Palau: International Academic and Community Partnership to Increase Cervical Cancer Screening Among Minority Women in Palau

Problem

Recent lifestyle changes in the Republic of Palau have resulted in a shift away from primarily subsistence living and reliance on locally produced crops and fish, to a more Westernized lifestyle (Rosenberg, 1996) that includes more sedentary occupations and greater reliance on imported foods (Shimizu, Hirakawa, Chiang, et al., 2021). The availability of illicit substances also has increased (United Nations Office on Drugs and Crime, 2016). These lifestyle changes were accompanied by a corresponding increase in non-communicable diseases, non-communicable disease risk factors, substance abuse, and decreased mental health (Palau Hybrid Survey Final Report, 2017).

Partially in response to these developments, the Palau Ministry of Health conducted a population-based household survey from May to December 2016 that addressed non-communicable diseases and their associated risk factors, substance abuse, and mental health indicators (Palau Hybrid Survey Final Report, 2017). A total of 1,768 individuals who were 18 years or older responded to the survey. Results revealed that 42% of Palauan women were not screened for cervical cancer, as compared to 51% of non-Palauan women. (Palau Hybrid Survey Final Report, 2017).

PSE Solution

To address the disparity in cervical cancer screening rates between Palauan and Filipino women, the Ministry of Health decided to develop a small media health communications campaign to promote cervical cancer screening among Filipino women. Interim steps in this process included partnering with an organization of Filipino women; developing a survey to further understand Filipino women’s knowledge, attitudes, and behavior around cervical cancer screening; training partners to administer the survey and using the results to develop focus group questions; and develop messaging that address the knowledge, attitudes and behaviors of cervical cancer screening identified by the survey and focus group results. Campaign materials scheduled to be developed include flyers, a fact sheet, and posters addressed to the population of interest.

Actions/Results

Actions

Action items for this PSE change effort were governed by a detailed logic model (linked below). An initial step was a series of meetings, beginning in 2019, between representatives of the Ministry of Health and a representative of the Filipino Association of Palau, who also was an active member of the Belau Foreign Spouse Society (BFSS), an organization of Filipino women married to Palauan men. Additional partners were the Breast and Cervical Cancer Screening Program and community health centers (Step 1: Engage). Subsequent meetings with all members of the BFSS took place. Through a personal interview with the Ministry of Health, the BFSS representative advised that approximately 4,000 Filipino migrant workers reside in Palau, that most of them are women, and that the BFSS has more than 100 members (Ministry/BFSS Personal Interview, 2019).

To further inform the health communications campaign, the Ministry of Health developed a brief, 11-question survey (linked below) to assess the knowledge, attitudes and behavior of Filipino women regarding cervical cancer and cervical cancer screening. Ministry of Health officials trained partners from the BFSS to administer the survey. From December 2019 to February 2020, the survey was administered to Filipino women. Survey results were analyzed in March, and those results were used to develop questions for subsequent focus groups, which took place in August. The COVID-19 pandemic reduced the number of focus groups to four. Ministry of Health representatives analyzed focus group data in September and presented the results to its partners in November 2020.

Results

The Ministry of Health’s new partnership with the BFSS provided a bridge to a significant number of the Filipino women living in Palau. Insights from that partnership informed the development of the knowledge, attitudes and behavior survey that served as one of the early steps in this PSE change effort and also provided volunteers who were able to administer the survey to their peers. These incremental steps provided relevant data for use in developing key messages and small media.

Success Factors and Key Questions Addressed

What data were needed to support your position on the issue?

Data from the 2016 household survey addressing non-communicable diseases and their associated risk factors were the catalyst for this PSE change effort in revealing the disparity in cervical cancer screening rates between native Palauan and Filipino women. The knowledge, attitudes and behavior survey and subsequent focus groups also provided necessary data to support the position of the Ministry of Health.

What kind of data did you obtain (qualitative, quantitative, peer-reviewed journals, trusted sources, etc.)?

Both qualitative and quantitative data were obtained through surveys and focus groups.

What were your SMART (specific, measurable, attainable, relevant and time-bound) goals and objectives?

A future short-term objective included identifying five communication channels for dissemination of key messaging. The long-term objective was to increase the percentage of Filipino women who make appointments for cervical cancer screening, with the goal of increasing the rate of screening among Filipino women to 54% by 2022.

Next Steps

The next steps in the PSE change effort are to:

• Complete development of key messaging

• Develop small media

• Implement small media

• Evaluate the project

• Combine these efforts with an additional evidence-based intervention that will train participants to conduct one-on-one cervical cancer screening education and to recruit women for screening.

Related Resources

To learn more about this initiative, see the survey of knowledge, attitude and behavior of Filipino women in Palau and the logic model that guided the process.

References

Palau Hybrid Survey Final Report. 2017. http://www.palauhealth.org/MOHpages/MOHReports1.aspx

Rosenberg, E. 1996. The Politics of Progress in Palau. Cultural Survival Quarterly Magazine.

Shimizu, H., Hirakawa, Y., Chiang, C., Ngiralmau, B., Tellei, J. et al. (2021) Perceptions and behaviors related to noncommunicable diseases in Palau: a qualitative study. Nagoya Journal of Medical Science 83(2), 287-298. https://pubmed.ncbi.nlm.nih.gov/34239177/

United Nations Office on Drugs and Crime. 2016 Transnational Organized Crime in the Pacific: A Threat Assessment. Retrieved November 4, 2021.