Colorectal Cancer Screening Among Latinos in Three Communities on the Texas

Abstract

Objective. To assess colorectal cancer screening (CRCS) prevalence and psychosocial correlates of CRCS among Latinos in South Texas. Method. Using multivariable analyses, we examined the association of perceived susceptibility, self-efficacy, pros and cons, subjective norms, knowledge and fatalism on CRCS among 544 Latinos (50 years and older). Results. In this socioeconomically disadvantaged population, 40% had never heard of any CRCS test, only 34% reported ever completing any type of CRCS, and only 25% were adherent to CRCS guidelines. Insurance status, gender, perceived cons, CRCS self-efficacy, and CRCS norms were significantly associated with CRCS. Conclusion. CRCS interventions in this population should focus on improving access, increasing self-efficacy and perceived norms, and decreasing negative perceptions of CRCS.

Keywords

cancer screening colorectal cancer Hispanic Americans

The American Cancer Society (ACS) estimates that during 2013 in the United States, 73,680 men and 69,140 women will be diagnosed with colon and rectal cancer (CRC; American Cancer Society, 2013a). Among Hispanics, CRC is the second and third leading cause of cancer mortality among men (11% of cancer deaths) and women (10% of all cancer deaths), respectively (American Cancer Society, 2012). While Hispanics have lower CRC incidence and mortality rates than non-Hispanic Whites, they are more likely to be diagnosed at advanced stages of CRC at which point the 5-year survival rate declines from 89% (localized stage at diagnosis) to 68% (regional stage at diagnosis) and 15% (distant stage at diagnosis; American Cancer Society, 2012; Chien, Morimoto, Tom, & Li, 2005; O’Brien et al., 2003). Additionally, Hispanics have not experienced the decline in CRC incidence observed in non-Hispanic Whites (American Cancer Society, 2012). Texas Hispanics have higher age-adjusted mortality rates compared with Hispanics nationwide (16.9 per 100,000 and 15.1 per 100,000, respectively; U.S. Cancer Statistics Working Group, 2013).

Differences in mortality trends may be due to disparities in screening (O’Brien et al., 2003), early detection, and, therefore, survival (Smith, Cokkinides, & Brawley, 2009). Defining screening as a fecal occult blood test (FOBT) in the past year, sigmoidoscopy within the past 5 years, or a colonoscopy within the past 10 years, Hispanics 50 years and older had an age-adjusted CRC screening (CRCS) rate of 47% in 2010 compared with 62% for non-Hispanic Whites, 56% for Blacks, 48% for American Indian/Alaskan natives, and 46% for Asians (American Cancer Society, 2013b). Two literature reviews (Peterson & Vernon, 2000; Vernon, 1997) report inconsistent patterns of association between age, sex, marital status, or race/ethnicity and CRCS, depending on study population and study design. Socioeconomic status indicators, such as higher education, income, and access to health care (e.g., health insurance coverage), however, have a consistent positive association with CRCS (Ioannou, Chapko, & Dominitz, 2003; Seeff et al., 2004; Siegel, Jemal, Thun, Hao, & Ward, 2008; Swan, Breen, Coates, Rimer, & Lee, 2003). Few studies report psychosocial factors associated with CRCS among Hispanics. In a qualitative study, Fernandez et al. (2008) reported that low levels of knowledge and lack of physician recommendation were associated with low levels of screening among Hispanics living on the Texas–Mexico border. Other studies among Hispanics have reported that physician discussion or recommendation was positively associated with CRCS (Jandorf et al., 2010; Yepes-Rios, Reimann, Talavera, Ruiz, & Talavera, 2006). Jandorf et al. (2010) reported that fear was associated with lower levels of CRCS and knowledge of tests was associated with increased use of sigmoidoscopy only.

Guided by findings from our qualitative study and constructs of health behavior theories including the health belief model (Rosenstock, 1974), social cognitive theory (Bandura, 1986), and the transtheoretical model (Prochaska & Velicer, 1997), we examined the association between CRCS knowledge, perceived susceptibility, subjective norms, self-efficacy, pros and cons of screening, and fatalism with CRCS behavior. Ultimately, this research is intended to guide health promotion programs aimed at increasing CRCS uptake and adherence to recommended guidelines among Hispanics.

Method

Study Design and Data Collection

We conducted a cross-sectional study using face-to-face interviews with Hispanics living on the U.S. side of the Texas–Mexico border. We collected data in three areas: Brownsville, Laredo, and El Paso. The purpose of collecting data from multiple areas was to increase the sample size and the generalizability of the results as well as to compare screening rates in three different areas along the Texas–Mexico border. In Brownsville and Laredo, participants lived in colonias, unincorporated neighborhoods typically characterized by high rates of poverty and unemployment and low levels of community infrastructure (Ramos, May, & Ramos, 2001). Participants in El Paso County were low-income, primarily Hispanic, residents of selected census tracts.

In Brownsville and Laredo, we recruited participants in selected colonias by conducting door-to-door visits using the Expanded Programme on Immunization EPI Sampling Quadrants Scheme (Bennett, Radalowicz, Vella, & Tomkins, 1994). The colonias were divided into four quadrants and one data collector conducted interviews in each quadrant. Data collectors spun a pen to randomly select a starting direction and then proceeded to each household. Interviewers assessed eligibility of residents and invited one person per household to be interviewed. The person with the most recent birthday was selected when more than one person was eligible. At the end of the street, the interviewer proceeded clockwise to the next street until reaching the border of the quadrant. We recruited participants in El Paso County census tracts with the highest percentage of Hispanics. The census tracts were broken down into block groups, and block groups were randomly selected. Within each block group, data collectors approached dwellings and systematically conducted door-to-door visits as described above to identify eligible participants.

Eligibility criteria included age 50 years or older, Hispanic/Latino ethnicity, and no cancer diagnosis (excluding skin cancer). Age criteria were based on the American Cancer Society and Multi-Society Task Force on Colorectal Cancer guidelines (Levin et al., 2008). Data collectors gave participants a $20 dollar incentive on completion of the interview. Interviews were conducted in Spanish and lasted approximately 1½ hours. Interviewers and data collection supervisors were bilingual community members who completed a 2-day training program. During the training, data collectors reviewed the study protocol, completed certification in the protection of human subjects, reviewed the survey instrument, and practiced conducting structured interviews. Data collectors conducted the interviews according to study protocols during a 2-month period; investigators and staff supervised data collection at each site.

Measurement

The questionnaire consisted of 175 closed-ended items, including questions assessing sociodemographic factors such as age, education, place of birth, income, insurance, and marital status. It also included psychosocial measures of perceived susceptibility to CRC, self-efficacy for CRCS, CRCS pros (positive factors or perceived benefits associated with screening), cons of CRCS (negative factors or perceived barriers associated with screening), subjective norms of CRCS, knowledge of colorectal cancer, cancer fatalism, and (for nonadherent individuals) questions assessing barriers to screening. Table 1 provides a description and sample items from the relevant psychosocial constructs.

Table 1.

Descriptions and Sample Items of Psychosocial Constructs.

Pyschosocial Construct	Description	Sample Items
Perceived susceptibility	An individual’s belief that he or she is at risk for contracting a particular disease or condition	• I believe that I have a high chance of developing colon cancer in my lifetime.
		• Compared with other persons my age, I am more likely to get colon cancer in my lifetime.
Self-efficacy	An individual’s confidence in his or her ability to take action and to persist in that action despite obstacles or challenges	• How sure are you that you can get tested for colon cancer even if you cannot find the time?
		• How sure are you that you can get tested for colon cancer even if you are worried about the pain?
Pros (perceived benefits)	An individual’s belief that engaging in a preventive action will lower the risk of contracting colorectal cancer	• Having regular colon cancer tests would give me peace of mind about my health.
		• A colon cancer test can find a problem even before it develops into cancer.
Cons (perceived barriers)	The obstacles that an individual believes deter him or her from taking action to prevent colorectal cancer	• It is too expensive to have a colon cancer test.
		• It is too embarrassing to have a colon cancer test.
Subjective norms	Perceived social pressure to engage or not engage in a behavior	• Your family thinks you should be screened for colon cancer.
		• The doctor (or health professional) thinks you should be screened for colon cancer.
Cancer fatalism	The belief that death is inevitable when cancer is present/the belief that if one is destined to get cancer they will regardless of personal actions	• I think if someone has colon cancer, it is already too late to get treated for it.
		• I think if someone is meant to get colon cancer, they will get it no matter what they do.

Our primary outcome was adherence to CRCS, defined as having any screening test according to ACS recommended guidelines. At the time of the study, the ACS recommended: (a) FOBT annually, (b) sigmoidoscopy every 5 years, (c) annual FOBT plus flexible sigmoidoscopy every 5 years, (d) double-contrast barium enema (DCBE) every 5 years, or (e) colonoscopy every 10 years (Smith et al., 2001). We also assessed having had any CRCS test in one’s lifetime and calculated a dichotomous measure based on self-reported completion of at least one CRC screening test. To assess date of most recent CRCS, interviewers asked participants the exact month and year of their most recent exam. Those unable to remember the month and year estimated the number of years by choosing among four categories.

Questions used to assess CRCS behavior were developed through an iterative process by a working group sponsored by the Division of Cancer Control and Population Sciences of the National Cancer Institute (NCI). These questions underwent cognitive testing during development of the NCI Health Information National Trends Survey (Vernon et al., 2004). We translated and back-translated the items and used decentering techniques to resolve discrepancies (Chapman & Carter, 1979), making slight modifications in wording while retaining the original meaning. We then conducted formal cognitive testing of the Spanish language items with participants from the priority population including 4 individuals recruited from the Houston area and 4 recruited from the Lower Rio Grande Valley. Participants were interviewed by two researchers from the team who had training in cognitive testing techniques. The “think aloud” and verbal probing techniques (Collins, 2003) were used to elicit information during the interviews. The interviews were conducted one-on-one, in a private conference room, and participants signed consent forms for the interview, note-taking, and taping of the sessions. Participants received $20 compensation for their time. In general, most questions were clear to the participants and they were able to rephrase and easily explain what the questions meant to them; however, there were some preferred and more commonly used terms to describe specific items. The cognitive testing data led to modifications in wording of survey items to improve clarity and understanding and the final version was reviewed by participants in focus groups conducted in each of the three communities.

We followed a similar procedure to translate and adapt eleven items from the Powe Fatalism Inventory to measure cancer fatalism (Powe, 1995). Modifications to the original inventory were made based on cognitive interviews, focus group interviews, and assessment of psychometric properties of the measure. Response options were “yes,” “no,” or “don’t know.”

Measures of all other psychosocial constructs were developed for the current study based on previous Spanish language measures of the same constructs for other screening behaviors (Fernandez, Diamond, et al., 2009; Fernandez, Gonzales, et al., 2009). The measures developed were similar to those used to assess psychosocial constructs related to CRCS that have now been cross-validated in a number of different populations (McQueen, Tiro, & Vernon, 2008; Murphy et al., 2013; Rawl et al., 2013; Ritvo et al., 2008; Tiro, Vernon, Hyslop, & Myers, 2005). We used 5-point Likert-type items for all psychosocial constructs except knowledge. To assess knowledge of CRC, we used a 13-item index adapted from other studies with “yes,” “no,” or “don’t know” responses (Fernandez, Gonzales, et al., 2009). For the scales measuring perceived susceptibility (2 items), self-efficacy (10 items), pros (7 items) and cons (12 items), and subjective norms (6 item), we adapted items from preexisting scales developed for breast and cervical cancer screening (Fernandez, Diamond, et al., 2009). We tested level of understanding of these items during focus groups with the priority population. Slight modifications in wording were made as a result of this testing. We then used survey data to assess the psychometric properties. We conducted exploratory factor analysis, item analysis, and calculated the internal consistency reliability for each scale. We used this data to make decisions about final items to be included in these measures and calculated scale scores for analysis. Chronbach’s alpha of each are as follows: perceived susceptibility to colorectal cancer (.85), colorectal cancer screening pros (.81) and cons (.73), self-efficacy for colorectal cancer screening (.94), subjective norms for colorectal cancer screening (.82) and cancer fatalism (.78). All research protocols and instruments were approved by the University of Texas Health Science Center Institutional Review Board.

Analysis

We calculated frequencies of demographic and screening outcome variables by border region as well as barriers to screening among those participants who were nonadherent to all screening tests. With the exception of scales for subjective norms, knowledge, and fatalism, we determined scale scores for each psychosocial construct by calculating a mean of all items on each scale. For subjective norms, we calculated the scale score by multiplying scores on items measuring perceived expectation of others with scores on items measuring motivation to do what others expect. We calculated a scale score for cancer fatalism by adding one point for each item with a “Yes” response and calculated a knowledge scale score by adding one point for each item with a correct response. We conducted chi-square tests to identify demographic variables associated with CRCS adherence and t-tests to identify psychosocial constructs associated with screening. Following the recommendations of Hosmer and Lemeshow, we included in the final multivariable analysis all variables significantly associated with screening in bivariate analysis at the p < .25 level (Hosmer & Lemeshow, 2000). We conducted logistic regression to assess the independent association of the psychosocial constructs and CRCS, adjusting for relevant sociodemographic factors. We used SPSS software (SPSS, Inc., 1997) for all analyses.

Results

Among the 601 participants eligible for the study, 544 (91%) agreed to complete the survey. Participants’ ages ranged from 49 to 91 years and the majority were female (73%; Table 2). Almost all the participants (98%) self-identified as Hispanic of Mexican American/Mexican decent, and more than half (55%) were born in Mexico but most had lived in the United States for more than 20 years. The majority of the participants had little formal education, were underinsured (50% had no form of health insurance coverage), and had low incomes (57% had an annual household income of less than $10,000).

Table 2.

Sociodemographic Characteristics of Study Participants (N = 544).

	El Paso (N = 81)		Brownsville (N = 265)		Laredo (N = 198)		All Sites (N = 544)
	Number	%	Number	%	Number	%	Number	%
Age group (years)
50-59	30	37.0	143	54.0	75	37.9	248	45.6
60-69	22	27.2	72	27.2	66	33.3	160	29.4
70 and older	29	35.8	50	18.9	57	28.8	136	25.0
Gender
Male	30	37.0	65	24.5	52	26.3	147	27.0
Female	51	63.0	200	75.5	146	73.7	397	73.0
Marital status
Never married	6	7.4	11	4.2	7	3.5	24	4.4
Married	38	46.9	166	63.6	118	59.6	322	59.6
Separated	2	2.5	15	5.7	15	7.6	32	5.9
Divorced	12	14.8	13	5.0	7	3.5	32	5.9
Widowed	23	28.4	51	19.5	47	23.7	121	22.4
Living together	0	0.0	5	1.9	4	2.0	9	1.7
Education (years)
None	11	13.9	23	9.2	16	8.5	50	9.7
1-5	37	46.8	114	45.8	64	33.9	215	41.6
6-11	25	31.6	102	41.0	81	42.9	208	40.2
12 and over	6	7.6	10	4.0	28	14.8	44	8.5
Birth status and years in the U.S.
Born in U.S.	16	20.3	47	18.1	56	28.3	119	22.2
Born in Mexico, <5 years in the U.S.	1	1.3	9	3.5	8	4.0	18	3.4
Born in Mexico, 5-10 years in the U.S.	6	7.6	21	8.1	16	8.1	43	8.0
Born in Mexico, 11-19 years in the U.S.	9	11.4	32	12.3	21	10.6	62	11.5
Born in Mexico, over 20 years in the U.S.	47	59.5	151	58.1	97	49.0	295	54.9
Income
Less than $10,000	58	76.3	142	55.0	103	52.8	303	57.3
$10,000-$19,999	8	10.5	50	19.4	38	19.5	96	18.1
$20,000-$29,999	0	0.0	15	5.8	3	1.5	18	3.4
$30,000 or more	1	1.3	3	1.2	1	0.5	5	0.9
Don’t know	9	11.8	48	18.6	50	25.6	107	20.2
Insurance
None	24	29.6	149	57.5	96	49.0	269	50.2
Any	57	70.4	110	42.5	100	51.0	267	49.8

A large proportion of participants (40%) had never heard of any type of CRCS; only 41% were aware of FOBT and only 33% had heard of colonoscopy. More than one third (34%) of respondents reported having at least one of the CRCS tests at some time in their lives, but only 25% were adherent to recommended CRCS guidelines (10.8% to FOBT, 9.4% to colonoscopy, 6.8% to sigmoidoscopy, and 8.6% to barium enema; Table 3). Among those ever screened, 67% reported only one test ever in their lifetime, most commonly FOBT (50%), followed by sigmoidoscopy (19%), colonoscopy (18%), and barium enema (14%). Among nonadherent participants, lack of doctor recommendation was the most common barrier mentioned (36% to 40%) followed by “no reason” (30% to 35%).

Table 3.

CRCS Screening Status (N = 544).

		Test-Specific CRCS (%)
	Any CRCS Test (%)	FOBT	Colonoscopy	Sigmoidoscopy	Barium Enema
Lifetime (ever/never)	34.0	20.8	11.0	8.8	10.8
Adherence	24.8	10.8	9.4	6.8	8.6

Note. CRCS = colorectal cancer screening; FOBT = fecal occult blood test. Lifetime CRCS refers to at least one recommended CRCS test in one’s lifetime.

Sociodemographic factors significantly associated with adherence to CRCS recommendations in bivariate analyses included age, gender, insurance status, and number of years residing in the United States (Table 4). Among the potential psychosocial constructs, self-efficacy, CRCS cons, subjective norms of CRCS, and fatalism were significantly associated with screening status (Table 5). Multivariable logistic analysis showed that self-efficacy (odds ratio [OR] = 1.43; 95% confidence interval [CI] = 1.14, 1.80), CRCS cons (OR = 2.14; 95% CI = 1.41, 3.24), female gender (OR = 1.75; 95% CI = 1.06, 2.90), and having insurance (OR = 2.73; 95% CI = 1.66, 4.49) were significantly associated with CRCS adherence (Table 6).

Table 4.

Univariate Analysis of Sociodemographic Factors by Screening Behavior.

	Adherence to Recommended CRCS Screening
Variable	%	n	p
Age (N = 544)			.120*
50-59 years	21.8	54
60-69 years	30.6	49
70 years and older	23.5	32
Gender (N = 544)			.221*
Female	26.2	104
Male	21.1	31
Marital status (N = 540)			.816
No spouse/partner	25.4	53
Spouse/partner	24.5	81
Education (N = 517)			.310
None	14.0	7
1-5 years	25.1	54
6-11 years	26.4	55
12 or more years	27.3	12
Birth Place (N = 537)			.899
Born in Mexico	24.6	103
Born in the U.S.	25.2	30
Years living in the U.S. (N = 534)			.006*
Less than 20 years in U.S.	16.2	22
20 years or more in U.S.	27.9	111
Income (N = 529)			.768
Less than $10,000	25.7	78
More than $10,000	26.1	31
Don’t know	22.4	24
Insurance (N = 536)			<.001*
Any	33.3	89
None	16.4	44

p < .25.

Table 5.

Univariate Analysis of Theoretical Constructs by Screening Behavior Adherent to Recommended CRCS Screening Guidelines.

	Had Any Recommended CRCS Screening
	Yes (SD)	No (SD)	t	df	p
Self-efficacy of colorectal cancer screening	3.94 (0.93)	3.42 (1.15)	4.84	538	<.001*
Perceived susceptibility to colorectal cancer	3.38 (0.93)	3.46 (0.93)	0.86	538	.388
Knowledge of colorectal cancer	2.76 (3.26)	3.09 (3.65)	0.91	542	.361
CRCS Pros	4.22 (0.53)	4.20 (0.54)	0.47	539	.639
CRCS Cons	2.91 (0.60)	2.63 (0.55)	5.01	539	<.001*
Subjective norms of CRCS	12.38 (4.83)	11.76 (5.29)	1.20	536	.231*
Cancer fatalism	5.97 (2.92)	6.39 (2.78)	1.49	536	.137*

p < .25.

Table 6.

Multivariable Logistic Model of CRCS Adherence (N = 520).

	Odds Ratio	Confidence Interval
Self-efficacy	1.43	(1.14, 1.80)*
CRCS cons	2.14	(1.41, 3.24)*
Cancer fatalism	1.00	(0.93, 1.09)
Subjective norms of CRCS	1.02	(0.98, 1.06)
Gender
Referent: Male
Female	1.75	(1.06, 2.90)*
Age
Referent: 50-59 years old
60-69 years old	1.12	(0.66, 1.90)
70 years and older	0.82	(0.44, 1.51)
Years in the U.S.
Referent: <20 years in the U.S.
≥20 years in the U.S	1.54	(0.89, 2.67)
Insurance
Any	2.73	(1.66, 4.49)*

p < .05.

Discussion

In this primarily Spanish speaking population of Mexican Americans, we found low rates for ever having a CRCS test in one’s lifetime (34%). We also found lower overall CRCS adherence (25%) in our study, compared with 2012 BRFSS reports, in which 53.1% of Hispanics had an FOBT or endoscopy within recommended time frames (Centers for Disease Control and Prevention, 2013).

The lower screening rates in our study may reflect screening barriers unique to communities on the Texas–Mexico border burdened by poverty. In our study, over a third of participants had household incomes of less than $10,000 (57%) and only 4.3% reported an income of $20,000 or higher. Educational level, another proxy measure for socioeconomic status, was also very low with only 9% who completed high school (compared with 60.9% of Hispanics nationally; Ryan & Siebens, 2012). The relative homogeneity in the population across these SES measures makes it difficult to detect significant differences in screening by income or education levels. Nonetheless, having health insurance coverage was an important factor influencing screening and those reporting coverage had three times the odds of reporting CRCS adherence. This finding is consistent with previous reports that insufficient insurance coverage represents an important barrier to CRCS (Halbert et al., 2011; Halpern et al., 2008; Jerant, Fiscella, Tancredi, & Franks, 2013; Patel et al., 2012; Seeff et al., 2004; Shahidi, Homayoon, & Cheung, 2013; Shariff-Marco, Breen, Stinchcomb, & Klabunde, 2013; Ward, Fedewa, Cokkinides, & Virgo, 2010; Wee, McCarthy, & Phillips, 2005), especially among Hispanics (Modiri, Makipour, Gomez, & Friedenberg, 2013; Thompson, Coronado, Neuhouser, & Chen, 2005). In our study population, the significant effect of health insurance coverage, primarily representing Medicaid and Medicare coverage versus no insurance may also reflect the effect of immigration status (e.g., length of time in the United States and documented status) that may be compounded by poverty.

Self-efficacy and CRCS cons (perceived barriers associated with screening) were significantly associated with completing at least one CRCS test in multivariable analyses. Self-efficacy has been positively associated with CRCS in several studies (Halbert et al., 2011; Jerant et al., 2007; McQueen et al., 2007; Menon, Belue, Sugg, Rothwell, & Champion, 2007; Myers et al., 1990; Vernon, Myers, & Tilley, 1997; Wang et al., 2013); however, to our knowledge, our study is the first to report this association in a Hispanic population. Our study findings also supported previous work showing that perceived barriers to screening (cons) are associated with lower levels of CRCS. Other researchers have found this association in studies among non-Hispanic White participants (Menon et al., 2007; Shelton, Jandorf, Ellison, Villagra, & DuHamel, 2011) and among multiethnic participants (Christie et al., 2005; Gorin & Heck, 2005; Gregory et al., 2011; Greiner et al., 2005; Koo et al., 2012; Shokar, Carlson, & Weller, 2008).

The presence of fatalistic beliefs has been suggested as an additional barrier to cancer screening in minority cultures (Powe & Johnson, 1995). A number of studies, however, have reported inconsistent findings concerning the association between fatalism and CRCS. This includes studies conducted in Hispanic groups (Abraido-Lanza et al., 2007). While some researchers have reported a significant negative association between FOBT completion and fatalism (Gorin, 2005; Greiner et al., 2005; Miles, Rainbow, & von Wagner, 2011; Shelton et al., 2011), other studies, (using the original 15-item scale developed by Powe; Christie et al., 2005; Jandorf et al., 2010; Shokar et al., 2008) and our study (using the modified 11-item cancer fatalism scale) found no significant association between fatalism and CRCS. The inconsistent evidence may reflect differences in the definition and measurement of fatalism. Although substantial evidence exists showing that the belief that a cancer diagnosis is “like a death sentence” is prevalent among Hispanics, and that this can lead to lower levels of screening (Perez-Stable, Sabogal, Otero-Sabogal, Hiatt, & McPhee, 1992), the other definitions of fatalism (measured in the Powe Inventory), including the belief in predetermination (the belief that an outcome is inevitable regardless of personal actions), do not seem to be significantly associated with CRCS. This finding is consistent with the qualitative study we conducted in these same three cities along the border (Fernandez et al., 2008). From a health education perspective, it is important to distinguish between different definitions of the fatalism construct. For example, the belief that a diagnosis of cancer means death can be addressed relatively easily using strategies such as testimonials from role models who have survived CRCS. Predeterministic beliefs, on the other hand, tend to be more ingrained and difficult to change. More research is needed to elucidate the differences between various types of fatalistic beliefs and how these may or may not be associated with screening behaviors.

Our study had several limitations. First, the outcome variable was self-report of CRCS adherence. Relying on self-reports of screening behavior introduces the possibility of reporting or recall bias. However, Rauscher, Johnson, Cho, and Walk (2008) reported acceptable sensitivity, specificity and positive predictive value for CRCS self-report. Sensitivity was 82% (CI = 73-88), specificity was 78% (CI = 71-83), and positive predictive value was 62% (CI = 50-73) for FOBT; for screening endoscopy sensitivity was 79% (CI = 73-84), specificity was 90% (CI = 85-93), and positive predictive value was 51% (CI = 41-62). A more recent study in an insured, English-speaking Hispanic population found that CRCS rates captured through self-report on the California Health Interview Survey were similar to those obtained through medical records, and the difference between self-report rates and medical record rates were similar across ethnic groups (Palaniappan et al., 2011). Hiatt et al. (1995) reported that among a multiethnic study population, in which the majority (63%) were Hispanic, among Hispanics only, specificity of self-reported sigmoidoscopy was high for men (91.5%) and women (96.2%), and sensitivity was also high for women (100%), but not so for men (40%). Among Hispanic women and men, respectively, specificity of self-reported FOBT was 82.4% and 80.8%, and sensitivity was 53% and 61.2%. No statistically significant differences were detected between the two ethnic groups’ self-report of screening using these tests (compared with medical record reviews; Hiatt et al., 1995).

Due to the cross-sectional study design, associations found cannot be interpreted as temporal. It is also likely that our study population’s socioeconomic homogeneity produced insufficient variance in income and education to detect an effect of these variables on CRCS. Last, these findings cannot be generalized to all U.S. Hispanic populations, which represent many different countries of origin, levels of acculturation, socioeconomic, and environmental circumstances.

Findings from this study suggest the need for health promotion interventions aimed at modifiable factors such as self-efficacy and cons of CRCS to increase initiation of CRCS as recommended by current guidelines. Our study also confirmed that insurance status is a significant predictor of adherence to CRCS guidelines. Although the Affordable Care Act may alleviate this barrier for some, it is important to note that regardless of an individual’s belief, access to preventive services such as CRCS is essential to increasing adherence and reducing cancer-related health disparities. Further work is also needed to understand the full complexity of personal-level barriers affecting decisions to be screened as well as the access barriers experienced by this socioeconomically disadvantaged Mexican American population.

Footnotes

Authors’ Note

The content is solely the responsibility of the authors and does not necessarily represent the official views of Centers for Disease Control or the National Cancer Institute or the National Institutes of Health.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by Cooperative Agreements (CDC PRC SIP 202U48 CCU60009653 and CDC PRC SIP 1604U48 CCU6009653) from the Centers for Disease Control and Prevention; National Cancer Institute Grant 2 R25 CA57712; and National Cancer Institute Grant 5K01CA15178504.

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Colorectal Cancer Screening Among Latinos in Three Communities on the Texas–Mexico Border

Abstract

Keywords

Method

Study Design and Data Collection

Measurement

Analysis

Results

Discussion

Footnotes

Authors’ Note

Declaration of Conflicting Interests

Funding

References