Challenging Dogma - Fall 2009

Wednesday, December 16, 2009

Pink And Black: Proposed Revisions to a Boston Campaign to Promote Screening for Breast Cancer Among Black Women-Meghen De Santa

I. Introduction

African Americans suffer the highest death and shortest survival rates for all cancers compared to all other racial and ethnic groups in the United States [1]. Breast cancer is among the most commonly diagnosed cancers in African American women, accounting for 25% of diagnoses [1]. Disparities in mortality rates have increased for African Americans since the 1970s largely due to cancers of the breast, colon, prostate and lung, and mortality rates for all cancers are 16% higher in Black women than White women [1,2]. In 2005, the incidence rate for breast cancer in the United States was 119.1 per 100,000 for White women, and 110.2 per 100,000 Black women [2]. The incidence rate in Massachusetts was 131.9 versus 118.7 per 100,000 for White and Black women, respectively in that same year [2]. However, the death rate for Black women with breast cancer in the U.S. was 32.8 and in Massachusetts, 29, while the death rate for White women was 23.3 in the U.S. and 23.2 in Massachusetts [2]. Because the incidence of breast cancer is lower among Black women than White women, the higher mortality rate can be attributed to diagnosis at a later stage of cancer development and to racial disparities in appropriate and timely treatment [1-4]. However, according to the Boston Public Health Commission, more Black women over the age of 40 have been screened for breast cancer than White women in Boston, at 95.3% and 91.7% of women ever screened, respectively [5].
The Boston Public Health Commission’s “Pink and Black” campaign seeks to educate Black women about disparities in breast cancer outcomes between Black and White women and encourage Black women to be screened for breast cancer. The campaign is based on the fact that “Black women are more likely to die after being diagnosed with breast cancer than women of other races” and that the reason for this is failure to be screened for breast cancer until it is too late [5]. Mayor Thomas M. Menino worked with the BPHC to train “Pink and Black Amassadors,” Black women who have survived breast cancer, to spread the message to the Black community, encouraging and empowering women to be screened. Posters have been placed throughout Boston and include the following statements: “Despite higher rates of screening, Black women are more likely to die from breast cancer than White women;” and “Pink isn’t the only color associated with breast cancer.” Thirty-two female figures—12 white and 20 black—stand side by side on the poster to represent the higher percentage of Black women who die from breast cancer. In 2008, the campaign was extended from Boston to Springfield, Massachusetts [5].
The campaign draws attention to racial disparities in health outcomes and involves Black women in outreach to the Black community, a technique employed by proven effective interventions like the Truth campaign which trains youths to promote smoking prevention and cessation to other youths [6]. However, the central argument of this paper is that the Pink and Black initiative is generally flawed in its approach. Three flaws will be examined followed by three suggested modifications to the program. The proposed restructuring of the Pink and Black campaign’s current approach will integrate alternative theoretical models that address health behavior at the group level. It will also incorporate marketing theory and seek to address socio-cultural barriers to the improvement of health outcomes for Black women with breast cancer.
II. Pink and Black: A Critique
The Pink and Black campaign is unlikely to be effective for three reasons. First, the initiative is structured according to an antiquated theoretical model (namely, the Health Belief Model) that assumes health behaviors to be the outcome of an individual’s rational consideration of her perceived personal susceptibility to a disease and her knowledge of its severity. Second, the campaign fails to address cultural barriers including fear, distrust of the medical system, and distinctive ideas about illness and healing that exist in some Black communities and that are at odds with biomedical treatment protocol. These barriers are largely the result of structural and institutionalized racism [7]. Lastly, the message of the campaign is confusing and fails to utilize social marketing theory. It offers a “negative promise” in an attempt to empower women and neglects to conduct formative research in campaign development [8].

A. Pink and Black is Based Upon an Inappropriate Health Behavioral Model

The Pink and Black campaign assumes that health behavior (namely, being screened for breast cancer) is the result of an individual’s rational costs-benefits analysis of his or her health [9]. The program ambassadors and media outreach (posters) encourage women to be screened for breast cancer to address disparities in the mortality rates of Black and White women with the disease. The message targets individual behavior, a goal of the Health Belief Model (HBM) that is widely used in public health initiatives. The HBM posits that health behavior is determined by an individual’s perceived susceptibility to a health issue and perceived severity of that issue, along with the perceived benefits of a behavior and perceived barriers to performing that behavior [10].
Pink and Black seeks to inspire behavioral change within the individual; however, perceptions of personal risk alone are poor predictors of health-seeking behavior [11]. Furthermore, psychosocial and cultural forces are not addressed as factors influencing health-seeking actions at the group level. Many studies have criticized the negligence of campaigns based on social cognition models like the HBM to address complex environmental influences upon health behavior [9, 11-13]. These models are built upon a “logical positivist” framework that reduces human behavior to its most simplistic motivations and does not allow for behavioral variation [13]. Use of the Health Belief Model and theories of health behavior as the result of rational, straightforward cost-benefit analyses devoid of socio-cultural influence has “resulted in a perspective whereby women and people of color are viewed as deviations rather than variations” [13].
By targeting individuals and encouraging Black women to remedy health disparities by being screened for breast cancer, the Boston Public Health Commission neglects to focus its resources upon the education of health professionals and medical staff regarding disparities in treatment once screening has taken place. The statement that rates of mortality after diagnosis are higher for Black women than White women over 40 in Boston—despite a higher rate of screening—suggests that the treatment of Black women with cancer may be insufficient or inappropriate. Several studies report the tendency of Black women to be diagnosed at a later and more critical stage of cancer development that likely contributes to higher rates of mortality [3-4, 14-16]. However, it has also been acknowledged that the incidence of breast cancer before the age of 50 is higher in African American than White women, with White women having a higher incidence after age 50 [1,3].
Medical protocol regarding the recommended age at which women should be screened appears to be based on a White model of health that does not take into account the special needs of African American women. Furthermore, recent changes in screening recommendations by the U.S. Preventative Screening Task Force (USPSTF) suggesting that women pursue mammography after age 50 (as opposed to 40, the originally recommended age in 2002) suggest negligence on the part of health services to account for Black women’s higher risk at a younger age [17]. Disparities in treatment after diagnosis will be further addressed in section B.

B. Pink and Black Does Not Address Considerable Cultural Barriers to Effective Prevention and Appropriate Treatment

Though Pink and Black notes that many Black women in Boston are being screened for breast cancer, nationally the number is not uniformly high. In 2005, 64.9% of African American women over 40 in the U.S. reported having a mammogram within two years of the survey (though the national rate of screening has been similar for Black and White women) [1,18]. Several studies suggest that fear and distrust of the medical system, and not merely a lack of education about breast cancer, prevents women from being screened [4,14,19]. According to Frisby, “psychological responses such as fear, fatalism, and misperceptions about [breast cancer] have been identified as personal factors that inhibit Blacks from participating in cancer health promotion behaviors” [4]. Campaigns must therefore address psychosocial factors.
Distrust of the medical system also contributes to reticence to be screened for breast cancer. Studies have revealed greater levels of distrust of physicians and insurance companies for Black patients than White patients, and a feeling that one could be deceived by health professionals into a potentially harmful experiment or medical treatment [20-22]. Cultural beliefs about the etiology of illness that lead to fatalism or to alternative models of health-seeking behavior also contribute to lack of screening, and importantly, failure to seek follow-up treatment for a positive diagnosis of breast cancer. Russell and Jewell state that cultural beliefs can affect African Americans’ tendency to seek medical care independent of socioeconomic resources and access to care [23]. Central components of African American culture that must be considered include religious orientation, social support networks, and informal health-care systems [23]. Religion is a powerful force for many African Americans and health and religious beliefs often cannot be separated [23]. In times of crisis, many Black women may turn to their faith community, family, and lay or “folk” treatment systems rather than seeking formal biomedical care. This could potentially influence the degree of adherence to medical treatment. Some African Americans attribute their illness to force of God’s will and may therefore seek healing through spiritual means rather than medical treatment [4,24].
While the above factors may influence the likelihood that Black women will be screened for breast cancer, disparities in subsequent treatment have little to do with patient initiative in preventative care. Recent studies show that Black women are less likely than White women to receive breast conserving surgery and radiation, and that they typically receive lower dosages of chemotherapy as well [3]. Inappropriate radiation therapy and the availability of significantly fewer support and rehabilitation services for post-mastectomy patients have been noted for Black women in comparison to White women [16]. While low socio-economic status and the associated lower levels of education and medical insurance coverage do play a role for some patients, treatment disparities were present regardless of income and education [3].
At the root of screening and treatment disparities is institutionalized racism, indicating that the Pink and Black campaign must intervene at multiple levels, targeting local and state policy-makers and community health services. Institutionalized racism not only perpetuates the link between racial background and socio-economic status, but it also increases cultural dissonance and thus inequalities in personal and political power and well-being [7].
C. Pink and Black Fails to Incorporate Social Marketing and Advertising Theory

The goal of advertising has been described as the “creation of desire and habits” previously unknown to the consumer [25]. However, the marketing of products requires considerable formative research to determine the existing core values of a population which are then used to frame the product as fulfilling those desires [8]. Consumers respond to the promise that a certain product, service, or behavior will fulfill their innermost desires and core values. Attempts of public health professionals to educate the consumer using statistics to “sell” health fails to reach people on an emotional level and to offer what the public truly values [8]. While the Pink and Black Ambassadors, who function as empathetic models of empowerment and inspiration, are a valuable asset to the campaign, their assignment is to encourage individual health behavior change by promoting timely breast cancer screening [5]. Additionally, the posters utilize “stick figures” to represent the statistical rate of breast cancer mortality for Black women compared to White women. Such an illustration comes across as rather impersonal, and the message may be more effectively expressed through the use of real people and their stories—“a kind of portrait or biographical sketch of a character” that is admirable to the target population [26]. Considerably more formative research is needed to determine the core values and desires of Black women in America and to use these to encourage a shift in perspective and, ultimately, an increase in the usage of breast cancer screening procedures.
Effective marketing involves a powerful, positive, well-supported promise that the consumer will achieve her innermost desires should she invest in what is being offered [8, 26-28]. The promise of the Pink and Black campaign can be interpreted as, “Despite being screened for breast cancer, if you are Black you are more likely to die of the disease than White women.” This message is confusing in that it references higher rates of screening among Black women in Boston and yet implies that the only way to reconcile disparate mortality rates is to be screened. In addition, the promise conveys considerable hopelessness as individuals within the target population who have been screened (especially those who have been diagnosed with cancer) may feel powerless and depressed. The fear of those who have not been screened is likely to increase in response to this message. Furthermore, these women may not have received a mammogram due to the seemingly formidable barriers perpetuated by institutionalized racism. For the above reasons, the efficacy of Pink and Black is considerably compromised.

III. Revised Approach to Intervention

This section proposes a new approach to intervention that may be more effective in ultimately reconciling racial health disparities. Support for the intervention is provided in Section IV. While elements of Pink and Black—including the training of African American female ambassadors to implement the intervention and the acknowledgement of racial disparities—will be retained, three significant changes to the campaign are proposed.
First, the intervention will acknowledge that health-decision making is often the product of “irrational” thought processes that include emotional responses and social influences of which the individual may not be readily conscious. The intervention must therefore facilitate change at the group, rather than the individual, level. One way to explore the social dynamics that may influence the health behavior of African American women is by implementing community focus groups. This will encourage conversation within communities to determine group dynamics that may be influencing health-decision making that might then be addressed to encourage behavioral change. It will also be possible to locate women who are particularly notable or influential within the community. Working with these individuals may help public health messages to diffuse throughout the social group. In this way, the proposed intervention will address the social environment of the target population.
Perhaps most importantly, the intervention will focus resources on the education of health professionals who must be made aware of the physician decision-making process and how it affects health outcomes for Black women. Women must be empowered not only to take initiative in being screened for breast cancer, but to bring about change by targeting the health system at the local and state policy level. The Pink and Black ambassadors must be trained to build relationships with Black communities to empower women and facilitate action geared toward the education of their care providers and clinics.
The intervention will address broader cultural and political issues at work that affect the health and health behavior of Black women. Public health professionals must work with African American communities to address the fear and distrust of the medical system and to acknowledge cultural beliefs about illness in general and breast cancer in particular, and share this information with health professionals to increase understanding and encourage effective communication between Black women and their care providers. Research has been conducted to determine culture-specific barriers to care that go beyond financial resources and access to insurance and health care facilities [4,14,23]. Greater knowledge of and appreciation for African American religious practices and “folk” healing systems must be generated and public health interventions must acknowledge and validate these systems, incorporating health messages into existing and highly valued cultural frameworks. Public health professionals should work with religious leaders in churches, mosques, and temples to incorporate health education into faith practices in a community setting.
Information about African American cultural beliefs that may create barriers to screening and follow-up treatment will be implemented into health care reform rather than merely used to modify the health behavior of Black women. To address structural racism within the healthcare system, it will be necessary to target health professionals and track physician decision-making and courses of treatment for Black women in comparison to White women to draw the attention of health professionals to the influence of discrimination (which may be largely sub-conscious) in diagnosis and treatment. It will also be necessary to encourage health professionals to consider trends in breast cancer incidence among Black women (including its greater presence in Black women under 50) that differ from the White model. The revised intervention will thus inspire women to take part in a movement of social change.
Lastly, the proposed intervention incorporates marketing theory which states that, as suggested above, public health messages must be based upon formative research with the target population. Public Service Announcements will offer a positive promise supported by emotionally provocative images and stories that are meaningful to the target population. Media messages will highlight the role of faith and spirituality in empowering Black women to seek appropriate medical care and supporting them throughout the treatment process. Being screened for breast cancer will be marketed not as a health-promoting behavior, but as a way to ensure that women will continue to function as centers of their families and communities. It will emphasize the role of women in the Black community as strong leaders, teachers, and models of strength for future generations. Screening for breast cancer will not be encouraged by selling health, but by selling stability and control over one’s future and increased quality time with family [8].
IV. Defense and Support for Proposed Intervention

Many studies suggest that the above approaches will increase the efficacy of public health interventions for African Americans.
A. The Proposed Intervention Targets Group, Not Individual, Behavior

It is first necessary to recognize that health behavior is not the product of rational decision-making based on an individual’s cost-benefit analysis. Therefore, campaigns that assume individuals will act rationally when presented with factual information about their susceptibility to illness may not succeed in altering behavior [30-31]. Studying group behavior and designing an intervention that seeks to change the behavior of the entire group may be more effective. According to Social Expectations Theory, individuals’ behavior conforms to local behavioral norms; therefore, by discovering and addressing these norms, steps can be taken to promote behavioral change at the group level [29]. Similarly, Social Organization Theory posits that social groups conform to an unspoken hierarchical system whereby certain individuals emerge as influential leaders [29]. By working with women who are influential in their communities, public health messages may diffuse throughout the social group. Understanding the ways in which Black women’s social groups are organized is vital to understanding and changing the group’s health behavior.
The intervention must also target the appropriate groups. It is insufficient to assume that human actions and health outcomes exist in the absence of political and organizational determinations. Health promotion “includes efforts to change organizational behavior, as well as the physical and social environment of communities” [32]. Pink and Black must empower women not only to change their health-seeking behavior by being screened, but also to start a social change movement that targets health professionals and local and state policy makers to remedy disparities in access to insurance and in the way health care is delivered to Black women. Florida’s exceedingly successful Truth campaign to prevent youths from smoking utilizes youth leaders to suggest to the target population that by refusing to smoke, they are participating in a social movement [6]. The proposed intervention will likewise train African American leaders like the Pink and Black ambassadors to empower Black women to work for social change to reconcile disparate health outcomes.
B. The Proposed Intervention Addresses Cultural Barriers to Positive Health Behavior and Positive Health Outcomes

A failure to explore and understand the realities that many minority groups face contributes to their disempowerment [33]. It is necessary to address the considerable barriers that prevent African American women from being screened, and, where screening is not an issue, from experiencing inappropriate treatment due to institutionalized discrimination. Frisby examines Black women’s perceptions of breast cancer and mammography to inform appropriate nursing interventions [4]. Interestingly, she finds that “beliefs in the efficacy of disease prevention behaviors [and] perceived threats and feelings of personal susceptibility” decrease the likelihood that women will be screened [4]. This finding suggests, again, that social cognition models stipulating that perceived susceptibility to a disease encourages positive changes in health behavior are not necessarily accurate. Further studies show that many African American women take a fatalistic approach to health and illness, not only attributing the existence of cancer to an act of God, but also asserting that the power to heal lies within spiritual and not necessarily medical jurisdiction [4,24].
Many women cite not only fear, but faith as a reason for refusing or delaying follow-up treatment after being diagnosed with cancer [24]. “Rather than dichotomize health into physiological and psychological components as defined within traditional science-oriented framework of health, African Americans characterize health as a continuum revolving around mind, body, and spirit” [23]. The lack of attention to mental and spiritual health in biomedicine creates cultural dissonance that may influence adherence to treatment. Creating partnerships with the various spiritual and religious leaders in specific communities is necessary to promote breast cancer screening as an act of empowerment and faith, rather than something to be feared.
It is also important to acknowledge the faith community as a vital support network for many African American women if and when they do receive a positive diagnosis of breast cancer. Incorporating personal and group faith practices into medical care and treatment may significantly increase the likelihood that women will see treatment as a positive step in the healing journey. The American Cancer Society confirms the fact that “minority patients have reported a greater need for spiritual support to help provide meaning, hope, and comfort” [1]. The “Body & Soul” program, a partnership between the National Cancer Institute and African American churches throughout the country to promote healthy eating is an example of a successful health intervention that unites spirituality, the faith community, and health education [34]. This is also a good way to reach women in low-income communities who may have the least amount of access to education and support.
Recent studies support the ongoing need for interventions aimed at health professionals to effectively address racial health disparities. Schulman et al. conducted a study of physician decision-making in treating African American and Caucasian men and women for chest pain. Findings reveal that Black patients (particularly women) presenting symptoms identical to those experienced by White patients are less likely to be referred for appropriate and sufficient treatment despite equal levels of insurance coverage [35]. Another study correlates Black breast cancer survivors’ perception of racism with negative treatment outcomes [36]. It is likely that interventions targeting physicians and their decision-making processes would significantly alter the current disparities in treatment. The American Cancer Society has recently initiated a study of differences in the surgical treatment of colorectal cancer for Black and White patients for the purpose of developing improvements within the healthcare system [1, 37].
C. The Proposed Intervention Uses Marketing Theory to Maximize Efficacy

Social marketing, like commercial marketing, requires that formative research be conducted with the target population to determine core values [8]. The purpose of research for the revised Pink and Black campaign is to determine the salient cultural ideas and core values of African American women in order to frame the public health message as promoting and delivering those values [8,26]. Russell and Jewell conducted such research with African American patients in an attempt to improve nursing care of Black patients and increase cultural competence among health professionals. They list collectivity, spirituality, respect for elders, the importance of the past, and harmony with nature as being core cultural values that influence the African American worldview and concepts of health and illness [23]. Others cite images of the strong Black woman who “makes a way out of no way” as a salient ideal of Black womanhood in America [38]. These core values must be utilized in media outreach efforts to provoke a visceral reaction to the message. Public Service Announcements must frame participation in breast cancer screening as delivering these values (time with family, the unity of mind, body, and spirit, faith and strength in the face of frightening and emotionally draining tests and treatment), and not simply good health [8].
Frisby asserts that for African American women, “fear appeals and other attempts to encourage mammography may be less effective in encouraging involvement with the message” and encourages public health professionals and physicians alike to incorporate positive promises of hope and survival [4]. She also addresses the considerable invisibility of Black women in American society, noting that they appear in less than 1% of all advertisements [4]. There is thus a strong need for ads that feature African American breast cancer survivors. While the Pink and Black public service announcements feature stick-figure-like drawings of Black and White women, the proposed intervention will incorporate images of real women and families that have survived breast cancer. These images provide support for a more positive promise conveying that breast cancer is treatable and that preventative screening promotes harmony, happiness, and family and community stability.
V. Conclusion

In conclusion, the efficacy of the Boston Public Health Commission’s Pink and Black campaign to combat racial disparities in breast cancer mortality rates may be limited due to flaws in its design and implementation. The intervention can be reformed and its value enhanced by addressing group rather than individual-level behavior, acknowledging significant cultural barriers to positive health behavior and outcomes, and implementing techniques from marketing theory in media outreach.

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