Despite effective prevention and early detection screening methods, colorectal cancer (CRC) is the 2nd leading cause of cancer death in the United States [1
]. Unlike many other screening tools, such as mammography that detects existing cancer, CRC screening methods can prevent cancer from developing through the removal of pre-cancerous polyps. When CRC is found early and treated, the 5-year relative survival rate is 90 percent. However, less than 40% of colorectal cancers are found early due to the underutilization of CRC screening [2
]. In 2005, only 47% of adults age 50 and older in the U.S. reported having either a fecal occult blood test within the past year, sigmoidoscopy within the past five years, or a colonoscopy within the past 10 years, as recommended in the United States by the Centers for Disease Control and Prevention (CDC) and the American Cancer Society [3
]. An estimated 153,760 people in the U.S. were expected to be diagnosed with CRC in 2007, costing over $8 billion in treatment [4
]. Of the 52,180 people who were expected to die from CRC in 2007 in the U.S., half may have been prevented if all people age 50 and older were screened regularly [1
This study took place in rural and frontier counties which are part of the High Plains Research Network (HPRN) in eastern Colorado. In 2006, 30% of adults in the state of Colorado age 50 and older had an FOBT within the past 2 years, and 58% report ever having a proctoscopy, colonoscopy, or sigmoidoscopy [6
]. In rural and frontier eastern Colorado, a recent survey by the authors of age-eligible residents reported similar use of FOBT (32%), but only 51% had ever had flexible sigmoidoscopy or colonoscopy testing. Almost a quarter (23%) of the rural sample had never had any type of CRC screening [7
]. Colorectal cancer screening remains an underutilized method of cancer prevention and early detection, and rural areas may be susceptible to even lower screening rates.
Compared to other cancers such as breast and cervical, community-based interventions targeting CRC screening are rare [8
]. The Center for Disease Control and Prevention's (CDC) community preventive guidelines include no evidence-based recommendations for effective community interventions to improve CRC screening [9
]. In an attempt to fill this gap, the HPRN formed a group of local residents from eastern Colorado to develop a community-based CRC awareness and educational campaign uniquely tailored to a rural population with the goal of increasing colorectal cancer screening rates in residents age 50 and older in northeast Colorado. This paper describes the intervention implementation, reach of the materials, and the effect exposure to the intervention had on screening intentions in the rural target population. The study was conducted in the first 3 communities to receive the intervention and was funded by the CDC.
The Study Region: High Plains Research Network
The HPRN is a practice-based research network that covers the 16 counties of eastern Colorado. Of these counties, 10 are designated "frontier" (or less than 6 people per square mile), and the remaining 6 are "rural". The entire HPRN consists of 55 primary care practices, 16 hospitals, approximately 150 providers, and the communities that reside in this region. The 3 communities involved with this particular evaluation included 2 smaller communities (populations provided below), each with 1 primary care practice each. The third town is the largest community in the area and is home to 6 practices, including private solo practices and a hospital-based clinic. Ranching and farming are dominant sources of income and permeate the culture of this region. Residents living in the 3 counties included in this evaluation are older than the state as a whole, with a median age of 39 versus 34 for the state and a percent of the population age 65 and older of 16% versus 10% [10
The Intervention: Testing to Prevent Colon Cancer in Rural Colorado
The HPRN launched a community-based, multi-component colon cancer prevention intervention in the spring of 2006. "Testing to Prevent Colon Cancer in Rural Colorado" aims to increase CRC screening behaviors, knowledge, and attitudes in rural northeastern Colorado. The intervention consisted of an awareness and educational campaign that encouraged local residents to talk to their providers about colon cancer testing options, targeting residents age 50 and older.
Community-based participatory research (CBPR) methods were used to develop, implement, and test the intervention messages and materials. While the definition of community may vary by project, CBPR research involves a collaborative partnership with a group to increase the relevance of the research to the community. The HPRN uses CBPR approach regularly, having formed a Community Advisory Council (C.A.C.) in 2003 to help to guide the research it conducts. The C.A.C. consists of 9 residents of rural northeast Colorado, including farmers, teachers, ranchers, a home health visitor, and a retired administrator. Specifically for this intervention, the C.A.C. was expanded to include 2 local physicians, 2 public health workers, and a hospital administrator from northeast Colorado. The resulting group, named the Joint Planning Committee (JPC), designed the intervention's main messages, materials, and implementation strategies.
The JPC developed a 4-point message to address key catalysts of behavior change, including relevance, education, facilitation/encouragement, and action. The main messages are below.
1. Colon cancer is the 2nd leading cause of cancer death in the U.S.
2. Colon cancer is preventable.
3. Testing is worth it.
4. Talk to your doctor today.
The program's 4 main messages were incorporated into the intervention's materials, a set of 8 mostly bilingual components. Table provides a description of each component and implementation. The JPC selected program components that could be implemented in each intervention community and that linked community members back to their local primary care providers. Methods were selected that tapped into the communication culture of rural communities, including the use of local community members in program components, local newspapers and adaptations of familiar small print materials (communication methods engrained into every day life in rural towns), and local organizations that are very common and valued in rural communities. The JPC helped identify local residents to have their photos taken for the palm card series and series of ads in the local newspapers, to share their personal stories in local newspapers, and to co-present community talks with a local health care provider. All local newspapers agreed to run the 3 newspaper components of the intervention. Local residents and clinic staff were also recruited to distribute the small print materials, such as the palm cards and farm auction flyers, and recorded the number of copies left at each location. All primary care practices in the intervention communities agreed to distribute the "got polyps?" travel mugs to residents who redeemed a palm card or newspaper ad for a mug at the clinic.
Implementation of "Testing to Prevent Colon Cancer in Rural Colorado" in Three Communities