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International Journal of Nonprofit and Voluntary Sector MarketingInt. J. Nonprofit Volunt. Sect. Mark. 12: 338–349 (2007)Published online 8 January 2007 in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/nvsm.294
Consumer attitudes towardsself-referral with early signs ofcancer: Implications for symptomawareness campaignsDouglas Eadie* and Susan MacAskillInstitute for Social Marketing, University of Stirling and The Open University, UK

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*CorMarkling,E-ma

Cop

raditionally, secondary prevention programmes have employed mass screening

approaches to assess for asymptomatic signs of cancer. It has been suggested that early

detection strategies, involving public education and self-referral may prove more cost-

effective, with low-risk populations for cancers with symptomatic presentation. The

success of public education approaches is dependent on careful consideration of the

psycho-social factors of self-examination and referral. This paper presents the findings

from an exploratory study, using qualitative methods with an at-risk population of older

people living in deprived communities in west-central Scotland. The study examines

consumer perceptions of the early detection of cancer and the cultural barriers to

self-referral, as well as response to aspects of communication strategy. The implications

for design of symptom awareness campaigns, including use of message appeals, specifica-

tion of target symptoms, identification of target audience and selection of communication

channels, are discussed.

Copyright # 2007 John Wiley & Sons, Ltd.

Introduction

Cancer is now the most common cause ofdeath in the UK. Around a third of all people inthe UK will develop cancer, with the majorityof cancers occurring later in life—64% ofcancers occur in people aged 65 or over(Quinn et al., 2005). Cancer rates for some ofthe major cancers are significantly higher inmore deprived regions. One such area is thecentral belt of Scotland, where incidence and

respondence to: Douglas Eadie, Institute for Socialeting, Department of Marketing, University of Stir-Stirling FK9 4LA, UK.il: [email protected]

yright # 2007 John Wiley & Sons, Ltd. Int. J

mortality rates for cancer are 15% above thenational average.

Whilst the UK has witnessed a growth inthe incidence of cancer, mortality for thedisease has decreased. Key to these improve-ments has been developments in secondaryprevention approaches and early diagnosisof the disease. In the UK, like most otherdeveloped countries, major advances havebeen made in mass screening of at-riskpopulations to identify cancers at a pre-sym-ptomatic stage. However, the costs associatedwith mass screening can prove prohibitive,particularly when targeting populations atrelatively low risk (Bloom, 1994).

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Cancer prevention and symptom awareness campaigns 339

Given these constraints, recent attentionhas focussed upon the value of promotingsymptom awareness. In the UK, efforts havebeen made to promote early recognition ofsigns by doctors in primary care, as part of apackage of measures to speed up the referralprocess (Department of Health, 2000). How-ever, evidence indicates that the majority ofdelays are accounted for by patient failure toself-refer when symptoms present (Andersonet al., 1995; Ristvedt and Trinkaus, 2005).This raises important issues about the use ofmass media to inform people about cancersymptoms and the appropriate use of healthservices, where accurate identification andspeed of response to symptoms are criticalmeasures of success (Bloom, 1994).

The mass media are an established source ofinformation about cancer (Signorielli, 1990).They are also an important influence on publicattitudes: setting the public agenda by, forexample, putting certain cancers on thepublic radar; conferring status and legitimacyon specific topics or points view; and provid-ing a framework for public discourse aboutdisease (Wallack and Sciandra, 1990–91). Inthis way, the media have the potential, not onlyto reduce the stigma, fear and embarrassmentassociated with cancer, but also more funda-mentally to give people ‘permission’ and avocabulary for discussing specific cancers andtheir symptoms.

However, it is also important to recognise thelimitations and risks associated with interven-tions which seek to exploit the media, whetherdirectly through media campaigns or indirectlyby influencing unpaid media. There is abundantevidence in the field of primary prevention ofmedia interventions bringing about changes inawareness, knowledge, and, to a lesser extent,attitudes to modifiable health risk factors suchas smoking (e.g. Flay, 1987; Campion et al.,1994; Hafstad et al., 1997). However, evidencethat the media can influence health behaviour isless conclusive, with many evaluations showinglimited, short-term or no impact (e.g. Murrayet al., 1994; Bauman et al., 1989, 1991). Inview of this evidence, it is suggested thatsymptom recognition is more suited to media

Copyright # 2007 John Wiley & Sons, Ltd. Int.

intervention than lifestyle behaviour change,as it involves affecting what Pasick andWallack (1988–89) refer to as ‘one-time beha-viours’ eliciting ‘a request for information’(p. 93). Indeed, the ability of media campaignsto increase intentions and attendance for cancerscreening would appear to support this asser-tion (e.g. Turnbull et al., 1992; Byles et al.,1996; Jenkins et al., 1999), although there areimportant differences both in terms of motiv-ation and information specificity between massscreening and symptom awareness campaigns.

While the benefits of symptom awareness isaccepted for cancers where early signs arerecognisable, for example with malignantmelanoma (Rhodes, 1995), it is also hypothes-ised that poorly designed and implementedcampaigns have the potential to do more harmthan good. More specifically, health serviceproviders express concern about their abilityto cause delays in diagnosis and treatment.Observers warn that campaigns, intended toraise awareness of the early signs of diseasecan arouse fear in patients with appropriatesymptoms, leading to delays in self-referral,and encourage the so-called ‘worried well’ toseek reassurance with inappropriate symp-toms, blocking the system for those patientswith genuine need (MacKie, 1997).

Others have warned against the risk ofincreasing social disadvantage and healthinequalities. As higher income and moreeducated groups tend to derive more fromhealth information campaigns than do disad-vantaged groups (e.g. Windahl et al., 1992;McQuail, 1994), mass media campaigns whichaddress the whole population risk widening,rather than narrowing inequalities by dispro-portionately benefiting those with betteraccess and who are more disposed to exploit-ing preventive services (Arblaster et al., 1996).Evidence from cancer screening programmessuggests that with careful attention to cam-paign design, it is possible to narrow inequal-ities in health knowledge, behaviour andaccess to health care (e.g. Dignan et al.,1994; Sugg Skinner et al., 1994).

In order to realise the benefits and avoidthe pitfalls of media interventions intended to

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340 Douglas Eadie and Susan MacAskill

improve symptom awareness, formative re-search is critical to ensuring campaign devel-opment is shaped by an in-depth understand-ing of the factors which influence consumers’help-seeking behaviour and the social contextin which these take place (Eadie and Smith,1995). This paper describes the results toemerge from an exploratory study, examiningattitudes towards cancer recognition and thefactors which facilitate and hinder self-referralwith suspicious symptoms. The study wasconducted with an at-risk population ofolder people living in deprived communitiesin west-central Scotland, and formed part of abroader programme of research which aimedto inform the development of cancer-specificsymptom awareness campaigns in the studycommunities.

Method

The researchers adopted a positivist approachto the enquiry, using qualitative focus groupsto provide the necessary flexibility to under-stand the range of behavioural issues underinvestigation, a method other studies havefound useful for examining cancer preventionissues (e.g. Beeker et al., 2000; Wolf et al.,2001).

A total of eight focus groups were con-ducted with a mean of seven participantsper group (n¼ 57). A discussion guide wasdevised to ensure moderators covered thetopics relevant to the research. Topics werenot explored in a prescriptive manner. Instead,

Table 1. Discussion themes

Theme 1—Cancer awareness

Awareness and perceptions of cancer, including: signs aperceptions of who is at risk and awareness and understan

Theme 2—Presentation with potential symptoms of cance

Preparedness to undertake regular self-examination and twith suspicious signs and symptoms. Particular emphasis wbarriers (perceived and real) which could deter self-referra

Theme 3—Health information campaigns

Attitudes towards, and experience of, health informationregards to message, channel, language and tone of commuused to stimulate discussion and to examine alternative m

Copyright # 2007 John Wiley & Sons, Ltd. Int. J

participants were given the freedom to expresstheir own feelings and views, as part of anopen and free-ranging discussion. This flexibleformat enabled the researcher to developoriginal lines of enquiry, allowing salient topicsand behavioural insights to emerge. Table 1lists the main discussion themes.

Each focus group lasted approximatelyone and a quarter hours and was held in aneutral venue, such as a community centre orlocal hall. With the participants’ consent, thediscussion was recorded on voice tape, and thetapes transcribed in full for thematic analysis.Transcripts were organised, using a thematicframework, based on topics specified in thediscussion guide and emerging themes ident-ified through a process of familiarisation withtranscript texts.

In order to produce a relaxed atmosphereconducive to open discussion, it is usuallydesirable for focus groups to be as homo-geneous as possible in socio-demographicand/or other characteristics (Parasuraman,1991). It is also important to quota-samplesub-groups which represent relevant positionson the issues being researched, so that anydifferences between these sub-groups can beidentified (Atkin and Freimuth, 1989). Takinginto account these requirements, the sampleincorporated the following quota variables:gender, age, socio-economic group and placeof residence (see Table 2).

The research sought to sample a sub-population whose age, socio-economic statusand lifestyle placed them at elevated risk to

nd symptoms, seriousness and survival rates,ding of measures to help detect and prevent cancer

r

o present to primary care or other health care providers,as placed on examining the social and structural

l

campaigns: factors which enhance response withnication. A selection of cancer awareness materials wasessage and media formats


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Table 2. Study sample

Groupnumber

Gender Age Socio-economicgroup

Place ofresidence

1 Male 40–55 C1C2 Rural2 Female 56–70 C1C2 Urban3 Male 56–70 DE Urban4 Female 40–55 DE Urban5 Male 40–55 DE Urban6 Female 56–70 DE Rural7 Male 56–70 C1C2 Urban8 Female 40–55 C1C2 Urban


cancer. As well as the socio-economic variablesdescribed in Table 2, participants wererecruited as tobacco smokers (10 or morecigarettes per day), drinking alcohol in excessof the recommended weekly limit (14 unitsfor women and 21 units for men) and eatingless than the recommended five portions offruit and vegetables per day. Participants wererecruited from four health authority areasin west-central Scotland, a region with highrates of deprivation and a higher than averageincidence of cancer.

Results

The results presented here are organisedinto four discrete study themes: perceptionsand attitudes to early detection of cancer,experiences of early intervention campaigns,response to different message appeals andsources of advice about suspicious symptoms.

Perceptions and attitudes to early

detection of cancer

Cancer was regarded as a common diseasewhich could affect all sectors of Scottishsociety. The majority of participants knew ofat least one person in their social network,typically an elderly relative or family friend,who had cancer or who had died fromthe disease. A smaller number had personalexperience of the disease. Attitudes towardsthe disease were characterised by a sense


of fatalism and underlying fear, particularlyamongst older participants, although therewas a general belief that people were lessreluctant to talk about the disease, comparedwith previous generations, with the mediaappearing to have a normalising effect.

‘You never heard about it years and yearsago. It’s the same as other illnesses likeAlzheimer’s—they were just put under thecarpet’.

‘A lot of things are out in the open comparedto what they used to be’. (Female, 56–70,DE, Rural)

‘Now you see it on the telly all the time.’

‘If somebody famous died with anything likebowel cancer, if it goes on the news,everybody will be in the pub . . . ‘‘Did youhear so-and-so died of bowel cancer?’’ . . .Everybody would be talking about it’. (Male,55–70, DE, Urban)

Early detection was a familiar concept, moreso amongst women, many of whom wereregular participants in mass screening pro-grammes. It was also widely recognised thatearly detection and treatment improvedchances of survival, and that the individualhad the potential to affect their own health bypresenting early if they experienced suspicioussymptoms.

‘If you leave it too late, it’s curtains anyway.They tell you nowadays if they catch it intime they can do wonders’. (Male, 55–70,DE, Urban)

Fear of cancer and high levels of mortalityassociated with the disease were a recurringtheme in the discussions and had a negativeimpact on people’s willingness to considerself-detection strategies and to seek theopinion of a health professional or to discusssymptoms with family or friends. This patternof response was expressed in different ways.


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Women were more likely to recognise andverbalise these fears:

‘Everything would put me off. I’d bepetrified’.

‘You just suffer it. It’s the only chanceyou’ve got’. (Female, 56-70, DE, Rural)

Men, on the other hand, were more inclinedto deny these fears, which in some instancesled them to adopt extreme and entrenchedpositions on the issue as the following quoteillustrates:

‘I believe that once you’ve got cancer you’vegot it. I’ve known people who have hadcancer and not one of them is this day living.Nothing can be done’. (Male, 40–55, C1C2,Rural)

So whilst the benefits of early presentationand diagnosis were widely accepted at arational and objective level, when viewed ata personal level, the strong emotions whichcancer can arouse appeared to act as a barrierto confronting the issue.

‘It’s always in the back of your mind—yousay to yourself, ‘‘I’ve got this ache/pain’’.’

‘I’m in agony, but I’m no’ in enough agonyto phone the doctor.’

‘See what it’s like tomorrow’.

‘That’s the usual, isn’t it—see what it’s liketomorrow’. (Male, 40–55, DE, Urban)

Early intervention campaigns

In keeping with peoples’ objective evaluationof the benefits of early detection, participantswere generally supportive of interventionsdesigned to promote secondary prevention,although understanding of the concept and itsrelationship with curative procedures wassometimes limited.

Copyright # 2007 John Wiley & Sons, Ltd. Int. J. N

‘I think they should [run a campaign],something you should always be madeaware of’.

‘It is a wee prompt that, to go and get seen toif you think you’ve got a problem’.

‘I think there should be something like that,yeah’. (Male, 40–55, DE, Urban)

Participants also supported the principle ofpatient education and raising public awarenessof the early signs and symptoms of cancer. Thiswas a familiar idea with some recalling havingseen information posters in health care pre-mises and patient waiting areas raising aware-ness of specific cancers and their symptoms.

‘I think in a lot of the surgeries now havesigns up saying if there is any change in yourbowel habits get it seen to. Make sure it isnothing’. (Male, 55–70, C1C2, Urban)

Support for these campaigns was premisedon the belief that the individual could benefitin one of two ways: either from peace of mindfrom knowing that they were cancer free or,more significantly, from improved chances ofsurvival where the cancer is diagnosed andtreated early.

‘If it is cancer you get it early and they candeal with it’. (Male, 40–55, C1C2, Rural)

‘. . . there is always a strong possibility that itwill be clear. It puts your mind at ease’.(Female, 56–70, C1C2, Urban)

However, consistent with earlier findings,when participants considered how they werelikely to react to this type of message, if subjectto the symptoms highlighted at time ofexposure, responses were characterised byfeelings of angst and uncertainty, and led someto question the likely impact on demand forhealth services.

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‘I think the doctors might find they aresuddenly being inundated by peopletaking up their time because they arepanicking. I think doctors have got toomuch on their plate as it is’. (Female, 56–70,C1C2, Urban)

Cultural factors appeared to have an import-ant role in determining how the differentgenders were likely to respond to this kind ofhealth information, with female participantsshowing a greater propensity to seek pro-fessional advice than male participants. Thisdifference appeared to reflect women’s greaterfamiliarity and use of primary health careservices through, for example, participation inmass screening programmes and responsibilityfor children’s health care. In contrast, men,particularly men living in rural areas, were lessinclined to acknowledge health problems.Where illness was recognised, men generallypreferred to self-treat than to consult a doctoror health professional.

‘A man is more likely to sit there for monthsand say, ‘‘It’ll go away’’, whereas a womanwill go down to a Well Woman clinic orsomething like that—there are eight of ushere, if you go round the eight of us and sayhow many of you would go down to a WellMan clinic we’d be looking at each other tosee which one is the poof’.

‘It’s not within their psyche, especially inthe west of Scotland’.

‘It’s their make-up’.

‘If you find a wee lump, like the bloke wassaying, you say, ‘‘It’ll go away’’. You ignore it. . . and before you ken where you are it isthe size of a football’. (Male, 40–55, C1C2,Rural)

‘I think really when you have got somethingwrong with you—the first thing you do istry and doctor yourself’. (Male, 40–55, DE,Urban)


Message appeals

A range of message appeals were examined,using proposition boards and promotionalmaterials from existing campaigns. Theseincluded fear, humour, survivor testimonies,and celebrity endorsement; and in someinstances, combined messages, for examplecelebrities talking about their personal experi-ences of cancer.

Whilst fear emerged as an underlying themein discussions about the disease, its use inraising awareness of symptoms was widelychallenged. Indeed, the use of the term ‘cancer’was often sufficient on its own to trigger thistype of response:

‘You see ‘‘cancer’’ and you don’t read it’.(Female, 40–55, DE, Urban)

‘I think the thing you don’t really want to seeis ‘‘cancer’’. Everybody thinks of cancer butthey don’t really want to be talking about it’.(Female, 40-55, DE, Urban)

In contrast, humour had the potential toengage people by ameliorating underlyingfears, although the type of humour and itsexecution was critical to eliciting audiencesupport, and some cancers appeared to lendthemselves, more to humour than others.For example toilet humour provided a usefulvehicle for addressing the embarrassmentand fear associated with colorectal cancer asthe following response to an image of mansitting on a toilet seat, under-scored with thecaption ‘Do not sit on the problem’ demon-strates:

‘That’s good’.

‘I think that is quite funny’.

‘You need to make light of things and not tomake it the fear factor’.

‘That might make me go actually—yeah thattakes it away’.


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‘It’s not as frightening, it’s the kidology . . .’

‘Yeah I think that is really good’. (Male,40–55, C1C2, Rural)

News messages, particularly those employ-ing incidence and mortality statistics werecapable of capturing audience attention andstimulating some debate about the scale of thedisease. However, the nature of the infor-mation led participants to depersonalise themessage and the potential risks.

M: ‘Last year 6,000 Scots died of bowelcancer’

R: ‘But I wasn’t the one who died and I don’tknow anyone who did die of that so itwouldn’t affect me personally. I know thatsounds terrible but . . .’ (Male, 40-55, C1C2,Rural)

In contrast, personal testimonies, whetherfrom a carer or someone who has beendiagnosed with the cancer, brought a senseof realism to the debate and enabled parti-cipants to relate more directly to the disease,breaking down some of the emotional barriersto public discussion.

‘You’re not so scared because you aregetting inside what is happening to a personand you are actually seeing them still thereand they are telling you what exactly it waslike and how they feel now’.

‘I think you would need to have someonewho had been through it before it regis-tered’.

‘They could have a discussion like that ontelly and having people like ourselves thatknow bits and pieces about it and havingexperts that deal with it day in and day out.But also maybe having a couple of peoplewho have actually gone through it to giveyou their version of what has happened and


how it happened’. (Female, 56–70, C1C2,Urban)

Interestingly, whilst celebrity testimonialshelp to highlight human vulnerability to thedisease and to raise the public profile of thecancer, the focus on celebrity can underminepeoples’ ability to personalise the threat.

‘That is the only time you hear aboutcancer—when one of these celebrities orone of these pop stars has it’.

‘John Thaw (actor) took it and it waspublicised right left and centre because ofwho he was.’

‘His wife has done a great job because shewas on the television. She does a lot of goodwork. She set up a fund and everything’.(Male, 55–70, DE, Urban)

Sources of advice

A variety of sources emerged as first point ofcontact for advice about suspicious symptoms.These included primary care professionals,telephone helplines and lay sources such aspartners and close friends. The ‘family doctor’or ‘GP’ (general practitioner) was widelyregarded as the most likely point of contactwith the health care system for concernsrelating to cancer. Other primary care pro-fessionals, most notably community pharma-cists and primary care nursing staff, also had arole to play in raising awareness of potentialserious symptoms and directing patients toseek advice from their GP.

‘Even pharmacists can help people a lot ofways, can’t they’?

‘He can advise you—‘‘Take this. If it’sstill there in a couple of days then it’s timeto see the doctor’’. So you can use him as thefirst port of call.’ (Male, 40–55, DE, Urban)

Lay sources of advice emerged as animportant part of the consultation process.


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Participants, particularly female participants,cite lay networks as an important sourceof reassurance prior to seeking professionaladvice, in some instances providing additionalemotional support when attending forappointments. Lay sources also appeared tohave a critical role in encouraging men toconfront their symptoms and to seek pro-fessional advice.

‘I think if you had these symptoms youwould go and talk to another woman aboutbowel cancer . . . before you would go toyour doctor’.

‘But deep down in your mind you know youhave got to go’.

‘You’re frightened in case you are wastingthe doctor’s time’.

‘Whereas if it is a friend and they say, ‘‘No, Ithink you should go to the doctor’’.’(Female, 56–70, C1C2, Urban)

‘Men are big cowards—bad patients and bigcowards’.

‘They’d need a bit of nagging to go’.(Female, 56–70, DE, Rural)

In addition to relying on social networksfor support, participants also had strong tieswith their local communities and some wereregular participants in local events and activi-ties. Limited mobility and a community-centricethos meant that some rarely ventured outwiththeir local area. In view of this, a communitylevel approach, for example, combining theopen-ended discussion format of the researchfocus group with input from a local cancerspecialist, could be a useful way of stimulatinglocal interest and raising awareness of cancersymptoms and the consultation procedure.

‘If you had a Macmillan nurse (palliativecare nurse) or a health visitor who has

Copyright # 2007 John Wiley & Sons, Ltd. Int. J. N

specialised—and advertise a meeting orsomething’.

‘Just like we’re having tonight’.

‘Something like we’re doing tonight—in agroup’.

‘Where I live the community centre holds alot of things and the churches have that kindof thing’. (Female, 56-70, C1C2, Urban)

Conclusions

The results from the study suggest widespreadsupport for media campaigns, designed toraise awareness of the early signs of cancer.However, their success is dependent oncareful consideration of the psycho-socialfactors of self-examination and referral. Previousstudies have found that patient-generated delaysaccount for the largest proportion of delays inthe diagnosis of cancer, and that those withhigher levels of socio-economic deprivation aremore reluctant to seek help (e.g. Eiser et al.,2000). This study enhances our understandingof the individual level factors and, in particular,the importance of gender and lay networksto early presentation (Burgess et al., 2001).The results also have implications for thosewishing to use mass media approaches toencouraging people to self-refer with suspicioussymptoms. Four aspects of campaign strategyare discussed: message appeals, symptomspecificity, target audience and channel selec-tion.

Successful communication needs to becustomised to the needs of its target audience.The findings from this study guard against theuse of fear appeals in symptom awareness, sincefear can stimulate maladaptive responses suchas avoidance, discouraging those with genuinesymptoms from seeking professional advice.Similar results have been found with their usein cancer screening (Jones and Owen, 2006).Messages which offer reassurance and con-fidence are more likely to prove beneficial.Social modelling approaches such as personal

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testimonies, and careful use of humour havethe potential to aid identification with theissue, ameliorate underlying fears and normalisehelp-seeking behaviour. While celebrity testi-monies have been shown to have a powerfulagenda-setting effect and are helpful in raisingawareness of lesser known cancers (Corbettand Mori, 1999), findings from this studyindicate that the focus on celebrity candiscourage audiences from personalising risk.

Just as important as how to communicate themessage (i.e. which message appeals are bestto employ), is what to communicate, orin this instance, what symptom or combinationof symptoms will trigger appropriate referrals.Clearly, this is dependent upon the particularcancer being addressed. However, mediastrategy and communication channel alsohave a critical to role to play in informingthese decisions. In communication terms, sym-ptoms need to be simple to recognise and easyto differentiate from other inappropriate orbenign symptoms, since poor communicationincreases the risk of inaccurate referrals or ofsymptom information simply being ignored.The risks are greatest where the targetsymptoms can be confused with other benignsymptoms that are relatively common, leadingto large numbers of inaccurate referrals andpotential overloading of diagnostic services.

Given people’s resistance to acting on earlysymptoms, campaigns which exploit socialnetworks by encouraging word-of-mouth com-munication and personal recommendationcould prove more effective at encouragingentry into the health care system than cam-paigns which seek to promote self-referraldirectly. Such an approach involves directingmessages towards key opinion formers andcould prove an effective means of targetinghigh-risk groups with low propensity to pre-sent. This study identified older men livingin rural communities as one such group,and their wives and partners as key opinionformers. Communication theory, such as step-flow models of communication (e.g. Katzand Lazarsfeld, 1955), could provide usefulconstructs for developing communicationstrategy.


A community level approach, exploitingword-of-mouth communication, also has strongsynergies, when targeting older populationsliving in more deprived areas, since studyparticipants can have strong ties with theirlocal communities and are receptive to locallyco-ordinated activities and events. These find-ings are consistent with other studies con-ducted in disadvantaged communities in the UK(e.g. Johnston et al., 2000) and highlight thepotential of working with community networksto reinforce campaign messages deliveredthrough wider media channels. For examplemobilising local health care workers to act asadvocates, linking with local clubs and organ-isations to promote word-of-mouth communi-cation and engaging with local media, such aslocal radio and free-sheets, to generate newsstories pitched at a community level. Evidenceindicates that a multi-faceted approach com-bining media, interpersonal and communitycomponents is more effective than media alone,as the different components reinforce andamplify one another, and combine to generatemore persuasive messages and more enduringeffects (Fortmann et al., 1995; Pentz et al.,1997).

Finally, in summing up, given the fears andlimited readiness to change, great awarenessand sensitivity is required when developinginterventions which seek to engage people inthe prevention of cancer. The study findingsclearly illustrate how careful attention needsto be given to all aspects of communicationstrategy if target audiences at heightenedrisk are to benefit from advances in cancertreatments and new diagnostic procedures. Itis also important to recognise that whilstthese findings represent the views and needsof the at-risk population in the study commu-nities, consideration needs to be given tounderlying cultural factors, when assessinghow they might be generalised for otherat-risk populations and symptom awarenesscampaigns. In addition, the findings describedrepresent respondents’ predicted response tocancer symptoms. Further qualitative researchis required to examine patient response tosymptoms retrospectively, both to assess for


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consistency and to develop more detailedinsight into the role played by the patient-professional relationship on referral and use ofdiagnostic services.

Acknowledgements

The research is part of the West of ScotlandCancer Awareness Project funded by the NewOpportunities Fund, now The Big LotteryFund.

Biographical notes

Douglas Eadie is a Senior Researcher atthe Institute for Social Marketing (ISM). Dou-glas has a background in communicationsresearch and his research interests are in theapplication of communication techniquesdeveloped in commercial marketing to thenon-for-profit and public health sectors. Healso has an interest in corporate social respon-sibility and the relationship between commer-cial practice and public policy. He specialisesin the use of qualitative methods.Susan MacAskill is a Senior Researcher

at the Institute for Social Marketing (ISM).She joined the ISM, after working in primarycare and health promotion. Her research inter-ests include researching sensitive issueswith vulnerable and hard-to-reach groups in-cluding prisoners, youths, minority ethnic anddisadvantaged communities and victims ofdomestic violence. She also has an interestin exploring provision of health and socialservices from a range of perspectives, includ-ing the service users, direct providers andother relevant stakeholders.

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