Bismuth Toxicity Presenting as Declining Mobility and Falls.

A 77-year old woman presented with a history of falls. Known health problems included biopsy-proven collagenous colitis treated with bismuth subsalicylate. On examination, in addition to impaired balance and gait, she was found to have tremors and cognitive deficits. Investigations revealed a markedly elevated urinary bismuth level. Withdrawal of bismuth subsalicylate led to marked cognitive and physical improvement.

Patterns of participation over four rounds of annual fecal immunochemical test-based screening for colorectal cancer: what predicts rescreening?

BACKGROUND: Participation at the recommended intervals is critical for screening to be effective in reducing colorectal cancer (CRC) incidence. This study describes patterns of screening participation over four rounds of fecal immunochemical testing (FIT) to identify whether demographic variables and prior screening satisfaction are significantly associated with patterns of re-participation. METHODS: Baseline surveys were mailed to 4000 South Australians randomly selected from the electoral-roll. Respondents (n = 1928/48.2%) were offered four annual FIT rounds. Screening participation and satisfaction at each round were recorded. RESULTS: Study participation was 58.5, 66.9, 73.1 and 71.4% respectively over four rounds. Three participation patterns were described: consistent participation (43.1%), consistent non-participation (26.4%) and inconsistent participation (changeable; 30.5%), including intermittent and sustained change patterns. Sustained change described those who changed participatory behavior and then maintained for at least two rounds (n = 375/19.5%). Older people, and those not working were most likely to sustain participation. Younger invitees, especially men, were more likely to change participatory behavior and sustain the change. People with higher disadvantage, less education, not working and with no prior (pre-trial) screening experience were more likely to start participating and drop out. People dissatisfied with a prior screening test, including finding aspects embarrassing or unpleasant, were also more likely not to participate in annual screening or to drop out. CONCLUSIONS: The findings identify those at risk of non- or inconsistent participation in rescreening. They should aid targeting of interventions for demographic groups at risk and ensuring screening experiences are not perceived as unpleasant or difficult.

Exploring the Potential of Anticipated Regret as an Emotional Cue to Improve Bowel Cancer Screening Uptake.

Objective. Bowel cancer is currently the second leading cause of cancer-related death in Australia and screening participation is suboptimal. This study examined the role of emotion in the form of anticipated regret (AR) and its relationship to screening intentions. Methods. N = 173 persons aged 45 to 80 years completed a survey measuring demographic variables, readiness to screen, relative importance of health by comparison to other life priorities, satisfaction with current health, and AR if not participating in future bowel cancer screening. Results. AR was a significant predictor of future screening intentions. Those with higher levels of AR were seven times more likely (OR = 7.18) to intend to screen in the future compared to those with lower AR. This relationship was not compromised when controlling for other variables including gender and satisfaction with one's health. AR levels were significantly lower in people who had been screened previously and in those with full health insurance. Conclusions. These results demonstrate that AR is uniquely related to future bowel cancer screening intentions. Future studies should continue to consider this as a useful target for behavioural interventions and identify new ways of delivering these interventions to improve their reach.

Thinking Style as a Predictor of Men's Participation in Cancer Screening.

Men's participation in cancer screening may be influenced by their thinking style. Men's need for cognition (NFC) and faith in intuition were measured to explore whether they varied by demographic variables or predicted screening behavior. Australian males ( n = 585, aged 50-74 years) completed surveys about past screening and were subsequently offered mailed fecal occult blood tests (FOBTs). Demographic predictors included age, socioeconomic status, educational attainment, and language spoken at home. The screening behaviors were self-reported prostate cancer screening (prostate-specific antigen testing and digital rectal examinations [DREs]), and colorectal cancer screening (self-reported FOBT participation and recorded uptake of the FOBT offer). Analysis comprised principal component analysis and structural equation modelling. NFC was positively related to demographic variables education, socioeconomic status, and speaking English at home. Faith in intuition was negatively related to educational attainment. NFC predicted variance in self-reported DRE participation ( r = .11, p = .016). No other relationships with thinking style were statistically significant. The relationship of NFC to DRE participation may reflect the way certain attributes of this screening method are processed, or alternatively, it may reflect willingness to report participation. The relationship of thinking style to a range of healthy behaviors should be further explored.

Theory-based modifications of an advanced notification letter improves screening for bowel cancer in men: A randomised controlled trial.

RATIONALE: Male participation in screening for bowel cancer is sub-optimal. Theory-based interventions provide a means of improving screening uptake. OBJECTIVE: To test the efficacy of modifying consumer invitation material in line with continuum and stage theories of health behaviour on screening participation. METHODS: N = 9216 Australian men aged 50-74 years were randomised to one of four trial arms in a 2 × 2 factorial design randomised controlled trial. Participants received either standard invitation material (control group), or combinations of modified advance-notification and invitation letters. A subsample completed baseline and endpoint behavioural surveys. RESULTS: Participants who received the modified advance notification letter were 12% more likely to screen than those who received the standard version (RR = 1.12, χ(2)(1) = 10.38, p = 0.001). The modified invitation letter did not impact screening uptake (RR = 0.97, χ(2)(1) = 0.63, p = 0.424). No significant changes in psychological variables due to the intervention were observed. CONCLUSION: Modifications to advance notification letters in line with health behaviour theories significantly improves screening uptake in men. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12612001122842 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=362688.

Blood-based screening for bowel cancer may not resolve suboptimal screening participation in Australia.

OBJECTIVE: Emerging blood-based screening technologies for bowel cancer may improve screening participation compared to at-home stool sampling. This study assessed the impact of different screening delivery scenarios with increasing health system interactions on sampling preferences and likelihood of screening participation. METHODS: N=1,561 persons aged 45 to 74 years completed a behavioural survey measuring demographics, readiness to screen, overall collection method preference, and proposed participation in stool and blood methods across four screening scenarios differing in terms of the number of required health system interactions. RESULTS: Overall, respondents preferred a blood test (79.6%) compared to a stool test (20.4%). However, increasing health system interactions had a strong impact on the likelihood of participating in either sampling method (p<0.001). Moreover, likelihood of participating in each of the four blood-screening scenarios was significantly lower than the current at-home stool sampling approach (all p<0.001). CONCLUSIONS: Blood-based screening methods require increased contact with the health system but these interactions have negative impact on screening likelihood. All blood-based scenarios showed lower screening likelihood ratings than the current at-home FIT approach. Thus, blood-based screening may not resolve suboptimal screening participation rates in Australia.

Behavioural and demographic predictors of adherence to three consecutive faecal occult blood test screening opportunities: a population study.

BACKGROUND: Social cognitive variables are often examined for their association with initial participation in colorectal cancer screening. Few studies have examined the association of these variables with adherence to multiple screening offers i.e., rescreening. This study aimed to describe patterns of participatory behaviour after three rounds of screening using faecal immunochemical tests (FIT) and to determine social cognitive, demographic and background variables predictive of variations in adherence. METHODS: Participants were 1,540 men and women aged 50 to 75 living in South Australia who completed a behavioural survey measuring demographic (for example, age, gender) and social cognitive variables relevant to FIT screening (for example, perceived barriers, benefits, self-efficacy). The survey was followed by three, free FIT screening offers mailed on an annual basis from 2008 to 2010. Patterns of participation after three screening rounds were described as one of five screening behaviours; 1) consistent re-participation (adherent with all screening rounds), 2) consistent refusal (adherent with no screening rounds), 3) drop out (adherent with earlier but not later rounds), 4) intermittent re-participation (adherent with alternate rounds) and 5) delayed entry (adherent with later but not initial round(s)). Univariate (Chi Square and Analysis of Variance) and multivariate (Generalised Estimating Equations) analyses were conducted to determine variables predictive of each category of non-adherence (those that did not participate in every screening offer, groups 2, 3, 4 and 5) relative to consistent re-participation. RESULTS: Significant social cognitive predictors of non-adherence were; less self-efficacy (drop out and consistent refusal), greater perceived barriers (drop out) and lower levels of response efficacy (consistent refusal). Demographic predictors of non-adherence included; male gender (delayed entry), younger age (intermittent, delayed and consistent refusal), less frequent GP visits (intermittent re-participation) and 'ancillary only' private health insurance (drop out). Less satisfaction with screening at baseline predicted drop out, consistent refusal and delayed entry. CONCLUSIONS: Different combinations of demographic and behavioural variables predicted different patterns of rescreening adherence. Rescreening interventions may benefit from a targeted approach that considers the different needs of the population subgroups. Satisfaction with past FOBT screening measured prior to the study screening offers was an important predictor of adherence.

Comparison of mailed invitation strategies to improve fecal occult blood test participation in men: protocol for a randomized controlled trial.

BACKGROUND: Men have a significantly increased risk of being diagnosed with, and dying from, colorectal cancer (CRC) than women. Men also participate in fecal occult blood test (FOBT) screening at a lower rate than women. This study will determine whether strategies that target men's attitudes toward screening, and matched to stage of readiness to screen, increase men's FOBT participation compared to a standard approach. METHODS/DESIGN: Eligible trial participants will be a national sample of 9,200 men aged 50 to 74 years, living in urban Australia and randomly selected from the Australian electoral roll. Trial participants will be mailed an advance notification letter, followed 2 weeks later by an invitation letter and a free fecal immunochemical test (FIT) kit. The intervention is a factorial design, randomized controlled trial (RCT) with four trial arms, including a control. The content of the advance notification and invitation letters will differ by trial arm as follows: 1) standard advance notification and standard invitation (control arm); 2) targeted advance notification and standard invitation; 3) standard advance notification and targeted invitation; and 4) targeted advance notification and targeted invitation. The standard letters will replicate as closely as possible the letters included in the Australian National Bowel Cancer Screening Program (NBCSP). Modified advance notification and invitation letters will incorporate additional messages to target men in the precontemplation (advance notification) and contemplation stages (invitation). The primary outcome is return of the completed FIT within 12 weeks of invitation. Analysts will be blinded to trial assignment and participants will be blinded to the use of varying invitational materials. Subsamples from each trial arm will complete baseline and endpoint surveys to measure the psychological impact of the intervention, and qualitative interviews will be conducted to evaluate attitudes toward the intervention. DISCUSSION: The outcomes of this study will have implications for the way FOBT screening is offered to men. Findings will help to identify how invitations for men to screen should be framed and delivered in order to maximize participation. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12612001122842.

Using the Transtheoretical Model of Behaviour Change to describe readiness to rescreen for colorectal cancer with faecal occult blood testing.

ISSUE ADDRESSED: This study used the Transtheoretical Model of Behaviour Change (TTM) to describe reparticipation in colorectal cancer (CRC) screening according to social cognitive and background variables. METHODS: A random sample of men and women aged 50-74 years living in South Australia completed a questionnaire measuring TTM stage and attitudes toward screening using a faecal occult blood test (FOBT). Participants were categorised according to four stages of readiness to rescreen: action, maintenance, relapse and inconsistent. Multivariate techniques were used to determine predictors of lower readiness stages compared with maintenance. RESULTS: Of the 849 study participants, 29.9% were either non-adherent or had no intentions to maintain adherence (inconsistent and relapse). Compared with maintenance rescreeners, relapse participants reported less: social influences to screen (RR=0.86, p<0.001); satisfaction with prior screening (RR=0.87, p=0.03), self-efficacy (RR=0.96, p=0.01); and screening benefits (RR=0.84, p<0.001). Relapse participants were also more likely to not have private health insurance (RR=1.33, p=0.04) and be unaware of the need to repeat screening (RR=1.41, p=0.02). Inconsistent screeners were less likely to have planned when they will next rescreen (RR= 0.84, p=0.04) and reported greater barriers to rescreening (RR=1.05, p=0.05). Action participants were younger (RR= 0.98, p=<0.001), reported less social influences to screen (RR=0.94, p<0.001) and were less likely to have known someone who has had CRC (RR=0.82, p=0.01). CONCLUSIONS: Social cognitive, demographic and background variables significantly differentiated screening maintenance from lower readiness stages.

Demographic, social cognitive and social ecological predictors of intention and participation in screening for colorectal cancer.

BACKGROUND: Previous research points to differences between predictors of intention to screen for colorectal cancer (CRC) and screening behavior, and suggests social ecological factors may influence screening behavior. The aim of this study was to compare the social cognitive and social ecological predictors of intention to screen with predictors of participation. METHODS: People aged 50 to 74 years recruited from the electoral roll completed a baseline survey (n = 376) and were subsequently invited to complete an immunochemical faecal occult blood test (iFOBT). RESULTS: Multivariate analyses revealed five predictors of intention to screen and two predictors of participation. Perceived barriers to CRC screening and perceived benefits of CRC screening were the only predictor of both outcomes. There was little support for social ecological factors, but measurement problems may have impacted this finding. CONCLUSIONS: This study has confirmed that the predictors of intention to screen for CRC and screening behaviour, although overlapping, are not the same. Research should focus predominantly on those factors shown to predict participation. Perceptions about the barriers to screening and benefits of screening are key predictors of participation, and provide a focus for intervention programs.

Attitudes towards and beliefs about colorectal cancer and screening using the faecal occult blood test within the Italian-Australian community.

Studies with minority ethnic communities worldwide reveal important differences in the content of beliefs about cancer and attitudes towards screening. Current initiatives in colorectal cancer (CRC) screening highlight the importance of identifying any illness-specific beliefs that might influence participation rates within the targeted age-range. We conducted semi-structured interviews with 20 Italian-Australians aged between 50 and 78 years, living in Adelaide, South Australia. Qualitative data from the interviews were analysed using framework analysis. Participants articulated specific beliefs about the nature of cancer, risk factors, prevention possibilities, and variety of potential barriers and benefits to faecal occult blood testing (FOBT). Although participants'beliefs overlapped with conventional medical models of cancer, the results also demonstrated the presence of specific cultural perceptions that might influence FOBT participation. Our results suggest that models used to inform communication about cancer need to be sensitive to culture specific concerns. Within the context of the older Italian-Australian community, there is a suggestion that self and response efficacy may be serious barriers to screening behavior and that bi-lingual, verbal delivery of information may be the most effective mode of communication to increase screening participation.

Demographic associations with stage of readiness to screen for colorectal cancer.

OBJECTIVE: To describe the distribution of a population in southern urban Adelaide in terms of readiness to screen for colorectal cancer (CRC) by Faecal Occult Blood Test (FOBT) or colonoscopy according to the stages in the Transtheoretical Model (TTM) of behaviour change and to compare the stages according to demographic variables. METHODS: A random sample of 664 South Australians aged 50 to 74 were surveyed in June 2006. Chi-squared analyses were performed to determine if statistically significant differences on demographic variables existed between participants at different stages of readiness to screen. RESULTS: The precontemplation and contemplation stages when combined equated to more than half of the total respondents. Several significant differences were identified between the stages. Those in both the precontemplation and contemplation stages were older than those in the remaining stages and also had a significantly higher proportion of women when compared to the action stage. In the precontemplation stage there were significantly more respondents for whom English was a second language, and low levels of private health insurance, whereas the contemplation stage had the highest proportion of Australian-born respondents. Interestingly, levels of private health insurance were also low among those who intended to screen with colonoscopy. CONCLUSIONS AND IMPLICATIONS: The majority of the population were not found to have progressed beyond contemplation. Certain demographic characteristics varied significantly between people at different stages of readiness to screen for CRC.