Building Cancer Prevention and Control Research Capacity in Rural Appalachian Kentucky Primary Care Clinics During COVID-19: Development and Adaptation of a Multilevel Colorectal Cancer Screening Project

Aaron J. Kruse-Diehr, Mark Dignan, Mark Cromo, Angela L. Carman, Melinda Rogers, David Gross, Sue Russell

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


This study describes the development of a colorectal cancer (CRC) screening multilevel intervention with four primary care clinics in rural Appalachian Kentucky. We also discuss barriers experienced by the clinics during COVID-19 and how clinic limitations and needs informed project modifications. Four primary care clinics were recruited, key informant interviews with clinic providers were conducted, electronic health record (EHR) capacity to collect data related to CRC screening and follow-up was assessed, and a series of meetings were held with clinic champions to discuss implementation of strategies to impact clinic CRC screening rates. Analysis of interviews revealed multilevel barriers to CRC screening. Patient-level barriers included fatalism, competing priorities, and financial and literacy concerns. The main provider- and clinic-level barriers were provider preference for colonoscopy over stool-based testing and EHR tracking concerns. Clinics selected strategies to address barriers, but the onset of COVID-19 necessitated modifications to these strategies. Due to COVID-19, changes in clinic staffing and workflow occurred, including provider furloughs, a state-mandated pause in elective procedures, and an increase in telehealth. Clinics adapted screening strategies to match changing needs, including shifting from paper to digital educational tools and using telehealth to increase annual wellness visits for screening promotion. While significant delays persist for scheduling colonoscopies, clinics were encouraged to promote stool-based tests as a primary screening modality for average-risk patients.

Original languageEnglish
Pages (from-to)1407-1413
Number of pages7
JournalJournal of Cancer Education
Issue number5
StatePublished - Oct 2022

Bibliographical note

Funding Information:
This study was funded by an administrative supplement to the Markey Cancer Center NCI Cancer Center Support Grant and was supported by the Markey Cancer Center Shared Resource Facilities (P30CA177558, Evers: PI).

Funding Information:
Previous research has showcased the effectiveness of establishing academic partnerships with primary care clinics and federally qualified health centers (FQHCs) in improving CRC screening outcomes in rural areas [–]. FQHCs serve populations in underserved areas by providing primary care and preventive services to persons across the lifespan, regardless of their ability to pay []. These organizations are community-based, nonprofit, or public and are governed by a board of directors composed of citizens or patients from their service area. Kentucky has nearly 350 clinics [] designated as FQHCs due to receipt of grant funding from the Health Resources and Services Administration Bureau of Primary Care and specific reimbursement from Medicare and Medicaid []. In Appalachian Kentucky, many individuals receive their medical care from these rural primary care clinics and FQHCs []. Because of the lower number of physicians practicing in Appalachian Kentucky, clinics also employ physician extenders such as advance practice registered nurses (APRN), physician assistants (PA), and certified medical assistants (CMA) to assist with providing care. These medical staff often live and work within their own communities, creating opportunities to develop trust and rapport with their patients. Combined with their medical training, the aforementioned characteristics make these physician extenders ideal partners to develop and deliver locally tailored health interventions.

Publisher Copyright:
© 2021, American Association for Cancer Education.


  • COVID-19
  • Colorectal cancer
  • Formative research
  • Implementation science
  • Rural health

ASJC Scopus subject areas

  • Oncology
  • Public Health, Environmental and Occupational Health


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