Since its beginning, partnerships have been essential to the success of the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The NBCCEDP established invaluable partnerships that have expanded the capacity and resources of the program to enhance the coordination of screening activities, address barriers to recruiting priority populations, deliver educational information on breast and cervical cancer screening, and promote the delivery of services. In addition, community-based organization partners provide “in-kind” support (ie, staffing, food, facilities, equipment, expertise) to programs.
Partnerships established among public health programs, medical facilities, academic research centers, private sectors, and nonprofit organizations have an effect on behavioral changes in the community and provide a venue to disseminate health promotion and disease prevention programs to underserved populations. Definitions of partnerships include alliances among individuals and organizations, equitably negotiated arrangements among different groups, or organizations working together to achieve a common purpose.[3-5] The premise of a partnership is that groups of individuals or organizations are more successful in their collective efforts than those they undertake independently. The NBCCEDP defines partnerships as groups of individuals or organizations that are brought together by an established reciprocal agreement to share resources and responsibilities, achieve common goals, and derive mutual benefits. In this article, we use the NBCCEDP definition of partnership.
The roles of individuals and organizations within each partnership may vary (eg, advocacy, education, outreach, linking agents); however, each role is critical to the communication and dissemination of relevant information related to cancer control.[7-10] A linking agent refers to the connection between the source of an innovation and the ultimate adopter: A linking agent can be either a public entity or a private entity and has a primary role of making personal contacts, transmitting information, and actively advocating target innovations to service delivery agencies. Policy makers, program planners, and funding agencies rely on community coalitions and partners to communicate cancer-control strategies.[11-13] For example, member organizations of comprehensive cancer control coalitions encourage eligible women to seek cancer screening through NBCCEDP, whereas health promotion activities are provided in collaboration with the state or local affiliates of national partner organizations. Educational materials are distributed at libraries, faith communities, and other community settings.[14, 15] In the current article, we provide an overview and examples of how the formation of key partnerships have helped the NBCCEDP state, tribal, and territorial grantees achieve their goals.
Partnerships in Action at the National Level
The NBCCEDP national and state partnerships have contributed to implementing, strengthening, and maintaining the cancer prevention and control programs of the state, tribal, and territorial grantees. The Centers for Disease Control and Prevention (CDC) Division of Cancer Prevention and Control has diverse partnerships with sister federal agencies (eg, National Cancer Institute [NCI], Health Resources and Services Administration, Centers for Medicare and Medicaid Services, Food and Drug Administration), national organizations (eg, American Cancer Society [ACS], Susan G. Komen for the Cure, the Avon Foundation for Women, National Association of Chronic Disease Directors, C-Change, National Colorectal Roundtable, Prevent Cancer Foundation, LIVESTRONG), and state and local entities (eg, health departments, academic institutions).
The ACS Cancer Action Network and Susan G. Komen Advocacy Alliance are committed to supporting increased funding at the federal and state levels to ensure that more women receive direct breast and cervical screening services. These key federal partners were instrumental in supporting passage of the National Breast and Cervical Cancer Early Detection Program Reauthorization Act of 2007.
The ACS and Komen affiliates at the state level raise awareness and educate women in communities on the importance of mammography and Papanicolaou (Pap) testing, and they refer eligible women to participate in the NBCCEDP. Local promotional efforts raise funds that are used to support screening more women and to conduct public education and professional development activities. For example, many state programs receive donated funding raised through community-based Komen Race for the Cure events to provide screening to women ages 40 to 49 years. Both organizations support the education and training of community outreach workers and health care providers. In addition, the Avon Foundation Breast Cancer Care Fund has awarded millions in funding to community outreach and breast cancer screening programs nationwide since its inception. These community-based programs conduct outreach and education to link underserved women of diverse racial, ethnic, and cultural backgrounds, and those with significant socioeconomic barriers or in remote geographic areas, to screening services offered by the NBCCEDP.
Partnerships in Action at the State Level
The NBCCEDP states, tribes, tribal organizations, and territory grantees have independently sought out and cultivated partnerships with community organizations, businesses, public health agencies, and professional organizations. We present 3 examples of successful partnerships in action at the state level.
Indiana's Secret Sister Society partnership
The Indiana Breast and Cervical Cancer Program (IN-BCCP), which commenced in 1997, screens 6000 to 7000 women each year. For mammography screening, the priority population for the NBCCEDP is defined by the CDC as women ages 50 to 64 years, and, in the IN-BCCP, only women in this age range are eligible for screening mammograms because of limited federal funds. The IN-BCCP does not provide women ages 40 to 49 years with screening mammograms and relies on the monetary donations of partners, such as the Women's Task Force Secret Sisters Society to screen these women. The Secret Sisters Society is an all-volunteer organization comprised of female cancer survivors whose purpose is to raise awareness about women's health issues. Society members are charged a modest annual fee, and the collected fees are used to underwrite the cost of screening mammograms for women who cannot afford them.
Although the Secret Sisters Society collects fees to support mammography screening, it did not have an established infrastructure to screen women. A partnership was created with the IN-BCCP and its established clinical provider network at United Health Services, the regional coordination site for the IN-BCCP in northeastern Indiana, to administer the funds to get women screened. This partnership leveraged the use of the existing IN-BCCP infrastructure and ensures the availability of United Health Services to provide free mammograms, diagnostic testing, and patient navigation to women ages 40 to 49 years, and it removes the financial barriers that many of the women would face.
The 8-year partnership between the IN-BCCP and the Women's Task Force has had an immeasurable effect on the quality of life and health of women in northern Indiana. More than 4000 women ages 40 to 49 years have received screening mammograms through this program since March 2003. Of that total, approximately 500 women have received additional diagnostic services through the IN-BCCP. This mutually beneficial partnership embraces the goal of the IN-BCCP to reduce the burden of breast and cervical cancer morbidity and mortality through screening and diagnostic services, awareness, and education. It combines the funding resources of a community organization with the cancer screening delivery system and expertise of the IN-BCCP to provide mammography screening.
Nebraska Building Sustainable partnership
Nebraska's Every Woman Matters (EWM) Program has enhanced service delivery and program efficiency by partnering, coordinating, and integrating with other cancer screening programs, chronic disease programs, and health care systems. From 2004 to 2006, the EWM Program served approximately 10,000 women annually. An increase in enrollment and screening occurred in 2007 with implementation of the CDC-funded WISEWOMAN (Well-Integrated Screening and Evaluation for WOMen Across the Nation) project and the Colorectal Cancer Demonstration Project. The infrastructure and capacity of the EWM Program was strengthened by cost sharing and by using a cumulative support effect to provide combined office visits for clients, render a comprehensive care approach, display social marketing campaigns with inclusive messaging, perform professional education opportunities, and enhance provider and client correspondence and communication, case management, and staffing between these programs. This resulted in improved cost efficiency, allowing more women to receive services.
The EWM Program developed a collaborative partnership with the ACS and Nebraska's Comprehensive Cancer Control program to provide a wide array of services to improve breast and cervical cancer screenings for all women in Nebraska. This ranged from creating educational resources to seeking additional financial resources. In 2009, a statewide Cancer Coalition known as CARES (Cancer Awareness, Research, Education, and Service), representing more than 130 statewide partners, was formed with ACS and Susan G. Komen for the Cure jointly taking the lead role as advocates for the EWM Program. One of the primary objectives was to increase state funding through legislative action to support the EWM Program. Even in tight financial times, the advocacy effort was successful, resulting in a legislature appropriation of an additional $200,000 in direct screening funds.
Overall, through advocacy and partnership efforts from 2004 to 2008, the EWM Program was able to improve services provided to women by removing barriers, improving efficiency, and increasing funding for screening. These efforts resulted in a 52% program increase in women being screened through the EWM Program, with 2000 additional women receiving services by 2007, and an additional 6000 women receiving services by 2009.
Pennsylvania's Breast Cancer Coalition partnership
Pennsylvania's Healthy Woman Program (HWP) was established in 1994 through the Pennsylvania Department of Health (DOH) to reduce breast and cervical cancer morbidity and mortality through screening, referral, follow-up diagnostics, public education, outreach, professional education, quality assurance, surveillance, evaluation, partnership development, and community involvement. The DOH has had a long-standing partnership with the Pennsylvania Breast Cancer Coalition (PBCC), a nonprofit organization that serves as the only statewide grassroots organization that speaks for breast cancer survivors. This partnership was established to promote the HWP, establish research and awareness projects throughout the state, and secure new funding for breast and cervical cancer screening.
In the mid-1990s, there was a relatively low level of breast cancer awareness among middle-aged women in the Commonwealth. At that time, the DOH did not have adequate resources available to conduct a statewide campaign to address the problem. The DOH worked with the PBCC on several key recruitment and fundraising campaigns, as well as awareness, access, and education projects, to increase cancer screening. In 1998, the DOH and the PBCC promoted the Mother's Day Mammogram. Free mammograms were available during the month of May through private facility partners and through the HWP across the state. Women ages 50 to 64 years were referred to the HWP, and mammograms for women aged <50 years were paid for through private donations collected by the PBCC or through hospitals that donated these services. Over 2500 women were served during the 8 years of the project.
In 2006, at the height of threatened cuts to the state's cancer control budget, the PBCC secured $1.7 million in special state funding to support breast and cervical cancer screening efforts for women ages 40 to 49 years. In fiscal year 2006 to 2007, the number of breast and cervical cancer screenings rose by 52%, primarily because of this increase in legislative funding. The DOH and the PBCC continued to champion funding for the HWP to ensure that services were not adversely affected by state budget cuts. Annual reports were submitted to the legislature to demonstrate the accomplishments of the early preventive health screening services. HWP funding has remained in the state's cancer control budget because of the ongoing advocacy efforts of the PBCC.
In 2008 and 2009, the PBCC held 5 seminars across the state to educate hospital staff and health care providers about the Commonwealth's Breast and Cervical Cancer Treatment Program (BCCPT), which provides Medicaid coverage for breast or cervical cancer treatment. The DOH joined the PBCC and the Medicaid program to provide information to more than 165 representatives of hospitals and health care providers. In addition, the PBCC has showcased a traveling photo exhibit entitled “67 Women—67 Counties: Facing Breast Cancer in Pennsylvania,” which reflects the diversity and stories of women in Pennsylvania who had breast cancer. This educational work of art illustrates the courage, hope, and dignity of women and families who have battled breast cancer. The exhibit encourages women to learn about early detection of breast cancer and celebrates the life of women and families that have battled breast cancer.
This 20-year partnership between the DOH and the PBCC, which aimed to improve awareness, access, affordability, and quality of breast care for women in Pennsylvania, has been 1 of the department's most important and successful partnerships. This unique partnership has avoided challenges that frequently arise among partners. The agenda was clear, the lines of communication were frequent and compelling, there was no overlapping of duties and responsibilities, and there was a true uniting of strengths and resources. This partnership never lost sight of their clients, the women of Pennsylvania.
Over the past 2 decades, the NBCCEDP partners have demonstrated unwavering support for the state, tribal, and territorial grantees. The willingness to share their time, resources, and expertise has resulted in an expansion of the program's resources, better coordination of program activities, increase in the recruitment of priority populations, and promotion of comprehensive breast and cervical cancer screening services. To cultivate and sustain successful partnerships within the program, grantees and partners must have realistic timelines, focus, leadership, accountability, responsiveness, communication, decision making, and the management of issues or conflicts and assigned tasks.
Statewide and community partnerships have been an intricate part of grantees accomplishing their goals. The ACS, Susan G. Komen for the Cure, and Comprehensive Cancer Control coalitions at the state level are major partners that have effectively assisted with dissemination of education or outreach materials, promotion of the screening program in communities, and making screening referrals. Often, grantees rely on local grassroots organizations to rally support and garner financial resources. The most important partnership activities are enhancing access to screening, supporting patient education and recruitment activities, informing policy and legislation, sustaining professional development, and increasing awareness about early detection.
Building, Nurturing, and Leveraging Partnerships in the Years to Come
As the NBCCEDP programs move into the next decade, the challenges of limited resources and hard-to-reach populations will continue to exist. Grantees should assess their goals, available resources, and need for partnerships; evaluate the effectiveness of current partnerships; and determine whether new partners should be created. The effectiveness of partnerships, as demonstrated in the examples provided in this report, can be measured by their ability to increase the availability of screening services, increase the recruitment of priority populations, reduce structural barriers, coordinate relevant program activities, achieve data performance indicators, and expand the knowledge and skills of providers.
A paradigm shift focusing on the provision of clinical preventive services to the promotion of clinical preventive services to all women will occur over the next couple of years within the NBCCEDP. With the expansion of preventive services, there will be more public health opportunities and challenges for the program to acquire new partnerships. The NBCCEDP must continue to sustain and cultivate additional partnerships with national, state, regional, and local agencies (ie, Federally Qualified Health Centers, worksite wellness programs, insurers) to be more effective and efficient in program management, distribute and recycle resources to develop culturally appropriate outreach campaigns, develop population-based cancer screening registries and data linkages, promote efficient patient navigation and case management, and reduce structural and economic barriers. In the future, the NBCCEDP and its partnerships will continue to be vital in ensuring that effective and efficient quality care and cancer screenings are accessible to all women—the uninsured, underserved, and insured.