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Volume 7: No. 3, May 2010
Suggested citation for this article: Breslau ES, Rochester PW, Saslow D, Crocoll CE, Johnson LE, Vinson CA. Developing partnerships to reduce disparities in cancer screening. Prev Chronic Dis 2010;7(3):A62.
http://www.cdc.gov/pcd/issues/2010/
may/09_0153.htm. Accessed [date].
PEER REVIEWED
Community Context
From 2003 through 2007, three federal agencies and 1 nongovernmental agency
collaborated with county-level public health counterparts from 6 states to address screening disparities in cervical and breast cancer in counties
with the highest prevalence. This case study describes lessons learned from Team Up, a model pilot program.
Methods
We conducted a descriptive qualitative case study including 5 Southern states
and 1 Midwestern state: Alabama, Georgia, Kentucky, Missouri, South Carolina, and Tennessee.
The 6 states underwent a 5-step process to adopt, adapt, and implement 1 of 3 evidence-based interventions designed for cervical and breast cancer screening.
Outcome
The 6 participating states had various levels of success. Participating states formed and sustained viable interorganizational public health partnerships throughout the pilot program and beyond.
Interpretation
Although this innovative pilot faced many difficulties, participants overcame substantial obstacles and produced many key accomplishments. Team Up brought together 2 challenging public health strategies: the translation of evidence-based approaches to communities and populations, and partnerships among diverse people and organizations. Case study results suggest that using a mix of approaches can promote the transference of evidence from research into practice through local, regional, and
national partnerships.
As the Institute of Medicine reported in 2006, the health of racial and ethnic minorities, poor people, and other disadvantaged groups in the United States is worse than the health of the overall population (1). National health status reviews, including Healthy People 2010, have given a high priority to these associated excess illnesses and deaths, termed “health disparities” (2,3). Researchers have developed a blend of population-based strategies to improve the well-being of women who are not regularly screened for cervical and breast cancer; these strategies include implementing evidence-based practice guidelines and collaborating between public and private partners (4-7).
For many years, researchers assumed that implementing an intervention deemed effective in a research context into practice settings was not difficult (4). However, interventions developed in scientific settings to address cancer health disparities have failed because they are not fully understood, are not fully integrated into routine practice, are underused, or do not draw on the collaboration of practitioners working across different organizations and geographic regions (5). For community-based cancer prevention and control endeavors, creative strategies are necessary to address public health problems (8).
From 2003 through 2007, 3 federal agencies — the Centers for Disease Control and Prevention (CDC), the National Cancer Institute (NCI), and the US Department of Agriculture (USDA) — and 1 nonprofit national agency — the American Cancer Society (ACS) — partnered to conduct a pilot case study called Team Up. In addition to national partners, the pilot comprised state and county public health practitioners from 6 states: Alabama, Georgia, Kentucky, Missouri, South Carolina, and Tennessee. These states were chosen because they contained counties with the highest death rates and the lowest screening rates for cervical and breast cancer in the United States (9,10).
The objective of Team Up was to encourage regional public health programs to use cancer control approaches that are evidence-based to reach underserved groups. Typically, different agencies and organizations that target specific cancers undertake cancer prevention and control efforts, lacking coordination and collaboration (11). Such efforts also tend to use interventions that are not evidence-based. We saw an opportunity for regional programs and organizations to build capacity and improve health outcomes by partnering with national agencies and organizations. Communities with low screening rates could benefit from research and subsequent translation of interventions into evidence-based practice. Furthermore, multilevel partnerships — alliances formed between federal, regional, state, and community groups for a common purpose — needed to be studied as a conduit for using evidence-based approaches to encourage behavior change. Promoting evidence-based research is a federal priority, so the Team Up case study is described from the federal perspective.
Team Up had 5 phases: 1) development and planning, 2) partnership formation and building, 3) capacity building, 4) implementation of evidence-based strategies, and 5) evaluation.
Figure 1. Team Up: Pilot program (2001-2007) and evaluation (2003-2008) phases. [A text description of this figure is also available.]
Organization and coalition literature identifies a sequence of phases through which organizations or pilot programs need to move as they establish themselves to meet goals (12). By design, the development and planning of Team Up took time and included a series of diagnostic events that occurred before the official pilot launch in 2003.
To build the foundation for partnerships, we conducted a participatory needs assessment to develop a structured approach to potential programmatic and evaluation activities. Programmatic activities included 2 components: developing a concept map to understand outcome domains that needed to be addressed (13) and building a logic model to depict the sequential and causal relationships among outcome constructs identified in the concept map (14). The results created a bridge between the diverse cultures of participants from the research-funding agency (NCI) and service delivery-funding agencies (ACS, CDC, USDA) to build a partnership based on 3 core goals: 1) to reach women who are rarely or never screened; 2) to use evidence-based interventions as the approach; and 3) to forge partnerships as collaborative relationships.
Partnerships between institutions that conduct research and those that deliver health care and social services can help bridge the gap between knowledge and practice (15-17). Even if partners have worked together in another capacity, new partnerships can be inconsistent because of their unique mission or partner composition (6,11).
The 4 national partners (ACS, CDC, NCI, and USDA) provided initial support for Team Up and encouraged wide-reaching collaboration between preexisting health program infrastructures that regional, state, and county-level partners could access. Sources of partnership infrastructure included ACS’s regional offices and Division of Cancer Control (DCC) staff, CDC’s state and county-level National cervical and breast Cancer Early Detection Program (NBCCEDP), NCI’s Cancer Information Service (CIS), and USDA’s Cooperative State Research, Education, and Extension Service (CRESS) agents (Figure 2). We selected USDA agents because of their established educational programs in communities of interest and their access to underserved women. Regional, state, and county-level partners (CIS, CRESS, DCC, and NBCCEDP) were known as “state partners.” Throughout the life of the pilot program, national partners made efforts to engage state partners whenever possible to use their access to unscreened women.
Figure 2. Structural framework of Team Up partnership.
Abbreviations: ACS, American Cancer Society; AL, Alabama; CDC, Centers for
Disease Control and Prevention; GA, Georgia; KY, Kentucky; MO, Missouri; NCI,
National Cancer Institute; SC, South Carolina; TN, Tennessee; USDA, United
States Department of Agriculture.
[A text description of this figure is also
available.]
In 2003 Team Up developed a series of capacity-building activities to ensure that state partners had adequate skills and training to select and deliver complex evidence-based interventions appropriate for target populations. Capacity building provided tailored technical assistance for implementation activities. We originally planned these activities as a single kickoff meeting, but Team Up state partners required ongoing mentoring for the life of the pilot program. In all, we provided 9 capacity-building activities:
In the implementation phase, state partners translated research into practice through the delivery of evidence-based approaches to reach rarely or never screened women. All 6 states moved through a sequence of 5 core steps as they became familiar with new terminology and activities. Step 1 involved preparatory steps during which state staff conducted diagnostic needs assessments, collected surveillance data, and convened planning meetings. In many instances, these smaller planning groups became the nuclei for larger state initiatives with partners who would eventually deliver the intervention. In step 2, the state partners assessed interventions to determine if they were appropriate for their target populations. Interventions deemed appropriate were adopted. In step 3, adaptation involved fitting the specific intervention to the real world or field settings. Step 4 involved implementation and included training staff to deliver the intervention to women among whom rates of cancer screening were poor. In step 5, the state partners evaluated previous activities.
The organizational framework used in the evaluation planning and design (Figure 3) shows the relationship of the pilot program’s programmatic elements to the relevant short-term (eg, formation of partnerships) and midterm (eg, knowledge of and application of evidence-based methods) outcomes.
Figure 3. Team Up evaluation organizational framework.
Abbreviation: EBI, evidence-based intervention.
1. Partnership synergy is a collaborative process that
enables a group of people and organizations to combine complementary
knowledge, skills, and resources to accomplish more as a group than as
individuals (Lasker and Weiss, 2003). The Lasker and Weiss Partnership
Self-Assessment Tool identifies a partnership’s strengths and weaknesses in
areas known to be related to synergy: leadership, efficiency, administration
and management, and sufficiency of resources. Response categories are based
on 5-point Likert scales (extremely well [5] to not at all well [1];
excellent [5] to poor [1]; all of what it needs [5] to none of what it needs
[1]). Overall synergy results are based on a compilation of definitive
questions with the resulting categorical scores: Danger Zone (1.0-2.9)
requires a lot of improvement; Work Zone (3.0-3.9) requires effort to
maximize the partnership’s collaborative potential; Headway Zone (4.0-4.5)
encourages greater potential to progress further; and Target Zone (4.6-5.0)
requires focus to maintain a synergistic partnership
(http://partnershiptool.net/).
2. EBI: Evidence-based intervention. The term "evidence-based intervention"
refers to an intervention that has been tested through randomly controlled
experiments with efficacious results that have been published in
peer-reviewed journals (http://www.aoa.gov/doingbus/fundopp/announcements/2008/ ADDGS_Evidence_Based_FAQ.doc).
[A text description of this figure is also
available.]
The purpose of the 3-part theoretically guided evaluation was to determine whether Team Up achieved its goals. Part 1, the process evaluation, assessed the success of the state partners in building a synergistic partnership that resulted in an intersection of common knowledge, skills, and consensus (6). Part 2, the impact evaluation, measured attributes that influenced adoption, adaption, and implementation of evidence-based interventions. Part 3, the outcome evaluation, assessed whether state partners influenced short-term screening rates through the interventions.
On the basis of data collected throughout the pilot program, all Team Up states developed sustained public health partnerships (18). The states’ success in moving from a team of people to a viable partnership was measured by the extent to which individual and organization perspectives, nonmaterial resources, and skills of participating people and organizations contributed to and strengthened partnerships as a whole (6,18). By the end of the pilot, states with strong leaders obtained external funding, had dedicated staff, and collaborated across partners. In comparison, states with less robust leadership encountered interorganizational challenges that required considerable partner efforts to reconcile (18). This conflict was a consequence of partners’ having opposing goals and different problem-solving styles, agendas, and resource capacities.
Six states implemented an evidence-based screening intervention for breast or cervical cancer. The evidence-based interventions were selected, and specific components were implemented (Table). To select interventions, states consulted peer-reviewed publications, professional organizations, and The Guide to Community Preventive Services: What Works to Promote Health? (http://www.thecommunityguide.org/) and linked to interventions via a Web portal (Cancer Control PLANET [Plan, Link, Act, Network with Evidence-based Tools] http://www.cancercontrolplanet.com/). From the cancer control interventions available, combinations of 3 strategies were used.
Team Up offered promising strategies for accelerating the delivery of research-tested approaches into practice (19). Through partnerships, the pilot generated collaboration among diverse people and organizations enhanced understanding of implementation concepts and strategies (5). However, the resultant Team Up pilot also encountered many difficulties. Launching the pilot revealed a need for technical assistance in the areas of partnership maintenance and successful implementation. As a result, various strategies to enhance relationships were considered together with practical methods to contextualize the implementation of evidence into practice. After Team Up launched, national partners recognized the need to offer extensive capacity-building to assist state partners, an investment not initially realized. Further, since the evolution of Team Up, implementation science has become more predominant within public health (20). Consequently, the methods described here provide a useful context for other public health projects seeking to apply evidence-based strategies to decrease gaps in screening for cervical and breast cancer.
Promoting and encouraging the transfer of evidence from research into practice required a mix of methodologic approaches and a discourse between those moving the evidence from one environment to another. Although the results of Team Up were highly variable, successes were realized, and many lessons emerged.
Because each partner brought a unique perspective to Team Up state partnerships, states without full involvement from all partners had difficulty achieving Team Up’s goals. As in any collaborative initiative, reconciling these different partnerships required identifying and integrating complementary nonfinancial resources. Nonetheless, the partnerships worked to overcome their respective challenges. The collective commitment to the Team Up pilot goals and a respect for each other kept the 6 partnerships from separating.
Continuity of membership from initiation throughout the life cycle of the partnership is vital when interorganizational partners are involved. People and organizations that have experience working in the target communities come from diverse constituencies. These valuable partners typically know what is feasible and realistic, thus improving “buy-in” and participation during the delivery of the intervention (ie, the implementation phase). Involving and training people with backgrounds similar to those of the target population from the beginning can increase ownership, communication, and commitment and reduce turnover (11,17). Providers of public health interventions in underserved or minority populations also may require ongoing training in cultural competency (7,21). In addition, key leaders at all levels juggled competing priorities, nonfinancial resources, and their diverse sectors.
Until recently, the availability of evidence-based screening interventions specifically designed for underscreened populations was limited. Commonly, staff needed to be trained to identify appropriate interventions and how to use the Cancer Control PLANET and The Guide to Community Preventive Services. Both resources offered examples of interventions for different populations and contextual environments. Access to intervention components through contact with researchers diminished the research-to-practice gap (22).
When practitioners considered what to adopt, state partnerships did not always agree on what counted as evidence and under what circumstances. For example, interventions that did not contain the entire “suite” from the original research intervention may not maximize effectiveness in the new practice environment, a fact not measured in this pilot program. Furthermore, because of the demographic and geographic diversity of women within counties, research interventions were adapted at multiple levels of the partnership and continually evolved. Team Up found it essential to systematically track the adaptation progress throughout the implementation process. State partners repeatedly expressed the idea that “one size does not fit all,” and this belief translated into innovative county- and community-level adaptation, something that exceeded the state partnership initial plans.
No universal recommended process or set of established best practices exists for the adaptation of evidence-based interventions to populations, conditions, and environments different from those in the original research (23). Although adaptation is necessary to make the intervention more relevant for a new target population, the more intervention components were altered, the less fidelity to the original intervention remained. On the other hand, the process enabled those who were adopting the evidence-based intervention to gain ownership of the new intervention. A deeper question is whether we can or even need to develop specific early detection programs for every combination of language, culture, geographic location, and racial/ethnic subgroup (21). Even though the implementation context is vital, more important is the knowledge of how much an intervention can be altered before it becomes completely different (22).
Collaborations formed early in the partnership can be sustained beyond the pilot and can overcome obstacles in successful and creative ways. Synergy is a key measure of partnership success (6,18). In Team Up, synergy appeared to increase over time. However, in 1 state where leadership changed, the partnership synergy seriously dissipated for a time. In general, an indicator of Team Up’s success is the strong leadership and management structures that enhanced collaboration at the local level. Several states plan to sustain the Team Up model with other cancer control efforts.
Team Up had certain limitations. First, even though the Team Up multilevel partnerships were integral to programmatic goals, each state partnership functioned as a distinct unit with strong ties to both the local communities they operated in and to particular national organizations. Generalizing these methods to other multilevel partnerships interested in focusing on cancer control and prevention is encouraged; however, this task may be difficult because of the populations that state partnerships chose to reach. Team Up was a case study, and one cannot generalize from a single case (24). Second, evaluation outcomes need to be accompanied by an understanding of why or how a specific strategy did or did not work (25). Finally, future programs should consider building in a cost assessment associated with implementing such a multiyear program in several states.
As a case study, Team Up allowed us to examine a complex approach to address cancer screening disparities and to consider methods for translating scientific knowledge into practice. Although the field of health care disparities is firmly established, public health strives to find a practical blend of strategies and interventions that effectively work to reduce these disparities. This case study suggested that a combination of approaches should be tried before moving to a larger-scale study.
We thank the 6 states and their respective partners for engaging in this pilot program. We also thank the peer reviewers who provided insightful comments that clarified and improved this manuscript. We dedicate this article to Dr Lawrence Breslau (deceased), whose interest and support in this work was unending.
Corresponding Author: Erica S. Breslau, PhD, National Cancer Institute, 6130 Executive Blvd, Ste 4098, Bethesda, MD 20850. Telephone: 301-435-2539. E-mail: breslaue@mail.nih.gov.
Author Affiliations: Phyllis W. Rochester, Centers for Disease Control and Prevention, Atlanta, Georgia; Debbie Saslow, American Cancer Society, Atlanta, Georgia; Caroline E. Crocoll, US Department of Agriculture, Washington, DC; Lenora E. Johnson, Cynthia A. Vinson, National Cancer Institute, Bethesda, Maryland.
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The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
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