Colorectal Cancer Screening Intervention Program (CCSIP)

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancer death in the United States. While morbidity and mortality from CRC can be reduced through early detection and treatment, rates of CRC screening are lower than for other preventable cancers. Both incidence and mortality rates of CRC are higher among African Americans than White groups, yet screening rates among African Americans are lower.

Barriers to CRC screening for African Americans include fear of cancer, lack of knowledge, lack of health provider recommendation, embarrassment, lack of insurance, and the belief that cancer inevitably leads to death. Therefore, there is a need for a culturally specific intervention with a strong educational emphasis designed to address the barriers to CRC screening specific to African Americans. The Colorectal Cancer Screening Intervention Trial (CCSIT) evaluated two behavioral and educational counseling interventions and a financial support intervention in promoting CRC screening among African Americans. The most efficacious of the three was a group educational intervention. It is described here as the Colorectal Cancer Screening Intervention Program (CCSIP).

CCSIP is designed to educate African Americans on the importance of obtaining screening for CRC. This group education program features a community health educator who meets with participants in groups of 4 to 14 (average of 5) to review educational materials on CRC risk and screening. The program uses materials from the National Cancer Institute and the American Cancer Society and also original materials created for the intervention. The curriculum for the educational sessions includes genetics, incidence, and mortality rates for CRC; disparities in detection and treatment; and screening methods used to detect CRC. Information is also provided on the effectiveness of diet and exercise in the prevention of CRC.

CCSIP sessions are delivered weekly over the course of 3 weeks in senior centers, churches, community centers, or public health clinics. The sessions are organized as follows: Session 1 focuses on prevention and early detection of CRC; session 2 teaches participants how to recognize signs and symptoms of CRC and offers CRC screening recommendations; and session 3 offers information on maintaining healthy habits to prevent CRC. Sessions are presented by trained community health educators who have undergone 6 hours of training and have agreed to promote CRC screening guidelines from the U.S. Preventive Services Task Force, the American Cancer Society, and the Agency for Healthcare Research and Quality.

To administer the CCSIP program, the following time is required:

- Six hours to train each community health educator

- Five-to-seven hours for the community health director to supervise community health educators (varies according to baseline competencies of the educators)

- To administer services: (1) delivering three (1-hour) CRC educational sessions, (2) assisting participants in completion of quality assurance measures, and (3) determining each participant's 90-day postintervention CRC screening status

The intended audience for the CCSIP program is African American adults over age 49.

The CCSIP program is designed to be administered to participants in senior centers, churches, community centers, and public health clinics.

The CCSIP program toolkit includes the following materials:

- CCSIP Implementation Protocol

- CCSIP Facilitator's Manual (contains all the participant handout materials)

- Down Home Healthy Living (recipe book)

- Facilitator Training Slide Presentation

- Sample Facilitator Training Agenda

The Colorectal Cancer Screening Intervention Trial was a randomized community study that aimed to assess the efficacy of (1) small group education, (2) one-on-one education, or (3) financial support only, in contrast to (4) a control condition. The Metropolitan Atlanta Coalition on Cancer Awareness (MACCA), the Community Coalition Board of the Morehouse School of Medicine Prevention Research Center, churches, clinics, and other community organizations in Atlanta, Georgia, participated in the recruitment of study participants. To be eligible, participants had to be African American, over age 49, have no history of CRC, and no CRC screening test within the recommended time interval. Two full-time and one part-time community health workers made contacts in person at senior centers, churches, community centers, and public health clinics. They also worked with MACCA and members of the Community Coalition Board.

Participants in this study were primarily African American women over age 65 with a high school diploma or some technical college. Participants were randomized by the site (i.e., church, community/senior center, or clinic) where they were assigned to one of four different conditions. That is, all participants at a given site were assigned to the same arm of the study. This prevented the "contamination" that could result from participants in different arms of the study sharing information with one another. All participants were given a gift bag with small household items and printed literature on CRC.

For the one-on-one education cohort, a health educator met individually with participants for three 45-minute sessions over 3 weeks to review educational materials on CRC risk and screening. All meetings took place at the recruitment site. The educational material included descriptions of CRC symptoms, diagnosis and treatment, screening tests, and screening recommendations. Ninety-eight participants (76.5% women) were assigned to the one-on-one education cohort.

For the small group education cohort, a health educator met with participants in groups of 4-14 (average of 5) to review the educational material. Although the material was identical to that covered in the one-on-one cohort, there were more people at each meeting, and four sessions over 4 weeks were required to cover the material. Again, all meetings took place at the recruitment site. Ninety-nine participants (66.7% women) were assigned to the group education cohort.

For the reduced out-of-pocket expense (financial support) cohort, participants were offered financial reimbursement up to $500 for out-of-pocket expenses incurred for CRC screening, including transportation and other nonmedical expenses. A health educator was available to assist with negotiating direct payment and arranging transportation to the doctor's office or medical clinic for the screening test. The health educator also provided letters of introduction and guarantee of payment for the patient to assist in scheduling the test visit. The amount offered was more than sufficient to pay all costs involved in obtaining a fecal occult blood test, but less than half the cost of a colonoscopy. For patients seeking an endoscopic screening, the amount could cover the copayment and/or deductible for those with private insurance or Medicare or the full cost of screening at a reduced-cost public facility. A total of 84 participants (72.6% women) were assigned to the financial support group.

Control group participants attended the introductory session but received only the contents of the gift bag with the educational pamphlets. They received pretesting (at the introductory session), posttesting, and followup on a schedule identical to that of the participants in the other cohorts. Eighty-eight participants (76.1% women) were assigned to the control group.

Medical records were requested from the participants' physicians or health care facilities to determine whether they had been screened for CRC before enrollment in the study. All participants completed a questionnaire at pretest and posttest that included an assessment of their knowledge, attitudes, beliefs, and practices regarding general health issues and knowledge about CRC risk and screening. Posttest questionnaires were administered to the two educational cohorts at their final intervention session. The control and financial support cohorts completed the posttest questionnaire 2 weeks after the second introductory session. Screening status for CRC was assessed by telephone and/or mail during the followup assessment periods at 3 months and if necessary at 6 months after the intervention.

• Participants in the small group education cohort were significantly more likely to undergo colorectal cancer screening at the 6-month followup than participants in the control group (p=.039).

• There was no significant difference in rates of colorectal cancer screening at the 6-month followup for the one-on-one education cohort or the financial support cohort compared to the control group (n.s.).

Additional Findings

• Participants in the small group education cohort and the one-on-one education cohort showed a statistically significant increase in knowledge regarding the three most common cancers at followup as compared to baseline (p<.0001).


• There was no significant change in knowledge regarding the three most common cancers at followup as compared to baseline for the financial support cohort or the control group (n.s.).


• Participants in the small group education cohort and the one-on-one education cohort were significantly more likely to show an increase in knowledge about colorectal cancer on followup as compared to baseline (p<.009).


• There was no significant change in rates of knowledge about colorectal cancer from baseline to followup for the financial support cohort (n.s.).


• Participants in the small group education cohort and the one-on-one education cohort were significantly more likely to show an increase in knowledge of colorectal cancer prevention at followup as compared to baseline (p<.0001).


• There was no significant change in rates of knowledge regarding knowledge of colorectal cancer prevention from baseline to followup for the financial support cohort (n.s.).


• Participants in the small group education cohort and the one-on-one education cohort showed a significant increase in knowledge that detecting and removing polyps may be a way of preventing colorectal cancer from baseline to followup (p<.0001).


• Participants in the control group also showed a significant increase in knowledge that detecting and removing polyps may be a way of preventing colorectal cancer from baseline to followup (p<.001).


• There was no significant change in rates of knowledge that detecting and removing polyps may be a way of preventing colorectal cancer from baseline to followup for the financial support cohort (n.s.).


• Participants in the small group education cohort and the one-on-one education cohort were significantly more likely to show an increase in knowledge that individuals with ulcerative colitis are more likely to develop colorectal cancer from baseline to followup (p<.0002).


• There was no significant change in rates of knowledge that individuals with ulcerative colitis are more likely to develop colorectal cancer from baseline to followup for the financial support cohort (n.s.).


• Participants in the small group education cohort and the one-on-one education cohort were significantly more likely to show an increase in knowledge regarding the purpose of colorectal cancer screening tests at followup as compared to baseline (p<.0001).


• There was no significant change in rates of knowledge regarding the purpose of colorectal cancer screening tests from baseline to followup for the financial support cohort (n.s.).