Participatory Process for Implementing a Colorectal Cancer Screening Intervention: an Action Plan for Local Sustainability

INTRODUCTION METHODS Background: Rigid protocols can hamper translation of evidence-based interventions (EBIs) from research to real-world settings. Nevertheless, employing principles of community-based participatory research holds potential for successful implementation. The primary aim of this investigation was to develop procedures for modifying the study protocol of a colorectal cancer screening educational intervention implemented in African American communities to fit local needs while maintaining fidelity to its core elements. Methods: To ensure sustainability of the Educational Program to Increase Colorectal Cancer Screening (EPICS), four-hour guided discussions between researchers and 15 community coalitions were undertaken to include: 1) assessing strengths, weaknesses, opportunities and threats; 2) establishing specific, measurable, achievable, realistic and timely goals; and 3) developing local action plans. Results: In the local action plans, adherence to core intervention elements (theoretical framework, educational content, and sessions) was maintained with adaptation to roles and responsibilities. For example, the coalition leader modified views to reflect local ownership of data and members accepted responsibilities for marketing, education, communication, and data management. Conclusions: Enhancing interactions between researchers and community partners and addressing weaknesses and threats ensure transition from efficacy to implementation and promote sustainability of interventions. Grant Support: NIH 1R01CA166785  Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States and the third most common cancer in men and in women. African Americans (AAs) have the highest over-all incidence, incidence of advanced stage at disease presentation, attributable mortality, and the lowest survival rates after diagnosis.  Although screening is an effective tool for reducing CRC mortality, differences in screening accounted for 42% of disparity in CRC incidence and 19% of disparity in CRC mortality between AAs and Whites.  EPICS is an EBI for increasing CRC screening rates among AAs. Core elements are listed in Table 1.  EPICS implementation is in partnership with community coalitions organized by the National Black Leadership Initiative on Cancer (NBLIC) in 15 communities across the United States.  Sustainability of the EBI is based on acceptability, capacity, and resources within the targeted communities, using an approach that is flexible enough for local relevance.  In the present study, investigators describe a method for enhancing dissemination by adjusting the EPICS study protocol to meet local contextual challenges. Guided by Glasgow’s Evidence Integration Triangle (EIT) [Fig. 1], a variety of issues faced at the 15 sites and the process by which the basic protocol was modified are described. 1. Discussions between investigators and leaders of each NBLIC community coalition to share information and develop action plans was completed. 2. SWOT Analysis (strengths or characteristics of community coalitions needed for delivery; weaknesses or challenges/ barriers to implementation; opportunities or elements that could be exploited; and threats or contextual risks to successful trial completion) was completed. 3. SMART (specific, measurable, actionable, realistic and timely) Goals related to facilitator and participant recruitment and retention were established. 4. Modification of the study protocol to reach SMART goals was completed. 1. Draft action plan was reviewed, revised, and distributed. 2. Final action plan was distributed.  Differences in priorities of the 15 participating communities inform challenges experienced.  Major themes emerging from the guided discussions included: 1) facilitator recruitment, training and roles 2) participant recruitment and retention  Specific challenges identified by coalitions were unique to each community, with synergy across sites.  Strategies outlined were based on the barriers identified, informed by community stakeholders [Table 2].  The community and its individual members constitute a “research participant”; it is appropriate that communities have the last word on the research approach that works best for them.  Multi-site research protocols may require adjustments.  Application of a conceptual framework (e.g., EIT model) is essential to maintaining integrity and ensuring fidelity to EBI core elements. DISCUSSION Table 2. Local EPICS Implementation Action Plan Element Approach Adaptation Option Theoretical Framework Diffusion of Innovations Theory Educational Content Guidelines for CRC (DRE*; FOBT*, Sigmoidoscopy; Colonoscopy); CRC Risk Factors (modifiable; nonmodifiable) Dietary and physical activity information adapted to fit the audience Sessions Group settings; three (3) one-hour sessions Size of group settings 3) Facilitators Public health professionals, cancer survivors and advocates, community members, church and civic leaders Other individuals interested in lowering CRC incidence and mortality Facilitator Training Training (11⁄2 day session) and TA* TA based on randomization Settings Churches, clinics and community sites Other settings Table 1. EPICS Core Elements RESULTS