Knowledge and attitudes about colon cancer screening among African Americans

What is the effect of a decision aid on knowledge, values and preferences for lung cancer screening? An online pre-post study

OBJECTIVE

To examine if a decision aid improves knowledge of lung cancer screening benefits and harms and which benefits and harms are most valued.

DESIGN

Pre-post study.

SETTING

Online.

PARTICIPANTS

219 current or former (quit within the previous 15 years) smokers ages 55-80 with at least 30 pack-years of smoking.

INTERVENTION

Lung cancer screening video decision aid.

MAIN MEASURES

Screening knowledge tested by 10 pre-post questions and value of benefits and harms (reducing chance of death from lung cancer, risk of being diagnosed, false positives, biopsies, complications of biopsies and out-of-pocket costs) assessed through rating (1-5 scale) and ranking (top three ranked).

RESULTS

Mean age was 64.7±6.1, 42.5% were male, 75.4% white, 48.4% married, 28.9% with less than a college degree and 67.6% with income <US$50 000. Knowledge improved postdecision aid (pre 2.8±1.8 vs post 5.8±2.3, diff +3.0, 95% CI 2.7 to 3.3; p<0.001). For values, reducing the chance of death from lung cancer was rated and ranked highest overall (rating 4.3±1.0; 59.4% ranked first). Among harms, avoiding complications (3.7±1.3) and out-of-pocket costs (3.7±1.2) rated highest. Thirty-four per cent ranked one of four harms highest: avoiding costs 13.2%, false positives 7.3%, biopsies 7.3%, complications 5.9%. Screening intent was balanced (1-4 scale; 1-not likely 21.0%, 4-very likely 26.9%). Those 'not likely' to screen had greater improvement in pre-post knowledge scores and more frequently ranked a harm first than those 'very likely' to screen (pre-post diff:+3.5 vs +2.6, diff +0.9; 95% CI 0.1 to 1.8; p=0.023; one of four harms ranked first: 28.4% vs 11.3%, p<0.001).

CONCLUSIONS

Our decision aid increased lung cancer screening knowledge among a diverse sample of screen-eligible respondents. Although a majority valued 'reducing the chance of death from lung cancer' highest, a substantial proportion identified harms as most important. Knowledge improvement and ranking harms highest were associated with lower intention to screen.

Interventions to Reduce Healthcare Disparities in Cancer Screening Among Minority Adults: a Systematic Review

BACKGROUND

Racial minority populations face an increased burden relative to cancer interventions. Compared with Caucasians, the cancer screening rate is substantially lower among African American, Asian American, Latinx American, and American Indian/Alaska Native populations. Barriers such as low health literacy, lack of health insurance, and miscommunication between patients and providers have been identified as important factors that result in low screening rates among minority adults. This study was designed to identify interventions targeting racial minority adults 40 years of age or older that were effective in increasing cancer screening uptake rates.

METHODS

A systematic review of articles published in and after January 2009 was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Twenty-six published studies of cancer screening intervention tested with minority adults were identified through the searches of CINAHL, Global Health, PsycINFO, PubMed, and Scopus databases.

RESULTS

Thirteen (50%) of the studies utilized lay community health workers to increase cancer awareness and knowledge and to encourage screening. These methods took place over the telephone, at community education sessions, or within the context of personalized patient navigation support. The intervention programs utilized culturally relevant materials as well as spoken and written information in the targeted population's native language. Various intervention designs resulted in statistically significant increases in cancer screening adherence. However, we found no intervention that consistently elevated cancer screening rates across all racial/ethnic minority adults.

CONCLUSIONS

The finding suggests that highly segmented interventions are needed in order to improve cancer screening among various racial/ethnic minority adults.

Interventions for increasing colorectal cancer screening uptake among African-American men: A systematic review and meta-analysis

BACKGROUND

African-American men have the lowest 5-year survival rate in the U.S. for colorectal cancer (CRC) of any racial group, which may partly stem from low screening adherence. It is imperative to synthesize the literature evaluating the effectiveness of interventions on CRC screening uptake in this population.

MATERIALS AND METHODS

In this systematic review and meta-analysis, Medline, CINAHL, Embase, and Cochrane CENTRAL were searched for U.S.-based interventions that: were published after 1998-January 2020; included African-American men; and evaluated CRC screening uptake explicitly. Checklist by Cochrane Collaboration and Joanna Brigg were utilized to assess risk of bias, and meta-regression and sensitivity analyses were employed to identify the most effective interventions.

RESULTS

Our final sample comprised 41 studies with 2 focused exclusively on African-American men. The most frequently adopted interventions were educational materials (39%), stool-based screening kits (14%), and patient navigation (11%). Most randomized controlled trials failed to provide details about the blinding of the participant recruitment method, allocation concealment method, and/or the outcome assessment. Due to high heterogeneity, meta-analysis was conducted among 17 eligible studies. Interventions utilizing stool-based kits or patient navigation were most effective at increasing CRC screening completion, with odds ratios of 9.60 (95% CI 2.89-31.82, p = 0.0002) and 2.84 (95% CI 1.23-6.49, p = 0.01). No evidence of publication bias was present for this study registered with the International Prospective Registry of Systematic Reviews (PROSPERO 2019 CRD42019119510).

CONCLUSIONS

Additional research is warranted to uncover effective, affordable interventions focused on increasing CRC screening completion among African-American men. When designing and implementing future multicomponent interventions, employing 4 or fewer interventions types may reduce bias risk. Since only 5% of the interventions solely focused on African-American men, future theory-driven interventions should consider recruiting samples comprised solely of this population.

An Interventional Study to Improve Colorectal Cancer Screening Knowledge and Health Perceptions among Jordanians' Average Risk Population

Context:

Globally, Colorectal Cancer (CRC) is the second most commonly occurring cancer in women and the third most commonly occurring cancer in men.

Aims:

This study was conducted to investigate the current levels of Jordanians' CRC knowledge and health perceptions; and to test the effects of a health education intervention on them.

Settings and Design:

A descriptive quasi-experimental design was used to recruit a convenience sample of 197 Jordanian adult participants from two governmental hospitals in Amman.

Methods and Material:

A rolling enrolment strategy was used to randomly assign participants into intervention (n=98) and control (n=99) groups. An education intervention included a 1-hour Power Point presentation about CRC.

Results:

The mean knowledge scores were (6.51±1.60) and (6.91± 1.83) for females and males, respectively. The mean of the knowledge level in the intervention group subsequent to the intervention was significantly higher than that for the control group. More than half of the study participants (53.8%) did not believe they were susceptible to CRC, while about one third (37.4%) of the participants believed that CRC is a severe disease. 42.2% of study participants believed there were barriers preventing them from participating in CRC screening. The most frequently perceived barrier among them was the cost of screening tests. The means of the perceived susceptibility and severity subscales of the intervention group was significantly higher than that of the control group.

Conclusion:

Correcting the knowledge gap and improper health perceptions toward CRC could play an important role in facilitating early detection as a primary prevention measure. Findings may enhance health strategies to better address the needs of the average-risk population.

Colorectal cancer knowledge and screening adherence among low-income Hispanic employees

Hispanics have the lowest colorectal cancer (CRC) screening rates of all racial/ethnic groups and comprise the largest proportion of low-income manual laborers in the nation. We partnered with businesses to implement a community health worker (CHW)-led intervention among Hispanic workers in service-related and manual labor occupations, which often pay low wages and do not provide health insurance. CHWs measured knowledge, screening adherence and perceptions of CRC risk before and after educational interventions via interview. CHWs provided fecal immunochemical tests (FITs) to participants aged ≥50 years. Chi-square tests and logistic regression identified pre-intervention predictors of CRC knowledge of all participants and adherence among eligible participants. Adherence among participants increased from 40% (n = 307) pre-intervention to 66% post-intervention. Knowledge about CRC was associated with age ≥50 years (OR = 8.90 [95% CI = 2.61-30.35]; ref = 18-30) and perceived personal risk for CRC (Likely, OR = 3.06 [95% CI = 1.40-6.67]; ref = Not likely). Insurance status was associated with screening adherence pre-intervention (OR = 3.00 [95% CI 1.10-8.12]; ref = No insurance). Improvement in adherence post-intervention was associated with income between $25 000 and ≥$55 000 (OR = 8.49 [95% CI 1.49-48.32]; ref = $5000-<$10 000). Community-based health programs can improve CRC screening adherence among Hispanic workers in service-related and manual labor positions, but lowest-income workers may need additional support.

Patients' self-reported barriers to colon cancer screening in federally qualified health center settings

Colorectal cancer (CRC) is a leading cause of cancer-related death in the United States. Despite evidence that screening reduces CRC incidence and mortality, only about 60% of age-eligible adults are up-to-date on CRC screening. This analysis aims to identify self-reported barriers to CRC screening among patients in a safety-net healthcare setting.

Participants were recruited from safety-net primary care sites that were participating in a trial to increase CRC screening. At baseline, patients (n = 483) completed self-report surveys that assessed demographics, healthcare and CRC screening. Barriers to CRC screening were assessed through an open-ended question. Using a basic text analysis, data were coded and organized into key topics.

Overall, 65.2% ever had CRC screening; 46.4% were up-to-date. Of those who described barriers (n = 198), 22.9% said they were not due for screening or their provider had not recommended it. Other common barriers included fear or worry about the procedure or outcome, financial challenges such as lack of insurance or cost of testing, and logistic challenges such as transportation and time. Fewer said that screening was of low importance or mentioned discomfort with the procedure or colonoscopy preparation.

In this safety-net setting, CRC screening rates were lower than national rates. These qualitative results are similar to quantitative findings reported in the literature but the qualitative data add to our understanding of patient-reported concerns and challenges faced by safety-net patients. These results may be applied to developing targeting communication or intervention strategies to improve CRC screening rates within safety-net health centers.

Creating an mHealth App for Colorectal Cancer Screening: User-Centered Design Approach

Background

Patients are increasingly using mobile health (mHealth) apps to monitor their health and educate themselves about medical issues. Despite the increasing popularity of such apps, poor design and usability often lead to suboptimal continued use of these apps and subsequently to poor adherence to the behavior changes at which they are aimed. One solution to these design problems is for app developers to use user-centered design (UCD) principles to consider the context and needs of users during the development process.

Objective

This study aimed to present a case study on the design and development process for an mHealth app that uses virtual human technology (VHT) to encourage colorectal cancer (CRC) screening among patients aged 50 years and above.

Methods

We have first provided an overview of the project and discussed its utilization of VHT. We have then reviewed UCD principles and how they can be incorporated into the development of health apps. We have described how we used UCD processes during the app’s development. We have then discussed the unique roles played by communication researchers, computer scientists, clinicians, and community participants in creating an mHealth app that is credible, usable, effective, and accessible to its target audience.

Results

The principles of UCD were woven throughout the project development, with researchers collecting feedback from patients and providers at all stages and using that feedback to improve the credibility, usability, effectiveness, and accessibility of the mHealth app. The app was designed in an iterative process, which encouraged feedback and improvement of the app and allowed teams from different fields to revisit topics and troubleshoot problems.

Conclusions

Implementing a UCD process contributed to the development of an app, which not only reflected cross-disciplinary expertise but also the needs, wants, and concerns of patients.

Lay Beliefs About the Accuracy and Value of Cancer Screening

INTRODUCTION

Appreciating the accuracy and value of cancer screening is essential to informed decision making about screening. This study's objectives were to (1) examine people's beliefs about the accuracy and value of cancer screening, and (2) determine whether sociodemographics, cancer beliefs, and shared decision making are associated with these beliefs.

METHODS

Data from the National Cancer Institute's Health Information National Trends Survey (cycle 4, August-November 2014) were used. Respondents were non-institutionalized adults (aged ≥18 years, n=3,677). Weighted generalized linear modeling was used to examine bivariate and multivariate associations between key covariates and beliefs about cancer screening (assessed by four-item scale and independently). Secondary analyses examined whether these beliefs were associated with self-reported cancer screening. Data were analyzed between 2016 and 2017.

RESULTS

Only 5.6% (n=189) of respondents answered all four cancer screening items correctly. Men, racial/ethnic minorities, and those with lower education and higher cancer fatalism were less likely to have accurate beliefs about cancer screening. However, those who reported shared decision making for colorectal cancer screening were more likely to know that "when a test finds something abnormal, more tests are needed to know if it is cancer" and "when a test finds something abnormal, it is [not] very likely to be cancer" (adjusted risk ratio=1.13, p<0.01, adjusted risk ratio=1.25, p<0.01). Beliefs were not associated with likelihood of past mammography or Pap testing.

CONCLUSIONS

Educators, researchers, and clinicians should consider opportunities (e.g., through shared decision making) to improve the accuracy of individuals' beliefs about cancer screening.

Low Rates of Gastrointestinal and Non-Gastrointestinal Complications for Screening or Surveillance Colonoscopies in a Population-Based Study

BACKGROUND

The full spectrum of serious non-gastrointestinal post-colonoscopy complications has not been well characterized. We analyzed rates of and factors associated with adverse post-colonoscopy gastrointestinal (GI) and non-gastrointestinal events (cardiovascular, pulmonary, or infectious) attributable to screening or surveillance colonoscopy (S-colo) and non-screening or non-surveillance colonoscopy (NS-colo).

METHODS

We performed a population-based study of colonoscopy complications using databases from California hospital-owned and nonhospital-owned ambulatory facilities, emergency departments, and hospitals from January 1, 2005 through December 31, 2011. We identified patients who underwent S-colo (1.58 million), NS-colo (1.22 million), or low-risk comparator procedures (joint injection, aspiration, lithotripsy; arthroscopy, carpal tunnel; or cataract; 2.02 million) in California's Ambulatory Services Databases. We identified patients who developed adverse events within 30 days, and factors associated with these events, through patient-level linkage to California's Emergency Department and Inpatient Databases.

RESULTS

After S-colo, the numbers of lower GI bleeding, perforation, myocardial infarction, and ischemic stroke per 10,000-persons were 5.3 (95% confidence interval [CI], 4.8-5.9), 2.9 (95% CI, 2.5-3.3), 2.5 (95% CI, 2.1-2.9), and 4.7 (95% CI, 4.1-5.2) without biopsy or intervention; with biopsy or intervention, numbers per 10,000-persons were 36.4 (95% CI, 35.1-37.6), 6.3 (95% CI, 5.8-6.8), 4.2 (95% CI, 3.8-4.7), and 9.1 (95% CI, 8.5-9.7). Rates of dysrhythmia were higher. After NS-colo, event rates were substantially higher. Most serious complications led to hospitalization, and most GI complications occurred within 14 days of colonoscopy. Ranges of adjusted odds ratios for serious GI complications, myocardial infarction, ischemic stroke, and serious pulmonary events after S-colo vs comparator procedures were 2.18 (95% CI, 2.02-2.36) to 5.13 (95% CI, 4.81-5.47), 0.67 (95% CI, 0.56-0.81) to 0.99 (95% CI, 0.83-1.19), 0.66 (95% CI, 0.59-0.75) to 1.13 (95% CI, 0.99-1.29), and 0.64 (95% CI, 0.61-0.68) to 1.05 (95% CI, 0.98-1.11). Biopsy or intervention, comorbidity, black race, low income, public insurance, and NS-colo were associated with post-colonoscopy adverse events.

CONCLUSIONS

In a population-based study in California, we found that following S-colo, rates of serious GI adverse events were low but clinically relevant, and that rates of myocardial infarction, stroke, and serious pulmonary events were no higher than after low-risk comparator procedures. Rates of myocardial infarction are similar to, but rates of stroke are higher than, those reported for the general population.

Increasing Colorectal Cancer Screening at an Urban FQHC Using iFOBT and Patient Navigation

Introduction. Colorectal cancer is the second leading cause of cancer death in the United States. Black Americans suffer even higher incidence and death rates than the general population. Genetics and patient perceptions explain some of this difference, however, modifiable health care system factors such as lack of access to colon cancer screening also contribute. Partnering an academic health center with local community groups, we piloted a colorectal cancer screening program at a Federally Qualified Health Center (FQHC) serving predominately low socioeconomic status Black Americans. The program was designed to identify and remove barriers to screening and improve screening rates. Method. At a single center FQHC, we developed an outreach program centered around (1) patient and provider education, (2) immunochemical fecal occult blood test (iFOBT) distribution, and (3) patient navigation. We identified 402 eligible patients, of which 228 (56.7%) completed screening. Results. Our 56.7% screening rate represented a twofold increase above prepilot levels at the clinic. Nine (4%) iFOBT returned positive. Three of these nine patients completed colonoscopy. Screening rates and follow through were higher under a single navigator model. Conclusions. Our academic–community partnership provided an effective, evidence based, and sustainable model for increasing colorectal cancer screening in a high risk, low resource community.

Decreasing Black-White Disparities in Colorectal Cancer Incidence and Stage at Presentation in the United States

Background: There are long-standing black-white disparities in colorectal cancer incidence and outcomes in the United States. Incidence and stage at diagnosis reflect the impact of national efforts directed at colorectal cancer prevention and control. We aimed to evaluate trends in black-white disparities in both indicators over four decades to inform the future direction of prevention and control efforts.Methods: We used Surveillance, Epidemiology, & End Results (SEER) data to identify whites and blacks with histologically confirmed colorectal cancer from January 1, 1975 through December 31, 2012. We calculated the age-adjusted incidence and the proportion of cases presenting in late stage by race and year. We then calculated the annual percentage change (APC) and average APC for each indicator by race, examined changes in indicators over time, and calculated the incidence disparity for each year.Results: There were 440,144 colorectal cancer cases from 1975 to 2012. The overall incidence decreased by 1.35% and 0.46% per year for whites and blacks, respectively. Although the disparity in incidence declined from 2004 to 2012 (APC = -3.88%; P = 0.01), incidence remained higher in blacks in 2012. Late-stage disease declined by 0.27% and 0.45% per year in whites and blacks, respectively. The proportion of late-stage cases became statistically similar in whites and blacks in 2010 (56.60% vs. 56.96%; P = 0.17).Conclusions: Black-white disparities in colorectal cancer incidence and stage at presentation have decreased over time.Impact: Our findings reflect the positive impact of efforts to improve colorectal cancer disparities and emphasize the need for interventions to further reduce the incidence gap. Cancer Epidemiol Biomarkers Prev; 26(5); 762-8. ©2016 AACR.

Neighborhood Satisfaction and Colorectal Cancer Screening in a Community Sample of African Americans

Social determinants are important to cancer screening among African Americans. To evaluate the association between social determinants (e.g., psychological characteristics, perceived social environment, cultural beliefs such as present temporal orientation) and colorectal cancer (CRC) screening among African Americans. African American adults (n = 262) ages 50-75 completed a telephone interview. Multivariate logistic regression analysis was used to identify factors having significant independent associations with CRC screening. Only 57% of respondents reported having CRC screening. The likelihood of screening increased with greater neighborhood satisfaction (OR = 1.38, 95% CI = 1.01, 1.90, p = 0.04), older age (OR = 1.75, 95% CI = 1.24, 2.48, p = 0.002), greater self-efficacy (OR = 2.73, 95% CI = 1.40, 5.35, p = 0.003), and health care provider communication (OR = 10.78, 95% CI = 4.85, 29.94, p = 0.0001). Community resources are important precursors to CRC screening and outcomes among African Americans. In addition to addressing psychological factors and patient-provider communication, efforts to ensure the availability of quality health care facilities that provide CRC screening in the neighborhoods where African Americans live are needed.

Addressing Low Colorectal Cancer Screening in African Americans: Using Focus Groups to Inform the Development of Effective Interventions

African Americans have the highest burden of colorectal cancer (CRC) in the United States of America (USA) yet lower CRC screening rates than whites. Although poor screening has prompted efforts to increase screening uptake, there is a persistent need to develop public health interventions in partnership with the African American community. The aim of this study was to conduct focus groups with African Americans to determine preferences for the content and mode of dissemination of culturally tailored CRC screening interventions. In June 2013, 45-75-year-old African Americans were recruited through online advertisements and from an urban Veterans Affairs system to create four focus groups. A semi-structured interview script employing open-ended elicitation was used, and transcripts were analyzed using ATLAS.ti software to code and group data into a concept network. A total of 38 participants (mean age = 54) were enrolled, and 59 ATLAS.ti codes were generated. Commonly reported barriers to screening included perceived invasiveness of colonoscopy, fear of pain, and financial concerns. Facilitators included poor diet/health and desire to prevent CRC. Common sources of health information included media and medical providers. CRC screening information was commonly obtained from medical personnel or media. Participants suggested dissemination of CRC screening education through commercials, billboards, influential African American public figures, Internet, and radio. Participants suggested future interventions include culturally specific information, including details about increased risk, accessing care, and dispelling of myths. Public health interventions to improve CRC screening among African Americans should employ media outlets, emphasize increased risk among African Americans, and address race-specific barriers. Specific recommendations are presented for developing future interventions.

Colorectal Cancer in African Americans: An Update

This review is an update to the American College of Gastroenterology (ACG) Committee on Minority Affairs and Cultural Diversity's paper on colorectal cancer (CRC) in African Americans published in 2005. Over the past 10 years, the incidence and mortality rates of CRC in the United States has steadily declined. However, reductions have been strikingly much slower among African Americans who continue to have the highest rate of mortality and lowest survival when compared with all other racial groups. The reasons for the health disparities are multifactorial and encompass physician and patient barriers. Patient factors that contribute to disparities include poor knowledge of benefits of CRC screening, limited access to health care, insurance status along with fear and anxiety. Physician factors include lack of knowledge of screening guidelines along with disparate recommendations for screening. Earlier screening has been recommended as an effective strategy to decrease observed disparities; currently the ACG and American Society of Gastrointestinal Endoscopists recommend CRC screening in African Americans to begin at age 45. Despite the decline in CRC deaths in all racial and ethnic groups, there still exists a significant burden of CRC in African Americans, thus other strategies including educational outreach for health care providers and patients and the utilization of patient navigation systems emphasizing the importance of screening are necessary. These strategies have been piloted in both local communities and Statewide resulting in notable significant decreases in observed disparities.

Systematic Review and Meta-study Synthesis of Qualitative Studies Evaluating Facilitators and Barriers to Participation in Colorectal Cancer Screening

Screening reduces the incidence, morbidity, and mortality of colorectal cancer, yet participation tends to be low. We undertook a systematic review and meta-study synthesis of qualitative studies to identify facilitators and barriers to colorectal cancer screening participation. We searched major bibliographic databases for records published in all languages from inception to February 2015. Included primary studies that elicited views and perceptions towards colorectal cancer screening were appraised for relevance and quality. We used a two-stage synthesis to create an interpretation of colorectal cancer screening decisions grounded in primary studies; a thematic analysis to group themes and systematically compare studies and a meta-synthesis to generate an expanded theory of colorectal cancer screening participation. Ninety-four studies were included. The decision to participate in colorectal cancer screening depended on an individual's awareness of colorectal cancer screening. Awareness affected views of cancer, attitudes towards colorectal cancer screening modalities, and motivation for screening. Factors mediating awareness included public education to address misconceptions, primary care physician efforts to recommend screening, and the influence of friends and family. Specific barriers to participation in populations with lower participation rates included language barriers, logistical challenges to attending screening tests, and cultural beliefs. This study identifies key barriers, facilitators, and mediators to colorectal cancer screening participation. Cancer Epidemiol Biomarkers Prev; 25(6); 907-17. ©2016 AACR.

Colorectal cancer screening in African Americans: practice patterns in the United States. Are we doing enough?

Background: Colorectal cancer (CRC) is a common form of malignancy and a leading cause of death in the United States. Screening decreases CRC incidence and mortality. African Americans are at an increased risk of developing CRC, and recommendations are to initiate screening at the age of 45. This study aims to assess the rate of screening for colorectal cancer in African Americans between the ages of 45–49.

Methods: African Americans between the ages of 45–49 were identified in the Explorys national database. Patients who completed a colonoscopy, sigmoidoscopy or fecal occult blood test were identified and stratified by sex and insurance status. A P value < 0.05 was considered significant.

Results: A total of 181 200 African Americans were identified as eligible for screening. Only 31 480 patients (17.4%) received at least one screening procedure for CRC. The majority of patients (66.7%) were screened via colonoscopy. African American females were more likely to complete a screening test (17.8% vs 16.7%; P < 0.01). The majority of patients (66.0%) who completed a screening test had private insurance.

Conclusion: Race, gender and barriers to medical care contribute to disparities in CRC screening rates. Among African Americans, CRC screening remains suboptimal. Tailored public health initiatives, medical record alerts and improved communication between providers and patients are fundamental to addressing issues that impact poor adherence to CRC screening in African Americans.

Beyond Adherence: Health Care Disparities and the Struggle to Get Screened for Colon Cancer

Dominant health care professional discourses on cancer take for granted high levels of individual responsibility in cancer prevention, especially in expectations about preventive screening. At the same time, adhering to screening guidelines can be difficult for lower income and under-insured individuals. Colorectal cancer (CRC) is a prime example. Since the advent of CRC screening, disparities in CRC mortality have widened along lines of income, insurance, and race in the United States. We used a community-engaged research method, Photovoice, to examine how people from medically under-served areas experienced and gave meaning to CRC screening. In our analysis, we first discuss ways in which participants recounted screening as a struggle. Second, we highlight a category that participants suggested was key to successful screening: social connections. Finally, we identify screening as an emotionally laden process that is underpinned by feelings of uncertainty, guilt, fear, and relief. We discuss the importance of these findings to research and practice.

Patient Preferences Regarding Colorectal Cancer Screening: Test Features and Cost Willing to Pay Out of Pocket

The purpose of this investigation was to evaluate whether test features would make an individual more or less likely to undergo colorectal cancer screening and how much an individual would be willing to pay out of pocket for a screening test. The methods include an administration of a survey to consecutive adult patients of a general medicine clinic. The survey consisted of Likert-scale questions assessing the patients' likelihood of choosing a screening test based on various test characteristics. Additional questions measured the patients' age, race, gender, and maximum out-of-pocket cost they would be willing to pay. Chi-square tests were used to assess the associations between the likelihood questions and the various demographic characteristics. In results, survey response rate was 88.8% (213 of 240). Respondents were 48.4% female (103 of 213), 51.6% male (110 of 213), 82.6% White (176 of 213), 11.3% African-American (24 of 213), and 6.1% other (13 of 213). Risk of internal injury and light exposure to radiation were the least desirable test features. Light sedation was the only test feature that most respondents (54.8%) indicated would make them likely or very likely to undergo a colorectal cancer screening test. The vast majority of respondents (86.8%) were willing to pay less than $200 out of pocket for a colorectal cancer screening test. There was no statistically significant difference in the responses of males and females, or in the responses of individuals of different races or different ages regarding test features, or the amount individuals were willing to pay for a screening test. To conclude, survey results suggest that patient education emphasizing the low complication rate of computed tomographic colonography (CTC), the minimal risks associated with the low-level radiation exposure resulting from CTC, and the benefits of a sedation-free test (eg, no risk of sedation-related complication and no need for a driver) may increase patient acceptance of CTC. Additionally, an out-of-pocket cost of <$200 would be preferable from the patient perspective.

Colonoscopy Education Among African-American Males in the Primary Care Setting of Bronx County, New York

Healthcare disparities are prevalent throughout the United States of America, particularly among low socioeconomic communities and minority groups. As primary care providers in Bronx, New York, the authors have noted that African American males often decline colonoscopy screening measures more frequently than other minorities. Ironically, the same cohort of African American men has the highest incidence of colon cancer and less favorable outcomes from chemotherapy intervention. In hopes of making a segue into a more informed conversation with our patients, we have developed an informative fact sheet for patients and their families on the basis of evidence-based literature. The objective was to employ this fact sheet to educate patients about colorectal cancer screening in an understandable and clinically effective manner.

Explaining persistent under-use of colonoscopic cancer screening in African Americans: a systematic review

INTRODUCTION

Although African Americans have the highest incidence and mortality from colorectal cancer (CRC), they are less likely than other racial groups to undergo CRC screening. Previous research has identified barriers to CRC screening among African Americans. However we lack a systematic review that synthesizes contributing factors and informs interventions to address persistent disparities.

METHODS

We conducted a systematic review to evaluate barriers to colonoscopic CRC screening in African Americans. We developed a conceptual model to summarize the patient-, provider-, and system-level barriers and suggest strategies to address these barriers.

RESULTS

Nineteen studies met inclusion criteria. Patient barriers to colonoscopy included fear, poor knowledge of CRC risk, and low perceived benefit of colonoscopy. Provider-level factors included failure to recommend screening and knowledge deficits about guidelines and barriers to screening. System barriers included financial obstacles, lack of insurance and access to care, and intermittent primary care visits.

CONCLUSIONS

There are modifiable barriers to colonoscopic CRC screening among African Americans. Future interventions should confront patient fear, patient and physician knowledge about barriers, and access to healthcare services. As the Affordable Care Act aims to improve uptake of preventive services, focused interventions to increase CRC screening in African Americans are essential and timely.

Effect of public knowledge, attitudes, and behavior on willingness to undergo colorectal cancer screening using the health belief model

BACKGROUND/AIMS

Success of colorectal cancer (CRC) screening is dependent in part on the proportion of uptake by the targeted population. We aimed in this study to identify factors that were associated with willingness to undergo CRC screening based on the health belief model (HBM).

PATIENTS AND METHODS

This was a cross-sectional study among citizens of Riyadh, Saudi Arabia. Demographic data collected included gender, age, education, marital status, employment status, a history of CRC in the family or knowing a friend with CRC, as well as income. A questionnaire was developed in Arabic based on the HBM and included enquiries on knowledge about CRC symptoms and risk factors, types of CRC screening tests, perceived risk of CRC, previously undergoing CRC screening, intent to undergo CRC screening, perceived barriers to CRC screening, perceived severity of CRC, as well as attitudes toward CRC and its screening.

RESULTS

Five hundred participants were included. The mean age was 41.0 years (SD 10.7). Males were 50% and only 6.7% of those between 50 and 55 years of age had undergone CRC screening. Of those surveyed, 70.7% were willing to undergo CRC screening. Also, 70.5% thought that CRC is curable, 73.3% believed it was preventable, whereas 56.7% thought it was a fatal disease. Neither gender, level of education, occupation, income, marital status, nor general knowledge about CRC was found to be associated with the willingness to undergo CRC screening. Recognizing that colonoscopy was a screening test (OR 1.55, 95% CI; 1.04-2.29) was associated with a strong desire to undergo CRC screening while choosing a stool-based test was associated with not willing to undergo CRC screening (OR 0.59, 95%CI; 0.38-0.91).

CONCLUSION

We found that the majority of those interviewed were willing to undergo CRC screening and identified a number of barriers as well as potential areas that could be targeted in the promotion of CRC screening uptake if such a national program were to be implemented.

Factors Associated with Colorectal Cancer Screening among Younger African American Men: A Systematic Review

Of cancers affecting both men and women, colorectal cancer (CRC) is the second leading cancer killer among African Americans in the U.S. Compared to White men, African American men have incidence and mortality rates 25% and 50% higher from CRC. Despite the benefits of early detection and the availability of effective screening, most adults over age 50 have not undergone testing, and disparities in colorectal cancer screening (CRCS) persist. Owing to CRC's high incidence and younger age at presentation among African American men, CRCS is warranted at age 45 rather than 50. However, the factors influencing young adult (i.e., age < 50) African American men's intention to screen and/or their CRCS behaviors has not been systematically assessed. To assess whether the factors influencing young adult African American men's screening intentions and behaviors are changeable through structured health education interventions, we conducted a systematic review, with the two-fold purpose of: (1) synthesizing studies examining African American men's knowledge, beliefs, and behaviors regarding CRCS; and (2) assessing these studies' methodological quality. Utilizing Garrard's Matrix Method, a total of 28 manuscripts met our inclusion/exclusion criteria: 20 studies followed a non-experimental research design, 4 comprised a quasi-experimental design, and 4, an experimental design. Studies were published between 2002 and 2012; the majority, between 2007 and 2011. The factors most frequently assessed were behaviors (79%), beliefs (68%), and knowledge (61%) of CRC and CRCS. Six factors associated with CRC and CRCS emerged: previous CRCS, CRC test preference, perceived benefits, perceived barriers, CRC/CRCS knowledge, and physician support/recommendation. Studies were assigned a methodological quality score (MQS - ranging from 0 to 21). The mean MQS of 10.9 indicated these studies were, overall, of medium quality and suffered from specific flaws. Alongside a call for more rigorous research, this review provides important suggestions for practice and culturally relevant interventions.

Communication preference moderates the effect of a tailored intervention to increase colorectal cancer screening among African Americans

OBJECTIVE

Test the impact of tailoring CRC screening messages for African Americans (AAs) using novel theoretical variables and to examine moderating effect of communication preferences.

METHODS

Participants were randomized to receive two minimally tailored or two enhanced tailored print newsletters addressing CRC. The enhanced intervention was tailored on Self-Determination Theory and other novel psychological constructs. Minimal tailoring only used information available in the patient's EHR. The primary outcome was CRC screening based on EHR. Participants were AA members aged 50-74 of an integrated health care delivery system not up to date on CRC screening.

RESULTS

We enrolled 881 participants. CRC screening participation rates at 1-year follow up were 20.5% and 21.5% in the minimally and enhanced tailored groups, respectively. Communication preferences moderated the impact of the intervention. Specifically, among those with an autonomous communication preference, screening rates in the minimally and enhanced tailored groups were 17.1% and 25.9%, respectively, while no intervention effect was evident among those with a directive preference.

CONCLUSION

Future research is needed to explore the impact of communication preference tailoring for other health behaviors and among other populations.

PRACTICE IMPLICATIONS

Tailored communications should consider communication style preference to help guide the content and tone of messages.

Low uptake of colorectal cancer screening among African Americans in an integrated Veterans Affairs health care network

BACKGROUND

African Americans have the highest incidence and mortality from colorectal cancer (CRC). Despite guidelines to initiate screening with colonoscopy at age 45 in African Americans, the CRC incidence remains high in this group.

OBJECTIVE

To examine the rates and predictors of CRC screening uptake as well as time to screening in a population of African Americans and non-African Americans in a health care system that minimizes variations in insurance and access.

DESIGN

Retrospective cohort study.

SETTING

Greater Los Angeles Veterans Affairs (VA) Healthcare System.

PATIENTS

Random sample (N = 357) of patients eligible for initial CRC screening.

MAIN OUTCOME MEASUREMENTS

Uptake of any screening method; uptake of colonoscopy, in particular; predictors of screening; and time to screening in African Americans and non-African Americans.

RESULTS

The overall screening rate by any method was 50%. Adjusted rates for any screening were lower among African Americans than non-African Americans (42% vs 58%; odds ratio [OR] 0.49; 95% confidence interval [CI], 0.31-0.77). Colonoscopic screening was also lower in African Americans (11% vs 23%; adjusted OR 0.43; 95% CI, 0.24-0.77). In addition to race, homelessness, lower service connectedness, taking more prescription drugs, and not seeing a primary care provider within 2 years of screening eligibility predicted lower uptake of screening. Time to screening colonoscopy was longer in African Americans (adjusted hazard ratio 0.43; 95% CI, 0.25-0.75).

LIMITATIONS

The sample may not be generalizable.

CONCLUSIONS

We found marked disparities in CRC screening despite similar access to care across races. Despite current guidelines aimed at increasing CRC screening in African Americans, participation in screening remained low, and use of colonoscopy was infrequent.

Factors influencing colorectal cancer screening in rural southern Taiwan

BACKGROUND

Colorectal cancer (CRC) is the most common cancer in Taiwan. Colorectal cancer screening can prevent or detect cancer early, but the acceptance rate in rural southern Taiwan is unknown.

OBJECTIVE

The purpose of this study was to explore the prevalence of CRC screening and related factors in rural south Taiwan.

METHODS

Cross-sectional study was conducted. Sample population was recruited from 2 rural areas in southern Taiwan. A structured questionnaire was completed by 635 participants. The following outcomes were studied: sociodemographic characteristics, knowledge of CRC screening, acceptance of CRC screening, and the reasons for having or not having CRC screening.

RESULTS

The results indicated that 4.7% of the respondents had undergone a fecal occult blood test, 3.1% had undergone a sigmoidoscopy, and 2.7% had undergone a colonoscopy. For overall CRC screening, knowledge that CRC was the most common form of cancer was significant (P < .01). Among participants who knew that CRC was the most common form of cancer, the odds of undergoing CRC screening were 4.20-fold greater than among participants who did not know that CRC was the most common form of cancer (P < .01; confidence interval, 1.62-10.89).

CONCLUSIONS

This study demonstrates that the acceptance of CRC screening among men remains higher than among women in rural southern Taiwan. Efforts to improve CRC screening in rural areas should focus on increasing community residents' knowledge about cancer incidence and prevention.

IMPLICATIONS FOR PRACTICE

Colorectal cancer screening is a useful cancer prevention measure, and community health center nurses should assess and promote rural residents' acceptance for CRC screening.

A Pacific Islander Organization's Approach Towards Increasing Community Colorectal Cancer Knowledge and Beliefs

PURPOSE

Evaluate the educational intervention and determine if changes in knowledge and beliefs are associated with positive intentions to screen among Pacific Islanders (PIs).

DESIGN

Pre- and post-test surveys were utilized to evaluate the intervention. Educational materials included an in-language presentation, educational videos, and bookmarks with screening re-enforcement messages for community-based PI groups.

METHODS

One hundred and ninety-six PIs aged 50 years and older residing in Orange County completed the educational workshop. The dependent variable is intention and the independent variables are demographic, enabling, and predisposing characteristics. Statistical analyses included paired samples t-tests, chi-square tests, and two logistic regression models.

RESULTS

Knowledge and belief scores increased pre- to post-test. A majority intended to (1) talk to a doctor about colorectal cancer (CRC) screening (74.5%), and (2) participate in CRC screening (73.5%). Positive change in knowledge score was a significant predictor for intending to talk to a doctor about CRC screening; female gender and positive change in knowledge score were significant predictors for intending to participate in screening.

CONCLUSION

The study highlighted the effectiveness of tailored education in addressing cultural and linguistic needs of the community. Moreover, it demonstrated the education's potential for moving participants with limited CRC screening knowledge to intend to screen.

Association between intimate partner violence and preventive screening among women

BACKGROUND

Intimate partner violence (IPV) is defined as physical, sexual, or psychological harm that can be perpetrated by a former/current spouse. IPV has been linked to adverse health outcomes and risky behaviors, and victims of IPV tend to need more healthcare overall than nonvictims of IPV. The purpose of this study was to determine the association between IPV and preventive screening among women.

METHODS

The study used data from eight states/territories, which collected IPV information in the 2006 and 2007 Behavioral Risk Factor Surveillance System (n=30,182). IPV and preventive screening for HIV, cervical cancer, colorectal cancer, cholesterol, and breast cancer were determined by self-report. Multivariable logistic regression models provided adjusted estimates of odds ratios (aOR) and 95% confidence intervals (CI).

RESULTS

Approximately one in four women reported a history of lifetime IPV. Relative to those who did not report a history of IPV, IPV victims were twice as likely to have had an HIV test (aOR: 2.34; 95% CI: 2.06 to 2.66) or a breast exam (aOR: 1.76; 95% CI: 1.37 to 2.27). IPV victims are vigilant about certain screening practices related to sexual health (HIV testing) and passive screening (breast exam) compared to active screening.

CONCLUSION

The strongest association between IPV and preventive screening was seen for HIV testing, which likely reflects the women's perceived risk for HIV infection. That these women are in contact with the healthcare system provides support for recommendations for widespread adoption of IPV screening and counseling.

Late presentation of colorectal cancer in a vulnerable population

OBJECTIVES

We examined colorectal cancer (CRC) stage at presentation and mortality in a vulnerable population compared with nationally representative data.

METHODS

CRC cases were identified from San Francisco General Hospital (SFGH) and the Surveillance Epidemiology and End Results (SEER) database.

RESULTS

Fifty-five percent of the SFGH cohort presented with advanced disease, compared with 44% of the SEER cohort. Increased risk of advanced stage at presentation at SFGH compared with SEER was most evident among blacks and Asians. There was weak evidence for worse survival at SFGH compared with SEER overall. This varied by race with poorer survival at SFGH among whites and possibly blacks but some evidence for better survival among Asians. Among CRC patients at SFGH, Asians and Hispanics had better survival than whites and blacks. At SFGH, 44% had a diagnosis of CRC within 1 year of establishing care there. Of those who had established care at SFGH for at least 1 year, only 22% had exposure to CRC screening tests.

CONCLUSIONS

These findings allow examination of CRC presentation by ethnicity in vulnerable populations and identify areas where access and utilization of CRC screening can be improved.

"Cutting" on cancer: attitudes about cancer spread and surgery among primary care patients in the U.S.A

Many underserved groups in the United States experience disparities in cancer survival. Part of the disparity may be due to differences in treatment or treatment uptake. Previous studies uncovered patient beliefs that surgery could cause cancer to spread and have suggested that this belief may affect uptake of cancer treatment. We explored patients' explanations about surgical treatment of cancer and cancer spread, as well as the perceived impact on decision-making among primary care patients from an underserved area. Focus groups and interviews were conducted with patients (n = 42) at a primary care federally qualified health center in 2006 and 2007. Focus groups/interviews were semi-structured and were audio-taped and transcribed. An inductive text analysis with multiple coders was used to analyze the data and extract themes. We found that nearly all respondents had heard that surgery ("cutting") and exposing cancer to the air would hasten cancer spread and result in worse outcomes. Most participants expressed agreement with this belief. Many participants said this concern would influence their decision about whether to have surgery and/or reported that a family member had refused surgery for this reason. A smaller group of respondents disagreed with this belief and offered experiential evidence to the contrary or hypotheses about its origination. The idea that "cutting" and "air" during surgery can cause cancer to spread may be more prevalent among patients than suspected, based on this sample of predominantly African American patients. While we were unable to disentangle the ideas about "cutting" from those about "exposure to air", this set of beliefs, when held strongly, can negatively influence patients' or family members' decisions to seek surgical care and, if it is more prevalent in underserved groups, may contribute to cancer disparities.