CPCRN Signature Project: Evidence-Based Approaches to Cancer Control Boston, MA October 31 , 2007
Signature Project Development of a Training and Planning Tool for Using Evidence Based Approaches for Cancer Control • Partnership of all the CPCRNs • Builds on Dissemination work • Fills the needs of network partners and the wider community • Furthers a consensus process regarding dissementation, adaptation, and implementation
Our Vision for the EBA Training and Signature Project Program Planning Tool EBA Training and Planning Tool – Will support the best use of existing resources (Cancer PLANET, The Community Guide, RTIPs, Using What Works, etc. ) for planning and implementation processes – Will provide training and guide the user through the process – Will provide guidance for adapting evidence-based programs to fit community needs.
Signature Project Aims 1. Determine factors that influence use of evidence-based approaches (EBA), among cancer control planners; 2. Determine community training needs for finding, choosing, and adapting evidence-based approaches EBA, 3. To determine gaps in existing training materials on EBA, 4. To develop and pilot test a working prototype 5. Plan for the full development of the program
Signature Project Needs Assessment: • Summer 2006 EBA Workshops with Texas Cancer Control Toolkit Trainings – Midland, Abilene, San Antonio, Mc. Allen – Based on Using What Works – Short survey & focus group – Findings • Not aware of resources (e. g. Community Guide & RTIPs) • Did not know how to find, choose, or adapt an evidence-based programs
Signature Project Needs Assessment • Developed and pilot tested a survey instrument – Winter 2007 Workshop at Tools for Texans Conference – Spring 2007 TX-CPCRN (LINCC) Face-to. Face Meeting
Signature Project Needs Assessment • Survey of CDC Cancer Conference attendees – 67% said ½ – all of their job involved planning & implementing cancer control programs – 32% agreed EBPs were easy to find/get – 24% agreed EBPs were easy to adapt – 55% agreed EBPs didn’t come with much information about how to implement them – 80% agreed their funding agencies encouraged the use of EBPs
Signature Project Needs Assessment • Survey of CDC Cancer Conference attendees – 59% had used The Community Guide – 72% had never used Cancer PLANET – 35% had used RTIPS Most people who did use the tools found them “useful” or “very useful”
Signature Project Needs Assessment (planned): • Survey of CPCRN partners – 8 centers surveying at least 30 partners each (N = 240+) – Web-based, or paper surveys • In-depth interviews with program planners Identification of Existing Resources • EBA Resource Inventory : “The Consumer’s Guide” to EBP Planning Resources – What is there (Using What Works, Cancer Control Planet, etc) – How it performs
EBA Resource Inventory Module Number (UWW) Topic Covered Available on on-line 1 Defines "Evidenced-Based" 1 Describes benefits of using evidence based tools TCC Toolkit SLU EBPH CIS UWW The Guide yes yes yes no no X X RTIPs* Pink E-Roadmap to Book MICA EBPH Practice** PH Info & Data Tutorial*** Cancer PLANET Defines "Research Tested" 1 (Partial) X 2 a/2 b X X X X r X X X Health topic X X Audience X X X Potential strategies X X Resources available/cost effectiveness X X Describes a needs assessment 3 Describes developing goals and objectives 4 & 5 Describes how to find an evidenced based program Identifies resources for evidence based programs X Describes criteria for selecting program by considering topics such as: X X X X
Replication when there is a Guide recommended strategy & EBPs available Adaptation when there is an EBP available, but insufficient evidence Program creation when there are no programs available Introduction to EB Interventions Choosing a risk factor/cancer type Decision process for choosing an intervention goal and strategy, and then finding, reviewing and assessing programs
Signature Project • Development of the prototype – Working groups • Module content area development • User interface development – Usability Testing – Pilot Testing
Signature Project • The training and planning tool will accelerate the adoption of evidence-based cancer prevention and control in communities • Supports the best use of existing resources (Cancer PLANET, The Community Guide, RTIPs, Using What Works, etc. ) • Process draws upon the collective experience of the CPCRNs and their community partners • Engaging in the consensus process about issues related to dissemination/translation Examples: – What constitutes “core elements” of a program that should not be changed? – Can adaptation include adding objectives/determinants/program elements?
Evidence-Based Approaches to Planning Cancer Control Programs ACTIVITIES UPDATE & WORK SESSION
T h a n k s T e a m ! This has truly been a cross -CPCRN group effort.
Survey Instrument • Sampling Strategy: Completed • Online Version of Survey: Completed http: //uncodum. qualtrics. com/SE/? SID=SV_ 3 m. Cd 5 SNlp. XCmt 3 C&SVID=Prod • Paper Version of Survey: Completed
EBA Survey IRB Status (Last Updated 10/25/2007) • Final IRB Approval Received: – Harvard, Morehouse, SLU, UNC, UT, UW • UCLA – IRB approval received, but minor protocol changes have been submitted, and we’re awaiting final approval. • Emory – IRB requires copies of IRB approval notices from ALL other Network Centers. These will be sent once UW has resolved a typo in their approval letter and passed it on. – IRB would not accept the official UNC proof of CITI human subjects training notices for Rebecca Williams and Teresa Edwards—version from the CITI website, these have been sent to Emory.
EBA Survey IRB Status (Last Updated 10/25/2007) • CDC – Once all final IRB approval notices have been received from all Network Centers, Rebecca Williams will send them and the Coordinating Center IRB application to Kathi Wilson for submittal to the CDC IRB.
Module Development Workgroups • User Interface Development: SLU – SLU is focusing on user interface development and will bring the interface to the group for review.
Module Development Workgroups • Assessment: Dan, Roy, Alexis – Responsible for content areas 1, 2, & 3 of the flowchart. This group will be addressing community assessment, choosing a risk factor or type of cancer, and choosing an intervention goal and strategy.
Introduction to EB Interventions Choosing a risk factor/cancer type Decision process for choosing an intervention goal and strategy, and then finding, reviewing and assessing programs
Content Area 1: Introduction Content Area 1: (Overview, Levels of Evidence) Purpose: To introduce planners to the concept of evidence-based cancer and cancer-related interventions and the reasons these types of interventions are preferred in planning community health promotion programs. This module will provide both the conceptual framework for the web-based tool and the instructions for its use. Learning Objectives: 1. Discuss the purpose of the web-based tool a. Recognize the need to employ health promotion interventions with demonstrated effectiveness. b. Discuss the usefulness of a tool that will guide the selection of an evidence-based intervention appropriate for the community of interest. c. Describe the general functions of the web-based tool. 2. Utilize the web-based tool effectively a. Move through the modules and links as appropriate for user’s needs b. Access the “Help” function as needed.
Content Area 1: Introduction Content Area 1: (Overview, Levels of Evidence) 3. Describe the concept of “evidence-based” interventions a. Define and differentiate between efficacy and effectiveness b. Access the evidence base by using search engines (Pubmed etc. ), published compendia (Community Guide), and websites (Cancer PLANET) c. Describe basic elements of research design [Question: how “basic” should this be? ] d. List and describe levels of evidence used by Cancer PLANET and the Community Guide as strong, sufficient, expert opinion, or insufficient. e. List the factors employed to assess the strength of evidence as research design, quality of implementation, replication of findings, and effect size.
Content Area 1: Introduction Content Area 1: (Overview, Levels of Evidence) 3. Describe the concept of “evidence-based” interventions (continued) f. Describe issues that one must consider in assessing the evidence, such as: • How effective is a public health program in achieving its intended disease prevention objectives? • Under what conditions and circumstances have program approaches proven effective? • Does evidence point to ineffective practices that consequently cannot be recommended? • Does the level of effectiveness justify the expenditure of resources relative to what was achieved? • Is there a match between the sample in the research study and the population that the program would be replicated on? • What is the cost benefit and cost effectiveness of the intervention?
Content Area 2: Choosing a Content Area 2: Risk Factor or Cancer Type Purpose: To enable planners to choose a cancer risk factor or cancer type as the target of a health promotion intervention using epidemiologic data (e. g. state or federal data) or community data to provide a rationale for the choice. In the event that a risk factor or cancer type has already been chosen, the module will enable the planner to assemble the data to defend the choice, or will lead the planner to make a different choice. Learning Objectives: 1. Conduct a community health needs assessment with particular attention to cancer and cancer-related risk factors. a. b. c. d. e. f. Collect cancer-relevant data from secondary sources (state or local health department, SEER, BRFSS, census, etc. ) Engage in community entry processes as appropriate Conduct and interpret key informant interviews with community leaders Conduct focus groups with targeted audience and interpret findings Conduct community survey and interpret findings. Identify racial, ethnic, and socioeconomic cancer disparities.
Content Area 2: Choosing a Content Area 2: Risk Factor or Cancer Type 2. Present findings of community health needs assessment to community organizations and groups. a. Create and give presentation appropriate for educational and linguistic status of audience. b. Answer questions and obtain feedback from audience. 3. Select cancer risk factor or cancer type as target for intervention. a. Establish intervention priorities using data from community health needs assessment and other data sources. b. Incorporate feedback from community audiences (Objective 2) into priority selection. c. Present and defend choice or priority list to community leaders, political groups, funders, public health officials, and medical organizations.
Content Area 3: Choosing Intervention Goals & Strategies Purpose: To enable planners to identify the desired outcome of their intervention and select a general approach for achieving the outcome. Learning Objectives: 1. Choose an intervention goal a. Formulate goal as specific, measurable, achievable, relevant, and timelimited (“SMART”) b. Identify a feasible goal • Consider magnitude of problem • Consider characteristics of intervention community • Access appropriate literature • Consult with experts • Consult with experienced health promoters in other communities
Content Area 3: Choosing Intervention Goals & Strategies 2. Choose an intervention strategy a. Review evidence continuum in Guide to Community Preventive Services or other appropriate document b. Consider available resources: funds, staff, time c. Enumerate and evaluate strength of existing partnerships (agencies, churches, academic institutions, community organizations, professional societies, healthcare providers) 3. Assemble information on existing programs a. Identify programs in RTIPs (Research-Tested Intervention Programs) b. Identify programs from other sources: health promotion literature, presentations at professional meetings. c. Review core elements of candidate intervention against specifics of priority community • Race and ethnicity • Language issues • Educational level • Socioeconomic status • Access to care
Content Area 3: Choosing Intervention Goals & Strategies 3. Assemble information on existing programs d. Review core elements of candidate intervention against available resources e. Review core elements of candidate intervention against capabilities and potential participation of partners. • Meet with partners’ leadership • Solicit participation • Build coalition [Question: develop a module on coalition-building? ] 4. Make decision: select/adapt existing program or develop new program
Module Development Workgroups • Replication: Cathy, Vicky, Peggy – Responsible for content areas 4 a, 5 a, & 6 a of the flowchart. This group will be addressing the pathway regarding what to do when there is both a guide recommended strategy and available RTIPs assessing fit, replication, implementation and monitoring.
Replication when there is a Guide recommended strategy & EBPs available
Content Areas 4 a, 5 a, & 6 a: Replicate an Existing Program Purpose: To guide planners through the steps of implementing a program that has already been developed and successfully tested. The module will allow users to learn about the steps to replicate a program and how to cope with some of the challenges and barriers they may face when trying to replicate such a program. Learning Objectives: 1. Define replication a. Defines replication as implementing an evidence-based program as it was originally developed/tested. b. Notes any minor modifications (such as listing local resources) that can be made and still be considered replication.
Content Areas 4 a, 5 a, & 6 a: Replicate an Existing Program 2. Define program “fit” (how well would an existing program have to fit in order to make replication, rather than adaptation, the right choice) [COMMENT: This may be covered in Module 3 c] a. Defines critical “fit” elements as program objectives, methods, and strategies b. Looks for descriptions of what determinants of behavior were targeted in the original program; are these determinants considered important in your target community? c. Looks for descriptions of the community/setting in which the program was originally developed and tested 3. Identify key steps to program replication a. Obtaining enough information about the program to replicate • Program materials • Procedural manuals • Training for interventionists • When available, process and other measures
Content Areas 4 a, 5 a, & 6 a: Replicate an Existing Program 3. Identify key steps to program replication (continued) b. Community/stakeholder engagement and buy-in for the program c. Train interventionists to deliver program with fidelity d. Develop plan for implementation and evaluation 4. Describe how to overcome potential barriers to program replication a. Common barriers: obtaining program materials/procedure manuals (cost or contact problems), fidelity in program delivery, perceptions that a program delivered and tested elsewhere can’t work in my community b. Potential solutions: finding/connecting with the right person to deliver program materials, procedure manuals, training methods, and implementation advice (to solve getting program materials and ensuring fidelity); ownership issues dealt with below
Content Areas 4 a, 5 a, & 6 a: Replicate an Existing Program 5. Implement strategies to enable agency and community stakeholders to experience feelings of ownership for a replicated program a. Defines ownership as feeling that the program is the work of the community rather than the work of outsiders b. Work with agency and community stakeholders to develop implementation plan c. Work with agency and community stakeholders to evaluate program d. Share credit for program implementation among all stakeholders; look for opportunities (or obtain permission) to brand or co-brand intervention materials to identify them with the community e. Develop a plan to establish ownership among key stakeholders (identify leaders, allocate funds or other resources to keep plan going, etc. ) f. Convene stakeholders periodically to share implementation and evaluation reports; re-assess and modify the program if necessary (link to Adaptation Module in case of evidence of need for adapting program)
Module Development Workgroups • Adaptation: Maria, Pat, Kay, Sandra, Jennifer, Belinda, Michelle C. – Responsible for content areas 4 b, 5 b, & 6 b of the flowchart. This group will be addressing the pathway regarding what to do when the evidence is insufficient and there available RTIPs for adaptation (with emphasis on following guidelines for recommended strategies), developing an implementation plan, and a plan for monitoring program process and outcome.
Adaptation when there is an EBP available, but insufficient evidence
Content Areas 4 b, 5 b, & 6 b: Adapt an Existing Program Purpose: To guide planners through the steps in adapting a program that only partially fits their community context (culture, resources, etc. ). The module will allow users to both learn about the adaptation process and practice actual adaptation of an identified program. Learning Objectives: 1. Defines adaptation as a process of changing identified evidence-based programs (or program components) to fit the needs and characteristics of a community that differs from the one in which it was initially tested. b. Defines elements of the adaptation process as including activities such as language translation, role model matching to community racial/ethnic groups, and inclusion of local resource information. c. Defines adaptation as ensuring against change in, or deletion of, theoretical methods to promote change. For example, deleting methods such as role modeling, skill-building, practice, persuasion to change risk perceptions.
Content Areas 4 b, 5 b, & 6 b: Adapt an Existing Program 2. Identifies core elements of the existing program that, if changed, may compromise the expected effectiveness. a. Defines core elements of the program as the following: 1) Target populations; 2) Objectives for change in the behavior of the priority population/atrisk groups [QUESTION: Defined how? ]; [QUESTION: Defined how? ] 3) Objectives for change in elements of the environment; 4) Factors targeted for change as determinants of priority population behavior; 5) Factors targeted for change as determinants of environmental agents change behavior; 6) Theoretical change methods; and 7) Strategies for delivering theoretical change methods. b. Describes why changing each specific core element would jeopardize the demonstrated effectiveness of the program. [QUESTIONS: Not sure about this one- shouldn’t we have some kind of objective here that questions whether all of the “core elements need to be maintained – e. g. what if there was a focus on multiple environmental changes (among teachers, parents, etc) but their program is only going to focus on parents? ]
Content Areas 4 b, 5 b, & 6 b: Adapt an Existing Program 3. Describes the main behavioral (and other) outcomes of the existing program and compares them to their own program goals and objectives. a. b. c. d. Reviews or develops specific behavioral and or environmental change objectives for the desired program. Looks for descriptions of what behavioral or environmental change is targeted by the program to be adopted. If descriptions do not exist, draws assumptions about intended behavioral and environmental targets based on program materials that are available. Compares the desired change in the program to be adapted with the change desired by the adopting group and decides whether overlap in objectives is sufficient. If coverage of objectives is not sufficient, decides whether another program can be added to the program under consideration to expand the range of targeted objectives, whether new components can be developed to fill the gaps in the existing program, or whether another program should be considered. [QUESTION: Can adaptation include adding objectives? It seems that this is where our model gets fuzzy—Can you consider a program built from components of other programs as program “creation”? Seems it lies somewhere between adaptation and creation. ]
Content Areas 4 b, 5 b, & 6 b: Adapt an Existing Program 4. Compares determinants addressed in the existing program and compares them to the factors influencing the behavior in their community. a. b. c. d. Considers what factors may be determining the targeted behavior of the priority population, or of the environmental change in their community. Looks for descriptions of what determinants were targeted in the program being considered. Compares the determinants considered to be important in the community with the determinants targeted by the program under consideration. If focus on important determinants is not strong enough in the program under consideration, determines additional components and/or messages that should be added to the existing program for use in the new community. [QUESTIONS: Can adaptation include adding determinants? Don’t they first have to be able to define what is “strong enough” ? ]
Content Areas 4 b, 5 b, & 6 b: Adapt an Existing Program 5. Works with community groups to plan adaptations to make program culturally appropriate for the new community. [QUESTION: Just to make it culturally appropriate or for all of the other questions above as well? ] a. b. c. d. Defines culture and explains what is meant by cultural context. Describes elements of culture that are depicted in the materials of interest. Describe whether behaviors, or determinants, covered in the program are different for cultural groups in the community. Evaluate whether ways individuals are depicted in program materials (including those representing racial/ethnically defined groups of African Americans, Hispanics/Latinos, Asian Americans, European Americans and others) are congruent with community group’s culture including health practices, values, relationships, clothing, food, recreation, symbols, etc.
Content Areas 4 b, 5 b, & 6 b: Adapt an Existing Program 5. Works with community groups to plan adaptations to make program culturally appropriate for the new community (Continued) e. f. g. h. Explains whether community members in various groups would be receptive to the delivery channels and mechanisms required by the program. [QUESTION: Should they explain why vs. whether? ] Works with community members to suggest changes to make the program materials more culturally relevant. Works with community members to increase cultural appropriateness of intended delivery to assure reach of program. Identifies further sources of information and help regarding culture, cultural context, and cultural fit.
Content Areas 4 b, 5 b, & 6 b: Adapt an Existing Program 6. Proposes change in the existing program that can be accomplished to improve chances for program adoption, implementation and success a. b. c. d. e. f. Identifies program elements that can be changed without compromising the program’s integrity and potential effectiveness. Identifies program elements that can be changed within program budget. Evaluates visual elements of the materials (graphics, other images) to determine the suitability of materials for the new community. Describes how he/she would modify the existing program components to fit community context, e. g. , add role models and cultural elements to make program more relevant to the community. Evaluates readability/understandability of program materials. [QUESTION: Changes readability? ] Slightly modifies program delivery to meet communication channels of community residents.
Content Areas 4 b, 5 b, & 6 b: Adapt an Existing Program 7. Describes how to overcome potential barriers to adaptation (e. g. production cost, expertise, etc. ) [QUESTIONS: What did we have in mind here? Perhaps helping the planner begin to think creatively about overcoming various barriers—e. g. , finding sponsors to help defray costs, accessing university resources (faculty, students, etc. ) for expert help, and things of this nature? ] 8. Implements strategies to enable agency and community stakeholders to experience feelings of ownership of an adapted program. a. b. c. Defines ownership as feelings that the program is the work of the community rather than the work of outsiders. Works with agency and community stakeholders to evaluate and adapt program. Works with agency and community stakeholders to develop a specific community implementation plan
Content Areas 4 b, 5 b, & 6 b: Adapt an Existing Program 8. Implements strategies to enable agency and community stakeholders to experience feelings of ownership of an adapted program. (Continued) d. e. f. g. Shares credit for community adaptation and implementation among all stakeholders Develops a plan to establish and/or maintain ownership among key stakeholders (i. e. assign leadership positions, allocate resources, etc. Reassesses and modifies plan when necessary. Identifies opportunities where the adapted program and organization can be co-branded so that the adapted program is associated with the organization by consumers.
Module Development Workgroups • Program Creation: Michelle K. , Cam, Michelle C. , Debbie – Responsible for content areas 4 c, 5 c, & 6 c of the flowchart. This group will be addressing the pathway regarding what to do when there are no RTIPs, but there is a recommended strategy; creating a new program following guidelines for recommended strategies, and developing an implementation and outcome evaluation plan.
Program creation when there are no programs available
Content Areas 4 c, 5 c, & 6 c: Program Creation Purpose: To guide planners in developing programs when an evidence-based strategy is recommended by the Community Guide, but no evidence-based program is available on RTIPs. Learning Objectives: 1. Locate alternative sources of evidence-based programs for your content area a. Describe alternative sources of evidence-based programs, including the following: 1) Contact scientific experts or local university researchers who can provide program information, intervention strategies, and/or understand interpret the scientific literature; consider requesting an ongoing partnership for program planning and evaluation assistance 2) Locate Model Programs or Best Practices recommended by funding agencies 3) Obtain descriptions of effective programs directly from scientific literature
Content Areas 4 c, 5 c, & 6 c: Program Creation 1. Locate alternative sources of evidence-based programs for your content area (Continued) b. If conducting a literature search to locate effective programs: 1) Use databases such as Pub. Med, Medline, Psych. Info or search engines such as Google Scholar 2) Develop a search plan that has the appropriate key words/vocabulary for your content area to locate articles or reports of relevant programs 3) Prioritize articles or reports that describe programs that are part of a systematic review (e. g. , Cochrane), funded by a peer-reviewed grant, or published in a peer-reviewed journal 2. Examine articles or reports that describe effective programs for your content area a. b. Define effective (positive results) as demonstration of behavior change as opposed to intentions, attitudes or knowledge Determine level of effectiveness for each program alternative using evaluation results and/or research findings
Content Areas 4 c, 5 c, & 6 c: Program Creation 2. Examine articles or reports that describe effective programs for your content area (Continued) c. d. e. Examine the audience of interest, methods or procedures for the intervention, and determinants targeted by the program alternatives If applicable, read the discussions to understand the strengths and weaknesses of the article Determine which program alternatives are promising for potential use in your program planning based on a match with audience, determinants, context and local adaptability 3. Identify core program elements from program alternatives a. b. c. Define core elements and how to identify them from a research article Across the effective programs, list the program components or elements across the interventions Create a matrix of programs and their core elements for review
Content Areas 4 c, 5 c, & 6 c: Program Creation 3. Identify core program elements from program alternatives (Continued) d. e. f. Consider which of these elements may work in your community context and population of interest keeping in mind the audience of interest, behavioral determinants, environmental determinants, theoretical strategies, strategies for behavior change, and available resources Prioritize best possible evidence-based courses of action or elements to achieve the most important program outcomes Identify and engage partners in choosing program elements and developing the program 4. Design a program with the prioritized core elements a. b. c. d. State measurable objectives, including long-term (health problem), intermediate (behavioral and environmental outcomes), short-term (determinants), and process List major activities to accomplish each core element, associated tasks, and who is responsible for implementation Identify resources needed for implementation of each activity Develop a timeline for program implementation
Content Areas 4 c, 5 c, & 6 c: Program Creation 5. Develop a process and outcome evaluation plan [6 c] a. b. c. d. e. f. g. h. i. Engage stakeholders to guide evaluation efforts Ensure program objectives are measurable Develop logic model Develop evaluation questions Identify indicators to track objectives and answer evaluation questions Develop data collection tools and/or systems Collect data Analyze data Report results
Content Areas 4 c, 5 c, & 6 c: Program Creation Questions/Issues for the Larger Group: § There is a gap in the current Flow Chart: Insufficient evidence according to the Community Guide, and no RTIPS. § When in the process will Users identify major determinants of interest (2 a or 5 c)? § Is this module/template specific to breast cancer, and if so, should examples be specific to the Community Guide recommendations on breast cancer? In other words, should our examples cover small media and client incentives with reminders? § The need to develop an evaluation plan occurs in several places (6 a, 6 b & 6 c). Can this be just one module, and who will lead its development? § Will the website be maintained and updated so that we can include up-todate links to resources such as specific Cochrane reviews or specific Best Practices listed by federal agencies?
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