Colorectal cancer (CRC) is the fourth most commonly diagnosed cancer in Wisconsin and the second leading cause of cancer-related death (1). Statewide incidence and mortality rates for CRC vary by race and ethnicity; African Americans, American Indians, and certain Asian populations are more likely than whites to develop this disease and die from it (2). CRC disparities are related to the effect geography and socioeconomic status have on obtaining proper cancer screenings. Rural, low-income, and uninsured people are less likely to receive and be up-to-date with CRC screening (3,4).

CRC screening guidelines recommend a regular fecal occult blood test, sigmoidoscopy, or colonoscopy from age 50 until age 75; however, less than two-thirds of Americans aged 50 or older follow those recommendations (5,6).

More than 30% of eligible Wisconsin adults have never had a colonoscopy or sigmoidoscopy (7). Survival rates for CRC can exceed 90% if diagnosed early, yet over half of recent cases in Wisconsin were diagnosed at a regional or distant stage, indicating a need for earlier detection through improved screening programs (8).

The Wisconsin Comprehensive Cancer Control Program (WCCCP) works to engage public, private, and community partners to implement a statewide approach to cancer control (9). To examine possibilities for improving CRC screening statewide, WCCCP convened a stakeholder group, the Wisconsin Colorectal Cancer Screening Taskforce, which analyzed county-level screening rates and assessed current screening capacity. Those results guided the subsequent development of a grant application to fund health systems’ development of CRC screening events for underserved Wisconsin communities.

From 2010 through 2012, WCCCP awarded grants to 5 regional health systems for the purpose of planning and implementing CRC screening events. Health systems and community partners designated underserved populations in their service areas and then designed events to maximize participation for those attendees.

Wisconsin is a geographically varied state that includes urban, rural, and tribal areas. Although most of the state’s population is non-Hispanic white, there are regional concentrations of racial and ethnic minorities: 6.5% African American, 6.1% Hispanic or Latino, 2.4% Asian (33% of whom are Hmong), and 1.1% American Indian (10).

Disparities in CRC incidence and mortality between African Americans and whites in Wisconsin are large and worsened between 1995 and 2006 (11). Low socioeconomic status is associated with higher incidence of and poorer survival from CRC, and 12% of Wisconsin’s population lives below the poverty line (10,12). Nearly one-third of Wisconsinites also live in rural areas, where cancer screening and early detection services are frequently underused (13,14). In 2009, WCCCP conducted an endoscopic capacity assessment in Wisconsin and found that, although capacity to provide CRC screening to all residents of Wisconsin existed, distances, cost, and time from work were barriers to receiving cancer screenings for rural residents (14).

The objective of WCCCP’s CRC screening grants program was to reduce disparities by increasing CRC screening rates in underserved populations in Wisconsin. Our community engagement objective was to strengthen partnerships between regional health care systems, community partners, and target populations in their communities. We hoped that as an outcome of our community engagement efforts, grantees’ experiences would serve as examples for other health systems interested in increasing CRC screening rates in underserved populations.

Our community-based grant program enabled Wisconsin health systems and their community partners to develop and implement new CRC screening events for underserved populations in their respective service areas. We chose to use this partner approach to engage target populations because health systems have the technical capacity to offer screening and follow-up in a community setting, and local community partners understand the targeted populations and can offer grassroots outreach. Community–clinical partnerships are an essential element of this program.

WCCCP awarded grants to 5 health care systems with access to target populations whose demographic, geographic, or economic characteristics limit their access to CRC screening services. System A and System B are both urban-based health systems that serve a large number of African American and uninsured patients. System C spans a small city and surrounding rural geographic area containing a large immigrant Hmong community, and System D is a suburban health system that primarily serves a single county with many rural and Hispanic residents. System E is a rural, federally qualified health center (FQHC) ( Table 1 ).

Applications for this funding opportunity were solicited via several channels: an e-mail listserv, monthly newsletters, and direct recruitment by program staff. Applicants were asked to clearly identify a target population for their proposed event or events and explain the need for increased CRC screening. Preference was given to proposals that included access to free screenings for uninsured or underinsured populations. Applicants designated an institutional planning team, led by a screening event coordinator. Grant applications also included a budget, a timeline for implementation, and an evaluation plan.

Another important aspect of the application process was identification of community partners: local organizations or leaders outside of each health system who would be able to help with participant recruitment and event design and implementation. Health systems selected their own community partner or partners. The selection was made on the basis of past partnerships with the community partner. WCCCP reviewed applications for community partners’ commitment to the proposed event and successful previous engagement in cancer screening efforts. Finally, a CRC screening event requires staff to organize the event, a facility where the screening will occur, screening kits, access to patients, CRC educational materials, and capacity for follow-up with participants. Our grantees and their community partners were able to secure all of these additional resources.

Within 6 months of receiving funding, each award recipient was expected to develop and implement 1 or more CRC screening events. Grantees could create free-standing events or integrate screening activities into an existing event. Because of Centers for Disease Control and Prevention (CDC) regulations, grant money could not be used for direct patient services; all participating health care systems were therefore required to provide CRC screening test kits and documentation of available funds for additional diagnosis in case of a positive screening result in an uninsured or underinsured patient. All the participating health systems chose to offer immunochemical fecal occult blood tests (iFOBTs) as their screening method at their events. On the basis of published data, a 3% positive FOBT rate was anticipated (15).

The CRC screening events were conducted in 2 phases. Phase I began in October 2010. Throughout, grantees shared their progress by submitting monthly planning meeting minutes. Grantees were also required to participate in monthly teleconference calls to discuss progress and challenges. Events were advertised by using various promotional media developed in conjunction with community partners, including clinic-based flyers, mailed postcards, and Spanish-language radio ads. Most Phase I events took place in March 2011.

All grantees participated in process and outcome evaluations of their event or events. Evaluation methods used included event observations, interviews with key health system staff and their community partners, and screening forms that participants completed when they received their screening kit. Health systems also participated in monthly calls to discuss the planning process and completed final reports for both Phases I and II. WCCCP provided each of the grantees with a summary of Phase I evaluation results, including a “menu of ideas” for how they might improve future events. Phase I grantees were encouraged to tailor their original strategies on the basis of lessons learned and to apply for another round of funding.

Four of the 5 original grantees submitted applications and received funding in Phase II, which began in October 2011. The main purpose of Phase II was to refine previous events and test new ideas to bring community partners and health systems together to reach underserved populations with CRC screening. Most events in Phase II were held in February and March of 2012.

Our final project evaluation was based on multiple objectives: maximum community participation at events through increased CRC screening and the creation of community–clinical partnerships. WCCCP employed both process and outcome evaluation methods and collaborated with an external evaluator to review and synthesize evaluation data into 2 final reports. At the conclusion of each grant phase, the evaluator used qualitative and quantitative data to summarize the event planning process.

We collected information from individual event sites to learn as much about the implementation process as possible. Our evaluator created a database for grantees to track patients who received test kits at screening events. To track community representation, registration sheets at each event asked for demographic characteristics of the person being offered CRC screening. Additionally, either the external evaluator or WCCCP staff attended at least 1 of each grantee’s events and conducted an onsite observational assessment. We created a brief Internet survey for community partners’ representatives to solicit partnership ratings and comments for improvement, which received 27 responses — each of the 5 health systems recruited 1 or more community partners, and sometimes multiple people represented the community partners (16 from Phase I and 11 from Phase II). We also conducted telephone interviews with 2 additional partners who preferred that format for feedback. All but 2 community partners’ representatives stated they would definitely collaborate with a health system on future events. Several representatives provided ideas for other health-related events they would like to see in their areas.

The health systems in our grant program offered 36 CRC screening events in Phase I and II from 2010 through 2012; System A, which only participated in Phase I, did an evening presentation to participants in the Wisconsin Well Woman Program (the state’s National Breast and Cervical Cancer Early Detection Program), and Systems B and C also did events with the Wisconsin Well Woman Program participants in Phase II. System B also staffed 14 outreach booths at their urban clinics in Phase I. In Phase I, System C did 6 community health events, including 1 booth at an annual community health fair for Hmong elders. In Phase II, health systems focused on just 2 events: a booth at the Hmong Elder health fair and the Wisconsin Well Woman Program event. System D did a Hispanic cancer prevention fair held at a hospital in both Phases I and II. System E held 2 events for school district staff and an outreach booth at a health mission for Phase I, and in Phase II they had outreach booths at 5 previously scheduled country agricultural extension events ( Table 2 ). CRC screening kits were distributed at all of the events. All of these events were new or the screening component of the event was new, and the 5 health systems did not distribute iFOBT kits to these populations before this effort. Overall, systems differed in their approaches to planning and implementation, and resulting events varied widely in terms of number of screening kits distributed, percentage returned, and percentage testing positive for abnormalities.

With the primary goals of the grant project in mind, 3 key outcomes were assessed: event participation by members of underserved communities, distribution and return of CRC screening test kits, and effectiveness of community–clinical partnerships.

We believe this grant program was worthwhile, because of its ability to galvanize community–clinical partnerships and reach underserved populations with much-needed cancer screening. Lessons learned from this program are relevant to health systems wanting to offer cancer screenings to underserved populations, particularly with regard to considerations such as event settings, community partnerships, participant recruitment, and follow-up.

Holding a stand-alone event enabled distribution of higher numbers of tests than adding events to a pre-existing forum. However, in rural areas, special events still need to be tested as venues for screening to ensure that the target audience will be in attendance and be receptive to getting screened.

The choice of setting also affects recruitment; for example, grantees reported that it took more time and planning than anticipated to get staff and patients involved in screenings at busy low-income clinics. In all settings, recruitment may be boosted by the use of promotional mailings. Sites that sent out personalized letters in advance of events had a strong, positive response from community members targeted for screening.

To improve the success of community–clinical partnerships, clear roles and responsibilities among the partners should be delineated from the start. Community partners bring their relationships and expertise to tailor programming to the needs of local populations, and health systems can contribute clinical resources and knowledge to support the implementation of quality care services.

Budgeting adequate staff time to follow up on positive screening tests is another important element of completing a successful screening project. In particular, members of underserved minority groups may require dedicated and culturally competent outreach to ensure that they receive notification of their test results and adequate diagnostic follow-up.

Awarding grants to health systems for the purpose of implementing community screening events was an effective strategy for improving rates of CRC screening in Wisconsin, particularly in underserved populations. This program strengthened partnerships between health care systems and local organizations, both of which have ongoing potential to benefit the partners and participants involved.