Screening
Socio-psychological factors in the Expanded Health Belief Model and subsequent colorectal cancer screening

https://doi.org/10.1016/j.pec.2015.03.023Get rights and content

Highlights

  • Tested association between Expanded Health Belief Model factors and colorectal cancer screening.

  • Self-efficacy, stage of readiness, and discussions with provider were associated with screening.

  • Neither barriers nor knowledge were statistically significantly associated with screening.

  • Data are useful in parsimoniously predicting patients most likely to engage in CRC screening.

Abstract

Objective

CRC screening interventions tailored to the Expanded Health Belief Model (EHBM) socio-psychological factors have been developed, but the contributions of individual factors to screening outcomes are unclear.

Methods

In observational analyses of data from a randomized intervention trial, we examined the independent associations of five EHBM factors – CRC screening knowledge, self-efficacy, stage of readiness, barriers, and discussion with a provider – with objectively measured CRC screening after one year.

Results

When all five factors were added simultaneously to a base model including other patient and visit characteristics, three of the factors were associated with CRC screening: self-efficacy (OR = 1.32, p = 0.001), readiness (OR = 2.72, p < 0.001), and discussion of screening with a provider (OR = 1.59, p = 0.009). Knowledge and barriers were not independently associated with screening. Adding the five socio-psychological factors to the base model improved prediction of CRC screening (area under the curve) by 7.7%.

Conclusion

Patient CRC screening self-efficacy, readiness, and discussion with a provider each independently predicted subsequent screening.

Practice implications

Self-efficacy and readiness measures might be helpful in parsimoniously predicting which patients are most likely to engage in CRC screening. The importance of screening discussion with a provider suggests the potential value of augmenting patient-focused EHBM-tailored interventions with provider-focused elements.

Introduction

Screening for colorectal cancer (CRC) can reduce CRC mortality [1], but use of CRC screening remains low relative to other evidence-based preventive services [2]. Theory-driven interventions to encourage CRC screening have been developed to favorably influence the socio-psychological factors described in the Expanded Health Belief Model (EHBM) (e.g. screening barriers and self-efficacy) and related factors (e.g. stage of readiness), with the distal aim of increasing patient adoption of targeted screening behaviors [3], [4]. However, in randomized controlled trials (RCTs), theory-driven interventions have not consistently led to the desired changes in behaviors, including in CRC screening behaviors [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18]. Further, even in the trials that found significant behavioral effects, the standardized behavioral effect sizes generally were small [8], [9]. To improve intervention approaches for the future, it is important to understand why these approaches have not been more consistently successful.

Despite the fact that many interventions apply the EHBM, few studies have rigorously explored the relative contributions of the EHBM and related constructs to the behavior changes targeted in these interventions [19]. In intervention studies specifically related to CRC screening behaviors, few report on the status of such constructs post-intervention or their contribution to behavior change [20], [21], [22], [23]. Furthermore, CRC screening outcomes were typically self-reported by patients and measured simultaneously with socio-psychological factors [11], [14], [15], so the temporal nature of the relationships between the socio-psychological factors and the health behaviors was unclear. For these reasons the relative associations of factors commonly measured and addressed in EHBM-tailored interventions with subsequent objectively determined CRC screening behaviors remain unknown.

We examined this issue in the current study, conducting secondary observational analyses of data from an RCT of an experimental CRC screening intervention for patients that was individually tailored to EHBM socio-psychological factors. We evaluated the prospective associations of EHBM and related factors with objectively measured CRC screening. Measures of three EHBM factors (self-efficacy, barriers, and cues to action) and of two related factors (knowledge and stage of readiness) were collected after the participants had received their assigned study intervention and had seen their primary care provider for a scheduled visit. While knowledge and stage of readiness are not included in the description of the EHBM, both are important in evaluating how EHBM constructs contribute to CRC screening. Knowledge is often viewed as necessary to promote behavior change, and commonly cited as a modifying factor in the EHBM [24]. Similarly, behavioral experts call attention to the interrelationship of the EHBM with stage of readiness to change behavior [25]. CRC screening was ascertained objectively by medical record review at one year follow-up. Based on the existing literature regarding the association of socio-psychological factors with CRC screening [12], [26], we hypothesized that, after adjusting for baseline patient and visit characteristics that may influence screening (e.g., patient age, education, health status, insurance, and prior screening), CRC screening knowledge, barriers, self-efficacy, and stage of readiness and discussion of screening with the visit provider each would be significantly associated with receipt of CRC screening both when examined individually, and when examined simultaneously in a single adjusted model.

Section snippets

Participants

The study was conducted from February 1, 2010 through November 30, 2012. Patients aged 50–75 years who were either English- or Spanish-speaking and were not up-to-date for CRC screening were recruited at the time of previously scheduled appointments in primary care clinics in five sites: Sacramento, California (ten clinics); Bronx, New York (one clinic); Rochester, New York (three clinics); San Antonio, Texas (four clinics); and Denver, Colorado (eight clinics in and around Denver). Patients

Results

A total of 250 participants (22.7%) received CRC screening within the one year follow-up period; colonoscopy was performed in 190 (17.3%), FOBT in 75 (6.8%), and sigmoidoscopy in 2 (0.2%). Some people received more than one type of screening test during the follow-up period.

Table 1 shows the characteristics of the screened versus non-screened participants. Screened participants were younger, less likely English-speaking Hispanics, more likely insured, and more likely to report excellent or very

Discussion

To our knowledge, our study is the first to examine the prospective associations of various EHBM and related socio-psychological factors (knowledge, barriers, self-efficacy, stage of readiness for change, and cues to action) with objectively measured subsequent CRC screening outcomes at one-year follow-up. Our findings largely supported our first hypothesis, which was that all five of the socio-psychological factors would be individually associated with subsequent CRC screening when examined

Conflict of interest statement

None of the authors have conflicts of interest to disclose.

Acknowledgements

The National Cancer Institute (R01CA131386) and the American Recovery and Reinvestment Act (CA13138602S1) supported this work. The funders had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; the preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.

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      Seven studies either failed to provide clear sample inclusion criteria or describe the study setting and population (Macrae et al., 1984; Ben Natan et al., 2019; Tastan et al., 2013; Taş et al., 2019; Sammut et al., 2019). Nearly half the included studies utilised non-random sampling (Macrae et al., 1984; Almadi et al., 2015; Gorin, 2005; Ben Natan et al., 2019; Dashdebi et al., 2016; Hay et al., 2003; Lin et al., 2019; Menon et al., 2007; Sohler et al., 2015; Lee et al., 2019; Lee and Im, 2013; Taheri-Kharameh et al., 2016). Only two studies were able to objectively establish participants’ screening, medical and family history (Macrae et al., 1984; Sammut et al., 2019); and only three studies were able to measure their samples’ colorectal cancer screening uptake reliably without using participant self-report (Macrae et al., 1984; Gorin, 2005; Sohler et al., 2015).

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