Under its Evidence-based Practice Program, the Agency for Healthcare Research and Quality (AHRQ) is developing scientific information for other agencies and organizations on which to base clinical guidelines, performance measures, and other quality improvement tools. Contractor institutions review all relevant scientific literature on assigned clinical care topics and produce evidence reports and technology assessments, conduct research on methodologies and the effectiveness of their implementation, and participate in technical assistance activities.
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Overview / Reporting the Evidence / Methodology / Findings / Future Research / Final Comments / Availability of Full Report
The burden of illness imposed on society as a result of cancer represents a major issue in health care through out the world. Within the United States, cancer is the second leading cause of death. As a result, significant resources are directed towards research into cancer control. This includes a broad spectrum of basic and applied research in the behavioral, social, and population sciences. Such research covers the continuum of cancer control from prevention to early detection to diagnosis to treatment to end-of-life care. However, the impact of these advances in cancer control research is limited by the failure to transfer new, evidence-based findings into the widespread delivery of both individual and population health care. Recognition of this problem has prompted research initiatives investigating methods to assist the dissemination of new knowledge to a larger target audience, one that includes providers, policy makers, and the general public.
A variety of models of behavior change and theoretical frameworks have been developed to try to explain the process by which new knowledge is generated and disseminated to a broader audience. However, this process is hampered by diverse terminology and inconsistent definitions of terms such as diffusion, dissemination, knowledge transfer, uptake or utilization, adoption, and implementation.
Much of the research to date has focused on interventions to promote behavior change among health care providers (a group that includes physicians, public health professionals and allied health care practitioners). A recent review by the Cochrane Collaboration's Effective Practice and Organization of Care (EPOC) Group found that interventions that are considered more active, such as health care provider reminders, educational outreach, and the use of opinion leaders, were effective in changing health care provider behavior. Multi-component interventions were more likely to result in behavior change than single interventions. No single intervention was effective under all circumstances. Less active interventions, such as conferences, medical journals, or mailed clinical practice guidelines, were not effective in changing provider behavior. The EPOC review was not specific for cancer control research.
The goals of this evidence report were:
Preliminary research questions included:
A multidisciplinary research team was assembled with participation of members of the National Cancer Institute (NCI)—the topic-nominating organization—the Agency for Healthcare Research and Quality (AHRQ) Task Order Officer (TOO), invited technical experts, plus local experts and research staff from McMaster University. Discussion within this group led to a refinement of these preliminary questions.
The refined objectives were defined as:
Objective 1: What is the effectiveness of cancer control interventions to promote the uptake of cancer control behaviors?
Objective 2: What strategies have been evaluated to disseminate cancer control interventions?
During the initial consultation process, it became apparent that the topic area was too large to consider the entire cancer control continuum. Five topic areas were identified for this evidence report based on NCI priorities. These were: smoking cessation, healthy diet, mammography, cervical cancer screening and control of cancer pain. This generated a total of ten key questions:
Objective 1:
Objective 2:
The first objective of this evidence report was addressed by a review of systematic reviews examining the effectiveness of cancer control interventions in each of the five topic areas. The second objective was addressed by a systematic review of primary studies evaluating strategies to disseminate cancer control interventions in each of the five topic areas. The following criteria were used to select published articles for review and included:
Objective 1. What is the effectiveness of cancer control interventions to promote the uptake of cancer control behaviors?
Systematic reviews conducted on individuals (patients, clients, consumers, or the general public) or health care providers were considered for inclusion if they were in English, published no earlier than 1990, and addressed one of the five topic areas. A review was considered to be systematic if it had stated inclusion criteria for primary studies and had explicitly identified methods used in the review. Reports exclusively focused on children or adolescents were excluded.
Objective 2: What strategies have been evaluated to disseminate cancer control interventions?
Primary studies were considered for inclusion if they were in English, published no earlier than 1980 and evaluated dissemination of a cancer control intervention in one of the five topic areas. All primary studies, regardless of study design, were eligible for inclusion. Reports exclusively focused on children or adolescents were excluded.
Search strategies were developed as an iterative process in consultation with the McMaster Evidence-based Practice Centre (EPC) librarian. Similar databases were searched for both objectives, including: MEDLINE® (with HealthSTAR), PREMEDLINE®, CANCERLIT®, EMBASE, PsychINFO, CINAHL®, Sociological Abstracts, and the Cochrane Database of Systematic Reviews (CDSR). Additional reviews and articles were identified from reference lists of pertinent articles and reviews or were suggested by technical experts.
All data extraction forms were developed, pilot-tested, and revised by members of the local research team. Two reviewers completed data extraction independently for all reports. Any disagreements were resolved by consensus. Differences that could not be resolved by these reviewers were discussed by the local research team. Quality assessment was undertaken using standardized quality assessment tools developed by the Effective Public Health Practice Project.
Evidence and summary tables were constructed to describe the most salient characteristics of the eligible studies. Evidence tables were generated to summarize, by topic, all information extracted from the study reports. These tables are found at the end of each chapter along with the relevant supplementary tables. Meta-analysis was not undertaken because there were substantial differences across the studies, in terms of study design, intervention assessed, outcome measurements, methodological quality, and completeness of data reporting. Therefore, the report represents a systematic narrative review of the existing evidence, emphasizing the implications for practice and the opportunities to fill existing knowledge gaps.
More than 5,000 titles and abstracts were identified in the literature search for the review of systematic reviews. Full text screening was performed on 232 retrieved papers, data extraction was undertaken on 79 reports, and 41 unique studies are presented in the evidence tables. The weighted kappa for agreement on study inclusion was 0.6367 (95% Confidence Interval [95%CI] = 0.53-0.75).
More than 6,000 titles and abstracts were identified for the review of primary studies of dissemination strategies. Full text screening was performed on 456 retrieved papers, data extraction was undertaken on 40 reports and 31 unique studies are presented in the evidence tables. The weighted kappa for agreement on study inclusion was 0.5329 (95%CI = 0.31-0.76).
The primary objective of the report was to determine what strategies have been evaluated to disseminate effective cancer control interventions more widely in the five topic areas examined along the cancer control continuum. The assessment of published systematic reviews provides an overview of the state of evidence regarding interventions to promote the uptake of behavior change. There are some findings from these reviews that are generalizable across the topic areas:
Smoking cessation interventions found to be effective in this review include:
Effective multi-component interventions include office reminders combined with physician training, with or without patient education.
There is some evidence that physician education in dietary counseling is an effective dietary intervention. However, there is no consistent evidence of effectiveness of other health care provider-directed interventions. Interventions directed at individuals that were shown to have some effect in producing dietary change include:
Media campaigns may result in increased knowledge and awareness of behaviors to reduce risks.
Interventions that have been consistently shown to be effective for increasing mammography are:
Effective interventions to promote uptake of cervical cancer screening include office systems (computer or manual chart reminders), and invitations and reminders to individuals. There is limited evidence of effectiveness for educational materials, telephone counseling, removal of financial barriers, media campaigns, and advice from health care providers.
There is inadequate data regarding effective interventions for the control of cancer pain. Promising interventions include the transmission of patients' self-reported pain scales to oncologists, pain education for nursing staff, and the use of daily pain diaries.
Fifteen primary studies were identified in the systematic review of dissemination strategies for smoking cessation activities. The majority of these used nonrandomised designs to evaluate the dissemination strategy. There was no strong evidence of effective dissemination strategies for smoking cessation interventions.
Train-the-trainer approaches improve knowledge and awareness of the smoking cessation issues among health care providers, but there is no evidence they impact on advice to quit smoking or on smoking cessation rates. Several studies evaluated the use of educational facilitators to disseminate smoking specific information, or information about multiple preventive behaviors. Overall, preventive services appear to be increased but the specific impact on smoking cessation activities is more uncertain. Several studies examined the importance of different media sources for recruitment of patients or their families to use the Cancer Information Service (CIS). Media awareness campaigns, in particular those using television, are important strategies to disseminate information about CIS help lines.
There are few studies evaluating dissemination strategies to promote the uptake of a healthy diet. Seven studies were included in the review of strategies to promote an adult healthy diet. Many of the studies identified are primarily descriptive rather than evaluative. The use of educational facilitators to promote the use of office systems by health care providers shows some promise at improving the provision of preventive services in community practices. One additional study, using peer educators in the worksite, did demonstrate some short-term increase in dietary fruit and vegetable intake.
Only six studies were identified that examined dissemination strategies for mammography. These were predominantly targeting health care providers. Several studies examined the use of educational facilitators to promote the use of office systems. They provide mixed results for disseminating office system interventions. Overall, there is insufficient evidence to conclude that any dissemination strategy is effective at increasing mammography.
There were four studies identified in the review of dissemination of cervical cancer screening interventions. These studies examined the use of educational facilitators to disseminate office systems (for health care providers), or media awareness campaigns to disseminate information about the CIS. These studies all examined cervical cancer screening as one of a number of topic areas. Educational facilitators appeared to increase overall indicators of preventive care. However, there was no statistically significant increase in cervical cancer screening rates. There is no evidence for effective strategies to disseminate interventions to promote cervical cancer screening.
Three studies were included in a review of strategies to disseminate interventions for control of cancer pain. There is a lack of research examining dissemination of interventions to promote effective pain control. Dissemination of a treatment algorithm for pain management produced only short-term change in provider adherence. Cancer pain role-modeling programs were shown to improve process measures such as knowledge and education of other health care providers. However, no information is given on integrating pain assessment into clinical practice.
This evidence report identified a number of effective cancer control interventions designed to change provider or individual behavior. However, it also identified a need for research into strategies to disseminate these interventions into routine care. There are methodological issues that should be considered in future research:
There are other topics within the cancer control continuum that were not addressed in this evidence report. As dissemination approaches may vary across topic areas, there is a need for further systematic reviews to synthesize available data in these areas too.
Future systematic reviews should consider the following:
There were some suggestions for future research that were common across several of the five topic areas examined in this evidence report. Those issues, along with a number of more general considerations that should be considered in undertaking future research examining diffusion and dissemination of cancer control interventions, include:
Additional topic specific suggestions for future research are summarized in the report.
Much of the focus of dissemination research in the cancer continuum to date has been evaluating interventions to promote behavior change. This evidence report highlights the lack of data on how to disseminate these findings into the community. There is a need to prioritize some of the suggestions above. Additionally there is a need for National agencies to provide leadership and funding for future dissemination research.
The full evidence report from which this summary was derived was prepared for AHRQ by the McMaster University Evidence-based Practice Center under contract number 290-97-0017. Printed copies may be obtained free of charge from the AHRQ Publications Clearinghouse by calling 800-358-9295. Requesters should ask for Evidence Report/Technology Assessment No. 79, Diffusion and Dissemination of Evidence-based Cancer Control Interventions.
The Evidence Report can also be downloaded as a zipped file online at: www.ahrq.gov/clinic/evrptfiles.htm#cancontrl.
AHRQ Publication Number 03-E032
Current as of May 2003
Internet Citation:
Diffusion and Dissemination of Evidence-based Cancer Control Interventions. Summary, Evidence Report/Technology Assessment: Number 79. AHRQ Publication Number 03-E032, May 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/epcsums/canconsum.htm
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