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


Multiple studies have identified the importance of a physician recommendation for colorectal cancer screening.[28,29] The purpose of our study was to compare, subsequent to a clinician recommendation, patients at a federally qualified health center who did and did not participate in FIT for colorectal cancer screening. In our 6-month study of a large, racially/ethnically diverse clinic population, 875 patients received orders for FITs and the return rate was approximately 50%. Patients who were current smokers were at increased risk for failure to return the FIT, but there were no differences between returners and nonreturners in terms of sex, race/ethnicity, insurance status, and BMI. Our findings regarding poor screening adherence among current smokers is consistent with other work.[16,30] A growing body of evidence suggests that cancer screening settings may be a "teachable moment" for multiple lifestyle interventions, including increasing physical activity and healthy diet, alcohol consumption reduction, and smoking cessation.[31,32] Our findings regarding smoking may be particularly useful for primary care providers to identify and maximize person-centered clinical care opportunities and use strategies such as motivational interviewing to support patients with dual lifestyle changes regarding smoking and cancer screening.

The Health Belief Model is a commonly used framework to explain cancer screening behavior and posits that education and knowledge may modify the pathway between individual perceptions (eg, perceived susceptibility of the disease) and behavior.[33] The clinician plays a key role in patient behavior through advising, communicating, and educating the patient. Clinician-patient interactions regarding preventive services should follow the 5A's: assess, advise, agree, assist, and arrange.[34] In our study, most clinicians reported they would advise insured patients to receive a colonoscopy and uninsured patients to receive stool-based screening tests. Physician preferences for colonoscopies have been noted throughout the literature,[4–8] but the USPSTF equally endorses multiple colorectal cancer screening options. Education for the patient on the benefits, harms, and alternatives for each colorectal cancer screening modality may engage patients in the shared decision making process and increase screening adherence, particularly for race/ethnic minority patients.[33]

Recent evidence suggests that colorectal cancer mortality has increased since 2005 among those aged 40 to 54 years,[35] and in May 2018, the American Cancer Society expanded its colorectal cancer screening recommendations to begin screening at 45 years of age.[36] In our study of patients aged ≥50 years, younger individuals appeared to be at a marginally increased risk of FIT return failure, and although results were not statistically significant, this is consistent with other recent work[13] and troubling in light of trend data. In our study, we did not observe differences in patient-reported barriers or facilitators of FIT return between age strata (results not shown). More work is needed to understand why younger individuals in the United States are less likely to be screened and to develop strategies to increase motivation to be screened, which we noted as a common barrier to colorectal cancer screening in all ages. Large-scale education efforts at the societal level may be needed to educate the public to increase colorectal cancer screening motivation among midlife adults in their fifth (40 to 49 years) and sixth (50 to 59 years) decades of life.

Among those who did not return the FIT, patients reported that prepaid postage with return addresses on the FIT kit return envelope and live call reminders would facilitate FIT kit return. These facilitators were similar for all race/ethnic groups. Hispanic/Latino patients, and Spanish speakers in particular, were more likely to indicate that better test instructions, more educational materials, and more time with the clinician during their clinic visit would facilitate FIT return. In our study, although there were no race/ethnic differences in FIT return in the multivariate models, Hispanic/Latino patients were significantly more likely to report poor/confusing test instructions and fear of embarrassment as barriers to FIT screening. This is concordant with recent qualitative work among Hispanic/Latino patients by Leal et al,[37] who noted beliefs about illness and health, and reactions to illness such as embarrassment and fear, were major themes that limited the early detection and treatment of colorectal cancer among lower-income, minority patients. Several studies have also noted the use of bilingual community health workers, or promotoras de salud, in colorectal cancer screening interventions.[38] Promotoras are generally trained community members that connect community members to research or formal institutions through culturally targeted interventions.[39] The large disparities we noted in our study between English-speaking patients and Spanish-speaking patients may represent an opportunity to tailor patient care with bilingual community health workers or patient navigators in the future.

There are several limitations of our study. Approximately one quarter of patients (n = 121; 28% of the 435 nonreturners) who did not return the FIT participated in a telephone interview. In our patient population, many patients had inaccurate or out of service telephone numbers in their medical records, despite clinic protocol focused on updating this information at every clinical encounter. Although our response rate was lower than desired, the Pew Research Center has reported that response rates for telephone surveys have plateaued at approximately 9%, roughly 25 percentage points less than in 1997.[40] Selection bias may have occurred, such that survey participants may have differed from nonparticipants. Indeed, patient participants who completed the telephone survey in our study were less likely to be non-Hispanic black, but nonreturners who participated in the telephone survey were otherwise similar to nonreturners who did not participate in the telephone survey in terms of age, sex, insurance status, BMI, and smoking status. Future work should consider multiple survey modalities to increase participation. Although the telephone survey was confidential, some patients may have felt uncomfortable with the personal nature of the questions and thus underreported or misreported true barriers. For example, we did not have any patients report disgust by the idea of handling stool, but another study reported that approximately 20% of 82 patients who did not complete FIT testing reported disgust.[21] In addition, we did not collect information about possible clinical presentations that may have initiated a FIT or other colorectal examination. Although we excluded patients younger than 50 years of age to mitigate FIT workups for reasons other than general screening, it is possible that some patients may have presented with clinically relevant signs or have been ineligible for other screening methods. Finally, during the telephone survey, several patients whose medical records showed a FIT order stated that they did not receive a kit to take home, which may have slightly underestimated the FIT return rate in our clinic.

Nevertheless, findings from this research study benefited patient care in our clinic by identifying procedural glitches that were easily addressed and increased the overall screening rate from 28% to 35% within 6 months. For example, some clinicians were unaware that patients could return FIT kits via mail, so we created a brief physician training to increase clinician awareness and improve the assist/arrange phase of preventive care decision making between health care providers and patients. In addition, a review of clinic procedure following this study found that many providers relied on Spanish-speaking staff to orally dictate FIT instructions at the clinic visit, which may be the reason that that many Hispanic/Latino patients did not feel informed about test instructions. While Spanish-language test instructions have been available, many clinicians and nurses were unsure of where to locate them. Currently, we are working with our information technology team to auto-populate Spanish language instructions in the electronic medical record check-out paperwork whenever the patient's primary language is marked as Spanish. Strategies such as leveraging health information technology, optimizing team work, education to both patients and clinicians, use of patient navigators, and interactive workshops for clinician training have been shown to increase colorectal cancer screening in other primary care settings.[41]