Regular screening facilitates the early diagnosis of colorectal cancer (CRC) and contributes to the reduction of morbidity and mortality this cancer causes. Although a recent report showed an increasing trend in utilization of CRC screening tests, screening rates for minorities and low-income populations remain suboptimal. Having received a referral for CRC screening is one of the strongest predictors of adherence, but referrals are unlikely among those who have no clinic home, or rarely visit a primary care provider, factors that are more common among the poor and minority populations. Our currently proposed project is designed to build upon the evidence established by our team and others to test a method of disseminating evidence-based CRC screening promotion and protocols among a particularly difficult-to-reach population, many of whom do not name a """"""""regular"""""""" primary care clinic or provider. The purpose of this two-phase study is to test the effectiveness of an intervention using """"""""community-to-clinic navigators"""""""" to guide individuals from an especially hard-to-reach, multicultural and underinsured population into primary care clinics to receive a healthcare provider referral for CRC screening (Phase I) and, subsequently, for those who attend the clinic, to examine the impact of this phase I intervention on completion of CRC screening (Phase II). Cost-effectiveness analysis will lay the foundation for further evaluation of the dissemination policy potential of the intervention.
Aim 1 : Test effectiveness of community group education + tailored navigation versus community group education only in increasing clinic attendance among low-income, multi-cultural Arizona residents aged 50 or older. As a separate critical step for those who make clinic appointments, we will examine the effect of follow through to screening, using Phase I group assignment as a control variable in analysis. Patients making clinic appointments will receive the clinic-based navigation that has become usual care in several of our study clinics.
Aim 2 : Track effects of Phase I intervention assignment on increasing CRC test completion among those who attend clinic.
Aims 3 and 4 are designed to prepare to translate findings to broader contexts.
Aim 3 : Determine the cost-effectiveness of each phase of the interventions on increasing CRC screening completion among low-income, multicultural Arizona residents aged 50 to 75 years. Exploratory Aim 4: Examine the levels of program dissemination from community to clinic to final screenings using the RE-AIM model, asking, """"""""What is the degree of Reach, Efficacy, Adoption, Implementation, and Maintenance of the community-to-clinic navigation, and clinic-to-screening outcomes?"""""""" The central feature to be tested, navigation from community to clinic using tailored messages, is a novel intervention, shown in an initial pilot study to have a sizeable effect. The protocols in plae to navigate patients to screening have been shown to be effective for achieving screening adherence and reducing mortality. For both steps of the proposed research, we have adapted the design for realistic community/clinic contexts for maximum translation potential and cost estimates for most effective practices.

Public Health Relevance

Regular screening facilitates the early diagnosis of colorectal cancer (CRC), the second leading cause of cancer death, and contributes to the reduction of CRC morbidity and mortality, but the hardest-to-reach patients are still under-screened. This study will merge and incorporate two primary elements of successful interventions tested by the co-PIs to examine dissemination outcomes;we will test effects of community-to- clinic navigators using a tailored navigation protocol to guide individuals from an especially hard-to-reach, multicultural, and underinsured population into primary care clinics and, subsequently, track the effects of this intervention through a clinic navigation program to complete CRC screening. A cost-effectiveness analysis will lay the foundation for further implementation and dissemination research.

National Institute of Health (NIH)
National Cancer Institute (NCI)
Research Project (R01)
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Dissemination and Implementation Research in Health Study Section (DIRH)
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Breslau, Erica S
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Arizona State University-Tempe Campus
Schools of Nursing
United States
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Larkey, Linda; Szalacha, Laura; Herman, Patricia et al. (2017) Randomized controlled dissemination study of community-to-clinic navigation to promote CRC screening: Study design and implications. Contemp Clin Trials 53:106-114