year 2 report: bridging cancer and chronic disease · 2017. 4. 10. · ontents appendix :...

COMMUNITY ROUNDTABLES

Year 2 Report: Bridging Cancer

and Chronic Disease

March 2017

CONTENTS

INTRODUCTION

This Community Roundtables Year 2 Report: Bridging Cancer and Chronic Disease was developed to highlight successes and challenges of the second of three annual Community Roundtables that brought cancer, chronic disease and community stakeholders together to integrate efforts in four states between May and July 2016. Key highlights from Year 2 of the Community Roundtables include:

The Smoking Cessation Workgroup successfully integrated the Kentucky Cancer Program’s Tobacco Resource List into St. Claire Family Medicine’s Electronic Medical Records.

The Radon Workgroup in Kentucky created the Step Up to Reduce Radon Alliance and won a Mini-Grant from the Kentucky Department of Public Health to increase radon testing and improve access to radon mitigation services.

The Tobacco Treatment Specialist Workgroup in Kentucky created and pilot tested a training program that includes motivational interviewing techniques.

The Communications Workgroup in Vermont coordinated efforts with Health District offices to promote the 3-4-50 campaign to a wider audience, including faith-based communities.

Members of the Florida Community Roundtable included a clause in the Southwest Florida Cancer Control Collaborative strategic plan that emphasized the need for cancer and chronic disease collaboration.

Members of the Stanford Model of Chronic Disease Self-Management Workgroup in South Dakota adapted the smoking cessation referrals policy for the state chronic disease self-management program, Better Choices Better Health, and submitted for approval by the South Dakota Health Department.

Materials used at the roundtables are included as part of the report in the Appendices in hopes that they will be useful to comprehensive cancer control (CCC) programs and coalitions that seek to replicate the Community Roundtables.

BACKGROUND

In partnership with the National Area Health Education Center (AHEC) Organization, the Institute for Patient-Centered Initiatives and Health Equity at the George Washington University (GW) Cancer Center is working with four AHECs around the country to organize roundtables to integrate cancer and chronic disease prevention efforts by convening key stakeholders and strengthening relationships at the state or regional levels. The roundtables give participants the opportunity to develop a collaborative approach to address a specific risk factor for cancer and chronic disease over a three-year period. Participants at the roundtables may include representatives from CCC coalitions or programs, state and local departments of health, cancer and chronic disease programs, universities, clinics, or other groups working toward reduction of cancer and chronic disease in the state or region. This report is a summary of procedures and outcomes of the second of three roundtables which were held in 2016. The report from the first roundtable, held in 2015, is also available.

1

Introduction .................................................................................................................................................. 1

Background .............................................................................................................................................. 1

Methods and Roundtable Structure ........................................................................................................ 3

Evaluation ................................................................................................................................................ 4

Northeast Kentucky Regional Community Roundtable ............................................................................... 5

Champlain Valley Healthy Lifestyles Collaborative (Vermont) ................................................................... 13

Florida Community Roundtable ................................................................................................................. 21

South Dakota Community Roundtable ...................................................................................................... 28

Final Conclusion .......................................................................................................................................... 35

Appendices ................................................................................................................................................. 37

Appendix A: Facilitation Guide .............................................................................................................. 37

Appendix B: Workgroup Activity Plan Worksheet ................................................................................. 39

Appendix C: Collaboration Multiplier Tool ............................................................................................. 42

http://www.nationalahec.org/

http://bit.ly/RT2015Report

Goal of the Community Roundtables: To promote increased integration of cancer and chronic disease efforts by convening key stakeholders and strengthening relationships at the state or regional level. Intended Outcomes of the Second Community Roundtables:

1. Deeper and common understanding of how chronic disease and cancer efforts can be integrated. 2. Commitments from AHECs, chronic disease groups and community stakeholders in implementing strategies

to address cancer and chronic disease risk factors in the state or region. 3. Consensus on an action plan to build on successes in year 1 to improve cancer and chronic disease

outcomes in the state or region.

Partnering AHECs were selected through a competitive application process in 2014 to host these roundtables due to their strong community-level history and connections. They are well-positioned to bring diverse stakeholders to the roundtables and facilitate dialogue and collaboration toward common health outcomes. The following four AHECs were chosen to host the roundtables between 2015 and 2017:

1. Champlain Valley AHEC (Vermont) 2. Gulfcoast South AHEC (Florida) 3. Northeast Kentucky AHEC 4. Northeast South Dakota AHEC

The selected roundtable locations represent four different Centers for Disease Control and Prevention (CDC) National Center for Chronic Disease Prevention and Health Promotion Regions (Figure 1).

Each Community Roundtable will convene once a year between 2015 and 2017 in-person and participate in a six-month follow-up call. The roundtables selected one chronic disease risk factor that remains constant throughout the three years and one strategy that changes each year to advance cancer and chronic disease integration efforts in a comprehensive manner (Figure 2).

In 2015, the AHECs chose priority chronic disease risk factors and strategies informed by national and local data compiled in state profiles by GW Cancer Center, as well as national priorities and windows of opportunities highlighted in the State Cancer Plans Priority Alignment Resource Guide and Tool.

Figure 1. The selected AHEC roundtable hosts represent four

different CDC National Center for Chronic Disease Prevention

and Health Promotion Regions

Figure 2. The roundtables selected one chronic disease risk factor that remains constant throughout the three years and

one strategy that changes each year

2

https://smhs.gwu.edu/cancercontroltap/community-roundtables/cvvt

http://www.gsahec.org/

https://smhs.gwu.edu/cancercontroltap/community-roundtables/neky

https://smhs.gwu.edu/cancercontroltap/community-roundtables/sd

http://smhs.gwu.edu/cancercontroltap/sites/cancercontroltap/files/PriorityAlignmentToolCombined-FINAL_20150302.pdf

http://smhs.gwu.edu/cancercontroltap/sites/cancercontroltap/files/PriorityAlignmentToolCombined-FINAL_20150302.pdf

METHODS AND ROUNDTABLE STRUCTURE

The second of three Community Roundtables took place between May and July 2016 (Figure 3). Chronic disease risk factor topics remained the same from 2015. Florida and Kentucky chose year 2 strategies (coordination between health care professionals and workforce improvement, respectively) that are different from their year 1 strategies, as intended. Vermont and South Dakota kept the same strategies they chose in 2015, as they thought they had just started to gain momentum in their activities. The number of attendees was kept small, ranging from 22 to 34 to foster meaningful relationship-building (Figure 4). Kentucky and Vermont concentrated their efforts on the AHEC regions: Northeast Kentucky and Champlain Valley, respectively, while Florida and South Dakota decided on a state-level roundtable with wider reach.

Florida, Kentucky and Vermont created a planning committee to help organize the roundtable meeting, provide insights and perspectives to choose roundtable topics and strategies, brainstorm potential attendees and speakers and facilitate the roundtable meeting and activities. Planning committee members in Kentucky and Vermont also led the workgroup discussions. Vermont uniquely conducted pre-roundtable work with partners to populate the Prevention Institute’s Collaboration Multiplier Tool they used to highlight opportunities for collaboration.

All roundtables followed a general structure of presentations by experts in the morning to understand the current landscape of cancer and chronic disease in the region or state, best practices and current community activities on the

Figure 3. Summary of roundtable dates, time and length of meetings, chronic disease risk factor topic, strategy, number of

attendees and area of focus

2015

roundtable date

2016 roundtable

date

Time (Length of meeting)

Chronic disease risk factor topic

Year 1 strategy Year 2 strategy Area

Northeast Kentucky

April 30 May 9 9am - 4pm (7 hours)

Tobacco Prevention and

detection Workforce

improvement Regional

Champlain Valley (Vermont)

May 12 May 24 8:45am - 3:30pm

(6.75 hours)

Nutrition, physical activity

and obesity

Communication, education and

training

Communication, education and training

(no change) Regional

Gulfcoast South (Florida)

June 10 May 3 9am - 2pm (5 hours)

Nutrition, physical activity

and obesity

Community-clinical linkages

Coordination between health care

professionals State

Northeast South Dakota

July 28 July 26 12:30pm -

4:30pm (4 hours)

Health services access and utilization

Community-clinical linkages

Community-clinical linkages (no change)

State

Number of 2015 attendees

Number of 2016 attendees

Planning committee

Collaboration Multiplier Tool

Table set up Breakout

rooms

Northeast Kentucky

32 34 Yes No Roundtables Yes

Champlain Valley (Vermont)

30 29 Yes Yes Horseshoe Yes

Gulfcoast South (Florida)

28 31 Yes Yes Horseshoe Yes (room dividers)

Northeast South Dakota

20 22 No No Roundtables No

Figure 4. Summary of the number of attendees at the 2015 and 2016 roundtables, use of planning committees, Collaboration

Multiplier Tool, tables and breakout rooms

3

https://www.preventioninstitute.org/tools/collaboration-multiplier

chronic disease topics and areas for improvement. Participants then broke out into workgroups in the afternoon. Kentucky and Vermont used separate breakout rooms for each workgroup, while Florida used dividers to separate the workgroups and South Dakota had workgroups gather around opposite parts of the conference room. Workgroup topics were identified by planning committees or organizers and key stakeholders. Workgroup leaders and GW Cancer Center representatives facilitated the conversations using the Facilitation Guide (Appendix A) and noted key points and planned activities using the Workgroup Activity Plan Worksheet (Appendix B).

Roundtable participants also attended respective six-month roundtable follow-up conference webinars to celebrate progress, discuss challenges and troubleshoot. Details of each roundtable workgroup’s activities are outlined in the following chapters.

EVALUATION

Evaluation of the roundtables is ongoing to continuously assess areas for improvement. As part of this effort, GW Cancer Center administered the following before the roundtable:

1. An online survey collecting demographic information and assessing baseline levels of participants’ perceived capability to address the chronic disease risk factor topic; expectations of the roundtable; belief that they will be able to make a difference in the field; perceived support and reinforcement of their activities; and confidence&

2. An online survey collecting social network data, including how often participants contact other participants, to compare with baseline data collected before the first roundtable in 2015

The GW Cancer Center administered the following after the roundtable:

1. A paper survey to assess process outcomes and satisfaction levels 2. An online survey assessing changes in participants’ perceived capability to

address the chronic disease risk factor topic; expectations of the roundtable; belief that they will be able to make a difference in the field; perceived support and reinforcement of their activities; and confidence&

Results from the pre-roundtable social network survey were entered into UCINET, a software for social network analysis, and mapped with Netdraw, a program for drawing social networks. Data collected in 2015 and 2016 will be compared to determine whether the year 1 roundtables were successful in creating stronger ties between cancer and chronic disease professionals and advancing integration of efforts. Analysis will answer questions such as: Have roundtable members communicated with each other more frequently? Have the number of connections between cancer and chronic disease professionals increased? Who are the key members that bridge the gap between cancer professionals and chronic disease professionals? Has the network’s density, also known as the level of connectedness or integration, increased?

Note that changes in roundtable membership is anticipated, as year 1 members may or may not return for years 2 and 3 and new members may join. These changes will also be captured in the evaluation, and will be assessed for potential progress in finding, convening and building relationships with mission-focused roundtable members.

How to Read Social Network Maps and Indicators

As seen in Figures 6, 7, 12, 13, 18, 19, 24 and 25

The squares, also known as nodes, represent attendees.† Blue nodes represent self-identified cancer professionals, yellow represent chronic disease professionals, grey represent neither cancer nor chronic disease professionals, and white represents those who did not respond.

The lines between the squares represent existing channels of communication between attendees. The thicker lines represent more frequent contact.

Average degree: the average number of relationships roundtable attendees have. The larger the indicator, the better.

Average distance: the average number of “hops” people have to make to get from person a to b. The smaller the indicator, the better.

Dyad reciprocity: the level of reciprocal relationships of sending and receiving information. The closer to 1, the better.

4

&Development of this survey was made possible by partial support from Award Number UL1TR001876

from the National Institutes of Health (NIH) National Center for Advancing Translational Sciences. Its

contents are solely the responsibility of the authors and do not necessarily represent the official views of

the National Center for Advancing Translational Sciences or NIH.

†Node labels are not sequential, as those who were surveyed but were absent from the roundtable were excluded from the map for purposes of the analysis.

Goal:

To promote increased integration of cancer and chronic disease efforts by convening key stakeholders and strengthening relationships at the regional level.

Intended Outcomes of the Second Roundtable:

1. Deeper and common understanding of how chronic disease and cancer efforts can be integrated.

2. Commitments from Northeast Kentucky AHEC, Comprehensive Cancer Control stakeholders, chronic disease groups and community stakeholders to implementing prevention and early detection strategies to reduce the impact of tobacco on Northeast Kentuckians’ health.

3. Consensus on an initial plan of action to address tobacco use and for integration and collaboration of efforts in Northeast Kentucky.

Description and Overview

Thirty-four cancer, chronic disease and

community stakeholders convened on

Monday, May 9, 2016 in Morehead,

Kentucky for the second of three annual

Northeast Kentucky Regional Community

Roundtables. The Northeast Kentucky

region is highlighted in Figure 5.

Figure 6 and 7 are social network maps of

attendees in 2015 compared to 2016,

respectively. In 2015, 11 attendees identified as cancer professionals (indicated in

blue), five as chronic disease professionals (in yellow), 11 as neither (in grey) and

seven did not answer (white). In 2016, nine attendees identified as cancer

professionals, five as chronic disease, 12 as neither (in grey) and eight did not answer.

Participants on the top left corner of the social network maps did not complete the

survey. Between the 2015 and 2016 roundtables, cancer professionals’ lines of

communication with roundtable members decreased from 67.7% to 58.6%,

respectively, but chronic disease professionals’ lines of communication almost

doubled from 33.8% to 60%,respectively. While cancer professionals’ level of

communication was already high, chronic disease professionals’ communication

showed great improvement, which indicates their increased involvement and stake in

a network where cancer professionals are the majority.

There were diverse professions and interests represented at the roundtable, including

researchers and academics, health educators, health professionals, clinicians and

health administrators (Figure 8).

Figure 6. Social network of attendees of the

Year 1 Northeast Kentucky Regional

Community Roundtable (N=27)

Figure 5. Northeast Kentucky region high-

lighted in yellow (Image courtesy of North-

east Kentucky AHEC)

NORTHEAST KENTUCKY REGIONAL COMMUNITY ROUNDTABLE

5


Year 2 Northeast Kentucky Regional

Community Roundtable (N=34)

Topic and Strategy

Northeast Kentucky AHEC created a roundtable planning committee consisting of David

Gross from Northeast Kentucky AHEC, KaSandra Hensley from Northeast Kentucky

AHEC, Mary Horsley from St. Claire Regional Medical Center, Dr. Tony Weaver from

University of Kentucky (UK) HealthCare and Trina Winter from Kentucky Cancer

Program. Informed by disease prevalence and risk factor data compiled by GW Cancer

Center in year 1, the planning committee chose tobacco as the roundtable topic that

will remain constant across the three years of the initiative. The strategy was

prevention and early detection for year 1 and workforce

improvement for year 2.

Roundtable Meeting Summary

The first half of the one-day meeting consisted of informative

presentations from subject matter experts. After words of

welcome from the AHEC and GW Cancer Center organizers and

brief introductions, Dr. Ellen Hahn from UK College of Nursing/

College of Public Health presented first the Radon Workgroup’s

activities in year 1. The workgroup goal was to promote lung

cancer awareness and radon testing in rural Appalachia by

providing radon test kits to clinic patients. The workgroup members worked with St.

Claire Family Medicine Clinics in Frenchburg and Owingsville and organized lunch and

Dr. Hahn reports the Radon Workgroup’s year 1 activities

*Non-profit organization/non-governmental organization

**Some respondents selected more than one option

6

9

8 8

6

5

2

1 1 1 1

0

1

2

3

4

5

6

7

8

9

10

Figure 8. Self-identified professional representation of those in attendance** (n=24)

learns for staff in August and September 2015. Fifty-eight clinic patients were then

given free long-term (90 days) radon test kits. Of the 28 people that tested for radon in

their homes (48%, n=28/58), eight (29%, n=8/28) had radon levels exceeding the EPA

action level. Further, 25% of those with elevated radon levels also reported smoking in

the home, putting them at increased risk of developing lung cancer. However,

workgroup members found that mitigation support was not readily available or

accessible in the region; therefore, workgroup members reported challenging

themselves to increase mitigation services in the following year.

Dr. Jamie Studts from UK Markey Cancer Center gave an overview of the Lung Cancer

Screening Workgroup’s activities in year 1. The workgroup goals were to develop a

decision aid to help individuals make decisions about lung cancer screening that are

consistent with their values and preferences as part of the Terminate Lung Cancer (TLC)

project as well as to conduct a feasibility trial among individuals at high risk of lung

cancer. Workgroup members conducted focus groups with community members that

revealed that health providers are the most trusted source for lung cancer screening

information. The TLC project then distributed through channels including direct

mailers, information cards and radio spots. As part of the TLC project, workgroup

members also implemented an educational curriculum aimed at reducing lung cancer

rates through early screening and tobacco cessation in the rural region served by St.

Claire Regional Medical Center. Workgroup members also worked with the Kentucky

Lung Cancer Education, Awareness, Detection and Survivorship (LEADS) Collaborative to

establish a shared decision making protocol for follow-up services and participant

retention.

Mary Horsley from St. Claire Regional Medical Center provided an overview of the

Smoking Cessation Workgroup’s activities in year 1. The workgroup had two goals: 1)

to collaborate with the Gateway Wellness Coalition to survey the Northeast Kentucky

service area for available smoking cessation programs, perception of the programs by

the community and the barriers associated with

participating in the programs and 2) collaborate

with UK and Morehead State University to pursue

the possibility of offering a certified tobacco

treatment specialist training program in the

Northeast Kentucky region during 2016. The

workgroup accomplished both, by identifying

available smoking cessation resources; partnering

with Gateway Wellness Coalition; creating a

tobacco cessation sub-committee and developing

a survey to distribute to 13 health departments,

schools and hospitals in four counties to assess

barriers to accessing smoking cessation resources.

Northeast Kentucky Regional Community Roundtable

7

The Smoking Cessation Workgroup’s poster on their assessment of “Barriers to Smoking Cessation in Rural Eastern Kentucky”

The survey revealed that barriers include lack of providers’ time for cessation efforts,

lack of certified or qualified tobacco treatment specialists and lack of community

education opportunities.

The smoking cessation workgroup also successfully integrated the Kentucky Cancer

Program’s Tobacco Resource List into St. Claire Family Medicine’s Electronic Medical

Records. Their work in offering a tobacco treatment specialist

training is ongoing, but remains a priority, as they only identified

seven specialists in Kentucky. The workgroup is coordinating with UK

College of Nursing to develop a hybrid online-telehealth program.

Workgroup updates were followed by presentations on the year 2

strategy: workforce improvement. Vicki Belvins-Booth from Kentucky

CancerLink and Gina Brien and Keisha Cornett from Montgomery

County Department of Health presented on Patient Navigators and

Community Health Workers. Dr. Nina Whitehouse from Ephraim

McDowell Regional Medical Center presented on The Pharmacist’s

Position on the Smoking Cessation Team. Dr. Emily Belvins from St. Claire Regional

Medical Center presented on dentists’ stake in smoking cessation. Dr. Audrey Darville

from UK Health Care presented on Certified Tobacco Treatment Specialists.

There were two keynote speakers after lunch. Dr. Audrey Darville presented on

electronic cigarettes (e-cigarettes) and Dr. Amanda Fallin from UK College of Nursing

presented on Smoking and Mental Illness.

Equipped with knowledge of workgroups’ progress and current trends and priorities

for workforce improvement to address tobacco-use in Kentucky, participants broke

out into workgroups for the second half of the meeting. The workgroup topics that

were pre-determined by the planning committee were:

Radon with four members

Certified Tobacco Treatment Specialists with 11 members

E-Cigarettes with eight members

Participants joined the workgroups in which they were most interested.

Subject matter experts, at the invitation of Northeast Kentucky AHEC,

served as workgroup leaders. GW Cancer Center provided workgroup

leaders a facilitation guide (Appendix A) and worksheet (Appendix B) to

track key information and planned activities.

Each of the three workgroups planned activities over the next year that

will contribute to priorities and goals of all involved parties. Workgroups discussed

common goals, shared resources and activities that could improve the workforce and

reduce the health impact of tobacco in Kentucky. Activities included providing more

topical education for workgroup members, conducting a systematic review of e-

cigarette guidelines, developing an educational curriculum on radon for providers, and

Gina Brien and Keisha Cornett present on Patient Navigators and Community Health Workers

8

Dr. Audrey Darville presents on Certified Tobacco Treatment Specialists

launching an online Certified Tobacco Treatment Specialist training. Workgroups

committed to communicating and meeting as necessary, whether in-person or by

conference call.

Evaluation

A paper survey was administered after the meeting to assess process outcomes, which

showed positive results (Figure 9). Comments included:

“Great—loved the discussion and presenters. Great, innovative participants.”

“Very informative—enjoyed the networking, goal setting and follow-up.”

Roundtable participants were also asked to complete an online survey before and after

the roundtable to assess changes in participants’ perceived capability to address

tobacco; expectations of the roundtable; belief that they will be able to make a

difference in the field; perceived support and reinforcement of their activities; and

confidence, which all showed positive outcomes (Figure 10).

Roundtable participants completed a survey to assess changes in social networks

before the roundtable meeting in 2015 and 2016. The average degree, or the average

number of relationships roundtable attendees have, decreased from 6.61 in 2015 to

5.44 in 2016. This was expected to a certain extent since new members who were

introduced to the initiative may not have been as well-connected initially. For example,

as the use of e-cigarettes became more prevalent and the concerns over their health

consequences increased, the roundtable planning committee decided to widen their

scope beyond tobacco and bring on subject-matter experts in e-cigarettes. Such new

minds may have affected indicators such as average degree. Similarly, the average

distance, or the average number of “hops” roundtable participants have to make to

reach any other person in the network, increased from 1.89 in 2015 to 2.03 in 2016.

Again, this is likely due to new members added to the roundtable. Both average degree

and distance tell us that the challenge for Kentucky will be to strengthen those new

relationships. However, dyad reciprocity, or the level of reciprocal relationships of

sending and receiving information between participants increased from 0.12 in 2015 to

0.40 in 2016, which indicates coordination and complementary communication is

taking place.

Progress Reported Six Months Later

Eleven members attended the six-month roundtable follow-

up conference webinar to celebrate progress, discuss

challenges and troubleshoot.

Radon Workgroup updates:


9

1 Gateway District Health Department. (February 2017). EnviroHealthLink Mini-

Grant Proposal.

Roundtable participants listen to speakers

10

Figure 9. Post-roundtable process survey (1= strongly disagree; 5= strongly agree)

Process Indicators Post-roundtable

average (n=20)

The roundtable was run efficiently 4.85

Communication leading up to the roundtable was sufficient 4.65

The facility where the roundtable was held was sufficient 4.90

Food and drinks provided at the roundtable was sufficient 4.90

I met my personal/professional goals for participating in the event 4.80

Success Indicators

Pre-roundtable

average (n=23)

Post-roundtable

average (n=18)

I have the knowledge to address tobacco 4.17 4.33

I have the skills and resources to address tobacco 4.17 4.28

I expect to expand/have expanded my network at this roundtable

4.08 4.37

I expect to learn/have learned new skills, resources and oppor-tunities at this roundtable

4.04 4.26

This roundtable is addressing an important issue 4.83 4.95

I can make a difference in addressing tobacco 4.21 4.56

Making a difference in tobacco is within my control 4.00 4.17

Participation in this roundtable will empower/has empowered me to contribute to addressing tobacco

3.96 4.44

I have the support I need from the community in addressing tobacco

3.71 3.78

I have the support I need from local government entities in addressing tobacco

3.08 3.22

I have the support I need from state government entities in addressing tobacco

2.96 3.06

I have the support I need from national government entities in addressing tobacco

3.25 3.33

I have the support I need from academic entities in addressing tobacco

3.92 4.33

I have the support I need from health systems entities (e.g. hospitals, insurers) in addressing tobacco

3.79 4.17

I am confident in my ability to make a difference in tobacco 4.04 4.33

I am confident in the ability of the roundtable members to make a difference in tobacco

4.13 4.39

Addressing tobacco is an overwhelming task 3.75 3.78

Figure 10. Pre and post-roundtable survey results (1= strongly disagree; 5=strongly agree)

Workgroup objective: Increase access to radon mitigation in the Northeast Kentucky

region by May 2017.

Progress: Workgroup members created the Step Up to Reduce Radon Alliance that

met in July, September and November 2016. They started formalizing the

organization and its mission, vision and objectives. They will work to 1) partner

with community and technical colleges to train students in radon mitigation and 2)

create a safety net with financial options to cover mitigation such as low-cost loans

from the Environmental Protection Agency’s Environmental Justice Small Grant

Program and the Food and Drug Administration.

In February 2017, Step Up to Reduce Radon Alliance won the EnviroHealthLink Mini-

Grant from the Kentucky Department of Public Health. The funded project aims to

“increase radon testing and expand access to radon mitigation in the Gateway District

service area.”1 Workgroup members, including Northeast Kentucky AHEC are involved

with creating a paid and earned media awareness raising campaign and providing

assistance with mitigation costs for residents with the “greatest combined risk and

need based on radon level, smoking in the home and limited financial resources.”1 In

addition, workgroup members have submitted funding proposals to the National

Institutes of Health and Patient-Centered Outcomes Research Institute to continue

their work.

Workgroup members from Northeast Kentucky AHEC and St. Claire Regional Medical

Center also met with area development representatives and have been in contact

with U.S. Senator of Kentucky, Mitch McConnell and U.S. Congressman of Kentucky’s

5th District, Hal Rogers, who are both engaged with radon issues. For example,

Senator McConnell recently bought a house with high radon levels. The workgroup

has already started to advocate for changes in state policies, such as requiring

notification of radon levels at the point of sale for housing and testing for radon in

daycares.

Dr. Hahn also presented on the group’s radon mitigation efforts at the American

Public Health Association

Annual Conference in

November 2016.

Certified Tobacco Treatment

Specialists Workforce

Workgroup updates:

Workgroup objective: Develop

and support a Certified

Tobacco Treatment Specialist

training program by May 2017.

Progress: The workgroup


11

The Workforce Certified Tobacco Treatment Specialists Workgroup discuss objectives and plan activities

Acknowledgments: Special thanks to Northeast Kentucky AHEC’s David Gross, Director and KaSandra Hensley, Education Coordinator for coordinating the event. We would also like to thank presenters for sharing their expertise, and workgroup leaders: Mary Horsley, St. Claire Regional Medical Center; Kristian Wagner, Kentucky Cancer Consortium; Audrey Darville, UK HealthCare; and Ellen Hahn, UK College of Nursing/College of Public Health

CHAMPLAIN VALLEY HEALTHY LIFESTYLES COLLABORATIVE (VERMONT)

12

focused on increasing capacity and garnering support from various stakeholders

present at the roundtable meeting. UK Markey Cancer Center and College of Nursing

collated resources on e-cigarettes. Workgroup members then created a Certified

Tobacco Treatment Specialist training program that includes motivational

interviewing techniques, which was pilot tested with two groups. The workgroup

anticipates launching the training in early 2017, while also seeking accreditation.

E-Cigarettes Workgroup updates:

Workgroup objective: Develop and disseminate education on e-cigarette myths to

adolescent, adult and health provider communities in Northeast Kentucky by May 2017.

Progress: Workgroup members met three times since the roundtable to educate each

other about e-cigarettes and focus groups methods. To identify effective messages

about e-cigarettes, workgroup members planned to conduct focus groups with

Morehead State University students between the ages of 18 and 20 in January and

February 2017. Workgroup funding provided by GW Cancer Center was used for focus

group participant incentives. Messages about e-cigarettes deemed to be effective in the

focus groups will then be used in lung cancer screening and guidelines to educate multi-

disciplinary groups about smoking cessation and screening.

Challenges and Lessons Learned

Workgroups reported no challenges.

Conclusion

The second of three Northeast Kentucky Regional Community Roundtables convened

key cancer and chronic disease stakeholders and has continued to leverage passionate

stakeholders to advance its mission to reduce tobacco-related health effects. By taking

a workforce improvement approach, the roundtable is increasing radon mitigation in

homes; awareness of the dangers of e-cigarettes; smoking cessation and screening; and

the availability of cessation specialists.

Group photo of select roundtable attendees and conveners


Twenty-nine cancer, chronic disease and community

stakeholders convened on Tuesday, May 24, 2016 in

Colchester, Vermont for the second of three annual

Champlain Valley Healthy Lifestyles Collaborative

roundtable meetings. The Champlain Valley region is

highlighted in Figure 11.

Figure 12 and 13 are a social network map of attendees

in 2015 compared to 2016, respectively. In 2015, nine

attendees identified as cancer professionals (indicated

in blue), 13 as chronic disease professionals (in yellow),

four as neither (in grey) and four did not answer (white).

In 2016, eight attendees identified as cancer

professionals, nine as chronic disease, seven as neither

and five did not answer. Between the 2015 and 2016

roundtables, cancer professionals’ communication to

the rest of the group decreased from 25.0% to 16.0%,

respectively, but communication from the rest of the

group increased from 33.6% to 63.7%, respectively. Chronic disease professionals’

communication to the rest of the group increased from 34.9% to 59.4%, respectively,

and communication from the rest of the group also increased from 47.9% to

55.8%,respectively. These indicators suggest that Vermont can continue to improve

integration by engaging cancer professionals in a network where chronic disease

professionals are the majority.


clinicians, public health professionals, health educators and health administrators

(Figure 14).


year 1 Champlain Valley Healthy Lifestyles

Collaborative (N=27)

Figure 11. Champlain Valley re-

gion highlighted in yellow (Image

courtesy of Champlain Valley

AHEC)

13

CHAMPLAIN VALLEY HEALTHY LIFESTYLES COLLABORATIVE (VERMONT)


year 2 Champlain Valley Healthy Lifestyles

Collaborative (N=29)

Goal:

To promote increased integration of cancer and chronic disease efforts by convening key stakeholders and strengthening relationships at the regional level.



2. Commitments from Champlain Valley AHEC, Comprehensive Cancer Control stakeholders, chronic disease groups and community stakeholders to implementing communication, education and training strategies to reduce the impact of obesity on Vermonters’ health.

3. Consensus on an initial plan of action to improve nutrition and physical activity and for integration and collaboration of efforts in Champlain Valley.

14

Topic and Strategy

Champlain Valley AHEC created a roundtable planning committee consisting of Judy

Wechsler and Jane Nesbitt from Champlain Valley AHEC, Sharon Mallory from Vermont

Department of Health’s Comprehensive Cancer Control Program, Judy Ashley from

Vermont Department of Health St. Albans District and Kim Dittus from Vermont Cancer

Center and Vermont Center on Behavioral Health. The planning committee from year 1

chose nutrition, physical activity and obesity as the roundtable topic that will remain

constant across the three years of the initiative. The strategy was communication,

education and training for year 1, and the planning committee decided to keep the

same strategy for year 2, as they had just gained momentum and wanted to continue

with related workgroup activities.

The Connecting Physical Activity, Nutrition and Obesity with Disease, Including Cancer

Workgroup’s objective was to create and launch one communication campaign in the

Champlain Valley region by May 2016. The workgroup gained momentum near the end

of year 1, when the Vermont Department of Health’s Chronic Disease Branch launched

the adaptation of San Diego’s 3-4-50 campaign that focuses on three risk factors

(nutrition, physical activity and smoking and substance abuse) to reduce four diseases

(cancer, heart disease and stroke, type 2 diabetes and respiratory conditions) that




Ed DeMott presents on Community partnerships in Vermont

Champlain Valley Healthy Lifestyles Collaborative (Vermont)

cause 50% of all deaths worldwide. The workgroup decided that it was the best use of

its time to help promote and increase the reach of the 3-4-50 campaign in Vermont in

year 2.

The Compilation and Dissemination of Obesity Intervention Resources Workgroup’s

objective was to produce and disseminate one document of compiled obesity

intervention resources in the Champlain Valley region by May 2016. Greater Burlington

YMCA, Vermont Blueprint for Health and Vermont Department of Health, organizations

with workgroup representation, launched www.MyHealthyVT.org during year 1 that

provides a list of community resources. The workgroup sought to leverage this new

website to increase its reach in year 2.


After words of welcome from the AHEC and GW Cancer Center organizers and brief

introductions, the day began with informative presentations from subject matter

experts. Susan Kamp from Vermont Department of Health presented first on 3-4-50 and

ways the Collaborative can contribute and add value. Dorey Demers from RiseVT

followed with a presentation on RiseVT’s activities and its partnerships with the

Franklin County hospital, health department and community. Finally, Ryan Torres from

Greater Burlington YMCA presented on MyHealthyVermont.org, the web-based

resource guide to chronic disease self-management programs.

Then, Penrose Jackson from the University of Vermont Medical Center and Ed DeMott

from the Burlington District Office of the Vermont Department of Health presented on

community-level partnerships. Penrose spoke about Accountable Communities for

Health, a statewide approach to support the integration of medical care, mental and

behavioral health sciences, social and community services and community-wide

prevention efforts. Ed presented on a new paradigm for community planning that

bridges the environment, community, opportunity and sustainability (ECOS) in

Vermont.

Finally, Paulette Thabault the School of Nursing at Norwich University provided a clinical

perspective and presented on the Intensive Behavioral Treatment

Weight Loss Program in Adult Primary Care.

After lunch, the Collaborative reviewed the pre-completed

Collaboration Multiplier Tool from the Prevention Institute

(Appendix C). The roundtable speakers, representing major nutrition

and physical initiatives in Vermont were asked about their 1) goals,

2) results and outcomes and 3) key strategies. Champlain Valley

AHEC then mapped their answers in the Collaboration Multiplier

Tool to identify common goals, outcomes and strategies that can be

tackled as a Collaborative.

15

http://myhealthyvt.org/

Then, the Collaborative broke out into workgroups for the second half of the meeting.

The workgroup topics pre-determined by the planning committee were:

Communications Workgroup (AKA Promoting Healthy Lifestyles with 3-4-50

Workgroup) with 11 members

Providers and Referrals Workgroup with 10 members

Participants joined the workgroups in which they were most interested. The GW Cancer

Center facilitated the workgroup discussions and workgroup leaders tracked key

information and planned activities using the Workgroup Activity Plan Worksheet

(Appendix B).

Each of the two workgroups planned activities over the next

year that will contribute to priorities and goals of all involved

parties. Workgroups discussed common goals, shared resources

and potential communication, education and training activities

that could reduce the health impact of obesity in Champlain

Valley. Activities included inviting stakeholders missing from the

meeting, including regional coordinators from Blueprint for

Health, which helps health care providers meet the medical and

social needs of people in their communities, such as through

medical homes, identifying clinics with electronic health records

with low referrals to the Diabetes Prevention Program.

Workgroups committed to communicating and meeting as

necessary, whether in-person or by conference call.

Evaluation



“Thank you for creating an environment where my ideas can be heard and feel

useful as I support others.”

“While at first I thought the morning was a little too process heavy, I think it was

well worth it and led to some very productive workgroups in the afternoon.”

“Thank you for keeping us on task and on time. Loved learning about the programs

and I am looking forward to promoting the stated efforts. Also great facilitation. I

appreciated how they could hear the comments, make sense of them and combine

the thoughts.”

“Great to have the workgroups clear in setting goals and getting organized for the

year. Great facilitation contributed to the successful outcomes for the day.”

Roundtable participants were also asked to complete an online survey before and after

the roundtable to assess changes in participants’ perceived capability to address

nutrition, physical activity and obesity; expectations of the roundtable; belief that they

16

GW Cancer Center facilitator guides workgroup discussions

Thank you for creating an environment where my ideas can be heard and feel useful as I support others.

Feedback from participants include:

will be able to make a difference in the field; perceived support and reinforcement of

their activities; and confidence, which showed mostly positive outcomes with several

indicators unchanged (Figure 16). Comments included:

“This is an important opportunity to have cancer, chronic disease and community

program folks together to learn from each other and to work collaboratively on

ways to enhance our collective ability to improve physical activity and nutrition as

interventions to reduce obesity related disease and cancer.”

“This was a fantastic event, which allowed myself [sic.] to learn and expand upon

statewide ideas and values that we're collectively working towards to change

health behaviors. Can't wait for next year!”

“The facilitators did a great job. Important conversation. I thought the goal setting

and next steps could have been stronger.”

“Great networking opportunity!”

Roundtable participants completed a survey to

assess changes in social networks before the

roundtable meeting in 2015 and 2016. The

average degree, or the average number of

relationships roundtable attendees have,

increased from 4.97 in 2015 to 9.31 in 2016,

and average distance, or the average number

of “hops” roundtable participants have to

make to reach any other person in the

network, decreased from 2.17 in 2015 to 2.06

in 2016. Both indicators show significant

improvement in the flow of communication



average (n=18)




Food and drinks provided at the roundtable were sufficient 4.82



Workgroup leader reports out on identified common goals, shared resources, barriers and potential areas of collaboration

17

18

Success Indicators

Pre-roundtable

average (n=23)

Post-roundtable

average (n=19)

I have the knowledge to address nutrition, physical activity and obesity

4.00 4.35

I have the skills and resources to address nutrition, physical activity and obesity

3.77 4.00


4.14 4.15

I expect to learn/have learned new skills, resources and opportunities at this roundtable

4.27 3.90


I can make a difference in addressing nutrition, physical activity and obesity

4.18 4.30

Making a difference in nutrition, physical activity and obesity is within my control

3.77 4.10

Participation in this roundtable will empower/has empowered me to contribute to addressing nutrition, physical activity and obesity

3.95 4.00

I have the support I need from the community in addressing nutrition, physical activity and obesity

3.59 3.55

I have the support I need from local government entities in addressing nutrition, physical activity and obesity

3.27 3.30

I have the support I need from state government entities in addressing nutrition, physical activity and obesity

3.23 3.65

I have the support I need from national government entities in addressing nutrition, physical activity and obesity

3.18 3.00

I have the support I need from academic entities in addressing nutrition, physical activity and obesity

3.14 3.35

I have the support I need from health systems entities (e.g. hospitals, insurers) in addressing nutrition, physical activity and obesity

3.18 3.35

I am confident in my ability to make a difference in nutrition, physical activity and obesity

3.73 3.80

I am confident in the ability of the roundtable members to make a difference in nutrition, physical activity and obesity

3.86 3.75

Addressing nutrition, physical activity and obesity is an overwhelming task

3.36 3.90



19

AHEC and GW Cancer Center Roundtable organizers

between roundtable participants overall. However, dyad

reciprocity, or the level of reciprocal relationships of

sending and receiving information between participants

decreased from 0.38 in 2015 to 0.21 in 2016, possibly

indicating that the Collaborative should improve back-

and-forth communication.


Seventeen members attended the six-month roundtable

follow-up conference webinar to celebrate progress,

discuss challenges and troubleshoot.

Communications Workgroup Updates

Workgroup objective: Support the 3-4-50 campaign at the local level by amplifying

Vermont Department of Health District Office efforts through engagement of

community partners, messaging on social media, public presentations and

dissemination of information.

Progress: Workgroup members reported contacting the three Health District offices to

coordinate efforts on a monthly basis. Each district is tracking community contacts

using an Excel spreadsheet that delineates the type of contact and whether follow-up is

necessary. Collaborative members then assisted the district staff with promotion to

established contacts, expanding the reach of the district partners from sectors with

whom workgroup members have a relationship, such as faith-based communities.

Workgroup members have also integrated social media messaging as part of their

respective organizations’ channels.

Workgroup members originally discussed using workgroup funds from GW Cancer

Center to create additional 3-4-50 promotional materials such as branded flash drives

with educational materials or grocery bags, but decided to look for more sustainable

outlets. The workgroup is, therefore, considering providing each District Office with

prepaid cash cards to use at three worksites in exchange for their commitment to

organize a workplace wellness event focused on one of the three activities identified in

3-4-50 (nutrition, physical activity and tobacco).

Providers and Referrals Workgroup Updates

Workgroup objective: Increase awareness and referrals to community-based self

management programs, especially for diabetes prevention.

Progress: Members added a Blueprint Regional Self-Management coordinator to the

workgroup to add relevant perspectives and identified four clinics that have electronic

health records and the ability to do panel management. The workgroup has faced

challenges increasing referrals to self-management offerings. For example, a cancer

Acknowledgments: Special thanks to Champlain Valley AHEC’s Judy Wechsler and Jane Nesbitt for coordinating the event, presenters for sharing their expertise, and workgroup leaders, Ed DeMott, Burlington District Department of Health; Jenna Schiffelbein, Norris Cotton Cancer Center; Pam Farnham, University of Vermont Medical Center; and Kristi Poehlmann, SASH Health Systems

oncologist, who is part of the workgroup, cannot refer her patients to

the diabetes self-management program, as referrals must come from

primary care providers. However, discussions and efforts are ongoing.

For example, workgroup members are creating scripts for providers to

initiate conversations with and encourage patients to attend self-

management programs.


The pre-roundtable work using the Collaboration Multiplier Tool took

some time to put together and commitments from key stakeholders

who were asked to contribute to populating the tool, but this helped

to narrow and focus discussions during the roundtable meeting.

Systems change work continues to be a challenge, especially for the

Providers and Referrals Workgroup, as some barriers, such as with

electronic health records and engaging busy clinicians, are out of

workgroup members’ spheres of influence and control. However,

workgroups can continue to identify activities that are both important

and feasible to achieve and partner with organizations that could

advance their efforts.

Conclusion

The second of three Champlain Valley Healthy Lifestyles Collaborative roundtables

convened key cancer and chronic disease stakeholders and continued information

sharing and amplifying regional efforts to tackle nutrition, physical activity and obesity-

related health effects. By continuing with the communication, education and training

approach, the workgroups are working to increase access to nutrition, physical activity

and obesity interventions by aligning with a state communication campaign and

streamlining referrals to self-management programs.

20

RiseVT demonstrates the “smoothie bike” during lunch hour. The bike boasts a blender powered by physical activity and is often used as an educational tool at community events


Thirty-one cancer, chronic disease and

community stakeholders convened on Tuesday,

May 3, 2016 in Tampa, Florida for the second of

three annual Florida Community Roundtables

(Figure 17).

Figure 18 and 19 are a social network map of

attendees in 2015 compared to 2016,

respectively. In 2015, eight attendees identified

as cancer professionals (indicated in blue),

three as chronic disease professionals (in

yellow), two as neither (in grey) and 18 did not

answer (white). In 2016, 11 attendees identified

as cancer professionals, four as chronic disease,

10 as neither and six did not answer. Between the 2015 and 2016 roundtables, cancer

professionals’ communication to the rest of the group increased from 16.9% to 42.5%,

respectively but communication from the rest of the group decreased slightly from

48.3% to 47.5%, respectively. Chronic disease professionals’ communication to the

rest of the group also increased from 48.3% to 61.2%, respectively and communication

from the rest of the group increased from 49.3% to 61.2%, respectively.


health educators, public health professionals, public or government employees, non-

governmental or non-profit organization professionals and community health workers

(Figure 20).

FLORIDA COMMUNITY ROUNDTABLE

21

Figure 17. Gulfcoast South region

highlighted in dark blue (Image

courtesy of Gulfcoast South AHEC)


year 1 Florida Community Roundtable (N=28)


year 2 Florida Community Roundtable (N=31)

Goal:

To promote increased integration of cancer and chronic disease efforts by convening key stakeholders and strengthening relationships at the state level.



2. Commitments from Gulfcoast South AHEC, Comprehensive Cancer Control stakeholders, chronic disease groups and community stakeholders to implementing health care coordination strategies to reduce the impact of obesity on Floridians’ health.

3. Consensus on an initial plan of action to address nutrition and physical activity and integration and collaboration of efforts in Florida.


Topic and Strategy

Gulfcoast South AHEC created a roundtable planning committee consisting of Ansley

Mora from Gulfcoast South AHEC, Susan Scherer from RN Cancer Guides, Venessa

Rivera Colon from Moffitt Cancer Center, Kristin Chesnutt from American Cancer

Society, Megan Carmichael from Pinellas Country Florida Department of Health, Lynda

Gowing from Pasco County Florida Department of Health and Katy Wilbur from

Manatee Country Florida Department of Health. Planning committee members from

year 1 chose nutrition, physical activity and obesity as the roundtable topic that will

remain constant across the three years of the initiative. The planning committee from

year 1 chose community-clinical linkages as the strategy for year 1.

The Community Health Resources

Workgroup’s goal was to increase

enrollment in the Diabetes Prevention

Program and Small Steps to Living Health

by holding a webinar presentation and

promoting the programs to at least one

health care organization in each of the 16

counties by June 2016. Workgroup

members surveyed providers to ascertain

the best format for providers to better

understand available community



22

Roundtable participants discuss ways community-clinical linkages can be leveraged to improve nutrition and physical activity in Florida

resources, which revealed that providers prefer one-page descriptions of resources,

costs and enrollment processes.

The Community Health Workers Workgroup’s objective was to support the efforts of

the Florida Community Health Worker Coalition by recruiting at least one organization

with which to partner to compile and disseminate “soft data” showing the value of

community health workers and volunteers by May 2016. Workgroup members

conducted an assessment and found from Teledoc surveys that community health

workers are most often involved in prevention, chronic disease management (including

diabetes, high blood pressure and cardiovascular disease), senior health services and

social services enrollment, but noted that cancer is not available as an answer option.

Workgroup members explored ways to add a question to the survey about community

health workers’ involvement in obesity prevention and nutrition services, as the

alternative of adding a question in the Behavioral Risk Factor Surveillance System,

which is financially prohibitive. The workgroup also identified that members of the

Florida Community Health Workers Coalition should be invited to the next roundtable

meeting to add value to discussion and activities.

Gulfcoast South AHEC also leveraged their experience convening the meeting and

relationships built during the roundtable to win a year-long contract from the Florida

Department of Health Comprehensive Cancer Control Program to coordinate the South

West Florida Cancer Control Collaborative, one of six regional

collaborative groups in the state.

The year 2 planning committee chose coordination between

health care professionals as the strategy.


The first half of the one-day meeting consisted of informative

presentations from subject matter experts. After words of

welcome from the AHEC and GW Cancer Center organizers and

brief introductions, Fabiola Figueroa from Moffitt Cancer Center

presented on the connection between diabetes and cancer and

community resources and Megan Carmichael from Pinellas

County Florida Department of Health presented on increasing

access to healthy weight programs. Then, a panel of health care professionals discussed

best practices, challenges and strategies to improve care coordination. Kristin Chesnutt

from American Cancer Society moderated the panelists: Zenaida Amador, a community

services specialist from Premier Community HealthCare Group, Dr. Julia Cogburn from

Florida Cancer Specialists and Research Institute, Dr. Jennifer Graybill from veriMED

Health Group and Susan Scherer, the CEO and founder of RN Cancer Guides, Inc.

After a short networking break, participants huddled into four professional groups: 1)

administrators and nurses, 2) navigators, community health workers and case

Florida Community Roundtable

23

Megan Carmichael presents on healthy weight projects and opportunities in Florida

managers, 3) health educators and 4) researchers, evaluators and

program managers. With guidance from GW Cancer Center, these

groups worked on elements of Prevention Institute’s Collaboration

Multiplier Tool (Appendix C). Each group discussed an issue most

important to the group pertaining to nutrition, physical activity and

obesity; their priorities and goals; desired outcomes; and expertise

and resources they can provide. The GW Cancer Center facilitators

then consolidated issues, priorities, goals, outcomes shared by the

groups into topics, such as data collection, resource sharing and capacity building and

behavior change education coordination. Participants then voted on the most

important and feasible topics to focus roundtable activities.

After lunch, participants reviewed the results of their votes, which determined the

workgroup topics:

Federally Qualified Health Centers (FQHC) Referrals Workgroup (AKA Resource

Sharing and Capacity Building Workgroup) with 10 members

Resources and Electronic Health Records Workgroup with 10 members***

Participants joined the workgroups in which they were most interested. The GW

Cancer Center members facilitated workgroup discussions and tracked key information

and planned activities.

Each of the two workgroups planned activities over the next year that will contribute

to priorities and goals of all involved parties. Workgroups further discussed common

goals, shared resources and health care coordination strategies that

could reduce the health impact of obesity in Florida. Planned activities

included recruiting information technology experts that could help

advise and troubleshoot challenges with health data management and

sharing, reaching out to public health professionals in other states that

have successfully created a data sharing infrastructure such as Colorado,

reaching out to FQHCs and developing a recall process with FQHCs,

patient navigators, community health workers and case managers for

community resources.

Workgroups committed to create specific, measurable, attainable,

realistic and time-bound (SMART) objectives and communicating and

meeting as necessary, whether in-person or by conference call.

Evaluation



“Love this event! Ansley and GW team are clearly passionate about what they do!”

24

The moderator guides a panel discussion about health care coordination in Florida

Participants vote on the most important and feasible topics to improve nutrition, physical activity and obesity in Florida

***Many participants, especially the panelists and speakers could not stay for the whole meeting, and did not

participate in workgroup activity planning and discussions

“Good discussion—as a newcomer to the meeting group and cancer collaborative,

it was very clear and useful.”

“Great job ladies. Thank you for opportunity to network. Made two great new

resources for our agency.”

“Great roundtable. However, I think many, including myself, are unsure or

confused about where to go from here. Don't feel like there will be a good follow

through with projects.”

“Overall good process- ample opportunity to provide feedback/input; lead to a

specific measurable, realistic goal- Exciting opportunity!”

“Food: Maybe hot meals in the future. Workgroups: Felt rushed for time. Meeting:

Maybe movement (not sitting for too long).”

Roundtable participants were also asked to complete an online survey before and

after the roundtable to assess changes in participants’ perceived capability to address

nutrition, physical activity and obesity; expectations of the roundtable; belief that they

will be able to make a difference in the field; perceived support and reinforcement of

their activities; and confidence, which showed mostly positive outcomes with several

indicators unchanged (Figure 22). Comments included:

“Although the roundtable was interesting it didn't help me in my line of work. It

was geared towards cancers and not the prevention of cancers through nutrition,

[physical activity], policy and environmental changes. In order to get more

attendees the roundtable should focus more on prevention through chronic

disease prevention efforts.”

Roundtable participants also completed a survey to assess changes in social networks

before the roundtable meeting in 2015 and 2016. The average degree, or the average

number of relationships roundtable attendees have, increased from 2.83 in 2015 to

4.43 in 2016, and average distance, or the average number of “hops” roundtable

participants have to make to reach any other person in the network, decreased from

2.12 in 2015 to 1.99 in 2016. Dyad reciprocity, or the level of reciprocal communication

between participants also increased from 0.42 in 2015 to 0.62 in 2016. All indicators

have improved, which is promising, and may be attributed to the inclusion of

Southwest Florida Cancer Control Collaborative (SWCCC) members to the roundtable.


25



average (n=18)







26

Success Indicators

Pre-roundtable

average (n=22)

Post-roundtable

average (n=13)

I have the knowledge to address nutrition, physical activity and obesity

4.00 4.46

I have the skills and resources to address nutrition, physical activity and obesity

3.77 4.23


4.14 4.08


4.27 3.46


I can make a difference in addressing nutrition, physical activity and obesity

4.18 4.23

Making a difference in nutrition, physical activity and obesity is within my control

3.77 3.92

Participation in this roundtable will empower/has empowered me to contribute to addressing nutrition, physical activity and obesity

3.95 3.77

I have the support I need from the community in addressing nutrition, physical activity and obesity

3.59 3.85

I have the support I need from local government entities in addressing nutrition, physical activity and obesity

3.27 3.69

I have the support I need from state government entities in addressing nutrition, physical activity and obesity

3.23 3.69

I have the support I need from national government entities in addressing nutrition, physical activity and obesity

3.18 3.54

I have the support I need from academic entities in addressing nutrition, physical activity and obesity

3.14 3.54

I have the support I need from health systems entities (e.g. hospitals, insurers) in addressing nutrition, physical activity and obesity

3.18 3.54

I am confident in my ability to make a difference in nutrition, physical activity and obesity

3.73 3.92

I am confident in the ability of the roundtable members to make a difference in nutrition, physical activity and obesity

3.86 3.85

Addressing nutrition, physical activity and obesity is an overwhelming task

3.36 3.31


Acknowledgments: Special thanks to Gulfcoast South AHEC’s Ansley Mora for coordinating the event. We would also like to thank presenters for sharing their expertise and workgroup leaders: Denise Benavides from American Cancer Society and Venessa Rivera Colon from Moffitt Cancer Center

The challenge for Florida in the next year will be to continue on this trajectory to

improve these indicators overall by engaging participants with meaningful direction and

work.


Sixteen members attended the six-month roundtable follow-up conference webinar to

celebrate progress, discuss challenges and troubleshoot and present the roundtable

charter outlining the purpose of the roundtable and workgroup objectives.

The FQHC Referrals Workgroup Updates:

Workgroup objective: Increase referrals from FQHCs to patient navigators, community

health workers, case managers and resources to increase health promotion behaviors.

Progress: A workgroup member organization shared with the rest of the group that it

hired a community patient navigator to assist community members through the health

system and refer them to resources.

The Resources and Electronic Health Records Workgroup Updates:

Workgroup objective: Coordinate data using electronic health records.

Progress: Workgroup members reached out to electronic health records and

information technology experts at the University of San Francisco and realized the

complexities of advancing activities to improve data infrastructure. In the meantime,

members of SWCCC, who are also part of the workgroup coordinated referrals and

resources to local survivorship and nutrition programs.

Although implementation of planned activities are limited, the SWCCC wishes to

“promote collaboration efforts between cancer and chronic disease stakeholders” as

part of their 2016-2018 strategic plan.


Anecdotal feedback and the social network analysis results show that the roundtable

meetings have generally helped to increase coordination and communication of state

and regional nutrition and physical activity programs and activities. However,

implementation of planned activities are slow. The Florida Community Roundtable can

continue to hold discussions with dedicated SWCCC stakeholders about ways to actively

involve chronic disease professionals that could add value and provide information and

resources untapped by cancer initiatives.

Conclusion

The first of three Florida Community Roundtables convened key cancer and chronic

disease stakeholders to discuss ways to tackle nutrition, physical activity and obesity-

related health effects. Workgroups are working to coordinate state and regional efforts

to compile resources and coordinate care. Some supplemental funding and taking a

more general approach such as policy, systems and environmental change, may be

beneficial to galvanize continued efforts.

27


Twenty-two cancer, chronic disease and

community stakeholders convened on

Tuesday, July 26, 2016 in Mitchell, South

Dakota for the second of three annual

South Dakota Community Roundtables

(Figure 23).

Figure 24 and 25 are a social network

map of attendees in 2015 compared to

2016, respectively. In 2015, two

attendees identified as cancer

professionals (indicated in blue), 10 as chronic disease professionals (in yellow), three

as neither (in grey) and five did not answer (white). In 2016, six attendees identified as

cancer professionals, five as chronic disease, three as neither and seven did not

answer. Between the 2015 and 2016 roundtables, cancer professionals’

communication to the rest of the group decreased from 5.3% to 0.0%, respectively,

but communication from the rest of the group increased from 11.6% to 64.8%,

respectively. Chronic disease professionals’ communication to the rest of the group

also decreased from 89.5% to 79.6%, respectively, and communication from the rest

of the group also decreased from 100.0% to 66.7%, respectively. Possible reasons for

why these indicators decreased overall will be discussed later in this report.

Figure 23. Northeast South Dakota region

highlighted in brown (Image courtesy of

Northeast South Dakota AHEC)

SOUTH DAKOTA COMMUNITY ROUNDTABLE

28


year 1 South Dakota Community Roundtable

(N=24)


year 2 South Dakota Community Roundtable

(N=25)

Goal:

To promote increased integration of cancer and chronic disease efforts by convening key stakeholders and strengthening relationships at the state level.



2. Commitments from Northeast South Dakota AHEC, Comprehensive Cancer Control stakeholders, chronic disease groups and community stakeholders to implementing community-clinical linkage strategies to reduce the impact of tobacco on South Dakotans’ health.

3. Consensus on an initial plan of action to address access to health and for integration and collaboration of efforts in South Dakota.


public or government employees, non-profit and non-governmental professionals,

public health professionals and health educators (Figure 26).

Topic and Strategy

Rachel Haigh-Blume from Northeast South Dakota AHEC partnered with South Dakota

Department of Health’s Comprehensive Cancer Control Program Coordinator, Lexi

Pugsley in year 1 and chose access to and utilization of health services as the

roundtable topic that will remain constant across the three years of the initiative and

community-clinical linkages as the strategy for year 1. Northeast South Dakota AHEC

representatives chose to keep the same strategy for year 2, as they did not want to lose

momentum and relationships that they had established in this arena during year 1.

The Community Health Workers and Patient Navigators Workgroup’s goal was to

promote comprehensive chronic disease patient navigation services by providing

annual training and technical assistance. The workgroup collectively chose three areas

of focus: 1) Educational initiatives, 2) Reimbursement and 3) Diversification of patient

navigator title and scope. However, with the changing policy landscape, the workgroup

reported experiencing challenges of retaining key workgroup members. The workgroup

agreed to re-engage members in year 2.




South Dakota Community Roundtable

29

The Stanford Model of Chronic Disease Self-

Management Workgroup’s goal was to increase the

number of sites offering Better Choices Better Health,

South Dakota’s evidence-based chronic disease

lifestyle change program, in community settings from

two to 20 by 2016. The workgroup added new

members from the Department of Health’s Better

Choices Better Health program and compiled data to

create a map of statewide Diabetes Prevention

Programs, Diabetes Self-Management Education

programs and Better Choices Better Health

workshops and community health centers served by

the Community Healthcare Association of the Dakotas (CHAD). The map was put

together to help to promote and implement currently available programs in South

Dakota.


The first half of the one-day meeting consisted of informative rapid fire presentations

from subject matter experts. After words of welcome from the AHEC and GW Cancer

Center organizers and brief introductions, there were five “rapid fire” stories outlining

timely and priority initiatives in South Dakota. Lexi Pugsley from South Dakota

Comprehensive Cancer Control Program at the Department of Health presented on

Cancer Survivorship and Patient Navigation Training; Sharon Chontos and Ben Tiensvold

from Sage Project Consultants presented on Community Health Worker

Implementation in South Dakota; Sarah Aker from the South Dakota Department of

Social Services presented on New Medical/Health Solutions Taskforce; Lori Oster from

Good and Healthy South Dakota, Vicki Palmreuter representing Better Choices Better

Health and Jessica Rappe from Northeast South Dakota AHEC presented on Better

Choices Better Health, Stanford’s Model of Chronic Disease Self Management; and Vicki

Palmreuter presented again on Health Behavior Assessment and Interventions.

Equipped with knowledge of best practices, success stories and issues related to health

care access and utilization in South Dakota, participants broke out into workgroups for

the second half of the meeting. The workgroup topics remained the same as year 1:

Community Health Workers and Patient Navigators Workgroup with 12 members

Stanford Model of Chronic Disease Self-Management Workgroup with eight

members

Participants joined the workgroups in which they were most interested. The GW Cancer

Center facilitated workgroup discussions and tracked key information and planned

Sharon Chontos and Ben Tiensvold present on Community Health Worker Implementation in South Dakota

30

activities.

Each of the two workgroups planned activities over the

next year that will contribute to priorities and goals of all

involved parties. Workgroups discussed common goals,

shared resources and community-clinical linkages that

could improve health care access and utilization in South

Dakota. Activities included creating and sending a survey

to clinicians to assess their level of engagement with

Better Choices Better Health and creating a way for

electronic health records to accurately reflect whether a

patient was referred to Better Choices Better Health and

whether they attended a Better Choices Better Health workshop, so providers have the

most accurate information about their patients’ care. However, after much discussion,

the Patient Navigation and Community Health Worker Workgroup decided that it was

not the best use of their time to work as a group, as the state was actively working to

establish patient navigation and community health worker standards and certification

processes. Participants in this workgroup, therefore, decided to contribute to the

Better Choices Better Health workgroup as much as possible.

Workgroups committed to create SMART objectives and communicate and meet as

necessary, whether in-person or by conference call.

Evaluation



“Loved the process, helped create partnerships to look at the problem from different perspectives.”


Process Indicators Post-roundtable average (n=13)







Workgroup participants discuss common goals, shared resources, barriers and potential areas of collaboration

31

Loved the process, helped create partnerships to look at the problem from different perspectives

Feedback from participants include:

32

“Missing year 1 discussions caused some disconnect.”

“We appreciated the facilitation and introduction. Thank you!”

“[Need] more time to provide each group’s report out at the end.”

Roundtable participants were also asked to complete an online survey before and

after the roundtable to assess changes in participants’ perceived capability to address

access to and utilization of health services; expectations of the roundtable; belief that

they will be able to make a difference in the field; perceived support and

reinforcement of their activities; and confidence, which

showed mostly declining outcomes (Figure 28). There

were no other comments.

Roundtable participants also completed a survey to assess

changes in social networks before the roundtable meeting

in 2015 and 2016. The average degree, or the average

number of relationships roundtable attendees have,

decreased from 6.50 in 2015 to 6.15 in 2016, and average

distance, or the average number of “hops” roundtable

participants have to make to reach any other person in the

network, increased from 1.52 in 2015 to 1.66 in 2016. Dyad reciprocity, or the

level of reciprocal communication between participants also decreased from

0.86 in 2015 to 0.64 in 2016. These indicators likely reflect challenges the South

Dakota roundtable experienced with AHEC leadership changes: South Dakota’s

AHEC director and coordinator, who played an integral role in the network,

stepped down in April 2016 and the position was not filled for six months, which

strained participant engagement and workgroup activity implementation.


Twelve members, including the new AHEC coordinator, attended the six-month

roundtable follow-up conference webinar to celebrate progress, discuss challenges

and troubleshoot.

The Stanford Model of Chronic Disease Self-Management Workgroup updates:

Workgroup objective: By 2016, increase the number of sites offering evidence-based

chronic disease lifestyle change programs in community settings from two to 20.

Progress: As a result of the roundtable meeting, two workgroup members initiated

discussion about creating an electronic health record system that facilitates “closing

the loop” of communication once a provider refers patients out to Better Choices

Better Health, to then be notified that the patient attended a Better Choices Better

Health workshop. A challenge discussed during the roundtable was that it was difficult

GW Cancer Center staff facilitate workgroup discussions


33

Success Indicators

Pre-roundtable

average (n=14)

Post-roundtable

average (n=8)

I have the knowledge to address access to health services 3.64 3.75

I have the skills and resources to address access to health services

3.43 3.50


3.64 3.50


4.00 3.13


I can make a difference in addressing access to health services

3.86 3.63

Making a difference in access to health services is within my control

3.43 3.25

Participation in this roundtable will empower/has empowered me to contribute to addressing access to health services

3.64 3.25

I have the support I need from the community in addressing access to health services

3.36 3.50

I have the support I need from local government entities in addressing access to health services

3.29 3.13

I have the support I need from state government entities in addressing access to health services

3.29 3.25

I have the support I need from national government entities in addressing access to health services

3.21 3.25

I have the support I need from academic entities in addressing access to health services

3.29 3.25

I have the support I need from health systems entities (e.g. hospitals, insurers) in addressing access to health services

3.43 3.38

I am confident in my ability to make a difference in access to health services

3.64 3.50

I am confident in the ability of the roundtable members to make a difference in access to health services

3.57 3.25

Addressing access to health services is an overwhelming task 3.86 3.88


Acknowledgments: Special thanks to South Dakota AHEC’s Chelsea Smith for coordinating the event. We would also like to thank presenters for sharing their expertise, and key stakeholders, Vicki Palmreuter from Better Choices Better Health and Lexi Haux from the South Dakota Department of Health

34

to transfer this information from the Department of Health that oversees Better

Choices Better Health back to the primary care provider in a Health Insurance

Portability and Accountability Act (HIPAA)-compliant manner. However, workgroup

members are considering using an encrypted email system to work around this barrier.

Workgroup members adapted smoking cessation referrals policies and created an

electronic referrals models policy for Better Choices Better Health and submitted for

approval by the South Dakota Health Department. The new system is anticipated to

be approved spring of 2017. Workgroup members also discussed using workgroup

funding provided by GW Cancer Center to create a flyer to promote Better Choices

Better Health to cancer survivors, which would engage participants who were originally

in the Patient Navigation and Community Health Worker Workgroup.


The absence of AHEC roundtable conveners due to their resignation hindered

roundtable progress between year 1 and 2. GW Cancer Center provided additional

orientation and coaching to the new AHEC staff members, and conducted one-on-one

calls with key roundtable stakeholders to increase engagement and identify common

goals and objectives on which participants can work together. It is important to identify

committed workgroup leaders that can spearhead and maintain momentum between

the annual roundtable meetings. However, reluctance to make significant progress

remained among participants due to uncertainties surrounding the North Dakota

Medicaid expansion and changing definitions and training requirements for Community

Health Workers and Patient Navigators. Many voiced that it may not be the best time

to plan and implement new initiatives before such external factors are resolved.

Conclusion

The second of three South Dakota Community Roundtables convened key cancer and

chronic disease stakeholders to re-energize workgroup activities. By taking a

community-clinical linkage approach, the workgroup is on track to expand the reach of

the Stanford Model of Chronic Disease Self-Management in South Dakota. Given some

of the aforementioned challenges and limited progress, the AHEC and GW Cancer

Center mutually agreed to discontinue the roundtable after the second year concluded.

FINAL CONCLUSION

There are risk factors common to several chronic diseases, including cancer, such as smoking, physical inactivity, poor

nutrition and barriers to health care access. The CDC has identified the need for coordination across disease-specific

programs such as the national comprehensive cancer control programs to reduce duplication of efforts and improve

health outcomes. The GW Cancer Center designed the Community Roundtables to integrate cancer and chronic disease

efforts in four states and applied social network analysis to study and monitor the development of relationships

between roundtable participants and improve program design and delivery.

The GW Cancer Center organized Community Roundtables in 2015 in partnership with AHECs in Kentucky, Vermont,

Florida and South Dakota with the goal of increasing cancer and chronic disease integration over three years by

convening key stakeholders and strengthening relationships between them. Roundtable participants include

representatives from comprehensive cancer control programs and coalitions, chronic disease programs, universities

and clinics. Participants create respective regional or state action plans addressing a chronic disease risk factor and

choose a different strategy yearly to ensure that the risk factor is addressed in a comprehensive manner over the span

of the three-year initiative.

Participants in each of the four states completed an online social network analysis survey before the roundtable in 2015

and again before the roundtable in 2016. The GW Cancer Center will administer the survey again before the last year of

the roundtables in 2017. These data were used to analyze and map social networks to assess relational ties and

direction of communication between stakeholders to determine changes in collaboration and inter-organizational

relationships.

The two roundtables that started with the strongest networks in 2015 were Kentucky and South Dakota. The average

degree, or the average number of people with whom each attendee communicates within the network, was 6.61 and

6.50, respectively. However, this indicator for both locations decreased in 2016 to 5.44 and 6.15, respectively. This

likely was the case for Kentucky due the expansion of topical scope from tobacco in 2015 to include electronic

cigarettes in 2016. The decrease in average degree reflects the addition of new stakeholders in the Community

Roundtable network. South Dakota’s average degree likely decreased due to the AHEC Director’s resignation. The

position was unfilled for six months, which impeded stakeholder engagement. On the other hand, Florida and Vermont

started in 2015 with relatively weak networks, with 4.97 and 2.83 average degrees, respectively. By the 2016

roundtable, average degree increased to 9.31 and 4.43, respectively. This and other social network analysis indicators

confirm anecdotal and qualitative feedback and will be used to inform areas for program improvement.

Limitations to the social network analysis presented in this report include the fact that the indicator used—the

frequency of communication between roundtable participants—may not be fully representative of meaningful

relationships. For example, it is assumed that more communication is better; however, to busy public health and

stakeholder professionals, concise and pointed communication may, in fact, be more meaningful than the sheer

amount of communication.

The roundtable pilot will end in 2017. The GW Cancer Center will produce a report that includes overarching

conclusions about best practices for future implementation, replication and potential expansion, in addition to a more

in-depth and broader analysis of social network data and indicators.

For more information on the Community Roundtables or Comprehensive Cancer Control Technical Assistance offered by GW Cancer Center, visit www.CancerControlTAP.org or contact us at [email protected]

35

http://smhs.gwu.edu/cancercontroltap/

mailto:[email protected]

36

Figure 29. Word cloud of qualitative feedback received in post-roundtable surveys from all four states

SUGGESTED CITATION

The George Washington University Cancer Center. Community Roundtables Year 2 Report: Bridging Cancer and Chronic Disease. Washington, DC, March, 2017.

DISCLAIMER

This work was supported by Cooperative Agreement #1U38DP004972-04 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.

37 Appendix A

Community Roundtable Facilitation Guide Goal: Integrate cancer and chronic disease efforts to decrease [health problem] in [area, region or state] by implementing [strategy] Facilitators:

Organize workgroup ideas that will populate the activity plan worksheet by helping to identify and summarize common ideas and prioritize actions

Ensure the workgroup finalizes an action plan that includes specific tasks, timelines and responsibilities focused on increasing workforce improvement to address [health problem] in [area, region or state]

Ensure workgroup comes to a consensus on future workgroup meeting organizer(s) and frequency and method of meetings

Workgroup Goal: complete the workgroup worksheets to develop action plan

There will be flip charts to take notes during brainstorming. The second page of the worksheet can be

used to record final decisions. Note: any off-topic questions or comments raised during discussions

can be noted in the “Parking Lot” on page 3 to be addressed in the next meeting.

Introduction (15 mins)

1. Review purpose (goal, desired outcomes)

2. Review process (use of worksheet, flip chart and assign note taker)

3. Have members introduce themselves

Workgroup Activity Plan Worksheet

1. Have workgroup members write their names and organizations on the first page after they

introduce themselves

2. Ask someone to volunteer and record decision points on page two. This person will also be in

charge of reporting out at the end of the day

3. Discuss what success looks like and record on the right side of the second page (20 mins)

4. Discuss and record SMART workgroup goal at the top of the page based on what was determined

success looks like (10 mins)

5. Discuss and record specific action steps, responsible person(s), due date in the matrix in the arrow

(20 mins)

6. Discuss and record critical success factors (e.g. what needs to be in place for the actions to

happen and be successful), which could be PSE change, behavioral or partnership factors, in the

circles below the arrow (10 mins)

7. Discuss and record who should be involved, including those not present at the roundtable on the

left side of the page (10 mins)

8. Decide and record when the next workgroup meeting is, how often the workgroup will meet, who

the organizer is, and how on the third page (5 mins)

38 Appendix A

2

Facilitator Tips during the Workshop

Maintain your role as facilitator. You may need to reiterate your role as the facilitator in the discussions, especially if your team is looking to you to make decisions for the team. The team members need to make decisions themselves, as they will be the ones implementing the action plan back home.

Get past a controversy or stalemate. If the team seems to be stuck on an issue, or someone will not give up on an idea that is not supported by the majority of the team:

o Record the issue or idea on flipchart paper as a “parking lot” idea or idea to come back to. During priority setting, the issue will either surface as a priority, or not.

o Ask for a quick vote by the team—this will give you (and the team) a sense of where the group stands on the issue. Often these kinds of issues are perpetuated by one or two people, and not the whole team. Go with majority intent of the team.

Give everyone a chance to provide input and be a part of the discussion. If someone or a few people in the team are dominating the discussion:

o Go around the table and ask everyone to state their idea/suggestion o Specifically ask for a person’s opinion/idea. Say “Let’s hear from those we haven’t heard

from yet,” ask another person on the team, “What do you think about this?” o Ask the person(s) dominating the discussion to allow a chance for others to provide

input. Say “Great ideas, now let’s hear what the other people on the team think.”

Manage the team’s time and avoid spending too much time on a task. If the team is particularly vocal on a given topic or task:

o It is fine to spend some extra time on a task, provided the team is productive and dealing with issues related to the topic or task. Once you notice that new information is not being discussed, or the team is rehashing the same points, encourage the team to move forward.

o If the team’s discussion is productive, but the time being spent on the issue is causing the team to get too behind in the overall task, record the main discussion points, and identify the issue as one that needs to be discussed in further depth at a future meeting. Move forward with the remaining tasks.

39 Appendix B

Workgroup Activity Plan Worksheet

Workgroup topic:

Workgroup member names and organizations (indicate workgroup lead with *):

Name Organization

COMMUNITY ROUNDTABLE

[Date] [Topic] [Strategy]

40 Appendix B

Task Responsible Person(s) Due date (mm/dd/yy)

WHAT DOES

SUCCESS LOOK

LIKE?

WHAT WILL YOU DO?

CRITICAL SUCCESS FACTORS

WHO SHOULD

BE INVOLVED?

SMART Workgroup Goal: ____________________________________________________________________

_________________________________________________________________________________________

41 Appendix B

“Parking Lot” questions and comments to be added to the agenda during the next workgroup meeting:

Next meeting (date and time):

How often the group is meeting:

Who is organizing the meetings:

How the group is meeting (in-person, conference call, etc.):

1

Expertise/Resources:

Results/Outcomes:

Key Strategies:


Results/Outcomes:

Key Strategies:


Results/Outcomes:

Key Strategies:


Results/Outcomes:

Key Strategies:


Results/Outcomes:

Key Strategies:


Results/Outcomes:

Key Strategies:

WHAT RESULTS/OUTCOMES CAN BE ACHIEVED TOGETHER?

WHAT PARTNER STRENGTHS CAN THE COLLABORATIVE UTILIZE?

WHAT STRATEGIES/ACTIVITIES CAN 2+ PARTNERS WORK TOGETHER ON? WHO TAKES THE LEAD (L) AND WHO PLAYS A SUPPORTIVE (S) ROLE?

Part II: COLLABORATION MULTIPLIER ANALYSIS

www.preventioninstitute.org

COLLABORATOR 1

COLLABORATOR 2

COLLABORATOR 3

COLLABORATOR 4

COLLABORATOR 5

COLLABORATOR 6

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Appendix C

year 2 report: bridging cancer and chronic disease · 2017. 4. 10. · ontents appendix :...

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