Transcript No Slide Title

Cancer early detection
and prevention strategy
Social marketing
workstream
A presentation for:
22 October 2008
MCCN update
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
Page 2
MCCN update
Our framework for action
Page 3
MCCN update
What have we done so far?
Understanding the context
Analysis of excess incidence and mortality
to 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?
Segmenting target groups to understand:
Understanding the audience
Understanding behaviours

What are the risk factors for prevention?

Who is late presenting?

What are their lifestyles, attitudes
and behaviours?
Research among healthcare professionals
and 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?
Page 4
MCCN update
Page 5
Excess incidence and mortality by cancer
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
Lung - Females
Lung - Females
3.1%
Lung - Males
3.6% Lung - Males
Cervix - Females
1.4%Cervix - Females
Skin - Females
-32.3%
2.0%
16.9%
Bladder Females
-41.3%
Bladder - males
0.0%
Bladder - males
-16.5%
3.2%
Excess Mortality
Breast - Females
-50%
Breast - Females
Excess Incidence -15.5%
-40%
-30%
-20%
Source: NHS/NWCIS data – 2001 – 2005
-10%
0%
10%
-40%
Total Incidence
6257
Bladder total
34.5%
1179
Breast total
Colorectal total
Lung total
Skin total
Cervix total
18.9%
32.2%
55.7%
12.4%
32.1%
5520
4340
5701
1069
324
Total All Cancers
Colorectal - Males
-11.4%
% Mortality
(from
Incidence)
34.5%
30.1%
Colorectal Females
Colorectal - Males
Bladder Females
76.5%
-30.9%
Skin - Males
-17.5%
Colorectal Females
23.5%
Skin - Females
-14.6%
Skin - Males
32.1%
6.1%
-20%
0%
20%
40%
60%
80%
100%
MCCN update
Page 6
Some key differences across the network
Excess mortality
Total
region
Central
Cheshire
Eastern
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
High: Excess between 6 and 19.9% 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
Very High: Excess more than 20% higher than region
Source: NHS database, all comparisons with region average in % point
Very Low: Excess more than 20% lower than region
Low: Excess between 6 and 19.9% lower than region
Average: Excess between 5.9% lower or 5.9% higher than region
MCCN update
Page 7
Understanding the audience
Prevention – what are the risk factors?
Smoking
Lung Cancer
Drinking
Obesity/ diet
Genetics
Sunbed use
Sexually active
(many partners
/ STDs)



Breast Cancer



Cervical Cancer
Bowel Cancer

Bladder Cancer

Deprivation
(lifestyle
factors)









Malignant Melanoma
Detection – who presents late?
BME's
Lung Cancer
Older Men
Learning
Disabilities
Mental
Health
Muslim
religion
Sexually active
(many
partners/STDs)


Breast Cancer
Cervical Cancer

Bowel Cancer











Bladder Cancer
Malignant Melanoma
Deprivation
(attitude to
authority)

Primary factor
Source: 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
Secondary factor
MCCN update
Page 8
Inequality groups
BME’s
Learning disabilities
Mental health


Particularly relevant to cervical
and breast cancer, but also for
bladder and bowel

Particular issues for breast,
cervical and bowel cancer

less likely to attend screenings

Late detection as low
percentage attend screening

may not be monitored
sufficiently to pick up issues

Less aware, do not understand
the importance of symptoms
and therefore don’t go to the
doctor as quickly

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
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”
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
MCCN update
Profiling risk groups
Used TGI to segment the population by risk factors:
Heavy smokers
“I’ve got to die
of something
anyway”
Obese
Medium smokers
Light smokers
“Life’s for living - I
enjoy a smoke
and a drink”
“I’m too busy with
the kids to look
after myself”
“Drinking is
just part of my
everyday life”
Overweight
Unhealthy diet
“I’m not very
confident and am
self conscious”
Heavy drinkers
“I’m a big foodie
and know I should
lose a few pounds”
“I’m too young
to worry about
my health”
Sun-bed users
“It’s important
for me to look
good”
Page 9
MCCN update
Page 10
For example - Sun bed user Louisa from Liverpool, 16
years old
“It’s important for me to look good”
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
MCCN update
Understanding behaviours
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
Pharmacists
Nurses
Charities
GPs
At risk patients
Page 11
MCCN update
Achieving behaviour change
Perceived benefits
Perceived barriers
New Behaviour
Increase benefits
Decrease barriers
Competing
behaviour
Decrease benefits
Increase barriers
Messages
Personal and social
benefits of action
Personal and social
losses from inaction
Source: Fostering Sustainable Behaviour – Doug McKenzie Mohr, William Smith
Page 12
MCCN update
GP – barriers
What barriers do we need to overcome to improve early detection and
prevention of cancer?
Time
Fear


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 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
Page 13
MCCN update
GP - opportunities
What can we do to increase early detection and prevention of cancer?
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
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 earlier
Referral 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)
Page 14
MCCN update
Page 15
Pharmacy - barriers
All keen to emphasise their willingness to help,
but practical barriers exist:
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”
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
What can we do to increase
early detection and prevention of cancer?
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”
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
It’s all in the
genes anyway.
Eat, drink and
be merry for
tomorrow you
might die.
Life is for living
– when my time
is up, it’s up.
The last thing I
want is to become
dependant on
someone else.
MCCN update
Page 18
Attitudes to cancer
For the majority, cancer is not a major concern, despite
having seen the suffering of close family or friends
I’m not in pain at
the moment, so I
don’t need to worry
about my health.
If you get cancer, you
will die - eventually it
will get you and
treatment will only
prolong the inevitable.
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.
MCCN update
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
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.
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
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.
Page 19
MCCN update
Barriers - Attitudes to prevention
People not sufficiently motivated to alter their lifestyles in
the hope of avoiding cancer
Page 20
MCCN update
Barriers - Cancer knowledge
 Very
poor knowledge and lack of
desire to know more
 Virtually
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.
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
Page 21
MCCN update
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
Page 22
MCCN update
Page 23
Barriers - ignoring symptoms
Mostly






Don’t believe their symptoms are serious
Symptoms too trivial for doctor, don’t want to waste
doctors time
Miss self diagnose (Flu, piles etc.) and self medicate
Difficult 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 some






Too old to do anything about it – when time’s up it’s
up
Protecting their loved ones from what they suspect
deep down
Believe that treatment will only delay the inevitable
Frightened about what will be found
Probably too far gone for treatment
Nervous of the effects of the treatment
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 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
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 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
Opportunities – clear symptom information
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.
Page 24
MCCN update
Opportunities - Reaching out
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
Page 25
MCCN update
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 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.
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.
Page 26
MCCN update
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.
Page 27
MCCN update
Summary – emerging insights



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
Page 28
MCCN update
Next steps

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
Page 29
MCCN update
Thank you
Any questions?
For more information please contact
[email protected]
Page 30
MCCN update
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 cancer

No awareness of screening

Language barriers mean letters/information in
English are ignored

Women unwilling to discuss screening with
daughters –culturally not done

Preferences 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.
Page 31
MCCN update
Page 32
Knowledge of the causes and symptoms
Lung
Bowel
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”.

!
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
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
Bladder

Most unaware of causes
 Belief it could be linked to
alcohol
 Most 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
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