Advance Nursing Research

Woodall, M., & DeLetter, M. (2018).

Colorectal cancer: A collaborative approach to improve education and screening in a rural population

. Clinical Journal of Oncology Nursing, 22(1), 69–75.

Based on the research article you read, respond to the following prompts:

1. What, if any, was the theoretical framework that was used by article author(s)?

2. Describe the framework; was it from nursing or a borrowed theory?

3. Describe how the framework was used to inform the research study.

4. How much did the researchers write about it in the journal article? For example, was it weaved throughout the paper or mentioned only in the beginning?

5. In your opinion, what other nursing theory might have worked with this research study? Why?

APA style.

TURNITIN ASSIGNSMENT (FREE OF PLAGIARISM)

VOLUME 22, NUMBER 1 CLINICAL JOURNAL OF ONCOLOGY NURSING 69

CJON.ONS.ORG

C
Colorectal Cancer
A collaborative approach to improve education and screening
in a rural population

Marsha Woodall, DNP, MBA, RN, and Mary DeLetter, PhD, RN

COLORECTAL CANCER

(CRC) INCLUDES ANY CANCER THAT starts in the colon or
rectum. Most begin as an adenomatous polyp and grow into the wall of the
colon or rectum before metastasizing by invading tissues or structures, the
bloodstream, or the lymphatic system. About 95% of CRCs are adenocarci-
nomas (American Cancer Society [ACS], 2017b). The ACS (2017a) projected
that 135,430 people would be diagnosed with CRC in the United States in
2017. Although the CRC death rate has been dropping for the past 20 years,
the ACS still estimated 50,260 CRC-related deaths during 2017 (ACS, 2017a).

The Centers for Disease Control and Prevention ([CDC], 2017) recom-
mends screening for precancerous polyps for anyone aged 50 years or older.
Although early detection and

diagnosis greatly affect survival rates, only about

half of the U.S. population participates in screening (ACS, 2017a). A fecal
immunochemical test (FIT) is a noninvasive test used to detect blood in the
stool that cannot be seen with the human eye (Tresca, 2017). People at home
use the FIT kit by obtaining a sample of the stool with one of the FIT kit sticks
and inserting the sample back in the vial. The FIT kits are then either mailed or
hand-delivered to a laboratory for blood detection, most specifically from the
lower gastrointestinal tract (Tresca, 2017).

The State Cancer Profiles report by the National Cancer Institute (NCI)
and CDC (2014) ranked Kentucky seventh for mortality, with a death rate
of 17.6 per 100,000 compared to a national rate of 15.1. At the time of this
project, the CRC death rate in Hopkins County, Kentucky, was 14.1 per
100,000, one of the highest in the state. The death rate in Kentucky has been
trending downward over time from 25.8 in 1982 to 17.6 in

2013

(NCI and CDC,
2014). Incidence and death rates are depicted in Figure 1.

In 2008, the Kentucky Colon Cancer Screening Program (KCCSP) was
formed with the passage of Kentucky Regulatory Statute 214.540 to increase
CRC screening, reduce morbidity and mortality from CRC, and reduce costs
for CRC treatment. The goal of the KCCSP is to increase the number of CRC
screenings in Kentucky, using 75% FIT kits and 25% colonoscopies (Justia,
2011).

About 39% of CRCs are diagnosed at the local stage or confined to the
primary site, but 56% have already spread to regional lymph nodes or have
metastasized. If diagnosed at the localized stage, there is a 90% five-year rel-
ative survival rate, but this decreases to 14% when the cancer is in distant
sites. The survival rate for regional sites is 71% and 35% for unstaged. NCI
(2017a) projects that early detection of CRC could improve survival rates by
about 60%.

KEYWORDS

colorectal cancer screening; human caring

theory; evidence-based practice

DIGITAL OBJECT IDENTIFIER

10.1188/18.CJON.69-75

BACKGROUND: Colorectal cancer (CRC) is the third

most commonly diagnosed cancer and second

leading cause of cancer death for men and women

in the United States. Although early detection and

diagnosis greatly affect survival rates, only about

half of the U.S. population participates in screening.

OBJECTIVES: The purpose of this project was to

implement community-based CRC education and

screening. Outcomes included CRC knowledge,

CRC screening kit return rate, and rate of positive

screening results.

METHODS: Partnering with a community hospital,

CRC educational sessions and free screening oppor-

tunities were provided for 193 local city government

employees. CRC knowledge was assessed before

and after education with the Knowledge Assessment

Survey. A paired t test indicated significant improve-

ment in mean CRC knowledge.

FINDINGS: More than half of the participants elected

to take home fecal immunochemical test kits. Of the

29 participants who submitted their screening kits

for evaluation, eight had positive results and received

referral recommendations. All participants were

notified of their screening results. The community-

based CRC project was effective in improving CRC

knowledge and screening participation.

✔

70 CLINICAL JOURNAL OF ONCOLOGY NURSING VOLUME 22, NUMBER 1 CJON.ONS.ORG

COLORECTAL CANCER

“Targeted community
education successfully
increased colorectal
cancer knowledge
and screening rates.”

Literature Review
Multiple investigators reported improved CRC screening when var-
ious targeted strategies were used for CRC education (Dignan et al.,
2014; Feltner, Ely, Whitler, Gross, & Dignan, 2012; Smith et al., 2012;
Westfall et al., 2013). In addition, Green et al. (2013) and Menon
et al. (2011) reported higher rates of screening follow-through
when follow-up strategies, such as telephone contact and reminder
mailings, were implemented. Population-specific improvements
were reported by investigators who implemented targeted edu-
cational strategies in medically underserved areas, such as rural
Appalachian Kentucky (Dignan et al., 2014; Feltner et al., 2012) and
rural Colorado (Westfall et al., 2013).

In their systematic reviews, Morrow, Dallow, and Julka
(2010) and Wortley, Wong, Kieu, and Howard (2014) reported
the benefits of follow-up strategies that allowed patients to
make informed, individual choices regarding participation in
their preferred CRC screening method. Although the ability
to offer choices for screening methods was not feasible in this
project, there was ample evidence in the literature to support

implementing a community-based CRC screening program using
targeted education and FIT kits.

Objective and Purpose
Each March, the KCCSP engages in CRC awareness activi-
ties as a public health initiative, distributing FIT kits for CRC

FIGURE 1.

NATIONAL, STATE, AND LOCAL COLORECTAL CANCER INCIDENCE AND DEATH RATES
AND THE TRENDING COLORECTAL CANCER DEATH RATE IN KENTUCKY

Note. Based on information from National Cancer Institute and Centers for Disease Control and Prevention, 2014.

Incidence Rate Death Rate Kentucky Death Rates by Year

P

E

R

C
EN

TA
G

E

COLORECTAL CANCER INCIDENCE AND DEATH RATES

0

10

20

30

40

50

60

Hopkins County Kentucky United States

1982
2002

2013

VOLUME 22, NUMBER 1 CLINICAL JOURNAL OF ONCOLOGY NURSING 71CJON.ONS.ORG

CJON.ONS.ORG

screening. The objective of this project was to implement
community-based CRC education and screening for a targeted
population.

Theoretical Framework
Incorporating theory, philosophy, and ethics while integrating
technology and practicality outlines the human caring theory
(Watson & Smith, 2002). Watson’s (2009) human caring theory
focuses on a caring science for clinical decision making. This
theory guided the literature review on strategies to ensure caring
and connect with individuals in the community to improve public
health while decreasing costs to the healthcare system. This
ultimately led to a focus on targeted education and follow-up as
improvement strategies for the project.

Prochaska, DiClemente, Velicer, and Rossi’s (1992) trans-
theoretical model (TTM) assists individuals intentionally
changing behaviors or intending to change behaviors with
interventions to help them change by focusing on decision
making. One of the KCCSP’s goals is to increase CRC screening
by removing barriers and increasing awareness (National
Colorectal Cancer Roundtable, 2017). The TTM guided the
project focus to provide education, improve awareness, and offer
on-site screening opportunities promoting individuals’ CRC
screening decisions.

Methods
In Hopkins County, Kentucky, where this project was conducted,
2015 data demonstrated the benefit of community-based CRC
screening. The project was a joint venture between local city
government and a community hospital, Baptist Health Hospital
in Madisonville, Kentucky. Using a pre-/post-test design, 16 CRC
educational sessions were delivered at 12 departmental meetings
with employees. CRC knowledge was measured before and after
the education using the Knowledge Assessment Survey (KAS)
(Sanchez, Palacios, Thompson, Martinez, & O’Connell, 2013).
On-site FIT kit distribution was conducted by the community
hospital oncology nurse navigator (ONN).

Sample and Setting
The educational sessions were conducted at various times of day
and night in various locations to accommodate the working pat-
terns of the 193 city employees who participated. All employees
present at the departmental meetings were eligible to partici-
pate in the educational session, knowledge assessment, and FIT
kit distribution. All employees who attended the educational
sessions participated in the completion of the pre- and post-
intervention KAS.

The city employees represented a diverse population with
heterogeneity in gender, race, educational background, socioeco-
nomic status, and age. Many of the employees were in the CRC
high-risk age group.

Evidence-Based Intervention
Institutional review board approval was obtained through
Eastern Kentucky University Division of Sponsored Programs.
No participant-identifying information was included on the
knowledge assessments. The ONN obtained name and contact
information of participants who elected to accept a FIT kit. All
identifying information was protected using the hospital’s com-
munity screening policy and procedure and Health Insurance
Portability and Accountability Act (HIPAA) guidelines.

CRC screening educational flyers were posted in the city
government departments prior to project implementation. The
evidence-based intervention was a 10-minute CRC educational
session followed by the opportunity to participate in free CRC
screening by accepting a FIT kit.

Instrument
The KAS was administered pre- and postintervention. Permission
for use was obtained from the instrument author. The KAS
is a 14-item survey based on CRC risk information from NCI.
Responses to the KAS are assigned a value of 1 for each “yes” and
a 0 for each “no,” with a possible total score from 0–14 for each
survey. Higher scores indicate greater knowledge. The survey has
a 7.9 readability grade level and assesses CRC knowledge, CRC
screening history, behavioral intentions to participate in screen-
ing, and physician–patient interactions. The knowledge questions
are categorized into the following three categories, each with pre-
viously documented acceptable reliability coefficients:

TABLE 1.

ITEMS AND SCALE INTERNAL RELIABILITIES
COMPARED TO PROJECT RELIABILITIES FOR KAS

OVERALL PRE-EDUCATION POSTEDUCATION

SUBSCALE
CRONBACH

ALPHA

CRONBACH

ALPHA
CRONBACH
ALPHA

Total knowledge
(14 items)

0.94 0.64 0.78

General
knowledge of
CRC (2 items)

0.74 0.57 0.8

Knowledge of
CRC risk factors
(5 items)

0.88 0.27 0.22

Knowledge of
CRC screening
(7 items)

0.89 0.76 0.72

Physician
interactions
(2 items)

0.92 0.81 0.81

CRC—colorectal cancer; KAS—Knowledge Assessment Survey

72 CLINICAL JOURNAL OF ONCOLOGY NURSING VOLUME 22, NUMBER 1 CJON.ONS.ORG

ɐ General CRC knowledge (Cronbach alpha = 0.74)
ɐ CRC screening knowledge (Cronbach alpha = 0.89)
ɐ CRC risk factor knowledge (Cronbach alpha = 0.88)

Sanchez et al. (2013) reported acceptable internal reliability
on the KAS scales and subscales with Cronbach alphas ranging
from 0.74–0.94. Sanchez et al. (2013) did not report instrument
construct validity in the literature; however, this instrument
was selected because the face validity was acceptable to the
nurse experts involved in this project. For this project sample,
pre-/post-test reliability assessments were conducted for each
of the three subscales and total KAS. Coefficient alphas ranged
from 0.22–0.8 on the subscales and 0.64–0.94 on total KAS (see
Table 1).

The inability to demonstrate adequate subscale reliability in
this sample was most likely related to the limited number of items
in each subscale and the vast difference in samples. Although
Sanchez et al. (2013) tested the scale in predominantly Hispanic
women, the current sample was predominantly White men. Face
validity of the KAS was confirmed with the oncology and wellness
nurses in the city government and community hospital.

Implementation
A cover letter noting the nature of the project was provided and
read aloud to each participant prior to the session. Following
completion of the KAS before education occurred, a scripted
CRC teaching message was delivered while the participants were
viewing CDC’s (2017) Screen for Life: National Colorectal Cancer
Action Campaign materials and handout. Education included
CRC definition, risk factors, screening methods and options, and
benefits of screening. The ONN explained that CRC screening
was recommended for employees who met the following NCI
(2017b) at-risk criteria:

ɐ No screening in previous 12 months
ɐ Individuals aged older than 50 years or those aged 40–50 years
with a family history of colon cancer

Employees who did not meet NCI criteria but requested the free
CRC screening were included. The ONN distributed all FIT kits,
recorded all participants’ contact information, provided instruc-
tions, and discussed individuals’ questions or concerns. This was
her customary procedure during community service events.

Data Collection
The KAS was administered immediately before and immediately
after the educational session. The hospital ONN tracked the
number of FIT kits distributed, the number returned within four
weeks, and the number of participants who had positive screening
results. These aggregate data were provided to the project leader
without any individual identifiers. One week after distribution,
the ONN made personal telephone calls to all participants who
accepted but had not returned their FIT kits. The city wellness
nurse posted reminder flyers in all departments. After three weeks,

the ONN mailed 100 personal letters to the employees who had
not returned their FIT kits. All participants who returned kits for
evaluation were notified of their individual screening results by
the ONN. Results within normal limits were reported by regular
mail; results not within normal limits were reported by registered
mail. Participants with results that were not within normal limits
were encouraged to see their primary care provider for follow-up.
Upon request of any participant, provider referrals were made for
follow-up care. Data were analyzed with IBM SPSS Statistics, ver-
sion 23.0.

Results
Fifty-two individuals accepted a FIT kit, 12 submitted them to the
laboratory for screening, and 5 had positive CRC indicators. Table
2 depicts the distribution and return rate for FIT tests in Hopkins
County for 2013–2016.

Sample Characteristics
An initial sample of 193 employees participated in the education
and CRC knowledge assessments. Seven of the participants were
removed from the data set because of response set or a missing
pre- or posteducation KAS, resulting in 186 usable assessments.
The participants’ ages ranged from 20–65 years, with a mean
age of 40.6 (SD = 10.95). The majority were men (n = 169) and
Caucasian (n = 167). Only one-third of the participants had a col-
lege or advanced degree (n = 55). Demographic characteristics of
the participants are shown in Table 3.

Knowledge Assessment
The mean knowledge scores from the 14-item assessment tool
were 8.29 (SD = 1.862) before and 13.27 (SD = 1.363) after the
educational session. Knowledge scores were categorized as low

TABLE 2.

GENERAL COMMUNITY FIT KIT DISTRIBUTION
AND USE DATA FOR HOPKINS COUNTY, KENTUCKY

DISTRIBUTED RETURNED POSITIVE RESULTS

YEAR N n n

2013 37 12 4

2014 44 4 2

2015 52 12 5

2016 4 0 –

FIT—fecal immunochemical test

IMPLICATIONS FOR PRACTICE

ɔ Increase colorectal screening rates with targeted education.
ɔ Encourage patients to gain knowledge about screening rates and

how to get screened.
ɔ Adapt education to suit screening for other types of cancer to

increase screening rates overall.

COLORECTAL CANCER

VOLUME 22, NUMBER 1 CLINICAL JOURNAL OF ONCOLOGY NURSING 73CJON.ONS.ORG

knowledge (scores of 0–3), moderate knowledge (scores of 4–9),
and high knowledge (scores of 10–14) (Sanchez, Palacios, Cole, &
O’Connell, 2014). The majority of participants (n = 140) in this
sample were in the moderate knowledge category before the edu-
cational intervention; however, an even greater majority (n = 181)
scored in the high knowledge category after the education ses-
sion, as depicted in Figure 2.

A paired-samples t test demonstrated a significant increase in
mean total KAS scores from pre-education (

—
X = 8.29, SD = 1.86)

to posteducation (
—
X = 13.27, SD = 1.36) (t[181] = 35.289, p < 0.0001;

two-tailed). The mean increase in KAS scores was 4.95 (95% confi-
dence interval [4.7, 5.26]). The eta squared statistic (0.87) indicated
a large effect size for this intervention. Because of the low reliability
coefficient alphas obtained for this sample, individual subscale
scores were not evaluated for statistically significant changes.

Screening Outcomes
More than half of the participants (n = 130) elected to take home
FIT screening kits. Of the 29 participants (15%) who submitted
their screening kits for evaluation, eight (4%) had positive colon
cancer indicators and received referral recommendations.

Discussion
The literature supports personalized CRC education to promote
informed choices regarding type of CRC screening and to increase
adherence to screening (Dignan et al., 2014; Feltner et al., 2012;
Green et al., 2013; Menon et al., 2011; Morrow et al., 2010; Wortley
et al., 2014). CRC education programs in rural communities, sim-
ilar to the current project community, have been recommended
(Dignan et al., 2014; Feltner et al., 2012; Westfall et al., 2013).
Multiple authors emphasize the significance of informed choices in
promoting CRC screening through common interventions (Dignan
et al., 2014; Feltner et al., 2012; Green et al., 2013; Menon et al., 2011;
Morrow et al., 2010; Smith et al., 2012; Westfall et al., 2013; Wortley
et al., 2014).

This project evaluation demonstrated an improvement in
knowledge and intent to participate in screening following CRC
education, as reported in the literature. Several studies (Dignan
et al., 2014; Feltner et al., 2012; Green et al., 2013; Menon et al.,
2011; Morrow et al., 2010; Wortley et al., 2014) were also able
to demonstrate increased adherence to screening following
CRC screening education. In the current study, the partici-
pants viewed a handout during the formal educational session.
The concurrent, on-site exposure to the ONN, who provided
instruction and education on the FIT kit, was beneficial. In
addition, providing the FIT kit to all individuals who wanted to
participate, keeping results confidential, and providing appro-
priate follow-up for participants were strategies that enhanced
the CRC screening rate.

An unanticipated outcome of the project was the number
of anecdotal discussions that took place in the departmental

educational sessions and one-on-one. One man openly shared
his story of being diagnosed and treated for colorectal cancer
at age 42 years. He told his fellow employees that he was lucky
that his treatment was successful and urged everyone to partic-
ipate in screening. Several participants wanted to know more
about decreasing risk factors for themselves or family members.
Many wanted to share stories about someone they knew who
had lost his or her life to cancer. Overall, the participants were
welcoming, engaged, and open to the educational intervention
and screening.

Locations for project implementation varied greatly from a
formal department classroom to a work shed in the local cem-
etery. Knowing there would be a variety of settings, the decision
to use a verbal script and hard copies of educational materials
versus an electronic presentation was an appropriate alternate
strategy and made the implementation feasible.

Partnering with the ONN from the local hospital was critical
to the success of the project. The distribution of 130 FIT kits with

TABLE 3.

DEMOGRAPHIC CHARACTERISTICS OF PROJECT
PARTICIPANTS (N = 186)

CHARACTERISTIC n %

Gender

Male 169 91

Female 15 8

Missing data 2 1

Education level

Less than high school 8 4

High school graduate or GED 66 36

Some college but no degree 56 30

College degree 51 27

Advanced degree (MD, PhD, JD, master’s) 4 2

Missing data 1 1

Race

White (Caucasian, non-Hispanic) 167 90

Black or African American 16 9

American Indian or Native American 1 1

Other 1 1

Missing data 1 1

Note. Because of rounding, percentages may not total 100.

74 CLINICAL JOURNAL OF ONCOLOGY NURSING VOLUME 22, NUMBER 1 CJON.ONS.ORG

COLORECTAL CANCER

29 returns and 8 positive results is nearly the same as had been
accomplished in the previous three years on the CRC Screening
Days in the same community (H. Tow, personal communica-
tion, March 18, 2016). In the previous community effort and this
project, several participants demonstrated positive results, indi-
cating a need for follow-up with a healthcare provider. Finding
positive CRC indicators in the eight employees demonstrated
the potential life-saving value of the targeted education and
screening (see Table 4).

Limitations
One limitation to this project was the reliability of the KAS tool.
Although Sanchez et al. (2013) reported subscale Cronbach alphas
from 0.74–0.94, the subscales for this project sample did not
have acceptable reliability coefficients. Another limitation of the
KAS was that only one item was reverse-scored. Upon consulting
with a statistical expert, it was noted that disparity in instrument

FIGURE 2.

KNOWLEDGE CATEGORY BASED ON TOTAL

KAS SCORES

KAS—Knowledge Assessment Survey
Note. Pre-education mean was 8.29. Posteducation mean was 13.27.
Note. Low knowledge was scores of 0–3, moderate knowledge was scores of 4–9,
and high knowledge was scores of 10–14.

0
20
40
60

80

100

Pre-education Posteducation

PE
R

C
EN
TA
G
E
KAS SCORES

Low knowledge Moderate knowledge High knowledge

reliability comparisons could be from (a) a lack of construct validity
reported in the literature, (b) the dichotomous nature of all items,
(c) the limited number of items in each subscale (one subscale had
only two items), and (d) the difference in sample demographics
(B. Davis, personal communication, March 12, 2016). Sanchez et
al. (2013) reported reliability in their sample of primarily Hispanic
women, whereas this project included predominantly White men.

Implications for Nursing Practice
Results of the project and detection of positive indicators contrib-
ute to the National Colorectal Cancer Roundtable (2017) goal to
screen 80% of the nation’s population by 2018. More importantly,
this project allowed the detection of positive cancer indicators
in eight individuals that may have otherwise gone undetected.
Eliminating barriers through education was supported by this
project’s increase in knowledge, as evidenced by the total KAS
score improvement and the FIT kit return rate. Preliminary find-
ings of this project were shared with the community hospital
cancer committee; all were in agreement to increase focus on tar-
geted education rather than randomly handing out FIT kits at the
annual community awareness day in March.

Future Outreach
The community hospital has committed to future, purpose-
ful targeted educational outreach programs. Two specific ideas
for sustaining and improving community-based CRC screening
have come from this project. First, during the March 2016 CRC
Screening Day, the FIT kit education and distribution process was
altered from previous years. Rather than receive receive FIT kits,
interested participants received flyers with information for indi-
vidualized screening counseling appointments with the ONN.
Second, the ONN has proposed a local private business employ-
ing about 500 people as the next site for targeted education and
screening. Finally, a recommendation for specifically targeting
audiences and providing education for all types of cancer screen-
ing has emerged from this project recommendation.

TABLE 4.

FIT KIT DISTRIBUTION AND USE DATA
FOR THE CURRENT PROJECT COMPARED
TO THE GENERAL COMMUNITY PROJECT

DISTRIBUTED RETURNED POSITIVE RESULTS

PROJECT N n n

General
community,
2013–2016

137 28 11

Current
project, 2016

130 29 8

FIT—fecal immunochemical test

VOLUME 22, NUMBER 1 CLINICAL JOURNAL OF ONCOLOGY NURSING 75CJON.ONS.ORG

Conclusion
In this project, targeted community education successfully increased
CRC knowledge and screening rates. Increasing CRC screening rates
to 80% by the end of 2018 will take the efforts of leaders at all levels
(ACS, 2015). Ongoing commitment to participate in CRC education
and screening supported by the local hospital and cancer education
community has already contributed to this effort.

The TTM model was useful in identifying health behaviors
and implementing an effective educational intervention to facil-
itate decision making for CRC screening. This model will be a
guiding framework for future evidence-based education and
cancer screening. These positive influences on individual health
behaviors will promote overall health outcomes for targeted com-
munity populations.

Marsha Woodall, DNP, MBA, RN, was, at the time of writing, a graduate student

at Eastern Kentucky University and is currently a nurse administrator and program

coordinator in the Nursing Division at Madisonville Community College in

Kentucky; and Mary DeLetter, PhD, RN, was, at the time of writing, a faculty

member at Eastern Kentucky University and is currently an associate professor and

RN-BSN program director in the School of Nursing at the University of Louisville

in Kentucky. Woodall can be reached at marsha.woodall@kctcs.edu, with copy to

CJONEditor@ons.org. (Submitted April 2017. Accepted May 13, 2017.)

The authors take full responsibility for this content and did not receive honoraria or disclose

any relevant financial relationships. The article has been reviewed by independent peer review-

ers to ensure that it is objective and free from bias.

REFERENCES

American Cancer Society. (2015). Achieving 80% by 2018: Screening goal could prevent

200,000 colon cancer deaths in less than 2 decades. Retrieved from http://bit.ly/2l74rIq

American Cancer Society. (2017a). Cancer facts and figures, 2017. Retrieved from http://bit

.ly/2ksCPAg

American Cancer Society. (2017b). Key statistics for colorectal cancer. Retrieved from https://

www.cancer.org/cancer/colon-rectal-cancer/about/key-statistics.html

Centers for Disease Control and Prevention. (2017). Screen for life: National Colorectal Cancer

Action Campaign. Retrieved from https://www.cdc.gov/cancer/colorectal/sfl

Dignan, M., Shelton, B., Slone, S.A., Tolle, C., Mohammad, S., Schoenberg, N., . . . Ely, G. (2014).

Effectiveness of a primary care practice intervention for increasing colorectal cancer

screening in Appalachian Kentucky. Preventive Medicine, 58, 70–74.

Feltner, F.J., Ely, G.E., Whitler, E.T., Gross, D., & Dignan, M. (2012). Effectiveness of

community health workers in providing outreach and education for colorectal cancer

screening in Appalachian Kentucky. Social Work in Health Care, 51, 430–440.

Green, B.B., Wang, C.Y., Anderson, M.L., Chubak, J., Meenan, R.T., Vernon, S.W., & Fuller, S.

(2013). An automated intervention with stepped increases in support to increase uptake of

colorectal cancer screening. Annals of Internal Medicine, 158, 301–311.

Justia. (2011). Definitions for KRS 214.540 to 214.544—Establishment and limitation of Colon

Cancer Screening Program. Retrieved from http://bit.ly/2mewdoi

Menon, U., Belue, R., Wahab, S., Rugen, K., Kinney, A.Y., Maramaldi, P., . . . Szalacha, L.A. (2011).

A randomized trial comparing the effect of two phone-based interventions on colorectal

cancer screening adherence. Annals of Behavioral Medicine, 42, 294–303.

Morrow, J.B., Dallo, F.J., & Julka, M. (2010). Community-based colorectal cancer screening trials

with multi-ethnic groups: A systematic review. Journal of Community Health, 35, 592–601.

National Cancer Institute. (2017a). Cancer stat facts: Colon and rectum cancer. Retrieved from

https://seer.cancer.gov/statfacts/html/colorect.html

National Cancer Institute. (2017b). Colorectal cancer prevention (PDQ®)—Health professional ver-

sion. Retrieved from https://www.cancer.gov/types/colorectal/hp/colorectal-prevention-pdq

National Cancer Institute and Centers for Disease Control and Prevention. (2014). 5-year rate

changes—Mortality, United States, 2010–2014. Retrieved from http://bit.ly/2BdgIY6

National Colorectal Cancer Roundtable. (2017). 80% by 2018 communications guidebook:

Recommended messaging to reach the unscreened. Retrieved from http://bit.ly/2CLB3Ax

Prochaska, J.O., DiClemente, C.C., Velicer, W.F., & Rossi, J.S. (1992). Criticisms and concerns of the

transtheoretical model in light of recent research. British Journal of Addiction, 87, 825–828.

Sanchez, J.I., Palacios, R., Cole, A., & O’Connell, M.A. (2014). Evaluation of the walk-through

inflatable colon as a colorectal cancer education tool: Results from a pre and post research

design. BMC Cancer, 14, 626. https://doi.org/10.1186/1471-2407-14-626

Sanchez, J.I., Palacios, R., Thompson, B., Martinez, V., & O’Connell, M.A. (2013). Assessing col-

orectal cancer screening behaviors and knowledge among at-risk Hispanics in southern New

Mexico. Journal of Cancer Therapy, 4(6B), 15–25. https://doi.org/10.4236/jct.2013.46A2003

Smith, S., Johnson, L., Wesley, D., Turner, K.B., McCray, G., Sheats, J., & Blumenthal, D. (2012).

Translation to practice of an intervention to promote colorectal cancer screening among

African Americans. Clinical and Translational Science, 5, 412–415.

Tresca, A.J. (2017, September 7). Fecal immunochemical test (FIT): This test can detect hidden blood

in stool. Verywell. Retrieved from https://ibdcrohns.about.com/od/diagnostictesting/p/fit.htm

Watson, J. (2009). Caring science and human caring theory: Transforming personal and

professional practices of nursing and health care. Journal of Health and Human Services

Administration, 31, 466–482.

Watson, J., & Smith, M.C. (2002). Caring science and the science of unitary human beings:

A trans-theoretical discourse for nursing knowledge development. Journal of Advanced

Nursing, 37, 452–461. https://doi.org/10.1046/j.1365-2648.2002.02112.x

Westfall, J.M., Zittleman, L., Sutter, C., Emsermann, C.B., Staton, E.W., Van Vorst, R., & Dickinson,

L.M. (2013). Testing to prevent colon cancer: Results from a rural community interven-

tion. Annals of Family Medicine, 11, 500–507. https://doi.org/10.1370/afm.1582

Wortley, S., Wong, G., Kieu, A., & Howard, K. (2014). Assessing stated preferences for colorectal cancer

screening: A critical systematic review of discrete choice experiments. Patient, 7, 271–282.

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