results of a community-based randomized trial to increase colorectal cancer screening among filipino...

Results of a Community-Based Randomized Trialto Increase Colorectal Cancer Screening AmongFilipino AmericansAnnette E. Maxwell, DrPH, Roshan Bastani, PhD, Leda L. Danao, PhD, Cynthia Antonio, MPH, Gabriel M. Garcia, PhD, and Catherine M. Crespi, PhD

Colorectal cancer (CRC) is the second leadingcause of cancer death in the United States.1

Screening using a fecal occult blood test (FOBT),sigmoidoscopy, or colonoscopy is recommendedfor adults older than 49 years to reduce CRCmortality. However, population-based surveyshave documented low rates of CRC screeningamong Asian Americans.2 For example, datafrom the 2005 California Health InterviewSurvey show that only 46% of Filipino Ameri-cans are up-to-date with CRC screening com-pared with 59% of non-Hispanic Whites. 3 Lowrates of CRC screening contribute to late-stagediagnosis and poor survival outcomes amongAsian Americans compared with non-HispanicWhites.4 Despite these disparities, very few in-terventions to increase CRC screening have beendeveloped and rigorously tested for AsianAmericans.5

The Task Force on Community PreventiveServices, a group of public health and pre-vention experts that oversees systematic re-views of studies, recommends implementationof the following interventions to increase CRCscreening on the basis of strong evidence ofeffectiveness: (1) brochures and other smallmedia that describe screening tests and containindications for, benefits of, and ways to over-come barriers to screening; (2) interventions toreduce structural barriers, such as distributionof free FOBT kits; and (3) client reminders toadvise people they are due or late for screen-ing. The Task Force determined that there isinsufficient evidence to determine the effec-tiveness of small-group education.6

Small-group educational sessions had beenpopular among the Filipino community in 1 ofour prior studies;7 therefore, we again offeredsmall-group educational sessions in communitysettings. In keeping with the Task Force recom-mendations, we also used print materials anda reminder mailing. In addition, we distributed

free FOBT kits in 1 arm of the intervention. Ina second intervention arm, we did not distributefree FOBT kits, as this distribution may not befeasible for community organizations that wantto continue similar programs after the end of thestudy. A control arm offered small-group educa-tion and print materials on the health benefits ofphysical activity. We report the effect of themulticomponent intervention on CRC screeningrates among Filipino Americans. This is 1 of thefirst community-based randomized trialsdesigned to increase CRC screening amongAsian Americans and the first trial among Fili-pino Americans.

METHODS

In collaboration with 45 Filipino Americancommunity-based organizations and churches,we recruited 906 Filipino Americans whoeach completed a baseline interview (Figure1). Participants who were nonadherent toCRC screening guidelines (n=548) were

randomized into 1 of 3 arms. Two interventionarms consisted of a small-group CRC educa-tion session, print take-home materials, a re-minder letter, and a letter to the physician, withthe only difference being that participants in 1arm received a free FOBT kit, but those in theother arm did not. A third control groupconsisted of a small-group session promotingphysical activity. Another 55 participants whowere not adherent to CRC screening were notentered into the randomized trial because in-sufficient numbers or schedule conflicts pre-vented the scheduling of small-group sessions.A total of 103 small-group sessions were con-ducted; each session lasted 60 to 90 minutesand was led by a trained Filipino health pro-fessional, usually a nurse. Telephone inter-views 6 months after the session assessed theoutcome—self-reported receipt of any CRCscreening during the follow-up period—amongall participants who were randomized. Wealso validated self-reported CRC screening ina subsample.

Objectives. We conducted 1 of the first community-based trials to develop

a multicomponent intervention that would increase colorectal cancer screening

among an Asian American population.

Methods. Filipino Americans (n=548) nonadherent to colorectal cancer (CRC)

screening guidelines were randomized into an intervention group that received

an education session on CRC screening and free fecal occult blood test (FOBT)

kits; a second intervention group that received an education session but no free

FOBT kits; and a control group that received an education session on the health

benefits of physical activity.

Results. Self-reported CRC screening rates during the 6-month follow-up

period were 30%, 25%, and 9% for participants assigned to intervention with

FOBT kit, intervention without the kit, and control group, respectively. Partici-

pants in either of the 2 intervention groups were significantly more likely to

report screening at follow-up than were participants in the control group.

Conclusions. A multicomponent intervention that includes an educational

group session in a community setting can significantly increase CRC screening

among Filipino Americans, even when no free FOBT kits are distributed. (Am J

Public Health. 2010;100:2228–2234. doi:10.2105/AJPH.2009.176230)

RESEARCH AND PRACTICE

2228 | Research and Practice | Peer Reviewed | Maxwell et al. American Journal of Public Health | November 2010, Vol 100, No. 11

Recruitment, Eligibility Criteria, and

Randomization

Liaisons with community-based organiza-tions and churches distributed recruitmentflyers for the Filipino Health Study, invitedchurch and organization members to partici-pate, and gave a list of potential participants tostudy staff. In addition, recruitment ads wereposted on the bulletin boards and in newslet-ters of our partner organizations. During re-cruitment phase I (July 2005–October 2006),a person was eligible to participate in the studyif he or she was of Filipino heritage (any part),aged 50–70 years, and had no history of CRC.Baseline interviews were conducted with par-ticipants who were adherent or nonadherent toCRC screening guidelines to compare the 2groups.8 In this phase, community liaisons pro-vided a list of 732 names, all of whom werecontacted, and 598 interviews were completed(82% response rate). During recruitment phase II(November 2006–November 2007), we limitedrecruitment to participants who were nonadher-ent to CRC screening guidelines. We used a shortscreening questionnaire to exclude people whohad had FOBT screening within the past 12

months, a sigmoidoscopy within the past 5years, or a colonoscopy within the past 10years. In this phase, we received from ourcommunity liaisons a list of 683 names, ofwhom 256 were ineligible and 64 could notbe reached by phone. Of the 363 eligiblepotential respondents that we were able tocontact, 308 completed the baseline interview(85% response rate). Thus, 906 baseline in-terviews were completed from 1159 eligiblepotential participants, for an overall responserate of 83%.

Participants who were nonadherent to CRCscreening guidelines (no FOBT within the past12 months, no sigmoidoscopy within the past 5years, and no colonoscopy within the past 10years) were randomized in small groups of 6 to10 participants to take advantage of existingbonds between members of the same organi-zation. Couples and multiple members of thesame household were assigned to the samesmall group. Six unique study arm sequences(ABC, ACB, BAC, BCA, CAB, and CBA, whereA, B, and C represent the 3 study conditions)were each assigned a number from 1 to 6. Foreach community organization, the sequence of

the groups offered was determined by selectinga number from 1–6 using a table of randomnumbers.

Intervention

The multicomponent intervention was devel-oped with input from key informants and com-munity members who participated in 3 focusgroups. The intervention consisted of a small-group session to encourage CRC screening alongwith take-home print materials, a reminderletter, and a letter to participants’ providers.The Health Behavior Framework9,10 guidedthe intervention content and format. As shownin Table 1, we attempted to influence individ-ual factors of the Health Behavior Frameworkthat are usually associated with cancer screen-ing, including knowledge, attitudes, barriers,social norms and support, communicationwith provider, and cultural factors.11,12

Small groups of 6–10 participants met atcommunity organizations for a 60-to-90-minute educational session facilitated bya trained Filipino American health educator.Following a curriculum, facilitators and par-ticipants discussed incidence and mortality ofCRC among Filipino American men andwomen, risk factors and symptoms, benefits ofprevention and early detection, recommen-ded screening tests (FOBT, sigmoidoscopy,colonoscopy), where to obtain screening tests,and myths versus facts about CRC andscreening. Examples, illustrations, andgraphics were used, and interaction amongthe participants was encouraged as much aspossible. The health educator demonstratedhow to do an FOBT (using peanut butter andan FOBT kit) and showed a drawing of a scopeinserted in the colon and a picture of a polyp.The health educator addressed barriers toscreening that were pertinent to any of thegroup members by inviting opinions andadvice from other group members. As withother populations, common barriers includednot knowing how to do an FOBT, feeling thatcollecting stool samples is unpleasant, andbeing embarrassed to get an endoscopy orworrying about the discomfort. Using anestablished response format, the health edu-cator counseled the group members on how todeal with each of these barriers. The sessionwas an opportunity for the participants todiscuss their thoughts and concerns about

Note. FOBT = fecal occult blood test.

FIGURE 1—Participant flow for colorectal cancer (CRC) screening trial; Filipino Health Study,

Los Angeles, CA, 2004–2009.


November 2010, Vol 100, No. 11 | American Journal of Public Health Maxwell et al. | Peer Reviewed | Research and Practice | 2229

CRC screening and to ask questions. At theend of the session, the health educator madea strong recommendation to obtain an FOBTannually and encouraged participants to dis-cuss their need for CRC screening with theirphysicians. Participants signed a personalizedpledge to get a stool blood test and FOBT kitswere passed out to participants randomized tointervention group A.

Participants in both intervention groups re-ceived print materials in English and Filipinothat summarized the CRC screening informa-tion in a combination of pictures, graphs, andtext, together with the American Cancer Soci-ety brochure titled ‘‘Colon Testing Can SaveYour Life,’’ which was provided in English andFilipino and in large type. The print materials

had been previously reviewed by the commu-nity advisors for appropriate reading level,clarity, comprehensiveness, interest level, andappearance. Three months after the educa-tional session, participants who had attendedan intervention session received a personalizedletter, reminding them to obtain an FOBT oncea year. Physicians serving these participantswere informed by mail about their patients’participation in our CRC study and werenotified that their patients might submit a com-pleted FOBT kit or ask for CRC screening.Because of an oversight at the beginning of thestudy, only 166 physicians received this letterout of the 283 physicians of interventionparticipants for whom we had complete ad-dress information.

Participants randomized to the control armattended a small-group education session inwhich they discussed exercise and physicalactivity. Following a curriculum that we used ina previous study with Filipino Americanwomen,7,13 participants discussed and practicedaerobic, strengthening, and flexibility exercisesand received print information (‘‘Exercise! TenTips to Get You Started’’ and ‘‘I Walk Because . . . ’’from Journeyworks Publishing) in English andFilipino.

The educational sessions were conductedfrom July 2005 through November 2007.Participants were members or parishioners of45 community-based organizations andchurches with predominant or significant Fili-pino American membership. The CRC educa-tion sessions were facilitated by 6 healtheducators; the exercise sessions were led by 2health educators. During the 103 educationalsessions that were conducted, 36 groups re-ceived CRC education and free FOBT kits, 37received CRC education without FOBT kits,and 30 received exercise and physical activityeducation. Health educators were recruitedfrom and through the Philippine Nurses Asso-ciation of Southern California. They completeda 4-to-6-hour training session on how to con-duct the intervention or the control groupsession.

Baseline and Follow-up Interviews

All respondents were interviewed at base-line by telephone (70%) or in person (30%) inFilipino (40%) or English (60%). Each inter-view was completed in 22 minutes, on average,and assessed CRC screening history as well asdemographic characteristics, including accul-turation, access to health care, and doctor CRCscreening recommendations. We also assessedknowledge of screening guidelines and CRCrisk factors and attitudes regarding screeningthat will be reported in a future paper. Allparticipants who completed the baseline in-terview received a $20 incentive and werecontacted for a telephone follow-up interview 6months after the small-group session. Thefollow-up interview was completed in 23 min-utes, on average, predominantly by telephone(98%) and in English (86%), and assessed CRCscreening during the follow-up period—eitherby FOBT, sigmoidoscopy, or colonoscopy—andcorrelates of CRC screening that were also

TABLE 1—Selected Health Behavior Framework Factors Addressed by the Colorectal Cancer

Screening Intervention: Filipino Health Study, Los Angeles, CA, 2004–2009

Intervention

Individual factors

Knowledge CRC information, all types of screening tests, and guidelines are discussed in

the small-group session

Take-home print information includes a table that lists advantages and

disadvantages or limitations of all CRC screening tests

Beliefs

Perceived susceptibility Mortality of CRC among Filipino Americans is graphically shown to be higher

than mortality of other cancers

Self-efficacy to do FOBT FOBT demonstration with peanut butter and easy-to-read instructions with

pictures to increase self-efficacy to do FOBT

Barriers Barriers such as cost, not knowing that the test is needed, concern about

finding CRC, and absence of symptoms are discussed interactively

FOBT kits are provided at no cost to 1 intervention arm

Screening reminder letter is sent to participants after the session

Social norms and support Discussion group format among peers establishes positive social norms and

social support for CRC screening

Filipino social organizations and groups endorse study and screening

Group members share previous screening experiences

Communication with provider Strong recommendation from health educator to discuss CRC screening with provider

Handout: ‘‘Questions to Ask Your Doctor’’

Cultural CRC is discussed in small groups that know each other with opportunity for

socializing and refreshments

Sessions are provided in English and Filipino or ‘‘Taglish’’ language by Filipino

American health professional at community sites

Provider and Health Care System factors

Practice pattern Provider is informed that patient received CRC education and FOBT kit and

urged to recommend screening

Note. CRC = colorectal cancer; FOBT = fecal occult blood test.



assessed at baseline. Up to 9 callbacks (ondifferent days and times) were attempted toreach a participant. Participants who completedthe follow-up interview received a $20 incen-tive, and their names were entered into a lot-tery with a chance to win a $500 prize. Thelarge proportion of English-language inter-views at follow-up is because of the fact thatunlike at baseline, staff members who con-ducted follow-up interviews were more com-fortable in English than in Filipino and mostparticipants were able to answer questions ineither language.

Provider Validation

During the first face-to-face contact (either atthe baseline interview or at the group session),participants were asked for permission to con-tact their health care providers to confirmreceipt of CRC screening during the studyperiod. Of the 432 participants who completedthe follow-up interview, 324 (75%) providedcomplete contact information for their pro-viders and signed a release form. After com-pletion of the follow-up interview, validationpackets were mailed to providers of 110 par-ticipants who self-reported any screening dur-ing the follow-up period (FOBT, sigmoidos-copy, or colonoscopy) and 98 randomlyselected nonscreeners. We received providervalidations for 141 patients (86 of 110 [78%]self-reported screeners and 55 of 98 [56%]self-reported nonscreeners).

Statistical Analysis

To assess baseline balance across the studyarms, we tested for differences in baselinedemographics, acculturation, health, healthcare access, and CRC screening history amongthe 3 groups by using the c2 test and analysis ofvariance. To assess the potential for follow-upbias, we tested for differences between studycompleters and noncompleters by using the c2

test and the 2-sample t test.The primary outcome was self-reported re-

ceipt of any CRC screening (FOBT, sigmoidos-copy, or colonoscopy) between the session andthe follow-up interview. We conducted an in-tent-to-treat analysis of all randomized partici-pants that used self-reported outcomes andassumed participants without outcome datahad a ‘‘not screened’’ outcome. The analysisused mixed effects logistic regression with

random intercepts to account for clustering byorganization and session within organizationand included language of the baseline inter-view as a covariate to adjust for baselineimbalance across study arms.

The study was powered to detect a 15-percentage-point difference between interven-tion and control groups with 80% power.

RESULTS

At baseline, study participants were, onaverage, aged 59 years and had lived in theUnited States for 18 years; 66% were women(Table 2). All study participants were foreign-born. More than two thirds were married, hada college education, and had an annual incomeless than $50000. Most considered them-selves more Filipino than American (60%) orequally Filipino and American (36%), and only19% spoke mainly Filipino with their friends.Although most had health insurance (70%)and a regular doctor (79%), only 25% had everreceived any CRC screening test in the past, butthey were nonadherent to CRC screeningguidelines. Participants in the control groupwere more likely to have completed the base-line interview in English (69%) as comparedwith participants in the 2 intervention arms(57%; P<.04). No other significant differencesamong study arms were found.

Ninety-three percent of the participantsattended the education session (Figure 1). Fol-low-up interviews were started 6 months afterthe session, and the average time period be-tween the session, and follow-up was 8.2months (SD=2.7 months). Follow-up inter-views were completed with 79% of partici-pants. A comparison of study completers(n=432) and noncompleters (n=116) indi-cated that completers were more likely to becollege educated (72% vs 56% among non-completers; P<.001), to have an annual in-come of $50000 or more (36% vs 24%;P<.02), and to have completed the baselineinterview in English (63% vs 51%; P<.01).Completers were also more likely than non-completers to report receipt of a doctor’s rec-ommendation to obtain FOBT or an endoscopyat baseline (29% vs 19%; P<.03, and 32% vs22%; P<.03).

Based on intent-to-treat analysis with impu-tation of not screened for study noncompleters,

self-reported CRC screening rates were 30%,25%, and 9% for participants assigned to theintervention with a free FOBT kit, the inter-vention without an FOBT kit, and the controlgroup, respectively (Table 3). Participants ran-domized to either of the 2 intervention armswere significantly more likely to reportscreening at follow-up than were control groupassignees (odds ratios of 4.9 and 3.7 comparedwith the control group; both P<.001). Thestudy was not powered to detect differencesbetween the 2 intervention arms. After adjust-ing self-report for sensitivity and specificity ascalculated according to provider validationdata, the odds of screening in each interventionarm remained significantly higher than theodds in the control group (both P<.001; datanot shown).

Of the intervention participants whoreported CRC screening during the follow-upperiod (n=61 in intervention A and n=45 inintervention B), 73% received an FOBT only(74% and 71% in interventions A and B,respectively), 17% received an FOBT plus anendoscopy (15% and 20%), and 10% receivedan endoscopy only (11% and 9%), with nosignificant differences between the 2 interven-tion arms. Of the control group participantswho reported CRC screening during the follow-up period (n=14), 64% received an FOBTonly, 14% received an FOBT plus endoscopy,and 21% received an endoscopy only.

DISCUSSION

To our knowledge, this is the first trial to testan intervention to increase CRC screeningamong Filipino Americans and one of the firsttrials testing an intervention to increasescreening in a community rather than a clinicsetting. The intervention consisted of severalcomponents, including a small-group educa-tional session which was specifically tailoredfor Filipino Americans. Participants in thesmall-group session were members of churchesor community organizations who often kneweach other. The session offered an opportunityto socialize and to enjoy Filipino refreshmentsat the church or the community organization.Members of the same household were ran-domized to attend the same session so theycould discuss the need to get screened andremind each other after the session. Leaders



TABLE 2—Baseline Characteristics by Study Arm: Filipino Health Study, Los Angeles, CA, 2004–2009

Intervention With

FOBT Kit (n = 202),

Mean 6SD or No. (%)

Intervention

Without FOBT Kit (n = 183),

Mean 6SD or No. (%)

Control (n = 163),

Mean 6SD or No. (%)

Total (n = 548),a

Mean 6SD or No. (%) P b

General demographics

Age, y 59.2 66.2 59.7 66.1 59.0 66.5 59.3 66.2 .512

Years living in the United States 18.5 612.5 17.7 612.2 19.0 612.0 18.4 612.2 .602

Female 134 (66) 122 (67) 107 (66) 363 (66) .979

Married 135 (67) 137 (75) 105 (64) 377 (69) .088

Education .866

Less than college 66 (33) 58 (32) 49 (30) 173 (32)

College or more 136 (67) 125 (68) 114 (70) 375 (68)

Annual income less than $50 000 129 (68) 117 (67) 97 (63) 343 (66) .577

Acculturation

Baseline interview in English 116 (57) 103 (56) 112 (69) 331 (60) .034

Considers self .245

More Filipino than American 108 (56) 118 (65) 91 (60) 317 (60)

Equally Filipino and American 76 (39) 62 (34) 54 (36) 192 (36)

More American than Filipino 10 (5) 3 (2) 7 (5) 20 (4)

Language used with friends .367

Mainly Filipino 38 (19) 40 (22) 26 (16) 104 (19)

Half Filipino, half English 153 (76) 135 (74) 123 (76) 411 (75)

Mainly English 11 (5) 7 (4) 13 (8) 31 (6)

Health and access to health care

Has any health problem 161 (80) 150 (82) 123 (76) 434 (79) .322

Has family history of cancer 70 (35) 70 (38) 48 (29) 188 (34) .225

Has health insurance 138 (68) 129 (71) 117 (72) 384 (70) .764

Has regular doctor 162 (80) 144 (79) 125 (77) 431 (79) .718

Colorectal cancer screening

Doctor recommended any CRC screening 88 (44) 79 (43) 67 (41) 234 (43) .883

Ever had any CRC screening but not within guidelines 60 (30) 42 (23) 34 (21) 136 (25) .117

Doctor recommended FOBT 59 (29) 51 (28) 37 (23) 147 (27) .350

Ever had FOBT but not within last 12 mo 48 (24) 39 (21) 25 (15) 112 (20) .131

How likely to get FOBT in 6 mo .802

Not likely 33 (16) 33 (18) 25 (15) 91 (17)

Somewhat likely 38 (19) 33 (18) 31 (19) 102 (19)

Very likely 94 (47) 94 (52) 81 (50) 269 (49)

Depends on doctor recommendationc 36 (18) 22 (12) 25 (15) 83 (15)

Doctor recommended endoscopy 64 (32) 53 (29) 46 (28) 163 (30) .742

Ever had endoscopy but not within guidelines 19 (9) 8 (4) 14 (9) 41 (8) .14

How likely to get endoscopy in 6 mo .854

Not likely 83 (41) 73 (40) 63 (39) 219 (40)

Somewhat likely 52 (26) 41 (22) 41 (25) 134 (25)

Likely 66 (33) 69 (38) 59 (36) 194 (36)

Note. FOBT = fecal occult blood test. Endoscopy was either by sigmoidoscopy or colonoscopyaSome rows do not total 548 because of missing values.bP values based on the c2 test.cNot a response option, but many respondents volunteered this answer.



and liaisons of several community organiza-tions endorsed the study and the need for CRCscreening, enforcing social norms in support ofscreening. Filipino American health profes-sionals (nurses) led the sessions in English or inFilipino, ending the sessions with a strongrecommendation to get screened, and all ma-terials were provided in English and Filipinousing large type. The fact that more than 90%of participants attended a group session dem-onstrates the reach, acceptability, and feasibil-ity of this intervention component.

At follow-up, we achieved a large effect(odds ratios of 4.9 and 3.7) when comparingself-reported CRC screening in the interventiongroups versus the control group. Other studiesthat have implemented screening interventionsamong baseline nonadherent community sam-ples have found similar screening rates.14,15 Thelarge proportion of participants who did not getscreened (70%–75% in the intervention groups)may be attributed to 2 primary factors: manyparticipants had never been screened at baselineand may have been resistant to adopt a newscreening behavior, and participants had to takethe initiative either to complete the FOBT kits athome and return them to their provider or torequest a screening test from their provider.Providing participants with additional assistance,such as reminders to complete the FOBT kits orexplanations regarding bowel preparation beforethe sigmoidoscopy or colonoscopy, may furtherincrease screening rates.

The intervention consisted of multiple com-ponents, and we did not assess the effectivenessof each individual component. However,a comparison of the 2 intervention arms showsthat distribution of free FOBT kits increased

CRC screening rates (any test) only moderately(about 5 percentage points over and above theintervention without FOBT distribution). Thiseffect size is within the range found in previouscommunity setting studies in which FOBT kitswere mailed to residents of Wright County,Minnesota,16 or to patients of practice groupswho all had health insurance.17,18 In addition, ofthe participants who got screened, about 90% inboth intervention arms received an FOBT, eitherwith or without endoscopy. When interpretingthis finding, it is important to note that almost80% of Filipino Americans in our sample hada regular doctor and 70% had health insurance,reflecting the relatively high level of healthinsurance in this community.19 Distribution offree FOBT kits may lead to larger effects amongpopulations with lower access to health care. Inaddition, our study encouraged participants toask their providers for a CRC screening test, andmany providers were informed about the studyby mail and urged to recommend CRC screeningto their patients. Both of these components mayhave prompted a discussion of CRC screeningwith the provider. Distribution of free FOBT kitsmay lead to larger effects in studies that do notinclude these intervention components or similarcomponents.

Limitations

As in many other surveys and interventionstudies,15,20–22 our outcome was based on self-reported screening, which could be biased.However, intervention effects held up afteradjusting for the sensitivity and specificity of self-report. In addition, our sample did not constitutea population-based sample of Filipino Americans,which may limit the generalizability of our

findings. However, our sample is representativeof foreign-born Filipino Americans who areserved by many religious and community-basedorganizations, which could potentially implementsimilar interventions to increase CRC screeningin the future. Because members of the samecommunity organization who were assigned todifferent study arms may have interacted, thereis a potential for contamination. However, thiscontamination would bias our results againstfinding differences, making the results moreconservative.

Conclusions

Our results suggest that an educational groupsession in a community setting, followed by a re-minder letter to participants and a letter to pro-viders, can lead to a significant increase in CRCscreening, evenwithoutproviding free FOBTkits.This finding is important for future attempts toimplement similar programs more widelythrough Filipino American community organiza-tions, especially for organizations that may nothave the resources to distribute FOBT kits. j

About the AuthorsAt the time of the study, Annette E. Maxwell, RoshanBastani, Leda L. Danao, Cynthia Antonio, Gabriel M.Garcia, and Catherine M. Crespi were with the School ofPublic Health and Jonsson Comprehensive Cancer Center,University of California, Los Angeles.

Correspondence should be sent to Annette E. Maxwell,650 Charles Young South, Room A2-125 CHS, LosAngeles, CA 90095-6900 (e-mail: [email protected]).Reprints can be ordered at http://www.ajph.org by clickingthe Reprints/Eprints link.

This article was accepted February 4, 2010.

ContributorsA. E. Maxwell and R. Bastani designed and supervisedthe study and developed the article. A. E. Maxwell led thewriting. L. L. Danao, C. Antonio, and G. M. Garciaimplemented the study and contributed to the analysesand the writing. C.M. Crespi conducted the analyses andcontributed to the writing.

AcknowledgmentsThis work was supported by the American CancerSociety (grant RSGT-04-210-01-CPPB). C.M. Crespi wassupported by the National Institutes of Health, NationalCancer Institute (grant P30 CA 16042).

We would like to thank the members of the FilipinoAmerican community who participated in this study.

Human Participant ProtectionThis study was approved by the University of California,Los Angeles, institutional review board and all partici-pants provided informed consent. The trial was regis-tered at ClinicalTrials.gov (NCT00742729).

TABLE 3—Effectiveness of the Intervention by Intent-to-Treat Analysis: Filipino Health Study,

Los Angeles, CA, 2004–2009

Screened During

Follow-Up Period

(Self-Report), No. (%) OR (95% CI) P

Intervention with FOBT kit (n = 202) 61 (30) 4.9 (2.4, 9.9) < .001

Intervention without FOBT kit (n = 183) 45 (25) 3.7 (1.8, 7.5) < .001

Control (Ref) (n = 163) 14 (9)

Note. CI = confidence interval; FOBT = fecal occult blood test; OR = odds ratio. Analyses were conducted by using mixed effectslogistic regression with random intercepts for organization and session within organization and adjustment for language ofbaseline interview.



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