Challenging Dogma - Spring 2008

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

Wednesday, April 16, 2008

Screen For Life Campaign: How The CDC’s Campaign Promotes Colorectal Cancer Screening But Fails To Increase Screening Rates – Kelly Lamb

The Center for Disease Control’s multi-year “Screen for Life: National Colorectal Cancer Action Campaign” was launched on March 2, 1999 and is based on extensive review of existing communication and behavioral science literature, formative research and concept testing. The campaign has been credited for the drop in colon cancer death rates since its inception. However, findings from the National Health Interview Survey indicate that in 2000, only 42.5% of US adults ages 50 or older had undergone a sigmoidoscopy or colonoscopy within the previous ten years or had used a fecal occult blood test (FOBT) home test kit within the previous year as recommended (1). The campaign has primarily focused on the recent reduction in deaths from colon cancer, which is attributed to the “Katie Couric Effect (2). However, while the overall use of colorectal cancer screening did increase since the campaign began, ethnic and racial disparities have persisted (1). By overlooking disparities in screening rates, focusing primarily on celebrity endorsements to promote screening, and neglecting to effectively address socio-cultural factors that may deter people from screening, the campaign’s long-term effectiveness is in jeopardy.

Argument 1:
The Screen for Life campaign message is limited due to its total disregard for disparities in screening rates. Colon cancer screening rates vary between socio-demographic categories. For example, nonwhites and women have lower rates of screening (2). The likelihood of screening is significantly greater among people with middle or high school education levels than among those with low education levels (3). Despite the Medicare coverage for colorectal cancer screening, there still remain significant disparities between sex and racial/ethnic groups in screening practices (4). Factors leading to screening may differ both within and across populations. As a result, it is important to examine risk factors at both the inter-individual and inter-population levels (5). For example, findings from one study on blood pressure showed that darker skin color for blacks was related to higher blood pressure in a linear manner. These results suggest that analyses of the “Black-White” differences in blood pressure should take into account social meanings of race and ethnicity, as embodied in experiences of racial discrimination (6,7). These results may have implications in colorectal cancer screening as disparities in screening may be evident within socio-demographic categories. An example of this phenomenon has to do with obesity. It has been demonstrated that obese women are less likely to obtain screening while obese men are more likely to be screened (8,9). It is important to consider these within-group variations in targeting screening messages, and Screen for Life fails to even recognize these variations. The reach of the campaign is restricted by relying on primarily internet-based efforts to disseminate information about screening. Caucasians are nearly twice as likely to have Internet access in the home as compared to African Americans or Hispanics (10). Efforts to promote screening in minority populations and among people with less formal education must be made. Advertisements should be tailored to address the groups with lowest screening rates. While the campaign does use public service announcements in both Spanish and English, further efforts need to be made to target the groups with low screening rates. Obese women should be targeted, perhaps at a weight loss clinic, with educational material related to colorectal cancer screening. Effective campaigns for reducing the disparities should emphasize competence and community involvement directed at the specific groups of people with low screening rates.

Argument 2:
The Screen for Life campaign ads have primarily used celebrities to promote screening by stressing the severity of the disease and approaching screening with the statement, “If they can do it, so can you”. This slogan is an oversimplification of the underlying issue. Access to health care services are likely to be vastly different for these celebrities as compared to the general population, and especially to the groups with low screening rates. It is ridiculous to assume that if celebrities can get screened, people without access to health care or the means to pay for the screening test can get screened. As noted by Link and Phelan in their influential article, the relationship between fundamental social causes and health problems will endure due to persistent inequality in access to resources to reduce the risk (11). The Screen for Life campaign completely neglects the fundamental social causes that may lead to lower screening rates in certain socio-demographic groups. By simply using celebrities to promote the message about colorectal cancer screening, the campaign fails to address the barriers that many people face in getting screened. Further, studies have suggested that consumers generally feel that celebrities are more attractive than non-celebrities, something that may draw initial attention to the advertisement (12). However, beyond that, the celebrities do not seem to make the advertising any more effective or believable as compared to non-celebrity advertising. The implication is that advertisers need to be cautious when using celebrity advertising, as they are not believable in certain instances and hence may not deliver the intended effect. It would seem that for some classes of products, person-on-the-street type of advertising might be just as effective if not more so than those that use celebrities. (13). There is little doubt that celebrities can have a powerful impact on the public and that their influence can be put to good use. However, when it comes to public health endorsements, celebrities should be judicious in using their powers of persuasion. When it comes to communicating about complex decisions such as cancer screening, the goal should not be to persuade but to inform (14). In a study evaluating celebrity endorsements of cancer screening, researchers at the Vermont Department of Veteran’s Affairs concluded that simple, one-sided messages delivered by celebrities are better suited to simple, one-sided issues like avoiding tobacco than to complex issues like cancer screening (15).

Argument 3:
While the Screen for Life campaign may be successful in increasing awareness of colorectal cancer screening, it assumes that increasing awareness alone will lead to behavior change. In doing so, the campaign neglects to effectively address specific barriers to screening. In essence, the campaign relies on the Health Belief Model as a determinant of behavior change and neglects the Social Learning Theory, which emphasizes the role of the group in shaping individual behavior. The Health Belief Model states that health behavior decisions are based on a rational weighing of perceived susceptibility, severity, barriers and benefits of the health issue. It assumes that increasing knowledge and behavioral intention will lead to behavior change because health behaviors are based on rational decisions in which beliefs are tied to action (16). While this model has been utilized in public health research for many years, it is limited. It relies exclusively on individuals and does not incorporate socio-cultural influences that may play a role in health behaviors. The Health Belief Model does not allow for the inclusion of the relationship between health status and historical, social and political structures (17). These socio-demographic characteristics may be essential in changing people’s health behaviors. The Social Learning Theory emphasizes the importance of observing and modeling the behaviors, attitudes, and emotional reactions of others. It emphasizes the impact of social relationships in behavior change (18,19). These social theories may be particularly useful in increasing screening practices for groups of people with low rates. It is critical that researchers include socio-cultural dimensions, such as interconnectedness, health socialization, ecological factors and health care system factors into their intervention models with African American women. Comprehensive and socio-culturally based interventions are necessary to guide the scientific and policy challenges facing African American women (20). Effective interventions should emphasize cultural competence and involve community organizations in the efforts.

While the Screen for Life campaign may be successful in increasing awareness of colorectal cancer and the importance of screening, further efforts need to be made to ensure that this message is directed to the people in need, and that socio-cultural barriers to screening are addressed. It is important to consider variations in screening patterns and to tailor interventions to target populations with low rates of screening. While considering the variations in screening rates, we must focus on how and why these disparities exist in order to determine what specific barriers need to be overcome. For example, it is likely that ensuring women will have access to a woman endoscopist to perform their colonoscopy may increase the rates of colorectal screening among women. Strategies like these only result when we really delve into the barriers and challenges that individuals face and develop interventions to target these barriers. Factors deterring people from screening (time, cost, accessibility) must be considered and communicated effectively in order to increase screening rates. These issues must be addressed in a way that will eliminate or reduce the stigma often associated with colon cancer screening. Physician recommendation has consistently been identified as a predictor for colorectal cancer screening, and the percentage of adherence to these physician recommendations is often very high (21,22). It should become a standard of care practice for physicians to educate their patients on the risk factors regarding colorectal cancer and to recommend preventive screening at every annual exam. Efforts to improve physician understanding about the seriousness of colorectal cancer may improve compliance with making recommendations for colorectal cancer screening to patients (23). Particular attention should be paid to groups with lower screening rates. For example, African American women may need to be encouraged to participate in screening through recommendations from their primary care provider. It has been demonstrated in a population of African-American women aged 50 and older who are in a high risk category for developing colorectal cancer, that only 55% reported being recommended screening by their primary care provider (24). Utilization of a faith-approach in reaching African-American women may also be appropriate (25,26). Further, it is important to assure that individuals are aware of their coverage benefits for screening and diagnosis/treatment for colorectal cancer.

By oversimplifying the campaign message and neglecting to address specific barriers to screening, the Center for Disease Control’s Screen for Life campaign is failing at its objective of increasing screening rates and reducing disparities. By incorporating tailored messages, addressing socio-cultural factors that may influence screening behaviors, and expanding its methods to disseminate this message, it is not too late to put this campaign back on track.

1. Centers for Disease Control and Prevention.
2. Atlanta Journal Consortium.
3. Rex, DK. Disparities in colorectal cancer screening. Journal Watch Gastroenterology. April 2007
4. Ananthakrishnan A, et al. Disparities in colon cancer screening in the medicare population. Arch Intern Med. 2007;167:258-264
5. Schwartz S, Carpenter KM. The Right Answer for the Wrong Question: Consequences of the Type III Error for Public Health Research. American Journal of Public Health. August 1999. 89 (8) 1175-80.
6. Harburg E, et al. Skin Color, Ethnicity and Blood Pressure 1: Detroit Blacks. American Journal of Public Health. 1978. 68(12): 1177-1183
7. Krieger N., Sidney S. Racial Discrimination and Blood Pressure: The CARDIA Study of Young Black and White Adults. American Journal of Public Health. 1996. October. 86(10): 1370-78.
8. Heo M, et al. Overweight, obesity, and colorectal cancer screening: Disparity between men and women. BMC Public Health. 2004 (4).
9. Fontaine KR, Heo M, Allison DB. Body weight and cancer screening among women. Journal of Women’s Health and Gender-based Medicine. 2001, 10:463-70.
10. US Census Bureau. Computer and Internet Use in the United States: 2003.
11. Link BG, Phelan J. Social Conditions as Fundamental Causes of Disease. Journal of Health and Social Behavior. 1995. 80-94.
12. Mohan, KM, et al. Celebrity Advertising: An assessment of its relative effectiveness.
13. Atkin, Charles and Martin Block. Effectiveness of Celebrity Endorsers. Journal of Advertising. Research 23, 1 (February/March 1983): 57-62
14. Larson RJ, Woloshin S, Schwartz LM, Welch HG. Celebrity Endorsements of Cancer Screening. J Natl Cancer Inst 2005;97:693-5.
15. US News and World Report
16. Fulton JP, et al. A Study Guided by the Health Belief Model of the Predictors of Breast Cancer Screening of Women Ages 40 and Older. Public Health Reports. 1991. 106 (4). 410-18
17. Thomas LW. A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education. Journal of Professional Nursing. 1995. 11:127-31.
18. Bandura A. Health Promotion by Social Cognitive Means. 2004; 31: 143-164.
19. Bandura A. Social Learning Theory. New York: General Learning Press. 1977.
20. Ashing-Giwa, K. Health Behavior Change Models and their Socio-Cultural Relevance for Breast Cancer Screening in African American Women. Women and Health. 1999. 28;53-70.
21. Honda, K. Factors Associated with Colorectal Cancer Screening Among the US Urban Japanese Population. American Journal of Public Health. May 2004, 94 (5) 815-21
22. Janz NK, Wren PA, Schottenfeld D, Guire KE. Colorectal cancer screening attitudes and behavior: a population-based study. Preventive Medicine. 2003. 37;627-34
23. Shieh K, et al. The impact of Physician’s Health Beliefs on Colorectal Cancer Screening Practices. Digestive Diseases and Sciences. May 2005. 50(5) 809-14.
24. Swedmark, J. et al. Colon Cancer Screening: Knowledge, Attitudes, and Behavior among African-American Women. NP Poster. 138.
25. James AS, et al. Perceived Barriers and Benefits to Colon Cancer Screening among African Americans in North Carolina: How Does Perception Relate to Screening Behavior? Cancer Epidemiology, Biomarkers and Prevention. June 2002. (11) 529-34.
26. Frank D. et al. Colon Cancer Screening in African American women. July 2004. ABHF Journal.

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  • At April 24, 2008 at 1:44 AM , Anonymous Ting said...

    In the introduction the paper states that "overall use of colorectal cancer screening did increase since the campaign began" but argument #3 begins by stating "While the Screen for Life campaign may be successful in increasing awareness of colorectal cancer screening, it assumes that increasing awareness alone will lead to behavior change."

    It would therefore appear that the campaign has indeed increased screening rates. So in some ways the health belief model has managed to hit some part of the population (middle/upper class white population) and prompted them to get screened.

    Would having celebrities of different ethnic backgrounds be effective by having the target audience itself delivering the message?


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