Understanding Current Racial/Ethnic Disparities in Colorectal Cancer Screening in the United States: The Contribution of Socioeconomic Status and Access to Care

doi:10.1016/j.amepre.2013.10.023

American Journal of Preventive Medicine

Volume 46, Issue 3, March 2014, Pages 228-236

https://doi.org/10.1016/j.amepre.2013.10.023 Get rights and content

Background

Prior studies have shown racial/ethnic disparities in colorectal cancer (CRC) screening but have not provided a full national picture of disparities across all major racial/ethnic groups.

Purpose

To provide a more complete, up-to-date picture of racial/ethnic disparities in CRC screening and contributing socioeconomic and access barriers.

Methods

Behavioral Risk Factor Surveillance System data from 2010 were analyzed in 2013. Hispanic/Latino participants were stratified by preferred language (Hispanic-English versus Hispanic-Spanish). Non-Hispanics were categorized as White, Black, Asian, Native Hawaiian/Pacific Islander, or American Indian/Alaska Native. Sequential regression models estimated adjusted relative risks (RRs) and the degree to which SES and access to care explained disparities.

Results

Overall, 59.6% reported being up-to-date on CRC screening. Self-reported CRC screening was highest in the White (62.0%) racial/ethnic group; followed by Black (59.0%); Native Hawaiian/Pacific Islander (54.6%); Hispanic-English (52.5%); American Indian/Alaska Native (49.5%); Asian (47.2%); and Hispanic-Spanish (30.6%) groups. Adjustment for SES and access partially explained disparities between Whites and Hispanic-Spanish (final relative risk [RR]=0.76, 95% CI=0.69, 0.83); Hispanic-English (RR=0.94, 95% CI=0.91, 0.98); and American Indian/Alaska Native (RR=0.91, 95% CI=0.85, 0.97) groups. The RR of screening among Asians was unchanged after adjustment for SES and access (0.78, p<0.001). After full adjustment, screening rates were not significantly different among Whites, Blacks, or Native Hawaiian/Pacific Islanders.

Conclusions

Large racial/ethnic disparities in CRC screening persist, including substantial differences between English-speaking versus Spanish-speaking Hispanics. Disparities are only partially explained by SES and access to care. Future studies should explore the low rate of screening among Asians and how it varies by racial/ethnic subgroup and language.

Introduction

Despite recent national increases in colorectal cancer (CRC) screening,1, 2, 3 racial/ethnic minorities continue to have lower screening rates than Whites.2, 3, 4 A recent report from the CDC⁴ found that screening rates among Whites were substantially higher than those among Hispanics, Asian/Pacific Islanders, and American Indian/Alaska Natives (AI/AN). Although screening rates for Blacks have historically been lower than Whites,2, 5, 6 these two groups had similar national rates in 2010.⁴ In addition to presenting racial/ethnic screening disparities, the recent CDC report highlighted disparities by SES and access to care. However, multivariable analysis was not conducted to assess the independent contributions of these overlapping characteristics to disparities.

It is important to understand factors underlying disparities, particularly as the Affordable Care Act (ACA) ushers in a rapid expansion of insurance coverage and access to health care in 2014 and beyond. We therefore need to disentangle how factors that are associated with low screening rates and prevalent among racial/ethnic minorities⁷—such as lower education4, 8 and income⁹ levels, language barriers,10, 11 and lack of health insurance² and a regular source of care⁹—contribute to current screening disparities.

Previous multivariable analyses have shown that race/ethnicity, language, SES, and access to care are independently associated with CRC screening. However, these prior studies have important limitations. Diaz and colleagues¹¹ found that in 2006, the CRC screening rate in states administering the Spanish-language Behavioral Risk Factor Surveillance System (BRFSS) was higher among English-speaking non-Latinos (62%) than English-speaking Latinos (51%) and Spanish-speaking Latinos (33%); these differences persisted after adjustment for income, education, insurance, and regular source of care. This prior study, however, provided incomplete information on other potential disparities by combining all other race/ethnicities into one “non-Latino” category.

An analysis of 2010 National Health Interview Survey (NHIS) data found that race, ethnicity, older age, higher education and income levels, insurance, and a usual care source were independently associated with CRC screening.³ However, this NHIS analysis did not stratify Hispanic/Latino participants by preferred language (English versus Spanish) and had limited sample size for AI/AN and Pacific Islanders. In addition, race (White, Black, Asian, and AI/AN) and Hispanic/Latino ethnicity (yes/no) were modeled as separate variables, making it difficult to interpret differences between Hispanic/Latino individuals and the heterogeneous non-Hispanic/Latino group (e.g., Whites and Asians had 59.2% and 46.9% screening rates, respectively).

The current study was conducted to provide a more complete, up-to-date picture of racial/ethnic disparities in CRC screening and the contributing socioeconomic and access barriers in the U.S. Using more than 200,000 observations from the most current BRFSS data, screening was separately analyzed for English-speaking versus Spanish-speaking Hispanics and Asians versus Native Hawaiian/Pacific Islanders (NH/PI). Regional variation in screening rates among individual racial/ethnic groups was also investigated.

Section snippets

Data Source and Study Population

This study used data from the 2010 BRFSS, a state-based telephone survey of health risk behaviors, clinical preventive services, and health care access among noninstitutionalized U.S. adults. The BRFSS employs a disproportionate stratified random sampling design, with accompanying weights, to ensure the survey population is representative of each state’s age, gender, and racial/ethnic distribution. CRC screening questions are asked every other year; in 2013, at the time of analysis, 2010 was

Results

The unweighted study population included 226,546 BRFSS respondents. In the weighted descriptive analysis, 52.2% of participants were women, and approximately half were aged below 60 years (Table 1). More than three-fourths were White (78.2%). Among non-Whites, the most common race/ethnicity was Black (9.6%), followed by Hispanic-English (5.1%); Hispanic-Spanish (3.3%); Asian (2.3%); AI/AN (1.2%); and NH/PI (0.3%). Thirty-seven percent had graduated college, and 33.3% reported annual household

Discussion

This study provides the most complete and up-to-date picture of racial/ethnic disparities in CRC screening in the U.S.—and the degree to which disparities are explained by SES and access to care—for seven major race/ethnicity categories, including distinguishing between Hispanics who speak English versus Spanish. In 2010, the CRC screening rate was very low for Spanish-speaking Hispanics (30.6%; Table 3, Model 1, age- and gender-adjusted RR=0.52). In contrast, the disparity between Whites and

Acknowledgments

The authors thank Joe Feinglass, PhD, for his assistance during analysis planning. Funding support was provided by the Agency for Healthcare Research and Quality (#P01 HS021141).

No financial disclosures were reported by the authors of this paper.

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Research ArticleUnderstanding Current Racial/Ethnic Disparities in Colorectal Cancer Screening in the United States: The Contribution of Socioeconomic Status and Access to Care

Background

Purpose

Methods

Results

Conclusions

Introduction

Section snippets

Data Source and Study Population

Results

Discussion

Acknowledgments

Soc Sci Med

Prev Med

Am J Prev Med

Data and trends in cancer screening in the U.S.: results from the 2005 National Health Interview Survey

Cancer

Trends in colorectal cancer test use among vulnerable populations in the U.S

Cancer Epidemiol Biomarkers Prev

Patterns of colorectal cancer test use, including CT colonography, in the 2010 National Health Interview Survey

Cancer Epidemiol Biomarkers Prev

CDC. Prevalence of colorectal cancer screening among adults—Behavioral Risk Factor Surveillance System, U.S., 2010

MMWR Morb Mortal Wkly Rep

Cancer screening among racial/ethnic and insurance groups in the U.S.: a comparison of disparities in 2000 and 2008

J Health Care Poor Underserved

Determinants of racial/ethnic colorectal cancer screening disparities

Arch Intern Med

Primary care, economic barriers to health care, and use of colorectal cancer screening tests among Medicare enrollees over time

Ann Fam Med

Predictors of colorectal cancer screening behaviors among average-risk older adults in the U.S

Cancer Causes Control

Factors associated with colorectal cancer screening among Cambodians, Vietnamese, Koreans and Chinese living in the U.S

N Am J Med Sci (Boston)

Effect of language on colorectal cancer screening among Latinos and non-Latinos

Cancer Epidemiol Biomarkers Prev

Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement

Ann Intern Med

Multiple imputation after 18+ years

J Am Statist Assoc

A modified Poisson regression approach to prospective studies with binary data

Am J Epidemiol

Patient-physician language concordance and primary care screening among spanish-speaking patients

Med Care

Literacy barriers to colorectal cancer screening in community clinics

J Health Commun

Rural Mexican American men’s attitudes and beliefs about cancer screening

J Cancer Educ

Asian and Hispanic Americans’ cancer fatalism and colon cancer screening

Am J Health Behav

Cancer knowledge, self-efficacy, and cancer screening behaviors among Mexican-American women

J Cancer Educ

Barriers to follow-up of an abnormal Pap smear in Latina women referred for colposcopy

J Gen Intern Med

Research Article
Understanding Current Racial/Ethnic Disparities in Colorectal Cancer Screening in the United States: The Contribution of Socioeconomic Status and Access to Care