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© 2003 American Public Health Association
RESEARCH AND PRACTICE |
C. H. Brouse, C. E. Basch, and R. L. Wolf are with the Dept of Health and Behavior Studies, Teachers College, Columbia University, New York, NY. C. E. Basch is also with the Herbert Irving Comprehensive Cancer Center, New York, NY. C. Shmukler is with the Disease Management and Wellness Program, New York, NY. A. I. Neugut is with the Herbert Irving Comprehensive Cancer Center and the Dept of Medicine, Columbia University College of Physicians and Surgeons, New York, NY. S. Shea is with the Dept of Medicine, Columbia University College of Physicians and Surgeons.
Correspondence: Requests for reprints should be sent to Charles E. Basch, PhD, 525 W 120 St, Box 114, Department of Health and Behavior Studies, Teachers College, Columbia University, New York, NY 10027 (e-mail: ceb35{at}columbia.edu).
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INTRODUCTION |
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 TOP INTRODUCTION METHODSRESULTSDISCUSSIONReferences |
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Colorectal cancer is the second leading cause of cancer death in the United States.1 Appropriate screening can reduce incidence of and mortality from colorectal cancer.2–5 The US Preventive Services Task Force recommends that all average-risk individuals aged 50 years and older receive colorectal cancer screening.6 The American Cancer Society recommends several acceptable approaches to screening, including an annual 3-card home fecal occult blood test.7 The Healthy People 2010 objective is to increase the proportion of people aged 50 and older who have received a fecal occult blood test within the preceding 2 years to at least 50%.8 Lack of knowledge, confidence, and skills; negative attitudes toward the tests themselves; fear of the consequences of screening; and inadequate social support all have been suggested as possible barriers to colorectal cancer screening,9 whereas positive attitudes toward colorectal cancer screening and physician encouragement have been associated with receipt of a fecal occult blood test with a home stool kit.10
Despite these studies, gaps remain in what is known about barriers to successful interventions to increase colorectal cancer screening, particularly in minority populations.11,12 This study is based on the assumption that identification and definition of barriers to colorectal cancer screening in low-income, underserved minority populations can help guide the development of effective interventions.
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METHODS |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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The Healthy Colon Project is a randomized controlled trial designed to test whether a telephone-based health intervention will increase fecal occult blood test screening rates for colorectal cancer among active members and their dependents in a health care workers’ union.13 More than 80% of the union members are from lower-income occupations, including food service workers, custodians, laboratory technicians, and clerks. The approximate racial/ethnic composition is 35% Black non-Hispanic, 45% Hispanic, 15% White non-Hispanic, and 5% Asian/Pacific Islander. The fecal occult blood test is 100% reimbursable for all union members.
In the year 2000, a pilot study was conducted with 42 participants, aged 53 to 80 years, who had not had colorectal cancer screening within the preceding 2 years and who agreed to pilot test the telephone-based health education intervention. An intensive qualitative analysis of information obtained from 8 of these 42 pilot subjects was performed to improve understanding about barriers to successful intervention implementation.14 These 8 cases were selected because they illustrate particular barriers.
The intervention involved multiple telephone conversations between the health educator and each participant over a 2-month period. The initial call followed a loosely structured outline and contained selected factual information, tailored to the needs of each participant (e.g., stage of readiness to change, colorectal cancer knowledge, screening test preference, access to resources, skills, social support), as well as other individual characteristics (e.g., talkativeness). Several health behavior and health education theories guided these interactions.15–18 If a verbal commitment to complete a colorectal cancer screening test was made, follow-up contacts reinforced this commitment and addressed barriers. If a verbal commitment was not offered, subsequent calls addressed barriers to making such a commitment.
Data Collection and Analysis
The health educator took detailed written notes of each participant interaction during and after each telephone interaction. Descriptive qualitative analysis was used to identify and describe the barriers encountered and potential interventions to address the respective barriers for each participant. Data were summarized to identify recurrent issues.
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RESULTS |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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The 8 participants (6 women and 2 men) ranged in age from 54 to 72 years (mean = 61.4). Five participants characterized their race/ethnicity as Hispanic, 2 as Black or African American, and 1 as White. Descriptions of the participant interactions with the health educator are presented to illustrate the most common barriers encountered (Table 1
). The main barriers were lack of colorectal cancer knowledge, lack of communication skills and self-efficacy in skills to act on motivation, unavailability and inaccessibility of fecal occult blood test kits, perceived lack of social support, and fear and concomitant denial that colorectal cancer "won’t happen to me." In many cases, intervention strategies could be tailored to address these barriers (Table 1).
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DISCUSSION |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Limitations include (1) the small sample, (2) data based on self-report,19,20 and (3) data based on only the perspective of the participant, not the perspective of the primary care provider. Despite these limitations, these results provide new information about barriers to colorectal cancer screening in predominantly minority populations.
A previously unreported finding in several of the interviews was that participants encountered obstacles in obtaining the fecal occult blood test from their physicians. To date, little is known about barriers to participation by physicians in colorectal cancer screening with the home stool kit.21,22 We speculate that the barriers may include (1) lack of office personnel or systems to track requests, to mail fecal occult blood test kits to patients’ homes, and to follow up once the kit is returned; (2) concerns about patient compliance; (3) lack of knowledge about or belief in the effectiveness of fecal occult blood test–based colorectal cancer screening or the appropriate age range for colorectal cancer screening; and (4) possibly lack of reimbursement of physician time related to the test administration and tracking when done outside an office visit, despite the reimbursability of the fecal occult blood test itself. These possibilities need further exploration.
We found that the informal and unstructured educational approach used to promote patient participation in colorectal cancer screening allowed for maximum tailoring of the intervention to each individual. Tailoring permitted us to address a variety of needs for different participants. In some participants, tailoring focused on enhancing motivation (e.g., by increasing knowledge), whereas in others, emphasis was placed on addressing deficits in skills or self-efficacy through coaching and role-playing. In others, communications were tailored to provide social and emotional support, including dealing with fear and denial. We also found that even when individuals were motivated and initiated action, environmental barriers related to the availability or accessibility of the fecal occult blood test could significantly hinder their efforts to obtain colorectal cancer screening.
One of the greatest public health challenges we currently face is reducing disparities in health between social groups in the United States. Progress in reducing disparities in morbidity and mortality can be addressed by promoting preventive practices such as screening in underserved populations. We currently have little understanding of barriers to colorectal cancer screening in such populations and how they can be ameliorated. This study is intended to be one small but meaningful step in this direction by identifying issues that warrant further investigation.
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Acknowledgments |
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This research was supported by grants R01 CA81932, K05 CA89155, and P30 CA13696 24 from the National Cancer Institute.
We thank the technical and support staffs at Teachers College and Columbia University’s Herbert Irving Comprehensive Cancer Center for their ongoing contributions to this project. Our appreciation goes to the study participants for their time and participation.
Human Participant Protection
The institutional review boards at Teachers College and Columbia-Presbyterian Medical Center approved the study protocol. Informed consent was obtained from each participant. Initials of the participants have been changed to ensure confidentiality.
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Footnotes |
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Contributors
C. H. Brouse collected and analyzed the data. C. E. Basch and R. L. Wolf planned the study, dealt with methodological issues of data collection and analysis. S. Shea, A. I. Neugut and C. Schmuckler assisted with planning the study, dealt with medical issues related to the implementation of the study. All authors contributed to writing the brief.
Accepted for publication November 25, 2002.
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References |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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