VOLUME 22, NUMBER 1 CLINICAL JOURNAL OF ONCOLOGY NURSING 69CJO.docx

VOLUME 22, NUMBER 1 CLINICAL JOURNAL OF
ONCOLOGY NURSING 69CJON.ONS.ORG
C
Colorectal Cancer
A collaborative approach to improve education and screening
in a rural population
Marsha Woodall, DNP, MBA, RN, and Mary DeLetter, PhD, RN
COLORECTAL CANCER (CRC) INCLUDES ANY CANCER
THAT starts in the colon or
rectum. Most begin as an adenomatous polyp and grow into the
wall of the
colon or rectum before metastasizing by invading tissues or
structures, the
bloodstream, or the lymphatic system. About 95% of CRCs are
adenocarci-
nomas (American Cancer Society [ACS], 2017b). The ACS
(2017a) projected
that 135,430 people would be diagnosed with CRC in the United
States in
2017. Although the CRC death rate has been dropping for the
past 20 years,
the ACS still estimated 50,260 CRC-related deaths during 2017
(ACS, 2017a).
The Centers for Disease Control and Prevention ([CDC], 2017)
recom-
mends screening for precancerous polyps for anyone aged 50
years or older.

Although early detection and diagnosis greatly affect survival
rates, only about
half of the U.S. population participates in screening (ACS,
2017a). A fecal
immunochemical test (FIT) is a noninvasive test used to detect
blood in the
stool that cannot be seen with the human eye (Tresca, 2017).
People at home
use the FIT kit by obtaining a sample of the stool with one of
the FIT kit sticks
and inserting the sample back in the vial. The FIT kits are then
either mailed or
hand-delivered to a laboratory for blood detection, most
specifically from the
lower gastrointestinal tract (Tresca, 2017).
The State Cancer Profiles report by the National Cancer
Institute (NCI)
and CDC (2014) ranked Kentucky seventh for mortality, with a
death rate
of 17.6 per 100,000 compared to a national rate of 15.1. At the
time of this
project, the CRC death rate in Hopkins County, Kentucky, was
14.1 per
100,000, one of the highest in the state. The death rate in
Kentucky has been
trending downward over time from 25.8 in 1982 to 17.6 in 2013
(NCI and CDC,
2014). Incidence and death rates are depicted in Figure 1.
In 2008, the Kentucky Colon Cancer Screening Program
(KCCSP) was
formed with the passage of Kentucky Regulatory Statute
214.540 to increase
CRC screening, reduce morbidity and mortality from CRC, and
reduce costs

for CRC treatment. The goal of the KCCSP is to increase the
number of CRC
screenings in Kentucky, using 75% FIT kits and 25%
colonoscopies (Justia,
2011).
About 39% of CRCs are diagnosed at the local stage or confined
to the
primary site, but 56% have already spread to regional lymph
nodes or have
metastasized. If diagnosed at the localized stage, there is a 90%
five-year rel-
ative survival rate, but this decreases to 14% when the cancer is
in distant
sites. The survival rate for regional sites is 71% and 35% for
unstaged. NCI
(2017a) projects that early detection of CRC could improve
survival rates by
about 60%.
KEYWORDS
colorectal cancer screening; human caring
theory; evidence-based practice
DIGITAL OBJECT IDENTIFIER
10.1188/18.CJON.69-75
BACKGROUND: Colorectal cancer (CRC) is the third
most commonly diagnosed cancer and second
leading cause of cancer death for men and women

in the United States. Although early detection and
diagnosis greatly affect survival rates, only about
half of the U.S. population participates in screening.
OBJECTIVES: The purpose of this project was to
implement community-based CRC education and
screening. Outcomes included CRC knowledge,
CRC screening kit return rate, and rate of positive
screening results.
METHODS: Partnering with a community hospital,
CRC educational sessions and free screening oppor-
tunities were provided for 193 local city government
employees. CRC knowledge was assessed before
and after education with the Knowledge Assessment
Survey. A paired t test indicated significant improve-
ment in mean CRC knowledge.
FINDINGS: More than half of the participants elected
to take home fecal immunochemical test kits. Of the
29 participants who submitted their screening kits

for evaluation, eight had positive results and received
referral recommendations. All participants were
notified of their screening results. The community-
based CRC project was effective in improving CRC
knowledge and screening participation.
✔
70 CLINICAL JOURNAL OF ONCOLOGY NURSING
VOLUME 22, NUMBER 1 CJON.ONS.ORG
COLORECTAL CANCER
“Targeted community
education successfully
increased colorectal
cancer knowledge
and screening rates.”
Literature Review
Multiple investigators reported improved CRC screening when
var-
ious targeted strategies were used for CRC education (Dignan et
al.,
2014; Feltner, Ely, Whitler, Gross, & Dignan, 2012; Smith et
al., 2012;
Westfall et al., 2013). In addition, Green et al. (2013) and
Menon
et al. (2011) reported higher rates of screening follow-through
when follow-up strategies, such as telephone contact and

reminder
mailings, were implemented. Population-specific improvements
were reported by investigators who implemented targeted edu-
cational strategies in medically underserved areas, such as rural
Appalachian Kentucky (Dignan et al., 2014; Feltner et al., 2012)
and
rural Colorado (Westfall et al., 2013).
In their systematic reviews, Morrow, Dallow, and Julka
(2010) and Wortley, Wong, Kieu, and Howard (2014) reported
the benefits of follow-up strategies that allowed patients to
make informed, individual choices regarding participation in
their preferred CRC screening method. Although the ability
to offer choices for screening methods was not feasible in this
project, there was ample evidence in the literature to support
implementing a community-based CRC screening program using
targeted education and FIT kits.
Objective and Purpose
Each March, the KCCSP engages in CRC awareness activi-
ties as a public health initiative, distributing FIT kits for CRC
FIGURE 1.
NATIONAL, STATE, AND LOCAL COLORECTAL CANCER
INCIDENCE AND DEATH RATES
AND THE TRENDING COLORECTAL CANCER DEATH
RATE IN KENTUCKY
Note. Based on information from National Cancer Institute and
Centers for Disease Control and Prevention, 2014.
Incidence Rate Death Rate Kentucky Death Rates by Year
PE

R
C
EN
TA
G
E
COLORECTAL CANCER INCIDENCE AND DEATH RATES
0
10
20
30
40
50
60
Hopkins County Kentucky United States
1982
2002
2013

CJON.ONS.ORG
screening. The objective of this project was to implement
community-based CRC education and screening for a targeted
population.
Theoretical Framework
Incorporating theory, philosophy, and ethics while integrating
technology and practicality outlines the human caring theory
(Watson & Smith, 2002). Watson’s (2009) human caring theory
focuses on a caring science for clinical decision making. This
theory guided the literature review on strategies to ensure
caring
and connect with individuals in the community to improve
public
health while decreasing costs to the healthcare system. This
ultimately led to a focus on targeted education and follow-up as
improvement strategies for the project.
Prochaska, DiClemente, Velicer, and Rossi’s (1992) trans-
theoretical model (TTM) assists individuals intentionally
changing behaviors or intending to change behaviors with
interventions to help them change by focusing on decision
making. One of the KCCSP’s goals is to increase CRC
screening
by removing barriers and increasing awareness (National
Colorectal Cancer Roundtable, 2017). The TTM guided the
project focus to provide education, improve awareness, and
offer
on-site screening opportunities promoting individuals’ CRC
screening decisions.
Methods

In Hopkins County, Kentucky, where this project was
conducted,
2015 data demonstrated the benefit of community-based CRC
screening. The project was a joint venture between local city
government and a community hospital, Baptist Health Hospital
in Madisonville, Kentucky. Using a pre-/post-test design, 16
CRC
educational sessions were delivered at 12 departmental meetings
with employees. CRC knowledge was measured before and after
the education using the Knowledge Assessment Survey (KAS)
(Sanchez, Palacios, Thompson, Martinez, & O’Connell, 2013).
On-site FIT kit distribution was conducted by the community
hospital oncology nurse navigator (ONN).
Sample and Setting
The educational sessions were conducted at various times of day
and night in various locations to accommodate the working pat-
terns of the 193 city employees who participated. All employees
present at the departmental meetings were eligible to partici-
pate in the educational session, knowledge assessment, and FIT
kit distribution. All employees who attended the educational
sessions participated in the completion of the pre- and post-
intervention KAS.
The city employees represented a diverse population with
heterogeneity in gender, race, educational background,
socioeco-
nomic status, and age. Many of the employees were in the CRC
high-risk age group.
Evidence-Based Intervention
Institutional review board approval was obtained through
Eastern Kentucky University Division of Sponsored Programs.
No participant-identifying information was included on the
knowledge assessments. The ONN obtained name and contact
information of participants who elected to accept a FIT kit. All

identifying information was protected using the hospital’s com-
munity screening policy and procedure and Health Insurance
Portability and Accountability Act (HIPAA) guidelines.
CRC screening educational flyers were posted in the city
government departments prior to project implementation. The
evidence-based intervention was a 10-minute CRC educational
session followed by the opportunity to participate in free CRC
screening by accepting a FIT kit.
Instrument
The KAS was administered pre- and postintervention.
Permission
for use was obtained from the instrument author. The KAS
is a 14-item survey based on CRC risk information from NCI.
Responses to the KAS are assigned a value of 1 for each “yes”
and
a 0 for each “no,” with a possible total score from 0–14 for each
survey. Higher scores indicate greater knowledge. The survey
has
a 7.9 readability grade level and assesses CRC knowledge, CRC
screening history, behavioral intentions to participate in screen-
ing, and physician–patient interactions. The knowledge
questions
are categorized into the following three categories, each with
pre-
viously documented acceptable reliability coefficients:
TABLE 1.
ITEMS AND SCALE INTERNAL RELIABILITIES
COMPARED TO PROJECT RELIABILITIES FOR KAS
OVERALL PRE-EDUCATION POSTEDUCATION
SUBSCALE

CRONBACH
ALPHA
CRONBACH
ALPHA
CRONBACH
ALPHA
Total knowledge
(14 items)
0.94 0.64 0.78
General
knowledge of
CRC (2 items)
0.74 0.57 0.8
Knowledge of
CRC risk factors
(5 items)
0.88 0.27 0.22
Knowledge of
CRC screening
(7 items)
0.89 0.76 0.72
Physician
interactions
(2 items)

0.92 0.81 0.81
CRC—colorectal cancer; KAS—Knowledge Assessment Survey
ɐ General CRC knowledge (Cronbach alpha = 0.74)
ɐ CRC screening knowledge (Cronbach alpha = 0.89)
ɐ CRC risk factor knowledge (Cronbach alpha = 0.88)
Sanchez et al. (2013) reported acceptable internal reliability
on the KAS scales and subscales with Cronbach alphas ranging
from 0.74–0.94. Sanchez et al. (2013) did not report instrument
construct validity in the literature; however, this instrument
was selected because the face validity was acceptable to the
nurse experts involved in this project. For this project sample,
pre-/post-test reliability assessments were conducted for each
of the three subscales and total KAS. Coefficient alphas ranged
from 0.22–0.8 on the subscales and 0.64–0.94 on total KAS (see
Table 1).
The inability to demonstrate adequate subscale reliability in
this sample was most likely related to the limited number of
items
in each subscale and the vast difference in samples. Although
Sanchez et al. (2013) tested the scale in predominantly Hispanic
women, the current sample was predominantly White men. Face
validity of the KAS was confirmed with the oncology and
wellness
nurses in the city government and community hospital.
Implementation

A cover letter noting the nature of the project was provided and
read aloud to each participant prior to the session. Following
completion of the KAS before education occurred, a scripted
CRC teaching message was delivered while the participants
were
viewing CDC’s (2017) Screen for Life: National Colorectal
Cancer
Action Campaign materials and handout. Education included
CRC definition, risk factors, screening methods and options,
and
benefits of screening. The ONN explained that CRC screening
was recommended for employees who met the following NCI
(2017b) at-risk criteria:
ɐ No screening in previous 12 months
ɐ Individuals aged older than 50 years or those aged 40–50
years
with a family history of colon cancer
Employees who did not meet NCI criteria but requested the free
CRC screening were included. The ONN distributed all FIT kits,
recorded all participants’ contact information, provided instruc-
tions, and discussed individuals’ questions or concerns. This
was
her customary procedure during community service events.
Data Collection
The KAS was administered immediately before and immediately
after the educational session. The hospital ONN tracked the
number of FIT kits distributed, the number returned within four
weeks, and the number of participants who had positive
screening
results. These aggregate data were provided to the project
leader
without any individual identifiers. One week after distribution,
the ONN made personal telephone calls to all participants who

accepted but had not returned their FIT kits. The city wellness
nurse posted reminder flyers in all departments. After three
weeks,
the ONN mailed 100 personal letters to the employees who had
not returned their FIT kits. All participants who returned kits
for
evaluation were notified of their individual screening results by
the ONN. Results within normal limits were reported by regular
mail; results not within normal limits were reported by
registered
mail. Participants with results that were not within normal
limits
were encouraged to see their primary care provider for follow-
up.
Upon request of any participant, provider referrals were made
for
follow-up care. Data were analyzed with IBM SPSS Statistics,
ver-
sion 23.0.
Results
Fifty-two individuals accepted a FIT kit, 12 submitted them to
the
laboratory for screening, and 5 had positive CRC indicators.
Table
2 depicts the distribution and return rate for FIT tests in
Hopkins
County for 2013–2016.
Sample Characteristics
An initial sample of 193 employees participated in the
education
and CRC knowledge assessments. Seven of the participants
were
removed from the data set because of response set or a missing

pre- or posteducation KAS, resulting in 186 usable assessments.
The participants’ ages ranged from 20–65 years, with a mean
age of 40.6 (SD = 10.95). The majority were men (n = 169) and
Caucasian (n = 167). Only one-third of the participants had a
col-
lege or advanced degree (n = 55). Demographic characteristics
of
the participants are shown in Table 3.
Knowledge Assessment
The mean knowledge scores from the 14-item assessment tool
were 8.29 (SD = 1.862) before and 13.27 (SD = 1.363) after the
educational session. Knowledge scores were categorized as low
TABLE 2.
GENERAL COMMUNITY FIT KIT DISTRIBUTION
AND USE DATA FOR HOPKINS COUNTY, KENTUCKY
DISTRIBUTED RETURNED POSITIVE RESULTS
YEAR N n n
2013 37 12 4
2014 44 4 2
2015 52 12 5
2016 4 0 –
FIT—fecal immunochemical test
IMPLICATIONS FOR PRACTICE
ɔ Increase colorectal screening rates with targeted education.

ɔ Encourage patients to gain knowledge about screening rates
and
how to get screened.
ɔ Adapt education to suit screening for other types of cancer to
increase screening rates overall.
COLORECTAL CANCER
knowledge (scores of 0–3), moderate knowledge (scores of 4–
9),
and high knowledge (scores of 10–14) (Sanchez, Palacios, Cole,
&
O’Connell, 2014). The majority of participants (n = 140) in this
sample were in the moderate knowledge category before the
edu-
cational intervention; however, an even greater majority (n =
181)
scored in the high knowledge category after the education ses-
sion, as depicted in Figure 2.
A paired-samples t test demonstrated a significant increase in
mean total KAS scores from pre-education (
—
X = 8.29, SD = 1.86)
to posteducation (
—

X = 13.27, SD = 1.36) (t[181] = 35.289, p < 0.0001;
two-tailed). The mean increase in KAS scores was 4.95 (95%
confi-
dence interval [4.7, 5.26]). The eta squared statistic (0.87)
indicated
a large effect size for this intervention. Because of the low
reliability
coefficient alphas obtained for this sample, individual subscale
scores were not evaluated for statistically significant changes.
Screening Outcomes
More than half of the participants (n = 130) elected to take
home
FIT screening kits. Of the 29 participants (15%) who submitted
their screening kits for evaluation, eight (4%) had positive
colon
cancer indicators and received referral recommendations.
Discussion
The literature supports personalized CRC education to promote
informed choices regarding type of CRC screening and to
increase
adherence to screening (Dignan et al., 2014; Feltner et al.,
2012;
Green et al., 2013; Menon et al., 2011; Morrow et al., 2010;
Wortley
et al., 2014). CRC education programs in rural communities,
sim-
ilar to the current project community, have been recommended
(Dignan et al., 2014; Feltner et al., 2012; Westfall et al., 2013).
Multiple authors emphasize the significance of informed
choices in
promoting CRC screening through common interventions
(Dignan
et al., 2014; Feltner et al., 2012; Green et al., 2013; Menon et

al., 2011;
Morrow et al., 2010; Smith et al., 2012; Westfall et al., 2013;
Wortley
et al., 2014).
This project evaluation demonstrated an improvement in
knowledge and intent to participate in screening following CRC
education, as reported in the literature. Several studies (Dignan
et al., 2014; Feltner et al., 2012; Green et al., 2013; Menon et
al.,
2011; Morrow et al., 2010; Wortley et al., 2014) were also able
to demonstrate increased adherence to screening following
CRC screening education. In the current study, the partici-
pants viewed a handout during the formal educational session.
The concurrent, on-site exposure to the ONN, who provided
instruction and education on the FIT kit, was beneficial. In
addition, providing the FIT kit to all individuals who wanted to
participate, keeping results confidential, and providing appro-
priate follow-up for participants were strategies that enhanced
the CRC screening rate.
An unanticipated outcome of the project was the number
of anecdotal discussions that took place in the departmental
educational sessions and one-on-one. One man openly shared
his story of being diagnosed and treated for colorectal cancer
at age 42 years. He told his fellow employees that he was lucky
that his treatment was successful and urged everyone to partic-
ipate in screening. Several participants wanted to know more
about decreasing risk factors for themselves or family members.
Many wanted to share stories about someone they knew who
had lost his or her life to cancer. Overall, the participants were
welcoming, engaged, and open to the educational intervention
and screening.
Locations for project implementation varied greatly from a

formal department classroom to a work shed in the local cem-
etery. Knowing there would be a variety of settings, the
decision
to use a verbal script and hard copies of educational materials
versus an electronic presentation was an appropriate alternate
strategy and made the implementation feasible.
Partnering with the ONN from the local hospital was critical
to the success of the project. The distribution of 130 FIT kits
with
TABLE 3.
DEMOGRAPHIC CHARACTERISTICS OF PROJECT
PARTICIPANTS (N = 186)
CHARACTERISTIC n %
Gender
Male 169 91
Female 15 8
Missing data 2 1
Education level
Less than high school 8 4
High school graduate or GED 66 36
Some college but no degree 56 30
College degree 51 27

Advanced degree (MD, PhD, JD, master’s) 4 2
Missing data 1 1
Race
White (Caucasian, non-Hispanic) 167 90
Black or African American 16 9
American Indian or Native American 1 1
Other 1 1
Missing data 1 1
Note. Because of rounding, percentages may not total 100.
COLORECTAL CANCER
29 returns and 8 positive results is nearly the same as had been
accomplished in the previous three years on the CRC Screening
Days in the same community (H. Tow, personal communica-
tion, March 18, 2016). In the previous community effort and
this
project, several participants demonstrated positive results, indi-
cating a need for follow-up with a healthcare provider. Finding
positive CRC indicators in the eight employees demonstrated
the potential life-saving value of the targeted education and
screening (see Table 4).

Limitations
One limitation to this project was the reliability of the KAS
tool.
Although Sanchez et al. (2013) reported subscale Cronbach
alphas
from 0.74–0.94, the subscales for this project sample did not
have acceptable reliability coefficients. Another limitation of
the
KAS was that only one item was reverse-scored. Upon
consulting
with a statistical expert, it was noted that disparity in
instrument
FIGURE 2.
KNOWLEDGE CATEGORY BASED ON TOTAL
KAS SCORES
KAS—Knowledge Assessment Survey
Note. Pre-education mean was 8.29. Posteducation mean was
13.27.
Note. Low knowledge was scores of 0–3, moderate knowledge
was scores of 4–9,
and high knowledge was scores of 10–14.
0
20
40
60
80
100

Pre-education Posteducation
PE
R
C
EN
TA
G
E
KAS SCORES
Low knowledge Moderate knowledge High knowledge
reliability comparisons could be from (a) a lack of construct
validity
reported in the literature, (b) the dichotomous nature of all
items,
(c) the limited number of items in each subscale (one subscale
had
only two items), and (d) the difference in sample demographics
(B. Davis, personal communication, March 12, 2016). Sanchez
et
al. (2013) reported reliability in their sample of primarily
Hispanic
women, whereas this project included predominantly White
men.
Implications for Nursing Practice
Results of the project and detection of positive indicators
contrib-
ute to the National Colorectal Cancer Roundtable (2017) goal to

screen 80% of the nation’s population by 2018. More
importantly,
this project allowed the detection of positive cancer indicators
in eight individuals that may have otherwise gone undetected.
Eliminating barriers through education was supported by this
project’s increase in knowledge, as evidenced by the total KAS
score improvement and the FIT kit return rate. Preliminary find-
ings of this project were shared with the community hospital
cancer committee; all were in agreement to increase focus on
tar-
geted education rather than randomly handing out FIT kits at
the
annual community awareness day in March.
Future Outreach
The community hospital has committed to future, purpose-
ful targeted educational outreach programs. Two specific ideas
for sustaining and improving community-based CRC screening
have come from this project. First, during the March 2016 CRC
Screening Day, the FIT kit education and distribution process
was
altered from previous years. Rather than receive receive FIT
kits,
interested participants received flyers with information for indi-
vidualized screening counseling appointments with the ONN.
Second, the ONN has proposed a local private business employ-
ing about 500 people as the next site for targeted education and
screening. Finally, a recommendation for specifically targeting
audiences and providing education for all types of cancer
screen-
ing has emerged from this project recommendation.
TABLE 4.
FIT KIT DISTRIBUTION AND USE DATA
FOR THE CURRENT PROJECT COMPARED

TO THE GENERAL COMMUNITY PROJECT
DISTRIBUTED RETURNED POSITIVE RESULTS
PROJECT N n n
General
community,
2013–2016
137 28 11
Current
project, 2016
130 29 8
FIT—fecal immunochemical test
Conclusion
In this project, targeted community education successfully
increased
CRC knowledge and screening rates. Increasing CRC screening
rates
to 80% by the end of 2018 will take the efforts of leaders at all
levels
(ACS, 2015). Ongoing commitment to participate in CRC
education
and screening supported by the local hospital and cancer
education

community has already contributed to this effort.
The TTM model was useful in identifying health behaviors
and implementing an effective educational intervention to facil-
itate decision making for CRC screening. This model will be a
guiding framework for future evidence-based education and
cancer screening. These positive influences on individual health
behaviors will promote overall health outcomes for targeted
com-
munity populations.
Marsha Woodall, DNP, MBA, RN, was, at the time of writing, a
graduate student
at Eastern Kentucky University and is currently a nurse
administrator and program
coordinator in the Nursing Division at Madisonville Community
College in
Kentucky; and Mary DeLetter, PhD, RN, was, at the time of
writing, a faculty
member at Eastern Kentucky University and is currently an
associate professor and
RN-BSN program director in the School of Nursing at the
University of Louisville
in Kentucky. Woodall can be reached at [email protected], with
copy to
[email protected] (Submitted April 2017. Accepted May 13,
2017.)
The authors take full responsibility for this content and did not

receive honoraria or disclose
any relevant financial relationships. The article has been
reviewed by independent peer review-
ers to ensure that it is objective and free from bias.
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