Development of a Spiritually-based Educational Program to Promote Colorectal Cancer Screening through African American Churches

Cheryl Holt, PhD1, Isabel Scarinci, PhD2, Martha Crowther, PhD3, John Bolland, PhD3, Mark Litaker, PhD4, Mohamad Eloubeidi, MD5, Steve Coughlin, PhD, MPH6, Leonardo Stroud, MD, MPH7, Joanice Thompson, BSM1, Chastity Roberts, BS, MPH, CHES1, and Penny Southward, BS1. (1) Division of Preventive Medicine, Univ. of Alabama, Birmingham, 1717 11th Ave. South, Medical Towers, Suite 641, Birmingham, AL 35205, 205-934-2816, cholt@uab.edu, (2) Preventive Medicine, University of Alabama at Birmingham, 1717 11th Avenue South, Room 609, Birmingham, AL 35205, (3) School of Public Health/Department of Health Behavior, Univ. of Alabama, Birmingham, 1530 3rd Avenue South, RPHB 227H, Birmingham, AL 35294-0022, (4) Diagnostic Sciences, Univ. of Alabama, Birmingham, 1530 3rd Avenue South, LHRB 134, Birmingham, AL 35294-0007, (5) Medicine/Gastroenterology, Univ. of Alabama, Birmingham, 1530 3rd

Avenue South, ZRB 408, Birmingham, AL 35294-0007, (6) Division of Cancer Prevention and Control, CDC, Atlanta, GA, (770)488-4776, (7) Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford HWY NE, Atlanta, GA 30341

African Americans have higher colorectal cancer incidence and mortality than do all other racial/ethnic groups1. Underutilization of screening by African Americans has been identified as a probable cause of the significant racial disparity. Screening rates differ among African Americans and Caucasians (41% AA v. 47% CA for blood stool test; 47% AA v. 50% CA for sigmoidoscopy or colonoscopy)2. A number of interventions have been proposed to address the underutilization of screening.  One approach is to work through churches using a spiritually-based approach. This is done by including relevant spiritual themes to frame the cancer educational message thereby putting health in a spiritual context.

• The intervention consists of providing training to Community Health Advisors from each church, who deliver two educational group sessions on colorectal cancer and early detection to their fellow church members.  • The intervention is supplemented by spiritually-based print materials developed and pilot tested in this project.  

Phase 1: Intervention Development The expertise of an Advisory Panel (n=10) and two focus groups (n=20) consisting of individuals from the priority population was utilized to assist in the development of the spiritually-based messages and the colorectal cancer content to be used in the intervention.

Phase 2: Pilot Testing the Intervention Materials (Print)• Two additional focus groups (n=16) were conducted to pilot test the graphics and layout of the intervention print materials.  • Twenty Cognitive Response Interviews were conducted to assess the acceptability and appropriateness of the content of these print materials. • Following a qualitative review of the focus group results and the Cognitive Response Interviews, the print materials will be revised as recommended by the priority population, and the intervention implemented and evaluated.

Using a community-based approach to formative research in the development of an intervention ensures that the program is culturally appropriate, personally relevant, and will be more likely to stimulate cognitive elaboration, leading to attitudinal and behavior change.

Introduction

Purpose

Method

Results Discussion

With the assistance of community members: • Develop and pilot test spiritually-based educational print materials through

focus groups and cognitive response testing.

Acknowledgments

Formatting/Graphics/Design: •Most respondents preferred booklet A because of the Christian symbols on the cover, pictures on the cover, and larger text font.

•Booklet B was considered by most respondents to be a medical brochure, one you would expect to see in a more clinical setting.

•Suggestions for improvement included adding more culturally relevant pictures (Afrocentric vs. Eurocentric) and making the colors of the cover of Booklet A bolder to reflect the “Take Charge of Your Health” theme.

Educational Content: •Although some of the colorectal cancer content in the booklets was technical, it could be understood within context.

•Scriptures and spiritual-based content provoked reflection of personal experiences in which reliance upon faith helped to overcome barriers to participation in other screenings.

This project is supported by Health Promotion and Disease Prevention Research Centers: Special Interest Project Competitive Supplements, SIP #5-2005, RFA DP-04-003A.

References1. American Cancer Society. Cancer facts and figures 2004. Atlanta, Georgia: American Cancer Society, Inc.; 2004

2. Centers for Disease Control and Prevention. BRFSS online information. U.S. Department of Health and Human Services. Available at: http://cdc.gov/brfss/. Accessed January 23, 2003.

Table 1: Participant Demographics (n=66)

Table 2: Advisory Panel Recommendations•Emphasize stewardship of the body•Incorporate scriptures that will help people to overcome fear•Incorporate scriptures that will empower people to make a change•Share anecdotal stores, personalize•Don’t be too “preachy”•Make sure scriptures and core content are related, smooth linkages•Add pictures to illustrate concepts that may be difficult to understand (dietary portions and colonoscopy procedures).

Table 3: Focus Group 1&2 Recommendations•Define colorectal cancer•Identify early warning signs and symptoms•Identify who is at risk•Identify methods of prevention•Provide information about the screening tests•Provide information about insurance coverage•Provide questions for the patients to ask their doctors•Supply information about alternative treatments (i.e. herbs, vitamins etc.)

Prototype Development

← Booklet A Booklet B →

Table 4: Focus Group 3&4 Recommendations•Find booklet A more attractive than B•Booklet A is more religious-looking, pleasant, and hopeful (i.e. images of Christ, bright colors)•Booklet B is bold, medical-looking, solemn•Like questions to ask MD found in both books•Booklet A needs more Afro-centric pictures•Booklet B needs pictures on the cover to increase attractiveness

Table 5: Cognitive Response Interview Findings• Scriptural passages were understood by the majority of respondents• Colorectal cancer-specific content was understood by the majority of respondents• Non-scriptural, but thematic religious concepts were a little difficult for some respondents to explain; However, those respondents did indicate that they understood the point.• Some of the technical terminology as it relates to vitamins, minerals, procedures were difficult to pronounce and translate into useful information.

Advisory Panel (n=10) Focus Groups 1 & 2 (n=20) Focus Groups 3 & 4 (n=16) Cognitive Response Interviews (n=20)

% African American 80% 100% 100% 100%

% Female 60% 60% 69% 85%

Age (range) 39-71 50-82 50-80 51-82

Educational level (avg.) Bachelor’s Degree Some College High School Graduate/GED Some College

% Married/ Live w/ Partner 75% 55% 44% 50%

Denominations Represented Baptist, Non-denominational, Lutheran Baptist, Missionary Baptist Pentecostal, African Methodist Episcopal Baptist, Pentecostal, Methodist, Lutheran

Conclusions