2. An Innovative Capacity Building Approach for Preparing Tribal Community Health Representatives (CHRs) to Deliver Colorectal Health Education, Outreach and Patient Navigation Services An Innovative Capacity Building Approach for Preparing Tribal Community Health Representatives (CHRs) to Deliver Colorectal Health Education, Outreach and Patient Navigation Services Kevin English, RPh, MPH Albuquerque Area Indian Health Board, Inc. Navajo Nation Human Research Review Board Conference Window Rock, AZ November 16, 2011

3. Colorectal Health Data Trends: American Indians  Cancer is leading cause of death among AI/AN women and the 2 nd leading cause of death among AI/AN men. (CDC 2006)  Colorectal cancer is the 3 rd most common type of cancer among American Indian & Alaska Native men & women. (SEER; Wiggins et al Supplement to Cancer 2008). (SEER; Wiggins et al Supplement to Cancer 2008).  Colorectal Cancer is the 2 nd most common type of cancer for American Indians in the Southwest. (SEER; Wiggins et al Supplement to Cancer 2008). (SEER; Wiggins et al Supplement to Cancer 2008).  Colorectal cancer is the 3 rd leading cause of cancer- related death for AI/AN men & women. ( NCHS; Espey et al Cancer 2007) ( NCHS; Espey et al Cancer 2007)

4. Colorectal Health Data Trends: American Indians Nationally, the death rate from colorectal cancer has been dropping for more than 20 years. Nationally, the death rate from colorectal cancer has been dropping for more than 20 years. Death rates from colorectal cancer are not decreasing among American Indians/Alaska Natives Death rates from colorectal cancer are not decreasing among American Indians/Alaska Natives WHY NOT? WHY NOT?

5. Colorectal Health Data Trends: American Indians  Late detection  AI/AN men and women are more than two times more likely to be diagnosed with late stage CRC than early stage CRC. (SEER, Perdue et al. Supplement to Cancer 2008)  Insufficient screening  Only 4% of AI/AN men and women age 50-80 who utilize IHS obtained CRC screening in accordance with recommended guidelines. (Day, Espey, Madden et al Dig Dis Sci 2011)  Delayed treatment

6. The main goals of the AAIHB Tribal Community Colorectal Health Project are to: 1.Build capacity among CHRs related to colorectal health education, outreach & patient navigation 2.Establish a multidisciplinary colorectal health task force in each participating tribe 3.Implement local colorectal health awareness and patient navigation activities 4.Share successful strategies with other tribal communities throughout the country AAIHB Tribal Colorectal Health Program

7. CHR Capacity Development Approach  Three, two-day workshops:  December 9/10, 2009  April 7/8, 2010  August 18/19, 2010  19 unique participants  All 7 AAIHB Tribes

8. CHR Capacity Development Approach KEY WORKSHOP TOPICS:  Colorectal Cancer (CRC) 101  Epidemiology of CRC for AI/AN  Screening Guidelines for CRC  CRC Screening Procedures  Bowel Preparation  Colorectal Cancer Risk Factors  CRC Diagnosis and Treatment  Talking about sensitive health issues  Theories of health behavior/communication

9. CHR Capacity Development Approach TRAINING TECHNIQUES  PowerPoint  Videos  Anatomical Models  Field visit to colonoscopy facility  Survivor stories  Role playing  Language groups  Interactive games  Health education materials development/dissemination

12. CHR Capacity Development Evaluation  A 34-item pre-post test was administered to participants at the 3 rd workshop measuring:  Knowledge (15 items)  Self-efficacy (11 items) –I am confident that I can teach my community members about colorectal cancer screening –It will be easy to add colorectal cancer screening outreach & education to my regular workload.  Norms & intentions (8 items) –I think colorectal cancer is an important health issue. –I intend to assist my community members in getting colorectal cancer screenings.

13. Evaluation Analysis  Paired sample t-tests were utilized to analyze mean differences in pre-post test scores.  Mean differences were also analyzed according to training exposure  To assess the impact of attendance at multiple training sessions upon CHR capacity

14. Evaluation Findings

15. CHR Capacity Development Evaluation Qualitative feedback was also collected related to:  Training benefits  Satisfaction with training materials/approaches  Areas for training improvement  Future capacity development needs

16. Qualitative Findings “I am now knowledgeable about the different tests and how screening can prevent the progression to cancer. I understand the procedure from start to finish.” “I understand more, so people I talk with will benefit from this.” “I am now able to help self, family and community by having tools and knowledge to share this important information.” “I’m prepared to discuss colorectal health, I feel confident.”

17. Qualitative Findings “My favorite part was the hands-on tour and actually seeing the live instruments and setting.” “I understand the process of colonoscopy after visiting the facility that performs the colonoscopies.” “I enjoyed the survivor’s story; it really helped me understand colorectal screening form a personal point of view. That was helpful.” “We have been given all of the tools, now it is up to us to organize classes and disseminate the information.” “We can do our job by providing the education, but IHS must provide the needed services.”

18. Conclusions/Implication for Practice  Significant attention should be placed upon CHR capacity development.  Incorporating experiential learning activities into trainings is a preferred approach.  The use of multiple training sessions appears to confer advantages in retention of knowledge and engendering CHR confidence and motivation to intervene.  The concomitant implementation of system-level initiatives with CHR capacity development may be especially important towards improving local access to colorectal cancer control services.

19. Next Steps Develop tool kit – “Best of” CRC workshops/activitiesDevelop tool kit – “Best of” CRC workshops/activities Provide CRC workshops for CHR programs in other IHS regionsProvide CRC workshops for CHR programs in other IHS regions Develop brochures, videos, posters, etc. (English & Navajo)Develop brochures, videos, posters, etc. (English & Navajo) Evaluation focus groups with CHRsEvaluation focus groups with CHRs Clinic provider detailingClinic provider detailing Continue routine task force meetings in participating tribesContinue routine task force meetings in participating tribes

20. Contact Information Kevin English – Program Director Tribal Community Colorectal Health Education and Navigation Program Albuquerque Area Indian Health Board, Inc. 5015 Prospect Ave NE Albuquerque, NM 87110 kevinenglish@aaihb.org (917) 962-2603 This project was realized with funding from CDC’s Division of Cancer Prevention and Control in collaboration with the Indian Health Service Division of Epidemiology and Disease Prevention