A multilevel adaptation approach for the sustainable scale-up of family cancer history screening in rural public health clinics

BACKGROUND: National guidelines (e.g., the U.S. Preventive Services Task Force) and public health organizations (e.g., the Centers for Disease Control and Prevention) recommend population-level family cancer history screening to enhance hereditary cancer risk assessment. Despite over a decade of statewide implementation in Georgia, participation in and the impact of family cancer history screening in rural public health clinics remains limited, highlighting the need for systematic adaptation of existing program delivery approaches. Furthermore, the application of implementation frameworks to the documentation and evaluation of adaptations in genomic service delivery is infrequent. In this report, we apply the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework and the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) to systematically document multilevel adaptations aimed to increase access to Georgia's statewide family cancer history screening program for BRCA-associated cancers among women in rural Georgia. METHODS: We conducted a 14-month adaptation process in the Southwest Public Health District of Georgia from November 2023 to January 2025. Using the FRAME, we systematically documented adaptations in five steps: (1) stakeholder identification, (2) multilevel needs assessment, (3) development of prototype adaptations, (4) adaptation validation and prioritization through stakeholder deliberation, and (5) pilot testing. RESULTS: We convened a stakeholder committee (n = 15) representing multiple levels of healthcare delivery, including patients, internal stakeholders from 14 public health clinics in the district, and external stakeholders from regional cancer coalitions and healthcare systems. A total of 15 adaptations were prioritized across individual (n = 2), provider (n = 1), clinic (n = 7), organization (n = 3), and community (n = 2) levels. Most adaptations focused on implementation and scale-up activities (n = 10), followed by changes to contextual modifications (n = 4) and communication content (n = 1). Key adaptations included new outreach (e.g., posters, phone scripts, social media), streamlined screening workflow (e.g., simplified data entry, automated referrals), and integration of theory-based, risk-stratified communications about screening results. CONCLUSIONS: Strong partnerships between public health agencies, community organizations, and academic institutions were essential to guiding our adaptation process. By combining implementation frameworks, multilevel stakeholder engagement, and proactive pre-implementation adaptation, our study offers a replicable, stepwise approach for adapting, scaling up, and sustaining other hereditary cancer screening programs in underserved public health settings.