Public Health Critique: The “Inside Knowledge” Campaign – Elizabeth Harrah

The Centers for Disease Control and Prevention (CDC) developed a national campaign called Inside Knowledge: Get the Facts About Gynecologic Cancer to raise awareness of the five main types of gynecologic cancer: cervical, ovarian, uterine, vaginal, and vulvar. The goal of the campaign is to reduce the number of women diagnosed with gynecological cancer by increasing women’s and health care providers’ awareness about gynecologic cancer (5). It relies heavily on educational materials that state the risks of getting gynecological cancers, how to prevent gynecological cancers, and promote health as the ultimate desired outcome.

Although this campaign was designed with good intentions, its approach does not allow for maximum effectiveness. The campaign fails to go beyond educating women on their risk of gynecological cancers, it fails to market the values that women aspire to, and it fails to reach the appropriate audience of women.

Critique I – Relying Solely on Education Fails to Motivate

The Inside Knowledge campaign relies heavily on the traditional constructs of the Health Belief Model (HBM) to influence women’s behavior. The four constructs of the HBM are (1) perceived susceptibility, which is an individual's assessment of their risk of getting the condition, (2) perceived severity, also known as an individual's assessment of the seriousness of the condition, and its potential consequences, (3) perceived barriers, in other words, the individual's assessment of the influences that facilitate or discourage adoption of the promoted behavior, and (4) perceived benefits, which is an individual's assessment of the positive consequences of adopting the behavior (7).

The campaign assumes that if women are just educated and aware of the various gynecological cancers then they will see their doctor for the appropriate care. The campaign relies on communication materials, such as radio ads, tv ads, brochures, fact sheets, and a symptoms diary. There is a brochure for each of the five cancers, all of which are structured to answer a set of questions that someone may have for that specific cancer. For example, here is the list of questions answered in the uterine cancer brochure:

· What is uterine cancer?

· What are the signs and symptoms of uterine cancer?

· Who gets uterine cancer?

· What raises a woman’s chance of getting uterine cancer?

· What raises a woman’s chance of getting uterine cancer?

· Are there tests that can find uterine cancer early?

· What should I do if my doctor says I have uterine cancer?

· Where can I find more information about uterine and other gynecologic cancers?

Each brochure also includes statistics on the number of women diagnosed with that specific type of cancer. In addition to the printed materials, there are tv ads that educate women about the warning signs of gynecological cancers and tell women to see their doctor. The first tv ad features several women who describe the warning signs and symptoms related to the five main gynecologic cancers. The ad advises women to know what is normal for them, and if they think something is wrong, to see a doctor and ask about gynecologic cancer. The second tv ad has one woman describing the symptoms she noticed, seeking medical care, and being diagnosed with and treated for a gynecologic cancer. She urges women to listen to their bodies, and if something doesn't feel right for two weeks or longer, to see a doctor. Getting the 'inside knowledge' about gynecologic cancer, she says, can make all the difference in the world (5). These materials make it apparent that the HBM tends to overemphasize the rationality of a person’s behavior, without taking into consideration other constraints on the individual’s ability to seek medical attention or engage in preventative behavior.

This campaign attempts to influence women’s perceived susceptibility, but will most likely be ineffective. Several studies have shown widespread misunderstanding about cervical screening and cervical cancer. One study in England found women perceived their risk of cervical cancer to be low and found that younger women were more likely to attribute cervical cancer to promiscuity or the contraceptive pill, while older women cited smoking or a 'germ' as possible causes. Women who have experienced menopause often believe they are no longer at risk for diseases of the reproductive organs (4). This study provides an example of how people will often perceive their own personal outcomes as being more positive than those of other people in similar circumstances. This is often referred to as the Optimistic Bias Theory. It occurs when an individual’s level of optimism may be unrealistic (3). As a result, simply listing the number of women at risk and the type of women at risk is not enough to convince women they are in fact at risk for a gynecological cancer. They are more likely to ignore the information and assume they are healthy and will remain healthy. The campaign may do an adequate job with influencing women’s perceived severity, but it actually may have unintended consequences. For example, the same study, found that women perceive cervical cancer to have serious consequences. However, fear of detection of cervical cancer has been found to inhibit attendance for screening, particularly among older women and women in lower social classes. Just the word ‘cancer’ instills fear in people and could have a negative effect on their desire to get the proper screenings for fear of finding cancer. The study found that 79% of those who did not attend a screening clinic were afraid of cancer compared to 36% of those who did attend the screening expressed fear in cancer (3).

The campaign does address one potential barrier for women to seek care, which is the cost of screenings. The campaign mentions in several of the brochures that if you have low income or do not have insurance, that you may be able to get a free or low-cost Pap test through the National Breast and Cervical Cancer Early Detection Program (5). It provides the phone number and website. However, it does not address the barrier of fear that women have about the actual performance of the tests and screenings. One study found that the strongest predictor of nonattendance was the belief that the test would be painful, embarrassing or unpleasant (3).

Other barriers that determine whether or not women seek medical attention are family and work commitments, access and transport problems, which also may be the reason for persistent inequalities in general health status between different social classes (4).

Critique II - Marketing Approach Fails To Offer Core Values

The goal of the campaign materials is education and awareness, but does very little to motivate women to take the next step in protecting their health. The campaign fails to offer any core values, rather it lists the preventative behaviors that can help prevent cancers and expects that to be enough motivation.

Here is a sample of the preventative activities that the campaign materials list that can lower a woman’s risk of getting any five of the cancers (5):

• Using birth control pills
• Not using birth control pills
• Maintaining a healthy weight and being physically active
• Taking progesterone if you are taking estrogen
• See your doctor regularly for a Pap test
• Get the HPV vaccine
• Follow up with your doctor, if your Pap test results are not normal
• Don’t smoke
• Use condoms during sex
• Avoid sex
• Limit your number of sexual partners
• Pay attention to your body, and know what is normal for you

Unfortunately, many of these behaviors may seem unrealistic, extreme, contradictory, or vague that many women could feel overwhelmed or hopeless rather than encouraged and motivated to take preventative measures.

The marketing approach used here is the “traditional public health paradigm” (7), where health is the product being sold and marketed based on people’s desire for health. The problem with this model is that it assumes health to be a core value.

Health in and of itself is not a core value. Past and current public health campaigns continue to show how ineffective it is to sell a healthy behavior as a product. A more effective approach for the campaign would be to use the “marketing paradigm”. This model does not start with selling a specific product; rather it sells a core value, something people want or need, and then packages the product to meet the core value. Some examples of core values are love, freedom, control, security, independence, support, family, self-esteem, ownership, youth, and respect (7). These core values are what people to aspire to and the Inside Knowledge campaign does little to provide any of these core values. Instead of conjures up emotions of fear and helplessness and lacks a positive or inspirational message. For example, the campaign could sell the desired product (screenings, doctor visits) using core values such as control or support.

Another shortcoming of the campaign’s marketing approach is that by listing the ideal preventative behaviors, it assumes women can easily give up a poor lifestyle behavior and replace it with a healthy lifestyle behavior. Unfortunately, it does not consider the social context for why women may engage or not engage in a certain behavior. The Prospects Theory, which states that most people assign value to a behavior based on past experiences without considering the costs or benefits of that behavior, can help provide insight into the difficulty of changing women’s behaviors. Women will not just replace a poor behavior for a healthy behavior if all they are gaining from it is future health (7). Again, that would assume future health is a core value for women.

Critique III – Failure To Use Psychological Persuasion

The campaign also fails to address some additional psychological reasons why women may not have incentives to engage in screenings or tests. The campaign does not apply the principle of commitment, principle of social proof, or principle of liking, all of which would have created a more effective campaign.

These principles are discussed in the book, “Influence”, written by Robert B. Cialdini. The principle of Commitment explains that once people become a part of movement or belong to a group, they are more likely to be tied to it and continue to support it. This campaign creates no opportunity for commitment or belonging. The campaign also makes no attempt to create a support network, which is more likely to encourage commitment to a cause. The campaign should create tools, such as blogs where women can communicate with each other to ask questions or share their experiences. There could also be an ongoing support group for women who have been diagnosed with a gynecological cancer.

The principle of social proof states that people are likely to a do a behavior if they see someone else doing that behavior. It shows the power of observing other people (2). This campaign uses visual media, yet does not take advantage of showing women going to the doctor. The women in the ads are standing around in a room saying short monologues of their symptoms. The women should be that of typical women who are facing day to day challenges such as juggling jobs, kids, house work, sports, social events, and friends and family. More obvious is the campaigns failure to target the age group that would most benefit from the HPV vaccine – teenage girls and young women. The HPV vaccine can protect girls and young women against the types of HPV that cause most cervical cancers. The vaccines work best when given before a person's first sexual contact, when she could be exposed to HPV (1). However, since the vaccine needs to be administered at an early age, it is baffling as to why the materials urging women to get the HPV vaccine are not targeted to the appropriate age group. There is no opportunity for younger women to connect with the campaign. It would be appropriate to apply the principle of liking in this situation in order to have young women relate to the campaign. The principle of liking assumes that if you can relate or like the person you see doing a particular behavior, then you are more likely to engage in that same behavior (2). The women used in the commercials are all middle aged, dressed maturely, and appear to be financially stable. The setting for the tv ads take place in a modern, well-furnished room. Not many teenagers would be able to relate to this commercial and feel motivated to get the HPV vaccine. Nor do the ads attempt to motivate mother’s to have their young teenage daughters get the vaccine. The HPV vaccine can be somewhat controversial, but if marketed correctly (using core values), it could be less awkward for girls and mothers to discuss with each other. Another reason the ads should target young women is because they are in the age range where they will most likely benefit from engaging in the preventative activities. Most lifestyle changes are altered or influenced in the teenage years, such as smoking, sexual activity, diet and exercise, and annual visits to the gynecologist (1).

Proposed Intervention:

The new intervention will keep the same name, Inside Knowledge, but it will expand its role beyond education and awareness. The new intervention will focus on modifying parts of the existing Inside Knowledge campaign, while also creating new goals for the campaign and targeting young females in addition to older females. It’s new goals will be to reach women in the community at other access points while conveying a more positive and motivating message.

Defense I – Remove Perceived Barriers And Lessen Perceived Severity

The proposed intervention will remove some of the limitations of the current campaign by addressing the perceived barriers that many women have, such as fear of pain or embarrassment and the lack of social support. New tools and resources will be added to the Inside Knowledge website. There will be a blog for women to share their stories and experiences. This will give women the opportunity to share any concerns they have about screenings or ask questions about what to expect for the first time at an annual check-up or screening. A blog will also allow women to hear from other women their age or with similar backgrounds who might understand their culture or lifestyle behaviors. It will be a safe environment for women to connect with other women without feeling embarrassed. Women may be surprised to learn that other women have the same fears or concerns about the doctor visits and screenings. It will also allow women to get advice on what questions to ask their doctors. The blogs will also feature a panel of experts consisting of gynecologists who can help answer medical questions.

Another resource on the new website will be for women to sign up and volunteer in their community to help educate other women about gynecological cancers. For example, women could sign up to station a booth at health fairs, at the library, or even at local supermarkets. This is an opportunity to take information directly to women in an environment that they are typically in. It will meet women where they are rather then expect women to have the time or access to the other media communications, such as tv, radio, or internet. This will also address the principle of social proof and principle of liking because women will see women who are like themselves helping educate other women in their community. It helps facilitate an informal discussion about health in a friendly and stress free environment.

Defense II – Market Core Values Rather Than Health

The Inside Knowledge campaign assumes women highly value their health. The majority of women probably do value their health, but ultimately, no one is perfect and will sometimes make irrational decisions that could compromise their health. Providing a list of bad behaviors that could result in increased risk for gynecological cancers is not the most realistic method for influencing women’s behaviors. Most people will look at the list of preventative activities and agree that they make sense – women know that smoking is bad, and they should eat healthy, exercise, and use condoms during sex. However, it fails to acknowledge that behavior is not always planned and under an individual’s control. Sometimes visceral factors, such as mood, desire, and emotions can crowd out an individual’s ability to make an otherwise common sense decision (6). In order to get women to buy-in to the healthy behaviors associated with preventing gynecological cancers, the campaign should adopt the marketing paradigm, which was explained previously. The values that the new campaign will address are control and support. The current marketing materials used by the Inside Knowledge campaign, do just the opposite. The materials have the women listing their symptoms in a serious manner. The ads are dull and depressing. The message that these ads conveyed were portraying women as victims of the cancer. This message is not engaging, nor does it motivate a woman to take action; it instills fear and lack of control. Instead the message should be inspirational, positive and empower women to take the best care then can of themselves by selling them the core values they truly desire.

Older women value control or support. A good resource for women to utilize in order to meet their desire for support is to have either an online community (as described above) or a physical community that they can meet with in person. One opportunity for women to have some form of physical community is an annual walk to raise awareness of gynecological cancers. An annual walk will allow women in the community to give back to other women in the community by organizing the event, donating to the event, or participating in the event. The walk can be advertised through multiple communication channels such as fliers, TV ads, and radio ads. It is a chance for women to meet other women who may have been diagnosed with a gynecological cancer and have overcome the cancer or for friends and family to show their support. An annual walk is a stress-free environment that is easy enough for most people to participate in and it sends a healthy positive message. An annual walk is also an opportunity to reach women who would otherwise not have access to education via other forms of awareness such as tv, radio, or internet.

Messages tailored to younger women should sell the core value of independence. Marketing independence is a good way to motivate girls to take ownership of their health and feel mature by initiating the scheduling of an annual gynecologist visit or talking to their mom, friend, or college health center to learn more about the HPV vaccine. Additional methods for marketing core values to younger women can be explained in the next component of the new campaign.

Defense III – Target Innovators Among College Females

The third piece of the new intervention will focus specifically on college females. It is important to instill healthy behaviors in women while they are still young and learning. Young women need to be targeted early and in a manner that they can relate to in order to start good health practices, such as seeing a gynecologist at the appropriate age and on an annual basis, and understanding their bodies and how to take care of their health before developing a cancer. The new intervention will build off of some of the previously mentioned new intervention techniques, such as using independence as the core value. Another core value for girls this age is a sense of belonging. Creating a community among students will help foster a safe learning environment. If girls see other girls running and participating campaign efforts, it can help spark motivation for other girls to become involved.

It will also incorporate a new method, which is motivating girls to adopt healthy lifestyle behaviors and engage in preventative activities by applying the Diffusion of Innovations Theory. The college environment is a good environment for implementing a group level model, such as Diffusion of Innovations Theory.
The theory can predict behavior at the population level rather than at the individual level. The behavior being adopted is often a behavior out of the individual’s control and it may even appear irrational (8). The theory assumes you have “early adopters”, which are individuals that first adopt the behavior. Then, other individuals start to adopt that same behavior as they see more and more individuals doing it. Eventually the effect reaches a critical point called the “tipping point” where a majority of the population adopts the behavior. Finally, the “laggards” in the population, the last to adopt the behavior, will slowly adopt the behavior. In order to ensure that the tipping point is met, it is important to have early adopters who are influential in the population of interest. This model is useful because it takes advantage of the herding phenomenon – this allows a public health professional to not worry about reaching every person, but rather focus on only those who will most likely facilitate the population in reaching the tipping point (7).

Applying this theory to the college setting will require identification of the individuals most likely to be the early adopters and have a strong influence on those around them. This campaign will target a combination of female athletes, students from the class council, and girls in sororities. The leaders organizing the campaigns should be primarily upper classman; girls that are well respected at the college, but it will also recruit and use lower classman in order to grow the community.

Responsibilities of the campaign on campus will include setting up booths near the cafeteria or in the dorm lobbies, and ensuring girls are aware of the resources on campus and the importance of getting the HPV vaccine. The community will also design campaign events or partnership with existing efforts in the surrounding community, such as an annual walk. The college environment can also take advantage of the importance of social networking. The campaign can create a facebook page that helps organize and communicate upcoming events or share educational materials. The campaign will also help organize a fundraiser to raise money to allow the school to offer free HPV vaccines to students without insurance coverage.

Conclusion:

A successful campaign for any public health issue should attempt to go above and beyond traditional methods for motivating the public to engage in healthy behaviors. Campaigns should challenge themselves to be more creative and compete with other messages from sources that are targeting people to buy an unhealthy product or engage in risky behavior. Marketing core values rather than health, intervening in the community, conveying a positive and empowering message, and using influential innovators are all methods that can maximize campaigns effectiveness and ultimately influence people’s decision to live a healthier and more satisfying life.

REFERENCES

American Social Health Association. HPV and Cervical Cancer Prevention Resource Center, 2010. http://www.ashastd.org/hpv/hpv_learn_women.cfm

2. Cialdini, B. Robert, Influence: Science and practice (4th ed.). Boston: Allyn & Bacon, 2001

3. Clarke, A., Valerie. Unrealistic Optimism and the Health Belief Model. Journal of Behavioral Medicine (Vol. 23, No. 4), 2000.

4. Gillam, S.J. Understanding the uptake of cervical cancer screening: the contribution of the health belief model. The British Journal of General Practice. 1991; 510–513.

5. The Inside Knowledge Campaign. Centers for Disease Control and Prevention. 2010.

http://www.cdc.gov/cancer/knowledge/

6. Loewenstein, George. Out of Control: Visceral Influences on Behavior. Organizational Behavior and Human Decision Processes (Vol. 65, No. 3), 1996; 272–292.

7. Siegel M. SB 721: Social and Behavioral Sciences for Public Health Notes. Fall 2010.

8. Valente, W. Thomas. Accelerating the Diffusion of Innovations Using Opinion Leaders. Annals of the American Academy of Political and Social Science, 1999; 55-67.

http://www.jstor.org/stable/1048842