- Email: [email protected]
Adherence and barriers to colorectal cancer screening varies among Arab Americans from different countries of origin
Arab Journal of Gastroenterology xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Arab Journal of Gastroenterology journal homepage: www.elsevier.com/locate/ajg
Original Article
Adherence and barriers to colorectal cancer screening varies among Arab Americans from different countries of origin Nizar Talaat ⇑ East Carolina University, Greenville, NC, USA
a r t i c l e
i n f o
Article history: Received 1 February 2015 Accepted 11 July 2015 Available online xxxx Keywords: Arab-Americans Colon cancer screening Colorectal cancer
a b s t r a c t Background and study aims: Arab-Americans (ArA) in Michigan, USA had the lowest colorectal cancer screening (CRCS) in 2008 compared to the state’s general population (45.6% vs. 60.8%). The adherence rate and barriers to CRCS have been identified in a previous study; however, these differences have been not examined among ArA from different countries of origin. Patients and methods: Community-based study through a survey filled by 130 Arab-Americans aged P50 years. Demographic information and information about CRC screening knowledge were obtained. Responses were compared between the two largest population groups (Lebanese and Yemenis). Results: The majority of the participants (80%) were from Lebanon (52.3%) and Yemen (27.7%). Majority of the Yemenis group have never been screened for CRC (72.2% vs. 27.9%, p < 0.001). Majority of the unscreened Yemenis were males (100% vs. 63.2%, p = 0.002). Both unscreened groups had similar length of residence in U.S., citizenship status, education level, health insurance and access to primary care physicians. Results: Unscreened Lebanese had a higher family history of CRCS (31.6% vs. 0%, p = 0.002). The most common reported barrier for both groups was the misconception that CRCS is not necessary (62% for Yemenis & 42% for Lebanese, p = 0.197). Unscreened Yemenis were more unaware about CRCS (46% vs. 11%, p = 0.002). Conclusion: CRC screening rates vary among Arab-Americans from different countries of origin. Physicians should consider the country of origin when recommending CRC screening to Arab-Americans. Ó 2015 Arab Journal of Gastroenterology. Published by Elsevier B.V. All rights reserved.
Introduction Colorectal Cancer (CRC) screening has proven to reduce the incidence and mortality of colon cancer by detecting early cancer and precancerous polyps among patients who are 50 years of age or older [1,2]. The Centers for Disease Control and prevention (CDC) reported that the national screening rates for colorectal cancer have been steadily increasing to reach 65.1% in 2012 [3]. This percent was even higher in Michigan where 69% of adults 50 years or older were up to date with CRC screening [3]. Despite this increase, CRC screening is still lagging behind among certain ethnic groups including Arab Americans [4,5]. Arab Americans are made up of immigrants from Arabic-speaking countries from southwest Asia and North Africa that have settled in the United States as early as the 1800s [6]. Their Arab heritage is a reflection of the 22 Arab countries ⇑ Address: Department of Gastroenterology, University of Missouri, 1 Hospital Drive, CE443, USA. Tel.: +1 916 743 6403. E-mail address: [email protected]
constituting the Arab League including Egypt, Lebanon, Morocco, Yemen, Tunisia, and Palestine. According to the 2010 U.S. census, there are 1.9 million Arab American representing up to 0.5% of the population [7]. They represent more than 40% of the population in Dearborn, MI [7]. It is important to note that the United States national census ancestry data have historically undercounted the Arab American population by up to sixty percent and that the true number is underestimated. According to the Arab American Institute there are 3.5 million Arab Americans and approximately one third of them has Lebanese or Syrian roots [6]. Arab Americans demonstrated the lowest overall colorectal cancer screening rate when compared to the general population and other ethnic groups in Michigan. In 2008, only 45.6% of Michigan’s Arab American adults who are aged 50 years or older have received appropriate colorectal cancer screening compared to 60.8% of the state’s general population [4]. Several studies have identified barriers and predictors for low CRC screening rate in various ethnic groups such as inadequate physician communication, trouble with scheduling and lack of screening knowledge [8,9]. These barriers have been reported
http://dx.doi.org/10.1016/j.ajg.2015.07.003 1687-1979/Ó 2015 Arab Journal of Gastroenterology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Talaat N. Adherence and barriers to colorectal cancer screening varies among Arab Americans from different countries of origin. Arab J Gastroenterol (2015), http://dx.doi.org/10.1016/j.ajg.2015.07.003
2
N. Talaat / Arab Journal of Gastroenterology xxx (2015) xxx–xxx
variably among African Americans, Hispanics and Asians [8,10–12]. However, even within the same ethnic group, adherence to CRC screening varied by country of origin [12,13]. Arab Americans share some of these barriers and it was found that adherence to CRC screening varies among Arabs originating from different countries [14]. We therefore hypothesise that even among Arab American descendants, barriers to colorectal cancer screening vary by country of origin. We aim to compare the current colorectal cancer screening rate and the barriers associated with non-adherence to current screening guidelines in two Arabic American populations. Patients and methods We conducted a community based observational study through an anonymous survey in English and Arabic. The study protocol was approved by Wayne State University Institutional Review Board (IRB). After announcing for the study in three mosques in Dearborn, Michigan, One hundred and thirty individuals aged 50 years and older who identified themselves as Arab Americans (descendants from one of the 22 Arab states) volunteered to fill the study survey. The survey contained basic demographic questions such as age, gender, country of origin, religion, annual income, duration of residence in the United States and access to primary care and whether their primary care physician (PCP) speaks Arabic. More questions inquired about history of colorectal cancer in the respondent and/or their family members and whether they previously underwent colonoscopy, sigmoidoscopy, or Fecal Occult Blood Test (FOBT). Information about barriers to undergo CRC screening such as cost, language barriers or awareness of the procedure was also obtained. Lastly, questions about the participant’s willingness to undergo CRC if barriers were eliminated were asked. Data were recorded into an excel spreadsheet and transferred into SPSS software version 19 (SPSS Inc., Chicago, IL) for statistical analysis. Eighty percent of the participants were from Lebanon (52.3%) and Yemen (27.7%). Comparisons were done between the Lebanese and Yemenis who did not have prior CRC screening (Fig. 1). Descriptive statistics, mean ± standard deviations, and range were calculated for continuous data; frequencies and percentages
were calculated for categorical data. For comparisons between groups, Student t-test and One-Way ANOVA were used for continuous variables and Chi-square test for categorical variables. A p-value of less than 0.05 was considered statistically significant. Results Of the 130 surveyed participants, 68 (52.3%) were from Lebanon and 36 (27.7%) were from Yemen (Fig. 2). The overall screening rate was 56.7% for individuals from Lebanon and Yemen combined. Majority of the Yemenis participants have never been screened for colorectal cancer compared to the Lebanese (72.2% vs. 27.9%, p < 0.001) (Fig. 3). Table 1 summarises the characteristics of the unscreened Lebanese and Yemenis participants. All of the unscreened Yemenis were males compared to 63.2% of the unscreened Lebanese (p = 0002). Education level, Annual income, health insurance and access to primary care physicians were similar between both groups. Among those who have primary care physicians (PCPs), 100% of the Yemenis and 93.8% of the Lebanese have a PCP who speaks Arabic (p = 0.245). None of the unscreened Yemenis had a family member who underwent colorectal cancer screening while 31.6% of the unscreened Lebanese did (p = 0.002). None of the unscreened Lebanese and Yemenis had a family history of colorectal cancer. The screening rate and barriers for undergoing colorectal cancer screening were compared between the unscreened Lebanese and Yemenis (Figs. 3 and 4). The most common reported barrier was the misconception by the participants that colorectal cancer screening is not needed (42% of the unscreened Lebanese vs. 62% of the unscreened Yemenis, p = 0.197). Almost half of the unscreened Yemenis were not aware of the need to undergo colorectal cancer screening compared to the unscreened Lebanese (46% vs. 11%, p = 0.011). Other barriers such as recommendation by PCP and financial, language, and scheduling barriers were similarly reported in both groups. Additionally, fear, inability to tolerate, and embarrassment to undergo the screening procedure were also similarly reported (Fig. 4). Most of the unscreened participants would agree to undergo colorectal cancer screening if the above barriers are eliminated (84.2% Lebanese vs. 88.5% Yemenis, p = 0.679). Discussion
Fig. 1. Flow diagram of individuals selected for analysis.
In this study, Arab Americans originating from Lebanon have a higher screening rate compared to those originating from Yemen. This confirms the variation in uptake of colorectal cancer screening among Arab Americans from different countries of origin. Moreover, this is the first population-based study to examine CRC screening in several different Arab American subgroups rather than combining them into a single ethnic group. Although the number of participants in this study was small, our observed screening rate correlated with the reported rate by Michigan’s Department of Health [4]. Racial/ethnic disparities in colorectal cancer screening have been shown in multiple national and regional studies [15,16]. In a study of over 500,000 Medicare patients, it was found that nonwhites including Hispanics and African Americans were less likely to undergo CRC screening than were white persons [17]. Furthermore, several studies have shown variations in CRC screening rate within the same ethnic group from different countries of origin. In a study that included over 3000 Hispanic whites, it was found that CRC screening uptake was lower for those people of Dominican origin as compared to Hispanics from Cuba [18]. Other studies have identified similar patterns among Asian Americans, where Korean and Filipino individuals had lower CRC
Please cite this article in press as: Talaat N. Adherence and barriers to colorectal cancer screening varies among Arab Americans from different countries of origin. Arab J Gastroenterol (2015), http://dx.doi.org/10.1016/j.ajg.2015.07.003
3
N. Talaat / Arab Journal of Gastroenterology xxx (2015) xxx–xxx
Fig. 2. Country of Origin for participating individuals.
Table 1 Characteristics of unscreened Lebanese and Yemenis.
Fig. 3. Comparison of Lebanese and Yemenis by screening status.
screening rate compared to Chinese [12,13]. Both of the Hispanic and Asian populations seemed to have barriers related to socio-economic as well as socio-demographic barriers, including language, and access to care [12,18]. An interesting finding in our study population is that most of the unscreened participants had health insurance and access to primary care physicians. Additionally, both the unscreened groups had a decent annual income at or above the state of Michigan poverty line in 2010 [19]. The only barrier for CRC screening that was significantly different was the high unawareness level of the benefits of screening among unscreened Yemenis (46% vs. 11%, p = 0.011). Lebanese are the largest and one of the earliest Arabic populations to immigrate to the United States [6,20]. Their larger number and early exposure to western civilisation might have increased their familiarity and acculturation to the U.S. health system and thus became more compliant with CRC screening guidelines. Acculturation has previously shown to play a role in adhering to CRC screening in Hispanics and Asian American and this might
Gender Male Age Years of residence in the U.S. Citizenship U.S. Citizen Educational Level Grade school and lower High School and higher Annual Income Less than $20,000 $20,000 or more Health Insurance Yes Primary Care Physician Have PCP PCP speaks Arabic Family history of Colonoscopy Family history of CRC
Lebanon (n = 19)
Yemen (n = 26)
12 (63.2%) 62 ± 10 (51–88) 40 ± 15 (20–73)
26 (100%) 65 ± 9 (50–80) 32 ± 14 (4–57)
18 (94.7%)
22 (84.6%)
23 (33.8%) 45 (66.2%)
11 (31.4) 24 (68.6%)
26 (38.2%) 42 (61.8%)
13 (36.1%) 23 (63.9%)
19 (100%)
25 (96.2%)
16 (84.2%) 15 (93.8%) 6 (31.6%) 0 (0.0%)
21 (80.8%) 21 (100%) 0 (0%) 0 (0%)
p-Value 0.002 0.444 0.064 0.286 0.807
0.831
0.387 0.766 0.245 0.002 0.179
explain the increased awareness to colorectal cancer screening in Lebanese compared to Yemenis [21,22]. Several studies have reported that a family history of colon cancer and/or a family member being screened for CRC is a good predictor of compliance with CRC screening [22–24]. This could also explain the higher rate of CRC in the Lebanese participants as one third had a family of CRC screening compared to none of the Yemenis participants (31.6% vs. 0%, p = 0.002). The small number of participating individuals could be a limitation to our study. All of the participating individuals were Muslims, therefore we do not know if these barriers would apply to non-Muslim Arab Americas. Females were under represented in our sample, especially among Yemenis, but this was expected because generally fewer females attend prayer services in formal settings, such as Mosques.
Please cite this article in press as: Talaat N. Adherence and barriers to colorectal cancer screening varies among Arab Americans from different countries of origin. Arab J Gastroenterol (2015), http://dx.doi.org/10.1016/j.ajg.2015.07.003
4
N. Talaat / Arab Journal of Gastroenterology xxx (2015) xxx–xxx
Fig. 4. Barriers to colorectal cancer screening.
A larger scale study that would include other religious groups and more female participation will be needed to further define the barriers to colorectal cancer screening in Arab Americans. In conclusion, the low colorectal cancer-screening rate in Arab Americans is mainly due to socio-behavioural factors. This is found to vary by the country of origin of the Arab American patient. Programs should be developed to educate and address this specific population; in addition the country of origin should be taken into consideration when offering colorectal cancer screening to Arab American patients. Educating Arab Americans about the benefits of colorectal cancer screening may not only improve screening rates for the current generation but also among future generations. Further investigation and implementation of education interventions would help further elucidate this concept. Conflicts of interest The authors declared that there was no conflict of interest. References [1] Edwards BK, Ward E, Kohler BA, et al. Annual report to the nation on the status of cancer, 1975–2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer 2010;116:544–73. [2] Kahi CJ, Imperiale TF, Juliar BE, Rex DK. Effect of screening colonoscopy on colorectal cancer incidence and mortality. Clin Gastroenterol Hepatol 2009;7:770–5. quiz 11. [3] Centers for Disease C, Prevention. Vital signs: colorectal cancer screening test use–United States, 2012. MMWR Morb Mortal Wkly Rep 2013;62:881–8818.
[4] Michigan Cancer Consortium (MCC). Special Cancer Behavioral Risk Factor Survey, 2008. April 2010. Available at:. [5] Jerant AF, Fenton JJ, Franks P. Determinants of racial/ethnic colorectal cancer screening disparities. Arch Intern Med 2008;168:1317–24. [6] Census estimated Arab American population: how do Arab Americans identify themselves? Where do Arab Americans live? 2012. at
Please cite this article in press as: Talaat N. Adherence and barriers to colorectal cancer screening varies among Arab Americans from different countries of origin. Arab J Gastroenterol (2015), http://dx.doi.org/10.1016/j.ajg.2015.07.003
N. Talaat / Arab Journal of Gastroenterology xxx (2015) xxx–xxx [18] Jerant AF, Arellanes RE, Franks P. Factors associated with Hispanic/nonHispanic white colorectal cancer screening disparities. J Gen Intern Med 2008;23:1241–5. [19]. [20] Cruz G, Britthingham A. The Arab population: 2000. In: BUREAU USDoCEaSAUSC, editor. United States Census 2000–2003. [21] Shah M, Zhu K, Potter J. Hispanic acculturation and utilization of colorectal cancer screening in the United States. Cancer Detect Prev 2006;30:306–12.
5
[22] Honda K. Factors associated with colorectal cancer screening among the US urban Japanese population. Am J Public Health 2004;94:815–22. [23] Beydoun HA, Beydoun MA. Predictors of colorectal cancer screening behaviors among average-risk older adults in the United States. Cancer Causes Control 2008;19:339–59. [24] Brittain K, Murphy VP. Sociocultural and health correlates related to colorectal cancer screening adherence among urban African Americans. Cancer Nurs 2014.
Please cite this article in press as: Talaat N. Adherence and barriers to colorectal cancer screening varies among Arab Americans from different countries of origin. Arab J Gastroenterol (2015), http://dx.doi.org/10.1016/j.ajg.2015.07.003
Contents lists available at ScienceDirect
Arab Journal of Gastroenterology journal homepage: www.elsevier.com/locate/ajg
Original Article
Adherence and barriers to colorectal cancer screening varies among Arab Americans from different countries of origin Nizar Talaat ⇑ East Carolina University, Greenville, NC, USA
a r t i c l e
i n f o
Article history: Received 1 February 2015 Accepted 11 July 2015 Available online xxxx Keywords: Arab-Americans Colon cancer screening Colorectal cancer
a b s t r a c t Background and study aims: Arab-Americans (ArA) in Michigan, USA had the lowest colorectal cancer screening (CRCS) in 2008 compared to the state’s general population (45.6% vs. 60.8%). The adherence rate and barriers to CRCS have been identified in a previous study; however, these differences have been not examined among ArA from different countries of origin. Patients and methods: Community-based study through a survey filled by 130 Arab-Americans aged P50 years. Demographic information and information about CRC screening knowledge were obtained. Responses were compared between the two largest population groups (Lebanese and Yemenis). Results: The majority of the participants (80%) were from Lebanon (52.3%) and Yemen (27.7%). Majority of the Yemenis group have never been screened for CRC (72.2% vs. 27.9%, p < 0.001). Majority of the unscreened Yemenis were males (100% vs. 63.2%, p = 0.002). Both unscreened groups had similar length of residence in U.S., citizenship status, education level, health insurance and access to primary care physicians. Results: Unscreened Lebanese had a higher family history of CRCS (31.6% vs. 0%, p = 0.002). The most common reported barrier for both groups was the misconception that CRCS is not necessary (62% for Yemenis & 42% for Lebanese, p = 0.197). Unscreened Yemenis were more unaware about CRCS (46% vs. 11%, p = 0.002). Conclusion: CRC screening rates vary among Arab-Americans from different countries of origin. Physicians should consider the country of origin when recommending CRC screening to Arab-Americans. Ó 2015 Arab Journal of Gastroenterology. Published by Elsevier B.V. All rights reserved.
Introduction Colorectal Cancer (CRC) screening has proven to reduce the incidence and mortality of colon cancer by detecting early cancer and precancerous polyps among patients who are 50 years of age or older [1,2]. The Centers for Disease Control and prevention (CDC) reported that the national screening rates for colorectal cancer have been steadily increasing to reach 65.1% in 2012 [3]. This percent was even higher in Michigan where 69% of adults 50 years or older were up to date with CRC screening [3]. Despite this increase, CRC screening is still lagging behind among certain ethnic groups including Arab Americans [4,5]. Arab Americans are made up of immigrants from Arabic-speaking countries from southwest Asia and North Africa that have settled in the United States as early as the 1800s [6]. Their Arab heritage is a reflection of the 22 Arab countries ⇑ Address: Department of Gastroenterology, University of Missouri, 1 Hospital Drive, CE443, USA. Tel.: +1 916 743 6403. E-mail address: [email protected]
constituting the Arab League including Egypt, Lebanon, Morocco, Yemen, Tunisia, and Palestine. According to the 2010 U.S. census, there are 1.9 million Arab American representing up to 0.5% of the population [7]. They represent more than 40% of the population in Dearborn, MI [7]. It is important to note that the United States national census ancestry data have historically undercounted the Arab American population by up to sixty percent and that the true number is underestimated. According to the Arab American Institute there are 3.5 million Arab Americans and approximately one third of them has Lebanese or Syrian roots [6]. Arab Americans demonstrated the lowest overall colorectal cancer screening rate when compared to the general population and other ethnic groups in Michigan. In 2008, only 45.6% of Michigan’s Arab American adults who are aged 50 years or older have received appropriate colorectal cancer screening compared to 60.8% of the state’s general population [4]. Several studies have identified barriers and predictors for low CRC screening rate in various ethnic groups such as inadequate physician communication, trouble with scheduling and lack of screening knowledge [8,9]. These barriers have been reported
http://dx.doi.org/10.1016/j.ajg.2015.07.003 1687-1979/Ó 2015 Arab Journal of Gastroenterology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Talaat N. Adherence and barriers to colorectal cancer screening varies among Arab Americans from different countries of origin. Arab J Gastroenterol (2015), http://dx.doi.org/10.1016/j.ajg.2015.07.003
2
N. Talaat / Arab Journal of Gastroenterology xxx (2015) xxx–xxx
variably among African Americans, Hispanics and Asians [8,10–12]. However, even within the same ethnic group, adherence to CRC screening varied by country of origin [12,13]. Arab Americans share some of these barriers and it was found that adherence to CRC screening varies among Arabs originating from different countries [14]. We therefore hypothesise that even among Arab American descendants, barriers to colorectal cancer screening vary by country of origin. We aim to compare the current colorectal cancer screening rate and the barriers associated with non-adherence to current screening guidelines in two Arabic American populations. Patients and methods We conducted a community based observational study through an anonymous survey in English and Arabic. The study protocol was approved by Wayne State University Institutional Review Board (IRB). After announcing for the study in three mosques in Dearborn, Michigan, One hundred and thirty individuals aged 50 years and older who identified themselves as Arab Americans (descendants from one of the 22 Arab states) volunteered to fill the study survey. The survey contained basic demographic questions such as age, gender, country of origin, religion, annual income, duration of residence in the United States and access to primary care and whether their primary care physician (PCP) speaks Arabic. More questions inquired about history of colorectal cancer in the respondent and/or their family members and whether they previously underwent colonoscopy, sigmoidoscopy, or Fecal Occult Blood Test (FOBT). Information about barriers to undergo CRC screening such as cost, language barriers or awareness of the procedure was also obtained. Lastly, questions about the participant’s willingness to undergo CRC if barriers were eliminated were asked. Data were recorded into an excel spreadsheet and transferred into SPSS software version 19 (SPSS Inc., Chicago, IL) for statistical analysis. Eighty percent of the participants were from Lebanon (52.3%) and Yemen (27.7%). Comparisons were done between the Lebanese and Yemenis who did not have prior CRC screening (Fig. 1). Descriptive statistics, mean ± standard deviations, and range were calculated for continuous data; frequencies and percentages
were calculated for categorical data. For comparisons between groups, Student t-test and One-Way ANOVA were used for continuous variables and Chi-square test for categorical variables. A p-value of less than 0.05 was considered statistically significant. Results Of the 130 surveyed participants, 68 (52.3%) were from Lebanon and 36 (27.7%) were from Yemen (Fig. 2). The overall screening rate was 56.7% for individuals from Lebanon and Yemen combined. Majority of the Yemenis participants have never been screened for colorectal cancer compared to the Lebanese (72.2% vs. 27.9%, p < 0.001) (Fig. 3). Table 1 summarises the characteristics of the unscreened Lebanese and Yemenis participants. All of the unscreened Yemenis were males compared to 63.2% of the unscreened Lebanese (p = 0002). Education level, Annual income, health insurance and access to primary care physicians were similar between both groups. Among those who have primary care physicians (PCPs), 100% of the Yemenis and 93.8% of the Lebanese have a PCP who speaks Arabic (p = 0.245). None of the unscreened Yemenis had a family member who underwent colorectal cancer screening while 31.6% of the unscreened Lebanese did (p = 0.002). None of the unscreened Lebanese and Yemenis had a family history of colorectal cancer. The screening rate and barriers for undergoing colorectal cancer screening were compared between the unscreened Lebanese and Yemenis (Figs. 3 and 4). The most common reported barrier was the misconception by the participants that colorectal cancer screening is not needed (42% of the unscreened Lebanese vs. 62% of the unscreened Yemenis, p = 0.197). Almost half of the unscreened Yemenis were not aware of the need to undergo colorectal cancer screening compared to the unscreened Lebanese (46% vs. 11%, p = 0.011). Other barriers such as recommendation by PCP and financial, language, and scheduling barriers were similarly reported in both groups. Additionally, fear, inability to tolerate, and embarrassment to undergo the screening procedure were also similarly reported (Fig. 4). Most of the unscreened participants would agree to undergo colorectal cancer screening if the above barriers are eliminated (84.2% Lebanese vs. 88.5% Yemenis, p = 0.679). Discussion
Fig. 1. Flow diagram of individuals selected for analysis.
In this study, Arab Americans originating from Lebanon have a higher screening rate compared to those originating from Yemen. This confirms the variation in uptake of colorectal cancer screening among Arab Americans from different countries of origin. Moreover, this is the first population-based study to examine CRC screening in several different Arab American subgroups rather than combining them into a single ethnic group. Although the number of participants in this study was small, our observed screening rate correlated with the reported rate by Michigan’s Department of Health [4]. Racial/ethnic disparities in colorectal cancer screening have been shown in multiple national and regional studies [15,16]. In a study of over 500,000 Medicare patients, it was found that nonwhites including Hispanics and African Americans were less likely to undergo CRC screening than were white persons [17]. Furthermore, several studies have shown variations in CRC screening rate within the same ethnic group from different countries of origin. In a study that included over 3000 Hispanic whites, it was found that CRC screening uptake was lower for those people of Dominican origin as compared to Hispanics from Cuba [18]. Other studies have identified similar patterns among Asian Americans, where Korean and Filipino individuals had lower CRC
Please cite this article in press as: Talaat N. Adherence and barriers to colorectal cancer screening varies among Arab Americans from different countries of origin. Arab J Gastroenterol (2015), http://dx.doi.org/10.1016/j.ajg.2015.07.003
3
N. Talaat / Arab Journal of Gastroenterology xxx (2015) xxx–xxx
Fig. 2. Country of Origin for participating individuals.
Table 1 Characteristics of unscreened Lebanese and Yemenis.
Fig. 3. Comparison of Lebanese and Yemenis by screening status.
screening rate compared to Chinese [12,13]. Both of the Hispanic and Asian populations seemed to have barriers related to socio-economic as well as socio-demographic barriers, including language, and access to care [12,18]. An interesting finding in our study population is that most of the unscreened participants had health insurance and access to primary care physicians. Additionally, both the unscreened groups had a decent annual income at or above the state of Michigan poverty line in 2010 [19]. The only barrier for CRC screening that was significantly different was the high unawareness level of the benefits of screening among unscreened Yemenis (46% vs. 11%, p = 0.011). Lebanese are the largest and one of the earliest Arabic populations to immigrate to the United States [6,20]. Their larger number and early exposure to western civilisation might have increased their familiarity and acculturation to the U.S. health system and thus became more compliant with CRC screening guidelines. Acculturation has previously shown to play a role in adhering to CRC screening in Hispanics and Asian American and this might
Gender Male Age Years of residence in the U.S. Citizenship U.S. Citizen Educational Level Grade school and lower High School and higher Annual Income Less than $20,000 $20,000 or more Health Insurance Yes Primary Care Physician Have PCP PCP speaks Arabic Family history of Colonoscopy Family history of CRC
Lebanon (n = 19)
Yemen (n = 26)
12 (63.2%) 62 ± 10 (51–88) 40 ± 15 (20–73)
26 (100%) 65 ± 9 (50–80) 32 ± 14 (4–57)
18 (94.7%)
22 (84.6%)
23 (33.8%) 45 (66.2%)
11 (31.4) 24 (68.6%)
26 (38.2%) 42 (61.8%)
13 (36.1%) 23 (63.9%)
19 (100%)
25 (96.2%)
16 (84.2%) 15 (93.8%) 6 (31.6%) 0 (0.0%)
21 (80.8%) 21 (100%) 0 (0%) 0 (0%)
p-Value 0.002 0.444 0.064 0.286 0.807
0.831
0.387 0.766 0.245 0.002 0.179
explain the increased awareness to colorectal cancer screening in Lebanese compared to Yemenis [21,22]. Several studies have reported that a family history of colon cancer and/or a family member being screened for CRC is a good predictor of compliance with CRC screening [22–24]. This could also explain the higher rate of CRC in the Lebanese participants as one third had a family of CRC screening compared to none of the Yemenis participants (31.6% vs. 0%, p = 0.002). The small number of participating individuals could be a limitation to our study. All of the participating individuals were Muslims, therefore we do not know if these barriers would apply to non-Muslim Arab Americas. Females were under represented in our sample, especially among Yemenis, but this was expected because generally fewer females attend prayer services in formal settings, such as Mosques.
Please cite this article in press as: Talaat N. Adherence and barriers to colorectal cancer screening varies among Arab Americans from different countries of origin. Arab J Gastroenterol (2015), http://dx.doi.org/10.1016/j.ajg.2015.07.003
4
N. Talaat / Arab Journal of Gastroenterology xxx (2015) xxx–xxx
Fig. 4. Barriers to colorectal cancer screening.
A larger scale study that would include other religious groups and more female participation will be needed to further define the barriers to colorectal cancer screening in Arab Americans. In conclusion, the low colorectal cancer-screening rate in Arab Americans is mainly due to socio-behavioural factors. This is found to vary by the country of origin of the Arab American patient. Programs should be developed to educate and address this specific population; in addition the country of origin should be taken into consideration when offering colorectal cancer screening to Arab American patients. Educating Arab Americans about the benefits of colorectal cancer screening may not only improve screening rates for the current generation but also among future generations. Further investigation and implementation of education interventions would help further elucidate this concept. Conflicts of interest The authors declared that there was no conflict of interest. References [1] Edwards BK, Ward E, Kohler BA, et al. Annual report to the nation on the status of cancer, 1975–2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer 2010;116:544–73. [2] Kahi CJ, Imperiale TF, Juliar BE, Rex DK. Effect of screening colonoscopy on colorectal cancer incidence and mortality. Clin Gastroenterol Hepatol 2009;7:770–5. quiz 11. [3] Centers for Disease C, Prevention. Vital signs: colorectal cancer screening test use–United States, 2012. MMWR Morb Mortal Wkly Rep 2013;62:881–8818.
[4] Michigan Cancer Consortium (MCC). Special Cancer Behavioral Risk Factor Survey, 2008. April 2010. Available at:
Please cite this article in press as: Talaat N. Adherence and barriers to colorectal cancer screening varies among Arab Americans from different countries of origin. Arab J Gastroenterol (2015), http://dx.doi.org/10.1016/j.ajg.2015.07.003
N. Talaat / Arab Journal of Gastroenterology xxx (2015) xxx–xxx [18] Jerant AF, Arellanes RE, Franks P. Factors associated with Hispanic/nonHispanic white colorectal cancer screening disparities. J Gen Intern Med 2008;23:1241–5. [19]
5
[22] Honda K. Factors associated with colorectal cancer screening among the US urban Japanese population. Am J Public Health 2004;94:815–22. [23] Beydoun HA, Beydoun MA. Predictors of colorectal cancer screening behaviors among average-risk older adults in the United States. Cancer Causes Control 2008;19:339–59. [24] Brittain K, Murphy VP. Sociocultural and health correlates related to colorectal cancer screening adherence among urban African Americans. Cancer Nurs 2014.
Please cite this article in press as: Talaat N. Adherence and barriers to colorectal cancer screening varies among Arab Americans from different countries of origin. Arab J Gastroenterol (2015), http://dx.doi.org/10.1016/j.ajg.2015.07.003