Background Colorectal cancer screening remains suboptimal among poor and underserved people. Purpose We tested the effectiveness of a community-to-clinic navigator intervention to guide multicultural, underinsured individuals into primary care clinics to complete colorectal cancer screening. Methods This two-phase behavioral intervention study was conducted in Phoenix, Arizona (2012–2018). Community sites were randomized to group education or group education plus tailored navigation to increase attendance at primary care clinics (Phase I). Individuals who completed a clinic appointment received the tailored navigation in person or via phone (Phase II). Results In Phase I (N = 345), 37.9% of the intervention group scheduled a clinic appointment versus 19.4% of the comparison group. In Phase II, 26.5% of the original intervention group were screened versus only 10.4% of the original comparison group. Those in the intervention group were 3.84 times more likely to be screened than were those in the comparison group (odds ratio = 3.84; 95% confidence interval = 1.81–6.92). Conclusions Translation of an efficacious tailored navigation intervention for colorectal cancer screening to a community-to-clinic context is associated with significantly increased rates of colorectal cancer screening. Navigation assistance to address barriers to screening may serve as the most important component of any educational program to increase individual adherence to colorectal cancer screening.
Purpose Although screening for colorectal cancer (CRC) lowers mortality and morbidity and is generally cost-effective, little is known about the cost-effectiveness of screening promotion. Design Cost-effectiveness analysis alongside a group-randomized trial. Setting: Multicultural, underinsured communities in the Phoenix, Arizona, area. Subjects English- or Spanish-speaking adults who were out of compliance for CRC screening guidelines. Intervention All participants received community-based group education (GE), and the intervention group also received tailored community-to-clinic navigation (GE+TN). Measures Number of participants screened and costs of tailored navigation, clinic visits, and CRC screening tests. Analysis Incremental cost per additional person screened from the perspective of the healthcare system with bootstrapped confidence intervals. Results Community sites were recruited and randomized to GE (n = 120) and GE + TN (n = 119). Across these sites 1154 individuals were screened, 504 were eligible, and 345 attended the group education class (n = 134 GE; n = 211 GE + TN). Screening rates (26.5% GE + TN; 10.4% GE; 16.1% increase 95% CI: 7%, 23%) and costs per participant ($271 GE + TN; $167 GE; a net cost increase of $104 95% CI: $1, $189) were significantly higher in the intervention group. Incremental cost-effectiveness was $646 (95% CI: -$68, $953) per additional person screened. Conclusion Depending on the value placed on an additional person screened, the addition of community-to-clinic tailored navigation to a community-based CRC screening promotion program may be highly cost-effective.
Background: Dissemination strategies to reach underserved and minority populations to promote screening for colorectal cancer (CRC) are key to reducing disparities. We conducted a study to examine a tailored messaging approach to navigate individuals from communities (i.e., lower income, less access to care, and underscreened) to clinics to receive CRC screening. We encountered several political, demographic, and secular trend issues that required reconsideration and redesign of implementation strategies.Objectives: Through study implementation from 2012 to 2017, changes in medical reimbursement and immigration policiesat the state level and later at the national level-affected healthcare delivery systems that had initially committed to supporting the study and our recruitment methods. Although our selected zip codes and sites had previously yielded high rates of CRC screening nonadherence, within a few years, these sites showed substantially higher screening adherence rates-yielding limited numbers of eligible participants. In addition, state immigration policy trends created mistrust and fear, leading to lower participation rates than anticipated. This report documents and provides valuable insights on how we and the community network developed creative strategies to overcome these challenges.Methods: New relationships with community partners were extended to tap advisory board input to meet the challenges. Criteria for clinic participation widened from originally selected Federally Qualified Health Centers (FQHCs) to various nonprofit, hybrid, and privately insured reimbursement types. Recruitment site options were creatively redefined to reach community participants where they live, work, and receive services.Results: Strategies that engage community members in identifying alternative healthcare delivery structures and that link recruitment efforts to community-based service organizations were found to be critical to recapturing community trust in the face of unfavorable political environments. Widening the type of clinic partners from FQHCs to stand-alone nonprofits and private clinics and identifying unusual types of recruitment sites provided alternative solutions for successful study implementation.Discussion: In prevention-based studies that face unplanned system and political barriers to recruitment, embedding the study in the community may aid in reestablishing trust levels to improve engagement and recruitment of clinic partners and eligible participants.
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