A Critique of the Screen for Life Colorectal Cancer Screening Campaign – Jeremy Hetzel

Introduction
Colorectal cancer is the second leading cause of cancer-related death in the United States. In 2008, an estimated 148,000 individuals were diagnosed with colorectal cancer and 50,000 individuals died from colorectal cancer.(1) Colorectal cancer is also preventable through screening interventions such as fecal occult blood test, flexible sigmoidoscopy, and colonoscopy. The United States Preventive Services Task Force currently recommends these screening interventions for all men and women over the age of 50.(2) However, less than half of the US population has received proper screening.(3) Clearly, public health interventions are needed to encourage screening behavior and subsequently reduce cancer related morbidity and mortality. In this paper, an existing public health campaign, the Screen for Life campaign, will first be critiqued. A new campaign, the Polyp Man campaign, will then be proposed to improve upon the shortcomings of the Screen for Life campaign.
In 1999, the Screen for Life campaign was launched by the Center for Disease Control and Prevention, the Center for Medicare and Medicaid Services, and the National Cancer Institute. The campaign is based extensive literature reviews, informant interviews, focus groups, conversations with medical experts, and guidance from a professional communications firm. The goal of the campaign is to raise awareness for colorectal cancer screening among all Americans over the age of 50, with a special focus on African Americans, Hispanics, Alaska Natives, and Medicare beneficiaries. The campaign consists of public service announcements via television and radio, as well as posters, brochures, fact sheets, and print advertisements.(4)
The Screen for Life campaign is grounded theoretically in the Health Belief Model. Subsequently, it shares benefits and flaws common to all Health Belief Model campaigns. The Health Belief Model posits that behavior is motivated by the balance of four factors: perceived susceptibility, perceived severity, perceived benefits of an action, and perceived barriers to taking that action. If the perceived benefits and susceptibility outweigh the perceived An individual weighs his perceptions of a behavior to formulate an intention regarding the behavior. The probability that the individual will act on his intention is dependent on the occurrence of an external event to motivate the action, known as a cue to action, and the individual’s belief in his ability to successfully change his behavior, known as self-efficacy(5; 6) The intention of the Screen for Life campaign is to alter individuals’ perceptions of colorectal cancer screening to minimize the perceived barriers and maximize the perceived benefits, severity, and susceptibility. The campaign also offers cues to action and attempts to increase individuals’ self-efficacy.
The campaign assumes sufficient causes
A fundamental assumption of the Screen for Life campaign is that insufficient knowledge of colorectal cancer and colorectal cancer screening causes a reduction in the probability that an individual will undergo screening. This assumption is well supported by previous studies. In a review of the literature, Subramanian and colleagues(7) found six studies that reported a statistically significant association between knowledge of prevention strategies and adherence to screening guidelines, and only one studied failed to find such an association.(8) Additionally, subjects who believed that screening was effective were more likely to undergo screening, and subjects with a fear of cancer or belief that cancer is incurable were less likely to undergo screening.(5; 9) The Screen for Life campaign subsequently aims to better the public’s knowledge of colorectal cancer screening, which it assumes will cause an increase in screening adherence.
The assumption of the Screen for Life campaign is flawed because it implicitly treats colorectal cancer screening knowledge as a sufficient cause of colorectal cancer screening adherence, when it is instead a component cause. This subtle yet important distinction is illustrated in Rothman’s heuristic model of causal inference,(10) which will be referred to here as the Causal Pie model. The basis of the Causal Pie model is that an outcome may be caused by the combined effect of many individual causes. Individual causes are named ‘composite causes’. Any combination of composite causes that results in an outcome is named a ‘sufficient cause’.
To demonstrate, three sufficient causes of colorectal cancer screening adherence will be defined. Sufficient Cause A is composed of colorectal cancer screening knowledge and physician recommendation. Sufficient Cause B is composed of colorectal cancer screening knowledge and socioeconomic status. Sufficient Cause C is composed of physician recommendation and socioeconomic status. In this example, perfectly educating the population of the benefits of colorectal cancer screening will result in increased adherence only if physician recommendation or a threshold socioeconomic status is also present. Adherence may also be increased by increasing physician recommendation and socioeconomic status without any increase in colorectal cancer screening knowledge. The important lesson is that increasing knowledge will complete a sufficient cause in some individuals but not all individuals.
There is reason to suspect that the population’s knowledge of colorectal cancer screening will reach a level where the causal component of knowledge will be satisfied for all individuals. Increasing the knowledge past this threshold will have no effect on adherence rates, since all non-adhering individuals will be lacking a different component cause. Jorgensen and colleagues admit that in 1998, when the four year formative focus group research for the Screen for Life campaign began, participants “showed a lack of knowledge and skepticism about the incidence of the disease, combined with discomfort discussing it”. During later years “participants were generally more aware of colorectal cancer and appeared more comfortable talking about the disease and the need for screening”.(4) This is evidence that the public awareness of colorectal cancer was already increasing prior to the launch of the campaign.
Many other component causes for colorectal cancer screening adherence have been identified. Physician recommendation of screening was always found to be associated with adherence in Subramanian and colleagues’ review of the literature.(7) In one study, subjects were 12 times more likely to comply with screening guidelines if recommended by their physician.(11) Other potential component causes include continuity of care, education, health insurance, sex, smoking, family history of colorectal cancer, and race.(12) Future campaigns could improve upon the Screen for Life campaign by targeting these additional component causes.
The campaign is urban-centric
Jorgensen and colleagues explicitly state that racial minorities were a target audience of the Screen for Life campaign. Televised, radio, and print media were tailored to African-American, Hispanic, and Native Alaskan sub-populations after extensive focus group research.(4) However, the campaign has been criticized for being urban-centric and ignoring rural populations. In a focus group study, Appalachian residents aged 50 years or more reported that the actors in the Screen for Life advertisements were too old, appeared less active and healthy than the study participants, and lacked simple eye-catching messages.(13)
Campo and colleagues conducted a series of studies in rural Appalachia to monitor the effectiveness of the Screen for Life campaign and assess discrepancies in the campaign aims and needs of individuals living in rural Appalachia.(13) Appalachia residents are particularly susceptible to reduced colorectal cancer screening adherence due to reduced access to health care facilities, economic vulnerability, and reduced health care coverage.(14) A quasiexperimental trial comparing the effect of the Screen for Life education materials to unexposed controls in Appalachia demonstrated that individuals exposed to the Screen for Life education materials were no more likely than the unexposed individuals to plan to undergo screening or to understand the risks of colorectal cancer and benefits of screening.(13) A survey of 905 individuals revealed that less than 50% could correctly identify the recommended age to begin colorectal screening surveillance, age 50. In a 2007 study of 356 individuals at a primary care facility in Boston, 74% correctly identified the recommended age to begin surveillance.(12)
The Screen for Life campaign is an evidence based public health campaign, however it is based on racially diverse yet regionally homogenous focus group research. The educational materials of the campaign were developed to appeal to urban individuals, however the campaign fails to address the complex interactions between cultural, sociopolitical, and economic conditions across the United States, especially in rural areas.(15)
The campaign assumes behavior follows intent
The failure of the Screen for Life campaign to modify the behavior of colorectal cancer screening in the Appalachian cohort is also illustrative of a third flaw common to all Health Belief Model Interventions: behavior does not follow from reasoned intent.(16) An assumption of the Screen for Life campaign, and all Health Belief Model campaigns, is that individuals intending to undergo screening actually will undergo screening. Although being exposed to the logical argument that colorectal cancer screening reduces the risk of morbidity and mortality, Appalachian residents reported being more concerned that the Screen for Life advertisements depicted subjects who did not look like Appalachians and used messages that were neither simple nor eye-catching.(13)
A study conducted by Vanderpool and colleagues provides anecdotal evidence that the increased awareness of colorectal cancer screening does not yield increased adherence. The study interviewed directors of the community based Appalachia Cancer Network, a National Cancer Institute funded special populations network created to address cancer disparities in Appalachia. The Appalachia Cancer Network was responsible for disseminating television, radio, and print media at the local community level. The authors concluded that the aims of the Screen for Life campaign were not well executed at the community level. The authors reported that the sentiments of the directors were summarized by the following quote, “Screen for Life is a great idea. It's good for national awareness, but it needs another level to actually impact CRC screening”.(17) The director acknowledges that the campaign succeeds at creating a national awareness of colorectal cancer screening, however this does not result in changed behavior at the local level. Further evidence for a lack of change in behavior resulting from the increased awareness is difficult to assess given a lack of longitudinal studies assessing both knowledge of screening and screening rates. However, the most recent estimates of screening adherence alone in the United States from the Behavioral Risk Factor Surveillance System. The overall adherence has risen slightly from 56.8% in 2004 to 60.8% in 2006.(18) While a 4% rise is a change in the right direction, it is unknown what proportion if any of the change is attributable to the Screen for Life campaign.
Conclusion
The Screen for Life campaign is a Health Belief Model based public health intervention. As such, it assumes that providing individuals with rational evidence in support of screening behavior will result in an increase in adherence behavior. Theory suggests that this logic is flawed, and anecdotal reports from the directors distributing the material suggest that there is a disconnect between national awareness and local adherence. Furthermore, the campaign is urban-centric, having been developed in urban focus groups, and fails to address the complex interactions between cultural, sociopolitical, and economic conditions in differing regions. Finally, by only addressing the knowledge deficit of colorectal cancer screening, the campaign focuses on only one component cause of screening adherence. Failure to incorporate other component causes into future public health interventions may result in stagnation of the screening rate.

Proposal for the Polyp Man Campaign
In 1999, the Screen for Life campaign was launched by the Center for Disease Control and Prevention, the Center for Medicare and Medicaid Services, and the National Cancer Institute, to improve screening adherence. Although based on substantial research, the campaign suffers fundamental flaws which are addressed in an accompanying article. Here, I propose an alternative campaign, named the Polyp Man campaign, which is a national and regional advertising campaign aimed multiple barriers to screening and sensitive to regional contextualization. Common to the advertisements is an anthropomorphized polyp attempting to interfere with the daily lives of hard working Americans, only to be squashed, allowing the Americans to return to their daily, jovial activities. The Polyp Man campaign is inspired from the American Cancer Society campaign of the same name, but much expanded in scope.4 A brief example of a Polyp Man advertisement is provided to facilitate discussion.
A family is sitting around the television watching the show Jeopardy! Included are a grandmother, grandfather, father, mother, young boy, and a toddler-aged girl sitting in a highchair. The family is laughing and carrying on. The Final Jeopardy music begins to play. A man in a polyp suit, Polyp Man, slowly waddles through the door towards the grandmother. He resembles Curly from the Three Stooges. The laughter softens as Polyp Man approaches the grandmother, and the laughter stops as he begins to pull the grandmother and her chair away from the family. The family begins glancing at each other nervously as the grandmother is pulled farther away. As the third to last note in the Final Jeopardy song sounds, the toddler-aged girl knocks Polyp Man on the head with a toy, resulting in a loud ‘boink’. Polyp Man reacts in a fashion similar to the Three Stooges and runs away, leaving the grandmother behind. The toddler girl giggles, and the family resumes laughing and carrying on. The commercial closes with Alex Trebek saying, “And the answer is, ‘Squash the polyp, contact your doctor or visit squashthepolyp.com’”.
Advertisement theory escapes the fallacy of reasoned intent
The Polyp Man campaign improves on one flaw of the Screen for Life campaign by its foundation in advertisement theory instead of the health belief model.(6) A fatal flaw of the health belief model is that behavior follows from reasoned intent.(16) The Polyp Man campaign will be instead modelled after the Y&R Creative Work Plan (the Plan), an advertisement theory which does not rely upon reasoned intention. The components of the Y&R Creative Plan are the following: Key Fact, Problem, Advertising Objective, and Creative Strategy. In the Polyp Man campaign, the Key Fact is that unmet component causes are preventing subjects from adhering to screening recommendations , and the Problem is that failure to adhere to screening guidelines increases morbidity and mortality from colorectal cancer. The Advertising Objective is to increase screening adherence. However, the Objective is achieved by a Creative Strategy, not an appeal to reason. The Creative Strategy has an additional four components. First, the Prospect Definition is a description of the target audience. Second, the Competition is the status quo of not adhering to screening guidelines. Third, the Promise is the best argument in favor of screening given the key fact. Finally, a Reason why the campaign will deliver the promise.(19; 20)
Importantly, the Y&R Creative Plan does not appeal to the reason of the target audience and is adaptable to varying component causes and regional audiences. An appeal to reason is avoided, because the Promise is not about the attributes of screening, such as reduction in mortality statistics or descriptions of social norms regarding colonoscopy. Instead, the Promise is about a benefit of screening, which in the introductory example is continued membership in an American family. However, the Promise may be modified to best appeal to varying target audiences. The Reason why is not an explicit explanation of how screening prevents CRC or why other individuals have chosen screening colonoscopy, it is a simple implication that people undergoing screening achieve the Promise. In the introductory example, the Reason was that the Polyp Man was dispatched by a toddler, which hints at the protective effect of removing polyps, but without any reference to medical terminology or invasive procedures. Finally, the Polyp Man campaign is sensitive to the psychological and cultural differences between regional audiences, which is lacking in the traditional health belief model.(15) Regional focus groups will allow for the creation of regional advertisements that address Key Facts and target audiences specific to a region.
Sensitivity to regional contextualization
Although racial minorities were explicitly stated as a target audience of the Screen for Life campaign,10 the campaign has been criticized for being urban-centric and ignoring rural populations.11 The educational materials of the campaign were developed to appeal to urban individuals and fail to address the complex interactions between cultural, sociopolitical, and economic conditions across the United States, especially in rural areas.(15)
The Polyp Man campaign will improve on the Screen for Life campaign by separating the national and regional advertisement campaign efforts. The national campaign will focus on the general US population, with a long term goal of changing screening behavior by socialization methods.(21) The regional campaigns will be more sensitive to the sociocultural context of local communities. These regional campaigns will be managed by local teams which will rely on focus groups to develop material optimized for the regional community. For example, Campo and colleagues conducted focus groups of Appalachian residents aged 50 years or more and reported that the actors in the Screen for Life advertisements were too old, appeared less active and healthy than the study participants, and lacked simple eye-catching messages.(13) The Polyp Man regional campaigns in Appalachia will employ young, active image in order to contextualize the campaign messages to Appalachia. Additionally, as described in the previous section, the regional campaigns will address Key Facts of the specific region.
Focus on multiple component causes
A third flaw of the Screen for Life campaign is its focus on a single component cause of colorectal cancer screening behavior, namely subject knowledge of colorectal cancer. The Polyp Man campaign will improve upon the Screen for Life campaign by specifically addressing multiple component causes that have been exposed in the literature. For example, Subramanian and colleagues identified physician recommendation as a consistent predictor of colorectal cancer screening among 44 reviewed studies.(7) In a cross-sectional study by Zapka and colleagues, subjects were 12 times more likely to comply with screening guidelines if recommended by their physician.(11) Thus one component of the Polyp Man campaign will be aimed at physicians through advertisement campaigns in medical journals, related websites, and professional conferences. The campaigns will use advertisement theory methods, discussed later in this paper, to encourage physicians to recommend screening to patients and to make physicians aware of physician-patient communication barriers such as personal health beliefs, power, listening ability, trust, directness, and racial or ethnic discordance.(22)
Individual patient level component causes will be addressed by national and regional advertisement campaigns. These campaigns will focus on barriers to screening identified in the literature such as continuity of care, education, health insurance, sex, smoking, family history of colorectal cancer, race,(12) dislike for blood tests, time off from work, and transportation.(23) A lack of knowledge of the risks of colorectal cancer remains a barrier to screening, Subramanian and colleagues(7) found significant associations between knowledge of prevention strategies and adherence to screening guidelines in all but one study reviewed.(8) Additionally, subjects who believed that screening was effective were more likely to undergo screening, and subjects with a fear of cancer or belief that cancer is incurable were less likely to undergo screening.(9; 24) Thus the Polyp Man campaign will collaborate with national and regional television networks to incorporate colorectal cancer educational segments into news programming. However, unlike the Screen for Life campaign, patient education will not be the sole aim of the Polyp Man campaign.
Conclusion
The Polyp Man campaign is a national and regional advertising campaign aimed at multiple barriers to screening and sensitive to regional contextualization. The campaign improves upon the traditional health belief model based Screen for Life campaign in three important ways. First, by employing advertising theory, the Polyp Man campaign escapes the fallacy of reasoned intent. Second, the campaign is sensitive to contextual differences in regional populations. Third, the campaign focuses on multiple component causes, increasing the likelihood that sufficient causes will be fulfilled and screening adherence increased. Colorectal cancer is a major cause of morbidity and mortality in the United States. Traditional public health interventions have not substantially increased screening adherence. The Polyp Man campaign is a non-traditional alternative that aims to reduce the burden of colorectal cancer.

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