In Focus

Underserved populations and colorectal cancer screening: Patient perceptions of barriers to care and effective interventions


 


Dr. Sandra Quezada, University of Maryland School of Medicine, Baltimore

Dr. Sandra Quezada

Another often overlooked group, are individuals with physical or cognitive disabilities. In this group, screening rates range from 49% to 65%.10

Finally, while information is available for many health care conditions and disparities faced by various ethnic groups, there are few CRC screening data for the LGBTQ community. Perhaps amplifying this problem is the existence of conflicting data in this population, with some studies suggesting there is no difference in CRC risk across groups in the LGBTQ community and others suggesting an increased risk.11,12 Notably, sexual orientation has been identified as a positive predictor of CRC screening in gay and bisexual men – CRC screening rates are higher in these groups, compared with heterosexual men.13 In contrast, no such difference has been found between homosexual and heterosexual women.14

Dr. Lukejohn W. Day, University of California at San Francisco

Dr. Lukejohn W. Day

What are the barriers?

Several common themes contribute to disparities in CRC screening among minority groups, including psychosocial/cultural, socioeconomic, provider-specific, and insurance-related factors. Some patient-related barriers include issues of illiteracy, having poor health literacy or English proficiency, having only grade school education,15,16 cultural misconceptions, transportation issues, difficulties affording copayments or deductibles, and a lack of follow-up for scheduled appointments and exams.17-20 Poor health literacy has a profound effect on exam perceptions, fear of test results, and compliance with scheduling tests and bowel preparation instructions21-25; it also affects one’s understanding of the importance of CRC screening, the recommended screening age, and the available choice of screening tests.

Dr. Rotonya M. Carr, University of Pennsylvania, Philadelphia

Dr. Rotonya M. Carr

Even when some apparent barriers are mitigated, disparities in CRC screening remain. For example, even among the insured and among Medicare beneficiaries, screening rates and adequate follow-up rates after abnormal findings remain lower among AAs and those of low socioeconomic status than they are among whites.26-28 At least part of this paradox results from the presence of unmeasured cultural/belief systems that affect CRC screening uptake. Some of these factors include fear and/or denial of CRC diagnoses, mistrust of the health care system, and reluctance to undergo medical treatment and surgery.16,29 AAs are also less likely to be aware of a family history of CRC and to discuss personal and/or family history of CRC or polyps, which can thereby hinder the identification of high-risk individuals who would benefit from early screening.15,30

Dr. Esi Lamouse-Smith, Janssen Pharnmaceuticals Research and Development, LLC, Spring House, Penn.

Dr. Esi Lamouse-Smith

The deeply rooted sense of fatalism also plays a crucial role and has been cited for many minority and immigrant populations. Fatalism leads patients to view a diagnosis of cancer as a matter of “fate” or “God’s will,” and therefore, it is to be endured.23,31 Similarly, in a qualitative study of 44 Somali men living in St. Paul and Minneapolis, believing cancer was more common in whites, believing they were protected from cancer by God, fearing a cancer diagnosis, and fearing ostracism from their community were reported as barriers to cancer screening.32

Dr. Miguel Malespin, University of Florida Health, Jacksonville, Fla.

Dr. Miguel Malespin

Perceptions about CRC screening methods in Latino populations also have a tremendous influence and can include fear, stigma of sexual prejudice, embarrassment of being exposed during the exam, worries about humiliation in a male sense of masculinity, a lack of trust in the medical professionals, a sense of being a “guinea pig” for physicians, concerns about health care racism, and expectations of pain.33-37 Studies have reported that immigrants are afraid to seek health care because of the increasingly hostile environment associated with immigration enforcement.38 In addition, the impending dissolution of the Deferred Action for Childhood Arrivals act is likely to augment the barriers to care for Latino groups.39

Dr. Antonio Mendoza-Ladd, Texas Tech University Health Sciences Center El Paso

Dr. Antonio Mendoza-Ladd

In addition, provider-specific barriers to care also exist. Racial and ethnic minorities are less likely than whites to receive recommendations for screening by their physician. In fact, this factor alone has been demonstrated to be the main reason for lack of screening among AAs in a Californian cohort.40 In addition, patients from rural areas or those from AI/AN communities are at especially increased risk for lack of access to care because of a scarcity of providers along with patient perceptions regarding their primary care provider’s ability to connect them to subspecialists.41-43 Other cited examples include misconceptions about and poor treatment of the LGBTQ population by health care providers/systems.44

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