Abstract C80: Implementing a mailed colorectal cancer screening program: A safety-net clinic case study
Authors: Schneider Jennifer L. , Fuoco Morgan J. , Rivelli Jennifer S. , Coury Jennifer , Green Beverly B. , Petrik Amanda F. , Turner Ann , Kapka Tanya 
Published: February 2019

Abstract
Introduction: Screening for colorectal cancer (CRC) may reduce incidence and mortality, but screening rates are low, particularly in the community health center setting that often serves patients experiencing the greatest health disparities. Lack of time during office visits for providers to engage in CRC screening discussions, insufficient access to colonoscopy resources, and patients' fears regarding the colonoscopy preparation and procedure are some of the challenges community health centers face when promoting CRC screening.
Methods: We conducted a qualitative case study to document the acceptability and reactions to a pilot direct-mail CRC screening program using fecal immunochemical testing (FIT). The pilot was implemented in a Latino-serving safety-net clinic that provides primary care to diverse and low-income populations. After the implementation of the direct-mail CRC screening program, we conducted 29 semistructured telephone interviews: nine with clinic staff and leaders involved in implementing the screening program, and twenty with patients who had received the CRC outreach via a mailed FIT test. Patient interviews were conducted with both English (10) and Spanish (10) language participants. To analyze our case study, we used a qualitative content analysis approach, guided by grounded theory coding techniques, to identify themes from the interviews. Two coding dictionaries (one patient and one staff/leader) were developed by having each member of the analysis team (JLS, JSR, GC) read several patient and staff transcripts and mark passages of text with codes indicating their content. The team compared coding notes, discussed areas of disagreement, and from this process developed a coding scheme for use with subsequent transcripts. Transcripts were coded by trained coders (JLS, JSR, GC); Spanish-language transcripts were coded and reviewed by bilingual coders (JSR, GC). All coded transcripts were entered into Atlas.ti 5.0, a qualitative analysis software program used to electronically code and manage data and to generate reports of coded text for ongoing thematic analysis. The analysis team reviewed coded text using an iterative process to develop and refine themes.
Results: Our content analysis revealed that staff valued the program and found it could be integrated into their workflow and electronic medical record. Organizational facilitators to program implementation included having skilled staff, a culture that supported change, engaged leaders, and an overall desire to improve CRC screening rates. Access to colonoscopy was sufficient, because only the few percent of individuals with positive fecal tests needed colonoscopy. Health center barriers included managing the complexity of program components (e.g., ordering, packaging, and mailing kits; documentation in the medical record; reminders; coordination following a positive result, etc.) and limited staffing resources to deliver the intervention. The majority of patients, both Spanish and English, found the direct-mail fecal testing program acceptable and personally helpful, with eighty percent supporting the program and related materials. Four patients either disliked the idea of mailing fecal matter (2), or could not recall receiving the outreach (2). All staff and patients (regardless of personal utility of the outreach) felt the program should be continued as an ongoing health center outreach activity.
Conclusion: Our interview findings may by useful to other community health centers looking to improve their CRC screening rates through implementation of a similar type of mailed, population-based CRC screening approach. Many of the barriers anticipated by community health centers were not realized; however, some challenges remained.
Citation Format: Jennifer L. Schneider, Morgan J. Fuoco, Jennifer S. Rivelli, Jennifer Coury, Beverly B. Green, Amanda F. Petrik, Ann Turner, Tanya Kapka. Implementing a mailed colorectal cancer screening program: A safety-net clinic case study [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C80.