Table 2.

Categories, Themes, and Illustrative Quotes Obtained From Narratives of Clinic Personnel.

Categories/Themes	Illustrative Quotes
Individual (patient-level) factors Low awareness of colorectal cancer and the need for screening Psychosocial factors (fear/anxiety) Low-income, uninsured Testis perceived as unpleasant	“There is an element in the Hispanic population to a degree—you know, not recognizing that cancer caught early is curable.” (Registered nurse) “I think it’s the knowledge. I think if they knew what usually happens and what can cause, I think they would be more willing to do it versus not.” (Medical assistant) “… just sort of seems insurmountable to get the population of under 100% of poverty to think about going and paying for a colonoscopy.” (Physician) “Definitely the uninsured don’t get a colonoscopy, or I shouldn’t say “don’t get,” but it’s much harder for them to come up with the resources to go and get the test.” (Nurse practitioner)
Organizational factors Low patient adherence to referral to colonoscopy Conversion to fecal immunochemical testing may improve screening rates Providers have limited time Providers must address patients’ more acute concerns Limited clinic resources (panel sizes too large, unable to recruit/retain providers)	“I can think of 2 or 3 patients this year that I’ve referred and they’ve been set up for the initial consultation and then they either go to that and they don’t follow up or they don’t go that and those are patients with insurance.“ (Physician) “We are the clinic where people would come for quick care. We’re trying to follow people more than we’ve done in the past to do prevention, but we’ve really had to also put out fires for people to keep them out of the ER. We’re trying to do both, and that’s why our access is so tight.” Licensed practical nurse) “You know, it’s not particularly pleasant. It’s expensive. I think there’re just barriers, a lot of barriers.” (Physician)
External factors High cost of exam (colonoscopy) Limited access to follow-up colonoscopies ○ Limited number of facilities that provide colonoscopies ○ Facilities that provide colonoscopy rarely offer sliding fee scales ○ Limited community resources to pay for colonoscopies for the uninsured	“I hear a lot of frustration from doctors that want to have their patient have the colonoscopy and it’s just not happening. It’s really an expensive exam …” (Nurse practitioner) “Even if you have insurance … it takes about nine months for a routine colonoscopy in this community. Usually, to get a colonoscopy with any speed, you need some reason.” (Medical director) “People say, “What if I found something out? Then where would I be because I would never go get it treated? Why would I want to test knowing I would have to carry that burden, you know?” (Registered nurse—manager) “So, (one program) is helpful for colonoscopy for the very, very, very indigent. That’s a good thing. I don’t know of any other programs for colonoscopy.” (Registered nurse-manager)