Polk County Get Screened!

Total Funding Requested: $65,317 Project Duration: 14 Months Project Start Date: July 1, 2014 Project End Date: August 31, 2015 Project Director: Dominic Picetti 123 Wellness Dr. Des Moines, IA 50314 Phone: 415 342 2748 Email: dpicetti@calpoly.edu Award should be made to: Polk County Public Health Department Proposal Submitted to: Office of Disease Prevention and Health Promotion Abstract: Overall Purpose: The goal of this program is the increase the rate of colorectal cancer (CRC) screening among African American males over 50 years old in Polk County, Iowa. This goal is working to meet the Healthy People 2020 C-5 Objective of reducing the colorectal death rate. Polk County Get Screened! is a program designed to allow the aforementioned group, who are disproportionally affected by colorectal cancer specific mortality, to receive a free fecal occult blood test to test for colorectal cancer. The program will be facilitated by trained volunteers providing free fecal occult blood tests to eligible community members at six local churches within Polk County. In addition, the University of Iowa has agreed to test the fecal occult blood tests (FOBT), mail the results to the participants and report their findings back to the Polk County Public Health Department. Lastly, a local primary care physician group has agreed to provide free colonoscopies for participants who have a positive FOBT. Through the implementation of Polk County Get Screened! the death rate from colorectal cancer has the potential to decrease among African Americans. In addition, other demographic groups could become aware about the benefits and cost-effectiveness of colorectal cancer screenings.

NARRATIVE: Needs Statement: The colorectal cancer (CRC) death rate remains a significant public health problem in 2013, so much so that it is a Healthy People 2020 objective. Chapter C-5, defines the goal of reducing the CRC death rate from 17 deaths per 100,000 persons in 2007 to 14.5 deaths per 100,000 persons in 2002.1 From 2006 through 2010 the national CRC specific mortality rate has been declining by 2.5% per year.2 In 2010 the national CRC specific mortality rate for all ethnicities was 15.5 persons/100,000 persons, but the CRC specific mortality for African American males was 27.5 deaths per 100,000 persons, the highest death rate among any gender and ethnicity.3 In addition to ethnicity, studies have shown males, especially over the age of fifty are more at risk to have CRC specific mortality due an increase in abdominal obesity, increased rates of drinking alcohol and hormones that are onco-genic for colorectal cancer.4 The long-term effects of CRC mortality will prove to be a significant burden on the health care system. One study estimates that if the current trend of CRC mortality remains constant there will be a 53% increase in the health care costs associated with CRC from 2008 to 2020.5 More specifically if the trend remains constant (decreasing incidence, improving survival, and increasing costs) the total health care costs associated with CRC will be $14.03 billion, which is 0.3% of total estimated health care costs by 2020.5,6 In addition, these costs do no include the societal burden of chronic, long-term unemployment or non-productive hours from CRC treatment.5 While the CRC death rate has been declining over the past four years, the rate of decline has been unequally distributed. The CRC death rate has been rapidly declining within the NonHispanic White population while the CRC death rate has stagnated for the African American population.7 The decline in the CRC death rate is mainly attributed to the increased screening rates for CRC, but African Americans have not been exposed to the increased screening rates.4

The primary contributor to the higher rate of CRC deaths among the African American male population than the Non-Hispanic white male population is the rate at which African American males get screened for CRC.4 One organization found that African American males are more likely to be diagnosed with CRC after the cancer has already spread to different organs, and that African American males have a decreased likelihood to have proper surgery to remove the tumor than their Non-Hispanic white counter parts.4 In addition to the factors of age and low screening rates, the modifiable risk factors for CRC specific morality are physical inactivity, moderate the heavy alcohol consumption, overweight/obesity, and limited access to health care.8 The 2011 Iowa Behavioral Risk Factor Surveillance System identified that the behaviors of the African American male population over the age of fifty place them at risk for CRC death.9 For example only 19.6% of African American males in Iowa meet the requirement of participating in 150 minutes of physical activity per week.10 Specifically, 12.9% of the African American males over the age of 55 meet this requirement.10 In addition, 33.4% of the African American male population in Iowa has no access to health care, while only 11.6% of Iowans lack health care.10 While the African American male population in Iowa lacks health care access, they also have lower rates of CRC screening compared to the national average.7 Specifically, 63.5% of the male population over 50 years of age receives an appropriate CRC screen, while only 58% percent of the African American population in Iowa receives an appropriate CRC screen.7 An appropriate CRC screen includes a fecal occult blood test, a sigmoidoscopy, a colonoscopy or a double contrast barium enema.9 Polk County in Iowa is an ideal county for a community wide intervention to reduce the CRC specific mortality rate in African American males over fifty years of age. On a national level, the state of Iowa has a CRC death rate of 17.3 deaths per 100,000 persons while the

national average is 16.4 deaths per 100,000 persons.3,8 More specifically the African American male population in Polk County is disproportionally affected by CRC deaths, as illustrated by table 1.3

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Table 1: CRC Death Rate In Polk County

Other cancers, such as breast or prostate cancer, which attract more media attention, underscore the importance of CRC specific mortality as a current public health concern. The higher rate of CRC specific mortality and the low rate of CRC screening of the African American male population over 50 years of age in Polk County, Iowa indicate a need for more screening of CRC. One study discovered that screening for CRC with a fecal occult blood test had a 32% reduction in the CRC specific mortality rate over a thirty-year period.11 In addition, the survival rate of individuals with colorectal cancer found in the initial stage (Stage I) was 74%, while the survival rates of individuals with colorectal cancer found in the final stage was 6% (Stage IV).12 There are currently two programs within Iowa to address the Healthy People 2020 goal of reducing the CRC death rate to 14.5 deaths per 100,000 people, and both programs are using fecal occult blood tests (FOBT) as the screening method.13,14 While these efforts are aimed at 4

reducing CRC deaths, neither of these programs specifically targets the African American community. For example, in one study 91% of participants were of the Non-Hispanic White ethnicity and in another study 99.2% of participants were of the Non-Hispanic White ethnicity.13,15 While neither of the programs in Iowa to reduce the CRC death rate are specifically aimed at the African American population, there have been programs within other states designed to target the African American population.16 These programs relied heavily on community centers, such as churches, to offer CRC screenings.16 Many African Americans cite the cost and transportation associated with CRC screening as barriers to receiving a proper CRC screen.16 Offering free non-invasive CRC screening techniques, such as, fecal occult blood tests at churches will reduce the barriers African American cite for receiving CRC screening. Since the African American male population within Polk County has low rates of CRC screening and is at an increased risk for CRC death there is need for an intervention within Polk County. The project team plans to recruit 400 African American males over the age of 50 to join Polk County Get Screened! Goals and Objectives: The Healthy People 2020 goal of reducing the number of CRC deaths to 14.5 persons per 100,000 persons may by achieved within Polk County, Iowa by adhering to the following goals and objectives. Goal: To decrease the CRC death rate among African American males over the age of 50 within Polk County, Iowa by 10%. a. Develop a CRC screening intervention program in conjunction with six local churches, local nurses and physicians.

b. Train 15 volunteers from the University of Iowa to check for participants eligibility at the six churches and enter their information. c. To evaluate the effectiveness of the CRC screening intervention with regards to a decline in CRC deaths among the African American male population over the age of fifty. METHODS: Project Design: Polk County Get Screened! will occur in 4 phases. First, the project team will work in conjunction with six local churches, local primary care physicians, nurses that work for the Polk County Public Health Department, The University of Iowa, a bio-statistician, a graphic designer and health educators to develop the intervention. Second, the health educators will work in conjunction with The University of Iowa to recruit 15 volunteers and train them to check for participants eligibility, learn how to enter participants information into the computer system and work in accordance with ethical codes. Third, the intervention at the six local churches will occur for six months, and fourth there will be a summative evaluation that occurs after the intervention has occurred. Development of Intervention: The program director, the four public health educators and the public health nurses will work together from July 1, 2014 to November 1, 2014 to develop the Polk County Get Screened! intervention at the six local churches. In addition, the program director will contact The University of Iowa to ensure their Scientist In Training program will analyze the fecal occult blood tests and send the results to both the participants and to the Polk County Public Health Department. The program director will also contact: Polk County

1st Presbyterian, First United Methodist Church, Grace Church, 1st Episcopalian Church in Polk County, St. Patricks Catholic Church, and Lutheran Church Of Hope to ensure the intervention can occur at those locations. The program director will also order 350 fecal occult blood test kits for the intervention and contact the Primary Care Physician Group in Polk County to ensure they will provide free colonoscopies to participants who have a positive FOBT. The public health educators will work with the nurses to develop a training program for the 15 volunteers they recruit from The University of Iowa to help recruit participants for the program. In addition, the program director will work with a bio-statistician to understand what information the volunteers will need to gather from the participants and what information will need to be received from The University of Iowa and from the local physician offices. The program director will then take this information and work with the information technologies division of the Polk County Public Health Department to create an online database for the volunteers to enter the participants data into. Lastly, the program director will work with a local graphic designer to create advertisements and flyers to promote the intervention at the six local churches. Recruitment and Training of 15 volunteers from The University of Iowa: The public health educators will work with the Volunteer Service Program at The University of Iowa to recruit 15 volunteers. These volunteers will be stationed at one of the six churches during the six months of the intervention to recruit participants to Polk County Get Screened! Once the 15 volunteers have been recruited the nurses will train them on how to use the FOBT and how to explain how to purpose of the FOBT to the participants. The nurses will also instruct the volunteers to explain how the on-call nurse program for Polk Count Get Screened! intervention works. There will be on on-call nurse

from the hours of from 9am-4pm each day during the intervention and the phone number to call is (555) 555-1991. The nurses will be able to answer questions regarding CRC, how to use the FOBT, where to send the FOBT after a sample has been taken, and what to do with the results. The public health educators will then explain to the volunteers how to check for eligibility and how to enter the participants information into the online database. They will be taught that the online database will ensure there are no duplicates and will provide each participate with a random identification number. Every odd number participate will be apart of the control group and ever even numbered participate will receive a free FOBT and therefore be apart of the experiment group. The public health educators will assign each volunteer to one of the six churches and will provide each volunteer with a form to be reimbursed for travel expenses. Lastly, the public health educators and the nurses will have each volunteer take a FERPA training program to ensure they follow the ethical codes when interacting with humans. Polk County Get Screened! Intervention at six local churches: Three weeks before the intervention begins on November 16, 2014 the Program Director will pick up the flyers and advertisement material from the graphic designer and bring them to all six churches. Each church will place flyers around the common areas and the pastor and/or priest will mention the intervention and who is eligible at the end of each mass service. One week before the intervention begins the public health educators will join the volunteers and travel to each church to meet the pastors and/or priests for introductions and instruction on where the intervention will occur within each church. The first day of the intervention will occur on November 16, 2014 and will occur for each subsequent Sunday until April 12, 2015. The purpose of having the intervention from

November until April is there are typically more people attending church surrounding the holiday season of Thanksgiving, Christmas and Easter. The volunteers will be at their designated church from 8am-1pm each Sunday and they will recruit members of the church to check and see if they are eligible to participate in the intervention. The potential participants will need to provide a form of identification where the volunteers can verify their age and their place of residence. If the potential participant is eligible and would like to participate, the volunteer will enter their name, address, age, and marital status into the online database. The data will then generate a random number, which is how the participant will be identified for the intervention. The participants name will only be used to ensure no duplicates arise during the intervention. If the number generated by the online database is an odd number that participant will be apart of the control group. If the number generated by the database is an even number, that participant will be part of the experiment group and will be mailed a FOBT within one week of their registration. In addition, the participants part of the control group will be educated on how to use the FOBT by the volunteers at the intervention site. The participants part of the experimental group will be mailed the FOBT, a diagram created by the graphic designer on how to use the FOBT, and an empty preaddressed, pre-stamped envelope to mail the FOBT to The University of Iowa for testing. After The University of Iowa has analyzed the FOBTs, they will mail the results back to the participants with the names and phone numbers of the local physicians who agreed to see and perform a colonoscopy on participants who had a positive FOBT. In addition, The University of Iowa will electronically send the results to the Polk County Public Health Department using the random number assigned to the participant at one of the churches. During the intervention, the Program Director

will be communicating with The University of Iowa and the local primary care physicians to ensure their responsibilities are being performed adequately. Summative Evaluation of Intervention and Data Analysis: Data will be collected from The University of Iowa and the local physicians who agreed to receive the participants who had a positive FOBT. The bio-statistician will use governmental CRC data on Polk County as his baseline data. He will collect how many participants had a positive FOBT compared to how many participants had a negative FOBT. He will then analyze how many participants who had a positive FOBT, utilized on of the primary care physicians to receive a free colonoscopy to remove a possible polyp. He will use data from the local physicians to identify how many participants utilized the services of the physicians and received a colonoscopy. As previous studies have shown if a cancerous polyp is discovered during a colonoscopy and removed the chances of survival is greatly increased.12 Using this knowledge and with the time limits of this intervention, if a polyp is removed and there is no evidence of metastases the biostatistician will count this result as a life saved from CRC death. After the six months of the intervention in the churches and the extra three months for analysis the bio-statistician will compare the CRC death rate between the control and experiment group. He will analyze this comparison to see if the experimental group had a lower CRC death rate. The bio-statistician will also use governmental data on Polk County to assess if Polk County Get Screened! reduced the CRC death rate among African American males over the age of 50 by 10%.

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Sample: 600 participants for Polk County Get Screened! will be recruited from African American males over the age of 50 who live n Polk County, Iowa. Participants will be randomly assigned to one of two groups, the experiment group which will have their information entered into the system and receive the FOBT, and the control group which will have their information entered into the system but will not receive a FOBT. The number of potential eligible participants attending one of the six churches each week is approximately 150. Partners: Polk County Get Screened! will be working with the following individuals/organizations outside of the Polk County Public Health Department: Polk County 1st Presbyterian, First United Methodist Church, Grace Church, 1st Episcopalian Church in Polk County, St. Patricks Catholic Church, and Lutheran Church Of Hope. These six churches have agreed to be the sites of the intervention where the 15 volunteers will check for eligibility and enter the participants information into the database. Fifteen University of Iowa Students will be recruited to volunteer to check for eligibility at one the six local churches. The Scientists in Training Program at The University of Iowa. The program has agreed to analyze the FOBTs and send the results back to the participants via the US Postal Service. The Primary Care Physician Group in Polk County. The 10 physicians within the group have agreed to receive the participants who have a positive FOBT result and provide them with a free colonoscopy as part of their yearly philanthropy efforts.

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A local graphic designer, Sofia Gonzalez, will be creating the posters and visuals used to promote the intervention at the six churches beginning 2 months prior to the beginning of the intervention start date.

A Bio-statistician, Eric Vaught, has agreed to analyze the data collected from the intervention and assess if the CRC screening rate has increased and if the CRC death rate has decreased. He will be using government data on CRC as his baseline data.

Time Frame: Task 7 Development of Intervention 1. Contact 6 churches 2. Contact University of Iowa and sign contract 3. Purchase 350 FOBT Kits 4. Develop Intervention 5. Develop Volunteer Training Program 6. Collaborate with biostatistician to create post intervention evaluation 7. Collaborate with Graphic Designer about advertising for intervention 8. Acquire equipment for intervention (laptops, FOBT, gloves) 9. Collaborate with Public Health IT division to create system to enter participate information that can be wireless accessed X X X X X X X X X X Year: 2014 8 9 10 11 12 Year 2015 3 4 5 6

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10. Collaborate with Public Health IT division to set up phone that public health employed nurses will answer when participants have questions Recruitment and Training of 15 Volunteers from University of Iowa 1. Recruit volunteer from University of Iowa 2. Train volunteers on how to use the computer system, check for eligibility and deliver FOBT Polk County Get Screened! intervention at six local churches 1. Print flyers and place flyers in six churches 2. 2 volunteers will be at each church from 8am-1pm each Sunday 3. Communicate with University of Iowa to ensure they are receiving and testing the FOBTs 4. Notify local physicians they should be receiving communication from participants within the next 8 months 5. FOBT results mailed back to participants and data sent from The University of Iowa to Polk County Public Health Department Summative Evaluation of Intervention and Data Analysis: 1. Follow up with participants (both experiment and control group) 2. Bio-statistician will analyze data

X X

X X X X X X X

X X X X

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Sustainability: The proposed intervention will continue within Polk County and hopefully spread to other counties within Iowa from the continued support of The University of Iowa, The Primary Care Physician Group in Polk County, and Bio-statisticians from The University of Iowa. The graphic images designed by Sofia Gonzalez will be recycled for the interventions at other churches and community centers throughout Polk County, by changing the dates and location. Students from The University of Iowa will continue to participate and take on more responsibility as the program grows. Eventually the public health educators will not need to train the volunteers because the past volunteers will become the trainers. The funding for the FOBTs, postage, and travel expenses will be provided by The University of Iowa as part of their Scientists in Training Program. This intervention provides an educational opportunity for the students at The University of Iowa, and the University will continue to pay for the aforementioned items as long as their students are getting the experience. Dissemination: Results of this intervention will be given to other churches and community centers, like the YMCA within Polk County and surrounding counties. Furthermore, this intervention will be announced on the local Christian radio station, 98.5 KLOVE, and the local pop music radio station, 101.3 KFOG, in order to reach a broad audience. Intervention guides will be distributed to each local church and community center within Polk County, and there will be more available upon request. The Program Director will be open for any press releases, meetings with other Public Health Departments and community leaders seeking involvement in the program.

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Budget:
All awards are subject to the availability of appropriated funds.

Get Screened Polk County! Budget

Hourly Pay Rate Salaries and Wages Project Director: Dominic Picetti Public Health Educator: Susan Prince Public Health Educator: Lynn Flood Public Health Educator: Bryan Albini Public Health Educator: William Dawson On-Call Registered Nurse Biostatistician: Eric Vaught Graphic Designer: Sofia Gonzalez Public Health Information Technologies Division Total Salaries and Wages $35.00 $30.00 $30.00 $30.00 $30.00 $10.00 $45.00 $45.00 $40.00 Total Number of Hours 325 200 200 200 200 600 50 25 40 Pay or Costs $11,375 $6,000 $6,000 $6,000 $6,000 $6,000 $2,250 $1,125 $1,600 $46,350

Fringe Benefits Project Director: Dominic Picetti Public Health Educator: Susan Prince Public Health Educator: Lynn Flood Public Health Educator: Bryan Albini Public Health Educator: William Dawson On-Call Registered Nurse Public Health Information Technologies Division Total Fringe Benefits Costs Total Personnel Costs Office Expenses 10 laptops Postage Copying Software Materials Phone/fax Total Office Expenses Domestic Travel Mileage (per mile) Total Travel Other Expenses Fecal Occult Blood Test Kits Rate

Total Cost of CSU Hours 9.40% 9.40% 9.40% 9.40% 9.40% 9.40% 9.40% 325 200 200 200 200 600 50 $31 $19 $19 $19 $19 $56 $5 $167 $46,517

$4,000 $400 $1,000 $500 $500 $500 $6,900 Total Number of Miles 1,000

$0.40

$400 $400

Cost per Kit $30 300 $9,000

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Total Other Expenses Expenses

$9,000

Peer Review
Copy Editing and Publication Formatting Printing Journal Publication Award Conference Presentation Travel Award Total MTI Expenses

$2,000 $250 $250 $0 $0 $2,500

Expense Summary Personnel Office Expenses Travel Other Expenses MTI Expenses Total Project Expenses

$46,517 $6,900 $400 $9,000 $2,500 $65,317

Budget Narrative: A. Salaries and Wages 1. Project Director (PD): Dominic Picetti: Will supervise the Polk County Get Screened! intervention planning, implementation and evaluation. Responsibilities include: contacting The University of Iowa, contacting the six local churches to secure their cooperation, contacting the graphic designer and working with the graphic designer, purchasing of FOBT for intervention, working with IT division to create online database, and contacting the local physicians for data collection. 2. 4 Public Health Educators: Susan Price, Lynn Flood, Bryan Albini, and William Dawson: Will work with PD and public health nurses to develop intervention. Will work with nurses to develop training of 15 volunteers. Will train volunteers and cooperatively work with volunteers at the churches during the first 2 months of the intervention.

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3. There will be a nurse employed by the Polk County Public Health Department able to answer phone calls from 9am-4pm each day during the intervention. This will not be their sole responsibility during the specified time, it will be an added responsibility. 4. Bio-statistician, Eric Vaught, will analyze the data collected from the intervention and assess if the CRC screening rate has increased and if the CRC death rate has decreased. He will be using government data as his baseline data. 5. A local graphic designer, Sofia Gonzalez, will be creating the posters and visuals used to promote the intervention at the six churches beginning 2 months prior to the beginning of the intervention start date. 6. Public Health Information Technologies Division: Responsibilities include: creating online database system to enter participants information and installation of phone-line for the participants to call the on-call nurse.

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References: 1. U.S. Department of Health and Human Services. Cancer - Healthy People. Heal. People 2020. 2013. Available at: http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=5. Accessed November 15, 2013. 2. Cancer Trends Progress Report - Colorectal Cancer Screening. Available at: http://progressreport.cancer.gov/doc_detail.asp?pid=1&did=2007&chid=72&coid=718#benefits. Accessed December 9, 2013. 3. Death Rates - State Cancer Profiles - Iowa Counties. Available at: http://statecancerprofiles.cancer.gov/cgibin/deathrates/deathrates.pl?19&020&00&0&001&1&1&1. Accessed November 12, 2013. 4. Bandi P, Brooks D, Calle J, et al. Colorectal Cancer Facts & Figures 2008-2010. Am. Cancer Soc. 2010. 5. Yabroff KR, Mariotto AB, Feuer E, Brown ML. Projections of the costs associated with colorectal cancer care in the United States, 2000-2020. Health Econ. 2008;17(8):94759. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17910108. Accessed October 24, 2013. 6. Center for Medicare & Medicaid Services. National Health Expenditure Projections 20102020.; 2010:1. 7. U.S. Department of Health and Human Services. CDC Health Disparities and Inequalities Report - United States, 2013.; 2013. 8. Alteri R, Bandi P, Brooks D, Cokkinides V, Doroshenk M, Gansler T. Colorectal Cancer Facts & Figures 2011-2013. Am. Cancer Soc. 2013. 9. Culver CJ, Judge P, Governor L. Health in Iowa: Annual Report From the 2007 Iowa Behavioral Risk Factor Surveillance System.; 2007:5761. 10. Shepard D. Health in Iowa: Annual Report Behavioral Risk Facotr Surveillance System.; 2011:194. 11. Shaukat A, Mongin S, Geisser M, et al. Long-Term Mortality after Screening for Colorectal Caner. N. Engl. J. Med. 2013;369(12):110614. 12. Survival rates for colorectal cancer. Available at: http://www.cancer.org/cancer/colonandrectumcancer/overviewguide/colorectal-cancer-overviewsurvival-rates. Accessed October 23, 2013.

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13. Levy BT, Daly JM, Xu Y, Ely JW. Mailed fecal immunochemical tests plus educational materials to improve colon cancer screening rates in Iowa Research Network (IRENE) practices. J. Am. Board Fam. Med. 2012;25(1):7382. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22218627. Accessed December 8, 2013. 14. Iowa Department of Public Health. Iowa Get Screened: Colorectal Cancer Program: Information Manual.; 2012:139. 15. Levy B, Daly J, Luxon B, et al. The Iowa Get Screened Colon Cancer Screening Program. J. Prim. Care Community Health. 2010;1(43):4349. 16. Sherman C. Programs Help More Blacks Get Needed Colorectal Cancer Screening | Center for Advancing Health. Centers Adv. Heal. 2010. Available at: http://www.cfah.org/hbns/2010/programs-help-more-blacks-get-needed-colorectal-cancerscreening. Accessed December 7, 2013.

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