Breast cancer is the most common cause of cancer-related death among women worldwide, with more than 1 million women diagnosed and more than 500,000 deaths from breast cancer each year.1, 2 Although breast cancer incidence is lower in developing countries when compared with the US, the mortality is often much higher.3, 4 To reduce the serious disparity in breast cancer mortality in limited-resource countries, efforts must be taken to promote early detection and the delivery of the best available treatments and support for breast cancer. Strategic health communication can perform an important role in achieving these goals. This article examines strategic health communication factors in developing and implementing effective evidence-based, economically feasible, and culturally appropriate interventions to improve breast cancer outcomes that can be applied in nations with limited healthcare resources.
Strategic health communication is a critical component of healthcare that should be implemented across the continuum of care. Recognizing the importance of communication strategies and incorporating such strategies into healthcare policies, programs, and interventions is essential to the effective delivery of breast cancer care. The authors reviewed relevant literature and suggested practical evidence-based strategies for effective communication interventions across the continuum of care for breast cancer patients, including early detection, diagnosis, treatment, survivorship, palliative care, and end-of-life care. Examples were provided from limited-resource nations to support health communication recommendations. Cancer 2008;113(8 suppl):2331–37. © 2008 American Cancer Society.
Communication Across the Continuum of Care
Health communication is an essential component in each phase of the continuum of cancer care.5 Strategic health communication campaigns for breast cancer prevention that use multiple channels of communication can be used to effectively disseminate relevant information regarding breast health risks to vulnerable populations and encourage adoption of health-promoting behaviors (such as good nutrition, regular exercise, weight management, moderate intake of alcoholic beverages, smoking cessation, and minimizing contact with known carcinogens) to reduce these risks.6–12 Communication campaigns should be designed and implemented using persuasive communication strategies based on local social, cultural, and economic factors, and should include an analysis of the health beliefs, values, and orientations of the target audience.5
In limited-resource countries, communication campaigns to promote early detection of breast cancer are needed to encourage participation in regular breast cancer screening activities.13, 14 Early detection of breast cancer has been shown to improve outcomes from breast cancer treatment.15, 16 Cultural, economic, and technological factors often minimize participation in screening procedures by those at high risk for breast cancer.17–20 Communication campaigns to promote early detection of breast cancer must be designed to address the unique constraints of a population that influence participation in cancer screening activities. Constraints may include cultural norms of modesty that may discourage women from seeking breast cancer screening, lack of familiarity with and distrust of the modern healthcare system, and/or socioeconomic factors that may make it difficult for women to travel to clinics where they can access breast cancer screening services.21, 22
Accurate diagnoses of breast cancers depend on effective communication between healthcare providers (eg, primary care physician, pathologist, radiologist, oncologist, nursing staff), as well as between providers and patients. Strategic communication is needed to gather, analyze, and interpret relevant symptom and laboratory test data, as well as to sensitively report diagnostic results to patients.5, 23 Significant impediments in communication at any step in the process can lead to delays in breast cancer diagnoses, resulting in late-stage presentation of breast cancers, when these cancers are most difficult to treat.24, 25 Impediments can include poor or insensitive communication skills of providers. Efforts must be made to develop effective communication strategies for gathering and analyzing relevant diagnostic data, and delivering diagnostic results to consumers in the most meaningful and helpful ways.23
Communication is an important component of breast cancer treatment. Treatment of breast cancer is a complex process that depends on effective communication between providers and patients (and often with patients' family members and support networks) for successful outcomes. Active patient participation in treatment decision making has been shown to significantly enhance health outcomes, increase patients' sense of control over their care, and improve overall satisfaction with care.24–29 Effective communication can be challenging, especially when healthcare providers need to deliver difficult treatment options and results (bad news) to their patients.30, 31 These challenges are exacerbated in developing countries where there are often limited resources, personnel, and technologies available for cancer care.32 Developing strategic health communication policies, programs, and interventions across the continuum of care is essential to maximizing the effectiveness of cancer care treatment.23
Sensitive and timely communication is essential for effective cancer survivorship.23, 33, 34 There are currently approximately 11 million cancer survivors in the US and many more worldwide, with the numbers of cancer survivors increasing.35, 36 Cancer survivors report poorer health, lower quality of life, lost productivity, and many health limitations; they are also at risk for reoccurrence of cancer, with 10% of all new cancers diagnosed in survivors.37, 38 Cancer survivors often have significant unmet health information needs, based upon the many uncertainties they face. They have many questions, including how to prevent reoccurrence (and fear of reoccurrence); how to manage health problems and side effects from cancer treatments; whether to seek additional treatments, or use supplements or alternative therapies; how to reintegrate into their personal and professional lives after cancer treatment; and how to cope with challenges to their mortality.39, 40 Communication regarding quality of life, relief of pain and suffering, and coping with end-of-life issues need to be addressed for cancer survivors, especially in limited-resource countries in which there may be few formal sources of health information, palliative care, and social support for cancer survivors.41, 42
Culturally Sensitive Health Communication Strategies
It is important to develop culturally sensitive health communication programs and policies, especially in limited-resource countries.43, 44 Culture frames the social norms, beliefs, values, and languages that healthcare consumers use to respond to and communicate about breast cancer.45 There are multiple cultural groups in any population or country, and each group influences the way members interpret and communicate about health and illness.46 Any single set of health communication practices is not likely to work equally well in different countries. For example, health communication programs that are appropriate and effective in the US may be ineffective and inappropriate if used in Brazil, Cambodia, or Indonesia. Interventions need to be guided by in-depth analyses of the unique culturally based communication features of each country or target population and should have a measurable evaluation component when possible.
An example is seen in the Prashanti Cancer Care Mission program developed in Pune, India.47 The target audience was segmented into key homogenous groups based on religion; literacy and education; financial status; castes; status as urban, semiurban, or rural; language of communication; and relevancy. With greater than 415 languages spoken, a multilingual approach was required. Other cultural differences were addressed, including education level and interests. For example, highly educated women scientists were presented a combination of facts and statistics related to breast cancer, molecular targeted therapies, trastuzumab (Herceptin), and specific biomarkers; whereas women who came from protected backgrounds and were high school educated were given a more basic educational program, using posters, power point presentation, and leaflets adapted to their languages, needs, and beliefs. Culture-specific visual images for posters were gathered from classical Indian art forms to present culturally acceptable images of women, breasts, and torsos using tree spirits and deities from sculptures. Using these art forms to present the breast as integral to a woman's feminine, maternal, sexual, biologic, physical, emotional, and spiritual reality provides a grounding in the cultural ethos of the community and hence mitigates aversion and uncomfortable reactions.
Communication and Social Support
The provision of social support has been shown to be an effective communication strategy for moderating many negative psychological reactions to breast cancer, and helps promote psychosocial adaptation, such as reducing cancer-related pain and suffering, encouraging participation in cancer prevention and control activities, and coping with end-of-life concerns.48–51 Social support can be provided to cancer patients by healthcare providers, family members, friends, and peers who experience similar healthcare challenges.52–54 The ability to provide meaningful social support depends on the communicators' abilities to engage in sensitive and empathetic interpersonal communication. Research suggests that peers who share similar experiences with breast cancer (often in online support groups) are particularly rich sources for social support.55, 56 In limited-resource countries it is particularly important to develop programs that facilitate access to relevant sources of social support to promote adaptation to the stresses of breast cancer. Strategic health communication programs that promote effective breast cancer survivorship should provide opportunities for participation in social support networks.
Interpersonal interaction between patients and healthcare providers is a primary channel for health information regarding breast cancer.26, 49, 57 Both healthcare providers and consumers need to share relevant health information. Providers depend on gathering full and accurate information from their patients about symptoms, health behaviors, and psychosocial responses to cancer.5 Patients need the most accurate and up-to-date information concerning breast cancer diagnosis, treatment, survivorship, palliative care, and end-of-life issues. In general, patients consider their physicians to be preferred sources for such information.29, 43, 58 Effective patient-provider communication can encourage patient cooperation (compliance) with treatment recommendations.57, 59 Sensitive and culturally competent communication strategies are needed to ameliorate the significant differences in cultural backgrounds (such as age, education, socioeconomic status, sex, and national origin) that often exist between patients and providers.45 Similarly, competent interpersonal communication among interdependent healthcare providers (physicians, nurses, therapists, pharmacists, and other professionals) who are part of the breast cancer treatment team is essential for coordinating effective breast cancer care.60
Family/social network communication
The family is a primary cultural unit for health education across most countries despite the level of economic development, and helps establish culturally engrained beliefs about health and illness.61 Family members and friends are significant sources for health information that can influence cancer prevention, control, and care activities.45 Family members, especially in many limited-resource countries, often provide needed home care to spouses, parents, and children with cancer. Strategic health communication efforts in limited-resource countries must include educating key family members and friends about ways they can serve as advocates to help support the health information needs of those with breast cancer.
The social networks that healthcare consumers have within their local communities are very powerful influences on health beliefs and health behaviors.62 Local opinion leaders have high credibility and are often ideal sources for delivering and reinforcing breast health messages.45 For example, in Malaysia, local folk healers known as “bomos” are potentially important health information sources for many women, if bomos are educated regarding the latest relevant breast health information.46 However, health promoters have found that significant time and resources are often needed to identify and develop relationships with key community leaders within at-risk communities in limited-resource countries.61–63 To maintain changes in health behavior over time, it is important to develop broad community support.64 For example, although it is good to encourage women to engage in recommended mammography screening, it is even better to build local social policies and programs within the communities where these women live to support mammography services. However, it is not productive to encourage women to seek early detection, diagnosis, and treatment of cancer when they have limited access to care, which is a reality in many developing countries.3 Community engagement in breast cancer awareness and prevention in low-income countries is needed and should be part of an overall strategic health communication strategy to enhance breast cancer prevention, early detection, and access to care.64, 65
Communication Campaign Interventions
Strategic communication campaigns help influence health behaviors at the group, community, and population levels.64 They have been used to decrease the prevalence of smoking, to increase consumption of fruits and vegetables, and to increase adherence with recommended cancer screening recommendations.66 For campaigns to be most effective they must be carefully targeted to meet the unique needs and communication orientations of the targeted audience in limited-resource countries.67–69 Data regarding target audiences should help identify relevant consumer characteristics and guide message design.63 Messages should appeal to the central beliefs, attitudes, and values of targeted audiences, and use familiar and culturally acceptable language, images, and examples. Messages should be disseminated by familiar, credible information sources, and build on well-accepted cultural beliefs and values. For example, a campaign strategy for promoting breast cancer screening for Islamic women in countries such as Pakistan, Lebanon, or Libya might emphasize woman-friendly Islamic tenets such as prevention and individual responsibility for health promotion by following good habits, because this is a cultural belief that strongly supports breast cancer screening, while minimizing potential cultural barriers such as sex, patriarchy, marital, and modesty issues that might inhibit screening for breast cancer.70, 71
Redundancy and reinforcement are effective communication strategies that use multiple, overlapping messages to enhance message exposure and impact.72 Multiple messages can help to capture audience attention, reinforce message content, and illustrate key health education concepts. Campaigns should use visual and dramatic imagery that is attractive to specific target audiences and can reinforce message content, considering the health literacy of the audience and problems with numeracy that make it difficult to understand complicated text, statistics, and numerical risk estimates.73
Developing media partnerships
The media can be a powerful communication outlet about breast health in both limited- and high-resource countries.18, 23 Breast health promoters need to persuade media producers (print, online, television, radio, film, etc) that breast health issues are of concern to their audiences and provide relevant stories and supporting materials concerning breast health. Entertainment education, such as the use of serial radio programs, novellas, and dramatic performances, has been shown in many limited-resource Latin American, African, and Asian countries to be a powerful medium for disseminating influential health information.74, 75 Television is a well-utilized source for cancer-related information in more developed nations, particularly by low-income, low-education, and low-literacy groups who often suffer from serious disparities in cancer outcomes.58
Health promoters need to pitch specific stories to media outlets that will be of interest to audiences in a way that is easy for media producers to use. For example, to promote news coverage about key cancer issues, the National Cancer Institute's Press Office has developed cancer education training programs for journalists, and has provided easily accessible updated information about breaking cancer news online (available at: http://www.cancer.gov/newscenter/ accessed on June 8, 2008) with news summaries, direct quotes from subject experts, and geographically relevant statistical information that could easily be used in news stories. Similarly, the Centers for Disease Control and Prevention has established a cooperative agreement with the Hollywood Health and Society Program to encourage the development of dramatic programs for television, radio, and film concerning important health issues.76 Similar collaborative strategies for working with local media producers in limited-resource countries can be used to enhance media coverage of breast health issues.
Implementing public policies for cancer communication
To be effective, health communication interventions need to be carefully planned, based on research evidence, strategically designed, and carefully implemented and refined over time based on evaluation of outcomes, especially in limited-resource countries. National, regional, and international policies for breast health promotion are needed to guide effective health communication efforts. Healthcare providers and consumers need to develop culturally sensitive communication competencies for sharing relevant information and coordinating efforts. Healthcare delivery systems need communication strategies and resources to promote breast health. Breast health promoters should plan communication interventions that use key media and present accurate and persuasive information via the most influential communication channels. An evaluation component should be included to help refine future communication strategies. For example, it is important to formally assess through formative and summative evaluation research the costs and potential benefits of cancer prevention and control interventions to make sure that limited resources are effectively used.5, 23, 63, 64 This is a process that holds great promise to reduce the burden of breast cancer in limited-resource nations.
Funding for the BHGI, 2007 Global Summit on International Breast Health-Implementation and Guidelines for International Breast Health and Cancer Control-Implementation publication came from partnering organizations who share a commitment to medically underserved women. We thank and gratefully acknowledge these organizations and agencies for grants and conference support: Fred Hutchinson Cancer Research Center; Susan G. Komen for the Cure; American Society of Clinical Oncology (ASCO); US National Cancer Institute, Office of International Affairs (OIA); American Cancer Society; Lance Armstrong Foundation; US Agency for Healthcare Research and Quality (*Grant 1 R13 HS017218-01); US Centers for Disease Control and Prevention, Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion; American Society of Breast Disease; Oncology Nursing Society; US National Cancer Institute, Office of Women's Health (OWH); and US National Institutes of Health, Office of Research on Women's Health (ORWH).
*Funding for the 2007 Global Summit on International Breast Health—Implementation was made possible (in part) by Grant No. 1 R13 HS017218-01 from the Agency for Healthcare Research and Quality (AHRQ). The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations suggest endorsement by the US Government.
We thank and gratefully acknowledge the generous support of our corporate partners through unrestricted educational grants: Pfizer Inc.; AstraZeneca; Bristol-Myers Squibb Company; Ethicon Endo Surgery, Inc.; GE Healthcare; F. Hoffmann-La Roche AG; and Novartis Oncology.
BHGI is a global health alliance of organizations and individuals. We are grateful to our collaborators throughout the world who share the BHGI mission and vision. Thank you for your important contributions to this endeavor for medically underserved women.