cancer early detection and prevention strategy social marketing workstream
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Cancer early detection and prevention strategy
Social marketingworkstream
22 October 2008
A presentation for:
MCCN update Page 2
Why are we here?
To share progress in developing a social marketing intervention to reduce the health inequalities found in the early detection and prevention of cancer
MCCN update Page 3
Our framework for action
MCCN update Page 4
What have we done so far?
Segmenting target groups to understand: What are the risk factors for prevention? Who is late presenting? What are their lifestyles, attitudes
and behaviours?
Understanding the context
Understanding the audience
Understanding behaviours
Analysis of excess incidence and mortalityto identify: Which are the largest cancers? Which cancers kill the most people? What is the scale of inequality for each cancer?
Where are the differences across the network?
Research among healthcare professionalsand at risk groups to establish: What are their underlying motivations for action? What are the key benefits and barriers to
prevention and early detection? What can MCCN do to add most value?
MCCN update Page 5
Excess incidence and mortality by cancer
Source: NHS/NWCIS data – 2001 – 2005
-15.5%
-16.5%
-41.3%
-11.4%
-32.3%
-17.5%
-14.6%
1.4%
3.6%
3.1%
-50% -40% -30% -20% -10% 0% 10%
Breast - Females
Bladder - males
Bladder Females
Colorectal - Males
Colorectal -Females
Skin - Males
Skin - Females
Cervix - Females
Lung - Males
Lung - Females
Excess Incidence 6.1%
3.2%
0.0%
16.9%
2.0%
-30.9%
30.1%
76.5%
23.5%
32.1%
-40% -20% 0% 20% 40% 60% 80% 100%
Breast - Females
Bladder - males
Bladder Females
Colorectal - Males
Colorectal -Females
Skin - Males
Skin - Females
Cervix - Females
Lung - Males
Lung - Females
Excess Mortality
% Mortality (from
Incidence) Total IncidenceTotal All Cancers 34.5% 6257
Bladder total 34.5% 1179Breast total 18.9% 5520Colorectal total 32.2% 4340Lung total 55.7% 5701Skin total 12.4% 1069Cervix total 32.1% 324
Lung cancer accounts for majority of excess deaths. Below average incidence for most other cancers but high excess mortality suggests need for earlier detection focus
MCCN update Page 6
Some key differences across the network
Low: Excess between 6 and 19.9% lower than region
Very Low: Excess more than 20% lower than region
Average: Excess between 5.9% lower or 5.9% higher than regionHigh: Excess between 6 and 19.9% higher than region
Very High: Excess more than 20% higher than region
Given total region has higher than expected excess for all except female bladder and male skin cancer, only those regions with a “Very Low” difference to total region have lower than expected mortality compared to national average
Source: NHS database, all comparisons with region average in % point
Total
regionCentral
CheshireEastern Cheshire Halton St Helens Knowsley
North Liverpool
Central Liverpool
South Liverpool
Breast - Females 6.1% very low very low very high low average average high very high
Bladder - males 3.2% high very low very high average very high very high low very low
Bladder Females 0.0% high very low very low very high very low very low very high low
Colorectal - Males 16.9% low low low low high very high very high very low
Colorectal - Females 2.0% average very low very high high very low very high average very high
Skin - Males -30.9% low very high very low very low very high very low very high average
Skin - Females 30.1% high very low very low very low very low very high very low very high
Cervix - Females 76.5% very low very low very high very high very high very low very low high
Lung - Males 23.5% low very low high high high very high very high very high
Lung - Females 32.1% very low very low very high low very high very high very high low
Excess mortality
MCCN update Page 7
Understanding the audience
Source: Cancer reform strategy, NHS, Dec. 07, Background information to inform the Cancer Early Detection and Prevention Strategy – Oct 07Reducing Health Inequalities through improved Early Detection and Prevention of cancer – a strategy for 2008-2010, Jan 08
Smoking Drinking Obesity/ diet Genetics Sunbed use
Sexually active (many
partners / STDs)
Deprivation (lifestyle factors)
Lung Cancer
Breast Cancer
Cervical Cancer
Bowel Cancer
Bladder Cancer
Malignant Melanoma
Secondary factor
Primary factor
BME's Older MenLearning
DisabilitiesMental Health
Muslim religion
Sexually active (many
partners/STDs)
Deprivation (attitude to authority)
Lung Cancer
Breast Cancer
Cervical Cancer
Bowel Cancer
Bladder Cancer
Malignant Melanoma
Prevention – what are the risk factors?
Detection – who presents late?
MCCN update Page 8
Inequality groups
Sources: Cancer reform strategy, NHS, Dec. 07, Background information to inform the Cancer Early Detection and Prevention Strategy – Oct 07, Reducing Health Inequalities through improved Early Detection and Prevention of cancer – a strategy for 2008-2010, Jan 08, Wirral Cancer Equity Audit, Apr 08, National Audit Office 2001, Tracking Obesity in England, the stationary office
BME’s Diverse group with inherent cultural
differences (e.g. 44% of Bangladeshi men smoke, Caribbean women are more likely to be obese)
Particular issues around detection of Cervical and Bowel cancer: Not aware of symptoms to look out for Talking about bodily functions is
a cultural taboo Females cannot be seen by a
male doctor Religion might prevent from
seeking help and perceptions of screening as “unclean”
Learning disabilities Particularly relevant to cervical
and breast cancer, but also for bladder and bowel
Late detection as low percentage attend screening
Less aware, do not understand the importance of symptoms and therefore don’t go to the doctor as quickly
Mental health Particular issues for breast,
cervical and bowel cancer less likely to attend screenings may not be monitored sufficiently
to pick up issues Perception that symptoms
can be overlooked or assumed to be part of the pre-existing condition
Schizophrenics are 84% more likely to get bowel cancer than average
MCCN update Page 9
Profiling risk groups
Used TGI to segment the population by risk factors:Heavy smokers Light smokersMedium smokers
“I’ve got to die of something
anyway”
Heavy drinkers
“Drinking is just part of my everyday life”
OverweightObese
“I’m not very confident and am self conscious”
Unhealthy diet
“I’m too young to worry about
my health”
Sun-bed users
“It’s important for me to look
good”
“Life’s for living - I enjoy a smoke and a drink”
“I’m too busy with the kids to look after myself”
“I’m a big foodie and know I should lose a few pounds”
MCCN update Page 10
For example - Sun bed user Louisa from Liverpool, 16 years old
Louisa lives at home and is at college taking a vocational qualification in hairdressing. She really cares what people think of her and outward appearance is everything. Status conscious, she looks up to celebs and is a fashion conscious shopaholic. She is always on a diet and feels self conscious about her weight so she skips meals to keep in shape. She likes taking risks, trying new things and adventure. Always out, she binge drinks with her mates and tries to get in the bars to be seen in. She pops to the doctors periodically – perhaps to pick up her contraceptive prescription
14.1% of the NW population aged 15+ likely to use a sun-bed. (1.6% above national average) – 2/3 are female, all social grades
“It’s important for me to look good”
MCCN update Page 11
Understanding behaviours
Charities
At risk patients
GPs
Pharmacists Nurses
One to one depth research, focus groups and workshops among healthcare professionals and at risk groups to understand knowledge and attitudes and to identify any potential barriers and opportunities for the future
MCCN update Page 12
Achieving behaviour change
Perceived benefits Perceived barriers
Increase benefits
Decrease benefits
Personal and social benefits of action
Decrease barriers
Increase barriers
Personal and social losses from inaction
New Behaviour
Competing behaviour
Messages
Source: Fostering Sustainable Behaviour – Doug McKenzie Mohr, William Smith
MCCN update Page 13
GP – barriers
Time Not enough appointments
available/phone-lines are busy Not in QOF/not my responsibility Work overload for primary care staff Approachability of HCP
Apathy/denial Attitude: “it’s nothing serious” Age – too young to be anything serious /
too old for it to matter now no family history “People are too busy – they don’t check
and they don’t ask” Don’t want to bother doctor
Fear Fear of cancer and of screening
process itself Embarrassment at symptoms (esp
males)Awareness/information/mis-information Lack of awareness of symptoms Lack of information getting through
to public Lack of information for staff Carers of learning disability
patients need education
What barriers do we need to overcome to improve early detection and prevention of cancer?
MCCN update Page 14
GP - opportunities
Easy access to screening More opportunities in different locations to give
patients choice, including open clinics and drop in
Better information and education Patient education and awareness raising Simple checklists of what to do to prevent
cancer and what to look out for Signposting to clinics and screening Practice website, Newsletter, Message on
prescriptions, leaflets, TV ads and storylines, schools and colleges
Training for staff and on screen reminders Reward patients/ better follow-up Good system for rewarding patients especially
if miss initial screening Follow up and education of non-attendees
What can we do to increase early detection and prevention of cancer?
Relationship building/more conducive environment:
Approachability of staff Good relationship GP or practice nurse
encouraging patients to mention symptoms
Confidential areas to speak with staff/patients
Refer earlierReferral system: Change referral form to not include
irrelevant symptoms Fast-track referral when not
symptomatic One-stop anaemia clinic Not sticking too rigidly to guidelines Hunch clinic (sixth sense)
MCCN update Page 15
Pharmacy - barriers
Time Pharmacists are enthusiastic but “there is a
limit to what we can do” “the workload, we are near saturation
point...the government is asking us to do more year on year”
Confidence Pharmacists aren’t specialists, can’t diagnose
and will always refer patients to their GP “we don’t get an in depth view of patients
symptoms” “you have to be really wary about how you say
things” “you can’t force people to go to their GP if you
think it is cancer” “Drs are trained to break news like that using
their skills”
All keen to emphasise their willingness to help, but practical barriers exist:
Fear “people think cancer means death they don’t want to know ”
Embarrassment “some screening is invasive and people don’t like that...or bowel cancer you have to provide a sample”
Apathy/denial “Biggest thing about screening - what I don’t know, won’t hurt me’...
Awareness“Education, education, education’ is the main barrier to early detection - we don’t expect to get screening unless you pay for private healthcare’“half the battle is getting people to the hospital even if they do make an appointment for screening, 50% don’t turn up - perhaps a small charge should be made for appointments?”
MCCN update Page 16
Pharmacy - opportunities
Building knowledge and extending signposting
Training as part of CPD “If you train the pharmacists to know
where people could go to get extra help and say ‘these are the options”
“Remember pharmacists don’t always know as much as people think they do – there are new drugs mentioned all the time and everyone wants to know about it”
Communicating via the RPS, professional press and post
Providing information to patients Leaflets and posters in store and
inserts into prescription bags ‘‘make things more accessible”
What can we do to increase early detection and prevention of cancer?
Education “it’s an ongoing battle... education is
always going to be needed” “Make people more aware of self checks
or what is available at pharmacies”Follow up “targeting those requiring smear tests but
following up with a phone call”Referrals “Pharmacists might not want to advise
people so they would need a suitable way to refer them”
MCCN update Page 17
Risk groups – attitudes to health
Combination of drinking, smoking and poor diet is the norm – yet they do not link this to the possibility of cancer
Heart problems more of an immediate concern and many visit GP for blood pressure and cholesterol checks
Generally unwilling to bother doctor un-necessarily – only visit if everyday life is threatened
More likely to worry about the health of others (e.g. partner) than their own
Biggest fear is not being independent and having to rely on others – leveraging this concern around the process of cancer may be a key trigger to behaviour change
Eat, drink and be merry for
tomorrow you might die.
The last thing I want is to become
dependant on someone else.
Life is for living – when my time is up,
it’s up.It’s all in the genes anyway.
MCCN update Page 18
For the majority, cancer is not a major concern, despite having seen the suffering of close family or friends
If you get cancer, you will die -
eventually it will get you and treatment
will only prolong the inevitable.
I’m not in pain at the moment, so I
don’t need to worry about my
health.
If you don’t talk or think about
cancer, it won’t happen to you.
There’s very little you can do to
prevent cancer happening – it’s more about the luck of the draw.
Attitudes to cancer
MCCN update Page 19
Attitude to screening services
Majority positive to screening if it is suggested to them but do not actively seek it out because it is not on their radar
Women more familiar than men via cervical and breast programmes
Some experience of bowel screening via DIY postal packs - a couple rejected as they didn’t like the idea of the test and subsequent colonoscopy
A few would resist screening: Fear of having to change lifestyle – once you know
you can’t ignore it Would rather not know they might die Scared of the treatment for cancer if positive Cancer would mean too much emotional and
financial pressure for their partner (men) Scared of the other consequences of cancer –
colostomy bags
I would like to know if there was something
wrong with me because I think I’m half way there
now (50 yrs) so I’m thinking anything that
can make my life better at my age no matter
how big or small it is a good thing.
The NHS sent me a simple test and I haven’t bothered.
There’s nothing you can do about it if
you’ve got it you’ve got it. If you’re
numbers up, your numbers up.
MCCN update Page 20
Barriers - Attitudes to prevention
People not sufficiently motivated to alter their lifestyles in the hope of avoiding cancer
MCCN update Page 21
Key insight: Communication needs to be straightforward and simple to understand. There is a need to dispel the belief that cancer is solely about genes
Very poor knowledge and lack of desire to know moreVirtually nobody could articulate the causes – when pushed,
most mention genes, polluted environment and smoking Information gained via shock stories in the media leaving the
majority unable to separate myths from facts
They reckon smoking causes cancer but I won’t have that. You see babies with it in the paper. It’s not healthy but it doesn’t
cause cancer.
Barriers - Cancer knowledge
MCCN update Page 22
Barriers - Symptom awareness Limited awareness of symptoms and common misconceptions Strongest knowledge of lung symptoms accompanied by denial and written off as “just
winter” Bowel symptoms assumed to be tummy bug or piles – would self medicate Bladder symptoms assumed to be infection and most likely to be ignored Strong desire to know more as a trigger to action: One respondent had all 3 bowel symptoms but hadn’t realised they could be connected.
She vowed to make an appointment that day showing that once symptoms are known, the information would be acted upon
MCCN update Page 23
MostlyDon’t believe their symptoms are seriousSymptoms too trivial for doctor, don’t want to waste
doctors timeMiss self diagnose (Flu, piles etc.) and self medicateDifficult to get an appointment at the doctors Embarrassed about talking about their symptoms
(men)Too proud (illness is a sign of weakness for some
men)For someToo old to do anything about it – when time’s up it’s
upProtecting their loved ones from what they suspect
deep downBelieve that treatment will only delay the inevitableFrightened about what will be foundProbably too far gone for treatmentNervous of the effects of the treatment
Barriers - ignoring symptoms
Sometimes I think I’ll leave it because I’ll go round the corner to the chemist and he’ll give me
something.
It’s hard work to get an appointment at the doctors. You
could be dead by the time you’ve got one in a fortnight’s
time
I went to the doctor because I found blood when I was coughing. He told me I’d burst a blood vessel in my throat. I cough up blood all the time now but I don’t go to the doctor because I know what it is
It’s not that he doesn’t want to tell his wife, he’s afraid to tell her. He doesn’t want to
worry her.”
MCCN update Page 24
Playing on symptoms people may be experiencing can exacerbate fear although there is a need to elevate perceptions of minor ailment to overcome unwillingness to bother doctor.
Opportunities – clear symptom information
MCCN update Page 25
Unanimously positive to mobile clinics – convenient, local, friendly nurses. Seen as more specialist and more approachable than the GP. Strong desire for signposting to find out more
Opportunities - Reaching out
MCCN update Page 26
Opportunities – peer to peer
Engaging real people to share positive early detection stories and tools to pass on knowledge to others
My husband wouldn’t go to the doctor unless he really had to. He had bleeding and wouldn’t do anything about it until I found out. (female)
I’ve just been to Ireland with this man and I heard him getting up in the middle of the night and he was taking forever to wee and I said to him you need to go to the doctors. He said there’s nothing wrong with me and I said there is, there must be, you were up and down all night and I could hear you. I said look, it could be prostrate, it’s no big deal, just go, most men suffer with it.
I have a mate down at the pub. He goes to the toilet, like every five minutes. I’ve told him he should go to get checked out, we’ve all told him, but he won’t listen. He says, ‘I’ll be fine, I’m fine’, I think he thinks it’s too late and he’s a bit frightened.
MCCN update Page 27
Consequences of in-action...More shocking and personally relevant for those who persistently don’t attend screening. Link to trauma they would put their family through resonates highly.
MCCN update Page 28
Driving earlier detection offers more opportunities than prevention There are significant barriers to overcome among healthcare
professionals as well as risk groups To trigger people to act:
— Symptom education must be simple, consistent and sustained across all channels
— Screening should be heavily promoted and followed up— Services should be more accessible within the community — Maximise opportunities to engage during routine visits to
pharmacy, practice nurses, workplaces— Grass roots activity using peer pressure and impact on loved
ones – tools for positive role models who bust the myth that cancer is death and inspire others to come forward early
Summary – emerging insights
MCCN update Page 29
Further research among patients - one to one depths among risk groups for cervical, breast and skin cancer
Interviews with experts in specific inequality areas of mental health and learning disability
Stakeholder engagement to share insights and prioritise actions
Articulate the social marketing strategy and design interventions to reduce inequalities among key groups
Next steps
MCCN update Page 30
Thank youAny questions?For more information please contact belinda.miller@corporateculture.co.uk
MCCN update Page 31
Health and the Muslim community
‘Health’ is highly valued – it is the teaching of the Koran to take care of body and health
Belief that God decides your fate and you need to accept that
Did not look out for the symptoms of cancerNo awareness of screeningLanguage barriers mean letters/information in
English are ignoredWomen unwilling to discuss screening with
daughters –culturally not donePreferences for screening would be for it to be
conducted in the GP’s or via a mobile unit (near the Community Centre) by a female nurse
Although we are not supposed to drink
alcohol if a doctor said drink alcohol for 2
weeks and then you would be better we
would do it, we would be expected to do it.
Health overrides.
MCCN update Page 32
Many see weight loss as symptom of any cancer. If blood is detected anywhere, this would signal that something is wrong and probably trigger a visit to the doctor – but their immediate thought is not cancer!
Key insight: All were genuinely interested in what to look out for. Although they wouldn’t change their behaviour to prevent cancer , if they found out they had signs of cancer they claimed they would seek treatment for it
Lung Wide knowledge of link to smoking,
accompanied by much denial. Some mention environmental and industrial pollution
Some recall of symptoms (coughing, phlegm, breathless) often written off as “just winter”.
Bowel Most unaware of causes Belief it may be linked with contaminated
food rather than lack of fibre Most did not know the symptoms and
would self medicate for “tummy bug” A few mention blood in stools –
assumed to be piles
BladderMost unaware of causes Belief it could be linked to alcoholMost did not know the symptoms –
generally passed off as a urinary tract infection and particularly likely to be ignored
Some mention pain when passing water
Knowledge of the causes and symptoms
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