Barriers to colorectal cancer screening in Latino and Vietnamese Americans. Compared with non-Latino white Americans

Knowledge and belief of fecal occult blood screening: A systematic review

INTRODUCTION

Colorectal cancer (CRC) is associated with a high incidence and mortality rate. Fecal occult blood test (FOBT) is effective in the prevention of CRC.

OBJECTIVE

This study aimed to assess knowledge and beliefs regarding FOBT-based screening.

METHODS

This study used PubMed, Cochrane Library, MEDLINE Complete, and Web of Science to search for articles. Original full-text studies in English language focusing on knowledge and beliefs of FOBT screening were included.

RESULTS

A total of 32 articles were included. This study indicated that the population in most studies had inadequate knowledge and lacked beliefs toward FOBT-based screening. Most of the extracted studies showed that less than half of the participants had heard of FOBT-based screening. Six studies showed that less than 50% of participants had knowledge of FOBT age. Three studies found that less than 40% of participants were aware of the screening interval. Some participants perceived the benefits of FOBT-based screening, while others perceived many barriers to the test.

CONCLUSION

Participants' knowledge and belief in FOBT-based screening were insufficient. This review highlights the importance of educational programs to increase knowledge and beliefs regarding FOBT-based screening. It is important to include FOBT-based screening in the health care system to promote the secondary prevention of CRC.

Knowledge, Attitudes, and Beliefs About Colorectal Cancer Screening in Puerto Rico

The purpose of this study was to describe the psychosocial factors influencing participation in colorectal cancer screening (CRCS) among Puerto Rican men and women. We conducted seven focus groups in metropolitan and rural areas of Puerto Rico (PR) with men and women (using gender specific groups) aged 50 to 80 years (n = 51) who were non-adherent to CRC guidelines. The focus group guide included questions related to colorectal cancer (CRC) and CRC screening knowledge, attitudes, and beliefs. We analyzed data using a modified grounded theory approach to identify emergent themes. Focus groups revealed seven major themes that represented barriers to CRCS: (1) lack of CRC knowledge, (2) lack of knowledge about colorectal cancer screening tests as well as the required preparation, (3) embarrassment, (4) low perceived benefit of CRCS and sense of fatalism, (5) transportation (mostly among participants in rural areas), (6) lack of time, and (7) financial burden. All participants understood the benefits of CRCS once the procedure was explained. Additionally, participants reported a lack of provider recommendation for CRCS. In this group of Puerto Rican participants who were non-adherent to CRCS, there were misconceptions about CRC, screening tests available, and preparation and testing procedures. Participants' low levels of knowledge and negative attitudes concerning CRCS and low reported provider recommendation were important deterrents to screening. These findings suggest the need for educational efforts to increase knowledge and attitudes about CRCS and improved patient-provider communication to reduce missed opportunities to recommend.

A systematic review of ethnic disparities in the uptake of colorectal cancer screening

AIMS

Colorectal cancer (CRC) screening reduces mortality, but variation exists in uptake. Ethnicity is suggested to play a role; however, there is no high-level evidence to support this. We aim to clarify the impact of Ethnicity on CRC screening uptake and our barriers to its understanding.

METHODS

A systematic review to identify studies reporting on the participation of ethnic minorities in CRC screening worldwide was performed. MEDLINE, Embase, Scopus and Google Scholar databases up until 31 May 2019 were searched. Compliance with screening according to ethnic groups and screening modality was evaluated compared to the 'White' control group.

RESULTS

Twenty-two studies were included in the review reporting on 2,084,213 patients. Substantial variation in categorisation of ethnicities (40 sub-categories), screening modality studied and confounding factors accounted for was observed. 8/15 studies for 'Blacks', 10/13 for 'Hispanics', 2/2 for 'Asians' and 1/1 for 'South East Asians' suggest a less likely or significantly decreased compliance with screening for all screening modalities (p < .05) compared to 'Whites'. Interestingly 'Japanese', 'Vietnamese' and 'Filipino' groups consistently show no difference in the uptake of CRC screening compared to the 'White' majority.

CONCLUSION

This is the only systematic review on this topic. It highlights the inconsistency in screening uptake behaviour in different ethnic minority groups and identifies barriers like variation in ethnicity categorisation, screening modality and study design utilised to understanding the intricacies of this relationship. Further collaboration and action needs to be undertaken internationally to clarify and improve inequity in the uptake of screening.

Chinese Livery Drivers' Perspectives on Adapting a Community Health Worker Intervention to Facilitate Lung Cancer Screening

Chinese immigrant livery drivers with a smoking history are at high risk for lung cancer. A culturally adapted community health worker (CHW) program may be an effective approach to increase lung cancer screening (LCS) uptake in this underserved group. Five focus groups were conducted with 39 Chinese immigrant male livery drivers with a smoking history in New York City to assess their needs, priorities, and preferences regarding the proposed intervention. Transcripts were qualitatively analyzed using Atlas. ti. Focus group participants were uncertain about whether smoking was associated with cancer, unfamiliar with LCS, and reported numerous barriers to LCS uptake. Most believed a CHW program to facilitate LCS would be acceptable and feasible, if tailored to meet their needs. Our results have implications for improving access to early detection of lung cancer and preventive care (e.g., culturally appropriate smoking cessation and health education programs) for Chinese livery drivers.

Adaptation of a Mailed-FIT Kit and Patient Navigation Intervention to Increase Colorectal Cancer (CRC) Screening Among Spanish-Speaking Hispanic/Latino Patients

BACKGROUND

Hispanic/Latino populations experience significant barriers to colorectal cancer (CRC) screening. ProCRCScreen is a multicomponent CRC screening program that can help primary care clinics improve CRC screening rates, but it needs adaptation to better meet the health care needs of Spanish-speaking Hispanic/Latino populations.

METHODS

We conducted four focus groups with 22 Spanish-speaking Latino patients and used inductive qualitative content analysis to identify potential program adaptations.

RESULTS

We identified lack of social support for CRC screening and confusion about completing stool-based testing as important barriers to CRC screening. Participants recommended increased specificity of the fecal immunochemical test (FIT) instructions to increase the likelihood of successful test completion, especially for first-time screening. They also endorsed patient navigation for support in completing CRC screening.

DISCUSSION

We adapted the informational materials and workflows for the ProCRCScreen program. Future research to test the adapted program is needed.

Assessing Colorectal Cancer Screening Barriers in Rural Appalachia

OBJECTIVES

The age-appropriate colorectal cancer (CRC) screening rate in the rural Appalachian area is low compared with the national rate, which may account for the overall higher incidence of CRC in this area. The purpose of this study was to explore potential barriers to CRC screening in the West Virginia Appalachian area.

METHODS

A cross-sectional survey was designed to identify patient-reported barriers to CRC screening using the health belief model to assess their attitudes and behaviors. Autonomous paper-based surveys were randomly handed to individuals older than 50 years at various locations, including healthcare and nonhealthcare facilities. All of the responses were then categorized into two groups: the screened group and the unscreened group. Differences among both groups were statistically analyzed.

RESULTS

There were three main areas that significantly accounted for the discrepancies between the screened and unscreened groups: perceptions of discomfort from screening tests, psychological and behavior deterrents in CRC screening and diagnosis, and limited resources for accessing care, especially transportation. In particular, psychological and behavioral deterrents in CRC screening appeared to play a role in promoting aversion to CRC screening.

CONCLUSIONS

Lack of CRC screening awareness and knowledge may be responsible for fatalism regarding CRC and aversion to screening. Thus, multidisciplinary interventions that provide education about CRC screening, early intervention prognosis, and treatment options, as well as addressing systemic barriers to screening, such as assistance with scheduling, prep instructions, and transportation, can improve the screening rate in Appalachia and eventually lead to better outcomes through the early diagnosis of CRC.

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.

Race/ethnicity, sex and insurance disparities in colorectal cancer screening among individuals with and without cardiovascular disease

Colorectal cancer (CRC) and cardiovascular diseases (CVD) share several risk factors. We examined the relationships between CRC screening and CVD history by race/ethnicity and sex. Data from 15 states across the United States with high age-adjusted CVD rates from the 2012-2016 Behavioral Risk Factor Surveillance System were used to examine prevalence of self-reported screening for CRC among 179,276 adults ages 50-75 years with and without history of CVD. Multivariable logistic regression was used to evaluate the association between socio-demographics and CRC screening in the expansion and stable phases of the Affordable Care Act (ACA) era. Prevalence of CRC screening was high among those with history of CVD. After multivariable adjustment, Whites and Hispanics with CVD had 19% (95%[CI]: 1.13-1.26) and 50% (95%[CI]: 1.10-2.06) higher odds for CRC screening, respectively, versus those without CVD. Individuals in both sexes with CVD had higher odds for CRC screening compared those without CVD. Strikingly, the odds for CRC screening in Hispanics with history of CVD were 72% higher in the stable phase of the ACA era for the fully adjusted model. Whites and Hispanics with history of CVD are more likely to undergo CRC screening, perhaps due to greater exposure to the healthcare system due to CVD. This association was not observed in Blacks. Interventions are needed to improve CRC screening rates among Blacks, especially due to their well-documented higher risk of CVD.

Colorectal Cancer-Related Knowledge, Acculturation, and Healthy Lifestyle Behaviors Among Low-Income Vietnamese Americans in the Greater Philadelphia Metropolitan Area

Colorectal cancer (CRC) is the second and fourth most common cancer in Vietnamese American women and men, respectively. Recent research has highlighted the importance of modifiable lifestyle behaviors such as smoking, alcohol use, dietary behaviors, and physical activities in CRC prevention for the general population. However, it is not well understood how well Vietnamese Americans knew about CRC prevention and risk factors, and whether there were any disparities in knowledge within this vulnerable population. This study examined whether comprehensive measures of acculturation and knowledge of CRC risk are associated with different health behaviors, specifically physical activity, protective dietary behaviors, and risky dietary behaviors in Vietnamese Americans. We recruited 374 Vietnamese Americans aged 50 or above from community-based organizations in the Vietnamese American communities in the greater Philadelphia metropolitan area. Through a cross-sectional survey, we collected data on their knowledge of CRC prevention and risk factors, acculturation-related factors, and sociodemographic characteristics. We found limited knowledge of CRC prevention and risk factors, and suboptimal physical activity and healthy dietary behaviors in the Vietnamese Americans. We also found that higher levels of knowledge about CRC and risk factors were associated with less unhealthy diets but not with more protective diets or physical activity. Acculturation was not significantly associated with overall dietary behaviors in our study. Our findings addressed gaps in current literature concerning the impact of knowledge about CRC risk factors and acculturation on different dimensions of dietary behaviors as well as physical activity. Research and practical implications were discussed.

Barriers to flexible sigmoidoscopy colorectal cancer screening in low uptake socio-demographic groups: A systematic review

OBJECTIVE

To synthesise qualitative evidence related to barriers and facilitators of flexible sigmoidoscopy screening (FSS) intention and uptake, particularly within low socio-demographic uptake groups. FSS uptake is lower amongst women, lower socio-economic status (SES), and Asian ethnic groups within the United Kingdom (UK) and United States of America.

METHODS

A total of 12 168 articles were identified from searches of four databases: EMBASE, MEDLINE, PsycINFO and Web of Science. Eligibility criteria included: individuals eligible to attend FSS and empirical peer-reviewed studies that analysed qualitative data. The Critical Appraisal Skills Program tool evaluated the methodological quality of included studies, and thematic synthesis was used to analyse the data.

RESULTS

Ten qualitative studies met the inclusion criteria. Key barriers to FSS intention and uptake centred upon procedural anxieties. Women, including UK Asian women, reported shame and embarrassment, anticipated pain, perforation risk, and test preparation difficulties to elevate anxiety levels. Religious and cultural-influenced health beliefs amongst UK Asian groups were reported to inhibit FSS intention and uptake. Competing priorities, such as caring commitments, particularly impeded women's ability to attend certain FSS appointments. The review identified a knowledge gap concerning factors especially associated with FSS participation amongst lower SES groups.

CONCLUSIONS

Studies mostly focussed on barriers and facilitators of intention to participate in FSS, particularly within UK Asian groups. To determine the barriers associated with FSS uptake, and further understand how screening intention translates to behaviour, it is important that future qualitative research is equally directed towards factors associated with screening behaviour.

Factors Influencing Colorectal Cancer Screening Among Thais in the U.S

This study examined factors related to colorectal cancer (CRC) screening uptake among Thais in the United States. A total of 121 Thais between 50 and 75 years of age, who were married and living in southern California participated in the survey (mean age = 61 years). Out of all the participants, only 21% of the participants had fecal occult blood tests, 21% had sigmoidoscopy, and 45% had colonoscopy that were within the recommended period. Overall, 55% of participants met CRC screening adherence criteria. Participants who had had regular checkups in the previous 2 years without having any symptoms were 16 times more likely to have obtained CRC screening than their counterparts (OR 16.01, CI 3.75-68.75) in the multivariable logistic regression model. Other significant predictors of screening adherence included older age (OR 1.08, 95% CI 1.00-1.17), having lived in the U.S. 15 years or longer (OR 6.65, 95% CI 1.55-28.59), having had at least some college education (OR 3.74, 95% CI 1.23-11.37), and higher levels of perceived self-efficacy (OR 1.88, 95% CI 1.01-3.50) to obtain CRC screening. Targeted interventions for Thais who are less likely receive CRC screening could be effective in improving CRC screening. Interventions to improve the populations' awareness of the importance of preventive measures when they are not sick could be also effective.

PreView: a Randomized Trial of a Multi-site Intervention in Diverse Primary Care to Increase Rates of Age-Appropriate Cancer Screening

BACKGROUND

Women aged 50-70 should receive breast, cervical (until age 65), and colorectal cancer (CRC) screening; men aged 50-70 should receive CRC screening and should discuss prostate cancer screening (PSA). PreView, an interactive, individually tailored Video Doctor Plus Provider Alert Intervention, adresses all cancers for which average risk 50-70-year-old individuals are due for screening or screening discussion.

METHODS

We conducted a randomized controlled trial in 6 clinical sites. Participants were randomized to PreView or a video about healthy lifestyle. Intervention group participants completed PreView before their appointment and their clinicians received a "Provider Alert." Primary outcomes were receipt of mammography, Pap tests (with or without HPV testing), CRC screening (FIT in last year or colonoscopy in last 10 years), and PSA screening discussion. Additional outcomes included breast, cervical, and CRC screening discussion.

RESULTS

A total of 508 individuals participated, 257 in the control group and 251 in the intervention group. Screening rates were relatively high at baseline. Compared with baseline screening rates, there was no significant increase in mammography or Pap smear screening, and a nonsignificant increase (18% vs 12%) in CRC screening. Intervention participants reported a higher rate of PSA discussion than did control participants (58% vs 36%: P < 0.01). Similar increases were seen in discussions about mammography, cervical cancer, and CRC screening.

CONCLUSION

In clinics with relatively high overall screening rates at baseline, PreView did not result in significant increases in breast, cervical, or CRC screening. PreView led to an increase in PSA screening discussion. Clinician-patient discussion of all cancer screenings significantly increased, suggesting that interventions like PreView may be most useful when discussion of the pros and cons of screening is recommended and/or with patients reluctant to undergo screening. Future research should investigate PreView's impact on those who are hesitant or reluctant to undergo screening.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02264782.

Cancer Knowledge Among Mexican Immigrant Farmworkers in North Carolina

Latino farmworkers are exposed to a number of carcinogens in the workplace. Cancer survival rates for Latinos are below average. This paper describes Mexican immigrant farmworkers' knowledge of colorectal, breast, and testicular cancer, and compares farmworkers' cancer knowledge to that of other Mexican immigrants. Survey interviews for this study were conducted with 100 farmworkers and 100 non-farmworkers in 2015 in North Carolina as part of an ongoing community-based participatory research project. We found low to moderate levels of knowledge about colorectal, breast, and testicular cancer among farmworkers. Compared to non-farmworkers, farmworkers had similar levels of knowledge about breast and testicular cancer, but slightly lower knowledge about colorectal cancer (p = 0.0087). Few studies have used quantitative methods to assess farmworkers' knowledge of specific types of cancer. Our results demonstrate a need for increased dissemination of existing cancer education programs and further research to develop additional educational tools.

Factors Associated with Reported Colorectal Cancer Screening Among Lao-American Immigrants in Minnesota

Colorectal Cancer (CRC) is common in Lao Americans, but screening is suboptimal. To investigate CRC screening rates of Lao Americans in Minnesota, and how predisposing characteristics, enabling resources, and perceived need are associated with screening. We conducted a convenience-sample cross-sectional survey of 50-75-year-old Lao Americans, using step-wise multivariate logistic regression to identify factors associated with ever being screened. Of the 118 survey participants, 45% ever received CRC screening. In univariate regression, some enabling resources (having a primary care provider, higher self-efficacy in pursuing screening) and perceived needs (knowledge of who should be screened, higher number of chronic illnesses) were associated with screening. In multivariate logistic regression, the odds of ever being screened was 12.4 times higher for those with a primary care provider than for those without (p = 0.045). The findings reinforce a need for developing culturally tailored interventions focused on Lao-American immigrants to promote CRC screening.

Colorectal cancer screening: Understanding the health literacy needs of hispanic rural residents

Purpose

Hispanics residing in rural areas are among those who are least likely to be screened for colorectal cancer (CRC) and more likely to present with late stage CRC than other racial or ethnic groups. We conducted a pilot study utilizing a mixed-method approach to explore perceptions of CRC and CRC screening among Hispanic adults residing in South Texas rural communities and to identify health literacy needs associated with CRC screening uptake.

Methods

A convenience sample of 58 participants, aged 35–65, were recruited to complete questionnaires and participate in focus groups, ranging in size from 4 to 13 participants. Six focus groups were conducted across 3 adjacent rural counties. A semi-structured moderator's guide was designed to elicit discussion about participants' experiences, knowledge, and perceptions of CRC and CRC screening.

Findings

Lack of knowledge of CRC and CRC screening as cancer prevention was a common theme across focus groups. A majority, 59%, reported never been screened. Thirty-nine percent reported they had been screened for colon cancer and 5% reported they did not know if they had been screened. Participants with lower educational levels perceived themselves at high risk for developing CRC polyps, would not want to know if they had CRC, and if they did have CRC, would not want to know until the very end. Limited information about CRC and CRC screening, a lack of specialized providers, limited transportation assistance, and compromised personal privacy in small-town medical facilities were perceived to be barriers to CRC screening.

Conclusions

Low screening rates persist among rural Hispanics. Improving CRC screening literacy and addressing factors unique to rural Hispanics may be a beneficial strategy for reducing screening disparities in this at-risk population.

The impact of travel time on colorectal cancer stage at diagnosis in a privately insured population

BACKGROUND

Rural residents are less likely to receive screening for colorectal cancer (CRC) than urban residents. However, the mechanisms underlying this disparity, especially among people aged 50-64 years old with private health insurance, are not well understood. We examined the impact of travel time on stage at CRC diagnosis.

METHODS

This retrospective cohort study used data from the Blue Cross and Blue Shield of Nebraska. Members of this private insurance company aged 50-64 years, diagnosed with CRC during the period 2012-2016, and continuously enrolled in the insurance plan for at least 6 months prior to CRC diagnosis, were selected for this study. Using Google Maps, we estimated patients' travel time from their home ZIP code to the ZIP code of their colonoscopy provider. Using logistic regression, we analyzed the association between stage at CRC diagnosis, travel time, use of preventive services (i.e., check-ups or counseling to prevent or detect illness at an early stage) and patient characteristics.

RESULTS

A total of 307 subjects met the inclusion criteria. People who had not used preventive services 6 months prior to CRC diagnosis had 2.80 (95% CI, 1.00-7.90) times the odds of metastatic CRC compared to those who had used these services. No statistically significant association was found between travel time and metastatic CRC diagnosis (P = 0.99; 95% CI, 0.98-1.01).

CONCLUSIONS

The fact that 13% of the study population presented with metastatic CRC suggests some noncompliance with preventive services such as screening guidelines. To increase screening uptake and reduce metastatic cases, employers should offer incentives for their employees to make use of preventive services such as CRC screening.

Rapid review of factors associated with flexible sigmoidoscopy screening use

Flexible sigmoidoscopy (FS) screening has been shown to reduce colorectal cancer (CRC) incidence and mortality among screened adults. The aim of this review was to identify patient-related factors associated with the screening test's use. We searched PubMed for studies that examined the association between FS screening use and one or more factors. To determine the eligibility of studies, we first reviewed titles, then abstracts, and finally the full paper. We started with a narrow search, which we expanded successively (by adding 'OR' terms) until the number of new publications eligible after abstract review was <1% of the total number of publications. We then abstracted factors from eligible papers and reported the number of times each was found to be positively or negatively associated with FS screening use. We identified 42 papers, most of which reported studies conducted in the United States of America (n = 21, 50%) and the United Kingdom (n = 13, 31%). Across studies, a wide range of factors were examined (n = 123), almost half of which were found to be associated with FS screening use at least once (n = 60). Sociodemographic and health and lifestyle factors that were frequently positively associated with FS screening use included: male gender, higher socioeconomic status and a family history of CRC. Frequently positively associated psychosocial factors included low perceived barriers and high perceived benefits. Findings suggest that future research should focus on developing a theoretical framework of cancer screening behaviour to allow a greater level of consistency and specificity in measuring key constructs.

The Role of Access to a Regular Primary Care Physician in Mediating Immigration-Based Disparities in Colorectal Screening: Application of Multiple Mediation Methods

BACKGROUND

Colorectal cancer screening participation is lower among recent immigrants than among Canadian-born individuals. We assessed whether this screening disparity is mediated by access to regular primary care physicians (PCP).

METHODS

Pooling years 2003 to 2014 of the Canadian Community Health Survey, lifetime screening in respondents aged 50 to 75 years of age who immigrated in the previous 10 years (n = 1,067) was compared with Canadian-born respondents (N = 102,366). Regression- and inverse probability weighting-based methods were used to estimate the total effect (TE) and controlled direct effect (CDE) of recent immigration on never having received either a stool- or endoscopic-based screening test. The proportion of the TE that would be eliminated if all had a PCP was computed using these estimates [proportion eliminated (PE) = (TE - CDE)/(TE - 1)]. Analyses were stratified by visible minority status and adjusted for income, rurality, age, sex, marital status, education, and exposure to a provincially organized colorectal screening program.

RESULTS

The prevalence of never having been screened was 71% and 57% in visible minority and white recent immigrants, respectively, and 46% in white Canadian-born respondents. If all had regular PCPs, there would be no reduction in the screening inequality between white recent immigrants and Canadian-born (null PE), and the inequality between visible minority immigrants and white Canadian-born may increase by 6% to 13%.

CONCLUSIONS

Ensuring all have regular PCPs may lead to greater screening gains among Canadian-born than recent immigrants.

IMPACT

Improving access to PCPs may increase colorectal screening overall, but not reduce immigration-based disparities screening. Alternative interventions to reduce this disparity should be explored.

Alaska Native Patient and Provider Perspectives on the Multitarget Stool DNA Test Compared With Colonoscopy for Colorectal Cancer Screening

Objective: Alaska Native (AN) people have among the world's highest rate of colorectal cancer (CRC). We assessed perceptions of AN people and their health care providers of a new take-home multitarget stool DNA test (MT-sDNA; Cologuard) relative to colonoscopy. Methods: Cross-sectional surveys of AN people aged 40 to 75 years (mailed) and providers (online). Results: Participants included 1616 AN patients (19% response rate) and 87 providers (26% response rate; 57% AN people). Over half (58%) of patients preferred colonoscopy for CRC screening, while 36% preferred MT-sDNA. Unscreened patients were significantly more likely to state a preference for MT-sDNA than previously screened patients (42% vs 31%, P < .05) as were younger patients (<60 years old) compared with older patients (40% vs 30%, P < .05). Most providers thought that MT-sDNA would improve screening rates (69%), would recommend if available (79%), and be implementable (79%). Perceived barriers differed substantially between patients and providers in both type and magnitude. Leading colonoscopy barriers reported by patients were travel (44%) and bowel preparation (40%), while providers thought that fear of pain (92%) and invasiveness of the test (87%) were the primary barriers. For MT-sDNA, patients' belief that colonoscopy was better (56%) and not knowing how to do the test (40%) were primary barriers, while providers thought stool collection (67%) and having a stool sample in their home (63%) were leading barriers. Conclusions: This study found that MT-sDNA has potential acceptability among AN people and their health care providers. Both groups reported a willingness to use MT-sDNA and did not perceive major barriers to its use. This preference was especially true of unscreened and younger patients. The majority of providers indicated they would use MT-sDNA if available and that it would improve CRC screening rates. In this population, where colonoscopy access is limited, MT-sDNA has the potential to improve CRC screening adherence.

Anxiety Associated with Colonoscopy and Flexible Sigmoidoscopy: A Systematic Review

OBJECTIVES

Addressing procedure-related anxiety should improve adherence to colorectal cancer screening programs and diagnostic colonoscopy. We performed a systematic review to assess anxiety among individuals undergoing colonoscopy or flexible sigmoidoscopy (FS).

METHODS

We searched multiple electronic databases for studies evaluating anxiety associated with colonoscopy or FS published from 2005 to 2017. Two reviewers independently identified studies, extracted data, and assessed study quality. The main outcomes were the magnitude of pre-procedure anxiety, types of concerns, predictors of anxiety, and effectiveness of anxiety-lowering interventions in individuals undergoing lower endoscopy. The protocol was prospectively registered in PROSPERO.

RESULTS

Fifty-eight studies (24,490 patients) met the inclusion criteria. Patients undergoing colonoscopy had a higher mean level of anxiety than that previously reported in the general population, with some studies reporting more than 50% of patients having moderate-to-severe anxiety. Areas of anxiety-related concern included bowel preparation, difficulties with the procedure (embarrassment, pain, possible complications, and sedation), and concerns about diagnosis; including fear of being diagnosed with cancer. Female gender, higher baseline anxiety, functional abdominal pain, lower education, and lower income were associated with greater anxiety prior to colonoscopy. Providing higher-quality information before colonoscopy, particularly with a video, shows promise as a way of reducing pre-procedure anxiety but the studies to date are of low quality.

CONCLUSIONS

A large proportion of patients undergoing colonoscopy report anxiety before the procedure. Improvement in pre-procedure information delivery and evaluation of approaches to reduce anxiety is required, especially for those with predictors of pre-procedure anxiety.

Emotional predictors of bowel screening: the avoidance-promoting role of fear, embarrassment, and disgust

Background

Despite considerable efforts to address practical barriers, colorectal cancer screening numbers are often low. People do not always act rationally, and investigating emotions may offer insight into the avoidance of screening. The current work assessed whether fear, embarrassment, and disgust predicted colorectal cancer screening avoidance.

Methods

A community sample (N = 306) aged 45+ completed a questionnaire assessing colorectal cancer screening history and the extent that perceptions of cancer risk, colorectal cancer knowledge, doctor discussions, and a specifically developed scale, the Emotional Barriers to Bowel Screening (EBBS), were associated with previous screening behaviours and anticipated bowel health decision-making.

Results

Step-wise logistic regression models revealed that a decision to delay seeking healthcare in the hypothetical presence of bowel symptoms was less likely in people who had discussed risk with their doctor, whereas greater colorectal cancer knowledge and greater fear of a negative outcome predicted greater likelihood of delay. Having previously provided a faecal sample was predicted by discussions about risk with a doctor, older age, and greater embarrassment, whereas perceptions of lower risk predicted a lower likelihood. Likewise, greater insertion disgust predicted a lower likelihood of having had an invasive bowel screening test in the previous 5 years.

Conclusions

Alongside medical and demographic factors, fear, embarrassment and disgust are worthy of consideration in colorectal cancer screening. Understanding how specific emotions impact screening decisions and behaviour is an important direction for future work and has potential to inform screening development and communications in bowel health.

Barriers to Colorectal Cancer Screening in a Racially Diverse Population Served by a Safety-Net Clinic

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the US, yet screening rates remain low among minority populations. The purpose of the current study was to identify differences in the endorsement of barriers to CRC screening and to evaluate the association between provider recommendation and CRC screening adherence among Hispanic, Pacific Islander and White patients. This study utilized a cross sectional survey design to identify patient-reported barriers to CRC screening. Logistic regression was utilized to evaluate the association between patient demographic characteristics (race/ethnicity, gender, age), having received provider recommendation, and patient awareness of CRC screening. The study sample was comprised of a diverse population (N = 197); 48% Hispanic, 25% White, 10% Pacific Islander, 4% Black and 13% other races/ethnicity. The median age of participants was 58, yet fewer than 30% were up-to-date for CRC screening. The most commonly cited barriers included fear of test results (27.6%), inability to leave work for a CRC screening appointment (26.9%), being unaware of the need for colonoscopy (25.4%), and lack of provider recommendation for CRC screening (24.9%). Only 16.2% of participants reported that a provider had discussed CRC screening options with them. After adjusting for age and gender, Hispanic patients were less likely to report having had a provider discuss CRC screening options compared to White patients (OR = 0.24, 95% CI: 0.09-0.68, p < 0.05). The findings from this study indicate that patient's perceived screening barriers, lack of awareness and a lack of provider communication about CRC screening options may contribute to low screening rates among minority populations.

Colorectal Cancer Screening Initiation After Age 50 Years in an Organized Program

INTRODUCTION

Recent studies report racial disparities among individuals in organized colorectal cancer (CRC) programs; however, there is a paucity of information on CRC screening utilization by race/ethnicity among newly age-eligible adults in such programs.

METHODS

This was a retrospective cohort study among Kaiser Permanente Northern California enrollees who turned age 50 years between 2007 and 2012 (N=138,799) and were served by a systemwide outreach and facilitated in-reach screening program based primarily on mailed fecal immunochemical tests to screening-eligible people. Kaplan-Meier and Cox model analyses were used to estimate differences in receipt of CRC screening in 2015-2016.

RESULTS

Cumulative probabilities of CRC screening within 1 and 2 years of subjects' 50th birthday were 51% and 73%, respectively. Relative to non-Hispanic whites, the likelihood of completing any CRC screening was similar in blacks (hazard ratio, 0.98; 95% CI=0.96, 1.00); 5% lower in Hispanics (hazard ratio, 0.95; 95% CI=0.93, 0.96); and 13% higher in Asians (hazard ratio, 1.13; 95% CI=1.11, 1.15) in adjusted analyses. Fecal immunochemical testing was the most common screening modality, representing 86% of all screening initiations. Blacks and Hispanics had lower receipt of fecal immunochemical testing in adjusted analyses.

CONCLUSIONS

CRC screening uptake was high among newly screening-eligible adults in an organized CRC screening program, but Hispanics were less likely to initiate screening near age 50 years than non-Hispanic whites, suggesting that cultural and other individual-level barriers not addressed within the program likely contribute. Future studies examining the influences of culturally appropriate and targeted efforts for screening initiation are needed.

Assessing Colorectal Cancer Knowledge Among Puerto Rican Hispanics: Implications for Cancer Prevention and Control

In Puerto Rico, colorectal cancer (CRC) incidence and mortality rates are increasing. Moreover, adherence rates to CRC screening (52.2%) are still below the goals (70.5%) established by Healthy People 2020. Lack of knowledge is described as a significant barrier to adherence to CRC screening. The aim of this study was to assess CRC knowledge and screening rates among Puerto Rican Hispanics. Participants aged 40-85 years were recruited from the internal medicine outpatient clinics at the University of Puerto Rico. Demographic characteristics and knowledge about CRC, including risk factors and CRC screening tests, were obtained through face-to-face interviews. A mean CRC knowledge score was calculated based on correct responses to 13 validated questions. Mean knowledge scores were evaluated according to demographic characteristics using the Wilcoxon-Mann-Whitney test. A total of 101 participants were recruited with mean age of 63 (±10.6) years. Fifty-eight (58%) of participants were females, 59% reported ≥12 years of education, and 71% reported ever screening for CRC. The mean CRC knowledge score was significantly lower (p < 0.05) among participants with lower annual family income, those who had never received a recommendation for CRC screening by a healthcare provider, and those who had no history of CRC screening. Knowledge about CRC must be improved in Puerto Rico. Efforts must be made to promote and develop culturally appropriate CRC educational strategies. Future studies should focus on identifying other barriers and factors that may limit CRC screening in the Puerto Rican Hispanic population.

Promoting cancer screening among churchgoing Latinas: Fe en Acción/faith in action

Cancer screening rates among Latinas are generally low, reducing the likelihood of early cancer detection in this population. This article examines the effects of a community intervention (Fe en Acción/Faith in Action) led by community health workers (promotoras) on promoting breast, cervical and colorectal cancer screening among churchgoing Latinas. Sixteen churches were randomly assigned to a cancer screening or a physical activity intervention. We examined cancer knowledge, barriers to screening and self-reported mammography, clinical breast exam, Pap test, fecal occult blood test and sigmoidoscopy or colonoscopy at baseline and 12 months follow-up. Participants were 436 adult Latinas, with 16 promotoras conducting a cancer screening intervention at 8 out of 16 churches. The cancer screening intervention had a significant positive impact on self-reported mammography (OR = 4.64, 95% CI: 2.00-10.75) and breast exams in the last year (OR= 2.82, 95% CI: 1.41-5.57) and corresponding reductions in perceived (87.6%) barriers to breast cancer screening (P < .008). Cervical and colorectal cancer screening did not improve with the intervention. These findings suggest Fe en Acción church-based promotoras had a significant impact on promoting breast cancer screening among Latinas. Colon cancer screening promotion, however, remains a challenge.

Race/Ethnicity and Primary Language: Health Beliefs about Colorectal Cancer Screening in a Diverse, Low-Income Population

Colorectal cancer (CRC) is an important cause of cancer death in adults in the U.S.; screening is effective but underutilized, particularly among minorities. The purpose of this paper was to explore whether health belief model (HBM) constructs pertaining to CRC screening differ by race/ethnicity and primary language. Data were from the baseline surveys of 933 participants (93.5%) in a randomized trial promoting CRC screening in San Francisco. Composite scores for each construct were created from multiple items, dichotomized for analysis, and analyzed using multivariate logistic regression. Most participants were Asian (29.7%) or Hispanic (34.3%), and many were non-English speakers. Non-English speaking Hispanics (p<.001) and English-speaking Asians (p=.002) reported lower perceived susceptibility than non-Hispanic Whites (NHW). Non-English speaking Hispanics reported more and non-English speaking Asians fewer perceived barriers (psychological and structural) than NHW. Understanding how different populations think about CRC screening may be critical in promoting screening in diverse populations.

Is Colorectal Cancer A Western Disease? Role of Knowledge and Influence of Misconception on Colorectal Cancer Screening among Chinese and Korean Americans: A Mixed Methods Study

Background:

Chinese and Korean Americans have lower colorectal cancer (CRC) screening rates than other racial/ethnic groups, which may be explained by a low level of CRC knowledge and a high level of misconceptions. This study explores the role of knowledge in CRC screening among these groups.

Methods:

Chinese (N=59) and Korean (N=61) Americans older than 50 were recruited from the Washington D.C. Metropolitan area. They completed a detailed survey and participated in focus groups to discuss their knowledge on CRC and CRC screening. Seventeen physicians, community leaders, and patient navigators participated in key informant interviews. Using a mixed methods approach, data were analyzed quantitatively and qualitatively.

Results:

Participants lacked knowledge about CRC and CRC screening. More than half did not know that screening begins at age 50 and there are several types of tests available. More than 30% thought CRC screening was not necessary if there were no symptoms or there was nothing they could do to prevent CRC. Focus group findings suggested understanding about CRC was limited by an inadequate source of linguistically and culturally relevant health information. For example, many participants considered CRC a western condition mainly caused by unhealthy diet. This led to under-estimations about their susceptibility to CRC. Knowledge was positively associated with self-reported screening. Participants who had higher knowledge scores were more likely to report ever having had a colonoscopy and confidence in ability to have CRC screening.

Conclusions:

Mixed-methods analysis provides multi-faceted perspectives on CRC knowledge and its influence on screening. Study findings can help inform interventions to increase CRC screening among Chinese and Korean Americans.

Racial Disparities in Colorectal Carcinoma Incidence, Severity and Survival Times Over 10 Years: A Retrospective Single Center Study

BACKGROUND

Colorectal cancer (CRC) is the third leading cause of cancer-related deaths in the United States. Although studies have been performed on malignancy behavior in African Americans and Caucasians, scant data are present on other minority racial groups.

METHODS

A retrospective single center study was performed where 1,860 patient charts with a diagnosis of CRC from January 1, 2004 to December 31, 2014 were reviewed. Data collected on each patient included age, gender, ethnicity, primary site and histological stage at the time of diagnosis. Survival time over the course of 5 years was documented for patients from January 1, 2004 to December 31, 2009. Comparisons were made amongst different racial groups for the above mentioned factors.

RESULTS

Study population consisted of 27.09% African Americans, 65.61% Caucasians, 3.86% Hispanics, 0.54% South Asians, 1.03% Arabs, 0.54% Asians and 0.22% American Indians. Mean age of CRC presentation was found to be significantly different (P < 0.05) between the three largest racial groups: 71 years for Caucasians, 69 years for African Americans, and 61 years for Hispanics. African Americans (27.09%) and Hispanics (28.79%) presented predominantly at stage IV in comparison to other racial groups. Caucasians presented predominantly at stage III (24.84%). The rectum was the most common site of CRC across all racial groups with the exception of Asians, where sigmoid colon was the predominant site (30%). Adenocarcinoma remained the predominant cancer type in all groups. Hispanics had relatively higher incidence rate of carcinoid tumor (12.68%). Survival time analysis showed that Caucasians tend to have better survival probability over 5 years after initial diagnosis as compared to African Americans and Hispanic (P < 0.05).

CONCLUSION

There is lack of studies performed on minority racial groups in North America. Our study highlighted some important clinical differences of CRC presentation in different racial groups which are not well studied and can be used to formulate future multi-center studies to assess disease behavior.

Cancer Outcomes in Hispanics/Latinos in the United States: An Integrative Review and Conceptual Model of Determinants of Health

Cancer is the leading cause of death among Hispanics. Compared to non-Hispanic Whites, Hispanics are more likely to be diagnosed with advanced stages of disease and experience poor quality of life following a cancer diagnosis. Cancer outcomes are influenced by a confluence of social, cultural, behavioral and biological factors. Yet, much of the behavioral and psychosocial research in oncology has focused on non-Hispanic Whites, thus limiting our understanding of the potential web of factors that can influence cancer-related outcomes among Hispanics. Furthermore, features of Hispanic ethnicity and culture may influence and interact with, social, psychosocial, health care, disease-specific, and medical factors known to influence cancer-related outcomes, yet very few studies have integrated Hispanic cultural processes when addressing cancer-related outcomes for this ethnic group. Guided by the extant literature in oncology, Hispanic culture and health, and previously established models of determinants of minority health, we present a conceptual model that highlights the interplay of social, cultural, psychosocial, disease-specific, health care, and medical factors as determinants of cancer outcomes (morbidity, mortality, quality of life) and review key evidence of how features of Hispanic culture may influence cancer outcomes and contribute to the disparate outcomes observed in Hispanic cancer samples relative to non-Hispanic Whites. Finally, we conclude with a discussion of future research opportunities and existing challenges to researching oncology outcomes among Hispanics.

Determinants of variations in self-reported barriers to colonoscopy among uninsured patients in a primary care setting

Colorectal cancer (CRC) is the third most common type of cancer among both males and females in the United States and the second leading cause of cancer-related deaths. Although largely preventable through screening, early detection and removal of polyps, screening rates are considered sub-optimal. Perceived barriers to screening have been reported to influence screening rates. This paper examines variations in the extent to which uninsured patients identified barriers to CRC screening using colonoscopy based on race/ethnicity, educational attainment, age, gender, marital status and prior colonoscopy. Multivariate analyses showed that compared to Caucasians, African Americans had an increased likelihood of identifying lack of transportation as a barrier [odds ratio (OR) 2.68; 95 % confidence interval (CI) 1.35-5.32] while Hispanics were more likely to identify fear of finding cancer as a barrier (OR 2.09; 95 % CI 1.19-3.66). Compared to those with more than a high school education, there was increased likelihood of identifying lack of knowledge as a barrier among individuals with high school education (OR 3.51; 95 % CI 1.94-6.36) or less than a high school education (OR 2.16; 95 % CI 1.04-4.50). Our findings suggest that strategies aimed at increasing colonoscopy screening rates among underserved populations should take into consideration race/ethnicity, educational attainment, age, and prior colonoscopy experience when developing education and outreach plans to reduce barriers to colonoscopy.

Fe en Accion/Faith in Action: Design and implementation of a church-based randomized trial to promote physical activity and cancer screening among churchgoing Latinas

OBJECTIVES

To describe both conditions of a two-group randomized trial, one that promotes physical activity and one that promotes cancer screening, among churchgoing Latinas. The trial involves promotoras (community health workers) targeting multiple levels of the Ecological Model. This trial builds on formative and pilot research findings.

DESIGN

Sixteen churches were randomly assigned to either the physical activity intervention or cancer screening comparison condition (approximately 27 women per church). In both conditions, promotoras from each church intervened at the individual- (e.g., beliefs), interpersonal- (e.g., social support), and environmental- (e.g., park features and access to health care) levels to affect change on target behaviors.

MEASUREMENTS

The study's primary outcome is min/wk of moderate-to-vigorous physical activity (MVPA) at baseline and 12 and 24 months following implementation of intervention activities. We enrolled 436 Latinas (aged 18-65 years) who engaged in less than 250 min/wk of MVPA at baseline as assessed by accelerometer, attended church at least four times per month, lived near their church, and did not have a health condition that could prevent them from participating in physical activity. Participants were asked to complete measures assessing physical activity and cancer screening as well as their correlates at 12- and 24-months.

SUMMARY

Findings from the current study will address gaps in research by showing the long term effectiveness of multi-level faith-based interventions promoting physical activity and cancer screening among Latino communities.

Characterization of the Hispanic or latino population in health research: a systematic review

The size and diversity of the Hispanic population in the United States has dramatically increased, with vast implications for health research. We conducted a systematic review of the characterization of the Hispanic population in health research and described its implications. Relevant studies were identified by searches of PubMed, Embase Scopus, and Science/Social Sciences Citation Index from 2000 to 2011. 131 articles met criteria. 56% of the articles reported only "Hispanic" or "Latino" as the characteristic of the Hispanic research population while no other characteristics were reported. 29% of the articles reported language, 27% detailed country of origin and 2% provided the breakdown of race. There is great inconsistency in reported characteristics of Hispanics in health research. The lack of detailed characterization of this population ultimately creates roadblocks in translating evidence into practice when providing care to the large and increasingly diverse Hispanic population in the US.

Racial and Ethnic Disparities in Colonoscopic Examination of Individuals With a Family History of Colorectal Cancer

BACKGROUND & AIMS

Guidelines recommend that persons with a high-risk family history of colorectal cancer (CRC) undergo colonoscopy examinations every 5 years, starting when they are 40 years old. We investigated factors associated with colonoscopy screening of individuals with a family history of CRC, focusing on race and ethnicity.

METHODS

In a retrospective study, we analyzed data from the 2009 California Health Interview Survey on persons 40-80 years old with a first-degree relative (mother, father, sibling, or child) with CRC who had visited a physician within the past 5 years. Our study included an unweighted and population-weighted sample of 2539 and 870,214 individuals with a family history of CRC, respectively. We performed a survey-weighted logistic regression analysis to adjust for relevant demographic and socioeconomic variables and used estimates to calculate relative risks and 95% confidence intervals (CIs) for colonoscopy examination within the past 5 years.

RESULTS

In the weighted sample, 60.0% of subjects received a colonoscopy within the past 5 years. A physician recommendation for CRC screening increased the odds that an individual would undergo colonoscopy examination (relative risk, 1.89; 95% CI, 1.61-2.24). Latinos were 31% less likely to receive colonoscopies than whites (95% CI, 7%-55%). Among individuals 40-49 years old, blacks were 71% less likely to have had a colonoscopy than whites (95% CI, 13%-96%).

CONCLUSION

On the basis of an analysis of data from the California Health Interview Survey, less than two-thirds of individuals with a family history of CRC reported receiving guideline-recommended colonoscopy examinations within the past 5 years. We observed racial and ethnic disparities in colonoscopy screening of this high-risk group; Latinos and blacks were less likely to have had a colonoscopy than whites.

Estimation of the Adenoma Detection Rate From the Polyp Detection Rate by Using a Conversion Factor in a Predominantly Hispanic Population

BACKGROUND

Calculating the adenoma detection rate (ADR) is a complex process in contrast to the polyp detection rate (PDR) that can be easily calculated. The average adenoma to polyp detection rate quotient (APDRQ) was proposed as a conversion factor to estimate the ADR for individual endoscopists from the endoscopist's PDR. However, this conversion factor was not validated in different practice settings.

GOAL

To validate the use of the proposed conversion factor in a practice setting with a predominantly Hispanic population.

STUDY

We conducted a retrospective, cross-sectional study (December 2007 to November 2012) of screening colonoscopies at a university practice setting with an 86.9% Hispanic population. The actual ADR and PDR were calculated for all endoscopists. The weighted average of ADR to PDR ratio for each endoscopist was used to obtain APDRQ. The APDRQ was used as a conversion multiplier to estimate each endoscopist's ADR using the single endoscopist's PDR.

RESULTS

A total of 2148 screening colonoscopies were included. The average PDR for the whole group was 36.9% (range, 11% to 49%). The actual ADR was estimated as 25.5% (range, 11% to 37%). The average APDRQ for our group was 0.68. The estimated ADR was 25.48% (range, 8% to 33%). There was a high correlation between actual ADR and the estimated ADR (Pearson correlation=0.92).

CONCLUSIONS

In a practice setting with a predominantly Hispanic population, a conversion factor can be used to estimate ADR from PDR providing a high degree of correlation with the actual ADR.

Regret on choice of colorectal cancer screening modality was associated with poorer screening compliance: a 4-year prospective cohort study

Purpose

Very few studies examined the issue of regret on choosing colorectal cancer (CRC) screening tests. We evaluated the determinants of regret and tested the hypothesis that regret over screening choices was associated with poorer screening compliance.

Methods

A bowel cancer screening centre invited all Hong Kong citizens aged 50-70 years who were asymptomatic of CRC to participate in free-of-charge screening programmes. Upon attendance they attended health seminars on CRC and its screening, and were offered an option to choose yearly faecal immunochemical test (FIT) for up to four years vs. one direct colonoscopy. They were not allowed to switch the screening option after decision. A self-administered, four-item validated survey was used to assess whether they regretted over their choice (> 2 = regretful from a scale of 0 [no regret]-5 [extreme regret]). A binary logistic regression model evaluated if initial regret over their choice was associated with poorer programme compliance.

Results

From 4,341 screening participants who have chosen FIT or colonoscopy, 120 (2.8%) regretted over their decision and 1,029 (23.7%) were non-compliant with the screening programme. Younger subjects and people who felt pressure when making their decision were associated with regret. People who regretted their decision were 2.189 (95% C.I. 1.361-3.521, p = 0.001) times more likely to be non-compliant with the programme.

Conclusions

This study is the first to show that regret over the initial CRC screening choice was associated with later non-compliance. Screening participants who expressed regret over their choice should receive additional reminders to improve their programmatic compliance.

Physician counseling on colorectal cancer screening and receipt of screening among Latino patients

BACKGROUND

Latinos have lower rates of colorectal cancer (CRC) screening and later stage diagnosis than Whites, which may be partially explained by physician communication factors.

OBJECTIVE

We assessed associations between patient-reported physician counseling regarding CRC screening and receipt of CRC screening among Latino primary care patients.

DESIGN

This was a cross-sectional telephone survey.

PARTICIPANTS

The participants of this study were Latino primary care patients 50 years of age or older, with one or more visits during the preceding year.

MAIN MEASURES

We developed patient-reported measures to assess whether physicians provided explanations of CRC risks and tests, elicited patients' barriers to CRC screening, were responsive to patients' concerns about screening, and encouraged patients to be screened. Outcomes were patient reports of receipt of endoscopy (sigmoidoscopy or colonoscopy) and fecal occult blood test (FOBT) within recommended guidelines.

KEY RESULTS

Of 817 eligible patients contacted, 505 (62 %) completed the survey; mean age was 61 years (SD 8.4), 69 % were women, and 53 % had less than high school education. Forty-six percent reported obtaining endoscopy (with or without FOBT), 13 % reported FOBT only, and 41 % reported no CRC screening. In bivariate analyses, physician explanations, elicitation of barriers, responsiveness to concerns, and greater encouragement for screening were associated with receipt of endoscopy (p < 0.001), and explanations (p < 0.05) and encouragement (p < 0.001) were associated with FOBT. Adjusting for covariates, physician explanations (OR = 1.27; 95 % CI 1.03, 1.58) and greater physician encouragement (OR = 6.74; 95 % CI 3.57, 12.72) were associated with endoscopy; patients reporting quite a bit/a lot of physician encouragement had six times higher odds of obtaining the FOBT as those reporting none/a little encouragement (OR = 6.54; 95 % CI 2.76, 15.48).

CONCLUSIONS

Among primarily lower-socioeconomic status Latino patients, the degree to which patients perceived that physicians encouraged CRC screening was more strongly associated with screening than with providing risk information, eliciting barriers, and responding to their concerns about screening.

Knowledge, attitudes, and behaviours towards cancer screening in indigenous populations: a systematic review

Cancer mortality among indigenous peoples is increasing, but these populations commonly under use cancer-screening services. This systematic review explores knowledge, attitudes, and behaviours towards cancer screening among indigenous peoples worldwide. Searches of major bibliographic databases identified primary studies published in English up to March, 2014; of 33 eligible studies, three were cohort studies, 27 cross-sectional, and three case-control. Knowledge of and participation in screening was greater for breast cancer than for other cancers. Indigenous peoples tended to have less knowledge, less favourable attitudes, and a higher propensity to refuse screening than non-indigenous populations. The most common factors affecting knowledge, attitudes, and behaviours towards cancer screening included access to screening, knowledge about cancer and screening, educational attainment, perceived necessity of screening, and age. Greater understanding of knowledge, attitudes, and behaviours towards cancer screening in diverse indigenous cultures is needed so that culturally appropriate cancer prevention programmes can be provided.

Barriers and facilitators to colorectal cancer screening in Vietnamese Americans: a qualitative analysis

Vietnamese Americans are the fourth largest Asian ethnic group in the USA. Colorectal cancer (CRC) ranks as one of the most common cancers in Vietnamese Americans. However, CRC screening rates remain low among Vietnamese Americans, with 40 % of women and 60 % of men reporting never having a sigmoidoscopy, colonoscopy, or fecal occult blood test (FOBT). We partnered with a Federally Qualified Health Center (FQHC) in Seattle, WA, to conduct focus groups as part of a process evaluation. Using interpreters, we recruited and conducted three focus groups comprised of six women screened for CRC, six women not screened for CRC, and seven men screened for CRC, which made up a total of 19 FQHC patients of Vietnamese descent between 50 and 79 years old. Three team members analyzed transcripts using open coding and axial coding. Major themes were categorized into barriers and facilitators to CRC screening. Barriers include lack of health problems, having comorbidities, challenges with medical terminology, and concerns with the colonoscopy. Participants singled out the risk of perforation as a fear they have toward colonoscopy procedures. Facilitators include knowledge about CRC and CRC screening, access to sources of information and social networks, and physician recommendation. Our focus groups elicited information that adds to the literature and has not been previously captured through published surveys. Findings from this study can be used to develop more culturally appropriate CRC screening interventions and improve upon existing CRC screening programs for the Vietnamese American population.

Motivating underserved Vietnamese Americans to obtain colorectal cancer screening: evaluation of a culturally tailored DVD intervention

BACKGROUND

Colorectal cancer (CRC) is a leading cause of cancer death among Vietnamese Americans, yet screening remains underutilized. We investigated the effectiveness of a culturally tailored DVD intervention in promoting CRC screening among unscreened Vietnamese Americans age 50 and over.

MATERIALS AND METHODS

Using a community-based participatory research approach, we conducted a trial comparing twenty-eight subjects who received a mailed DVD in Vietnamese, with twenty-eight subjects who received a mailed brochure in Vietnamese. Subjects completed telephone surveys at baseline, One-month, and one-year. The primary outcome was receipt of screening. Secondary measures were participants' knowledge, attitudes, and beliefs about CRC screening. Two focus groups explored the intervention's acceptability and effectiveness.

RESULTS

At one year, CRC screening rates of 57.1% and 42.9% were observed in experimental and control group respectively (p=0.42), Subjects in both groups showed increased knowledge about CRC after one month. Focus group findings revealed that the DVD was an effective method of communicating information and would help promote screening.

CONCLUSIONS

The findings suggest that culturally tailored, linguistically appropriate content is more important than the type of media used. This relatively low intensity, low cost intervention utilizing a DVD can be another useful method for outreach to the often hard-to-reach unscreened population.

Acculturation and cancer screening among Asian Americans: role of health insurance and having a regular physician

Cancer is the leading cause of death among Asian Americans, but screening rates are significantly lower in Asians than in non-Hispanic Whites. This study examined associations between acculturation and three types of cancer screening (colorectal, cervical, and breast), focusing on the role of health insurance and having a regular physician. A cross-sectional study of 851 Chinese, Korean, and Vietnamese Americans was conducted in Maryland. Acculturation was measured using an abridged version of the Suinn-Lew Asian Self-Identity Acculturation Scale, acculturation clusters, language preference, length of residency in the US, and age at arrival. Age, health insurance, regular physician, gender, ethnicity, income, marital status, and health status were adjusted in the multivariate analysis. Logistic regression analysis showed that various measures of acculturation were positively associated with the odds of having all cancer screenings. Those lived for more than 20 years in the US were about 2-4 times [odds ratio (OR) and 95 % confidence interval (CI) colorectal: 2.41 (1.52-3.82); cervical: 1.79 (1.07-3.01); and breast: 2.11 (1.25-3.57)] more likely than those who lived for less than 10 years to have had cancer screening. When health insurance and having a regular physician were adjusted, the associations between length of residency and colorectal cancer [OR 1.72 (1.05-2.81)] was reduced and the association between length of residency and cervical and breast cancer became no longer significant. Findings from this study provide a robust and comprehensive picture of AA cancer screening behavior. They will provide helpful information on future target groups for promoting cancer screening.

Colorectal cancer among Koreans living in South Korea versus California: incidence, mortality, and screening rates

OBJECTIVES

This study compared trends in colorectal cancer (CRC) incidence and mortality rates among Koreans in South Korea and Korean Americans and non-Hispanic whites in California between 1999 and 2009, and examined CRC screening rates and socio-demographic correlates of CRC screening in the two Korean populations.

DESIGN

Age-standardized CRC incidence and mortality rates of Koreans in South Korea and Korean Americans and non-Hispanic whites in California for the years 1999-2009 were obtained from annual reports of cancer statistics and modeled using joinpoint regression. Using 2009 data from the Korean National Health and Nutrition Examination Survey and the California Health Interview Survey, we estimated and compared CRC screening rates and test modalities. We used multiple logistic regression to examine socio-demographic correlates of completion of CRC screening according to the guidelines among the two Korean populations.

RESULTS

CRC incidence and mortality rates among South Koreans increased during 1999-2009 but more slowly during the late 2000s. In California, CRC incidence increased among Korean American females but decreased among non-Hispanic whites. About 37% of South Koreans and 60% of Korean Americans reported completion of CRC screening according to guidelines in 2009. Among South Koreans, married status, higher income, and private health insurance were associated with CRC screening, adjusting for other factors. Among Korean Americans, having health insurance was associated with CRC screening.

CONCLUSION

Despite almost identical CRC screening guidelines in South Korea and the USA and substantially higher screening rates among Korean Americans as compared to South Koreans, disparities remain in both populations with respect to CRC statistics. Thus, efforts to promote primary and secondary prevention of CRC in both Korean populations are critically important in both countries.

Facilitating culture-centered communication between health care providers and veterans transitioning from military deployment to civilian life

OBJECTIVE

To describe returning veterans' transition experience from military to civilian life and to educate health care providers about culture-centered communication that promotes readjustment to civilian life.

METHODS

Qualitative, in-depth, semi-structured interviews with 17 male and 14 female Iraq and Afghanistan veterans were audio recorded, transcribed verbatim, and analyzed using Grounded Practical Theory.

RESULTS

Veterans described disorientation when returning to civilian life after deployment. Veterans' experiences resulted from an underlying tension between military and civilian identities consistent with reverse culture shock. Participants described challenges and strategies for managing readjustment stress across three domains: intrapersonal, professional/educational, and interpersonal.

CONCLUSIONS

To provide patient-centered care to returning Iraq and Afghanistan veterans, health care providers must be attuned to medical, psychological, and social challenges of the readjustment experience, including reverse culture shock. Culture-centered communication may help veterans integrate positive aspects of military and civilian identities, which may promote full reintegration into civilian life.

PRACTICE IMPLICATIONS

Health care providers may promote culture-centered interactions by asking veterans to reflect about their readjustment experiences. By actively eliciting challenges and helping veterans' to identify possible solutions, health care providers may help veterans integrate military and civilian identities through an increased therapeutic alliance and social support throughout the readjustment process.

A colorectal cancer screening program in an underserved, ethnically diverse population in Chicago, IL

The purpose of this project was to describe the structure and outcomes of a colorectal cancer screening program at CommunityHealth, the largest free health clinic in Illinois. We conducted a retrospective observational study using administrative clinical data from 2006 to 2011. A total of 4,026 patients were eligible for colorectal cancer screening of which 2,418 (60.0 %) completed fecal occult blood testing (FOBT). Subsequently, 1,657 patients had negative FOBT results and 1,365 patients underwent on-site flexible sigmoidoscopy. Over 90 % of patients had never had a prior screening examination. A majority of patients were female (61.7 %) and self-identified as Mexican (37.5 %) or Polish (28.2 %). A total of 203 biopsies were performed resulting in the detection of 69 adenomas (5.0 %) and 1 adenocarcinoma (0.1 %). A comprehensive colorectal cancer screening program was successfully implemented in a large community health center serving a population of diverse racial and ethnic backgrounds without prior access to screening. This program could serve as model for colorectal cancer screening in diverse, low resource communities.

Colorectal cancer screening among Asian Americans

OBJECTIVES

Colorectal cancer (CRC) is the most commonly diagnosed cancer for all US populations including Asian Americans. CRC screening has considerable benefits to prevent CRC and reduce mortality. The purpose of this article was to review the published literature on rates of colorectal cancer screening and factors associated with colorectal cancer screening practice among Asian Americans.

METHODS

Through searching electronic reference databases from 2000 to 2013, 30 articles were found on Chinese, Filipino, Japanese, Korean, and Vietnamese Americans.

FINDINGS

Asian Americans had significantly low rates for CRC screening; Korean Americans reported the lowest rates, while higher screening rates were found among Japanese Americans. Older age, longer length of stay in the US, and having a physician's recommendation were the most common facilitators to receiving screening. The common inhibiting factors were financial issues, employment status, and worries/fears about the procedure.

CONCLUSIONS

Despite a number of Asian Americans being vulnerable to CRC, individual Asian subgroups were underserved with CRC screening and intervention. Further studies should focus on each individual Asian subgroup and culturally proficient CRC screening intervention programs should be developed for each.

Mammography screening among Mexican, Central-American, and South-American women

Cancer and cancer screening disparities exist across Latino subgroups; however the reasons for these disparities are not fully known. This study examines (1) mammography screening among Latinas born in Mexico, Central-America and South-America and (2) the impact of birthplace and acculturation on mammography screening. Data were derived from the California Health Interview Survey 2007. Analyses included 1,675 Latina women 40 years of age and older. Multivariate logistic regression examined predictors of mammography screening. Mexican and Central-American women were less likely to report ever receiving a mammogram while Mexican women were less likely to report a recent mammogram. Low-acculturated women were less likely to report ever receiving a mammogram and less likely to report recent mammography. Different screening patterns across Latina subgroups were observed. Differences in screening patterns and the factors associated with screening highlight the need for unique intervention strategies tailored specifically to Latinas.

PRE-VIEW: Development and Pilot Testing of An Interactive Video Doctor Plus Provider Alert to Increase Cancer Screening

BACKGROUND

Interventions to increase recommended cancer screening tests and discussions are needed.

METHODS

We developed PRE-VIEW (The PREventive VIdeo Education in Waiting Rooms Program), a multimedia cancer prevention intervention for primary care clinics based on the Transtheoretical Model of Behavior Change We pilot tested PRE-VIEW An Interactive Video Doctor plus Provider Alert for feasibility and acceptability in primary care clinic settings in the San Francisco Bay Area, California in 2009-2010.

RESULTS

Eighty participants (33 men and 47 women; more than half non-white) at 5 primary care clinics were included. After PRE-VIEW, 87% of women were definitely interested in mammography when due and 77% were definitely interested in a Pap test. 73% of participants were definitely interested in colorectal cancer screening when due, and 79% of men were definitely interested in a discussion about the PSA test. The majority indicated that they received an appropriate amount of information from PRE-VIEW and that the information presented helped them decide whether or not to be screened.

CONCLUSIONS

PRE-VIEW was well received and accepted and potentially provides an innovative and practical way to support physicians' efforts to increase cancer screening.