We found that viewing a Spanish-language decision aid for CRC was associated with increased screening-related knowledge, self-efficacy, and intent among Latinos with LEP, demonstrating that the information provided by the decision is accessible and compelling to this target population. These findings suggest that such a decision aid may be useful as an effective means of communicating this relatively complex message content about evidence-based cancer screening guidelines to a vulnerable population outside of an actual health care provider encounter.
In our telephone follow up survey, we also found that more than half of respondents had discussed CRC screening with a health care provider within four months of decision aid viewing. While our study lacked a comparison group against which to directly compare these figures, data from nationally representative surveys suggests that such discussions occur infrequently. In one survey, less than one third of Spanish speaking Latinos had discussed CRC screening with a physician within the past two years
]. Interventions such as this that can promote informed discussions between patients and health care providers about screening represent one promising means of addressing screening disparities since patient provider communication plays a key role in promoting CRC screening. Other studies have found that receiving a physician recommendation for CRC screening is an independent predictor of adherence to CRC screening guidelines in the general population,
] and suboptimal communication between patients and providers is likely one of several factors contributing to screening disparities in Latinos
In our follow-up survey, we also found that one in five respondents actually completed a screening test, with more than half completing a FOBT. Although this study lacked a direct comparison group, other evidence suggests it is unlikely that 19% of unscreened members of this target population would become current with CRC screening in any four month period in the absence of an intervention
]. Being current with CRC screening requires having had a colonoscopy anytime in the past 10
years (or FOBT within one year), and only about 33% of Spanish speaking Latinos are current with CRC screening
To our knowledge, this is the first study to describe patient-reported clinical communication and screening behavior after viewing a CRC screening decision aid in this population. This is also the first study to assess the extent to which individuals from this population who view such a CRC screening tool outside of a clinic setting subsequently discuss CRC screening with a health care provider or complete a recommended CRC screening test. Thus, our study complements and extends findings from a limited number of other studies of multimedia CRC screening educational interventions in Spanish speaking Latinos. One other study found that an educational video about CRC improved patient knowledge about CRC in Spanish speaking patients; however, that study did not ascertain subsequent clinical communication or screening behavior
]. Another promising study conducted in 2009 in an urban teaching hospital found that screening among Spanish speaking Latinos was more likely after receiving an intervention that included an educational video; however the study was small (31 patients received the intervention) and the researchers did not collect data from patients regarding their communication with physicians
This decision aid intervention addresses barriers to suboptimal patient-provider communication and low screening rates in limited English proficiency (LEP) Latino populations. These barriers include literacy issues, brief primary care patient-provider visits in which competing demands from other health issues result in lack of time to fully counsel patients about screening, inadequate numbers of Spanish speaking health care providers, and poor integration of trained interpreters into primary care service delivery
]. Nevertheless, the fact that only a minority of viewers actually completed a screening test suggests that important questions still remain about how to achieve high levels of adherence to screening guidelines and the role that multimedia patient education tools such as decisions aids have in promoting screening in these populations. Other studies of CRC screening decision aid interventions in English speaking patient populations have also found that while decision aids help patients become informed and activated regarding screening, screening rates remain low because other barriers interfere with actual completion of screening tests
]. These other barriers can include lack of access to insurance or financial assistance to cover the cost of colonoscopy (either as the primary screening test or to follow up an abnormal FOBT test), transportation challenges, lack of reliable telephone access, unpredictable work schedules, child care responsibilities, lack of understanding how to complete a home stool test, and difficulties with colonoscopy preparation procedures
]. Similarly, our findings suggest that although this decision aid can help patients become informed and activated regarding CRC screening and can promote clinical discussions, it is likely that additional interventions that address other barriers to CRC screening test completion are needed to effectively promote screening and eliminate screening disparities in vulnerable populations. Individualized one-on-one support such as patient navigation to help patients overcome other practical barriers as well as policies or programs that address access barriers to colonoscopy will likely be needed in order to eliminate disparities in CRC screening
Our study has some limitations. Because we used a one group (pre-post) design without a separate control group, we are unable to determine whether ongoing efforts by local or regional organizations to promote CRC screening influenced screening behavior among our participants. We are also unable to determine how a less intensive intervention, such as written information about CRC screening, would have affected outcomes in this population. However, the provision of written materials alone has had very little if any effect as a single intervention in studies conducted in English speaking populations,
] and given low educational and literacy levels in our target population, it is likely that providing written material alone would have little impact on communication or screening. Second, our follow-up survey outcomes relied on participant self-report and may be subject to recall bias. Third, our study used a convenience sample recruited from a single region and our results may not be generalizable to other LEP Latino communities regionally or nationally. Nevertheless, our observed effects were large and our sample included diverse Latino communities and countries of origin. Hence, we believe the decision aid should be tested in larger studies involving Latino populations and communities.