4Primary Studies that Evaluate Strategies used to disseminate cancer control interventions

Dissemination studies that targeted healthcare providers

1. Train-the-trainer
   Two studies evaluated train-the-trainer approaches.^{134, 136} Albright et al.¹³⁴ evaluated physician training in disseminating a clinical preventive medicine curriculum (CPM). The CPM included six topics: risk factors for coronary heart disease and cancer; smoking cessation, nutrition, weight control and exercise, pharmacological interventions for hyperlipidemia, and screening. Ten general internists from across the US were trained to deliver the CPM to local faculty (n=91). Outcomes included process measures such as the fidelity of the training given to local faculty; change in knowledge; attitudes, and clinical practice of participants and faculty; and the subsequent teaching of CPM topics by local faculty to house staff.
   General internal medicine faculty trained to deliver the CPM program reproducibly delivered this to local faculty.¹³⁴ Local faculty was more knowledgeable about smoking cessation. Using a self-rated scale, they were more likely to implement smoking cessation interventions following the seminars (p<0. 0001). There were significant increases in the proportion of patients with whom smoking cessation was usually or always discussed and in the utilization of specific behavior-change strategies for smoking cessation. Between 85 and 96 percent of faculty reported teaching CPM strategies to house staff. There were significant increases in self-reported efficacy of the 125 house staff to implement specific CPM strategies. However, significant changes in the frequency of advice to stop smoking were not observed. No information was provided on potential barriers to this approach.
   Muramato et al.¹³⁶ evaluated the Arizona Department of Health Services Tobacco Education and Prevention Program (AzTEPP) of certification in tobacco cessation skills. This is a three-tiered certification model to disseminate Public Health Service (PHS) clinical practice guidelines in smoking cessation. It is funded from revenue generated from tobacco tax excises. Personnel working in Arizona's tobacco control program local community-based projects were trained in basic tobacco cessation skills. A proportion of these individuals received additional training as tobacco cessation specialists (including training individuals in basic tobacco cessation skills), and tobacco treatment services managers. Only the first two tiers were evaluated. The evaluation included process measures such as satisfaction and knowledge, plus behavioral outcomes including smoking cessation-related activities. Data are being collected on intermediate and longer-term outcomes including quit attempts, quit methods, use of intensive services, and statewide tobacco use prevalence.
   This study also demonstrated positive outcomes in tobacco control activities from a train-the-trainer approach. Significant increases in knowledge were observed following basic and intensive training courses. Eighty-two individuals received specialist level certification. Nearly half of these individuals were delivering intensive smoking cessation interventions and 69.5 percent were teaching basic certification courses. Individuals who completed basic level certification also showed significant increases in baseline knowledge following the training, and 81 percent reported they had performed at least one brief intervention. No data were presented on smoking cessation outcomes.
2. Recruitment of professional organizations
   Epps et al.¹²⁹ reported on a strategy to recruit professional organizations to co-sponsor train-the-trainer sessions with the NCI. This study was a post-test only design. Data were reported on the recruitment of professional organizations, but not the outcomes of the train-the-trainer programs. Eight national organizations were initially identified and approached, of whom six agreed. Five additional organizations were subsequently involved. Cooperating organizations collaborated in developing training plans, setting dates and locations, and naming coordinators for all seminars. Over four years, 53 train-the-trainer seminars were conducted in 22 states, training 2,098 individuals. Recruitment of professional organizations appeared to be an effective dissemination strategy. However, no information is presented on the outcome of the train-the-trainer component.
3. Educational facilitators
   Three studies evaluated educational facilitators as a dissemination strategy.^{124, 143, 144} Two studies examined the use of educational facilitators to disseminate information about office systems to promote the delivery of preventive services in family practice,^{143, 144} and one examined the use of educational facilitators to disseminate information about smoking cessation kits.¹²⁴
   Cockburn et al.¹²⁴ compared three strategies to disseminate smoking cessation kits to family practitioners. This was the only trial comparing different dissemination strategies. General practitioners (GPs) were randomized to delivery by an educational facilitator, delivery by friendly courier, or postal delivery of smoking cessation kits. Academic detailing by an educational facilitator was considered a dissemination strategy in this case, as it was used to promote the delivery of evidence-based smoking cessation interventions by GPs. The main outcome assessed was use of the kit by the GPs. Process measures were also assessed including initial reaction to the kit, motivation engendered by mode of delivery, and overall acceptability of the kit.
   Delivery by an educational facilitator was rated as more motivating than personal delivery by a courier or postal delivery. GPs in the educational-facilitator group were significantly more likely to have seen the kit (facilitator 99 percent, courier 83 percent, mail 88 percent, p=0.003). They were more likely to believe the kit was less complicated and were more knowledgeable about use of the kit. GPs in the educational-facilitator group used significantly more contract cards than GPs in the courier or mail groups (mean 6.54 vs. 3.79 vs. 1.92, p=0.02). There were no differences in use of other interventions in the kit. No data were presented on smoking cessation rates.
   There were no significant differences between the groups in their perceptions of the overall acceptability of the kit. While some measures favored the educational- facilitator group, delivery by an educational facilitator was 24 times the cost of postal delivery (A$142 vs. A$6). In the absence of data on smoking cessation rates, the additional cost does not appear to be warranted.
   Lemelin et al.,¹⁴³ randomized health service organizations (community primary care practices that have a payment system primarily based on capitation) to an educational facilitator or no intervention. The intervention used seven strategies based on review of the literature. These included audit and feedback, consensus building, opinion leaders and networking, academic detailing and educational materials, reminder systems, patient mediated activities, and patient educational materials. The educational facilitators discussed strategies with the physicians and practice staff, worked with them to adopt the strategies, provided feedback about performance using mini audits, and provided management support to practices. The primary outcome was a preventive performance index. This was defined as the proportion of eligible patients who received recommended preventive maneuvers minus the proportion of eligible patients who received inappropriate preventive maneuvers (as defined by Canadian Task Force on Preventive Health Care). Preventive maneuvers were assessed by audit of 100 charts per practice.
   Forty six practices were randomized. All facilitator-group practices received preventive performance audit and feedback, achieved consensus on a plan for improvement, and implemented a reminder system. Ninety percent implemented a customized flow sheet, 10 percent used a computerized reminder system, 95 percent wanted critically appraised evidence for prevention, and 100 percent received patient educational materials. The overall preventive performance index improved 11.5 percent in favor of the intervention group (31.9 percent vs. 32.1 percent pre- intervention; 43.2 percent vs. 31.9 percent post-intervention, p<0.001). There was no significant difference in smoking cessation-counseling activities (37.6 percent vs. 40.5 percent pre-intervention; 41.2 percent vs. 38.7 percent post-intervention, p>0.05).
   Dietrich et al.,¹⁴⁴ used a factorial design to randomize family physicians and internists to an educational facilitator, a workshop, both, or neither. The workshop was a day long educational session, plus written syllabus. The educational facilitator provided consultation on design and implementation of an office system including a preventive care flow sheet in patients' records, identification of smokers, health education posters and brochures, and patient-held diaries. Outcome data were collected in two different cross-sectional surveys of 20 to 30 patients from each physician in the study (pre-study and 12 to 14 months later). A significantly higher proportion of patients in the educational-facilitator- only group than the control group reported their physician had advised them to quit smoking (0.84 vs. 0.67, p<0.05). No significant differences were observed between the educational-facilitator-plus-workshop group compared with the control group (0.80 vs. 0.67, p>0.05). The authors concluded that overall provision of cancer early detection and preventive services was improved through the use of an educational facilitator to establish office systems.
   The overall findings of these two studies suggest that the delivery of preventive services can be improved through the use of educational facilitators disseminating information about office systems. However, there is uncertainty whether this approach impacts on smoking cessation activities.
4. Postal delivery
   Three studies examined postal delivery as a dissemination strategy.^{125, 128, 133} Fowler et al.,¹³³ used a cross-sectional survey to examine the impact of postal delivery of a smoking cessation booklet to UK GPs. A random sample of, 5,000 GPs were sent a survey. The response rate to the original questionnaire was less than 50 percent. Therefore a shortened version of the questionnaire was sent out. An overall response rate of 75 percent was achieved. Only 50 percent of responding GPs recalled receiving the smoking cessation book and 28 percent read it. Among doctors who read the book, only 19 percent could recall one or two essential steps to advising their patients to stop smoking, and 12.5 percent recalled all three steps.
   One of the barriers to dissemination may have been the mode of delivery. Booklets were delivered with the British Medical Association News Review. Some GPs may discard this without opening it. Additionally, the booklet was distributed with minimal publicity. Nevertheless, simple mailing of smoking cessation booklets to GPs appears to be an ineffective dissemination strategy.
   Mullins et al.¹²⁵ used an interrupted time series to survey members of the general public regarding the extent to which they remembered GPs discussing smoking. The survey was conducted every two years between 1990 and 1996. The aim was to assess the impact on GPs' smoking cessation activities of the dissemination by mail of a self-help booklet on quitting smoking. The main outcome was individuals' recollections of GPs' discussions about smoking cessation. Over 95 percent of GPs recalled receiving a patient self-help book on smoking cessation delivered by post and 97 percent of GPs who recalled receiving the self-help books distributed them. There were no changes between 1990 and 1996 in the proportion of patients that smoked who reported being asked about smoking status by their GP (22.4 percent vs. 21.3 percent), or who recalled being advised to quit smoking by their GP (34.8 percent vs. 37.4 percent). However, significantly more smokers (10.7 percent vs. 20.6 percent, p<0.001) were given information or help to stop after dissemination of the self-help books.
   The third study evaluated postal delivery of a letter, recruiting pharmacists to distribute patient self-help booklets on smoking cessation.¹²⁸ The Manitoba Pharmaceutical Association supported this strategy. In addition, a media campaign (television, radio, and billboards) promoted the distribution of the booklets. Only process measures were reported (number of booklets distributed). The majority of pharmacies agreed to participate (87 percent), and 93.5 percent of 46,000 booklets were picked up. No additional information was provided.
   The findings from the last two of these studies suggest that mailed invitations or postal delivery are strategies to disseminate patient self-help materials. However, the strength of this evidence is weak. No information is provided in either study about behavioral outcomes such as quit rates.
5. Multiple dissemination strategies
   One additional study targeting healthcare professionals utilized multiple dissemination strategies as part of an approach to improve smoking cessation counseling practices of family physicians in Montreal.^{138, 142} The multicomponent approach included: postal delivery of smoking cessation guidelines (based on PHS clinical practice guidelines); educational materials to facilitate counseling; smoking cessation publications (including publication of guidelines); public awareness campaigns to encourage individuals to ask for help to stop smoking from their family practitioner; and desktop cards presenting an algorithm of smoking cessation interventions. The program was initiated in 1997. Mailed questionnaires were sent to Montreal family physicians in 1998 and 2000. The outcomes assessed were family physicians' self-reported attitudes and beliefs about smoking cessation counseling, perceived skills, and importance of perceived barriers to smoking cessation activities.
   There were no changes in process measures (attitudes, perceived abilities, or interest in updating smoking cessation counseling skills) among male physicians. Female physicians perceived ability to provide smoking cessation counseling improved over time. Female physicians showed more improvement in smoking cessation-counseling practices between the two evaluations. Lack of time was perceived as a significant barrier to smoking cessation counseling by both male and female physicians. No data on behavioral outcomes such as actual physician smoking cessation activities, or patient outcomes such as quit rates were assessed. It is therefore difficult to make any firm conclusions regarding the effectiveness of this multicomponent dissemination strategy.

Dissemination studies that targeted individuals

1. Media awareness campaigns
   Seven studies reported on the effectiveness of the media as a dissemination strategy for smoking cessation interventions.^{126, 127, 130, 131, 140, 141, 146} Two studies retrospectively evaluated the importance of different media sources as strategies for patient recruitment.^{127, 140} Elder et al.¹²⁷ evaluated the importance of different media sources for recruitment to a community smoking cessation contest, whereas Anderson et al.¹⁴⁰ surveyed callers to Cancer Information Service (CIS) telephone hotlines inquiring about smoking, diet and nutrition, pap smears, and breast self examination, to determine how individuals found out about the CIS.
   Elder et al.¹²⁷ found that television was the most important media source for people joining a Quit to Win community smoking cessation program.¹²⁷ The importance of television increased with decreasing income (71 percent for income <$20,000 v. 40.5 percent for income >$40,000, p<0.05). Similarly, Anderson et al.¹⁴⁰ reported that television was the most important source of learning about the CIS hotline. Men (72 percent) were more likely to cite television than women (61 percent). The likelihood of citing television as major source of learning about CIS increased with younger age (<20 years 81.7 percent vs, >60 years 39.6 percent) and lower education. Television was the first source of knowledge about the CIS for the majority of people inquiring about smoking (78.5 percent). Both of these studies are retrospective and provide weak evidence for the effectiveness of the media as a dissemination strategy.
   Pierce et al.¹⁴¹ evaluated the impact of public service announcements (PSAs) about smoking cessation on use of CIS using an interrupted time series. Three of 12 PSAs explicitly encouraged viewers to call the CIS. Monthly call volumes to the CIS were compared with the timing of PSAs from the Office of Smoking and Health. The three peak call periods to the CIS over a five-year period were observed following these three PSAs. Television promotion increased the proportion of callers who were male, younger, and less educated.
   Three prospective studies also observed that media dissemination (primarily via television) increased calls to a CIS.^{126, 131, 135, 145, 146} Cummings et al.¹³¹ prospectively evaluated the impact of a targeted media campaign (television and print media) on calls to CIS in seven media markets. Matched media markets were utilized as controls. Mothers with young children were specifically targeted and the primary outcome was a comparison of call rates between the groups during the media campaigns. Calls regarding smoking cessation to the CIS were increased 4.8 times in the targeted media audiences compared with the control areas. In the experimental group, 28.9 percent of calls were from the target group compared with 9.5 percent in control markets. Call volumes increased substantially during the television campaigns and then dropped off back to baseline soon after. In followup interviews with the targeted group (women with young children), more women in the experimental group attempted to quit (64 vs. 46 percent, p> 0.05). However, there was no difference in the number of women who reported they quit (13 vs. 15 percent).
   Pierce et al. ^{145, 146} evaluated media dissemination of a smoking cessation clinic (“Quit for Life” campaign). Calls to the “Quit Line” and enrolments at the “Quit Centre” were monitored following a campaign of three television commercials. Over 50,000 calls were made to the Quit Line over the first three months of the campaign compared with an expected 8,600 calls based on previous call rates. Enrolments in the Quit Centre smoking cessation programs were almost 3,000 for the year of the campaign, compared with 352 in the prior year. Cohorts of people in two cities (intervention and control cities) were surveyed prior to and one year after the start of the campaign. Smokers in the intervention city were significantly more likely to report quitting or cutting down the number of cigarettes smoked (35 vs. 18 percent, p<0.05). They were also more likely to have attempted to quit during the 12 months following the media campaign (66 vs. 60 percent, p<0.05).
   Boyd et al.¹²⁶ targeted African American populations in a randomized trial of a media campaign to increase use of CIS. Several strategies were used including television and radio commercials, along with a community outreach packet utilizing peer leaders. The majority of calls received by the CIS in both control and experimental communities during the study period were from African Americans (565 vs. 144). The number of calls from African Americans in the experimental communities was 80 times greater than that from control communities. Increased call volumes persisted for about eight weeks following the first media wave and four weeks following the second media wave. Callers in the experimental communities were more likely to cite radio (51.4 percent) than television (41.6 percent) as the way they heard about the CIS. Radio generated 8.89 calls per 10,000 African American smokers and television generated 6.89 calls per 10,000 African American smokers. All other sources combined accounted for 1.38 calls per 10,000 African American smokers.
   A series of reports by Marin et al.^{130, 132, 139} provided information about media dissemination of the Programa Latino Para Dejar de Fumar to Latino residents in San Francisco. Information about a self-help manual targeted to Latinos was disseminated via a variety of media sources. Cross-sectional surveys were conducted annually between 1986 and 1993 to assess the impact of the program. Awareness of the smoking cessation program increased from 18.5 to 41.5 percent at the end of the evaluation. The increase in awareness was similar in the less acculturated as well as highly acculturated population. Awareness of printed smoking cessation material increased over time. The largest increase was in less acculturated Hispanics. The proportion of respondents who had a copy of the self-help manual increased from 7.6 to 19.7 percent over time. These changes were associated with an overall decrease in prevalence of smoking from 24.5 percent in 1986 to 16.4 percent in 1991.
   The findings of these seven studies provide some consistent evidence that media awareness campaigns are important strategies to disseminate information about CIS help lines. Television was the more important source of information in all but one study. Several of the studies suggest that television is a more important source of media awareness for certain demographic groups, such as younger people and people from less educated and lower income groups. However, the studies generally do not provide information about the subsequent outcomes following the call to CIS. It would be important to know about the use of other smoking cessation interventions, along with the quit rates from these populations of individuals. This is particularly relevant given the uncertainty about the effectiveness of reactive telephone counseling in the findings for key question #1. A significant consideration of media awareness campaigns is cost. This becomes an important issue given that the above studies suggest the impact of any media awareness campaign disappears within one or two months after the campaign finishes.

Dissemination studies that targeted worksites

1. Passive dissemination
   One paper evaluated a passive dissemination strategy in the worksite.¹³⁷ Control worksites in the Working Well Trial were given the intervention materials at the completion of the trial. The way in which this information was given to control sites is not specified. This study reported on smoking cessation rates two years after completion of the trial. Dissemination of the program to control sites had little impact on the level of smoking activities in control worksites. This passive dissemination strategy was ineffective.

Dissemination studies that targeted healthcare providers

1. Train-the-trainer
   One “train-the-trainer” study aimed at disseminating preventive medicine education to physicians.¹³⁴ Faculty from general internal divisions across the US were invited to apply for a month-long Stanford Faculty Development Program; 10 were chosen and trained to be Clinical Preventive Medicine facilitators. They then went to their home institutions and trained other faculty at their home site. Fidelity checks concluded that facilitators adhered closely to the curriculum they had been taught. Those medical faculty educated by the facilitators had an increase in knowledge and self-efficacy to use behavior changes to promote healthy diets. Subsequently, house staff physicians interacting with faculty who had attended the facilitator-run sessions reported an increase in the degree of preventive medicine content in teaching interactions and an increase in their ratings of self-efficacy to implement preventive medicine strategies.¹³⁴ While the train-the-trainer model shows some promise, it needs to be evaluated with a more rigorous design; furthermore, many biases are likely to be inherent in the selection of internists who were able to leave their work situation for a month of training.
2. Academic detailing (educational facilitators)
   One RCT¹⁴⁴ targeted dissemination to healthcare providers using academic detailing. In this trial by Dietrich et al., primary care medical practices were randomized to one of four groups: facilitator only, facilitator-plus-workshop, workshop only, or a control group. Practices in the facilitator-only group (n=24) received three to four visits from a facilitator who provided detailed instruction and assistance in selecting and implementing non-computer-based office-system interventions. Practices in the facilitator-plus-workshop group (n=26), in addition to receiving visits from an educational facilitator, had a physician from the practice attend a one-day workshop. The workshop session reviewed NCI's prevention and screening recommendations, but did not provide information on the use of office-system interventions. Practices in the workshop-only group (n=24) attended the workshop. Practices in the control group (n=24) received no information.
   Cross-sectional patient surveys were conducted before randomization and again at 12-month followup. The study reported on two diet-related outcomes: (1)the number of patients reporting that their physician had advised them to reduce their fat intake and (2) the number of patients reporting their physician had advised them to increase their fiber consumption. At 12-month followup, significantly more eligible patients in the facilitator-only group reported their physician had advised them to reduce their fat intake compared with patients in the control group (0.56 vs. 0.47, p<0.05). There was no significant difference in the number of patients reporting advice to decrease fat intake between the facilitator-plus-workshop group and the control group at 12- month followup (0.51 vs. 0.47). There was no significant increase in the number of eligible patients in the facilitator-only or facilitator-plus-workshop groups reporting advice to increase fiber consumption compared with patients in the control group at 12-month followup (facilitator vs. control 0.48 vs. 0.38; facilitator-plus-workshop vs. control 0.41 vs. 0.38). The overall conclusion from this RCT was that the use of educational facilitators to disseminate and implement office-system interventions can improve the provision of prevention and early detection services in community practices.
   The use of educational facilitators (academic detailers) to disseminate office-system interventions appears to be a promising strategy. Further research in this area is needed.
3. Workshops
   The RCT Tziraki et al.¹⁵¹ assessed the effectiveness of two strategies for promoting the use of an NCI nutrition manual by primary care physicians and their office staff. The nutrition manual was modeled after the NCI publication “How to help your patients stop smoking”. Medical practices randomized to the workshop group (n=244) were invited to send one staff member to a three-hour training workshop on how to use the nutrition manual. Training was provided in four major components of the manual: (1) how to organize the office environment, (2) how to screen for patient adherence, (3) how to provide dietary advice, and (4) how to implement a patient followup system. Medical practices assigned to the postal-delivery group (n=256) received the nutrition manual in the mail with no further information. Medical practices in the control group (n=255) did not receive the nutrition manual.
   Followup interviews with medical staff and observational assessments were conducted at four to six months after dissemination of the manual. Adherence scores were calculated for four areas: office organization, nutrition screening, nutrition advice or referral, and patient followup. There was low attendance at the workshop session; less than 50 percent of assigned practices sent representatives (120 of 244). The authors of the trial used an “intent to treat” approach for the primary statistical analyses and included all practices in the workshop group regardless of attendance. The workshop group was significantly more adherent to the manual's recommendations for office organization at followup than either the postal-delivery group (28.5 vs. 24.7 percent, p<0.005) or the control group (28.5 vs. 23.0 percent, p<0.001). Of those practices who sent a representative to the workshop, 30.6 percent were adherent to the recommendations for office organization. There was no significant difference between the postal-delivery group and the control group for office organization (24.7 vs. 23.0 percent).
   The workshop group was also significantly more adherent to the manual's recommendation for nutrition screening than either the postal-delivery group (23.5 vs. 21 percent, p<0.05) or the control group (23.5 vs. 20.5 percent, p<0.05). Of those practices that sent a representative to the workshop, 25 percent were adherent to the nutrition screening recommendations. There was no significant difference between the postal-delivery group and the control group for nutrition screening (21 vs. 20.5 percent). There was no statistically significant difference between the three groups for providing nutrition advice (workshop 54.9 percent, postal delivery 53 percent, control 52.3 percent), nor for patient followup (workshop 14.6 percent, postal delivery 13.6 percent, control 13.6 percent). A secondary analysis showed that those practices who attended the workshop were significantly more likely than either the postal-delivery group (57 vs. 53 percent, p<0.05) or the control group (57 vs. 52.3 percent, p<0.05) to provide nutrition screening. There was no significant difference observed for patient followup on secondary analysis.
   Training workshops appear to hold some promise as a dissemination strategy; however, motivating medical professionals to attend these sessions may be a difficult barrier to overcome. Further research in this area is needed.
4. Postal delivery
   One RCT¹⁵¹ evaluated the effectiveness of postal delivery as a dissemination strategy. This trial compared the effectiveness of postal delivery with a training workshop to disseminate an NCI nutrition manual to primary care practices. Postal delivery was not found to be an effective method to disseminate the nutrition manual. Please refer to the section above on Workshops for the detailed results of this study.

Dissemination studies that targeted worksites

1. Passive dissemination
   The Working Well Trial^{92, 137} randomized 114 worksites of over 28,000 workers to test the effectiveness of health promotion activities that were planned and delivered with a high level of employee participation. The intervention phase lasted for two years, and then nutrition materials were disseminated to the control sites, followed by a further two-year assessment. The investigators were particularly interested to see if the control sites would utilize the materials. No information was given about the actual strategies used to get the nutrition intervention materials to the control group, nor was any report of measure of uptake given. No changes occurred in the level of nutrition activities in the control sites.
   An opinion leader strategy was tested using peer educators in the worksite intervention called “5-A-Day: Healthier Eating for the Overlooked Worker”. While rated methodologically weak, it holds promise as an area for further research. It was an RCTof 5-A-Day intervention to increase fruit and vegetable consumption in an ethnically mixed population of 2,091 lower socioeconomic and trade employees.^{147, 148} Both the intervention group and the control worksites received an 18-month intervention program of education materials through workplace mail, cafeteria promotions, and speakers. In the intervention group, naturally occurring work “cliques” were identified, and within those, ratings were given to each individual regarding their degree of “centrality” to communication ties and flow. Those rated highest in “centrality” became the peer educator for that clique, mimicking the “opinion leader” strategy.
   Peer educators attended a 16-hour training program where they were given information about health benefits of eating fruits and vegetables, cultural trends in dietary practices, peer educator's roles and responsibilities, and five persuasive communication strategies (foot-in-the-door, fear appeal, benefits, peer pressure, and questioning) and ways to initiate informal conversations about fruits and vegetables. They were instructed to engage in nutrition education of the co-workers for about two hours per week, on work time. They also distributed 5-A-Day materials produced specifically for this population: a nine-booklet resource guide, four issues of a newsletter, enabling gifts such as a recipe book, and vegetable seeds. The peer educator intervention lasted nine months, with consumption measured at the end of the intervention and six-month followup.
   The result was an increase in fruit and vegetable consumption of 0.77 total servings per day more in the intervention group compared with the controls (measured by recall, p<0.001) and an increase of 0.46 total daily servings (measured by food frequency, p<0.002).¹⁴⁷ The effect was maintained at six-month followup for intake recall (increase of 0.41 daily servings, p=0.034) but not for food frequency¹⁴⁷. In analysis of the frequency and duration of peer-education contact with co-workers, greater contact with the peer educators was related to larger immediate increases in fruit and vegetable intake, particularly vegetable intake, but was not related to total intake at six-month followup.¹⁴⁸ A qualitative design, used to study the educational strategies used by the peer educators in the intervention group,¹⁴⁹ found that these studies differed by gender and ethnicity.¹⁴⁹ Hispanic educators were more likely to use individual, rather than group, change strategies than non-Hispanic educators; men more frequently used strategies such as “mock competition”, “giving materials” and “encouragement”, while female peer educators more often used “creating context”, and “keeping 5-A-Day visible”.¹⁴⁹
   Few worksite dissemination strategies have been evaluated. In one, the dissemination strategy was not evaluated.⁹² The other study using an opinion leader strategy had at least a short-term impact on consumption.

Dissemination studies that targeted individuals

1. Media strategies
   Two studies evaluated multiple media channels (print, television, and radio) to assess the impact of the media campaigns on telephone calls to an information telephone line.^{140, 150} “Project Lean” (Low-Fat Eating for America Now) was a three-year initiative, begun in 1989, to reduce dietary fat consumption. The media campaign led to hotline access of 300,000 consumer calls in 18 months (25,000 to 28,000 calls/month), but the calls declined as publicity declined, and the line was terminated due to expense, estimated to be US $300,000 per year.¹⁵⁰ While these outcomes were not assessed in a direct comparison, some important lessons were learned in this study:¹⁵⁰ that well-placed advertising may be the most appropriate and effective communications strategy for a national nutrition social marketing campaign as it can, more easily than PSAs, be tailored to the particular audience; can communicate information more directly and can reduce the need for an information hotline or followup materials. Furthermore, building a network of state and local programs and partnerships with the food service industry allowed the campaign to reach a broader audience.¹⁵⁰
   A second primary study was identified which was an analysis of calls to the CIS hotline. Callers were asked, “How did you first find out about the CIS?” Records of a subsample of people (214,472) who inquired about smoking, nutrition, Pap smears, and breast self-evaluation were reviewed. Television was the most frequently reported source of learning about the information line, regardless of age, gender, or ethnic group (except callers of Asian or Pacific heritage, who reported publications as the more common source of information about the hotline).¹⁴⁰
   The media dissemination strategies, particularly television messages, can make people aware of information lines and prompt them to call. However, from these two studies, it appears that the lines are expensive to advertise and maintain.

Dissemination studies that targeted healthcare providers

1. Academic detailing (educational facilitators)
   Of the four studies^{143, 144, 153, 156} that targeted dissemination to healthcare providers using academic detailing, the Kinsinger et al.¹⁵³ RCT provides the strongest evidence. Medical practices within the experimental group (n=32) received detailed instruction and assistance on how to implement office systems tailored to increase breast cancer screening. Practices in the control group (n=31) received no academic detailing visits and were not provided with any information on the development of office systems. Five indicators of the use of an office system were assessed at baseline and again at followup in each of the practices¹⁵³. These indicators were: (1) ≥50 percent of patient records have an entry on a flow sheet; (2) ≥50 percent of physicians in the practice report having written preventive care policy; (3) ≥50 percent of the physicians in the practice report that nurses frequently or sometimes recommend mammograms to patients; (4) ≥50 percent of physician in the practice report that nurses identify patients who are due for mammograms; and (5) ≥50 percent of physicians in the practice report frequent use of flow sheets or computerized reminders to identify patients due for mammograms.
   The mean number of indicators increased significantly in practices in the experimental group (1.3 to 2.8) compared with control group practices (decrease from 1.5 to 1.4) (p<0.0003). There were significant increases in three of the five indicators in experimental group practices compared with practices in the control group (Indicators [1], [2], and [3] above; all p<0.05). At followup, however, no indicator was present in more than two-thirds of intervention practices, and only seven of the 32 practices in the experimental group reported a complete office system for breast cancer screening.
   Kinsinger et al.¹⁵³ also conducted a chart review on a random sample of eligible patient records at baseline and again at followup. There was no significant difference between experimental and control practices in the change in proportion of women's records with an actual mammogram report within the last year (increase of 4.7 vs. 3.4 percent). The study identified physician attitude regarding the value and feasibility of office systems for mammography screening as a barrier to successful implementation of complete office systems.
   Lemelin et al.¹⁴³ randomized health service organizations (community primary care practices that have a payment system primarily based on capitation) to an educational-facilitator group (n=22 practices) or to a control group (n=23 practices) that received no visits from an educational facilitator. Over an 18-month period, educational facilitators visited practices in the experimental group an average of 33 times with each visit lasting about one hour. The facilitators performed an initial audit and feedback of each practice's baseline preventive performance. The academic detailers then acted to facilitate the development of practice goals and policy for preventive care and assisted the practices in selecting and implementing interventions to improve preventive care. All of the practices in the experimental group implemented a reminder system. Ninety percent implemented a customized flow sheet, 10 percent used a computerized reminder system, 95 percent wanted critically appraised evidence for prevention, and 100 percent received patient educational materials. Ninety-five percent of the physicians in the experimental group reported that they were either satisfied or very satisfied with the educational-facilitator approach.
   The primary outcome measured was a preventive performance index. This was defined as the proportion of eligible patients who received recommended preventive maneuvers minus the proportion of eligible patients who received inappropriate preventive maneuvers (as defined by Canadian Task Force on Preventive Health Care). Preventive maneuvers were assessed by audit of 100 charts per practice. At baseline, the preventive performance index was not significantly different between the facilitator and control groups (31.9 vs. 32.1 percent, respectively). At followup, the corresponding values were 43.2 percent for the facilitator group and 31.9 percent for the control group. The absolute increase in the preventive performance index of 11.5 percent in the educational-facilitator group was statistically significant (p<0.001). At followup, there was no significant improvement in the number of eligible patients in the facilitator group having mammograms compared with the control group (67.5 vs. 58.7 percent, respectively). Refer to Evidence Table 8 for further detail. The overall conclusion of the study's authors was that use of this educational-facilitator approach resulted in significant improvements in preventive care performance.
   Dietrich et al.¹⁴⁴ conducted an RCT in which primary care medical practices were randomized to one of four groups: facilitator only, facilitator plus workshop, workshop only, or a control group. Practices in the facilitator-only group (n=24) received three to four visits from a facilitator who provided detailed instruction and assistance in selecting and implementing non-computer-based office-system interventions. Practices in the facilitator-plus-workshop group (n=26), in addition to receiving visits from an educational facilitator, had a physician from the practice attend a one-day workshop. The workshop session reviewed NCI's prevention and screening recommendations, but did not provide information on the use of office-system interventions. Practices in the workshop-only group (n=24) attended the workshop. Practices in the control group (n=24) received no information.
   Cross-sectional patient surveys were conducted before randomization and again at 12-month followup. The proportion of patients reporting having a mammogram at 12- month followup was significantly higher in each of the three experimental groups compared with the control group (facilitator plus workshop vs. controls 0.78 vs. 0.57, p<0.01; facilitator only vs. controls 0.77 vs. 0.57, p<0.01; workshop only vs. controls 0.71 vs. 0.57, p<0.01). There was no significant difference among the three experimental groups in the proportion of eligible patients reporting having had a mammogram. A chart review of a random sample of patient records confirmed the mammography-related findings from the cross-sectional patient surveys (see Evidence Table 8 for further detail). The overall conclusion from this RCT was that the use of educational facilitators to disseminate and implement office-system interventions can improve the provision of prevention and early detection services in community practices.
   Williams et al.¹⁵⁶ also evaluated the use of academic detailing as a dissemination strategy. In this one-group pre-post-test study, GPs were provided with information about the effectiveness of medical record prompts and recall systems, and the availability of ACS resources.¹⁵⁶ The academic detailers also provided the physicians with ACS patient educational materials and display racks. At baseline only one of the 10 practices used ACS patient educational materials. After academic detailing visits, all 10 practices used the ACS materials and nine displayed the information in the racks provided. In contrast, only minor changes to office systems were found at followup. Practices that had not used medical record prompts at baseline did not add them. However, practices that previously used chart summaries or prompts added items, typically mammography or Pap test notations (no further details provided). At baseline, only one practice had a recall system for scheduling mammograms. At followup, one practice with a Pap test recall system at baseline had added mammography recalls and one practice with no recall system at baseline implemented both Pap and mammography recalls. The principal barriers to intervention implementation identified were: time, lack of administrative process or infrastructure, and lack of third party reimbursement.
   The use of academic detailers (educational facilitators) was reported to be acceptable to healthcare providers in the three studies in which it was assessed. This strategy yielded mixed results for disseminating office-system interventions to increase mammography uptake.^{143, 144, 153, 156} This strategy may be a promising way to disseminate patient educational materials and information about local resources for healthcare providers.¹⁵⁶ Further research is needed in this area to clarify whether educational facilitators can be an effective strategy to disseminate office-system interventions or patient educational materials. Further research is also needed to elucidate variables that influence the effectiveness of this strategy.
2. Workshops
   Scott et al.¹⁵⁵ compared two strategies to disseminate a manual of evidence-based interventions promoting mammography uptake to managed care organizations. Half of the managed care organizations attended an intensive one-day workshop on how to use the intervention manual and received an accompanying user guide. In contrast, managed care organizations in the passive-dissemination group received only the intervention manual with no training workshop or user guide. This was predominantly a descriptive study in which in-depth interviews were conducted with quality-improvement personnel at each managed care organization to elucidate motivating factors and identify barriers to use of the manual or subsequent implementation of interventions from the manual.
   Little difference was found between managed care organizations that attended the workshop and those in the passive dissemination group in use of the manual or in interventions implemented (no statistical analysis reported). Overall, seven of the eight managed care organizations in the study used the manual and implemented more interventions to promote mammography uptake in the year after receiving the manual compared with the year prior to its dissemination (no statistical analysis reported).¹⁵⁵ Improvement was found in the type of interventions implemented (i.e., more were evidence-based). All seven plans implemented a physician-directed intervention. This was most frequently a performance feedback letter encouraging physicians to recommend mammograms to their patients who were due for them. Some of the managed care organizations also implemented interventions directed towards patients (e.g., reminder letters). The only managed care organization that did not use the manual had the point person for the organization change jobs during the study.
   Mammography rates in the year prior to dissemination of the manual were compared with the rates in the year after dissemination. In all seven of the managed care organizations that used the intervention manual, the mammography rates increased (range 0.22 to 4.0 percent). Mammography rates in the managed care organization that did not use the intervention manual decreased by 2.67 percent.
   In this study, the intensive one-day workshop strategy did not seem to confer an added advantage to successful dissemination of the manual, nor to the subsequent implementation of interventions from the manual compared with passive dissemination. Overall, the managed care organizations were receptive to the dissemination of cancer control interventions to promote mammography.
   In-depth interviews with key personnel at each of the managed care organizations identified local factors that influenced implementation of interventions from the manual. A key factor for implementation seemed to be the length of employment of the point person for the managed care organization. The two organizations that implemented the least intensive interventions had point people who had only been in their positions for a relatively short period of time. Other factors that facilitated use of the manual and implementation of interventions were: (1) the motivation of the point person to improve mammography rates, (2) support of senior management, (3) adequate resources (time, personnel, and funds), and (4) the organization and content of the intervention manual. The two major barriers to implementation of interventions from the manual were resources and data limitations. The resource limitations identified were finances, time, and programming. The data limitation concerned the ability to identify the baseline population of members to be targeted for the interventions.

Dissemination studies that targeted worksites

One study evaluated the dissemination of interventions that promote mammography uptake to worksites. In this self-selected, four-group post-test only study, Paskett et al.¹⁵⁴ evaluated whether approaching worksite management by introductory letters, followed by telephone contact, was an effective strategy to recruit worksites to sponsor breast cancer screening education programs for their employees¹⁵⁴. Worksite management was offered the choice of sponsoring three increasingly intensive interventions: (1) printed educational materials, (2) breast cancer screening educational sessions, or (3) training of worksite nurses in breast cancer education. Of the 102 worksites approached, 97 completed the baseline survey. Of these, 63 worksites accepted and offered a program to their employees. Fourteen worksites chose the intensive nurse training, 14 sponsored worksite classes, and 35 chose the educational display of brochures. Worksites that chose to sponsor one of the interventions were more likely to have sponsored breast cancer education programs before (p=0.027) or to have a medical department (p=0.006).

The intervention chosen was significantly associated with a history of sponsoring other health education programs (p<0.01). Worksites that had sponsored a similar program in the past were more likely to send a nurse to be trained. Of the 73 worksites that had never sponsored a breast cancer program, a majority (n=43) was responsive to this dissemination strategy and chose to sponsor one of the interventions. The least intensive intervention (educational displays with brochures) was selected by 29 of these worksites.

Responses from the 34 worksites that chose not to sponsor one of the interventions indicated the presence of several barriers to implementation. These barriers were: (1) finances, (2) geographic composition (several branches in different locations), (3) employee characteristics (majority of employees not women or not in target age range), and (4) presence of a corporate policy that prohibits offering a program to a subgroup of employees (while excluding others).

Approaching worksite management by introductory letters and telephone contact appears to be a promising strategy to disseminate interventions to promote mammography uptake. This strategy was even successful in recruiting worksites that had not previously sponsored programs for their employees to implement one of the interventions promoting mammography uptake. Further research in this area should definitely be undertaken.

Dissemination studies that targeted healthcare providers

1. Academic detailing (educational facilitators)
   Three studies^{143, 144, 156} assessed the effectiveness of disseminating interventions to healthcare professionals using educational facilitators (academic detailing). Lemelin et al.¹⁴³ randomized health service organizations (community primary care practices that have a payment system primarily based on capitation) to an educational-facilitator group (n=22 practices) or to a control group (n=23 practices) that received no visits from an educational facilitator. Over an 18-month period, educational facilitators visited practices in the experimental group an average of 33 times with each visit lasting about one hour. The facilitators performed an initial audit and feedback of each practice's baseline preventive performance. The academic detailers then acted to facilitate the development of practice goals and policy for preventive care and assisted the practices in selecting and implementing interventions to improve preventive care. All of the practices in the experimental group implemented a reminder system. Ninety percent implemented a customized flow sheet; 10 percent used a computerized reminder system; 95 percent wanted critically appraised evidence for prevention; and 100 percent received patient educational materials. Ninety-five percent of the physicians in the experimental group reported that they were either satisfied or very satisfied with the educational- facilitator approach.
   The primary outcome measured was a preventive performance index. This was defined as the proportion of eligible patients who received recommended preventive maneuvers minus the proportion of eligible patients who received inappropriate preventive maneuvers (as defined by Canadian Task Force on Preventive Health Care). Preventive maneuvers were assessed by audit of 100 charts per practice. At baseline, the preventive performance index was not significantly different between the facilitator and control groups (31.9 vs. 32.1 percent, respectively). At followup, the corresponding values were 43.2 percent for the facilitator group and 31.9 percent for the control group. The absolute increase in the preventive performance index of 11.5 percent in the educational-facilitator group was statistically significant (p<0.001). At baseline, Pap testing was performed on 60.8 percent of eligible patients in the facilitator group and on 57.9 percent of patients in the control group. At followup, there was no significant improvement in the number eligible patients in the facilitator group having a Pap test compared with the control group (66.2 vs. 59.1 percent, respectively). The overall conclusion of the study's authors was that use of this educational-facilitator approach resulted in significant improvements in preventive care performance.
   Dietrich et al.¹⁴⁴ conducted an RCT in which primary care medical practices were randomized to one of four groups: facilitator only, facilitator plus workshop, workshop only, or a control group. Practices in the facilitator-only group (n=24) received three to four visits from a facilitator who provided detailed instruction and assistance in selecting and implementing non-computer-based office-system interventions. Practices in the facilitator-plus-workshop group (n=26), in addition to receiving visits from an educational facilitator, had a physician from the practice attend a one-day workshop. The workshop session reviewed NCI's prevention and screening recommendations, but did not provide information on the use of office-system interventions. Practices in the workshop-only group (n=24) attended the workshop. Practices in the control group (n=24) received no information.
   Cross-sectional patient surveys were conducted before randomization and again at 12-month followup. There was no significant difference in the proportion of patients reporting having had a Pap test at 12-month followup in any of the three experimental groups compared with the control group (facilitator plus workshop vs. controls 0.65 vs. 0.61; facilitator only vs. controls: 0.71 vs. 0.61; workshop only vs. controls 0.63 vs. 0.61). The overall conclusion from this RCT was that the use of educational facilitators to disseminate and implement office system interventions can improve the provision of prevention and early detection services in community practices.
   The RCTs by Lemelin et al.¹⁴³ and Dietrich et al.¹⁴⁴ both found that using educational facilitators to disseminate office-system interventions resulted in significant improvements in overall indicators of preventive care. Neither study, however, found that the use of educational facilitators led to an increase in cervical cancer screening rates.
   Williams et al.¹⁵⁶ conducted a demonstration project using academic detailing to provide GPs with information about cancer-screening guidelines, the effectiveness of medical record prompts and recall systems, and the availability of ACS resources. This was a one-group pre-post-test study. Four education representative volunteers (ERVs) were recruited and trained to lead discussions and to involve participating staff and physicians. The academic detailers provided the primary care physicians with ACS patient educational materials and display racks. Of the 10 primary practices visited, only one of the practices used ACS patient educational materials pre-intervention. Post-intervention, all 10 practices used the ACS materials, and nine displayed the information in the racks that were provided. In contrast, only minor changes to office systems were found at followup. Practices that had not used medical record prompts at baseline did not add them. However, practices that previously used chart summaries and/or prompts added items (i.e., Pap notations). One practice, which was initially without a recall system, instituted one that included Pap test and mammography recalls. The principal barriers to delivering preventive care were: (1) time (which was reported by all physicians and staff as the major barrier to implementation), (2) lack of administrative process or infrastructure, and (3) third party reimbursement.
   The use of academic detailing for healthcare providers was reported as acceptable in the two studies in which it was measured.^{143, 156} While this strategy improved overall indicators of preventive care, it did not yield promising results for disseminating office systems to increase cervical cancer screening.^{143, 144, 156} Further research is needed in this area, in particular, to identify variables that may impact on the effectiveness of this strategy for cervical cancer screening.

Dissemination studies that targeted individuals

1. Media Awareness campaigns
   One study evaluated the importance of different media sources in disseminating information about the telephone-based CIS. In this descriptive study, Anderson et al.¹⁴⁰ examined inquiries received by the CIS to determine effects of different media in stimulating calls to the service, as well as demographic characteristics of callers in four cancer prevention and early detection topics: Pap smear screening, smoking cessation, nutrition, and breast self-examination.
   A retrospective analysis of five years of inquiries to one national and 26 local CIS offices in four topics provided data. A standardized call record form was completed for each call. The variable of interest was one of the questions posed to callers: “How did you first find out about CIS?” The local CIS office manager assigned one out of a possible 52 codes to their response. For the purpose of their analysis, the codes were collapsed into six categories: (1) television - including several prime and fringe time public service announcements; (2) publications - advertisements, magazines, newsletters, and health brochures/pamphlets; (3) radio - combining several PSAs; (4) healthcare providers - including health agencies such as the ACS, physicians, or members of their staff; (5) significant others - including friends, relatives, neighbors, and co-workers; and (6) telephone assistance - which included telephone book, directory assistance, and the 1-800- operator assistance.
   Telephone assistance (phone book and directory assistance) was the most frequently reported source of learning about the CIS by callers seeking Pap-smear screening information (27.7 percent). The second most cited source was healthcare providers (22.7 percent). Publications (including newspapers, magazines, pamphlets, and posters) were cited by 19.7 percent of Pap-smear- related callers. Television was cited by 17.7 percent of Pap-smear-related callers, 10.3 percent cited significant others, and two percent cited radio. Television was the primary source reported for callers for all education levels. In general, the lower the caller's level of education the more frequently television was cited as the information source.
   Four of the five ethnic groups identified across all preventive topic areas - Caucasians, African Americans, Hispanics, and Native Americans - identified television as the primary source. For callers of Asian or Pacific Island heritage, the most frequently cited source was publications (46.7 percent), followed by television (32.1 percent). Further analysis suggested that news publications, not health publications, were the greatest source of information for this ethnic group.
   This review provides “weak” evidence for the effectiveness of media dissemination strategies to raise awareness of CIS. Additionally, there is little evidence from systematic reviews regarding the effectiveness of reactive telephone counseling for cervical cancer screening.
   The use of physician-directed interventions, such as office systems in the form of medical record prompts and recall systems, has been shown to be somewhat effective in promoting the uptake of cervical cancer screening. The use of the CIS was not an intervention that was identified by our review of systematic reviews addressing cancer control interventions to promote the uptake of cervical cancer screening.

Dissemination studies targeted to healthcare providers

1. Application of an algorithm with community oncologists and nurses
   Du Pen et al.¹⁵⁸ randomized nine institutions (two managed care organizations, three small community hospitals, four large community/regional hospitals) to either training or no training group. Each group had 10 oncologists and 18 to 20 nurses. Patients were included if they were: English speaking, had diagnostic evidence of a locally invasive or metastatic solid tumor, were ambulatory, and had at least six-month life expectancy. The curriculum for the dissemination strategy was designed to address problems previously identified. It consisted of a one-time five-hour training session incorporating the physician/nurse teams as well as a workbook containing the algorithm flow chart, guiding principles of pharmacologic management, and a pain flow sheet. It was unclear if the actual participants were passively or actively involved in the training. Patients were not trained. Overall, there was a statistically significant improvement in overall provider adherence, but there were no significant differences in any of the subscales. A significant deterioration in training effect was found over the study. Patient adherence was a confounder in both groups and was highly correlated with usual and worst pain at the end of the study. The authors reported that other factors, such as a lack of time and resources, may have been factors in the inability to sustain the effect of the training.
2. Role-modeling
   In a pre-post design, Weisman and Dahl¹⁵⁹ evaluated the Wisconsin Cancer Pain Initiate Role Model program. This purpose of this one-day program was to train pairs of clinician educators and their clinical partners to be role models in their local communities. The authors reported significant improvement in knowledge. Sixty-four percent of participants reported that they had met their goal of conducting an in-service program or longer-term programs such as integrating pain assessment into clinical practice.
   Breitbart et al.¹⁵⁷ also used a pre-post design to evaluate the Observership Program, which was one of four components of the “The Network Project”, a project funded by the NCI. This strategy consisted of a two-week educational program targeted toward individuals who were likely to promote education in their own institution or community.
   The program consisted of attendance at rounds, meetings, and observing doctor-patient interactions. The authors reported increases in participant knowledge after training compared with baseline. Thirty-seven percent completed a followup questionnaire pertaining to their local educational and training activities. Of those responding to the survey, just under half reported that they had organized a pain management symposium or educational program.

Dissemination studies targeted to individuals

Although there is evidence that a nursing pain-education program coupled with a daily pain diary or a nursing counseling intervention combined with a pain management booklet can increase patient pain relief, no dissemination studies of these types of interventions were identified.