Factors associated with colorectal cancer screening intent and uptake among adult Non-Hispanic Black men

Abstract

Non-Hispanic (NH) Black men in the United States have the lowest five-year colorectal cancer (CRC) survival rate across all racial/ethnic and sex subgroups and are less likely than their NH White counterparts to complete CRC screening. We hypothesized that greater masculinity barriers to medical care (MBMC) would be negatively associated with CRC screening uptake. Employing a survey design, we examined the MBMC scale and other psychosocial factors influencing CRC screening intent and uptake in a sample of 319 NH Black men aged 45 to 75 years residing in Minnesota, Ohio, and Utah. A series of ordinary least squares and logistic regression models were run with intention and uptake as the outcome variable while controlling for various demographic characteristics. Independent variables in all models included average score on the MBMC; CRC screening knowledge, beliefs and values; and barriers to and social support for CRC screening. Social support, marital status, and age were positively associated with CRC screening intention. Increased CRC screening knowledge and older age were associated with a greater likelihood of completing a stool-based screening test for CRC. Fewer masculinity-related and CRC screening barriers were associated with a greater likelihood of undergoing a sigmoidoscopy or colonoscopy. Contrary to our primary hypothesis, lesser MBMC-related perceptions were associated with increased CRC screening uptake among NH Black men. Our findings inform future CRC promotion programs and emphasize the need for multilevel interventions tailored toward this marginalized population to reduce disparities in screening and survival.

Introduction

Colorectal cancer (CRC) is the second leading cause of cancer death and third most-diagnosed cancer among both men and women in the United States [1]. CRC incidence is 31% higher in men than in women, while men aged 55 to 74 years have the highest incidence rate across all racial/ethnic and sex subgroups [2-4]. Non-Hispanic (NH) African-American/Black men and women experience a disproportionate burden of CRC, with incidence rates 24% and 19% higher, respectively, than their NH White counterparts [2,5]. Between 2011 and 2015, CRC incidence rates for NH Black men and women were 55.2 and 40.7 per 100,000, respectively, compared with 44.6 and 34.2, respectively, for NH White men and women [5].

Between 1990 and 2014, across all racial/ethnic subgroups, one in every 10 new CRC diagnoses occurred in an individual aged under 50 years [6]. Between 1995 and 2014, CRC incidence increased by 2.41% among individuals aged 25 to 29 years [7]. These data demonstrate a trend of increasing incidence of early-onset CRC (EOCRC), defined as CRC diagnosed in a person aged 50 years or younger [8-12]. Compared with NH White men, NH Black men have a higher age-adjusted incidence rate of EOCRC and are diagnosed at an earlier age [6,13]. Furthermore, higher mortality is observed in NH Black men diagnosed with EOCRC than in their NH White counterparts [13,14].

For over 25 years, NH Black men have been less likely than NH White men to complete CRC screening [2,15-19]. A complex interplay of masculinity, racism, and attitudes toward CRC screening contributes to screening inequities among NH Black men [20-28]. Because higher CRC screening completion rates correspond with lower CRC-related morbidity and mortality [2,22,29-31], efforts to increase CRC screening uptake among NH Black men in the United States should be a public health priority.

Whether to reduce the recommended age at which to begin CRC screening in NH Blacks has been a matter of debate since 2008 [22,32,33]. Although those diagnosed with CRC before age 50 years are more likely to have advanced disease at diagnosis, they are also more likely to have better overall survival than those who are aged 50 or older at diagnosis [34].

The National CRC Roundtable established the 80% in Every Community initiative to focus on increasing CRC screening rates to 80% in every community by 2024 [35]. To achieve this goal, barriers to CRC screening faced by NH Black men require deeper investigation, including examination of psychosocial factors such as knowledge and attitudes, masculinity barriers, medical mistrust, and access to care [28,36-38]. Accordingly, the purpose of this study was to explore the association of masculinity barriers to medical care (MBMC) constructs developed by the study’s first author, along with other psychological factors such as knowledge, attitudes, beliefs, and social support, with CRC screening intention and uptake. The study employed a survey design in a sample of NH Black men aged 45 to 75 years residing in Minnesota, Ohio, and Utah. Our central hypothesis was that greater masculinity barriers to medical care would be negatively associated with CRC screening uptake.

Conceptual framework

A conceptual framework integrating constructs of the Theory of Planned Behavior (TPB) guides this study, coined #CuttingCRC. The TPB posits that behavior is a function of intention, which is influenced by a person’s attitudes and beliefs [39]. Our conceptual framework has been transformed since it was initially proposed, where medical mistrust was hypothesized to be a standalone construct [40]. After conducting 11 focus groups in Minnesota, Ohio, and Utah (to inform development of our team’s masculinity barriers to medical care [MBMC] scale [41], followed by 10 cognitive interviews with CRC advocate-survivors (to improve the MBMC scale’s face validity) and item review by two experts in NH Black men’s health and one survey-methodology expert (to improve the MBMC scale’s content validity), revision of the MBMC scale resulted in six factors (Provider Role, Health-related Self-Reliance, Health Problem Minimization, Restrictive Emotionality, Fear of being Perceived as Gay, and Medical Mistrust). Figure 1 illustrates how the updated MBMC construct, other psychosocial factors, and demographic characteristics (e.g., age, insurance status) may influence CRC screening intention and ultimately uptake among NH Black men.

Figure 1.

Conceptual model of factors influencing CRC uptake among African-American men.

Materials and methods

Study design and samples

Men were eligible for the study if they (a) self-identified as NH Black; (b) were aged 45 to 75 years; (c) were born in the United States; (d) resided in Minnesota, Ohio, or Utah; (e) understood and spoke English; and (f) had a telephone or computer/tablet with internet access. The University of Utah’s institutional review board approved the study protocol prior to data collection.

Between March and December 2020, a convenience-sampling plan was employed online and via 11 barbershops and three churches. From March to October, survey data were collected via the Internet-based survey research tool PsychData. During November and December, data were collected via the Qualtrics online survey platform. Smartphones were primarily used to complete the survey. NH Blacks outpace all demographic groups for smartphone use [42]; moreover, the use of smartphones and computers soared during the COVID-19 pandemic. Additionally, a central website permitted participation by eligible men who did not frequent barbershops.

A total of 343 NH Black men completed the online survey (n=208 via PsychData, n=135 via Qualtrics), of whom 319 (93%) met all inclusion criteria after missing data were assessed; 189 surveys were completed on smartphones, 114 on computers or tablets.

Recruitment

Participants were initially recruited through culturally tailored flyers and handbills shared across social media platforms (e.g., Facebook, Twitter); email listservs; gastroenterology centers; and predominantly NH Black-serving barbershops and churches [40]. Due to unforeseen recruitment challenges stemming from the forced closures of barbershops and churches during the COVID-19 pandemic, in November and December 2020 the research team partnered with the software company Qualtrics to recruit additional participants from sources such as online gaming sites, permission-based online networks, and loyalty web portals.

Data collection

The survey was housed at CuttingCRC.com. Informed consent was obtained online from all study participants before they started the survey. Participants who completed the survey via PsychData could enter a random drawing for one of five incentives in the form of items often wanted by men. Participants who completed the survey via Qualtrics were compensated through various sources that they agreed upon before entering the survey, including frequent flyer miles, retail-outlet points, and gift cards.

Measures

We employed the new Masculinity Barriers to Medical Care, Psychosocial Factors, and CRC Screening instrument derived from our previous, psychometrically sound Male Role Norms, Knowledge, Attitudes, and Perceptions associated with CRC Screening (MKAP-CRCS) survey [43]. We made some modifications to the survey for this study to increase its relevance to our conceptual model (Figure 1). First, our new MBMC scale replaced the masculine role-norms questions. This key independent variable was followed by three additional independent variables, namely the knowledge, attitudes, and perceptions sections of the MKAP-CRCS survey, removing items for which α was less than 0.5 in our previous study [27].

Next, we used two Behavioral Risk Factor Surveillance System (BRFSS) questions to assess our outcome variable, CRC screening uptake: (1) “A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. Have you ever had this test using a home kit?”; And (2) “Sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the colon for signs of cancer or other health problems. Have you ever had either of these exams?” [44]. Lastly, we included demographic covariates such as age, marital status, educational level, and income, as previous studies by our group and others have found that these factors are related to CRC screening behaviors among NH Black men [22,45-47]. Additional details regarding both the characteristics and psychometric properties of these items are documented elsewhere [43,48].

Data analyses

All analyses were conducted using Stata version 14 (StataCorp, College Station, TX, USA), with statistical significance set at P<0.05. Descriptive statistics summarize participants’ demographic characteristics and main outcome variables. To explore associations among the proposed constructs (see Supplementary Table 1), we ran a series of ordinary least squares (OLS) and logistic regression models with intention and uptake as the outcome variables while controlling for various demographic characteristics. CRC screening intention was the outcome variable in the OLS model, whereas CRC screening uptake was the outcome variable in the logistic regression models. The independent variables in all models included the average score of the following constructs: MBMC (24 items), knowledge about CRC screening (6 items), beliefs and values about CRC screening (5 items), barriers to CRC screening (4 items), and social support for CRC screening (4 items).

Results

Sample characteristics

Study participants were 319 NH Black men residing in Minnesota (n=52), Ohio (n=139), and Utah (n=105). Most were aged between 56 and 64 years (43.3%), married (45.4%), and had at least a high school diploma. Most of the study sample (94.24%) identified as heterosexual. Many participants had an income greater than $75,000 (42.07%) and were employed full-time (57.29%). Table 1 presents additional descriptive information and frequencies for the key independent and dependent outcomes.

Table 1.

Participant and item characteristics

Demographic variables (n=319)	Summary statistics
	N	%
Age
45-49 years	68	21.3
50-55 years	58	18.2
56-64 years	138	43.3
65-75 years	52	16.3
Educational level
Partial high school	5	1.7
GED or equivalent	8	2.7
High school diploma	40	13.6
Bachelor’s degree	77	26.1
Partial college (at least one year)	56	19.0
Two year college/associate degree	61	20.7
Master’s/advanced degree	48	16.3
Marital Status
Married	134	45.4
Other	161	54.6
State
Minnesota	52	17.39
Ohio	139	46.49
Utah	105	35.12
Sexual orientation
Heterosexual/straight	278	94.24
Homosexual/gay	10	3.39
Bisexual	5	1.69
Household income
Less than $15,000	21	7.24
$15,000-$24,999	21	7.24
$25,000-$34,999	37	12.76
$35,000-$49,999	39	13.45
$50,000-$74,999	50	17.24
More than $75,000	122	42.07
Work
Full-time	169	57.29
Part-time	27	9.15
Laid off	15	5.08
Retired	84	28.47
Health insurance
Yes	274	92.88
No	21	7.12
CRC diagnosis
Yes	7	2.38
No	287	97.62
Access to PCP
Yes	259	87.50
No	36	12.16
Doctor’s visit in last 12 months
Yes	256	86.49
No	39	13.18
CRC screening advice
Yes	112	38.10
No	182	61.90
Religiosity
Christian	230	78.50
Other (i.e., atheist, Muslim)	63	21.51
Smoking
Daily	65	22.81
Less than daily	21	7.37
Not at all	199	69.82
Family history of cancer
Yes	34	11.60
No	145	49.49
Unsure	114	38.91
Family history of CRC
Yes	30	10.17
No	232	78.64
Unsure	33	38.91
Independent variables	Summary statistics
	M	SD
Masculinity Barriers to Medical Care	3.52	0.35
Knowledge about CRC screening	5.06	1.23
Beliefs and values about CRC screening	3.76	0.99
Barriers to CRC screening	4.31	0.88
Social support for CRC screening	3.75	1.02
Dependent variables	Summary statistics
	M or N	SD or %
Do you plan to obtain CRC screening in the future?
Ranges from No (1) to within 6 months	4.49	1.54
Have you ever had a blood stool test using a home kit?
Yes	93	32.98
No	189	67.02
Have you ever had a sigmoidoscopy or colonoscopy?
Yes	167	59.22
No	115	40.78

PCP, primary care physician. Note: Because of missing data, some categories may not sum to 100%.

Main findings

Table 2 summarizes findings for the OLS model on CRC screening intention; Tables 3 and 4 summarize findings for the logistic regression models on CRC screening uptake.

Table 2.

Associations between factors in Rogers’ conceptual model and CRC screening intention (N=253)

Variables	Model 1 (R2=0.03)			Model 2 (R2=0.05)
	B	95% CI	P>|z|	B	95% CI	P>|z|
Masculinity barriers to medical care	0.61	-0.01, 1.23	0.05	0.60	-0.00, 1.22	0.05
Knowledge about CRC screening	0.06	-0.09, 0.22	0.40	0.08	-0.07, 0.24	0.29
Beliefs and values about CRC screening	-0.00	-0.24, 0.22	0.94	0.01	-0.21, 0.25	0.88
Barriers to CRC screening	-0.06	-0.33, 0.21	0.66	-0.07	-0.36, 0.20	0.58
Social support for CRC screening	0.12	-0.07, 0.32	0.22	0.21*	0.00, 0.42	0.04
Age	--	--	--	-0.03	-0.23, 0.16	0.73
Marital status	--	--	--	-0.48*	-0.89, -0.07	0.02
Educational status	--	--	--	0.02	-0.11, 0.16	0.73
Constant	1.77	-0.29, 3.83	0.09	1.61	-0.47, 3.69	0.12

Note: B=Regression Coefficients, CI=Confidence Interval;

^*P<0.05.

Model 1 is unadjusted, and Model 2 is adjusted for covariates.

Table 3.

Associations between factors in Rogers’ conceptual model and CRC screening uptake (via blood stool test using a home kit)

Variables	Model 1 (Pseudo R2=0.01)			Model 2 (Pseudo R2=0.04)
	OR	95% CI	P>|z|	OR	95% CI	P>|z|
Masculinity barriers to medical care
Yes (1) vs. No (0)	0.91	0.38, 2.16	0.83	0.83	0.34, 2.01	0.68
Knowledge about CRC screening
Yes (1) vs. No (0)	1.29*	1.01, 1.65	0.03	1.30*	1.01, 1.66	0.03
Beliefs and values about CRC screening
Yes (1) vs. No (0)	0.96	0.69, 1.32	0.81	1.04	0.74, 1.45	0.81
Barriers to CRC screening
Yes (1) vs. No (0)	0.95	0.65, 1.39	0.80	0.89	0.59, 1.33	0.58
Social support for CRC screening
Yes (1) vs. No (0)	0.81	0.62, 1.08	0.65	0.85	0.63, 1.15	0.31
Age
Yes (1) vs. No (0)	--	--	--	1.41*	1.04, 1.89	0.02
Marital status
Yes (1) vs. No (0)	--	--	--	0.76	0.42, 1.38	0.37
Educational status
Yes (1) vs. No (0)	--	--	--	0.89	0.72, 1.09	0.26

OR, odds ratio; CI, confidence interval;

^*P<0.05.

Note: Model 1 is unadjusted. Model 2 is adjusted for covariates.

Table 4.

Associations between factors in Rogers’ conceptual model and CRC screening uptake (via sigmoidoscopy or a colonoscopy)

Variables	Model 1 (Pseudo R2=0.10)			Model 2 (Pseudo R2=0.15)
	OR	95% CI	P>|z|	OR	95% CI	P>|z|
Masculinity barriers to medical care
Yes (1) vs. No (0)	3.83*	1.56, 9.43	0.01	3.56*	1.41, 8.99	0.01
Knowledge about CRC screening
Yes (1) vs. No (0)	1.07	0.85, 1.34	0.52	1.02	0.81, 1.28	0.84
Beliefs and values about CRC screening
Yes (1) vs. No (0)	0.71*	0.51, 1.00	0.05	0.74	0. 51, 1.05	0.09
Barriers to CRC screening
Yes (1) vs. No (0)	1.82*	1.23, 2.68	0.01	1.60*	1.06, 2.41	0.02
Social support for CRC screening
Yes (1) vs. No (0)	1.26	0.95, 1.68	0.10	1.16	0.85, 1.58	0.34
Age
Yes (1) vs. No (0)	--	--	--	1.80*	1.33, 2.43	0.01
Marital status
Yes (1) vs. No (0)	--	--	--	1.51	0.82, 2.78	0.17
Educational status
Yes (1) vs. No (0)	--	--	--	1.10	0.89, 1.36	0.35

OR, odds ratio; CI, confidence interval;

^*P<0.05.

Note: Model 1 is unadjusted. Model 2 is adjusted for covariates.

In summary, study participants with better social support and those who were not married had greater intent to be screened for CRC sooner than later (β=0.21, P=0.04 and (β=-0.48, P=0.02, respectively). In adjusted models, a positive unit change in knowledge about CRC screening (OR=1.30, P=0.03) and chronological age (OR=1.41, P=0.03) were associated with increased likelihood of taking a blood stool test at home. Lastly, in adjusted models, a positive unit change in average MBMC score was associated with more than three times the likelihood of taking a sigmoidoscopy or colonoscopy exam (OR=3.56, P=0.01), while a positive unit change in the average score for CRC screening barriers was associated with more than one-half the likelihood of taking a sigmoidoscopy and colonoscopy (OR=1.60, P=0.02). Chronological age was also a statistically significant covariate in this last adjusted model (OR=1.80, P=0.01).

Discussion

The purpose of this study was to investigate whether the MBMC scale developed by the first author, together with other psychological factors, including knowledge, attitudes, beliefs, and social support, was associated with CRC screening intention and uptake in a sample of NH Black men living in Minnesota, Ohio, and Utah. Our results indicated that social support, and chronological age were positively associated with CRC screening intention, while marital status was inversely associated with screening intention. Increased knowledge about CRC screening and chronological age was associated with a greater likelihood of completing a stool-based CRC screening test. Fewer masculinity and CRC screening barriers were associated with a greater likelihood of undergoing a sigmoidoscopy or colonoscopy. These findings support our hypothesis that greater masculinity barriers to care are negatively associated with CRC screening uptake.

Social support and being unmarried were significantly associated with CRC screening intention in our adjusted models. This finding may be unique to NH Black men and may relate to COVID-19 stressors in play when the data were collected. It merits further investigation, as it contradicts prior studies demonstrating a strong association among partner concordance, marital status, and CRC screening participation favoring married individuals [49-54]. This association has been extensively demonstrated among White populations and has also been shown among both insured and uninsured NH Black cohorts [55,56]. Prior studies have also found that unmarried patients have a higher risk than married patients of a diagnosis of advanced-stage cancer, including CRC [57,58]. Chen and colleagues (2021) found in their large Surveillance, Epidemiology, and End Results (SEER) Program-focused study that married patients had greater CRC survival than unmarried patients; they concluded that marriage may play a greater protective role in cancer-specific survival among men than among women, a finding similar to that of Hanske et al. (2016) [59,60]. Future health promotion and interventional studies should continue to consider the complex interplay of social support and spousal influence on increasing both CRC screening intention and completion among NH Black men to stimulate earlier CRC diagnosis and better survival [41,61].

Positive unit changes in both age and CRC screening knowledge corresponded to a greater likelihood of completing at-home CRC screening tests. Chronological age was a statistically significant covariate, with NH Black men more likely to have the intention to complete CRC screening as they got older. This finding is consistent with previous literature focused on CRC screening intent among men both older and younger than the previously recommended screening age of 50 [27,62]. Additionally, several previous studies have found that NH Black men who are more knowledgeable about CRC screening are more likely to be screened [37,63,64]. While CRC screening rates for NH Black men are relatively low [2,18], those with more exposure to CRC-relevant print materials, educational pamphlets, commercials, and billboards are more likely to complete colonoscopies and other early-detection CRC screening tests [41,65].

Our findings complement those of studies by Greaney et al. (2014) and Seef et al. (2004), which found that increased education and awareness efforts by public health professionals and institutions, including primary care physicians, can increase the likelihood of at-home CRC screening among NH Black men [62,66]. Our results also corroborate the findings of Joseph et al. (2012) that older NH Black men have higher completion rates than younger men for in-home blood-stool CRC screening tests, possibly due to primary care physician recommendations, positive attitudes toward CRC screening, and familial/social support [52,62,67-70].

Findings from numerous studies suggest that systemic and interpersonal racism may differentially influence CRC screening rates among NH Black men aged 45 years and older compared with their counterparts aged under 45 years [20,23,24,52,71]. Nevertheless, this phenomenon merits further exploration. As EOCRC incidence continues to increase at alarming rates [9,11,72], public health professionals and advocacy organizations have a responsibility to engage in efforts to decrease the disproportionate CRC morbidity and mortality affecting NH Black men by encouraging them to learn about CRC screening (including at-home screening exams) at a younger age, as well as about key potential and proven CRC risk factors (e.g., high-fructose corn syrup consumption, sedentary behavior, smoking, stress, unhealthy cooking methods) [2,73].

Our results indicate that each positive unit change in average MBMC score was associated with more than three times the likelihood of undergoing a sigmoidoscopy or colonoscopy. Aligning with our central hypothesis, lesser masculinity barriers to medical care were associated increased with CRC screening uptake. From a sociocultural perspective, traditional hegemonic masculinity has been found to strongly influence men’s health-seeking behaviors and completion of physical examinations [74-76]. A decreased willingness to engage in CRC screenings has been associated with strong endorsement of masculine role norms, including “being strong,” self-reliance, and preserving heterosexual authority [36,77-79].

Conversely, masculine identity has been negatively correlated with adoption of healthcare-seeking and positive health behaviors among NH Black men [52,80-82]. Innately invasive and potentially affecting an individual’s view of his sexuality, sigmoidoscopy and colonoscopy examinations can create feelings of vulnerability that conflict with deeply rooted ideals of what it means to be a man [76,78]. Reinforcing this idea, Heslin et al. (2008) showed that, in a sample of 19,410 racially diverse men aged 45 years and older, men who identified as gay or bisexual were 67% more likely to engage in CRC screenings [83]. This potentially presents a considerable barrier for heterosexual men to overcome in order to seek these crucial preventive health screenings. Further research is required to learn how best to overcome this barrier and increase colonoscopy uptake among NH Black men, who are often likely to refuse this procedure despite its necessity to examine polyps that develop deeper in the colon [6,84,85].

In our adjusted models, fewer CRC screening barriers-demonstrated by a positive unit change in the average score for CRC screening barriers-were associated with more than one-half of the likelihood of completing a sigmoidoscopy or colonoscopy. Prior literature extensively describes the multilevel barriers to CRC screening completion among NH Black men [85-89], including patient-level barriers such as fear, cost, lack of knowledge, and lack of time [74,85,86,90]. The most predominant barriers often reported among NH Black men include fear of invasion or pain during a colonoscopy, lack of knowledge about their elevated risk for CRC and the benefits of screening, and fear of a CRC diagnosis [74,85,86,91].

Our results also confirmed the importance of CRC awareness, as increased knowledge was associated with a higher likelihood of completing an at-home stool-based CRC screening test. Although the strongest predictor of CRC screening is physician recommendation [85,89], physicians are one-third less likely to recommend CRC screening to NH Blacks than to NH Whites [85]. More health professionals recommending CRC stool tests to NH Black patients could increase the proportion of cases caught when the disease is “treatable and beatable”. Lower income also corresponds to a lower likelihood of being recommended for screening among NH Blacks [85]. Given the low rates of CRC screening among NH Black men [2,15-19], our results reiterate the importance of addressing the systemic and multilevel barriers to CRC screening with approaches tailored towards NH Black men.

EOCRC incidence has doubled over the past two decades and is predicted to increase by 28% to 46% by 2030 among those aged 35 to 49 years, including NH Black men [8]. Because it is estimated that by 2030 CRC will be the number one cause of cancer death in the 20 to 49 age group [92], and because NH Blacks experience nearly double the rate of EOCRC as NH Whites [93], the recent endorsement by the U.S. Preventive Services Task Force (USPSTF) of CRC screening utilization beginning at age 45 is a vital effort [94]. This decision emerges as even more critical considering the finding by Sehgal et al. (2021) that colonoscopy uptake between the ages of 45 to 49 and 50 to 54 years resulted in significant decreases in CRC incidence compared with no colonoscopy [95].

It has been suggested that unless screening capacity is also expanded, implementation of the revised USPSTF recommendations may only intensify existing screening and outcome inequities among underserved groups, including but not limited to NH Black men [96]. For this reason, although colonoscopy is the “gold standard” for CRC screening, efforts to increase screening rates among NH Black men-in addition to encompassing culturally targeted campaigns and provider education to increase recommendations for CRC screening to NH Black men-should include interventions focused on increasing the uptake of stool-based CRC testing.

Our findings are valuable for informing interventions, CRC activist organizations, and health promotion studies focused on increasing rates of early-detection CRC screening among NH Black men. However, the study’s limitations should be considered. First, our findings may not be generalizable to a larger population of NH Black men because we used a convenience-sampling plan and study participation was limited to men living in Minnesota, Ohio, and Utah. Moreover, the COVID-19 pandemic did not permit our planned in-person data collection efforts via barbershops for this hypothesis-generating study, so a larger confirmatory study is warranted as recommended by Hackshaw (2008) [97]. Notwithstanding the historical exclusion of NH Black men from health and medical research and their continuing underrepresentation in such research, we implemented a suitable strategy to engage and recruit participants in our sample, despite extensive COVID-19-related challenges. Secondly, several outcome measures were used as composite variables and scales were drawn from sources that have yet to test their validity. Nevertheless, creating composite scores was the most effective strategy for dealing with highly correlated individual data sets, as these were conceptually developed to denote theoretically relevant concepts in this area of inquiry.

Conclusion

Although the overall annual rate of CRC diagnosis has been decreasing nationally since the mid-1980s, NH Black men continue to have the highest mortality rate from CRC of any ethnic group in the United States. At the same time, early-detection CRC screening has been demonstrated to reduce CRC mortality. Broader endorsement of early-detection screening, combined with consideration of the facilitators of CRC screening intent and uptake in NH Black men identified in our study, may reduce the disproportionate CRC mortality rate among NH Black men. Specifically, we observed that increasing age, having social support, and being unmarried increased CRC screening intent among NH Black men aged 45 to 75 years, while screening knowledge and chronological age were associated with a greater likelihood of completing a stool-based screening test for CRC and fewer masculinity-related barriers were correlated with a greater probability of undergoing a sigmoidoscopy or colonoscopy. Considering the recent USPSTF recommendation that routine CRC screening begin at age 45 years, together with the fact that the 5-year survival rate for localized (i.e., stage I or II) CRC is 90%, interventional research is warranted that considers the critical role of our findings, lifestyle factors, and social determinants in enabling CRC screening uptake and reducing NH Black men’s risk of dying from this destructive yet preventable disease.

Disclosure of conflict of interest

Although unrelated to this study, Dr. Charles R. Rogers offers scientific input to research studies through an investigator services agreement between the University of Utah and Exact Sciences.