"Do we really need all that equipment?": factors influencing colorectal cancer screening decisions

Characterizing the Perceived Need for CRC Screening among the Elderly Living in Rural Areas in the Pacific Northwest US: Roles of Miscommunication, Experience of Discrimination, and Dependence

PURPOSE

Increasing the perceived need for CRC screening can facilitate undertaking CRC screening. This study aims to identify factors associated with the need for CRC screening in rural populations.

DESIGN

A cross-sectional online survey.

SETTING

The survey was conducted in June - September 2022 in the rural areas of Alaska, Idaho, Oregon, and Washington, US.

SUBJECTS

The subjects of this study were 250 adults (completion rate: 65%) aged 45-75 residing in rural Alaska, Idaho, Oregon, and Washington.

MEASURES

Perceived need for CRC screening, internet usage for health purposes, demographics, and intrapersonal, interpersonal, community, and environmental characteristics.

RESULTS

Perceived need for CRC screening were negatively associated with patient-provider miscommunication (β = -.23, P < .001) and perceived discrimination (β = -.21, P < .001), cancer fatalism (β = -.16, P < .05), individualism (β = -.15, P < .05), and dependence on community (β = -.11, P < .05), but positively with compliance with social norms (β = .16, P < .05), trust in health care providers (β = .16, P < .05), knowledge about colorectal cancer (β = .12, P < .05).

CONCLUSIONS

Our study showed potential individual and situational characteristics that might help increase colorectal cancer screening. Future efforts might consider addressing discrimination in health care settings, improving patient-provider communication, and tailoring messaging to reflect the rural culture.

Factors Affecting Attitudes Towards Cancer, Cancer Prevention, and Early Diagnosis Behaviors Among Cancer Patient Relatives

Attitudes towards cancer may affect the cancer prevention behaviors of cancer patients' relatives and their participation in cancer screening. Knowing the factors affecting attitudes will shed light on the education programs to be planned to encourage individuals to gain a positive attitude towards cancer and positive health behaviors in cancer prevention. Determining the behaviors towards cancer prevention and cancer screening, identifying reasons that prevent participation in cancer screening, determining the factors associated with the attitudes of cancer patients' relatives towards cancer, determining the factors affecting their attitudes towards cancer of cancer patients' relatives, can increase the awareness of healthcare professionals and patient relatives on the subject. The aim of the present study was to determine cancer prevention and early diagnosis behavior and the factors affecting the attitudes of towards cancer of cancer patient relatives. The descriptive and analytical study was completed with 321 relatives of cancer patients. The data were collected by the face-to-face interview method. The interview was conducted in a quiet place, alone with the participant, using a clear and simple language, allowing people to speak freely, and avoiding criticism and evaluation. About half of the participants smoked (49.5%), many did not do regular physical activity (67.3%) or protect themselves from the sun (77.3%), and only 10.9% had regular screening tests. The reasons for not having a screening test were ignorance, disregard, lack of complaints, and fear. Acording to binary logistic regression analysis, the determinants included factors of negative attitudes toward cancer with the age of the patient (Exp(β): 1.024), low education level (Exp(β): 2.572), being the child (Exp(β): 8.484) or sibling (Exp(β): 8.801) of the patient, not being protected from the sun (Exp(β): 2.063), and not doing physical activity (Exp(β): 1.744). Even for those having positive health behaviors, such as not smoking (Exp(β): 2.008) and using sun protection (Exp(β): 2.280), the attitudes towards cancer were negative for the Impossible to Recover sub-dimension. Cancer prevention behaviors and regular participation in cancer screening of cancer patients' relatives were very low. It was determined that low education level, increasing age of the patient, and the degree of relation to the patient negatively affected attitudes towards cancer, and that there was a need for education. We believe that the results of the present study will contribute to evidence-based practice for cancer prevention and early diagnosis.

Barriers and facilitators towards colonoscopy: a qualitative systematic review

OBJECTIVES

Colonoscopy is integral in the early detection of colorectal cancer (CRC), be it for screening, diagnostic or therapeutic intentions. Despite the presence of multiple screening modalities, colonoscopy remains integral in providing a definitive CRC diagnosis. However, uptake rates remain low worldwide with minimal understanding towards stakeholders' perspectives. This systematic review is the first to outline the barriers and facilitators faced by providers and patients in receiving colonoscopy specifically.

METHODS

Using PRISMA guidelines, our systematic review consolidates findings from Medline, Embase, CINAHL, PsycINFO and Web of Science Core collection. All perceptions of healthcare providers and screening participants aged 45 and above towards colonoscopy were included.

RESULTS

Forty-five articles were included in our review. Five major analytical themes were identified - procedural perceptions, personal experiences, thoughts and concerns, societal influences, doctor-patient relationship and healthcare system. The discrepancies in knowledge between patients and providers have evidently reduced in the present decade, potentially attributable to the rising influence of social media. The sharing of providers' personal experiences, involvement of patients' family in colonoscopy recommendations and propagation of patients' positive recounts were also more apparent in the past compared to the present decade, highlighting the need to reevaluate the balance between medical confidentiality and personal touch. Additionally, Asian patients were reportedly more apathetic towards CRC diagnosis due to their strong belief in destiny, a crucial association consistent with present studies.

CONCLUSION

This study highlights pertinent gaps in our healthcare system, providing crucial groundwork for interventions to be enacted in engendering higher colonoscopy uptake rates.

Assessing emotions conveyed and elicited by patient narratives and their impact on intention to participate in colorectal cancer screening: A psychophysiological investigation

In the context of colorectal cancer screening, we aimed to compare the effectiveness of different emotion-laden narratives, to investigate the specific emotions elicited at both subjective and physiological levels, and to test the effects of emotions explicitly expressed by the narrative character. Study 1 used a between-participants design comparing four conditions: relief-based narrative, regret-based narrative, control (test-uptake only) narrative, and standard invitation material (no-narrative condition). Study 2 used a mixed design, with the narrative content as a within-participants factor and whether emotions were expressed by the narrative character or not as between-participants factor. The main outcome measures were: intention to undergo testing (Studies 1 and 2), knowledge, risk perception, proportion of informed choices (Study 1), subjective emotional responses, changes in skin conductance, heart rate, and corrugator muscle activity (Study 2). In Study 1, relative to the non-narrative condition (51%), only the relief-based narrative significantly increased intention to undergo testing (86%). Relative to the standard invitation material, the narrative conditions did not decrease knowledge, alter risk perception, or decrease the proportion of informed choices. In Study 2, the relief-based narrative elicited the lowest self-reported negative affect, and received greater implicit attention, as suggested by the larger heart rate decrease. Making the emotions experienced by the narrative character explicit decreased negative affect, as indicated by the lower skin conductance and corrugator responses during reading. Our findings provide support for the use of a relief-based narrative with emotions expressed by the character in addition to the standard information material to promote colorectal cancer screening.

Testing innovative strategies to reduce the social gradient in the uptake of bowel cancer screening: a programme of four qualitatively enhanced randomised controlled trials

Background

Bowel cancer screening reduces cancer-specific mortality. There is a socioeconomic gradient in the uptake of the English NHS Bowel Cancer Screening Programme (BCSP), which may lead to inequalities in cancer outcomes.

Objective

To reduce socioeconomic inequalities in uptake of the NHS BCSP’s guaiac faecal occult blood test (gFOBt) without compromising uptake in any socioeconomic group.

Design

Workstream 1 explored psychosocial determinants of non-uptake of gFOBt in focus groups and interviews. Workstream 2 developed and tested four theoretically based interventions: (1) ‘gist’ information, (2) a ‘narrative’ leaflet, (3) ‘general practice endorsement’ (GPE) and (4) an ‘enhanced reminder’ (ER). Workstream 3 comprised four national cluster randomised controlled trials (RCTs) of the cost-effectiveness of each intervention.

Methods

Interventions were co-designed with user panels, user tested using interviews and focus groups, and piloted with postal questionnaires. RCTs compared ‘usual care’ (existing NHS BCSP invitations) with usual care plus each intervention. The four trials tested: (1) ‘gist’ leaflet (n = 163,525), (2) ‘narrative’ leaflet (n = 150,417), (3) GPE on the invitation letter (n = 265,434) and (4) ER (n = 168,480). Randomisation was based on day of mailing of the screening invitation. The Index of Multiple Deprivation (IMD) score associated with each individual’s home address was used as the marker of socioeconomic circumstances (SECs). Change in the socioeconomic gradient in uptake (interaction between treatment group and IMD quintile) was the primary outcome. Screening uptake was defined as the return of a gFOBt kit within 18 weeks of the invitation that led to a ‘definitive’ test result of either ‘normal’ (i.e. no further investigation required) or ‘abnormal’ (i.e. requiring referral for further testing). Difference in overall uptake was the secondary outcome.

Results

The gist and narrative trials showed no effect on the SECs gradient or overall uptake (57.6% and 56.7%, respectively, compared with 57.3% and 58.5%, respectively, for usual care; allp-values > 0.05). GPE showed no effect on the gradient (p = 0.5) but increased overall uptake [58.2% vs. 57.5% in usual care, odds ratio (OR) = 1.07, 95% confidence interval (CI) 1.04 to 1.10;p < 0.0001]. ER showed a significant interaction with SECs (p = 0.005), with a stronger effect in the most deprived IMD quintile (14.1% vs. 13.3% in usual care, OR = 1.11, 95% CI 1.04 to 1.20;p = 0.003) than the least deprived (34.7% vs. 34.9% in usual care OR = 1.00, 95% CI 0.94 to 1.06;p = 0.98), and higher overall uptake (25.8% vs. 25.1% in usual care, OR = 1.07, 95% CI 1.03 to 1.11;p = 0.001). All interventions were inexpensive to provide.

Limitations

In line with NHS policy, the gist and narrative leaflets supplemented rather than replaced existing NHS BCSP information. This may have undermined their effect.

Conclusions

Enhanced reminder reduced the gradient and modestly increased overall uptake, whereas GPE increased overall uptake but did not reduce the gradient. Therefore, given their effectiveness and very low cost, the findings suggest that implementation of both by the NHS BCSP would be beneficial. The gist and narrative results highlight the challenge of achieving equitable delivery of the screening offer when all communication is written; the format is universal and informed decision-making mandates extensive medical information.

Future work

Socioculturally tailored research to promote communication about screening with family and friends should be developed and evaluated.

Trial registration

Current Controlled Trials ISRCTN74121020.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 8. See the NIHR Journals Library website for further project information.

What Do Men Want from a Health Screening Mobile App? A Qualitative Study

There is a lack of mobile app which aims to improve health screening uptake developed for men. As part of the study to develop an effective mobile app to increase health screening uptake in men, we conducted a needs assessment to find out what do men want from a health screening mobile app. In-depth interviews and focus group discussions were conducted with 31 men from a banking institution in Kuala Lumpur. The participants were purposely sampled according to their job position, age, ethnicity and screening status. The recruitment was stopped once data saturation was achieved. The audio-recorded interviews were transcribed verbatim and analyzed using thematic approach. Three themes emerged from the analysis and they were: content, feature and dissemination. In terms of the content, men wanted the app to provide information regarding health screening and functions that can assess their health; which must be personalized to them and are trustable. The app must have user-friendly features in terms of information delivery, ease of use, attention allocation and social connectivity. For dissemination, men proposed that advertisements, recommendations by health professionals, providing incentive and integrating the app as into existing systems may help to increase the dissemination of the app. This study identified important factors that need to be considered when developing a mobile app to improve health screening uptake. Future studies on mobile app development should elicit users' preference and need in terms of its content, features and dissemination strategies to improve the acceptability and the chance of successful implementation.

Masculinity Beliefs and Colorectal Cancer Screening in Male Veterans

As the third most common cause of cancer death among United States men, colorectal cancer (CRC) represents a significant threat to men's health. Although adherence to CRC screening has the potential to reduce CRC mortality by approximately half, men's current rates of adherence fall below national screening objectives. In qualitative studies, men have reported forgoing screenings involving the rectum (e.g., colonoscopy) due to concern about breaching masculinity norms. However, the extent to which masculinity beliefs predict men's CRC screening adherence has yet to be examined. The current study tested the hypothesis that greater endorsement of masculinity beliefs (i.e., self-reliance, risk-taking, heterosexual self-presentation, and primacy of work) would be associated with a lower likelihood of adherence to CRC screening with any test and with colonoscopy specifically. Participants were 327 men aged 51-75 at average risk for CRC who were accessing primary care services at a Midwestern Veterans Affairs Medical Center. Contrary to hypotheses, masculinity beliefs did not predict CRC screening outcomes in hierarchical regression analyses that controlled for demographic predictors of screening. Although results are largely inconsistent with masculinity theory and prior qualitative findings, further research is needed to determine the degree to which findings generalize to other populations and settings.

Systematic Review and Meta-study Synthesis of Qualitative Studies Evaluating Facilitators and Barriers to Participation in Colorectal Cancer Screening

Screening reduces the incidence, morbidity, and mortality of colorectal cancer, yet participation tends to be low. We undertook a systematic review and meta-study synthesis of qualitative studies to identify facilitators and barriers to colorectal cancer screening participation. We searched major bibliographic databases for records published in all languages from inception to February 2015. Included primary studies that elicited views and perceptions towards colorectal cancer screening were appraised for relevance and quality. We used a two-stage synthesis to create an interpretation of colorectal cancer screening decisions grounded in primary studies; a thematic analysis to group themes and systematically compare studies and a meta-synthesis to generate an expanded theory of colorectal cancer screening participation. Ninety-four studies were included. The decision to participate in colorectal cancer screening depended on an individual's awareness of colorectal cancer screening. Awareness affected views of cancer, attitudes towards colorectal cancer screening modalities, and motivation for screening. Factors mediating awareness included public education to address misconceptions, primary care physician efforts to recommend screening, and the influence of friends and family. Specific barriers to participation in populations with lower participation rates included language barriers, logistical challenges to attending screening tests, and cultural beliefs. This study identifies key barriers, facilitators, and mediators to colorectal cancer screening participation. Cancer Epidemiol Biomarkers Prev; 25(6); 907-17. ©2016 AACR.

Characterizing Online Narratives About Colonoscopy Experiences: Comparing Colon Cancer "Screeners" Versus "Survivors"

Effective screening can reduce colorectal cancer mortality; however, screening uptake is suboptimal. Patients' stories about various health topics are widely available online and in behavioral interventions and are valued by patients. Although these narratives may be promising strategies for promoting cancer screening behavior, scant research has compared the influence of different role models. This study involving content analysis of online stories aimed to (a) describe the content of online experiential narratives about colonoscopy; (b) compare narratives from individuals who had a colonoscopy and either had colon cancer (survivors) or did not have colon cancer (screeners); and (c) generate hypotheses for future studies. The authors identified 90 narratives eligible for analysis from 15 websites. More stories were about White patients, men, and routine (vs. diagnostic) colonoscopy. A higher-than-expected number of narratives reported a family history of colorectal cancer or polyps (20%) and a colorectal cancer diagnosis (47%). Colorectal cancer survivor (vs. screener) stories were longer, mentioned symptoms and diagnostic reasons for getting a colonoscopy more often, and described the colonoscopy procedure or referred to it as easy or painless less often. Future studies should examine the effects of the role model's personal characteristics and the colonoscopy test result on reader's perceptions and intentions to have a colorectal cancer screening.

Turkish social attitudes towards to cancer prevention: a health belief model study

This research was planned to reveal society's attitude towards cancer and early diagnosis using the health belief model. This study was planned as descriptive research in Isparta. A random sample of n=256 individuals of both genders was recruited at the largest shopping center. As a means of collection tool, a survey consisted of two forms, the first designed for sociodemographic information and the second covering 29 questions suitable for the content of Health Belief Model. Of the participants, 66.8% were female and 33.2% were male, and the average age was 33.3±11.0 years. Some 46.1% partly thought that they may develop cancer, and 49.6% were afraid of this possibility. As many as 50% indicated that cancer is an issue that comes from Allah. A significant difference was found between not going for control unless feeling bad, and blood analysis for cancer screening (χ2=3.780 p= 0.03). It was seen that in an area with a high rate of cancer, people's awareness of cancer prevention and early diagnosis and attitudes towards these are insufficient.

Reasons for non-uptake and subsequent participation in the NHS Bowel Cancer Screening Programme: a qualitative study

BACKGROUND

Screening for bowel cancer using the guaiac faecal occult blood test offered by the NHS Bowel Cancer Screening Programme (BCSP) is taken up by 54% of the eligible population. Uptake ranges from 35% in the most to 61% in the least deprived areas. This study explores reasons for non-uptake of bowel cancer screening, and examines reasons for subsequent uptake among participants who had initially not taken part in screening.

METHODS

Focus groups with a socio-economically diverse sample of participants were used to explore participants' experience of invitation to and non-uptake of bowel cancer screening.

RESULTS

Participants described sampling faeces and storing faecal samples as broaching a cultural taboo, and causing shame. Completion of the test kit within the home rather than a formal health setting was considered unsettling and reduced perceived importance. Not knowing screening results was reported to be preferable to the implications of a positive screening result. Feeling well was associated with low perceived relevance of screening. Talking about bowel cancer screening with family and peers emerged as the key to subsequent participation in screening.

CONCLUSIONS

Initiatives to normalise discussion about bowel cancer screening, to link the BCSP to general practice, and to simplify the test itself may lead to increased uptake across all social groups.

Benefits and barriers to participation in colorectal cancer screening: a protocol for a systematic review and synthesis of qualitative studies

INTRODUCTION

Colorectal cancer (CRC) poses a serious health problem worldwide. While screening is effective in reducing CRC mortality, participation in screening tests is generally suboptimal and social inequities in participation are frequently reported. The goal of this review is to synthesise factors that influence an individual's decision to participate in CRC screening, and to explore how those factors vary by sex, ethnicity and socioeconomic status.

DATA SOURCES

A primary search of Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, EMBASE, PsycINFO, and a secondary search of grey literature and articles taken from references of included articles (from inception to July 2013).

DESIGN

A systematic review and Meta-study synthesis of qualitative studies that address perceived benefits and barriers to participation in CRC screening tests among adults 50 years of age or older.

REVIEW METHODS

The two-staged Meta-study methodology by Paterson will be used to conduct this review. In stage 1, similarities/differences, patterns and themes will be identified across three levels of analysis while preserving the context of original studies. In stage 2, synthesis will extend beyond the analysis to generate new theory of the phenomenon through a process called Meta-synthesis.

DISCUSSION

This review offers to generate a framework to better understand benefits and barriers that affect decision-making to participate in CRC screening among different sectors of the population. This framework will be a relevant tool for policy makers in framing educational materials, for patient-centered communication, and for researchers interested in the science of equity. This review is registered in PROSPERO (registration number: CRD42013005025).

Integrating men's health and masculinity theories to explain colorectal cancer screening behavior

Colorectal cancer (CRC) is the third most common cause of cancer deaths among men in the United States. Although CRC screening has been found to reduce CRC incidence and mortality, current screening rates among men are suboptimal due to various practical and psychosocial barriers. One potential barrier to CRC screening identified in qualitative studies with men is the threat to masculinity that endoscopic screening methods pose. Indeed, beliefs about masculinity have been predictive of other preventive health behaviors among men. In this review article, we propose a novel conceptual framework to explain men's CRC screening behavior that integrates masculinity norms, gender role conflict, men's health care experiences, behaviors, and beliefs, and social and background variables. This framework has the potential to guide future research on men's CRC screening behaviors and other health behaviors and may inform gender-sensitive interventions that target masculinity beliefs to increase preventive health behaviors.

Ambivalence and its influence on participation in screening for colorectal cancer

Colorectal cancer (CRC) is one of the most prevalent cancers worldwide, and an ideal target for early detection and prevention through cancer screening. Unfortunately, rates of participation in screening are less than adequate. In this article we explore why people who were offered a fecal immunochemical test for CRC decided to participate or not, and for those who did participate, what influenced them to take action and complete the test. We conducted four focus groups and 30 telephone interviews with 63 people. The main reason people decided to screen was "wanting to know" their CRC status, which operated on a continuum ranging from wanting to know, through varying degrees of ambivalence, to not wanting to know. The majority of participants expressed ambivalence about CRC screening, and the main cue to action was the opportunity to screen without being too inconvenienced.

How do rural health care providers and patients view barriers to colorectal cancer screening? Insights from appalachian kentucky

This article reports findings from a qualitative study that explored the attitudes and beliefs concerning colorectal cancer (CRC) screening among patients and health care providers in Appalachian Kentucky. Results from 5 focus groups are discussed here: 3 with primary care providers and 2 with patients. Although there are some areas of agreement, there are marked differences between the perceptions of Appalachian health care providers and participants regarding CRC screening. This article compares and contrasts those perceptions and provides suggestions for culturally competent practice and culturally relevant research to improve CRC screening in this vulnerable population.

Colorectal cancer screening: patients' and physicians' perspectives on decision-making factors

While patient barriers to colorectal cancer (CRC) screening have been identified, how well this knowledge is utilized during the patient-physician interaction is not fully understood. This study aims to assess among primary care physicians the degree of consensus between perceived and actual patients' CRC screening decision-making influential factors. During 2004-2006, 30 patients were interviewed to identify factors influencing screening decisions and 66 physicians were interviewed to understand what factors they thought were important to patients. The factors were categorized using the PRECEDE-PROCEED framework, and perspectives were compared. The researchers found little consensus on CRC screening decision-making influential factors between family practitioners, general internists, and patients. The recommendations to reach consensus are provided on the individual (e.g., updating the contents of a physician's screening recommendation to proactively address patients' decision-making needs) and population (e.g., providing cross-cultural training to medical students enabling them to better understand their patients) levels.

Knowledge and beliefs of Jordanians toward colorectal cancer screening

BACKGROUND

Colorectal cancer is a significant health problem; it is the most common malignancy of the gastrointestinal tract. Colorectal cancer is closely related to the clinical and pathological stage of the disease at diagnosis, which can be detected early through screening tests.

OBJECTIVE

This descriptive cross-sectional study was conducted to investigate the knowledge and beliefs of Jordanians toward colorectal cancer (CRC) screening using the Health Belief Model.

METHODS

One hundred sixty participants, 50 years and older, were identified in the outpatient clinics at the 2 largest Jordanian hospitals located in the north of the country; the King Abdullah University Hospital and the Princess Basma Hospital.

RESULTS

Data analyses revealed that most participants are not well informed about CRC and screening. Less than half perceived themselves as susceptible to developing CRC. Half comprehended the seriousness of CRC, the majority understood the benefits of CRC screening, and one-third realized the barriers of CRC screening. Moreover, most understood the importance of preventative medicine and was highly motivated.

CONCLUSION

Most Jordanians treated at outpatient clinics comprehend the benefits from CRC screening, understand the seriousness of CRC, and perceive barriers, and more than half of the patients perceive the general health motivation beliefs and outcomes.

IMPLICATION FOR PRACTICE

The healthcare system and the decision makers must develop strategies to increase the general population's awareness about CRC and the accompanying screening tests.

Modeling the decision to undergo colorectal cancer screening: insights on patient preventive decision making

BACKGROUND

Little is known about how patients decide whether or not to undergo colorectal cancer screening. Although low screening rates evidence the outcome of these decisions, the processes patients use to balance benefits, risks, and costs with their own values and preferences are unclear. To increase screening rates, and ultimately save lives, it is important for providers to be aware of how patients make screening decisions.

OBJECTIVES

The purpose of this study was to identify patterns of patient colorectal cancer screening decisions that might be supported by health care providers.

POPULATION

In this study, we focused on people from Central Kentucky--a region with historically low screening rates.

METHOD

We interviewed patients using a semi-structured format. Three members of the research team independently analyzed each interview transcript for factors that influenced the decision, and a pictorial representation of each decision process, based on Kurt Lewin's theory of decision making, was constructed for each participant. The individual decision processes were compared with identify patterns.

RESULTS

Seventeen women and 13 men made up the sample. We discerned 7 decision patterns.

CONCLUSIONS

This research documents 7 patterns and identifies common driving and restraining forces.

Physician colorectal cancer screening recommendations: an examination based on informed decision making

OBJECTIVE

The purpose of this research was to examine the content of physicians' colorectal cancer screening recommendations. More specifically, using the framework of informed decision making synthesized by Braddock and colleagues, we conducted a qualitative study of the content of recommendations to describe how physicians are currently presenting this information to patients.

METHODS

We conducted semi-structured interviews with 65 primary care physicians. We analyzed responses to a question designed to elicit how the physicians typically communicate their recommendation.

RESULTS

Almost all of the physicians (98.5%) addressed the "nature of decision" element. A majority of physicians discussed "uncertainties associated with the decision" (67.7%). Fewer physicians covered "the patient's role in decision making" (33.8%), "risks and benefits" (16.9%), "alternatives" (10.8%), "assessment of patient understanding" (6.2%), or "exploration of patient's preferences" (1.5%).

CONCLUSION

We propose that the content of the colorectal screening recommendation is a critical determinant to whether a patient undergoes screening. Our examination of physician recommendations yielded mixed results, and the deficiencies identified opportunities for improvement.

PRACTICE IMPLICATIONS

We suggest primary care physicians clarify that screening is meant for those who are asymptotic, present tangible and intangible benefits and risks, as well as make a primary recommendation, and, if needed, a "compromise" recommendation, in order to increase screening utilization.

Measures used in studies of informed decision making about cancer screening: a systematic review

Interventions to promote informed decision making (IDM) for cancer screening are increasingly common. The resulting body of literature provides an opportunity for a systematic review of measures in use. We searched standard databases for intervention trials and other studies of screening decisions and decision aids, finding 2,110 unique citations (most with abstracts) that we reduced to 104 full-text articles; 36 studies met inclusion criteria (prostate = 20, colorectal = 9, breast = 6, cervical = 1). Two independent coders abstracted data on study characteristics, constructs, and measures. Our findings revealed that most studies measured screening (or intention) and knowledge; fewer measured recommended IDM-related constructs and none measured all outcomes proposed for evaluating IDM interventions. Validity and reliability of measures received inadequate attention in study reports, and conceptual overlap exists among measures. Few IDM measures have been developed/carefully adapted from treatment measures and tested for cancer screening or in diverse populations. We recommend that new and in-progress studies emphasize outcomes beyond knowledge-participation in decision making according to personal preference, satisfaction with the process, and consistency between decisions and values. Also needed is better use of theory to guide conceptualization and operationalization of measures, greater attention to reliability and validity (particularly in diverse populations), more thorough reporting of sources and operating characteristics of measures, and increased emphasis and resources focused on these issues by funders, researchers, and journal editors.