Healthy Colon, Healthy Life

Colorectal cancer (CRC) is the second leading cause of death from cancer in the United States. Among Latinos, CRC is the second leading cause of cancer death in men and the third leading cause of cancer death in women. CRC is also the third most common cancer in Vietnamese Americans in the United States. Regular CRC screening is recommended for all individuals beginning at age 50 and continuing through at least age 75. Although rates of CRC screening are increasing, they are still low and tend to be lower among ethnic minority groups, including Latinos and Vietnamese, than among non-Latino Whites. Development of interventions that efficiently reach these subgroups with effective screening promotion strategies represents an important public health challenge. 

Healthy Colon, Healthy Life is an intervention program to increase colorectal cancer screening among Latino and Vietnamese Americans aged 50-79 through the use of the fecal blood tests such as the fecal occult blood test (FOBT) or fecal immunochemical test (FIT). In the study reviewed for this summary, the intervention used FOBT, the preferred CRC screening option for low-income, medically underserved populations based on its availability and relatively low cost.

The intervention consists of a culturally tailored, informational brochure and customized fecal blood test kit sent to participants by mail, followed by telephone counseling 1-2 weeks later. The intervention targets patients seen in a primary care practice. Program support staff work with the practice staff to generate a list of potential participants from the practice's patient database, based on age criteria and the absence of contraindicating conditions (e.g., existing cancer diagnosis). Individual physicians at the practice review their patient lists to confirm that each patient is eligible for screening and to exclude patients deemed not appropriate for screening (e.g. dementia or end stage disease). Program support staff then call eligible participants and administer a baseline survey to determine whether individuals are due for CRC screening, what their adoption stage is (i.e., readiness to engage in screening), and any perceived barriers to screening.

Shortly after the baseline interview, participants receive an informational brochure and a fecal occult  blood test kit by mail. The bilingual, culturally tailored brochure addresses the need for CRC screening, a description of CRC screening tests, barriers, and commonly asked questions. Examples of barriers addressed included embarrassment, concern about the stool collection being dirty or messy, the need for testing if one feels healthy or eats a healthy diet, and concern about the cost of the test. The brochure also includes an English translation of the text and pictures of physicians and community members. Components that are tailored to each community include the size and color of the brochure, the types and placement of pictures, and the placement of the English translation.

The fecal occult blood test kit contains three cards for collecting stool, three wooden applicator sticks, a stamped return envelope, and a letter from the participant's primary care physician emphasizing the importance of CRC screening. Also included are simplified written instructions in English and either Spanish or Vietnamese for collecting the stool, and information on dietary restrictions prior to taking the test particular to Latino and Vietnamese culture.

Approximately 1-2 weeks after the brochure and kit are mailed, participants receive telephone counseling. Using an interview protocol and scripts tailored to each stage of change, bilingual Latino and Vietnamese community health advisors counsel participants on the benefits of screening and the individual's perceived barriers, based on the information collected from participants during the baseline interview.

The community health advisors receive a manual and more than 20 hours of training using didactic coursework, role plays, and practice counseling sessions. The training provides an overview of colon cancer and CRC screening, who needs to be screened, and what tests are used for screening. Other topics covered during training include Motivational Interviewing, stages of change based on the transtheoretical model (pre-contemplation, contemplation, action, maintenance or relapse), and guidelines to use when making counseling calls.

On average, the telephone counseling component of the intervention lasts about 17 minutes. Each participant receives one telephone counseling session unless additional calls are requested by the participant. Community health advisors receive more than 20 hours of training.

Healthy Colon, Healthy Life is designed for Latino and Vietnamese primary care patients aged 50-79 years with no history of cancer.

Primary care facilities that serve a relatively large number of Latino and/or Vietnamese patients can implement the program in collaboration with a community-based organization (e.g., Catholic Charities in the study reviewed). The delivery of telephone counseling by Spanish- or Vietnamese-speaking community health advisors at the community-based organization helps to enhance the credibility of the program among participants. The intervention also can be implemented in outpatient clinics and community clinics, working similarly with a community-based organization.

Required resources to implement the program include the following:
- Intervention Training Manual
- Appendix
- Slideshows in English, Spanish, and Vietnamese
- Baseline Survey
- Informational Brochure
- Fecal Blood Test Kit
- Telephone Counseling Script in English, Spanish, and Vietnamese
- OPTIONAL: Follow-Up Survey
- Lay community health advisors fluent in Spanish or Vietnamese
- FOBT

For costs associated with this program, click on Contact Program Developer on the Program Materials page.

Participants were 1,789 Latino (n=996) and Vietnamese (n=793) patients aged 50-79 receiving care from one of the primary care satellite sites of a county-operated medical center. Participants were 69.3% female.

Participants were stratified by gender and ethnicity and then randomized to receive (1) usual care, with physicians offering CRC screening to all patients aged 50 and older, during usual practice (2) mailed FOBT kit and culturally tailored brochure, or (3) mailed FOBT kit and culturally tailored brochure plus culturally tailored telephone counseling.

Participants completed a baseline survey prior to randomization, and a follow-up survey was administered between 9 and 12 months after baseline. Surveys were administered using computer-assisted telephone interviewing in Vietnamese, Spanish, or English, according to the participant's choice, by trained, bilingual telephone interviewers located in a community-based organization. Respondents were asked if they had ever completed a home stool blood test (FOBT), and if so, the recency of their latest FOBT. Participants were also asked if they had ever had a sigmoidoscopy or colonoscopy, and if so, the recency of that endoscopy.

• Rates of CRC screening using FOBT increased 25.1% from baseline to follow-up among participants who received the FOBT kit, brochure, and telephone counseling. In comparison, the increase in FOBT screening was 15.1% for those who received the FOBT kit and brochure without telephone counseling, and only 7.8% for the usual care group. The increases for both intervention groups were significantly greater than that in the usual care group (FOBT + brochure: p=.01; FOBT + brochure + telephone calls: p<.001). The increase in FOBT screening among those who received the FOBT kit, brochure, and telephone counseling was significantly greater than the increase among those who received only the FOBT kit and brochure (p<.001).
   
• Among Latino participants, the baseline-to-follow-up increase in FOBT screening for both intervention groups was significantly greater than that for the usual care group (FOBT + brochure: p<.001; FOBT + brochure + telephone calls: p<.001). There was no significant difference between the intervention groups.
   
• Among Vietnamese participants, those who received the FOBT kit, brochure, and telephone counseling had a larger baseline-to-follow-up increase in FOBT screening than those who received the FOBT kit and brochure only (p<.001) and those who received usual care (p=.006). There was no significant difference in FOBT screening between Vietnamese participants who received the FOBT kit and brochure without telephone counseling and those who received usual care.

• Rates of CRC screening by any method (FOBT within the past year, sigmoidoscopy within the past 5 years, or colonoscopy within the past 10 years) increased 21.4% from baseline to follow-up among those who received the FOBT kit, brochure, and telephone counseling. In comparison, the increase in any CRC screening was 11.9% for those who received the FOBT kit and brochure only, and only 4.1% for those who received usual care. The increases for the two intervention groups were both significantly greater than that for the usual care group (FOBT + brochure: p=.002; FOBT + brochure + telephone calls: p<.001). The increase in any CRC screening among those who received the FOBT kit, brochure, and telephone counseling was significantly greater than the increase among those who received the FOBT kit and brochure only (p<.001).
   
• Among Latino participants, the baseline-to-follow-up increase in any CRC screening for both intervention groups was significantly greater than that for the usual care group (FOBT + brochure: p<.001; FOBT + brochure + telephone calls: p<.001). The increase in any CRC screening among Latino participants who received the FOBT kit, brochure, and telephone counseling was significantly greater than the increase among those who received the FOBT kit and brochure only (p=.003).
   
• Among Vietnamese participants, the baseline-to-follow-up increase in any CRC screening was significantly greater for those receiving the FOBT kit, brochure, and telephone counseling than for those who received the FOBT kit and brochure only (p=.001). There were no other group differences in changes in any CRC screening.