To date, the majority of studies in the United States addressing CRC screening have been situated in primary care, with fundamental similarities in how CRC and screening options are introduced, explained, and recommended. This study is the first to deconstruct, in a very precise way, these common elements of recommendation, information, or education, providing the test itself to determine what is most salient for encouraging patient CRC screening behavior. In general, participants who reported receiving any of the individual services were significantly more likely to complete FOBT screening than those who did not receive the service. The service that had the greatest impact on CRC screening in these resource-poor FQHCs was the physician actually giving the FOBT kit to the patient. This alone had the most profound impact compared to the receipt of a recommendation or education. In fact, rates of completion were not improved with the addition of those services among those who received the FOBT kit.
This study’s findings, like those of other studies, indicate physician recommendation is clearly important.5,7,8,10,11,13,14,19,27
Previous studies have also indicated that low-income and minority patients and those with low literacy may lack sufficient knowledge of CRC screening and its benefits, and desire more information.9,13,14,28,29
Therefore, the literature recommends CRC screening education, information, and counseling.5,9,11,28
If possible, these services need to be provided. However, the literature has noted the challenges of improving and sustaining CRC physician recommendations, particularly among safety net primary care providers focused on the acute medical and social needs of their patients.7,16,19
This study’s finding that the physician providing the FOBT kit was the strongest predictor of screening completion has important implications and suggestions for further studies. Over 80% of participants who reported ever being given an FOBT kit by a physician reported that they had completed at least 1 FOBT. The act of giving the patient the test may reduce any access barriers to obtaining the kit (ie, knowing where to get an FOBT, cost, degree of interest). Also, a physician giving the kit is a concrete and powerful recommendation, especially for low-income patients at greater risk for limited education and literacy skills.
While it may be a seemingly simple aspect of screening promotion, our findings provide clear guidance for subtly redesigning the delivery of preventive services in primary care. When considering other proposed strategies, improving recommendation rates and providing FOBTs are relatively low-intensity strategies with a greater likelihood for adoption. O’Malley suggested the possibility of organizational change where nurses deliver the FOBT cards, instructions, and reminders to promote screening.7
Future studies are needed to determine if the physician needs to give patients the kit or if it can be given by a nurse or other clinic staff.7
In a recent study where a nurse gave the kit, there was an increase in screening in community clinics in San Francisco. During an 18-week influenza vaccination campaign, patients in the intervention group were given FOBT kits by nurses during primary care visits, and FOBT completion rates went from 33% to 46% vs from 31% to 36% in the control group where nurses provided FOBT only when ordered by the primary care physician.30
Another approach that does not rely on the physician to give the kit was found to be effective in Scotland. In this study, patients aged 50–69 enrolled in the National Health Service were mailed an FOBT kit with a letter inviting them to be screened. The kits were mailed from a single screening center and participants sent back a specially designed envelope to a central laboratory.31
The initial return rate was 55%; with subsequent mailings, the initial return rate increased to 63%.
For FOBTs to be an effective means of CRC screening, they must be done annually. Studies are needed to determine if clinics handing out annual FOBTs or mailing them to patients would be effective year after year. In the UK study, the results of year 2 mailings were disappointing; only 15% of patients returned their FOBTs to the clinic.
Our study has limitations: the findings may not be generalizable to all patient populations, as the majority of patients were female and African American. However, this is representative of FQHC populations, particularly in the southern area of the United States. Half of the sample had low literacy, which is more common in older, lower-income populations. FQHCs in the study were in 1 state and all patients were English-speaking; therefore, results may not be generalized to FQHCs serving Hispanic and other minority patients in other states. Data on previous physician recommendation, FOBT education, physician giving an FOBT, and FOBT completion were self-reported. However, the majority of CRC studies use self-reported data for screening completion. While the questions on receipt of services and completion of the FOBT did not provide greater detail such as the type of CRC screening test(s) the physician recommended or the extent of FOBT education/information received, the answers as provided portray the overall relationship between service provided and patient action.
This investigation of factors that influenced FOBT completion in low-income individuals who were not up-to-date with CRC screening indicated that a physician giving rural and inner city safety net clinic patients the FOBT kit was the strongest predictor of their completing screening. These findings have implications for clinical medicine and public health. Identifying practices that have the strongest impact on completion of CRC screening (in inner city and rural clinics that serve low-income patients and those who lack insurance) has the potential to dramatically reduce CRC deaths among groups that are disproportionately affected.31