Advertisement

Journal of General Internal Medicine

, Volume 23, Issue 6, pp 834–840 | Cite as

Barriers to Screening Colonoscopy for Low-income Latino and White Patients in an Urban Community Health Center

  • Alexander R. Green
  • Angelleen Peters-Lewis
  • Sanja Percac-Lima
  • Joseph R. Betancourt
  • James M. Richter
  • Maria-Pamela R. Janairo
  • Gloria B. Gamba
  • Steven J. Atlas
Populations at Risk

Summary

Background

Colonoscopy is a screening modality for the early detection of colonic polyps and cancers but is underutilized, particularly among minorities.

Objective

To identify potential barriers to screening colonoscopy among low income Latino and white non-Latino patients in an urban community health center.

Design, participants, and approach

We conducted semistructured interviews with a convenience sample of patients 53 to 70 years old, eligible for colorectal cancer screening that spoke English or Spanish. Open-ended questions explored knowledge, beliefs, and experience with or reasons for not having screening colonoscopy. We performed content analysis of transcripts using established qualitative techniques.

Results

Of 40 participants recruited, 57% were women, 55% Latino, 20% had private health insurance, and 40% had a prior colonoscopy. Participants described a wide range of barriers categorized into 5 major themes: (1) System barriers including scheduling, financial, transportation, and language difficulties; (2) Fear of pain or complications of colonoscopy and fear of diagnosis (cancer); (3) Lack of desire or motivation, including “laziness” and “procrastination”; (4) Dissuasion by others influencing participants’ decision regarding colonoscopy; and (5) Lack of provider recommendation including not hearing about colonoscopy or not understanding the preparation instructions.

Conclusions

Understanding of the range of barriers to colorectal cancer screening can help develop multimodal interventions to increase colonoscopy rates for all patients including low-income Latinos. Interventions including systems improvements and navigator programs could address barriers by assisting patients with scheduling, insurance issues, and transportation and providing interpretation, education, emotional support, and motivational interviewing.

KEY WORDS

colon cancer screening colonoscopy Latino barriers patient navigation cultural competency qualitative 

Notes

Acknowledgments

The authors would like to thank Elyse Park for help with the qualitative methodology and Sarah Abernathy-Oo and Joan Quinlan for assisting in the early conceptualization of the study and ongoing support. This paper was presented at the 30th Annual Meeting of the Society of General Medicine in April 2007. This study was funded by Jane’s Trust and the Clinical Innovation Award: Translating Clinical Insights into Improved Patient Care at the Massachusetts General Hospital.

Conflict of Interest

None disclosed.

References

  1. 1.
    Greiner K, Born W, Nollen N, Ahluwalia J. Knowledge and perceptions of colorectal cancer screening among urban African Americans. J Gen Intern Med. 2005;20(11):977–83. Nov.PubMedCrossRefGoogle Scholar
  2. 2.
    Walsh J, Kaplan C, Nguyen B, Gildengorin G, McPhee S, Perez-Stable E. Barriers to colorectal cancer screening in Latino and Vietnamese Americans. Compared with non-Latino white Americans. J Gen Intern Med. 2004;19(2):156–66. Feb.PubMedCrossRefGoogle Scholar
  3. 3.
    Goodman M, Ogdie A, Kanamori M, Canar J, O’Malley A. Barriers and facilitators of colorectal cancer screening among Mid-Atlantic Latinos: focus group findings. Ethn Dis. 2006;16(1):255–61.PubMedGoogle Scholar
  4. 4.
    Shokar N, Vernon S, Weller S. Cancer and colorectal cancer: knowledge, beliefs, and screening preferences of a diverse patient population. Fam Med. 2005;37(5):341–7. May.PubMedGoogle Scholar
  5. 5.
    American Cancer Society. Cancer Facts and Figures 2006. Atlanta, GA: American Cancer Society; 2006.Google Scholar
  6. 6.
    U.S. Preventive Services Task Forces. The Guide to Clinical Preventive Services. Rockville, MD: Agency for Healthcare Research and Quality; 2006.Google Scholar
  7. 7.
    Lieberman DA, Weiss DG. One-time screening for colorectal cancer with combined fecal occult-blood testing and examination of the distal colon. N Engl J Med. 2001;345(8):555–60.PubMedCrossRefGoogle Scholar
  8. 8.
    Vijan S, Hwang E, Hofer T, Hayward R. Which colon cancer screening test? A comparison of costs, effectiveness, and compliance. Am J Med. 2001;111(8):593–601. Dec 1.PubMedCrossRefGoogle Scholar
  9. 9.
    Green P, Kelly B. Colorectal cancer knowledge, perceptions, and behaviors in African Americans. Cancer Nurs. 2004;27(3):206–15. May–Jun.PubMedCrossRefGoogle Scholar
  10. 10.
    Ries L, Eisner M, Kosary C, et al. SEER Cancer Statistics Review, 1975–2000. Bethesda, MD: National Cancer Institute; 2003.Google Scholar
  11. 11.
    Jemal A, Clegg L, Ward E, et al. Annual report to the nation on the status of cancer, 1975–2001, with a special feature regarding survival. Cancer. 2004;101(1):3–27. Jul 1.PubMedCrossRefGoogle Scholar
  12. 12.
    Hoffman-Goetz L, Breen N, Meissner H. The impact of social class on the use of cancer screening within three racial/ethnic groups in the United States. Ethn Dis. 1998;8(1):43–51.PubMedGoogle Scholar
  13. 13.
    Gilliland F, Hunt W, Key C. Trends in the survival of American Indian, Hispanic, and Non-Hispanic white cancer patients in New Mexico and Arizona, 1969–1994. Cancer. 1998;82(9):1769–83. May 1.PubMedCrossRefGoogle Scholar
  14. 14.
    Denberg T, Melhado T, Coombes J, et al. Predictors of nonadherence to screening colonoscopy. J Gen Intern Med. 2005;20(11):989–95. Nov.PubMedCrossRefGoogle Scholar
  15. 15.
    O’Malley AS, Beaton E, Yabroff KR, Abramson R, Mandelblatt J. Patient and provider barriers to colorectal cancer screening in the primary care safety-net. Am J Prev Med. 2004;39(1):56–63. July.CrossRefGoogle Scholar
  16. 16.
    Klabunde C, Schenck A, Davis W. Barriers to colorectal cancer screening among Medicare consumers. Am J Prev Med. 2006;30(4):313–9. Apr.PubMedCrossRefGoogle Scholar
  17. 17.
    Klabunde C, Vernon S, Nadel M, Breen N, Seeff L, Brown M. Barriers to colorectal cancer screening: a comparison of reports from primary care physicians and average-risk adults. Med Care. 2005;43(9):939–44. Sep.PubMedCrossRefGoogle Scholar
  18. 18.
    Brouse C, Basch C, Wolf R, Shmukler C. Barriers to colorectal cancer screening: an educational diagnosis. J Cancer Educ. 2004;19(3):170–3.PubMedCrossRefGoogle Scholar
  19. 19.
    Holmes-Rovner M, Williams GA, Hoppough S, Quillan L, Butler R, Given CW. Colorectal cancer screening barriers in persons with low income. Cancer Pract. 2002;10(5):240–7.PubMedCrossRefGoogle Scholar
  20. 20.
    Wolf R, Zybert P, Brouse C, et al. Knowledge, beliefs, and barriers relevant to colorectal cancer screening in an urban population: a pilot study. Fam Commun Health. 2001;24(3):34–47. Oct.Google Scholar
  21. 21.
    Lawsin C, Duhamel K, Weiss A, Rakowski W, Jandorf L. Colorectal cancer screening among low-income African Americans in East Harlem: a theoretical approach to understanding barriers and promoters to screening. J Urban Health. 2007;84(1):32–44.PubMedCrossRefGoogle Scholar
  22. 22.
    Lipkus I, Rimer B, Lyna P, Pradhan A, Conaway M, Woods-Powell C. Colorectal screening patterns and perceptions of risk among African-American users of a community health center. J Commun Health. 1996;21(6):409–27. Dec.CrossRefGoogle Scholar
  23. 23.
    Katz M, James A, Pignone M, et al. Colorectal cancer screening among African American church members: a qualitative and quantitative study of patient-provider communication. BMC Public Health. 2004;4:62. Dec 15.PubMedCrossRefGoogle Scholar
  24. 24.
    James A, Campbell M, Hudson M. Perceived barriers and benefits to colon cancer screening among African Americans in North Carolina: how does perception relate to screening behavior? Cancer Epidemiol Biomarker Prev. 2002;11(6):529–34. Jun.Google Scholar
  25. 25.
    Agrawal S, Bhupinderjit A, Bhutani M, et al. Colorectal cancer in African Americans. Am J Gastroenterol. 2005;100(3):515–23. Mar.PubMedCrossRefGoogle Scholar
  26. 26.
    Powe B, Finnie R, Ko J. Enhancing knowledge of colorectal cancer among African Americans: why are we waiting until age 50? Gastroenterol Nurs. 2006;29(1):42–9. Jan–Feb.PubMedCrossRefGoogle Scholar
  27. 27.
    Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Bryman A, Burgess R, eds. Analysing Qualitative Data. London: Routledge; 1993:173–94.Google Scholar
  28. 28.
    Yepes-Rios M, Reimann J, Talavera A, Ruiz de Esparza A, Talavera G. Colorectal cancer screening among Mexican Americans at a community clinic. Am J Prev Med. 2006;30(3):204–10. Mar.PubMedCrossRefGoogle Scholar
  29. 29.
    Polite B, Dignam J, Olopade O. Colorectal cancer model of health disparities: understanding mortality differences in minority populations. J Clin Oncol. 2006;24(14):2179–87. May 10.PubMedCrossRefGoogle Scholar
  30. 30.
    Coronado G, Thompson B. Rural Mexican American men’s attitudes and beliefs about cancer screening. J Cancer Educ. 2000;15(1):41–5.PubMedGoogle Scholar
  31. 31.
    Thompson B, Coronado G, Neuhouser M, Chen L. Colorectal carcinoma screening among Hispanics and non-Hispanic whites in a rural setting. Cancer. 2005;103(12):2491–8. Jun 15.PubMedCrossRefGoogle Scholar
  32. 32.
    Nash D, Azeez S, Vlahov D, Schori M. Evaluation of an intervention to increase screening colonoscopy in an urban public hospital setting. J Urban Health. 2006;83(2):231–43. Mar.PubMedCrossRefGoogle Scholar
  33. 33.
    Battaglia TA, Roloff K, Posner MA, Freund KM. Improving follow-up to abnormal breast cancer screening in an urban population. A patient navigation intervention. Cancer. 2007;109(2 Suppl):359–67. Jan 15.PubMedCrossRefGoogle Scholar
  34. 34.
    Steinberg ML, Fremont A, Khan DC, et al. Lay patient navigator program implementation for equal access to cancer care and clinical trials: essential steps and initial challenges. Cancer. 2006;107(11):2669–77. Dec 1.PubMedCrossRefGoogle Scholar
  35. 35.
    Freeman HP, Muth BJ, Kerner JF. Expanding access to cancer screening and clinical follow-up among the medically underserved. Cancer Pract. 1995;3(1):19–30. Jan–Feb.PubMedGoogle Scholar
  36. 36.
    Rahm AK, Sukhanova A, Ellis J, Mouchawar J. Increasing utilization of cancer genetic counseling services using a patient navigator model. J Genet Couns. 2007;16(2)171–7. Apr.PubMedCrossRefGoogle Scholar
  37. 37.
    Jandorf L, Gutierrez Y, Lopez J, Christie J, Itzkowitz S. Use of a patient navigator to increase colorectal cancer screening in an urban neighborhood health clinic. J Urban Health. 2005;82(2)216–24. Jun.PubMedGoogle Scholar
  38. 38.
    Beeker C, Kraft J, Southwell B, Jorgensen C. Colorectal cancer screening in older men and women: qualitative research findings and implications for intervention. J Commun Health. 2000;25(3)263–78. Jun.CrossRefGoogle Scholar
  39. 39.
    Price JH. Perceptions of colorectal cancer in a socioeconomically disadvantaged population. J Commun Health. 1993;18(6)347–62. Dec.CrossRefGoogle Scholar
  40. 40.
    Wong-Kim E, Sun A, DeMattos M. Assessing cancer beliefs in a Chinese immigrant community. Cancer Control. 2003;10(5 Suppl):22–8. Sep–Oct.PubMedGoogle Scholar
  41. 41.
    Morgan C, Park E, Cortes D. Beliefs, knowledge, and behavior about cancer among urban Hispanic women. J Natl Cancer Inst. 1995;18:57–63. (Monographs).Google Scholar
  42. 42.
    Powe B, Hamilton J, Brooks P. Perceptions of cancer fatalism and cancer knowledge: a comparison of older and younger African American women. J Psychosoc Oncol. 2006;24(4)1–13.PubMedCrossRefGoogle Scholar
  43. 43.
    Spurlock W, Cullins L. Cancer fatalism and breast cancer screening in African American women. ABNF J. 2006;17(1)38–43. Jan–Feb.PubMedGoogle Scholar
  44. 44.
    Greiner K, James A, Born W, et al. Predictors of fecal occult blood test (FOBT) completion among low-income adults. Prev Med. 2005;41(2)676–84. Aug.PubMedCrossRefGoogle Scholar
  45. 45.
    Powe B, Finnie R. Cancer fatalism: the state of the science. Cancer Nurs. 2003;26(6):454–65. (quiz 466–457), Dec.PubMedCrossRefGoogle Scholar
  46. 46.
    Powe B. Perceptions of cancer fatalism among African Americans: the influence of education, income, and cancer knowledge. J Natl Black Nurses Assoc. 1994;7(2):41–8. Fall–Winter.PubMedGoogle Scholar
  47. 47.
    Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract. 2005;55(513):305–12. Apr.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Alexander R. Green
    • 1
  • Angelleen Peters-Lewis
    • 1
    • 2
  • Sanja Percac-Lima
    • 1
    • 3
  • Joseph R. Betancourt
    • 1
  • James M. Richter
    • 2
    • 4
  • Maria-Pamela R. Janairo
    • 1
  • Gloria B. Gamba
    • 3
  • Steven J. Atlas
    • 1
    • 4
  1. 1.The Disparities Solutions Center at the Institute for Health PolicyMassachusetts General HospitalBostonUSA
  2. 2.Division of GastroenterologyMassachusetts General HospitalBostonUSA
  3. 3.Chelsea Health CenterMassachusetts General HospitalBostonUSA
  4. 4.Division of General MedicineMassachusetts General HospitalBostonUSA

Personalised recommendations