THE PROMOTION OF COLORECTAL CANCER SCREENING

Prepared by Renzo Amaya

American Cancer Society Mendota Heights, MN

2007

Table of Contents Colorectal Cancer................................................................................................................ 1

Purpose ............................................................................................................................ 1

Methods........................................................................................................................... 1

Barriers to Colorectal Cancer Screening (CRCS) ............................................................... 1

Colorectal Cancer Screening Interventions ........................................................................ 4

Current Studies................................................................................................................ 4

Printed Materials ............................................................................................................. 4

Videotapes....................................................................................................................... 5

One-on-One and Telephone Outreach ............................................................................ 7

Fecal Occult Blood Testing (FOBT) Kits ....................................................................... 9

Multi-Component Interventions.................................................................................... 10

Other Efforts ................................................................................................................. 10

Conclusion & Recommendations ..................................................................................... 11

References ......................................................................................................................... 14

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Colorectal Cancer Colorectal cancer (CRC) is the second deadliest cancer related disease in the U.S.1 In 2007, approximately 153,760 new cases are expected to be diagnosed and 52,180 deaths will be attributed to the disease. These figures include 2,650 new cases and approximate-ly 810 deaths in Minnesota.2 Data from randomized trials has demonstrated that through screening, early detection of precancerous cells is possible, as well as the removal of ab-normal polyps, thus keeping the disease from progressing to advanced stages when it be-comes more difficult to treat.3 Despite the fact that CRC incidence and mortality rates have been decreasing in the last two decades, many people who are at risk of the disease have not been screened.4 Increasing screening rates is paramount to reduce the number of deaths and the burden in the healthcare system, which spends six billion dollars a year on treatment of CRC.5

Purpose This document is a review of components from colorectal cancer education interventions aimed at increasing screening rates in the U. S. An important element within the context of the review is a synopsis of factors that inhibit the utilization of colorectal cancer screening among eligible individuals. After this summary, intervention strategies are pre-sented and recommendations for consideration in future endeavors are provided.

Methods The review is based mostly on peer-reviewed journal articles published within the last five years that describe mostly randomized-controlled trials. A few of those articles also describe comparative studies. Other resources with information relevant to the subject available on the internet were also used in the preparation of this document. It is impor-tant to note that in many cases, participants self-reported their screening status, which can give room to bias as participants may be tempted to provide a „socially desirable‟ answer.

Barriers to Colorectal Cancer Screening (CRCS) The adoption of preventive behaviors such as physical activity, healthy diet, avoidance of tobacco products, and screening are not easily achievable. There are often multiple fac-tors that contribute to this reality. Many studies have been conducted using both quantita-tive and qualitative research methods to identify the common barriers to CRCS. The con-sistency in the findings of those studies constitutes a compelling argument for the need for integral interventions in interpersonal, family, worksite, clinical and community set-tings. The major barriers to CRCS that have been identified are:

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■ Lack of a physician recommendation. ■ Lack of knowledge about the need for screening and screening guidelines. ■ Low perceived risk of disease and underestimation of the importance of screening

due to lack of symptoms or family history. ■ Embarrassment. ■ Inconvenience and/or time demand. ■ Fear of pain or injury. ■ Fear of results. ■ Inadequate or lack of health insurance. ■ Low literacy level. ■ Logistical obstacles such as lack of transportation and difficulty making appoint-

ments. ■ Perceived lack of social support. ■ Distrust of the health system. ■ Lack of English skills and little acculturation (few years living in the U.S.).6-16

Most of these barriers operate at the patient level, but there are also barriers at the

clinical and the health care system level that need to be addressed as well. To illustrate, a comparative study about the impact of Medicare coverage on the use of colonoscopy showed that four years following the legislation that approved Medicare coverage in July 2001, there was an increase in use of colonoscopy from 4% to 14%.17 Although adequate access is an important pre-requisite, quality of care is also a critical concern. Research based on the Veterans Health Administration‟s electronic medical records found that four out of ten individuals who had a positive fecal occult blood test (FOBT) did not receive follow up testing.18 Almost half of possible cases were not confirmed through more accu-rate testing, which translates into missed opportunities to prevent cancer from progressing, if it was indeed present. Access to healthcare is only one piece of the puzzle in reducing the multiple barriers that are keeping a major portion of the U.S. aging population from being screened. Although there has been some increase in patient education on colorectal cancer, the topic still does not receive as much attention as it deserves.

The impact of having a regular health provider on CRCS knowledge is rather disap-pointing. According to a study based on the National Health Interview Survey, 94% of eligible individuals who had not been screened were not recommended by their physician to get screened during the previous year. As a result, a high number of eligible individu-als are not aware of the need for screening (up to 72% according to the same study).7 Multiple studies have identified the failure of physicians to bring up the subject of CRCS during patient visits as one of the top reasons for lack of screening among eligible indi-viduals.6-9,12,14,19,20 Several of those studies have also pointed out that racial minorities, low educated and low income individuals are less likely to be recommended for screen-ing by a physician.21 Therefore, having a regular health provider is not, in many cases, the best guarantee for screening due to the lack of adequate physician-patient communi-cation in regards to the need, options, and benefits of screening. This reality could sug-gest that individuals believe that if a physician does not advise a course of action, then one is not needed, which is especially problematic because many of them rely on their physicians for a considerable amount of health information.7 Good quality of health care

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is partly reflected in physicians‟ ability to discuss with their patients the health issues they should pay attention to and to offer available options in dealing with such issues. Recommendation for preventive action that can save suffering, economic expenses, and ultimately many lives is an ethical matter. With the existence of various screening options from which patients can choose, there is no excuse for physicians not to share this impor-tant piece of information.

Health communication is needed, first, to provide individuals the information they lack, and second, through message reinforcement to influence individuals‟ perceptions, beliefs, and attitudes, and consequently change the social norms related to CRCS. In this aspect, there is a pressing need to create messages that are suitable to specific populations based on socio-economic status, culture, and education. Gender is another variable that requires consideration. A few studies suggest that female gender is associated with less adherence to screening.7,18,22 One hypothesis for this reality is that some women have a strong preference for their physician‟s gender. In one survey, most women cited embar-rassment as the number one reason why they would prefer a female physician over a male one. Better empathy, listening skills, and competence were attributes that women be-lieved female physicians possessed.23 This survey was conducted among highly educated women, which limits the generalization of the results, but it demonstrates the necessity to assess attitudes and beliefs in a target population in order to identify its relevant barriers.

A comparative study based on the National Cancer Institute‟s Health Information Na-tional Trends Survey (HINTS) carried out in 2003 revealed that although a moderately large number of respondents had heard about FOBT, colonoscopy or sigmoidoscopy (57%), the majority did not have adequate screening knowledge (79%).i Many respon-dents mistakenly believed that screening had to be done more frequently than it is actual-ly recommended. This finding is noteworthy because such perception can become anoth-er barrier to screening if, as mentioned earlier, individuals also believe that screening is inconvenient, expensive, time consuming, and embarrassing. A large number of individu-als (60%), especially older Americans, considered their health care provider as their first source of cancer information.24 This is also very true for Hispanics, but they also turned to family and friends. A higher percentage of African Americans referred to educational materials. The internet became a leading source of information for White, Asian, male and younger populations.25 In other words, people are using different sources of informa-tion based on their ethnicity, age and gender, which means that screening messages have to be offered through many different mediums.

Similar to knowledge, individuals‟ perception of risk is another important factor that predicts CRCS compliance. In another study based on HINTS 2003, almost half of the respondents stated that they thought they were at a reduced risk of CRC compared to oth-er people of their same age and sex.26 Other studies suggest that women are more likely to underestimate the risk of CRC than men, which would be another reason why women are less compliant.6 Whereas lack of family history has been identified as a factor that may contribute to lower perceived risk of CRC, personal experience with family suffer- i For the purpose of the study, CRCS knowledge was defined as knowing about screening tests, the age of initiation for screening, and the frequency of screening.

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ing or loss due to CRC can lead some individuals to feel hopeless or fearful about the disease. There is enough evidence to conclude that this phenomenon known as “cancer fatalism” is more prevalent among poor African American and Hispanic individuals who tend to have more negative attitudes towards CRCS. They consider the diagnosis of CRC as a „death sentence‟, and therefore, do not see the point of complying with an embarrass-ing and inconvenient screening test. 8,15,27,28 Evidence suggests that even when individu-als gain knowledge about CRC, many will not comply with screening when their attitudes and beliefs toward the disease and screening do not change. This makes CRCS promotion a very challenging endeavor and it means that intensive interventions are required for even moderate improvements to happen.

Colorectal Cancer Screening Interventions

Current Studies The Division of Cancer Prevention and Control at the Centers for Disease Control (CDC) has funded eight studies to promote colorectal cancer screening among underserved pop-ulations, specifically African Americans, Hispanics, less literate and rural residents. This effort is a response to the lack of interventions promoting preventive behaviors such as CRCS among those populations. The Task Force on Community Preventive Services, a team appointed by the Director of CDC that evaluates intervention strategies and devel-ops the Guide to Community Preventive Service, has made only two recommendations to increase colorectal cancer screening. These are the removal of structural barriers (e.g. ex-tended clinic hours, child care provision, availability of interpreters, etc) and client re-minders. Both of these recommendations have been made based on determined sufficient evidence.29 The eight studies funded by CDC incorporate a variety of strategies that, once evaluated, will provide insight in regards to the types of components that may be imple-mented in communities across the country. Unfortunately, results from these studies are not discussed here because either the studies are still being implemented or the data is under analysis. The studies use a variety of approaches that include small media (video-tapes, posters, booklets, etc.), group and one-on-one education sessions, lay health advi-sors, physician recommendations, and a few others.5 Some of these strategies have been used in other studies in the last years and their findings are reviewed next. Again, the Task Force has not determined the evidence from these studies to be sufficient in order to include other strategies in the Guide to Community Preventive Service.

Printed Materials In the promotion of preventive behaviors such as CRCS, print materials can be an impor-tant strategy in communities with limited community health services, health education personnel, transportation, and other resources needed for mass health promotion. Printed materials, like any other method of education, do not automatically increase people‟s knowledge or understanding of health issues. Several considerations need to be made in regards to presentation, amount of information, and language (reading level and/or Eng-

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lish proficiency vs. other languages), among other aspects. To illustrate, focus groups were conducted to compare and evaluate written educational materials in the Appalachian region of Kentucky, which is prominent for its socioeconomic and health disparities, in order to develop materials specifically tailored for its largely rural communities. Two of the materials were from the CDC campaign “Screen for Life,” one from the Cancer Re-search and Prevention Foundation and another from the American Cancer Society. The materials were two fact sheets and two brochures that contained comparable types of in-formation and presented them in different ways. The CDC “Screen for Life” educational materials were preferred over the others because they contained bigger print size, dia-grams, color, a „non-intimidating‟ tone and concise information.30

The most important pieces of information that were identified as essential to be included in the educational materials were: 1) colorectal cancer is a preventable disease, 2) early detection through screening can save people‟s lives, 3) colored diagrams of the co-lon and rectum, 4) risk factors and warning signs, 5) brief and clear description of screen-ing tests. Most participants agreed that items 1 and 2 should be the first facts presented in the educational materials. One aspect highlighted by Davis et al. is that the amount of in-formation presented about screening tests does not always match the amount of informa-tion that individuals seek. Some individuals become overwhelmed while others wish to learn as many details as possible in order to make a decision. A suggested alternative is to offer basic information about the tests in the presence of large groups and later offer more in-depth information for those who need it or want it before making a decision.30 Al-though the results from these focus groups cannot be generalized, they provide insights about the kind of elements to be considered in the development of materials for commu-nity educational programs aimed at low income, low literate individuals. This example also makes a case for the significance of creating educational materials based on the pre-ferences of the communities to which such materials will be offered.

It is helpful to consider that printed materials alone may not account for much dif-ference in screening rates. Many interventions have used printed materials to accompany other types of strategies, even when that means offering a different form of educational material. Their main advantage is that they are the simplest and cheapest way to commu-nicate health information, which often makes it feasible to incorporate with other strate-gies.

Videotapes Although the Task Force on Community Preventive Services concluded that the use of written materials and the web can increase screening knowledge, they may have little ef-fect on individuals‟ interest to get screened.30 These materials are very impersonal and do not provide role modeling or a visual representation of the screening tests. Moreover, written materials will never work for individuals who lack reading abilities. For these reasons, videotapes have been used in multiple studies to educate and motivate the public to get screened. Like printed materials, videotapes can address several barriers including physicians‟ poor communication skills and time constraints to educate patients as well as

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inconsistency of screening recommendations. In addition, videotapes make up for low literacy and brevity of Public Service Announcements (PSAs), which can never provide enough information and can only lead people to look for that information on their own at best.31

A few studies have sought to determine the role of videotapes in decision making for screening. For example, in a study in which a set of participants watched an 11-minute video on colon cancer screening and later received a tailored brochure, 50% of participants moved from low to high interest in screening compared to 26% in the control group, and 37% completed a screening test compared to 23% in the control group.32 Al-though not all of the participants who gained interest in screening completed a screening test at the time of the study, the use of the videotapes and the accompanying materials was fairly effective in increasing interest. Increased interest, like knowledge, does not necessarily translate into screening adherence, but it is a primary objective that must be met.

In another study, one group of low income, low educated African Americans re-ceived a video and printed materialsi (which focused on FOBT) at different intervals dur-ing twelve months and achieved the highest screening compliance (61%) compared to a group that received only the videoii at the beginning (46%). A third group that did not receive any of the materials had a 15% screening rate.33 Comparable results were ob-tained when the intervention was implemented only among women of the same ethnic group.34 In a study in which a brochure was sent to participants‟ home address within ten days of being referred by a physician to get a colonoscopy, the adherence rate was almost 12 percentage points higher in the intervention group.35 Conversely, in a study that only used a 15-minute educational videoiii without any accompanying materials, there was a modest increase in sigmoidoscopy use and no significant effect on the overall rate of CRCS. These findings suggest that the reinforcement of screening messages through oth-er materials (and perhaps also through relatives, friends, physicians, or PSAs) might be a helpful tactic to get more people to move from interest or intention to action. Reinforce-ment serves the purpose of reminding the public about the importance and need for screening, and enough evidence has been gathered to conclude that this should be an es-sential part of an educational intervention.

A study involving rural African Americans sought to compare a videoiv with ac-companying tailoredv materials and education provided by a lay health advisor (LHA). The first strategy led to a 15% increase in FOBT compliance, while the LHA did not lead to significant improvements from baseline.36 Another intervention that used LHA to tar-

i An educational calendar, a brochure, a poster, and a flyer. ii The video featured well known members and leaders of the communities that participants belonged to and identified with participants in many cultural aspects. iii The video focused on sigmoidoscopy and was meant to encourage participants to discuss the topic with their physician. iv The video demonstrated how to conduct the FOBT. v This means that the newsletters were personalized and the messages were developed according to cogni-tive and behavioral information obtained through a baseline survey such as perceived barriers, literacy level, and lifestyle habits.

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get Latinas revealed that the attention and support provided by these individuals proved to be moderately effective for breast and cervical screening interventions but not for in-creasing CRCS.37 LHA are hired from the target communities and have knowledge of local social and cultural aspects. Numerous variables might have hindered the ability of this interpersonal approach to deliver the intended outcomes in regards to CRCS. The study does support the premise that LHA interventions are effective for promoting breast and cervical cancer, which has been confirmed elsewhere.38 The results also support the assumption that efforts to increase CRCS need to be more intensive than for other types of cancer screening given the less attention that CRC has received over the years, the dis-like some people have of the subject, and their fears for undergoing a screening proce-dure and its results.

Various reports point out to the efficiency of videotapes to address various types of health issues. Video messages that last between eight and fifteen minutes can provide the public enough information about risks, screening options, and benefits of screening. In regards to colorectal cancer screening, it is possible that videotapes do increase interest and intention, but additional strategies might be needed to reinforce the messages con-veyed in them. As educational as they are, videotapes and printed materials can only re-duce certain barriers related to knowledge, perceptions, language, and literacy level. They might even reduce the fear of pain or injury when these issues are satisfactorily discussed, but they do not necessarily decrease individuals‟ sense of embarrassment for undergoing a colonoscopy or their fear of results. No matter how effective, one single strategy will not address all the needs and barriers of individuals, even within a specific ethnic popula-tion.

One-on-One and Telephone Outreach Although some research in CRCS has not supported the effectiveness of LHAs, other studies involving one-on-one strategies with preventive care personnel have shown some positive results. In one study promoting FOBT through the use of primary care nurses,i the rate of compliance was higher among the intervention group (66%) compared to the control group (51%). There was also a notable difference in the median time of return of FOBT cards: 36 days for the study group compared to 143 days for the control group.39 A potential advantage of one-on-one sessions is to provide individuals the opportunity to ask questions about how to perform the test when written instructions are not enough, what happens when the test is sent for analysis, what the results mean and what the alter-natives are when there are positive results. Satisfactorily answering those types of ques-tions can help reduce fear and anxiety and increase confidence in performing the test. The major drawbacks of one-on-one sessions is that they are time consuming and costly. Group interventions are an alternative to this dilemma, but there is also a lack of evidence to support their effectiveness. i Primary care nurses talked about the importance of CRCS, offered instructions on the use of FOBT, and clarified the meaning of screening results. Control participants only received the FOBT cards with written instructions from the manufacturer.

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Following the one-on-one approach, telephone outreach has been shown to reduce some of the barriers related to motivation, fear, and lack of coping skills by providing personalized attention to individuals‟ unique needs. A comparison on the effectiveness of telephone outreach and a mailed CDC brochure was carried out in an urban African American population in New York. Those who were reached by telephone were almost four and a half times more likely to undergo a screening test than the control group within six months of intervention.3 An undeniable advantage of interpersonal communication (even through a telephone) is the sense of caring and support that someone can provide in ways that printed material does not. During telephone calls, individuals have the opportu-nity to ask questions and share concerns that may have risen after talking with a physi-cian or reading an educational brochure. Some individuals may also find particularly helpful the faceless interaction during a telephone call to talk about what they perceive to be an uncomfortable or embarrassing subject.

Similar to interventions using LHAs, telephone outreach has yielded positive re-sults for breast and cervical cancer interventions. This is significant because compliance with breast cancer screening, in particular, has been found to be a predictive factor for other types of screening among women.40 That is why in communities like Harlem and East Harlem in New York City, which have large African American and Hispanic popu-lations, mammography is being used as an entry point to talk about and recommend CRCS.41 For example, in a study at eleven community health centers in New York, wom-en were contacted an average of four times via telephone by prevention care managersi to educate and encourage them to get screened for breast, cervical, and colorectal cancer at the same time. According to medical records, screening rates improved over baseline for all tests. There was a 17% improvement for mammography, a 10% improvement for Pa-panicolaou and at least a 60% improvement for any CRCS test (FOBT accounted for the biggest increase). It is suggested that such large increase in CRCS may also be attributed to a CRCS mass media initiative carried out by another entity.42 While such an event was not intended in the study and its correlation with the screening rates has not been eva-luated, it is plausible to consider that media and telephone outreach may have acted as a reinforcement system. Outcomes for breast and cervical cancer screening illustrate how disproportionate media attention and implementation of interventions for colorectal can-cer screening promotion is. This certainly does not help to reduce the discomfort many people feel to talk about the colon and the rectum. As it was previously mentioned, health communication can be used to give and reinforce messages that can change the attitudes and social norms of individuals regarding this topic and make it less taboo.

i During calls, which averaged 14-17 minutes, prevention care managers provided emotional support, an-swers to questions, and clarifications on misperceptions and barriers by following a script that was pro-duced based on previous interviews with women of the target population. They also helped to schedule patients‟ appointments and to locate transportation.

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Fecal Occult Blood Testing (FOBT) Kits The availability of screening options and the type of screening recommendation can have significant effects on compliance. In a study involving referral of FOBT to a large group of patients and flexible sigmoidoscopy to another group, compliance was higher among those referred for FOBT (17.2%) than for those referred to flexible sigmoidoscopy (7%).43 A screening education program in Maryland targeted to low-income, uninsured individuals revealed that among those who chose to undergo FOBT, 48% completed a colonoscopy as well (both methods were free).44 Many other studies confirm the high rates of compliance among those to whom FOBT has been made easily available. The test is the preferred method for most populations because it is perceived as less intimidat-ing given that it is the least invasive and can be performed conveniently and privately at home.40,44 Furthermore, according to the literature, compliance with FOBT tends to be even higher when FOBT kits are mailed to individuals‟ homes. In one study, 85% of in-dividuals who had received an FOBT kit via mail returned the FOBT cards compared to 32% of those who picked up the kit at the clinic.45 In other words, CRCS interventions that promote or make available FOBT among the screening options have good chances of ensuring moderate rates of compliance given the preference that individuals tend to have for it and its convenience for distribution.

Indeed, a major advantage of FOBT is its cost effectiveness for mass dissemina-tion. In a New York CRCS campaign, there was more than a 40% increase in compliance in some facilities by providing free screening to eligible uninsured men and women and by carrying out media campaigns that informed those eligible individuals about the avail-ability of the free services.46 Another colorectal awareness campaign in Minnesota (Wright County Colorectal Screening Project) spread messages through newspapers, pub-lic service announcements (PSA), radio shows, and presentations at various events, and made available FOBT kits to eligible residents. The percentage changes in FOBT adhe-rence after one year were 1.5% for the control group, 16.9% for a group that received FOBT kits without reminders and 23.2% for the group that received FOBT kits and re-minders.47 Other research also shows that in groups that received impersonal interven-tions, FOBT completion ranged between 10% and 30%,39 whereas those that have re-ceived the kit and subsequent reminders from providers have shown compliance rates of up to 50%.48

Individuals respond favorably to FOBT screening because of its convenience and this response is enhanced when additional tactics are used. However, there are some indi-viduals whose response is not positive because they see the task of carrying out the test as complex or have an aversion to collecting stool.6 Although the sensitivity of FOBT is not nearly as high as that of a colonoscopy, based on several randomized trials, its use an-nually can reduce CRC mortality by 15-33%.40 Moreover, getting people to comply with FOBT helps them to familiarize themselves with the concept of screening and its signi-ficance, which is a factor that could lead individuals to move on to more sensitive tests (such as colonoscopy) and, most importantly, to comply regularly with screening.

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Multi-Component Interventions Several interventions have incorporated various strategies with the purpose of reducing multiple barriers at once. For instance, in a study that was part of the National Breast and Cervical Cancer Early Detection Program (NBCCEDP)i urban, poor, uninsured, low edu-cated, female Hispanics received free FOBT kits. In addition, they received bilingual print materials and guidance from a bilingual health educator.ii The compliance rate in this group was 77%.40 A study with similar characteristics involving low income and less acculturated Chinese immigrants with limited health information revealed comparable results. Participants were offered a trilingual and bicultural health educator, and bilingual materialsiii and an FOBT kit. 69% of study participants completed the FOBT compared to 27% in the control group within six months of participation.11 In another controlled study involving urban, African Americans who were scheduled to see a physician, intervention participants were sent an FOBT kit home with a signed letter by a physician and received reminders two weeks prior to the clinic visit. The rate of return of FOBT cards was 41% for the intervention group compared to 5% in the control group. 45

These notable outcomes were possible with the use of multiple strategies that re-duced barriers that are common in underserved populations: cost, low literacy, lack of support, and lack of reinforcement. The studies demonstrate that programs that are educa-tionally and culturally tailored and use multiple components have proved to be promising. Obviously, this carries important implications such as increased time and costs. However, it seems evident that people need information to learn about CRC and screening, answers to questions that arise from the information they obtain and or do not obtain, support and encouragement, and reminders to comply with screening. All of these elements contribute in different ways to an individual‟s decision to get screened.

Other Efforts

Aware of the essential role that churches play in the lives of many African Americans, this year the Society has launched an initiative to reach more African Americans through churches across the U.S. by distributing information kits and connecting churches with the Society‟s local offices.49 According to a few comparative studies, faith-based centers and institutions with experience serving diverse populations may have an advantage in helping to promote health initiatives because of people‟s trust in those institutions.12 Si-milarly, other organizations like the Colon Cancer Alliance has partnered with Walgreens Pharmacies for an education campaign in which informational brochures have been dis-tributed to reach nearly thirty two million customers across the country. As part of the program, fifty thousand Walgreens pharmacists and techs have received training to serve

i A program that has offered free breast and cervical cancer screening for underserved women. ii The health educator provided oral instructions on the use of the FOBT in addition to written instructions. iii A video, one motivational and one informational pamphlet, and FOBT instructions. These materials were created based on previous qualitative findings from semi-structured interviews and focus groups with members of the target population.

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as information resources for people who have questions.50 These types of initiatives seek to extend the reach of information about screening to places that people associate with wellbeing and personal care.

Indeed, it is very important for the subject of colorectal cancer to be talked about outside of clinics since many individuals are not hearing the messages from their physi-cians and others do not have a regular health care provider. The Cancer Research and Prevention Foundation has organized since 1999 an annual national conference, Dialogue

for Action: Bringing colorectal cancer screening home, attracting representatives from many fields including primary care providers, researchers, health educators, and dele-gates from government agencies such as CDC. The event takes place during the National Colorectal Cancer Awareness Month and seeks to encourage attendees to share new ideas and materials for the implementation of colorectal cancer screening programs. Some state forums modeled on the national conference have also been organized.51 This type of initi-atives bringing together people from many fields are important activities to increase the attention devoted to CRC and knowledge about strategies used by different groups and their outcomes. As research has revealed, most CRCS interventions, however effective, have proven to be less successful than those promoting other type of cancer screening.52 This reveals the need for intensive campaigns that reinforce CRCS messages, low-cost or free screening, and strong partnerships, especially with the target communities.

Conclusion & Recommendations

Most colorectal cancer screening interventions have focused on the traditional primary care setting where eligible individuals are more reachable. A variety of strategies have been tested to reduce barriers already identified based on a wealth of evidence. For ex-ample, for addressing lack of knowledge and perception of risk, language barriers, and physicians‟ time constraints, printed materials, videotapes, and health educators have been used. For addressing fears, lack of support and logistical obstacles, health educators have been employed once again. For addressing cost, inconvenience, and time demand, FOBT kits have been provided. There is widespread agreement among researchers that physician recommendation is one of the most important factors for increasing the rates of CRCS. However, many physicians do face patients‟ resistance to screening because of additional barriers related to patients‟ perceptions, fears, and logistical aspects such as transportation and appointment scheduling. Most interventions have used printed material because it is often cost-effective and easy to distribute. In fact, the mailing of any type of material to participants has been made on grounds of efficiency, mass outreach, cost-effectiveness, and participant‟s convenience. This has included FOBT kits, which in many studies has proved to increase FOBT screening rates in most populations. The tim-ing of mailings to a clinic appointment, reminder cues, and personalized messages all ap-pear to be important elements in helping raise screening rates.

The number of barriers that must be reduced require the use of comprehensive, culturally and linguistically tailored interventions. At present, the Task Force on Com-munity Preventive Services only recommends two strategies based on the argument that

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there is not sufficient evidence to recommend other approaches. Nonetheless, research findings do suggest that those approaches using multiple strategies to target more than one barrier are more likely to succeed. Although using multiple strategies carry time and cost implications, this should not let all those concerned lose sight of the ultimate goal: to reduce the incidence and mortality rate of colorectal cancer - a preventable disease – and in doing so, to reduce the economic costs and a great amount of unnecessary pain and suffering.

Several of the strategies described in this document are being tested in communi-ties across the U.S. with the sponsorship of CDC. The results of those studies will hope-fully provide better insights about how those approaches work in low income and low literate populations in which they are being implemented. Effectiveness is important, but the sustainability of any approach is equally important. That is the reason why knowing as much as possible about the target audience and building relationships with the com-munity are vital to the success of CRCS interventions. Some ways to enhance colorectal cancer screening promotion include: ► Assessing the unique characteristics of the target population in order to tailor intervention strategies and messages. A myriad of factors contribute to the presence or absence of personal barriers to CRCS. Assessing knowledge, attitudes, beliefs, cultural values, literacy, learning preferences, and resources in the target communities can provide valuable information that is key to producing interventions and materials that are linguistically, culturally, and literacy-level appropriate. Qualitative methods such as focus groups and questionnaires can be used to carry out this task. The more data is collected, the better the chances for planners to de-veloped tailored programs and for a community to understand and accept such programs. A few examples are: It may be also helpful to: □ Create videotapes in multiple languages when the lack of reading abilities or bilingual personnel requires it. □ Explain insurance coverage including Medicare and Medicaid. □ Simplify information on screening guidelines to reduce information overload. ► Using theory to guide programs. Health behavior theories such as stages of change, social support, and social marketing can also help to tailor health education interventions and their use is fundamental for eva-luating such programs. ► Building credibility and trust by involving members of the target communities. These individuals can offer valuable input and skills for communicating health informa-tion, and they can assist with both the development and the implementation of a program. Recruiting public leaders or well-known members of the communities can be advanta-

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geous given the respect they have and their visibility. Cancer survivors can also be an as-set for conveying the significance of the disease and screening. ► Developing community partnerships. Organizations that serve African American, Hispanic, Hmong, and Somali populations, among others, are committed to advancing the welfare of these populations, which posi-tively affects their reputation. They usually have personnel with appropriate language skills and cultural sensitivity to approach topics that some people find uncomfortable to talk about or difficult to understand. ► Reaching out to local health care providers. It is critical that health care personnel highlight the importance of CRCS. The American Cancer Society has produced materials specifically aimed at health care personnel that can be reviewed through the Society‟s Communication Materials Library (CML). It is also important for these personnel to: □ Use mammogram and Papanicolaou recommendations as an entry point to talk about CRCS. □ Offer patients all available options for CRCS. □ Provide adequate reminders to patients. ► Reinforcing messages through different means. Repetition is key to the promotion of health behaviors. In addition to a primary method of message delivery, other techniques should be used to emphasize the importance of the messages and remind individuals to take action. Physician letters and mass media are par-ticularly effective means to accomplish this. ► Helping individuals navigate the screening process. Many individuals need help figuring out where to go for a screening, how to schedule an appointment, how to arrange transportation, what paperwork is needed for insurance cov-erage, etc. Logistical issues can be confusing and discourage a large number of people with intentions to get screened. Whatever medium is used, it is helpful to discuss these kinds of details. ► Offering coping skills to improve individuals’ self-confidence. People need more than increased knowledge. Embarrassment, fear of pain or injury, and concern about test results can add a lot of stress and anxiety. Therefore, individuals need skills to manage their negative feelings before complying with screening and while wait-ing for test results.

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References i American Cancer Society. Detailed Guide: Colon and Rectum Cancer What Are the Key

Statistics for Colorectal Cancer? Retrieved May 02, 2007 from http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_are_the_key_statistics or_colon_and_rectum_cancer.asp?sitearea

2 American Cancer Society. Cancer facts & figures 2007. Retrieved June 02, 2007 from http://www.cancer.org/docroot/stt/stt_0.asp [accessed June 02, 2007].

3 Basch CE. Wolf RL. Brouse CH. Shmukler C. Neugut A. DeCarlo LT. Shea S. Tele-phone outreach to increase colorectal cancer screening in an urban minority popu-lation. American Journal of Public Health. 96(12):2246-53, 2006 Dec.

4 Centers for Disease Control and Prevention. Colorectal (Colon) Cancer. Fast Facts. Re-trieved June 05, 2007 from http://www.cdc.gov/cancer/colorectal/basic_info/facts.htm

5 Coughlin SS. Costanza ME. Fernandez ME. Glanz K. Lee JW. Smith SA. Stroud L. Tessaro I. Westfall JM. Weissfeld JL. Blumenthal DS. CDC-funded intervention research aimed at promoting colorectal cancer screening in communities. Cancer. 107(5 Suppl):1196-204, 2006 Sep 1.

6 Wender RC. Barriers to screening for colorectal cancer. Gastrointestinal Endoscopy Clinics of North America. 12(1):145-70, 2002 Jan.

7 Tessaro I, Mangone C, Parkar I, Pawar V. Knowledge, barriers, and predictors of colorectal cancer screening in an Appalachian church population. Preventive Chronic Disease. 2006 Oct. Available from: http://www.cdc.gov/pcd/issues/2006/oct/06_0033.htm. 8 Walsh JM. Kaplan CP. Nguyen B. Gildengorin G. McPhee SJ. Perez-Stable EJ. Barriers

to colorectal cancer screening in Latino and Vietnamese Americans compared with non-Latino white Americans. Journal of General Internal Medicine. 19(2):156-66, 2004 Feb.

9 Busch S. Elderly African American women's knowledge and belief about colorectal cancer. ABNF Journal. 14(5):99-103, 2003 Sep-Oct.

10 Brouse CH. Basch CE. Wolf RL. Shmukler C. Neugut AI. Shea S. Barriers to colorec-tal cancer screening with fecal occult blood testing in a predominantly minority urban population: a qualitative study. American Journal of Public Health. 93(8):1268-71, 2003 Aug.

11 Tu SP. Taylor V. Yasui Y. Chun A. Yip MP. Acorda E. Li L. Bastani R. Promoting culturally appropriate colorectal cancer screening through a health educator: a randomized controlled trial. Cancer. 107(5):959-66, 2006 Sep 1.

12 Tabbarah M. Nowalk MP. Raymund M. Jewell IK. Zimmerman RK. Barriers and faci-litators of colon cancer screening among patients at faith-based neighborhood health centers. Journal of Community Health. 30(1):55-74, 2005 Feb.

13 Brouse CH. Basch CE. Wolf RL. Shmukler C. Neugut AI. Shea S. Barriers to colorec-tal cancer screening with fecal occult blood testing in a predominantly minority urban population: a qualitative study. American Journal of Public Health. 93(8):1268-71, 2003 Aug.

15

14 Greisinger A. Hawley ST. Bettencourt JL. Perz CA. Vernon SW. Primary care patients' understanding of colorectal cancer screening. Cancer Detection & Prevention. 30(1):67-74, 2006.

15 Greiner KA. James AS. Born W. Hall S. Engelman KK. Okuyemi KS. Ahluwalia JS. Predictors of fecal occult blood test (FOBT) completion among low-income adults. Preventive Medicine. 41(2):676-84, 2005 Aug.

16 Thompson B. Coronado G. Neuhouser M. Chen L. Colorectal carcinoma screening among Hispanics and non-Hispanic whites in a rural setting. Cancer. 103(12):2491-8, 2005 Jun 15.

17 Harewood GC. Lieberman DA. Colonoscopy practice patterns since introduction of medicare coverage for average-risk screening. Clinical Gastroenterology & Hepa-tology. 2(1):72-7, 2004 Jan.

18 Etzioni DA. Yano EM. Rubenstein LV. Lee ML. Ko CY. Brook RH. Parkerton PH. Asch SM. Measuring the quality of colorectal cancer screening: the importance of follow-up. Diseases of the Colon & Rectum. 49(7):1002-10, 2006 Jul.

19 Costanza ME. Luckmann R. Stoddard AM. Avrunin JS. White MJ. Stark JR. Clemow L. Rosal MC. Applying a stage model of behavior change to colon cancer screen-ing. Preventive Medicine. 41(3-4):707-19, 2005 Sep-Oct.

20 Menon U. Champion VL. Larkin GN. Zollinger TW. Gerde PM. Vernon SW. Beliefs associated with fecal occult blood test and colonoscopy use at a worksite colon cancer screening program. Journal of Occupational & Environmental Medicine. 45(8):891-8, 2003 Aug.

21 Wee CC. McCarthy EP. Phillips RS. Factors associated with colon cancer screening: the role of patient factors and physician counseling. Preventive Medicine. 41(1):23-9, 2005 Jul.

22 Gili M. Roca M. Ferrer V. Obrador A. Cabeza E. Psychosocial factors associated with the adherence to a colorectal cancer screening program. Cancer Detection & Pre-vention. 30(4):354-60, 2006.

23 Bakalar, Nicholas. Choosing a costly wait for cancer screening. The New York Times. 2005, August 23. Online. LexisNexis® Academic. Retrieved June 30, 2007.

24 Ford JS. Coups EJ. Hay JL. Knowledge of colon cancer screening in a national proba-bility sample in the United States. [Journal Article] Journal of Health Communi-cation. 11 Suppl 1:19-35, 2006.

25 HINTS briefs number 1. Health Information National Trends Survey. Retrieved June 07, 2007 from http://hints.cancer.gov/docs/hints_briefs122705.pdf.

26 Hay J. Coups E. Ford J. Predictors of perceived risk for colon cancer in a national probability sample in the United States. Journal of Health Communication. 11 Suppl 1:71-92, 2006.

27 Green PM. Kelly BA. Colorectal cancer knowledge, perceptions, and behaviors in African Americans. Cancer Nursing. 27(3):206-15; quiz 216-7, 2004 May-Jun.

28 Meade CD. Calvo A. Rivera MA. Baer RD. Focus groups in the design of prostate can-cer screening information for Hispanic farmworkers and African American men. Oncology Nursing Forum. Online. 30(6):967-75, 2003 Nov-Dec.

29 Cancer. Centers for Disease Control and Prevention. Retrieved May 30, 2007 from http://www.thecommunityguide.org/cancer/screening/default.htm.

16

30 Davis RE. Armstrong DK. Dignan M. Norling GR. Redmond J. Evaluation of educa-tional materials on colorectal cancer screening in Appalachian Kentucky. Prevent-ing Chronic Disease. 3(2):A43, 2006 Apr.

31 Zapka JG. Lemon SC. Puleo E. Estabrook B. Luckmann R. Erban S. Patient education for colon cancer screening: a randomized trial of a video mailed before a physical examination. Annals of Internal Medicine. 141(9):683-92, 2004 Nov 2.

32 Harewood G. Videotape-based decision aid for colon cancer screening. Annals of In-ternal Medicine. 135(8 Pt 1):634-5, 2001 Oct 16.

33 Powe BD. Ntekop E. Barron M. An intervention study to increase colorectal cancer knowledge and screening among community elders. Public Health Nursing. 21(5):435-42, 2004 Sep-Oct.

34 Powe BD. Promoting fecal occult blood testing in rural African American women. Cancer Practice. 10(3):139-46, 2002 May-Jun.

35 Denberg TD. Coombes JM. Byers TE. Marcus AC. Feinberg LE. Steiner JF. Ahnen DJ. Effect of a mailed brochure on appointment-keeping for screening colonoscopy: a randomized trial. Annals of Internal Medicine. 145(12):895-900, 2006 Dec 19.

36 Campbell M. James A, Hudson MA, et al. Improving multiple behaviors for colorectal cancer prevention among African American church members. Health Psychology. 23:492-502, 2004

37 Larkey L. Las mujeres saludables: reaching Latinas for breast, cervical and colorectal cancer prevention and screening. Journal of Community Health. 31(1):69-77, 2006 Feb.

38 Lam TK. McPhee SJ. Mock J. Wong C. Doan HT. Nguyen T. Lai KQ. Ha-Iaconis T. Luong TN. Encouraging Vietnamese-American women to obtain Pap tests through lay health worker outreach and media education. Journal of General In-ternal Medicine. 18(7):516-24, 2003 Jul.

39 Stokamer CL. Tenner CT. Chaudhuri J. Vazquez E. Bini EJ. Randomized controlled trial of the impact of intensive patient education on compliance with fecal occult blood testing. Journal of General Internal Medicine. 20(3):278-82, 2005 Mar.

40 Gorin SS. Correlates of colorectal cancer screening compliance among urban Hispanics. Journal of Behavioral Medicine. 28(2):125-37, 2005 Apr.

41 Freeman, H. Dialogue for action: bringing colorectal cancer screening home. March 2003.

42 Dietrich AJ. Tobin JN. Cassells A. Robinson CM. Greene MA. Sox CH. Beach ML. DuHamel KN. Younge RG. Telephone care management to improve cancer screening among low-income women: a randomized, controlled trial. Annals of Internal Medicine. 144(8):563-71, 2006 Apr 18.

43 Federici A. Marinacci C. Mangia M. Borgia P. Giorgi Rossi P. Guasticchi G. Is the type of test used for mass colorectal cancer screening a determinant of compliance? A cluster-randomized controlled trial comparing fecal occult blood testing with flexible sigmoidoscopy. Cancer Detection & Prevention. 30(4):347-53, 2006.

44 Sarfaty M. Feng S. Choice of screening modality in a colorectal cancer education and screening program for the uninsured. Journal of Cancer Education. 21(1):43-9, 2006.

17

45 Goldberg D. Schiff GD. McNutt R. Furumoto-Dawson A. Hammerman M. Hoffman A. Mailings timed to patients' appointments: a controlled trial of fecal occult blood test cards. American Journal of Preventive Medicine. 26(5):431-5, 2004 Jun.

46 Reyes, D. Colon cancer screenings increase. The New York Amsterdam News. 32-38, 2004 Oct. 21-27.

47 Church TR. Yeazel MW. Jones RM. Kochevar LK. Watt GD. Mongin SJ. Cordes JE. Engelhard D. A randomized trial of direct mailing of fecal occult blood tests to increase colorectal cancer screening. Journal of the National Cancer Institute. 96(10):770-80, 2004 May 19.

48 Agrawal, J. Syngal, S. Colon cancer screening strategies. Medscape Today. 2005, Jan. 27. Retrieved June 14, 2007 from http://www.medscape.com/viewarticle/497013_1

49 American Cancer Society enlists African American churches in fight against cancer. Health Insurance Week. 2007, May 13. Online. LexisNexis® Academic. Re-trieved June 11, 2007.

50 The Colon Cancer Alliance partners with Walgreens Pharmacies and Salix Pharma-ceuticals for major health education campaign. Preventive Medicine Week. 2007, March 18. Online. LexisNexis® Academic. Retrieved June 11, 2007.

51 Prevent cancer. Cancer Research and Prevention Foundation. Retrieved June 29, 2007 from http://www.preventcancer.org/programs/dialogue_overview.cfm.htm.

52 Marcus AC. Mason M. Wolfe P. Rimer BK. Lipkus I. Strecher V. Warneke R. Morra ME. Allen AR. Davis SW. Gaier A. Graves C. Julesberg K. Nguyen L. Perocchia R. Speyer JB. Wagner D. Thomsen C. Bright MA. The efficacy of tailored print materials in promoting colorectal cancer screening: results from a randomized trial involving callers to the National Cancer Institute's Cancer Information Service. Journal of Health Communication. 10 Suppl 1:83-104, 2005.