Implementation of an evidence-based intervention to promote colorectal cancer screening in community organizations: a cluster randomized trial

Educational interventions to improve bowel cancer awareness and screening in Organisation for Economic Co-operation and Development countries: A scoping review

Objectives

Summarise theory informed educational interventions for improving bowel cancer awareness and screening.

Methods

A search was conducted in PubMed, EMBASE, Web of Science and CINAHL. English studies from 2016 to 2022 which implemented community-based bowel cancer awareness and/or screening education interventions for adults in Organisation for Economic Co-operation and Development countries were included.

Results

Sixty-two studies were included, 32 measured both screening and awareness (24 measured screening only, 6 measured awareness only). Education interventions were grouped and summarised in five education types: lay community health education/counselling (n = 28), education material (n = 5), health professional education/counselling (n = 10), mass media (n = 5) and other (n = 19). Other included education interventions which did not fit into the four types previously mentioned. Six studies tested more than one education type. Each type within these studies were reported/summarised separately within the appropriate education type. Lay educators resulted in improved awareness and screening. Brochures were effective education materials for screening and combined with lay educators resulted in increased awareness. State-wide mass media campaigns significantly improved screening uptake for up to 2-months post-campaign. Fear and loss-framed messaging improved screening intentions compared to humour or gain-based messaging. Decision aids had limited improvements in awareness. Facebook campaign and telephone counselling had limited improvements in screening.

Conclusions

Lay community health educators, brochures, and mass media campaigns occurring multiple times a year may be effective interventions in improving screening and/or awareness. Such approaches should be considered when developing community education. Education interventions should include multiple components suggested above to maximise improvements of awareness and screening.

Scoping Review of Interventional Studies in Chronic Disease for Native Hawaiian, Pacific Islander, and Filipino Populations in the United States

Native Hawaiians (NHs), Pacific Islanders (PIs), and Filipinos experience health disparities in the United States (US) and need interventions that work for them. The purpose of this paper is to present a review of interventions designed to address chronic disease in Native Hawaiian, Pacific Islander, and Filipino populations in the US that were tested for clinical impact through a randomized controlled trial (RCT). Articles were identified through a search of 4 databases, citation chasing, and colleagues. The 23 included articles reported on 21 interventions addressing 4 chronic conditions-cancer, obesity, cardiovascular disease, and diabetes. All projects were guided by advisory groups, and all interventions were theory-based and tailored to the population, with culturally- and language-appropriate educational materials delivered by same-race individuals in familiar church, club, or home settings. About half were tested through cluster RCT. The majority of the interventions were successful, confirming the value of developing and delivering interventions in partnership with community. Given the growing numbers of NHs, PIs, and Filipinos in the US, more investigational studies are needed to develop and test culturally tailored and grounded interventions that meet the health needs of these populations.

Systematic review of randomised controlled trials on interventions aimed at promoting colorectal cancer screening amongst ethnic minorities

OBJECTIVES

Significant disparities exist between different ethnic groups when it comes to participation in colorectal cancer (CRC) screening programmes. A variety of interventions have been proposed to improve participation rates of ethnic minorities for CRC screening. This systematic review aims to appraise the evidence available from published randomised controlled trials (RCTs) and to identify effective interventions aimed at promoting CRC screening amongst underserved ethnic minorities.

DESIGN

We searched EmBASE, Medline, PsychInfo, Scopus and CINAHL for RCTs that analysed interventions to promote CRC screening in all ethnic minorities. CRC screening was measured as documented or self-reported screening rates. The protocol of this study was registered prospectively on PROSPERO with the registration number CRD42020216384.

RESULTS

We identified 42 relevant RCT articles, out of 1805 articles highlighted by the initial search. All except one were conducted in the US. The most frequently studied ethnic groups were African-Americans (33%), East Asians (30%), and Hispanics/Latinos (23%). In total, 7/42 (16%) RCTs had multiple arms. Interventions mainly intended to educate (52%), provide patient navigation services (21%), or provide a combination of these interventions (19%). We demonstrate that combination methods are most effective.

CONCLUSION

Many RCTs, mostly in the US, have trialed interventions aimed to increase CRC screening uptake amongst ethnic minorities to varying success. We conclude that using a combination of methods with patient navigation, education, and cultural tailoring is most effective at increasing CRC screening uptake amongst ethnic minorities. This highlights that multiple factors may hinder CRC screening and finding a one-size-fits-all solution that can be reliably implemented among different cultures and countries may be complex.

Cluster-randomized trials of cancer screening interventions: Has use of appropriate statistical methods increased over time?

BACKGROUND

In a cluster randomized trial, groups of individuals (e.g., clinics, schools) are randomized to conditions. The design and analysis of cluster randomized trials can require more care than individually randomized trials. Past reviews have noted deficiencies in the use of appropriate statistical methods for such trials.

METHODS

We reviewed cluster randomized trials of cancer screening interventions published 1995-2019 to determine whether appropriate statistical methods had been used for sample size calculation and outcome analysis and whether they reported intraclass correlation coefficient (ICC) values. This work expanded a previous review of articles published 1995-2010.

RESULTS

Our search identified 88 articles published 1995-2020 that reported outcomes of cluster randomized trials of breast, cervix, and colorectal cancer screening interventions. There was increased reporting of the trials' sample size calculations over time, with the percentage increasing from 31% in 1995-2004 to 77% in 2014-2019. However, the percentage of calculations failing to account for cluster randomization did not change over time and was 17% of studies in 2014-2019. There was a nonsignificant trend towards increased use of outcome analysis methods that accounted for the cluster randomized design. However, in lower impact journals, use of appropriate analysis methods was only 80% in 2014-2019. Only 33% of studies reported ICC values in 2014-2019.

CONCLUSION

For cluster randomized trials with cancer screening outcomes, there have been improvements in the reporting of sample size calculations but methodological and reporting deficiencies persist. Efforts to disseminate, adopt and report the use of appropriate statistical methodologies are still needed.

What are the effects of colorectal cancer screening interventions among Asian Americans? A meta-analysis

Objective: Great strides have been made to conduct intervention studies aimed at increasing colorectal cancer (CRC) screening rates that are informed by sound theoretical frameworks and conducted using rigorous methodologies; however, efforts are still gaining wave to understand the efficacy of theory-based interventions among Asian American (AA) population. The purpose of this study was to report the results of a meta-analysis conducted on the effects of CRC screening interventions.Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to evaluate the CRC screening interventions. Literature search was performed on October 2018, and studies published in English and conducted in the United States were eligible for inclusion if they (1) conducted interventions with aims to increase CRC screening rates among AA and (2) utilized a randomized control trial or quasi-experimental study design, (3) reported quantitative screening rates following the intervention, and (4) included a comparison or control group for comparison. No publication year restriction was applied.Result: In total, 14 Odds Ratio (OR) from 16 studies were included in the meta-analysis. Overall, results indicated that AA participants who received the screening interventions aimed at improving screening were 1.78 times more likely to obtain a CRC screening at post-intervention compared to those in the control or comparison group, OR = 1.78 (1.44, 2.11).Conclusion: Understanding the efficacy of interventions designed to promote CRC screening among AA population is imperative to decrease CRC burden and mortality. Although research in this area is limited, this review sheds light on important socio-cultural strategies to developing a CRC screening intervention aimed at increasing screening rates among AA. Findings in this review demonstrate that improvement in screening can be achieved through a variety of ways, but the common feature across all the studies was the culturally responsive foundation of their respective interventions.

Promoting Community Awareness of Lung Cancer Screening Among Disparate Populations: Results of the cancer-Community Awareness Access Research and Education Project

BACKGROUND

Lung cancer is the no. 1 cause of cancer death in the United States. Racial/ethnic minority and medically underserved populations suffer higher mortality than whites. Early detection through uptake of low-dose computed tomography (LDCT) among screening-eligible adults may mitigate high mortality. However, nearly 5 years since the publication of the US Preventive Services Task Force lung cancer screening guideline, population awareness of LDCT is low, and only 4% of screening-eligible adults have undergone screening.

OBJECTIVE

This project used an education intervention to change participants' knowledge, attitudes, and beliefs about cancer risk factors and lung cancer and to connect eligible individuals to LDCT screening and tobacco cessation services.

INTERVENTIONS/METHODS

Community-engaged strategies were used to deliver a 4-week educational program in 13 community sites. Trained community health workers delivered the intervention. The intervention was guided by the Health Belief Model. Data were collected by survey to 481 participants; 93% were African American, the majority was female (73.1%), mean age was 58.3 (SD, 10.9) years.

RESULTS

There were knowledge increase regarding lung cancer screening (P = .001), a significant decrease in Perceived Severity and Perceived Barriers subscales (P = .001), and an overall increase in response to Perceived Benefits of lung cancer screening and Self-efficacy (P = .001). Fifty-four percent of tobacco users engaged in cessation; 38% of screening-eligible participants underwent LDCT screening.

CONCLUSIONS

Community health workers are effective in increasing awareness of lung cancer screening and affecting behavior change among disparate populations.

IMPLICATIONS FOR PRACTICE

Community health workers may have a clinical role in LDCT shared decision making.

Expanding Implementation Research to Prevent Chronic Diseases in Community Settings

Chronic disease prevention continues to be inadequate, overall and in achieving health equity, in spite of the many evidence-based practices and policies (EBPPs) available to address risk behaviors such as unhealthful eating, lack of physical activity, and tobacco use. Although clinical settings are needed for EBPPs that involve medical procedures such as immunization or early detection, dissemination of EBPPs can be effective in a variety of settings such as schools and childcare centers, worksites, social service organizations, and religious organizations. More implementation research is needed to meet challenges of effective application of EBPPs in such community settings, in which primary missions, capacity, cultures, and values do not focus on health services delivery. To address health equity, consideration of social and economic contexts of people reached in these settings is essential. This review presents lessons learned from past studies to guide future implementation research and practice across diverse settings and geographies.

Training Community Health Advisors in African American Churches: Do Training Outcomes Predict Performance?

Programs that utilize Community Health Advisors (CHAs) to promote cancer screening are effective in community settings. However, predictors of CHA performance are not well understood. From 2016 to 2018, we partnered with 9 African American churches in South Los Angeles and trained 49 CHAs to promote cancer screening in an effort to build capacity for health promotion in a low-resource community. This paper examines CHA characteristics and training outcomes in African American faith-based settings and explores the relationship of these variables to successful recruitment of participants by CHAs. Pre- and post-tests showed statistically significant increases in knowledge of colorectal cancer screening guidelines (4 items) and human subjects protection rules (5 items) and CHAs' perceived self-efficacy to perform specific tasks for the study (13 items, Cronbach's alpha > 0.90). There were no significant differences between active CHAs who recruited at least 10 participants (N = 29) and inactive/less active CHAs (N = 20) with respect to demographic characteristics and training outcomes. We report challenges and facilitators to recruitment from CHA debriefings at 12 months follow-up. Based on our findings, we make recommendations for future studies to move this field forward.

Effectiveness of a health belief model intervention using a lay health advisor strategy on mouth self-examination and cancer screening in remote aboriginal communities: A randomized controlled trial

OBJECTIVE

Oral cancers caused by chewing betel nuts have a poor prognosis. Using a lay health advisor (LHA) can increase access to health care among underprivileged populations. This study evaluated a health belief model (HBM) intervention using LHAs for oral cancer screening (OCS) and mouth self-examination (MSE) in remote aboriginal communities.

METHODS

The participants were randomly assigned to intervention (IG; n = 171) and control groups (CG; n = 176). In the IG, participants received a three-chapter one-on-one teaching course from LHAs, whereas those in the CG received only a leaflet.

RESULTS

The IG participants were 2.04 times more likely to conduct a monthly MSE than those in the CG (95% confidence interval: 1.31-3.17) and showed significantly higher self-efficacy levels toward OSC and MSE (β = 0.53 and 0.44, effect size = 0.33 and 0.25, respectively) and a lower barrier level for OSC (β = -1.81, effect size = -0.24).

CONCLUSION

The LHA intervention had a significantly positive effect on MSE, strengthening self-efficacy and reducing barriers to OCS among aboriginal populations.

PRACTICE IMPLICATIONS

The effectiveness of the clinical treatment of underprivileged group can be improved through early diagnosis, which can be achieved using LHAs to reduce barriers to OSC.

Unlocking the potential of population-based cancer registries

Population-based cancer registries have improved dramatically over the last 2 decades. These central cancer registries provide a critical framework that can elevate the science of cancer research. There have also been important technical and scientific advances that help to unlock the potential of population-based cancer registries. These advances include improvements in probabilistic record linkage, refinements in natural language processing, the ability to perform genomic sequencing on formalin-fixed, paraffin-embedded (FFPE) tissue, and improvements in the ability to identify activity levels of many different signaling molecules in FFPE tissue. This article describes how central cancer registries can provide a population-based sample frame that will lead to studies with strong external validity, how central cancer registries can link with public and private health insurance claims to obtain complete treatment information, how central cancer registries can use informatics techniques to provide population-based rapid case ascertainment, how central cancer registries can serve as a population-based virtual tissue repository, and how population-based cancer registries are essential for guiding the implementation of evidence-based interventions and measuring changes in the cancer burden after the implementation of these interventions.

Unlocking the potential of population-based cancer registries

Population-based cancer registries have improved dramatically over the last 2 decades. These central cancer registries provide a critical framework that can elevate the science of cancer research. There have also been important technical and scientific advances that help to unlock the potential of population-based cancer registries. These advances include improvements in probabilistic record linkage, refinements in natural language processing, the ability to perform genomic sequencing on formalin-fixed, paraffin-embedded (FFPE) tissue, and improvements in the ability to identify activity levels of many different signaling molecules in FFPE tissue. This article describes how central cancer registries can provide a population-based sample frame that will lead to studies with strong external validity, how central cancer registries can link with public and private health insurance claims to obtain complete treatment information, how central cancer registries can use informatics techniques to provide population-based rapid case ascertainment, how central cancer registries can serve as a population-based virtual tissue repository, and how population-based cancer registries are essential for guiding the implementation of evidence-based interventions and measuring changes in the cancer burden after the implementation of these interventions.

Results of a lay health education intervention to increase colorectal cancer screening among Filipino Americans: A cluster randomized controlled trial

BACKGROUND

Filipino colorectal cancer (CRC) screening rates fall below Healthy People 2020 goals. In this study, the authors explore whether a lay health educator (LHE) approach can increase CRC screening among Filipino Americans ages 50 to 75 years in Hawai'i.

METHODS

A cluster randomized controlled trial from 2012 through 2015 compared an intervention, which consisted of LHEs delivering 2 education sessions and 2 telephone follow-up calls on CRC screening plus a CRC brochure versus an attention control, in which 2 lectures and 2 follow-up calls on nutrition and physical activity plus a CRC brochure were provided. The primary outcome was change in self-reported ever receipt of CRC screening at 6 months.

RESULTS

Among 304 participants (77% women, 86% had > 10 years of residence in the United States), the proportion of participants who reported ever having received CRC screening increased significantly in the intervention group (from 80% to 89%; P = .0003), but not in the control group (from 73% to 74%; P = .60). After covariate adjustment, there was a significant intervention effect (odds ratio, 1.9; 95% confidence interval, 1.0-3.5). There was no intervention effect on up-to-date screening.

CONCLUSIONS

This first randomized controlled trial for CRC screening among Hawai'i's Filipinos used an LHE intervention with mixed, but promising, results. Cancer 2018;124:1535-42. © 2018 American Cancer Society.

Exploring the effects of longstanding academic-community partnerships on study outcomes: A case study

While sustained academic and community partnerships can improve relationships between research partners, they could also influence study outcomes. Research on this issue is limited.

We conducted a trial (2010–15) to test two implementation strategies for an evidence-based intervention to promote colorectal cancer (CRC) screening at community organizations in Los Angeles (N = 17). For both strategies, trained community health advisors (CHAs) recruited Filipino Americans (N = 673) who were non-adherent to CRC screening guidelines. The main study outcome was CRC screening status of participants at 6-month follow-up. This case study compares outcomes among organizations that had participated in our prior effectiveness trial and new organizations with which we had no prior relationship. Using multilevel logistic regression with multiple imputation for missing outcomes, we compared CRC screening rates among previous versus new partners controlling for study condition and organizational, CHA and participant characteristics.

Screening rates were substantially higher among participants of previous versus new partner organizations in unadjusted analysis (77% versus 55%, OR 2.8, p = 0.12), after adjusting for organization-level variables (81% versus 42%, OR 7.5, 95% CI [2.0–28.7], p = 0.003) and after additionally adding CHA and participant level factors to the model (79% versus 47%, OR 5.9, CI [1.3–27.3], p = 0.02). Analyses using complete cases and assuming not-screened for missing outcomes indicated similar differences in screening rates (30 and 33 percentage points, respectively).

Study outcomes that are achieved with long-term community partners may not be generalizable to new partners. However, inclusion of new community partners is important for external validity of dissemination efforts in community settings.

NCT01351220 (ClinicalTrials.gov)

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Long-term partnerships between academia and community can affect study outcomes.

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Study outcomes achieved with long-term community partners may not be generalizable.

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Inclusion of new partners may improve external validity of dissemination efforts.

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We recommend further examination of this issue in future studies.

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Inclusion of this construct in theoretical formulations should be considered.