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Interventions_for_increasing_c.PDF
RESEARCH ARTICLE
Interventions for increasing colorectal cancer
screening uptake among African-American
men: A systematic review and meta-analysis
Charles R. RogersID 1*, Phung Matthews1, Lei Xu2, Kenneth Boucher3, Colin Riley1,
Matthew Huntington 1 , Nathan Le Duc
1 , Kola S. Okuyemi
1 , Margaret J. Foster
4
1 Department of Family & Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah,
United States of America, 2 Department of Health Education and Promotion, East Carolina University,
Greenville, NC, United States of America, 3 Cancer Biostatistics Shared Resource, Huntsman Cancer
Institute, Salt Lake City, UT, United States of America, 4 Medical Sciences Library, Texas A&M University,
College Station, TX, United States of America
Abstract
Background
African-American men have the lowest 5-year survival rate in the U.S. for colorectal cancer
(CRC) of any racial group, which may partly stem from low screening adherence. It is imper-
ative to synthesize the literature evaluating the effectiveness of interventions on CRC
screening uptake in this population.
Materials and methods
In this systematic review and meta-analysis, Medline, CINAHL, Embase, and Cochrane
CENTRAL were searched for U.S.-based interventions that: were published after 1998–
January 2020; included African-American men; and evaluated CRC screening uptake
explicitly. Checklist by Cochrane Collaboration and Joanna Brigg were utilized to assess
risk of bias, and meta-regression and sensitivity analyses were employed to identify the
most effective interventions.
Results
Our final sample comprised 41 studies with 2 focused exclusively on African-American men.
The most frequently adopted interventions were educational materials (39%), stool-based
screening kits (14%), and patient navigation (11%). Most randomized controlled trials failed
to provide details about the blinding of the participant recruitment method, allocation con-
cealment method, and/or the outcome assessment. Due to high heterogeneity, meta-analy-
sis was conducted among 17 eligible studies. Interventions utilizing stool-based kits or
patient navigation were most effective at increasing CRC screening completion, with odds
ratios of 9.60 (95% CI 2.89–31.82, p = 0.0002) and 2.84 (95% CI 1.23–6.49, p = 0.01). No
evidence of publication bias was present for this study registered with the International Pro-
spective Registry of Systematic Reviews (PROSPERO 2019 CRD42019119510).
PLOS ONE
PLOS ONE | https://doi.org/10.1371/journal.pone.0238354 September 16, 2020 1 / 27
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OPEN ACCESS
Citation: Rogers CR, Matthews P, Xu L, Boucher K,
Riley C, Huntington M, et al. (2020) Interventions
for increasing colorectal cancer screening uptake
among African-American men: A systematic review
and meta-analysis. PLoS ONE 15(9): e0238354.
https://doi.org/10.1371/journal.pone.0238354
Editor: Joseph Telfair, Georgia Southern University,
UNITED STATES
Received: March 4, 2020
Accepted: August 7, 2020
Published: September 16, 2020
Copyright: © 2020 Rogers et al. This is an open access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
files.
Funding: This study was supported by the National
Cancer Institute of the National Institutes of Health
(NIH) [grant number K01CA234319]. The content
is solely the responsibility of the authors and does
not necessarily represent the official views of the
NIH.
Competing interests: The authors have declared
that no competing interests exist.
Conclusions
Additional research is warranted to uncover effective, affordable interventions focused on
increasing CRC screening completion among African-American men. When designing and
implementing future multicomponent interventions, employing 4 or fewer interventions types
may reduce bias risk. Since only 5% of the interventions solely focused on African-American
men, future theory-driven interventions should consider recruiting samples comprised solely
of this population.
Introduction
African-American men and women in the United States (U.S.) have the highest rates of most
cancers in terms of both mortality and morbidity [1]. Despite being highly treatable when
detected early, colorectal cancer (CRC) remains the second leading cause of death in the U.S.
from cancers affecting both men and women, and the third deadliest among African Ameri-
cans [2]. African-American men are disproportionately affected by CRC, experiencing the
lowest 5-year survival rate of all racial and gender groups. Furthermore, African-American
men are 24% more likely to have CRC than white men [3]. Contributing factors to these CRC
incidence and mortality inequities among African-American men include a lack of health
insurance and limited access to early detection screening, in addition to socioeconomic disad-
vantages such as lower education levels and higher poverty rates [1, 2, 4, 5]. Other contributing
factors noted in the literature include lifestyle factors, existing chronic conditions, family his-
tory, tumor characteristics, a lack of social support, mistrust of medical systems, and percep-
tions of both racial discrimination and the African-American masculine role [3–14].
In June 2016, the U.S. Preventive Services Task Force (USPSTF), a panel of independent
national experts who provide recommendations about clinical preventive services, recom-
mended that all people, unless at heightened risk, should begin obtaining regular CRC screen-
ing at age 50 [15, 16]. In May 2018, the American Cancer Society (ACS) recommended that,
due to increasing rates of CRC in younger individuals, routine screening should begin at age
45 [17]. Evidence-based screening for CRC exists in the form of either stool-based laboratory
tests or camera-aided visual exams of the colon and rectum [17]. These options for asymptom-
atic individuals who are at average risk include the fecal immunochemical test (FIT) and
guaiac-based fecal occult blood test (FOBT), recommended yearly; the multi-targeted stool
DNA test every 3 years; a computed-tomography colonography or flexible sigmoidoscopy
every 5 years, or a colonoscopy every 10 years [17]. An estimated 50% reduction in CRC mor-
tality among the total U.S. population has been attributed to adherence to these guidelines
[18].
Although CRC screening rates have been improving since 2005, evidence suggests that
uptake remains low among African-American men and that screening is poorly understood in
this population [19, 20]. African Americans “in general” have lower screening rates than
whites (55.5% versus 61.5%) [1]. Recent research has identified several key factors associated
with lower CRC screening uptake in African-American men, including fear and anxiety, espe-
cially in regard to colonoscopy, and a lack of knowledge about the curability of early-stage
CRC [13, 21]. African-American men may also overestimate the risks associated with CRC
screening procedures [13]. In addition, the FOBT—that requires patients to avoid eating cer-
tain kinds of meat and vegetables before the collection of stool, has a lengthy testing time, and
necessitates patients handling their own fecal matter—has been associated with negative atti-
tudes among African Americans [22].
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Understanding and implementing evidence-based interventions that increase screening
uptake among African-American men is a challenge. Intervention studies have reported
mixed results about determining the most efficacious methods of increasing CRC screening
uptake overall, and few studies of this nature specific to African-American men have been con-
ducted. Furthermore, many of these trials are of low quality. Gee, Walsemann, and Brondolo
argue that such interventions should be grounded in a theoretical approach that includes cul-
tural and social factors as agents of change, as all too often healthcare interventions neglect the
importance of these aspects in patients’ healthcare decisions [23]. Accordingly, our research
team advocated for an assessment and evaluation of current evidence-based interventions that
target increasing CRC screening uptake in African-American men. To meet this goal, we con-
ducted a systematic review of the literature and a quantitative meta-analysis, with 2 aims: (1)
synthesize the evidence from published studies evaluating interventions to increase CRC
screening uptake among African-American men; and (2) quantitatively assess the evidence
from these published studies through meta-analysis to determine the most effective screening
uptake interventions for African-American men.
Rationale for systematic literature reviews
In recent decades, the amount of research on interventions to increase the uptake of CRC screen-
ing among African-American men has increased exponentially [24]. Consequently, it is more dif-
ficult for some researchers and medical professionals to digest current findings and directions in
the literature [24]. Systematic reviews thus fill an important role by providing an overview of the
current state of research on a particular topic, pointing out weaknesses and gaps in the literature,
and clarifying where disagreement or contradictions are reported, as findings from individual
studies may be inconsistent [25, 26]. Systematic methods must be used to conduct literature
reviews because nonsystematic or narrative reviews are difficult to properly assess [27]. The use of
a systematic approach also permits the researcher to create a set of parameters that allows for the
elimination of bias by excluding flawed studies from the ultimate analysis [27].
Rationale for meta-analyses
Single studies are informative for building the literature on a particular topic, especially when
evaluating treatments and interventions, but are prone to false positives and negatives [25]. A
meta-analysis provides a systematic approach for evaluating a series of studies in which those
with larger sample sizes carry more weight [25]. The strength of this technique also includes 1)
enabling researchers to provide a quantitative estimate for the effect of a treatment or interven-
tion, 2) helping researchers identify more precise estimates of intervention effectiveness or
other outcomes than any individual study in a pooled analysis [28]. Thus, by aggregating the
findings of many studies and correcting for potential error or bias, a meta-analysis helps to
identify the potential pitfalls within any single study as well as to identify studies with consis-
tent results [24]. Additionally, this technique enables researchers to identify the overall effect
of a particular treatment or intervention [25].
Materials and methods
Study selection
To be included in the review, studies had to be: (1) inclusive of African-American/Black adult
men 18 years of age or older; (2) focused on interventions for CRC screening uptake; (3) pub-
lished after 1998, 2 years before the initial publication of the American College of Gastroenter-
ology’s CRC screening guidelines [29]; (4) written in English and conducted in the U.S.; and
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(5) published, peer-reviewed, full-text journal articles. The (colorectal) cancer profile of Afri-
can-born Blacks differs from that of U.S. States-born Blacks and also varies by region of birth
[30], thus, our research team solely focused on U.S.-born African-American men. Studies
based on secondary analyses of data were excluded. Although potential for publication bias
remains, only peer-reviewed articles were considered as review for quality, relevancy, and
accuracy by multiple experts in the field provides a higher level of validity [31]. In addition,
because the research team was interested in interventions that proved to be effective in achiev-
ing increased screening completion, included studies had to report on actual CRC screening
uptake, as opposed to changes in CRC screening beliefs or intent to screen.
To determine an article’s eligibility, a team consisting of 3 systematic review screening-
trained co-investigators (authors CR, MH, and PM) performed 2 rounds of assessment. In the
first round, they reviewed potentially eligible studies by article title and abstract from the
results obtained in Rayyan QCRI, a web-based systematic-review platform that was created to
expedite the initial screening of abstracts and titles, and uses a process of semi-automation
while incorporating a high level of usability [32]. The databases Medline (Ovid), CINAHL
(EBSCO), Embase (Ovid), and Cochrane CENTRAL (Wiley) were individually searched, and
Rayyan QCRI was used to sort the retrieved manuscripts.
Last ran on January 14, 2020, the literature search combined 4 concepts: colorectal cancer,
screening, African American, and men. Each concept was searched using database thesaurus
terms and keywords as appropriate (see S1 Appendix). This method was based on the princi-
ples discussed in the Cochrane Handbook, including the combination of keywords and subject
headings [33]. Discrepancies between the 2 team members were adjudicated by the study Prin-
cipal Investigator (PI; first author CRR).
After this initial screening process, articles that potentially met all criteria, or the eligibility
of which was unclear, underwent a second round of screening in which the same 2 authors
again independently screened each article, and conflicts were resolved through face-to-face
meetings with the PI. The screening team also reviewed the references of included articles. As
a systematic review, this study did not require informed consent or institutional review board
approval as human subjects were not involved. Yet, the protocol was registered with the Inter-
national Prospective Registry of Systematic Reviews (PROSPERO 2019 CRD42019119510).
Data abstraction, risk of bias assessment, synthesis, and analysis
After articles had been accepted for the systematic review, the same 3 members of the research
team (CR, MH, PM) coded each paper individually by entering information into a standardized
Google form. Extracted data covered study characteristics such as sample size, demographics, and
eligibility criteria. Other data gathered from the accepted articles included statistical analyses used,
intervention type, theoretical background used, and limitations cited by the study authors. CR,
MH, and PM also abstracted data and met weekly to resolve any coding conflicts. Tables were con-
structed to qualitatively describe the study design and report the results of each included study.
In order to determine the potential risk of bias, each study was randomly assigned to 2 of 3
study members (CRR, PM, MF) who assessed the studies by applying the appropriate critical
appraisal criteria based on each study’s type independently. During this quality assessment
process, the two authors followed the blind review protocol [34]. In detail, Cochrane Collabo-
ration’s checklist was used to assess risk of bias for randomized control trials [35], as well as
Joanna Brigg’s checklist for quasi-experimental [36] and cohort [37] studies. All disagreements
were settled through discussions with a third member until consensus was reached.
For the meta-analysis, we first defined the values of I 2
statistics; our results showed that I 2
>75%, indicating that considerable heterogeneity was present [38, 39]. Next, substantial
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heterogeneity was investigated using meta-regression for intervention type (control interven-
tion, FIT or other stool-based screening test, printed education materials, or patient naviga-
tion) as recommended by Sharp [40] and Newton [41]. Control intervention denoted the
control group in the studies. For example, some studies reported usual care as a control group
while others mailed letters recommending CRC screening. Then, we conducted sensitivity
analyses to evaluate the effect of removing any 1 study from each meta-regression. To evaluate
for bias resulting from the absence of studies with negative or insignificant results (often
termed “publication bias”), we examined funnel plots visually for asymmetry and used the
method of Egger and colleagues to formally test for funnel-plot asymmetry [25]. The “meta-
prop” and "metareg” functions in R package “meta” and “metafor” were employed for statisti-
cal analysis, using a random intercept logistic regression model that was fitted using restricted
maximum likelihood (REML). We also used Clopper-Pearson exact binomial confidence
intervals to report, respectively, for individual studies on the funnel plots. These analyses were
conducted using R, and figures were produced using the meta package [42–44].
Results
Sample
A total of 1,465 articles were initially identified from the 4 databases searched, 41 (2.79%) were
included in the final sample for the systematic review [45–85]. As recommended by the
PRISMA group [86], Fig 1 provides details regarding the identification, screening, eligibility,
and inclusion processes. S2 Appendix details the research team’s adherence to PRISMA’s
checklist—which helped improve the reporting quality for the current study.
Characteristics of included studies
Most interventions (73%) were performed in clinical or medical facilities. The remaining 11
(27%) studies that were not conducted in a clinical setting took place in a church (12%), busi-
ness (3%), or did not report their intervention setting (12%). Studies were published between
2000 and 2019, with most (n = 12) appearing between 2010 and 2012. Two authors published
more than 1 study on the topic (11%), namely, Blumenthal (n = 2), and Leone (n = 2) [50, 54,
68, 77]. Slightly more than half (56%; n = 23) of the studies included only participants aged 50
years and older, while five (12%) included participants starting at age 45 years, three (7%)
included participants younger than 45. Twelve of the studies (29.27%) reported demographics
specific to African-American men [50, 52, 56, 57, 59, 60, 63, 66, 71, 74, 82, 84]. In the studies
aimed at increasing CRC screening uptake among African-American men, the intervention
components most frequently employed (among 135 interventions types utilized) were tele-
phone encounters or education (18%; n = 25), mailed or electronically sent educational materi-
als (13%; n = 18), FIT or other CRC stool-based screening kits (mailed or administered in
person) (13%; n = 17), patient navigation (10%; n = 13), and printed materials given to individ-
uals in person (12%; n = 16). A matrix of the included studies, sorted according to their theo-
retical design and methodological features, is found in Table 1; these features are detailed
below.
Theory. Nearly half of the studies (39%; n = 16) did not report a theoretical framework,
while the remaining studies (61%; n = 25) used 1 to 3 frameworks. A theoretical foundation
built on 1 conceptual model was most common (56%; n = 14), with the Health Belief Model
the most utilized (28%; n = 7), followed by the Preventive Health Model (16%; n = 4) and the
Transtheoretical Model (also referred to as Stages of Change) (16%; n = 4). For example, in a
study grounded by the Preventive Health Model and input from a community advisory board,
Christy and colleagues tested the effectiveness of their self-created CRC photonovella booklet
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Fig 1. Selection of studies for inclusion in review and meta-analysis.
https://doi.org/10.1371/journal.pone.0238354.g001
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Table 1. Matrix of 41 reviewed studies, according to theoretical design and methodological features.
Study Theoretical
Framework
Study Design Most Advanced Statistical
Analysis
Validly and Reliably
Reported
Number of African-American Male
Participants Reported
Arnold et al. (2019) Explicit use RCT Multivariate evaluation Validity: No Reliability:
No
Not reported
Basch et al. (2006) No framework RCT Descriptive Validity: No Reliability:
No
Not reported
Bastani et al. (2015) Explicit use RCT Multivariate evaluation Validity: No Reliability:
No
Yes
Blumenthal at al.
(2005)
Explicit use Quasi-
experimental
Multivariate evaluation Validity: No Reliability:
No
Not reported
Blumenthal et al.
(2010)
Explicit use RCT Chi-square tests Validity: No Reliability:
No
Yes
Chen et al. (2008) No framework Cohort Chi-square tests Validity: No Reliability:
No
Not reported
Christy et al. (2016) Explicit use RCT Multivariate evaluation Validity: No Reliability:
No
Not reported
Cole et al. (2017) No framework RCT Multivariate evaluation Validity: No Reliability:
No
Yes
Davis S et al. (2017) Explicit use RCT Multivariate evaluation Validity: No Reliability:
No
Not reported
Davis T et al. (2019) Explicit use RCT Multivariate evaluation Validity: No Reliability:
No
Not reported
DeGroff et al.
(2017)
Explicit use RCT Multivariate evaluation Validity: Yes Reliability:
No
Not reported
Eberth et al. (2018) No framework Cohort Descriptive Validity: No Reliability:
No
Not reported
Fiscella et al. (2011) No framework RCT Multivariate evaluation Validity: No Reliability:
No
Not reported
Ford et al. (2006) Explicit use RCT Chi-square tests Validity: No Reliability:
No
Yes
Greiner et al. (2014) Explicit use RCT Multivariate evaluation Validity: No Reliability:
No
Not reported
Gupta et al. (2013) No framework RCT Chi-square tests Validity: No Reliability:
No
Not reported
Hendren et al.
(2014)
Explicit use RCT Multivariate evaluation Validity: No Reliability:
No
Not reported
Hoffman et al.
(2017)
Explicit use RCT Multivariate evaluation Validity: No Reliability:
No
Yes
Holt et al. (2011) Explicit use Quasi-
experimental
Multivariate evaluation Validity: No Reliability:
No
Not reported
Horne et al. (2015) No framework RCT Multivariate evaluation Validity: No Reliability:
No
Yes
Inadomi et al.
(2012)
No framework RCT Multivariate evaluation Validity: No Reliability:
No
Not reported
Jandorf et al. (2013) Explicit use RCT Multivariate evaluation Validity: No Reliability:
No
Yes
Kempe et al. (2012) No framework Quasi-
experimental
Multivariate evaluation Validity: No Reliability:
No
Not reported
Khankari et al.
(2007)
No framework Quasi-
experimental
Chi-square tests Validity: No Reliability:
No
Not reported
Lasser et al. (2011) Explicit use RCT Chi-square tests Validity: No Reliability:
No
Not reported
Leone et al. (2013) No framework Quasi-
experimental
Multivariate evaluation Validity: No Reliability:
No
Not reported
(Continued)
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plus a fecal immunochemical test (FIT) kit and the CDC’s standard “Screen for Life” brochure
(not targeted to African-Americans plus a FIT kit among 330 Black participants (308 African
Americans, 22 Caribbean/Haitians/Other) in Florida who were not current with CRC screen-
ing [5]. Fifty-two percent of this sample was male. The educational messages developed for the
CRC photonovella were based on the following theoretical constructs: barriers, self-efficacy,
CRC screening coherence and salience, response efficacy, and susceptibility of focus. Also,
noteworthy, a randomized control trial (RCT) by DeGroff and colleagues was the only study
driven by 3 frameworks: the Health Belief Model, Theory of Reasoned Action, and social learn-
ing theories [73]. This patient-navigation intervention aimed to address multilevel patient-
defined barriers to CRC screening completion among 840 patients who were referred for a
colonoscopy by primary care providers in Massachusetts. Eighty percent of participants were
either non-Hispanic Black (40%) or Hispanic (40%). Two bilingual lay navigators (1 male, 1
female) delivered the intervention primarily via telephone, while some activities were con-
ducted by mail or in person, with an average time of 44 minutes per patient. Both navigators
received additional training in motivational interviewing.
Geography. Interventions were evaluated by geographic location, with 4 regions consid-
ered during coding: West, Midwest, South, and Northeast [87]. Interventions were conducted
in all 4 geographic regions: South (44%), Northeast (32%), Midwest (12%), and West (12%).
Table 1. (Continued )
Study Theoretical
Framework
Study Design Most Advanced Statistical
Analysis
Validly and Reliably
Reported
Number of African-American Male
Participants Reported
Leone et al. (2016) Explicit use RCT Multivariate evaluation Validity: No Reliability:
No
Not reported
Martin et al. (2017) Explicit use Quasi-
experimental
Descriptive Validity: No Reliability:
No
Not reported
Maxwell et al.
(2019)
No framework RCT Descriptive Validity: No Reliability:
No
Yes
Mehta et al. (2019) Explicit use Quasi-
experimental
Descriptive Validity: No Reliability:
No
Not reported
Miller et al. (2011) Explicit use RCT Multivariate evaluation Validity: No Reliability:
No
Not reported
Morgan et al.
(2010)
Explicit use RCT Multivariate evaluation Validity: No Reliability:
No
Yes
Myers et al. (2014) Explicit use RCT Multivariate evaluation Validity: No Reliability:
No
Yes
Philip et al. (2010) Explicit use Quasi-
experimental
Descriptive Validity: No Reliability:
No
Not reported
Pignone et al.
(2011)
No framework RCT Multivariate evaluation Validity: No Reliability:
No
Not reported
Resnicow et al.
(2014)
Explicit use RCT Multivariate evaluation Validity: No Reliability:
No
Yes
Reuland et al.
(2017)
No framework RCT Multivariate evaluation Validity: No Reliability:
No
Not reported
Schroy et al. (2012) Explicit use RCT Multivariate evaluation Validity: No Reliability:
No
Not reported
Siddiqui et al.
(2011)
Explicit use RCT Multivariate evaluation Validity: No Reliability:
No
Yes
Singal et al. (2017) No framework RCT Chi-square tests Validity: No Reliability:
No
Not reported
Zubarik et al.
(2000)
No framework Cohort Descriptive Validity: No Reliability:
No
Not reported
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Most studies (90%; n = 37) reported that intervention delivery occurred in a single geographic
region, 2 articles reported delivery in 2 regions, and 2 articles did not report the location of
their interventions. For example, Leone and colleagues performed their intervention in both
Michigan and North Carolina, stating that the 2-state approach was as an effort to increase the
generalizability of their results [54].
Setting. Setting—where studies take place—is a highly influential factor for intervention
outcomes due to its potential impact on sample representation, intervention uptake, and sus-
tainability. Approximately 81% of studies implemented interventions in 1 primary setting, 7%
used multiple settings, and 12% did not report the intervention setting. For example, Blu-
menthal and colleagues delivered CRC education messages via radio, newsletters, public trans-
portation, health fairs, festivals, television programs, etc [68]. Blumenthal and colleagues used
community-based participatory research, which places the responsibility for intervention
design and delivery, including setting, in the hands of community partners [50, 68]. DeGroff
et al., Fiscella and colleagues, and Gupta et al. are examples of studies that used local resources
(i.e. established medical networks and safety clinics) to meet the disproportionate health needs
of largely minority areas [46, 58, 73]. Two studies used clinical/medical settings due to the
presence of an open-access endoscopy system, which was defined by Chen and colleagues as
providing direct referrals for CRC screening and thus bypassing additional gastroenterology
exams and decreasing the number of appointments that study participants needed to attend
[47, 49].
Interventions that took place outside of clinical or medical settings were conducted in
churches (12%), local businesses (5%), and other communal spaces (e.g., community centers,
social organizations) (~5%). Several studies justified using church-based settings because reli-
gion and faith are central themes of African-American culture; church settings are a natural
venue to introduce faith-based intervention materials; previous church-based interventions
have proven effective for addressing other health disparities in African-American populations;
and church settings may be able to reach those with limited access to healthcare [54, 60, 78].
Cole and colleagues, who conducted their intervention in New York City barbershops, empha-
sized the community-based approach, stating that––as is commonly seen among African-
American men––those with the greatest need are not accessing the healthcare system [57]. Set-
ting selection in our sample was likely also influenced by available resources, funding sources,
and population need. The effectiveness of interventions conducted in clinical versus commu-
nity-based settings should be further evaluated.
Post-intervention screening uptake. Reported screening uptake percentages among
study participants ranged from 8% to 90% [45, 76]. The intervention with the highest overall
screening uptake (81.9%) involved sending participants a culturally sensitive photonovella and
a free FIT kit [45]. Interestingly, however, this same study reported that 90% of their con-
trols––subjects who received a standard CRC screening brochure developed by the CDC,
along with the free FIT kit––also reported screening uptake [45]. Most, but not all, studies
reported higher screening uptake rates in the intervention group than in the control group.
Intervention types. Many of the studies evaluated used more than 1 intervention to
increase CRC screening (see Table 2). Often, 2 or more intervention arms were used, along
with a control arm. Intervention arms often included more than 1 component or type of inter-
vention. For example, 1 study compared patient navigation alone with patient navigation plus
motivational interviewing or a control group [57]. Another study combined a screening deci-
sion aid with patient navigation [62]. One intervention was a citywide messaging campaign
that included educational sessions at local community centers, yard signs, and messages in
newspapers [68]. Because of this heterogeneity, it was difficult to succinctly categorize studies
by the type of intervention used. However, we found that 43% (n = 16) of studies used some
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Table 2. Number of CRC interventions used in a sample of (41) reviewed studies.
Intervention Type (n = # of studies) Study
Telephone encounter/ education (n = 25) Arnold et al (2019) Eberth et al. (2018) Lasser et al. (2011) Reuland et al. (2017)
Basch et al. (2006) Fiscella et al. (2011) Leone et al. (2013) Siddiqui et al. (2011)
Bastani et al. (2015) Ford et al. (2006) Leone et al. (2016) Singal et al. (2017)
Chen et al. (2008) Gupta et al. (2013) Martin et al. (2017) Zubarik et al. (2000)
Christy et al. (2016) Hendren et al. (2014) Maxwell et al (2019)
Cole et al. (2017) Jandorf et al. (2013) Mehta et al (2019)
DeGroff et al. (2017) Kempe et al. (2012) Myers et al. (2014)
Mailed/electronic version of education materials (n = 18) Christy et al. (2016) Hendren et al. (2014) Leone et al. (2016)
Cole et al. (2017) Jandorf et al. (2013) Pignone et al. (2011)
Davis T. et al (2019) Kempe et al. (2012) Resnicow et al. (2014)
DeGroff et al. (2017) Lasser et al. (2011) Siddiqui et al. (2011)
Fiscella et al. (2011) Leone et al. (2013) Singal et al. (2017)
Gupta et al. (2013) Myers et al. (2014) Zubarik et al. (2000)
FIT/iFOBT/Stool test kit (n = 17) Christy et al. (2016) Gupta et al. (2013) Leone et al. (2016) Siddiqui et al. (2011)
Cole et al. (2017) Hendren et al. (2014) Martin et al. (2017) Singal et al. (2017)
Davis T. et al (2019) Inadomi et al. (2012) Mehta et al. (2019)
Fiscella et al. (2011) Kempe et al. (2012) Myers et al. (2014)
Greiner et al. (2014) Lasser et al. (2011) Reuland et al. (2017)
Patient Navigation (n = 13) Chen et al. (2008) Fiscella et al. (2011) Lasser et al. (2011) Reuland et al. (2017)
Cole et al. (2017) Ford et al. (2006) Leone et al. (2013)
DeGroff et al. (2017) Horne et al. (2015) Martin et al. (2017)
Eberth et al. (2018) Jandorf et al. (2013) Myers et al. (2014)
Printed Materials (n = 16) Arnold et al. (2019) Christy et al. (2016) Inadomi et al. (2012) Miller et al. (2011)
Bastani et al. (2015) Davis S et al (2017) Khankari et al. (2007) Morgan et al. (2010)
Blumenthal at al. (2005) Davis T et al (2019) Leone et al. (2016) Philip et al. (2010)
Blumenthal et al. (2010) Holt et al. (2011) Maxwell et al. (2019) Reuland et al. (2017)
One-on-One Education (n = 13) Arnold et al. (2019) Fiscella et al. (2011) Inadomi et al. (2012) Reuland et al. (2017)
Blumenthal et al. (2010) Hendren et al. (2014) Maxwell et al. (2019)
Davis S et al. (2017) Holt et al. (2011) Martin et al. (2017)
Eberth et al. (2018) Khankari et al. (2007) Philip et al. (2010)
Decision Aid (n = 6) Hoffman et al. (2017) Miller et al. (2011) Reuland et al. (2017)
Leone et al. (2013) Pignone et al. (2011) Schroy et al. (2012)
Group Education (n = 5) Blumenthal at al. (2005) Holt et al. (2011) Morgan et al. (2010)
Blumenthal et al. (2010) Leone et al. (2016)
Community Outreach (n = 4) Blumenthal at al. (2005) Leone et al. (2016) Martin et al. (2017) Morgan et al. (2010)
DVD/Video (n = 4) Hoffman et al. (2017) Leone et al. (2016) Martin et al. (2017) Morgan et al. (2010)
Educate/Train Clinical Staff (n = 4) Martin et al. (2017) Pignone et al. (2011) Schroy et al. (2012) Zubarik et al. (2000)
Case Management (n = 1) Ford et al. (2006)
Financial Assistance (n = 1) Blumenthal et al. (2010)
Financial Incentive (n = 1) Mehta et al. (2019)
Interactive Kiosk (n = 1) Greiner et al. (2014)
Open Access Colonoscopy (n = 1) Eberth et al. (2018)
Peer Counselors (n = 2) Leone et al. (2016) Maxwell et al (2019)
Resource Sheet (n = 1) Leone et al. (2016)
Online Risk Assessment (n = 1) Schroy et al. (2012)
Sigmoidoscopy Program (n = 1) Zubarik et al. (2000)
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form of tailored educational material; 32% (n = 12) included patient navigation; 22% (n = 9)
included some form of group or 1-on-1 education; 22% (n = 9) gave subjects free FIT or
immunochemical fecal occult blood test (iFOBT) kits; 9% (n = 4) employed telephone out-
reach; and 3% (n = 1) intervened at the physician level.
The intervention that performed best compared with controls was in a study by Reuland
and colleagues that incorporated a screening decision aid along with patient navigation; 68% of
participants in the intervention arm reported screening uptake compared with 27% of controls
[62]. Unfortunately, this study did not break out its screening-uptake results by race; thus, it
cannot be determined how much this intervention affected African Americans specifically.
Among African Americans specifically, the intervention that resulted in the highest screening
uptake compared with controls mailed a free FIT kit to participants, 43% of whom returned the
kit, compared with 15% of controls who engaged in some other form of screening [58].
The 2 interventions that most commonly reported significant differences in screening
uptake among African-American participants compared with controls were patient navigation
and free FIT or iFOBT kits. Tailored materials, such as culturally sensitive brochures or videos,
and education, whether in person or in a group setting, also had positive outcomes, but not to
the extent of patient navigation or free screening kits. Interestingly, Mehta and colleagues
approached CRC screening uptake by providing financial incentives via 3 arms: unconditional,
conditional, and lottery [81]. The unconditional arm was given a $10 gift card along with the
FIT kit, while those in the conditional arm received the $10 gift card after completion of the
FIT testing if within 2 months. Participants randomized to the lottery arm were afforded the
opportunity to win a $100 gift card–with a 1 in 10 chance of winning—if the FIT test were
completed and returned within the 2 months mark [81].
Intervention delivery. Interventions were most commonly implemented by the study
researchers themselves, medical personnel, or public health workers (as was the case among
patient navigation interventions). Some studies enlisted the help of local community members,
including churches, barbershops, and other local businesses [57, 68, 78, 82]. Besides the use of
patient navigators in general, there was no observed trend in CRC screening uptake related to
who implemented the intervention. For example, standard patient navigation resulted in
higher CRC screening uptake (80%) compared with peer–patient navigators (African-Ameri-
can community members who were specially trained to be patient navigators) (74%) or pro–
patient navigators (healthcare professionals who were trained to deliver culturally sensitive
patient navigation) (76%) [60].
Limitations of interventions. Most studies recognized a lack of generalizability in their
results due to the subject population or the geographic region in which the study was con-
ducted. For example, 1 study reported that “participants were recruited from healthcare pro-
viders in large urban settings, consisted of 75% females and had regular contact with a
healthcare provider, and thus are not representative of the African American community in its
entirety [67].” Another reported issue regarding generalizability relates to the potential for
selection bias, especially in studies in which the main intervention was a free FIT/iFOBT kit.
These studies first contacted the individuals to see if they were willing to participate in the
study, and then the subjects received the free kits. Because the participants were already willing
to participate in research, they may have been more likely than other members of the general
public to use and send back the FIT kits.
In many studies, especially those that used patient navigation or provided free FIT/iFOBT
kits, cost was often cited as problematic for wide-scale implementation of the intervention. A
study of 2 citywide interventions that implemented various intervention strategies reported
that radio and TV were the most effective media used, but recognized these are expensive
options that may not be financially feasible for others [68]. However, if granted financial
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incentives, Mehta et al. found the incentive amount of $10 might have been too small to pro-
mote any increase in FIT kit completion [81].
Another commonly reported limitation was the nature of the intervention follow-up. In
general, follow-up to check CRC screening status ranged from 3 to 12 months. However, it is
possible that participants obtained screening after these follow-up points and thus their data
were missed. Along with follow-up time, the ability to contact participants at follow-up was
also reported to be problematic. This was especially true in low-income populations. In 1
study, patient navigators were unable to follow up with 23% of participants [55]. This problem
was avoided in studies that had access to electronic health records where screening status
could easily be verified. However, not all studies had such capability.
Study design was also commonly mentioned as a potential limitation. Though most studies
were RCTs, few incorporated any kind of blinding because of the nature of the interventions
used (patient navigation, free FIT kits, culturally tailored brochures).
Risk of bias
Studies were allocated into 3 categories to assess for biases: Randomized Controlled Trials
([RCTs], Fig 2), Cohort (Fig 3), and Quasi-Experimental (Fig 4). Twenty-nine studies [45, 46,
48, 50–52, 54–66, 69, 71, 73–75, 77, 79–81, 83, 84] in the RCT category were largely rated as
unclear risk, yet 20 of the studies had low risk on random sequence generation (i.e., descrip-
tion of randomization procedure) [50–52, 56–63, 69, 74, 75, 79–81]. The majority of the stud-
ies (n = 13) did not explain or detail if any blinding of the participants and/or personnel in group allocation occurred, which included 18 studies with an unclear risk on allocation con-
cealment [48, 50, 52, 54, 55, 57, 63–66, 71, 74, 77, 79, 80, 83]. Either listed as a supplement in
the manuscript or published elsewhere, only 5 studies [50, 57, 58, 61, 80] reported their study
Fig 2. Risk of bias graph for RCTs.
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protocol. Overall, 26 RCTs did not account for blinding of outcomes while 6 RCTs [45, 48, 50,
56, 57, 63] received a high bias rating due to their report of additional biases. Moreover, studies
with the highest numbers of interventions (n = 9, Leone et al. 2016 [54], n = 7, Martin et al. 2017 [72], and n = 6, Reuland et al. 2017 [62]) demonstrated risk of bias scores ranging from unclear to high risks. Multicomponent studies with the lowest risk bias utilized 4 or fewer
types of interventions.
Next, 9 of the studies were classified as quasi-experimental [49, 53, 67, 68, 70, 72, 76, 78,
82]. Although only 2 of these studies contained a control group [68, 76], a high bias risk was
yielded for the remaining 7 studies. All 9 studies revealed low bias risk for outcome measure-
ment appropriate statistical analysis use. Lastly, 2 studies were considered for the cohort design
[47, 85], with both having similar ratings for low bias risk.
Meta-analyses
Meta-regression was used to compare the 4 intervention types (Table 3). The endpoint for the
meta-analysis was intervention effectiveness, defined as the proportion of participants that
obtained CRC screening during or after the intervention. Interventions that used a FIT kit or
patient navigation were significantly better than the print and control intervention at increas-
ing CRC screening uptake among African-American men, with odds ratios (ORs) of 9.60 (95%
CI 2.89–31.82, p = 0.0002) and 2.84 (95% CI 1.23–6.49, p = 0.01), respectively. Meta-analysis
results were reported for each intervention type separately (see Figs 5–7). Interventions that
used print materials were not significantly better than control interventions. To directly
Fig 3. Risk of bias graph for cohort studies.
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compare pairs of interventions, additional models were fitted restricting the studies to a pair of
interventions. In these models, FIT interventions were not superior to patient-navigation (PN)
interventions (OR = 3.42, 95% CI 0.75–15.62, p = 0.11), FIT interventions were superior to
print interventions (OR = 5.01, 95% CI 1.87–13.67, p = 0.001), and PN interventions were not
significantly different from print interventions (OR = 1.52, 95% CI 0.59–3.90, p = 0.38). There
was evidence of substantial statistical heterogeneity (range of I 2
between 93% and 98% for the
4 interventions, all p < 0.01) for combined ORs across categories. No single study significantly
influenced the meta-regression results.
Publication bias analysis
As depicted in a symmetric funnel plot (see S1 Fig), no publication bias was found in this
study [88]. Moreover, no evidence of bias was detected by Egger and colleagues’ test (bias = –
1.17, SE = 3.18, P = .72) [89].
Fig 4. Risk of bias graph for Quasi-experimental studies.
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Table 3. Random effects meta-regression results.
Variable Coefficient SE Odds Ratio Z P-value
Est. Lower 95% CI Upper 95% CI
Intercept -1.13 0.31 0.32 0.18 0.59 -3.66 0.0003
Arm
Control Intervention� (reference)
FIT 2.26 0.61 9.6 2.89 31.82 3.69 0.0002
PN 1.04 0.42 2.84 1.23 6.49 2.46 0.01
Print 0.63 0.46 1.87 0.76 4.62 1.35 0.18
�Control Intervention denoted the control group in the studies.
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Discussion
Findings overview
The purpose of this systematic review and meta-analysis was to ascertain which interventions
were most effective in increasing CRC screening uptake among African-American men. In
our qualitative analysis of the extant literature examining the various types of interventions,
patient navigation and the distribution of free stool-based test kits, including FIT and iFOBT
kits, emerged as the most consistently effective interventions. Print and other educational
materials were the most common interventions, but their results were mixed, with some stud-
ies reporting increased screening rates compared with controls, while others reported similar
or lower screening rates compared with control groups. Through using the Cochrane risk of
bias tools to assess the eligible studies in our review, we found that most RCTs failed to provide
any details about the blinding of the participants recruitment method, the allocation conceal-
ment method, and/or the outcome assessment. Future RCT research should focus on enhanc-
ing the research design quality in these specific areas, particularly in the implementation and
evaluation stages. In addition, most of the quasi-experimental studies lacked control groups in
Fig 5. Meta-analysis for control and FIT (fecal immunochemical test) interventions. Events: number of participants with screening outcomes in the arm of
the study; Total: number of participants in the arm of the study; Proportion: the ratio between Events and Total.
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their study design. Therefore, the ability to make group comparisons among participants was
challenging and it was nearly impossible to compare the interventions’ effectiveness. Statistical
evidence with both clearly defined controls are needed in future studies.
Heterogeneity of the findings made it challenging to determine which intervention was
most effective and should be considered for future studies focused on African-American men
as recommended by Kwaan and Jones-Webb [90]. Due to the diversity of settings, geographic
Fig 7. Meta-analysis for print interventions. Events: number of participants with screening outcomes in the arm of the study; Total: number of participants in the arm
of the study; Proportion: the ratio between Events and Total.
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Fig 6. Meta-analysis for PN (patient navigation) interventions. Events: number of participants with screening outcomes in the arm of the study; Total: number of
participants in the arm of the study; Proportion: the ratio between Events and Total.
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regions, interventions employed, and outcomes measured, factors other than the intervention
may have influenced CRC screening uptake. For example, most studies were conducted within
a medical clinical or hospital. This setting in and of itself may have increased CRC screening
uptake by increasing access to other resources (e.g., electronic health records, scheduling ser-
vices, screening materials).
Further, it should be noted that most of the interventions were implemented by healthcare
professionals, including physicians, public health workers (e.g., patient navigators), and the
researchers themselves. This may have influenced screening uptake rates as participants may
have had an implicit bias toward obtaining CRC screening to please researchers or doctors.
Conversely, medical mistrust—a common factor that significantly contributes to delays in
healthcare system utilization by African-American men—may have discouraged African
American study participants specifically from obtaining CRC screening [3].
Future directions
Only 2 of 41 studies reviewed (5%) focused exclusively on African-American males [57, 66].
Though each study included some African-American males, researchers rarely examined bar-
riers and enablers specific to this group, which continues to suffer the most from CRC inci-
dence and mortality [1]. The lack of understanding of CRC screening-completion barriers and
enablers among African-American men was exacerbated in our study by the lack of distinction
in the data reported for race and gender. Studies that segmented data by race or gender did
one or the other but not both, leaving the African-American male experience with CRC
screening further underrepresented in intervention studies. To achieve the goal of reducing
CRC-related inequities among African-American men, health promotion and prevention
interventions that centralize cultural identity and cultural empowerment should be developed
in order to better capture African-American men’s CRC screening experiences within a cul-
ture-specific context and their understanding of those experiences [91, 92].
Our inclusion criteria for the review required a study population that included African-
American men, and this specification may have been the cause of the geographic dispersion
among the interventions evaluated. The U.S. Census Bureau reports that a majority of the Afri-
can-American population of the U.S. is concentrated in the Southern and Northeastern
regions [93]. Additionally, African Americans experience greater CRC incidence, higher mor-
tality, and lower survival at all stages, when compared to their white counterparts, and several
articles mentioned that the geographical locations where interventions were implemented had
large populations of African Americans experiencing CRC disparities [3, 19, 49, 59, 78]. How-
ever, the majority of the studies (76%) is this review occurred in Eastern and Southern states,
with only 25% in Western and Midwestern states. The preponderance of data from the East
and South––while helpful for providing insight into regional barriers and enablers to CRC
screening uptake––is not equally applicable to all African-American populations. Given geo-
graphical variability in diet, culture, and intergenerational attitudes along with the effect of
these variables on CRC screening outcomes, more-specific regional information is required to
develop effective interventions in understudied areas. Western states, though included in only
12% of the studies evaluated, are home to the nation’s most ethnically diverse populations and
currently represent what is projected to be a nationwide shift in the ratio of ethnic-to-noneth-
nic residents [94, 95]. Specifically, the West encompasses 13 of the 25 most ethnically diverse
cities in the nation and the most ethnically diverse state, California, with a census-reported
population that is 39% Hispanic-white and 36% non-Hispanic white [94, 96]. As more regions
transform to resemble California’s demographic distribution, it is critical that future research
includes and emphasizes the barriers and enablers of CRC screening completion in minority-
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majority areas. More geographically dispersed studies occurring outside of the Southern and
Northeastern regions of the U.S. are needed. Moreover, with the unscreened populations in
these regions, subgroup differences for those experiencing CRC disparities are yet to be
identified.
It is noteworthy that slightly over 75% of the interventions aimed at increasing CRC screen-
ing uptake occurred in medical or clinical settings. Although many of these studies did not
provide a justification for choosing to provide the intervention in a clinical setting, this deci-
sion may have been due to ease of data access, convenience sampling, or community needs.
While many of the initiatives to promote CRC screening described in this review took place in
healthcare settings and have proved successful, it is likely that individuals who did not seek
routine medical care, did not have a regular healthcare provider, or lived with lower socioeco-
nomic status were excluded from the interventions [19]. In particular, the aforementioned sce-
narios have been demonstrated as potential barriers that prevent African-American men from
seeking or obtaining CRC screening [97–100]. Therefore, to reduce the pervasive CRC screen-
ing disparities faced by African-American men, it is important for future public health work-
ers, healthcare organizations, patient navigators, researchers, and physicians to consider
collaborating to design, evaluate, and implement interventions in non-healthcare settings.
In this review, 24% of the included studies formulated and conducted their CRC interven-
tion programs in churches, local businesses (e.g., barbershops), and other community settings
[47, 57, 68, 78, 101]. For example, Holt and colleagues discussed using church-based
approaches to promote CRC prevention behaviors through a series of community health advi-
sor–led educational modules [78]. However, results from the educational series suggested that
adding spiritual themes did not result in significant behavioral changes among attendees. This
might further validate the role of other contributing factors, such as lack of health insurance,
lack of access to early-detection screening, medical system mistrust, and socioeconomic disad-
vantages as mediators influencing early detection screening behavior changes among African-
American men, and thus, should be considered alongside the other well-documented barriers
to CRC screening [101, 102].
Furthermore, as highlighted in a previous systematic review by Rogers and colleagues, there
is a need to better understand the influence of sociocultural determinants that may influence
African-American men’s negative responses, reluctance, and apprehension associated with
CRC screening [103]. Culturally sensitive community-based interventions among African-
American men should be further developed and implemented. However, a few other cautions
should be considered by future researchers while designing Federally Qualified Health Center
(FQHC) non-clinically–based programs. Maxwell and colleagues noted that it remained chal-
lenging to implement and sustain their community-based programs to increase CRC screening
among Filipino Americans primarily due to (1) the need for program participants to seek
screening through their healthcare providers, (2) lack of funds to sustain the program, and (3)
lack of an adequately trained workforce to maintain program activities [104]. Similarly, it is
imperative to test the effectiveness of community-based interventions in an environment that
supports the sustainable growth of CRC screening promotion programs for African-American
men. Moreover, to ensure that African-American men receive the optimal benefits of early
detection screening for CRC, researchers must move beyond traditional practice-based set-
tings into community-based locations.
Lastly, from the research team’s observations, cost was a dominant concern or barrier in
implementing large-scale CRC screening interventions across the selected studies. Cost-effec-
tiveness strategies require an overall assessment of patient and provider barriers, the naviga-
tion system, and other potential inhibitors of CRC screening [105]. Because a significant
burden of CRC and observed disparities in CRC screening uptake still exists among African-
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American men, programs tailored to this population should consider how to effectively
enhance knowledge of the benefits of CRC screening, improve access to health care, and ele-
vate the related insurance services [15, 103–105]. In clinical settings, strategies to better utilize
patient navigation systems to emphasize the importance of screening and enhance educational
outreach for healthcare providers who provide routine care for African-American men could
conceivably aid in lowering the cost of promoting CRC screening, particularly among low-
income patients [105]. In community settings, interventions that could efficaciously dispel the
mistrust and ease the anxiety associated with screening are vital to promoting screening
among African-American men [19, 102]. According to Adams and colleagues in a recent sys-
tematic review, African-American men often face unique challenges and express substantial
fears about medical procedures associated with CRC [106–108]. Adams and colleagues
reported that higher mistrust scores correlated with lower CRC screening rates among Afri-
can-American men in most of the quantitative studies included in their review [96, 106, 109].
In addition, several dominant recurring themes such as “mistrust as a barrier to screening,”
“skepticism of provider motives,” and “mistrust of competence and quality of providers/sys-
tems” were identified in qualitative studies [74, 106, 110].
Future studies should thoroughly evaluate the effectiveness of different modes of interven-
tion—e.g., patient navigators, telephone outreach, and text messaging. For example, in an
effort to explore CRC screening among African-American church members using both quali-
tative and quantitative methods, the quality of patient-provider communication proved to be
the most influential factor in participants’ completion of CRC screening [111]. From the arti-
cles included in this review, we can conclude that it is debatable which CRC promotion modes
work best for African-American men. However, our meta-analysis results revealed that future
interventions utilizing FIT or enhancing patient navigation suited better than traditional
methods in increasing CRC screening uptake among this group. Traditional methods included
usual care as seen in the control groups of the study, and was significantly inferior to the FIT
(p = 0.0002) and patient navigation interventions (p = 0.01). Print interventions were also sec- ondary juxtaposed to FIT (p = 0.001). As recommended in the 2019 CRC screening messaging guidebook, promoting CRC screening via text messaging could be a cost-effective strategy to
improve interventions compared with traditional methods (e.g., mailings, printed materials,
telephone reminders) [112]. More research and evidence are warranted to identify more cost-
beneficial interventions focused on motivating unscreened African-American men to seek rec-
ommended CRC screening.
Limitations
Our study is not without limitations. First, although our publication bias analysis found no
such bias, it cannot be ruled out, as studies with negative findings were less likely to be pub-
lished. Secondly, a significant challenge with our meta-analysis was the heterogeneity of the
published data. Most of the studies we reviewed could not be included in the meta-analysis
because they did not provide sample or study-outcome data specific to African Americans,
especially African-American men, or because the interventions were too dissimilar to combine
with other studies. Moreover, since most studies had different inclusion criteria, it was impos-
sible to adjust for a confounder or covariate unless all levels of the covariate were available in
all studies. Since this resulted in difficulty teasing out which intervention components were
most effective, the meta-analysis results must be interpreted with caution. Next, due to the
small sample, aforementioned heterogeneity, and the notion that ‘the best CRC screening test
is the one that gets done’, the data captured for the meta-analysis focused on the proportion of
participants who completed CRC screening juxtaposed to specific types of screening. On
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account of the significant difference in the nature of CRC screening modalities, such as colo-
noscopy vs. FIT, separate analyses (both in future systematic review and meta-analyses) may
reveal different results regarding strengthening future interventions for increasing CRC
screening completion. Furthermore, since most clinical trials require 2–4 phases—potentially
causing minor to major percentage differences for CRC screening uptake based on the effects
of different intervention approaches, a more thorough systematic approach that compares
these differences as well as conduciveness of different CRC screening modalities in clinical ver-
sus community settings may be useful to detect the intervention outcomes. Nevertheless, our
findings highlight the lack of consensus in the literature regarding interventions for increasing
CRC screening uptake, especially among African-American males. Lastly, although our
research team made every effort to ensure our search yielded all applicable data and no publi-
cation bias was found in this study, it is possible that some articles were missed and the ability
of bias to distort results of future meta-analyses and systematic reviews should be considered.
Conclusions
In summary, this systematic review and meta-analysis examined the existing evidence for
interventions aimed at increasing CRC screening uptake among African-American men. Most
of the included studies used approaches such as patient navigation, telephone outreach, tar-
geted brochures, and other multicomponent promotion packages to enhance CRC screening
rates. Yet, our findings reflected a dearth of studies unambiguously focused on African-Ameri-
can men. Only 2 of the 41 studies in our review (5%) specifically explored the efficacy of CRC
screening-promoting initiatives among African-American men. Since half of the reviewed
studies were guided by 1 or multiple conceptual frameworks, a greater number of theory-
driven CRC screening interventions are needed. Since studies with the lowest risk of bias
employed 4 or fewer interventions, future multicomponent interventions should consider this
evidence when designing and implementing CRC screening completion-focused studies
among African-American men and other underserved populations. To achieve the National
Colorectal Cancer Roundtable’s challenge to attain screening rates of 80% or higher in every
community, further study is warranted that considers employing evidence-based, cost-effec-
tive, and culture-specific techniques targeting CRC screening completion among African-
American men outside of traditional clinic settings.
Supporting information
S1 Appendix. Search strategy syntax.
(PDF)
S2 Appendix. PRISMA checklist.
(PDF)
S1 Fig. Begg’s funnel plot with 95% confidence limits.
(PDF)
Acknowledgments
The research team extends appreciation to Eleanor Mayfield for editorial support. This study
was supported by Huntsman Cancer Institute’s Cancer Biostatistics Shared Resource at the
University of Utah and the National Cancer Institute of the National Institutes of Health
(NIH) [grant numbers K01CA234319 and P30CA042014]. All relevant materials discussed in
this study—registered with the International Prospective Registry of Systematic Reviews
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(PROSPERO 2019 CRD42019119510)—may be requested from the corresponding author free
of charge. The content is solely the responsibility of the authors and does not necessarily repre-
sent the official views of the NIH, Huntsman Cancer Institute, or the University of Utah.
Author Contributions
Conceptualization: Charles R. Rogers, Kenneth Boucher, Kola S. Okuyemi, Margaret J.
Foster.
Data curation: Charles R. Rogers, Margaret J. Foster.
Formal analysis: Charles R. Rogers, Phung Matthews, Kenneth Boucher, Colin Riley, Matthew
Huntington.
Funding acquisition: Charles R. Rogers.
Investigation: Charles R. Rogers.
Methodology: Charles R. Rogers, Phung Matthews, Kenneth Boucher, Margaret J. Foster.
Project administration: Charles R. Rogers.
Supervision: Margaret J. Foster.
Validation: Phung Matthews.
Writing – original draft: Charles R. Rogers, Lei Xu, Kenneth Boucher, Colin Riley, Matthew
Huntington, Nathan Le Duc, Kola S. Okuyemi, Margaret J. Foster.
Writing – review & editing: Charles R. Rogers, Phung Matthews, Lei Xu, Kenneth Boucher,
Colin Riley, Matthew Huntington, Nathan Le Duc, Kola S. Okuyemi, Margaret J. Foster.
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