Against Colorectal Cancer in Our Neighborhoods (ACCION)

In the United States, colorectal cancer (CRC) is the second-leading cause of cancer-related deaths. Approximately 50,000 people die from colorectal cancer each year. Hispanics are less likely than non-Hispanic Whites to be diagnosed with localized CRC, which may be linked to lower screening rates among the Hispanic population. Hispanics are less likely than any other racial or ethnic group to have insurance and about half as likely as non-Hispanic Whites to have a usual source of health care, both of which affect use of preventive services such as cancer screening.

Screening can prevent CRC by identifying polyps for removal before they become cancerous. Screening can also detect CRC at an early stage when treatment is more likely to be successful. The U.S. Preventive Services Task Force recommends regular screening beginning at age 50 and continuing until age 75 using high-sensitivity fecal occult blood testing (FOBT), sigmoidoscopy, or colonoscopy. Interventions designed to promote colorectal cancer screening are needed to reduce the morbidity and mortality among under-insured Hispanics residing in the United States.

Against Colorectal Cancer in Our Neighborhoods (ACCION) is a bilingual, community-based intervention designed to increase colorectal cancer screening among uninsured Hispanic adults aged 50-75 who are due for CRC screening. ACCION is implemented in community settings such as churches, health fairs, food pantries, low-income housing complexes, community centers, and clinics serving the uninsured. The intervention is based on the health belief model and social cognitive theory, which together address perceived benefits, barriers, susceptibility, and self-efficacy; knowledge; social norms; and reinforcement. Specifically, the intervention works to increase awareness of colorectal cancer and provide access to CRC screening. The intervention consists of three components: an educational program, access to no-cost screening and navigation services. It is delivered by promotoras, community members who are trained to educate their peers about colorectal cancer and screening for the disease.

After determining participant eligibility, promotoras deliver an educational program about CRC incidence, mortality, risk factors, warning signs, treatment, screening options, and common myths and barriers related to screening. The promotoras deliver one of three versions of the education component: a presentation that uses an interactive, standardized flip chart, a novela (short story) video, or the presentation plus the video. The promotoras decide which version to deliver based on available time and resources. The video, available in English and Spanish, depicts a conversation between two people about the epidemiology of CRC, the importance of screening, and the different tests, and it includes footage of a various screening procedures. While the video is playing, the promotora pauses the video at specified times to prompt and facilitate discussion. Promotoras are guided by the ACCION Program Manual, which includes a program protocol and tracking forms to document program participation.

Following the educational component, participants are given either an in-home FIT test or are referred to the navigator for scheduling a screening colonoscopy; navigation services consist of tracking the participants, providing two reminder calls and sending a reminder letter to encourage screening, colonoscopy scheduling and appointment reminders, transportation, help addressing individual psychosocial or logistical barriers, assistance with finding health care coverage or a primary care physician, and facilitation of treatment for any cancers diagnosed.

Participants at low risk for CRC receive an at-home fecal immunochemical test (FIT) with a pre-paid envelope, while those who are at higher risk (those with a history of abnormal colonoscopy or family history of colorectal cancer) receive a colonoscopy screening.

This program uses intervention approaches recommended by the Community Preventive Services Task Force: patient navigation services to increase cancer screening and advance health equity (Colorectal Cancer Screening - FIT/FOBT and/ or with colonoscopy), client reminder interventions (Colorectal Cancer Screening - FIT/FOBT and/ or with colonoscopy), multicomponent interventions (Colorectal Cancer Screening - FIT/FOBT and/ or with colonoscopy) and interventions to reduce structural barriers for clients (Colorectal Cancer Screening - FIT/FOBT and/ or with colonoscopy). This program also uses the following intervention approach for which the Community Preventive Services Task Force finds insufficient evidence: group education interventions (Colorectal Cancer Screening - FIT/FOBT and/ or with colonoscopy). Insufficient evidence means the available studies do not provide sufficient evidence to determine if the intervention is or is not effective. This does not mean that the intervention does not work. It means that additional research is needed to determine whether the intervention is effective.

-- 4-8 hours to train promotoras
-- 23 minutes to deliver the presentation
-- 17.5 minutes to deliver the video
-- 24.5 minutes to deliver the presentation and video
-- Approximately 10-30 minutes to provide navigation services

The intervention is intended for uninsured Hispanic adults aged 50-75 who are due for colorectal cancer screening.

The intervention is designed to be implemented in community and clinic settings.

Required resources to implement the program include the following:
-- ACCION Program Guide
-- ACCION Colorectal Cancer Education Training Curriculum
-- English & Spanish Service Consent Form
-- Participant Manual
-- Trainer Guide
-- English & Spanish Colorectal Cancer Education Flip Chart
-- English & Spanish Educational Leaflet
-- Display FIT Kit—English & Spanish Hemoccult Instructions
-- ACCION Case Management Service Agreement Plan
-- English & Spanish Advocacy Form
-- Intake Form
-- Liability Form
-- F92 Colonoscopy Request Form
-- FIT Request Lab Form
-- Colonoscopy Results to PCP Fax Sheet
-- FIT Test Results to PCP Fax Sheet
-- Patient Contact Sheet
-- English & Spanish FIT Test Normal Results Letter
-- English & Spanish Abnormal FIT Results Letter
-- English & Spanish Patient FIT Reminder Letter
-- English & Spanish Doctor Insurance Resource
-- Community Partners for Colorectal Cancer Education Template
-- English & Spanish Insured Patient Letter to Physician
-- Navigation Eligible Patient Letter
-- Patient Closure form
-- ACCION Video (English and Spanish)
-- FIT Kit

For costs associated with this program, click on Contact Program Developer on the Program Materials page.

A two-arm non-equivalent quasi-experimental study evaluated the impact of three versions of a community-based intervention and control condition on colorectal cancer screening among patients of Hispanic ethnicity in two similar Texas counties. Participants in the intervention county (El Paso) were randomized into one of three intervention groups: presentation only, video only, or presentation plus video. Participants in the control county (Cameron County) were enrolled in the study through convenience sampling methods and received usual care and no intervention components. The study intended to compare the three versions of the intervention with each other and with the control condition. Participants were recruited from 169 community and 17 clinical sites in the intervention county and from 40 community and 2 clinical sites in the control county. Inclusion criteria included being aged 50-75, being uninsured, living in Texas, and being due for CRC screening. Exclusion criteria were having a history of blood in the stool in the previous 3 months or having a history of CRC.

The intervention county (n=467) included 148 participants in the presentation only group, 160 participants in the video only group, and 159 participants in the presentation plus video group. The control county had 317 participants. The population was predominantly Hispanic (99%); 78% were female, 93% were younger than 65 years old, 63% were married, 45% made less than $10,000 yearly, 78% had less than a high school diploma, and 90% were born in Mexico. The intervention and control counties differed significantly in education level, gender, site type (clinic or community), survey language (English or Spanish), familiarity with CRC, and having received a doctor's recommendation for CRC.

The primary outcome was receipt of CRC screening (FIT or colonoscopy). Screening rates were assessed by self-report through a survey administered at baseline and 6-month follow-up. A program database was reviewed to validate self-report data, and 98.4% of self-report data were confirmed for all participants in the intervention county. The analysis compared screening rates between the intervention county and control county and among the three intervention groups in the intervention county.

 

• At 6-month follow-up, screening rates were higher in the intervention county than in the control county (80.5% vs. 17.0%; p<.001).

 

Additional Findings

• At 6-month follow-up, no significant differences in screening rates were found among the three intervention conditions in the intervention county.