Patient and provider barriers to colorectal cancer screening in the primary care safety-net

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Abstract

Objectives. This study examines patient and provider barriers to screening for colorectal cancer among low-income uninsured African-Americans aged 50 years or older in an urban safety-net primary care clinic, with the goal of informing a future intervention.

Methods. Four focus groups were conducted among 40 patients from, or living in the immediate neighborhood of, a primary care clinic for uninsured residents of Washington, DC. An additional focus group was conducted among primary care providers from the same clinic. Using semistructured open-ended questions, moderators elicited perceptions of barriers and promoters of colorectal cancer screening and suggestions to improve adherence to screening guidelines. The focus groups were audio-taped and transcribed verbatim. The transcripts were independently coded by two reviewers using established qualitative methodology.

Results. Patient and provider comments from the five focus groups fell into one of eight content areas: primary care characteristics (36% of comments), procedural issues related to screening (16% of comments), knowledge (14% of comments), cost/insurance coverage (13%), ordering of priorities (12%), attitudes (5%), information sources (2%), and perceptions of discrimination (2%). Involving various members of the primary care team in colorectal cancer screening processes, and using reminders with feedback, were identified as promising avenues for future interventions in the safety-net setting. Patients and providers cited the lack of referral sources for colonoscopy for follow-up of abnormal fecal occult blood tests (FOBT), and lack of treatment sources as major barriers to the initiation of colorectal cancer screening in uninsured populations.

Conclusions. Organizational level interventions, such as a team approach to colorectal cancer screening, are important areas identified for future colorectal cancer screening interventions in the safety-net primary care setting. Larger policy efforts to provide coverage for screening, diagnosis, and treatment among the uninsured are critical to implementing adequate colorectal cancer screening for this population.

Introduction

African-Americans are at increased risk for the occurrence of and mortality from colorectal cancer, especially if they live in low socioeconomic areas [1], [2], [3]. Washington, DC, has the highest colorectal cancer death rate in the United States and one of the highest urban concentrations of African-Americans (62%) in the US [4]. The average annual age-adjusted mortality rates for colorectal cancer deaths per 100 000 persons is 29.8 for African-Americans in Washington, DC, versus 21.7 for the nation [2]. Advanced stage at diagnosis accounts for more than 50% of the excess mortality observed in African-Americans [5]. When detected at an early stage, colorectal cancer is highly treatable [6], [7]. Despite the large body of evidence supporting the recommendation that persons aged 50 and older undergo colorectal cancer screening [6], [7], actual rates remain low [8]. Uninsured African-Americans are at especially high risk of not receiving screening [9].

Numerous barriers faced by both patients and primary care providers contribute to these low colorectal cancer screening rates [10]. Previously reported patient barriers include lack of knowledge or of health literacy, negative attitudes about prevention and cancer, inconvenience, and the lack of a doctor recommendation for the test [11], [12], [13], [14]. African-Americans face the additional barriers of historical mistrust of the medical system, and perceived bias in care delivery [14]. Low-income populations likely face further barriers such as lack of insurance, high cost of care, and practical considerations such as lack of child care, job demands, or inadequate transportation to the doctor's office or colonoscopy site.

Health care providers face related barriers to performing and ordering colorectal cancer screening for their patients. Some providers lack knowledge that there is randomized controlled trial evidence about the effectiveness of screening with fecal occult blood test (FOBT) in reducing colorectal cancer mortality [10]. Provider attitudes and discouragement caused by the anticipated lack of patient cooperation and by time pressures also pose barriers [10]. Promoters of colorectal cancer screening include having a health maintenance visit, provider recommendation of the test, and overcoming the abovementioned barriers [10], [15], [16].

Among safety-net primary care providers who care for low-income and uninsured patients, the above barriers are likely to be magnified, and additional barriers specific to safety-net settings exist. However, the topic of colorectal cancer screening barriers for African-Americans in safety-net settings has received little attention in the literature.

Of the prior studies on colorectal cancer barriers among African-Americans [12], [14], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], only three focused on primary care clinic settings [17], [18], [24]. None focused on uninsured patients in safety-net primary care, or included the perspectives of both patients and providers. Identification of barriers in these unique and under-resourced settings is necessary before designing appropriate and feasible screening interventions. The purpose of this study was to identify, through patient and provider focus groups, the promoters and barriers to colorectal cancer screening for low-income and uninsured patients in a typical urban primary care safety-net clinic.

Section snippets

Setting and recruitment

Focus group participants were recruited by the nurse coordinators and by flyers circulated at the primary care clinic in Washington, DC, in December of 2002. This clinic was selected because it provides primary care to uninsured residents of Washington, DC, and because it is in a large medically underserved area. (This clinic is not a federally funded community health center.) The primary care providers at this clinic see an average of 1,200 unique patients over age 50 per year, about 75% of

Participant characteristics

A total of 18 women and 22 men participated in the focus groups. Two-thirds of patient participants were aged 50–59, and the remaining third were aged 60–75. Eighty-six percent of patient participants self-identified as Black/African-American, the remaining 14% described themselves as some combination of African-American and other ethnicity (Latino, American Indian). Consistent with the general clinic population, 82% of focus group participants had total household annual incomes below $20,000,

Conclusions

This focus group study identified barriers and promoters of colorectal cancer screening among patients and providers of a safety-net primary care clinic. Primary care characteristics such as the use of reminders, organizational accessibility of the clinic, and the “whole-person approach” to the patient were mentioned as promoters of colorectal cancer screening. Prioritization of patients' acute social and medical needs, with preventive care having a low priority, was a barrier mentioned by both

Acknowledgements

Funded by NCI 5KO7 CA 91848 and ACS IRG 97-152-04 (ASO).

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