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2023

Language Barrier: An Unmet Challenge for Low Screening of Language Barrier: An Unmet Challenge for Low Screening of

Colorectal Cancer Among Hispanic Americans in Texas Colorectal Cancer Among Hispanic Americans in Texas

Moses Owusu Walden University

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Walden University

College of Health Sciences and Public Policy

This is to certify that the doctoral dissertation by

Moses Owusu

has been found to be complete and satisfactory in all respects,

and that any and all revisions required by

the review committee have been made.

Review Committee

Dr. Simone Salandy, Committee Chairperson, Public Health Faculty

Dr. Howell Sasser, Committee Member, Public Health Faculty

Dr. Loretta Shields, University Reviewer, Public Health Faculty

Chief Academic Officer and Provost

Sue Subocz, Ph.D.

Walden University

2023

Abstract

Language Barrier: An Unmet Challenge for Low Screening of Colorectal Cancer Among

Hispanic Americans in Texas

Moses Owusu

MBA, Plymouth State University, 2015

MS, New School University, 2000

B.Sc., Kwame Nkrumah University of Science and Technology, 1994

Dissertation Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Philosophy

Public Health: Epidemiology

Walden University

August 2023

Abstract

Hispanic population represents the fastest growing minority group in the United States,

and only California surpasses Texas with Hispanic residents in the United States. Overall,

non-Hispanic Whites have higher rates of colorectal cancer (CRC) incidence than

Hispanics; however, Hispanic Americans have lower survival rates than non-Hispanic

Whites. Using cross-sectional analysis, CRC screening modalities were examined to

assess disparities among White only, non-Hispanic, Black only, non-Hispanic, and

Hispanic populations in Texas to evaluate the impact of limited English proficiency

(LEP) on CRC screening among Hispanic Americans residents. The age of study

participants ranged from 50 to 79 (mean age = 65.8 years), and the data were obtained

from the 2020 Texas Behavioral Risk Factor Surveillance System (BRFSS) survey. The

primary outcome was self-reported CRC screening status by the respondents. The study

had a sample population, N =766, chosen randomly with 68.5% White only, non-

Hispanic, 10.1% Black only, non-Hispanic, and 21.4% Hispanic participants. Pearson

Chi-square test was used to compare CRC screening rates and modalities and bivariate

and multivariate logistic regression to determine predictors of CRC screening among

participants in the study. The Chi-square tests indicated that there was a statistically

significant association between LEP and non-LEP respondents. The findings showed that

Hispanics with LEP have low CRC screening rates. Suggestions for positive social

change include improvement in CRC screening using social centers to promote CRC

screening, promotion of health literacy and transportation accessibility for vulnerable

communities without access to public transport.

Language Barrier: An Unmet Challenge for Low Screening of Colorectal Cancer Among

Hispanic Americans in Texas

Moses Owusu

MBA, Plymouth State University, 2015

MS, New School University, 2000

B.Sc., Kwame Nkrumah University of Science and Technology, 1994

Dissertation Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Philosophy

Public Health: Epidemiology

Walden University

August 2023

Dedication

This dissertation is dedicated to my late mother, Madam Deborah Akosua

Ankamaa; my wife, Rosemary Barney Owusu; and our children, Patricia, Mimi, Nana,

Adwoa, Brenda, and David. I also appreciate the unshakable support from Mr. Kofi

Fofie, Elder Francis Koosono, Mr. Augustine Amankona (Peace) (brothers), Auntie

Agnes Mmuah, and my sisters in Berekum, Ghana. I am also highly indebted to Dr.

Francis Asomah (Australia) who mentored me in academic pursuits during my high

school days and remains a bedrock supporter in this journey. Similarly, I am grateful to

Dr. Godfred Owusu-Boateng of Kwame Nkrumah University of Science and Technology

(Kumasi, Ghana); Mr. Abor Yeboah (Walter Sisulu University, South Africa); and

nieces, Salome (Mayo Clinic, Rochester, MN) and Francisca (Berekum, Ghana); Mad.

Charlotte Awuku Boateng (mother-in-law); Ms. Stella Green; Dr. Elizabeth Hagan

Asamoah; Ms. Leslie Gillman (Walden University); Mr. Patrick Obeng; Ms. Wilhelmina

Asabea Adu-Darko; Rev. James Acquaah and Ms. Lydia Acquaah; and my nephews,

nieces, family members, distant relatives, and colleagues who encouraged me along the

way. Finally, I understand that I could not have completed this journey without the Lord

Almighty and His strength and grace. All the glory is accredited unto Him for making

this journey fruitful to its successful end.

Acknowledgments

I wish to express my profound gratitude to special people who contributed in

numerous ways to make my dissertation a success. I have successfully come to the

pinnacle of this journey because the Lord Almighty granted me an aura of reassuring

solidity through many people who held my hand in friendship and support. Still, many

others selflessly availed themselves as a springboard to carry me through the journey. My

deepest appreciation goes to my dissertation chair, Dr. Simone W. Salandy for guidance,

patience, encouragement, and prompt responses to all dissertation concerns and

commitment to my success in excelling through the thick and thin of academic trajectory

that has finally become a reality of success. In a similar way, Dr. Howard C. Sasser, my

second committee member, whom I was blessed to have in a pre-dissertation course,

played an irreplaceable role, forming a triad together with my chair and me to ensure that

this journey was destined for a successful completion. Dr. Sasser, thank you for being

around both day and night with an unending patience and boundless epidemiological

knowledge that sailed me through quantitative methodology and its intricacies and

nuances. My gratitude also goes to Dr. Loretta R. Shields, the URR, whose contributions

and expertise ensured that this dissertation met Walden University’s highest doctoral

standard. I would also like to thank my academic advisor, Mr. Garth Woodbury, whose

prompt emails always alerted me of important deadlines. Equally, my sincere thanks goes

to Dr. Christy Fraenza (Lead, Instructional Design at Walden University Peer Mentors

program); Ms. Cassie Fox (MPH) of Texas Department of State Health Services for

BRFSS data for analysis; Ms. Libby Munson, Research Ethics Support Specialist at IRB;

and Ms. Bethany G. Duarte, Senior Editor, Form and Style of the Office of Research and

Doctoral Services, both of Walden University.

I am very grateful to my wife, Rosemary Barney Owusu, whose support and

sacrifices in diverse ways, eased a lot of family stress and ensured a surgical focus on

academic work. Importantly, I’m equally grateful for the patience and understanding

exhibited by my children, Mimi, Nana, Adwoa, and Patricia for all their concerns and

encouragements. I am particularly indebted to Mr. Isaac Boateng and his wife, Mrs. Lily

Gaba Boateng, for their boundless brotherly love, motivation, and support that calmed

tumultuous and stormy periods, making this journey a successful one. My gratitude also

goes to the Rt. Rev. Dr. Yaw Frimpong-Manso (Papa), former Moderator of the

Presbyterian Church of Ghana, and his wife, Mrs. Lucy Frimpong-Manso whose

towering presence of motivation served as an illuminating power of hope during this

academic journey. Papa, thank you! My deepest appreciation also goes to Rev. Ebenezer

Darko Boateng, Mrs. Ellen Boateng, and the entire congregation of the Presbyterian

Church of the Redeemer in Houston, USA, for all their motivational support. Special

thanks to Mr. Robert Kyeremateng, Mrs. Jane Seweh Kyeremateng, Mr. Joseph Danquah,

Mrs. Cecilia Amponsa Danquah, Mr. Yaw Adjei, Mr. James Brobbey, Mrs. Grace Asiedu

Mensah, Ms. Doris Tachie, Ms. Florence Serwaa, Mr. Isaac O. Boateng, Mrs. Emma

Boateng, Mr. Aurelio Lozano (Paul, Weiss, Rifkind, Wharton & Garrison, LLP, NYC),

Nana Yaw Ogyiri, Mr. Samuel Kwabena Britwum Carr, and Mrs. Mary Grant Carr for all

their moral support.

Table of Contents

List of Tables .......................................................................................................................v

Chapter 1: Introduction to the Study ....................................................................................1

Background of the Study ...............................................................................................4

Problem Statement .........................................................................................................6

Purpose of the Study ......................................................................................................9

Research Questions and Hypothesis ............................................................................10

Framework: Conceptual or Theoretical .......................................................................12

Nature of the Study ......................................................................................................15

Definitions of Study Variables .....................................................................................17

Assumptions .................................................................................................................19

Scope and Delimitations ..............................................................................................19

Limitations ...................................................................................................................20

Significance of the Study .............................................................................................21

Summary ......................................................................................................................22

Chapter 2: Literature Review .............................................................................................24

Introduction ..................................................................................................................24

Theoretical Foundation ................................................................................................26

Conceptual Framework: Health Belief Model .............................................................27

Literature Review Related to Key Variables and/or Concepts ....................................36

CRC Screening...................................................................................................... 36

Health-related LEP................................................................................................ 52

Gender and CRC Screening .................................................................................. 57

Cultural Influences on CRC Screening ................................................................. 59

Methodology ......................................................................................................... 60

Summary and Conclusions ..........................................................................................72

Chapter 3: Research Method ..............................................................................................75

Overview ......................................................................................................................75

Instrument to Measure Limited English Proficiency ............................................ 76

Research Design and Rationale ...................................................................................79

Population ............................................................................................................. 81

Sampling Design ................................................................................................... 82

Data Collection ............................................................................................................84

Variables ............................................................................................................... 86

Threats to Validity .......................................................................................................87

Descriptive Statistical Analysis ...................................................................................90

Inferential Statistics .....................................................................................................91

Test of Assumption ......................................................................................................92

Continuous and Categorical Variables.........................................................................93

Inferential Statistical Analysis .....................................................................................93

Ethical Procedures .......................................................................................................94

Summary ......................................................................................................................96

Chapter 4: Results ..............................................................................................................98

Introduction ..................................................................................................................98

iii

Research Questions and Hypotheses ...........................................................................99

Data Analysis .............................................................................................................101

Descriptive Statistics ..................................................................................................101

Sociodemographic Factors .................................................................................. 101

Inferential Statistical Analysis ............................................................................ 149

Model with Interaction Effects ........................................................................... 150

Interaction of the Independent Variable ............................................................. 154

Summary ....................................................................................................................164

Chapter 5: Discussion, Conclusions, and Recommendations ..........................................166

Introduction ................................................................................................................166

Sample Description Summary ...................................................................................167

Interpretation of Findings ..........................................................................................168

Participants Grouped by Age .............................................................................. 168

Sex…................................................................................................................... 169

Race…................................................................................................................. 170

Language ............................................................................................................. 171

Income (Annual Household) ............................................................................... 171

Employment Status ............................................................................................. 172

Healthcare Access ............................................................................................... 173

Education Status.................................................................................................. 173

Colorectal Screening Types .......................................................................................174

Colonoscopy ....................................................................................................... 174

Sigmoidoscopy .................................................................................................... 180

Fecal Occult Blood Test...................................................................................... 182

Sensitivity, Compliance, and Access of CRC Screening Types ................................183

Gender Influences on CRC Screening ................................................................ 184

Research Questions and Hypotheses .........................................................................188

Analysis: The Health Belief Model Conceptual Framework .....................................192

Mediating Effects of Limited English Proficiency ....................................................194

Summary ....................................................................................................................197

Strengths and Limitations ..........................................................................................198

Recommendations ......................................................................................................200

Implications................................................................................................................202

Social Change ............................................................................................................204

Conclusion .................................................................................................................205

References ........................................................................................................................206

Appendix: Abbreviations .................................................................................................252

List of Tables

Table 1 Sample Size per Instrumental Variables ........................................................... 101

Table 2 Sex of Participants ............................................................................................ 102

Table 3 Frequency Table 1: Five-year Groups, Sex, Race, Language .......................... 106

Table 4 ............................................................................................................................ 107

Table 5 Descriptive Statistics of Study Population Based on Screened and Unscreened

for Colorectal Cancer (N=766). .............................................................................. 108

Table 6 Five-year Age Groups and Colorectal Screening Status .................................. 109

Table 7 Chi-Square Tests on Five-Year Age Groups .................................................... 110

Table 8 Symmetric Measures on Five-year Age Groups ............................................... 110

Table 9 Sex of Participants and Colorectal Screening Status ........................................ 111

Table 10 Chi-Square Tests on Sex of Participants and Colorectal Screening Status .... 111

Table 11 Symmetric Measures on Sex of Participants and Colorectal Screening Status

................................................................................................................................. 112

Table 12 Participant Race and Colorectal Screening Status .......................................... 113

Table 13 Chi-Square Tests on Race of Participants and Colorectal Screening Status .. 113

Table 14 Symmetric Measures on Participant Race and Colorectal Status ................... 114

Table 15 Language of Participants and Colorectal Screening Status ............................ 114

Table 16 Chi-Square Tests on Participants’ Language and Colorectal Screening Status

................................................................................................................................. 115

Table 17 Symmetric Measures on Language of Participants and Colorectal Screening

Status ....................................................................................................................... 115

Table 18 Employment Status and Colorectal Cancer Screening ................................... 116

Table 19 Chi-Square Tests on Employment of Participants and Colorectal Screening

Status ....................................................................................................................... 117

Table 20 Symmetric Measures on Employment of Participants and Colorectal Screening

Status ....................................................................................................................... 117

Table 21 Healthcare Access and Colorectal Cancer Screening ..................................... 118

Table 22 Chi-Square Tests on Healthcare Access of Participants and Colorectal

Screening Status ...................................................................................................... 118

Table 23 Symmetric Measures on Health Care Access of Participants and Colorectal

Screening Status ...................................................................................................... 119

Table 24 Group Statistics for English Speaking and Spanish Speaking Participants in

CRC Screening........................................................................................................ 120

Table 25 One Sample Statistics 1: Independent Samples Test on Colorectal Cancer

Screening and Age of Participants .......................................................................... 120

Table 26 One Sample Statistics 2: Independent Samples Test on Colorectal Cancer

Screening and Age of Participants .......................................................................... 121

Table 27 Number of Participants (N), Mean, Std Deviation, and Std Error Mean and CRC

Screening and Participants with Income and Education ......................................... 122

Table 28 One-Sample T Test for CRC Screening with Income and Education of

Participants .............................................................................................................. 122

Table 29 Crosstabulation of Five-year Age Groups and Colonoscopy Screening Status

................................................................................................................................. 123

vii

Table 30 Chi-Square Tests on Five-year Age Groups and Colonoscopy Screening Status

................................................................................................................................. 123

Table 31 Symmetric Measures on Five-year Age Groups and Colorectal Screening Status

................................................................................................................................. 124

Table 32 Sex of Participants and Colonoscopy Screening Status .................................. 124

Table 33 Chi-Square Tests on Males and Females and Colonoscopy Screening Status 125

Table 34 Symmetric Measures on Sex of Participants and Colorectal Screening Status

................................................................................................................................. 125

Table 35 Race of Participants and Colonoscopy Screening Status................................ 126

Table 36 Chi-Square Tests on Race of Participants and Colonoscopy Screening Status

................................................................................................................................. 127

Table 37 Symmetric Measures on Race of Participants and Colonoscopy Screening

Status ....................................................................................................................... 127

Table 38 Language of Participants and Colonoscopy Screening Status ........................ 128

Table 39 Chi-square Tests on Language of Participants and Colonoscopy Screening

Status ....................................................................................................................... 128

Table 40 Symmetric Measures on Language of Participants and Colonoscopy Screening

Status ....................................................................................................................... 129

Table 41 Five-year Age Groups and Colonoscopy Screening Status Within the Past 10

Years ....................................................................................................................... 129

Table 42 Chi-square Tests on Five-year Age Groups and Colonoscopy Screening Status

Within the Past 10 Years......................................................................................... 130

viii

Table 43 Symmetric Measures on Five-year Age Groups and Colonoscopy Screening

Status Within the Past 10 Years .............................................................................. 130

Table 44 Sex of Participants and Colonoscopy Screening Status Within the Past 10 Years

................................................................................................................................. 131

Table 45 Chi-Square Tests on Sex of Participants and Colonoscopy Screening Status

Within the Past 10 Years......................................................................................... 131

Table 46 Symmetric Measures on Sex of Participants and Colonoscopy Screening Status

Within the Past 10 Years......................................................................................... 132

Table 47 Race of Participants and Colonoscopy Screening Status Within the Past 10

Years ....................................................................................................................... 133

Table 48 Chi-Square Tests on Race of Participants and Colonoscopy Screening Status

Within the Past 10 Years......................................................................................... 133

Table 49 Symmetric Measures on Race of Participants and Colonoscopy Screening

Status Within the Past 10 Years .............................................................................. 134

Table 50 Language of Participants and Colonoscopy Screening Status Within the Past 10

Years ....................................................................................................................... 134

Table 51 Chi-Square Tests on Language of Participants and Colonoscopy Screening

Status Within the Past 10 Years .............................................................................. 135

Table 52 Symmetric Measures on Language of Participants and Colonoscopy Screening

Status Within the Past 10 Years .............................................................................. 135

Table 53 Five-year Age Groups and Sigmoidoscopy Screening Status Within the Past

Five Years ............................................................................................................... 136

Table 54 Chi-Square Tests on Five-year Age Groups and Sigmoidoscopy Screening

Status Within the Past Five Years ........................................................................... 137

Table 55 Symmetric Measures on Five-year Age Groups and Sigmoidoscopy Screening

Status Within the Past Five Years ........................................................................... 137

Table 56 Sex of Participants and Sigmoidoscopy Screening Status Within the Past Five

Years ....................................................................................................................... 138

Table 57 Chi-Square Tests on Sex of Participants and Sigmoidoscopy Screening Status

Within the Past Five Years ..................................................................................... 138

Table 58 Symmetric Measures on Sex of Participants and Sigmoidoscopy Screening

Status Within the Past Five Years ........................................................................... 139

Table 59 Race of Participants and Sigmoidoscopy Screening Status Within the Past Five

Years ....................................................................................................................... 140

Table 60 Chi-Square Tests on Race of Participants and Sigmoidoscopy Screening Status

Within the Past Five Years ..................................................................................... 140

Table 61 Symmetric Measures on Race of Participants and Sigmoidoscopy Screening

Status Within the Past Five Years ........................................................................... 141

Table 62 Language of Participants and Sigmoidoscopy Screening Status Within the Past

Five Years ............................................................................................................... 141

Table 63 Chi-Square Tests on Language of Participants and Sigmoidoscopy Screening

Status Within the Past Five Years ........................................................................... 142

Table 64 Symmetric Measures on Language of Participants and Sigmoidoscopy

Screening Status Within the Past Five Years .......................................................... 142

Table 65 Five-year Age Groups and Blood Stool Test Within the Past Year ............... 143

Table 66 Chi-Square Tests for Five-year Age Groups and Blood Stool Test Within the

Past Year ................................................................................................................. 144

Table 67 Symmetric Measures on Five-year Age Groups and Blood Stool Test Within

the Past Year ........................................................................................................... 144

Table 68 Sex of Participants and Blood Stool Test Within the Past Year ..................... 145

Table 69 Chi-Square Tests on Sex of Participants and Blood Stool Test Within the Past

Year ......................................................................................................................... 145

Table 70 Symmetric Measures on Sex and Blood Stool Test Within the Past Year ..... 146

Table 71 Race of Participants and Blood Stool Test Within the Past Year ................... 146

Table 72 Chi-Square Tests on Race of Participants and Blood Stool Test Within the Past

Year ......................................................................................................................... 147

Table 73 Symmetric Measures on Race and Blood Stool Test Within the Past Year ... 147

Table 74 Language of Participants and Blood Stool Test Within the Past Year ........... 148

Table 75 Chi-Square Tests on Language of Participants and Blood Stool Test Within the

Past Year ................................................................................................................. 148

Table 76 Symmetric Measures on Language of Participants and Blood Stool Test Within

the Past Year ........................................................................................................... 149

Table 77 DV Encoding .................................................................................................. 150

Table 78 Classification Table: Colorectal Cancer Status .............................................. 150

Table 79 Omnibus Tests of Model Coefficients ............................................................ 151

Table 80 Hosmer and Lemeshow Test........................................................................... 151

Table 81 Model Summary ............................................................................................. 151

Table 82 Improved Predictor Variables ......................................................................... 152

Table 83 Variables in the Equation ................................................................................ 153

Table 84 Parameter Estimates of Variables on Colorectal Cancer: Yes - Screened for

Colorectal Status ..................................................................................................... 155

Table 85 Parameter Estimates of Variables on Colorectal Cancer: Yes - Had a

Colonoscopy ........................................................................................................... 156

Table 86 Parameter Estimates of Variables on Colorectal Cancer: Yes - Colonoscopy

Within Past 10 Years .............................................................................................. 157

Table 87 Parameter Estimates of Variables on Colorectal Cancer: Yes - Sigmoidoscopy

Within Past 5 Years ................................................................................................ 158

Table 88 Parameter Estimates of Variables on Colorectal Cancer: Yes – Blood Stool Test

Within the Past Year ............................................................................................... 159

Table 89 Case Processing Summary .............................................................................. 160

Table 90 Observations and Predicted Frequencies of Males and Females Among the

Racial Groups in the Study ..................................................................................... 162

Chapter 1: Introduction to the Study

Colorectal cancer (CRC) is the third leading cause of cancer mortality in both

men and women in the United States but assumes a second position when men and

women are put together (Siegel et al., 2020). Although CRC morbidity and mortality

could be reduced through relevant screening and surveillance measures, such preventive

steps are often lacking, particularly among minorities in the United States (Jackson et al,

2016). For 2021, the American Cancer Society (ACS) estimated that CRC incidence

cases were estimated to be 149,500, and 52,980 were expected to die from it. Researchers

argue that 68% of deaths could be prevented with screening, and CRC at its most

treatable state (stage I), it is 90% curable. However, only 38% of CRCs are diagnosed at

stage I; that number is further reduced for individuals diagnosed before age 50, whereas

approximately 10% often receive late-stage disease (stages III and IV), even though the

ACS guidelines recommend screening to be started at 45 years of age (Siegel et al.,

2021).

Nationwide, data indicate that African Americans have the highest increased

burden of CRC compared to other ethnic groups such as Whites and Asians, with higher

incidence, worse outcomes, and earlier-onset of disease (Siegel et al., 2017). However, in

recent years, data demonstrate that like African Americans, the proportion of the

Hispanic population younger than age 50 and diagnosed with CRC is nearly double the

rate seen in Whites (12% vs. 6.7%; Rahman et al., 2015). This is the case even though

Hispanics have lower overall CRC incidence than Whites across all age groups, including

for individuals younger than 50 years of age (Muller et al., 2021). Yet, recent

epidemiological data show that the incidence of early-onset CRC is rising at a faster rate

among Hispanic people (Ellis et al., 2018), with Hispanic men among the fastest growing

demographic of early-onset CRC with an annual increase of 2.7% from 1992 to 2005

(Siegel et al., 2009). In contrast, the incidence for Hispanic women increased only 1.2%

annually during the same time (Siegel et al., 2009). In total, analysis indicates that annual

incidence of early-onset CRC among Hispanics has increased 2.35%, as compared to

2.02% for Whites, and these data reflect similar trends in statewide data obtained from

California and Texas (Wang et al., 2017).

According to the Census Bureau, between 2000 and 2010, the United States total

population grew steadily at a rate of 9.7% (United States Census Bureau, 2011). More

than half of the growth was attributed to the rising population of Hispanics, growing from

35.3 million in 2000 to 50.5 million in 2010, a soaring rate of 43%. The increase in the

Hispanic population accounted for over half the 27.3 million increase in the total United

States population within the period. In 2010, Hispanics comprised 16% of the total

United States population of 308.7 million (United States Census Bureau, 2011),

ballooning to 18.5% or 60.6 million in 2020 (United States Census Bureau, 2020). A

significant point reveals that in 2019, 30.8% of Hispanics were under the age 18, in

comparison to 18.6% of non-Hispanic whites, based on data available at the Office of

Minority Health (OMH) at the United States Department of Health and Human Services

(HHS; 2021).

Notwithstanding their soaring population growth, English language fluency is a

major challenge for many Hispanics. Analysis from the Census Bureau (2019) data on the

profile of Hispanic and Latino Americans demonstrated that English language fluency

varies among Hispanic subgroups who reside within the continental United States. The

data indicate that 71.1% of Hispanics speak a language other than English at home

(OMH, 2021). For example, 70.4% of Mexicans, 58.9% of Puerto Ricans, 77.7% of

Cubans, and 86.2% of Central Americans speak different languages at home, while

28.4% of the overall Hispanics state that they are not fluent in English (OMH, 2021).

Studies indicate that limited English proficiency (LEP) individuals have difficulty

reading, writing, and understanding English (Genoff et al., 2016), which creates

hindrances to participation in the English-language dominant healthcare system in the

United States. Language impediments contribute to poor health processes and outcomes

(Al Shamsi et al., 2020), such as reduced access of preventive services and cancer

screening rates among LEP patients (Tatari et al., 2020).

As the largest ethnic minority group in the United States, the rising CRC

incidence among the Hispanic group needs a serious public health attention that could

influence policymaking to reduce its impact on the population. Barriers, such as language

and other cultural considerations, need to be addressed to enhance screening of CRC in

this population as a means of addressing its adverse effects on the population. This study

focuses on language as an obstacle that leads to challenges for low screening of CRC

among Hispanic Americans in Texas. With the limitations of language on health

outcomes, this study seeks to understand the impact of the language barrier in CRC

screening and treatment among Hispanics in Texas, which ranks only second to

California as the largest Hispanic population in the United States.

Background of the Study

Language barrier describes a roadblock to communication between people who

are unable to speak a common language, such as English. In public health sense,

language barrier is more than merely speaking limitation of a language. Because LEP

individuals have difficulty reading, writing, and understanding English (Genoff et al,

2016), they struggle to participate in the English-dominant healthcare system in the

United States. Thus, language barriers contribute significantly to poor health processes

and outcomes (Fernandez et al., 2011; Stephen & Zoucha, 2020), including limited ability

to access preventive services (Tseng et al., 2008), low cancer screening rates among LEP

patients (Busch et al., 2015; Griffey et al., 2015), nonadherence to medication schedules,

and skipping physician office visits due to misunderstanding physician instructions (Al

Shamsi et al., 2020; Brown & Bussell, 2011).

Clinicians suggest that several types of CRC screening exist, and their respective

procedures differ from one to another. While most of them are performed in clinical

settings, others could be done at home. Notable recommended tests performed by health

care providers in clinical settings include colonoscopy, virtual colonoscopy, and

sigmoidoscopy, whereas Cologuard, which is an at-home fecal immunochemical test-

DNA (FIT-DNA) test, is conducted by patients themselves (Butterly, 2020). These

screening tests are important in detecting CRC in its rudimentary stages when prognosis

often leads to positive outcomes because precancerous polyps could be removed before

they turn into cancer. Without screening, CRC is often detected late because early stages

tend to be asymptomatic (Siegel et al., 2021).

A lack of symptoms at its initial stages keeps CRC hidden where it could only be

found out with screening at that time. The instructions that patients must follow to

undertake CRC screening could be difficult to understand if individuals have limitations

in their knowledge of the English language, which is the main medium of communication

in the United States. Literature demonstrates that individuals with LEP are often reluctant

to seek health care, particularly preventive care, such as CRC screening, owing to

difficulties they experience in communicating or following health care provider

instructions (Sentell et al., 2013). As a result of LEP challenges, prevalence of patients

with cancer and other chronic diseases tends to be significantly higher than in the general

population (Gunn et al., 2020).

Similarly, low health literacy (LHL) negatively affects CRC screening due to

unmet informational needs over the relevance of interventions, such as CRC screening.

Effects of social determinants of health (SDH) like low socioeconomic status (SES)

coupled with LHL could potentially exacerbate the effects of LEP on CRC screening

(Schillinger, 2020). Studies indicate that while each of these factors (SDH, LHL, and

LEP) independently decreases preventive care measures like CRC screening, their

combined effects could make the situation worse for individuals identified with all those

factors (Sentell et al., 2015). Most immigrants, particularly those whose primary

language is not English such as Hispanic Americans, tend to suffer from SDH, LEP, and

LHL (Jacobson et al., 2016). Consequently, these factors pose significant public health

challenges on health care preventive interventions. With a high Hispanic population in

Texas, which ranks only second to California in size, this study sought to understand the

impact of LEP on CRC screening among Hispanic residents in the state. The study also

assessed whether gender differences lead to any variations in CRC rates among Hispanics

in the state.

Problem Statement

Studies indicate that the United States Hispanic population, identified by

individuals of Mexican, Puerto Rican, Cuban, Dominican, and additional Central/South

American as well as other Spanish ancestry based on self-identification (Jackson et al.,

2016), particularly reflects low rates of CRC screening, which may be blamed on certain

barriers, especially deficits in their ability to use the English language (Wang et al.,

2013). While not all individuals suffering from LEP may also have LHL, investigators

argue that a vast majority of individuals with LEP also have LHL status (Schillinger,

2020). Because LHL is associated with less cancer knowledge, negative attitudes toward

cancer screening, lower self-efficacy, and less likelihood of completing screening,

individuals suffering from LEP are confronted with compounded barriers in

comprehending and accessing health information and services (Arnold et al., 2016).

Researchers suggest that LEP individuals in patient-provider language-concordant

relationships experience increased rates of CRC screening as compared to individuals in

language-discordant relationships (Hsueh et al., 2021), thereby making LEP a key

component of effective health management (Schillinger, 2020). Similarly, other studies

indicate that LEP status is associated with multiple suboptimal health outcomes, partly

because of misinterpretation of patient complaints. Although hospitals often make

provisions for language translations, such provisions do not necessarily enhance the

understanding of patients to appreciate the services available to them, including effective

preventive measures like screening for CRC (Al Shamsi et al., 2020).

Because CRC screening involves individuals scheduling beyond a regular

doctors’ appointment, independent test preparation, and/or complex completion

instructions, it is often adversely influenced by LEP (Hill et al., 2021). Consequently,

most individuals who are diagnosed with CRC, particularly those with LEP challenges,

are found in late stages of the disease (Andrew et al., 2018). To gain a comprehensive

understanding of obstacles to CRC screening in the Hispanic population, an integrative

analysis of possible factors such as low literacy/educational levels, lack of provider

recommendations primarily due to lack of health insurance, cost of screening, and fear of

colonoscopy procedure is necessary. Most of these factors may be associated with LEP,

which constrains immigrants in the larger American society and culture (Zhang et al.,

2012). Researchers suggest that no matter the stage at which CRC is found, challenges

remain for patients, even after successful treatments, including surgery, radiotherapy,

and/or chemotherapy (Xie et al., 2020).

Late-stage CRC often leads to poor prognosis due to complications in treatment

and disease management because the cancer is no longer resectable when it has

metastasized to other organs such as the liver and lungs; this leaves chemotherapy as the

mainstay treatment option, which involves frequent provider office visits (Huang et al.,

2020). Even though the overall incidence of CRC among Hispanics compared to non-

Hispanic Whites is lower, the former’s incidence rate of 35.5 per 100,000 population is

still significant, and overall five-year CRC survival rates are equivalent between

Hispanics and non-Hispanic Whites (Jackson et al., 2016). However, researchers have not

observed increases in survival among Hispanics in comparison with non-Hispanic Whites

for metastatic CRC, raising questions about nonmedical factors like language barrier and

other cultural impediments (Sineshaw et al., 2014).

These findings indicate that the Hispanic population in the United States is

confronted with problems associated with CRC screening for early detection and poor

management when diagnosed late with CRC. Investigators suggest that several

randomized screening trials have shown a decrease in CRC mortality by repeated fecal

occult blood test (FOBT) testing annually or biannually, followed by colonoscopy for

participants with positive test results (Lin et al., 2021). Whether the low screening rates

for CRC among the Hispanic population in Texas are due to their deficiencies in the

English language remains unknown. Researchers have sought to understand the impact of

language barrier on health outcomes of many diseases elsewhere in the United States and

beyond; however, no attempt has been made to study the impact of language barrier on

CRC screening among communities of Hispanic origin in the state of Texas. The gap

makes this study, which assesses the impact of language barrier as a potential unmet

challenge in screening for early detection of CRC among Hispanics in Texas, important

to evaluate whether LEP contributes to low screening with its concomitant elevated

morbidity and mortality among Hispanic residents in Texas. The study also evaluated

whether LEP effects on CRC screening affect both male and female genders differently.

Purpose of the Study

The purpose of this study was to determine the impact of LEP on CRC screening

among Hispanic Americans in Texas. The study also sought to explore the differences in

the effect of language proficiency on CRC screening by their male and female

counterparts. I compared the CRC screening rate differences between English-speaking

and non-English speaking populations in Texas using a quantitative method to analyze

data obtained from the 2020 Texas Behavioral Risk Factor Surveillance System (BRFSS,

2020; the latest Texas BRFSS with data on CRC at the time of the study) on the general

population to deduce general health information of noninstitutionalized civilian

(Hispanic) residents of Texas. The study findings may assist in understanding the impact

of LEP and gender differences and CRC screening among Hispanic Americans in Texas.

Importantly, it would inform policymakers about any improvements they need to

undertake to promote and enhance CRC screening by initiating programs that would

reduce LEP in the target population. It would also highlight gender influences on

differences in CRC screening within the target community and find means to address any

hindrances that suppress CRC screening rates by gender.

Language barrier was the independent variable (IV) of the study. Language ability

may be defined by grouping study participants into language barrier or no language

barrier categories based on responses to the question, “Which language(s), English or

Spanish, do the study participants speak?” Given that English is the main language

spoken in Texas, “Spanish only” respondents were categorized as having language

barriers, while respondents who spoke “only English” or “both English and Spanish”

were categorized as having no language barriers. CRC screening was the dependent

variable (DV), or outcome variable of this study. Potential confounding variables in this

study included age and SES, such as income and educational levels of participants, which

were controlled in the data analysis. To absolve the confounding variables, age and other

factors associated with SES such as education, migration background, marital status,

statistical area of residence, employment, and income were considered in the computation

to assess LEP as a barrier to low CRC screening among the target population of the

study. The research questions were designed to measure the impact of language barrier on

screening rates for CRC among the Hispanic population in Texas. By understanding the

impact of the English language deficit on the Hispanic population, effective public health

measures could be developed to improve upon their CRC screening rates.

Research Questions and Hypothesis

The main independent variable (IV) was LEP. Because LEP individuals could not

communicate well in English, they attempted to respond to the BRFSS questionnaire in

Spanish. The IV was divided into eight categories: Non-Hispanic White Men, Non-

Hispanic White Women, Non- Hispanic Black Men, Non- Hispanic Black women,

Hispanic Men Responding in English, Hispanic Women Responding in English, Hispanic

Men Responding in Spanish, and Hispanic Women Responding in Spanish. The

dependent variable (DV) was based on CRC screening tests and described as reporting

FOBT within the past year, and/or sigmoidoscopy within the past 5 years, and/or

colonoscopy within the past 10 years. The research questions (RQs) and hypotheses were

as follows.

RQ1: Are CRC screening rates different between residents in Texas with and

without proficiency in English, when potential confounding variables including age,

income, occupation, health care access, and educational levels of participants are

controlled?

H01: There is no significant relationship between language barrier and CRC

screening rates among Hispanic and non-Hispanic populations in Texas, when potential

confounding variables including age, income, occupation, health care access, and

educational levels of participants are controlled.

Ha1: There is a significant relationship between language barrier and CRC

screening rates among Hispanic and non-Hispanic populations in Texas, when potential

confounding variables including age, income, occupation, health care access, and

educational levels of participants are controlled.

RQ2: Are CRC screening rates different between male and female residents in

Texas with and without proficiency in English, when potential confounding variables

including age, income, occupation, health care access, and educational levels of

participants are controlled?

H02: There is no significant relationship between gender and CRC screening of

Hispanic and non-Hispanic populations in Texas, when potential confounding variables

including age, income, occupation, health care access, and educational levels of

participants are controlled.

Ha2: There is a significant relationship between gender and CRC screening of

Hispanic and non-Hispanic populations in Texas, when potential confounding variables

including age, income, occupation, health care access, and educational levels of

participants are controlled.

Framework: Conceptual or Theoretical

Developed initially in the 1950s by social psychologists employed by the United

States Public Health Service, the health belief model (HBM) has assumed a central

position among theoretical frameworks that seek to account for the broad failure of

individuals to participate in events to avert or detect asymptomatic disease (Hochbaum,

1958; Rosenstock, 1966, 1974). In addition, HBM seeks to explain individuals’ responses

based on their experienced symptoms (Kirscht, 1974) and their behavior in response to

clinically diagnosed illnesses, especially in compliance to medical regimens (Becker,

1974). Social psychologists developed the HBM due to significant limitations of success

regarding various programs within the public health system in the 1950s and thereafter.

Consequently, efforts were committed to developing a theory that would delineate public

acceptance (or lack thereof) of programs to screen for disease and to vaccinate against

viral diseases like poliomyelitis and influenza, as well as attempts to improve on

compliance with medical advice regarding diabetes, hypertension, cancer, obesity,

exercise, seat-belt use, and HIV-risk behavior (Janz & Becker, 1984; Stretcher &

Rosenstock, 1997). Being one of the most broadly applied theories of health behavior,

HBM postulates six constructs, including risk susceptibility, risk severity, benefits to

action, barriers to action, perceived self-efficacy, and cues to action predict health

behavior (Becker, 1974).

The logical connections between HBM and the nature of this study are explained

by the HBM postulates. These constructs are relevant to understanding the impact of

language barrier in identifying asymptomatic CRC patients through screening for early

detection, which leads to positive disease prognosis. The constructs also relate to clinical

instructions of managing CRC symptoms and improve on core determinants of disease

prognosis (Hochbaum, 1958; Rosenstock, 1966, 1974).

The risk susceptibility describes an individual’s subjective awareness of the risk

of acquiring an illness or disease. The risk severity deals with an individual’s

assumptions on the concerns of contracting CRC, and the possibility of not receiving an

appropriate treatment, thereby leading them to a wide variation of apprehensiveness,

including medical consequences like death or disability, and social consequences that

may adversely affect their families with economic hardships. The benefits to action

explain an individual’s understanding of the effectiveness of available actions to

minimize the threats of CRC (or to cure CRC). Individuals who perceive these dangers

take actions to prevent or cure the cancer based on their understanding and evaluation of

both perceived susceptibility and perceived benefit as a motivation to accept the

recommended health action they consider beneficial.

Barriers to action refers to an individual’s recognition of impediments to

undertake a recommended health action on CRC, which may involve a broad variation of

barriers, such as costs, time-consumption, and inconvenience associated with health

actions they accept in dealing with CRC. As a result, individuals perform cost and benefit

analysis and weigh the effectiveness of decisions they embrace. Perceived self-efficacy

describes individuals’ confidence in their ability to appropriately perform a behavior,

which was a construct that was added to the model in mid-1980s; it is also a construct in

many behavioral theories as it is directly associated with whether an individual takes up

the desired behavior. The cues to action, which could be internal factors like fatigue due

to anemia, lack of appetite and weight loss, are often associated with CRC residual

symptoms; external cues such as advice from close relatives and friends, illness of family

member, and newspaper articles serve as a stimulus that influence decision-making

process to embrace a recommended health action.

To appreciate the relevance of these constructs, individuals suffering from or

prone to acquiring CRC need to overcome the barrier of language limitations to

understand the American healthcare delivery system and be able to communicate

effectively with healthcare providers. Thus, the fundamental importance of HBM

constructs makes it an appropriate public health theory in appreciating the unmet

challenges, like language barrier, for individuals in identifying asymptomatic CRC

patients and the ability to relate to clinical instructions of managing CRC residual

symptoms (Rakhshanderou et al., 2020).

This indicates that HBM demonstrates a value-expectancy theory, where behavior

assumes the function of the subjective value of an outcome and the subjective probability,

or expectation, where a specific action would lead to the expected outcome (Lewin et al.,

1944). In the context of health-associated behavior, the value-expectancy theory

demonstrates the willingness to prevent illness or to get well (value), which also signifies

the belief that a particular health action available to individuals would avoid or

ameliorate illness (expectancy), where individual’s estimate of personal susceptibility to

and the severity of an illness could be linked to the likelihood of being able to reduce that

threat through personal action.

Like other cognitive theories, HBM underscores those mental processes, such as

thinking, reasoning, hypothesizing, or expecting as fundamental components of the

model. In the same way, behaviorists like Skinner (1938) maintain that reinforcements or

consequences of behavior impact behavior directly, whereas cognitive theorists assume

that reinforcements function by influencing expectations (or hypotheses) about situations

instead of affecting behaviors directly (Bandura, 1965). The primary tenet in the HBM

reveals that people would make sound decisions to ward off, screen for, or control ill-

health conditions, such as CRC, if they consider themselves as susceptible to the

detrimental effects of the disease; if they perceive that an accessible course of action to

them would be helpful in lowering either their susceptibility to or the severity of the

condition; and if they perceived that the predicted obstacles or costs related to taking the

action are overridden by its benefits (Lin et al., 2019). Thus, the fundamental importance

of HBM makes it an appropriate public health theory in understanding language barrier

for individuals screening for CRC (Lau et al., 2020).

Nature of the Study

I employed quantitative method and cross-sectional design to examine the

relationships in the RQs and hypothesis between and among the variables using

secondary data from the Texas BRFSS (2020) on the general population to deduce

general health information of noninstitutionalized civilian residents of Texas. Individuals

younger than 50 years of age were excluded from the study because the United States

Preventive Services Task Force (USPSTF) recommendation for CRC screening begins at

age 50 to 75 years. Although recommendations from the ACS include individuals who

are at least 45 years of age in CRC screenings, because this study used data from BRFSS,

which is prepared by the CDC and follows recommendations from the USPSTS, I set the

baseline for this study at 50 years of age for participants. The Texas BRFSS provides

information on all races and ethnic groups for analyses of cancer incidence to support

health care assessment, evaluation, and planning, identifying populations at increased risk

of cancer, improving research associated with cancer etiology, prevention, and control

with appropriate interventions. The IV, which was represented by LEP in this study, was

dichotomous (language as a barrier to screening—yes/no), and the DVs (screening rates

among ethnic groups and between male and female gender differences) were categorical

variables. The DVs, which were based on CRC screening tests and described as reporting

FOBT within the past year, and/or sigmoidoscopy within the past 5 years, and/or

colonoscopy within the past 10 years, could be described as high screening rate, average

screening rate and low screening rate, indicating that these categorical variables were

ordinal variables.

The secondary data contained sociodemographic information on subjects who

participated in the study. To compute for language barrier levels, I employed

sociodemographic features such as age, gender, Hispanic origin (place of birth), Spanish

as first language, highest educational attainment, income level, and English fluency. To

find variables that could promote screening for CRC or improve on poor quality of life

after diagnosis with CRC, I evaluated cancer screening knowledge, accessibility and

utilization of health care services, health literacy, and environmental barriers, such as

legal status and preparation for and fear of colonoscopy procedure. The Texas BRFSS

database provides all sociodemographic characteristics needed to analyze language

barrier as an unmet challenge to screen for CRC and improve upon the quality of life

after diagnosis.

Definitions of Study Variables

Language barrier, which in this study is cited as limited English proficiency

(LEP): Refers to the inability of a health care provider and individuals they serve to

communicate because the former and latter speak different languages. When health care

providers and patients speak different languages, quality of care is adversely affected

because language concordance between patients and providers is essential for patients to

participate in effective preventive medicine, including screening for CRC. Investigators

note that language-incongruent encounters within the United States healthcare system

suppress individuals whose primary language is not English from participating in

preventive measures, such as CRC screening (Cano-Ibáñez et al., 2021). These

individuals who suffer from LEP may have difficulty reading, writing, and understanding

English, which creates hindrances to participation in the English-language dominant

healthcare system in the United States (Genoff et al., 2016).

Health literacy: The Centers for Disease Control and Prevention (CDC) defines

health literacy as “the degree to which individuals have the ability to find, understand,

and use information and services to inform health-related decisions and actions for

themselves and others” (Office of Disease Prevention and Health Promotion, 2021).

Researchers state that while literacy and health literacy are different, both factors are

interconnected to influence people’s eagerness to undertake preventive health measures,

such as CRC screening. Thus, health literacy is connected to literacy and implies

individuals’ knowledge, motivation, competences to access, comprehend, appraise, and

apply health information to make informed evaluations that result in suitable decision

making on their health. Low literacy promotes nonparticipation, which is influenced by

poor SES, defined by factors like income, educational level, and employment status

(Horshauge et al., 2020).

CRC screening: refers to medical procedures used to detect polyps and early

cancers in the large intestine (colon and rectum). CRC screening allows providers to

identify such abnormalities and treat them before cancer spreads or metastasizes. Studies

indicate that regular CRC screening prevents late detection of CRC and often make it

treatable with good prognostic outcomes (Issa & Noureddine, 2017).

Hispanic American: The United States Office of Management and Budget (OMB)

defines “Hispanic or Latino” as a person of Cuban, Mexican, Puerto Rican, South or

Central American, or other Spanish culture or origin regardless of race. Individuals who

trace their background origins to a Spanish-speaking country are referred to as Hispanic,

whereas those described as Latino refer to individuals who identify themselves with the

background origin of a Latin American country.

Assumptions

Costas-Muñiz et al. (2106) proposed that low rates of CRC screening among

immigrants, such as Hispanics, in relation to United States natives may be due in part to

the different values and beliefs exhibited by immigrants about health services used in the

United States. It may also be due to acculturation resistance to adapting the American

social norms on CRC screening. While previous studies among Hispanic and Asian

Americans found mixed results, it is important to assume that healthy migrant effects

could also influence low rates of CRC screening among Hispanic immigrants in the

United States; although, established facts indicate that Hispanic Americans tend to

improve on CRC screening when socioeconomic factors and access to care are addressed

(Velasco-Mondragon et al., 2016). Another important assumption among Hispanic

Americans is that this segment of American immigrants come from different countries

with varied cultures that may potentially influence their approach to the American native

culture on healthcare (Castañeda et al., 2019), an indication that sociocultural factors that

influence CRC screening may differ from one country to the other.

Scope and Delimitations

I focused my research on the noninstitutionalized, civilian, Hispanic American

population in Texas at the time of the study. The study focused on individuals who were

at least 50 years of age, as recommended by the USPSTF (United States Preventive

Services Task Force, 2021). Although ACS recommends that individuals need to be

screened at 45 years of age with increased potential benefits to detect early-onset disease

and minimize higher incidence and mortality from CRC (Abualkhair et al., 2020), the

BRFSS data are prepared by the CDC, which depends on the recommendations by the

USPSTF. Hispanic Americans residing in Texas but younger than 50 years of age were

not included in the study because the USPSTF recommendation for CRC screening

begins at age 50 to 75 years. Since preparation and screening procedures like a

colonoscopy could be complicated and cumbersome, they may pose a health risk for

individuals older than 75 years old. For that reason, for individuals aged 76 years or

more, USPSTF suggests making decision based on individuals overall health and history

of CRC screening (United States Preventive Services Task Force, 2021).

Limitations

Because my study used secondary data, I was unable to establish the validity of

the method used to collect the data. Any errors made in the collection of the data, such as

how questions were worded, may elicit responses in a certain way and could lead to a

measurement error, which could have introduced misinformation bias or miscalculation

into this study. BRFSS data are a probability sample of United States households with

both landline and cellphone telephones. Since telephone coverage differs by state and

subpopulations, selection bias exists in BRFSS data collection. This means that

individuals whose numbers are not selected, and those who do not have telephones could

not be covered by BRFSS sampling. Also, the participants’ ability to recall details of

responses they provide relies on how much time has elapsed since the event, leading to

response errors or recall bias in their answers. Notwithstanding its limitations, BRFSS

remains the best estimated source of health data for assessment at geographic levels

smaller than state employing limited community analysis techniques (Iachan et al., 2016).

Significance of the Study

This study sought to explore the effects of LEP on CRC screening among

Hispanic Americans in Texas and assess whether variations in their gender have any

influences on CRC screening. To date, review of literature on CRC health outcomes

among Hispanics primarily focuses on the Hispanic population around the United States,

with little to no research available on more than 11.5 million Hispanic residents, or nearly

40% of the 29 million people living in Texas (OMH, 2021). This study would offer clues

to understanding the impact of the English language as a barrier to low screening rates for

early CRC detection. Such clues would contribute to the knowledge in public health

about the adverse effects of lack of CRC screening and nonadherence to physician

instructions, particularly among migrants whose understanding of the English language is

limited, such as the Hispanic population in Texas.

Furthermore, the study findings may assist in understanding the impact of LEP

and gender differences on CRC. Importantly, it would inform policymakers on public

health policy about any improvements they need to undertake to promote and enhance

CRC screening by initiating programs that would reduce LEP in the target population. It

would also highlight gender influences on differences in CRC screening within the target

community and find means to address perceived hindrances that suppress CRC screening

rates by gender. Such a transformation would likely enhance positive social change in

those communities.

Summary

Timely CRC screening leads to early detection of CRC and better treatment

outcomes. Although nationwide, Hispanics have lower overall CRC incidence than

Whites across all age groups, including for individuals younger than 50 years of age

(Muller et al., 2021), recent epidemiological data show that the incidence of early-onset

CRC is rising at a faster rate among Hispanic people (Ellis et al., 2018), with Hispanic

men among the fastest growing demographic of early-onset CRC, with an annual increase

of 2.7% from 1992 to 2005 (Siegel et al., 2009). Whereas the incidence for Hispanic

women increased only 1.2% annually during the same time (Siegel et al., 2009), in total,

analysis indicates that annual incidence of early-onset CRC among Hispanics has

increased 2.35%, compared to 2.02% for Whites; these data reflect similar trends in

statewide data obtained from California and Texas (Wang et al., 2017).

As the largest ethnic minority group and fastest growing population in the United

States, the rising CRC incidence among the Hispanic group needs serious public health

attention that would influence policymaking on applications to reducing its impact on the

population. Investigators have studied the impact of language barrier on many diseases,

including CRC; however, no attempt has been made to study its impact on the overall

Hispanic population in the in the state of Texas. The gap makes this study, which seeks to

evaluate the impact of language barrier as a potential unmet challenge in screening for

early detection of CRC among Hispanics in Texas important to evaluate whether LEP

contributes to low screening with its concomitant elevated morbidity and mortality

among Hispanic residents in Texas. The study also evaluates whether LEP effects on

CRC screening affect male and female genders differently. Using HBM, the purpose of

this study was to evaluate secondary quantitative data from the Texas BRFSS (2020) to

analyze whether there was a significant relationship between language barrier and low

CRC screening rate among the target population. Similarly, the study sought to assess

whether there was a significant relationship between male and female genders in the

target population. Knowledge garnered from the study could contribute to the body of

knowledge to guide health enhancement programs within the ethnic group.

To further understand challenges that may confront the Hispanic Americans in

Texas about the impact of LEP and gender differences on CRC screening, I undertook an

extensive literature review from peer-reviewed journals. I also performed quantitative

data analyses using cross-sectional design on publicly available data from the Texas

BRFSS (2020) to evaluate the relationships between the variables. The results from this

investigation were then compared to the current body of knowledge to examine whether

they were in harmony with the literature and offered possible explanation regarding any

observed discrepancies. Chapter 2 focuses on the body of literature on CRC, LEP, and

sociodemographic data of the population of interest. Chapter 3 includes the methodology,

Chapter 4 deals with the results, and Chapter 5 focuses on discussion and analysis of the

results, and recommendations.

Chapter 2: Literature Review

Introduction

Researchers understand that irrespective of different racial and ethnic

backgrounds, health concerns are important to people of all backgrounds (Williams et al.,

2016). Significantly, investigators argue that sociocultural differences and socioeconomic

disparities in the immigrant communities play a leading role in limiting their access to

healthcare in the United States. The complex interplay between numerous factors such as

LEP, literacy skills, health knowledge, sociocultural factors, and the established

healthcare system, which embodies health care practitioners, health care infrastructure,

and quality of health care workforce that work together to promote health access have not

been adequately explored (Schillinger, 2020). This is particularly significant in the

Hispanic population whose primary language is often different from English, the main

language of the United States. Singularly, various factors that influence the LEP are

directly related to the effectiveness of CRC screening among Hispanic people in the

United States (Schillinger, 2020).

These factors are not limited to basic literacy but are made up of complex

interactions of individual limitations and varied sociocultural deficiencies that fail to

promote screening for CRC in its rudimentary, localized state. For example, minority

status, young age, less education, recent immigration to the United States, or being a

foreign born, low knowledge about CRC screening and reduced contact with the United

States healthcare system contribute to the poor participation in the CRC screening among

Hispanic Americans. The underutilization of CRC screening leads to lost opportunities

for CRC prevention and control (Savas et al., 2015). Overall, Hispanic Americans run

into a higher burden of access-associated screening limitations, such as living below the

federal poverty level (FPL) and reduced insurance coverage, which could also be blamed

on their limitations in English proficiency. Lack of health insurance is consistently

related to underutilization of CRC screening, particularly among Hispanic Americans

(Ou, et al., 2019). Investigators that have considered individual constituents such as LEP

and CRC screening knowledge, awareness, attitudes, beliefs, and availability of health

care have not exhaustively accounted for low CRC screening among Hispanic Americans

in Texas.

Chapter 2 highlights on peer-reviewed articles exploring the main IVs of

ethnicity, LEP and its determinants, while the DV was based on CRC screening, and the

association between and among the variables. Most of the literature used include articles

and other sources published in English since 2016. The articles in this review were

chosen using PubMed/Medline, Biological Abstracts, Biosis Citation Index, Cumulative

Index to Nursing and Allied Health, Cochrane Library, Embase Classic, SAGE,

ScienceDirect, and Web of Science. Relevant keywords/text words employed in the

search for appropriate literature were Texas Hispanics OR Latinos OR

Hispanic/Latino/Latina; Language barrier AND Mass screening OR Screening OR

Prevention; Colorectal cancer OR Colorectal neoplasms OR Colonic cancer OR Colonic

neoplasm OR CRC OR Colorectal carcinoma OR Colon carcinogenesis OR Sigmoid

carcinoma or Colon adenocarcinoma OR Colon carcinogenesis. Studies indicate that

these wide range of unique choices of research instruments often provide clear and

concise literature on target populations in investigations (Charrois, 2015).

Theoretical Foundation

It is well established that early detection of CRC improves prognosis, and many

screening tests are available to most of the general population in the United States. Yet,

CRC screening is suboptimal, particularly among individuals within the lower SES

brackets (Li, 2018). In view of lack of effective participation in CRC screening, various

models of public health have been developed by behavioral scientists to identify and

assess the elements that contribute to people’s participation of CRC screening (Topaloğlu

& Aydoğdu, 2021). Researchers suggest that HBM is one of the most important model-

based interventions that explains behaviors toward cancer screening, particularly among

subjects of low SES (Zare et al., 2016). The HBM could provide guidance for researchers

to assess screening behaviors of people and to appreciate their decision to accept

screening as a preventive mechanism against cancer. Health analysts indicate that HBM,

theory of justified action, theory of planned behavior, social cognitive theory,

transtheoretical model and health promotion model assume positions among the

models/theories often employed in the literature to understanding adherence with CRC

screening. Researchers have also employed other models, such as health behavior

framework (HBF), sociocultural health behavior model (SCHBM), and behavioral model

of health services use (BMHSU) to study CRC screening. While all these models are

approvingly useful in estimating CRC screening behaviors, it is demonstrated that

models/theories other than HBM are relatively deficient in predicting these relationships

(Topaloğlu & Aydoğdu, 2021), because the HBM essentially illustrates the association

between both internal and external health beliefs and health behaviors or intentions (Feng

et al., 2021). In this study, I used the HBM to ascertain the impact of its six constructs on

preventive care and how it influences individuals to seek CRC screening.

Conceptual Framework: Health Belief Model

Health investigators use the HBM as a model to evaluate cancer screenings and

other preventive health behaviors, thereby assessing the willingness of individuals to take

action to avoid, control, or screen for disease. Such an action leads to identifying

particular constructs that alter the individual’s behavior. For instance, if people become

vulnerable to the negative effects of CRC, they are more likely to accept screening

behavior, appreciate the benefits of CRC screening, and exhibit less resistance to

screening. As one of the most broadly applied theories of health behavior, the HBM

postulates six constructs, including risk susceptibility, risk severity, benefits to action,

barriers to action, perceived self-efficacy, and cues to action predict health behavior

(Becker, 1974). The logical connections between the HBM and the nature of this study

are explained by the HBM postulates. These constructs are relevant to understanding the

impact of language barrier in identifying asymptomatic CRC patients through screening

for early detection, which leads to positive disease prognosis. The constructs also relate

to clinical instructions of managing CRC symptoms and improve on core determinants of

disease prognosis (Hochbaum, 1958; Rosenstock, 1966, 1974).