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This presentation holds the results of my Capstone Project research on colorectal cancer screening knowledge and behaviors.
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Colorectal Cancer: Patient Knowledge, Attitudes, and
Screening BehaviorsCapstone Project Presentation
by
Sharon D. Brantley, RN, BSN
in partial fulfillment of theRequirement for the Degree
MASTER OF SCIENCE IN NURSING
December 2, 2009
Colorectal Cancer (CRC) 2nd leading cause of all cancer deaths
(Bazensky, Shoobridge-Moran, & Yoder, 2007)
Ranks 3rd in prevalence of behind prostate and lung CA in men and breast and lung CA in females (Centers for Disease Control, 2007)
Affects men and women of all races equally (Bazensky et al., 2007)
Approximately 150,000 new cases each year (American Cancer Society, 2007)
Over 50,000 die from CRC each year (ACS, 2007)
CRC: The Problem
Represents significant public health risk
Early detection and polyp removal could reduce mortality by 50% (Smith, Cokkinides, & Eyre, 2004)
Only about 50% of Americans received recommended screening (National Cancer Institute, 2007)
Literature Review
Limited knowledge or low literacy is related to negative attitudes about CRC and CRC screening methods (Dolan et al., 2004)
› 377 male veterans in VA Medicine Clinic› Survey based on Health Belief Model (HBM)› Completed CRC questionnaire + REALM› Assessed ability to name or describe CRC
screening tests: Fecal Occult Blood Test (FOBT), flexible sigmoidoscopy (flex sig), or colonoscopy
› Felt FOBT was messy, inconvenient, and would not use FOBT kit if provided by MD
Literature Review
Clients with limited literacy were less likely to be knowledgeable about CRC (Miller, Brownlee, McCoy, & Pignone, 2007).
› Pilot study of 50 subjects at internal medicine clinic in teaching facility
› Survey of 26 questions about CRC screening and personal learning methods about health topics + REALM assessment
› Researchers explained screening tests and asked when subjects had last received: FOBT, flex sig, or colonoscopy
Need for this Study
Current low screening rates are believed to result from fear of cancer and fear of the tests associated with screening for CRC (Ueland, Hornung, & Greenwald, 2006)
One-on-one education session produced significant change in beliefs about CRC prevention and CRC screening (Ueland, Hornung, & Greenwald, 2006).
Theoretical Framework: Health Belief Model
Developed in the 1950’s by four psychologists: Hochbaum, Kegeles, Leventhal, and Rosenstock
US Public Health Service wanted to explain lack of participation in free disease prevention programs
Conceptual Definitions Education = the process of acquiring
knowledge through engagement in the interdependent activities of teaching and learning.
Knowledge = what is known about CRC and CRC screening methods.
Compliance = adherence to the advisement or health guidelines provided by a healthcare practitioner.
Hypotheses #1: The knowledge level of patients
participating in an educational session on colorectal cancer screening will change upon completion of the class.
#2: The colorectal cancer screening compliance behaviors in patients who participate in an educational session on colorectal cancer screening will change upon completion of the class.
Research Design
Descriptive, pretest-posttest design After consent was given, subjects
completed demographic form and pretest.
After class, posttest given and REALM assessment completed.
Sampling
Convenience sampling of clients at a large metropolitan hospital serving a disproportionately indigent population through use of flyers and investigator recruitment
Potential subjects were scheduled to attend a class on CRC and CRC screening methods
RAPID ESTIMATE OF ADULT LITERACY IN MEDICINE (REALM)©Terry Davis, PhD ∙ Michael Crouch, MD ∙ Sandy Long, PhD (1991)
Sample Tool:
List 1fatflupill
doseeye
stresssmearnervesgermsmeals
diseasecancercaffeineattackkidney
hormonesherpesseizurebowel
asthmarectal incest
List 2fatiguepelvic
jaundiceinfectionexercisebehavior
prescriptionnotify
gallbladdercalories
depressionmiscarriagepregnancy
arthritisnutrition
menopauseappendixabnormalsyphilis
hemorrhoidsnauseadirected
List 3allergic
menstrualtesticlecolitis
emergencymedicationoccupation
sexuallyalcoholism
irritationconstipationgonorrhea
inflammatorydiabeteshepatitis
antibioticsdiagnosispotassium
anemiaobesity
osteoporosisimpetigo
CRC Class Content
Colon cancer: incidence, risk factors, development, symptoms
CRC screening: FOBT, sigmoidoscopy, colonoscopy
Colonoscopy in detail DECISION to make appt Prep instructions Day of procedure: sequence of events
Assumptions
Subjects provide accurate self-reported information.
Subjects honestly report their beliefs and opinions and make a valid attempt to answer questions correctly.
Subjects retain knowledge over time.
Limitations
Small sample size (n=112) Localization of the sample Learning environment—room size,
technical difficulties Quasi-experiment design—no control
group Homogeneity of population
Data Collection
Data collected Tests graded and REALM assessments
scored Data coded and entered into SPSS file
for analysis
Sample by Age
< 452% 45-50
13%
51-5531%
56-6024%
61-6513%
66-707%
71-756%
75+3% No resp
2%Age< 4545-5051-5556-6061-6566-7071-7575+No resp
Sample by Ethnicity
5%
90%
1%1% 1% 2%
Caucasian African Amer HispanicAsian Other No resp
Sample by Gender & Marital Status
Male27%
Female73%
Gender
Never married
23%
Married10%
Separated13%
Divorced38%
Widowed16%
Marital Status
Sample by Educational Level
dropout31%
diploma or GED31%
attend college23%
bachelor'
s5%
attend grad6% grad deg
2%no resp
1%
gradecmp’d
no. %
3rd 1 2.9
7th 2 5.7
8th 3 8.6
9th 2 5.7
10th 11 31.4
11th 12 34.3
no resp
4 11.4
Total 35 100
Sample by Household Income
<15K 15K-19K
20K-29K
30K-39K
40K-49K
50K-59K
60K-69K
No resp
In-come
61 20 15 4 3 1 2 6
5152535455565
Income
Sample by Insurance Status
Uninsured46%
Medicare21%
Medicaid6%
M&M7%
Comm2%
No resp18%
M&M = Medicare & MedicaidComm = Commercial
Sample by REALM Score
3rd gr or less4%
4th - 6th gr17%
7th - 8th gr30%
9th gr or better49%
Data Analysis: DescriptivesN Min Max Mean Std
Dev
Age 110 41 83 57.63 7.939
Total Pretest Score
112 10 100 67.1429
20.98599
Total Posttest Score
112 20 100 73.5714
21.59651
Score Change
112 -30 60 6.4286 16.86497
Data Analysis: Findings
Mean N Std Dev Std Err Mean
Total Pretest Score 67.1429 112 20.98599 1.98299
Total Posttest Score
73.5714 112 21.59651 2.04068
t df Sig. (2-tailed)
Total Pre Score – Total Post Score
-4.034 111 .000
Paired t-Test
Data Analysis: Spearman ρ CorrelationsTotal Pre Total
PostREALM
Gender Corr CoeffSig N
.186*
.049112
.215*
.023112
.146
.124112
Educ Lev Corr CoeffSigN
.323**
.001111
.416**
.000111
.484**
.000111
Income Corr CoeffSigN
.097
.323106
.210*
.031106
.265**
.006106
Total Pre Corr CoeffSigN
.708**
.000112
.522**
.000112
Total Post Corr CoeffSigN
.708**
.000112
.551**
.000112
** Correlation significant at 0.01 level (2-tailed) * Correlation significant at 0.05 level (2-tailed)
Data Analysis: Spearman ρ Correlations
Income Current Health View
Income Corr CoeffSig N
.272**
.005106
# of annual MD visits
Corr CoeffSigN
.045
.649103
-.228*.018108
** Correlation significant at 0.01 level (2-tailed) * Correlation significant at 0.05 level (2-tailed)
FINDINGS: Hypotheses SUPPORTED – Significant change in
knowledge#1: The knowledge level of patients participating in an educational session on colorectal cancer screening will change upon completion of the class.
UNABLE TO ASSESS – Colonoscopy appointments were several months after class.#2: The colorectal cancer screening compliance behaviors in patients who participate in an educational session on colorectal cancer screening will change upon completion of the class.
Implications for Nursing
Knowledge regarding current CRC screening guidelines
Diverse and interactive teaching and learning methods
Establish cues to identify low literacy clients
Tailor educational activities and patient education materials to meet lower literacy levels
Recommendations for Future Study
Replication on a larger scale with diverse populations
Follow-through on actual subject compliance with screening
Longitudinal studies to examine long-range compliance and knowledge retention
Investigation of different teaching modalities and media
ACKNOWLEDGMENTS
Dr. Linda Streit—Capstone Project Advisor
Dr. Linda Kimble—Statistical Analysis Support
Greta Baldwin-Mason, RN, MSN—Data Coding
Dr. Henry Olejeme—Physician Sponsor Gertrude Dunlap, LPN—Research
Assistant