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Latino perceptions about colorectal cancer screening: A community-based approach to effective message design
Patient Education and Counseling 68 (2007) 145–152 www.elsevier.com/locate/pateducou
Investigating Hispanic/Latino perceptions about colorectal cancer screening: A community-based approach to effective message design Kenzie A. Cameron a,b, Lee Francis b,e, Michael S. Wolf a,c,d, David W. Baker a,b, Gregory Makoul a,b,d,* a
Center for Communication and Medicine, Northwestern University Feinberg School of Medicine, Chicago, USA b Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, USA c Institute for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, USA d Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, USA e Erie Family Health Center, Chicago, USA Received 1 February 2007; received in revised form 2 April 2007; accepted 11 April 2007
Abstract Objective: The Hispanic/Latino population has been documented as having the lowest colorectal cancer (CRC) screening rates in the United States, putting this group at-risk for late-stage presentation of disease. We assessed knowledge, attitudes, and behavior regarding CRC screening to inform the development of messages that promote screening among Hispanic/Latino patients. Methods: In-person structured interviews with Spanish-speaking adults age 50–80 at two clinics and a senior center in a Hispanic/Latino community (N = 234). Results: Most (67.1%) participants had no more than an eighth-grade education and 63.3% reported their reading ability as less than ‘‘very good.’’ Only 18.4% of participants correctly identified the colon on a diagram; 19.2% correctly described at least one aspect of a polyp. Less than half of the participants perceived themselves as at-risk for CRC, and less than one-third knew about any of the standard screening tests. After hearing descriptions of the screening tests, participants perceived stool cards as easier, safer, less painful, less embarrassing, and less scary than endoscopy ( p < .001). Approximately two-thirds of unscreened patients said that screening had never been mentioned or suggested to them; about onequarter said they did not get screened because they felt fine or were not worried. Over 96% of participants said they would get screened if a doctor suggested it. Conclusion: Assessing knowledge, attitudes, beliefs, and experiences in the community of interest is a promising approach for developing effective targeted health messages. Practice implications: Messages to increase CRC screening knowledge and behavior in the Hispanic/Latino community should address risk factors, identify relevant anatomy, explain polyps and their asymptomatic presentation, and clearly describe options. # 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Colorectal cancer screening; Patient perceptions; Patient education; Targeted messages
1. Introduction Colorectal cancer (CRC) is the second leading cause of cancer death for American men and women [1–4]. In 2006, approximately 148,600 American adults were diagnosed with colorectal cancer, and an estimated 55,200 died as a result of the
* Corresponding author at: Center for Communication and Medicine, Northwestern University Feinberg School of Medicine, Division of General Internal Medicine, 676 North St. Clair, Suite 200, Chicago, IL 60611, USA. E-mail address: [email protected] (G. Makoul). 0738-3991/$ – see front matter # 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2007.04.004
disease [1,4]. Colorectal cancer is ideally suited for early detection strategies because pre-cancerous adenomas precede the development of malignancies [5–14]. The U.S. Preventive Services Task Force strongly recommends that persons age 50 and older undergo screening for CRC using standard screening technologies, with a screening frequency that varies from test to test [15–17]. The American Cancer Society, International Union Against Cancer, and professional associations have issued similar guidelines [4,18–23]. Recommended screening tests include fecal occult blood test (FOBT), fecal immunochemical test (FIT), flexible sigmoidoscopy, colonoscopy and double-contrast barium enema [4].
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However, CRC screening has one of the lowest delivery rates of all clinical preventive services with high-priority rankings [24]. Available data suggest that less than half of the 90 million Americans at-risk by age and/or family history have been appropriately screened for CRC [24,25]. Barriers to CRC screening in the general population include inadequate knowledge of CRC and related screening options [26–31]. Low levels of knowledge have been linked with compromised perceptions of risk for CRC and under-utilization of appropriate screening services [32–40]. Several studies investigating CRC screening found that the primary reason for non-compliance was that the patient was asymptomatic and did not see the need to participate [28–30,38,40–43]. Physician failure to discuss and/or recommend appropriate CRC screening also hinders early detection and prevention efforts [35,44–52]. A recent study by Klabunde and colleagues revealed that only 10% of average-risk adults who were not current with colorectal cancer screening reported receiving a recommendation during their doctor visit [53]. The Hispanic/Latino population has been documented as having the lowest CRC screening rates, putting this group at great risk for late-stage presentation of disease [1,52]. Indeed, screening rates for breast, cervical, and colon cancer are lower among Hispanic/Latinos than other groups [54]. Hispanic/ Latino women have the lowest knowledge of cancer screening guidelines and lowest screening rates of any ethnic group [55– 57]. Similarly, Mexican-American men have less knowledge about cancer causes and screening practices than do nonMexican-American men, regardless of acculturation [58]. This lack of screening knowledge and behavior has initiated a disturbing trend: during a time period in which the overall rates of invasive CRC decreased, CRC rates increased in the Hispanic/Latino population, particularly among men [59]. These studies provide evidence for the need to develop culturally appropriate approaches aimed at increasing cancer screening rates among the Hispanic/Latino population [60,61]. One promising approach to creating culturally appropriate messages is the development and dissemination of targeted messages. Targeted messages are designed to reach a defined population sub-group, generally based on demographic characteristics; they differ from tailored messages, which are created for individuals [62,63]. Both targeted and tailored messages have been effective in health promotion efforts, including efforts related to cancer screening [64–67]. Successfully creating targeted messages requires understanding the knowledge and perceptions of the community of interest. While a literature review can provide some guidance, it is critical to identify current attitudes and beliefs of the target population before developing and disseminating a message. For example, the literature indicates that machismo, which incorporates multiple attitudes and beliefs relating to the societal definition of the role of men, is a theme in the Hispanic/Latino culture [68]. Understanding if the endoscopy procedure is viewed as a threat to the machismo of Hispanic/Latino men is a critical step in effective message development. Literacy is another important consideration [69,70]. People in the Hispanic/Latino community have lower health literacy
rates than do Caucasians [71,72]. Moreover, those who primarily speak Spanish and have limited fluency in English tend to have low literacy even when literacy is tested in Spanish [71,72]. It is therefore essential to design health promotion tools that can reach across literacy levels in both Spanish and English. This study gauges relevant knowledge, attitudes and behaviors to inform the design of messages about CRC and CRC screening for the Hispanic/Latino community. 2. Methods Our study was conducted between July–December 2004 at two clinics of a federally-qualified health center and an affiliated senior center in Chicago. These sites serve a predominantly Hispanic/Latino community. People were eligible for recruitment if they were age 50–80, spoke English or Spanish, and reported Hispanic/Latino ethnicity. All study procedures were approved by the Northwestern University Institutional Review Board. 2.1. Structured interview development We developed a structured interview protocol by combining existing items on perceived susceptibility to CRC, barriers to screening, and benefits of screening with new items designed to assess specific knowledge, attitudes, and experience related to CRC and CRC screening [73]. We also included items designed to record language preference, use, and ability, as well as primary health information sources and sociodemographics. We subjected all items to a Lexile analysis, and refined wording as necessary to facilitate the participation of patients with low literacy. Lexile analysis, which is based on sentence length and word frequency, measures the reading difficulty of sentences or passages [74–76]. Our target was a sixth-grade reading level. In addition, we designed the protocol to be read to participants by an interviewer so literacy level would not affect data collection. To limit the length of structured interviews, we developed two versions of the protocol: one with questions related to FOBT and flexible sigmoidoscopy; the other focusing on FOBT and colonoscopy. We chose FOBT to be the consistent test for each protocol, as that is the option most likely to be recommended by physicians at similar federally-qualified health centers [51,77–79]. Cognitive interviews were conducted with six English-speaking individuals over the age of 50 to pretest the instrument and assess representative validity of the protocol items [80]. These participants were recruited from the health clinics and received $20 in appreciation of their participation. Feedback from the cognitive interviews led to slight revisions that simplified the presentation of protocol items and response options. The revised interview protocol was translated into Spanish, and then back-translated into English to ensure accuracy and consistency across languages [81]. Following this translation process, six cognitive interviews were conducted in Spanish with individuals in the target age group, who also received $20 for their participation. Therefore
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a total of four versions of the questionnaire were available for use in the interviews: two versions in English and two in Spanish. Upon choosing a language for the interview, participants were randomly assigned to one of the two versions. 2.2. Structured interview protocol The structured interview protocol began with items focusing on language use and preference, self-reported reading ability, and preferred ethnic description (i.e., Hispanic or Latino). The protocol continued with an item asking about primary sources of information about health topics such as cancer; participants could name up to two sources. The next set of items asked participants to report whether they had heard of CRC, and, if so, to describe what they knew about it. These items were followed by a definition of CRC (‘‘Colorectal cancer is cancer that develops in the colon or rectum’’). In order to assess relevant anatomical knowledge, we provided a simplified illustration of abdominal anatomy. This drawing, which was shown to participants as they answered questions, included the stomach, small intestine, large intestine/colon, and the rectum, each presented in a separate color. Participants were initially asked about relevant organs (e.g., ‘‘Do you know what the ‘colon’ is?’’). Anyone who answered affirmatively was asked to point to the organ on the drawing. If the participant was incorrect, the interviewer pointed out the organ. This section included an item asking whether the term ‘‘colon’’ or ‘‘large intestine’’ made the most sense. Participants were then asked if they know what a polyp is and, if so, to define it. Regardless of the answer given by the participant, we provided a clear, accurate definition of a polyp. Participants then answered an open-ended question regarding the age at which people should begin CRC screening. Participants were also asked to indicate their level of interest in receiving information about how to prevent colorectal cancer. The structured interview continued with items eliciting participants’ knowledge of CRC risk and risk factors as well as screening tests. These knowledge items were formatted such that the correct answer was embedded in the question (e.g., ‘‘Is someone’s risk of developing colorectal cancer higher if a close relative had it?’’); response options were ‘‘yes,’’ ‘‘no,’’ and ‘‘not sure.’’ This section concluded with a question regarding perceived susceptibility (‘‘Do you think you are at-risk for colorectal cancer’’). Participants were then asked if they knew about specific CRC screening tests and, if so, to define them. Regardless of their response, participants were provided with brief, accurate descriptions of each of the primary screening options (i.e., FOBT, flexible sigmoidoscopy, colonoscopy). Participants were asked whether they had ever completed particular screening tests and, if so, who had recommended the screening. People who indicated they had not been screened were asked to provide reasons for lack of screening. All participants were asked if they would complete screening if various individuals (friend, family, doctor) suggested it. They then used a Likert scale (1 = strongly disagree, 2 = slightly disagree, 3 = slightly agree, 4 = strongly agree) to rate the ease, messiness,
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painfulness, embarrassment, humiliation, scariness, and safety of screening options on the questionnaire. Participants also responded to a set of sociodemographic questions, including items that asked ‘‘Who are the important people in your life?’’ and querying if the participants had children and/or grandchildren. The structured interview concluded with items assessing self-reported health and insurance status. 2.3. Interview procedure We hired four bilingual promotoras (health educators) to conduct structured interviews with participants. These promotoras completed training in human-subjects research and received specific training and calibration from the study team regarding research procedures. Promotoras approached potential participants in common areas of the study sites, and asked if they would be willing to engage in a brief interview about colorectal cancer and colorectal cancer screening. If an individual expressed interest, the promotora began the informed-consent process in the individual’s preferred language. Structured interviews were only carried out with individuals who provided written consent. Promotoras were trained to conduct interviews in either Spanish or English, whichever language the participant preferred. The approximate time required to complete the interview was 20 min; participants were thanked and given a small gift (keychain flashlight) upon completion. 2.4. Data analysis Data were analyzed using SPSS (v14.0) using frequencies, crosstabs, paired sample t-tests, and multiple response sets. Open-ended responses were written verbatim in Spanish by the promotoras, then translated into English and double-coded by two members of the study team. This set of variables included participants’ description of CRC, definition of a polyp, definition of specific CRC tests, list of important people in their lives, and type of insurance. The few disagreements in coding responses were resolved by discussion. 3. Results A total of 234 individuals between the ages of 50 and 80 (M = 61.9, S.D. = 7.5) participated in the study, all of whom chose to do the structured interview in Spanish. Overall, participants reported 14 countries of origin: most (59.0%) were from Mexico; only five people were from the U.S. Approximately 60% of the sample was female. Two-thirds (66.7%) of the participants had an education level of eighth grade or below. Most rated their health as ‘‘fair’’ (41.9%) or ‘‘good’’ (38.0%). Over half (58.1%) were uninsured. Table 1 provides additional detail about the sample, which is representative of the patient population in this community. 3.1. Language use and preferred description of ethnicity Over 90% of participants indicated that they usually spoke Spanish in the home; 85.9% reported they usually read in
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Table 1 Characteristics of study sample
3.4. Knowledge and beliefs related to CRC
Characteristic
% (N = 234)
Female Country of origin Mexico Puerto Rico Ecuador Guatemala Colombia United States Other (Caribbean) Other (South America)
59.8
Education Eighth grade or below Some high school High school graduate/GED Some college College graduate and above
59.0 15.4 8.1 6.0 3.0 2.1 3.5 2.9 67.1 9.4 13.7 8.5 1.3
When asked if they knew what a polyp was, 19.2% could describe at least one aspect correctly. When defining a polyp, most discussed either what it is (e.g., growth) or where it would be found (e.g., colon, rectum, large intestine). Beliefs about when people should begin to be tested for CRC ranged from 10 to 60 years old; 25.2% of participants provided the correct answer of age 50. As shown in Table 2, a significant majority of participants were aware that the risk of CRC increases after age 50 and that both men and women are at-risk for CRC. However, less than half of the participants perceived themselves to be atrisk for CRC, despite the fact that all were at least 50 years old. Moreover, approximately one-third of participants were unaware that their own risk of CRC is higher if a close relative has had CRC. 3.5. Knowledge related to CRC screening tests
Insurance Uninsured Public (Medicare/Medicaid) Private Public and private Don’t know
58.1 31.2 6.4 2.6 1.7
Health status Excellent Very good Good Fair Poor
4.3 11.5 38.0 41.9 4.3
Spanish. Only 36.7% reported that their reading ability was either ‘‘very good’’ or ‘‘excellent’’. When asked about terms for ethnicity, 55.1% preferred ‘‘Hispanic,’’ 18.8% preferred ‘‘Latino,’’ and 25.6% reported no preference. 3.2. Primary sources of information When asked about where they get most of their information about health topics such as cancer, participants identified physicians (47.6%), television (30.0%), health centers (20.7%), friends/family (14.1%), and newspapers/magazines (11.0%). Other sources (e.g., radio, nurses, books, Internet) were cited by fewer than 10% of participants. It is important to note that participants could mention up to two sources. 3.3. Basic anatomical knowledge Only 18.4% of participants were able to correctly identify the colon when asked to point it out on the medical drawing, yet 61.1% correctly identified the large intestine by the same method. Analyses indicated that just 14.5% of respondents recognized that the large intestine and the colon are isomorphic. When asked which term made the most sense to them, there was no clear preference: 24.8% said colon, 29.1% said large intestine, and 45.7% thought that both terms were equally appropriate. When asked to point out the rectum in the medical drawing, 70.1% were able to do so correctly.
Knowledge related to the general purpose and scope of CRC screening was fairly high. Over 90% of participants agreed that tests are available to help prevent CRC and to find early signs of CRC, and that CRC can be cured if found early (see Table 2). A sharp decrease in knowledge was detected when participants were asked about specific screening tests: Only 19.7% (46/234), 5.1% (6/117) and 29.9% (35/117) were able to correctly describe any aspect of FOBT, flexible sigmoidoscopy, and colonoscopy, respectively. Almost 75% of participants indicated a high level of interest in receiving information about preventing CRC. 3.6. Attitudes about CRC screening options As there were no differences in participants’ perceptions of the qualities associated with flexible sigmoidoscopy and colonoscopy, results were combined to compare the endoscopic options against FOBT. As shown in Table 3, participants perceived FOBT as easier, safer, less painful, less embarrassing, and less scary than either of the invasive tests ( p < .001), as well as slightly less messy and humiliating ( p < .05). Although participants rated the endoscopic options as more embarrassing and humiliating than FOBT, responses were on the ‘‘disagree’’ side of the scale, suggesting that the endoscopic options were not seen as particularly embarrassing (M = 2.1) or humiliating (M = 1.3). Table 2 Knowledge and beliefs about CRC and CRC screening % agree (N = 234) Knowledge and beliefs related to CRC Both men and women are at-risk for CRC Risk of CRC increases after age 50 Risk is higher if close relative has had CRC Perceive self at-risk for CRC
92.3 89.3 67.9 48.7
Knowledge about CRC screening tests CRC can be cured if found early There are tests that can find early signs of CRC There are tests that can help prevent CRC
95.7 94.4 91.0
K.A. Cameron et al. / Patient Education and Counseling 68 (2007) 145–152 Table 3 Perceptions of FOBT vs. flexible sigmoidoscopy/colonoscopy
Easy to do Messy Painful Embarrassing Humiliating Scary Safe
FOBT
Endoscopy
3.65 1.60 1.32 1.47 1.22 1.53 3.70
3.20 1.78 2.50 2.12 1.31 2.22 3.45
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general. In response to specific follow-up questions, 93% of participants reported having children, and 85% reported having grandchildren. p < .001 p < .05 p < .001 p < .001 p < .05 p < .001 p < .001
Scale: 1 = strongly disagree, 2 = slightly disagree, 3 = slightly agree, 4 = strongly agree.
3.7. CRC screening behavior More than half (54.7%) of the participants reported receiving an FOBT, 14.5% said they had a flexible sigmoidoscopy, and 33.3% indicated that they had a colonoscopy. An additional 8.1% were unsure if they had received a flexible sigmoidoscopy or a colonoscopy. However, only 28.9% of those who reported receiving an FOBT, 29.4% who reported a flexible sigmoidoscopy, and 69.2% who reported a colonoscopy could correctly describe at least one aspect of the screening test, suggesting that the self-reports might over-estimate rates of actual screening completion. 3.8. Barriers and facilitators to CRC screening Nearly two-thirds (65.7%) of patients who had never done an FOBT reported that the test had not been mentioned or suggested to them. An additional 27.3% of participants indicated that they did not do an FOBT because they were not worried or felt fine. Other reasons for lack of screening were invoked far less frequently (1–6% of participants). These included not being interested in screening, negative attitudes toward screening, lack of insurance, and having appointments scheduled in the future. The same pattern was evident for patients who had never received an endoscopy: 68.0% said that they were unaware of the test and 24.2% said they were not worried or felt fine; other reasons were mentioned by only 1– 5% of the participants. When asked about message sources, 97.4% of participants indicated that they would have an FOBT if their doctor recommended it, compared to 73.1% if the recommendation came from a family member or 57.7% if it came from a friend. Similarly, 96.2% of participants reported that they would undergo endoscopic options if their doctor recommended it, compared to 50.0% if recommended by a family member or 37.6% if recommended by a friend. Almost all of those who had received an FOBT (98%) and all of those who reported receiving either endoscopic option indicated that it had been recommended by their doctor. 3.9. Importance of family When asked to identify important people in their life, every participant mentioned specific family members or family in
4. Discussion and conclusion 4.1. Discussion Consistent with earlier studies, participants reported low levels of CRC screening knowledge and completion [54–58], reinforcing the need for innovative patient education strategies. An encouraging finding is that interest in receiving information about CRC and CRC screening is high. This community-based approach to message design yielded important evidence that can drive the development and design of messages to increase CRC-related knowledge and screening behavior among the Hispanic/Latino population. While physicians were identified as the primary source of health information by less than one-half of the sample, physician recommendation clearly emerged as the greatest facilitator of CRC screening. Virtually all participants who had received CRC screening indicated they did so upon their doctor’s recommendation, and a vast majority indicated they would be willing to get screened if their doctor suggested it. Moreover, the greatest reason for lack of screening cited by participants was not receiving any such recommendation, a factor noted in other studies as well [35,44–53]. Physicians have noted several barriers to discussing CRC screening, and tend to highlight the issue of time limitations [51,53,60,78]. Messages that provide patients with basic information about available tests before the visit could save doctors time by preparing patients for a focused discussion of CRC screening. These messages are most likely to succeed if they position doctors as the key information source and reinforce the need to talk with the doctor. Messages designed to increase CRC screening must directly address risk perception. Only one-quarter of participants knew that CRC screening should begin at age 50. Despite being age 50 or older, and thus considered at-risk by definition, less than half of the participants considered themselves at-risk for CRC. Approximately one-third of the participants were unaware of increased personal risk related to family history. Messages therefore need to clarify the age range for screening, explicitly present information regarding the impact of family history, and seek to increase perceived susceptibility among message recipients. The lack of perceived susceptibility to CRC may be related to participants’ beliefs that that they do not need to undergo CRC screening because they are symptom free. About one in four patients said they had never been screened because they were not worried or felt fine. As participants were largely unaware of polyps, messages related to CRC and CRC screening should describe both what a polyp is (e.g., ‘‘a growth that shouldn’t be there’’) and stress that one could have polyps growing inside the body but not feel anything. Messages should also strive to illustrate and define relevant anatomy as well as CRC screening procedures, given that little knowledge of these basic elements was demonstrated.
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It is likely that the most effective messages will avoid relying on text because recipients may be unfamiliar with terminology and may have low health literacy [71,72]. Patient education programs, particularly about difficult-to-conceptualize topics such as CRC screening, are likely to be greatly facilitated by illustrations and animation. The increasing flexibility of multimedia technology can enhance the consistency of information patients receive, while allowing messages to be presented in a dynamic and time efficient manner [82–84]. A multimedia approach that incorporates graphic design and audio voice-over can help overcome limitations associated with patients’ health literacy and education level by increasing comprehension and reducing the need to draw inferences [85–88]. Participants noted that television was a primary source of health information, suggesting that multimedia presentation formats may feel familiar to this audience. Bivariate analyses indicated no differences in knowledge, attitudes, or beliefs based on age of participants, indicating that separate messages do not need to be constructed for different age groups. Results also indicate that embarrassment and humiliation related to CRC screening does not appear to concern men or women, even in a culture where machismo is said to operate. Accordingly, there is little need to devote resources to preempting concern about this issue. Our study revealed another important lesson: exclusively using the term ‘‘Hispanic’’ or the term ‘‘Latino’’ may alienate some individuals. Messages should either use both terms to identify ethnicity or, if possible, avoid using such terms at all. When asked about important people in their life, every participant mentioned at least one family member and most reported having both children and grandchildren. In light of this finding, it is possible that messages invoking family may increase receptivity to health messages. This study focused on knowledge, perceptions, and behaviors that can inform the design of messages to promote CRC screening. Accordingly, CRC screening status was obtained by participant self-report; responses were not confirmed by medical record review. Participants indicated whether or not they had ‘‘ever’’ had a screening test; not whether or not they were up to date with CRC screening (e.g., FOBT within the past year). Thus, reported screening rates may over-estimate adherence to recommended screening protocols, and should not be compared to national estimates. Further, it is possible that participants were remembering undergoing digital rectal exams as opposed to FOBT. Indeed, Klabune and colleagues reported that approximately twothirds of obstetrician/gynecologists and one-fourth of other physicians conducted FOBT solely through digital rectal exam, as opposed to the recommended standard of having patients complete stool cards at home [4,89]. Finally, all participants chose to complete the interview in Spanish. While the results may not generalize to Hispanic/Latino individuals whose preferred language is English, it is important to note that approximately three-quarters of Hispanic/Latino population in the United States speaks Spanish at home [90].
4.2. Conclusion Targeted messages are ‘‘intended to reach some specific subgroup of the general population, usually based on a set of demographic characteristics shared by its members [63].’’ As noted by Weinick and colleagues, the Hispanic/Latino population is not monolithic, a point reinforced by the 14 countries of origin in our sample [91]. Going beyond a focus on demographic factors by assessing knowledge, attitudes, beliefs, and experiences in the community of interest is a promising approach toward developing culturally and linguistically appropriate health messages. Patient education materials that adopt this approach are likely to more effectively convey the significance of CRC and the crucial need for screening so the disease can be treated, or even cured, before it is too late. 4.3. Practice implications To increase CRC screening knowledge and behavior in the Hispanic/Latino community, targeted messages should address risk factors, identify relevant anatomy, explain polyps and their asymptomatic presentation, and describe CRC screening options. Messages that transcend literacy levels, position doctors as the key information source, and invoke family are likely to be most successful. Acknowledgements This research was supported by the American Cancer Society–Illinois Division (Grant PSB-10 to Dr. Makoul). Dr. Cameron is supported by a career development award through the Centers for Disease Control and Prevention (8K01CD000285) as is Dr. Wolf (5K01EH000067). Portions of this paper have been presented at the annual meetings of the Society of General Internal Medicine (May 2005), the American Public Health Association (December 2005), and the International Conference on Communication in Healthcare (September 2006). The authors thank Josh Sager, Liliana Cortez, Luz Jimenez, Michael Malcolm, Daisy Rodriguez, Melisa Cartegna, Lourdes Salazar, Aracely Gaytan, Fernanda Pacurucu, and the staff at Erie Family Health Center and Casa Central for their assistance in recruitment and data collection. References [1] American Cancer Society. Cancer facts and figures 2006. Atlanta: American Cancer Society; 2006. [2] Ries LAG, Melbert D, Krapcho M, Mariotto A, Miller BA, Feuer EJ, Clegg L, Horner MJ, Howlader N, Eisner MP, Reichman M, Edwards BK, editors. SEER Cancer Statistics Review, 1975–2004, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2004/, based on November 2006 SEER data submission, posted to the SEER web site, 2007. [3] Centers for Disease Control and Prevention. Increased use of colorectal cancer tests-United States, 2002 and 2004. MMWR: Morbidity and Mortality Weekly 2006;55:308–11. [4] American Cancer Society. Detailed Guide: Colon and Rectum Cancer. Available from: http://www.cancer.org/docroot/CRI/content/ CRI_2_4_3X_Can_colon_and_rectum_cancer_be_found_early.asp. Accessed 24 January 2007.
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Investigating Hispanic/Latino perceptions about colorectal cancer screening: A community-based approach to effective message design Kenzie A. Cameron a,b, Lee Francis b,e, Michael S. Wolf a,c,d, David W. Baker a,b, Gregory Makoul a,b,d,* a
Center for Communication and Medicine, Northwestern University Feinberg School of Medicine, Chicago, USA b Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, USA c Institute for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, USA d Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, USA e Erie Family Health Center, Chicago, USA Received 1 February 2007; received in revised form 2 April 2007; accepted 11 April 2007
Abstract Objective: The Hispanic/Latino population has been documented as having the lowest colorectal cancer (CRC) screening rates in the United States, putting this group at-risk for late-stage presentation of disease. We assessed knowledge, attitudes, and behavior regarding CRC screening to inform the development of messages that promote screening among Hispanic/Latino patients. Methods: In-person structured interviews with Spanish-speaking adults age 50–80 at two clinics and a senior center in a Hispanic/Latino community (N = 234). Results: Most (67.1%) participants had no more than an eighth-grade education and 63.3% reported their reading ability as less than ‘‘very good.’’ Only 18.4% of participants correctly identified the colon on a diagram; 19.2% correctly described at least one aspect of a polyp. Less than half of the participants perceived themselves as at-risk for CRC, and less than one-third knew about any of the standard screening tests. After hearing descriptions of the screening tests, participants perceived stool cards as easier, safer, less painful, less embarrassing, and less scary than endoscopy ( p < .001). Approximately two-thirds of unscreened patients said that screening had never been mentioned or suggested to them; about onequarter said they did not get screened because they felt fine or were not worried. Over 96% of participants said they would get screened if a doctor suggested it. Conclusion: Assessing knowledge, attitudes, beliefs, and experiences in the community of interest is a promising approach for developing effective targeted health messages. Practice implications: Messages to increase CRC screening knowledge and behavior in the Hispanic/Latino community should address risk factors, identify relevant anatomy, explain polyps and their asymptomatic presentation, and clearly describe options. # 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Colorectal cancer screening; Patient perceptions; Patient education; Targeted messages
1. Introduction Colorectal cancer (CRC) is the second leading cause of cancer death for American men and women [1–4]. In 2006, approximately 148,600 American adults were diagnosed with colorectal cancer, and an estimated 55,200 died as a result of the
* Corresponding author at: Center for Communication and Medicine, Northwestern University Feinberg School of Medicine, Division of General Internal Medicine, 676 North St. Clair, Suite 200, Chicago, IL 60611, USA. E-mail address: [email protected] (G. Makoul). 0738-3991/$ – see front matter # 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2007.04.004
disease [1,4]. Colorectal cancer is ideally suited for early detection strategies because pre-cancerous adenomas precede the development of malignancies [5–14]. The U.S. Preventive Services Task Force strongly recommends that persons age 50 and older undergo screening for CRC using standard screening technologies, with a screening frequency that varies from test to test [15–17]. The American Cancer Society, International Union Against Cancer, and professional associations have issued similar guidelines [4,18–23]. Recommended screening tests include fecal occult blood test (FOBT), fecal immunochemical test (FIT), flexible sigmoidoscopy, colonoscopy and double-contrast barium enema [4].
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However, CRC screening has one of the lowest delivery rates of all clinical preventive services with high-priority rankings [24]. Available data suggest that less than half of the 90 million Americans at-risk by age and/or family history have been appropriately screened for CRC [24,25]. Barriers to CRC screening in the general population include inadequate knowledge of CRC and related screening options [26–31]. Low levels of knowledge have been linked with compromised perceptions of risk for CRC and under-utilization of appropriate screening services [32–40]. Several studies investigating CRC screening found that the primary reason for non-compliance was that the patient was asymptomatic and did not see the need to participate [28–30,38,40–43]. Physician failure to discuss and/or recommend appropriate CRC screening also hinders early detection and prevention efforts [35,44–52]. A recent study by Klabunde and colleagues revealed that only 10% of average-risk adults who were not current with colorectal cancer screening reported receiving a recommendation during their doctor visit [53]. The Hispanic/Latino population has been documented as having the lowest CRC screening rates, putting this group at great risk for late-stage presentation of disease [1,52]. Indeed, screening rates for breast, cervical, and colon cancer are lower among Hispanic/Latinos than other groups [54]. Hispanic/ Latino women have the lowest knowledge of cancer screening guidelines and lowest screening rates of any ethnic group [55– 57]. Similarly, Mexican-American men have less knowledge about cancer causes and screening practices than do nonMexican-American men, regardless of acculturation [58]. This lack of screening knowledge and behavior has initiated a disturbing trend: during a time period in which the overall rates of invasive CRC decreased, CRC rates increased in the Hispanic/Latino population, particularly among men [59]. These studies provide evidence for the need to develop culturally appropriate approaches aimed at increasing cancer screening rates among the Hispanic/Latino population [60,61]. One promising approach to creating culturally appropriate messages is the development and dissemination of targeted messages. Targeted messages are designed to reach a defined population sub-group, generally based on demographic characteristics; they differ from tailored messages, which are created for individuals [62,63]. Both targeted and tailored messages have been effective in health promotion efforts, including efforts related to cancer screening [64–67]. Successfully creating targeted messages requires understanding the knowledge and perceptions of the community of interest. While a literature review can provide some guidance, it is critical to identify current attitudes and beliefs of the target population before developing and disseminating a message. For example, the literature indicates that machismo, which incorporates multiple attitudes and beliefs relating to the societal definition of the role of men, is a theme in the Hispanic/Latino culture [68]. Understanding if the endoscopy procedure is viewed as a threat to the machismo of Hispanic/Latino men is a critical step in effective message development. Literacy is another important consideration [69,70]. People in the Hispanic/Latino community have lower health literacy
rates than do Caucasians [71,72]. Moreover, those who primarily speak Spanish and have limited fluency in English tend to have low literacy even when literacy is tested in Spanish [71,72]. It is therefore essential to design health promotion tools that can reach across literacy levels in both Spanish and English. This study gauges relevant knowledge, attitudes and behaviors to inform the design of messages about CRC and CRC screening for the Hispanic/Latino community. 2. Methods Our study was conducted between July–December 2004 at two clinics of a federally-qualified health center and an affiliated senior center in Chicago. These sites serve a predominantly Hispanic/Latino community. People were eligible for recruitment if they were age 50–80, spoke English or Spanish, and reported Hispanic/Latino ethnicity. All study procedures were approved by the Northwestern University Institutional Review Board. 2.1. Structured interview development We developed a structured interview protocol by combining existing items on perceived susceptibility to CRC, barriers to screening, and benefits of screening with new items designed to assess specific knowledge, attitudes, and experience related to CRC and CRC screening [73]. We also included items designed to record language preference, use, and ability, as well as primary health information sources and sociodemographics. We subjected all items to a Lexile analysis, and refined wording as necessary to facilitate the participation of patients with low literacy. Lexile analysis, which is based on sentence length and word frequency, measures the reading difficulty of sentences or passages [74–76]. Our target was a sixth-grade reading level. In addition, we designed the protocol to be read to participants by an interviewer so literacy level would not affect data collection. To limit the length of structured interviews, we developed two versions of the protocol: one with questions related to FOBT and flexible sigmoidoscopy; the other focusing on FOBT and colonoscopy. We chose FOBT to be the consistent test for each protocol, as that is the option most likely to be recommended by physicians at similar federally-qualified health centers [51,77–79]. Cognitive interviews were conducted with six English-speaking individuals over the age of 50 to pretest the instrument and assess representative validity of the protocol items [80]. These participants were recruited from the health clinics and received $20 in appreciation of their participation. Feedback from the cognitive interviews led to slight revisions that simplified the presentation of protocol items and response options. The revised interview protocol was translated into Spanish, and then back-translated into English to ensure accuracy and consistency across languages [81]. Following this translation process, six cognitive interviews were conducted in Spanish with individuals in the target age group, who also received $20 for their participation. Therefore
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a total of four versions of the questionnaire were available for use in the interviews: two versions in English and two in Spanish. Upon choosing a language for the interview, participants were randomly assigned to one of the two versions. 2.2. Structured interview protocol The structured interview protocol began with items focusing on language use and preference, self-reported reading ability, and preferred ethnic description (i.e., Hispanic or Latino). The protocol continued with an item asking about primary sources of information about health topics such as cancer; participants could name up to two sources. The next set of items asked participants to report whether they had heard of CRC, and, if so, to describe what they knew about it. These items were followed by a definition of CRC (‘‘Colorectal cancer is cancer that develops in the colon or rectum’’). In order to assess relevant anatomical knowledge, we provided a simplified illustration of abdominal anatomy. This drawing, which was shown to participants as they answered questions, included the stomach, small intestine, large intestine/colon, and the rectum, each presented in a separate color. Participants were initially asked about relevant organs (e.g., ‘‘Do you know what the ‘colon’ is?’’). Anyone who answered affirmatively was asked to point to the organ on the drawing. If the participant was incorrect, the interviewer pointed out the organ. This section included an item asking whether the term ‘‘colon’’ or ‘‘large intestine’’ made the most sense. Participants were then asked if they know what a polyp is and, if so, to define it. Regardless of the answer given by the participant, we provided a clear, accurate definition of a polyp. Participants then answered an open-ended question regarding the age at which people should begin CRC screening. Participants were also asked to indicate their level of interest in receiving information about how to prevent colorectal cancer. The structured interview continued with items eliciting participants’ knowledge of CRC risk and risk factors as well as screening tests. These knowledge items were formatted such that the correct answer was embedded in the question (e.g., ‘‘Is someone’s risk of developing colorectal cancer higher if a close relative had it?’’); response options were ‘‘yes,’’ ‘‘no,’’ and ‘‘not sure.’’ This section concluded with a question regarding perceived susceptibility (‘‘Do you think you are at-risk for colorectal cancer’’). Participants were then asked if they knew about specific CRC screening tests and, if so, to define them. Regardless of their response, participants were provided with brief, accurate descriptions of each of the primary screening options (i.e., FOBT, flexible sigmoidoscopy, colonoscopy). Participants were asked whether they had ever completed particular screening tests and, if so, who had recommended the screening. People who indicated they had not been screened were asked to provide reasons for lack of screening. All participants were asked if they would complete screening if various individuals (friend, family, doctor) suggested it. They then used a Likert scale (1 = strongly disagree, 2 = slightly disagree, 3 = slightly agree, 4 = strongly agree) to rate the ease, messiness,
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painfulness, embarrassment, humiliation, scariness, and safety of screening options on the questionnaire. Participants also responded to a set of sociodemographic questions, including items that asked ‘‘Who are the important people in your life?’’ and querying if the participants had children and/or grandchildren. The structured interview concluded with items assessing self-reported health and insurance status. 2.3. Interview procedure We hired four bilingual promotoras (health educators) to conduct structured interviews with participants. These promotoras completed training in human-subjects research and received specific training and calibration from the study team regarding research procedures. Promotoras approached potential participants in common areas of the study sites, and asked if they would be willing to engage in a brief interview about colorectal cancer and colorectal cancer screening. If an individual expressed interest, the promotora began the informed-consent process in the individual’s preferred language. Structured interviews were only carried out with individuals who provided written consent. Promotoras were trained to conduct interviews in either Spanish or English, whichever language the participant preferred. The approximate time required to complete the interview was 20 min; participants were thanked and given a small gift (keychain flashlight) upon completion. 2.4. Data analysis Data were analyzed using SPSS (v14.0) using frequencies, crosstabs, paired sample t-tests, and multiple response sets. Open-ended responses were written verbatim in Spanish by the promotoras, then translated into English and double-coded by two members of the study team. This set of variables included participants’ description of CRC, definition of a polyp, definition of specific CRC tests, list of important people in their lives, and type of insurance. The few disagreements in coding responses were resolved by discussion. 3. Results A total of 234 individuals between the ages of 50 and 80 (M = 61.9, S.D. = 7.5) participated in the study, all of whom chose to do the structured interview in Spanish. Overall, participants reported 14 countries of origin: most (59.0%) were from Mexico; only five people were from the U.S. Approximately 60% of the sample was female. Two-thirds (66.7%) of the participants had an education level of eighth grade or below. Most rated their health as ‘‘fair’’ (41.9%) or ‘‘good’’ (38.0%). Over half (58.1%) were uninsured. Table 1 provides additional detail about the sample, which is representative of the patient population in this community. 3.1. Language use and preferred description of ethnicity Over 90% of participants indicated that they usually spoke Spanish in the home; 85.9% reported they usually read in
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Table 1 Characteristics of study sample
3.4. Knowledge and beliefs related to CRC
Characteristic
% (N = 234)
Female Country of origin Mexico Puerto Rico Ecuador Guatemala Colombia United States Other (Caribbean) Other (South America)
59.8
Education Eighth grade or below Some high school High school graduate/GED Some college College graduate and above
59.0 15.4 8.1 6.0 3.0 2.1 3.5 2.9 67.1 9.4 13.7 8.5 1.3
When asked if they knew what a polyp was, 19.2% could describe at least one aspect correctly. When defining a polyp, most discussed either what it is (e.g., growth) or where it would be found (e.g., colon, rectum, large intestine). Beliefs about when people should begin to be tested for CRC ranged from 10 to 60 years old; 25.2% of participants provided the correct answer of age 50. As shown in Table 2, a significant majority of participants were aware that the risk of CRC increases after age 50 and that both men and women are at-risk for CRC. However, less than half of the participants perceived themselves to be atrisk for CRC, despite the fact that all were at least 50 years old. Moreover, approximately one-third of participants were unaware that their own risk of CRC is higher if a close relative has had CRC. 3.5. Knowledge related to CRC screening tests
Insurance Uninsured Public (Medicare/Medicaid) Private Public and private Don’t know
58.1 31.2 6.4 2.6 1.7
Health status Excellent Very good Good Fair Poor
4.3 11.5 38.0 41.9 4.3
Spanish. Only 36.7% reported that their reading ability was either ‘‘very good’’ or ‘‘excellent’’. When asked about terms for ethnicity, 55.1% preferred ‘‘Hispanic,’’ 18.8% preferred ‘‘Latino,’’ and 25.6% reported no preference. 3.2. Primary sources of information When asked about where they get most of their information about health topics such as cancer, participants identified physicians (47.6%), television (30.0%), health centers (20.7%), friends/family (14.1%), and newspapers/magazines (11.0%). Other sources (e.g., radio, nurses, books, Internet) were cited by fewer than 10% of participants. It is important to note that participants could mention up to two sources. 3.3. Basic anatomical knowledge Only 18.4% of participants were able to correctly identify the colon when asked to point it out on the medical drawing, yet 61.1% correctly identified the large intestine by the same method. Analyses indicated that just 14.5% of respondents recognized that the large intestine and the colon are isomorphic. When asked which term made the most sense to them, there was no clear preference: 24.8% said colon, 29.1% said large intestine, and 45.7% thought that both terms were equally appropriate. When asked to point out the rectum in the medical drawing, 70.1% were able to do so correctly.
Knowledge related to the general purpose and scope of CRC screening was fairly high. Over 90% of participants agreed that tests are available to help prevent CRC and to find early signs of CRC, and that CRC can be cured if found early (see Table 2). A sharp decrease in knowledge was detected when participants were asked about specific screening tests: Only 19.7% (46/234), 5.1% (6/117) and 29.9% (35/117) were able to correctly describe any aspect of FOBT, flexible sigmoidoscopy, and colonoscopy, respectively. Almost 75% of participants indicated a high level of interest in receiving information about preventing CRC. 3.6. Attitudes about CRC screening options As there were no differences in participants’ perceptions of the qualities associated with flexible sigmoidoscopy and colonoscopy, results were combined to compare the endoscopic options against FOBT. As shown in Table 3, participants perceived FOBT as easier, safer, less painful, less embarrassing, and less scary than either of the invasive tests ( p < .001), as well as slightly less messy and humiliating ( p < .05). Although participants rated the endoscopic options as more embarrassing and humiliating than FOBT, responses were on the ‘‘disagree’’ side of the scale, suggesting that the endoscopic options were not seen as particularly embarrassing (M = 2.1) or humiliating (M = 1.3). Table 2 Knowledge and beliefs about CRC and CRC screening % agree (N = 234) Knowledge and beliefs related to CRC Both men and women are at-risk for CRC Risk of CRC increases after age 50 Risk is higher if close relative has had CRC Perceive self at-risk for CRC
92.3 89.3 67.9 48.7
Knowledge about CRC screening tests CRC can be cured if found early There are tests that can find early signs of CRC There are tests that can help prevent CRC
95.7 94.4 91.0
K.A. Cameron et al. / Patient Education and Counseling 68 (2007) 145–152 Table 3 Perceptions of FOBT vs. flexible sigmoidoscopy/colonoscopy
Easy to do Messy Painful Embarrassing Humiliating Scary Safe
FOBT
Endoscopy
3.65 1.60 1.32 1.47 1.22 1.53 3.70
3.20 1.78 2.50 2.12 1.31 2.22 3.45
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general. In response to specific follow-up questions, 93% of participants reported having children, and 85% reported having grandchildren. p < .001 p < .05 p < .001 p < .001 p < .05 p < .001 p < .001
Scale: 1 = strongly disagree, 2 = slightly disagree, 3 = slightly agree, 4 = strongly agree.
3.7. CRC screening behavior More than half (54.7%) of the participants reported receiving an FOBT, 14.5% said they had a flexible sigmoidoscopy, and 33.3% indicated that they had a colonoscopy. An additional 8.1% were unsure if they had received a flexible sigmoidoscopy or a colonoscopy. However, only 28.9% of those who reported receiving an FOBT, 29.4% who reported a flexible sigmoidoscopy, and 69.2% who reported a colonoscopy could correctly describe at least one aspect of the screening test, suggesting that the self-reports might over-estimate rates of actual screening completion. 3.8. Barriers and facilitators to CRC screening Nearly two-thirds (65.7%) of patients who had never done an FOBT reported that the test had not been mentioned or suggested to them. An additional 27.3% of participants indicated that they did not do an FOBT because they were not worried or felt fine. Other reasons for lack of screening were invoked far less frequently (1–6% of participants). These included not being interested in screening, negative attitudes toward screening, lack of insurance, and having appointments scheduled in the future. The same pattern was evident for patients who had never received an endoscopy: 68.0% said that they were unaware of the test and 24.2% said they were not worried or felt fine; other reasons were mentioned by only 1– 5% of the participants. When asked about message sources, 97.4% of participants indicated that they would have an FOBT if their doctor recommended it, compared to 73.1% if the recommendation came from a family member or 57.7% if it came from a friend. Similarly, 96.2% of participants reported that they would undergo endoscopic options if their doctor recommended it, compared to 50.0% if recommended by a family member or 37.6% if recommended by a friend. Almost all of those who had received an FOBT (98%) and all of those who reported receiving either endoscopic option indicated that it had been recommended by their doctor. 3.9. Importance of family When asked to identify important people in their life, every participant mentioned specific family members or family in
4. Discussion and conclusion 4.1. Discussion Consistent with earlier studies, participants reported low levels of CRC screening knowledge and completion [54–58], reinforcing the need for innovative patient education strategies. An encouraging finding is that interest in receiving information about CRC and CRC screening is high. This community-based approach to message design yielded important evidence that can drive the development and design of messages to increase CRC-related knowledge and screening behavior among the Hispanic/Latino population. While physicians were identified as the primary source of health information by less than one-half of the sample, physician recommendation clearly emerged as the greatest facilitator of CRC screening. Virtually all participants who had received CRC screening indicated they did so upon their doctor’s recommendation, and a vast majority indicated they would be willing to get screened if their doctor suggested it. Moreover, the greatest reason for lack of screening cited by participants was not receiving any such recommendation, a factor noted in other studies as well [35,44–53]. Physicians have noted several barriers to discussing CRC screening, and tend to highlight the issue of time limitations [51,53,60,78]. Messages that provide patients with basic information about available tests before the visit could save doctors time by preparing patients for a focused discussion of CRC screening. These messages are most likely to succeed if they position doctors as the key information source and reinforce the need to talk with the doctor. Messages designed to increase CRC screening must directly address risk perception. Only one-quarter of participants knew that CRC screening should begin at age 50. Despite being age 50 or older, and thus considered at-risk by definition, less than half of the participants considered themselves at-risk for CRC. Approximately one-third of the participants were unaware of increased personal risk related to family history. Messages therefore need to clarify the age range for screening, explicitly present information regarding the impact of family history, and seek to increase perceived susceptibility among message recipients. The lack of perceived susceptibility to CRC may be related to participants’ beliefs that that they do not need to undergo CRC screening because they are symptom free. About one in four patients said they had never been screened because they were not worried or felt fine. As participants were largely unaware of polyps, messages related to CRC and CRC screening should describe both what a polyp is (e.g., ‘‘a growth that shouldn’t be there’’) and stress that one could have polyps growing inside the body but not feel anything. Messages should also strive to illustrate and define relevant anatomy as well as CRC screening procedures, given that little knowledge of these basic elements was demonstrated.
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It is likely that the most effective messages will avoid relying on text because recipients may be unfamiliar with terminology and may have low health literacy [71,72]. Patient education programs, particularly about difficult-to-conceptualize topics such as CRC screening, are likely to be greatly facilitated by illustrations and animation. The increasing flexibility of multimedia technology can enhance the consistency of information patients receive, while allowing messages to be presented in a dynamic and time efficient manner [82–84]. A multimedia approach that incorporates graphic design and audio voice-over can help overcome limitations associated with patients’ health literacy and education level by increasing comprehension and reducing the need to draw inferences [85–88]. Participants noted that television was a primary source of health information, suggesting that multimedia presentation formats may feel familiar to this audience. Bivariate analyses indicated no differences in knowledge, attitudes, or beliefs based on age of participants, indicating that separate messages do not need to be constructed for different age groups. Results also indicate that embarrassment and humiliation related to CRC screening does not appear to concern men or women, even in a culture where machismo is said to operate. Accordingly, there is little need to devote resources to preempting concern about this issue. Our study revealed another important lesson: exclusively using the term ‘‘Hispanic’’ or the term ‘‘Latino’’ may alienate some individuals. Messages should either use both terms to identify ethnicity or, if possible, avoid using such terms at all. When asked about important people in their life, every participant mentioned at least one family member and most reported having both children and grandchildren. In light of this finding, it is possible that messages invoking family may increase receptivity to health messages. This study focused on knowledge, perceptions, and behaviors that can inform the design of messages to promote CRC screening. Accordingly, CRC screening status was obtained by participant self-report; responses were not confirmed by medical record review. Participants indicated whether or not they had ‘‘ever’’ had a screening test; not whether or not they were up to date with CRC screening (e.g., FOBT within the past year). Thus, reported screening rates may over-estimate adherence to recommended screening protocols, and should not be compared to national estimates. Further, it is possible that participants were remembering undergoing digital rectal exams as opposed to FOBT. Indeed, Klabune and colleagues reported that approximately twothirds of obstetrician/gynecologists and one-fourth of other physicians conducted FOBT solely through digital rectal exam, as opposed to the recommended standard of having patients complete stool cards at home [4,89]. Finally, all participants chose to complete the interview in Spanish. While the results may not generalize to Hispanic/Latino individuals whose preferred language is English, it is important to note that approximately three-quarters of Hispanic/Latino population in the United States speaks Spanish at home [90].
4.2. Conclusion Targeted messages are ‘‘intended to reach some specific subgroup of the general population, usually based on a set of demographic characteristics shared by its members [63].’’ As noted by Weinick and colleagues, the Hispanic/Latino population is not monolithic, a point reinforced by the 14 countries of origin in our sample [91]. Going beyond a focus on demographic factors by assessing knowledge, attitudes, beliefs, and experiences in the community of interest is a promising approach toward developing culturally and linguistically appropriate health messages. Patient education materials that adopt this approach are likely to more effectively convey the significance of CRC and the crucial need for screening so the disease can be treated, or even cured, before it is too late. 4.3. Practice implications To increase CRC screening knowledge and behavior in the Hispanic/Latino community, targeted messages should address risk factors, identify relevant anatomy, explain polyps and their asymptomatic presentation, and describe CRC screening options. Messages that transcend literacy levels, position doctors as the key information source, and invoke family are likely to be most successful. Acknowledgements This research was supported by the American Cancer Society–Illinois Division (Grant PSB-10 to Dr. Makoul). Dr. Cameron is supported by a career development award through the Centers for Disease Control and Prevention (8K01CD000285) as is Dr. Wolf (5K01EH000067). Portions of this paper have been presented at the annual meetings of the Society of General Internal Medicine (May 2005), the American Public Health Association (December 2005), and the International Conference on Communication in Healthcare (September 2006). The authors thank Josh Sager, Liliana Cortez, Luz Jimenez, Michael Malcolm, Daisy Rodriguez, Melisa Cartegna, Lourdes Salazar, Aracely Gaytan, Fernanda Pacurucu, and the staff at Erie Family Health Center and Casa Central for their assistance in recruitment and data collection. References [1] American Cancer Society. Cancer facts and figures 2006. Atlanta: American Cancer Society; 2006. [2] Ries LAG, Melbert D, Krapcho M, Mariotto A, Miller BA, Feuer EJ, Clegg L, Horner MJ, Howlader N, Eisner MP, Reichman M, Edwards BK, editors. SEER Cancer Statistics Review, 1975–2004, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2004/, based on November 2006 SEER data submission, posted to the SEER web site, 2007. [3] Centers for Disease Control and Prevention. Increased use of colorectal cancer tests-United States, 2002 and 2004. MMWR: Morbidity and Mortality Weekly 2006;55:308–11. [4] American Cancer Society. Detailed Guide: Colon and Rectum Cancer. Available from: http://www.cancer.org/docroot/CRI/content/ CRI_2_4_3X_Can_colon_and_rectum_cancer_be_found_early.asp. Accessed 24 January 2007.
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