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Colorectal cancer education and 
screening program for the un- or under- 
insured in a primarily rural setting in 
Northeast Texas: Design and methods 
Gabriela Orsak1, Carlton M. Allen2, Anastasia Miller3, Karan P. Singh1, Paul McGaha2 

1The University of Texas Health Science Center at Tyler, Department of Epidemiology and Biostatistics, 
Tyler, TX, USA,  2The University of Texas Health Science Center at Tyler, Department of Community Health, 
Tyler, TX, USA, 3The University of Texas Health Science Center at Tyler, Department of Healthcare Policy, 
Economics and Management, Tyler, TX, USA 

*Corresponding author: Gabriela Orsak, Email: gabriela.orsak@uthct.edu,  

ABSTRACT 
Although early detection and screening for colorectal cancer (CRC) saves lives, screening rates remain 
suboptimal, especially for minorities, underserved populations, older adults (>60), men, un/under 
insured, and those living in rural settings. The goal of the colorectal cancer education and screening 
program is to target the un- or under- insured in a 19-county primarily rural target area to provide: 1) 
education concerning CRC and CRC screening to 12,000 individuals, and 2) CRC screenings 
(colonoscopy and/or fecal immunochemical test [FIT]) to 5,1613 un- or under- insured individuals. The 
education outreach team targets local health fairs, clinics, churches, etc. to educate individuals on CRC 
and the importance of screening. The program aims to then have those individuals electively undergo a 
colonoscopy and/or a FIT test. The number of those educated and screened is recorded. The results 
related to colonoscopy, FIT, and follow-up are collected. Primary outcomes include number of 
individuals educated, number of FIT test/colonoscopies performed and results of screening procedures. 
This education and screening outreach program is designed to reach primarily rural and underserved 
populations eligible for colorectal screening. Results of efficacy of program will advance knowledge on 
how to conduct colorectal cancer outreach programs in rural settings. 

KEYWORDS: colorectal cancer; rural colorectal cancer outreach program; colonoscopy; FIT testing; 
uninsured; underinsured 

Citation: Orsak G, et al (2019) Colorectal cancer education and screening program for the un- or under- 
insured in a primarily rural setting in Northeast Texas: Design and methods. Cancer Health Disparities 4: 
e1-e11. doi:10.9777/chd.2019.1010 
 
 



 
 
 
 
 

 
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1. INTRODUCTION AND RATIONALE 

1.1 Burden of colorectal cancer and the importance 
of early screenings 

Colorectal cancer (CRC) prevention is an important 
public health issue. CRC is the fourth most common 
cancer and the fourth most common cause of 
malignancy-related death in the United States (U.S. 
Cancer Statistic Working Group, 2018). Mortality can 
be significantly reduced through regular CRC 
screenings (Friedrich et al., 2015). CRC lends itself well 
to public health initiatives as it is a slowly progressive 
disease that can be cured if treated early. Specifically, 
the detection and removal of precancerous polyps 
can prevent colorectal cancer with recent reports 
reporting  subsequent reduced mortality by 67% 
(Doubeni et al., 2018; Lieberman et al., 2012). CRC 
survival is dependent upon early detection, thus, 
highlighting the importance of early screenings 
(Levin et al., 2008). Although screenings save lives, 
screening rates remain suboptimal, especially for 
minorities, underserved populations, older adults 
(>60), men, un/under insured, and those living in 
rural settings (Alteri et al., 2014; Salas et al., 2014).   

1.2 CRC screening methods 
Two common methods for CRC screening are 
colonoscopy and the fecal immunochemical test 
(FIT). Colonoscopy is considered the gold standard 
for CRC screening due to its ability to screen and 
consequently remove precancerous polyps (Friedrich 
et al., 2015). However, there are significant barriers to 
patients undergoing a colonoscopy such as 
education, a significant financial and temporal 
commitment, as well as fear or avoidance of the 
invasive procedure. For example, patients often are 
not aware they need the procedure, need to take 
time off work, prep in advance, arrange 
transportation (it is not recommended to drive 
afterward), and personally finance the procedure. 

Finally, there is an additional burden of the fear or 
avoidance of the procedure. While colonoscopy is 
considered the gold standard in the medical 
profession, FIT seems to be better accepted (Segnan 
et al., 2007). 

FIT offers an alternative to the financial, temporal, 
and personal barriers of a colonoscopy. FIT is an 
inexpensive CRC screening option that allows 
patients to send in a stool sample to a laboratory, 
collected at their own convenience. This eliminates 
the need for prep, transportation, fear and 
avoidance of an invasive procedure, time off work, 
and financial burden for many patients with a normal 
result. While this can be especially advantageous to 
the un- or under-insured, it is not a complete CRC 
screening method on its own (Quintero et al., 2012). 
FIT test results yield either a normal or abnormal 
result. After an abnormal test result, patients are 
urged to undergo a colonoscopy.  

1.3 CRC in Northeast Texas 
Northeast Texas is a 35-county area that is home to 
over 1.5 million individuals (Nehme et al., 2016). It 
consists of primarily rural communities, with few 
small metropolitan statistical areas. CRC incidence 
and mortality is higher in this rural setting (Cancer 
Prevention & Research Institute of Texas, 2010). 
Specifically, the age-adjusted incidence (43.3-43.6 in 
Northeast Texas vs. 38.1 in Texas and 38.27 in the 
United States) and CRC mortality (15.8-16.9 in 
Northeast Texas vs. 14.4 in Texas and 14.1 in the 
United States) far exceed state and national levels 
(National Cancer Institute, 2017; Texas Cancer 
Registry, 2018a, b).  

1.4 Rationale for targeting improving CRC 
screening rates in Northeast Texas 

The U.S. Department of Health and Human Services’ 
current goal is to achieve a 70.5% CRC screening 
rate (U.S. Department of Health and Human Services, 



 
 
 
 
 

 
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2018). However, even with the availability of both 
screening methods, CRC screening rates remain 
suboptimal in the general public (62.4%; (U.S. 
Department of Health and Human Services, 2018) 
and in rural communities (58.2%(U.S. Department of 
Health and Human Services), with rates being 
increasingly suboptimal in Northeast Texas 
(44.63%(Hall, 2018). They are even lower among the 
uninsured (25.1%). The high CRC prevalence and 
lower screening rates in the Northeast Texas region 
represent a growing concern. The high incidence 
and mortality rates of CRC may be due to factors 
such as non-adherence to cancer screening 
recommendations, diagnosis of cancer at a later 
stage, and higher cancer mortality, which are more 
likely among rural residents (Cole et al., 2012; Fan et 
al., 2012; Hines et al., 2014). With evidence 
demonstrating the slow progression of the disease 
and proven efficacy of CRC screening to reduce 
cancer mortality(Doubeni et al., 2018; Friedrich et al., 
2015), it is imperative that public health programs 
develop programs that target populations with 
historically low rates of screening, such as the 
un/under insured, older populations, minorities, 
underserved populations, and those living in rural 
settings. The current program aims to target these 
individuals. 

1.5  Challenges of a colorectal cancer education 
and screening program in a primarily rural 
setting for the un- or under-insured 

Living in a rural or mostly rural community offers 
unique challenges to implementing a colorectal 
education and screening program targeting the un- 
or under- insured. Challenges to screening such a 
lack of education concerning the importance of 
screening and the different screening options are 
common. Dissemination of educational information 
is also onerous as residents are widespread and 
various events (e.g. health fairs) do not attract the 

same number of participants as in urban settings. 
Transportation problems often prove burdensome in 
the region. Specifically, residents often must travel 
long distances to seek care and the number of 
specialists in the area is often limited. This problem 
intensifies for older adults or for those who are un- 
or under- insured. Public transportation is mostly 
lacking in the area, limiting ones’ ability to return 
home following the procedure, as driving is restricted 
for safety reasons. Therefore, seeking preventive 
services such as colonoscopies and/or FIT may not 
be a priority for individuals in these communities. 

1.6 The University of Texas Health Science Center 
at Tyler (UTHSCT) CRC education and 
screening program for the un- or under-
insured  

The goal of the UTHSCT CRC education and 
screening program is to target the un- or under- 
insured in a 19-county primarily rural target area 
concerning CRC education and screening over a 5-
year period (Years 1 and 2 targeted 7 counties with 
expansion into 19 counties for Years 3-5). Specifically, 
the program aims to provide: 1) education 
concerning CRC and CRC screening to 12,000 
individuals, and 2) CRC screenings (colonoscopy 
and/or FIT) to 5,161 un- or under- insured individuals.   

2. METHODS 

2.1 Overview 
Process flow of the program is detailed in Figures 1-
3. Figure 1 details the initial participant process. 
Figure 2 details participant process when electing FIT 
testing, while Figure 3 details participant process 
when undergoing colonoscopy. This is an education 
and screening program targeting the un- or under-
insured. The education outreach team targets local 
health fairs, clinics, churches, etc. to educate 
individuals on CRC and the importance of screening. 
The program aims to then have those individuals 



 
 
 
 
 

 
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electively undergo a colonoscopy and/or a FIT test. 
The number of those educated and screened is 

recorded. The results related to colonoscopy, FIT, 
and follow-up are collected. 

 

Figure 1. Initial Participant Process  



 
 
 
 
 

 
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Figure 2. Participant FIT Process 



 
 
 
 
 

 
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Figure 3. Participant Colonoscopy Process 

2.2 The program team  
The members of the team consist of a Program 
Director, Co-Program Director, Program Manager, 
an Outreach Education Coordinator, Program 
Specialist, Nurse Navigator, and 3 Health Education 
Coordinators. The Program Manager, Outreach 
Education Coordinator, Program Specialist, Nurse 
Navigator, and Health Education Coordinators have 
gone through the Texas CHW certification training. 
They maintain their certification by completing CHW 
continuing education requirements. In addition, they 
are trained in Motivational Interviewing.  

2.3 Recruitment setting, eligibility, and enrollment 
Recruitment had both a community based and a 
clinical focus. Our strategy involved reaching out to 
individuals to make them aware of the need to 
undergo CRC screening, educating them about their 
screening options, performing the screening 
methodology of choice (FIT or colonoscopy), 
providing access to treatment for CRC, and 
providing follow-up. Individuals are recruited from 
clinics at UTHSCT, health fairs, charity clinics, local 
health departments and districts, and federally 
qualified health centers (FQHCs). The primarily rural 



 
 
 
 
 

 
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19- county region, known as Northeast Texas, has an 
area of about 14,762 (National Association of 
Counties, 2017) square miles with a total population 
of 2,167,769 (United States Census Bureau, 2017) in 
2017. Eligibility for colonoscopy/FIT are determined 
after education outreach and/or physician 
recommendation. 

To determine eligibility, US Preventive Services Task 
Force (USPSTF) guidelines, which recommend 
screening all races/ethnicities between the ages of 50 
and 75, were followed. Individuals are eligible to 
participate if they are between 50 and 75 years of 
age, speak English or Spanish, are un- or under- 
insured, do not have a medical reason for not 
undergoing the procedure(s) (e.g. taking blood 
thinners), and have not been previously diagnosed 
with CRC. Individuals also couldn’t have had a 
colonoscopy in the last ten years, a sigmoidoscopy in 
the last five years, or a stool test in the last year 
before becoming eligible for the Cancer Prevention 
and Research Institute of Texas (CPRIT) screening 
program.  

2.4  CRC education 
Our community-based approach reaches out 
through social media and community events. Social 
media is used through Facebook, Twitter and 
YouTube. Educational sessions at various community 
venues and health fairs throughout East Texas 
stressed the need for routine screenings and 
recruited individuals from these events. Community 
health workers (CHWs), in conjunction with the 
program manager and other support staff, 
coordinated these community educational activities, 
with the support of many church and minority 
business groups to spread awareness of the 
screening program and provided venues for 
community education. An educational tool that was 
used in the community outreach program was a 

giant inflatable colon. This colon model includes 
various stages of CRC progression (from normal 
through polyps to invasive cancer). This among other 
tools served as an educational and interactive exhibit 
during outreach activities by CHW’s to educate 
communities.  

Promotion is also being accomplished through 
partnerships and outreach with various community 
organizations including churches, workplaces, and 
barber/beauty shops. Individuals attending these 
meetings are asked to listen to a brief presentation 
about CRC screening, review a tailored decision-aid, 
complete a short intake form to determine eligibility, 
and sign a commitment specifying which screening 
option they plan to choose if eligible. The intake 
form includes demographics, screening status, health 
insurance, screening method preference, reminder 
preferences, barriers to participation, and intention to 
undergo screening. The intake form responses are 
entered and maintained in an electronic community 
outreach registry.  

Our clinical based approach involved us enlisted the 
help of multiple clinical partners to optimize 
recruitment. Our partners include an academic 
medical center, a charity clinics, local health 
departments and districts, and FQHCs.  We work 
with providers in primary care at UTHSCT and at 
other healthcare facilities to refer their patients for 
CRC screening. The focus of our recruitment is on 
the un- and under-insured. 

We worked with the American Cancer Society (ACS) 
to align cancer control opportunities and solutions 
with the needs and challenges of our health center, 
emphasizing sustained capacity building to result in 
improved public health outcomes. Specifically, the 
ACS assisted us by providing strategic planning 
guidance, provider and CHW education to optimize 
client and provider interventions. The ACS has 



 
 
 
 
 

 
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trained CPRIT and clinical staff. The partnership with 
ACS has increased our ability to educate providers 
and staff to optimize participant education and CRC 
screening. The ACS also provided linkages to 
community resources and other health systems to 
support sustained continuity of care.   

2.5 CRC screening 
Once all inclusion/exclusion criteria have been met, 
participants are offered colonoscopy and/or FIT test 
based on their preference and/or provider 
recommendation. Our nurse navigator will identify 
eligible individuals from a weekly report. The 
navigator will facilitate the coordination of the 
participant through the system for colonoscopy. 
Once it was determined that participants who were 
deemed un- or under- insured were unable to pay 
for services, screenings were provided free-of-
charge. In addition, participants undergoing a 
colonoscopy received a $20 gift card for 
transportation upon completion of a colonoscopy. If 
a participant did not undergo proper bowel prep 
and the colonoscopy is unsuccessful, an alternative 
date is scheduled. Participants who elected to have a 
FIT were scheduled for a colonoscopy if they had an 
abnormal FIT result (and subsequently received the 
same $20 gift card upon completion of services). The 
team works diligently to contact participants in 
regard to mailing FIT to the appropriate addresses, 
recontact individuals with their results and to 
schedule colonoscopy appointments with those who 
elect colonoscopy or receive an abnormal FIT test.  

If no additional procedures are immediately 
warranted, after the procedure, the patient is sent a 
letter detailing their results and when they should 
follow-up. They are also spoken to about attaining a 
primary care physician, if they do not already have 
one. If something additional is required, the patient is 
called and asked to return to the clinic. During that 

visit, the Nurse Navigator is present for support and 
clarification of treatment plan and decision making 
when diagnosis is given. For participants that require 
surgery first, the navigator will assist, if necessary, in 
treatment plan decisions (post-op radiation, post-op 
radiation and chemotherapy, or post-op 
chemotherapy). The navigator will continue to follow 
the participant through the continuum of care. 

If individuals who were educated at local events are 
found to have adequate insurance, they are referred 
to colonoscopy/FIT services, but are not financially 
compensated for their procedures. For individuals 
who were uninsured and required cancer treatment, 
CHWs and a Nurse Navigator assisted in finding 
alternative methods of funding for future procedures 
if needed. These alternative methods, included but 
were not limited to, the Affordable Care 
Act/Marketplace insurance, Medicaid, the County 
Indigent Health Care Program, or hospital insurance.  
For surveillance, the navigator will hand-off patients 
to the oncology team but will ensure follow-up of 
CRC screening is scheduled. For alternative 
pathways, Nurse Navigator will hand-off participant 
to medical/radiation oncology nurse and receive 
updates periodically. The Nurse Navigator will still 
ensure follow-up of CRC screening is scheduled. Due 
to the difficulty of tracking those individuals, data is 
only available for the un- or under- insured.  

2.6 Challenges concerning no-show rates.  
Noncompliance to completion of a CRC procedure is 
very common, especially with colonoscopy. Our 
program isn’t unique to the many barriers faced by 
individuals including coordinating transportation, fear 
the test is painful, embarrassment, and/or fear of 
abnormal findings (Chen et al., 2008). Our program 
uses CHWs to call individuals using motivational 
interviewing for participants that cancelled or no-
showed to their appointments. Our GI clinic also 



 
 
 
 
 

 
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attempts to reach out to individuals via phone calls 
as well. If unable to reach via phone, a letter is sent 
to their listed address inviting them to call to 
reschedule their appointment. We also work with 
community partners and update the clinics on the 
status of individuals that were referred to us by them. 
This was done so if an individual were to return to 
their primary care clinic before contacting us, the linic 
would be able to get in contacts with the individual 
again. 

2.7 Data collection 
Data collection is conducted at UTHSCT and 
outreach events. Data is comprised of self-reported 
questionnaire items and medical records. Reports are 
collected on a quarterly basis.  

2.7.1  Education outreach data 
The data collected at outreach events includes: 
Name, phone number, address, date of birth, race, 
ethnicity, gender, insurance status, if individuals are a 
health professional, if they have had a colorectal 
screening in the past, and if they would like to 
receive more information. This data was collected at 
outreach events by project staff. Sign-in sheets were 
then scanned into password-protected folders and 
the data was transferred into an excel sheet. 

2.7.2  Demographic data 
Demographic data is collected from medical chart 
data and through survey questionnaires. Data 
collected include, age, race, ethnicity, zip code, 
family history of CRC, previous CRC screenings, and 
insurance status.  

2.7.3 Colonoscopy data 
Data concerning colonoscopy procedures is 
collected from medical chart data. The data includes 
the date of colonoscopy, bowel prep 
(adequate/insufficient), result of colonoscopy, 

whether additional colonoscopies were warranted by 
the treating physicians.  

2.7.4  FIT data 
Data concerning FIT is collected from medical chart 
data. The data includes the date of FIT test, test 
result, duration of time to colonoscopy following 
abnormal FIT result.   

3.1 DISCUSSION 

3.1 Need for intervention to increase CRC 
education and screening rates 

CRC screening to prevent cancer is only effective if 
individuals elect to undergo screening services 
(Friedrich et al., 2015). Despite the efficacy of 
screening services such as colonoscopy and FIT, 
screening rates remain suboptimal (Alteri et al., 2014; 
Levin et al., 2008; Salas et al., 2014). Therefore, 
interventions targeting improvement in education 
and screening regarding CRC are crucial. Public 
health programs can initiate such programs and 
target populations with low screening rates. This will 
help to reduce the incidence of CRC and CRC 
mortality. The un/underinsured can particularly 
benefit from such programs, as they would not 
regularly undergo this preventive screening, as it 
would be an added medical cost. In addition, the 
un/under insured are particularly vulnerable as they 
would most likely not be able to afford treatment if 
CRC would develop, highlighting the important of 
public health programs adopting similar initiatives to 
increase education and subsequent CRC screening in 
populations with low screening rates. An additional 
barrier to many potential programs may include the 
rurality of the proposed region for intervention. 
Whereas, the education and screening of thousands 
of adults may be achieved with more ease in urban 
areas, teams working in rural settings face unique 
challenges to motivate individuals to undergo 



 
 
 
 
 

 
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screening. The primary barrier to care that is unique 
to rural areas is distance. Interventions programs 
must persuade individuals about the important of 
CRC screening and follow-up despite the additional 
burden of transportation and distance.  

3.2 Potential limitations and methodological 
considerations 

The current program has several limitations. First, 
while some individuals will elect to undergo 
colonoscopy first, others will undergo colonoscopy 
after a positive FIT test. However, both groups will 
have many individuals who fail to arrive for their 
scheduled colonoscopy due to transportation issues 
and despite receiving a $20 gift card for travel. 
Unfortunately, to the current program does not 
provide transportation services to individuals. 
Second, as mentioned earlier, many individuals 
choosing to undergo FIT testing will not follow-up 
with colonoscopy after an abnormal FIT test result. 
This will hinder assessing the efficacy of FIT test in 
detecting polyps. Similarly, those with a negative FIT 
will not undergo a colonoscopy. Third, the degree of 
education retained by individuals will not be able to 
be assessed due to the lack of time provided in 
health fairs. Only the number educated can be 
assessed.  

3.3 Conclusion and implications 
In conclusion, the CRC education and screening 
program aims to increase education and CRC 
screenings in a primarily rural population in 
Northeast Texas with low CRC screening rates and 
high CRC incidence and mortality. Results from this 
program have the potential to advance knowledge 
on effective ways to increase CRC screenings among 
underserved populations. Due to the nascency of FIT 
testing, evaluation of programs utilizing both FIT and 
colonoscopy are limited. The current program will 
provide insight into the advantages and 

disadvantages to each method in a primarily rural 
setting. Finally, it may also provide a method to 
those who were educated but did not undergo 
screening at the time, to undergo screening in the 
future, or for those who underwent screening to 
continue with screening methods outside of the 
program.  

Acknowledgements 
This study was funded by the Cancer Prevention & 
Research Institute of Texas (PP140018) and the 1115 
Medicaid Waiver. 
 
Conflict of interest 
The authors declare that no competing or conflict of 
interests exist. The funders had no role in study 
design, writing of the manuscript, or decision to 
publish. 

Authors’ contributions 
Carlton Allen and Paul McGaha contributed to the 
acquisition of data and the conduct of the project. 
Gabriela Orsak, Anastasia Miller and Karan Singh 
contributed to the statistical analysis of the project 
and generated the initial draft of the article. 
 
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