Screening rates for colorectal cancer (CRC) lag for low-income, minority populations, contributing to poorer survival rates. A model of storytelling as culture-centric health promotion was tested for promoting CRC screening.
Design.
A two-group parallel randomized controlled trial.
Setting.
Primary care, safety-net clinics.
Subjects.
Low-income patients due for CRC screening, ages 50 to 75 years, speaking English or Spanish.
Intervention.
Patients were exposed to either a video created from personal stories composited into a drama about “Papa” receiving CRC screening, or an instrument estimating level of personal cancer risk. Patients received a health care provider referral for CRC screening and were followed up for 3 months to document adherence.
Measures.
Behavioral factors related to the narrative model (identification and engagement) and theory of planned behavior.
Analysis.
Main effects of the interventions on screening were tested, controlling for attrition factors, and demographic factor associations were assessed. Path analysis with model variables was used to test the direct effects and multiple mediator models.
Results.
Main effects on CRC screening (roughly half stool-based tests, half colonoscopy) did not indicate significant differences (37% and 42% screened for storytelling and risk-based messages, respectively; n = 539; 33.6% male; 62 % Hispanic). Factors positively associated with CRC screening included being female, Hispanic, married or living with a partner, speaking Spanish, having a primary care provider, lower income, and no health insurance. Engagement, working through positive attitudes toward the behavior, predicted CRC screening.
Conclusion.
A storytelling and a personalized risk-tool intervention achieved similar levels of screening among unscreened/underscreened, low-income patients. Factors usually associated with lower rates of screening (e.g., no insurance, being Hispanic) were related to more adherence. Both interventions' engagement factor facilitated positive attitudes about CRC screening associated with behavior change.
US Cancer Statistics Working Group. United States cancer statistics: 1999–2008 incidence and mortality Web-based report. Available at: www.cdc.gov/uscs. Accessed December 20, 2012.
2.
HewitsonPGlasziouPIrwigL. Screening for colorectal cancer using the faecal occult blood test, hemoccult. Cochrane Database Syst Rev.2007:1–30.
3.
KumaravelVHaydenSPHallGSBurkeCA. New fecal occult blood tests may improve adherence and mortality rates. Cleve Clin J Med.2011;78:515–520.
4.
StockCKnudsenABLansdorp-VogelaarI. Colorectal cancer mortality prevented by use and attributable to nonuse of colonoscopy. Gastrointest Endosc. 2011;73:435–443.
5.
ZauberAGWinawerSJO'BrienMJ. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med.2012;366:687–696.
6.
Centers for Disease Control and Prevention (CDC). Vital signs: Colorectal cancer screening, incidence, and mortality—United States, 2002–2010. MMWR Morb Mortal Wkly Rep.2011;60:884–889.
7.
KlabundeCNBrownMBallard-BarbashR. Cancer screening. MMWR Morb Mortal Wkly Rep.2012;61:41–45.
8.
SiegelRDeSantisCJemalA. Colorectal cancer statistics. Cancer J Clin.2014;64:104–117.
9.
BeydounHABeydounMA. Predictors of colorectal cancer screening behaviors among average-risk older adults in the United States. Cancer Causes Control. 2008;19:339–359.
10.
MeissnerHIBreenNKlabundeCNVernonSW. Patterns of colorectal cancer screening uptake among men and women in the United States. Cancer Epidemiol Biomarkers Prev.2006;15:389–394.
11.
VernonSWBrissPATiroJAWarneckeRB. Some methodologic lessons learned from cancer screening research. Cancer. 2004;101(suppl 5):1131–1145.
12.
EdwardsBKWardEKohlerBA. Annual report to the nation on the status of cancer, 1975–2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer. 2010;116:544–573.
13.
PignoneMWinquistASchildLA. Effectiveness of a patient and practice-level colorectal cancer screening intervention in health plan members: The CHOICE trial. Cancer. 2011;117:3352–3362.
14.
LingBSSchoenRETrauthJM. Physicians encouraging colorectal screening: A randomized controlled trial of enhanced office and patient management on compliance with colorectal cancer screening. Arch Intern Med.2009;169:47–55.
15.
LaneDSMessinaCRCavanaghMFChenJJ. A provider intervention to improve colorectal cancer screening in county health centers. Med Care. 2008;46(9suppl 1):S109–S116.
16.
NeaseDEJrRuffinMTIVKlinkmanMS. Impact of a generalizable reminder system on colorectal cancer screening in diverse primary care practices: A report from the prompting and reminding at encounters for prevention project. Med Care. 2008;46(9suppl 1):S68–S73.
17.
MenonUBelueRWahabS. A randomized trial comparing the effect of two phone-based interventions on colorectal cancer screening adherence. Ann Behav Med.2011;42:294–303.
18.
MaxwellAEBastaniRDanaoLL. Results of a community-based randomized trial to increase colorectal cancer screening among Filipino Americans. Am J Public Health. 2010;100:2228–2234.
19.
LarkeyLKWilsonJSillanpaaB. Effect of risk discussion source and perceptions of provider communication style on patient compliance with CRC screening in primary care clinics. Ann Behav Sci Med Educ.2009;15:30–36.
20.
MillerDPJrSpanglerJGCaseLD. Effectiveness of a web-based colorectal cancer screening patient decision aid: A randomized controlled trial in a mixed-literacy population. Am J Prev Med.2011;40:608–615.
21.
MillerKMBrennerAGriffithJM. Promoting decision aid use in primary care using a staff member for delivery. Patient Educ Couns. 2012;86:189–194.
22.
VernonSWMyersRETilleyBCLiS. Factors associated with perceived risk in automotive employees at increased risk of colorectal cancer. Cancer Epidemiol Biomarkers Prev.2001;10:35–43.
23.
Royak-SchalerRBlockerDEYaliAM. Breast and colorectal cancer risk communication approaches with low-income African-American and Hispanic women: Implications for healthcare providers. J Natl Med Assoc. 2004;96:598–608.
24.
HopwoodPHowellALallooFEvansG. Do women understand the odds: Risk perceptions and recall of risk information in women with a family history of breast cancer. Community Genet. 2003;6:214–223.
25.
WoloshinSSchwartzLMMoncurM. Assessing values for health: Numeracy matters. Med Decis Making. 2001;21:382–390.
26.
HoustonTTK. Culturally appropriate storytelling to improve blood pressure: A randomized trial. Ann Intern Med.2011;154:77.
27.
KreuterMWBuskirkTDHolmesK. What makes cancer survivor stories work: An empirical study among African American women. J Cancer Surviv. 2008;2:33–44.
28.
KreuterMWGreenMCCappellaJN. Narrative communication in cancer prevention and control: A framework to guide research and application. Ann Behav Med.2007;33:221–235.
29.
HwangKOOttenbacherAJGrahamAL. Online narratives and peer support for colorectal cancer screening: A pilot randomized trial. Am J Prev Med.2013;45:98–107.
30.
LarkeyLKHechtML. A model of effects of narrative as culture-centric health promotion. J Health Commun. 2010;15:114–135.
31.
Williams-BrownSBaldwinDMBakosA. Storytelling as a method to teach African American women breast health information. J Cancer Educ.2002;17:227–230.
32.
LarkeyLKStatenLRitenbaughC. Communication strategies used by Latina lay advocates of the women's health initiative. Women Cancer. 2000;2:37–42.
33.
LarkeyLK. Las mujeres saludables: Reaching Latinas for breast, cervical and colorectal cancer prevention and screening. J Community Health. 2006;31:69–77.
34.
Banks-WallaceJ. Talk that talk: Storytelling and analysis rooted in African American oral tradition. Qual Health Res.2002;12:410–426.
35.
FixicoD. The American Indian Mind in a Linear World: American Indian Studies and Traditional Knowledge. New York, NY: Routledge; 2013.
36.
HodgeFSPasquaAMarquezCAGeishirt-CantrellB. Utilizing traditional storytelling to promote wellness in American Indian communities. J Transcult Nurs.2002;13:6–11.
37.
SchoulteJC. Bereavement among African Americans and Latino/a Americans. J Ment Health Couns. 2011;33:11–20.
38.
HoybyeMTJohansenCTjornhoj-ThomsenT. Online interaction. Effects of storytelling in an internet breast cancer support group. Psychooncology. 2005;14:211–220.
39.
SinghalARogersEM. A theoretical agenda for entertainment—education. Commun Theory. 2002;12:117–135.
40.
GreenMCStrangeJJBrockTC. Narrative Impact: Social and Cognitive Foundations. Mahwah, NJ: Taylor & Francis; 2002.
41.
LarkeyLKGonzalezJ. Storytelling for promoting colorectal cancer prevention and early detection among Latinos. Patient Educ Couns. 2007;67:272–278.
42.
LarkeyLKLopezAMMinnalAGonzalezJ. Storytelling for promoting colorectal cancer screening among underserved Latina women: A randomized pilot study. Cancer Control. 2009;16:79–87.
43.
McQueenABartholomewKLGreisingerAJ. Behind closed doors: Physician-patient discussions about colorectal cancer screening. J Gen Intern Med.2009;24:1228–1235.
US Preventive Services Task Force. Screening for colorectral cancer: US preventive services task force recommendation statement. Ann Intern Med.2014;149:627–637.
46.
LarkeyLKColditzGWilsonJ. Test of a VideoGuide for Harvard Cancer Risk Index in low literate population. J Biocommun. 2005;31(2).
47.
VernonSWTiroJAVojvodicRW. Reliability and validity of a questionnaire to measure colorectal cancer screening behaviors: Does mode of survey administration matter?Cancer Epidemiol Biomarkers Prev.2008;17:758–767.
LarkeyLKLopezAMRoeDJ. Conference poster: Measures to assess narrative influences on cancer prevention behaviors. American Association for Cancer Research: Frontiers in Cancer Prevention Research;2008.
50.
FishbeinMYzerMC. Using theory to design effective health behavior interventions. Commun Theory. 2003;13:164–183.
51.
WeinsteinND. Testing four competing theories of health-protective behavior. Health Psychol. 1993;12:324–333.
52.
FishbeinMAjzenI. The influence of attitudes on behavior. In: The Handbook of Attitudes. Hillsdale, NJ: Erlbaum; 2005:173–221.
WestSGFinchJFCurranPJ. The robustness of test statistics to nonnormality and specification error in confirmatory factor analysis. Psychol Methods. 1996;1:16–29.
55.
EfronB. Nonparametric estimates of standard error: The jackknife, the bootstrap and other methods. Biometrika. 1981;68:589–599.
56.
EndersCKBandalosD. The relative performance of full information maximum likelihood estimation for missing data in structural equation models. Struct Equ Modeling. 2001;8:430–457.
57.
SchaferJLGrahamJW. Missing data: Our view of the state of the art. Psychol Methods. 2002;7:147–177.
58.
SchumackerRELomaxRG. A Beginner's Guide to Structural Equation Modeling. Vol 288. Mahwah, NJ: Lawrence Erlbaum Associates; 1996:144.
FanXThompsonBWangL. Effects of sample size, estimation methods, and model specification on structural equation modeling fit indexes. Struct Equ Modeling. 1999;6:56–83.
61.
HuLBentlerPM. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Struct Equ Modeling. 1999;6:1–55.
62.
YadamaGNPandeyS. Effect of sample size on goodness-fit of-fit indices in structural equation models. J Soc Serv Res.1995;20:49–70.
63.
YuC. Evaluating Cutoff Criteria of Model Fit Indices for Latent Variable Models With Binary and Continuous Outcomes. Los Angeles, Calif: University of California Los Angeles; 2002.
64.
TaylorABMacKinnonDPTeinJ. Tests of the three-path mediated effect. Organ Res Methods. 2008;11:241–269.
65.
KlabundeCNLanierDBreslauES. Improving colorectal cancer screening in primary care practice: Innovative strategies and future directions. J Gen Intern Med.2007;22:1195–1205.
66.
DuBardCASchmidDYowA. Recommendation for and receipt of cancer screenings among medicaid recipients 50 years and older. Arch Intern Med.2008;168:2014–2021.
67.
O'MalleyASForrestCBFengSMandelblattJ. Disparities despite coverage: Gaps in colorectal cancer screening among medicare beneficiaries. Arch Intern Med.2005;165:2129–2135.
68.
CoronadoGDGolovatyILongtonG. Effectiveness of a clinic-based colorectal cancer screening promotion program for underserved Hispanics. Cancer. 2011;117:1745–1754.
69.
VernonSWBartholomewLKMcQueenA. A randomized controlled trial of a tailored interactive computer-delivered intervention to promote colorectal cancer screening: Sometimes more is just the same. Ann Behav Med.2011;41:284–299.
70.
LasserKEMurilloJLisboaS. Colorectal cancer screening among ethnically diverse, low-income patients: A randomized controlled trial. Arch Intern Med.2011;171:906–912.
71.
MyersREBittner-FaganHDaskalakisC. A randomized controlled trial of a tailored navigation and a standard intervention in colorectal cancer screening. Cancer Epidemiol Biomarkers Prev.2013;22:109–117.
72.
GuptaSHalmEARockeyDC. Comparative effectiveness of fecal immunochemical test outreach, colonoscopy outreach, and usual care for boosting colorectal cancer screening among the underserved: A randomized clinical trial. JAMA Intern Med.2013;173:1725–1732.
73.
SequistTDZaslavskyAMMarshallR. Patient and physician reminders to promote colorectal cancer screening: A randomized controlled trial. Arch Intern Med.2009;169:364–371.
74.
JandorfLGutierrezYLopezJ. Use of a patient navigator to increase colorectal cancer screening in an urban neighborhood health clinic. J Urban Health. 2005;82:216–224.
