Characterizing screening champions in the center for disease control and prevention’s Colorectal Cancer Control Program (CRCCP)

Abstract

Background

CDC’s Colorectal Cancer Control Program (CRCCP) aims to increase colorectal cancer (CRC) screening prevalence by implementing evidence-based interventions (EBIs) in health system clinics partnering with the program. Program champions, as one of the key program components, are expected to facilitate the implementation of EBIs and support desired changes in many ways. Given limited information about the champions in clinical systems, this study investigated champion types, roles, and sustainability within the CRCCP.

Methods

This mixed methods, cross-sectional study included a survey of 205 respondents (health system and clinic staff) representing 303 clinics and 12 qualitative interviews of CRCCP award recipients and partnering clinics. The survey assessed clinic characteristics, EBI implementation, information about program champions, and sustainability. Interview topics included champion roles, benefits, turnover, and maintenance.

Findings

Champions worked at either the health system or clinic level. Among health systems, champions were quality improvement (QI) managers (48.5%), physicians (36.4%), or high-level administrators (27.3%). In clinics, champions were physicians (37.0%), QI managers (26.1%) or medical assistants (23.9%). Champions in both health systems and clinics were most often assigned the role (45.5% and 45.7%, respectively); yet clinic champions were more likely to naturally emerge than health system champions (26.1% vs. 15.2%). Among naturally emerging champions, 64.3% experienced zero turnover, more than for assigned champions. While champions in both groups received training, more champions in health systems reported being trained than those in clinics (75.8% vs 52.2%). No significant differences in EBIs implemented were observed between those clinics with and without a champion. Zero champion turnover was associated with great or very great leadership support (68.9%), program adaptation (60.7%) and organizational capacity (54.1%). Interviews found that champions’ roles included advocating for CRC screening, providing technical assistance for EBI implementation, creating organizational policies for CRC screening, and overseeing QI. Interviewees reported a desire to address champion sustainability.

Conclusion

These findings inform the use of program champions for clinic-based public health programs. Naturally emerging champions were more stable than those assigned the role.

Supplementary information

The online version contains supplementary material available at 10.1186/s43058-025-00759-0.

Contributions to the literature.

• Research has demonstrated that program champions can assist in the implementation of evidence-based interventions; however, there is limited understanding of the types of champions, their roles, and turnover.

• These findings contribute to this gap by describing the types of program champions, their training and major roles in implementing evidence-based interventions for colorectal cancer screening.

• Common roles for champions were implementers, advocates, connectors, motivators, changemakers, data wranglers, educators, and sustainability resource.

Introduction

Among cancers affecting both men and women, colorectal cancer (CRC) is the second most diagnosed cancer as well as the second leading cause of cancer-related deaths in the United States​ [1]. In 2021, 141,902 new cases of CRC were reported, and in 2022, the latest year for which the mortality data are available, 52,967 persons died of the disease [2]. Screening for CRC is an effective way to reduce CRC related morbidity and mortality as screening can prevent CRC from occurring or detect early when treatment is more effective [3]. The U.S. Prevention Services Task Force (USPSTF) recommends screening for average risk adults ages 45–75 using stool tests, flexible sigmoidoscopy, colonoscopy, or CT colonography [4]. Even though CRC is preventable, and progress has been made to increase CRC screening prevalence, a significant gap remains between screening prevalence and the Healthy People 2030 target [5]. Additionally, disparities in CRC screening have been reported among individuals with low income and education levels, residing in certain counties, without regular source of care or health insurance, and with Medicaid coverage [6]​.

The Colorectal Cancer Control Program (CRCCP), funded by the Centers for Disease Control and Prevention (CDC), aims to increase CRC screening prevalence in primary care clinics by evidence-based interventions (EBIs) [7]. The CRCCP funds various entities, including state health departments, universities, tribal organizations, and other organizational types. Currently, CDC funds 35 such entities, known as award recipients, which partner with more than 500 primary care clinics providing them with technical assistance and resources to implement four priority EBIs: client reminders, provider reminders, provider assessment and feedback, and reducing structural barriers [8]. These EBIs are proven strategies to increase CRC screening as recommended in the Community Guide [9]. Evaluation studies of the CRCCP have found strong uptake of the EBIs, including the strong associations between the EBIs and clinic level CRC screening prevalence [10, 11].

A CRC screening champion is another key CRCCP component that is not an EBI but considered supportive of the program implementation [7]. Champions have been described in the literature as key individuals or implementation leaders who play the role of organizational innovators to drive the change to achieve desired outcomes [12, 13]. Champions in the context of CRC screening conduct a variety of activities: generating support, encouraging or motivating team members, providing expertise and facilitation, troubleshooting, and leading the efforts to promote, communicate, advocate for the change [14–18]. Champions are also important to successfully manage changes, adopt and integrate new practices, secure clinic resources and funding, and ensure long-term sustainability of interventions [15, 16, 18–20]. Previous CRCCP research has identified champions among the most significant drivers for increasing screening prevalence in partnering clinics [11, 21, 22]. However, despite being a key CRCCP element, there are limited data on who champions are, their roles in clinical settings, and the long-term sustainability of champions in health systems and clinics. The purpose of this paper is to examine the identity, roles, and sustainability of program champions in health systems and clinics implementing CRCCP. Findings from this study will inform efforts to optimize the use of program champions in promoting CRC screening in diverse clinical settings and offer insights that can be applied to increase recommended screenings for other cancer types.

Methods

We used a mixed methods approach of a convergent parallel design to conduct this study. This design has quantitative and qualitative data collection occurring simultaneously; data were analyzed separately and then we triangulated data on similar topics [23]. Our interviews were structured to explore in-depth the type of staff who were champions, their characteristics and their roles in increasing CRC screening, while the survey explored issues related to the champions’ identities, numbers, training and turnover. We analyzed data from an online survey of CRCCP partner clinics conducted in 2020 and qualitative interviews of a subset of CRCCP award recipients funded from 2015–2020 and 2020–2025.

Data collection

CRCCP Survey

University of Washington conducted a survey with clinic representatives, mostly administrators or quality improvement managers, of 303 partner clinics with 15 CRCCP award recipients. These clinics are nested within 107 health systems and were part of two CRCCP funding cycles (2015, 2020). The UW and UCLA investigators conducted a literature review to identify relevant existing measures of constructs related to seven domains to design the survey and received input from all authors. The survey was pilot tested by nine health professionals familiar with the CRCCP. The clinic respondents completed a one-time, web-based survey administered using Research Electronic Data Capture (REDCap). The survey was administered over a six-week period in November–December 2020. The purpose of the survey was to assess the implementation of EBIs in clinics partnering with the CRCCP, and it included questions about program champions, patient navigators, activities associated with EBIs implementation or enhancement, etc. Related to program champions, the survey asked if there is a current champion, location of the champion (health system-wide vs clinic) and numbers of champions in each clinic, the role of champions in their clinic, how the champion was selected (selected or assigned, emerged naturally and took the role, and don’t know), receipt of training for the champions and how many times have there been turnover among the champion(s). For items related to selection of champions, those categories were not defined for the respondent. Sustainability items inquired about leadership support, funding stability, organizational capacity and program adaptation. The survey was approved by the Office of Management and Budget (OMB, generic information collection titled “Assessment of Colorectal Cancer Control Program Implementation at Health System Clinic Sites” under OMB #0920–0879, exp. 01/31/2021) and deemed exempt by the University of Washington Institutional Review Board given its categorization as program evaluation.

Clinic data

We also used clinic level program evaluation data collected by CDC via the Clinic Data Form. The CRCCP survey data was linked to the clinical characteristics data (listed in the next sentence) to obtain relevant clinic information for a more robust analysis characterizing champions. Clinic data includes variables related to health system and clinic characteristics, EBI implementation, and CRC screening rates. For the analysis, we selected these survey domains: 1) clinic characteristics (e.g., urban–rural status, patient and provider characteristics, primary CRC test type either colonoscopy or immunochemical test (FIT)/fecal occult blood test (FOBT), varies, unknown), mailed fecal testing, CRC screening policy), 2) presence of a champion (i.e., champion for CRC screening internal to this clinic or parent health system) and 3) implementation of the 4 priority EBIs recommended by the program (e.g., “Patient reminder system/Provider reminder system/Provider assessment and feedback/Reducing structural barriers for CRC screening was in place at the clinic”). In the EBI domain, respondents also reported the number of EBIs the clinics were implementing as well as the intensity of each EBI (e.g., number of times a patient reminder was sent).

Interviews with CRCCP programs and clinics

We conducted 12 interviews; 9 with CRCCP award recipients and 3 with partner health system clinic representatives. These interviews were conducted in two phases: 1) the nine CDC award recipients and 2) three clinic representatives with which recipients had contracts to implement the CRCCP. The first phase offered general information about how recipients viewed the role of champions in their program across partnering health systems or clinics. In the clinic interviews, the staff reported on the use of champions at their specific location(s). The interviews were conducted from 2020 to 2022. We purposely sampled CRCCP award recipients based on the following criteria: screening prevalence, EBI implementation, and type of clinic (standalone or health system). This selection involved awards recipients that had moderate to high screening prevalence, and a range of EBIs that they implemented and a variety of types of clinics. Prior to the interviews, we held informational interviews with the CDC program consultant of the respective program to gather background information about each program. In the next step, we conducted a 1-h interview of the CRCCP award recipients represented by the program director or lead staff covering the topics of interest. In those interviews, we used an interview guide which covered many domains including conduct of the readiness assessment, a systematic evaluation of primary care clinics' ability to implement new and enhance existing EBIs to increase cancer screening. The other domains of the interview guide also included current EBIs implemented, impact of the COVID-19 pandemic on program implementation, quality improvement (QI) activities, and receipt of training and technical assistance. Related to program champions, we asked questions to explore whether there were persons defined as champions, who they were, the role of the champion(s), and how they support the program. We also made inquiries regarding the benefits of the champions, roles of champions to support sustainability of the CRC EBIs, and safeguards to address challenges of losing champions. After the interviews, each respondent was asked to recommend partner clinics to participate in 1-h long clinic interviews. At the start of each interview, the interviewer provided an overview of the study, their role, how findings would be used, and obtained verbal consent from the respondent to conduct and record the interview.

Data analysis

Quantitative data were downloaded from RedCAP and analyzed using SAS software, version 9.4 [24]. We compared summary statistics for champions fulfilling their roles across an entire health system versus within a single clinic, considering their numbers, roles, modality of selection, and recipient of training. Similarly, we also explored the presence of champions with respect to clinic type, location (urban/rural), proportion of uninsured patients, number of patients and providers, primary test type, implementation of mailed fecal testing, and having a CRC screening policy. We also explored, through cross-tabulations, champion turnover by selection method and factors related to sustainability of practice improvement for those clinics with Fisher’s exact tests. Finally, we combined the responses “small extent” with “moderate extent” and the responses “great extent” with “very great extent” for the factors related to sustainability. P-values ≤ 0.05 was used to determine statistical significance where such tests are used and reported.

To analyze qualitative data, all interviews were recorded and transcribed verbatim by a professional transcription service. Data were de-identified and audio and transcript files were stored securely with password protection. We employed rigorous qualitative data analyses methods including verbatim transcription, iterative codebook development, use of multiple coders, and consensus checking [25]. We developed the codebook from the first three interview transcripts and subsequent transcripts employed the codebook with minor changes. Data were analyzed using deductive coding (e.g., guided questions around roles, benefits, etc.) and thematic analysis with constant comparison [26]. This included (1) reviewing and coding the transcripts, (2) comparing different responses to identify recurring themes, (3) coding more interviews and (4) refining or adding new themes. Two coders used a finalized codebook to code all transcripts using Nvivo version 12.0 software [26, 27]. Coders met to discuss inconsistent codes and reached consensus. Nvivo was used to extract themes and representative quotes. For the convergent parallel design, we summarized the data by data collection method (i.e. quantitative or qualitative, respectively); data summaries related to role of the champion and sustainability of champions were created. We described where the data converged and where the interviews expanded our understanding of program champions in the delivery of CRC screening [23, 28].

Results

Quantitative findings

There were 205 respondents to the survey. Our study sample had a total of 119 champions (range: 1–11 per health system) across 33 health systems and 68 champions across 46 clinics (range: 1–4 per clinic) (Table 1). Among health systems, a higher proportion of champions were quality improvement managers/specialists (48.5%), physicians (36.4%), and administrators (27.3%). Among individual clinics, a higher proportion of champions were physicians (37.0%), quality improvement managers/specialists (26.1%) or medical assistants (23.9%). Similarly, a higher proportion of champions in health systems and clinics were selected or assigned (45.5% and 45.7%, respectively) than emerged naturally (15.2% and 26.1%). Champions in both groups received training, but those in health systems received training in higher proportions vs. those in clinics (75.8% vs 52.2%). Champion training was delivered by each clinical site/system and was not standardized. Champions in clinics showed less zero turnover vs those in health systems (43.5% vs 36.4%).

Table 1.

Programs Champions in the Colorectal Cancer Control Program

	Health system wide (health systems = 33)		Specific to clinic (clinics = 46)
Variable	n	%	n	%
Presence of Champion
Number	119a		68b
Range	1–11		1–4
Champion’s role
QI specialist/manager	16	48.5	12	26.1
Physician	12	36.4	17	37.0
Administrator (e.g., CEO, Director)	9	27.3	8	17.4
Patient navigator/Community Health Worker (CHW)	8	24.2	9	19.6
Nurse or nurse practitioner	8	24.2	6	13.0
Medical Assistant	8	24.2	11	23.9
Nurse manager	8	24.2	1	2.2
Administrative staff	6	18.2	3	6.5
Referral specialist	1	3.0	0	0.0
Physician Assistant	0	0.0	1	2.2
Other	2	6.1	4	8.7
Champion selection
Selected or assigned/Emerged naturally c	11	33.3	7	15.2
Selected or assigned	15	45.5	21	45.7
Emerged naturally	5	15.2	12	26.1
Don’t know	2	6.1	6	13.0
Received training and/or technical assistance
Yes	25	75.8	24	52.2
No	3	9.1	8	17.4
Don’t know/missing	5	15.2	14	30.4
Turnover of champion(s)
Never	12	36.4	20	43.5
Once	9	27.3	10	21.7
2–3 times	8	24.2	6	13.0
More than 3 times	1	3.0	3	6.5
Don’t know	3	9.1	7	15.2

^a Excluded two health systems due to missing data. ^b Excluded one clinic due to missing data

^c The category of Selected or Assigned/Emerged Naturally was based on survey response in which both options ‘Selected Assigned’ and ‘Emerged Naturally’ were selected by the survey respondents. They could choose more than one response, so percentages sum to more than 100

Abbreviations: CEO chief executive officer, CHW community health workers

We also compared the presence of program champions by clinic characteristics, with a chi-square test for the significance of their differences. Overall, there were 196 clinics of which 155 had a champion in place (Table 2). The results showed significant differences in the distribution of champions based on clinic type (p = 0.01). Specifically, a higher proportion of Community Health Centers/Federally Qualified Health Centers had champions in place (83.2%) compared to those without champions (65.9%). No significant differences were found in the presence of champions based on the percentage of uninsured patients (p = 0.10), the number of providers in the clinic (p = 0.18) or implementation status of mailed fecal testing (p = 0.20). Notably, among clinics with number of providers < 5 a smaller proportion (46.4% vs. 61.0%) had champions, again without statistical significance. Similarly, clinics with a champion in place were similar to those without champions in terms of their primary test type (p = 0.46), urban–rural status (p = 0.69), number of patients (p = 0.80), and the presence of a CRC screening policy (p = 0.80).

Table 2.

Presence of Program Champion by Clinic Characteristics (n = 196)

	Champion(s) in place (n = 155)		Champion(s) not in place (n = 41)		p for χ2 test*
Characteristics	n	%	n	%
Clinic type					0.01
CHC/FQHC (n = 156)	129	83.2	27	65.9
HS/Hospital owned (n = 20)	15	9.7	5	12.2
Other (n = 20)	11	7.1	9	21.9
% patients uninsured					0.10
< 5% (n = 57)	41	26.5	16	39.0
5–20% (n = 69)	58	37.4	11	26.8
> 20% (n = 41)	36	23.2	5	12.2
Unknown (n = 29)	20	12.9	9	22.0
Number of providers					0.18
< 5 (n = 97)	72	46.4	25	61.0
5–9 (n = 40)	34	21.9	6	14.6
≥ 10 (n = 54)	46	29.7	8	19.5
Missing (n = 5)	3	1.9	2	4.9
Implementing mailed fecal testing					0.20
Yes (n = 105)	78	50.3	27	65.8
No (n = 79)	65	42.0	14	34.2
Unknown (n = 12)	12	7.7	0	0.0
Primary test type					0.46
Colonoscopy (n = 61)	52	33.6	9	21.9
FIT/FOBT kits (n = 111)	86	55.5	25	61.0
Varies by provider (n = 18)	14	9.0	4	9.8
Unknown (n = 6)	3	1.9	3	7.3
Urban–rural status					0.69
Metro (n = 156)	125	80.6	31	75.6
Urban (n = 26)	20	12.9	6	14.6
Rural (n = 6)	4	2.6	2	4.9
Unknown (n = 8)	6	3.9	2	4.9
Number of patients					0.80
≤ 700 (n = 66)	52	33.5	14	34.2
> 700–1,700 (n = 66)	51	32.9	15	36.6
> 1,700 (n = 61)	50	32.3	11	26.8
Missing (n = 3)	2	1.3	1	2.4
CRC screening policy					0.80
Yes (n = 173)	136	87.7	37	90.2
No (n = 21)	17	11.0	4	9.8
Unknown (n = 2)	2	1.3	0	0.0

 * Clinics with “Unknown” or “Missing” status were excluded in χ² tests

Abbreviations: CRCCP colorectal cancer control program, CHC community health center, FQHC federally qualified health center, HS health system, FIT fecal immunochemical test, FOBT fecal occult blood test

Table 3 shows the comparison of EBI implementation by clinics by their screening champion status. We did not detect statistically significant differences in the implementation of any single EBI or the number of EBIs in clinics with champion status. However, we would like to note that when a screening champion was in place, higher proportions of clinics implemented provider assessment and feedback (80.0% vs 73.2%, p = 0.34) and reducing structural barriers (87.1% vs 78.0%, p = 0.15). The proportions of clinics implementing provider reminders, patient reminders, and number of EBIs by champion status were not notably different.

Table 3.

Impact of champions on EBI implementation (n = 196)

	Champion(s) in place (n = 155)		Champion(s) not in place (n = 41)
EBI implementation	n	%	n	%	p for χ2 test
Provider reminders					0.67
Yes (n = 163)	128	82.6	35	85.4
No (n = 33)	27	17.4	6	14.6
Patient reminders					0.81
Yes (n = 160)	126	81.3	34	82.9
No (n = 36)	29	18.7	7	17.1
Provider assessment and feedback					0.34
Yes (n = 154)	124	80.0	30	73.2
No (n = 42)	31	20.0	11	26.8
Reducing structural barriers					0.15
Yes (n = 167)	135	87.1	32	78.0
No (n = 29)	20	12.9	9	22.0
Number of EBIs					0.89
0 (n = 2)	1	0.7	1	2.4
1 (n = 13)	10	6.5	3	7.3
2 (n = 32)	25	16.1	7	17.1
3 (n = 29)	23	14.8	6	14.6
4 (n = 120)	96	61.9	24	58.5

^* Clinics with “Unknown” or “Missing” status were excluded in χ² tests

Abbreviations: EBIs evidence-based interventions

We also explored the method of champion selection and turnover (Table 4). Champions who were in the category of ‘emerged naturally’ had the highest percentage of zero turnover (64.3%) versus those who were fell into the mixed category of ‘selected/assigned or emerged naturally’ (54.8%), and the category of ‘selected/assigned’ (29.9%). Related to factors that support CRCCP sustainability, zero champion turnover was associated with ‘great or very great’ leadership support (68.9%), program adaptation (60.7%) and organizational capacity (54.1%). Program adaptation and funding stability were associated significantly with different levels of champion turnover.

Table 4.

Relationship between Champion Selection and Turnover and Turnover and Sustainability of CRC screening practice improvements (n = 155)

	Champion selection, n (%)
Turnover times	Selected or assigned/Emerged naturally* (n = 31)			Selected or assigned (n = 87)		Emerged naturally (n = 28)		Don’t know (n = 9)
0 (n = 61)	17 (54.8)			26 (29.9)		18 (64.3)
1 (n = 36)	3 (9.7)			25 (28.7)		6 (21.4)		2 (22.2)
≥ 2 (n = 46)	7 (22.6)			33 (37.9)		4 (14.3)		2 (22.2)
Unknown (n = 12)	4 (12.9)			3 (3.4)				5 (55.5)
Fisher’s exact test#								P < 0.01
Sustainability of Screening practices		Turnover times, n (%)
		0 (n = 61)	1 (n = 36)		≥ 2 (n = 46)		Unknown (n = 12)
Leadership support
Not at all (n = 0)
Small/Moderate (n = 53)		16 (26.2)	14 (38.9)		19 (41.3)		4 (33.3)
Great/Very great (n = 92)		42 (68.9)	17 (47.2)		26 (56.5)		7 (58.3)
Missing (n = 10)		3 (4.9)	5 (13.9)		1 (2.2)		1(8.3)
Fisher’s exact test#							P = 0.16
Funding stability
Not at all (n = 10)		9 (14.8)			1 (2.2)
Small/Moderate (n = 80)		25 (41.0)	19 (52.8)		29 (63.0)		7 (58.3)
Great/Very great (n = 55)		24 (39.3)	12 (33.3)		15 (32.6)		4(33.3)
Missing (n = 10)		3 (4.9)	5 (13.9)		1 (2.2)		1 (8.3)
Fisher’s exact test#							P = 0.02
Organizational capacity
Not at all (n = 1)		1 (1.6)
Small/Moderate (n = 70)		23 (37.7)	15 (41.7)		28 (60.9)		4 (33.3)
Great/Very great (n = 73)		33 (54.1)	16 (44.4)		17 (37.0)		7 (58.3)
Missing (n = 11)		4 (6.6)	5 (13.9)		1 (2.1)		1 (8.4)
Fisher’s exact test#							P = 0.13
Program adaptation
Not at all (n = 0)
Small/Moderate (n = 77)		21 (34.4)	15 (41.7)		36 (78.3)		5 (41.7)
Great/Very great (n = 68)		37 (60.7)	16 (44.4)		9 (19.6)		6 (50.0)
Missing (n = 10)		3 (4.9)	5 (13.9)		1 (2.1)		1 (8.3)
Fisher’s exact test#							P < 0.01

^* The category of Selected or Assigned/Emerged Naturally was based on survey response in which both options ‘Selected Assigned’ and ‘Emerged Naturally’ were selected by the survey respondents

^# Clinics with “Unknown” or “Missing” status were excluded for Fisher’s exact tests

Qualitative findings

All 12 health system clinics interviewed affirmed that each of their clinics had a champion. Among the nine award recipients interviewed, three specifically required their clinics to have a champion, one recipient encouraged but did not require having a champion, and the remaining five award recipients were not specific about whether champions were required or only encouraged. Champions were embedded in individual clinics or supported multiple clinics within a health system. The health systems interviewed were initially asked that there be a clinic champion at each clinic site, however this was relaxed during the COVID-19 pandemic due to staffing levels and retention issues, resulting in a staff serving as champions for multiple clinics or system-wide.

Champion titles

The identities of champions encompassed numerous working titles which tended to vary from one clinic to another. Triangulation of our data showed this was an area of data convergence. Interviewees provided 2–4 titles used to identify the role of champions within a specific site. In total, 17 different titles were reported, including physician, nurse practitioner, quality improvement specialist, navigator, medical director, project coordinator, care coordinator, and roundtable representative, among others. We grouped these titles into five broad categories: health care/medical providers, quality improvement staff, non-administrative clinic staff, system or clinic-level leaders, and community partner representatives (Supplemental Material 1 Table). Health care/medical provider titles were the most frequently named category (named by seven out of nine interviewees), followed by quality improvement staff (named by four out of nine interviewees).

Champion characteristics

Champions both naturally emerged or were selected/assigned by others to serve in the role. Champions with leadership-level working titles (e.g., medical directors, physicians, committee chairs) were most often reported to have been self-selected, i.e., they volunteered to serve as screening champions in their clinics. Champions generally served at the clinic-level, although one interviewee reported that some of their clinic champions also functioned as the cancer screening champions at their state level. Interviewees provided additional description about champion characteristics: being passionate about CRC screening in the populations they serve; being knowledgeable about screening clinic practices, quality improvement practices, and electronic medical record (EMRs); willing to share their knowledge and resources; having demonstrated ability to follow-through, being able to get things done quickly; and possessing leadership qualities including being able to “push for change if there needs to be a change.”

Champion role

The notion of screening champion and its importance was reflected in both the depth and breadth of their responsibilities, as described by the interviewees. We identified 8 distinct roles summarizing the scope of activities that champions performed to support their clinic’s CRC screening efforts (Table 5). These roles, commonly identified in the literature, also emerged in our interviews. As the overall program implementer, champions provided input on how to better integrate EBIs into clinic workflows as well as oversaw program implementation. In some settings, they were also responsible for implementing EBIs such as assessing providers’ screening rates and providing feedback on how the provider could improve their rates. Interviewees also consistently described how their champions served as advocates for their CRC screening program, clinic staff, and patients. This included facilitating and securing provider buy-in to participate in the program and related activities, ensuring that clinic staff and patients received appropriate education about CRC screening, and playing a critical role in establishing/having a CRC screening policy in place and improving adherence to it by administrative, front office, and clinic staff. As changemakers, the impact of champions could be observed in lowered colonoscopy fees resulting from the discussions that champions initiated with partnering GI clinics as well as the increase in number of clients the clinics served. To keep screening momentum steady, champions were often viewed as key motivators inside and outside the clinic – they motivated clients inside the clinic by making the screening topic “fun” and accessible, and outside the clinic they motivated partners by messaging the importance of screening and conducting the community outreach to identify key individuals who could serve as screening champions in their communities. As educators, champions reached audiences inside and outside the clinic. Within the clinic, champions delivered training to staff about CRC screening and related tools (e.g., data dashboards). They created public-facing educational materials such as newsletter articles for audiences outside the clinic.

Table 5.

Champion Roles and Activities

Role and Selected Champion Activities	Exemplar quote
1. Program Implementer • Oversee CRC program implementation • Inform how EBIs are integrated into the workflow – see quote • Implement EBIs, i.e. Assess providers’ CRC screening rates and provide them with feedback	“…after we implement the EBI, [the champion will] take a look at their workflow again to see if they’re engaged in the workflow, if they’re actually doing it. If it’s easier for them, if there are any issues, if they want to change anything, do a follow up on that and change any, little things or create order sets or a template to make it easier for them.” – Site 1
2. Advocate • Facilitate staff-buy in – see quote • Ensure clinic staff and patients have the CRC screening education they need • Advocate for CRC screenings/activities during clinic team meetings • Advocate for the program among physicians • Advocate for a CRC screening policy (not just a protocol)	“[Our champions] are like the very first front-line people for the project. They meet with us first. Then they actually have to get buy in from their providers. Having providers buy-in is crucial to the project. Having [the champions] explain how everything’s going to work to their providers and getting their provider’s buy in is awesome too."– Site 1
3. Changemaker • Negotiate a lower colonoscopy price with hospitals to better serve the underinsured – see quote 1 • Strategically identify and engage others who will strengthen program efforts – see quote 2 • Create a CRC screening policy if one does not exist	“…one of the challenges that we tell our clinics is we’re going to give you this amount of money, which is the Medicare rate to do a positive FIT after colonoscopy for uninsured people. You don’t have an unlimited number of colonoscopies, but if you can negotiate a lower price with your hospitals to – you could get more colonoscopies done. And [our program champion] went and talked to the hospital, and they went from about $2,300 down to $950 for a full colonoscopy for an uninsured patient. So they just like tripled – almost tripled – the amount of colonoscopies that they can do.”- Site 2 “Our champion is passionate. They’re coming up with creative ideas and pushing the EBIs… further than we thought. Like for example, the champion brought on a resident who was also very passionate about colorectal cancer and now he’s doing a cancer screening app. I mean, we never thought about that."—Site 3
4. Motivator • Keep CRC screening at the fore as a clinic priority • Make CRC screening discussions “fun” for patients while underscoring its importance – see quote 1 • Identify and recruit champions outside the clinic – see quote 2	“[Our champion] is so excited about [CRC screening]. Just his push and his passion about making sure that the patients are getting what they need and making it fun – because [with] colon stuff …– people are like “ew” about that but he kind of does an extra push with… bringing it to the patient’s level so they know the importance of it. Which of course makes them more engaged to do it because they’re like “Oh I know Dr. [name]. He’s going to fuss at me if I don’t do it,”…” – Site 4 “[Our champion] is just absolutely great. She sought out champions in the community…. [from the hospital] management-side because they were able to use additional funds [to cover some colonoscopy screening costs].” – Site 2
5. Educator • Create public-facing educational materials – See quote • Deliver education to clinic staff, including peer-to-peer – Same quote as above	“Literally everything that we've asked him to do – from presenting to providers, writing an article in the [State] Medical Association Newsletter – that one was specifically about the USPTF change—literally everything we've asked him to do, he's stepped up and done for us.”- Site 5
6. Convener and Connector • Connector: Convey program-level information directly to leadership and clinic staff, and relay leadership and clinic staff input to program – see quote 1 • Facilitate connection and communication between leadership and external screening providers – see quote 2 • Convener: Coordinate, facilitate and/or participate on regular calls, e.g. monthly system-wide meetings, clinic-specific meetings, state CRC roundtables	“the champion is our main point of contact. I think having them as a voice to the clinical staff and the leadership, we may not always meet with leadership or some of the clinical staff in all of our meetings, but that champion [is] either relaying things to leadership or bringing back input from clinical staff on ways that they have changed their processes, or hope to.” – Site 6 “[Our] tribal communities are not using Cologuard at all. And [our champion] was very interested in that. She engaged her medical director… to come to a meeting with the Cologuard reps for [State] and work out some of the logistic issues that we have with that. [It] is a very rural reservation. It's huge, covers a lot of land, and there are not UPS drop boxes… So you know… how are we going to work around that? …how would this work for a payment from IHS? And you know, work around that… [There are] lots of those logistic issues and [our champion] was just a real leader for that as well.” – Site 7
7. Data Wrangler: Data Collector, Facilitator, and Communicator • Conduct assessments; • Assess workflows; • Retrieve data from EMRs or other sources; • Share data with staff – see quote	"we've struggled to get their data but the data that [our champion] is collecting… she does share back to the providers. And she is probably doing the most in terms of provider assessment and feedback, pointing out – she's not afraid to point – that one provider is doing extremely well, and another isn't doing as well. And how can we learn from each other to improve. She really prods them to communicate well with the patients for whom they've distribution stool tests and really working hard to get those back.” – Site 7
8. Sustainability Support • Record presentation tutorials for asynchronous learning and future reference – See quote	“[Our champion] did a presentation that we recorded for EPIC users, [where] she shared her strategies for using the EPIC slicer-dicer tool. …This has been very well received by the other clinics.” – Site 7

Abbreviations: CRC colorectal cancer, EBI evidence-based intervention, FIT fecal occult blood test, EMR electronic medical record

Champions were often the cog in their screening program’s wheel to keep momentum moving forward in operational ways. As convener and connector, champions were responsible for conveying program-level information to leadership, clinic, and administrative staff, and facilitating discussions about screening activities between these groups. Champions functioned as a data wrangler to ensure access to, collection, understanding, and use of data by leadership and clinic staff. Specific activities included conducting targeted assessments, retrieving data from the EMR, and sharing findings. Champions also were viewed as a sustainability resource as activities such as trainings and presentations would be documented and recorded for future reference and learning by the clinic staff.

Challenges with the Champion Role

While champions were generally highly regarded and valued among interview respondents, interviewees identified meaningful challenges in relation to identifying, training, and sustaining the role of champion (Table 6). Challenges included limited training, poor fit, staff turnover, and funding stability. Few interviewees provided training specifically for champions to perform their role – in most cases, training focused primarily on orienting champions to the CRCCP cooperative agreement. Poor fit was observed among interviewees who experienced limited engagement with the named champion or when the performance of champions did not meet expectations. Staff turnover in the champion role was cited as not only a challenge but also as something that was commonly feared by both clinics and award recipients due to a lack of funding stability. Staff turnover was particularly problematic if the champion possessed extensive program knowledge and was highly involved in program implementation. Unless a champion was fully funded to focus on CRC screening, they additionally had competing priorities driven by other funding sources thereby reducing focus on CRC screening activities. Conversely, if a champion was fully funded by a single CRC-focused funding source then the sustainability of their role was limited to the fixed duration of that funding source, unless continued or alternative funding was secured. To mitigate these challenges and facilitate sustainability of champions, interviewees offered two suggestions: giving champions the resources they need to do and maintain their jobs, or integrating champion responsibilities into quality improvement team responsibilities, thereby aligning champion activities with quality improvement objectives.

Table 6.

Challenges with the Champion Role

Challenge	Exemplar quote
Limited training	“Where we have not been able to include them [in trainings], or they've chosen not to participate in everything, that's been a little more difficult.” – Site 7
Staff turnover	“We have experienced turnover. And a lot of times, sometimes, if that clinic champion holds a lot of the program knowledge and has done a lot of the grant requirements, the transition to the new person can be tough, because sometimes the knowledge was taken with the champion that left, of where they were and what their processes that they were implementing were, where they were in the phase of those.” – Site 6
Poor fit/limited engagement	". the clinic contact has been identifying who [the champion] is and has been inviting them to accept that role. But in some cases we haven't necessarily been able to communicate with the champion or connect with them through the TA calls… There's definitely a couple [champions] where we have questioned whether or not this is the right person for the job, and [the clinic contact] confirmed that it is… But we haven't necessarily seen them do the tasks that we kind of thought maybe that they would pick up on naturally.” – Site 7
Funding stability	“We’re always hesitant to fund like 100% in a staff position, because we are not sure how they would be able to sustain it after funding goes.” – Site 3

Discussion

Screening champions are a key component of CRCCP and identified as important drivers of the increase in CRC screening rate in the program. But despite the significance of a screening champion, there is a limited understanding about who the champions are. This study intended to fill an important gap by providing in-depth information on champions in a national cancer screening program. We found that, in CRCCP clinics, screening champions used numerous working titles that were chiefly determined by their primary roles. The most common titles used to identify CRC screening champions were quality improvement managers/specialist, physicians/medical providers, and administrators. This is important because these are often managerial or clinic leadership roles who can facilitate organizational change and improve readiness to implement the EBIs in clinics. For example, QI managers can lead efforts in relevant and high-quality data collection to inform program activities and outcomes. They can also facilitate changes to clinical infrastructure to institutionalize EBIs (e.g., provision of medical record alerts or client reminders). Similarly, physician screening champions can have a leading role promoting EBI implementation within their clinics. Champions serving these roles have been found to be particularly beneficial in previous literature related to CRC screening interventions [19, 20, 28]. In selecting champions, public health programs, therefore, may benefit if staff roles are well integrated into clinical practice who can promote change, and make necessary organizational adaptations to achieve desired outcomes. Furthermore, we found that clinics with more uninsured patients and smaller healthcare teams were less likely to have champions. Therefore, the use of shared champions by these clinics could be explored to address possible resource constraints.

Our mixed methods data collection allowed for convergence in several areas. Data from the survey were consistent with the interview findings and further supported that physicians and quality improvement staff were the most common types of champions. In terms of selecting champions, several interviews described what is meant by the survey item “assigning champions”—clarifying that CRCCP clinic contacts typically identified who the champions were and invited them to assume those roles. In addition, both the interviewees and survey respondents reported that there was low turnover of CRCCP champions. From the interviews, we identified strategies to sustain champions, including providing ongoing training, necessary resources, and aligning their roles clearly with the quality improvement plan.

We explored the characteristics of CRC screening champions within the CRCCP and found that they were passionate and knowledgeable leaders. This confirms previous research that champions exhibited leadership skills and motivated others, possessed unwavering enthusiasm and commitment to a project's goals, and acted as advocates and catalysts of change [29, 30]. In addition, a recent mixed methods study of administrator or clinical program champions reported that champions were motivators for innovation adoption by being enthusiastic, intrinsically motivated, persistent, and an effective communicator [31]. Furthermore, their colleagues described them as approachable, empathetic, curious, and often soliciting feedback from others [31]. These findings are consistent with a recent systematic review of champions for cancer prevention and control, which reported that champions possessed qualities of influence, intrinsic motivation, and dedication [32]. In addition, our champions served in many roles in the clinics including educator, implementer, convenor, data coordinator/wrangler, and advocate, to name a few. These diverse roles are important to making CRC screening a priority in their clinic, making organizational changes such as data reviews and conduct of quality improvement initiatives that result in program success.

We found that the implementation of the EBIs did not show statistically significant differences in clinics with and without champions despite some differences noted in descriptive analysis in the case of two EBIs: provider assessment and feedback and reducing structural barriers. This might be partially attributed to the small sample size and other limitations inherent in the quantitative data. The clinics partnering with CRCCP have a high rate of adoption of EBIs as well as the presence of CRC screening champion, with 41 of 196 clinics lacking a champion. This limited our ability to detect significant differences in EBI implementation across clinics with and without champions. However, previous research by CDC has found that having champions was associated with increases in CRC screening in CRCCP programs [11, 21]. Additionally, other studies have found that program champions have been associated with successful adoption [16] and implementation of other CRC screening programs [19, 20], and increase in cancer screenings [33, 34]. The existing literature suggests that champions improve the overall quality of program implementation; however, this study did not show a positive association. This association also may be difficult to identify since screening champions are one of several implementation strategies that are bundled together—and often integrated—within CRCCP partner clinics and health system(s). A recent review of program champions in community-based cancer interventions found that these interventions have employed champion complimented by other activities such as educating, planning for implementation, use of audit and feedback as part of quality management, and securing finances [32]. But what it is about champions that increases the effectiveness of interventions to increase CRC screening remains unclear and clearly beyond the scope of the current study. Several studies focused on community cancer interventions have found that champions can be impactful in creating a support climate for change [35, 36], keeping the initiative a priority [33, 35], and reducing barriers to implementation [33, 37]. Further research could evaluate the linkages between champion and various aspects of program implementation (such as quality and integration of EBIs) to identify the mechanisms by which champions contribute to program effectiveness [38].

Related to sustainability of champions, about 40% of health systems and clinics did not witness any recent champion turnover, and turnover was greater in clinics which selected or assigned champions. This implies that programs trying to improve the role of champions could consider creating an environment or having a process in place that encourages potential champions to self-emerge versus selecting them from the start. A review of champions in cancer-related interventions found that most are appointed to their role and that the process of identifying emergent champions needs further investigation [32]. One important point is that this study did not try to identify informal champions, but there is research exploring formal versus informal champions. Furthermore, there is a need to further research in this area; Luz and colleagues in a study of nurse champions found that informal champions led novel projects usually through bottoms-up approaches, had seniority, and reported more enthusiasm and confidence in the projects that they led [39]. Less turnover in champions observed in this study was also essential to continue key program activities that could lead to sustained CRCCP implementation. Gupta et al. found that screening champions contributed to the maintenance of a mailed FIT program [18]. More qualitative research in this area could explore how champion turnover can be minimized and how the role of champions can be leveraged to improve program sustainability.

Strengths of this study include the use of mixed methods to characterize the role of champions and inclusion of data from clinical settings across the country. We also noted several limitations. The data are from award recipients and clinics from the CRCCP and may not be representative of all CRCCP recipients or primary care clinics. In addition, participating recipients’ partner clinics exhibited higher screening prevalence and more EBI implementation than the majority of CRCCP recipients and therefore likely had higher capacity than non-participating clinics. Therefore, they may have higher motivation or organizational readiness for implementation compared to other recipients. The information on champions was self-reported. Respondents in the interview provided varying depth of information on program champions in their context because this was a part of a larger study, and interviews were also conducted on various other domains. Finally, the sample size for the interviews was small although the quantitative data was a robust augmentation.

Conclusion

This study provided comprehensive quantitative and qualitative insights into the implementation, identity, roles, turnover, and challenges associated with champions in a national screening program. We found that program champions associated with the CRCCP award recipients varied quite substantially in terms of their titles and primary roles. Notably, staff turnover among champions was lower, particularly when these champions emerged naturally. Successful adoption and scaling of CRC interventions requires a process in place to naturally identify and promote the right types of champions, with training and strategies to reduce their turnover. Given the existing knowledge gap about the effective utilization of champions, further research in this area could greatly enhance the effectiveness of public health intervention programs.

Abbreviations

CRCCP

Colorectal cancer control program

CDC

Centers for Disease Control and Prevention

CHC

Community health center

CRC

Colorectal cancer

EBI

Evidence-based intervention

EMR

Electronic medical record

FQHC

Federally qualified health center

FIT

Fecal immunochemical test

FOBT

Fecal occult blood test

HS

Health system

QI

Quality improvement

QA

Quality assurance

Authors’ contributions

CE: Conceptualization, formal analysis, investigation, methodology, validation, writing original draft, review and editing. JS: Data collection, investigation, methodology, software, validation, review and editing. KS: Conceptualization, formal analysis, investigation, methodology, validation, writing original draft, review and editing. AG: Conceptualization, investigation, methodology, project administration, supervision, validation, writing original draft, review and editing. MM: Data curation, investigation, methodology, software, validation, visualization, review and editing. TV: Conceptualization, investigation, supervision, validation, review and editing. DS: Conceptualization, investigation, supervision, validation, review and editing. PH: Conceptualization, investigation, supervision, validation, review and editing.

Funding

This work was supported by a contract from the National Association of Chronic Disease Directors to the University of Washington. Additional support was provided by CDC through the Cancer Prevention and Control Research Network, a network within the CDC’s Prevention Research Centers program (Emory University, U48DP006377; University of California, Los Angeles, U48DP001934; University of Washington, U48DP001911 and U48DP006398). The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Centers for Disease Control and Prevention Foundation.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval 

The data came from a combination of sources.

Consent to participate

Survey data were reviewed by the University of Washington IRB.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.