HEALTH PROMOTION INTERNATIONAL© Oiford University Preu 1996

Vol. 11, No. 4Printed in Great Britain

Community action for cancer prevention: overview of theCancer Action in Rural Towns (CART) project, Australia

CART Project Team:

LYNNE HANCOCK,1 ROB SANSON-FISHER,1 SALLY REDMAN,2 ROBERTBURTON,1 LOUISE BURTON,3 JIM BUTLER,4 ROBERT GIBBERD,5 AFAFGIRGIS,6 MICHAEL HENSLEY,1 ANN MCCLINTOCK,3 ALEXANDERREID,1 MARGOT SCHOFTELD,1 TONY TRIPODI6 and RAOUL WALSH1

'Faculty of Medicine and Health Sciences. University of Newcastle, Newcastle, Australia, 2NationalBreast Cancer Centre, Sydney, Australia,3 NSW Cancer Council, Sydney, Australia, ^National Centrefor Epidemiology and Population Health, Australian National University, Canberra, Australia,5 Department of Statistics, University of Newcastle, Newcastle, Australia and6 NSW Cancer CouncilCancer Education Research Program, University of Newcastle, Newcastle, Australia

SUMMARYThis paper describes the rationale, aims, design andmethods of a large-scale community action cancer pre-vention project. Cancer Action in Rural Towns(CART). The primary aim of the CART project is toevaluate the effectiveness of a community action pro-gram in increasing community rates of preventive andscreening behaviours relating to breast, cervical, smok-ing-related and skin cancer. Twenty towns in rural NewSouth Wales, Australia (population 5001-15 000) wereselected for inclusion in the CART project. A matched-pairs design was used, with one town from each pair ran-domly allocated to either experimental or control condi-tion. In experimental towns, community action is beingpromoted through established community networks andwithin key access-points (schools, workplaces, commu-

Key words: cancer prevention; community action

nity organisations, health care providers, retailers andthe media), to encourage uptake of cancer-related pre-ventive and screening behaviours. Outcome evaluationincludes self-report measures of adult smoking quitrates, Health Insurance Commission provider presenta-tions data, surveys of adolescent smoking and solar pro-tection practices, and direct observation of solarprotection practices at schools and community venues.Economic evaluation includes cost-effectiveness, travelcost, and contingent valuation methods of cost analysis.Process measures for the project include media monitor-ing, measures of change in institutional policies, andrecords of CART intervention activities. The evaluationofCARTwillbecompletedbytheendofl997.

INTRODUCTION

During the 1990s, cancer is likely to become themajor cause of death in developed countries [USPreventive Services Task Force, 1989; AustralianCancer Society (ACS), 1993; Canadian Taskforceon the Periodic Health Examination, 1995]. An

effective method of reducing mortality and mor-bidity from cancer is through primary and second-ary prevention. However, despite intensive publiceducation campaigns, community rates of preven-tive and early detection behaviours for cancer

277

by guest on July 8, 2011heapro.oxfordjournals.org

Dow

nloaded from

278 L. Hancock et al.

remain low (US Preventive Services Task Force,1989; ACS, 1993; Canadian Taskforce on the Peri-odic Health Examination, 1995). There is there-fore a need to develop and evaluate new and cost-effective strategies to encourage populations toengage in cancer-related preventive and earlydetection behaviours. One potentially promisingstrategy is a community action approach (Kinneetai, 1989; Green and Kreuter, 1990).

A community action approach to health pro-motion involves multiple intervention compo-nents across multiple access-points withcommunity participation integral to programimplementation and maintenance. Communityaction appears to be a promising method for thedissemination of health promotion initiatives(WHO, 1986; Dixon, 1989; Green and Kreuter,1990; Tones et al., 1990). However, debate con-tinues about the effectiveness of this approach inchanging health behaviour (Dixon, 1989; Fisher,1995; Susser, 1995). In part, this uncertainty isdue to a lack of adequately evaluated communityaction programs (Donner et al., 1990; Clover,1992).

Community-wide interventions present a parti-cular challenge to evaluators. Ensuring rigorousscientific evaluation involves consideration of sev-eral domains: design of the evaluation, includingsampling and control procedures; types of mea-sures used, including reliability and validity ofinstruments; and analysis issues, including clus-tering and statistical power (Koepsell et al., 1991).

Perhaps the most difficult methodological issuefor community action programs is the establish-ment of adequate control groups. When commu-nity-wide treatments are evaluated, communitiesrather than individuals must be assigned to con-trol and treatment groups (cluster randomisa-tion), and many communities must be assigned toeach group (Donner, 1987; Donner et al, 1987).Study designs which involve only one or two treat-ment communities cannot exclude the possibilitythat changes in behaviour are due to factors otherthan the intervention (Koepsell et al. ,1991).

There are two main types of measures whichshould be utilised in evaluating a communityaction program: process and outcome measures(Hawe etal., 1990). To be useful, process measuresshould allow the evaluator to report confidentlywhat the intervention involved within each clus-ter, and the level of exposure of each cluster to theintervention. The outcome measures used shouldideally be validated, standardised instruments.When this is not possible, reliability and validity

should be tested within the study, or accuracyenhancement strategies employed.

Community action program evaluationrequires the consideration of both individual var-iation within a community and community-levelvariation within a treatment group (Donner,1987; Donner et al., 1987; Koepsell et al., 1991).Two sets of sample sizes must be considered: thenumber of individuals in a community to besampled and the number of communities to beincluded. Studies should report justification forsample size at both these levels (Donner, 1987;Donner et al., 1987; Koepsell et al., 1991).

Community action programs have been shownto be effective in decreasing modifiable risk factorsand mortality from cardiovascular disease(Puska, 1984; Puska etal., 1985). However, therehave been relatively few studies which havesought to assess the impact of community actionprograms on cancer-related health behaviours.The substantial resources required to implementand evaluate large-scale community action pro-grams mean that experimentation is expensiveand rare (Kinne et al., 1989). There will conceiva-bly be very few opportunities to test whether com-munity programs can be effective in reducingcancer risk behaviours. Indeed, the recent disap-pointing outcome of the methodologically appro-priate COMMIT study, in producing only amoderate reduction in community smoking rates,clearly demonstrates the need to use rigorousscientific methods if community-level effects areto be detected (COMMIT Research Group,1995a, b).

This paper describes the rationale, aims, designand methods of a community action project,Cancer Action in Rural Towns (CART), whichattempts to meet the methodological specifica-tions necessary to evaluate effectively thisapproach to encouraging health behaviourchange. It focuses on the evaluation of CART,giving only a brief description of the intervention,which will be described in greater detail in subse-quent publications.

The primary aim of the CART project is toexplore the effectiveness of a community actionprogram in increasing community rates of preven-tive and screening behaviours relating to breast,cervical, smoking-related and skin cancer in ruraltowns of New South Wales (NSW), Australia.The four target cancers (breast, cervical, smok-ing-related and skin) were chosen for the CARTproject for several reasons. Firstly, they are asso-ciated with a considerable burden of illness

by guest on July 8, 2011heapro.oxfordjournals.org

Dow

nloaded from

within Australia. Breast cancer is the mostcommon cause of cancer death in Australianwomen, accounting for 18.2% of all female cancerdeaths in 1988 (ACS, 1993). In 1990, 340 Austra-lian women died from cervical cancer (ACS,1993). Lung cancer is the most common cause ofcancer death in Australian males and the thirdleading cancer for women [Australian Bureau ofStatistics (ABS), 1991]. Tobacco smoking is also amajor cause of cancers of the oral cavity, oesopha-gus and larynx, and has been linked to cancers ofthe stomach, pancreas, cervix, kidneys and blad-der (Holman etai, 1988). Australia has the high-est rate of skin cancer in the world (Armstrong,1988). Secondly, these cancers were consideredpriorities for intervention, given that they areeither highly preventable or the prognosis fortreatment is very good with early detection (ACS,1993). And, thirdly, there are agreed guidelines inAustralia for primary and secondary preventionstrategies for these priority cancers (ACS, 1993).The ACS recommends: all women aged 50-69years should have 2 yearly screening mammo-grams; all women who have ever had sexual inter-course should have a Pap Test every 2 yearsbetween the ages of 18 and 70 years; peopleshould not themselves smoke and should avoidpassive smoking; people should always protecttheir skin and eyes when outside between 10 a.m.and 2 p.m. [Eastern Standard Time (EST)] (ACS,1993).

AIMS OF THE CART PROJECT

The aims of the CART project are:

(i) To describe current rates of preventive andscreening behaviours for breast, cervical,smoking-related and skin cancers in ruralcommunities in NSW, Australia.

(ii) To explore the effectiveness of a communityaction program in increasing communityrates of preventive and screening behavioursrelating to breast, cervical, smoking-relatedand skin cancers when compared with con-trol rural communities.

(iii) To monitor the economic and financial costsof community action programs for indivi-duals and service providers.

(iv) To undertake an economic appraisal in orderto assess the cost-effectiveness of a commu-nity action program in comparison to otherstrategies.

Overview of the CART project 279

(v) To describe the implementation of the com-munity action program and to assess itsacceptability to participating communities.

(vi) To develop a strategy and resource materialswhich could be used to implement commu-nity action programs relating to cancer inother rural communities.

DESIGN OF THE CART PROJECT

The CART design flowchart is shown in Figure 1.In 1992, 20 towns in rural NSW (population5001-15 000) were selected for inclusion in theCART project. Community allocation wasimperative, given that a community actionapproach aims to mobilise whole communities. Amatched-pairs design was used, with one townfrom each pair randomly allocated to eitherexperimental or control condition. The impetusfor the decision to utilise this design was gainedfrom a workshop on methodological issues in theevaluation of community intervention programsheld in Newcastle, Australia, in September 1992,which drew on statistical and design expertisefrom throughout Australia and overseas (CARTProject Team, Donner and Green, 1995). The pri-mary reasons for selecting only ten pairs werefinancial and feasibility considerations. Althoughthe need to include as many clusters as possiblewas understood, practically and financially, tenpairs was the maximum which could be affordedby the research group, despite the statistical diffi-culties involved in so few clusters. Given tenmatched pairs, more than eight out of the pairs oftowns will need to show a significant improvementin the direction of the intervention town, for theintervention to be considered successful. Theprobability of obtaining this result given thatthere is no difference between towns is 5%(Donner, 1987).

Town selectionTowns with a population range of 5001-15 000were chosen for the CART project for severalreasons. First, there needed to be sufficienttowns in the population range to allow for appro-priate matching of ten town pairs. There are 49towns in rural NSW in the population range5001-15 000 persons. Five towns were excludeddue to proximity to a larger centre (within 50 kmof the three major urban centres of NSW), andone town was excluded for having less than three

by guest on July 8, 2011heapro.oxfordjournals.org

Dow

nloaded from

280 L. Hancock et al.

Nov-Dec 92

Jun-Oct 93

Oct 93

Jan-Mar 94

Mar 94

Ocl 96-Mar 97

Fig. 1: CART design flowchart.

49 towns (5 001-15 000) in rural NSW

Select 10 town pairs, matched on demographic data

Randomly allocate 1 or each pair

Control Intervention

Baseline measures Tor 1st 5 town pairsadult survey, school surveys, HIC data,

solar protection direct observations

Implement intervention in1st 5 towns (staggered)

Baseline measures for 2nd 5 town pairs

Implement intervention in2nd 5 towns (staggered)

3 yr follow-up

general practitioners (a condition of supply ofHealth Insurance Commission data). Demo-gTaphic, infrastructure and geographical infor-mation was gathered on 43 towns, allowing areasonable pool from which to select studytowns. Second, Henderson and Thomas (1980)have argued that the appropriate catchment areafor community programs should be between6000 and 20 000. Given the differences in Austra-lian town sizes as compared to the UK, it wasdecided that 5001-15 000 approximated thispopulation bracket. Third, based on the experi-ence of this research group during a previouscommunity action project, it was felt that thissize community would be both large and smallenough to allow for effective activation strategies(Knight et al, 1994). Figure 2 shows a map ofNew South Wales with CART towns marked.

Town matchingA computer program was created which gave eachpossible pair of towns a 'matching score' basedon the following variables:

• demographic structure which included age dis-tribution, ethnicity (country of birth), occupa-tion, education levels and non-English-speaking background, from 1986 AustralianCensus data (ABS, 1987);

• population density as an isolation index;• average summer temperature.The variables for town matching were chosen fol-lowing extensive consultation with statistical andmethodological experts, both in Australia andoverseas. The effectiveness of this matching proce-dure will be assessed in a paper which is now inpreparation.

Each possible pair of towns was ranked accord-

by guest on July 8, 2011heapro.oxfordjournals.org

Dow

nloaded from

Overview of the CART project 281

CART TOWNS

Fig. 2: Map of New South Wales with CART towns marked.

ing to this matching score, from the most similarpair of towns down to the least similar pair. Townpairs were then selected by working down theranking list starting from the best matched pair.Town pairs were rejected if:

• geographical position of both towns did notcoincide (coastal or inland);

• towns were within 100 km of each other;• one town in the pair was within 50 km of a town

in a pair already selected.

Randomisation of town pairsOne town from each pair was randomised intoeither intervention or control conditions, using alist of random numbers. Proximity (being within100 km but > 50 km apart) of towns from different

matched pairs randomised into the same condi-tion (intervention or control) was allowed. Proxi-mity of towns from different matched pairsrandomised into different conditions was notallowed, due to the risk of contamination. In thiscase, the pair ranked highest on the computer-gen-erated ranking sheet was retained. Baseline datafor town pairs was collected at the same time, soit is expected that any seasonal variation will beaccounted for when considering differencesbetween conditions.

THE CART INTERVENTION

The community action intervention has involvedthe formation of community committees and the

by guest on July 8, 2011heapro.oxfordjournals.org

Dow

nloaded from

282 L. Hancock et al.

utilisation of access-point networks to initiate andmaintain intervention strategies within eachtown. The approach used in the CART interven-tion was developed with reference to past similarprojects (Puska, 1984; COMMIT ResearchGroup, 1991; Knight et al., 1994) and throughconsultation with identified experts in the field,local health promotion workers and lay people.Although the research team approach to townswas standardised, and extensive materials foractivation were provided to encourage similaractivities in each town, it was expected from theoutset that flexibility would be the key to securingand maintaining community involvement. Conse-quently, activities and time frames have variedconsiderably between communities.

The community facilitatorAs a starting point, a community facilitator (NSWCancer Council Health Education Officers withexperience in community-based cancer reductionstrategies) was recruited for each interventiontown. The main role of the facilitator is to act as alink between the community and the researchteam. Facilitators were involved in organising thefirst community meeting and are responsible forongoing liaison with the community committeeand access-point networks. Maintenance of thefacilitators' role and motivation has been throughregular bi-monthly meetings with the ResearchTeam. Supervision of facilitators is through theNSW Cancer Council Community ProgramsUnit, which has donated 1 day per week of eachfacilitator's time to be involved in the CART pro-ject.

The community meetingCART was introduced to each intervention townthrough an open-invitation community meeting.A priority task for the facilitator was to recruit asubcommittee of suitable key people to launchthe CART community meeting. Each CART com-munity meeting was extensively advertised usingstrategies such as personalised letters to keypeople with telephone follow-up, posters in strate-gic venues, letterbox flyers, newspaper advertise-ments and press releases and interviews. Themain focus of the CART meeting, which waschaired by an invited key person from the commu-nity (usually the town mayor), was a presentationby a member of the CART Research Team aboutcancer issues and strategies for change whichincluded town-specific cancer statistics. Membersof the community were then invited to form a

CART committee. A balance of representativesacross key community access-points was sought(health care providers, community organisations,media, retailers, schools and workplaces). If bal-ance was not achieved at the community meeting,representatives from each access-point wereactively recruited by the facilitator or other com-mittee members.

Community committees and utilising access-point networksThe first committee meetings were held within 2months of the community meeting. A committeemanual was developed as a guide to implementingcommunity activities. CART committees wereasked to convene at least every 2 months. Facilita-tors are expected to be present at all committeemeetings to provide guidance and support.

The CART committee was asked at the firstmeeting to nominate representatives to takeresponsibility for activation through the six keyaccess-points: health care providers, communityorganisations, media, retailers, schools, andworkplaces. Access-point networks are the mainvehicle of the CART intervention, and it isintended that as many people from the communityas possible be involved in the intervention at thislevel. Figure 3 represents the model put forwardto community committees, whereby all targetbehaviours are considered across all access-points, at the same time. Thus, when a committeemember approaches, say, a workplace, they areencouraged to motivate awareness and activityaround mammograms and Pap tests if there arewomen employees, solar protection if there areoutdoor workers, and smoking. Access-point net-work members have been involved through bothplanned and opportunistic contact with commit-tee members and the facilitator.

Standard strategy packages were developedpre-implementation, which outlined recommen-dations for activities in each access-point.Resource packages with pamphlets, posters,draft letters and other resources were providedfor each access-point, to aid in conducting activ-ities. These access-point packages have been pro-gressively refined and abbreviated throughoutintervention implementation, in response to com-munity feedback about their usefulness. The stan-dard recommendations for types of strategiesconsidered effective have not changed.

by guest on July 8, 2011heapro.oxfordjournals.org

Dow

nloaded from

Schools

Workplaces

Retailers

Community organisations

Health care providers

Media

Mammograms

1H j ' active BjH

active

active

active

Pap Tests

active

active

active

active

Quit smoking

j j^H active

active

active

active

active

active

Solar protection

«* mactive "

active ':'i:

active ;

active

active •

;:-.!ivc

Fig. 3: The access point approach.•8,

2

1

by guest on July 8, 2011heapro.oxfordjournals.org

Dow

nloaded from

oo

Table 1: Summary of outcome targets and evaluation measures for the CART project

Cancer Outcome

To examine if the community action program results in:

Measure

Breast an increase in the number of women (SO-69 years) receiving screening mammograms

Cervical an increase in the number of women (not screened in the previous 2 years) receivingcervical cancer screening (Pap tests)

Smoking-related a decrease in the number of adolescents who begin to smoke

an increase in the proportion of adult smokers who quit

Skin: protection an increase in the proportion of secondary school children who use solar protection

an increase in the proportion of secondary school children who wear Cancer Councilapproved hats in the sun or shade, while at school

an increase in the proportion of people who use solar protection at communityswimming pools and recreation areas

a decrease in acquisition of pigmented naevi on the backs of primary school children

Skin: detection an increase in the number of skin biopsies

Adult Cohort Study self-report

attendances at screening stations

Health Insurance Commission Pap test rates

cross-sectional school-based self-report survey, with boguspipeline enhancement

Adult Cohort Study smoker self-report of quitting

cross-sectional school-based survey using diary self-reportof weekend behaviour

direct observation of hat and shade use in school yards

direct observation of solar protection behaviours atswimming pools and recreational areas

photograph naevi counts of backs for 5-7 year-olds

Health Insurance Commission skin biopsy rate

by guest on July 8, 2011heapro.oxfordjournals.org

Dow

nloaded from

EVALUATION OF THE CART PROJECT

Outcome measuresOutcome evaluation can include measures ofhealth risk behaviours, health outcomes and cost-effectiveness. The CART outcome evaluationmainly assesses intervention impact on healthrisk behaviours. Given the short time-frame foroutcome measurement, changes in health out-comes such as cancer incidence would not beexpected (Hawe et al., 1990). Most outcome mea-sure studies will use a pre-post design. The effec-tiveness of the community action program will beevaluated by comparing changes in health riskbehaviours from baseline to follow-up, andbetween conditions.

Sample size calculations for each outcome mea-sure were performed using the formula:

Nc=(\+(m-\)r)N.n,

where Nc=the clustered sample size, m=the aver-age cluster size, r=rho, the intraclass correlationcoefficient and ATlr,=naive sample size, assumingsimple random sample. Alpha was set at 0.05,and the intratown correlation coefficient (rho) foreach outcome variable has been calculated frombaseline data (Snedecor and Cochran, 1980;Hsieh, 1988). The outcomes for CART and relatedmeasures are summarised in Table 1, anddescribed briefly below.

Adult Cohort StudyA random community survey (iV=1000) was con-ducted, primarily as a cohort recruitment foradult smokers, across all communities for pre-test only. Cohort follow-up is proposed for post-test. The aim of the Adult Cohort Study is to eval-uate the impact of the community action programon:

• women's knowledge of and self-reported mam-mographic screening;

• women's knowledge of and self-reported cervi-cal screening;

• smoking cessation rate in a cohort of adult smo-kers;

• community prevalence of smoking.

The main post-test outcome measure will benumber of quitters from a cohort of regular andoccasional smokers. This outcome measure waschosen as consistent with the main outcome mea-sure for the COMMIT project (COMMITResearch Group, 1991, 1995a, b). The cohorts

Overview of the CART project 285

proposed for follow-up are: 150 current smokers(at baseline) and 150 non-smokers. For smokers,this sample size should allow the detection of a5% difference in quit rates between conditionswith 90% power, given a rho of 0.03 (Snedecorand Cochran, 1980; Hsieh, 1988). At follow-up,biochemical validation of the level of carbon mon-oxide in expired air will be performed on a sub-sample of quitters as a reliability check on self-reported smoking status.

Health Insurance Commission (HIC) DataStudyThe HIC are responsible for recording all claimsdata from Medicare, the Australian nationalmedical costs rebate scheme. All presentations toprivate doctors throughout Australia arerecorded, with specific item numbers assigned tomany procedures. Procedures data are stored inreference to several variables, including postcode.

The HIC Data Study aims to examine theimpact of the community action program on:

• number of diagnostic mammograms;• number of women attending for Pap tests;• number of skin biopsies.A major advantage of using HIC data for impactevaluation is that HIC data can be obtained on allmembers of the community, according to post-code, so sampling problems can be avoided. Asecond advantage is that HIC data can be collatedaccording to both patient and provider, thereforeallowing examination of changes in both patientand provider behaviours. HIC data can also beconsidered more reliable and less biased, forsome outcome measures, than data collectedusing alternate methodologies, such as self-report surveys (Bowman et al., 1991; Byles et al.,1994,1995).

However, one problem with using HIC data isthat procedures performed by non-HIC or publicsector providers will not be included in the HICdatabase. For example, Pap tests performed bycommunity nurses will not be recorded by theHIC. This is not a major problem providing thatthere is no significant shift in 'public versus pri-vate' mix over the period of the data collation. Inan attempt to allow for this confounder, somequestions on screening behaviours and providershave been included in the Adult Cohort Study.

The procedures to be monitored were decidedfollowing extensive consultation with cliniciansand the HIC with regard to appropriateness andproblems with definitions and availability. The

by guest on July 8, 2011heapro.oxfordjournals.org

Dow

nloaded from

286 L. Hancock et al.

procedures chosen for monitoring needed to be,first, related to the cancers of interest to CART,second, screening or screening-related proceduresand, third, procedures which were primarily deliv-ered by the individuals' doctor in the privatesector. Maramograms were a particular problem,as Medicare rebates are paid only for 'diagnosticmammograms', those sought in response to symp-toms or previous cancer history. 'Screening mam-mograms', obtained in the absence of symptomsor previous cancer history, are currently providedfree of charge by the NSW Program for Mammo-graphic Screening to women aged 40 years andover. The research group is still negotiating toobtain data on screening mammogram levelsthrough the NSW Program for MammographicScreening.

HIC statistics are being collated 3-monthly for5 years pre-intervention, and throughout thecourse of the intervention, for all experimentaland control towns. This research group has exten-sive experience in using HIC data as an impactmeasure (Bowman et al., 1991; Bylesefa/. , 1994,1995).

Adolescent Smoking Prevalence StudyAll Year 9 and Year 10 students from all second-ary schools in each rural town will be included inrepeated cross-sectional surveys of smoking beha-viours and attitudes. This study aims to evaluatethe impact of the community action program onsecondary school students':

• prevalence of smoking;• knowledge of smoking-related health issues.

A sample size of 200 students per school shouldallow the detection of a 5% difference in smokingprevalence rates between conditions with 90%power, given a rho of 0.01 (Snedecor and Cochran,1980; Hsieh, 1988). Given that biochemical vali-dation of adolescent smoking is known to be unre-liable (Murray et al, 1987), 'bogus pipeline'enhancement of self-report will be employed atpost-test.

Adolescent Solar Protection StudiesThe effects of the community action interventionon adolescent solar protection behaviours will beassessed in two ways: cross-sectional school-based surveys on knowledge, attitudes, and self-reported solar protection behaviour; and school-based direct observation of solar protective beha-viours.

Adolescent solar protection self-report sur-vey This survey aims to evaluate the impact ofthe community action program on secondaryschool students':

• use of solar protection measures when outdoorsduring the weekend;

• knowledge about skin cancer and solar protec-tion issues;

• attitudes towards solar protection practices.

A sample of 200 students from each secondaryschool will be asked to complete a solar protectionquestionnaire. Whole classes will be randomlyselected from each of Years 7-11, to ensure anapproximately equal distribution of the differentage groups within the 200 students. A sample sizeof 200 students per school should allow the detec-tion of a 10% difference in solar protection beha-viours between conditions with 90% power, givena rho of 0.02 (Snedecor and Cochran, 1980;Hsieh, 1988).

The questionnaire will include:

• a self-report solar protection behaviour diary toassess use of protection during the precedingweekend (Cockburn et al, 1989; Sanson-Fisher, 1992, 1993, 1994, 1995; Girgis et al,1993); the proportion of students who used ahigh level of solar protection during the pre-vious weekend will be calculated by using a for-mula which was previously developed by thisresearch team (Girgis et al., 1993).

• questions on knowledge and attitudes aboutskin cancer and solar protection.

Direct observation of solar protection at secondaryschool This study aims to evaluate the impact ofthe community action program on secondaryschool students' use of shade and hats when out-doors during randomly selected lunch periods atschool. This study seeks to provide a 'snapshot' ofschool-based behaviour, so observations aremade during one random lunchtime period onlyper school.

All secondary schools will be included in thedirect observation study. Direct observations willbe conducted on one randomly selected sunnyday per school, by trained observers recruitedfrom each town. Observers will move around sys-tematically to all sections of the school grounds,during lunchtime, noting rates for each of the fol-lowing categories:

• number of students in the shade, without hats;• number of students in the shade, with hats;

by guest on July 8, 2011heapro.oxfordjournals.org

Dow

nloaded from

• number of students in the sun, without hats;• number of students in the sun, with hats.

Direct observation of solar protection atcommunity venuesThis study, which aims to evaluate the impact ofthe community action program on communitymembers' use of solar protection measures whenoutdoors at recreational areas during the week-end, involves two parts: a short interview toassess sunscreen use and determine age, countryof birth and skin type of individuals; and directobservations of use of solar protection items suchas hats, clothing and shade. Recreational areas,which include swimming pools, beaches, parksand sports fields, will be selected based on localknowledge of the popularity of each site duringthe weekend. This research group has consider-able experience in the conduct of direct observa-tion studies in schools (Schofield et ai, 1991;Girgis et ai, 1993), on beaches (Foot et al,1993), and with outdoor workers (Girgis et al.,1994).

A total of 200 interviews and observations ofadults, and up to one accompanying child, will beconducted by trained observers recruited fromeach town, on sunny Saturdays and Sundays,between the hours of 10 a.m. and 2 p.m. (EST). Asample size of 200 should allow the detection of a10% difference in solar protection behavioursbetween conditions with 90% power, given a rhoof 0.02 (Snedecor and Cochran, 1980; Hsieh,1988).

Naevi count studyIt has been shown that sun exposure is a majorfactor in the development of pigmented naevi inAustralian school children (Kelly et al., 1994).English and Armstrong (1994a) have shown thatAustralian primary school children at latitude32°S in the age range 5-10 years acquire, on aver-age, one new pigmented naevus each year on theirback. Thus it was of interest to determine whetherrates of acquisition of pigmented naevi on thebacks of primary school children in this age rangediffered between experimental conditions.

A professional photographer photographed thebacks of ~ 60 children aged 5-7 years old from 12of the CART towns, on site at their school, sinceit has been shown that photographs of backs arean effective substitute for clinical examination(English and Armstong, 1994a). The photogra-pher was accompanied by a trained nurse, who

Overview of the CART project 287

collected data on hair, eye and skin colour, andperform a manual count of pigmented naevi > 2mm in diameter. A questionnaire was also sent toparticipating parents to ascertain each child's sun-burn history and sun sensitivity (burners versustanners).

Photographs were developed as slides, and pro-jected lifesize onto a white board for counting bya nurse trained by a dermatologist. This type ofmethodology has been found to be reliable fornaevi counts of backs (English and Armstong,1994b). Countable lesions were defined as 'brownto black pigmented macules or papules of any sizewhich are darker in colour than the surroundingskin', as defined by English and Armstrong(1994b).

Three years after the first round of photogra-phy, the same schools will be revisited and asmany of the same children as possible re-exam-ined and re-photographed. Most children shouldstill be at the same rural primary school, in Grade4 or 5 when they are revisited. It is expected that,on average, each child would have acquired threepigmented naevi on their backs in the 3-yearperiod. A multivariate analysis will be conductedto determine whether town is an independent pre-dictor of acquisition of naevi. That is, if there is aresidual effect when all other known variableswhich might explain differences in naevi acquisi-tion rates between intervention and controltowns, such as hair, skin and eye colour and tan-ning propensity, are taken into account.

Economic evaluationAn important component of the evaluation of theCART project involves assessing whether com-munity action strategies are a cost-efficient wayof reducing cancer risk behaviours in rural com-munities. The economic evaluation of CART willuse both cost-effectiveness and cost-benefit ana-lysis to determine whether community actionrepresents 'value for money' within the context ofthe Australian health care system. This compo-nent of the CART project aims to:

• determine the cost-effectiveness of communityaction in reducing cancer risk behaviour inrural towns;

• examine the impact of how non-monetary fac-tors affect individuals' access to cancer screen-ing;

• estimate the monetary value of benefits of theCART project using contingent valuationmethods through a community survey.

by guest on July 8, 2011heapro.oxfordjournals.org

Dow

nloaded from

288 L. Hancock et al.

In the economic analysis we will apply three differ-ent methods to evaluate different aspects of theCART project:

(i) cost-effectiveness analysis (Drummond etal, 1987);

(ii) travel cost method (Acton, 1975);(iii) contingent valuation method (Johannesson

The details of the economic evaluation will be thesubject of subsequent papers.

Process measuresGiven that the CART intervention involves signif-icant community participation, considerable var-iation was expected in the manner in which theintervention was implemented across towns.Careful monitoring of intervention activity ineach town will allow an accurate description ofthe intervention to be given, and also allow forvariations in the intervention process to be usedas potential confounders in the evaluation analy-sis. A number of process measures are being col-lected.

Recording CART activitiesCommittee meeting minutes and 'activity sum-mary sheets' will be used to summarise thenumber and type of intervention activities withintowns and community responses to these activ-ities. Standard forms for meeting minutes andrecording CART activities have been provided toall committees. Information specifically soughtfrom community committees is: important dates(such as committee meetings and activities); inter-vention content (such as types of activities andresources used); and intervention reach (such asnumber of people attending CART meetings,functions and activities). This information isintended to provide a measure of interventionexposure, acceptability of community activitiesand an estimate of intervention costs (Hawe etal., 1990).

Commun ity surveyThe post-test adult community survey will includesome questions on awareness of CART, aware-ness of the Cancer Council, cancer preventionactivities which have occurred in each town overthe past 2 years, knowledge of cancer risk reduc-tion strategies, and questions aimed at assessingto what degree community members understoodthat their community was involved in a scientifictrial. These details should provide another mea-

sure of intervention exposure, as well as detailson non-intervention activities within experimen-tal and control towns.

Measuring change in institutional policies andpracticesMany institutions within the community have thepotential to influence cancer risk status throughimplementing appropriate policies and practices.A measure of policy changes can serve as a poten-tial predictor of outcome and a qualitative indica-tor of the extent of intervention activity.

A survey of current policies and practices willbe used to assess changes in policies and practices,with respect to smoking and sun protection, forschools and local government. For schools, mail-out self-report surveys to all school principalswill be undertaken in all primary and secondaryschools in the 20 CART towns. For local govern-ment, phone interviews will be undertaken withlocal council representatives in all CART towns.This research group has considerable past experi-ence with this type of research (Schofield et al.,1991;Girgise/a/.,1994).

Media monitoringThe media constitute one of the access-pointsbeing mobilised for CART. Given that the mediamay also be potential confounders between theintervention and control groups, the number andquality of media reports will be monitored in allstudy towns. The aims of media monitoring are:

• to determine whether the CART interventionresults in a greater number and higher salienceof print-media events on cancer related issuesin intervention versus control towns;

• to monitor the acceptability of CART interven-tion activities by ratings of the tone and orienta-tion of media reports.

Cancer-related articles from newspapers withinthe 20 towns are being regularly collected, using acommercial media monitor. Articles will be ratedon several dimensions, including characteristicsof the media source (such as coverage, publicationfrequency, number of pages) and content (such astype of item, 'pro' versus 'anti' health, mentionsCART or not). Rating methods utilised will besimilar to those used in previous Australian stu-dies (Chapman, 1989).

by guest on July 8, 2011heapro.oxfordjournals.org

Dow

nloaded from

CONCLUSIONS

This paper has described the rationale, aims,design and methods of a community action pro-ject to reduce cancer. The CART project has beendesigned to meet the methodological criterianecessary effectively to evaluate a communityaction approach to encouraging behaviourchange. It is hoped that the post-test in 1997 willyield some comprehensible conclusions about theeffectiveness of a community action approach forincreasing cancer-related preventive and screen-ing behaviours. However, it is also recognisedthat long-term evaluation of health outcomes isnecessary to demonstrate the effectiveness of thisapproach for improving public health. While it isbeyond the scope of the current project to measurethe permanency of structural outputs, the involve-ment of the NSW Cancer Council in delivery ofthe intervention has meant that continuation ofthe project initiatives is much more likely than itotherwise may have been. Discussions havealready been conducted with community repre-sentatives about if and how they see CART conti-nuing in their community.

ACKNOWLEDGEMENTS

The CART project is a collaborative projectjointly funded by the National Health and Medi-cal Research Council (Australia) and the NSWCancer Council (Australia).

Address for correspondence:Dr Lynne HancockFaculty of Medicine and Health SciencesUniversity of NewcastleLocked Bag 10Wallsend 2287 NSWAustralia

REFERENCES

Acton, J.P. (1975) Nonmonetary factor* in the demand formedical services: some empirical evidence. Journal of Politl-ealEconomy, 83,595-614.

Armstrong, B.K. (1988) The epidemiology and prevention ofcancer in Australia. Australian and New Zealand Journal ofSurgery, 58,179-187.

Australian Bureau of Statistics (1987) Population and HousingCensus, 1986. Australian Bureau of Statistics, Canberra.

Australian Bureau of Statistics (1991) 1990 Deaths in Austra-lia, Cat.No. 3302.0. Australian Bureau of Statistics, Can-berra.

Australian Cancer Society (1993) National Cancer PreventionPolicy 1993. The Australian Cancer Society, Sydney.

Overview of the CART project 289

Bowman, J., Redman, S., Dickinson, J., Gibberd, R. andSanson-Fisher, R. (1991) The accuracy of Pap smear utilisa-tion self-report: a methodological consideration in cervicalscreening research. Health Services Research, 26, 97-107.

Byles, J., Sanson-Fisher, R., Redman, S., Dickinson, J. andHalpin, S. (1994) Effectiveness of three community basedstrategies to promote screening for cervical cancer. Journalof Medical Screening, 1,150-158.

Bytes, J., Redman, S., Sanson-Fisher, R. and Boyle, C. (1995)Effectiveness of two direct-mail strategies to encouragewomen to have cervical (Pap) smears. Health PromotionInternational, 10,5—16.

Canadian Taskforce on the Periodic Health Examination(1994) The Canadian Guide to Clinical Preventive HealthCare. Canada Communication Group, Ottawa.

CART Project Team, Dormer, A. and Green, S. (1995) Devel-oping methodologies for evaluating community-widehealth promotion. Health Promotion International, 11,227-236.

Chapman, S. (1989) The news on smoking: editorial coverageof tobacco and health issues in Australian newspapers,1987-1988. American Journal of Public Health, 4, 1419-1421.

Clover, K. (1992) Strategies for increasing utilisation of mam-mographic screening. Doctoral thesis. University of New-castle, Newcastle, Australia.

Cockburn, J., Hennrikus, D., Scott, R. and Sanson-Fisher,R.W. (1989) Adolescent use of sun-protection measures.Medical Journal of Australia, 151,136-140.

COMMIT Research Group (1991) Community InterventionTrial for Smoking Cessation (COMMIT): summary ofdesign and intervention. Journal of the National CancerInstitute, 83,1620-1628.

COMMIT Research Group (1995a) Community InterventionTrial for Smoking Cessation (COMMIT): I. Cohort resultsfrom a four-year community intervention. American Jour-nal of Public Health.SS, 183-192.

COMMIT Research Group (1995b) Community InterventionTrial for Smoking Cessation (COMMIT): II. Changes inadult cigarette smoking prevalence. American Journal ofPublic Health, 85,193-200.

Dixon, J. (1989) The limits and potential of community devel-opment for personal and social change. Community HealthStudies, 13,82-92.

Donner, A. (1987) Statistical methodology for paired clusterdesigns. American Journal of Epidemiology, 126,972-979.

Donner, A., Birkett, N. and Buck, C. (1987) Randomization ofcluster: sample size requirements and analysis. AmericanJournal of Epidemiology, 114, 906-914.

Donner, A., Brown, K.S. and Brasher, P. (1990) A methodolo-gical review of non-therapeutic intervention trials employ-ing cluster randomization, 1979-1989. InternationalJournal of Epidemiology, 19,795-800.

Drummond. M.F., Stoddart, G.L. and Torrance, G.W. (1987)Methods for the Economic Evaluation of Health Care Pro-grammes. Oxford Medical Publications, Oxford.

English, D.R. and Armstrong, B.K. (1994a) Melanocytic neviin children: I. Anatomic sites and demographic and hostfactors. American Journal of Epidemiology, 139,390-401.

English, D.R and Armstrong, B.K. (1994b) Melanocytic neviin children: II. Observer variation in counting nevi. Ameri-can Journal of Epidemiology, 139,402-407.

Fisher, E.B. (1995) Editorial: the results of the COMMIT trial.American Journal of Public Health,9S, 159-160.

Foot, G., Girgis, A., Boyle, C.A. and Sanson-Rsher, R.W.

by guest on July 8, 2011heapro.oxfordjournals.org

Dow

nloaded from

290 L. Hancock et al.

(1993) Solar protection behaviours: a study of beachgoers.Australian Journal of Public Health, 17,209-214.

Girgis, A., Sanson-Fisher, R.W., Tripodi, T. and Golding, T.(1993) Evaluation of interventions to improve solar protec-tion in primary schools. Health Education Quarterly, 20,275-288.

Girgis, A., Sanson-Fiiher, R.W. and Watson, A. (1994) Aworkplace intervention for increasing outdoor workers' useof solar protection. American Journal of Public Health, 84,77-81.

Green, L.W. and Kreuter, M.W. (1990) Health promotion as apublic health strategy for the 1990s. Annual Review ofPublic Health, 11, 319-334.

Hawe, P., Degeling, D. and Hall, J. (1990) Evaluating HealthPromotion. MacLennan & Petty, Sydney.

Henderson, P. and Thomas, D.N. (1980) Skills in Neighbour-hood Work. Allen & Unwin, London.

Holman, C D J., Armstrong, B.K., Arias, L.N. et al. (1988).The Quantification of Drug caused Morbidity and Mortalityin Australia. Commonwealth Department of CommunityServices and Health, Canberra.

Hsieh, F.Y. (1988) Sample size formulas for intervention stu-dies with the cluster as unit of randomization. Statistics inMedicine, 7,1195-1201.

Johannesson, M., Jonsson, B. and Borgquist, L. (1991) Will-ingness to pay for antihypertensive therapy—results of aSwedish pilot study. Journal of Health Economics, 10, 461-473.

Kelly, J.W., Rivers, J., MacLennan, R., Harrison, S., Lewis, A.E. and Tabe, B. J. (1994) Sunlight: a major factor associatedwith the development of melanocytic nevi in Australianschoolchildren. Journal of the American Academy ofDermatology, 30,40-48.

Kinne, S., Thompson, B., Chrisman, N.J. and Hanley, J.R.(1989) Community organization to enhance the delivery ofpreventive health services. American Journal of PreventiveMedicine, 5,225-229.

Knight, J., Bowman, J., Considine, R., Sanson-Fisher, R. andRedman, S. (1994) The Adolescent Project: reducing adoles-cent smoking and unsafe drinking in rural towns in theHunter area of NSW. Health Promotion Journal, 4, 54-56.

Koepsell, T.D., Martin, D.C., Diehr, P.H., Psaty, B.M. andWagner, E.W. (1991) Data analysis and sample size issues inevaluation of community-bated health promotion and dis-ease prevention programs: a mixed-model analysis of var-

iance approach. Journal of Clinical Epidemiology, 44, 701—714.

Murray, D.M., O'Connell, CM., Schmid, L.A. and Perry, C.L.(1987) The validity of smoking self-reports by adolescents: areexamination of the bogus pipeline procedure. AddictiveBehaviours, 12,7-13.

Puska, P. (1984) Community based prevention of cardiovascu-lar disease: The North Karelia Project. In Matarazzo, J.D.(ed.) A Handbook of Health Enhancement and Disease Pre-vention. John Wiley, New York.

Puska, P., Nissinen, A., Tuomilehto, J., Salonen, J.T., Koskela,K., McAlister, A., Kottke, T.E., Maccob, N. and Farquhar,J.W. (1985) The community-based strategy to prevent coron-ary heart disease: conclusions from the ten years of theNorth Karelia Project. Annual Review of Public Health, 6,147-193.

Sanson-Fisher, R.W. (1992) Me No Fry 1991/92 Summer Cam-paign: Evaluation Report. NSW Health Department,Sydney.

Sanson-Fisher, R.W. (1993) Me No Fry 1992/93 Summer Cam-paign: Evaluation Report. NSW Health Department,Sydney.

Sanson-Fisher. R.W. (1994) Me No Fry 1993/94 Summer Cam-paign: Evaluation Report. NSW Health Department,Sydney.

Sanson-Fisher, R.W. (1995) Me No Fry 1994/95 Summer Cam-paign: Evaluation Report. NSW Health Department,Sydney.

Schofield, M.J., Tripodi, D.A., Girgis, A. and Sanson-Fisher,R.W. (1991) Solar protection issues for schools: policy, prac-tice and recommendations. Australian Journal of PublicHealth,lS,nS-\4\.

Snedecor, G.S. and Cochran, W.G. (1980) Statistical Methods.Iowa State University Press, Ames, IA.

Susser, M. (1995) Editorial: the tribulations of trials—inter-vention in communities. American Journal of PublicHealth.S5,\56-l5$.

Tones, K., Tilford, S. and Robinson, Y.K.. (1990) Health Edu-cation: Effectiveness and Efficiency. Chapman & Hall,London.

US Preventive Services Task Force (1989) Guide to ClinicalPreventive Services: An Assessment of the Effectiveness of169 Interventions. Williams & Wilkins, Baltimore, MD.

World Health Organization (1986) Ottawa Charter for HealthPromotion. Health Promotion, 1, iii.

by guest on July 8, 2011heapro.oxfordjournals.org

Dow

nloaded from