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Journal of Clinical Oncology, Vol 22, No 13 (July 1), 2004: pp. 2617-2622 © 2004 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.10.149 Colorectal Cancer Screening Knowledge, Attitudes, and Beliefs Among Veterans: Does Literacy Make a Difference?From the VA Midwest Center for Health Services and Policy Research, VA Chicago Healthcare System; the Divisions of Gastroenterolgy, General Internal Medicine, and Hematology/Oncology of the Department of Medicine, Department of Preventive Medicine, and the Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, the Robert H. Lurie Comprehensive Cancer Center; the Center for Healthcare Studies, Northwestern University, Chicago, IL; and the Department of Family Medicine, Louisiana State University Health Sciences Center, Shreveport, LA Address reprint requests to Nancy C. Dolan, MD, Northwestern University, Feinberg School of Medicine, 675 N St Clair St, Suite 18-200, Chicago, IL 60611; e-mail:ndo428{at}northwestern.edu
PURPOSE: To evaluate whether lower literacy is associated with poorer knowledge and more negative attitudes and beliefs toward colorectal cancer screening among veterans without recent colorectal cancer screening. PATIENTS AND METHODS: Three hundred seventy-seven male veterans, age 50 years and older, who had not undergone recent colorectal cancer screening, were surveyed about their knowledge, attitudes, and beliefs regarding colorectal cancer screening. Patients' literacy was assessed with the Rapid Estimate of Adult Literacy in Medicine, an individually administered screening test for reading. RESULTS: Thirty-six percent of the 377 men had an eighth grade literacy level or higher. Men with lower literacy were 3.5 times as likely not to have heard about colorectal cancer (8.8% v 2.5%; P = .006), 1.5 times as likely not to know about screening tests (58.4% v 40.9%; P = .0001), and were more likely to have negative attitudes about fecal occult blood testing (FOBT), but not about flexible sigmoidoscopy. Specifically, men with lower literacy skills were two times as likely to be worried that FOBT was messy (26.7% v 13.3%; P = .008), 1.5 times as likely to feel that FOBT was inconvenient (28.7% v 18%; P = .05), and four times as likely to state they would not use an FOBT kit even if their physician recommended it (17.9% v 4.0%; P = .02). CONCLUSION: Limited literacy may be an overlooked barrier in colorectal cancer screening among veterans.
Colorectal cancer is the third most common cancer in men and women and the second most common cause of cancer death in the United States, accounting for 147,500 new cases and 57,100 deaths in 2003.1 The survival rate for localized disease is 90%, compared to less than 10% for metastatic disease.2 As a consequence, colorectal cancer screening is among the most efficacious cancer screening programs available today. The US Preventive Services Task Force, the American College of Gastroenterology, and the American Cancer Society all recommend that men and women age 50 years and older should be regularly screened for colorectal cancer with yearly fecal occult blood testing (FOBT) and/or every 5-year use of periodic flexible sigmoidoscopy, colonoscopy, or barium enema.3
Colorectal cancer screening rates are dismally low, lagging far behind those of all other cancer screening tests.4–6 In 2001, only 43% of adults aged Limited literacy skills may be an important factor in explaining low rates of use of colorectal cancer screening at VA hospitals.10,11 Prior studies in non-VA settings have found an association between poor health literacy skills and lack of knowledge about and more negative attitudes towards breast and cervical cancer screening.12,13 Persons with lower levels of literacy skills may have a limited capacity to understand basic cancer screening information and educational materials, many of which are written at a literacy level above that of a significant portion of the American population.14,15 It is estimated that 21% of the adult population in this country has limited literacy skills, with 23 million adults being functionally illiterate.16 Veterans who use VA healthcare services may have especially high rates of poor health literacy skills. At our VA hospital, only 42% of hospitalized VA patients have health literacy skills above a ninth grade level.17 In this study, we interviewed a cohort of veterans who had not received recent colorectal cancer screening tests and evaluated (1) the frequency with which these individuals had limited health literacy skills and (2) if having limited health literacy skills was associated with poor knowledge about colorectal cancer screening as well as negative attitudes and beliefs towards specific colorectal cancer screening tests.
The study is a cross-sectional survey of knowledge, attitudes, and beliefs related to colorectal cancer and colorectal cancer screening among male veterans who received general medical care at the VA Chicago Healthcare System. The study was approved by the Northwestern University institutional review board. Subjects were male veterans, age 50 and older, who presented to a general medicine clinic appointment between May 1, 2001, and December 31, 2002. Patients were ineligible if they had: received an FOBT within 1 year; received a flexible sigmoidoscopy or colonoscopy within 5 years; a personal history of colorectal cancer or polyps; a family history of colorectal cancer or polyps; or a personal history of inflammatory bowel disease. Seventy-nine percent of persons who receive care in the VA Chicago medical system have incomes that fall below the Means Test Threshold of $24,644 for veterans with no dependents and $36,188 for veterans with five dependents.18 Trained research assistants approached and consented eligible patients before their general medicine appointment. A survey, which included questions on basic demographic information, literacy, and colorectal cancer screening knowledge, attitudes, and beliefs (CCKAB questionnaire), was then administered verbally. Patients' literacy in a healthcare context was assessed using the Rapid Estimate of Adult Literacy in Medicine (REALM) instrument, a commonly used health word recognition test.19–21 Literacy in a healthcare context will hereafter be referred to as "literacy." REALM is highly correlated with other general reading tests, such as the Test for Functional Health Literacy in Adults. REALM raw scores range from 0 to 66, and can be converted into one of four reading grade levels: third grade or less (0 to 18), fourth to sixth grade (19 to 44), seventh to eighth grade (45 to 60), and ninth grade and above (61 to 66). A CCKAB questionnaire was developed by study investigators to assess knowledge, attitudes, and beliefs about colorectal cancer and colorectal cancer screening among patients with low literacy. The questionnaire assessed five constructs of the Health Belief Model: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action.22 A multidisciplinary team of collaborators consisting of a gastroenterologist, a general internist, an oncologist, and two psychologists, reviewed the items for medical accuracy and relevance. We then further refined the instrument by meeting with VA patients with similar sociodemographic characteristics as those of prospective participants to further assess understandability. The revised questionnaire was piloted among 10 patient consultants to confirm understandability and length appropriateness. The mean REALM score of the 10 veterans who participated in pilot testing of the CCKAB questionnaire was 41, corresponding to a fourth to sixth grade reading level (range, 7 to 63). The final version of the questionnaire consisted of 43 items, was administered over 15 to 20 minutes, and has vocabulary that is graded at a Flesch-Kincaid fourth grade level. The CCKAB questionnaire has not been formally tested for validity and reliability.
Limited health literacy was operationally defined as a literacy level of eighth grade level and below (REALM score
During the study period, research assistants approached 589 eligible patients. Of these, 156 (26.4%) refused to be in the study and 56 (9.6%) did not complete the study questionnaire primarily because their general medicine physician was ready to begin the scheduled outpatient visit. Of 377 respondents who completed the study questionnaires, 51% were white and 41% were black; the majority had completed high school and 22% had completed college; and 36% had health literacy skills measured with the REALM instrument at a level of eighth grade or below (Table 1). More than three-fourths of the study population rated their health as good to excellent. Compared with respondents with literacy skills greater than the ninth grade level, respondents with limited literacy skills were more than twice as likely to be black (64.4% v 28.3%; P < .001) and almost four times as likely not to have completed high school (34.3% v 9.2%; P < .001).
Most respondents had heard of colorectal cancer, believed that colorectal cancer was serious if found either early or late in the course of the disease, and indicated that they would want to know if they had colorectal cancer (Table 2). However, 47.3% had not heard of tests to find colorectal cancer. When asked specifically if they knew what a flexible sigmoidoscopy or FOBT was, 71.0% and 76.4% of the respondents were unable to provide a general description of FOBT or flexible sigmoidoscopy procedures, respectively. After the interviewer briefly described each test, many respondents indicated they were familiar with the concepts of flexible sigmoidoscopy (70.8%) or FOBT (70.0%). Among the respondents who, after hearing descriptions of each colorectal cancer screening test, indicated that they had heard of colorectal cancer screening tests but had never had them, 36.7% and 39.7% indicated that they had received a doctor's recommendation for FOBT or a flexible sigmoidoscopy, respectively. Many of those respondents who indicated that they had never received a doctor's recommendation for either colorectal cancer screening test indicated that if their doctor would recommend colorectal cancer screening, they would likely get screened with either a FOBT (92.2%) or a flexible sigmoidoscopy (81.7%; Table 3).
Knowledge, attitudes, and belief measures about colorectal cancer screening differed according to literacy levels (Tables 2 and 3). With respect to knowledge, respondents with limited literacy skills were more likely not to: be familiar with colorectal cancer (8.8% v 2.5%; P < .006); be familiar with screening tests for colorectal cancer (58.4% v 40.9%; P < .001); be able to describe what was involved in performing a FOBT test (94.9% v 65.8%; P < .001) or a flexible sigmoidoscopy procedure (84.7% v 63.3%); and know what age most physicians would recommend screening for colorectal cancer to begin (75.2% v 66.7%; P = .08). With respect to attitudes, respondents with limited literacy skills were more likely to: be concerned that a FOBT was messy (27.7% v 13.3%; P = .008) and inconvenient (28.7% v 18.0%; P = .05); indicate that they would not use a FOBT kit even if recommended by their physician (17.9% v 4.0%; P = .02) and that procrastination was a primary reason for not getting a flexible sigmoidoscopy (7.4% v 1.2%; P = .007). In contrast, respondents with limited literacy were more likely to believe they were at average-to-high risk to develop colorectal cancer (69.6% v 55.2%; P = .01). Even after adjustment for race and employment status, literacy-related differences in measures of knowledge and attitudes were still apparent (data not shown).
Improving rates of colorectal cancer screening is a priority in the VA healthcare system. In 2002, a joint National Cancer Institute/Department of Veterans Affairs Quality Enhancement Research Initiative program was funded; the mission of the program was "to promote the translation of research discoveries and innovations into patient care and systems improvements in order to reduce the incidence, late detection, suffering, and mortality from colorectal cancer among all veterans."23 A major focus is in identifying barriers to colorectal cancer screening and implementing interventions that may overcome these barriers. Our results provide insights into one potential barrier. In particular, among veterans at our VA hospital who had not undergone recent colorectal cancer screening, knowledge about colorectal cancer screening tests was poor, and attitudes toward colorectal cancer screening were negative, especially among those with limited literacy skills. Poor literacy skills have been identified as an important barrier for other cancer screening tests, including mammography, digital rectal examinations, prostate-specific antigen measurement, and Pap smears.11,13,24–28 Many women with limited health literacy skills confuse mammograms with Pap tests.20 Having adequate literacy skills is a better predictor of adequate levels of cervical cancer screening knowledge than either race/ethnicity or education.24 Among veterans who presented with newly diagnosed prostate cancer, limited literacy skills (but not African-American race) was a significant predictor of both higher prostate-specific antigen levels as well as advanced-stage disease.29,30 Individuals with limited literacy skills often have difficulty obtaining information from cancer control messages, materials, and conversations and are more likely to identify their physician as the primary source of health information.25–27,31 However, physicians may have difficulty providing readily understandable health information to patients with poor health literacy skills.24 Certain features of colorectal cancer screening may be difficult for physicians to communicate to persons with limited literacy skills. Focus groups of veterans at our VA hospital found that few participants could say "flexible sigmoidoscopy" or "hemoccult," knew where or what the colon or bowel was, were familiar with terms such as "polyp," "growth," or "lesion," or understood the concept of cancer screening.28 The Health Belief Model provides a theoretical framework for evaluating colorectal cancer screening behavior, as well as designing potential interventions (Table 3). The Model suggests that health-related action depends on perceptions of disease severity and susceptibility, screening benefits and barriers, and cues to action.22 Using the Model as a guide, we found that veterans with limited literacy skills viewed FOBT more negatively and were less responsive to action cues for FOBT, although they also expressed a heightened susceptibility to colorectal cancer. Our findings suggest that interventions to improve colorectal cancer screening for veterans with limited health literacy skills should focus on improving understanding of FOBT as a screening test, overcoming common negative attitudes towards this test through efficacy messages, and providing easy to understand instructions for returning FOBT kits. FOBTs are of particular importance in colorectal cancer screening initiatives in the VA healthcare setting, as availability to flexible sigmoidoscopy or colonoscopy is often limited because of long waiting periods and/or a limited number of trained VA physicians who can perform these procedures. The limitations of our study should be addressed. First, patients were recruited from general medicine clinics at one VA hospital. However, the VA healthcare system is an equal access healthcare system and the largest integrated delivery system in the country. Second, the refusal rate for this study was 26%. Veterans who refused to participate in this study were older than those who agreed to participate (mean of 72 v 67 years; P < .001) but were similar with respect to race. Others have reported that among the Medicare population who received care in HMO settings, older individuals have lower rates of adequate literacy skills.11 We therefore speculate that nonrespondent veterans, who on average were 5 years older than respondent veterans, may have been less knowledgeable and had more negative attitudes towards colorectal cancer screening tests. Our findings, therefore, may underestimate the magnitude of literacy-related differences in knowledge and attitudes about colorectal cancer screening among veterans who had not undergone recent colorectal cancer screening procedures at our VA hospital. Third, we operationally defined limited health literacy skills at an eighth grade level or below. Reading at an eighth grade reading level reflects limited, rather than low literacy skills, but can be an important barrier to understanding health materials which are on average written between a 10th and 11th grade reading level.10 Fourth, we did not measure the income levels of the study participants. Over half of all VA users have reported annual incomes below $20,000. However, it is not known if, among veterans, there are income-related differences in knowledge, attitudes, or beliefs toward colorectal cancer screening. Fifth, we were unable to assess differences in colorectal cancer screening rates according to health literacy skills, as all participants in this study had not undergone recent colorectal cancer screening tests. Finally, it is possible that limited health literacy skills may be a marker for unmeasured factors, such as lower socioeconomic status or lower prioritization of colorectal cancer screening relative to other life issues. While future studies might probe these issues, longer interviews would be required. In conclusion, health literacy is likely to be an important, and frequently overlooked, barrier to colorectal cancer screening for veterans. In the VA healthcare setting where resource constraints limit the feasibility of sigmoidoscopy, culturally sensitive, low-literacy educational materials that address both FOBT and flexible sigmoidoscopy procedures should be disseminated.
The authors indicated no potential conflicts of interest.
Supported by the Department of Veterans Affairs (PCI 99-158) and the National Institute of Health (R01CA86424-01A2). Presented at the VA Health Services and Research Development Services National Meeting, March 10, 2004, Washington, DC, and the 28th Annual Meeting of the American Society of Preventive Oncology, Bethesda, MD, March 15, 2004. Authors' disclosures of potential conflicts of interest are found at the end of this article.
1. Jemal A, Murray T, Samuels A, et al: Cancer Statistics, 2003. CA Cancer J Clin 53:5–26, 2003 2. Miller BA, Ries LAG, Hankey BF, et al: SEER Cancer Statistics Review: 1973–1990 (NIH Pub. No. 93-2789). National Cancer Institute, Bethesda, MD, 1993
3. U.S. Preventive Services Task Force: Screening for colorectal cancer: Recommendation and rationale. Ann Intern Med 2002:137:129–131 4. Centers for Disease Control and Prevention: Colorectal cancer test use among persons aged 50 years—United States, 2001. MMWR 52:193–196, 2003[Medline]
5. Sirovich BE, Schwartz LM, Woloshin S: Screening men for prostate and colorectal cancer in the United States: Does practice reflect the evidence? JAMA 289:1414–1420, 2003 6. Centers for Disease Control and Prevention (CDC). 2000 BRFSS Summary Prevalence Report. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Atlanta, GA, 2000
7. Jha AK, Perllin JB, Kizer KW, et al: Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med 348:2218–2227, 2003 8. Cokkinides VE, Chao A, Smith RA, et al: Correlates of underutilization of colorectal cancer screening among U.S. adults, age 50 years and older. Prev Med 36:85–91, 2003[CrossRef][Medline]
9. Kazis LE, Miller DR, Clark J, et al: Health-related quality of life in patients served by the Department of Veterans Affairs: Results from the Veterans Health Study. Arch Intern Med 158:626–632, 1998
10. Davis TC, Williams MV, Marin E, et al: Health literacy and cancer communication. CA Cancer J Clin 52:134–149, 2002
11. Gazmararian JA, Baker DW, Willims MV, et al: Health literacy among medicare enrollees in a managed care organization. JAMA 281:545–551, 1999 12. Davis T, Arnold C, Berkel H, et al: Knowledge and attitude on screening mammography among low-literate, low-income women. Cancer 78:1912–1920, 1996[CrossRef][Medline] 13. Lindau ST, Tomori C, Lyons T, et al: The association of health literacy with cervical cancer prevention knowledge and health behaviors in a multiethnic cohort of women. Am J Obstet Gynecol 186:938–943, 2002[CrossRef][Medline] 14. Miles S, Davis T: Patients who can't read: Implications for the health care system. JAMA 274:1719–1720, 1995[CrossRef][Medline] 15. Berger D, Inkelas M, Myhre S, et al: Developing health education materials for inner-city low literacy parents. Public Health Rep 109:168–172, 1994[Medline] 16. Kirsh I, Jungeblut A, Jenkins L, et al: Adult literacy in America: A first look at the results of the National Adult Literacy Survey. National Center for Education Statistics, United States Department of Education, Washington, DC, 1993 17. Arozullah AM, Khan T, Kurup S, et al: The impact of health literacy and social support on hospital and outpatient care utilization. Proceedings of the 2004 VA Health Services Research and Development Meeting, 1037a. 18. VHA Directive 2002–082. Washington, DC, Department of Veterans Affairs, December 13, 2002 19. Davis TC, Crouch MA, Long S, et al: Rapid assessment of literacy levels of adult primary care patients. Fam Med 23:433–435, 1991[Medline] 20. Davis TC, Long S, Jackson R, et al: Rapid estimate of adult literacy in medicine: A shortened screening instrument. Fam Med 25:391–395, 1993[Medline] 21. Parker RM, Baker DW, Williams MV, et al: The Test of Functional Health Literacy in Adults: A new instrument for measuring patients' literacy skills. J Gen Intern Med 10:537–554, 1995[Medline] 22. Rosenstock IM, Strecher VJ, Becker MH: Social learning theory and the health belief model. Health Education Quarterly 15:175–183, 1988[Medline] 23. CRC QUERI. Colorectal Cancer Quality Enhancement Research Initiative. Minneapolis VA Medical Center. http://www.hsrd.minneapolis.med.va.gov/CRC/CRDHome.asp 24. DHHS, National Institutes of Health, National Library of Medicine (NLM). In: Seiden CR, Zorn M, Ratzan S, et al (eds): Health Literacy, January 1990 Through 1999. NLM Pub No. CBM 2000–1. Bethesda, MD, NLM, February 2000, IV 25. Doak LG, Doak CC, Meade CD: Strategies to improve cancer education materials. Oncol Nurs Forum 23:1305–1312, 1996[Medline] 26. Davis TC, Williams MV, Branch WT, et al: Explaining illness to patients with limited literacy. In, Whaley B (ed): Explaining Illness: Research, Theory, and Strategies for Comprehension. Mahwah, NJ, Lawrence Erlbaum Associates, Inc, 1999 27. Doak C, Doak L, Friedell B, et al: Improving comprehension for cancer patients with low literacy skills: Strategies for clinicians. CA Cancer J Clin 48:151–162, 1998[Abstract] 28. Davis T, Dolan N, Ferreira MR, et al: The role of inadequate health literacy skills in colorectal cancer screening. Cancer Invest 19:193–200, 2001[CrossRef][Medline]
29. Bennett CL, Ferreira MR, Davis TC, et al: Relation between literacy, race, and stage of presentation among low-income patients with prostate cancer. J Clin Oncol 16:3101–3104, 1998 30. Lyons EA, Wolf M, Bennett CL: Race and literacy effects on prostate cancer biology and access. Proc Am Soc Clin Oncol 23:1303a, 2004 31. Wolf MS, Davis TC, Cross JT, et al: Health literacy and patient kowledge in a Southern U.S. HIV clinic. Int J Std AIDS (in press) Submitted October 22, 2003; accepted April 14, 2004. This article has been cited by other articles:
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Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
50 years had received a lower endoscopy (flexible sigmoidoscopy or colonoscopy) in the preceding 10 years; 23.5% had an FOBT in the preceding year.
60), and adequate health literacy as ninth grade and above (REALM score of > 60). 
2 tests and student t-tests were performed to assess for differences between subjects with adequate versus limited literacy levels. Logistic regression analysis was used to evaluate the relationship of race, employment status, and literacy with various measures of colorectal cancer knowledge, attitudes, and beliefs. 
