Approaches to address common barriers to colorectal cancer screening in rural communities of the CDC’s colorectal cancer control program

Abstract

Introduction:

We identified potential approaches to address barriers to colorectal cancer (CRC) screening in rural communities of award recipients from the Centers for Disease Control and Prevention’s Colorectal Cancer Control Program (CRCCP).

Methods:

Nine program managers and directors discussed approaches to address barriers to CRC screening. The programs served areas with rural communities and tribal reservations. Participants participated in five monthly web-based meetings and completed questionnaires regarding the use and usefulness of approaches. We conducted two focus groups with award recipients’ partners to validate the approaches.

Results:

Participants indicated that patient reminders, small media, and translated materials were useful in increasing uptake. There were six approaches that all programs used and agreed were useful for providers, including creating standard operating procedures and promoting stool-based testing. There was more variation on usefulness at the health system level, but all programs used and agreed standing orders for stool-based tests were useful.

Discussion:

Through discussions, questionnaires, and focus groups with participants, we found that many of the approaches to overcoming barriers in rural areas focused on aiding patients in accessing screening and automating procedures to mitigate the impacts of staff and provider turnover. Further evaluation can determine effective, sustainable and cost-effective approaches.

Introduction

Colorectal cancer (CRC) screening is an evidence-based practice to prevent and detect CRC early. Among people aged 50–75 years in the United States, only 72% are up to date with CRC screening [1]. CRC screening uptake varies by race and ethnicity: 74.0% of White persons, 71.3% of Black persons, 62.6% of American Indian and Alaska Native persons, and 62.1% of people who report Hispanic ethnicity were up to date with CRC screening in 2021 [1]. There are also differences in screening among people living in urban and rural areas, as people living in metropolitan areas have a higher percentage of screening compared to nonmetropolitan areas (e.g. rural and frontier regions) [1]. Further, in terms of diagnosis and mortality, individuals living in rural counties are more likely to be diagnosed with late-stage CRC and have higher mortality from CRC, compared to individuals living in other geographic classifications [2,3].

Barriers to accessing primary health care and cancer preventive services are well documented in the literature [4,5]. These challenges include lack of providers (primary care and specialists), distance to and wait times for an appointment, cost and insurance coverage, and transportation. Although barriers to care are similar in metropolitan and nonmetropolitan areas, challenges are exacerbated by living in rural communities, which include frontier communities and tribal reservations (hereafter referred to as ‘rural communities’), with fewer primary care providers and cancer specialists, greater distance to an appointment, and fewer ways in which to travel to appointments [4,6–9].

In 2009 the Centers for Disease Control and Prevention (CDC) began the Colorectal Cancer Control Program (CRCCP), which focused on improving CRC screening uptake among people who were uninsured and underinsured, now between the ages of 45 and 75 years [10]. The CRCCP currently funds 35 award recipients, such as state health departments, universities, and tribal and other organizations, to partner with clinics and health systems to implement evidence-based interventions to encourage CRC screenings [11]. Evidence-based interventions are: patient and provider reminders, provider assessment and feedback, interventions that reduce structural barriers, and patient navigation. There are also support strategies, such as use of health information technology and enhancements to electronic health records and population tools. As a component of the evaluation of the CRCCP, CDC and RTI International (hereafter ‘the evaluation team’) brought together program managers and program directors of 9 CRCCP award recipients with programs that served areas with rural communities. The objectives were: to learn from CRCCP program managers and directors about barriers people in rural areas face in accessing CRC screening and follow-up colonoscopies; and to use a more quantitative approach to determine the perceived usefulness or effectiveness of the approaches they took to overcome the barriers. The lessons learned from these discussions could be scaled and used by other CRCCP award recipients and public health programs to overcome barriers and improve CRC screening in rural populations.

Methods

The evaluation team used a purposive sampling strategy to identify 9 CRCCP program managers and directors (Figure 1) to serve as discussants for this study (‘participants’). We chose 9 participants based on our previous work for CRCCP and the literature, which indicates that a sample size of 9 is sufficient to reach saturation in qualitative research [12–14]. The 9 CRCCP program managers were invited from the CRCCP Learning Collaborative, which is a subset of 21 CRCCP award recipients that we have worked with to conduct cost and effectiveness assessments on interventions they have implemented to increase CRC screening uptake. We asked participants to join because their populations of focus included rural communities and because of the participants’ ability to speak to their experiences with rural partners, health systems and health clinics, and communities in implementing CRC screening. (For reference, we added a map of all CRCCP recipients in Appendix A.) To recruit participants, the evaluation team emailed invitations containing a brief description of the evaluation and expectations for participants. All participants who were selected for the study agreed to participate in both phases of the study.

Figure 1.

Participants of CRCCP award recipients.

The evaluation team conducted this study using a 2-phase approach based on components from the Delphi method. The Delphi method is a systematic approach that involves discussions with experts with the goal to reach agreement about a particular topic using a structured and iterative process [15]. An overview of the phases is presented in Table 1.

Table 1.

Overview of study phases by participant and process.

Phase	Participant	Process
I	9 award recipients selected from a subset (the CRCCP Learning Collaborative) of 35 CRCCP award recipients	There were 5 meetings with different topics (e.g. multi-level approaches to barriers) discussed at each meeting.
		After each meeting we emailed the participants a questionnaire. The topics differed for each questionnaire and were based on approaches discussed during meetings. Participants responded to the questionnaires.
II	9 CRCCP award recipient partners (1 partner selected by each award recipient to participate) who were representatives of health systems/health clinics.	We reviewed the list of approaches generated during Phase I for partners’ consideration and validation.

Phase I

Monthly meetings

Participants took part in a multistep process between January and August 2023 to identify common barriers to CRC screening and identify potential approaches that can be adopted by rural communities to address common implementation barriers. The evaluation team conducted 5 monthly meetings with the participants. At the first meeting, the participants were presented with a list of barriers to CRC screening, which we drafted after reviewing the literature [9,16–20]. We encouraged participants to supplement the list of barriers and to remove any barriers they thought were not directly applicable to rural communities. We placed the list of barriers in Appendix B, which shows at the individual-, provider, and system – or societal-levels the initial barriers presented. We noted which barriers provided to participants that they agreed with, and which barriers were added by participants. During subsequent monthly meetings, the evaluation team presented barriers from the list the participants had generated and asked participants for input on the effectiveness of approaches that had been implemented to address these barriers. The approaches included those funded by CDC and by other agencies and organizations. All meetings were recorded using Zoom, and 2 members of the evaluation team reviewed and compiled the content for use in questionnaires.

After each monthly meeting the evaluation team identified all approaches discussed and developed a questionnaire for participants to respond to. The purpose of the questionnaires was to ascertain quantitatively which approaches participants used and whether the participants thought the approaches that they used were useful. The questionnaires contained an average of 17 questions (range: 12–20). First, the 9 participants were asked if clinics had implemented a particular approach that had been discussed during the meeting (e.g. Have sites within your program provided CRC screening reminders for patients?) with Yes/No response options. Understanding that there would be some degree of variability between clinics within the programs, participants were asked to respond based on what most clinics had in place. Using a 5-point Likert scale (from strongly disagree to strongly agree) participants were asked to indicate the usefulness of the approach for CRC screening uptake (e.g. ‘Providing CRC screening reminders for patients was a useful strategy or intervention’). The term ‘useful’ reflects the effectiveness of the approach utilizing terminology that was more familiar to the participants. All participants responded to each questionnaire. The evaluation team managed the data using Microsoft Excel, and the data was used for descriptive analysis.

Phase II

After the 5 monthly meetings were completed, the evaluation team conducted 2 60-minute focus groups via Zoom with nine CRCCP award recipient partners (e.g. health clinic representatives). The nine CRCCP award recipient partners were recommended by the participants. For ease of reference when reporting the results, the partners are also referred to as ‘participants.’ During these focus groups, the evaluation team reviewed the list of approaches generated during Phase I for partners’ consideration and validation. The focus groups also provided an opportunity for the evaluation team to ask additional clarifying questions regarding the use of the approaches and how these were implemented within clinics.

In this study, we report the barriers identified by the participants and the potential approaches, such as EBIs and support strategies, that can address the barriers to increase CRC screening in rural communities. Furthermore, we summarize the findings from the questionnaires and identify the proportion of the respondents who used a specific approach to address barriers. We also indicate the level of agreement that the approach implemented was useful in improving CRC screening. Findings from Phase II are incorporated into the results as well. The focus of the findings is on the effectiveness of single interventions based on feedback from both program managers and health system partners.

Ethics Approval RTI International’s institutional review board determined that this evaluation was not research involving human subjects. We received verbal consent from all participants.

Results

Barriers to CRC screening

During Phase I, participants reviewed a list of common barriers to CRC screening within rural communities and supplemented it where necessary (Table 2). Patient-level barriers to screening included a lack of interest or awareness in CRC screening. Patients’ lack of proximity to providers and lengthy wait times for colonoscopies were also frequently cited barriers. One participant explained that residents living in rural communities in their state routinely faced 120 miles of travel each way to reach the nearest colonoscopy site. Although one participant reported average wait times of only 2 weeks for a screening or follow-up colonoscopy, others shared that wait times ranged from 3–12 months. Even when providers and appointments were available, participants described the ways in which patients’ competing priorities could pose barriers to CRC screening:

[If an employed 49-year-old is] going to have a colonoscopy, [he has] to take time off of work for an office visit, another time off of work for a pre-op. [He has] to do the prep. So in this age group, you’re probably missing a ball game or missing something for your kids, or maybe you’re taking care of a parent or whatever. … That bowel prep is taking away from something else. And then [he has] to have a driver, so now not only [he] but also … [a spouse] or [his] friend. … So there’s a lot of barriers to a colonoscopy for a working person, and they [providers] just need to be reminded. In their [providers’] world, it’s an hour of time, so what’s the big deal? But they’re not thinking about everything that person has to do in order for that 1 h of time to be spent having a colonoscopy.

(Participant)

Provider-level barriers included a reluctance to distribute stool-based tests; participants stated this was because most stool-based tests must be repeated annually, require additional resources to ensure patient completion, and may be associated with perceptions that stool-based tests are less accurate compared with a colonoscopy. One participant explained that some providers describe colonoscopies as being ‘worth the wait’ and will only refer patients to colonoscopies. A general lack of provider recommendation for CRC screening during appointments posed challenges, along with the view that CRC screening is a low priority for providers relative to other patient needs.

Table 2.

Participant report of barriers and potential approaches to colorectal cancer screening in rural communities.

Level	Barriers	Potential approaches
Individual	Lack of knowledge or awareness about the importance of CRC screening	Use or create a patient decision support tool. Use patient navigators to promote CRC screening. Develop small media (e.g. videos, pamphlets, newsletters).
	Financial constraints (e.g. having to pay out of pocket because insurance won’t cover procedure)	Partner with endoscopists to acquire free or low-cost colonoscopies.
	Language barriers in some patient groups	Ensure that patient materials are available in patients’ primary languages Provide access to translation services.
	Lack of transportation	Provide transportation to colonoscopies. Identify or recruit patient escorts who can attend colonoscopies. Use patient navigators to address structural barriers.
Provider	Provider reluctance to administer stool-based testing	Promote use of stool-based testing (e.g. contests, education). Offer provider education (e.g. workshops, CME courses).
	Lack of provider recommendation for CRC screening	Use provider reminders. Offer provider education from an internal source (e.g. another provider). Offer provider education from an external source (e.g. medical liaison). Use provider assessment and feedback. Review patient charts to identify those in need of screening. Establish standing orders for CRC screening. Conduct chart audits/reviews to identify patients in need of screening.
	Lower relative priority of CRC screening	Identify a provider champion.
Organization or System	Provider shortages	Use an itinerant provider (e.g. independent gastrointestinal provider, endoscopist).
	Provider time constraints during appointments	Refine existing clinical workflows. Formalize a protocol or standard operating procedures for CRC screening. Use other clinical staff to provide patient education. Provide financial compensation for staff time to prioritize CRC screening.
	Loss to follow-up after positive stool-based test	Use patient reminders (e.g. calls, texts, emails). Manually extract data to track CRC screening results. Manually extract data to track patients from the time of an abnormal stool-based test to follow-up colonoscopy results. Create systems to track other CRC screening data not captured in EHRs. Create systems to track other follow-up colonoscopy data not captured in EHRs.
	Challenges related to EHR use (e.g. software updates, interoperability between different systems)	Educate providers on using EHR systems. Access or provide technical assistance to staff members using EHR.

Abbreviations: CRC = colorectal cancer; CME = continuing medical education; EHR = electronic health record.

Participants reported organizational – or system-level barriers, such as provider shortages, provider time constraints during appointments, and patient loss to follow-up after positive stool-based testing. Technology was a pervasive system-level barrier, with participants describing challenges learning and operating multiple electronic health record (EHR) systems across health systems, as well as limited ability to identify and track patients from CRC screening through treatment.

Lastly, another barrier participants discussed was the impact of social determinants of health on CRC screening:

Like if they can’t put food on their table, … [CRC screening] may not be a top priority for them if they’re struggling to eat and just live their life.

(Participant)

Participants also described how poverty, a structural barrier participants felt powerless against, exacerbated barriers to CRC screening:

More than transportation [as a barrier], it’s just overall poverty. I mean … we’re the largest city within 60 miles around, and we have a 30% poverty level. It’s just incredibly difficult. … To me, … one of the biggest challenges is all of the things that poverty brings.

(Participant)

Approaches

Approaches to barriers that participants discussed are shown in Table 2. The barriers were used to create questionnaires after each discussion. Table 3 shows the questionnaire results from the 9 participants in the 5 monthly interviews. In the questionnaires, we asked whether the participants’ partners used an implementation strategy and about its perceived usefulness. The results are separated by patient-, provider-, and organizational-level approaches.

Table 3.

Participant report of multilevel approaches to colorectal cancer screening in rural communities within partner clinics.

Approaches	Participants who implemented the approach CSBARLINE N (%)	Agreed or strongly agreed that the approach was useful (among those who implemented the strategy) CSBARLINE N (%)
Patient-level approaches
Use patient reminders (e.g. calls, texts, emails)	9 (100)	9 (100)
Develop small media (e.g. videos, pamphlets, newsletters)	9 (100)	9 (100)
Ensure that patient materials are available in patients’ primary languages	9 (100)	9 (100)
Provide access to translation services	7 (78)	7 (100)
Use or create a patient decision support tool	7 (78)	5 (71)
Use patient navigators to promote CRC screening	6 (67)	6 (100)
Use patient navigators to address structural barriers	6 (67)	6 (100)
Partner with endoscopists to acquire free or low-cost colonoscopies	6 (67)	6 (100)
Provide transportation to colonoscopies	4 (44)	3 (75)
Identify or recruit patient escorts who can attend colonoscopies	2 (22)	1 (50)
Provider-Level Approaches
Formalize a protocol or standard operating procedures for CRC screening	9 (100)	9 (100)
Use other clinical staff to provide patient education	9 (100)	9 (100)
Promote use of stool-based testing (e.g. education, contests)	9 (100)	9 (100)
Use provider assessment and feedback	9 (100)	9 (100)
Use provider reminders	9 (100)	9 (100)
Identify a provider champion	8 (89)	8 (100)
Offer provider education from an internal source (e.g. another provider)	8 (89)	8 (100)
Offer provider education from an external source (e.g. medical liaison)	7 (78)	7 (100)
Use itinerant providers (e.g. independent gastrointestinal provider, endoscopist)	1 (12)	1 (100)
Organization – or System-Level Approaches
Establish standing orders for CRC screening	9 (100)	9 (100)
Review patient charts to identify those in need of screening	9 (100)	9 (100)
Access or provide technical assistance to staff members using EHR	9 (100)	8 (89)
Educate providers on using EHR systems	8 (89)	8 (100)
Provide financial compensation for staff time to prioritize CRC screening	8 (89)	8 (100)
Refine existing clinical workflows	8 (89)	8 (100)
Create systems to track other CRC screening data not captured in EHRs	7 (78)	4 (57)
Manually extract data to track CRC screening results	7 (78)	4 (57)
Manually extract data to track patients from the time of an abnormal stool-based test to follow-up colonoscopy results	6 (67)	3 (50)
Create systems to track other follow-up colonoscopy data not captured in EHRs	6 (67)	5 (83)
Promote CRC screening outside of clinic visits (e.g. community events)	6 (67)	5 (83)

Abbreviations: CRC, colorectal cancer; EHR, electronic health record.

Note: Only participants who used the approach were asked whether the approach was useful.

Individual-level approaches: Each participant described how their clinics had utilized patient reminders, usually through a combination of calls, texts, or mailings, to encourage patients to schedule and attend appointments after positive screenings. Each of these participants also agreed or strongly agreed that the approach was useful. Every participant provided examples of clinics creating small media to promote screening (e.g. showing informational videos on CRC screening in waiting rooms, disseminating educational flyers or brochures during community events) and utilizing patient reminders. Additionally, each participant agreed or strongly agreed that these approaches were useful when implemented.

All participants described efforts to provide educational materials in patients’ primary language, which sometimes involved translating existing materials or creating new materials. Most participants reported providing access to translation resources, and of those participants, each one described this as a useful approach. One participant shared how a clinic employed 2 patient navigators to bridge language and cultural barriers with native Marshallese speakers:

I think it goes back to the navigator being that trusted liaison and representing the community. … In one clinic, they hired 2 Marshallese native speakers, and that’s been one way to relate to the Marshallese population and establish trust through this process. And then along the lines of standard translation services, offering materials in a reading level, in a language that meets the patients. You know, those are all standard things, but, yeah, definitely, I feel like we need a push – more ideas on what else to do.

(Participant)

Nearly 80% of participants reported using decision support tools within their clinics. Of those participants, most identified the use of decision support tools as a feasible approach for informing patients about CRC screening options without placing additional burdens or time constraints on providers:

Some of our clinics have developed a decision support tool that outlines the different screening options, cost, timeframe for screening—any prep that’s needed … and they will give that to the patient in the exam room or in the waiting room to provide that background information about screening to help them have an informed discussion with the physician.

(Participant)

The use of patient navigators to promote CRC screening was implemented in two-thirds of clinics. Each of the participants from those clinics reported that the approach was useful. Participants described other approaches to mitigate the effects of structural barriers. For example, roughly two-thirds of participants had partnered with endoscopists to acquire free or low-cost colonoscopies for patients experiencing financial barriers. To address transportation barriers, some participants reported providing transportation assistance for patients (e.g. gas cards), identifying people who could escort patients to and from colonoscopies, or enlisting the guidance of patient navigators to coordinate community resources. One participant indicated that their program used UberHealth to help transport patients home after a colonoscopy; however, a medical escort was still needed. When the program tried to find medical escorts, the people they found were unreliable and the program was, ‘back to zero and starting over.’

Provider-level approaches: Several provider-level app roaches were both commonly used and unanimously described as useful: utilizing provider reminders, formalizing protocols or standardizing operating procedures, promoting the use of stool-based testing, and using provider assessment and feedback to improve CRC screening uptake.

The implementation of provider reminders differed across clinics, ranging from EHR notifications to colorful stickers on patient charts to in-person reminders during providers’ daily huddles. Participants explained how these reminders were intended to prompt physicians to recommend CRC screening and described the importance of the recommendations:

I think that it’s really important that the provider—physician or NP [nurse practitioner] or PA [physician assistant]—really recommend the screening because the patients will tune into them. … Sometimes, again, the providers need reminders, and so we’ve developed a mechanism in some of our clinics where they’ll go through all the patients for that day and know which ones need to be screened … so that the providers can be flagged so that they can mention it to the patients.

(Participant)

Participants also shared a myriad of approaches to promote the use of stool-based testing, such as providing education regarding test accuracy, particularly compared with colonoscopies. One participant shared that she often reminds providers that colonoscopy is not the only way to screen for CRC; she added, ‘The best test is the one that gets done.’

Nearly all participants reported identifying a provider champion to work to make CRC screening more of a priority for providers. Of those who had identified provider champions, each participant described the approach as useful.

Finally, participants identified approaches aimed at increasing the supply of providers in rural communities. Participants described the benefits of providing a way for providers to restructure their medical school debt and offering sign-on and referral bonuses to recruit additional providers to rural communities. However, it is worth noting that these approaches, while relevant, cannot be implemented by CRCCP, so these were not included in the list of potential approaches.

Organizational – or system-level approaches: Many participants discussed adapting organizational infrastructure to address system-level barriers, including time constraints during appointments and technology issues. Each participant reported that clinics had created standard operating procedures to improve the uptake of CRC screening and indicated that it had been a useful approach. Most participants shared that clinics had refined existing clinical workflows, and each one reported that it had been a useful approach. In some instances, this involved other clinical staff speaking with patients about CRC screening or distributing stool-based kits before the provider entered the exam room.

Several approaches involved working to overcome technological barriers and resulted in technical assistance and education for clinical staff being provided:

I would say that one of the challenges we face in some of our clinics is that they don’t have the technical knowledge … . They don’t have an IT specialist or an EHR analyst on their staff, so they’re having to learn how to do things as we go. And we have staff people who have been given permission to actually have an account and access into their EHR system so that they can look around, help navigate, help them become equipped to use their EHR better.

(Participant)

Each participant reported seeking technical assistance for their EHRs outside of their organization and reported high levels of usefulness from the approach. To provide technical assistance, other participants educated a single staff member on EHR use, who then served as a point person for EHR navigation within the organization.

At the organization level, most participants reported hosting low-stakes, friendly competitions and providing incentives and inexpensive awards within clinics to encourage provider recommendation and distribution of stool-based tests. To mitigate loss to follow-up for patients, participants described the process of manually extracting EHR data to track CRC screening results, as well as patient data between a positive stool-based test and a follow-up colonoscopy. However, of those participants who had manually extracted EHR data, only about half reported that it had been a useful approach for tracking CRC screening results and even a smaller number reported that it was useful for tracking follow-up colonoscopies.

Participants reported that they were often unable to address system-level structural barriers to CRC screening with grant funds and that there were issues that they could not help with. For example:

We can try with patient navigation and support to overcome barriers, but there’s just a lot of barriers that we just can’t directly assist with … . Like if they wake up that morning and their car doesn’t start and we just didn’t know about that and they don’t have the funds to repair it—We can give them a gas card, or we can help with, like some transportation. But in the rural areas, there’s not buses. … They almost have to have a functioning car.

(Participant)

Discussion

Our objectives for this study were to learn from participants, who are a part of the CDC’s CRCCP, about common barriers to CRC screening among that populations living in rural communities encounter, and to learn about participants’ experiences in implementing approaches to overcome these barriers. As an unintended benefit, participants also learned from each other about different strategies that help overcome various challenges. At the patient level, the evaluation team heard that individuals may lack knowledge about the importance of CRC screening; may face financial constraints in affording screening and, if necessary, follow-up colonoscopy; and may need assistance with obtaining translated materials into their primary language. Providers may not recommend CRC screening to patients if patients have higher priority needs, such as comorbidities that require attention, and physicians may only recommend colonoscopy instead of stool-based test options. At the organizational level there are staff shortages and technical assistance needed for working with EHRs and health population tools in order to provide reminders, identify patients eligible for screening, and track screening results. Urban and rural areas have similar barriers, but some of these are exacerbated in rural areas, especially at the patient-level due to long travel distances and at the organization – and system-levels with staff shortages and lack of providers [6,7].

Across patient-level approaches, most participants agreed that if an approach was used, it was generally helpful. CRCCP participants related that their partners used the evidence-based intervention recommended by the Community Guide [21] of patient reminders, and all either agreed or strongly agreed that these interventions were helpful. Although distance to the health centers was cited as a barrier by the participants, less than half (4 of 9) reported that they assisted patients with transportation and only 3 of 4 found transportation support useful. Clinics may not be able to offer this assistance because they may not have the resources and staff capacity for it.

Most participants’ partners used patient navigators to both promote CRC screening and to help patients navigate structural barriers, such as helping to translate and interpret information and transportation. All participants whose partners used navigators indicated that they agreed or strongly agreed that the navigators were helpful. Previous studies have indicated the impact of patient navigators in improving CRC screening as well as follow-up colonoscopy after a positive stool-based test [22,23]. Use of navigators is also consistent with the recommendation of the Community Preventive Services Task Force, which endorses the use of patient navigators ‘for historically disadvantaged racial and ethnic populations and people with lower incomes’ to increase CRC screening in addition to breast and cervical cancer screening [21].

Participants noted that one substantial challenge in the rural communities was poverty. Data indicate that approximately 15.4% of people living in nonmetropolitan areas live in poverty compared with 11.9% of people living in metro areas [24]. This percentage can vary widely by race and ethnicity as well as geographic areas within the United States. According to the participants, poverty affects all aspects of a person’s life, such that CRC screening might not rise to a level of importance in comparison with social determinants of health like food insecurity, employment, and transportation. Participants indicated that it was often the efforts of patient navigators and community health workers, as well as clinic staff and providers, to educate patients and encourage them to be screened. Patient navigators, like community health workers [25], also acted as the linkages between health clinics and community organizations that help to provide patient support.

Of the 9 provider-level approaches participants reported, there were 6 that all participants indicated their partners implemented and found useful. All used approaches recommended in the Community Guide of provider assessment and feedback and provider reminders [26]. Furthermore, the approaches partners implemented included the use of a protocol or standard operating procedure for CRC screening and the promotion of stool-based testing. These approaches help lessen the impact of staff turnover. In addition, all participants indicated that their partners promoted the use of stool-based testing. Stool-based tests can be completed at a time that is convenient for the person, require little preparation, and take only a short amount of time to complete. Mailed FIT (fecal immunochemical test) programs, where FIT kits are mailed to patients and patients return completed kits to the health centers or the laboratories for processing, have also been shown as a viable CRC screening option [27–29]. In addition, having pharmacists educate individuals and distribute FIT kits might also be an alternative [30,31], particularly given the growth of pharmacies in grocery and big-box stores. Community-based participatory approaches have been recommended as a potential solution to encourage the use of stool-based tests in rural communities [28].

Even though the participants implemented many provider-level approaches and found them useful, challenges remain. The shortage of providers in rural communities, along with high staff turnover, was reported by participants as a barrier to CRC screening as well. Compared with physicians in metropolitan areas, there are fewer physicians in nonmetropolitan areas, and physicians in rural communities are also older than their metropolitan counterparts [32,33]. Overall, physician retirement and demand for primary and specialty care are all expected to increase [34], and this is likely to exacerbate gaps in access to care in rural communities. Further, rural areas often depend on international medical graduates (IMGs) to supplement the number of physicians providing care; however, IMGs may face immigration challenges that affect their ability to practice [35–37]. This is a very brief overview of provider supply issues. Policy changes proposed in the literature include: incentivizing providers to practice specifically in rural areas and remain there: student loan forgiveness and repayment programs [38,39]; increasing compensation [37]; restructuring of graduate medical education [38] and IMG policy [35]; and a focus in medical schools and residency programs on the importance of practicing in areas that are medically underserved [38,40].

There was less agreement on approaches implemented and their usefulness across the organization and system level when compared with patient – and provider-level approaches. Establishing standard operating procedures was the one approach that all participants employed and agreed was useful. All participants indicated their partners had access to EHRs. However, not all participants reported that their partners used EHRs to track screening or follow-up colonoscopies, and fewer agreed that extraction of the data was helpful. This finding might be due to participants’ and partners’ lack of familiarity with all the functions of the various EHRs and with population health tools. Support and resources to provide teaching and technical support for health information technology may not be available in small and rural clinics. This shortcoming may hinder the ability of partners and participants to identify patients for screening, assist patients through the screening continuum, and report outcomes. Both the participants and health systems/health clinics required informatics technical assistance to optimize use of EHRs for CRC screening.

There were several limitations to this study. First, participants were invited and volunteered to take part, so they may not be a representative sample of all rural communities. The one criterion that applied to their selection was that their CRCCP participants population of focus included rural communities; we did not speak directly with representatives of rural health systems. Second, due to the selection process, the findings from this study cannot be generalized or more broadly attributed to all rural communities. Third, our study was mostly qualitative, so the findings are based on themes and on the perspectives shared by participants during the meetings and focus groups. Fourth, there may be barriers within rural communities that were not captured in this study. Lastly, although the participants may have all agreed that a particular implementation approach was helpful, the evaluation team was unable to determine whether the approach was effective in real-world practice. Furthermore, we were not able to assess the effectiveness of multiple interventions that were delivered as part of multicomponent programs.

During the study the participants described the challenges of their partners serving rural communities experience, as well as approaches partners implemented to promote CRC screening in rural communities. Our findings present the key barriers of a sample of CRCCP award recipients and interventions that they have tried and that they have found useful to help improve CRC screening in their rural populations. The barriers identified in this study are reflected in the existing literature on challenges of implementing screening in rural settings [4–7,9], but our findings expand on prior studies to identify interventions that can be implemented to address the barriers. Our findings do indicate that a combination of individual-, provider-, and system-level approaches are considered helpful in addressing common barriers to CRC screening. Examples of approaches that were found useful at the patient level included patient reminders and small media, especially when translated into patients’ primary language. At the provider level, having non-physician providers educate patients about CRC screening and having all providers promote stool-based tests were useful; and implementing standing orders and chart reviews for patients due for CRC screening were useful at the organization/system-level. Our findings also show a few interventions, such as the use of transportation assistance and health information technology, where the CRCCP award recipients either did not use, or did use and did not find useful. Innovative approaches to solve transportation barriers are required in rural areas and rural clinics need support to improve use of EHR for tracking screening process steps. Further evaluation can determine which approaches are indeed effective, as well as sustainable and cost-effective, in rural communities in order to assist CRCCP award recipients and others involved in promoting CRC screening in determining which interventions to implement.

Supplementary Material

Supplemental data for this article can be accessed at https://doi.org/10.1080/28322134.2025.2504900.