Abstract
In this practice note, we examine the implementation and impact of the Texas Cancer Screening, Training, Education, and Prevention (C-STEP) program, which aims to reduce cancer disparities in medically underserved and rural areas. The program utilizes community health workers (CHWs) or promotor(a)s to provide outreach, education, and early detection services for breast, cervical, colorectal, and lung cancers. C-STEP employs a multidisciplinary approach, partnering with the Center for Community Health Development National Community Health Worker Training Center to certify CHWs in cancer prevention and detection. The program establishes community and clinical partnerships to promote cancer screening uptake in priority populations. Key outcomes include training over 33 CHWs, establishing more than 1500 partnerships, providing cancer education to over 30,000 individuals, conducting over 8300 screening exams and 600 diagnostic procedures, and diagnosing 69 cancers. Successes encompass increased screening rates, community engagement, and partnership development. Challenges involve financial inequities, technology literacy, role complexity, and outreach difficulties. Lessons learned highlight the need for proactive planning, diverse recruitment, and consistent communication with partners. Our findings suggest that integrating CHWs into cancer screening programs effectively increases awareness and screening rates, particularly among low-income populations. Future implications suggest the importance of strategic planning, systematic training, and creative partnership approaches to recognize CHWs as vital health care team members. The findings highlight the potential of community-based interventions in addressing cancer disparities and improving health outcomes practices in rural and underserved areas.
Improving cancer screening, training, education, and prevention services is a major concern, especially in Texas where individuals residing in medically underserved and/or rural areas face significantly higher rates of cancer incidence and mortality. To alleviate this burden, the Texas Cancer Screening, Training, Education, and Prevention (C-STEP) program began in 2011 to provide safety-net colorectal cancer screening services and increase the number of qualified medical professionals capable of performing cancer screening and diagnostic procedures. The program expanded in 2013 to include breast and cervical cancer screening services and further expanded in 2021 to include lung cancer screening and prevention. C-STEP currently serves 25 Texas counties. In this practice note, we detail Texas C-STEP’s program development and impact, demonstrating how community health worker-led interventions can address cancer disparities and advance health promotion practices in rural and underserved areas.
Assessment of Need
Despite a decline in overall cancer rates over the past decade, significant disparities still exist among racial and ethnic minoritized populations. These disparities persist across race, ethnicity, gender, educational levels, income, and geographical areas. In Texas, breast and cervical cancer incidence rates are higher in Hispanic and Black communities; non-Hispanic (NH) Black women diagnosed with breast cancer have significantly higher mortality rates and Hispanic women are more likely to experience late-stage cervical cancer (American Cancer Society, 2023). NH Black populations have the highest incidence and mortality rates for colorectal cancer (American Cancer Society, 2022). Hispanic individuals have liver cancer incidence and death rates nearly double those of NH White populations (American Cancer Society, 2023; Texas Cancer Registry, 2018). Late-stage diagnoses of breast and cervical cancers are more common in rural regions of Texas compared with urban areas (Texas Cancer Registry, 2024).
Multilevel barriers impact cancer screening uptake in minoritized populations at individual, provider, and system levels (Ibekwe et al., 2023; Mayhand et al., 2021; President’s Cancer Panel, 2022; Scheppers et al., 2006). Individual level barriers related to personal characteristics include demographics, social structure variables, health beliefs and attitudes, personal enabling resources, and personal health practices. At the provider level, barriers are associated with provider characteristics such as skills and attitudes. Finally, system level barriers correlated with the organization of the health care system. Each highlights the need to implement strategies to improve cancer screening priority populations. At each level, there are opportunities to implement strategies to improve cancer screening in priority populations.
Description of Strategy and Innovation
To address and alleviate barriers and associated cancer disparities and burdens, Texas C-STEP utilizes a multidisciplinary approach to provide outreach, education, and early detection services. At the center of this care model is the community health worker (CHW) or promotor(a). CHWs/promotor(a)s are trusted community members with a close understanding of the culture, language, socioeconomic status, and life experiences of the community served (American Public Health Association, 2023; Brandford et al., 2019). They are uniquely positioned to assist with access to health care and build individual, community, and system capacity to address disparities through outreach, patient navigation, follow-up, health education, informal counseling, social support, advocacy, and encouragement of participation in clinical research.
To train and develop the CHW/promotor(a) workforce, Texas C-STEP partnered with the Center for Community Health Development National Community Health Worker Training Center to certify individuals as CHWs with a cancer prevention and detection focus. CHWs/promotor(a)s complete a 160-hour certification course focusing on eight core competencies and receive ongoing cancer-specific education.
A multitiered collaboration model consisting of community and clinical partnerships was established to promote cancer screening, education, and prevention uptake in lower income, rural, medically underserved areas. Outreach is accomplished through disseminating informational materials at health fairs, food pantries, resource centers, community presentations, public speaking engagements, clinical partner meetings, and various media platforms.
Intended Impact/Outcomes/Evaluation Approach
The intended impact of C-STEP is to reduce the cancer burden by (a) providing cancer education, (b) increasing cancer screening uptake, (c) developing and sustaining a CHW infrastructure, and (d) strengthening community partnerships. Outcomes included training over 33 CHWs, establishing more than 1500 community and clinical partnerships, providing indirect and direct cancer education outreach services to over 30,000 laypeople and professionals, and conducting more than 8,300 screening exams and 600 diagnostic procedures, diagnosing 69 cancers. The C-STEP program is continuously evaluated through monthly team meetings, quarterly and annual reports, and oversight from a doctoral-level prepared evaluator.
Successes and Challenges
The successes and challenges experienced primarily occurred in these main areas (a) CHW/Promotor(a) development, (b) partnerships, and (c) outreach. Successes of the C-STEP program include increased cancer screening rates and diagnoses, community trust and engagement, implementation of standardized training, establishment of clinical partnerships, and outreach expansion. The C-STEP program achieved significant successes in improving cancer screening rates and diagnoses, demonstrating the effectiveness of their community-based approach. Through dedicated efforts, the program fostered strong community trust and engagement, establishing CHWs as trusted champions and friends within their communities. The implementation of standardized training enhanced the quality and consistency of CHW services across the program’s reach. Clinical partnerships were successfully developed to facilitate screenings, showcasing the program’s ability to bridge the gap between community outreach and medical care. The program’s adaptability allowed for successful expansion, both geographically and in the scope of cancer education and information dissemination, reaching more underserved communities over time.
Challenges encountered involve financial inequities, technology and literacy challenges, complexity of the CHW role and responsibilities, attrition and turnover, outreach complexity, clinical and treatment barriers, transitional roadblocks, acceptability, accessibility, data compliance, and time constraints. The C-STEP program faced numerous challenges in its implementation and expansion. Financial inequities and technological barriers hindered the program’s reach and effectiveness, while the complex nature of the CHW role contributed to high turnover rates. Outreach efforts were complicated by geographical, cultural, and clinical barriers, making it difficult to connect underserved communities with necessary cancer screening and treatment services. The program also grappled with issues of acceptability and accessibility, striving to gain trust and provide convenient services across diverse populations. In addition, data compliance requirements and time constraints posed ongoing challenges for both CHWs and the communities they served, requiring continuous adaptation and problem-solving from the program team. Table 1 highlights additional notes on successes and challenges, central themes across categories, and program adjustments.
Successes and Challenges, Central Theme Across Categories, and Adjustments Based on Successes and Challenges
Lessons Learned
Lessons learned throughout the C-STEP program include the need to plan for CHW/promotor(a) attrition, be mindful of technology and literacy challenges, proactively establish and maintain certification and renewals, create engaging educational resources, prioritize diverse CHW recruitment, utilize an independent contractor employment model, focus on consistent and systematic communication with partners, seek out diverse partnerships, group CHWs by geographic locations, and provide trauma-informed strategies and tools.
Next Steps and Implications for Practice
Integration of CHWs/promotor(a)s into cancer screening, training, education, and prevention is an effective method for increasing awareness and screening rates among members of a community, particularly populations with lower incomes. Utilizing CHWs/promotor(a)s leads to increased patient initiation of cancer screening discussions and outreach, which has increased screening recommendations by providers (Liu et al., 2021), significantly addressing and impacting the presentation and associated mortality of breast, cervical, colorectal, and liver cancers in rural and medically underserved regions (Okasako-Schmucker et al., 2023).
To achieve the goal of recognizing CHWs/promotor(a)s as vital members of the multidisciplinary health care team, there must be intentional strategic planning in conjunction with systematic and consistent education and training to ensure competency, readiness, and confidence. CHWs/promotor(a)s must possess linguistic and technological tools to function at the desired level of independence during community outreach and engagement activities. In addition, it is crucial to implement creative strategies and approaches to establishing and maintaining community and clinical partnerships.
Footnotes
Authors’ Note:
The authors acknowledge Anna Lichorad, Jason McKnight, Robert Pope, and Brandon Williamson. The Texas Cancer Screening, Training, Education, and Prevention Program (Texas C-STEP) was funded by the Cancer Prevention and Research Institute of Texas (Grant # PP220013, Grant #PP210027, and Grant # PP200070).
