Men’s Knowledge and Beliefs about Colorectal Cancer and Three Screenings: Education, Race and Screening Status

Abstract

Objective

This study compared how education, race, and screening status affected men’s knowledge about colorectal cancer, and their views of three screenings, the fecal occult blood test (FOBT), sigmoidoscopy, and colonoscopy.

Methods

In-depth interviews were conducted with 65 African-American and white men with diverse education backgrounds with similar numbers screened and unscreened.

Results

Education was associated with knowledge about colorectal cancer and the colonoscopy. Screening status and education were related to FOBT knowledge. Men knew little about the sigmoidoscopy.

Conclusion

Intervention programs should tailor education about colorectal cancer and screening by educational attainment levels, not by race.

Colorectal cancer is the third most common cancer and the second leading cause of cancer deaths among men in the United States. The American Cancer Society (ACS) reports that in 2009 doctors diagnosed nearly 147,000 new cases of colorectal cancer and that 49,920 people died from the cancer the same year.¹ Compared to white men, African-American men have more than 20 percent higher incident rates and 45 percent higher mortality rates from colorectal cancer.² Because routine colorectal cancer screening detects cancer at an earlier, more treatable stage, the American Cancer Society and the United States Preventive Services Task Force recommend routine screening at age 50 for those at average risk, and at earlier ages for those at high risk, with one or more of the following: fecal occult blood test (FOBT) each year, flexible sigmoidsocopy or double-contrast barium enema every five years, or colonoscopy every 10 years.^3,4

However, most adults over age 50 have not undergone screening, and disparities in screening persist with African-American men having lower levels of screening than white men.² Research shows a relationship between knowledge about colorectal cancer screening and adherence with screening recommendations.⁵ Levels of knowledge increased with educational attainment⁶ and by race with African-Americans reporting less knowledge than non-Hispanic whites.^6,7 Additional barriers to screening include perceived discomfort and pain,⁸ lack of physician recommendation^9–11 and concerns that screening procedures threaten masculinity.¹²

Physician recommendation is key to increasing screening rates.^13,14 Improving physician communication and patient education programs require understanding what men know about colorectal cancer and screening. Yet little research has examined men’s knowledge about colorectal cancer, its causes and effects;⁷ most research has focused on screening knowledge.^5,6,8–10 Screening barriers may also vary by type of screening, but little research has compared men’s beliefs about distinct screenings for colorectal cancer.^15,16 Prevention programs that do not take into account different screening barriers may not be effective.¹⁵ Finally, few qualitative studies have examined men’s knowledge and attitudes about colorectal cancer screenings.^17–20 These studies focus on specific groups such as minority populations¹⁹ or low-income populations²⁰ thereby minimizing researchers’ abilities to determine whether beliefs and attitudes about colorectal cancer screening differ between population groups.

The purpose of this study is to compare how education, race, and screening status affect men’s knowledge about colorectal cancer, and their attitudes and experiences with three types of screening, the FOBT, sigmoidoscopy, and colonoscopy. To accomplish this goal, we analyzed qualitative data based on in-depth interviews with 65 African-American and white men from urban and rural areas with different educational attainment backgrounds. We recruited similar numbers of men who had been screened and who had not been screened.

Colorectal Cancer Knowledge and Screening Barriers Background

Published studies do not compare screened and unscreened African-American and white men across educational attainment levels concerning their knowledge about a variety of colorectal cancer topics. Research on colorectal cancer knowledge in the general population²¹ and on older, low-income African-Americans found that overall knowledge about colorectal cancer is low.²² Qualitative research similarly reported low knowledge about colorectal cancer overall,^17,23 but one study found that whites demonstrated the most knowledge compared to other ethnic groups.⁷ These studies, however, are limited in three ways. The samples consisted of predominantly white participants;²³ those that included African-American and white participants did not compare knowledge and beliefs by race;¹⁷ and those that included racially diverse samples did not compare race across all educational attainment levels⁷ thereby creating a confound between race and education.

Research that investigated screening knowledge by specific screening exams found that knowledge in the general population is low for sigmoidoscopy compared to colonoscopy.²¹ In addition to knowledge as a barrier to screening, FOBT barriers include scheduling conflicts, lack of interest,²⁴ discomfort,¹⁶ lack of family history and doctor recommendation.²⁵ Barriers most often reported for sigmoidoscopy and colonoscopy were lack of symptoms, being too busy,²⁴ discomfort with the preparation¹⁶ and fear of pain.²⁵ The most often reported barrier for all screening exams was lack of physician recommendation.¹³

Research describing what men know about colorectal cancer is needed for physicians to effectively educate men about screening. Qualitative studies have focused on particular populations, often low-income or African-Americans,^18,19 but these studies are limited because the absence of comparison groups does not allow researchers to understand if described beliefs are unique to the studied group or shared more generally. In addition, for physicians to successfully communicate about different screening exams, more research is needed to understand men’s views about each screening procedure. Past research either focused on one screening exam¹⁹ or combined sigmoidoscopy and colonoscopy.¹⁶ Given the lack of research on colorectal cancer knowledge and about particular exams, we compared race, education, and screening status for white and African-American men’s knowledge and beliefs about the colon and rectum, colorectal cancer, colorectal cancer causes and effects, the FOBT, sigmoidoscopy and the colonoscopy.

Methods

Study design: sample and interviews

In-depth interview data were collected from 65 men, aged 40–64, from diverse socio-economic backgrounds. None of the respondents had ever been diagnosed with colorectal cancer. The project was framed by Kleinman’s explanatory models of illness. Explanatory models (EMs) are the ideas individuals use to make sense of a condition or illness and to evaluate possible treatment or prevention strategies.^26,27 EMs provide information on six aspects of illness: (a) naming the condition, (b) etiology, (c) precipitating circumstances and mode of onset of symptoms, (d) an explanation of pathophysiology, (e) course of sickness and appropriate patient behavior, and (f) available treatments. People vary in the content of their EMs, which are usually only partly articulated and may be inconsistent or even self-contradictory. Individual models share common features to the extent that persons share a common cultural and social orientation.²⁸

This study is part of a larger project on African-American and white men’s beliefs, knowledge, and screening for prostate and colorectal cancer. The larger study consisted of two in-depth interviews for each man conducted in 2006–2007. Men were compensated 50 dollars for completing both interviews. During the first interview, beliefs about health, illness, cancer, and general cancer screening tests were discussed. The first meeting allowed the interviewer to develop rapport for the second, which covered potentially sensitive topics on beliefs, knowledge, and screening practices for prostate and colorectal cancer. In this paper, we focus on data collected from the second interview.

We received approval from the Wake Forest University Health Science Institutional Review Board before conducting interviews. Two male researchers conducted the interviews and gave men a choice of locations to meet. Some men preferred their own homes, while others chose conference rooms in churches or in the department where the researchers work; all interviews were private to ensure participant privacy and to encourage open discussion. Each interview ranged from one to two hours, was tape-recorded, and transcribed.

Based on a semi-structured interview guide, men were asked what they knew about the colon and rectum, colorectal cancer, colorectal cancer prevention and screening, FOBT, sigmoidoscopy, colonoscopy, and screening barriers. Men were asked about the sigmoidoscopy because when the data was collected, doctors used this screening exam and some men had experiences with it. After asking each man a question about what they knew about each screening test and prior to asking their beliefs, a description of colorectal screening from the ACS was read, regardless of men’s levels of knowledge. All men were asked their views about each screening exam. Follow-up questions were used to clarify vague responses as is standard in qualitative interviewing. For example, if men said that an exam was “good” or “bad,” interviewers probed to elicit more detailed responses. We assigned each man an identification number to preserve anonymity.

Participants were recruited from across North Carolina, including rural and urban areas. Interviewers worked with area organizations such as churches, social service agencies, and men’s social groups, to recruit men between the ages of 40 and 64 who had not had colorectal cancer. The goal in recruitment was to obtain a balance of screened and unscreened African-American and white men from rural and urban areas across three educational attainment levels: low education, defined as high school graduate or less; medium educational attainment, defined as some college; and high educational attainment, defined as college graduate and higher.

We defined screened as those respondents who had a FOBT, sigmoidoscopy or colonoscopy for cancer screening. We defined unscreened as those men who had not had any of these tests for colorectal cancer screening. Participants included 65 men, 35 African-American men and 30 white men. The sample’s race, educational attainment, and screening status are described in Table 1.

Table 1.

Sample Summary by Education, Race and Screening Status

Participant Education and Race	Screened		Unscreened		Total
	N	%	N	%	N
Low Education
African American	7	20.6	9	30.0	16
White	2	5.9	1	3.3	3
Total	9	26.5	10	33.3	19
Medium Education
African American	5	14.7	1	3.3	6
White	6	14.7	5	16.7	11
Total	10	29.4	6	20.0	17
High Education
African American	6	17.6	7	23.3	13
White	9	26.5	7	23.3	16
Total	15	44.1	14	46.6	29
Cumulative Total	35	100	30	100	65

Data analysis

The research team developed a coding dictionary based on a general review of the transcripts. Each transcript was coded by one investigator and then reviewed by a different investigator. Discrepancies between the coding of the two investigators were resolved at team meetings. As new issues arose, the team collectively agreed to add or to collapse codes. ATLAS.ti, a qualitative analysis software program, was used to code and to analyze the data.²⁹ Data analysis consisted of sorting the men into three educational attainment groups, and by race and screening status within each group, and running analysis reports based on colorectal codes. The colorectal codes covered discussions about the rectum and colon; colorectal cancer; causes and symptoms; and knowledge and views of three screening exams: FOBT, sigmoidoscopy and colonoscopy. Summaries were generated for each educational attainment group, and for screening status and racial groups within each education group, and then distributed to the team for identification of salient themes. Through consensus, the team established themes about men’s beliefs and knowledge about the colon, rectum, colorectal cancer, and screening exams.

Results

Overall, men in this study had low levels of knowledge about the colon, rectum and sigmoidoscopy, regardless of education, race or screening status. We found differences by educational attainment for most topics including the colon and rectum, colorectal cancer, colorectal cancer causes, effects of colorectal cancer, and screening knowledge and attitudes. Screening status played a role in high educational attainment men’s knowledge about the colon and rectum and colorectal cancer causes, and their knowledge and experiences with sigmoidoscopy and colonoscopy. Finally, screening status was also related to overall FOBT knowledge.

Knowledge about colon and rectum

Most men across all education groups identified the colon as part of the intestines, while very few knew the location or purpose of the rectum, often misidentifying it as the anus. The low educational attainment group had the least knowledge about the colon and rectum with responses ranging from: “Colon would be your stool part? (And the rectum) Yea…that’s where…stool go” (#45, white, unscreened) to “The colon is your large intestine (and the rectum) is sort of like your anus and on up” (#34, African-American, unscreened). Most men with medium educational attainment had some knowledge that the colon is part of the intestines, but none explained that it is part of the large intestine. Most men misidentified the rectum as the anus, and only one man identified the rectum with the digestive process: “(It) has something to do with getting the bowel movements…through its last stage in the digestion process” (#48, white, unscreened).

Men with the highest levels of education demonstrated the most knowledge about the colon and rectum with many identifying the colon as part of the large intestine, for example: “Colon is also called the large intestines, about 5 or 6 feet long” ( #32, white, unscreened). Only a few described the rectum as part of the colon, such as: “the rectum is simply the end of the colon, which is where you expel it (waste)” (#14, African-American, screened). Overall, the men with the highest levels of knowledge in this group were all screened.

Knowledge about colorectal cancer

As education increased, so did men’s levels of knowledge about colorectal cancer, regardless of race or screening status. In the low education group, less than half of the men had heard of colorectal cancer; some said they had heard of colon cancer but not colorectal. In the medium educational attainment group, most had heard of colorectal cancer and a few said that “most people just say colon, not colorectal cancer” (#6, African-American, screened). Four in this group said that they had not heard of colorectal cancer. Similarly, most men with high educational attainment had heard of colorectal cancer. Two men, both unscreened, said that they had not heard of it, but one of them had heard of colon cancer: “(I’ve) heard of people getting colonoscopies…but I’ve never heard of colorectal cancer” (#54, white, unscreened).

Causes of colorectal cancer

Overall, most men regardless of race or screening status did not know what causes colorectal cancer. Most with low educational attainment said, “I have no idea” (#50, African-American, screened), but several speculated that diet plays a role, such as: “not eating properly…I know grease is not good…a lot of fats…just eats your colon, your lining and stuff up” (#28, African-American, unscreened). The most common response from men with medium educational attainment was that they did not know what causes colorectal cancer, but the most common reason provided was diet. For example, “I would say the more fatty food…and a lot of alcohol would be bad for you” (#7, white, screened).

Unlike the other two education groups, screening status played a role for men with high educational attainment. The most common response was diet, usually with other factors such as genetics or toxins. These men tended to be screened and gave detailed responses. For example:

“First of all if you define cancer, cancer is a growth of cells that are out of control. Something is aggravated at that point that causes those cells to trigger that. We eat too much red meat. Plus … we put too many other chemicals in our body by eating red meat, because we don’t grow it range free anymore (#14, African-American, screened).

However, the second most common response was that they did not know what causes colorectal cancer; these men tended not to be screened.

Effects of colorectal cancer

Beliefs about the effects of colorectal cancer differed by education, but not by race or screening status. Men with low educational attainment discussed pain, digestive problems and death as the main effects of colorectal cancer. For example, “I guess it would eventually rotten out your digestive system if the colon cancer kicks in” (#34, African-American, unscreened) and “I reckon if it wasn’t found, it’d kill you” (#45, white, unscreened). Men with medium educational attainment also cited these effects but discussed the colostomy as a particularly difficult effect of colorectal cancer. For example, “(The main effect of colorectal cancer would be) the breaking down of the foods…And plus the bag….(which is) an embarrassment” (#62, white, screened), and “…bowel resection and probably colostomy bag. The indignity…that’d be the chief initial problems” (#27, white, unscreened).

Men with high educational attainment most often discussed death and digestive issues as the main effects. Several men also discussed the colostomy as a main effect, similar to men with medium educational attainment, such as “you’d have to get it treated, which would probably involve colostomy at some point… If it’s permanent…that’s another variable you have to deal with for the rest of your life” (#2, African-American, unscreened). Two African-American men said that the discomfort from the colorectal cancer screening would be a main effect. For example, “I think men have more of a problem with it (colorectal cancer) because of the examinations, I’m saying that from a male point of view” (#14, screened).

Knowledge and views of screening exams

Fecal occult blood test

Screening status and education played a role in men’s levels of knowledge about the FOBT. Men with low levels of educational attainment had the least knowledge. The most common response was “I never heard of that” (#19, African-American, unscreened), but the few who knew how the exam is performed and its purpose were all screened. For example, one man explained: “It’s like they take a sample of your stool and check for if it’s got blood in it” (#12, African-American, screened). Most men with medium educational attainment had some knowledge of the FOBT, but often gave a partial explanation how the test is performed. Those with the highest levels were all screened and gave responses such as: “They give you a little piece of cardboard and say ‘Smear a little bit on there and mail it back in this special envelope, we’re gonna check for blood’” (#38, white, screened). Those with the least knowledge about the FOBT were unscreened and simply said “No” (i.e. #48, white, unscreened) when asked if they had heard of the fecal occult blood test.

Like men with medium educational attainment, most men with high educational attainment had partial knowledge about the FOBT. They either knew that the FOBT was used to screen for blood or knew how the test was performed: “So they just took a card and put their finger on some dots on the card and sent it to the lab. (Do you know what they were checking?) Not really” (#59, African-American, screened). Similar to the other groups, men with the most knowledge tended to be screened while those who did not know anything about the FOBT tended not to be screened.

Overall, most men in this study said that the FOBT was a “good test.” Most men with low and medium educational attainment said that the FOBT was a “fine” test “because if you are passing blood, you need to find out what’s causing it” (#1, white, screened, low educational attainment); “from the fecal matter they can learn quite a few things, and…you’re not getting (jabbed) or anything, so it’s an easy test” (#34, African-American, unscreened, low educational attainment); and it can help decide “whether or not you need to do the colonoscopy” (#57, African-American, screened, medium educational attainment). Just two men in each of the low and medium educational attainment groups were negative about the exam primarily because: “that’s unsanitary…. sending that through the mail” (#11, African-American, unscreened, low educational attainment) and “it would be aggravating and messy to try to poop and put it on a stick” (#25, white, unscreened, medium educational attainment).

Screening status played a role in high educational attainment men’s views of the FOBT. Overall, many viewed the FOBT as a “good” test and these men tended not to be screened; they typically said: “It’s a pretty reliable, widely used test” (#32, white, unscreened). Those with negative views tended to be screened and disliked the exam because: “it’s nasty…and too embarrassing and nobody’s really jumped me about it” (#60, white, screened). Some of the men said that they refuse to do the exam; one explained: “I had resistance around it. I mean, I know in my head that it’s okay to do it….It seems nasty to me” (#39, white, screened).

Sidmoidoscopy and colonoscopy

Most men in this study had never heard of a sigmoidoscopy, while most had some knowledge about a colonoscopy. As education increased, so did knowledge about what was involved with both exams. Regardless of race and screening status, men with the lowest levels of education had the least knowledge. Many said that they had never heard of either exam. With one exception, none of them had ever heard of sigmoidoscopy. About half of the men in this group had some knowledge about the preparation and the purpose of colonoscopy, but, with one exception, none knew how the procedure was performed. Their explanations of a colonoscopy ranged from: “Guy was telling me he had to…drink the stuff or something…You can’t eat anything for a certain period of time…and that cleans the bowels out” (#19, African-American, unscreened) to: “It’s checking your colon to see if there’s any cancer growth or polyps or anything….I don’t know what the procedure was” (#12, African-American, screened).

Most men with medium educational attainment had heard of a colonoscopy; however, none could explain both how and why the procedure was performed. Only three said they had heard of sigmoidoscopy and none of them could describe it. Compared to the men with low educational attainment, several in this group had some knowledge about how a colonoscopy was performed. For example, “I think it’s an in-house procedure that…they take a scope…and go in through the anus, through the rectum and look all up inside your intestines” (#10, African-American, screened), and “That’s where they stick the camera up there (in the rectum), they look for little lumps” (#48, white, unscreened).

Men with high educational attainment had the highest levels of knowledge. Most knew about colonoscopy, and while several accurately described sigmoidoscopy, most men did not have knowledge about it. Unlike the other two groups, screening status played a role in well-educated men’s levels of knowledge. Those who knew both sigmoidoscopy and colonoscopy were all screened while those with the least knowledge were all unscreened, with one exception. The following example represents the high level of knowledge that several showed by distinguishing between sigmoidoscopy and colonoscopy: “(The colonoscopy is) a procedure where they run the tube…the full length of the intestines…the sigmoidoscopy…you don’t have to be that highly sedated for it…it’s a less extensive type of test…they could see the bottom part of the intestine, the colon, but not the full intestine” (#41, white, screened). The men who had little knowledge of colonoscopy similarly said they heard of the colonoscopy but could not describe it. Only one highly educated man could not describe either sigmoidoscopy or colonoscopy although he had heard of both: “What they are, I don’t know” (#52, African-American, unscreened).

As education increased, so did men’s negative views of sigmoidoscopy and colonoscopy. Most with low educational attainment, regardless of screening status, said that the tests were “important.” However, some said they were reluctant to be screened with sigmoidoscopy or colonoscopy because they “sound like sort of painful” (#20, Black, unscreened). One unscreened man was particularly adamant that he would not have a sigmoidoscopy or colonoscopy: “I don’t like that, nn nnh. I don’t like that at all…I don’t want nothing up in me like that. It’s just that simple” (#28, African-American). The men with the most negative views of both exams were all unscreened.

Several with medium educational attainment said that a colonoscopy was “a good test,” while several others did not like it because the preparation was “inconvenient” (#38, white, screened), “uncomfortable” (#48, white, unscreened) or the exam required a “compromised position…(where)…you’re pretty much at the mercy of somebody” (#7, white, screened). Two men were adamant that they disliked the test. One explained that his “biggest fear is…someone placing something in my rectum, that’s how most men are” and if his doctor recommended the test he would “have to think about it” (#8, African-American, screened). The other said that the test is “demeaning…(because) that’s where you’re most vulnerable” (#27, white, unscreened).

Over half the men with high educational attainment said that colonoscopy and sigmoidoscopy are “good tests,” such as “I look at them as being probably the number one method of detecting colorectal cancer” (#9, African-American, screened). However, most of these men qualified their answers by adding that the tests were “uncomfortable” (#29, white, unscreened), “unpleasant” (#42, white, screened) or “painful” (#52, African-American, unscreened). A few men distinctly described the tests as invasive. For example, “You might want to call me old school…certain part of the body wasn’t made for entrance in a man (laughs)” (#33, African-American, screened) and “I think they’re, you know, invasive and physically unpleasant” (#32, white, unscreened).

Discussion

Our results indicate that men have little knowledge of colorectal cancer or screening exams. Consequently, they have partial and fragmented explanatory models of colorectal cancer. Regardless of education, ethnic group or screening status, men have little knowledge of the colon, rectum or sigmoidoscopy. Past research found that colorectal cancer knowledge is low in the general population.²¹ This study suggests that, in part, knowledge is low because men lack basic information about the colon and the rectum; men consistently could not describe the colon as the large intestine and confused the rectum with the anus. Similar to past research,²¹ most men knew little about the sigmoidoscopy.

Men’s explanatory models of colorectal cancer, causes, effects, and screening exams improved with education, similar to past research on screening knowledge.^6,9,21 In contrast to other research,^7,21 however, the present study did not find differences in knowledge by race. The difference in findings is likely due to sampling issues. The present study included African-American and white men across all levels of education including college graduates and above, whereas past research included only white participants in the highest levels of education.⁷ Other research relied on samples of low-income African-Americans and found low levels of knowledge.¹⁹ While we similarly found low levels of knowledge among men with low educational attainment, our low education group included both African-American and white men. In other words, men did not differ in their beliefs by race within the same educational attainment groups. Therefore, our study suggests that education, not race, is the key factor for knowledge about colorectal cancer and screening.

Screening status played a role in high educational attainment men’s explanatory models of the colon, rectum and colorectal cancer causes, and their knowledge and experiences with sigmoidoscopy and colonoscopy. This finding suggests that high educational attainment men who have been screened retain knowledge about colorectal cancer and screening from their interactions with their doctors. Screening status was also related to levels of knowledge about the FOBT over all education groups. This finding suggests that screening results in men retaining knowledge about how the exam is performed but not necessarily its purpose. As education increased, so did men’s knowledge about the FOBT’s purpose, which again suggests that physicians are effectively communicating with men who have higher levels of education. Another possibility is that higher educated men tend to seek out information about cancer screenings.

Men’s attitudes about the FOBT, sigmoidoscopy and colonoscopy exams varied with education; as education increased so did men’s negative views. Even though low educational attainment men were unable to explain what sigmoidoscopy and colonoscopy entail, they generally described them as “good” tests possibly because of a dominant cultural belief that medical exams are important.³⁰ Men’s negative views of the FOBT, sigmoidoscopy and colonoscopy increased with educational attainment, regardless of race and screening status. The more men knew about what the exams entail, the more they disliked the exams. Also, some men from each education group explicitly stated that they disliked the sigmoidoscopy and colonoscopy exams because they are “invasive.” Men who associate their masculinity with exams that involve the rectum may experience these exams more negatively;¹² future research with larger samples could investigate whether such views affect screening rates.

In addition to education, screening status played a role with high educational attainment men’s views of the FOBT. This finding suggests that some men who have high levels of knowledge and have been screened experience the FOBT negatively. Although more men in the high educational attainment group said that they refuse to comply with the FOBT compared to the other two groups, we found that men in each education group refused to comply. Past research reported that barriers to FOBT are greater compared with sigmoidoscopy or colonoscopy,¹⁵ but little research has documented the nature of FOBT barriers because most survey research generally defined barriers as “embarrassment” or “concerns about the test” (eg¹⁴). This study suggests that the embarrassment of putting stool on a stick and mailing fecal samples in addition to lack of physician follow-up could prevent men from complying with screening and rescreening; future research could investigate this possibility with a larger sample.

This qualitative study is the largest to date to examine a broad range of topics about colorectal cancer knowledge and screening, and it provides a unique comparison of screened and unscreened white and African-American men. However, it has limitations. Men in the low educational attainment group are predominantly African-American because interviewers had difficulties locating white men with low educational attainment. The findings can be generalized to the Southeast from which the sample was recruited, but they cannot be generalized to the whole population. We also did not examine other socioeconomic factors like income or access to health-care, which may be factors that also affect colorectal cancer screening knowledge.⁶ However, the findings suggest important considerations for improving men’s knowledge, screening rates and screening experiences.

Much of the past research on colorectal cancer screening barriers found that physicians should increase screening recommendations, yet much of that research did not detail issues that doctors should address when encouraging screening.^10,14 Prevention programs that do not take into account different screening barriers may not be effective¹⁵ and because rescreening rates are low,³¹ attending to men’s negative screening experiences is important. Unlike past research that suggests educational messages should be targeted to African-Americans,¹⁹ this study suggests that educational attainment, not race, should be the focus. This study found that education played the primary role in men’s knowledge about colorectal cancer and screening, and their concerns about different screening exams, so physicians and programs should tailor their messages based on educational attainment levels.

This study found that men with low education have little knowledge about anything related to colorectal cancer and screening, and that low knowledge in addition to structural issues (e.g., access to healthcare and screening) may partly account for screening disparities. While men with more education knew more about the FOBT and the colonoscopy, their more negative views suggest that physicians could provide more information about the importance of each screening exam to improve men’s experiences. All men need more information about the colon, rectum, and sigmoidoscopy, which physicians could provide either verbally or in written form when they discuss colorectal cancer screening. Also, past intervention research found that mailing printed information increased screening rates.³² Future research could determine whether an intervention that tailors printed information by education and different screening barriers in addition to increasing physician recommendations would provide a significant increase in screening and rescreening rates for diverse groups of men.