• Jamie Zoellner, Kathleen Porter, Esther Thatcher, Erin Kennedy, James L Werth, Betsy Grossman, Tomas Roatsey, Heather Hamilton, Roger Anderson, and Wendy Cohn.
• Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia.
• J Rural Health. 2021 Jun 1; 37 (3): 585-601.

PurposeTo explore system/staff- and patient-level opportunities to improve colorectal cancer (CRC) screening within an 11-clinic Federally Qualified Health Center (FQHC) in rural Appalachia with CRC screening rates around 22%-30%.MethodsUsing a convergent parallel mixed-methods design, staff (n = 26) and patients (n = 60, age 50-75, 67% female, 83% ResultsAmong staff, inner setting factors that could promote CRC screening included high workplace satisfaction, experiences tracking other cancer screenings, and a highly active Performance Improvement Committee. Inner setting hindering factors included electronic medical record inefficiencies and requiring patients to physically return fecal tests to the clinic. Outer setting CRC screening promoting factors included increased Medicaid access, support from outside organizations, and reporting requirements to external regulators, while hindering factors included poor social determinants of health, inadequate colonoscopy access, and lack of patient compliance. Among patients, perceived screening benefits were rated relatively higher than barriers. Top barriers included cost, no symptoms, fear, and transportation. Patients reported high likelihood of getting a stool-based test and colonoscopy if recommended, yet self-efficacy to prevent CRC was considerably lower.ConclusionsContextualized perceptions of barriers and practical opportunities to improve CRC screening rates were identified among staff and patients. To optimize multilevel CRC screening interventions in rural Appalachia clinics, future quality improvement, research, and policy efforts are needed to address identified challenges.© 2020 National Rural Health Association.

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