Primary Care Based Interventions to Increase Colorectal Cancer Screening

1. Primary Care Based Interventions to Increase Colorectal Cancer Screening Usha Menon, PhD, RN, FAAN Professor and Vice Dean College of Transforming Health NursingTransforming Lives

2. Co-Investigators • Rhonda Belue (Pennsylvania State U) • Anita Kinney (U of Utah) • Peter Maramaldi (Simmons College) • Kathryn Rugen (Jesse Brown VAMC) • Laura Szalacha (Ohio State University) • Stephanie Wahab (Portland State U) • Debra Wujick (Vanderbilt U) College of Transforming Health NursingTransforming Lives

3. Colorectal Cancer • 3rd largest cause of cancer death • Primary and secondary prevention • Polyps can take 7-12 years to turn cancerous • Screening shown to decrease morbidity and mortality • Screening rates remain low College of Transforming Health NursingTransforming Lives

4. Use of interactive, culturally-sensitive education to improve primary health practices • Race • Ethnicity • Culture • Language • Literacy • Health Literacy College of Transforming Health NursingTransforming Lives

5. Tailored vs. Targeted • Tailored versus targeted health education • Integrating culture into tailoring • Exemplars from colorectal cancer screening research College of Transforming Health NursingTransforming Lives

6. Targeted Health Education • Address variables with little within-group variance • Appropriate for newsletters, group education • Lower cost, less S/W programming • Easier to adapt for various groups College of Transforming Health NursingTransforming Lives

7. Tailored Health Education • When variables have increased variance within-group • Personalized to individual beliefs, knowledge, etc. • Combination of information or change strategies intended to reach one specific person, based on characteristics that are unique to that person, related to the outcome of interest, and derived from an individual assessment1 • 1 Kreuter MW, Farrell D, Olevitch L, & Brennan L. Tailoring Health Messages: • Customizing Communication with Computer Technology. Lawrence Erlbaum; 2000. College of Transforming Health NursingTransforming Lives

8. Tailored messages are more likely to be remembered and viewed as relevant • Health promotion messages may be tailored to beliefs, knowledge, stage of readiness, or any combination of these constructs1 1 Kreuter MW, Farrell D, Olevitch L, & Brennan L. Tailoring Health Messages: Customizing Communication with Computer Technology. Lawrence Erlbaum; 2000 College of Transforming Health NursingTransforming Lives

9. Strategies to target health education programs • Peripheral strategies – colors, images, graphics • Evidential strategies - enhance the perceived relevance of a health issue for a given group by presenting evidence of its impact on that group College of Transforming Health NursingTransforming Lives

10. Linguistic strategies – language, vernacular, idioms • Constituent-involving strategies – lay health workers, community members as staff • Sociocultural strategies - a group’s cultural values, beliefs, and behaviors are recognized, reinforced, and built upon to provide context and meaning to information and messages about a given health problem or behavior College of Transforming Health NursingTransforming Lives

11. Beware… • Race and ethnicity are frequently used as proxies for culture. • Important—even central—parts of a given culture but are not definitive of culture • For example, all African Americans do not share single monolithic culture • Cultural subgroups may exist, and any African American may belong to one, none, or several College of Transforming Health NursingTransforming Lives

12. Transdisciplinary research • Multi-lens approach • Integrate relevant components of various theoretical frameworks • Focus on factors that are changeable College of Transforming Health NursingTransforming Lives

13. What should I tailor on? • Demographics of sample • Language (translation; cultural language) • HEALTH LITERACY • Delivery medium (computer, mail, etc) • Who is delivering the message? (LHW, nurse, etc) College of Transforming Health NursingTransforming Lives

14. Remember your sample is not the entire population of interest • Beware of within group differences • Age • Gender • Race/ethnicity College of Transforming Health NursingTransforming Lives

15. Translation • Linguistic equivalence versus Content equivalence • Single person translation versus committee method College of Transforming Health NursingTransforming Lives

16. Linguistic equivalence versus Content equivalence* • The vodka was great but the steak was bad. • The spirit was willing but the flesh was weak. • Single person translation versus committee method • *used with permission of. Dr. Laura Szalacha College of Transforming Health NursingTransforming Lives

17. Examples of Tailored Messages • Knowledge • Answered: Most polyps are not cancer. • Yes, most growths or polyps are not cancer. Only a few people get are diagnosed with cancer. Make sure that you are safe by getting tested soon. Knowing you do not have cancer can give you peace of mind. College of Transforming Health NursingTransforming Lives

18. Perceived Risk: Female; • Answered: Not at risk because of older age • Many women do not think they are at NOT AT risk for colon cancer because they are now older. Colon cancer is mostlydiagnosedfound in women over 50. Because you are now 56 you are at risk of getting colon cancer. Getting tested regularly can save your life.

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23. Increasing CRC Screening in Primary Care Settings (R01NR8425) • Differences in CRC screening uptake among control, tailored education and motivational interviewing groups • Differential impact of tailoring and motivational interviewing interventions by race and gender College of Transforming Health NursingTransforming Lives

24. Primary care patients non-adherent with CRC screening, and with no history of cancer (n = 515) • Usual care (n=169), Tailored Counseling (n=168) or Motivational Interview (n = 178) • Trained interventionists delivered TC and MI over the telephone College of Transforming Health NursingTransforming Lives

25. Sample • 70% Male • 72% African American • 21% Working • 72% No partner • 58 (sd7.9) Mean age College of Transforming Health NursingTransforming Lives

26. Highest screening occurred in the TC group (23.8%, p>.02) • TC participants had 2.2 timesodds of completing post-intervention CRC screening than the control group (AOR = 2.2, CI = 1.2 - 4.0) • Those receiving MI or usual care did no significantly increase screening College of Transforming Health NursingTransforming Lives

27. Research funded by the National Institutes of Health (National Institute of Nursing Research (R01NR8425) and National Cancer Institute(CA10056) References • Wahab, S, Menon, U, & Szalacha, LA. (2008). Motivational Interviewing and Colorectal Cancer Screening: A Peek from the Inside Out. Patient Education & Counseling, 72(2):210-17. • Menon U, Belue R, Wahab S, Rugen K, Kinney AY, Maramaldi P, Wujcik D, Szalacha LA. (2011). A randomized trial comparing the effect of two phone-based interventions on colorectal cancer screening adherence. Annals Behavioral Medicine, 42(3):294-303. • BeLue R, Menon U, Kinney AY, Szalacha LA. (2011). Psychosocial risk profiles among black male Veterans Administration patients non-adherent with colorectal cancer screening. Psychooncology., 20(11):1151-60. • Kreuter MW, Farrell D, Olevitch L, & Brennan L. Tailoring Health Messages: Customizing Communication with Computer Technology. Lawrence Erlbaum; 2000. College of Transforming Health NursingTransforming Lives

28. Please do not use materials from this presentation without expressed permission of the first author. Thank you. College of Transforming Health NursingTransforming Lives