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Adaptation of a Community Health Advisor 
Intervention to Increase Colorectal Cancer 
Screening Among African Americans in the 
Southern United States 
Matthew A. Vargas1, Olayemi O. Matthew1, Deloria R. Jackson1, Tifini Austin1, Rima Tawk1, Kristin Wallace2,3, 
Clement K. Gwede4,5, John S. Luque*1 

1 College of Pharmacy & Pharmaceutical Sciences, Institute of Public Health, Florida A&M University, 1515 
Martin Luther King, Jr. Blvd., Tallahassee, FL 32307, USA 
2 Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, 68 
President Street, Charleston, SC 29425, USA 
3 Hollings Cancer Center, Medical University of South Carolina, 86 Jonathan Lucas Street, Charleston, SC 
29425, USA 
4 Division of Population Sciences, Department of Health Outcomes and Behavior, Moffitt Cancer Center, 
12902 Magnolia Dr., FOW-EDU, Tampa, FL 33612, USA 
5 Morsani College of Medicine, University of South Florida, 12902 Magnolia Dr., FOW-EDU, Tampa, FL 
33612, USA 

*Corresponding author and email: John S. Luque; john.luque@famu.edu. 

ABSTRACT 
Community health advisor (CHA) interventions increase colorectal cancer (CRC) screening rates. African 
Americans experience CRC disparities in incidence and mortality rates compared to whites in the US. 
Focus groups and learner verification were used to adapt National Cancer Institute CRC screening 
educational materials for delivery by a CHA to African American community health center patients. Such 
academic-community collaboration improves adoption of evidence-based interventions. This short article 
describes the adaptation of an evidence-based cancer education intervention for implementation in an 
African American community. 

KEYWORDS: Colorectal cancer; colorectal cancer screening; health disparities; African Americans. 

Citation: Vargas MA et al (2021) Adaptation of a Community Health Advisor Intervention to Increase 
Colorectal Cancer Screening Among African Americans in the Southern United States. Cancer Health 
Disparities 5:e1-e10. doi:10.9777/chd.2021.1002. 
 
 
  



 
 
 
 
 

 
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INTRODUCTION 
Evidence-based public health involves merging 
science-based interventions and programs with 
community-identified needs and capacity aiming for 
the goal of improving population health (Kohatsu et 
al., 2004). Patient navigation for colorectal cancer 
(CRC) is an evidence-based approach to improve 
patient outcomes in the areas of cancer screening, 
diagnostic procedures, and follow-up for cancer 
treatment (Leach et al., 2021). A recent systematic 
review reported that colorectal, breast, and cervical 
cancer screening rates were higher in patients who 
received patient navigation services, which can be 
very impactful for African Americans who experience 
cancer health disparities (Nelson et al., 2020). African 
Americans have lower CRC screening rates than 
whites, and consequently, there have been numerous 
intervention studies to increase screening rates for 
African Americans through patient navigation, 
technological innovations, and improvements to 
appointment scheduling or reminder systems 
(Boutsicaris et al., 2021; Davis et al., 2017; Miller et al., 
2020). 

As one of the four major cancer sites, CRC mortality 
rates have been declining since 1980, but in recent 
years these declines have slowed (Siegel et al., 2021). 
African Americans experience CRC disparities in 
mortality rates which can be attributed to persistent 
income inequalities and its effects on access to 
healthcare and lower screening adherence, which 
may result in late-stage diagnosis and lower survival 
rates (DeSantis et al., 2019). According to the latest 
available data, the mortality rate for African Americans 
is 36% higher than whites (18.5 per 100,000 population 
compared to 13.6 per 100,000 population for whites), 
with more pronounced disparities for men compared 
to women (Siegel et al., 2021). CRC incidence rates are 
also higher among African Americans compared to 
whites, and in terms of geographic variation, 
incidence rates in the US South are higher compared 

to other regions of the US, which is another factor to 
consider especially with the rise in early-onset 
colorectal cancer (Siegel et al., 2019). This short article 
summarizes the adaptation and refinement of a 
community health advisor (CHA) intervention which 
employs evidence-based patient navigation 
approaches and includes educational materials from 
the National Cancer Institute (NCI) Screen to Save 
(S2S) Colorectal Cancer Outreach and Screening 
Initiative (National Cancer Institute, 2021). 

Educational Materials Development 
S2S is a national initiative which aims to enhance CRC 
outreach and screening. According to the NCI, the 
aim is to increase CRC screening rates among men 
and women ages 50 and older from racially and 
ethnically diverse communities and in rural areas 
(National Cancer Institute, 2021). In alignment with the 
NCI’s goal of increasing CRC screening rates, the Test 
Up Now Education Program (TUNE-UP) created and 
adapted materials which consisted of an educational 
brochure and a narrated presentation video - based 
on the S2S materials - to deliver a culturally tailored 
intervention to African Americans living in low-income 
communities. The intervention is delivered by the CHA 
to African Americans in North Florida who are patients 
of community health centers and are not up to date 
with CRC screening. This research project is part of a 
Research Centers in Minority Institutions grant from 
the National Institute on Minority Health and Health 
Disparities which is focused on addressing cancer 
health disparities in Leon County and Gadsden 
County, Florida. Gadsden County is the only county in 
Florida with a majority African American population. 
The utilization of a CHA and the adaptation of S2S is 
an evidence-based approach for promoting CRC 
screening. The S2S initiative has been shown to be 
effective based on the published findings from the 
national outreach initiative which leverages NCI-
designated Cancer Centers. The program evaluation 
reported 3,183 pre/post surveys were obtained from 



 
 
 
 
 

 
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participants, ages 50 to 74, during 347 educational 
events (Whitaker et al., 2020). Results demonstrated 
an increase in colorectal cancer-related knowledge 
and revealed a positive association between attending 
educational events and intention to receive 
subsequent CRC screening. In addition, 82% of 
participants who received a CRC screening three 
months after attending the events successfully 
obtained their screening results (Whitaker et al., 2020). 
The results of the S2S initiative suggest the 
effectiveness of the community-based approach to 
achieve positive outcomes in terms of CRC screening 
adherence in diverse populations. 

Focus Group Learner Verification 
The TUNE-UP study began with formative research 
with African American community participants using 
focus group methodology. The objective of the focus 
groups was to explore knowledge, attitudes, and 
beliefs about CRC and CRC screening as well as to 
obtain learner verification of the educational 
brochure. This was an important step to ensure that 
the educational materials were comprehensible to the 
intended audience and provided easily digestible 
information on CRC screening. In this article, we 
describe the sections of the educational brochure and 
the adaptation of the presentation, but the complete 
findings from the focus group results have been 
published elsewhere (Luque et al., 2021). 

The brochure was designed as a tri-fold brochure. For 
the initial version, the brochure cover had a header of 
the study name, stock photos of a group of friends 
walking for exercise and an older couple with the 
TUNE-UP title and university logo and underneath, 
the text “What Black Men and Women need to know 
about Colorectal Cancer Screening.” The back cover 
contained TUNE-UP contact details, information on 
covering the cost of CRC screening and where to get 
more information from the American Cancer Society 
and the NCI. The inside flap covered information on 
the types of available screening tests with an emphasis 

on stool-based tests and a picture of the test kit. Most 
importantly for our study, under the description of the 
Fecal Immunochemical Test (FIT) were bullet points 
describing that the FIT is used to check stool for blood, 
the stool sample is placed in a small vial, and is then 
returned to the doctor or laboratory for testing. In 
addition, it was described that the FIT is done every 
year, and in the case of a positive FIT, the patient is 
referred to colonoscopy. The inside panel 1 showed a 
picture of the human colon with polyps and a bulleted 
list of modifiable and nonmodifiable risk factors for 
CRC. The inside panel 2 showed a picture of the 
anatomy of the colon and a definition of CRC. The 
inside panel 3 described what happens after a CRC 
screening, details on the colonoscopy procedure and 
answered some questions about CRC screening with 
a short testimonial on how to overcome the fear of 
completing the test. 

Based on the feedback we received from focus group 
meetings 1 and 2, changes were made to the 
brochure and the second version was created. 
Specifically, the color was changed to make it more 
attractive, texts were made bold for ease of reading, a 
picture of a famous person who had died from CRC 
was added, detailed formatting was done and the 
picture of the anatomical figure depicting the colon 
was edited by darkening the skin tone so it did not 
appear to be a white person - based on feedback 
from the focus groups. This version of the brochure 
was used for focus groups 3, 4, and 5. 

Focus group feedback was further used to make 
changes to the brochure for a final version. A 
professional design of the entire brochure was done, 
and the color scheme changed, using two major 
colors – blue signifying CRC and green signifying our 
university’s school colors. On the inside of the 
brochure, a picture of a newer test kit replaced the 
older kit picture, and a photo of a well-known Black 
couple in the community was inserted. This final 



 
 
 
 
 

 
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version was used for focus group meetings 6 and 7 
with no further suggested changes (Figure 1). 

Community Health Advisor 

CHAs also known as community health workers, peer 
health educators, promotoras, lay health advocates 
and other similar titles are trusted public health 
workers who possess intimate knowledge about the 
communities they serve and facilitate access to health 
and social services with improved quality and cultural 
competency. CHAs may be paid employees within a 
health care system or volunteer patient advocates, 
and for increasing cancer screening, their work is cost-
effective (Attipoe-Dorcoo et al., 2021). Improved 
adherence to recommended health practices is a 
recognized benefit of CHA services and several 
reviews of CHA CRC screening interventions have 
shown a positive effect on receipt of screening (Naylor 
et al., 2012; Rawl et al., 2012). In the context of our 
current behavioral clinical trial, a CHA was trained by 
the research team to deliver a 6-week intervention 
consisting of an initial face-to-face or virtual CRC 
educational presentation, two weeks of phone-call 

follow-up, and three weeks of text message follow-up. 
The intervention’s one-on-one education, small 
media, follow-up reminders, and reduction of 
structural barriers to screening aligns with client-
oriented recommendations of the Community Guide 
to Preventive Services (Guide to Community 
Preventive Services, 2021). We hypothesize that the 
CHA intervention described here and utilized in the 
behavioral clinical trial will demonstrate positive CRC 
screening outcomes compared to a “usual care” 
approach among a population of African Americans 
not up to date with current screening 
recommendations. 

We prioritized designing a CHA screening 
intervention for effectiveness in promoting CRC 
screening among African Americans who suffer 
disproportionately from CRC (Figure 2). Therefore, we 
sought to identify and recruit a CHA from our local 
African American community. We engaged African 
American community leaders for assistance 
promoting the 

 

Figure 1. CHA Intervention Development 

 

S2S 
Resources

Draft 
Brochure, 
Video & 

Text 
Messages

Focus 
Group 

Feedback

Research 
Team 

Refinement

Finalization 
of 

Materials

Delivery of 
CHA 

Intervention 

Intervention 
Materials 



 
 
 
 
 

 
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CHA job opportunity. The candidate selected 
through this outreach had been a member of the 
community for many years, had provided 
community education around other health topics, 
was comfortable discussing CRC with African 
American women and men, and expressed desire 
to work in service to the community. To prepare the 
CHA to deliver the CRC educational intervention, 
we developed and delivered the didactic and 
interactive training described below. 

CHA Training 
The CHA training consisted of three didactic and 
two interactive sessions focused on colorectal 
cancer education, the role of the CHA, intervention 
components, and practice interactions using role 
playing. The training was delivered by three study 
investigators (JL, CG, KW) and the project 
coordinator (MV). The cancer module provided an 
overview of cancer and CRC and covered CRC 
incidence, risk factors, common symptoms, lifestyle 
changes, prevention, and screening 
recommendations and options (i.e., stool-based 
tests, colonoscopy, sigmoidoscopy and CT 
colonography). Didactic materials were drawn from 

reliable sources such as the NCI, the CDC, and the 
American Society of Clinical Oncologists (ASCO). 
The didactic PowerPoint modules included 
hyperlinks to all information sources and were 
supplemented with graphics (e.g., anatomical 
images) and YouTube video tutorials. Delivery of 
the didactic modules was recorded as a training 
product for future reference. The training also 
discussed the importance of intervention fidelity 
and skills for maintaining fidelity of the CHA 
educational intervention using a conversation script 
and presenting different possible scenarios. 
Additionally, an introduction to motivational 
interviewing was provided, and the CHA trained on 
using basic principles of motivational interviewing 
to help them achieve success with participants who 
present with barriers to screening and need support 
or counseling (Luckmann et al., 2013). In the final 
training session, the CHA completed practice 
sessions to simulate CHA-client interaction 
situations, using talking points, followed by 
feedback from the project coordinator, who 
assessed fidelity using checklists. 

NCI, CDC, 
ASCO 

Resources

Didactic & 
Interactive 
Modules

Research 
Team 

Refinement

CHA 
Didactic 
Trainings

CHA 
Interactive 
Trainings

CHA Training 



 
 
 
 
 

 
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Refining the CHA Intervention 
The CHA educational presentation to intervention 
arm participants includes the use of NCI CRC 
resources and materials, including the 
approximately 11-minute S2S PowerPoint 
presentation video that was adapted and created. 
Using pictures, charts and figures, the video begins 
with an initial description of CRC, its incidence, risk 
factors and prevention, with a highlight on health 
disparities, comparing CRC incidence and mortality 
rates between the black and white U.S. population. 
Screening recommendations and options are 
further explained, with a focus on colonoscopy and 
the stool-based test. The final part of the video 
transitions to provide information on the TUNE-UP 
study including eligibility criteria, study procedures, 
and details on participant incentives. 

The CHA meets with participants at their preferred 
location to provide the intervention. After using a 
tablet to show the S2S video to the study participant 
and allowing for questions/discussion, the CHA 
shows the participant a second video which explains 
how to complete a stool-based CRC screening test 
(FIT kit) at home. This 5-minute CRC screening 
patient tutorial video was obtained by the study 
team through agreement with the manufacturer. 
Following presentation of the second video, the 
CHA again engages the participant to allow for 
questions or discussion. At the conclusion of the 
face-to-face meeting, the CHA informs the 
participant that the CHA will check in with them by 
phone a week later to ask if they were successful in 
completing and mailing in their FIT kit.  Intervention 
arm participants receive this 30-minute face-to-
face meeting followed by two CHA phone calls in 
one-week intervals over a period of three weeks 
beginning within one month following baseline 
survey completion. Using fidelity checklists for 
weeks 1-3, the CHA records qualitative data from 
the intervention session and subsequent phone 

calls. The duration of educational intervention 
sessions depends on the participants’ inquiries and 
typically last 25-35 minutes. Follow-up phone calls 
for weeks 2 and 3 are generally short in duration. 

To maintain intervention fidelity, the CHA follows a 
conversation guide/standard script and completes 
checklists for the face-to-face meeting and phone 
calls. The CHA takes notes of each interaction to 
document call length, tone, and deviations from the 
script. Participants are already knowledgeable 
regarding FIT screenings at weeks 2-3 and 
therefore the fidelity checklists for weeks 2-3 
document receipt or non-receipt, completion, and 
mailing in of FIT screenings, and to address any 
concerns that the participant raises following the 
intervention. The CHA implements motivational 
interviewing to address any questions or concerns 
the participant may have about the educational 
presentation. Participants receive an additional text 
message reminder once a week for an additional 
three-week period. 

The personalized text messages have positive tones 
and include short messages about the importance 
of CRC screening (Weaver et al., 2015). The three 
text messages selected were the most preferred by 
focus group participants during the learner 
verification phase. The initial text message that is 
sent in week 4 of the intervention states, “Screening 
for colon cancer saves lives.” The text message sent 
in week 5 states, “Seven out of ten people diagnosed 
with colorectal cancer often have no obvious signs 
and symptoms, regular screening is the key to early 
detection.” The final text message sent in week 6 
states, “Don’t let fear of diagnosis stop you from 
getting tested, early detection is key to prevent colon 
cancer. Get tested today.” Acceptability of the CHA 
intervention is assessed by two items included in the 
3-month phone survey with intervention arm 
participants. One question asks participants to rank 
on a Likert scale their satisfaction with support 



 
 
 
 
 

 
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received from the CHA, and the second item asks if 
they would recommend working with a CHA to 
others who have not been screened. 

Conclusion 
Academic-community partnerships provide a 
mechanism to test intervention strategies to 
increase CRC screening and address cancer health 
disparities (Meade et al., 2011). By seeking 
community input on the adaptation of the S2S 
evidence-based CRC screening education 
resources as part of a CHA intervention, the 
resulting intervention is received well in the 
community. In addition, the engagement of the 
community health centers and other community 
partners to advertise the study (churches, small 
businesses) is being used to leverage participation 
of African American patients in the community. The 
findings from these academic-community research 
partnerships will generate knowledge about how to 
adapt evidence-based community health educator 
programs in both community and clinical settings. 

Acknowledgement 
We acknowledge support of the U54 RCMI Center 
Office – Ms. Leola Hubert-Randolph and Ms. Gloria 
O. James–Academic Support Services, Florida A&M 
University College of Pharmacy and Pharmaceutical 
Sciences, Institute of Public Health and U54 RCMI 
Principal Investigator, Dr. Karam F. Soliman. We 
acknowledge study team members Dr. Cynthia M. 
Harris, Dr. Askal Ali, and Dr. Gebre Kiros. We also 
acknowledge the assistance of Dr. Alexandria 
Washington with help facilitating in-person focus 
groups. 

This article was supported by funding from the 
National Institute on Minority Health and Health 
Disparities of the National Institutes of Health under 
Award Number U54 MD007582. The content is 
solely the responsibility of the authors and does not 

necessarily represent the official views of the 
National Institutes of Health. 

Conflict of interest 
The authors declare no conflict of interest. 

Authors’ contributions 
This manuscript was conceived by J.S.L. J.S.L. and 
M.A.V. led the writing. All authors contributed to 
writing and editing the manuscript. 

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Supplemental Figure 1. TUNE-UP Brochure 

 



 
 
 
 
 

 
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	INTRODUCTION
	Educational Materials Development
	Focus Group Learner Verification
	CHA Training
	Refining the CHA Intervention
	Conclusion
	Acknowledgement
	Conflict of interest
	Authors’ contributions
	Supplemental Figure 1. TUNE-UP Brochure

