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.

MISSION
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.

PARTNERSHIP WITH SELF MAGAZINE
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 Self.com 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 Self.com 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 Self.com 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.

CASUAL UP
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.
Intervention

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. Refresheverything.com” (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.














References
REFERENCES
1 The National Breast Cancer Foundation. http://www.nationalbreastcancer.org/default.aspx.

2 Beyond The Shock: A step-by-step guide to understanding breast cancer. http://www.nationalbreastcancer.org/About-Breast-Cancer/Beyond-The-Shock.aspx.

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. http://www.breastcancerfund.org/site/pp.asp?c=kwKXLdPaE&b=84427.

4 Health Day, News for Healthier Living. Black Women at Higher Risk for More Aggressive Breast Tumors. ScoutNews, LLC. http://healthday.com/Article.asp?AID=625376.

5 U.S. Department of Health and Human Services. Minority Women’s Health, Breast Cancer. http://www.womenshealth.gov/minority/africanamerican/bc.cfm.

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. http://www.breastcancerfund.org/site/pp.asp?c=kwKXLdPaE&b=84427.

7 Women Caring for Women. Latinas: Breast and Cervical Cancer. CharityAdvantage.com. http://www.latinabca.org/LatinasBreastandCervi.asp.

8 The National Breast Cancer Foundation. http://www.nationalbreastcancer.org/default.aspx.

9 QuantCast. Dr. Phil. Quantified Publisher Program. http://www.quantcast.com/drphil.com.

10 Callee, E. et al. Demographic Predictors of Mammography and Pap Smear Screening in US Women. American Cancer Society 1993; 83: 53-60. http://www.ncbi.nlm.nih.gov/pubmed/8417607.

11 National Breast Cancer Foundation. Join My NBCF. http://community.nationalbreastcancer.org/.

12 US Census Bureau. Computer and Internet Use in the United States. Washington, DC: U.S. Department of Commerce. http://www.census.gov/prod/2005pubs/p23-208.pdf.

13 National Telecommunications and Information Administration. Falling Through the Net: Defining the Digital Divide. US Department of Congress, http://www.ntia.doc.gov/NTIAHOME/FTTN99/part2.html.

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. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5439a2.htm.

15 National Breast Cancer Foundation. News Releases. http://www.nationalbreastcancer.org/About-NBCF/Media-Room/News-Releases.aspx.

16 Self. New York, NY. Conde Nast Publications Inc. http://www.self.com/.

17 Magazine Agent. Self. http://www.magazine-agent.com/self/magazine.

18 Kreuter, M. et al. The Role of Culture in Health Communication. Annual Review of Public Health 2004; 25: 439 – 455. http://arjournals.annualreviews.org/doi/abs/10.1146/annurev.publhealth.25.101802.123000.

19 University of Oregon. African Americans. http://darkwing.uoregon.edu/~gnhall/psyc459/africanam.html.

20 The Ohio State University. Understanding the Hispanic Culture. Columbus, OH. Family and Consumer Sciences. http://ohioline.osu.edu/hyg-fact/5000/5237.html.

21 National Breast Cancer Foundation. Casual Up. http://casualup.org/.

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. http://booklocker.com/pdf/2780s.pdf.

23 Kolata, G. IDEAS & TRENDS; Mammography Campaigns Draw In the Young and Healthy. The New York Times, 1993. http://www.nytimes.com/1993/01/10/weekinreview/ideas-trends-mammography-campaigns-draw-in-the-young-and-healthy.html?sec=health.

24 CNN. Christina Applegate: Why I Had a Double Mastectomy. http://www.cnn.com/2008/LIVING/10/14/o.christina.applegate.double.mastectomy/index.html.

25 WebMD. Christina Applegate’s Mastectomy: FAQ. http://www.webmd.com/breast-cancer/news/20080820/christina-applegates-mastectomy-faq.

26 abc NEWS. Exclusive: Appleate Underwent Breast Removal to Stop Cancer. http://abcnews.go.com/GMA/story?id=5606034.

27 Cleveland Clinic. Breast Cancer in Young Women. http://my.clevelandclinic.org/disorders/breast_cancer/hic_breast_cancer_in_young_women.aspx.

28 Author, Unknown. Young Women ‘Shouldn’t Seek Mammograms.’ The Sydney Morning Herald, 2008. http://news.smh.com.au/national/young-women-shouldnt-seek-mammograms-20081027-599b.html

29 NCCNeon. Pepsi My Generation Spot. http://www.youtube.com/watch?v=MFAF-bR6Y0o

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
http://www.essence.com/

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 http://www.mbcglobal.org/News2006-10-31-EthnicBeauty.html

35 Kreuter, M. et al. The Role of Culture in Health Communication. Annual Review of Public Health 2004; 25: 439 – 455. http://arjournals.annualreviews.org/doi/abs/10.1146/annurev.publhealth.25.101802.123000.
36 Jablin, F., Putnam, L. Framing (88-89) in The New Handbook of Organizational Communication. http://books.google.com/books?id=6fumvnF6BsEC&pg=PA88&lpg=PA88&dq=framing+theory+fairhurst+%26+sarr&source=bl&ots=E1NwqY7L3y&sig=fCDWKc01sSt0hARfRtEHljHcp4s&hl=en&ei=cw_6SYvJKYyeM9GGqa0E&sa=X&oi=book_result&ct=result&resnum=7
37 Susan G. Komen Circle of Promise
http://www.circleofpromise.org/

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.

REFERENCES
1. Jemal A, Siegel R, Ward E, Hao Y, Xu J, Murray T, Thun MJ. Cancer statistics, 2008. CA Cancer J Clin. 58(2):71-96.

2. Levin B, Lieberman DA, McFarland B, Andrews KS, Brooks D, Bond J, Dash C, Giardiello FM, Glick S, Johnson D, Johnson CD, Levin TR, Pickhardt PJ, Rex DK, Smith RA, Thorson A, Winawer SJ. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology. 2008 May ;134(5):1570-95.

3. Smith RA, Cokkinides V, Brawley OW. Cancer screening in the United States, 2008: a review of current American Cancer Society guidelines and cancer screening issues. CA Cancer J Clin. 58(3):161-79.

4. Jorgensen CM, Gelb CA, Merritt TL, Seeff LC. Observations from the CDC: CDC's Screen for Life: a National Colorectal Cancer Action Campaign. J Womens Health Gend Based Med. 2001 Jun ;10(5):417-22.

5. Janz NK, Becker MH. The Health Belief Model: A Decade Later. Health Educ Behav. 1984 Jan 1;11(1):1-47.

6. Edberg MC. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, Mass: Jones and Bartlett; 2007.

7. Subramanian S, Klosterman M, Amonkar MM, Hunt TL. Adherence with colorectal cancer screening guidelines: a review. Prev Med. 2004 May ;38(5):536-50.

8. Hsia J, Kemper E, Kiefe C, Zapka J, Sofaer S, Pettinger M, Bowen D, Limacher M, Lillington L, Mason E. The importance of health insurance as a determinant of cancer screening: evidence from the Women's Health Initiative. Prev Med. 2000 Sep ;31(3):261-70.

9. Powe BD, Daniels EC, Finnie R. Comparing perceptions of cancer fatalism among African American patients and their providers. J Am Acad Nurse Pract. 2005 Aug ;17(8):318-24.

10. Rothman KJ, Greenland S. Causation and causal inference in epidemiology. Am J Public Health. 2005 ;95 Suppl 1S144-50.

11. Zapka JG, Puleo E, Vickers-Lahti M, Luckmann R. Healthcare system factors and colorectal cancer screening. Am J Prev Med. 2002 Jul ;23(1):28-35.

12. Schroy PC, Glick JT, Robinson PA, Lydotes MA, Evans SR, Emmons KM. Has the surge in media attention increased public awareness about colorectal cancer and screening? J Community Health. 2008 Feb ;33(1):1-9.

13. Campo S, Askelson NM, Routsong T, Graaf LJ, Losch M, Smith H. The green acres effect: the need for a new colorectal cancer screening campaign tailored to rural audiences. Health Educ Behav. 2008 Dec ;35(6):749-62.

14. Rosenblatt RA. A view from the periphery - health care in rural America. N Engl J Med. 2004 Sep 9;351(11):1049-51.

15. Marks DF. Health Psychology in Context. J Health Psychol. 1996 Jan 1;1(1):7-21.

16. Thomas LW. A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education. Journal of Professional Nursing. 1995 ;11(4):246-52.

17. Vanderpool RC, Coyne CA. PEER REVIEWED: Qualitative Assessment of Local Distribution of Screen for Life Mass Media Materials in Appalachia. Prev Chronic Dis. 2006 Apr ;3(2):A54.

18. Use of colorectal cancer tests--United States, 2002, 2004, and 2006. MMWR Morb Mortal Wkly Rep. 2008 Mar 14;57(10):253-8.

19. DT Egensteiner, FD Fraser, D Fullerton, AS Kroll, AS Rubicam, H Rieger. The Y&R Creative Work Plan [Internet]. [cited 2009 Mar 5 ] Available from: http://legacy.library.ucsf.edu/tid/wnc02b00

20. Bendinger B. The Copy Workshop Workbook 2002. 3rd ed. Copy Workshop; 2002.

21. DeFleur ML, Bale-Rokeach S. Theories of Mass Communication. 5th ed. Allyn & Bacon; 1989.

22. Gao G, Burke N, Somkin CP, Pasick R. Considering Culture in Physician-Patient Communication During Colorectal Cancer Screening [Internet]. Qual Health Res. 2009 Apr 10;[cited 2009 Apr 30 ] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19363141

23. Nichols C, Holt CL, Shipp M, Eloubeidi M, Fouad MN, Britt K. Physician knowledge, perceptions of barriers, and patient colorectal cancer screening practices. Am J Med Qual. 2009 Apr ;24(2):116-122.

24. Beeker C, Kraft JM, Southwell BG, Jorgensen CM. Colorectal cancer screening in older men and women: qualitative research findings and implications for intervention. J Community Health. 2000 Jun ;25(3):263-78.