El Proyecto de Salud Colorectal, The Colorectal Health Project

In the United States, colorectal cancer is the second-leading cause of cancer-related deaths. Approximately 50,000 people die from colorectal cancer each year. Incidence rates are lower among Hispanics than non-Hispanic whites; however, in comparison with non-Hispanic whites, Hispanics are less likely to be diagnosed with localized colorectal cancer and more likely to be diagnosed with the disease in later stages.

Screening can detect colorectal cancer at an early stage when treatment is more likely to be successful. Further, the detection and removal of polyps can prevent colorectal cancer from developing. The U.S. Preventive Services Task Force recommends regular screening beginning at age 50 and continuing until age 75 using high-sensitivity fecal occult blood testing (FOBT), including fecal immunochemical testing (FIT), sigmoidoscopy, or colonoscopy. Interventions designed to promote colorectal cancer screening are needed to reduce the incidence of mortality among Hispanics residing in the United States.

El Proyecto de Salud Colorectal, The Colorectal Health Project, is an outreach intervention designed to increase colorectal cancer screening among Hispanic adults aged 50-79 who have not received recent colorectal screening (colonoscopy or sigmoidoscopy within the past 5 years or FOBT within the past 15 months). Implemented by community health care clinics, the intervention is delivered by community members known as promotores who are trained to educate their peers on colorectal cancer and screening for the disease.

After identifying eligible patients, the promotor sends each patient a mailing containing a letter, an FOBT card, an instruction card explaining how to complete the FOBT card, and a stamped and addressed envelope with which to return the completed FOBT card to the clinic. The letter encourages completion of the screening test and is signed by the clinic's medical director. The promotor contacts each patient by telephone within about 2 weeks of the mailing to confirm that he or she received the mailing and to encourage screening if the patient has not already completed it. Two weeks later, if the patient has not returned the card, the promotor makes a second telephone call to schedule a home visit. During this visit, the promotor uses visual aids (e.g., flipchart) to present information on colorectal health, cancer risks, and colorectal cancer screening and reviews the test instructions with the patient. Promotores are guided by the FOBT Training Handbook, which includes telephone scripts, guidance on scheduling and conducting home visits, and tracking forms to document program participation. Program materials (i.e., letter, instruction card, FOBT Training Handbook) are available in English and Spanish.

-- Half-day for the promotor training
-- 15-20 minutes per patient to review the chart, assemble and send mailing, and track results
-- 10 minutes for each telephone reminder
-- 2 hours per patient for home visit (including attempts)

The intervention is intended for Hispanic adults aged 50-79 who have not had a recent colorectal screening exam.

The intervention is designed to be implemented in community health care clinics.

Required resources to implement the program include the following:
-- FOBT Instruction Card (English)
-- FOBT Instruction Card (Spanish)
-- FOBT Training Handbook (English)
-- FOBT Training Handbook (Spanish)
-- Colorectal Display Flipchart (English, Spanish)
-- Letter Mailed To Households (English)
-- Letter Mailed To Households (Spanish)
-- FOBT

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

A randomized controlled trial evaluated the impact of a clinic-based intervention on colorectal cancer screening among patients of Hispanic ethnicity in South King County, Washington. Patients were recruited from 1 of 11 Sea Mar Community Health Centers in South Park selected because of its convenience. Paper medical records were used to extract baseline screening data on Hispanic patients aged 50-79 years who had a clinic visit at the South Park clinic from January 1, 2002, through May 31, 2006. Patients with a recent colorectal screening exam (a colonoscopy or sigmoidoscopy within the past 5 years or an FOBT within the past 15 months) were excluded from the study.

Patients were randomized to one of two intervention arms or usual care. Patients in the intervention arms received either El Proyecto de Salud Colorectal, consisting of mailing plus outreach (n=168), or just the mailing component of that intervention (n=168). Patients in the usual care group (n=165) did not receive any formal prompting to undergo colorectal cancer screening other than that provided during a physician visit. More than half the participants were aged 50-59 years, and 53% were female, with the age and gender breakdown being approximately the same across the three study groups. 

Promotores reached 115 of the 168 patients in the mailing plus outreach group by phone (16 had invalid addresses and therefore did not receive the mailing, and 37 had disconnected phones or wrong numbers). Of the 37 patients in this group who were eligible for a home visit (i.e., they were still living in the region and had not completed the FOBT), promotores completed 13 home visits. Visits were not made to the remaining patients primarily because promotores had the wrong addresses or patients refused or could not be reached.

The primary outcome was receipt of FOBT. Screening rates were assessed by a review of clinic medical records 9 months after the intervention. In addition, study participants completed a telephone interview assessing screening awareness, participation, knowledge, attitudes, and normative influences.

• At follow-up, compared with screening rates in the usual care group (2%), screening rates were higher in the mailing intervention group (26%; p<.001) and the mailing plus outreach intervention group (31%; p<.001). No significant differences in screening rates were found between the two intervention groups.