title: Explaining persistent under-use of colonoscopic cancer screening in African Americans: a systematic review.
abstract: BACKGROUND
  Although African Americans have the highest incidence and mortality from colorectal cancer (CRC), they are less likely than other racial groups to undergo CRC screening. Previous research has identified barriers to CRC screening among African Americans. However we lack a systematic review that synthesizes contributing factors and informs interventions to address persistent disparities.
  
  
  METHODS
  We conducted a systematic review to evaluate barriers to colonoscopic CRC screening in African Americans. We developed a conceptual model to summarize the patient-, provider-, and system-level barriers and suggest strategies to address these barriers.
  
  
  RESULTS
  Nineteen studies met inclusion criteria. Patient barriers to colonoscopy included fear, poor knowledge of CRC risk, and low perceived benefit of colonoscopy. Provider-level factors included failure to recommend screening and knowledge deficits about guidelines and barriers to screening. System barriers included financial obstacles, lack of insurance and access to care, and intermittent primary care visits.
  
  
  CONCLUSIONS
  There are modifiable barriers to colonoscopic CRC screening among African Americans. Future interventions should confront patient fear, patient and physician knowledge about barriers, and access to healthcare services. As the Affordable Care Act aims to improve uptake of preventive services, focused interventions to increase CRC screening in African Americans are essential and timely.
authors.affiliation: Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; UCLA/VA Center for Outcomes Research and Education (CORE), Los Angeles, CA, USA.
authors.forename: Erica G
authors.initials: EG
authors.lastname: Bromley
authors.affiliation: Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Department of Medicine, Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; UCLA/VA Center for Outcomes Research and Education (CORE), Los Angeles, CA, USA. Electronic address: fmay@mednet.ucla.edu.
authors.forename: Folasade P
authors.initials: FP
authors.lastname: May
authors.affiliation: University of California Los Angeles, Los Angeles, CA, USA.
authors.forename: Lisa
authors.initials: L
authors.lastname: Federer
authors.affiliation: Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Department of Medicine, Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; UCLA/VA Center for Outcomes Research and Education (CORE), Los Angeles, CA, USA.
authors.forename: Brennan M R
authors.initials: BM
authors.lastname: Spiegel
authors.affiliation: Department of Medicine, Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; University of Utrecht, The Netherlands.
authors.forename: Martijn G H
authors.initials: MG
authors.lastname: van Oijen
mesh_terms: D001741:Black or African American / Q000523:psychology*; D000368:Aged; D002983:Clinical Competence; D003113:Colonoscopy / Q000523:psychology* / Q000706:statistics & numerical data*; D015179:Colorectal Neoplasms / Q000175:diagnosis; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006801:Humans; D007348:Insurance, Health; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance / Q000208:ethnology / Q000523:psychology / Q000706:statistics & numerical data; D058991:Patient Protection and Affordable Care Act; D010817:Physician-Patient Relations; D014481:United States
keywords: African-American; Barriers; Colonoscopy; Colorectal cancer; Ethnicity; Race; Screening