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01.12.2018 | Research article | Ausgabe 1/2018 Open Access

BMC Cancer 1/2018

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?

BMC Cancer > Ausgabe 1/2018
Melinda M. Davis, Michele Freeman, Jackilen Shannon, Gloria D. Coronado, Kurt C. Stange, Jeanne-Marie Guise, Stephanie B. Wheeler, David I. Buckley
Wichtige Hinweise

Electronic supplementary material

The online version of this article (https://​doi.​org/​10.​1186/​s12885-017-3813-4) contains supplementary material, which is available to authorized users.



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.

Trial registration

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).
Additional file 1: Appendix A. Search Strategies. Appendix B. Study Selection: Table of Inclusion/Exclusion Codes, Definitions and Key Questions. Appendix C. Quality Assessment: Quality Assessment for Randomized Controlled Trials (RTC) or Control Trial (CT) Designs, Quality Assessment for Studies using a Pre-Post Design. Appendix D. Data Supplement: D1. Characteristics and findings of included studies, stratified by intervention, D2. Participant recruitment and recruitment success in intervention studies to improve FIT/FOBT screening for CRC, stratified by intervention setting, D3. Intervention Components – Tracked for the most complex intervention arm tested in a study, D4. Contextual Factors in Interventions to Improve FIT/FOBT screening for CRC, stratified by setting, and D5. Implementation strategies used in interventions to improve FIT/FOBT CRC screening, stratified by setting. (DOCX 442 kb)
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