Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Friday, April 18, 2008

The American Dental Association’s Oral Cancer Campaign: Raising Awareness And Positive Behavioral Changes, But to What Effect? - Amulya Jayanty

Introduction

The American Dental Association (ADA) in collaboration with Oral CDx Laboratories, Inc. Oral CDx, a vendor for oral cancer detection, conducted a three-year nationwide public service campaign in late 2001 to raise awareness of oral cancer (1). The campaign focused on increasing awareness of oral cancer as a means of inspiring people to take action and lead healthier lives.

Oral cancer involves abnormal, malignant tissue growth in the mouth.(2) Oral or mouth cancer involves lips, tongue, floor of mouth, cheek lining or palate.(2) The vast majority of oral cancer is attributed to the use of tobacco products (70-80% of oral cancer cases) that are smoked or chewed, with cigarettes being the major culprit (3-13). Men are affected twice as often as women, particularly men older than 40 (3). “Oral cancer strikes an estimated 34,360 Americans each year. An estimated 7,550 people (5,180 men and 2,370 women) will die of these cancers in 2007, according to the Centers for Disease Control and Prevention” (4-24) More than 25% of the 30,000 Americans who get oral cancer will die of the disease (3-4). According to a study African Americans are especially vulnerable, the incidence rate is 1/3 higher than Whites and mortality rate is almost twice as high (4).

The ADA campaign uses large billboards and posters to deliver the awareness message to people in 11 cities. One of the ads shows an attractive young woman with a spot on her tongue circled beside the slogan, “It’s tiny now. Don’t let it grow up to be oral cancer” Below those slogans are two more: “See your dentist,” and “Testing is now painless” (5-22). “We want people to realize that oral cancer is out there, that it's a big problem, and that if they have a suspicious condition in the mouth, they should see a dentist,” said Clayton Mickel, director of the division of communications for the ADA (6).

This paper aims to critique the current public health approach of the American Dental Association’s oral cancer campaign to raise awareness and positive behavioral changes towards early detection of oral cancer. The ADA oral cancer campaign fails to account for psychological, social and socioeconomic factors that determine a certain behavior, thus it fails to inspire people to quit smoking and alcohol consumption, and visit a dentist for the early detection of oral cancer. Self efficacy and attitudes towards certain behavior reveal an important driver to health behavior and should be used as a motivator and as a means of helping people address many of the barriers they face (such as socioeconomic status, access to care and distrust of health care system). Unfortunately, the ADA oral cancer campaign has ignored these data points because they are inhibited by the rigid, illogical structure of the Health Belief Model.

Flaw in basic design of campaign

The ADA oral cancer campaign was developed with the assumption that all health behaviors are rational, such that basic awareness of oral cancer risk will inspire people to visit their dentists and get screened. Coupling this postulation, seemingly derived from the Health Belief Model (HBM), which dictates people rationally weigh the benefits and costs of engaging in a specific behavior (7), the campaign assumes that intention to visit a dentist will lead to behavior.

The ADA oral cancer campaign appears to have been built on the HBM, as its primary aim is to make people understand that they are highly susceptible to oral cancer and that contracting it will cause considerable harm. According to the HBM, internalizing this susceptibility and potential severity should cause people to see the benefit of visiting a dentist and, therefore, cause them to intend to adopt this behavior. The theoretical basis on which the campaign is designed assumes that intention leads to action.

The campaign’s disregard for sociocultural and economic variables would further render the intervention ineffective. It assumes that once a person identifies oral cancer that he/she would visit a dentist. It does not consider the fact that those with oral cancer might not be able to afford going to a dentist in the very first place. Persons of low socioeconomic status are more likely to engage in high-risk behaviors, such as tobacco or alcohol use, a fact that may explain some of their poor performance on oral cancer indicators. (10)

The ADA oral cancer campaign fails to address important causes of oral cancer because it overlooks the psychological and emotional hardships that lead to the consumption of tobacco/alcohol which are the primary causes of oral cancer. The campaign featured two advertisements which stated the facts of oral cancer and how smoking leads to oral cancer. Emphasis is placed on the statistics of oral cancer and the association of it with smoking. The social and psychological factors that lead one to smoking are ignored. The campaign fails to address the basic driving force that makes people smoke or consume alcohol (such as when under stress or pressure, in order to be more sociable or just because it is cool to smoke or consume alcohol). (8)

The ADA oral cancer campaign sends out the wrong message

The campaign merely uses billboards that advise people to visit a dentist in case they happen to find a growth in the mouth. Emphasis is placed on visiting a dentist to test for oral cancer rather than the actual cause of oral cancer and the means of preventing it.

In the campaign conducted in 2001, Oral CDx gave ADA 2.5 million dollars to run the billboard campaign. (10) The words oral cancer and early detection are getting out there in the same sentence to an American populace that hasn’t even heard of the disease for the most part, let alone the need for early detection of it. But oral cancers are NOT like colon cancer that requires a polyp to exist before it can become full-blown cancer. (10) Or cervical cancer that requires an HPV infection prior to the development of a malignancy. There is no “mandatory” oral precancerous lesion that always appears before manifestation of this disease. (10)Many times even the primary disease itself can be occult and not visible, only detectable early through the palpation and touching of the tissues - feeling for indurations or hard spots, or in some cases the primary lesion is completely occult right up until a metastasis of the disease is discovered as an enlarged lymph node in the neck, and the primary is never found. (10)

The Oral CDx Brush Test is a method that dentists use to detect oral cancer. (9) This screening method helps sort out those who likely have the disease from those who do not. It cannot be equated to diagnosis of oral cancer. When Oral CDx does find abnormality, it usually means that the spot is dysplastic (with abnormal cells), not cancerous. (9)The reliability and validity of the test is also questionable. The gold standard for diagnosis of oral cancer is a conventional punch or incisional biopsy, and not the test suggested by Oral CDx.(10) Thus, people are given the wrong message that the painless testing method would suffice to determine whether oral cancer is present or not.

Whether the right audience is being targeted is questionable

The campaign featured two advertisements on billboards, bus shelters and taxi tops in 11 cities that read- “See your dentist. Testing is now painless”. (5) The ADA oral cancer campaign is restricted because the primary means of disseminating information to the people is through the use of billboards. It is highly correlated to income-level and geographic region, rendering the health information less accessible to a large proportion of the population.

The ADA oral cancer campaign strongly suggests people to develop a healthy relationship with their dentist to determine their risk of oral cancer. Yet in the general US population, distrust of the health care system is high. (11) This distrust in the health care system also varies considerably by race and culture. Significant racial differences in the level of trust (mostly amongst African Americans) in medical care have also been found to exist. (11)

The ad depicts a woman with a tiny little cold-sore dot highlighted on her tongue, and bludgeon the reader with these words of caution: “It’s tiny now. Don’t let it grow up to be oral cancer.” They also advise: “See your dentist. Testing is painless.” (5) So, the ads are ostensibly trying to stop cancer. You can’t possibly object to that. The scourge of cancer and importance of early detection is undeniable. The advertisements recommend going to your dentist, where – and this is just implicit – you are probably going to get a check up as long as you are in, and maybe wind up spending a bunch of money on fillings and other things.

The ads feature an attractive young woman (or just her tongue or mouth, by themselves) as the victim.The advertisement depicts a young attractive woman, which does not in the real sense depict a person with oral cancer. According to the patterns of oral cancer, the image of a young woman is highly deceptive. It may no doubt grab attention of the youngsters; however whether it really targets the population at high risk is questionable. In fact, when you look at the odds for a young city like Boston, it seems like a weird thing to try to inform every single Bostonian that they're at risk for oral cancer. Look at it this way: There are 589,141 people in the city of Boston. The US population as a whole is 477.68 times bigger than Boston itself, according to the US Census Bureau. Therefore, Boston probably suffers about 17 of the 8,000 annual deaths from oral cancer in the US. Does this warrant a campaign that most Bostonians will come in contact with every week, if not every day? (12) No. The ADA campaign is admirable in a way- it will probably save lives. But it will also needlessly panic a legion of cold-sore sufferers, and it squanders its money addressing the audience that is least at risk for this terrible disease. Properly targeted, the enormous sums of money the ADA is no doubt spending on this campaign could make an enormous difference against a terrible disease. Instead, dentists across the US will be making a large some of money from high-strung hypochondriacs of all ages stampeding in for their check up.

Conclusion

Through the oral cancer campaign, the ADA has the opportunity to bring about awareness of oral cancer by expanding its use of communication channels and rethinking its advertisement placement. Adjusting the content of promotional materials to take social and cultural as well as environmental and economic factors into account would make the messages and behavior modifications more realistic. Acknowledging that obstacles to adopting a given health behavior do exist, would serve to make the intervention a powerful resource and means of affecting health behavior change. With approximately 30,000 newly diagnosed oral cancer cases and 8,000 deaths annually, a vigorous agenda that includes education, policy and research initiatives, and taking into account social and behavioral sciences is needed to enhance oral cancer prevention and early detection.(5-19)

The ADA oral cancer campaign is built on the Health Belief Model, which does not take into account how attitudes and beliefs may affect a particular behavior. Thus, the reach of the campaign is restrained. This could be rectified by incorporating components of other health behavior models (Bandura’s notion of self-efficacy or the Theory of reasoned action that takes into account perceived attitudes, social factors and the belief that one can actually do the behavior) to address the obstacles people face in adopting behavior beneficial to their well being.(15) Also, if the ADA oral cancer campaign makes use of the Advertising Theory and promises to offer strong core values, support them with effective images would make the intervention far more effective in bringing about a positive behaviour(in this case to quit smoking and visit a dentist).(16)If these modifications can be made, the ADA oral cancer campaign still has a chance to make a true impact in not only bringing about awareness but also positive behavioral changes amongst the population.

References

1. http://www.ada.org/prof/resources/topics/cancer.asp

2. Medical Health Encyclopedia :Heath Care 2008

3. http://www.healthcentral.com/ency/408/001035.html

4. http://www.woodlandhillsdentist.org/adaoralcancer.php

5.http://jada.ada.org/cgi/content/full/135/9/1261

6.http://www.cancer.org/docroot/NWS/content/NWS_1_1x_Dental_Group_Campaigns_for_Oral_Cancer_Awareness.asp

7. Rosenstock I.M Historical Origin of the Health Belief Model. Journal Health Education Monogr.1974 Volume 2 pages 328-335

8. http://ezinearticles.com/?Why-Do-People-Smoke-Cigarettes?&id=688804

9.http://www.oralcdxindia.com/

10. http://www.oral-cancer.info/?p=4

11.http://www.kff.org/minorityhealth/upload/Key-Facts-Racial-and-Ethnic-Differences-in-Medical-Care-Chartbook.pdf

12. http://www.flakmag.com/misc/adaads.html

13. Journal Cancer Causes and Control-Volume 15, Number 2/ March 2004

14. 2001 Journal of the California Dental Association

15 Journal: Cognitive Therapy and Research Volume 8, Number 3/ June 1984

16.The Quarterly Journal of Economics, Vol. 108,No. 4( Nov 1993) pp. 941-964- A Simple Theory of Advertising as a Good or Bad

17. Baden E. Prevention of cancer of the oral cavity and pharynx. Cancer 1987;37:49.

18. National Cancer Institute. Cancer statistics review 1973-1987. Washington , DC : US Department of Health and Human Services, National Institutes of Health, National Cancer Institute, 1989. NIH publication no. (NIH) 88-2789.

19. American Cancer Society webpage.

20. National Institute of Dental and Craniofacial Research, National Institutes of Health, website 2007.

21. Funk GF, Karnell LH, Robinson RA, Zhen WK, Trask DK, Hoffman HT. Presentation, treatment, and outcome of oral cavity cancer: a National Cancer Data Base report. Head Neck 2002;24(2):165–80.[Medline]

22. Horowitz AM, Goodman HS, Yellowitz JA, Nourjah PA. The need for health promotion in oral cancer prevention and early detection. J Public Health Dent 1996;56(6):319–30.[Medline]

23. Ries LA, Miller AB, Hankey FB, Kosary CL, Harras A, Edwards BK, eds. SEER cancer statistics review, 1973–1991: tables and graphs. Bethesda, Md.: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute; 1994. NIH publication 94-2789.

24. CDC and the National Institutes of Health. Cancers of the oral cavity and pharynx: a statistics review monograph, 1973-1987. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1991.

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2 Comments:

  • At April 24, 2008 at 11:06 AM , Anonymous Ting said...

    What about the risks and pain of a brush vs. a gold standard punch biopsy? Would not the additional discomfort discourage screening if a traditional punch biopsy were always obtained and potentially reduce the number of individuals screened?

    Is there evidence that the billboards are segmented into geographic locations that would support the conclusion that the campain is "highly correlated to income-level and geographic region, rendering the health information less accessible to a large proportion of the population"? It is not clear from the citation, which references an unreferenced opinion blog, that there has been any type of systematic study of the billboard placement.

     
  • At May 12, 2008 at 9:38 PM , Anonymous Anonymous said...

    Nice post, with an interesting perspective. In answer to ting, screening does not always involve a punch or incisional biopsy (or for that matter a brush biopsy)and only in those cases where suspect tissue is there is it necessary. This is in actuality a very small number of patients screened. My own preference would be to have the gold standard biopsy, not some brush cytology idea, that IF it finds something, has to be confirmed by an incision or punch biopsy anyway. And yes, there was a study on the billboard campaign published in the ADA rag, JADA. Of course it found that the effort had merit (the author was the marketing director for Oral CDx / S. Stahl)and JADA, to anyone that understands these things, has never been seriously taken as a peer reviewed science journal.

    But there is more wrong with the ADA campaign than this. The entire argument they are making is about diagnosis, when they should be talking about discovery. Every cancer including this one, in which we have made major progress against the death rate it has been through early detection. The ADA has the cart before the horse. Of course they always have been more about the money than anything else, after all CDx has promised them 9+ million dollars for the latest incarnation of this BS. When they get into bed with a commercial company, and ignore their own science council's perspective on whether or not the marketing rhetoric from CDx is even accurate, they are in trouble. That is evidenced recently by the dismissal of the two top people in the ADA, and the re-evaluation of this relationship by the organization. For a different perspective on all this, in many posts over several months, check out http://www.oral-cancer.info

     

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