Bowel cancer is the second biggest cause of cancer death in Australia, even though 90% of bowel cancers can be successfully treated if found early. Early detection of bowel cancer is easy through the free home screening test that is mailed to Australians between the ages of 50 to 74 by the National Bowel Cancer Screening Program (NBCSP). The program was first rolled out in 2006. Current participation rates remain low with a national average of 41% of eligible participants completing the kits. Among these, some communities have lower screening rates than the average population.
Cancer Council Victoria engaged with three key communities as part of a 2018 Bowel Campaign. These included Hindi, Tamil and Sinhalese communities, which consisted of close to 50,000 people aged 45 to 74 years.
These communities were identified as a key target group as they are one of the fastest growing migrant groups in Victoria. Bowel cancer screening participation rates remain low within members from the South Asian community, especially given there are no screening programs in their originating countries and screening is a new concept for many of them.
The NBCSP participation rates by language spoken are:
- Tamil 30%
- Hindi 32%, and
- Sinhalese 44.2% (compared to 41% participation nationally).
While the Sinhalese community has higher than average kit returns, it has a low participation (32.2%) among the 50-54 year old age group.
A place-based approach was used to determine the roll out of the community engagement component of the campaign. According to census data, community groups speaking the above languages can be found in clusters throughout the suburbs of Greater Melbourne and Victoria.
The City of Whittlesea and Greater Dandenong City were to receive the bulk of the engagement. With other activities focused on areas with high numbers of Indian and Sri Lankan community members residing in: Wyndham, Casey, Monash and Knox.
Key stakeholders were contacted to discuss the major barriers to bowel cancer screening as well as strategies that would improve participation rates in bowel cancer screening. Bilingual Health Facilitators provided links to the community, as well as specific community-driven organisations such as the OORJA Foundation and to leaders of several different religious groups at temples and Gurudwaras.
Focus groups and one-on-one interviews were conducted with 31 community members from the Sri Lankan and Indian communities. Community members were asked to decide what resources and social media outlets would be most effective for the bowel campaign. These interviews were conducted in-language and in a community setting.
Listed below are the most common barriers to participating in the NBCSP, as well as strategies to overcome these issues as identified by the community. These strategies were actioned and implemented by Cancer Council Victoria alongside the community.
|Barrier to participation||Strategy to overcome|
|Lack of bowel cancer awareness / Lack of awareness about risk/susceptibility of bowel cancer||Video is a good format to reach the community. Feature a local GP and local community member to identify the importance|
|Lack of knowledge about the test and how to do it||Develop videos to explain how to navigate the bowel cancer screening pathway – before (early detection and prevention) and the pathway upon receiving a positive FOBT result|
|Instructions on how to do the test is not in their language||Create step-by-step instructions on how to do the kit in language and create videos in-language|
|Disgust in collecting the test sample||Key message should emphasise that the test is hygienic|
|Fear of diagnosis||Organising a follow-up appointment with GP upon positive test result|
|Community highlighted endorsement from a trusted GP as a key motivator for doing the kit|
The community highlighted that the evidence-based strategy of an endorsement letter from a trusted GP would serve as a key motivator for doing the kit and for attending a follow-up appointment upon positive test result. A pilot program was developed using an endorsement letter from a GP clinic primarily serving the South Asian community.
Endorsement letters were sent to all patients in the selected age cohort. The letter recommended patients to participate in the national bowel cancer screening program by completing the home screening test when it arrives in the mail. The GP Clinic was funded to handle all mail outs and patient data, including a follow up evaluation phone call.
A multi-pronged approach to engaging, educating and promoting the NBCSP to the community included:
- bilingual health facilitators delivering over 20 sessions to educate community groups on the importance of bowel cancer screening and how the home screening test works
- a media campaign that utilised Facebook, YouTube, print, radio and convenience advertisement. This was outsourced to a media company to implement.
Alongside the endorsement letter strategy, multiple strategies were implemented to support comprehensive engagement with the South Asian community.
|Development of informative video in language||Create video script|
|Recruit local doctor and community member|
|Consult with community on video||2 videos, featuring a local GP and community member endorsing the home screening test, were created in Sinhalese and Hindi|
|Disseminate video||These 2 videos were disseminated through: Facebook advertisement, YouTube, and community education sessions|
|Instructional ‘how to’ brochure in language||Translate English version of ‘how to’ brochure into Tamil and Sinhalese (Hindi not translated as it is very formal and would not translate well. Community advised many Hindi speakers could read simple English)||Completed through a translation service|
|Consult with community on brochure appropriateness|
|Disseminate to the community||Distributed through Bilingual Health Facilitators at community education sessions|
|Endorsement letter sent from a trusted GP||GP to review and edit the NBCSP sample letter so that the letter meets the health literacy needs of the patients||GP endorsement letter was distributed by a single GP Clinic which primarily served South Asian patients|
|GP clinic to identify patients in the target age-range and mail out letters to them||Used PenCat system at clinic to mail out letters to eligible patients|
|Follow up calls made to participants to assess effectiveness of the letter||Nurse called patients to follow up on the effectiveness of the letter|
|Media advertising||Develop key advertising product|
|Radio ad message||162 x 30” radio ads across the 3 languages were played across local radio stations|
|Convenience ads||Convenience ads were disseminated at 80 community locations|
|Translate ads into each language|
|Consulted a media firm to roll out traditional media (radio) and social media advertising campaign||2 in-language videos were shared across Facebook during a 7-week social media campaign. Social media buy was geo-targeted to specific LGAs targeting South Asian communities|
|Community Education Session||Recruit bilingual health facilitators|
|Consulted with bilingual health facilitators and adjusted key messages to be culturally appropriate|
|Trained bilingual health facilitators|
|Delivered community education sessions||21 community education sessions were conducted across Whittlesea, Greater Dandenong, Wyndham, Casey, Monash and Knox. Each session held between 15-60 community members. Pre and post-test was collected at each session to evaluate impact.|
Overall the South Asian Bowel Campaign had a positive outcome. The results indicated an increased awareness and likelihood of completing the NBCSP kit. The effectiveness of the strategy will not be known until the NBCSP releases data surrounding completed kits in 2019.
2,682 letters were sent to patients.
Results from follow-up phone calls to patients:
- 78% of participants surveyed intended to complete the bowel kit when it next arrived
- 78% of participants surveyed took some action towards screening.
Social media advertising
For an investment of $1,470, the two videos were viewed 8,800 times during the 7-week campaign period.
- There were 400 social shares and 350 social reactions to the two videos.
- 580 people clicked the link to the landing pages with more in-language information on bowel cancer.
Community education sessions
- 13 community education sessions were conducted.
- Over 250 community members were educated at these sessions.
Pre and post-test evaluation results:
- 82% of participants surveyed reported increased knowledge.
- 75% of participants surveyed intended to complete the bowel kit.
- 82% of participants surveyed reported increased confidence to complete the bowel kit.