To increase colorectal cancer screening rates, the Centers for Disease Control and Prevention (CDC), in collaboration with the Center for Medicare and Medicaid Services (CMS) and the National Cancer Institute (NCI), developed a national awareness campaign, Screen for Life: National Colorectal Cancer Action Campaign (Screen for Life), which was launched in 1999. The campaign messages are based on an extensive literature review, informant interviews, focus groups, conversations with medical experts, and guidance from a professional communications firm (1).

The goal of the campaign is to raise awareness of colorectal cancer screening among all Americans aged 50 years and older; populations of special interest include African Americans, Hispanics, Alaska Natives, and Medicare beneficiaries (1). Components of the Screen for Life campaign include television and radio public service announcements (PSAs), posters, brochures, fact sheets, and print advertisements. CDC distributes campaign materials to television, radio, and print media in major market areas throughout the United States. CDC also maintains a Web site that provides additional information about the campaign and instructions for ordering materials (available from www.cdc.gov/screenforlife).

In addition to directly distributing campaign materials, CDC makes campaign materials available to state health departments for distribution to local media. CDC works with intermediaries such as state and local organizations to promote the Screen for Life campaign at the local level and increase the likelihood that broadcast media materials are aired at times favorable for reaching target audiences.

According to process evaluation data provided by CDC, Screen for Life television PSAs have aired more than 143,000 times in the United States, accounting for 2.2 billion audience impressions and an estimated dollar value of $13 million (CA Gelb, written communication, February 2005). CDC also is monitoring colorectal cancer screening rates using data from the Behavioral Risk Factor Surveillance System and the National Health Interview Survey. Data from both surveys indicate colorectal cancer screening rates are low among U.S. adults aged 50 or older (2,3). However, additional evaluation methods, such as assessing the dissemination of the Screen for Life campaign through intermediaries such as state and local organizations — a critical component of cancer prevention and control — have not been examined. It is therefore unknown whether state and local organizations are effectively using this educational resource.

Intermediaries are frequently used to enhance the distribution and use of health communication campaign materials. Intermediaries are individuals or groups that control the flow of information or resources to intended audiences. If intermediaries do not like the messages or materials being distributed, they may serve as barriers to audience exposure (4). When conducting formative research for the design of communication materials, it is important to ask intermediaries to review materials (4); however, it is not always possible for all potential intermediaries to review materials being developed at the national level. It is especially important to examine the role of intermediaries when there is concern that a segment of the target audience is not being reached. Obtaining feedback from intermediaries on the distribution mechanism for the materials and the materials themselves is important when assessing campaign implementation, which is an essential component of process evaluation.

As defined by the Appalachian Regional Commission (ARC), the Appalachia region encompasses 410 counties in 13 states along the spine of the Appalachian Mountains (Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Virginia, and West Virginia) (5). The mortality rate of colorectal cancer in Appalachia (17.2 per 100,000 population) is higher than the national rate (16.9 per 100,000) (6). Of particular interest to this study are the colorectal cancer death rates in Kentucky (18.4 per 100,000), West Virginia (18.2 per 100,000), and Pennsylvania (18.8 per 100,000) (6). Colon and rectal cancer incidence rates in the Appalachian regions of these three states are also reported to be significantly elevated compared with the U.S. rates approximated from NCI's Surveillance, Epidemiology, and End Results (SEER) program (relative risk, colon cancer = 1.13; relative risk, rectal cancer = 1.19) (7). In addition, colorectal screening rates in parts of Appalachia and other rural areas in the United States are lower than national, metropolitan, and suburban rates (2,8). Appalachia is also recognized for growing disparities related to poverty, employment, education, chronic disease and disability, overall health status, health insurance coverage, and access to preventive health care services and medical providers (9,10). Recognizing the need for increased awareness about colorectal cancer screening in Appalachia, the Appalachia Cancer Network (ACN) examined the distribution of Screen for Life materials in this region through intermediary organizations, including state health departments and its own program directors. ACN, an NCI-funded Special Populations Network, was created to address cancer health disparities among Appalachian residents in eight states: Kentucky, Maryland, New York, Ohio, Pennsylvania, Tennessee, Virginia, and West Virginia (9). Investigators sought to obtain insight into potential barriers to distributing and using Screen for Life materials in Appalachian communities within the network as well as insight into the usefulness of the materials and preferences for the different types of campaign materials. The research question posed by investigators was, Are Screen for Life materials being used and distributed by state or local organizations serving Appalachian residents? In addition, the authors examined local intermediaries' perceived acceptability of the materials among Appalachian populations.

The two ACN regions that distributed and used the Screen for Life materials reported greater campaign activity than the two state health departments. These two regions worked through their network of field staff and established community coalitions to distribute the Screen for Life materials to various settings, including beauty shops, banks, churches, health departments, hospitals, school systems, grocery stores, civic organizations, cancer centers, fitness centers, libraries, senior centers, rural clinics, and cooperative extension offices. As an example, one of the ACN programs distributed 180 posters and more than 8000 brochures to area libraries and 200 posters and 5000 brochures to local Area Agencies on Aging.

The two participating state health departments distributed the Screen for Life materials to state employees and local and regional health departments. One state health department disseminated the materials through its six regional cancer prevention coordinators; these coordinators serve in the state's six health districts. The coordinators distributed the brochures at presentations and health fairs throughout the state and promoted the television PSAs. The other state health department made the Screen for Life posters available to its local and regional health departments at regional meetings and provided links to CDC's Screen for Life Web site through the state health department's listserv. These actions enabled local health departments to access and order materials themselves.

When asked how they would improve CDC's distribution of the Screen for Life materials, responses from both ACN and the state health department staff centered on perceived CDC programmatic issues. Comments were made that CDC could work more actively with the states, increase ordering limits, and dedicate more staff for processing orders. It was suggested that materials be given directly to local health departments because, as stated by one respondent, materials were "usually stalled at the state level." This respondent recommended that CDC "target clinics where people are actually being seen and screened."

Rather than commenting on CDC's distribution, one state health department respondent commented on her organization's distribution challenges: "Distribution is an age-old issue. There wasn't enough funding to make sure the health departments used the materials. There was no follow-up. There was no time or money to discover the outcome or to track the use of the materials by the local health departments."

The ACN program directors and the state health department staff perceived that the Screen for Life materials were successful in stimulating and increasing colorectal cancer screening awareness. However, respondents either were doubtful or unable to answer when asked whether the materials had an effect on improving colorectal cancer screening rates in their communities.

All respondents seemed to recognize Screen for Life as an awareness campaign, but as one ACN program director commented, "Screen for Life is a great idea. It's good for national awareness, but it needs another level to actually impact colorectal cancer screening." Beyond anecdotal comments from community coalition members, activity reports from ACN field staff, and follow-up surveys with community groups inquiring about future participation in cancer control activities, there were no formal analyses related to material effectiveness.

When asked which of the materials were most effective, several respondents reported that they felt the posters were most effective; one respondent, however, did not feel comfortable answering the question because of a lack of formal evaluation. Other perceptions were related to factors that might affect the effectiveness of the PSAs. For example, PSAs aired late at night may not be as effective as PSAs aired during prime television viewing hours. Another respondent commented, "There just wasn't a reasonable way to get the PSAs to the local health departments and their media contacts. No funding was available to make copies."

The ACN program directors and the state health department staff agreed that a "plan of action" should accompany the Screen for Life campaign materials. Each organization using the materials decides how they are used and distributed, but each may not have time to develop an implementation strategy. Study respondents expressed the belief that the Screen for Life campaign materials should be part of a comprehensive cancer education program, which would also include successful methods for their use and distribution.

One respondent commented that she especially liked the "Let's Break the Silence" brochure because it was written in a low-literacy format, it was organized into succinct sections, and it included good visuals. She noted, however, that the brochure was not available for the 2003 Screen for Life campaign. Respondents offered suggestions, including developing a slide show, using more family-centered rather than individual-focused materials, and creating more materials for health educators. Another respondent stated that enabling the state health department to tag the television PSAs with its own information made the PSAs more personal. 

As noted previously, local contacts were named by state-level respondents who stated that Screen for Life campaign materials had been sent to that individual or organization. Of the seven local contacts, three recalled receiving the Screen for Life campaign materials and were familiar with them, two thought "maybe" they had received the materials but were not familiar with Screen for Life, and two respondents reported that they had not received the materials nor were they familiar with them. Of the three respondents who received the Screen for Life materials and were familiar with them, two used the materials in a similar fashion: both exhibited the posters throughout their communities in clinic waiting rooms, medical examination rooms, physicians' offices, and hospital corridors. Neither respondent targeted a specific audience but rather used a general approach to reach all visitors to these locations. One of these two respondents also used the brochures in community outreach activities, including mobile blood pressure clinics. Neither respondent had assessed how well the materials were received by the audience.

The third community-level respondent who received the Screen for Life materials and was familiar with them used the Screen for Life materials in an entirely different way. Instead of disseminating the materials, the organization represented by this respondent chose to conduct qualitative research on the materials (11). The organization's staff members reviewed the materials to determine the appropriateness of the materials for Appalachian populations, whether they needed to be tailored to Appalachians, and the best way to disseminate them. The organization conducted focus groups in two Appalachian counties with members of the general public to examine their reactions to the Screen for Life brochures and fact sheets. In addition, the organization conducted interviews with the office staff of family practice physicians in the same two counties in which the focus groups were held to determine additional perceptions.

Of the two respondents who used the materials in their clinics, one perceived that the Screen for Life campaign was effective in increasing colorectal cancer screening awareness, because it "seems as though patients are doing more screening." The other respondent hesitated when asked this question and ultimately responded with the following comment: "That's a tough question. With awareness campaigns, you need to hit the audience from every angle, especially rural populations. PSAs could have been helpful. We needed something to get their attention, like the American Cancer Society's 'Polyp Man' campaign." The respondent from the organization that conducted focus groups replied, "Honestly, I don't know if Screen for Life is effective in raising awareness."

Similar to the state-level intermediaries, one community-level respondent recommended training for users of the materials and direction on how to make presentations. Additional suggestions included the development of print-ready materials that could be personalized and tailored to a participating organization, which would "help to save time and keep from reinventing the wheel." One respondent commented, "Couldn't we do more than just handing stuff out? It would be nice to receive a comprehensive program — 'Here's what you do!'" In response to these remarks, particularly the comment about print-ready materials, the study interviewer provided the Screen for Life Web site address to the respondent. The respondent went straight to the Web site during the interview and stated, "This is great! I had no idea! It would have been helpful to have known about the Screen for Life Web site to download information."