Colorectal Cancer Screening in 3 Racial Groups

Abstract

Objectives

To understand predictors of colorectal cancer (CRC) screening in African Americans, European Americans, and Native Americans as these groups differ in CRC incidence and mortality.

Methods

Participants were surveyed for knowledge, beliefs, and behaviors related to CRC.

Results

Predictive regression modeling found, after adjusting for race, CRC risk, and CRC worry, the odds of screening within guidelines were increased for men, those receiving doctor’s recommendation, those with polyp/tumor history, those under 70, those with more knowledge about CRC, and those with fewer barriers to screening. CRC screening rates did not differ by race.

Conclusions

These results reiterate the importance of knowledge, barriers, and physician recommendation for CRC screening in all racial groups.

Colorectal cancer (CRC) is the third leading cause of cancer and the second leading cause of cancer death in the United States for men and women combined. In 2005, over 145,000 people were estimated to have been diagnosed with CRC, and over 56,000 people were estimated to have died of CRC.¹ Incidence of CRC differs as a function of racial group. In the period 1997-2001, African Americans (men: 72.9; women: 56.5 per 100,000) had higher rates of CRC than those of European Americans (men: 63.1; women: 45.9 per 100,000). Native Americans had a lower incidence of CRC (men: 38.3; women: 32.7 per 100,000) than that of either of these groups. CRC mortality rates follow a similar pattern with African Americans (men: 34.3; women: 24.5 per 100,000) having higher rates of CRC mortality than those of European Americans (men: 24.8; women: 17.1 per 100,000). Native Americans had lower mortality from CRC (men: 17.1; women: 11.7 per 100,000) than both of the other groups did. For all races, women had lower incidence of and mortality from CRC compared to men.¹

CRC screening prevents cancer through the removal of precancerous polyps² and detects cancer at an earlier, more treatable stage.^3,4 Many organizations provide recommendations for routine screening for CRC. For example, the US Preventive Services Task Force (USPSTF) recommends the following for men and women 50 years and older: annual Fecal Occult Blood Tests (FOBT), flexible sigmoidoscopy (FS) every 5 years with or without annual FOBT, or colonoscopy every 10 years.¹ Recently, the American College of Gastoenterology recommended that, due to their higher incidence and later stage of presentation, CRC screening should begin for African Americans at age 45.⁵ Recommendations notwithstanding, CRC screening rates are lower than recommended. Approximately half or fewer of Americans have had recommended CRC screening.^6-9

Certain populations within the United States have lower levels of CRC screening, and disparities in CRC mortality may be attributable, in part, to differential screening rates.^10,11 In 2000, 41% of European Americans, 35.4% of African Americans, and 30.6% of Native Americans had an FOBT in the past year or a screening endoscopy (ie, FS or colonoscopy) in the past 5 years.¹ Some smaller studies have found no difference in CRC screening rates as a function of race,^7,9,12-15 whereas others have observed differences in screening behavior by race.^6,10,16-21 Further, African Americans were less likely to receive physician counseling regarding CRC screening than were European Americans.^18,19

Other predictors of CRC screening beyond race have been identified. Perhaps the most consistent barrier to CRC screening uptake is lack of physician recommendation.^17,22-28 Other barriers include concerns about pain or discomfort,^{21,24,25,28-30} fear of finding cancer,²⁹ scheduling concerns,²⁹ embarrassment,^17,28 cost,^25,28 inconvenience,²⁵ belief that the test is not needed or that no symptoms means no need for a test,^17,24 and lack of knowledge/awareness.^31-33 Perceiving benefits of CRC screening^28,34 and having a family history of CRC²³ have been identified as predictors of CRC screening. A number of studies have found both that perceived risk is positively associated with cancer screening^34-38 and that perceived risk is not related to cancer screening.^25,39 Some studies have found both to be true depending on the type of CRC screening test,²⁶ the length of time between assessments,¹² or the racial group.⁹ In addition to the barriers of fear of finding cancer and concern about pain from the procedure, some studies have examined cancer worry as a predictor of cancer screening. One study found less cancer worry to be a predictor of screening,³⁵ whereas other studies have found no relationship.^25,26

No studies were identified which examined colorectal screening in a triracial population of men and women. In addition, most studies have not explored the relationship of psychosocial variables (ie, perceived risk and worry) along with barriers, beliefs, and knowledge to CRC screening. The primary purpose of this report is to understand the predictors of CRC screening in a triracial (ie, African American, European American, and Native American) rural population.

METHODS

Participants

This study was conducted in Robeson County, NC, from 1998 to 2002. Robeson County is a rural county in southeastern North Carolina composed of 3 primary racial groups: Native American (38%), African American (25%), and European American (33%).⁴⁰ The Native American population in Robeson County, mostly comprising Lumbees, is the largest concentration of Native Americans east of the Mississippi River. The origins of the Lumbees are debated, with many believing they have links to or are modern-day remnants of the Hatteras, Eastern Cherokee, Croatan, or Cheraw tribes.^41,42 Although the Lumbees were formally recognized by the state of North Carolina as a tribe in 1885, efforts for federal recognition have not been as fruitful.⁴² As of 2002, there were nearly 53,000 active members of the Lumbee tribe, with most (65%) concentrated in 7 communities in Robeson County.⁴²

At the time of the study, the population of Robeson County had the eighth highest poverty rate in the state. The median family income in this county was $28,000 and was lower than state ($39,184) and national figures ($41,994). Approximately 20% of the families in this county lived below the poverty line.⁴⁰ In addition, the unemployment rate in this rural county (8%) was higher than the state (5%) and national (7%) unemployment rates. Only 49% of the county’s population had obtained a high school education or higher, and only 11% had a bachelor’s degree or higher. These percentages were much lower than state or national averages for high school education at 78% and 80%, respectively. This also holds true for state and national averages for those who have attained a bachelor’s degree or higher, 23% and 24% respectively.⁴⁰

Procedures

IRB approval was obtained prior to the conduct of this study, which was designed as a supplemental study to the Robeson County Outreach, Screening, and Education (ROSE) project.^43-45 The goal of the ROSE project was to improve screening for breast cancer in 3 underserved groups of women (rural European American, African American, and Native American). Participants in the current study were selected from the same clinical facility as the main project, the Robeson Health Care Corporation (RHCC). RHCC consists of 4 clinical sites where the majority of the population in the county received care; therefore, patients of the clinical sites were representative of the lower income population of the county. Potential participants, aged 51 and older, were randomly selected from patient lists provided by the RHCC with the intent of obtaining an equal number of Native Americans, African Americans, and European Americans. After random selection, an employee of RHCC confirmed eligibility and provided contact information of those eligible. Once the individual was determined eligible (eg, aged 51 and older, alive, and for women, not in the main ROSE project), a letter was sent to the patient’s physician of record informing the physician that the patient was eligible for the study. If after a week the physician did not object to the patient’s participation, a letter was sent from the RHCC chief medical director inviting the patient to participate in the study.

The invitation letter informed the patient of the nature and purpose of the study, explained that an interviewer would be contacting the patient to determine eligibility, and listed names and contact information for staff members to call if the patient was interested in participating in the study. Two weeks after mailing, nonrespondents were telephoned by a member of the study who was a resident of the local community. During this telephone call, a member of the ROSE staff introduced herself and the study to the patients. If the patient agreed to participate, an in-person interview was scheduled. Written consent was sought and obtained prior to initiating the interview. Those completing the interview received a $10 grocery store gift certificate in appreciation of their time.

Measures

Standard demographic information asked of participants included age, gender, marital status, education, and work status. Participants were asked the extent to which they worried about colon cancer on a 5-point scale (not at all to extremely) and their perceived risk of colon cancer compared to others of their gender, age, and race on a 5-point scale (much lower to much higher).^9,38 One item assessed physician recommendation for CRC screening.²⁵ Survey items included barriers (ie, “Flexible sigmoidoscopy costs too much.” ), beliefs (ie, “If you feel OK, a flexible sigmoidoscopy won’t find anything.”), and knowledge (ie, “Name a test useful in detecting colon cancer.”) of CRC and of CRC screening (FS in particular).^9,25,45 Barriers, beliefs, and knowledge items were summarized into composite measures by adding or subtracting a “point” according to responses for each item as listed in Appendix A. The measures were then standardized on a scale of 0 to 10 in each category and split at the median (<=5) for display in tables. The outcome variable of CRC screening was a selfreported measure of whether an individual had an FOBT in the past year, a sigmoidoscopy in the past 5 years, or a colonoscopy in the past 10 years.

Appendix Scoring of Survey Items for Barriers, Beliefs, and Knowledge Composite Measures

Barriers items: A higher score for Barriers indicates more barriers to getting a flex sig.
	Yes		No
Someone encouraged me to have FS.	−1		+1
Someone discouraged me to have FS.	+1		−1
I have insurance.	−1		+1
	Strongly		Disagree/
	Agree/	Not	Strongly
	Agree	Sure	Disagree
FS takes too much time.	+1	+0	−1
I don’t know where to get FS.	+1	+0	−1
FS costs too much.	+1	+0	−1
Discomfort keeps me from getting FS.	+1	+0	−1
Beliefs items: A higher score for Beliefs indicates positive beliefs about flex sig.
	Strongly		Disagree/
	Agree/	Not	Strongly
	Agree	Sure	Disagree
If you feel OK, a FS won’t find anything.	−1	+0	+1
The FS is uncomfortable.	−1	+0	+1
Enemas are a bother.	−1	+0	+1
It’s safe.	+1	+0	−1
FS hurts.	−1	+0	+1
FS is useful.	+1	+0	−1
FS is embarrassing.	−1	+0	+1
Afraid if they find something, part of my colon would be removed.	−1	+0	+1
Knowledge items: A higher score for Knowledge indicates more knowledge about the tests and colorectal cancer.
	Knew		Didn’t Know
Name a test useful in detecting colon cancer. (FS, FOB, or colonoscopy)	+1		−1
Do you know what a FS or FOBT is?	+1		−1
Do you know how often to be screened for FS or FOBT?	+1		−1
	Agree		Disagree
After a couple tests are ok, don’t need to be tested anymore.	−1		+1
Colon cancer runs in families.	+1		−1
Only people who eat a lot of high-fat foods will get colon cancer.	−1		+1
Black people are more likely to get colon cancer than white people.	+1		−1
Men are more likely to get colon cancer than women	−1		+1
	Strongly		Disagree/
	Agree/	Not	Strongly
	Agree	Sure	Disagree
People have no control over whether colon cancer will be detected early.	−1	−1	+1
Taking vitamins can help prevent colon cancer.	+1	−1	−1
Regular exercise can help prevent colon cancer.	+1	−1	−1
A person can tell if he/she has colon cancer without going to the doctor for tests.	−1	−1	+1
Colon cancer can’t be cured, so there’s no reason to get screened.	−1	−1	+1
High-fiber, low-fat diet prevents colon cancer.	+1	−1	−1

Statistical Analysis

Frequencies and percentages were calculated for demographic variables, physician recommendation for a CRC screening test, barriers, beliefs, knowledge, and psychological variables by race and overall. Chi-square tests and Fisher’s exact tests tested for a relationship between each factor and race, separately by gender. These methods also examined relationships between each factor and CRC screening separately by race and gender. Predictive logistic regression modeling, using purposeful forward selection,⁴⁶ was completed to determine which variables (of those listed in Tables 1 and 2) constituted the best set of predictors of CRC screening. Gender, race, risk, and worry were forced into the model as they were of particular interest and as a means of accounting for any confounding effects. All analyses were performed with the SAS System for Windows, version 9.1.

Table 1.

Demographic and Psychosocial Factors Compared between 3 Races, Separately by Gender, Among Participants from the Robeson Health Care Corporation (N=171)^a

Variable		European American (n=49) N (%)	African American (n=65) N (%)	Native American (n=57) N(%)	Total (n=171) N (%)
Age (yrs)
Female	Mean (SE)	65.51 (1.4)	67.68 (1.4)	62.89 (1.4)	65.39 (9.3)
Male	Mean (SE)	59.05 (3.3)	62.81 (2.2)	64.22 (2.6)	62.48 (9.7)
Education
Female	Less than high school	20 (50)	27 (60)	27 (63)	74 (58)
	High school graduate, GED	10 (25)	14 (31)	6 (14)	30 (23)
	Some college, trade school	10 (25)	4 (9)	10 (23)	24 (19)
Male	Less than high school	4 (44)	13 (65)	8 (57)	25 (58)
	High school graduate, GED	2 (22)	7 (35)	5 (36)	14 (33)
	Some college, trade school	3 (33)	0 (0)	1 (7)	4 (9)
Working
Female	Unemployed/volunteer/disabled	14 (35)	15 (33)	19 (44)	48 (38)
	Part/Full Time	10 (25)	10 (22)	12 (28)	32 (25)
	Retired	16 (40)	20 (44)	12 (28)	48 (38)
Male	Unemployed/volunteer/disabled	6 (67)	14 (70)	5 (36)	25 (58)
	Part/Full Time	2 (22)	2 (10)	4 (29)	8 (19)
	Retired	1 (11)	4 (20)	5 (36)	10 (23)
Married
Female**	Single/Separated/Widowed	19 (48)	36 (80)	32 (74)	87 (68)
	Married/Living Together	21 (53)	9 (20)	11 (26)	41 (32)
Male **	Single/Separated/Widowed	6 (67)	10 (50)	3 (21)	19 (44)
	Married/Living Together	3 (33)	10 (50)	11 (79)	24 (56)
Insurance
Female	No	8 (20)	11 (24)	9 (21)	28 (22)
	Yes	32 (80)	34 (76)	34 (79)	100 (78)
Male	No	2 (22)	2 (10)	3 (21)	7 (16)
	Yes	7 (78)	18 (90)	11 (79)	36 (84)
Did doctor ever recommend FS?
Female	No	34 (85)	38 (84)	35 (81)	107 (84)
	Yes	6 (15)	7 (16)	8 (19)	21 (16)
Male	No	8 (89)	19 (95)	13 (100)	40 (95)
	Yes	1 (11)	1 (5)	0 (0)	2 (5)
Did doctor ever recommend FOBT?
Female	No	21 (53)	25 (56)	27 (63)	73 (57)
	Yes	19 (48)	20 (44)	16 (37)	55 (43)
Male	No	9 (100)	13 (65)	9 (64)	31 (72)
	Yes	0 (0)	7 (35)	5 (36)	12 (28)
Perceived risk of CRC
Female	Somewhat/Much Lower	5 (14)	11 (27)	5 (13)	21 (18)
	About the Same	28 (76)	27 (66)	25 (66)	80 (69)
	Somewhat/Much Higher	4 (11)	3 (7)	8 (21)	15 (13)
Male	Somewhat/Much Lower	2 (25)	2 (11)	6 (43)	10 (24)
	About the Same	5 (63)	12 (63)	4 (29)	21 (51)
	Somewhat/Much Higher	1 (13)	5 (26)	4 (29)	10 (24)
Worry about getting CRC
Female	Quite a bit/Extremely	5 (13)	5 (11)	6 (14)	16 (13)
	Moderately	1 (3)	5 (11)	5 (12)	11 (9)
	A Little	14 (35)	10 (22)	14 (33)	38 (30)
	Not at All	20 (50)	25 (56)	18 (42)	63 (49)
Male	Quite a bit/Extremely	0 (0)	3 (15)	1 (7)	4 (9)
	Moderately	1 (11)	2 (10)	0 (0)	3 (7)
	A Little	0 (0)	3 (15)	5 (36)	8 (19)
	Not at All	8 (89)	12 (60)	8 (57)	28 (65)
Has doctor told you that you have tumor or polyps?
Female *	Yes, Tumor or Polyps	8 (20)	1 (2)	6 (14)	15 (12)
	No	32 (80)	44 (98)	37 (86)	113 (88)
Male	Yes, Tumor or Polyps	1 (11)	1 (5)	2 (14)	4 (10)
	No	8 (89)	18 (95)	12 (86)	38 (90)
Barriers Score
Female *	Mean (SE)	5.18 (0.4)	6.24 (0.4)	5.02 (0.4)	5.50 (2.5)
Male	Mean (SE)	5.22 (0.7)	5.25 (0.5)	6.00 (0.5)	5.49 (2.0)
Belief Score
Female *	Mean (SE)	4.70 (0.3)	4.42 (0.3)	5.58 (0.3)	4.90 (2.1)
Male	Mean (SE)	6.87 (0.9)	5.68 (0.6)	4.22 (0.7)	5.45 (2.7)
Knowledge Score
Female	Mean (SE)	5.96 (0.3)	5.05 (0.3)	5.19 (0.3)	5.38 (2.0)
Male	Mean (SE)	5.28 (0.5)	5.75 (0.4)	5.83 (0.4)	5.68 (1.6)
CRC Screening in Guidelines
Female	No	31 (78)	41 (91)	35 (81)	107 (84)
	Yes	9 (23)	4 (9)	8 (19)	21 (16)
Male	No	8 (89)	16 (80)	10 (71)	34 (79)
	Yes	1 (11)	4 (20)	4 (29)	9 (21)

Note.

^*P<.05;

^**P<.01

^aTo compare demographic factors between races, separately by gender, F-tests (ANOVA) were used for comparison of means, chi-square tests were used for categorical data with ample sample size, and Fisher’s exact test was used where any cell counts were smaller than 5.

Table 2.

Guidelines for CRC Screening Compared Between Levels of Demographic and Psychosocial Factors, Separately by Race and Gender, Among Participants from the Robeson Health Care Corporation (N=171)a

Variable		European American (n=49) N (%)	African American (n=65) N (%)	Native American (n=57) N (%)
Age (yrs)
Female	51 to 59	2 (17)	0 (0)	4 (22)
	60 to 69	5 (36)	2 (13)	3 (15)
	70 and over	2 (14)	2 (13)	1 (20)
Male	51 to 59	0 (0)	3 (38)	2 (40)
	60 to 69	1 (100)	1 (14)	1 (17)
	70 and over	0 (0)	0 (0)	1 (33)
Education
Female	Less than high school	4 (20)	2 (7)	2 (7)*
	High school graduate, GED	3 (30)	1 (7)	0 (0)
	Some college, trade school	2 (20)	1 (25)	6 (60)
Male	Less than high school	1 (25)	2 (15)	2 (25)
	High school graduate, GED	0 (0)	2 (29)	1 (20)
	Some college, trade school	0 (0)	0 (0)	1 (100)
Work status
Female	Unemployed/volunteer/disabled	5 (36)	0 (0)	3 (16)
	Part/Full Time	2 (20)	0 (0)	3 (25)
	Retired	2 (13)	4 (20)	2 (17)
Male	Unemployed/volunteer/disabled	0 (0)	2 (14)	1 (20)
	Part/Full Time	1 (50)	0 (0)	1 (25)
	Retired	0 (0)	2 (50)	2 (40)
Married
Female	Single/Separated/Widowed	5 (26)	2 (6)	6 (19)
	Married/Living Together	4 (19)	2 (22)	2 (18)
Male	Single/Separated/Widowed	1 (17)	1 (10)	0 (0)
	Married/Living Together	0 (0)	3 (30)	4 (36)
Insurance
Female	No	1 (13)	1 (9)	0 (0)
	Yes	8 (25)	3 (9)	8 (24)
Male	No	0 (0)	0 (0)	2 (67)
	Yes	1 (14)	4 (22)	2 (18)
Did doctor ever recommend FS?
Female	No	5 (15)	1 (3) **	4 (11) *
	Yes	4 (67)	3 (43)	4 (50)
Male	No	0 (0)	3 (16)	3 (23)
	Yes	1 (100)	1 (100)	0 (0)
Did doctor ever recommend FOBT?
Female	No	2 (10)	1 (4)	4 (15)
	Yes	7 (37)	3 (15)	4 (25)
Male	No	1 (11)	1 (8)	1 (11)
	Yes	0 (0)	3 (43)	3 (60)
Perceived risk of CRC
Female	Somewhat/Much Lower	0 (0)	0 (0)	1 (20)
	About the Same	7 (25)	1 (4)	6 (24)
	Somewhat/Much Higher	2 (50)	0 (0)	1 (13)
Male	Somewhat/Much Lower	0 (0)	0 (0)	1 (17)
	About the Same	1 (20)	4 (33)	1 (25)
	Somewhat/Much Higher	0 (0)	0 (0)	2 (50)
Worry about getting CRC
Female	Quite a bit/Extremely	3 (60)	0 (0)	0 (0)
	Moderately	0 (0)	0 (0)	1 (20)
	A Little	4 (29)	1 (10)	3 (21)
	Not at All	2 (10)	3 (12)	4 (22)
Male	Quite a bit/Extremely	0 (0)	0 (0)	1 (100)
	Moderately	0 (0)	0 (0)	0 (0)
	A Little	0 (0)	0 (0)	1 (20)
	Not at All	1 (13)	4 (33)	2 (25)
Has doctor told you that you have polyps or tumor?
Female	Yes, Tumor or Polyps	3 (38)	0 (0)	4 (67) **
	No	6 (19)	4 (9)	4 (11)
Male	Yes, Tumor or Polyps	1 (100)	0 (0)	2 (100)
	No	0 (0)	4 (22)	2 (17)
Barriers [Above Median (>5)]
Female	No	6 (38)	3 (21)	7 (33) *
	Yes	3 (13)	1 (3)	1 (5)
Male	No	1 (14)	3 (27)	2 (29)
	Yes	0 (0)	1 (11)	2 (29)
Beliefs [Above Median (>5)]
Female	No	4 (20)	2 (7)	1 (6)
	Yes	5 (25)	2 (12)	7 (28)
Male	No	0 (0)	2 (25)	2 (22)
	Yes	1 (14)	2 (17)	2 (40)
Knowledge [Above Median (>5)]
Female	No	0 (0) *	3 (11)	2 (10)
	Yes	9 (35)	1 (6)	6 (27)
Male	No	1 (20)	2 (25)	1 (17)
	Yes	0 (0)	2 (17)	3 (38)

Note.

^*P<.05;

^**P<.01

a CRC Screening includes FS in 5 years, FOBT in 1 year, and colonoscopy in 10 years.

No tests are reported comparing the 3 races.

All tests were performed, separately by race and gender, with Fisher’s exact test due to small cell counts.

RESULTS

Four hundred fifty-one individuals were randomly selected to participate in this survey. Upon medical chart review, 328 were eligible (ie, over age 50, not deceased, and not a participant in the main ROSE project) and approached for participation in the study. Thirty-six (11.0%) refused participation. An additional 73 individuals (22.3%) were not available for interview for a variety of reasons (eg, moved, deceased, mental/physical incompetence). Therefore, a total of 219 participants (159 women and 60 men) completed the survey. Participants who had only received CRC tests for diagnostic purposes or had missing data (n=48 or 21.9%) were removed from analysis, resulting in a total of 171 participants (128 women and 43 men) included in all analyses.

Table 1 shows differences among races within each gender. For women, the African Americans in the sample were slightly older on average (M=67.68 years, SE=1.4) than the European Americans (M=65.51 years, SE=1.4) and Native Americans (M=62.89 years, SE=1.4) (F(2,125)=3.05, P=0.051). More European American women were married/living together (53%) than African American (20%) or Native American women (26%) (χ²(2)=11.51, P=0.003). Only 2% of African American women were ever told by a doctor they had a polyp compared to 14% of Native Americans and 20% of European Americans (Fisher, P=0.020). More barriers to screening were reported by African American women (0 to 10 scale: M=6.24 SE=0.4) than European Americans (M=5.18 SE=0.4) or Native Americans (M=5.02 SE=0.4) (F(2,125)=3.26, P=0.042). African American women also reported less positive beliefs about CRC screening (0 to 10 scale: M=4.42 SE=0.3) than did European Americans (M=4.60 SE=0.3) and Native Americans (M=5.58 SE=0.3) (F(2,125)=3.81, P=0.025). Men did not differ as much between races. European American men had a marginally higher belief score (0 to 10 scale: M=6.87 SE=0.9) than those of African American men (M=5.68 SE=0.6) and Native American men (M=5.45 SE=2.7) (F(2,40)=3.02, P=0.060).

Only 17.5% (30/171) of the sample was within current CRC screening guidelines (excluding diagnostic tests). Table 2 includes the frequencies and percentages of participants within guidelines for CRC screening by race and gender for the variables of interest. For Native Americans, women with some college education were more likely to be screened (60%) than those who were high school graduates (0%) or those who had less than a high school degree (7%) (Fisher P=.002) Women who had a doctor’s recommendation for FS had higher screening rates compared to those without a doctor’s recommendation within each race (European Americans 67% vs 15%, Fisher P=.016; African Americans 43% vs 3%, Fisher P=.009; Native Americans 50% vs 11%, Fisher P=.028). Of Native American women who previously had a polyp, 67% were within CRC screening guidelines compared to only 11% of those who had not had a polyp (Fisher P=.007). Native American women with barrier scores below the median were more likely to be screened (33%) than those above the median (5%) (Fisher P=.021). European American women with knowledge scores above the median were more likely to be screened (35%) than those below the median (0%) (Fisher P=.016).

The final logistic regression model for predicting whether or not an individual was within guidelines for CRC screening contained effects for gender, race, risk, and worry (forced into the model); doctor’s recommendation for FOBT or FS; history of polyps or tumors; age; barrier score; and knowledge score. After simultaneously adjusting for all of these variables in the model, the odds of screening within guidelines were increased for men (OR=6.69, 95% CI: 1.41, 31.78), participants who reported a doctor’s recommendation for FOBT (OR=8.45, 95% CI: 2.20, 32.40) or FS (OR=7.96, 95% CI: 1.24, 51.03), those with a history of polyps or tumors (OR=11.24, 95% CI: 1.68, 75.15), those under 70 years old (OR=8.54, 95% CI: 1.07, 68.41), and with every unit increase in CRC knowledge score (OR=1.72, 95% CI: 1.16, 2.56). Participants’ odds of screening within guidelines decreased with every unit increase in barriers score (OR=0.73, 95% CI: 0.56, 0.96).

DISCUSSION

The primary purpose of this study was to understand predictors of CRC screening in African American, European American, and Native American men and women in a poor, distressed county. Overall, less than one fifth of the sample was up-todate on CRC screening. This does not compare favorably with screening rates found in prior studies.¹ Because this county was rural and one of the poorest in North Carolina, access to CRC screening may have been a greater challenge for individuals in our study than in those of prior studies reporting higher screening rates. The finding that males were more likely to be within guidelines for CRC screening than females is consistent with males’ greater likelihood of having the disease. However, the guidelines for CRC screening do not differ for men and women; therefore, this disparity in screening is of concern. Greater efforts are needed to promote CRC screening in women 50 years of age and older.

We found that European, African, and Native Americans did not differ in cancer screening rates, and this was true even though a single race categorization (ie, no mixed races) consistent with the US Census⁴⁰ was used, which has been noted to decrease the similarity between European and Native American screening rates.⁴⁷ In our analyses, we used the previous guideline of age 50 and older for CRC screening in African Americans. Further analyses indicated that African American women were less likely to be married/living together than European Americans (possibly indicating less social and financial support), were less likely than other racial groups to be told they had a polyp, had more barriers to CRC screening than did other racial groups, and less positive beliefs about CRC screening. Thus, promotion of the revised guidelines for earlier CRC screening in African Americans (particularly for women)⁵ faces the additional obstacles of more barriers to and less positive beliefs about CRC screening in African American women.

The predictors of CRC screening in this triracial population also indicate potential interventions to increase screening. Essentially, there are 2 interrelated areas for intervention: increasing patient desire and improving physician recommendation for screening. For patient desire for screening, consistent with prior studies,^9,25 our results indicate the following may be necessary: (a) acknowledgment of the need of CRC screening (ie, knowledge of screening) and (b) few, if any, barriers to screening. In addition to patient desire for screening, consistent with prior studies,^17,22-28 we found physician recommendation was a critical predictor of CRC screening, and only about half of women and less than half of men (nearly 40%) in the study reported physician recommendation for CRC screening. For those with less knowledge about the need and availability of cancer screening, physician recommendation may be the key source of information regarding CRC screening. However, even with physician recommendation, if the individual has too many barriers to CRC screening (eg, inadequate time to have colonoscopy), physician recommendation may be insufficient. Thus, interventions to increase knowledge and decrease barriers, along with increasing physician recommendation, are needed to increase CRC screening in all racial groups.

A number of limitations to the present study must be noted. First, income level and family history of CRC were not included in our study. These may be important predictors of CRC screening.^38,48 Second, our sample was from a population with relatively low socioeconomic status who were available for interview. Thus, the generalizability of our findings to other samples of higher socioeconomic status or those unavailable for interview is limited. Third, as most Native Americans in Robeson County were Lumbees, we are uncertain how these results will generalize to other Native American groups in other locations. Fourth, the scales used were taken from previously published studies and were derived from qualitative methods; hence psychometric properties of the scales have not been established. Further, the use of a 5-point scale may have decreased the likelihood that we were able to discriminate among groups. Finally, self-reported CRC screening was not confirmed by actual medical records.

In conclusion, this is the first study examining CRC screening in European American, African American, and Native American men and women. Consistent with other studies, the results of this study reiterate the importance of physician recommendation for a screening test, individual knowledge about screening tests, and barriers to CRC screening. For the physician, interventions are needed which increase the likelihood of recommendation for screening by physicians, such as chart reminders and educational efforts.⁴⁹ For the individual, efforts are needed to increase knowledge of CRC and CRC screening and to decrease barriers for CRC screening. One such intervention method that shows promise is the use of lay health advisors to promote CRC screening.^50,51 This may be of particular importance in the African American community because (a) African Americans have the highest incidence of CRC and earliest age of CRC onset;⁵ (b) African Americans have more barriers to, less positive beliefs about, and lower knowledge of CRC screening; and (c) guidelines for the African American community have been recently revised to 45 years of age. In summary, to see increases in CRC screening, particularly in the African American population most at risk for CRC, a combined effort is needed, directed at the physician to increase CRC screening recommendation and the individual to decrease barriers to and to improve knowledge about CRC screening.