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Prevention of Cancer of the Cervix Program:
DL HIST
Public Education Program
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NT DEPARTMENT OF HEALTH . . ~ AND COMMUNITY SERVICESu
HISTORICAL COLLECTION
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Prevention of Cancer of the Cervix Program:
Public Education Program
DATE DUE
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ANOV 2000
Contents
Rationale 3
Program Goal 3
Defining the Eligible Population 3
Defining the Target Groups 4
Location of the Target Groups 4
Pap Smear Utilisation
inthe Northern Territory 7 Incidence of Cancer of the Cervix in the Northern Territory 9
Analysis of the Health Problem 9
Educational Goals 11
Resources 11
Constraints 12
Public Education Program Objectives 13
Strategies, Methods and Activities 13
Implementation Plan 14
Evaluation Plan 14
Appendix One: 17
Northern Territory Pap Smear Recruitment and Promotion
Strategies, Methods and Activities Booklet
Rationale
It is well recognised that cancer of the cervix is a disease which can usually be prevented if detected early (Department of Health, Housing and Community Services, 1991 Screening for the Prevention of Cervical Cancer p. 1). The detection of cancer of the cervix is achieved through the use of the Pap smear. The Organised Approach to screening has been developed to increase the rate of screening in a population and to improve the outcomes of women who have abnormal smears.
The Organised Approach to screening includes:
* systematic and coordinated methods of ensuring regular participation by women to attend screening and of notifying them of their results;
* outcome measures which monitor the technical quality of screening;
* mechanisms to ensure women receive appropriate assessment, counselling and treatment when necessary; and
* ongoing evaluation, monitoring and adjustment of screening and related services.
The effectiveness of cervical screening is strongly related to the percentage of women eligible for screening who attend for regular screening. Certain groups of women in the Northern Territory who are eligible for screening are currently under-screened. It is acknowledged that these women currently experience barriers to attending screening activities. This program has identified these factors so that appropriate recruitment and promotion strategies can be suggested to increase the number of Territory women have Pap smears. These strategies are outlined in the Northern Territory Pap Smear Recruitment and Promotion Strategies,
Methods and Activities Booklet which can be found at Appendix One.
Program Goal
To contribute to the well-being of women in the Northern Territory by reducing avoidable deaths from cancer of the cervix.
Needs Analysis
I .Defining the Eligible Population
The eligible population for screening for cancer of the cervix, as defined by the National Policy on Screening for the Prevention of Cervical Cancer is all women aged 18 to 70 years.
Total Northern Territory Population Total Female Population
Total Male Population Total Females aged 18 - 69
* Australian Bureau of Statistics 1991 Census
175 895*
84 294*
91 601 *
56 51 O* (approximately)
The eligible population for this screening program totals 56 510 Northern Territory women.
- - ( . . ) , 0
2.Defining the Target Group
It has been established in a number of recent Australian studies that the following groups of women who are eligible for screening are currently under-screened, or unscreened:
* older women ( aged 50 - 70 years)
* women from Non English Speaking Backgrounds (NESB): The Australian Bureau of Statistics defines these women as women who are born overseas in non-English speaking countries.
* Aboriginal women
(Australian Institute ofHealth, 1991 Cervical Cancer Screening in Australia: options for change p. 8).
NT women aged 50 - 70 years who do not describe themselves 8 614 (Approximately)*
as Aboriginal or NESB
Aboriginal women in the NT aged 18 - 70 10 71 O*
NESB women in the NT (in total) 5 458*
NESB women in the NT who describe themselves as speaking 1 271 * English 'Not Well' or 'Not at All.'
* Australian Bureau of Statistics 1991 Census
In the NT the potential target group members constitute 3 6% of the eligible population.
Various cultural issues and beliefs which discourage women from having Pap smears have been ascertained prior to the implementation of this program. Several strategies have been used to discover these factors: focus group activities and consultation with representatives of the target groups, health professionals and other related parties. Further examination of these issues will occur in the future through a survey of NT women and continuing consultation with target group members and service providers.
3. Location of the Target Groups
3 .1 Older Women ( women aged 50-70 years) excluding Aboriginal Women ( except Palmerston)
Alice Springs Region Barldy Region Darwin Urban Darwin Rural
East Arnhem Region Katherine Region Palmerston
* Australian Bureau of Statistics 1991 Census
2 048*
345*
4 066*
546*
230*
916*
359*
[
3.2 Aboriginal Women (aged 18-70) Alice Springs Rural
Alice Springs Urban Barkly Region East Arnhem Region Darwin Urban Darwin Rural Katherine Region
* Australian Bureau of Statistics 1991 Census
1 846*
1 084*
742*
1 524*
2 105*
1 886*
1 525*
3.3 Women from NESB who rate their English speaking ability as 'Not well,' or 'Not at all.' Includes all ages listed in town/ city localities only.
Alice Springs Darwin Katherine Palmerston Tennant Creek Nhulunbuy
* Australian Bureau of Statistics 1991 Census 93 992 20 36 17 12
The Australian Bureau of Statistics advises that in order to protect the identity of people from small groups, the numbers have been distorted to an extent. These figures should be taken as a guide only.
3 .4 Main Birthplace Countries from which each localities NESB Women Originate (In order of prevalence: the largest incidence is at the top of each area's list)
Alice Springs
Darwin
Katherine
Palmerston
Tennant Creek
Nhulunbuy
* Australian Bureau of Statistics 1991 Census
Germany Italy Viet Nam Greece China Viet Nam Philippines Malaysia Italy Germany Philippines Viet Nam Germany China Philippines Germany Greece Yugoslavia
Pap Smear Utilisation in the Northern Territory during the year 1992-1993
These statistics come from the Department of Health, Housing, Local Government and
Community Services' Health Insurance Commission. They do not include the smears tested by the laboratory at Royal Darwin Hospital, as this data is currently unavailable.
Type of Service
Cytological examination of smears from vagina or cervix for detection of pre-cancerous or cancerous changes.
Repeat cytological examination due to previous unsatisfactory routine smear.
Follow-up cytological examination of smears from the cervix in association with the management of previously detected abnormalities, or the
investigation of women with signs or symptoms suggestive of neoplasia.
Cytological examination of smears from the vagina.
Total
14 449
2
1 303 125 15 877
Utilisation of Pap smears by Population Areas (Post Codes) 1992 - 1993
Darwin Nightcliff Casuarina Malak Winnellie Berrimah Palmerston Howard Springs HumptyDoo Berry Springs Batchelor Adelaide River Pine Creek
Bathurst Island, Croker Island, Maningrida (etc) Katherin el
Tindal
Ngukurr and Mataranka Borroloola
Tennant Creek Alice Springs
Elliott, Ti Tree, Uluru (etc) Nhulunbuy
Alyangula Jabiro
Total Pap Smears
1 229
2 708 707
2 189 1 775
83 929 139 216 74 49 33 42
375
1 143 63 54 37 275 2 727 179 610
108 173
These statistics come from the Department of Health, Housing, Local Government and Community Services' Health Insurance Commission. They do not include the relatively small number of Pap smears taken in the Northern Territory public hospitals.
It is appreciated that due to the mobility of women in the NT, plus the fact that a number of women have more than one Pap smear in a year, that the data is flawed to a degree. However it is useful to compare the number of Pap smears taken in a particular locality to the number of elegible women in that locality. From this comparison localities which are not screening many women can be highlighted, and steps to improve the situation considered. It is expected that once the Cervical Cytology Register is established, useful information such as the number of women having a Pap smear every two years will become available.
The data does con.firm that in the Northern Territory, between 40% and 50% of women had at least a biannual Pap smear. This frequency is similar to the rest of Australia (Australian Bureau of Statistics, 1993 Women in Australia p. 63.).
The Incidence of Cancer of the Cervix in the Northern Territory Morbidity and Mortality Rates
Recent statistics on the morbidity rates for cancer of the cervix are currently unavailable. It is expected that data covering the period 1988-92 will be published early in 1994 by the NT Department of Health and Community Services. The available data ( 1981-1986) indicates the following:
Cervix Cancer
In Situ Invasive Mortality
N. T Aboriginal Women 24/100 000 26/100 000 29/100 000
N. T. Non-Aboriginal Women 64/100 000 14/100 000 2/100 000
Age standardised data supplied by the Northern Territory Department of Health and Community Services.
It can be seen from this information that:
Australian Women 38/100 000 10/100 000 4/100 000
1. Northern Territory Aboriginal women have a much higher mortality rate than other Australian and Northern Territory women from cervical cancer.
2. In Northern Territory Aboriginal women the incidence of carcinoma in situ appears from the statistics to be lower than in other Australian and Northern Territory women. The probable cause of this is that because many Aboriginal women are not having regular Pap smears, they are not being diagnosed until invasive cancer ( and its symptoms) develop.
3. In Northern Territory non-Aboriginal women the incidence of carcinoma in situ is significantly higher than in the rest of Australia.
Analysis of the Health Problem
The data from the needs analysis has provided information on how many NT women are eligible for a Pap smear every two years, the target groups, their population numbers and locations in the Territory plus pap smear utilisation data.
From this information we have learnt that our target groups are women aged over 50 years, women from Non English Speaking Backgrounds and Aboriginal women. We have also learnt that only 40% - 50% of all women in the Northern Territory are having either annual or biannual Pap smears. The result of this is an unacceptably high rate of both carcinoma in situ and invasive cancer of the cervix among Territory women.
In order to design and recommend strategies to encourage more women to have Pap smears, it is important to understand why they are not having regular Pap smears. Unfortunately it is difficult to identify these women personally to find out why they are not having regular Pap smears. In order to gather this information, various consultative activities were undertaken between September and December 1993. The women consulted included target group members, non-target group members and service providers. The information gained from these people has been categorised into three groups: predisposing, enabling and reinforcing factors. The following definitions are taken from Hawe, Degeling and Hall, 1990 Evaluating Health Promotion Sydney: MacLennan and Petty (p.247).
Predisposing: any characteristic of an individual, a community or an environment that predisposes behaviour or other conditions related to health. Predisposing factors include knowledge, beliefs, attitudes and socioeconomic status.
Enabling: any characteristic of an individual, group or environment that facilitates health behaviour or other condition affecting health, including any skill or resource ( or lack there of) required to attain that condition.
Reinforcing: any reward or punishment or any feedback following or anticipated as a consequence of the health behaviour.
It is important to prioritise these factors so that the recommended promotion and recruitment strategies can be prioritised. These factors have been prioritised based on the frequency they were raised during the consultative activities. It is appreciated that this is not a sound basis for prioritising them, and that ideally some form of survey would be a more accurate basis for prioritising them. It is hoped that during 1994 such a survey will be conducted, and from the results of the survey, the priority of these factors may change.
Predisposing
* forget to have a Pap smear
* lack of knowledge about Pap smears: the procedure and/or why you should have one
* having the wrong knowledge about how often you need to have a Pap smear
* inaccurate knowledge about who should have a Pap smear
* believing that they have more important things to do: usually caused by the pressure of caring for other people ( children, partners, parents etc)
* modesty and/ or embarrassment
* lack of knowledge about where you can get a Pap smear (includes women new to an area)
* fear of the procedure and/or the results of the test
* indifference towards having a Pap smear (especially among younger women)
* talking about Pap smears, even among female friends is considered embarrassing ( especially for some Aboriginal women)
Enabling
* the person taking the smear is considered inappropriate: male doctor, friend/acquaintance, avoidance relationship (in some Aboriginal communities)
* the health service providers in a remote area do not take smears due to lack of training or cultural/personal reasons
* recruitment/promotion message is in the wrong language: the message can't be understood
*
the woman considers the venue inappropriate: lack of privacy or it has a poor community image (For example community health centres on Aboriginal communities are historically linked to diagnosing STDs. Some women are concerned that if they are seen going to the clinic, people will think they have an STD).Reinforcing
* the woman finds the procedure 'unpleasant' or painful
* the woman's doctor does not suggest having a Pap smear during consultation for another matter, therefore the woman thinks having a Pap smear is not necessary It is important to remember that it is very rare for a health behaviour, such as not having regular Pap smears, to be caused by just one of the above factors (predisposers, enablers and reinforcers). Usually a health behaviour is caused by a combination of factors, and this combination varies from person to person. This is why it is important to use a variety of recruitment and promotion strategies to encourage more women to have regular Pap smears.
Educational Goals
* To motivate NT women to have a Pap smear every two years.
* To increase awareness among NT women of the need for regular Pap smears and to increase their understanding that a regular two-yearly Pap smear is an important step in preventing cancer of the cervix.
* To increase understanding among NT women about female anatomy, what cellular changes in cervical tissue mean, and what sort of treatment is available to prevent these cell changes becoming cancerous.
* To provide women in the NT with the information as to where Pap smears can be obtained and their cost (if any).
Resources
This program has been designed to maximise the utilisation of resources which are already in existence. Such existing resources include:
* Community Care and Community Health Centre Staff (including non-government clinics)
* Medical Officers: specialists, GPs and District Medical Officers
* Hospital Staff
* Health Promotion Officers
* Info Net
* Interpreter and Translator Services
* Community Libraries
* The NT Family Planning Association
* The NT Anti-Cancer Foundation
* Various community and government organisations which access the target groups
Financially the program is funded jointly by the Northern Territory Department of Health and Community Services and the Commonwealth Government. Funding has been guaranteed until June 1995. In 1995 the funding will be renegotiated for another four years. The annual budget for recruitment and promotion is approximately $50 000.
All Australian states and territories have established units specialising in promoting Pap smear utilisation and recruiting women to Pap smear activities. These units have all expressed a desire to assist the Northern Territory program. Contact names/addresses etc are listed in the Northern Territory Pap Smear Recruitment and Promotion Strategies, Methods and Activities Booklet.
The NT Department of Health and Community Services Women's Health Unit has established a Women's Health Network across the Territory. This network consists of health
professionals who have a special interest in women's health, and who, in addition to their normal work activities, can provide resources/information about women's health issues.
Contact details are found in the Northern Territory Pap Smear Recruitment and Promotion Strategies, Methods and Activities Booklet.
Two Registered Nurses (East Arnhem and Katherine) plus four Aboriginal Health Worker positions (East Arnhem, Katherine, Alice Springs rural and Barkly) have been established.
These positions will be attached to the Remote Area Well Women's Screening Program.
Screening for cancer of the cervix forms an important component of this program. These people will be able to provide information about Pap smears, and will play an active role in coordinating and evaluating Pap smear recruitment and promotion activities in their area.
A variety of educational resources which convey information about Pap smears and cancer of the cervix now exist. They include videos, flip charts and pamphlets and are detailed in the Northern Territory Pap Smear Recruitment and Promotion Strategies, Methods and Activities Booklet.
Constraints
The program deals with an area of health which is considered by some people inappropriate to address, in that it is related to the female reproductive organs. This factor relates particularly to the target groups.
The program aims to increase the utilisation of regular Pap smears among target groups who present a challenge because of their reduced access to common advertising methods, and their reduced understanding of the main language (English).
The program only has guaranteed funding until June 1995.
The program's funding is based on a per capita formula. This formula acknowledges the needs of an urban population only. There is no built-in consideration of the special needs of the Northern Territory, in particular the proportion of the target population which is Aboriginal and isolated.
The program does not have a full-time, central coordinator who could implement, monitor and
The program has inadequate funding to employ a dedicated person responsible for recruitment and promotion.
Public Education Program Objectives
* To provide a range of information and resources to community groups and service providers which will enable them to take steps to recruit more women to have regular Pap smears.
* By July 1995 60% of the eligible population will be having biannual Pap smears as demonstrated by the cervical cytology register.
* By July 1997 70% of the eligible population will be having biannual Pap smears as demonstrated by the cervical cytology register.
Strategies, Methods and Activities
The following definitions are from Egger, Spark and Lawson, 1990 Health Promotion Strategies and Methods, Sydney: McGraw-Hill p.10 -13 ..
Strategies: are broad tactics which aim to achieve the program's goal. Strategies concentrate on either individuals, groups or whole populations. There are two main strategies: socio- economic (which addresses poverty, lack of education, unemployment and social/cultural factors) and individualist ( which addresses inadequate information, lack of skills or a negative attitude). Both strategies have merit and should be incorporated into the program according to the appropriateness of the situation.
Methods: are procedures by which change is brought about within a target group, for example mass media and community development are two methods used to describe a host of activities aimed at modifying health behaviour within a community. The most important criterion for methods is acceptability within the target population. This is particularly important when we consider both our target groups ( older women, Aboriginal women and women from Non English Speaking Backgrounds) and the sensitive nature of our area of concern ( cancer of the cervix).
Activities: are the specific applications of the method selected. For example if mass media is the method to be used, producing a poster, a video or a television commercial would be activities using this method. A variety of health promotion activities should be used in trying to achieve the program goal. Again, consideration of the values and cultural norms of the target group must be considered when selecting activities. Ideally, target group members would be recruited to trial activities prior to implementation.
From the research and the consultation activities conducted over the past five months, a number of strategies, methods and activities have been compiled into the Northern Te"itory Pap Smear Recruitment and Promotion Strategies, Methods and Activities Booklet
(Appendix One). Please refer to this document for further information on the specific recommendations of this program.
Implementation Plan
The program was launched on Monday the 6th of December 1993. The launch was organised by the Women's Health Unit in consultation with a number of departmental and community group representatives. The launch consisted of a lunch and educational seminar in Darwin.
The launch was designed to attract media attention. This was achieved. Across the Territory, activities were conducted to raise public awareness.
The ongoing program implementation involves:
1) The appointment of Well Women's Screening Nurses and Aboriginal Health Workers to Katherine, East Arnhem, Barkley and Alice Springs Districts by March 1994.
2) The orientation and initial education of the Well Women's Screening staff on cancer of the cervix, and recommended recruitment and promotion activities by August 1994.
3) The ongoing purchase and distribution of educational resources to service providers, and other appropriate people.
4) The conduct of a survey to gauge Northern Territory women's attitudes, knowledge and behaviours with regards to cancer of the cervix and Pap smears by June 1994.
5) Ongoing facilitation of and working with community agencies in the provision of public education activities on cancer of the cervix and Pap smears.
6) The conduct of three media campaigns a year to promote and recruit women to have regular Pap smears: February, May and October.
7) Ongoing consultation with target group and service provider representatives to learn how effective the program is, and seek suggestions for improvement.
8) The monitoring of data on Pap smear usage in order to evaluate the program. This will be done at least once a year.
Evaluation Plan
A number of strategies will be adopted to assess the success or otherwise of this program.
Several questions will form the basis of this evaluation. These questions are:
* Should this program be continued in its present form?
* How can the program's activities be improved?
* Which strategies, methods and activities produce the best results?
* How much money should be spent on the program?
The evaluation will occur at a number oflevels:
Level One
Process Evaluation
Here evaluation is focused on whether people are in place to conduct the program and whether the necessary activities involved in accomplishing program objectives are being carried out. District managers ( or their delegates) will be asked to supply this information to the Women's Health Unit at least annually.
Level Two
Process Evaluation
Here evaluation is used to assess whether or not the program is being accessed by the target population, and if the cost of the program is under control. Evaluation strategies will include the examination of information from the Cytology Register and monitoring incurred costs regularly. Repeating the survey annually or every years would be very useful too.
Level Three Impact Evaluation
This level evaluates how efficient the program is at recruiting women to have a Pap smear.
Efficiency will be gauged by comparing activities to districts and the number of women from those districts having a Pap smear. The results of this evaluation will be used to answer the question, 'How can our efficiency be improved?' This form of evaluation should be conducted at least every year.
Leve/Four
Impact Evaluation
This level examines program effectiveness, that is -is the program motivating more women to have a Pap smear? As this program will be implemented before accurate data on Pap smear screening rates can be established, the program will be unable to produce true 'before and after' cause and effect data. Once the Cytology Register is established (late 1994) it will be possible to ascertain the Pap smear screening rate for the Northern Territory, and be able to compare it to the national rate, and then monitor whether or not the program is moving towards meeting it's objectives. In order to assess women's knowledge and attitudes towards cancer of the cervix and Pap smears, the survey which will be conducted early in 1994 will be repeated every two years.
Level Five
Outcome Evaluation
This level of evaluation measures the outcome validity of the program's goal, that is 'to
contribute to the well-being of women by reducing avoidable deaths from cancer of the cervix.' In early 1994, the latest edition of the Health Indicators for the Northern Territory will be published. A base-line mortality rate from cancer of the cervix will be established from this information. It is expected that this information will be provided annually in the near future.
Progress towards the program's goal can then be assessed more frequently and more accurately.
Level Six
This level of evaluation addresses the appropriateness of the program in the overall system of health care. The program will be assessed to see how well it is fitting in with other programs
with similar goals. The related programs are the Screening for Early Detection of Breast Cancer program and the Well Women's Screening program. Qualitative evaluation through interviews with service providers will provide the relevant information. This information should be compiled and considered every year.
