Edited by: William Edson Aaronson, Temple University, United States
Reviewed by: Angela Sy, University of Hawaii at Manoa, United States; Iffat Elbarazi, United Arab Emirates University, United Arab Emirates
Specialty section: This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
Colorectal cancer (CRC) is a leading cause of cancer-related mortality in Puerto Rico (PR). Although largely preventable through screening and treatment of precancerous polyps, CRC screening rates in PR remain low while CRC incidence and mortality continue to increase.
We used intervention mapping (IM), a systematic framework using theory and evidence to plan a health promotion intervention to increase colorectal cancer screening (CRCS) among Puerto Rican adults 50 years and older who are patients of Federally Qualified Health Centers (FQHCs) in PR.
To inform the development of a logic model of the problem during the needs assessment phase, we determined the CRC incidence and mortality rates in PR using recent data from the PR Cancer Registry, conducted a literature review to better understand behavioral and environmental factors influencing CRC among Hispanics in general and in Puerto Ricans, and collected new data. We conducted seven focus groups to identify community needs and resources, specific sub-behaviors related to CRCS (performance objectives) and the determinants of CRCS. We then developed matrices of change objectives that would guide the content, behavioral change method selection, and the practical applications that would be included in the program. We selected two overarching methods: entertainment education and behavioral journalism and developed practical applications, materials, and messages containing several other methods including modeling, persuasion, information, and tailoring. We developed and pretested a Tailored Interactive Multimedia Intervention, newsletter, an action plan, and supplemental print materials for patients. We also developed a patient mediated provider prompt to increase provider recommendation and improve patient provider communication.
The use of IM for systematic planning produced a detailed coherent plan for the CRCS educational intervention. Guided by IM processes, steps, and tasks, we used community level information, existing literature, theory, and new data to develop health education materials that were well received by the priority population and will likely increase CRCS among FQHC patients in PR.
In Puerto Rico (PR), colorectal cancer (CRC) is the second leading cause of death due to cancer among both men and women (
Both personal determinants such as low knowledge, fear of detection, and low perceived risk; and environmental factors such as lack of doctor’s recommendation, lack of health insurance, and issues related to the local Health-Care System (i.e., high turnover rate among providers, low number of gastroenterologists, and increased patient ratio for primary care physicians) negatively influence CRCS in PR (
Salient personal determinants that negatively affect CRCS among Hispanics in the U.S. and in PR include the following: lack of knowledge and misconceptions regarding CRC and CRCS, low health literacy, social norms and negative attitudes toward screening, low perceived risk of CRC, and perceived barriers such as a lack of time, perceived high cost of testing, or difficulties with transportation (
The Guide to Community Preventive Services (Community Guide) recommends one-on-one education in combination with small media and patient/provider reminders as strategies to increase CRCS (
Intervention mapping is a systematic approach for the development of theory and evidence-based health promotion interventions and for planning their implementation (
The IM process is composed of six steps; each one involves specific tasks (
In step 1, we conducted a needs assessment based on the PRECEDE/PROCEED model (
Intervention mapping (IM) to develop health educational components to increase colorectal cancer screening in Puerto Rico (PR) (steps 1–4).
Step 1: Logic model of the problem | Establish a planning group |
Conduct a needs assessment based on the PRECEDE/PROCEED model: | |
Data from PR Registry Review of empirical and theoretical literature Focus Group |
|
Identify the factors the program should address | |
Step 2: Program outcome and matrix of change objectives | Identify overall behavior goal |
Step 3: Educational components design | Identify theoretical and evidence-based change methods: |
Entertainment education Behavioral journalism Patient activation method |
|
Select practical applications and strategies to operationalize the methods | |
Step 4: Educational components production | Design format, themes, and messages of the educational components: |
Tailored Interactive Multimedia Intervention Printed materials (newsletter, infographics, and action plan) Provider prompt Patient reminder support call |
|
Create drafts of the educational components: | |
In Spanish Adapted to the Puerto Rican culture Low health literacy |
|
Pretest the educational components |
To identify factors associated with the risk behavior and with the health-promoting behavior (CRCS in this case), IM suggests an integrated and iterative approach using theory and evidence. We used constructs from the Integrated Behavioral Model (
Data from the PR Registry (
We completed an extensive review of empirical and theoretical literature to identify factors influencing CRCS in US Hispanic populations and PR. As mention earlier, we used the Integrated Model to guide exploration of potential constructs (determinants). We also identified determinants that were either correlates or predictors of CRCS among Hispanics from empirical studies. For example, a systematic review (
We conducted seven focus groups (
Personal determinants and environmental factors influencing colorectal cancer screening (CRCS) among Puerto Ricans.
Categories | Subcategories |
---|---|
Personal determinants influencing CRCS | Knowledge about CRC/CRCS |
Attitudes: | |
Machismo Fatalism Procrastination |
|
Affective factors: | |
Fear (concerning the colonoscopy procedure) Embarrassment (concerning the colonoscopy procedure) Fear (of the results of the test) |
|
Perceived structural barriers: | |
Lack of time Transportation problems |
|
Environmental factors influencing CRCS (interpersonal) | Lack of provider recommendation |
Based on the review of the empirical and theoretical literature we found that the following personal determinates influenced CRCS: low knowledge, perceived social norms, fear of finding CRC negative attitudes toward CRCS, perceived barriers, and low perceived risk (
Results from the focus groups indicated that the following personal determinants influenced CRCS: lack of knowledge and misconceptions about CRC and CRCS; low risk perception about getting CRC; attitudes such as machismo, fatalism and procrastination; feelings of fear and embarrassment concerning the colonoscopy procedure, fear of test results, and perceived barriers such as lack of time and transportation problems. As in the literature, lack of provider recommendation was the primary environmental factor that emerged in the focus group findings. There was a high level of consistency in personal determinates and environmental factors identified through the literature review and focus groups.
When asked about the type of information they would like to receive, focus group participants indicated they would like to know more about CRC and CRCS tests, type of coverage government issued health insurance provided for CRCS, and where they could undergo testing. Participants said that it would be both helpful and important if health-care providers informed them about these issues. Participant preferences for educational materials included videos or printed materials with attractive images containing simple vocabulary.
Based on the needs assessment, we defined the overall behavioral outcome: “Puerto Ricans ages 50 and older adhere to CRCS guidelines.” Once the overall behavioral outcome was established, we formulated performance objectives (i.e., what participants need to do to complete CRCS) (see Table
Behavioral outcome with associated performance objectives.
Behavioral outcome |
---|
Puerto Ricans ages 50 and older adhere to CRCS guidelines |
Make an appointment with the provider Discuss CRC and CRCS with the provider Request FIT/FOBT or obtain a referral for colonoscopy Identify location to get screened Make an appointment to get screened Arrange transportation Seek social support Get screened for FIT/FOBT Get screened for colonoscopy if recommended Record and keep appointment to the discuss the results with the provider |
Sample cells from matrix of change objectives.
Performance objectives | Overall behavioral outcome: “Puerto Ricans ages 50 and older adhere to CRCS guidelines” |
||||||
---|---|---|---|---|---|---|---|
Determinants |
|||||||
Knowledge | Perceived susceptibility (risk) | Decisional balance (pros and cons) | Outcome expectations | Self-efficacy/skills | Perceived social norms (subjective norms) | attitudes | |
PO8. Get screened FOBT/FIT Pick up test from the lab or accept test from PCP Read instructions Complete test Return test to lab |
K8a. States that FOBT/FIT is recommended to be done annually for people over 50-year old |
PR8. Perceives that he/she is at risk of getting CRC | DB8a. States the advantages of doing FOBT/FIT annually |
OE8a. Expects that if he/she gets CRCS they will reduce the risk of CRC or detect it early enough to be cured |
SE8a. Expresses confidence in ability to pick up the test |
SN8a. Believes that other adults like them pick up the FOBT/FIT annually |
ATT8a. Believes that CRCS is important |
PO9. Get screened for colonoscopy |
K9a. States that colonoscopy is recommended to be done every 10 years for people over 50-year old |
DB9a. States the advantages of doing colonoscopy |
OE9a. Expects that if he/she gets a colonoscopy they will reduce the risk of CRC or detect it early enough to be cured |
SE9a. Expresses confidence in ability to identify someone to go with him/her to appointment |
SN9a. Believes that other adults like them identify person to accompany them to the appt |
ATT9a. Believes that colonoscopy is useful and important because it can identify cancer and polyps (pre-cancer) |
We then identified theoretical change methods that are known to influence the determinants identified and conducted a literature review to help identify these methods as well as the practical applications or strategies to operationalize these. The intent of this step was to create strategies, materials, and messages that would address specific change objectives. We selected two overarching methods: entertainment education (
Despite the importance of the organizational and provider level factors influencing CRCS identified during the needs assessment phase and our desire to create a multilevel intervention to address these factors, resources and project scope limited the ability of the team to do so. Nevertheless, since provider recommendation is an important and necessary component of any CRCS intervention, we decided to intervene using the patient activation method. This method is strongly associated with self-reported quality of care, a better doctor–patient communication, and increase CRCS rates (
In this step, we designed, produced and pretested the educational materials guided by the matrix of change objectives, methods, and strategies previously described. We reviewed the information obtained from the focus group analysis. Keeping in mind participants’ preferences about informational needs and educational materials format, and guided by the change objectives from the matrices developed in step 2, we created a series of drafts that conveyed messages and content. We then modified drafts according to the format and type of educational material that would be presented. All developed materials were produced in Spanish and designed to be culturally relevant and appropriate for Puerto Ricans and individuals with low or no literacy skills.
The educational program consists of four components: a Tailored Interactive Multimedia Intervention (TIMI), printed materials (newsletter, infographics, and action plan), a provider prompt, and a patient reminder support call. The TIMI was created based on entertainment education criteria (
To develop the newsletter, we followed behavioral journalism techniques (
We also developed an infographic and an action plan. These included images and messages with information about CRC and CRCS, steps to follow to complete CRCS tests, and mini-testimonials from people who completed CRCS.
As mentioned earlier, we created a provider prompt based on the patient activation method. This method enables patients to assume an active role in their health care (
We conducted focus groups (
In this article, we describe the development of an intervention to increase CRCS using IM. We described the first four steps used in the development process. The last two steps of IM, planning for implementation and evaluation, are currently underway and will be described in a subsequent paper. By using the process of IM, we ensured the systematic incorporation of theory and evidence from the literature and new data from the community participation to address the personal determinants and environmental factors using an ecological perspective. IM also guided the selection of the most appropriate methods and practical strategies, as well as the design and creation of the educational components of the program.
We found that entertainment education and behavioral journalism were two overarching effective methods relevant for addressing the identified personal determinants and environmental factors. These methods that are aimed at changing social norms attitudes, and self-efficacy (
Using IM to design
Due to the qualitative nature of some of the activities of this study such as focus groups, results are not generalizable to all populations 50 years of age and older in PR. Nevertheless, participants were selected to represent the target population for the intervention, therefore, the identified determinants of CRCS are likely those most relevant. In addition, most of those who participated in the behavioral journalism interviews were of higher socioeconomic status and had a better access to private health insurance than the island’s general population. Nevertheless, participants identified similar barriers to those documented for lower socioeconomic status. In addition, those with private health insurance recognized that their situation was different to that of the general population and related the experiences of friends and family members who do not have private health insurance.
The study, its components, and protocol were approved by the Institutional Review Boards of the UPR-MSC and the University of Texas Health Science Center at Houston.
MF, VC-L, LS, and SV: program conceptualization. MF, YS-M, VC-L, NF-E, CV, and AA: development of the program. YS-M and MF: manuscript development and primary writers.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The authors thank Ileska M. Valencia-Torres and Jayson Rhoton for their suggestions and their help in translating this article.