Early Detection: Education
Education is a key aspect of any national effort to control cancer. Its activities affect every level of programming. What follows here is a general discussion of the role of education in a national cancer control program and the kinds of programming that a country might consider.
An important aspect of the mission of a National Cancer Control Program (NCCP) is professional education. It creates its academic mission by affiliating with a university to play a critical role in undergraduate education, not only for medical students, but also for students in the allied health sciences such as nursing, nutrition, psychology, or social work. It may be involved in technical training including a school for radiotherapy technicians, and in the education of researchers in various disciplines. Its participation in professional graduate and continuing education in oncology at all levels is also essential. Thus a strategic plan for an NCCP as it evolves must eventually include a careful analysis of its mission in education. In a developing setting the shortage and attrition of trained health personnel at all levels make this particularly important. Medical students will receive some oncology teaching already, but as the NCCP develops, a strong oncology component to the medical school curriculum is perhaps one of the highest priorities so that the next generation of a country’s physicians can deal competently with cancer at various levels of practice. Professional attitudes and fears that prevent early diagnosis and referral of early cancer or the proper relief of pain and suffering in patients with terminal cancer are examples of the importance of the influence that the NCCP can play in professional education. In considering educational needs for oncology for the future, these need to be linked to the NCCP’s manpower plan for all specialties. Moreover, terms of employment have to be such as to allow clinicians sufficient time to devote adequately to their educational contributions.
The NCCP also has an important role in public education. This role it will play in collaboration with a country’s voluntary agencies like a Cancer Society, that may already be doing some of this. These activities need to be coordinated in collaboration with the NCCP within a larger vision rather than multiple independent initiatives, sometimes with conflicting messages.
The NCCP needs strategies for promoting public awareness and community support for cancer control. These would be carried out through its national office to coordinate the provision of information, education and communication (IEC) materials and consultant services in support of the activities of advertising agencies, radio and television advertisement and publicity services, NGO services, training, workshops and conferences.
The NCCP would use four strategies to create public awareness and community support to obtain behavioral change that would contribute to the reduction of the cancer burden and control of suffering: (a) promotion of lifestyle change, for example through reduction in tobacco use, (b) changing attitudes so that the public knows that diseases like cervical and breast cancers are curable with early detection; (c) changing beliefs about suffering - that cancer pain can be relieved; and (d) improving the knowledge of patients, the public, and health service providers about cancer and cancer control. The IEC strategy might have two components:
(a) Mass Media: for creating a favorable environment towards prevention, early detection and the relief of suffering, providing critical information and facilitating lifestyle change, especially related to tobacco use, in communities across the whole social fabric; and
(b) Interpersonal communication and focused health promotion interventions to the target populations: face to face contact with (i) patients and their families; (ii) tobacco users in all forms; (iii) young adults and school children; (iv) villagers, especially women, in rural settings; and (v) health professionals involved in cancer care.
The NCCP could use three broad assumptions in coordination: (i) that access in some jurisdictions to target groups may be inadequate through the existing health system because of resources and staff attitudes about cancer. Where NGOs may have more effective access to a community than the health system their channels and services could be used, especially those involved in primary health care delivery; (ii) the role of NGOs and action groups in cancer control could be further motivated at the regional and community levels; and (iii) among rural communities the public health system may be the key actor, utilizing several formal and informal communication channels available; health workers, school teachers, village officials, private medical practitioners, women's groups, and others.
Operationally, this would lead the NCCP to adopt several approaches through the services of: (a) NGOs to reach target groups; (b) television, radio and private sector agencies for mass media; and (c) the existing and developing urban and rural health system infrastructure and resources.
The NCCP could make considerable progress by just finding and coordinating volunteer and charitable contributions from these three sectors. The NCCP should consider instituting a form of ongoing public recognition to bring these important voluntary contributions to the welfare of a country’s citizens to prominent national attention. If funds can be obtained, they can be used to contract IEC services from these three sectors in a more deliberate fashion.
Intersectoral Coordination and Conferences for Opinion Leaders. Cancer is stigmatized in public and health professional awareness as equated with suffering and death, and not being treatable, too expensive to treat, or not worth treating. This delays the development of timely interventions. Mobilizing political, social and medical leadership is critical to addressing this issue. Conferences for opinion leaders could be coordinated annually by the NCCP through its national office both centrally and provincially. Representatives of regional and national governments including politicians, staff of ministries, social, medical and religious authorities, business and industrial groups and senior administration should be involved. Participants would be briefed on: (a) the cancer situation in the world, the region, and the country; (b) prospects on its growing importance; (c) major policies of WHO, its Regional Office and the NCCP on cancer prevention and control; and (d) the opportunities for involvement in the NCCP from various sectors, agencies and NGOs.
Public education programs might be centered on tobacco control, for example, and should be concerned with reaching specific target audiences, both nationally and at the regional and community levels, by means of group activity, person-to-person communication, and a variety of individualized processes, to inform, to motivate and to change behavior through the interplay of changes in attitudes and behaviors with knowledge. Objectives are basically those of the public information program listed above. Specific targets can include health care workers including physicians, teachers and schools, religious organizations, the work place, as well as clubs and organizations - especially women's organizations. The general strategy includes presenting decision-makers with succinct and understandable presentations of the health and economic implications of tobacco use, both now and in the future, raising and supporting public awareness and opinion against tobacco to influence decision-makers (issues of danger to children and the rights of non-users can be potent), and developing awareness and mobilizing the support of civic groups at the national and regional level. In designing the program consideration should be given to who will deliver the educational messages, to which population group (young and adult, literacy level, male and female, etc.), what training they will need, and what incentives will keep them on the job.
For both public information and education programs, it will be necessary to design the specifics to suit the target audience. At the community level this will necessitate surveys of the local populations served, including appropriate training of the health workers who carry them out. Survey instruments are available from W.H.O. for local adaptation. It will be important to involve all participants in the community using participatory approaches in the survey process, its analysis, and the subsequent educational program design to maximize commitment and eventual sustainability of the effort. It is worth noting in education programs that tobacco control also affects other diseases besides cancer.
Although tobacco control is the major focus in this example, in the design of public information and education programs, additional messages would be considered to complete the program:
*the rising importance of cancer as a public health problem;
*a basic understanding of what cancer is and the health problems it can cause, including the seven early warning signs;
*that for breast, cervical and oral cancers cost-effective measures exist for cure with early detection and treatment;
*that effective measures exist for cancer pain and symptom relief;
*the importance of feminine hygiene in prevention of cervical cancer;
*safe sexual lifestyle for the prevention of sexually transmitted diseases (STDs), AIDS as well as cervical cancer;
*control of alcohol abuse which has a synergistic effect with tobacco on the development of oral cancer.
University school(s) of medicine in a country could play a key role in survey training, implementation and analysis, educational program design, and procurement and production of appropriate educational materials. National coordination of the effort through the NCCP would allow sharing of experience and materials and prevent duplication of effort.
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