title: Associations between contextual factors and colorectal cancer screening in a racially and ethnically diverse population in Texas.
abstract: BACKGROUND
  Colorectal cancer is the third most commonly diagnosed cancer and the third leading cause of cancer death in the United States. Increased attention has been given to understanding the role of local contexts on cancer screening behaviors. We examined the associations between multiple tract-level socioeconomic measures and adherence to colorectal cancer screening (CRCS) in Harris County and the City of Houston, Texas.
  
  
  METHODS
  We conducted a cross-sectional multilevel study linking individual-level data on CRCS from the 2010 Health of Houston Survey with contextual data from the U.S. Census and the U.S. Department of Housing and Urban Development. We examined tract-level poverty, education, employment, income inequality, and foreclosure measures across 543 Census tracts. Analyses were limited to individuals aged 50-74 years (N=1720).
  
  
  RESULTS
  Overall, 58.0% of the sample was adherent to any recommended CRCS test. In bivariate analyses, increasing levels of area poverty, low education, unemployment, and foreclosures were associated with lower odds of adherence to CRCS. After controlling for individual-level covariates, only tract-level unemployment remained associated with adherence to CRCS (adjusted OR=0.80; 95% CI: 0.66-0.99; P=.037).
  
  
  CONCLUSIONS
  Neighborhood socioeconomic disadvantage is increasingly recognized as a determinant of health, and our study suggests that the contextual effect of area unemployment may extend to cancer screening outcomes. Our finding is important to cancer control planners because we identified a contextual marker of disparity that can be used to target local interventions to promote CRCS and thereby reduce cancer disparities among non-adherent individuals who reside in communities with high unemployment rates.
authors.affiliation: The University of Texas School of Public Health, Department of Management, Policy and Community Health, 7000 Fannin, Suite 2568, Houston, TX, United States. Electronic address: wacalo@live.unc.edu.
authors.forename: William A
authors.initials: WA
authors.lastname: Calo
authors.affiliation: The University of Texas School of Public Health, Center for Health Promotion and Prevention Research, 7000 Fannin, Suite 2560, Houston, TX, United States.
authors.forename: Sally W
authors.initials: SW
authors.lastname: Vernon
authors.affiliation: The University of Texas School of Public Health, Center for Health Services Research, 1200 Pressler, RAS E307, Houston, TX, United States.
authors.forename: David R
authors.initials: DR
authors.lastname: Lairson
authors.affiliation: The University of Texas School of Public Health, Institute for Health Policy, 1200 Pressler, RAS E1013, Houston, TX, United States.
authors.forename: Stephen H
authors.initials: SH
authors.lastname: Linder
mesh_terms: D000368:Aged; D015179:Colorectal Neoplasms / Q000175:diagnosis*; D003430:Cross-Sectional Studies; D055088:Early Detection of Cancer / Q000706:statistics & numerical data*; D005006:Ethnicity; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000208:ethnology* / Q000706:statistics & numerical data*; D044469:Racial Groups; D012959:Socioeconomic Factors; D013781:Texas; D014481:United States
keywords: Census tract; Colonoscopy; Colorectal cancer screening; Contextual effect; Fecal occult blood testing; Inequalities; Multilevel analysis; Sigmoidoscopy; Socioeconomic factors