Even in a primary care clinic population, CRC screening rates are still sub-optimal; only about half of respondents were up-to-date, which is comparable to national rates from a community-based sample [3
]. Even in this population where all individuals have access to care, many are not receiving CRC screening.
Individuals younger than 65 were more likely to be up-to-date. This is in contrast to a prior study in a multi-ethnic population where individuals aged 50–64 were less likely to be screened than older individuals [16
]. Latinos with more education were more likely to be up-to-date with endoscopic or any CRC screening, which comports with findings of prior studies [17
In our study, Latino women were more likely to be up-to-date with screening than were men, although in the California Health Interview survey, a community-based survey of a diverse population of participants, men were more likely to be tested than women [17
]. It may be that women who are seen in primary care clinic settings are more used to undergoing regular screening tests such as mammography and Pap smears and hence also receive FOBT.
Individuals who were less acculturated were more likely to be up-to-date with FOBT or any CRC screening. It is possible that those who are more acculturated may be opting more for endoscopic screening, which may reflect the public perspective that has been widespread in the media that COL is a “better” test. A prior study showed that low acculturation was associated with less endoscopic screening, but acculturation was not associated with FOBT screening [18
]. Alternatively, it is possible that those who are less acculturated are less likely to question their physician and have testing if it is recommended.
Although there was an association of two knowledge questions with CRC screening in univariate models, the overall knowledge score was only associated with endoscopic screening.
Physician factors affected the likelihood of receiving CRC screening. Individuals who had female physicians were more likely to receive screening than those with male physicians. Prior studies have shown that women physicians do more screening for female cancers such as breast and cervix [19
] as well as more counseling and immunization for and about gender-neutral recommendations. This suggests that women physicians may have an overall greater prevention orientation, rather than the screening being related to gender concordance between patient and physician [23
]. Although previous studies have suggested that physician–patient communication may be enhanced and or that physicians' decision making styles may be more participatory when physicians and patients belong to the same race [24
], this did not translate into an increase in screening in our study.
Surprisingly, language concordance was not associated with increased screening; in fact, patients whose physicians spoke Spanish were less likely to receive FOBT. In a prior study, language concordance positively influenced agreement about exercise but negatively influenced agreement about medication use [26
]. For CRC screening, it is possible that Spanish-speaking physicians would know of a possible cultural distaste for discussing these matters and they may not bring it up. Further studies on the relationship between language concordance and health outcomes are needed.
Our study had several limitations. Participants were drawn from a single geographic setting, with Latinos who were mostly Spanish speaking, and of low acculturation with little formal education, thus these results may not be representative of Latinos in different geographic settings or those who are more acculturated or more highly educated. Second, those who participated in the survey are probably those with more interest in screening and are thus more likely to be screened. It is likely that the overall rate of screening among all clinic patients is lower than that reported here. In addition, SCVMC is a site that already strives to provide culturally sensitive care; they provide many educational materials in Spanish and have a readily accessible interpreter service. Finally, causality cannot be inferred from a cross-sectional survey.
Despite the limitations, this study provides important information about the contribution of patient and physician factors to receipt of CRC screening in Latinos. Younger individuals, women, and those who were more educated are more likely to be up-to-date with screening. Even for this gender-neutral cancer, patients of female physicians receive more screening. Although younger individuals may be more likely to be up-to-date because of increased awareness and knowledge, because the risk of CRC increases with age, it is particularly important to ensure that older individuals receive screening. Future efforts should target older Latinos, males, and those who are less educated to ensure that all receive appropriate screening. Future research should also address ways in which all physicians, regardless of gender, ethnicity, or language concordance with their patients, can encourage Latino patients to undergo recommended CRC screening.