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The Role of a State Health Agency in Promoting Cancer Prevention at the Community Level

Examples from New York State

      Abstract

      Cancer is a major cause of morbidity and mortality in the U.S. and more work is needed to decrease the number of new cancer cases and the number of cancer cases diagnosed at a late stage. In New York State, about 106,000 people are diagnosed with cancer each year, 37% of which are diagnosed in adults aged 45–64 years and 55% in those aged ≥65 years. State health agencies are in a unique role to support implementation of cancer prevention strategies at the local level that may have a large impact on the burden of cancer by changing the context in which an individual makes health decisions.
      The New York State Department of Health, with support through the CDC, is implementing an 18-month cancer prevention demonstration project in two counties aimed at increasing access to nutritious foods, promoting exclusive breastfeeding and decreasing barriers to obtainment of cancer screening. The specific activities being used by the two counties are highlighted, and promising results after the first 6 months of the project are described. Lessons learned from these projects will be reported at regular intervals and used to inform development of larger, statewide initiatives aimed at reducing cancer incidence and death in New York State.

      Introduction

      In New York State (NYS), approximately 106,000 cases of cancer are diagnosed each year; more than 95 New Yorkers die each day from cancer (www.health.ny.gov/statistics/cancer/registry). In 2010, the age-adjusted cancer incidence rate was 473.1 cases per 100,000 New Yorkers, the ninth highest cancer incidence rate in the U.S. and above the national average of 430.5 cases per 100,000 people (http://statecancerprofiles.cancer.gov/). Currently, the 5-year relative survival rate in the U.S. for all cancer types across all races is 65%.

      National Cancer Institute. SEER cancer statistics review, 1975–2009. http://seer.cancer.gov/csr/1975_2009_pops09/.

      The potential to apply scientific knowledge to decrease the number of new cancer cases and decrease the number of cancer cases diagnosed at a late stage has yet to be fully realized.
      The risk of cancer increases with age and most cancers occur in adults who are middle-aged or older. In NYS, about 37% of all cancers are diagnosed in adults aged 45–64 years and 55% in those aged ≥65 years (www.health.ny.gov/statistics/cancer/registry). Cancer prevention and early detection efforts can benefit individuals across the life span, including adults aged 45–64 years. Cancer risk factors affecting adults in this age range include tobacco use; physical inactivity; poor nutrition; exposure to ultraviolet radiation (e.g., artificial tanning) or ionizing radiation (e.g., computed tomography [CT] imaging); and alcohol use.

      NYS Cancer Consortium. 2012–2017 NYS Comprehensive Cancer Control Plan. 2012. www.nyscancerconsortium.org/documents/NYSCompCancerPlan2012-2017-FINAL.pdf.

      Although such risk factors are typically measured at the level of the individual, effective change interventions can be implemented at the level of the community. For example, increasing access to nutritious foods and decreasing barriers to obtainment of cancer screening offer important opportunities for cancer prevention and early detection in adults aged 45–64 years. Investments in strategies such as these can result in a return on investment in annual healthcare costs.

      Trust for America’s Health. Prevention for a healthier America: investments in disease prevention yield significant savings, stronger communities, 2008. www.healthyamericans.org/reports/prevention08/Prevention08.pdf.

      A multilevel approach can address individual behaviors and include population-based strategies to support and reinforce healthy behaviors and reduce cancer risk. Policy, systems, and environmental change strategies can have a large impact by changing the context in which an individual makes health decisions.
      • Frieden T.R.
      A framework for public health action: the health impact pyramid.
      Such approaches, recommended and utilized in the areas of tobacco control and healthy communities,
      • Giles W.H.
      • Holmes-Chavez A.
      • Collins J.L.
      Cultivating healthy communities: the CDC perspective.

      CDC. Best practices for comprehensive tobacco control programs, 2007. www.cdc.gov/tobacco/stateandcommunity/best_practices/pdfs/2007/BestPractices_Complete.pdf.

      shift whole populations to a lower level of risk.
      IOM of the National Academies
      The future of the public’s health in the 21st century.
      This paper gives real-world examples of population-focused policy, system, and environmental approaches.
      The CDC funds the National Comprehensive Cancer Control Program (NCCCP; www.cdc.gov/cancer/ncccp) to establish cancer coalitions and develop and disseminate specific, actionable, and time-phased cancer plans in states, tribes, and territories. The NYS Department of Health (NYSDOH) receives CDC funding for cancer prevention and control through the NCCCP. This program is housed in the NYSDOH’s Division of Chronic Disease Prevention, which recently developed a Coordinated Chronic Disease Framework (Figure 1) based on four key domains outlined by the CDC’s National Center for Chronic Disease Prevention and Health Promotion.

      CDC. Chronic disease prevention and health promotion domains. USDHHS, 2012. www.cdc.gov/chronicdisease/pdf/Four-Domains-Nov2012.pdf

      As shown in Figure 1, the framework outlines a set of strategies and activities specific to each domain that aim to promote health and reinforce healthful behaviors. The framework reflects the fact that programs across the Division often target closely related chronic diseases and shared risk and protective factors. The purpose of developing a common framework for the Division of Chronic Disease Prevention was to improve coordination and consistency and thereby increase efficiency and effectiveness. This paper focuses on the implementation of this framework in two county-based cancer prevention demonstration projects and the 6-month progress to date using environmental approaches that promote health and support and reinforce healthy behaviors (Domain 2).
      Figure thumbnail gr1
      Figure 1NYSDOH Division of Chronic Disease Prevention Coordinated Chronic Disease Prevention Framework

      Population-Based Cancer Prevention Strategies and Activities

      Cancer prevention and control activities in the Department are guided by the 2012–2017 NYS Comprehensive Cancer Control Plan (the Plan). Cancer prevention and early detection are priority goal areas of the Plan.

      NYS Cancer Consortium. 2012–2017 NYS Comprehensive Cancer Control Plan. 2012. www.nyscancerconsortium.org/documents/NYSCompCancerPlan2012-2017-FINAL.pdf.

      The NYSDOH began supporting implementation of the Plan strategies specific to cancer prevention in January 2013 through two community demonstration projects. The overall aim of these projects is to mobilize communities to be supportive of strategies that focus on policy, system, and environmental changes in order to reduce the risk of cancer among community residents. Schenectady County and Broome County have high chronic disease rates and high prevalence of behaviors associated with increased cancer risk; they also represent small city and rural demographics (www.health.ny.gov/prevention/prevention_agenda/indicator_map.htm).
      Each county has strong existing community coalitions supported by governmental and nongovernmental organizations and resources. These coalitions have experience using evidence-based strategies implemented at the community level to improve population health. The coalition consists of various partners, including healthcare providers, health plans, community-based organizations, and local businesses, each carrying out appropriate roles to support or implement these strategies. The Broome County coalition has worked with community leaders since 2003 to support more than 100 broad-based strategies, such as eliminating the use of trans fats in restaurants. The Schenectady County coalition has worked with community leaders since 2008 to support more than 40 community-based strategies, such as chain restaurants including calorie information on their menus.
      Beginning in January 2013, with the support of the NYSDOH, the two counties began implementation and evaluation of three cancer prevention initiatives, two of which are particularly relevant during midlife. The first initiative is an example of environmental change and aims to increase access to nutritious foods by improving food-procurement standards within at least two community-based organizations and one municipality. Establishing a food-procurement policy that defines nutrition standards may help shape social norms by changing the eating habits of people working for or visiting a particular venue

      CDC. Improving the food environment through nutrition standards: a guide for government procurement. 2011. USDHHS. www.cdc.gov/salt/pdfs/DHDSP_Procurement_Guide.pdf.

      and support the NYSDOH’s obesity and cancer prevention efforts. The second initiative is an example of systems change and aims to encourage at least four pediatric and/or obstetric offices to adopt policies that eliminate the distribution of free formula samples and other sponsored materials such as pamphlets, notepads, or gifts that have formula company logos so that clinicians do not inadvertently promote formula feeding over breastfeeding.

      Office of the Surgeon General. The Surgeon General’s call to action to support breastfeeding. USDHHS, 2011. www.surgeongeneral.gov/library/calls/breastfeeding/calltoactiontosupportbreastfeeding.pdf.

      Breastfeeding exclusively and for longer periods of time (at least 6 months) is linked to lower rates of childhood obesity and lower risks of breast and ovarian cancer in mothers who breastfeed (www.cdc.gov/vitalsigns/breastfeeding/). This initiative fosters environments supportive of breastfeeding, which ties into the NYSDOH’s intent to increase rates of breastfeeding exclusivity and duration and aligns with the state’s overall obesity and cancer prevention efforts. The third initiative is an example of a policy approach and aims to remove barriers for getting timely recommended cancer screenings by collaborating with at least one municipality to improve leave policies for municipal workers. A recent study found that employees with paid leave were more likely to undergo cancer screenings at recommended intervals.
      • Peipins L.A.
      • Soman A.
      • Berkowitz Z.
      • White M.C.
      The lack of paid sick leave as a barrier to cancer screening and medical care-seeking: results from the National Health Interview Survey.
      The demonstration project work plans are built around four key activities outlined in the environmental approaches domain (Figure 1):
      • 1
        Educating and Engaging Communities refers to conducting targeted efforts to raise public awareness and inform individual opinions, beliefs, attitudes, and behaviors. Success is reflected in establishing public understanding of and support for health-promoting policies and environmental changes. In the first 6 months of the project, the two counties updated their public websites and began attending community events to disseminate information about the three initiatives.
      • 2
        Mobilizing and Empowering Communities involves informing influential community members and organizations about the impact that prevention and control initiatives can have on the health of their communities. The counties are in the process of training their community coalition members about the three initiatives. At least once per month, these community partners will deliver this information in social media and other public forums as appropriate.
      • 3
        Engaging Organizational Decision Makers refers to the education that is provided to community decision makers who are developing, implementing, or modifying organizational practices or programs in support of prevention and control activities. To date, both counties attended an academic detailing training and began development of educational materials that they will use to support implementation of cancer prevention initiatives.
      • 4
        Educating Governmental Decision Makers refers to educating local, state, and regional policymakers about the benefits and importance of cancer prevention and control efforts. When requested, educational materials and presentations will be delivered to county legislative healthcare committees and other elected officials. In the first 6 months, both counties and their community partners were invited to present information about the project to their county executives and public health advisory boards. Both will continue to communicate, when appropriate, with local decision makers at in-person meetings or via e-mail, letters, or social media.

      Monitoring Progress and Measuring Success

      The ongoing collection of information to inform programmatic decision making is essential for future program planning.
      CDC
      Framework for program evaluation in public health.
      Generating this information is one of the strategies of the Coordinated Chronic Disease framework (Figure 1) and will be accomplished through performance management, evaluation, and surveillance activities.

      Performance Management

      Performance management documents progress and demonstrates program accountability through the regular collection and reporting of data to track work produced and results achieved.

      University of Washington Health Policy Analysis Program. Guidebook for performance measurement, 1997. www.turningpointprogram.org/Pages/pdfs/perform_manage/pmc_guide.pdf.

      Performance management data for the demonstration projects are linked to required work plan activities and provide important information on the steps that lead to the desired community outcomes. These work plans drive program planning and ensure that contractor activities are on course. The counties are currently reporting on project implementation measures such as the number of community education events, the number of visits with organizational decision makers, and the achievement of key milestones like the number and types of settings where partnerships have been built and where partners are supportive of interventions that focus on policy, systems, and environmental change. The counties are also reporting on factors that contribute to or interfere with success in these areas.
      During the first 6 months of the project, both counties have made great strides to implement the four key activities outlined in the environmental approaches domain (Figure 1). In support of the initiative to increase access to nutritious foods by improving food-procurement standards, both counties are partnering with administrative staff and leaders of local organizations that serve food to adults in a variety of settings, providing educational sessions and materials to staff and clients at various organizations and harnessing the expertise of local registered dieticians to inform implementation planning steps such as menu planning and client communications. For the breastfeeding promotion initiative with local primary care offices, one county is utilizing respected physicians and working with large health networks to conduct academic detailing in provider offices. Both counties are partnering with their local cancer screening programs to develop educational materials and key messages; one county has been invited to present a draft model leave policy for municipal workers in support of increased cancer screening access at an upcoming county administrative meeting.

      Program Evaluation

      Program evaluation ensures that resources are being invested wisely and measures whether progress is being made toward specified goals. Guided by the CDC Framework for Program Evaluation
      CDC
      Framework for program evaluation in public health.
      and following a model used by the NYSDOH’s Bureau of Tobacco Control to evaluate policy interventions,
      • Schillo B.A.
      • Babb S.
      • Juster H.R.
      Developing approaches for evaluating smoke-free policies: a case study of a collaborative response to an emerging technical assistance need.
      evaluation of the community demonstration projects will answer questions about public and decision maker awareness of and support for evidence-based community interventions, strength of chosen interventions compared to model interventions, and intervention impact on health outcomes. Short-term outcome measures include the strategies chosen as a result of project efforts, information on the number and type of settings where strategies have been implemented, characteristics of populations reached, and characteristics of locations that implemented chosen strategies. For example, each county will collect demographic data of each community-based organization or municipality that improves food-procurement standards so that the potential number of individuals affected by the change can be calculated to estimate the reach of the adopted standards. Intermediate-term outcomes, which include changes in attitudes, behaviors, practices, and health, may demonstrate the health impact of the policy intervention. To track utilization of the time-off benefits, the number of individuals that use them to obtain cancer screening will be reported on an annual basis. These data will be compared to the percentage of the workforce aged ≥50 years that would be eligible to take advantage of the benefit.
      Information gathered during the first 6 months of the project reflects progress that is being made in each of the three initiatives. For example, both counties each have commitments from two local organizations to begin developing and implementing food-procurement guidelines in their settings. As counties meet with key decision makers in these settings, they are collecting information on the target populations that would be affected by the adoption of food-procurement guidelines. The counties have collected data on the number of individuals that access these sites as well as the geographic location of sites that would be covered under these guidelines. Both counties are tracking and reporting barriers and challenges to their efforts and describing plans for overcoming these issues. For example, one county is addressing higher costs of healthier food options by working with one organization to phase in such options over several grocery bid periods.

      Public Health Surveillance

      Public health surveillance is the ongoing collection, analysis, interpretation, dissemination, and use of data to guide public health program planning and evaluation.
      • Buehler J.W.
      CDC
      CDC’s vision for public health surveillance in the 21st century.
      Data from the NYS Expanded Behavioral Risk Factor Surveillance System, which collects county-level information, and NYS Cancer Registry will be monitored in these two counties and used to educate decision makers and the public about the burden of cancer and the prevalence of behavioral risk factors in their communities. Behavioral risk factors include fruit and vegetable consumption and cancer screening rates. Data from the Registry are used to examine cancer incidence and includes analyses by cancer site, age, gender, race/ethnicity, location (county) and stage at diagnosis.

      Conclusion

      Implementation of the cancer prevention and early detection strategies outlined in the 2012–2017 NYS Comprehensive Cancer Control Plan requires a continued focus on individual education, but population-based approaches implemented at the local level and broadly are also needed to support and reinforce healthy behaviors among adults. Cancer prevention and control programs need additional experience to foster environments that are supportive of evidence-based interventions that involve policy, system, and environmental changes. State health agencies are in a unique role to support implementation of such interventions. By effectively educating the public and governmental and organizational decision makers about such strategies, two NYS counties, Schenectady County and Broome County, are working to improve population health and reduce cancer risk throughout their communities. The NYS Coordinated Chronic Disease Framework is guiding performance management, evaluation, and surveillance activities. Lessons learned from these projects will be reported at regular intervals and used to inform development of larger, statewide initiatives aimed at reducing the burden of cancer in NYS.

      Acknowledgments

      The authors thank Barbara Wallace, MD, MSPH, and the Division of Chronic Disease Prevention Management Team at the New York State Department of Health for their work developing the Division’s Coordinated Chronic Disease Framework, and specifically Dr. Ian Brissette, Cindy Jaconski, Suzanne Kuon, and Wendy Gould, in the Division of Chronic Disease Prevention in the New York State Department of Health, for reviewing drafts of the paper. The authors also thank the Broome and Schenectady County Departments of Health for their review of this paper.
      This publication was supported by Cooperative Agreement 5U58DP003879 from the CDC. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.
      The publication of this supplement was made possible through the CDC and the Association for Prevention Teaching and Research (APTR) Cooperative Agreement No. 1 U360E000005-01. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC or the APTR.
      No financial disclosures were reported by the authors of this paper.

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