Cancers of the reproductive system are life threatening and induce much suffering in patients. Women who receive screening services can reduce their chances of developing these cancers. Women who undergo screening can also benefit from early diagnosis and treatment that result in a better prognosis. However, not all cancer prevention programs targeting women are successful of which the Every Woman Matters Program is an example. Of those that are successful, there are common elements contributing to the increased service utilization of women targeted by these screening services.
The Every Woman Matters Program
The Every Woman Matters program is funded by the federal government but managed by the states. Its purpose is to build awareness of these cancers as well as remove the financial and other barriers preventing women from availing of cervical and breast cancer screening (Backer et al., 2005). By increasing the utilization of mammography, breast examination, and Papanicolaou smear at free or minimal cost, the program aims to reduce the rate of reproductive cancers among women. Clinics providing primary care were targeted to implement the program. They are tasked to create systems to identify who should avail of screening, alert the staff and patients when screenings are due, and facilitate the transfer of screening results from other practices (Backer et al., 2005). Primary care providers are also responsible for raising patient awareness of cancer and screening through health education and providing reading materials. Thus, women’s preventive health care was approached through a program designed and implemented without the participation of primary stakeholders, namely the women in the communities serviced by participating clinics.
In an evaluation of seven clinics implementing the program, not all of the tasks and responsibilities of primary care providers were fulfilled leading to a low baseline utilization rate by eligible women in general. While the program evaluators facilitated goal setting sessions to improve organizational systems and service delivery, there were internal problems that hindered successful changes in practice (Backer et al., 2005). There was ineffective change management owing to poor leadership. There was little attempt to elicit staff buy-in given that the enactment of the change occurs at this level. Instead, a top-down approach was employed, and staff resistance was often strong.
There was no champion whose role is to convince the staff about the need for change and generate enthusiasm for it (Backer et al., 2005). In fact, prevention was not even a clear priority in some of the clinics and screening was regarded as just another add-on service. There was often a lack of cohesion among the staff making teamwork difficult (Backer et al., 2005). At the same time, human and material resources were often stretched to or beyond the limit. Finally, there was no clear system of accountability as to the outcomes of the program so that the staff members were often satisfied with their baseline screening utilization rates. There was no motivation to further increase patient utilization.
Other Cancer Prevention Programs for Women
Disadvantaged women such as the unemployed and members of ethnic minority groups are at greater risk for seeking health care late in breast or cervical cancer progression. These groups of women are often not seen at primary care clinics owing to barriers such as lack of insurance, inability to communicate in English, cultural beliefs about disease, fear, and lack of transportation (Fernandez et al., 2010). Community-based programs providing education and screening for these women were successful in increasing utilization and follow-up care for positive results. A major factor contributing to the success was the assessment of individual barriers to utilization and program design that addressed these barriers (Tejeda et al., 2013).
The Hopi Women’s Health Program (HWHP) was established in response to the disparity in reproductive cancer outcomes among American Indian women (Brown et al., 2011). The program received grants from the Centers for Disease Control and Prevention (CDC) and from a cancer research program that, in addition, provided technical support. The program is based within the reservation and run by the tribe through its tribal council. Services included female reproductive cancer education and counseling delivered in Hopi or English by trained lay health workers (Zhu, 2012). Pap smear, breast examination, and mammography services takes place at the local health center (Native People’s Wellness, 2012). In addition, the program makes sure that women were accompanied to their screening appointments, as well as treatments outside the reservation (Zhu, 2012). Further, the HWHP also consists of support groups for survivors of cancer and their families. An evaluation showed statistically significant increases in the number of Hopi women utilizing the screening services and those who perceived that screening aids in the detection of cancer (Brown et al., 2011). Significantly more women also had notable improvements in knowledge regarding screening procedures and the recommended frequencies. The success of the program is attributed to its cultural congruence, strong community participation that fostered ownership of the program, and the elimination of barriers relating to language, access, and social support.
The Breast and Cervical Cancer Client Navigator Program (BCCCNP) in Georgia employs a different, but similarly effective strategy among low-income and rural women who are likely to have difficulties accessing screening services (Pendrick, 2011). The rate of utilization of such services relies on the work of community health workers trained to function as Client Navigators. They serve as health advocates bridging patients to public health. They provide individualized services including health education, reminders to clients of when screening is due, client follow-up, troubleshooting of barriers to accessing care, and assistance in navigating the health care system (Pendrick, 2011; GASCO, 2010). A survey of women in the communities reported high satisfaction with the program citing the attentiveness and dedication of the Client Navigators in meeting individual cancer prevention needs (Pendrick, 2011). The effectiveness of the program is attributed to its holistic and individualized approach, the reduced cost of screening that fostered access, assistance that eased patient contact with health care providers, and patient follow-up for timely screening and treatment (GASCO, 2014).
Proposed Strategies
Based on the impact of different women’s health programs advocating screening, there are several strategies invaluable to the success of a follow-up to the Every Woman Matters program. Service components must continue to include awareness building through education and counseling. However, it is necessary to conduct a stakeholder survey or consultation to ascertain more specific needs such as social support as well as barriers preventing eligible women from receiving cancer screening and early treatment (Tejeda et al., 2013). Addressing these barriers gives every woman at risk for reproductive cancers a chance at prevention and early detection, thus reducing the disparity noted among medically underserved populations.
While the high cost of screening is a hindrance addressed by the program through free and low-cost services, other common barriers include language, culture, mobility, misconceptions, and psychosocial issues such as fear (Fernandez et al., 2010; Brown et al., 2011). For this reason, the program design should allow the provision of holistic and culturally congruent care in a language that the women understand. For women who fail to connect with providers in health centers and primary care clinics, community-based client navigators will be recruited and trained to reach out to them individually (Pendrick, 2011).
Doing so removes additional or unique barriers and ensures these women receive life-saving screening services.
In addition, mechanisms of accountability for outcomes are indispensable to ensuring the quality of services. For instance, research must establish baseline knowledge and service utilization rates among women and monthly or annual targets to ensure further improvements from baseline performance (Backer et al., 2005). Clinics participating in the proposed follow-up program must undergo an evaluation for human and material resource capacity. The clinics should further have a strong commitment to prevention as well as effective leadership and organizational cohesion. These are elements necessary in adapting to client and community needs and engaging in quality improvement. Clinics who choose to take part in the program should receive support and assistance in troubleshooting organizational barriers to the delivery of preventive care.
Conclusion
Women’s health programs advocating reproductive cancer screening play an important role in ensuring the availability, accessibility, and acceptability of preventive services. Prevention can minimize the modifiable risk factors to breast and cervical cancer. It also permits early detection and management. Not all programs are successful, however. Low-utilization rates are often the product of organizational factors affecting the delivery of care or barriers on the part of patients that organizations fail to address. An evaluation of what makes programs work and what makes them unsuccessful generate important learning insights and evidence useful as a guide in designing and implementing similar programs for women.
References
Backer, E.L., Geske, J.A., McIlvain, H.E., Dodendorf, D.M., & Minier, W.C. (2005). Improving female preventive health care delivery through practice change: An Every Woman Matters study. Journal of the American Board of Family Practitioners, 18(5), 401-408. Retrieved from http://www.jabfm.org/content/18/5/401.long
Brown, S.R., Nuno, T., Joshweseoma, L., Begay, R.C., Goodluck, C., & Harris, R.B. (2011). Impact of a community-based breast cancer screening program on Hopi women. Preventive Medicine, 52(5), 390-393. doi: 10.1016/j.ypmed.2011.02.012.
Fernandez, M.E., Lin, J., Leong-Wu, C., & Aday, L. (2010). Pap smear screening among Asian Pacific Islander women in a multisite community-based cancer screening program. Health Promotion Practice, 10(2), 210-221. doi: 10.1177/1524839909332798.
Georgia Society of Clinical Oncology (2010). Georgia Society of Clinical Oncology forms a patient navigator affiliate. Journal of Oncology Practice, 6(1), 49. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2805349/
Georgia Society of Clinical Oncology (2014). Cancer Patient Navigators of Georgia. Retrieved from http://www.gacancerpatientnavigators.org/
Native People’s Wellness (2012). Tribal and urban native breast and cervical program contacts 2012. Retrieved from http://natamcancer.org/PDFs/Wellness3/NPWellnessCervicalpg18_19.pdf
Pendrick, D.M. (2011). An evaluation of the Client Navigator Program for enhanced breast and cervical cancer screening among underserved women in the State of Georgia. Public Health Theses, Paper 181. Retrieved from http://scholarworks.gsu.edu/cgi/viewcontent.cgi?article=1188&context=iph_theses
Tejeda, S., Darnell, J.S., Cho, Y.I., Stolley, M.R., Markossian, T.W., & Calhoun, E.A. (2013). Patient barriers to follow-up care for breast and cervical cancer abnormalities. Journal of Women’s Health, 22(6), 507-517. doi: 10.1089/jwh.2012.3590.
Zhu, C. (2012). Cancer screening in Aboriginal communities: A promising practices review. Retrieved from http://www.albertahealthservices.ca/poph/hi-poph-aboriginal-health- review-2012.pdf
