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Introduction
Colorectal cancer (CRC) is the second leading cause of death from cancer among American Indian and Alaska Native (AI/AN) men and third among AI/AN women (1). Although screening has been shown to reduce death rates, the percentage of people up to date with CRC screening is low in many AI/AN communities. Less than half (48.4%) of AI/AN adults aged 50 to 75 were up to date with CRC screening in 2015 (2).
The US Preventive Services Task Force (USPSTF) recommends stool-based tests and direct visualization tests (colonoscopy, flexible sigmoidoscopy, or virtual colonoscopy) for CRC screening. (3). In health care systems with limited capacity to provide direct-visualization screening tests, stool-based tests such as high-sensitivity, guaiac-based fecal occult blood tests (FOBT) and fecal immunochemical tests (FIT) are often the most accessible options for CRC screening. However, various patient and structural barriers exist to completing FOBT and FIT: geographic isolation, lack of a regular health care provider, failure of providers to recommend screening, lack of clinical tracking and reminder systems, lack of transportation, embarrassment, privacy concerns, distrust of the health care system, and insufficient knowledge about CRC, its risk factors, and screening recommendations (4). Many of these barriers can be mitigated. According to the Community Preventive Services Task Force, there is sufficient evidence that using patient reminders and small media (eg, letters, pamphlets, brochures, flyers) can increase CRC screening with stool tests (5). Reducing structural barriers (eg, eliminating or simplifying administrative procedures required for CRC screening, reducing time or distance for screening services) is also an effective way to increase the use of stool tests (6). Direct mailing of FOBT or FIT is an approach that can address both patient and structural barriers. Mailing FOBT or FIT kits to patients and providing outreach through telephone calls and home visits can reduce patient and structural barriers, and both have been shown to be effective strategies to improve participation in CRC screening in various underserved populations (7–10). The objective of our study was to determine if such evidence-based interventions could also lead to increased CRC screening among rural AI/AN populations.
Methods
Participant recruitment
We recruited 3 tribally operated health care facilities with which we had a previous working relationship to participate in our study. The selected facilities were in...