Challenging Dogma - Spring 2009

Thursday, May 14, 2009

A Social Sciences Revision of Help for Today, Hope for Tomorrow – Jennifer Stedman

Breast cancer is one of the leading causes of death in women. Unfortunately, even with this knowledge, not enough women are proactive in their health and having regular mammogram screenings. Often, those who are getting screened are not even the target population. One program trying to promote breast cancer awareness and early detection is The National Breast Cancer Foundation (1). For several reasons, The National Breast Cancer Foundation falls short and does not have an effective campaign. The first shortcoming comes directly from the mission of the program. The second is a result of their partnership with Self magazine. Lastly, they have an ineffective Casual Up program.


The mission of The National Breast Cancer Foundation has two objectives: first is education about breast cancer and second is provision of mammograms to those women in need. To accomplish this mission, they have laid out three means to reach the target, at risk population. One method is their Beyond the Shock educational video. The video is actually a tutorial of slides, covering thirteen overview topics, taking approximately forty-five minutes to watch. One of the first topics covered is the Risk Factors for breast cancer. The slide mentions that non-Hispanic Caucasian women are at higher risk than African – American women (2). This is a true statement, however it fails to mention that African – American women have the highest mortality rates out of any ethnic or racial group (3). This happens because African – American women tend to have their breast cancer diagnosed at later, more advanced stages when it has metastasized and there are fewer treatment options (4). Reasons for later diagnosis and treatment are a result of a few social factors including lack of health insurance, no follow up on abnormal tests or a belief that mammograms are not necessary (5). Issues such as this need to be address in the public health field, especially in visible campaigns such as The National Breast Cancer Foundation, however are often over looked and therefore reinforced within the African – American community.

In addition to neglecting African – American women, the video also leaves out the Latino women community. Like the African – American women, Latino women experience more aggressive types of breast cancer, which results in difficult treatment and higher mortality rates. Breast cancer is the leading cause of cancer – related death in this population. It is speculated that environmental factors such as working on farms may be a cause of increased rate (6), as well as social factors such as low-income status affecting their means of receiving appropriate health care (7). Therefore, even though the incidence and mortality rates of breast cancer are lower in Hispanic women when compared to non-Hispanic Caucasian and African – American women, they have their own unique issues needing to be addressed.

The National Breast Cancer Foundation also tries to portray its mission through endorsement. This can be seen on the homepage of their website with a video message from Dr. Phil front and center encouraging women to go for yearly mammograms (8). Even though the Dr. Phil television show receives high viewer ratings, the use of Dr. Phil as a spokes person severely limits the target audience. When looking at the demographics of those who watch the Dr. Phil show, the age and gender are appropriate with 66% female, 38% between the ages of 35 – 49 years old and 30% at least 50 years old. However, the viewers are also 88% Caucasian (9), which is the population of least concern for under utilization for mammogram screenings (10).
The National Breast Cancer Foundation also promotes their mission through the use of an online community. Both women and men of any age can register; identify themselves as a patient, survivor, supporter, or provider; find support or ask questions; and they can share their stories (11). Having the main forum for support and information through an online resource also selectively targets a specific population, which is non-Hispanic Caucasian. Within this group, 59.9% have internet access. This is drastically reduced for African – Americans and Hispanics who both only have 36.0% of their population with access to the internet (12).

The use of and access to the internet is also segregated according to socioeconomic status. Within those with a higher socioeconomic status, approximately 60% will have access, whereas approximately 12% within the lower group will have access (13). The same trend can be see between socioeconomic status and those who go for mammogram screenings. Women with household earnings greater than $50,000 had 82.5% report having a mammogram within the past two years; conversely, women with house hold earnings less than $15,000 reported that 68.4% had received a mammogram within the past two year (14). This demonstrate the need for new ways to promote education and support to communities such as African – American and Hispanic women who are not being reached through the current means.

In an effort to reach more women and cover a wider domain of breast cancer topics, The National Breast Cancer Foundation partnered with Self magazine. The purpose is to allow those registered with The National Breast Cancer Foundation to have greater access to health information, how to donate to charity and how to make sure their money is well spent (15). This collaboration is, in theory, a great idea; Self magazine and are great resources for women to learn about having a proper diet, appropriate exercise regimes and other self improvement lessons. However, upon clicking the link to access the website or looking at the cover of the magazine, every image is one of a young, healthy non-Hispanic Caucasian woman (16). These images reflect Self’s ideal reader:
You're an active, educated, sophisticated woman who yearns to improve the quality of your life. You're interested in health, nutrition, money management, the mind-body-spirit connection, culture, fashion, psychology, fitness and the environment. If that describes you, then this is the magazine that will help you develop your untapped potential (17).

There is a narrow group who can identify with a statement such as this. When promoting breast cancer awareness, the target audience should be broad and encompassing, very different from this campaign. As mentioned before, it is the African – American and Hispanic women who are in greatest need for an intervention. If they were to come across this promotion, the majority would feel it does not apply to them. The prominent reason for failing to reach this group is because the campaign violates McGuire’s Communication / Persuasion Matrix, which focuses on the source, message and channel factors as a means of effectively reaching a group (18). The source refers to whom the message is coming from. The message reflects the core values being presented. The channel is the means of reaching the audience. As demonstrated in viewing the website and reading the description of the ideal reader of Self, the source of the message comes from non-Hispanic Caucasian women of higher socioeconomic status who are fashionable, educated and healthy. The core values of the message include nutrition, money – management and the environment. The channel of the message is through access to the internet or subscription to the magazine. It is clearly visible as to why African – American and Hispanic women cannot identify with the source of the message from Self magazine and The National Breast Cancer Foundation, no one looks like they do. Why would they feel this program would help them when the message is coming from a group visibly different than them? The core values of the message do not associate with the values of African – American or Hispanic women. The traditional values, which are held by African – American women, include communalism, such as the family and child centered, and spirituality (19), none of which can be found in the message from Self magazine. Within the values of Hispanic culture, the family is at the forefront and the mother is responsible for the home (20). These responsibilities become their focus and prominently include cooking and cleaning. Nutrition would fit within the values of the Hispanic woman, however because money – management and the environment are so far out of the scope of their daily lives that the connection will be lost. Lastly, the means to gain access to the benefits of Self are limiting. As previously mentioned, the women who are able to go online and login to the network (or The National Breast Cancer Foundation website) are those who are non-Hispanic Caucasian women in a higher socioeconomic bracket. This group is already going for regular mammogram screenings and living a generally healthier life-style. The women excluded from access are the African – American and Hispanic women, the group in need of screenings and healthier life-style information.

The last initiative of The National Breast Cancer Foundation is Casual Up. This program is designed to take “casual Fridays” in the work environment to raise money and awareness for breast cancer. It refers to casual Fridays as a time to boost employee morale and serve as a function to “increase education about the benefits of early detection and provide mammograms for those in need” (21). Casual Fridays have also become part of the norm for today’s youth, therefore campaigns involving this dress down day are automatically targeted to the young-professionals in our country (22). As a result, even though this campaign is beneficial for employers to take part in for the tax deductions and at the same time raise money for mammograms, the awareness is going towards the wrong demographic. Studies have shown that mammograms are on the rise in young professional women. Campaigns are now drawing attention through the use of young, healthy models promoting early detection (23). It can be understood why campaigns such as Casual Up are having an impact on young women when recent news headlines and medical websites covered Christina Applegate’s diagnoses of breast cancer at age 36 and her decision to have a double mastectomy (24, 25, 26). An occurrence such as Ms. Applegate’s is rare though and often cannot be prevented through screenings at a young age. Only 5% of all breast cancers occur in women under 40 years of age. Those that do occur in younger women are more difficult to detect as their breast tissue is much more dense (27). As a result, it is recommended that women under the age of 40 do not go for mammograms, but instead take part in regular self-breast examination (28). Therefore, despite a creative method, aimed at reaching a broader population, Casual Up may have greater shortcomings than benefits. The goal of raising money to provide mammograms to those in need is definitely needed. Regrettably, the group receiving their message from the campaign is already going for mammograms at too early of an age and should have its efforts focused elsewhere.

The National Breast Cancer Foundation, whose motto is “Help for Today, Hope for Tomorrow,” has great intentions of raising awareness and education in breast cancer and also providing a means of mammograms to women in need. Unfortunately, this message only reaches one, specific population and it fails to reach those women truly in need. The primary methods of execution through their Beyond the Shock video, early detection message from Dr. Phil and on-line community forum are only reaching women of high socioeconomic status who are non-Hispanic Caucasian. Similarly, their effort to reach more women and promote healthier life-styles through a partnership with Self magazine again leaves out African – American and Hispanic women who are in greater need of public health interventions for breast cancer. Finally, the Casual Up campaign, put on by The National Breast Cancer Foundation, has a target audience of women who are under 40 and already, unnecessarily going to mammogram screenings. If The National Breast Cancer Foundation were to look at their methods of spreading awareness through Multi – Level research, the flaws currently in place would become clear to them and allow for the development of more effective and diverse programs. Their programs rely on individual – level models, with the belief that providing information will compel women into action. It does not acknowledge the reasons certain groups, such as African – American and Hispanic women, have more aggressive tumors and high mortality rates when they are at lower risk. The multi – level model would demonstrate information such as lack of access to health care, lack of access to the internet, or even lack of a spokes person who this audience can identify with. The National Breast Cancer Foundation has the potential to be an essential tool of helping women; it just needs a new mode of reaching those who need their help.

The attempts and failings of public health interventions, such as The National Breast Cancer Foundation, give cause for a new perspective to be employed in order to find a solution. The NBCF has specific shortcoming with their implementation of a few programs, including the mission of the foundation, their partnership with Self magazine, and their Casual Up program. The primary issues resulting from these ineffective campaigns are 1) targeting non-Hispanic Caucasian women and neglecting African – American women, who have the highest mortality rates from breast cancer, 2) delivering a message through an inappropriate source, where the viewers cannot relate, and 3) reaching a subset of women who are too young and therefore preventive mammograms are non necessary and ineffective for.

A new intervention that promotes breast cancer screenings, especially for African – American women, needs to be developed. This intervention should be based on the Social Sciences in order to capture the underlying causes of discrepancy regarding the preventive measures used, and mortality rates occurring, for African – American women. An effective intervention would be similar to the Pepsi My Generation commercials. This works by displaying images reflective of a certain group. In the Pepsi commercial, the images spanned from the early 1900’s through to the 1980s, capturing images of youth, rebellion and communality. At the end of the commercial, the message of “Every generation refreshes the world, now it’s your turn. Pepsi.” (29) appears, providing the viewers with information bringing them together. This campaign works through Social Marketing Theory. The important concept behind the theory is market segmentation, which divides the population into significant subgroups in order to successfully delivery their message (30). The reason this is an effective campaign tool is because it allows the targeted subgroup to feel like they are part of something bigger than themselves; it is something they can associate with, feel an emotional connection to and remind them of the times when they were young, rebellious and connected to others because of these commonalities, which are values that are important to and resonant with most people.

By drawing on the methods used in the Pepsi My Generation commercial, a revised approach can be made in promoting preventive mammograms in an appropriate group of women. Similar to Pepsi, the commercial would have images and music reflective of an older population of women. The targeted women would be about forty years old as it has been shown that a women’s risk of developing breast cancer does not become significant until she is forty years old and that is the recommended age to start going for regular mammograms (31). Therefore, to capture the times of youth for women aged 40 through 85, the images should come from 1940s through the mid 1980s. The images should be reflective of all women, with some emphasis on African – American women, coming together, having fun, and being empowered. The end of the commercial would have a message, like Pepsi, telling women to band together, to hold on to the ideals of their youth and to go for their yearly mammograms. The commercial would then have a website to go to or a phone number to call for more information. By giving them the next step in action, it is more likely to “hook” the audience and be successful.

Having a television commercial is the most common means of reaching the population. Having ads in magazines is also widely used. An advertisement with one of the images displayed in the commercial and the message written on it would also be beneficial to the campaign. A specific magazine that should be utilized is Essence magazine (33) in order to target the African – American women. The reason this magazine has been chosen is because it was an effective tool in recruiting a large population of women to participate in the Black Women’s’ Health Study (32). By choosing this magazine, along with others to target specific groups of women, the campaign should successfully promote it’s message.

Becoming Inclusive
The first criticism of the NBCF program was the way it solely targeted non-Hispanic Caucasian women. This is a substantial problem as the women with the highest mortality rates are African – American women. Having a campaign promoting breast cancer awareness, but not including African – American women in the campaign is a form of institutionalized racism. The revised campaign, based on marketing theory from the social sciences, does not fall into the trap of excluding any groups, specifically African – American women. By utilizing resources such as Essence magazine, which already reaches out and connects with the target population, the campaign is able to get through to these women. Essence magazine is committed to understanding its audience and as a result commissioned a study to define the micro-demographics among black women (34). The study is designed to help effectively advertise for products sold to black women; however the ways the advertisements are designed should also be applied to public health campaigns. The six mini-demographics described represent different values and ideals that are held by different percentages of African – American women. By knowing what values to appeal to the more likely it is that the campaign will be successful, whether for a product or for public health.

Promoting with an appropriate source
The second criticism of the NBCF program was the delivery of their message from an inappropriate source. The messengers were only white women and therefore the African – American women, who are at the greatest risk for mortality from breast cancer, cannot relate to the message. This violates McGuire’s communication / persuasion matrix from the social sciences communications theory (35). This revised approach does not violate the communication / persuasion matrix through the images it displays of all types of women through the generations. The message is coming from someone who resembles the viewer, no matter her background. Every woman has a history and every woman has been a youth. Therefore, by capturing images of different women through out the designated time periods, this becomes an inclusive campaign for the target audience.

Reaching an older age group
The third criticism of the NBCF was due to the programs reaching an audience who should not yet be going for mammograms because they are still too young. The young audience occurred as a result of the Casual UP promotion in the work place. Attracting a younger population should not be an issue for the social science based intervention. By using images that only pertain to the target group’s youth, the images would not apply to younger women and therefore would not appeal to them in the same way. They might find the commercial or magazine ad interesting, but they will not feel the connection with it that the intended group of women, ages 40 and up, will feel. The intended group will have lived through the images shown and experienced the emotions associated with it. This should also be effective as it takes advantage of the social science’s framing theory which centers the message on the core values of the viewer in order to make it appealing (36). For this campaign, the values are reflective of the women’s youth and empowerment. This should trigger a connection to the commercial through shared experiences and subsequently should have positive results influencing these women to engage in preventive mammograms.
The methodology of the revised campaign should be effective in promoting preventive mammography to all women, but especially African – American women. The design of the campaign is group – level, rather than individual – level. This means it acknowledges that groups are different than a simple collection of individuals; it allows for groups of individuals to be effected at the same time; it accounts that behavioral decisions are dynamic and that people can change their mind instantaneously; and it acknowledges that behavior is irrational, not planned or reasoned.

This intervention does have limitations. It does not take into account funding for a campaign such as this. Perhaps if this were to be implemented by an existing program, the funding would be available. An ideal program to do this would be the Susan G. Komen Circle of Promise, which is designed to engage African – American women in their fight against breast cancer (37). Another limitation involves the higher – level factors that might also be preventing African – American women from participating in preventive mammography. One factor that may cause this is a distrust of the medical field within the community. This campaign does not account for this high – level factor, however by focusing on this group and finding a way to connect to these women, I believe it truly is a step in the right direction. Perhaps a pilot campaign should be tested on a group of African – American women to determine how they react and if it might be effective.

1 The National Breast Cancer Foundation.

2 Beyond The Shock: A step-by-step guide to understanding breast cancer.

3 Breast Cancer Fund, Prevention Starts Here Eliminating the Environmental Causes of Breast Cancer. Breast Cancer Incidence and Mortality by Race and Ethnicity. San Francisco, CA: Breast Cancer Fund.

4 Health Day, News for Healthier Living. Black Women at Higher Risk for More Aggressive Breast Tumors. ScoutNews, LLC.

5 U.S. Department of Health and Human Services. Minority Women’s Health, Breast Cancer.

6 Breast Cancer Fund, Prevention Starts Here Eliminating the Environmental Causes of Breast Cancer. Breast Cancer Incidence and Mortality by Race and Ethnicity. San Francisco, CA: Breast Cancer Fund.

7 Women Caring for Women. Latinas: Breast and Cervical Cancer.

8 The National Breast Cancer Foundation.

9 QuantCast. Dr. Phil. Quantified Publisher Program.

10 Callee, E. et al. Demographic Predictors of Mammography and Pap Smear Screening in US Women. American Cancer Society 1993; 83: 53-60.

11 National Breast Cancer Foundation. Join My NBCF.

12 US Census Bureau. Computer and Internet Use in the United States. Washington, DC: U.S. Department of Commerce.

13 National Telecommunications and Information Administration. Falling Through the Net: Defining the Digital Divide. US Department of Congress,

14 Centers for Disease Control and Prevention. Breast Cancer Screening and Socioeconomic Status --- 35 Metropolitan Areas, 2000 and 2002. Atlanta, GA: Morbidity and Mortality Weekly Report, 2005.

15 National Breast Cancer Foundation. News Releases.

16 Self. New York, NY. Conde Nast Publications Inc.

17 Magazine Agent. Self.

18 Kreuter, M. et al. The Role of Culture in Health Communication. Annual Review of Public Health 2004; 25: 439 – 455.

19 University of Oregon. African Americans.

20 The Ohio State University. Understanding the Hispanic Culture. Columbus, OH. Family and Consumer Sciences.

21 National Breast Cancer Foundation. Casual Up.

22 Meredith, G., Schewe, C. and Karlovich, J. Defining Markets, Defining Moments, America’s 7 Generational Cohorts, Their Shared Experiences, and Why Businesses Should Care.

23 Kolata, G. IDEAS & TRENDS; Mammography Campaigns Draw In the Young and Healthy. The New York Times, 1993.

24 CNN. Christina Applegate: Why I Had a Double Mastectomy.

25 WebMD. Christina Applegate’s Mastectomy: FAQ.

26 abc NEWS. Exclusive: Appleate Underwent Breast Removal to Stop Cancer.

27 Cleveland Clinic. Breast Cancer in Young Women.

28 Author, Unknown. Young Women ‘Shouldn’t Seek Mammograms.’ The Sydney Morning Herald, 2008.

29 NCCNeon. Pepsi My Generation Spot.

30 Edberg, M. Essentials of Health Behavior, Social and Behavioral Theory in Public Health. Surbury, MA. 2007. (60-61)

31 Méndez, Jane. Boston University School of Medicine. April 15, 2009.

32 Essence Magazine

33 Cozier, Yvette. Boston University School of Public Health. February 25, 2009.

34Author, Unknown. Study identifies 6 micro-demographics among black women. Tapestry cultural threads of success. Rochester Hills, MI. 2006

35 Kreuter, M. et al. The Role of Culture in Health Communication. Annual Review of Public Health 2004; 25: 439 – 455.
36 Jablin, F., Putnam, L. Framing (88-89) in The New Handbook of Organizational Communication.
37 Susan G. Komen Circle of Promise

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