3.Key Challenges and Strategies

To ensure that the Program meets its Goals, Aims and Objectives (Appendix 1), the NSW Cervical Screening Program has identified the following five key challenges which need to be addressed :

• 1. engaging stakeholder collaboration at local, statewide and professional level;
• 2. recruiting women at risk;
• 3. supporting compliance with national standards for laboratories processing pap smears;
• 4. ensuring best clinical practice; and,
• 5. operations-oriented research, evaluation and monitoring .

As the majority of Pap smears are taken by general practitioners and analysed by private pathology, the success of the NSW Cervical Screening Program in achieving its objectives will depend significantly on its capacity to harness the efforts of others. The Program’s primary challenge must be to build effective partnerships between public and private sector services at state and local level. It is therefore important to establish a framework for co-operation and communication between public and private sectors, at all levels of government and with all key stakeholders in the Program.

To meet this challenge the Program will:

• engage key experts in the development of statewide priorities and strategies across all stages of the screening pathway through the established State Advisory Committee on Cervical Cancer Screening;
• establish expert working parties and task forces to review technical and policy issues and advise on strategies for program implementation in areas such as general practice, recruitment, laboratory services, gynaecological issues, medico legal issues and on development of co-ordinated programs that will improve access for the key target groups;
• liaise with peak professional groups, consumer organisations, the Commonwealth, other States and Territories and key stakeholders;
• work with Health Services specifically by supporting the establishment of a network of Cervical Screening Coordinators within the Services to develop and implement local strategic plans for cervical cancer screening, in consultation with Divisions of General Practice, public health and health promotion units, hospital services, women’s health nurses, relevant non-government organisations, aboriginal health workers, women’s groups and other local stakeholders;
• act as a resource by providing data, research, key messages and policies to assist in the evaluation of strategies and to promote evidence based practice; • liaise with the NSW Health Department on the Program including providing briefings to the Senior Executive Council at appropriate intervals; and,
• liaise with the Commonwealth Department of Health and Family Services and with other State and Territory Cervical Screening Programs on issues of national interest.

Communication Plan

The NSW Cervical Screening Program is committed to establishing effective links with all key stakeholders involved in the cervical screening pathway. A Communication Plan is a fundamental part of this strategy and forms the cornerstone of the statewide Recruitment Strategy.

The Program will:

• develop an overarching Communications Plan to promote all aspects of the NSW Cervical Screening Program and to increase the profile of the Program. The Plan will involve strategies to develop networks for communicating latest research findings, key messages and policies to all stakeholders.

3.2 Recruiting women at risk

General Recruitment Strategies

There are few published data about the NSW rate of screening for cervical cancer but what is available suggests that the rate of screening in NSW is around 58% for women up to the age of 50 and lower for women over the age of 50. This appears to be comparatively lower than other States and Territories (Cervical Screening in NSW. Situation Analysis, 1997). In addition, the evaluation of the National Program found that older women, rural women, women of non-English speaking backgrounds, and Aboriginal and Torres Strait Islander women appeared to be substantially under screened nationally although, again, a lack of data makes it difficult to assess actual rates of screening for these groups in NSW.

The major challenge for the NSW Cervical Screening Program, therefore, is the development of a statewide strategy for increasing the overall number of women who are screened every two years and in particular to increase the screening rates of the key target groups.

The Program will:

• establish a Recruitment Task Force consisting of community representatives from women’s groups and key target groups to provide expert advice in the development and implementation of the recruitment strategy, focusing on increasing recruitment for under screened women;
• develop an overarching statewide recruitment strategy, in consultation with the key stakeholders, which draws on cancer epidemiology data, evidence of effective strategies for increasing recruitment and links with the General Practice Plan and the Statewide Communications Plan;
• collate and disseminate information on screening rates produced by the NSW Pap Test Register and other sources, to support the development of targeted recruitment strategies at state and Health Service level and provide workshops to assist Cervical Screening Coordinators and Pap smear providers in the interpretation and use of this data;
• support Cervical Screening Coordinators in the development and evaluation of community based strategic plans and projects to improve screening rates;
• summarise and disseminate evidence based information on recruitment strategies and barriers to screening for use by Health Services and Divisions of General Practice;
• work with all stakeholders to co-ordinate initiatives which link national, statewide and local media strategies to maximise impact;
• develop culturally sensitive educational material, including videos in community languages;
• develop networks for communicating latest research findings, key messages and policies to all stakeholders;
• explore innovative communication strategies using new technology for rural and remote women; and,
• actively promote messages aimed at increasing screening rates in women, with particular focus on reaching the key target group.

Hard to Reach Women

A number of key target groups have traditionally been unscreened or underscreened. To target these ‘hard to reach’ women the Program will:

• consult with statewide groups representing key target groups or groups with significant links to these groups to identify health promotion strategies, service outreach and community development techniques aimed at recruiting ‘hard to reach’ women to cervical screening;
• undertake specific research into the needs of and effective strategies for these groups of women, including provision of specially designed services using Women’s Health Nurses; and,
• work with groups presently accessing disabled women, boarding house and caravan park residents, homeless women and lesbian women to ensure the key messages from the Program are communicated to them in an appropriate and/or culturally relevant context.

General Practice Plan

General practitioners are the key to increasing screening rates in women through opportunistic screening. As well, there is evidence that community development strategies are most effective when combined with general practice initiatives (Cervical Screening in NSW, Situation Analysis, 1997).

To maximise the effectiveness of general practitioners in recruiting women the Program will:

• establish a General Practice Task Force to enable the Program to seek advice and consult on cervical screening issues related to General Practice with appropriate professional groups. The Task Force will include representation from the Royal Australian College of General Practitioners, the Australian Medical Association, Divisions of General Practice, and other relevant bodies;
• through systematic review of the literature, identify strategies which positively and predictably increase general practitioners’ provision of Pap smears;
• develop a General Practice Plan for Cervical Screening, in consultation with the General Practice Task Force and other appropriate groups, which draws on the systematic review to identify strategies for implementation and evaluation as part of the plan;
• hold a General Practice forum with representatives from all Divisions of General Practice to advise on the General Practice Plan;
• make available a range of educational materials for general practitioners (for which accreditation for Quality Assurance & Continuing Education points will be sought) on all components of the screening pathway (see also Section 3.4) including Continuing Medical Education material and Practice Assessment Activity material; and,
• facilitate the establishment of local links between general practitioners and Cervical Screening Coordinators to develop and implement evidence based strategies for increasing screening rates in a particular community or key target group.

3.3 Supporting compliance with national standards for laboratories processing Pap smears

The Report of the steering group on Quality Assurance in Screening for the Prevention of Cancer of the Cervix, ‘Making the Pap Smear Better’ (CDHSH 1993) examined quality assurance requirements for the component steps of the screening pathway. Since its publication, improved quality assurance practices have been introduced into cytology laboratories (CDHSH 1995). Laboratory Quality Assurance indicators are well established at a national level (Performance Standards for Australian Laboratories Reporting Cervical Cytology CDHFS 1996; Requirements for Gynaecological (Cervical) Cytology, CDHFS 1997). These now need to be incorporated into routine laboratory practice. The Program will:

• establish a Laboratories Task Force to advise the Program on strategies and mechanisms to work with the laboratories to achieve the Program objectives including:
• the use of effective quality improvement systems for laboratories;
• widespread implementation and utilisation of existing quality assurance tools;
• the implementation of the Australian system for reporting gynaecological (cervical) cytology standardised terminology and format incorporating a management recommendation consistent with current NHMRC Guidelines (CDHFS 1997);
• support the National Association of Testing Authorities and the Royal College of Pathologists of Australasia accreditation system; and • review workforce and training issues and standards for cytotechnologists and pathology registrars; and,
• ensure timely provision and dissemination of quality assurance data generated by the Pap Test Register.

In relation to Pap smear taking, ‘Making the Pap Smear Better’ (CDHHLG&CS 1993) recommended that health professionals who take Pap smears need training in theoretical aspects of screening, as well as practical tuition to ensure satisfactory Pap smears are collected. Additionally, the report recommended that health professionals who take smears should be sensitive to the concerns and possible embarrassment of their clients and be particularly aware of cultural sensitivities. The results of a woman’s Pap smear should be made available to her in a clear, timely and sensitive manner and any necessary follow-up undertaken.

Despite the publication of the NHMRC Guidelines on the Management of Women with Screen Detected Abnormalities (NHMRC 1994), there is evidence that clinical management of women with screen detected abnormalities is variable.

To meet these challenges the Program will:

• encourage adherence to best practice guidelines for all elements of the screening and treatment pathway;
• identify acceptable options for notification of results to women and examine their feasibility and cost effectiveness;
• promote continuing education and quality assurance programs for general practitioners and gynaecologists in association with relevant colleges and professional associations;
• assist in the development of best practice guidelines and credentialling systems for non-medical providers such as women’s health nurses and Aboriginal health workers;
• assess quality, accessibility and acceptability of colposcopy services in NSW;
• examine training needs;
• provide training videos and other resources aimed at improving skills in smear taking;
• encourage a positive interaction between laboratories and Pap smear providers to assist monitoring and improving smear quality;
• encourage further development of quality assurance programs;
• in collaboration with the providers, women and representatives of the referring General Practice network, develop and test criteria and standards for best practice assessment for colposcopy services; and,
• evaluate current resources for women about colposcopy and mechanisms for the effective distribution of these.

The current medico-legal environment in relation to cervical screening, particularly in NSW, demands strong involvement by the NSW Cervical Screening Program at a local level. Medico-legal concerns are a preoccupation of the clinical community at present and represent a potential threat to the viability of the cervical screening system.

To address this challenge the Program will:

• establish a Medico-Legal Task Force to provide an issues paper and advise on medico-legal issues and problems as required;
• in association with the National Advisory Committee on Cervical Cancer convene a National conference which will have medico-legal issues as one of its themes and which will bring together Australia wide expertise;
• develop a position paper to be the basis for a definitive medico-legal statement on cervical screening in New South Wales; and,
• investigate the feasibility of producing a consensus "Product Liability Statement", that defines the risks and benefits of cervical screening for consumers as a potential strategy for minimising medico-legal concerns.

3.5 Operations-oriented research, evaluation and monitoring

The NSW Program will exemplify an evidence based approach to clinical and public health practice. A responsive and reliable Research and Evaluation Plan will support this approach. It will be based on the following principles:

• responsiveness to needs and priorities of the NSW Cervical Screening Program;
• commitment to methodological rigour in applied cancer screening research and evaluation;
• dissemination of results through peer review;
• proactive approach to research transfer and application in public health practice;
• consumer orientation; and,
• timeliness, reliability and relevance.

Further, the Statewide Evaluation Plan will be derived from the performance indicators and contractual obligations for the NSW Cervical Screening Program. In addition, economic aspects of key components of program activity will be evaluated. The Evaluation Plan will also document evidence of the effectiveness of activities undertaken.

The NSW Cervical Screening Program will:

• liaise with the NSW Pap Test Register to provide data on screening rates which can be used to evaluate Program initiatives at a statewide and Health Service level;
• provide summaries of NSW data on cancer epidemiology and sociodemographic characteristics of target groups; and,
• provide all Health Services with a profile of the current status of cervical screening in their area.

Commonwealth Department of Human Services and Health. Making the Pap smear better. Report of the steering group on quality assurance for the prevention of cancer of the cervix. AGPS, Canberra. 1993.

Commonwealth Department of Human Services and Health. The Interim Evaluation of the Organised Approach to Preventing Cancer of the Cervix 1991-95. Report of the Evaluation Steering Committee. AGPS Canberra. 1995.

Commonwealth Department of Health and Family Services. Requirements for Gynaecological (Cervical) Cytology, National Pathology Accreditation Advisory Committee. AGPS, Canberra. 1997.

Jelfs PL. Cervical Cancer in Australia. Australian Institute of Health and Welfare: Cancer Series No 3, AIHW, Canberra. 1995.

National Health and Medical Research Council. Screening to Prevent Cervical Cancer: Guidelines for the Management of Women with Screen Detected Abnormalities. Commonwealth Department of Human Services and Health. AGPS, Canberra. 1994.

NSW Cervical Screening Program, Cervical Screening in NSW. Situation Analysis, NSW Cervical Screening Program, 1996.