RESEARCH PROPSAL CORRECTIONS

RUNNING HEAD: COLORECTAL CANCER SCREENING AND LOW HEALTH

LITERACY 1

The Relationship Between Colorectal Cancer Screening and Low Heath Literacy Levels in

Hispanic/Latina Women Over 50 Years Old in United States

A Capstone

Presented to the School of Health and Human Services

Department of Community Health

National University, San Diego, CA

In Partial Fulfillment

of the Requirements for a Master in Public Health Degree

Concentration in Health Promotion

by

Student Name

We accept this capstone project on behalf of the Community Health Department, School of

Health and Human Services, National University.

_________________________________ ______________________________

Director of Master in Public Heath Date

_________________________________ ______________________________

Capstone Project, Committee Chair Date

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 2

Dedication

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 3

Abstract

Background: Colorectal cancer is the second leading cause of cancer deaths in the United States

and the third most common cancer in men and women. According to research, there is a

relationship between low health literacy levels and colorectal cancer (CRC) screening in

minorities. This study assessed the relationship between CRC screening and low health literacy

in Hispanic/Latina women over 50 years old in United States.

Methods: Secondary analysis was done using Behavioral Risk Factor Surveillance System

(BRFSS) 2012. Analysis included adults 50 years of age and older, who completed BRFSS 2012

interview in English and Spanish. Statistical analyses included univariate and bivariate

associations, and logistic regression to determine the odds of colorectal cancer screening and low

health literacy after adjusting for race, sex, age, blood stool test (FOBT), BMI, physical activity,

current health plan, current employment, income, smoking status and interview language.

Results: The majority of respondents who had less than 9th grade education were female

(64.2%). Respondents who had less than a 9th grade educational level had 1.19 adjusted odds of

not having a CRC screening compared to those of 9th grade or higher (95% CI=1.06-1.34).

Female respondents had 0.77 adjusted odds of not having a colorectal cancer screening compared

to men (95% CI=0.70-0.84).

Conclusion: The results of the study showed that there was a relationship between low health

literacy levels and not having colorectal cancer screening. Further research is recommended to

assess the relationship between low health literacy levels and CRC screening in Hispanic/Latina

women including country of origin.

Keywords: women, limited English proficiency, colorectal cancer screening, colonoscopy, low

health literacy, Latinos, Hispanics, Behavioral Health Risk Factor Surveillance.

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 4

Table of Contents

INTRODUCTION………………………………………………………………………...5

LITERATURE REVIEW….…………………………………………………….………..7

METHODS AND DATA SOURCES……………………………………………...……16

DATA ANALYSIS.……………………………………………………………………...20

RESULTS.……………………………………………………………………………….21

DISCUSSION.…………………………………………………………………………...27

CONCLUSION.………………………………………………………………………….33

REFERENCES.……………………………………………………………………….....36

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 5

Introduction

According to the CDC, colorectal cancer is the second leading cause of cancer-related

deaths in the United States and the third most common cancer in men and women (Center for

Disease Control and Prevention [CDC], 2011). Approximately, sixty percent of colorectal cancer

deaths could be prevented with regular testing of adults 50 years and older, but current screening

rates are lower than recommended (US Department of Health and Human Services [DHSS],

2010). Screenings can find precancerous polyps that are abnormal growths in the colon or rectum

and they can be removed before turning into cancer. Also, screenings can assist in finding

colorectal cancer at an early stage and treatment often leads to a cure (CDC, 2014). The five year

survival rate for colorectal cancer for early stages (i.e., stage I) is approximately 95%, to

advanced stages (i.e., stage IV) is approximately less than 5% (Hummel, 2013). According to the

previous data, the earlier the detection for colorectal cancer the higher the chance for survival.

According to some research, there is a relationship between low health literacy levels and

colorectal cancer screenings in ethnic minorities including Hispanic/Latinos. However, only a

few studies have been conducted addressing the specific relationship between low health literacy

levels and colorectal cancer screenings (CRC).

Increasing CRC rates is important for older adults, it is especially challenging to reach

people with low health literacy levels which is defined as the inability to read, understand, and

use health care materials (Shea, 2004). According to the 2003 National Adult Literacy Survey,

about half of adult US population have deficient reading skills. When patients have low health

literacy levels, they also have a poorer knowledge and understanding of their health condition

(Shea, 2004).

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 6

There are a limited number of studies to date on colorectal cancer and health literacy.

Traditionally, patient health education relies heavily on written educational material about

disease processes, medical management, and self-care instructions but many of them are written

at a level too high for a low health literacy level person to understand (as cited in Williams,

1998). Limited or inadequate health literacy was significantly associated with less knowledge of

CRC and CRC screening and with more related barriers to completing the fecal occult blood

testing (FOBT) and colonoscopy (Peterson, 2007). Thus, patients with low health literacy levels

also report lower rates in participating in preventive health services such as colorectal cancer

screenings (Shea, 2004). Moreover, even when patients in this demographic sign up for

screenings, they run into problems with understanding the procedure and getting accurate results.

The U.S. Preventive Services Task Force (USPSTF) recommends that colorectal cancer (CRC)

screenings be conducted in average-risk adults aged 50 years or older using home fecal occult

blood testing (FOBT), flexible sigmoidoscopy (FS), FS and FOBT, colonoscopy, or double-

contrast barium enema (DCBE) (Whitlock, 2008).

One of the goals of Healthy People 2020 is to reduce the number on new cancer cases as

well as the illnesses, disability, and death caused by cancer (Healthy people 2020, 2014).

According to Imperiale, despite the benefits of early detection, almost 40% of Americans are not

up to date with their colorectal cancer screenings (CRC). According to the CDC, the 2011

National Health Disparities Report, calls for immediate efforts to increase CRC screenings

among Hispanic/Latinos in a cultural appropriate manner, and at a literacy level below ninth

grade (CDC, 2014). Thus, health care access for populations with a less than a ninth grade

education is more challenging since they have difficulty understanding health education

materials and have less access to health services.

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 7

This study will examine the association between low health literacy levels and colorectal

cancer screenings in Hispanic/Latino women over 50 years old in United States. Understanding

health disparities in colorectal cancer screenings is very important since Hispanic/Latinos are

more likely than Whites to be diagnosed with more advanced colorectal cancer stages and have

higher mortality rates (Diaz, 2008). In women, possession of health insurance coverage may

increase the likelihood of having a usual source of care and consequently, use of preventive

cancer services (Gonzalez et al, 2012).

In this study, we utilized the Behavioral, Risk Factor Surveillance System (BRFSS) 2012.

This data allows for a state comparison of health behaviors; however, comparative analyses of

the colorectal cancer test used in the Hispanic/Latino community among states with large

Hispanic populations has not been conducted (Pollack, 2006). Thus, more research is needed in

this area to design more specific interventions to increase colorectal cancer screenings and in

turn, reduce colorectal mortality rates in the Hispanic/Latino community.

Literature Review

The following literature review summarizes previous conducted studies that have

investigated the association between low health literacy and colorectal cancer screening in

minorities Hispanic/Latinos including some studies addressing Hispanic/Latina women. This

study investigated the association between low health literacy levels and colorectal cancer

screenings in Hispanics/Latino women over 50 years old in United States while adjusting for

race, sex, age, blood stool test (FOBT), Body Mass Index (BMI), physical activity, consumption

of fruits and vegetables, current health plan, current employment, income, smoking status, and

interview language.

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 8

The literature review is divided into three categories:

A) Colorectal cancer screening in Hispanic/Latinos

B) Low health literacy and colorectal cancer screening

C) Other risk factors for colorectal cancer

The first section addresses studies conducted that showed participation of

Hispanic/Latinos in colorectal cancer screenings. The second section provides an overview on

how low health literacy can affect participation of patients in having a colorectal cancer

screening. Lastly, the third section addresses other risk factors associated in developing

colorectal cancer.

Colorectal cancer screening in Hispanic/Latinos

In 2010, 131,607 people in the United States were diagnosed with colorectal cancer,

including 67,700 men and 63,907 women. Out of those, 52,045 people in the United States died

from colorectal cancer (CDC, 2014). Approximately, sixty percent of colorectal cancer deaths

could be prevented with regular testing of adults 50 years and older, but current screening rates

are lower than recommended (US Department of Health and Human Services [DHSS], 2010). In

multiple studies, screening for colorectal cancer (CRC) has demonstrated to significantly reduce

morbidity and mortality by finding colorectal cancer at an early stage and treatment often leads

to a cure (Peterson, 2007; Center for Disease Control and Prevention [CDC], 2014; Agency for

Healthcare Research and Quality [AHRQ], 2014). A colonoscopy is a preventive exam where a

doctor uses a flexible tube to examine the colon and rectum for early cancer or growths called

polyps. It is also used for intestinal symptoms such as bleeding (CDC, 2014). The five year

survival rate early stages for colorectal cancer (i.e., stage I) is approximately 95%, to advance

stages (i.e., stage IV) is approximately less than 5% (Hummel, 2013). One study concluded that

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 9

the intention to attend a colorectal screening procedure is likely to increase if the screening

technique is safer and causes less discomfort (Hummel, 2013).

The U.S. Preventive Services Task Force (USPSTF) recommends that colorectal cancer

(CRC) screening be conducted in average-risk adults aged 50 years or older using home fecal

occult blood testing (FOBT), flexible sigmoidoscopy (FS), FS and FOBT, colonoscopy, or

double-contrast barium enema (DCBE) (Whitlock, 2008). One of the goals of Healthy People

2020, is to reduce the number on new cancer cases as well as the illnesses, disability, and death

caused by cancer (Healthy people 2020, 2014).

In August 2014, the Food and Drug Administration (FDA) approved a new stool DNA

test (Cologuard, Exact Sciences) for colorectal cancer screening. Many people do not get

screened because they relate the CRC screening to a colonoscopy. The Cologuard test performed

better than the FOBT in identifying advanced adenomas, which are the lesions that are most

likely to progress into invasive colorectal cancer (Imperiale et al., 2014). As genetic testing

becomes more available, most people preferred that genetic information be delivered in person

by a healthcare or genetics professional rather than through print materials or a computer

(Leventhal et al., 2013).

Research needs to also consider barriers to colonoscopy which includes: not

understanding what to do, embarrassing, time consuming, fear of finding something wrong, fear

of pain, having to follow special diet and take laxatives, cost concerns, not having problems or

symptoms, possibility of bleeding or colon tearing, transportation problems (Peterson, 2007).

Low health literacy and colorectal cancer screening

Reading skills are deficient in 46% to 51% of adult US citizens according to the National

Adult Literacy Survey. Some studies has shown that lower literacy skills also correlate with

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 10

poorer self-reported health status and because of their worse health, patients with poor literacy

skills are in greater educational needs (as cited in Williams, 1998). Low health literacy is define

as the inability to read, understand, and use health care materials. When patients have low health

literacy levels, they also have a poorer knowledge and understanding of their health condition

(Shea, 2004; Doubeni et al, 2010). Studies showed that limited of inadequate health literacy was

significantly associated with less knowledge of CRC and CRC screening and with more related

barriers to completing the fecal occult blood testing (FOBT) and colonoscopy as well as poorer

use of health care services (Peterson, 2007; Berkman, 2011). Traditionally, patient health

education relies heavily on written educational material about disease processes, medical

management, and self-care instructions and despite the extensive amount of them, many of them

are written at a level too high for a low health literacy level person to understand (as cited in

Williams, 1998). People impacted by low health literacy may struggle to understand disease,

prevention and treatment (Kinsgley, 2010; Baker et al., 2014). When establishing interventions

to improve CRC screening should consider the health literacy of patients especially when

addressing barriers to screening and health educational materials (Peterson, 2007; as cited in

Williams, 1998).

Other risk factors for colorectal cancer

Race, sex, age, blood stool test (FOBT), Body Mass Index (BMI), physical activity,

consumption of fruits and vegetables, current health plan, current employment, income, smoking

status, and interview language.

Race

Colorectal cancer (CRC) screening rates are lower among Latinos and people living in

poverty (Baker et al., 2014). According to some research, there is a relationship between low

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 11

health literacy levels and colorectal cancer screenings in ethnic minorities including

Hispanic/Latinos (Getrich et al., 2011).

One study examined the disparities in colorectal cancer (CRC) screening between US and

foreign born populations. The study found that the rate of screening in foreign born individuals

with high income and with health insurance was significantly lower than those born in the US

(Shih, 2008). Moreover, there was not much difference in the rate when comparing US born

individuals with lower socio economic levels; thus, being born in another country was associated

with having lower rates of CRC screenings (Shih, 2008). A study conducted in Puerto Rican

Hispanics showed that continuing of acculturation to a Western lifestyle and dietary habits, the

incidence of CRC would continue to rise and resemble that of the US (Lathrum, 2012).

Understanding health disparities in colorectal cancer screenings is very important since

Hispanic/Latinos are more likely than Whites to be diagnosed with more advanced colorectal

cancer stages and have higher mortality rates (Diaz, 2008). Thus, distinguishing between

Hispanics subpopulations might be critical to providing culturally specific CRC counseling and

affordable colorectal cancer screening in primary care settings to eliminate health disparities

(Getrich et al., 2011; Doubeni et al., 2010). According to the CDC, the 2011 National Health

Disparities Report, calls for immediate efforts to increase CRC screenings among

Hispanic/Latinos in a cultural appropriate manner, and at a literacy level below ninth grade

(CDC, 2014; JCAHO, 2007). Therefore, promotora facilitated home-based interventions offer

ways to reach Hispanics in rural and other underserved communities to reduce barriers and

improve access to cancer screening. (Moralez, 2012).

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 12

Sex

According to the CDC, colorectal cancer is the second leading cause of cancer-related deaths in

the United States and the third most common cancer in men and in women (CDC, 2014). While

women’s possession of health insurance coverage may increase the likelihood of having a usual

source of care and consequently, use of preventive cancer services (Gonzalez et al, 2012) other

Hispanic women have commented extensively on the effects of machismo on both men and

women’s screening attitudes and practices (Getrich et al., 2011).

Age

The U.S Preventive Services Task Force (USPSTF) currently recommends all individuals

ages 50–75 receive annual screening for CRC including a colonoscopy every 10 years (DHSS,

2012). Increasing CRC rates is important for older adults, it is especially challenging to reach

people with low health literacy levels which is define as the inability to read, understand, and use

health care materials (Shea, 2004). Moreover, nearly 67% of Hispanics ages 50 and older report

that they have never had a screening colonoscopy (Moralez, 2012).

In recent studies, an increasing incidence rate was observed for patients with rectal cancer

aged 35 to 49 years (Bailey et al, 2014). Based on current trends, in 2030, the incidence rates for

colon and rectal cancers will increase by 90.0% and 124.2%, respectively, for patients 20 to 34

years and by 27.7% and 46.0%, respectively, for patients 35 to 49 years (Bailey et al, 2014). This

figure represents 131.1% incidence rate change of colon cancer by 2030 in 20-34 years old, as

compared to patients older than 50 years (Bailey et al., 2014).

Blood stool test (FOBT)

Limited of inadequate health literacy was significantly associated with less knowledge of

CRC and CRC screening and with more related barriers to completing the fecal occult blood

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 13

testing (FOBT) and colonoscopy (Peterson, 2007) and research has shown that early detection

with FOBT and sigmoidoscopy/colonoscopy with early treatment of precancerous lesions at

early stages decreases the mortality from colorectal cancer (NCCD, 2012). Thus, early detention

with fecal occult blood testing and sigmoidoscopy/colonoscopy, treatment of precancerous

lesions, and treatment in the early stages of cancer decreases the mortality from colon and rectum

cancer (NCCD, 2012).

Body Mass Index (BMI)

The higher a person's BMI, the greater the likelihood he or she would develop a

colorectal cancer (Livescience, 2014). Furthermore, halth conditions including obesity, chronic

disease (diabetes, asthma, cardiovascular disease) and anxiety/depression symptoms, may also

mediate the association between higher area level poverty rate and CRC screening (Lian, 2008).

Physical activity

Physical activity, healthy diet, and avoidance of overweight might also reduce the risk of

colorectal cancer (NCCD, 2012) and there is strong evidence that physical activity is associated

with reduced risk of cancers of the colon and breast (NCI, 2014).

Fruits and Vegetables

Colorectal cancer rates are higher in more affluent countries like the U.S. due to diets that are

higher in fats, refined carbohydrates, animal protein and lower levels of physical activity

(Kingsley, 2012) and studies have shown that healthy diets rich in fruits and vegetables may

reduce the risk of cancer and other chronic diseases (CDC, 2014).

Current health plan

Insurance coverage for CRC screening should be considered as part of a comprehensive

approach to address CRC disparities (Lian, 2008; Emmons, 2009). Moreover, the rates of not

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 14

having colorectal cancer screenings are amongst low income individuals, with Medicare or

Medicaid, no health insurance, disadvantages from lower education, racial/ethnic minorities, and

those living in rural areas (Arnold et al, 2012; Doubeni et al, 2010). On the other hand, insured

women may be more likely to practice healthier behaviors including cancer screenings

(Gonzalez, 2012).

Current employment

According to Baker et al study, the FOBT should not be used for CRC screening at

community health centers unless the organization have enough access to affordable diagnostic

colonoscopy and navigator programs to assist those with a positive result (Baker et al, 2014). ).

Cost may be relevant since CRC screening exams such as a colonoscopy are often more costly

than mammograms and Pap exams (Gonzalez, 2012). Thus, greater attention to increasing access

to and use of affordable colorectal cancer screening for socioeconomically disadvantaged

populations is needed if colorectal cancer health disparities are to be eliminated (Doubeni et al.,

2010).

Income

Lower rates of screening among minorities and low income populations contribute to

colorectal cancer health disparities (Doubeni et al., 2010) and compared with those with higher

income group, lower-income enrollees had lower rates of screening (Doubeni et al., 2010). Also,

low income enrollees in metropolitan service areas had lower rates of testing than those with

higher income (Doubeni et al., 2010).

Smoking status

Lifestyle risk factors for CRC include alcohol, tobacco use, obesity, short amount of

fruits and vegetables and lack of physical activity (CDC, 2014) and the 2014 Surgeon General’s

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 15

Report (SGR) identifies additional cancers that are linked to smoking: cancer of the colon and of

the rectum also called colorectal cancer (CDC, 2014).

Interview language

Studies have shown that even when patients in this demographic sign up for screenings,

they run into problems with understanding the procedure and getting accurate results (Whitlock,

2008) and perhaps using Spanish speaking promotoras can address the linguistic and cultural

barriers in the Hispanic population (Moralez, 2012).

Barriers to screening

According to the literature some of the barriers for not having colorectal cancer screening

are minimal knowledge of colorectal cancer, lack of screening information, low perceived risk,

fear of cancer and the expectation of pain and embarrassment (Zapka, 2004). Also, other possible

factors for low heath literacy levels affecting colorectal screenings can include age at

menopause, hormone replacement therapy and perhaps immediate relatives with colon cancer

(CDC, 2014. Furthermore, one study conducted in the Netherlands, concluded that the intention

to attend a colorectal screening procedure is likely to increase if the screening technique is safer

and causes less discomfort (Hummel, 2013). The interplay of multiple factors influencing

screening behavior is not well understood, and there have been mixed findings in regards to the

role of health insurance in addressing disparities in screening (Emmons, 2009). Thus, particular

attention should be paid to modifiable factors that could become the focus of interventions aimed

at increasing cancer-screening adherence (Gonzalez, 2012).

Theoretical Framework

In this study, the Transtheoretical Model (TTM) was used to show the different stages a

patient goes through when considering having a CRC screening. The TTM model states that

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 16

people are in different stages of readiness to make health behavior changes and these stages

move people closer to behavior change (Glanz, 2008). The TTM model includes the stages of

pre-contemplation, contemplation, preparation, action, maintenance and relapse stages.

Purpose

This study investigated the association between low health literacy levels and colorectal

cancer screenings in Hispanics/Latino women over 50 years old in United States while adjusting

for race, sex, age, blood stool test (FOBT), Body Mass Index (BMI), physical activity, current

health plan, current employment, income, smoking status, and interview language.

Hypothesis

The null hypothesis is colorectal cancer screening independent of low health literacy.

Methods and Data Resources

Study population and Design

The data set utilized in this study was from the Behavioral, Risk Factor Surveillance

System (BRFSS) 2012. The Behavioral Risk Factor Surveillance System (BRFSS) is a

collaborative project of the Centers for Disease Control and Prevention (CDC) and U.S. states

and territories. It is a based survey of health behaviors with a standardized format that allows

comparison between states. It is conduct it in all 50 states in the United States and targets adults

18 years and older who are randomly selected. The phone interviews reached 475,687

participants in 2012 and the survey is considered the largest telephone survey in the world.

BRFSS conducts both landline telephone and cellular telephone-based surveys and data is

collected from a randomly selected adult in a household (CDC, 2013). If a significant portion of

the state population does not speak English, states have the option of translating the

questionnaire into other languages. At the present time, CDC also provides a Spanish version of

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 17

the core questionnaire and optional modules (CDC, 2013). A population of 13,910 from the

BRFSS 2012 were utilized for this study. The target population was representative of all

Hispanic/Latino over 50 years old in the United States. BRFSS data has been utilized by

universities, organizations and researches and is considered an instrument for the United States

Government to monitor public health (CDC, 2013).

This study investigated the association between low health literacy levels and colorectal

cancer screenings in Hispanics/Latino women over 50 years old in United States while adjusting

for race, sex, age, blood stool test (FOBT), Body Mass Index (BMI), physical activity, current

health plan, current employment, income, smoking status, and interview language.

When patients have low health literacy levels, they also have a poorer knowledge and

understanding of their health condition (Shea, 2004). The impact of low literacy on patients'

knowledge of their own illnesses has not been research in detail, however, patients with low

health literacy levels also report lower rates in participating in preventive health services such as

colorectal cancer screenings (Shea, 2004).

Variables

Data were analyzed and managed using SAS Studio English Version 9.4 (Cary, NC,

USA). A National University IRB review waiver was granted as the current research analyses,

which used data previously collected by CDC, and did not involve human subjects. In the

analysis, “don’t know” and “missing values” were excluded.

The outcome variable “ever having a sigmoidoscopy or colonoscopy” (_RFSIGM2) was

categorized into two levels: (1) “yes” and (2) “no” and was renamed (_RFSIGM1). The

predictor variable was “lowest level educational attainment” (EDUCA) was originally

categorized into six levels: (1) “never attended school or only kindergarten”, (2) “1st-8th”, (3) “9-

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 18

11”, (4) “12 or GED”, (5) “College 1-3 years”, and (6) “College 4 years or more”. Limited of

inadequate health literacy was significantly associated with less knowledge of CRC and CRC

screening and with more related barriers to completing the fecal occult blood testing (FOBT) and

colonoscopy (Peterson, 2007). Research has shown that there is a correlation between lower

literacy and poor self-reported health status and because of their worse health, patients with poor

literacy skills are in greater educational needs (as cited in Williams, 1998). Low literacy level

below 9th grade is an important predictor of colorectal cancer screening therefore, “never or only

kindergarten” and “1st-8th grade” were combined into one variable “<9th grade”. The final

predictor variable (EDUCA2) included two categories: (1) “< 9th grade”, (2) ≥ 9th grade.

The independent variables included race, sex, age, blood stool test (FOBT), BMI,

physical activity, consumption of fruits and vegetables, current health plan, current employment,

income, smoking status and interview language. Gender variable name was (SEX) and had two

categories (1) “male” and (2) “female”. The variable Age (_AGEG5YR) was originally

categorized into fourteen categories (1) “Age 18-24”, (2) “Age 25-29”, (3) “Age 30-34”, (4)

“Age 35-39”, (5) “Age 40-44”, (6) “Age 45-49”, (7) “Age 50-54”, (8) “Age 55-59”, (9) “Age 60-

64”, (10) “Age 65-69”, (11) “Age 70-74”, (12) “Age 75-79”, (13) “Age 80 or older”. The

variable was renamed to (_AGE4YR) and started at age 50 years since the study focused on 50

years and older and was combined into five categories (1) “50-54 years”, (2) “55-59 years”, (3)

“60-64 years”, (4) “65-69 years”, (5) “≥ 70+ years”. The blood stool test (FOBT) for people over

50 years old and having the test done in the past two years was originally named (_RFBLDS2)

and had three categories (1) “yes”, (2) “no” and was re named (_RFBLDS1) into two categories

(1) “yes” and (2) “no”. The original variable Body Mass Index (_BMI5CAT) and four categories

(1) “underweight”, (2) “normal weight”, (3) “overweight”, and (4) “obese”. Lifestyle risk factors

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 19

for colon cancer include alcohol, tobacco use, obesity, short amount of fruits and vegetables and

lack of physical activity (CDC, 2014). Research has shown that obesity can be a predictor of

colorectal cancer screening, therefore, “underweight” was omitted. The variable was re named

(_BMI3CAT) into three categories (1) “normal”, (2) “overweight” and (3) “obese”. The original

variable Physical Activity “in the past 30 days” named (_TOTINDA) had three categories (1)

“had physical activity”, (2) “no physical activity” and was re named (_TOTINDA1) into two

categories (1) “yes physical activity in past 30 days” and (2) “no physical activity in past 30

days”. The original variable Fruits and Vegetables consumption in the past month (how many

times per day, per week, or per month) was originally measured in three variables Fruit

(FRUIT1), Dark green vegetables (FVGREEN) and Orange color vegetables (FVORANG). The

categories were combined into a new variable re named (FRVG3) with two categories (1) “yes”

and (2) “no”. The original variable current Health Plan (HLTHPLN1) had three categories (1)

“yes”, (2) “no” and was renamed (HLTHPLN2) with two categories (1) “yes”, and (2) “no”. The

original variable current Employment (EMPLOY) was had originally eight categories (1)

“employed for wages”, (2) “self-employed”, (3) “out of work for more than a year”, (4) “out of

work for less than a year”, (5) ‘homemaker”, (6) “student”, (7) “retired”, (8) “unable to work”.

The variable was combined and renamed (emplcat) with two categories (1) “yes”: employed, (1)

self-employed; and (2) “no”: unemployed, (2) out of work >1 YR, (2) out of work <1 YR, (2)

homemaker, (2) student, (2) retired and (2) unable to work.

The original variable Income (_INCOMG) had five categories (1) “less than $15,000”,

(2) “$15,000 to less than $25,000”, (3) “$25,000 to less than $35,000”, (4) “$35,000 to less than

$50,000”, and (5) “$50,000 or more”. The variable was combined and renamed (_INCOMG1)

with four categories (1) “less than $15,000”, (2) “$15,000 to $24,999”, (3) “$25,000 to $34,999”

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 20

and (4) “≥$35,000”. The originally variable Smoking Status (_SMOKER3) had four categories

(1)” current smoker every day”, (2) “current smoker some days”, (3) “former smoker”, and (4)

“never smoked”. The variable was re named (_SMOKCAT) with a combined three categories (1)

“current smoker every day” and “current smoker some days”, (2) “former smoker”, and (3)

“never smoked”. The last variable was interview language (QSTLANG) with three categories (1)

“English” and (2) “Spanish” and was renamed to (QSTLANG1) into two levels (1) “English”,

and (2) “Spanish”.

Data Analysis

Data were analyzed using SAS Studio English Version 9.4 (Cary, NC, USA). Analyses

were conducted with univariate statistics to describe the frequency and proportion of respondents

and bivariate associations were used to determine statistical significance of association using in

Pearson Chi-Square. Logistic regression was used to determine the odds of colorectal cancer

screening and low health literacy after adjusting for race, sex, age, blood stool test (FOBT), BMI,

physical activity, , current health plan, current employment, income, smoking status and

interviews language.

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 21

7. Results

TABLE 1: Bivariate Associations of Educational Level and Other Characteristics among 13,859 U.S. Hispanic/Latino Respondents Over 50 Years Old, Behavioral Risk Factor Surveillance System, CDC, 2012

Educational Level Variable Population Less than 9th grade 9th grade or higher p value*

N% 13,859 (100)

n% n% 10,860 (78.4)

2,999 (21.6)

Sex Male Female

5,217 8,642

(37.6) (62.4)

1,075 1,924

(35.9) (64.2)

4,142 6,718

(38.1) (61.9)

0.0217

Age (years) 50-54 55-59 60-64 65-69 ≥70

2,911 2,654 2,371 2,052 3,871

(21.0) (19.2) (17.1) (14.9) (27.9)

467 442 471 454

1,165

(15.6) (14.8) (15.7) (15.1) (38.9)

2,444 2,212 1,900 1,598 2,706

(22.3) (20.4) (17.5) (14.7) (24.9)

<.0001

Blood Stool Test (last 2 years)

Yes No

2,337 11,261

(17.2) (82.8)

432 2,490

(14.8) (85.2)

1,905 8,771

(17.8) (82.2)

<.0001

Body Mass Index Normal Overweight Obese

3,436 5,273 4,229

(26.6) (40.8) (32.7)

583

1,012 937

(23.0) (39.9) (37.0)

2,853 4,261 3,292

(27.4) (40.9) (31.6)

<.0001

Physical Activity (past 30 days)

Yes No

8,616 5,185

(62.4) (37.6)

1,517 1,460

(50.9) (49.0)

7,098 3,725

(65.6) (34.4)

<.0001

Fruits & Vegetables (past month)

Yes No

950 213

(81.7) (18.3)

219 72

(75.3) (24.8)

731 141

(83.3) (16.2)

0.0011

Current Health Plan Yes No

11,749

2,074

(85.0) (15.0)

2,341

644

(78.4) (21.6)

9,408 1,430

(86.8) (13.2)

<.0001

Current Employment Yes No

4,625 9,188

(33.5) (66.5)

634

2,349

(21.3) (78.8)

3,991 6,839

(36.9) (63.2)

<.0001

Income < $15,000 $15,000-$24,999 $25,000-$34,999 ≥ $35,000

3,857 3,083 1,370 3,549

(32.5) (26.0) (11.6) (29.9)

1,398

615 192 117

(60.2) (26.5) (8.3) (5.0)

2,459 2,468 1,178 3,432

(25.8) (25.9) (12.4) (35.9)

<.0001

Smoking status Current smoker Former smoker

Never smoked1

1,648 3,849 8,294

(11.9) (27.9) (60.1)

292 815

1,874

(9.8) (27.3) (62.9)

1,356 3,034 6,420

(12.5) (28.1) (59.4)

<.0001

Language English Spanish

7,293 6,491

(52.9) (47.1)

542

2,446

(18.1) (81.9)

6,751 4,045

(62.5) (37.4)

<.0001

*p-values based on Pearson chi-square test of association where alpha=0.5 1Never smoked (100 cigarettes in a lifetime)

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 22

In Table 1, the majority of respondents to the question of educational level were female

(62.4%), ≥70 years old (27.9%), did not have a blood stool test in the past two years (82.8%),

were overweight (40.8%), had physical activity in the past thirty days (62.4%), had consumed

fruits and vegetables in the past month (81.7%), had a health plan (85.0%), were not currently

employed (66.5%), had an income of less than $15,000 (32.5%), never smoked (60.1%), and

took the survey in English (52.9%). The majority of respondents who had less than 9th grade

education were female (64.2%), ≥70 years old (38.9%), did not a have a blood stool test in the

past two years (85.2%), were-overweight (39.9%), had physical activity in the past thirty days

(50.9%), had consumed fruits and vegetables in the past month (75.3%), had a health plan

(78.4%), were not currently employed (78.8%), had an income of less than <$15,000 (60.2%),

never smoked (62.9%), and took the survey in Spanish (81.9%). The majority of respondents

with a 9th grade education or higher were female (61.9%), ≥70 years old (24.9%), did not have a

blood stool test in the past two years (82.2%), were overweight (40.9%), had physical activity in

the past thirty days (65.6%), had consumed fruits and vegetables in the past month (83.3%), had

a health plan (86.8%), were not currently employed (63.2%), had an income of more than

>$35,000 (35.9%), never smoked (59.4%), and took the survey in English (62.5%). The

relationship between educational level and sex, age, blood stool test (FOBT), body mass index,

physical activity in the past thirty days, consumption of fruits and vegetables in the past month,

current health plan, current employment, income, smoking status, and interview language were

statistically significant (p≤0.0217).

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 23

TABLE 2: Bivariate Associations of Colorectal Cancer Screening and Other Characteristics among 13,910 U.S. Hispanic/Latino U.S. Hispanic/Latino Respondents Over 50 Years Old, Behavioral Risk Factor Surveillance System, CDC, 2012.

Colorectal Cancer Screening (Ever) Sigmoidoscopy/Colonoscopy

Variable Population Yes No p value*

N% 13,910 (100)

n% 7,926 (56.9)

n% 5,984 (43.0)

Educational Level < 9th grade ≥9th grade

2,999

10,860

(21.6) (78.4)

1,439 6,456

(18.2) (81.8)

1,560 4,404

(26.2) (73.8)

<.0001

Sex Male Female

5,237 8,673

(37.6) (62.4)

2,844 5,082

(35.9) (64.1)

2,393 3,591

(39.9) (60.0) (61.9)

<.0001

Age (years) 50-54 55-59 60-64 65-69 ≥70

2,919 2,659 2,374 2,063 3,895

(20.9) (19.1) (17.1) (14.8) (28.0)

1,149 1,379 1,412 1,368 2,618

(14.5) (17.4) (17.8) (17.3) (33.0)

1,770 1,280

962 695

1,277

(29.6) (21.4) (16.1) (11.6) (21.3)

<.0001

Blood Stool Test (last 2 years)

Yes No

2,341 11,303

(17.2) (82.4)

1,562 6,189

(20.2) (79.8)

779 5,114

(13.2) (86.8)

<.0001

Body Mass Index Normal Overweight Obese

3,444 5,285 4,248

(26.6) (40.7) (32.7)

1,977 3,140 2,424

(26.2) (41.6) (32.1)

1,467 2,145 1,824

(26.9) (39.5) (33.6)

0.0426

Physical Activity (past 30 days)

Yes No

8,641 5,210

(62.4) (37.6)

5,087 2,808

(64.4) (35.6)

3,554 2,402

(59.7) (40.3)

<.0001

Fruits & Vegetables (past month)

Yes No

953 214

(81.7) (18.3)

562 124

(81.9) (18.1)

391 90

(81.3) (18.7)

0.7825

Current Health Plan Yes No

11,794

2,080

(85.0) (14.9)

7,290

622

(92.1) (7.9)

4,504 1,458

(75.6) (24.5)

<.0001

Current Employment Yes No

4,632 9,228

(33.4) (66.6)

2,285 5,611

(28.9) (71.1)

2,347 3,617

(39.3) (60.7)

<.0001

Income < $15,000 $15,000-$24,999 $25,000-$34,999 ≥ $35,000

3,867 3,090 1,372 3,553

(32.5) (26.0) (11.6) (29.9)

1,992 1,597

766 2,368

(29.6) (23.8) (11.4) (35.2)

1,875 1,493

606 1,185

(36.3) (28.9) (11.8) (22.9)

<.0001

Smoking status Current smoker Former smoker

Never smoked1

1,652 3,861 8,328

(11.9) (27.9) (60.2)

781

2,368 4,740

(9.9) (30.0) (60.1)

871

1,493 3,588

(14.6) (25.1) (60.3)

<.0001

Language English Spanish

7,311 6,524

(52.8) (47.2)

4,588 3,288

(58.3) (41.8)

2,723 3,236

(45.7) (54.3)

<.0001

*p-values based on Pearson chi-square test of association where alpha=0.5 1Never smoked (100 cigarettes in a lifetime)

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 24

In Table 2, the majority of respondents to the question of ever having a colorectal cancer

screening (Sigmoidoscopy/Colonoscopy) had a 9th grade education or higher (78.4%), were

females (62.4%), ≥70 years old (28.0%), did not have a blood stool test in the past two years

(82.4%), were overweight (40.7%), had physical activity in the past thirty days (62.4%), had

consumed fruits and vegetables in the past month (81.7%), had a health plan (85.0%), were not

currently employed (66.6%), had an income of less than < $15,000 (32.5%), never smoked

(60.2%), and took the survey in English (52.8%). The majority of respondents to the question

of not having a colorectal cancer screening had a 9th grade education or higher (73.8%), were

female (60.0%), 50-54 years old (29.6%), did not have a blood stool test in the past two years

(86.8%), were overweight (39.5%), had physical activity in the past thirty days (59.7%), had

consumed fruits and vegetables in the past month (81.3%), had a health plan (75.6%), were not

currently employed (60.7%), has an income of less than < $15,000 (36.3%), never smoked

(60.3%), and took the survey in Spanish (54.3%). The majority of respondents to the question

of yes having a colorectal cancer had 9th grade education or higher (81.8%), were female

(64.1%), ≥70 years old (33.0%), did not have a blood stool test in the past two years (79.8%),

were overweight (41.6%), had physical activity in the past thirty days (64.4%), had consumed

fruits and vegetables in the past month (81.9%), had a health plan (92.1%), were not currently

employed (71.1%), had an income of greater than ≥$35,000 (35.2%), never smoked (60.1%),

and took the survey in English (58.3%). The relationship between colorectal cancer screening

and educational level, sex, age, blood stool test (FOBT), body mass index, physical activity in

the past thirty days, consumption of fruits and vegetables in the past month, current health plan,

current employment, income, smoking status, and language interview were statistically

significant (p≤0.0426).

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 25

TABLE 3: Logistic Regression Analysis to Determine the Odds of Colorectal Cancer Screening and Educational Level of 10,875 Hispanic/Latino Respondents Over 50 years Old in the United States After Adjusting for Socio-Demographic and other Characteristics, Behavioral Risk Factor Surveillance System, CDC, 2012.

Colorectal Cancer Screening (Ever) Sigmoidoscopy/Colonoscopy

Variable Yes No AOR** 95% CI◊ n%

7,926 (56.9) n%

5,984 (43.0)

Educational Level < 9th grade ≥9th grade

1,439 6,456

(18.2) (81.8)

1,560 4,404

(26.2) (73.8)

1.19 1.00

(1.06-1.34) --

-- Sex

Male Female

2,844 5,082

(35.9) (64.1)

2,393 3,591

(39.9) (60.0) (61.9)

1.00 0.77

-- (0.70-0.84)

Age (years) 50-54 55-59 60-64 65-69 ≥70

1,149 1,379 1,412 1,368 2,618

(14.5) (17.4) (17.8) (17.3) (33.0)

1,770 1,280

962 695

1,277

(29.6) (21.4) (16.1) (11.6) (21.3)

3.03 1.76 1.39 1.16 1.00

(2.64-3.47) (1.54-2.01) (1.22-1.59) (1.01-1.33) --

Blood Stool Test (last 2 years)

Yes No

1,562 6,189

(20.2) (79.8)

779 5,114

(13.2) (86.8)

1.00 1.33

-- (1.19-1.49)

Body Mass Index Normal Overweight Obese

1,977 3,140 2,424

(26.2) (41.6) (32.1)

1,467 2,145 1,824

(26.9) (39.5) (33.6)

1.00 0.82 0.88

-- (0.74-0.90) (0.79-0.97)

Physical Activity (past 30 days)

Yes No

5,087 2,808

(64.4) (35.6)

3,554 2,402

(59.7) (40.3)

1.00 1.13

-- (1.04-1.23)

Current Health Plan Yes No

7,290

622

(92.1) (7.9)

4,504 1,458

(75.6) (24.5)

1.00 2.36

-- (2.08-2.67) Current Employment

Yes No

2,285 5,611

(28.9) (71.1)

2,347 3,617

(39.3) (60.7)

1.00 0.73

-- (0.66-0.81)

Income < $15,000 $15,000-$24,999 $25,000-$34,999 ≥ $35,000

1,992 1,597

766 2,368

(29.6) (23.8) (11.4) (35.2)

1,875 1,493

606 1,185

(36.3) (28.9) (11.8) (22.9)

2.17 1.90 1.56 1.00

(1.90-2.47) (1.69-2.15) (1.35-1.79) --

--

Smoking status Current smoker Former smoker Never smoked1

781

2,368 4,740

(9.9) (30.0) (60.1)

871

1,493 3,588

(14.6) (25.1) (60.3)

1.27 0.87 1.00

(1.19-1.45) (0.79-0.96) --

Language English Spanish

4,588 3,288

(58.3) (41.8)

2,723 3,236

(45.7) (54.3)

1.00 1.32

-- (1.20-1.45)

**Adjusted Odds Ratio; ◊CI=Confidence Interval 1Never smoked (100 cigarettes in a lifetime)

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 26

In Table 3, Hispanic/Latino respondents who had less than 9th grade educational level had

1.19 adjusted odds of not having a colorectal cancer screening (sigmoidoscopy/colonoscopy)

compared to those of 9th grade or higher educational level (95% CI=1.06-1.34). This suggests

that colorectal cancer screening (sigmoidoscopy/colonoscopy) is statically significantly less

likely among respondents with low health literacy levels. Female respondents had 0.77 adjusted

odds of having a colorectal cancer screening (sigmoidoscopy/colonoscopy) compared to male

respondents (95% CI=0.70-0.84). This suggests that female respondents were statically

significantly more likely to have colorectal cancer screening than male respondents. Respondents

50-54 years old had 3.03 adjusted odds of not having a colorectal cancer screening

(sigmoidoscopy/colonoscopy) compared to those of 70 years or older (95% CI=2.64-3.47). This

suggests that respondents of 50-54 years old were statically significantly more likely of not

having a colorectal cancer screening compared to respondents 70 years or older. Respondents

answering that had not completed a blood stool test in the last two years had 1.33 adjusted odds

of never having a colorectal cancer screening (sigmoidoscopy/colonoscopy) compared to those

who completed a blood stool test in the past two years (95% CI=1.19-1.45). This suggests that

respondents who did not complete a blood stool test in the past two years were statically

significantly more likely of never having a colorectal cancer screening.

Respondents who were obese had 0.88 adjusted odds of having a colorectal cancer

screening (sigmoidoscopy/colonoscopy) compared to those of normal weight (95% CI=0.79-

0.97). This suggests that respondents who were obese were statistically significantly more likely

of having a colorectal cancer screening compared to those of normal weight. Respondents

answering of not having physical activity in the past thirty days had 1.13 adjusted odds of never

having a colorectal cancer screening (sigmoidoscopy/colonoscopy) compared to those who had

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 27

physical activity (95% CI=1.04-1.23). This suggests that respondents who did not have physical

activity in the past thirty days were statistically significantly more likely of never having

colorectal cancer screening. Respondents answering no having a health plan had 2.36 adjusted

odds of never having a colorectal cancer screening (sigmoidoscopy/colonoscopy) compared to

those who had a health plan (95% CI=2.08-2.67). This suggests that respondents who did not

have a health plan were statistically significantly more likely of never having a colorectal cancer

screening (sigmoidoscopy/colonoscopy). Respondents answering not being currently employed

had 0.73 adjusted odds of having a colorectal cancer screening (sigmoidoscopy/colonoscopy)

compared to those who were employed (95% CI=0.66-0.81). This suggests that respondents who

were not currently employed were statistically significantly more likely of having colorectal

cancer screening than those with current employment. Respondents who considered themselves

current smokers had 1.27 adjusted odds of not having a colorectal cancer screening

(sigmoidoscopy/colonoscopy) compared to those who never smoked (95% CI=1.19-1.45). This

suggests that respondents who considered themselves current smokers were statistically

significantly more likely of never having a colorectal cancer screening

(sigmoidoscopy/colonoscopy). Respondents who did the BRFSS 2012 survey in Spanish had

1.32 adjusted odds of never having a colorectal cancer screening (sigmoidoscopy/colonoscopy)

compared to those who did the survey in English (95% CI=1.20-1.45). This suggests that

respondents who took the BRFSS 2012 survey in Spanish were statistically significantly more

likely of never having a colorectal cancer screening (sigmoidoscopy/colonoscopy).

Discussion

According to the CDC, colorectal cancer is the second leading cause of cancer-related

deaths in the United States and the third most common cancer in men and in women (Center for

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 28

Disease Control and Prevention [CDC], 2014). In multiple studies, screening for colorectal

cancer (CRC) has demonstrated to significantly reduce morbidity and mortality from CRC

(Peterson, 2007). Screenings can assist in finding colorectal cancer at an early stage and

treatment often leads to a cure (CDC, 2014). The five year survival rate for colorectal cancer for

early stages (i.e., stage I) is approximately 95%, to advance stages (i.e., stage IV) is

approximately less than 5% (Hummel, 2013). Despite the benefits of early detection, almost 40%

of Americans are not up to date with their colorectal cancer screenings (CDC, 2014). The cost of

treatment of CRC per survival year, stage IV CRC patients incurred $31,000 in excess costs

compared with $3,000 for stage 0 patients (Lang, 2009). Studies showed that low health literacy

have been related to less understanding of educational materials. Low health literacy is defined

as the inability to read, understand, and use health care materials. When patients have low health

literacy levels, they also have a poorer knowledge and understanding of their health condition

and may struggle to understand disease, prevention and treatment (Shea, 2004; Kinsgley, 2010).

The purpose of this study was to investigate the association between low health literacy

levels and colorectal cancer screenings in Hispanic/Latina women over 50 years old in United

States while adjusting for race, sex, age, blood stool test (FOBT), BMI, physical activity,

consumption of fruits and vegetables, current health plan, current employment, income, smoking

status and interview language. In this study, we utilized the Behavioral, Risk Factor Surveillance

System (BRFSS) 2012. This data allows for a state comparison of health behaviors, however,

comparative analyses of the colorectal cancer test used in the Hispanic/Latino community among

states with large Hispanic populations has not been conducted (Pollack, 2006). Because the

BRFSS questions did not allow for separation of sigmoidoscopy and colonoscopy use, we

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 29

defined CRC screening as ever having a sigmoidoscopy/colonoscopy for persons 50 years and

older.

The variables chosen for the study were based on diverse research which shows the

relationship between not having a colorectal cancer screening (CRC) and having less than a 9th

grade educational level, being unemployed, low income, not having a blood stool test in the last

two years and speaking English as a second language (Peterson, 2007; Whitlock, 2008; Doubeni

et al, 2010; Lathrum, 2012). One study concluded that the intention to attend a colorectal

screening procedure is likely to increase if the screening technique is safer and causes less

discomfort (Hummel, 2013).

To support the findings of this study research has shown that there is a relationship

between low health literacy levels and colorectal cancer screenings in ethnic minorities including

Hispanic/Latinos and the rates are the lowest amongst low income individuals, those with

Medicaid or no health insurance, adults with fewer years of education, racial/ethnic minorities

and those living in rural areas (Arnold et al, 2012). According to literature, possession of health

insurance coverage may increase the likelihood of having a usual source of care and

consequently, use of preventive cancer services (Gonzalez, 2012; Emmons, 2012). According to

the CDC, the 2011 National Health Disparities Report, calls for immediate efforts to increase

CRC screenings among Hispanic/Latinos in a cultural appropriate manner, and at a literacy level

below ninth grade (CDC, 2014; JCAHO, 2007). Moreover, culturally relevant CRC interventions

are necessary in order to increase Hispanics/Latino participation. Other possible factors that can

affect colorectal screenings can include age at menopause, hormone replacement therapy and

perhaps immediate relatives with colon cancer (CDC, 2014).

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 30

The results in this study were not weighed, therefore, the results represent the participant’s

response to the survey. The majority of respondents to the question of not having colorectal

cancer screening had a 9th grade education or higher (73.8%), were female (60.0%), were 50-54

years old (29.6%), did not have a blood stool test in the past two years (86.8%), were overweight

(39.5%), had physical activity in the past thirty days (59.7%), had consumed fruits and

vegetables in the past month (81.3%), had a health plan (75.6%), were not currently employed

(60.7%), had an income of less than $15,000 (36.3%), never smoked (60.3%), and took the

survey in Spanish (54.3%).

As previously mentioned, the respondents who did not have colorectal cancer screening

had a 9th grade education or higher showing that even though you have a high school education

or higher understanding, CRC educational materials can be more complicated and confusing that

previously thought. The respondents who were 50-54 year olds are at a higher risk to get CRC in

the future being the youngest population in the study. Research has shown an increase in the

incidence rate for patients with rectal cancer aged 35 to 49 years (Bailey et al, 2014). Based on

current trends, by 2030, the incidence rates for colon and rectal cancers will increase by 90.0%

and 124.2%, respectively, for patients 20 to 34 years and by 27.7% and 46.0%, respectively, for

patients 35 to 49 years (Bailey et al, 2014). In the future, these groups will have the highest need

for culturally and linguistically appropriate educational materials.

In the logistic analysis, the fruits and vegetables question was omitted because the data

was restricted to using a voluntary module and only included respondents who answered all of

the questions. The results of the logistic regression analysis showed that Hispanic/Latino

respondents who had less than 9th grade educational level, were 50-54 years old, did not

complete a blood stool test in the last two years, did not have physical activity in the past thirty

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 31

days, did not have a health plan, had an income of less than $15,000, were current smokers, and

took the survey in Spanish were statically significantly less likely to have a sigmoidoscopy or

colonoscopy than other respondents. The results of female respondents who were obese and not

currently employed were protected. This shows that females who were obese and not currently

employed were statically significantly more likely to have colorectal cancer screening

sigmoidoscopy or colonoscopy than the male respondents in the survey. Also, the results may

suggest that females visit their physician more often, they may have health insurance under their

husband’s or partner’s policy and even when obesity was an issue, they still try to get screened.

Further research is needed to investigate the relationship between females not being currently

employed and having CRC screening. The study also showed that former smokers were

protected and it seemed that they are taking care of their health once they quit smoking,

therefore, having CRC screening. The 2014 Surgeon General’s Report (SGR) linked cancer of

the colon and of the rectum to smoking (CDC, 2014).

According to the literature, some of the barriers for not having colorectal cancer

screening are minimal knowledge of colorectal cancer, lack of screening information, low

perceived risk, fear of cancer and the expectation of pain and embarrassment (Zapka, 2004). One

study conducted in the Netherlands, concluded that the intention to attend a colorectal screening

procedure is likely to increase if the screening technique is safer and causes less discomfort

(Hummel, 2013).

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 32

Figure 1: Prochaska and DiClemente: Stages of Change Model (Adapted from Rehab, 2014).

As described in figure 1, the TTM model move patients from the pre-contemplation stage

seeing a TV commercial, to the preparation stage reading or getting informed on colorectal

cancer, to the preparation stage in which a patient contacts a physician to start the process of

discussing colorectal cancer screening and followed by the action stage where the patient makes

the appointment for the colonoscopy and completes the screening or procedure. Although, the

theoretical model of the Stages of Change was used in this study, other theoretical models could

Seeing a CRC TV commercial,

individual is not considering

change.

Reading about colorectal cancer

and family history in the

internet. Finding out about

colorectal cancer in parents

medical history. Individual is

considering change.

Discussing with physician

the importance of CCR

screening. Review 3 day

prep for colonoscopy.

Making an apt for a

colonoscopy. Individual

decides for change.

Complete colonoscopy

screening. Individual acts

on change.

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 33

apply when considering the social influences and environmental factors that affects the decision

of having CRC screening. Moreover, at the present time, there are no models that considers

culture, immigration generation gap as well as language and its effects on the decision of CRC

screening. Thus, future study is recommended to address this issue and perhaps new theoretical

models could evolve and be utilized to improve CRC screenings in Hispanic/Latinas.

Strengths of the study

The BRFSS survey is the largest continuously phone conducted health survey in the

world and their data set is a yearly largely randomly selected, geographically wide sample of the

American population. Given that the survey is a public data set with large number of variables, it

is possible to control for differences. Another strength of the study is that was conducted in

Spanish, therefore, reaching a population that otherwise would have remained unknown.

Limitations of the study

One of the limitations of the study was the data obtained from BRFSS, 2012 did not ask

specific questions about low health literacy levels and did not ask for the country of origin of

respondents. Also, the fruits/vegetables question was omitted because the data was restricted to

using a voluntary module. Another limitation is the small number of studies that have been

conducted relating low health literacy levels to colorectal cancer screenings in Hispanic/Latina

women.

Conclusion

The purpose of this study was to investigate the association between low health literacy

levels and colorectal cancer screenings in Hispanic/Latina women over 50 years old in United

States while adjusting for race, sex, age, blood stool test (FOBT), BMI, physical activity,

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 34

consumption of fruits and vegetables, current health plan, current employment, income, smoking

status and interview language.

Research have shown that lower literacy skills also correlate with poorer self-reported

health status and because of their worse health, patients with poor literacy skills are in greater

educational needs (as cited in Williams, 1998). The results of this study showed that there was an

association between low health literacy levels and colorectal cancer screenings in

Hispanic/Latina women over 50 years old in United States. Moreover, having a less than 9th

grade educational level influences having a CRC screening. Thus, this shows that a lay verbal

explanation may be needed from the physician, nurse, health educator or promotora to

complement reading the educational materials and answering any questions that the patient may

have regarding CRC screening. Using Spanish speaking promotoras can address the linguistic

and cultural barriers in the Hispanic population (Moralez, 2012). Limited of inadequate health

literacy was significantly associated with less knowledge of CRC and CRC screening and with

more related barriers to complete the fecal occult blood testing (FOBT) and colonoscopy as well

as poorer use of health care services (Peterson, 2007; Berkman, 2011). Moreover, even when

patients in this demographic signed up for screenings, they ran into problems with understanding

the procedure and getting accurate results (Whitlock, 2008).

A recent study showed an increase in the incidence rate for patients with rectal cancer

aged 35 to 49 years (Bailey et al, 2014). This figure represents 131.1% incidence rate change of

colon cancer by 2030 in 20-34 years old, as compared to patients older than 50 years (Bailey et

al, 2014). As this group gets older, more culturally and age appropriate educational materials are

needed to increase the CRC screening numbers in this younger population, therefore, they can

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 35

identify with the information being provided and they will be more likely to consider CRC

screenings.

In August 2014, the Food and Drug Administration (FDA) approved a new stool DNA

test (Cologuard, Exact Sciences) for colorectal cancer screening. According to Dr. Imperiale,

many people do not get screened because they relate the CRC screening to a colonoscopy. The

Cologuard test performed better than the FOBT in identifying advanced adenomas, which are the

lesions that are most likely to progress into invasive colorectal cancer (Imperiale et al, 2014).

It is recommended that future research be conducted to compare the effectiveness of using the

colonoscopy versus Cologuard testing in Hispanic/Latinos.

Further research is also recommended to assess this relationship in Hispanic/Latinos

including country of origin (Latin-American countries) as well as the used of cultural appropriate

educational materials for colorectal cancer screening preparation. Traditionally, patient health

education relies heavily on written educational material about disease processes, medical

management, and self-care instructions. Particular attention should be paid to modifiable factors

that could become the focus of interventions aimed at increasing cancer-screening adherence

(Gonzalez, 2012). In addition, future research is needed to address the role of marriage and CRC

screenings in Hispanics/Latinos where family has a big impact in taking care of someone’s

health. Thus, immediate and culturally relevant CRC interventions are necessary in order to

increase Hispanics/Latina women participation that may lead to an increase in the number of

preventable deaths from colorectal cancer.

COLORECTAL CANCER SCREENING AND LOW HEALTH LITERACY 36

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