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JULY / AUGUST 2014 :: 75(4)
Cancer in North Carolina

Cancer is the leading cause of death in North Carolina. This issue of the NCMJ discusses cancer prevention, screening, treatment, and survivorship; disparities in incidence and mortality; and ethics of clinical trials. Highlighting the importance of comprehensive data for understanding cancer, original articles in this issue address how medical homes can reduce health care utilization among breast cancer patients and how distance to care affects receipt of radiation therapy.

INVITED COMMENTARY

Speeding the Dissemination and Implementation of Evidence-Based Interventions for Cancer Control and Prevention

Jennifer Leeman, Stephanie Jilcott-Pitts, Allison Myers

N C Med J. 2014;75(4):261-264.PDF | TABLE OF CONTENTS



Despite the growing menu of evidence-based interventions to prevent and control cancer, such interventions continue to be underused in practice. This commentary describes interactive approaches to speeding the dissemination and implementation of evidence-based interventions and illustrates these approaches using examples from obesity prevention and tobacco control.

Cancer is the leading cause of death in North Carolina, with mortality rates higher than the national average [1]. Rates of tobacco use, physical inactivity, and obesity are also higher in North Carolina than in the country as a whole [1], which further contributes to cancer risk [2]. The National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), and other groups have invested extensively in developing and testing interventions to reduce cancer risk and to improve cancer detection and treatment. With this funding, researchers have developed effective interventions to increase rates of cancer screening, to facilitate treatment decision making, and to help patients stop smoking [3, 4]. Researchers also are identifying ways to create environments that support healthy choices and thereby reduce cancer risk; for example, implementing smoke-free policies at work sites can reduce tobacco use and exposure to secondhand smoke [5]. As a result, clinicians and public health practitioners now have access to a growing menu of evidence-based interventions (EBIs).

However, EBIs continue to be underused [6-8]. According to one estimate, it takes an average of 17 years for just 14% of research to transfer to practice [9]. Thus a central challenge in preventing and controlling cancer is identifying better ways to speed the dissemination and implementation of EBIs into practice. A recent NIH funding opportunity announcement defined dissemination as “the targeted distribution of information and intervention materials to a specific public health or clinical practice audience,” and it defined implementation as “the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings” [10].

Historically, the translation of research to practice has been a linear process, with researchers generating findings, translating them for use, and then disseminating them to nurses, physicians, health educators, administrators, and other public health and clinical practitioners who individually and collectively implement EBIs [11]. Given the unidirectional nature of this process, researchers’ priorities have driven the development and dissemination of interventions, and less attention has been given to the needs and priorities of practitioners [12]. As a result, many EBIs are either irrelevant or too complex and costly to apply within the constraints of current practice environments [13]. Even when EBIs are relevant and feasible, they are often disseminated in formats that provide little guidance on how to adapt them to different contexts and/or how to integrate them into practice [13, 14]. Also, by the time EBIs are disseminated effectively, they may no longer be congruent with practitioners’ priorities and resources.

In recent years, there has been growing recognition that transferring EBIs into practice is more successful when the flow of information is bidirectional, with researchers and practitioners interacting to develop, disseminate, and implement EBIs. In this commentary, we will apply the Interactive Systems Framework for dissemination and implementation [15] to describe interactive approaches that can be used to transfer EBIs into practice. Because high rates of tobacco use, physical inactivity, and obesity are among the reasons why cancer is the leading cause of death in North Carolina, we will use examples from obesity prevention and tobacco control to illustrate these approaches.

The Interactive Systems Framework posits that the successful dissemination and implementation of EBIs requires interaction among 3 types of systems: synthesis and translation systems, which disseminate EBIs; delivery systems (eg, practitioners), which implement EBIs; and support systems, which build the capacity of delivery systems to adopt and implement EBIs within specific settings [15]. Examples of each of these 3 types of systems can be found in Figure 1.

Interaction at the Level of Synthesis and Translation Systems
Table 1 lists some of the organizations that synthesize and translate EBIs for practitioners working in cancer prevention and control. The US Preventive Services Task Force and the Guide to Community Preventive Services conduct systematic reviews of the literature to identify interventions that have worked across multiple research studies. This approach yields EBIs with the strongest evidence in support of their effectiveness [16], but it provides minimal guidance on how to implement these EBIs. The National Cancer Institute takes a different approach and identifies Research-Tested Intervention Programs (RTIPs), which are specific interventions whose efficacy has been demonstrated by one or more reasonably well-designed research studies. The RTIP interventions are translated into a format that provides detailed guidance and materials to support implementation [17]. This process yields a “packaged” intervention that is intended to be ready for adoption and implementation in practice.

Despite the extensive resources invested in synthesis and translation of EBIs, public health and clinical practitioners have been slow to adopt and implement EBIs [7, 18]. Practitioners are often overwhelmed by the number of EBIs and may lack the information and guidance needed to use them in practice [19-21]. In response, synthesis translation systems are partnering with practitioners to translate EBIs into formats that better address practitioners’ needs and priorities.

For example, researchers and staff at the Center for Training and Research Translation (Center TRT), which is based in the Center for Health Promotion and Disease Prevention at the University of North Carolina at Chapel Hill (UNC–CH), have conducted numerous interviews and surveys to understand the needs and preferences of public health practitioners working in obesity prevention. Center TRT staff members then translate EBIs into a template that provides the information that practitioners say they need to adopt and implement interventions in practice [21, 22]. Furthermore, many of the interventions that Center TRT disseminates were developed and evaluated by public health practitioners rather than by researchers. These practice-based interventions all employ recommended EBI strategies, such as those recommended by the Community Guide, and they provide guidance that is based on practitioners’ real-world experience implementing the strategies [23]. The Center TRT template includes a summary of the evidence in support of the intervention, details on the steps required to implement the intervention, and links to materials and tools that practitioners can use to implement it and to evaluate processes and outcomes. Center TRT disseminates intervention templates via its Web site (www.centertrt.org), which is accessed by more than 22,000 unique visitors annually.

In another example of a synthesis and translation system partnering with practitioners, researchers at East Carolina University (ECU), UNC–CH, and Appalachian State University in 2011–2012 interviewed county managers, mayors, planning staff, and other local leaders from eastern and western North Carolina to discover how these individuals viewed the adoption of CDC-recommended environmental and policy-change EBIs [24]. The researchers found that rural leaders rated EBIs as more feasible and acceptable when the EBIs created opportunity and choice (eg, improving access to outdoor recreational facilities), and they rated EBIs as less feasible and acceptable when they were more restrictive and regulatory (eg, limiting advertisement of unhealthy foods and beverages) [25]. The same research team is currently working to translate the CDC’s recommended EBIs for use in rural areas, with the goals of reducing disparities among North Carolina residents and preventing obesity, cancer, and other chronic conditions. Taken together, these partnerships between researchers and practitioners illustrate the potential benefits of an interactive approach to synthesizing, translating, and disseminating EBIs.

Interaction Between Delivery Systems and Support Systems
Although the Internet is an effective channel for disseminating EBIs, posting interventions online is generally insufficient to promote their adoption and implementation. The Interactive Systems Framework posits that health care providers and health care delivery systems require additional support to select the EBIs that best fit their needs and to adapt and implement these EBIs in their practice settings [26]. Thus researchers and staff members at universities across the country are functioning as “support systems” and partnering with providers and communities to build their capacity to implement EBIs.

Researchers take a variety of approaches to supporting providers. These interactions range from engaging in participatory partnerships to providing training, technical assistance, and tools. An example of a participatory approach is the partnership between the North Carolina Department of Health and Human Services (DHHS) and researchers from ECU and UNC–CH. Within this CDC-funded partnership, researchers are enhancing DHHS’s capacity to evaluate EBIs that aim to increase access to farmers’ markets—a goal identified in the CDC’s list of recommended policy and environmental strategies [24]. With support from DHHS, local communities are increasing access to farmers’ markets through promotional activities, Supplemental Nutrition Assistance Program (SNAP) Electronic Benefit Transfer systems, and new zoning ordinances. The researchers and DHHS are then evaluating the impact of farmers’ markets on the fruit and vegetable consumption of North Carolina residents [27].

At the other end of the engagement continuum, UNC–CH researchers—working in collaboration with the Center for Public Health Quality, the Center for Healthy North Carolina, and the North Carolina Institute of Public Health—are training public health practitioners in the use of EBIs. The 2-day training program provides guidance on how to engage partners, select EBIs, adapt and implement EBIs in practice, and evaluate processes and outcomes. In addition to training, support systems often provide tools that encourage adoption and implementation of EBIs in local settings. Such tools can include any electronic or print resources that practitioners could use to plan, implement, or evaluate an intervention.

Examples of tools created by researchers at UNC–CH include those disseminated by CounterTobacco.org, a CDC-funded Web-based resource, and Counter Tools, a nonprofit organization, both of which were developed to boost practitioners’ capacity to counter tobacco marketing in retail environments such as gas stations, pharmacies, and corner stores. Marketing tobacco in these locations creates an environment that prompts initiation of tobacco use and interferes with quit attempts [28]. In addition to translating and disseminating EBIs, CounterTobacco.org disseminates toolkits for engaging youth and galleries of photos and other media that can be used to raise awareness and to engage partners. Counter Tools provides enhanced technical assistance and disseminates both the Store Audit Center, a mobile data-collection system that public health and other community-based practitioners can use to document individual retailer environments, and the Store Mapper, an interactive mapping Web site that allows providers to find and display the locations of tobacco retailers and to calculate geospatial data needed for local decision making (eg, retailer density, correlations between density and race or poverty, and the population reach of policy solutions). These examples represent novel approaches through which support systems can boost the ability of delivery systems to implement EBIs.

Increased use of EBIs is essential to reducing cancer morbidity and mortality. EBIs are most likely to be relevant and usable when researchers and practitioners work together on their development, dissemination, and implementation. Thus synthesis and translation systems benefit from inquiries into practitioners’ priorities, constraints, and preferences as they relate to EBIs and the ways they are disseminated. In addition, support systems (eg, university researchers and staff) should interact with delivery systems to build their capacity to use EBIs; those interactions can range from participatory partnerships to the provision of training, technical assistance, and tools. Researchers at ECU and UNC–CH are interacting with public health organizations and health care providers across the state to find innovative ways of efficiently and effectively bringing EBIs for cancer prevention and control to the people of North Carolina.

Acknowledgments
Financial support. J.L.’s work on this commentary was supported by 4CNC: Moving Evidence into Action, a collaborating site in the Cancer Prevention and Control Research Network (Grant U48/DP001944), which is funded by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute. J.L. and S.J-P. also are supported by the CDC-funded Nutrition and Obesity Policy Research and Evaluation Network (NOPREN) (Grantee Number 5-37850). All 3 authors are supported by the CDC-funded Prevention Research Center at the University of North Carolina at Chapel Hill (#U48/DP000059). The content of this commentary is solely the responsibility of the authors and does not necessarily represent the official views of the CDC or the National Institutes of Health.

Potential conflicts of interest. A.M. receives compensation as the deputy director and cofounder of Counter Tools, a North Carolina–based nonprofit organization that provides software tools, training, and technical assistance to communities addressing point-of-sale tobacco control and obesity issues. J.L. and S.J-P. have no relevant conflicts of interest.

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Jennifer Leeman, DrPH, MDiv assistant professor, School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
Stephanie Jilcott-Pitts, PhD associate professor, Department of Public Health, Brody School of Medicine, East Carolina University, Greenville, North Carolina.
Allison Myers, MPH deputy director, Counter Tobacco, Department of Health Behavior, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Address correspondence to Dr. Jennifer Leeman, School of Nursing, University of North Carolina at Chapel Hill, CB #7460, Chapel Hill, NC 27599 (jleeman@email.unc.edu).