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Abstract
Background and objective Colorectal cancer (CRC) screening is effective at reducing the incidence and mortality of CRC. To address suboptimal CRC screening rates, a faecal immunochemical test (FIT) multicomponent intervention was piloted in four urban multidisciplinary primary care clinics in Alberta from September 2021 to April 2022. The interventions included in-clinic distribution of FIT kits, along with FIT-related patient education and follow-up. This study explored barriers and facilitators to implementing the intervention in four primary clinics using the Consolidated Framework for Implementation Research (CFIR).
Methods In-depth qualitative semistructured key informant interviews, guided by the CFIR, were conducted with 14 participants to understand barriers and facilitators of the FIT intervention implementation. Key informants were physicians, quality improvement facilitators and clinical staff. Interviews were analysed following an inductive–deductive approach. Implementation barriers and facilitators were organised and interpreted using the CFIR to facilitate the identification of strategies to mitigate barriers and leverage facilitators for implementation at the clinic level.
Results Key implementation facilitators reported by participants were patient perceived needs being met; the clinics’ readiness to implement FIT, including staff’s motivation, skills, knowledge, and resources to implement; intervention characteristics—evidence-based, adaptable and compatible with existing workflows; regular staff communications; and use of the electronic medical record (EMR) system. Key barriers to implementation were patient’s limited awareness of FIT screening for CRC and discomfort with stool sample collection; the impacts of COVID-19 (patients missed appointment, staff coordination and communication were limited due to remote work); and limited clinic capacity (knowledge and skills using EMR system, staff turnover and shortage).
Conclusion Findings from the study facilitate the refinement and adaption of future FIT intervention implementation. Future research will explore implementation barriers and facilitators in rural settings and from patients’ perspectives to enhance the spread and scale of the intervention.
- COLORECTAL CANCER
- SCREENING
- Implementation science
- Quality improvement
Data availability statement
Data are available upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
The evidence suggests that colorectal cancer (CRC) screening is effective at reducing the incidence and mortality of CRC, as well as costs related to treatment. While there are effective screening modalities, such as the faecal immunochemical test (FIT) available for early detection, recent estimates from Alberta, Canada indicate suboptimal screening rates. The factors associated with the adoption of CRC screening interventions is an area for process improvement.
WHAT THIS STUDY ADDS
There is existing literature that explores the factors that influence the successful uptake and implementation of CRC screening interventions, such as the FIT. However, most quality improvement initiatives do not employ a rigorous theory and evidence-based approach to understanding the underlying barriers and facilitators to FIT implementation. This study uses the Consolidated Framework for Implementation Research to more fully explore how the characteristics of this particular intervention and the context of implementation may impact implementation, and thus, address low screening rates for CRC.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study provides practical guidance to refine and inform ongoing and future efforts to integrate CRC screening into primary care through the identification of barriers and facilitators to FIT implementation. Strategies can be developed that mitigate barriers and leverage facilitators to promote adoption and optimise implementation of multicomponent CRC screening interventions. This has important implications for early detection of CRC, patient outcomes and costs to the healthcare system.
Background
Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second most common cause of cancer death worldwide, including Canada.1–3 In the province of Alberta in 2019, 2500 people were projected to be diagnosed with CRC, with 780 expected to die from it.3 CRC screening is highly effective at reducing the incidence and mortality of CRC, through the early detection of precancerous polyps, and facilitating their early management and treatment.1 4 5 If detected early, more than 90% of CRC cases can be successfully treated and 5-year CRC-associated mortality after diagnosis is also significantly reduced. Earlier diagnosis also results in significant reductions to the cost of treatment.6 7
Endoscopy-based (colonoscopy or sigmoidoscopy) and stool-based (faecal immunochemical test (FIT)) tests are the most commonly used effective screening modalities for the early detection of CRC.1 7 In Alberta, the FIT is the recommended first-line screening test for early detection of CRC or precancerous polyps in people aged 50–74 at average risk for CRC, which represents approximately 75% of the eligible population.8 9 Colonoscopy/sigmoidoscopy is only recommended in Alberta, for the population with increased risk (eg, family history of CRC) or those who have a positive result on the FIT.8 10 11 The most recent estimate of the provincial CRC screening participation rate is 58%, including both endoscopic-based and stool test-based screening methods involving people of all CRC risk levels.5 The FIT participation rate, on its own, is less than 40% of eligible (average risk) people in Alberta.12
Overall, the barriers affecting patients’ FIT participation are complex, multilevel and interrelated (health system or organisational processes and practices, providers’ service provision and patients’ perception).1 In Alberta, the typical FIT process for CRC screening poses inconveniences for patients and family physicians, which are causing missed opportunities for screening. Additionally, patients’ fear of being diagnosed with CRC, and limited understanding of the importance of CRC screening, all negatively affect patients’ acceptability of the FIT.1
A multicomponent intervention approach is effective in increasing CRC screening and FIT participation, and the application of this approach has been recommended by the Community Preventive Service Task Force.13–16 Multicomponent interventions combine two or more patient-targeted interventions to promote cancer screening, through three strategies: increasing demand, access and delivery of screening services.15 16 The Cancer Prevention and Screening Innovation team within Alberta Health Services (Alberta’s provincial health service delivery organisation) piloted a patient-centred, multicomponent intervention influencing different levels of the FIT process to address barriers, and sustainably modify patients’ FIT participation behaviour to increase FIT participation.
Implementation of interventions into routine primary care can be influenced by a wide range of factors including those related to clinic context, intervention characteristics, providers’ behaviour, patient needs and the implementation process.17 A comprehensive understanding of these factors provides a foundation for planning implementation strategies.17–19 A recent systematic review reports that many of the existing studies had limited use of implementation science frameworks to guide a comprehensive theory and/or evidence-based understanding of the implementation factors specific to CRC screening interventions in primary care.20
In this paper, we present the barriers and facilitators to implementing a multicomponent intervention in four primary clinics using the Consolidated Framework for Implementation Research (CFIR).17 The CFIR was chosen to understand the implementation of the FIT intervention at the clinic level, recognising the importance of how implementation processes impact individual behaviour change within a specific context.17 The CFIR was developed from a synthesis of the implementation literature, incorporating theory as well as empirical evidence regarding the factors that influence implementation.17 In particular, the framework provides comprehensive guidance in assessing contextual factors that may impact the success of implementing an intervention in the real world. The CFIR includes five core domains to guide the assessment of implementation barriers and facilitators: the individual characteristics, the inner setting, the outer setting, the implementation process and the characteristics of the innovation itself.17
Methods
Study design
This is a qualitative descriptive study using semistructured key informant interviews with 14 participants involved in the multicomponent FIT implementation. As our guiding theoretical framework, the CFIR was used to inform the development of our interview guide and analysis of the implementation barriers and facilitators.17 Interviews were conducted following the 6-month implementation period, to obtain an in-depth understanding of the barriers and facilitators to implementation.21 This study was part of a larger implementation-effectiveness study, which has not yet been published.
FIT intervention components
The FIT intervention was developed based on implementation evidence regarding multicomponent CRC screening innovations.20 In-clinic distribution of FIT kits was designed to reduce organisational structural barriers for FIT access for patients aged 50–74 visiting pilot primary care clinics who are eligible for FIT according to Alberta CRC screening guidelines (ie, average-risk population, FIT not completed within the last 2 years; screening colonoscopy or sigmoidoscopy not completed within the last 10 years). Along with patients’ access to FIT kits in clinics, patient education was designed to educate patients on the importance of CRC screening/FIT and the FIT sample collection and return procedure. Patient follow-up and reminder phone calls were designed to support patients’ timely FIT sample collection and return for FIT completion within 1 month of accessing a FIT kit from the pilot primary care clinics. Online supplemental appendix 1 illustrates usual practice regarding the use of FIT for CRC screening in Alberta compared with the quality improvement initiative described in this paper.
Supplemental material
Intervention implementation setting
We piloted these interventions in four primary care clinics in urban Alberta from September 2021 to April 2022. A total of 32 participants involving 11 physicians, 9 medical office assistants (MOAs), 3 quality improvement facilitators (QIFs), 2 clinic managers, 2 licensed practical nurses (LPNs), 2 electronic medical record (EMR) consultants, a registered nurse (RN), a panel management assistant (PMA) and a proactive office encounter technician (POET) from 4 participating clinics implemented the FIT intervention.
Participant recruitment and data collection
The interviewer, a member of the project implementation research team, sent emails to all 32 primary care staff from the 4 participating clinical sites, requesting their participation. The interviewer, a PhD trained researcher, with expertise in evaluation methods, was not directly involved in the implementation of the initiative and had not previously worked with the participants. Fourteen participating key informants of the 32 invited consented to be interviewed. The participants were four physicians, three QIF, two clinical managers, two MOAs, an RN, a PMA and a POET, representing all four clinics that participated in the intervention.
In-depth semistructured interviews were conducted virtually from February to April 2022 at the participant’s convenience, and were audio recorded, and transcribed using MS Teams by the research team members who were not directly involved in implementation. The CFIR informed the development of the semistructured interview guide. First, 17 interview questions were developed to represent the relevant CFIR constructs. These questions were then summarised into five semistructured interview questions with prompts (see online supplemental appendix 2 for the interview guide). Interviews were conducted with consideration of the busy clinical schedules of participants, lasting between 20 and 40 min. Of the 14 interviews, 12 were conducted one to one, 1 interview involved 2 participants to fit the participants’ busy clinical schedule and 1 participant declined to be recorded but permitted the interviewer to take detailed notes of the conversation. To ensure the accuracy of the transcripts, audio recordings were compared with the transcript during the transcript review.
Supplemental material
Data analysis
A combined inductive and deductive approach was used to identify barriers and facilitators to the FIT intervention. NVivo Pro V.12 was used to organise and code data for thematic inductive analysis. Themes were generated from codes using thick description and iteratively analysed by two individuals for redundancy through a process of comparison to ensure each theme was distinct: MP coded the first three interviews and SM ensured codes were distinct and accurately interpreted. The rest of the interviews were coded iteratively back and forth using the same process until all the interviews were coded.
These themes were organised into barriers and facilitators of FIT intervention implementation. Once themes for barriers and facilitators were identified, themes were refined and reorganised through the process of deductively mapping the themes to the CFIR framework to understand how the inductively identified barriers and facilitators related to existing theory and evidence regarding the determinants for implementation.
Patient and public involvement
Patients and the public were not involved in this study.
Results
Six overarching themes regarding facilitators and barriers to FIT implementation were identified. The results are presented as facilitators or barriers under each theme. These themes have also been categorised according to the relevant CFIR constructs, along with select illustrative quotes in tables 1–5 following the description of each theme below.
Barriers and facilitators related to Consolidated Framework for Implementation Research (CFIR) outer setting of the faecal immunochemical test (FIT) intervention
Barriers and facilitators related to Consolidated Framework for Implementation Research (CFIR) intervention characteristics of the faecal immunochemical test (FIT) intervention
Barriers and facilitators related to Consolidated Framework for Implementation Research (CFIR) inner setting of the faecal immunochemical test (FIT) intervention
Barriers and facilitators related to Consolidated Framework for Implementation Research (CFIR) characteristics of the individual of the faecal immunochemical test (FIT) intervention
Barriers and facilitators related to the Consolidated Framework for Implementation Research (CFIR) process of the faecal immunochemical test (FIT) intervention
Theme 1: meeting patient needs through the FIT intervention
Facilitators
The primary facilitator was patient convenience. In-clinic FIT kit distribution removed the obstacle of requiring patients to take a test requisition to a laboratory location to pick up a FIT kit.
Another benefit of in-clinic distribution of FIT kits was that clinic staff gave the kit to patients and provided education on its importance and how to complete the kit (eg, expiry dates, cleanest way to collect sample, where to take the sample) for those that had not completed one before. This proactively addressed patient hesitancy. Staff appreciated the opportunity to endorse and discuss the FIT with patients.
First-time users found the printed one-page summary helpful as an additional education source. Some staff highlighted sections of the instructions to ensure that patients would follow the appropriate steps for collection and document necessary information (eg, date and time of collection) for the sample. Staff suggested that prehighlighted printed resources could reduce staff workload because not all patients needed verbal instructions to complete the FIT. One clinic that served a large Punjabi-speaking patient population provided written instructions in Punjabi, which bridged the language barrier and improved patient education on FIT completion.
The clinic used follow-up reminder calls at 4 and 8 weeks after FIT distribution when patients had not completed the test.
Barriers
While clinics provided education for patients and tried to alleviate the discomfort around FIT completion, common patient barriers still prevented some from completing a FIT. Completion was dependent on: patients’ awareness of the importance of screening; fear of finding out they have CRC from the FIT kit; feelings of embarrassment carrying the FIT outside the clinic; forgetting to complete the FIT; feeling too busy; or feeling uncomfortable with sampling (eg, think that it is dirty to ‘play with poop’).
Some patients had other pressing health challenges that caused staff to deprioritise CRC screening at the time. While one clinic provided patient resources to support non-English speakers, other clinics did not have resources in other languages, so English language and FIT instruction comprehension and literacy were barriers for some patients. Additionally, the pandemic impacted patient appointments by disrupting communication between providers and patients (from in-person to online or phone appointments), closing waiting rooms, creating staff shortages and availability due to work from home, and creating fear of in-person appointments. For some patients, the fear of COVID-19 prevented them from returning their FIT sample to a laboratory location, despite receiving the FIT at their clinic appointment.
Theme 2: clinic staff motivation to adopt and implement FIT intervention
Facilitators
Participants understood the importance and value of the kits and were motivated to incorporate FIT distribution and tracking within their clinics. They believed it would be effective in increasing patient FIT screening. Physicians were motivated to improve screening rates because they believed in the effectiveness of FIT screening for early detection.
Generally, clinics had a culture of improving patient care and the FIT screen was part of the work clinics were already doing with patients. Some participants felt that the size of the clinics and staffing capacity of clinics affected their ability to undertake initiatives for improving patient health. Feedback reports on FIT completion rates and seeing early CRC detections in patients motivated clinicians because they saw the improvements and positive outcomes of FITs.
Barriers
Challenges arose when staff could not fulfil their roles in the processes of the intervention. This was often related to not understanding the importance of the intervention. When QIFs clearly explained the purpose of the practice change, the reason for data collection, and how it could be done, staff came on board.
Theme 3: compatibility of FIT workflow processes
Facilitators
Physicians viewed the FIT intervention as compatible with their ongoing process improvement as they already had FIT screening built into their practice. Furthermore, non-physician clinic staff perceived that additional work like distributing FIT kits and follow-up calls was easy to add on to their existing work.
The multicomponent FIT intervention could be flexibly integrated into clinical workflow in each clinic. For example, some clinics used paper-based tracking for FIT screening and follow-up reminder phone calls; others used excel spreadsheets, word documents or their EMR. Using a simple workflow chart in the clinics provided clarity on staff roles for the intervention implementation. Additionally, patient information and requisitions were easily printed in the clinic, which supported clinics to carry out the intervention.
Barriers
Some issues did arise, such as too many requisitions for patients to take with them; the FIT required a separate requisition or form (from all laboratory tests). Additionally, multiple follow-up phone calls were hard for staff to complete (two calls 1 month apart). Inconvenient storage places for kits also added more time to implementation. However, due to the process improvement approach used in the project, clinics addressed these issues by testing different ways to manage these tasks, for example, adding FIT to a common requisition form used for all laboratory tests; setting a limit on the number of follow-up calls that would be made; and storing kits in the appointment rooms.
Theme 4: communication among staff was important for FIT implementation and quality improvement
Facilitators
Communication within the clinic was important to support quality improvement for the FIT intervention, and address any issues that arose. Staff communication facilitated effectively carrying out the FIT interventions and following the same key implementation steps and supported them in addressing barriers to implementation. Recurring internal meetings in clinics provided staff with opportunities to discuss implementation progress and issues, and review clinic results (ie, FIT kit distribution rates; test completion rates)
Barriers
The lack of clinic process improvement meetings meant that there were fewer opportunities to troubleshoot challenges with FIT implementation or to discuss project progress and barriers. The lack of informal communication between the clinical team to troubleshoot workflow issues hindered delivery of FIT. COVID-19 public health restrictions, that resulted in some staff working offsite during the study period, led to decreased opportunities for informal communications to troubleshoot workflow issues ‘in the moment’ as well. While use of virtual communication technologies helped clinic teams to maintain communication, their use was limited at times by poor internet (unstable) access.
Theme 5: clinic capacity to implement FIT
Facilitators
Partnership support and buy-in from health system stakeholders important to the new FIT processes facilitated implementation in the clinics (eg, laboratory services (Dynalife), primary care networks (PCNs) provided EMR consultants and panel managers), and physicians' involvement. Additionally, QIFs supported staff with EMR set-up, ordering FIT kits or printed resources, which ensured processes were in place for project roll-out and made tasks simple and manageable. Some clinics had additional supports for staff, which facilitated implementation and made the continuity of the FIT intervention possible. These supports included: clinic office managers, clinic MOAs, EMR consultants, panel managers and PMAs, who assessed and ordered FIT kits online, taught patients how to use kits, completed patient calls and tracked patient sign out of kits. When these staff assumed some of the work, it reduced the workload for other staff and enabled project feasibility.
Barriers
Barriers arose when staff did not feel they had sufficient information to begin or continue a task, especially with regards to ordering FIT kits from laboratory services. There was confusion about the expected lag time between ordering and receiving FIT kits, how to order them (ie, online) and how many to order.
When clinics were busy, staff had tight time constraints, so they had less time to follow-up with patients, which occasionally led to missed FIT screening opportunities. Occasionally, FIT processes were impacted by busy clinic schedules, not enough staff trained, and thus not having capacity to talk to every eligible patient. The pandemic also impacted FIT screening by encouraging staff to work from home, which meant fewer staff could distribute kits and education to patients.
High staff turnover and gaps in training in the clinics led to disruptions in the implementation as new staff needed to be oriented to the intervention processes. As a result, other staff had to pick up the slack, leading to increased workload for them until new staff were fully oriented to the workflow. Staff turnover highlighted the need for risk mitigation and change management. For example, use of the EMR for FIT helped to document the FIT screening processes and ensuring that each member of the clinical team was clear on their role in the implementation process, including who will complete patient follow-up and outreach.
Theme 6: use of the EMR to track FIT patient information impacted implementation processes
Facilitators
Automated prompts within the clinic EMRs increased the ease and reliability of the intervention by prompting staff to screen and complete follow-up calls with patients. The EMR also enabled easy patient data extraction when clinics needed to track patient information or create reports so that staff could see the impact of their improvement efforts. Staff appreciated the automated system and recognised its time saving quality.
Barriers
While the EMR reduced workload in some clinics, others chose to use manual information tracking instead because they were not familiar or comfortable with using their EMR. Some clinics wanted to incorporate the EMR, but they faced challenges with incorporating the automated system. Consequently, data for project implementation was difficult to retrieve. Clinics that worked with an EMR consultant, however, could easily develop patient data collection and alert clinical staff on necessary patient follow-up. Clinics without an EMR consultant struggled with setting up information management through their EMR and thus found the intervention labour intensive. In the clinics that were not able to use their EMR to track and manage their intervention, the project provided a manual tracking sheet to record FIT distribution, follow-up calls and test completion. Clinics that used the manual tracking sheet found it was easy to use of inputting and extracting the information they needed.
Discussion
Key findings and interpretation
This study explored the barriers and facilitators to implementing multicomponent interventions to improve CRC screening (FIT) in four primary clinics in Alberta using semistructured interviews with 14 participants involved in the intervention implementation. Key facilitators to implementation included: perception of patient needs being met, a clinics’ readiness to implement (including staff’s motivation and capacities (eg, skills, knowledge, resources)), the design and perceived quality of the intervention (eg, evidence-based, practical, compatible with existing workflows) and the use of the EMR system to track patient information regarding their FIT screening.22 Participants also described the following barriers impacting the implementation of the FIT intervention: patient awareness regarding the importance of FIT screening and discomfort with stool sample collection, impacts of COVID-19 (ie, restricted in-person patient appointment, limited coordination and communication between staff related to remote work), and limited clinic capacity (ie, skills using the EMR system, staff turnover and shortage).
According to our recent systematic review of 12 studies that synthesised the barriers and facilitators to CRC screening; engagement of the clinic team, leadership team and partners; clinics’ motivation to improve CRC screening rates; use of the EMR system with continuous monitoring and feedback; and a supportive environment for implementation were the most commonly reported implementation facilitators.20 Limited time for the clinic team to devote to a new project, challenges in getting accurate, timely data related to CRC screening, limited capacity/support to use the EMR system and disconnection between clinic team members were the most commonly reported implementation barriers. While this study corroborates many of the findings from the systematic review, we have also identified other specific contextual factors that impacted implementation, including the role of additional support staff to facilitate implementation.
Strong evidence exists on the effectiveness or benefits of a multicomponent intervention to improve CRC screening participation rate.13–16 Our project effectiveness findings also show the improvement in the FIT participation rate compared with the preimplementation participation rate (absolute increase of 13%). In addition, the clinics who implemented the FIT intervention have reported that the newly adopted FIT kit processes are now routine practice in their clinics. As such, while barriers may have challenged aspects of implementation, many of the facilitators described by participants supported overall successful implementation of the FIT intervention.
Using the CFIR, we identified several facilitators related to the intervention characteristics; participants were motivated by the FIT intervention’s strong evidence base and promoting convenience and access to patients. Offering patients the FIT kit at their clinic visit can reduce barriers for accessing FIT kits by promoting timely/easy access of FIT kits, and reducing the extra patient travel steps associated with the usual access to FIT in Alberta. Physician distribution of FIT kits also offers the opportunity for face-to-face interaction between patients and providers about FIT.
Considering factors related to the ‘Outer Setting’ of the CFIR: patient’s lacking awareness of the importance of FIT screening resulted in incomplete FITs. Participants reported that the intervention provided opportunities for educational conversations between patients and providers. Patient engagement is critical in promoting the importance of CRC screening and FIT to improve their knowledge and change their fatalistic beliefs and fears about CRC and screening.23 Furthermore, availability of information provided in multiple languages promoted FIT completion in historically marginalised or underserved populations.24
While the COVID-19 pandemic influenced patient appointments for completing a FIT and increased their hesitations to go to a lab, the pandemic also impacted the clinic implementation context (CFIR Inner Setting). Disruptions to clinic staffing impacted intervention training for available staff and capacity for FIT intervention activities from reduced clinic team sizes. A systematic review on the impact of COVID-19 on CRC screening found that CRC screening decreased from 28% to 100% in different countries after the onset of the pandemic.25 This has important implications for early detection and reduction of mortality due to CRC. Contextual adaptations are needed to support implementation of CRC screening programmes in primary care during a pandemic.23 In the context of the FIT intervention in the four clinics, staff capacity limitations were countered by support from key stakeholders and partners, including PCNs (who provided support for EMR patient information tracking), Alberta Health Services (Provincial Colorectal Cancer Screening Program who championed the initiative), as well as other administrative clinic staff (who completed additional tasks related to FIT kit orders and patient follow-ups).
Using the CFIR enabled identification of a multitude of facilitators and barriers across and within constructs, demonstrating a complex picture of challenges and opportunities while implementing an evidence-based intervention in primary care. This study has provided an in-depth understanding of the specific contextual factors that will guide future implementation, spread and scale of the FIT initiative in primary care in Alberta. This work is essential to move forward, given setbacks in CRC screening due to the COVID-19 pandemic.
At 6 months after the project intervention period, all pilot clinics reported that the intervention was now routine practice for them. This suggests that ensuring that the intervention was codeveloped and adapted to fit individual clinic workflows promoted long-term sustainability of the intervention. Following the success of this project, the project team codesigned and tested an implementation guide intended to aid in the spread of the intervention across Alberta with relevant stakeholders. The guide includes resources for the target audience explaining the rationale of the intervention, tools and resources for implementation, implementation strategies and performance measurement to gauge implementation success within a clinic. The final implementation guide will be hosted on the online platform for the Alberta Cancer Screening Program and will be readily accessible to the clinics interested in implementing interventions to improve FIT participation rates. The Alberta Cancer Screening Program is currently championing the spread of this intervention as part of its own Strategic Plan objective to increase CRC screening participating rates in the province.
Strengths and limitations
Our previous systematic review identified few studies exploring barriers and facilitators to CRC screening and a lack of studies employing implementation science approaches to understand how to enhance implementation efforts.20 This study uses an implementation science framework, the CFIR, for data collection, analysis, organisation and interpretation, which has facilitated an understanding of a wide range of factors within a given context that influenced implementation of the FIT intervention, from a strong empirical and theoretical basis. However, there are also important limitations to note. First, while this study interviewed diverse (various roles) clinical providers to obtain varied perspectives related to implementation, we were unable to recruit LPNs due to their unavailability to participate in the study. Second, this study does not include patients’ perspective and implementation factors in rural settings. While this study draws on clinical staff perspectives, patient perspectives are a key factor in guiding the development of patient interventions. Clinics in rural settings can face different or additional barriers and inequity in cancer screening due to fewer resources and challenges in access. Finally, data about the clinic’s overall patient load, the number of eligible patients visiting the clinics during the study period and the patients’ characteristics were not collected. Hence, limiting the interpretation of our findings, as we are unable to assess how implementation factors may have been impacted by these characteristics. Including a trained, dedicated person for the primary data collection and the EHR data extraction as part of the implementation team may help address this issue.
Future research
Next phases of this research will be to incorporate the findings of this study into the refinement and adaptation of FIT intervention strategies for application in other primary care settings, including rural settings in Alberta and the patient perspective regarding barriers and facilitators to inform future implementation efforts.
Conclusion
Our findings suggest that the FIT intervention’s strong evidence base, convenience for patients, compatibility with existing workflows and clinic’s readiness to implement were key factors in facilitating implementation. Limited clinic capacity, particularly during COVID-19, and lack of patient awareness and beliefs around CRC screening were important barriers. Efforts to enhance patient education and materials, in addition to leveraging supports from project partners, helped to mitigate implementation challenges.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This implementation project was a health quality improvement project, approved by the ARECCI (A pRoject Ethics Community Consensus Initiative) screening process for ethical conduct, exempted this study. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors are thankful for the contributions of the Cancer Prevention Screening and Innovation team members, especially Muhammad (Kashif) Mughal, who supported the evaluation of the intervention, as well as the leadership and implementation team who played important roles in facilitating the implementation and coordinating project partners. The authors would also like to extend their gratitude to all of the staff at the participating clinics, our partner Primary Care Networks, Dynalife laboratory services, and Alberta Health, who collaborated with us on this initiative and participated in the interviews.
Supplementary materials
Supplementary Data
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Footnotes
Contributors KA, KM and GFT were involved in the conception and design of the study. KM, SSM and MP were involved in data analysis. KA and KM were responsible for interpreting the data and drafting the manuscript. All coauthors contributed to interpretation of data and provided intellectual content and revisions to manuscript. All authors read and approved the final draft. KA is the guarantor of this manuscript.
Funding This research was funded by Alberta Health through the Cancer Prevention and Screening Innovation (CPSI) in Alberta Health Services. Provision of funding by Alberta Health does not signify that this project represents the policies or views of Alberta Health. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.