Challenging Dogma - Fall 2007

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

Sunday, December 9, 2007

The Insurance Myth: An Examination of the American Cancer Society's Misappropriation of Advertising Funds – Laura Gatzos

In August of 2007, the American Cancer Society (ACS) announced that it planned to devote its entire $15 million dollar advertising budget to raising awareness of the consequences of inadequate insurance coverage. This is a departure from the society’s traditional public health advertising focus that touts the importance of cancer prevention and early detection.(1) The society’s new tag line states, “No one deserves to get cancer, but everyone deserves the right to fight it. Find out what we are doing to help.”(2) On its website, the ACS states that the biggest obstacle that Americans face in battling cancer is the lack of universal healthcare coverage. (2)

This decision is flawed for many reasons. First, universal health insurance will not equalize the health status of all Americans; insurance status plays only a small role in individuals overall health status and prognosis if diagnosed with cancer. Second, insurance status is not the only factor that determines whether or not an individual will decide to be screened for cancer. Finally, the statement "No one deserves to get cancer" is distracting from the Society's usual messages that promote the importance of healthy behaviors that may prevent the development of cancer.

Socioeconomic Status as a Component of Overall Health Status
Health insurance status plays only a small role in the overall health of an individual. There is a correlation between low education, low SES, and poor health.(3) Individuals who are of a lower socioeconomic status (SES) typically have poorer health outcomes and higher incidences of chronic diseases, including cancer, than people of a higher SES.(4) An analysis of data collected in 2000 through the Kentucky Behavioral Risk Factor Surveillance System revealed that the differences in health among different levels of "SES remained strong and significant" even after adjusting for individual health behaviors and health insurance coverage.(3)

Differences in SES usually result in unequal access to safe neighborhoods and comfortable living conditions. People of a lower SES are less likely to live in neighborhoods with healthy food options, safe spaces to exercise, or good schools. Traveling to safer neighborhoods to access better resources or a healthcare facility is often beyond the means of an individual with limited resources. Moving out of a poor neighborhood to a better neighborhood is often unthinkable. (5)

Many individuals who are of a lower SES exhibit decreased health literacy.(6) Individuals lack the ability to obtain and understand basic health information, such as cancer risks and the warning signs of disease. They often do not understand the reasons why they should seek preventative medical interventions and screening tests.(7) It is likely that if cancer is detected in these individuals, it will be at a later stage that is more difficult to treat(8), and may result in a poor disease prognosis.

It is imperative that researchers look beyond insurance coverage to understand disparities in health. Insurance coverage is not a large enough factor to account for all of the differences in health outcomes that exist between individuals of varying SES levels. Researchers need to explore methods to change the differing economic, educational, and social variables between individuals of higher and lower SES. "The construction, distribution, and institutionalization of economic resources, social relations, and cultural and psychological forces through social policy and political structure may account for more of the SES-related differences in health than…health insurance coverage."(3)

Screening Decisions: The Health Belief Model versus the Transtheoretical Model of Behavior Change
Health intervention programs that encourage individuals to seek cancer screening are frequently based on the Health Belief Model (HBM). In its earliest inception, the HBM postulated that decisions about health behavior were motivated by four factors: perceived susceptibility, perceived severity, perceived benefits of action, and perceived barriers to taking action. Two more components, cues to action and self efficacy, were added to the model in an attempt to further explain the process of behavior change.(9) Successful intervention programs that are based on the HBM identify and increase perceived benefits and remove perceived barriers to screening while minimizing the emphasis of the severity of a condition.(10)

The use of the HBM to motivate individuals to seek cancer screening has many shortcomings. Interventions based on the HBM focus on individual decisions and do not consider social and environmental factors that are present in an individual’s life.(9) The model assumes that intention leads to action and does not explain how individuals should overcome barriers such as cost, inconvenience, pain, or embarrassment.(10) Individuals of a lower SES are often more restricted by social and environmental factors and sometimes do not have the resources to access screenings, even if the tests are offered for free. Many people of low SES decide not to access services for reasons that include lack of paid time off to have testing performed, burdensome transportation to testing sites, and unavailable childcare.(8)

A 2001 study examined the relation of barriers and benefits for Colorectal Screening, based on the HBM, among African Americans in North Carolina. The study revealed that the largest barriers to widespread usage of colorectal screening among the study group were insufficient of awareness of risk, lack of interaction with a healthcare provider, and the absence of disease symptoms. When provided with a list of benefits of screening, study participants agreed that reasons for screening had merit, but most were not able to translate benefit into action.(11)

The HBM may not be the most appropriate model to explain the implementation of complex decisions that require both long term behavior changes and the acquisition of new skills.(10) The Transtheoretical Model (TTM) of change provides an alternate method to encourage individuals to adopt new health behaviors, such as seeking cancer screening. In the TTM, decisions are made along a continuum, and big decisions are seen as a compilation of many smaller decisions made over a period of time. Interventions based on the TTM have proven to be successful in modifying both simple and complex health behaviors.(12) Social Marketing is the systematic application of marketing techniques to achieve or change specific behavioral goals. It can be used to augment the transmission of a message to individuals at risk to motivate them to make a change in their health behavior.(9)

A 1999 study demonstrated the application of the TTM and social marketing techniques to encourage the adoption of cervical cancer screening in culturally diverse communities in Queensland, Australia. In this study, researches applied the TTM, in combination with social marketing, to identify and characterize the needs of women from diverse cultures and ethnicities. These actions allowed researchers to tailor interventions to meet specific cultural needs. (12)

Women in the study group were guided through the TTM’s series of five stages (precontemplation, contemplation, preparation, action, and maintenance) in their decision to seek cancer screening.(9) The study revealed that many women in each stage of change had different needs.(12) Movement through the five stages of the TTM is influenced by the weighing of perceived positive and negative aspects, with a resultant decisional balance influencing the process of change in one direction or another.(9) Most women in contemplation, preparation, action stages (intending to be screened) were more likely to have positive decisional balance scores than women in the precontemplation stage. Most women in early stages of behavior adoption required greater resources to reduce negative preconceptions about the test and to reinforce positive attitudes about cervical cancer screening. Many women in the maintenance stage required information to maintain positive health behaviors; this information was often in the form of a phone call or mailing from a physician’s office reminding women to be re-screened for cancer.(12)

The researchers employed social marketing techniques by recruiting women of the same ethnicity to educate and coach others. Coaches provided culturally relevant information about the risk of developing cervical cancer, eased feats about the screening test for cervical cancer, and encouraged and assisted women to make appointments for screening tests. Many women learned of the benefits of screening and gained skills that they could use to pursue screening in the future.(12)

While this study was conducted in Australia, there appears to be no obvious reason that the principles of using TTM and social marketing to raise awareness of cancer risk and increase rates of cervical cancer screening in underserved communities would not be successful in the United States. In summary, the study provided evidence that a message specifically tailored to women of diverse communities could effectively be used to convey information about disease risk and the importance of cancer screening.(12) It can also be assumed that the technique would be useful to increase awareness about other types of cancers and other screening tests.

Conflicting Messages from the American Cancer Society: Decreasing Preventative Behaviors
The ACS's statement that "No one deserves to get cancer" is distracting from the society's usual messages of positive self care and importance of healthy behaviors that can prevent the development of cancer. The ACS is choosing to focus on fighting, rather than preventing cancer. The society should not use fear of developing cancer to motivate individuals into action. Fear can have a paralyzing effect, causing individuals to lose hope and negating beliefs that positive health changes can have long lasting beneficial effects.(13) The society instead should focus on efforts to increase individual beliefs of self efficacy. It should work to create environments where individuals have the both capacity and the support to make positive changes in their lives.

The Social Cognitive Theory (SCT) of change is a model that the ACS should employ to help individuals adopt healthy behaviors. The SCT specifically focuses on interactions between individuals and their immediate environments.(9) The Harvard Cancer Prevention Program Project employed the SCT as a social contextual model of health behavior change to target an intervention aimed at increasing fruit and vegetable consumption among blue collar workers at manufacturing facilities in Massachusetts. (14)

In this study, the experimental group included all workers at a particular manufacturing facility. The control group consisted of workers at different facilities who received no intervention. This allowed for interventions to be targeted at everyone in a facility, thus creating an environment where everyone was expected to enact change.(14)

Over the course of 18 months, workers in the study group participated in monthly interventional activities that were focused on changing individual behaviors to increase fruit and vegetable consumption. Environmental interventions, such as increased availability of fruit and vegetables in the cafeteria, and company wide policy changes were implemented to promote the adoption of positive health behaviors. Researchers’ targeted the social contextual factors that were amenable to change, such as social norms, among individuals and groups to further augment the creation of supportive environments. In addition, study participants received educational material that provided educational information about the benefits of eating more fruits and vegetables.(14)

Individuals must develop behavioral capacity, or skill and knowledge of a new behavior, to make a change. Individuals gain self efficacy and develop emotional coping capabilities when they feel they can make behavior change. Individuals who make changes to adopt healthy behaviors in supportive environments are likely to maintain newly adopted behaviors. This is because individuals often learn new behaviors from modeling others in their environment and observing the consequences of those behaviors. They are likely to repeat behaviors that are positively supported by their peers.(9)

Change is further enhanced by an interactive process of reciprocal determinism, whereby a person acts on social cues and environmental cues, and adjusts their behavior based on responses from their environment. This can be a continually cyclical process of learning and behavior modification.(9) In this study, a high rate of participation among factory workers created a worksite environment where peers encouraged each other to eat more fruits and vegetables. At the conclusion of the study, many of the individuals who received interventions in supportive environments increased fruit and vegetable consumption while most of the individuals in the control group did not. The findings of this study suggest that positive behavior changes that are made supportive environments are likely to be successful. (14)

Researchers also noted that increased fruit and vegetable consumption was more likely to occur in individuals with a high self efficacy who understood that there is link between healthy diet and decreased risk of developing cancer.(14) Self efficacy, positive affect, and self confidence are strongly correlated with an ability to adopt new behaviors and develop healthy habits.(9) Individuals with a positive affect and high self efficacy are more likely than negative people to engage in health promoting behaviors. These activities include reading about health information, eating healthy diets, exercising, visiting health professionals, and having screening tests. (13)

By choosing not to broadcast a positive, health promoting message, the ACS is inadvertently telling people to that its okay to give up. In contrast, the Harvard Cancer Prevention Project demonstrated that a social-contextual model to promote health behavior change can enable individuals to adopt positive behaviors. (14) Certainly, no one deserves to get cancer, but by promoting this message, the ACS is reversing the effects of millions of advertising dollars previously spent touting the benefits of early detection and healthy lifestyles. This message is inadvertently telling people that it doesn’t matter if they make healthy choices to avoid cancer because they may get it anyway.

Health Disparities Have Multiple Origins; Insurance is the Easiest Target
The rise in the number of uninsured patients in the United States who lack access to adequate healthcare is a salient issue that deserves consideration, deliberation, and a solution. Even so, one must question why the ACS has joined the debate at this time. The change in advertising focus may be serving to send the wrong message at the wrong time. The ACS is framing the issue of SES disparities in health too narrowly (15). By choosing to focus only on insurance coverage, the ACS is ignoring all of the other factors that create differences in health outcomes between the rich and the poor. The ACS is setting the social agenda (15) and creating a message that universal insurance coverage will eliminate health disparities.

In addition, millions of advertising dollars are already being spent to draw attention to the plight of the uninsured. (16,17) The lack of affordable and accessible healthcare has become a central component of the 2008 presidential election campaign. With multiple presidential candidates clamoring for airtime and attention from the press, this issue is being brought to the attention of the American population. The issue ranks as the 5th of 6 priorities on the Democratic Party agenda for 2008,(16) and is listed as one of the Republican Party top 12 priorities for the 2008 election.(17) With so many media outlets already talking about this issue, we can question why the ACS is allocating its entire 2007-2008 advertising budget to this issue. The ACS allocation of advertising funds is a duplication of efforts and a waste of money.

If the ACS, and our presidential candidates, really wanted to create a society where health and healthcare are equitably distributed, they would need to start by examining the distribution of wealth in our country. During the same period of time that the rate of people living in severe poverty (an income of less than $10,000 for a family of four) increased from 4.4% to 5.4% of the population, the richest 1% of our population experienced unprecedented income growth.(5)

There are many socioeconomic factors that prevent the poor from having access to quality healthcare. However, these factors are not easily modifiable and are very political charged. In choosing to rally attention toward issues of health insurance, the ACS has chosen to focus on an issue that is socially acceptable and politically accessible. Public health measures that examine poverty as a cause of poor health are often found to be in conflict with governmental policies. (18) If the ACS executives focused attention on the real issues that lead to poor cancer prognosis in underprivileged members of our society, they might create derision in its donor base and alienate their political ties.

REFERENCES
1. Sack, Kevin. “Cancer Society Focuses Its Ads on the Uninsured,” New York Times online edition, http://www.nytimes.com/2007/08/31/us/31cancer.html?adxnnl=1&adxnnlx=1191690592-TshXe+vWMVyQxjB/QedKUg, Accessed on 10/6/2007
2. American Cancer Society Homepage, http://www.cancer.org/docroot/home/index.asp, accessed on 10/6/2007
3. Lu, Samuels, and Wilson. Socioeconomic Differences in Health: How Much Do Health Behaviors and Health Insurance Coverage Account For? Journal of Health Care for the Poor and Underserved 2004. 15;618-630.
4. Link and Phelan. Social Conditions as a Fundamental Cause of Disease. Journal of Health Behavior 1995, (Extra Issue): 80-94
5. Woolf, S., Future Consequences of the Current Decline in US Household Income. Journal of the American Medical Association 2007; 298. pp.1931-1933.
6. Paasche-Orlow and Wolf. The Causal Pathway Linking Health Literacy to Health Outcomes. American Journal of Health Behavior; Sep/Oct2007 Supplement 1, Vol. 31, p.S19-S26
7. Murphy-Knoll, L. Low Health Literacy Puts Patients at Risk: The Joint Commission Proposes Solutions to National Problem. Journal of Nursing Care Quality. 22:3, pp.205-209.
8. Sampselle, C. Nickel-and-Dimed in America: Underserved, Understudied, and Underestimated, Family & Community Health; Jan-Mar2007 Supplement, Vol. 30, pS4-S14.
9. Edberg, M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers
10. Salazar, MK. Comparison of Four Behavioral Theories: A Literature Review. American Association of Occupational Health Nurses March 1991, Vol. 39, 128-135.
11. James, A., et. al. Perceived Barriers and Benefits to Colon Cancer Screening Among African Americans in North America. Cancer Epidemiology Biomarkers and Prevention. Vol. 11, June 2002.
12. Kelaher et. al., The Transtheoretical Model and Cervical Cancer Screening: Its Application Among Culturally Diverse Communities in Queensland, Australia. Ethnicity and Health, 1999; 4(4): 256-276.
13. Kelsey, S., et al., Positive Affect, Exercise and Self Reported Health in Blue-Collar Women American Journal of Health Behavior 2006, 30 (2): 199-207.
14. Sorenson, G. et al.,The Influence of Social Context on Changes in Fruit and Vegetable Consumption: Results of the Healthy Directions Studies, American Journal of Public Health July 2007, Vol. 97, no. 7, 1216-1227.
15. Siegel, M. SB721 Problems with Public Health Interventions, 11/29/2007 Class Lecture.
16. The Democratic Party Homepage, http://www.democrats.org/agenda.html, accessed on 10/6/07.
17. The Republican Party Homepage, http://www.gop.com/Issues/ accessed on 10/6/07.
18. Pearce, N., Traditional Epidemiology, Modern Epidemiology and Public Health. American Journal of Public Health. May 1996; 86,5. pp. 678-683.

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