Despite widespread recognition of the potential health benefits and evidentiary basis for timely colorectal cancer screening (CRCS) of adults aged 50–75 years (US Preventive Services Task Force et al., 2021), uptake is suboptimal in persons who are under-resourced (He et al., 2023; Viramontes et al., 2020; Glaser et al., 2024). Among U.S. adults aged 50–75 years in 2020, rates of up-to-date CRCS were 72.4% for the U.S. population overall but only 63.9% among Hispanic persons, 64.1% among those with less than a high school education, 66.9% among those with annual household income of less than $15,000, and 38.6% in those without health insurance coverage (He et al., 2023). The U.S. Centers for Disease Control and Prevention (CDC) has identified improvements in CRCS rates among under-resourced persons as a high priority, using integrated care models and other outreach initiatives delivered through federally qualified health centers (FQHCs) that provide health care to those who are medically underserved (Subramanian et al., 2022; Zhan et al., 2023).

Ideally, these outreach initiatives would mitigate barriers to screening, which may vary by population subgroup (Zhu et al., 2021). For example, lack of knowledge of CRCS is reported more commonly as a barrier by males than females, by lower- than higher-income individuals, and by Black non-Hispanic and Hispanic than White non-Hispanic persons (Zhu et al., 2021). Suboptimal access to care has also been reported as a barrier to CRCS, especially by those aged 50–64 years, those with some college but not completing a degree, those in fair or poor health, and those with no health care visits in the past 2 years (Zhu et al., 2021). Barriers also occur in geographic areas where rates of uninsurance exceed the national average (Zhan et al., 2023). Finally, sensory, physical, or cognitive impairments may prevent CRCS because of difficulties in making appointments or accessing transportation to health care services (Steele et al., 2017).

Several population subgroups most affected by these barriers are also among those with the highest rates of CRC morbidity and mortality. Black men and women, respectively, have CRC incidence rates 22% and 18% higher, and mortality rates 46% and 33% higher, than do their White counterparts (American Cancer Society, 2020). Alaska Native persons are at markedly elevated CRC risk, with an incidence rate that is 131% higher, and a mortality rate that is 187% higher, than those of White non-Hispanic persons (American Cancer Society, 2020). Health habits associated with lack of screening, such as cigarette smoking (Mayhand et al., 2021), also contribute to CRC incidence, with relative risks of 1.3 for heavy alcohol consumption, 1.3 for obesity, and 1.5 for current smoking (American Cancer Society, 2020). This combination of elevated disease risk and lower screening rates makes it essential to tailor outreach efforts or screening modality to address challenges common in these subgroups.

Newer, noninvasive testing modalities that do not require extensive bowel preparation or time commitment may be advantageous for under-resourced persons (He et al., 2023; Hol et al., 2010), such as part-time or temporary workers with limited access to paid time-off benefits (Bureau of Labor Statistics, 2022). Supporting this view, residence in areas with high levels of deprivation has been associated with reluctance to use flexible sigmoidoscopy and greater willingness to use fecal immunochemical testing (FIT) than other methods (Mayhand et al., 2021; Ali et al., 2023). Additionally, bowel preparation is a commonly mentioned barrier to colonoscopy (Ali et al., 2023). In a study using 2016 Behavioral Risk Factor Surveillance System (BRFSS) survey data, Hispanic respondents who received screening were less likely to undergo colonoscopy and more likely to use fecal occult blood testing (FOBT) or FIT than were their White non-Hispanic counterparts (Viramontes et al., 2020).

Among these noninvasive strategies, stool deoxyribonucleic acid (sDNA) testing with FIT may pose additional advantages because it is more sensitive, although less specific, than other noninvasive modalities (Lin et al., 2021); requires no dietary preparation; and needs repeating only every 1–3 years, unlike other fecal detection modalities that require annual screening (US Preventive Services Task Force et al., 2021). Moreover, sDNA testing may overcome cultural and gender-related sensitivities around anal examination, which has been reported in studies of colonoscopy hesitancy (Rogers et al., 2017). Finally, the sDNA test is delivered by mail, and its manufacturer provides a patient outreach system of education and reminders after the test is ordered (Anand and Liang, 2022).

Despite the potential advantages of sDNA testing for under-resourced groups, limited evidence of its use in these groups is available. A recent analysis of national trends in CRCS reported sDNA utilization rates in several underserved groups that were higher than the national average of 5.8% in 2020 (e.g., Black non-Hispanic, 8.3%; annual income <$15,000, 12.1%) (He et al., 2023). However, that analysis was bivariate and did not account for confounding or for health conditions that could affect screening likelihood or modality (He et al., 2023; Steele et al., 2017). Additionally, no study has assessed use of sDNA versus other modalities in populations with sensory or other impairments, who may also experience challenges in accessing care. Moreover, previous research suggests reduced uptake of new or advanced health care technologies in under-resourced compared with adequately resourced groups (van Kessel et al., 2023; Nelson et al., 2002; Dreyer et al., 2018).

To provide current data on uptake and predictors of CRCS for key population subgroups, the purpose of this study was to assess prevalence and predictors of sDNA test utilization in a large, nationally representative sample of U.S. residents. We expected that use of sDNA, a relatively new technology, might be reduced in under-resourced groups. However, owing to lack of published information on predictors of sDNA use, the study approach was exploratory, with no formal hypotheses.