Dorilyn Francisco, MSN, RN Larry Rankin, PhD, RN Son Chae Kim, PhD, RN
Adherence to Colorectal Cancer and Polyps Screening Recommendations Among Filipino-Americans ABSTRACT This cross-sectional study explored the perceptions and behaviors toward colorectal cancer screening and the predictors of adherence to colorectal cancer and polyps screening recommendations among Filipino-Americans. A total of 188 participants were recruited from community churches in southern California from September to November 2011. About half of the participants were found to be adherent to the screening recommendations. Multivariate logistic regression analysis revealed the following significant predictors of adherence: having a relative with colon or rectal cancer (odds ratio [OR] = 6.17), having heard of fecal occult blood test (OR = 4.58), strong agreement with benefit of screening in reducing worry about cancer (OR = 2.81), age ≥ 65 years (OR = 2.64) and very easy communication with providers (OR = 2.43). Patient awareness of colorectal cancer screening and its benefits through effective patient–provider communication were significant modifiable predictors of adherence to colorectal cancer and polyps screening recommendations. Nurses could have a major impact in improving screening behaviors through patient education in increasing patient awareness and benefits of cancer screening.
Introduction Colorectal cancer (CRC) is the third leading cause of cancer death, accounting for 9% of all cancer deaths in the United States with an estimated 143,460 new cases and 51,690 deaths in 2012 (American Cancer Society [ACS], 2012a). Colorectal cancer is preventable if discovered in the premalignant adenomatous polyp stage (Zauber et al., 2012). It is also curable if discovered at an early localized stage, but a majority of patients have Received January 4, 2013; accepted June 25, 2013. About the authors: Dorilyn Francisco, MSN, RN, is Staff Nurse, Scripps Green Hospital, La Jolla, California. Larry Rankin, PhD, RN, is Professor, School of Nursing, Point Loma Nazarene University, San Diego, California. Son Chae Kim, PhD, RN, is Professor, St. David’s School of Nursing, Texas State University, Round Rock. This study was performed as a part of the Master’s of Science in Nursing degree requirements at School of Nursing, Point Loma Nazarene University, San Diego, California. The authors declare no conflict of interest. Correspondence to: Son Chae Kim, PhD, RN, St. David’s School of Nursing, Texas State University, 1555 University Blvd., Round Rock, TX 78665 ([email protected]). DOI: 10.1097/SGA.0000000000000071
regional spread or distant metastasis at the time of initial diagnosis (ACS, 2012a). Because of the increased early detection of CRC or removal of adenomatous polyps through flexible sigmoidoscopy or colonoscopy, the mortality rate of CRC has been declining (ACS, 2012a; Zauber et al., 2012). The Joint Guidelines from the ACS, the US MultiSociety Task Force on Colorectal Cancer, and the American College of Radiology recommend either flexible sigmoidoscopy every 5 years or colonoscopy every 10 years for asymptomatic adults aged 50 years or older for early detection of CRC and adenomatous polyps (Levin et al., 2008). Additional options for early detection of CRC and adenomatous polyps are double-contrast barium enema every 5 years or computed tomographic colonography every 5 years (Levin et al., 2008). Annual fecal occult blood test (FOBT) is an option for early detection of CRC, but the rate of annual FOBT has been declining from 17% in 2000 to 8.8% in 2010 and adenomatous polyps are not detectable by this screening procedure (ACS, 2012b). Among Asian Americans, the rate of adherence to the recommended sigmoidoscopy or colonoscopy is much lower (44.5%) than that for the non-Hispanic Whites (58.5%) (ACS, 2012b). Some of the common barriers to
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CRC screening behaviors are lack of symptoms, difficulties involved with the bowel cleaning, fear and embarrassment associated with the procedure, fear of the consequences, inadequate social support, low socioeconomic status, lack of health insurance, lack of encouragements from the healthcare provider, and being an ethnic minority (Ferrer, Ramirez, Beckman, Danao, & Ashing-Giwa, 2011; Friedemann-Sanchez, Griffin, & Partin, 2007; Goel et al., 2004; Lasser, Ayanian, Fletcher, & Good, 2008; Zheng, 2006). In a randomized controlled trial of 548 FilipinoAmericans, multifaceted interventions, including distribution of free FOBT kits and education, improved the 6-month CRC screening rate from 9% to 30%, most of which were done as FOBT (Maxwell et al., 2010). The rate of sigmoidoscopy or colonoscopy was improved from 3% to 8%. Similar results were obtained in another randomized trial that compared mailed FOBT kit along with CRC fact sheet versus the usual care in a racially diverse population (Jean-Jacques et al., 2012). The first group had 30% rate of cancer screening versus 5% for the usual care. However, there was no difference in the rate of sigmoidoscopy or colonoscopy in spite including the information regarding precancerous polyps, screening with FOBT, sigmoidoscopy, and colonoscopy in the mailing. In contrast, a 3-arm randomized trial of recommendation for FOBT versus colonoscopy versus choice of FOBT/colonoscopy showed that overall completion rate of screening was only 38% for colonoscopy only group, whereas FOBT or choice of FOBT/colonoscopy had screening rate of 67% and 69%, respectively (Inadomi et al., 2012). Interestingly, among the subjects randomized to either the colonoscopy or choice of FOBT/colonoscopy arms, the colonoscopy rate for the Asians was lower (33%) than that for the non-Hispanic Whites (47%–52%). Among Filipino immigrants, the income and levels of acculturation may determine what screening modality is utilized (Maxwell et al., 2008). Filipino-Americans with extensive acculturation experience are more able to make use of the screening services that place significance on maintaining good health (Periyakoil & Dela Cruz, 2010). Many Filipino-Americans still turn first to traditional remedies before going to the physician or clinic for help. They do not consider such care as part of mainstream healthcare practices, but rather as part of tradition and as a contributor to their well-being (Asian and Pacific Islander American Health Forum, 2003; The Historic Filipinotown Health Network, 2007). To reduce the mortality rate from CRC, adherence to screening for CRC and polyps needs to be improved, especially among ethnic minorities (Doubeni et al., 2010; McCracken et al., 2007). The purpose of this study was to explore the perceptions and behaviors
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toward CRC screening and to determine the predictors of adherence to CRC and polyps screening recommendations among Filipino-Americans.
Methods Design and Sample Filipino-Americans attending three community churches in southern California were recruited for this crosssectional study from September to November 2011. The eligibility criteria for study participants were (a) Filipino in ethnicity, (b) age of 50 years or older, and (c) fluent in either English or Tagalog.
Questionnaire The study questionnaire included demographics, 19 items from the Cultural and Health Among Filipinos and Filipino-Americans in Central Los Angeles survey covering traditional health beliefs and practice, religion and spirituality, language use, communication with healthcare providers (The Historic Filipinotown Health Network, 2007), six items assessing family history of CRC and fecal occult test (Vernon et al., 2004), four items from Behavioral Risk Factor Surveillance System survey questionnaire assessing perception of general health and sigmoidoscopy and colonoscopy (Centers for Disease Control and Prevention, 2011). In addition, five-item Rawl’s Perceived Benefits Scale (Rawl et al., 2005) was used to measure the perceived benefits of FOBT, flexible sigmoidoscopy, and colonoscopy on a 5-point Likert Scale, ranging from strongly disagree (1) to strongly agree (5). The questions measured the degree of agreement on whether the screening procedures help finding the cancer, reducing the chances of dying from the cancer, saving life, not worrying about the cancer and easier treatment if the cancer is found early. Cronbach’s alpha values for reliability were .65, .67, and .70 for FOBT, flexible sigmoidoscopy, and colonoscopy, respectively. A Tagalog version of the questionnaire was also developed using back-translation to ensure the validity of each question item.
Ethical Considerations This study was reviewed and approved by the university institutional review board. The community church congregations were invited to participate in the study. Because this study has minimal risks for participants, waiver of consent was granted with completion of study questionnaire as implied consent to the study. Those who agreed to participate completed the study questionnaire and were informed that all responses would be aggregated and numerically coded to provide anonymity of individual responses.
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Data Analysis
TABLE 1. Demographic (N = 188)
The data were analyzed using SPSS Version 20.0 (Statistical Package for the Social Sciences, Chicago, IL). Descriptive statistics of frequencies and percentages were used to summarize the characteristics, health beliefs and practice, and perceived benefits of CRC screening behaviors among participants. The adherence to screening recommendations, that is, sigmoidoscopy within past 5 years or colonoscopy within past 10 years for participants aged 50 years or older or family history, was the dependent variable and was recoded as a dichotomous variable (1 = yes; 0 = no). To determine the demographic and other factors that predict adherence to screening recommendations, bivariate correlation and multivariate logistic regression procedures were employed. The demographic and other variables were recoded as dichotomous variables (e.g., 1 = strongly agree; 0 = agree, neutral, disagree, or strongly disagree) as needed to allow odds ratio (OR) calculations. Kendall’s tau bivariate correlation was used to assess the relationships among the dichotomous independent variables and the dichotomous dependent variable. The statistically significant variables were then entered into a multivariate logistic regression model with backwards elimination. The level of significance was set p < .05 for all data analyses.
n (%) Age, mean (range), years Age ≥ 65 years
Twenty-one participants (11.2%) reported fair health status and 18 participants (9.6%) had a relative with colon or rectal cancer (Table 3). About half of the
86 (45.7)
Male
75 (39.9)
Female
113 (60.1)
Education Less than high school
20 (10.6)
High school
30 (16.0)
Some college
42 (22.3)
College/graduate
96 (51.1)
Married
129 (68.6)
Country of birth U.S.-born Philippines-born
3 (1.6) 183 (98.4)
Living in the United States (years) 10
159 (84.6)
Employment
Sample Characteristics, Health Beliefs, and Practice
CRC and Polyps Screening Behaviors and Perceived Benefits
64 (49–94)
Gender
Results
A majority of the 188 participants were women, college graduates, married, and employed (Table 1). Most of them were born in the Philippines, had lived in the United States for more than 10 years, and were of Catholic faith. A majority stated their beliefs as being “deeply religious,” attending religious services on weekly basis (Table 2). Most of the participants believed that there is a God who will take care of their health and provides care or healing through healthcare providers. Most have visited a healthcare provider more than once in the past year and reported having very easy communication. A majority had talked about preventing illness with doctors all the time and followed through with their instructions all the time. However, most of them still believed in traditional Filipino preventive practice and about 40% used alternative remedies for health problems.
Characteristics
95 (50.5)
Religion Catholicism
163 (86.7)
Protestantism
6 (3.2)
Islam
1 (0.5)
Others
18 (9.6)
Note. Percentage may not add up to 100% because of the missing data or rounding.
participants had heard of an FOBT (54.8%) and a third had an FOBT using a home test kit (34.6%). The rate of adherence to the recommendation of a sigmoidoscopy within the past 5 years or a colonoscopy within the past 10 years was 49.5%. A majority of the participants strongly agreed with the perceived benefits of CRC screening questions (Figure 1).
Predictors of Adherence to CRC and Polyps Screening Recommendations Kendall’s tau bivariate correlation analyses identified a large number of independent variables that correlated
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TABLE 2. Health Beliefs and Practices n (%)
TABLE 3. Colorectal Cancer (CRC) Screening Behaviors (N = 188) n (%)
Deeply religious
105 (55.9)
Weekly religious service attendance
161 (85.6)
Belief in God taking care of health
183 (97.3)
Belief in God working through healthcare providers
177 (94.1)
Praying for healing is important
131 (69.7)
Used alternative remedies for health problems
73 (38.8)
Have a relative who had colon or rectal cancer
Traditional Filipino preventive practice
95 (50.5)
Have heard of a FOBT
103 (54.8)
Have done a FOBT using a home test kit
65 (34.6)
Have had FS
21 (11.2)
Frequency of healthcare visit in the past year 0 times
7 (3.7)
≥1
181 (96.3)
Preference in speaking with healthcare providers English
87 (46.3)
Tagalog
23 (12.2)
Both
74 (39.4)
Very easy communication with healthcare providers
122 (64.9)
Talked about preventing illness with doctor all the time
122 (64.9)
Trust in doctor completely
137 (72.9)
Willing to follow doctor’s advice for medicine
148 (78.7)
Follow through with doctor’s instruction all the time
131 (69.7)
with adherence to the CRC and polyps screening recommendations: age 65 years or greater, living in the United States for more than 10 years, employment, Catholicism, having a relative with CRC, preference for English, very easy communication with healthcare providers, doctor talking about prevention all the time, strong willingness to follow doctor’s advice, having heard of FOBT, having done FOBT using a home-test kit, and strongly agreeing with several benefits of colorectal screening (Table 4). All these independent variables that correlated with adherence to the CRC and polyps screening recommendations were entered into a multivariate logistic regression model. Five variables emerged as significant predictors of adherence to the screening recommendations: having a relative with colon or rectal cancer (OR = 6.17; p = .011), having heard of FOBT (OR = 4.58; p < .001), strong agreement with benefit of VOLUME 37 | NUMBER 6 | NOVEMBER/DECEMBER 2014
General health status Excellent
15 (8.0)
Very good
72 (38.3)
Good
80 (42.6)
Fair
21 (11.2) 18 (9.6)
Have had CS
76 (40.4)
Adherence to the CRC and polyps screening recommendationsa
93 (49.5)
Note. CS = colonoscopy; FOBT = fecal occult blood test; FS = flexible sigmoidoscopy. Boldface indicates dependent variable for multivariate analysis. a Sigmoidoscopy within past 5 years or colonoscopy within past 10 years for age ≥50 years or family history.
screening procedures reducing worry about CRC (OR = 2.81; p = .005), age 65 years or greater (OR = 2.64; p = .008), and very easy communication with healthcare providers (OR = 2.43; p = .018) (Table 5).
Discussion In this study, a large number of variables were found to correlate with the adherence to CRC and polyps screening recommendations in bivariate correlation analyses. However, multivariate logistic regression model showed that only five variables were significant
A FOBT, FS, CS will help you not worry as much as about CRC
59.6%
A FOBT, FS, CS will decrease your chance of dying from CRC
58.0%
A FOBT, FS, CS will help CRC early
69.7%
Treatment for CRC may not be as bad if the cancer is found early
67.0%
Finding CRC early will save your life
81.4%
0%
20% 40% 60% 80% 100%
FIGURE 1. Perceived benefits of colorectal cancer (CRC) screening (%, strongly agree). Note. CS = colonoscopy; FOBT = fecal occult blood test; FS = flexible sigmoidoscopy. 387
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TABLE 4. Significant Correlations Between Adherence to the Colorectal Cancer (CRC) and Polyps Screening Recommendations and Independent Variables
TABLE 5. Multivariate Logistic Regression Model Predicting Adherence to the Colorectal Cancer (CRC) and Polyps Screening Recommendations
Adherence to CRC and Polyps Screening Recommendations
OR
95% CI
p
Have a relative who had colon or rectal cancer
6.17
1.52, 25.09 .011
Age ≥65 years
0.202a
Have heard of FOBT
4.58
2.24, 9.34
10 years
0.206b
An FOBT, FS, and CS will help you not worry as much as about CRC
2.81
1.37, 5.77
.005
Age ≥65 years
2.64
1.29, 5.40
.008
Very easy communication with healthcare providers
2.43
1.17, 5.08
.018
Employment
−0.170a
Catholicism
0.199b
Preference for English in speaking with healthcare providers
0.149a
Very easy communication with healthcare providers
0.260c
Talked about preventing illness with doctor all the time
0.148a
Willing to follow doctor’s advice for medicine
0.150a
Have a relative who had colon or rectal cancer
0.220b
Have heard of an FOBT
0.322c
Have done an FOBT using a home test kit
0.310b
Treatment for CRC may not be as bad if the cancer is found early
0.241b
An FOBT, FS, and CS will help you not worry as much as about CRC
0.295c
An FOBT, FS, and CS will decrease your chance of dying from CRC
0.282c
An FOBT, FS, and CS will help find CRC early
0.282c
Note. Adherence to CRC and polyps screening recommendations, flexible sigmoidoscopy within past 5 years or CS within past 10 years. CS = colonoscopy; FOBT = fecal occult blood test; FS = flexible sigmoidoscopy. a p < .05. b p < .01. c p < .001 by Kendall’s tau test.
predictors of adherence: having a relative with colon or rectal cancer, having heard of FOBT, strongly agreeing that screening procedures would reduce worry about CRC, age 65 years or older, and very easy communication with healthcare providers. It is interesting that those variables unique to the immigrant populations, such as living in the United States more
Note. CI = confidence interval; CS = colonoscopy; FOBT = fecal occult blood test; FS = flexible sigmoidoscopy; OR = odds ratio.
than 10 years, and preference for English in speaking with healthcare providers, were not significant predictors of adherence, which is consistent with previous studies (Ferrer et al., 2011; Koo et al., 2012). Among the five predictors of adherence, OR was the highest for participants who had a relative with colon or rectal cancer with greater than sixfold higher odds of adherence to screening recommendation compared with those without a relative with colon or rectal cancer. This is consistent with a previous study finding that showed an 11-fold higher odds of willingness to undergo colonoscopy screening for those who had a first-degree relative with CRC compared with those without (Delgado-Plasencia, Lopez-TomassettiFernandez, Hernandez-Morales, Torres-Monzon, & Gonzalez-Hermoso, 2009). Although having a relative with CRC or age of 65 years or older is not modifiable, three of the five predictors are potentially modifiable: that is, having heard of FOBT, strongly agreeing that screening procedures would reduce worry about CRC, and having a very easy communication with healthcare providers. These three predictors are likely associated with effective patient–provider communications and interactions where the benefits of CRC screening are discussed. A similar study finding on the patient– provider communications was also reported in a previous study that showed a fivefold higher OR of colonoscopy for those who received physicians’ recommendations for screening (Taouqi, Ingrand, Beauchant, Migeot, & Ingrand, 2010). The findings of the current study are consistent with the results from a randomized controlled trial of educational interventions with distribution of free FOBT kit among Filipino-Americans where the 6-month rate of sigmoidoscopy or
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colonoscopy was improved with 8% in the intervention group compared with the 3% in the control group (Maxwell et al., 2010). In this study, only 49.5% of the participants were adhering to the CRC and polyps screening recommendations, which is very similar to the 44.5% rate reported among Asians in 2010 (ACS, 2012b). Furthermore, slightly more than half of the participants in the current study had heard about FOBT (54.8%), perceived benefit of reduced worry through CRC screening (59.6%), and had ease of communication with healthcare providers (64.9%). Thus, there is still much room for improvements in the adherence to screening recommendations, perhaps by improving the modifiable predictors. These are the areas where nurses could play a major role through patient education to increase patient awareness about CRC screening and reinforcing the screening recommendations. In addition, nurses can help institute a checklist or reminder procedures for CRC screening to identify nonadherent patients for targeting of interventional efforts (Atassi, 2012; Greenwald, 2011).
Limitations There were several limitations of this study. The relationship between predictors and adherence to the screening recommendations should not be taken as cause-and-effect relationships because this study was a cross-sectional study. The self-reported responses to the questionnaire may have overestimated the true adherence to the CRC and polyps screening recommendations. Because the participants were all FilipinoAmericans attending community churches, the study findings may not be generalizable to the population at large. Finally, the adherence to the annual FOBT recommendation was not assessed in this study. Although FOBT is noninvasive and easy to perform, FOBT alone cannot detect adenomatous polyps. For the future, innovative and cost-effective strategies are needed to achieve high rates of adherence to the screening recommendations for early detection of CRC and adenomatous polyps to reduce mortality rate from CRC, including the use of nurse endoscopists to increase availability of screening sigmoidoscopy and colonoscopy (LimogesGonzalez et al., 2011; van Putten et al., 2012).
Conclusions Patient awareness of CRC screening and its benefits through effective patient–provider communication were significant modifiable predictors of adherence to the CRC and polyps screening recommendations among Filipino-Americans. To improve cancerscreening behaviors, nurses could have a major impact through effective patient education in increasing patient awareness and benefits of cancer screening. VOLUME 37 | NUMBER 6 | NOVEMBER/DECEMBER 2014
Innovative and cost-effective strategies are needed to achieve high rates of adherence to screening recommendations. This study was performed as a part of the Master of Science in Nursing degree requirements at School of Nursing, Point Loma Nazarene University, San Diego, CA. ✪
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Adherence to Colorectal Cancer and Polyps Screening Recommendations Among Filipino-Americans ABSTRACT This cross-sectional study explored the perceptions and behaviors toward colorectal cancer screening and the predictors of adherence to colorectal cancer and polyps screening recommendations among Filipino-Americans. A total of 188 participants were recruited from community churches in southern California from September to November 2011. About half of the participants were found to be adherent to the screening recommendations. Multivariate logistic regression analysis revealed the following significant predictors of adherence: having a relative with colon or rectal cancer (odds ratio [OR] = 6.17), having heard of fecal occult blood test (OR = 4.58), strong agreement with benefit of screening in reducing worry about cancer (OR = 2.81), age ≥ 65 years (OR = 2.64) and very easy communication with providers (OR = 2.43). Patient awareness of colorectal cancer screening and its benefits through effective patient–provider communication were significant modifiable predictors of adherence to colorectal cancer and polyps screening recommendations. Nurses could have a major impact in improving screening behaviors through patient education in increasing patient awareness and benefits of cancer screening.
Introduction Colorectal cancer (CRC) is the third leading cause of cancer death, accounting for 9% of all cancer deaths in the United States with an estimated 143,460 new cases and 51,690 deaths in 2012 (American Cancer Society [ACS], 2012a). Colorectal cancer is preventable if discovered in the premalignant adenomatous polyp stage (Zauber et al., 2012). It is also curable if discovered at an early localized stage, but a majority of patients have Received January 4, 2013; accepted June 25, 2013. About the authors: Dorilyn Francisco, MSN, RN, is Staff Nurse, Scripps Green Hospital, La Jolla, California. Larry Rankin, PhD, RN, is Professor, School of Nursing, Point Loma Nazarene University, San Diego, California. Son Chae Kim, PhD, RN, is Professor, St. David’s School of Nursing, Texas State University, Round Rock. This study was performed as a part of the Master’s of Science in Nursing degree requirements at School of Nursing, Point Loma Nazarene University, San Diego, California. The authors declare no conflict of interest. Correspondence to: Son Chae Kim, PhD, RN, St. David’s School of Nursing, Texas State University, 1555 University Blvd., Round Rock, TX 78665 ([email protected]). DOI: 10.1097/SGA.0000000000000071
regional spread or distant metastasis at the time of initial diagnosis (ACS, 2012a). Because of the increased early detection of CRC or removal of adenomatous polyps through flexible sigmoidoscopy or colonoscopy, the mortality rate of CRC has been declining (ACS, 2012a; Zauber et al., 2012). The Joint Guidelines from the ACS, the US MultiSociety Task Force on Colorectal Cancer, and the American College of Radiology recommend either flexible sigmoidoscopy every 5 years or colonoscopy every 10 years for asymptomatic adults aged 50 years or older for early detection of CRC and adenomatous polyps (Levin et al., 2008). Additional options for early detection of CRC and adenomatous polyps are double-contrast barium enema every 5 years or computed tomographic colonography every 5 years (Levin et al., 2008). Annual fecal occult blood test (FOBT) is an option for early detection of CRC, but the rate of annual FOBT has been declining from 17% in 2000 to 8.8% in 2010 and adenomatous polyps are not detectable by this screening procedure (ACS, 2012b). Among Asian Americans, the rate of adherence to the recommended sigmoidoscopy or colonoscopy is much lower (44.5%) than that for the non-Hispanic Whites (58.5%) (ACS, 2012b). Some of the common barriers to
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CRC screening behaviors are lack of symptoms, difficulties involved with the bowel cleaning, fear and embarrassment associated with the procedure, fear of the consequences, inadequate social support, low socioeconomic status, lack of health insurance, lack of encouragements from the healthcare provider, and being an ethnic minority (Ferrer, Ramirez, Beckman, Danao, & Ashing-Giwa, 2011; Friedemann-Sanchez, Griffin, & Partin, 2007; Goel et al., 2004; Lasser, Ayanian, Fletcher, & Good, 2008; Zheng, 2006). In a randomized controlled trial of 548 FilipinoAmericans, multifaceted interventions, including distribution of free FOBT kits and education, improved the 6-month CRC screening rate from 9% to 30%, most of which were done as FOBT (Maxwell et al., 2010). The rate of sigmoidoscopy or colonoscopy was improved from 3% to 8%. Similar results were obtained in another randomized trial that compared mailed FOBT kit along with CRC fact sheet versus the usual care in a racially diverse population (Jean-Jacques et al., 2012). The first group had 30% rate of cancer screening versus 5% for the usual care. However, there was no difference in the rate of sigmoidoscopy or colonoscopy in spite including the information regarding precancerous polyps, screening with FOBT, sigmoidoscopy, and colonoscopy in the mailing. In contrast, a 3-arm randomized trial of recommendation for FOBT versus colonoscopy versus choice of FOBT/colonoscopy showed that overall completion rate of screening was only 38% for colonoscopy only group, whereas FOBT or choice of FOBT/colonoscopy had screening rate of 67% and 69%, respectively (Inadomi et al., 2012). Interestingly, among the subjects randomized to either the colonoscopy or choice of FOBT/colonoscopy arms, the colonoscopy rate for the Asians was lower (33%) than that for the non-Hispanic Whites (47%–52%). Among Filipino immigrants, the income and levels of acculturation may determine what screening modality is utilized (Maxwell et al., 2008). Filipino-Americans with extensive acculturation experience are more able to make use of the screening services that place significance on maintaining good health (Periyakoil & Dela Cruz, 2010). Many Filipino-Americans still turn first to traditional remedies before going to the physician or clinic for help. They do not consider such care as part of mainstream healthcare practices, but rather as part of tradition and as a contributor to their well-being (Asian and Pacific Islander American Health Forum, 2003; The Historic Filipinotown Health Network, 2007). To reduce the mortality rate from CRC, adherence to screening for CRC and polyps needs to be improved, especially among ethnic minorities (Doubeni et al., 2010; McCracken et al., 2007). The purpose of this study was to explore the perceptions and behaviors
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toward CRC screening and to determine the predictors of adherence to CRC and polyps screening recommendations among Filipino-Americans.
Methods Design and Sample Filipino-Americans attending three community churches in southern California were recruited for this crosssectional study from September to November 2011. The eligibility criteria for study participants were (a) Filipino in ethnicity, (b) age of 50 years or older, and (c) fluent in either English or Tagalog.
Questionnaire The study questionnaire included demographics, 19 items from the Cultural and Health Among Filipinos and Filipino-Americans in Central Los Angeles survey covering traditional health beliefs and practice, religion and spirituality, language use, communication with healthcare providers (The Historic Filipinotown Health Network, 2007), six items assessing family history of CRC and fecal occult test (Vernon et al., 2004), four items from Behavioral Risk Factor Surveillance System survey questionnaire assessing perception of general health and sigmoidoscopy and colonoscopy (Centers for Disease Control and Prevention, 2011). In addition, five-item Rawl’s Perceived Benefits Scale (Rawl et al., 2005) was used to measure the perceived benefits of FOBT, flexible sigmoidoscopy, and colonoscopy on a 5-point Likert Scale, ranging from strongly disagree (1) to strongly agree (5). The questions measured the degree of agreement on whether the screening procedures help finding the cancer, reducing the chances of dying from the cancer, saving life, not worrying about the cancer and easier treatment if the cancer is found early. Cronbach’s alpha values for reliability were .65, .67, and .70 for FOBT, flexible sigmoidoscopy, and colonoscopy, respectively. A Tagalog version of the questionnaire was also developed using back-translation to ensure the validity of each question item.
Ethical Considerations This study was reviewed and approved by the university institutional review board. The community church congregations were invited to participate in the study. Because this study has minimal risks for participants, waiver of consent was granted with completion of study questionnaire as implied consent to the study. Those who agreed to participate completed the study questionnaire and were informed that all responses would be aggregated and numerically coded to provide anonymity of individual responses.
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Data Analysis
TABLE 1. Demographic (N = 188)
The data were analyzed using SPSS Version 20.0 (Statistical Package for the Social Sciences, Chicago, IL). Descriptive statistics of frequencies and percentages were used to summarize the characteristics, health beliefs and practice, and perceived benefits of CRC screening behaviors among participants. The adherence to screening recommendations, that is, sigmoidoscopy within past 5 years or colonoscopy within past 10 years for participants aged 50 years or older or family history, was the dependent variable and was recoded as a dichotomous variable (1 = yes; 0 = no). To determine the demographic and other factors that predict adherence to screening recommendations, bivariate correlation and multivariate logistic regression procedures were employed. The demographic and other variables were recoded as dichotomous variables (e.g., 1 = strongly agree; 0 = agree, neutral, disagree, or strongly disagree) as needed to allow odds ratio (OR) calculations. Kendall’s tau bivariate correlation was used to assess the relationships among the dichotomous independent variables and the dichotomous dependent variable. The statistically significant variables were then entered into a multivariate logistic regression model with backwards elimination. The level of significance was set p < .05 for all data analyses.
n (%) Age, mean (range), years Age ≥ 65 years
Twenty-one participants (11.2%) reported fair health status and 18 participants (9.6%) had a relative with colon or rectal cancer (Table 3). About half of the
86 (45.7)
Male
75 (39.9)
Female
113 (60.1)
Education Less than high school
20 (10.6)
High school
30 (16.0)
Some college
42 (22.3)
College/graduate
96 (51.1)
Married
129 (68.6)
Country of birth U.S.-born Philippines-born
3 (1.6) 183 (98.4)
Living in the United States (years) 10
159 (84.6)
Employment
Sample Characteristics, Health Beliefs, and Practice
CRC and Polyps Screening Behaviors and Perceived Benefits
64 (49–94)
Gender
Results
A majority of the 188 participants were women, college graduates, married, and employed (Table 1). Most of them were born in the Philippines, had lived in the United States for more than 10 years, and were of Catholic faith. A majority stated their beliefs as being “deeply religious,” attending religious services on weekly basis (Table 2). Most of the participants believed that there is a God who will take care of their health and provides care or healing through healthcare providers. Most have visited a healthcare provider more than once in the past year and reported having very easy communication. A majority had talked about preventing illness with doctors all the time and followed through with their instructions all the time. However, most of them still believed in traditional Filipino preventive practice and about 40% used alternative remedies for health problems.
Characteristics
95 (50.5)
Religion Catholicism
163 (86.7)
Protestantism
6 (3.2)
Islam
1 (0.5)
Others
18 (9.6)
Note. Percentage may not add up to 100% because of the missing data or rounding.
participants had heard of an FOBT (54.8%) and a third had an FOBT using a home test kit (34.6%). The rate of adherence to the recommendation of a sigmoidoscopy within the past 5 years or a colonoscopy within the past 10 years was 49.5%. A majority of the participants strongly agreed with the perceived benefits of CRC screening questions (Figure 1).
Predictors of Adherence to CRC and Polyps Screening Recommendations Kendall’s tau bivariate correlation analyses identified a large number of independent variables that correlated
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TABLE 2. Health Beliefs and Practices n (%)
TABLE 3. Colorectal Cancer (CRC) Screening Behaviors (N = 188) n (%)
Deeply religious
105 (55.9)
Weekly religious service attendance
161 (85.6)
Belief in God taking care of health
183 (97.3)
Belief in God working through healthcare providers
177 (94.1)
Praying for healing is important
131 (69.7)
Used alternative remedies for health problems
73 (38.8)
Have a relative who had colon or rectal cancer
Traditional Filipino preventive practice
95 (50.5)
Have heard of a FOBT
103 (54.8)
Have done a FOBT using a home test kit
65 (34.6)
Have had FS
21 (11.2)
Frequency of healthcare visit in the past year 0 times
7 (3.7)
≥1
181 (96.3)
Preference in speaking with healthcare providers English
87 (46.3)
Tagalog
23 (12.2)
Both
74 (39.4)
Very easy communication with healthcare providers
122 (64.9)
Talked about preventing illness with doctor all the time
122 (64.9)
Trust in doctor completely
137 (72.9)
Willing to follow doctor’s advice for medicine
148 (78.7)
Follow through with doctor’s instruction all the time
131 (69.7)
with adherence to the CRC and polyps screening recommendations: age 65 years or greater, living in the United States for more than 10 years, employment, Catholicism, having a relative with CRC, preference for English, very easy communication with healthcare providers, doctor talking about prevention all the time, strong willingness to follow doctor’s advice, having heard of FOBT, having done FOBT using a home-test kit, and strongly agreeing with several benefits of colorectal screening (Table 4). All these independent variables that correlated with adherence to the CRC and polyps screening recommendations were entered into a multivariate logistic regression model. Five variables emerged as significant predictors of adherence to the screening recommendations: having a relative with colon or rectal cancer (OR = 6.17; p = .011), having heard of FOBT (OR = 4.58; p < .001), strong agreement with benefit of VOLUME 37 | NUMBER 6 | NOVEMBER/DECEMBER 2014
General health status Excellent
15 (8.0)
Very good
72 (38.3)
Good
80 (42.6)
Fair
21 (11.2) 18 (9.6)
Have had CS
76 (40.4)
Adherence to the CRC and polyps screening recommendationsa
93 (49.5)
Note. CS = colonoscopy; FOBT = fecal occult blood test; FS = flexible sigmoidoscopy. Boldface indicates dependent variable for multivariate analysis. a Sigmoidoscopy within past 5 years or colonoscopy within past 10 years for age ≥50 years or family history.
screening procedures reducing worry about CRC (OR = 2.81; p = .005), age 65 years or greater (OR = 2.64; p = .008), and very easy communication with healthcare providers (OR = 2.43; p = .018) (Table 5).
Discussion In this study, a large number of variables were found to correlate with the adherence to CRC and polyps screening recommendations in bivariate correlation analyses. However, multivariate logistic regression model showed that only five variables were significant
A FOBT, FS, CS will help you not worry as much as about CRC
59.6%
A FOBT, FS, CS will decrease your chance of dying from CRC
58.0%
A FOBT, FS, CS will help CRC early
69.7%
Treatment for CRC may not be as bad if the cancer is found early
67.0%
Finding CRC early will save your life
81.4%
0%
20% 40% 60% 80% 100%
FIGURE 1. Perceived benefits of colorectal cancer (CRC) screening (%, strongly agree). Note. CS = colonoscopy; FOBT = fecal occult blood test; FS = flexible sigmoidoscopy. 387
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TABLE 4. Significant Correlations Between Adherence to the Colorectal Cancer (CRC) and Polyps Screening Recommendations and Independent Variables
TABLE 5. Multivariate Logistic Regression Model Predicting Adherence to the Colorectal Cancer (CRC) and Polyps Screening Recommendations
Adherence to CRC and Polyps Screening Recommendations
OR
95% CI
p
Have a relative who had colon or rectal cancer
6.17
1.52, 25.09 .011
Age ≥65 years
0.202a
Have heard of FOBT
4.58
2.24, 9.34
10 years
0.206b
An FOBT, FS, and CS will help you not worry as much as about CRC
2.81
1.37, 5.77
.005
Age ≥65 years
2.64
1.29, 5.40
.008
Very easy communication with healthcare providers
2.43
1.17, 5.08
.018
Employment
−0.170a
Catholicism
0.199b
Preference for English in speaking with healthcare providers
0.149a
Very easy communication with healthcare providers
0.260c
Talked about preventing illness with doctor all the time
0.148a
Willing to follow doctor’s advice for medicine
0.150a
Have a relative who had colon or rectal cancer
0.220b
Have heard of an FOBT
0.322c
Have done an FOBT using a home test kit
0.310b
Treatment for CRC may not be as bad if the cancer is found early
0.241b
An FOBT, FS, and CS will help you not worry as much as about CRC
0.295c
An FOBT, FS, and CS will decrease your chance of dying from CRC
0.282c
An FOBT, FS, and CS will help find CRC early
0.282c
Note. Adherence to CRC and polyps screening recommendations, flexible sigmoidoscopy within past 5 years or CS within past 10 years. CS = colonoscopy; FOBT = fecal occult blood test; FS = flexible sigmoidoscopy. a p < .05. b p < .01. c p < .001 by Kendall’s tau test.
predictors of adherence: having a relative with colon or rectal cancer, having heard of FOBT, strongly agreeing that screening procedures would reduce worry about CRC, age 65 years or older, and very easy communication with healthcare providers. It is interesting that those variables unique to the immigrant populations, such as living in the United States more
Note. CI = confidence interval; CS = colonoscopy; FOBT = fecal occult blood test; FS = flexible sigmoidoscopy; OR = odds ratio.
than 10 years, and preference for English in speaking with healthcare providers, were not significant predictors of adherence, which is consistent with previous studies (Ferrer et al., 2011; Koo et al., 2012). Among the five predictors of adherence, OR was the highest for participants who had a relative with colon or rectal cancer with greater than sixfold higher odds of adherence to screening recommendation compared with those without a relative with colon or rectal cancer. This is consistent with a previous study finding that showed an 11-fold higher odds of willingness to undergo colonoscopy screening for those who had a first-degree relative with CRC compared with those without (Delgado-Plasencia, Lopez-TomassettiFernandez, Hernandez-Morales, Torres-Monzon, & Gonzalez-Hermoso, 2009). Although having a relative with CRC or age of 65 years or older is not modifiable, three of the five predictors are potentially modifiable: that is, having heard of FOBT, strongly agreeing that screening procedures would reduce worry about CRC, and having a very easy communication with healthcare providers. These three predictors are likely associated with effective patient–provider communications and interactions where the benefits of CRC screening are discussed. A similar study finding on the patient– provider communications was also reported in a previous study that showed a fivefold higher OR of colonoscopy for those who received physicians’ recommendations for screening (Taouqi, Ingrand, Beauchant, Migeot, & Ingrand, 2010). The findings of the current study are consistent with the results from a randomized controlled trial of educational interventions with distribution of free FOBT kit among Filipino-Americans where the 6-month rate of sigmoidoscopy or
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colonoscopy was improved with 8% in the intervention group compared with the 3% in the control group (Maxwell et al., 2010). In this study, only 49.5% of the participants were adhering to the CRC and polyps screening recommendations, which is very similar to the 44.5% rate reported among Asians in 2010 (ACS, 2012b). Furthermore, slightly more than half of the participants in the current study had heard about FOBT (54.8%), perceived benefit of reduced worry through CRC screening (59.6%), and had ease of communication with healthcare providers (64.9%). Thus, there is still much room for improvements in the adherence to screening recommendations, perhaps by improving the modifiable predictors. These are the areas where nurses could play a major role through patient education to increase patient awareness about CRC screening and reinforcing the screening recommendations. In addition, nurses can help institute a checklist or reminder procedures for CRC screening to identify nonadherent patients for targeting of interventional efforts (Atassi, 2012; Greenwald, 2011).
Limitations There were several limitations of this study. The relationship between predictors and adherence to the screening recommendations should not be taken as cause-and-effect relationships because this study was a cross-sectional study. The self-reported responses to the questionnaire may have overestimated the true adherence to the CRC and polyps screening recommendations. Because the participants were all FilipinoAmericans attending community churches, the study findings may not be generalizable to the population at large. Finally, the adherence to the annual FOBT recommendation was not assessed in this study. Although FOBT is noninvasive and easy to perform, FOBT alone cannot detect adenomatous polyps. For the future, innovative and cost-effective strategies are needed to achieve high rates of adherence to the screening recommendations for early detection of CRC and adenomatous polyps to reduce mortality rate from CRC, including the use of nurse endoscopists to increase availability of screening sigmoidoscopy and colonoscopy (LimogesGonzalez et al., 2011; van Putten et al., 2012).
Conclusions Patient awareness of CRC screening and its benefits through effective patient–provider communication were significant modifiable predictors of adherence to the CRC and polyps screening recommendations among Filipino-Americans. To improve cancerscreening behaviors, nurses could have a major impact through effective patient education in increasing patient awareness and benefits of cancer screening. VOLUME 37 | NUMBER 6 | NOVEMBER/DECEMBER 2014
Innovative and cost-effective strategies are needed to achieve high rates of adherence to screening recommendations. This study was performed as a part of the Master of Science in Nursing degree requirements at School of Nursing, Point Loma Nazarene University, San Diego, CA. ✪
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