Interventions to Increase Colorectal Cancer Screening Uptake in Rural Settings: A Scoping Review

Christine M. Kava, PhD, MA¹; Judith Lee Smith, PhD, MS¹; Emily K. Kobernik, PhD, MS, MPH¹; Jan M. Eberth, PhD, MSPH²; Cynthia French, MPA¹; Sarah H. Nash, PhD, MPH³; Whitney E. Zahnd, PhD, MS⁴; Ingrid J. Hall, PhD, MPH¹ (View author affiliations)

Suggested citation for this article: Kava CM, Smith JL, Kobernik EK, Eberth JM, French C, Nash SH, et al. Interventions to Increase Colorectal Cancer Screening Uptake in Rural Settings: A Scoping Review. Prev Chronic Dis 2025;22:250025. DOI: http://dx.doi.org/10.5888/pcd22.250025.

PEER REVIEWED

Abstract

Introduction

An estimated 6,000 preventable cancer deaths — including from colorectal cancer (CRC) — occurred in rural America in 2022. Screening can prevent CRC or identify disease at earlier stages when it is more treatable. However, national estimates for CRC screening lag behind Healthy People 2030 objectives. In rural settings, barriers to screening are unique and persistent.

Methods

We performed a scoping review to describe the types and effectiveness of interventions to increase CRC screening in primarily rural settings. We included US-based studies published during January 2010 through May 2024. Interventions were categorized according to US Community Preventive Services Task Force–recommended strategies for multicomponent interventions.

Results

Of 508 unique publications identified, 36 met inclusion criteria. Most studies were multicomponent interventions (n = 34). Most studies were associated with an increase in CRC screening uptake. The most common intervention approaches were client reminders (eg, telephone reminders about screening) (n = 25), small media (eg, pamphlets) (n = 25), and reducing structural barriers to screening (eg, patient navigation) (n = 24). Over half (n = 21) of studies reported using a theory, framework, or research approach to inform intervention development, implementation, or evaluation. Six studies (17%) included cost evaluations. The studies included in this review represented less than half of all US states.

Conclusion

This scoping review provides insight into CRC screening intervention implementation in rural settings. The limited geographic representation of the interventions included in our review may highlight an opportunity to improve implementation and dissemination of effective CRC screening interventions in rural settings to reduce CRC incidence and death.

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Introduction

Rural populations in the US have higher rates of colorectal cancer (CRC) incidence and deaths compared with urban populations (1–3). Use of screening tests as recommended by the US Preventive Services Task Force (USPSTF) (4) and the American College of Gastroenterology (5) can help detect and prompt treatment to remove most precancerous polyps before they develop into cancer (6). Screening can also reduce the risk of death (7) by finding tumors early — when treatment is most effective. However, the current prevalence of CRC screening (63.5%) nationally lags behind the prevalence of breast (79.8%) and cervical (73.9%) cancer screening and the recommended Healthy People 2030 target of 72.8% (8).

People living in rural versus urban settings are less likely to receive CRC screening (9,10). This screening disparity may partially explain the association of rural residency with presentation of advanced disease (11). However, even when controlling for screening, recent estimates suggest that rural US counties have higher rates of CRC deaths (12). People in some racial and ethnic minority groups in rural settings are less likely to be screened compared to their urban counterparts (13). The disparity between urban and rural populations may be due to limited access to quality health care and delays in obtaining timely, recommended treatment — given longer travel distances, transportation difficulties, provider shortages, and limited access to specialty care (14).

Previous reviews of CRC screening have included studies conducted in rural settings in combination with other populations regardless of rurality (eg, rural and low-income populations [10]). To our knowledge, no previous reviews have focused on CRC screening interventions in primarily rural settings only. We performed a scoping review to describe interventions implemented in rural settings to increase CRC screening and identify how effectiveness might differ across populations. Included studies were categorized according to the Community Preventive Services Task Force (CPSTF)-recommended intervention strategies: increase community demand, increase community access, and increase provider delivery of screening services (15).

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Methods

We performed a scoping review in May and June 2024. The general purpose of a scoping review is to identify and map available evidence on a given topic (16). We identified available evidence on CRC screening interventions conducted in primarily rural settings. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines (17). Like previous scoping reviews (18,19) and aligned with the defining characteristics and reporting requirements for a scoping review (16,17), our assessment did not report on study quality or risk of bias.

Data sources

We developed a search strategy in consultation with a librarian. Search engines were CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, Medline, and Scopus. Example search terms included colorectal, neoplasms, screen, colonoscopy, FOBT (fecal occult blood test), immunochem, sigmoidoscopy, stool, rural, intervention, and program (the Appendix includes the full search strategy and terms). Eligibility criteria for our search included English-language publications in peer-reviewed journals during January 2010 through May 2024. We did not limit our search to specific CRC screening tests or study designs, because we wanted to capture data on a wide range of CRC screening interventions. We identified 1,107 records from our search. After removing duplicates (n = 599), there were 508 records for abstract review based on our inclusion and exclusion criteria.

Study selection

Abstracts were divided among 4 members of the research team (C.M.K., E.K.K., J.L.S., I.J.H.) for review. Given country-level differences in cancer screening capacity, coverage, and guidelines, only studies conducted in the US were included. We included studies that reported being focused primarily on rural settings. We excluded studies focused on urban settings, even if they serviced rural populations. Studies that did not implement or evaluate an intervention for CRC screening were excluded. We also excluded conference abstracts and book chapters. Of the 508 abstracts reviewed, 36 studies met our inclusion criteria (Figure 1).

Figure 1.
Article search and selection, scoping review of colorectal cancer (CRC) screening interventions in rural settings, January 2010–May 2024. “Other reason” for excluding research from this review were that, eg, the item was a book chapter or that the research was not focused on rural settings. Abbreviation: CINAHL, Cumulative Index to Nursing and Allied Health Literature. [A text description of this figure is also available.]

Data extraction

We abstracted data from the 36 included studies into an Excel (Microsoft) spreadsheet and summarized the following: study design, population, and setting; whether the authors provided a formal definition of rurality; screening tests and guidelines used; intervention description; sample size(s) and characteristics; and summary of results. We categorized interventions according to the 3 CPSTF-recommended strategies for multicomponent interventions and used the abstracted data to develop summary tables and findings.

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Results

Study characteristics

The 36 articles included in our review evaluated populations from 19 states (Table 1, Figure 2). Four pairs of articles (n = 8 total) described the same study. The states with the most articles published were Iowa, Kentucky, Louisiana, Ohio, and Washington (n = 4, each). Studies were primarily conducted in health care settings, including federally qualified health centers (FQHCs), tribally operated health care facilities, and other community health clinics and systems..

Figure 2.
Age-adjusted colorectal cancer incidence and distribution of included articles (N = 36) by state, scoping review of colorectal cancer screening interventions in rural settings, January 2010–May 2024. Age-adjusted colorectal cancer incidence rates per 100,000 standard population were based on US cancer incidence data from 2017 through 2021. The numbers represent the number of articles that were included in our review whose intervention was implemented in that state. Four pairs of articles (n = 8 total) were publications on the same study. [A tabular description of this figure is also available.]

Nine studies defined rurality (Table 1). The underlying measures used to define rurality varied across studies and included Rural–Urban Continuum Codes (56) (n = 3), rural–urban commuting area codes (57) (n = 4), and a description of population size (n = 2). With the exception of 1 study in which the mean age of the participants was less than 50 years old (54), the mean age of study participants ranged from 50.3 to 64.8 years among the 21 studies that reported this information. Most participants in most studies were female and White.

Twenty-one studies reported using a theory, framework, or research approach to inform intervention development, implementation, or evaluation (Table 2). Fifteen studies used a randomized controlled trial study design; other designs included pretest–posttest, quasi-experimental, and mixed methods. Most studies evaluated CRC screening uptake as a primary outcome. The screening tests evaluated were colonoscopy (n = 26), fecal immunochemical test (FIT) (n = 21), FOBT (n = 19), sigmoidoscopy (n = 12), barium enema (n = 5), and Cologuard (n = 2). Of studies that evaluated FIT or FOBT, 13 reported on positive test results. Of studies that evaluated colonoscopy, 7 provided data on colonoscopies as a diagnostic test after receipt of a positive FIT or FOBT result.

Intervention strategies and approaches

Interventions used various approaches to increase CRC screening completion or follow-up (Table 3). Of the 36 studies, 34 were multicomponent interventions. Of these studies, 27 implemented approaches from 2 or more of the 3 CPSTF-recommended strategies: increase community demand, increase community access, and increase provider delivery of screening services.

Increase community demand

The most common approaches used to increase community demand for screening were client reminders (n = 25), small media (n = 25), and one-on-one education (n = 20). Client reminders were sent to people due for CRC screening or follow-up and were typically done via telephone calls and mailed letters from health care staff. Small media approaches included educational pamphlets, visual aids, brochures, short videos, and audio-recorded information about CRC screening. Some small media was either culturally tailored or provided tailored messaging based on a person’s family history or health beliefs. Fewer studies used group education (n = 4), mass media (n = 1), or client incentives to encourage screening (n = 1).

Increase community access

Twenty-four studies focused on reducing structural barriers to CRC screening (Table 3). Most commonly, interventions reduced barriers to accessing and receiving CRC screening by mailing FIT kits with prestamped, preaddressed return envelopes. Some interventions used a lay health advisor or patient navigator approach; for example, Vachon et al 2024 (52) used patient navigators to help with screening, including arranging transportation for interested patients. Three studies addressed cost barriers by offering — or partnering with organizations to provide — reduced-cost colonoscopies for screening or diagnostic testing. For example, Briant et al 2015 (23) worked with local hospitals, clinics, and programs to provide free or low-cost colonoscopies to participants with a positive FOBT test result.

Increase provider delivery of screening services

Ten studies implemented approaches to increase provider delivery of screening services (Table 3). Of these studies, 7 used provider assessment and feedback, 4 implemented provider reminders, and 4 used provider incentives to increase CRC screening. Provider incentives were largely confined to academic detailing, which can offer continuing medical education credit (nonmonetary incentive), to enhance provider knowledge and delivery of CRC screening. Multiple studies used quality improvement methods to facilitate CRC screening, often combining 1 or more approaches as part of this strategy. For example, Schlauderaff et al (50) used the Plan-Do-Study-Act model to inform implementation of multiple workflow processes, including a provider reminder system to assist with follow-up testing.

Intervention outcomes and results

Most studies observed an increase in CRC screening following the intervention. Our results, including examples from selected studies, are summarized below.

CRC screening uptake

Multiple studies reported a significant increase in CRC screening compared with usual care or control conditions. Charlton et al 2014 (25) observed significantly higher CRC screening (21%) with a mailed education and FIT kit intervention compared with both education only (6%) and usual care (6%) (P values < .001). Hardin et al 2020 (33) implemented a patient incentive and navigation program, which included patient reminders and assistance with screening barriers. The FIT return rate increased from 21.7% during the usual care period to 47.6% during the implementation period (P = .001).

Haverkamp et al 2020 (34) tested the effectiveness of 2 interventions for American Indian or Alaska Native patients: 1) mailing FIT kits alone and 2) mailing plus telephone or home outreach from an American Indian Community Health Representative. The percentage of completed FIT kits was significantly higher in both intervention groups (16.9% and 18.8%) compared with usual care (6.4%) (P values < .01). Hirko et al 2020 (35) tested the effectiveness of a mailed motivational message reminder for CRC screening and found a significant increase in CRC screening in the intervention group (30.1%) vs control group (22.5%) (P < .001).

Some studies examined intervention effectiveness without comparison to usual care. In 2 related studies, Arnold et al 2019 (22) and Davis et al 2020 (30) compared the relative effectiveness of a personal call vs automated call intervention. The percentage of patients who had ever completed a FOBT was similar at baseline in both personal call (20%) and automated call (17%) groups (22). While the study found no significant difference in return of initial FIT kit within 12 months between groups, the screening prevalence in both groups was nearly 70% postintervention (22). Uptake of repeat FIT within 12 to 18 months of initial FIT was also comparable in both groups (33.6% in personal call vs 36.5% in automated call group) (30).

Four studies did not observe significant improvements in CRC screening for their main outcome or in primary analysis (20,32,42,53). For example, Adegboyega et al 2022 (20) evaluated a motivational interviewing intervention provided by lay health advisors and observed no significant difference in CRC screening between the intervention and the control group (12% vs 15%; P = .72). Westfall et al 2013 (53) implemented a county-level awareness and education campaign that encouraged residents to get screened. They found no significant differences in reported CRC screening between intervention and control regions (81% vs 77%; P = .22), although the authors did report a significant increase in screening at higher levels of intervention exposure at follow-up.

Some studies examined CRC screening but did not report on significance or include a usual care or control group. For example, Christiansen et al 2016 (26) used patient empanelment (ie, assigned patients to a primary care provider and designated care team) and implemented systems-level and practice-level changes to promote CRC screening, which increased from 9% at baseline to 19% at 12 months postempanelment. Davis et al 2023 (31) conducted a mixed-methods, single-arm exploratory pilot study to evaluate the preliminary effectiveness of a mailed FIT and patient reminder intervention. Patients who were not up to date with CRC screening were eligible to participate. At 12 months postmailing, 21% of patients had completed a mailed FIT and 15% had completed a clinic-distributed FIT or other screening.

Multiple studies conducted subgroup analyses to examine differences in the effect of the intervention(s) on CRC screening by sociodemographic and health-related characteristics, with varied results. For example, Arnold et al 2019 (22) and Davis et al 2020 (30) found no significant differences in initial or repeat FIT completion between study groups among people with limited health literacy or adequate health literacy (P values range, .12 to .77). Davis et al 2020 (30) found treatment effects by age; the personal call vs automated call intervention was more effective among participants aged 60 years or older, while the automated call intervention was more effective among participants aged 50 to 59 years (P = .01). Charlton et al 2014 (25) and Hirko et al 2020 (35) did not find significant differences in screening prevalence by sex and study group.

Other outcomes

Some studies examined outcomes beyond screening uptake, including CRC screening familiarity, intent, and referral. Briant et al 2015 (23) held community fairs to provide education on and awareness of CRC screening. The authors reported a significant increase in familiarity with CRC screening among numerous demographic groups as well as associations between older age and Hispanic ethnicity, with higher odds of CRC screening intent after intervention. In a subsequent study, Briant et al 2018 (24) implemented promotor(a)-led “home health parties” and reported an increase in CRC screening awareness and knowledge, as did Woodall and DeLetter 2018 (54), who implemented brief CRC education sessions. Honeycutt et al 2013 (36) abstracted medical record data to evaluate an integrated community cancer screening program for CRC implemented between 2009 and 2011. The authors found a significantly higher percentage of colonoscopy referrals in intervention clinics (58.0%) compared with comparison clinics (23.9%) (P < .001).

Intervention costs

Six studies conducted analyses to examine costs associated with the intervention, which varied with scope and scale of the intervention used. For example, Christiansen et al 2016 (26) reported a total project cost of $52,987 to assign a designated primary care provider for patients, along with other systems-level and practice-level changes. Conn et al 2020 (27) reported the average total cost to track patients and mail reminders per FIT test returned as $60.18. The average cost of reminders only per FIT test returned was $11.20. Davis et al 2013 (29) reported incremental costs of $250 per additional person screened over usual care for the educational intervention and $1,337 for the nurse support intervention.

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Discussion

The purpose of this scoping review was to describe the published literature on interventions to increase CRC screening in rural settings. The interventions included in our review were largely effective at increasing CRC screening uptake. The most common intervention approaches were client reminders (n = 25), small media (n = 25), and reducing structural barriers (n = 24). Several studies focused on reducing structural barriers used patient navigation. In 2022, the CPSTF recommended patient navigation based on strong evidence of its effectiveness in increasing CRC screening and reducing inequities (58). Patient navigation is also a cost-effective strategy (58) — an important consideration in rural settings with fewer resources for intervention implementation.

Thirty-four studies implemented multicomponent interventions, and most of these studies combined 2 or more of the 3 CPSTF-recommended intervention strategies. Evidence from CPSTF suggests that multicomponent interventions are more effective when they combine intervention strategies to increase community demand for and access to cancer screening (15). Sharma et al 2022 (59) further demonstrated the benefit of multicomponent interventions among clinics participating in a national CRC screening program. The largest increases in annual CRC screening rates were observed among clinics that implemented 3 or more evidence-based interventions (59).

Our review shows that use of individual-level approaches (eg, one-on-one education) were more common than systems-level approaches (eg, quality improvement), though several studies implemented approaches at multiple levels. Multilevel interventions offer benefits over single-level interventions, including the ability to intervene upon multiple causes of health disparities and produce positive synergistic effects (60). Previous studies have identified barriers to CRC screening at multiple levels, including patient (eg, no health care coverage), provider (eg, lack of awareness of CRC screening protocols), systems (eg, shortage of specialists), and county (eg, high county-level rates of poverty), emphasizing the importance of implementing interventions that can reduce barriers at each level (61).

Rural settings

Most studies did not provide a formal definition of rurality, limiting our understanding of the contexts in which these interventions might be most effective. The definition of rurality, as well as its measurement, has changed and become more complex over time (62). Depending on the definition of rural used, the population can include as much as 19% of the US population (59 million people) (63). None of the available rural classification schemes are considered a gold standard definition of rurality.

Shifting definitions of rurality challenge the ability of researchers and public health practitioners to review and compare data and findings, assess the suitability of interventions for their populations of interest, and determine similarities in community need and context. Future studies should be clear about how rurality is defined so that it is possible to determine potential relevance to one’s own context. Defining rurality also allows for better comparison of screening rates across different settings described as rural, including whether expected outcomes are achieved across diverse settings.

States with large Appalachian regions known to have lower CRC screening prevalence (eg, Kentucky, Ohio) (64) were well represented among the studies meeting our inclusion criteria. However, other states in the southern Appalachian region with large rural populations (eg, Tennessee, North Carolina, South Carolina) were not. The populations in these states include rural residents of varying racial and ethnic groups, including Black, White, Hispanic, and American Indian or Alaska Native. Distance and travel time to health care facilities are also important considerations for rural residents (65) and can vary widely by geographic region. As illustrated in Figure 2, we did not identify studies in several states with the highest CRC incidence, including southern states such as Mississippi and Alabama. This could indicate that populations in greatest need are not being evaluated in studies for the best approaches to effectively reach them.

The national CRC screening program evaluated in Sharma et al 2022 (59) provides an opportunity to improve evidence-based implementation of CRC screenings in rural settings. The program works with health care systems, academic institutions, and other organizations to strengthen intervention strategies for CRC screening (66). The focus on serving people with lower incomes and reaching across multiple states makes the program uniquely positioned to address barriers to screening in rural settings. The program currently operates with 35 funded recipients (66) and could be expanded to states where we identified no studies meeting our inclusion criteria.

Costs

A small number of studies included data on intervention costs. Rural communities face unique economic and access challenges that can hinder intervention delivery, implementation, and participation. Less access to specialty care (eg, endoscopist), longer travel distances to facilities for in-person screening services, and greater financial burden due to higher uninsured rates are important considerations in rural settings (14,67). Understanding intervention costs can help communities decide which evidence-based interventions might be most feasible to implement. For example, mean costs are lower for FIT/FOBT-based programs than colonoscopy (68) and thus may be more feasible for initial screening of average-risk adults in rural health care systems. Multicomponent interventions that are delivered remotely can reduce access barriers and increase CRC screening rates (39).

Race and ethnicity

Few studies provided a comprehensive examination of differences in the effect of CRC screening interventions by characteristics such as race and ethnicity. Black and American Indian or Alaskan Native people have the highest overall CRC incidence rates, with Black people experiencing the highest mortality (69). Accessible CRC screening could make a substantial impact on CRC burden in these groups, as shown by studies included in our review such as Redwood et al (49). Opportunities for future research include 1) conducting focused intervention recruitment among subgroups underserved by screening and 2) understanding how different intervention strategies might vary in effectiveness given the intersection of rurality and characteristics such as race and ethnicity.

Strengths and limitations

One study strength is our use of broad search criteria that covered a 10-year span, allowing for greater inclusion of studies to inform our understanding of CRC intervention implementation and effectiveness. This study also has limitations. Not all studies used a randomized controlled trial design or included a control group, limiting understanding of how interventions might fare compared with usual care. Our review includes only peer-reviewed publications and does not account for interventions that have not been described in publications. Given changes in screening guidelines over time, some of the included studies delivered or evaluated tests that are no longer recommended (eg, barium enema).

Conclusion

This scoping review of CRC screening is, to our knowledge, the first to focus primarily on rural settings. Most studies implemented multicomponent interventions and were effective at increasing CRC screening uptake. The most commonly implemented approaches were client reminders, small media, and reducing structural barriers. While most studies evaluated multicomponent interventions, we had insufficient data to evaluate which intervention approaches, or combinations of approaches, could have the greatest effect on CRC screening in rural settings. This effect is an important consideration for implementation, particularly in rural health care clinics that are often overstretched and understaffed (70). Understanding how and why an intervention is effective can demonstrate its feasibility and build evidence on what works in rural settings.

Opportunities for future research and practice include developing a uniform definition of rurality, using theory to inform intervention development, collecting data on intervention costs, and evaluating how intervention effectiveness might vary by intervention strategies and across subgroups. Expanded implementation of CRC screening efforts across the US — and particularly in states and regions with large rural populations — may help to ensure all residents can receive timely CRC screening.

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Acknowledgments

We thank Denise Farley, MLIS Reference Librarian, Goldbelt Professional Services under contract with the Office of Science, Centers for Disease Control and Prevention, who assisted with our literature search for the scoping review. We also thank Florence Tangka for providing feedback to inform our discussion. We declare no potential conflicts of interest with respect to the research, authorship, or publication of this article. We received no external financial support for the research, authorship, or publication of this article. No copyrighted material, surveys, instruments, or tools were used in the research described in this article.

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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Author Information

Corresponding Author: Christine M. Kava, PhD, MA, Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, MS S107-4, Atlanta, GA 30341 (tqz1@cdc.gov).

Author Affiliations: ¹Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. ²Drexel University, Department of Health Management and Policy, Philadelphia, Pennsylvania. ³University of Iowa, Department of Epidemiology, Iowa City. ⁴University of Iowa, Department of Health Management and Policy, Iowa City.

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Tables

Abbreviations: FIT, fecal immunochemical test; FOBT, fecal occult blood test; FQHC, federally qualified health center; NR, not reported.
^a Sample characteristics are listed as reported. “Other” and “Non-White” responses are reported here as “another identity.” Some studies provided sample characteristics only by group (eg, preintervention vs postintervention) rather than in total; for these studies, the range of values across groups is reported. Percentages may not total 100% because of rounding or missing data.
^b Whether the study provided a definition of rurality based on population size or established census-tract or county-level standards (eg, Rural–Urban Continuum Codes).
^c Arnold et al 2016 and Davis et al 2013 report on the same intervention. Davis et al 2013 report on return of initial FOBT within 3 months and 12 months (initial results), while Arnold et al 2016 report return of 1, 2, or 3 FOBTs over a 3-year period (final results).
^d Arnold et al 2019 and Davis et al 2020 report on the same intervention. Arnold et al 2019 report on return of initial FIT within 12 months, while Davis et al 2020 report on return of repeat FIT within 12 to 18 months.
^e Race and ethnicity was asked only among eligible respondents who completed the survey, not among all respondents assigned to a study group.
^f Ethnicity reported separately from race.
^g Levy et al 2012 and Levy et al 2013 report on the same intervention. Levy et al 2012 report results for all 4 study groups (chart reminder group, mailed education group, mailed education and telephone reminder group, usual care control group), while Levy et al 2013 compare results between 2 study groups (mailed education group vs mailed education and telephone reminder group).
^h Number of participants who participated in a CRC home health party and completed baseline and follow-up surveys; demographic information reported is based on this number. The total number of community residents who attended at least 1 CRC home health party was 252.
ⁱ Rawl et al 2023 and Vachon et al 2024 report results from the same intervention. Rawl et al 2023 report data on receipt, uptake, and satisfaction of the intervention, while Vachon et al 2024 report on CRC screening outcomes.
^j Includes African American, Asian, Native Hawaiian or other Pacific Islander, and “other” responses. Refer to the article for detailed breakdown by race and ethnicity.

Abbreviations: BMI, body mass index; FIT, fecal immunochemical test; FOBT, fecal occult blood test; gFOBT, guaiac fecal occult blood test; NA, not applicable; USPSTF, US Preventive Services Task Force.
^a Tests that were delivered or evaluated as a CRC screening outcome (eg, percentage screened). Includes tests performed as initial screening and diagnostic follow-up.
^b Theories, frameworks, or research approaches (eg, community-based participatory research) used to inform the development, implementation, or evaluation of the intervention.
^c Describes main or relevant findings pertaining to CRC screening, sociodemographic or health-related differences in CRC screening, and evaluations of cost effectiveness. The results reported in this table are not meant to serve as an exhaustive list (ie, NA does not mean that no additional results were reported). Refer to each study for a detailed description of findings.
^d Arnold et al 2016 and Davis et al 2013 report on the same intervention. Davis et al 2013 report on return of initial FOBT within 3 months and 12 months (initial results), while Arnold et al 2016 report return of 1, 2, or 3 FOBTs over a 3-year period (final results).
^e Arnold et al 2019 and Davis et al 2020 report on the same intervention. Arnold et al 2019 report on return of initial FIT within 12 months, while Davis et al 2020 report on return of repeat FIT within 12 to 18 months.
^f Listed as 51.0% in the referenced article’s abstract.
^g Listed as $134.61 in the referenced article’s abstract.
^h Levy et al 2012 and Levy et al 2013 report on the same intervention. Levy et al 2012 report results for all 4 study groups (chart reminder group, mailed education group, mailed education and telephone reminder group, usual care control group), while Levy et al 2013 compare results between 2 study groups (mailed education group vs mailed education and telephone reminder group).
ⁱ Intervention also included materials for and evaluation of cervical cancer screening; for the purposes of this review, we report only on CRC screening.
^j Rawl et al 2023 and Vachon et al 2024 report results from the same intervention. Rawl et al 2023 report data on receipt, uptake, and satisfaction of the intervention, while Vachon et al 2024 report on CRC screening outcomes.
^k The information reported here describes results for CRC screening only. Results on other cancer screening content included in the original intervention are reported in the article cited.
^l Description of usual care group, as well as detailed description of intervention activities, are reported in the baseline publication: Biederman E, Baltic R, Katz ML, Rawl S, Vachon E, Monahan PO, et al. Increasing breast, cervical, and colorectal cancer screening among rural women: baseline characteristics of a randomized control trial. Contemp Clin Trials. 2022;123:106986. doi:10.1016/j.cct.2022.106986

^a Categorized according to Community Preventive Services Task Force–recommended strategies for multicomponent interventions for colorectal cancer screening.
^b Arnold et al 2016 and Davis et al 2013 report on the same intervention. Davis et al 2013 report on return of initial FOBT within 3 months and 12 months (initial results), while Arnold et al 2016 report return of 1, 2, or 3 FOBTs over a three-year period (final results).
^c Arnold et al 2019 and Davis et al 2020 report on the same intervention. Arnold et al 2019 report on return of initial FIT within 12 months, while Davis et al 2020 report on return of repeat FIT within 12 to 18 months.
^d Levy et al 2012 and Levy et al 2013 report on the same intervention. Levy et al 2012 report results for all 4 study groups (chart reminder group, mailed education group, mailed education and telephone reminder group, usual care control group), while Levy et al 2013 compare results between 2 study groups (mailed education group vs mailed education and telephone reminder group).
^e Rawl et al 2023 and Vachon et al 2024 report results from the same intervention. Rawl et al 2023 report data on receipt, uptake, and satisfaction of the intervention, while Vachon et al 2024 report on CRC screening outcomes.

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Appendix. Search Strategy

^a Limiters: Pub Year: 2010–2024; Geography: USA.

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