The results of this study confirm that, regardless of ethnicity, colorectal cancer test use among men and women aged 50 years and older is low compared with other well-known cancer screening tests (4
). We estimate that 42% of Hispanic respondents reported having had the recommended colorectal cancer testing compared with 55% of non-Hispanic respondents. This finding of lower screening rates for Hispanic men and women than for non-Hispanic men and women is consistent with other studies (4
). Despite the relation of education, income, insurance, and a usual source of care to reported test use, adjusting for these factors does not fully account for the lower percentage of reported colorectal cancer test use among Hispanics. The adjusted analysis suggests that there are factors beyond health care access that prevent Hispanic men and women from receiving colorectal cancer tests.
This study also shows that Hispanic colorectal cancer test use differs among states. Colorado, California, and Texas had low percentages of Hispanic respondents reporting recommended test use and a greater disparity in colorectal cancer testing between Hispanic and non-Hispanic respondents than other states. In Massachusetts and New Jersey, test use among Hispanic men and women was higher than other states, and the disparity between Hispanic and non-Hispanic respondents was less. For states that had too few Hispanic BRFSS respondents for this analysis, colorectal test use and disparities are unknown. Often, Hispanic populations are analyzed as a single group, and these state-specific differences are not apparent. In addition to variation among states, there may be variation within each state as well. For example, Coughlin et al suggested that Hispanic women living in counties along the U.S.–Mexico border, regardless of their state of residence, were less likely to receive breast and cervical cancer screening than Hispanic women in nonborder counties (36
A factor that may account for state differences is the unique composition and culture of Hispanic subgroups in each state. In general, the Western states have an overall higher Hispanic proportion of the population and, in the Western United States, Hispanic individuals are more likely to be of Mexican descent than they are in the Northeast, which has Puerto Rican, South American, and Central American populations (23
). Hispanic subgroups could not be reflected in this analysis because BRFSS respondents who reported Hispanic ethnicity were not asked to report their subgroup. However, a recent study of the 2000 National Health Interview Survey (NHIS) analyzed cancer screening among Latino subgroups. Similar to our results, Sheinfeld Gorin and Heck found that FOBT use among Hispanic populations was low (14%) (37
). In the subgroup study, a higher percentage of Mexican and Puerto Rican respondents (15%–22%) reported FOBT use than Cuban, Dominican, Central American, or South American respondents (9%–11%) (37
). The same study showed endoscopy use within 5 years was highest among Cuban respondents (25%) and lowest among Dominicans, Central Americans, and South Americans (14%) (37
). Our finding that screening rates are lower in the Western states, where the predominate Hispanic subgroup is Mexican, contrasts with the NHIS findings that Mexican respondents were more likely to have an endoscopy within the past 5 years.
Understanding the individual influences of ethnicity, socioeconomic factors, and health care access on colorectal cancer test use is challenging. Previous studies cite the lack of a usual source of health care as the most consistent reason that Hispanic individuals are not being screened for colorectal and other cancers (38
) and also indicate that Hispanic men and women who receive other prevention services are more likely to be screened regularly (7
). This study demonstrated that men and women without a usual source of health care are less likely to receive recommended colorectal cancer testing. However, studies that have attempted to separate socioeconomic factors and health care access from ethnicity in different populations have had differing results. Two separate studies in Washington State and the San Francisco Bay area reported that fewer Hispanic men and women reported receiving colorectal cancer tests than non-Hispanic individuals, but the differences disappeared when they adjusted for health care access and education (24
). In contrast, a study in Texas reported that Hispanic women were less likely than non-Hispanic women to have ever received colorectal cancer screening by FOBT after adjusting for similar socioeconomic factors (41
). Our findings, which represent a larger, national population, support the latter study that Hispanic men and women remain less likely to be screened despite education, income, and health care access.
The BRFSS survey did not ask whether Hispanic respondents were born outside of the United States and, if so, time since immigration to the United States. Therefore, we were not able to assess the role of acculturation and language of BRFSS respondents in this study. Analyses of other national health behaviors surveys have shown acculturation to be associated with reduced colorectal cancer rates (7
). However, the effect of acculturation and language on screening for cervical and breast cancer has not always been shown to be as significant as access factors (8
There were several limitations to this study. Actual compliance with screening guidelines may be lower than percentages reported in this article. In our study, to fully capture the use of colonoscopy, having a lower endoscopy (which refers to both sigmoidoscopy and colonoscopy) "within 10 years" is considered to be within recommended screening intervals. With this definition, individuals who received sigmoidoscopy outside the recommended 5-year screening interval but within 10 years were considered compliant with screening guidelines. In addition, there was no way to differentiate between tests performed for screening purposes and tests performed for diagnostic purposes. Also, the use of a double-contrast barium enema, an acceptable but less often recommended choice (43
), was not available from the BRFSS survey. Comparisons of the rates in this report with other colorectal cancer screening studies must be made with caution because the time frame used for having received screening varies (29
); some studies have examined whether respondents have ever been tested, while other studies have asked respondents about tests administered within the time frame of screening guidelines.
Telephone survey data are limited by several factors. The response rate to the 2002 BRFSS was 58%. Low response rates may bias results by selecting a unique population that differs from the general population in health care access, use, and beliefs. Despite this low response rate, BRFSS data have been shown to be valid and reliable when compared with other national surveys, and bias in demographic characteristics of respondents in BRFSS data was not associated with response rate (44
). Additionally, the BRFSS excludes individuals who do not have household telephones and households that use a cellular phone exclusively. Low-income Hispanic households are less likely to own telephones than other low-income households (45
) and may be underrepresented. Some Hispanic respondents may have experienced linguistic barriers to understanding the survey questions or may have answered the questions without having been familiar with the colorectal cancer tests. The U.S. Census Bureau estimates that more than one third of the more than 21 million people aged 18 and older who speak Spanish at home reported that they spoke English "not well" or "not at all" (46
Responses were self-reported. The BRFSS questions did not ascertain whether the respondents had "ever heard of" the colorectal cancer test of interest. Despite previous studies, which have shown moderate and good concordance between self-reported colorectal cancer testing when validated with medical records (47
), cognitive testing has shown that respondents have difficulty comprehending colorectal cancer questions because they often do not recognize or understand particular colorectal cancer tests (49
). In this study, the responses were not validated, and respondents may not have been familiar with the test, may have felt a positive response was socially desirable, or both (29
Colorectal cancer test use is estimated to be lower among Hispanic than non-Hispanic adults. Differences in test use cannot be fully explained by education, income, and health care access because, after adjusting for these factors, Hispanic men and women remain less likely to report having had colorectal cancer testing at recommended intervals. Certain Western states had a large disparity between the percentages of Hispanic and non-Hispanic test use, whereas Northeastern states had similar percentages of use. Regardless of the differing degrees of disparities, increasing awareness of and access to colorectal cancer screening among Hispanics is needed. The differences in colorectal cancer test use among states call attention to the diverse health care experience of Hispanic adults in the United States. Future studies that explore the reasons for differences in test use among Hispanic communities may highlight effective programs and practices that encourage increased screening.