Explaining persistent under-use of colonoscopic cancer screening in African Americans: A systematic review

Abstract

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.

Systematic Review and Meta-study Synthesis of Qualitative Studies Evaluating Facilitators and Barriers to Participation in Colorectal Cancer Screening

“…Conversely, a sufficient level of awareness was a key enabler for individual decision-making (9-11, 13, 31, 34-40, 52, 57, 60, 67, 68, 75, 78, 80, 87, 106, 108). This is a concordant finding with a previous systematic review of 19 articles examining patient barriers to colonoscopy among African-Americans (109).…”

Association Between Primary Care Visits and Colorectal Cancer Screening Outcomes in the Era of Population Health Outreach

“…These studies showed that PCP visits [4][5][6][7][8] and physician recommendation were strong predictors of prevalent CRC screening (mostly with colonoscopy). 2,6,8 Our study extends prior work by demonstrating an independent association between prior primary care visits and subsequent Bincident^CRC screening, including outreach screening not linked directly to the primary care visit. This work is particularly important in the modern era, where large private and public health systems have extensive CRC screening outreach programs and are promoting annual FIT/FOBT as a dominant strategy.…”

“…1 Screening can prevent CRC and reduce cancerrelated mortality. 2 National guidelines recommend CRC screening via colonoscopy, flexible sigmoidoscopy, or fecal immunochemical tests (FIT) or high-sensitivity guaiac occult blood tests (FOBT). 3 Primary care providers (PCP) traditionally initiate cancer screening, and prior work has shown that patients seen by PCPs are more likely to receive CRC screening.…”

Psychosocial Factors Related to Underuse of Medical Services

“…Likely mechanisms by which financial difficulty ultimately results in the underuse of medical services are varying earnings, high medical costs, lack of health insurance, and/or lower household income and resources. 27,28 Consistent with FIT, our findings indicate that greater depressive mood undermines one's ability and/or opportunity to obtain social support in adulthood. Social support typically refers to the functions (including emotional, informational, and instrumental assistance) performed for the individual by significant others and friends.…”

“…1,5,[27][28][29] For example, using the National Health Interview Survey (NHIS), Berkowitz et al 27 estimated that approximately one in three chronically ill NHIS participants are unable to afford food, medications, or both. Bromley et al 28 reported that financial obstacles, lack of insurance, decreased access to care, and intermittent primary care visits are associated with a lower likelihood of undergoing colorectal cancer screening in an at-risk African American population.…”