Challenging Dogma

...Using social sciences to improve the practice of public health

Friday, April 27, 2007

Ontario’s Colorectal Cancer-Screening Campaign: How Reliance on the Health Belief Model Leads to Overlooking Many Barriers- Megan Statkewicz

In January of 2007 the government of Ontario, Canada launched a province-wide colorectal cancer-screening program. This program, set to begin in spring of 2007, is aimed at increasing screening rates so that colorectal cancer diagnoses can be made earlier in the attempt to reduce the mortality of this disease. During the slow five-year build-up period, Ontario’s colorectal cancer-screening program will provide public education on colorectal cancer as well as the importance of screening. Specifically, citizens of Ontario over the age of 50 will be targeted with both mailed reminders and physician counseling because that is the age group most at risk for developing colorectal cancer. In addition to this education, the screening program will be making fecal occult blood test (FOBT) screening kits available for these individuals at their physician’s offices. FOBT kits are able to detect trace amounts of blood in the stool, a symptom of colorectal cancer or polyps. This trace blood is detected after an individual applies a small amount of his or her own stool to a cardboard slide. The hope is that patients will take these tests home, perform the test, and then return it to a lab for testing. The lab will then notify individuals and physicians of their results and encourage follow-up in the case of a positive test and reinforce the importance of yearly testing for those who test negative (1).
Although the goals of this public health campaign are focused and well intentioned, there are several problems and barriers that Cancer Care Ontario, the agency organizing the program, will likely encounter in the process of implementing the plan. This campaign is focusing predominately on education of the target population in the hopes that it will be sufficient to ensure the success of their program. However, Ontario’s colorectal cancer-screening program fails to identify how they will approach many barriers on the society and individual levels.
Information about the colorectal screening program can be found at the Cancer Care Ontario website. This website provides individuals with information about the benefits of screening for colorectal screening and also lets them know how they will be able to access the FOBT at their doctor’s office. This presentation of information entrusts much of the success of this program to the effectiveness of the Health Belief Model (2). The premise of the Health Belief Model is that if any individual has information about the benefits and costs of a behavior, they will weigh that information so that it results in an intention to engage in a certain behavior. However, wholly subscribing to the Health Belief Model and assuming that informing individuals about the risks and benefits of a behavior is enough to motivate individuals to actually engage in the behavior can be problematic.
We have learned for other public health interventions such as the Five A Day campaign that merely providing individuals with the risks and benefits of engaging in a behavior does not always result in them opting to engage in that desired behavior (3). For the Ontario Colorectal campaign, there is an expectation that individuals will take the initiative to do a FOBT at home based predominately on knowledge of the benefits of doing so and the risks of not doing so. Unfortunately, previous studies have shown that this alone has not been sufficient. A 2006 study looking solely at the ability of the Health Belief Model to influence patient’s participation in FOBTs. They found that when reliance on the Health Belief Model did not help in meeting the goal of increasing patient participation in FOBTs(4). Reasons that they cited for this included many social and individual-level barriers that interefered with a person’s behaviors and intentions. Following from this research, it therefore seems doubtful reliance on the Health Belief Model will be enough to push the citizens of Ontario towards developing an intention to follow through with both the test and any necessary follow-up.
Although this program appears to be relying predominately on the Health Belief Model, it is useful to use other models as a lens with which to further critique Ontario’s colorectal cancer screening program. The Theory of Reasoned Action identifies social norms and attitudes towards certain behaviors as variables that greatly influence an individual’s likelihood of engaging in a behavior (5). This theory addresses one of the shortcomings of the Health Belief Model, that societal forces have the ability to change minds. Unfortunately, this colorectal cancer-screening program has to confront attitudes and social norms concerning two behaviors in order to succeed. The social norms and attitudes surrounding colorectal issues present somewhat of a challenge. In a study published in 2007, patients cited both fear and embarrassment as barriers to colorectal cancer screening (6). In addition, it is a procedure and type of cancer that many individuals are very uncomfortable discussing, and are very fearful of developing (7).
Although the Ontario’s colorectal cancer-screening campaign is designed to detect colorectal cancer early, many individuals have a tendency to be in denial when it comes to diseases such as colorectal cancer. In addition to this attitude of fear, attitudes surrounding the handling of one’s own feces have to be overcome. Even if it is in order to perform a medical test, getting individuals to smear their feces on a testing strip and to then return it to a medical center will likely present many barriers because of an aversion to the behavior under other circumstances.
Framing problematic aspects of Ontario’s colorectal cancer screening program with social science models allows you to critique on a broader social level. However, there are many individual level factors that also determine the success of a program. Since success of the program is largely pending on an individual’s willingness to take the test, drop it off and to see their physician for any follow up visits that may be needed it is important to consider barriers that may be encountered in this process. The major barriers related to the colorectal cancer-screening program can be looked at in two categories on the individual-level; environmental and personal barriers.
Barriers that individuals have to overcome on the personal level range from ability to pay for visits to family and work obligations that may impair one’s ability to participate. Lacking insurance or having an insurance plan that does not cover colorectal screening testing is very much related to an individual’s personal ability to take part in the screening program. In addition, time obligations to both family and work help to determine the likelihood that an individual will have the ability to take part (8). Environmental factors include things such as proximity to a doctor’s office, access to transportation as well as ability to schedule an appointment. All of these environmental factors present barriers to individuals that may determine their ability to participate in this program, regardless of other desires to do so. Unfortunately, those individuals with the most personal and environmental barriers tend to be of lower socioeconomic status. Therefore, it is no surprise that this group that tends to be more susceptible to colorectal cancer (9).
Ontario’s colorectal cancer-screening program is not hopeless though. By focusing on the reduction of barriers and recognizing the impact that some social norms and attitudes have, this program has the potential to be rather effective when it comes to increasing colorectal cancer-screening rates. By allowing individuals to perform the FOBT at their physician’s office during their visit rather than having them take it home many of the personal barriers will be avoided because the test will be in conjunction with another outing, accomplishing both the physical and FOBT in a single errand. Doing the test in the physician’s office also allows the patient to discuss any conflicting attitudes they may have towards performing the test.
In the end Ontario’s colorectal-cancer screening program is an example of how heavy reliance on the Health Belief Model can result in overlooking many other barriers to effective implementation. The Health Belief Model shows us that this particular public health campaign may encounter difficulties because of the sensitivity to cancer as well as the aversion to performance of the fecal occult blood test. In addition to these broad social barriers, individuals each have specific environmental and personal barriers that may impact their ability or desire to participate. Ultimately, the program will likely be more successful if it recognizes these complications and gears their education campaign towards breaking down some of the negative attitudes and norms as well as reducing some of the individual level variables such as transportation and time conflicts simultaneously. It will be interesting to watch the progress of Ontario’s colorectal cancer-screening campaign over the next five years as an example of the Health Belief Model in action. Hopefully this will not turn into another Five A Day campaign and the government of Ontario as well Cancer Care Ontario will be able to adapt to any of the challenges that they may encounter throughout their five-year implementation period.
1.Cancer Care Ontario, Colorectal Cancer-Screening Program. 2007.
2. Rosenstock, H. Health Belief Model. 2002.
3. Kelly, CM. Diet and Cardiovascular disease in the UK: are the messages getting across? Cambridge Journals. 2003(62):583-589.
4. Coughlin, Stephen. CDC-funded intervention research aimed at promoting colorectal cancer screening in communities. Cancer. 2006:107:1196-1204.
5. Hale, J. L., Householder, B.J., & Greene, K.L. (2003). The theory of reasoned action. The persuasion handbook: Developments in theory and practice (pp. 259 - 286)
6. Kelly, KM. Physician and staff perceptions of barriers to colorectal cancer screening in Appalachian Kentucky. Cancer Control. 2007: Apr 14(2):167-75.
7. Tessaro I. Knowledge, barriers and predictors of colorectal cancer screening in an Appalachian church population. Prevention of Chronic Disease. 2006:Oct 3(4):A123.
8. Worthley DL et al. Screening for colorectal cancer by faecal occult blood test: why people choose to refuse. Internal Medicine Journal. 2006. Sep 26(9):607- 610.
9. Ward, Elizabeth. Cancer Disparities by Race/Ethnicity and Socioeconomic Status. CA Cancer Journal, 2004:54:78-93.

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