REPORT FROM THE COMMISSION TO THE COUNCIL, THE EUROPEAN PARLIAMENT, THE ECONOMIC AND SOCIAL COMMITTEE AND THE COMMITTEE OF THE REGIONS ON THE EVALUATION OF THE EUROPEAN CANCER WEEK 1995
#**4p«Wtti COMMISSION OF THE EUROPEAN COMMUNITIES VOLUME I Brussels, 10. 02. 1997 COM(97) 19 final REPORT FROM THE COMMISSION TO THE COUNCIL, THE EUROPEAN PARLIAMENT, THE ECONOMIC AND SOCIAL COMMITTEE AND THE COMMITTEE OF THE REGIONS ON THE EVALUATION OF THE EUROPEAN CANCER WEEK 1995 CONTENTS 0. 1. SUMMARY PRESENTATION OF EUROPEAN CANCER WEEK 1995 1. 1 1. 2 1. 3 1. 4 1. 5 1. 6 Legal basis Previous Weeks Importance of information campaigns European Code against Cancer General organisational principles 1. 5. 1 Partnership with non-governmental organisations 1. 5. 2 European character, Community added value and subsidiarity 1. 5. 3 Professionalism Specific features of the 1995 Week 1. 6. 1 Campaign aims 1. 6. 2 Campaign tone 1. 6. 3 Target groups 1. 6. 4 Types of material 1. 6. 5 Activity levels II. QUANTITATIVE ANALYSIS II. 1 Campaign aimed at general public II. 1. 1 Posters and leaflets II. 1. 2 Media relations II. 1. 3 Advertising II. 1. 4 Conclusions. II. 2 Campaign targeted on general practitioners 11. 2. 1 Brochure design, publication and dissemination 11. 2. 2 Advertising III. QUALITATIVE ANALYSIS III. 1 Campaign aimed at general public III. 1. 1 Evaluation methodology III. 1. 2 Results at European level III. 1. 3 Results per country III. 1. 4 Conclusions III. 2 Campaign aimed at general practitioners 111. 2. 1 Evaluation methodology 111. 2. 2 Reaction to and views on the brochure 111. 2. 3 Knowledge of and views on the Code 4 5 5 5 6 7 7 7 8 9 10 10 10 11 11 12 12 12 12 13 14 14 15 15 16 16 17 17 18 19 20 21 21 21 22 111. 2. 4 Reaction to and views on other materials used in the campaign 111. 2. 5 Conclusions IV. FOLLOW-UP ACTIVITIES V. BUDGET 22 23 23 25 0. SUMMARY Every year the "Europe against Cancer" Programme holds a European Cancer Week in the second week of October with the support of Member States' anti cancer Leagues and Associations. In 1995 this information campaign focused on promoting the revised version of the European Code against Cancer consisting of 10 simple recommendations for cancer prevention. The aim of the Europe-wide campaign was to get the vital message across to the general public that everyone can reduce their own personal risk of contracting cancer, to encourage people to adopt a more balanced lifestyle and to draw attention to the benefits of early detection. To achieve these aims the general public was approached not only directly but also indirectly - through targeting general practitioners as intermediaries with a major role to play in this respect. The abovementioned Leagues and Associations printed 6. 7 million copies of common European materials (posters and leaflets) made available by the Commission in connection with the Week. Furthermore, a media campaign coordinated under the Programme generated 172 million contacts with European citizens (112 million via press articles and at least 60 million via television or radio programmes), to which can be added some 172 million contacts achieved via free advertising in the European press (37 million contacts) and on television (135 million contacts). The media pressure thus created, underpinned by a whole host of events organised by the Leagues during the Week, had a major impact on European Union citizens' knowledge of cancer prevention. Thus, by the end of the campaign over 20 million more Europeans were convinced that cancer is preventable, while the various risk factors (lack of fruit, vegetables and cereals in diet, fatty foods, excessive consumption of alcohol, lack of physical exercise, smoking) were better known after the campaign. European Cancer Week 1995 also helped reinforce the profile of Community action in the public health field: 24% of Europeans said they had heard of European Cancer Week, while 12% (spontaneously) and 24% (with prompting) said they knew of the European Code against Cancer. During the Week almost all the Union's general practitioners (321 000) received a brochure on the European Code against Cancer published under the Programme. A telephone survey of GPs showed that this publication was viewed very favourably (87. 6% of doctors who recalled receiving the brochure said it was well done, while 77. 5% found it very useful or moderately useful). Therefore, GPs can now be expected to incorporate the cancer prevention recommendations into their medical practice on a wider basis. I. 1 2 3 PRESENTATION OF EUROPEAN CANCER WEEK 1995 This report provides facts and figures for evaluating (quantitatively and qualitatively) the European dimension of European Cancer Week 1995 in line with the duty of transparency incumbent upon the Commission in the exercise of its powers. 1. 1 Legal basis As a key element in the activities undertaken as part of the "Europe against Cancer" Programme in the public information and health education field, organisation of a European Cancer Week is one of the measures set out in the Annex to the Council Decision adopting a 1990 to 1994 action plan1 ("second action plan") as well as in the Annex to the decision of the European Parliament and of the Council adopting an action plan to combat cancer for 1996 to 20002 ("third action plan "). Due to considerable delays in the adoption procedure, the decision of the European Parliament and of the Council adopting the third action plan did not materialise until 29 March 1996, which meant that the Programme had no action plan in 1995. The legal basis for organising European Cancer Week (as well as for the other activities undertaken under the Programme in 1995) was therefore contained in the remarks on budget line B3-43043, namely that the appropriation for the Programme is intended to cover "expenditure on public information campaigns and on increasing awareness". It is worth noting here that organisation of European Cancer Weeks was at no time called into question during the procedure to adopt the third action plan. 1. 2 Previous Weeks 4 European Cancer Week is held every year in the second week of October. Since the second action plan started the Week has centred on the following topics: 1990 : Tobacco and alcohol 1991 : Early detection and systematic screening 1992 : Cancer prevention at work 1993 : Passive smoking 1994 : Beneficial effects of fresh vegetables and fruit. Decision of the Council and the representatives of the governments of the Member States meeting within the Council on 17 May 1990 adopting a 1990 to 1994 action plan in the context of the "Europe against Cancer" Programme (OJ L 137, 30. 5. 1990, p. 31). Decision No 646/96/EC of the European Parliament and of the Council of 29 March 1996 adopting an action plan to combat cancer within the framework for action in the field of public health (1996 to 2000) (OJ L 95, 16. 4. 1996, p. 9). General Budget of the European Union, OJ L 369, 31. 12. 1994/ 5 Further information on these campaigns can be found in the report from the Commission on the evaluation of the action undertaken under the Programme between 1987 and 19924, in the report from the Commission on the execution of the Programme in 19935 as well as in the report from the Commission on the implementation of the second action plan6. 1. 3 Importance of information campaigns It is generally accepted that some 70% of deaths linked to cancer stem from personal choices governing lifestyle and environment. Consequently, regardless of medical advances there will be no major reduction in the incidence of cancers and mortality linked to this disease unless the public can be persuaded to modify certain habits and attitudes. Therefore, people need information to allow them to choose a lifestyle providing maximum protection against the risk of contracting certain cancers, although such risks can never be totally banished. For this reason, providing the public with information plays an important role both in the second and in the third action plans under the "Europe against Cancer" Programme. In addition to annual organisation of European Cancer Week, the third action plan also focuses on: - - - - getting the cancer prevention message across more effectively; supporting networks involved in exchanging information and experience on cancer prevention; promoting information and awareness campaigns targeted on specific groups; promoting Europe-wide cancer prevention projects, especially concerning smoking. those A Eurobarometer survey undertaken in the 15 Member States in spring 1995 - see section III. 1 of this report for more details - shows how vital it is to run information campaigns on cancer prevention, since it reveals that 33% of Europeans believe cancer cannot be prevented (with the rate exceeding 50% in some countries). Therefore, Europeans are not sufficiently aware that every individual can do something to reduce their personal risk of contracting cancer, an information deficit which the European Cancer Weeks attempt to put right. Report from the Commission to the Council, the European Parliament and the Economic and Social Committee on the evaluation of the effectiveness of Community action undertaken in the context of the "Europe against Cancer" Programme (1987-1992), COM(93) 93 final, 15. 3. 1993. Report from the Commission to the Council, the European Parliament, the Economic and Social Committee and the Committee of the Regions on the execution of the "Europe against Cancer" Programme in 1993, COM(94) 550 final, 5. 12. 1994. Report from the Commission to the Council, the European Parliament, the Economic and Social Committee and the Committee of the Regions on the implementation of the second Action Plan (1990-1994), COM(95) 356final, 18. 7. 1995. 6 1. 4 European Code against Cancer Each European Cancer Week concentrates on a specific topic related to cancer prevention. The 1995 Week set out to promote the revised version of the European Code against Cancer, the first version of which was drawn up in 1987 by the High-level Committee of Cancer Experts7 set up under the aegis of the Commission in January 1986 and which has since become the Programme's main scientific adviser. This Code - consisting of 10 simple recommendations putting across the essential messages on cancer prevention - has become a cornerstone of the Programme, with all the other information activities being based on it. Since its launch in 1987 the Code has mainly been disseminated by non-governmental organisations active in combatting cancer in Member States. In order to keep up with scientific progress, the Commission asked the European Institute of Oncology (Milan) to draw up a revised version plus an annex giving the scientific reasons for each of the 10 recommendations. The Institute coordinated the work done by a group of European experts in drafting the new text for the revised version of the Code, which the High-level Committee of Cancer Experts approved in December 1994 (Annex VI. 4). The objective of the 1995 Week was to draw attention to all 10 basic rules for cancer prevention (see 1. 6. 1). 1. 5 General organisational principles /. 5. 1 Partnership with non-governmental organisations The anti-cancer Leagues and Associations constitute the Programme's main partners when it comes to implementing the information campaigns. These bodies - whose role is acknowledged both in the second and third action plans - not only have considerable resources allowing them to bolster the European campaign at national, regional and local level, but also considerable experience in getting prevention messages across to the public. The Programme's main partners during the 1995 Week are listed in Annex VI. 5. Committee members in 1995: Prof Veronesi Prof. Bleehen Prof Boon Prof, van der Schueren Prof. Diehl Prof Overgaard Prof. Estape Dr Gonzalez Enriquez Prof Kleihues Prof Pujol Prof. Garas Dr Buttimer Prof. Dicato Prof. Kroes Prof Conde Prof. Einhorn Prof. Holm 10 11 12 13 14 Thus, the Commission makes a point of cooperating closely with the Leagues and Associations from the very outset, i. e. when drawing up the plans for the Week. To this end, the group of European representatives of these bodies (which met three times in 1995 under the Programme to prepare or evaluate the Week) set up a working group which the Commission departments running the Programme kept very closely involved in all decisions on the campaign's overall strategy and target groups, as well as on the text, slogans and visual materials to be used for the campaign. Furthermore the working group - which keeps the plenary group up to date on the progress made at the preparatory stage - was consulted by the Programme organisers on selection of the contractor commissioned to devise and coordinate the campaign (see 1. 5. 3). Involving the Leagues upstream of the Week proper ensures that the messages they put across are European ones and that they mobilise their resources to this end during the Week. As for the part of the 1995 campaign involving general practitioners (see II. 2), the Programme also cooperated with the European Group of Representatives of General Practitioners. /. 5. 2 European character, Community added value and subsidiarity From the very outset of the planning stage the Commission and the Leagues and Associations stressed the need to run a European campaign based on a common concept and materials of instantly recognisable Community origin. For the Programme this means showing European citizens that the Community plays an active role in the public health field, cancer prevention in particular, a role which also involves developing synergy between all the activities of national or regional bodies. For the Leagues and Associations it means harnessing the campaign design work done at European level and showing that they are active and acknowledged % partners - not only at national level but also at European level - in promoting a major Community cause, i. e. the war on cancer. The working group is the vehicle through which the European anti-cancer Leagues' expertise in getting messages on prevention across to the general public is channelled to devise and implement the information drives run as part of European Cancer Weeks. This pooling of effort generates considerable economies of scale (as compared to national campaigns run separately alongside one another) not only in regard to human resources but also financial ones. For example, the visual elements of the posters and leaflets are the same and therefore need to be designed and photoengraved only once; it is just the texts which vary from one country to another. In addition to the abovementioned economies, organising a Europe-wide campaign also boosts the impact of the publicity drive, given the fact that certain events receive more attention, from both the media and the public, when presented as international events. The UN's No-Smoking Day and Women's Day would probably receive less publicity if they were purely national events, and the same 8 15 16 17 18 applies to European Cancer Week. It seems that the public and the media like the idea of people in several countries uniting their efforts to promote a major social cause for a special day or week. Although the European Weeks are homogeneously presented in all member countries (same visuals and basic message), they do allow some margin for national modifications to reflect differences in the health policy field. Thus, for example, in 1995 Point 10 of the European Code against Cancer8 was expanded on in some countries to fit in with national policy on screening for breast cancer. In specific terms, the Commission and the Leagues divided up the work for the 1995 Week as follows: the Programme provided its partners with the films for printing the leaflets and posters, while the printing and dissemination of these materials was paid for by the Leagues (with a financial contribution from the Programme though - see V. ). Furthermore, the Commission also handled, via its contractor, much of the media relations before and during the Week (see II. 1. 2) and endeavoured to obtain free advertising (see*II. 1. 3 and II. 2. 2). For their part, the Leagues organised a whole host of activities during the Week making use of the common materials produced (colloquies, exhibitions, events in schools, shows, etc. ). /. 5. 3 Professionalism In order to make sure the campaign was highly visible Europe-wide, the Programme decided to bring in a professional public relations and media communications agency. An open invitation to tender was published in June 1995 to sound out the market9. There were 21 replies, and (following the go-ahead from the working group of Leagues and Associations) the firm of EURO-RSCG was awarded the contract not only on the basis of the quality and price of its tender but also because it was well established in almost all Member States - a must, especially for handling relations with the national media. It should be noted that the contract with EURO-RSCG covers not only design and coordination of European Cancer Week but also promotion of the Programme in general. However, in 1995 the company's energies were almost exclusively devoted to the Week. The contract was concluded for one year, renewable four times for a further year. Following the company's successful work for the 1995 campaign and in line with a recommendation from the Leagues and Associations' plenary group, the contract was renewed for 1996. "Check your breasts regularly. Participate in organised mammographie screening programmes if you are over 50. " - See also 1. 4. OJC 134, 1. 6. 1995. 9 1. 6 Specific features of the 1995 Week /. 6. J Campaign aims 19 The campaign's main aim was to promote the European Cancer Code (see 1. 4), through highlighting the 10 prevention recommendations to ensure that Europe's citizens were: - - - informed of the fact that everyone can reduce their personal risk of contracting cancer; encouraged to adopt a healthier lifestyle based on the recommendations; made aware of the benefits accruing from early detection of cancer. This objective was pursued by addressing the general public - - directly via a Europe-wide publicity campaign; indirectly, by raising the awareness of general practitioners as key intermediaries (also see 1. 6. 3). 20 The campaign also set out to let the Union's citizens know that the Community is a player in the public health field (Community character of the Week). /. 6. 2 Campaign tone 21 22 23 All cancer prevention players agree that any information campaign aimed at modifying certain aspects of citizens' behaviour adversely affecting their health needs to adopt a positive tone, to encourage and motivate, and avoid pointing the finger of blame. Working from general guidelines the Programme contractor came up with a campaign stressing that everyone can opt for a healthy lifestyle, consult their doctor about certain persistent symptoms or disorders and - for women - participate in screening programmes, all with the aim of reducing the risk of contracting cancer. That every individual can opt for this responsible approach is reflected in the campaign slogan - "Preventing cancer - what I can do". The visual materials used in the campaign also reflect this same positive approach, presenting as they do 10 smiling and reassuring faces (10 people from 10 different countries, one for each of the Code's 10 points), each announcing the choice they have made to reduce their risk of contracting cancer and encouraging others to follow their example (also see Annex VI. 3). The accompanying texts were couched in very straightforward language because several Eurobarometer surveys had shown that people with no more than a rudimentary education know the least about cancer prevention possibilities. However, although it was deemed essential to keep things simple, major importance was attached to the scientific content of the materials, all of which were based on the scientific annex to the European Code against Cancer. An expert from the European Institute of Oncology in Milan was given the task of 10 24 25 26 27 28 29 coordinating the work to revise the European Code against Cancer and thus ensured that the texts drawn up were scientifically sound and consistent. /. 6. 3 Target groups The main target of the 1995 Week was the general public, because the European Code against Cancer's 10 recommendations concern all Europeans. General practitioners formed the campaign's second target group, with them being urged to pass on the Code's prevention messages to their patients. GPs' central role in educating their patients is self-evident because they are on the frontline when it comes to delivering health care to the populace as a whole. /. 6. 4 Types of material The pictures of people promoting the Code's 10 recommendations were incorporated into various types of material aimed at the general public, i. e. a series of 11 posters, a series of 11 leaflets, a video and a press release. The series of 11 posters (A2-format), produced in 11 language versions, contained a general poster covering the Code overall plus one for each of the Code's 10 points. Similarly, the series of 11 leaflets (folded A4-format) consisted of a general one plus 10 individual ones pressing home the Code's individual points. The six pages of these leaflets consisted of the following: - - - - Page 1: 10 faces (general leaflets) Face of person "representing" the particular point of the Code (other leaflets) Pages 2 to 4: Prevention messages Page 5: Presentation of the 10 points of the European Code against Cancer Self-evaluation test allowing individuals to determine how much they know about cancer prevention. Page 6: featured on the posters and A video (35 mm, black and white) presenting the Code's 10 key recommendations was produced in 11 language versions. During the 30-second clip each of the 10 actors the Code's 10 recommendations in their mother tongue. While the introduction and ending were in the vernacular, the rest of the soundtrack remained multilingual - but with subtitles added (11 language versions) - thus lending the video the desired multicultural flavour. The video was then made available to the major European television networks (see II. 1. 3). leaflets presented 30 The front page of the general leaflet (showing the 10 faces) was also used for an announcement intended for the general press (see II. 1. 3). 11 31 The following materials were produced for media relation purposes: - - "master" press information pack (European level); "national" press info packs; video news release linked to the campaign; these cassettes, 20 minutes long, were sent to the main European television stations. 32 The materials used for the GP campaign are dealt with under II. 2. 1. 6. 5 A ctivity levels 33 34 35 The 1995 European Cancer Week involved two clear-cut levels of activity, as explained below. Drawing on advice from the group of anti-cancer Leagues and Associations, the "Europe against Cancer " Programme devised and implemented - through its contractor - a European campaign whose various elements, based on common materials and a common approach to media relations, were used in all the European Union's 15 countries. Chapters II and III of this report contain quantitative and qualitative analysis data on the campaign. The campaign was supplemented by activities at national, regional or local level undertaken by the anti-cancer Leagues and Associations which organised, in most countries, a wide range of different events (scientific colloquies, health forums, exhibitions, educational shows, concerts, events in schools, street theatres, use of "infomobiles", etc. ) during European Week. Although not directly supported by the Programme, these activities underscored the European origin of the campaign of which they formed part. Since such activities were the exclusive responsibility of the anti-cancer Leagues and Associations, they have not been included in this evaluation report. While difficult to quantify, they considerably amplified the impact of the European campaign however. EL QUANTITATIVE ANALYSIS 36 This chapter contains the main analysis data at European level. Annex VI. 2 of this report contains the individual results sheets giving the qualitative and quantitative data. per country. II. 1 Campaign aimed at general public II. 1. 1 Posters and leafle is 37 in each country printed From films made available to them under the Programme, the Leagues and Associations the common European materials in accordance with their financial resources and publicity policies. All in all, 6 700 000 posters and leaflets were printed in this manner throughout the European Union countries, of which there were: 12 5 436 000 "general" leaflets (covering the Code's 10 points) 964 000 "specific" leaflets (on a particular point of the Code) 124 500 "general" posters 170 200 "specific" posters. These materials were disseminated via the networks operated by the Leagues and Associations in each Member State. Exact distribution figures are not available for all countries, but on the basis of the available figures it is estimated that an average of some 80% of the documents printed by the Leagues and Associations were distributed on the occasion of European Week. //. 1. 2 Media relations The Commission's contractor was given the job of approaching the media in the 15 countries in connection with European Cancer Week and coordinating media relations, all in cooperation with the anti-cancer Leagues and Associations. A European press conference, attended by Commissioner Flynn, plus a series of 14 press conferences in Member States10 were held to launch the Week. More than 200 journalists attended them. Following the press conferences and as a result of press relations in general, the European Week, and more particularly the Code, were mentioned by some 700 articles in the Member States' print media. Both the national and the regional press in most countries covered the event. Specific mention of the European Commission and, more particularly, the "Europe against Cancer" Programme as the originators of the campaign varies from country to country; on average, some 50% of the articles name the European Commission as the originator of the campaign. The number of contacts obtained via the general press amounted to some 112 million11. As for radio and television coverage, the European Week was covered by some 170 news broadcasts or other mentions in the Union countries, both on private and public national radios and televisions as well as regional stations. In the 10 countries for which audience figures are available12, radio and television coverage created some 60 000 000 contacts; the total number of contacts generated via the media therefore amounts to at least 172 000 000. In Germany the anti-cancer organisations went in for other types of press relations. As is customary, this figure was calculated by multiplying by 2. 5 the number of copies sold of the dailies and periodicals concerned so as to arrive at the number of effective contacts (= circulation); some 45 million copies of the newspapers etc. involved were therefore sold in the 15 Member countries. Figures not communicated for the 61 programmes/mentions in Spain (38), Luxembourg (3), Italy (4), Portugal (10) and Netherlands (6). 13 38 39 40 41 42 10 H 12 43 44 45 46 47 13 14 ILL3 Advertising Since the budget involved was relatively modest for a publicity campaign aimed at getting through to the citizens of 15 countries, the decision was taken not to buy advertising. However, the Commission's contractor was asked to obtain free advertising on television (showing of video) and in the press (publication of press release in magazines and daily papers). Given the deadlines set for achieving this, the contractor's efforts were focused on television. It should be noted here that the legal provisions adopted by certain countries (in particular Spain, United Kingdom, Finland and - since November 1995 - Greece) limit the provision of free advertising, while other countries will grant free advertising only if advertising is also purchased. The figures given in the following paragraphs relate only to advertising obtained during the campaign', in some cases free advertising continued to be granted afterwards, thus amplifying the Week's impact. Despite the difficulties mentioned above, the Commission managed - via its contractor - to obtain a large chunk of free television advertising: thus, the video was shown more than 300 times in seven countries (Germany, Denmark, France, Greece, Italy, Netherlands, Portugal) and on the Eurosport channel. The number of contacts generated by this was approximately 135 000 000 OTS13. It should be noted that in monetary terms the free television advertising thus obtained amounted to around ECU 800 000. In addition to the above, the press release promoting the European Code against Cancer was published for free on 42 occasions in the general press in five countries, thus generating some 37 000 000 contacts14, amounting in cash terms to over ECU 200 000. 77. 7. 4 Conclusions To sum up the quantitative analysis, the campaign to promote the European Code against Cancer among the general public created at least 344 000 000 contacts (see Annex VI. 1, Fig. 1): 172 000 000 via media relations (112 000 000 for the press and at least 60 000 000 for radio and television) and 172 000 000 via free advertising (135 000 000 for television, 37 000 000 for the general press). To this should be added the number of contacts - difficult to quantify - created through distribution of the 6. 7 million leaflets and posters. OTS = "Occasion to See", i. e. the number of people likely to have seen the video. As is customary, this figure was calculated by multiplying by 2. 5 the number of copies sold of the dailies and periodicals concerned so as to arrive at the number of effective contacts (= circulation); some 15 million copies of the newspapers etc. involved were therefore sold in the five countries in question. 14 48 49 50 51 n. 2 Campaign targeted on general practitioners II. 2. 1 Brochure design, publication and dissemination Once general practitioners had been chosen as the campaign's second target group (see 1. 6. 2), the "Europe against Cancer" Programme consulted the European Group of Representatives of GPs' Associations, with which it maintains regular contact, to jointly determine the best way of getting through to this group and making it aware of the prevention recommendations contained in the European Code against Cancer. It was agreed to mail a brochure, consisting of three main sections as set out below, to every GP in the European Union: a. b. c. the text of the 10 points of the European Code against Cancer; a section common to all countries setting out the science behind each of the Code's recommendations and based on the scientific annex; a section aimed at persuading GPs to incorporate the recommendations of the European Code against Cancer into their medical practice. Italy and United Kingdom). The The common part of the brochure was written by a team of representatives of general practitioner associations from five European countries (Germany, France, Ireland, (incorporating recommendations into medical practice) is specific to each country, because national settings vary considerably due not only to different social security systems and health policies but also different cultures and customs. The authors of these "national" sections were also representatives of general practitioner associations. section last In order to ensure scientific consistency between the Annex to the European Code against Cancer and the common section of the brochure, the European Institute of Oncology (Milan) was asked to undertake the necessary scientific coordination. The "Europe against Cancer" Programme's contribution to publication of the brochure involved: - - - - - - - approaching prospective authors;. organising working meetings; paying authors' fees, travel and secretariat expenses; coordinating translation of the common part into all Community languages, in cooperation with the European Commission's Translation Service; formatting, proof-reading and printing the brochure, in cooperation with the Office for Official Publications of the European Communities (EUROFFICE); compiling a list (in electronic form) of addresses of all GPs in the European Union15; addressing and mailing the brochure, in cooperation with EUROFFICE. 15 official For most countries associations; in countries where this was not possible - in particular for data protection reasons - these addresses were obtained through a broker. these addresses were supplied by the general practitioners' 15 52 53 54 It should be noted that all the necessary data protection measures were taken when handling the GPs' addresses. The 16 versions16 of the brochure (containing a foreword from Commissioner Flynn) were distributed to the GPs at the beginning of European Cancer Week. The total number of copies mailed was around 321 000, covering almost all general practitioners in the European Union. The percentage of those "returned to sender" was under 1% on average, which testifies to the high reliability of the address files used. The editions for Denmark and the Netherlands did not keep to the general structure of the brochure as described in paragraphs 48 and 49 above. In Denmark's case, the professional associations contacted opted for a brochure bereft of a national part and containing the Annex to the European Code instead of the common text mentioned above. In the Netherlands, the brochure distributed to GPs contained only the Code's 10 points and the common part, since the general practitioners' associations there did not wish to write a national part. As the qualitative analysis shows, this different approach had an effect on the reception accorded the brochure by the medical profession in these two countries (see III. 2). II. 2. 2 Advertising The Commission contractor was asked to obtain free advertising in professional health journals in the 15 countries in the form of publication of an announcement informing GPs that the "Europe against Cancer" Programme would be sending them a brochure. The negotiations were difficult in view of the short deadlines and the media priorities laid down for television as part of the general public campaign. Nevertheless, free advertising was obtained on 11 occasions in eight medical journals in four countries. This corresponded to a monetary value of ECU 100 000 and generated over 800 000 OTS among the medical professions. m. QUALITATIVE ANALYSIS 55 56 Qualitative analysis of European Cancer Week 1995 is based on two main tools: "Eurobarometer" surveys covering the campaign aimed at the general public and a telephone survey for the campaign targeted on general practitioners. This chapter gives the main findings of the qualitative analysis. See Annex VI. 2 of this report for the individual results sheets containing the qualitative and quantitative data, per country (general public campaign and GP campaign). 16 Two versions for Belgium. 16 EQ. 1 Campaign aimed at general public III. 1. 1 Evaluation methodology 57 58 The 1995 European Cancer Week's impact on the general public has been evaluated on the basis of Eurobarometer surveys 43. 0 (March/April 1995) and 44. 0 (October/November 1995). During these two surveys - which involved a representative sample of some 16 000 Europeans17 and were carried out by INRA (EUROPE), a European network of market research and public opinion agencies - a number of identical questions were asked before and after European Week; comparing the replies received during the two surveys allows us to draw certain conclusions about the campaign's impact on the Union's citizens. As far as the Commission departments running the "Europe against Cancer" Programme know, no major "rival" campaign informing the general public of ways of preventing cancer was held in the period between the two surveys. The campaign's main objective was to promote the European Code against Cancer, which contains the essential recommendations enabling everyone to reduce their own individual risk of contracting cancer. Thus, most of the questions concerned ways of preventing cancer and the factors likely to increase cancer risks. Other questions concerned people's awareness of European Cancer Week and the European Code against Cancer. 59 In order to obtain a more detailed analysis per country, the Eurobarometer survey results were used to calculate the following two performance indices: - - performance index pertaining to the change in Europeans' attitudes, calculated by comparing the change in the percentage of the population in a particular country believing that cancer can be prevented with the change in the European average18; performance index pertaining to awareness of the European Code against Cancer, calculated by comparing the change in the percentage of the population in a particular country aware of the European Code against Cancer with the change in the European average19. 17 18 2 000 for Germany, 1 100 for Great Britain, 300 for Northern Ireland, 500 for Luxembourg and 1 000 for the other countries. This index i, is calculated as follows: ij = 100 x nt' - nt Et' - Et x Et nt where: E = Europe n = country considered t = spring 95 value t' = autumn 95 value 19 This index i2 is calculated as follows: 17 Furthermore, the rate of media pressure was established for each country; this is calculated by dividing the total number of contacts generated nationally via the campaign (advertising + media relations) by the number of that particular country's inhabitants. The two performance indices plus the rate of media pressure are given in the quantitative and qualitative analysis results sheets per country in Annex VI. 2. III. 1. 2 Results at European level Prior to the campaign (March/April 1995 survey) 33. 3% of the Union's citizens20 did not think it was possible to prevent cancer; after the campaign (Eurobarometer October/November 1995 survey) this figure had dropped by 7. 2 percentage points to 26. 1% (see Annex VI. 1, Fig. 2). Applied to the entire population of the European Union aged 15 and over (286. 6 million) - the age range of the population sample surveyed - this reduction means that after the campaign over 20 million more Europeans believed it possible to prevent cancer. One of the campaign's main aims had therefore been achieved, i. e. to make European citizens aware of the fact that combatting cancer also hinges on doing more for one's health. This same trend towards greater awareness of cancer preventability emerges when comparing attitudes before and after the campaign towards certain individual risk factors forming a sub-group of the risk factors highlighted in the Code (see Annex VI. 1, Fig. 3). Thus, the percentage of Europeans believing that excessive weight can increase the risk of cancer rose from 40% before the campaign to 48% after; the corresponding rate for excessive consumption of alcohol rose from 60 to 67%, for too much fatty food from 56% to 60%, for lack of exercise from 36% to 41%, for a diet low in fruit and vegetables from 50 to 53% and for a diet low in cereals from 45 to 48%. Awareness of the risks associated with smoking - very high before the campaign started (94% of Europeans believed that smoking increased the risk of cancer) - rose even higher, because after the campaign the corresponding figure was 96%. Both surveys contained two questions on screening for breast cancer, and these were therefore directly linked to Point 10 of the European Code against Cancer ("Check your breasts regularly. Participate in organised mammographie screening programmes if you are over 50"). The first asked whether women had ever heard about national screening programmes in connection with breast cancer. Prior to the campaign 77% of European women said they had heard of such programmes, 60 61 62 /, = 100 x nt'-nt Et' - Et x Et' nt' where: E = Europe n = country considered t = spring 95 value t' = autumn 95 value Weighted European averages. 20 whereas after the campaign the corresponding figure was 81%. The second question asked women whether they would take part in such a screening programme. The percentage of women stating that they would participate on their own initiative in such programmes rose from 65% before the campaign to 66% afterwards, while the percentage of women replying that they would participate only if they received a written invitation or reminder from their doctor remained the same at 27%, and the percentage of women saying they would not take part in a screening programme fell from 7% before the campaign to 6% afterwards. The campaign for 1997 European Cancer Week (whose main theme will be prevention of female cancers) will focus on this subject and endeavour to further heighten women's awareness in this key prevention field. Both surveys asked two identical questions aimed at measuring people's awareness of the European Code against Cancer (which has existed since 1987 and the revised version of which formed the campaign's focal point). The first measures spontaneous knowledge of the Code, whereas the second jogs respondents' memory somewhat by giving an example of the Code, thus evaluating knowledge when prompted (i. e. assisted recall). An increase in such awareness, by as much as eight percentage points, is observed in all countries apart from Sweden (see III. 1. 3); the European average for spontaneous knowledge went up from 9% before the campaign to 12% afterwards. Knowledge when prompted was approximately double that of spontaneous recall, and the European average increased from 21% before the campaign to 24% after. Two questions were asked only during the autumn survey in order to evaluate people's awareness of European Cancer Week and to find out from which sources they had heard about it. It turned out that some one quarter of Europeans (24%) say they had heard something about European Cancer Week (spontaneous knowledge) - a remarkable result highlighting the fact that the campaign's European origin is relatively well established. The replies to the second question show that television - whether in the form of current affairs programmes/reports (44%) or advertising (41%) - was clearly the main medium through which Europeans came to hear about European Cancer Week. Newspapers and periodicals/magazines came a poor second in this respect. III. 1. 3 Results per country 63 64 65 Analysis of the two performance indices calculated from the Eurobarometer results (see III. 1. 1) gave rise to four distinct groups of countries in terms of the campaign's overall impact: - - - - countries where the campaign was a huge success; countries where it was a success; countries below the European average; non-classifiable countries. 19 66 67 68 69 70 71 The campaign was a huge success in Germany, Austria, Spain, Greece and Ireland both as regards awareness of cancer preventability and knowledge of the campaign's European origin. In these countries the two performance indices are well above the average and the campaign's two aims in this regard were achieved to a very large degree, i. e. heightening European citizens' awareness and putting across European messages so as to make the Community's action in this field wider known. Furthermore, these countries benefitted in general from a strong and high-profile campaign (high rate of media pressure). The second group of countries consists of Belgium, Denmark, Finland, Italy and the United Kingdom; here one of the two performance indices is much higher than the European average, while the other is at an acceptable level. And in most of these countries the rate of media pressure is also above the European average, reflecting the link which exists between the extent of the publicity drive and the campaign's effectiveness. The countries where the campaign's impact was below the European average are France, Luxembourg and the Netherlands; in these countries the two performance indices were at a satisfactory level overall, although below the average. The media pressure in these countries was lower, due mainly to the difficulties encountered in obtaining free advertising. Two countries - Portugal and Sweden - are difficult to classify under the evaluation system used. In Portugal, despite a very high rate of media pressure and the printing and distribution of a very large amount of campaign materials, the campaign performance indices are negative. It should be recalled here that the Eurobarometer results before the campaign were particularly positive in Portugal. The results for Sweden may stem from the fact that i) no materials were printed or distributed for the campaign and ii) media pressure during it was very low. III. 1. 4 Conclusions The campaign undertaken during 1995 European Cancer Week had a significant influence on the Union's citizens' knowledge about cancer prevention: after the Week 20 more million Europeans believed they could reduce their individual risk of contracting cancer. The campaign's prime objective (see 1. 6. 1) was therefore achieved for the most part, even if the impact within the 15 countries varies considerably and the knock-on effect of this improved knowledge on Europeans' behaviour with regard to the risk factors is not yet known. The campaign also contributed to giving a higher profile to the Community's activities in the public health field, in particular in the fight against cancer: after the Week, 24% of Europeans knew of the European Code against Cancer (see Fig. 4) while 24%o also said they had heard of European Cancer Week. 20 72 73 74 m. 2 Campaign aimed at general practitioners This campaign's aims were to familiarise GPs with the prevention messages contained in the European Code against Cancer and to make them aware of the importance of including advice on cancer prevention in their medical practice. The approach adopted to achieve this involved production of a brochure (specifically adapted to this profession's information requirements) and its dispatch to every general practitioner in the European Union during European Cancer Week (also seen. 2. 1). III. 2. 1 Evaluation methodology The GP campaign was evaluated by means of a telephone survey undertaken in the Union's 15 countries. During this survey 2 050 general practitioners were contacted21, which is a representative sample of 0. 7% of the Union's GPs. The GPs approached were chosen by the opinion poll agency from lists which differed from the address files used to mail the brochure (protection of data entrusted to the Commission). The telephone surveys were conducted in November 1995 on the basis of a semi-structured questionnaire containing 18 questions. These did not just ask the GPs' opinion about the brochure and the European Code against Cancer's 10 recommendations but also covered the other European materials and messages with which general practitioners came into contact during the whole campaign (press releases in professional journals, leaflets and posters distributed by the anti-cancer Leagues and Associations, messages put across via the mass media). III. 2. 2 Reaction to and views on the brochure GPs are literally deluged every day by advertising in their post; the risk of the European Code against Cancer brochure "drowning" in this flood was therefore relatively large. Seen in this light, the doctors' recall of the brochure is at an acceptable level as regards spontaneous recall (European average22 - 15. 3%), and is very good (39. 4%) in the case of recall when prompted (also called assisted recall - see Annex VI. 1, Fig. 5). However, the differences from country to country are very large, with the lowest spontaneous recall rate being 2. 9% in Sweden and the highest 40% in Luxembourg, and the lowest assisted recall rate being 22. 1% in Greece and the highest 86% in Luxembourg. 21 22 200 in Germany, Belgium, Spain, France, Italy and the United Kingdom; 100 in Austria, Denmark, Finland, Greece, Ireland, Portugal, Sweden and the Netherlands; 50 in Luxembourg. Weighted European averages. 21 75 76 Of the GPs recalling having received the brochure, 87. 6% felt it had been well done and 77. 5% considered it to be very useful or moderately useful (very useful: 31. 5%, moderately useful: 46. 5% - see Annex VI. 1, Fig. 6). It should be noted that the worst results for these two questions were recorded in Denmark (46. 4% for both questions), where the GPs' associations had not adopted the approach favoured by the "Europe against Cancer" Programme (also see II. 2. 1). The second country where a different approach had been adopted (Netherlands) also had results for the two questions very much below the average (60. 4% for brochure design, 57. 1% for brochure usefulness). Of the doctors who recalled having received the brochure, 20% said they had learned something from it (lowest rate 3. 8% in Italy, highest 38. 3% in Spain) while 10. 5% of them stated that the recommendations contained in the brochure had actually changed certain aspects of their medical practice (lowest rate 0% in Ireland and Sweden, highest 18% in Spain). 77 It should also be noted that 68. 2% of doctors recalling having received the brochure considered it useful to repeat the exercise in the future. Ill 2. 3 Knowledge of and views on the Code 78 79 80 The survey on general practitioners' recall of and views on the brochure sent to them was also used to determine GPs' knowledge of the European Code against Cancer and their views concerning its usefulness for the general public. Thus, 37% of all the doctors interviewed (regardless of whether they remembered receiving the brochure or not) said they knew the European Code against Cancer (see Annex VI. 1, Fig. 7). Of these, 82. 7% said the Code was very useful or useful for providing the general public with information (see Annex VI. 1, Fig. 8), a reply which vindicates the pride of place accorded to the Code by the "Europe against Cancer" Programme in its information drives. III. 2. 4 Reaction to and views on other materials used in the campaign It was deemed useful to use the same survey to find out the extent to which general practitioners had received, for placing in their waiting rooms, the leaflets and posters printed by the anti-cancer Leagues and Associations from the films supplied by the "Europe against Cancer" Programme. It should be noted here that waiting rooms were not the only place for distributing such materials - they were also made available to the general public in pharmacies, via direct mailing or handed out during various events put on during the Week. 15. 9% of all the doctors interviewed said they had received leaflets on the Code for their patients; the corresponding figure for the posters was 14%. Among the doctors having received these materials, a very large majority found them to be very interesting or moderately interesting (81. 8% for the leaflets, 71. 3% for the posters). 22 III. 2. 5 Conclusions 81 82 83 GPs had clearly picked out the brochure specifically intended for them from among the flood of advertising mail they receive. The doctors recalling having received the brochure judged it extremely positively, as they did the usefulness of the European Code against Cancer as a tool for informing the general public. This positive evaluation emerging from the telephone survey is confirmed by the very large number of requests for additional copies of the brochure received by the "Europe against Cancer" Programme from individual doctors (GPs or others), doctors' associations, medical faculties, other medical profession training bodies and various public health and health education institutions. More than 21 000 copies of the brochure will be reprinted in 1996 in order to meet this demand. Numerous statements from individual doctors and official declarations from many GP associations are highly appreciative of the fact that the European Commission approached doctors directly; in terms of the telephone survey, this is reflected in the high percentage of doctors in favour of a similar venture being undertaken in the future. IV. FOLLOW-UP ACTIVITIES 84 85 86 At its meeting on 13 December 1995 the Advisory Committee set up for the second action plan was presented by the Commission with an initial analysis of 1995 European Week's impact. The Committee members agreed that the Week had gone very well. The Commission also informed the European group of anti-cancer Leagues and Associations (14. 11. 1995), the Committee of Cancer Experts (23. 11. 1995) and the European Group of Representatives of GPs' Associations (23. 4. 1996) of the results of the 1995 European Cancer Week. These three groups also concluded that the 1995 Week had generated remarkable results. Furthermore, the group of Leagues and Associations - the Programme's main partner in organising the Week - recommended to the Commission that the contract (for planning and coordinating the Week) concluded with the EURO-RSCG media communications agency be renewed for 1996. A number of conclusions were drawn from the way the 1995 Week went for preparing and implementing the 1996 Week. Thus, in order to ensure greater synergy between the activities undertaken by all the players involved in the campaign at Member State level (anti-cancer League(s), Health Ministry, other bodies involved, Commission representative's office, media communications agency's local office), preparation meetings were organised in most countries among all the abovementioned players as well as representatives of the "Europe against Cancer" Programme and the media communications agency's head office. 23 87 88 89 It was decided to decentralise translation for future campaigns in order to improve the linguistic quality of the translated versions of the materials used and to adapt them to the particular circumstances in each country; henceforth the various language versions will be produced in cooperation between the contact person named by the League(s) in a given country and the media communications agency's office in that country. In order to improve the information flow between the Leagues, and in particular to those not represented in the working group advising the "Europe against Cancer" Programme on the Week, the group's minutes are to be systematically distributed to all members of the European group of Leagues; furthermore, each member of the working group will assume responsibility for informing the League(s) of a country not represented within the group. An independent evaluation of the second action plan (1990-1994) to be arranged by the Commission will also deal with 1995 - a year which was not covered by an action plan (also see 1. 1) - and will therefore include an evaluation of the 1995 European Week. That evaluation will be in addition to the one already undertaken by the Commission on the basis of the Eurobarometer surveys and the telephone survey of GPs used for the qualitative analysis contained in this report. 24 V. 90 BUDGET The budget allocated for implementation of 1995 European Cancer Week was as follows: - - - - - contract with the EURO-RSCG agency23 24 ECU 1 170 000 funding for anti-cancer Leagues and Associations for printing and distribution of materials: 14 x ECU 10 000 ECU 140 000 fees paid to authors for the "national" part of the GP brochure (8 x ECU 5 000): ECU 40 000 cost of project 95/C/45309 (production of the common part of the GP brochure) ECU 66 341 printing of GP brochure (322 000 copies, 16 versions) ECU 154 762 purchase of GPs' addresses for five countries ECU 10 000 TOTAL ECU 1581 103 23 24 The contract totalling ECU 1. 3 million also covers promotion of the "Europe against Cancer" Programme in general, but in 1995 the agency's activities concentrated almost exclusively (some 90%) on the Week. The contract did not foresee the buying of advertising space. However, free advertising space amounting in cash terms to over 1 MECU has been obtained by the agency (see also II. 1. 3 and 11. 2. 2) 25 ANNEX cf Volume 2 <2C ISSN 0254-1475 COM(97) 19 final DOCUMENTS EN 04 05 16 Catalogue number : CB-CO-97-015-EN-C ISBN 92-78-15102-5 Office for Official Publications of the European Communities L-2985 Luxembourg il