Low Literacy Intervention for Colorectal Cancer Screening

Bennett CL, Schmitt B, Ferreira R. Low Literacy Intervention for Colorectal Cancer Screening. Paper presented at: VA Oncology Annual Symposium; 2002 Jan 1; Alexandria, VA.

Background: Flexible sigmoidoscopy/fecal occult blood testing (FOBT) is both one of the most effective and least commonly used cancer screening test. Concern exists that African American Veterans may present with advanced stage colorectal cancers as a consequence of very low rates of screening. Postulated underlying factors that may account for low screening rates among African American Veterans include patient-factors (poorer health literacy skills, less knowledge, and sociocultural considerations) and physician-factors (poor communication with low literacy Veterans). Our goal is to improve colorectal cancer screening rates for low literacy African American and white Veterans.Methods: We have conducted focus groups with Veterans and VA physicians about general knowledge and attitudes related to colorectal cancer and screening, recommendations for improvement, and experiences with screening discussions. Subsequently, with VA funding, we have initiated a randomized intervention targeted at patients, who receive low literacy materials on colorectal cancer screening, and physicians, who are both trained in low literacy techniques as well as enrolled in a feedback exercise where individual physicians receive quarterly feedback about individual versus group average screening rates. Results. The focus groups (21 patients/13 physicians) found that patients frequently did not know cancer related terms such as polyp, tumor, growth, or lesion; could not name the FOBT or flexible sigmoidoscopy tests (instead called them 'the Walgreen's test'); were unaware of the benefits of screening or early detection; felt that currently available literature was not comprehensible; and would be responsive to suggestions about these tests if a health care provider recommended the procedure. Physicians felt that a low literacy, culturally sensitive videotape that explained the screening procedures would be helpful; formal training that highlighted proven methods of communication to low literacy individuals; and a continuous quality improvement effort with feedback about screening rates would be helpful. The randomized intervention was initiated in our firm system, with firm A being the intervention group and firm B the control. Our VA provides care to 12,000 Veterans annually, 45% of whom are African American, 33% of whom have a third grade or lower literacy level, and over 90% of whom are of lower socioeconomic status. Preliminary findings based on assessments of 53 Veterans and 12 physicians include: 1) the 6-minute low literacy, culturally sensitive videotape that was designed for this project was well-received by physicians and patients (with viewers particularly responsive that four Veterans from our hospital suggest that 'YOU should consider taking the FOBT or flex-sig screening test as it could save YOUR life;' (2) low literacy is a prevalent problem, with the average reading level of general medicine clinic patients being 7th to 8th grade, while the reading level of VA provided colorectal cancer screening materials being 9th grade or higher; and (3) large variations exist in baseline screening rates of individual providers.Conclusions: African American Veterans are disproportionately adversely affected by colorectal cancer. We plan to 1) present results from the first 6 months of our randomized intervention, with updated findings on baseline and follow-up screening rates of the intervention and control arm of the randomized trial and 2) show the VA funded low literacy colorectal cancer screening videotape to attendees, in anticipation that other VA medical centers might want to provide the educational materials that we have developed for this project to their patients.