Colorectal cancer screening among underserved minority population: Discrepancy between physicians’ recommended,scheduled, and completed tests

Objective

This study examines the correlates of: (1) health care provider recommendation of CRC testing; (2) provider scheduling for recommended CRC testing using sigmoidoscopy, colonoscopy, or double-contrast barium enema; and (3) adherence to CRC scheduling among underserved minority populations.

Methods

Medical record and schedule logbook reviews and interviewer-administered surveys. Setting: Large urban safety-net, outpatient primary care setting in Los Angeles County. Participants: 306 African-American and Latino patients aged 50 years and older.

Results

A vast majority of minority patients do not receive standard CRC testing in urban safety-net primary care settings. Of those patients who were actually scheduled for sigmoidoscopy or colonoscopy, almost half completed the procedure. Completing CRC testing was associated with marital status, co-morbid chronic physical conditions, number of risk factors for colorectal cancer, and lower perceived barriers to CRC testing.

Conclusion

Effective interventions to reduce CRC mortality among underserved minority populations require an integrated approach that engages patients, providers, and health care systems.

Practice implications

Designing interventions that (1) increase physician–patient communications for removing patients’ perceived barriers for CRC testing and (2) promote a non-physician-based navigator system that reinforces physicians’ recommendation are strongly recommended.     

Assessment of family history of colorectal cancer in primary care: Perceptions of first degree relatives of people with colorectal cancer

Objective

First degree relatives (FDRs) of someone with colorectal cancer (CRC) are at increased risk of the disease. In this study we examine the factors associated with discussing family history of CRC with a health professional.

Methods

People with CRC, recruited through the population-based Victorian Cancer Registry in Australia, were asked to refer FDRs to the study. Eight hundred and nineteen FDRs completed a telephone interview.

Results

Thirty-six percent of FDRs recalled ever being asked about their family history of bowel cancer by a health professional. Factors associated with having this discussion were being aged 50–60 years, having a university education, being in the potentially high risk category, being very worried about getting bowel cancer and knowing that family history increases risk through discussions with family, friends or their own education.

Conclusion

Despite evidence that doctor endorsement is a key factor in the uptake of CRC screening, our study shows that the majority of FDRs do not recall being asked by a health professional about their family history.

Practice implications

There is a need to identify the most appropriate method to improve rates of health professional discussion of family history with relatives of CRC patients in order to improve screening rates.     

Patient–physician colorectal cancer screening discussion content and patients’ use of colorectal cancer screening

Objective

The US Preventive Services Task Force recommends using the 5As (i.e., Assess, Advise, Agree, Assist and Arrange) when discussing preventive services. We evaluate the association of the 5As discussion during primary care office visits with patients’ subsequent colorectal cancer (CRC) screening use.

Methods

Audio-recordings of n = 443 periodic health exams among insured patients aged 50–80 years and due for CRC screening were joined with pre-visit patient surveys and screening use data from an electronic medical record. Association of the 5As with CRC screening was assessed using generalized estimating equations.

Results

93% of patients received a recommendation for screening (Advise) and 53% were screened in the following year. The likelihood of screening increased as the number of 5A steps increased: compared to patients whose visit contained no 5A step, those whose visit contained 1–2 steps (OR = 2.96 [95% CI 1.16, 7.53]) and 3 or more steps (4.98 [95% CI 1.84, 13.44]) were significantly more likely to use screening.

Conclusions

Physician CRC screening recommendations that include recommended 5A steps are associated with increased patient adherence.

Practice implications

A CRC screening recommendation (Advise) that also describes patient eligibility (Assess) and provides help to obtain screening (Assist) may lead to improved adherence to CRC screening.     

Public perceptions and preferences for CT colonography or colonoscopy in colorectal cancer screening

Objectives

To examine public perceptions of and preferences for colonoscopy vs. CT colonography (CTC) as technologies for colorectal cancer (CRC) screening.

Methods

Six discussion groups were carried out with 30 adults aged 49–60 years (60% female). Information about different aspects of the tests (e.g. sensitivity, practical issues) was presented sequentially using a semi-structured, step-by-step topic guide. Discussions were recorded and analyzed using framework analysis.

Results

CTC was favored on the parameters of invasiveness, extra-colonic evaluation and interference with daily life, whereas sensitivity, avoiding false-positives and the capacity to remove polyps immediately were perceived to be important advantages of colonoscopy. Ultimately, there was no strong preference for either test: with 46% preferring colonoscopy vs. 42% for CTC.

Conclusion

With comprehensive information, colonoscopy and CTC were seen as having different advantages and disadvantages, yielding no clear preferences between the two. The sensitivity of colonoscopy was a decisive factor for some people, but the lower invasiveness of CTC was seen as an asset in the screening context.

Practice implications

CTC may be an acceptable alternative to colonoscopy in CRC screening. Healthcare professionals working in the screening context should be sensitive to the range of characteristics that can determine preferences for CRC screening tests.     

Factors influencing adherence among Irish haemodialysis patients

Objective

Adherence to dietary and fluid restrictions among haemodialysis patients with end stage renal failure (ESRD) is a multi-factorial concept. This study seeks to assess the predictive value of demographic and psychological variables in non-adherence.

Methods

A multi-centre cross sectional design assessed 50 haemodialysis patients on self reported adherence, attitudes towards dietary restrictions, quality of life, depression and anxiety. Adherence to fluid and dietary restrictions was measured objectively using potassium (K), phosphorus (PO₄) and inter-dialytic weight gain (IDWG) parameters.

Results

62% of patients were non-adherent with at least one aspect of the treatment regime. Regression analysis revealed age as significantly associated with adherence, in particular IDWG, with younger patients displaying poorer adherence.

Conclusion

Younger patients may experience greater difficulty integrating complex treatment demands into their lifestyles, and non-adherence may be a consequence of the severe lifestyle limitations imposed by the haemodialysis treatment regime.

Practice implications

Individualised interventions may be more effective than traditional methods of adherence monitoring in reducing the non-adherent behaviour.     

Informed decision-making in colorectal cancer screening using colonoscopy or CT-colonography

Objective

To evaluate the level of informed decision making in a randomized controlled trial comparing colonoscopy and CT-colonography for colorectal cancer screening.

Methods

8844 citizens aged 50–75 were randomly invited to colonoscopy (n = 5924) or CT-colonography (n = 2920) screening. All invitees received an information leaflet. Screenees received a questionnaire within 4 weeks before the planned examination, non-screenees 4 weeks after the invitation. A decision was categorized as informed when characterized by sufficient decision-relevant knowledge and consistent with personal attitudes toward participation in screening.

Results

Knowledge and attitude items were completed by 1032/1276 colonoscopy screenees (81%), by 698/4648 colonoscopy non-screenees (15%), by 824/982 CT-colonography screenees (84%) and by 192/1938 CT-colonography non-screenees (10%). 1027 colonoscopy screenees (>99%) and 815 CT-colonography screenees (99%) had adequate knowledge; 915 (89%) and 742 (90%) had a positive attitude. 675 non-screenees invited to colonoscopy (97%) and 182 invited to CT-colonography (95%) had adequate knowledge; 344 (49%) and 94 (49%) expressed a negative attitude.

Conclusion

A large majority of screenees made an informed decision on participation. Almost half of responding non-screenees, made an uninformed decision, suggesting additional barriers to participation.

Practice implications

Efforts to understand the additional barriers will create opportunities to facilitate informed participation to colorectal cancer screening.     

Inconsistencies in patient perceptions and observer ratings of shared decision making: The case of colorectal cancer screening

Objective

To compare patient-reported and observer-rated shared decision making (SDM) use for colorectal cancer (CRC) screening and evaluate patient, physician and patient-reported relational communication factors associated with patient-reported use of shared CRC screening decisions.

Methods

Study physicians are salaried primary care providers. Patients are insured, aged 50–80 and due for CRC screening. Audio-recordings from 363 primary care visits were observer-coded for elements of SDM. A post-visit patient survey assessed patient-reported decision-making processes and relational communication during visit. Association of patient-reported SDM with observer-rated elements of SDM, as well as patient, physician and relational communication factors were evaluated using generalized estimating equations.

Results

70% of patients preferred SDM for preventive health decisions, 47% of patients reported use of a SDM process, and only one of the screening discussions included all four elements of SDM per observer ratings. Patient report of SDM use was not associated with observer-rated elements of SDM, but was significantly associated with female physician gender and patient-reported relational communication.

Conclusion

Inconsistencies exist between patient reports and observer ratings of SDM for CRC screening.

Practice implications

Future studies are needed to understand whether SDM that is patient-reported, observer-rated or both are associated with informed and value-concordant CRC screening decisions.     

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

Objective

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

Methods

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

Results

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

Conclusion

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

Practice Implications

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

Caregiver health literacy and adherence to a daily multi-vitamin with iron regimen in infants

Objective

To determine whether or not limited caregiver health literacy is associated with adherence to a daily multi-vitamin with iron regimen in infants.

Methods

110 caregiver/infant dyads were enrolled in a prospective study to assess the relationship between caregiver health literacy and adherence to a daily multi-vitamin with iron regimen for infants. Households were contacted biweekly over a 3-month period. Adherence was based upon caregiver report. High adherence, our primary outcome, was defined as the administration of the multi-vitamin with iron on 5–7 days over the past week.

Results

As measured by the Short Test of Functional Health Literacy in Adults (S-TOFHLA), 18% of caregivers had limited health literacy skills. Caregivers with limited health literacy skills were more likely to have higher adherence than caregivers with adequate health literacy, after adjusting for a number of possible confounding variables (AOR = 2.13; 95% 1.20–3.78).

Conclusion

Caregivers with limited health literacy were twice as likely to report high adherence to a daily multi-vitamin with iron regimen in infants as caregivers with adequate health literacy in adjusted analysis.

Practice implications

Health literacy may exert a differential influence on adherence depending upon the complexity of the desired health behavior.     

Adherence to nebulised antibiotics in cystic fibrosis

Objective

To examine the adherence of patients with cystic fibrosis to nebulised antibiotics.

Methods

A longitudinal design with adherence data collected over 12 weeks. 38 patients (mean age 24.6 years, S.D. 5.3) were recruited from an adult cystic fibrosis (CF) clinic. Adherence was electronically monitored using a Prodose adaptive aerosol delivery (AAD) device.

Results

Three indices of adherence were calculated: mean percentage of times the nebuliser was used as prescribed was 50.0% (S.D. = 39.7, range 1.1, 155.6); mean percentage of days fully adhered was 31.6% (S.D. = 29.4, range 0, 97.2); mean percentage of days nebuliser used at least once was 57.1% (S.D. = 34.2, range 3.3, 100).

Conclusion

Rates of adherence were generally low. Adherence was not associated with any variables apart from age. There were wide variations between individuals, and differences in rates of adherence depending on how this was defined, with potentially important health consequences for the patients.

Practice implications

Technology that improves medication administration may still be associated with low rates of adherence. Health professionals need to be mindful of the pattern of non-adherence for each individual, and factors which may be influencing this.     

A multimedia patient education program on colorectal cancer screening increases knowledge and willingness to consider screening among Hispanic/Latino patients

Objective

To test a multimedia patient education program on colorectal cancer (CRC) screening that was designed specifically for the Hispanic/Latino community, and developed with input from community members.

Methods

A total of 270 Hispanic/Latino adults, age 50–80 years, participated in Spanish for all phases of this pretest–posttest design. Patients were randomly assigned to a version of the multimedia program that opened with either a positive or negative introductory appeal. Structured interviews assessed screening relevant knowledge (anatomy and key terms, screening options, and risk information), past screening behavior, willingness to consider screening options, intention to discuss CRC screening with the doctor, and reactions to the multimedia patient education program.

Results

The multimedia program significantly increased knowledge of anatomy and key terms (e.g., polyp), primary screening options (FOBT, flexible sigmoidoscopy, colonoscopy), and risk information as well as willingness to consider screening (p < .001 for all). No significant differences emerged between positive and negative introductory appeals on these measures, intention to discuss CRC screening with their doctor, or rating the multimedia program.

Conclusion

Multimedia tools developed with community input that are designed to present important health messages using graphics and audio can reach Hispanic/Latino adults across literacy levels and ethnic backgrounds. Additional research is needed to determine effects on actual screening behavior.

Practice implications

Despite promising results for engaging a difficult-to-reach audience, the multimedia program should not be considered a stand-alone intervention or a substitute for communication with physicians. Rather, it is a priming mechanism intended to prepare patients for productive discussions of CRC screening.     

Motivational interviewing and screening colonoscopy in high-risk individuals. A randomized controlled trial

Objective

To measure the impact of motivational interviewing (MI) on cancer knowledge and screening practice among first degree relatives (FDRs) of patients with colon cancer.

Patients' experiences and reported barriers to colonoscopy in the screening context--a systematic review of the literature

Objective

A systematic review of the literature was conducted to characterise patients’ own experience of colonoscopy in the screening context.

Methods

A search strategy was applied in MEDLINE, EMBASE and PSYCHinfo (1996-2009). Thematic analysis and narrative summary techniques were used.

Results

Fifty-six studies met eligibility criteria and were included in the analysis. Seven studies examined patients’ views after having colonoscopy. Forty-seven studies addressed patient-reported barriers to an anticipated primary colonoscopy. Most patients perceived the laxative bowel preparation to be the most burdensome part of colonoscopy. Other reported difficulties included anxiety, anticipation of pain, feelings of embarrassment and vulnerability. Inadequate knowledge and fear of finding cancer were identified as obstacles to the uptake of screening colonoscopy. Physician endorsement, having a family history, knowing someone with cancer, and perceived accuracy of the test were incentives to having a colonoscopy. Two studies focused on colonoscopy after faecal occult blood screening. Similar procedural, personal, and practical concerns were reported.

Conclusions

Bowel preparation, lack of awareness of the importance of screening, and feelings of vulnerability in women are all significant barriers to screening colonoscopy.

Practice implications

Patient reported obstacles and barriers to screening colonoscopy needs to be addressed to improve adherence.     

Effects of tailored knowledge enhancement on colorectal cancer screening preference across ethnic and language groups

Objective

Tailoring to psychological constructs (e.g. self-efficacy, readiness) motivates behavior change, but whether knowledge tailoring alone changes healthcare preferences – a precursor of behavior change in some studies – is unknown. We examined this issue in secondary analyses from a randomized controlled trial of a tailored colorectal cancer (CRC) screening intervention, stratified by ethnicity/language subgroups (Hispanic/Spanish, Hispanic/English, non-Hispanic/English).

Methods

Logistic regressions compared effects of a CRC screening knowledge-tailored intervention versus a non-tailored control on preferences for specific test options (fecal occult blood or colonoscopy), in the entire sample (N = 1164) and the three ethnicity/language subgroups.

Results

Pre-intervention, preferences for specific tests did not differ significantly between study groups (experimental, 64.5%; control 62.6%). Post-intervention, more experimental participants (78.6%) than control participants (67.7%) preferred specific tests (P < 0.001). Adjusting for pre-intervention preferences, more experimental group participants than control group participants preferred specific tests post-intervention [average marginal effect (AME) = 9.5%, 95% CI 5.3–13.6; P < 0.001]. AMEs were similar across ethnicity/language subgroups.

Conclusion

Knowledge tailoring increased preferences for specific CRC screening tests across ethnic and language groups.

Practice Implications

If the observed preference changes are found to translate into behavior changes, then knowledge tailoring alone may enhance healthy behaviors.     

Patient–provider communication and cancer screening among unmarried women

Objectives

Unmarried women are less likely than married women to receive recommended cancer screenings. Patient–provider communication is a consistent predictor of cancer screening among women. The purpose of this study was to investigate the relationship between patient and provider communication, barriers to cancer screening, and on-schedule breast and cervical cancer screening (BCCS) among unmarried women.

Methods

Data were from the Cancer Screening Project for Women, a 2003–2005 survey examining cancer screening practices. We computed polytomous logistic regression models to examine the relationship between communication (communication about tests, communication about sexual and intimate relationships), barriers to screening, and on-schedule BCCS among unmarried women.

Results

A total of 630 women were enrolled, and 605 women completed the baseline questionnaire. Overall, more than 60% reported on-schedule BCCS. More than half reported that their providers communicated about BCCS most or all of the time. Fewer than half communicated about sexual history and intimate relationships. Women who reported that their providers communicated about screening tests and their sexual and intimate relationships were more likely to be on-schedule for BCCS.

Conclusion

Patient–provider communication about multiple topics may encourage women to remain on-schedule for their recommended cancer screenings. Longitudinal research should be conducted to examine whether communication predicts BCCS, and to examine how patient and provider characteristics may influence communication in order to promote adherence to screening guidelines for unmarried women.

Practice implications

Comprehensive communication that goes beyond information about screening tests may impact adherence to cancer screening guidelines.     

Attitudes of Jewish and Bedouin responders toward family physicians’ use of electronic medical records during the medical encounter

Objective

Culture is known to impact expectations from medical treatments. The effects of cultural differences on attitudes toward Electronic Medical Records (EMR) have not been investigated. We compared the attitudes of Jewish and Bedouin responders toward EMR's use by family physicians during the medical encounter, and examined the contribution of background variables to these attitudes.

Methods

86 Jewish and 89 Bedouin visitors of patients in a regional Israeli University Medical Center responded to a self-reporting questionnaire with Hebrew and Arabic versions.

Results

T-tests and a linear regression analysis found that culture did not predict attitudes. Respondents’ self-reported health status, Internet and e-mail use, and estimates of their physician's typing speed explained a total of 18.6% of the variance in attitudes (p < 0.001).

Conclusion

Bedouins respondents’ attitudes toward EMR use were better than expected and similar to those of their Jewish counterparts. The most significant factor influencing respondents’ attitudes was the physician's typing speed.

Practice implications

(1) Further studies should consider the possible impact of cultural differences between the family physician and the healthcare client on attitudes. (2) Interventions to improve physicians’ skill in operating EMRs and typing will potentially have a positive impact on patients’ satisfaction with physicians’ EMR use.     

Telephone nurse counseling for medication adherence in ulcerative colitis: A preliminary study

Objective

Adherence is challenging in episodic chronic conditions that require medication during both symptomatic and quiescent periods, such as ulcerative colitis (UC). Adherence for these conditions is under-studied. This study was a preliminary test of telephone nurse counseling to address cognitive and emotional barriers to adherence in UC.

Methods

524 people taking mesalamine for UC were referred by their health care providers, and 278 (53%) enrolled. There were no demographic differences between program participants and nonparticipants. Participants reported multiple comorbidities and concomitant medications. All participants received telephone follow-up (M = 2.1 calls) from a registered nurse who used cognitive-behavioral and motivational interviewing counseling techniques. Adherence measured by structured interview was compared to a population baseline using a binomial test.

Results

Attrition was 51% over 6 months but was unrelated to adherence. Participants had better adherence than the expected population rate, with a significant dose-response effect. Reasons for nonadherence were primarily psychological or efficacy-related.

Conclusion

Adherence following intervention was better than typical mesalamine adherence. Self-efficacy predicted adherence, but demographic and clinical variables did not. Adherent participants reported more adverse events.

Practice implications

Attention to patients’ cognitive and emotional reactions may help to improve adherence in episodic chronic diseases such as UC.     

Tailored telephone counseling to improve adherence to follow-up regimens after an abnormal pap smear among minority,underserved women

Objective

The present study explored the impact of a tailored telephone counseling intervention on increasing follow-up adherence after an abnormal Pap smear result among low-income, minority women, which may reduce cervical cancer disparity.

Methods

Participants (N = 211) were randomly assigned to receive: (1) a telephone reminder that included an assessment of barriers to adherence, as well as counseling tailored to the barriers elicited; (2) telephone reminder and barriers assessment, followed by a mailed home tailored barriers print brochure; or (3) enhanced standard care comprising telephone reminder and barriers assessment. Assessments were obtained at initial contact and 1-week later, as well as at 6- and 12-months after the initial colposcopy.

Results

The telephone counseling group showed greater adherence to follow-up recommendations than did the combined other two groups (p < 0.05). For the initial colposcopy, tailored telephone barriers counseling was more effective among women with a high school education or less.

Conclusion

Tailored telephone barriers counseling improves adherence to initial colposcopy, as well as to longer-term medical follow-up, among low-income, inner-city women.

Practice Implications

Dissemination of barriers counseling into ongoing telephone reminder calls and contacts may decrease disparities in cancer outcomes, especially among women with less than post-secondary education.     

Treatment adherence in bipolar I and schizoaffective disorder,bipolar type

Background

Poor adherence rates in Bipolar Disorder type I (BDI) and Schizoaffective Disorder, bipolar type (SAD) may be high This study was aimed at comparing the clinical correlates of adherence to treatment and the course of illness in BDI and SAD patients.

Methods

75 SAD and 150 BDI DSM-IV outpatients were included. Adherence was assessed on the basis of patients’ and care-givers’ reports and serum levels, when available. Socio-demographic, clinical and treatment variables were collected and compared between diagnostic subsamples and then between goodly and poorly adherent patients. Multiple logistic regressions were performed, controlling for diagnostic subsample differences, to identify correlates of adherence in BDI and SAD groups.

Results

Poor adherence was highly prevalent both in BDI (32%) and in SAD patients (44%), with no significant differences between diagnostic categories. Presence of psychotic symptoms (p=0.029), higher number of manic relapses (p<0.001), comorbidity with personality disorders (p=0.002), and lithium therapy (p=0.003) were associated with poor adherence to treatment. Diagnostic subgroup analyses showed different predictive models, with the BDI poorly adherent subsample being more likely to include comorbid personality and manic recurrences and the SAD poorly adherent subsample being less clinically predictable.

Limitations

The cross-sectional nature of the study limits de capacity to ascertain the direction of the relationship between certain variables.

Conclusions

Rates of poor adherence to oral treatments are similar in SAD and BDI. BDI patients with comorbid personality and substance use disorders are likely to be poorly adherent. Treatment adherence may be more difficult to predict in SAD patients.