Public Health Intervention Failures in Reducing the Incidence and Mortality Rates of Prostate Cancer Among African-American Men- Anthony Agosto

Prostate Cancer is a disease that develops in the prostate, a gland in the male reproductive system, which occurs when there is a mutation within the cells of the prostate leading to an abnormal multiplication. Prostate Cancer is the second leading cause, after lung cancer, of cancer deaths of men in the United States, and the third leading cause of cancer deaths among African-American men. Although mortality rates for prostate cancer in the United States have declined for all racial/ethnic groups, there are studies showing that the incidence and mortality rates are higher among African-American men than any other racial/ethnic group. The purpose of this paper is to critique Public Health intervention failures in addressing certain aspects of three important health models; The Health Belief Model, Ecological Model and Theory of Reasoned Action, which have led to both higher incidence and mortality rates of prostate cancer among African-American men.

Failure in Addressing Certain Aspects of The Health Belief Model

According to the oldest and most widely used individual model, the Health Belief Model, individuals act upon reasoned behavior, whereby if they are able to perceive that positive outcomes outweigh negative barriers, then they are most likely to engage in preventive health action. Public Health interventions, based on the Health Belief Model, have failed to address how African-American men will overcome their fear of being diagnosed with prostate cancer, which is the greatest barrier that has limited their participation in preventive measures.

There is direct correlation between a fear of diagnosis as such, a corresponding reluctance to engage in preventive action such as DRE (Digital Rectal Examination) and PSA (Prostate Specific Assay) and higher incidence and mortality rates among African-American men. According to various studies, African-American men are most susceptible among racial/ethnic groups to a fear of diagnosis that is so consuming that they are likely to drop out of screening programs, if they participate in them at all (1). In addition, it is evident that the embarrassment and stigma associated with having a doctor insert a lubricated glove into the anus to check for prostate abnormalities during a DRE has led African-American men choose private prostate cancer appointments or self care, over mass screening programs, and to seek prostate-related complementary and alternative medicines. In order to be most effective, Public Health interventions for prostate cancer using the Health Belief Model need to be aware of how powerfully fear and embarrassment influence patients in their willingness to take precautionary measures to monitor their health periodically.

Failure in Addressing Certain Aspects of The Ecological Model

Behavioral decisions are influenced by many individual factors and by the environment which, when taken together, form the Ecological Model. Within this model, the important factor of preventive knowledge has not been considered when implementing public health interventions for prostate screening among African-American men. According to recent studies, there have been recommendations by professional organizations to inform men about known risks and potential benefits of screening, and even so, there continues to be limited knowledge among men, particularly African-American men (2). As stated in the American Journal of Public Health (AJPH) “ There is an uncertainty between what African-American men know and what they ought to know in order to make an informed decision about screening”. This uncertainty was addressed by coming to an understanding of the basic facts that all men should know in order to make an informed decision regarding preventive health measures, moreover, there is also limited knowledge that screening test may reduce prostate cancer mortality rates, but that they do occasionally result in false-positive, negative results. Twenty-two percent of African-American men believed, wrongly, that DRE (Digital Rectal Examination) was a blood test for prostate cancer (3). It is therefore important to focus on this target group, first by highlighting the essential facts they must know about screening that will hopefully demystify the process and destigmatize the experience of screening or treatment, leading to greater efficacy.

Failure in Addressing Certain Aspects of The Theory of Reasoned Action

Limited faith among African-American men in the efficacy of screening or treatment has been another deterrent in taking preventive health measures for prostate cancer. There is no scientific evidence to prove that screening tests for prostate cancer do in fact decrease the incidence of mortality. Public Health interventions have difficulty convincing African-American men to take preventive actions in light of this culture of stigmatization and fear. The Theory of Reasoned Action, an individual-oriented theory, incorporates an individual’s attitude regarding preventive measures based on expectations of (limited) positive or negative outcomes. Without evidence confirming that the benefits of screening outweigh the discomfort of the experience for many, it is unlikely that men’s attitude will shift towards taking preventive health action for prostate cancer more seriously. Research has suggested that faith in the efficacy of screening or treatment correlates more frequently with a willingness to take preventive action for prostate cancer (4).

Public Health interventions have failed to consider those aspects of the health models; The Health Belief Model, Ecological Model, and Theory of Reasoned Behavior, which may explain higher incidence and mortality rates of prostate cancer among African-American men. In order to develop effective public health interventions for prostate cancer among this target group, there needs to be further research and funding readily available for such interventions, informative material distributed that would be self-explanatory regardless of patients’ educational background and effective communication between providers and patients. Most importantly, there needs to be continuing effort to promote more informed decision-making, so that men can overcome hesitation they may have about screening and be more fully engaged in the prevention and treatment of prostate cancer.

References

1. Roumier, X. Azzouri. Adherence to an annual PSA screening program over 3 years for brothers and sons of men with prostate cancer. European Urology, 45, 280-286.

2. Denmark-Wahnefried W, Strigo T, Catoe T. Knowledge, beliefs and prior screening behavior among blacks and whites reporting for prostate cancer screening. Urology. 1995; 46:346-351.

3. C.Y. Chan Evelyn, MD Vernon, W Sally, PhD, T O’Donnel Frederick, MS. Informed Consent for Cancer Screening with Prostate-Specific Antigen: How Well are Men Getting the Message? The American Journal of Public Health 2003; 93:779-784.

4. Consedine S Nathan, PhD, Horton David, Ungar Tracy, PhD, Joe. K Andrew, MD, Ramirez Paul, PhD and Borrel Luisa, PhD. Fear, Knowledge, and Efficacy Beliefs Differentially Predict the Frequency of Digital Rectal Examination Versus Prostate Specific Antigen Screening in Ethnically Diverse Samples of Older Men. The American Journal of Public Health 2007; 1:29-42.

5. Edberg Mark. Essentials of Health Behavior Social and Behavioral Theory in Public Health. Washington, DC, 2007.

Don’t Hold Your Breath-Changes Needed in Lung Health Education- Rachel Hill

The National Lung Health Education Program (NLHEP) is a group of professionals including doctors, respiratory therapists, and esteemed members of the American Association of Respiratory Care (AARC) who are dedicated to increasing the awareness of Chronic Obstructive Pulmonary Disease (COPD) across the spectrum of healthcare and the general population. They utilize pamphlets, speaking engagements, and documented research to help further their goal. I am going to argue that the NLHEP has failed in its goal to create a successful program of intervention and early detection of COPD in its early stages among the population at risk, and to increase awareness of COPD within the general public or among healthcare professionals. The NLHEP has also been unsuccessful in raising awareness among primary care physicians about the use of simple spirometry testing as a tool for early detection and diagnostic criteria of COPD. And focus even less on early intervention of those at risk for COPD. This is the primary method to which this institution states it uses to achieve its goals of increasing awareness, early intervention, and early diagnosis of COPD. Their goals of increasing awareness and promoting early screenings, while great ideas, are not being executed in the best possible methods.

The NLHEP campaigns have traditionally not focused on any specific population. Their target population as stated in the mission statement is “all smokers, former smokers, and people who are regularly exposed to environmental tobacco smoking or occupational exposures” as well as, “physicians, all health care professionals, patients and the public” (6). The population target is just too broad and expansive with each group requiring specific needs in order to have any form of success within each target group. Physicians require a more medical message of screening and diagnosis using statistics and peer reviewed studies. The general population message needs to focus more on awareness and risk factors. By trying to figure out the best most understandable message for each group instead of focusing on one single message that is either too elementary or too complex, they would be more successful in having more people being aware of COPD in the dimension that makes the most sense for each group. For Example: A person with no medical training does not need (or want) to know what the specific diagnostic numbers in the spirometry testing formally point to the diagnosis of COPD. Nor does a physician need someone telling them what COPD stands for and what diseases encompass COPD.

Based on Social Marketing Theory which is basically figuring out what people want and understand and tailoring the message to that target population. We can not deliver a message to physicians in the same manner as we would address the public. Physicians require a different language and tone in order to capture their attention (generally more scientific and statistical) than the general public which has little (if any) medical training and varying educational backgrounds. Not only does each group have specific requirements regarding message delivery, they also have different outlooks about lung health (2, 7). Physicians are generally ready and able to promote lung health, while the general population does not see lung health as an overt problem until symptoms arise. This is partly shown by the number of late stage diagnoses of COPD and emergency room visits for shortness of breath by the general public whom if diagnosed earlier would be better managed (8). Among people aged 45-54 years 32% had an unscheduled emergency doctor’s visit for their COPD and 27% among the same population had emergency room visits for COPD. Had these people been diagnosed earlier they would have been better managed and not needed so many emergency services. COPD is not getting diagnosed in this population who is most at risk until they exhibit such severe symptoms it warrants emergent trips to a physician or the ED. This is proof that the word about COPD is not out in public and the message is obviously not clear, people continue to remain in denial of COPD until it is too late.

People generally lack a self-efficacy around their lung health status, especially the smokers. They tend to feel that the damage is already there and they can do nothing to change it. There is a nihilistic attitude among smokers and even among healthcare workers about the status of their lungs. The NLHEP campaign messages should emphasize that behavior change can make a difference in the status of their lung health, not the nihilistic attitude that you did this to yourself now you have to deal with it. Once people start to realize that it is not too late to quit smoking or make a lifestyle change and they will still make a positive impact on their health, I think people will develop a more positive attitude towards taking control of their lung health.

Physicians tend to focus on secondary prevention (or diagnosis and cessation) and in the general population it is primary prevention that is needed specifically around the area of what COPD is and ways to prevent it (such and not smoking). There is no mention of primary interventions of COPD within the NLHEP.

People need to realize that COPD starts up to 20 years prior to symptoms. Our bodies are amazing in that they will compensate as long as they can, functioning at a lower level (of oxygen) until something happens and it just can not compensate anymore. The importance of a primary care physician being able to do a simple spirometry is that the physician is able to earlier diagnose COPD and act through early interventions (education, medication, etc…) so our bodies do not have to keep compensating. This is part of the mission behind the NLHEP however; there is no plan within the mission for reimbursement for spirometry testing. The cost of doing this test, while relatively small, would just be another added expense to the overhead unless there was a way to reimburse for the test. Currently insurances do not reimburse for spirometry screening, only spirometry as a means of diagnosing symptoms. If it were possible to conduct this simple test more often, we would be able to diagnose earlier and provide earlier intervention (1). There have been a few studies that show that when a diagnosis of COPD is coupled with intervention of smoking cessation there is a much higher rate of success quitting smoking. NLHEP encourages health care professionals to use simple spirometry to conduct prescreenings of patients, primarily those at risk, in the same way we use mammography, for early detection of COPD. This is a great idea, however, they go on to only support certain brands of spirometers fail to propose ways for physician’s offices to be reimbursed for the expense of doing the test. Because of the challenges physicians face with reimbursement for spirometry testing, only 20% of primary care offices (in the US) even have a spirometer to screen patients (4). This means that if a physician would want to screen a patient (or test a patient) they would have to send the patient out to another facility for testing, wait for the test to be scheduled, wait for the results to be read by the physician at the referral facility, wait for a copy of the test to be sent, schedule a follow up visit or follow up testing, the potential for this process to take months is not unusual. Also, the test that would be done would be a full pulmonary function test, a very time consuming and expensive test of which all portions may not be necessary to diagnose and stage COPD compared to the simple spirometry. The initial cost of a spirometer and its set up (computer software, disposable mouthpieces, and other necessary equipment) is expensive estimated at $2000 and up according to several medical device companies including medicalresources.com. Why would a physician spend the money out of pocket with no means of reimbursement? Looking closer into what the physician would want/need in order to comply with the goals of screening all patients (at least those most at risk) for COPD the two things most important to the physician is autonomy in which spirometer they feel most comfortable using. Forcing someone to use equipment they do not like or do not understand is not helpful is furthering the goal of getting this particular population to use the spirometer. The other issue is monetary. While we all would like to see as many patients screened for COPD as possible, if the physician is going to lose money on the project, they can not be expected to give their services away for free. Would you do that? The importance of financing this screening program with the insurance companies, Medicare but more importantly the private insurances and Medicaid is fundamental in the program’s success. We are aiming to identify these people with COPD in early stages, before they qualify for Medicare which is why the private insurances and Medicaid is most important.

NLHEP needs to rally with other groups to start lobbying for more reimbursement coverage for screening of COPD with simple spirometry, especially with Medicare. By working to get more coverage, more and more physicians will be able to afford to test their patients earlier and physicians will be more likely to consider having a spirometer in their office.

The NLHEP has many professional affiliates including the American Thoracic Society, American College of Physicians, American College of Allergy, Asthma, and Immunology, The National Heart, Lung and Blood Institute, and several other prestigious groups (6). Among their affiliates there are several missing key affiliates. Those would be the grassroots affiliates by using community leaders as “elite opinion”. By using these significant people (such as a clergy person, school principal, or social action leader) within their target audience groups (neighborhood, religious, or cultural communities, for example) for their message of prevention and early intervention there is a higher chance of getting the message of COPD translated within that community. This is the institutional diffusion model (7). By using the elite within the community they are able to translate behavior throughout the institution including policy changes, and social norms which in turn affects individual behavior (such as smoking) (7). A person’s attitude towards a specific behavior is based on the person’s perception of social norms associated with that behavior. This means that by getting grassroot affiliates (especially the elite) involved in helping to pass on the word of lung health chances are more likely that people in that target group would be more likely to listen.

Using combinations of Social diffusion models which focus on changing public norms and Institutional diffusion models which focus change from a higher perspective we can incorporate many different uses of grassroot community leaders (Social Network Theory, Social Marketing Theory, Diffusion of Innovations). We can change policy to effect change of individual behavior as well as using social networks to invoke behavior change (7).

Social Networks are a way grassroots organizations can play a vital role in the passage of health promotional messaging. It starts out with just one person being diagnosed with COPD and they tell their family/friends to get themselves checked out before it’s too late. Those people pass it on to their friends/family and pretty soon the group gets larger and larger. People generally belong to more than one community (neighborhoods, jobs, religious, social circles). As more individual communities become more aware of COPD and testing their lungs, the faster the information gets spread. By utilizing a small amount of strategically placed resources we could have a larger influence over a larger population than by just utilizing physicians alone. The use of chain reaction techniques and grassroots organizations could also raise awareness among populations who do not always trust the medical systems. This would work very well among the younger populations (under age 50) who do not necessarily think that they are at risk for COPD. And as we stated earlier, these are the people we need to focus on. This method, although slow moving, has the potential when planned correctly to be more effective and long lasting than the traditional “because the doctor said so” methods. This method is the same as any fashion trend. One person starts a habit such as dying their hair and before we know it everyone is dying their hair. Although a juvenile comparison, the comparison fits. People want to do what is popular. So the goal would be to make testing your lungs popular.

While the NLHEP has many great ideas, their process of implementation is drastically flawed. By applying a more varied method in the way they approach the different target groups they would probably get a more effective message across. They should support a physician’s choice in equipment, not mandate only certain brands. They should also collaborate with the more influential grassroot organizations to develop better strategies to notify and involve the general population in the process of education and intervention. Until the NLHEP opens its eyes to the flaws in its prevention and intervention messages and strategies, they will continue to be unsuccessful in their attempts to decrease the number of people dying from COPD.

References
1. Diagnosis of Airflow Limitation Combined with Smoking Cessation Advice Increases Stop Smoking Rate, Gorecka, D et al. Chest 2003; 123:1916-1923
2. Global Initiative for Chronic Obstructive Lung Disease, Executive Summary 2005, www.goldcopd.org
3. Mechanisms and Management of COPD, Chest/113/4/April, 1998 Supplement
4. Office Spirometry: Key to Ventilatory Assessment. The Clinical Advisor; July/August, 2002
5. Confronting COPD in America; Schulman, Ronca, Bucuvalas, Inc. Access at www.lungusa.org
6. The Early Recognition and Management of Chronic Obstructive Pulmonary Disease, Doherty, Dennis et al, National Lung Health Education Program, http://www.nlhep.org/
7. Edberg, Essentials of Health Behavior, Sudbury, MA Jones and Bartlett 2007
8. GlaxoSmithKline. COPD in America. The Burden of COPD. 2007 http://www.copdinamerica.com/burden.html

Wrong Agenda: Early Detection Program’s Failure to Promote the Early Detection of Cervical Cancer Among at Risk Women in Florida–Emily Butler

Introduction
Cervical cancer was once a leading cause of cancer death for women in the United States. The availability of the Papanicolaou smear (Pap test) as an early detection tool is largely credited for reducing the mortality rate by 74% between the years 1955 and 1992 (1). Despite the availability of early detection, it is estimated that 11,150 women will be diagnosed with cervical cancer in the United States during the year 2007. Furthermore, although cervical cancer treatments may be curative or life extending, approximately 3,670 women are expected to die of the disease during the same year. The Pap test allows cervical cancer to be detected and treated before it becomes cancerous, in its earliest most curable stage, (2). Although it does not yield perfect results, it is believed that the vast majority of cervical cancer cases can be prevented if women participate in regular screening with the Pap test. Approximately 60% to 80% of new cervical cancer diagnoses occur in women who report not having a Pap test in the last five years (3).

In an effort to improve access to screenings for breast and cervical cancer, Congress passed The Breast and Cervical Cancer Mortality Prevention Act of 1990. The Act established the Centers for Disease Control and Prevention’s National Breast and Cervical Cancer Early Detection Program (NBCCEDP) to provide early detection screenings for low income and uninsured women in all 50 states. The expressed goal of the program is to provide breast cancer screenings for women between the ages of 40 and 64 and cervical cancer screenings for women between 18 and 64 years of age, and at or below 250% of federal poverty level. The program has to date provided more than 6.9 million screenings (4).

Although a success in many respects, the NBCCEDP’s lack of funding prohibits many categorically eligible women from accessing free screenings. Nationally, funding is only available to offer screenings to four out of five women who should be eligible according to the program’s age and financial qualifications. Some states match or contribute to program funding with state funds, thereby allowing as many eligible women to participate as possible. Eleven states, however, do not contribute any state funds to their state’s screening program (5).

Without adequate funding, many states choose to limit the availability of screenings to women in select geographic areas and in particular age groups, thereby excluding at risk women from accessing free screenings. The availability of cervical cancer screenings in the state of Florida serves as a case example for the limitations of the program under budgetary constraints. Florida is one of the eleven states that does not contribute any state funds to the program (4). The Florida Breast and Cervical Cancer Early Detection Program (FBCCEDP) limits cervical cancer screenings to women between the ages of 50 and 64, narrows financial eligibility to women at or below 200% of Federal Poverty Level, and offers the program in only 16 sites in the state (6). Due to these limitations, the FBCCEDP is ineffective in screening young, low-income, and rural women who are at risk for developing cervical cancer. It is estimated that there were 842 new cases of invasive cervical cancer diagnosed in Florida in the year 2003. Florida’s incidence rate of cervical cancer in 2003, 9.2 new cases per 100,000 women, is above the national incidence rate of 8.1 and ranks 14th highest in the nation (8). Although the incidence of cervical cancer is lower than many other types of cancer, early detection efforts warrant attention as many of these cases might be prevented with increased access to and use of the Pap test.

Geographic Inaccessibility Prohibits Utilization of Screenings
Although the FBCCEDP offers services to women in all 67 Florida counties who meet program requirements, there are only 16 sites where the screening services are actually offered (6). Even if a woman qualifies for a screening, she may not have the means to travel to a program site to have the screening done. Eligible women, between the ages of 50 and 65, are of working age and may find it difficult to take time off work to travel to a site. Furthermore, eligible women with incomes less than 200% of Federal Poverty level may not have transportation or the means to afford the expense of travel. The geographic distribution of screening sites may effectively prohibit eligible women from traveling to access a site that offers screenings. It is also highly possible that these women in more rural or remote areas may be less able to afford a Pap test from an alternate provider, if there is even a provider available within the local community. Women living in rural counties, especially in counties not adjacent to a county with an urban area, are less likely to have health insurance coverage or have access to employer-sponsored health insurance (9). Compared to the urban population, people in rural areas also earn lower incomes and are less healthy in general (9.)

Age Criteria Creates a Public Agenda
Under the FBCCEDP program, women under the age of 50 are not eligible to receive screenings despite financial eligibility (6). Although it is rare for a woman under the age of 20 to develop cervical cancer, it is estimated that 50% of cases occur in women between age 35 and 55 (2). Therefore, a significant number of at risk women are not eligible for program services. By systematically excluding younger women, the program may be inadvertently setting a public agenda to promote screening-seeking behavior primarily in older women. A public program’s emphasis on a particular public health issue may direct the public’s attention to perceive the issue as being “high on the agenda” (7). In this case, the availability of a public program to offer cervical cancer screenings for women only between the ages of 50 and 64 may inadvertently set the public’s agenda to view cervical cancer as a risk primarily in this age group. It is then possible that younger, excluded women might not seek screenings from other providers because they do not perceive that their risk as “high on the agenda,” or of significant proportion. Although likely unintended, the program’s age restrictions may be creating a public perception that younger women are not as at risk of developing cervical cancer, when in fact they represent a significant proportion of new cases.

Lack of an Alternative Screening Option
The NBCCEDP and the FBCCEDP do not offer an alternate screening option for the approximate 80% of women that should, but do not qualify for screening services. Women that cannot access screenings are left to navigate the patchwork system of charitable medical services offered by other organizations and institutions. If the program offered a solution, such as a sliding scale fee for excluded women, more women might access reduced cost services even though they could not qualify for a free screening. Without a viable alternative, many women may choose to forgo screenings altogether.

According to the theory of Diffusion of Innovations, health behaviors may be increasingly adopted over time as more people begin to perform the behavior (7). By neglecting to offer a low cost or alternate screening option for ineligible women, the FBCCEDP fails to utilize the potential benefits of this theory. If more women were able to access screenings, perhaps at a small personal cost, adoption of the behavior might increase more rapidly.

Conclusion
The FBCCEDP fails to offer cervical cancer screenings to a large population of at risk women in the state of Florida. Although funding may be limited, careful attention should be paid to the way that screenings are made available so that the most at risk women have the opportunity to stop cervical cancer at its earliest stage. The systematic disqualification of younger women and women in rural areas may prevent some of these at risk women from accessing a Pap test altogether. Furthermore, this inaccessibility may consequently portray a message that younger women are not as at risk of developing cervical cancer. The program does not seize the opportunity to encourage an early habit of annual Pap test screening. The FBCCEDP should be revised to more equitably distribute screening services and encourage more women to access cervical cancer screenings.

Compared to other cancer screening tools, the Pap test is a relatively inexpensive intervention. Although cervical cancer incidence rates have declined rapidly since its innovation, there is no reason why rates should not continue to fall. With appropriately designed public health interventions, the Pap test could be made available to more at risk women.

REFERENCES
1. National Cancer Institute. Cancer Advances in Focus: Cervical Cancer. National Cancer Institute: 2006. Accessed 8 December 2007, from
http://www.cancer.gov/aboutnci/cancer-advances-in-focus/cervical
2. American Cancer Society. Detailed Guide: Cervical Cancer. Atlanta, GA: American Cancer Society: 2007. Accessed 8 December 2007, from http://www.cancer.org/docroot/CRI/CRI_2_3x.asp?rnav=cridg&dt=8
3. American Cancer Society. Cancer Facts & Figures. Atlanta, GA: American Cancer Society: 2007.
4. Centers for Disease Control and Prevention. National Breast and Cervical Cancer Early Detection Program. Atlanta, GA: Centers for Disease Control and Prevention: 2007. Accessed 8 December 2007, from http://www.cdc.gov/cancer/nbccedp/about.htm
5. The American Cancer Society Cancer Action Network. How Do You Measure Up?: A Progress Report on State Legislative Activity to Reduce Cancer Incidence and Mortality, August 2007. Washington, DC: ACS CAN: 2007.
6. Florida Department of Health. Program Overview: the Florida Breast and Cervical Cancer Early Detection Program. State of Florida: 2007. Accessed 8 December 2007, from http://www.doh.state.fl.us/Family/bcc/default.html
7. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
8. State Cancer Profiles. Incidence Rate Report by State. National Cancer Institute: 2007. Accessed 8 December 2007, from http://statecancerprofiles.cancer.gov/incidencerates/index.php?stateFIPS=00&cancer=057&race=00&age=001&type=incd&sortVariableName=rate&sortOrder=desc
9. Kaiser Commission on Medicaid and the Uninsured. The Uninsured in Rural America: Key Facts. The Henry J. Kaiser Family Foundation. April 2003.

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.

The National Breast and Cervical Cancer Early Detection Program and its Failure to Reach Minorities – Julie Nguyen

Created in the early 1950s, the Health Belief Model (HBM) grew as a theory without consideration of practical problem solving (1). Rosenstock, one of HBM’s founders, further explains how this psychological model attempts to explain and predict health behaviors. The HBM relies on several factors that include the individual’s susceptibility to the disease, that the occurrence of the disease would have at least moderate severity on some component of life, and that the taking of a particular action would be beneficial. Rosenstock also notes the disconnect between practical problem solving and the evolution of the HBM. Although this theory’s wide use indicates its favored status for practical application, I argue that the practical applications of the HBM have many limitations, particularly with minority populations. Particularly true for The National Breast and Cervical Cancer Early Detection Program (NBCCEDP), the limitations of the HBM fails to increase cancer screenings in the United States (US) as intended.

The HBM applied: the failures of NBCCEDP and its outreach to minorities
The NBCCEDP, for example, still directs most of its energy and resources to provide cancer screenings using the HBM. The results of the NBCCEDP indicate the HBM to be useful for United States citizens overall but ineffective in changing behaviors for specific minority populations. After a decade-long program of screenings, the progress report states, “Minority populations . . . however, still have high incidence and mortality rates” (2). Instead of reformulating current approaches for minority populations, the NBCCEDP continues to rely heavily on the HBM to address minority populations within the US (3). The NBCCEDP merely categorizes minority populations in the US, like Hawaiian Americans, Vietnamese Americans, Chinese Americans, and applies the HBM to each specific population. In the Chinese American section of the Web site, lies a list of knowledge, attitudes and beliefs. The program similarly outlines the same list of knowledge, attitudes and beliefs for Vietnamese Americans. The outline reflects the NBCCEDP’s commitment to the HBM and the program’s failure to reach minority populations as summarized in its failure to use broader social science definitions in the conditions of the minority population and in the conditions of the societies where those minority populations exist.

The NBCCEDP similarly relies on the HBM’s limited assumption that intentions lead to behavior. The HBM’s assumption of intentions leading to behavior is arguably the weakest link in the theory (4). Assuming intention leads to behavior is fundamentally flawed, as we know that not everyone who intends to do something will do so effectively. For example, not everyone who intends to smoke successfully quits due to the addicting effects of nicotine, a concept not accounted for in the HBM (4). Applying this concept to the NBCCEDP and the HBM, the patient’s intention to prevent cervical or breast cancer will eventually lead to regular screenings for cancer. This concept of intention leading to behavior is invalidated by an unsuccessful outreach effort in Alameda and Santa Clara Counties, California (3). The failure of the outreach effort shows that a patient’s intentions do not lead to behavior. This campaign proves that the recognition of the Pap test for patients of the Alameda/Santa Clara Counties increased “but did not increase screening behavior” (3). Instead of using an effective social science theory, the NBCCEDP bases its intervention on the HBM, which lacks the reality component that many other social science theories offer.

Perceived costs vs. perceived barriers: A main driving force for the NBCCCEDP
It is an unrealistic to rely on the HBM’s narrow definition of perceived costs and barriers to address minority behavior. The HBM states that people will act when they outweigh the costs to the benefits of the disease (4). The HBM assumes rational thinking on behalf of the patient’s health-seeking behaviors. The NBCCEDP, additionally, assumes that minorities can accurately weigh the perceived benefits versus perceived costs of receiving a mammogram or Pap test. By showing that the perceived severity of cervical cancer may lead to increased screening, the NBCCEDP relies heavily on the HBM’s assumption that outweighing the benefits with the costs will increase screening (3). In a study describing cultural influences and access to care, the authors find that the most important reason for declining a screening test is that patients “didn’t have problems/symptoms” (5). This study invalidates HBM’s claim that patients accurately weigh the benefits and the costs. If the patient accurately weighs the costs and benefits of a mammogram or pap test, surely the patient will have the intention to screen for cancer and, therefore, act on that intention by being screened. Since the study indicates that minorities only screen if they have a problem or symptom, a conclusion can be derived that costs and benefits are not as important in decision-making for patients as the HBM purports.

The HBM’s perceived barriers, central to the model and application to the NBCCEDP, often limits the NBCCEDP’s ability to reach minorities. The HBM’s perceived barriers component derives from a social science theory many theorists call “contextualizing risk factors (7).” The theory calls for an “interpretive framework to understand why people came to be exposed to the risk” and “to determine the social conditions under which individual risk factors are related to disease (5).” A perceived barrier, according to these theorists, needs to be understood within a context, or experience, of the individual. The reasons behind the individual’s exposure to various risks and susceptibility to disease need further explanation in every solution. The NBCCEDP’s failure to look at the various individual risks in context of social conditions flawed its reach to minorities. For example, many groups exhibited low levels of literacy among differing minority populations while a few others did not (3). If women perceive themselves to be illiterate, or having low levels of literacy, this characteristic may greatly affect health-seeking behaviors. If women see a lack of education as a barrier, these women may not seek out medical care. If the NBCCEDP does not address this greater social issue, screening rates of low-literacy, minority women will remain stagnantly low. By attacking a general social problem, the NBCCEDP can greatly increase cancer screening through various, indirect methods like increasing literacy.

Self-Efficacy unrealized: NBCCEDP’s neglected component
The HBM’s failure to include a self-efficacy component also neglects the NBCCEDP’s initiative to reach minority populations in the US. Self-efficacy is summarized as an individuals’ “beliefs about their capabilities to produce designated levels of performance” (7). Applied to health, it is the individuals’ ability to sustain desired levels of performance. If further applied to cancer screenings, self-efficacy explains the reasoning behind regular cancer screenings. The NBCCEDP does not account for the lack of self-efficacy in minority populations. One study states that among Chinese Americans, “86% of respondents reported that they had once had a mammogram, [but] only 48.5% had a mammogram within the last year” (4). With an overwhelmingly low statistic for mammography retesting, self-efficacy is not realized under the NBCCEDP’s plans to reach minorities. As reported by the study, only half of the Chinese Americans received a mammogram in the last year. Chinese Americans, in this context, see themselves underpowered to sustain regular mammography screenings. As seen for minority Chinese Americans, the NBCCEDP fails to account for the self-efficacy component into its campaign to increase cancer screenings.

The NBCCEDP’s campaign to increase cancer screenings can not effectively reach minority populations as intended. As an important public health goal, health campaigns, such as the NBCCEDP, needs to use available research effectively and efficiently. The practical applications of various social science theories, including the HBM, are of the utmost importance in implementing the campaign and additionally in sustaining an effective campaign. While the HBM is important in realizing individual risk factors for the low levels of cancer screenings, the first 12 years of the NBCCEDP’s campaign show that it is inapplicable for minority populations in the US. Minority populations, particularly, do not accurately weigh perceived costs and perceived barriers to increase cancer screenings. Intentions and behavior are not directly correlated in the NBCCEDP’s goal to increase cancer screenings for minority populations. Self-efficacy, when used as a success indicator, is arguably one of the most important concepts surrounding public health campaigns for minority populations such as the NBCCEDP. Programs like the NBCCEDP need to broaden campaign perspectives to include various social science theories in respect to the minority population and in respect to the social conditions where the minority population exists. Only after the profession acknowledges and applies various, broad social science concepts can programs like the NBCCEDP effectively address sustainable, long-term, healthy behaviors for minority populations.

REFERENCES
1. Rosenstock, I.M. Historical Origins of the Health Belief Model.” Health Education Monographs 1974; 2:328-335.
2. Centers for Disease Control and Prevention. Summarizing the First 12 Years of Partnerships and Progress Against Breast and Cervical Cancer. http://www.cdc.gov/cancer/nbccedp/bccpdfs/national_report.pdf. Date Accessed: Nov 30 2007.
3. Centers for Disease Control and Prevention. National Breast and Cervical Cancer Early Detection Program: Vietnamese American Women. Center for Disease Control. http://www.cdc.gov/cancer/nbccedp/publications/cc-strategies/vietnamese.htm. Date Accessed Dec 3 2oo7.
4. Siegel, M. Why Social and Behavioral Sciences in Public Health? A consideration of Three Failed Public Health Interventions Lecture. Date of Lecture: Sep 13 2007.
5. Phipps, E., Cohen, M.H., Sorn, R., Braitman, L.E. “A pilot study of cancer knowledge and screening behaviors of Vietnamese and Cambodian women.” Health Care for Women International. 1974; 20:195-207.
6. Bandura, A. Self-efficacy defined. Encyclopedia of human behavior. 1995; 4:71-81.
7. Yu, M., Wu, T., Mood, D. “Cultural affiliation and mammography screening of Chinese women in an urban county of Michigan.” Journal of Transcultural Nursing. 2005; 16:107-116.