CRC has the second highest cancer-related mortality rate in the United States.1,2
Perhaps most importantly for African Americans, they have the highest incidence and mortality rates of CRC than any other ethnic group in the United States.1
Understanding the factors that may be associated with African American’s adoption of colonoscopy may be critically important not only because of their high CRC incidence and mortality rate, but because there is evidence to suggest that African Americans have a higher prevalence of right-sided polyps, which are detected by colonoscopy, but not detected by flexible sigmoidoscopy.12
This is one of the few studies to assess sociodemographic factors that may be associated with stage of readiness to undergo screening colonoscopy among African Americans at average risk for CRC. However, none of the sociodemographic factors we assessed (age, sex, marital status, education, employment, or income) were found to be associated with stage of readiness. Previous studies have shown that many of the demographic factors mentioned above are associated with an advanced cancer stage diagnosis and a worse prognosis.31
Furthermore, uninsured and Medicaid-insured patients have been found to be significantly more likely to present with advanced-stage cancer compared with privately insured patients.31
Thus the findings of this study support the need to assess screening adherence and provide education regarding CRC screening particularly among individuals from these socioeconomic backgrounds as they may be more vulnerable to non-adherence and in turn, worsened prognosis of the disease.
Many studies have found that minority race, lower educational levels, unemployment, and low-income status are associated with lower screening rates. However, few studies assessed stage of readiness in those African Americans who have agreed to participate in an intervention trial seeking to improve CRC screening. We recruited a population that was previously unscreened for CRC (by colonoscopy), insured, and had a PCP and staged them based on readiness to undergo screening. Forty-two percent were in one of the precontemplation stages for undergoing colonoscopy at baseline vs 58% in the contemplation or preparation stage. We evaluated the sociodemographic differences between the two groups to understand what may be important in moving patients out of each group and closer to completing cancer screening. We have learned that the process of planning educational interventions must consider where people are in the decision-making process. This is particularly important with regard to creating interventions for target subgroups. Therefore, in our study of patients with access to usual care, we have to incorporate other factors besides access to care into our educational materials designed to increase CRC screening. We must continue to tailor public health interventions to specific groups based on multiple factors such as sociodemographic, healthcare access, spiritual and psychosocial factors.
The lack of statistical difference in sociodemographic factors between stages in our study may be related to many factors. First, our population was mostly low-income, African Americans. Therefore, in many ways they were sociodemographically similar. Secondly, the numbers may have been too small to detect a difference between the two groups. Education was the sociodemographic variable most closely associated with stage of readiness to undergo CRC screening. Furthermore, there was a trend for more college educated patients to be in the preparation stage. Studies have shown that having less than a high school education is associated with underuse of CRC screening.32
The exact impact of lower education levels on under utilization is unclear. However, low education levels may confound the impact of income, health insurance status, and access to healthcare on colon cancer screening rates. In our study, patients have similar health insurance status and access to care. Therefore, we would not see this affect.
Importantly, our patient’s knowledge specific to colon cancer screening as well as recommendation for CRC screening differed significantly between the two stages. Patients in the contemplation or preparation stage were more likely to have heard of colonoscopy and had a physician recommend CRC screening. This reflects the importance of patients having usual care and physician recommendation in a patient’s decision to undergo screening. While receiving a physician recommendation has been identified by prior studies as one of the most important factors associated with CRC screening it is not the only factor.15,33
Therefore, although, we did not find a difference in sociodemographic factors in this analysis, we will analyze other factors that may affect stage of readiness in patients with a usual source of care as well as with their physician recommendation.
One of the limitations to this study is the relatively small sample size. One may argue that larger numbers might yield a statistical difference in sociodemographic factors between the two stages. However, the P value for all the factors with the exception of education is quite high suggesting that no difference would have been found despite larger numbers. Another limitation is that the study population was too sociodemographically homogenous to detect a difference. Perhaps had we had slightly higher income levels as well as differences in insurance status, a difference in stage of readiness could have been detected. On the other hand, this study contributes to our understanding the need and ways to increase CRC screening among African Americans who have disproportionate incidence and mortality, potentially related to lower levels of screening.
Despite not demonstrating a difference in sociodemographic factors between the pre-contemplation and contemplation stages, this study has several strengths. The population studied, low-income African Americans, are understudied with regard to factors that influence colon cancer screening. Indeed, low-income African Americans are significantly under-screened. As such, our patients are a representative sample of this group. The current study helps us to better understand the relevance of demographic as well as other factors that may be associated with completion of CRC screening. Certainly, we confirmed that physician recommendation plays a significant role in cancer screening. These data suggest the importance of including physician recommendation in interventions designed to increase CRC screening. In a relatively homogenous group such as ours, other factors such as spirituality, psychosocial factors such as fatalism may also have a significant impact on whether a patient decides to be screened. Using the educational materials we created, we will explore how these other factors affect stage of adoption in future analysis.