Barriers and facilitators for colorectal cancer screening in a low-income urban community in Mexico City

Abstract

Background: Colorectal cancer (CRC) incidence and mortality are increasing in many low-and middle-income countries (LMICs), possibly due to a combination of changing lifestyles and improved healthcare infrastructure to facilitate diagnosis. Unfortunately, a large proportion of CRC cases in these countries remain undiagnosed or are diagnosed at advanced stages, resulting in poor outcomes. Decreasing mortality trends in HICs are likely due to evidence-based screening and treatment approaches that are not widely available in LMICs. Formative research to identify emerging opportunities to implement appropriate screening and treatment programs in LMICs is, therefore, of growing importance. We sought to identify potential barriers and facilitators for future implementation of fecal immunochemical test (FIT)-based CRC screening in a public healthcare system in a middle-income country with increasing CRC incidence and mortality. Methods: We performed a qualitative study with semi-structured individual and focus group interviews with different CRC screening stakeholders, including 30 lay people at average risk for CRC, 13 health care personnel from a local public clinic, and 7 endoscopy personnel from a cancer referral hospital. All interviews were transcribed verbatim for analysis. Data were analyzed using the constant comparison method, under the theoretical perspectives of the social ecological model (SEM), the PRECEDE-PROCEED model, and the health belief model. Results: We identified barriers and facilitators for implementation of a FIT-based CRC screening program at several levels of the SEM. The main barriers in each of the SEM levels were as follows: (1) at the social context level: poverty, health literacy and lay beliefs related to gender, cancer, allopathic medicine, and religion; (2) at the health services organization level: a lack of CRC knowledge among health care personnel and the community perception of poor quality of health care; and (3) at the individual level: a lack of CRC awareness and therefore lack of risk perception, together with fear of participating in screening activities and finding out about a serious disease. The main facilitators perceived by the participants were CRC screening information and the free provision of screening tests.

Colorectal cancer screening in the COVID-19 era

“…Poverty has long been a barrier to CRC screening, especially in countries with limited resources. Patients are unlikely to seek out preventative services when they are unable to fulfill their basic needs[ 26 ]. The effects of the pandemic are likely to worsen these barriers and result in further decreases in screening in these populations.…”

“…Regarding colonoscopies for these patients, grassroot advocacy programs are encouraged to generate a list of community gastroenterologists to provide colonoscopies to CHC patients[ 79 ]. A qualitative study from Mexico shows that implementation of screening programs that offer FIT and colonoscopy at no cost would greatly increase CRC screening participation[ 26 ]. To alleviate knowledge gaps in patients, existing platforms should provide information about COVID-19 and extend CRC awareness throughout the year[ 78 ].…”

Awareness of colorectal cancer signs and symptoms: a national cross-sectional study from Palestine

“…This may reflect poor health education about CRC signs and symptoms in Arab countries and underline the need for establishing continuous educational programs. Another contributing factor could be the shared, misleading cultural beliefs in these countries [ 52 ]. A living example of this was noticed during the data collection for this study.…”

“…A previous study in Denmark showed that cancer was perceived as a terminal illness that cannot be treated and screening was only relevant for symptomatic patients [ 53 ]. The hopelessness and helplessness people feel towards CRC could be the result of their poor insight—healthcare illiteracy—towards the role of early detection in the morbidity and mortality of the disease [ 52 ]. Thus, a multidisciplinary approach should be considered to raise the public awareness about the importance of early detection.…”

Screening Intention Prediction of Colorectal Cancer among Urban Chinese Based on the Protection Motivation Theory

“…Those who had deficient knowledge of CRC risk factors, clinical symptoms, and detection would be discouraged from attending screening. So, implementation of educational interventions on the part of participants and staff of the primary healthcare system for removing barriers to CRC knowledge was quite essential, as it has already been proved to be a successful facilitator of CRC screening [ 48 ].…”