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

Highlights

• African Americans are at high risk of mortality from CRC but have low screening rates.

• Current literature does not contain a systematic review or conceptual framework synthesizing barriers to colonoscopic screening.

• Patient-level barriers to colonoscopic screening include fear, lack of knowledge about CRC screening, and competing personal and medical issues.

• Provider-level factors include knowledge deficits of guidelines and barriers, and counseling practices.

• System-level factors include access to care, financial barriers, and infrequent primary care visits.

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.

Introduction

African Americans have a higher incidence and mortality from colorectal cancer (CRC) than any other ethnic group in the United States (U.S) (Howlader et al., 2012). Despite compelling evidence that CRC screening results in early cancer diagnosis and decreased CRC-related mortality in African Americans, African Americans are less likely to undergo appropriate CRC screening than Whites (Pigone et al., 2002, Zauber et al., 2010, Agrawal et al., 2005, Centers for Disease Control and Prevention (CDC), 2012). In recent national estimates, 55% of African Americans, compared to 60% of White Americans were compliant with CRC screening (Centers for Disease Control and Prevention (CDC), 2012). Prompted by these disparities, as well as by data supporting a high prevalence of right-sided colonic lesions among African Americans, the American College of Gastroenterology (ACG) began recommending in 2009 that CRC screening begin at age 45 for African Americans, with colonoscopy as the preferred screening method (Agrawal et al., 2005, Cress et al., 2000, Nelson et al., 1999, Rex et al., 2009).

In a 2002 report on racial and ethnic inequities in healthcare, the Institute of Medicine (IOM) conceptualizes racial and ethnic disparities in health as the result of factors in patient-, provider-, and healthcare system-level domains (Smedley et al., 2003). While prior studies have identified patient-, provider-, and system-level barriers to several screening methods (fecal occult blood testing [FOBT], sigmoidoscopy, and colonoscopy) in African Americans, the literature lacks a systematic and summative presentation of the barriers to screening in this ethnic subgroup (Ward et al., 2010 Apr, O’Malley et al., 2005, Dimou et al., 2009, McLachlan et al., 2012). Further, although recent society guidelines emphasize colonoscopy as the preferred screening tool in African Americans, the barriers preventing African Americans from participating in this method of screening are not fully characterized. Given these gaps in the literature, we aimed to provide a systematic review of the literature pertaining to barriers to colonoscopic screening in African Americans. We use the three domains proposed by the IOM to develop a conceptual model that synthesizes the barriers to colonoscopic screening. The resulting conceptual framework provides clinicians, researchers, and healthcare organizations with potential strategies in the design of effective, system-wide interventions to increase the use of colonoscopic screening among African Americans and to reduce disparities in CRC outcomes.