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Reduced health literacy in Veterans is related to poor knowledge and negative attitudes toward colorectal cancer screening in the VALUE study: Veterans as Leaders in Understanding and Education.
Azoulay L, Gralnek IM, Provenzale D, Talley J, Griffin JM. Reduced health literacy in Veterans is related to poor knowledge and negative attitudes toward colorectal cancer screening in the VALUE study: Veterans as Leaders in Understanding and Education. [Abstract]. Gastroenterology. 2012 May 1; 142(5):S-772.
Background: Health literacy (HL) is a person's ability to read, understand and use healthcare
information to make decisions and follow instructions for tests and treatments. Reduced
HL may be associated with less knowledge and negative attitudes/beliefs towards disease,
and may be a risk factor for poor CRC screening adherence and CRC disease outcomes.
Aims/Methods: We conducted a cross-sectional survey to evaluate differences in knowledge,
attitudes, and beliefs regarding CRC and CRC screening by HL skills in US Veterans. Patients
at four geographically and racially diverse VA medical centers were stratified by age ( < 50yrs,
50-75yrs, > 75yrs) and randomly selected to participate. Interviewers collected demographic
data and assessed HL using the Short Test of Functional Health Literacy in Adults (STOFHLA),
a well-validated HL instrument. HL was defined as either adequate or inadequate/
marginal. Veterans 50-75 years old were then queried about their knowledge (10 items),
salience (7 items), worry (3 items), social norms (2 items), efficacy (3 items), and susceptibility
(4 items) about CRC and CRC screening. We then assessed relationships between HL level
and these constructs. Separate analyses were conducted for those with and without a personal
history of CRC or colon polyps. Results: 3,850 Veteran patients were asked to participate
and 2,456 (64%) agreed. 29.3% (n = 719) were ages 50-75 years (mean age = 61.5) and
completed the S-TOFHLA and CRC questions. 72.0% (n = 518) had no CRC or polyp history.
Of those without CRC or polyp history, 71.6% were White; 27.4% completed HS and 55.6%
had attended or graduated from college; 54.6% were married or living with someone. 10.6%
(n = 76) had inadequate/marginal HL. Regardless of the patient's history of CRC or polyps,
those with inadequate/marginal HL, compared to those with adequate HL, were significantly
less likely to know that tests to detect CRC were available, p = 0.029, LR = 5.2 and p = 0.014,
LR = 6.4. Those with a history of CRC or polyps were significantly less likely to know that
personal risk of CRC is higher if a family member had CRC (p = 0.006, LR = 8.8) and that
CRC tests are necessary even if problems are not present (p = 0.008, LR = 7.1). Moreover,
patients with inadequate/marginal HL were significantly more likely to report a strong
influence of family members regarding CRC screening (p = 0.028, LR = 5.3). Conclusion:
Veterans with inadequate/marginal HL had significantly less knowledge and were more
strongly influenced by family attitudes about CRC and CRC screening. Yet, in other constructs
assessed, these same Veterans had similar knowledge, beliefs and attitudes toward CRC and
CRC screening as those with adequate HL. CRC screening programs for Veterans should
use clear communication strategies to present information about CRC and CRC screening
to Veterans and their families.