Challenging Dogma - Fall 2009

Wednesday, December 16, 2009

A Critique of the Pink and Black Campaign: How a Campaign Based on Race Disregards Social Factors – Beth Greene

I. Introduction
Breast cancer has become a major focus of healthcare due to the large number of women affected by it. In fact, breast cancer is the second leading cause of death among women in the U.S. (1). The concern about breast cancer is particularly relevant to Black women, as mortality rates are significantly higher than for White women diagnosed with breast cancer (1,2,3,4). The following paper aims to highlight the disparity in breast cancer diagnosis and treatment for Black women, assess a current program in Massachusetts that intends to reduce this disparity, and make recommendations for a more effective program.
White women are diagnosed with breast cancer at a higher rate than Black women, with 113 cases per 100,000 compared to 96 cases per 100,000 (2). Despite this, Black women suffer from a higher mortality rate from breast cancer than White women at all ages (1,2,3). In Boston, MA, 43 per 100,000 Black women die from breast cancer, compared to 24 per 100,000 White women (5).
This disparity has been investigated to determine why Black women have a higher mortality rate than White women. Data show that Black women over 40 are just as likely to receive mammography screening as White women (6). However, breast tumors in Black women tend to be diagnosed at a more advanced stage than White women, indicating that the age at which mammography is performed or the consistency of getting a mammogram each year varies between the two groups (2). Significantly more White women are diagnosed at a localized stage compared to Black women, who tend to be diagnosed at a regional or distant stage (2). In addition, Black women are just as likely to receive a mastectomy or breast conserving surgery in early stages of the disease (1). Yet, Black women are less likely to receive radiation, an integral part of treatment to improve survival at early stages (1).
Most importantly, socioeconomic factors tend to impact the mortality of Black women diagnosed with breast cancer. Black women with early stage invasive breast cancer tend to be poorer than White women (1). In addition, marital status and insurance type are important factors that impact Black women’s treatment of breast cancer. For example, married women are more likely to receive guideline concordant care than single women. At the same time, a lower percentage of Black women diagnosed with breast cancer are married compared to White women diagnosed with breast cancer (1).
In October 2007, Mayor Thomas Menino and the Boston Public Health Commission launched the Pink and Black Campaign with the goal of educating Black women on the effects of breast cancer, in hopes of eliminating the disparity in mortality rates (7). “The campaign aims to empower Black women to, ‘See your doctor. Get screened. Get treatment’” (8). It hopes to encourage Black women to get screened earlier and more consistently so that detection can occur at an earlier stage of the disease. The campaign has run every October for the entire month since 2007.
The Pink and Black Campaign consists of billboard advertising on city buses and in subway stations, and a website that encourages Black women to see their doctor to get screened and get treatment (8,9). In addition, the campaign features Pink and Black Ambassadors, Black women who have survived breast cancer. These ambassadors travel across the state to encourage Black women to, “defy the odds,” and get screened for breast cancer (8,10). They tell personal stories of breast cancer survival and hope to be an inspiration to other Black women who may have breast cancer.
II. A Critique of the Pink and Black Campaign
Although the Pink and Black Campaign has a very important mission in reducing the disparity of mortality rates from breast cancer among Black women, there are several flaws with the program. The following section outlines the reasons why the Pink and Black Campaign may not be successful in reducing the breast cancer mortality rate among Black women.
A. Assumption that People are Rational
First of all, the Pink and Black Campaign follows the Health Belief Model. The Health Belief Model assumes that a combination of perceived susceptibility, perceived severity, perceived benefits and perceived barriers all come together to form intentions, which in turn, result in behaviors (11). In the case of the Pink and Black Campaign, the campaign aims to educate women through ambassadors and billboards the benefits of early screening for breast cancer, as well as how susceptible Black women are to breast cancer and how to reduce the severity of breast cancer (i.e., fatality). The campaign aims to educate Black women on how to minimize barriers and gives them resources for making an appointment with their doctor and getting screened.
The Health Belief Model makes many assumptions, however. In particular, it assumes that women act rationally and are able to weigh the options to make a decision of whether to see their doctor and get screened (11). Several theories give reason to believe that rational behavior is unrealistic. Often, people have a hard time maintaining self-control. Whether a person is going on a diet, trying to quit smoking, or remembering to obtain preventive medicine, studies have shown that people often procrastinate or lose self-control and engage in behavior contrary to intentions (12,13).
In addition, optimism can interfere with people engaging in rational behavior. The optimistic bias demonstrates that people tend to be unreasonably optimistic about future life events and often underestimate the chance of negative events happening to themselves (14). In fact, studies on the optimism theory found that the more undesirable the event, the less likely people believe the event will happen to them (14). In the case of breast cancer, a Black woman may feel that her chance of getting breast cancer is not likely to happen to her, and therefore, she does not need to get screened until later in life. Simply educating Black women about breast cancer may not necessarily convince them to act rationally and get screened, since they may underestimate their personal chance of getting breast cancer.
People may also act irrationally because of the method in which they learn. Bandura’s Social Learning Theory says that people learn through imitation, observation and modeling the actions of others (15). The models are used like scripts and can be applied to real-life scenarios (16). For example, if a child watches her parent go to the gym every day, she may grow up believing that she should also exercise and go to the gym. Similarly, if a woman comes from a family that places high value on getting screened for cancer and openly gets a mammogram on an annual basis, her daughter may learn this same behavior and do the same when she is older. However, irrational behavior can also come out of the social learning theory, since all behaviors may be modeled by others. Therefore, a woman who comes from a family that has never been screened for cancer, does not regularly see a primary physician, and has many high-risk behaviors, may pass these models and behaviors on to her children and family members. Again, this shows how the Health Belief Model, in its assumption that people act rationally, could fail to change behaviors.
B. Disregard for Social and Environmental Factors
Another reason why the Pink and Black Campaign may be unsuccessful is that the campaign does not take into account socio-economic factors, or other environmental factors. As stated earlier, socio-economic factors can impact the prevalence of a disease, as well as the mortality of a disease (1). In addition, factors such as access to resources and cost of various treatment options can act as barriers to diagnosis and treatment.
Feminist critiques often disapprove of traditional health models because they focus on majority populations and do not take into account diversity, particularly in terms of women and Blacks (17). Historical, social, and political factors are rarely considered when applying traditional health models, and therefore, can represent barriers to changing behaviors (17). For example, the models do not consider the disparity in access to healthcare resources among different sub-groups of people. Poorer families have a different type of access to healthcare compared to more affluent families, and therefore, barriers and benefits can be perceived differently. Without considering these external factors, behavior change can be challenging.
In addition to socio-economic factors, discrimination can affect the type of care available to certain sub-groups. As noted already, there are several disparities in treatment of disease for Black women diagnosed with breast cancer (1). One study showed that institutionalized racism can result in Black patients receiving different information, healthcare education, quality of medical facilities, and treatment options (18). A Black woman may want to get screened for breast cancer, but does not have a primary care physician and cannot find one willing to take on new patients.
Another study showed that physicians’ recommendations for cardiac catheterization depended significantly on the patient’s race and gender (19). In this study, women were less likely to be referred for cardiac catheterization than men with the same symptoms. Further, Blacks were significantly less likely to be referred for cardiac catheterization than Whites (19). Understanding that race or gender, alone, can impact the type of care recommended and received, has a major implication for disparities in health. For example, Black women may be diagnosed with more aggressive breast cancer than White women because physicians tend to screen Black women at a later age than White women. Physicians may also have influence over who receives radiation therapy and who does not, and race could play a role in this determination. In conclusion, a campaign that simply provides information about Black women’s susceptibility to breast cancer and encourages visits to a primary care physician is not likely to solve the disparity in diagnosis and treatment of breast cancer in Black women.
C. Failure to use Marketing Theory in Campaign
The last problem with the Pink and Black Campaign is that it does not use principles from marketing and advertising theories. Successful marketing campaigns include several crucial components that are able to change people’s motivations or behaviors. The first component a marketing campaign must have is a promise (20). In the case of the Pink and Black Campaign, the promise is, “If you follow our suggestions and see your doctor, get screened, and get treatment, you will defy the odds of dying from breast cancer” (8). Nevertheless, simply having a promise is not enough to be persuasive. Successful marketing campaigns provide promises that appeal to core values. Core values that typically appeal to people include freedom, control, opportunity, and acceptance (20,21). The Pink and Black Campaign uses health and life as its core values. However, the promise of health does not typically sway consumers to change behavior (21). Therefore, the Pink and Black campaign needs a more meaningful promise in order to persuade Black women to see their doctors and get screened.
In addition to providing a promise, successful marketing campaigns typically are based on research on the target audience. Formative research helps understand the target group’s values, motivations, appeals, and desires (21). Knowing this information helps an organization to custom-design a campaign that will appeal to the target group. The Pink and Black Campaign targets Black women, but does not appear to know much about these women. As stated before, the campaign assumes that the core value to these women is health. In reality, they may value family, acceptance or freedom more than health. In addition, the campaign does not frame its message in a way that supports the target audience’s core values. Having breast cancer survivors tell their stories at conferences and meetings is not likely to support the communication to its target audience (10). Rather, the message should be catered to its target group so that it immediately appeals to them, in setting, message, and evidence. For example, having Ambassadors speak at a church or school about the core value they would have missed if they did not get early screening and detection of breast cancer may be more persuasive for its audience than the current campaign.
III. Proposed Intervention Using Social and Marketing Theories
A more successful intervention for reducing the disparity in breast cancer mortality rates among Black women would include components that address social factors related to access to care, empower women to minimize the effects of institutionalized racism, as well as incorporate marketing principles that result in a more persuasive campaign.
A new and improved Pink and Black Campaign would apply proven marketing techniques in creating a persuasive message that is meaningful to its target audience. Formative research on the target audience would help determine the core values most important Black women (20,21). The message of the Pink and Black Campaign would be rebranded into a promise that is both meaningful and persuasive to Black women. This message would be supported by the Pink and Black Ambassadors, who would continue to travel the state telling their stories. However, in the new campaign, these women would tell stories, not of surviving breast cancer, but of how they gained a core value, such as control, by getting screened early or receiving appropriate treatment.
A revised Pink and Black Campaign would also aim to empower Black women to take responsibility to get screened regularly starting at the guideline-recommended age. The campaign would educate women on appropriate treatments for breast cancer so that if they are diagnosed with breast cancer, they do not suffer from institutional racism. Teaching Black women to proactively request the same care that White women receive may help minimize the disparity in mortality rates among women with breast cancer.
Not only would the Pink and Black Campaign target individual women, but it would also target social relationships. Social network websites, such as, can help spread the message of the Pink and Black Campaign, by having women make a promise to get screened. A Pink and Black logo could be added to profiles of women who take this pledge, and women could send the pledge to their friends.
Lastly, the Pink and Black Campaign would consist of more than just a website, signage, and Ambassadors. In addressing external factors that impact breast cancer screening for Black women, the campaign would provide resources that currently exist as barriers in obtaining screening. The Pink and Black Campaign would provide a breast cancer screening clinic once a month in a convenient location, accessible by public transportation. The clinic would be open after work hours so that women would not have to take time off from work. In addition, the campaign would work with the government to provide free screening exams, so that cost of care would not be the barrier to receiving breast cancer screening.
The following sections explain the proposed improvements to the Pink and Black Campaign in more detail.
A. Applying Social Ecological Model to Account for External Factors
The social ecological model takes into account not only an individual’s perspective, but also the individual’s environment, including relationships with other people, living conditions, communities, institutions, and public policies (15). By assessing the environment an individual lives in, one can better understand the context in which behaviors occur. As previously discussed, people often behave contrary to expectations when assessed at the individual level. However, many irrational behaviors can be explained by a person’s environment.
The current Pink and Black Campaign assumes that Black women rationally weigh the risks and benefits of seeing their physicians and will likely get screened for breast cancer if they become more aware of the effects of the disease. The social ecological model shows that there are many levels of influence that impact the decision of whether to get screened for breast cancer, not just the individual (15). For example, a Black woman may be aware of the negative effects of breast cancer, but be too scared to get the test. On an interpersonal level, the woman’s friends may tell her that she does not need the screening exam, since it has never benefited them. At an organizational level, the woman may want a breast cancer screening exam, but she does not have a primary care physician, or cannot get an appointment with her doctor. Further, at a policy level, she may not have health insurance that covers a screening exam and she cannot afford the cost of the exam (15). Therefore, many different factors go into the decision of whether to get a breast cancer screening exam.
A successful Pink and Black Campaign should acknowledge these external factors and target not only the women at risk, but their surrounding network, community, and policies that affect them. At the interpersonal level, the campaign could take advantage of social networks and encourage groups of Black women to be supporters of the campaign. This would require a successful marketing campaign, which will be discussed further in Section C. Several studies have shown that social networks can be predictors of health behaviors (22,23). For example, one study showed that social networks were related to smoking cessation. If one cluster of people stop smoking, additional linked clusters were likely to quit smoking, regardless of geographic proximity (22). The Pink and Black Campaign could take advantage of social networks and use a grassroots method for encouraging “clusters” of social groups to get screened on a yearly basis for breast cancer.
Data also show that physical neighborhoods can be a determinant of advanced-stage breast cancer, particularly for Black women (24). On an institutional level, the Pink and Black Campaign could acknowledge where there is lack of access to primary care doctors or high rates of advanced-stage breast cancer, and provide screening clinics on a monthly basis. These clinics would be located in areas that are easily accessible by public transportation, and would be open after normal working hours so that women would not need to take time off to get screened. Further, if the campaign acknowledged that lack of insurance coverage and costs are barriers to breast cancer screening, the Pink and Black Campaign could work with the government to cover the cost of the screening exams, so that they are free to women regardless of coverage.
B. Using Empowerment Theory to Minimize Institutionalized Racism
Applying the empowerment theory can also address external factors related to Black women obtaining breast cancer screening. Similar to the social ecological model, the empowerment theory acknowledges that external factors have an impact on individuals. The empowerment theory, however, is based on the idea that giving people the power to control their environment will enable them to improve their lives (25,26).
Often, members of minority groups internalize racism and act according to stereotypes (18,27). In addition, institutionalized racism occurs when different treatment regimens are recommended by physicians depending on the patient’s race or gender (18,19). These two types of racism can interfere with Black women’s perception of control, and in turn, can contribute to the disparity in treatment of breast cancer. The empowerment theory can be incorporated into the Pink and Black Campaign so that women are given the power to control their healthcare decisions and eliminate the effects of internalized and institutionalized racism.
The campaign would aim to achieve the four levels of empowerment by encouraging self-efficacy, reaching group consciousness, reducing self-blame, and assuming responsibility (26). Self-efficacy can be achieved by making women believe that they are in control and can make a difference by getting screened for breast cancer. Group consciousness is important for gaining control for not just individual women, but networks of women as a whole. Group consciousness enables women to see that they are not alone and can be effective by encouraging each other to get screened. Reducing self-blame helps Black women realize that it is not their fault that certain barriers (interpersonal, institutional, and policy) exist in accessing breast cancer screening. Lastly, the campaign should emphasize that there is a responsibility for each woman to take initiative to protect herself from breast cancer and get screened and treated (26).
The current Pink and Black campaign achieves some of the objectives of the empowerment theory, but is not successful at targeting those that are related to a woman’s environment. All of the factors – intrapersonal, interpersonal, institutional, and policy-related – must be addressed for empowerment theory to be effective at empowering Black women. With empowerment, Black women can minimize institutional racism by requesting breast cancer screening exams, even if their physicians do not recommend them. In the case of treatment, empowerment can also give Black women the education needed to know that they should request radiation treatment when appropriate, thus eliminating disparity in care treatment among the races.
C. How Marketing Theory can Send a Persuasive Message
Most importantly, none of the above strategies for enhancing the Pink and Black Campaign will be successful without the appropriate use of marketing theory. In order for the campaign to successfully persuade Black women to see a physician and get screened early, the campaign message must be convincing.
Currently, the Pink and Black Campaign makes a promise of health and life if the message is followed. However, this type of message has been proven unsuccessful, since it relies on a value that not everyone appeals to (21). The first step in creating a successful message is to conduct formative research on Black women in order to understand their core values, desires, and needs (20,21). For example, research may show that Black women tend to value freedom and acceptance the most. With this information, the campaign could reform its promise as such: “If you get screened for breast cancer on a yearly basis, you will feel more control over your life.” The role of Pink and Black Ambassadors would be to reinforce this promise, by sharing their stories, not of how early screening and treatment saved their lives, but how these actions gave them more freedom and control over their lives. Visual images on campaign posters and signage could show Black women making decisions (i.e., taking control) and playing with their children (i.e., freedom).
In addition to re-branding the Pink and Black Campaign by adjusting the promise and support, the campaign could also benefit by introducing a catchier slogan. Catch phrases are commonly used in marketing consumer products and are successful depending on how memorable they are (20,21). The current slogan of the Pink and Black Campaign is, “See your doctor. Get screened. Get treatment” (8). These words are not the most memorable, nor persuasive. A better catch phrase for the Pink and Black Campaign could be something like, “Get screened, get control.” This phrase incorporates the potential core value that its target audience appreciates.
Lastly, research can help pinpoint how the target audience obtains or learns information best. Currently, the Pink and Black Campaign sends Ambassadors across the state to conferences and meetings to tell their stories of surviving breast cancer. However, conferences may not be the most ideal spot for getting their message out to their target audience. Conducting research on where Black women get their information could reveal that they often get information from church groups, schools, or community centers. The Pink and Black Campaign should assess the locations and mediums through which it would like to distribute its message so that it successfully reaches the most number of Black women.
In conclusion, there are several ways to enhance the success of the Pink and Black Campaign in terms of eliminating the disparity of breast cancer mortality among Black women. By taking a more comprehensive look at women’s external environments and giving Black women the tools to perceive more control over their actions, the Pink and Black Campaign has the potential to persuade women to get screened early, routinely, and seek timely appropriate treatment when necessary. With the incorporation of traditional marketing techniques used in business, the campaign is likely to be a sure success, not only changing individual behavior, but impacting the Black community as a whole.

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