Journal of Community Health

, Volume 34, Issue 2, pp 79–89 | Cite as

Factors Influencing Choices for Colorectal Cancer Screening Among Previously Unscreened African and Caucasian Americans: Findings from a Triangulation Mixed Methods Investigation

  • Mack T. RuffinIV
  • John W. Creswell
  • Masahito Jimbo
  • Michael D. Fetters
Original Paper


We investigated factors that influence choice of colorectal cancer (CRC) screening test and assessed the most- and least-preferred options among fecal occult blood testing (FOBT), flexible sigmoidoscopy, colonoscopy, and double contrast barium enema among adults with varied race, gender, and geographic region demographics. Mixed methods data collection consisted of 10 focus group interviews and a survey of the 93 focus group participants. Participants were ≥50 years of age and reported not having been screened for colorectal cancer in the last ten years. Analyses examined differences by race, gender, and geographic location. Participants had modest knowledge about CRC and there were fewer correct answers to knowledge questions by African Americans. Participants recognized value of early detection, and identified health symptoms and their doctor’s recommendation as influential for obtaining CRC screening. They chose colonoscopy and FOBT as the most preferred tests, while barium enema was least preferred. The analysis revealed intra-group variations in preference, though there were no significant differences by race, gender, or location. Openness of discussing this sensitive topic, lack of knowledge about colorectal cancer and screening costs, and diversity of preferences expressed within study groups suggest the importance of patient-physician dialogue about colorectal cancer screening options. New approaches to promoting colorectal cancer screening need to explore methods to facilitate patients establishing and expressing preferences among the screening options.


Colorectal cancer screening Decision making Gender Race 



The authors wish to thank all the participants for their precious time and participation. Debra Power of Power Marketing provided invaluable assistance with data collection. The investigators additionally thank the sponsors who made this research possible. This research was supported by funding from the Michigan Department of Community Health and National Cancer Institute. Dr. Fetters’ participation was also made possible in part by the generous support of the Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Program and the Jitsukokai Medical Foundation. Dr. Ruffin’s participation was also made possible by support from the National Cancer Institute (K24-CA80846-010).


  1. 1.
    Jemal, A., Murray, T., Samuels, A., Ghafoor, A., Ward, E., & Thun, M. J. (2003). Cancer statistics, 2003. CA Cancer Journal for Clinicians, 53(1), 5–26.CrossRefGoogle Scholar
  2. 2.
    Donald, J. J., & Burhenne, H. J. (1993). Colorectal cancer. Can we lower the death rate in the 1990s? Canadian Field-Naturalist, 39, 107–114.Google Scholar
  3. 3.
    Burt, R. W., Bishop, D. T., Cannon, L. A., Dowdle, M. A., Lee, R. G., & Skolnick, M. H. (1985). Dominant inheritance of adenomatous colonic polyps and colorectal cancer. New England Journal of Medicine, 312(24), 1540–1544.PubMedGoogle Scholar
  4. 4.
    DeCosse, J. J., Tsioulias, G. J., & Jacobson, J. S. (1994). Colorectal cancer: Detection, treatment, and rehabilitation. CA Cancer Journal for Clinicians, 44(1), 27–42.CrossRefGoogle Scholar
  5. 5.
    Fuchs, C. S., Giovannucci, E. L., Colditz, G. A., Hunter, D. J., Speizer, F. E., & Willett, W. C. (1994). A prospective study of family history and the risk of colorectal cancer. New England Journal of Medicine, 331(25), 1669–1674.PubMedCrossRefGoogle Scholar
  6. 6.
    Ries, L., Eisner, M., Kosary, C., et al. (2003). SEER Cancer Statistics Review, 1975–2000. Bethesda, MD: National Cancer Institute.Google Scholar
  7. 7.
    Smith, R. A., Cokkinides, V., & Eyre, H. J. (2006). American Cancer Society guidelines for the early detection of cancer, 2006. CA Cancer Journal for Clinicians, 56(1), 11–25; quiz 49–50.Google Scholar
  8. 8.
    Behavioral Risk Factor Surveillance System Survey Data. (1997). Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.Google Scholar
  9. 9.
    Schwartz, L. M., Woloshin, S., Fowler, F. J., Jr., & Welch, H. G. (2004). Enthusiasm for cancer screening in the United States. Jama, 291(1), 71–78.PubMedCrossRefGoogle Scholar
  10. 10.
    Beeker, C., Kraft, J. M., Southwell, B. G., & Jorgensen, C. M. (2000). Colorectal cancer screening in older men and women: Qualitative research findings and implications for intervention. Journal of Community Health, 25(3), 263–278.PubMedCrossRefGoogle Scholar
  11. 11.
    Vernon, S. W. (1997). Participation in colorectal cancer screening: A review. Journal of the National Cancer Institute, 89(19), 1406–1422.PubMedCrossRefGoogle Scholar
  12. 12.
    Neilson, A. R., & Whynes, D. K. (1995). Determinants of persistent compliance with screening for colorectal cancer. Social Science & Medicine, 41(3), 365–374.CrossRefGoogle Scholar
  13. 13.
    Woolf, S. H. (2000). The best screening test for colorectal cancer—a personal choice. New England Journal of Medicine, 343(22), 1641–1643.PubMedCrossRefGoogle Scholar
  14. 14.
    Van Ness, M. M., Chobanian, S. J., Winters, C., Jr., Diehl, A. M., Esposito, R. L., & Cattau, E. L., Jr. (1987). A study of patient acceptance of double-contrast barium enema and colonoscopy. Which procedure is preferred by patients? Archives of Internal Medicine, 147(12), 2175–2176.PubMedCrossRefGoogle Scholar
  15. 15.
    Leard, L. E., Savides, T. J., & Ganiats, T. G. (1997). Patient preferences for colorectal cancer screening. Journal of Family Psychology, 45(3), 211–218.Google Scholar
  16. 16.
    Pignone, M., Bucholtz, D., & Harris, R. (1999). Patient preferences for colon cancer screening. Journal of General Internal Medicine, 14(7), 432–437.PubMedCrossRefGoogle Scholar
  17. 17.
    Fetters, M. D., Ivankova, N. V., Ruffin, M. T., Creswell, J. W., & Power, D. (2004). Developing a Web site in primary care. Family Medicine, 36(9), 651–659.PubMedGoogle Scholar
  18. 18.
    Ruffin, M. T. I., Fetters, M. D., & Jimbo, M. (2007). Preference-based electronic decision aid to promote colorectal cancer screening: Results of a randomized controlled trial. Preventive Medicine, 45, 267–273.PubMedCrossRefGoogle Scholar
  19. 19.
    Creswell, J. W., Fetters, M. D., & Ivankova, N. V. (2004). Designing a mixed methods study in primary care. Archives of Family Medicine, 2(1), 7–12.CrossRefGoogle Scholar
  20. 20.
    Creswell, J. (2003). Research design: Qualitative, quantitative, and mixed methods approaches. Thousand Oaks, CA: Sage.Google Scholar
  21. 21.
    Creswell, J. W., Plano Clark, V. L., Gutmann, M. L., & Hanson, W. E. (2002). Advanced mixed methods research designs. In A. Tashakkori & C. Teddlie (Eds.), Handbook of mixed methods in social and behavioral research (pp. 209–240). Thousand Oaks, CA: Sage Publications.Google Scholar
  22. 22.
    Creswell, J. W. (2001). Mixed method designs. In Educational research: Planning, conducting, and evaluating quantitative and qualitative research (1st ed., pp. 559–601). Upper Saddle River, NJ: Prentice Hall.Google Scholar
  23. 23.
    Creswell, J. W. (2003). Research design: Qualitative, quantitative, and mixed method approaches (2nd ed.). Thousand Oaks, CA: Sage Publications.Google Scholar
  24. 24.
    Teddlie, C., & Yu, F. (2007). Mixed methods sampling: A typology with examples (Vol. 1). Sage Publications.Google Scholar
  25. 25.
    Stange, K. C., Miller, W. L., Crabtree, B. F., O’Connor, P. J., & Zyzanski, S. J. (1994). Multimethod research: Approaches for integrating qualitative and quantitative methods. Journal of General Internal Medicine, 9(5), 278–282.PubMedCrossRefGoogle Scholar
  26. 26.
    Stange, K. C. (1996). One size doesn’t fit all. Multimethod research yields new insights into interventions to increase prevention in family practice. Journal of Family Practice, 43(4), 358–360.PubMedGoogle Scholar
  27. 27.
    Borkan, J. M. (2004). Mixed methods studies: A foundation for primary care research. Archives of Family Medicine, 2(1), 4–6.CrossRefGoogle Scholar
  28. 28.
    Power, D. (2001). Rewriting the rules: Recruiting for focus groups on colorectal cancer required a creative approach. Quirk’s Marketing Research Review, 15(11), 24–29.Google Scholar
  29. 29.
    Gregg, J., & Curry, R. H. (1994). Explanatory models for cancer among African-American women at two Atlanta neighborhood health centers: The implications for a cancer screening program. Social Science and Medicine, 39(4), 519–526.PubMedCrossRefGoogle Scholar
  30. 30.
    The Multicentre Australian Colorectal-neoplasia Screening (MACS) Group. (2006). A comparison of colorectal neoplasia screening tests: A multicentre community-based study of the impact of consumer choice. Medical Journal of Australia, 184(11), 546–550.Google Scholar
  31. 31.
    Elston, L. J., Divine, G., Moon, C., & Wiliams, L. (2006). Patient-physician colorectal cancer screening discussions and screening use. American Journal of Preventive Medicine, 31, 202–209.CrossRefGoogle Scholar
  32. 32.
    Salkeld, G. P., Young, J. M., & Solomon, M. J. (2006). Consumer choice and the National Bowel Cancer Screening Program. Medical Journal of Australia, 184(11), 541–542.PubMedGoogle Scholar
  33. 33.
    Segnan, N., Senore, C., Andreoni, B., et al. (2005). Randomized trial of different screening strategies for colorectal cancer: Patient response and detection rates. Journal of the National Cancer Institute, 97(5), 347–357.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Mack T. RuffinIV
    • 1
  • John W. Creswell
    • 2
  • Masahito Jimbo
    • 1
  • Michael D. Fetters
    • 1
  1. 1.Department of Family MedicineUniversity of Michigan Health SystemAnn ArborUSA
  2. 2.Department of Educational PsychologyUniversity of Nebraska-LincolnLincolnUSA

Personalised recommendations