Abstract

Purpose and Objectives

Colorectal cancer (CRC) is the second-leading cause of cancer death in the United States. Although effective CRC screening tests exist, CRC screening is underused. Use of evidence-based interventions (EBIs) to increase CRC screening could save many lives. The Colorectal Cancer Control Program (CRCCP) of the Centers for Disease Control and Prevention (CDC) provides a unique opportunity to study EBI adoption, implementation, and maintenance. We assessed 1) the number of grantees implementing 5 EBIs during 2011 through 2015, 2) grantees’ perceived ease of implementing each EBI, and 3) grantees’ reasons for stopping EBI implementation.

Intervention Approach

CDC funded 25 states and 4 tribal entities to participate in the CRCCP. Grantees used CRCCP funds to 1) provide CRC screening to individuals who were uninsured and low-income, and 2) promote CRC screening at the population level. One component of the CRC screening promotion effort was implementing 1 or more of 5 EBIs to increase CRC screening rates.

Evaluation Methods

We surveyed CRCCP grantees about EBI implementation with an online survey in 2011, 2012, 2013, and 2015. We conducted descriptive analyses of closed-ended items and coded open-text responses for themes related to barriers and facilitators to EBI implementation.

Results

Most grantees implemented small media (≥25) or client reminders (≥21) or both all program years. Although few grantees reported implementation of EBIs such as reducing structural barriers (n = 14) and provider reminders (n = 9) in 2011, implementation of these EBIs increased over time. Implementation of provider assessment and feedback increased over time, but was reported by the fewest grantees (n = 17) in 2015. Reasons for discontinuing EBIs included funding ending, competing priorities, or limited staff capacity.

Implications for Public Health

CRCCP grantees implemented EBIs across all years studied, yet implementation varied by EBI and did not get easier with time. Our findings can inform long-term planning for EBIs with state and tribal public health institutions and their partners.

Introduction

Colorectal cancer (CRC) is the second-leading cause of cancer death in the United States ^[1]. The US Preventive Services Task Force (USPSTF) recommends CRC screening for average risk adults, aged 50 to 75 years, using either stool-based tests (ie, fecal occult blood test [FOBT], fecal immunochemical test [FIT], or multitargeted stool DNA test [FIT-DNA]) or tests that directly visualize the colon (ie, colonoscopy, sigmoidoscopy, or computed tomographic colonography) ^[2]. However, CRC screening is underused; estimates of screening rates in the United States range from 63% (National Health Interview Survey, 2015) to 68% (Behavioral Risk Factor Surveillance System, 2016) ^{[3, 4]}. CRC screening rates are substantially lower for populations without health insurance, populations without a medical home, and Asian and Pacific Islander and Hispanic populations ^{[3, 5, 6]}. Increasing CRC screening rates to 80% has the potential to prevent 277,000 CRC cases and 203,000 CRC deaths by 2030 ^[3], partly because CRC screening has the potential not only to detect cancer early but also to prevent it through the identification and removal of precancerous polyps. Many organizations support the “80% in Every Community” initiative, which established the goal of 80% of the total population of adults aged 50 to 75 years being up to date for CRC screening.

The Colorectal Cancer Control Program (CRCCP) is a CDC initiative to increase CRC screening among adults aged 50 to 75. The program’s grantees — most often state health departments and tribal health agencies — are funded (in part) to promote CRC screening by using 5 evidence-based interventions (EBIs). We focus on the first cycle of the CRCCP from 2009 through 2015, which funded 29 grantees. The evaluation activities we describe were conducted from 2011 through 2015.

Purpose and Objectives

The CRCCP provides a unique opportunity to study EBI adoption, implementation, and maintenance over several years in a stable group of grantee organizations and in the context of a national program. Few studies examine EBI implementation among the same organizations longitudinally over the course of 5 years or more ^{[8, 9]}. We studied grantees’ early experiences with adopting and implementing EBIs and compared their experiences with National Breast and Cervical Cancer Early Detection Program (NBCCEDP) grantees that did not receive CRCCP funding and were not explicitly directed to use EBIs ^[10–13]. Grantees and nongrantees were equally likely to implement practices that are not recommended by the Guide to Community Preventive Services (Community Guide), but grantees were more likely to implement EBIs ^[13]. This finding showed that CDC’s encouragement and financial support to the grantees to use these EBIs was effective, because all grantees were using at least 1 or 2 EBIs by the end of the second program year. The intended contribution of this study is to determine whether grantees maintained the EBIs they implemented over time and why (or why not). We assessed 1) how many grantees implemented each EBI from 2009 through 2015; 2) grantees’ perceived ease of implementing each EBI; 3) the maintenance of specific EBIs from year to year; and 4) qualitative data describing why grantees stopped using EBIs as well as facilitators and barriers to implementing EBIs.

Intervention Approach

CDC’s Division of Cancer Prevention and Control initially funded the CRCCP in 2009. The overall goal of CRCCP was to increase CRC screening rates to 80% in funded states and tribal areas by the end of the funding cycle, with a long-term objective of reducing CRC incidence and mortality. In 2009, a total of 22 states and 4 tribal entities were awarded CRCCP funds; an additional 3 states received CRCCP funds in 2010. All grantees’ awards lasted through June 2015 ^[7].

Grantees used CRCCP funds for 2 program components. First, grantees provided CRC screening services to low-income and uninsured people in their region. Second, grantees promoted CRC screening at the population level. Grantees were strongly encouraged to use 1 or more of 5 EBIs from the Community Guide to promote CRC screening (grantees were free to choose any combination of the EBIs to implement and could change their choices over time). The Community Guide conducts systematic reviews of evidence to identify effective strategies to increase cancer screening and other health desirable behaviors ^[14]. Three of the EBIs are classified as “client-oriented,” meaning they focus on the person needing screening; these EBIs are small media (such as brochures, postcards, or posters), client reminders, and reducing structural barriers. Two of the EBIs are classified as “provider-oriented,” meaning they increase the likelihood that providers will recommend screening; these EBIs are provider reminders and provider assessment and feedback ^{[15, 16]}. In addition, CDC encouraged grantees to use patient navigation; the NIH state-of-the-science conference statement on enhancing the use and quality of CRC screening recommends patient navigation as an evidence-based strategy for CRC screening ^[17].

The EBIs listed above vary in terms of complexity and partnerships required. The client-oriented EBIs could be implemented directly by grantees or by their clinical or community partners. The provider-oriented EBIs may be more complex from the perspective of a typical grantee organization because they require 1 or more clinic or health system partners. In addition, implementing provider reminders or provider assessment and feedback may require working with or adapting electronic health records. Given the grantees’ organizational context (state and tribal departments of health), the provider-oriented EBIs may be more challenging to implement than the client-oriented EBIs.

A key assumption underlying the CRCCP is that if grantees implement EBIs, CRC screening rates will increase. The evaluation described below focused on whether grantees implemented and maintained EBIs over the funding cycle (measured with quantitative survey items) and barriers and facilitators to implementing and maintaining EBIs (measured with open-text survey responses).