CRC Screening Program Narrowed Equity Gaps Over 9 Years

Participation in colorectal cancer (CRC) screening climbed steadily across socioeconomic groups in Hong Kong following the government’s organized screening program, with the steepest gains among historically underserved populations, according to a cross-sectional study published today in JAMA Health Forum.¹ Concentration indices, a standard measure of how unevenly a health service is distributed across income groups, fell sharply over the 9-year study window, suggesting the program moved the needle on equity even as overall uptake remained below benchmarks seen in other high-income countries.

What the Program Did, and Didn’t, Accomplish

Hong Kong’s CRC screening program (CRCSP) launched as a pilot in 2016 and reached full implementation in 2020, ultimately covering residents aged 50 to 75 years from 3 repeated territory-wide population surveys. The CRCSP uses a public-private partnership model, subsidizing the first fecal immunochemical test and consultation with a primary care physician and then a second consult for those who screen positive plus colonoscopy. Researchers analyzed data from 14,602 adults across 3 population health surveys spanning 2014 to 2022, covering both the prelaunch and full-implementation periods. The mean (SD) patient age was 60.62 (7.03) years and more than half were female patients (52.84%)

Weighted fecal test participation grew from 19.88% (95% CI, 18.70%-21.05%) of eligible adults before the program launched (2014-2015) to 27.15% (95% CI, 26.12%-28.18%) between 2020 and 2022, or nearly 37%. Colonoscopy uptake rose by approximately 55% over the same period, from 17.65% (95%CI, 16.53%-18.77%) to 27.28% (95%CI, 26.24%-28.31%). These gains were observed across age groups, both sexes, and all income tiers.

More notably, disparities narrowed. Before the CRCSP, fecal test participation was heavily concentrated among higher socioeconomic status (SES) groups, with a concentration index of 0.11. By 2020 to 2022, that figure had declined to 0.02, or nearly flat, indicating close-to-equal distribution across SES levels. Colonoscopy showed a parallel pattern. Prior to the program, individuals in the highest SES bracket were more than 3 times as likely to undergo screening compared with those in the lowest bracket (adjusted OR, 3.52; 95%CI, 2.80-4.43; 2014-2015); that disparity narrowed significantly following implementation (OR, 2.34; 95%CI, 1.97-2.77; 2020-2022).

Who Is Still Being Left Behind

Despite the progress, the study identified persistent gaps that warrant targeted intervention. Younger-eligible adults aged 50 to 54 years lagged behind older cohorts, with participation reaching only 23.4% by 2020 to 2022 vs 33.4% among those aged 70 to 75 years. Single-person households, individuals with primary or secondary school education only, lower-income adults, and public housing residents all showed below-average uptake even after program implementation.

Employment status presented a counterintuitive finding: employed adults were less likely to participate in both fecal testing (OR, 0.83; 95% CI, 0.70-0.98) and colonoscopy (OR, 0.70; 95% CI, 0.59-0.83) than those not employed. The researchers noted that employed participants were predominantly aged 50 to 64 years, suggesting time constraints and scheduling barriers may be suppressing uptake in this age segment.

The structural features of Hong Kong’s primary care system help explain the persistence of these gaps. Primary health care is heavily privatized, with 75% of expenditures occurring in the private sector, and relies substantially on out-of-pocket costs. Only about 23% of the population has an established relationship with a family physician, and consultations are typically brief and episodic. Even though the CRCSP subsidizes screening to near-zero cost for most participants, individuals must still proactively schedule an appointment with an enrolled private physician, a step that may disadvantage those with lower health literacy, fewer social supports, or limited time.

Lessons for Managed Care and Health System Design

These findings offer a useful data point in a global conversation about how organized screening programs can improve not just uptake but equity. In the US, CRC rates remain persistently lower in rural areas than in urban communities, with socioeconomic and structural barriers driving a gap that measurable factors explain only partially.² In addition, a 2025 analysis of US National Health Interview Survey data found that racial and ethnic differences in CRC screening were largely attributable to demographic and socioeconomic factors, except for persistently low colonoscopy use among Asian individuals.³

The Hong Kong study’s authors point to population-based invitation systems, in which eligible individuals are centrally identified and mailed fecal immunochemistry test (FIT) kits or invitations, as a model for improving equity in fragmented health care environments. They cited Finland’s biennial FIT program and US research showing that mailed FIT outreach combined with patient navigation improved screening in underserved communities as potential templates. Research published in JAMA Network Open earlier this year showed that integrating social care into health care workflows and addressing multiple barriers simultaneously may help reduce persistent CRC screening disparities.⁴

Overall, Hong Kong’s current overall CRC screening participation rate, approximately 46% of eligible adults as of 2023, per the study, remains well below the 68% to 74% range reported in Finland, the US, and the United Kingdon. The study’s authors call for greater integration of cancer screening into primary care pathways, expanded community outreach, and continued surveillance to monitor which groups benefit least from current program design.

“The study findings suggest that the population-wide availability of the screening program was associated with an increased overall uptake and narrowed disparities,” the authors concluded, “but targeted efforts are needed for certain socioeconomic groups.” These include single households, lower-income groups, public housing residents, and individuals with up to a secondary school education.

References

1. Xiong X, Ng CS, Zhang Y, et al. Health equity after a colorectal cancer screening program. JAMA Health Forum. 2026;7(6):e261520. doi:10.1001/jamahealthforum.2026.1520
2. Owusu DN, Mensah EA, Mamudu S, et al. Rural-urban disparities in colorectal cancer screening in United States: Blinder-Oaxaca decomposition analysis of BRFSS data. Cancer Causes Control. 2025;36(12):1911-1917. doi:10.1007/s10552-025-02071-7
3. Wang YR. Racial/ethnic differences in colorectal cancer screening in the US. Am J Manag Care. 2025;31(8):e235-e237 doi:10.37765/ajmc.2025.89779
4. Ewing AP, Tounkara F, Lawrence WR, et al. Colorectal cancer screening and health-related social needs in a national sample of US adults. JAMA Netw Open. 2026;9(4):e266000. doi:10.1001/jamanetworkopen.2026.6000