J Community Health (2014) 39:230–238 DOI 10.1007/s10900-013-9812-8
ORIGINAL PAPER
The Influence of Gender on Colorectal Cancer Knowledge, Screening Intention, Perceived Risk and Worry Among African Americans in South Florida Sheila Y. McKinney • Richard C. Palmer
Published online: 28 December 2013 Ó Springer Science+Business Media New York 2013
Abstract The aim of this study was to examine if gender differences exist for colorectal cancer (CRC) knowledge, intention to screen, perceived risk and cancer worry among African Americans for CRC. African American males and females (N = 336) aged 45 years or older living in southeast Florida were recruited to participate in a crosssectional survey that assessed intentions to screen as well as CRC knowledge, cancer worry, perceived risk. No significant differences were found between men and women in their intention to screen for CRC or in their worry about cancer. Results did suggest that men and women differed significantly about their understanding of CRC knowledge. Findings also showed that there were differences in perceived risk between genders, with female study participants possessing lower levels of risk than men. Study results suggest that future interventions need to ensure that females understand their risk for CRC and understand the benefits associated with CRC screening. Findings also suggest that interventions promoting CRC screening may need to be tailored if increased participation in CRC screening is to be achieved for women. Keywords CRC screening African Americans Gender differences CRC knowledge Intention Perceived risk Worry
S. Y. McKinney (&) R. C. Palmer Robert Stempel College of Public Health and Social Work, 11200 SW 8th Street, Miami, FL 33199, USA e-mail: [email protected] R. C. Palmer e-mail: [email protected]
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Introduction Colorectal cancer (CRC) disproportionately affects African American men and women with both having the highest mortality and morbidity rates than in any other racial or ethnic group in the United States [1–4]. A key factor influencing this pattern is that African Americans participate infrequently in CRC screening [3]. Low CRC participation rates have shown to contribute to these higher rates of CRC morbidity and mortality [3]. As a result, African Americans remain unaware that they may be developing precancerous polyps within their colon area, and if diagnosed in time can be removed. Subsequently, efforts are needed to increase African Americans’ acceptance and adherence to CRC screening because screening allows for removal of precancerous polyps and can prevent late-stage diagnoses [5]. Despite these benefits, the most common CRC screening tests remain underutilized by African Americans [6]. Several factors predispose a person to complete CRC screening. Data suggest that increased disease knowledge is linked to increased intention to complete CRC screening [7]. Therefore, if a person has greater knowledge about the disease, its consequences and how to prevent or treat the disease, she would be more apt to avoid developing the disease by engaging in CRC screening. Also, comprehensive knowledge about the disease may promote a better understanding of how personal choices to engage in preventive activities influence ones risk for developing the disease or avoiding the disease altogether [8]. Wong et al. (2013) in a purposive study of 29 African Americans over 50, found a significant difference between those that had completed a colonoscopy (n = 17) and those that had not (n = 12) in their level of knowledge about CRC. This study determined that those completing screening had a
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stronger foundation in knowledge about the disease and CRC screening information. In fact, knowledge was found more influential than physician recommendation to screen. This suggests that patient knowledge about CRC is a critical component to developing the capacity to make a decision for or against CRC screening. Likewise, psychosocial factors, such as, cancer worry and perceived risk, have played an important role to improve health behaviors. These factors act as mediators for intention to screen, whereby, people who worry about and perceive they are at risk for poor health, have a greater likelihood to want to screen for CRC [9, 10]. The influence of intention alone and in tandem with these psychosocial factors have shown to influence health behavior in areas such as breast cancer, obesity and smoking cessation but these effects can be inconsistent [11–13]. At times these factors strengthen a patient’s intent to screen or take actions that improve her health status and in others there is marginal effect, at best. [11–13] For instance, Chilton et al. (2013) described how an educational component within a community mammography screening event that addressed risk and provided information about breast cancer in a culturally responsive context increased intention post intervention of American Indian women to continue annual screenings in the future. But, Soureti et al. (2013) found that perceived risk alone was not as effective a mediator to stop smoking and that perceived risk in conjunction with an affective component may increase intention to stop smoking. These inconsistencies indicate that more work is needed to understand the context for which intention can consistently lead to changed health behavior. Investigations have also occurred to better understand the uptake patterns of African American men and women to complete CRC screening. What is known is that participation in screening varies by race and gender, with African Americans less likely than whites to receive preventive health services including CRC screenings [14]. And, African-American women tend to participate more in overall screening activities than men, but in terms of colon cancer, they screen less [15, 16]. Lower participation rates of African American women happen even though women may be more actively engaged in preventive care, or have ongoing, consistent relationships with a care facility; thus providing them greater access to screening services over men [17, 18]. The challenge to improving CRC screening for women is to encourage their participation in CRC screening as part of their current repertoire of care and, for men, to first get them enrolled into care then indoctrinate them into preventive health routines [17–19]. Current research has offered inconsistent findings about the effect of intention, mediated by psychosocial factors, on health behaviors. It is therefore uncertain why these inconsistencies exist, and these relationships are less
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studied in their application to colon cancer, particularly among African Americans. Among this segment even fewer studies, have examined gender’s effect on CRC knowledge, cancer worry, perceived risk and intention to complete CRC screening. Exploring these issues would strengthen the field’s ability to answer whether patient intent to screen prior to an intervention can serve as a reliable indicator that a patient will screen after exposure to an intervention. The aim of this study was to examine if gender differences exist among African Americans who are not adherent to CRC recommendations in terms of CRC knowledge, cancer worry, perceived risk, and intention to screen.
Methods Participants African-American males and females aged 45 years and older were recruited to participate in this study. Study participants were recruited from clinic and community organizations throughout southeast Florida. Individuals were screened by study staff and self-reported meeting eligibility criteria. Eligibility consisted of (1) self-identified as African American or black, (2) at least 45 years of age, (3) understood spoken English language, (4) not adherent to CRC screening guidelines, and (5) working telephone. Procedures Research staff recruited participants from common waiting areas by distributing flyers about the study. Following informed consent, study participants were asked to complete a questionnaire. Study staff offered to read the questionnaire if needed. If participants declined, they completed the questionnaire independently in approximately 20 min. This study was approved by the institutional review board of Florida International University. Data Collection Tool Individuals were asked to complete a survey that contained 30 items. Measures Demographic Characteristics Eleven questions recorded participants’ ethnicity, age, last completed grade in school, insurance status, total household income, marital status, living arrangements, parental status, guardianship of child less than 18 years, and average monthly attendance for religious services.
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Table 1 Demographic characteristics by gender (N = 336) Variable
Males (n = 119)
Females (n = 217)
N
%a
N
104
87.4 %
178
10
.08
25
Black (African)
1
.01
4
Black (Hispanic)
2
.02
3
.01
Multiracial
2
.02
3
.01
Other
0
0
4
.02
33
28.7
72
p
%
Ethnicity Black (African American) Black (Caribbean)
82.0 %
.581
11.5 .02
screen for CRC (yes, no, don’t know) and, if so, when. Participants were also asked about their certainty to complete CRC screening as ‘‘how sure’’ (4-point Likert from not very sure to very sure) and ‘‘how likely’’ (4-point Likert from not very likely to very likely) to test. These items were taken from pre-existing scales [20–23]. Responses were coded according to the response option number, then averaged to create an intention to screen mean scale score. Perceived Risk
Age (In Years) 45–49
33.6
50–59
55
47.8
92
43.0
60?
27
23.5
50
23.4
.617
Education (highest grade) Less than high school
28
24.3
41
19.3
High school or GED
50
43.5
95
44.8
College and above
37
32.2
76
35.8
Yes
14
12.2
39
18.3
No
101
87.8
174
81.7
Under $15,000
43
39.1
99
47.1
$15,000–$25,000
13
11.8
30
14.3
$25,001–$35,000
10
9.1
15
7.1
Insurance
.150
Previous year’s household income
.512
$35,001 and above
15
13.6
23
11.0
Don’t Know
29
26.4
43
20.5
Yes, married/living with partner
49
41.2
72
33.2
I am neither married nor living with a partner
70
58.8
145
66.8
One (1), I live by myself
46
41.4
68
32.5
Two (2) people
27
24.3
55
26.3
Three (3) people
17
15.3
32
15.3
Four (4) people
14
12.6
20
9.6
7
6.3
34
16.3
Yes
92
80.7
184
86.8
No
22
19.3
28
13.2
Marital status
.144
Living arrangements
Five (5) or more people
.146
Guardian of child 18 or under
.055
Yes
43
38.1
59
27.7
No
70
61.9
154
72.3
One time per month
29
25.2
23
11.0
Two times per month
13
11.3
30
14.3
Three or more times per month
45
39.1
132
62.9
I don’t attend services
28
24.3
25
11.9
\.001
Attends Religious Services
Percentages may not add to 100 % because of missing responses
Intention to Screen for CRC Participants answered six questions about future plans to screen. All participants were asked whether they plan to
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CRC Knowledge Participants were asked five items that assessed knowledge. These items were modified from Sanderson et al. and Palmer [24, 25]. Responses were coded 1 for true and 0 for false. A mean CRC knowledge score was calculated. Worry about Cancer
.093
Children
a
.547
Participants answered three questions on CRC risk. Participants were asked about their overall chance of developing cancer, whether they viewed themselves at lower risk for developing cancer compared to others the same age, and whether they thought they would likely develop CRC. Responses were provided on a 4-point Likert scale anchored by 1 strongly disagree and 4 strongly agree. These items were modified from pre-existing scales [23]. A mean scale score was calculated.
Two questions were used to assess participants’ worry about developing cancer. A 4-point Likert assessed their level of agreement to the statements ‘‘I am afraid of having an abnormal colon cancer screening test result’’ and ‘‘I am worried that colorectal cancer screening will show that I have colon cancer.’’ These items were taken from preexisting scales and averaged to create a score [23]. Data Analysis Data were cleaned prior to analysis and checked for data entry errors. Frequencies, percentages, means and standard deviations were used to describe the demographic characteristics. Differences in knowledge scores, intention to screen, perceived risk and cancer worry by gender were analyzed using Chi square and t tests. Multivariate logistic regression was then performed as the primary analysis which is to understand the extent that gender has an effect on intention to screen for colon cancer. Multivariate linear regression explored the secondary analyses of gender’s effect on perceived risk and worry about cancer. Data were analyzed using IBM SPSS Statistics 20 [26].
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Results
233 Table 2 Response summary to psychosocial variables by gender N = 336
Demographics There were a total of 336 study participants (Table 1). Of these, 119 were male and 217 female and the majority was between the age of 50 and 59. Most participants were also uninsured, were high school graduates, reported an annual income less than $15,000, lived alone and were unmarried but had children older than 18 years. Intention to Screen for CRC For both men and women the majority, 66.4 and 61.2 % respectively, indicated that they would screen for CRC. Further, almost one-third of the men (29.9 %) and onefifth of the women (21.6 %) did not know whether they would complete CRC screening. Gender had no effect on participants’ intention to screen (p = .220). There were no significant differences for the individual items that measured intention to screen gender (p = .984) (Table 2). The majority of both men and women were interested in screening and planned to do so in the near future. Perceived Risk for CRC There was a significant difference between men and women in their perceived risk for developing CRC with men [M = 2.53, SD (.46), p \ .001] having a stronger perception of personal risk compared to women [M = 2.34, SD (.52)]. More men (59.5 %) agree with the statement that their chance of developing cancer is high compared to 33.4 % of women. In fact, almost 67 % of the women disagreed with this statement. Moreover, women viewed the likelihood of ever developing CRC to be a remote possibility compared to men (75.7 versus 57.8 %, p \ .001) (Table 2).
Knowledge about CRC Men and women differed significantly about their understanding of CRC facts with men having a better understanding about the disease than women according to the CRC knowledge scale (p = .005) (Table 2). Specifically, men and women have a common understanding for what constitutes risk for developing this disease, but, 36.2 % of the men and 48.8 % of the women underestimate their personal risk for developing CRC (p = .009) (Table 3)
Males n (%)
Females n (%)
p
Intention to Screen Do you ever plan to have a colon cancer screening test?
.220
Yes
77 (66.4 %)
No
14 (12.1)
131 (61.2 %) 19 (8.9)
Don’t know
25 (21.6)
64 (29.9) .463
How likely are you to have a colon cancer screening in the next 6 months? Not likely
21 (18.1)
Somewhat likely
27 (23.3)
36 (16.8) 63 (29.4)
Likely
35 (30.2)
50 (23.4)
Very likely
33 (28.4)
65 (30.4)
How likely are you to have a colon cancer screening in the future?
.912
Not likely
10 (8.5)
Somewhat likely
22 (18.8)
18 (8.4) 45 (20.9)
Likely
39 (33.3)
64 (29.8)
Very likely
46 (39.3)
88 (40.9)
How sure are you that you will have a test to detect colon cancer in the next 6 months?
.894
Not at all sure
19 (16.4)
42 (19.5)
Only a little sure
16 (13.8)
26 (12.1)
Somewhat sure
37 (31.9)
68 (31.6)
Very sure
44 (37.9)
79 (36.7) .776
How sure are you that you will have a test to detect colon cancer in the future? Not at all sure
18 (15.5)
25 (11.7)
Only a little sure
13 (11.2)
28 (13.1)
Somewhat sure
32 (27.6)
60 (28.0)
Very Sure
53 (45.7)
101 (47.2)
Perceived risk \.001
The chance that I may develop colon cancer is high Strongly disagree
9 (7.8)
46 (21.6)
Disagree
38 (32.8)
96 (45.1)
Agree
56 (48.3)
53 (24.9)
Strongly agree
13 (11.2)
18 (8.5)
Compared with other persons my age, I am at lower risk for colon cancer
.868
Strongly agree
10 (8.7)
19 (8.9)
Agree
36 (31.3)
62 (29.0)
Disagree
56 (48.7)
102 (47.7)
Strongly disagree
13 (11.3)
31 (14.5) \.001
It is very likely that I will develop colon cancer Strongly disagree
13 (11.2)
43 (20.1)
Disagree
54 (46.6)
119 (55.6)
Agree
45 (38.8)
30 (14.0)
4 (3.4)
22 (10.3)
Strongly agree
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Table 2 continued Males n (%)
Females n (%)
p
Cancer worry I am afraid of having an abnormal colon cancer screening test result
.635
Strongly disagree
16 (13.8)
38 (17.8)
Disagree
51 (44.0)
84 (39.3)
Agree
4 (34.5)
70 (32.7)
Strongly agree
9 (7.8)
22 (10.3) .180
I am worried that colorectal cancer screening will show that I have colon cancer Strongly disagree
21 (18.4)
57 (26.5)
Disagree
52 (45.6)
103 (47.9)
Agree
33 (28.9)
44 (20.5)
8 (7.0)
11 (5.1)
Strongly agree
Worry About Cancer There was no statistically significant difference between men and women in their worry about cancer and CRC cancer in particular (p = .191) (Table 2). The two items used to measure cancer worry indicated that men and women have similar levels of concern regarding having an abnormal test result and fear that the test will indicate CRC. Gender’s Effect on Cancer Screening The models created using regression included all predictors explored in the bivariate analyses. Although not every predictor was found to be significant in the bivariate analyses, they were used because other studies have found them to be important predictors for cancer screening among African Americans [17, 27]. Multivariate logistic regression was conducted to determine the effect of patient’s gender on baseline intention to screen for colon cancer. As a dichotomous option of yes, I intend to screen or no, I don’t intend to screen, gender did not have a statistically significant effect v2 = 20.479, df (12), p = .059 within the overall model; its effect accounting for 63 % of the variance in the
sample. And while gender was not significant, two other factors, not having health insurance (p = .048) and not attending religious services were statistically significant to predict intention to screen in the multivariate logistic model as noted in Table 4. These findings suggest that black women without health insurance (OR 2.129) or do not attend religious services (OR 2.215) are almost twice as likely lack an initial intention to screen for colon cancer compared to other black women and men. Multivariate linear regression was conducted to determine how well a patient’s gender predicted the effect on his or her perceived risk for developing colon cancer. This analysis confirmed this study’s bivariate findings that gender significantly effects a patient’s perception of risk for developing colon cancer for mean scores, R2 = .083, adjusted R2 = .051, F(10, 288) = 2.595, p = .005. Table 5 illustrates that perceived risk was significantly influenced only by the patients’ gender (p = .001), suggesting that black women differ in their perception of risk than black men. While not significant women without children approached significance (p = .057). These findings suggest that black women, particularly among those without children, may have lower perceived risk for developing colon cancer than black men and other black women. Multivariate linear regression was also conducted to determine how well a patient’s gender predicted the effect on his or her worry about developing colon cancer. This analysis also confirmed the earlier bivariate findings that gender does not predict a patient’s sense of worry for developing colon cancer and worry about developing colon cancer as documented using the mean scores R2 = .25 adjusted R2 = -.009, F(10, 289) = .739, p = .688. In this analysis none of the individual factors were found to have a significant effect on cancer worry as noted in Table 6.
Discussion The goal of this study was to examine if intention to screen for CRC differed by gender among African Americans who are non-adherent to screening guidelines. Likewise,
Table 3 CRC knowledge by gender N = 336 Knowledge items
Males n (%) True
Females n (%) False
People can have colon cancer without having symptoms
99 (86.1 %)
16 (13.9 %)
Colon cancer can be prevented
19 (16.4)
97 (83.6)
n (%) True 172 (80.4 %) 32 (15.0)
p n (%) False 42 (19.6 %) 181 (85.0)
.195 .745
Young people are more likely to get colon cancer than older people
10 (8.6)
106 (91.4)
30 (14.5)
184 (86.0)
.151
Only people who eat poorly will develop colon cancer Men are more likely to get colon cancer than women
11 (9.5) 74 (63.8)
105 (90.5) 42 (36.2)
31 (14.5) 105 (48.8)
183 (85.5) 110 (51.2)
.193 .009
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Table 4 Multivariate logistic regression: intention to screen for colon cancer (N = 336)
Table 5 Multivariate linear regression: perceived risk to develop colon cancer (N = 336)
Variable
p
Variable
.970
Constant
Constant
OR
CI
.973
Gender Male versus Female*
Gender .644
.349, 1.071
.085
Age (in years) Under 50 versus Above 50*
1.211
.702, 2.090
.491
Education (highest grade) Less than high school High School or GED
.740 .905
.366, 1.496 .506, 1.617
.401 .736
More than high school* 2.129
1.007, 4.500
.048
Under $25,000
1.391
.775, 2.497
.268
$25,001 and above
1.275
.631, 2.575
.498
Previous year’s household income
1.272
.958, 1.689
.096
.663
.369, 1.191
.169
Living arrangements Children Yes versus no* Guardian of child 18 or under Yes versus No*
1.172
.584, 2.350
.655
.622
.346, 1.116
.111
2.215
1.614, 4.216
.015
Attends religious services Yes versus No*
p
2.413, 3.135
\.001
-.345, -.093
.001
.089
-.038, .217
.169
Education (highest grade)
-.028
-.107, .052
.492
Insurance
-.022
-.180, .135
.781
Previous year’s household income
.006
-.061, .074
.855
Marital status Living arrangements
.032 .042
-.032, .096 -.092, .176
.330 .541
Age (in years)
-.156
-.316, .005
.057
Guardian of child 18 or under
.065
-.071, .202
.347
Attends religious services
.027
-.068, .122
.572
Table 6 Multivariate linear regression: worry about colon cancer (N = 336)
Marital status
Alone versus with someone*
-2.19
CI
Bold values are statistically significant (p \ 0.05)
Doesn’t know* Married/Partner versus Not married*
2.774
Children
Insurance Yes versus No*
b
Variable
b
CI
p
Constant
2.471
1.956, 2.986
\.001
Gender
-.143
-.323, -.036
.117
Age (in years)
-.054
-.236, .128
.561
Education (highest grade)
-.149
-.374, .076
.194
Insurance
-.015
-.128, .099
.801
Previous year’ household income
-.012
-.108, .084
.806
Marital status Living arrangements
-.108 .047
-.299, .084 -.044, .139
.269 .311
Bold values are statistically significant (p \ 0.05)
Children
.113
-.116, .343
.332
* Referent
Guardian of child 18 or under
-.097
-.291, .098
.350
Attends religious services
-.024
-.160, .112
.732
explore if similar differences exist for knowledge, worry and perceived risk for developing CRC. Of the variables examined in this study, several did show differences between males and females but there were no gender differences for intention to screen. While this study did not find statistically significant differences with intention by gender, there is substantial empirical data that maintains support for behavioral intention as an important predictor for the uptake of cancer screening [28, 29]. This study did find significant relationships between gender and a person having health insurance, actively engaged in religious services and having some education. These findings are congruent with other studies that have found lack of insurance presents as a major barrier to completing screening and individuals without insurance are less likely to seek medical care where screening assessments and activities occur [29, 30]. Other studies have found that church group membership and involvement are associated with lower cancer risk because of the social ties and networks found in these centers [31, 32]. Specifically, the
p \ .05
activities sponsored in churches and places of worship often promote physical, emotional and mental wellbeing; particularly advantageous for African Americans because of the historical importance and role of church and religion on decision making, behavior and the overall life course of African Americans [31–33]. Therefore, these venues could be used to promote cancer screening for African Americans by reaching those not engaged with a medical home providing support for a person from intention to successful completion. Future interventions should continue to target changing behavioral intention since it is a strong precursor to CRC screening as well as other cancer screening behaviors [30, 34, 35]. In the current study more men than women intended to screen for CRC, yet more African American women report actually being screened in the literature [36]. This lack of intention to participate is somewhat ironic since women will engage with the
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healthcare system and participate more in screening for other diseases than men [37, 38]. A natural opportunity exists to screen women as part of routine care, and this may account for why women are screened more often. Men on the other hand, are not as easily accessible to engage and educate about CRC risk because they do not routinely seek preventive health care [15, 39]. This study did find a significant difference by gender for CRC risk perception. Our findings are congruent with other research where perceived risk is shown to influence screening behavior whereby a person who thinks they are at risk will be motivated to screen [40, 41]. In this study, the majority knew about colon cancer and that this disease impacted African Americans, but there appeared to be a pattern, especially among women, not to contextualize this information as personal risk. Also, these women are younger (under 60) and may have not been counseled to screen during routine medical visits. Coupled with seeing themselves as healthy, CRC would not be an immediate concern. In such instances, provider recommendations may become more important for women [27]. To be effective, CRC information should contain personally relevant perspectives to foster a relationship between knowledge and risk that leads to screening participation [42]. Most importantly, people who perceive themselves at risk are more likely to act in a manner that reduces their risk compared to others. This is particularly interesting because in controlling for gender the regression model found that having children increased risk perception among a sample where the majority of both women (86.8 %) and men (80.7 %) had children. This suggests that the importance of being a care giver or provider may be equally important for men and women both having shown as effective to motivate people to screen for CRC in previous studies. [43] This study also found that higher educational attainment made a person more receptive to the perception of risk unlike intention, where this research did not find such a distinction by level of education. Other research does show that individuals who are educated are more likely to adhere to screening guidelines and that there is a positive correlation between educational attainment and CRC screening [8, 43]. This study then adds that perceived risk, which is a critical factor for CRC adherence, may be more influential among those with more education than less education. The combined implications may be that regardless of education level and gender, addressing issues related to family or care of children may be the most influential to encourage a person to complete CRC screening and this influence may be strongest for those with less education. This study found significant differences in CRC knowledge between men and women which are congruent with other research [15]. Women responded more often that men were at greater risk for developing CRC than
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themselves when the risk is equal. This misperception of personal risk might be explained by CRC knowledge deficiencies whereby women’s sense of personal risk is reduced because of their poor knowledge about CRC. Research has also shown that knowledge influences screening behavior since improved understanding about a particular disease leads to greater perceived risk for developing the disease and stronger motivation to screen [15, 41, 44, 45]. Given that CRC is a preventable disease, providers caring for similar patients should improve their CRC knowledge as an important first step to increase the number of people, especially women, that intend to screen for CRC. Research has also shown that CRC screening is a complex behavior influenced by many factors, including CRC awareness [44]. In this study, over one-third of both men and women had no intention to screen yet most had a working knowledge of CRC. Other research has shown that the benefits of knowledge are often mitigated by fear defined as refusing to engage with the care system, distrust, and fatalism [7]. This same fear may be linked to emerging research on feelings of risk which focus on the emotion of risk versus traditional concepts of perceived risk; and have proven relevant to screening messages and screening attitudes [41]. The implication is that health messaging requires disease facts and content covering the fear and emotions associated with CRC screening to change behavior. Intervention studies that incorporate messages with content relevant to gender-based concerns against feelings-of-risk are recommended. Although findings suggest that there are gender differences in CRC knowledge and perceived risk, there are study limitations that need to be acknowledged. This is a cross-sectional study and no causality is implied. These results may be limited in their generalizability because the study was conducted with patients who received care from a community health clinic. Subsequently, the majority of the participants reported lower income and the responses may not be generalizable to other African American populations. Finally, data were selfreported and participation bias could exist. African Americans participate in CRC screening less often than other racial/ethnic groups. Understanding what variables may influence intention is an important first step in developing appropriate community-based and clinical interventions that could help reduce the disparity seen for CRC. Although there was no difference in screening intention, findings demonstrated gender differences in CRC knowledge and perceived risk. Study findings suggest that African American women lack accurate CRC knowledge and have less perceived risk for developing CRC. Subsequently, interventions that tailor CRC health information to African American women so that they better understand their risk are clearly warranted.
J Community Health (2014) 39:230–238 Acknowledgments The authors gratefully acknowledge the support of Jessie Trice Community Health Center and The Beautiful Gate Cancer Support and Resource Center for their contributions made to this project. This research was sponsored with funding from the National Cancer Institute (K22 CA126979). Conflict of interest None of the authors have any financial conflicts of interest to declare.
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ORIGINAL PAPER
The Influence of Gender on Colorectal Cancer Knowledge, Screening Intention, Perceived Risk and Worry Among African Americans in South Florida Sheila Y. McKinney • Richard C. Palmer
Published online: 28 December 2013 Ó Springer Science+Business Media New York 2013
Abstract The aim of this study was to examine if gender differences exist for colorectal cancer (CRC) knowledge, intention to screen, perceived risk and cancer worry among African Americans for CRC. African American males and females (N = 336) aged 45 years or older living in southeast Florida were recruited to participate in a crosssectional survey that assessed intentions to screen as well as CRC knowledge, cancer worry, perceived risk. No significant differences were found between men and women in their intention to screen for CRC or in their worry about cancer. Results did suggest that men and women differed significantly about their understanding of CRC knowledge. Findings also showed that there were differences in perceived risk between genders, with female study participants possessing lower levels of risk than men. Study results suggest that future interventions need to ensure that females understand their risk for CRC and understand the benefits associated with CRC screening. Findings also suggest that interventions promoting CRC screening may need to be tailored if increased participation in CRC screening is to be achieved for women. Keywords CRC screening African Americans Gender differences CRC knowledge Intention Perceived risk Worry
S. Y. McKinney (&) R. C. Palmer Robert Stempel College of Public Health and Social Work, 11200 SW 8th Street, Miami, FL 33199, USA e-mail: [email protected] R. C. Palmer e-mail: [email protected]
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Introduction Colorectal cancer (CRC) disproportionately affects African American men and women with both having the highest mortality and morbidity rates than in any other racial or ethnic group in the United States [1–4]. A key factor influencing this pattern is that African Americans participate infrequently in CRC screening [3]. Low CRC participation rates have shown to contribute to these higher rates of CRC morbidity and mortality [3]. As a result, African Americans remain unaware that they may be developing precancerous polyps within their colon area, and if diagnosed in time can be removed. Subsequently, efforts are needed to increase African Americans’ acceptance and adherence to CRC screening because screening allows for removal of precancerous polyps and can prevent late-stage diagnoses [5]. Despite these benefits, the most common CRC screening tests remain underutilized by African Americans [6]. Several factors predispose a person to complete CRC screening. Data suggest that increased disease knowledge is linked to increased intention to complete CRC screening [7]. Therefore, if a person has greater knowledge about the disease, its consequences and how to prevent or treat the disease, she would be more apt to avoid developing the disease by engaging in CRC screening. Also, comprehensive knowledge about the disease may promote a better understanding of how personal choices to engage in preventive activities influence ones risk for developing the disease or avoiding the disease altogether [8]. Wong et al. (2013) in a purposive study of 29 African Americans over 50, found a significant difference between those that had completed a colonoscopy (n = 17) and those that had not (n = 12) in their level of knowledge about CRC. This study determined that those completing screening had a
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stronger foundation in knowledge about the disease and CRC screening information. In fact, knowledge was found more influential than physician recommendation to screen. This suggests that patient knowledge about CRC is a critical component to developing the capacity to make a decision for or against CRC screening. Likewise, psychosocial factors, such as, cancer worry and perceived risk, have played an important role to improve health behaviors. These factors act as mediators for intention to screen, whereby, people who worry about and perceive they are at risk for poor health, have a greater likelihood to want to screen for CRC [9, 10]. The influence of intention alone and in tandem with these psychosocial factors have shown to influence health behavior in areas such as breast cancer, obesity and smoking cessation but these effects can be inconsistent [11–13]. At times these factors strengthen a patient’s intent to screen or take actions that improve her health status and in others there is marginal effect, at best. [11–13] For instance, Chilton et al. (2013) described how an educational component within a community mammography screening event that addressed risk and provided information about breast cancer in a culturally responsive context increased intention post intervention of American Indian women to continue annual screenings in the future. But, Soureti et al. (2013) found that perceived risk alone was not as effective a mediator to stop smoking and that perceived risk in conjunction with an affective component may increase intention to stop smoking. These inconsistencies indicate that more work is needed to understand the context for which intention can consistently lead to changed health behavior. Investigations have also occurred to better understand the uptake patterns of African American men and women to complete CRC screening. What is known is that participation in screening varies by race and gender, with African Americans less likely than whites to receive preventive health services including CRC screenings [14]. And, African-American women tend to participate more in overall screening activities than men, but in terms of colon cancer, they screen less [15, 16]. Lower participation rates of African American women happen even though women may be more actively engaged in preventive care, or have ongoing, consistent relationships with a care facility; thus providing them greater access to screening services over men [17, 18]. The challenge to improving CRC screening for women is to encourage their participation in CRC screening as part of their current repertoire of care and, for men, to first get them enrolled into care then indoctrinate them into preventive health routines [17–19]. Current research has offered inconsistent findings about the effect of intention, mediated by psychosocial factors, on health behaviors. It is therefore uncertain why these inconsistencies exist, and these relationships are less
231
studied in their application to colon cancer, particularly among African Americans. Among this segment even fewer studies, have examined gender’s effect on CRC knowledge, cancer worry, perceived risk and intention to complete CRC screening. Exploring these issues would strengthen the field’s ability to answer whether patient intent to screen prior to an intervention can serve as a reliable indicator that a patient will screen after exposure to an intervention. The aim of this study was to examine if gender differences exist among African Americans who are not adherent to CRC recommendations in terms of CRC knowledge, cancer worry, perceived risk, and intention to screen.
Methods Participants African-American males and females aged 45 years and older were recruited to participate in this study. Study participants were recruited from clinic and community organizations throughout southeast Florida. Individuals were screened by study staff and self-reported meeting eligibility criteria. Eligibility consisted of (1) self-identified as African American or black, (2) at least 45 years of age, (3) understood spoken English language, (4) not adherent to CRC screening guidelines, and (5) working telephone. Procedures Research staff recruited participants from common waiting areas by distributing flyers about the study. Following informed consent, study participants were asked to complete a questionnaire. Study staff offered to read the questionnaire if needed. If participants declined, they completed the questionnaire independently in approximately 20 min. This study was approved by the institutional review board of Florida International University. Data Collection Tool Individuals were asked to complete a survey that contained 30 items. Measures Demographic Characteristics Eleven questions recorded participants’ ethnicity, age, last completed grade in school, insurance status, total household income, marital status, living arrangements, parental status, guardianship of child less than 18 years, and average monthly attendance for religious services.
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Table 1 Demographic characteristics by gender (N = 336) Variable
Males (n = 119)
Females (n = 217)
N
%a
N
104
87.4 %
178
10
.08
25
Black (African)
1
.01
4
Black (Hispanic)
2
.02
3
.01
Multiracial
2
.02
3
.01
Other
0
0
4
.02
33
28.7
72
p
%
Ethnicity Black (African American) Black (Caribbean)
82.0 %
.581
11.5 .02
screen for CRC (yes, no, don’t know) and, if so, when. Participants were also asked about their certainty to complete CRC screening as ‘‘how sure’’ (4-point Likert from not very sure to very sure) and ‘‘how likely’’ (4-point Likert from not very likely to very likely) to test. These items were taken from pre-existing scales [20–23]. Responses were coded according to the response option number, then averaged to create an intention to screen mean scale score. Perceived Risk
Age (In Years) 45–49
33.6
50–59
55
47.8
92
43.0
60?
27
23.5
50
23.4
.617
Education (highest grade) Less than high school
28
24.3
41
19.3
High school or GED
50
43.5
95
44.8
College and above
37
32.2
76
35.8
Yes
14
12.2
39
18.3
No
101
87.8
174
81.7
Under $15,000
43
39.1
99
47.1
$15,000–$25,000
13
11.8
30
14.3
$25,001–$35,000
10
9.1
15
7.1
Insurance
.150
Previous year’s household income
.512
$35,001 and above
15
13.6
23
11.0
Don’t Know
29
26.4
43
20.5
Yes, married/living with partner
49
41.2
72
33.2
I am neither married nor living with a partner
70
58.8
145
66.8
One (1), I live by myself
46
41.4
68
32.5
Two (2) people
27
24.3
55
26.3
Three (3) people
17
15.3
32
15.3
Four (4) people
14
12.6
20
9.6
7
6.3
34
16.3
Yes
92
80.7
184
86.8
No
22
19.3
28
13.2
Marital status
.144
Living arrangements
Five (5) or more people
.146
Guardian of child 18 or under
.055
Yes
43
38.1
59
27.7
No
70
61.9
154
72.3
One time per month
29
25.2
23
11.0
Two times per month
13
11.3
30
14.3
Three or more times per month
45
39.1
132
62.9
I don’t attend services
28
24.3
25
11.9
\.001
Attends Religious Services
Percentages may not add to 100 % because of missing responses
Intention to Screen for CRC Participants answered six questions about future plans to screen. All participants were asked whether they plan to
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CRC Knowledge Participants were asked five items that assessed knowledge. These items were modified from Sanderson et al. and Palmer [24, 25]. Responses were coded 1 for true and 0 for false. A mean CRC knowledge score was calculated. Worry about Cancer
.093
Children
a
.547
Participants answered three questions on CRC risk. Participants were asked about their overall chance of developing cancer, whether they viewed themselves at lower risk for developing cancer compared to others the same age, and whether they thought they would likely develop CRC. Responses were provided on a 4-point Likert scale anchored by 1 strongly disagree and 4 strongly agree. These items were modified from pre-existing scales [23]. A mean scale score was calculated.
Two questions were used to assess participants’ worry about developing cancer. A 4-point Likert assessed their level of agreement to the statements ‘‘I am afraid of having an abnormal colon cancer screening test result’’ and ‘‘I am worried that colorectal cancer screening will show that I have colon cancer.’’ These items were taken from preexisting scales and averaged to create a score [23]. Data Analysis Data were cleaned prior to analysis and checked for data entry errors. Frequencies, percentages, means and standard deviations were used to describe the demographic characteristics. Differences in knowledge scores, intention to screen, perceived risk and cancer worry by gender were analyzed using Chi square and t tests. Multivariate logistic regression was then performed as the primary analysis which is to understand the extent that gender has an effect on intention to screen for colon cancer. Multivariate linear regression explored the secondary analyses of gender’s effect on perceived risk and worry about cancer. Data were analyzed using IBM SPSS Statistics 20 [26].
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Results
233 Table 2 Response summary to psychosocial variables by gender N = 336
Demographics There were a total of 336 study participants (Table 1). Of these, 119 were male and 217 female and the majority was between the age of 50 and 59. Most participants were also uninsured, were high school graduates, reported an annual income less than $15,000, lived alone and were unmarried but had children older than 18 years. Intention to Screen for CRC For both men and women the majority, 66.4 and 61.2 % respectively, indicated that they would screen for CRC. Further, almost one-third of the men (29.9 %) and onefifth of the women (21.6 %) did not know whether they would complete CRC screening. Gender had no effect on participants’ intention to screen (p = .220). There were no significant differences for the individual items that measured intention to screen gender (p = .984) (Table 2). The majority of both men and women were interested in screening and planned to do so in the near future. Perceived Risk for CRC There was a significant difference between men and women in their perceived risk for developing CRC with men [M = 2.53, SD (.46), p \ .001] having a stronger perception of personal risk compared to women [M = 2.34, SD (.52)]. More men (59.5 %) agree with the statement that their chance of developing cancer is high compared to 33.4 % of women. In fact, almost 67 % of the women disagreed with this statement. Moreover, women viewed the likelihood of ever developing CRC to be a remote possibility compared to men (75.7 versus 57.8 %, p \ .001) (Table 2).
Knowledge about CRC Men and women differed significantly about their understanding of CRC facts with men having a better understanding about the disease than women according to the CRC knowledge scale (p = .005) (Table 2). Specifically, men and women have a common understanding for what constitutes risk for developing this disease, but, 36.2 % of the men and 48.8 % of the women underestimate their personal risk for developing CRC (p = .009) (Table 3)
Males n (%)
Females n (%)
p
Intention to Screen Do you ever plan to have a colon cancer screening test?
.220
Yes
77 (66.4 %)
No
14 (12.1)
131 (61.2 %) 19 (8.9)
Don’t know
25 (21.6)
64 (29.9) .463
How likely are you to have a colon cancer screening in the next 6 months? Not likely
21 (18.1)
Somewhat likely
27 (23.3)
36 (16.8) 63 (29.4)
Likely
35 (30.2)
50 (23.4)
Very likely
33 (28.4)
65 (30.4)
How likely are you to have a colon cancer screening in the future?
.912
Not likely
10 (8.5)
Somewhat likely
22 (18.8)
18 (8.4) 45 (20.9)
Likely
39 (33.3)
64 (29.8)
Very likely
46 (39.3)
88 (40.9)
How sure are you that you will have a test to detect colon cancer in the next 6 months?
.894
Not at all sure
19 (16.4)
42 (19.5)
Only a little sure
16 (13.8)
26 (12.1)
Somewhat sure
37 (31.9)
68 (31.6)
Very sure
44 (37.9)
79 (36.7) .776
How sure are you that you will have a test to detect colon cancer in the future? Not at all sure
18 (15.5)
25 (11.7)
Only a little sure
13 (11.2)
28 (13.1)
Somewhat sure
32 (27.6)
60 (28.0)
Very Sure
53 (45.7)
101 (47.2)
Perceived risk \.001
The chance that I may develop colon cancer is high Strongly disagree
9 (7.8)
46 (21.6)
Disagree
38 (32.8)
96 (45.1)
Agree
56 (48.3)
53 (24.9)
Strongly agree
13 (11.2)
18 (8.5)
Compared with other persons my age, I am at lower risk for colon cancer
.868
Strongly agree
10 (8.7)
19 (8.9)
Agree
36 (31.3)
62 (29.0)
Disagree
56 (48.7)
102 (47.7)
Strongly disagree
13 (11.3)
31 (14.5) \.001
It is very likely that I will develop colon cancer Strongly disagree
13 (11.2)
43 (20.1)
Disagree
54 (46.6)
119 (55.6)
Agree
45 (38.8)
30 (14.0)
4 (3.4)
22 (10.3)
Strongly agree
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Table 2 continued Males n (%)
Females n (%)
p
Cancer worry I am afraid of having an abnormal colon cancer screening test result
.635
Strongly disagree
16 (13.8)
38 (17.8)
Disagree
51 (44.0)
84 (39.3)
Agree
4 (34.5)
70 (32.7)
Strongly agree
9 (7.8)
22 (10.3) .180
I am worried that colorectal cancer screening will show that I have colon cancer Strongly disagree
21 (18.4)
57 (26.5)
Disagree
52 (45.6)
103 (47.9)
Agree
33 (28.9)
44 (20.5)
8 (7.0)
11 (5.1)
Strongly agree
Worry About Cancer There was no statistically significant difference between men and women in their worry about cancer and CRC cancer in particular (p = .191) (Table 2). The two items used to measure cancer worry indicated that men and women have similar levels of concern regarding having an abnormal test result and fear that the test will indicate CRC. Gender’s Effect on Cancer Screening The models created using regression included all predictors explored in the bivariate analyses. Although not every predictor was found to be significant in the bivariate analyses, they were used because other studies have found them to be important predictors for cancer screening among African Americans [17, 27]. Multivariate logistic regression was conducted to determine the effect of patient’s gender on baseline intention to screen for colon cancer. As a dichotomous option of yes, I intend to screen or no, I don’t intend to screen, gender did not have a statistically significant effect v2 = 20.479, df (12), p = .059 within the overall model; its effect accounting for 63 % of the variance in the
sample. And while gender was not significant, two other factors, not having health insurance (p = .048) and not attending religious services were statistically significant to predict intention to screen in the multivariate logistic model as noted in Table 4. These findings suggest that black women without health insurance (OR 2.129) or do not attend religious services (OR 2.215) are almost twice as likely lack an initial intention to screen for colon cancer compared to other black women and men. Multivariate linear regression was conducted to determine how well a patient’s gender predicted the effect on his or her perceived risk for developing colon cancer. This analysis confirmed this study’s bivariate findings that gender significantly effects a patient’s perception of risk for developing colon cancer for mean scores, R2 = .083, adjusted R2 = .051, F(10, 288) = 2.595, p = .005. Table 5 illustrates that perceived risk was significantly influenced only by the patients’ gender (p = .001), suggesting that black women differ in their perception of risk than black men. While not significant women without children approached significance (p = .057). These findings suggest that black women, particularly among those without children, may have lower perceived risk for developing colon cancer than black men and other black women. Multivariate linear regression was also conducted to determine how well a patient’s gender predicted the effect on his or her worry about developing colon cancer. This analysis also confirmed the earlier bivariate findings that gender does not predict a patient’s sense of worry for developing colon cancer and worry about developing colon cancer as documented using the mean scores R2 = .25 adjusted R2 = -.009, F(10, 289) = .739, p = .688. In this analysis none of the individual factors were found to have a significant effect on cancer worry as noted in Table 6.
Discussion The goal of this study was to examine if intention to screen for CRC differed by gender among African Americans who are non-adherent to screening guidelines. Likewise,
Table 3 CRC knowledge by gender N = 336 Knowledge items
Males n (%) True
Females n (%) False
People can have colon cancer without having symptoms
99 (86.1 %)
16 (13.9 %)
Colon cancer can be prevented
19 (16.4)
97 (83.6)
n (%) True 172 (80.4 %) 32 (15.0)
p n (%) False 42 (19.6 %) 181 (85.0)
.195 .745
Young people are more likely to get colon cancer than older people
10 (8.6)
106 (91.4)
30 (14.5)
184 (86.0)
.151
Only people who eat poorly will develop colon cancer Men are more likely to get colon cancer than women
11 (9.5) 74 (63.8)
105 (90.5) 42 (36.2)
31 (14.5) 105 (48.8)
183 (85.5) 110 (51.2)
.193 .009
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235
Table 4 Multivariate logistic regression: intention to screen for colon cancer (N = 336)
Table 5 Multivariate linear regression: perceived risk to develop colon cancer (N = 336)
Variable
p
Variable
.970
Constant
Constant
OR
CI
.973
Gender Male versus Female*
Gender .644
.349, 1.071
.085
Age (in years) Under 50 versus Above 50*
1.211
.702, 2.090
.491
Education (highest grade) Less than high school High School or GED
.740 .905
.366, 1.496 .506, 1.617
.401 .736
More than high school* 2.129
1.007, 4.500
.048
Under $25,000
1.391
.775, 2.497
.268
$25,001 and above
1.275
.631, 2.575
.498
Previous year’s household income
1.272
.958, 1.689
.096
.663
.369, 1.191
.169
Living arrangements Children Yes versus no* Guardian of child 18 or under Yes versus No*
1.172
.584, 2.350
.655
.622
.346, 1.116
.111
2.215
1.614, 4.216
.015
Attends religious services Yes versus No*
p
2.413, 3.135
\.001
-.345, -.093
.001
.089
-.038, .217
.169
Education (highest grade)
-.028
-.107, .052
.492
Insurance
-.022
-.180, .135
.781
Previous year’s household income
.006
-.061, .074
.855
Marital status Living arrangements
.032 .042
-.032, .096 -.092, .176
.330 .541
Age (in years)
-.156
-.316, .005
.057
Guardian of child 18 or under
.065
-.071, .202
.347
Attends religious services
.027
-.068, .122
.572
Table 6 Multivariate linear regression: worry about colon cancer (N = 336)
Marital status
Alone versus with someone*
-2.19
CI
Bold values are statistically significant (p \ 0.05)
Doesn’t know* Married/Partner versus Not married*
2.774
Children
Insurance Yes versus No*
b
Variable
b
CI
p
Constant
2.471
1.956, 2.986
\.001
Gender
-.143
-.323, -.036
.117
Age (in years)
-.054
-.236, .128
.561
Education (highest grade)
-.149
-.374, .076
.194
Insurance
-.015
-.128, .099
.801
Previous year’ household income
-.012
-.108, .084
.806
Marital status Living arrangements
-.108 .047
-.299, .084 -.044, .139
.269 .311
Bold values are statistically significant (p \ 0.05)
Children
.113
-.116, .343
.332
* Referent
Guardian of child 18 or under
-.097
-.291, .098
.350
Attends religious services
-.024
-.160, .112
.732
explore if similar differences exist for knowledge, worry and perceived risk for developing CRC. Of the variables examined in this study, several did show differences between males and females but there were no gender differences for intention to screen. While this study did not find statistically significant differences with intention by gender, there is substantial empirical data that maintains support for behavioral intention as an important predictor for the uptake of cancer screening [28, 29]. This study did find significant relationships between gender and a person having health insurance, actively engaged in religious services and having some education. These findings are congruent with other studies that have found lack of insurance presents as a major barrier to completing screening and individuals without insurance are less likely to seek medical care where screening assessments and activities occur [29, 30]. Other studies have found that church group membership and involvement are associated with lower cancer risk because of the social ties and networks found in these centers [31, 32]. Specifically, the
p \ .05
activities sponsored in churches and places of worship often promote physical, emotional and mental wellbeing; particularly advantageous for African Americans because of the historical importance and role of church and religion on decision making, behavior and the overall life course of African Americans [31–33]. Therefore, these venues could be used to promote cancer screening for African Americans by reaching those not engaged with a medical home providing support for a person from intention to successful completion. Future interventions should continue to target changing behavioral intention since it is a strong precursor to CRC screening as well as other cancer screening behaviors [30, 34, 35]. In the current study more men than women intended to screen for CRC, yet more African American women report actually being screened in the literature [36]. This lack of intention to participate is somewhat ironic since women will engage with the
123
236
healthcare system and participate more in screening for other diseases than men [37, 38]. A natural opportunity exists to screen women as part of routine care, and this may account for why women are screened more often. Men on the other hand, are not as easily accessible to engage and educate about CRC risk because they do not routinely seek preventive health care [15, 39]. This study did find a significant difference by gender for CRC risk perception. Our findings are congruent with other research where perceived risk is shown to influence screening behavior whereby a person who thinks they are at risk will be motivated to screen [40, 41]. In this study, the majority knew about colon cancer and that this disease impacted African Americans, but there appeared to be a pattern, especially among women, not to contextualize this information as personal risk. Also, these women are younger (under 60) and may have not been counseled to screen during routine medical visits. Coupled with seeing themselves as healthy, CRC would not be an immediate concern. In such instances, provider recommendations may become more important for women [27]. To be effective, CRC information should contain personally relevant perspectives to foster a relationship between knowledge and risk that leads to screening participation [42]. Most importantly, people who perceive themselves at risk are more likely to act in a manner that reduces their risk compared to others. This is particularly interesting because in controlling for gender the regression model found that having children increased risk perception among a sample where the majority of both women (86.8 %) and men (80.7 %) had children. This suggests that the importance of being a care giver or provider may be equally important for men and women both having shown as effective to motivate people to screen for CRC in previous studies. [43] This study also found that higher educational attainment made a person more receptive to the perception of risk unlike intention, where this research did not find such a distinction by level of education. Other research does show that individuals who are educated are more likely to adhere to screening guidelines and that there is a positive correlation between educational attainment and CRC screening [8, 43]. This study then adds that perceived risk, which is a critical factor for CRC adherence, may be more influential among those with more education than less education. The combined implications may be that regardless of education level and gender, addressing issues related to family or care of children may be the most influential to encourage a person to complete CRC screening and this influence may be strongest for those with less education. This study found significant differences in CRC knowledge between men and women which are congruent with other research [15]. Women responded more often that men were at greater risk for developing CRC than
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themselves when the risk is equal. This misperception of personal risk might be explained by CRC knowledge deficiencies whereby women’s sense of personal risk is reduced because of their poor knowledge about CRC. Research has also shown that knowledge influences screening behavior since improved understanding about a particular disease leads to greater perceived risk for developing the disease and stronger motivation to screen [15, 41, 44, 45]. Given that CRC is a preventable disease, providers caring for similar patients should improve their CRC knowledge as an important first step to increase the number of people, especially women, that intend to screen for CRC. Research has also shown that CRC screening is a complex behavior influenced by many factors, including CRC awareness [44]. In this study, over one-third of both men and women had no intention to screen yet most had a working knowledge of CRC. Other research has shown that the benefits of knowledge are often mitigated by fear defined as refusing to engage with the care system, distrust, and fatalism [7]. This same fear may be linked to emerging research on feelings of risk which focus on the emotion of risk versus traditional concepts of perceived risk; and have proven relevant to screening messages and screening attitudes [41]. The implication is that health messaging requires disease facts and content covering the fear and emotions associated with CRC screening to change behavior. Intervention studies that incorporate messages with content relevant to gender-based concerns against feelings-of-risk are recommended. Although findings suggest that there are gender differences in CRC knowledge and perceived risk, there are study limitations that need to be acknowledged. This is a cross-sectional study and no causality is implied. These results may be limited in their generalizability because the study was conducted with patients who received care from a community health clinic. Subsequently, the majority of the participants reported lower income and the responses may not be generalizable to other African American populations. Finally, data were selfreported and participation bias could exist. African Americans participate in CRC screening less often than other racial/ethnic groups. Understanding what variables may influence intention is an important first step in developing appropriate community-based and clinical interventions that could help reduce the disparity seen for CRC. Although there was no difference in screening intention, findings demonstrated gender differences in CRC knowledge and perceived risk. Study findings suggest that African American women lack accurate CRC knowledge and have less perceived risk for developing CRC. Subsequently, interventions that tailor CRC health information to African American women so that they better understand their risk are clearly warranted.
J Community Health (2014) 39:230–238 Acknowledgments The authors gratefully acknowledge the support of Jessie Trice Community Health Center and The Beautiful Gate Cancer Support and Resource Center for their contributions made to this project. This research was sponsored with funding from the National Cancer Institute (K22 CA126979). Conflict of interest None of the authors have any financial conflicts of interest to declare.
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