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Effect of multimodal information delivery for diabetes care on colorectal cancer screening uptake among individuals with type 2 diabetes

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Title:
Effect of multimodal information delivery for diabetes care on colorectal cancer screening uptake among individuals with type 2 diabetes
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Preventive Medicine Reports
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Hong, Young-Rock
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Elsevier
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English
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Journal Article

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Despite the significant increase in the risk of colorectal cancer (CRC), one-third of individuals with diabetes who met screening recommendations, reported not being up-to-date on CRC screening in the United States. We determined the means through which individuals with type 2 diabetes (T2DM) learned about diabetes care; we further examined their associations with CRC screening uptake. This was a retrospective study of US adults aged 50–75 years diagnosed with T2DM (sample n = 5595, representing 14,724,933 Americans). Data from the 2011–2014 Medical Expenditure Panel Survey were analyzed to compare CRC screening uptake in four learning groups for diabetes care: (1) did not learn, (2) learning from health providers only, (3) learning from other sources (including online sources and group class), and (4) learning from health providers and other sources together (combined learning group). Overall, 70.4% individuals with T2DM were up-to-date with CRC screening during 2011–2014. In multivariate logistic regression analysis, the combined learning group had 1.32 (95% confidence interval, 1.01–1.74) times higher odds of being up-to-date on CRC screening than those who did not learn about diabetes care. The odds of being up-to-date on CRC screening were not significant for other learning groups. Our findings suggest that combined ways of health information delivery for diabetes care is associated with increased odds of being up-to-date on CRC screening among individuals with T2DM. Multimodal health information delivery has the potential to result in unintended, positive consequences in preventive care services use.
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Collected for University of Florida's Institutional Repository by the UFIR Self-Submittal tool. Submitted by Young-Rock Hong.

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Contentslistsavailableat ScienceDirectPreventiveMedicineReportsjournalhomepage: www.elsevier.com/locate/pmedr BriefOriginalReportE ectofmultimodalinformationdeliveryfordiabetescareoncolorectal cancerscreeninguptakeamongindividualswithtype2diabetesYoung-RockHonga, ,KalyaniB.Sonawanea,DerekR.Holcombb,AshishA.DeshmukhaaDepartmentofHealthServicesResearch,ManagementandPolicy,UniversityofFlorida,Gainesville,FL,UnitedStatesbDepartmentofPublicHealth,EasternKentuckyUniversity,Richmond,KY,UnitedStatesABSTRACTDespitethesigni cantincreaseintheriskofcolorectalcancer(CRC),one-thirdofindividualswithdiabeteswhomet screeningrecommendations,reportednotbeingup-to-dateonCRCscreeningintheUnitedStates.Wedeterminedthe meansthroughwhichindividualswithtype2diabetes(T2DM)learnedaboutdiabetescare;wefurtherexamined theirassociationswithCRCscreeninguptake.ThiswasaretrospectivestudyofUSadultsaged50 75yearsdiagnosed withT2DM(sample n =5595,representing14,724,933Americans).Datafromthe2011 2014MedicalExpenditure PanelSurveywereanalyzedtocompareCRCscreeninguptakeinfourlearninggroupsfordiabetescare:(1)didnot learn,(2)learningfromhealthprovidersonly,(3)learningfromothersources(includingonlinesourcesandgroup class),and(4)learningfromhealthprovidersandothersourcestogether(combinedlearninggroup).Overall,70.4% individualswithT2DMwereup-to-datewithCRCscreeningduring2011 2014.Inmultivariatelogisticregression analysis,thecombinedlearninggrouphad1.32(95%con denceinterval,1.01 1.74)timeshigheroddsofbeingupto-dateonCRCscreeningthanthosewhodidnotlearnaboutdiabetescare.Theoddsofbeingup-to-dateonCRC screeningwerenotsigni cantforotherlearninggroups.Our ndingssuggestthatcombinedwaysofhealthinformationdeliveryfordiabetescareisassociatedwithincreasedoddsofbeingup-to-dateonCRCscreeningamong individualswithT2DM.Multimodalhealthinformationdeliveryhasthepotentialtoresultinunintended,positive consequencesinpreventivecareservicesuse.1.Introduction Itiswelldocumentedthatindividualsdiagnosedwithtype2diabetes (T2DM)areatalmost40%greaterriskforcolorectalcancer(CRC)than thenon-diabetics( SiddiquiandPalmer,2011 ; Peetersetal.,2015 ; Yang etal.,2005 ).Earlyepidemiologicstudiessuggestthatmetabolicsyndrome, hyperinsulinemiaorinsulinresistancemayincreasetheriskofCRCamong diabeticpatients(SiddiquiandPalmer,2011 ),andarecentmeta-analysis hasshownthathavingdiabetesincreasestheriskofcancer-speci cmortalitybyabout12%amongpatientswithCRC( Millsetal.,2013 ). Despitetheprovenbene tsofearlydetection( Bibbins-Domingo etal.,2016 ),theuptakerateofCRCscreeninghasbeensuboptimal ( Hongetal.,2017).Itwasestimatedthataboutone-thirdofindividuals aged50orolderwithdiabetes,whometscreeningrecommendations, reportednotbeingup-to-dateonCRCscreening( Porteretal.,2016).A recentstudyfoundthat,amongindividualswithT2DM,thefrequency ofdiabetes-relatedvisitstocarewasnotassociatedwithreceiptofCRC screening,suggestingthatdiabeticpatientsmaynotbereferredforCRC screeningdespitethegreaterriskofCRC( Porteretal.,2016 ). Currently,littleisstillknownaboutthefactorsthatcanhelppromote recommendedCRCscreeningamongthosewithT2DM. Behavioralpatienteducation/counselingisconsideredanessential partoftheoptimalcareforthosewithchronicconditions( Wagner, 2011 ).Educationalinterventioninvarioussettingsfordiabetescare (includingself-management,community-basedcare,andprimarycare) hasdemonstrateditse ectivenessinimprovingpatientsandtreatment outcomes( Wagner,2011; YamaokaandTango,2005; Norrisetal., 2002 ).However,todate,noknownstudyhasattemptedtoexaminethe associationbetweendiabetescareeducationanduptakeofrecommendedscreeningforCRCamongthosewithT2DM.UsinganationallyrepresentativesampleofUSadults,wedeterminedthemeans throughwhichindividualswithT2DMlearnedaboutdiabetescareand thenexaminedtheirassociationswithCRCscreeninguptake. 2.Methods Weconductedaretrospectiveanalysisofthe2011 2014Medical ExpenditurePanelSurvey(MEPS).TheMEPSisacomplexdatasethttps://doi.org/10.1016/j.pmedr.2018.05.008 Received25July2017;Receivedinrevisedform24April2018;Accepted5May2018 Correspondingauthorat:DepartmentofHealthServicesResearch,ManagementandPolicy,CollegeofPublicHealthandHealthProfessions,1225CenterDrive,HPNP3118, UniversityofFlorida,Gainesville,FL32611,UnitedStates. E-mailaddress: requiem34@phhp.u .edu (YR.Hong).

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utilizingamultistageprobabilitysampledesignthatprovidesnationallyrepresentativeinformationonhealthserviceuse,expenditures, sourcesofpayment,andhealthinsurancecoveragefortheUSnoninstitutionalizedpopulation( AgencyforHealthcareResearchand Quality,2017 ).TheMEPSHouseholdComponent(HC)data lesincludetheDiabetesCareSurvey(DCS)tosupplementthedatasetwith questionsrelatedtodiabetescare.MEPSadministerstheDCStorespondentwasevertoldbyadoctororhealthprofessionalthathe/she haddiabetes( AgencyforHealthcareResearchandQuality,2016 ).We identi edrespondentsaged50 75years,forwhomscreeningisrecommendbytheUSPreventiveServicesTaskForce( Bibbins-Domingo etal.,2016),anddiagnosedwithT2DM.Then,wede nedthemas beingup-to-dateonCRCscreeningiftheyreportedhavinghadablood stooltestwithinthepastyear,sigmoidoscopyinthepast veyears,or colonoscopyinthepast10years.Weexcludedindividualsdiagnosed withCRC. TheDCSincludesinformationaboutthereceiptofdiabetestestsand complicationsofdiabetes( AgencyforHealthcareResearchandQuality, 2016 ).Respondentsalsoreportedthewaysinwhichtheylearnedabout diabetescare.BasedontheresponsesindividualswithT2DMwere categorizedintofourgroups:(1)didnotlearnaboutcare(servedasthe referencegroup),(2)learningfromhealthcareprovidersonly,(3) learningfromothersources(includingreadingsontheInternetand takingagroupclass),and(4)learningfromhealthcareprovidersand othersourcescombined(combinedlearninggroup). Analyseswereconductedin2017.Weestimatedmultivariatelogisticregressionmodelstocalculateoddsratios(ORs)fortheoddsof beingup-to-dateonCRCscreening,adjustingforsociodemographic characteristics(age,gender,race/ethnicity,education,familyincome, employment,maritalstatus,andcensusregion),healthinsurance, smokingstatus,andcomorbidconditions(hypertension,highcholesterol,heartdisease,stroke,congestiveheartfailure,andrenalfailure). Becausethegreaterfrequencyofprovidervisitincreasestheoddsof CRCconsultation( Porteretal.,2016),wecontrolledforhealthservices utilization(numberofvisitstophysiciansandnon-physicianproviders) inourmodel.Wesetthe P valueforstatisticalsigni canceat0.05.All analyseswereperformedusingSPSSComplexSurvey,version24(IBM Corp.,Armonk,NY)andSAS ,version9.4(SASInstitute,Cary,NC). Thisstudywasreviewedandgrantedexemptionbytheinstitutional reviewboardoftheUniversityofFlorida. 3.Results Ourstudysampleincluded5595individuals,representing 14,724,933Americansaged50 75yearswithT2DM.Overall,70.4% (95%CI,67.9% 72.9%;10millionAmericans)individualswithT2DM wereup-to-datewithCRCscreeningduring2011 2014. Table1 presentsup-to-dateCRCscreeningratesbyindividual characteristics.Exceptforsex( P =0.12),thereweresigni cantdifferencesinCRCscreeninguptakeacrossindividualcharacteristics.The percentageofbeingup-to-datewashighestamongindividualsaged 65yearsorolder(79.3%[95%CI,75.9% 82.4%]),non-Hispanic Whites(73.6%[95%CI,71.0% 75.9%]),thosewithhighereducation (75.3%[95%CI,72.4% 77.9%]),higherfamilyincome(75.4% [72.5% 78.0%]),whowerereportedlymarried(72.6%[95%CI, 70.0% 75.1%]),hadhealthinsurance(74.4%private[95%CI, 72.3% 76.7%]and68.9%public[95%CI,66.4% 71.3%]),werenonsmoker(71.1%[95%CI,69.0% 73.1%]),andhadgreaternumberof comorbidconditions(76.2%[95%CI,73.5% 78.7%]).Intermsof healthinformationdelivery,up-to-dateCRCscreeningratewashighest inthecombinedlearninggroup(76.2%[95%CI,73.5% 78.8%])followedbyhealthprovidersonly69.3%(95%CI,67.1% 71.3%),other resources67.5%(95%CI,56.6% 76.8%),anddidnotlearnaboutcare (66.1%,[95%CI,62.4% 69.5%])groups. Inmultivariatelogisticregressionanalysis( Fig.1 ),individualswith T2DMwholearnedaboutdiabetescarefromhealthprovidersandother resourcescombinedhadagreateroddsforbeingup-to-dateonCRC(OR 1.32,95%CI,1.01 1.74)comparedwiththosewhodidnotlearnabout diabetescare.Theoddsofbeingup-to-dateonCRCscreeningwerenot signi cantforthosethatreportedlearningfromhealthprovidersonly ( P =0.78)andalsothegroupthatreportedlearningfromothersources only( P =0.52)whencomparedwiththedidnotlearnaboutdiabetes caregroup. 4.Discussion Toourknowledge,thisisthe rststudytoexaminetheassociation betweenthewaysofhealthinformationdeliveryfordiabetescareand CRCscreeninguptakeamongindividualswithT2DM.Our ndingsindicatethataboutone-thirdofT2DMpatientswerenotup-to-datewith CRCscreening,whichisconsistentwithapriorstudy( Porteretal., 2016 ).WealsofoundthatindividualswithT2DMwholearnedabout diabetescarefromhealthprovidersandotherresources(internetand groupclasssession)combinedhadahigherprevalenceofbeingup-todateonCRCscreeningthanthereferencegroup(thosedidnotlearn about).Screeninguptakewasthehighestamongindividualsinthe combinedlearninggroupthanthosewholearnedfromhealthproviders onlyorotherresourceonlygroup.Consistentwithbivariateanalyses, individualsinthecombinedlearninggroupweremorelikelytobeupto-dateonCRCscreeningthantheotherthreegroupsintheadjusted analyses.Theseresultsindicatethatamultimodalpatienteducation format(e.g.,combiningbothonlineresources/groupclassesorface-tofaceproviderinteraction)isassociatedwithimproveddiabetes-related preventivecareservicesuse,likeCRCscreeninginthisstudy. Itisimportantforpublichealthworkersandhealtheducatorsto betterunderstandthewaysinwhichmodeofdeliveryofhealthinformationa ectsscreeningbehaviorpositively.Previousstudieshave notshownthee ectivenessofgroupsessionandonline-basedinterventions( Rickheimetal.,2002; Cavalloetal.,2012 );however,we observedincreasedoddsofbeingup-to-datewhentheyarecombined withhealthproviderstogether.Our ndingsarenotsurprising,given thatthemajorityofinterventionforbehaviorchangeisdesignedasa combinationofprogramsorstrategiestomaximizetheretentionof informationdelivered( Giuseetal.,2012 ; Changetal.,2014).Inaddition,interventionsincludingmultipleeducationalprogramsand stagesarefoundtobeexceptionallye ectiveforindividualbehavior changesuchasweightloss( Johnsetal.,2014 )andvaccination ( DempseyandZimet,2015).Takentogether,our ndingssuggestthat delivering healthinformationusingasinglemodemaynotbee ective atgettingpatientup-to-dateonrecommendedhealthscreening,but maybee ectivewhendeliveringinacombinationformat. 5.Limitations Thecurrentstudyhasitslimitation.First,itwasacross-sectional design,whichlimitedourabilitytoexplorethecausalitybetween diabetescareeducationandCRCscreening.Futurerandomizedcontrolledtrialiswarrantedtocertifythisassociation.Second,alarger samplesizeofscreeningup-to-dategroup(70%)mayyieldahigher signi cancelevelwhencomparedwiththenotup-to-dategroup(30%). Lastly,inthenatureofsecondarydataanalysis,wewereabletoexamineonlyavailableinformationinthedataset.Ithasbeenreported thatinterventionsofself-managementforasinglechroniccondition mayhaveaspillovere ecttoimprovemanagementofotherconditions ( Fosteretal.,2007 )andimprovedinteractionqualitywithhealthcare providersarepositivelyassociatedwiththeuptakeofCRCscreening ( Hongetal.,2018).Furtherstudiesshouldexploreandexamineother possible,unintendedpositivee ectsoffactors,asidefromsocioeconomicdeterminants,onpatienthealthbehaviorandassociated outcomesamongthosewithT2DM.YR.Hongetal.

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6.Conclusions Inconclusion,combinedwaysoflearningaboutdiabetescare,but notlearningfromhealthprovidersorotherresources(onlinematerial orgroupsession)alone,isassociatedwithstatisticallysigni cantincreasedoddsofbeingup-to-dateonCRCscreeningamongindividuals withT2DM.Collaborativepatienteducation/interventionsusingvariousmediamaycontributetoe ortstoimproveCRCscreeninguptake amongindividualsatincreasedrisk. Declaration Thisresearchreceivednospeci cfundfromanyagencyinthe public,commercial,ornot-for-pro tsectors.AllAuthorshavenoconictsofinterestrelevanttothisstudy. FinancialdisclosureYoung-RockHonghasno nancialdisclosures.KalyaniSonawanehasno nancialdisclosures.DerekHolcombhasno nancialdisclosures.AhsishDeshmukhasno nancialdisclosure. Table1 CharacteristicsofindividualswithdiabetesbyCRCscreeningup-to-datestatus.IndividualswithDM(row%[95%CI]) Pvalue Up-to-date Notup-to-date Variable SampleN 3731 1864 WeightedN 10,212,775 4,512,158 Age <0.001 50 54 48.2(43.2 53.2) 51.8(46.8 56.8) 55 59 65.0(60.3 69.5) 35.0(30.5 39.7) 60 64 72.3(68.3 76.0) 27.7(24.0 31.7) 65 69 79.3(75.9 82.4) 20.7(17.6 24.1) 70 75 76.9(72.5 80.7) 23.1(19.3 27.5) Sex 0.122 Male 71.6(69.2 74.0) 28.4(26.0 30.8) Female 69.2(66.8 71.5) 30.8(28.5 33.2) Race/ethnicity <0.001 Non-Hispanicwhite 73.6(71.0 75.9) 26.4(24.1 29.0) Non-Hispanicblack 72.4(69.8 74.9) 27.6(25.1 30.2) Hispanic 59.1(55.3 62.8) 40.9(37.2 44.7) Non-HispanicAsian 55.8(49.3 62.0) 44.2(38.0 50.7) Others 72.1(59.8 81.7) 27.9(18.3 40.2) Education <0.001 Highschool/GEDorless 67.7(65.2 70.1) 32.3(29.9 34.8) Somecollegeorhigher 75.3(72.4 77.9) 24.7(22.1 27.6) Familyincome < 0.001
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Acknowledgment PublicationofthisarticlewasfundedinpartbytheUniversityof FloridaOpenAccessPublishingFund(UFOAP).Theauthorsalsothank theDepartmentofHealthServicesResearch,ManagementandPolicyin CollegeofPublicHealthandHealthProfessionsattheUniversityof Floridaforsupportingthedevelopmentofthisarticle. ReferencesAgencyforHealthcareResearchandQuality,2016.MEPSHC-171:2014fullyearconsolidateddata le. https://meps.ahrq.gov/data_stats/download_data/pufs/h171/ h171doc.shtml#DCS (Published2016). AgencyforHealthcareResearchandQuality,2017.MEPSHC-036:1996 2015pooled linkagevarianceestimation le. https://meps.ahrq.gov/data_stats/download_data/ pufs/h36/h36u15doc.shtml (Published2017). Bibbins-Domingo,K.,Grossman,D.C.,Curry,S.J.,etal.,2016.Screeningforcolorectal cancer.JAMA315(23),2564. http://dx.doi.org/10.1001/jama.2016.5989 Cavallo,D.N.,Tate,D.F.,Ries,A.V.,Brown,J.D.,Devellis,R.F.,Ammerman,A.S.,2012.A socialmedia-basedphysicalactivityintervention:arandomizedcontrolledtrial.Am. J.Prev.Med.43(5),527 532. http://dx.doi.org/10.1016/j.amepre.2012.07.019 Chang,S.J.,Choi,S.,Kim,S.-A.,Song,M.,2014.Interventionstrategiesbasedoninformation-motivation-behavioralskillsmodelforhealthbehaviorchange:asystematicreview.AsianNurs.Res.(KoreanSoc.Nurs.Sci.)8(3),172 181. http://dx. doi.org/10.1016/j.anr.2014.08.002 Dempsey,A.F.,Zimet,G.D.,2015.Interventionstoimproveadolescentvaccination.Am. J.Prev.Med.49(6),S445 S454. http://dx.doi.org/10.1016/j.amepre.2015.04.013 Foster,G.,Taylor,S.J.,Eldridge,S.,Ramsay,J.,Gri ths,C.J.,2007.Self-management educationprogrammesbylayleadersforpeoplewithchronicconditions.In:Foster, G.(Ed.),CochraneDatabaseofSystematicReviews.JohnWiley&Sons,Ltd, Chichester,UK. http://dx.doi.org/10.1002/14651858.CD005108.pub2 Giuse,N.B.,Koonce,T.Y.,Storrow,A.B.,Kusnoor,S.V.,Ye,F.,2012.Usinghealthliteracy andlearningstylepreferencestooptimizethedeliveryofhealthinformation.J. HealthCommun.17(Suppl.3),122 140. http://dx.doi.org/10.1080/10810730. 2012.712610 Hong,Y.R.,Jo,A.,Mainous,A.G.,2017.Up-to-dateonpreventivecareservicesunder A ordableCareAct:atrendanalysisfromMEPS2007-2014.Med.Care55(8), 771 780. http://dx.doi.org/10.1097/MLR.0000000000000763 Hong,Y.R.,Tauscher,J.,Cardel,M.,2018.Distrustinhealthcareandculturalfactorsare associatedwithuptakeofcolorectalcancerscreeninginHispanicandAsian Americans.Cancer124(2),335 345. http://dx.doi.org/10.1002/cncr.31052 Johns,D.J.,Hartmann-Boyce,J.,Jebb,S.A.,Aveyard,P.,2014.Dietorexerciseinterventionsvscombinedbehavioralweightmanagementprograms:asystematicreview andmeta-analysisofdirectcomparisons.J.Acad.Nutr.Diet.114(10),1557 1568. http://dx.doi.org/10.1016/j.jand.2014.07.005 Mills,K.T.,Bellows,C.F.,Ho man,A.E.,Kelly,T.N.,Gagliardi,G.,2013.Diabetesmellitusandcolorectalcancerprognosis.DisColonRectum56(11),1304 1319. http:// dx.doi.org/10.1097/DCR.0b013e3182a479f9 Norris,S.L.,Lau,J.,Smith,S.J.,Schmid,C.H.,Engelgau,M.M.,2002.Self-management educationforadultswithtype2diabetes:ameta-analysisofthee ectonglycemic control.DiabetesCare25(7),1159 1171. http://dx.doi.org/10.2337/diacare.25.7. 1159 Peeters,P.J.H.L.,Bazelier,M.T.,Leufkens,H.G.M.,DeVries,F.,DeBruin,M.L.,2015.The riskofcolorectalcancerinpatientswithtype2Diabetes:associationswithtreatment stageandobesity.DiabetesCare38(3),495 502. http://dx.doi.org/10.2337/dc141175 Porter, N.R.,Eberth,J.M.,Samson,M.E.,Garcia-Dominic,O.,Lengerich,E.J.,Schootman, M.,2016.Diabetesstatusandbeingup-to-dateoncolorectalcancerscreening,2012 BehavioralRiskFactorSurveillanceSystem.Prev.ChronicDis.13,150391. http:// dx.doi.org/10.5888/pcd13.150391 Rickheim,P.L.,Weaver,T.W.,Flader,J.L.,Kendall,D.M.,2002.Assessmentofgroup versusindividualdiabeteseducation:arandomizedstudy.DiabetesCare25(2), 269 274. http://dx.doi.org/10.2337/diacare.25.2.269 Siddiqui,A.A.,Palmer,B.F.,2011.Metabolicsyndromeanditsassociationwithcolorectal cancer:areview.AmJMedSci341(3),227 231. http://dx.doi.org/10.1097/MAJ. 0b013e3181df9055 Wagner,J.,2011.Behavioralinterventionstopromotediabetesself-management. DiabetesSpectr.24(2),61 62. http://dx.doi.org/10.2337/diaspect.24.2.61 Yamaoka,K.,Tango,T.,2005.E cacyoflifestyleeducationtopreventtype2diabetes:a meta-analysisofrandomizedcontrolledtrials.DiabetesCare28(11),2780 2786. http://dx.doi.org/10.2337/diacare.28.11.2780 Yang,Y.-X.,Hennessy,S.,Lewis,J.D.,2005.Type2diabetesmellitusandtheriskof colorectalcancer.Clin.Gastroenterol.Hepatol.3(6),587 594 Fig.1. AdjustedAssociationsbetweenWaysofLearningaboutDiabetesCare andColorectalCancer(CRC)Screening. Abbreviations:CRC,colorectalcancer;OR,oddsratio;CI,con denceinterval; DM,diabetesmellitus.OthersourcesincludereadingsontheInternetortaking groupsessions.Oddsratiosand95%con denceintervalwerecomputedusing multivariatelogisticregressionmodelsadjustingforage,sex,race/ethnicity, familyincome,maritalstatus,employment,region,insurancestatus,smoking status,comorbidconditions,andnumberofhealthcarevisits(PlaceofStudy: Gainesvile,FL.Timeofstudy:June2017).YR.Hongetal.