Correlates of colorectal cancer screening among residents of Ohio Appalachia

Multilevel Pathways of Colorectal Cancer Screening Among Low-Income Vietnamese Americans: A Structural Equation Modeling Analysis

Background:

Colorectal cancer (CRC) disproportionately affects Vietnamese Americans, especially those with low income and were born outside of the United States. CRC screening tests are crucial for prevention and early detection. Despite the availability of noninvasive, simple-to-conduct tests, CRC screening rates in Asian Americans, particularly Vietnamese Americans, remain suboptimal. The purpose of this study was to evaluate the interplay of multilevel factors – individual, interpersonal, and community – on CRC screening behaviors among low-income Vietnamese Americans with limited English proficiency.

Methods:

This study is based on the Sociocultural Health Behavior Model, a research-based model that incorporates 6 factors associated with decision-making and health-seeking behaviors that result in health care utilization. Using a community-based participatory research approach, we recruited 801 Vietnamese Americans from community-based organizations. We administered a survey to collect information on sociodemographic characteristics, health-related factors, and CRC screening-related factors. We used structural equation modeling (SEM) to identify direct and indirect predictors of lifetime CRC screening.

Results:

Bivariate analysis revealed that a greater number of respondents who never screened for CRC reported limited English proficiency, fewer years of US residency, and lower self-efficacy related to CRC screening. The SEM model identified self-efficacy (coefficient = 0.092, P < .01) as the only direct predictor of lifetime CRC screening. Educational attainment (coefficient = 0.13, P < .01) and health beliefs (coefficient = 0.040, P < .001) had a modest significant positive relationship with self-efficacy. Health beliefs (coefficient = 0.13, P < .001) and educational attainment (coefficient = 0.16, P < .01) had significant positive relationships with CRC knowledge.

Conclusions:

To increase CRC screening uptake in medically underserved Vietnamese American populations, public health interventions should aim to increase community members’ confidence in their abilities to screen for CRC and to navigate associated processes, including screening preparation, discussions with doctors, and emotional complications.

Disparities in colorectal cancer screening among breast and prostate cancer survivors

Background

Colorectal cancer (CRC) screening is recommended as an integral part of cancer survivorship care. We compared the rates of CRC screening among breast and prostate cancer survivors by primary cancer type, patient, and geographic characteristics in a community‐based health‐care system with a mix of large and small metro urban areas.

Materials and Methods

Data for this retrospective study were abstracted from medical records of a multi‐specialty practice serving about 250,000 individuals in southern Maryland. Breast (N = 1056) and prostate (N = 891) cancer patients diagnosed prior to 2015 were followed up till June 2018. Screening colonoscopy within the last 10 years was considered to be guideline concordant. Multivariate logistic regression was used to determine the prevalence odds ratios of being concordant on CRC screening by age, gender, race, metro area type, obesity, diabetes, and hypertension.

Results

Overall 51% of survivors had undergone a screening colonoscopy. However, there was a difference in CRC screening rate between prostate (54%) and breast (44%) cancer survivors. Older age (≥65 years), being a breast cancer survivor compared to prostate cancer, and living in a large compared to small metropolitan area were associated with a lower probability of receiving CRC screening. Having hypertension was associated with higher likelihood of being current on colonoscopy screening guidelines among survivors; but diabetes and obesity were not associated with CRC screening.

Conclusions

Low levels of CRC screening utilization were found among breast and prostate cancer survivors in a single center in Southern Maryland. Gender, comorbidities, and residential factors were associated with receipt of CRC screening.

Social support and breast cancer screening in rural Appalachia

PURPOSE

Women in the Appalachian region have a high mortality rate attributable to cancer in spite of lower incidence of cancer compared with the general US population. Empirical evidence suggests that social support influences cancer outcomes, including adherence to screening guidelines and treatment recommendations. The purpose of this study is to examine the impact of social support on breast cancer screening patterns in a sample of rural Appalachian women.

METHODS

This paper reports the results of analyses of baseline cross-sectional data on breast cancer screening collected during a community-based group-randomized trial. We used the 2010 National Health Institute Survey questionnaires and the Medical Outcomes Study Social Support Survey to assess screening behavior and perceived social support, respectively. Data were analyzed using ANCOVA and ANOVA to assess the mean social support on breast cancer screening patterns (frequently, irregularly, and rarely/never) and relevant sociodemographic variables.

FINDINGS

Of the eligible participant records analyzed (N = 289), 50% were married, 36% were employed, 20% attended college, 40% had no mammogram in 6 years, and 20% never had mammograms. Overall social support score was high at 73.1 (SD = 18.2). Association between breast cancer screening patterns and social support scores was not statistically significant at α < 0.05 (P value = 0.09).

CONCLUSIONS

Although social support as it measured in this study does not show significant associations with screening patterns, it is important to understand how social network structures may influence screening patterns. Familial and social roles/responsibilities that result in reported social support may also be the barrier to cancer screening and other prevention health behaviors.

Predictors of Colorectal Cancer Screening in Two Underserved U.S. Populations: A Parallel Analysis

Background

Despite declining colorectal cancer (CRC) incidence and mortality rates in the U.S., significant geographic and racial disparities in CRC death rates remain. Differences in guideline-concordant CRC screening rates may explain some of these disparities. We aim to assess individual and neighborhood-level predictors of guideline-concordant CRC screening within two cohorts of individuals located within CRC mortality geographic hotspot regions in the U.S.

Methods

A total of 36,901 participants from the Southern Community Cohort Study and 4,491 participants from the Ohio Appalachia CRC screening study were included in this study. Self-reported date of last CRC screening was used to determine if the participant was within guidelines for screening. Logistic regression models were utilized to determine the association of individual-level predictors, neighborhood deprivation, and residence in hotspot regions on the odds of being within guidelines for CRC screening.

Results

Lower household income, lack of health insurance, and being a smoker were each associated with lower odds of being within guidelines for CRC screening in both cohorts. Area-level associations were less evident, although up to 15% lower guideline adherence was associated with residence in neighborhoods of greater deprivation and in the Lower Mississippi Delta, one of the identified CRC mortality hotspots.

Conclusion

These results reveal the adverse effects of lower area-level and individual socioeconomic status on adherence to CRC guideline screening.

Impact of provider-patient communication on cancer screening adherence: A systematic review

Cancer screening is critical for early detection and a lack of screening is associated with late-stage diagnosis and lower survival rates. The goal of this review was to analyze studies that focused on the role of provider-patient communication in screening behavior for cervical, breast, and colorectal cancer. A comprehensive search was conducted in four online databases between 1992 and 2016. Studies were included when the provider being studied was a primary care provider and the communication was face-to-face. The search resulted in 3252 records for review and 35 articles were included in the review. Studies were divided into three categories: studies comparing recommendation status to screening compliance; studies examining the relationship between communication quality and screening behavior; and intervention studies that used provider communication to improve screening behavior. There is overwhelming evidence that provider recommendation significantly improves screening rates. Studies examining quality of communication are heterogeneous in method, operationalization and results, but suggest giving information and shared decision making had a significant relationship with screening behavior. Intervention studies were similarly heterogeneous and showed positive results of communication interventions on screening behavior. Overall, results suggest that provider recommendation is necessary but not sufficient for optimal adherence to cancer screening guidelines. Quality studies suggest that provider-patient communication is more nuanced than just a simple recommendation. Discussions surrounding the recommendation may have an important bearing on a person's decision to get screened. Research needs to move beyond studies examining recommendations and adherence and focus more on the relationship between communication quality and screening adherence.

Association Between Primary Care Visits and Colorectal Cancer Screening Outcomes in the Era of Population Health Outreach

BACKGROUND

Population outreach strategies are increasingly used to improve colorectal cancer (CRC) screening. The influence of primary care on cancer screening in this context is unknown.

OBJECTIVE

To assess associations between primary care provider (PCP) visits and receipt of CRC screening and colonoscopy after a positive fecal immunochemical (FIT) or fecal occult blood test (FOBT).

DESIGN

Population-based cohort study.

PARTICIPANTS

A total of 968,072 patients ages 50-74 years who were not up to date with CRC screening in 2011 in four integrated healthcare systems (three with screening outreach programs using FIT kits) in the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium.

MEASURES

Demographic, clinical, PCP visit, and CRC screening data were obtained from electronic health records and administrative databases. We examined associations between PCP visits in 2011 and receipt of FIT/FOBT, screening colonoscopy, or flexible sigmoidoscopy (CRC screening) in 2012 and follow-up colonoscopy within 3 months of a positive FIT/FOBT in 2012. We used multivariable logistic regression and propensity score models to adjust for confounding.

RESULTS

Fifty-eight percent of eligible patients completed a CRC screening test in 2012, most by FIT. Those with a greater number of PCP visits had higher rates of CRC screening at all sites. Patients with ≥1 PCP visit had nearly twice the adjusted-odds of CRC screening (OR = 1.88, 95 % CI: 1.86-1.89). Overall, 79.6 % of patients with a positive FIT/FOBT completed colonoscopy within 3 months. Patients with ≥1 PCP visit had 30 % higher adjusted odds of completing colonoscopy after positive FIT/FOBT (OR = 1.30; 95 % CI: 1.22-1.40).

CONCLUSIONS

Patients with a greater number of PCP visits had higher rates of both incident CRC screening and colonoscopy after positive FIT/FOBT, even in health systems with active population health outreach programs. In this era of virtual care and population outreach, primary care visits remain an important mechanism for engaging patients in cancer screening.

Rural-Urban Differences in Colorectal Cancer Screening Barriers in Nebraska

Nebraska ranks 36th nationally in colorectal cancer screening. Despite recent increases in CRC screening rates, rural areas in Nebraska have consistently shown lower rates of CRC screening uptake, compared to urban areas. The objective of this study was to investigate reasons for lower CRC screening rates among Nebraska residents, especially among rural residents. We developed a questionnaire based on Health Belief Model (HBM) constructs to identify factors associated with the use of CRC screening. The questionnaire was mailed in 2014 to adults aged 50-75 years in an urban community in the east and a rural community in the west regions of the state. Multiple logistic regression models were created to assess the effects of HBM constructs, rural residence, and demographic factors on CRC screening use. Of the 1200 surveys mailed, 393 were returned (rural n = 200, urban n = 193). Rural respondents were more likely to perceive screening cost as a barrier. Rural residents were also more likely to report that CRC cannot be prevented and it would change their whole life. In multiple regression models, rural residence, perceived embarrassment, and perceived unpleasantness about screening were significantly associated with reduced odds of receiving colonoscopy. Older age (62 years and older), having a personal doctor, and perceived risk of getting CRC were significantly associated with increased odds of receiving colonoscopy. Interventions to increase uptake of colorectal cancer screening in rural residents should be tailored to acknowledge unique perceptions of screening methods and barriers to screening.

A Media and Clinic Intervention to Increase Colorectal Cancer Screening in Ohio Appalachia

Objective. To test the effectiveness of a colorectal cancer (CRC) screening intervention among adults living in Ohio Appalachia. Methods. We conducted a group-randomized trial of a county-level intervention among adults living in 12 Ohio Appalachian counties who received a media campaign and clinic intervention focused on either CRC screening or fruits and vegetables. Participants' percentage within CRC screening guidelines was assessed with cross-sectional surveys conducted annually for four years, and validated with medical record review of screening. Results. On average, screening data were obtained on 564 intervention and 559 comparison participants per year. There was no difference in the Wave 4 CRC screening rates of intervention and comparison counties (35.2% versus 31.4%). Multivariate analyses found that high perceived risk of CRC, willingness to have a CRC test if recommended by a doctor, doctor recommendation of a CRC screening test, and patient-physician communication about changes in bowel habits, family history of CRC, and eating fruits and vegetables were significant (p < 0.05) predictors of being within CRC screening guidelines. Conclusions. The intervention was not effective in increasing CRC rates among Ohio Appalachian adults. Future research should determine how media and clinic-based interventions can be modified to improve CRC screening rates among this underserved population.

Community Members' Input into Cancer Prevention Campaign Development and Experience Being Featured in the Campaign

BACKGROUND

Colorectal cancer (CRC) incidence and mortality rates are increased and CRC screening rates are lower among Appalachia Ohio residents.

OBJECTIVES

We sought to describe 1) a partnership of cancer researchers and community members that developed county-specific media campaigns to improve CRC screening rates (intervention) and fruit and vegetable consumption (control) and 2) the experience of community members featured in the campaigns.

METHODS

Community members assisted with campaign development, were featured in campaigns, identified locations for materials, and promoted the campaigns. Campaigns included billboards, posters, and information in local newspapers. A mailed survey assessed featured community members' experiences in the campaigns.

LESSONS LEARNED

Ongoing communication among members of the partnership was critical to successful community-level campaigns. Featured community members had mostly positive experiences about being included in the campaigns.

CONCLUSIONS

Having a shared vision, ongoing trust, and good communication are essential elements to maintaining a viable academic-community partnership.

Adherence to Multiple Cancer Screening Tests among Women Living in Appalachia Ohio

BACKGROUND

There is a lack of information about the correlates of completing all three cancer screening tests among women living in Appalachia.

METHODS

Cross-sectional telephone interviews were conducted (April-September 2013) among women (n = 637) ages 51 to 75 years from 12 Appalachia Ohio counties. Outcomes of within screening guidelines were verified by medical records. Multivariable logistic regression models identified correlates of being within guidelines for all three cancer screening tests.

RESULTS

Screening rates included mammography (32.1%), Pap test (36.1%), and a colorectal cancer test (30.1%). Only 8.6% of women were within guidelines for all tests. Having had a check-up in the past 2 years and having received a screening recommendation were significantly related to being within guidelines for all three tests (P < 0.01). Participants with higher annual household incomes [$60,000+; OR, 3.53; 95% confidence interval (CI), 1.49-8.33] and conditions requiring regular medical visits (OR, 3.16; 95% CI, 1.29-7.74) were more likely to be within guidelines for all three screening tests.

CONCLUSION

Less than 10% of women had completed screening within guidelines for all three screening tests. Regular contact with the health care system and higher incomes were significant predictors of being within guidelines.

IMPACT

Within guidelines rates for the three recommended cancer screening tests are low among women in Appalachia Ohio. This finding illustrates the need for innovative interventions to improve rates of multiple cancer screening tests.

Analysis of barriers to cognitive screening in rural populations in the United States

There is scant research regarding barriers to cognitive screening in rural US populations. This is surprising when there is evidence of the importance of preventative health behaviors such as memory screening that can lead to earlier diagnosis and treatment of Alzheimer's disease and decrease in associated costs. A systematic review of published research revealed modifiable barriers to screening such as lack of knowledge and lack of knowledgeable providers to screen. Recommendations for diminishing barriers include the use of storytellers to provide culturally relevant education and informing practitioners of new Medicare coverage for cognitive screening.

No association between colorectal cancer worry and screening uptake in Appalachian Ohio

BACKGROUND

Limited data are available on the association between colorectal cancer (CRC) worry and CRC screening uptake, particularly in rural and underserved populations where there is an excess burden of CRC.

METHODS

Between September 2009 and March 2010, we conducted a cross-sectional study among a randomly selected sample of Appalachian Ohio residents aged 51-75 years (n= 1084). We also reviewed their medical records. Multivariable-adjusted models examined the association between CRC worry and screening by medical record review, assessed effect modification by CRC worry and determined the correlates of higher CRC worry.

RESULTS

Approximately 50% of participants were adherent to CRC screening guidelines. There was no significant association between higher CRC worry and screening adherence [odds ratio (OR) = 1.32, 95% confidence interval (CI): 0.86-2.02]. CRC worry did not modify the association between any covariate and screening adherence. Participants who were unemployed/disabled (OR = 2.15, 95% CI: 1.34-3.45) and had higher CRC risk perception (OR = 3.49, 95% CI: 2.19-5.56) had higher odds of moderate-to-extreme worry.

CONCLUSIONS

These findings highlight the need for meaningful exploration of why higher CRC worry is not associated with adherence to CRC screening, particularly in rural, medically underserved populations. Development and implementation of interventions to increase CRC screening in such areas is a significant public health priority.