Introduction Although African Americans have the highest incidence and mortality from colorectal cancer (CRC), they are less likely than other racial groups to undergo CRC screening. Previous research has identified barriers to CRC screening among African Americans. However we lack a systematic review that synthesizes contributing factors and informs interventions to address persistent disparities. Methods We conducted a systematic review to evaluate barriers to colonoscopic CRC screening in African Americans. We developed a conceptual model to summarize the patient-, provider-, and system-level barriers and suggest strategies to address these barriers. Results Nineteen studies met inclusion criteria. Patient barriers to colonoscopy included fear, poor knowledge of CRC risk, and low perceived benefit of colonoscopy. Provider-level factors included failure to recommend screening and knowledge deficits about guidelines and barriers to screening. System barriers included financial obstacles, lack of insurance and access to care, and intermittent primary care visits. Conclusions There are modifiable barriers to colonoscopic CRC screening among African Americans. Future interventions should confront patient fear, patient and physician knowledge about barriers, and access to healthcare services. As the Affordable Care Act aims to improve uptake of preventive services, focused interventions to increase CRC screening in African Americans are essential and timely.

Background African Americans have the highest incidence and mortality from colorectal cancer (CRC). Despite guidelines to initiate screening with colonoscopy at age 45 in African Americans, CRC incidence remains high in this group. Objective To examine rates and predictors of CRC screening uptake as well as time-toscreening in a population of African Americans and non-African Americans in a healthcare system that minimizes variations in insurance and access. Design Retrospective cohort study. Setting Greater Los Angeles Veterans Affairs (VA) Healthcare System. Patients Random sample (N=357) of patients eligible for initial CRC screening. Interventions NA. Main Outcome Measurements Uptake of any screening method, uptake of colonoscopy in particular, predictors of screening, and time-to-screening in African Americans and non-African Americans. Results The overall screening rate by any method was 50%. Adjusted rates for any screening were lower among African Americans than non-African Americans (42%v.58%; OR=0.49,95%CI=0.31–0.77). Colonoscopic screening was also lower in African Americans (11%v.23%; adjusted OR=0.43,95%CI=0.24–0.77). In addition to race, homelessness, lower service connectedness, taking more prescription drugs, and not seeing a primary care provider within two years of screening eligibility predicted lower uptake of screening. Time-to-screening colonoscopy screening was longer in African Americans (adjusted HR=0.43,95%CI=0.25–0.75). Limitations The sample may not be generalizeable. Conclusions We found marked disparities in CRC screening despite similar access to care across races. Despite current guidelines aimed to increase screening in African Americans, participation in screening remained low and use of colonoscopy was infrequent.

Low healthcare utilization is a prime contributor to adverse health outcomes in both the general population and the Hispanic community. This study compares background characteristics and rates of prenatal and postpartum health care utilization between Hispanic and non-Hispanic white women. Using the Rhode Island Pregnancy Risk Assessment Monitoring System (PRAMS), 2002-2008, we assess rates of prenatal and postpartum healthcare utilization relevant to maternal and neonatal care. Associations between maternal ethnicity and adequacy of health care utilization were quantified using survey weighted multivariable logistic regression. Compared with non-Hispanic white women, Hispanic women were younger (less than 24 years, 43.8% vs. 25.2%), had less education (less than 12 years of education, 38.2% vs. 10.6%), lower annual income levels (incomes less than $19,999, 72.2% vs. 21.7%), and lower insurance rates before pregnancy (47.8% uninsured vs. 12.8%). Hispanic women had higher odds of having delayed prenatal care (AOR 1.84, 95% CI 1.27-2.65) or inadequate prenatal care (AOR 2.01, 95% CI 1.61-2.50), and their children had higher odds of not having a 1-week check-up (AOR 1.73, 95% CI 1.21-2.47) or any well-baby care (AOR 3.44, 95% CI 1.65-7.10). Disparities in inadequate prenatal care and not having any well-baby care remained significant after adjusting collectively for age, marital status, education, income, and insurance status of mother and newborn. Although many previously uninsured women became insured during pregnancy, disparities in healthcare utilization remained. Interventions focusing on reducing barriers to access prior to and during pregnancy should consider potential structural, informational, and educational barriers.

Background African Americans have the highest burden of colorectal cancer (CRC) in the United States yet lower CRC screening rates than whites. Although poor screening has prompted efforts to increase screening uptake, there is a persistent need to develop public health interventions in partnership with the African American community. Purpose To conduct focus groups with African Americans to determine preferences for the content and mode of dissemination of culturally-tailored CRC screening interventions. Methods In June 2013, 45-75 year-old African Americans were recruited through online advertisements and from an urban VA system to create four focus groups. A semi-structured interview script employing open-ended elicitation was used, and transcripts were analyzed using ATLAS.ti software to code and group data into a concept network. Results A total of 38 participants (mean age=54) were enrolled, and 59 ATLAS.ti codes were generated. Commonly reported barriers to screening included perceived invasiveness of colonoscopy, fear of pain, and financial concerns. Facilitators included poor diet/health and desire to prevent CRC. Common sources of health information included media and medical providers. CRC screening information was commonly obtained from medical personnel or media. Participants suggested dissemination of CRC screening education through commercials, billboards, influential African American public figures, Internet, and radio. Participants suggested future interventions include culturally specific information, including details about increased risk, accessing care, and dispelling of myths. Conclusions Public health interventions to improve CRC screening among African Americans should employ media outlets, emphasize increased risk among African Americans, and address ethnic-specific barriers. Specific recommendations are presented for developing future interventions.

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