Colorectal Cancer: Patient Knowledge, Attitudes, and

Screening BehaviorsCapstone Project Presentation

by

Sharon D. Brantley, RN, BSN

in partial fulfillment of theRequirement for the Degree

MASTER OF SCIENCE IN NURSING

December 2, 2009

Colorectal Cancer (CRC) 2nd leading cause of all cancer deaths

(Bazensky, Shoobridge-Moran, & Yoder, 2007)

Ranks 3rd in prevalence of behind prostate and lung CA in men and breast and lung CA in females (Centers for Disease Control, 2007)

Affects men and women of all races equally (Bazensky et al., 2007)

Approximately 150,000 new cases each year (American Cancer Society, 2007)

Over 50,000 die from CRC each year (ACS, 2007)

CRC: The Problem

Represents significant public health risk

Early detection and polyp removal could reduce mortality by 50% (Smith, Cokkinides, & Eyre, 2004)

Only about 50% of Americans received recommended screening (National Cancer Institute, 2007)

Literature Review

Limited knowledge or low literacy is related to negative attitudes about CRC and CRC screening methods (Dolan et al., 2004)

› 377 male veterans in VA Medicine Clinic› Survey based on Health Belief Model (HBM)› Completed CRC questionnaire + REALM› Assessed ability to name or describe CRC

screening tests: Fecal Occult Blood Test (FOBT), flexible sigmoidoscopy (flex sig), or colonoscopy

› Felt FOBT was messy, inconvenient, and would not use FOBT kit if provided by MD

Literature Review

Clients with limited literacy were less likely to be knowledgeable about CRC (Miller, Brownlee, McCoy, & Pignone, 2007).

› Pilot study of 50 subjects at internal medicine clinic in teaching facility

› Survey of 26 questions about CRC screening and personal learning methods about health topics + REALM assessment

› Researchers explained screening tests and asked when subjects had last received: FOBT, flex sig, or colonoscopy

Need for this Study

Current low screening rates are believed to result from fear of cancer and fear of the tests associated with screening for CRC (Ueland, Hornung, & Greenwald, 2006)

One-on-one education session produced significant change in beliefs about CRC prevention and CRC screening (Ueland, Hornung, & Greenwald, 2006).

Theoretical Framework: Health Belief Model

Developed in the 1950’s by four psychologists: Hochbaum, Kegeles, Leventhal, and Rosenstock

US Public Health Service wanted to explain lack of participation in free disease prevention programs

Conceptual Definitions Education = the process of acquiring

knowledge through engagement in the interdependent activities of teaching and learning.

Knowledge = what is known about CRC and CRC screening methods.

Compliance = adherence to the advisement or health guidelines provided by a healthcare practitioner.

Hypotheses #1: The knowledge level of patients

participating in an educational session on colorectal cancer screening will change upon completion of the class.

#2: The colorectal cancer screening compliance behaviors in patients who participate in an educational session on colorectal cancer screening will change upon completion of the class.

Research Design

Descriptive, pretest-posttest design After consent was given, subjects

completed demographic form and pretest.

After class, posttest given and REALM assessment completed.

Sampling

Convenience sampling of clients at a large metropolitan hospital serving a disproportionately indigent population through use of flyers and investigator recruitment

Potential subjects were scheduled to attend a class on CRC and CRC screening methods

RAPID ESTIMATE OF ADULT LITERACY IN MEDICINE (REALM)©Terry Davis, PhD ∙ Michael Crouch, MD ∙ Sandy Long, PhD (1991)

Sample Tool:

List 1fatflupill

doseeye

stresssmearnervesgermsmeals

diseasecancercaffeineattackkidney

hormonesherpesseizurebowel

asthmarectal incest

List 2fatiguepelvic

jaundiceinfectionexercisebehavior

prescriptionnotify

gallbladdercalories

depressionmiscarriagepregnancy

arthritisnutrition

menopauseappendixabnormalsyphilis

hemorrhoidsnauseadirected

List 3allergic

menstrualtesticlecolitis

emergencymedicationoccupation

sexuallyalcoholism

irritationconstipationgonorrhea

inflammatorydiabeteshepatitis

antibioticsdiagnosispotassium

anemiaobesity

osteoporosisimpetigo

CRC Class Content

Colon cancer: incidence, risk factors, development, symptoms

CRC screening: FOBT, sigmoidoscopy, colonoscopy

Colonoscopy in detail DECISION to make appt Prep instructions Day of procedure: sequence of events

Assumptions

Subjects provide accurate self-reported information.

Subjects honestly report their beliefs and opinions and make a valid attempt to answer questions correctly.

Subjects retain knowledge over time.

Limitations

Small sample size (n=112) Localization of the sample Learning environment—room size,

technical difficulties Quasi-experiment design—no control

group Homogeneity of population

Data Collection

Data collected Tests graded and REALM assessments

scored Data coded and entered into SPSS file

for analysis

Sample by Age

< 452% 45-50

13%

51-5531%

56-6024%

61-6513%

66-707%

71-756%

75+3% No resp

2%Age< 4545-5051-5556-6061-6566-7071-7575+No resp

Sample by Ethnicity

5%

90%

1%1% 1% 2%

Caucasian African Amer HispanicAsian Other No resp

Sample by Gender & Marital Status

Male27%

Female73%

Gender

Never married

23%

Married10%

Separated13%

Divorced38%

Widowed16%

Marital Status

Sample by Educational Level

dropout31%

diploma or GED31%

attend college23%

bachelor'

s5%

attend grad6% grad deg

2%no resp

1%

gradecmp’d

no. %

3rd 1 2.9

7th 2 5.7

8th 3 8.6

9th 2 5.7

10th 11 31.4

11th 12 34.3

no resp

4 11.4

Total 35 100

Sample by Household Income

<15K 15K-19K

20K-29K

30K-39K

40K-49K

50K-59K

60K-69K

No resp

In-come

61 20 15 4 3 1 2 6

5152535455565

Income

Sample by Insurance Status

Uninsured46%

Medicare21%

Medicaid6%

M&M7%

Comm2%

No resp18%

M&M = Medicare & MedicaidComm = Commercial

Sample by REALM Score

3rd gr or less4%

4th - 6th gr17%

7th - 8th gr30%

9th gr or better49%

Data Analysis: DescriptivesN Min Max Mean Std

Dev

Age 110 41 83 57.63 7.939

Total Pretest Score

112 10 100 67.1429

20.98599

Total Posttest Score

112 20 100 73.5714

21.59651

Score Change

112 -30 60 6.4286 16.86497

Data Analysis: Findings

Mean N Std Dev Std Err Mean

Total Pretest Score 67.1429 112 20.98599 1.98299

Total Posttest Score

73.5714 112 21.59651 2.04068

t df Sig. (2-tailed)

Total Pre Score – Total Post Score

-4.034 111 .000

Paired t-Test

Data Analysis: Spearman ρ CorrelationsTotal Pre Total

PostREALM

Gender Corr CoeffSig N

.186*

.049112

.215*

.023112

.146

.124112

Educ Lev Corr CoeffSigN

.323**

.001111

.416**

.000111

.484**

.000111

Income Corr CoeffSigN

.097

.323106

.210*

.031106

.265**

.006106

Total Pre Corr CoeffSigN

.708**

.000112

.522**

.000112

Total Post Corr CoeffSigN

.708**

.000112

.551**

.000112

** Correlation significant at 0.01 level (2-tailed) * Correlation significant at 0.05 level (2-tailed)

Data Analysis: Spearman ρ Correlations

Income Current Health View

Income Corr CoeffSig N

.272**

.005106

# of annual MD visits

Corr CoeffSigN

.045

.649103

-.228*.018108

** Correlation significant at 0.01 level (2-tailed) * Correlation significant at 0.05 level (2-tailed)

FINDINGS: Hypotheses SUPPORTED – Significant change in

knowledge#1: The knowledge level of patients participating in an educational session on colorectal cancer screening will change upon completion of the class.

UNABLE TO ASSESS – Colonoscopy appointments were several months after class.#2: The colorectal cancer screening compliance behaviors in patients who participate in an educational session on colorectal cancer screening will change upon completion of the class.

Implications for Nursing

Knowledge regarding current CRC screening guidelines

Diverse and interactive teaching and learning methods

Establish cues to identify low literacy clients

Tailor educational activities and patient education materials to meet lower literacy levels

Recommendations for Future Study

Replication on a larger scale with diverse populations

Follow-through on actual subject compliance with screening

Longitudinal studies to examine long-range compliance and knowledge retention

Investigation of different teaching modalities and media

ACKNOWLEDGMENTS

Dr. Linda Streit—Capstone Project Advisor

Dr. Linda Kimble—Statistical Analysis Support

Greta Baldwin-Mason, RN, MSN—Data Coding

Dr. Henry Olejeme—Physician Sponsor Gertrude Dunlap, LPN—Research

Assistant