Empowering Societies to be Free of Cervical Cancer

SDG CERVICAL CANCER 7

Empowering Societies to be Free of Cervical Cancer Project by the Breast and Cervical Cancer Screening Program (BCCSP)

Section 1: Introduction

The Breast and Cervical Cancer Screening Program (BCCSP) is an initiative of the Doctors Community Hospital in Prince George County, Maryland. The program began as a center offering free breast cancer education and screening to low-income women (age 40 or older) residing in Prince George County. However, with the rising cases of cervical cancer across the state, the BCCSP decided to expand its scope to cover cervical cancer and also move beyond screening and education to offer subsidized treatment and support to patients. The BCCSP is funded by the Maryland Department of Health and Mental Hygiene. The program proposes to implement a project dubbed ‘Empowering Societies to be Free of Cervical Cancer’ between January 2024 and December 2025. The program’s clinical team comprises of seven directors of medicine (MD), two certified registered nurse practitioners (CRNP), and one physician assistant (PA). On the support side, the program has a nurse navigator, a chaplain, a team of oncology social workers, a medical acupuncturist, an occupational therapist, a licensed dietician, and a financial counselor.

Section 2: Sustainable Development Goal

Sustainable Development Goal (SDG) 3 focuses on promoting healthy lives and well-being for people of all ages as a channel for sustainable development (United Nations, 2023). Target 7 of SDG 3 is to ensure that reproductive healthcare services, including education and information, are universally accessible and that reproductive health is integrated into national programs and strategies by the end of 2030 (United Nations, 2023). Ultimately, this will reduce cases of premature mortality resulting from non-communicable diseases globally (United Nations, 2023). Cervical cancer affects reproductive health in thousands of women, particularly in cases where practitioners recommend surgery to remove a woman’s womb (radical hysterectomy). Even in cases where surgery is not necessary, studies have shown that 46 percent of cervical cancer survivors are unable to conceive despite receiving reproductive counseling due to damages to the reproductive organs resulting from radiotherapy (Shah et al., 2019).

Data from the World Health Organization (WHO) shows that 604,000 new cases of cervical cancer and 342,000 deaths were reported globally in 2020 alone, making it the fourth most common cancer among women (WHO, 2022). In the United States, an estimated 295,000 women had cervical cancer in 2019, and 5,000 women die from cervical cancer every year (National Cancer Institute, 2022). The National Cancer Institute indicates that new cases are diagnosed at a rate of 7.8 per 100,000 women annually (National Cancer Institute, 2022). While it is less common than other cancers such as breast cancer, the BCCSP chooses to focus its efforts on cervical cancer because is not only treatable, but more preventable due to the availability of vaccines.

Cervical cancer is caused by the human papilloma virus (HPV), which is spread through sexual activity (WHO, 2022). It is estimated that all sexually-active women get HPV, although one can reduce their chances of developing cervical cancer through vaccination (WHO, 2022). African-American women disproportionately bear a higher burden of cervical cancer in the US and are less likely to be vaccinated (National Cancer Institute, 2022). For this reason, the proposed project targets African-American women residing in Prince George County. It adopts a radical approach that incorporates preventive, curative, and palliative strategies to improve the quality of life, reduce incidence, and minimize deaths resulting from cervical cancer.

On the preventive front, the program will offer free screening to uninsured women, sensitize communities on the importance of screening and vaccination, organize telehealth and in-person campaigns to educate communities on the benefits of vaccination and where to get vaccines, and increase access to thermal ablation for cervical pre-cancer treatment. Curative strategies will include offering free radiotherapy, chemotherapy, and hormone therapy for invasive cervical cancer cases. Palliative strategies will include free counseling and fertility treatment for survivors wishing to get pregnant, free financial counseling services, and subsidized genetic counseling for at-risk family members. Financial counseling is geared at helping patients manage their expenses and finances, and make decisions that enhance their financial health. Genetic counseling focuses on helping family members with a family history of cancer understand the risks they face and strategies for managing or lowering their risk of cancer.

Section 3: Logical Model

Overarching Goal: to create a world free of cervical cancer

Logical Model Date: 7th April, 2023

Inputs

Outputs

Outcomes -- Impact

Activities

Short

Medium

Long

Grants, community leaders, licenses

Grants

Staff (human resources), grants

University of Maryland’s Marlene and Stewart Comprehensive Cancer Center

Radiation equipment

Prince George County Health Centre

Financial counselors

Oncology social workers

Organize quarterly medical camps where women can access free HPV screening and pap smear tests

Offer non-coercive rewards such as coupons to encourage women to undergo screening as a means to curb cultural practices and beliefs that discourage screening

Conduct Monthly sensitization campaigns to educate women on cervical cancer and the importance of regular screening and vaccination

Develop tele-health mobile applications through which women can obtain virtual advice from oncologists and social workers on when and where to get free screening tests

Partner with the University of Maryland Cancer Center, where women with special conditions such as epilepsy, could be referred upon screening to access subsidized pre-cancer treatment through thermal ablation

Offer free radiotherapy, chemotherapy, and free hormone therapy for invasive cervical cancer cases.

Partner with fertility clinics from which cervical cancer survivors wishing to get pregnant could access free reproductive counseling

Offer free financial and genetic counseling to program participants and their family members

Uninsured women benefit from free HPV screening and pap smear tests

Women are more knowledgeable about cervical cancer and where to get free tests and vaccines

Women with special conditions get access to less invasive therapies

Uninsured women get access to quality cervical cancer treatment

Women gain access to reproductive counselling that would otherwise be unaffordable

Women from low-income backgrounds and their families gain access to free genetic and financial counseling

Increased rates of regular HPV screening among uninsured African-American women

Improved attitudes towards vaccination and screening

Increased access to less-invasive pre-cancer treatments for women with special health conditions

Uninsured women living with cervical cancer lead satisfying lives

Over 50% of cervical cancer survivors get pregnant after undergoing counseling

Women are able to make informed financial decisions and families understand how to minimize their risk of cervical cancer

Increase in cases of HPV infections that are detected and treated early before developing into cancer

Increase in the number of women presenting their children for HPV vaccination

Reduced deaths related to cervical cancer among women with special health conditions

Reduced deaths related to cervical cancer among women with special health conditions

Improved reproductive health for cervical cancer survivors

Cancer patients and their families lead financially stable lives with low risk of getting cervical cancer

Assumptions

The program will acquire the funding it needs to implement the activities

The target group will embrace the program and its interventions

The partners engaged in the program will carry out its mission with enthusiasm

External Factors

Effect of government politics on the operations and management of the program

Cultural and religious beliefs that could limit communities’willingness to undergo screening

Section 4: Stakeholders

The project’s stakeholder analysis encompasses both internal and external stakeholders. Internal stakeholders have a direct relationship of investment, ownership or employment in the program. They include the program staff, funders, the board of management at Doctors Community Hospital, partner organizations involved directly in program activities, and project beneficiaries. The project beneficiaries are the members of the community who heed to the call to take part in the project’s interventions. The program’s main source of funding is the Maryland Department of Health and Mental Hygiene.

To realize its mission, the program will partner with fertility clinics and organizations within the state, where patients could be referred for specialized support such as thermal ablation treatment and reproductive counseling. There are few facilities in the state that offer thermal ablation. The program will partner with the University of Maryland’s Marlene and Stewart Comprehensive Cancer Center for thermal ablation services as the two organizations already have a pre-existing working relationship, and the facility has been carrying out thermal ablation longer than other facilities in the state. For reproductive counseling, the program will partner with the Prince George County Health Centre in an arrangement that will see its specialist counselors visit the BCCSP on selected days to offer services to beneficiaries.

The program will engage its program staff through monthly roundtable meetings and quarterly meetings with the board of management, where they could voice their ideas and opinions on the program for action. The program’s clients or beneficiaries will be engaged through biannual customer satisfaction surveys. Suggestion boxes will also be available for participants to drop notes with their feedback regularly. The rest of the internal stakeholders will be engaged through biannual meetings organized by the BCCSP to bring all stakeholders together and listen to their views, experiences, and recommendations. The stakeholders will also receive quarterly progress reports on the program in addition to periodic emails informing them of progress.

Conversely, external stakeholders do not have a direct relationship with the project, but influence its outcomes and are affected by its operations. These include the general Prince George community, other facilities running cancer awareness and treatment programs in the county, and the county and state governments. The program will keep these engaged and informed through quarterly newsletters that will be distributed in their offices and availed for free in strategic places such as popular malls and convenient stores, where members of the public could easily pick a copy. The newsletters will communicate past and upcoming events while inviting the stakeholders to be part of the program through sharing their views, attending events, and referring other interested persons. The program will also engage the county and state governments through CSR activities by sponsoring events and initiatives run by the local authorities.

Table 2 below presents the stakeholder analysis matrix summarizing the different stakeholders, their level of influence, how they contribute to the project, and ways through which the project will engage them.

Table 2: Stakeholder Analysis Matrix

Stakeholder Name

Impact (extent to which the program impacts them)

Influence (Extent to which they influence the program)

What is important to them?

How they contribute to the program

How could they block the program

Engagement strategies

Program staff (physicians, social workers, nurses, counselors) – Internal

High

High

The stability of the program and a good work environment

Offer direct services to clients

Going on strikes or boycotts

Monthly meetings, quarterly meetings with board of management

Program beneficiaries/clients – Internal

High

High

That the program offers high quality services

They market the program through referrals

They could taint the program’s reputation through negative feedback

Biannual customer satisfaction surveys, having a suggestion box where they could offer feedback on the services offered

Maryland Department of Mental Health and Hygiene (funder) - Internal

Medium

High

High levels of accountability and transparency in management of resources

Provide grants to run program activities

Could refuse to advance future grants

Biannual meetings, quarterly progress reports, periodic emails

Doctors Community Hospital board of management – Internal

High

High

That the program realizes the intended goals

Offer oversight and governance through policy-making

Could come up with misinformed policies or decisions

Quarterly meetings and progress reports, periodic emails

University of Maryland’s Marlene and Stewart Comprehensive Cancer Center – Internal

Medium

High

That the program sticks to the contractual arrangement

Offer thermal ablation treatment to patients with special conditions such as epilepsy

Failure to respect contractual terms of engagement with the program

Biannual meetings and quarterly progress reports, periodic emails

Prince George County Health Center Fertility Clinic – Internal

Medium

High

That the program sticks to the contractual arrangement

Offer reproductive counseling and fertility treatments to survivors referred from the BCCSP

Failure to respect contractual terms of engagement with the program

Biannual meetings and quarterly progress reports, periodic emails

Prince George community – External

Medium

High

That the program brings about the benefits it claims

They determine the program’s continuity by choosing whether or not to participate in its projects

Refusal to embrace the program’s interventions

Quarterly newsletters, sponsoring local events

Other facilities running similar programs - External

High

High

That the program is not a strong competitor to them

They influence the quality of interventions at BCCSP

They could cause reputational damage to BCCSP

Quarterly newsletters

Prince George county and Maryland State governments – External

Low

Medium

That the program leads to improved public health

Offer an enabling environment for the program to operate through licensing

They could refuse to offer operating licenses

Quarterly newsletters, sponsoring local events organized by the local and state government

Section 5: Implementation

The project will be implemented over a two-year period. The first milestone before the grant funds are received is the development of the program strategic plan. This was done by the board chairperson, who has substantial experience in developing strategic plans for not-for-profit organizations. As part of developing the strategic plan, the board chairperson and his team held sessions with program staff, government officials, and community representatives, including religious leaders; to assess the community’s needs in relation to cervical cancer prevention and treatment. The needs assessment exercise formed the basis upon which the program interventions and goals were developed.

Once the project proposal for funding is approved and funding received, the board of management will organize a session bringing together the program staff, community leaders, selected partner organizations, and representatives from the local and state governments. The meeting will provide the platform for the various stakeholders to be familiar with each other, familiarize themselves with the program’s goals and interventions as per the strategic plan, and understand their role in the project. At the end of the meeting, the board of management and partner organizations will sign the contractual agreement stipulating the responsibilities, duties, and limits of each of the parties. This will formally mark the beginning of the program’s implementation phase.

Since the Doctors Community Hospital has been carrying out breast cancer treatment, most of the radiation equipment are available. The project only requires minimal purchases of equipment to facilitate HPV screening and pap smear testing. The program will market itself through advertisements on the ‘Your Health’ local magazine as well as local television stations that are popular among women. The advertisements will make the program known, while inviting interested women to visit the program’s website for further information and to even attend the medical camps organized for free testing and screening.

The program intends to hold eight quarterly medical camps over the implementation period. The camps will be held in Lanham, where Doctors Community Hospital is located, as well as in seven of the county’s most populous towns: Bowie, Clinton, Chillum, College Park, South Laurel, Laurel, and Fort Washington. The county’s most populous towns are selected to ensure that the camps reach a larger proportion of the target population. The first medical camp will be held in Lanham. The interaction with the local community in Lanham will provide crucial insights on how to organize medical camps in the other towns.

The program team will hold biannual evaluations to assess the impact of the program in terms of beneficiary numbers and impact. At the end of the first year, the program will be subjected to a summative evaluation exercise by external evaluators that will assess its performance based on feedback collected from beneficiaries and reviews of beneficiary progress reports. The evaluation will provide crucial insights on how to design policies in the second year of implementation. A final summative evaluation will be conducted at the end of the second year to determine whether the program has realized its goals and whether or not it needs to continue for another two years.