Development of a multilevel intervention to increase colorectal cancer screening in Appalachia

Abstract

Background Colorectal cancer (CRC) screening rates are lower in Appalachian regions of the United States than in non-Appalachian regions. Given the availability of various screening modalities, there is critical need for culturally relevant interventions addressing multiple socioecological levels to reduce the regional CRC burden. In this report, we describe the development and baseline findings from year 1 of “Accelerating Colorectal Cancer Screening through Implementation Science (ACCSIS) in Appalachia,” a 5-year, National Cancer Institute Cancer MoonshotSM-funded multilevel intervention (MLI) project to increase screening in Appalachian Kentucky and Ohio primary care clinics. Methods Project development was theory-driven and included the establishment of both an external Scientific Advisory Board and a Community Advisory Board to provide guidance in conducting formative activities in two Appalachian counties: one in Kentucky and one in Ohio. Activities included identifying and describing the study communities and primary care clinics, selecting appropriate evidence-based interventions (EBIs), and conducting a pilot test of MLI strategies addressing patient, provider, clinic, and community needs. Results Key informant interviews identified multiple barriers to CRC screening, including fear of screening, test results, and financial concerns (patient level); lack of time and competing priorities (provider level); lack of reminder or tracking systems and staff burden (clinic level); and cultural issues, societal norms, and transportation (community level). With this information, investigators then offered clinics a menu of EBIs and strategies to address barriers at each level. Clinics selected individually tailored MLIs, including improvement of patient education materials, provision of provider education (resulting in increased knowledge, p = .003), enhancement of electronic health record (EHR) systems and development of clinic screening protocols, and implementation of community CRC awareness events, all of which promoted stool-based screening (i.e., FIT or FIT-DNA). Variability among clinics, including differences in EHR systems, was the most salient barrier to EBI implementation, particularly in terms of tracking follow-up of positive screening results, whereas the development of clinic-wide screening protocols was found to promote fidelity to EBI components. Conclusions Lessons learned from year 1 included increased recognition of variability among the clinics and how they function, appreciation for clinic staff and provider workload, and development of strategies to utilize EHR systems. These findings necessitated a modification of study design for subsequent years. Trial registration Trial NCT04427527 is registered at https://clinicaltrials.gov and was registered on June 11, 2020.

The Rural Household Production of Health Approach: Applying Lessons from Zambia to Rural Cancer Disparities in the U.S.

“…It also complements current work being carried out in the U.S. that has strong backing from funding agencies, such as the National Institutes of Health. For example, an increasing number of rural cancer disparities researchers have turned to multi-level interventions to address cancer control at the individual, household, clinic/hospital, and community levels [ 46 ]. An HHPH approach fits such a model by acknowledging the connections and relations among these levels, including during times of dramatic change, such as during the COVID-19 pandemic, which has changed the resources available within households and household members’ mobility.…”

Video brochures in a mailed fecal immunochemical test outreach program provide cancer screening information in a user‐friendly format for rural Appalachian community members

“…Overall FIT return in this pilot study was less than other mailed FIT outreach programs that average a 28% absolute increase over usual care 12 . Potential reasons for the lower FIT return are cancer fatalism that has been documented in this population, 29 the Appalachian culture, and many other known social determinants of health that affect residents of this geographic region like lower educational attainment 30 . There are, however, potential strategies to optimize the components included in mailed FIT kits.…”

“…12 Potential reasons for the lower FIT return are cancer fatalism that has been documented in this population, 29 the Appalachian culture, and many other known social determinants of health that affect residents of this geographic region like lower educational attainment. 30 There are, however, potential strategies to optimize the components included in mailed FIT kits. Video brochures provide an opportunity to deliver targeted cancer screening information in a user-friendly format using a narrative that may increase cultural relevance to the population and may be important for individuals with limited health literacy.…”

Provision of colonoscopy in rural settings: A qualitative assessment of provider context, barriers, facilitators, and capacity

“…[17][18][19][20] Since insurance expansion alone is not sufficient to increase screening rates to meet national targets, 21,22 examining multilevel barriers to screening, including access, in rural areas more broadly can help inform efforts to increase screening rates and decrease inequities. 12,16,[23][24][25] The provision of colonoscopy in rural areas is likely to differ from that in urban settings, because of variation in who provides colonoscopy, geographic proximity to medical facilities, and patterns of referral to screening and treatment. 12,13,26,27 Notably, colonoscopy is effective as a primary screening method, but also is needed as a followup procedure after abnormal results from other types of screening, such as fecal immunochemical tests (FITs) or FIT-DNA tests.…”

“…While expanded Medicaid coverage through the Affordable Care Act has been associated with increased rates of CRC screening, this improvement has limiting factors, such as continued lower rates of access to primary and specialist providers for Medicaid compared to other insurance types 17–20 . Since insurance expansion alone is not sufficient to increase screening rates to meet national targets, 21,22 examining multilevel barriers to screening, including access, in rural areas more broadly can help inform efforts to increase screening rates and decrease inequities 12,16,23–25 …”