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


Our study was conducted in a large, multi-site federally qualified health center located in central Texas. The Waco Family Health Center provides care for over 58,000 unique patients, or approximately 1 in every 5 county residents, over 90% of whom live at or below 200% of the federal poverty guidelines.[14] One quarter of patients are non-Hispanic black/African American, 40% are Hispanic/Latino, and 30% are non-Hispanic white.[14] Approximately 1 in 6 patients do not have health insurance and are afforded care through a sliding scale discounted fee program that expands coverage to approximately 1 quarter of self-pay patients.[14] In 2016, 165,784 primary medical care encounters were provided by 68 physicians (21 family physicians, 38 resident/fellow family physicians, 2 pediatricians, 3 internists, 4 obstetrician/gynecologists), 14 nurse practitioners, and 5 physician assistants.[14]

From January 1, 2017 to July 1, 2017, 8717 patients aged 50 to 75 years without a history of colon cancer had a clinic visit at the Waco Family Health Center. Of those, 2473 (28%) met USPSTF colorectal cancer screening recommendations by any screening method. The electronic health record system, Epic, was used to query all patient visits during which a FIT order was placed during this time period. The follow-up status of the FIT order was used to define screening adherence. Completed orders included FIT results from home-test kits that were returned for analysis; patients who returned the FIT were defined as screened and adherent to recommendations. Blank orders indicated that patients did not return the FIT kit; patients who had not returned the FIT were defined as nonadherent with USPSTF screening recommendations. In total, there were 1489 FIT orders between January 1 and July 1, 2017. After removing duplicates, patients younger than 50 years, and those with incomplete data, the final analytic sample included 875 nonduplicate patients aged ≥50 years.

In addition to FIT screening completion, patient sociodemographic variables were obtained from the health record. Age in years was categorized as 50 to 59 years, 60 to 69 years, and 70 years or older. Sex was defined as female or male. Race/ethnicity was defined as Hispanic or Latino, non-Hispanic white, non-Hispanic black, or non-Hispanic other. Patient insurance status was described as private insurance, public insurance, or self pay. Private insurance included commercial options (Blue Cross Blue Shield, Humana, United, etc.) and public insurance included Medicare and Medicaid. Self pay included patients without insurance and those covered by the sliding-scale discount fee program, nonprofit organizations, and other regional grant funding that provides subsidized care at the clinic. Body mass index (BMI) and smoking were also included as covariates because of documented associations with colorectal cancer screening.[15,16] BMI was calculated using weight in kilograms (kg) and height in meters (m) from the health record and categorized as underweight or normal (<25 kg/m2), overweight (≥25 and <30 kg/m2), or obese (≥30 kg/m2). Smoking status was defined as never smoker, former smoker, or current smoker.

Patients who did not return the FIT were contacted via telephone and provided information about participation in a survey in English or in Spanish, based on their language preference. Interviewers followed a script to obtain verbal informed consent from patients, which was approved by the Baylor University Institutional Review Board (IRB Reference #1125461). As part of survey development, potential barriers and facilitators of colorectal cancer screening were identified using empirically supported barriers in the literature as well as those identified by administrators at our health center. Potential barriers included cost,[17] time,[18] poor/confusing instructional materials,[17] transportation to FIT return sites,[19] limited drop-off sites or return site hours of operation (recommended by local clinic administrators), fear of abnormal findings,[17,20] embarrassment,[21] lack of motivation,[21] and forgetfulness.[18] Potential facilitators included a prepaid postage with proper return address;[22] more drop-off sites (recommended by local clinic administrators); reminders by phone, email, text, or mail;[19] better test instructions;[23] additional colorectal cancer screening educational materials;[17] or more time spent with the clinician.[17] Patient participants were asked to respond with yes, no, or prefer not to answer to each barrier and facilitator. In addition, 2 open-ended questions accounted for unidentified barriers and facilitators (eg, what about the FIT process was difficult for you?, what would help you return the FIT in the future?). All responses were recorded in Microsoft Excel. Patients were called up to 6 times; of the 435 patients who did not return the FIT, 121 (28%) participated in the telephone survey.

Eighty-seven clinicians, including physicians, resident/fellow physicians, physician assistants, and nurse practitioners, were sent an online invitation by an administrator at our health center to complete a survey using Qualtrics software. The clinician survey evaluated perceptions of patient barriers and facilitators related to colorectal cancer screening and their preferred colorectal cancer screening test based on patient's insurance status (colonoscopy, flexible sigmoidoscopy, fecal occult blood tests [FOBT]/FIT, other), adapted from previous literature.[4,24–26] The clinician survey included the same FIT-related barriers and facilitators as the patient telephone survey. Provider preference for colorectal cancer screening test was measured by choosing 1 screening option for insured and 1 option for uninsured patients (colonoscopy, FIT, gFOBT, flexible sigmoidoscopy, patient preference, no preference, none of these). Thirty-one clinicians (36% of the 87 who were invited) participated in the survey.

Statistical analyses were performed using SAS v9.4 (SAS Institute Inc., Cary, NC). Descriptive statistics, including frequencies, means, and proportions, were generated for all study variables in the total sample. χ2 statistics were used to compare patients who did and did not return FITs. Log-binomial regression was conducted using the GENMOD procedure to estimate risk ratios and corresponding 95% confidence intervals[27] for FIT nonreturn compared with FIT return. Bivariate models estimated the risk of FIT nonreturn for each patient characteristic separately and multivariate models included all covariates in a single model. Finally, frequencies and proportions were used to identify the most common barriers and facilitators to FIT return identified by patients and by clinicians. We compared patient-reported barriers by insurance status, race/ethnicity, and language preference using Fisher's exact test. Statistical significance was 2-sided and defined at the α = 0.05 level.