Access Is Not Enough: Socioeconomic Barriers to Colorectal Cancer Screening Among Insured Older African American Men
Colorectal cancer (CRC) is the third most common type of cancer found in the U.S. Notably, African American men have a higher age-adjusted incidence rate and death rate for CRC than men or women of any other racial/ethnic group. In addition, they are less likely than white men or women to be diagnosed at an early stage when treatment is promising or to survive five years after diagnosis. The U.S. Preventive Services Task Force recommends routine screening for CRC for adults over 50, but African American men are less likely to adhere to these recommendations compared to other groups. We aim to identify potential socioeconomic, psychosocial, and physical health predictors of CRC screening utilization among African American male Medicare enrollees.
Participants were African American male Medicare enrollees participating in a randomized trial conducted by a large Midwestern health system (N=1,666). Data were collected using a baseline patient survey. Measures included self-reported CRC screening use in the past 10 years, demographic variables (age, income, education, marital status), physical health characteristics (pain, mobility, difficulty with usual activities), and psychosocial characteristics (family history of CRC, perceived risk of cancer, level of cancer worry, anxiety/depression). In order to identify predictors of CRC screening use, a sequential logistic regression model was developed from variables significantly associated with the outcome in bivariate analyses. Based on these results, income, education, marital status, and age were entered in step one of the model, while family history of CRC, self-reported depression or anxiety, and difficulty with mobility were entered in step two.
The mean age of participants was 73.5 years. Forty five percent of participants were married, and nearly 31% had completed some college or more education. In addition, 33% reported an annual household income below $20,000. Nearly 75% of participants had been screened for CRC prior to this baseline assessment, and nearly all (96%) participants reported a usual source of health care. Model one was significant (χ2 = 192.44, p<.001, Nagelkerke’s R2 = .16). All socioeconomic variables (income, education, marital status, and age) significantly contributed to model one. Model two was not significant compared to the null model (χ2 = 6.4, p=.094). In the final model, annual income over $20,000 (p<.001), some college or more education (p=.001), being married (p<.001), being aged 75 and older (p<.001), and having a family history of CRC (p=.029) were significantly associated with prior CRC screening utilization (χ2 = 198.84, p<.001, Nagelkerke’s R2 = .16). Self-reported anxiety/depression and difficulty with mobility did not significantly contribute to the final model.
Conclusions and Implications
This study highlights the prominent role of socioeconomic disparities in CRC screening behavior, even among a group of insured older African American men reporting a usual source of health care. Clinicians working in primary care or oncology settings should be aware that even with health insurance access, certain sub-populations of older African American men are less likely to engage in routine cancer screening and may require additional support or intervention.