PICOT Paper

Implementation of Community-Based Education to Promote CRC Knowledge

Introduction

According to the estimates provided by WHO, in the year 2017, adults diagnosed with Colorectal Cancer (CRC) were 130,000; those who died were 50,000 (Briant et al., 2018). Among other cancers affecting adults, CRC 3rd most common in the US and the 2nd most commonly diagnosed among Hispanic adults. According to Brenner et al. (2016), the US has witnessed a gradual decline in the incidences and mortalities of CRC since the 1980s, and this is attributed to the removal of rectal polyps, increased screening rates, and behavior modification, which address potential risk factors. However, this decline is not evident in all US adults.

Existing research suggests that Hispanics are at a higher risk of CRC-related mortality and morbidity due to lower education levels, high rates of poverty, being uninsured, and not being able to access healthcare services (Jackson et al., 2016). These disparities are evident in the rates of CRC and screening rates. To address this issue, research suggests that health education programs to improve screening and create awareness are the most effective approach for prevention and improved health outcomes. This paper examines the background information and significance of CRC screening and CRC knowledge among Hispanics. Using the PICO process, a PICO question is formulated to facilitate clinical inquiry to improve knowledge on CRC and screening rates among Hispanics.

Background

In the United States, CRC affects close to 5% of the general population. For instance, in the year 2016, there were up to 135,000 new cases (Briant et al., 2018). Besides, it is notably the primary cause of mortalities among Hispanics in the US, where every three Hispanic women and men are diagnosed in the life course. Among deaths secondary to cancers, it is the 2nd and the third that causes mortalities among adults of Hispanic origin (Barzi et al., 2017).  Hispanics make up 85% of the population where our facility is located and have high mortality and incidence rates compared to whites, who comprise 13% of the population.

Screening for CRC is vital for early detection and diagnosis since it also increases the survival rates. Although Hispanics are less likely to undergo screening for CRC, it is necessary to identify reasons that lead to very low screening rates in this population. According to a 2017 report by the ACS (American Cancer Society), mortality is reducing at a slower rate among Hispanics in comparison to Blacks and Whites (Barzi et al., 2017). Diagnosis in the late stages and lower screening rates are significant contributors to disparities in mortality.

According to the USPSTF, other ethnicities strictly observe the screening recommendations for CRC. In comparison to Asians, Whites, and African Americans, CRC screening rates increased the least among Hispanics. For instance, between the years 2005 and 2013, among adults aged 50-75 years old, the screening rates for whites increased from 41-60%, blacks 35-58%, and Asians 27-50%. However, for Hispanics, the rates only increased from 27-41% (Jackson et al., 2016). Besides, there are also disparities in screening between urban and rural dwellers, with Hispanics having the least prevalence of CRC screening at 28%. Among African Americans and Whites, the screening prevalence was 35% and 39%, respectively. These rates are lower when compared to population s residing in urban regions whose screening prevalence were: Whites (45%), Blacks (42%), and Hispanics (30%).

In our healthcare facility, CRC is the most prevalent diagnosed cancer that causes morbidity and mortality among Hispanics, and the majority are diagnosed in the late stages. However, diagnosis in the advanced stages hinders the effectiveness of treatment. The facility has also witnessed high mortality rates among Hispanics living in rural areas. As supported by Ladabaum et al. (2015), this indicates an inability to access PCP and follow-up for abnormal findings. It is inarguable that for Hispanic’s rural dwellers, the hurdles for rural dwelling and being an ethnic minority worsens the situation.

CRC is treatable and preventable. However, in the advanced form, its prognosis is very poor. Therefore, early diagnosis and detection increase treatment success and survival outcomes. Underutilization of screening plays a significant role in staging and diagnosis of CRC, where the unscreened are at a higher risk of diagnosis in the advanced stages (Martinsen et al., 2016). Similar to the inequity rates of CRC, disparities in the rates of CRC screening and adherence to screening guidelines contribute to high incidences of CRC among Hispanics. This has been attributed to geography, ethnicity, and socioeconomic status. As supported by Shokar et al. (2015), there are more barriers for rural-dwelling Hispanics, such as long-distance traveling in search of care, inability to access PCPs and specialists, uninsured people. Those with a lower income and lower education levels will rarely follow the screening guidelines for CRC.

Significance

Present guidelines for 2020 Healthy People on adult percentage for individuals aged 50-75 years reveals that people who received screening for CRC is 70%. The national survey data indicates that the US is currently at 62 % ( Briant et al., 2018). However, when this data is systematically analyzed by ethnicity/race, the disparities become so evident. Hispanic adult men and women (48.5%) rarely go for CRC screening in comparison to whites (63%) and Black  Americans (60.5%). The rates are much lower among Spanish-speaking Hispanics (30.5%) and uninsured Hispanics (11%) (Bryant et al., 2018). Similarly, based on our facility’s statistics, there exist disparities in the incidence and mortality rates of CRC among ethnic and racial minority groups. CRC-related mortality and morbidity are even worse among ethnic and racial minority groups living in rural areas, more so Hispanics. 

CRC is a significant cause of mortality among Hispanics in the US. It accounts for 22% of deaths among Hispanics who suffer a high burden of cancer compared to other ethnic minority groups. Research shows that a diagnosis of CRC among Hispanics has implications for patients, families, and the nation. According to the National Cancer Institute, the approximate direct medical and mortality costs and indirect morbidity costs of cancer in 2016 were more than $260 billion, and CRC constitutes more than 10% of this burden (Wittich et al., 2019). As more Hispanics get diagnosed in late stages and require more expensive treatment, it is expected that these costs will continue to increase. Evidence also suggests that the patient costs of treating CRC in a lifetime exceed $4,500. Today, apart from direct medical costs, these costs include travel and out-of-pocket expenses and time.  

Other costs for Hispanic CRC patients and their families are emotional costs. Families and patients are at high risk of suffering from depression, anger, or anxiety. The complex nature of both conditions results in a very poor prognosis. Combining the financial and emotional costs reduces income for most patients already with a poor social-economic status. This has wide-ranging consequences, including an inability to meet financial commitments, reducing general spending in a household, and reduced income.

PICO Question

PICO is an evidence-based model for clinical inquiry. The PICO framework is used to frame and answer a clinical question and develop strategies to search for literature. The acronym stands for P-population/problem, I-chosen intervention, C-comparison, O-expected outcome. In this context, the PICO discusses as follows:

Population

Among adult Hispanics, CRC is the 2nd most frequently diagnosed cancer. Among Hispanic women, it is the 3rd major cause of death and 2nd among men of Hispanic origin. Hispanics are at high risk of a CRC diagnosis in the late stages, and this has a poor prognosis. The high mortality and incidence rates are attributed to their poor socioeconomic status, low education levels, lack of access to healthcare services, specialists, and PCPs.

Intervention

Increasing knowledge, awareness, and screening of CRC are opportunities that improve population health outcomes. As suggested by Bryant et al., (2018), this can be done through social engagement where individuals are advised to take part in CRC screening by friends and family to inspire CRC behaviors among Hispanic rural or urban dwellers. Previous interventions proved effective in increasing screening for CRC among Hispanics. Nevertheless, since the majority of the interventions were affected in PC settings, the majority of the underserved Hispanics who lacked access to care and those who were uninsured miss out. In this context, education will be implemented in a community setting. Community educators will educate and inspire individuals from the Hispanic population to go for screening using culturally appropriate education materials.

Comparison

The comparison is not providing community-based education

Outcome

Hispanics are less likely to undergo screening and seek care when CRC is in the late stages. The intended outcome is to increase the rates of CRC screening, and knowledge on CRC, which will ultimately improve survival rates and impact health disparities.

PICO Question

In the Hispanic community (P), what is the effect of the implementation of Community-based education (I) to promote CRC knowledge and screening rates (O) compared to no intervention (C)?

Population	Hispanic community
Intervention	Community-based intervention
Comparison	No community-based intervention
Outcome	Promote CRC knowledge and screening rates

REVIEW OF THE LITERATURE

According to WHO, approximately 130,000 adults were diagnosed with CRC in 2017 in the US. Of this population, 50,000 died (Briant et al., 2018). Although there has been a gradual decline in the mortalities, morbidities, and incidences of CRC since the 1980s in the US, this decline is not significant across all US adult populations. According to Barzi et al., (2017), significant disparities persist among Hispanics and these disparities are not only observed in the rates of CRC but also the screening rates such that screening is underutilized especially among communities with low educational attainment, low income, and limited English proficiency.

Current studies reveal that Hispanics are at the highest risk of CRC-associated morbidities and mortalities, due to high poverty rates, limited access to healthcare services and illiteracy (Martinsen et al., 2016). To address this health disparity, current evidence emphasizes that the most effective prevention approach that also improves health outcomes in community health programs to create awareness and improve the screening rates. Therefore, the purpose of this paper is to search for literature that supports community-based education on CRC to promote knowledge on CRC and screening rates using a well-designed PICOT question It also includes a description of the methods for searching the literature, findings of the literature review and the limitations.

LITERATURE SEARCH METHODS

Sampling Strategy

I conducted an initial comprehensive search for literature in some scientific electronic databases. To start with, in the Cochrane database, I use the keywords CRC education, CRC knowledge, CRC screening, and Hispanics. For a more refined search outcome, I used the Boolean search operators ‘or’ and ‘and’. This search resulted in four articles. One article was withdrawn and another excluded since they focused on screening Hispanic community members for CRC. I conducted another search in the PubMed database using the following keywords: CRC education, CRC knowledge, CRC screening, and Hispanics. I activated the following filters: RCTs and systematic reviews published within the past 5 years in English. This search yielded 26 articles. A further search using ‘or’ and ‘and’ search operators, the articles reduced to eight.

The reference lists of the articles obtained were searched for relevant articles. I used a similar search strategy to obtain more articles from PubMed’s weekly search updates.  The search focused on studies with both non-experimental and experimental designs with increased CRC screening rates and low incidences as the primary outcome measures. The search also incorporated systematic reviews that were associated with early CRC screening through community-based education. All the articles obtained were later assessed based on their relevance to the PICOT question.

Inclusion/Exclusion Criteria

The overall search incorporated peer-reviewed articles published in English. The articles had either non-experimental designs or experimental designs including RCTs and systematic reviews. The search was specific to articles whose primary intervention was to provide community-based education on CRC with improved knowledge on CRC and increased CRC screening rates as the primary outcome measures. Thus, the search excluded all articles published in other languages other than English, articles published beyond the past 5 years and those that discussed other interventions other than educating communities on CRC resulting in seven articles. The number of articles that met the criteria for inclusion out of the 29 were 8. The final articles based on the following subjects: community-based education, Hispanics colorectal cancer knowledge colorectal cancer awareness, colorectal cancer screening.

LITERATURE REVIEW FINDINGS

General Findings

Colorectal Cancer Screening

Early screening for CRC is essential for early detection and increased survival. Hispanics underutilize screening and this contributes to late-stage diagnosis hence mortality disparities. Based on the recommendations given by the USPSTF, adults aged 50-75 years old should undergo mandatory CRC screening for using fecal Occult blood tests, colonoscopy and sigmoidoscopy (Shokar, 2015). Hispanics are less likely to undergo screening thus present with late-stage CRC due to limited health literacy.

Health literacy needs among Hispanics is due to the lack of understanding that screening significantly decreases mortality rates. In other instances, most individuals prefer not to know a diagnosis of CRC, a pointer towards the need for more enhanced communication strategies to to discuss the essence of CRC screening among Hispanics such as using culturally tailored salient and relevant messages integrated into multi-component interventions (Wittich et al., 2019). The media is an influential tool to advocate for CRC screening as it influences Hispanics’ decision to undergo screening.

Treatment of Colorectal Cancer By Stage

The management of local, regional or distant colorectal cancer depends on the appropriate use of combined therapies. The management of local colon cancer involves surgical resection while that of regional colorectal cancer is adjuvant radiation and chemotherapy. For distant colorectal cancer, specialists use chemotherapy and only a fraction of patients undergoes extensive surgeries (Barzi et al., 2017). The gradual development of surgical techniques used in CRC has generally resulted in better outcomes. Most Hispanics are uninsured and cannot access specialist’s, factors that contribute to a stagnant mortality rate. Besides, the management of colorectal cancer depends on the surgery and the administration of radiation therapy. Therefore, the poor outcomes of colorectal cancer among Hispanics are due to limited access to care (Barzi et al., 2017). 

It is also right to conclude that, Hispanics experience delays in receiving adjuvant chemotherapy and this leads to reduced benefits from chemotherapy especially in patients with regional colorectal cancer. The combination of surgical resection of colorectal cancer, chemotherapy and using target agents has contributed to an overall decline in mortalities including mortalities from the distant form of colorectal cancer (Barzi et al., 2017). The FDA has approved the use of numerous new agents for the standard management of CRC. For instance, it has approved the use of Bevacizumab, an anti-angiogenic agent that has a strong action in CRC when combined with chemotherapy. While the costs of this drug might prevent Hispanics from accessing it, they are also less likely to benefit from Bevacizumab due to specific factors in their genetics, which cannot account the drugs mode of action (Barzi et al., 2017).  

Potential Barriers to CRC Screening

Most Hispanics reside in rural settings and have issues related to transportation and accessibility to healthcare providers which contribute to difficulties to obtain screening for CRC and reduce CRC-related mortalities. For instance, patients whose colonoscopy is performed by a gastroenterologist have a lower risk of dying in comparison to those with colonoscopies done by primary care surgeons and physicians (Wittich et al., 2019). Another barrier is that of a lack of health insurance due to low income. In the Hispanic population, a low-income status is problematic since, to undergo screening for CRC, there are directly associated costs of screening and wages lost in time offs to undergo screening (Wittich et al., 2019). For Hispanics residing in a rural area, there are additional transportation costs to distant facilities that provide screening services in the urban setting.

Chosen Intervention- Community-Based Education to Promote Colorectal Cancer Knowledge and Screening Rates

The findings of the article by Briant et al., (2018) notes that the combination of community-based education with no-cost screening leads to a significant improvement in the awareness screening for colorectal cancer. This educational intervention strategy also promotes social engagement and knowledge that promotes positive screening behaviors among rural Hispanic populations. Briant et al., (2018) further contend that this educational program is particularly important because it will solve the healthcare disparity that has excluded adults residing in rural settings from early screening for colorectal cancer. By eliminating these persistent disparities in screening adults for colorectal cancer, the adults in the rural areas will be at the same level as their urban counterparts, thereby promoting the effective diagnosis of an advanced colorectal cancer stage diagnosis.

According to the findings of the study by Cruz-Correa et al. (2016), screening for colorectal cancer awareness can only be enhanced by improving access to accurate colorectal cancer awareness. This awareness must, however, be created through a culturally appropriate education method that disseminates knowledge aimed at eliminating the barriers to adherence to CRC screening in minority ethnic groups living in rural areas. The study revealed that mean scores associated with the awareness for CRC knowledge and screening were comparatively before with a significant crease after intervention implementation an during follow-up revealing a significant effect. Cruz-Correa et al. (2016) further noted significant improvements in colorectal cancer screening following the use of Community-based education in form of TTT (Train-The-Trainer) workshops. The utilization of Community-based education among participants scaled beyond the projections of Healthy People 2020 on screening goals for colorectal cancer. Besides, the TTT programs influenced positive outcomes in CRC screening and knowledge.

Brenner et al. (2016) noted that implementing community-based education programs before CRC  screening improved understanding and knowledge which is essential before the screening of patients for both low-risk and high-risk colorectal cancer. Education can be done by promotors with adequate knowledge and does not have to be in any clinical setting. This approach is a gateway to improving the overall knowledge and awareness of screening patients for colorectal cancer. Education opens up the opportunity to discuss alternative screening strategies such as colonoscopy.

Brenner et al. (2016) further note that healthcare disparities that cause a barrier to access to colorectal cancer awareness and screening persist among the Hispanic citizens who speak Spanish despite the reduction in the financial barriers related to colorectal cancer screening. To eliminate these persistent barriers, Brenner et al. (2016) propose the significance of using a hybrid CRC screening and awareness strategy that combines culturally sensitive educational interventions and no-cost screening. This hybrid strategy should target the underserved population in rural areas because they are the most affected by a lack of access to primary care that causes healthcare disparity.

The study by Brenner et al. (2016) reported FOBT screening effects higher than the scores reported by previous studies, which utilized the HHP-only in assessing the efficacy screening for CRC and knowledge. In particular, when compared to the control group, participants in the intervention group had greater knowledge of CRC and opted for screening.  

DISCUSSION

The literature review findings illustrate that educating Hispanics on CRC improves their knowledge and awareness of CRC, which ultimately improves the screening rates. Among those already diagnosed with CRC,   education promotes emotional and social support from close friends and family and promotes consistency and adherence to management. The findings also demonstrated several approaches to educating communities on CRC and the expectations following a diagnosis. There is also adequate information on the pharmacological and non-pharmacological management of CRC.

Limitations

A major limitation of this literature review is that most of its articles used a convenience sample and this limits the generalizability of the findings to the wider Hispanic population. Besides, some studies included English-speaking participants and this limits the ability to generalize the outcomes to Hispanics in the rural settings who do not speak English. Besides, some of the studies used self-reported CRC screening reports and measures rather than through corroboration by medical records. Although this potentially increases the likelihood of bias, evidence suggests that CRC self-screening reports are a valid and reliable source.

Conclusion of Findings

This study sought to establish if community-based education on CRC among Hispanics increases CRC knowledge, awareness and CRC screening rates. A significant finding was that CRC is a health disparity among Hispanics. The studies supported educating Hispanics as an effective strategy to increase CRC knowledge, CRC awareness, and CRC screening. The findings demonstrated that integrating education programs at community level alongside ‘no-cost’ screening for underserved populations resulted in screening rates higher than the 70.5% goal of Healthy People 2020.

These findings can be used to inform future research exploring community-based education on CRC among other minority populations in rural settings experiencing the same burden of cancer and obstacles for disparities in screening for CRC. Further studies can examine the effectiveness of community-based educators’ experiences with screening for CRC since it has a significant influence on their performance. Future studies should also establish the most effective strategies of addressing barriers related to screening and follow-up.

Potential Practice Change

The available information sources on this subject matter support the education of Hispanics on CRC. If individuals and families do not receive the relevant information on CRC, most cases can go either undiagnosed, undetected or diagnosed when cancer has already advanced which results in poor health outcomes. Lack of CRC knowledge dos not only affect an individual but also families and an entire community. The lack of knowledge to distinguish between CRC and other colorectal conditions especially hemorrhoids. Educating medically underserved communities is not only a nursing role. Alternatively, healthcare leaders should incorporate social workers in healthcare systems to educate Hispanic populations on CRC. This research recommends fecal occult blood test (FOBT), colonoscopy and sigmoidoscopy screening tests for the early detection of CRC.

Conclusion

Colorectal cancer is undeniably an issue of public health significance in the US among Hispanics. The rates of screening are generally increasing apart from rural dwelling Hispanics who show a different trend. Potential barriers for the existing disparities in the incidence and mortality rates and screening among Hispanics are poverty, lack of access to specialists and Primary Care Providers, uninsured, lack of access to health facilities, among others. Research supports community-based education to advance Hispanics’ knowledge on CRC, awareness, and screening. This intervention promotes healthy seeking behavior and improves survival rates.

Doctor of Nursing Practice roles also play a vital role in implementing, facilitating, and leading educational efforts to promote a healthy lifestyle and advocate for cancer prevention, specifically relating to colorectal cancer. Thus, it is crucial to educate our communities in increasing colorectal cancer knowledge and screening rates.

References

Barzi, A., Yang, D., Mostofizadeh, S., & Lenz, H. J. (2017). Trends in CRC mortality in Hispanics: a SEER analysis. Oncotarget, 8(65), 108771.

Brenner, A. T., Hoffman, R., McWilliams, A., Pignone, M. P., Rhyne, R. L., Tapp, H., & Reuland, D. S. (2016). CRC screening in vulnerable patients: promoting informed and shared decisions. American journal of preventive medicine, 51(4), 454-462.

Bryant, K. J., Sanchez, J. I., Ibarra, G., Escareño, M., Gonzalez, N. E., Gonzalez, V. J., & Thompson, B. (2018). Using a culturally tailored intervention to increase CRC knowledge and screening among Hispanics in a rural community.

Cruz-Correa, M., Cordero, F., Betancourt, J. P., Diaz-Algorri, Y., Lopez, S. M., Rivera, M., & Rodriguez-Quilichini, S. (2016). Implementation and outcomes of a community-based educational program for CRC prevention in Hispanics. Journal of family medicine and disease prevention, 2(3).

Jackson, C. S., Oman, M., Patel, A. M., & Vega, K. J. (2016). Health disparities in CRC among racial and ethnic minorities in the United States. Journal of gastrointestinal oncology, 7(Suppl 1), S32.

Ladabaum, U., Mannalithara, A., Jandorf, L., & Itzkowitz, S. H. (2015). Cost‐effectiveness of patient navigation to increase adherence to screening colonoscopy among minority individuals. Cancer, 121(7), 1088-1097.

Martinsen, R. P., Morris, C. R., Pinheiro, P. S., Parikh-Patel, A., & Kizer, K. W. (2016). CRC trends in California and the need for greater screening of Hispanic men. American journal of preventive medicine, 51(6), e155-e163.

Shokar, N. K., Byrd, T., Lairson, D. R., Salaiz, R., Kim, J., Calderon-Mora, J., & Ortiz, M. (2015). Against CRC in our neighborhoods, a community-based CRC screening program targeting low-income Hispanics: program development and costs. Health promotion practice, 16(5), 656-666.

Wittich, A. R., Shay, L. A., Flores, B., De La Rosa, E. M., Mackay, T., & Valerio, M. A. (2019). CRC screening: Understanding the health literacy needs of Hispanic rural residents. AIMS public health, 6(2), 107.

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