Exploring Factors of Colorectal Cancer Screening Using the Precaution Adoption Process Model (PAPM): A Conceptual Framework for Tailoring Interventions

Background: Colorectal cancer (CRC) is the second most commonly-diagnosed form of cancer and the leading cause of death for Korean Americans (KAs). Incidence rates of CRC among KAs are increasing, while rates for other ethnic groups are stable or declining. Despite such disproportionate CRC burden facing KAs, their CRC screening rates remain significantly lower than the national targets. Previous studies have consistently reported associations of CRC screening uptake with knowledge and physician recommendations, but there are many individuals who receive information and recommendations from health providers or family members, yet do not complete screening. Thus, this study aimed to (1) examine the distribution and characteristics of a decisional stage for adoption of CRC screening among KAs using the Precaution Adoption Process Model (PAPM) and (2) assess the differences across the stages.

Methods: Quota sampling was conducted to recruit KAs ages 50 and older in the Atlanta metropolitan area through local radio advertisement, religious organizations, and referrals. Participants (n=526) in a cross-sectional survey self-reported information regarding CRC screening history, PAPM stage and knowledge, attitudes and beliefs (decisional balance) about CRC screening, health-related information, and socio-demographics. The main outcome was PAPM stage of adoption of CRC screening (i.e., Stage 1: Unaware, Stage 2: Unengaged, Stage 3: Deciding, Stage 4: Decided No, Stage 5: Decided Yes, Stage 6: Action, Stage 7: Maintenance) based on the following guidelines: colonoscopy every 10 years alone or the combination annual FOBT plus sigmoidoscopy every 5 years.

Most participants were female (62%), married (84%), and uninsured (57%). Their mean age was 59.5 (SD=7.65), 42% had not completed college, and 43% had an annual household income below $40,000. Multiple logistic regression analysis was conducted to investigate associations of potential predictor variables with PAPM stage of CRC screening adoption. Multivariable associations were examined by comparing statistically independent combinations (orthogonal contrasts) of PAPM stage categories and using multiple logistic regression analysis.  

Results: 36% were up-to-date with at least one test; 34% were adherent with the study guidelines. 17% were Stage 1/2 (Unaware/Unengaged); 16% were Stage 3 (Deciding); 21% were Stage 4 (Decided No); 11% were Stage 5 (Decided Yes); and 35% were Stage 6/7 (Action/Maintenance). Physician recommendation, positive decisional balance score, and greater perceived self-efficacy were significantly associated with higher compared to lower PAPM stages except for Stages 3/5/6/7 vs. Stage 4 and Stages 6/7 vs. Stage 5. Higher scores of e-health literacy, physical recommendation, and greater perceived self-efficacy were significantly associated with Stages 3/5/6/7 compare to Stage 4; Regular check-up, physician recommendation, and lower self-efficacy were significantly associated with Stages 6/7 compared to Stage 5.

Implications: The findings suggest that the PAPM-based characteristics of CRC screening adoption provide useful information for designing tailored interventions, especially among underserved populations. Future studies could examine the feasibility and effectiveness of stage-based messages delivered by ethnic physicians for improving attitudes, beliefs, and self-efficacy pertaining to CRC screening in a target population, which would lead to screening promotion. Eliminating disparities in cancer screening is critical for social workers in both research and clinical contexts.