Testing a Spanish-language colorectal cancer screening decision aid in Latinos with limited English proficiency: Results from a pre-post trial and four month follow-up survey

Colorectal cancer (CRC) is the second leading cause of cancer mortality in the US. National guidelines recommend that individuals over age 50 receive colorectal cancer screening[1, 2]. Although screening rates have increased in recent years, important screening disparities exist for ethnic and racial minorities. CRC screening rates in Hispanic/Latino populations, now the nation’s largest and fastest growing racial/ethnic minority group, are among the lowest nationally[3, 4]. Latinos are also more likely to be diagnosed with advanced stage CRC than non-Hispanic whites and have a lower probability of survival after diagnosis[5, 6]. Latinos who have limited English proficiency (LEP) represent a vulnerable population. Compared with Latinos who are proficient in English, LEP Latinos tend to have lower levels of formal education and literacy, experience challenges to communication in health care settings, and lack awareness of CRC screening guidelines[7‐14]. Latinos with LEP have lower CRC screening rates than Latinos who are proficient in English,[9, 10] and having LEP is an independent risk factor for lack of screening even after accounting for multiple socio-economic and healthcare access factors[8, 11, 15].

Multimedia patient education tools have the potential to improve communication about CRC screening for vulnerable populations, including those with LEP. Multimedia formats may be particularly helpful in overcoming literacy barriers by having text read aloud by a narrator and through the use of graphics and animations[16]. Because they can be delivered outside of the patient-provider encounter, multimedia educational tools may also help to overcome provider-level communication barriers such as lack of time to educate patients about screening. Decision aids in particular may promote screening adherence by more explicitly incorporating patients’ preferences into colorectal cancer screening decisions. Studies in English speaking populations have found that CRC screening decision aids can increase patients’ knowledge and intent to obtain screening and may increase screening test completion[16‐20]. However, few studies have evaluated multimedia CRC screening educational interventions in Spanish speaking Latinos, a population with low health literacy and often low formal education, and no studies have evaluated an actual CRC screening decision aid in Spanish speakers[21‐23]. Further, no studies have assessed whether individuals from this population who view a decision aid outside of a clinic setting subsequently discuss CRC screening with a health care provider or complete a recommended CRC screening test.

In this article we report the findings of two study phases. The objective of the first phase was to determine the effect of viewing a Spanish-language CRC screening decision aid on CRC screening-related knowledge, self-efficacy, and intent among screening-eligible Latinos with LEP. The objective of the second phase was to assess the rates of CRC screening discussions with health providers and screening test completion at four months after decision aid viewing.

We enrolled 80 participants whose characteristics are summarized in Table1. Fifty seven percent were recruited via the community ads, and the remaining 43% were recruited from the clinical registry sources. The mean age of participants was 56 years, and 64% were female. Two-thirds were from Mexico and Central American countries, and most (91%) spoke English either “not very well” or “not at all”. A majority (61%) had household incomes under $20,000; two-thirds were uninsured, and three-fourths had less than high school education. A majority of participants (58%) either did not use or were “uncomfortable” using computers. Most indicated a preference for either an active (49%) or shared role (35%) in medical decisions.

We found that viewing a Spanish-language decision aid for CRC was associated with increased screening-related knowledge, self-efficacy, and intent among Latinos with LEP, demonstrating that the information provided by the decision is accessible and compelling to this target population. These findings suggest that such a decision aid may be useful as an effective means of communicating this relatively complex message content about evidence-based cancer screening guidelines to a vulnerable population outside of an actual health care provider encounter.

In our telephone follow up survey, we also found that more than half of respondents had discussed CRC screening with a health care provider within four months of decision aid viewing. While our study lacked a comparison group against which to directly compare these figures, data from nationally representative surveys suggests that such discussions occur infrequently. In one survey, less than one third of Spanish speaking Latinos had discussed CRC screening with a physician within the past two years[31]. Interventions such as this that can promote informed discussions between patients and health care providers about screening represent one promising means of addressing screening disparities since patient provider communication plays a key role in promoting CRC screening. Other studies have found that receiving a physician recommendation for CRC screening is an independent predictor of adherence to CRC screening guidelines in the general population,[7, 8, 32] and suboptimal communication between patients and providers is likely one of several factors contributing to screening disparities in Latinos[9].

In our follow-up survey, we also found that one in five respondents actually completed a screening test, with more than half completing a FOBT. Although this study lacked a direct comparison group, other evidence suggests it is unlikely that 19% of unscreened members of this target population would become current with CRC screening in any four month period in the absence of an intervention[4, 11, 15]. Being current with CRC screening requires having had a colonoscopy anytime in the past 10 years (or FOBT within one year), and only about 33% of Spanish speaking Latinos are current with CRC screening[15].

To our knowledge, this is the first study to describe patient-reported clinical communication and screening behavior after viewing a CRC screening decision aid in this population. This is also the first study to assess the extent to which individuals from this population who view such a CRC screening tool outside of a clinic setting subsequently discuss CRC screening with a health care provider or complete a recommended CRC screening test. Thus, our study complements and extends findings from a limited number of other studies of multimedia CRC screening educational interventions in Spanish speaking Latinos. One other study found that an educational video about CRC improved patient knowledge about CRC in Spanish speaking patients; however, that study did not ascertain subsequent clinical communication or screening behavior[21]. Another promising study conducted in 2009 in an urban teaching hospital found that screening among Spanish speaking Latinos was more likely after receiving an intervention that included an educational video; however the study was small (31 patients received the intervention) and the researchers did not collect data from patients regarding their communication with physicians[22].

This decision aid intervention addresses barriers to suboptimal patient-provider communication and low screening rates in limited English proficiency (LEP) Latino populations. These barriers include literacy issues, brief primary care patient-provider visits in which competing demands from other health issues result in lack of time to fully counsel patients about screening, inadequate numbers of Spanish speaking health care providers, and poor integration of trained interpreters into primary care service delivery[7, 13, 33‐35]. Nevertheless, the fact that only a minority of viewers actually completed a screening test suggests that important questions still remain about how to achieve high levels of adherence to screening guidelines and the role that multimedia patient education tools such as decisions aids have in promoting screening in these populations. Other studies of CRC screening decision aid interventions in English speaking patient populations have also found that while decision aids help patients become informed and activated regarding screening, screening rates remain low because other barriers interfere with actual completion of screening tests[16, 20, 29]. These other barriers can include lack of access to insurance or financial assistance to cover the cost of colonoscopy (either as the primary screening test or to follow up an abnormal FOBT test), transportation challenges, lack of reliable telephone access, unpredictable work schedules, child care responsibilities, lack of understanding how to complete a home stool test, and difficulties with colonoscopy preparation procedures[10, 12‐14, 34]. Similarly, our findings suggest that although this decision aid can help patients become informed and activated regarding CRC screening and can promote clinical discussions, it is likely that additional interventions that address other barriers to CRC screening test completion are needed to effectively promote screening and eliminate screening disparities in vulnerable populations. Individualized one-on-one support such as patient navigation to help patients overcome other practical barriers as well as policies or programs that address access barriers to colonoscopy will likely be needed in order to eliminate disparities in CRC screening[36, 37].

Our study has some limitations. Because we used a one group (pre-post) design without a separate control group, we are unable to determine whether ongoing efforts by local or regional organizations to promote CRC screening influenced screening behavior among our participants. We are also unable to determine how a less intensive intervention, such as written information about CRC screening, would have affected outcomes in this population. However, the provision of written materials alone has had very little if any effect as a single intervention in studies conducted in English speaking populations,[37] and given low educational and literacy levels in our target population, it is likely that providing written material alone would have little impact on communication or screening. Second, our follow-up survey outcomes relied on participant self-report and may be subject to recall bias. Third, our study used a convenience sample recruited from a single region and our results may not be generalizable to other LEP Latino communities regionally or nationally. Nevertheless, our observed effects were large and our sample included diverse Latino communities and countries of origin. Hence, we believe the decision aid should be tested in larger studies involving Latino populations and communities.

In conclusion, this study suggests that this decision aid is efficacious in educating Latinos who have LEP about CRC and activating them to communicate with health care providers about screening. Overall, this decision aid could function as an effective component of a CRC screening intervention aimed at addressing disparities in CRC screening for LEP Latinos.