Abstract A telephone survey with 604 men and women without history of colorectal cancer (CRC)(age 50-74
years) explored knowledge of, attitudes toward, and intention to screen for CRC using faecal occult blood tests (FOBT) in a rural
Australian population. Overall, 53% intended to participate in and 86% would follow a doctor’s recommendation for FOBT screening. In contrast, only 18% had ever had a FOBT, and fewer than 60% of those with high-risk family history had undergone appropriate screening for CRC. Prior
of FOBT
3.2) O ( , R= high perceived susceptibility to CRC OR belief in the importance ( =2.4), of screening despite the absence of OR were positively ( symptoms =2.1) and older age ( OR 0.5) was negatively related to screening intention in multivariate logistic regression analysis. A doctor’s recommendation improved screening intention among those use
=
who never tested for CRC before but believe in the importance of early treatment. This study highlights the lack of compliance with standard CRC screening recommendations in Australia and provides evidence for the of continued importance educational efforts, with the particular emphasis on older adults and the medical community. Asia Pac JPublic Health 5(1): 2003; 1 5056.
: Colorectal cancer, faecal Key words occult blood test, family history, intention, screening.
Correspondence: Beth Newman, PhD Professor of Public Health School of Public Health Queensland University of Technology Victoria Park Road Kelvin Grove Q 4059, Australia Phone: ++61 7 3864 5839; Fax: ++61 7 3864 3369; E-mail:
[email protected]
Knowledge, Attitude and Intentions Related to Colorectal Cancer Screening Using Faecal Occult Blood Tests in a Rural Australian
Population Monika Janda 1 , M Phil, PhD Warren R Stanton , MAPS, PhD 2 Karen Hughes 1 , BA , MD, FRACGP 3 Christopher Del Mar Alexandra Clavarino , BA, PhD 2 Joanne F , 4 MS, PhD Aitken Shilu Tong’, M Med, PhD Leonie Short , BA, MHP 1 Barbara , 5 MD, FRACP Leggett Beth Newman , MS, PhD 1 Centre for Public Health Research, Queensland University of Technology, Queensland, 1 Australia. Centre for Health Promotion and Cancer Prevention Research, University of Queensland, 2 Queensland, Australia. 3Centre for General Practice, University of Queensland, Queensland, Australia. Queensland Cancer Fund, Brisbane, Queensland, Australia. 4 Royal Brisbane Hospital, Department of Gastroenterology and Hepatology, Herston 5 Medical School, Queensland, Australia.
Introduction
Colorectal cancer is a significant burden for Australia, affecting about 10,000 Australians and causing approximately 4500 deaths per year I, 2. There is now considerable evidence that screening with a faecal occult blood test (FOBT) can reduce mortality from CRC3. A populationwide FOBT screening programme for average-risk individuals which might be considered in the near future in Australia’, is being discussed in other countries, such as the UK4, and has been recommended by the Advisory Committee on Cancer Prevention for consideration by the Member States of the European Unions. However, too little is known about community preferences and possible implications
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screening3-4,6-7 or how the high participation rates required for cost-effective implementation can be achievedg-1°, particularly in rural communities. A further area requiring consideration is the issue of informed consent (i.e., the appropriate communication about potential for FOBT
benefits and risks to assist individuals in the decision-making procesS)6. Several Australian&dquo;-’s and international 16 studies have examined In CRC screening behaviour. Australia, screening intent ranges between 10% and 77%&dquo;-&dquo;. Survey samples reporting a low intention to screen also reported a high degree of uncertainty regarding the importance and usefulness of CRC screening&dquo;. A high screening intent was found when
framed screening in terms recommendation by health authorities or a doctorl7. Gender, age, and socioeconomic level were significantly related to FOBT screening intention and uptake in several studies 14,17, 19 and perceived susceptibility to CRC also appears to be a strong predictor of FOBT the of
study
a
screening 14 . However, again, most studies have largely reflected views of urban residents. There is limited research addressing populations with perceived or actual increased risk of CRC, especially relatives of CRC patients2o21. First-degree relatives are more knowledgeable about CRC, but remain unlikely to screen. In a study of 225 first-degree relatives of CRC patients, only three had been screened in accordance with guidelines for firstdegree relatives published by the Australian Cancer Society2l. Further, although individuals with a family history report concern about their CRC risk, these concerns are not necessarily being addressed adequately by their doctors. Focus groups with firstdegree relativess reveal that participants feel at risk irrespective of whether their family history conforms with definitions of high-risk provided by the Australian National Health and Medical Research CouncilI (N H M RC ) ’ ,~~ . Participants also reported that their general practitioners (GPs) rarely initiated discussion on CRC and screening22 . This finding could have implications for CRC screening in rural communities where the GP is often the only readily accessible source of medical advice23. The present study is part of a demonstration project utilising FOBT screening in a rural setting. The first phase was to document current practice. A telephone survey with a random sample of residents was conducted prior to GPs offering a free FOBT to all of their patients aged 5074 years. The intention of survey respondents to engage in FOBT screening was examined and the participants’ family history of CRC status was taken into account.
Methods A
telephone
survey
was
conducted
with men and women aged 50 to 74 years living in a rural area of Northern Australia. The area contains approximately 4,200 residents aged 50 years or older. Households were contacted using an extended electronic white pages (EEWP) random sampling procedure. The EEWP is an electronic version of the latest telephone directory and considered a reliable and comprehensive list of residential telephone numbers. All telephone numbers within the geographical area of interest were loaded into a database and presented to the interviewers in random order to achieve a random sample. We intended to interview 600 residents. This sample size allowed sufficient precision to provide for estimates with a maximum confidence interval of ± 3.7% (two-tailed alpha=0.05). The sample was stratified to include equal numbers of men and women. Professional telephone interviewers administered a brief, structured
questionnaire using a computerassisted telephone interviewing (CATI) system. The interview took approximately 12 minutes to complete. In total, 4208 numbers were attempted, with each number contacted up to six times over a spread of times and days. Among these, 3,355 numbers were excluded for one of the following reasons: ineligible household member (no one of specified sex or age (n=2145), prior history of CRC (n=22), no answer after six attempts (n=220), fax or answering machine (n=110), engaged
phone
or
language problems (n=90),
non-residential (n=98), wrong (n=16) or disconnected (n=650) number or the person was reached twice (n=4). Overall, 248 potential participants refused 122 after eligibility was confirmed and 126 before eligibility could be evaluated resulting in 605 completed interviews. Correcting for the number of households with a predicted eligible member, the overall response rate was 79.4%. One participant was subsequently excluded because he did not meet the age requirement. Analyses are therefore based on 604 (303 women and 301 men) completed interviews. The questionnaire was based on an instrument previously utilised by -
members of our research team&dquo;. Questions related to perceived susceptibility, intention to screen with FOBT, and agreement with the goals of screening (i.e., ’It is important to check for bowel cancer even if I have no symptoms, ’ and‘Treating bowel cancer in the early stages increases a persons chance of survival ) utilised 5-point likert response categories. Additional questions addressed: family history, prior use/ awareness of tests for CRC, attitude to diet restrictions, and demographic factors. To assess family history, participants were asked to outline whom in their family had CRC and at what age they were diagnosed. Based on responses, participants were assigned to one of four distinct groups: ’high-risk family history of CRC’ (see definition in footnote of Table 2); ’other family history of CRC’; ’know somebody with CRC’; ’know no one with CRC’. To assess screening intent, participants were asked about their likelihood of participating in future FOBT screening. Those who answered ’very likely’ were not queried further; all other participants were asked if they would be more likely to follow a recommendation by their health department or by their doctor. Statistical
analysis
Chi-square tests were conducted to highlight differences between groups defined by family history or other familiarity with CRC patients. Multivariate logistic regression analyses were performed to detect those
characteristics
that
are
independently associated with participants being ’likely’ or ’very likely’ to consider future FOBT screening.
-
Results
.
Screening intention Table 1 summarises the demographic characteristics of the 604 participants and presents the proportion intending to participate in future FOBT within each subgroup. Mean age was 60 years and both genders were equally represented. The majority of the sample lived with a partner. When 51
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Table 1. Distribution of faecal occult blood test
socio-demographic
characteristics and
proportion indicating intention
to
screen
with
ap < 0.01 (participants aged 70-74 years were significantly less likely to express an intention to participate in FOBT compared to younger
participants). asked how likely they were to participate in FOBT screening in the future, 89 (15%) participants responded ’very likely’ and an additional 231 (38%) indicated that
they
were
’likely’
to
participate.
Recommendation by a doctor increased the likelihood of participation substantially, with 441
(86%) responding ’very likely, likely’ to
participate in FOBT. Significantly participants were &dquo;very likely&dquo;
more
to follow a recommendation from their
doctor (66%) than a recommendation by the health department (32%) (XI 109.9, p
