Historical report

Transcription

1 PapScreen Victoria Communications and Recruitment Program Historical report

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3 PapScreen Victoria Communications and Recruitment Program Historical report Produced by PapScreen Victoria and The Cancer Council Victoria September

4 PapScreen Victoria Acknowledgements Produced by PapScreen Victoria and The Cancer Council Victoria September 2006 ISBN Produced as part of PapScreen Victoria, the Victorian component of the National Cervical Screening Program. PapScreen s Communications and Recruitment Program is resourced through Commonwealth and State funding from the Victorian Department of Human Services. Additional copies are available from or by contacting: PapScreen Victoria The Cancer Council Victoria 1 Rathdowne Street Carlton Vic 3053 Australia Ph: (03) Fax: (03) papscreen@cancervic.org.au 2

5 Historical Report Contents ABBREVIATIONS 5 EXECUTIVE SUMMARY 6 Program highlights 6 INTRODUCTION 7-10 Program overview 7 STATISTICAL OVERVIEW Cervical cancer incidence and mortality 11 Screening participation 12 Early re-screening 14 COMMUNICATION AND RECRUITMENT STRATEGIES Communication strategies 15 Mass media 15 Direct mail 17 Resource development 18 Media relations 18 Education and training of health professionals 19 Community programs 21 Grants program 21 Peer education 23 Policy development and enhancement 24 Research and evaluation 25 3

6 PapScreen Victoria Contents TARGET GROUPS Young women aged 18 to Older women 28 Koori women 29 Women from diverse cultures 30 Vietnamese and other South East Asian women 32 Women with disabilities 33 Lesbians 35 Rural women 36 The community health sector 37 General practitioners 38 Nurse Pap test providers 39 Gynaecologists 40 Appendix 1: PapScreen Victoria research and evaluation reports

7 Historical Report Abbreviations CBRC Centre for Behavioural Research in Cancer Cancer Council The Cancer Council Victoria CLP Community Language Program CTA Clinical Teaching Associate DHS Department of Human Services GP General Practitioner HPV Human Papilloma Virus NHMRC National Health and Medical Research Council PCP Primary Care Partnership (the) program PapScreen Victoria Communications and Recruitment Program VAHS Victorian Aboriginal Health Service VCCR Victorian Cervical Cytology Registry VCS Victorian Cytology Service 5

8 PapScreen Victoria Executive Summary PapScreen Victoria, the Victorian Cervical Screening Program, is a joint Commonwealth- State funded program coordinated by the Victorian Department of Human Services (DHS). Since 1991, The Cancer Council Victoria has coordinated the program s communications and recruitment activities. The program works together with the Victorian Cytology Service (VCS), Victorian Cervical Cytology Registry (VCCR) and DHS to contribute to the reduction in the incidence and mortality from cervical cancer. This report is an overview of the activities and achievements of PapScreen s Communications and Recruitment Program ( the program ) as delivered by the Cancer Council between 1991 and Please note that in 1996, PapScreen s name changed from Pap Test Victoria to PapScreen Victoria. The Anti-Cancer Council of Victoria also changed its name in 2002 to The Cancer Council Victoria, and is referred to in this report as the Cancer Council. Program highlights It is not easy to summarise all of PapScreen s achievements during the 14-year period Highlights include: The program s contribution to the significant decrease in cervical cancer incidence and mortality rates; now both the lowest of all Australian states and territories. The enhanced role of nurses in cervical screening: an important strategy to increase screening rates, particularly of unscreened and under-screened women. In partnership with the University of Melbourne, the development of an integrated training program for medical students, GP registrars and practice nurses, enhancing practitioner skills in cervical screening practice. The development of world-first and first-class resources, including videos, brochures and audio resources. PapScreen also developed a highly successful mass media campaign, which has since been adopted by several other state cervical screening programs. 6

9 Historical Report Introduction Program overview Background The opportunity to screen for the early signs of cervical cancer became available in Australia in the 1950s with the introduction of the Pap test. This was the first opportunity to prevent cervical cancer and the Cancer Council quickly became involved. In the late 1950s, funds were provided to send a local pathologist overseas to train in cytopathology and for the Royal Women s Hospital to train pathologists 1. In the 1960s, two nurses were employed by the Cancer Council to run the first educational campaign and to introduce this new screening test to doctors and women. The Victorian Cytology Service (VCS) was set up in 1965 to receive, read and report on Pap tests and was funded for the first two years by the Cancer Council before the state government took over the funding role. The Cancer Council is still represented on the Board of Management today. In 1985, the VCS employed an epidemiologist and significant gaps were identified in screening in the Victorian community. An international report in 1986 revealed that cervical screening programs around the world had failed to achieve expected reductions in cervical cancer mortality, and outlined the key elements of a successful screening program 2. These included the need to focus on specific age groups where incidence is high, to re-screen at regular intervals, to have high rates of compliance and to appropriately follow up abnormal cytological findings. In 1987, the Australian Health Ministers Advisory Council established a national sub-committee for cervical screening to review progress and determine future directions. Its recommendations, published in 1991, suggested an organised approach to cervical screening and the establishment of a central registry to ensure all data were available for analysis. As a result, the Organised Approach to Preventing Cancer of the Cervix was established as a joint Commonwealth-State/Territory funded program in This program is known today as the National Cervical Screening Program. Meanwhile, in Victoria a number of initiatives were underway. In 1987, following a report from a Cancer Council working party Mass Screening for Cervical Cancer four recruitment campaigns were undertaken in rural areas, along with community consultation, to gain support for the establishment of a statewide cervical screening register. In 1989, the Victorian Cervical Cytology Registry (VCCR) was established, and the Well Women s Community Health Project implemented. This project, funded by the Victorian Health Promotion Foundation, influenced the way in which women s health services were offered in community-based agencies. In late 1991, the VCCR and the Cancer Council were jointly funded by the Victorian Health Promotion Foundation and the state government to run a three-year statewide education program, Pap Test Victoria ( ). This program aimed to increase screening rates among specific groups of women. Following the significant success of this program and under the auspices of the national Organised Approach to Preventing Cancer of the Cervix, the Cancer Council was contracted by the Victorian Department of Human Services (DHS) to develop and implement a three-year Communications and Recruitment Program strategy ( ) for the Victorian Cervical Screening Program. This was followed by a further five-year program strategy ( ). 1 Anti-Cancer Council of Victoria, PapScreen Victoria evaluation report volume one , Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria, Melbourne, 2001, p.iii. 2 International Agency for Research on Cancer, Working group on evaluation of cervical cancer screening programmes, Screening for squamous cervical cancer: duration of low risk after negative results of cervical cytology and its implications for screening policies, British Medical Journal (Clin Res Ed), vol. 293, no. 6548, pp ,

10 PapScreen Victoria Introduction Strategic framework Since the program commenced, PapScreen has operated within a strategic framework. Goals, objectives and screening targets Since 1991, the goals of the program have been: to decrease the incidence of cervical cancer among unscreened and under-screened Victorian women to decrease morbidity and mortality from cervical cancer among Victorian women, particularly those who have not been regularly screened. Detailed program objectives have evolved over the years. The primary objective of the first strategy, , was to increase screening rates of women in the specific target groups, with 75% of all women in Victoria having at least one Pap test within a three-year period by This goal was surpassed by the end of The objective of the strategy was to increase the proportion of women screened within a two-year period by: encouraging previously unscreened and poorly screened women into the program maintaining the high levels of screening among currently screened women 4. The screening targets for this period were: 66% of all eligible women aged 20 to 69 would have been screened at least once in the two-year period % of all eligible women aged 20 to 69 would have been screened at least once in the three-year period Both of these targets were achieved. Screening data indicate that 69% of eligible women were screened in the two-year period , and 81% of women in the three-year period In , the objectives were: to screen at least 70% of eligible women aged 18 to 69 during a two-year period to improve the screening rates of unscreened and under-screened women to increase screening rates among identified priority groups of women to monitor data on morbidity and mortality rates of cervical cancer in Victorian women to encourage general practitioners (GPs), nurses and gynaecologists who do not usually provide screening services to participate in the screening program to encourage service providers to adhere to the National Health and Medical Research Council s (NHMRC) cervical screening policy to reduce the barriers to cervical screening as perceived by women and health professionals to improve and enhance the cervical screening knowledge of community health professionals to enhance and maintain high-quality screening services, incorporating sensitive screening practice by GPs and nurses 6. Since significant gains had been achieved in screening rates over the previous five-year period, it was thought that screening targets would reflect maintenance rather than more significant increases. The screening target set, therefore, was that at least 70% of eligible women aged 18 to 69 would screen once during a two-year period 7. However, this target proved difficult to achieve. During the two-year period , 65% of eligible Victorian women aged 18 to 69 had a Pap test Anti-Cancer Council of Victoria, Pap Test Victoria , final report, Anti-Cancer Council of Victoria, Melbourne, 1995, p.2. 4 Anti-Cancer Council of Victoria, PapScreen Victoria communications and recruitment strategy , final report, Anti-Cancer Council of Victoria, Melbourne, 2000: vii. 5 ibid., p.4. 6 Anti-Cancer Council of Victoria, PapScreen Victoria communications and recruitment strategy , Anti-Cancer Council of Victoria, Melbourne, 2000, p.6. 7 ibid., p.7. 8 Victorian Cervical Cytology Registry, Statistical Report 2005, Victorian Cervical Cytology Registry, Melbourne, 2006, p.8.

11 Historical Report Introduction Principles and values Since 1991, the program s values and principles have embraced women s rights to information, a high-quality screening service and a provider of choice; the need to develop and maintain coordinated, sensitive, flexible, cost-effective and sustainable strategies; the development of productive community and professional partnerships; and a commitment to research and evaluation 9. Intervention strategies The strategy was implemented as a rolling campaign on a regional basis over the three-year period, with one metropolitan health region targeted each year, together with one or two rural regions. The key intervention strategies were: a low-profile media campaign personalised letters of invitation sent to women aged 50 to 69 a program providing information and educational materials to GPs a program offering grants to community agencies to develop activities to reach particular groups of unscreened and under-screened women research and evaluation activities to guide, support and evaluate the program. The strategy employed very similar approaches, including personalised letters of invitation, communications, community action, communicating with Pap test providers, and research and evaluation activities. The strategy proposed: mass communication through paid and unpaid media campaigns and promotions, as well as targeted message and resource development education and training of health educators, nurse Pap test providers, GPs and gynaecologists to ensure understanding of the issues related to cervical screening the development of community programs to ensure women are reached in appropriate settings and sustainable ways policy development and enhancement, including formulating PapScreen-specific policies, contributing to relevant state and national policies, and keeping abreast of potential issues with relevant groups and organisations research and evaluation, including campaign research and development, literature reviews, data monitoring and the design and implementation of specific studies. 9 Anti-Cancer Council of Victoria, PapScreen Victoria communications and recruitment strategy , Anti-Cancer Council of Victoria, Melbourne, 2000, p.5. 9

12 PapScreen Victoria Introduction Target groups The early strategy nominated women aged 50 to 69, followed by women from rural, non-english-speaking and low-income backgrounds, Koori women and women with special needs, such as women with disabilities. Based on emerging data on incidence and screening rates, in the next three-year period ( ) these target groups were broadened to include: unscreened women aged 25 to 69 women from Vietnam and South East Asia Koori women women from other culturally diverse backgrounds rural women women with disabilities lesbians. The strategy focused on: unscreened and under-screened women aged 18 to 69, with a particular focus on young women aged 18 to 39 and older women aged 50 to 69 Koori women GPs and gynaecologists. The strategy also provided support and enhancement initiatives to: lesbians women with disabilities women from culturally diverse backgrounds nurse Pap test providers 10 the community health sector Originally termed nurse practitioners. 11 Originally termed community health practitioners.

13 Historical Report Statistical Overview Cervical cancer incidence and mortality The number of new cases of cervical cancer in Australia has declined since the National Cervical Screening Program commenced in In 2002, 555 new cases were reported in the target age range 20 to 69, compared with 894 detected in In Victoria, age-standardised incidence rates for women in the target age range have declined from 11.9 per 100,000 women in the period to 7.7 in the period This represents a rate significantly below the national rate of 9.7 per 100,000 women 13 and is the lowest incidence rate of all Australian states and territories. Nationally, deaths from cervical cancer of women of all ages declined from 337 in 1990 to 212 in Deaths of women aged 20 to 69 declined from 246 to The most recent available mortality data for Victoria indicate similar declines. In , a total of 104 Victorian women aged between 20 and 69 died of cervical cancer, an agestandardised death rate of 1.6 per 100,000 women 15. This represents a decline from the previous four-year period ( ), when 124 women aged 20 to 69 died, an age-standardised rate of 2.0 deaths per 100,000 women 16. This is a significant achievement and represents the lowest mortality rate of all the states and territories as well as a figure lower than the national rate of 2.1 per 100,000 women 17. Figure 1: Cervical cancer incidence & mortality, Victoria, Rate per 100,000 women Incidence Mortality Year of diagnosis / death Source: Victorian Cancer Registry Reports, Australian Institute of Health and Welfare (AIHW) Cervical screening in Australia , AIHW cat. no. 28. Canberra: AIHW. Cancer Series no. 33. p ibid., p ibid., p ibid., p ibid., p ibid., p

14 PapScreen Victoria Statistical Overview Screening participation There have been significant changes in screening participation since the start of the statewide screening campaign in 1991; however, accurate and comparable data are only available from Two-yearly screening rates peaked at 70% in However, between 2000 and 2003, screening rates declined in both two- and threeyearly intervals. As indicated below, this apparent decline in screening rates has been attributed in large part to changes in data collection and analysis methods. Age-related screening participation rates over two and three years show a similar slow decline, except in the 60 to 69 age group. Overall, younger women aged 20 to 29 and older women aged 60 to 69 have lower screening rates than women aged 30 to 59. The VCCR provided three possible reasons for this apparent decline in screening in Victoria: 1. In 2001, new data became available on estimates of the proportion of women who have a cervix, eliminating those who have had a hysterectomy. Based on these new data, substantially more Victorian women are eligible for screening compared with previous estimates provided in 1995, meaning that previous screening rates may have been over-estimated. 2. VCCR has progressively improved its record-linkage since 1999, so that now women are more accurately identified. 3. A television mass media campaign had not been run in Victoria since Table 2 indicates that the national screening rates also show a slight decline since a peak in This suggests that the first two reasons provided above for a decline in Victorian rates, while valid, may not be the entire reason. There could also be genuinely less participation in more recent years, affected by the lack of a television campaign and other unknown factors. Due to this decline in screening, in 2004 PapScreen implemented a mass media campaign resulting in Victoria s first increase in screening rates since Due to its success, the mass media campaign was repeated in 2005, and consequently in , a second increase in two-yearly participation rates is apparent. Both campaigns particularly targeted women aged 40 to 69, and during and , an increase in screening rates in these age groups is apparent H Mitchell, C Burrows, V Scott, Statistical report 2002, Victorian Cervical Cytology Registry, Melbourne, 2003, p.6-7.

15 Historical Report Statistical Overview Table 1: Screening participation of Victorian women by age on a two-year basis Age group % 61% 61% 58% 62% 58% 56% 57% 55% 54% 54% % 74% 75% 73% 74% 71% 70% 67% 66% 67% 67% % 72% 75% 74% 75% 73% 74% 69% 69% 70% 70% % 71% 81% 75% 74% 74% 76% 70% 70% 72% 72% % 51% 58% 55% 58% 56% 58% 58% 58% 60% 61% NA 67.0% 70.0% 67.7% 69.0% 67.0% 66.6% 64.4% 63.9% 64.4% 65.0% Source: VCCR statistical reports Table 2: Screening participation of eligible Australian women on a two-year basis Age group NA NA 62.4% 64.4% 65.4% 63.1% 61.1% 61.0% 60.7% 60.7% NA Source: AIHW statistical reports Table 3: Screening participation of Victorian women by age on a three-year basis Age group NA 78% 78% 74% 77% 76% 72% 72% 71% 70% 69% NA 89% 89% 87% 86% 86% 85% 80% 81% 81% 81% NA 85% 87% 86% 86% 86% 87% 81% 81% 82% 82% NA 81% 89% 84% 84% 84% 87% 80% 80% 82% 82% NA 61% 65% 63% 65% 66% 65% 66% 66% 67% 68% NA 81.0% 83.0% 80.4% 81.2% 81.0% 80.2% 77.0% 76.9% 77.0% 77.1% Source: VCCR statistical reports 13

16 PapScreen Victoria Statistical Overview Early re-screening Significant and continuing declines have been achieved in unnecessary early re-screening of women with normal results. The current National Cervical Screening Program policy recommends that women with a normal Pap test result be re-screened in two years. However, a considerable number of women are re-screened earlier than this, a pattern that is of no great benefit and has significant cost implications. Data on early re-screening are available from 1996, when 43% of women were re-screened within 21 months of a normal Pap test result. This rate declined steadily over eight years to 26% in The declining trend appears to be reflected across all age groups, with early re-screening rates highest among women aged 30 to 39 and lowest among women aged 60 to 69. Table 4: Percentage of Victorian women re-screened within 21 months of a normal result Age group NA NA NA NA NA 32% 30% 26% 26% NA NA NA NA NA 35% 33% 30% 29% NA NA NA NA NA 33% 32% 28% 27% NA NA NA NA NA 32% 30% 27% 25% NA NA NA NA NA 26% 24% 22% 20% % 41% 37% 34% 35% 32% 31% 27% 26% Source: VCCR Victorian Cervical Cytology Registry, Statistical Report 2005, Victorian Cervical Cytology Registry, Melbourne, 2006, p.19.

17 Historical Report Communication and Recruitment Strategies Communication strategies Since 1991, the program has used a range of public relation activities to deliver its messages, including writing newsletter articles, liaising with stakeholders, training spokespeople and preparing position statements. Information is provided below on mass media and direct mail strategies, resource development and media relations. Mass media During , the media strategies included mainstream and multicultural campaigns ranging from low-key community service announcements, radio interviews and press coverage in local papers to a paid radio campaign and extensive print media coverage. Anecdotal evaluation indicated that women received the campaigns positively. Increases in screening rates occurred in 1994 when the media campaign and a medico-legal case involving undetected cervical cancer hit the press simultaneously. The multicultural focus was assessed as successful following an 8% increase in screening rates in postcode areas with a high population of women from diverse cultures compared with postcode areas with less culturally diverse populations 20. In the period, the program appointed the first dedicated public relations officer, resulting in significantly increased media coverage in subsequent years. Again, a mix of targeted and mainstream media campaigns was implemented, involving radio, television and print media. In 1997, a multicultural media campaign resulted in a 5% increase in screening in postcode areas with high populations of women from diverse cultures compared with postcode areas with less diverse populations 21. In 1998, a radio and press campaign was held in English that involved both paid and unpaid media in metropolitan and regional media. This resulted in increased screening among women aged 50+, with a lower increase evident among women aged 35 to 49; however, a decrease was recorded among women aged under Commonwealth media campaign featuring Geraldine Doogue 20 Anti-Cancer Council of Victoria, Pap Test Victoria , final report, Anti-Cancer Council of Victoria, Melbourne, 1995, p Victorian Cervical Cytology Registry, PapScreen Victoria: impact of the NESB media campaign, Unpublished report, Anti-Cancer Council of Victoria, PapScreen Victoria communications and recruitment strategy , final report, Anti-Cancer Council of Victoria, Melbourne, 2000, p

18 PapScreen Victoria Communication and Recruitment Strategies Commonwealth media campaign, Don t Make Excuses, Make an Appointment In 1999, PapScreen extended the four-week national television advertising campaign, Don t make excuses, for a further eight weeks. This successfully increased the number of daily Pap tests by 16% during the campaign period, and resulted in an increase in women s awareness of screening messages 23. During the period, communications interventions were targeted to young women (print media), older women (radio, television, print and an infomercial on the Good Health TV channel, which was screened only in medical practices), and women from diverse cultures (radio and print media). Different language groups were targeted each year: 2000 Arabic, Mandarin, Polish, Russian and Serbian women 2002 Chinese, Greek, Italian, Spanish and Vietnamese women aged over Bosnian, Croatian, Serbian, Polish and Filipino women. In 2004, PapScreen implemented its first mass media campaign since It was the first time the program had created and run its own television campaign. Following a successful launch in July 2004, the Don t Just Sit There radio and television advertisement screened for three and a half weeks. During the campaign period, the number of daily Pap tests increased by 18.3%, then settled back to pre-campaign levels. The greatest percentage increase (40.3%) was in the group who had not had a Pap test for more than 36 months. There was an increase in the group who had allowed 24 months to three years to elapse (up 22%), and among those who had never had a Pap test (up 21%) 24. Due to its success, the campaign was repeated for a seven-week period during May and June In addition to the paid advertising during this period, over $90,000 worth of bonus television spots were acquired, and more than 80 free print filler advertisements were placed in The Age. This 2005 campaign also resulted in significant increases in cervical screening in Victoria. During the campaign period, the number of daily Pap tests increased by an average of 15.3%. Again, the greatest percentage increase occurred among those who had not had a Pap test for more than three years (up 34%), but there were also increases in the group who had allowed between 24 months to three years to elapse (up 17%), among those who had never had a Pap test (up 19%) and among those who were 12 to 24 months overdue (up 12%). Although the percentage changes were smaller than in 2004, they were sustained over a longer period as the campaign in 2005 was longer in duration ibid., p R Mullins, Evaluation of PapScreen Victoria s 2004 media campaign, Unpublished report prepared by the Centre for Behavioural Research in Cancer for PapScreen Victoria, 2005, p R Mullins, Evaluation of PapScreen Victoria s 2005 media campaign Don t just sit there. Prepared by the Centre for Behavioural Research in Cancer for PapScreen Victoria, Unpublished report, Melbourne, 2006.

19 Historical Report Communication and Recruitment Strategies Direct mail The direct mail approach sending letters to women inviting them to have a Pap test has been used a number of times since the program began. During , 363,000 letters were sent to women aged 50 to 69 in identified regions on a staggered basis over several years. This resulted in a 45%-49% increase in screening in women aged 60 to 69 in the campaign regions, compared to a 7%-14% increase in women in control areas. Increases were smaller in the group aged 50 to During ,160,900 letters were sent to unscreened and under-screened women aged 40 to 59 and 2500 letters to younger women aged 25 to 39. A brochure including a message in 10 languages other than English was included with each letter. Research showed that this approach was largely acceptable to women, and that 6.4% of the older women were screened within three months of receipt of the letter. This rose to 8.2% within a six-month period when a media campaign was also in place. However, similar response rates were identified among women who received the letter during the media campaign and those who were exposed to the media campaign but did not receive a letter 27. Research to assess the impact of the direct mail approach among younger women involved observing two groups of women for five months. The active group received the letter plus the media campaign; the control group were exposed to the media campaign on its own. Increased levels of screening were observed in the active group at three months; however, there was little difference between the active group and the control group at five months 28. During the period, 193,529 letters were sent to unscreened and under-screened women aged 50 to 69. Of the women who were eligible to respond (i.e. those who hadn t had a hysterectomy), 12.2% had a Pap test within six months of receiving the letter. This equates to nearly 9000 unscreened and under-screened women having a Pap test. Four different versions of the invitation letter were also used. An evaluation found that while there were no significant differences in terms of women presenting for a Pap test, the letter on PapScreen letterhead framed to emphasise the gain from having a Pap test appeared to be more motivating Anti-Cancer Council of Victoria, Pap Test Victoria , final report, Anti-Cancer Council of Victoria, Melbourne, 1995, p Anti-Cancer Council of Victoria, PapScreen Victoria communications and recruitment strategy , final report, Anti-Cancer Council of Victoria, Melbourne, 2000, p Victorian Cervical Cytology Registry, PapScreen Victoria: impact of electoral letters to women aged years, VCCR Evaluation Project No 3, Melbourne, R Mullins, Evaluation of a strategy to increase cervical screening through the use of personalised letters, Unpublished report prepared by the Centre for Behavioural Research in Cancer for PapScreen Victoria, 2005, p.6. 17

20 PapScreen Victoria Communication and Recruitment Strategies Resource development A wide range of resources has been developed over the years. Highlights include: For All Women: The Pap Test video, translated into 18 languages and adapted for women with a hearing disability brochures and fact sheets for women produced in languages other than English and for women with visual and intellectual disabilities the launch of the PapScreen website in 2001 development of the human papilloma virus (HPV) booklet in 2002, which resulted in an immediate distribution of over 25,000 copies and a continuing strong demand development of the Lesbians Need Pap Tests Too brochure, which generated a wide response right round Australia and internationally. One of PapScreen s most requested resources, the HPV booklet Media relations By working with the media, PapScreen has acquired positive coverage, which assists in delivering the program s key messages. Prior to 2003, approximately six media releases were issued each year. These releases were mostly a component of the communications strategy, but in some cases were in response to issues. Table 5: Media activities carried out during 2003 to 2005 Year Unprompted media enquiries Media releases issued Clips/news items branded PapScreen

21 Historical Report Communication and Recruitment Strategies Education and training of health professionals In , innovative approaches were trialled to encourage GPs to increase screening in their practices. Through a peer education program, over 300 GPs were visited in their practice. Although research indicated this was a highly acceptable strategy to GPs, it did not result in significantly higher levels of screening in the intervention postcode areas compared with the control areas 30. Over the same period, 79 nurses were trained in taking Pap tests: initially through Pap Test Victoria and subsequently through Family Planning Victoria. This was seen to be an important strategy, as nurses screened a higher proportion of unscreened and under-screened older women compared to other service providers. Education programs were also delivered to over 500 community health workers, 60 Aboriginal health workers and hospital liaison officers. During the strategy period, PapScreen placed an increased emphasis on communicating with Pap test providers as a means of encouraging and supporting the GPs and nurses who undertake cervical screening in Victoria. Strategies included the development of partnerships with peak medical, health and community organisations and key individuals, and presentations at professional settings such as the Royal Australian College of General Practitioners Annual Conference. Since 1997, the Department of General Practice at the University of Melbourne has provided GP liaison services to PapScreen. Initially, a major activity as part of this consultancy was the redevelopment of the PapScreen Clinical Audit, a practice-based activity for GPs. The audit aimed to review systems within general practice that help to identify and target unscreened and under-screened women. The audit was offered to GPs in the and trienniums, and during these periods more than 600 GPs completed the audit. Since 1999, a nurse consultant has provided support to PapScreen s strategies related to nurse Pap test providers. This appointment has helped increase recognition of the vital role of nurses in providing cervical screening to women, particularly to those in the older age groups and in rural and remote areas. In the period, Family Planning Victoria was funded to undertake a range of training activities targeting nurses, and the PapScreen grants program supported many local nurse-based screening services. The proportion of Pap tests taken by nurses steadily rose from 0.8% in 1996 to 2.5% in A range of education activities was also provided for community health workers: 25 seminars attended by over 500 community workers, cervix update seminars at the Royal Women s Hospital attended by 60 workers, and Cancer Update Seminars attended by 84 workers. Two education manuals for community workers and a campaign kit to encourage local activity during media campaigns were prepared. The period saw ongoing work to support nurses, including education and networking seminars across Victoria, regular mail-outs and updates, and grants to support nurse-based services through clinic extension and media work. PapScreen continued to work with Family Planning Victoria and funded inservice sessions for nurses involved in Pap test provider training. The University of Melbourne developed an accredited Pap test provider training course targeted to practice nurses. To encourage enrolment, practice nurses were offered scholarships of $500 each. These innovative strategies have helped to support nurses working within general practice and foster a wider acceptance of nurses in general practice taking Pap tests. Additionally, in 2003, the Communications and Recruitment Program began coordinating the credentialling and re-credentialling of Victorian nurse Pap test providers. This involves working closely with the Royal College of Nursing Australia and ensuring the maintenance of nurse 30 H Mitchell, Participation of Victorian women in cervical screening by Division of General Practice , Unpublished report, Victorian Cervical Cytology Registry, Melbourne, Victorian Cervical Cytology Registry, Statistical Report 2005, Victorian Cervical Cytology Registry, Melbourne, 2006, p

22 PapScreen Victoria Communication and Recruitment Strategies credentialling standards. The program boasts many benefits, including providing a consistent process to monitor and evaluate the professional competency of nurse Pap test providers; providing a mechanism to demonstrate responsibility, accountability of practice, continuing competency and recognition of individual nurse expertise; and helping to make nurse cervical screening practice visible and credible. In 2005, there were 278 credentialled nurse Pap test providers in Victoria. The credentialling program helps to make nurse cervical screening practice visible and credible In 2004, PapScreen coordinated the organisation of the cervical screening stream of the 18th World Conference on Health Promotion and Health Education held in Melbourne. More than 200 health professionals attended the one-day stream. Activities were also undertaken during this strategy period to support and train medical practitioners. The University of Melbourne was funded to review quality issues in screening for cervical cancer. This review also provided recommendations on the best way to teach medical practitioners how to provide a sensitive, woman-centred Pap test service 32. As an outcome of this review, PapScreen funded the University of Melbourne to develop a comprehensive, multifaceted education program for undergraduate medical students, general practice registrars and GPs. This included: the development and inclusion of the Sensitive Examination Technique (SET) CD-ROM in the University of Melbourne s medical curriculum the development and implementation of the Clinical Teaching Associate (CTA) program at the University of Melbourne continued promotion and dissemination of the PapScreen Clinical Audit to GPs. Undergraduate medical students from Monash University also participated in the CTA program; however, when the funding agreement shifted to require the universities to match funds, only the University of Melbourne continued the program. The University of Melbourne s comprehensive, multifaceted education program has won notable awards: the University of Melbourne s Norman Curry Award (for Clinical Teaching Associate program and SET) and the Royal Women s Hospital Excellence in Teaching Award K Hegarty, J Gunn, Towards sensitive Pap examinations by medical practitioners, Unpublished report prepared by the University of Melbourne for PapScreen Victoria, Anti-Cancer Council of Victoria, Pap Test Victoria , final report, Anti-Cancer Council of Victoria, Melbourne, 1995, p.40.

23 Historical Report Communication and Recruitment Strategies Community programs A range of activities to support and enhance local action around cervical screening has been undertaken during the 14-year period. Some fall under the heading of communication strategies and education and training of health professionals, as described above. Others involve the PapScreen grants program and peer education, described below. Grants program This began with small grants to community agencies and neighbourhood houses to run educational sessions targeted to specific groups of women, including older women, rural women, women from diverse cultures and Koori women. The grant program has evolved and its focus more recently is not simply on educating women and service providers, but also on extending screening capacity at the local level to support PapScreen s media campaigns. Over , a total of 42 metropolitan and 65 rural programs were funded to run cervical screening education activities at an overall cost of $137,500. This resulted in an estimated 16,340 women in the community being reached, either directly through involvement in an educational activity or indirectly through Pap Test Victoria funded screening services or through receiving a brochure. Evaluation indicated that some community agencies had concerns with the sustainability of projects once funding had ceased and with the time needed to apply for and administer the grants. In response, a more diversified grants program was introduced in This included: Small grants of up to $14,000: 49 community agencies were funded to provide over 124 information sessions and 13 women s health day activities targeting under-screened women. More than 3900 women attended and 1950 women made appointments for Pap tests with nurse providers. Large grants of between $30,000 and $80,000: four community agencies received funding to recruit women in rural areas, women from diverse cultures, Vietnamese women and women with disabilities. Multicultural mini-grants of $100 each were distributed to community organisations to encourage them to host Pap test information sessions in languages other than English. More than 200 Pap test education sessions were held, with information delivered by bilingual health educators from the Cancer Council s Community Language Program (see Peer Education). The grant program has evolved and focuses on extending screening capacity at the local level Women from diverse cultures attending PapScreen funded activities 21

24 PapScreen Victoria Communication and Recruitment Strategies Special grants of up to $40,000 (some in conjunction with BreastScreen Victoria) were awarded to a number of organisations to enhance awareness, train nurses, develop resources or stage special activities. During , the grants program was modified again: Grants of $250 each were provided to 163 neighbourhood houses to hold a community education event for women aged 50 to 69. Two hundred and twenty-nine education sessions in languages other than English were funded through $100 multicultural mini-grants. Thirty-seven organisations were funded up to $5000 each to run a six-month health promotion project reaching older women, 14 of them with the specific target of reaching Koori women. One hundred and fifteen community health services were funded to extend their clinical hours and provide cervical screening outreach services in rural areas. In 2004 and 2005, these grants were specifically designed to support PapScreen s Don t Just Sit There media campaign. Seventeen media grants were distributed to nurses and community health services to help them advertise and seek editorial to promote regular cervical screening in their local community. Many of the grants were also used to promote the additional clinics funded through the clinic extension grants. Grants of up to $10,000 were distributed to six Divisions of General Practice (which matched the funded amount) to develop innovative strategies for identifying and screening unscreened and under-screened women within general practice. Healthy Women s Day, a project run by Lakes Entrance Community Health Service for the Koori women of Lake Tyers 22 Twenty organisations were funded $500 each to seek and pay for print, radio and television media coverage. From 2003 onwards, the grant approach became more target group specific and outcome focused: Fourteen projects were funded to target women with disabilities and disability workers. Joint funding (with the Jean Hailes Foundation) was provided to seven Aboriginal health services to plan and deliver a women s health project. Multicultural mini-grants were expanded to include education on breast health. One hundred and forty-one grants were distributed to assist in the delivery of information sessions to women from diverse cultures, and the sessions were delivered by the Cancer Council s bilingual health educators. In 2004 and 2005, three new grant initiatives were trialled: Eighteen community health organisations were funded up to $2500 each to purchase essential items for Pap test service provision, such as height adjustable beds and portable

25 Historical Report Communication and Recruitment Strategies lights. Grant recipients were required to contribute 25% of the purchase cost of the items and complete a comprehensive disability access audit. This grant program focused on Pap test service provision for women with disabilities and socially/geographically isolated women. Three designated Department of Human Services Neighbourhood Renewal areas received funding of up to $5000 to implement a health promotion project that focused on unscreened and under-screened women and women of low socio-economic status. Four multicultural organisations were funded to develop and implement a cervical screening project to encourage women from diverse cultures to screen. Peer education PapScreen has encouraged peer education strategies since the program commenced. Several organisations have been funded through the community grants program to develop and implement local peer education programs. During , the first peer education program was trialled. Sixteen older women trained as peer educators to run formal activities in metropolitan Melbourne, such as community presentations and attending shopping centre displays. In two years they implemented 312 activities and reached over 6500 women, around half of whom participated in a direct educational activity and half of whom were reached more indirectly by receiving a brochure 33. This approach was assessed as valuable but requiring significant levels of support from PapScreen staff to recruit, train and support the peer educators. A peer education program was implemented for women with a disability. The Women s Health Service for the West developed the Paps I Should project, which also won a community health award in This program continued through Peer educators delivered 44 Pap test education sessions and reached 441 women with disabilities and 69 workers 35. PapScreen supported the program until 2002, when the renamed Women s Health West ceased the program for redevelopment. PapScreen has worked closely with the Cancer Council s Community Language Program (CLP), a partnership that continues today. The CLP has 30 specially trained bilingual health educators who collectively speak 22 languages. The program is based on the peer education model, and culturally appropriate information is presented to women in their own language. Between 2000 and 2005, 596 education sessions focusing on the benefits of regular Pap tests have been conducted for women from diverse cultures. On average, 20 women attended each session, resulting in approximately 12,000 women receiving information about the Pap test in their first language. Women from diverse cultures attending peer education activities 33 Anti-Cancer Council of Victoria, Pap Test Victoria , final report, Anti-Cancer Council of Victoria, Melbourne, 1995, p Women s Health Service for the West, Paps I should, A peer education project addressing the need for cervical screening for women with disabilities, Unpublished report, Women s Health West, Peer education program report incorporating Paps I should and Breast for me, Unpublished report,

26 PapScreen Victoria Communication and Recruitment Strategies 24 Policy development and enhancement This was named as a key intervention strategy during ; however, it has clearly been a component of the program from its inception. The proposal states that policy development and enhancement covers: formulating PapScreen-specific policies, such as all partner organisations adopting inclusive language contributing to relevant policies (for example, the Ministerial Advisory Committee on Gay and Lesbian Health Action Plan, the Nurse Practitioner Task Force and the review of the NHMRC guidelines for the management of women with screened detected cervical abnormalities), and influencing the inclusion of cervical screening into the Victorian Aboriginal Health Plan maintaining a watching brief on relevant government departments and policies and providing input, for example in relation to women s health, Aboriginal health, informed consent, and sexual and reproductive health education for women with disabilities; and developing a joint Cancer Council tool kit (with Quit and SunSmart) for Primary Care Partnerships managers establishing and maintaining links with relevant advisory, decision-making and professional organisations, such as: Victorian Aboriginal Health Service, Victorian Aboriginal Community Controlled Health Organisation, locally based Aboriginal health services and organisations Regional Health Promotion Officers and Local Government Health Promotion Officers Networks Royal Australian College of General Practitioners, Royal Australian and New Zealand College of Obstetricians and Gynaecologists, medical student and nurse training at the University of Melbourne, Family Planning Victoria and Monash University, General Practice Divisions Victoria Women s Health Victoria, BreastScreen Victoria, Department of Human Services Disability Unit, Centre for Developmental Disability Health Victoria, Women s Health West, Holmesglen Institute of Technical and Further Education Women s Health Nurse Association of Victoria, Australian Practice Nurse Association, Royal College of Nursing Australia Adult Migrant Education Services, Victorian Immigrant and Refugee Women s Coalition.

27 Historical Report Communication and Recruitment Strategies Research and evaluation In the early period , there were limited research and evaluation resources; however, the program managed to undertake some reviews of existing research into interventions and carry out small evaluations of its own activities. These included an assessment of the effectiveness and acceptability of the direct mail strategy of personalised letters of invitation, the impact of the national media campaign in 1993, and the educational approaches implemented with GPs. In 1997, a dedicated research and evaluation position was appointed within the Cancer Council s Centre for Behavioural Research in Cancer (CBRC). This provided the support of an experienced, highly regarded and well resourced research unit, and enabled valuable work to be undertaken both to guide the strategic planning of the program and to evaluate interventions and initiatives. The period saw the analysis of screening data, evaluation of media campaigns and community activities, surveys of issues relating to specific target groups and two literature reviews. In 2001 the PapScreen Victoria Evaluation Report Volume One was published, featuring 14 research and evaluation reports completed since During , the Cancer Council conducted a number of research and evaluation studies, of which four were published as peer-reviewed papers. Table 6 summarises the research and evaluation work undertaken during The literature reviews covered: cervical cancer and cervical screening 1997 the responses of women with abnormal Pap test results 1999 young women s cervical screening 2001 Table 6: Research and evaluation publications outpatient cervical screening 2004 the effectiveness of reminder letter strategies Evaluations and pre-test studies were carried out into various aspects of the communication and recruitment strategies, including: 1997, 1999, 2001, 2004 and 2005 media campaigns 1997, direct mail approaches 2001 mini-grant and neighbourhood house grants programs 2001 regional seminar series 2004 website. Surveys were carried out into factors related to the behaviour, attitudes and experiences of women and health practitioners in the target groups: issues relating to cervical cancer and screening for women from Vietnam and from the former Yugoslavia, also Macedonian and Spanish-speaking women lesbians cervical screening practices young women s issues associated with Pap tests perceptions of women and practitioners towards Pap test quality women s attitudes and beliefs when diagnosed with cervical abnormalities issues in communicating the benefits and limitations of Pap tests to women barriers experienced by women to cervical screening. A full list of research and evaluation reports is contained in Appendix 1, and includes CBRC s published papers and peer reviewed publications, as well as research contracted to other organisations. Program Literature Evaluation of Survey in Other Total research period review an aspect of relation to a and evaluation the PapScreen specific issue publications strategy or target group

28 PapScreen Victoria Target Groups The program has nominated specific groups of women and health service providers as target groups. Older women, Koori women, women from diverse cultures and women with disabilities have remained target groups since the inception of PapScreen. Other groups, including young women, lesbians and health service providers, were adopted at a later stage. Rural women and women from Vietnam and other South East Asian countries were selected as target groups for one or two strategy periods only. Women from low-income backgrounds are mentioned as a target group in the final report of the strategy 36 period but no details were given. It may be that data on low-income women were not readily available and that it was considered they would be reached within other target groups, such as older women, Koori women, women from diverse cultures and women with disabilities. The program has nominated specific groups of women and health service providers as target groups Young women aged 18 to 39 Rationale Epidemiological data indicate that a significant proportion of deaths from cervical cancer occur in women aged 35 to 49. On average, it takes around a decade for high-grade cervical changes to progress to invasive cervical cancer. An increase in screening among young women aged 18 to 39 will impact on incidence, staging and mortality as they move into the 40 to 49 years age group. Young women were a target group for the program between 1996 and Achievements Screening rates: The two-yearly screening rates of women aged 20 to 29 reached a high of 62% in but this declined to 54% in Rates among women aged 30 to 39 followed a similar pattern with a high of 75% in down to 67% in As mentioned previously, methodological changes could largely account for this decline. Two- and three-year interval screening rates among women aged 20 to 29 remain lowest or second lowest of all age groups (see Tables 1 and 3) after those aged 60 to 69. The overall trend of increasing screening rates in the late 1990s and then decreasing in the early 2000s match those for other age groups. Data on early re-screening (Table 4) indicate that the proportion of women aged 20 to 29 who have been re-screened within 21 months of a normal result declined significantly from 32% in 2001 to 26% in Anti-Cancer Council of Victoria, Pap Test Victoria , final report, Anti-Cancer Council of Victoria, Melbourne, 1995, p.3.

29 Historical Report Target Groups Communications: Specific activities to reach young women have included a direct mail campaign in 1997; a targeted media buy for the Don t Make Excuses TV advertisement in 1999; postcard and poster distribution; development of media kits directed to young women s magazines, university campus nurses and student newspapers; inserts added to tampon packets carrying messages about Pap tests; and the development of PapScreen s website with a focus on young women. A print media campaign, Good News, was developed in 2002 and featured in young women s magazines in The advertisement aimed to communicate to women that one Pap test every two years is enough, and that more frequent screening is unnecessary. Education: Emerging information on the link between HPV and cervical cancer informed the development of the brochure Human Papilloma Virus and the Pap Test. The brochure was launched in January 2003, and over 25,000 copies were distributed that year. A strong demand has remained. Research and evaluation: Routine VCCR data have been used to evaluate overall participation rates by women in all age groups. An extensive literature review 37 and a qualitative study of young Victorian women 38 examined issues associated with cervical screening for younger women. Evaluation of interventions included the direct mail approach to young women in , and the 1999 mass media campaign 40 that included specific data on young women s uptake of screening messages before, during and after the campaign. An analysis of images provided useful information to inform the development of the 2002 print media campaign directed to young women. Following the print media campaign, an evaluation of young women s responses to the advertisement was carried out J Condron, M Fernbach, Young women s cervical screening: a literature review, Unpublished report prepared by the Centre for Behavioural Research in Cancer for PapScreen Victoria, M Fernbach, Young women s issues associated with Pap tests: a qualitative study of Victorian women, Health Promotion Journal of Australia, vol. 12, no. 3, pp.254-7, J Jones, Responses to a Pap test recruitment letter, 1997, PapScreen Victoria evaluation report volume one , Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria, Melbourne, 2001, pp M Fernbach, The impact of the 1999 media campaign on cervical screening knowledge and self-efficacy, PapScreen Victoria evaluation report volume one , Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria, Melbourne, 2001, pp L Hoey, D Dempsey, R Mullins, 2004, Evaluation of PapScreen s magazine advertisement 2003: focus groups with early re-screeners, CBRC research paper series no. 8, Centre for Behavioural Research in Cancer, The Cancer Council Victoria, Melbourne,

30 PapScreen Victoria Women s Health Grampians reach older women through their GOLD (Growing Older, Living Dangerously) program Target Groups Older women Rationale Older women have lower screening rates and higher incidence and mortality rates than most age groups. Increased screening of women aged in their 40s and 50s will reduce incidence and deaths in women aged 60 and over. Only 45% of women aged 60 to 69 were screened in the two-year period , and although rates increased to 61% in , overall screening rates for this age group remained second lowest over this two-year period and lowest over the three years (68%). In addition, epidemiological data suggest that nearly two-thirds of women diagnosed with cervical cancer are aged over 60, as are over one-third of women who die from cervical cancer. Older women remained a target group for the program during the entire period. Courtesy of The Courier Ballarat, 18 December 2002 Achievements In , screening rates for women aged 50 to 59 reached 72%, the highest participation rate for all age groups 42. Additionally, across the period , two-yearly screening rates for women aged 60 to 69 did not decrease (as they had for all other age groups); rather, by , they had increased to 61%. This is the highest screening rate for this age group since 1994, when reliable records became available. Communications: A combination of personalised letters and radio, television and print media targeted to all women and to older women has raised awareness and increased screening among older women. Education: The range of education and training strategies, including the development of a peer educator program and the widespread resourcing of health service providers particularly the strong development of services provided by nurse Pap test providers has increased older women s knowledge about the need for Pap tests and ensured access to sensitive Pap test providers. Community programs: The community grants program has had a strong focus on older women. As detailed previously, many of the community, neighbourhood house and multicultural grants were targeted to older women. Very large numbers of women were reached through these programs, including many in older age groups. Evaluations suggest the grants program has been effective in reaching and educating women 43. Research and evaluation: Routine VCCR data have been used to measure participation rates by women in all age groups. Evaluation studies have assessed the reach and impact on older women of all of the media campaigns as mentioned previously, and have been used to assess and to guide communications strategy development Victorian Cervical Cytology Registry, Statistical Report 2005, Victorian Cervical Cytology Registry, Melbourne, 2006, p J Condron, M Fernbach, Evaluation of the 2001 PapScreen Victoria neighbourhood house grants program, Unpublished report prepared by the Centre for Behavioural Research in Cancer for PapScreen Victoria, 2002; C Walker, C Remedios, N Schwarz, M Fernbach, Evaluation of the 2001 Victorian PapScreen mini grant program, Unpublished report prepared by the Centre for Behavioural Research in Cancer for PapScreen Victoria, 2002.

31 Historical Report Target Groups Koori women Rationale Interstate data suggest that Indigenous women have lower screening rates, and higher incidence and mortality rates from cervical cancer than non-indigenous women. Victorian data on screening rates among Indigenous women is difficult to obtain as Indigenous status is not recorded when a Pap test is taken. Although interstate data are unable to adequately reflect the screening rates of Indigenous women in Victoria, PapScreen assumes that the situation is similar. Koori women remained a target group for the program during the entire period. Achievements Screening rates: As mentioned, Victorian data on screening rates among Indigenous women are difficult to obtain. In 1998, PapScreen funded the Victorian Aboriginal Health Service (VAHS) to undertake an audit of 200 client files. The audit revealed that of the 200 women, 36% had had a Pap test at some point, and 17% had been screened in the previous two years. Over a five-year period, , trend analysis comparing women screened at the VAHS against other Victorian women showed that a consistently higher percentage of Indigenous women s Pap tests were reported as abnormal compared to the general population. National data continue to suggest high mortality among Indigenous women 44. Communications: The development and delivery of effective media communications targeted to Koori women has been challenging. A poster and pamphlet were developed in the first strategy period. Some media work has also been undertaken through Koori programs on local radio stations. Education and training for Aboriginal health workers and Koori hospital liaison officers has been consistent. PapScreen has also funded mainstream health services to attend Aboriginal cultural awareness training. Community program strategies have been implemented on the understanding that working with and through Koori community organisations and groups is the most effective way of reaching Indigenous women. However, it is also recognised that continuity and the development of trust over a long period are necessary to facilitate communication and cooperation between mainstream and Koori agencies. The community grants program has supported many activities over the years in the Koori community, including information days, women s camps and clinic extension activities. In recognition of the broader health issues faced by Koori women, PapScreen has often worked in conjunction with programs such as BreastScreen Victoria and the Jean Hailes Foundation to increase the skills and knowledge of health workers in the Koori community. 44 Australian Institute of Health and Welfare (AIHW), Cervical screening in Australia, , AIHW cat.no. 22, AIHW, Canberra, 2004, p.34. Tracking back to better health resource for Koori women 29

32 PapScreen Victoria Target Groups Since 1996, PapScreen has funded and supported a Koori women s health worker at the VAHS to organise women s camps, women s health days, client file audits and outreach clinical services, and to implement and maintain recall and reminder systems at the VAHS. Policy development has been supported by the Cancer Council s Aboriginal Health Interest group, as has the development of links between the Cancer Council, the VAHS, the Victorian Aboriginal Community Controlled Health Organisation, locally based Aboriginal health services and organisations, and the Department of Human Services Koori Health Unit. Research and evaluation: The file audit and Pap test results comparison projects in the late 1990s remain the only research that has been carried out in relation to this target group. Women from diverse cultures Rationale Cultural and linguistic differences may impose barriers to accurate health information about cervical screening and to appropriate service provision. National Health Survey data (2001) indicate that women whose main language spoken at home is other than English, particularly women who speak Mandarin, Cantonese, Vietnamese, Arabic, Italian, Greek or German, have lower screening rates than English-speaking households 45. Women from diverse cultures have been a target group for the program since Achievements Screening rates: Rates among cultural groups are difficult to obtain as country of birth is not recorded when a Pap test is taken. However, VCCR analysis of postcode areas with a high proportion of non-english-speaking residents compared to postcode areas with low proportions show increases in screening during the multicultural media campaigns. The 2001 National Health Survey reports that 37.2% of Greek-born women aged 18 to 69 have never had a Pap test, compared to 16.3% of women born in other countries, 12.7% of Italian-born women, 9.1% of Australian-born women, and 2.9% of English-born women. Data on smaller cultural groups and recent immigrant communities are not available 46. Communications: The many television, radio and print media campaigns and direct mail strategies targeting women from diverse cultures have been described previously Australian Institute of Health and Welfare (AIHW) & Australasian Association of Cancer Registries (AACR), Cancer in Australia 2000, AIHW cat, no, CAN 18, AIHW, Canberra, 2003, p ibid., p.55.

33 Historical Report Target Groups In the first strategy period, the program focused on developing printed resources in many different languages. The time and money expended on these resulted in high-quality resources and demand remains strong. Since then, additional resources have been developed as new groups of migrants enter the country, such as women from the Horn of Africa. The video For All Women: The Pap Test is now available in 18 languages: Arabic, Cantonese, Greek, Italian, Spanish, Turkish, Vietnamese, Bosnian, Croatian, English, Filipino, Macedonian, Maltese, Polish, Russian, Serbian, Somali and Tigrinya. There is also a Pap test audiotape in Somali. Education and training: There has been considerable professional development for the Community Language Program s (CLP) bilingual health educators and consultation and work with language or cultural groups and ethnospecific agencies. Many hundreds of sessions have been held in community languages and thousands of women reached Policy development: This has consisted largely of consulting and developing links with the Adult Migrant Education Service and the Victorian Immigrant and Refugee Women s Coalition. Research and evaluation: This has been used to guide communication messages, assess the impact of these messages and assess need. For example, due to epidemiological data showing comparatively high rates of cervical cancer in women from former Yugoslavia, consultations were held with community members 47. The results showed that screening rates were comparable with all Victorian women and the higher incidence is related to the detection of previous cancers rather than to an under-screening issue. A comparison of the uptake of screening messages by Macedonian and Spanish-speaking women 48 during the 1999 multicultural media campaign highlighted the need for culturally appropriate health campaigns. Community programs: The multicultural grants program has been in place since Many hundreds of sessions have been held in community languages and thousands of women reached. Collaboration with other health programs, such as the CLP, BreastScreen Victoria and the Jean Hailes Foundation, has resulted in many joint efforts in funding, information provision, education and resource development. The partnership formed with Working Women s Health in 2005 resulted in education sessions delivered in the workplace to 278 women from diverse cultures. 47 M Fernbach, Exploration of factors linked with high cervical cancer rates among women from former Yugoslavia in Victoria, Australia, PapScreen Victoria evaluation report volume one , Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria, Melbourne, 2001, pp M Fernbach, Uptake of cervical screening messages by Macedonian and Spanish-speaking women: an evaluation of the PapScreen Victoria multicultural media campaign, 1999, PapScreen Victoria evaluation report volume one , Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria, Melbourne, 2001, pp

34 PapScreen Victoria Target Groups Vietnamese and other South East Asian women Women from Vietnam and other South East Asian countries were a target group during By 1999, community workers indicated that enough intensive work had been done in these communities and research reported increased screening rates among these women. This group was therefore not adopted as a target group in the strategy. Women from diverse cultural backgrounds however, remained a target during Rationale In 1996, the program adopted this target group because cervical cancer rates among Vietnamese migrant women were higher than among the Australian population, and the largest numbers of unscreened migrant women were those who had been resident for more than 20 years. This included women from Vietnam; a country from which migration to Australia began in the 1970s. Achievements Screening rates: Rates among cultural groups are difficult to obtain as country of birth is not recorded when a Pap test is taken. A 1997 telephone survey of Vietnamese women showed that 65% of participants reported having been screened within a 2-year period 49. A follow-up survey conducted in 1999 showed that 65% of the Vietnamese women aged 30 to 70 had been screened in the previous two years 50. Although these rates were lower than for women in the general population, the Vietnamese women interviewed demonstrated an increasingly sophisticated understanding of cervical screening, with a reduction in early re-screening over the two-year period. Communications: Throughout a range of multicultural media work was implemented through radio and print media, and bilingual doctors and health educators participated in radio and press interviews. All the direct mail campaigns included a multilingual insert. Community programs: Grants program projects targeted women from Vietnam and South East Asia. Funded projects included an 18-month project at Women s Health West to reach women from Vietnam and South East Asia living in the City of Maribyrnong. In 1999, one of the grant projects resulted in the development of a Khmer cervical screening brochure in consultation with the Cambodian community. Research and evaluation: In 1997, PapScreen undertook a telephone survey by bilingual researchers of 250 randomly selected Vietnamese women and a follow-up study two years later. The VCCR also completed a study of Pap tests recorded from women with a Vietnamese surname over four and a half years ( ) that showed an increase in screening M Fernbach, J Jones, V Clarke, S Hirst, Vietnamese women and cervical screening: knowledge, beliefs and behaviour at two time periods, PapScreen Victoria evaluation report volume one , Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria, Melbourne, 2001, p ibid.

35 Historical Report Target Groups Women with disabilities Rationale All women aged 18 to 70 who have ever been sexually active are eligible for cervical screening; however, there are barriers for many women with disabilities, including access to suitable services and information to enable them to make informed decisions. Attitudes and beliefs of some carers and health professionals may also be a barrier to women with disabilities seeking a Pap test. Women with disabilities have been a target group for the program since Achievements Screening rates: These remain difficult to assess due to a lack of baseline data. However, a preliminary statewide database developed by the Centre for Developmental Disabilities Health There are barriers for many women with disabilities, including access to suitable services and information Victoria in indicated that 10% of women with an intellectual disability were involved in cervical screening in the previous 12 months. Eighty-one per cent of women visited a GP for a medical check-up at least once during the same timeframe. Only 8% of the youngest age group (18 to 35), 14% of women aged 36 to 50 and 13% of women aged over 50 had been screened. Education, training and resource development: A peer education program, Paps I Should, funded by PapScreen, was coordinated by Women s Health West from the early nineties to December Limited evaluation data indicate that this was successful in educating women with disabilities; however, it was difficult to determine the number of women who subsequently had a Pap test. Some valuable resources have been developed. In 1996, the program funded Family Planning Victoria to develop the brochure Women with an Intellectual Disability Need Pap Tests Too! In 2004, the program funded the development of an updated brochure, Pap Test: The Plain Facts, by the Centre for Developmental Disabilities Health Victoria. The video For All Women: The Pap Test was captioned to assist the hearing impaired, and an audiotape on Pap test information was developed for sight impaired women. All PapScreen fact sheets were reviewed for readability, and, where possible, produced in large print. In 2005, PapScreen worked with BreastScreen Victoria to develop a training resource, Overcoming the Barriers. The resource is aimed at students undertaking Certificate IV in Disability Work, and highlights the barriers experienced by women with a disability in accessing breast and cervical screening services. The training also provides strategies for disability support workers to assist in overcoming these barriers. 51 K Johnson, R Strong, L Hillier, M Pitts, Screened out! Women with disabilities and cervical screening, Australian Research Centre in Sex Health and Society, La Trobe University and PapScreen Victoria, Melbourne,

36 PapScreen Victoria Target Groups Community programs: Women with disabilities were the focus of two grants programs. In 2003, 14 community health services were funded to implement a health promotion project targeting women with disabilities and cervical screening. In 2004, 18 agencies received funding to purchase mobility assistance equipment to assist in screening women with disabilities. Policy development: This has been based around the development of links and partnerships with the Department of Human Services Disability Unit and the Disability Learning and Development Unit, the Centre for Developmental Disabilities Health Victoria, Women s Health West, and Holmesglen Institute of TAFE. Research: In 2000, PapScreen commissioned Family Planning Victoria to explore cervical screening needs of women with a psychiatric disability, which resulted in Moving Shadows, Psychiatric Disability: No Barrier to Physical Health 52. The following year, the Australian Research Centre for Sex, Health and Society was contracted by PapScreen to research issues related to cervical screening for women with intellectual disabilities. Their report, Screened Out!, was launched in November , and generated significant interest. The recommendations informed PapScreen s disability strategy during PapScreen Victoria & Family Planning Victoria, Moving shadows, psychiatric disability: no barrier to physical health, Unpublished report, PapScreen Victoria & Family Planning Victoria, K Johnson, R Strong, L Hillier, M Pitts, Screened out! Women with disabilities and cervical screening, Australian Research Centre in Sex Health and Society, La Trobe University and PapScreen Victoria, Melbourne, 2002.

37 Historical Report Lesbians Rationale When this target group was adopted in 1996, evidence suggested that lesbians and health professionals were unaware of the need for lesbians to participate in cervical screening. This was formed by a commonly held belief that women who did not engage in heterosexual sex were not at risk of cervical cancer. Lesbians are at risk due to the association between the HPV and cervical cancer, the reported presence of HPV in lesbians, and the way HPV is transmitted by genital skin to genital skin contact. Lesbians have been a target group since Achievements Screening rates: Results of surveys of lesbians attending gay and lesbian festivals in metropolitan and rural Victoria in 2002 and 2004 indicate 54 that lesbians have screening rates comparable with the overall population aged 20 to 69. Communication: Activities have included print and radio media work, resource development and outreach activities to settings where lesbians gather, such as community festivals. Examples include the communication of the PapScreen message through lesbian media on radio station Joy FM and feature articles in the journal Lesbiana. PapScreen has also had a presence at the MidSumma gay and lesbian carnival each year between 2001 and 2005, and at the Chillout festival held in Daylesford in 2004 and These activities have been an opportunity to disseminate cervical screening information to lesbians. Education, training and resource development: A PapScreen Lesbian Advisory Committee was established to assist with resource development. In 1999, the committee assisted in the development of a world-first brochure, Lesbians Need Pap Tests Too. This was widely distributed in Victoria and adopted nationally and internationally. The advisory committee reformed in 2004 to help revise the brochure. The committee (together with GP representatives) Target Groups also assisted in developing a complementary card for GPs to guide sexual history taking. Interest in the resources have been strong and responses positive to presentations at the Health in Difference Conferences held in Melbourne (1998), Adelaide (2000) and Sydney (2002); the National Women s Health Conference in Adelaide (2000); and the 18th World Conference on Health Promotion and Health Education in Melbourne (2004). The resource cards were also distributed at the Royal Australian College of General Practitioners Conference (2004). Policy development: Links have been made with the Ministerial Advisory Committee on Gay and Lesbian Health around the development of an action plan, and with Gay and Lesbian Health Victoria. Research: Two surveys on lesbians experiences of cervical screening were carried out in 2002 and 2004 as described above, providing some useful data and indicating that screening rates, at least among attendees, are comparable with all Victorian women 55. Lesbians Need Pap Tests Too brochure 54 A Brown, J Hassard, M Fernbach, E Szabo, M Wakefield, Lesbians experiences of cervical screening, Health Promotion Journal of Australia, vol. 14, no. 2, 2003, pp R Mullins, Brief report on a survey conducted at the Chillout Festival about lesbians cervical screening practices, Unpublished report prepared by the Centre for Behavioural Research in Cancer for PapScreen Victoria,

38 PapScreen Victoria Target Groups Rural women Rural women were a target group during and With mounting epidemiological evidence that screening rates of rural women matched those of suburban women, this group was not targeted in However, many of the strategies implemented during this period have included a rural focus. Achievements Screening rates: By the end of 1994, data from the VCCR indicated that the screening levels in the rural health regions had increased substantially and there was no longer a difference between rural and metropolitan women 56. A total of 1986 women attended nurse-based screening clinics in rural Victoria compared with 536 women attending such services in metropolitan Melbourne. GP Divisions data showed that two-yearly screening levels in rural areas were comparable with metropolitan areas 57. Communication strategies: These included extensive media coverage during and in 1997 targeting rural areas, followed by a major national media campaign broadcast on regional TV during This was accompanied by a media kit for community agencies. In 1999, the National Cervical Screening Program broadcast a commercial for three weeks in June, followed by an eight-week advertising campaign funded by PapScreen. In the first strategy period, personalised letters of invitation were also sent to approximately 97,000 women aged 50 to 69 years in rural Victoria. Community action: Over both strategy periods, this included training rural community workers and peer educators and grants to rural agencies for education sessions and screening services. These strategies resulted in a significant increase in the number of rural health services offering screening services. Research and evaluation: This included an analysis of participation rates in cervical screening by Division of General Practice 58, as screening levels of rural versus metropolitan women were not routinely reported by the VCCR H Mitchell, V Higgins, Statistical report 1994, Victorian Cervical Cytology Registry, Melbourne, H Mitchell, 1998, Participation of Victorian women in cervical screening by Division of General Practice , Unpublished report, Victorian Cervical Cytology Registry, Melbourne, Anti-Cancer Council of Victoria, PapScreen Victoria communications and recruitment strategy , Final report, Anti-Cancer Council of Victoria, Melbourne, 2000, p.23.

39 Historical Report Target Groups The community health sector Rationale The community health sector comprises community health centres, women s health services, local government agencies, Divisions of General Practice and hospitals, all of which play a key role in the delivery of PapScreen s messages to unscreened and under-screened women. The community health sector was adopted as a target group in the strategy period. Achievements The community health sector is informed of initiatives via a range of strategies. These have included Cancer Council seminars run with Quit and SunSmart in and with the Cancer Education Unit in 2004 and 2005; and the Women s Cancer Team newsletters and PapScreen website. The website includes a Pap test provider directory which lists Victorian providers by location, gender, language spoken and disability access. Links with providers have been maintained through the development of a joint Cancer Council tool kit with Quit and SunSmart for Primary Care Partnership managers, and communication with regional health promotion officers, the Local Government Health Promotion Network and the state government s Neighbourhood Renewal Program. 37

40 PapScreen Victoria Target Groups General practitioners Rationale GPs take the majority of Pap tests in Victoria. By improving the sensitivity and approach of GPs, women may have more positive screening experiences, which could influence future screening behaviour. GPs were adopted as a target group in the strategy period. Achievements Since 1997, the Department of General Practice at the University of Melbourne has provided GP liaison services to PapScreen. This has contributed to improved communication with GPs, particularly in relation to the Clinical Teaching Associates program at the University of Melbourne (and its temporary extension to Monash University), the Royal Australian College of General Practitioners-accredited PapScreen Clinical Audit, the inclusion of the Sensitive Examination Technique CD-ROM into medical curriculum, the provision of screening rate data to Divisions of General Practice, the publication of articles in key newsletters and journals, and presentations at various seminars and conferences. The PapScreen Clinical Audit was found to be an effective way to increase screening rates: practices that completed the entire audit during the triennium showed a 4.9% increase in screening rates. The grant program to Divisions of General Practice in 2002 and 2004, with matched funds provided by the recipients, resulted in innovative projects complementing the Commonwealth s Cervical Screening Practice Incentive Program. This has also helped Divisions to assess cervical screening practice within their areas. Overall, the work of the period has resulted in an integrated and comprehensive educational program for training medical practitioners, from studentship to senior practice, in taking sensitive Pap tests and maintaining a quality Pap test service. 38

41 Historical Report Target Groups Nurse Pap test providers Rationale Nurses play a key role in providing cervical screening, particularly in rural Victoria and with older unscreened and under-screened women. Nurse Pap test providers were adopted as a target group in the strategy period. Achievements Since the program commenced, PapScreen has played an influential role in increasing the number of nurses who provide cervical screening, and for ensuring nurse practice was visible and of a high quality. By 2005, the number of Victorian credentialled nurse Pap test providers reached an all time high of 278. PapScreen works closely with a nurse consultant to implement relevant strategies, contributing to improved communication with nurses and enabling strong relationships with nurse training providers, such as Family Planning Victoria, the Melbourne Sexual Health Centre and the University of Melbourne. The program has held education seminars across the state, and maintained communication through regular mailouts, updates and newsletter articles. The program continues to support the Women s Health Nurse Association of Victoria with administrative duties. Since 2000, Clinic Extension Grants have enabled nurses to extend their clinical hours and offer outreach clinics and Nurse Media Grants have helped nurses to promote their Pap test clinics. These grants have not only been extremely popular with nurses, but also with the women who access the greater range of services. Evaluation indicates that both these grant programs are effective in supporting nurses to reach unscreened and under-screened women, particularly in rural regions. PapScreen continues to support the development and implementation of Royal College of Nursing Australia-accredited Pap test provider training for nurses in Victoria, including providing funding for nurse preceptor programs (clinical supervision of nurses) at Family Planning Victoria and the University of Melbourne. 39

42 PapScreen Victoria Target Groups Gynaecologists Rationale Although gynaecologists take around 20% of Pap tests, they play a key role in the management of abnormalities and subsequent screening recommendations. They are seen as opinion leaders who influence the behaviour of GPs with regard to cervical screening. Gynaecologists were named as a target group in the strategy period. Achievements PapScreen resources, including the website, continue to be promoted to gynaecologists via newsletters and direct mailouts. In 2004, a gynaecologist was recruited to act as an honorary PapScreen spokesperson at relevant forums, for media and as an adviser to the program. 40

43 Historical Report Appendix 1: PapScreen Victoria research and evaluation reports Published papers (refereed journals) Brown A, Hassard J, Fernbach M, Szabo E and Wakefield M Lesbians experiences of cervical screening. Health Promotion Journal of Australia 14(2): Fernbach M Exploration of factors linked with high cervical cancer rates in women from former Yugoslavia in Victoria, Australia. Ethnicity & Health 7(3): Fernbach M The impact of a media campaign on cervical screening knowledge and self-efficacy. Journal of Health Psychology 7(1): Fernbach M Young women s issues associated with Pap tests: a qualitative study of Victorian women. Health Promotion Journal of Australia 12(3): Published papers (other) Fernbach M (Ed.) PapScreen Victoria Evaluation Report Volume One Melbourne: Anti-Cancer Council of Victoria. This volume includes: Fernbach M, Jones J, Clarke V and Hirst S. Vietnamese women, health concerns and cervical cancer screening: knowledge, beliefs and behaviours at two time periods. Fernbach M, Remedios C and Faelli R. Attitudes and beliefs of women diagnosed with cervical abnormalities. Fernbach M. Barriers to cervical screening. Fernbach M. Exploration of factors linked with high cervical cancer rates in women from the former Yugoslavia in Victoria, Australia. Fernbach M. The impact of the 1999 media campaign on cervical screening knowledge and self-efficacy. Appendix Fernbach M. Uptake of cervical screening messages by Macedonian and Spanish-speaking women: an evaluation of the PapScreen Victoria multicultural campaign, Fernbach M. Young women s issues associated with Pap tests: a qualitative study of Victorian women. Hodgson C. The responses of women with abnormal cervical smears: a literature review. Jones J. Evaluation of the impact of the 1997 Amcal Stickers project. Jones J. Responses to a Pap test recruitment letter, Jones T and Clarke V. An analysis of cervical screening messages in Jones T and Clarke V. Cervical cancer and cervical cancer screening: a review of the literature. Jones T and Clarke V. Communicating the benefits and limitations of Pap tests. Savage S, Clarke V, Fernbach M, Hirst S and Jones J. Evaluation of the 1997 media campaign. Internal research and evaluation reports (since 2001) Prepared by the Centre for Behavioural Research, The Cancer Council Victoria, for PapScreen Victoria 2001 Condron J and Fernbach M. Evaluation of the 2001 PapScreen Victoria neighbourhood house grants program. Condron J and Fernbach M. Young women s cervical screening: a literature review Condron J and Fernbach M. Evaluation of the 2001 cervical screening media campaign. Condron J and Fernbach M. Evaluation of the 2001 regional seminar series. Condron J, Remedios C and Fernbach M. Evaluation of the 2001 PapScreen Victoria multicultural media campaign. 41

44 PapScreen Victoria 42 Appendix Oh, S. HPV focus group research report. Walker C, Remedios C, Schwarz N and Fernbach M. Evaluation of the 2001 Victorian PapScreen mini grant program Hoey L and Mullins R. PapScreen media 2003/2004: pre-campaign interviews report. Callander R, Hoey L and Mullins R. PapScreen media 2003/2004: evaluation of television advertisement concepts. McKenzie M, Wakefield M and Broun K. PapScreen Victoria Good Health television 2003 infomercial evaluation Anderson J. Evaluation plan (Phase 1): GP communication and information needs. Anderson J. Guidelines for the compilation of website statistical reports. Anderson J. Omnibus survey: cervical cancer questions. Anderson J. Options for accessing and evaluating GPs. Anderson J. Literature review of effective reminder letter strategies used in screening programs. Anderson J. Literature review of outpatient cervical screening. Anderson J. PapScreen Victoria website: evaluation options. Anderson J, Fernbach M and Mullins R. Pap test quality: practitioners perceptions of service provision. Hoey L, Dempsey D and Mullins R. Evaluation of PapScreen s magazine advertisement 2003: focus groups with early re-screeners. Mullins R. Brief report on a survey conducted at the Chillout Festival about lesbians cervical screening practices. Mullins R, Fernbach M and Anderson J. Pap test quality: women s perceptions of service provision Anderson J. Findings from the preliminary website evaluations Anderson J. Stage 1 report of the website focus groups: design preferences. Anderson J. Stage 2 report of the website focus groups: content preferences. Anderson J and Cheshire S. PapScreen Victoria s original website user-testing and qualitative interviews. Mullins R. An evaluation of PapScreen Victoria s 2004 media campaign. Mullins R. Cancer Issues Population Survey 2005: cervical screening. Mullins R. Evaluation of a strategy to increase cervical screening through the use of personalised invitation letters. Mullins R. Evaluation of PapScreen Victoria s 2004 media campaign: interim report. Externally funded reports Hegarty K and Gunn J Towards sensitive Pap examinations by medical practitioners. Prepared by The University of Melbourne & PapScreen Victoria. Johnson K, Strong R, Hillier L and Pitts M Screened Out! Women with Disabilities and Cervical Screening. Melbourne: Australian Research Centre in Sex Health and Society, La Trobe University & PapScreen Victoria. PapScreen Victoria (PSV) & Family Planning Victoria (FPV) Moving Shadows. Psychiatric Disability: No Barrier to Physical Health. Melbourne: PSV & FPV. Melbourne.

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