| 4. In which ways is the initiative creative and innovative?
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With the objectives to get all the women in the target group to undergo screening tests and to follow up on the cases indicating the presence of abnormal cells, to facilitate public access the services, to open up to opinions and feedback from service recipients, to set up strategies, to increase service quality, and to make available alternative service accesses, the following was implemented:
In the beginning of the fiscal Year 2012, we held a meeting informing all concerned staff about the objectives of the project as well as surveyed and registered target groups. In collaboration with the Health Alliance Network, Public Health Volunteers and community members, we visited every target household in the area and searched for in-depth information on the reasons why people did not come to receive the service they were entitled to.
We obtained information indicating 50 percent of the target group believed that showing one’s reproductive organs to someone other than her husband or family was a sin and contradicted their religious principles, 20 percent did not pay attention to their health and thought it was not an immediate issue, 10 percent found it inconvenient to commute to receive the service and were not confident in the safety due to the unrest in the area while the remaining 10 percent were shy.
Later, towards the end of 2012, Takbai health team invited all involved individuals to meet and plan solutions for the problems, especially those related to religious principles. The meeting with local religious leaders, who were also consultants for Takbai Hospital, was hosted in order to create understanding among religious leaders and change their attitude and point of view. Subsequently, religious leaders from all 8 sub-districts were invited to participate in the discussion with the chief religious leader of Narathiwat Province who was present as the main figure. Conclusions on religious belief were reached stating that the screening is a process to help prevent cervical cancer frequently found in women and therefore is not contradictory to the religious principles. Attempts to reach the husbands of the target women at the mosques and coffee shops were then made so as to change their attitudes and beliefs.
This activity has continued to take place up to present. Religious leaders help share health knowledge during Quran reading sessions at the mosques on Fridays. The strategy also solves the rest of the problems such as time restrictions, fear for unsafe commuting and shyness.
The health team has implemented the strategy and initiated proactive screening service since December 2012, offering cervical cancer screening in the community utilizing Mobile Prep Smear. This has helped women with time constraint who found it inconvenient to go to the hospital for the screening. Some of the target women work in the neighboring country of Malaysia while others have to care for their children at home. They are now able to choose in advance the screening venue and date for their convenience. In the case of shyness, they are able to choose the staff member with whom they feel comfortable. As a result, the number of women receiving cervical cancer screening has doubled. In the middle of the year 2013, we organized a house visit program, visiting those who have been diagnosed with cervical cancer. Women who witnessed the distress of cervical cancer patients and realized how it affected their lives and families began to have an awareness and fear. This also results in more women undergoing the screenings.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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The work of various departments and the Health Alliance Network are integrated and team work takes place. Involved groups include Community and Family Medicine Department, Nursing Department, Administration Department, Village Health Volunteers, Local Administration Organization. Having worked together in surveying and gathering data, exploring problems, and acknowledging nature of problems, all parties involved in the project contributed to the implementation; for example, the transportation department of Takbai Hospital provided transports used in all proactive implementation, the Emergency Room Department of Takbai Hospital contributed ideas for utilization of innovative equipments, and Takbai Municipality sponsored budget for incentives in the form of small gifts for women who come for the screening. Public Health Volunteers and community members also rendered their support in campaigning for and publicizing the project through community live broadcast, community radio stations, brochures or appointment cards. Additionally, religious leaders played a significant role in encouraging the changing of religious-related attitudes. This has resulted in an increase in the number of women undergoing screening.
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| 6. How was the strategy implemented and what resources were mobilized?
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Human Resources
Religious leaders were employed as a major channel to impart information and create acceptance by encouraging change in attitude and belief that are focused on religious principles. The selected religious leaders must be well respected in the community, visionary and possess good communication skills.
Health personnel who monitor services must be dedicated and skillful in screening. They too must exhibit good interpersonal skills to create trust among the women in the service.
Technical and multimedia resources
To transcend religious difference, it is very important to approach “Muslim husbands”. This should be done with sincerity and through religious leaders who are well respected in the community. All religious leaders were invited to take part in discussions on the importance of the screening and the problems associated with the refusal to undergo the screening. The meeting concluded with the concept ‘Religion Brings Health’. We came up with techniques for implementing one-stop screening. This has helped eliminate complicated and redundant procedures and reduce waiting time to the guaranteed 20 minutes.
A multi-media system was also developed by creating a database program named Cervical Screening 2010 to facilitate the usage for all levels of staff.
Financial Resources: Financial issues were not a major concern as innovation and equipment utilization does not incur a large budget. Other expenses included public relations budget, transportation fees for service recipients who opt for the screening at the hospital, and gifts for the women as a token of encouragement. Supporting funds from the Local Administration Organization have enabled smooth implementation.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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11 religious leaders were main participants during the discussions intended to cover all 8 sub-districts in Takbai District, including Chehe and Salamai sub-districts where the population is large and where Health Promoting Mosque events usually take place. These leaders will be in charge of encouraging adjustment of religious-related attitudes of the targeted women, their husbands and families.
From 2012-2014, of the 4,393 women aged between 30 to 60 years old in the target group, 246, 294 and 830 women received cervical cancer screenings respectively. The numbers doubled each year. Our team was able to perform our field work and render services, as planned in conjunction with the target women. Our field work took place approximately 2 times a week, totaling 96 outreaches in a year and covering all 8 sub-districts of Takbai District in Narathiwat Province.
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| 8. What were the most successful outputs and why was the initiative effective?
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Project evaluation and progress monitoring were implemented through studies on time, budget, quality assessment and risk appraisal plans. In the first stage, we monitored officers’ promptness in preventing obstacles from work. The Community and Family Medicine Department, along with the members of the Takbai Hospital community and public health volunteers, appointed personnel to perform duties at various work stations. Officers with a good understanding of the goals of the project and with good work performance were appointed to monitor the selection of participants in the target group in different communities and ensure that the targeted number of women seeking the service based on the project is reached. They kept a registry of the women undertaking the cervical cancer test. They also worked in close coordination with village help volunteers to monitor those in the target group who have not been tested for cervical cancer. Meetings to appraise the work were organized every three months to evaluate progress and identify problems and obstacles faced during the implementation of the project in various dimensions. Also discussed during the meetings with the Takbai Public Health Coordination Committee were important issues, such as solutions to problems and ways to increase the project’s efficiency.
Project appraisals on cervical cancer screening in the three Southern most provinces with the participation of local communities through the Takbai Hospital Quality Development Community were conducted with consideration on religious sensitivity. Comparisons were made between the old and new processes and the ensuing results on efficiency and productivity. Indicators were set up and employed to appraise the success rate of the project every six months. Emphatically, appraisals were made on the rate of participation of the cervical cancer screening project among the women in the target group and the number of women with abnormal cells who underwent re-screening. Comments and opinions from participants were heeded so that the project could be further developed in accordance with regional religious sensitivities. Risk on running the project in areas affected by unrest can also be minimized by paying attention to the advice and comments of the project participants. Continuous development will ensure further progress, efficiency, and innovativeness of our service provision
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| 9. What were the main obstacles encountered and how were they overcome?
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Language barriers
Since 80 percent of the people in the area are followers of Islam and communicate through the Yawi language (a Malay dialect), interpreters are required in communication. Illiteracy among people in the area makes it difficult to communicate both in writing. It is highly important to ensure that the interpreters, who are middle persons, understand and translate our messages accurately. Interpreters must, therefore, be the people who thoroughly understand the importance, essentiality and benefits of cervical cancer screenings. The interpreter roles are taken by public health volunteers and local staff throughout the implementation.
The insurgency in the 3 southern provinces
When traveling to provide screening services in areas faced with unrest, we are usually supported by military officers and local residents who help prepare the venues and update us with news when the situation becomes unsafe and risky. These local residents always demonstrate their willingness to help with the outreach.
Creating acceptance and fostering adjustment in the attitude of the target women and their husbands:
Time and effort are required to help the target group overcome their misconception of their religious doctrines. Information and facts were communicated directly and continuously through religious leaders.
The target women were shy and afraid.
Meetings were organized to encourage the women to exchange their experiences in cervical cancer screening. This has helped establish a meaningful relationship and trust between the target group and the staff. It also helped them to overcome their shyness and fear of pain caused by the screening.
Innovation and New Equipment:
To implement the proactive cervical cancer screening service in many different areas, we developed and improved screening beds and lamps so as to fit the venues. The equipment can be used at the venues where electricity is not available and also during power cuts. This equipment has been developed to ensure compatibility with reserved batteries.
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