The Role of Health Literacy in Explaining the Relation between Educational Level and Decision Making about Colorectal Cancer Screening.

Anke J Woudstra,Ellen M A Smets,Mathilde G E Verdam,Mirjam P Fransen

doi:10.3390/ijerph16234644

Abstract

Little is known about why educational inequalities exist in informed decision making in colorectal cancer (CRC) screening. Insight into the role and impact of health literacy is essential for intervention development. This study investigates associations between health literacy and informed decision making in CRC screening and explores to what extent health literacy mediates the association between education and informed decision making in CRC screening. In total, 696 individuals eligible for CRC screening (55–75 years of age) were recruited from online panels and filled in an online questionnaire at T0 (n = 696), T1 (n = 407) and T2 (n = 327). A hypothetical mediation model was tested using structural equation modelling. Outcomes included CRC knowledge, CRC screening knowledge, attitude, injunctive norm, descriptive norm, risk perception, self-efficacy, decisional conflict and decisional certainty. Health literacy domains included Comprehension, Application, Numeracy and Communication. Comprehension, Application and Numeracy, were found to mediate the association between education and knowledge about CRC and CRC screening, injunctive norm, descriptive norm, decisional conflict and decisional certainty. In light of these findings, targeting multiple health literacy domains in decision-support interventions is essential for facilitating informed decision making in CRC screening.

Highlights

Colorectal cancer screening (CRC) is an effective strategy to reduce the mortality and morbidity in the population [1]
In line with previous research on the relationship between education, health literacy and health outcomes [41], our findings show that Health literacy (HL) plays a larger role among those with a lower education than those with higher education for most of the informed decision making (IDM) outcomes
Our findings suggest that interventions to decrease educational inequalities in informed decision in the context of IDM in CRC screening should focus on multiple HL

Summary

Introduction

Colorectal cancer screening (CRC) is an effective strategy to reduce the mortality and morbidity in the population [1]. As with all screening programs, not all participants will benefit from participation, and screening programs have the potential to do harm through risks of the procedure itself, false test results, unnecessary detection and anxiety [2,3]. It is increasingly being recognized that screening programs should aim to facilitate informed decision making (IDM) [4]. IDM refers to the process of weighing up individual potential benefits and harms of CRC screening [4]. IDM in CRC screening is difficult to achieve, especially for those with a lower educational level. Previous studies found that individuals with a lower educational level have lower knowledge on cancer, cancer risk and cancer screening and are less likely to make informed decisions [5,6]

Results

Discussion

Conclusion