Author ORCID Identifier

Date Available


Year of Publication


Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation


Communication and Information



First Advisor

Dr. Elisia Cohen

Second Advisor

Dr. Anthony Limperos


Colorectal cancer (CRC) is preventable through regular screening; however, incidence and mortality rates in Appalachia are among the highest in the United States. Public health programs and interventions meant to mitigate the higher CRC burden and increase screening rates are ongoing in the U.S. and Appalachia. In continuing the efforts to reduce the burden of CRC in Appalachian communities, this dissertation uses a two-part study to investigate communication practices relative to problematic integration and health beliefs in CRC screening conversations from the perspective of both patients and patient navigators in the region. As part of efforts directed by the Rural Cancer Prevention Center (RCPC; 2009-2019), patients who received a positive fecal immunochemical test (FIT) and the patient navigators assigned to connect them with direct visualization follow-up testing were interviewed one-on-one to better understand the role of problematic integration in CRC screening communication. Study 1 investigates patient navigators' (n = 9) perspectives of their efforts to connect patients with appropriate CRC screening, while Study 2 analyzes the accounts of patients (n = 10) with positive FIT who refused follow- up colonoscopy testing (at the time of recruitment) after engaging in patient navigation services. With problematic integration theory and the health belief model as a guide, data from these two studies in the Appalachian Kentucky context support an overarching model for how patient navigators and patients address uncertainty in CRC screening. Analyzing these phenomena at the intersection of communication and health behavior theories highlights the utility of health communication research expertise in guiding interventions across the healthcare continuum. In addition, data from the studies may be used to understand the nature of participation in CRC screening conversations and how these dynamics contribute to patient-centered care and shared decision-making, which is especially important with the additional challenges for screening exacerbated by a global COVID-19 pandemic. The findings from these studies are discussed in terms of contributing to more effective clinical and patient navigation communication practices and providing public health practitioners with essential considerations for shaping interventions to support shared decision-making and improve CRC screening rates in similar populations.

Digital Object Identifier (DOI)

Funding Information

This dissertation was supported by cooperative agreement number 1U48DP001932-01 from the Centers for Disease Control and Prevention (2009-2019).