Factors Predicting Stage of Adoption for Fecal Occult Blood Testing and Colonoscopy among Non-Adherent African Americans

Hsiao-Lan Wang, PhD, RN, CMSRN, HFS

Assistant Professor

University of South Florida

September, 2012

Team• Indiana University School of Nursing

– Susan M. Rawl, PhD, RN, FAAN– Victoria Champion, PhD, RN, FAAN– Connie Krier, BS

• Indiana University School of Medicine – Susan Perkins, PhD – Yan Tong, PhD, MS– Netsanet Gebregziabher, MS

• University of Texas Southwestern Medical Center– Celette Sugg Skinner, PhD

• University of Georgia – Jeffrey Springston, PhD

• Purdue University School of Science, Department of Psychology, IUPUI– Shannon M. Christy, MA

Funding

• National Cancer Institute grant awarded to Dr. Rawl (R01 CA115983-01)

• National Institute of Nursing Research postdoctoral training grant awarded to Dr. Wang (T32 NR007066), Indiana University

Background: Colorectal Cancer (CRC)

• CRC in the United States in 2012 is estimated as: – 3rd most commonly diagnosed cancer– 3rd leading cause of cancer deaths

• African Americans have the highest CRC incidence and mortality rate of all racial groups.

Background: CRC Screening

• CRC is curable and preventable by screening.• Participation of CRC screening remains low,

especially in African Americans. • Primary care practice is often the first place for

delivery of CRC screening services. • Theory-based tailored messages to increase

screening are more likely to be successful, especially those tailored to stage of adoption.

Purpose

• To examine predictors of stage of adoption for fecal occult blood testing (FOBT) and colonoscopy screening among non-adherent African American primary care patients.

Data Source:

Rawl SM, Skinner CS, Champion V, Perkins SM, Springston J, Russell KM, et al. Computer-delivered Tailored Intervention Improves Colon Cancer Screening Knowledge and Health Beliefs of African Americans. Health Education Research, In press.

Conceptual Framework

Stage of Adoption- FOBT- Colonoscopy

Clinical VariablesBody Mass IndexFamily history of CRC Personal history of cancer Objective risk

CRC Health Beliefs/KnowledgePerceived Risk Perceived Benefits Perceived BarriersSelf-EfficacyCancer FatalismCRC knowledge

Social Support Marital statusFamily/friend encouragement Provider recommendation

Demographics Age, Gender, Education, Employment, Income, Health insurance Clinical Site

Non-Adherent African Americans

 Stages Precontemplation Contemplation Preparation

Fecal Occult Blood Test (FOBT):Never had OR had one more than 12 months ago

Does not intend to have one in next 6 months.

Intends to have one in next 6 months.

Is planning to do in next six months, and has an FOBT kit.

Colonoscopy: Never had OR had one more than 10 years ago

Does not intend to have one in next 6 months.

Intends to have one in next 6 months.

Is planning to do in next six months, and has an appointment scheduled.

Recruitment (N= 817)

• 11 primary care clinics and community health centers affiliated with two urban academic medical centers, including a VA medical center.

Eligibility Criteria

• Self-identified as African American or Black• Not current with CRC screening• Ages 51-80• No history of CRC • Able to read and speak English• No medical condition prohibiting screening• No cognitive, speech, and hearing impairment

Data Collection/Instruments• Structured telephone interviews conducted prior to

randomization in a RCT.

Scale # Items AlphaPerceived Risk 5 0.79

FOBT Benefits 3 0.72

FOBT Barriers 9 0.81

FOBT Self-Efficacy 8 0.88

Colonoscopy Benefits 4 0.69

Colonoscopy Barriers 15 0.89

Colonoscopy Self-Efficacy

11 0.88

Cancer Fatalism 11 0.86

CRC Knowledge 10 0.64

Data Analyses

• Predictor variables (p<.20) for hierarchical models were identified using univariate analysis.

• Demographic variables were entered as predictors in Step 1, followed by clinical variables (Step 2), CRC health beliefs and knowledge (Step 3), and social support variables (Step 4). Final hierarchical models identified significant predictors of stages (p<.05).

Sample Characteristics

• Mean age was 57.4 years (±6.3)• Average education was 12.2 years (±1.9)• 47% were male. • The majority were not married or partnered (69%), not

employed (79%), had insurance (89%), and reported incomes of <$15, 000 (59%).

• The majority had no personal history of cancer (92%) or family history of cancer (74%) and were not VA patients (80%).

• The mean BMI was 31.2 (±7.9).

Stage of Adoption Distributions

 Stages Precontemplation Contemplation Preparation

FOBT:Never had OR had one more than 12 months ago

n (%)

Does not intend to have one in next 6 months.

484 (59)

Intends to have one in next 6 months.

277 (34)

Is planning to do in next six months, and has an FOBT kit.

54 (7)Colonoscopy: Never had OR had one more than 10 years ago

n (%)

Does not intend to have one in next 6 months.

353 (43)

Intends to have one in next 6 months

378 (46).

Is planning to do in next six months, and has an appointment scheduled.

84 (11)

  FOBT Colonoscopy

Significant Predictors  Step 4OR (95% CI)

Step 4OR (95% CI)

DemographicsAgeMaleIncome 15K-30K vs. <15K > 30K vs. < 15KVAMC site

 1.04 (1.01-1.06)**1.70 (1.16-2.49)**

 0.82 (0.57-1.16)1.03 (0.63-1.69)

2.80 (1.76-4.44)**

 0.98 (0.96-1.00)1.29 (0.95-1.75)

0.83 (0.60-1.14)0.46 (0.28-0.75)**

 -

Clinical Variables Personal History of Cancer

 0.37 (0.19-0.70)**  -

CRC Health Beliefs/KnowledgePerceived BenefitsPerceived BarriersPerceived Self-efficacy

 

1.15 (0.88-1.50)0.79 (0.63-0.99)*1.59 (1.13-2.23)**

 

1.56 (1.23-1.98)**0.88 (0.71-1.08)

1.66 (1.25-2.22)**

Social SupportFamily/friend EncouragementDoctor Recommendation

 1.64 (1.18-2.29)**

2.05 (1.48-2.85)**

 1.71 (1.23-2.36)**

2.47 (1.84-3.33)**

Discussion

• Involving families and friends in addition to healthcare providers may be a very effective component of interventions to promote CRC screening.

Discussion

• VAMC patients were at more advanced stage of adoption for FOBT compared with the non-VAMC.

• Participants with greater perceived benefits were more likely to be in more advanced stages of adoption for colonoscopy only.

• Participants with greater perceived self-efficacy were more likely to be in more advanced stages of adoption for both FOBT and colonoscopy.

Limitations

• Selection bias. Baseline data from an intervention trial to promote CRC screening.

• Limited generalizability: low income African Americans who have insurance and are able to access primary care services.