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Effectiveness of a Contextually Tailored E-Learning Module in Improving Colorectal Cancer Screening Knowledge and Practice Among Primary Care Physicians in Malaysia: A Pre-Post Interventional Study

A pre-post interventional study involving 110 primary care physicians in Kuching, Sarawak, demonstrated that a contextually tailored e-learning module significantly improved colorectal cancer screening knowledge and clinical reasoning, though systemic barriers such as time constraints and limited clinic infrastructure continue to hinder the consistent translation of this knowledge into clinical practice.

Original authors: Snehlata Prashant Samberkar, Retnagowri Rajandram, Jason Yang Chern Khaw, Mohamed Rezal Abdul Aziz

Published 2026-06-29

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CC BY 4.0

Original authors: Snehlata Prashant Samberkar, Retnagowri Rajandram, Jason Yang Chern Khaw, Mohamed Rezal Abdul Aziz

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

The Big Picture: A "Digital Refresher Course" for Doctors

Imagine the healthcare system as a massive library. Colorectal Cancer (CRC) is like a very common, dangerous book that people often don't read until it's too late. In Malaysia, this "book" is a major health problem, but the library (the healthcare system) has a specific tool to find it early: a simple stool test called FOBT.

The problem? The librarians (the Primary Care Physicians or PCPs) who are supposed to recommend this test to visitors (patients) were often confused about how to use it, when to use it, or even which tool was the right one. Some thought they needed a giant, expensive machine (colonoscopy) for everyone, while others didn't know the test was free and easy.

The Study's Goal: The researchers wanted to see if a custom-made, online "refresher course" (an E-learning module) could fix this confusion and get the doctors back on track.

The Experiment: A "Before and After" Test

The researchers gathered 110 doctors from government clinics in Kuching, Sarawak. Think of this as a classroom of 110 students.

The Pre-Test: First, they gave the doctors a quiz to see what they already knew.
- The Result: The doctors were doing okay, but they had some big holes in their knowledge. About half of them thought the "big machine" (colonoscopy) was the first step for everyone, even low-risk people. They also mixed up the starting age for the test.
The Lesson: The doctors then took a break to go through a special, interactive website. This wasn't a boring lecture; it was a tailored digital module based on Malaysia's own official rules. It explained exactly who needs the test, when, and why.
The Post-Test: Immediately after the lesson, they took the same quiz again.

The Results: A "Lightbulb Moment"

The results were like a classroom where everyone suddenly understood the lesson.

Knowledge Boost: The average score jumped from 66% to 93%. That is a massive improvement.
Fixing Myths: Before the lesson, many doctors were confused about the "first-line" test. After the lesson, almost everyone knew that the simple stool test (FOBT) is the correct first step for average-risk people.
Risk Sorting: Doctors got much better at playing "detective." They learned how to sort patients into "low risk," "medium risk," and "high risk" groups correctly. Before, they were guessing; after, they were almost 100% accurate.

The Analogy: Imagine the doctors were trying to build a house but were confused about which bricks to use. The E-learning module handed them the perfect blueprint. Suddenly, they knew exactly which bricks (tests) to use for which walls (patients).

The Catch: Knowing vs. Doing

Here is the twist in the story. Even though the doctors now knew the right answer (they had the blueprint), they still faced hurdles in actually building the house.

The Gap: About two-thirds of the doctors said they were doing the screening, but many admitted they weren't doing it for every eligible patient.
The Real Obstacles: When the researchers asked why they weren't doing it, the doctors didn't say, "I forgot the rules." They said:
- "We are too busy." (Time constraints)
- "We don't have a good system to track who needs the test." (Infrastructure)
- "We aren't sure if the clinic has the resources to follow up." (Capacity)

The Key Finding: The study found that a doctor's knowledge didn't predict whether they would actually screen patients. Instead, what mattered most was whether the doctor believed the test was worth the cost and whether they felt their clinic had the tools to follow up with patients.

The Conclusion: A Good Start, But More Work Needed

The study concludes that the E-learning module was a huge success at teaching the doctors the facts. It was like giving them a super-charged map.

However, having a map doesn't mean you can drive the car if the roads are broken or the car has no gas. The paper claims that while the digital training fixed the knowledge gap, the systemic gaps (like lack of time, poor tracking systems, and unclear workflows) are still stopping the doctors from putting that knowledge into practice.

In short: The doctors are now smart enough to do the job, but the clinic environment needs to be fixed to let them actually do it. The paper suggests that in the future, we need to fix the "roads" (clinic systems) just as much as we teach the "drivers" (doctors).

Technical Summary: Effectiveness of a Contextually Tailored E-Learning Module in Improving Colorectal Cancer Screening Knowledge and Practice Among Primary Care Physicians in Malaysia

Problem Statement
Colorectal cancer (CRC) is a leading cause of cancer-related mortality in Malaysia, with over 72% of cases diagnosed at advanced stages. Despite national guidelines recommending faecal occult blood testing (FOBT) as a first-line screening tool, uptake remains critically low (estimated below 1% nationally). This suboptimal screening rate is attributed to significant knowledge gaps and practice inconsistencies among primary care physicians (PCPs), who serve as the primary drivers of patient screening participation. While evidence suggests that physician recommendations are the strongest predictor of patient screening adherence, existing data indicates that many Malaysian PCPs lack accurate knowledge regarding screening modalities, risk stratification, and guideline adherence. Furthermore, there is a lack of evaluated interventions specifically designed to address these deficits within the Malaysian primary care context using scalable digital tools.

Methodology
The study employed a cross-sectional pre-post interventional design conducted from August 2023 to February 2024 across 38 Ministry of Health primary care clinics in Kuching, Sarawak.

Participants: The study involved 110 primary care doctors (response rate 75.3%) who were registered medical practitioners actively working in the selected clinics. Exclusion criteria included those on extended leave, pilot study participants, and expert validators.
Intervention: A bespoke, web-hosted E-learning module was developed based on the Malaysian Clinical Practice Guideline (CPG) for Colorectal Cancer Screening (2020), supplemented by international guidelines (USPSTF, ACS). The module covered CRC epidemiology, screening evidence (FOBT, colonoscopy), risk stratification frameworks, national guidelines, and clinical decision-making pathways. The content was validated by a panel of nine expert clinicians and pilot-tested with 15 doctors.
Data Collection: Participants completed a structured, self-administered questionnaire comprising five sections: sociodemographics, knowledge of screening modalities, knowledge of risk stratification, practice trends, and perceived barriers. The knowledge assessment consisted of 21 items (13 on modalities, 8 on risk stratification scenarios). The procedure involved a pre-intervention knowledge test, the E-learning module, and a post-intervention knowledge assessment administered via a secure, time-controlled web platform.
Statistical Analysis: Data were analyzed using IBM SPSS Statistics (v28.0). Pre-post knowledge score comparisons utilized paired-samples t-tests. Binary logistic regression was employed to identify independent predictors of CRC screening practice.

Key Results

Knowledge Improvement: The E-learning module resulted in a statistically significant improvement in overall CRC screening knowledge. Mean scores increased from 13.9/21 (66.2%) pre-intervention to 19.5/21 (92.9%) post-intervention, representing a 26.7% improvement ( $p < 0.001$ $p < 0.001$ ).
- Screening Modalities: Scores rose from 69.2% to 91.5%. Notably, the misconception that colonoscopy is the first-line test for average-risk patients was corrected, and the incorrect identification of serum CEA as a screening tool dropped to 0%.
- Risk Stratification: Accuracy improved from 61.3% to 96.3%. Correct classification of average-risk, moderate-risk, and high-risk patients saw substantial gains, reaching 100% for average-risk scenarios post-intervention.
Practice Trends: 67.3% of participants reported routinely offering CRC screening. However, 30–40% did not screen eligible patients routinely, and a significant portion failed to consistently elicit personal or family history.
Barriers and Predictors: Logistic regression identified two independent predictors of screening practice:
1. Perceived cost-effectiveness: Physicians who agreed screening was cost-effective were 2.5 times more likely to practice screening (OR = 2.50, 95% CI: 1.90–10.45).
2. Perceived clinic capacity: Physicians who believed their clinic had sufficient resources for patient follow-up were 2.5 times more likely to screen (OR = 2.50, 95% CI: 1.06–6.00).
- Note: Knowledge scores, age, gender, and postgraduate qualifications were not statistically significant independent predictors of screening practice in the regression model.
Systemic Barriers: Over 70% of doctors cited insufficient knowledge as a barrier, and 75.5% cited competing medical priorities and inadequate clinic resources for follow-up. 100% of participants endorsed the need for a dedicated CRC screening service.

Significance and Claims
The authors claim this study provides the first evidence of the effectiveness of a contextually tailored E-learning module in improving CRC screening knowledge and clinical reasoning among Malaysian primary care physicians. The study demonstrates that a single-session, self-paced digital intervention can produce substantial, statistically significant gains in knowledge and correct specific clinical misconceptions (e.g., inappropriate colonoscopy referrals).

However, the paper maintains a modest stance regarding the translation of knowledge into practice. While the intervention successfully enhanced knowledge, the authors conclude that knowledge improvement alone is insufficient to drive behavioral change. The persistence of systemic barriers—specifically limited clinic infrastructure, competing clinical priorities, and insufficient patient tracking systems—indicates that structural enablers are equally critical. The study posits that while scalable, locally contextualized digital education is a meaningful step toward strengthening CRC screening, future efforts must complement individual education with targeted health system interventions to address the identified resource and workflow gaps. The authors explicitly state that further research is required to assess long-term knowledge retention and real-world clinical behavior changes.