'Hard to Reach' Workshop Participant Report
The National Screening Service (NSS) was established by the Minister for Health and Children in 2007, and endeavours to provide quality assured cancer screening programmes for the people of Ireland. The NSS has a remit to implement additional measures to promote participation in its screening programmes among 'hard to reach'/marginalised populations.
Health promotion within screening programmes aims to create an environment that is conducive to and supportive of informed participation in screening. This helps ensure people who can benefit from screening are informed and empowered to take advantage of the potential benefits. In collaboration with key community partners and health professionals, the screening promotion team aims to implement additional measures to reduce barriers and enable eligible women to participate in BreastCheck and CervicalCheck.
In the autumn of 2009, the NSS established a formal consultation process seeking to hear the views and opinions of community networks and health professionals on initiatives that in their opinion could be developed to maximise and sustain uptake among '‘hard to reach'/marginalised populations. Over 40 written submissions were received from a cross-section of individuals and networks who are working in the area of social inclusion, health inequalities, health promotion, community development and primary care.
In terms of initiatives that could be developed to maximise and sustain uptake among 'hard to reach'/marginalised populations there were a number of recurring themes in the submissions received that can be categorised under the following headings:
Access-enhancing interventions can be defined as those which address the structural, economic and geographical barriers to screening use such as bringing the service to the women in mobile screening units, the location of mobile screening units, access to transport to screening units and access to translated materials.
Community Based Interventions
Collaborating with community networks and ensuring community involvement is vital to the success and sustainability of any screening promotion intervention. Using multi-strategy initiatives in the community setting are generally more successful.
Primary Care Team (PCT) Interventions
Within healthcare settings one of the strongest motivators to avail of screening is encouragement from a GP or another health professional. This is particularly relevant in the case of cervical screening which is conducted in the primary care setting.
A roundtable workshop, independently facilitated, took place on 11 March 2010. Participants were asked to discuss approaches to engaging with 'hard to reach'/marginalised populations using case vignettes for both the BreastCheck and CervicalCheck programmes. Outcomes from the roundtable workshop were presented to the executive management teams of both programmes. Based on these outcomes a summary of current activities and future plans for both programmes are presented below.
- An important principle for the BreastCheck programme is to offer screening services locally to women in counties and locations convenient to where they live. To achieve this each of the four regional BreastCheck units operates in tandem with mobile digital screening units. The majority of participating women in BreastCheck actually have their mammogram in one of these mobile units
- Given the complexity of the site selection process, some sites may be criticised on the basis that there is a view that there is another more suitable site. The programme’s experience over the last 10 years has demonstrated that there is no ‘perfect’ site location and compromises have to be made to ensure a ‘best fit’ against the many selection criteria involved to maximise participation in the programme and ultimately achieve best outcomes for all women
- An explanatory summary on the process of selection of sites for mobile screening units has been developed and is now available on http://www.breastcheck.ie/content/mobile_site_selection
- BreastCheck has an Access Officer who coordinates assistance for women with disabilities to access the BreastCheck service
- A population register has been compiled from a number of sources, principally data from General Medical Services (GMS) Scheme, the Department of Social Protection, private health insurance companies and self registration by women. As the register does not include all women, women are encouraged to check they are on the BreastCheck register
- As much as possible BreastCheck advises women that if they cannot keep their appointment they can telephone the screening unit and arrange a time that suits them
- BreastCheck offers additional time to women who have specific needs to be considered during a screening appointment e.g. if a woman has breast implants, mobility issues, is a deaf woman, a blind woman or has an intellectual disability
- An internal team has been formed to review accessibility to the BreastCheck service. This team will encourage compliance with the Disability Act 2005 and has developed an action plan to progress accessibility requirements across BreastCheck and other screening programmes
- The BreastCheck programme Commitment to Accessibility has recently been updated and is available on http://www.breastcheck.ie/content/accessibility
- The programme is reviewing the full suite of BreastCheck information materials to improve and enhance content and messaging. National Adult Literacy Agency (NALA) approval will be sought to ensure information is in plain English
- BreastCheck is working in collaboration with the Social Inclusion Unit, HSE to provide specific information in different languages on the website
- For Deaf women a sign language interpreter can be made available on request
- BreastCheck currently raises awareness of the screening programme through an integrated screening promotion and communications approach. This approach includes information provision at public events, website availability, media national and regional newspapers and advertising using a variety of formats including television and radio, large outdoor billboards at bus shelters and shopping centres across rural and urban locations
- Letters and brochures are available in Braille. Further items can be made available on request
- Information is available regarding the BreastCheck screening service on request in an accessible form including a video tape and a DVD
- A loop system for deaf people is available in all BreastCheck units
- An illustrated ‘Guide to Breast Screening’ has been developed for women with an intellectual disability. The guide, approved by NALA is available on request and can also be accessed through our website. Radiographers in all the BreastCheck units hold a copy. In addition a copy can be mailed to residential homes on request. We are currently updating and reviewing this guide in consultation with external stakeholders representing women with intellectual disabilities
Community Based Interventions
- Screening Promotion Officers (SPOs) work in a partnership approach with community networks regionally creating awareness of the BreastCheck screening programme and supporting informed choice for eligible women. We have developed a specific training programme which provides core knowledge on cancer screening for community workers to enable them to deliver the screening message to communities. The evaluation of this programme will inform any future plans for a community health advocacy approach
- SPOs have provided information sessions to staff working with women with intellectual disabilities informing them of the BreastCheck process for their clients
- Group bookings for women are possible
- A ‘Buddy System’ is available whereby women can bring a support person with them to their appointment
Primary Care Team Interventions
- BreastCheck currently provides information to GPs, Practice Nurses and Public Health Nurses with regard to screening in their area. SPOs are available to answer questions and provide links and information on support for women to access the service
- CervicalCheck has developed a Cervical Screening Register (CSR). This is a list of eligible women aged 25 to 60 from information received from the Department of Social Protection. As the register does not include all women, women are encouraged to check they are on the CervicalCheck register
- Mass media efforts to promote CervicalCheck include public relations and advertising using a variety of formats, press adverts, large outdoor billboards at bus shelters and shopping centres across rural and urban locations
- Leaflets and invitation letters are provided in a clear, concise and easy to understand format for all eligible women and all CervicalCheck leaflets are NALA approved
- Braille leaflets are being developed and will be provided on a digital format on the website
- A pictorial leaflet ‘About your free smear test’ has been developed for women with literacy difficulties
- CervicalCheck has an Access Officer who co-ordinates assistance for women with disabilities to access the CervicalCheck service
- One of the main topics of discussion arising from the workshop in relation to CervicalCheck was a perceived barrier to participation for ‘hard to reach’ /marginalised women by the introduction of call, re-call in September 2009
- In March 2010 the NSS Board agreed that the next phase of CervicalCheck will be the introduction of direct programme entry (by smeartakers) of eligible women to supplement call, re-call as a means of recruiting eligible women and in particular ‘harder to reach’ women. It is likely that direct programme entry will be required at some point after the CervicalCheck programme enters the final year of the first three year screening round in September 2010
Community Based Interventions
- Full and detailed information regarding choice of local smeartakers is available on https://apps.cervicalcheck.ie/screening-locations/find-a-smeartaker.588.findsmeartakersearch.html
- SPOs currently work with national and local community network groups raising awareness of the CervicalCheck programme and supporting informed choice through multi-strategy community based interventions
- CervicalCheck intends to strengthen links with agencies such as the National Council for the Blind and the Irish Deaf Society to raise awareness of the services provided to blind and deaf women and to determine how our services can be enhanced for these women
- CervicalCheck intends to strengthen links with intercultural groups and explore projects which support individuals from ‘new communities’ to act as interpreters
Primary Care Team Interventions
- CervicalCheck currently provides information stands and speakers at health professional conferences nationally and regionally. Information sessions to Public Health Nurses, Practice Nurses and primary care teams will continue regionally and nationally
- CervicalCheck training updates are provided by the CervicalCheck Smeartaker Training Unit (STU) to general practice reception staff, GPs and Practice Nurses