patient) in a primary care setting.

Method

We conducted a group randomized trial (Clinical Trials registration no. NCT01568151) among 10 primary care clinics in Columbus, Ohio that were randomized to a study condition (intervention or usual care). We determined the effect of a multi-level, stepped behavioral intervention on receipt of a CRC screening test among average-risk patients from these clinics over the study period.

Results

Patients (n = 527) who were outside of CRC screening recommendations were recruited. Overall, 35.4% of participants in the intervention clinics had received CRC screening by the end of the study compared to 35.1% of participants who were in the usual care clinics. Time to CRC screening was also similar across arms (HR = 0.97, 95% CI = 0.65–1.45).

Conclusion

The multi-level intervention was not effective in increasing CRC screening among participants who needed a test, perhaps due to low participation of patients in the stepped intervention. Future studies utilizing evidence-based strategies to encourage CRC screening are needed.

•

This study tested the effectiveness of a multi-level CRC screening intervention.

•

There was no difference in receipt of CRC screening between study arms.

•

Innovative strategies need to be developed to improve CRC screening rates.

Male Role Norms, Knowledge, Attitudes, and Perceptions of Colorectal Cancer Screening among Young Adult African American Men

Racial disparities in health among African American men (AAM) in the United States are extensive. In contrast to their White counterparts, AAM have more illnesses and die younger. AAM have colorectal cancer (CRC) incidence and mortality rates 25% and 50% higher, respectively, than White men. Due to CRC's younger age at presentation and high incidence among AAM, CRC screening (CRCS) is warranted at the age of 45 rather than 50, but little is known about younger AAM's views of CRCS. Employing survey design, the purpose of the study was to describe the male role norms (MRN), knowledge, attitudes, perceived subjective norms, and perceived barriers associated with screening for CRC among a non-random sample of 157 young adult AAM (ages 19-45). Sixty-seven percent of the study sample received a passing knowledge score (85% or better), yet no significant differences were found among the three educational levels (i.e., low, medium, high). More negative attitudes toward CRCS correlated with the participants' strong perceptions of barriers, but no extremely negative or positive MRN and perceived subjective norms were found. The factors significantly associated with attitudes were family history of cancer (unsure), work status, and perceived barriers. Findings from this study provide a solid basis for developing structured health education interventions that address the salient factors shaping young adult AAM's view of CRC and early detection screening behaviors.

Reducing inequities in colorectal cancer screening in North America

Colorectal cancer (CRC) is an important cause of mortality and morbidity in North America. Screening using a fecal occult blood test, flexible sigmoidoscopy, or colonoscopy reduces CRC mortality through the detection and treatment of precancerous polyps and early stage CRC. Although CRC screening participation has increased in recent years, large inequities still exist. Minorities, new immigrants, and those with lower levels of education or income are much less likely to be screened. This review provides an overview of the commonly used tests for CRC screening, disparities in CRC screening, and promising methods at the individual, provider, and system levels to reduce these disparities. Overall, to achieve high CRC participation rates and reduce the burden of CRC in the population, a multi-faceted approach that uses strategies at all levels to reduce CRC screening disparities is urgently required.