Open Access Research article

Evaluating the impact of public health initiatives on trends in fecal occult blood test participation in Ontario

Gladys N Honein-AbouHaidar1, Linda Rabeneck23456, Lawrence F Paszat67, Rinku Sutradhar26, Jill Tinmouth45678 and Nancy N Baxter569*

Author Affiliations

1 Division of Support, System and Outcomes, University Health Network, Toronto, ON, Canada

2 Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada

3 Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON, Canada

4 Department of Medicine, University of Toronto, Toronto, ON, Canada

5 Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada

6 Institute for Clinical Evaluative Sciences, Toronto, ON, Canada

7 Sunnybrook Research Institute, Toronto, ON, Canada

8 ColonCancerCheck Program, Cancer Care Ontario, Toronto, ON, Canada

9 Department of Surgery and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada

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BMC Cancer 2014, 14:537  doi:10.1186/1471-2407-14-537

Published: 25 July 2014



Since the publication of two randomized controlled trials (RCT) in 1996 demonstrating the effectiveness of fecal occult blood test (FOBT) in reducing colorectal cancer (CRC) mortality, several public health initiatives have been introduced in Ontario to promote FOBT participation. We examined the effect of these initiatives on FOBT participation and evaluated temporal trends in participation between 1994 and 2012.


Using administrative databases, we identified 18 annual cohorts of individuals age 50 to 74 years eligible for CRC screening and identified those who received FOBT in each quarter of a year. We used negative binomial segmented regression to examine the effect of initiatives on trends and Joinpoint regression to evaluate temporal trends in FOBT participation.


Quarterly FOBT participation increased from 6.5 per 1000 in quarter 1 to 41.6 per 1000 in quarter 72 (January-March 2012). Segmented regression indicated increases following the publication of the RCTs in 1996 (Δ slope = 6%, 95% CI = 4.3-7.9), the primary care physician financial incentives announcement in 2005 (Δ slope = 2.2%, 95% CI = 0.68-3.7), the launch of the ColonCancerCheck (CCC) Program (Δ intercept = 35.4%, 95% CI = 18.3 -54.9), and the CCC Program 2-year anniversary (Δ slope = 7.2%, 95% CI = 3.9 – 10.5). Joinpoint validated these findings and identified the specific points when changes occurred.


Although observed increases in FOBT participation cannot be definitively attributed to the various initiatives, the results of the two statistical approaches suggest a causal association between the observed increases in FOBT participation and most of these initiatives.

Public health policy; Colorectal cancer screening; Epidemiologic study