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Promoting Community Awareness of Lung Cancer Screening Among Disparate Populations

Results of the cancer-Community Awareness Access Research and Education Project

Williams, Lovoria B. PhD, FNP-BC, FAANP; Looney, Stephen W. PhD; Joshua, Thomas MS; McCall, Amber PhD, APRN, FNP-BC; Tingen, Martha S. PhD, RN, FAAN

Author Information
doi: 10.1097/NCC.0000000000000748
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Abstract

Despite organized and extensive public health efforts to prevent and reduce cigarette smoking, lung cancer is the no. 1 cause of cancer death among men and women in the United States and worldwide.1,2 According to the latest National Cancer Institute data, in 2012 lung cancer accounted for 13% of all new cancer diagnoses (1.8 million) and 19.4% of cancer mortality (1.6 million).3 Higher lung cancer mortality is partly due to late-stage diagnosis, given that most lung cancers are discovered at advanced stages, which limits the option of surgical resection and results in a poor 5-year survival rate of only 5%.3 From 1999 to 2015, overall cancer mortality for men, women, and children decreased4; even lung cancer decreased—approximately 1.5%,4 yet long-standing disparities in mortality persist with African Americans and the medically underserved, bearing an overall higher mortality than whites and individuals with adequate medical access.5–8

Early detection through screening has reduced the mortality of breast,9 cervical,10 and colon cancer.11 Despite the lethal nature of lung cancer, until relatively recently there were no evidence-based screening guidelines. In 2013, the US Preventive Services Task Force (USPSTF) published the first ever lung cancer screening guidelines.12 Development of the guidelines resulted from compelling evidence of the 8-year National Lung Screening Trial, which demonstrated that annual screening of high-risk individuals with low-dose computed tomography (LDCT) reduced lung cancer mortality by 20% relative to chest x-rays.13 The USPSTF guidelines recommend annual LDCT for asymptomatic high-risk individuals, defined as follows: age 55 to 80 years who have a heavy smoking history (30-pack year), currently smoke, or who have quit within the last 15 years.13 The publication of the USPSTF guidelines promulgated lung cancer screening guidelines from other national medical organizations, such as the National Comprehensive Cancer Network14 and the American Cancer Society.15 Each guideline has slight variations in screening criteria relative to patient age and consideration of additional lung cancer risk factors (eg, family history, occupational exposures, etc). However, because cigarette smoking is linked to 80% to 90% of lung cancer cases, all of the guidelines include a history of heavy cigarette smoking as the main eligibility criteron.16

Based on the screening effectiveness of colon, breast, and cervical cancer and given that stage I lung cancer has a 5-year favorable survival rate of 75%, early detection of lung cancer through screening could reduce lung cancer mortality.17 Unfortunately, nearly 5 years after the publication of the USPSTF guidelines, there has been little uptake of lung cancer screening—only 2% to 4% of screening-eligible individuals have undergone this potentially lifesaving measure.18,19 Studies have shown that it takes a decade or more to adopt evidence into clinical practice.20 Part of the practice lag associated with lung cancer screening is related to institution level and clinician factors, including lack of resources to purchase the necessary computed tomography equipment and lack of clinician knowledge of the new guidelines,21,22 or clinician concerns regarding the risk/benefit of the screening22,23; however, research suggests that lack of patient knowledge of the lung cancer screening recommendations may contribute to the slow screening uptake.24–26 To achieve reductions in lung cancer mortality, increased knowledge of the lung cancer screening guidelines is warranted, and a substantial proportion of at-risk individuals must adopt the screening recommendation. Without widespread uptake, the health impact of the screening recommendation cannot be realized, and worsening cancer health inequities may result, especially among historically marginalized groups, such as African Americans and rural and lower socioeconomic status (SES) individuals. These populations are known to have lower cancer screening behaviors27,28 and subsequently disparate cancer outcomes.7,29

Lung cancer screening has complexities not found with other screening guidelines that may present additional barriers to uptake for marginalized and underprivileged groups. For instance, lung cancer screening requires documentation of a shared decision-making encounter, as a condition of coverage that is an unprecedented mandate for the Centers for Medicare & Medicaid Services.30 In addition, the screening eligibility criteria are largely related to a modifiable behavior risk factor—cigarette smoking, which may cause psychological barriers to screening. Additionally, an important psychological factor that is unique to lung cancer is social stigma or smoking-related stigma where the patient diagnosed with lung cancer has feelings of guilt or blame related to the diagnosis. Social stigma is associated with delayed cancer treatment–seeking behaviors and psychological distress and may be a barrier to increased lung cancer screening uptake among high-risk individuals.31,32 These potential psychological barriers to lung cancer screening warrant the delivery of culturally sensitive interventions.

Community health workers (CHWs), who are lay or professional individuals, have been shown to be effective in increasing cancer screening uptake among racial/ethnic minority and medically underserved populations for other cancers (eg, breast, colon, and cervical cancer).33–36 However, research with CHWs within the context of lung cancer screening has been primarily formative24; researchers sought to understand community preferences for lung cancer screening media. Other research, although not with CHWs yet important in understanding the uptake of lung cancer screening, has been conducted to develop a theoretical framework to predict factors that determine screening behaviors.37,38 To our knowledge, to date there is no published research on a community-based lung cancer screening education intervention delivered by trained CHWs.

To fill this evidence gap, we developed the cancer-Community Awareness Access Research and Education (c-CARE) project. The purpose of c-CARE was to train CHWs to reach racial/ethnic minority and/or lower SES individuals and educate them on the lung cancer screening guidelines. This project aimed to change participants’ knowledge, attitudes, and beliefs about cancer risk factors and lung cancer; and to connect screening-eligible individuals to no-cost LDCT screening facilities and tobacco users to evidence-based tobacco cessation services.

Methods

The c-CARE project was implemented in a semiurban city in east-central Georgia, where the African American population represents nearly 57% of the population and 24.4% of residents live below the poverty line.39 We used a pretest-posttest design with community-engaged strategies to develop and deliver the intervention. The study was approved by the Augusta University institutional review board, and all participants provided informed consent. The full details of the project design and implementation strategies are reported elsewhere.40 Briefly, from January 2015 to May 2015, we recruited 12 community sites: 8 African American churches, 3 federally qualified health clinics, and 1 community recreation center. The intervention was implemented from August 2015 to June 2017. We initially sought to include 12 sites; however, to meet recruitment goals, in May 2017 we recruited 1 additional church. The primary aim was to increase knowledge of lung cancer screening. Secondary aims included changing participants’ knowledge, attitude, and beliefs related to lung cancer and increasing lung cancer early detection and prevention behaviors by identifying and connecting high-risk and/or nicotine-dependent individuals to LDCT screening centers and/or tobacco cessation services.

Theoretical Underpinning

To our knowledge, during the time of our project, there were no published theoretical models specific to lung cancer screening; therefore, we applied the well-tested Health Belief Model (HBM) as the guiding conceptual model for the development of the c-CARE intervention and the evaluation methods. The HBM postulates that individuals will engage in health behavior change, predicated on their belief that engaging in the behavior—in this case lung cancer screening—will reduce the threat of a negative condition.41 The key HBM constructs are as follows: perceived susceptibility, perceived threat, perceived severity, perceived barriers, perceived benefits, cues to action, and self-efficacy; additionally, because intent has been associated with self-efficacy to screen for lung cancer in other studies, we examined this construct.25

Intervention Description

We developed the intervention based on relevant cancer programs (eg, breast, colon) that were available on the Research Tested Intervention Programs42 database. The intervention consisted of four 90-minute sessions, which were delivered once weekly. A team member attended each session to assess fidelity. Each session addressed the core constructs of the HBM by providing information that included the harmful effects of tobacco and radon exposure (perceived susceptibility), the health benefits of tobacco avoidance/cessation (perceived benefits), and the cost of lung cancer screening (perceived barriers). Additionally, all participants were given a card that included a checklist of the lung cancer screening eligibility criteria as a cue to action to discuss the screening with their healthcare provider or to discuss lung cancer screening with screening-eligible family members. We trained 2 to 4 CHWs from each community site to assist with recruitment of participants, deliver the intervention, coordinate implementation of a tobacco-free policy at their site, and identify and connect high-risk and/or nicotine-dependent individuals to LDCT screening and/or tobacco cessation services. All intervention activities occurred at the respective community site. Full details of the intervention, the tobacco policy implementation, and the CHW training are described elsewhere.40

Participant Inclusion

Participants were included if they were aged 21 to 80 years, English speaking, and able to complete an electronic survey, with or without assistance. Unlike other cancer screening tests where the general population is aware of the recommendation irrespective of personal screening eligibility, for example, colonoscopy and Papanicolaou smears, the general population is largely unaware of lung cancer screening. Because the project’s primary purpose was to promote the general awareness of the lung cancer screening guidelines, we enrolled participants who had no tobacco-use history as well as those who were current or past tobacco users. To reach individuals who might be screening eligible, during recruitment we encouraged tobacco users at each site to participate with the project; in the clinics, we specifically engaged the healthcare providers to refer tobacco users to the project. Community health workers used investigator-developed flyers, announcements, and church bulletin inserts to recruit. To reach our recruitment goal of 480 participants, we sought to enroll up to 60 participants at each site.

Instruments and Data Collection

Full details of the screening behaviors survey are described elsewhere.43 Briefly, the baseline survey collected sociodemographic data and cancer risk behaviors (eg, obesity status, tobacco use, and personal/family cancer history). To assess cancer screening behaviors, we used the screening guidelines of the American Cancer Society.44 Respondents indicated having had the cancer screening with “yes” or “no”; a follow-up question assessed the time interval of the screening.

After an extensive literature review regarding lung cancer screening, we revised a validated instrument that used the HBM constructs originally developed by Champion41 for breast cancer screening. The 21-item survey instrument, fully described elsewhere,40 was Likert style and assessed the HBM constructs as well as participants’ attitudes and beliefs regarding a cancer diagnosis, lung cancer screening, cues to action, and intent to obtain lung cancer screening, if eligible. We assessed the primary outcome variable—knowledge of the lung cancer screening guideline—with 1 multiple-choice item. The remaining items assessed knowledge of cancer risk factors, signs of lung cancer, and attitudes related to clinical trial participation. During the formative stage of the project, 3 content experts reviewed the surveys. Subsequently, we conducted 4 focus groups with community members and multiple semistructured interviews with the Community Advisory Board to receive feedback. Based on their feedback, we made iterative changes. Full details of the survey development are published elsewhere.40

Study team members administered the baseline questionnaires prior to intervention start and postintervention questionnaires within 1 week of completion of session 4. The participants took approximately 30 minutes to complete the study questionnaires.

Data Analysis

To reduce barriers to participation, all data were collected at the respective sites. Team members used encrypted iPads and touch-screen laptop computers to collect all survey data with Snap Survey software (https://www.snapsurveys.com/). The primary research questions focused on finding a significant postintervention improvement in lung cancer screening knowledge. Secondary outcomes included preintervention and postintervention changes in knowledge, attitudes, and beliefs regarding cancer, cancer screening, and changes in the use of tobacco products. SPSS version 21 (IBM Corporation, Armonk, New York, 2012) was used for descriptive analyses (means, measures of variability, frequencies, and proportions) to summarize sample characteristics and cancer risk and screening behaviors. We used SAS 9.4 (SAS Institute, Cary, North Carolina, 2012) for detailed statistical analyses; all statistical tests were 2-sided with a .05% 2-sided significance level. Associations of baseline cancer screening behaviors with sample characteristics (eg, current health status, age) were analyzed using the t test and Fisher exact test. Spearman correlations was used to examine associations of participant characteristics (eg, tobacco use status) with change scores for the HBM subscales (eg, intent, self-efficacy, perceived benefits) and with change in risk behaviors between baseline and follow-up. Analysis of variance was used to compare levels of demographic subgroups (eg, insurance status, ethnicity, marital status) in terms of change scores for the HBM constructs.

Results

Data were available for 481 participants at baseline. Of these 481, follow-up data were available for 451 (93.8%). Sample sizes varied across survey items due to missing data and nonapplicability to some participants. Table 1 summarizes the sample’s demographics, health behaviors, and health histories. Age of participants ranged from 24 to 80 years, with a mean age of 58.3 (SD, 10.9) years. More than two-thirds of the participants were female (73.1%), and majority were African American (93.2%). Most participants were sedentary (61%) and overweight (24.9%) or obese (59.4%). Most of the participants were not currently employed, with retired (43.5%) or unemployed (14.2%); the remaining participants were employed full time (32.3%) or part-time (8.1%). More than half of the participants (63.8%) had a current household income of less than $50 000 per year; a small percentage (8.5%) were uninsured. Approximately 13% (13.3%) of the participants stated that they had been diagnosed with cancer, and breast or prostate cancer was the most common (50%); 4 participants (7.7%) had a previous lung cancer diagnosis. At baseline, 78 participants (16.2%) indicated they were current smokers. Number of years of smoking ranged from 1 to 57 years, with a mean of 27.2 (SD, 12.2) years and a median of 27 years (n = 71). Almost 80% of the participants responded that they were exposed to secondhand smoke at least some of the time.

Table 1 - Participant Sociodemographic Characteristics, Health Behaviors, and Health History
Characteristic Frequency Percent
Gender (n = 481)
 Male 129 26.8
 Female 352 73.2
Race (n = 481)
 African American 444 92.3
 White (non-Hispanic) 20 4.2
 Other/preferred not to specify 17 3.5
Yearly income, n = 466
 <$50 000 297 63.8
 ≥$50 000 169 36.2
Education (n = 481)
 Some elementary school 5 1.0
 Some high school 38 7.9
 High school graduate 117 24.3
 Some college 171 35.6
 College graduate 95 19.8
Graduate degree 55 11.4
Insurance (n = 481)
 Medicare 134 27.9
 Medicaid 39 8.1
 Private insurance 214 44.5
 Military coverage 53 11.0
 None 41 8.5
Obesity status (n = 478)
 Normal (BMI <25 kg/m2) 75 15.7
 Overweight (25 ≤ BMI < 30 kg/m2) 119 24.9
 Obese (30 ≤ BMI < 40 kg/m2) 214 44.8
 Morbidly obese (BMI ≥40 kg/m2) 70 14.6
Health status (n = 481)
 Excellent 33 6.9
 Very good 120 24.9
 Good 291 60.5
 Poor 37 7.7
Health behaviors
Smoking history (n = 481)
 Current smoker 78 16.2
 Quit smoking 99 20.6
 Quit smoking within 15 y 36 7.5
Exercise (days during the past week with exercise of at least moderate intensity) (n = 481)
 0–1 d 207 43.0
 2–3 d 165 34.3
 4–5 d 68 14.3
 6–7 d 40 8.3
Health history/cues to action
Clinician-recommended lung cancer screening (n = 451)
 Yes 49 10.9
 No 402 89.1%
Cancer history (n = 451)
 Yes 60 13.3
 No 391 86.7
First-degree relative with lung cancer History (n = 450)
 Yes 88 19.6
 No 316 70.2
 Don’t know 46 10.2
Characteristic
First-degree relative with any cancer history (n = 450)
 Yes 259 57.6
 No 191 42.4
Abbreviation: BMI, body mass index.

Comparison of Participants, Preintervention and Postintervention Knowledge and Attitudes

Table 2 presents a comparison of the participants’ responses to survey items before and after intervention that assessed knowledge of the primary outcome variable (lung cancer screening), general cancer knowledge (eg, causes, risks, signs), and attitudes related to the health effects of e-cigarettes and clinical trial participation. There were significant improvements in the percentage of correct responses to each of the knowledge items (P < .001 for all items). Prior to the intervention, 25.3% responded incorrectly to the multiple-choice item that assessed knowledge of lung cancer screening; after the intervention, 79.8% responded correctly that LDCT was the recommended test for lung cancer screening.

Table 2 - Preintervention and Postintervention Survey Responses to Knowledge and Attitude Questions
Preintervention Correct Response Postintervention Correct Response P
Knowledge questions
 Knowledge of lung cancer screening test 25.3% 79.8% <.001
 Nicotine as cause of lung cancer 0% 46.8% <.001
 Risks and benefits of lung cancer screening 61% 89.4% <.001
 Cancer risk factors 41% 74.9% <.001
 Signs of lung cancer 33.3% 46.8% <.001
Preintervention Negative Response Postintervention Positive Response
Attitude statements
 E-cigarettes just as harmful as cigarettes 43.7% 81.4% .018
 Clinical trial participation 65% 68% <.001

Change in Participant Responses to Likert-Style Survey of HBM Subscales and Attitude

The HBM survey yielded preintervention Cronbach’s α = .82 (n = 481) and postintervention Cronbach’s α = .87 (n = 451), indicating adequate instrument reliability. Table 3 presents preintervention and postintervention responses to the survey items based on the HBM constructs. After the intervention, there was an overall significant decrease in the following subscales: perceived severity (eg, most people who get lung cancer will not survive) and perceived barriers (eg, costs, fear of LDCT). There was an overall increase in response to perceived benefits (eg, early detection improves cancer outcomes) of lung cancer screening and self-efficacy (eg, ability to discuss with healthcare provider) to obtain lung cancer screening if indicated. There were no significant changes in perceived susceptibility (eg, my risk for lung cancer is high), perceived threat (eg, my risk for lung cancer is high), intent (eg, intent to get screened for lung cancer, if eligible), or cues to action (eg, discussing lung cancer screening assessment card with healthcare provider).

Table 3 - Comparison of Preintervention and Postintervention Responses to Health Belief Model Subscales and Intent (n = 451)
Subscale Time Point Mean (SD) P
Perceived susceptibility Pre 2.10 (0.60) .353
Post 2.12 (0.63)
Perceived severity Pre 2.03 (0.67) .021
Post 1.95 (0.66)
Perceived threat Pre 4.43 (2.34) .071
Post 4.28 (2.23)
Perceived benefits Pre 3.19 (0.72) <.001
Post 3.34 (0.68)
Perceived barriers Pre 1.85 (0.48) <.001
Post 1.69 (0.51) .002
Self-efficacy Pre 3.20 (0.83)
Post 3.36 (0.82)
Intent Pre 2.94 (0.80) .121
Post 3.01 (0.84)
Cues to action Pre 1.16 (0.98) .812
Post 1.17 (0.95)

Additionally, there was a significant decrease in attitude regarding the statements “If I have lung cancer, it was meant to be” and “If I have lung cancer, it is better not to know.” Lastly, there was a significant decrease in participants’ false beliefs about cancer (Table 3).

Change in Responses to HBM Subscales and Attitude Among Screening-Eligible Participants

Thirty-seven of the participants met the lung cancer screening criteria of either the USPSTF or the National Comprehensive Cancer Network.14 Complete data were available for 35. An analysis of the HBM subscales for this subgroup indicated a statistically significant decrease (P < .001) in the responses to the perceived barriers to obtain LDCT screening; in false beliefs regarding cancer treatment, perceived severity of lung cancer (P = .001), and perceived threat (P = .002); and a positive change in attitude regarding a lung cancer diagnosis (P = .010) (Table 4).

Table 4 - Comparison of Preintervention and Postintervention Responses to Health Belief Model Subscales and Intent Among Screening-Eligible Participants (n = 35)
Subscale Time Point Mean (SD) P
Perceived susceptibility Pre 2.56 (0.69) .521
Post 2.48 (0.63)
Perceived severity Pre 2.37 (0.65) <.001
Post 1.94 (0.50)
Perceived threat Pre 6.31 (2.82) .002
Post 4.96 (2.04)
Perceived benefits Pre 3.26 (0.59) .648
Post 3.19 (0.76)
Perceived barriers Pre 2.12 (0.47) <.001
Post 1.71 (0.51) 1.00
Self-efficacy Pre 3.23 (0.43)
Post 3.23 (0.94)
Intent Pre 3.20 (0.41) .638
Post 3.11 (0.99)
Cues to action Pre 1.66 (0.94) 1.00
Post 1.66 (0.91)

Additionally, there was a significant decrease in attitude (P = .010) regarding lung cancer as described above. There was also a significant decrease in false beliefs regarding cancer treatment (P < .001).

Behavior Change

A follow-up call 3 months after the conclusion of the intervention indicated that 38% (n = 14) of those meeting screening eligibility criteria (n = 37) had undergone LDCT screening. Of the 78 participants who reported use of tobacco products at baseline, 54% (n = 42) of them had chosen to participate in tobacco cessation treatment.

Discussion

This community-engaged project found that trained CHWs are effective in increasing the knowledge of lung cancer screening and in changing general cancer knowledge, attitudes, and beliefs related to lung cancer among racial/ethnic minority and lower SES individuals. The use of community-engaged strategies engendered community relations and buy-in of the project and enhanced survey development and the development of a culturally acceptable curriculum.40,43 The intervention was effective in promoting behavior change to undergo lung cancer screening and attempt tobacco cessation. To our knowledge, our project is among the first to train CHWs to deliver a community-based intervention to promote lung cancer screening awareness among racial/ethnic minority and/or medically underserved populations.

The baseline finding of low knowledge about lung cancer screening is consistent with those of others who have collected data from both disparate24,45,46 and high-risk populations.44 Lung cancer has the highest cancer mortality; given the slow uptake of lung cancer screening (2%–4% nationwide) and the participants’ lack of awareness of lung cancer screening, there is a critical need to implement broad-scale public health efforts to educate the public about this potentially lifesaving screening. Making lung cancer screening awareness a public health priority will elevate the level of knowledge regarding lung cancer screening among the general public to be commiserate with that of other cancers such as colon and breast cancer.

Overall, self-efficacy to obtain lung cancer screening increased among the c-CARE participants, and this finding is consistent with those of others, such as Bui et al.46 Contrary to expectations, self-efficacy and intent did not increase among the c-CARE screening-eligible participants despite the care navigation provided by the CHWs. Moreover, despite the no cost provision of LDCT, fewer than half (38%) of the screening-eligible participants underwent screening. Lack of intent to obtain screening and opting out of cancer screening despite the removal of fiscal barriers have been found among disparate populations with other cancer screenings, for example, colon.28 Carter-Harris et al47 explored this finding among a sample of LDCT screening-eligible whites; their results indicated reasons that are consistent with the psychological aspects of the HBM, including lack of perceived benefit to having the screening and fear of the findings, as well as perceptions of fatalism. To increase lung cancer screening and subsequently reduce lung cancer mortality, more research is warranted to explore the psychological barriers to LDCT uptake and to develop interventions or messaging to alleviate them. Further, research is also needed to explore methods to improve lung cancer screening decision aids and shared decision-making encounters, which may be key to addressing this barrier to LDCT uptake. A strength of CHWs is that because they are from the same community as the participants they often share the same lived experiences. Therefore, they may be effective partners in elucidating the participants’ reasons for opting out of screening. Moreover, because of the trust relationship that they often have with the participants, CHWs may be uniquely instrumental in resolving decisional conflict among screening-eligible participants, thereby increasing participation in LDCT screening. Future researchers should consider extending the training of CHWs beyond delivering educational interventions, to formally training them on using a lung cancer screening shared-decision aide.

This brief intervention was effective in prompting more than half of the tobacco users to attempt a tobacco cessation attempt. These results are consistent with the findings of others that CHWs are effective in promoting tobacco cessation among disparate racial/ethnic and medically underserved groups.48 Future research should explore the factors that predict the success of CHWs in delivering tobacco cessation interventions.

No significant changes were observed in perceived susceptibility, perceived threat, intent, or cues to action. To further explore this finding, we conducted a subanalysis of the screening-eligible participants, and unlike the overall participants, among this high-risk group, there was a significant change in perceived threat. These findings support those of Quaife et al,49 who conducted a mixed-methods study in the United Kingdom and found a high perceived risk among smokers compared with nonsmokers. A possible explanation is that because of the public health emphasis on the harmful effects of tobacco use, before the intervention the participants in general already had a high level of understanding of their perceived risks and threats to lung cancer. This finding emphasizes the public health impact of cancer prevention education and the important role of all healthcare providers continuing to discuss the harmful effects of tobacco use with their patients. However, to avoid perpetuating smoking-related stigma32 associated with lung cancer and the false belief that lung cancer diagnosis is limited to individuals with a tobacco-use history, care must be taken to include education about radon exposure—the second most common cause of lung cancer among nonsmokers50—and the dangers of secondhand smoke in the discussion of lung cancer prevention.

Discussion

There remains a dearth of research that explores lung cancer screening uptake among racial/ethnic minority populations. Although c-CARE provides a promising model for increasing lung cancer screening awareness among disparate populations, it is not without limitations. Our project was conducted in a high-resource area that has an academic medical center with an affiliated cancer center that offers a free lung cancer screening program. When implementing interventions to change screening behaviors in disparate groups, it is imperative to ensure that resources are available to increase access to the recommended screening; the healthcare resources available to c-CARE participants are not available in all settings, thereby limiting our findings to geographic areas with similar circumstances. Second, given that heavy tobacco use is the main criterion for lung cancer screening, it is possible that individuals who are not tobacco users are likely to have different scores on the HBM subscales (eg, perceived risk, perceived threat) than those who smoke and meet the screening-eligibility requirements. We attempted to control this limitation by conducting a subanalysis of the screening-eligible participants. Moreover, a small number of the participants (n = 4) had a previous history of lung cancer; therefore, their knowledge, attitudes, and beliefs about LDCT screening recommendation and the frequency of their screening may differ from the other participants. However, this subgroup represented less than 1% of the sample. A third limitation is that the conceptual model did not account for smoking-related social stigma, which is a major issue among lung cancer patients and likely a factor affecting lung cancer screening behavior. As the general knowledge of the lung cancer screening increases, future researchers should consider limiting inclusion to screening-eligible participants. Additionally, consideration should be given to using an HBM that is specifically intended for use within the unique context of lung cancer screening and is inclusive of smoking-related stigma as a barrier to screening uptake, such as that developed and validated by Carter-Harris and colleagues.38 Lastly, our study has limitations that are inherent in a single-group pretest-posttest design. Although a stronger study design such as a randomized trial would have resulted in stronger internal validity, the primary aim of the project was to increase knowledge of this potentially lifesaving test among racial/ethnic minority and medically underserved individuals—populations that are known to be slower than others in adopting new cancer screening recommendations.

Our project has several unique strengths. First, we engaged the community in all aspects of the project, to include curriculum and questionnaire design. Second, all project activities were conducted in community settings that were accessible to the respective population, whether a church, federally qualified health clinic, or recreation center. This facilitated participation and excellent retention (94%) and allowed us to reach a large sample of racial/ethnic minority and/or medically underserved individuals. Third, our training of the CHWs from within the sites to deliver the intervention may increase sustainability of the program. A fourth strength is that we presented lung cancer screening within the context of all other recommended cancer screenings, and our goal was to normalize LDCT as a recommended screening that all should be aware of. Additionally, the LDCT was free to those who met the screening eligibility.

The findings of this project have important implications for nurses. There continues to be a lack of general knowledge about the relatively new lung cancer screening recommendation. Given the complexities associated with the test (eg, false-positive rate, eligibility criteria), it may be unreasonable to expect patients to fully understand the recommendation during a single patient encounter. Clinicians should consider advocating for the use of electronic clinical reminders that are similar to those used for immunizations and other cancer screenings to prompt clinicians to provide information about lung cancer screening to all tobacco users. If the clinical reminder indicates that the patient is at high risk of lung cancer, the nurses could initially explain LDCT screening to the patient prior to the patient having a shared decision-making discussion with the clinician. However, to be effective, nurses must be fully educated on LDCT screening and prepared to explain the screening recommendation while balancing the discussion regarding the benefits and risks, while allaying misunderstandings and fears. Also, given the clear evidence that tobacco use is the primary cause of lung cancer, nurses should always couple lung cancer screening discussions with information about the health benefits of tobacco avoidance and cessation. However, to avoid perpetuating smoking-related stigma and misperceptions that tobacco use is the sole cause of lung cancer, the discussions should also include information about the dangers of secondhand smoke and radon exposures.

In conclusion, this community-engaged project was successful in increasing participants’ awareness of lung cancer screening and changing their cancer risk and screening behaviors. The methodology of training CHWs to deliver the intervention may be a model for others seeking to reach disparate populations for health promotion and sustainability. Moreover, this methodology may be a sustainable model for the delivery of additional cancer prevention programs.

ACKNOWLEDGMENTS

The authors thank the student team members, Mrs Lynda Thomas, Mrs Maudesta Caleb, and Mrs Charee Dotton for their support of the project. Lastly, this project would not have been possible without the partnerships with pastors, clinic administrators, CHWs, and participants.

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Keywords:

Awareness; Cigarette smoking; Community health workers; Computed tomography; Early detection of cancer; Health Belief Model; Lung neoplasms; Minority groups; Public health; X-ray

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