Dissemination and implementation of evidence-based programs (EBPs) for cancer prevention and control is essential to achieve public health outcomes [1–2]. EBPs are available through web-based resources such as the Guide to Community Preventive Services, Cancer Control P.L.A.N.E.T., Research-tested Intervention Programs, and Using What Works, all of which provide users with free access to a variety of cancer control recommendations, programs, and materials [3–6]. Although cancer control planners are encouraged by their organizations and funders to use EBPs, several barriers hinder their widespread adoption and implementation [7]. Organization-level constraints, lack of knowledge about EBPs and where to find them, and limited training to effectively adapt EBPs are among the most common barriers to using EBPs in regular practice [8–11]. In addition, barriers faced at the community-level, such as failing in adapting existing EBPs to “real-world” conditions [9], low awareness of local preferences [12], and failure to use local data during adaptation efforts [13] impede the success of effective dissemination strategies.

The Puerto Rico Community Cancer Control Outreach Program (CCCOP) was funded by the National Cancer Institute to develop and implement a cancer control outreach, research, and training program guided by community-based participatory research methods [14]. The CCCOP was the first Island-wide cancer control community-academic partnership established in Puerto Rico and is led by the University of Puerto Rico Cancer Center and The University of Texas MD Anderson Cancer Center. The CCCOP consists of a Network of community members and cancer control planners from various areas around the Island. The purpose of the CCCOP is to help identify and prioritize cancer control issues in the community (e.g. low access to breast cancer screening, Pap test screening, HPV vaccination, and tobacco cessation programs) and develop strategies for addressing those problems. Among the goals identified by the Network was to increase the adoption of EBPs for cancer control and to adapt these programs to fit their community context and values. Because the CCCOP sought to increase the Network’s capacity to deliver effective and culturally appropriate EBPs, understanding the Network members’ knowledge and attitudes about finding, choosing, adapting, and implementing EBPs in their communities was necessary.

As such, the CCCOP surveyed Network partners to assess their awareness of and experience using EBPs resources, as well as any type of training that might be needed to increase the use of EBPs in communities. Thus, the study goal was to identify gaps in EBPs awareness, use, and capacity to inform the further development of EBPs training tools and technical assistance to accelerate and expand the use of EBPs in Puerto Rico.

This is the first study to assess awareness of and experience using EBPs among cancer control planners in Puerto Rico. The study yielded several important findings. First, despite relatively high levels of confidence in adapting EBPs, there were low levels of awareness and use of existing resources for EBPs. Second, respondents’ prior use of EBPs resourceswas associated with several positive beliefs about EBPs and with their ratings for several program characteristics when choosing cancer control programs. Third, although prior use of EBPs resources was not associated with the need for any given training topic, perceived training needs across topics were high among all respondents. These findings underscore the importance of providing such training to address cancer control planners’ needs for finding, adapting, and implementing EBPs in communities in PR.

The high levels of confidence in adapting a program to fit local needs reported in this study could be the result of a misconception that adaptation simply means the translation of materials from English to Spanish rather than a systematic process using information from the community and available needs assessment data [16]. Additionally, since there were low levels of awareness and use of existing EBAs, it is likely that most respondents had never attempted to adapt existing EBPs in the past. The levels of awareness and use of EBPs resources found in this study were much lower (by almost half) than the levels reported by Hannon and colleagues [8] in a sample of 240 CPCRN cancer control planners across the United States. This does not seem to be due to access to these resources since most of the respondents had Internet access at work to search for EBPs web-based resources. Respondents’ positive beliefs about EBPs were also quite low as compared to the CPCRN study [8]; therefore, it might explain the low use of EBPs.

Among those respondents who had adopted or adapted a program in the last year, scientific evidence saying that the program works was the most cited reason for choosing such programs. Nonetheless, among all respondents (EBPs users and non-users) the percentage of who noted that scientific evidence of effectiveness was an important consideration was much lower than the percentage who endorsed this characteristic among CPCRN cancer control planners [8]. This finding could suggest the lack of awareness among CCCOP partners that using EBPs is a best practice. Another important finding is that several factors reported in the literature [8, 17–18] as important reasons for selecting programs, such as fitting into the organization’s budget, ease of implementation, and pressure from funder agencies were not highly mentioned among respondents when choosing programs. Thus, assessing all these factors before adapting cancer control programs is essential for achieving successful implementation [19].

Compared to EBPs users, non-users placed a higher value on program innovation and compatibility with the organization’s mission when choosing cancer control programs. Noonan and colleagues [20] have suggested that EBPs must be disseminated as complementary to an organization existing practices rather than competing products. As expected, and consistent with findings from the CPCRN study [8], respondents who had used any EBPs resource reported greater agreement with the statements that they know where to find EBPs and that EBPs are easy to find and get. In addition, compared to non-users, EBPs users were also more likely to agree with the statement that EBPs don’t come with very much information about how to implement them. These findings suggest that to facilitate the adoption and implementation of EBPs in communities, planners need materials such as implementation protocols or manuals that describe key components of the program and how it should be delivered [8].

Consistent with data from the CPCRN study [8], prior use of EBPs resources was not associated with endorsing the need for any given training topic. More than half of all respondents indicated a need for training in nine out of the ten topics assessed in the survey. Most respondents indicated that their organizations need training on identifying what program aspects can and cannot be changed and how to adapt programs and materials for cultural appropriateness. Implementing EBPs beyond the communities and contexts for which they were originally developed presents a major challenge that includes balancing program fidelity and adaptation to improve fit [21]. EBPs are often poorly adapted or implemented without their essentials components; this can weaken the program and compromise effectiveness [22]. Training programs aimed at supporting cancer control planners should address the issues of fidelity and adaptation. Intervention Mapping has been proposed as a tool to identify what program components must be retained and what of its elements can be adapted to better fit new settings and populations [21].

Current research on dissemination and implementation of EBPs has suggested the need for interactive training programs and technical assistance to guide cancer control planners through the process of finding, choosing, adapting, implementing, and evaluating EBPs [8]. Based on the findings from this study, such training should include messages to emphasize the importance of choosing programs backed by scientific evidence, increase positive attitudes toward EBPs, and address intervention and organizational characteristics when choosing EBPs. In addition, because successful dissemination of EBPs does not typically result from passive diffusion of programs into routine practice [9], training programs can increase the demand for EBPs [23].

Finally, research has shown a widening gap between the skills necessary to effectively deliver cancer control interventions and the current set of skills that public health practitioners have [24–25]. Any training program aimed at increasing EBPs dissemination and implementation must be tailored to assess users’ competences and skills. The CPCRN is in the process of developing an interactive tailored decision support and technical assistance tool to increase the capacity of both individuals and organizations for adopting and implementing EBPs [26].

An important strength of this study is that it captured a broad and diverse community-based perspectives related to cancer-related EBPs use in Puerto Rico. The findings from this study can help the cancer control movement in Puerto Rico develop training tools and to offer technical assistance to accelerate and expand the use of EBPs. A limitation of this study is that the sample size was too small to perform additional statistical analysis for some variables such as organizational and representative characteristics. Another limitation is that the findings are based on self-reported data. Due to the relationship of the partner organizations with the CCCOP Network; there is a possibility that current awareness and use of, and beliefs about EBPs were overestimated if respondents were influenced by social desirability [8].

Although the survey did not measure the influence of language as a potential barrier for accessing EBPs resources, since the majority of these resources are in English, Spanish-speaking cancer control planners may face additional challenges in identifying and adapting EBPs. Thus, existing and new resources for promoting EBPs must be developed in different languages to increase their penetration and acceptance among communities whose primary language is not English such as Puerto Ricans.

An understanding of current awareness and use of EBPs among cancer control planners in Puerto Rico is necessary to accelerate the use of effective cancer control programs in PR. Although current awareness and use of EBPs was low, respondents had some positive beliefs for EBPs and expressed the need for training. These results underscore the need for a robust training program and the offering of technical assistance to enhance the capacity of both individuals and organizations to successfully adopt and implement cancer control EBPs in their communities.