Health Education Research Advance Access originally published online on May 20, 2004
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Health Education Research, Vol. 19, No. 4, 457-468,
August 2004
© 2004 Oxford University Press
Media interventions to increase cervical screening uptake in South Africa: an evaluation study of effectiveness
1 Lewisham VTS, SLOVTS, Gassiot House, St Thomas's Hospital, London SE1 7EH, UK, 2 Health Services Research Department, Institute of Psychiatry, London SE5 8AF, UK, 3 London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, 4 Department of Sexually Transmitted Diseases, London WC1E 6AU, UK, 5 Khayelitsha Cervical Screening Project, Cancer Association, PO Box 13330, Mowbray 7705, South Africa, 6 EngenderHealth, New York, NY 10001, USA and 7 Department Obstetrics and Gynaecology, Groote Schuur, Cape Town 7937, South Africa
8 Correspondence to: J. Bindman; E-mail: j.bindman{at}iop.kcl.ac.uk
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Abstract |
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 Top Abstract IntroductionMethodsResultsDiscussionConclusions and further researchReferences |
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Successful cervical cancer prevention depends on reaching, screening and treating women with pre-invasive disease. We aimed to evaluate the effectiveness of two media interventions—a photo-comic and a radio-drama—in increasing cervical screening uptake. A randomized controlled trial compared a photo-comic on cervical cancer screening with a placebo comic. One month after the comics were distributed a radio-drama paralleling the photo-comic was broadcast on the community radio station and a retrospective evaluation was carried out. The trial was set in Khayelitsha, a peri-urban squatter community near Cape Town, South Africa. A random sample consisted of 658 women between the ages of 35 and 65 years, from a stratified sample of census areas. The main outcome measure was self-reported cervical screening uptake 6 months after distribution of the comics. Seven percent (18 of 269) of women who received the intervention photo-comic reported cervical screening during the 6 months follow-up, compared with 6% (25 of 389) of controls (P = 0.89). Women who recalled hearing the radio-drama were more likely to report attending screening (nine of 53, 17%) than those who did not (19 of 429, 4%; P < 0.001). We conclude that the photo-comic was ineffective in increasing cervical screening uptake in this population. The radio-drama may have had more impact, but only a minority of women recalled being exposed to it. Future research must concentrate not only on achieving high level of exposure to health messages, but also on investigating the links between exposure and action.
Successful cervical cancer prevention depends on reaching, screening and treating women with pre-invasive disease. We aimed to evaluate the effectiveness of two media interventions—a photo-comic and a radio-drama—in increasing cervical screening uptake. A randomized controlled trial compared a photo-comic on cervical cancer screening with a placebo comic. One month after the comics were distributed a radio-drama paralleling the photo-comic was broadcast on the community radio station and a retrospective evaluation was carried out. The trial was set in Khayelitsha, a peri-urban squatter community near Cape Town, South Africa. A random sample consisted of 658 women between the ages of 35 and 65 years, from a stratified sample of census areas. The main outcome measure was self-reported cervical screening uptake 6 months after distribution of the comics. Seven percent (18 of 269) of women who received the intervention photo-comic reported cervical screening during the 6 months follow-up, compared with 6% (25 of 389) of controls (P = 0.89). Women who recalled hearing the radio-drama were more likely to report attending screening (nine of 53, 17%) than those who did not (19 of 429, 4%; P < 0.001). We conclude that the photo-comic was ineffective in increasing cervical screening uptake in this population. The radio-drama may have had more impact, but only a minority of women recalled being exposed to it. Future research must concentrate not only on achieving high level of exposure to health messages, but also on investigating the links between exposure and action.
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionConclusions and further researchReferences |
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Cervical cancer is the commonest preventable cancer amongst South African women and plans are underway to implement a national screening programme (Fonn et al., 1993
). In South Africa, women often attend different health facilities in rural and urban areas, and may be opportunistically screened at any stage. Lack of understanding of the steps involved in the screening process (Emdon et al., 1984; Wood et al., 1997) means many fail to attend for results or for clinical follow-up if needed. Prior to implementing national screening, pilot programmes must first demonstrate that women can be educated about the need for cervical screening and how to access services. Increasing understanding about screening is the first step as women who do not understand why they are being screened are less likely to return for results and possible further treatment (Sherris et al., 1993).
The choice of media for public education about health interventions in developing countries presents challenges, and targeted magazine advertising, billboards, radio and, more recently, television have all been used in national campaigns. Radio and television, frequently covering health-related topics, are the leading source of information about important health issues, and are targeted by those who aim to influence the behaviour of health professionals and patients. However, costs tend to be high per person screened. Despite the limited information about key aspects of mass media interventions and the poor quality of the available primary research, there is some evidence from a systematic review that these channels of communication may have an important role in encouraging the use of effective services and discouraging those of unproven effectiveness (Grilli et al., 2002). Considering the problem of increasing public awareness of cervical screening specifically, there is some evidence that strategies combining mass media campaigns with direct tailored education to women and/or health care providers are more likely to be successful (Black et al., 2002).
Since 1996, the Khayelitsha Cervical Cancer Screening Project (KCCSP) has provided a comprehensive cervical screening service. The project, described in detail elsewhere (Denny et al., 2000), offers free cervical screening and follow-up treatment to locally resident women who are recruited by community health care workers. In 1998, the KCCSP developed a strategy aimed at increasing uptake of cervical screening, which combined a mass media intervention—a single episode radio-drama broadcast on the community radio station—with a targeted educational intervention—a health education photo-comic.
A radio-drama was chosen as a suitable mass media intervention because in Khayelitsha, as elsewhere in South Africa, radio is a widely used link to the larger community. Radio has the capacity to bring education within reach of its listeners, particularly women, without interfering with their tasks (in the home or caring for children), which normally prevents listeners from participating in formal education programs (Samuels et al., 1998). Khayelitsha has its own community radio station, Radio Zebonele, which focuses on environmental and social development, and broadcasts from a shipping container behind a health clinic. Radio Zebonele is able to reach the whole township and combines affordability with wide listenership.
Photo-comics are increasingly being used around the world as a medium to make health messages culturally appropriate and accessible (Lent, 1986). Comics are able to communicate the emotional aspects of cause and effect (Cain, 1986). The visual display facilitates transmission in a non-didactic way and can be tailored to reach groups with low literacy, relying on the photographs to tell the story (Toroyan and Reddy, 1997). South Africa is characterized by many different languages (more than 11) and several subcultures, and reading skills are often limited. Photo-comics are simple and adaptable, and lend themselves easily to a context of low literacy (Zielinski, 1986). The intervention package was modeled on ‘Soul City’, a successful mass media intervention covering health and other community education issues that includes photo-comics, radio and television dramas, and which has been extensively evaluated (Barker and Schneider, 1998; Everatt, 1995; Samuels et al., 1999).
This paper describes the evaluation of the effectiveness of both strategies. We aimed to test the primary hypothesis that subjects who received the intervention photo-comic would report significantly higher uptake of cervical screening over a 6-month follow-up than those receiving a control ‘placebo’ photo-comic. In addition the evaluation aimed to investigate two secondary hypotheses: (1) that listening to the radio-drama would be associated with a higher uptake of cervical screening over a 6-month follow-up and (2) that both interventions would interact to increase screening uptake.
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionConclusions and further researchReferences |
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Design
The primary hypothesis was tested with a randomized controlled trial which compared the effect of receiving a photo-comic with a control comic on reported uptake of cervical screening over a 6-month follow-up. One month after distributing the intervention and control comics the radio-drama was broadcast on the local radio station 10 times over 4 weeks at prime time. The effect of the radio-drama was evaluated retrospectively at the follow-up point in the entire cohort of subjects randomized to either intervention.
Setting and subjects
The study was undertaken in Khayelitsha, a peri-urban community of 350 000–500 000 people, near Cape Town, South Africa. Khayelitsha is a mainly unplanned community. Not all areas have waterborne sewage or regular refuse removal and some residents (‘squatters’) live on land not intended as residential (Mash, 1998).
Women aged 35–65 years, resident in Khayelitsha during the baseline survey (February 2000), who gave verbal consent, were eligible to take part in the study. A statutory organization, STATSA, identified a sampling frame based on the 1996 census of Khayelitsha, which established characteristics of 29 770 households in 670 census areas; 219 census areas with populations less than 15% women aged 35–65 were excluded (these areas have a high proportion of male only hostels). Seventy-five census areas were randomly sampled from the remaining 451 (16.6%). Ten households per census area were randomly selected and one eligible woman identified from the census. The house was then visited and the selected woman invited to participate. Up to three attempts were made to contact the selected woman, after which another eligible woman at the same dwelling was substituted or the adjacent dwelling to the right selected and another eligible woman substituted. A baseline interview was conducted and a sealed envelope containing a randomly allocated photo-comic was provided.
Development of materials
The intervention package was modeled on ‘Soul City’, and used a common story line which was first developed and tested and then elaborated into the photo-comic and the radio-drama with the same actors reading the drama and being photographed in character to illustrate the comic. The interventions were developed in Xhosa, the first language of 99% of the target audience.
In the initial stage of development focus groups were held with clients attending the KCCSP for their cervical smear, with unemployed women in the community and with traditional healers (sangomas). Based on a review of the literature and local experience, the following areas in which barriers to uptake of screening might exist were explored in the focus groups:
- Emotional/psychological: fear of cancer, knowledge of someone who has died of cancer, unwillingness to have pelvic examination associated with a previous bad obstetric experience, embarrassment or past rape/sexual abuse (gender of service provider, age and cultural barriers to pelvic examination).
- Misconceptions: the cervical smear being associated with ‘cleaning of the womb’ (‘womb scrape’) or associated with promiscuity or with HIV/AIDS or sexual activity (i.e. an assumption that if one is not currently sexually active then a cervical smear is unnecessary).
- Health: whether women understood the need for an examination, particularly a pelvic examination, when they feel well/have no symptoms (lack of perceived need) or lack of belief in cancer susceptibility.
- Geographic: service not accessible or available.
- Socioeconomic: transport costs, employment not allowing for time to access service.
- Clinic/service related: closed after hours, previous experience of an unfriendly service or lack of privacy during examinations.
- Vehicles for carrying the message: associated with credibility of the medium (problems with form or content—inappropriate/alienating symbols), limited repetition of the message in different ways or inadequate/non-existent baseline knowledge.
- Traditional/cultural barriers: associated with a mistrust of Western medical services; low value attributed to women's health; women's needs eclipsed by children/partner health needs; control over decisions to access health services; limited by husband/father-in-law; issues of time and forgetfulness.
The findings from the focus groups provided the basis for developing the script for the radio-drama which was written first in Xhosa (the target language of most of the community) and translated into English (see Figure 1). The storyline was then used to develop the photo-comic. The radio-drama script was pre-tested with Xhosa speaking actors, who were selected within Khayelitsha, and amended. The radio-drama was broadcast in Xhosa. Once the story board (an outline comic with sketched frames and text) was developed for the photo-comic, it was shown to Xhosa staff and clients at the clinic who suggested amendments. It was printed and distributed in English after a pilot showed that this was the preferred reading language. The resulting comic was 20 pages long with between five and nine frames per page (see Figure 2). The last page looked at some of the situations in the story and explained them in more detail, and the inside of the back cover described the different stages of cervical cancer.
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Delivery of interventions
As described above, the first intervention consisted of participants receiving comics in sealed envelopes after completing the baseline survey. Two comics were randomly allocated: these were the intervention comic, ‘Nokwhezi's Story’ and a control or ‘placebo’ comic from the Soul City series entitled ‘How to save for your dreams’ which contained educational information on personal finances and no health care messages.
One month after the baseline survey and distribution of the comics, the second intervention, the radio-drama, was broadcast on the community radio station 10 times over 1 month. Based on information from an evaluation of listenership carried out by Radio Zebonele itself, which estimated community listenership at around 40%, and analysed listenership by gender and time of day, we were able to select the 10 time slots (the maximum affordable) which maximized reaching our target audience of women between 35 and 65 years. Broadcast of the radio-drama was preceded and followed by advertisements directing women to the KCCSP.
Interviews
An interviewer-administered questionnaire was developed for the study. This sought the participant's demographic characteristics, education, health-service use, knowledge about cervical screening, radio ownership and listening habits. The questionnaire was translated from English into Xhosa, and then back-translated for medical and vernacular accuracy. Bilingual interviewers conducted the survey. Language choice in interviews was recorded. The same women were visited again for a follow-up interview 6 months after baseline, repeating some questions from the baseline interview and adding a question concerning the primary outcome: ‘Have you had a cervical smear since February 2000?’. To minimize possible desirability bias, those answering affirmatively were asked ‘Where did you have your cervical smear?’. Those unable to respond to this probe were assumed not to have attended. Similar questions were used to establish participant's recall of the photo-comic and radio-drama. Respondents stating they had heard the radio-drama and/or read the photo-comic were asked to describe the storyline. These responses were recorded verbatim and post-coded for correct recall of specific themes of the storyline; a correct rating being given to answers including or implying the words ‘cancer’, ‘prevention’ and ‘womb’. No inducements were offered for completing baseline or follow-up surveys as previous experience suggested the KCCSP was well regarded locally and good response rates could be anticipated. To maximize follow-up rates the study was planned for the first half of the year when women are least likely to return to the rural areas.
There were two female bilingual Xhosa/English interviewers, aged 28 years both residing in Khayelitsha. Both had worked on collecting census data conducted by STATSA for the last census in Khayelitsha and therefore knew the area well. They were both previously trained in interviewing techniques. They attended workshops where the meaning of Xhosa expressions particularly for the open-ended questions was explored and they contributed to the development of the questionnaires. They were masked to the contents of the envelopes they distributed, the envelopes being filled with comics randomly allocated in the correct ratio and sealed by the study coordinator. They described themselves as employees of Nokwhezi Media and not the KCCSP, although if asked showed identification and gave a contact number which linked to the Cancer Association of Cape Town.
Power calculation and statistical analysis
Questionnaire data were analysed using standard statistical software (STATA 5.0 1996) using t-tests for continuous data and 
2-tests for dichotomous variables. Univariate associations were sought between the primary outcome and intervention status, and also between the primary outcome and a range of sociodemographic and clinical variables derived from baseline and follow-up questionnaires. Having tested the primary and secondary hypotheses with univariate statistics, a logistic regression model was developed to examine potential predictors of cervical screening uptake. A parsimonious model was then sought using those variables with a significant individual association entered using a stepwise procedure using a P value of 0.05 for exclusion from the model and 0.1 for retention.
A random allocation ratio of three controls to two intervention comics was chosen. The controls were oversampled in this way in order to increase the number of controls exposed to neither intervention, making it possible to test the secondary hypothesis concerning interaction of the two interventions. Only an estimated power calculation could be made initially as accurate figures for the pre-baseline rate of screening were not available. Considering the primary hypothesis, the study was powered to show an approximate doubling of uptake in the intervention group from the actual pre-baseline rate of 6% over 6 months to 13% requiring, at a ratio of 2:3, an intervention group of 245 and a control group of 368.
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Results |
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Response rate and characteristics of sample at baseline
Only 88% (66 of 75) of the census areas were visited at baseline and follow-up due to resource limitations. A total of 741 households were visited in February 2000: 65 had no eligible resident and at 659 of the remaining 676 (97.6%) a subject consented to complete a baseline surveys. Three eligible residents (0.4%) declined to participate and 14 (2%) could not be contacted or substituted. At follow-up during August 2000, 658 of 659 (99.8%) of the baseline participants completed a follow-up questionnaire.
Table I shows the sociodemographic characteristics of the sample. There were no significant differences in sociodemographic characteristics of the intervention and control groups.
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Table II shows self-reported uptake of cervical screening prior to baseline and subjects awareness of cervical screening.
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Primary outcome of randomized controlled trial
Figure 2 shows the allocation of subjects in the trial, together with their self-reported recall of the photo-comics and self-reported exposure to the radio-drama. Table III shows the number of women in each arm of the randomized controlled trial who reported having had a cervical smear test during the follow-up period. No significant difference in cervical smear uptake is attributable to the intervention photo-comic.
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Effectiveness of the radio-drama
The evaluation of the radio-drama necessitated a retrospective assessment of exposure. At baseline, 54.6% (359 of 658) of all subjects reported listening to the local station at some time, but this measure of exposure is not directly comparable with exposure to the photo-comic. We therefore asked respondents to report their actual recall of both interventions. Table IV shows the relationship between recall of the interventions and reported smear uptake. Adding those who recalled the radio-drama alone to those who recalled the radio-drama and comic, a total of 87 of the 658 women exposed recalled the radio-drama (13.2%). Of the 229 who were given the comic, 176 (65.4%) recalled the story. The hypothesis that recall of the radio-drama would be associated with higher reported uptake of screening is supported, but there is no evidence of an interaction between the two interventions.
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Factors associated with smear uptake
Having tested the primary and secondary outcomes, other factors associated with reported uptake of cervical screening over the follow-up period were explored. Table V shows the univariate associations between uptake and a range of sociodemographic and clinical variables. Stepwise logistic regression was then used to explore confounding between these variables. Sociodemographic variables showing a univariate association with smear uptake at a significance level of 0.05 or less were entered first, followed by the baseline clinical variable ‘attendance at a clinic within 3 months’. All variables remained in the model. The addition of clinical variables from the follow-up questionnaire showed that seeking help for problems during the follow-up period remained in the model, but the presence of problems did not. Finally, the variable concerning recall of the radio-drama (Table IV) was added. The final model is shown in Table VI.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionConclusions and further researchReferences |
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Principal findings
This study shows that in the randomized controlled study, receipt of a carefully designed cervical screening education photo-comic did not increase uptake of cervical screening services over a 6-month follow-up period. A retrospective evaluation of a contemporaneously broadcast radio-drama with the same message suggests that this did appear to have had a positive effect on cervical screening uptake. However, the impact was limited, with only 13% of the exposed population recalling the radio-drama and only 6.6% of them (43 of 658) reporting having a cervical screen during a 6-month follow-up period. There was no evidence of an interaction between the two interventions. A post hoc examination of factors which were associated with cervical screening uptake in the follow-up period showed that in addition to listening to the radio-drama, being in a relationship and having visited a clinic for vaginal symptoms during the follow-up period (and possibly therefore being exposed to opportunistic screening) were associated with having a smear. Having attended a clinic shortly prior to baseline was negatively associated with smear uptake, as was living in a brick house (a proxy for socioeconomic status), for reasons which are unclear.
Strengths and weaknesses of the study
The interventions assessed in this evaluation were developed in consultation with the target audience, were feasible to deliver and were well received by potential members of the target audience in focus groups. A high response rate was achieved from a representative sample and follow-up rates were also very high.
As a pragmatic evaluation undertaken in real-life conditions, the study design was necessarily complex, as exposure to the radio intervention could not be controlled. Exposure to the radio-drama was therefore assessed retrospectively, making it impossible to exclude the possibility of bias in the ascertainment of the primary outcome or of the exposure of interest.
The power of the interventions to have an effect may have been limited by the rate of previous smear uptake by the population, which was high at 45%, and also by the failure to achieve high levels of exposure to the radio-drama. Although over half the population reported listening at some time to the station on which the drama was broadcast, and it was broadcast on multiple occasions at varying times, the low levels of recall suggest that actual exposure to the drama may have been much lower than 50%. Cost precluded the broadcasting of the radio-drama on South African Broadcasting Company (SABC), which is the more popular station.
The reliance on self-reported service use is another potential limitation, though a degree of validation was achieved by careful exploration of the respondent's understanding of the outcome measure. However, it was not practically possible to validate individuals' reports against clinic records because of the number of potential providers of medical care regionally.
Strengths and weaknesses in relation to other studies
Other studies have shown that recall of health messages has a positive impact on self-reported intention and attempts to change health behaviours (Bauman et al., 2001, Karlyn, 2001). However, relatively little is known about the time delay from intervention exposure to the adoption of positive health behaviour. It may be that the high levels of recall about cervical screening shown will have an effect that goes beyond the short period of follow-up studied. However, other studies (Black et al., 2002) have suggested that while mass media campaigns such as this can be effective in raising awareness of interventions, they may fail to change actual behaviour unless followed with individualized contact and discussion. Prochaska et al. (Prochaska et al., 1994) have described a sequence of cognitive stages between receipt of health messages and a decision to act which may assist in planning interventions to change behaviour.
Implications of the study
Even carefully designed interventions should not be assumed to bring benefit (Imrie et al., 2001) and investment needs to be justified, especially where resources are limited (Little et al., 2001). This study suggests that a photo-comic should not be a major part of any strategy to increase uptake of screening, although we cannot exclude the possibility that it may be useful for targeted subgroups such as young adults (Toroyan and Reddy, 1997). Findings in relation to the radio-drama are less clear. Although the overall impact was limited, it is possible that this was a consequence of failure to achieve adequate exposure, in turn a consequence of limited resources. The study shows levels of television ownership are very high (87%) and it is possible that a television or video version of the drama would have more impact (Mahloch et al., 1999), possibly in association with efforts to achieve direct contact with the target audience through peer educators (Black et al., 2002).
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Conclusions and further research |
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TopAbstractIntroductionMethodsResultsDiscussionConclusions and further researchReferences |
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The study suggests that of the two interventions only the radio-drama showed any evidence of effectiveness; however, its effectiveness was limited by low levels of exposure. Future research must concentrate not only on achieving high level of exposure to health messages, but also on investigating the links between exposure and action.
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Acknowledgments |
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We are grateful to Athalie Crawford who was responsible for developing the multi-media package consisting of the radio-drama, photo-comic and video (which is not included in this evaluation). We would also like to thank Mamase Mkhutswana, Sibongile Nkohla, Nomvulo Ndwaba, Ayesha Susman, Nosisi Dingani, Linzi Fredman, Cal Volks and STATSA. Funding was provided by EngenderHealth and Soul City. Materials were developed from funding provided by the Royal Netherlands Embassy, ABSA Bank, Bosman & Johnson Advertising Agency and the South African Cancer Association.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionConclusions and further researchReferences |
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Received on September 8, 2002; accepted on July 17, 2003
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