OBJECTIVE/BRIEF

Australian Bureau of Statistics data show that immigrants from India and Sri Lanka are one of the largest and fastest growing ethnic groups in Australia, and particularly in the state of New South Wales (NSW). Immigration patterns indicate that, over the coming years, there will be a substantial increase in women aged 50 to 74 in these groups. This is the age group in which women are most susceptible to breast cancer. However, Cancer Institute NSW (2014) data show that women from India and Sri Lanka living in Australia have among the lowest rates of breast screening (mammograms) – the primary recommended strategy for early detection and treatment of breast cancer.

To address this significant health and social problem, the Cancer Institute NSW awards annual grants of up to AUD$100,000 to design and implement programmes that increase:

• The knowledge of enablers and barriers to address current low rates of screening among Indian and Sri Lankan women in NSW aged 50–74;
• Awareness and influence positive community attitudes towards breast screening;
• The capacity of screening services to engage effectively with the target communities;
• Breast screen rates among women from the target communities by at least 5 percent

The Multicultural Health Communication Service (MHCS), a specialist division of the NSW Ministry of Health, applied for and received one such grant of AUD$100,000 (the budget for this project) in 2014–2015.

STRATEGY

In developing a communications strategy, MHCS noted and took account of:

• The difficulty of reaching culturally and linguistically diverse (CALD) communities such as Indian and Sri Lankan women aged 50-74 – an older generation of migrants, many of whom do not speak or read English fluently and who often continue to live within tight community groups and cultural enclaves;
• A number of previous campaigns using mass media advertising and publicity (top-down information) had failed to significantly increase breast screening rates among these groups;
• Most information for CALD communities were direct translations of English language materials.

MHCS resolved to implement an evidence-based programme informed by research, to engage in innovative ways with stakeholders and this important group, and to rigorously evaluate the project. To facilitate this, MHCS implemented three key strategy development steps:

1. MHCS engaged a team of researchers at the University of Technology Sydney (UTS), led by Professor Jim Macnamara, to assist in conducting formative and evaluative research to guide the project;
2. MHCS established a Project Steering Group comprised of key stakeholders. Members included representatives of the NSW Refugee Health Service and BreastScreen Liverpool, a breast screening clinic in an area of Indian and Sri Lankan migrant concentration, as well as UTS academics and senior executives of MHCS. The Project Steering Committee also consulted with local area health services (e.g. South-West Sydney Local Health District);
3. On the advice of UTS and the Steering Group, MHCS commissioned three formative research studies:
   a) A survey of women in the target audience (n = 250);
   b) Focus groups to gain in-depth understanding of the target audience’s awareness and attitudes towards breast cancer and screening; concerns and barriers to increased breast screening; and their primary sources of information and influence in relation to health issues; and
   c) A global literature review of academic and professional research in relation to cancer detection programs and CALD community health communication. This produced a 24-page report summarising international research findings prior to launching the project.

Formative research revealed that:

• While Indian and Sri Lankan women in the target age group use mass media, including ethnic newspapers, as a source of local news, they do not use or attach credibility to mass media as a major source of information about health issues;
• They rely mostly on their peers, families, and local communities for health information, including local Indian and Sri Lankan doctors and community leaders.

Formative research also revealed a number of barriers and challenges that needed to be overcome in order to increase breast screening rates among Indian and Sri Lankan women, including:

• A lack of knowledge about breast cancer;
• Lack of understanding of English and poor translation of information from English;
• Deep-seated fears and superstitions (e.g. that attending screening for breast cancer could indicate ill health in a family and reduce the chances of marriage for daughters);
• Concern for family honour if cancer is detected;
• A resulting ‘culture of silence’ (cancer is just not something to talk about);
• Modesty, including concerns about exposure in front of men working in breast screen clinics; and
• A lack of cultural competency in breast screening clinics (e.g., lack of privacy, unavailability of translators).

Based on the above research findings, MHCS developed a strategy that involved:

1. The establishment of community partnerships with a wide range of organisations representing and interacting with Indian and Sri Lankan women. As well as members of the Project Steering Group, such as the NSW Refugee Health Service and BreastScreen NSW clinics in relevant areas, these included the Sri Lankan Health Professionals’ Association, the Indian Doctors’ Association, the Sri Lankan and Indian Welfare Association, Migrant Resource Centres and women’s health services in Local Health Districts;
2. Identification of ‘community champions’. Through the partnerships established, a number of ‘community champions’ and leaders were identified and engaged in spearheading the project. These included Indian and Sri Lankan doctors, community and religious leaders, and some women who had survived breast cancer and were willing to support the project;
3. Based on these partnerships and their outreach into Indian and Sri Lankan communities, a community-based collaborative planning and design approach was taken in developing the project. This included collaborative design of all materials from naming of the project and logo design to planning all activities undertaken as part of the project (see ‘Execution/Implementation’);
4. All information materials were written/rewritten ‘in language’ by native speakers of each of the key languages (Tamil, Hindi, and Sinhalese) – not as translations of English language content.

EXECUTION/IMPLEMENTATION

Based on the in-depth research and the community-based collaborative approach adopted, a range of activities was undertaken over a 12-month period to July 2015, including:

• Creation of the ‘Pink Sari’ name, logo and artwork – based largely on ideas and suggestions from the
• Development of a Pink Sari Project website (http://pinksariproject.org);
• Creation of a Pink Sari Facebook page (https://www.facebook.com/thepinksariproject);
• A number of Pink Sari community leaders’ forums were held at which ‘community champions’ were briefed and engaged in the project;
• Community information sessions were held for Indian and Sri Lankan women;
• A Pink Sari pledge was created in which women were encouraged to write a pledge to have a breast screen or encourage other women to have one;
• 100 Indian and Sri Lankan women marched in pink saris in the Parramasala parade through the streets of Parramatta, Sydney. Parramasala is a major festival involving street parades, food stalls, music, dance, poetry, film, art and street performances (;
• Volunteers planned and organised A Pink Sari fashion show;
• A Pink Sari Photo Exhibition of 14 breast cancer survivors was held during the project period. Indian and Sri Lankan women came up with the idea, volunteered and 14 leading photographers donated their time to creating the exhibition;
• Another innovative initiative was to enlist daughters, who are mostly more educated and Westernised than older generations, to encourage their mothers to have a breast screen through online videos, pledges and personal communication;
• The various activities resulted in a large amount of highly favourable media publicity;
• A study of the cultural competency of a BreastScreen NSW clinic was undertaken and recommendations made to increase cultural competency as a key enabler of increased breast screening for CALD groups.