The results of this pilot study indicate that the use of lay health worker outreach to promote colorectal cancer screening is feasible among Chinese Americans and is effective, albeit in an uncontrolled study, in increasing the rate of colorectal cancer screening in this population. Other important findings from this study include preliminary information about how LHW outreach may work in this population and the acceptability of LHW outreach among Chinese American men.
There has been increasing interest on how to increase uptake of health interventions that have been proven effective [32
]. Despite the size of the Chinese American population and the lack of adequate colorectal cancer screening, there has been only one published intervention to increase this proven modality in this population—a clinic-based intervention in Seattle, WA using a professional health educator, bilingual materials, and direct provision of FOBT cards [13
]. That study found that the intervention was superior to usual care for FOBT receipt. The intervention group had an increase of 69% in the receipt of colorectal cancer screening, a rate that is slightly higher than the increase of 55% in this LHW outreach study. The results of both studies show that culturally and linguistically appropriate health education, whether community- or clinic-based, can lead to large increases in the rate of colorectal cancer screening among Chinese Americans.
In addition to the effect on increasing colorectal cancer screening, the LHW outreach participants also increased their knowledge about the known risk factors of colorectal cancer. There was an increase in the knowledge that screening prevents colorectal cancer, although there was no change in knowledge of other prevention modalities such as eating fibers and vegetables or taking aspirin to prevent colorectal cancer. This was because, for simplicity, the intervention focused on screening, and thus, the LHWs did not discuss other modalities other than to acknowledge that they were valid. The lack of emphasis may have led the participants to believe that the other preventive methods may not be effective. Since those other behaviors should be encouraged, this would be an issue to address in future studies.
There was an increase in concern about colorectal cancer, but no changes in the perception of logistical barriers. This is likely a result of the way this LHW outreach program was structured, with the main focus on knowledge and risk, and, other than providing participants with referral to places to go to obtain screening, less focus on providing navigation support. This feature separates the type of outreach conducted by LHWs from patient navigators, one of whose main functions is to provide navigation and logistical support. Future studies with LHWs could include additional components that address logistical problems.
Rogers argued that, among the five stages of diffusion theory’s adoption process—knowledge, persuasion, decision, trial, and adoption—interpersonal contact and social networks are more influential than other modalities, such as mass media, in driving the last two or three phases [33
]. Lay health workers in this study successfully transmitted knowledge about colorectal cancer and its screening to their participants. Most participants acknowledged that knowledge delivery was a key component of the LHW outreach, but they reported that the LHWs also helped to provide other important information such as logistics (e.g., where to go to obtain screening) and emotional support to encourage the participants to get screened. Participants also selected the characteristics of being helpful, friendly, and respectful more frequently than being knowledgeable as what they liked about their LHWs. Although this study was not designed to address the question of how LHW outreach works, these interpersonal qualities may have been as important as knowledge diffusion in increasing adoption of colorectal cancer screening among the participants. LHW outreach should be strongly considered in programs that work with minority populations such as Chinese Americans because LHWs have natural cultural and linguistic competence, because LHWs fit the needs of diffusion theory, and there is increasing empirical evidence, including this study, for the effectiveness of LHW outreach [20
A recent review of LHW outreach reported a need for studies with male participants [19
]. This study showed that it is feasible to implement LHW outreach for Chinese American men on the topic of colorectal cancer screening. Interestingly, even though some female LHWs worked with male participants, there were minimal differences in the effect of the intervention on knowledge and uptake of colorectal cancer screening between male and female participants. However, men did have lower rates of intention to obtain screening in the future. It was also harder to find qualified men interested in becoming LHWs. These findings suggest that concerns remain about the applicability of LHW outreach methods to ethnic minority men and that LHW outreach with these men should be tested in a larger study.
An important and often underappreciated feature of LHW outreach programs is the building of community capacity to address health concerns. In this study, this occurred in three ways. First, existing social networks, which were probably channels of communication about a variety of issues, including health concerns, were utilized to spread the word about an evidence-based effective intervention, colorectal cancer screening. The message did not stop after the participants listened to the LHWs because many participants reported discussing colorectal cancer screening with others in their networks. Utilizing the social networks in this way may prepare for future health-related outreach by setting the norm for those in the network that this is an acceptable content for communication. Secondly, the LHWs become ready resources for further linguistically and culturally competent interventions on health. This did occur in a direct way, when NICOS utilized trained LHWs to provide teaching about colorectal cancer screening to large numbers of participants at health fairs. The presentation and research skills that they learned will also prepare them to conduct similar work on other health topics. On a more fundamental level, some LHWs become activated to work in health outreach, as in the example of the LHW who then seeked and obtained further employment with NICOS. Finally, the capacity of a community organization such as NICOS to work in research and in cancer prevention also increased, and it is currently working with this team of researchers on other funded projects to carry out community-based participatory research among Chinese Americans.
This study has several important limitations. As a feasibility study, the sample size was small, and there was no control group. The outcome of colorectal cancer screening was based on self-reports, not on medical record validation, and little is known about the validity of self-reports for colorectal cancer screening among Asian Americans.
The findings from this study show that LHW outreach to promote colorectal cancer screening among Chinese American men and women is feasible and possibly effective. Further studies are needed to document the effectiveness of this culturally appropriate intervention and to describe the mechanisms through which this intervention works.