Examination of population-wide trends in barriers to cancer screening from a diffusion of innovation perspective (1987–2000)
Introduction
The devastating effects of many types of cancer and their associated treatments may be reduced with increased adherence to recommended screening practices. In particular, Pap tests, mammography, and colorectal screening have been found to detect cancer at earlier stages and improve cancer survival rates [1], [2], [3], [4], [5], [6], [7], [8], [9]. Despite improvements in screening utilization, rates of colorectal screening have lagged behind that of Pap and mammography and remain low [10], [11]. In general, screening services continue to be underutilized in certain ethnic minorities, age groups, and persons with low socioeconomic status [5], [12], [13], [14], [15], [16], [17].
Underutilization has led to considerable research on barriers to screening. However, this research has not examined changes in barriers over time. To address this gap in previous research, we examined changes in barriers to adopting Pap tests, mammography, and colorectal screening on a population-wide basis using Diffusion of Innovation (DOI) [18] as a framework. The DOI process proceeds within a population along an S curve. Initially, a small group within a population begins using an innovation early (early adopters), followed by a more rapid increase among the majority of a population, and then another small percentage of the population who adopt an innovation much later (late adopters).
National data regarding screening utilization over the past decade reveal that Pap tests, mammography, and colorectal screening, which were introduced into clinical practice at different times, are at different stages in the diffusion process. Colorectal screening is early in the diffusion process with a minority of the population engaging in recent screening; evidence-based guidelines for colorectal screening were made in 1997. In contrast, recommendations for screening mammography were introduced in the 1980s, after which utilization rapidly increased among the majority of the population. Pap screening, which was well established when we first began monitoring its use in 1987, remains widely diffused with the majority of the population engaging in recent screening.
The characteristics of early adopters differ from late adopters, and there are many factors that influence whether individuals adopt innovations [18]. In DOI, the decision processes of individuals who adopt an innovation proceed through five sequential stages: knowledge, persuasion, decision, implementation, and confirmation [18]. Knowledge refers to people becoming aware of an innovation, and persuasion refers to the need of adopters to believe that an innovation has merit and is relevant to them. In the decision stage, people decide to either accept or reject an innovation, and implementation refers to actually using an innovation. Confirmation is the stage when individuals either confirm or reject future use [18].
Barriers can exist at each stage of the diffusion process. Specific individual and structural level barriers to the widespread use of Pap tests, mammography, and colorectal cancer screening have been identified in previous research. These include procrastination, belief that screening is unnecessary (especially in the absence of symptoms), lack of knowledge about screening tests, unpleasant/embarrassing nature of tests, inconvenience, lack of a physician recommendation, lack of health insurance, cost of screening, and no usual source of health care [13], [14], [15], [16], [17], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32].
Barriers to cancer screening, and their relative importance, likely change over time as screening tests are introduced into clinical practice and adopted by the public. Thus, when a new screening test is first introduced, one can anticipate that awareness among clinicians and the public may be the major barrier to use. Later, as awareness is raised, other barriers to screening will likely come into play, such as expense and not having a usual source of health care.
To our knowledge, changes in barriers to cancer screening among a nationally representative sample of adults have not been studied. Such analyses highlight how screening barriers evolve over time as screening modalities become more widely adopted, and provide evidence as to which barriers remain impediments to cancer screening. Furthermore examination of trends in barriers indirectly assesses the success of public health efforts in reducing barriers.
The specific aims of our study were to evaluate: (1) overall national trends from 1987 to 2000 in self-reported barriers to Pap, mammography, and colorectal screening; and (2) trends in barriers to these cancer screening tests over this same period by sociodemographic and health care access variables.
Section snippets
Methods
Data for this study came from the 1987, 1992, and 2000 NHIS, as cancer supplements were included in these years. The NHIS is a national household health survey conducted annually by the Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS). In the 1987 and 1992 surveys, non-Hispanic Blacks were oversampled to allow for more precise estimations of health in minority populations; in 2000, both non-Hispanic Blacks and Hispanics were oversampled. Further details
Sociodemographic characteristics
Sociodemographic characteristics of respondents are shown in Table 2. The proportion of non-Hispanic White respondents decreased over time while the proportion of Hispanic respondents increased, which probably reflects both changing demographics and oversampling of Hispanics in 2000. The proportion of non-Hispanic others was low (1% to 3.1%); thus, trends for this subgroup are not reported.
Overall trends in barriers
Significant increases in screening occurred for each screening exam, with especially large increases for
Discussion
Our study examines trends in barriers to Pap, mammography, and colorectal screening. This analysis provides insight into how barriers change over time as screening modalities come into greater acceptance.
Conclusions
Interventions to reduce barriers to cancer screening informed by a DOI perspective parallel the continuum of public health approaches which ranges from environmental- or structural-level interventions (upstream interventions) to individual-level interventions (downstream interventions). When introducing a new screening technology into clinical practice, upstream approaches are needed to ensure the availability of screening technology in communities and to enable the infrastructure for providing
Acknowledgements
The authors acknowledge Dr. William Rakowski for his helpful feedback on an earlier draft of this manuscript. We also thank Mr. Timothy McNeel of Information Management Services, Inc. and Dr. Richard Moser and Dr. William Davis for statistical support.
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