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J Natl Med Assoc. Oct 2007; 99(10): 1105–1112.
PMCID: PMC2574401

The influence of health literacy on colorectal cancer screening knowledge, beliefs and behavior.


OBJECTIVE: To determine if health literacy is associated with knowledge of colorectal cancer (CRC) and CRC screening tests, with perceived benefits and barriers to CRC screening, with perceived risk of CRC, with reported self-efficacy for completing CRC screening and with receipt of CRC tests. METHODS: A convenience sample of 99 subjects completed a health literacy assessment, the Rapid Estimate of Adult Literacy in Medicine (REALM) and a structured interview. RESULTS: Limited or inadequate health literacy was significantly associated with less knowledge about CRC and CRC screening and with more reported barriers to completing fecal occult blood testing (FOBT) and colonoscopy in multivariate analysis. Health literacy was not associated with perceived benefits or reported self-efficacy for completing FOBT or colonoscopy, with perceived risk of developing CRC or with completing CRC tests. However, our small sample size limited our power to detect differences. CONCLUSIONS: Patients with limited health literacy have less knowledge about CRC and CRC screening and report more barriers to completing FOBT and colonoscopy. Interventions to improve CRC screening should consider the health literacy of patients, especially when addressing barriers to screening. Future studies are needed to better define the role of health literacy in CRC screening.

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  • Smith Robert A, Cokkinides Vilma, Eyre Harmon J. American Cancer Society guidelines for the early detection of cancer, 2006. CA Cancer J Clin. 2006 Jan-Feb;56(1):11–50. [PubMed]
  • Screening for colorectal cancer: recommendation and rationale. Ann Intern Med. 2002 Jul 16;137(2):129–131. [PubMed]
  • Winawer Sidney, Fletcher Robert, Rex Douglas, Bond John, Burt Randall, Ferrucci Joseph, Ganiats Theodore, Levin Theodore, Woolf Steven, Johnson David, et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale-Update based on new evidence. Gastroenterology. 2003 Feb;124(2):544–560. [PubMed]
  • Increased use of colorectal cancer tests--United States, 2002 and 2004. MMWR Morb Mortal Wkly Rep. 2006 Mar 24;55(11):308–311. [PubMed]
  • Mandelson MT, Curry SJ, Anderson LA, Nadel MR, Lee NC, Rutter CM, LaCroix AZ. Colorectal cancer screening participation by older women. Am J Prev Med. 2000 Oct;19(3):149–154. [PubMed]
  • Shapiro JA, Seeff LC, Nadel MR. Colorectal cancer-screening tests and associated health behaviors. Am J Prev Med. 2001 Aug;21(2):132–137. [PubMed]
  • Sutton S, Wardle J, Taylor T, McCaffery K, Williamson S, Edwards R, Cuzick J, Hart A, Northover J, Atkin W. Predictors of attendance in the United Kingdom flexible sigmoidoscopy screening trial. J Med Screen. 2000;7(2):99–104. [PubMed]
  • Vernon SW. Participation in colorectal cancer screening: a review. J Natl Cancer Inst. 1997 Oct 1;89(19):1406–1422. [PubMed]
  • Walsh Judith M E, Posner Samuel F, Perez-Stable Eliseo J. Colon cancer screening in the ambulatory setting. Prev Med. 2002 Sep;35(3):209–218. [PubMed]
  • Lemon S, Zapka J, Puleo E, Luckmann R, Chasan-Taber L. Colorectal cancer screening participation: comparisons with mammography and prostate-specific antigen screening. Am J Public Health. 2001 Aug;91(8):1264–1272. [PMC free article] [PubMed]
  • Zapka Jane G, Puleo Elaine, Vickers-Lahti Maureen, Luckmann Roger. Healthcare system factors and colorectal cancer screening. Am J Prev Med. 2002 Jul;23(1):28–35. [PubMed]
  • Taylor Vicky, Lessler Daniel, Mertens Kathy, Tu Shin-Ping, Hart Alton, Chan Nadine, Shu Jianfen, Thompson Beti. Colorectal cancer screening among African Americans: the importance of physician recommendation. J Natl Med Assoc. 2003 Sep;95(9):806–812. [PMC free article] [PubMed]
  • Pollack Lori A, Blackman Donald K, Wilson Katherine M, Seeff Laura C, Nadel Marion R. Colorectal cancer test use among Hispanic and non-Hispanic U.S. populations. Prev Chronic Dis. 2006 Apr;3(2):A50–A50. [PMC free article] [PubMed]
  • Dewalt Darren A, Berkman Nancy D, Sheridan Stacey, Lohr Kathleen N, Pignone Michael P. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med. 2004 Dec;19(12):1228–1239. [PMC free article] [PubMed]
  • Dolan Nancy C, Ferreira M Rosario, Davis Terry C, Fitzgibbon Marian L, Rademaker Alfred, Liu Dachao, Schmitt Brian P, Gorby Nicolle, Wolf Michael, Bennett Charles L. Colorectal cancer screening knowledge, attitudes, and beliefs among veterans: does literacy make a difference? J Clin Oncol. 2004 Jul 1;22(13):2617–2622. [PubMed]
  • Guerra Carmen E, Dominguez Francisco, Shea Judy A. Literacy and knowledge, attitudes, and behavior about colorectal cancer screening. J Health Commun. 2005 Oct-Nov;10(7):651–663. [PubMed]
  • Miller David P, Jr, Brownlee Caroline D, McCoy Thomas P, Pignone Michael P. The effect of health literacy on knowledge and receipt of colorectal cancer screening: a survey study. BMC Fam Pract. 2007 Mar 30;8:16–16. [PMC free article] [PubMed]
  • Davis TC, Crouch MA, Long SW, Jackson RH, Bates P, George RB, Bairnsfather LE. Rapid assessment of literacy levels of adult primary care patients. Fam Med. 1991 Aug;23(6):433–435. [PubMed]
  • Davis TC, Long SW, Jackson RH, Mayeaux EJ, George RB, Murphy PW, Crouch MA. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med. 1993 Jun;25(6):391–395. [PubMed]
  • Menon Usha, Champion Victoria L, Larkin Gregory N, Zollinger Terrell W, Gerde Priscilla M, Vernon Sally W. Beliefs associated with fecal occult blood test and colonoscopy use at a worksite colon cancer screening program. J Occup Environ Med. 2003 Aug;45(8):891–898. [PMC free article] [PubMed]
  • Lindau Stacy Tessler, Basu Anirban, Leitsch Sara A. Health literacy as a predictor of follow-up after an abnormal Pap smear: a prospective study. J Gen Intern Med. 2006 Aug;21(8):829–834. [PMC free article] [PubMed]
  • Lincoln Alisa, Paasche-Orlow Michael K, Cheng Debbie M, Lloyd-Travaglini Christine, Caruso Christine, Saitz Richard, Samet Jeffrey H. Impact of health literacy on depressive symptoms and mental health-related: quality of life among adults with addiction. J Gen Intern Med. 2006 Aug;21(8):818–822. [PMC free article] [PubMed]
  • Rothman Russell L, DeWalt Darren A, Malone Robb, Bryant Betsy, Shintani Ayumi, Crigler Britton, Weinberger Morris, Pignone Michael. Influence of patient literacy on the effectiveness of a primary care-based diabetes disease management program. JAMA. 2004 Oct 13;292(14):1711–1716. [PubMed]
  • Lindau Stacy T, Tomori Cecilia, Lyons Tom, Langseth Lizbet, Bennett Charles L, Garcia Patricia. The association of health literacy with cervical cancer prevention knowledge and health behaviors in a multiethnic cohort of women. Am J Obstet Gynecol. 2002 May;186(5):938–943. [PubMed]
  • Davis TC, Dolan NC, Ferreira MR, Tomori C, Green KW, Sipler AM, Bennett CL. The role of inadequate health literacy skills in colorectal cancer screening. Cancer Invest. 2001;19(2):193–200. [PubMed]
  • Cokkinides Vilma E, Chao Ann, Smith Robert A, Vernon Sally W, Thun Michael J. Correlates of underutilization of colorectal cancer screening among U.S. adults, age 50 years and older. Prev Med. 2003 Jan;36(1):85–91. [PubMed]
  • Seeff Laura C, Nadel Marion R, Klabunde Carrie N, Thompson Trevor, Shapiro Jean A, Vernon Sally W, Coates Ralph J. Patterns and predictors of colorectal cancer test use in the adult U.S. population. Cancer. 2004 May 15;100(10):2093–2103. [PubMed]
  • Swan Judith, Breen Nancy, Coates Ralph J, Rimer Barbara K, Lee Nancy C. Progress in cancer screening practices in the United States: results from the 2000 National Health Interview Survey. Cancer. 2003 Mar 15;97(6):1528–1540. [PubMed]
  • Gordon NP, Hiatt RA, Lampert DI. Concordance of self-reported data and medical record audit for six cancer screening procedures. J Natl Cancer Inst. 1993 Apr 7;85(7):566–570. [PubMed]
  • Montori Victor M, Rothman Russell L. Weakness in numbers. The challenge of numeracy in health care. J Gen Intern Med. 2005 Nov;20(11):1071–1072. [PMC free article] [PubMed]
  • Golbeck Amanda L, Ahlers-Schmidt Carolyn R, Paschal Angelia M, Dismuke S Edwards. A definition and operational framework for health numeracy. Am J Prev Med. 2005 Nov;29(4):375–376. [PubMed]
  • Kaphingst Kimberly A, Zanfini Christine J, Emmons Karen M. Accessibility of web sites containing colorectal cancer information to adults with limited literacy (United States). Cancer Causes Control. 2006 Mar;17(2):147–151. [PubMed]
  • Messina Catherine R, Lane Dorothy S, Grimson Roger. Colorectal cancer screening attitudes and practices preferences for decision making. Am J Prev Med. 2005 Jun;28(5):439–446. [PubMed]

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