Understanding the processes that Federally Qualified Health Centers use to select and implement colorectal cancer screening interventions: a qualitative study

Abstract

Colorectal cancer (CRC) screening is highly effective at reducing cancer-related morbidity and mortality, yet screening rates remain suboptimal. Evidence-based interventions can increase screening rates, particularly when they target multiple levels (e.g., patients, providers, health care systems). However, effective interventions remain underutilized. Thus, there is a pressing need to build capacity to select and implement multilevel CRC screening interventions. We report on formative research aimed at understanding how Federally Qualified Health Center (FQHC) staff select and implement CRC screening interventions, which will inform development of capacity-building strategies. We report the qualitative findings from a study that used a mixed methods design, starting with a quantitative survey followed by a qualitative study. In-depth interviews were conducted with 28 staff from 14 FQHCs in 8 states. The Consolidated Framework for Implementation Research (CFIR) guided interview questions and data analysis. Related to the CFIR process domain, few respondents described conducting formal assessments of factors contributing to low screening rates prior to planning their interventions. Many described engaging champions, implementation leaders, and external change agents. Few described a systematic approach to executing implementation plans beyond conducting plan-do-study-act cycles. Reflection and evaluation consisted primarily of reviewing Uniform Data System performance measures. Findings also include themes related to factors influencing these implementation processes. Although FQHCs are implementing CRC screening interventions, they are not actively targeting the multilevel factors influencing their CRC screening rates. Our findings on gaps in FQHCs’ implementation processes will inform development of strategies to build capacity to select and implement multilevel CRC screening interventions.

A Multilevel Approach to Understand the Context and Potential Solutions for Low Colorectal Cancer (CRC) Screening Rates in Rural Appalachia Clinics

“…The CFIR includes 39 factors across 5 domains (ie, intervention characteristics, outer setting, inner setting, process, individual characteristic) that influence system‐level intervention implementation and has been applied widely in general health systems research and specifically to cancer screening initiatives 12,17,18,32,41 . Given the formative phase of this research, the semistructured staff interview script was developed to capture the CRC screening clinical workflow process and to explore 2 CFIR domains, inner setting and outer setting factors, that influence CRC screening.…”

“…Likewise, many clinics in rural and medically underserved areas may have limited capacity to prioritize cancer prevention and control initiatives. This is due, in part, to limited resources and high patient demand for chronic disease self‐management and complaint‐driven primary care 11–13 . Both patient‐level barriers and practice challenges faced by staff and systems must be addressed to improve documented CRC screening disparities.…”

“…Focusing on barriers and opportunities among clinics as well as patients’ perceived barriers in accessing CRC screening services in rural, medically underserved areas fills a critical gap in the CRC screening literature by focusing on the need for multilevel interventions adapted to specific environments 16 . Despite literature relevant to system‐level CRC screening, 12,17–19 no known research has focused on the unique perspectives and experiences of front‐line clinic staff, especially in rural Appalachia where CRC screening rates are often low (ie, <40% of age‐eligible adults). While some patient‐level CRC screening barriers can be gleaned from the literature, 20 rural Appalachian residents are known to have unique micro‐ and macrolevel barriers (eg, cancer information seeking behaviors, fatalistic attitudes toward cancer, access to health care, and cancer treatment) 21–29 .…”

Interventions to Increase Colorectal Cancer Screening Uptake in Primary Care: A Systematic Review

“…All qualitative studies [20][21][22][23][24][25][26][27][28] were judged to have a clear research aim, appropriate qualitative methodology and research design, data collection that addressed the research issue, a clear statement of findings, and results that would provide local benefit. However, none of the studies mentioned whether the relationship between the researcher and participants was adequately considered.…”

Adoption of an Evidence-Based Intervention for Mammography Screening Adherence in Safety Net Clinics

“…Similarly, charity care clinics provides free or reduced cost care to patients without health insurance. Despite their importance, these clinics need assistance in adopting and implementing EBIs as many do not have staff with expertise or experience in this area or capacity to implement them on their own (8)(9)(10). Recent systematic reviews have identified some strategies shown to improve the adoption and scale-up of EBIs at clinical and system levels (11,12).…”