Challenging Dogma - Fall 2009

Wednesday, December 16, 2009

The Pink and Black Campaign: “Pink isn’t the only color of breast cancer” Analysis of Conceptual Challenges and Recommendations for Success- Cristin

Breast cancer is the most common invasive cancer facing women (1). It crosses all age sectors, though it is most prominent in the 30 and over age group (2). Globally, over one million women are diagnosed with breast cancer, and 600,000 women lose their battle with the disease (2). Marketing strategies have emerge to create more awareness on this issue, encourage individual action and combat this cancer. Breast cancer has received increasing media coverage in recent years. (3) Initiatives like the Susan G. Komen Foundation’s Pink Ribbon campaign are achieving unprecedented success and awareness for the cause (4). Projects focused on early detection and mammogram education have targeted some of the challenges on identifying reasons for the late discovery of the disease (4). Despites these programs, breast cancer remains the fifth leading cause of death for women (5).
There is a great deal of concern on what role socio-economic levels, culture, race and education play in access to care and early detection for breast cancer (6). Evidence suggests that access to care is dependent on certain variables (3). One of the largest enigmas is between breast cancer and Black women (7). Statistics show that Black women on average receive a higher proportion mammograms compared to white women (6). A number of initiatives focus on increasing the number of screenings for both populations (2). However, despite the high proportion of mammograms and screenings done, Black women are far more likely to die from the disease than white women (8). The below graphs illustrate this comparison.
(9) (9)
Science suggests that although Black women receive mammograms at a higher rate than white women, at these mammograms, Black women on average have larger, more cancerous tumors and have reached later stages of cancers at the time of mammograms (3). Reasons for this furthered disease state is partially attributed to genetics, but implications of health disparities are also suggested (8).
Health disparities reference gaps in healthcare that run across socioeconomic, racial, ethnic or sexual orientation lines (9). The discrepancy between detection of breast cancer and death of Black women with breast cancer suggests a health disparity (10). Research indicates cultural and socioeconomic factors influence the delay in seeking mammograms (8).

The Pink and Black Campaign
With the momentum and awareness breast cancer has received in recent years, various programs have developed initiatives to target this disparity (4). The Pink and Black Campaign is a joint effort from the Boston Public Health Commission (9). This campaign began in 2005, in order to address the high number of deaths in Black women from breast cancer in Boston (9). It is supported and advocated for by Mayor Menino, as well as partnerships with local hospitals like Brigham and Womens (9).
The Pink and Black Campaign is an initiative of REACH, Racial and Ethnic Approaches to Community Health (5). This effort is part of The Center for Disease Control and Prevention’s initiative to eliminate health disparities through community-based participatory approaches (4).
The premise of the Pink and Black Campaign is to raise awareness on breast cancer risks facing Black women (9). The aim is to empower women to “See your doctor. Get screened. Get treatment (9).” The program’s tagline is “Pink isn’t the only color associated with breast cancer (9).” The program entering its fourth year focuses on mass public awareness campaigns in print media formats in order to advocate and market the cause (9). Advertising in the local transit system, most commonly the subway and bus, comprises the marketing scheme of the program (9). In addition, a website offers a useful toolkit to target the at-risk population (9). There are videos documenting the struggles of Black women in the community overcoming breast cancer (9). They detail their journeys in a personal and intimate way. These videos are not utilized in any other manner than the website and range in length from 3 to 9 minutes (9).
Ambassadors within the community are appointed to educate and serve as the face of breast cancer (9). These are successful and respected Black women in the greater Boston area that are all breast cancer survivors. Tools on the project’s website offer means to educate those at-risk on options. A translator gadget allows for a wider audience. Collaborations, with hospitals like Brigham and Womens, cultivate the project’s accountability and level of awareness (11). In addition, a partnership with Boston’s Mobile Mammogram Van gives an opportunity for women to have mammograms regardless of their ability to pay. Other resources, such as the Mayor’s Help Line, gives resources for women to access services. The Help Line is a service that assists in finding an appropriate service provider (9).
The Pink and Black campaign provides education and resources to combat the disparities that Black women face in terms of breast cancer in Boston. In addition, Massachusetts has set a precedent for the rest of the nation with state-wide healthcare requirements for all residents (9). With these precautions in place, the conflict as to why the mortality rate for Black women is so high is inconclusive (10).

The Pink and Black campaign’s development
The Pink and Black campaign follows traditional health models in that it focuses on the individual as opposed to the community (12). The program aims to serve individual women. This includes need, access and behavior change (12). The Pink and Black campaign is strategic in its methodology of serving the community better for breast cancer awareness and prevention, however it falls short on a number of levels in achieving its goal.
The Health Belief Model is the basis for the conception and implementation of the Pink and Black campaign (12). In this theory, there is an assumption that individuals have a perceived susceptibility for the disease, they have a perceived severity of the consequences of breast cancer, they have perceived benefits of early detection through mammograms, they have perceived barriers to getting mammograms, there are cues to action to the behavior and finally and that there is self-efficacy (12). The self-efficacy is critical, in that the individual must believe that they can achieve and maintain the behavior change (12). According to the Health Belief Model, health-seeking behaviors are driven by an individual’s motivation to adopt a behavior (12). The assumptions that the Health Belief Model requires fail to be present in target population for the Pink and Black Campaign.

Critique 1: Assumption of Rationality
The Pink and Black campaign functions on the premise that individuals are rational. As learned in “Predictably Irrational,” despite logical and rational reasoning, people often act against rationality (13). Irrational decision-making presents itself with typical life challenges, stresses and access to care (8). It can also be affected by socio-economic, racial, cultural and gender lines. The Pink and Black campaign’s assumption that people are rational is one of its failures.
Assuming that people are rational, the campaign would be effective in many respects. The campaign’s website specifies that women should receive annual mammograms and perform self-mammograms monthly (9). A rational individual would in most cases adhere to these recommendations. There is a loss of connection between what is recommended and choices that are affected by outside influences (13). More Black women present with breast cancer that is further advanced than women in other racial groups (5). Evidence suggests that by majority Black women are not seeking annual mammograms on a consistent basis (7). The lapse is occurring between information dissemination and behavior change.
A logical and rational person knows that breast cancer is a risk, they may also have the education-base to know that they should see a physician annually for a mammogram (8). The reality is, in many cases, the awareness and knowledge does not transition to the appropriate behavior (2). The unfortunate nature of this situation is a perfect example of how traditional approaches to public health by majority fail.
Numerous campaigns reside on the premise that individuals act rationally. One example is smoking. Education is so broad on smoking that it can be assumed that the vast majority of the population know the risks of smoking, however, they still make the choice to participate in the activity (14). This is an irrational action, given all the information that tells the public the effects of smoking, yet still 19% of American women smoke cigarettes (11). People are not rational, they are in fact, predictably irrational (13). Programs that base their assumptions on the actions of the rational will almost always fail to achieve their goal (13).
The Pink and Black campaign gives information to seek treatment, resources and services (9). The information is user friendly and efficient. However, it all rests on the assumption that individuals will take action and reach out for this information.

Critique 2: Social and Environmental Factors are not considered and assumption are made
The Social-Ecological model must be considered to gain success in this campaign. Considerations that it entails are not illuminated by the Pink and Black campaign, and this lack of acknowledgement is a flaw. Societal complications like socio-economic levels and cultural constraints should be taken into account when developing a campaign that would best achieve the goal (11). The complexities of individual, relationship, community, and societal factors have on decisions and behavioral change must be evaluated (15). The Social-Ecological model considers the individual first, but it also considers the impact of relationships, their community and society as a whole, as the below graph indicates (15).


Environmental factors have a great impact on behavior change (8). Central geographic locations create community dynamics and access to address challenges. For the Pink and Black campaign, it is unclear whether advertising methods were considered in geographic locations where there is a higher concentration of Black women in Boston. The advertisements merely directs women to the website, not making the locations convenient for them in their community or environment (9).
The Pink and Black campaign also assumes that people will have access to this information. Beyond the print advertisements, the campaign information is predominantly on the website. The assumption is made that all in the target population has access to the internet. More importantly, the web-based information makes the conclusion that this is the most pertinent way women receive information. With the large premise of the collateral materials on buses and subways, the target population would have to be motivated by the print media to seek out the information on the website and then take action for the mammogram from information gained on the internet.
Socioeconomic status is directly related to behavior change (6). In many respects, the economically challenged populations have fewer healthcare options, less education and minimal exposure to the deeper context of disease (6). It is important to understand that these factors act as barriers to behavior change, particularly in reference to the Pink and Black campaign (8). The campaign relies on women to take initiative from seeing an advertisement, to seek additional information, only to have to take a third step to find a provider for the mammogram (9). These steps all must take place prior to the actual behavorial change, the mammogram. With all of the steps to care involved, socioeconomic factors may inhibit individuals from seeking the mammograms until the disease has progressed (3). Logical considerations due to socio-economic factors should be considered (15). For women in more constraining work areas, it may not be feasible or prioritized to take time away from work in order to have annual exams.

Critique 3: Issues of motivation, hierarchy of needs, unrealistic perceptions are not considered
In conjunction with Maslow’s hierarchy of needs, individuals seek out needs in a specific framework (16). Basic needs include psychological, physical safety, love, esteem and self-actualization (16). In essence, the basics states must be satisfied in order to move onto less vital concerns.
The Theory of Motivation states that actions have more than one motivation and satisfy a basic need (16). The framing of the Pink and Black campaign fails to satisfy the elements that would effectively motivate an individual. Humans are perpetually wanting animals, the goal of the campaign needs to be framed in a manner that motivates (16).
The need for early detection and use of mammograms for Black women in the community is evident. Current advertising for the campaign does not speak to a fundamental need and it is concerning long-term outcome, therefore it is easier for the target population to disregard and not be engaged in the message of the advertisements (17). The target population needs to have a vested interest and value the service (18). They should feel a priority to have the service to satisfy a need (19).
The print materials focused their marketing direction on scare tactics (14). One flyer states the slogan of “pink isn’t the only color associated with breast cancer.” It then details outlined figures of women fewer white ones and more black ones. The Black figures are crossed out to indicate death. The advertisement then says this is how many more Black women will die of breast cancer than white (9). This tactic is trying to scare women into utilizing mammograms more routinely, which is a tactic that has shown success; however, the effectiveness with the Pink and Black campaign is lacking (14).
Currently, motivation is replaced with unrealistic optimism (20). Individuals by nature assume that negative events will happen to them on a less than average scale (20). Despite evidence, individuals are under the unrealistic perception that they are less susceptible to the disease or risk (21). They validate that the issue at hand affects a number of individuals, but they do not associate themselves within that pool, even if possessing a number of risk factors (21).
For example, one study reflected perceived risk of heart disease and cancer of cigarette smokers (21). Results showed that smokers, despite knowledge, did not view themselves at increased risk for heart disease or cancer (21). This can be classified as denial in many ways, and furthers the testament that people behave irrationally (13). Additionally, it conveys that individuals have an illusion of control over their realities (22).
Black women in Boston by majority fail to take action concerning their vulnerability for breast cancer (9). According to the theory of human motivation, the Pink and Black campaign is flawed (16). It does not provide adequate motivators to encourage behavior change (11). Considering Maslow’s Hierarchy of Needs, unrealistic optimism and a false sense of perceived risks, a successful campaign needs to engage individuals as a community and instill a realistic sense of risks, increase the priority for the individual in their lives and motivate them to take action (16)(23)(20).

The Pink and Black campaign explores the enigma of higher Black deaths from breast cancer despite higher mammogram utilization. The resources it offers are solid and useful, however, the campaign falls short in its assumption that the target population will make rational decisions, its failure to acknowledge socio-economic and environmental factors and the inappropriate use of motivation theory and assessment of the target population’s perceptions.
The goal of the campaign is to have more Black women getting mammograms sooner, as a substantially higher proportion of Black women have farther progressed breast cancer, compared to other racial groups, thus leading to higher deaths of Black women (4). Considering outside factors, women are lacking incentives to utilize mammogram services before the onset of breast cancer. Restructuring this campaign would give a stronger and more promising foundation and tactics to address these disparities.
A conditional cash transfer program (CCT) should be developed for the Pink and Black campaign. CCT programs are widely successful in the developing world for programs promoting school attendance, nutrition and cervical cancer screening (24). The premise is that by utilizing the service, the agency pays the individual (25). This encourages the individual to take action. The incentive can range from monetarily to any number of items. Research indicates that offering free services, such as mammograms free of charge, does not result in success, as might be expected (25).
A successful model used in Mexico gives conditional cash transfers to mothers in order to have their children attend school (25). If attendance consistency occurs, which is the condition, mothers then in turn are awarded financial incentives.
The Pink and Black campaign faces a differing set of challenges than the program in Mexico, but the premise for the intervention is the same. The behavior change is not only encouraged but immediately rewarded. The program, Oportunidades, is extremely successful and is currently being modeled by four other countries (26). This initiative created a cultural norm through CCTs (26). By giving the community incentives, they responded to the condition. This changed the normal culture of the community. Black women in Boston are not going to mammograms early enough or often enough (1). In order to change this community norm, there must be an incentive (26). CCT would be a strategic and effective means to achieving this goal.
A CCT program would motivate the community (24). The Pink and Black campaign addresses the individual, but success lies in addressing the community, so a community perspective and angle must be addressed (11). Advertisements would indicate small monetary incentives. If a woman refers a small group of Black women for mammograms and service is completed, they are rewarded. If a woman is able to recruit three other Black women in the community to complete mammograms, they are in turn rewarded. Those three women would be encouraged to reach out and recruit more in the target population, and they would be rewarded by CCT. The CCT would change the cultural norm quickly and increase community awareness. This utilizes framing. The program is no longer selling the long-term result of a cancer-free life, but they are selling the CCT (18).

Utilization of a CCT strategy would satisfy motivation theory (16). Currently, mammograms are not taking place as early as needed in Black women, the CCT program would serve as a recruitment tactic (24). Once the women are part of the campaign, education would solidify breast cancer prevention on a higher level on their own hierarchy of needs, alter their perceptions of risk and adjust their illusion of control to a more realistic alternative (20)(22). This would serve to better achieve the goals of the campaign.
Mammogram centers should be identified on the Pink and Black campaigns website to show what facilities have partnered and are giving mammograms. These facilities should be located in central areas and areas where there are higher populations of Black women in Boston. Convenient and familiar practitioners will encourage active behavior change (19). Creating greater access opportunities will address societal and environmental influences that harbor barriers in the current campaign (15). By giving the Pink and Black campaign a presence within the community, individuals will have a greater ease in making it a priority in their lives.
The print media should offer a calling option. Upon calling the number specified on fliers, the caller will be prompted for their zip code. The individual will give enter their code, and the automated system will give them the closest facility that performs mammograms as part of the Pink and Black campaign. This tool should also be available on the website.
Ambassadors are an effective strategy to mobilize the targeted population on a community level, but the current use of the ambassadors by the Pink and Black campaign needs to be pushed to a more proactive levels. Social networks should be developed in order to promote the Pink and Black campaign (11). Social Marketing Theory should be heavily employed to validate elements of self-efficacy and evaluate perceived costs and benefits for the target population (15). Online groups would offer the target population the opportunity to have candid discussion with the ambassadors serving as facilitators. The women could have sessions with online networking sites that cater to different age brackets or social mediums. The Pink and Black campaign should extend this program and implementation of Social Marketing Theory to events at the partnered hospitals. These meetings would be community-based events encouraging networking within the Black female community (15). Promotion of early detection of breast cancer will continually be the focus, and the campaign will build a presence in the community. Ambassadors should be present at these events to facilitate discussion and sharing of experiences.
By placing these new opportunities to attain and disperse information, asymmetric paternalism can be achieved (27). Institutions created throughout the community, like the partnered hospitals and online social networking sites, convey that this health issue is a priority from a policy level standpoint (27). This creates a avenue for sustainable change. Referencing Malcolm Gladwell’s, “The Tipping Point,” the goal of the campaign is to gain a momentum of its own, so that it is in essence unstoppable, and it becomes its own machine, cementing the behavior change (28). Gladwell compares this momentum to a virus spreading (28). The goal of any successful campaign is to achieve the tipping point, and it can only be reached by having a realistic understanding of the barriers within the target population (28).
The Pink and Black campaign attempts to create a culture of awareness that Black women are dying from breast cancer at substantially higher rates than other racial groups (9). Despite a higher number of mammograms in this sector, early detection and knowledge of the disease are means to combat the illness (7). The program fails to recognize that individuals are in essence “predictably irrational,” the role that socio-economic and environmental factors play and acknowledgement that behavior change lies in motivation, perception and illusions (13)(15) (22).
By refocusing the marketing and advertising strategies of the Pink and Black campaign to address these challenges, the success rate of the program will be increased. Implementing a conditional cash transfer would not only assist in recruitment, but it would also serve as a forum to make these concerns a greater priority (26).
Utilization of resources like the ambassadors and the website more efficiently will assist in creating a sense of community and thus accountability for Black women in Boston (11). Social networking schemes will aide in providing a venue for support and education on a peer level (8). Adding to the toolkit by having a call in number for mammogram locations will filter women into convenient locations for addressing this health concern. Mobilizing communities with higher concentrations of Black women to host mammogram screenings will instill a further sense of community and support. The collaborative effort of these strategies will fill the gap that the present Pink and Black campaign illustrates.

Works Cited
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