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. Author manuscript; available in PMC: 2013 Jul 1.
Published in final edited form as: Cancer Nurs. 2012 Jul;35(4):288–294. doi: 10.1097/NCC.0b013e31822e7859

The Relationship Between Colorectal Cancer Screening Adherence and Knowledge Among Vulnerable Rural Residents of Appalachian Kentucky

Shoshana H Bardach 1, Nancy E Schoenberg 1, Steven T Fleming 1, Jennifer Hatcher 1
PMCID: PMC3248994  NIHMSID: NIHMS319691  PMID: 21946905

Abstract

Background

Colorectal cancer (CRC) is one of the leading causes of cancer related deaths among residents of rural Appalachia. Rates of guideline-consistent CRC screening in Appalachian Kentucky are suboptimal.

Objective

This study sought to determine the relationship between colorectal cancer screening knowledge, specifically regarding recommended screening intervals, and receipt of screening among residents of rural Appalachian Kentucky.

Methods

Residents of Appalachian Kentucky (n=1096) between the ages of 50 and 76 completed a telephone survey including questions on demographics, health history, and knowledge about colorectal cancer screening between November 20, 2009 and April 22, 2010.

Results

While 67% of respondents indicated receiving screenings according to guidelines, respondents also demonstrated significant knowledge deficiencies about screening recommendations. Nearly half of respondents were unable to identify the recommended screening frequency for any of the colorectal cancer screening modalities. Accuracy about the recommended frequency of screening was positively associated with screening adherence.

Conclusions

Enhanced educational approaches have the potential to increase colorectal cancer screening adherence in this population and reduce cancer mortality in this underserved region.

Implications for practice

Nurses play a critical role in patient education, which ultimately may increase screening rates. To fulfill this role, nurses should incorporate current recommendation about CRC screening into educational sessions. Advanced practices nurses in rural settings should also be aware of the increased vulnerability of their patient population and develop strategies to enhance awareness about CRC and the accompanying screening tests.

Introduction

Cancer is the second leading cause of death in the United States and colorectal cancer (CRC) is the second most common cause of cancer-related death.1 CRC mortality rates in Kentucky are significantly higher (22.0 per 100,000) than national averages (18.8 per 100,000),2 and rates within the eastern region of Appalachian Kentucky exceed mortality rates in non-Appalachian Kentucky.3 These mortality rates are alarming, particularly given that CRC is preventable and treatable through prevention efforts including lifestyle modification (e.g., smoking cessation and optimal dietary intake), cancer screening, early detection, and efficacious treatments.4–5

The American Cancer Society screening guidelines suggest that beginning at age 50, most patients, should undergo CRC screening. Screening options include annual Fecal Occult Blood Test (FOBT), double contrast barium enema or flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years.6 Current Behavioral Risk Factor Surveillance System (BRFSS) data indicate that only 36% of respondents in Appalachian Kentucky reported CRC screening consistent with recommended guidelines compared to 47.2% in Kentucky and 53% nationwide.7–8

Previous research among Appalachian residents has suggested several key barriers to cancer screening, including limitations in screening knowledge; however, these studies do not link CRC screening with knowledge. Much of the existing Appalachian literature instead focuses on perceptions of barriers to screening, including or knowledge deficiencies, but does not link such barriers to screening adherence.9–11 Greater knowledge of cancer risk, the benefits of cancer screening, and the likelihood of cancer survival also are positively associated with cancer screening adherence.12–14

Interventions to increase screening have focused on educational campaigns emphasizing the value of CRC screening.15 Research has demonstrated that maximizing the effectiveness of these interventions requires an improved understanding of the relationship between CRC knowledge and the acceptance of screening.16 Such insights are lacking within rural Appalachian Kentucky, a region well known for its high cancer mortality.17–18

Previous research has suggested that knowledge about screening guidelines,19 and in particular, knowledge about screening intervals increases the likelihood of compliance with guidelines.12 This study seeks to test the hypothesis that there is a positive relationship between knowledge of CRC screening guidelines and adherence to CRC screening among rural Appalachian residents. These data are part of a larger study exploring predictors of CRC screening adherence in rural Appalachia, focusing specifically on how multiple chronic diseases serve as either barriers to or facilitators of colorectal cancer screening.

Methods

Institutional Review Board approval was obtained from the University of Kentucky, after which the University of Kentucky Survey Research Center (SRC) administered the survey between November 20, 2009 and April 22, 2010. Eligible participants were residents of the Appalachian region of Kentucky who were between 50 to 76 years old, an age range generally considered consistent with eligibility for CRC screening recommendations. Trained, experienced, and continuously monitored SRC interviewers conducted surveys with randomly selected households using a modified list-assisted Waksberg-Mitofsky random-digit dialling procedure.20–21 For each telephone number, up to 15 attempted calls were made. After 15 call attempts or when a respondent declined participation, no further call attempts were made to that number. If respondents indicated that the timing was inconvenient, interviewers attempted up to 10 call-backs. Potential participants were read a statement about the study purpose and target population and asked for their willingness to continue.

The survey consisted of questions on (1) demographics; (2) burden of disease by the presence of fifteen different chronic conditions; (3) the 4 predominant methods of CRC screening; (4) the barriers and facilitators of CRC screening. Participants were given a brief description of each of 4 predominant types of colorectal cancer screening tests, and asked 3 questions for each test: (1) Have you ever had this test? (2) How long ago did you have this test? (3) How often do the medical guidelines say you should have this test? Participants were asked for reasons why they had or had not been screened.

Statistical Analyses

Data were entered into and analyzed using SAS v9.2. Participants with missing data for age, sex, marital status, education, financial status, health status, or race were excluded from analysis. Consistent with established guidelines,22 participants were coded as adherent if they conformed to screening guidelines. Participants who had received any of these tests but not within these time frames were labeled as screened but not within guidelines. In order to test for differences between individuals with different levels of screening knowledge, ANOVA was used for continuous data and chi-square tests were used for categorical data. Logistic regression was used to study the association between knowledge accuracy about screening recommendations and adherence to screening recommendations, controlling for age, gender, number of conditions, self-reported health status, subjective financial status, and education. P values less than .05 were considered to be significant.

Results

Sample description

Including ineligible participants in both the numerator and the denominator, the response rate was 55%, ((1,182+3,226)/8,019). After excluding participants missing data on the demographic variables indicated, 1096 participants remained. On average, participants were 61 years old, the majority (70.6%) were female, married (62.8%), and White (96.6%). Participants reported an average of 3.3 medical conditions. Over a third of participants (36.4%) reported struggling financially, with almost half of participants (44.9%) feeling they had just enough to get by, and roughly a fifth of the sample (18.7%) feeling that they had more than enough to get by. Nearly 42 percent had more than a high school education, 36.7% had a high school education or a GED, and 21.6% had less than a high school education. See Table 1 for additional sample description.

Table 1.

Sample Descriptiona

Screening Adherence
Characteristics All
Respondents
(n=1096)		 Screened
Within
Guidelines
(n=733)		 Screened Not
Within
Guidelines
(n=122)		 Never
Screened
(n=241)
Age, mean (SD)b 61.2 (7.2) 62.0 (7.2) 61.1 (6.2) 58.7 (7.1)
Number of conditions, mean (SD)b 3.3 (2.2) 3.6 (2.3) 3.3 (2.1) 2.6 (1.9)
Sex, No. (%)
    Male 322 (29.4) 212 (28.9) 33 (27.1) 77 (32.0)
    Female 774 (70.6) 521 (71.1) 89 (73.0) 164 (68.1)
Marital Status, No. (%)
    Married/partnered 688 (62.8) 465 (63.4) 78 (63.9) 145 (60.2)
    Separated/Divorced 169 (15.4) 111 (15.1) 20 (16.4) 38 (15.8)
    Widowed 161 (14.7) 111 (15.1) 15 (12.3) 35 (14.5)
    Single, never married 75 (6.8) 44 (6.0) 9 (7.4) 22 (9.1)
    Other 3 (0.3) 2 (0.3) 0 1 (0.4)
Education, No. (%)c
    <High School 237 (21.6) 152 (20.7) 22 (18.0) 63 (26.1)
    High School/GED 402 (36.7) 252 (34.4) 47 (38.5) 103 (42.7)
    >High School 457 (41.7) 329 (44.9) 53 (43.4) 75 (31.1)
Perceived Financial Status, No. (%)d
    More than enough 205 (18.7) 150 (20.5) 17 (13.9) 38 (15.7)
    Just enough 492 (44.9) 333 (45.4) 62 (50.8) 97 (40.3)
    Struggle to get by 399 (36.4) 250 (34.1) 43 (35.3) 106 (44.0)
Current Health Status, No. (%)
    Excellent/Very Good/Good 620 (56.6) 417 (56.9) 71 (58.2) 132 (54.8)
    Fair/ Poor 476 (43.4) 316 (43.1) 51 (40.8) 109 (45.2)
Race, No. (%)
    White 1059 (96.6) 716 (97.7) 118 (96.7) 225 (93.4)
    Non-White 37 (3.4) 16 (2.3) 4 (3.3) 16 (6.6)
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a

Percentages may not add up to 100% due to rounding

b

p<.0001

c

p=.0043

d

p=.028

Screening behaviors and accuracy of knowledge regarding screening frequencies

Contrary to BRFSS data, most study respondents reported having been screened for CRC according to medical guidelines (n=733, 66.9%), an additional 11.1% of the sample (n=122) had been screened previously but not within recommended guidelines, and the remaining 22.0% of the sample had never been screened for CRC. The most common screening test participants reported receiving was colonoscopy (65.8%), followed by FOBT (39.4%), double contrast barium enema (28.7%), and sigmoidoscopy (20.2%). Responses add up to more than 100% because many individuals reported being screened with multiple modalities.

Respondents provided the most accurate responses to questions about the recommended frequency of FOBT (47.9%), followed by double-contrast barium enema (33.0%) and sigmoidoscopy (32.5%), and finally colonoscopy (12.3%). All respondents who did not correctly identify the recommended FOBT frequency suggested a less frequent schedule than advised. In contrast, for colonoscopy, the majority of respondents (85.5%) incorrectly suggested a more frequent screening schedule. For sigmoidoscopy and double contrast barium enema, 49.4% and 42.5% of respondents, respectively, suggested schedules more frequent than advised.

Respondents demonstrated significant knowledge deficiencies about screening guidelines. Nearly half (541, 49.4%) of respondents provided inaccurate responses regarding the suggested screening frequency for all 4 modalities. In support of the hypothesis, accuracy about the recommended frequency of screening was positively associated with screening adherence. The degree of accuracy was also associated with number of chronic medical conditions; those with the least knowledge about screening guidelines tended to have a greater number of medical conditions than those with the most knowledge about screening frequencies. In addition, those with lower knowledge accuracy tended to have poorer health, greater financial difficulty, and less education than those who were more accurate about suggested screening frequencies. See Table 3 for additional details.

Table 3.

Accuracy of Knowledge Regarding Screening Frequenciesa

Accurate responses for screening guidelines
0 (n=541) 1 (n=381) 2+ (n=174) P Value
Adherence, No. (%) <.001
    Screened within guidelines 335 (61.9) 268 (70.3) 130 (74.7)
    Screened, not within guidelines 56 (10.4) 46 (12.1) 20 (11.5)
    Never screened 150 (27.6) 67 (17.6) 24 (13.8)
Number of conditions, mean (SD) 3.5 (2.2) 3.2 (2.3) 2.8 (2.1) <.001
Gender, No. (%) .03
    Male 174 (32.2) 93 (24.4) 55 (31.6)
    Female 367 (67.8) 288 (75.6) 119 (68.4)
Health, No. (%) .002
    Excellent/ Very Good/Good 284 (52.3) 218 (57.2) 118 (67.8)
    Fair/ Poor 257 (47.5) 163 (42.8) 56 (32.2)
Financial Status, No. (%) <.001
    More than enough 80 (14.7) 68 (17.9) 57 (32.8)
    Just enough 249 (45.9) 170 (44.6) 73 (42.0)
    Struggle to get by 212 (39.2) 143 (37.5) 44 (25.3)
Education, No. (%) <.001
    <High School 143 (26.4) 78 (20.5) 16 (9.2)
    High School/GED 188 (34.8) 152 (39.9) 62 (35.6)
    >High School 210 (38.8) 151 (39.6) 96 (55.2)
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a

Numbers may differ from totals due to missing data; Percentages may not add up to 100% due to rounding

Logistic Regression Analysis

Analysis of receiver operating curves suggests that the model utilized had good overall fit, c=.67. Logistic regression results also supported the hypothesis that knowledge was positively associated with screening adherence. As compared to individuals who were not knowledgeable about any recommended screening frequency, those who were accurate about 2 or more screening test guidelines had twice the odds of being adherent to screening, controlling for age, numbers of conditions, sex, education, perceived financial status, and subjective health status. Thus, these results indicate that knowledge accuracy regarding screening frequency is associated with screening adherence, even when controlling for other variables in the model. See table 4 for details.

Table 4.

Logistic Regression Model Determining Factors Associated with Adherence to Screening Recommendations

Adherence to Screening
Recommendations
OR (95% CI)a
Knowledge Accuracy (# accurate responses)
0 Reference
1 1.6 (1.2, 2.1)
2+b 2.0 (1.3, 2.9)
Agec 1.0 (1.0, 1.1)
Number of conditionsc 1.2 (1.1, 1.3)
Sex
    Male 1.0 (0.8, 1.4)
    Female Reference
Education
    <High School 0.6 (0.4, 0.9)
    High School/GED 0.7 (0.5, 0.9)
    >High School Reference
Perceived Financial Status
    More than enough 1.6 (1.0, 2.4)
    Just enough 1.2 (0.9, 1.7)
    Struggle to get by Reference
Current Health Status
    Excellent/Very Good/ Good 1.1 (0.8, 1.5)
    Fair/Poor Reference
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a

Adjusted for other variables in the model; Abbreviations: CI, confidence interval; OR, odds ratio

b

p=.02

c

p<.001

Of the 363 individuals not screened within guidelines, (241 had never been screened and 122 had been screened previously but not within guidelines), 43.0% provided reasons for non-adherence that can be categorized as lacking awareness. Such reasons included having never thought about CRC, not realizing screening was needed, not thinking CRC was important, or not believing oneself to be at risk. These awareness-related reasons for not being screened were not associated with any demographic variables.

Discussion

Over two-thirds (66.9%) of study participants reported adhering to CRC screening recommendations, an unanticipated result given the CDC’s finding that just over one-third of Appalachian Kentuckians are guideline adherent. Although participants were most likely to report receiving colonoscopy than any other screening modality, only 12.3% accurately reported the recommended screening frequency. Inaccurate information about recommended screening frequencies were pervasive, with only 15.9% of respondents able to identify the correct screening frequency for two of the screening options and nearly half of all respondents unable to identify the recommended frequency for any test. Prior research has shown similar knowledge deficits among rural Appalachian women regarding breast cancer and guidelines regarding screening timing; these knowledge deficits were evident even among well-educated women.9 The knowledge deficiencies identified in the present study warrant attention since the study hypothesis was supported; that is, having fewer accurate responses was associated with a lower likelihood of being screened within guidelines.

Those with fewer medical conditions, those in better health, and those with higher socioeconomic status (SES, consisting of income and education) were more likely to respond accurately about screening recommendations. The association between higher SES and greater CRC knowledge and likelihood of screening is consistent with prior research.23–24 The finding that fewer medical conditions are associated with greater knowledge about CRC screening has not been reported extensively. This association, at first glance, seems to present a paradox since those with fewer conditions also had a lower level of CRC screening adherence. It is plausible that individuals with higher SES may have greater health knowledge and resources, resulting in fewer conditions, and presumably fewer health encounters; and such encounters probably are a stronger predictor of screening adherence than knowledge. This explanation is consistent with patient reports that a provider recommendation is the strongest predictor of screening adherence.25–26 This study’s findings support this possibility as the number of self-reported medical conditions was independently associated with adherence, whereas finances and education were not associated with adherence.

These findings suggest that when trying to improve adherence, it is important to consider the relationship between the number of medical conditions and contact with health care providers. Research has demonstrated that older adults in poorer health had higher rates of FOBT;27 this may suggest that greater health needs result in increased contact with providers and consequently more opportunities for discussions related to screening. These findings also suggest that although it is beneficial for individuals to have fewer chronic conditions, they may run the risk of inadequate exposure to health care providers who direct patients toward screening.

After controlling for other salient factors (sex, age, number of conditions, education, financial status, subjective health), knowledge about frequency of screening recommendations remained a significant predictor of screening adherence. These results may even suggest a dose-response relationship between knowledge and screening, with a greater degree of knowledge associated with higher odds of screening adherence.

Conclusions

The findings from this study suggest that, given the strong association between knowledge and screening adherence, enhanced educational approaches may be useful in increasing CRC screening adherence. A substantial percentage of respondents also offered knowledge-related reasons for why they were not screened. Thus, while individuals are not always able to identify the role that knowledge plays in their screening decisions, significant knowledge deficiencies do seem to be associated with lower screening adherence rates.

Implications for practice

Nurses at all levels of practice routinely provide recommendations for preventive care to patients.28 In light of their increased contact with patients, nurses are ideally situated to provide information that will increase knowledge regarding CRC screening guidelines. One approach to reducing the knowledge deficiencies identified in this study may be enhanced CRC screening counseling, especially among those primary care providers, including NPs and physicians, who are most accessible to their patients. Providers in rural Appalachia, only one third of whom report recommending screening to their patients, may assume that their patients have limited interest in CRC screening tests or may lack the means to obtain screening and consequently may be reluctant to advocate for screening.29 Mammogram research suggests that many patients indicate a willingness to engage in screening, but identify the lack of a provider referral as a key reason why they do not get cancer screening.27, 30–31 Providers have a valuable opportunity during routine examinations to reinforce and/or clarify screening guidelines, rectifying knowledge limitations, thereby increasing awareness and possibly screening adherence.32 Unfortunately, while nurses recognize the need to be involved in cancer prevention and detection, their current rate of delivery of cancer prevention practices remains low.33

Nurses in primary care roles should base recommendations on a combination of best practice and current guidelines. Recent research indicates that nurses recognize the need for and would like additional training related to cancer prevention and detection.34–35 Continuing education programs designed specifically for nurses should emphasize evidence-based cancer-screening guidelines and their translation into clinical practice. A review of such guidelines would aid clinicians in sorting out any ambiguity in the guidelines.36

A careful examination of the unique considerations of rural Appalachian adults also will provide insight into what methods work best to increase understanding and awareness of CRC and screening recommendations among this population. Research indicates that cultural practices and beliefs, particularly in relation to communication norms and expectations, influence the processing of knowledge acquisitions regarding CRC screening.37–38 Future research should therefore focus on enhancing providers’ abilities to offer culturally sensitive interventions to increase knowledge of CRC and thereby improve screening uptake. Another promising approach to promote screening is to identify and educate opinion leaders, leveraging the strong social networks within rural communities, creating a community demand for screening.39–41 These individuals can also be trained as lay health advisers or patient navigators, and their familiarity with the local community will increase their ability to address patient barriers to screening.42–45 This is a particularly promising approach given the nursing and other provider shortages endemic in rural areas.46

Study limitations and strengths

These results must be interpreted with some caution. First, generalizability is limited by the possibility that respondents may differ from non-respondents. Although this sample’s race/ethnicity reflects the predominance of Whites in Appalachian, such homogeneity limits generalizability.47 Additionally, the sample was disproportionately female. Second, since this project was meant to explore CRC among vulnerable Appalachian residents, the results may not be generalizable to other rural populations. Third, there is potential for retrospective memory biases or social-desirability responses due to self-report. These potential biases may explain the unexpected finding that most participants reported being screened according to guidelines. In addition, many respondents did not answer questions about their knowledge of medical guidelines and it is unclear whether this reflects uncertainty about guidelines or omissions in survey delivery or response recording. Finally, this study focused on a single proxy for knowledge, screening intervals.

Despite these limitations, this study helps elucidate the relationship between knowledge and screening among rural Appalachian residents. The current study evaluated behavioral outcomes and the reasons for those behaviors, rather than focusing solely on barriers and asking respondents to imagine what they would do if the barriers were removed. In conclusion, the insights gained from this study, stressing the importance of knowledge in predicting CRC screening adherence, can be used to inform future efforts to increase CRC screening and reduce cancer mortality in this underserved region. Nurses are positioned to play a pivotal role in promoting screening and reducing cancer mortality.

Table 2.

Screening Behaviors and Responsesa

FOBT, No.
(%)		 Colonscopy,
No. (%)		 Sigmoidoscopy,
No. (%)		 Double-contrast
Barium Enema,
No. (%)
Ever Had Test?
   Yes 431 (39.4) 718 (65.8) 218 (20.2) 306 (28.7)
   No 663 (60.6) 374 (34.3) 861 (79.8) 762 (71.4)
How long ago did you get this test?b
   Within past year 135 (32.0) 228 (31.8) 52 (24.8) 42 (14.1)
   Within past 2 years 70 (16.6) 154 (21.5) 29 (13.8) 25 (8.4)
   Within past 3 years 36 (8.5) 89 (12.4) 21 (10.0) 17 (5.7)
   Within past 5 years 73 (17.3) 132 (18.4) 26 (12.4) 32 (10.7)
   Within past 10 years 48 (11.4) 72 (10.1) 26 (12.4) 46 (15.4)
   10+ years ago 60 (14.2) 41 (5.7) 56 (26.7) 136 (45.6)
How often do medical guidelines suggest this test?c n=710 n=865 n=535 n=473
   Every year 340 (47.9) 160 (18.5) 124 (23.2) 92 (19.5)
   Every two years 129 (18.2) 122 (14.1) 85 (15.9) 64 (13.5)
   Every three years 51 (7.2) 93 (10.8) 55 (10.3) 45 (9.5)
   Every four or five years 117 (16.5) 365 (42.2) 174 (32.5) 156 (33.0)
   Every six to ten years 29 (4.1) 106 (12.3) 49 (9.2) 47 (9.9)
   Never 44 (6.2) 19 (2.2) 48 (9.0) 69 (14.6)
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a

Numbers may differ from totals due to survey skip patterns and missing data; Percentages may not add up to 100% due to rounding

b

Responses within medical guidelines are bolded

c

Correct response is bolded

Acknowledgments

Conflicts of Interest:

Support for this research was provided by the grant “Increasing Colorectal Cancer Screening for Patients with Multiple Morbidities” (National Institutes of Health/ National Cancer Institute. R21CA129881-01, PI: Schoenberg).

Footnotes

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