Abstract
Purpose
The incidence and mortality rates of colorectal cancer (CRC) remain consistently high in rural populations. Telehealth can improve screening uptake by overcoming individual and environmental disadvantages in rural communities. The present study aimed to characterize varying barriers to CRC screening between rural individuals with and without experience in using telehealth.
Method
The cross-sectional study surveyed 250 adults aged 45–75 residing in rural U.S. states of Alaska, Idaho, Oregon, and Washington from June to September 2022. The associations between CRC screening and four sets of individual and environmental factors specific to rural populations (i.e., demographic characteristics, accessibility, patient–provider factors, and psychological factors) were assessed among respondents with and without past telehealth adoption.
Result
Respondents with past telehealth use were more likely to screen if they were married, had a better health status, had experienced discrimination in health care, and had perceived susceptibility, screening efficacy, and cancer fear, but less likely to screen when they worried about privacy or had feelings of embarrassment, pain, and discomfort. Among respondents without past telehealth use, the odds of CRC screening decreased with busy schedules, travel burden, discrimination in health care, and lower perceived needs.
Conclusion
Rural individuals with and without previous telehealth experience face different barriers to CRC screening. The finding suggests the potential efficacy of telehealth in mitigating critical barriers to CRC screening associated with social, health care, and built environments of rural communities.
Similar content being viewed by others
Data availability
The data that support the findings of this study are available from the corresponding author upon request.
References
Siegel RL, Miller KD, Fuchs HE, Jemal A (2021) Cancer statistics, 2021. CA Cancer J Clin 71:7–33
Blake KD, Moss JL, Gaysynsky A, Srinivasan S, Croyle RT (2017) Making the case for investment in rural cancer control: an analysis of rural cancer incidence, mortality, and funding trends. Cancer Epidemiol Biomarkers Prev 26:992–997
US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC et al (2016) Screening for colorectal cancer: us preventive services task force recommendation statement. JAMA 315:2564–2575
Henley SJ, Anderson RN, Thomas CC, Massetti GM, Peaker B, Richardson LC (2017) Invasive cancer incidence, 2004–2013, and deaths, 2006–2015, in nonmetropolitan and metropolitan counties—United States. MMWR Surveill Summ 66:1
Wheeler SB, Davis MM (2017) “taking the bull by the horns”: four principles to align public health, primary care, and community efforts to improve rural cancer control: four principles in rural cancer control. J Rural Health 33:345–349
James WL (2014) All rural places are not created equal: revisiting the rural mortality penalty in the United States. Am J Public Health 104:2122–2129
Wang H, Roy S, Kim J, Farazi PA, Siahpush M, Su D (2019) Barriers of colorectal cancer screening in rural USA: a systematic review. Rural Remote Health 19:5181
Kirkwood MK, Hanley A, Bruinooge SS, Garrett-Mayer E, Levit LA, Schenkel C, Seid JE, Polite BN, Schilsky RL (2018) The state of oncology practice in America, 2018: results of the ASCO practice census survey. J Oncol Pract 14:e412–e420
Ambroggi M, Biasini C, Del Giovane C, Fornari F, Cavanna L (2015) Distance as a barrier to cancer diagnosis and treatment: review of the literature. Oncologist 20:1378–1385
Charlton M, Schlichting J, Chioreso C, Ward M, Vikas P (2015) Challenges of rural cancer care in the United States. Oncology 29:633–640
Wang H, Qiu F, Gregg A, Chen B, Kim J, Young L, Wan N, Chen L-W (2018) Barriers and facilitators of colorectal cancer screening for patients of rural accountable care organization clinics: a multilevel analysis. J Rural Health 34:202–212
Ryvicker M (2018) A conceptual framework for examining healthcare access and navigation: a behavioral-ecological perspective. Soc Theory Health 16:224–240
Rariy C, Truesdale L, Ahn ER, Gershenhorn BG, Easthon K, Garoutte B, Govorchin P, Schink JC (2021) Bridging the gap by providing access to oncology care to rural communities: a hybrid delivery model combining in-person visits with telehealth. J Clin Orthod 39:e18528–e18528
Golembiewski EH, Gravholt DL, Torres Roldan VD et al (2022) Rural patient experiences of accessing care for chronic conditions: a systematic review and thematic synthesis of qualitative studies. Ann Fam Med 20:266–272
Nodora JN, Gupta S, Howard N et al (2021) The COVID-19 Pandemic: identifying adaptive solutions for colorectal cancer screening in underserved communities. J Natl Cancer Inst 113:962–968
Dignan M, Shelton B, Slone SA, Tolle C, Mohammad S, Schoenberg N, Pearce K, Van Meter E, Ely G (2014) Effectiveness of a primary care practice intervention for increasing colorectal cancer screening in Appalachian Kentucky. Prev Med 58:70–74
Kruse-Diehr AJ, Dignan M, Cromo M, Carman AL, Rogers M, Gross D, Russell S (2022) Building cancer prevention and control research capacity in rural Appalachian Kentucky primary care clinics during COVID-19: development and adaptation of a multilevel colorectal cancer screening project. J Cancer Educ 37:1407–1413
López L, Green AR, Tan-McGrory A, King R, Betancourt JR (2011) Bridging the digital divide in health care: the role of health information technology in addressing racial and ethnic disparities. Jt Comm J Qual Patient Saf 37:437–445
Morris BB, Rossi B, Fuemmeler B (2022) The role of digital health technology in rural cancer care delivery: a systematic review. J Rural Health 38:493–511
DeGroff A, Sharma K, Satsangi A et al (2018) Increasing colorectal cancer screening in health care systems using evidence-based interventions. Prev Chronic Dis 15:E100
Kreuter MW, Holmes K, Alcaraz K, Kalesan B, Rath S, Richert M, McQueen A, Caito N, Robinson L, Clark EM (2010) Comparing narrative and informational videos to increase mammography in low-income African American women. Patient Educ Couns 81:S6–S14
Downey LH, Castellanos DC, Yadrick K, Threadgill P, Kennedy B, Strickland E, Prewitt TE, Bogle M (2010) Capacity building for health through community-based participatory nutrition intervention research in rural communities. Fam Commun Health 33:175–185
Leeman J, Calancie L, Hartman MA, Escoffery CT, Herrmann AK, Tague LE, Moore AA, Wilson KM, Schreiner M, Samuel-Hodge C (2015) What strategies are used to build practitioners’ capacity to implement community-based interventions and are they effective?: a systematic review. Implement Sci 10:80
Marks VA, Hsiang WR, Umer W, Haleem A, Kim D, Kunstman JW, Leapman MS, Schuster KM (2022) Access to telehealth services for colorectal cancer patients in the United States during the COVID-19 pandemic. Am J Surg 224:1267–1273
Sabesan S (2015) Specialist cancer care through telehealth models. Aust J Rural Health 23:19–23
Martin M (2021) Computer and Internet Use in the United States, 2018. In: U.S. Census Bureau. https://www.census.gov/content/dam/Census/library/publications/2021/acs/acs-49.pdf. 2023
Leigh JW, Gerber BS, Gans CP, Kansal MM, Kitsiou S (2022) Smartphone ownership and interest in mobile health technologies for self-care among patients with chronic heart failure: cross-sectional survey study. JMIR Cardio 6:e31982
Atske S, Perrin A (2021) Home broadband adoption, computer ownership vary by race, ethnicity in the U.S. In: Pew Research Center. https://www.pewresearch.org/fact-tank/2021/07/16/home-broadband-adoption-computer-ownership-vary-by-race-ethnicity-in-the-u-s/. Accessed 27 Mar 2023
US Preventive Services Task Force, Davidson KW, Barry MJ et al (2021) Screening for colorectal cancer: US preventive services task force recommendation statement. JAMA 325:1965–1977
Scott JD, Unruh KT, Catlin MC et al (2012) Project ECHO: a model for complex, chronic care in the Pacific Northwest region of the United States. J Telemed Telecare 18:481–484
Qualtrics (2019) Online Research Panels & Samples for Surveys. In: Qualtrics. https://www.qualtrics.com/research-services/online-sample/. Accessed 5 Sep 2023
USDA Economic Research Service (2020) Racial and ethnic minorities made up about 22 percent of the rural population in 2018, compared to 43 percent in urban areas. In: United States Department of Agriculture. https://www.ers.usda.gov/data-products/chart-gallery/gallery/chart-detail/?chartId=99538. Accessed 25 Feb 2023
Miller CA, Guidry JPD, Dahman B, Thomson MD (2020) A tale of two diverse qualtrics samples: information for online survey researchers. Cancer Epidemiol Biomarkers Prev 29:731–735
Boas TC, Christenson DP, Glick DM (2018) Recruiting large online samples in the United States and India: Facebook, Mechanical Turk, and Qualtrics. Political Science Research and Methods 1–19
Holt TP, Loraas TM (2019) Using qualtrics panels to source external auditors: a replication study. J Infrastruct Syst 33:29–41
Fennell K, Hull M, Jones M, Dollman J (2018) A comparison of barriers to accessing services for mental and physical health conditions in a sample of rural Australian adults. Rural Remote Health 18:4155
López-Cevallos DF, Harvey SM, Warren JT (2014) Medical mistrust, perceived discrimination, and satisfaction with health care among young-adult rural latinos. J Rural Health 30:344–351
Wilkins T, Gillies RA, Harbuck S, Garren J, Looney SW, Schade RR (2012) Racial disparities and barriers to colorectal cancer screening in rural areas. J Am Board Fam Med 25:308–317
Sibold HC, Thomson MC, Hianik R et al (2021) Videos improve patient understanding of chemotherapy terminology in a rural setting. Cancer 127:4015–4021
Reschovsky JD, Staiti AB (2005) Access and quality: does rural America lag behind? Health Aff 24:1128–1139
Shavers VL, Fagan P, Jones D, Klein WMP, Boyington J, Moten C, Rorie E (2012) The state of research on racial/ethnic discrimination in the receipt of health care. Am J Public Health 102:953–966
Wong PKK, Christie L, Johnston J, Bowling A, Freeman D, Joshua F, Bird P, Chia K, Bagga H (2014) How well do patients understand written instructions?: health literacy assessment in rural and urban rheumatology outpatients. Medicine 93:e129
Vernon SW, Myers RE, Tilley BC (1997) Development and Validation of an Instrument to Measure Factors Related to Colorectal Cancer Screening Adherence’. Cancer Epidemiol Biomarkers Prev 6:825–832
Jones RM, Devers KJ, Kuzel AJ, Woolf SH (2010) Patient-reported barriers to colorectal cancer screening: a mixed-methods analysis. Am J Prev Med 38:508–516
Powe BD (1995) Fatalism among elderly African Americans. Effects on colorectal cancer screening. Cancer Nurs 18:385–392
Miles A, Voorwinden S, Chapman S, Wardle J (2008) Psychologic predictors of cancer information avoidance among older adults: the role of cancer fear and fatalism. Cancer Epidemiol Biomarkers Prev 17:1872–1879
IBM (2022) IBM SPSS Statistics for Windows.
Chen J, Amaize A, Barath D (2021) Evaluating telehealth adoption and related barriers among hospitals located in rural and urban areas. J Rural Health 37:801–811
Balzora S, Issaka RB, Anyane-Yeboa A, Gray DM 2nd, May FP (2020) Impact of COVID-19 on colorectal cancer disparities and the way forward. Gastrointest Endosc 92:946–950
Born W, Engelman K, Greiner KA, Bhattacharya SB, Hall S, Hou Q, Ahluwalia JS (2009) Colorectal cancer screening, perceived discrimination, and low-income and trust in doctors: a survey of minority patients. BMC Public Health 9:363
Crawley LM, Ahn DK, Winkleby MA (2008) Perceived medical discrimination and cancer screening behaviors of racial and ethnic minority adults. Cancer Epidemiol Biomarkers Prev 17:1937–1944
Findling MTG, Blendon RJ, Benson JM, Miller C (2022) The unseen picture: issues with health care, discrimination, police and safety, and housing experienced by native American populations in rural America. J Rural Health 38:180–186
Waad A (2019) Caring for Our community: telehealth interventions as a promising practice for addressing population health disparities of LGBTQ+ communities in health care settings. Dela J Public Health 5:12–15
Whitehead J, Shaver J, Stephenson R (2016) Outness, Stigma, and primary health care utilization among rural LGBT populations. PLoS One 11:e0146139
Silva MA, Perez OFR, Añez LM, Paris M Jr (2021) Telehealth treatment engagement with Latinx populations during the COVID-19 pandemic. Lancet Psychiatry 8:176–178
Cooks EJ, Duke KA, Flood-Grady E et al (2022) Can virtual human clinicians help close the gap in colorectal cancer screening for rural adults in the United States? The influence of rural identity on perceptions of virtual human clinicians. Prev Med Rep 30:102034
Durant NH, Bartman B, Person SD, Collins F, Austin SB (2009) Patient provider communication about the health effects of obesity. Patient Educ Couns 75:53–57
Correa JB, Brandon KO, Meltzer LR, Hoehn HJ, Piñeiro B, Brandon TH, Simmons VN (2018) Electronic cigarette use among patients with cancer: reasons for use, beliefs, and patient-provider communication. Psychooncology 27:1757–1764
Nölke L, Mensing M, Krämer A, Hornberg C (2015) Sociodemographic and health-(care-)related characteristics of online health information seekers: a cross-sectional German study. BMC Public Health 15:31
McDonald YJ, Goldberg DW, Scarinci IC, Castle PE, Cuzick J, Robertson M, Wheeler CM (2017) Health service accessibility and risk in cervical cancer prevention: comparing rural versus nonrural residence in New Mexico. J Rural Health 33:382–392
Brewer NT, Chapman GB, Gibbons FX, Gerrard M, McCaul KD, Weinstein ND (2007) Meta-analysis of the relationship between risk perception and health behavior: the example of vaccination. Health Psychol 26:136–145
Antonovsky A (1987) Unraveling the mystery of health: How people manage stress and stay well. Jossey-Bass, San Francisco
Antonovsky A (1996) The salutogenic model as a theory to guide health promotion. Health Promot Int 11:11–18
Super S, Wagemakers MAE, Picavet HSJ, Verkooijen KT, Koelen MA (2016) Strengthening sense of coherence: opportunities for theory building in health promotion. Health Promot Int 31:869–878
Galletta M, Cherchi M, Cocco A et al (2019) Sense of coherence and physical health-related quality of life in Italian chronic patients: the mediating role of the mental component. BMJ Open 9:e030001
Allison BA, Rea S, Mikesell L, Perry MF (2022) Adolescent and parent perceptions of telehealth visits: a mixed-methods study. J Adolesc Health 70:403–413
Shachar C, Engel J, Elwyn G (2020) Implications for telehealth in a postpandemic future: regulatory and privacy issues. JAMA 323:2375–2376
Hall JL, McGraw D (2014) For telehealth to succeed, privacy and security risks must be identified and addressed. Health Aff 33:216–221
Peng W, McKinnon-Crowley J, Huang Q, Mao B (2023) Assessing Fear, embarrassment, and disgust in colonoscopy: the development of measurement instruments and psychometric evidence. Health Educ Behav. https://doi.org/10.1177/10901981231177075
Consedine NS, Ladwig I, Reddig MK, Broadbent EA (2011) The many faeces of colorectal cancer screening embarrassment: preliminary psychometric development and links to screening outcome. Br J Health Psychol 16:559–579
Wilkinson TA, Kottke MJ, Berlan ED (2020) Providing contraception for young people during a pandemic is essential health care. JAMA Pediatr 174:823–824
Spelten ER, Hardman RN, Pike KE, Yuen EYN, Wilson C (2021) Best practice in the implementation of telehealth-based supportive cancer care: using research evidence and discipline-based guidance. Patient Educ Couns 104:2682–2699
Cottrill CD, Brooke S, Mulley C, Nelson JD, Wright S (2020) Can multi-modal integration provide enhanced public transport service provision to address the needs of vulnerable populations? Res Transp Econ 83:100954
Arcury TA, Preisser JS, Gesler WM, Powers JM (2005) Access to transportation and health care utilization in a rural region. J Rural Health 21:31–38
Choi NG, DiNitto DM, Marti CN, Choi BY (2022) Telehealth use among older adults during COVID-19: associations with sociodemographic and health characteristics, technology device ownership, and technology learning. J Appl Gerontol 41:600–609
Sizer MA, Bhatta D, Acharya B, Paudel KP (2022) Determinants of telehealth service use among mental health patients: a case of rural louisiana. Int J Environ Res Public Health. https://doi.org/10.3390/ijerph19116930
Klee D, Pyne D, Kroll J, James W, Hirko KA (2023) Rural patient and provider perceptions of telehealth implemented during the COVID-19 pandemic. BMC Health Serv Res 23:981
Lyles CR, Fruchterman J, Youdelman M, Schillinger D (2017) Legal, practical, and ethical considerations for making online patient portals accessible for all. Am J Public Health 107:1608–1611
Zahnd WE, Murphy C, Knoll M et al (2021) The intersection of rural residence and minority race/ethnicity in cancer disparities in the United States. Int J Environ Res Public Health. https://doi.org/10.3390/ijerph18041384
Funding
This work was partially supported by Patrick Coolen Health Communication Entrepreneurs Endowment at Washington State University.
Author information
Authors and Affiliations
Contributions
All authors contributed to the conceptualization and design. WP: Conceptualization, Methodology, Formal analysis, Writing – original draft, Writing – review & editing, Funding acquisition. QH: Conceptualization, Methodology, Writing – original draft, Writing – review & editing. BM: Conceptualization, Methodology, Writing – original draft. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Corresponding author
Ethics declarations
Conflict of interest
The authors have no relevant financial or non-financial interests to disclose.
Ethical approval
IRB exemption was granted by Washington State University for this study.
Consent to participate
Informed consent was obtained from all individual participants included in the study.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Peng, W., Huang, Q. & Mao, B. Evaluating variations in the barriers to colorectal cancer screening associated with telehealth use in rural U.S. Pacific Northwest. Cancer Causes Control 35, 635–645 (2024). https://doi.org/10.1007/s10552-023-01819-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10552-023-01819-3