The Role of Health Literacy in Explaining the Relation between Educational Level and Decision Making about Colorectal Cancer Screening

Evaluation of Knowledge, Attitudes, and Practices towards Colorectal Cancer in a Community in Mexico City: A Cross-Sectional Study Based on Surveys

Colorectal cancer (CRC) is one of the most common and deadly neoplasms worldwide, with a growing burden in low- and middle-income countries, such as Mexico. This study seeks to evaluate the knowledge, attitudes, and practices related to CRC in a community in Mexico City. A cross-sectional survey was conducted between March and April 2023 among adults aged 45 to 74 residing in six neighborhoods of the Tlalpan borough in Mexico City. The questionnaire included sections on sociodemographic characteristics, medical family history, lifestyle habits, knowledge about CRC, attitudes towards prevention, and willingness to undergo screening. Data were analyzed using logistic regression models to identify factors associated with greater knowledge, attitudes, and practices. A total of 349 people were surveyed. A total of 35.2% reported knowing what CRC is, with greater knowledge of CRC being associated with higher education levels and having a family history of cancer. A total of 23.8% showed positive attitudes towards CRC screening, influenced by having a tertiary level of education. A total of 80.8% of participants expressed willingness to undergo CRC screening if offered, with lower intention observed among men. Levels of knowledge about CRC within the studied community are low, especially among those with lower education levels and without a family history of cancer. Intervention strategies should improve CRC education and foster positive attitudes towards early detection, particularly in high-risk groups.

Decision-making in breast cancer screening: A qualitative exploration of the match between women's beliefs and screening information in the Netherlands

OBJECTIVE

Decision-making about breast cancer screening requires balanced and understandable information that takes prior beliefs of screening invitees into account.

METHODS

In qualitative interviews with 22 Dutch women who were invited for screening for the first time (49-52 years of age, varying health literacy levels), we gained insight in their beliefs on breast cancer and breast cancer screening, and explored how the current screening information matched these beliefs.

RESULTS

Breast cancer was perceived as an unpredictable, severe, and uncontrollable disease. Women considered screening as self-evident and an important mean to gain some control over breast cancer. Information on benefits of screening was in line with women's prior beliefs and confirmed women's main reasons to participate. Information about false-positive outcomes, overtreatment, and false negative outcomes did not correspond to women's prior beliefs and this information was generally not considered relevant for decision-making. Preferences for additional information merely concerned practical information on the screening procedure.

CONCLUSION

Complex information on the harms of screening does not match women's beliefs and is not taken into account in their decision-making.

PRACTICE IMPLICATIONS

Information regarding breast cancer screening could be further aligned to prior beliefs by taking into account values, filling knowledge gaps and correct misconceptions.

Does health literacy mediate the relationship between socioeconomic status and health related outcomes in the Belgian adult population?

BACKGROUND

Health literacy (HL) has been put forward as a potential mediator through which socioeconomic status (SES) affects health. This study explores whether HL mediates the relation between SES and a selection of health or health-related outcomes.

METHODS

Data from the participants of the Belgian health interview survey 2018 aged 18 years or older were individually linked with data from the Belgian compulsory health insurance (n = 8080). HL was assessed with the HLS-EU-Q6. Mediation analyses were performed with health behaviour (physical activity, diet, alcohol and tobacco consumption), health status (perceived health status, mental health status), use of medicine (purchase of antibiotics), and use of preventive care (preventive dental care, influenza vaccination, breast cancer screening) as dependent outcome variables, educational attainment and income as independent variables of interest, age and sex as potential confounders and HL as mediating variable.

RESULTS

The study showed that unhealthy behaviours (except alcohol consumption), poorer health status, higher use of medicine and lower use of preventive care (except flu vaccination) were associated with low SES (i.e., low education and low income) and with insufficient HL. HL partially mediated the relationship between education and health behaviour, perceived health status and mental health status, accounting for 3.8-16.0% of the total effect. HL also constituted a pathway by which income influences health behaviour, perceived health status, mental health status and preventive dental care, with the mediation effects accounting for 2.1-10.8% of the total effect.

CONCLUSIONS

Although the influence of HL in the pathway is limited, our findings suggest that strategies for improving various health-related outcomes among low SES groups should include initiatives to enhance HL in these population groups. Further research is needed to confirm our results and to better explore the mediating effects of HL.

Anxiety and Health Literacy Levels of Patients Undergoing Colonoscopy

This descriptive, correlational study was conducted to determine the anxiety and health literacy levels of patients undergoing colonoscopy and the variables affecting them. The study population consisted of individuals who presented for colonoscopy to the endoscopy department of a state hospital. The sample consisted of 160 individuals who met the inclusion criteria. Three data collection tools (Identifying Information Form, State-Trait Anxiety Inventory, and Health Literacy Scale) were used to determine anxiety and health literacy levels. Findings show that the state-trait anxiety of individuals who would undergo colonoscopy for the first time was moderate, and their health literacy scores were inadequate, problematic, and weak. There was a positive and significant relationship between patients' anxiety and health literacy levels. Variables such as age, gender, marital status, education level, employment status, disease-related symptoms, a family history of cancer, and fear of colonoscopy influenced anxiety and health literacy. Based on these findings, we recommend that individuals' anxiety and health literacy status be determined before a colonoscopy procedure to improve gastroenterology nurses' management of these patients.

A health equity framework to support the next generation of cancer population simulation models

Over the past 2 decades, population simulation modeling has evolved as an effective public health tool for surveillance of cancer trends and estimation of the impact of screening and treatment strategies on incidence and mortality, including documentation of persistent cancer inequities. The goal of this research was to provide a framework to support the next generation of cancer population simulation models to identify leverage points in the cancer control continuum to accelerate achievement of equity in cancer care for minoritized populations. In our framework, systemic racism is conceptualized as the root cause of inequity and an upstream influence acting on subsequent downstream events, which ultimately exert physiological effects on cancer incidence and mortality and competing comorbidities. To date, most simulation models investigating racial inequity have used individual-level race variables. Individual-level race is a proxy for exposure to systemic racism, not a biological construct. However, single-level race variables are suboptimal proxies for the multilevel systems, policies, and practices that perpetuate inequity. We recommend that future models designed to capture relationships between systemic racism and cancer outcomes replace or extend single-level race variables with multilevel measures that capture structural, interpersonal, and internalized racism. Models should investigate actionable levers, such as changes in health care, education, and economic structures and policies to increase equity and reductions in health-care-based interpersonal racism. This integrated approach could support novel research approaches, make explicit the effects of different structures and policies, highlight data gaps in interactions between model components mirroring how factors act in the real world, inform how we collect data to model cancer equity, and generate results that could inform policy.

Development and psychometric validation of the Colorectal Cancer Literacy Scale-Uruguay Version

Colorectal cancer is a leading cause of cancer death in Uruguay, yet less than half of the eligible population is up to date with screenings. Research is hampered because no measures exist to assess psychosocial factors that influence screening decisions in this population. To address this gap, we report on the development and psychometric validation of the Colorectal Cancer Literacy Scale-Uruguay Version, a scale based on the health literacy model. We developed an item pool based on the extant literature, obtained feedback from experts, and conducted focus groups with community participants and health care providers. After revision, we conducted a psychometric validation with a national community sample of 405 participants. Through an exploratory factor analysis, we identified four factors that were collapsed into two for theoretical and pragmatic reasons, representing (a) disposition toward cancer prevention and (b) attitudes, beliefs, and emotions about cancer. A third factor, knowledge about colorectal cancer, was examined separately given its distinct focus. Subsequently, we conducted a confirmatory factor analysis with the remaining sample participants using Rasch measurement theory for validation purposes and to further assess the scales' psychometric properties. The resulting 44-item scale presented a good model fit with adequate EAP reliabilities and good initial discriminant validity. Further criterion-related validity analyses should be performed when additional measures are available. The Colorectal Cancer Literacy Scale-Uruguay Version is a theoretically based measure that can bring to light barriers and facilitative factors in an underscreened population at risk. Implications for theory, research, and practice are discussed.

Perceived Importance of the Benefits and Harms of Colorectal Cancer Screening: A Best-Worst Scaling Study

OBJECTIVES

To elicit the relative importance of the benefits and harms of colorectal cancer (CRC) screening among potential screening participants in the Dutch population.

METHODS

In a consensus meeting with 11 experts, risk reduction of CRC and CRC deaths (benefits) and complications from colonoscopy, stress of receiving positive fecal immunological test (FIT) results, as well as false-positive and false-negative FIT results (harms) were selected as determinant end points to consider during decision making. We conducted an online best-worst scaling survey among adults aged 55 to 75 years from the Dutch Health Care Consumer Panel of The Netherlands Institute for Health Services Research to elicit preference values for these outcomes. The preference values were estimated using conditional logit regression.

RESULTS

Of 265 participants, 234 (89%) had ever participated in CRC screening. Compared with the stress of receiving a positive FIT result, the outcome perceived most important was the risk of CRC death (odds ratio [OR] 4.5; 95% confidence interval [CI] 3.9-5.1), followed by risk of CRC (OR 4.1; 95% CI 3.6-4.7), a false-negative FIT result (OR 3.1; 95% CI 2.7-3.5), colonoscopy complications (OR 1.6; 95% CI 1.4-1.8), and a false-positive FIT result (OR 1.4; 95% CI 1.3-1.6). The magnitude of these differences in perceived importance varied according to age, educational level, ethnic background, and whether the individual had previously participated in CRC screening.

CONCLUSION

Dutch men and women eligible for FIT-based CRC screening perceive the benefits of screening to be more important than the harms.

Context Matters: Emotional Sensitivity to Probabilities and the Bias for Action in Cancer Treatment Decisions

BACKGROUND

Past studies have shown a commission bias for cancer treatment, a tendency to choose active treatment even when watchful waiting is less risky. This bias suggests motivations for action beyond mortality statistics, but recent evidence suggests that individuals differ in their emotional sensitivity to probabilities (ESP), the tendency to calibrate emotional reactions to probability. The current study aims to examine the role of ESP in the commission bias, specifically whether those higher in ESP are more likely to choose watchful waiting when risk probabilities align with that choice.

METHODS

Participants (N = 1,055) read a scenario describing a hypothetical cancer diagnosis and chose between surgery and watchful waiting, with random assignment between versions where the mortality rate was either lower for surgery or for watchful waiting. We modeled choice using the Possibility Probability Questionnaire (PPQ), a measure of ESP, and several other individual differences in a logistic regression.

RESULTS

We observed a commission bias as in past studies with most participants choosing surgery both when surgery was optimal (71%) and when watchful waiting was optimal (58%). An ESP × Condition interaction indicated that the predictive role of ESP depended on condition. Those higher in ESP were more likely to choose surgery when probabilities favored surgery, β = 0.57, P < 0.001, but when probabilities favored watchful waiting, ESP had a near-zero relationship with choice, β = 0.05, P < 0.99.

CONCLUSIONS

The role of ESP in decision making is context specific. Higher levels of ESP predict choosing action when that action is warranted but do not predict a shift away from surgery when watchful waiting offers better chances of survival. ESP does not overcome the commission bias.

HIGHLIGHTS

Past studies have identified a "commission bias," a tendency to choose active treatment over watchful waiting, even when mortality rate is lower for waiting.Evaluation of risk probabilities is related to individual differences in emotional sensitivity to probabilities (ESP) and has been shown to predict reactions to and decisions about health risk situations.ESP appears to be selectively factored into decision making. ESP was a robust predictor of choosing surgery when probability information supported surgery but did not predict decisions when probability information supported watchful waiting.Those who are most emotionally attuned to probabilities are just as susceptible to the commission bias as those who are less attuned.

Decisional Conflict after Deciding on Potential Participation in Early Phase Clinical Cancer Trials: Dependent on Global Health Status, Satisfaction with Communication, and Timing

When standard treatment options are not available anymore, patients with advanced cancer may participate in early phase clinical trials. Improving this complex decision-making process may improve their quality of life. Therefore, this prospective multicenter study with questionnaires untangles several contributing factors to decisional conflict (which reflects the quality of decision-making) in patients with advanced cancer who recently decided upon early phase clinical trial participation (phase I or I/II). We hypothesized that health-related quality of life, health literacy, sense of hope, satisfaction with the consultation, timing of the decision, and the decision explain decisional conflict. Mean decisional conflict in 116 patients was 30.0 (SD = 16.9). Multivariate regression analysis showed that less decisional conflict was reported by patients with better global health status (β = −0.185, p = 0.018), higher satisfaction (β = −0.246, p = 0.002), and who made the decision before (β = −0.543, p < 0.001) or within a week after the consultation (β = −0.427, p < 0.001). These variables explained 37% of the variance in decisional conflict. Healthcare professionals should realize that patients with lower global health status and who need more time to decide may require additional support. Although altering such patient intrinsic characteristics is difficult, oncologists can impact the satisfaction with the consultation. Future research should verify whether effective patient-centered communication could prevent decisional conflict.

Relationship between Health Literacy and Medication Adherence of Turkish Cancer Patients Receiving Oral Chemotherapy

Objective:

The aim of this study was to explore the relationship between health literacy and self-report medication adherence of Turkish cancer patients receiving oral chemotherapy.

Methods:

The present research was a descriptive and cross-sectional study and conducted with 100 voluntary cancer patients who were admitted to the medical oncology outpatient clinic and received oral chemotherapy. The data were collected through a questionnaire form consisting of the Oral Chemotherapy Adherence Scale and the Turkish Health Literacy Scale (TSOY-32). The collected data were analyzed using descriptive statistics, one-way ANOVA, and Pearson's correlation coefficient.

Results:

The results revealed that 57% of the patients were female, 35% were primary school graduates, 51% were breast cancer, and 36% took capecitabine. The mean index scores of the participants on both scales were calculated as 12.39 ± 1.51 and 73.25 ± 6.18, respectively. Overall, a positive and strong correlation was found between oral chemotherapy adherence and health literacy of the participants (r = 0.707, P = 0.000).

Conclusions:

Medication adherence and health literacy levels among the cancer patients in Turkey are alarming so that patient-centered interventions and training are required to overcome the barriers to medication adherence.