CDC Comprehensive Cancer Control Program Directors Meeting May 5, 2011

1. Training on Cancer Affecting Women and Practical Solutions for Early Detectionand Information Dissemination: a peereducation and community outreachproject in Pohnpei, FSM CDC Comprehensive Cancer Control Program Directors Meeting May 5, 2011 Department of Family Medicine and Community Health John A. Burns School of Medicine, University of Hawaii

2. Funding Funding for this project was made possible by a cooperative agreement from the US Centers for Disease Control and Prevention, REACH US through Pacific Center of Excellence in the Elimination of Disparities (CEED), award number 5U58DP000976

3. Leading Partners Pohnpei Women’s Advisory Council (PWAC) – officers & members Pohnpei Comprehensive Cancer Control (CCC) Coalition – members and CCC program coordinator Resource Partners: Pohnpei Department of Health Services; Island Food Community of Pohnpei; FSM Resources & Development; FSM Department of Youth and Social Affairs

4. Acknowledgements Enerika Peterson, PWAC Selina Johnson, PWAC X-ner Luther, formerly Pohnpei CCC Program, currently FSM CCC Program Jennifer Ssaimon Dr. KesusaBermanis, Pohnpei Department of Health Services Perdihna Albert Susana Sohs Elizabeth Hadley - survivor Nancy Edward, STI Program, Pohnpei Aileen Mauricio, SAMH Program, Pohnpei Dr. Johnny Hedson, Cancer Council of Pacific Islands BernoHedson, Pohnpei Hospital Lois Englberger, Island Food Community of Pohnpei

5. Acknowledgements Technical assistance provided by former Cancer Information Service – Pacific Region staff Angelina Mummert, based at the University of Guam Cancer Center, and Hali Robinett at the University of Hawaii Cancer Center as well as Dr. Karen Heckert, former director of Pacific CEED at the Department of Family Medicine, John A. Burns School of Medicine, University of Hawaii

6. Authors and Affiliations X-ner Luther, Pohnpei State Comprehensive Cancer Control Program, Pohnpei, FSM Lisa David, Pohnpei State Comprehensive Cancer Control Program, Pohnpei, FSM Hali Robinett, MPH, Pacific CEED, University of Hawaii Cancer Center, Honolulu, HI

7. Background US Affiliated Pacific Islands (USAPI): 3 Freely Associated States (independent countries): Federated States of Micronesia (Pohnpei, Chuuk, Yap, Kosrae), Republic of Marshall Islands, Republic of Palau 3 US Pacific Territories: Guam, Commonwealth of the Northern Mariana Islands, American Samoa Cancer 2nd most common cause of death in USAPI; Cervical Cancer leading cause of cancer deaths among women in Pohnpei (14.2%, 1998-2002) Severely limited resources and access to appropriate screening services; most cancers detected at advanced stages

8. Background – geographic area • 107,000 people • 8 major indigenous languages • Limited transportation: one airline carrier; supplies ship • In free association with U.S. FSM

9. Background Sept 2008, FSM Dept of Health & Social Affairs, the 4 State Depts of Health Services and theComprehensive Cancer Control Programs (CCC)convened a technical meeting in Pohnpei with support from the Pacific Center of Excellence in the Elimination of Disparities (Pacific CEED), the University of Hawaii Cancer Center and the Secretariat for the Pacific Community to develop resource-appropriate National Breast & Cervical Cancer (B&CC) Standards for prevention, early detection, diagnosis, treatment, and care PWAC officers and members participated in 9/08 meeting

10. Background • March 2009, FSM endorsed National Standards of Practice for B&CC Prevention, Early Detection, Diagnosis, Treatment & Palliative Care: • Resource-based implementation levels: Core, Expanded & Desirable • “Core” practice standards for cervical cancer early detection: Visual Inspection with Ascetic Acid (VIA) – successfully tested & effectively applied screening method in low resource countries • “Core” practice standards for breast cancer early detection: BSE and CBE (mammography unavailable)

12. Background March 2009, 12 doctors & nurses were certified as Visual Inspection with Acetic Acid (VIA) trainers at Jhpiego’s train-the-trainers workshop in Manila, supported by CCC March 2009, school-based HPV immunization program launched in Pohnpei

13. Objectives To increase knowledge and training skills of peer educators responsible for delivering information about breast and cervical cancer risk factors, preventive and protective factors, and screening and early detection methods and services to women in remote villages of Pohnpei State. To support the implementation of the National Breast and Cervical Cancer Standards of Practice To support primary prevention, screening and early detection B&CC objectives in Pohnpei’s CCC Plan.

14. Methods Two phase project: Training of Trainers: 60 women leaders representing 19 PWAC groups Village mini-trainings: PWAC trainers conduct trainings for their groups and village women Training Core Competencies: Understand B&CC risks Methods of prevention Methods of early detection Seeking early treatments Mini-trainings implemented in coordination with VIA training for health assistants in village dispensaries

15. Methods – training of trainers February2009, two day training of trainers planned and conducted by PWAC officers and local resource experts Training content: B&CC; risk factors, screening and early detection (BSE, CBE, VIA), preventive & protective factors - healthy nutrition, regular physical activity, elimination of tobacco use, prevention of STIs Also included planning session for village mini-trainings Evaluation: pre/post tests, self-efficacy questionnaire, course evaluation, verbal feedback Resource experts and partners: FSM National Dept. of Resources and Development, Pohnpei State Dept. of Health Services, Pohnpei State Office of Youth and Social Affairs, Island Community Food of Pohnpei

16. Methods – training of trainers

17. Methods – village mini-trainings August 2009 - January 2010 Conducted by 19 PWAC groups at 57 sites Groups coordinated trainings; secured venues, speakers and buy-in from traditional leaders, school principals and other influential members of the community Also planned and contributed to media roll out: billboard and radio PSAs and promotion of village trainings Materials included posters and flyers Evaluation: Activity reports for each training site

18. Methods – village mini-trainings

19. Methods – health assistants training VIA Breast and Cervical Cancer Screening August 31 – September 04, 2009 22 participants: 18 health assistants (67%); 4 nurse practitioners 9 dispensaries: 5 in outer islands & 4 on main island CHC & PHC Training conducted by Dr. Dr. Kesusa Bermanis

20. Results Training of trainers: 60 PWAC officers and members trained 15% increase in knowledge: 83% pre-test, 98% post-test 86% felt this statement was directly related/related: The training materials provided were helpful & will aid in my presentations.’ 67% felt this statement was directly related/related: ‘I think I am able to conduct the mini-trainings’ Mini-trainings: 60 trainers conducted training and community awareness in 58 villages to motivate women to seek CBE and VIA VIA training for health assistants: 22 Health Assistants trained (18 HA + 4 practical nurses)

21. Results 4/16/09-9/10 VIA’s : 8 3 – (+) cervical cancer 1 – poss. Endometrial cancer 4 – S/P TAH – breast cancer screening 22 – repeat VIA’s ; failed to RTC TOTAL Eligible women – 8,400 (3/4th in main island & 1/4th in outer islands)

22. Conclusions The project brought a community-based NGO (PWAC) together with the Pohnpei CCC and other key partners to provide B&CC awareness and education to village women Improved, and continues to improve, cervical and breast cancer screening skills and services provided by Pohnpei’s Health Assistants Introduced VIA and contributed to the increase in cervical cancer screening Strengthened the capacity of Pohnpei Women’s Advisory Council PWAC has the infrastructure and expertise to support future health promotion & disease prevention initiatives

23. Kalangan www.pacificcancer.org Pacificceed.gmail.com