A qualitative study of patient preferences for prompts and reminders for a direct-mail fecal testing program

Abstract

Programs that directly mail fecal immunochemical tests (FIT) to patients can increase colorectal cancer (CRC) screening, especially in low-income and Latino populations. Few studies have explored patient reactions to prompts or reminders that accompany such programs. As part of the Participatory Research to Advance Colon Cancer Prevention pilot study, which tested prompts and reminders to a direct-mail FIT program in a large, urban health center, we conducted telephone interviews among English- and Spanish-speaking participants who were assigned to receive a series of text message prompts, automated phone call reminders, and/or live phone call reminders. We analyzed interviews using a qualitative content analysis approach. We interviewed 41 participants, including 25 responders (61%) and 16 nonresponders (39%) to the direct-mail program. Participants appreciated program ease and convenience. Few participants recalled receiving prompts or automated/live reminders; nevertheless, the vast majority (95%, n = 39) thought reminders were acceptable and helpful and suggested that 2–3 reminders delivered starting 1 week after the mailed FIT would optimally encourage completion. Prompts and reminders used with mailed-FIT programs are accepted by patients, and my help boost response rates.

Implications.

Practice: Prompts and timely automated/live reminders associated with mailed fecal immunochemical test (FIT) programs are appreciated by patients and can boost response rates, particularly in delayed responders.

Policy: To optimize the effectiveness of mailed FIT programs, policymakers should advocate for funding to cover kit distribution, as well as premailing and postmailing outreach.

Research: Future research is needed to determine how to best scale mailed FIT programs and to identify strategies that support FIT completion in never responders.

INTRODUCTION

Cancers of the colon and rectum are among the most common types of cancer and a leading cause of cancer mortality in the USA [1]. Colorectal cancer (CRC) is highly preventable with guideline-concordant screening in adults aged 50–75 using endoscopic or fecal testing options [2, 3]. Although strides have been made to increase CRC screening among age-eligible adults [4, 5], screening disparities persist in federally qualified health centers (FQHCs) and low-income, ethnically diverse patients [2, 6–8]. Fecal testing is often the preferred screening modality in populations experiencing low screening rates [9, 10].

Research shows that population-outreach strategies—those that engage patients in homes or communities rather than exclusively during scheduled clinic visits [11] (Davis et al., unpublished data)—are among the most effective strategies to increase cancer screening [12–14]. A highly effective population-outreach strategy for CRC screening is to directly mail fecal immunochemical test (FIT) to a patients’ home (direct mail), which may also serve to reduce screening disparities [15–20]. Direct-mail programs are a multicomponent intervention that combines strategies to increase community demand (e.g., client reminders and small media), community access (e.g., reduce structural barriers), and provider delivery of services [16, 21]. While recent systematic reviews demonstrate the effectiveness of direct-mail programs on CRC screening, FIT kit return rates in these studies vary widely—from 3.9% to 44.9% [16, 17].

Variation in the effectiveness of direct-mail programs are likely due in part to the clinical and structural context in which programs are implemented, characteristics of the target population, prior exposure to FIT, and the timing, intensity, and modality (e.g., text message, phone call, and letter) of the premailing prompts and postmailing reminders used [19, 22, 23]. Using pilot data from the Participatory Research to Advance Colon Cancer Prevention (PROMPT) study, our team previously reported higher FIT completion rates among adults assigned to receive live phone call reminders (32.3%) or the combination of automated and live prompts/call reminders (35.7%) compared to adults who received only automated prompts/reminders (26%) [24]. While prompts and reminders can boost CRC screening uptake, few studies examine how patients perceive these reminders [16] or focus on the experiences of nonresponders or disadvantaged groups [23]. Such research is needed to inform refinements to population-outreach programs, including direct-mailed FIT so that prompts and reminders are optimized to encourage completion by subgroups within (e.g., never screened and complex patients).

The present analysis explores patient experiences and preferences in response to the frequency, timing, and modality of the prompts and reminders used in PROMPT. PROMPT is a pragmatic trial within a large, urban FQHC. PROMPT is designed to compare the effectiveness of direct-mail FIT programs when optimized to include prompts and reminders, whose content and format were informed by patients [25, 26]. Our qualitative analysis explored patients’ reactions to the direct-mail program overall and to the prompts and reminders delivered during the study’s pilot phase.

METHODS

Study site and pilot background

PROMPT is being conducted in partnership with a large independent FQHC in Southern California using participatory research methods [25]. In 2017, the FHQC operated 27 medical clinics that served over 280,000 patients. The majority of the FQHC’s patients are Latino (82%); 40% of these Latino patients prefer speaking Spanish.

The first stage of PROMPT employed a patient engagement approach, known as boot camp translation (BCT), to aid in the development of content and selection of formats for patient-facing mailing materials, text message prompts, and automated and live phone call reminders for the study [26, 27]. The second stage focused on implementing the reminder pilot interventions in two of the FQHC’s larger primary care clinics; details of the pilot study are provided elsewhere and briefly summarized here [24]. Based on feedback from the BCT process, the pilot study involved delivering a direct-mail FIT outreach program to age-eligible adults identified by electronic medical records as overdue for CRC screening and randomized to receive either: (a) automated prompts and reminders only, (b) live reminder calls only, or (c) combined automated prompts/reminders plus live reminder calls. As summarized in Fig. 1, patients in all three intervention arms were mailed a FIT with an introductory letter and one-page educational sheet. The FIT used was InSure (Clinical Genomics; Bridgewater, NJ), a two-specimen FIT that requires no dietary restrictions. Patients in the automated-only arm were sent a text message prompt (before the patient was expected to receive the kit) and two automated phone call reminders approximately 1 week apart. For patients in the live-only arm, centralized clinic outreach staff delivered a single live phone call reminder starting 2 weeks after the FIT was mailed; staff made up to three call attempts if they were unable to reach the patient, with each attempt separated by approximately 1 week. Patients in the combined automated and live arm were sent the text message prompt, two automated phone calls, and one live phone call reminder (three total attempts), delivered on the same schedule as the automated and live arms. All mailed materials (e.g., introductory letter and educational sheet) were two sided, with one side in English and the other side in Spanish. Automated and live reminder phone calls were delivered in English or Spanish (depending on the patients’ language indicated in the medical record). Details and outcomes of the pilot study, showing FIT completion rates of 26.0%, 32.3%, and 35.7% in patients assigned to the automated-only, live-only, and automated plus live conditions have been previously reported [24].

Fig 1.

Participatory Research to Advance Colon Cancer Prevention pilot intervention groups.

Participants and recruitment

Our goal was to interview a purposive sample of 45 patients exposed to the pilot study. We aimed to interview approximately 30 responders (those who returned an FIT 6 months after the mailing and reminders) and 15 nonresponders (those that had not returned an FIT 6 months after the mailing and reminders). We chose to oversample responders with the goal of obtaining feedback on the acceptability of and reaction to the content, format, and timing of the various prompts and reminders being tested. Centralized FQHC staff generated a list of responders and nonresponders representative of both pilot clinics, all three intervention arms, and English-language (EL) and Spanish-language (SL) patients. Study staff mailed recruitment letters to 221 responders (86 EL patients and 135 SL patients) and 235 nonresponders (145 EL patients and 90 SL patients) followed by a phone call to recruit and book a telephone interview. Patients were verbally consented to participate; all were mailed a $20 gift card after the completion of the interview.

Data collection and analysis

Based on prior literature [28–30] and the experience of the research team, we developed a semistructured, open-ended interview guide. The guide explored general awareness of CRC screening methods, prior screening history, general barriers, and facilitators to CRC screening, receipt and reaction to the PROMPT program and related reminders, reasons for completing or not the FIT kit, and suggestions for improving the program. Telephone interviews conducted by staff trained in qualitative methods lasted about 30–45 min and were conducted from February to June 2018. All interview procedures and materials were reviewed and approved by the institutional review board with ceding agreements.

Interviews were audio-recorded with permission from the participant and transcribed verbatim by an independent transcriptionist. Patient interviews conducted in Spanish (by a trained bilingual/bicultural interviewer) were also transcribed in Spanish to ensure we accurately conveyed the true meaning of the patient’s experience while at the same time ensuring the reliability of the data. Transcripts were entered into Atlas.ti, a qualitative analysis software program used to electronically code and manage data and generate reports of coded text for ongoing thematic analysis [31, 32]. Patient transcripts were coded by trained coders who worked closely together to attain internal consistencies in coding and interpretation of data. Spanish-language transcripts were coded and reviewed by two bilingual coders to facilitate understanding (e.g., regional and cultural variations and slang terms). We used a qualitative content analysis approach using open-coding techniques [31–33] to summarize interview data. First, a coding dictionary was developed by having each member of the analysis team read several transcripts and mark passages of text with codes indicating its content. Codes could denote questions posed to the interview participants during the discussion (e.g., barriers of the program), while others represented issues that emerged during the discussions (e.g., feelings of surprise about the program). The team compared coding notes, discussed areas of disagreement within and between the EL and SL transcripts, and together developed a coding scheme for use with all subsequent transcripts.

Coded text was subsequently reviewed by the analysis team through an iterative process to identify themes. First, two members of the study team produced analytic summaries, which were used to identify preliminary themes for EL and SL participants. A second pass of the data was made to explore and compare variation within each thematic category by respondent type (responder and nonresponder). It was in this pass that we realized the need to separate nonresponders to the direct-mail FIT program into two categories: those who later reported completing an FIT given to them during a scheduled clinic visit (delayed responders) and those who had not yet completed the FIT (never responders). To monitor and illustrate similarities and differences between the three participant groups (responders, delayed responders, and never responders) and by preferred language (SL and EL) our team quantified certain elements from the qualitative data by counting the number of participants that reported certain behaviors, prior knowledge, or preferences toward CRC screening reminders and prompts [34, 35]. We shared preliminary themes with the larger study team and the PROMPT steering committee (which includes clinical partners) for peer review [36, 37]; this feedback was incorporated into our interpretation of the final themes presented in this manuscript.

RESULTS

We conducted interviews with a total of 41 participants—including 25 responders (61%) and 16 nonresponders (39%) to the direct-mail program; see Table 1. Three-fourths of participants were female (76%, n = 31); most had been receiving care at the FQHC for 5 years or less (73%, n = 30) and the majority were active clinic patients at the time of the interview (95%, n = 39). Both respondents and nonrespondents were equally distributed across the three pilot intervention arms. At the time of the interview (6–8 months after FIT mailing), 27 of the 41 participants (66%) recalled receiving an FIT through the direct-mail program; these include 96% of the responders (n = 24/25) compared to 19% of the nonresponders (n = 3/16). Thirteen of the 16 nonresponders (81%) did not recall receiving an FIT in the mail—but they described recently receiving an FIT from their clinic. Nine of the 16 initial nonresponders indicated that they had recently completed and returned an FIT received from their clinic (delayed responders, 56%) and 7 reported that they had not yet completed the FIT (never responders, 44%).

Table 1.

Characteristics of direct-mail (DM) interview participants (N = 41)

		DM nonresponder (n = 16)*
	DM responder (n = 25)	Delayed responders (n = 9)	Never responders (n = 7)	Totals (N = 41)
Gender
Female	20	7	4	31
Male	5	2	3	10
Primary language
Spanish	13	6	1	20
English	12	3	6	21
Currently receives care at clinic
Yes	25	7	7	39
No	0	2	0	2
Years receiving care at clinic
0–5 years	18	9	3	30
6 year or more	7	0	4	11
Pilot intervention arm
Auto only	8	3	2	13
Live only	9	2	3	14
Combined auto/live	8	4	2	14

*Based on clinic-level data, 16 participants had not returned their fecal immunochemical test (FIT) 6 months following the mailing (nonresponders). Interviews were conducted 6–8 months after the mailing. During these interviews, nine nonresponders reported recently returning an FIT kit to the clinic (delayed responders) and seven reported they had yet to complete an FIT (never responders).

Over half (56%, n = 23) of all participants described knowing that CRC was preventable and could be detected early with screening. However, 66% (n = 27) noted that screening was scary because it elicited thoughts about life and death. Overall, two out of three participants interviewed (66%, n = 27) reported prior experience completing a FIT; 32% (n = 13) reported prior experience with colonoscopy. Of those who reported past FIT completion, SL participants (37%, n = 10) and nonresponders (33%, n = 9) were less likely to report previous FIT screening than EL participants (63%, n = 17) or responders (66%, n = 18). Across responders and nonresponders, factors identified as influencing CRC screening were: primary care provider (PCP) recommendations (78%, n = 32), friend and family encouragement (49%, n = 20), and personal agency in relation to staying healthy (20%, n = 8). Of these factors, responders strongly endorsed encouragement from family and friends (75%, n = 15) and PCP discussion/recommendation (63%, n = 20) as motivators to complete CRC screening.

Responses to the direct-mail program

Among responders (n = 25), the majority completed the FIT within 2 weeks of receiving the mailing (84%, n = 21/25). Four responders reported taking months to complete the FIT due to “procrastination” or “forgetfulness”; these individuals noted that the reminders to the direct-mail program were helpful in getting them to complete the screening. One-half of the EL responders (n = 6/12) and none of the SL responders (n = 0/13) had prior experience completing an FIT.

Direct-mail program respondents generally returned their FIT by mail (80%, n = 20/25), although five reported a preference for returning the completed test to the clinic directly. One SL responder noted, “I like it because it comes to my house and I do not have to go to the clinic…if people do not do it in their house, it’s a lot of laziness.” The following quote from an EL responder further illustrates perceived program ease:

It was my first time [completing a FIT], and I thought it was fine…it was easy. I didn't have to waste time going down to a doctor. I didn’t have to fight with somebody on the phone… I would say continue [with the program]. I value my health and my life (EL responder).

Overall, nonresponders (n = 16) reported the following barriers to timely FIT completion through the direct-mail program: lack of recall of receiving the FIT by mail, procrastination, wanting additional clarification from the clinic on how to complete or label the kit, and/or not being aware that the FIT expired (a subset of patients were asked to repeat an FIT because kits near or at their expiration data were mailed). These factors were reported by both delayed responders and never responders. However, the never responders identified additional challenges to FIT completion, such as no prior experience completing FIT (n = 4), other health conditions that took precedence (n = 4), ignoring the test or pushing it off to “do it later” (n = 4), or feeling the test was “too much work,” “too messy,” or had “too many steps involved” (n = 3). Two never responders also reported concerns about cost or lack of coverage.

It was the instructions itself on how to do it and then what information to write on there and what not to write on there that was a little confusing. Actually, that was the most confusing part…because the form had a place for me to write everything down. And then on the little stool kit it had everything written down again…what the heck am I supposed to be filling in on this form? I don't understand what to do (EL delayed responder).

I think if I knew that it wasn’t as complicated [FIT kit]…the packaging is a little thick, you know what I mean? And there’s a lot of paperwork, you know a lot of reading material…So if you tend to procrastinate like myself then you haven’t lived up to the bargain or responsibility in getting it in (EL never responder).

Facilitators to FIT Completion

As summarized in Fig. 2, the majority of EL and SL responders (92%, n = 23) appreciated the ease, privacy, and efficiency of completing the FIT by mail. As one SL participant noted, "[Completing a FIT] was marvelous. I could not believe that it was so easy, so clean, neat, and it cost me nothing." Both EL and SL responders also reported feeling “cared for” by their clinic because of the direct-mail program and clinic outreach as illustrated in the following quote:

Fig 2.

Facilitators for fecal immunochemical test completion by responders (n = 25) and delayed responders* (n = 9).

It is a very big help, that they continue to have more information, that they continue to take us into account, for me it would be very good ... And well, that they continue to worry about us, it’s nice that they take us into account ... (SL responder).

Additionally, EL responders identified the need for screening because of one’s age, the potential threat of cancer, encouragement from their PCP and prior experience/familiarity with the FIT as important factors motivating timely test completion. Some EL responders described having “systems” at home for completing the FIT and were eager to share their current and past strategies to support timely and thorough test completion as illustrated in the following comment:

It's always the same…the paperwork that comes. And the little card and everything is all the same. And, it's pretty simple... As far doing it… it's all basically filled out for me. I just got to put my dates on my bowel movements that I tested myself and that's it. And I usually do one test, wait like about maybe five days and then I do it again. And then, I go ahead and drop it off (EL responder).

The nine nonresponders that reported eventually completing and returning the FIT (aka delayed responders) described similar facilitators to FIT completion as the responders but with different emphasis (see Fig. 2). The majority (67%, n = 6) were motivated to complete the FIT due to age and the potential threat of cancer and 56% (n = 5) described both reminders and familiarity due to prior exposure to FIT as factors shaping completion.

Reactions to the direct-mail prompts and reminders

Participants reported limited recall for the prompts and reminders used across the three arms of the direct-mail program (see Table 1). Three out of four participants that should have received a text prompt prior to receiving the direct-mail FIT had no recall of it (n = 20/27); this included both responders (81%, n = 13/16) and nonresponders (64%, n = 7/11). The seven participants that recalled the prompt (five responders, two nonresponders) reported that it was appropriate, professional, and helpful. Recall rates for the automated and live reminder calls were also low at 19% (n = 5/27) and 39% (n = 11/28) respectively. The participants who did not recall the auto reminder call (n = 22/27) or the live reminder call (n = 17/28) suggested that they just did not remember the outreach and that they did not receive the call due to completing the FIT quickly (within 10 days) because someone else in the household may have taken the call or message or because they confused that reminder with other calls from the clinic. Participants that remembered the auto and live calls reported that they were appropriate and helpful to support kit completion (e.g., helped with procrastination and reminded them to request a second FIT if needed). Participants that received the live call also noted that it helped with understanding kit labeling, as well as the reason they received it. While auto calls, live calls, and text message approaches were considered acceptable across language and responder/nonresponder groups, the text prompt was identified overall as the preferred mode (32%, n = 13) when participants were asked to choose. One EL responder commented, “I’m always getting texts from doctors’ offices and the pharmacies…I think [text reminders are] great.” EL participants preferred the auto telephone call (n = 7/11), while SL participants endorsed the live telephone call (n = 7/8).

It's fine, just like how they did it with me, they sent me texts, they called me ... Above all, they called me. I took that more... I mean, they sent me texts and I did not make the decision, until they called me, so the call they made to me was very important (SL responder).

Direct-mail reminder and overall program recommendations

Despite limited recall for the prompts or reminder calls, 95% of all participants (39/41) reported that they thought outreach encouraging mailed FIT completion was acceptable, helpful, and conferred the importance of completing the test. One participant noted:

I think that it's good that [the clinic] is being proactive. Especially with something that could be a very serious health issue. It’s good to be proactive with us and give a friendly reminder. You know, we obviously don't need to be hounded with all kinds of reminders. But, you know, just one or two after the fact or whatever would be appropriate (EL responder).

Generally, participants had thoughts on the number, timing, and content of reminders. Participants suggested that two to three reminders were sufficient to inspire completion; more than three may become annoying and create negative emotions that discourage patients from completing the FIT. Participants also suggested that the reminders should come about 1 week after mailing, then spaced apart 1–2 weeks to give individuals time to complete the FIT. Both English- and Spanish-speaking participants preferred reminder messages that are short and to the point and emphasized the importance/urgency of screening, whether or not they are automated or live calls. While EL participants suggested using a celebrity voice, SL participants suggested using a patient story to convey these messages.

You can also use people who already had the experience that [the FIT] saved their lives ... telling their story ... it can also help (SL responder).

Other recommended improvements to the direct-mail program focused on enhancements to the FIT materials, as well as changes to in-clinic promotional efforts. Participants wanted more information posted around their clinics about the importance of CRC screening, details on what FIT is, and information related to what happens after an abnormal FIT (a factor expressed primarily by SL participants and an equal number of responders and nonresponders). EL participants suggested improvements to the mailed FIT could include: reducing the paperwork within the kit as it may cause confusion, improving the FIT brush and having a larger cutout for collecting the sample, and providing rubber gloves. EL participants also wanted their PCPs and clinic staff to start talking about FIT before it needs to happen, such as when patients are in their late 40s so that they are more prepared by the time screening is due. Nonresponders especially requested more in-person education about CRC screening—such as showing them how to complete a FIT and communicating why it is important to be screened, even when there are no symptoms.

I remember thinking, how do I do this [FIT kit], you know? And reading it and maybe I put too much [fecal matter] in …[The kit instructions] don’t exactly tell you. I remember thinking, how in the heck do I do this? And what a struggle. And that’s probably why people don’t do it (EL delayed responder)

DISCUSSION

Our study explored patient experiences and preferences in response to the frequency, timing, and modality of prompts and reminders used to support FIT completion following a direct-mail program. Across the three study arms, eligible participants infrequently recalled the automated text prompts (26%) and automated (19%) or live reminder calls (39%) encouraging FIT completion. However, the majority reported that they thought reminders were acceptable and helpful in overcoming barriers and supporting FIT completion. Participants suggest that 2–3 short reminders that emphasize the importance of CRC screening, occurring 1 week after mailing and, then, spaced 1–2 weeks would be optimal to inspire completion without irritating patients. Although the majority of participants that completed the FIT did so within 2 weeks of receiving the mailing (84%), those who were slow to complete the FIT reported that the reminders helped overcome barriers related to procrastination, lack of understanding or challenges with kit labeling. Reminders also encouraged participants to ask questions of the clinic staff, allowing for education on screening and to obtain replacement FITs if needed.

Findings from this study support prior research about the barriers and facilitators to mailed FIT programs in FQHCs [38], while adding additional nuance in relation to patient views toward the modality and timing of reminders from both responders and nonresponders. For example, both responders and nonresponders reported the importance of PCPs’ recommendations, friend and family encouragement, and personal agency in supporting CRC screening completion. However, responders were more likely to report prior experience with FIT or colonoscopy and to share stories related to their strategies for FIT completion (suggesting that completing at-home screening is a skill that may be built over time). Nonresponders, in contrast, reported that they were less familiar with CRC screening options, that they did not recall receiving the FIT via mail, described more pronounced difficulties with kit completion, and articulated other complex health problems as a reason for putting off completing their FIT. Prior research shows that patients with complex health conditions experience problems relating to care access and burdens of time and travel [39, 40], yet other research suggests that patients with more chronic conditions are more likely to screen for CRC. The findings also suggest that these patients with complex health needs—or those with no prior exposure to FIT—may need more than a set of reminders to complete a kit. Given prior work demonstrating the effectiveness of navigation programs for CRC screening [41–44], future research should examine the impact of a patient navigator or community health worker in assisting patients at higher risk for nonresponse (e.g., highly complex health needs and no prior exposure to FIT) on completion rates. Such research could utilize risk prediction models to determine which patients should be offered navigation services either as frontline support or for follow-up after abnormal FIT. Given that the majority of interventions to increase fecal testing for CRC have occurred in urban settings and within larger health systems [16], research exploring how to systematically adapt mailed FIT programs [45] and to scale implementation in rural settings is needed.

Remarkably, by the time of our interviews (6 months after kits were mailed), nearly all of the participants who did not respond to the direct mailing had completed CRC screening using FIT kits provided at a recent clinic visit. This finding supports the importance of both visit-based and population-outreach strategies in clinics striving to achieve national CRC screening goals [11, 46] (Davis et al., unpublished data). It also supports the use of multicomponent, multilevel interventions targeting patients, practices, and health systems in order to optimize CRC screening [21].

This study had some limitations, which should be noted. Our small sample size may have limited the range of themes identified in our analysis, particularly with the smaller nonresponder group. Despite small sample cells in certain categories, our team chose to count qualitative responses in order to illustrate similarities and differences between the participants based on responder type and preferred language, concluding that the pros for clarity outweighed the cons of converting rich qualitative data into numbers [34, 35]. The time elapse (6–8 months) from FIT mailing to when we conducted the interviews likely contributed to low recall of experiences and reactions to both the FIT mailing and different reminders. Those patients agreeing to be interviewed may have been more receptive to the program overall and may have told us what we wanted to hear rather than their actual beliefs (social desirability bias), thus, possibly limiting the accuracy and range of responses. Nevertheless, we employed several strategies to improve the credibility and trustworthiness of our interview data, including: trained qualitative interviewers; consistent use of an interview guide; a formal, team-based approach to coding and analysis; and iterative reviews of our findings with the raw transcripts to check our thematic interpretations [47, 48]. Although we did not conduct a formal member checking exercise, we shared initial themes with our steering committee, which included clinical partners, as a form of peer review [36, 37]. Furthermore, we conducted, transcribed, and analyzed Spanish interviews in Spanish to maintain integrity of meaning. Even with these limitations, we believe that the experiences and feedback from our patient interviews are useful guideposts to other FQHC programs considering a mailed FIT approach that employs prompts or reminders. Our findings can inform clinic-based efforts to optimize FIT completion rates in response to direct-mail programs.

CONCLUSION

Prompts and reminders, which can boost response rates to direct-mail FIT programs, were perceived by participants as acceptable and helpful in overcoming barriers to and supporting the completion of FIT. Participants suggested that two to three short reminders emphasizing the importance of CRC screening, delivered 1 week after the FIT mailing, and, then, spaced by 1–2 weeks would be adequate to inspire completion. Future research may help identify strategies to support FIT completion in delayed and never responders.

Funding:

This study was funded by the National Institute on Minority Health and Health Disparities (U01MD010665). M.M.D. was supported in part by a Cancer Prevention, Control, Behavioral Sciences, and Populations Sciences Career Development Award from the National Cancer Institute (K07CA211971). M.M.D. and G.D.C. receive funding from the National Cancer Institute and National Institute on Minority Health and Health Disparities on research to improve colorectal cancer screening through implementation of direct-mail programs. The findings and conclusions in this study are those of the authors and do not necessarily represent the official position of the funders.

Compliance with Ethical Standards: This study was approved by the Institutional Review Board of Kaiser Permanente Northwest (Portland, OR), with ceding agreements from relevant institutions.

Conflicts of Interest: From November 2014 to August 2015, G.D.C. served as a Co-Investigator on an industry-funded study to evaluate patient adherence to an experimental blood test for colorectal cancer. The study was funded by EpiGenomics. From September 2017 to June 2018, G.D.C. served as the Principal Investigator on an industry-funded study to compare the clinical performance of an experimental FIT to an FDA-approved FIT. This study is funded by Quidel Corporation. The studies had no influence on the design, conduct, or reporting of the present study.

Authors’ Contributions: M.M.D., J.L.S., R.G., J.S.R. and G.D.K. contributed to the overall study conception and design. M.M.D., J.L.S., R.G. and J.S.R. contributed to data acquisition. All authors contributed to data analysis. M.M.D., J.L.S. and R.G. drafted the manuscript and all others contributed to revising it critically for important intellectual content.

Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study received approval from the Kaiser Permanente Northwest Institutional Review Board (IRB #593), with ceding agreements from the health center and Oregon Health and Science University. This article does not contain any studies with animals performed by any of the authors.

Informed Consent: Informed consent was obtained from all individual participants included in the study.

Prior Presentations: None.