Factors Predicting Stage of Adoption for Fecal Occult Blood Testing and Colonoscopy among Non-Adherent African Americans Hsiao-Lan Wang, PhD, RN, CMSRN, HFS Assistant Professor University of South Florida September, 2012

Team Indiana University School of Nursing –Susan M. Rawl, PhD, RN, FAAN –Victoria Champion, PhD, RN, FAAN –Connie Krier, BS Indiana University School of Medicine –Susan Perkins, PhD –Yan Tong, PhD, MS –Netsanet Gebregziabher, MS University of Texas Southwestern Medical Center –Celette Sugg Skinner, PhD University of Georgia –Jeffrey Springston, PhD Purdue University School of Science, Department of Psychology, IUPUI –Shannon M. Christy, MA

Funding National Cancer Institute grant awarded to Dr. Rawl (R01 CA ) National Institute of Nursing Research postdoctoral training grant awarded to Dr. Wang (T32 NR007066), Indiana University

Background: Colorectal Cancer (CRC) CRC in the United States in 2012 is estimated as: –3 rd most commonly diagnosed cancer –3 rd leading cause of cancer deaths African Americans have the highest CRC incidence and mortality rate of all racial groups.

Background: CRC Screening CRC is curable and preventable by screening. Participation of CRC screening remains low, especially in African Americans. Primary care practice is often the first place for delivery of CRC screening services. Theory-based tailored messages to increase screening are more likely to be successful, especially those tailored to stage of adoption.

Purpose To examine predictors of stage of adoption for fecal occult blood testing (FOBT) and colonoscopy screening among non- adherent African American primary care patients. Data Source: Rawl SM, Skinner CS, Champion V, Perkins SM, Springston J, Russell KM, et al. Computer-delivered Tailored Intervention Improves Colon Cancer Screening Knowledge and Health Beliefs of African Americans. Health Education Research, In press.

Conceptual Framework Stage of Adoption - FOBT - Colonoscopy Clinical Variables Body Mass Index Family history of CRC Personal history of cancer Objective risk CRC Health Beliefs/Knowledge Perceived Risk Perceived Benefits Perceived Barriers Self-Efficacy Cancer Fatalism CRC knowledge Social Support Marital status Family/friend encouragement Provider recommendation Demographics Age, Gender, Education, Employment, Income, Health insurance Clinical Site

Non-Adherent African Americans StagesPrecontemplationContemplationPreparation Fecal Occult Blood Test (FOBT): Never had OR had one more than 12 months ago Does not intend to have one in next 6 months. Intends to have one in next 6 months. Is planning to do in next six months, and has an FOBT kit. Colonoscopy: Never had OR had one more than 10 years ago Does not intend to have one in next 6 months. Intends to have one in next 6 months. Is planning to do in next six months, and has an appointment scheduled.

Recruitment (N= 817) 11 primary care clinics and community health centers affiliated with two urban academic medical centers, including a VA medical center.

Eligibility Criteria Self-identified as African American or Black Not current with CRC screening Ages No history of CRC Able to read and speak English No medical condition prohibiting screening No cognitive, speech, and hearing impairment

Data Collection/Instruments Structured telephone interviews conducted prior to randomization in a RCT. Scale # Items Alpha Perceived Risk50.79 FOBT Benefits30.72 FOBT Barriers90.81 FOBT Self-Efficacy80.88 Colonoscopy Benefits40.69 Colonoscopy Barriers Colonoscopy Self- Efficacy Cancer Fatalism CRC Knowledge100.64

Data Analyses Predictor variables (p<.20) for hierarchical models were identified using univariate analysis. Demographic variables were entered as predictors in Step 1, followed by clinical variables (Step 2), CRC health beliefs and knowledge (Step 3), and social support variables (Step 4). Final hierarchical models identified significant predictors of stages (p<.05).

Sample Characteristics Mean age was 57.4 years (±6.3) Average education was 12.2 years (±1.9) 47% were male. The majority were not married or partnered (69%), not employed (79%), had insurance (89%), and reported incomes of <$15, 000 (59%). The majority had no personal history of cancer (92%) or family history of cancer (74%) and were not VA patients (80%). The mean BMI was 31.2 (±7.9).

Stage of Adoption Distributions StagesPrecontemplationContemplationPreparation FOBT: Never had OR had one more than 12 months ago n (%) Does not intend to have one in next 6 months. 484 (59) Intends to have one in next 6 months. 277 (34) Is planning to do in next six months, and has an FOBT kit. 54 (7) Colonoscopy: Never had OR had one more than 10 years ago n (%) Does not intend to have one in next 6 months. 353 (43) Intends to have one in next 6 months 378 (46). Is planning to do in next six months, and has an appointment scheduled. 84 (11)

FOBTColonoscopy Significant Predictors Step 4 OR (95% CI) Step 4 OR (95% CI) Demographics Age Male Income 15K-30K vs. <15K > 30K vs. < 15K VAMC site 1.04 ( )** 1.70 ( )** 0.82 ( ) 1.03 ( ) 2.80 ( )** 0.98 ( ) 1.29 ( ) 0.83 ( ) 0.46 ( )** - Clinical Variables Personal History of Cancer 0.37 ( )** - CRC Health Beliefs/Knowledge Perceived Benefits Perceived Barriers Perceived Self-efficacy 1.15 ( ) 0.79 ( )* 1.59 ( )** 1.56 ( )** 0.88 ( ) 1.66 ( )** Social Support Family/friend Encouragement Doctor Recommendation 1.64 ( )** 2.05 ( )** 1.71 ( )** 2.47 ( )**

Discussion Involving families and friends in addition to healthcare providers may be a very effective component of interventions to promote CRC screening.

Discussion VAMC patients were at more advanced stage of adoption for FOBT compared with the non- VAMC. Participants with greater perceived benefits were more likely to be in more advanced stages of adoption for colonoscopy only. Participants with greater perceived self-efficacy were more likely to be in more advanced stages of adoption for both FOBT and colonoscopy.

Limitations Selection bias. Baseline data from an intervention trial to promote CRC screening. Limited generalizability: low income African Americans who have insurance and are able to access primary care services.