Applying a stage model of behavior change to colon cancer screening
Introduction
Colorectal cancer (CRC) is the second leading cause of cancer-specific death for men and for women combined in the United States (American Cancer Society, 2003) and accounted for approximately 57,000 deaths in 2003 (American Cancer Society, 2003). A number of studies have demonstrated that screening for CRC is effective in reducing CRC-specific mortality (Mandel et al., 1993, Selby et al., 1992, Winawer et al., 1993, Newcomb et al., 1992, Mueller and Sonnenberg, 1995, Pignone et al., 2002b). However, specific screening recommendations are complex because multiple screening options are available, reflecting evidence that several individual tests as well as combinations of tests are effective (U.S. Preventive Services Task Force, 2002, Pignone et al., 2002a). Also, the recommendations are complex because each test must be repeated periodically at a specific intervals ranging from 1 to 10 years. Various professional groups recommend some or all of the following individual tests or combinations for those at average risk: annual fecal occult blood test (FOBT), sigmoidoscopy (SIG) every 5 years, a combination of annual FOBT and SIG every 5 years, double contract barium enema (DCBE) every 5–10 years, or colonoscopy (COL) every 10 years (Winawer et al., 1997, Byers et al., 1997, Goldstein and Messing, 1998, Primary and Preventive Care: Periodic Assessments, 2000, Colorectal Cancer Screening, 2001). While the U.S. Preventive Services Task Force does not state a preference for any one or a combination of tests, the American Cancer Society (ACS) has stated a preference for the combination of FOBT and SIG or COL because emerging epidemiologic evidence suggests that including SIG or COL in a screening regimen can significantly improve screening effectiveness. Despite efforts by a coalition of national groups to publicize screening recommendations during the past few years, adherence rates for CRC screening are still low (Screening for colorectal cancer, 1999). Comparable data from the Behavioral Risk Factor Surveillance System reported in 1997, 1999, and 2001 suggest that less than half of the U.S. population aged 50 years and over are current with minimal CRC screening and that the annual rate of increase in adherence has been relatively low, about 1–2% per year absolute increase on average (Seeff et al., 2001).
Most previous studies have examined either factors associated with completion of any of the CRC screening tests (Zapka et al., 2002, Vernon et al., 1997, Arveux et al., 1992, Weitzman et al., 2001, Vernon, 1997) or associated with the intention to complete at least one of the tests (Watts et al., 2003, De Vellis et al., 1990, Myers et al., 1994, Herbert et al., 1997, Myers et al., 1998, Weller et al., 1995). Three reports (Manne et al., 2002, Trauth et al., 2003, Brenes and Paskett, 2000) have investigated factors associated with the stages of adoption using the Transtheoretical Model (Prochaska et al., 1997). Manne et al. (2002) reported on the correlates of stage of adoption in a high-risk group, namely siblings of individuals with CRC. This study used the combination FOBT in the last year plus SIG in the prior 3–5 years or COL in the last 10 years as the measure of compliance. The focus was an exploration of psychological and attitudinal factors and family relationships. Trauth et al. (2003) examined mainly socioeconomic variables in relation to stage of adoption and the use of FOBT or SIG in two low-income populations in 1999. Brenes and Paskett (2000) studied the association of stage of adoption for SIG alone in low-income African-American women. Our study is unique in that we explored the stages of CRC screening adoption based on the Precaution Adoption Process Model (PAPM) (Weinstein, 1988, Weinstein and Sandman, 1992) in a primary care population typical of a mid-sized community from which the sample was drawn. We assessed the applicability of PAPM to CRC screening by examining a number of measures including socioeconomic and health system variables, relevant attitudes and beliefs, and each of the CRC screening behaviors FOBT, SIG, COL, and DCBE, as well as the combination of FOBT and SIG.
Classifying individuals by the stage of adoption of a health behavior has proven useful in tailoring interventions because subjects grouped within a stage tend to share similar knowledge, attitudes, beliefs, and barriers relevant to the behavior, and often have a different pattern of these attributes compared to those in other stages. Most studies focusing on stages of adoption allocate subjects to stages based on their stance towards a relatively simple, measurable behavioral outcome (e.g. quitting smoking, engaging in physical activity of a designated intensity, getting a screening test). We elected to focus on the ACS preferred screening guidelines, which define complete screening as one of the following: (1) COL in the last 10 years, (2) FOBT annually and SIG in the last 5 years, or (3) DCBE in the last 10 years (see http://www.cancer.org/docroot/CRI/content/CRI_2_2_3X_How_is_colorectal_cancer_found.asp?sitearea). We chose the ACS preferred guidelines because of the emerging emphasis on COL and SIG in CRC screening and because these guidelines were adopted by all the PCPs in our study. However, becoming compliant and maintaining compliance with ACS preferred CRC screening is conceptually more complex than some health behaviors for several reasons: (1) There are two pathways to compliance (COL, and the combination of FOBT and SIG); (2) Partial compliance may be achieved by getting one test on the FOBT/SIG pathway; (3) Ongoing compliance requires repetition of the tests at different intervals ranging from 1 to 10 years; and (4) Adherence can be achieved whether a test is done for screening or for diagnostic purposes.
This study examines the stages of adoption of the ACS preferred CRC screening guidelines and is based on a mailed survey sent in 2002 to patients of primary care providers in a major hospital-based health care system in an exurban Northeastern county. The two organizing questions are: (1) What are the stages of adoption of CRC screening among members of a representative primary care patient population? and (2) Are there unique characteristics and important differences among the various stages of adoption of CRC screening?
Section snippets
Study setting
The survey was part of a larger randomized controlled study designed to assess the effectiveness of a tailored telephone counseling intervention to promote regular CRC screening among patients of community-based primary care providers (PCPs) in the UMass Memorial Health Care (UMMHC) System. The UMMHC system includes an extensive network of affiliated medical practices and hospitals and provides care for Worcester county area in central Massachusetts and in northern Connecticut.
Theoretical framework
The theoretical
Results
Sociodemographic and health system characteristics of the study sample are shown in Table 1. Seventy-five percent of the sample were between 50 and 64 years old. Sixty percent were female. The group was relatively homogeneous in terms of race/ethnicity (94% White; 6% non-White, and/or Hispanic). This racial/ethnic distribution reflects the area's general population. The majority of respondents had completed high school and a quarter had had some post-graduate education. Family income was
Discussion
In this study, identified sociodemographic characteristics, attitudes and beliefs, and healthcare factors were associated with PAPM stage of adoption of the ACS preferred CRC screening guideline in a primary care population typical of a mid-sized northeastern community. The relatively complex CRC guideline differs from most other, simpler, cancer screening guidelines because it offers two optional pathways to adherence (COL or FOBT and SIG), one of which requires the combination of two tests
Acknowledgments
Support provided by Centers for Disease Control and Prevention Contract No. U57 CCU120639.
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