- Email: [email protected]
Recruitment for the National Breast and Cervical Cancer Early Detection Program
Recruitment for the National Breast and Cervical Cancer Early Detection Program Cam T. Escoffery, PhD, MPH, Michelle C. Kegler, DrPH, MPH, Karen Glanz, PhD, MPH, Tracie D. Graham, MPH, Sarah C. Blake, MA, Jean A. Shapiro, PhD, Patricia D. Mullen, DrPH, Maria E. Fernandez, PhD Background: To reduce disparities in breast and cervical cancer in the U.S., it is essential that programs such as CDC’s National Breast and Cervical Cancer Early Detection Program (NBCCEDP) use evidence-based strategies. Recommendations for interventions to increase breast and cervical cancer screening have been disseminated by national public health organizations. To increase screening, cancer control planners would benefıt from use of evidence-based strategies for recruitment of participants in their communities.
Purpose: The purpose of the study was to inventory recruitment activities for cancer screening within NBCCEDP programs and assess if activities used to increase cancer screening are evidencebased. Methods: Interviews were conducted with 61 recruitment coordinators in 2008 to elicit their recruitment activities, use of evidence-based resources, and barriers to using evidence-based interventions (EBIs). Study data were analyzed in 2009.
Results: Of the 340 activities reported, many were categorized as educational materials, one-on-one education, mass media, group education, and special events. Two thirds of inventoried activities matched an EBI. Coordinators reported that colleagues and the CDC are their primary sources of information about EBIs and few coordinators had used evidence-based resources. Lack of money or funding, questionable applicability to priority populations, limited staffıng or staff time, and insuffıcient evidence-based research were the most important barriers to EBI use. Conclusions: Although the majority of NBCCEDP recruitment activities were evidence-based, one third were not. Additional training and technical assistance are recommended to help public health agencies adopt the use of these strategies. (Am J Prev Med 2012;42(3):235–241) © 2012 American Journal of Preventive Medicine
Introduction
D
espite progress in screening uptake, increasing breast and cervical cancer screening use continues to be an important public health objective. Certain subgroups of women experience increased morbidity and mortality from cancer. African-American From the Department of Behavioral Sciences and Health Education (Escoffery, Kegler) and the Department of Health Policy and Management (Blake), Division of Cancer Prevention and Control (Shapiro), CDC, Atlanta, Georgia; the Schools of Medicine and Nursing (Glanz), University of Pennsylvania, Philadelphia, Pennsylvania; and the Division of Health Promotion and Behavioral Sciences (Mullen, Fernandez), University of Texas School of Public Health, Houston, Texas Address correspondence to: Cam T. Escoffery, PhD, MPH, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road, NE, 5th Floor, Atlanta GA 30322. E-mail: [email protected]. 0749-3797/$36.00 doi: 10.1016/j.amepre.2011.11.001
© 2012 American Journal of Preventive Medicine. All rights reserved.
women experience higher mortality from breast cancer, and Hispanic women have a higher incidence of cervical cancer than other groups.1 Disparities in screening also exist; 68% of white women aged ⱖ40 years have received a mammogram in the past 2 years, compared with only 61% of Hispanic women.2 For cervical cancer screening, although 77% of white women and 79% of AfricanAmerican women aged ⱖ18 years have been tested in the past 3 years, only 74% of Latinas in this age group have been screened.2 Women with lower SES or no health insurance have lower rates of both mammography and Pap testing.2 Barriers to screening include lack of health insurance, language, geography, cultural differences, provider biases,3 women’s perception of low risk,4 lack of social support,5,6 and lack of reminders.7 The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) was created by the U.S. Congress after passage of the Breast and Cervical Cancer Am J Prev Med 2012;42(3):235–241
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Mortality Prevention Act of 1990 to improve access to screening among low-income women.8 The CDC administers the NBCCEDP, which provides breast and cervical cancer screening and diagnostic services for low-income, uninsured, or underinsured women through programs in all 50 states, the District of Columbia, fıve U.S. territories, and 12 American-Indian/Alaska Native tribes. Programs provide clinical breast examinations, mammograms, Paps, pelvic examinations, diagnostic testing for abnormal results, and referrals to treatment.9 Federal legislation that authorizes the NBCCEDP stipulates that 60% of funds are directed to clinical services; other activities are essential to support screening. The NBCCEDP is implemented at the state and local level. No two programs are identical because each is designed to address its own unique characteristics and needs such as population demographics and size, geography, public health and medical infrastructure, and cultural and screening barriers. Recruitment is defıned as “the act of seeking to enroll program-eligible women into breast and cervical cancer screening services.”10 Each program has a staff person who is responsible for coordinating public education and in-reach strategies to achieve recruitment goals (known as recruitment coordinators). The CDC supports the coordinators by providing strategic direction, skill development opportunities, and forums for information sharing and collaboration. Since inception, grantees have screened 3.9 million women and diagnosed more than 52,694 breast cancers, 2856 invasive cervical cancers, and more than 56,115 high-grade premalignant cervical lesions.8 More recently, in 2009, the NBCCEDP provided mammograms for 324,912 women and found 4635 breast cancers; it offered Paps for 320,627 women and found 4694 cervical cancers and precancerous lesions.8 Screening numbers can include women who have never been screened or women who were screened previously. The purpose of the present study was to inventory NBCCEDP recruitment activities for cancer screening, assess to what extent the recruitment activities corresponded with recommended evidence-based interventions to increase breast and cervical cancer screening, describe use of evidence-based resources, and describe barriers to the use of evidence-based interventions.
Methods
Measures This research was part of a larger project to inventory the (1) professional development and (2) recruitment activities performed by the NBCCEDP grantees. A Work Group and an Advisory Committee (Cancer Prevention and Control Research Network researchers) provided guidance and recommendations about the study process. The Work Group consisted of Emory University investigators, CDC staff, and two NBCCEDP recruitment coordinators. The Emory University IRB approved this study (IRB00005831). The recruitment survey had eight sections: program information, description of the activities, implementation of the activities, results and evaluation of the activities, general questions about the activities, use of evidence-based cancer prevention resources, barriers to use of evidence-based practices, and implementation of core elements for major activities. Respondents were asked to describe their major (e.g., those that required more resources/time) and minor activities in the past year through an open-ended question and categorize them into broad recruitment strategies. Respondents also described use of several sources of evidence-based interventions, including The Guide to Community Preventive Services, and the National Cancer Institute’s Cancer Control P.L.A.N.E.T. (plan, link, act, network with evidence-based tools) and Research-Tested Intervention Programs (RTIPs). The Taskforce for the Guide synthesizes scientifıc evidence regarding the effectiveness of health promotion and disease prevention interventions, including recommendations for interventions to increase cancer screening.11 Cancer Control P.L.A.N.E.T is a portal with links to other web resources that can assist in the design, implementation, and evaluation of evidence-based cancer control programs.12 Finally, RTIPs website houses cancer control programs and products that have been research tested.13 For the analysis of the extent to which EBIs were used, the evidence-based strategies recommended by the Community Guide were employed (Table 1).14 –17 Interviewers collected data on the coordinator’s professional training, degree and years with the program. The level of fıdelity in implementing core elements and/or key process steps during implementation of major recruitment strategies also was measured. Core elements are the essential components that are believed to make an evidence-based program effective and should be kept in order to maintain intervention effectiveness.18 Key process steps are requisite activities necessary for the adequate implementation of an evidence-based strategy. The list of process steps or core elements was developed by the authors based on intervention articles from RTIPs, Community Guide, Cochrane reviews, and RCT articles on mammography and Pap interventions. Descriptive steps in conducting an evidencebased strategy were extracted from these articles. These steps were compiled into tables by type of recruitment categories (e.g., client reminders). The Advisory Committee rated the steps and provided comments about the steps (e.g., deleting, adding a step). The authors then reviewed the comments and selected the fınal steps for the interview guide based on the majority of the ratings.
Sample and Data Collection
Statistical Analyses
Recruitment coordinators from the NBCCEDP-funded states, tribes, and territories were contacted for the study. Sixty-eight potential respondents were contacted by e-mail, and 61 were interviewed by phone between February and June 2008.
Study data were analyzed in 2009. Frequencies were calculated for all categoric variables including respondents’ demographics, description of the major activities, use of core elements, and use of evidence-based resources. Qualitative items were recorded in narwww.ajpmonline.org
Escoffery et al / Am J Prev Med 2012;42(3):235–241
Table 1. Evidence-based strategies to increase breast and cervical cancer screening Strategy
a
237 14 –17
Definition
Client reminders
Printed postcard or letter or telephone message telling individuals that they are due or late for cancer screening
Small media
Printed material such as brochures, newsletters, pamphlets, fliers, or videos that provide information or motivational messages about being screened for cancer
One-on-one education
Information or motivational messages about cancer screening delivered either in person or by telephone to an individual
Group educationa
Information or encouragement about cancer screening delivered to assembled individuals by health professionals or lay people
Reducing structural barriersa
Strategies to reduce or remove barriers such as location, distance, language barriers, or inconvenient hours by offering transportation or reducing distance to screening, assisting in scheduling screening appointments or providing interpreter services, reducing administrative burdens, or expanding hours of operations
Reducing out-of-pocket costsa
Lowering clients’ cost through vouchers, reimbursement, reductions in copayments, or other methods to lower clients’ contributions to increase access to screening services
These are evidence-based strategies recommended for breast cancer screening only.
rative form. For the analyses on the use of evidence-based strategies and conduct of core elements, recruitment activities that were focused on breast and cervical cancer screening individually or combined and were in the categories that had core elements that were defıned were selected. For each major category of recruitment strategy, the proportion of recruitment activities that were reported to include each core element or process step was reported.
Results Recruitment interviews were completed in 61 of 68 programs (response rate⫽90%). The interviews were conducted within 48 state programs, 10 tribal programs, and three territorial programs, representing 71% of state programs, 83% of tribal programs, and 60% of the territorial programs. The interview length ranged from 9 minutes to 1 hour 53 minutes (M⫽50 minutes). Recruitment coordinators had been in their positions for an average of 4.3 years. Although they may hold more than one degree, the most common type of training was a bachelor’s degree (53.8%), followed by an MPH (15.4%); other master’s degree (9.2%); associate’s degree (7.7%); and MPA (6.2%). Respondents were asked to list their program’s “major” and “minor” recruitment activities for the past year and categorized activities into 11 a priori categories. These categories included reminders/invitations; educational materials; one-on-one education; group education; social networks; mass media; small media (i.e., educational materials); cost reduction; incentives; access-enhancing strategies; and special events (i.e., health fairs). There were a total of 340 reported recruitment activities. Of the 198 major activities, the four most common categories, in order of frequency, were educational materials, one-onone education, mass media, and reminders/invitations. Of the 142 minor activities, the most common categories March 2012
were educational materials, group education, one-on-one education, and special events. Categories were not mutually exclusive because one activity could incorporate several recruitment categories.
Use of Evidence-Based Resources Cancer Control P.L.A.N.E.T. was used by the largest percentage of recruitment coordinators (59.4%), and RTIPs was used least (20.3%) (Table 2). P.L.A.N.E.T. was used to obtain data on cancer and/or risk factor burden (78.9%) and to learn about effective intervention approaches (76.3%). The Community Guide was used most often to learn about effective intervention approaches (68.0%) and to identify other resources (68.0%). Among RTIP users, most used it to incorporate aspects of an RTIPs program into an existing program (76.9%) or for inspiration for program development (53.8%).
Use of Evidence-Based Strategies in Recruitment Efforts Of the 309 recruitment activities focused on breast and/or cervical cancer screening exclusively, 66.0% used at least one of the classifıed evidence-based strategies (Table 3). The use of small media was the most common strategy (43.0%), followed by one-on-one education (34.6%) and reminders (29.4%). Additionally, although the coordinators reported using evidence-based strategies, they did not provide the name of a specifıc intervention. The association between use of evidence-based strategies and use of any evidence-based online resources was explored. There was no association between use of these strategies and utilization of the Community Guide (p⫽0.69); RTIPs (p⫽0.66); and Cancer Control P.L.A.N.E.T. (p⫽0.38).
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Table 2. Self-reported use of and reasons for use of evidence-based resources by NBCCEDP recruitment coordinators, n (%) Cancer Control P.L.A.N.E.T.
Community Guide
RTIPs
38 (59.4)
25 (39.1)
13 (20.3)
—
—
—
To learn about effective intervention approaches
29 (76.3)
17 (68.0)
—
To obtain data on cancer and/or risk factors burden
30 (78.9)
—
—
To identify other resources
23 (60.5)
17 (68.0)
—
Just to browse
20 (52.6)
13 (52.0)
—
To learn about evidence-based programs and products
27 (71.1)
15 (60.0)
—
To find guidelines for planning evaluation
18 (47.4)
—
—
To identify potential program/community partners
13 (34.2)
—
—
To identify areas where more evidence is needed
8 (21.1)
To identify potential research partners
6 (15.8)
Use of evidence-based resources Reasons for using Cancer Control P.L.A.N.E.T. or Community Guide (among users, n⫽38 and n⫽25)
To find logic models listing strategies for cancer control Reasons for using RTIPs (among users, n⫽13)
—
5 (20.0) — 5 (20.0)
— — —
—
—
—
Incorporating aspects of an RTIP into an existing program
—
—
10 (76.9)
Use of RTIPs as an inspiration for program development
—
—
7 (53.8)
Reference purposes
—
—
5 (38.5)
Sharing with colleagues
—
—
5 (38.5)
Identifying program/community partners
—
—
5 (38.5)
Note: N⫽64; some of the grantees’ sites have other contractors also reporting on activities, so the number of respondents is ⬎61. NBCCEDP, National Breast and Cervical Cancer Early Detection Program; P.L.A.N.E.T., plan, link, act, network with evidence-based tools; RTIP, Research-Tested Intervention Program (National Cancer Institute)
The quality of implementation was assessed by asking about adherence to core elements and/or best processes associated with each evidence-based strategy for the major activities (Table 3). Completion of core elements was generally high. For small media, the step most frequently skipped was pretesting materials (53.7% completed). For one-on-one education, all process steps usually were completed (87.5% or greater). Client reminders usually included information on how to get the screening test. Increasing or changing the hours of services was the most commonly reported access-enhancing strategy. When asked where they learned about the recruitment strategies they use, the most frequently mentioned external source was a colleague or professional (19.8%), followed by the CDC or American Cancer Society combined (11.1%) and conferences (6.8%). Other sources were internal, with 35.4% of activities reported as always being done by the organization and 16.0% developed by the staff. The most frequently cited barriers to using evidence-based strategies by the two thirds of respondents who reported experiencing barriers were lack of
money/funding/budget (40.9%); lack of applicability to priority population or area (22.7%); lack of staff time (15.9%); lack of evidence-based research (13.6%); limited staffıng (13.6%); and lack of knowledge of evidence-based interventions (11.4%).
Discussion The present study found that although NBCCEDP coordinators used a range of recruitment strategies to encourage women to obtain breast and cervical cancer screening, 66% of activities were evidence-based strategies recommended by the Community Guide. Overall, the use of resources to fınd evidence-based strategies was fairly low, perhaps explaining the less than optimal use of recommended approaches. Knowledge of evidence-based interventions is important to ensure adequate adoption and implementation.19 The fındings of this project inform several recommendations for the NBCCEDP, many of which are applicable to cancer prevention in other settings. There is need to www.ajpmonline.org
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Table 3. Use of evidence-based strategies and adherence to core elements and/or best processes among inventoried activities, n (%) Evidence-based strategy (n⫽309)a Small media
133 (43.0)
One-on-one education/counseling
107 (34.6)
Reminders/invitations
91 (29.4)
Access-enhancing strategies
43 (13.9)
Multicomponent activity
27 (8.7)
Cost reduction Any evidence-based activity
0 204 (66.0)
CORE ELEMENTS/BEST PROCESS FOR MAJOR ACTIVITIES (n⫽198) Small media (n⫽82) Pretest concepts, messages, and materials
44 (53.7)
Describe its importance and benefits of getting a mammogram/Pap
75 (91.5)
Describe the screening guidelines
67 (81.7)
Address barriers or concerns about getting a mammogram/Pap
64 (78.0)
Provide information on how to get a mammogram/Pap
81 (98.8)
One-on-one education (n⫽72) Discuss the benefits of screening
70 (97.2)
Identify individual barriers to getting a mammogram/Pap
66 (91.7)
Discuss ways to overcome barriers to screening
65 (90.3)
Assist women in making an action plan
63 (87.5)
Client reminders (n⫽66) Provide information on how to get a mammogram/Pap
61 (92.4)
Contact women more than one time
47 (71.2)
Access enhancing (n⫽34)
a
Reduce time or distance between the setting and the target population
26 (76.5)
Offer services in alternative or nonclinical settings
23 (67.6)
Increase or change hours of service
27 (79.4)
Eliminate or simplify administrative burdens for patients
24 (70.6)
Only interventions that were focused on breast cancer, cervical cancer, or both were included in this analysis.
train coordinators about resources for identifying EBIs and to increase their capacity to adopt those interventions. Trainings should emphasize strategies that were used less such as small media. A recent study20 suggests March 2012
239
that active and multi-modal strategies (e.g., training or provision of materials) can disseminate more effectively evidence-based interventions. Greater knowledge of evidence-based strategies and increased capacity for program planning may strengthen recruitment and also improve both overall effectiveness and effıciency.21 Training also needs to be maintained because there is frequent turnover in the coordinator positions. In addition, the NBCCEDP program consultants, CDC staff who support the grantees, could provide technical assistance to grantees in using evidence-based strategies and encourage sharing of activities. Specialized coaching and monitoring of the fıdelity to the original intervention are important to increasing use and effectiveness of evidence-based programs, particularly as they are implemented in new settings and with different target audiences.22–25 This is critical because coordinators reported that their primary sources of EBIs were other colleagues and the CDC or ACS. The program offers multiple ways for grantees to interact with each other. These personal sources may be more credible and, therefore, a more effıcient source of EBIs. The NBCCEDP could help reduce barriers to use of evidence-based strategies. Overall, barriers reported include lack of money, staffıng, and lack of applicability to target population. DiFranceisco and colleagues26 found similar constraints to use of research-based HIV prevention interventions. The grantees serve very diverse populations and there may be a need for cultural, language, and literacy adaptations in some cases. Strategies such as educating coordinators about the benefıts of EBIs and instruction on adaptation may limit some of these barriers. The specifıc steps that community planners need to carry out to adapt existing programs are described in Intervention Mapping27 where authors include a chapter on adapting evidence-based programs that could be shared with the grantees.28 Finally, the NBCCEDP could promote the identifıcation and use of core elements of EBIs to help grantees use evidence-based strategies. In the current study, the authors attempted to defıne core elements of EBIs through an expert consensus process, and assessed fıdelity to those elements. Nevertheless, in the literature on translation, “core elements” of interventions often are not well defıned by program developers.29 –31 Changes in standards for literature reviews have reduced bias and improved reliability, and reporting guidelines for intervention trials have improved the transparency of study methods.32–34 Clear identifıcation of these core elements is an essential step for program adaptation and implementation because changing these may compromise the effectiveness of the program.
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The CDC has already considered these fındings as a part of strategic planning efforts that began in 2009 to enhance outreach efforts. CDC has strengthened its training support for grantees, including webinars, inperson training meetings, and standardized technical assistance by developing a series of resources for grantees to encourage uptake of EBIs. The present study has several limitations. The fındings are based on self-reported activities by the coordinators. Because of the scope of this analysis, it was not possible to verify the conduct of the activities. The authors asked about facilitators’ use of evidence-based interventions through only two questions related to the use of online evidence-based resources and where they had heard about these interventions. In addition, the number of activities that were determined to be “evidence-based” may be overrepresented because their categorization could be verifıed only by the title and nature of the reported activities. The core elements and process steps were articulated by an expert consensus process and have not been defıned in the fıeld. Also, questions were asked about only the conduct of core elements for the major activities. The NBCCEDP grantees are conducting many potentially effective activities to recruit women for cancer screening. Although a large percentage of their recruitment activities matched evidence-based strategies, more research is needed to understand the fıdelity of their implementation to evidence-based strategies and effectiveness in their settings. Factors related to the individual professional, the intervention, and the organization have been associated with adoption and quality implementation of evidence-based programs.35–38 More generally, additional research is needed on the determinants of uptake of evidence-based strategies among public health agencies.39,40 More proactive or intensive training and technical assistance may be necessary to assist public health agencies to adopt the use of EBIs to reduce disease incidence and mortality. This work was supported by the CDC (U 48 DP000043, SIP 1⫺06). The fındings and conclusions in this paper are those of the authors and do not necessarily represent the offıcial position of the CDC. We thank our other CPCRN advisory committee members: Roshan Bastani, Daniel Blumenthal, Jeffrey Harris, Matthew Kreuter, Glorian Sorensen, Victoria Taylor, and Kathi Wilson. We also thank Faye Wong, Felicia Solomon, and Georgina Castro for their review of this paper and the NBCCEDP Recruitment Coordinators for their participation. No fınancial disclosures were reported by the authors of this paper.
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Purpose: The purpose of the study was to inventory recruitment activities for cancer screening within NBCCEDP programs and assess if activities used to increase cancer screening are evidencebased. Methods: Interviews were conducted with 61 recruitment coordinators in 2008 to elicit their recruitment activities, use of evidence-based resources, and barriers to using evidence-based interventions (EBIs). Study data were analyzed in 2009.
Results: Of the 340 activities reported, many were categorized as educational materials, one-on-one education, mass media, group education, and special events. Two thirds of inventoried activities matched an EBI. Coordinators reported that colleagues and the CDC are their primary sources of information about EBIs and few coordinators had used evidence-based resources. Lack of money or funding, questionable applicability to priority populations, limited staffıng or staff time, and insuffıcient evidence-based research were the most important barriers to EBI use. Conclusions: Although the majority of NBCCEDP recruitment activities were evidence-based, one third were not. Additional training and technical assistance are recommended to help public health agencies adopt the use of these strategies. (Am J Prev Med 2012;42(3):235–241) © 2012 American Journal of Preventive Medicine
Introduction
D
espite progress in screening uptake, increasing breast and cervical cancer screening use continues to be an important public health objective. Certain subgroups of women experience increased morbidity and mortality from cancer. African-American From the Department of Behavioral Sciences and Health Education (Escoffery, Kegler) and the Department of Health Policy and Management (Blake), Division of Cancer Prevention and Control (Shapiro), CDC, Atlanta, Georgia; the Schools of Medicine and Nursing (Glanz), University of Pennsylvania, Philadelphia, Pennsylvania; and the Division of Health Promotion and Behavioral Sciences (Mullen, Fernandez), University of Texas School of Public Health, Houston, Texas Address correspondence to: Cam T. Escoffery, PhD, MPH, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road, NE, 5th Floor, Atlanta GA 30322. E-mail: [email protected]. 0749-3797/$36.00 doi: 10.1016/j.amepre.2011.11.001
© 2012 American Journal of Preventive Medicine. All rights reserved.
women experience higher mortality from breast cancer, and Hispanic women have a higher incidence of cervical cancer than other groups.1 Disparities in screening also exist; 68% of white women aged ⱖ40 years have received a mammogram in the past 2 years, compared with only 61% of Hispanic women.2 For cervical cancer screening, although 77% of white women and 79% of AfricanAmerican women aged ⱖ18 years have been tested in the past 3 years, only 74% of Latinas in this age group have been screened.2 Women with lower SES or no health insurance have lower rates of both mammography and Pap testing.2 Barriers to screening include lack of health insurance, language, geography, cultural differences, provider biases,3 women’s perception of low risk,4 lack of social support,5,6 and lack of reminders.7 The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) was created by the U.S. Congress after passage of the Breast and Cervical Cancer Am J Prev Med 2012;42(3):235–241
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Mortality Prevention Act of 1990 to improve access to screening among low-income women.8 The CDC administers the NBCCEDP, which provides breast and cervical cancer screening and diagnostic services for low-income, uninsured, or underinsured women through programs in all 50 states, the District of Columbia, fıve U.S. territories, and 12 American-Indian/Alaska Native tribes. Programs provide clinical breast examinations, mammograms, Paps, pelvic examinations, diagnostic testing for abnormal results, and referrals to treatment.9 Federal legislation that authorizes the NBCCEDP stipulates that 60% of funds are directed to clinical services; other activities are essential to support screening. The NBCCEDP is implemented at the state and local level. No two programs are identical because each is designed to address its own unique characteristics and needs such as population demographics and size, geography, public health and medical infrastructure, and cultural and screening barriers. Recruitment is defıned as “the act of seeking to enroll program-eligible women into breast and cervical cancer screening services.”10 Each program has a staff person who is responsible for coordinating public education and in-reach strategies to achieve recruitment goals (known as recruitment coordinators). The CDC supports the coordinators by providing strategic direction, skill development opportunities, and forums for information sharing and collaboration. Since inception, grantees have screened 3.9 million women and diagnosed more than 52,694 breast cancers, 2856 invasive cervical cancers, and more than 56,115 high-grade premalignant cervical lesions.8 More recently, in 2009, the NBCCEDP provided mammograms for 324,912 women and found 4635 breast cancers; it offered Paps for 320,627 women and found 4694 cervical cancers and precancerous lesions.8 Screening numbers can include women who have never been screened or women who were screened previously. The purpose of the present study was to inventory NBCCEDP recruitment activities for cancer screening, assess to what extent the recruitment activities corresponded with recommended evidence-based interventions to increase breast and cervical cancer screening, describe use of evidence-based resources, and describe barriers to the use of evidence-based interventions.
Methods
Measures This research was part of a larger project to inventory the (1) professional development and (2) recruitment activities performed by the NBCCEDP grantees. A Work Group and an Advisory Committee (Cancer Prevention and Control Research Network researchers) provided guidance and recommendations about the study process. The Work Group consisted of Emory University investigators, CDC staff, and two NBCCEDP recruitment coordinators. The Emory University IRB approved this study (IRB00005831). The recruitment survey had eight sections: program information, description of the activities, implementation of the activities, results and evaluation of the activities, general questions about the activities, use of evidence-based cancer prevention resources, barriers to use of evidence-based practices, and implementation of core elements for major activities. Respondents were asked to describe their major (e.g., those that required more resources/time) and minor activities in the past year through an open-ended question and categorize them into broad recruitment strategies. Respondents also described use of several sources of evidence-based interventions, including The Guide to Community Preventive Services, and the National Cancer Institute’s Cancer Control P.L.A.N.E.T. (plan, link, act, network with evidence-based tools) and Research-Tested Intervention Programs (RTIPs). The Taskforce for the Guide synthesizes scientifıc evidence regarding the effectiveness of health promotion and disease prevention interventions, including recommendations for interventions to increase cancer screening.11 Cancer Control P.L.A.N.E.T is a portal with links to other web resources that can assist in the design, implementation, and evaluation of evidence-based cancer control programs.12 Finally, RTIPs website houses cancer control programs and products that have been research tested.13 For the analysis of the extent to which EBIs were used, the evidence-based strategies recommended by the Community Guide were employed (Table 1).14 –17 Interviewers collected data on the coordinator’s professional training, degree and years with the program. The level of fıdelity in implementing core elements and/or key process steps during implementation of major recruitment strategies also was measured. Core elements are the essential components that are believed to make an evidence-based program effective and should be kept in order to maintain intervention effectiveness.18 Key process steps are requisite activities necessary for the adequate implementation of an evidence-based strategy. The list of process steps or core elements was developed by the authors based on intervention articles from RTIPs, Community Guide, Cochrane reviews, and RCT articles on mammography and Pap interventions. Descriptive steps in conducting an evidencebased strategy were extracted from these articles. These steps were compiled into tables by type of recruitment categories (e.g., client reminders). The Advisory Committee rated the steps and provided comments about the steps (e.g., deleting, adding a step). The authors then reviewed the comments and selected the fınal steps for the interview guide based on the majority of the ratings.
Sample and Data Collection
Statistical Analyses
Recruitment coordinators from the NBCCEDP-funded states, tribes, and territories were contacted for the study. Sixty-eight potential respondents were contacted by e-mail, and 61 were interviewed by phone between February and June 2008.
Study data were analyzed in 2009. Frequencies were calculated for all categoric variables including respondents’ demographics, description of the major activities, use of core elements, and use of evidence-based resources. Qualitative items were recorded in narwww.ajpmonline.org
Escoffery et al / Am J Prev Med 2012;42(3):235–241
Table 1. Evidence-based strategies to increase breast and cervical cancer screening Strategy
a
237 14 –17
Definition
Client reminders
Printed postcard or letter or telephone message telling individuals that they are due or late for cancer screening
Small media
Printed material such as brochures, newsletters, pamphlets, fliers, or videos that provide information or motivational messages about being screened for cancer
One-on-one education
Information or motivational messages about cancer screening delivered either in person or by telephone to an individual
Group educationa
Information or encouragement about cancer screening delivered to assembled individuals by health professionals or lay people
Reducing structural barriersa
Strategies to reduce or remove barriers such as location, distance, language barriers, or inconvenient hours by offering transportation or reducing distance to screening, assisting in scheduling screening appointments or providing interpreter services, reducing administrative burdens, or expanding hours of operations
Reducing out-of-pocket costsa
Lowering clients’ cost through vouchers, reimbursement, reductions in copayments, or other methods to lower clients’ contributions to increase access to screening services
These are evidence-based strategies recommended for breast cancer screening only.
rative form. For the analyses on the use of evidence-based strategies and conduct of core elements, recruitment activities that were focused on breast and cervical cancer screening individually or combined and were in the categories that had core elements that were defıned were selected. For each major category of recruitment strategy, the proportion of recruitment activities that were reported to include each core element or process step was reported.
Results Recruitment interviews were completed in 61 of 68 programs (response rate⫽90%). The interviews were conducted within 48 state programs, 10 tribal programs, and three territorial programs, representing 71% of state programs, 83% of tribal programs, and 60% of the territorial programs. The interview length ranged from 9 minutes to 1 hour 53 minutes (M⫽50 minutes). Recruitment coordinators had been in their positions for an average of 4.3 years. Although they may hold more than one degree, the most common type of training was a bachelor’s degree (53.8%), followed by an MPH (15.4%); other master’s degree (9.2%); associate’s degree (7.7%); and MPA (6.2%). Respondents were asked to list their program’s “major” and “minor” recruitment activities for the past year and categorized activities into 11 a priori categories. These categories included reminders/invitations; educational materials; one-on-one education; group education; social networks; mass media; small media (i.e., educational materials); cost reduction; incentives; access-enhancing strategies; and special events (i.e., health fairs). There were a total of 340 reported recruitment activities. Of the 198 major activities, the four most common categories, in order of frequency, were educational materials, one-onone education, mass media, and reminders/invitations. Of the 142 minor activities, the most common categories March 2012
were educational materials, group education, one-on-one education, and special events. Categories were not mutually exclusive because one activity could incorporate several recruitment categories.
Use of Evidence-Based Resources Cancer Control P.L.A.N.E.T. was used by the largest percentage of recruitment coordinators (59.4%), and RTIPs was used least (20.3%) (Table 2). P.L.A.N.E.T. was used to obtain data on cancer and/or risk factor burden (78.9%) and to learn about effective intervention approaches (76.3%). The Community Guide was used most often to learn about effective intervention approaches (68.0%) and to identify other resources (68.0%). Among RTIP users, most used it to incorporate aspects of an RTIPs program into an existing program (76.9%) or for inspiration for program development (53.8%).
Use of Evidence-Based Strategies in Recruitment Efforts Of the 309 recruitment activities focused on breast and/or cervical cancer screening exclusively, 66.0% used at least one of the classifıed evidence-based strategies (Table 3). The use of small media was the most common strategy (43.0%), followed by one-on-one education (34.6%) and reminders (29.4%). Additionally, although the coordinators reported using evidence-based strategies, they did not provide the name of a specifıc intervention. The association between use of evidence-based strategies and use of any evidence-based online resources was explored. There was no association between use of these strategies and utilization of the Community Guide (p⫽0.69); RTIPs (p⫽0.66); and Cancer Control P.L.A.N.E.T. (p⫽0.38).
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Table 2. Self-reported use of and reasons for use of evidence-based resources by NBCCEDP recruitment coordinators, n (%) Cancer Control P.L.A.N.E.T.
Community Guide
RTIPs
38 (59.4)
25 (39.1)
13 (20.3)
—
—
—
To learn about effective intervention approaches
29 (76.3)
17 (68.0)
—
To obtain data on cancer and/or risk factors burden
30 (78.9)
—
—
To identify other resources
23 (60.5)
17 (68.0)
—
Just to browse
20 (52.6)
13 (52.0)
—
To learn about evidence-based programs and products
27 (71.1)
15 (60.0)
—
To find guidelines for planning evaluation
18 (47.4)
—
—
To identify potential program/community partners
13 (34.2)
—
—
To identify areas where more evidence is needed
8 (21.1)
To identify potential research partners
6 (15.8)
Use of evidence-based resources Reasons for using Cancer Control P.L.A.N.E.T. or Community Guide (among users, n⫽38 and n⫽25)
To find logic models listing strategies for cancer control Reasons for using RTIPs (among users, n⫽13)
—
5 (20.0) — 5 (20.0)
— — —
—
—
—
Incorporating aspects of an RTIP into an existing program
—
—
10 (76.9)
Use of RTIPs as an inspiration for program development
—
—
7 (53.8)
Reference purposes
—
—
5 (38.5)
Sharing with colleagues
—
—
5 (38.5)
Identifying program/community partners
—
—
5 (38.5)
Note: N⫽64; some of the grantees’ sites have other contractors also reporting on activities, so the number of respondents is ⬎61. NBCCEDP, National Breast and Cervical Cancer Early Detection Program; P.L.A.N.E.T., plan, link, act, network with evidence-based tools; RTIP, Research-Tested Intervention Program (National Cancer Institute)
The quality of implementation was assessed by asking about adherence to core elements and/or best processes associated with each evidence-based strategy for the major activities (Table 3). Completion of core elements was generally high. For small media, the step most frequently skipped was pretesting materials (53.7% completed). For one-on-one education, all process steps usually were completed (87.5% or greater). Client reminders usually included information on how to get the screening test. Increasing or changing the hours of services was the most commonly reported access-enhancing strategy. When asked where they learned about the recruitment strategies they use, the most frequently mentioned external source was a colleague or professional (19.8%), followed by the CDC or American Cancer Society combined (11.1%) and conferences (6.8%). Other sources were internal, with 35.4% of activities reported as always being done by the organization and 16.0% developed by the staff. The most frequently cited barriers to using evidence-based strategies by the two thirds of respondents who reported experiencing barriers were lack of
money/funding/budget (40.9%); lack of applicability to priority population or area (22.7%); lack of staff time (15.9%); lack of evidence-based research (13.6%); limited staffıng (13.6%); and lack of knowledge of evidence-based interventions (11.4%).
Discussion The present study found that although NBCCEDP coordinators used a range of recruitment strategies to encourage women to obtain breast and cervical cancer screening, 66% of activities were evidence-based strategies recommended by the Community Guide. Overall, the use of resources to fınd evidence-based strategies was fairly low, perhaps explaining the less than optimal use of recommended approaches. Knowledge of evidence-based interventions is important to ensure adequate adoption and implementation.19 The fındings of this project inform several recommendations for the NBCCEDP, many of which are applicable to cancer prevention in other settings. There is need to www.ajpmonline.org
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Table 3. Use of evidence-based strategies and adherence to core elements and/or best processes among inventoried activities, n (%) Evidence-based strategy (n⫽309)a Small media
133 (43.0)
One-on-one education/counseling
107 (34.6)
Reminders/invitations
91 (29.4)
Access-enhancing strategies
43 (13.9)
Multicomponent activity
27 (8.7)
Cost reduction Any evidence-based activity
0 204 (66.0)
CORE ELEMENTS/BEST PROCESS FOR MAJOR ACTIVITIES (n⫽198) Small media (n⫽82) Pretest concepts, messages, and materials
44 (53.7)
Describe its importance and benefits of getting a mammogram/Pap
75 (91.5)
Describe the screening guidelines
67 (81.7)
Address barriers or concerns about getting a mammogram/Pap
64 (78.0)
Provide information on how to get a mammogram/Pap
81 (98.8)
One-on-one education (n⫽72) Discuss the benefits of screening
70 (97.2)
Identify individual barriers to getting a mammogram/Pap
66 (91.7)
Discuss ways to overcome barriers to screening
65 (90.3)
Assist women in making an action plan
63 (87.5)
Client reminders (n⫽66) Provide information on how to get a mammogram/Pap
61 (92.4)
Contact women more than one time
47 (71.2)
Access enhancing (n⫽34)
a
Reduce time or distance between the setting and the target population
26 (76.5)
Offer services in alternative or nonclinical settings
23 (67.6)
Increase or change hours of service
27 (79.4)
Eliminate or simplify administrative burdens for patients
24 (70.6)
Only interventions that were focused on breast cancer, cervical cancer, or both were included in this analysis.
train coordinators about resources for identifying EBIs and to increase their capacity to adopt those interventions. Trainings should emphasize strategies that were used less such as small media. A recent study20 suggests March 2012
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that active and multi-modal strategies (e.g., training or provision of materials) can disseminate more effectively evidence-based interventions. Greater knowledge of evidence-based strategies and increased capacity for program planning may strengthen recruitment and also improve both overall effectiveness and effıciency.21 Training also needs to be maintained because there is frequent turnover in the coordinator positions. In addition, the NBCCEDP program consultants, CDC staff who support the grantees, could provide technical assistance to grantees in using evidence-based strategies and encourage sharing of activities. Specialized coaching and monitoring of the fıdelity to the original intervention are important to increasing use and effectiveness of evidence-based programs, particularly as they are implemented in new settings and with different target audiences.22–25 This is critical because coordinators reported that their primary sources of EBIs were other colleagues and the CDC or ACS. The program offers multiple ways for grantees to interact with each other. These personal sources may be more credible and, therefore, a more effıcient source of EBIs. The NBCCEDP could help reduce barriers to use of evidence-based strategies. Overall, barriers reported include lack of money, staffıng, and lack of applicability to target population. DiFranceisco and colleagues26 found similar constraints to use of research-based HIV prevention interventions. The grantees serve very diverse populations and there may be a need for cultural, language, and literacy adaptations in some cases. Strategies such as educating coordinators about the benefıts of EBIs and instruction on adaptation may limit some of these barriers. The specifıc steps that community planners need to carry out to adapt existing programs are described in Intervention Mapping27 where authors include a chapter on adapting evidence-based programs that could be shared with the grantees.28 Finally, the NBCCEDP could promote the identifıcation and use of core elements of EBIs to help grantees use evidence-based strategies. In the current study, the authors attempted to defıne core elements of EBIs through an expert consensus process, and assessed fıdelity to those elements. Nevertheless, in the literature on translation, “core elements” of interventions often are not well defıned by program developers.29 –31 Changes in standards for literature reviews have reduced bias and improved reliability, and reporting guidelines for intervention trials have improved the transparency of study methods.32–34 Clear identifıcation of these core elements is an essential step for program adaptation and implementation because changing these may compromise the effectiveness of the program.
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The CDC has already considered these fındings as a part of strategic planning efforts that began in 2009 to enhance outreach efforts. CDC has strengthened its training support for grantees, including webinars, inperson training meetings, and standardized technical assistance by developing a series of resources for grantees to encourage uptake of EBIs. The present study has several limitations. The fındings are based on self-reported activities by the coordinators. Because of the scope of this analysis, it was not possible to verify the conduct of the activities. The authors asked about facilitators’ use of evidence-based interventions through only two questions related to the use of online evidence-based resources and where they had heard about these interventions. In addition, the number of activities that were determined to be “evidence-based” may be overrepresented because their categorization could be verifıed only by the title and nature of the reported activities. The core elements and process steps were articulated by an expert consensus process and have not been defıned in the fıeld. Also, questions were asked about only the conduct of core elements for the major activities. The NBCCEDP grantees are conducting many potentially effective activities to recruit women for cancer screening. Although a large percentage of their recruitment activities matched evidence-based strategies, more research is needed to understand the fıdelity of their implementation to evidence-based strategies and effectiveness in their settings. Factors related to the individual professional, the intervention, and the organization have been associated with adoption and quality implementation of evidence-based programs.35–38 More generally, additional research is needed on the determinants of uptake of evidence-based strategies among public health agencies.39,40 More proactive or intensive training and technical assistance may be necessary to assist public health agencies to adopt the use of EBIs to reduce disease incidence and mortality. This work was supported by the CDC (U 48 DP000043, SIP 1⫺06). The fındings and conclusions in this paper are those of the authors and do not necessarily represent the offıcial position of the CDC. We thank our other CPCRN advisory committee members: Roshan Bastani, Daniel Blumenthal, Jeffrey Harris, Matthew Kreuter, Glorian Sorensen, Victoria Taylor, and Kathi Wilson. We also thank Faye Wong, Felicia Solomon, and Georgina Castro for their review of this paper and the NBCCEDP Recruitment Coordinators for their participation. No fınancial disclosures were reported by the authors of this paper.
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