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Colon Cancer Screening

Abstract: African American women are more likely to die of colorectal cancer than are women of any other racial or ethic group. Early diagnosis depends on routine examination and screening. However, studies have shown that African American women are not utilizing available screening tools. African American women age fifty or older were questioned about their risk factors and frequency of CRC screening. The conceptual framework used was the Health Belief Model. Women who perceived fewer barriers, more benefits, higher perceived susceptibility, and increased confidence in the accuracy of screening, were likely to undergo screening. Implications for nursing practice are discussed especially focused on the role of advanced practice nurses as primary care providers. Utilization of a faith-based approach to reaching this population was also suggested.

Key Words: Colon Cancer Screening: Black Females

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Colorectal carcinoma (CRC) is the second most common cause of cancer mortality in the United States. Despite the fact that it is highly preventable, approximately 147,500 new cases of CRC were predicted to be diagnosed in 2003 with 57,100 people dying from the disease (Cancer Research and Prevention Foundation, 2004). Although this cancer can be cured if detected early, over half of all cases are diagnosed with distal disease, decreasing the 5-year survival. African Americans had higher incidence and mortality rates from 1998 through 2000, while these rates decreased for Caucasians (American Cancer Society [ACS], 2003). American women are more likely to die of colon cancer than are women of any other racial or ethic group (ACS, 2003). These women often tall in the high risk category because of multiple risk factors including obesity, low fiber, high protein diets and low physical activity levels (Cancer Prevention and Research Foundation, 2004).

Colorectal cancer screening (CRC) offers potential for both primary and secondary prevention. A combination of three screening methods is used to accomplish early detection of colorectal cancer. These include rectal examination, fecal occult blood testing (FOBT) and a test used to evaluate the colon and rectum, the flexible sigmoidoscopy, colonoscopy, or barium enema. Scientific evidence supports the effectiveness of CRC in reducing mortality (Helm, Russo, Biddle, Simpsin, Ranoboff, & Sandler, 2000).

The ACS offers three options for regular colorectal surveillance screening beginning at age 50:

1. Baseline FOBT and flexible sigmoidoscopy initially, then FOBT repeated annually and sigmoidoscopy repeated every five years after initial screening.

2. Baseline total colon exam (TCE) with Distal Colon Barium Enema (DCBE) every five years.

3. Baseline TCE with colorectal every ten years.

These guidelines are based on a normal first exam. A strong personal and/or family history of colorectal cancer or polyps should prompt colorectal screening earlier.

Unfortunately, while African American women are at high risk, they are less likely than Caucasian women to receive this screening (ACS, 2003).

Several studies have addressed the health of minorities and women, regarding knowledge and participation in primary prevention activities such as cancer screening. (cf: Mann, Sherman, Clayton et al., 2002; Felton, 2000; Shanker, 1995). Specifically related to CRC, Lipkus (1996) found that over half of a sample of 1,318 African American, the age of 50 plus, placed themselves at average or low risk for CRC and over a third did not know their risk for CRC. Half also believed it was "better to not know" if one had CRC and perceived "being healthy" as negating the need to be screened. These beliefs were held more strongly by the women. In addition, qualitative studies related to the cancer screening behaviors of African American women from 1980 to 1996 have been critically reviewed by Hoffman and Goetz (1997). They support the lack of education about cancer screening and risk factors as influencing women not getting CRC screening. Further, they suggest that the low priority women placed on their personal preventive screening behavior and the important of social networks in the flow of cancer information influenced screening behavior

Given the disproportionate burden that faces African American women regarding CRC, the purpose of this study was to examine the knowledge, attitudes and beliefs of CRC screening, as well as frequency of screening, in this population. The Health Belief Model (HBM), revised by Champion (1999) for use in low income African American populations, served as the framework for the study.

RESEARCH QUESTIONS

1. What is the frequency of colorectal cancer screening performance among selected African American women age 50 and older?

2. What is the relationship between the concepts of perceived susceptibility, seriousness, benefit, barriers, confidence and health motivation in the Health Belief Model and frequency of colorectal cancer screening?

METHODOLOGY

Research Design

The design utilized in this study was descriptive/correlative using a non-experimental survey approach. Four primarily African American churches in four quadrants of a north Florida city were sites for the study.

Instruments

The main instrument utilized in this study was the HBM Scale (Champion, 1999). Permission was obtained from Champion for use. The scale measures the concepts of perceived benefits, perceived barriers, perceived susceptibility, perceived confidence and health motivation, in relation to CRC screening in African American women. Subscales measure each of the six dominions. Each item is rated on a a 5-point scale with 5 equaling "strongly agree" and a score of 1 equaling "strongly disagree." The HBM Scale yields a total score and an individual score for each of the subscales. The questionnaire consists of 45 items, each of which contributes to the total score and the summative score of one of the 6 subscales. All items particular to each subscale are scored and averaged to calculate each subscale score. Reported reliability for internal consistency and test retest ranges from 68 to 90 (Champion, 1999). Demographic information and data regarding health history and health practices were also elicited.

Protection of Human Subjects

The appropriate Institutional Review Board Approval was obtained. An informed consent cover letter explaining the purpose, risks, and benefits of the study was included in the survey packet. Participants were informed of their anonymity and of their right to refuse to participate, without penalty. The survey did not ask tot participant's name or other sources of identification and individual's responses remained confidential. Completion of the survey was considered as consent to participate in the study.

Procedure

A list of the female congregation members was provided by each of the directors of the churches. All African American women ages 50 and older were identified. Of these 150 were randomly selected to be mailed questionnaires. This included a return addressed, stamped envelope. To maintain anonymity the return address on each envelope was the church from which they were selected. The packet included the description of the research, human subjects information, and the survey with instructions on filling it out and returning it. Data collection lasted six weeks.

RESULTS

Sample

A total of 150 questionnaires were mailed out from four churches. Fifty-three questionnaires were returned of which forty-nine were usable, yielding a return rate of 35%. Approximately, 25 to 30% of the participants in each age group with the exception of eighty and older (15%). Noteworthy, was that 69 of the participants either had high school or less education (divided equally). Over half reported that their insurance covered the cost of colorectal cancer screening, while 20% did not know. Fifty five percent stated their primary care provider (PCP) had recommended colorectal cancer screening. However, 15% did not even have a provider. For a summary of participant characteristics, see Table 1.

Personal history data included questions about the incidence of colorectal cancer genetic or immune disorders of the ovary, uterus, or breast, and prolonged exposure to toxic fumes. Ten percent reported a history of colon cancer, 4% a genetic or immune disorder and 18% a history of ovarian, breast or uterine cancer. Sixty seven-percent reported having had prolonged exposure to toxic fumes during their lifetime. Twenty-three percent reported having a family medical history of a genetic or immune disorder while 38% identified history of ovarian, breast, or uterine cancer.

Over half of the respondents reported they smoked more than one pack of cigarettes a day. Fifty-three percent reported consuming a low fiber/high fat-diet. The amount of exercise in a given week was another risk factor questioned. Only 12% exercised more than three times a week, while 29% never exercised. Over 56% reported being overweight or obese.

Frequency of CRC Screening

Participants were asked to report screening they had ever performed in their lifetime. The total percentage of screening that took place for the entire sample was 32%. Thirty-five percent of the women reported performance of CRC screening with the hemoccults. One percent had a flexible sigmoidoscopy while 27% reported to having a colonoscopy. Fifty-five percent of the sample had received a rectal exam from their care providers while 31% had received a barium enema. (See Table 2)

HEALTH BELIEF MODEL

Internal Consistency

Cronbach's alpha was used to test the internal consistency of the HBM. It showed an internal consistency reliability of 0.92. higher than Champion (1999) who reported a total internal consistency value for the HBM of 0.84. The subscale internal consistency reliability was 0.61.

Analysis

Frequency distributions were used to calculate the responses for each question and subscale in the HBM. The relationship between the concepts of the HBM and the frequency of CRC screening was assessed through the use of Pearson Correlation. Findings revealed statistical significance found with a positive correlation between the sum of the HBM and CRC screening (r = (0.71, p<001),

Approximately 50% of the sample scored low on the susceptibility scale indicating that they did not believe they were at risk for developing colorectal cancer. Only 17% agreed that they were susceptible to developing colorectal cancer while 33%, remained neutral. There was a significant correlation between low scores on the susceptibility subscale and low incidence of CRC screening (r = .70, p<001).

Analysis of the perceived seriousness subscale revealed that approximately 50% of the women scored higher, indicating that they believe that colorectal cancer would pose a serious threat to their health. Twenty-eight percent indicated a neutral answer. Twenty-two percent of the women disagreed, suggesting they did not feel that colorectal cancer posed a threat to their heath. There was a significant negative correlation between high seriousness scores and CRC screening, suggesting that although they agreed that colorectal cancer posed a serious threat, screening was not still obtained (r = .51, p<001)

Almost half (49%) were neutral regarding the benefits of CRC screening. Thirty-seven percent agreed that CRC screening is beneficial in detecting cancer sooner while 13% disagreed. There was a significant correlation between CRC screening and believing that CRC is effective in detecting cancer sooner (r = .70,p<001).

Higher scores on the perceived barriers subscale indicated stronger agreement with statements regarding the negative aspects of colorectal cancer screening, such as embarrassment, time, privacy, cost, and discomfort or pain. Approximately 55% of the women agreed that the barriers were enough reason to avoid having CRC screening. Twenty-three percent answered neutral and 22% did not feel that barriers would prevent them from performing CRC screening. Thus, in this sample perceived barriers were significantly associated with low screening (r = .34, p<015).

A higher score on the perceived confidence scale represents a stronger belief that one is confident in effectively performing CRC screening behaviors, such as hemocults cults. A lower score is indicative of less confidence in effectively performing such tests. Fifty-one percent of the women scored low suggesting they did not feel confident that they could effectively perform the hemocult testing. Twenty-four percent were neutral and 25% were confident that they could effectively perform hemocults. There was a significant relationship between women not feeling confident about performing these tests and CRC screening not being done (r = .56, p<001).

A higher score on the perceived motivation subscale indicates a higher level of health motivation such as preventive medicine, regular check-ups, and searching for new health information. Fifty-three percent of the sample perceived a higher level of motivation while 22% perceived a lower level of motivation. Twenty-five percent of the sample was neutral. There was a significant negative relationship suggesting that while the majority of women perceived themselves as being highly motivated, they did not obtain CRC screening (r = .72, p<001).

SUMMARY

Women who perceive greater susceptibility, benefits, confidence about performing CRC screening effectively, and fewer barriers had an increased frequency of complying with the ACS guidelines for CRC screening. Unfortunately, a negative association was found with regard to perceived significance of the disease and/or motivation to get screening, and the frequency of CRC screening.

DISCUSSION AND IMPLICATION FOR PRACTICE

The overall frequency of CRC screening in this sample, (32%) was approximately the same as that reported nationally, which is still very low, even in 2004. It emphasizes the need for increasing awareness of PCP's and the target population regarding the need for CRC screening. It was disturbing that only 52% of the PCP's had actually recommended/performed CRC screening. It is crucial that advanced practice nurses who function as PCP's have the knowledge and skills to provide options to these women. Additionally, the finding that so many of the women in this sample did not even know whether CRC screening is covered by their insurance (almost 50%) suggests the need for increased communication between PCP's and their patients regarding this barrier.

A personal risk factor discussed in the research is prolonged exposure to toxic fumes during one's lifetime, such as asbestos or cigarette smoke. An overwhelming sixty-seven percent of the sample reported yes to this risk factor, yet the frequency of CRC screening was still low. It would seem that the women need to be educated by their PCP's that this is a serious risk factor which increases their risk of colorectal cancer.

Family personal medical history indicated that 61% of the sample reported a positive history of ovarian, breast, or uterine cancer, or a genetic or immune disorder. All of these are risk factors to recommend CRC screening. Yet, the frequency of CRC screening still remained low. The findings support that it is important for PCP's to educate their patients on the risk factors regarding colorectal cancer and to recommend they receive this screening,

Overall, it appears that many African American women have a poor understanding about the risks of colorectal cancer. Seeking information about the general health practices of these women may help PCP's understand the underlying barriers, such as pain, cost, fear, embarrassment, and time that contribute to the lack of screening being performed. Nurse practitioners who are PCP's, can initiate communication regarding these issues and perhaps alleviate barriers to screening.

Educating women about risk factors for colorectal cancer may motivate them to comply with ACS recommended screening. PCP's need to emphasize lifestyle factors and their impact on the overall health of women, and specifically the relationship of these lifestyle factors to colorectal cancer. Additionally, African American women need to be educated about personal and family health history and its potential impact on their health.

All PCP's have a responsibility in the educational effort to promote the early detection of colorectal cancer. In addition, to personal contact with patients, handouts, and counseling, could be included. Also, educational efforts could be directed toward the African American population in churches, or community centers. Implementing education or screening programs in the places where African American women regularly congregate has been shown to be effective in reaching this population (Mann, Sherman & Clayton et al., 2000)

It is vital that PCP's always provide and/or perform the recommended caner screening available to patients based on the recommendations of the ACS. If the professionals responsible for guiding women to health are unreliable in their accountability, then the overall health of women is compromised. Professional nursing and medical societies should encourage their members to teach their patients about the early detection of cancer and the importance of screening.

LIMITATIONS

A limitation of this study was sample size. A response rate greater than 60% is sufficient for most purposes, but a lower response rate is acceptable (Polit, 1999). The expected return rate was taken into account (calculated at approximately 40% due to the population selected. The number of surveys mailed out was increased to accommodate this. However, the actual return rate was slightly lower than expected. On the other hand, this study employed a randomly selected sample that yields more reliable results than a sampling method of convenience. Results based on sampling may be generalized toward a selected general population. This North Florida County is divided into four quadrants known as the Northwest, Northeast, Southwest, and Southeast. The four churches selected were located in each of these quadrants so that the entire county area was represented. This allows for the ability to generalize finding to the entire population of African American women over the age of 50 that attend church in the North Florida area.

CONCLUSION

CRC screening is an effective method in detecting colorectal cancer. However, there is limited knowledge regarding African American women and colorectal cancer. African American women need to be encouraged to participate in their own healthcare through education and recommendations from their PCP's. Nurse researchers must continue to examine questions that would be helpful in supporting African American women to comply with colorectal cancer screening recommendations. PCP's should adopt similar attitudes regarding health promotion and early screening so that the risk for CRC can be minimized or at least identified early to maximize a positive treatment outcome Screening/education programs that go "to the population" at church or community centers may be effective in increasing knowledge and screening of this at risk population.

Table l. Social Demographic Characteristics

Variables              Frequency     %

Age
  50-59                   14       29.2
  60-69                   16       33.3
  70-79                   11       22.9
  80+                     7        14.6
Marital Status
  Single                  5        10.2
  Separated/Divorced      13       20.5
  Married                 12       24.5
  Widowed                 19       38.8
Education
  No High School          17       34.7
  High School             17       34.7
  AA Degree               5        10.2
  Bachelor Degree         7        14.3
  MS/PhD                  3         6.1
Insurance Coverage        32       66.2

PCP Recommendation        26       55.3

Table 2. Total Frequency of Colorectal Cancer Screening

CRC Screening (N=49)     Frequency   %

Hemocults                   17       35
Flexible Sigmoidoscopy       7        1
Colonoscopy                 13       27
Rectal Exam                 27       55
Barium Enema                15       31

Total                       79       32

REFERENCES

American Cancer Society (2003) ACS Cancer Facts and Figures. Retrieved January 30, 2004 from www.cancer.org

Baskin, M. Resnicow, K. & Campbell, M. (2001). Conducting health interviews in black: A model for building effective partnership. Ethnic Disparities, 11(4), 823-33

Cancer Research Prevention Foundation (Updated January 20, 2004) About Colorectal Cancer. Retrieved January 30, 2004 from www.preventcancer.org

Champion, V.I (1999). Revised susceptibility, benefits and barriers scale for mammography screening. Research in Nursing and Health, 22, 341-348.

Felton, G.M. (2000), Physical activity stages of changes in African American women: Implications for nurse practitioners. Nurse Practitioner Forum, 11 (2), 116-123.

Helm, J. Russo, M, Biddle, A, Simpsin, K., Ranoboff, D, & Sandler, R. (2000). Effectiveness and economic impact of screening for colorectal cancer by mass fecal occult blood testing. The American Journal Gastroenterology, 95(11), 3250-3258.

Hoffman-Goetz, I, & Mills, S.I. (1997). Cultural barriers to cancer screening among African-American women: A critical review of the qualitative nature. Womens Health, 3(3-4), 183-201.

Lipkus, I., Rimer, B., Lyna, P., Pradhaan, A., Conaway, M., & Woods-Powell, C. (1996). Colorectal screening patterns and perceptions of risk among African American users of a community health center. Journal of Community Health, 21(6), 409-425.

Mann, R., Sherman, U., Clayton, C, Johnson, R., Keates, J. Kasenge, R., Streeter, K., Goldherg, I., & Nieman, I. (2002). Screening to the converted: An educational intervention in African American churches. Journal of Cancer Education, 15, (1), 46-50.

Polit, D. & Hungler, B. (2003). Essentials of nursing research: Methods and application. New York: Lippincott Williams and Wilkins.

Shankar, S., Kofie, V., Helzlsoouer, K., Rivo, M., & Bonney, G., (1995). Cancer prevention behavior among African American adults: A survey of wards 7 and 8 in Washington, DC. Journal of National Medical Association, 87(1), 39-46.

Deborah Frank, PhD, MET, ARNP, is a professor of Nursing at Florida State University School of Nursing, Tallahassee, FL 32306-4310. She is a licensed marriage and family therapist and psychiatric mental health nurse practitioner. Her research focuses on health behaviors including screening and treatment adherence. Recent research has focused specifically on underserved populations including the rural elderly, and African Americans. Dr. Frank may be reached at E-mail: dfrank@nursing.fsu.edu

Jennifer Swedmark, MSN, ARNP, is a nurse practitioner with extensive experience in oncology, family medicine and internal medicine. Colon cancer screening is a component of her practice. Ms. Swedmark may be reached at 1841 Fiddler Court, Tallahassee, FL 32308.

Laurie Grubbs, PhD, ARNP, is a professor of Nursing at Florida State University School of Nursing, Tallahassee, FL 32306-4310. She is also a practicing adult nurse practitioner. Her research is on health promotion and primary prevention. Specific emphasis is on exercise, nutrition, health screening, and early identification of symptoms in at risk populations. Dr. Grubbs may be re ached at Email: lgrubbs@nursing.fsu.edu

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