The purpose of this study was to describe the psychosocial factors influencing participation in colorectal cancer screening (CRCS) among Puerto Rican men and women. We conducted seven focus groups in metropolitan and rural areas of Puerto Rico (PR) with men and women (using gender specific groups) aged 50 to 80 years (n = 51) who were non-adherent to CRC guidelines. The focus group guide included questions related to colorectal cancer (CRC) and CRC screening knowledge, attitudes, and beliefs. We analyzed data using a modified grounded theory approach to identify emergent themes. Focus groups revealed seven major themes that represented barriers to CRCS: (1) lack of CRC knowledge, (2) lack of knowledge about colorectal cancer screening tests as well as the required preparation, (3) embarrassment, (4) low perceived benefit of CRCS and sense of fatalism, (5) transportation (mostly among participants in rural areas), (6) lack of time, and (7) financial burden. All participants understood the benefits of CRCS once the procedure was explained. Additionally, participants reported a lack of provider recommendation for CRCS. In this group of Puerto Rican participants who were non-adherent to CRCS, there were misconceptions about CRC, screening tests available, and preparation and testing procedures. Participants’ low levels of knowledge and negative attitudes concerning CRCS and low reported provider recommendation were important deterrents to screening. These findings suggest the need for educational efforts to increase knowledge and attitudes about CRCS and improved patient-provider communication to reduce missed opportunities to recommend.

From 2010-2014, colorectal cancer (CRC) was the second highest incident cancer and leading cause of cancer-related deaths in Puerto Rico (PR). Although preventable through screening and treatment, colorectal cancer screening (CRCS) using fecal occult blood test (FOBT) or colonoscopy remains low for adults in PR. Data from the 2016 Behavioral Risk Factor Surveillance System indicated that 18.0% of the PR population aged 50 to 75 had undergone an FOBT within the past year compared to 8.0% in the United States (US). Additionally, 50.1% of age-eligible Puerto Ricans report ever having a colonoscopy in the past 10 years compared to 63.5% in the US. Given the higher burden of CRC and the low CRCS rates in PR, we developed ¡Salud!, por la Vida (SPLV), an educational program which aims to increase CRCS in non-adherent men and women aged 50 and 75 who attend Federally Qualified Health Clinics (FQHCs) in PR. We used Intervention Mapping (IM) as framework to develop an educational intervention that is theoretically sound and grounded in evidence. For the development of SPLV, steps 1 to 4 of IM were completed. Step 1: a needs assessment conducted through focus groups and key informant interviews to gather quantitative and qualitative data for the development of the logic model and the program; step 2: development of a logic model of change and matrices of change objectives; step 3: selection of theory and evidence-based methods and strategies; and step 4: program production, components, and materials. Step 1 revealed 5 main themes: (1) lack of knowledge about CRC and CRCS practices; (2) patient’s fear of the CRC test results; (3) low risk perception of CRC; (4) lack of provider CRCS recommendation; and (5) the importance of social support. Interviews revealed that the majority of clinics offer FOBT as part of their CRCS protocol; where 74.0% of these had a clinical laboratory on-site. Over half (53.0%) had implemented electronic medical records and 82.0% had health educators on staff. A logic model was developed by combining personal behaviors with behavioral determinants and identifying beliefs targeted by the intervention (step 2). Tailored interactive multimedia intervention (TIMI) and small media were selected as the practical application to deliver the intervention (step 3). Development of the program included 5 components: script development; testimonials; animations; written materials; and newsletter. Pre-testing was conducted to evaluate the usability of the program. Our educational program, SPLV, is completed and currently being implemented, using a randomized trial. Trial is being conducted in 10 FQHCs and will recruit 710 participants aged 50 to 75 who have no prior history of CRC and are not adherent to CRCS guidelines. Clinics are randomized to either the intervention group (TIMI) or the control group (usual care). We aim that this intervention will significantly increase CRCS rates and provide evidence to disseminate this educational effort to FQHCs in PR. Citation Format: Vivian Colón-López, Camille Vélez-Alamo, Adrianna Acevedo-Fontanez, Marievelisse Soto-Salgado, Jorge L Rodríguez-Lebrón, Josheili Y Llavona-Ortiz, Yolanda Serra-Martínez, Ileska Valencia-Torres, María Fernández. ¡Salud!, por la Vida, an educational intervention to increase colorectal cancer screening in Puerto Ricans [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B009.

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Introduction: Colorectal cancer (CRC) is the second-highest incident cancer among men and women in Puerto Rico (PR); however, CRC screening (CRCS) rates remain low. Data from the 2014 Behavioral Risk Factor Surveillance System indicate that only 18.5% of the PR population 50+ years has undergone an FOBT within the past two years compared to 12.8% in the United States of America (USA). Additionally, only 50.6% of age-eligible Puerto Ricans report ever having a sigmoidoscopy or colonoscopy compared to 68.8% in the USA. At a national level, the goal established by the National Colorectal Cancer Round Table is to reach a CRCS rate of 80% for 2018. Improving educational and interventional strategies to promote behavioral changes and screening uptake can help increase CRCS rates in the island. The Community Preventive Services Task Force (the community guide) recommends the adoption of interventions that use small media based on strong evidence of their effectiveness in increasing colorectal cancer screening by fecal occult blood test (FOBT); yet there is no sufficient evidence for sigmoidoscopy or colonoscopy. Using Intervention Mapping (IM), the Puerto Rico Community Cancer Control Outreach Program of the UPR/MDACC Partnership for Excellence in Cancer Research developed a self-directed tailored interactive multimedia intervention (TIMI) aimed to increase CRCS in Puerto Ricans. Objective: Develop a TIMI entitled ¡Salud! por la Vida, aimed to increase CRCS among non-adherent men and women 50 years and older in FQHCs in Puerto Rico. Methods: We developed a series of tailored colorectal cancer screening messages that were both culturally and linguistically appropriate. First, the concept and flow of the TIMI was developed. The concept includes subject matter, length, and user interface. Then, the script and storyboard were created to produce a prototype that was tested within the Community Advisory Group (CAG) and community members to obtain feedback on cultural relevance and linguistics. The script was adapted according to recommendations and fictional content, including acted scenes and testimonies, and animations were produced. The TIMI was beta tested for sequence, interface, and graphics. During the beta test, the application was scrutinized for errors or missing elements. The final TIMI consists of brief interactive videos that are tailored by variables considered relevant for CRCS (e.g., perceived risk, family history, among others) and will be delivered using tablets. Results and Conclusions: This innovative educational intervention using technology and developed from a guiding framework will help increase CRCS among men and women nonadherent to CRCS visiting FQHCs in Puerto Rico. To test the efficacy of this program on CRCS completion, we will conduct a randomized behavioral intervention trial in 10 FQHC clinics island wide. Note: This abstract was not presented at the conference. Citation Format: Camille Velez-Alamo, Adrianna I. Acevedo-Fontanez, Vivian Colon-Lopez, Marievelisse Soto-Salgado, Yolanda Serra-Martinez, Ileska M. Valencia-Torres, Maria E. Fernandez. Development of a tailored interactive multimedia intervention (TIMI) to promote colorectal cancer screening among Puerto Ricans [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C11.

Introduction: Colorectal cancer (CRC) represents the second highest incidence in both men and women in Puerto Rico (PR). This cancer is the leading cause of death in PR. Although largely preventable through screening and treatment of precancerous polyps, colorectal cancer screening (CRCS) using fecal occult blood test (FOBT), sigmoidoscopy, or colonoscopy remains low for adults in PR. Data from the 2014 Behavioral Risk Factor Surveillance System indicate that only 18.5% of the PR population 50+ years has undergone an FOBT within the past two years compared to 12.8% in the United States of America (USA). Additionally, only 50.6% of age-eligible Puerto Ricans report ever having a sigmoidoscopy or colonoscopy compared to 68.8% in the USA. Therefore, given the higher burden of CRC and the low CRCS rates in the island, we developed ¡Salud!, por la Vida (SLPV), an educational program that aims to increase CRCS in nonadherent men and women 50 years and older who attend Federally Qualified Health Clinics (FQHCs) in PR. Methods: Intervention mapping (IM) was used as the guiding framework to develop an educational intervention that is theoretically sound and grounded in evidence. For the development of SPLV, steps 1 to 4 of IM were completed: step 1: a needs assessment conducted through focus groups and face-to-face interviews with patients, medical directors, and other key informants from the FQHCs to gather quantitative and qualitative data for the development of the logic model and the program; step 2: development of a logic model of change and matrices of change objectives; step 3: selection of theory and evidence-based methods and strategies; and step 4: program production, components, and materials of a CRCS patient-education intervention. Results: The needs assessment (step 1) data revealed five main themes: (1) limited knowledge about CRC and CRCS practices; (2) patients' fear of the CRC test results; (3) low risk perception of CRC; (4) reporting not having received a provider recommendation regarding the screening test; and (5) the importance of social support in making the decision of getting screened for CRC. Key informant interviews showed that the vast majority of the clinics offer FOBT as part of the CRCS protocol, with 74.0% of these having a clinical laboratory at their facilities. Over one half (53.0%) had already implemented electronic medical records (EMR) and 82.0% had health educators as part of their full-time staff. A logic model was developed by combining personal behaviors with behavioral determinants and identifying beliefs targeted by the intervention (step 2). Tailored interactive multimedia intervention (TIMI) and small media were selected as the practical application to deliver the intervention (step 3). Development of the program included 5 components: (1) script development for fictional videos; (2) testimonials; (3) animations; (4) written materials; and (5) newsletter. After all five components were developed, the team completed a pretesting to evaluate the usability of the program. Pretesting assessment conducted with 9 participants showed that the program was easy to use and that they understood the commands of the interactive platform. Conclusion: Our educational program, !Salud!, por la Vida is completed and currently in implementation phase, using a randomized trial. This trial will be conducted in 10 FQHCs and is expected to recruit 710 participants between the ages of 50-75 who have no prior history of CRC and who are not adherent to CRCS guidelines. The randomization of this study is at the clinic level, in which we randomly allocated each clinic to either the intervention group (TIMI) or the control group (usual care). We aim for this intervention to significantly increase CRCS rates and provide evidence to disseminate this educational effort to FQHCs island wide. Note: This abstract was not presented at the conference. Citation Format: Vivian Colon-Lopez, Camille Velez-Alamo, Adrianna Acevedo-Fontanez, Marievelisse Soto-Salgado, Yolanda Serra-Martinez, Ileska Valencia-Torres, Maria E. Fernandez. Salud!, por la Vida, an educational intervention to increasing colorectal cancer screening in Puerto Ricans [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr B24.