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The University of Texas Health Science Center at Houston, School of Public Health, Houston, Texas 77225; Department of Medicine, Division of Neoplastic Disease, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania 19107 [R. E. M.]; Department of Biometry and Epidemiology, College of Medicine, Medical University of South Carolina, Charleston, South Carolina 29425 [B. C. T.]; and Marketing Risk Analytics, Global Risk Management, Ford Motor Credit Company, Dearborn, Michigan 48121 [S. L.]
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Abstract |
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 Top Abstract IntroductionPatients and MethodsResultsDiscussionReferences |
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We analyzed data on a subset of 5042 employees who participated in The Next Step Trial, a randomized health promotion trial to encourage colorectal cancer screening and dietary change. We restricted our analysis to only those automotive workers who were white, male, and did not have colorectal cancer (4477/5042) and who returned surveys both at baseline (2,684/4,477) and at year 2 of follow-up (1955/2684). Initial analyses detected interactions between a history of polyps and several of the other covariates. Therefore, univariate and multivariable analyses were conducted separately for men with and without a personal history of colorectal polyps. Within each of the four subgroups (those with or without polyps in the baseline or follow-up analyses), we examined associations between perceived risk measured at baseline (cross-sectional analyses) and at year 2 of follow-up (prospective analyses) in relation to intervention group status, demographic, medical history, psychosocial, and worksite characteristics measured at baseline. To assess the predictive ability of the models, we computed sensitivity and specificity as measures of each model’s ability to correctly classify men into their respective subgroup.
Although there was no association between perceived risk and intervention group status in the four subgroups analyzed, we included intervention group status as a covariate in all analyses. At baseline (cross-sectional analyses) among men with and without a history of polyps, perceived risk was positively associated with family history of colorectal polyps or cancer, family support for screening, and worry about being diagnosed with colorectal cancer. In addition, for men without polyps, perceived risk was positively associated with being a current smoker. At year 2 of follow-up (prospective analyses) for men with and without polyps, perceived risk at year 2 was positively associated with family history and baseline perceived risk and was negatively associated with having a normal screening examination or no examinations during the trial. In addition, for men with polyps, perceived risk was positively associated with belief in the salience and coherence of screening and with intention to be screened and was negatively associated with access to screening at the worksite. Specificity was higher than sensitivity in three of four subgroups and was >65% in all subgroups.
Except for family history, messages to influence perceived risk would emphasize different factors, depending on whether associations were based on baseline or follow-up data and depending on whether men reported a personal history of polyps. For example, although intervention messages using baseline data would emphasize the same factors for men with or without polyps, messages based on follow-up data would emphasize psychosocial characteristics, such as salience and coherence of screening and intention for men with a history of polyps but not for men without. Our findings support the need to delineate subgroups in the study population to target and tailor health-related messages based on respondent characteristics. Our findings also underscore the need to base health-related messages on prospective data as well as cross-sectional data to better address health-related beliefs and behaviors.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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Because risk perception may be an important motivator of a number of health-related behaviors, it is important to understand both the patterns of association between perceived risk and specific health-related behaviors as well as the correlates of risk perception. Correlates of perceived risk may differ depending on whether the outcome, i.e., perceived risk, is measured using baseline (cross-sectional) or follow-up (prospective) data. For example, cross-sectional data may inform our understanding of factors associated with prior screening behavior but may be misleading if the goal is to develop interventions to encourage future screening, particularly repeat screening. Likewise, correlates of a behavior may vary for subgroups with different medical or screening histories, such as a personal history of colorectal polyps or prior experience with screening. In a similar vein, correlates of perceived risk may vary depending on how data were collected and on personal characteristics.
There is increasing interest in developing and evaluating educational messages to change risk perceptions (12) . An understanding of the correlates of perceived risk can inform the development of risk communication messages that encourage adoption of health behaviors. In a recent literature review on risk perception and risk communication for cancer screening behaviors, Vernon (12) noted that all but two studies3 (13) of correlates of perceived risk for cancer used a cross-sectional study design (14, 15, 16, 17, 18, 19, 20, 21, 22, 23) . Five studies3 (14 , 15 , 17 , 23) were of persons at increased risk based on a family history of cancer. Very few studies examined psychological or psychosocial correlates of perceived risk, and only two (15 , 20) examined correlates of perceived risk for colorectal cancer. One (15) compared siblings of colorectal cancer patients with siblings of general surgical patients, and the other (20) studied older, predominantly African-American, clinic users. Data on the consistency of correlates of perceived risk across different population subgroups would inform our efforts to develop tailored intervention messages.
In this report, we used a subset of data from a large cohort of current and former automotive employees participating in The Next Step Trial (24) to examine baseline (cross-sectional) and year 2 follow-up (prospective) associations between perceived risk of colorectal cancer or polyps measured at baseline and at year 2 of follow-up in relation to intervention group status, demographic, medical history, psychosocial, and worksite characteristics measured at baseline. The Next Step Trial was a worksite-based health promotion trial of interventions designed to encourage colorectal cancer screening and dietary change (24) . The cohort of employees in the trial was at increased risk for colorectal cancer mortality (25) and had been offered periodic screening between 1980 and 1985 through a company-sponsored program. At the time the trial was initiated, screening participation was low.
We addressed the following questions: (a) What factors measured at baseline are associated with perceived risk, also measured at baseline, in men with and without a history of polyps (cross-sectional analyses)? (b) What factors, measured at baseline, are associated with perceived risk measured at year 2 of follow-up in men with and without a history of polyps (prospective analyses)? (c) Are correlates of perceived risk similar in baseline (cross-sectional) and follow-up (prospective) analyses? and (d) What is the predictive ability (i.e., sensitivity and specificity) of the models of correlates of perceived risk?
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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Of 5042 employees in the total cohort at baseline, 4550 (90%) were white men, of whom 4477 were without a history of colorectal cancer prior to or during the trial. Of the 4477, 2684 (60%) returned a baseline survey, 2041 (46%) returned a survey at year 2, and 1955 (44%) returned surveys both at baseline and year 2 follow-up. Men with colorectal polyps were included in the trial, but recommendations for follow-up examinations may have differed, e.g., colonoscopy instead of FOBT,4 digital rectal examination, or flexible sigmoidoscopy.
Details about the design, implementation, and baseline findings, as well as the primary outcome results from the trial, are published elsewhere (24 , 26 , 27) . Briefly, 28 worksites were randomized to receive either an educational intervention or usual care. Employees at all worksites were offered colorectal cancer screening (i.e., digital rectal examination, FOBT, and/or flexible sigmoidoscopy) on work time. Each worksite developed its own process for offering screening. In addition, employees at the intervention worksites received a mailed invitation to the screening program and an educational booklet tailored to the employee’s screening history and individual screening recommendations followed by a telephone call to reinforce messages from the booklet. The booklet was based on behavior change theories and models (1 , 28, 29, 30) .
Measures of the Variables.
The dependent variables for this analysis were perceived risk of
developing colorectal cancer or polyps as measured on the baseline
survey in 1993 and on the year 2 follow-up survey in 1995. Perceived
risk was measured using a 3-item, Likert-style scale with four response
categories from strongly agree (4)
to strongly disagree (1)
. Items
were: I believe that the chance I might develop colorectal cancer is
high; I think it is very likely that I will develop colorectal cancer
or polyps; and I believe that the chance that I will develop colorectal
polyps is high. Cronbach’s coefficient 
was 0.79 in the study
population. Because scale scores were skewed and some cell sizes were
small when the entire range of the scale was used, we dichotomized
perceived risk as the belief that one is at risk (scale score 
3) or
not at risk (scale score <3) of developing colorectal polyps or
cancer.
Most of the independent variables examined in relation to perceived
risk were measured on the baseline survey. Demographic and medical
history variables were abstracted from employment records and were
augmented by the surveys. In addition to screening history in the 2
years prior to baseline, screening examination status between baseline
and year 2 of follow-up was ascertained. Scales were used to measure
some constructs, including belief in the salience and coherence of
colorectal cancer screening (four items), intention to be screened (two
items), perceived self-efficacy related to screening (four items), and
worries or fears about being diagnosed with colorectal cancer (two
items). Single items were used to measure other variables shown in
Tables 1
2
3
. All psychosocial variables were measured using the same
4-point scale as for perceived risk. Some items were reverse coded so
that high scores corresponded to more of the variable being measured,
e.g., more worry, greater intention, more discomfort. Scale
scores were standardized by dividing the total score by the number of
items in a scale. Because these data were skewed and some cells were
sparse when the entire range of the scale was used, all items and
scales were dichotomized at 3 (strongly agree or agree) or <3
(disagree or strongly disagree). Scale development and validation are
described in detail elsewhere (31)
. Because of issues of
skewness and kutosis, we also categorized age and education
(32)
.
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Statistical Analyses.
Because this was a randomized controlled trial, intervention or control
group status was included in all multivariable models, although it was
not statistically significant in univariate analyses. By including the
intervention term in the models, we adjusted for even modest
intervention effects before drawing conclusions about other factors
associated with perceived risk. All analyses were done using SUDAAN
statistical software to adjust for the effects of cluster sampling
(worksite), taking correlations within worksite into account
(33)
. We first examined the characteristics of respondents
and nonrespondents to the baseline and year 2 surveys using
P 
0.05 to evaluate the statistical significance of
these comparisons. We also conducted preliminary univariate analyses
that included respondents to either of the surveys to examine
associations between perceived risk measured at baseline
(n = 2684 in baseline analyses) or at year 2 follow-up
(n = 2041 in prospective analyses) and the independent
variables. Results of those analyses were similar to results for the
more restricted subset of respondents who answered both surveys
(n = 1955). Therefore, analyses were based on 1955
survey respondents.
As noted above, personal history of colorectal polyps might affect risk
perception; therefore, we tested for two-way statistical interactions
between personal history of polyps and all other independent variables.
Because there were a number of interactions, we stratified all analyses
by personal history of polyps measured at baseline. Univariate
comparisons of perceived risk in relation to the independent variables
were tested for statistical significance using Wald
2 tests. To assess the relative importance of
the independent variables measured at baseline in relation to perceived
risk measured at baseline (cross-sectional analyses) and perceived risk
measured at year 2 of follow-up (prospective analyses), we conducted
multivariable analyses by fitting logistic regression models separately
for each time period and for men with and without a history of
colorectal polyps. Independent variables with a P
0.20 in univariate analyses were included in step one of the logistic
regression analyses. In subsequent steps, covariates with
P > 0.05 in the prior step were removed until all
covariates in the model were statistically significant at
P < 0.05. Variables in the models were adjusted for
the effects of other variables in the model. Odds ratios and 95%
confidence intervals were used to summarize the analyses for the final
multivariable models. Categorization of the variables for the
multivariable analysis is shown in Tables 1
2
3
. The reference groups
for calculating the odds ratios are indicated in Table 4
.
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3 for each study participant. We then categorized the
individuals as <3 or 3 using a cutoff value for the probability
equal to the observed proportion 3. We calculated the sensitivity and
specificity of each model and assessed the predictive ability of the
models by comparing the classification based on the model to the
observed classifications as reported by the participants. |
Results |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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Additional data were available from the baseline survey for respondents and nonrespondents to the year 2 survey. Compared with nonrespondents at year 2 of follow-up, respondents were more likely to intend to be screened, to believe in the salience and coherence of screening, to have high self-efficacy related to screening, to believe in the efficacy of screening (marginally significant), to express concern about screening-related discomfort, to be receptive to what family members wanted them to do regarding screening, and to report that family members supported their being screened.
Baseline (Cross-Sectional) Analyses.
In baseline univariate analyses, we observed generally similar patterns
of association for men with and without a history of polyps (Tables 1
2
3)
. There were four exceptions. For men with a history of polyps,
age was inversely associated with perceived risk, and education showed
a curvilinear pattern of association (Table 1)
. Among men with a history of polyps, the percentage who scored 3 on
the perceived risk scale was higher for men with less than a high
school education and for those with more than a high school education
compared with men who graduated from high school (Table 1)
. For men
with polyps, perceived risk was positively associated with plant
notification that FOBT was due and was negatively associated with
offering screening at the worksite (Table 3)
. Those four associations
were not observed in the group without polyps.
In baseline multivariable analyses, with the exception of smoking
status, the same variables were positively associated with perceived
risk for men with and without a personal history of polyps,
i.e., family history, support for screening from family
members, and fear or worry about being diagnosed with colorectal cancer
(Table 4)
.
Year-2 Follow-Up (Prospective) Analyses.
In general, the univariate results of the year 2 follow-up analyses
were similar for men with and without a personal history of polyps
(Tables 1
2
3)
. There were four exceptions. In men without a history of
polyps, perceived risk was positively associated with being a current
smoker (Table 1)
. It also was positively associated with belief in the
efficacy of screening and with perceived self-efficacy related to
screening (Table 2)
. Although these patterns were similar for men with polyps,
associations were not statistically significant. Among men with polyps,
perceived risk was negatively associated with offering screening at the
worksite (Table 3)
.
In multivariable analyses, family history and baseline perceived risk
were positively associated, and having no examinations or normal
examinations was negatively associated with perceived risk at year 2
follow-up in men with and without polyps (Table 4)
. In addition, for men with a history of polyps, salience and coherence
and intention to be screened were positively associated and whether the
plant offered examinations on site was negatively associated with
perceived risk.
Comparison of Baseline (Cross-Sectional) and 2-Year Follow-Up
(Prospective) Analyses.
In all univariate comparisons, both baseline and year 2 follow-up
analyses, the percentages of men who scored 3 on the perceived risk
scale were greater for men with a history of polyps compared with men
without a history of polyps. The percentage of men who scored 3 on
the perceived risk scale decreased between baseline and year 2 of
follow-up in virtually all univariate comparisons. In multivariable
analyses, family history was the only variable that was consistently
associated with perceived risk in all analyses. Differences between
baseline and year 2 follow-up analyses were more pronounced for men
with a history of polyps, where fewer psychosocial variables were
associated with perceived risk in baseline compared with year 2
follow-up analyses (Table 4)
. This pattern was not observed for men
without a history of polyps.
Sensitivity and Specificity Analyses.
The sensitivity, i.e., the percentage of men who scored 3
on the perceived risk scale and were correctly predicted by the model
as scoring 3, was higher in year 2 of follow-up than in baseline
analyses for men with and without a history of polyps (Table 5)
. For each type of analysis, i.e., baseline and year 2
follow-up, the estimates were similar for men with and without a
history of polyps.
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Discussion |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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Our finding that family history of colorectal cancer was consistently positively associated with perceived risk was similar to findings reported in the breast cancer literature. We did not directly assess participants’ knowledge of colorectal cancer risk factors in any of the surveys. However, the patterns in the data showed that men with a family history of colorectal cancer or a personal history of polyps were more likely than men without those risk factors to perceive themselves at risk, indicating an awareness of their objective medical risk of developing the disease. Although family history is an important factor to emphasize in developing intervention messages, it is relevant only for a minority of the general population. Therefore, there is a need to identify other factors that can be addressed in interventions.
Our focus on correlates of perceived risk assumes that those associations are important because perceived risk is related either directly or indirectly to behavior, in this case participation in colorectal cancer screening. In a review of the literature on colorectal cancer screening adherence, Vernon (34) found that two (35 , 36) of eight studies reported a positive association between perceived risk and completion of FOBT, whereas six (37, 38, 39, 40, 41, 42) reported no association. In contrast, studies of perceived risk of breast cancer showed a fairly strong and consistent pattern with mammography screening (43) . Although only three studies examined the association between perceived risk and sigmoidoscopy completion (36 , 44 , 45) , all found a positive association. In an analysis of our data on the correlates of coverage (i.e., completion of at least one screening examination during the study period) and compliance (i.e., completion of all recommended screening examinations during the study period), perceived risk was associated with both outcomes in univariate but not in multivariable analysis.5 It may be the case that the effects of perceived risk are mediated through another variable, such as intention. Cross-sectional analysis of our baseline data (46) showed that perceived risk was independently associated with intention to have colorectal cancer screening (odds ratio, 2.1; 95% confidence interval, 1.7–2.6). Although the magnitude of the association lessened, baseline perceived risk also was associated with intention measured at year 1 of follow-up (odds ratio, 1.5; 95% confidence interval, 1.1–2.0) but not with intention at year 2 of follow-up (47) .
The patterns between perceived risk and examination status between baseline and year 2 were noteworthy. Compared with men who had abnormal findings on examination, perceived risk was low among men, both with and without polyps, who were not examined during the study period and was similar to that for men whose exams were normal. For men whose exams were normal, it is logical that perception of risk could decrease, at least in the short term, because screening with sigmoidoscopy or colonoscopy may reduce the risk of developing cancer. Thus, participation in the screening program may have decreased feelings of susceptibility to developing colorectal cancer or polyps.
The group of men who were not examined during the study period, and who perceived their risk to be low, represent a subgroup that may require more intensive intervention efforts. Nonparticipants in a study of colorectal cancer genetic counseling and testing (48) reported lower perceived ability to cope with mutation-positive test results and were more likely to report the presence of depressive symptoms, especially among women. Psychological distress also has been associated with reduced adherence to preventive behaviors for colorectal cancer (49) . A possible explanation is that these persons wished to avoid unfavorable health information (48) . These findings support the need to include other psychosocial variables, not measured in our study, such as psychological distress and coping ability, that may affect how information about risk is processed and may result in failure to adopt or sustain health-promoting behaviors.
No association was detected between perceived risk and intervention
group status at baseline or year-2 follow-up, although there was a
modest effect of the intervention on screening compliance
(27)
. The absence of an association between perceived risk
and intervention group status in the year 2 follow-up analysis is of
interest because men in the intervention group received educational
materials that conveyed personal medical risk information, including
their risk factors for colorectal cancer and prior screening history.
Although men in the control group were not given personalized risk
information, they were told that, as an occupational group, they were
at increased risk of developing colorectal cancer. Men in the control
group also may have received information about their personal risk from
their employer or union, although if provided, such information would
not have been delivered in a consistent or standardized manner. The
modest impact of the intervention on colorectal cancer screening
adherence as reported for the trial as a whole (27)
, the
lack of an association between the intervention and perceived risk at
year 2 of follow-up, the perception of low risk in those not screened
during the trial, and the decreased proportion of men scoring 3 on
the perceived risk scale at year 2 of follow-up compared with baseline
are consistent with the interpretation that the intervention was not
effective at increasing perceived risk. Alternatively, the impact of
the intervention on perceived risk may have been diluted because men at
all worksites were told that they were at increased risk of colorectal
cancer and were offered several opportunities to be screened prior to
the intervention. Under these circumstances, simply providing
information about risk factors may be insufficient to increase risk
perception. An intervention with more emphasis on the psychosocial
correlates of perceived risk may have the potential to increase risk
perception, but this possibility would need to be tested in another
prospective trial.
In our data, specificity was higher than sensitivity in all but one subgroup and was 65% or greater in all subgroups. To our knowledge, other investigators have not reported the sensitivity and specificity of their models, and thus we have no basis for comparison. In the context of conducting an intervention to increase perceived risk, particularly among persons at increased risk, it is preferable to have high specificity in order to have a better chance of correctly identifying those who perceive themselves to be at low risk. It would be informative to validate our models in other populations. The inclusion of other variables, not studied here, might increase sensitivity and specificity.
At present, the body of empiric research on cancer risk communication is relatively small (12 , 50) . As noted by Harding and Eiser (51) , to understand and influence a person’s behavioral decisions on health-related issues, specific behaviors must be studied separately in relation to perceived risk. Moreover, as Slovic (52 , 53) and Fischhoff (54) pointed out, perceptions of risk are determined not only by quantitative estimates of risk but also by qualitative characteristics of a particular risk. Just as the importance of perceived risk may vary in relation to different health-related behaviors, various factors may assume differential importance in relation to risk perception, depending on the health behavior being assessed. For instance, risks may be perceived differently by persons with different medical risk, e.g., personal history of polyps or family history of cancer. Perception of risk also may differ for cancers that can be prevented through early detection of premalignant lesions, such as cervical and colorectal cancers, compared with those, such as breast cancer, where early detection confers a survival benefit but does not prevent the disease. We found some support for this view in the follow-up analyses that showed differences in the correlates of perceived risk for men with and without polyps.
There are several limitations that should be considered in interpreting our results. The baseline and subsequent response rates, although similar to response rates for other worksite interventions that used mailed questionnaires (55 , 56) , were relatively low. Respondents and nonrespondents to the baseline and year 2 surveys differed in terms of some demographic, medical history (including previous colorectal cancer screening behavior), and psychosocial characteristics; however, there was no difference in perceived risk between respondents and nonrespondents to the year 2 survey. In general, the pattern of response was similar to that observed by Lerman and Shemer (57) , who reported that respondents to health promotion programs tended to be people already committed to healthy lifestyles. Other considerations in generalizing our findings are that the study population included only white males and that the entire cohort was at increased risk for colorectal cancer mortality. However, the patterns of association for men with a history of polyps may generalize to other groups of men who are at increased risk because of family history of colorectal cancer or polyps or to a personal history of inflammatory bowel disease. Most studies of colorectal cancer screening adherence were conducted prior to the dissemination of colorectal cancer screening guidelines (58, 59, 60) , when public awareness about colorectal cancer risk and the benefits of prevention and early detection was low. However, because of the promotion of colorectal cancer screening by the employer and union prior to the trial (24) , there may have been increased awareness in our study population compared with the general public. The rates of colorectal cancer screening adherence observed in our trial support this view (27) .
In conclusion, although there are limitations, our study is one of the few to compare correlates of perceived risk for colorectal cancer using both baseline and follow-up data and to evaluate whether correlates were similar for men with and without a personal history of colorectal polyps. Our findings, that correlates of perceived risk differed for baseline and follow-up analyses and for men with and without polyps, have implications for intervention development. Except for family history, messages to influence perceived risk would emphasize different factors, depending on whether associations were based on baseline (cross-sectional) or follow-up (prospective) data and depending on whether men reported a personal history of polyps. For example, messages based on cross-sectional data would emphasize the same factors for men, regardless of their history of polyps, whereas messages based on follow-up data would emphasize psychosocial characteristics, such as salience and coherence of screening and intention for men with a history of polyps but not for men without. Our findings support the need to delineate subgroups in the study population to target and tailor health-related messages based on respondent characteristics. Our findings also underscore the need to base health-related messages on prospective data as well as on cross-sectional data to better address health-related beliefs and behaviors.
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Acknowledgments |
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Footnotes |
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1 This work was supported by Grant CA52605 from
the National Cancer Institute. 
2 To whom requests for reprints should be
addressed, at The University of Texas Health Science Center at Houston,
School of Public Health, P. O. Box 20036, Houston, TX 77225. E-mail: svernon{at}sph.uth.tmc.edu
3 E. A. Fries, K. S. White, D. J. Bowen, S.
Talpin, and D. E. Montaño. A prospective study of accuracy of
risk perceptions for breast cancer and mammography use. Unpublished
data.
4 The abbreviation used is: FOBT, fecal occult
blood test.
5 R. E. Myers, S. W. Vernon, and B. C. Tilley,
unpublished data.
Received 3/29/00; revised 10/ 5/00; accepted 11/ 1/00.
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