Introduction

Comprehensive cancer control (CCC) coalitions are made up of key cancer control stakeholders—both organizations and individuals that are engaged in the work of cancer control separately—and come together to identify shared goals and outcomes that focus on shared goals of fighting cancer, improving health outcomes, and reducing the burden from cancer.

The forming of a group of individual organizations presents a multitude of opportunities as well as challenges. Leveraging and creating opportunities and minimizing or addressing challenges are key to effective, efficient, and outcome-driven CCC coalitions.

CCC coalitions are often referred to as the “engines of change” for cancer control in the United States [1]. The development, implementation and evaluation of state, tribe, territory, and jurisdiction cancer plans are the mission of CCC coalitions. These “engines of change” conduct their work through collaborative, coordinated, and value-added efforts. However, creating, managing, and maintaining a CCC coalition does not just occur organically. Thoughtful, purpose driven, and sustained leadership and partnership is necessary for the coalition to achieve its ongoing mission.

The Nine Habits of successful CCC coalitions (Nine Habits) [2] were developed recognizing the unique and powerful potential of CCC coalitions. Based on coalition, partnership, community action evidence, the Nine Habits take into account the variation of membership, leadership, organizational structure, and communications among the U.S. CCC coalitions, and identify the key successful elements that are common among these coalitions. The Nine Habits guide incorporates questions at the beginning of each habit section to enable coalitions to assess their functioning or performance in relationship to that Habit. The guide promotes discussions so that coalition members can think about their coalition from a different perspective.

In this article, the development and the use of the Nine Habits are described by illustrating how they were developed and used nationally. The article also describes how two individual CCC coalitions incorporated them into their coalition. Aristotle once said, “We are what we repeatedly do. Excellence then, is not an act, but a habit.” The Nine Habits were designed to assist CCC coalitions to refine and drive their successful work on cancer control and strive to achieve excellence.

Development of the Nine Habits of successful CCC coalitions guide

The Nine Habits are based on an evaluation supported and conducted in 2011 by the U.S. Centers for Disease Control and Prevention (CDC) and the American Cancer Society (ACS) with assistance from Southeast Program Evaluation, Inc.

A literature review was conducted to identify key elements of coalition functioning, coalition evaluation strategies, and examples of coalition evaluation tools that provided a foundation for the evaluation conducted by CDC and ACS. The literature review was initiated using specific search terms, phrases, and well-known authors. Using electronic search engines including Pubmed, search terms were used to generate citations. The citations were screened to identify literature to be included in the review and the selected articles were retrieved and reviewed [3]. The literature review helped inform an online survey of CCC coalition members across the nation. The survey assessed factors related to coalition functioning, organizational characteristics and processes, coalition impact and outcomes, and technical assistance needs. Based on the characteristics identified through the online survey, coalitions were scored and characterized as high, medium, or low functioning. Key informant interviews were conducted with high-functioning coalitions to identify critical success factors, relationships with national partners, and technical assistance needs related to functioning. A survey instrument was developed to guide interview questions, which included 14 questions related to assessing factors that contribute to coalition performance level and the role of technical assistance. A total of 25 qualitative interviews with individuals from 17 coalitions were conducted. Eleven were in paid staff positions for the past 2–4 years. The other 14 were volunteers involved with the coalition. Many of them had been with their coalition since its inception or for “many years” and had occupied various positions, from coalition member to chair/co-chair of a workgroup to overall chair/vice-chair [4]. Based upon the qualitative data collected through interviews, factors or characteristics of successful CCC coalitions were identified.

Key informant interviews revealed three general categories of characteristics that play a strong role in identifying high-performing coalitions. The characteristics relate to how the coalition is structured, how it organizes its work and develops work plans, and how the work plans are implemented. Similar characteristics of high-performing coalitions were seen from the quantitative survey results, which are summarized in Fig. 1 below with examples from high-performing coalition members interviewed [4].

Fig. 1
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Characteristics of high-performing CCC coalitions

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The Comprehensive Cancer Control National Partnership (CCCNP), working with Strategic Health Concepts (SHC), used the results of the evaluation to guide the development of a set of practical guidelines for CCC coalitions, with the intention of offering technical assistance to improve coalition functioning and to provide real-life CCC coalition models of success that could be emulated by all CCC coalitions. The Nine Habits and a brief explanation of each are shown in Table 1.

Table 1 The Nine Habits of successful CCC coalitions
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The Nine Habits were presented to all state, tribe, territory, and Pacific Island Jurisdictions in a series of on-site workshops in 2012–2013, including a pilot workshop that resulted in refinement of the Nine Habits [5].

Based upon CCC coalition interest in the Nine Habits during the workshops, CDC and ACS worked with SHC to create a written guide for CCC coalitions. SHC gathered information through an informal email survey of CCC program directors and CCC coalition leaders to understand what would be useful in a written guide and how it could best be disseminated. The email survey was sent to 18 individuals from 13 coalitions. Responses were received from 11 individuals from 10 different coalitions. The written guide was released in 2014 [2]. The Nine Habits Guide is currently being updated by the CCCNP.

National use of the Nine Habits of successful CCC coalitions

As noted above, it was during a series of technical assistance workshops for CCC coalition leaders in 2012–2013 that the Nine Habits of successful CCC coalitions coalesced. Drawing from published studies [6, 7] which suggest that most state or local public health practitioners learn about new research via seminars or workshops, the CCCNP embarked on a series of in-person workshops to enhance the uptake of the Nine Habits.

In August and September 2012, CCCNP representatives facilitated two interactive sessions: Ideas to Action: Making an Impact through Your CCC Coalition at the State and Tribal CCC Technical Assistance Workshops [8]. These workshops served as a pilot for the 9 Habits and perspectives shared by workshop attendees were integrated into subsequent content.

In March 2013, representatives from 10 US Pacific Island Jurisdiction (PIJ) CCC coalitions participated in a technical assistance workshop modeled on the 9 Habits. In a survey that followed the session, participants noted the training helped elucidate the practical applications of “PSE strategies” by using the Nine Habits as a framework for implementing PSE changes through CCC coalitions.

Most recently, in August 2017, the CCCNP convened a Sustaining Effective Comprehensive Cancer Control Coalitions Workshop. Participants noted in a follow-up survey that the Nine Habits framework helped them understand how other coalitions have applied the framework to their coalition’s efforts. Of note, participants valued how the tool helped them identify strengths and challenges for their CCC coalition.

Strategic health concepts also used the Nine Habits as their framework for a series on the Research to Reality cancer control community of practice. The National Cancer Institute convened this online community of practice from 2011 to 2018 [9]. This series of nine “Coalition Corner” discussion posts generated 33 posts in response to the questions posed by the authors. The three posts that generated the highest response (greater than 6 published responses) were those that featured lessons learned and resources from several CCC coalitions.

National efforts to develop and present the Nine Habits suggest that the framework provides not only a helpful guide to effective coalition management but a framework for cancer control practitioners to share resources and experiences.

Pennsylvania’s use of the Nine Habits

The Pennsylvania Comprehensive Cancer Control Program (CCCP) is the recipient of the U.S. Centers for Disease Control and Prevention’s Comprehensive Cancer Control grant. The Pennsylvania Cancer Coalition (Cancer Coalition) is responsible for the development and implementation of the state’s cancer control plan. The successful rebuilding of the Cancer Coalition was the result of Pennsylvania CCCP’s efforts guided by the Nine Habits [10, 11], and committed stakeholders.

During 2011–2012, the CCCP began rebuilding its cancer partnerships and infrastructure to engage a broader and more diverse group of partners to reduce the burden of cancer in the state, after Pennsylvania’s former cancer coalition dissolved. The Pennsylvania Cancer Control Prevention and Research Advisory Board (CAB) is legislatively mandated to advise the Secretary of Health with respect to cancer control, prevention, and research in Pennsylvania. The CAB assumed a broader leadership role to guide CCC activities by forming the Plan Steering Committee (PSC) (later to become the Pennsylvania Cancer Coalition). The new Cancer Coalition in Pennsylvania was convened to initiate the process of rebuilding a state coalition and to oversee the revision of the state cancer plan. The Cancer Coalition reports directly to the CAB and is not a 501(c)(3). The CCCP conducted an evaluation of former coalition member organizations to determine which efforts had the greatest potential to facilitate reaching plan goals, supporting stakeholder meetings, and communicating among members.

The scope of the new Cancer Coalition became (1) to plan, develop, implement, and evaluate the Pennsylvania Comprehensive Cancer Plan (Plan); (2) to identify effective approaches to cancer control implementation priorities; (3) to strengthen coalitions and partners in exchanging information and to identify and utilize resources; and (4) to identify areas that needed evaluation in relation to the development and delivery of cancer prevention and control efforts.

The new coalition held their first meeting on 29 August 2012. The following month, representatives from the CAB, the Cancer Coalition, CCCP, and the American Cancer Society attended a two-day workshop, titled “From Ideas to Action: Making an Impact through Your CCC Coalition” sponsored by the CCCNP in Atlanta Georgia, as listed above in September 2012. The group spent 2 days learning about the Nine Habits and assessing where Pennsylvania was in relationship to the Nine Habits while developing a work plan for Pennsylvania. The team prioritized the habits of empowering leadership, value-added collaboration, and clear roles and accountability at the workshop as key areas for development of the new coalition.

Simultaneously, the first Cancer Coalition meeting and the workshop played an important role in developing the commitment and engagement of stakeholders, maintaining momentum, defining clear roles, and fostering effective communication in the early stages of the coalition’s development. The Nine Habits became the roadmap to rebuilding the Cancer Coalition in Pennsylvania.

The workshop reaffirmed the strategic plan the CCCP had in place for moving forward. Now in its infancy, the Cancer Coalition representatives that participated in the workshop presented their newly gained knowledge from the Nine Habits to the CAB and full Cancer Coalition at subsequent meetings to ensure that the knowledge and skills learned at the conference were effectively communicated to all staff of the CCCP, the CAB, and the Cancer Coalition.

The CCCP utilized the following methods in building the Cancer Coalition: (1) strategic engagement; (2) identification of key stakeholders; (3) conducting in-person meetings with key partners (including members of the prior coalition); (4) identification of communication as key with stakeholders; and (5) roles and priorities previously identified by the Cancer Coalition (Table 2).

Table 2 How the CCCP and the cancer coalition implemented the Nine Habits
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The rebuilding of the Pennsylvania Cancer Coalition was guided by the Nine Habits, as well as by lessons learned. Membership of the Cancer Coalition includes organizations strategically positioned to implement plan activities and priorities effectively across the state of Pennsylvania. To achieve this goal, the membership is diverse and represents various sub-groups. The engagement of the coalition is critical to the success of the implementation of the plan. The success of the new Cancer Coalition can be attributed to many key principles and strategies employed to ensure coalition engagement. Specifically, (1) providing a sense of purpose, (2) clear roles and accountability, (3) shared decision making (including an understanding of the decision-making process), (4) effective communication, (5) flexible structure, (6) dedicated staff support at all levels, (7) availability of high-quality surveillance data, (8) coalition satisfaction surveys, (9) addressing the issues of the coalition, and (10) funding. These principles provided the Cancer Coalition with wider credibility and reach, more so, than any one individual member or organization could provide. There is a collaborative range of advice and perspectives on any given topic.

Key to the successful rebuilding of the Cancer Coalition was the application of the Nine Habits tools. The tools and the dedication of the CCCP staff have contributed to the long-standing engagement of the coalition. Sharing of evaluation results and taking into consideration member concerns and suggestions served to re-energize members and establish increased value of membership. While coalition members are volunteers, it is important to recognize they generally have other full-time commitments. Dedicated CCCP staff support is essential. However, the Cancer Coalition, in collaboration with the CCCP staff, has been able to successfully strategize and identify solutions to maintain momentum.

The Pennsylvania Cancer Coalition has grown in membership over the last eight years from seven members to over 260 individuals and organizations. The Pennsylvania Cancer Coalition was successfully rebuilt due to the dedication and endless energy of many individuals, implementation of the Nine Habits, and Plan develop during the time of rebuilding. The Nine Habits tool is continually utilized to support the Cancer Coalition and advance the priorities of the Cancer Coalition and CCCP.

Wisconsin’s use of the Nine Habits

The Wisconsin Cancer Council is Wisconsin’s CCC coalition. It is a coalition of diverse organizations dedicated to the implementation of the Wisconsin Comprehensive Cancer Control Plan. The Wisconsin Cancer Council was founded in 1980 by the University of Wisconsin Carbone Cancer Center and the American Cancer Society-Wisconsin Division. In 2002, the Wisconsin Department of Health Services received a planning grant from the CDC and partnered with the University of Wisconsin Carbone Cancer Center, home to the Wisconsin Cancer Council, to establish the state’s first comprehensive cancer control plan and in 2005, the Wisconsin Cancer Council and its partners developed the first Wisconsin Comprehensive Cancer Control Plan 2005–2010.

Since 2005, the Wisconsin Cancer Council, staffed and facilitated by the Wisconsin Comprehensive Cancer Control Program staff, experienced rapid growth, going from 40-member organizations to 119-member organizations in just 10 years. However, the rapid growth was met with declining member engagement. With the release of the third edition of the Wisconsin CCC Plan and decreased member engagement, the Wisconsin CCC Program and Wisconsin Cancer Council Steering Committee identified a need to review and revitalize the Wisconsin Cancer Council to better engage diverse partners to implement the statewide comprehensive approach to cancer control.

To assess member engagement prior to any changes, a survey was administered to Wisconsin Cancer Council members and partners in January 2016. At the time of the survey, members and non-members received similar benefits and little distinction was made between the two groups. Consequently, the survey was sent to both members and non-member partners. 1408 people were surveyed. 913 of the people surveyed were affiliated with a member organization and the remaining 520 people were either individual members or were affiliated with non-member organizations. 147 respondents completed the survey, a 10.4% response rate.

The one-year revitalization process, framed by the Nine Habits, set out to address the needs identified in the member survey. The process began in January 2016 with three objectives: re-engage members; improve benefits offered to members to support local cancer control efforts; and to enhance the Wisconsin Cancer Council’s structure to help sustain improvements.

The process was facilitated by Wisconsin CCC Program staff and led by a diverse group of 14 Wisconsin Cancer Council members named the Leadership Team. The Leadership Team met nine times, by webinar and in-person, from January 2016 to February 2017. The first meeting introduced Leadership Team members to the revitalization’s objectives and an overview of the Nine Habits, presented by Strategic Health Concepts.

After the first meeting, every meeting agenda item was framed by the specific habits that related to the topic being discussed. A one-page summary of the Nine Habits was included in Leadership Team members’ meeting material as a reference. Discussion items included: benefits of being a member; types of organizations and experts to engage; how to engage members; revising the membership structure; creating an online member application; priority work plans; and a vision for the future. Halfway through the revitalization process, a lengthier conversation also took place to reassess the Nine Habits’ integration into the Leadership Team’s efforts. With the Nine Habits’ guidance, the Leadership Team made several recommendations to improve the Wisconsin Cancer Council. As a result, several changes were made, summarized in Fig. 2.

Fig. 2
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Changes made as result of Wisconsin Cancer Council’s use of Nine Habits

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Another survey was administered to Wisconsin Cancer Council members in January 2018 to assess the effectiveness of the revitalization process in reengaging members. 196 people were surveyed, and all were Wisconsin Cancer Council members, either affiliated with member organizations or as an individual member. 84 people completed the survey, which was a 43% response rate, up by 32.6% from 2016.

Data limitations exist given the change in 2018 to a members-only survey. It can be assumed that the 2018 survey respondents come from the more engaged members and partners surveyed in 2016, resulting in higher response rate and more favorable responses to the effectiveness of the Wisconsin Cancer Council. Future surveys with similar survey samples will provide a more accurate comparison than those in 2016 and 2018.

Despite this limitation in data, the survey results indicated members have an increased awareness of the information and resources available to members to assist Wisconsin CCC Plan 2015–2020 implementation (see Chart 1). Respondents also indicated greater satisfaction with the Wisconsin Cancer Council’s facilitation of networking and collaboration opportunities (see Chart 2). These results indicate that the Nine Habits’ incorporation into the revitalization process clarified the role of Wisconsin Cancer Council members and preliminarily showed an increase in the coalition’s effectiveness in addressing comprehensive cancer control in Wisconsin. A comparison of 2016 and 2018 Wisconsin Cancer Council member applications which collects their Wisconsin CCC Plan 2015–2020 implementation activities will provide another opportunity to more closely assess the coalition’s effectiveness before and after changes were made using the Nine Habits guide.

Chart 1
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Wisconsin Cancer Council Member awareness of resources to implement the WI CCC Plan 2015–2020

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Chart 2
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Wisconsin Cancer Council’s facilitation of networking/collaboration outside organization

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Since the 2016 revitalization process, the Nine Habits were an instrumental guide in developing in the Wisconsin Cancer Council’s Priority Work Plans. Using processes outlined in the Nine Habits, the Wisconsin Cancer Council collectively selected three priority areas and created corresponding action plans: raising awareness of the alcohol-cancer connection; increasing HPV vaccination rates; and improving cancer screening rates, a habit included in the resource.

The Nine Habits continues to be a helpful tool for the Wisconsin Cancer Council and Wisconsin Comprehensive Cancer Control Program. New members of the Wisconsin Cancer Council Steering Committee will be given an overview of the Nine Habits in their orientation and it will continue to be used as a framework to support and engage Wisconsin Cancer Council members.

Moving forward

The CCCNP Sustaining Coalitions workgroup, established in 2016, adopted the Nine Habits as its framework for developing technical assistance and training programs for CCC coalitions. The workgroup began its work with hosting a one-day Nine Habits technical assistance workshop for NCCCP grantees and CCC coalition chairs in August 2017. After reviewing the workshop evaluation, the Sustaining Coalitions workgroup launched a three-part webinar series on the Nine Habits in the summer of 2018. The webinar series focused on the top three habits identified in the workshop evaluation as well as other feedback received by the NCCCP grantees and coalition chairs. The top three habits were empowering leadership, priority work plans, and diversified funding.

Going forward, efforts are underway by the workgroup to refresh the Nine Habits and to develop a dissemination plan. Additional technical assistance and training activities for CCC coalitions will be offered.