Screen to Save: Results from NCI’s Colorectal Cancer Outreach & Screening Initiative to Promote Awareness and Knowledge of Colorectal Cancer in Racial/Ethnic and Rural Populations

Abstract

Background:

The Center to Reduce Cancer Health Disparities (CRCHD), National Cancer Institute (NCI), implemented Screen to Save (S2S), NCI’s Colorectal Cancer Outreach and Screening Initiative to promote awareness and knowledge of colorectal cancer (CRC) in racial/ethnic and rural populations.

Methods:

The initiative was implemented through CRCHD’s National Outreach Network (NON). NON is a national network of Community Health Educators (CHEs) aligned with NCI-designated Cancer Centers (CC) across the nation. In Phases I and II, the CHEs focused on the dissemination of cancer-related information and implementation of evidence-based educational outreach.

Results:

In total, 3,183 pre/post surveys were obtained from male and female participants, aged 50–74 years, during the 347 educational events held in Phase I. Results demonstrated all racial/ethnic groups had an increase in CRC-related knowledge, and each group strongly agreed that the educational event increased the likelihood that they would engage in CRC-related healthful behaviors (e.g., obtain CRC screening, increase physical activity). For Phase II, Connections to Care, event participants were linked to screening. Eighty-two percent of the participants who obtained CRC screening during the 3-month follow-up period obtained their screening results.

Conclusions:

These results suggest that culturally tailored, standardized educational messaging, and data collection tools are key change agents that can serve to inform the effectiveness of educational outreach to advance awareness and knowledge of CRC.

Impact:

Future initiatives should focus on large-scale national efforts to elucidate effective models of connections to care, related to CRC screening, follow-up, and treatments that are modifiable to meet community needs.

Introduction

Screening to detect cancer and excise premalignant lesions has been proven to reduce overall colorectal cancer incidence and mortality rates. Since the screening recommendations three decades ago, trends in overall cancer incidence and mortality have declined for men and women and most racial/ethnic populations¹. Similarly, a decline in disease and death has been noted for colorectal cancer, although decreases in morbidity and mortality are not equal across all populations^{1, 2}.

Colorectal cancer continues to be one of the most commonly diagnosed cancers, and is the third most diagnosed cancer among women and men³. Prior research in the general population indicates racial/ethnic minorities and medically underserved populations (defined as subgroups of people living in a defined geographic area with a deficiency of health care resources and services⁴) are more likely to face increased CRC morbidity and mortality⁵. For example, age-standardized incidence and mortality rates for cancers of the colon and rectum are highest among African Americans/Blacks when compared to non-Hispanic Whites⁶. It has also been documented that screening is underutilized, as is timely follow-up on abnormal results in these populations^{7, 8, 9, 10}. Such disparities are likely attributable to sociocultural barriers including economic disadvantage, lack of insurance and provider continuity, and longer travel distances to care^{11, 12, 3, 13}. Given these factors and a commitment to address the critical need for improved knowledge of colorectal cancer, its risk factors and screening modalities, a culturally-tailored evidenced-based outreach and education intervention was implemented.

The Screen to Save (S2S) Initiative was implemented in racial/ethnic and rural populations in the catchment areas of NCI-designated Cancer Centers (CC), by trained community health educators (CHEs). Each of the CHEs at 42 sites reflect the demographics of the populations served. The CHE serves as an intermediary between the community and health/social services and is a culturally adept care team member who informs patients about health conditions and facilitates expanded access to services across the care continuum. The aim of this community-based effort was to improve and expand access to colorectal cancer information, and to provide the opportunity for culturally sensitive discussions about colorectal health and early detection procedures. Lastly, S2S efforts sought to direct and encourage screening uptake using CHE-facilitated connections to care and services.

Community outreach and education models have been shown to be a powerful tool for community engagement on issues of health and health disparities^14,15. Specifically, community health educator (CHE), community health worker (CHW), and patient navigator (PN) programs have been critical. Tey provide education and link medically underserved individuals to financial and advocacy resources to address barriers to care¹⁶. The CHEs/CHWs/PNs close understanding of the attitudes, beliefs and practices of diverse and medically underserved populations have been increasingly responsible for improvements in the effectiveness of screening and reduced time to diagnosis and care efforts. For example, in a peer-reviewed study focused on a primary care setting serving predominantly racial/ethnic populations, screening rates following physician recommendation were compared for participants who did and did not receive patient education and navigation services^17,18. Higher rates of screening completion were noted for the navigation group. In an article examining the effectiveness of a lay community health worker intervention, Pap test and mammography screening completion at follow-up was higher among low-income Hispanic women in the intervention versus the control group¹⁹. These findings are similar to the preceding on navigation services. Promotoras (community health workers) have even been used in randomized trials. In a two-group randomized trial, Arredondo and colleagues²⁰ showed bilingual/bicultural promotoras can positively influence physical activity and preventive screening behaviors among Latinos in faith-based settings. In view of documented benefits of CHE/CHW/PN approaches in the literature, the Community Guide to Preventive Services recommends the use of community outreach and education strategies to increase CRC screening at the population level¹⁴.The guide also notes that there is a gap in community-based strategies to increase CRC screening and reduce structural barriers to screening utilization targeting medically underserved communities including racial/ethnic minorities. Accordingly, S2S, with its focus on increasing awareness of CRC, expanding access to and availability of CRC information and early detection procedures, and encouraging screening uptake using facilitated connections to care for racial/ethnic and rural populations, represents a step toward filling that unmet need.

Materials and Methods

Screen to Save (S2S) is a CRCHD/NCI national initiative to increase awareness and knowledge of colorectal cancer and promote uptake of U. S. Preventive Services Task Force (USPSTF) screening recommendations²¹ in racial/ethnic and rural populations. In order to facilitate a national evaluation of the two Phase initiative, CRCHD, in conjunction with the NCI Office of Communications and Public Liaison (OCPL), developed a toolkit that was provided to all participating sites. The toolkit included: 1) a one-page initiative overview; 2) an outreach plan template; 3) an educational PowerPoint presentation that NON CHEs could adapt and culturally tailor to their target populations; and 4) NCI-approved messaging regarding CRC along with suggested communication channels including social media (e.g., Twitter, Facebook).

All toolkit content and messaging were derived from OCPL approved sources of peer-reviewed and evidence-based content. Two sites translated the presentation and survey into Chinese, and 15 sites used the Spanish translation of the presentation and survey. All S2S sites completed Phase I requirements, meaning that the site conducted educational outreach and information dissemination activities on colorectal cancer and administered pre/post surveys. S2S sites that elected to complete Phase II complied with Phase I requirements and linked outreach activity participants to medical providers/partners providing screening and follow-up care where appropriate. Connections to care may have included activities such as the distribution of FIT/FOBT kits or colonoscopy referral. Administering a three month follow-up survey was also required for Phase II participation. The educational outreach for Phases I and II of the initiative occurred in parallel and began in March of 2017 to coincide with National Colorectal Cancer Awareness Month. Data collection concluded in December of 2018. Of note, select sites incorporated the use of an inflatable colon/colon walking tours, mini-colon exhibits, flipcharts/flipbooks, and videos/theatrical performances into CRC outreach activity implementation to enhance community engagement. Although the toolkits were culturally adapted for each target population, the CHEs were required to cover each of the designated CRC-related topic areas. Modifications to the surveys were not allowed except translation from English into Spanish and Chinese/Mandarin. Minor variations to the Spanish survey were allowed based on specific language nuances from Hispanic/Latino subgroups (e.g. Mexican Spanish vs. Puerto Rican Spanish). Participating grantee sites were NCI-Designated Cancer Centers, geographically dispersed throughout the continental U.S., Hawaii, Guam and Puerto Rico. The NON sites (grantees) were selected from a competitive NCI review process in response to the following funding opportunity: https://www.cancer.gov/about-nci/organization/crchd/funding-training-opportunities/adminsupplement-non-fy15.

CRCHD developed an 18-item knowledge survey to be administered before and after the educational presentation, in each Phase, to assess change in knowledge. The true/false items covered knowledge of screening methods and guidelines and risk factors for CRC, including heritability. Survey questions were informed by existing instruments found in peer-reviewed literature and modified to be in alignment with the educational presentations. In addition, new items were constructed to reflect topic areas not covered in existing surveys. The initial set of items, developed by NCI, reflect important concepts regarding CRC risks and screening presented as part of the educational activity. These items were reviewed by a workgroup of NON CHEs credentialed with a Master of Public Health or higher and extensive experience in both outreach education and cancer health disparities research. To validate the survey questions for clarity and readability, the final pre-, post, and 3-month follow-up surveys were pilot-tested with the intended target audiences in collaboration with this NON CHE workgroup. In addition to the knowledge items, the survey contained information regarding participant demographics, CRC screening history, family history of CRC, and intentions to engage in healthful behaviors regarding CRC screening and prevention.

The toolkit was culturally-tailored to meet the needs of the racially/ethnically diverse target populations^{22, 23, 24, 25, 26, 27}. Cultural adaptation is defined as “the systematic modification of an evidence-based treatment (EBT) or intervention protocol to consider language, culture, and context in such a way that it is compatible with the client’s cultural patterns, meanings, and values”²⁸. NON staff and CHEs implemented the Barrera and Castro²⁹ cultural adaptation model, which included five intervention adaptation stages: 1. Information gathering, 2. Preliminary adaptation design, 3. Preliminary adaptation tests, 4. Adaptation refinement, and 5. Final implementation.

Various studies have found that culturally tailored behavioral health interventions for racial/ethnic populations are highly effective²⁹. Cultural tailoring of the S2S toolkits for each group being targeted went beyond the process of translation. It included tailoring to the cultural, religious, linguistic, and literary skills of the communities being targeted. All sites included ‘peripheral strategies’ as described by Kreuter et al.³⁰ to culturally tailor the S2S Power Point, including certain colors, graphics/images, pictures and titles that were relevant to each racial/ethnic group. CHEs targeting Blacks/African Americans worked collaboratively with faith-based organizations and ensured that linguistic and literacy levels were adequate for their communities. A site targeting American Indians (AI) relied on trusted and already established community events to implement S2S. This site also incorporated an AI male to share his CRC screening testimonial to further encourage trust among community members. This approach relied on the cultural importance of story-telling within the AI community. Moreover, an innovative intervention within the H/L community in South Texas relied on a Theatre Outreach program to reach their community through a culturally accepted novella-style educational program. In Hawaii, a video testimonial from a respected doctor, whose father had recently passed away from CRC, was produced highlighting the importance of CRC screening. This video was incorporated in the S2S community education intervention. Sites targeting Asian communities relied heavily on cultural values of respect, including respect for elders and respect for medical authorities.

Although not mandated by this initiative, nine of the 42 participating sites opted to pilot Phase II, which required connections to care that were already in place at those sites. Different models of connections to care were implemented, including distribution of CRC screening tests, provision of colonoscopy referrals, partnerships with differing health care facilities (e.g., gastroenterology practices, Federally Qualified Health Centers-FQHCs, NCI-designated Cancer Centers), use of patient navigators, and support from community-based organizations. Phase II’s 3-month follow-up surveys were developed by CRCHD, in conjunction with the NON-workgroup.

All participating sites obtained local IRB approval prior to participation in S2S. Non-identified survey data were entered into a database and a 10% random sample of all surveys were double-entered for purposes of quality control and quality assurance.

Subjects.

The community-based sample was recruited from communities in the catchment area of the 42 participating sites. Potential participants were engaged via CHE verbal announcements at faith-based organizations (e.g. Spanish language masses), community clinics/FQHCs, barbershops/salons, other partner agencies; fliers, printed announcements in church bulletins, social media postings and word of mouth. The requirement for participation in S2S was that each participating site would provide a minimum of 50 completed pre- and post-test surveys. The actual number of surveys provided by sites ranged from a low of 30 to a high of 466, with the majority of sites providing between 100–200 pre and post-test surveys. Collectively, these sites conducted 347 educational sessions and administered 4,349 pre/post surveys. The analyses were restricted to those participants who were in the target age group of 50–74 years, resulting in a final sample of 3,183 participants who completed both the pre and post-test surveys. Persons attending an educational session were not excluded because of age, as there is value in learning about CRC risks, prevention, and screening methods at an earlier age than recommended for screening by the USPSTF²¹.

Analysis.

Descriptive analyses (frequencies and means) were conducted on the demographic information. Two-way analyses of variance and paired t-tests were conducted on the knowledge survey and behavioral intentions. A descriptive analysis was also performed on the 3-month follow-up data which included statistics of follow-up rates and CRC screening methods. Data were analyzed using Stata version 14.0.

Results

Demographics.

The characteristics of the sample are provided in Table 1. Nearly three-quarters of the sample was female. The sample is comprised of the following and contains large numbers of Asians (n=329), Black/African Americans (AA; n=872), Hispanic/Latinos (HL; n=1,172) and non-Hispanic Whites (NHW; n=670), but small numbers of American Indian/Alaska Natives (AI/AN; n=81) and Native Hawaiian/Other Pacific Islanders (NH/PI; n=30). Nearly 30% of the sample reports having a college degree and nearly a quarter of the sample reports having less than a high school education. Educational attainment is not evenly distributed across racial/ethnic groups. Nearly 50% of non-Hispanic Whites reported being college graduates compared to 37% of AA, 34% of AI/AN, 25% of Asians, 24% of NH/PI, and just 18% of HL. Conversely, 32% of both Asians and HL report having less than an 8^th grade education, compared to 10% of NH/PI, 3% of AI/AN, 2% of non-Hispanic Whites and 1% of AA (Chi-square (20) = 757, p<.0001).

Table 1.

Demographic Characteristics (Age 50–74 years)

Characteristic	Percentage (N=3,183)
Gender: % Female	73.3%
Race/Ethnicity:
American Indian/Alaska Native	2.5%
Asian	10.3%
Black/African American	27.4%
Hispanic/Latino	36.8%
Native Hawaiian/Other Pacific Islander	0.91%
Non-Hispanic White	21.1%
Not reported	0.6%
Education:
8th grade or less	15.7%
Some H.S.	9.2%
H.S. diploma/GED	18.9%
Some college	24.2%
College graduate (4 yr.)	30.1%
Not reported	1.9%
Preferred Language:
English	63.6%
Spanish	27.3%
Chinese	6.9%
Other	1.6%
Not reported	0.6%

Knowledge.

Two-way ANOVA was conducted on each of the knowledge items at baseline. No sex differences were noted, so we report only on racial/ethnic differences in baseline knowledge. Significant ANOVAs were followed with Bonferroni post hoc test to determine differences among the racial/ethnic groups. The results of these analyses are shown in Table 2. Seventeen of the 18 knowledge items exhibited racial/ethnic differences that are statistically significant. In general, the seven items assessing knowledge of risk factors for CRC exhibited the greatest differences among the racial/ethnic groups, with Asians demonstrating the least amount of knowledge regarding these risk factors. These results have possible implications for the focus of future educational outreach events and what factors might be emphasized as part of the educational activity.

Table 2.

Proportion of Participants Responding Correctly to Each of the Knowledge Items Pre-Educational Activity, by Race/Ethnicity (Ages 50–74)^*

Survey Items	Proportion of Respondents Providing Correct Response
	Total (N=3,183)	AI/AN (n=81)	Asian (n=329)	Black/AA (n=872)	H/L (n=1,172)	NH/PI (n=30)	NHW (n=670)
1. Colorectal cancer starts in what part of the body?	0.739	0.765	0.8361,2	0.7241	0.7052,3	0.700	0.7693
2. A stool test (FIT/FOBT) checks your stool (poop) for?	0.570	0.6421	0.5782,3	0.5714,5	0.4721,3,5,6	0.633	0.7212,4,6
3. Risk factor: Poor diet	0.764	0.728	0.8181	0.7502	0.7211,3	0.733	0.8372,3
4. Risk factor: Smoking/tobacco use	0.546	0.6671,2	0.4201,3,4	0.5643,5,6	0.4782,6,7	0.567	0.6944,5,7
5. Risk factor: Lack of physical activity	0.501	0.6541,2,3	0.3801,4,5	0.4772,4,6	0.4333,7	0.533	0.6915,6,7
5. Risk factor: Heavy drinking (alcohol consumption)	0.522	0.6791,2	0.4161,3,4,5	0.5203,5	0.4572,6	0.533	0.6764,5,6
7. Risk factor: Overweight/obesity	0.580	0.7161,2	0.3401,3,4,5	0.5963,6,7	0.5322,5,7,9	0.4678	0.7514,6,8,9
8. In general, a colonoscopy should be performed every 10 years starting at age:	0.644	0.5431	0.7142	0.6313	0.5832,4	0.600	0.7451,4
9, In general, a stool (poop) test (FIT or FOBT) should be done every year starting at age:	0.471	0.407	0.5531	0.4982	0.4241,2	0.387	0.485
10. Lynch Syndrome is a disorder that runs in families and increases my chances of developing colorectal cancer.	0.558	0.543	0.6411,2	0.5331	0.5322	0.667	0.593
11. The earlier that colorectal cancer is found, the greater my chances of survival.	0.937	0.938	0.961	0.931	0.9201	0.867	0.9671
12. Even if I have NO symptoms, I may still have colorectal cancer.	0.860	0.827	0.878	0.8421	0.8292	0.833	0.9341,2
13. Polyps are growths in the lining of the colon or rectum that can develop into colorectal cancer.	0.907	0.8151,2,3	0.9301,4	0.9242,5	0.8664,5,6	0.833	0.9573,6
14. A colonoscopy can be used to find polyps in the colon and rectum.	0.928	0.889	0.942	0.935	0.9011	0.900	0.9671
15. A diet high in red meats and processed meats (lunch meat, hot dogs) increases my chances of developing colorectal cancer.	0.837	0.790	0.882	0.829	0.818	0.733	0.869
16. It is ok to skip colorectal cancer screening if I do not have any symptoms.	0.807	0.8771	0.7632,3	0.8412,4,5	0.7161,5,6,7	0.9676	0.9313,4,7
17. My chances of developing colorectal cancer are higher if someone in my immediate family has it or has had it.	0.829	0.790	0.8571	0.8172	0.7881,3	0.800	0.9092,3
18. Increasing my physical activity will NOT lower my chances of developing colorectal cancer.	0.550	0.6671	0.3831,2,3,4	0.5512,5	0.5034,6	0.533	0.6993,5,6

^*Pair-wise comparisons among racial/ethnic groups were conducted for each item. Groups with the same numerical superscript are significantly different from each other, using a Bonferroni correction for multiple pairwise comparisons following a significant ANOVA.

Paired t-tests were conducted on the pre- and post-educational activity knowledge scores for each racial/ethnic group. As shown in Figure 1, all racial/ethnic groups demonstrated a significant change in knowledge following the educational activity. A one-way ANOVA was performed on the knowledge change scores to determine if there were racial/ethnic differences in the magnitude of change. A significant ANOVA was followed by Bonferroni pairwise comparisons to identify which racial/ethnic groups were significantly different from each other (Figure 1). HL demonstrated the greatest increase in knowledge (mean change = 3.4 items) regarding CRC following the educational activity. This change was significantly greater than Asians (mean change = 2.7 items, p<.01), AA (mean change = 2.7 items, p<.0001) and NHW (mean change = 2.2 items, p<.0001).

Figure 1. Mean Knowledge Scores, Pre- and Post-Educational Activity by Race/Ethnicity.

Figure 1 shows the change in knowledge from pre- to post-educational activity. N = 3,183.

Intentions.

Intentions to engage in healthful behaviors related to CRC were assessed immediately following the educational activity. These behaviors included talking to a healthcare provider about CRC screening, getting screened for CRC, talking to family members/friends about CRC, eating healthier, and increasing physical activity. Items were worded as “Because of the educational activity how likely are you to…” engage in each of the measured behaviors. Responses were measured on a 4-point Likert scale ranging from strongly agree to strongly disagree. One-way ANOVAs were performed on each of the five measured intentions and post hoc tests were performed following a significant ANOVA to assess racial/ethnic differences. These results are presented in Figure 2. Overall, NHW were least likely to report that they intended to adopt the assessed behaviors compared to all other racial/ethnic groups. Post hoc tests indicated that 1) Asians and HL were significantly more likely to talk to a health care provider (HCP) about CRC screening compared to NHW (p<.05 for both groups); 2) AA and HL were significantly more likely to talk about CRC with family/friends compared to NHW (p<.001 and p<.01, respectively); 3) Asians and AA were significantly more likely to eat healthier compared to NHW (p<.05 and p<.01, respectively); and 4) HL were significantly more likely to increase physical activity compared to NHW (p<.05). No other significant differences were obtained.

Figure 2. Reported Intentions to Engage in CRC-related Healthful Behaviors.

Figure 2 shows the percent of respondents who strongly agree, “Because of the CRC educational session, I am more likely to ….” Some respondents chose not to answer the intentions items.

Connections to Care (Phase II).

As noted above, nine S2S sites participated in this education and outreach initiative to assess follow-up with CRC screening. The demographic characteristics of the follow-up sample are provided in Table 3. It should be noted that a single site contributed just over a third of the follow-up sample, thus results are skewed towards the characteristics of that site. Compared to the baseline sample, the follow-up sample is more HL (60% vs 37%), less educated (34% vs 25% had less than a high school education), and more likely to indicate Spanish as their preferred language (44% vs 27%).

Table 3.

Demographic Characteristics of the 3-month Follow-up Sample (Age 50–74 years)

Characteristic	Percentage (N=441)
Gender: % Female	73.5%
Race/Ethnicity:
American Indian/Alaska Native	1.1%
Asian	7.5%
Black/African American	13.4%
Hispanic/Latino	60.1%
Native Hawaiian/Other Pacific Islander	0.0%
Non-Hispanic White	16.6%
Not reported	1.4%
Education:
8th grade or less	24.5%
Some H.S.	9.8%
H.S. diploma/GED	21.3%
Some college	18.8%
College graduate (4 yr.)	24.3%
Not reported	1.4%
Preferred Language:
English	44.2%
Spanish	44.2%
Chinese	7.5%
Other	0.0%
Not reported	1.4%

All participating sites reported existing partnerships with multiple health care providers including Federally Qualified Health Centers (FQHCs) and safety-net hospitals that provided care and services (e.g., processing FIT/FOBT results, conducting colonoscopies). Additionally, all the sites distributed FIT kits at the educational events. Three of the sites had a nurse navigator in attendance to facilitate a direct colonoscopy referral for persons at greater than average risk for CRC. If a positive result was obtained from the FIT/FOBT test, the health care facility that processed the kit referred the individual to no/low cost colonoscopy at a partner facility. Positive colonoscopies were referred to the CC or medical school of the participating site.

Three month follow-ups were conducted with 441 participants in the target age range of 50–74 years. These 441 participants were those that agreed to be contacted for follow-up and whom the CHEs at the 9 sites were able to re-contact after the 3-month follow-up period. Forty-five percent of this sample (n=200) had never been screened for CRC. Of those who had never been screened, 50% (n=99) obtained CRC screening during the 3-month follow-up period. In addition, 109 participants who were due for screening or were out of compliance with USPSTF²² CRC screening recommendations obtained CRC screening. Therefore, a total of 208 participants, or 47% of the follow-up sample, obtained CRC screening during the follow-up period. The majority of those who obtained screening during the 3-month follow-up period were screened by FIT/FOBT – 79% compared to 21% who obtained a colonoscopy. At the time of the follow-up, 82% (n=171) of this group had obtained the results of their screening test.

Discussion

S2S is an outreach and educational intervention, focused on colorectal cancer (CRC) education and screening, using a national sample of existing CC sites with a NON CHE. The current initiative is unique in that the data elements, data collection instruments and CRC-messaging provided in the toolkits to all sites were standardized and based on evidence-based literature. This standardization allowed for direct comparisons of the pre and post survey data and behavioral intentions both within and across individual racial and ethnic populations.

The common data elements and standard messaging allowed for pooling of data across sites, which then provided sufficient power for statistical analyses, including comparisons among racial/ethnic groups. The S2S initiative confirmed that culturally-tailored colorectal cancer education facilitated by CHEs is an effective way to increase CRC knowledge, screening awareness, and screening intentions in racial/ethnic and rural populations. Findings align with prior research indicating that culturally-tailored interventions and CHE implementation strategies improve information acceptability and influence positive health behavior uptake^{31, 32, 33, 20, 34, 35, 37, 37, 38}. Incentives for programs that address and support increased screening by leveraging community partnerships, streamlining data requirements, and utilizing culturally competent resources are essential for sustainability and the reduction of disparities.

S2S findings demonstrate a significant change in knowledge and behavioral intentions, following the educational activity participation, including the intent to speak with a health care provider and friends/family about screening and to adopt healthier eating and routine exercise (Figure 3). For the nine connections to care sites, dissemination of cancer-related information at educational events with FIT/FOBT kit distribution or referral for colonoscopy and associated follow-up care led to substantial increases in screening compliance and follow-up. Identifying partners that can provide clinical care for low to no-cost is essential for ensuring that those who engage in screening and receive an abnormal result can be treated. In many instances, the CHEs included providers from the CC in the outreach activities to promote increased levels of comfort and trust between the health care professionals and the community. There are, however, several limitations to consider when interpreting the findings observed. This was an intervention that involved convenience samples of persons who chose to attend the educational events provided by the CHEs; consequently, all persons attending these events received the education. Thus, it is not possible to say that the intervention was successful compared to no intervention or an alternative intervention. For the Phase II data, sample participants were those that agreed to be followed and then responded. Lastly, this effort did not include analysis of the cultural adaptions. This would be the next step to better understand specific elements of an intervention that motivate persons to obtain appropriate CRC screening.

The final sample included small numbers of AI/AN and NH/PI. According to the 2010 census, over three quarters of AI/AN populations live outside of tribal areas, with ten states having the largest number of AI/AN persons. The CHEs encountered challenges with obtaining tribal approval for data collection on reservations, trust lands and Oklahoma tribal statistical areas. In addition, identifying connections to care was another substantial challenge due to lack of provider access among other factors. For S2S, there was a single NON site in Hawaii and Guam. Therefore, the small number of AI/AN and NH/PI was partly a reflection of the location of NON sites and access to clinical care partners.

In view of these findings, an important area of future research should be the implementation of connections to care as a required component of outreach and education. Promising models could then be adapted and used for other preventable/screenable cancers irrespective of race or ethnicity. Our goal is to move beyond examination and the analysis of cancer health disparities to developing solutions that address them. Creating awareness of the challenges at each step along the continuum of cancer care helps providers consider how well they are serving patients in the context of the entire cancer experience. Unless patients can transit the continuum in a way that is patient-centric and respectful of their values and priorities, their care will be suboptimal and health outcomes will suffer.

S2S, with its harmonized messaging/instruments and national sample, confirms that this culturally-tailored community health education intervention can improve cancer knowledge and awareness of screening recommendations. Further, this work preliminarily sheds light on how the inclusion of a culturally-tailored intervention and the implementation strategy can improve information acceptability and influence implementation effects as seen in other community health education interventions^{31, 32, 33, 20, 34, 35, 36, 37,38}. In summary, this initiative provided compelling data to support the hypothesis that culturally-tailored, standardized educational messaging, data elements, and data collection tools are effective in educational outreach to advance colorectal cancer knowledge among racial/ethnic and rural populations.

KEY TAKEAWAYS.

• Standardized data collection instruments, toolkits, and data elements are essential

• Connections to care are a required component in conjunction with outreach and education efforts

• Culturally-tailored health communication strategies must be actionable