The main goal of this R21 application is to pilot test and evaluate a system for referral of primary care (PC) patients in need of colorectal cancer (CRC) screening to a tailored telephone counseling (TTC) service designed for patients of all levels of health literacy and supported by interpreters for low English proficiency patients. Referred patients would receive tailored education about CRC and CRC screening, assistance in making screening decisions, motivational counseling to encourage screening, and follow-up to promote adherence to screening. CRC screening of men and women age greater than or equal to0 50 reduces CRC mortality but is underused, especially among minority and lower income populations. For most people the pathway to screening is through their primary care provider (PCP), but competing demands on PCP time, limitations in office reminder systems, and the challenges of effectively counseling patients about multiple CRC screening options are barriers to improving rates of CRC screening in PC. We hypothesize that when PCP's are reminded to recommend CRC screening at every visit made by screening-eligible patients and can refer patients for CRC counseling to a TTC service that they will recommend CRC screening more often and their patients will accept and follow through with screening more frequently. We believe that this referral/TTC model has the potential to improve delivery of many types of prevention counseling services in PC. We have developed and are currently studying a computer-assisted telephone counseling (CATC) system for CRC screening. We propose to revise and further develop this system for use in diverse populations that include individuals with limited health literacy and limited English proficiency. The system would be supported by a variety of print materials delivered to patients at appropriate times during the referral and counseling process. Telephone counselors would have access to provider-specific information on CRC testing preferences, which they would use to emphasize their role as an extension of the provider and to facilitate completion of CRC testing. Phase 1 of this study uses focus groups of patients with low levels of health literacy and usability testing to support the revision of print materials and counseling protocols. A pretest of the system occurs in Phase 2. In Phase 3 the referral / counseling/follow-up system is pilot tested in a sample of 200-250 patients from 7 diverse PC practices comprising more than 100 providers. Evaluation includes assessment of system performance, provider/patient satisfaction, and screening outcomes through surveys, interviews, and process and outcome data collection and analysis.