A Partnership Model for Dissemination of Effective Evidence-Based Interventions

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• A Partnership Model for Dissemination of
  Effective Evidence-Based Interventions

Lenora Johnson, MPH, CHES, National Cancer
Institute Phyllis Rochester, PhD Centers for
Disease Control and Prevention Debbie Saslow,
PhD, American Cancer Society Shirley A Gerrior
PhD, RD, LD, United States Department of
Agriculture
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Presentation Overview

• Team Up Overview
• The Rarely/Never Screened Woman
• Using Evidence
• Building Partnerships
• Implications for Research and Practice
• Discussion/Q A

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• The Problem

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Age-adjusted Cervical Cancer Mortality Rates by
State Economic Areas, All Women, U.S., 1995-1999

Source Grauman D., NCI http//www3.cancer.gov/at
lasplus/
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Team Up Overview

• Pilot program to increasebreast and cervical
  screening
• In states with high mortalitycounties
• AL, GA, KY, MO, SC, TN
• Two states left the pilot (IL, MS)
• Guided by 3 principles
• RRarely or never screened woman as our focus
• EEvidence-based as our approach
• PPartnership as our underlying theme

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Four Unique Partners
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Multi-level Partnership
ACS CDC NCI USDA
National Level Department of Health Promotion National Breast and Cervical Cancer Early Detection Program Office of Cancer Information Service (and other divisions/ offices) Cooperative State Research, Education and Extension Service
State Level Divisions State Breast and Cervical Cancer Early Detection Programs Regional CIS Partnership Program Extension at Land Grant Universities
County Level Staff and Volunteers Program Staff and Screening Providers Partner Organizations Extension Educators
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Team Up Roadmap
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Team Up Years 2.5-3.5
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Team Up Years 1-2.5

• Partnership Building
• Convened National Partners
• Facilitated state team formation
• State teams developed action plans
• Built infrastructure to support the pilot

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Team Up Years 1.5-4

• Capacity Building
• Initial training on Cancer Control PLANET
• Formed Partnership Assistance and Technical Help
  (PATH) Team, led by Coaches
• Conducted PATH visits to identify TA needs

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Team Up Years 1.5-4 contd

• Capacity Building
• Convened trainings to address TA needs
• Webinars, newsletters

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Team Up Years 2.5-3.5

• Implementation
• Identified intervention counties
• Identified EBI
• Adapted EBI
• Implemented programs
• Evaluated state-level efforts

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Phyllis Rochester, PhD, LeadProgram Evaluation
And Partnership TeamDivision Of Cancer
Prevention And ControlCenters For Disease
Control And Prevention

• The Rarely/Never Screened Woman

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Why never and rarely screened women?
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Cervical Cancer Mortality Rates, U.S. Born and
Foreign-Born Women, U. S., 1985-1996
Foreign Born
Total
US Born
Modified from Seeff et al., Cancer Detect Prev.
200327(3)203-8.
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Invasive Cervical Cancer Incidence and Mortality
Rates by Race/Ethnicity, U.S., 1998-2001
Hispanic
Source Saraiya M., et al., IPV Conference, 2005.
Incidence rates cover 77, and mortality rates
cover 100 of the U.S. population. Hispanic is
not mutually exclusive from white, black, and
Asian/Pacific Islander.
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Factors Contributing to Cervical Cancer
5-10
False negative cytology test
50-60
10-15
Never or Rarely Screened
Cytology test abnormal, patient lost to follow-up
Cytology test abnormal, mismanaged
10-15
Rapidly progressive
Uncommon cancers difficult to detect
5-10
9-12
SourcesNIH Consensus Conference Janerich,
Connecticut Sung, California
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Team UP definition of never/rarely-screened woman
Cervical woman gt 25 years unscreened ever
(never) or within the last three years
(rarely) Breast woman gt 40 years unscreened
ever (never) or greater than 5 years (rarely)
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Where do we find the rarely/never screened woman.

• Data
• Cancer Control P.L.A.N.E.T.
• State statistics
• Breast and Cervical Screening Program (NBCCEDP)
  for services
• Cooperative Extension for access to communities

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Did screening rates increase?

• Evaluation of Outcomes 2004-2007
• Intervention counties (n1,914) state-selected
• Control Counties (n3 per intervention) n4,790
• - Female age distribution
• Urban/Rural classification
• Female Race/Ethnicity Distribution
• Female education level
• population living in poverty

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But

• BRFSS and NBCCEDP data did not show significant
  differences
• Screening rates were very similar
• Differences by survey year tho with minimal
  screening increases
• Attribution?
• Issues
• Timing
• Women

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Challenges in Identifying the Never/Rarely
Screened
Challenge Solution
Inconsistent data in finding women Clarification of data sources and which to use
Lack of definition for rarely never screened for breast National partner negotiation
Implications for BCCEDP Money for screening acceptance within Refined and continued messages to state participants
Unequal cancer knowledge in local communities Leveraging team knowledge
Burden of evaluation Acceptance by all of delayed outcomes, reduction in data collection, some funding
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Shirley A Gerrior Phd, RD, LD, National Program
LeaderHuman Nutrition Research And
ExtensionFamilies. 4-H And NutritionCooperative
State, Research, Education, and Extension
ServiceUnited States Department Of Agriculture

• Building Partnerships

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Partnerships
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Why Partner?

• Leverage of different knowledge, skills
  resources
• Delivery implementation of comprehensive
  interventions connecting multiple entities
• Increased outreach dissemination of information
• Synergies or added value towards a common goal

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Defining Partnership Profile

• Partnership characteristics
• Number, leadership, management standards
  involvement
• Partnership relationships
• Trust, respect conflict resolution
• Partnership resources
• Sufficiency, effective use equitable
  contributions

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Building Partnerships Questions

• What is the shared vision that motivates the
  partnership?
• Can we achieve more than as individual partners?
• Who else should be involved?
• What expectations do we have of each other?

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Building Partnerships Questions cont.

• What can each partner contribute?
• How will each partner involved benefit?
• How will we get the work done?
• What sources of funding are available?

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Team Up A Unique Combination of Strengths

• National networks that covered the U.S., tribes,
  and territories
• Trained, dedicated field staff that reached all
  levels (regional, state, community)
• Content expertise cancer, health, nutrition
• Technical expertise public education, outreach,
  cancer control planning, training, evaluation

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Team Up A Unique Combination of Strengths cont

• Vast network of trusted partners reach to high
  risk populations
• A variety of tools, data, quality materials
  publications
• Strategic locations and settings cancer centers,
  state health departments, Land Grant Universities

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What Makes a Partnership Successful?

• Synergy
• A key indicator of a successful collaborative
  process because it reflects the extent to which
  the partnership can do more than any of its
  individual participants
• Lasker and Weiss
• Collaboration
• To achieve true collaboration, organizations must
  move through a spectrum of change toward mutual
  understanding and commitment
• Arthur T. Himmelman

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Partnership Success Synergy

• Partnership states with higher synergy
• Strong leaders, high participation, obtained
  external resources and were committed to
  implementing evidence-based interventions.
• Partnership states with lower synergy
• More likely experienced inter-organizational
  cultural challenges, had different agendas, and
  limited resource capabilities.

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Building and Supporting Team Up Partnership

• National Level Activities
• National Meetings
• Coaching, web forum, newsletters
• State Level Efforts
• Memorandums of Understanding
• State agenda and regular meetings
• Retreats
• Management structure (co chairs of state teams)

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Partnership National Partners
Challenge Solution
Becoming a functional model of partnership at the national level Used data as a basis for discussing partnership issues, facilitated team-building, shared struggles
Conflicting priorities of the national partners Negotiation, advocating pilot to leadership
Moving money Creative management of funds through contracts and awards
Varying authority from national to state level Resolved with delicacy on an organizational level
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Partnership Infrastructure
Challenge Solution
High turn-over Orientation package, state co-chairs
Time to manage project nationally and at state-level Dedicated staff at national level and defined leadership structure at state-level
Geography, Time, and Communications and infrastructure
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Partnership Dynamics
Challenge Solution
Getting to know and trust each other turf issues Facilitated team building, retreats, coaching, getting to know each organizations mission and goals coaching
Leveraging resources Accepting that each partner has a unique contribution resources
Self-initiated National partnership vs. pre-determined partnership at the state level Reinforcing rationale for a core team, team-building, coaching, goal orientation
Interpersonal conflict Coaching, retreats, time, withdrawal
Sharing accountability and success MOU, team management structure, newsletter
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Debbie Saslow , PhD, DirectorBreast And
Gynecologic CancerAmerican Cancer

• Using Evidence

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What Is Evidence?

• Surveillance Data
• Systematic Reviews of Multiple Intervention
  Research Studies
• An Intervention Research Study
• Program Evaluation
• Word of Mouth
• Personal Experience

...like beauty, it's in the eye of the beholder
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What is an Evidence-Based Program?

• An evidence-based program has been
• Implemented within a group
• Evaluated
• Found to be effective
• (Preferably) peer-reviewed

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An Informed Decision-Making Model for the
Selection of Cancer Screening Interventions
Types of Programs Types of Programs Types of Programs Types of Programs Types of Programs
RTIPs Eligible Program (peer reviewed funded research publication) Evaluated Program (peer reviewed publication) Evidence-Informed Program (based on literature) Program based on personal experience/ tacit knowledge (no reference to literature)
Systematic Review (Community/ Clinical Guides) 1 2 4 NA
Other Systematic Evidence Reviews (e.g., Cochrane) 2 3 6 NA
Individual Efficacy/ Effectiveness Study 4 5 7 NA
Individual Program Evaluation NA NA 8 9
Type of Evidence Review

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Building Capacity in Evidence-based Program
Planning

• Using What Works http//cancercontrol.cancer.gov/u
  se_what_works/start.htm
• Coaching
• Retreats
• Meetings
• Newsletter Articles
• Web seminars

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FoCas An Evidence-based Program
Forsyth County Cancer Screening Project (Level 1)

• African American women
• Ages 40 and over
• Living in low-income housing
• Limited health care access
• Distrust of physicians
• Program in churches, community centers, homes,
  clinics
• Includes a church program, educational brochures,
  provider training
• Breast and cervical cancer screening

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Challenges Evidence-Based
Challenge Solution
Definition of EBI Education and negotiation Evidence levels table
Lack of knowledge of EBI Awareness, education, and tool development Using What Works
Application of EBI Awareness and education Program adaption and modification
Lack of EBI options Utilized Community Guide and Cancer Control PLANET
EBI resource implications Funding workshops

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Lenora Johnson, MPH, CHES, DirectorOffice of
Communications and EducationNational Cancer
Institute

• Implications for Research and Practice

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Evaluation framework
Partnership Effectiveness
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Investments in the Pilot

• Training
• Travel and logistics
• Systems development

• Coach
• Evaluation
• Infrastructure
• Materials development
• Telecom

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Power in Partnerships

• Appreciate the value of partnership
• Partnership development takes time
• Partnerships (and organizations) change over
  time all levels need to be flexible

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Power in Partnerships contd

• Identify the right partners
• Think outside of the box recognize the value of
  nontraditional partners

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Responsible Custodianship contd

• National partners must lead by example
• Strong, articulated support on a national level
  is critical
• Engaging state-level partners in decision-making
• Evaluation can be an intervention

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Responsible Custodianship

• Not everything that counts can be counted and
  not everything counted counts Einstein
• Exercising patience a pilot is a necessary to
  know what works and what does not work. Dont
  jump to conclusions before it is over

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Program Identity-Branding

• A name is important to establish identity
• Effective communication is key
• Communications materials developed on national
  level

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Infrastructure

• Infrastructure is critical flexibility to
  address challenge
• Document partnership agreement (i.e. MOU or LOA)
• State team leadership structure greater
  structurebetter performance
• Coaches have been invaluable

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Infrastructure contd

• Important to identify TA needs and how to address
• Evaluation is expensive, time-consuming, and
  takes planning but necessary

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QUESTIONS?