Smoking Cessation Support in the Context of Other Social and Behavioral Needs in Community Health Centers.

BACKGROUND: Cigarette smoking rates remain disproportionately high among low income populations with unmet social and behavioral health needs. To address this problem, we sought to develop and evaluate the feasibility, acceptability, and preliminary effectiveness of a novel smoking cessation program for community health centers that serve these populations. METHODS: We implemented a randomized pilot trial of two smoking cessation programs in three county operated community health center (CHC) sites: (1) a systematic assessment of smoking habits and standard tools to assist with smoking cessation counseling ("Enhanced Standard Program" or ESP), and (2) another that added a structured assessment of social and behavioral barriers to smoking cessation, ("Connection to Health for Smokers" or CTHS). Clinical outcomes were evaluated between 10 to 16 weeks, supplemented with interviews of patient participants and health care team members. RESULTS: 141 adults were randomized and 123 completed the intervention (61 in ESP, 62 in CTHS). At follow-up, over half of participants reported ≥1 quit attempts (59.7% ESP and 56.5% CTHS; adjusted p = .66) while more in ESP (24.6% vs. 12.9%) were documented as not smoking in the last 7 days (adjusted p = 0.03). In addition to being in ESP, predictors of smoking cessation included higher baseline confidence in ability to quit (p = 0.02) and more quit attempts during the study (p = 0.04). Health care teams, however, generally preferred the more comprehensive approach of CTHS. CONCLUSION: Lessons learned from this pilot study may inform the development of effective smoking cessation programs for CHCs that combine elements of both interventions.

The Cervical Cancer Treatment Gap in Mexico Under Seguro Popular, 2006-2016.

From 2005 to 2019, the Mexican government financed cervical cancer treatment for individuals without social security insurance through Seguro Popular's Fund for Protection against Catastrophic Health Expenses. To better understand the impact of this program on access to treatment, we estimated the cervical cancer treatment gap (the proportion of patients with cervical cancer in this population who did not receive treatment). To calculate the expected number of incident cervical cancer cases we used national surveys with information on insurance affiliation and incidence estimates from the Global Burden of Disease study. We used a national claims database to determine the number of cases whose treatment was financed by Seguro Popular. From 2006 to 2016, the national cervical cancer treatment gap changed from 0.61 (95% CI 0.59 to 0.62) to 0.45 (95% CI 0.43 to 0.48), with an average yearly reduction of -0.012 (95% CI -0.024 to -0.001). The gap was greater in states with higher levels of marginalization and in the youngest and oldest age groups. Although the cervical cancer treatment gap among individuals eligible for Seguro Popular decreased after the introduction of public financing for treatment, it remained high. Seguro Popular was eliminated in 2019; however, individuals without social security have continued to receive cancer care financed by the government in the same healthcare facilities. These results suggest that barriers to care persisted after the introduction of public financing for treatment. These barriers must be reduced to improve cervical cancer care in Mexico, particularly in states with high levels of marginalization.

Implementation of a novel program to support colorectal cancer screening in a community health center consortium before and after the onset of COVID-19: a qualitative study of stakeholders' perspectives.

BACKGROUND: In 2017, the San Francisco Cancer Initiative (SF CAN) established the Colorectal Cancer (CRC) Screening Program to provide technical assistance and financial support to improve CRC screening processes, and outcomes in a consortium of community health centers (CHCs) serving low-income communities in San Francisco. The purpose of this study was twofold: to evaluate the perceived influence of the support provided by the CRC Screening Program's Task Force on CRC screening processes and outcomes in these settings and to identify facilitators and barriers to SF CAN-supported CRC screening activities before and after the onset of the COVID-19 pandemic. METHODS: Semi-structured key informant interviews were conducted with consortium leaders, medical directors, quality improvement team members, and clinic screening champions. Interviews were audio-recorded, professionally transcribed, and analyzed for themes. The Consolidated Framework for Implementation Research (CFIR) was used to develop the interview questions and organize the analysis. RESULTS: Twenty-two participants were interviewed. The most commonly cited facilitators of improved screening processes included the expertise, funding, screening resources, regular follow-up, and sustained engagement with clinic leaders provided by the task force. The most salient barriers identified were patient characteristics, such as housing instability; staffing challenges, such as being understaffed and experiencing high staff turnover; and clinic-level challenges, such as lack of ability to implement and sustain formalized patient navigation strategies, and changes in clinic priorities due to the COVID-19 pandemic and other competing health care priorities. CONCLUSIONS: Implementing CRC screening programs in a consortium of CHCs is inherently challenging. Technical assistance from the Task Force was viewed positively and helped to mitigate challenges both before and during the pandemic. Future research should explore opportunities to increase the robustness of technical assistance offered by groups such as SF CAN to support cancer screening activities in CHCs serving low-income communities.

Mammography prevalence in Mexico from 2001-2018: Results from the Mexican Health and Aging study.

After introducing guidelines for breast cancer screening in 2003, Mexico began to prioritize the implementation of mammography screening nationally. Since then, there have been no studies assessing changes in mammography in Mexico using the two-year prevalence interval that corresponds to national guidelines for screening frequency. The present study analyzes the Mexican Health and Aging Study (MHAS), a national population-based panel study of adults aged 50 and older, to evaluate changes in 2-year mammography prevalence among women aged 50 to 69 across five survey waves from 2001 to 2018 (n = 11,773). We calculated unadjusted and adjusted mammography prevalence by survey year and health insurance type. Overall prevalence increased substantially from 2003 to 2012 and leveled off in the period from 2012 to 2018 (2001: 20.2 % [95 % CI 18.3, 22.1]; 2003: 22.7 % [20.4, 25.0]; 2012: 56.5 % [53.2, 59.7]; 2015: 62.0 % [58.8, 65.2]; 2018: 59.4 % [56.7,62.1]; unadjusted prevalence). Prevalence was higher among respondents with social security insurance, who are more likely to work in the formal economy, than among respondents without social security, who are more likely to work in the informal economy or be unemployed. The overall prevalence estimates observed were higher than previously published estimates of mammography prevalence in Mexico. More research is needed to confirm findings regarding two-year mammography prevalence in Mexico and to better understand the causes of observed disparities.

Neighborhood socioeconomic status and the effectiveness of colorectal cancer screening outreach with mailed fecal immunochemical tests within a safety net healthcare system in San Francisco, CA: A subgroup analysis of a randomized controlled trial.

Neighborhood context shapes opportunities and barriers for residents to access healthcare and cancer screening. Neighborhood socioeconomic status (nSES) is associated with disparities in colorectal cancer (CRC) screening, but the extent to which the effectiveness of specific screening interventions vary by nSES has not been studied. The original trial conducted in San Francisco, CA from 2016 to 2017 randomly assigned patients eligible for CRC screening either to a multicomponent intervention including advanced notification, mailed fecal immunochemical test (FIT) kits and reminders or to a control group receiving usual care. For the nSES analysis addresses for 9699 patients were geocoded and stratified by city-wide nSES quintile (Q1 lowest, Q5 highest) using an established index at the census tract level. Compared to usual care, the outreach intervention improved FIT test completion at one year (58.7% vs 38.4%; OR 2.32 [2.14, 2.52]) but its effectiveness did not vary substantially by nSES quintile (adjusted OR Q1 2.64 [2.30, 3.04]; Q2 2.43 [2.04, 2.90]; Q3 2.31 [1.84, 2.89]; Q4 2.47 [1.86, 3.28]; Q5 2.64 [1.83, 3.81]; Wald test for interaction p = 0.87). The implementation of mailed FIT outreach has the potential to increase CRC screening completion without leading to disparities in screening related to nSES (ClinicalTrials.gov NCT02613260).

mHealth: experiences and opportunities for cancer research in Mexico.

Not available.

Capacidad de colonoscopías diagnósticas en la Ciudad de México.

No disponible.

Developing a collaborative international partnership for cancer control in Mexico.

In 2014, a partnership was established between the Univer-sity of California and Mexico, which subsequently catalyzed formation of collaborations between cancer researchers at University of California, San Francisco and in Mexico. Over the past two decades cancer burden has dramatically increased in Mexicans on both sides of the California - Mexico border. Together, we face a growing burden of cancer in the context of globalized economies, diverse migration patterns, and dynamic immigration policies. Our partnership aims to: (1) understand the life course impact of cancer risk factors and interactions with changing environments; (2) address cancer disparities within Mexico, in Mexican migrants to the United States, and in naturalized Mexican-Americans; and (3) identify effective cancer screening strategies and cancer control policies that are tailored to existing healthcare systems and social and cultural factors. Herein, we describe the principles of partner-ship and early successes and challenges of this collaboration.

From Cancer Epidemiology to Policy and Practice: the Role of a Comprehensive Cancer Center.

Purpose of Review: Cancer incidence and mortality are decreasing, but inequities in outcomes persist. This paper describes the San Francisco Cancer Initiative (SF CAN) as a model for the systematic application of epidemiological evidence to reduce the cancer burden and associated inequities. Recent Findings: SF CAN is a multi-institutional implementation of existing evidence on the prevention and early detection of five common cancers (i.e., breast, prostate, colorectal, liver, and lung/tobacco-related cancers) accounting for 50% of cancer deaths in San Francisco. Five Task Forces follow individual logic models designating inputs, outputs, and outcomes. We describe the progress made and the challenges faced by each Task Force after 5 years of activity. Summary: SF CAN is a model for how the nation's Comprehensive Cancer Centers are ideally positioned to leverage cancer epidemiology for evidence-based initiatives that, along with genuine community engagement and multiple stakeholders, can reduce the population burden of cancer.

In-vivo T-cell depleted reduced-intensity conditioned allogeneic haematopoietic stem-cell transplantation for patients with acute lymphoblastic leukaemia in first remission: results from the prospective, single-arm evaluation of the UKALL14 trial.

BACKGROUND: The outcome of chemotherapy in patients older than 40 years with acute lymphoblastic leukaemia is poor and myeloablative allogeneic haematopoietic stem-cell transplantation (HSCT) has a high transplant-related mortality (TRM) in this age cohort. The aim of this study was to assess the activity and safety of reduced-intensity conditioned allogeneic HSCT in this patient population. METHODS: This was a single-arm, prospective study within the UKALL14 trial done in 46 centres in the UK, which recruited patients to the transplantation substudy. Participants in UKALL14 had B-cell or T-cell acute lymphoblastic leukaemia, were aged 25-65 years (BCR-ABL1-negative) or 18-65 years (BCR-ABL1-positive), and for this subcohort had a fit, matched sibling donor or an 8 out of 8 allelic matched unrelated donor (HLA-A, HLA-B, HLA-C, and HLA-DR). On June 20, 2014, the protocol was amended to allow 7 out of 8 matched unrelated donors if the patient had high risk cytogenetics or was minimal residual disease (MRD)-positive after the second induction course. Patients were given fludarabine, melphalan, and alemtuzumab (FMA; intravenous fludarabine 30 mg/m2 on days -6 to -2, melphalan 140 mg/m2 on day -2, and alemtuzumab 30 mg on day -1 [sibling donor] and days -2 and -1 [unrelated donor]) before allogeneic HSCT (aged ≥41 years patient pathway). Donor lymphocyte infusions were given from 6 months for mixed chimerism or MRD. The primary endpoint was event-free survival and secondary and transplantation-specific endpoints included overall survival, relapse incidence, TRM, and acute and chronic graft-versus-host disease (GVHD). This study is registered with ClinicalTrials.gov, NCT01085617. FINDINGS: From Feb 22, 2011, to July 26, 2018, 249 patients (236 aged ≥41 years and 13 younger than 41 years) considered unfit for a myeloablative allograft received an FMA reduced-intensity conditioned HSCT. 138 (55%) patients were male and 111 (45%) were female. 88 (35%) participants received transplantations from a sibling donor and 160 (64%) received transplantations from unrelated donors. 211 (85%) participants had B-precursor acute lymphoblastic leukaemia. High-risk cytogenetics were present in 43 (22%) and another 63 (25%) participants were BCR-ABL1-positive. At median follow-up of 49 months (IQR 36-70), 4-year event-free survival was 46·8% (95% CI 40·1-53·2) and 4-year overall survival was 54·8% (48·0-61·2). 4-year cumulative incidence of relapse was 33·6% (27·9-40·2) and 4-year TRM was 19·6% (15·1-25·3). 27 (56%) of 48 patients with TRM had infection as the named cause of death. Seven (15%) of 48 patients had fungal infections, 13 (27%) patients had bacterial infections (six gram-negative), and 11 (23%) had viral infections (three cytomegalovirus and two Epstein-Barr virus). Acute GVHD grade 2-4 occurred in 29 (12%) of 247 patients and grade 3-4 occurred in 12 (5%) patients. Chronic GVHD incidence was 84 (37%) of 228 patients (50 [22%] had extensive chronic GVHD). 49 (30%) of 162 patients had detectable end-of-induction MRD, which portended worse outcomes with event-free survival (HR 2·40 [95% CI 1·46-3·93]) and time-to-relapse (HR 2·41 [1·29-4·48]). INTERPRETATION: FMA reduced-intensity conditioned allogeneic HSCT in older patients with acute lymphoblastic leukaemia in first complete remission provided good disease control with moderate GVHD, resulting in better-than-expected event-free survival and overall survival in this high-risk population. Strategies to reduce infection-related TRM will further improve outcomes. FUNDING: Cancer Research UK.

National and state-level colorectal cancer mortality trends in Mexico, 1998-2018 / Tendencias nacionales y estatales de mortalidad por cáncer colorrectal en México, 1998-2018

Abstract: Objective: To describe the burden of colorectal cancer (CRC) in Mexico and understand mortality patterns based on sex, geography, and insurance status. Materials and methods: Mortality data (1998-2018) from the Instituto Nacional de Estadística y Geografía was obtained. We included colon (C18.0, C18.2-18.9) and rectal cancer ICD-10 codes (C19, C20), and estimated age-standardized national, state-level and health insurance mortality rates. We estimated the average annual percent change using joinpoint regression. Results: Between 1998 and 2018, the observed women and men mortality rate increased annually by 1.3 and 2.7%, respectively. Higher CRC mortality was observed in northern and more urbanized states and in groups with greater access to health insurance, which currently facilitates but does not routinely cover screening. Conclusion: CRC mortality in Mexico is increasing rapidly, with marked differences based on sex, geography, and insurance status. Our findings underscore potential benefits of increased investment in comprehensive screening, diagnosis, and treatment strategies for the general population.

Resumen: Objetivo: Describir la carga del cáncer colorrectal (CCR) en México y patrones de mortalidad según sexo, geografía y servicios de salud. Material y métodos: Se obtuvieron datos de mortalidad (1998-2018) del Instituto Nacional de Estadística y Geografía. Se incluyeron códigos CIE-10 de cáncer de colon (C18.0,C18.2-18.9) y recto (C19,C20). Se estimaron tasas de mortalidad nacionales, estatales y por servicio de salud, estandarizadas por edad. Se estimó el cambio porcentual anual promedio usando regresión joinpoint. Resultados: Entre 1998-2018, la tasa de mortalidad aumentó anualmente 1.3% en mujeres y 2.7% en hombres. Se observó mayor mortalidad por CCR en estados del norte, más urbanizados y con afiliación a servicios de salud que actualmente facilitan pero no cubren rutinariamente la detección. Conclusión: La mortalidad por CCR en México está aumentando rápidamente, con diferencias por sexo, geografía y afiliación. Los presentes hallazgos destacan los beneficios potenciales de mayor inversión en estrategias integrales de detección, diagnóstico y tratamiento para la población.

Developing a collaborative international partnership for cancer control in Mexico / Desarrollo de una alianza internacional colaborativa para el control del cáncer en México

Abstract: In 2014, a partnership was established between the University of California and Mexico, which subsequently catalyzed formation of collaborations between cancer researchers at University of California, San Francisco and in Mexico. Over the past two decades cancer burden has dramatically increased in Mexicans on both sides of the California - Mexico border. Together, we face a growing burden of cancer in the context of globalized economies, diverse migration patterns, and dynamic immigration policies. Our partnership aims to: 1) understand the life course impact of cancer risk factors and interactions with changing environments; 2) address cancer disparities within Mexico, in Mexican migrants to the United States, and in naturalized Mexican-Americans; and 3) identify effective cancer screening strategies and cancer control policies that are tailored to existing healthcare systems and social and cultural factors. Herein, we describe the principles of partnership and early successes and challenges of this collaboration.

Resumen: En 2014, se estableció un convenio de colaboración colaboración entre la Universidad de California y México, que posteriormente catalizó colaboraciones específicas entre investigadores en cáncer en la Universidad de California, San Francisco y en México. En las últimas dos décadas, la carga del cáncer ha aumentado drásticamente en mexicanos de ambos lados de la frontera entre California y México. Juntos, enfrentamos una carga creciente de cáncer en un contexto de economías globalizadas y diversos patrones y políticas de migración dinámicas. Nuestra colaboración tiene como objetivo: 1) entender el impacto a lo largo de la vida de factores de riesgo de cáncer y sus interacciones en un entorno cambiante; 2) abordar disparidades del cáncer dentro de México, en os migrantes mexicanos a los Estados Unidos y en los mexicoamericanos naturalizados; y 3) identificar estrategias efectivas de detección del cáncer y políticas de control del cáncer que se adapten a sistemas de salud existentes y a factores sociales y culturales. Aquí describimos los principios de esta colaboración y los primeros éxitos y retos de la misma.

Defects in NLRP6, autophagy and goblet cell homeostasis are associated with reduced duodenal CRH receptor 2 expression in patients with functional dyspepsia.

Functional dyspepsia (FD) affects up to 15% of the population and is characterised by recurring upper gastrointestinal (GI) symptoms occurring in the absence of clinically identifiable pathology. Psychological stress is a key factor associated with the onset of FD and locally acting hypothalamic-pituitary-adrenal (HPA) axis hormones have been implicated in GI motility and barrier dysfunction. Recent pre-clinical work has identified mechanistic pathways linking corticotropin-releasing hormone (CRH) with the innate epithelial immune protein NLRP6, an inflammasome that has been shown to regulate GI mucus secretion. We recruited twelve FD patients and twelve healthy individuals to examine whether dysregulation of hypothalamic-pituitary adrenal (HPA) axis hormones and altered NLRP6 pathways were evident in the duodenal mucosa. Protein expression was assessed by immunoblot and immunohistochemistry in D2 duodenal biopsies. Plasma HPA axis hormones were assayed by ELISA and enteroid and colorectal cancer cell line cultures were used to verify function. FD patients exhibited reduced duodenal CRH-receptor 2, compared to non-GI disease controls, indicating a dysregulation of duodenal HPA signalling. The loss of CRH-receptor 2 correlated with reduced NLRP6 expression and autophagy function, processes critical for maintaining goblet cell homeostasis. In accordance, duodenal goblet cell numbers and mucin exocytosis was reduced in FD patients compared to controls. In vitro studies demonstrated that CRH could reduce NLRP6 in duodenal spheroids and promote mucus secretion in the HT29-MTX-E12 cell line. In conclusion, FD patients exhibit defects in the NLRP6-autophagy axis with decreased goblet cell function that may drive symptoms of disease. These features correlated with loss of CRH receptor 2 and may be driven by dysregulation of HPA signalling in the duodenum of FD patients.

Addressing tobacco use in the context of complex social needs: A new conceptual framework and approach to address smoking cessation in community health centers.

Objective: This article presents a new conceptual framework "Connection to Health for Smokers" (CTHS), its application to address smoking cessation, and its acceptability in community health centers (CHCs). Methods: CTHS, an online interactive patient educational tool comprehensively implements the "5 A's" (ask, advise, assess, assist, and arrange) within the context of patients' social and behavioral health needs. Semi-structured interviews were conducted with five health educators (nurses) who administered CTHS with 62 patients to evaluate the acceptability of the program. Thematic analyses were conducted with interview transcripts. Results: CHC health educators viewed CTHS has enhanced patient-centered communication, was able to identify patients' needs beyond tobacco use, and individualize action planning to integrate social and behavioral health needs. Conclusion: CTHS received enthusiasm from CHC health educators as a helpful tool to address tobacco use among their patients. Comprehensive on-site smoking cessation programs at CHCs that provide a structured evidence-based approach informed by an understanding of each patient's coexisting social and behavioral health needs may play an important role in reducing tobacco use disparities in the United States. Innovation: CTHS offers a new promising framework to comprehensively integrate the 5A's within the context of social and behavioral determinants of health for smoking cessation.

Evaluating the sustainability of a cancer screening intervention through a PRISM: The PreView experience.

Although many trials of cancer screening interventions evaluate efficacy and effectiveness, less research focuses on how to sustain interventions in non-research settings, which limit the potential reach of these interventions. Identifying the factors that influence the potential for sustainability is critical. We evaluate the factors influencing sustainability of PreView, a Cancer Screening Intervention, within the context of the Practical, Robust Implementation and Sustainability Model (PRISM). PRISM includes organizational and patient perspectives of the intervention as well as characteristics of the organizational and patient recipients. It considers how the program or intervention design, external environment, implementation, and sustainability infrastructure and the recipients influence program adoption, implementation, and maintenance. We evaluate the attempts at sustainability of PreView within the constructs of PRISM. Encouraging patients to use PreView was more difficult outside of a clinical trial. Organizational perspectives on how the intervention fit in with other goals, patient perspectives on how the intervention is individualized (i.e. being able to choose which cancer screening to address) and focused on barriers, patient characteristics (i.e. having multiple comorbidities making cancer screening less of a priority), organizational characteristics (i.e. middle managers having competing responsibilities), external environment influences (i.e. reimbursement for achieving certain cancer screening goals), and sustainability infrastructure all affect the likelihood of PreView being sustained in clinical practice. Despite advance planning for sustainability, adapting interventions to achieve sustainability is difficult. Lessons learned from evaluating PreView within the PRISM model can inform future sustainability efforts.

Second allogeneic transplants for multiple myeloma: a report from the EBMT Chronic Malignancies Working Party.

The EBMT Chronic Malignancies Working Party performed a retrospective analysis of 215 patients who underwent a second allo-HCT for myeloma between 1994 and 2017, 159 for relapse and 56 for graft failure. In the relapse group, overall survival (OS) was 38% (30-46%) at 2 years and 25% (17-32%) at 5 years. Patients who had a HLA-identical sibling (HLAid-Sib) donor for their first and second transplants had superior OS (5 year OS: HLAid-Sib/HLAid-Sib: 35% (24-46%); Others 9% (0-17%), p < 0.001). There was a significantly higher incidence of acute grade II-IV GvHD in those patients who had also developed GvHD following their initial HLA-identical sibling allo-HCT (HLAid-Sib/HLAid-Sib: 50% (33-67%); Other 22% (8-36%), p = 0.03). More as opposed to fewer than 2 years between transplants was associated with superior 5-yr OS (31% (21-40%) vs. 10% (1-20%), P = 0.005). On multivariate analysis, consecutive HLA-identical sibling donor transplants conferred a significant OS advantage (0.4 (0.24-0.67), p < 0.001). In the graft failure group, OS was 41% at 2 years. In summary, a second allo-HCT using a HLA-identical sibling donor, if available, provides the best transplant outcomes for relapsed myeloma in this setting.

National and state-level colorectal cancer mortality trends in Mexico, 1998-2018.

OBJECTIVE: To describe the burden of colorectal cancer (CRC) in Mexico and understand mortality patterns based on sex, geography, and insurance status. MATERIALS AND METHODS: Mortality data (1998-2018) from the Instituto Nacional de Estadística y Geografía was obtained. We included colon (C18.0, C18.2-18.9) and rectal cancer ICD-10 codes (C19, C20), and estimated age-standardized national, state-level and health insurance mortality rates. We estimated the average annual percent change using joinpoint regression. RESULTS: Between 1998 and 2018, the observed women and men mortality rate increased annually by 1.3 and 2.7%, respectively. Higher CRC mortality was observed in northern and more urbanized states and in groups with greater access to health insurance, which currently facilitates but does not routinely cover screening. CONCLUSION: CRC mortality in Mexico is increasing rapidly, with marked differences based on sex, geography, and insurance status. Our findings underscore potential benefits of increased investment in comprehensive screening, diagnosis, and treatment strategies for the general population.

Barriers and facilitators for colorectal cancer screening in a low-income urban community in Mexico City.

BACKGROUND: Colorectal cancer (CRC) incidence and mortality are increasing in many low- and middle-income countries (LMICs), possibly due to a combination of changing lifestyles and improved healthcare infrastructure to facilitate diagnosis. Unfortunately, a large proportion of CRC cases in these countries remain undiagnosed or are diagnosed at advanced stages, resulting in poor outcomes. Decreasing mortality trends in HICs are likely due to evidence-based screening and treatment approaches that are not widely available in LMICs. Formative research to identify emerging opportunities to implement appropriate screening and treatment programs in LMICs is, therefore, of growing importance. We sought to identify potential barriers and facilitators for future implementation of fecal immunochemical test (FIT)-based CRC screening in a public healthcare system in a middle-income country with increasing CRC incidence and mortality. METHODS: We performed a qualitative study with semi-structured individual and focus group interviews with different CRC screening stakeholders, including 30 lay people at average risk for CRC, 13 health care personnel from a local public clinic, and 7 endoscopy personnel from a cancer referral hospital. All interviews were transcribed verbatim for analysis. Data were analyzed using the constant comparison method, under the theoretical perspectives of the social ecological model (SEM), the PRECEDE-PROCEED model, and the health belief model. RESULTS: We identified barriers and facilitators for implementation of a FIT-based CRC screening program at several levels of the SEM. The main barriers in each of the SEM levels were as follows: (1) at the social context level: poverty, health literacy and lay beliefs related to gender, cancer, allopathic medicine, and religion; (2) at the health services organization level: a lack of CRC knowledge among health care personnel and the community perception of poor quality of health care; and (3) at the individual level: a lack of CRC awareness and therefore lack of risk perception, together with fear of participating in screening activities and finding out about a serious disease. The main facilitators perceived by the participants were CRC screening information and the free provision of screening tests. CONCLUSIONS: This study's findings suggest that multi-level CRC screening programs in middle-income countries such as Mexico should incorporate complementary strategies to address barriers and facilitators, such as (1) provision of free screening tests, (2) education of primary healthcare personnel, and (3) promotion of non-fear-based CRC screening messages to the target population, tailored to address common lay beliefs.