ann. behav. med. (2014) 47:280–291 DOI 10.1007/s12160-013-9562-y
ORIGINAL ARTICLE
Intention to Undergo Colonoscopy Screening Among Relatives of Colorectal Cancer Cases: a Theory-Based Model Watcharaporn Boonyasiriwat, Ph.D. & Man Hung, Ph.D., M.Stat., M.Ed. & Shirley D. Hon, B.S. & Philip Tang, B.S. & Lisa M. Pappas, M.Stat. & Randall W. Burt, M.D. & Marc D. Schwartz, Ph.D. & Antoinette M. Stroup, Ph.D. & Anita Y. Kinney, Ph.D., R.N.
Published online: 5 December 2013 # The Society of Behavioral Medicine 2013
Abstract Background It is recommended that persons having familial risk of colorectal cancer begin regular colonoscopy screening at an earlier age than those in the general population. However, many individuals at increased risk do not adhere to these screening recommendations. Purpose The goal of this study was to examine cognitive, affective, social, and behavioral motivators of colonoscopy intention among individuals at increased risk of familial colorectal cancer. Methods Relatives of colorectal cancer cases (N =481) eligible for colonoscopy screening completed a survey assessing constructs from several theoretical frameworks including fear appeal theories. Results Structural equation modeling indicated that perceived colorectal cancer risk, past colonoscopy, fear of colorectal W. Boonyasiriwat : M. Hung : L. M. Pappas : R. W. Burt : A. Y. Kinney Huntsman Cancer Institute, University of Utah, Salt Lake City, USA
cancer, support from family and friends, and health-care provider recommendation were determinants of colonoscopy intention. Conclusions Future interventions to promote colonoscopy in this increased risk population should target the factors we identified as motivators. (ClinicalTrials.gov number NCT01274143). Keywords Colorectal cancer screening . Colonoscopy . Family history . Intention . Extended parallel process model Colorectal cancer is the third most common cancer diagnosed and the second leading cause of cancer death in both men and women in the USA. A family history of colorectal cancer is R. W. Burt Division of Gastroenterology, Department of Medicine, School of Medicine, University of Utah, Salt Lake City, USA
M. Hung e-mail: [email protected] W. Boonyasiriwat (*) Faculty of Psychology, Chulalongkorn University, 7th Fl. Borommaratchonnani Srisattapat Bldg., Rama 1 Rd., Patumwan, Bangkok, 10330, Thailand e-mail: [email protected] M. Hung : S. D. Hon Department of Orthopaedic Surgery Operations, University of Utah, Salt Lake City, USA S. D. Hon University of Utah College of Computer & Electrical Engineering, Salt Lake City, USA
M. D. Schwartz Department of Oncology, Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA A. M. Stroup : A. Y. Kinney Division of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, USA
M. Hung Division of Epidemiology, Department of Medicine, School of Medicine, University of Utah, Salt Lake City, USA
P. Tang School of Medicine, University of Utah, Salt Lake City, USA P. Tang Touro University California College of Osteopathic Medicine, Vallejo, USA
A. Y. Kinney Division of Epidemiology, Department of Internal Medicine, University of New Mexico and University of New Mexico Cancer Center, Albuquerque, NM, USA
ann. behav. med. (2014) 47:280–291
one of the strongest risk factors for the disease. Twenty-five to thirty percent of colorectal cancer cases are related to inheritance [1, 2]. Close relatives of colorectal cancer patients have a two- to eightfold increased risk of the disease when compared to the general population, depending on the age of relatives at diagnoses [3, 4]. Strong evidence indicates that colorectal cancer mortality can be prevented by early detection through screening, and thus, it is recommended that individuals at intermediate familial risk begin colonoscopy screening either at age 40 or 10 years younger than the earliest diagnosis in the family, and then repeat this screening method no less than every 5 years [5–7]. The majority of relatives of colorectal cancer patients tend to overestimate their colorectal cancer risk [8] and are more worried about developing colorectal cancer than those without a familial colorectal cancer history [9]. Nonetheless, many at-risk relatives (0.76), except for an acceptable family support (α =0.68). Confirmatory factor analyses showed that our four self-efficacy items had poor fit (RMSEA=0.45, CFI=0.79, SRMR=0.10), as did the sixitem family and friend support scale (RMSEA=0.31, CFI= 0.66, SRMR=0.17). To improve the fit of measurement models, both latent constructs were respecified. Specifically, one self-efficacy item was removed due to a high correlation
286
ann. behav. med. (2014) 47:280–291
Table 2 Descriptive statistics for psychosocial variables and results of measurement model tests
Perceived risk (RMSEA=0.00, CFI=1.00, SRMR=0.00) Item 1: I am at risk for getting colorectal cancer Item 2: It is possible that I will get colorectal cancer Item 3: I am susceptible to getting colorectal cancer Item 4: It is likely that I will get colorectal cancer Perceived severity (RMSEA=0.01, CFI=1.00, SRMR=0.01) Item 1: I believe that colorectal cancer is serious Item 2: I believe that colorectal cancer is harmful Item 3: I believe that colorectal cancer is a significant disease Item 4: I believe that colorectal cancer has serious negative consequences Response efficacy (RMSEA=0.00, CFI=1.00, SRMR=0.00) Item 1: Having a colonoscopy can prevent the onset of colorectal cancer Item 2: Colonoscopy works in preventing colorectal cancer Item 3: Having a colonoscopy is effective in preventing colorectal cancer Item 4: If I have a colonoscopy, I am less likely to get colorectal cancer Self-efficacy (RMSEA=0.00, CFI=1.00, SRMR=0.00) Item 1: I am able to get a colonoscopy to prevent the onset of colorectal cancer Item 2: Having a colonoscopy to prevent the onset of colorectal cancer is easy for me Item 4: Having a colonoscopy for prevention of colorectal cancer is convenient for me Fear of colorectal cancer (RMSEA=0.05, CFI=1.00, SRMR=0.01) Item 1: I get frightened when I think I could get colorectal cancer Item 2: Thinking about getting colorectal cancer makes me afraid Item 3: I get a bad feeling just thinking about the possibility of getting colorectal cancer Item 4: Thinking about my chances of getting colorectal cancer makes me uncomfortable Item 5: I dread getting colorectal cancer Item 6: I can't think about getting colorectal cancer without feeling afraid Family and friend support (RMSEA=0.00, CFI=1.00, SRMR=0.00) Item 3: I have a family member or someone who can take the time to take me home from a colonoscopy Item 5: If I feel worried or concerned and want to talk to someone about my risk of getting colorectal cancer, I can discuss it with my family or someone else Item 6: Generally speaking, I want to do what my family or significant others think I should do
Min
Max
M
SD
1 1 1 1
5 5 5 5
3.95 3.87 3.74 2.97
0.86 0.80 0.89 0.77
1 1 1 1
5 5 5 5
4.81 4.82 4.77 4.77
0.53 0.51 0.53 0.53
1 1 1 1
5 5 5 5
3.71 3.69 3.71 3.24
1.18 1.18 1.15 1.17
1
5
3.34
1.14
1 1
5 5
2.91 2.74
1.12 1.06
1 1 1 1 1 1
4 4 4 4 4 4
2.48 2.41 2.36 2.49 2.60 2.29
0.90 0.87 0.89 0.85 1.01 0.89
1 1
5 5
4.22 3.99
0.94 0.95
1
5
3.74
0.87
α 0.86
0.92
0.90
0.76
0.94
0.68
α Cronbach's alpha. RMSEA root mean square error of approximation, CFI comparative fit index, SRMR standardized root mean square residual
with another self-efficacy item (r =0.77, modification index= 175.08), and three family and friend support items were also excluded due to high correlations with other items. After excluding one self-efficacy item, the self-efficacy construct showed excellent fit (RMSEA=0.00, CFI=1.00, SRMR= 0.00). The modified family and friend support construct showed excellent fit (RMSEA=0.00, CFI=1.00, SRMR= 0.00). Overall, the measurement model assessment provided evidence of reliability of the variables. Means and standard deviations of the variables of interest indicate that in general, participants perceived colorectal cancer as very serious and believed that their colorectal cancer risk was moderate to high (Table 2). Participants also viewed colonoscopy screening as a moderately to highly effective way of preventing colorectal cancer, while they held a moderate-level belief in their intention to undergo colonoscopy. On average, participants' fear of
colorectal cancer was moderate. They also indicated moderately strong support from family and friends. Table 3 presents correlations among the variables in the SEM. Structural Equation Analysis Testing of the hypothesized model indicated that the data fit the model reasonably well (RMSEA=0.05; CFI=0.94; SRMR= 0.06). The structural equation analysis explained a modest amount of variance (25.8 %) concerning intention to undergo colonoscopy, after controlling for age, gender, education, household income, employment status, health insurance status, and number of first- and second-degree relatives who had colorectal cancer. Given the good fit of the data to the structural equation model, the next step was to interpret the path coefficients (i.e., the standardized regression coefficients).
ann. behav. med. (2014) 47:280–291
287
Table 3 Correlations among variables in the SEM
1. Past colonoscopy 2. Physician recommendation 3. Intention 4. Perceived risk 5. Perceived severity 6. Fear 7. Family and friend support 8. Response efficacy 9. Self-efficacy
1
2
3
4
5
6
7
8
9
–
0.09** –
0.02 0.13** –
0.02 0.07** 0.24** –
0.01 0.02 0.06** 0.11** –
0.02 0.04* 0.18** 0.19** 0.06** –
0.01 0.02 0.16** 0.13** 0.08** 0.08** –
0.02 0.02 0.13** 0.18** 0.07** 0.10** 0.08* –
0.03 0.01 0.15** 0.07** 0.03* 0.01 0.12** 0.25** –
*p
ORIGINAL ARTICLE
Intention to Undergo Colonoscopy Screening Among Relatives of Colorectal Cancer Cases: a Theory-Based Model Watcharaporn Boonyasiriwat, Ph.D. & Man Hung, Ph.D., M.Stat., M.Ed. & Shirley D. Hon, B.S. & Philip Tang, B.S. & Lisa M. Pappas, M.Stat. & Randall W. Burt, M.D. & Marc D. Schwartz, Ph.D. & Antoinette M. Stroup, Ph.D. & Anita Y. Kinney, Ph.D., R.N.
Published online: 5 December 2013 # The Society of Behavioral Medicine 2013
Abstract Background It is recommended that persons having familial risk of colorectal cancer begin regular colonoscopy screening at an earlier age than those in the general population. However, many individuals at increased risk do not adhere to these screening recommendations. Purpose The goal of this study was to examine cognitive, affective, social, and behavioral motivators of colonoscopy intention among individuals at increased risk of familial colorectal cancer. Methods Relatives of colorectal cancer cases (N =481) eligible for colonoscopy screening completed a survey assessing constructs from several theoretical frameworks including fear appeal theories. Results Structural equation modeling indicated that perceived colorectal cancer risk, past colonoscopy, fear of colorectal W. Boonyasiriwat : M. Hung : L. M. Pappas : R. W. Burt : A. Y. Kinney Huntsman Cancer Institute, University of Utah, Salt Lake City, USA
cancer, support from family and friends, and health-care provider recommendation were determinants of colonoscopy intention. Conclusions Future interventions to promote colonoscopy in this increased risk population should target the factors we identified as motivators. (ClinicalTrials.gov number NCT01274143). Keywords Colorectal cancer screening . Colonoscopy . Family history . Intention . Extended parallel process model Colorectal cancer is the third most common cancer diagnosed and the second leading cause of cancer death in both men and women in the USA. A family history of colorectal cancer is R. W. Burt Division of Gastroenterology, Department of Medicine, School of Medicine, University of Utah, Salt Lake City, USA
M. Hung e-mail: [email protected] W. Boonyasiriwat (*) Faculty of Psychology, Chulalongkorn University, 7th Fl. Borommaratchonnani Srisattapat Bldg., Rama 1 Rd., Patumwan, Bangkok, 10330, Thailand e-mail: [email protected] M. Hung : S. D. Hon Department of Orthopaedic Surgery Operations, University of Utah, Salt Lake City, USA S. D. Hon University of Utah College of Computer & Electrical Engineering, Salt Lake City, USA
M. D. Schwartz Department of Oncology, Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA A. M. Stroup : A. Y. Kinney Division of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, USA
M. Hung Division of Epidemiology, Department of Medicine, School of Medicine, University of Utah, Salt Lake City, USA
P. Tang School of Medicine, University of Utah, Salt Lake City, USA P. Tang Touro University California College of Osteopathic Medicine, Vallejo, USA
A. Y. Kinney Division of Epidemiology, Department of Internal Medicine, University of New Mexico and University of New Mexico Cancer Center, Albuquerque, NM, USA
ann. behav. med. (2014) 47:280–291
one of the strongest risk factors for the disease. Twenty-five to thirty percent of colorectal cancer cases are related to inheritance [1, 2]. Close relatives of colorectal cancer patients have a two- to eightfold increased risk of the disease when compared to the general population, depending on the age of relatives at diagnoses [3, 4]. Strong evidence indicates that colorectal cancer mortality can be prevented by early detection through screening, and thus, it is recommended that individuals at intermediate familial risk begin colonoscopy screening either at age 40 or 10 years younger than the earliest diagnosis in the family, and then repeat this screening method no less than every 5 years [5–7]. The majority of relatives of colorectal cancer patients tend to overestimate their colorectal cancer risk [8] and are more worried about developing colorectal cancer than those without a familial colorectal cancer history [9]. Nonetheless, many at-risk relatives (0.76), except for an acceptable family support (α =0.68). Confirmatory factor analyses showed that our four self-efficacy items had poor fit (RMSEA=0.45, CFI=0.79, SRMR=0.10), as did the sixitem family and friend support scale (RMSEA=0.31, CFI= 0.66, SRMR=0.17). To improve the fit of measurement models, both latent constructs were respecified. Specifically, one self-efficacy item was removed due to a high correlation
286
ann. behav. med. (2014) 47:280–291
Table 2 Descriptive statistics for psychosocial variables and results of measurement model tests
Perceived risk (RMSEA=0.00, CFI=1.00, SRMR=0.00) Item 1: I am at risk for getting colorectal cancer Item 2: It is possible that I will get colorectal cancer Item 3: I am susceptible to getting colorectal cancer Item 4: It is likely that I will get colorectal cancer Perceived severity (RMSEA=0.01, CFI=1.00, SRMR=0.01) Item 1: I believe that colorectal cancer is serious Item 2: I believe that colorectal cancer is harmful Item 3: I believe that colorectal cancer is a significant disease Item 4: I believe that colorectal cancer has serious negative consequences Response efficacy (RMSEA=0.00, CFI=1.00, SRMR=0.00) Item 1: Having a colonoscopy can prevent the onset of colorectal cancer Item 2: Colonoscopy works in preventing colorectal cancer Item 3: Having a colonoscopy is effective in preventing colorectal cancer Item 4: If I have a colonoscopy, I am less likely to get colorectal cancer Self-efficacy (RMSEA=0.00, CFI=1.00, SRMR=0.00) Item 1: I am able to get a colonoscopy to prevent the onset of colorectal cancer Item 2: Having a colonoscopy to prevent the onset of colorectal cancer is easy for me Item 4: Having a colonoscopy for prevention of colorectal cancer is convenient for me Fear of colorectal cancer (RMSEA=0.05, CFI=1.00, SRMR=0.01) Item 1: I get frightened when I think I could get colorectal cancer Item 2: Thinking about getting colorectal cancer makes me afraid Item 3: I get a bad feeling just thinking about the possibility of getting colorectal cancer Item 4: Thinking about my chances of getting colorectal cancer makes me uncomfortable Item 5: I dread getting colorectal cancer Item 6: I can't think about getting colorectal cancer without feeling afraid Family and friend support (RMSEA=0.00, CFI=1.00, SRMR=0.00) Item 3: I have a family member or someone who can take the time to take me home from a colonoscopy Item 5: If I feel worried or concerned and want to talk to someone about my risk of getting colorectal cancer, I can discuss it with my family or someone else Item 6: Generally speaking, I want to do what my family or significant others think I should do
Min
Max
M
SD
1 1 1 1
5 5 5 5
3.95 3.87 3.74 2.97
0.86 0.80 0.89 0.77
1 1 1 1
5 5 5 5
4.81 4.82 4.77 4.77
0.53 0.51 0.53 0.53
1 1 1 1
5 5 5 5
3.71 3.69 3.71 3.24
1.18 1.18 1.15 1.17
1
5
3.34
1.14
1 1
5 5
2.91 2.74
1.12 1.06
1 1 1 1 1 1
4 4 4 4 4 4
2.48 2.41 2.36 2.49 2.60 2.29
0.90 0.87 0.89 0.85 1.01 0.89
1 1
5 5
4.22 3.99
0.94 0.95
1
5
3.74
0.87
α 0.86
0.92
0.90
0.76
0.94
0.68
α Cronbach's alpha. RMSEA root mean square error of approximation, CFI comparative fit index, SRMR standardized root mean square residual
with another self-efficacy item (r =0.77, modification index= 175.08), and three family and friend support items were also excluded due to high correlations with other items. After excluding one self-efficacy item, the self-efficacy construct showed excellent fit (RMSEA=0.00, CFI=1.00, SRMR= 0.00). The modified family and friend support construct showed excellent fit (RMSEA=0.00, CFI=1.00, SRMR= 0.00). Overall, the measurement model assessment provided evidence of reliability of the variables. Means and standard deviations of the variables of interest indicate that in general, participants perceived colorectal cancer as very serious and believed that their colorectal cancer risk was moderate to high (Table 2). Participants also viewed colonoscopy screening as a moderately to highly effective way of preventing colorectal cancer, while they held a moderate-level belief in their intention to undergo colonoscopy. On average, participants' fear of
colorectal cancer was moderate. They also indicated moderately strong support from family and friends. Table 3 presents correlations among the variables in the SEM. Structural Equation Analysis Testing of the hypothesized model indicated that the data fit the model reasonably well (RMSEA=0.05; CFI=0.94; SRMR= 0.06). The structural equation analysis explained a modest amount of variance (25.8 %) concerning intention to undergo colonoscopy, after controlling for age, gender, education, household income, employment status, health insurance status, and number of first- and second-degree relatives who had colorectal cancer. Given the good fit of the data to the structural equation model, the next step was to interpret the path coefficients (i.e., the standardized regression coefficients).
ann. behav. med. (2014) 47:280–291
287
Table 3 Correlations among variables in the SEM
1. Past colonoscopy 2. Physician recommendation 3. Intention 4. Perceived risk 5. Perceived severity 6. Fear 7. Family and friend support 8. Response efficacy 9. Self-efficacy
1
2
3
4
5
6
7
8
9
–
0.09** –
0.02 0.13** –
0.02 0.07** 0.24** –
0.01 0.02 0.06** 0.11** –
0.02 0.04* 0.18** 0.19** 0.06** –
0.01 0.02 0.16** 0.13** 0.08** 0.08** –
0.02 0.02 0.13** 0.18** 0.07** 0.10** 0.08* –
0.03 0.01 0.15** 0.07** 0.03* 0.01 0.12** 0.25** –
*p
