The research questions guiding this research study were:
1. What are the levels of functional health literacy among adults between the ages of 50 to
75 years in the South Central Louisiana parishes of Lafourche, St. Mary, and
Terrebonne?
2. What is the stage of readiness to participate in colorectal cancer screening tests among
adults between the ages of 50 to 75 years in the South Central Louisiana parishes of
Lafourche, St. Mary, and Terrebonne?
3. What is the effect of a colorectal cancer screening education fact sheet written at
standard, high and low levels of intensity on the stage of readiness to participate in
colorectal cancer screening tests among adults between the ages of 50 to 75 years in the
South Central Louisiana parishes of Lafourche, St. Mary, and Terrebonne?
4. What are the relationships between the levels of functional health literacy and stages of
readiness to participate in colorectal cancer screening tests among adults between the
ages of 50 to 75 years in the South Central Louisiana parishes of Lafourche, St. Mary,
and Terrebonne?
REVIEW OF THE LITERATURE
The prevalence of low health literacy is discussed through illustrative research studies
detailing the effects of low health literacy on health and health outcomes. The seminal research
from the early 1990s is included to portray the importance of the emergence of the health literacy
concept. Lastly, studies utilizing the transtheoretical model and language expectancy theory are
discussed to demonstrate the applicability of these models and theories to this research study.
Prevalence of Colorectal Cancer
In the United States it was reported in 2004 that a total of 53,772 deaths (18.0 cases per
100,000 population) were attributed to colorectal cancer, with 919 occurring in Louisiana (21.2
cases per 100,000 population) (Cancer deaths, 2007). Additionally for 2004, Louisiana recorded
an incidence rate of 100.1 cases per 100,000 population for colorectal cancer diagnosed at an
advanced stage for men and women over 50 years of age (Colorectal cancer incidence, 2007).
This placed Louisiana 3rd in colorectal cancer deaths and 2nd in cases of advanced stage diagnosis
for the year 2004. Current statistics presented in Chapter 1 indicate a decrease in the incidence
and death rates for CRC, but it continues to remain the second leading cause of cancer deaths in
the United States. CRC screening can allow for the early detection and treatment of colorectal
abnormalities in a pre-cancerous or early-stage cancer situation, with a 76% to 90% prevention
or cure rate (Levy et al., 2007).
Colorectal Cancer Screening
A number of qualitative and quantitative research articles were reviewed to demonstrate
the presence of colorectal screening in the literature. Davis et al. (2001) conducted a
phenomenological study to determine the knowledge, beliefs, and attitudes of 21 low health
literacy skill primary care patients (PCPs) regarding colorectal cancer screening. Included in this
study was the identification of common barriers and facilitators to colorectal cancer screening.
In addition, 13 physicians were also utilized in the identification of common barriers and
facilitators, and information was solicited regarding their educational efforts with, and
recommendations to, patients concerning screening (Davis et al.). Focus groups were structured,
and the Health Belief Model was employed to guide the study. The Health Belief Model
theorizes that preventive health behaviors will be determined by a person’s perception of
susceptibility, severity, and an awareness of a practical course of action (Glanz, Rimer, &
Viswanath, 2008).
Data analysis revealed several common themes among the PCPs including
misunderstanding of screening concepts and benefits of early detection, non-susceptibility to
cancer related to “feeling well,” and fear of having cancer if they were tested (Davis et al., 2001).
These negative beliefs and attitudes may lead low health literacy patients to not get tested,
thereby delaying interventions that could possibly stop cancer. The physicians and patients
agreed that lack of time was a barrier to talking about screening, and suggestions were offered
that pamphlets could be given followed by viewing of a video as part of the physician’s visit to
accomplish education on screening (Davis et al.). However, the patients stressed that the
information should be simple, to-the-point, and hopeful. Davis et al. noted that these requests are
in line with the Health Belief Model.
Dolan et al. (2004) surveyed 377 male veterans aged 50 years and older to determine
their knowledge, attitudes, and beliefs regarding CRC screening. It was hypothesized within the
study that literacy would have an effect on these determinants affecting participation in CRC
screening exams. Of the participants, 36% had health literacy skills at or below the level of
eighth grade as measured by the REALM. Results of the survey revealed that those with lower
health literacy were 3.5 times more likely to have not heard about CRC, 1.5 times more likely to
not be aware of screening tests, 2.0 times more likely to be concerned about messiness of FOBT,
1.5 times more likely to believe that FOBT was inconvenient, and 4.0 times more likely to refuse
to use a FOBT kit even if one were supplied to them by their physician (Dolan et al.).
Interestingly, even though unfamiliar with CRC or screening tests, those with limited health
literacy believed that they were at average-to-high risk for the development of CRC.
Trauth et al. (2003) sought to describe the CRC screening behaviors of lower income
communities using the TTM to stage readiness to participate in FOBT or flexible sigmoidoscopy
(FSG). Survey results, using the Colorectal Cancer Screening Survey (CCSS), of 414
individuals between the ages of 50 and 79 years revealed that 86% of the respondents were
familiar with FOBT, and were relatively evenly distributed (14% - 19%) across the six stages of
the TTM stages of readiness to participate in screening (Trauth et al.). Only 51% of respondents
were aware of FSG, with 21% of those individuals in the precontemplation stage (Trauth et al.).
This would indicate that behavioral readiness to participate in FSG lags behind FOBT.
Additionally, Trauth et al. reported a direct positive association between increased age and
decreased intention to participate in CRC screening. Lastly, the authors concluded that readiness
to participate in CRC screening remains low, and targeted interventions are necessary to achieve
CRC screening levels that are comparable to breast cancer screening levels.
In a study of 111 African-American individuals in a low-income East Harlem
neighborhood, where mortality rates are higher than national averages related to CRC, adherence
to CRC screening guidelines was reported to be low (Lawsin, DuHamel, Weiss, Rakowski, &
Jandorf, 2006). The focus of this study was to identify barriers and facilitators to CRC
screening. Lawsin et al. reported that higher levels of education and greater knowledge of FSG
procedure contributed to greater adherence to the recommended five-year cycle for FSG, and
greater knowledge of FOBT along with physician recommendation contributed to greater
adherence to annual FOBT guidelines. Application of the TTM for CRC screening procedures
revealed that the majority of individuals were unaware of, or had never heard of, FSG (83%) or
FOBT (42%) (Lawsin et al.).
Zimmerman, Tabbarah, Trauth, Nowalk, and Ricci (2006) surveyed 325 individuals from
three inner-city health centers to determine adherence and barriers to CRC screening procedures.
The study identified an adherence rate for “lower endoscopy” screening procedures of 46%
among the participants. It is noted that this is close to the Healthy People 2010 goal of 50% of
individuals greater than 50 years of age receiving CRC screening (Zimmerman et al.).
Additionally, the authors reported lower rates of CRC screening among African Americans,
smokers, and those who viewed the procedures as inconvenient or unpleasant. This would
indicate that better educational interventions may be necessary to address this population and
these specific fears (Zimmerman et al.).
In a study of 206 individuals with a mean age of 61 years, Menon, Belue, Skinner,
Rothwell, and Champion (2007) applied the Health Belief Model and the traditional TTM of
change to (a) determine the distribution of individuals across the stages of change, (b) assess for
differences in beliefs and knowledge across stages of change, and (c) identify specific beliefs
affecting the stage of change. Results of the study revealed that (a) the majority of individuals
were in the precontemplation stage for FOBT (43%) and FSG (53%); (b) precontemplators had
lower perceived risk, lower perceived benefits from action, and higher barriers to screening than
those at higher stages for both FOBT and FSG; and (c) barriers to FOBT included “not knowing
how to do the test” and “not having symptoms” for those in precontemplation; while barriers to
FSG included pain, cost, not having symptoms, and a clear liquid diet for those in
precontemplation (Menon et al.).
It is apparent from this selected review that literacy and education play a role in CRC
screening adherence. With the exception of one of the studies reviewed, most individuals are in
a stage of unaware or precontemplation, according to the TTM. With the identification of
specific barriers to CRC screening, interventions can begin to address these issues in an effort to
increase participation in CRC screening at the stage of action or maintenance. As noted by
Sarfaty & Wender (2007), “If screening for CRC were universal-beginning at age 50 years for
those at average risk and earlier for those at increased risk-with timely removal of adenomas and
early cancers, the mortality rate from CRC could be drastically reduced” (p. 364).
The Prevalence of Low Health Literacy
The term health literacy was first used in 1974 in a paper written as a clarion call to draw
attention to the need for social policy directed at including health education at all school-grade
levels (National Library of Medicine, 2000); however, no further mention was located in the
literature for the next two decades. However, in 1995, health literacy reemerged as a concept
with the publication of a study conducted by Williams et al. in which 2,659 participants
completed the Test of Functional Health Literacy in Adults (TOFHLA). Williams et al. noted
that this was the first study to comprehensively assess the patient’s ability to perform specific
literacy tasks related to health care information. Study findings revealed that of the participants,
(a) 42% did not understand medication instructions or medical procedure instructions, (b) 26%
did not understand follow-up appointment schedules, and (c) 60% did not understand the
wording on informed consent documents (Williams et al.).
One of the strongest stimulus for the reemergence of health literacy as a topic of interest
was the 1992 National Adult Literacy Survey (NALS) in which it was reported that 40 to 44
million Americans were functionally illiterate, with another 50 million Americans labeled as
marginally literate (Kirsch, Jungeblut, Jenkins, & Kolstad, 1993). Kickbusch (2001) noted that
literacy levels are a key determinant of health, as well as an important predictor of health status.
Additionally, Kickbusch noted that for too long within the health care environment general
literacy results have been relied upon without a specific focus on the measurement of health
literacy.
A follow-up study to the 1992 NALS, the National Assessment of Adult Literacy
(NAAL), conducted in 2003, indicated no significant changes in prose and document literacy
scores; however, an eight point increase in quantitative literacy was noted (Kutner, Greenburg, &
Baer, 2006). More importantly, the NAAL included items that were designed to measure levels
of health literacy in American adults. For the purpose of the NAAL, the Institute of Medicine
definition of functional health literacy was utilized as “the degree to which individuals have the
capacity to obtain, process, and understand basic health information and services needed to make
appropriate decisions” (Nielson-Bohlman, Panzer, & Kindig, 2004, p. 7). Findings indicated that
53% of all adults had intermediate levels of health literacy, while 14% had below basic health
literacy skills (Kutner, Greenburg, Jin, & Paulsen, 2006). Adults between the ages of 50 to 64
years demonstrated similar percentages in level of health literacy, while adults over the age of 65
years demonstrated an alarming measurement of 38% with intermediate levels of health literacy
and 29% with below basic levels of health literacy (Kutner, Greenburg, Jin, et al.).
There is a paucity of literature in the health care sciences related to health literacy in the
two decades that preceded 1995. Most notable is the absence of health literacy research in the
nursing literature (Speros, 2005). Considering that nurses spend a significant amount of time
with patients and bear the responsibility for educating them, it is time that nurses begin to
seriously consider health literacy as an area of research interest.
It has been well documented that the lack of adequate health literacy is a threat to the
financial, material, and human resources of our public health system (Pawlak, 2005). The
Institute of Medicine (IOM) (Nielsen-Bohlman et al., 2004) has reported that approximately half
of all Americans, totaling nearly 90 million people, may have some difficulty reading and/or
understanding health information. This figure comes from the 1993 National Adult Literacy
Survey (NALS) that placed 40 to 44 million Americans in the category of functionally illiterate
with a reading level below 5th grade, and 50 million Americans in the category of marginally
literate (Kirsch et al., 1993). Included in this 90 million are 44% of adults over the age of 65 (Ad
Hoc Committee, 1999; Baker, Parker, Williams, & Clark, 1998; Baker et al., 2002; Gazmararian
et al., 1999; Speros, 2005).
It was previously noted that neither the NALS nor any other study had attempted to
assess the national level of health literacy (Kirsch et al., 1993). However, the recently completed
2003 National Assessment of Adult Literacy (NAAL) survey contained items specifically
targeted to measure health literacy. In this survey of over 19,000 participants, the National
Center for Education Statistics (NCES) reported no significant differences between the 1993
NALS survey for prose and documentation literacy, and a slightly significant increase in
quantitative literacy from 1993 to 2003 (n.d.). Analysis of the items specific to health literacy
revealed that 36% of the total population surveyed had basic to below basic health literacy (US
Department of Education, 2006). Among adults aged 65 years or above, 59% ranked at the basic
to below basic health literacy level (US Department of Education). It should be noted that the
number of ranking levels changed between the 1993 and 2003 surveys. Where the 1993 NALS
utilized five categories, the 2003 NAAL utilized four categories. The result of this change has
led to a lower percentage of persons being placed in the two lowest categories, basic to below
basic, which may falsely indicate that there have been national improvements in literacy levels
between the two measurement periods (US Department of Education).
The prevalence of low health literacy has been well documented in a number of studies
over time. Williams et al. (1995) reported that in a cross-sectional survey of 2,659 indigent and
minority patients at two public hospitals, 41.6% were unable to comprehend medication or
procedure instructions, 26% were unable to understand follow-up appointment instructions, and
59.5% could not understand informed consent forms. From a convenience sample of 63 cancer
patients, Cooley, Moriarity, Berger, Selm-Orr, Coyle, and Short (1995) reported 27% of the
participants could not read any of the 30 available pamphlets containing cancer information.
Gazmararian et al. (1999) reported that in a sample size of 3,260 new Medicare enrollees, 33.9%
of English speaking enrollees and 53.9% of Spanish speaking enrollees had inadequate or
marginal health literacy. In a non-experimental descriptive study of 92 randomly selected adults
with a mean age of 59 years, 28% were identified to have less than adequate health literacy
(Artinian, Lange, Templin, Stallwood, & Hermann, 2002). Benson and Foreman (2002), in a
descriptive cross-sectional study of 93 residents in an affluent Albuquerque, NM retirement
community, reported that 30% of the residents were unable to adequately comprehend written
information.
Differentiation of Literacy, Health Literacy, and Functional Health Literacy.
In an effort to better understand the terminology of the studies that have been reviewed, it
is important to revisit the definitions of literacy, health literacy, and functional health literacy.
Kickbusch (2001) defined the complexities of literacy in the following manner:
Literacy involves a complex set of abilities to understand and use the dominant symbol
system of a culture for personal and community development. The need and demand for
these abilities vary in different societies. In a technological society, the concept is
expanding to include the media and electronic text in addition to alphabets and numbers.
Individuals must be given life-long learning opportunities to move along a continuum that
includes reading, writing, critical understanding and the decision-making abilities they
need in their communities. (p. 292)
Health literacy has been consistently defined throughout the literature as the ability to
access, process, and understand health related information necessary for health care decisions
(Benson & Forman, 2002; Boswell, Cannon, Aung, & Eldridge, 2004; Wolf, Gazmararian, &
Parker, 2005). Functional health literacy goes beyond the ability to access, process, and
understand health related information to include the capacity to apply these abilities to
successfully act upon health information and directions (Kickbusch).
It is clear from these definitions that although literacy and health literacy are two
different entities, a person must possess a degree of literacy to be health literate. However, it
does not stand to reason that just because a person is literate, they will possess health literacy or
functional health literacy. Considering Kickbusch’s (2001) reference to a technological society
and the increasingly technical aspects of the current health care system, it is imperative that
nursing finds ways to increase the health literacy and functional skills of the population.
Health Literacy in Research
A number of qualitative and quantitative research articles were reviewed to demonstrate
the presence of health literacy in the literature. Lam, Cheng, & Chan (2004) conducted a
grounded theory study utilizing 36 participants involved in six focus groups and nine individual
interviews. The researchers stress that although it is known that low literacy is a problem in
Hong Kong and China, it is not known how this low literacy affects interactions with the health
care system. Participants were purposively sampled from a Hong Kong clinic according to
established criteria, and were asked to tell their stories in a semi-structured interview process.
The structured portions of the interview were concerned with effects of low-literacy on medical
care, medical experiences and coping strategies, and possible ways that the medical system could
help persons with low-literacy (Lam et al.).
The tape-recorded, verbatim transcribed texts were entered into NUD*IST software for
analysis and the following themes emerged: a) low literacy is a problem, b) low literacy is not a
problem. For those for whom it was a problem, they identified coping mechanisms such as
reliance on family and friends, the use of colors and shapes to remember medications, and the
drawing of symbols to indicate day and night. This study exhibits strength in that five randomly
chosen transcripts were independently coded by two qualitative researchers, and five randomly
chosen participants reviewed the data interpretations, both with no significant corrections to the
data (Lam et al. 2004). Likewise, it is of interest that the researchers chose a non-medical
interviewer in an effort to minimize the effects of the interviewer on the patients. A conscious
decision was made to not have a known member of the team interview the participants, as they
may have experienced anxiety being interviewed by a direct caregiver form the clinic.
DeWalt, Pignone, Malone, Rawls, Kosnar, George et al. (2004), representing a
multidisciplinary team of physicians, nurses, pharmacists, and health educators created a patient
education booklet for use with heart failure patients. The booklet was then tested with four
patients in a 2-hour focus group concentrating on clarity and\or confusing information. In
addition, four other patients participated in cognitive response interviews (CRIs) where they
were encouraged to think out loud and paraphrase the information in the booklet. These sessions
led to minor changes in the booklet.
Following revision of the booklet, a 3-month pilot study using a before and after
framework was conducted to determine the usefulness of the booklet as an interventional tool to
increase effective disease management (DeWalt et al., 2004). One outcome of the intervention
was effective fluid volume control as evidenced by weight control through adjustment of diuretic
therapy. Twenty-three participants received educational training, a copy of the booklet, and a
digital scale. To be certain that all participants were low-health-literate, two validated measures
were employed. Follow-up phone calls were made by the research team on days three, seven,
14, 21, 28, 56, and 84 after the initial intervention for reinforcement purposes.
At the initial visit and atthree months, several measures were assessed for intervention
success. These included the Heart Failure Knowledge scale, the Minnesota Living with Heart
Failure questionnaire, and the created self-efficacy scale. Having tested these scales with the
same focus group and CRIs, colorful picture-based illustrations were created to illustrate the
answers on the Likert-type scales in an effort to decrease poor understanding (DeWalt et al.,
2004). The three month measurement revealed no change in heart failure knowledge, positive
change in daily weighing behaviors (100%), an increase in self-efficacy, and a statistically
significant increase in improvement related to heart failure symptoms.
In a 2004 study Chew, Bradley, Flum, Cornia, and Koepsell investigated the impact of
low health literacy on surgical practice. As it was noted that outpatient surgery is becoming more
prevalent, the researchers were specifically interested in studying adherence to preoperative
instructions. Using 332 patients arriving for a preoperative surgical visit at a VA hospital, the
Short Test of Functional Health Literacy in Adults was administered to determine health literacy
level after the patient received their preoperative instructions. Upon returning to the hospital on
the scheduled day of their surgery, the nurses assessed adherence to the preoperative instructions
including fasting and medications through patient self-report. Through the use of chi square,
Student t-tests, and multivariate logistic regression it was determined that low health literacy
appeared to be borderline associated with lower adherence to preoperative instructions (Chew et
al., 2004).
Baker, Parker, Williams, and Clark (1998) followed a convenience sample of 979
emergency department patients over a two-year period to determine a relationship between
health literacy and hospital admission rates. Patients were recruited from, and followed at, an
indigent care hospital. It was assumed that the patient base was relatively stable at this
institution related to no-cost health care, and that the patients would return here for all of their
health care (Baker et al., 1998). Controlling for demographics, the researchers used logistic
regression to determine if health literacy was independently related to hospital admissions. The
odds ratio indicated that patients with low health literacy, as identified by use of the Test of
Functional Health Literacy in Adults, were 1.69 times more likely to be hospitalized than those
with adequate health literacy (Baker et al., 1998).
In a 2005 systematic review of interventions designed to improve health outcomes for
persons with low health literacy conducted by Pignone, DeWalt, Sheridan, Berkman, and Lohr,
only five studies indicated a direct link stratified by health literacy level. Out of a total of 20
studies that were reviewed, three study methodologies were identified: a) randomized controlled
trials, best for eliminating biases that may compromise study validity (Shadish, Cook, &
Campbell, 2002); b) nonrandomized controlled trials, whereby participants were non-randomly
assigned to groups (Pignone et al., 2005); and c) uncontrolled, single group trials.
Considering the five studies measuring a direct stratified link between health literacy and
intervention outcomes, all five measured knowledge as the only outcome, and all five were
randomized controlled studies (Pignone et al., 2005). The remaining studies measured health
behaviors, biochemical markers, measures of disease incidence, and use of preventive care
services. Although these studies linked the outcome of the intervention to health literacy in
general, only the previously mentioned five studies linked specific levels of literacy to the
outcome (Pignone et al.).
Pignone et al. (2005) indicated that the major weaknesses of the reviewed interventional
studies included: a) frequent use of a nonrandomized design, b) use of multimodal interventions
making it difficult to evaluate and link positive effects, c) lack of description regarding how the
outcomes were assessed, and d) weak explanation of the interventions. The strength of
interventional studies lies in the randomized clinical trial that stratifies outcome by literacy level
so that users of the knowledge can determine whether an intervention is more or less effective in
the lowest literacy levels (Pignone et al.).
Servellen et al. (2003) conducted a quasi-experimental, randomized controlled trial
involving intervention care versus standard clinic care in a pilot study to determine the
acceptability and effectiveness of a program to enhance health literacy in a group of low income
Latino HIV-positive men and women. Eighty-five participants were assessed at baseline and 6weeks on variables including health literacy, quality of communication between patient and
provider, and mastery of adherence to medication and treatment (Servellen et al.).
The Rapid Estimate of Adult Literacy in Medicine (REALM) was modified for use in the
HIV-positive population and validation testing was completed on the modified form. All other
measurement tools existed and were validated measurement tools. The random assignment to
control and intervention groups allowed the researchers to draw comparisons. Utilizing
descriptive and comparative statistics including univariate, chi square, ANOVA, and bivariate
linear regression with change scores, the intervention group was found to have a significant
increase in knowledge regarding treatment, HIV terms, and medications (Servellen et al., 2003).
However, there was no significant difference between the two groups on mastery of adherence or
health behaviors. It appears that knowledge was increased, but behaviors remained unchanged.
Paasche-Orlow, Parker, Gazmararian, Nielson-Bohlman, and Rudd (2004) highlighted 85
studies that were reviewed, the majority being cross-sectional, and reported that 25% of the
subjects throughout the studies exhibited low health literacy, and almost 50% had low or
marginal health literacy. This is consistent with the Institute of Medicine report (NielsenBohlman, Panzer, & Kindig, 2004) that provided ground breaking insight into the health literacy
problems in the United States. It is noted in the critical review of the literature on the prevalence
of low health literacy (Paasche-Orlow et al.) that investigators often choose a cross section of a
population from medical settings that serve low socioeconomic status patients. It is possible that
these sampling techniques of the population have skewed the representative results of these
studies. This is perhaps the strongest weakness of the cross-sectional study; researchers are
likely to conduct research in the areas with the highest rates of low health literacy (PaascheOrlow et al.). The strength remains in the ability to gather large amounts of data from large
samples of the population at one point in time. Care must be exercised in the choosing of the
sample to insure that it is representative of the population to which one wants to generalize the
findings.
It is evident from these reviewed studies that varying levels of health literacy exists
across diverse populations. Individuals have both self-identified as having problems associated
with low health literacy, and have been identified as having low health literacy with associated
problems. Attempts have been made to design interventions to address the problems of low
health literacy with varying degrees of success; but it is apparent that interventions to address the
needs of all persons have not yet been discovered. Until solutions are achieved that address the
majority of a population, strain will continue to be placed on the resources of the health care
system.
Transtheoretical Model
The Transtheoretical Model (TTM) has been used in previous studies examining the
decisions and readiness to participate in health behavior changes and screening activities. The
model has been most widely used in promoting smoking cessation (Herzog, Abrams, Emmons,
Linnan, & Shadel, 1999; Prochaska & DiClemente, 1983; Prokhorov, Hudmon, & Gritz, 1997).
However, few studies have applied the model to health screening behaviors. Rakowski, et al.
(1992), in a study evaluating 142 working women for mammography usage, reported that pros,
cons, and the resulting decisional balance were associated with the stage of mammography
adoption. Furthermore, as pros and cons differ by stage of adoption, so too do the cognitive and
behavioral processes used in decision making. For this reason, behavioral interventions should
support movement to the next stage of the TTM (Rakowski et al., 1992). Recommendations from
this study included extending the TTM to other early detection screenings including
sigmoidoscopy, stool testing, cholesterol testing, prostate exams, and glaucoma testing
(Rakowski et al., 1992).
Rakowski et al. (1993) replicated the previous study in a sample of 676 women after
refining several factors to provide even stronger evidence for an association of stages of adoption
according to the TTM. Most notable was a) a change in the definition of stages of adoption to
differentiate between intention and action, based on past behavior; b) consideration of the time
elapsed since prior mammograms; c) a differentiation between screening and diagnostic
mammograms; and d) targeting a low-income population as opposed to working women. Results
of the replicated study supported the initial findings. Stage of adoption and decisional balance
were found to be useful guides for the development of interventions to increase the use of
mammography screening (Rakowski et al., 1993).
The TTM has also been applied to staging screening behaviors for colorectal cancer.
Trauth et al. (2003), in a sample of 414 men and women aged 50 to 79 years, examined the use
of fecal occult blood testing (FOBT) and flexible sigmoidoscopy (FSG). Trauth et al. reported
86% of the participants were aware of the FOBT, and were evenly distributed across the 6 stages
of the TTM as adapted for CRC screening (unaware, precontemplation, contemplation, relapse,
relapse risk, and maintenance). In comparison only 51% were aware of the FSG test, with the
majority percentage (21%) placed in the precontemplation stage. Trauth et al. interpreted these
findings as an indication that awareness-raising is paramount for FSG testing, then more specific
interventions to increase screening can be addressed; whereas the heterogeneity of the FOBT
staging suggested “that a variety of interventions might be necessary” (p. 331).
Language Expectancy Theory
Language expectancy theory (LET) is a language-based theory of persuasion that
assumes language is a rule-governed system, and that people develop expectations and
preferences about message strategies used in persuasive attempts (Berger, 1998). When the
expectations and preferences are violated, receptivity to the persuasive messages will be affected
in either a facilitative or inhibitory manner (Berger). Positive violations of a receiver’s
expectations result in a change of behavior in the desired direction (Buller et al., 2000). These
positive violations can occur in one of two ways: (a) when the sent message or enacted behavior
is better than what was expected and preferred, therefore the receiver changes attitudes or
behaviors in the direction promoted by the sender; or (b) when a sender of a message or an actor
of a behavior who is expected to perform incompetently or inappropriately actually conforms to
social norms or cultural values and is evaluated in an overly positive manner, and the receiver
adopts the change advocated by the sender (Berger; Buller et al.).
Alternately, negative violations of expectations that result from language choices or
message strategies that are perceived in a negative direction will produce no attitude or behavior
changes, or will cause a change in the opposite direction advocated by the sender (Berger, 1995;
Buller et al., 2000). Individuals have expectations of communication arising from cultural values
and societal norms. These expected ideals represent an acceptable bandwidth of communication,
and can thus be positively or negatively violated. Credible sources have wider bandwidths of
appropriate communication and can therefore use more aggressive strategies than less credible
sources, resulting in positive evaluations and increased compliance (Buller et al.). Although
aggressive, high intensity language is not the norm in the majority of preventive health messages,
health care professionals should be evaluated as credible sources; therefore, messages implying
concern and urgency should be positively evaluated and produce compliance (Buller et al.).
Buller et al. (2000), in a final sample of 804 parents, reported that messages constructed
using high-intensity language according to LET had a greater effect on sun safety compliance for
pediatrics than messages with low-intensity language. Using a pretest/posttest design parents
were surveyed on knowledge and attitudes about sun exposure and sun safety, sun safe
behaviors, skin cancer risk factors, and demographic information (Buller et al.). They were then
exposed to sun safety and prevention messages in the form of newsletters, brochures, and tip
cards over a period of time. During posttest evaluation it was reported that parents who had
received high-intensity language messages decreased their own sun exposure; planned to
decrease sun exposure for themselves and their children in the upcoming seasons; and planned to
increase the frequency of sunscreen application, use of protective clothing, and limit the amount
of midday sun exposure for their children in the upcoming seasons, when compared to those who
received low-intensity language messages.
Summary
Two very important objectives of the Healthy People 2020 campaign were addressed in
this study. First, Healthy People 2020 (2010) objective number C HP2020-5 calls for a reduction
in the colorectal cancer death rate. Through raising awareness of CRC and the early detection
screening tests, it is expected that this objective can be met. Secondly, Healthy People 2020
objective number HC/HIT HP2020–3 calls for a focus on the health literacy of the population.
A review of the literature evidenced the prevalence and costs of low levels of literacy,
health literacy, and functional health literacy. In addition, links were established between low
levels of literacy, health literacy, and functional health literacy and the decreased use of
preventive services such as CRC screening. Likewise, the prevalence of CRC and the low use of
screening exams were also established. Language expectancy theory and the transtheoretical
model may serve as guiding theories to address the barriers and communication deficiencies to
CRC screening, and assist in developing interventional strategies to increase the use of CRC
screening tests.
Chapter Threewill detail the methodology for this research study including the pilot study
and the research study. Selection, assignment, and protection of human subjects will be
addressed; as well as collection, protection and analysis of data. Measurement tools and
educational media will also be discussed.