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BMC Cancer. 2018 Jan 6;18(1):40. doi: 10.1186/s12885-017-3813-4.

A systematic review of clinic and community intervention to increase fecal testing for colorectal cancer in rural and low-income populations in the United States - How, what and when?

Author information

Oregon Rural Practice-based Research Network (ORPRN), Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L222, Portland, 97239, OR, USA.
Department of Family Medicine & OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR, USA.
VA Evidence-based Synthesis Program, Portland VA Medical Center, Portland, OR, USA.
OHSU-PSU School of Public Health and Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland, OR, USA.
Center for Health Research, Kaiser Permanente, Portland, OR, USA.
Center for Community Health Integration, Departments of Family Medicine & Community Health, Population & Quantitative Health Sciences, Sociology, and the Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA.
Departments of Obstetrics & Gynecology, Medical Informatics and Clinical Epidemiology, and Emergency Medicine and the OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR, USA.
Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
Departments of Family Medicine, Medical Informatics and Clinical Epidemiology, Public Health & Preventive Medicine, Oregon Health & Science University, Portland, OR, USA.



Interventions to improve fecal testing for colorectal cancer (CRC) exist, but are not yet routine practice. We conducted this systematic review to determine how implementation strategies and contextual factors influenced the uptake of interventions to increase Fecal Immunochemical Tests (FIT) and Fecal Occult Blood Testing (FOBT) for CRC in rural and low-income populations in the United States.


We searched Medline and the Cochrane Library from January 1998 through July 2016, and Scopus and through March 2015, for original articles of interventions to increase fecal testing for CRC. Two reviewers independently screened abstracts, reviewed full-text articles, extracted data and performed quality assessments. A qualitative synthesis described the relationship between changes in fecal testing rates for CRC, intervention components, implementation strategies, and contextual factors. A technical expert panel of primary care professionals, health system leaders, and academicians guided this work.


Of 4218 citations initially identified, 27 unique studies reported in 29 publications met inclusion criteria. Studies were conducted in primary care (n = 20, 74.1%), community (n = 5, 18.5%), or both (n = 2, 7.4%) settings. All studies (n = 27, 100.0%) described multicomponent interventions. In clinic based studies, components that occurred most frequently among the highly effective/effective study arms were provision of kits by direct mail, use of a pre-addressed stamped envelope, client reminders, and provider ordered in-clinic distribution. Interventions were delivered by clinic staff/community members (n = 10, 37.0%), research staff (n = 6, 22.2%), both (n = 10, 37.0%), or it was unclear (n = 1, 3.7%). Over half of the studies lacked information on training or monitoring intervention fidelity (n = 15, 55.6%).


Studies to improve FIT/FOBT in rural and low-income populations utilized multicomponent interventions. The provision of kits through the mail, use of pre-addressed stamped envelopes, client reminders and in-clinic distribution appeared most frequently in the highly effective/effective clinic-based study arms. Few studies described contextual factors or implementation strategies. More robust application of guidelines to support reporting on methods to select, adapt and implement interventions can help end users determine not just which interventions work to improve CRC screening, but which interventions would work best in their setting given specific patient populations, clinical settings, and community characteristics.


In accordance with PRISMA guidelines, our systematic review protocol was registered with PROSPERO, the international prospective register of systematic reviews, on April 16, 2015 (registration number CRD42015019557 ).


Colorectal cancer; Fecal testing; Implementation science; Rural; Systematic review; Vulnerable populations

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