Dave Haran

Attendance for cervical screening—Whose problem?

Despite the existence of an effective screening technique for cancer of the cervix, incidence and mortality from this disease have not declined in the United Kingdom. The basic problem is that women most at risk of the disease are under-represented in the screened population. The evidence for two different points of view to explain this situation is examined. These viewpoints are the failure of the women to attend, and the failure of the service to meet the needs of women. This paper argues that the evidence supports the view that the organisation of the existing screening service impedes the maximum participation of at-risk women. We discuss the features that an effective service needs to incorporate, and put forward principles for the development of a more effective screening system, namely, that it should be provider-initiated and user-oriented.

Reasons for non-attendance for computer-managed cervical screening: Pilot interviews

A pilot interview study looked at reasons why women did not attend a clinic following an invitation for a cervical smear test offered via a computer-managed scheme. Three broad issues were identified. First, the inaccuracy of the computer database (the FPC register) meant some women were inaccessible because they no longer lived at the address recorded. Other women were ineligible or unsuitable within the criteria of the scheme but had been sent invitations inappropriately because their screening records were incomplete or out of date. Second, aspects of service organisation and provision led to misclassification of some attenders as non-attenders and to various failures of communication such as non-receipt of the invitation or health education leaflet or unsuccessful attempts to rearrange appointments. In addition, the appointment or venue offered could be unsatisfactory. The third issue concerned the characteristics of the women which sometimes interacted with practical problems connected with service provision. Other women believed the test to be inappropriate for themselves while some were deterred by the prospect of the test itself. In general, embarrassment was pervasive and reflected in preferences for different types of service provision. Women who had neither attended nor been otherwise tested were particularly likely to express feelings of fear and fatalism. General attitudes to the test were favourable but this was not always applied personally. A typology of reasons for non-attendance for computer-managed cervical screening is presented.

Back to basics: does decentralization improve health system performance? Evidence from Ceará in north-east Brazil

OBJECTIVE To examine whether decentralization has improved health system performance in the State of Ceara, north-east Brazil. METHODS Ceara is strongly committed to decentralization. A survey across 45 local (municipio) health systems collected data on performance and formal organization, including decentralization, informal management and local political culture. The indicators for informal management and local political culture were based on prior ethnographic research. Data were analysed using analysis of variance, Duncans post-hoc test and multiple regression. FINDINGS Decentralization was associated with improved performance, but only for 5 of our 22 performance indicators. Moreover, in the multiple regression, decentralization explained the variance in only one performance indicator; indicators for informal management and political culture appeared to be more important influences. However, some indicators for informal management were themselves associated with decentralization but not any of the political culture indicators. CONCLUSION Good management practices in the study led to decentralized local health systems rather than vice versa. Any apparent association between decentralization and performance seems to be an artefact of the informal management, and the wider political culture in which a local health system is embedded strongly influences the performance of local health systems.

Living with an amputation: the helper.

One hundred and nine key helpers were interviewed in connection with a study of the psychosocial implications of amputation. They were found to carry formidable burdens. Social isolation was a major problem which increased over time and was associated with diminished capacity to express needs. The respondents discussed emotional problems readily. Social workers had little sustained contact with helpers: welfare agencies had intervened mainly to provide practical help. The Artificial Limb Centre did not routinely see helpers or communicate with General Practitioners. A more realistic approach to the support of those who implement community care policies is advocated, with particular reference to the need for respite care to be provided in the domestic setting. The dangers of the exploitation of women as carers are highlighted.

A computer-managed call and recall system for cervical screening

Abstract In order to maximine the response of women to cervical screening the service needs to be re-oriented towards the needs of the consumer, with a greater initiative coming from the service provider. These considerations imply that the system should take account of various barriers and in order to do so systematically and comprehensively requires a database and a management system. This paper described the development of a computer-managed scheme for cervical screening using the Family Practitioner Committee (FPC) register as a database to identify women for screening. This system can be used for calling previously unscreened women as well as for recall.

Health education in a computer-managed cervical screening programme:

IN designing health education material for a cervical screening programme, attention needs to be given to those features identified by research as influencing womens use of screening services. These include not only womens attitudes and beliefs about cervical screening, but also organisational and administra tive barriers that can deter women from attending for a smear test. Health information may be presented through a variety of media and at different stages in the cervical screening decision-making process. This paper describes the specific health education used in a computer-managed scheme and how it was modi fied in the light of findings from research which monitored and evaluated the scheme.

Trends in the organization of cervical cancer screening.

CERVICAL CYTOLOGICAL screening has been available in the UK for several decades, but has not achieved a significant reduction in the incidence of and mortality from cervical cancer. In this paper we describe past problems of cervical screening, discuss the impact of recent innovations to computerize call and recall, and suggest further improvements for the future.

The use of Breast Self-Examination as a Screening Modality

In the past twenty years or so breast self-examination (BSE) has been increasingly advocated in health education programmes and from time to time has appeared in newspapers and magazines. Rarely is a TV programme on breast cancer not coupled with some mention of BSE. Most of the emphasis by health educators has been on persuading women to adopt the habit. In this paper current studies of the efficacy of BSE in the control of breast cancer will be compared with the results of screening by mammography. Findings from a large-scale study in Lancashire of the teaching of BSE prompt consideration of the implications of performing BSE. In contrast to the situation in cervical screening the health behaviour involved in BSE acts as the screening modality itself and this realisation on the womans part may have unforeseen consequences. Finally the paper discusses the service commitment required to support BSE teaching adequately. Breast self-examination (BSE) as a means of achieving the diagnosis and treatment of breast cancer at the earliest possible stage is a screening modality in which the clinical input can be minimal and the education and persuasion components appear of paramount importance. We would argue that the clinical input needs more consideration than it has received hitherto, and that enthusiastic efforts to encourage women to take up this comparatively new procedure might benefit from the constraints imposed by recognising BSE not just as a commendable health habit but as a screening procedure. 1. Screening prerequisites The principles are that it is of advantage in the care or control of disease to diagnose and treat it as early as possible and that the patient will ultimately be better off by screening than otherwise. These rely on medical and ethical judgements about which health educators need to be satisfied but which we will take as read in relation to breast cancer for the purpose of this paper. 2. Screening criteria For determining the requirements for any screening procedure a number of criteria have been defined. Here six core criteria are considered in relation to BSE (table 1).