Abstract
BackgroundWith a secular trend of increasing colorectal cancer (CRC) screening, concerns about disparities in CRC screening also have been rising. It is unclear if CRC screening varies geographically, if area-level poverty rate affects CRC screening, and if individual-level characteristics mediate the area-level effects on CRC screening.MethodsUsing 2006 Missouri Behavioral Risk Factor Surveillance System (BRFSS) data, a multilevel study was conducted to examine geographic variation and the effect of area-level poverty rate on CRC screening use among persons age 50 or older. Individuals were nested within ZIP codes (ZIP5 areas), which in turn, were nested within aggregations of ZIP codes (ZIP3 areas). Six groups of individual-level covariates were considered as potential mediators.ResultsAn estimated 51.8% of Missourians aged 50 or older adhered to CRC screening recommendations. Nearly 15% of the total variation in CRC screening lay between ZIP5 areas. Persons residing in ZIP5 areas with ≥ 10% of poverty rate had lower odds of CRC screening use than those residing in ZIP5 areas with <10% poverty rate (unadjusted odds ratio [OR], 0.69; 95% confidence interval [95% CI], 0.58–0.81; adjusted OR, 0.81; 95% CI, 0.67–0.98). Persons who resided in ZIP3 areas with ≥ 20% poverty rate also had lower odds of following CRC screening guidelines than those residing in ZIP3 areas with <20% poverty rate (unadjusted OR, 0.66; 95% CI, 0.52–0.83; adjusted OR, 0.64; 95% CI, 0.50–0.83). Obesity, history of depression/anxiety and access to care were associated with CRC screening, but did not mediate the effect of area-level poverty on CRC screening.ConclusionLarge geographic variation of CRC screening exists in Missouri. Area-level poverty rate, independent of individual-level characteristics, is a significant predictor of CRC screening, but it only explains a small portion of the geographic heterogeneity of CRC screening. Individual-level factors we examined do not mediate the effect of the area-level poverty rate on CRC screening. Future studies should identify other area- and individual-level characteristics associated with CRC screening in Missouri.
Highlights
With a secular trend of increasing colorectal cancer (CRC) screening, concerns about disparities in CRC screening have been rising
Based on our previous study which showed geographic variation in CRC screening across the United States [17], in this study we examined the geographic variation of CRC screening in our state (Missouri) and if area-level poverty rate was associated with CRC screening and substantially contributed to the geographic heterogeneity of CRC screening
We considered 18 individual-level covariates in six groups as potential factors by which area-level poverty would be associated with CRC screening (Table 1): (1) demographic characteristics; (2) personal health condition; (3) access to medical care; (4) social support; (5) health-related behaviors; and (6) self-rated health status
Summary
With a secular trend of increasing colorectal cancer (CRC) screening, concerns about disparities in CRC screening have been rising. Important disparities in CRC screening, which have been reported, include age [8,9], gender [8,10,11], race/ethnicity [11], obesity [12], individual socioeconomic status [8,13], education [14], availability and type of health insurance [11,13,15], and access to care [8,11,14]. It is still unknown if there is a geographic disparity in CRC screening associated with area characteristics
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