Introduction

The development of the 2011–2015 Alabama Comprehensive Cancer Control Plan is the culmination of two decades of ongoing collaboration among statewide organizations and individuals committed to improving the state’s cancer incidence and mortality rates.

In 1989, the Alabama Department of Public Health (ADPH) participated in an organization-wide strategic planning process for which specific programmatic areas developed strategic plans. A cancer control strategic planning committee consisting of eight members was appointed by the State Health Officer. These original members represented the state health department, academic medical institutions, and the clinical oncology community. Additional individuals, organizations and agencies were consulted during the development of the plan to assure that the proposed goals, objectives, and strategies were appropriate and inclusive. The first statewide comprehensive plan for cancer control in Alabama was a product of this process. In July 1998, the Cancer Prevention Branch of the Alabama Department of Public Health initiated a review for the purpose of updating the plan to carry forward cancer prevention into the next century.

The original committee members were contacted to participate in this revision, and a newly formed Comprehensive Cancer Control Core Work Group (CWG) provided the vision and leadership to expand the scope of the original plan. The work continued until the full Alabama Comprehensive Cancer Control Coalition met in September 2001 to adopt the 2001–2005 Plan. A competitive grant awarded the same year from the Centers for Disease Control and Prevention (CDC) to the Alabama Department of Public Health provided the necessary funding to begin statewide implementation. The original 2001–2005 Plan had seven main sections (Prevention, Early Detection, Treatment and Care, Environmental and Occupational Health, Research, Surveillance, and Evaluation) with a total of 53 objectives.

The release of the 2006–2010 Plan expanded on the framework of the 2001–2005 Plan and focused on cancer disparities with added sections on cancer survivorship and emerging cancer research. Differences in cancer experiences vary considerably across populations and cancer control approaches have been reviewed [1, 2]. Also, a much greater emphasis was placed on primary prevention including proper nutrition and weight management, regular physical activity, tobacco prevention or cessation, and protection from over-exposure to ultraviolet light. The 2006–2010 Plan had six main sections (Prevention; Early Detection; Survivorship; Environmental, Medical and Occupational Exposure; Surveillance; and New and Emerging Research), and expanded the total objectives from 53 to 126. As predicted in the 2006–2010 Plan, lifestyle choices would be the health focus for the 21st century. Peer education, community-based interventions, and improved access to preventive health care would support Alabamians in making better lifestyle choices, and would help the state continue to make progress in the battle against cancer.

The original organizational structure of the ACCCC has been an effective basis for developing Plan objectives and their implementation; however, the structure was not broad enough to meet the challenge of updating the Plan for 2011–2015. Therefore, a new planning process and timeline were adopted to ensure timely completion of the 2011–2015 Plan.

The purpose of this paper is to describe the planning and implementation process for development, writing, delivery, and evaluation of the 2011–2015 Alabama Comprehensive Cancer Control Plan. Comprehensive cancer control implementation building blocks have been recently described by Given [3]. The Plan itself, along with detailed goals and objectives for the control of cancer in Alabama, can be found at http://www.alabamacancercontrol.org/ and on the Cancer Control Planet website along with other state plans (http://www.cancercontrolplanet.org).

Materials and Methods

The ACCCC conducts regular business at quarterly meetings scheduled in Montgomery where the Alabama Department of Public Health is located. Additional planning sessions with key individuals are scheduled in Birmingham as needed. The process measures selected for this review include the number of planning meetings, attendance at planning meetings, and evaluation of Coalition member satisfaction. Table 1 shows the objectives for each meeting, as well as the short term outcomes. On average about 42 persons attended the quarterly meetings; a total of 169 attended in 2010 and 165 in 2011.

Table 1 Description of meetings, objectives, and follow-up outcomes for the Alabama comprehensive cancer coalition cancer plan 2011–2015
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Results

Evaluation

In early 2010, the ACCCC partnered with the University of Alabama at Birmingham (UAB), Division of Preventive Medicine, to evaluate implementation of the Plan and to assess ongoing activities and operations of the Coalition. A self-administered survey was given to measure coalition satisfaction. Survey participantion was anonymous and the instrument was approved by the UAB Institutional Review Board (IRB). The survey took 10–15 min to complete and 28 participants provided responses. On average, the members surveyed had been members for 4 years (range 1–12 years). The content areas in the survey included communication; mission; meeting logistics, participation, and decision making; personal satisfaction; coalition leadership; organizational involvement; and capacity building. The responses to each item were on a Likert scale with 1 = very dissatisfied and 5 = very satisfied. For each survey item the mean, median and range were reported.

Overall, the results of the survey indicated high satisfaction with development of Coalition objectives and goals. Respondents surveyed gave high scores to the materials and agenda prepared for meetings in advance and to the timely notification of meetings. Members agreed that the ACCCC had strong leadership and stated that they felt confident in expressing their ideas and opinions, and speaking out at meetings. In addition, members stated that their organizations were very supportive of the ACCCC and that they frequently relied on the Coalition as a resource for cancer information.

More than half (63.0 %) of respondents agreed that the organization provided orientation for new members and 70.4 % indicated that the ACCCC reviewed its mission, goals, and objectives periodically. Nearly all (96.3 %) indicated the ACCCC had a supportive environment with appropriate attention to planning for the future (88.9 %). Members were generally satisfied with the Coalition’s working committees.

Members were supportive of the election process for Coalition leadership, but also wanted more information on the slate of candidates, including a short biosketch of each member. Ideas for attracting new members included improving diversity of speakers at quarterly meetings, advance promotion of upcoming meetings, and bringing guests to meetings. Most members indicated that their organization acknowledged the ACCCC activities through supporting attendance and assisting with transportation costs.

Plan Objectives and Strategies

The UAB-led evaluation team, along with the ADPH Coalition staff, adopted the framework of Healthy People 2020 [4] for the evaluation of 2006–2010 objectives. The Committee agreed that baseline data (e.g., smoking rates, mammograms performed) were essential, and if unavailable, proposed means to obtain this baseline information should be described. The objectives were to drive strategies that can be achieved by 2015 and the objectives should be supported by evidence-based interventions and strategies. Whenever possible, the objectives should address disparities, including a method for quantifying the disparity (by race, ethnicity, gender, or socioeconomic status) with population-based data. The ACCCC agreed that all of the objectives should be data-driven utilizing valid, reliable state data in the public domain with assurance of data points throughout the Plan period. The objectives from the 2006–2010 plan were reviewed by our sub-committees for content area, and the disposition of each objective was categorized as retain, retain with modifications, archive, or develop a new objective.

The ACCCC conducted a formal evaluation through Committee member input in April 2010 to initiate the process of reviewing the Plan’s objectives. A total of 42 members assisted with this process, resulting in realignment of the Plan to include the following content areas: Primary prevention to include (1) Tobacco Use; (2) Nutrition and Weight Status; (3) Physical Activity and Fitness; (4) Ultraviolet Light and Ionizing Radiation Exposures; (5) HPV and Cancer Vaccines; Secondary Prevention to include (6) Early Detection (Breast, Cervical, Colorectal, Prostate, Melanoma); (7) Genomics; and Tertiary Prevention to include (8) Treatment and Clinical Trials (9) Survivorship, Follow-up and Palliative Care; and (10) Health Information Technology (IT), Health Communication, and Surveillance. The objectives were stratified within each content area by Adult, Youth, and Policy objectives. Health education and community-based programs are considered as strategies under the thematic objective areas. The ACCCC committees recommended these content areas as they were better aligned with Healthy People 2020 areas, and because reordering of the Plan in this fashion would facilitate cross-referencing between State and National Data. The Plan would facilitate the use of data metrics across the human lifespan, and would allow for the inclusion of socioeconomic status (SES) and demographic measures in drafting and evaluating relevant objectives. At the quarterly spring 2010 meeting, a chairperson was designated for each topic and was charged with leading the discussion and collecting written comments from each session. The results were analyzed by a subcontractor and a formal report was delivered in May 2010 to the Coalition’s Executive Committee. The implementation records were summarized in a format that matched the objectives in the current Plan.

Table 2 shows an example of objectives for tobacco cessation that were under consideration for the Plan’s revision. For each objective, available data were reviewed and compared to state and national targets. The chair submitted written comments for each objective, and the draft edits were available for comment by the entire membership at the following quarterly meeting.

Table 2 Example of tobacco objectives for used in 2011–2015 planning
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For some topic areas, particularly in cancer screening, there was lengthy discussion because there had been national debate over guidelines (especially for breast and prostate cancers) addressing topics such as age criteria and risk history. In these instances, an iterative process was carried out with several draft objectives and strategies that were updated as new information became available.

Drafting of Plan and Editing

The ACCCC met again in July 2010 and discussed progress based on the early drafting of the objectives. The July meeting was focused on preparation of strategies for each objective and advocacy goals. The Alabama Comprehensive Cancer Control Plan was divided into sections that address topics relevant to cancer control in Alabama. The narrative material that introduces each section and subsection covers information about current prevalence and mortality, and the particular activities and programs that are working to decrease cancer incidence and mortality rates in the state.

The objectives in each section are based on the most current data available. Significant consideration was given to each objective and strategy to ensure all population cohorts were addressed. Each section includes the following: an overall goal, objectives (including baseline and target objectives), information sources, and strategies. The goal statements reflect long-term aspirations and are meant to guide the direction of Alabama’s cancer control activities. Objective statements provide target measures that the ACCCC will work toward by the year 2015. Where applicable, these measures are based on Healthy People 2020 recommendations. Some statements do not include baseline data; in these cases, ACCCC planned to establish these baselines and set appropriate targets to be met by the end of the five-year period.

Objectives were listed by alphanumeric identifiers with the section (TU = Tobacco, NWS = Nutrition and Weight Status, PAF = Physical Activity, UV = Ultraviolet Light, EH = Environmental Health, I = Infectious, C = Cancer (Early Detection), G = Genomics, TR = Treatment, S = Survivorship and HC = Health Communications) followed by AL (for Alabama) and the years 2011–2015; and the chronologic number of that objective, designed to align with Healthy People 2020 terminology where possible.

“Strategies” are specific activities designed to accomplish the objectives. Key entities are partners who are agencies, organizations, or programs that have primary responsibility or involvement for a given activity. Other partners have a supportive role to play in achieving the given strategy and may be associate members of the ACCCC whose mission may not be strictly relevant to cancer prevention and control. Other individuals, organizations, and programs that can provide resources for cancer control research are also a major component in the Plan. ACCCC has included specific research goals, outcomes, and objectives in each section to allow for a greater dialogue between clinical and non-clinical providers, policy makers and researchers.

Final editing of the Plan focused on integrating the new objectives and proposed strategies with a Plan that encompassed the overall goals of Healthy People 2020: 1) emphasizing primary prevention; 2) coordinating early detection and treatment interventions; 3) addressing public health needs of cancer survivors; 3) implementing policy, system and environmental changes to sustain cancer control; 4) measuring outcomes and impact through evaluation; and 5) eliminating health disparities to achieve health equity.

Building and Strengthening Partnerships in the ACCCC

Following updating of the Coalition membership, targeted members were identified who possessed expertise that would be beneficial to the Coalition’s goals. A recommendation was made to update the membership directory annually. The evaluation contractors at UAB and the ADPH Comprehensive Cancer Control staff worked together to identify potential new members, who were then personally invited to the spring 2011 meeting. A media gap was identified, and subsequently a public information specialist was hired as staff in the ADPH Comprehensive Cancer Control Program to increase the visibility of the Coalition. He works with the ACCCC to update the website and send electronic dispatches to members regarding current activities. Other works in progress include updating the ACCCC website, and plans to expanding social marketing of the ACCCC on social networking sites such as Facebook.

Focus Areas of 2011–2015 and Themes in Cancer Education

Part of the goal of the 2011–2015 Plan was to identify themes that could be incorporated into Coalition meetings and disseminated throughout the membership. Each year, priority focus areas in cancer education are chosen. During 2011, cancer education focused on clinical trials, skin cancer prevention, and breast cancer screening. In addition to the focus areas, strategies among coalition partners to reduce cancer disparities in screening and treatment in Alabama are discussed at each meeting. The January 2012 meeting was held in Tuskegee, Alabama following the first Bioethics Conference on Cancer Health Disparities Research (http://www.healthdisparity.tuskegee.edu/Bioethics/bioethics_conference.htm). Cervical cancer education was the focus of this quarterly meeting. At this session the completed “Path to Cancer Control in Alabama 2011-2015” was unveiled and officers were elected.

The ACCCC will continue to focus on strategies that include public policy and environmental changes to modify health behaviors, and reduce disparities in health status. Traditional health education and promotion activities will be included in systems changes that will have a broader impact on the health of Alabamians in reducing cancer risk.

Discussion

The underlying concept behind cancer control is to create and build upon synergy among categorical cancer control programs [5]. Comprehensive Cancer Control (CCC) ensures that surveillance data are used to make decisions that promote effective strategy implementation in cancer populations. The CCC can bring together diverse partners to address the needs of particular populations. The goals of the ACCCC include identifying and improving the health equity of disparate populations in Alabama affected by cancer, and enhancing data collection and evaluation of programs in these populations.

Challenges that face ACCCC include sustainability, limited resources, and competition for these resources. In Alabama, the priorities are the top cancers that afflict Alabamians including female breast cancer, colorectal cancer, lung cancer and prostate cancer. The goals of the program also focus on improving treatment outcomes and reducing disparities in disease incidence and mortality. The ACCCC has developed a logic model that is used as a framework for the 2011–2015 Plan (Fig. 1).

Fig. 1
figure 1

Alabama comprehensive cancer control logic model depicting the inputs as well as short and long term outcomes for the 2011–2015 Plan

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The current Plan is written to fulfill the vision for 2011–2015, which is to reduce cancer incidence and mortality among all Alabamians and to work to build a sustainable effort for cancer prevention and control in Alabama. In 2008, the Division of Cancer Prevention and Control of the Centers for Disease Control and Prevention (CDC) marked the first decade of the National Comprehensive Cancer Control Program (NCCCP) [6]. Alabama will continue to partner with NCCCP and CDC to bring about improvements in prevention, early detection, treatment, survival, and quality of care among Alabamians diagnosed with cancer. The overall goals will be aligned with priorities of the CDC outlined in 2009. The strategic direction of the Coalition is aligned with CDC priorities.

The evaluation component of the Alabama Comprehensive Cancer Control Plan assesses program implementation and program outcomes at the short-term, intermediate-term, and long-term levels. Objectives within each section of the Plan are examined to determine the degree to which they are realistic and measurable. In addition, it is recognized that it may not be possible at this time to evaluate every objective in this comprehensive plan. A degree of flexibility is to be expected, and the evaluation plan is limited to priority areas, accessible data, and available implementation strategies.

In the past, data were collected through use of a Monitoring Form and were compiled for the evaluation report. Currently, data are collected through Survey Monkey (http://www.surveymonkey.com) prior to quarterly meetings, and paper copies are distributed at the meetings to collect data on additional ACCCC member activities. Implementation data, coupled with surveillance data, provide a more comprehensive picture of Plan activities. Evaluation reports are prepared on an annual basis with input by the Advisory Board, as well as other primary stakeholders. These reports are used in a feedback loop to improve and strengthen the Plan. The ACCCC must ensure that the activities reflect surveillance data and capacity development to achieve quality evaluations. This routine evaluation of all Coalition activities is disseminated and used to improve programmatic efforts in the State, especially to reduce incidence and mortality from the most common cancers in the State for each gender. The Coalition Satisfaction survey is also administered biannually in the spring, and the results are presented to the Executive officers as well as the Coalition membership. Finally, the methods of program evaluation are updated as the field is evolving in cancer prevention and control.

New strategies should be implemented to enhance data collection and reporting on differences in incidence, prevalence, mortality, and cancer burden among various disparate populations such as older individuals; minority groups; groups with lower income, education, and health literacy; rural populations; and non-English speaking populations. The Coalition will work to maintain diversity in the stakeholders who will be able to contribute to identification of appropriate strategies for such disparate populations.

Coalition members and their respective organizations (i.e. Deep South Network for Cancer Control) share missions similar to the ACCCC; therefore, the individual goals of many of the organizations that receive extramural funding will provide financial support. These partners will allocate funds to support implementation of the strategies to meet these objectives. Other states have brought together diverse groups to align state strategies [7]. In order to ensure sustainability of the resources over time, the ACCCC membership must grow to reach out to new partners. Analyses of research collaborations have shown that national policy efforts to influence the integration of research knowledge do occur across organizations, and cancer research efforts are generally well-connected [8]. The quantification of a coalition’s relational structure and this effect on sustainable capacity for health promotion is an area of future research [9]. Broad systems changes that improve help achieve health equity through education, policy and environmental change can have a continued impact on cancer prevention and control in Alabama and other states.