|Year : 2015 | Volume
| Issue : 1 | Page : 20
Motivating Factors Associated With Receipt of Asymptomatic Colonoscopy Screening
Corey H Basch1, Charles E Basch2, Randi L Wolf2, Particia Zybert2
1 Department of Public Health, William Paterson University, Wayne, NJ 07470, USA
2 Department of Health and Behavior Studies, Teachers College, Columbia University, New York, NY 10027, USA
|Date of Submission||20-May-2014|
|Date of Acceptance||11-Oct-2014|
|Date of Web Publication||03-Mar-2015|
Corey H Basch
Department of Public Health, William Paterson University, Wing 150, Wayne, NJ 07470
Source of Support: The American Cancer Society (grant
number RSGT-09-012-01-CPPB),, Conflict of Interest: None
Background: Colonoscopy is the preferred screening method for colorectal cancer (CRC). This study aimed to identify factors motivating a beneficial health behavior, that is, the decision to complete a colonoscopy.
Methods: We surveyed 91 primarily urban minority health care workers who were ineligible for a large randomized controlled trial due to self-reported asymptomatic colonoscopy screening. Participants were asked an open-ended question about what made them get screened. Responses were classified as external or internal motivations.
Results: The most commonly reported external motivation was a primary care physician's recommendation (n = 60, 65.9%). Other external motivations were familiarity with CRC or polyps through family or work (n = 16, 17.6%) and pressure from relatives or friends (n = 8, 8.8%). Seventeen respondents were deemed self-motivated; these individuals were more likely have income over $50K/year (P < 0.05) and to be US born (P = 0.05); they were more likely to mention being age-appropriate for screening (P < 0.05); knew more people who had colonoscopies (P < 0.001); they were less likely to believe that most of the age-appropriate population in New York City has been screened (P < 0.01) and less likely to be deterred from colonoscopy by work schedule (P < 0.001) or by having to take a powerful laxative (P < 0.001).
Conclusions: A primary care physician's recommendation may be the most prevalent motivating factor in patients' decisions to receive a colonoscopy, but a subgroup seeks CRC screening on their own. Analysis of the motivations of individuals who have sought colonoscopy screening may offer useful insights into motivating those who have not.
Keywords: Colon cancer, colonoscopy, screening
|How to cite this article:|
Basch CH, Basch CE, Wolf RL, Zybert P. Motivating Factors Associated With Receipt of Asymptomatic Colonoscopy Screening. Int J Prev Med 2015;6:20
|How to cite this URL:|
Basch CH, Basch CE, Wolf RL, Zybert P. Motivating Factors Associated With Receipt of Asymptomatic Colonoscopy Screening. Int J Prev Med [serial online] 2015 [cited 2020 May 25];6:20. Available from: http://www.ijpvmjournal.net/text.asp?2015/6/1/20/152496
| Introduction|| |
In the United States, of cancers impacting both men and women, colorectal cancer (CRC) is the second leading cause of cancer-related deaths.  In 2014, it is estimated that there will be 136,830 cases of CRC and that 50,310 will result in mortality.  Screening tests for colonoscopy can reduce the incidence via polyp removal, ,, and screening is recommended for all men and women over age 50. , The US Preventive Services Task Force recommends the following three CRC screening tests: high-sensitivity fecal occult blood test, sigmoidoscopy, and colonoscopy.  The favored screening test of the American College of Gastroenterology is the colonoscopy.  A benefit of the colonoscopy is the ability to identify and remove abnormal polyps.  Data from the 2010 Behavioral Risk Factor Surveillance System on the prevalence of CRC screening among adults indicates that 64.5% of 50-75 year old respondents aged had received one of the three recommended CRC screening tests, with 60.3% screened by colonoscopy.  This is more than a 10% increase from 2002, indicating that strides have been made in reaching CRC screening goals.  It is important to note that reports from the past and present indicate that the populations who do not fulfill screening requirements are those with low levels of income and education. ,,, Minority populations are also less likely to receive timely recommended screening. ,,,
An important aim of public health research is to improve understanding about ways to promote decisions conducive to health. Research typically focuses on individuals exhibiting risk behaviors. This study aimed to identify factors motivating a beneficial health behavior, that is, the decision to complete a colonoscopy. Analysis of the motivations of individuals who have sought colonoscopy screening may offer useful insights into motivating those who have not.
| Methods|| |
Study design and participants
This study was ancillary to a larger study, The Healthy Colon Project II, a randomized trial funded by the American Cancer Society to evaluate the incremental effectiveness of alternative interventions for increasing rates of CRC screening among a sample that was age-eligible (>50 years), but had not been screened. For this cross-sectional sub-study, 91 primarily urban minority health care workers who were ineligible for the main trial because they had self-reported asymptomatic colonoscopy screening, were interviewed by telephone.
Study instrument and variable assessment
We interviewed the first 100 participants who were ineligible because they had completed CRC screening. After excluding those who completed a test other than a colonoscopy and those who received the test because they were symptomatic, we arrived at our sample size. Participants were all over age 50 and were insured. The interview included an open-ended question, "Tell me, what made you get your (first) CRC screening test when you did? Responses were recorded verbatim and subsequently classified as external or internal. External motivation had a source outside the individual. Self-motivation came from within the individual and with no mention of an outside source. Development of the survey was guided by our past research with this population.  Trained research assistants conducted the interviews, and a senior statistician, who was not linked to the population of participants, coded and analyzed all of the data (P.Z.). The time interval for this data collection was 2/26/10 and 11/7/10.
Use of qualitative data proved important as open-ended questions allowed for the use of follow-up questions to get detailed information about what motivated the participants to receive CRC screening. Descriptive statistics, including frequencies and percentages, or means and standard deviations (SD), were calculated, and differences were assessed with Chi-square, and the Mann-Whitney U-test. This study was approved by the Institutional Review Boards at Teachers College, Columbia University, Columbia University Medical Center, and William Paterson University.
| Results|| |
Seventy-four participants (81.3%) were deemed externally motivated and 17 (18.7%) were internally (self) motivated. [Table 1] displays demographic characteristics and beliefs by motivational status. The mean age was 59.8 (5.4 SD). The most commonly reported motivation was external, and that was that respondents heeded their primary care physician's recommendation (n = 60, 65.9%). Other external motivations were having had exposure to CRC or polyps through family or work (n = 16, 17.6%) and having been pressured to get tested by relatives or friends (n = 8, 8.8%). Seventeen participants mentioned none of these external motivations and offered responses such as "knew it was important," "made appointment on my own;" these individuals were deemed self-motivated. Compared with the externally motivated, the self-motivated were more likely to have an income over $50K/year (46.2% vs. 16.4%, P < 0.05) and to be US born (35.3% vs. 12.2%, P = 0.05); they were more likely to mention that they were age-appropriate for the test (58.8% vs. 28.4%, P < 0.05), knew more people who had had colonoscopies (median 6, range = 2-25 vs. median 3, range= 0-20, (P < 0.001); they were less likely to report thinking that most of the age-appropriate population in New York City had received colonoscopy screening (35.3% vs. 77.0%, P < 0.005) and less likely to be deterred from colonoscopy by work schedule (0% vs. 50%, P < 0.001) or by having to take a powerful laxative (11.8% vs. 62.2%, P < 0.001). Though just missing statistical significance (P = 0.063), it is interesting to note that more than half (56.3%) of the self-motivated versus under a third (28.2%) of the externally motivated reported that their doctors displayed educational materials. [Table 2] serves as a depiction of the open-ended questions asked to all participants along with examples of follow-up questions.
|Table 1: Demographic characteristics and beliefs for self-motivated versus externally motivated CRC screening colonoscopya |
Click here to view
| Discussion|| |
Our findings indicate that a heterogeneous set of motivations led respondents to receive asymptomatic colonoscopy screening. Over 80% of respondents reported external motivations, most notably a recommendation from a primary care physician. Our prior research on CRC screening in an independent sample, , has highlighted the importance of a recommendation from a primary care physician. This is consistent with the finding that physicians are the most trusted source of health information and demonstrates the importance of physicians' recommendations for increasing rates of CRC screening. In this paper, we also describe characteristics that distinguish the self-motivated from the externally motivated. This study was limited by the cross-sectional design and a small sample size. In addition, because the participants in the study work in a health care setting this could make them more privy to the need for a screening test. Nevertheless, this study contributes to the sparse research related to factors motivating the decision to complete a colonoscopy.
Analysis of the motivations of individuals who have sought colonoscopy screening versus those who have not has yielded important findings. To place these ideas about motivation for screening in a broader theoretical context, we recognize motivation is a necessary, but not sufficient, factor influencing initiation or maintenance of behavioral changes. Even if motivated, some individuals may not be able to act on their motivation or have adequate social support to reinforce their choices. 
Literature on correlates of cancer screening, namely that minorities,  those of lower socioeconomic status, , and those with lower levels of education , are less likely to be screened. This study fills a gap in the literature by focusing on factors that motivated participants from a primarily minority population to complete CRC screening. To the extent that similar motivating factors can be generalized to other settings and populations requires further study.
| Conclusions|| |
Most of the characteristics we found to be associated with self-motivation are not amenable to change (e.g., birthplace) or are difficult to change (e.g., income); others may be addressed through education. These latter include knowledge about the age at which CRC screening is recommended, tolerability of preparation, and facilitation in taking time off from work. The significance of this last factor is that while health insurance may cover direct medical cost, other financial costs may interfere with motivation or ability to act on motivation to be screened.
| Acknowledgments|| |
This work was primarily supported by the American Cancer Society (grant number RSGT-09-012-01-CPPB), and for CHB by the ART fund at William Paterson University.
| References|| |
American Cancer Society. Cancer Facts and Figures 2010. Atlanta, GA: American Cancer Society; 2010.
Siegel R, DeSantis C, Jemal A. Cancer statistics, 2014. CA Cancer J Clin 2014;64:104-17.
Zauber AG, Winawer SJ, O'Brien MJ, Lansdorp-Vogelaar I, van Ballegooijen M, Hankey BF, et al.
Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012;366:687-96.
Whitlock EP, Lin JS, Liles E, Beil TL, Fu R. Screening for colorectal cancer: A targeted, updated systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2008;149:638-58.
Levin B, Lieberman DA, McFarland B, Andrews KS, Brooks D, Bond J, et al.
Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: A joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology 2008;134:1570-95.
Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM, et al.
American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol 2009;104:739-50.
U.S. Preventive Services Task Force. Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;149:627-37.
Prevalence of Colorectal Cancer Screening Among Adults - Behavioral Risk Factor Surveillance System, United States, MMWR; 2010. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/su6102a9.htm.[Last accessed on 2014 Apr 20].
CDC. Colorectal cancer screening - United States, 2002, 2004, 2006, and 2008. MMWR Morb Mortal Wkly Rep 2011;60:42-6.
Centers for Disease Control and Prevention (CDC). Vital signs: Colorectal cancer screening among adults aged 50-75 years-United States, 2008. MMWR Morb Mortal Wkly Rep 2010;59:808-12.
Shapiro JA, Seeff LC, Thompson TD, Nadel MR, Klabunde CN, Vernon SW. Colorectal cancer test use from the 2005 National Health Interview Survey. Cancer Epidemiol Biomarkers Prev 2008;17:1623-30.
National Center for Health Statistics. Health, United States, 2010: With Special Feature on Death and Dying. Hyattsville, MD: National Center for Health Statistics; 2011. p. 18.
Stimpson JP, Pagán JA, Chen LW. Reducing racial and ethnic disparities in colorectal cancer screening is likely to require more than access to care. Health Aff (Millwood). 2012;31:2747-54.
Liss DT, Baker DW. Understanding current racial/ethnic disparities in colorectal cancer screening in the United States: The contribution of socioeconomic status and access to care. Am J Prev Med 2014;46:228-36.
Basch CE, Wolf RL, Brouse CH, Shmukler C, Neugut A, DeCarlo LT, et al.
Telephone outreach to increase colorectal cancer screening in an urban minority population. Am J Public Health 2006;96:2246-53.
Brouse CH, Wolf RL, Basch CE. Facilitating factors for colorectal cancer screening. J Cancer Educ 2008;23:26-31.
Brouse CH, Basch CE, Wolf RL, Shmukler C. Barriers to colorectal cancer screening: An educational diagnosis. J Cancer Educ 2004;19:170-3.
Ata A, Elzey JD, Insaf TZ, Grau AM, Stain SC, Ahmed NU. Colorectal cancer prevention: Adherence patterns and correlates of tests done for screening purposes within United States populations. Cancer Detect Prev 2006;30:134-43.
Wee CC, McCarthy EP, Phillips RS. Factors associated with colon cancer screening: The role of patient factors and physician counseling. Prev Med 2005;41:23-9.
[Table 1], [Table 2]