Barriers and Facilitators of Colorectal Cancer Screening in a Federally Qualified Health Center (FQHC)

Kelly R. Ylitalo, PhD; Brendan G. Camp, MPH; M. Renée Umstattd Meyer, PhD, MCHES; Lauren A. Barron, MD; Gabriel Benavidez, BS; Burritt Hess, MD; Ryan Laschober, MD; Jackson O. Griggs, MD


J Am Board Fam Med. 2019;32(2):180-190. 

In This Article

Abstract and Introduction


Introduction: Colorectal cancer is a leading cause of cancer-related mortality in the United States. Current screening recommendations for individuals aged 50 to 75 years include colonoscopy every 10 years, flexible sigmoidoscopy every 5 years, or annual stool-based testing. Stool-based testing, including fecal immunochemical tests (FITs), are cost effective, easy to perform at home, and noninvasive, yet many patients fail to return testing kits and go unscreened. The purpose of the study was to identify patient characteristics and perceived barriers and facilitators of FIT return.

Methods: Patients in a large, federally qualified health center who received a FIT kit order between January 1 and July 1, 2017 were identified. We compared sociodemographic and health characteristics between patients who returned and did not return FITs. We used telephone surveys to nonreturners to identify potential barriers (cost, knowledge, psychosocial factors) and facilitators (prepaid postage, outreach) of FIT kit return. An online survey of clinicians assessed perceived patient barriers and facilitators of colorectal cancer screening.

Results: Of the 875 patients who received a FIT order, 435 (49.7%) did not return the kit and 121 of the nonreturners completed a telephone survey. Current smokers had an increased risk of FIT nonreturn compared with never smokers (RR = 1.32; 95% CI, 1.13–1.54). Forgetfulness and lack of motivation were the most common FIT return barriers perceived by both patients and clinicians. Prepaid postage with return address on FIT return envelopes and live call reminders were the most commonly reported facilitators. Barriers and facilitators varied greatest between English- and Spanish-speaking patients.

Conclusion: In this study, the most common perceived barriers to return of screening fecal test kits were forgetfulness and lack of motivation. The most common perceived facilitators were live call reminders and postage-paid return envelopes. Understanding barriers and facilitators to FITs may be necessary to enhance cancer screening rates in underserved patient populations.


Colorectal cancer is the second most common type of cancer-related death in men and the third most common in women; over 50,000 deaths a year in the United States are attributable to colorectal cancer.[1] Although substantial progress was made over the past 2 decades and colorectal cancer death rates decreased by 34% among individuals ≥50 years,[1] gains have not been experienced equitably. Colorectal cancer deaths rates among non-Hispanic blacks are presently 40% higher than death rates among non-Hispanic whites, and Hispanics are the least likely race/ethnic group to be screened for colorectal cancer.[1,2]

The United States Preventive Services Task Force (USPSTF) recommends that healthy adults begin colorectal cancer screening at age 50 years and continue until at least age 75 years, at varying intervals depending on the screening test.[3] Screening methods can include direct visualization tests such as colonoscopy every 10 years or flexible sigmoidoscopy every 5 years, or more frequent stool-based tests such as annual guaiac fecal occult blood tests (gFOBTs) or annual fecal immunochemical tests (FITs).[3] Although USPSTF recommendations indicate no preference for colorectal cancer screening method,[3] physicians overwhelmingly prefer to recommend colonoscopies.[4–8] This is particularly problematic for underserved patients because the high cost, intensive time preparation, and invasive nature of colonoscopies are common barriers to participation.[9]

Recent estimates suggest that only 61% of adults age ≥50 years were up to date with colorectal cancer screening in 2015,[10] which falls short of the 70.5% goal of Healthy People 2020 national objectives.[11] Low-income patients, particularly those served by federally qualified health centers, have the lowest colorectal cancer screening rates in the nation. Nationally, only 38.3% of federally qualified health center patients are screened[12] and thus represent a priority population for colorectal cancer prevention. Stool-based tests, such as the FIT, are low cost, noninvasive, and simple, which may be more amenable for hard-to-reach patient populations. Recent work has shown that FIT participation is associated with older age, female sex, and higher socioeconomic status,[13] but considerably less is known about low-income patients. The purpose of the study was to identify patients at a federally qualified health center who received a FIT order, compare patient characteristics between those who returned and did not return the FIT, and describe barriers and potential facilitators of future FIT participation. The secondary purpose of the study was to identify clinician perceptions of patient barriers and facilitators and colorectal cancer screening recommendations.