Increasing CRC Screening among Filipino Americans (Maxwell, Bastani, Danao, Crespi, UCLA. ACS ) Recruitment of subjects in 45 CBOs and churches Baseline Interview (N=906) RANDOMIZATION of subjects who are non-adherent at baseline (N=548)* Control (Exercise) Intervention 1 (Education, FOBT kit + reminder letter + letter to provider) 6 month telephone follow up: any CRC screening during follow-up 9% 30% 25% Verification of self-reported screening Intervention 2 (Education, NO FOBT kit + reminder letter + letter to provider) Randomization of small groups, couples attend the same session.

Estimates of the efficacy of the intervention Analysis ApproachPercent screenedIntervention effect estimate SubjectsOutcome variable Intervention w/FOBT kit Intervention w/o FOBT kit Control Intervention w/FOBT kit versus control Intervention w/o FOBT kit versus control OR (95% CI) P OR (95% CI) P 1 Study completers (n=432) Self-reported screening status 39% (61/156) 31% (45/146) 11% (14/130) 5.6 (2.8, 11.4) < (1.9, 7.8) <.001 2*2* All randomized participants (n=548) Study completers: self- reported screening status Study non-completers: single imputation of not screened status 30% (61/202) 25% (45/183) 9% (14/163) 4.9 (2.4, 9.9) < (1.8, 7.5) < All randomized participants (n=548) Study completers: self- reported screening status Study non-completers: multiple imputation of self- reported screening status; All subjects: adjustment for PPV and NPV of self-report 32%22%6% 7.8 (2.8, 21.3) < (1.5, 14.1).009 NPV, negative predictive value; PPV, positive predictive value. * Maxwell AE, Bastani R et al. American Journal of Public Health 2010.

Efficacy of combinations of intervention components Intervention combination subgroupsControl Intervention components N=81 N=74 N=56 N=35N=113 Small-group session, print materials* & reminder letter*  FOBT kit *  Letter to provider*  Estimated percent screened26%27%21%18%6% OR vs. control group 5.7 (1.3, 23.8) 5.7 (1.3, 24.9) 4.8 (1.1, 21.6) 4.1 (0.6, 29.2) P-value Analyses included all participants who attended a small-group session and provided sufficient information to enable a letter to be mailed to their provider. Adjusted for baseline differences, PPV and NPV of self-report. * evidence-based intervention strategies

Community Dissemination of an Evidence-based CRC Screening Intervention (Maxwell, Bastani, Danao, Crespi, UCLA. ACS 2010 – 2014) 10 CBOs Randomize 5 CBOs Basic Dissemination (one-time training of CHAs & distribution of materials) 5 CBOs Organizational Dissemination (basic dissemination + workshop with CBO leaders to implement 5 organizational changes to promote CRC screening + 6 booster sessions/year with CHAs) 5 CBOs x 5 CHAs x 8 subjects = 200 subjects 5 CBOs x 5 CHAs x 12 subjects = 300 subjects Group-randomized design (as funded) CHA = Community Health Advisor Assessments: Telephone interviews of subjects, organizational assessments, health advisor debriefings and log sheets.

The Racial and Ethnic Approaches to Community Health (REACH) Model of Change Insurance status Health care providers Health Care Environment Filipino American Community Changes in health Changes in risk factors and protective factors Organizational changes Changes in change agents Develop community capacity Community awareness of issue Actions Targeting CBOs Filipino CBOs Centers of Disease Control and Prevention, adapted from Hill et al., Question: Include only orgs from CRC1 Study, new orgs or both?

Research Question: What strategy to disseminate a CRC screening intervention has the greatest impact when administered in Filipino American community settings? Evaluation Framework: RE-AIM REACH: CHAs in the organizational dissemination arm will disseminate CRC screening to more subjects than CHAs in the basic dissemination arm. EFFECTIVENESS: Filipino Americans in the organizational dissemination arm will exhibit higher screening rates at 6 mos follow-up than those in the basic dissemination arm. ADOPTION: Organizational dissemination will result in better organizational adoption of activities to promote CRC screening compared to basic dissemination. IMPLEMENTATION: Given technical assistance and resources, CBOs can implement evidence- based strategies to promote CRC screening among Filipino Americans. MAINTENANCE: Organizational dissemination will result in better maintenance of activities to promote CRC screening compared to basic dissemination. Question: what constitutes Maintenance? No more technical and financial support for orgs? How do we assess Maintenance activities without influencing organizations and CHAs? When does Maintenance phase start in the basic and organizational dissemination arm?

RE-AIM Measures Reach: # of subjects enrolled, how do enrolled subjects compare to the larger FA population? Compare refusals & participants, drop-outs & completers Effectiveness: # of subjects screened at 6 months Adoption: # of dissemination activities conducted per month and per subject in year 2. Implementation: compare activities reported by CHAs and subjects to protocols. Maintenance: # of dissemination activities conducted per month and subject in years 3 to 4.

NCCDPHP Knowledge to Action Framework Research Phase Efficacy Effectiveness and Implementation Supporting Structures Discovery Inst. Phase Institution- alization Decision to Adopt Knowledge to Products Practice Supporting Structures Diffusion Practice-based Discovery Decision to Translate Dissemination Engagement Translation Phase Evaluation Supporting Structures Practice-based Evidence Question: Can a 4 year study really assess all components from effectiveness to institutionalization?

Size Type Health promotion experience Leadership attitude towards intervention Admin/financial support ORGANIZATIONAL-LEVEL Background Interest in intervention Interest as CHA Self-efficacy to implement the intervention CHA-LEVEL Demographics Prior screening behavior Health insurance Baseline MD recommendation PARTICIPANT-LEVEL Intensity/complexity Technical assistance Level of training Extent of tailoring Observability INTERVENTION Individual & Setting Level Predictors of Implementation Relationship Position of CHA within org Relationship Length of relationship, credibility, trust Graphic developed from article by Rabin, Nehl, Elliot, Deshpande, Brownson, Glanz. Implementation Science 2010 Question: Are there existing measures we can use to assess these variables? Which variables are most important?

Discussion Questions Importance of community awareness: Conduct the trial with “veteran” or “virgin” organizations or both? Criteria for selection & randomization of orgs (size of membership, SES of geographic area in which org is located, church versus non-faith based orgs) Basic dissemination arm: how can we conduct frequent assessments without contaminating this arm Maintenance phase - when does it start: after 2 years of implementation? - continue to provide financial support to orgs during maintenance phase? - limit assessments to one exit interview to not influence level of activities during the maintenance phase? Assessment What are the main organizational and CHA variables that we should assess? How to deal with organizations that are dropping out? Contribution to Dissemination & Implementation Science How can our data inform the Model of Change and RE-AIM?