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CUBAN MEDICAL RESEARCH

Education’s Role in the Prevention of Breast Cancer in Cuba
Teresa de la C. Romero Pérez, MD

Dr. Brundtland goes on to say that the epidemic of non-communicable diseases is spreading quickly and already is responsible for about 60% of world mortality. This provides a particular and alarming idea of the current causes of morbidity and mortality, as well as of their underlying factors.

This is evident in the relationship between changing lifestyles in numerous societies around the world and the effect this change is having on the health of individuals, families, communities and entire populations.(1). She points out that in the end, most people will choose to adopt healthier ways of living, especially if they receive reliable information from authorities they trust, backed by realistic legislation, good health promotion programs and vigorous public debate (1).

Important topics were discussed in the World Health Assembly in Geneva in May, 2002. The world’s general health panorama was described, making it possible to make valuable assessments of health risks that nations consider the most important in today’s world—labelling these risks as “enemies of health and allies of poverty”: (extreme shortages, unsafe water, deficient hygiene, risky sexual practice, among others), as well as risks related to wealthier societies, such as high blood pressure and hypercholesterolemia (1).

Participants in the Rome World Food Summit (June, 2002) debated whether economic development and globalization need produce negative consequences for health, or whether, to the contrary, they could be taken advantage of to attenuate inequity.

The importance of health is undeniable. Nobel Prize laureate Amartya Sen argues that health (like education) is among the basic capabilities that give value to human life, “freedom to participate in political life or the opportunity to receive basic education or health care are constituent components of development” (2).

From this vantage point, investing in health is not just a social investment, but rather an indispensable investment for economic progress. In such terms, health and education are two keystones of human capital, which is the basis for economic productivity (as demonstrated by Nobel Prize winners Theodore Shultz and Gary Becker).

The statements made by the Cuban Ministry of Public Health in relation to the policies outlined by the World Health Organization and the Pan American Health Organization, were included in the Memoirs of the 8th International Seminar on Primary Health Care “Lessons from the 20 th Century and Challenges for the 21 st Century”. Urgent recommendations are made to consider necessary actions and to choose the most suitable and economically feasible ones to reduce risks and promote a healthy life for the population. Great importance is attached to clear and open communication of the risks to the general public, and to creating an atmosphere of trust and shared responsibility between health care professionals, the community and the media (3).

In Cuba, municipal development and decentralization of health promotion, risk control and health prevention actions take on greater importance, as does work in and with groups—that is, the organization and functioning of truly multidisciplinary and inter-sectorial teams to tackle health problems in an integrated way (local intelligences). Mastering methods and techniques (3) to work with healthy, sick and more vulnerable groups is also crucial, using personalized action plans to achieve lifestyle changes, (for instance, using models to achieve lifestyle change in stages, or through counseling (4) and “face-to-face” education), keeping the public informed and carrying out efficient health education (4).

The almost complete extension of the Family Doctor Program throughout the country, in addition to improvements in the populations’ health (despite economic problems), has greatly enhanced health promotion and disease prevention in Cuba. One important factor has been the generation of space for deliberation and social exchange as a result of the development and institutionalization of local, provincial and national government bodies of People’s Power. Health administration is subordinated to elected assemblies, at the municipal, provincial and national levels; and the municipal health director is one of the vice-presidents of the municipal assembly (5).

The Cuban experience, based on the most recent and broadest conceptualization of health, attaches great importance to the contribution health makes to the life of individuals and entire communities, as well as to its integration with social development, looking beyond the loss of individual capacities caused by disease, to underscore the direct relationship between health and the population’s quality of life, incorporating a gender approach into its policies and programs (6).

The fact that non-communicable diseases are foreseen as the new pandemics of the 21 st Century, and that many of their risk factors are conditioned by modes of individual behavior (lack of physical activity, unhealthy nourishment, smoking, etc.), led the Pan American Health Organization to develop the CARMEN network in 1996 (CARMEN: Spanish acronym for the set of actions for multi-factor reduction of non-communicable diseases). The aim of the project is to implement effective methods to for disease prevention and control. Cuba has been a member of this network, and the municipality of Cienfuegos was selected as its demonstration area (7). The Cuban experience in the control of chronic diseases was also extended, as a result of decentralization and technical cooperation provided by PAHO/WHO, to 53 of the country’s 169 municipalities, included in the “Healthy Municipalities Movement”. Five focal points for this cooperation have been established in medical schools, which has benefited the health system’s technical development and installed capacities. Priority has been given to training of human resources in each locale. (5).

In 1996, the Association of Ibero-American Leagues against Cancer (ALICC), proposed that Cuba and 17 other countries join the “Latin America Against Cancer” Program, financed by the European Union through the Spanish Association Against Cancer, aimed at helping reduce incidence and mortality rates through information, education and social communication. Coordinating Committees were formed at the national, provincial, and municipal levels, going beyond multidisciplinary to become truly inter-sectorial teams (8).

In 1998, at the initiative of the Canadian Embassy in Havana--in coordination with the Ministry of Foreign Relations, the Ministry of Public Heath, and the National Institute for Sports, Physical Education and Recreation (INDER ) (Marabana)—the first ”Terry Fox Hope Marathons” began in Havana. By 2003, these had been extended to the whole country, with the purpose of involving the whole population in the struggle against cancer, promoting healthy lifestyles, and raising funds to help finance three basic studies carried out by the National Oncology and Radiology Institute (9).

The National Program for Cancer Education was designed based on the accumulated experience with this international collaboration, the results from a number of research projects on the subject, the National Cancer Control Program, and the Control Programs for Breast, Cervical and Mouth Cancer, as well as collaboration with the National Health Promotion and Education Center, the Cuban Women’s Federation, the Committees for the Defence of the Revolution and the Ministry of Education, among others. Gradual implementation of this program started in 1999, and it is now being implemented in practically every province and municipality of the country (10).

The National Cancer Education Program:

Its Role in Breast Cancer Education and Prevention

Despite an increase in breast cancer incidence, some developed countries have managed to keep mortality rates stable or reduce them. This has been possible through screening programs aimed at early diagnosis and proper treatment (11). Actions aimed at early diagnosis of breast cancer (based mainly on three procedures planned and offered by health institutions: self-examination, clinical examination by the family doctor, and mammography) cannot render optimum results without women’s active participation and the support of their families and the community.

Countless studies (12) suggest that women’s knowledge of breast cancer may positively influence secondary prevention and the degree to which they seek medical attention upon recognizing the signs and symptoms.(13).

The proposal by the National Cancer Education Program (NCEP) for breast cancer control, framed in the context of a gender approach, adopts the Competence Model as its theoretical framework. This model attempts to socialize knowledge so that the population becomes involved and actively participates in the social production of health, risk factor control, early diagnosis and opportune treatment, reducing the time between symptom detection and the seeking of medical attention.

With this objective in mind, an Information, Education and Communication Strategy (IECS) has been designed for the Breast Cancer Control Program, aimed at determining what and who to inform, how to educate, and how to reinforce these messages through social communication.

The goals of the IECS are to increase the efficacy of the objectives of the National Breast Cancer Control Program, by encouraging women’s effective participation in self-examinations; and visits to their family doctor, at least once a year, for a clinical examination or mammogram. The goal is to contribute to a reduction in incidence and mortality, as well as to achieve closer adherence to treatment and rehabilitation instructions, thus improving the quality of life for women.

The interdisciplinary and multi-sectorial teams are expected to carry out the following main actions:

• Inform the population of risk factors, warning signs, and the actions of the

National Breast Cancer Control Program.

• Educate the population about healthy lifestyles related to breast cancer prevention.
• Reinforce information and education actions through social communication.
• Achieve active and conscious participation by the population and personnel of the

National Health System in the implementation of this program.

• Systematically train personnel throughout the health system and community promoters concerning topics related to health promotion and breast cancer prevention.
• Involve decision-makers and volunteers in breast cancer control.
•  Achieve effective participation at all levels of the health care system.
•  Participate in research on breast cancer.

Target audiences have been divided into Primary and Secondary Audiences for the purpose of educational work. The Primary Audience is composed by the following strata:

The Selected Secondary Audience is composed of professionals and technical personnel of the National Health System and the Ministry of Education, the National Boards of both these institutions, governing bodies at different levels, informal leaders and volunteers, mainly from the Cuban Women’s Federation. The contents communicated are the following:

The Information, Education and Communication Strategy, as part of the health promotion and cancer prevention activity, is implemented in every family doctor office, with flexibility and in accordance with the knowledge, attitudes and practices of people in each community.

This strategy is also developed at other levels of attention, including those secondary and tertiary centers where education is needed to ensure early diagnosis in families with a history of breast cancer, or to contribute to timely treatment and patient rehabilitation.

The messages that should be given priority are: risk factors, including a family history of breast cancer (mother, sisters, aunts) early menarche and late menopause, first child after 30, women with no children, stress, radiation, fatty diet, and smoking. Reference should also be made to the services offered by the National Breast Cancer Control Program (self- examination, clinical examination and mammogram), and to the need for therapeutic adherence and biological, psychological and social rehabilitation of patients who have been diagnosed and treated.

Various messages and materials have been prepared for use in training health care providers, leaders and volunteers, to be used as essential sources of information throughout the country. These materials include educational handouts distributed by the Latin American Cancer Program; the three volumes of the Program’s National Seminars; the Program Guide for Health Promotion and Education prepared by the Ministry of Education (one in every school in the country), and the sections dedicated to cancer education in Mujeres magazine.

In addition, several television programs have been broadcast on this topic, mainly on the Let’s Talk about Health show.

The commissions of the National Breast Cancer Control Program at each level (national, provincial, and municipal) train and coordinate educational activities, forming multidisciplinary and inter-sectorial teams (Cuban Women’s Federation, Committees for the Defense of the Revolution, and others) that will implement and advise, thus becoming active promoters at each level.

These teams, headed by the person in charge of the Breast Cancer Control Program (technical leader), will coordinate with the media to promote educational messages. They will oversee implementation of all educational activities, and assess the development and impact of the Information, Education and Communication Strategy, ensuring that the resulting recommendations are introduced.

The health team—working at the level of family doctors and community polyclinics (and including Basic Work Group professors) identifies the community’s learning needs by means of:

• Assessing the Health Situation
• Conducting knowledge, attitudinal and practice surveys
• Creating self-help groups
• Using nominal group techniques

At the same time, the Health Group determines the felt needs of the women in the Program, through group sessions by using experiential techniques and such procedures as brainstorming, the problem tree and others. The Group explores the users’ level of satisfaction, achieves adequate communication to promote health, prevent disease and contribute to rehabilitation. They permanently observe health events associated with breast cancer and other modifications of living conditions and styles, and based on the attained results, they will adjust the contents of the training courses for health promoters and will propose tasks for the next period’s workplan.

The following steps have been defined as a practical guide for designing educational messages:  

1.   Clearly define the kind of health behavior we want to promote.

2.   Select the population group we seek to influence .

3.   Understand and respect the beliefs of the group, to be able to reinforce the ones most helpful and modify the ones most harmful to health.

4.   Find out how much they know and their attitude towards the new conduct we want to promote.

5.   Check the sources of information the target group uses.

6.   Select ideal channels and means of communication to reach the population.

7.   Learn to work in and with groups.

8.   Elaborate messages which are easy to understand, brief, direct, relevant, culturally and socially acceptable, technically correct and positive.

9.   Evaluate the efficacy of the educational and promotional material that was prepared.

10.   Select the methods, procedures and techniques required to produce lifestyle changes.

11.   Synchronize educational action with other social development actions, whenever possible.

12.   Repeat the educational messages frequently, constantly and intensively.

13.   Assess the adoption and permanence of behavior changes.

14.   Adapt the program periodically, as results are evaluated.

With these tools, each level of attention in the Cuban National Health System plans, executes and oversees activities to promote healthy lifestyles for the prevention of breast cancer, trying to fulfill that dreamed-of goal of involving communities and especially women in the struggle against one of their most deadly diseases. This remains a great challenge, and a problem that has been only partially addressed.

References:

(1) OMS. Informe sobre la Salud en el Mundo. Reducir los riesgos y promover una vida sana. Mensaje de la Directora General Dra. Gro Harlem Brundtland. Ginebra. Octubre de 2002.

(2) Sen, A. 1999. Development as Freedom. Nueva York: Alfred A. Knopf.

(3) MINSAP y colab. Memorias del VIII Seminario Internacional de Atención Primaria de la Salud.”Lecciones del Siglo XX; Desafíos del Siglo XXI”.17 al 21 de Junio, 2002. CD.

(4) Pilar Arranz, José Javier Barbero, Pilar Barreto y Ramón Bayés. Intervención emocional en cuidados paliativos. Modelo y protocolos. Ariel Ciencias Médicas.2003; pág. 33-48.

(5) P. Yépez, G. Montalvo, J. Molina. Seminario Internacional sobre Desarrollo Municipal y la Cooperación Técnica Descentralizada. Edición Especial por el Centenario de la OPS. Representación de la OPS/OMS en Cuba.2002. Pág. 5-10.

(6) OPS. Incorporación del enfoque de género en la salud. Nuevos rumbos para la salud en las Américas. Informe Cuadrienal del Director. Edición del Centenario. Documento Oficial No. 306. Pág. 43-45.2002.

(7) OMS. Salud 21. El marco político de salud para todos en la Región Europea de la OMS. 2000.

(8) ALICC/AECC. Programa Latinoamérica Contra el Cáncer. Vademecum. 1997.

(9) T. Romero, R Camacho. El Maratón de la Esperanza Terry Fox. Plegable editado para la edición del 2003. La Habana. Cuba.

(10) T. Romero, J. Grau, R Camacho, M. Chacón y colab. Evaluación de la Eficacia de una estrategia basada en métodos educativos para desarrollar conductas promotoras y preventivas en la lucha contra el cáncer en Cuba. Mención Forum Nacional de Ciencia y Técnica. CD Memorias del Evento. 2003.

(11) OMS. Programa Nacional de Lucha Contra el Cáncer. Directrices sobre política y gestión. 1995.

(12)  T. Romero y colab. Actualidad y proyecciones del Departamento de Control del Cáncer Rev. Cubana de Oncología 1996; 12 (2):126-130.

(13) T. Romero y colab. Programa Nacional de Educación en Cáncer. MINSAP. 1999-2003.

Second Degree Specialist in Epidemiology. Associate Researcher. Full Professor. Chair, Technical Commission, National Cancer Education Program