Knowledge, perception and practices of colorectal cancer screening in an ethnically diverse population

Abstract

Background: Colorectal cancer (CRC) screening improves survival and its success depends on the participation of the at-risk population. Few studies have adequately assessed screening knowledge, perception and participation according to birthplace. This study assesses the knowledge and perception of CRC in an ethnically diverse population, and evaluates the association with screening participation and intention. Identification of specific predictors of screening may aid the development of interventions to improve overall CRC screening. Methods: An interview-based survey, conducted on subjects aged 30–70 years, assessed knowledge and perception towards CRC and screening tests. Primary endpoints were screening participation and intent. Statistical methods used were Chi-square, Mann–Whitney U and logistic regression. Results: A total of 543 subjects (43% males, 53% Australian-born (AB), 63% aged 50 years and above) were recruited. Compared with AB, non-Australian-born (NAB) respondents had poorer knowledge, and NAB background predicted for poorer knowledge independent of sex, education, media and familiarity with CRC patient. Compared with AB respondents aged 50 years and above, NAB respondents had lower screening participation (17.4% vs. 31.8%; P = 0.01), lesser intention (75.8% vs. 90.5%; P < 0.001), and had received fewer doctors’ screening recommendations (16.5% vs. 27.1%; P = 0.04). In multivariate analysis, doctors’ recommendation, media and improved perception independently predicted screening participation; knowledge and media exposure predicted intent. Conclusions: The knowledge of CRC and screening is significantly poorer in the immigrant population. Knowledge predicts for greater screening intent. Therefore, implementing language- and culture-specific educational programs involving medical practitioners and media are necessary to improve CRC screening participation rates.

Introduction

Colorectal cancer (CRC) is the second leading cause of cancer and cancer death in Australia [1]. CRC screening with fecal occult blood test (FOBT) improves survival [2], [3]. However, participation rates remain universally low and are consistently lower in minority and immigrant groups [4], [5], [6], [7], [8]. In the United States, ethnic differences in the knowledge, awareness and perception of CRC screening have contributed to the lower screening rates in minority groups [4], [5], [6], [7], [8]. Understanding these disparities has resulted in the implementation of health promotional programs aimed at improving screening utilization in these groups.

CRC screening is a complex and involved process and it requires all of its components to function for it to be successful. These components include: patient awareness, attitudes and acceptance, medical practitioner knowledge, attitudes and recommendations, logistical and financial considerations, timely follow-up and diagnosis, and continued adherence to a program. It is complex because of its various options with their inherent benefits and risks; it requires moderate patient effort and specialised health care providers with skills in colonoscopy. The US Preventive Services Task Force recommends either annual FOBT, flexible sigmoidoscopy or annual FOBT and flexible sigmoidoscopy every 5 years [9]. Recently, it has become evident that simply recommending a screening test alone is insufficient to improve participation—the emphasis has now shifted towards increasing patients’ involvement in decision making, namely Informed Decision Making (IDM) [10]. IDM occurs when an individual believes he or she has made a personal and informed decision based on a clear understanding of the disease and available management options including benefits, risks, alternatives and uncertainties. Individuals are encouraged to decide on these options consistent with their preference and values, and may therefore decline or defer effective screening tests recommended by their doctors. Interventions to improve IDM and uptake of CRC screening tests have also been reported [10], [11], [12], [13].

In Australia, the National Bowel Cancer Screening Program Pilot study reported significantly lower FOBT screening participation rates in non-English speaking residents [14]. Furthermore, a study of CRC patients from a multi-ethnic community revealed fewer immigrants had CRC detected through screening compared with Australian-born patients, highlighting the apparent discrepancy in screening utilization in the immigrant population [15]. This study aims to determine the variations in knowledge, perception and health behaviour towards CRC and screening tests according to birthplace in an ethnically diverse population. It will examine the factors that mediate the differences in CRC screening in non-Australian-born compared with Australian-born residents. Endpoints include self-reported participation in CRC screen and intent to participate in future screening, and predictors of these endpoints are determined. This study has the potential to determine factors and barriers according to birthplace affecting screening participation which is crucial towards improving participation in a community with a projected increase in immigration rates [16].