Community Involved Cervical Cancer Screening in the 3 Southern Provinces
Takbai Hospital

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
According to the National Institute of Cancer, the number of cervical cancer cases has the tendency to increase every year. Each day, approximately 7 Thai women die from cervical cancer. (Data from Public Heath Statistics of the Year 2010, The National Cancer Institute. 2010) In addition, it was found that diagnoses and proper treatment at the early stages can reduce the occurrences of cervical cancer and the resulting death rate. 80 percent of the population of Takbai are Muslims. The female population who strictly observe the religious rules and culture generally have children at a very young age. Birth control is not a popular practice as it is against their religious principles, which results in women having many children. The risks for cervical cancer are consequently high. Besides, the province of Narathiwat has the lowest literacy rate of children in Thailand. Campaigning to help the women who are our target group realize the benefits of cervical cancer screening and the fact that it does not violate their religious rules: revealing one’s reproductive organs to someone other than her husband or family is considered a sin. Therefore this a very difficult task to complete. As a result, only 4.95, 5.97 and 5.60 percent of women underwent the cervical cancer screening utilizing Pap Smear tests in the years 2010, 2011, 2012 respectively. These are considered very low figures in comparison to the number of women in the reproductive age range in the area and much lower than the goals set for cervical cancer screening in Thailand which is to cover 20 percent of women in their reproductive years, between 30 to 60 years of age. Moreover, the insurgency in the 3 southern provinces and the fact that Takbai is a district located on the Thai-Malaysian border as well as the escape route for terrorists have affected the people’s ability to commute to receive cervical cancer screening service. Often, the roads are cut off as a result of bombings intended to shut down the roads to block officers’ pursuit while the terrorists are attempting to escape across the border. Consequently, people are afraid to come out to receive services or choose to wait until they are confident it is safe to commute. As long as these problems exist, women, Muslims in particular, will remain deprived of the opportunity to be aware of their own health situation and access to the basic health care they are entitled to. This may cause a large amount of expense and fatality in the cases of which the diagnosis is done during invasive stages.

B. Strategic Approach

 2. What was the solution?
Takbai Hospital is a community hospital operated under the Ministry of Public Health. The hospital’s missions are to develop a quality and standardized health system, ensure appropriate health behavior in community members at individual, family and community levels, encourage whole community involvement in health problem management, assure easy access to essential services, and maintain good coordination under suitable and efficient system and environment. As a result, the cervical cancer screening with community involvement projects was created under the following guidelines: Adjust the screening process to correspond with religious doctrines. Discussions with religious leaders who are also community leaders were hosted. The chief religious leader of Narathiwat Province was present as the main figure during discussions and became a channel to discuss the project at the mosques or coffee chops with the aim of adjusting the attitudes of our target women, their families and husbands. Offer access to service to the community by implementing proactive screening services, initiating house visitation, inventing mobile Pap Smear, altering and recycling leftover materials to create beds used in cervical cancer screening that are light in weight, easy to transport, inexpensive and make screenings as efficient as those carried out at the hospital. Build health alliance network and encourage community involvement in finding resolutions for health problems among community members, surveying target groups, inquiring needs, deciding on venues for screenings that are convenient and private to which people feel safe to commute despite the unrest, creating acceptance, and changing attitudes of the community.

 3. How did the initiative solve the problem and improve people’s lives?
The efforts to overcome the differences in religious beliefs stating that revealing one’s body parts to someone other than her husband or family is a sin and a violation to the religious principles had never been made. We carried out house visits with the attempt to find out the reasons why Muslim women do not reach out for cervical cancer screening service and discovered that they did not get the permission from their husbands. (A married Muslim woman needs her husband’s approval prior to carrying out any tasks.) Due to the belief that it is against the religious rule about dressing to covering up their whole body, revealing a body part especially the private parts, unless for the purpose of medical treatment, is a sin. The Community and Family Department of Takbai Hospital reviewed the matter and came up with a strategy to approach the ‘husbands’ through religious leaders to create better understanding. The innovation of ‘Mobile Pap Smear’ is creative and innovative. Beds and lamps used in screening tests are made from leftover materials found in the hospital. They are light in weight, can be conveniently transported, of good quality, enabling us to render screening services at venues requested by our target women. Salon beds, light and easy to move, are used in place of obstetric beds which are heavy, bulky, and costly. The lamp lights are made from office chair legs, mop sticks, microphone wires, and lamps. The lights require 220 Volt power and are compatible with in-building power system and, therefore, can be used throughout the whole service time in the area where in-building electricity is available or a reserved battery in the case of immediate power shutdown caused by the insurgency.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
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.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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.
 6. How was the strategy implemented and what resources were mobilized?
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.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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.

 8. What were the most successful outputs and why was the initiative effective?
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

 9. What were the main obstacles encountered and how were they overcome?
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.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Service recipients: Access of target group (women aged 30-60) has doubled. The cervical cancer screening rate for 2010, 2011, and 2012 were 4.95, 5.97 and 5.60% respectively. The rates have risen in 2013 and 2014 to 11.25 and 18.89% respectively. Although the target of 20% has not been reached, the steady increase in the participation rate has been encouraging. We have been successful in reducing the waiting time and minimize stages required to undergo screening tests. In addition, we now employ modern technology to help coordinate work between the hospitals and public health centers. This has significantly improved the quality of our service. As an illustration, the average waiting time of the target group, from the time they report to the registration counter to the time they complete the screening, receive counsels and go home, has been shorted from 40 minutes per woman to only 15-20 minutes. The results of our survey have also indicated a significant rise in satisfaction of service recipients in all areas—time, service quality, and convenience. The survey results are discussed thoroughly in meetings. Work of service improvement is assigned to relevant personnel immediately after each meeting. Satisfaction surveys are conducted and the results are used as indicators for future improvement. All officers have been instructed to pay close attention when service recipients make inquiries. The ensuing result is a 95% rate of satisfaction among service recipients of the project. Public Health Volunteers: There is a significant increase in awareness, knowledge, and understanding about the importance of cervical cancer screening among public health volunteers. This has stimulated the interest of the volunteers to undergo screening themselves. It has also stimulated their desire to help publicize the service provided to people in their communities. Officers: Teamwork is enhanced. There is also an increase in effort to coordinate the work between the officers and village development volunteers. Cooperation among various parties has improved, resulting in better a relationship between officers, volunteers, and service recipients. Communities and Target Group: There is an increase awareness of the importance of cervical cancer screening. Accessibility to services has also been greatly improved.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Our innovation has been widely accepted and we share the know-how with other health institutions in our network and interested parties to enable them to use or apply them in their work. For the Takbai health alliance network, Takbai Hospital allocated budget for making the Mobile Prep Smear available to every public health center in order to support further proactive project implementation. The project became well accepted as a result of the participation of community members and religious leaders, which helps confirm that the service is not contradictory to religious principles. The budget required for this was moderate, and support from the health alliance network enabled this to happen. The project can be applied and implemented in any of the 3 southern provinces that share similar religious beliefs and experience similar problems. It can also be adjusted to encourage the adjustment of attitudes on cervical cancer screening among female teenagers attending Islamic schools in the area.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The degree of ease or difficulty in fostering acceptance by religious leaders varies across the region. It is important to recognize the roles of community and religious leaders. In Naratiwas, the leader of the provincial mosque, who is also a member of Naratiwas Islamic Committee, has been invited to be the chairman of the committee to discuss our project from the Islamic perspective. A total of eleven religious leaders from 8 sub-districts in the province have also been invited to join the committee. Thorough discussions continued until a consensus was made. There must be regular meetings to discuss how to proactively work in the 3 provinces along the border which are plagued with political unrest, and officers must be informed about the contents of the meetings. Participation should be opened to all, including volunteers, to ensure the continuation of the project. Caution should be exercised, specifically on issues involving religious and political sensitivities. If work must be done, they should be performed by staff that has gained the trust of the members of the communities. Motto Village Health Volunteers have the mission to fix bad news, spread good news, shed light on services available, coordinate public health, relieve distress and live life as a good example.

Contact Information

Institution Name:   Takbai Hospital
Institution Type:   Government Agency  
Contact Person:   Dr.Somchai Srisombandit
Title:   Director,Takbai Hospital  
Telephone/ Fax:   +(66) 7 358 1200/+ (66) 7 352 4227
Institution's / Project's Website:  
Address:   114/63 Takbai Hospital
Postal Code:   96110
City:   Takbai
State/Province:   Narathiwat

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