J Community Health (2010) 35:592–601
DOI 10.1007/s10900-010-9247-4
ORIGINAL PAPER
Community-Based Colorectal Cancer Screening Trials
with Multi-Ethnic Groups: A Systematic Review
Jay B. Morrow • Florence J. Dallo •
Manjula Julka
Published online: 12 March 2010
 Springer Science+Business Media, LLC 2010
Abstract The objective of this review was to summarize
the current literature of community-based colorectal cancer
screening randomized controlled trials with multi-ethnic
groups. The CDC reports 40% of adults do not receive
time-appropriate colorectal cancer screening. Although
overall screening rates have improved since 2000, dispar-
ities remain. Studies examining community characteristics
may offer insight into improving screening rates and
eliminating disparities. We identified community-based
colorectal cancer screening studies using PubMed and Ovid
Medline database searches. Inclusion criteria were: com-
munity-based, randomized controlled trials; English lan-
guage; published from 1/2001 to 8/2009; all colorectal
cancer screening test interventions recommended in the
2008 ‘‘Joint Consensus’’ report; and study participants
from at least two racial/ethnic groups, with not more than
90% representation from one group. There were 29 rele-
vant articles published during 2001–2009; with 15 meeting
inclusion criteria. We categorized the final studies (n = 15)
into the four categories of Patient mailings (n = 3), Tele-
phone outreach (n = 3), Electronic/multimedia (n = 4),
and Counseling/community education (n = 5). Of 15
studies, 11 (73%) demonstrated increased screening rates
for the intervention group compared to controls, including
all studies (100%) from the Patient mailings and Telephone
J. B. Morrow (&)
M. Julka
Department of Family and Community Medicine,
UT Southwestern Medical Center at Dallas,
6263 Harry Hines Blvd, Dallas, TX 75390-9067, USA
e-mail: jay.morrow@utsouthwestern.edu
F. J. Dallo
School of Health Sciences, Rochester, Michigan,
Oakland University, 2200 N. Squirrel Road,
Rochester, MI 48309-4401, USA
123
outreach groups, 4 of 5 (80%) Counseling/community
education studies, and 1 of 4 (25%) Electronic/multimedia
interventions. Patient choice and tailoring of information
were common features of trials that increased screening
rates across study categories. Including community-level
factors and social context may be useful in future design
and evaluation of colorectal cancer interventions to reduce
or prevent new cases of colorectal cancer.
Keywords Community-based
Colorectal cancer
screening
Randomized controlled trials

Health disparities
Introduction
Colorectal cancer is the third most commonly diagnosed
and the third leading cause of cancer death in both men and
women in the US. The Center for Disease Control and
Prevention (CDC) estimates that 60% of colorectal cancer
deaths could be prevented by regular screening of adults
50 years of age and older [1]. The CDC found in their 2000
National Health Information Survey (NHIS) that 40% of
adults do not receive time-appropriate colorectal cancer
screening.
Colorectal Cancer Disparities
Colorectal cancer rates have decreased from 55.5 cases per
100,000 persons in 2000, to 50.3 cases per 100,000 persons
in 2008 [2]. Overall colonoscopy screening rates improved
from 53.5% in 2004 to 62.2% in 2008 [3]. Despite recent
improvements in overall colorectal cancer screening, dis-
parities are still evident. An analysis of NHIS 2000 data
demonstrated screening rate improvements varied by race/
J Community Health (2010) 35:592–601
ethnicity, usual source of care, insurance and nativity
status [4].
Screening disparities may be due to physician and
patient factors. Hawley et al. [5] found that physicians were
over-estimating their recommendations to patients for
appropriate colorectal cancer screening. Two studies
illustrate patient factors that may explain screening dis-
parities. Researchers analyzing the 2001 California Health
Interview Survey found that Whites and African Americans
were more likely than other racial/ethnic groups to state
that their physician did not recommend the test, and that
the test was painful or embarrassing [6]. Hawley et al. [7]
followed up with a comparative study in 2008 to establish
patient preferences for colorectal cancer screening modal-
ities within a diverse, multi-ethnic primary care research
network. The group found that the patient factor of test
preference varied among racial/ethnic groups. To increase
screening adherence, they recommended offering patients a
menu of options to tailor screening to match their prefer-
ences. Hawley et al. call for further research of simplified
decision tools to help providers tailor screening.
Beyond physician and patient factors, De Jesus et al.
identified important community level factors that improve
screening adherence in low-income multi-ethnic popula-
tions [8]. The study described important social context
levels such as patients’ work, home, and school environ-
ments; their worries about health; and their personal values
and beliefs. Patients who felt their providers understood
them on two or more of these social context levels were
significantly more likely to be current with CRC screening
compared to those who reported their providers understood
them on one or none of these levels (OR = 1.56; CI
95% = 1.06, 2.29).
These studies describing physician, patient and com-
munity-level factors underscore the need to deliver cul-
turally competent care to racially/ethnically diverse
populations to improve screening rates. The studies also
suggest that community-based interventions could play a
meaningful role in this future research.
Community-Based Participatory Research
versus Community-Based Interventions
Our systematic review of interventions best describes
‘‘community-based’’ research, but would not be classified
as ‘‘community-based participatory research,’’(CBPR). The
Agency for Health Care Research and Quality (AHRQ), in
collaboration with the W.K. Kellogg Foundation, define
CBPR as participation by communities, organizations and
researchers in all aspects of the research process [9]. When
conducted appropriately, CBPR can result in long-term bi-
directional relationships leading to longitudinal studies to
improve screening outcomes. However, a 2009 search
593
using the Ovid Medline subheading ‘‘Community based
participatory research’’ revealed 61 articles since 2001, with
none representing colorectal cancer screening studies.
Community-based interventions meeting inclusion criteria
for this review are conducted within community populations
to whom the benefits are directly targeted, and include
multiple ethnic groups for appropriate disparities analysis.
We define ‘‘community’’ according to MacQueen et al. as:
‘‘a group of people with diverse characteristics who are
linked by social ties, share common perspectives, and
engage in joint action in geographical locations or settings.’’
[10] Communities in which colorectal cancer screening
research is conducted are often defined by racial/ethnic and
geographical ties. Many studies do not include multiple
ethnic groups, an essential element for disparities research
measurement. A 2006 Cancer supplement from Coughlin
et al., [11] CDC-funded intervention research aimed at
promoting colorectal cancer screening in communities,
provides a valuable prospective description of eight CDC
investigators’ studies, but is not a comprehensive review of
community-based trial results. Authors noted that few
studies at the time were importantly focusing on colorectal
cancer screening in diverse populations.
This systematic review provides a narrative synthesis of
community-based colorectal cancer screening randomized
controlled trials using multi-ethnic groups. We recognize
that single ethnic group studies offer powerful insights into
interventions that improve screening rates for target popu-
lations. However, we focus on multi-ethnic group trials for
two reasons: (1) To consider other factors of social context,
besides race/ethnicity, affecting screening rates, and (2) To
describe interventions that might be generalized to larger
populations than single-ethnic group studies. Analysis in
this review may help colorectal cancer screening researchers
design community-based randomized controlled trials based
on strategies that have increased screening rates within
populations experiencing screening disparities.
Methods
Study Design
This systematic review of the colorectal cancer screening
literature retrieves all articles describing community-based
randomized controlled trials with multi-ethnic groups.
Final articles match inclusion and exclusion criteria
described below.
Data Sources and Searches
We used PubMed and Ovid Medline to conduct our search
and included studies published from January 2001 to June
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2009. The 2001 start date is concurrent with Medicare
offering universal enrollee coverage for colonoscopy,
beyond high-risk patients only [12]. We chose the 2001
date because it significantly marks the beginning of the
current screening era in which colonoscopy is widely and
consistently accepted as the gold standard screening
modality.
The literature review was first performed using Ovid
Medline, and then reproduced in PubMed to cross-match
search results. The Ovid Medline literature review is
divided into eight exclusionary stages, seven within the
Ovid Medline system itself, and the last stage consisting of
a manual review of the electronically-filtered articles to
obtain the final review articles.
Keywords in the Ovid Medline search include ‘‘colon
cancer’’ or ‘‘colorectal cancer,’’ as keywords and mapping
to the respective subheadings of ‘‘colonic neoplasms’’ and
‘‘colorectal neoplasms,’’ respectively; ‘‘prevent$’’ or
‘‘screen$’’; ‘‘program’’ or ‘‘intervention’’; ‘‘communit$’’ or
the subheadings exp ‘‘Health Promotion/’’ or exp ‘‘Com-
munity Networks/’’ or exp ‘‘Community Health Services/’’
or exp ‘‘Education, Nursing/’’ or exp ‘‘Community based
Participatory Research/’’.
The Ovid Medline search was cross-matched with a
PubMed search with the following keywords and MESH
terms: (‘‘residence characteristics’’[MeSH Terms] OR
(‘‘residence’’[All Fields] AND ‘‘characteristics’’[All
Fields]) OR ‘‘residence characteristics’’[All Fields] OR
‘‘community’’[All Fields]) AND (‘‘colorectal neo-
plasms’’[MeSH Terms] OR (‘‘colorectal’’[All Fields] AND
‘‘neoplasms’’[All Fields]) OR ‘‘colorectal neoplasms’’[All
Fields] OR (‘‘colorectal’’[All Fields] AND ‘‘cancer’’[All
Fields]) OR ‘‘colorectal cancer’’[All Fields]) AND
(‘‘diagnosis’’[Subheading] OR ‘‘diagnosis’’[All Fields] OR
‘‘screening’’[All Fields] OR ‘‘mass screening’’[MeSH
Terms] OR (‘‘mass’’[All Fields] AND ‘‘screening’’[All
Fields]) OR ‘‘mass screening’’[All Fields] OR ‘‘screen-
ing’’[All Fields] OR ‘‘early detection of cancer’’[MeSH
Terms] OR (‘‘early’’[All Fields] AND ‘‘detection’’[All
Fields] AND ‘‘cancer’’[All Fields]) OR ‘‘early detection of
cancer’’[All Fields]) AND (‘‘randomized controlled
trial’’[Publication Type] OR ‘‘randomized controlled trials
as topic’’[MeSH Terms] OR ‘‘randomized controlled
trial’’[All Fields] OR ‘‘randomized controlled trial’’
[All Fields]).
Study Selection
The Ovid Medline review consists of nine stages. We
selected studies with seven preliminary, electronic stages,
followed by two stages to review abstracts and then full
papers, respectively. Both the Ovid Medline and PubMed
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J Community Health (2010) 35:592–601
searches were conducted with the search terms described
above.
We applied the following inclusion/exclusion criteria for
full text articles from both Ovid Medline and PubMed
searches:
(i) Types of studies
Randomized controlled trials, prevention or screening,
community-based settings in the US, English-only,
published from 2001 to current. Sample sizes of
approximately 100 or greater.
(ii) Type of participants
Participants from at least two racial/ethnic groups in
each study, with not more than 90% representation
from one group. We excluded studies that did not
include a disadvantaged ethnic group and a reference
group.
(iii) Types of interventions
All colorectal cancer screening test interventions
recommended in the March 2008 ‘‘joint consensus’’
colorectal cancer screening guideline consensus
report: [13] high sensitivity fecal occult blood testing
(FOBT) or fecal immunochemistry; flexible sig-
moidoscopy; colonoscopy; double contrast barium
enema; CT colonography or ‘‘virtual colonoscopy’’;
or stool DNA testing. Interventions are targeted to
patients, not health care providers.
(iv) Types of outcome measures
Studies that measured the difference in screening
adherence between intervention group participants
and controls receiving the standard of care.
Data Extraction
Two authors (JBM, FJD) independently reviewed each of
the resultant abstracts, and then articles. At each of the two
manual review stages, authors excluded studies that did not
have characteristics matching the above criteria. Inclusion
in the review required unanimous decision. The final
colorectal cancer screening articles included in the sys-
tematic review describe community-based randomized
controlled trials using multi-ethnic groups.
Data Analysis
To meet the objective of the review, the study selection
process follows the Quality of Reporting of Meta-analyses
(QUOROM) group’s flow diagram technique, as described
by Moher et al. [14]. Final study results are described in a
table, based on The Cochrane Handbook’s protocol rec-
ommended criteria for systematic review [15]. Study
groupings are determined by the review authors, according
to screening medium. Review articles are described by the
J Community Health (2010) 35:592–601 595

following table columns: Study; Community Setting; Sample

size; Race/Ethnicity; Socioeconomic indicators; Screening
modality; Comparison groups; Odds ratios (95% CI); and
p. Community Setting describes the location, type of com-
munity or health care center and predominant population to
whom the screening intervention was delivered. Race/Eth-
nicity includes all population sub-groups reported in the
study population characteristics by investigators. Socioeco-
nomic indicators are study population characteristics repor-
ted by investigators, including occupation, education,
income, and their proxies. Screening modality describes the
screening test(s) used in the studies. Comparison groups lists
all intervention and control groups for each trial. Odds ratios
(95% CI) is the most common measure of effect size that
was reported in review articles. Risk ratios are reported
when used instead. The P column indicates the P-value for
the reported odds or risk ratios for each study.

Results

Search Results

The electronic database search resulted in 107 potentially

relevant abstracts. The QUOROM group [13] search flow
diagram in Fig. 1 details the review process in excluding
78 abstracts: 24 were not conducted in the U.S.; 20 were
not screening trials; 18 were not community-based inter-
ventions; 9 reported a single racial/ethnic group; 5 were
provider interventions; and 2 were duplicates. We retrieved
and reviewed 29 full papers and subsequently excluded 14
for the following reasons: 6 were not community-based
interventions; 5 described a single racial/ethnic group; and
3 were not screening trials. Based on these exclusion cri-
teria, 15 articles are included in this review.
Study Characteristics
Table 1 summarizes the study characteristics of the inclu-
ded studies. We categorized the final studies (n = 15) into
four categories: Patient mailings (n = 3), Telephone out-
reach (n = 3), Electronic/multimedia (n = 4), and Coun-
seling/community education (n = 5). Of 15 studies, 11
(73%) demonstrated increased screening rates for the
intervention group compared to controls, including 6 of 6
(100%) studies from the Patient mailings and Telephone
outreach groups, 4 of 5 (80%) Counseling/community
education studies, and 1 of 4 (25%) Electronic/multimedia
interventions.
We found 10 of 15 (67%) studies reporting screening
adherence outcomes by race/ethnicity. Of these 10 studies,
Fig. 1 QUOROM Search flow diagram
8 (80%) demonstrated no significant effect of race/ethnicity
on these outcomes. We discuss all findings below.
Patient Mailings
Three of three (100%) studies that used a patient mailing
strategy [16–18] demonstrated significant differences
between intervention and control groups to enhance colo-
rectal cancer screening adherence. These studies were
conducted within the large, urban settings of Philadelphia,
Denver and Chicago. Study strategies included mailed
tailored messages based on Preventive Health Model
(PHM) constructs [18], mailed brochures reminding
patients to schedule a colonoscopy and educating them
about the benefits and risks of the procedure [16], and
mailed FOBT cards with a letter signed by the Clinic
Director [17].
Telephone Outreach
All three studies (100%) we categorized as telephone
outreach studies [19–21] demonstrated significant screen-
ing rate improvements in the intervention group compared
to controls, and were performed in New York City. Two
studies by the same author targeted underserved Medicaid

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 Table 1 Community-based colorectal cancer randomized controlled trials with multi-ethnic groups (n = 15)
596

Study Community setting Sample Race/ethnicity Socioeconomic Screening Comparison groups Odds ratiosa (95% CI) P
size indicators modality

123
Patient mailings
Myers (2007) [18] Urban family medicine 1546 African American Education FOBT • Mailing 1.7 (1.25–2.53) .001
practice in White FIT • Tailored mail 1.6 (1.18–2.12) .002
Philadelphia
DCBE • Tailored mail ? phone 1.9 (1.42–2.56) \.001
Colonoscopy reminder
• Usual care
Denberg (2006) [16] Two general internal 781 White Income Colonoscopy • Brochure No odds reported. -
medicine practices in Black Insurance type • Usual care Screening adherence
Denver, CO 11.7% greater in
Latino
brochure group
Other
Goldberg (2004) Urban, public hospital 119 African American - FOBT • Mailed FOBT cards ? 16 (3.5–71.4) \.001
[17] clinic in European Flex Sig reminders
Winston-Salem, NC American Colonoscopy • Usual care
Hispanic DCBE
Other
Telephone outreach
Dietrich (2007) [21] Six community health 626 English - FOBT • PCM (Mailing ? 1.69 (1.03–2.77) .04
centers in New York Women Spanish Flex Sig unscripted phone
City assistance)
(Primary Colonoscopy
Language) • AMOP (Mailing ?
DCBE
scripted phone
recommendation to
discuss CRC screening
with health care
professional
Dietrich (2006) [20] Eleven community and 11 Sites English Insurance FOBT • Women receiving No odds reported. .016
migrant health centers Spanish Flex Sig telephone calls from Absolute
in New York City prevention care managers difference = 0.13
Other Colonoscopy
• Usual care (.07–.19)
(Primary DCBE
Language)
Basch (2006) [19] New York City 456 Black Education FOBT • Tailored telephone 4.4 (2.6–7.7) .05
metropolitan area White Work status Flex Sig education
Other Annual household Colonoscopy • Controls receiving printed
income materials
DCBE
J Community Health (2010) 35:592–601
 Table 1 continued
Study Community setting Sample Race/ethnicity Socioeconomic indicators Screening Comparison groups Odds ratiosa (95% CI) P
size modality

Electronic/multimedia
Chan (2008) [23] Homes, public libraries 97 White Education FOBT • A public and private NSF NSF
in Houston, TX African-American Income intervention arms
receiving NETLET
Other Insurance
physician email
Transportation to doctor
• A public and private
visits
control arms receiving
usual care
J Community Health (2010) 35:592–601

Ruffin (2007) [22] Urban, suburban, rural 175 Caucasian Insurance FOBT • Patients using screening 3.23 (2.73–3.50) \.05
communities in African-American Currently employed Flex Sig preferences-based
Michigan Colorectal Web
Education Colonoscopy
• Standard colorectal
has regular doctor
website
Miller (2005) [24] Community-based 204 Black Education FOBT • Multimedia computer NSF NSF
internal medicine White Insurance program education
outpatient practice • Nurse counseling
Friedman (2001) [25] Community clinic in 160 African American Education FOBT • Peer educator/health NSF NSF
Houston, Texas Caucasian Income professional video
education
Hispanic
• No video
Other
Counseling/community education
Potter (2009) [28] Flu shot clinic at San 514 African-American Insurance FOBT • Flu shots ? FOBT kits 11.3 (5.8–22.0) \.001
Francisco General Asian/Pacific Yearly income during flu shot clinics
Hospital Islander • Flu shots only
Latino
Non-Latino White
Other
Percac-Lima (2008) Urban community 1223 White Insurance FOBT • Patients receiving No odds reported. \.001
[27] health center in Latino Flex Sig ‘‘navigator’’ services Relative risk=2.25
Chelsea, MA • Usual care
Black Colonoscopy
Asian Barium enema
Other
Thompson (2006) Twenty predominantly 20 Sites Hispanic Education FOBT • Comprehensive NSF NSF
[30] Hispanic communities Non-Hispanic Income Flex Sig community screening
in Washington State White behavior program
Occupation Colonoscopy
• Usual care
Insurance status
597

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.013
patients and migrant workers. The third study population

.03
P
consisted of insured fund beneficiaries with colorectal
cancer screening coverage.
Odds ratiosa (95% CI)

Dietrich et al. [20, 21] evaluated telephone outreach

No odds reported
3.08 (1.13–8.35)
strategies in 2006 and 2007 including a prevention care
management (PCM) program with a scripted assessment of
the barriers to colorectal cancer screening tests, assistance
to overcome these barriers, and further scheduling assis-
tance and appointment reminders. Another telephone
strategy involved tailored support and elicitation of a
• Modified cultural group
verbal commitment for screening from patients, and the
Counseling (CCRC)
• Colon Cancer Risk

Counseling (GHC)

• Cultural and self-

emphasis on support from scientists, medical doctors, and

Comparison groups

• Traditional group
• General Health

health organizations, rather than referral to a primary care

empowerment

provider [19].

Electronic/Multimedia Interventions

One of four studies (25%) we categorized in the Elec-

tronic/multimedia group demonstrated a significant differ-
Colonoscopy

ence between intervention and control groups [22]. This

Screening
modality

Flex Sig

study focused on FOBT screening only.

FOBT

FOBT

Failed electronic/multimedia interventions included

strategies of personalized email messages from the
patients’ primary care provider, and a mailed reminder
Other (Filipino, Chinese, % Regular source of
% Health insurance

Years of education
Household income

letter from their physician to increase mailed FOBT

Socioeconomic

adherence [23], educational computer programs to improve

FOBT screening [24], and video peer education [25]. They
Education
indicators

Income

cited barriers to accessing and using email as the primary

care

reason for public access group failure.

Ruffin et al. [22] demonstrated the superiority of a
preference-based screening website, Colorectal Web, to a
non-interactive CDC website.
Hispanic, Korean,

African American
Race/ethnicity

Caucasian

Caucasian

Counseling/Community Education
Hawaiian
Japanese

mixed)

Studies in the Counseling/Community Education category

were conducted in diverse community settings, included
heterogeneous subject populations, and assessed various
Sample

screening modalities. Of 5 studies, 4 (80%) demonstrated

size

First degree relatives of 176

134

significant differences between intervention and control

groups [26–29].
patients in Hawaiian

15 Senior centers in

Strategies that improved screening rates in this category

Community setting

South Carolina

included pairing FOBT kits with annual flu shots in a large

tumor registry

urban hospital clinic [28], a culturally tailored patient

navigator program based on language needs [27], colon
cancer risk counseling for first degree relatives of indi-
viduals in a state tumor registry [26], and a comprehensive,
Table 1 continued

culturally relevant elder education program [29]. The

Glanz (2007)

strategy in this category that failed to improve screening

Powe (2004)

rates was a comprehensive community screening behavior

[26]

[29]

program that included, free colonoscopy screening, among

Study

many other activities [30].

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J Community Health (2010) 35:592–601
Discussion
Patient mailings and telephone outreach strategies con-
veyed patient choice best among the screening trials in this
review. Studies in these categories offered participants a
menu of screening options. All of the electronic/multi-
media strategies that focused on a FOBT-only option for
screening (3 of 3, 100%) failed to demonstrate a significant
adherence difference between intervention and control
groups. Our review findings contrast the experience of
Griffith et al. that offering patients more screening options
had little effect on interest in colorectal cancer screening
[31].
In this review, patient choice was as an important
factor to improve screening adherence in studies report-
ing improved screening rates of intervention group to
controls. In fact, patient choice also played a central role
in the only study of four in the electronic/multi-media
group to demonstrate a significant adherence difference
compared to controls. Ruffin et al. [22] explored the
effects of embarrassment, discomfort, prep, and other
potential factors influencing choice of colorectal cancer
screening procedures. Colorectal Web offered patients
preference-based screening options taking these factors
into account.
A second factor of trials in this review that improved
screening rates is tailoring of information for individual
patients. Of 11 studies in this review with positive
screening adherence intervention effects compared to
controls, 6 (55%) included tailored patient education and/or
messages. Tailoring involved customization of printed
materials with individual data in two studies [18, 26], using
semi-structured telephone interviews [19, 27], providing
options based on individual screening preferences [22], and
delivering culturally-relevant education to community
elders [29].
A third common factor among trials that improved
screening rates in this review is that investigators
respected community-level factors and social context, by
targeting interventions in underserved communities
where the direct benefits to participants were potentially
the highest. Investigators reviewed the incidence, mor-
tality and screening literature to focus on diverse popu-
lations in underserved communities. The hospital flu shot
clinic study by Potter et al. is a good example of how
review interventions were well-targeted [28]. Patients
with no usual source of care, the uninsured, and recent
immigrants experience the greatest health disparities [4].
The hospital flu clinic population matched all these
characteristics. Investigators across all studies in this
review also used sound, evidence-based behavioral the-
ory and models as rationale to target interventions to
those most in need.
599
Screening Disparities
We identified 10 of 15 (67%) studies that reported
screening adherence outcomes by race/ethnicity. Of these
10 studies, 8 (80%) demonstrated no significant effect of
race/ethnicity on these outcomes. We posit that the com-
munity-based focus of the reviewed studies provided a
framework that indirectly controlled for socioeconomic
status. The sample populations in most of our included
studies were predominantly of lower socioeconomic status,
with significant minority and underserved representation.
The socioeconomic homogeneity of the sample popu-
lations may have provided de facto study control across the
various indicators of socioeconomic status such as insur-
ance status, occupation, education, income, and their
proxies. An obesity geocoding study by Drewnowski,
Rehm and Solet supports the predictive strength of com-
munity-level socioeconomic factors [32]. In one of the first
studies to map obesity at the zip code level, they found
wide disparities between zip codes that were not present at
county and state levels. These disparities were not associ-
ated with race/ethnicity or individual income, but more
precisely by an alternate community-level measure of
socioeconomic status, median house value. Although these
findings for obesity may not be generalizable to other
health disparities, they do indicate that geocoding at the
community level may provide alternate sociodemographic
indicators for health disparities studies.
Strengths and Weaknesses of the Study
Studies included in the review are limited by a common
publication bias: interventions that do not find an effect are
less likely to be published. This limitation underestimates
our report of negative or null findings. We limited our
focus to randomized controlled trials with multi-ethnic
groups in the community setting. There are many cross-
sectional and cohort studies beyond the scope of this
review that describe innovative colorectal cancer screening
interventions. We chose randomized controlled trials
because they are the gold standard in epidemiology. The
process of random assignment of participants to interven-
tion and comparison groups balances demographics and
other potential confounders that may impact study results.
In their evaluation of the community-based participatory
research to date in 2002, AHRQ maintained that as long as
reliability and validity were rigorously analyzed, random-
ized controlled trials were not a necessary indictor of study
quality [9]. AHRQ welcomed studies using group assign-
ment, commonly seen in community-based studies, as long
as intervention and comparison groups were carefully
matched. They verified that study generalizations were
appropriate to study findings, and there was no significant
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loss to follow-up. In contrast, Rosen et al. [33] argue that
conducting randomized controlled trials should be a prior-
ity when appropriate. They counter arguments that ran-
domized controlled trials cannot evaluate multi-faceted
outcomes, consider community clusters rather than indi-
viduals, address real-world conditions, tailor interventions
to local needs, and contain costs. For all these reasons, we
required randomized controlled trials in our current review.
We excluded many quality trials similar to the following
examples that were: not community-based (A randomized
trial of two print interventions to increase colon cancer
screening among first-degree relatives [34]); provider
interventions (A provider intervention to improve colo-
rectal cancer screening in county health centers [35]); and
that only included one racial/ethnic group or more than
90% representation of the sample population from one
racial/ethnic group, (Storytelling for promoting colorectal
cancer screening among underserved Latina women: a
randomized pilot study [36]). This narrow focus excluded
much robust research on colorectal cancer screening, par-
ticularly in select minority populations that experience the
widest incidence, mortality and screening disparities, such
as African Americans. However, the review articles
described strategies within predominantly underserved
communities with diverse multi-ethnic populations that
carry the incidence, mortality and screening burden, and
may be more likely to benefit directly from these studies.
Many university-affiliated colorectal cancer screening
studies we excluded had sample populations that were
predominantly White, from high socioeconomic strata,
with private health insurance, and high levels of education.
Results from these studies are not likely generalized to
minority, underserved populations who are experiencing
health disparities.
To provide an evaluative framework for the review, we
grouped studies into four categories based on intervention
characteristics. The widely different study settings of
clinics, hospitals and community centers somewhat con-
found analysis by these group categories. We recognize
that a mailing or phone call from a patient’s clinic or pri-
mary care provider is very different from a community
setting such as a senior center.
Conclusions/Future Research
Patient choice and tailoring education and/or messages to
individuals may be important factors in improving colo-
rectal cancer screening adherence rates. DeJesus et al.
remind us that community-level factors, including under-
standing the social context of patients, are key factors to
help improve screening rates [8]. Early results suggest that
technology strategies in community-based trials have not
been overly successful with underserved populations. This
123
J Community Health (2010) 35:592–601
may be more method than rule. Investigators using tech-
nology strategies might benefit from offering participants a
menu of screening options, rather than a single option. We
found only 15 community-based randomized controlled
trials that included multi-ethnic populations, from a sig-
nificant body of literature on colorectal cancer screening.
Based on limited findings to date, we recommend that
future community-based colorectal cancer screening trials
include diverse populations who are experiencing inci-
dence, survival, mortality and screening disparities. The
focus on community-based research may de facto help
investigators move beyond race/ethnicity alone as a prime
determinant of health disparities, and explore issues of
socioeconomic status equally.
Our review evaluated community-based screening
interventions targeted predominantly at underserved pop-
ulations experiencing the greatest colorectal cancer
screening disparities. Our findings reinforced prior research
suggesting that moving beyond considerations of race/
ethnicity only, to include community-level indicators of
social class, may be useful when targeting interventions in
which health disparities exist. Providing benefit to those
most in need ensures not only that we are accurately tar-
geting interventions, but also that we proceed with the
public health goals of correcting social inequity and
injustice.
Acknowledgments The authors gratefully acknowledge Raul
Caetano, MD, MPH, PhD for his guidance and conceptual contribu-
tions to this manuscript.
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