a critical review of australian cancer organizations’ public education material

COMMUNITY H E U T H STUDIES VOLUME XN, NUMBER 2 , I M

A CRITICAL REVIEW OF AUSTRALIAN CANCER ORGANIZATIONS' PUBLIC EDUCATION MATERIAL

Gloria Webb*, Rosemary Jurisicht. Rob Sanson-Fisher?

* f

New South Wales Cancer Council New South Walcs Cancer Council Education Research Project, Discipline of Behaviowal Science. Facdly of Medicine, University @Newcastle

Abstract Because of the potential benefits of primary

prevention and early detection of cancer, a considerable proportion of the efforts of State cancer organizations has been directed towards public educational programs. The study aimed to determine the level of agreement in the messages contained in the written educational material of the State and Territory cancer organizations in Australia. Pamphlets and brochures dealing with primary and secondary prevention of breast, cervical, skin and bowel cancers were obtained. The materials were compared on a number of dimensions: the characteristics of people who are at increased risk of contracting the cancer. how to avoid the cancer through primary prevention, how and when to screen in the case of secondary prevention, and action to be taken if a sign or symptom indicative of cancer is discovered. The study found a lack of agreement in the messages of the State cancer organizations. Some hypotheses are suggested to explain the discrepancies. In addition, some suggestions for remedying this situation are provided.

Introductlon After heart disease, cancer is the second most

common cause of death for all age groups in Australia, accounting for approximately 25 per cent of male deaths and 23 per cent of female deaths. Between the ages of 45 and 64 years, cancer is the leading cause of death, being responsible for 39 per cent of deaths.'

It is argued that approximately 80 per cent of deaths due to cancer are potentially preventable, given that they result from modifiable environmental factors, such as exposure to cigarette smoke, sunlight, industrial carcinogens, diet and alcohol excess.' Some cancers such as

smoking-related cancers are amenable to primary prevention, through measures such as persuading children not to take up cigarette smoking and the enforcement of smoke-free arcas in public places, including public transport services and the workplace. In the area of skin cancer, primary prevention can occur by encouraging the use of sunscreens and hats and avoidance of sun exposure during the period of the day when ultra- violet radiation is most intense, and by protecting babies and young children from early severe exposure to sunlight.'

Secondary prevention of cancer is effected by screening at-risk populations to ensure early detection and treatment of curable cancers. Cancers which meet the criteria for selection for preventive efforts include those which have serious effects in terms of mortality and morbidity and a high prevalence among the population screened, and where M effective treatment exists if the cancer is detected early. There also needs to be in existence a screening device that is simple, inexpensive and acceptable to the target population. and has high sensitivity and specificity.' Cervical, breast and skin cancers appear to fulfil these criteria. Bowel cancer meets the first two of these criteria. However, the evidence about effectiveness of treatment for bowel cancer following early detection i s equivocal, and there is no adequate, cost-effective screening measure.

As a consequence of the potential benefits of primary and secondary prevention of cancer, a considerable proportion of cancer organizations' efforts has been directed towards educational programs in these areas. While a wide variety of media, such as film, video tapes, radio and television advertising and posters, is used to convey cancer prevention messages to the

The views expressed is this paper do not necurarily reflect those of the New South Wder Cmar Council.

WEBB et al. 171 COMMUNITY HEALTH STUDIES

community, the use of written materials continues to be one of the most commonly employed strategies. In particular, distribution of pamphlets and fact sheets through various agencies such as doctors' surgeries, health clinics and pharmacies is an important part of educational efforts in each State.

Ideally, there should be consistency across the States, in terms of the content of educational material; in key areas such as the group or groups of people most at risk of a particular cancer; action to be taken regarding primary or secondary prevention; and, in the case of the latter, recommended screening intervals. In addition. it would be expected that the content of the pamphlets and fact sheets would enhance effective health education. These materials should provide the information that is required for people to change their behaviour if they wish. For example, members of the community need to be told which groups are at risk, so that they can decide about their own risk status, how to look for early signs of cancer, where and how quickly to present for screening if required, and what to do if signs or symptoms indicative of cancer are discovered.

The present system of autonomous State cancer organizations loosely joined to a central body, the Australian Cancer Society, has caused difficulty in terms of providing agreement in educational messages across the States. An attempt to overcome this problem was made as a result of a grant to the Australian Cancer Society by the Federal Department of Health, to enable the Society to conduct a series of workshops in order to work out a National Cancer Control Policy. This Policy was agreed by the individual State organizations and approved by the Federal Minister of Health in April, 1988. Another example of co-operation among the States is National Skin Cancer Awareness Week, a campaign that is held each summer throughout Australia, with agreed targets and pooling of resources.'

The aims of this review were twofold. The Fist was to examine the extent of agreement among the State cancer organizations in Australia with regard to the content of pubIic education written material in the areas of primary and secondary prevention of cervical, breast, skin and bowel cancer. The second aim was to dctermine whether the public education written material provided by each State cancer organization contains the information necessary for informed decision- making on the part of members of the public, with regard to primary and secondary prevention of the cancers listed previously. This paper does not

address the issue of the validity of the educational messages, but is concerned only with assessing the degree of consistency or reliability of the messages.

Method Copies of the educational pamphlets and fact

sheets designed for use by the general public in the areas of cervical, breast. skin and bowel cancer were obtained from the cancer organizations in each State. Material that was both current and designed for use by the general public was requested. Since the written education material used by each State is updated from time to time, it was decided that any material revised after 1st November, 1988 would not be included in the analysis. The search uncovered 31 pamphlets, fact sheets and leaflets on primary and secondary prevention of cancer, that is. five publications on bowel cancer, twelve on breast cancer, eight on cervical cancer and six on skin cancer. In addition, the policy guidelines of the Australian Cancer Society were included for comparison purposes.' In the case of breast cancer, the policy guidelines for the Australian Cancer Society are outlined in the paper by Fleming.'

The material was coded under a number of broad headings, including the characteristics of people who are at risk of the cancer; how to avoid the cancer through primary prevention; advice regarding how and when to screen, in the case of secondary prevention; and action to be taken in the event of discovering a sign or symptom indicative of cancer. After the initial coding was completed, the material was recoded independently by another of the authors, in order to check inter-rater reliability. Initial agreement between the coders occurred in 94.9 per cent of the categories. Where disagreement occurred with regard to categorization, the two coders conferred and reached agreement.

Results

Breast Cancer Regarding symptoms of breast cancer, all

States agreed about the importance of a lump or thickening in the breast. For Western Australia, this was the only symptom mentioned. All other States agreed that nipple changes, dimpling or puckering of the skin of the breast and changes in the size or shape of the breast were symptomatic of breast cancer. All States except Western Australia and the Australian Capital Territory listed nipple discharge as a symptom. There was considerable disagreement about the remaining


Flpre 1: Breast cancer symptoms listed In public education materials of AustralIan State Cancer Coundb.

SYMPTOM NSW VIC' QLD WA TAS ACT

Lumplthickening

Nipple discharge

Skin dimpling1 puckering

Nipple changes

Change in breast size. shape

New or sudden chanpe

Pain m-1 Rash

Itching of nipples I

'VIC is used by NT. SA. ACT

Figure 2: Breast cancer risk factors listed In pubk educatlon materials of AustraUan State Cancer Ceunclls.

RISK FACTORS Aw

Family History

High tat diet

Obesity

E W menarche

Nulliprrity

Late first birth

Ebnign breast disease

n Previous breast 1 HlghSES 3 1 cancer


symptoms. Only three States listed a new or sudden change as indicative of breast cancer. only two States listed a rash, two States listed pain and one State listed itching of the nipples (Figure 1).

With regard to risk factors for breast CIIIICCT, there was little agreement. The only risk factor that was listed by all States was family history of breast cancer. All States, with the exception of Western Australia, listed increasing age as a risk factor. While Queensland stated that the age above which breast cancer risk increased is 45 years, the other States did not indicate a specific age. All States except New South Wales listed previous breast cancer as a risk factor. Early menarche was not listed by any of the States as a risk factor, although the guidelines of the Australian Cancer Society indicate that it does increase risk. Then was little agreement among the remainder of the States in regard to a high-fat diet, obesity, nullipmity, late f i t birth and benign breast disease, although all of these were included in the Australian Cancer Society guidelines as constituting risk factors for breast cancer. The educational material of Victoria showed the closest agreement with the Australian Cancer Society guidelines. No State listed higher socioeconomic status as a risk factor for breast cancer, although the Australian Cancer Society did (Figure 2).

All m e n .

There was little agreement among the States regarding screening recommendations in the case of breast cancer. All cancer organizations recommended breast self-examination (BSE). However, while Queensland. Western Australia and Tasmania recommended monthly BSE for all women, New South Wales and Victoria recommended BSE for women 25 years and over. In the Australian Capital Territory, occasional, rather than monthly BSE was recommended for women under 35 years. While New South Wales, Victoria. Queensland and Western Australia recommended regular breast examination by a doctor, there was no clear agreement regarding the intervals. New South Wales and Queensland recommended annual examinations. while Victoria recommended annual examinations for women 35 years or over, at the discretion of the doctor to increase or decrease the frequency. Western Australia recommended medical examination only where the women did not perform BSE. Tasmania and the Australian Capital Territory did not recommend clinical or provider breast examinations. In the case of mammograms. there was no agreement about content of the messages of the States that mentioned the need for mammograms. Queensland and the Australian Capital Territory did not mention mammograms at all. The Australian Cancer Society stated that guidelines

AH women.

Figure 3: Breast cancer screening recammendations listed In public education materials of Australian State Cancer Counctla

N41v VIC' aD WA TAS ACT ACS

At lout annually.

Mediul examination

mimmogram.

WEBB et al.

F a women 2%

AnnuOlly lor wmen 35,

Doctor may say mar of bu.

isaanuu 40-50 mamma. g r m may be of benalit. 50+ - mammc- gram. Inlefvel 1-2 y

Jii@ r i g Discuss with doctor

Especially (of I increased nsk

174

AH women

In the taler years.

espclcially

Doclor may r.commend an annual mammogram.

und.r 35 occasional BSE

BSE mmvily when wer 25

I1 BSE w competenl and regular. then 3 yrly medicnl breast exam up to age 40 uh = annual Optimal use 01 mammography , especralty 11s

frequency, still 10 be determined w r& 40+ = annual. or a1 10 yrs pmr tc age at which relative lirst developed breast cancer

ACS is based on MJA Suppbmenl Vol 143. Swl 16. 1985.

COMMUNlTY HEALTH STUDIES

for optimal use of mammography have not yet been determined. However. the Society recommends annual mammography for high-risk women from the age of 40 years, or ten years earlier than the age at which a relative developed breast cancer (Figure 3).

Cervical Cancer Unusual vaginal bleeding was listed as a

symptom of cervical cancer by New South Wales, Victoria and Western Australia, but not by Queensland and South Australia. Increased vaginal discharge, possibly brown or blood- stained was listed by New South Wales, but not by the other States. New South Wales, Victoria and Western Australia noted the lack of symptoms in the pre-cancerous stage. Queensland and South Australia did not indicate any symptoms of cervical cancer.

There was considerable disagreement among the States in regard to risk factors for cervical cancer. Where a specific age was given, there was no agreement. The Australian Cancer Society guidelines indicate that women are at risk of cervical cancer if they have ever had sexual intercourse, commenced sexual intercourse at an early age or have had multiple sexual partners. These factors were listed only by Victoria. Western Australia listed sexual activity and multiple sexual partners as indicating increased risk of cervical cancer. Victoria and Western Australia both mentioned having a partner with multiple sexual partners or genital viral infections as indicating increased risk. In addition, Victoria listed the use of immuno-suppressive drugs, smoking and having a mother who had taken diethylstilboestrol during pregnancy as increasing the risk of cervical cancer.

Disagreement also occurred with regard to recommendations about who should be screened with the Pap test. New South Wales and Victoria stated simply that all women should have Pap tests. However, Queensland qualified this statement by indicating that all women over 18 years and all women who have had sexual intercourse at least once should be screened. South Australia recommended that all women who have had sexual intercourse should be screened. There was also considerable disagreement as to when Pap testing should commence. Recommendations ranged from as soon as possible after commencing sexual activity, to within three years after commencing sexual activity. Recommended intervals between Pap tests also showed considerable variation. Queensland and New South Wales recommended yearly intervals and Victoria three-yearly

intervals, while South Australia and Western Australia recommended different intervals for different groups of women. The Australian Cancer Society did not recommend an interval, noting only the lack of consensus among the States. Only Western Australia and the Australian Cancer Society indicated an upper age limit when women can stop having Pap tests. Only New South Wales and Queensland indicated that women who had undergone hysterectomy should check with their doctors to see whether they should have Pap tests. None of the States showed agreement with the Australian Cancer Society with regard to screening recommendations, with the exception that South Australia was in agreement about the target group for screening. that is. all women who had ever had sexual intercourse.

Skin Cancer In the case of skin cancer, the States showed a

reasonable level of agreement regarding symptoms. Some discrepancies occurred in that South Australia included freckles when discussing changes to moles while New South Wales included unusual freckles. Victoria and Western Australia did not mention moles that bleed or itch while Queensland, South Australia and Western Australia did not mention as a symptom a mole that is new. Only Queensland listed as a symptom a mole that became scaly or raised.

There was less agreement among the States in regard to the risk factors for skin cancer. While all States listed skin type and sun exposure as risk factors, only Victoria referred to ethnic origin, sun spots. and previous skin cancer as factors indicating increased risk. Only New South Wales and Victoria mentioned the importance of family history of skin cancer.

With regard to screening recommendations for skin cancer, all States advised people to consult a doctor in the case of an unusual skin condition. None of the pamphlets indicated how quickly to visit a doctor if changes occur. While New South Wales and Western Australia failed to indicate a need for self-checking of spots, moles and freckles, South Australia advised people to have a friend or spouse check their backs and other body areas that are difficult to see.

Bowel Cancer There was disagreement among the States

regarding bowel cancer symptoms listed in educational materials. All States noted that common symptoms are bleeding from the bowel. changes in bowel habits and abdominal pain. There was little agreement about the importance of symptoms such as presence of mucus,


weakness and malaise, unexplained weight loss and a sensation of incomplete emptying after a bowel motion.

In regard to risk factors, with the exception of Western Australia. there was reasonable agreement among the States regarding the importance of previous bowel cancer, age, family history of bowel cancer, polyps in the colon, familial polyposis and a high fatilow fibre diet. While New South Wales, Victoria and Queensland listed ulcerative colitis as a risk factor. there was disagreement about the duration of the condition that indicated increased risk.

There was little concordance among the States with regard to screening recommendations for bowel cancer. When the advice provided by the States was compared with the guidelines of the Australian Cancer Society, again there was little agreement. The greatest areas of disagreement related to adenomatous polyps, previous colorectal cancer or adenomas. familial polyposis and the presence of bowel cancer in first degree relatives. Only New South Wales and Western Australia recommended digital rectal examinations for people aged 40 years or more. Victoria agreed with the Australian Cancer Society recommendations that mass screening is not usually recommended. New South Wales and Victoria concurred that a doctor should be consulted if blood is seen in the stool. Queensland stated that blood in the stool should not be ignored, but did not indicate that a doctor should be seen. Western Australia did not provide any advice about self-screening.

Dlscussion It is clear from the comparisons presented that

there is considerable variation in the advice and information offered to the public in Australia through educational pamphlets and fact sheets of the different cancer organizations. Such variation is less than desirable, since i t can lead to confusion in the minds of members of the public about the appropriate action to be taken, in terms of primary prevention and early detection of cancer. This problem is especially acute when people are exposed to differing messages from two or more different cancer organizations. This can occur, for example, when people move from one State to another, or where cancer organizations in one State or territory use pamphlets and/or fact sheets that are prepared in two or more different States. An example of the latter case is where the Australian Capital Territory and the Northern Territory cancer organizations use material from more than one State.

As Egger notes in the context of media campaigns, there is no place in health promotion for the proliferation of diverse and conflicting messages.' The lack of agreement in the messages provided by the various cancer organizations may diminish the credibility of the organizations in the eyes of the general public. If conflicting messages are received, it is difficult for people to decide which of the messages to follow, and possible that they will disregard all of the messages. If the educational message is not credible, it is not likely to be followed.

However, omission of risk factors may be appropriate, if there is nothing that an individual can do in response to that piece of information. For example. it may be appropriate for information about the relationship between high socioeconomic status and breast cancer not to be included in public educational material, because socioeconomic status is not amenable to change. On the other hand, such infomation may provide an extra prompt for women in this socioeconomic group to practise breast self-examination or have mammograms.

A number of hypotheses can be put forward to explain the existence of discrepancies in educational messages about cancer. First. educational pamphlets and fact sheets are revised and updated periodically by the cancer organizations. Consequently. it could be argued that there is consistency in the policies of the different cancer organizations. but these are not reflected in the speed with which revision of educational material occurs. While this suggestion may be true, the explanation appears insufficient to account for all the observed variation. Furthermore, it can be expected that cancer organizations will seek diligently to ensure that information provided is in line with research findings.

A second hypothesis is that the publications may have been prepared for different audiences. For example, fact sheets may contain a greater amount of information than is contained in brief pamphlets which are for wide use by members of the public. Nonetheless. it may be desirable for the total amount of information provided by each State to be comparable.

A third hypothesis is that the research evidence is not clear enough in some areas for experts to make adequate judgements about the issues. thus producing the observed inconsistencies. For example, in the area of bowel cancer, it appears that there is debate about whether examination of faeces for blood and subsequent consultation with a medical practitioner makes a significant impact on increasing the length or quality of life.'@


Consequently, educational messages that promote the necessity for this form of early detection of bowel cancer may simply reflect a belief that early detection is a good idea. a belief which has no basis in research evidence. If this is the case, the value of, and ethical issues involved in. attempting to change behaviour which does not have a demonstrable benefit for the intended target group must be questioned.

A fourth hypothesis to explain discrepancies among States is that +ere is a lack of agreement among different S tate-based professional advisory groups about how they interpret the same research data regarding primary and secondary prevention of cancer. If this is the case, it is a matter for concern, since such advisory groups presumably utilise the same criteria regarding what constitutes adequate evidence for primary and secondary prevention. A variant of this hypothesis is that the advisory groups do not have access to the same research evidence. However, this notion has a fairly low probability, given that experts are expected to familiarise themselves with the latest developments in their field, and that members of cancer organizations have strong interests in remaining up to date with fresh evidence in the areas of primary and secondary prevention of cancer.

While this paper focuses on the issue of reliability among cancer organizations' public health messages, the demonstrated lack of consensus may raise doubts about the validity or accuracy of messages conveyed to the public. While reliability does not ensure that any advice is correct, a lack of agreement may cast doubt on the accuracy of the information. In turn. this raises questions about the ethics of public intervention in areas where the cost benefits associated with chmge are not well established. The issues of consistency and credibility have been acknowledged by the State cancer organizations, as evidenced by their agreement to contribute financially to and be involved in an active way with. the Australian Cancer Society. The Australian Cancer Society has also taken steps to address these issues, through the implementation of the Patient Affairs Committee and the Public Affairs Committee. It is anticipated that the outcome of these initiatives will be greater consistency in educational messages among the States.

The second aim of the paper was to determine whether the educational material provided sufficient information to allow people to make informed and intelligent decisions about their behaviours in regard to primary prevention and

early detection of cancer. For example, in the case of early detection, in order for behaviour change to occur, people have to be provided with clear, succinct messages about the signs and symptoms to look for, what they should do if they have a sign or symptom of cancer and how soon they should take action. It would appear from the material examined that few pamphlets and fact sheets provide clear directions for action. For example one pamphlet on bowel cancer advises that blood in the stool should not be ignored, but gives no specific advice about action, not even suggesting to the reader that they visit a doctor if this occurs. In the case of skin cancer only one State indicates that self- checking of skin on a regular basis is necessary. Another State suggests having a spouse or friend check one's back and other areas of the body that are difficult to see. However, the nece+ty for self-checking is not mentioned. UniGss the educational material presented to the public is concrete and specific, with clear guidelines about when, how and what to do in the case of a sign or symptom of cancer, the instructions are not likely to be followed.

Some general comments arise from the experience of reading the pamphlets to check content. The f i s t is that important information is often embedded within an inappropriate part of the pamphlet. For example, in one of the bowel cancer pamphlets information about the necessity for screening siblings and children of patients with familial polyposis is contained in the section on definitions. A second general problem is that since information about a particular cancer may not be contained in one pamphlet, it may be necessary to read a series of pamphlets to obtain all the information that is needed for informed decision making.

How can the problem of inconsistencies in cancer educational material be overcome? All State and Territory cancer organizations are affiliated with the Australian Cancer Society. It would appear logical. then, that the Australian Cancer Society provide appropriate guidelines to be followed by individual cancer organizations. These guidelines should be based on experimental data rather than clinical opinion. In addition, there needs to be a mechanism built into the system to allow for the reaching of agreement among the different cancer organizations. While the achievement of nationwide consensus may be difficult, ways must be found of achieving consistency. Otherwise, current discrepancies in advice across States regarding the primary and secondary prevention of cancer will continue and perhaps increase.

WEBB et al. 177 COMMUNlTY HEALTH STUDIES

Conclusion A review of the educational material of the

different State and Territory cancer organizations has revealed quite wide variation in the messages provided to the public. These discrepancies are unfortunate, because of the possibility of lack of credibility of the messages, and possible confusion for those who move from one State to another, or who live in an area where educational material from more than one State is provided. A number of possible reasons have been put forward to explain these discrepancies. including lack of agreement among experts, who have access to the same research evidence but who interpret the evidence in different ways, the fact that States have different lead times for revision of educational material to keep it up to date with new research evidence, the possibility that the research evidence in some areas is not sufficiently clear for precise recommendations to be given, and the possibility that the emphasis on economic considaations may change from one time period to another. A further issue is that educational messages need to provide clear and concise messages about what to do if a sign or symptom

suggestive of cancer is discovered. There is some evidence that this does not occur at present in some of the educational material produced.

There needs to be an attempt to bring about standardization of the educational messages directed towards the public in the areas of primary and secondary prevention of cancer. It appears that the Australian Cancer Society is an appropriate group to provide guidance to the States in this area. Once consensus has been reached about the nature of primary and secondary prevention messages, using agreed criteria,'' rather than each State attempting to develop its own educational material. some sharing of resources and expertise could eventuate. as has occurred in the case of National Skin Cancer Awareness Week.' For example, one State could take responsibility for developing, testing and finalising material for skin cancer, while another could concentrate on the same tasks in the area of breast cancer. Such strategies could reduce both inconsistencies among States and duplication of efforts in devising educational materials.

References

1. Australian Bureau of Statistics. Causes of Death: Australia, 1987. Canberra: Australian Bureau of Statistics, 1989. (Catalogue No. 3303.0)

2. Better Health Commission. Looking Forward to Better Heal th , Vo l . 2 . Canberra : Australian Government Publishing Service, 1986. McCar thy WH and Shaw HM. Skin cancer and Australia. Med J Aust 1989;

4. Marks R and Hill D. Behavioura l change in adolescence: A major challenge for skin-cancer control in Australia. Med J Aust 1988; 149

Australian Cancer Society. A National Cancer Prevention Policy for Australia Vols I and 11. Sydney: Australian Cancer Society, 1987.

3.

150 (9):469-470.

(21):514-515. 5 .

6. Fleming WB. The cancer-related health checkup: A guide fo r medica l prac t i t ioners . Med J Aust Specia l Supplement. 1985; 143 (6): S33439. Egger G. Health promotion. In: King NJ and Remenyi A. edr. Health Care: A Behavioural Approach, Sydney: Grune and Stratton. 1986; 257-264. Dent OF, Chapuis PH and Goulston KJ. Relationship of survival to stage of the tumor and duration of symptoms in colorectal cancer. Med J Aust 1983; 138~274-275. Payne JE. Symptoms and the diagnosis of bowel cancer: a critical view. Med J Aust 1988; 148505-507. Cadman D, Chambers LW, Seldman WR and Facket t DL. Assess ing the effectiveness of community screening programs. JAMA 1984; 251:1580.

7.

8.

9.

10.


APPENDIX

List of Public Educational Materials Analysed

STATE

Bowel

NSW

VIC QLD WA

BRPst

NSW

VIC

QLD

WA TAS

ACT

Cervlr

NSW

VIC

QLD SA WA

Skln

NS W VIC QLD SA

WA

TITLE

Bowel Cancer Bowel Cancer Facts Bowel Cancer Bowel Cancer Cancer of h e Colon and Rectum (Large Intestine)

So you have a breast lump? What is a manunogram? BSE Breast Cancer Breast Cancer Screaring BSE Breast Canw - Something No Woman Should Turn Her Back On The Facts about Breasts Breast Cancer BSE - Peace of Mind BSE - What? At My Age? How to Examine Your Breasts

Cancer of the Cervix The Pap Test Cancer of the Cervix Three Simple Questions Pap Test Results Smear Test Have a Cervical Smear Test Cancer of the Cervix

Skin Cancer Facts skin can= What is Skin Cancer? Have Fun In The Sun But ... Skin Cancer: Early Detection and Treatment is Very Important Sunburn and Skin Cancer

FORMAT

Pamphiet Fact Sheet Fact Sheet Pamphlet

Fact Sheet

Leaflet Pamphlet Fact Sheet Fact Sheet Fact Sheet Pamphlet

Pamphlet PampMet Pamphlet Leaflet Leaflet Leaflet

Pamphlet Leaflet Fact Sheet Pamphlet Fact Sheet Pamphlet PalTlphlet Fact Sheet

Fact Sheet Fact Sheet Infomation Sheet Pamphlet

Pamphlet Pamphlet

DATE

12/87 3/88 11/85 n.d.

11/85

3/88 3/88 8/88 11/86 10/88 6/88

6/88 n.d. n.d. n.d. n.d. n.d.

n.d. l0/88 Ion6 9/87 6/88 6/88 n.d. n.d.

8/88 10/88 9/88 n.d.

n.d. 1/88


a critical review of australian cancer organizations’ public education material

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