Inequalities in Health Would a pictorial / language leaflet improve uptake

Hope (Hurdles, Objectives, Progress, Education) Why start with “Hope”. If breast screening can detect cancer at an early stage then there is hope that women’s lives can be extended through better survival rates and quality than if they’d been detected symptomatically. Life is the most precious gift one is given.

Consequences of Informed choice not been accessed: These women do not attend ( a less efficient service). The knowledge and concept of screening hasn’t been achieved. If a small cancer is present & they don’t attend, this will not have been found until it presents symptomatically therefore their survival rates & quality of their remaining life may be affected.

To improve access to Black Minority Ethnic Groups for our service. Inequalities in Health Project 2009 Would a pictorial / language leaflet improve uptake. To improve access to Black Minority Ethnic Groups for our service. To target “Did not attend” (DNA) women from different ethnic groups as a well as Caucasians in relation to the Round Plan. To provide evidence for the need for first language as well as ethnicity to be recorded on the NHS data base.

Methodology Target DNA women in two ways:- With a pre screen letter + leaflet sent just before they receive their invitation letter to women who had DNA’d 3 years ago. Sending the services DNA letter in the appropriate language + new leaflet.

Results pre screen letter method Overall 47 women attended out of 228 (21%) and didn’t waste an invitation slot when in 2006 they did. Baseline comparison data with no intervention 30 attended out of 228 ( 13%) An improvement of 8%. Broken down into English batch & Different language batch. 31 women attended out of 164 with English only leaflet (18.9%) 16 women attended out of 64 with different language leaflet / literature (25%) The different language initiative had the better result but one must take into account the smaller sample size i.e. 64 This clearly demonstrates there has been an improvement with this initiative.

Results DNA letter method 60 women attended out of 420 (14.2%) Projects comparison data for the same period that the intervention was run is 15%, so no improvement shown overall.

When broken down into English & Different language literature /leaflet. The English only showed no improvement at all (11%) compared with the baseline of the same period of our service. The Different language leaflet (25%) showed an improvement of 10% compared with the baseline of 15% .

Graph to demonstrate whether there is a difference in effectiveness of the initiatives when broken down into English & Different Language Literature

Comparison between English leaflet with different language leaflet sent. Pre Screen Letter English Non English Combined Attended 31 (19%) 16 (25%) 47 (21%) None – Attended 133 (81%) 48 (75%) 181 (79%) Total Population 164 64 228 DNA letter +New leaflet 36 (11%) 24 (26%) 60 (14%) 291 ( 89%) 69 (74%) 360 (86%) 327 93 420

None English batches Both initiatives resulted in an attendance of 25% . Languages sent in these batches (157) were mainly to the South Asian communities 151 (96%): Punjabi = 72 (46%) Polish = 2 (1%) Urdu = 42 (27%) Somali = 2 (1%) Bengali = 27 (17%) Arabic = 1 Hindi = 7 (7%) Cantonese = 1 Gujarati = 3 (2%0

Comparison data with rebooking from DNA letter and actual attendance . DNA letter + new leaflet Rebooked Attended Did not attend English + Intervention 42 36 (86%) 6 (14%) English No intervention 383 62 (16%) 321(84%) Non English + Intervention 26 24 (92%) 2 (8%) Non English No Intervention 56 13 (23%) 43 (77%) The Table demonstrates when using the new leaflet initiative with the DNA letter that this greatly increases the attendance uptake when they rebook. Diff Lang + Intervention Att = 92% compared with 23% in Non Intervention group. English + Intervention Att. = 86% compared with 16% in Non Intervention group.

Comparison data of attendance after rebooking with & without the Initiative.

Summarising Rebooked Data This data has shown that there is a great improvement in attendance with this initiative and it is worth continuing to obtain a larger sample size to help give these results more weight.

Results of targeting Urdu only leaflet after the deadline date of the project.

Summarising In this sample of 52 women (Urdu) 26 women had the intervention 26 women had no intervention 10 women attended with the intervention (38%). Supporting and improving on the results in the project of 25%. No woman attended without the intervention. However 3 did rebook but didn’t attend (11%). This data is encouraging as it helps support the need for using the appropriate language leaflet / literature.

On going evaluation since project. This evidence has also been reflected when utilising the different language literature + leaflet with non attendance to Assessment Clinics: Population = 7 Attended = 7 This data is very encouraging and supports the need to record language on the NBSS so the Assessment appt. can be sent in the appropriate language and not waste valuable appt. slots. This data collection is now on going.

Feedback from women with regards to new leaflet Data collated from 63 women 61 women found it useful 2 responded “Don’t know”. 28 responded in the project: (Urdu 12, Punjabi 8, Bengali 5, English 2, Somali 1) Encouraged them to attend 70% Helped them to understand what to expect 78% Found the pictures & symbols helpful 78% Found having both English & first language useful 56%

Evaluation would a pictorial / different language leaflet improve uptake. The data has given some encouraging evidence that providing information in the relevant language can influence these women to attend the service. If the NHS data base did record language it would help ensure we could utilise this information to its full potential. Assuring these women have been given an informed choice. Data evaluation would be more accurate. Reduced None Attendance for women that rebook as the data suggests. It has demonstrated that a pro active pre screen initiative was far more effective in the Caucasian population so this can be taken into consideration when targeting this group.

Why Continue this project There is a lower uptake of screening among ethnic minority groups – 45% have never attended screening (independent of their socio-economic status). The NHS Cancer Screening Programmes have shown that uptake is lower: Among South Asians, especially among Muslims. NHS commissioning for London Translation of materials and interpreter services would go some way to address language barrier, although lower literacy rates among some ethnic groups needs to be taken into account.

Is the project feasible? The cost implication : Leaflet cost when ordering a 100 = £1.25 each leaflet + Postage cost 30p Total of ~ £1.55 / woman+ (Administration time). Leaflet cost is reduced when ordering in larger quantities i.e. 5000 = 15p for each leaflet making it much more feasible. Is this justifiable if this increases the attendance by a similar % i.e. 25% in this BME population batch.

Next steps A larger sample size is required. Concentrating on targeting specific community groups in the areas with low uptakes. Then the service can analyse which language leaflets are the most effective. Feedbacks can be collated from utilising the leaflets within different community groups. Evaluations can then be made on whether the pictures & relative language have been the key to this improvement.

Summarising 16 years I’ve worked in the Breast Screening Service and other than :- Dr Chiu’s work for the NHSBSP and her DVD. Breast Test Wales in 1999 who found sending the appropriate translated material, GP endorsement and language support by line workers improved uptake. There appears to have been little progress in improving this inequality. I hope that projects like this may help increase the progression for change.

Thank you WMCIU for providing the funding for this project. Elly McFadyen from Pan Birmingham Cancer Network for her work on the data. Margot Wheaton for running a programme so we could have a baseline data comparison. Sandwell & West Birmingham Hospitals for supporting my health promotion initiatives and for producing my leaflet