Surveillance colonoscopy

Socioeconomic factors

From Cancer Guidelines Wiki


Many socioeconomic factors influence health, including education, employment, income and wealth, family, neighbours, housing, access to services, migration and refugee status and food security.[1][2][3][4][5][6][7][8][9][10][11][12] Socioeconomic disadvantage, and its detrimental effects on health, is common in Australia.[1][13]

Social and economic circumstances are recognised determinants of access to health care and of healthcare outcomes, including for colorectal cancer (CRC).[2][3][4][14][15][16] Between 2009 and 2013, Australians living in the most disadvantaged areas had the highest age-standardised incidence for CRC.[17]

Apart from access to health services related to distance or transport, the cost of services is an additional factor, related to socioeconomic status (SES) that influences the care people receive. In 2015–2016, one in 12 (8%) Australians who needed to see a medical specialist delayed or did not attend because of the cost. Those with a long-term health condition were more likely to delay seeing or not see a medical specialist due to cost than those without (9% compared with 5%). People living in the areas of most socioeconomic disadvantage were more likely to delay seeing or not see a medical specialist due to cost than those living in areas of least disadvantage (9% compared with 6%).[18][14]

Many socioeconomic factors are beyond the capacity of individual clinicians to address. This section focuses on those modifiable SES-related factors which impact on surveillance in three settings:

  • following adenoma detection;
  • post curative resection for CRC;
  • in the setting of dysplasia surveillance in inflammatory bowel disease.

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Strategies for reducing socioeconomic inequality in surveillance colonoscopy

Clinicians can address three key areas linked to SES to improve the success of surveillance, by:

  • communicating information in a way that is meaningful and actionable for the patient
  • sharing decision-making with the patient and their support people
  • improving their own cultural competency to support effective communication with patients from different cultural groups and belief systems.

The goal should be to ensure that all patients' decisions, including whether or not to participate in surveillance colonoscopy, are well informed and freely made.

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Health literacy

Literacy is low in Australia. In 2011, only 56% of people had the general literacy needed to cope with everyday life and work.[19]

Health literacy is defined as the skills, knowledge, motivation and capacity of a person to access, understand, appraise and apply information to make effective decisions about health and health care and take appropriate action.[20] Poor health literacy is associated with low SES[21][22][23] and is relevant to surveillance.[24][25] Almost 60% of adult Australians have low health literacy.[26] In 2006, among those whose first language was English, 44% had a level of health literacy described as adequate or better but amongst the almost 3 million Australians aged 15–74 years who spoke English as a second language this level fell to only 25%.[27] Low health literacy is associated with low levels of knowledge and poorer health outcomes.[28]

Since 2011 all hospitals and day facility services in Australia have been required to meet the National Safety and Quality Health Service Standards for accreditation. A specific standard (the Partnering with Consumers Standard) requires demonstration of actions to improve consumer understanding and participation in decision making about their care.[29] With the introduction of the second edition of the National Safety and Quality in Health Care Standards, health service organisations will be required to communicate with consumers in a way that supports effective partnerships, in this way specifically addressing issues related to health literacy. A number of useful resources are available to assist clinicians, managers and other health professionals working outside the hospital or day facility to support improvements in health literacy and to develop information to meet the needs of patients with low health literacy.[30][31] These resources are readily accessible on a number of sites, including the National Health and Medical Research Council and Cancer Australia websites.

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Shared decision-making

People who are supported to make an informed decision by a healthcare professional may have better outcomes, better experiences, and less regret about their decisions.[32][33][34] Disadvantaged groups may benefit most.[35] Patient decision aids, decision support and navigation tools have been shown to increase CRC screening participation, but have not been trialled in the surveillance setting.[36][37][38][39][40][41][42] Larger studies are needed to identify which features of navigation are most effective in patients ongoing participation in CRC surveillance, particularly those from lower SES backgrounds.

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Cultural competency

Cultural competency is the capacity to interact with people across different cultures and requires cross-cultural communication skills. This competency is particularly important in Australia where 1 in 4 Australians is born overseas, and just under 3% identify as Aboriginal or Torres Strait Islander Australians.[43] Action at all levels of the health system is required to reduce the health inequalities that exist for many culturally and linguistically diverse background communities.[44] An important first step to reduce this source of health inequality is to ensure that environments provide a sense of cultural safety so that people feel sufficiently comfortable to discuss their cultural identity. This then enables information and discussions about treatment options to be undertaken in a culturally sensitive manner. A number of services are available to support health services and providers including translation services, cultural guides, social services and patient advocacy groups. Online and face-to-face training in cultural competence for health professionals and the broader health workforce is also available and is now considered by many professional bodies essential training for clinicians.

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  1. 1.0 1.1 Australian Institute of Health and Welfare. Australia’s health 2014. Australia’s health series no. 14. Cat. no. AUS 178. Canberra: AIHW; 2014.
  2. 2.0 2.1 National Health and Medical Research Council. Using socioeconomic evidence in clinical practice guidelines. Commonwealth of Australia: National Health and Medical Research Council; 2002 Jan 1 Available from:
  3. 3.0 3.1 Rosso S, Faggiano F, Zanetti R, Costa G. Social class and cancer survival in Turin, Italy. J Epidemiol Community Health 1997;51(1):30-34.
  4. 4.0 4.1 Ciccone G, Prastaro C, Ivaldi C, Giacometti R, Vineis P. Access to hospital care, clinical stage and survival from colorectal cancer according to socio-economic status. Ann Oncol 2000;11(9):1201-1204.
  5. Kogevinas M, Porta M. Socioeconomic differences in cancer survival: a review of the evidence. IARC Sci Publ 1997;(138):177-206.
  6. Carstairs V. Multiple deprivation and health state. Community Med 1981 Jan 1;3(1):4-13.
  7. Townsend P, Simpson D, Tibbs N. Inequalities in health in the city of Bristol: a preliminary review of statistical evidence. Int J Health Ser 1985;15(4):637-663.
  8. Rosengren A, Wilhelmsen L. Cancer incidence, mortality from cancer and survival in men of different occupational classes. Eur J Epidemiol 2004;19(6):533-540.
  9. Woods LM, Rachet B, Coleman MP. Origins of socio-economic inequlities in cancer survival: a review. Ann Oncol 2006;17(1): 5-19.
  10. Auvinen A, Karjalainen S. Possible explanations for social class differences in cancer patient survival. IARC Sci Publ 1997;(138):377-397.
  11. McArdle CS, Hole DJ. Outcome following surgery of colorectal cancer: analysis by hospital after adjustment for case-mix and deprivation. BR J Cancer 2002;86(3):331-335.
  12. Raine R, Wong W, Scholes S, Ashton C, Obichere A, Ambler G. Social variations in access to hospital care for patients with colorectal, breast and lung cancer between 1999 and 2006: retrospective analysis of hospital episode statistics. BMJ 2010;340:b5479.
  13. Australian Institute of Health and Welfare. Australia’s welfare 2017. Australia’s welfare series no. 13. AUS 214. Canberra: AIHW; 2017.
  14. 14.0 14.1 Breen N, Lewis DR, Gibson JT, Yu M, Harper S. Assessing disparities in colorectal cancer mortality by socioeconomic status using new tools: health disparities calculator and socioeconomic quintiles. Cancer Causes Control 2017 Feb;28(2):117-125 Available from:
  15. Eloranta S, Lambert PC, Cavalli-Bjorkman N, Andersson TM, Glimelius B, Dickman PW. Does socioeconomic status influence the prospect of cure from colon cancer--a population-based study in Sweden 1965-2000. Eur J Cancer 2010 Nov;46(16):2965-72 Available from:
  16. Weber MF, Banks E, Ward R, Sitas F. Population characteristics related to colorectal cancer testing in New South Wales, Australia: results from the 45 and Up Study cohort. J Med Screen 2008;15(3):137-42 Available from:
  17. Australian Institute of Health and Welfare. Cancer in Australia: an overview 2014. [Version updated 16 April 2015] Cancer series No 90. Cat. no. CAN 88. Canberra: AIHW;.
  18. Australian Bureau of Statistics. 4839.0 - Patient Experiences in Australia: Summary of Findings, 2015-16. Canberra: ABS; 2016.
  19. Australian Bureau of Statistics. 4228.0 - Programme for the International Assessment of Adult Competencies, Australia, 2011-2012. Canberra: ABS; 2013.
  20. Australian Commission on Safety and Quality in Health Care. Health Literacy:Taking action to improve safety and quality. Sydney: ACSQHC; 2014 [cited 2016] Available from:
  21. Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, et al. Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health 2012 Jan 25;12:80 Available from:
  22. Jordan JE, Buchbinder R, Osborne RH. Conceptualising health literacy from the patient perspective. Patient Educ Couns 2010 Apr;79(1):36-42 Available from:
  23. Paasche-Orlow MK, Wolf MS. The causal pathways linking health literacy to health outcomes. Am J Health Behav 2007 Sep;31 Suppl 1:S19-26 Available from:
  24. Radaelli F, Paggi S, Repici A, Gullotti G, Cesaro P, Rotondano G, et al. Barriers against split-dose bowel preparation for colonoscopy. Gut 2017 Aug;66(8):1428-1433 Available from:
  25. King-Marshall EC, Mueller N, Dailey A, Barnett TE, George TJ Jr, Sultan S, et al. "It is just another test they want to do": Patient and caregiver understanding of the colonoscopy procedure. Patient Educ Couns 2016 Apr;99(4):651-658 Available from:
  26. Australian Bureau of Statistics. 4233.0 - Health Literacy, Australia, 2006  . Canberra: ABS; 2008.
  27. Australian Bureau of Statistics. 4102.0 - Australian Social Trends. Canberra: ABS; 2009.
  28. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, Holland A, Brasure M, Lohr KN, Harden E, Tant E, Wallace I, Viswanathan M.. Health Literacy Interventions and Outcomes: An Updated Systematic Review. Evidence Report/Technology Assesment No. 199. Rockville, MD: Agency for Healthcare Research and Quality; 2011.
  29. Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards. Sydney: ACSQHC; 2012.
  30. Cindy Brach, Debra Keller, Lyla M. Hernandez, Cynthia Baur, Ruth Parker, Benard Dreyer, Paul Schyve, Andrew J. Lemerise, Dean Schillinger. Ten Attributes of Health Literate Health Care Organizations. Washington D.C.: IOM Roundtable on Health Literacy; 2012.
  31. National Health and Medical Research Council. General Guidelines for Medical Practitioners on Providing Information to Patients. Canberra: National Health and Medical Research Council; 2004.
  32. Coulter A, Collins A.. Making shared decision-making a reality. London UK: The King’s Fund; 2011.
  33. Weingart SN, Zhu J, Chiappetta L, Stuver SO, Schneider EC, Epstein AM, et al. Hospitalized patients' participation and its impact on quality of care and patient safety. Int J Qual Health Care 2011 Jun;23(3):269-77 Available from:
  34. Stacey D, Légaré F, Col NF, Bennett CL, Barry MJ, Eden KB, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2014 Jan 28;1:CD001431 Available from:
  35. Durand MA, Carpenter L, Dolan H, Bravo P, Mann M, Bunn F, et al. Do interventions designed to support shared decision-making reduce health inequalities? A systematic review and meta-analysis. PLoS One 2014;9(4):e94670 Available from:
  36. Reuland DS, Brenner AT, Hoffman R, McWilliams A, Rhyne RL, Getrich C, et al. Effect of Combined Patient Decision Aid and Patient Navigation vs Usual Care for Colorectal Cancer Screening in a Vulnerable Patient Population: A Randomized Clinical Trial. JAMA Intern Med 2017 Jul 1;177(7):967-974 Available from:
  37. Christie J, Itzkowitz S, Lihau-Nkanza I, Castillo A, Redd W, Jandorf L. A randomized controlled trial using patient navigation to increase colonoscopy screening among low-income minorities. J Natl Med Assoc 2008 Mar;100(3):278-84 Available from:
  38. Jandorf L, Cooperman JL, Stossel LM, Itzkowitz S, Thompson HS, Villagra C, et al. Implementation of culturally targeted patient navigation system for screening colonoscopy in a direct referral system. Health Educ Res 2013 Oct;28(5):803-15 Available from:
  39. Cavanagh MF, Lane DS, Messina CR, Anderson JC. Clinical case management and navigation for colonoscopy screening in an academic medical center. Cancer 2013 Aug 1;119 Suppl 15:2894-904 Available from:
  40. Braschi CD, Sly JR, Singh S, Villagra C, Jandorf L. Increasing colonoscopy screening for Latino Americans through a patient navigation model: a randomized clinical trial. J Immigr Minor Health 2014 Oct;16(5):934-40 Available from:
  41. DeGroff A, Coa K, Morrissey KG, Rohan E, Slotman B. Key considerations in designing a patient navigation program for colorectal cancer screening. Health Promot Pract 2014 Jul;15(4):483-95 Available from:
  42. Percac-Lima S, Ashburner JM, Zai AH, Chang Y, Oo SA, Guimaraes E, et al. Patient Navigation for Comprehensive Cancer Screening in High-Risk Patients Using a Population-Based Health Information Technology System: A Randomized Clinical Trial. JAMA Intern Med 2016 Jul 1;176(7):930-7 Available from:
  43. Australian Bureau of Statistics. 2075.0 - Census of Population and Housing - Counts of Aboriginal and Torres Strait Islander Australians, 2011  . Canberra: ABS; 2012.
  44. National Health and Medical Research Council. Cultural Competency in health: A guide for policy, partnerships and participation. Canberra: NHMRC; 2006.

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