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