DecodeME: community recruitment for a large genetics study of myalgic encephalomyelitis / chronic fatigue syndrome.

BACKGROUND: Myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS) is a common, long-term condition characterised by post-exertional malaise, often with fatigue that is not significantly relieved by rest. ME/CFS has no confirmed diagnostic test or effective treatment and we lack knowledge of its causes. Identification of genes and cellular processes whose disruption adds to ME/CFS risk is a necessary first step towards development of effective therapy. METHODS: Here we describe DecodeME, an ongoing study co-produced by people with lived experience of ME/CFS and scientists. Together we designed the study and obtained funding and are now recruiting up to 25,000 people in the UK with a clinical diagnosis of ME/CFS. Those eligible for the study are at least 16 years old, pass international study criteria, and lack any alternative diagnoses that can result in chronic fatigue. These will include 5,000 people whose ME/CFS diagnosis was a consequence of SARS-CoV-2 infection. Questionnaires are completed online or on paper. Participants' saliva DNA samples are acquired by post, which improves participation by more severely-affected individuals. Digital marketing and social media approaches resulted in 29,000 people with ME/CFS in the UK pre-registering their interest in participating. We will perform a genome-wide association study, comparing participants' genotypes with those from UK Biobank as controls. This should generate hypotheses regarding the genes, mechanisms and cell types contributing to ME/CFS disease aetiology. DISCUSSION: The DecodeME study has been reviewed and given a favourable opinion by the North West - Liverpool Central Research Ethics Committee (21/NW/0169). Relevant documents will be available online ( www.decodeme.org.uk ). Genetic data will be disseminated as associated variants and genomic intervals, and as summary statistics. Results will be reported on the DecodeME website and via open access publications.

The role of work in gender identity, stress and health in low-income, middle-aged African-American men.

Although progress has been made in reducing disparities in life expectancy, addressing the persistence of health inequities by race remains a high priority for public health professionals. The purpose of this research was to refine a minority stress model (MSM) by identifying previously unrecognized factors contributing to stress and chronic disease health disparities among low-income middle-aged African-American men. Using a Community-Based Participatory Research approach, we conducted semi-structured individual health interviews with 42 low-income middle-aged African-American men in a mid-size New England city. The interviews focused on the participants' perceptions of the causes of health disparities. Four major themes emerged from the analysis: the positive aspects of work, both financial and symbolic; and the negative repercussions of not working, both financial and symbolic in terms of a sense of self-respect. On an instrumental level, working men can support their family, be physically active and find social support. Symbolically, work provides a positive sense of identity as a man; it offers both social- and self-respect; it provides discipline and a sense of gratitude. Conversely, the lack of work is a significant source of stress, stemming both from the inability to support one's family and from having nothing to do, which lead to depression, low self-esteem, suicidal ideation and anger. With no perceived viable routes to socially approved roles, many low-income men of color succumb to internalizing a negative identity. This research demonstrates a clear link between structural problems with the US economy and harms to sense of identity among low-income, middle-aged African-American men.

Development of a Smartphone App for Regional Care Coordination Among High-Risk, Low-Income Patients.

Background: Despite widespread adoption of health information technology, U.S. providers face persistent barriers to coordination of care. We sought to develop and implement a patient-centered smartphone app that facilitates care coordination when patients receive care at any hospital in a region. Materials and Methods: Partnering with patients and primary care teams at a federally qualified health center (FQHC), we developed an app that (1) used real-time location data to identify encounters at 41 regional hospitals; (2) sent notifications to users' phones, asking them to confirm hospital arrival/discharge, and; (3) sent automated messages to primary care teams about confirmed hospital encounters. App design included multiple, successive rounds of active patient participation. In a small beta test of the initial version of the app, high-risk, low-income FQHC patients ran the app on their phone for 3 months. A formative mixed methods evaluation examined the app's technical performance and user experience. Results: Twelve patients enrolled in the beta test and provided follow-up data; 11 (92%) were racial/ethnic minorities. Participants obtained emergency or inpatient care at four regional hospitals. The app had 75% sensitivity to detect events when notifications should have fired, and 90% positive predictive value (PPV) of events when notifications fired. Barriers to implementation related to the app's user interface and the performance of its location tracking algorithm. Conclusions: We partnered with patients from a traditionally underserved population to develop a new smartphone-based approach to regional care coordination. The app had moderate sensitivity and high PPV for identifying regional hospital visits.

Participant Engagement and Ethical Digital Storytelling: The MOCHA Moving Forward Study.

African-American men continue to bear a disproportionate share of the burden of health disparities, in general, and chronic diseases, in particular. The Men of Color Health Awareness (MOCHA) Moving Forward study seeks to determine the effectiveness of an innovative, community-driven program to improve the health and quality of life of low-income African-American men between the ages of 35 to 70 years by reducing identified social risk factors for chronic disease for these men. The project uses digital storytelling (DST) to encourage African-American men to tell their stories, especially related to stress, gender role stereotypes, and mental and physical health and well-being. Thirty-six men were recruited to participate in one of four DST workshops, which resulted in each participant creating a 2- to 3-minute digital story. In this article, we describe and analyze three salient ethical dilemmas that arose in conducting the Men of Color Health Awareness Moving Forward study DST workshops with African-American men. The dilemmas can be traced to the distinct purposes for which DST can be used, data collection or intervention development, and the trade-offs between protecting and patronizing participants. We discuss potential ways to resolve or circumvent the identified issues.

Linking food insecurity and smoking cessation: In response to "Food insecurity transitions and smoking behavior among older adults who smoke".

This Letter to the Editor raises questions regarding a recently published article, "Food insecurity transitions and smoking behavior among older adults who smoke."

Aspects of Depression Among Socioeconomically Disadvantaged African American Young Adults.

The purpose of this phronetic/pragmatic, mixed-methods study was to integrate quantitative data with qualitative data in examining the complex relations among depression, exercise, screen-viewing time, and life plans among 14 socioeconomically disadvantaged African American young adults. Based on the thematic analysis, the two emerging themes were as follows: life priorities (passing the General Educational Development [GED] test, pursuing profession/career, and being dedicated to church/ministry) and challenges in passing GED examination (e.g., difficulties with the GED test, high stress and low confidence, low interest in studying, health issues, and feelings of rejection/isolation). Based on cross tabulation, depression was highly associated with aerobic exercise and screen-viewing time (Cramer's V = .44 and .42, respectively). Participants' life challenges diminished the antidepressant effect of exercise and were linked to depression and excessive screen use. Two active men and a somewhat active woman experienced educational or health-related struggles, heavy screen watching, and severe depression. All three active men experienced educational challenges and severe depression. Two inactive participants reported limited screen use and limited depression, possibly because of their valued life goals (e.g., writing poetry and spiritually helping others). Contrary to the dominant cultural stereotype about African Americans being lazy, the study results show that the participants had highly similar career goals to the majority population yet faced many, significant structural barriers that interfered with their progress and thus sapped their motivation in achieving their life plans. Policy change is needed to reduce social structural barriers and racial systems of oppression in order to decrease poverty and depression.

Delayed response to cold stress is characterized by successive metabolic shifts culminating in apple fruit peel necrosis.

BACKGROUND: Superficial scald is a physiological disorder of apple fruit characterized by sunken, necrotic lesions appearing after prolonged cold storage, although initial injury occurs much earlier in the storage period. To determine the degree to which the transition to cell death is an active process and specific metabolism involved, untargeted metabolic and transcriptomic profiling was used to follow metabolism of peel tissue over 180 d of cold storage. RESULTS: The metabolome and transcriptome of peel destined to develop scald began to diverge from peel where scald was controlled using antioxidant (diphenylamine; DPA) or rendered insensitive to ethylene using 1-methylcyclopropene (1-MCP) beginning between 30 and 60 days of storage. Overall metabolic and transcriptomic shifts, representing multiple pathways and processes, occurred alongside α-farnesene oxidation and, later, methanol production alongside symptom development. CONCLUSIONS: Results indicate this form of peel necrosis is a product of an active metabolic transition involving multiple pathways triggered by chilling temperatures at cold storage inception rather than physical injury. Among multiple other pathways, enhanced methanol and methyl ester levels alongside upregulated pectin methylesterases are unique to peel that is developing scald symptoms similar to injury resulting from mechanical stress and herbivory in other plants.

Complexity of Exercise Behavior Among Older African American Women.

Despite the exercise benefits, disparities among diverse older adults continue to exist, where African American women have the lowest percentage of any population group in meeting national recommended activity guidelines. Drawing on the philosophical tradition of phronesis (practical reasoning) introduced by Aristotle, we studied perceptions of the exercise value among 14 older African American women. Three themes included: (1) exercise goals (e.g., effort exerted), (2) exercise reasons (e.g., health benefits, enjoyment and convenience, and activity recommendation), and (3) inactivity reasons (e.g., health issues, lack of motivation, and family responsibilities/priorities). Although most women reported being active, only three participants met the Healthy People 2020 guidelines for aerobic and muscle-strengthening activities, while two individuals were inactive. Exercise promoters should consider the values that motivate older African American women to exercise, such as the provision of accessible, nondiscriminatory exercise facilities, and not to exercise, such as concerns about neighborhood safety, in designing programs.

Detecting Dysglycemia Using the 2015 United States Preventive Services Task Force Screening Criteria: A Cohort Analysis of Community Health Center Patients.

BACKGROUND: In 2015, the United States Preventive Services Task Force (USPSTF) recommended targeted screening for prediabetes and diabetes (dysglycemia) in adults who are aged 40 to 70 y old and overweight or obese. Given increasing prevalence of dysglycemia at younger ages and lower body weight, particularly among racial/ethnic minorities, we sought to determine whether the current screening criteria may fail to identify some high-risk population subgroups. METHODS AND FINDINGS: We investigated the performance of the 2015 USPSTF screening recommendation in detecting dysglycemia among US community health center patients. A retrospective analysis of electronic health record (EHR) data from 50,515 adult primary care patients was conducted. Longitudinal EHR data were collected in six health centers in the Midwest and Southwest. Patients with a first office visit between 2008 and 2010 were identified and followed for up to 3 y through 2013. We excluded patients who had dysglycemia at baseline and those with fewer than two office visits during the follow-up period. The exposure of interest was eligibility for screening according to the 2015 USPSTF criteria. The primary outcome was development of dysglycemia during follow-up, determined by: (1) laboratory results (fasting/2-h postload/random glucose ≥ 100/140/200 mg/dL [5.55/7.77/11.10 mmol/L] or hemoglobin A1C ≥ 5.7% [39 mmol/mol]); (2) diagnosis codes for prediabetes or type 2 diabetes; or (3) antidiabetic medication order. At baseline, 18,846 (37.3%) participants were aged ≥40 y, 33,537 (66.4%) were overweight or obese, and 39,061 (77.3%) were racial/ethnic minorities (34.6% Black, 33.9% Hispanic/Latino, and 8.7% Other). Overall, 29,946 (59.3%) patients had a glycemic test within 3 y of follow-up, and 8,478 of them developed dysglycemia. Only 12,679 (25.1%) patients were eligible for screening according to the 2015 USPSTF criteria, which demonstrated the following sensitivity and specificity (95% CI): 45.0% (43.9%-46.1%) and 71.9% (71.3%-72.5%), respectively. Racial/ethnic minorities were significantly less likely to be eligible for screening yet had higher odds of developing dysglycemia than whites (odds ratio [95% CI]: Blacks 1.24 [1.09-1.40]; Hispanics 1.46 [1.30-1.64]; and Other 1.33 [1.16-1.54]). In addition, the screening criteria had lower sensitivity in all racial/ethnic minority groups compared to whites. Limitations of this study include the ascertainment of dysglycemia only among patients with available test results and findings that may not be generalizable at the population level. CONCLUSIONS: Targeted diabetes screening based on new USPSTF criteria may detect approximately half of adult community health center patients with undiagnosed dysglycemia and proportionately fewer racial/ethnic minorities than whites. Future research is needed to estimate the performance of these screening criteria in population-based samples.

Diagnostic colonoscopy following a positive fecal occult blood test in community health center patients.

PURPOSE: Fecal occult blood testing (FOBT) is a pragmatic screening option for many community health centers (CHCs), but FOBT screening programs will not reduce mortality if patients with positive results do not undergo diagnostic colonoscopy (DC). This study was conducted to investigate DC completion among CHC patients. METHODS: This retrospective cohort study used data from three CHCs in the Midwest and Southwest. The primary study outcome was DC completion within 6 months of positive FOBT among adults age 50-75. Patient data was collected using automated electronic queries. Manual chart reviews were conducted if queries produced no evidence of DC. Poisson regression models described adjusted relative risks (RRs) of DC completion. RESULTS: The study included 308 patients; 63.3 % were female, 48.7 % were Spanish speakers and 35.7 % were uninsured. Based on combined query and chart review findings, 51.5 % completed DC. Spanish speakers were more likely than English speakers to complete DC [RR 1.19; 95 % confidence interval (CI) 1.04-1.36; P = 0.009], and DC completion was lower among patients with 0 visits than those with 1-2 visits (RR 2.81; 95% CI 1.83-4.33; P < 0.001) or ≥3 visits (RR 3.06; 95% CI 1.57-5.95; P = 0.001). CONCLUSIONS: DC completion was low overall, which raises concerns about whether FOBT can reduce CRC mortality in practice. Further research is needed to understand whether CHC navigator programs can achieve very high DC rates. If organizations use FOBT as their primary CRC screening approach and a substantial number of patients receive positive results, both screening rates and DC rates should be measured.

Best Practices in Integrating Theory and Practice in Graduate Education in Public Health Promotion.

Over the last several decades, consistent concerns have been raised about the quality of education and training provided to students in public health. In this article, we consider the implications of epidemiological transition-the decline of infectious diseases and rise of chronic diseases-for the types of education and training that would be most well suited for preparing students in health promotion to address the social and behavioral factors now associated with the leading causes of morbidity and mortality. As a result of this historic shift in disease etiology, the recommendation is to expand opportunities for applied experiential learning. Students need to become more adept at diagnosing the complex social, moral, and political dynamics that shape community priorities, perceptions of causes, and framing of health issues. The specific constellation of players, their history, relationships, and interpersonal dynamics are unique to each particular community setting, and hence, students need to become more sensitive to and proficient at picking up on the most significant influences and characteristics at work in the situation at hand. This type of "practical reasoning" stands in contrast to the perceived value of generalizable knowledge characteristic of models developed in the natural sciences. The ability to recognize and respond appropriately to the unique characteristics of a specific situation is best strengthened through extended practical experience.

Two-year follow-up of the effectiveness of a multifaceted intervention to improve adherence to annual colorectal cancer screening in community health centers.

PURPOSE: We previously found that a multifaceted outreach intervention achieved 82 % annual adherence to colorectal cancer (CRC) screening with fecal occult blood testing (FOBT). This study assessed adherence to FOBT after a second outreach. METHODS: We followed 225 patients in community health centers in Chicago, Illinois, who were randomized to the intervention group. Our primary analysis focused on 124 patients who completed FOBT during the first outreach and were due again for annual FOBT; 90% were Latino, 87% preferred to speak Spanish, and 77% were uninsured. Second outreach consisted of (1) a mailed reminder letter, a free fecal immunochemical test (FIT) with postage-paid return envelope, (2) automated phone and text messages, (3) automated reminders 2 weeks later if the FIT was not returned, and (4) a telephone call after 3 months. Our main outcome was completion of FIT within 6 months of the due date. We also analyzed the proportion of the original 225 patients who were fully screened for CRC over the 2-year study period. RESULTS: A total of 88.7% of patients completed a FIT within 6 months of their second outreach. Over the 2 years since the first outreach, 71.6% of the 225 patients assigned to the intervention group were fully up to date on CRC screening, another 11.1% had been screened suboptimally, and 17.3% were inadequately screened or not screened. CONCLUSIONS: It is possible to achieve high rates of CRC screening over a 2-year period for vulnerable populations using outreach with FIT as a primary strategy.

Comparative Effectiveness of Multifaceted Outreach to Initiate Colorectal Cancer Screening in Community Health Centers: A Randomized Controlled Trial.

INTRODUCTION: Colorectal cancer (CRC) screening rates are low among vulnerable populations. Fecal immunochemical tests (FITs) are one screening modality with few barriers. Studies have shown that outreach can improve CRC screening, but little is known about its effectiveness among individuals with no CRC screening history. We sought to determine whether outreach increases FIT uptake among patients with no CRC screening history compared to usual care. METHODS: This study was a patient-level randomized controlled trial, including 420 patients who had never completed CRC screening and were eligible for FIT; 66% were female, 62.1% were Latino, and 70.7% were uninsured. The main outcome measure was FIT completion within 6 months of the randomization date. We assessed FIT completion at different time points corresponding to receipt of outreach components. All analyses were re-run with 12-month data. RESULTS: Patients who received outreach were more likely to complete FIT than those in usual care (36.7% vs. 14.8%; p < 0.001). FIT completion was more common among patients with increased clinic visits. The difference in FIT completion between the outreach and usual care groups decreased over time. DISCUSSION: The intervention improved FIT uptake among patients with no CRC screening history. However, the intervention was less effective than in a previous trial targeting patients due for repeat screening. Additional research is needed to determine the best methods for improving CRC screening among this hard-to-reach group.

Chilling-related cell damage of apple (Malus × domestica Borkh.) fruit cortical tissue impacts antioxidant, lipid and phenolic metabolism.

'Soggy breakdown' (SB) is an internal flesh disorder of 'Honeycrisp' apple (Malus × domestica Borkh.) fruit that occurs during low temperature storage. The disorder is a chilling injury (CI) in which visible symptoms typically appear after several weeks of storage, but information about the underlying metabolism associated with its induction and development is lacking. The metabolic profile of flesh tissue from wholly healthy fruit and brown and healthy tissues from fruit with SB was characterized using gas chromatography-mass spectrometry (GC-MS) and liquid chromatograph-mass spectrometry (LC-MS). Partial least squares discriminant analysis (PLS-DA) and correlation networks revealed correlation among ester volatile compounds by composition and differences in phytosterol, phenolic and putative triacylglycerides (TAGs) metabolism among the tissues. anova-simultaneous component analysis (ASCA) was used to test the significance of metabolic changes linked with tissue health status. ASCA-significant components included antioxidant compounds, TAGs, and phytosterol conjugates. Relative to entirely healthy tissues, elevated metabolite levels in symptomatic tissue included γ-amino butyric acid, glycerol, sitosteryl (6'-O-palmitoyl) ß-d-glucoside and sitosteryl (6'-O-stearate) ß-d-glucoside, and TAGs containing combinations of 16:0, 18:3, 18:2 and 18:1 fatty acids. Reduced metabolite levels in SB tissue included 5-caffeoyl quinate, ß-carotene, catechin, epicatechin, α-tocopherol, violaxanthin and sitosteryl ß-d glucoside. Pathway analysis indicated aspects of primary metabolism differed according to tissue condition, although differences in metabolites involved were more subtle than those of some secondary metabolites. The results implicate oxidative stress and membrane disruption processes in SB development and constitute a diagnostic metabolic profile for the disorder.

Promoting Justice and Autonomy in Public Policies to Reduce the Health Consequences of Obesity.

Public policies to reduce the extent of obesity in the United States have generated considerable public controversy. The paper examines the implications of proposed policies for the principles of justice and autonomy and key assumptions underlying the major contending positions with respect to the relative weight that should be assigned to them in balancing their respective claims. The analysis traces the crux of the debate regarding the ethical warrant for policies to restrict access to calorie-dense foodstuffs to two key issues: the appeal to different and conflicting theories of justice, and the conflation of autonomy with negative liberty in public debates. After clarifying the ethically relevant characteristics of autonomy that merit defense, the paper concludes with a description of how the capabilities approach to justice may offer a more coherent ethical framework for developing and evaluating policies to address the current obesity epidemic.

Tensions between the conduct of randomised controlled trials in health promotion research and the role of autonomy in human health and well being.

The goal of developing increasingly effective interventions to change health-related behaviours, which is an inevitable result of the use of the scientific method, conflicts with respect for the autonomy and dignity of the individual. This paper recommends a new direction for the field of health promotion based on building people's capacity to exercise autonomy, in the ethically relevant meaning of the term, and thereby promote a more comprehensive understanding of the goals of the field, a state of health that includes the irreducible ethical dimension signified by human dignity.

Is chronic pain a disease?

OBJECTIVE: The discovery of neuroplastic phenomena such as central sensitization of nociception has challenged pain theory to evolve, to encompass unpredictable and unlikely chronic pain states, and to cope with the emerging complexity of the brain. Recently, the proposition that chronic pain is a disease in its own right has gained currency, based upon functional and structural changes in the brain constituting a distinctive pathology. Proponents have expanded the theory to identify "eudynia" ("good" pain) and "maldynia" ("bad" pain). METHODS: A critical examination of the proposition that chronic pain is a disease was conducted within the framework of evolution of pain medicine theory. RESULTS: Three dominant theories were identified: specificity theory (the "hard-wired" nervous system); neuroplasticity theory (the "soft-wired" nervous system); and pain-as-a-disease. The progression from specificity theory to neuroplasticity theory was based upon empirical evidence and conceptual clarity. The latter theory confronts the uncertainty and the unpredictability of pain, and offers explanations for conditions where ongoing noxious input is not discernible. However, not only does pain-as-a-disease elevate the neurophysiological mechanisms underlying the experience of chronic pain to the status of a disease, but also it conceives of pain as a "thing" that is itself capable of producing an effect. This reasoning is found to be faulty on two grounds: the confusion of pain as a symptom, a cause, and a pathology; and the fallacy that can arise when an interpretation is claimed to be a truth. CONCLUSIONS: The proposition that chronic pain is a disease cannot be supported on clinical and pathological grounds, as well as in terms of ways of knowing. The promulgation of "good" and "bad" pain has the potential to obstruct necessary dialogue for advancing the science and treatment of pain. We suggest a way forward to resolve this impasse.

Infants' use of contextual cues in the generalization of effective actions from imitation.

We examined infants' ability to generalize effective actions in an imitation task. In Experiment 1, 15-month-olds imitated effective and ineffective actions on two similarly designed toys. They were then shown a third toy of the same design with both actions available. Children reliably touched and manipulated the effective action handle first and more persistently. In Experiment 2, however, 15-month-olds did not generalize the efficacy of the action when the test toy was different from the two demonstration toys. Experiment 3 replicated the findings of Experiment 2 but also showed that infants generalized efficacy when the demonstration toys differed from one another as well as from the test toy. Our findings are consistent with a computational model that uses certain rational pedagogical assumptions. Overall, the results suggest that 15-month-olds are sensitive to the sampling information they observe and use this information to guide whether to generalize efficacy information they learn from imitation.

Design of a randomized controlled trial to assess the comparative effectiveness of a multifaceted intervention to improve adherence to colorectal cancer screening among patients cared for in a community health center.

BACKGROUND: Colorectal cancer (CRC) is common and leads to significant morbidity and mortality. Although screening with fecal occult blood testing (FOBT) or endoscopy has been shown to decrease CRC mortality, screening rates remain suboptimal. Screening rates are particularly low for people with low incomes and members of underrepresented minority groups. FOBT should be done annually to detect CRC early and to reduce CRC mortality, but this often does not occur. This paper describes the design of a multifaceted intervention to increase long-term adherence to FOBT among poor, predominantly Latino patients, and the design of a randomized controlled trial (RCT) to test the efficacy of this intervention compared to usual care. METHODS: In this RCT, patients who are due for repeat FOBT are identified in the electronic health record (EHR) and randomized to receive either usual care or a multifaceted intervention. The usual care group includes multiple point-of-care interventions (e.g., standing orders, EHR reminders), performance measurement, and financial incentives to improve CRC screening rates. The intervention augments usual care through mailed CRC screening test kits, low literacy patient education materials, automated phone and text message reminders, in-person follow up calls from a CRC Screening Coordinator, and communication of results to patients along with a reminder card highlighting when the patient is next due for screening. The primary outcome is completion of FOBT within 6 months of becoming due. DISCUSSION: The main goal of the study is to determine the comparative effectiveness of the intervention compared to usual care. Additionally, we want to assess whether or not it is possible to achieve high rates of adherence to CRC screening with annual FOBT, which is necessary for reducing CRC mortality. The intervention relies on technology that is increasingly widespread and declining in cost, including EHR systems, automated phone and text messaging, and FOBTs for CRC screening. We took this approach to ensure generalizability and allow us to rapidly disseminate the intervention through networks of community health centers (CHCs) if the RCT shows the intervention to be superior to usual care. TRIAL REGISTRATION: ClinicalTrials.gov NCT01453894.

Adherence to repeat fecal occult blood testing in an urban community health center network.

Annual fecal occult blood testing (FOBT) has the potential to reduce colorectal cancer mortality, but in practice it is challenging to complete FOBT every year. Repeat FOBT adherence may be especially low in community health center (CHC) settings, where many patients face barriers to annual FOBT completion. We conducted a retrospective cohort analysis to investigate adherence to annual FOBT in an urban CHC network that serves a predominantly Spanish-speaking, uninsured adult patient population. This study used data from the two-year period between January 2010 and December 2011, and included adults aged 50-74 who completed a screening FOBT with a negative result during the first 6 months of 2010. We examined whether each patient completed a second FOBT between 9 and 18 months after the initial negative FOBT, and tested whether repeat FOBT adherence was associated with patient characteristics or the number of clinic visits after the initial negative FOBT. Only 69 of 281 included patients completed repeat FOBT (24.6 % adherence), and none of 62 patients (0 %) with 0 clinic visits completed repeat FOBT. We detected no significant differences in adherence by age, sex, preferred language, insurance status, or number of chronic conditions. In multivariable regression, the adjusted relative risk of repeat FOBT was 1.66 (95 % CI 1.09-2.54; p = 0.02) among patients with 3 or more clinic visits (referent: patients with 1-2 visits). The observed low rate of adherence greatly diminishes the effectiveness of FOBT in reducing CRC mortality. Findings demonstrate the need for systems-based interventions that increase adherence without requiring face-to-face encounters.