1. Gender differences in colorectal cancer screening, attitudes and information preferences Joan M. Griffin, PhD Greta Friedemann-Sánchez, PhD Diana Burgess, PhD Melissa Partin, PhD

2. Background  Colorectal cancer is the 3 rd most common cancer and the 3 rd leading cause of cancer deaths.  Adherence to screening guidelines has been found to reduce mortality.  Several studies have found women are less likely to be adherent to colorectal cancer (CRC) guidelines than men.

3. Background Sources of the screening gender gap are unknown. Some possible reasons for the gap include:  Differences in mode preference (men prefer endoscopy; women prefer FOBT).  Differences in barriers.  Differences in facilitators.

4. Exploratory Sequential Design 1. Focus Groups 2. Survey Generate Hypotheses Develop Items Cognitive Interviews Qualitative Analysis Quant Analysis Quant Results Qual Results

5. Qualitative research main findings* SIMILAR PREFERENCES  Men and women both prefer colonoscopy for screening. BARRIERS/FACILITATORS  Overall  Perception that women were at lower risk for CRC (CRC is a “male disease”)  Endoscopy specific  Fears of exposure, vulnerability for women. Fear of pain for men  Different preferences for information about tests. *Friedemann-Sanchez, et al. 2007. Health Expectations.

6. Objectives To assess gender differences in:  CRC screening rates  CRC screening mode preferences.  Barriers and facilitators for CRC screening

7. Hypotheses SCREENING BEHAVIOR Men will be more adherent to CRC screening guidelines. Men will be more adherent to CRC screening guidelines. Greater proportion of men than women will screened by endoscopy (flex sig or colonoscopy). Greater proportion of men than women will screened by endoscopy (flex sig or colonoscopy). SCREENING PREFERENCES Men and women will not differ in mode preference for colonoscopy. Men and women will not differ in mode preference for colonoscopy.

8. Hypotheses BARRIERS TO SCREENING Women will be more likely to report affective barriers (embarrassment, exposure, vulnerability) to endoscopic screening procedures than men Women will be more likely to report affective barriers (embarrassment, exposure, vulnerability) to endoscopic screening procedures than men Men will be more likely to report pain as a barrier to endoscopic screening procedures than women Men will be more likely to report pain as a barrier to endoscopic screening procedures than women Women will report lower perceived risk for CRC Women will report lower perceived risk for CRC

9. Hypotheses FACILITATORS TO SCREENING  Women will report stronger preferences for information prior to and during endoscopic procedures than men.

10. Methods Cross-sectional, mixed mode (mail and phone) survey Cross-sectional, mixed mode (mail and phone) survey Male and female veterans, ages of 50-75 (600 men, 300 women) Male and female veterans, ages of 50-75 (600 men, 300 women) Used the Minneapolis VAMC’s primary care services in the two years prior to the study Used the Minneapolis VAMC’s primary care services in the two years prior to the study Those with colorectal cancer (CRC), dementia or Alzheimer’s diagnoses excluded Those with colorectal cancer (CRC), dementia or Alzheimer’s diagnoses excluded

11. Measures Adherence:Self-report and VA medical records Preferences:Single-item question Barriers:Questions developed from qualitative work and Vernon’s perceived risk for CRC Facilitators:Questions developed from qualitative work

12. Results WomenMenp-value Age (mean) 59.262.4<0.01 Marital status (% married) 49.459.5 0.01 0.01 Income (% <$20,000) 34.141.2NS CRC family history (% yes) 24.920.6NS Overall response rate: 77% (n=686, 241/300 women; 445/600 men) Demographics:

13. Results-CRC adherence determined by self-report % Guideline Adherent (n=686) WomenMenp-value All modes 73.179.3.08.08 FOBT22.323.6.72.72 Flex sig 31.937.0.12.12 Barium enema 11.417.1.06.06 Colonoscopy42.452.4.02.02

14. Results-CRC adherence determined by medical record % Guideline Adherent (n=686) WomenMenp-value All modes 49.453.3 NS NS FOBT19.120.2 Flex sig 25.327.2 NS NS Barium enema 3.72.5 NS NS Colonoscopy18.320.2

15. Results Report to records ratio WomenMenp-value All modes 1.081.17 NS NS FOBT1.381.27 Flex sig 1.311.36 NS NS Barium enema 3.09.0 NS NS Colonoscopy1.241.53 <.05 <.05

16. ResultsResults-Preferences Mode preference % (n=686) WomenMen p<p<p<p< FOBT29.125.8 NS NS Barium Enema 2.62.7 NS NS Flex sig 8.58.2 NS NS Colonoscopy41.039.0 Don’t want to be tested* 5.12.5.05.05 Don’t know* 13.721.7.01

17. Results-Barriers Affective barriers (% who strongly agree or agree) WomenMen p<p<p<p< Worry about vulnerability 36.820.1.01 Worry about body exposed 35.113.5.01 Tests are embarrassing 35.113.0.01

18. Results-Barriers Anxiety about pain as a barrier (% who strongly agree or agree) WomenMen p<p<p<p< Worry tests will be painful 44.727.5.01 Want medicine for pain before test 56.652.6NS

19. Results-Barriers Perceived risk (% who strongly agree or agree) WomenMen p<p<p<p< Chance I might get CRC is high 15.224.7.01 Very likely I will get CRC 5.17.2.01 Chance of getting polyps high 15.918.7NS

20. Results-Facilitators Information needs (% who strongly agree or agree) WomenMen p<p<p<p< Before exam, want to learn what exam will be like 93.489.8NS During exam, want to know what is happening at every step 78.267.2.01 I don’t want any details 13.115.9.03

21. Conclusions  Self-reports of screening behavior shows a gender gap in screening; medical record data do not. Gender gap in screening may be due to the fact that men are more likely to over report having been screened.Gender gap in screening may be due to the fact that men are more likely to over report having been screened.  Men and women have similar screening mode preferences.  Differences in screening barriers/facilitators Women have more affective, anxiety-related barriers.Women have more affective, anxiety-related barriers. Men have a higher perceived risk for developing CRC.Men have a higher perceived risk for developing CRC. Women and men prefer different types of information before and during endoscopy exams.Women and men prefer different types of information before and during endoscopy exams.

22. Future Directions for Research and Policy Future research examining gender differences in CRC screening should use medical record data. Future research examining gender differences in CRC screening should use medical record data. Need to test if strength of association between barriers/facilitators that vary by gender affect screening adherence. If so: Need to test if strength of association between barriers/facilitators that vary by gender affect screening adherence. If so: –Campaigns to promote screening should include efforts to reduce beliefs that CRC is a male disease. –Issues of exposure, vulnerability and embarrassment prior to and during exam should be considered through patient education.

23. Thank you

24. Adherence-subsample with complete medical records % Guideline adherent based on self report (n=345) WomenMenp-value All modes 79.584.7.23.23 FOBT25.024.9.98.98 Flex sig 38.839.4.92.92 Barium enema 10.918.6.08.08 Colonoscopy45.260.4 <.01 <.01

25. Adherence-subsample with complete medical records % Guideline Adherent by medical record (n=345) WomenMenp-value All modes 71.172.8 NS NS FOBT18.821.7 Flex sig 32.031.8 NS NS Barium enema 4.72.8 NS NS Colonoscopy36.738.2