A Multilevel Approach to Understand the Context and Potential Solutions for Low Colorectal Cancer (CRC) Screening Rates in Rural Appalachia Clinics

Abstract

Purpose To explore system/staff‐ and patient‐level opportunities to improve colorectal cancer (CRC) screening within an 11‐clinic Federally Qualified Health Center (FQHC) in rural Appalachia with CRC screening rates around 22%‐30%. Methods Using a convergent parallel mixed‐methods design, staff (n = 26) and patients (n = 60, age 50‐75, 67% female, 83% <college, 47% Medicare, 23% Medicaid) were interviewed about CRC‐related screening practices. Staff and patient interviews were guided by the Consolidated Framework for Implementation Research and Health Belief Model, respectively, and analyzed using a hybrid inductive‐deductive approach. Results Among staff, inner setting factors that could promote CRC screening included high workplace satisfaction, experiences tracking other cancer screenings, and a highly active Performance Improvement Committee. Inner setting hindering factors included electronic medical record inefficiencies and requiring patients to physically return fecal tests to the clinic. Outer setting CRC screening promoting factors included increased Medicaid access, support from outside organizations, and reporting requirements to external regulators, while hindering factors included poor social determinants of health, inadequate colonoscopy access, and lack of patient compliance. Among patients, perceived screening benefits were rated relatively higher than barriers. Top barriers included cost, no symptoms, fear, and transportation. Patients reported high likelihood of getting a stool‐based test and colonoscopy if recommended, yet self‐efficacy to prevent CRC was considerably lower. Conclusions Contextualized perceptions of barriers and practical opportunities to improve CRC screening rates were identified among staff and patients. To optimize multilevel CRC screening interventions in rural Appalachia clinics, future quality improvement, research, and policy efforts are needed to address identified challenges.

Perspectives of cancer prevention and control resources from stakeholders in rural southern Illinois

“…Stakeholders revealed multiple regional cancer prevention and control needs that must be considered in the context of minimal available services, concerns about service quality, and other systemic barriers that reduce access to care. Some of these findings—such as transportation concerns 37–39 and the use of nurse/patient navigators, 40,41 for example—have been emphasized in previous research on rural cancer care. However, others are more novel findings, such as the emphasis on informal health communication as a strategy to understand care needs and access resources, stakeholder concerns about outdated health care machinery, and issues with program qualifications to receive services.…”

“…Stakeholders revealed multiple regional cancer prevention and control needs that must be considered in the context of minimal available services, concerns about service quality, and other systemic barriers that reduce access to care. Some of these findings-such as transportation concerns [37][38][39] and the use of nurse/patient navigators, 40,41 for example-have been emphasized…”

Cancer Screening Among Rural and Urban Clinics During COVID-19: A Multistate Qualitative Study

“…[13][14][15][16][17] Rural primary care practices have notable barriers to delivering cancer screening, such as insufficient electronic health record (EHR) capacity for reminder and recall systems and staffing shortages. 18,19 New barriers to cancer screening were created by the pandemic, creating a need for research on COVID-19-related effects on cancer screening in rural clinics.…”

Improving Fecal Immunochemical Test Return Rates: A Colorectal Cancer Screening Quality Improvement Project in a Multisite Federally Qualified Health Center

“…The QI-CRC team adapted the semi-structured interview protocol from a related CRC screening project conducted in an FQHC system in the same region (Zoellner et al, 2021), which was guided by the Consolidated Framework for Implementation Research (CFIR; Damschroder et al, 2009). The CFIR includes 39 factors across 5 domains (i.e., intervention characteristics, outer setting, inner setting, process, individual characteristic) that influence system-level intervention implementation.…”