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The aim of this study is to critically review and evaluate a project proposal - the cervical cancer in Bolivia. This study will achieve its aim by looking at the magnitude and determinants of cervical cancer in Bolivia as well as the Health Needs Assessment (HNA), Logical Framework (Logframe), Health Action Model (HAM) and ethical implication of the project proposal. Subsequently, the project will be evaluated, an action plan for future health promotion will be developed as a form of reflection and conclusion will close the study.
MAGNITUDE OF THE PROBLEM
According to Wikipedia (2010), cervical cancer is defined as malignant neoplasm of the cervix uteri or cervical area. The free dictionary (2010) further simplified this definition as a disease in which the cells of the cervix become abnormal and start to grow uncontrollably, forming tumours.
Cervical cancer appeared to be a problem worldwide. In 2000, there were about 470,606 incident cases and 233,372 deaths that occurred annually among women worldwide (Pan American Health Organisation (PAHO), 2004). About 80% of these cases came from developing countries (PAHO, 2004). By 2002, this has risen to 493,000 new cases and 274,000 deaths and the majority of cases were from developing countries contributing about 83% (World Health Organisation (WHO), 2010).
Developing regions such as Latin America and the Caribbean have some of the highest cervical cancer incidence and mortality rates in the world (PAHO, 2004). According to PAHO (2008), cervical cancer is the second most common cancer among woman aged 15 to 44 and is the second cause of death due to cancer among women in Latin, central and South America. Addressing target age group for our project seem to be appropriate since the cancer is second most common from the age of 15. Our project would have benefited from setting an age target group from 15 years and above. Cervical cancer in Bolivia continues to increase even above the age of 65 plus when compared to the world incidence (see appendix 1).
We seek to direct our intervention towards Bolivia since it has the highest incident cases of cervical cancer in South America continent (WHO, 2010) (see appendix 2).
DETERMINANTS OF THE PROBLEM
Dahlgren and Whitehead (1991) formulated a useful framework to intensively explore the determinants of health. It is argued that public health is not mainly the absence of diseases (WHO, 1946) but to promote ways of prolonging people's lives (Acheson, 1988) through the complex interactions between social and economic factors, the physical environment and individual behaviour as well as fixed factors such as age, sex and hereditary (see appendix 3).
Our project also considered Dahlgren and Whitehead (1991)'s framework for the possible causes and other factors contributing to the development of cervical cancer in Bolivia. Human Papilloma Virus (HPV) is the major cause of cervical cancer (Cancer Research UK (CRUK), 2009). There are various types of HPV. But there are other types of HPV that are considered 'high risk'. PAHO (2008) argued that HPV is necessary but insufficient cause of cervical cancer because there are other factors that are likely to contribute to HPV persistence and the development of cervical cancer.
One of the co-factors that may be involved is when there is a family history of cervical cancer; one is likely to be predisposed to having cervical cancer as well as when one has a low immunity (CRUK, 2009).
The age most at risk of cervical cancer in Bolivia women seems to occur around aged 15 and above. According to WHO (2010), Bolivia has a population of 2.89 millions of women aged 15 and older, who are at risk of cervical cancer as this age bracket is perceived as sexually active age.
Lifestyles such as diet and personal hygiene (ehealthmd, 2004) as well as smoking and promiscuity (CancerHelp UK, 2009) increase the risk of getting cervical cancer.
Politics also has a part to play in growing rates of HPV infections especially where there are inadequate policies/medical facilities to protect people from minimising the risk of cervical cancer as it is in developing countries (WHO, 2002) such as Bolivia. This is well supported by Ottawa Charter for Health Promotion that all public policies should be examined for its impact on health (WHO, 1986).
HEALTH NEEDS ASSESSMENT
According to National Institute for Health and Clinical Excellence (2005, p.6), HNA 'is a systematic method for reviewing the health issues facing a population, leading to agreed priorities and resources allocation that will improve health and reduce inequalities'. Addressing the health problems facing a community is as important as reducing the health inequalities of such community. For example, UK has national policies addressing the issues of health inequalities such as 'Our Healthier Nation' (Department of Health (DH), 1999) and 'Making Healthy Choices Easier' (DH, 2004a).
Our project seeks to adopt community profiling as one of the ways to assess the health issues of a community (Bolivia). We chose this method for our project because is very comprehensive in that it makes use of qualitative and quantitative health information in analysing the problem facing a community (Haglund et al., 1990 In Green and Tones, 2010). It empowers the community as their views are as equally important in analysing its problems (Bartholomew et al., 2001 In Green and Tones, 2010). It also provides a basis for setting priorities and planning in relation to the resources available in the community as well as identifying the strengths and weakness of a community (Jack & Holt, 2008).
Unlike another HNA method such as rapid assessment and appraisal (RAA) which also encourages community participation. It relies heavily on the views of the key informants to provide detailed information about the community (Jirojwong & Liamputtong, 2009). Murray (1999) argued that the views of the key informants may introduce bias especially if they come from similar backgrounds where there are no contradictory viewpoints.
RAA collects health information quickly and at low cost to inform planning but it runs the risk of inaccuracy of health information due to the speed of collection, although triangulation is one of the features used to overcome this (Green and Tones, 2010). It is disadvantaged over community profiling in that it makes use of qualitative and quantitative techniques but qualitative techniques tend to be employed more in analysing the health issues facing the community (Beebe, 2001).
It should be noted that people in Bolivia did not perceive this issue as a problem, that is, either felt or expressed needs. Our project was based on normative needs, that is, the health needs that we (health professionals) identified to be the need of a community (Bolivia). However, Freire (1972 In Green and Tones, 2010) referred to this as 'cultural invasion' where the health professionals bring their own value systems to bear in the analysis of problems. DH (2004a) emphasises the need to involve the views of the community as well as WHO (1986, 1997) that state 'people have to be at the centre of health promotion action and decision-making processes for them to be effective'.
Health promotion program is likely to be successful if a systematic process is adopted during its planning (Jirojwong & Liamputtong, 2009). According to Green & Tones (2010), there are different types of planning models used in health promotion, namely; Precede-proceed, Logframe, The PABCAR and the Five-stage community Organisation Model. Our project seeks to adopt Logframe because it provides clear and concise summaries of whole programmes (Nancholas, 1998) which we have demonstrated in our project (see appendix 4). In view of this, it is less time consuming for us because we feel that Logframe eliminates duplication of having to go through the process of another HNA since phase 1 (social assessment), 2 (Epidemiological assessment) and 3 (behavioural and environmental assessment) of precede-proceed model gather the health needs of a community which had already been done by our community profiling. Although, Logframe also has the disadvantage of being inflexible, restrictive and inappropriate for creative community project and complex intervention (Daniel & Dearden, 2001 In Green & Tones, 2010) but we feel that the above reason justified its use. Additionally, Broughton (2001) suggested some recommendations that may be used to overcome some of the disadvantages of logframe such as developing a flexible and responsive planning as much as possible.
Logframe provides a framework to measure performance and to monitor report and evaluate a project (Broughton, 2001) as well as encouraging a multidisciplinary approach to project preparation and supervision (BOND, 2003) as opposed to precede-proceed model that has limited emphasis on multidisciplinary working and it is time consuming when formulating (Davies & Macdowall, 2006).
Our indicators of performance in the logframe were SMART (see appendix 4) as it indicated quantitative and time measurements and the Means of Verification (MOV) were also appropriate (BOND, 2003). However, activities in the Logframe did not state the specific ways on how the activities were going to be achieved but only showed on presentation slides (See appendix 5). Lobbying for finance through the key stakeholders, assertiveness training, counselling, improving knowledge through leaflets, campaigning are important components which are not inclusive in our Logframe (Ewles & Simnett, 2003). Logframe did not show the breakdown of cost of the project (BOND, 2003).
HEALTH ACTION MODEL
HAM is one of the useful behavioural change models in health promotion. We employed this model to bear in our project because it explores a variety of psychological, social and environmental influences which research and practice have shown to be essential determinants of a number of health-related choices (Ewles & Simnett, 2003). Other models such as health belief and stages of change were not adopted for this project as they do not explore these factors. Naidoo & Wills (2000) emphasises the need of health promoters to stimulate and maintain social support to aid behavioural change as changing behaviour is stressful on its own.
Another key feature of HAM is that it empowers people not only by providing information but by helping people to feel good about themselves, to value themselves and to acquire skills to assert themselves (Ewles & Simnett, 2003). HAM has two major sections; systems that contribute to behavioural intention and factors that determine the likelihood of that behavioural intention being translated into practice (Green & Tones, 2010).
Our project did not fully exercise the potential of HAM (see appendix 6) that focuses on barriers or facilitating factors such as exploring the individual/personal factors that could hinder or maintain behaviour (Green & Tones, 2010). Personal hindrance such as self regulatory, social interaction and psychomotor skills are important components to look into in order to aid behavioural change.
Evaluation 'is the process of assessing what has been achieved and how it has been achieved' (Ewles & Simnett, 2003, p.94). Naidoo & Wills (2000, p.370-371) suggested 'effectiveness and efficiency' as some of the criteria which can be used to judge the worth of a health promotion intervention. Effectiveness refers to the extent to which aims and objections are met while efficiency focuses on whether time, money and resources are well spent, given the benefit during the course of health promotion programme. Our project used MOV in the Logframe as a way of evaluation our intervention (see appendix 4); however this method is not robust enough as an evaluation tool.
Efficiency of a health promotion programme is appraised by performing economic assessments which will describe the cost of an intervention (Godfrey, 2001 In Green & Tones, 2010). The aim of this economic evaluation is to maximise what can be achieved by a given budget. Our project would have benefited from such evaluation but this was disregarded due to having enough slides for our presentation, not knowing that this is an important component of any health promotion programme.
If I were to repeat this project in the future, I will adopt quantitative (outcome evaluation) and qualitative (process evaluation) methods to evaluate my project. Qualitative methods tell us a great deal about the health promotion programme and the factors responsible for its success or failure, but they are unable to predict what would happen if the programme were to be replicated in other areas whereas the findings of quantitative research methods are representative to other areas as it expresses its result in numeric data (Naidoo & Wills, 2000). Findings of a quantitative research could be biased by researcher's perception thereby affecting the result. Quantitative methods use questionnaire while qualitative uses interviews, focus group and observation. Having been exposed to both research methods, I will be inclined to use both when evaluating my future health promotion programmes with a view to achieve a robust evaluation. In practice, questionnaires could be sent out and interviews could be conducted after a year of our interventions to Bolivia women to evaluate whether our intervention had reduced the incidence of cervical cancer.
Having gone through this project, I realised that evaluating ones health promotion programme comes with the advantage to improve practice especially if having to repeat similar project in the future and I can also help other people's practice through sharing my experience (Ewles & Simnett, 2003). I will strengthen myself in these areas by seeking feedback from trusted colleagues and asking for and getting feedback from my manager should also help to keep track of my performance. Ewles and Simnett (2003) suggested obtaining feedback from the clients is also part of assessing ones intervention. I will also bear this in mind in my future health promotion programmes.
This project considers the four widely accepted ethical principles (Beauchamp & Childress, 1995) which are autonomy, beneficence, non-maleficence and justice. This project will encourage Bolivia women to make choices based on the information provided. The right information will be passed to them and will be allowed to make their informed decisions. The project is also constructed in a way that is beneficial to Bolivia women, family and society at large. The confidentiality and respect of the people will be maintained. Lastly, the Bolivia women will be treated fairly and the resources will be shared equally among those that need support.
However, factors such as religion and culture are likely to hamper the success of this project. Bolivia men with very strong religion beliefs may not see the need to use condoms to minimise the growing rate of HPV infections. More so, Bolivia cultures encourage their men to have more than one wife. This can also be a problem in spreading HPV infections. Involving community leaders during the health promotion programmes may help to break through these barriers.
This study has attempted to critically review and evaluate a project proposal the cervical cancer in Bolivia, with raised and explored effective ways of assessing, planning and evaluating the health needs of a community.
It is recommended that a robust evaluation should form the key area in any health promotion intervention considering the benefits raised in this project.
It is hoped that this project proposal would address the rising rate of cervical cancer in Bolivia through the theories raised and explored in this study.