The program models and start-up process of the CRCSDP offer valuable insight to those with an interest in developing colorectal cancer screening programs. Several key factors emerged from the evaluation of the start-up experience of the five sites studied here. These factors include use of a multidisciplinary team, involvement of an MAB, relationships with partners, the use of preexisting resources, a program model that fits existing service delivery systems, and adequate planning time.
In these five programs, two to three staff with expertise in program management and administration (e.g., collaboration, contracting, policy development), program coordination (e.g., day-to-day management, training, support), and data management (e.g., data systems, data form development) provided an adequate team for program start-up. Clinical expertise and comfort discussing clinical issues with MAB members and service providers were important skills for the management team.
Access to clinicians with expertise in colorectal cancer was essential to start-up. A well-rounded MAB that included professionals in disciplines related to the screening process (e.g., endoscopists, pathologists, radiologists, surgical oncologists, social workers, community-based practitioners) was beneficial.
CDC and other organizations recognize that public health problems demand collaborative efforts rather than "going it alone" (18
). Active and extensive partnerships were fundamental in helping the programs plan to recruit clients, increase public awareness about the need for screening, and facilitate relationships with MAB members and screening sites.
The five CRCSDP sites leveraged existing resources to build a new colorectal cancer screening program. Partner agencies (e.g., CCC, ACS), other screening programs (e.g., NBCCEDP), and internal agency departments (e.g., health communications, epidemiology) helped reduce costs and support program development. The length of time needed to develop data systems and data collection forms suggests new programs may benefit from using existing data forms and data collection sets.
These five programs used program models that would most easily integrate into existing service delivery systems. For the decentralized models, integration involved allowing for varied implementation approaches within multiple service delivery sites for the same program (e.g., five different clinical sites providing colonoscopy screening). Reliance on in-reach to NBCCEDP clients and overall concerns about effectively recruiting men suggest programs may need to consider program models that include unique recruitment efforts for men.
Although CDC had anticipated a 6-month start-up period, these programs needed 9 to 11 months to hire staff, convene an MAB, develop policies, build partnerships, organize a service delivery system, plan for client recruitment, secure treatment resources, and develop data management systems. One staff member advised, "The devils are in the details — all the little things that you have to think through that we didn't even think of — things we thought we knew but we didn't."
The CRCSDP evaluation team will continue to work with the five sites as they provide colorectal cancer screening to low-income, underserved communities. The case study, in particular, contributes to important process evaluation efforts that improve our understanding of the CRCSDP's program operations, implementation, and service delivery (20
). Recognizing that the potential for evaluation to effect change is dependent on its use (21
), evaluators encourage others with an interest in colorectal cancer screening to consider the results presented here.