National Social Marketing Centre

In the light of the scoping research findings, it was agreed that the strategy for the project should be a mix of communication, community-based and service-led initiatives to ensure that the target audience are made aware of the importance of breast awareness and prompted and facilitated to change their behaviour.

Communication initiatives

Objectives

1. To provide women with a compelling case for regularly checking their breasts and reporting any changes to their GP as soon as possible.
2. To provide women with the information they need to enable them to check their breasts and identify the changes requiring further investigation; and where they can go for further help and support.

Key messages

• Early breast cancer diagnosis results in simpler and more effective treatment and increased survival rates.
• Take control of your health - being breast aware significantly reduces your risk of dying from breast cancer.
• It's quick and easy to be breast aware and can be incorporated into your everyday routine.
• Being breast aware gives you peace of mind.

Tone

• Positive and empowering with a focus on the benefits of being breast aware.

Activities

• Poster advertising in outdoor, health and community settings
• Information leaflet distributed to pharmacies, GP surgeries, pubs, hairdressers, and other community venues
• Direct mail - letter and information leaflet sent to all women aged 35-50 on the PCT practice list
• PR using local media
• Breast awareness website linked to the PCT and Council websites

Community-based initiatives

Objectives

1. To provide women with the opportunity to learn about breast awareness from their peers.
2. To provide women with an opportunity to learn about breast awareness, alongside other health issues, through informal face-to-face contact with health professionals.

Activities

• Breast awareness ‘community champions' recruited from the local population.
• Free ‘well women' event co-delivered with other local health and community stakeholders.

Service-led initiatives

Objectives

1. To provide health professionals with the knowledge and resources they need to inform, encourage and support women to be breast aware.
2. To build breast awareness into service delivery to ensure its systematic inclusion in all relevant primary care appointments.

Activities

• Breast awareness training for practice nurses, health trainers and community development workers
• Inclusion in GP contracts to ensure that breast awareness is routinely raised and discussed during cervical screening and family planning appointments (long-term activity)

The scoping stage of the project comprised of desk-based research, interviews with key stakeholders and primary research with the target audience. The primary research was conducted in two stages, with stage one being designed to generate insights to inform the development of the interventions, and stage two to test creative concepts and ideas for the community-based initiatives.

Desk-based research
Desk-based research was carried out in Summer 2008 to provide an overview and analysis of current secondary research and what is known from the evidence base of social marketing and other work. The research reviewed a wide range of literature on breast awareness, breast screening and breast cancer, and focused on gathering information on the target audience, current UK policy, and examples of good practice.

Qualitative research with target women
Primary research was conducted with women aged 35 to 50 years old living in Ashton Hurst (intervention area) and Denton South (control area). The aim of the research was to explore:

• Their knowledge, behaviour and attitudes around breast awareness
• Current and potential providers of breast awareness advice
• What might motivate women to be breast aware on an on-going basis
• Opportunities for disseminating information about breast awareness and raising overall awareness

Two focus groups were conducted with six to eight members of the public and 15 women were interviewed, either individually or as part of a friendship pair. All were from D and E socio-economic groups. The majority of the women were of White British origin and a small number were from BME communities, primarily Asian.

Interviews with stakeholders
20 in-depth interviews were conducted with key stakeholders to examine and define the issue of breast awareness in Ashton Hurst. The following professionals were interviewed:

• 4 GPs
• 1 practice nurse
• 1 practice nurse coordinator
• 2 Macmillan nurses
• The lead nurse at the Centre for Sexual Health
• The Associate Director of Health Improvement
• The Neighbourhood Partnership Manger for Smallshaw and Hurst
• The manager at Rosehill Children's Centre
• 1 locality lead for Health Improvement
• 2 community health development workers
• 1 workplace Health Improvement officer
• The manager of the health trainer programme
• 1 health trainer
• 1 Weight Matters trainer
• 1 health improvement practitioner (diet and nutrition)

Concept-testing and pre-testing
Two focus groups with target women and a stakeholder workshop were held in December 2009 to gather views on the creative concepts and possible initiatives designed to inform and support women to become breast aware.

As the creative concepts involved women who were partially-clothed, they were tested with a number of Community Development Workers from a BME background to check if they might be inappropriate or offensive to certain ethnic groups.

Baseline survey

• Knowledge and awareness of the risks of developing breast cancer are low. The majority of respondents were unclear about breast cancer incidence levels and believed levels to be higher than they are. The majority of respondents did not make the association of risk and increasing age.
• Nearly half of the women surveyed do not follow NHS guidelines, which advise examining your breasts at least once a month.
• Breast awareness is largely associated with finding lumps and the majority of women did not mention ‘feeling', ‘appearance' and ‘nipple abnormalities' as changes they would be concerned about. This could be cause for concern as 65% of women believe they know how to examine properly and around 75% are confident they would notice a change, suggesting that women don't have full correct knowledge about breast awareness.
• Women's knowledge about breast awareness comes from a variety of sources and a combination of influences rather than one particular source. Women's personal and social worlds play a large part in influencing their breast awareness behaviour, with friends and family having significant influences, as well as the media.
• The majority of women had not been offered advice on breast awareness or breast screening in their GP surgeries.

Qualitative research with women
The findings from the primary research with women were largely consistent with previous research:

• All participants were aware of the dangers of breast cancer and knew they should be checking their breasts and why.
• All knew they should look out for lumps, although few were aware of the other changes to look out for.
• Most said they checked their breasts, but infrequently and were probably doing it incorrectly.
• There was an active appetite for promotion and education around breast awareness.

With regard to breast awareness, the women interviewed fell into three different segments:

1. Have no understanding of what it means to be breast aware
2. Understand breast awareness to mean seeking medical advice if a lump is detected
3. Have a good understanding of what it means to be breast aware

The following barriers to breast awareness were identified in groups 1 and 2:

• Fear of finding breast cancer
• Do not see the benefits of being breast aware - Do not know how much easier breast cancer is to treat if detected early
• Fatalistic view - Do not believe that they can make a difference to the outcome
• Not a high priority - Other issues are more pressing
• Lack of confidence in their ability to self-examine - Unaware of the change in advice from systematic breast self-examination to the more simple breast awareness
• Do not know what they are checking for - Do not know that breast cancer can present itself in forms other than a lump
• Do not want to bother their GP - Don't find their GP approachable and may be embarrassed.

Qualitative research with key stakeholders

• All of the nurses interviewed had an accurate understanding of what it means to be breast aware.
• The GPs interviewed had a basic understanding, in particular the importance of seeking medical advice as soon as an abnormality is detected.
• All of the other professionals interviewed had a basic understanding of breast awareness, which had been acquired through personal experience rather than professional training.
• None of the professionals interviewed were spontaneously aware of the breast awareness code, but all were very positive about it when it was read out to them.

Current and potential channels for providing breast awareness advice

• GPs report that they give lifestyle advice opportunistically, as time permits, but do not routinely offer advice about cancer or cancer prevention, but will answer questions if asked. All women involved in the research were registered with a GP and some were regular attendees due to conditions such as allergies, asthma, back pain and arthritis. Some women said they felt uncomfortable asking their GP for lifestyle advice, mainly because they did not think they had enough time, and preferred to ask the practice nurse.
• Practice nurses report giving lifestyle advice, including advice about being breast aware, at every opportunity, e.g. during Well Women consultations; when discussing the contraceptive pill or HRT; and during cytology appointments. Most of the women interviewed said they are happy to see their nurse instead of the GP when appropriate. Some even preferred to see the nurse and considered them to be the most appropriate person to give breast awareness advice.
• Macmillan nurses only have contact with breast cancer patients and their relatives unless invited to give a talk at schools, GP practices or other organisations. The Macmillan Cancer bus, which offers breast awareness advice, tours the country and stops in the area once a year.
• Health trainers see people for one-to-one and group sessions and offer advice on a wide range of lifestyle issues, such as smoking, diet, alcohol and stress. Some of the trainers might give out leaflets about cancer, as appropriate, but they don't provide information about being breast aware.
• Mobile unit/stand/workshops are unlikely to be visited by women if they're unsure what they are about or if they are prominently associated with breast cancer.
• In the community - Most of the women involved in the research said they were amenable to receiving health messages from sources other than health professionals and in places other than their GP surgery, e.g. in the workplace or locally at a community centre. Women from BME groups were more likely to be involved with community-based organisations and felt they would be a good way of reaching the audience.
• Media channels - Women regarded the following to be most effective: advertising on outdoor poster sites and in health and community settings; a letter and leaflet from their GP; and articles in the local newspapers.
• Promotional items - Women thought the most appropriate promotional items were those that could be used when washing, such as shower gel, soap or moisturiser, or a tag to hang in the shower featuring the breast awareness code.

The short-term aims of the three-month pilot project are to:

• Increase the number of women aged 35 to 50 in Ashton Hurst who are aware of their breasts and who examine them regularly.

The longer-term aims of the project are to:

• Increase the speed at which women report an abnormality to their GP.
• Increase the number of women who attend breast screening from aged 50.
• Increase the number of GPs, practice nurses and community workers that routinely and systematically inform, encourage and support women to be breast aware.

In order to establish a baseline from which to evaluate the project, a prospective case-control study was designed comprising two waves of fieldwork. A questionnaire survey was developed to assess: women's current knowledge and awareness of the risks of breast cancer; their current self-examination practices; and their knowledge of and attendance at breast screening. Ashton Hurst ward has been selected as the intervention area, while South Denton (which is comparable in age structure, deprivation and urban/rural mix) has been selected as the control ward.

A ‘pre' survey was administered between April and June 2009 in both intervention control areas, before any of the interventions were launched. A follow-up ‘post' survey is planned for May-June 2010 in both intervention and control areas, after completion of a three-month pilot phase.

The target audience for the project is 35 to 50-year-old women living in Ashton Hurst, particularly those who have little or no understanding of breast awareness. This group has been identified for the following reasons:

Geographic segmentation
The Ashton Hurst ward has been selected for the interventions as it is one of the most deprived communities in the PCT and both breast screening uptake and breast cancer survival rates are particularly low.

Demographic segmentation
Women aged 35 to 50 from DE socio-economic groups have been selected as they are pre-breast screening age and late presentation is a particular issue amongst more deprived women.

Mosaic segmentation
Analysis using the Mosaic lifestyle segmentation tool identified three key Lifestyle Groups with a sizeable population in Ashton Hurst that fit the demographic segmentation outlined above:

• G - Municipal Dependency
• D - Ties of Community
• H - Blue Collar Enterprise

Behavioural segmentation
The primary research indicated that the target women can be segmented into three distinct groups with regard to ‘breast awareness':

Group1: Do not check their breasts and least likely to present to a health professional if an abnormality is detected

• Have no understanding of what it means to be breast aware
• Unlikely to know what is normal for them
• Associate being ‘breast aware' with breast cancer
• Unlikely to detect an abnormality

Group 2: Might check their breasts, but not consciously or regularly, and only likely to present to a health professional if a lump is detected

• Understand breast awareness to mean seeking medical advice if a lump is detected
• Expect an abnormality to present in the form of a lump
• Unaware of other abnormalities associated with breast cancer
• Unlikely to present to a health professional if an abnormality appeared in another form

Group 3: Check breasts regularly and likely to present to a health professional if an abnormality is detected

• Have a good understanding of what it means to be breast aware
• Likely to know someone who has had breast cancer or received treatment for an abnormality in the past
• Understands that outcomes are better if detected early

The interventions are developed to target groups 1 and 2, but group 3 are being used to spread their knowledge and behaviour throughout the community.

To create an attractive ‘exchange' between the target audience and the intervention, the benefits of being breast aware need to be maximised and the costs minimised. A number of barriers to breast awareness were identified during the research and the intervention aims to address these perceived or actual obstacles:

• Lack of knowledge of the symptoms: Promoting the breast awareness five-point code consistently to give the audience a full understanding of how to check, what to look for and why to act fast.
• Lack of confidence in their ability to self-examine: Emphasising the flexibility and ease of becoming breast aware and providing clear written and face-to-face advice to give the audience the confidence they need to become breast aware.
• Fear of finding breast cancer: Emphasising that breast awareness is about early detection, and early diagnosis and prompt treatment can improve survival rates to give the audience peace of mind.
• Do not believe that they can make a difference to the outcome: Promoting the message that being breast awareness can save your life to give the audience the feeling that they have control over their health.
• Do not want to bother their GP: Training for and engagement with GPs to offer advice and reassurance to their patients about breast awareness. Encouraging women to speak to their practice nurse or a community worker about breast awareness, rather than their GP.

In developing the intervention the following ‘competition' to breast awareness were addressed:

• Busy lives
  Many of the target audience have very full lives looking after their families and working outside of the home. The amount of time they have for themselves is limited and many women claim to be too busy to check their breasts. To overcome this, the interventions focus on how quick and simple it is to be breast aware and that it can be easily incorporated into everyday life.
• Other health issues more pressing
  Many women in the target audience lead unhealthy lives and are likely to smoke, drink and be overweight and, possibly, have other medical conditions to deal with. It is likely that addressing these issues will be a priority over breast awareness. The project aims to overcome this by encouraging healthcare and community partners to deliver breast awareness advice and support alongside other health interventions.
• Other breast cancer messages in the media
  Breast cancer receives a lot of media coverage and many organisations working in the field compete for women's attention for fundraising and health promotion purposes. The project has learned and capitalised from those that engage well with women (e.g. using existing breast awareness materials from Breast Cancer Care) and worked with those operating locally who share similar goals (e.g. employing a Macmillan nurse to deliver training to health and community workers).

The Health Belief Model was considered during the development of the interventions. This model is based on the belief that a person will act to prevent ill health if:

• They think they are susceptible to the health problem
• The consequences of the health problem are considered sufficient to warrant action
• They are confident they can do the action required
• The benefits of taking the action outweigh the costs
• There are adequate prompts or cues to act