How routine mammography of women under 50 diverts attention from cancer prevention and environmental factors - Lynn Rosenbaum

Setting the stage
Breast cancer in the United States is a highly prevalent and dangerous disease for women. According to the Breast Cancer Fund, a woman has a one in eight chance of getting breast cancer in her lifetime, and more women between the ages of 20 and 59 die from breast cancer than from any other cancer. From the 1930’s to the end of the 1990’s, a woman’s risk of breast cancer continually increased, and between 1973 and 1998 alone, increased by 40%. [1] In the last decade, we have finally seen a decrease in both incidence and mortality for women; however, the research is unclear as to whether these positive results were only relevant to women over age 50 [1,2]. Many sources agree that the decline was probably due mainly to the decrease in post-menopausal hormone replacement therapy which, in 2002, was found to be associated with an increased risk for breast cancer[1].
So what is the most effective way to prevent breast cancer? And what exactly do we mean by prevention? One of the most prevalent public health strategies to address breast cancer is screening through the use of mammograms. According to The American Cancer Society “Getting a mammogram is one of the best things a woman can do to protect her health.” They recommend, “Women age 40 and older should have a mammogram every year and should continue to do so for as long as they are in good health. While mammograms can miss some cancers, they are still a very good way to find breast cancer.” [3]
But does screening mammography truly prevent breast cancer? In this paper I will argue that an emphasis on routine screening mammography among average risk women under 50 is neither safe nor effective; it directs attention and resources to secondary rather than primary prevention; and it results in minimizing the links between environmental toxins and breast cancer.

Mammograms can be unsafe and ineffective
Although regular mammograms have been shown to offer benefits to post menopausal women, mammograms carry associated risks, and are not proven to offer the same benefits to healthy women under age 50. The first risk of routine mammography screening in premenopausal women is unnecessarily exposing them to radiation, which is potentially dangerous. Although many experts believe that this low-dose exposure radiation is of low risk (perhaps causing 1 additional breast cancer death per 10,000 women) [4], other researchers have argued that the risk has been underestimated and cannot adequately be predicted by models based on higher doses or radiation [1]. It has also been found that “young women with the very mutations that lead them to begin mammography screenings at earlier ages are actually more vulnerable to the cancer-inducing effects of early and repeated exposures to mammograms.” [1]
The second risk of routine mammography is that it may lead to unnecessary medical interventions. Mammograms, particularly for younger women whose breast tissue tends to be more dense and less likely to yield accurate results, can lead to both false positives and false negatives. As a result of false positives, women may end up getting dangerous and unnecessary surgeries and radiation treatments. “It is estimated that a woman who has yearly mammograms between ages 40 and 49 has about a 30 percent chance of having a false-positive mammogram at some point in that decade and about a 7 percent to 8 percent chance of having a breast biopsy within the 10-year period.”[5]
In the 1980-1990’s, according to a study by Horner 2009, rates of diagnosis of the non-invasive condition ductal carcinoma in situ (DCIS) increased by 4 times, mostly due to the greater use of mammogram screenings. [1] Because, current medical science cannot tell us which cases of DCIS will end up actually leading to cancer and, in fact, most do not [4], many women have been unnecessarily subjected to the risks of subsequent surgical biopsies, radiation and Tamoxifen.
There is very minimal evidence of benefits to outweigh the above risks. Some research has shown that for women between 40-49, after a seven year follow-up, there was no effect on mortality, and in order to even extend one life, it is estimated that 2500 women would have to be screened regularly. [4]
In 2009, the U.S. Preventive Services Task Force (USPSTF) published a controversial revision to its policies. It weighed the potential benefits (reduced chance of dying from breast cancer) and potential harms (for example, false-positive results and unnecessary biopsies) and then concluded that “there is moderate evidence that the net benefit is small for women aged 40 to 49 years.”
It recommended biennial mammograms to women age 50 and over, rather than annual screenings to women 40 and over, and for women of average risk, age 40-49, it recommended against routine screening. [6]
Despite this report and the evidence cited above, The American Cancer Society, National Cancer Institute, Susan B. Komen and others continue to recommend regular screening mammography for younger women[7], although other organizations such as the Cancer Prevention Coalition and Breast Cancer Action are in accordance with the Task Force’s recommendations in discouraging healthy young women to be screened [8,9]. And then there are those organizations such as the Center for Disease Control which have backed off of any strict recommendations and instead encourage women to talk with their doctors to make an individual decision based on the research and their particular set of conditions [10].
Another problem with a policy of routine mammograms for women under 50 is that women may think that getting a mammogram is all they need to do to avoid getting breast cancer, at the expense of attending to important lifestyle and environmental factors. Women are subject to the “illusion of control,” which refers to the expectation that one has more control over a situation than is objectively warranted by probability. This illusion is enhanced when one is involved or takes action in the situation at hand. [11] So in this case, young healthy women who take a specific action by getting mammogram screenings may feel more in control of preventing the likelihood of their getting breast cancer, even though the mammogram is a tool to potentially detect existing cancer rather than to prevent it and, as argued above, has questionable benefits. In order to truly prevent cancer, that is, address its underlying causes, young women should be encouraged to focus on controllable lifestyle factors, such as diet, exercise and alcohol consumption and perhaps more importantly, on environmental factors, such as toxins which permeate our food, air, water, and consumer products.

Primary versus secondary prevention
An emphasis on mammogram screening directs focus and resources at secondary prevention, that is, researching and promoting how to detect cancer early enough to treat it, instead of at true primary prevention, which identifies and eliminates preventable causes of the disease. The way in which a problem is framed determines what is seen as important. “Elements left out of the story are outside the frame and are thought to be unimportant.” [12] The framing of a medical problem in this way is not limited to breast cancer. “The dominant focus in epidemiology and perhaps the American culture in general is on individually-based risk factors that lie relatively close to disease in a causal chain.” [13] Thus the medical establishment has framed the issue such that both doctors and patients tend to approach breast cancer prevention as an individual level problem – it’s up to individual women to make sure they get regular mammograms and to monitor their individual risk level and their behavior around diet, exercise, and alcohol consumption.
Framing is very important in determining what types of interventions are used to address the problem. The medical establishment tends to frame breast cancer in such a way that leads to “downstream” solutions rather than “upstream” solutions. The money, research, and attention focused on detection, treatment, and finding a cure, greatly outweigh addressing causal factors, such as environmental toxins, which are contributing to the development of the disease in the first place.
The predominant frame described above is reinforced by both public health campaigns and the media. According to Agenda Setting Theory [14], how much the news media covers a particular issue directly affects how important people think the issue is. The media not only reflects the news agenda, but shapes it as well. The media emphasizes mammogram screenings, and to a lesser degree, diet and lifestyle, and thus encourages women to value these same issues. One recent analysis by Michigan State University of news stories covering breast cancer found that 31% focused on treatment, while just 18% addressed prevention [15]. Newspapers, television and advertising offer widespread coverage and promotion of fundraising walks such as the Avon Walk for Breast Cancer and the Susan B. Komen Race for the Cure, which are corporate sponsored and raise money mostly for screening, treatment and finding a cure, while spending very little on primary prevention [7,16].

Environmental factors
One major consequence of the framing of breast cancer as a downstream rather than an upstream issue, is that environmental factors of breast cancer are minimized and under funded. According to researchers at Cornell University, “Because established risk factors for breast cancer account for less than half of all cases, scientists believe environment may play a role in this disease.” [17] And despite the fact that breast cancer research is the most funded of all cancers [18] over the last decade, only a small percentage is spent on environmental links to the disease.
When underlying environmental toxins are addressed, they often point to large corporations, which are responsible for producing harmful chemicals in almost every area of life. These corporations often have a vested interest in continuing to produce these chemicals because of the profits they bring in. The close financial and political ties between large pharmaceutical/chemical corporations and some cancer organizations influence the “anti-cancer” agenda that is promoted. Several progressive organizations such as the Cancer Prevention Coalition, have pointed out that Breast Cancer Awareness Month is completely controlled by Astra/Zeneca, a multimillion dollar donor to the American Cancer Society. Astra/Zeneca is one of the world’s top ten largest pharmaceutical companies, formerly a part of Imperial Chemical Industries, and the producer of Tamoxifen, a drug used in breast cancer treatment and prevention. AstraZeneca retains the right to oversee all of the promotional materials of the awareness campaign and heavily promotes mammograms and treatment – including Tamoxifen – while ignoring links between industrial toxins and breast cancer [19].
Despite the relative lack of funding for research on links between environmental toxins and breast cancer, there is still much that we do know and need to be concerned about. “There are over 85,000 synthetic chemicals on the market, and fewer then 10 percent have been tested for their effects on our health.” [20] The harmful effects of toxins are particularly relevant to breast cancer because many toxins are concentrated in fat and thus breast tissue. And according to the Center for Disease Control and the Environmental Working Group, over 200 chemicals have been found in our body fluids. Furthermore, studies reveal 216 chemicals associated with increased mammary gland tumors in animals [21].
Harmful chemicals reach into virtually every aspect of our lives including our food, air, water, and consumer products. We ingest pesticides and additives in the foods we eat, are exposed to chemicals used in food packaging and production, and are subject to synthetic hormones in milk and meat. For example, recombinant bovine growth hormone (rBGH ) which is given to cows to increase their milk production, has been shown in several studies to contribute to links to increased risk of breast cancer, and has been banned in Europe, Canada and elsewhere. [21]
Plastics, which are used extensively in household products, toys, and electronics, contain many chemicals of concern, such as styrene, bisphenol A (BPA), and phtalates. For example some baby products such as bottles are particularly concerning because they contain a combination of carcinogens, such as vinyl chloride, and several endocrine-disrupting compounds, namely, BPA and phtalates. Cosmetics, including makeup, soap, and sunscreen, are rife with harmful chemicals which may affect our hormonal systems and affect breast development. Some of the chemicals have already been banned in European nations, but are still permitted in the United States. [21]
In sum, young healthy women do not need to undergo routine mammograms and take on their associated risks and resulting unnecessary interventions, all in the name of prevention. Instead, we must address the underlying root causes of the disease, particularly environmental toxins in our daily lives. We need to fund more research on links between environmental toxins and breast cancer, persuade corporations to use more caution in putting untested chemicals into our lives, and demand that our government increase its testing and regulation of harmful chemicals.

An Alternative Approach
So what is a truly effective way to prevent breast cancer among young healthy women? We can focus on changing corporate and governmental practices to remove from our daily lives the environmental toxins that put people at risk for breast cancer. We need to involve and empower young women and others in the population to bring about these changes. It is not enough to recommend that people individually try to avoid toxic chemicals by buying certain consumer products; this is not always possible to do, especially for those with limited income and accessibility. Furthermore, we all deserve to live in a society where we are not exposed to toxins which are known or suspected to increase risk for cancer.
One organization that advocates for this approach is Breast Cancer Action (BCA), a small non-profit organization which often works as part of larger coalitions to make social change. Despite its limited size and budget, it has succeeded in several of its campaigns to change policies. For example, in 2008, BCA’s “Think Before you Pink” campaign, successfully persuaded Yoplait yogurt to change its practices. Yoplait, which is manufactured by General Mills and touted as a “pink” company because it donates money to breast cancer treatment and sponsors the Susan B. Komen Race for the Cure, was producing yogurt from cows treated with rGBH, a suspected cancer-causing hormone. Through an online campaign in which thousands of consumers contacted General Mills in protest, BCA was able to exert enough public pressure to convince the company to commit to sourcing its dairy products from cows not treated with rGBH. After this victory, Dannon yogurt, a competitor, followed suit [22].
Unlike mammography screening, a campaign such as this was safe and effective : there were no medical risks involved for women (though speaking out against the status quo often involves other types of political/social risks.) Women were empowered by taking action, and unlike with mammography, were exerting real control in taking a step to reduce breast cancer risk as opposed to just the illusion of control; the campaign resulted in the actual elimination of the suspected cancer causing hormone from the source of the dairy products.
The Yoplait campaign took a group level approach which enabled change to happen quickly on a large scale, affecting thousands of consumers simultaneously. The campaign also framed the issue as one of primary prevention – targeting the company producing the yogurt, rather than targeting individuals’ buying or eating habits. This is an example of an effective upstream approach.
Finally, by focusing on rGBH, the Yoplait campaign raised awareness of environmental toxins, which not only affected Yoplait, but Dannon as well. Given that these 2 companies represent two thirds of America’s dairy products, it is likely that their change will also affect the practices of farmers, since they will no longer be able to supply these companies with milk unless they stop injecting their cows with the harmful hormone.
We need to continue to launch and expand upon policy campaigns such as the Yoplait example. A current environmental campaign which is in the works and is supported by a coalition of nearly 300 environmental health organizations is the proposed reform of the Toxic Substances Control Act of 1976 [23]. One way to motivate people to join a campaign for changing policy is to emphasize the ways in which women’s freedoms are being threatened by corporations and governmental agencies. According to the theory of psychological reactance, developed by Jack W. Brehm in 1966, as human beings we all need to feel in control of influencing our own environment. When we feel that our ability to be in control is threatened, we will experience “reactance” and resist against whatever is threatening us [24].
We can use this understanding of human psychology to our advantage in crafting a public health campaign. For example, the “Think Before you Pink” campaign used a form of psychological reactance by highlighting the hypocrisy of Yoplait in its giving money to breast cancer organizations while at the same time manufacturing a product thought to increase breast cancer risk. When women learned that they were being used in this way, they likely felt a threat to their sense of control and fairness and were motivated to write to General Mills in protest.
We need to deliver promotional messages to women that show how corporations who market harmful products are taking advantage of the public by profiting off of the chemicals which they produce and similarly, how governmental agencies who design environmental policies are failing to enforce them. As women learn about the way their freedoms are being squashed, they are likely to be motivated to fight back and join a campaign to restore those freedoms. In other words, if women feel like they are being duped, they are likely to take action.
We can make campaigns most effective by using tools honed by the advertising industry, which include making large promises to meet the needs of our target population, supporting these promises and appealing to universal core values [25]. This approach was used very successfully in the late 1990’s by the anti-tobacco Truth Campaign, which significantly reduced smoking rates among Florida youth. The campaign designed commercials, among other tools, aimed at the core value of rebelliousness among youth. They showed young people how they were being manipulated and lied to by big tobacco companies. The campaign promised them the “truth” and opportunities to rebel against the tobacco industry. Youth responded by joining in community activities directed against the tobacco industry and ultimately deterring more young people from starting to smoke [26].
Simon Sinek, a leader from the advertising industry, explains how to create an effective message that will inspire people to action. He describes the “golden circle” of three rings in which the message should start in the center with “why,” your purpose or cause. The “why” relates to universal core values, such as freedom and fairness. (Unfortunately “health” is not as important a core value to most people.) The next outer ring in the golden circle is “how,” the specific actions to take. And the final ring is “what,” the actual results [27].
So, for example, these tools could be applied to the campaign to reform the Toxic Substances Control Act (TSCA). The messages should emphasize the ways in which we are being duped by the law – we have been lead to believe that products brought to market have been tested and are safe, when it fact this is not the case. Thousands of chemicals in the marketplace have never been tested. The message should first introduce the “why” - we want our control back! We don’t want to be manipulated – and joining this campaign will allow all of us to do that. The “how” is to take concrete steps such as contacting legislators, garnering media attention, and raising money. Finally, the “what” is the result that we will all have healthier lives and less risk of breast cancer and other diseases.
In conclusion, in order to prevent breast cancer among young healthy women, we must bring more attention and action to the production, distribution and regulation of environmental toxins in our daily lives. In order to do so we need to inspire the public to put pressure on corporations and governmental agencies which are responsible for the manufacturing and regulation of chemicals. By using lessons learned from the social sciences and advertising, we can effectively mobilize the public to participate in campaigns which are safe and effective and ultimately change policies.

REFERENCES

1. Gray, Janet. State of the Evidence: The Connection Between Breast Cancer and the Environment, 6th Ed, Breast Cancer Fund, 2010.
2. American Cancer Society. Cancer Facts and Figures 2010. Atlanta: American Cancer Society, 2010.
3. American Cancer Society. “Mammograms Matter” 9/14/2010. http://www.cancer.org/Healthy/ToolsandCalculators/Videos/mammograms-matter-video
4. Love, Susan. Dr. Susan Love’s Breast Book, 4th Ed. Cambridge, MA: Da Capo Press, 2005.
5. Edison Imaging Associates. 2009. http://www.njradiology.net/what-is-mammography/
6. U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2009;151:716-726.
7. Susan B. Komen for the Cure. http://ww5.komen.org
8. Cancer Prevention Coalition. http://www.preventcancer.com/
9. Breast Cancer Action. http://bcaction.org/
10. Center for Disease Control. http://www.cdc.gov/cancer/breast/
11. Langer EJ. The illusion of control. Journal of Personality and Social Psychology 1975;32:311-328.
12. Dorfman, Lori, Lawrence Wallace, and Katie Woodruff. More than a message:Framing public health advocacy to change corporate practices. Health Education & Behavior, Vol. 32 (3): June 2005; 320-336. DOI: 10.1177/1090198105275046
13. Link,BG and Phelan, J. Social conditions as fundamental causes of disease. Journal of Health and Social Behavior 1995;35(extra issue):80-94.
14. McCombs, Maxwell.The Agenda-Setting Function of the Press (Chapter 9). In: Overholser, Geneva and Jamieson, Kathleen Hall, eds. Institutions of American Democracy: The Press. Oxford: Oxford Press, 2006.
15. Michigan State University (2008, April 15). Media Coverage of Breast Cancer Focuses Too Little on Prevention, Study Suggest. Science Daily. http://www.sciencedaily.com/releases/2008/04/080415111718.htm
16. Avon Walk for Breast Cancer. www.avonwalk.org
17. Program on Breast Cancer and environmental Risk Factors. Cornell University. 2010. http://envirocancer.cornell.edu/learning/basics.cfm
18. National Cancer Institute. Funded Research Portfolio http://fundedresearch.cancer.gov/search/funded;jsessionid=BC78DC94EFAEDA27F675478235BDB811?action=full&fy=PUB2009&type=site
19. Epstein, Samuel and Liza Gross, “The High Stakes of Cancer Prevention.” Tikkun Magazine, Nov/Dec 2000.
20. Breast Cancer Action http://fundedresearch.cancer.gov/search/funded;jsessionid=BC78DC94EFAEDA27F675478235BDB811?action=full&fy=PUB2009&type=site

21 Nudelman, Janet and Connie Engel. State of the Evidence: From Science to Action. Breast Cancer Fund, 2010
22. Breast Cancer Fund. http://thinkbeforeyoupink.org/?page_id=10
23. Safer Chemicals, Healthy Families. www.saferchemicals.org
24. Dillard, Price James and Michael Pfau. The Persuasion Handbook: Developments in Theory and Practice. Thousand Oaks, CA: Sage Publications, 2002.
25. Siegel, M. and Lotenberg, LD. Chapter 3 in Marketing Social Change: An Opportunity for the Public Health Practitioner, 2nd Ed . Sudbury, MA: Jones and Bartlett, 2007.
26. Bauer, U.E., Johnson, T.M., Hopkins, R.S., and Brooks, R.G. Changes in youth cigarette use and intentions following implementation of a tobacco control program: Findings from the Florida Youth Tobacco Survey, 1998-2000. JAMA 2000; 284:723-728.
27. Simek, Simon. http://www.startwithwhy.com/What/TheBook.aspx

Why the WISEWOMAN Program Needs to Smarten Up: A Critique of a National Cardiovascular Risk Factor Reduction Program- Andrea Pinzon

Cardiovascular disease is the number one killer of women over the age of 25 in the United States, regardless of race or ethnicity. There are over 8 million women living with heart disease, and one in three women have some form cardiovascular disease (1,2) Since 1984, the number of cardiovascular deaths for women has surpassed that for men. Surprisingly, only 13% of women recognize cardiovascular disease as the greatest health issue facing women today (1). Most women believe that breast cancer is the leading cause of death among women, although cardiovascular disease has claimed more lives than all forms of cancer combined (1).
Despite recent advances in cardiovascular medicine that have led to significant reductions in cardiovascular deaths in men, case-fatality rates in women have not achieved as dramatic reductions (3). These gender differences are due in part to differences in clinical presentation of heart disease and differences in diagnosis and treatment of cardiovascular disease (3). Women at risk for cardiovascular disease aged 45-64 are less likely than similarly aged men to receive evidence-based aspirin therapy. Rates of counseling for nutrition, weight management, and exercise are low overall, however, an age disparity is seen, as younger patients are more likely to receive counseling than older patients. Also risk factor screening, like cholesterol screening, are more often offered to men than women, and this disparity worsens with issues of underinsurance or no insurance (4). Socioeconomic status, and the concomitant insurance status, is a fundamental determinant of health status. Low socioeconomic status is associated with worsened cardiovascular risk profile. Socioeconomic status in women has exhibited an inverse relationship with major cardiovascular risk factors, including hypertension, diabetes, high cholesterol, smoking, low physical activity, poor nutrition, and BMI (5-7). Uninsured women are more likely to postpone critical preventive services that insured women (10). In addition, low-income, less educated, uninsured minority women have limited access to health services, which increases the risk for cardiovascular disease morbidity and mortality (7).

Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN Program)
The WISEWOMAN program offers low-income, underinsured and uninsured women with aged 40-64 with chronic disease screening, lifestyle intervention and referral services at a low or cost, in an effort to prevent cardiovascular disease in this high-risk population (8). Through the WISEWOMAN program, qualified women receive testing and educational programs that are supposed to help women lower their risk for cardiovascular risk. If women in the screening program are considered to have a high cardiovascular risk factor profile, follow-up visits and interventions are set up for 6 months and 12-months after the initial screening. WISEWOMAN utilizes programs that they believe help women adopt healthy eating behaviors and encourage women to be more physically active. The WISEWOMAN program was initiated in 1995 and is administered through the Center for Disease Control Division for Heart Disease and Stroke Prevention. Currently only 21 WISEWOMAN programs are offered in the United States, including one in Boston, Massachusetts. These programs are only offered to women who are enrolled in the National Breast and Cervical Cancer Early Detection Program. WISEWOMAN programs use the same framework and tools for to measure behavior and behavior change, with minor changes as needed per region of country and ethnicity (and at times language). Despite the fundamental similarities across the programs, considerable inter-program differences in initial and follow-up screening rates of minorities and in efficacy or effectiveness of interventions on risk factors are still evident (9). These inconsistencies could be due to inherent underlying issues with programs and interventions offered by the WISEWOMAN framework. These underlying issues include use of the Transtheoretical model for behavior change, low commitment and transportation concerns for qualified women, and low reach of program for minority participants.

Use of the Transtheoretical model for behavior change
The health disparity in cardiovascular disease risk across high and low socioeconomic status and ethnicity is well recognized. Minority women of lower socioeconomic status are more likely to have higher rates modifiable risk factors like obesity and overweight and smoking (5,6). Among WISEWOMEN participants, a spatial clustering of high BMI and high smoking is observed in five of the participating states (12). Consequently, BMI is one of the individual characteristics explaining ethnic disparities in the baseline cardiovascular risk factor profiles of the WISEWOMAN programs (12). In order to address these issues and foster healthy behaviors, The WISEWOMAN projects focus on individual models of behavior change, specifically the Transtheoretical model (Stages of Change); In fact, WISEWOMAN is currently federally mandated to spend 60% of its funds on individually oriented interventions (7). WISEWOMAN utilizes the Transtheoretical model in hopes of assessing subjects’ readiness to change in physical activity, smoking, and dietary behaviors and individually tailoring programs to encourage healthy behavior adoption depending on the “stage” the subject is in. However, recent research has shown that the Transtheoretical model is not an optimal tool to use in smoking and physical activity changes. The WISEWOMAN intervention programs have not reported significant changes in BMI, smoking, or blood glucose (13). For the participants, the programs have achieved maintenance of BMI, with average weight loss across programs has been less than one pound, with some programs showing unfortunate weight gain (9, 12). The average reduction in smoking rate among participants across WISEWOMAN programs is 8%. Nonetheless, they rates of change across program are widely spread, ranging from 0% to 50% reduction in smoking (9,13), exhibiting a complete lack of consistency in the Transtheoretical Model across groups. There appears to be no convincing evidence that moving a person closer to action leads to an actual maintained behavior change; in fact, studies have shown the ability to change one’s attitude without affecting any positive change in behavior (14) In regards to smoking behavior, the most effective and successful way to quit smoking is to quit without any proper or previous planning; this holds true across gender, age, and socioeconomic status (15).

Low commitment and Transportation Concerns for qualified women
In congruence with low positive results in cardiovascular risk factor reduction, intervention programs can only be effective if subjects attend the designed intervention sessions. Transportation may play an important role in a subject’s decision about attending an intervention, especially if attendance requires evening travel (16). Utilization of health care tends to decrease as the distance traveled to care increases; transportation barriers to care are associated with reduced compliance to treatment and lower rates of preventive care (17). Transportation issues are more likely to affect vulnerable populations, such as rural residents, and racial and ethnic minorities (17). In a WISEWOMAN survey, many subjects regarded transportation as a major barrier to attending intervention programs. Other factors related to attendance were higher education level, small family size, and having health insurance. The transportation barrier was greater for women living in rural, especially since the 21 programs around the United States are located in major urban cities (16). Among women living in rural areas, younger women were less likely to attend an intervention than older women at any given travel distance. For middle-aged rural women, the probability of attendance falls sharply after the driving distance to the intervention site is greater than 15 miles. This age trend on distance traveled is also seen among women who live less than 10 miles from the intervention site (16).
The transportation barrier to attendance of cardiovascular risk factor reduction interventions was evident in a study conducted in a South Dakota. The WISEWOMAN program was implemented in a South Dakota Women’s Prison along with the general population WISEWOMAN population in the South Dakota. When comparing the two WISEWOMAN populations over a 16-month period, incarcerated women were more likely to attend intervention program sessions than non-incarcerated women in South Dakota. Incarcerated women were more likely to take up the intervention than non-incarcerated women (18). Incarcerated participants attended an average of 2 lifestyle intervention sessions, compared with an average of 0.4 sessions attended by non-incarcerated participants. Intervention completion rates were significantly different among groups, with 42.5% incarcerated women completing an intervention and 3.6% non-incarcerated women completing an intervention (18).

Low Reach for Minority Participants
Racial and ethnic variation in cardiovascular disease risk and cardiovascular disease morbidity and mortality are widely documented in the United States. Differences in cardiovascular risk factors are major sources of the racial disparities (5). Minorities are at higher risk of developing hypertension and diabetes; BMI and smoking are also strongly patterned by race. Black men and women, specifically, have a greater overall cardiovascular mortality compared to similarly aged White men and women (2,5). Not surprisingly, the baseline risk factor characteristics of WISEWOMAN participants mirror the national trends. After controlling for age in eight WISEWOMAN sites, minority participants showed greater rates of hypertension, known diabetes, and higher BMI (7). However, despite the increased cardiovascular risk among women, enrollment and participation rates among minorities were lower compared the rates of non-minority women. In states with a mixed racial population, minority participation rates ranged from 20-30% (19,20). Non-White women participants were also more likely to be lost to follow-up and less likely to return to the 12-month follow-up intervention session (19). A recent meta-analysis of minority participation rates in health research studies showed that minorities do not differ from non-Hispanic whites in consent rates (21), contrary to earlier studies that show a low willingness to participate in minority research subjects (22,23). Low participation rates among minorities may represent a lack of sensitivity in cultural and social norms (23). In WISEWOMAN-participating states with a high proportion of minorities in the source population, higher rates of participation and retention were observed among the eligible minority women compared to other states (10/24). These increased rates of participation can be explained by the incorporation of health service programs that targeted minorities, which involved community health workers (10). The success rates from these states show that in order to increase the reach of cardiovascular risk factor reduction, culturally sensitive programs must be integrated into interventions.

“WISE” Alternatives
WISEWOMAN is a nation wide program with several state sites that is aimed at reducing cardiac risk factors among low-income women. Despite the issues and concerns presented above regarding the WISEWOMAN programs, there may be alternative social science theories that can help address these inherent flaws. WISEWOMAN programs across the country have varying rates of cardiovascular risk factor reduction success among participants. The following theories provide potential options for alternative interventions in problem areas in certain WISEWOMAN sites.
Social Network Theory
As previously stated, five WISEWOMAN state program demonstrated spatial clustering of smoking and high BMI. This fact demonstrates the significance of an individual’s social network. A social network consists family, friends, and anyone with whom a person has close contact on regular basis. Connected persons may share exposures to common environmental factors, experience of simultaneous events, or other common features, like socio-demographic attributes, that may also cause them to share certain behaviors, albeit, unhealthy behaviors, like smoking and low physical activity (25). This suggests that group dynamics better explain adherence to certain behaviors than an individual-level theory like the Transtheoretical Theory.
The existence of social networks means that people and health are interdependent (26). Social networks can also influence the adherence to healthy behaviors. Person-to-Person spread of behavior is not bound by geographic distance; social norms may spread more easily over a distance than a behavioral effect. (25). This observation suggests that by simply changing a subject’s social norms about the acceptability of an unhealthy behavior, that healthy behavior change is more likely to occur. Previous research has shown that successful intervention in underserved ethnic minorities, independent of status, age, or place, should be built into philosophies and cultural practices that mold norms and values of the communities (9). Social norms can be changed by not allowing smoking in certain places, like one’s home, or suggesting to take the stairs versus the elevators when out in public places. For the WISEWOMAN program to exhibit improved behavior changes in the participants, a peer support network may be an important tool to incorporate in the interventions. One kind of peer group could connect participants who have been able to quit smoking or have increased their physical activity with other participants who live near them to influence them to adopt healthy behaviors. Another option would be to meet with one or two members of a participant’s social network to encourage behavior change and to help come up with ideas as a group to help positive behavior adoption.

Framing Theory
Some WISEWOMAN programs suffered from low participation and completion rates of the one-year intervention. The apparent issues with transportation among low socioeconomic status women and distance to the intervention site are unfortunate obstacles to continued commitment. However, an age disparity was observed even controlling for distance traveled. Younger women were less likely to attend or complete an intervention. Although not measured or studied, this lack of adherence to the intervention may be viewed as a lack of commitment to change. Younger women are more likely to be employed and may still have younger children to rear in the home compared to older women. In essence, they may view an outside intervention as a disruption in their daily or weekly flow, for which they may not have the time to spare, when they are trying to provide for themselves and their family. So in order for the WISEWOMAN programs to make the participants understand the importance of cardiovascular risk factor reduction, they would need to re-frame the issue.
Maslow’s Hierarchy of needs describes that people need to have their basic human/physiologic needs (food, shelter, clothing) fulfilled before fulfilling higher level needs, like health. (27) Most women, especially mothers, place the needs of their family and friends before their own needs (27), so employment is an essential part of being able to provide for them. Although healthy people are more likely to be employed, an increasing number of people in the employed population in the United States are either overweight or obese, and more likely to have accompanied cardiovascular risk factors like hypertension, diabetes, and high cholesterol (28). These are cardiovascular risk factors are more prevalent in the middle aged and older working population. These cardiovascular risk factors can cause limitations on work and productivity. The effect of the aforementioned cardiovascular risk factors on work limitations is similar to the magnitude of 20 years of aging (28). Therefore, The WISEWOMAN program should frame the importance of cardiovascular risk factor reduction in a way that helps participants fulfill lower order needs of themselves and their families. WISEWOMAN should frame the issue as the only way to be able to provide food and shelter for their families is if the women themselves are healthy. Cardiovascular health is not solely important for the individual, but plays a major role in their ability to provide basic needs for their family. Participants may then realize that by taking better care of themselves, they in essence, will be taking better are of their family.

Diffusion of Innovations
As previously stated, WISEWOMAN minority cardiovascular risk factor trends follow the trends seen in the general population. Unfortunately, eligible minority women are less likely to enroll in a risk factor reduction program like WISEWOMAN; notwithstanding, minority women who are enrolled in a program are less likely to complete a full intervention. Population groups experiencing disparities in chronic diseases have generally been considered ‘hard to reach’ by public health research because of their lack of responsiveness to health messages targeting younger, White, affluent audiences (29). As previously noted, this lack of participation may reflect a lack of culture sensitivity and inappropriate communication in the program’s enrollment and retainment protocols. Acceptance of any intervention is dependent on how the messages of behavior change are spread and seen by the community.
Diffusion is the process through which an idea is communicated through certain channels over time among members of a social system (30). Diffusion occurs through a combination of the need for individuals to reduce personal uncertainty when presented with new information, the need for individuals to respond to their perceptions about what credible people in the community are thinking and doing with the new information and general social pressure to do as others are doing (30). Any uncertainty about a new idea typically leads to search for information from a trusted and respected source, especially, if the idea is deemed important in terms of having significant consequences for the potential adopter (30). Minorities tend to be very collective societies, with strong traditions and high interdependence on its individual community members for support and survival of the community (29). Many community based health promotion programs using minority ‘community insiders’ have shown great strides in healthy behavior adoptions (29).
The success of this theoretical practice is evident in the Arizona WISEWOMAN program. The Arizona WISEWOMAN population is comprised of a large number of Hispanic women. Arizona’s WISEWOMAN interventions employed the use of Hispanic community health workers and lay health advisors called promotoras. (10) Promotoras act as liaisons between the community and health organizations, bringing information into the Latino communities and often playing the roles of educator, mentor and role model (31). Arizona shows slightly higher rates of intervention completion compared to other states, and the inclusion of promotoras in the intervention programs is associated with increased adoption of healthy behaviors, such as moderate to vigorous physical activity, as well as increased fruit and vegetable consumption among the participants (10). These important behavior changes can have significant effects on the reduction of overall cardiovascular risk and associated co-morbidities. This example reinforces the model that recruiting respected community members, as advocates and role models of healthy behavior changes, is an important facet to diffusing the main objectives of the WISEWOMAN program. Also, WISEWOMAN programs should be cognizant of their participants’ cultural and social backgrounds, (in a feasible manner) in an attempt to identify appropriate community advocates. Respect for the dignity and preferences of potential participants is key (29).

References
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Boykin S, Diez-Roux A, Carnethon M, et al. Racial/ethnic Heterogeneity in the Socioeconomic Patterning of CVD Risk Factors: in the United States: The Multi-Ethnic Study of Athersclerosis. Journal of Health Care for the Poor and Underserved 2011; 22:111-127.
Kanjilal S, Gregg EW, Cheng YJ, et al. Socioeconomic Status and Trends in Disparities in 4 Major Risk Factors for Cardiovascular Disease Among US adults, 1971-2002. Arch Intern Med 2006; 166:2348-2355.
Finkelstein EA, Khavjou OA, Mobley LR, et al. Racial/Ethnic Disparities in Coronary Heart Disease Risk Factors among WISEWOMAN Enrollees. Journal of Women’s Health 2004; 13(5):503-518.
Centers for Disease Control and Prevention. WISEWOMAN: Well-integrated Screening and Evaluation for Women Across the Nation. Atlanta, GA: CDC Division for Heart Disease and Stroke Prevetion. www.cdc.gov/wisewoman/.
Farris RP, Will JC, Khavjou O, Finkelstein, EA. Beyond Effectiveness: Evaluating the Public Health Impact of the WISEWOMAN Program. American Journal of Public Health 2007; 97(4):641-647.
Staten LK, Gregory-Mercado KY, Ranger-Moore J, et al. Provider Counseling, Health Education, and Community Health Workers: The Arizona WISEWOMAN Project. Journal of Women’s Health 2004; 13(5):547-556.
Mobley LR, Finkelstein EA, Khavjoy OA, Will JC. Spatial Analysis of Body Mass Index and Smoking Behavior among WISEWOMAN participants. Journal of Women’s Health 2004; 13(5):519-528.
Yancey, AK. Commentary: Building Capacity to Prevent and Control Chronic Disease in Underserved Communities: Expanding the Wisdom of WISEWOMAN in Intervening at the Environmental Level. Journal of Women’s Health 2004; 13(5): 644-649.
Brownstein JN. Editorial: Addressing Heart Disease and Stroke Prevention Through Comprehensive Population-Level Approaches. Prev Chronic Dis 2008; 5(2): http://www.cdc.gov/pcd/issues/2008/apr/07_251.htm.
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Drop10 ‘Cause It’s Hot- Stephanie Cox

Healthworks is an all-women’s fitness center with locations all throughout the Boston-Metro area. As a high end fitness center it incorporates many different ways of catering to the wants of its clientele, including the utilization of group-based workout regimes in order to increase motivation and bolster commitment from ladies to their health goals. Among these regimes is Drop10, an 8-week progressive program which incorporates a wide range of high-intensity exercises including plyometrics, weight training and cardio, aimed to help ladies shed pounds and tone down.

While this program is an evidence-based workout designed and tested by Healthworks top personal trainers, the methods through which it has been marketed fail to demonstrate a sound understanding of the social psyche and rationale people utilize when making decisions, including those about how to attain their fitness goals. Specifically, the intervention promoting the program fails to first frame the issue from the most optimal perspective. Second, it doesn’t take full advantage of the manner in which the message is delivered and the titanic impact that can translate into. Finally, it lacks an appeal to people’s core values, as well as support that what it promises to do will reinforce those core values.

By critically analyzing each aspect of the current intervention and subsequently applying the proven theories of Framing, Advertising and Communication to make appropriate improvements, Healthworks can more effectively encourage their clientele to take an active approach towards their health goals and to utilize the Drop10 program in doing so.

Intervention- Current Methods of Promotion

The Drop10 Intervention currently utilizes a vast array of methods encouraged by some of the more traditional social science models used for promoting behaviors in public health. For example, the webpage for the program lists expected outcomes and benefits of it, a method supported by the Health Belief Model, the Theory of Reasoned Action and the Social Learning Theory (1-3). All of these theories rest on the premise that behavior is planned and reasoned by people and that to persuade people to change their behavior one must appeal to their reason. These theories all appeal to reason in part by making specific mention of the expected outcomes of a behavior and supporting one’s attitudes about such outcomes. While this can be a beneficial means of informing people about what the behavior change can accomplish, it is not enough to be the primary method of persuasion, which is how it currently stands in this intervention.

Promotion of the program also introduces it, although only briefly, by using a specific group currently enrolled and by providing a personal quote to go alongside the list of expected outcomes. The majority of the video solely focuses on these members performing exercises which are a part of the workout regime. This method of Modeling is also supported by the Social Learning Theory and holds that people will more readily adopt a behavior that they see being modeled (1). This is a belief that is also held by Communication Theory (4) and will be a point of major improvement for the intervention later in this paper. While these current methods can be appropriate means of persuasion for some behaviors and products, the realm of health behaviors is best marketed with an understanding of the social psyche, wherein the irrational nature of people is recognized, appreciated and tapped into as a source of power for persuasion.

Flaw 1- Framing

When trying to persuade people to change their behavior the context in which the issue is framed is of tantamount importance. The intervention for the Drop10 program is currently bereft of any particular frame around the issue, and thus fails to capitalize on this very powerful method of persuasion. By simply listing the facts which are relevant to the program and the expected outcomes of a change in behavior, the intervention is making the false presumption that this is enough to convince people to change their behavior, and also that getting people to change their attitude will result in their change in behavior.

Framing Theory, however, suggests otherwise. Instead of simply presenting people with facts and figures, Framing Theory states that context is crucial in the art of convincing. By setting your argument to be viewed through a specific lens by the client, it allows you to control the initial setting in which they see the issue, as well as the specific information they’re being exposed to. Utilizing the wrong lens through which to view your concept can trigger the wrong response from viewers and be the root cause of the failure of an intervention. Equally just as harmful to your campaign can be the

complete lack of a lens, which is what is demonstrated here. Advertisements and promotions of the program fail to provide prospective clientele with any prepped cues as to how they should respond to it.

Flaw 2- Message Delivery System

The main methods used by Healthworks to spread the message about the Drop10 program is simply the company’s own webpage, an uploaded video clip and posters in the gym itself. While the video does utilize a specific real-world group participating in the program, it fails, as do the other sources of information, to adequately utilize those messengers in delivering the information. The impersonal nature of the webpage and the authoritarian perspective from which it is delivered provide a less than ideal messenger for persuasion. The ideal messenger should be one most similar to the clientele to be persuaded. They should be very familiar, attractive and appealing, helping to aide the client in envisioning how they, too, can become like this person with the help of the product being advertised. The ideal messenger should be able to demonstrate how this program can be easily adopted by the new user and help them attain the promise they desire it to fulfill.

In addition to having a static, impersonal approach through which their message is communicated, the Healthworks Drop10 intervention insufficiently espouses the power of priming and positive labeling(5). It makes no mention to any type or mold that clientele can either identify with or live up to. This is a very powerful tool whose current use is extremely lackluster and dismal. Similar to the art of framing, providing potential

clients with appropriate figures to identify with empowers the marketer with the ability to highlight the type of clientele they would like to attract, as well as control the first images the client associates the product with. Those images should be ones that the client either identifies with already or aspires to identify with. Successful interventions readily make use of these tools and fit them to best match up with the clientele they possess. A failure to do so results in a primary reliance upon client reasoning, which has readily been established as irrational.

Flaw 3- Advertising Theory: Weak promise, no support, no value!

The entire premise of this intervention is that rationality is what governs people’s actions and that simply showing them what they need to do in order to reach their goals will convince them to do it. This is not the case, however, especially when it comes to healthy behaviors. Advertising Theory rests on the basic concepts of promise, support and values, none of which are successfully portrayed in the intervention as it currently stands. 1 A very weak promise is made by stating the expected outcomes of the program, however this promise does not follow the key principles of successful promises as outlined by the Advertising Theory (6); the promise is small in nature and fails to draw any kind of emotional appeal. A weak promise makes for a weak commitment, which is exactly what Healthworks is experiencing with their program. Furthermore, the current intervention insufficiently supports what tiny promise it does offer, but again fails to do

so in an effective way, mainly by offering a low degree of support for the relatively weak core value of health.

The Drop10 intervention makes a meager attempt through video to show what a client has to look forward to as a result of being a part of the group, however it does not go into depth nearly enough to draw meaningful results. Instead of promising clients that they can attain something they want and then showing them how to do it with the use of the program, it makes spiritless claims and provides a scarcity of appeal to the emotionally charged and invigoratingly motivational core values that people more easily identify with and are inspired by.

Finally, the current intervention has chosen to focus on the value of health. While fitness experts may see this as a crucial value to be highly regarded, there are many other core values with which the general population more readily identify with and regard to a higher level, such as security, family, control, freedom, and loyalty (6). People are more successfully compelled to take part in something that they view upholds the values close to them, rather than something backed by simply reason. By choosing to identify their program as one which upholds one or a combination of these core values the Drop10 program will take advantage of this concept upheld by Advertising Theory and thus be more successful in persuading ladies to participate in the program.

Fix It 1- A Matter of Control and Security

As stated, the first improvement that could be made to made the Drop10 program more successful would be to appropriately frame the issue. To use framing properly one must not only choose a frame, but make sure it is the correct frame and solicits the desired response. Choosing the correct frame through which to set the intervention requires the consideration of all of the different frames possible and the core values that underly each particular frame. It also requires a knowledge of the type of people being addressed by the intervention and the values most important to them.

A variety of possible frames exist for such an intervention. The issue could be framed as a physical health/weight loss issues, as a proven workout that gets results and isn’t a waste of time/energy, as a way of ridding the restrictions put on one’s life by carrying extra weight, whether those restrictions be on their dating life, their image, their work abilities, or even their social circles. An array of restrictions can be tied back to one’s weight, especially since society views personal appearance as such a highly regarded and influential aspect of life. But again, it is crucial that the appropriate frame is chosen and that the desired outcome can consistently arise from it.

Healthworks women are women of power, women of confidence, and women of action. Thus, these women focus on the core values of security, control, and freedom. I propose that Healthworks frame the Drop10 program as a program that aides already confident ladies in shedding any of the current restrictions they’re experiencing in their life by shedding their extra weight. Such restrictions can be exemplified by any of the previous examples, or as a combination of such, although demonstrating restrictions on one’s image or work abilities might reach the greatest number of clientele, as these can be problems faced by women of all ages at any point in their lives.

By framing the issue as one wherein their current status, power or confidence is threatened you can motivate more ladies to act in furthering the resistance of this threat. Framing the issue as one wherein their freedom and security is currently threatened allows the intervention to appeal to their emotional sense and desire to act on the situation. Further showing the issue as one wherein they have control over the presence of the very thing which is threatening these core values (the restrictions on the various aspects of their lives) will motivate women exposed to the intervention to participate in the behavior change and take back control over these areas of their lives as a result. The Illusion of Control theory suggests just this as it explains that people are more likely to participate in a behavior when they perceive to have control over it (8). Furthermore, successfully encouraging people to change their behavior first allows their attitude change to follow.

Framing this issue as such also allows proponents of the program to exemplify a proper response by a current Healthworks member. In understanding the Healthworks women are active, positive and powerful, it would be appropriate to prime those exposed to the intervention with related cues. For example, a strong, powerful woman carrying a few extra pounds could respond to the threat those pounds pose on her work or social environment, or on her personal image, and could view that as an opportunity to take an active role in shedding those pounds with the help of the Drop10 program.

Fix It 2- Don’t Shoot, but Do Change the Messenger

Instead of using the static and impersonal methods of delivery currently employed, the Drop10 program would benefit from revamping the primary ways of delivering their message, a concept backed by Communication Theory. This theory holds that the most important factor in trying to persuade someone to do something is who is making the request or sending the message in the first place (4). This concept is also backed by the Diffusion of Innovations Theory (9), wherein one of the key clusters of influence surrounding the rate of adoption of an innovation is the people who are currently using the innovation and the characteristics they possess and represent. Thus, by correctly identifying characteristics the target audience values, an effective method of delivery of the information can be attained by subsequently choosing a messenger which embodies these characteristics and is more similar to the client, rather than authoritarian in nature.

Communication Theory advocates that the messenger be believable, attractive or appealing, and familiar (4). Possible messengers, therefore, include current Healthworks women themselves who have gone through the program, popular media figures from the community (or their wives, as this is an all women’s center), or other Healthworks members who are directly connected to prospective clientele. Drop10 could be advanced by taking this messaging a step even further, and making direct consumer messaging as a means to get information about their program out. Encouraging and incentivizing current members to bring their own friends into the network and act as advocates themselves can have a tremendous impact on the

effectiveness of the message and subsequently the rate of adoption, a concept further upheld by Social Network Theory (10). By choosing messengers such as the aforementioned, prospective clients are able to envision how this program can affect them personally and can demonstrate how the program can be adopted by them.

Fix It 3

In order to remedy the lack of promise, support and value utilized in the current intervention strategy the program should first recall the core values most important to their prospective clientele. As previously stated, these values include security, control and freedom. Therefore, as with framing, the promise made to clients should be closely knit with these core values and really strive to be as strong and emotionally compelling as possible (7). Possible promises could be that participating in the program and losing ten pounds will help you regain control over seemingly shaky areas of your life, whether they be professional, social or personal, or that participation will help you build freedom in your life by shedding the stigma and the physical and psychological restraints that comes with carrying extra weight. Support for these promises could easily be provided through the use of imagery and music.

Due to the compounded problem with health change behaviors in that the benefits are not immediately seen, a successful intervention also requires either a lot of mind games capitalizing on other benefits to be had from the behavior change, or getting the person to commit from the beginning to the behavior change for a long enough time to be able to actually see results. The easier and more effective route of these two methods would be to present the benefits of a behavior change that can be immediate. Immediately after you join Drop10 you will be able to identify with the strong, powerful women of the Drop10 program that don’t just sit back and expect good things to happen but are willing to work for them, and work hard. Immediately after you join you can meet your group trainer and how they can inspire you to be proactive towards the commitment you just made. Immediately after you join you can have more confidence in your own ability to change things because you’ve already taken the first step to change yourself by making the commitment to yourself and to the program.

All of these immediate promises are strong mental and emotional motivators that will encourage people to act more than telling them they can drop ten pounds till you’re blue in the face. Again, they can be successful by being demonstrated to the prospective client and backed by strong support possible through video and music. By providing clients with a large promise that connects to the core values held closest to their care and supporting it with effective images and sensory inputs, the Drop10 program can effectively utilize Advertising Theory to market their program.

Conclusion

By critically analyzing each aspect of the current intervention and subsequently applying the proven theories of Framing, Advertising and Communication to make appropriate improvements, Healthworks can more effectively encourage their clientele to take an active approach towards their health goals and to utilize the Drop10 program in doing so. Successful application of these theories would lead marketers to frame the issue as one wherein a lady’s current status, power or confidence is threatened by bearing the burden of carrying extra weight, a problem which the program is successful at addressing, by utilizing messengers who are similar to the prospective clientele more effectively, and by making a promise that this program is one which can provide security and reinstate freedom and control to a woman’s life that is validated through effective support.

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