Background
Cervical Cancer is the uncontrolled growth of abnormal cells in the cervix, which usually starts on the surface and can spread to other parts of the body (metastasize). Cervical cancer is largely caused by infection of Human Papilloma Virus (HPV). HPV is transmitted through skin-to-skin contact during sexual activity with an infected person, either through skin-to-skin genital contact or through sexual intercourse. This transmission can occur through oral, vaginal, or anal sex. HPV is also linked with cancers of the anus, vulva, vagina, penis, head and neck cancers (WHO, 2018).
Globally, 570,000 women are affected by cervical cancer and every two minutes, one woman dies of it, making it the fourth most frequent cancer in women (WHO, 2018). However, an estimated 90% of deaths from cervical cancer occurs in low-and-middle-income countries. In Africa, every year cervical cancer accounts for 99,000 of all cancer cases, of which 93,200 occur in Sub-Saharan Africa (Ferlay et al, 2013). However, evidence has shown that this high mortality can be reduced greatly through comprehensive approaches including prevention, early detection, effective screening and treatment programs (WHO, 2018). This therefore has been the focus of Healthier & Happier Life Foundation (HHLF).
HHLF is a not-for-profit organization aimed at promoting preventive medicine, advocating for quality healthcare and equity in access to good health. HHLF believes that by bringing health to the people using innovative strategies and building individual/community and organizational capacities will not only prevent death but reduce economic, physical, social and psychological burdens that come with ill health and thereby improving quality of life. Our strategies include the infusion of arts into science by using theatre for development for our health promotions/education/awareness creation in order to help break cultural, language, educational and socioeconomic barriers to healthy living. We therefore employ these various strategies in our current project.
Situational Analysis
Cervical Cancer remains an important public health problem in Ghana. The incidence rate of cervical cancer in Ghana (24.3%) is higher compared to West Africa (17.2%) and the world (15.1%) at large (Ferlay et al, 2013). Additionally, a genotypic study revealed multiple infections of HPV among Ghanaian women (Awua et al, 2016). An estimated 8.6 million women aged 15 years and above out of the 14.8 million females in Ghana are therefore estimated to be at risk of developing cervical cancer (United Nations, 2015). Every year, more than 3,000 women are diagnosed of cervical cancer and more than 2,000 die from it in Ghana making it the second leading cause of female cancer but first leading cause of female cancer deaths with mortality rate of 67.2% (GLOBOCAN, 2018).
Meanwhile these figures were obtained from hospital based data, women who do not come to the hospital are not accounted for. This must be a worry for all especially the government. For instance, these deaths which occur in just a section of the female population is higher compared to road traffic accident which occurs across the entire Ghanaian population. Compounding this is the younger age at which the disease develops coupled with late-stage of presentation (Edmund et al., 2013; Laryea et al., 2014; Naku Ghartey et al., 2016; Nartey et al., 2017). Moreover, cervical cancer does not only cause death but also psychosocial and physical problems, decrease / loss of productivity at workplaces, diminish resources within families and burden society and health system (Edwin, 2010).
Despite these burdens, there exists no national screening nor vaccination program to reduce the cervical cancer burden among the Ghanaian women. Compounding this is the lack of awareness/knowledge of the risk factors, mode of transmission, symptoms and screening among these women and the general population (Ministry of Health, 2012). Additionally, there continues to be an increasing rate of the major risk factors of the disease. For instance there is an increasing growth of the population coupled with high prevalence of lifestyle and behavioral risk factors including early ages of sexual intercourse, having multiple sexual partners, early ages of child birth, multiple/several pregnancies, long term and indiscrimate use of hormonal and oral contraceptive pills, tobacco smoking, infections (eg HIV, STIs/STDs, TB etc), unhealthy diet, and psychological stress (Ferlay, Soerjomataram & Ervik, 2013; Plummer et al, 2016).
Rationale for cervical cancer awareness creation
Awareness promotes early detection and influences early health seeking behavior among the apparently healthy. Furthermore, policy makers are faced with issues including cultural implications as barriers to rolling out of many interventions including HPV vaccination. However, the HPV vaccine which has been approved by the World Health Organization (WHO) and national governments in many countries is proven as an effective public health intervention against cervical cancer and must be heralded by all.
Routine HPV vaccination comes with several benefits to individuals, societies and the nation as a whole: it prevents HPV infection and cervical cancer, decrease genital warts, establish herd immunity against HPV and it removes the negative physical and psychosocial impacts. Its cost effectiveness also ensures considerably huge cost savings in terms of the money spent on diagnosis and treatment. Likewise cervical cancer screening helps in identifying high-grade, pre-cancerous cervical lesions which can easily be treated and thereby preventing cervical cancer. Moreover evidence shows that women who screen twice or three times, between ages 30 and 45, can lower their lifetime risk of cervical cancer by 50% (Campos et al, 2015).
Evidence show that a key strategy for intervention in the prevention of cervical cancer is community education and participation (WHO, 2016).This project therefore seeks to educate, create awareness and empower individuals, communities and organizations/institutions on cervical cancer: its risk factors, routes of transmission, symptoms, its impacts and prevention strategies and by centrally focusing on screening and HPV vaccination through theatre for development to break the cultural, language, educational and socioeconomic barriers that hinder the Cervical Cancer Awareness and its eradication in Ghana
DETAILED PROJECT DESCRIPTION
- Project Goal
The main objective of this project is to prevent / eliminate cervical cancer by breaking the barriers at the community level through theatre for development
- Objectives
- To break the cultural, social, educational, language and socioeconomic barriers to HPV vaccination and screening
- To empower women and adolescents by educating them on cervical cancer, its impacts (social, economic, psychological and physical) on the individual, families, communities and Ghana as a whole.
- To empower communities and institutions/organizations by educating them on cervical cancer, its impacts (social, economic, psychological and physical) on the individual, families, communities and Ghana as a whole.
- To create awareness on cervical cancer preventive means: screening and HPV vaccination to increase HPV vaccination to at least 50% from the current insignificant level and also increase cervical cancer screening from the current 2.8% (in the general Ghanaian population) to at least 50%.
- To educate Ghanaian men on cervical cancer and the need for them to help their female counterparts and children to access preventive care
Individual/community/ institutional empowerment through Theatre for development:
- Drama
- Community participatory programs
- Educational programs using audiovisuals
- Peer educator programs
- Description of intervention
Every society upholds the culture and norms that define it in terms of disease intervention. Anything contrary to this is seen as foreign, nuisance and infiltration of their precious heritage and will be resisted. In order to ensure an effective intervention at societal/community levels, the cultural heritage of the people must be respected and intervention seen and understood with ‘cultural eyes’ and in a common language. To help meet these requirements and break the barriers to cervical cancer prevention in Ghana, Healthier & Happier Life Foundation leverages the knowledge and skills of professional dramatists and actors who understand the culture of the various communities of Ghana. The Foundation partners the Keepers Theatre Consult headed by Dr. Daniel Appiah-Adjei (Ph.D.), a Senior Lecturer at the University of Ghana School of Performing Arts to stage drama/play, community participatory and peer educator programs in addition to audiovisuals on cervical cancer. Additionally, Dr. Kofi Effah, a consultant gynecologist and head of the Cervical Cancer Prevention Centre at the Battor Catholic Hospital, Ghana provides direction in relation to cervical cancer screening and vaccination. Moreover, the Cervical Cancer Prevention Centre at the Battor Catholic Hospital acts as our referring facility.
Theatre for development is a participatory engagement (theatre for the people and can be by the people) that takes into consideration the people, be it illiterate or literate, formal or informal etc. This is based on the evidence that the mind is able to perceive and understand visuals more than mere words and much more so when it is participatory. Theater for development has always been a tool to break language barrier, ideological barrier amongst others. Way back from the 20th century AD, countries like Germany, under playwright like Betrolt Bretch, Norwegian playwright; Henrick Ibsen, American playwright; Arthur Miller etc, caused revolutionary changes just by using theater as a means to cause societal changes.
The project therefore seeks to break the barriers such as lack of knowledge on cervical cancer, unawareness of preventive mechanisms, myths and where to access care. Additionally, it will elaborate extensively on the benefits of cervical cancer vaccination, screening and early detection: a) the economic b) psychological, c) physical d) social and where to access the cervical cancer services. Moreover, the Foundation seeks to offer free cervical cancer screening and treatment of precancers to vulnerable groups in society who cannot afford.
This is a district-wide project. It considers the 216 current administrative districts in Ghana. The districts are chosen in order to ensure the effectiveness of the project. The project will also involve major stakeholders and advocates. The project has 4 phases (shown in table 1) which will last for 24 months. This is guided by the theory of change below.
- Methodology
This project will employ theory of change (ToC) to achieve its objectives
- Theory of Change (ToC)
Theory of change is a practical model that demonstrates what we do and what we hope to achieve. In other words it is a structured way of thinking about change and impacts an organization would like to achieve. It does not only consider how change can come but also what assumptions the organization will make and by taking into consideration what others do (partners).
This model (Fig.1) presents how we can create a long-term value or long-term positive effect on cervical cancer, its screening and vaccination at the community and institutional levels thereby empowering the individuals.
ToC includes five main components, namely input, process (activities), outputs (immediate results), outcome (intermediate goals) and impacts (long term goals). This is shown below:
Figure 1: A comprehensive cervical cancer awareness creation
Narrative
Outcomes and impacts are the overall intermediate and the long term goals/aims respectively. At outcome stage we desire to see tangible results including the proportion of people with knowledge on cervical cancer, proportion of people who are willing to be vaccinated and screened, proportion of people who are aware of where to access screening and vaccination services and proportion of people who have been screened or referred.
The outcome will result in the impact we intend to see by the end of the project: percentage increase in vaccination and screening for cervical cancer in the Ghana. The achievement of these goals are based on the following assumptions: 1) partnership will continue, 2) fund will be available 3) there will be good leadership, 4) there will be continuous improvement in strategies.
In order to achieve these goals however, the following must be considered:
What resources do we need for effective cervical cancer awareness creation, diagnosis (screening) and treatment without financial insolvency? What resources should we commit in order to be able to take away the burden of cervical cancer? Resources needed include partners, financial resource, staff/ human resource and equipment. Equipment include mobile colposcopy (EVA system) machine which is very cost effective. The human resource includes healthcare professionals, dramatists and actors, community volunteers, health economists and policy advisors, researchers and epidemiologists. The partners will include both local (MPs, Constituency leaders, District, GHS, Battor Catholic Hospital, schools, churches, communities, mission hospitals, private hospitals, Keepers Theatre, chiefs and community leaders etc) and foreign / developmental agencies (UNFPA, WHO, DFID, GAVI, UNICEF, ACTION AID, etc.). Provision of these resources is based on the assumption that partners will be willing to support financially, technically and logistically. Additionally, it is assumed that cervical cancer will remain on the agenda as a relevant issue / public health burden. The Battor Catholic Hospital Cervical Cancer Prevention Centre will serve as the capacity building (screening) and referring Centre for pre-cancer treatment.
The process involves the needed activities that will make our goals to be realized. This is the backbone or the machinery that will drive this vision. The activities will include:
- Partnership: Some of these partners are listed in section ii above. These partners will play their roles in achieving the goal of the project.
- Training and capacity building for staff and community volunteers.
- Awareness creation about cervical cancer, screening services and where to access care. This will be done through drama, community participatory programs, educational programs using audiovisuals and peer educator programs.
- Screening and treatment of precancer lesions for marginalised or vulnerable individuals
The output represents the immediate results that will be seen after the inputs and processes are in place. These outputs include:
- the number of people, communities, organizations/institutions reached through drama
- the number of people, communities, organizations/institutions reached through community participatory programs
- the number of people, communities, organizations/institutions reached through audiovisual educational programs
- the number of people, communities, organizations/institutions reached through peer educator programs
- the number of vulnerable groups reached
The output will result in the outcome. However, in order to achieve the outcome, the following assumptions are made:
- there will be continuity of partnership
- there will be good leadership
- there will be continuous improvement in all activities
- there will be fund available