Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2013 Jul 1.
Published in final edited form as: J Nurse Pract. 2012 July-August;8(7):522–533. doi: 10.1016/j.nurpra.2011.12.003

Family Support and Colorectal Cancer Screening among Urban African Americans

Kelly Brittain 1, Jacquelyn Y Taylor 2, Carol Loveland-Cherry 3, Laurel Northouse 3, Cleopatra H Caldwell 4
PMCID: PMC3474367  NIHMSID: NIHMS345800  PMID: 23086216

Abstract

Colorectal cancer (CRC) is the third leading cause of cancer death among African Americans. Less than 50% of African Americans have had CRC screening. This study examined the relationships between family support and influence, cultural identity, CRC beliefs, and a screening informed decision among 129 urban African Americans. Family support (p < .01) significantly predicted CRC beliefs and CRC beliefs significantly predicted informed decision (p < .01). Based on study results, practitioners should routinely assess family support and CRC beliefs with African Americans patients. This may improve patient-provider shared decision-making satisfaction and CRC screening adherence among African American patients.

Keywords: colorectal cancer screening, family support, African Americans, decision-making

Introduction

The incidence rate of colorectal cancer (CRC) among African Americans is 20% higher and the mortality rate is 45% greater than Caucasians1. Routine CRC screening is a key factor in CRC prevention 1, yet African Americans reported lower screening rates of fecal occult blood testing and endoscopy within the recommended time interval than Caucasians2. Increasing CRC screening rates is crucial in reducing the CRC disparity experienced by African Americans. Understanding the factors that influence an informed decision about CRC screening may be a strategy. An informed decision occurs when an individual understands the nature of the disease or condition; understands the clinical service and its potential consequences; has considered preferences; has participated in decision making at a personally desirable level; and makes a decision consistent with his or her preferences and values3. Informed decision interventions are not limited to decision aids, but include websites, DVDs, CDs and other types of media. Additionally, informed decision interventions can be done outside of healthcare settings in the community. Previous studies have found informed decision interventions increase decision satisfaction and screening adherence3. However, little is known about the factors that influence an informed decision about CRC screening among African Americans.

Research suggests few correlates of an informed decision about CRC screening. Having a family history of colorectal cancer is positively associated to CRC screening decisions 4–6. Interventions targeting families with a family history of CRC only impact a select group of individuals and are not appropriate for individuals with average risk for CRC. Other studies have found that a person’s beliefs about CRC risk, efficacy of CRC testing, CRC prevention and perceived barriers are associated with the intent to be screened and performance of CRC screening behavior 4–9. Among African Americans higher perceived barriers scores were associated with less likelihood of having been screened with an FOBT in the past year (OR = 0.91; CI: 0.86–0.97) 5. Research has found that a person is more likely to be screened if the person believes that CRC can be prevented and has a higher perceived risk of getting CRC 9. Interventions designed to increase CRC screening intention and CRC screening behavior based on CRC beliefs have been marginally effective among African Americans 10, 11.

Previous studies have examined psychosocial resources, like social support, that may influence an informed decision about CRC screening among African Americans. Most studies have examined social ties/network (e. g., church attendance/membership) and its relationship to CRC screening among African Americans 12–14. Research has shown that African Americans that attend church are more likely to be adherent to CRC screening guidelines and see a health care provider regularly 14. Therefore, research and interventions that utilize the church have limited generalizability to the segment of African American that need the most support to become or maintain adherence to CRC screening guidelines and are most likely targeting those with access to the requisite information and support for colorectal cancer screening.

The family has a significant influence on the health of its individual members 12–19. Characteristics of the family have been shown to be predictors of health outcomes including mortality, cardiovascular heart disease, and hypertension among African Americans12–19. Jernigan et al, found that African Americans are more likely most likely to report that their main influence for cancer screening was a family member 12. Understanding the African American family as a health-promoting unit and the role it takes in influencing cancer screening related beliefs can lead to the creation of more decision aids and interventions that are pertinent in terms of the support African Americans receive from their family.

Cultural identity has been used to understand health behaviors related to mammography, smoking and breast self-examination in African Americans 20–24. Cultural characteristics that are prevalent and most predictive among African Americans include collectivism, racial pride, religiosity, and time orientation 23, 24. One study found that certain cultural characteristics, time orientation and religiosity, were predictive of mammography adherence 23. In spite of what is known about cultural identity and cancer screening, cultural identity has yet to be extensively examined in relation to CRC beliefs and an informed decision about CRC screening3.

Despite previous research and interventions, CRC screening rates, incidence and mortality rates among African Americans remain disparate. Little new knowledge has been generated in terms of factors that may lead to innovative interventions to increase CRC screening, and reduce CRC disparities among African Americans. The purpose of this correlational study is to examine the relationships between family support and influence, cultural identity, CRC beliefs, and their relationship to an informed decision about CRC screening among African Americans and to test the model of an informed decision. Investigating these variables may elucidate new strategies to reduce CRC disparities among African Americans.

Methods

Participants

Inclusion criteria included being (1) an African American man or woman, (2) regardless of CRC screening history and family history of CRC, (3) age 50 and older and (4) able to speak English. Exclusion criteria included men and women that (1) were not African American, (2) were younger than 50 years of age, (3) have or had CRC and (4) do not have insurance coverage for CRC screening. Individuals without health care insurance coverage for CRC screening were excluded because lack of health insurance and/or coverage for CRC screening is a known barrier to CRC screening. Study participants received a $25 gift card for the average of 30 minutes of time spent in data collection.

Design and Procedures

Prior to data collection, the institutional review board of a University in the Midwest approved recruitment materials and the informed consent. Potential participants were recruited from places of business (e.g., barbershops and a local medical center), community organizations and through the social networks of the residents of Detroit, Michigan. Eligible participants were asked to refer others meeting the inclusion criteria to participate in the study.

Measures

Family Support and Influence

The Medical Outcomes Study Social Support Survey (MOS-SSS) was used to measure family support 25. The MOS-SSS measures the perceived availability of social support through five dimensions of social support: emotional support, informational support, tangible support, affectionate support and positive social interactions 25. Participants were instructed to rate each of the 19 items using a 5-point Likert scale, with 1 corresponding with none of the time and 5 representing all of the time. A higher score for an individual scale or for the overall support index indicates more support. For this study, the measure was found to be reliable (α = .93).

An additional 4-item scale to measure family influence was developed by the PI to specifically to measure the influence of the family on the respondent to complete and/or support CRC screening. Participants were instructed to rate each of the four items using a 5-point Likert scale, with 1 corresponding with strongly disagree and 5 representing strongly agree. A higher score indicates higher family support and influence for CRC screening. For this study, the scale was found have adequate internal consistency reliability (α = .74).

Cultural Identity

The Cultural Identity Scale was modified to be applicable to African American women and men24. Some of the 32-items specifically state “Black women” so for this study the scales were modified to be appropriate for both genders to respond. The subscales measure five significant African American cultural characteristics; collectivism, religiosity, racial pride, present time orientation and future time orientation using a 4-point Likert scale. There is no total score for the Cultural Identity Scale. Lower scores on the subscales indicate lower perceptions of the cultural characteristics. For this study, the subscales were found to be reliable: collectivism (α = .82), religiosity (α = .89), racial pride (α = .81), present-time orientation (α = .71) and future-time orientation (α = .70).

Colorectal Cancer Beliefs

To measure the beliefs about CRC screening among African Americans, the 35-item CRC Perceptions Scale was used6. The scale measures CRC susceptibility, CRC severity, CRC screening benefits and barriers to screening using a 5-point Likert scale, with 1 corresponding with strongly disagree and 5 representing strongly agree. Higher scores on the scale indicate that the respondent has positive perceptions about CRC and CRC screening. For this study, the measure was found to be reliable (α = .92).

Informed Decision regarding CRC Screening

PI adapted an informed decision regarding CRC screening scale from a 28-item measure of informed choice regarding prenatal testing26. The adapted measure assessed CRC screening understanding and preferences (Fecal occult blood test and colonoscopy), knowledge of risks related to CRC screening, value of CRC screening and decisional consistency. The survey use a 4-point Likert scale with 1 corresponding to strongly disagree to 4 corresponding to strongly agree. Lower scores indicate an informed decision that is low. Content validity was established by a review of the instrument by two experts in the field of decision-making. The measure was pre-tested and found to be adequately reliable for an exploratory measure (α=.65). For this study, the measure had an adequate level of internal reliability (α = .68).

Data Analysis

PASW SPSS-W 17.0 Windows program was used for data analysis. All data was cleaned and examined for outliers. Cross-tabulations and descriptive statistics were used to provide a profile of the study participants. Bivariate correlations were computed between each of the study variables (cultural identity, family support and influence, CRC beliefs and informed decision). Multiple regression analysis was used to examine the explained variance of the study variables. Path analysis, using AMOS 17.0, was used to test the model of an informed decision about CRC screening.

Results

Sample characteristics

The final sample for the study included 64 African American men and 65 African American women with health care coverage for CRC screening, and no personal history of CRC. Participants ranged in age from 50 to 86 years, with a mean of 58.5 (SD = 7.6) years. Fifty percent of the participants had completed some college courses and 70% were not married.

Family support and influence, cultural identity and colorectal cancer beliefs

The relationship between family support and some of the subscales of cultural identity were significant. Collectivism, religiosity and future-time orientation were positively and significantly related to the family support (Table 1). There was a significant negative relationship between family support and present-time orientation (Table 1). Family influence was positively and significantly related to racial pride (r = .26, p < .01). The relationship between the scores of the cultural identity subscales and CRC beliefs varied. Collectivism (r = .26, p < .01), religiosity (r = .21, p <.01) and future-time orientation (r = .35, p <.01) had significant positive relationships to CRC beliefs. Present-time orientation was positively and significantly related to negative beliefs about CRC and CRC screening (r = −.33, p <.01).

Table 1.

Correlations between variables (N = 129)

Measure 1 2 3 4 5 6 7 8 9
1. Collectivism —
2. Religiosity .36** —
3. Racial pride .13.8 .23** —
4. Present-time orientation −.24** −.18* −.10 —
5. Future-time orientation .37** .45** .02 −.32** —
6. Colorectal Cancer Beliefs .26** .21* −.14 −33** .35** —
7. Family Influence .04 .14 .26** .03 .13 .09 —
8. Family support .40** .27** −.04 −.31** .30** .50** .11 —
9. Informed decision .16 .15 .06 −.31** .11 .30** .03 .24** —
Open in a new tab

Note.

*

p<.05,

**

p<.01

Family support and influence and colorectal cancer beliefs

The relationship between family support and CRC beliefs was statistically significant (p < .01: See Table 1). The relationship between family influence and CRC beliefs was not statistically significant (Table 1).

Correlates of an informed decision

Family support was positively and significantly related to an informed decision (Table 1). Present-time orientation had a significantly negative correlation to an informed decision about CRC screening (r = −.31, p = .00). Family influence and other cultural identity subscales did not have a statistically significant relationship to an informed decision. CRC beliefs and an informed decision about CRC screening was statistically significant (p < .01) (Table 1).

Path analyses

The multiple regression model with family support and influence and the five subscales of cultural identity, as predictors of CRC beliefs accounted for 36% of the variance. However, family support was the only statistically significant variable in the model (β = .46, p < .01; Table 2). The linear regression model with CRC beliefs as a predictor of an informed decision regarding CRC screening was statistically significant and accounted for 9% of the variance in informed decision making (R2=.08, F (1,128) =12.24, p <.05; Table 2). The fit and misfit indices of the path analysis of the overall model show that the model did not fit the data well (X2 =10.16, 7df, p = .18, N= 129, NFI = .952, CFI = .981, RMSEA = .059) (Table 2).

Table 2.

Direct and Indirect Causal Effects of the Variables in the Overall Model (n = 129)

Effect Causal effects β R2
Direct Indirect Total
On colorectal cancer beliefs: .36
 Collectivism .006 .000 .006 .069
 Religiosity .020 .000 .020 −.091
 Racial pride −.113 .000 −.113 −.103
 Present-time orientation −.141 .000 −.141 −.129
 Future-time orientation .179 .000 .179 .130
 Family support .414 .000 .414 .462**
 Family influence −.144 −.144 −.125
On informed-decision regarding colorectal cancer screening: .09
 Colorectal cancer beliefs .296 .000 .296 .300**
 Collectivism .000 .002 .002
 Religiosity .000 .006 .006
 Racial pride .000 −.033 −.033
 Present-time orientation .000 −.042 −042
 Future-time orientation .000 .053 .053
 Family support .000 .123 .123
 Family influence .000 −.043 −.043
Open in a new tab

X2 = 10.16, 7df, p = .18, N = 129, NFI = .952, CFI = .981, RMSEA = .059

*

p< .05,

**

p<.01

Discussion

This study focused on the relationships among family support and influence, cultural identity, CRC beliefs and an informed decision regarding CRC screening among African Americans. In the current study, the relationship between religiosity and future-time orientation indicated that those respondents placing a higher value on a religiosity were more apt to plan for the consequences of events that are far away. In addition, perceived low family support was related to a person being more present-time oriented, meaning that the person is more likely to delay an activity that requires planning or future thought, like CRC screening. These results cannot be compared to past studies as this study is one of the few to examine the relationships between characteristics of cultural identity and family support.

The study’s findings indicate that collectivism, religiosity and future-time orientation, certain cultural characteristics, may be related to having positive CRC beliefs. The findings of this study show that respondents who place a high value on religiosity have CRC beliefs that support CRC screening. These results support Holt, Lewellyn and Rathweg (2005) findings that religiosity had a positive effect on health among African Americans 27. A new finding that adds to the literature is that respondents who scored high on collectivism, a belief in the importance of the family, had beliefs that supported CRC screening. Another new finding is that respondents who were more future-time oriented had positive CRC beliefs. These new results of this study add to the body of knowledge related to cultural identity and CRC beliefs among African Americans 6, 20–24.

In this study, positive perceived family support was related to having positive beliefs about CRC screening. Previous research on the relationship between perceived family support and health related behaviors have reported similar results12. This result supports the findings of Jernigan, et. al (2001) who found that African Americans reported that the support of family members was important in receiving cancer screening. Further, the current study found that study participants with positive beliefs related to colorectal cancer screening are more likely to make an informed decision about colorectal cancer screening. While, this study is one of the few to examine the relationship between CRC beliefs and an informed decision regarding CRC screening the results support previous research on CRC beliefs and CRC screening behavior. Ruffin, Creswell, Jimbo and Fetters (2009), found that CRC beliefs and information about colon cancer were important reasons to receive CRC screening. Menon et. al. (2011) found that tailoring CRC screening education to address CRC beliefs resulted in increased CRC screening rates.

In the current study, the overall model of an informed decision did not fit the data well. A larger sample followed over time may yield different results. However, the exploratory nature of the results and how close the model came to good fit indices indicates that further research is needed to continue to develop the model of an informed decision among African Americans.

The results of this study sheds light on new factors that influence an informed decision regarding CRC screening among African Americans. Also important to note is the significant participation of African American men in this study compared to similar studies.

Limitations

This study has important limitations that should be noted. First, the research design for this study was correlational and cross-sectional. Correlation research has limitations because only conclusions about relationships between factors of family support and influence, cultural identity, CRC beliefs and an informed decision can be drawn. Cause and effect cannot be inferred. Second, the study was limited to 129 African American men and women, age 50 and older. Thus, results cannot be generalized to other studies of men and women who are younger or are from other ethnic groups. Third, this study was limited to African American women and men living in a large urban area in the Midwest. African American women and men living in suburban and rural areas may have different experiences and outcomes. Last, as with any survey research, study participants may have given responses that could be considered socially acceptable, instead of providing accurate responses to the questions. More research on the relationship between family support and influence, cultural identity, CRC beliefs and an informed decision regarding CRC screening among African Americans is needed before conclusions can be drawn.

Implications for practice

This study has implications for nurse practitioners providing colorectal cancer screening information to African American women and men aged 50 and older who have or have not been screened for colorectal cancer. The results from this study indicate that perceived family support, certain cultural characteristics, and colorectal cancer beliefs are related to an African-Americans’ informed decision about colorectal cancer screening. The measures used in this study shed light on the study’s variables. Yet, the measures may not be practical for clinical use. Use of this study’s measures requires at least 10–30 minutes of the patient’s time and another 10–20 minutes of time to score the measure(s). However, assessing family support and beliefs related to colorectal cancer screening is important. Assessments, whether a part of a checklist or patient-provider discussion, should include questions about what the person has heard about colorectal cancer screening and from whom, how the person will get to and from the colonoscopy, who they will talk to about their decision regarding colorectal cancer screening and what might that person say. Additionally, assessing if the individual is more likely to plan for events or deals more in the present moment may also be key in increase the numbers of African American adhering to CRC screening guidelines.

Previous research has found that provider recommendation is a top reason why a person completes CRC screening. However, despite provider recommendation, CRC screening rates remain near 50%. Assessing family support, certain aspects of cultural identity, and CRC beliefs may increase patient-provider communication, lead to shared decision making between the patient-provider, increase patient satisfaction and increase CRC screening adherence among African Americans.

Conclusion

Preliminary results from this study are encouraging as they add knowledge regarding the factors that influence an informed decision regarding CRC screening among African Americans. Further research could provide more details into the sociodemographic context of an informed decision about CRC screening. Further research in this area may also inform intervention research that may improve CRC screening rates among African Americans.

Acknowledgments

Funding for this research was provided in part by the National Institutes of Health/National Institute of Nursing Research through the Ruth L. Kirschstein National Research Service Awards (NRSA), grant number 1F31NR010421 and the Rackham Graduate School at the University of Michigan through the King Chavez Parks Future Faculty Fellowship to Kelly Brittain.

Footnotes

Conflict of Interest

The authors have no conflict of interests to disclose.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

References

  • 1.American Cancer Society. Colorectal Cancer Facts and Figures 2011–2013. Atlanta: American Cancer Society; 2011. [Google Scholar]
  • 2.Seeff LC, Nadel MR, Klabunde CN, Thompson T, Shapiro JA, Vernon SW, Coates RJ. Patterns and predictors of colorectal cancer test use in adult US population. Cancer. 2004;100(10):2093–2103. doi: 10.1002/cncr.20276. [DOI] [PubMed] [Google Scholar]
  • 3.Briss P, Rimer B, Reilley B, Coates RC, Lee NC, Mullen P, et al. Promoting informed decisions about cancer screening in communities and healthcare systems. Am J Prev Med. 2004;26(1):67–80. doi: 10.1016/j.amepre.2003.09.012. [DOI] [PubMed] [Google Scholar]
  • 4.Brenes GA, Paskett ED. Predictors of stage of adoption for colorectal cancer screening. Preventive Medicine. 2000;31:410–416. doi: 10.1006/pmed.2000.0729. [DOI] [PubMed] [Google Scholar]
  • 5.Codori A, Peterson GM, Miglioretti DL, Boyd P. Health beliefs and endoscopic screening for colorectal cancer: Potential for cancer prevention. Preventive Medicine. 2001;33:128–136. doi: 10.1006/pmed.2001.0862. [DOI] [PubMed] [Google Scholar]
  • 6.Green PM, Kelly BA. Cancer knowledge, perceptions, and behaviors in African Americans. Cancer Nursing. 2004;27(3):206–215. doi: 10.1097/00002820-200405000-00004. [DOI] [PubMed] [Google Scholar]
  • 7.Myers RE, Vernon SW, Tilley BC, Lu M, Watts BG. Intention to screen for colorectal cancer among white male employees. Preventive Medicine. 1998;27:279–287. doi: 10.1006/pmed.1998.0264. [DOI] [PubMed] [Google Scholar]
  • 8.Powe BD. Cancer fatalism among elderly Caucasians and African Americans. Oncology Nursing Forum. 1995a;26(3):583–588. [PubMed] [Google Scholar]
  • 9.James AS, Campbell MK, Hudson MA. Perceived barriers and benefits to colon cancer screening among African Americans in North Carolina: how does perception relate to screening behavior? Cancer Epidemiology, Biomarkers & Prevention. 2002;11:529–534. [PubMed] [Google Scholar]
  • 10.Powe BD, Faulkenberry R, Harmond L. A review of intervention studies that seek to increase colorectal cancer screening among African Americans. American Journal of Health Promotion. 2010;25(2):92–99. doi: 10.4278/ajhp.080826-LIT-162. [DOI] [PubMed] [Google Scholar]
  • 11.Siddiqui AA, Sifri R, Hyslop T, Andrel J, Rosenthal M, Vernon SW, Cocroft J, Myers RE. Race and response to colon cancer interventions. Preventive Medicine. 2011;52:262–264. doi: 10.1016/j.ypmed.2011.01.005. [DOI] [PubMed] [Google Scholar]
  • 12.Jernigan JC, Trauth JM, Ferguson-Neal D, Ulrich-Cartier C. Factors that influence cancer screening in older African American men and women: Focus group findings. Family & Community Health. 2001:27–33. doi: 10.1097/00003727-200110000-00005. [DOI] [PubMed] [Google Scholar]
  • 13.Kinney AY, Bloor LE, Martin C, Sandler RS. Social ties and colorectal cancer screening among blacks and whites in North Carolina. Cancer Epidemiology, Biomarkers & Prevention. 2005;14:182–189. [PubMed] [Google Scholar]
  • 14.Aaron KF, Levine D, Burstin HR. African American church participation and health care practices. J Gen Intern Med. 2003;18:908–913. doi: 10.1046/j.1525-1497.2003.20936.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Grzywacz J, Fuqua J. The social ecology of health: Leverage points and linkages. Behavioral Medicine. 2000;26(3):101–115. doi: 10.1080/08964280009595758. [DOI] [PubMed] [Google Scholar]
  • 16.Lelinneth N, Barnes M, De La Cruz NG, Williams PN, Rogers J. Public health perspectives on the family: An ecological approach to promoting health in the family and community. Family & Community Health. 2006;29(1):28–42. doi: 10.1097/00003727-200601000-00005. [DOI] [PubMed] [Google Scholar]
  • 17.Loveland-Cherry CJ. Family health promotion and disease prevention. In: Stevenson JS, Sommers MS, editors. Alcohol Misuse, Abuse, and Addition Research. Annual Review of Nursing Research. Vol. 23. New York, NY: Springer; 2005. [Google Scholar]
  • 18.House JS, Umberson D, Landis KR. Structures and processes of social support. Ann Rev Sociol. 1998;14:293–318. [Google Scholar]
  • 19.Brittain K, Taylor JY, Wu CY. Family adaptability among urban African American women with hypertension. Journal for Nurse Practitioners. 2010;6(10):786–793. doi: 10.1016/j.nurpra.2010.02.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Becker G, Gates RJ, Newsom E. Self care among chronically ill African Americans: Culture, health disparities, and health insurance status. American Journal of Public Health. 2004;94(12):2066–2073. doi: 10.2105/ajph.94.12.2066. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Erwin DO, Spatz TS, Stotts RC, Hollenberg JA. Increasing mammography practice by African American women. Cancer Practice. 1999;7(2):78–85. doi: 10.1046/j.1523-5394.1999.07204.x. [DOI] [PubMed] [Google Scholar]
  • 22.Gueverra JS, Kwate NA, Tang TS, Valdimarsdottir HB, Freeman HP, Bovbjerg DH. Acculturation and its relationship to smoking and breast self-examination frequency in African American women. J Behav Med. 2005;28(2):191–199. doi: 10.1007/s10865-005-3668-z. [DOI] [PubMed] [Google Scholar]
  • 23.Russell KM, Perkins SM, Zollinger TW, Champion VL. Sociocultural context of mammography screening use. Oncol Nurs Forum. 2006;33(1):105–112. doi: 10.1188/06.ONF.105-112. [DOI] [PubMed] [Google Scholar]
  • 24.Lukwago SM, Kreuter MW, Bucholtz DC, Holt CL, Clark EM. Development and Validation of Brief Scales to Measures Collectivism, Religiosity, Racial Pride, and Time-Orientation. Family & Community Health. 2001;24(3):63–71. doi: 10.1097/00003727-200110000-00008. [DOI] [PubMed] [Google Scholar]
  • 25.Sherbourne CD, Stewart AL. The MOS Social Support Survey. Soc Sci Med. 1991;32(6):705–714. doi: 10.1016/0277-9536(91)90150-b. [DOI] [PubMed] [Google Scholar]
  • 26.Marteau TM, Dormandy E, Michie S. A Measure of Informed Choice. Health Expectations. 2001;4:99–108. doi: 10.1046/j.1369-6513.2001.00140.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Holt CL, Lewellyn LA, Rathweg MJ. Exploring religion-health mechanisms among African American parishioners. Journal of Health Psychology. 2005;10:511–527. doi: 10.1177/1359105305053416. [DOI] [PubMed] [Google Scholar]
  • 28.Ruffin MT, 4th, Creswell JW, Jimbo M, Fetters MD. Factors influencing choices for colorectal cancer screening among previously unscreened African and Caucasian Americans: Findings from a triangulation mixed methods investigation. Journal of Community Health. 2009;34(2):79–89. doi: 10.1007/s10900-008-9133-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Menon U, Belue R, Wahab S, Rugen K, Kinney AY, Maramaldi P, Wujcik D, Szalacha LA. A randomized trial comparing the effect of two phone-based interventions on colorectal cancer screening adherence. Annals of Behavioral Medicine. 2011;42:294–303. doi: 10.1007/s12160-011-9291-z. [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES