Colorectal cancer among Hispanics in the United States is a significant health problem and may be affected by low CRC screening rates.1
Physician recommendation has consistently been found to be the most important motivator of having a screening colonoscopy, yet some Hispanic patients do not follow their physician’s advice.2–6
The current study examined characteristics of Hispanics who did and did not follow their physician recommendation to complete CRC screening via colonoscopy in an effort to identify and understand different subject, provider and system factors that may modify adherence.
The findings of this study are critical because they frame the characteristics of a potentially identifiable group of Hispanics who may be less likely to adhere to their physician recommendation. Being able to anticipate which patients may be less likely to adhere to physician recommendation could enable healthcare providers to plan a more tailored approach of delivering the recommendation to that group.
We found that the largest differences between participants who followed their physician’s advice to undergo screening colonoscopy and those who did not were the characteristics of the study participants, specifically, age, place of birth, acculturation level, fear of undergoing the test, and language preference. Younger age, being born in the US and a preference to be interviewed in English were associated with less follow through on the recommendation for a CRC screening than older age, being born outside of the US and a preference to be interviewed in Spanish. Although an earlier study did not find a relationship between acculturation and screening colonoscopy behavior,46
in this study, participants who reported being more acculturated to US customs reported less adherence to CRC screening.
Fear of the colonoscopy procedure was another factor related to participants’ reported adherence to screening colonoscopy. Physicians should be aware that some Hispanics may not undergo colonoscopy because they are worried about possible cancer detection or about expected physical discomfort. Physicians or staff should inquire about specific fears and concerns and address them when recommending a screening colonoscopy.
The above findings appear to be related to each other and also appear to revolve around one main variable: the participants’ age. Younger Hispanics were more likely to be US born and consequently may be more likely to prefer English and to be more acculturated to US customs (p
0.001 for all three interactions). Possibly due to their age, younger people may be less likely to think about the possibility of being diagnosed with cancer and thus may be less inclined to undergo screening. This explanation is supported by the results of the multivariate analysis since age remained significant when all other covariates were controlled. Fear may also explain some of the obtained results. It might be that younger patients do not want to know or may be more afraid to find out that they have cancer and thus are less likely to undergo screening.
Both of these findings add more power to the main point of our study: we recognized a potentially identifiable sub-group of Hispanics who may be less likely to adhere to CRC screening recommendation. This sub-group consists of younger Hispanics who fear colonoscopy screening and/or are afraid to learn that they might have cancer. Therefore, more time needs to be spent with younger people to help them overcome their fear, address their concerns about colorectal cancer screening and encourage them to take the test.
Examining the relationship of having undergone colonoscopy or not with the characteristics of the healthcare provider resulted in encouraging findings. None of the physicians’ personal characteristics (race, ethnicity, gender, or spoken language) were associated with participants’ adherence to their physician recommendation. Furthermore, the source and setting of the physician recommendation was not associated with participants’ screening behaviors. No relationship was found between source of recommendation (whether usual healthcare provider, in a community or academic facility) and self-reported adherence. This suggests that if Hispanic patients receive a CRC screening recommendation from a physician, regardless of that physician’s race, gender, affiliation or spoken language, the likelihood that they would undergo screening colonoscopy is the same.
Healthcare system factors may play a less important role in determining participants’ completion of colonoscopy. This maybe influenced, however, by the fact that most of our participants had health insurance which presumably covered screening colonoscopy expenses. Studies that have explored system barriers to screening colonoscopy among Hispanics frequently cited either lack of insurance or lack of physician recommendation as main barriers,10,11
both of which are not applicable to this study.
Although our study has many strengths, there are some potential limitations. The results of this study may not apply to Hispanics who do not have health insurance and/or access to care. The dependent variable (screening colonoscopy) was indicated by participants’ self reports and may be subject to participants’ social desirability bias. Future research should include medical or billing record reviews. This study was also limited by its cross sectional design and causality could not be determined; longitudinal research could address this issue in the future. Finally, this study was conducted in only one community of Hispanics in NYC. Thus, the results may not generalize to Hispanics in different geographical locations and findings will need to be replicated to test their generalizability.
Physician recommendation has been found to be an important predictor of having a screening colonoscopy.12,19
Physician recommendation should be encouraged and efforts should be made to facilitate physician recommendation for screening colonoscopy. Participant factors associated with adherence to physician recommendation in Hispanics included being born outside the US, older age, and a preference to speak Spanish. This association remains strong regardless of the physician’s race, gender, or affiliation, even when that recommendation did not come from the patient’s regular provider. Additional time might need to be spent with younger US born Hispanics to address any possible fear or concerns and to encourage CRC screening; otherwise they may be less likely to complete their screening and thus may be vulnerable to develop CRC. If the same findings were replicated in nationwide studies, the new generation of Hispanics in the United States who may be less likely to follow their physician recommendations for screening colonoscopy could be more vulnerable to develop CRC than their immigrant parents.