CASES
PUBLIC HEALTH
COMMUNICATION & MARKETING
in
Volume 6, Winter 2012
A Multi-Year, Multi-Phased Colorectal
Cancer Screening Campaign
Leah M. Omilion-Hodges, PhD 1
Rebecca O’Grady 2
1 Western Michigan University
2 St. Joseph Mercy Oakland
Corresponding Author:
Leah M. Omilion-Hodges, PhD, School of Communication, Western Michigan University, 1903 W
Michigan Ave., Kalamazoo, MI 49008. Phone: (269) 287-3149.
Email: leah.omilion-hodges@wmich.edu
Suggested citation: Omilion-Hodges LM, O’Grady R. A Multi-Year, Multi-Phased Colorectal Cancer Screening
Campaign. Cases in Public Health Communication & Marketing. 2012;6:21-44.
Available from: www.casesjournal.org/volume6.
www.casesjournal.org
Peer-Reviewed Case Study
www.casesjournal.org
Abstract
Colorectal cancer (CRC) is one of the few cancers that can be prevented
through screening, yet it is still the third leading cause of cancer death
among men and women in the United States. St. Joseph Mercy Oakland, a
metropolitan Detroit non-profit hospital, created an award-winning campaign to make free fecal occult blood (FOBT) test kits available to community members annually. This screening device tests for blood in the stool
which may be a sign of cancer and is recommended for annual use. This
article details a multi-year, multi-phase CRC screening campaign that made
complimentary at-home screening kits available in over 20 Metro Detroit
communities each March since 2008 to coincide with National Colorectal
Awareness Month. Social cognitive theory was employed to organize and
guide the longitudinal campaign. Drawing from the theory of diffusion of
innovations and principle of social proof, the campaign target messages successively shifted each year, with an initial focus on individuals, to messages
and imagery focused on dyads in the subsequent year, and toward groups in
the third year. This progressive approach was employed to address perceived
benefits and barriers surrounding CRC screening. Results were promising
with annual increases in CRC screening kit return rates.
Keywords: Colonic Neoplasms, Cancer Screening, Health Campaigns, Diffusion of Innovation, Health Behavior, Attitude to Health
22
www.casesjournal.org
Introduction
Colorectal cancer (CRC), cancer of the colon or
the rectum, can be detected with regular screenings and oftentimes prevented altogether when
growths or polyps are found and removed before
becoming cancerous.1-7 In fact, 90% of diagnosed
individuals live for more than five years when the
cancer is found at a local stage where the disease is confined to the colon or rectum.8 Due in
large part to early detection, there are currently
over one million survivors of CRC in the United
States.9 Moreover, the death rate from CRC has
declined for the past twenty years. Despite these
promising statistics, CRC claimed over 100,000
lives between 2010 and 2011,9 is expected to
cause approximately 52,000 deaths in 2012, and
is the third leading cause of cancer-related deaths
among men and women.10
patients are precancerous or asymptomatic, when
treatment is most effective.11 In order to encourage the Metro Detroit area to engage in annual
CRC screenings, SJMO created an interdisciplinary team to produce a sustainable longitudinal
campaign that would (a) engage community partners such as churches, community centers, and
physician offices, (b) educate the surrounding
community on the importance of CRC screening, (c) teach community members how minor
changes to diet and exercise may reduce their
risk of developing CRC, and most importantly,
(d) provide complimentary CRC screening kits
to community members every March to coincide with National Colorectal Cancer Awareness
Month. This article details SJMO’s annual CRC
screening campaign; it describes the impetus
for undertaking the campaign, the theoretical
framework utilized, the progressive phases of
implementation, community partner and member participation rates, the adjustments made to
increase participation during the first three years
of implementation, as well as lessons learned.
St. Joseph Mercy Oakland (SJMO), a non-profit
Metro Detroit hospital, created a longitudinal
health campaign to encourage community members to partake in annual screenings. Participation in routine screenings can detect CRC when
Background
and is performed at home.13 While CRC is one
of the few cancers that can be prevented through
screening, up to 50% of Americans who qualify
have not been screened.14 Thus, while CRC can
be detected when patients are asymptomatic,
many forsake screening because they have no visible symptoms,15 screening has not been encouraged by their provider,16 or they fear that it will
be an invasive, uncomfortableexperience.17,18
The fecal occult blood test (FOBT) is a screening
method that tests for the presence of blood in the
stool which is a possible indicator of CRC. While
a positive finding may reveal other digestive disorders or cancers, the FOBT is recommended for
annual CRC screening for average-risk individuals.12 The test has been endorsed for populationbased mass use35 because it does not require a
special diet, has been praised for its ease of use,
23
www.casesjournal.org
Recognizing that misconceptions have previously led some to delay CRC screening, SJMO
developed a longitudinal campaign to alleviate potential obstacles. Therefore, coinciding
with the nonprofit hospital’s mission of caring
for the underserved, SJMO committed to make
complimentary FOBTs available each March as
serial use of the FOBT has been demonstrated to
decrease CRC mortality rates.1-6
This was important as a review of previous CRC
campaigns indicated that some individuals neglected screening because it was not perceived to
be a common practice.36,62-64
Campaigns were evaluated for best practices,
lessons learned, and deficiencies. While reviewing the campaigns, a formative coding scheme for
classifying the above criteria was developed in
order to complete a thematic analysis. Best practices and lessons learned were garnered directly
from the articles and recorded in a database for
use during the development phase. Deficiencies
were gathered via two methods: 1) examining
limitations cited by authors of the campaigns in
peer-reviewed journals; and 2) any other notable
missing campaign elements identified by the
reviewer such as forgoing educational materials,
asking potential participants to pay for screening
or neglecting to discuss how other lifestyle factors influence colorectal cancer.
Review of Previous
Colorectal Cancer and Social
Norms Marketing Campaigns
The initial step in developing the campaign was
a review of the colorectal cancer literature and
awareness/screening campaigns that were either
the product of a national health agency (e.g.,
American Cancer Society, Centers for Disease
Control, or National Cancer Institute) or published in a peer-reviewed journal in the previous
decade (1998-2008). Colorectal cancer, colorectal
cancer awareness, colorectal cancer screening,
colorectal cancer campaign, and fecal occult
blood test were the search terms utilized. Due to
the overwhelming quantity of applicable findings,
articles apropos to CRC screening campaigns
and perceived barriers to participation in CRC
screenings were examined most thoroughly. Articles focusing exclusively on clinical issues, on
individuals diagnosed with CRC, and those that
focused on high-risk individuals were excluded
from the review. Articles and or campaigns that
did not focus exclusively on CRC, or that focused
solely on CRC screening methods other than
FOBT were also excluded from the review. However, articles that dealt with special populations
(e.g., women) or were conducted internationally
were included to understand audience-specific
best practices. Overall, 48 campaigns were reviewed.2,4,6,7,11-55 Several social norms marketing
campaigns focused on other topical areas (e.g.,
alcohol, sexism)56-61 were also examined since
many of these campaigns centered on individuals’
perceptions of what is “normal” or “normative”.61
Summary of CRC Campaign Strengths &
Deficiencies. Most notable in terms of the best
practices identified was the employment of an
interdisciplinary team, the use of a theoretical
framework, and distribution of related CRC educational material. The review of previous CRC
campaigns also suggested two main areas for
improvement. First, the primary focus in other
campaigns rested solely on providing information regarding CRC, but little or no attention was
directed toward informing the target audience
about where to access a screening kit other than
directing the recipients to speak to their physician.1-5 This was particularly important since a
2004 study found that 75% of participants were
“very” or “quite” interested in taking a FOBT if
it were complimentary (i.e., available for free).23
The campaign literature review also indicated
participants were not given a dedicated hotline to
call if they had immediate questions (e.g., “how
do I use the kit”, “what if x, y or z happens?”) or
concerns—again, they were directed to speak to
24
www.casesjournal.org
their physician if questions arose. This is problematic as among industrialized nations, the U.S.
ranks the lowest in primary care functions.65
Additionally, nearly 30% of U.S. adults 19 years
of age and older were uninsured for at least some
time during 2010 and approximately 40% of U.S.
adults acknowledged not seeking health care or
skipping a recommended test to avoid associated
costs.66 This was particularly true in the Metro
Detroit area, where 15% of the population lacked
health insurance in 2008; this number exceeded
the national average, and rose to 18% by 2009.67
Furthermore, recent studies found that one of the
reasons why U.S. adults did not participate in
annual CRC screenings was because their physician did not suggest it.11,36 This finding coincides
with other literature that questions the impact of
primary care due to the relatively low delivery
rates of preventive care.68,69
site, or center, where those who lacked a primary
care provider could access more information or
a screening kit. Second, while some campaigns
informed audiences that CRC could be prevented
through routine screening, they did not encourage healthful eating and exercise in tandem with
screening as a preventative measure.35 Like many
other cancers, the risk of CRC is increased among
those with excess body fat or a Body Mass Index
of 25 or higher.31,34,70 While encouraging routine
screening is valuable information, it is unlikely
that a singular message will prompt broader preventative behavioral changes without telling community members how they might modify existing
behaviors (e.g., walk or jog at least 30 minutes,
3 days a week) or by providing tangible options
(e.g., attend a free healthy cooking seminar) for
changing dietary habits or lifestyles.
Identifying the strengths and deficiencies in predecessors’ campaigns allowed SJMO to develop
a campaign that was guided by best practices and
designed to bridge the gaps identified in similar
campaigns. After the review of previous CRC
screening campaigns, the SJMO campaign development and implementation commenced.
Taken together, the literature review suggested
that while previous campaigns provided information regarding CRC and stressed the importance
of regular screenings, most did not provide supplementary information or alternative screening
access points, such as a dedicated hotline, web-
Methods
Step 1: Assembling an
Interdisciplinary Campaign
Coordination Team
Community Nursing, and Laboratory. Nonclinical team representatives included Marketing, Community Programs, Physician Relations,
and Volunteer Services. Additionally, due to
the credibility and reputation of the American
Cancer Society (ACS), SJMO requested that an
ACS organizational representative become an active member of the project team. Individual roles
and responsibilities are detailed in Table 1 (next
page).
In order to create an integrated campaign and
ensure that necessary internal stakeholders were
represented, an interdisciplinary team, consisting
of clinical and non-clinical hospital departments
and community partners, was formed. Clinical departments represented at SJMO included
Oncology, Gastroenterology, Endoscopy, Faith
25
www.casesjournal.org
Table 1. Interdisciplinary Team Members, Goals & Roles
Non-Clinicians
Clinicians
Department
Goal(s)
Role
Oncology &
Gastroenterology
Continual increases in return of
FOBTs; Rectification of CRC myths
and screening misconceptions
Review of medical-related
information; Development of
contingency guidelines for abnormal
FOBTs
Endoscopy
Availability of appointments for
participants with abnormal FOBT
Development of contingency
guidelines for abnormal FOBTs
Laboratory
Efficient analysis of returned FOBTs
Analysis of returned FOBTs;
Development of contingency
guidelines for abnormal FOBTs
Faith Community
Nursing
Inform parish network of free CRC
screening; Rectification of CRC
myths and screening misconceptions
Distribution of kits to parish network;
Field all community member calls
regarding CRC screening; Introduce
campaign and speak about CRC at
local parishes
Marketing
Create a campaign based on theory;
Rectification of CRC myths and
screening misconceptions
Message and campaign
development; Campaign execution
Community Programs
Expand campaign to add nutrition
and lifestyle component
Develop and execute free monthly
nutrition seminars; Creation of
community recipe challenge
Physician Relations
Involvement of SJMO primary care
physicians as distribution center
Approach SJMO physician network
for participation in event
Volunteer Services
Assist other interdisciplinary team
members
Compilation of screening kits (i.e.,
FOBT, educational information,
consent form); Distribution of kits at
SJMO
American
Cancer Society
Representative
Provide Detroit Metro community
with accurate information regarding
CRC; Encourage community
members to participate in annual
CRC screening
Provide educational information;
Support campaign messages
Step 2: Identifying Potential
Barriers and Benefits
perceptions regarding CRC screening. Through
informal conversations with patients, the clinicians on the interdisciplinary team found that
some patients did not participate in CRC screening because they did not believe themselves to be
personally susceptible whereas others believed
Following the review of previous CRC campaigns, formative research was informally conducted by clinicians in the participating departments to ascertain local community member
26
www.casesjournal.org
screening was unnecessary because they were
asymptomatic. Others disclosed that screening
might be too embarrassing or uncomfortable. The
lack of kit availability, lack of time or insurance and misconceptions that other community
members were not undergoing CRC testing were
additional reasons cited for neglecting annual
testing. These concerns echoed apprehensions
found in previous campaigns where individuals expressed tentativeness in discussing CRC,62
fear that screening would be invasive,63 or that
the screening process was either unnecessary or
embarrassing.17,53,63
reiterated a desire for education regarding lifestyle modifications that could decrease one’s risk
for CRC. Through these informal conversations,
SJMO identified possible barriers and benefits
from the local participant’s perspective which
helped to establish potential campaign messages
and strategies.
Step 3: Establishing a
Theoretical Framework
Review of earlier CRC screening campaigns and
the social norms marketing literature demonstrated the importance of employing a theoretical
framework.47,71,72 Social cognitive theory 71-75
undergirded the development of this campaign,
however, the principles of social proof 76 and diffusion of innovation theory 77 were also employed
to grow and sustain the multiyear campaign.
These theories guided the campaign and message
development due to their repeated utility in previous health campaigns.74,75,78-83
The above informal provider-patient conversations were conducted with twenty-three individuals. Eleven individuals were 50 years of age or
older and had participated in routine CRC screenings for a minimum of 2 prior years. Twelve individuals, who were also 50 years of age or older,
but who did not participate in annual screenings
were also interviewed because prior research suggested that perceived barriers could potentially
be more important than perceived benefits in
predicting CRC screening compliance.64 Institutional Review Board approval was not sought
as these patient-provider discussions were informal, not designed to contribute to generalizeable
knowledge, and designed to inform the campaign.
No identifiable patient information was communicated to the team.
Social Cognitive Theory. Social cognitive theory
suggests that behavior is the outcome of internal
and environmental factors.71,73-75 Consequently,
even if community members are aware of the potential benefits of a health intervention, internal
factors such as knowledge, skills, emotions, and
environmental factors, including social approval
and physical environmental characteristics, may
discourage participation. For instance, if significant others perceive CRC screening to be unnecessary, expensive or invasive, then it is likely that
we will also hold these same beliefs.
These conversations revealed a diverse set of
motivations and several common themes were
observed. In addition to the anxiety associated
with CRC exams, many patients thought it would
be an expensive and intrusive process. Others
felt they might be embarrassed or stigmatized
if they were to take the FOBT home kit screening test since their friends, family members and
neighbors had not openly disclosed participating
in CRC screening. A general lack of knowledge
regarding the causes of CRC generated considerable uncertainty and many of those interviewed
According to social cognitive theory,71,73-75
behaviors are guided by two expectations: 1) the
expectation that an action will lead to a particular
outcome, and 2) the expectation (i.e., of success
or failure) that an individual has regarding his
or her ability to perform this action. Thus, by
increasing expectations that screening would lead
to positive outcomes and enhancing one’s health
self-efficacy — an individual’s beliefs in their
27
www.casesjournal.org
ability to engage in specific healthy behaviors
(e.g., I can participate in an annual CRC screening) — it was anticipated that community members would hold a more positive view of CRC
screening.
test. A hotline was also established and staffed
by registered nurses so those who had questions
could seek immediate assistance.
In terms of observability, adoption rates can be
expected to increase if the use of an innovation
is visible to others.76,77 Social proof concerns an
individuals’ tendency in uncertain situations to
look to others’ behavior as a cue to guide their
decisions and behavioral responses.76 According
to Cialdini, when we observe others, particularly
in a novel or ambiguous situation, we feel less apt
to make a mistake by acting in accord with social
evidence rather than behaving in a way that is
contrary to the norm.57,61,76 Thus, witnessing
others perform a certain behavior removes the
uncertainty associated with it, and increases the
likelihood that observers will follow suit.
Self-efficacy beliefs and expectations can be
increased when individuals are given opportunities to succeed. Since health self-efficacy beliefs
are a strong predictor of health-related behaviors,
a community outreach component was added
in the second year to increase opportunities for
community members to exert control over their
health. The community outreach component,
which will be described shortly, consisted of
giving community members opportunities to be
self-efficacious in taking the FOBT. By removing
social and financial barriers to engaging in FOBT
screening and offering free community events, it
was anticipated that community members would
be able to take small steps toward becoming more
health-conscious.
To activate the principle of social proof, local
community centers such as hospitals, physician
offices, and churches were identified as screening kit distribution locations. This was done so
that after religious services or while waiting for
an appointment at a physician’s office or local
hospital, community members might observe
others procure a complimentary screening kit
and subsequently decide to engage in this healthful behavior as well. Further, formative research
with community members indicated a hesitancy
to speak about CRC, but if they were provided a
reason (e.g., receiving a free CRC screening kit
at church), it was anticipated that they might be
more likely to speak about it with others. Understanding how new ideas are received and the rate
at which they are received, reinforced the idea
to create a longitudinal campaign which successively reinforced various stages of change.
Diffusion of Innovations and the Principle of
Social Proof. Research indicated that kit availability and social17,62,63 and financial 51,52,84 costs
were barriers cited for disregarding routine CRC
screening. However, by making complimentary
at-home screening kits available, benefits begin
to outweigh the barriers. To effectively communicate benefits, the theory of diffusion of innovations77 was utilized in tandem with the principle
of social proof.76 Diffusion of Innovations theory
details the process through which new ideas are
disseminated throughout a social system.77 While
innovations may not be immediately welcomed,
perceived innovation attributes (e.g., compatibility, complexity, observability, relative advantage
and trialability) may increase adoption rates.77
Because increased complexity is negatively
related to adoption, CRC screening kits were
packaged with educational information from the
American Cancer Society regarding CRC as well
as prescriptive instructions for correct use of the
Step 4: Analyzing and
Segmenting the Audience
Guidelines for inclusion were recommended by
the clinicians on the interdisciplinary team and
coincided with those forwarded by the American
28
www.casesjournal.org
Cancer Society. The target audience was defined
as men and women in the Detroit Metro area age
50 and older.7
The target audience was expanded to dyads and
groups in the second and third year respectively
in order to increase the scope of participation in
the campaign and to reinforce the message that
significant others both support and are taking
the FOBT screening test themselves. The theory
of diffusion of innovation acknowledges that
individuals who are similar (e.g., homophily) are
more likely to interact and exchange information with one another. However, in order for an
innovation to reach peak diffusion it is necessary
to engage others outside of our immediate social
circles (e.g., heterophily).77
Utilizing the CDC’s recommendation that CRC
screening campaigns run for multiple years,11
SJMO targeted the same audience each year, but
revised the campaign focus annually. Resting on
the theory of diffusion of innovations, this approach was utilized in an attempt to encourage
successive groups of the community who were
expected to be at varying stages of readiness to
participate in the annual CRC campaign.77 Diffusion occurs when an innovation, such as the CRC
screening campaign, is communicated through
various channels throughout a social system.
If the innovation is adopted through controlled
(i.e., SJMO directed communication) as well as
spontaneous (i.e., subjective personal conversations) communications, the process of diffusion is
more likely to take place successfully over time.
Innovators, or those who accept the innovation
first, are opinion leaders who are necessary for
the innovation to continue to disseminate.77 Innovators and early adopters tend to be motivated to
adopt innovations early, and without necessarily
looking for cues from others. Research suggests
that in uncertain situations, people who are most
likely mid- and late adopters, look to others for
behavioral cues, generally assuming that others
are better informed than they are, and they use
these cues to inform their own behavior.76,77
Step 5: Campaign Goals
Campaign goals were designed to expand the
depth and reach of the campaign annually for
each of the three phases. For the inaugural year,
SJMO’s goal was to ensure that the target audience was aware of the incidence of colorectal
cancer and was enabled to participate in an
at-home CRC screening. The campaign goal for
community partnership development in 2008 was
to establish relationships with at least 20 community partners in at least 10 cities. Subsequent
goals included increasing the quantity of community partners and adding a community outreach
component. The goal for 2009 was increased to
30 community partners in 15 cities and to 40
community partners in 20 cities for 2010.
Prior research further suggested that a 20%
return of CRC kits might be reasonable to expect.85 Utilizing previous studies as a guide, the
team aspired for a 20% return of CRC kits in
the inaugural year. Goals for CRC screening kit
return rates were raised in 2009 and 2010 to 30%
and 35% respectively based upon the levels of
responsiveness found during the campaign. These
goals were established by the Marketing Department and reflected the desire to not only extend
the campaign annually, but increase participation
as well.
Therefore, campaign messages and images in the
initial year were employed to motivate audience
members at the individual level. It was anticipated that innovators and early adopters would be
most likely to change their behaviors and would
be more likely to discuss CRC with their partners
and friends. Additionally, when innovators and
early adopters visited their physician’s office,
hospital, or church to obtain their free CRC
screening kit, it was anticipated that others would
imitate their actions.77
29
www.casesjournal.org
Development of Community Partners and
Community Outreach Components. Community
partnerships were established with community
centers, primary care physician offices, and
hospitals. Efforts were made to secure partnerships throughout the Detroit Metro Area to
ensure that regardless of socioeconomic status,
any interested community member could access a
complimentary CRC screening kit. Several locations were approached to participate in the campaign because of their status as family-oriented
community centers (e.g., physician offices or
churches) and proximity to public transportation.
Additionally, campaign materials (i.e., posters,
advertisements, radio) also informed community
members that they could call SJMO to have a
complimentary CRC screening kit mailed directly
to their home.
educational courses, a community recipe challenge and a community dinner. The year-long
educational series, Your Path to a Healthier Colon, focused on healthy eating, food preparation
and overall nutrition. A grant from the Michigan
Department of Community Health allowed SJMO
to conduct monthly classes to teach community
members about the role that healthful eating plays
in a balanced diet and in decreasing one’s risk for
CRC.86 The educational series also concentrated
on the nutritional differences inherent in meal
preparation, specifically encouraging participants
to consider baking and grilling over frying.
As an added means of involving community
members during National Colorecteral Cancer
Awareness Month, a recipe contest was held in
Year Two to identify flavorful yet health-conscious meals; winners were honored at a community dinner. Additionally, a cookbook that featured contest-recipes was designed to encourage
community members to cook healthfully even
after the conclusion of the campaign. Individuals
did not have to participate in the CRC screening in order to partake in the educational series,
recipe contest or community dinner. These events
were designed to offer community members opportunities to exert control over their health, and
thereby potentially increasing their self-efficacy
to foster a healthy lifestyle.74
In order to become a community partner, the
churches, physician offices or community centers were asked to display promotional materials
and kits in a public area throughout the National
Colorectal Cancer Awareness Month (i.e., the
month of March). Participating SJMO physicians
were asked to encourage applicable patients to
participate in the screening; physicians were
instructed to encourage patients to take the kit
home, read the educational material, complete the
test, and return it to SJMO in a pre-paid envelope. Results were returned to SJMO’s laboratory
department. After Year 1, it became clear that
there was a loss of approximately 75% of the kits
which was quite costly – since only 25% were
returned. During Years 2 and 3, SJMO narrowed
the focus of partnerships to only Oakland County, and reduced the numbers of kits distributed.
This shift resulted in having 33% of cities in
Oakland County (up from 17% in Year 1) with at
least one community partner.
Step 6: Selecting
Communication Channels
Several media outlets were utilized to deliver
campaign messages. With the target audience
being 50 years of age and older, some channels
were utilized more heavily than others. Among
individuals ages 50-64, approximately 47% report reading a daily newspaper and that number
increases to 58% for those age 65 and older.87
Further, over 75% of newspaper readers noted
that the majority of their newspaper reading time
is spent reading articles about health and medicine.87 As a result, advertisements were placed
A community outreach component was also initiated in Year Two and continued in Year Three.
Community outreach activities included monthly
30
www.casesjournal.org
Step 7: Designing Campaign
Messages
in local city newspapers (i.e. The Pontiac Times)
and also in the county-wide publications (i.e.
The Oakland Press). Additionally, a 60 second
radio spot ran on nine Metro Detroit radio stations popular with the target audience during the
a.m. and p.m. commutes for a portion of National
Colorectal Cancer Awareness Month in the inaugural year.
Campaign messages (see Table 2) across the
phases were similar, but were tailored for each
specific audience segment. All of the messages
communicated that if caught early, colorectal
cancer is one of the few cancers that can be
cured, and all messages encouraged recipients to
participate in the free at home FOBT screening.
Within the FOBT kits, there were prescriptive
guidelines that instructed community members
how to complete the test at home. Because the
goal of the initial year was to target individuals,
the messages and accompanying images were
tailored accordingly. Messages were expanded to
dyads and groups in Year 2 and 3 respectively.
Again, this strategy was based on diffusion of
innovations theory and used in order to build
momentum for the campaign.
Direct mail was also utilized to communicate
about the health campaign and where to get an
FOBT kit. Brochures were sent to all age-appropriate community members who lived within a
five mile radius of SJMO. This population was
further segmented through marketing databases to
target all households with men or women age 50
and over and an annual joint income of less than
$40,000 since lower socioeconomic status has
been correlated with lower participation.51,52,54,84
Each year, the SJMO Faith Community Nurses
also visited each church community partner to
educate parishioners on the pervasiveness of CRC
and inform them about the campaign.
Inaugural Year. For the initial phase of the
campaign (Year One), it was important to prompt
the target audience to visit the community center
Table 2. Overview of Colorectal Campaign
Community
Partners
Year
Target
Primary Tagline
2008
Individual
• 63 locations
• 24 cities
You make time in your
schedule for the most
ridiculous things. Why not
make time for something
important? Like a colorectal
screening.
A colorectal screening can
save your life. Don’t wait.
Get screened today.
2009
Dyad
• 80 locations
• 23 cities
Do yourself a favor. Do
your loved ones a favor.
Participate in our free
colorectal cancer screening.
One kit. One test. It could
save your life.
2010
Group
• 82 locations
• 23 cities
We took the test! So should
you! Participate in our free
colorectal cancer screening.
Our free test could save
your life.
31
Secondary Tagline
www.casesjournal.org
nearest them for a complimentary, at-home CRC
screening kit. Participation, defined as taking the
screening kit, would suggest that an individual
assessed the benefits (i.e., free FOBT) to outweigh the barriers (i.e., financial cost).71-75
ones a favor. Participate in our free colorectal
cancer screening.” focused on increasing the
scope of the campaign from individuals to dyads
(see Figure 2, next page).
In the third year, the campaign focus (both
messages and imagery) was expanded to reflect
groups (see Figure 3, next page). The imagery included two diverse, 60-something couples and the
following tagline, “We took the test! So should
you!” which was used to mimic a testimonial,
challenge participation and encourage community
members to engage in conversation over the campaign. This was also done in order to maintain
momentum, to demonstrate that FOBT screening
had become normative and that the community at
large should also take the test. Research indicates
that the more similar those making testimonials are to those they are attempting to persuade,
the more likely they are to succeed in convincing the target audience to take the recommended
actions.88 Campaign materials were available in
English and Spanish to accommodate the needs
of the target audience.
An image of a single, adult man was utilized in
the campaign’s inaugural year (2008) to emphasize the importance of taking care of one’s health
(see Figure 1). The direct mail promotional
information called attention to the pervasiveness
of CRC, but also informed participants that if
detected early, colorectal cancer is 90% curable
with treatment.8 The mailer also emphasized the
availability of the complimentary FOBT explicitly telling recipients, “St. Joseph Mercy Oakland
is making it easy. No more excuses. In March,
pick up a free colorectal screening kit at any of
the participating locations.”
Second and Third Years. The second and third
year of the campaign segmented the audience
by dyads and groups, respectively. In the second
year, the imagery focused on one couple and the
message, “Do yourself a favor. Do your loved
Figure 1. 2008 Direct Mail Message & Image
32
www.casesjournal.org
Figure 2. 2009 Direct Mail Message & Image
Figure 3. 2010 Direct Mail Message & Image
Step 8: Implementation
month. Community partners were established in
December and January of each year to coordinate
delivery of the colorectal screening kits prior to
the campaign’s commencement.
The SJMO campaigns were implemented in the
third week of February and ran through the end
of March each year. This timeline was selected
because March is National Colorectal Awareness
33
www.casesjournal.org
The communication aspect of the health campaign
began approximately two weeks prior to the program’s launch each year, with targeted individuals receiving an informational brochure by mail.
Additional advertisements were placed in city and
county newspapers approximately one week prior
to the beginning of the program. In 2008, the radio
spot ran for the two middle weeks of March. In 2009
and 2010, the radio spots were not used in order to
narrow the campaign solely to Oakland County.
pletely accurate in detecting colorectal cancer,
and an abnormal test result did not necessarily
mean the presence of cancer. Participants were
also informed that they would receive results by
mail; but those with abnormal results would be
contacted by phone as would their family physician. Anyone without a physician could elect to
allow SJMO Community Programs to help them
find a primary care physician.
After completing the test, participants were
instructed to place the test in the pre-paid envelope that was included. Kits were returned to
SJMO’s laboratory where they were processed and
analyzed. Those who received negative results
received notification by mail. Kit results that
tested possible for blood in the stool--a possible
indicator of CRC--were contacted via telephone.
In compliance with HIPPA, information regarding individuals who tested positive on the FOBT
remained within the SJMO clinical departments
and was not reported to the remainder of the team.
Participants were encouraged to pick up a free
FOBT from a community partner. In addition
to the screening test, the kit included prescriptive guidelines on how to properly complete the
at-home test in addition to educational materials regarding CRC that were provided from the
American Cancer Society. To permit SJMO to
analyze a returned FOBT, community members
who returned their kits signed a consent form
which reiterated that they had read the educational information, understood the FOBT is not com-
Results
Community Partnerships
CRC Screening Kit
Distribution, Return Rates &
Test Positive Results
To increase campaign reach, it was essential to
establish as many community partners as possible to distribute the FOBT kits. As can be seen in
Table 3 (next page), a total of N=63 community
partners signed on in Year 1, and N=80 and N=82
in Years 2 and 3 respectively. Partnerships were
established with over 20 cities all three years and
1/3 of all of the cities that comprised Oakland
County by the third year.
Return rates were calculated by dividing the
number of screening kits returned by community
members to SJMO for testing by the quantity of
kits distributed to community partners. Return
rates increased from 25.2% in Year 1, to 34.7%
and 37.6% in Years 2 and 3 respectively (see
Table 4, next page). Further, CRC screening test
positive results, a statistic which was derived by
dividing the total number of positive test results
by the total number of FOBT tests returned, decreased annually (11.5%, 8.2%, and 4.6%).
Participation in Community
Outreach Events
A total of 140 individuals participated in the community dinner. Each month the seminars hosted
approximately 15 to 20 community members.
34
www.casesjournal.org
Table 3. Quantity of Community Partners and Geographic Presence in Metro Detroit Cities
Year
Community Partners
Cities Represented
2008
63
24
2009
80
23
2010
82
23
Table 4. Kit Distribution, Return Rates & Test Results from the Multi-Year Campaign
Year
Kits Distributed
Kits Returned
Return Rate a
Positive CRC
Test Resultsb
2008
4,700
1,186
25.2%
11.5%
2009
2,600
902
34.7%
8.2%
2010
2,924
1,099
37.6%
4.6%
a The Return Rate reflects the number of kits returned divided by the number of kits distributed to community partner
organizations (e.g., religious, primary care providers) where free FOBTs were made available; the number of those
kits actually taken home by their constituency is unknown.
b Reflects the percent of kits returned that had a positive test result, which reflects the presence of blood in the stool
and is a possible indicator of CRC.
Discussion
While prevention, early detection and advances in
treatment aid in the declining rates of diagnosed
CRC, it is important to remain vigilant in our
commitment to educating the community about
this disease. Often overshadowed by other cancers and diseases, CRC is the third leading cause
of death from cancer in the U.S. for both men
and women.9 The formative research conducted
in advance of this campaign identified a number of reasons why community members might
neglect routine CRC screening; these findings
were consistent with prior research on barriers to
screening such as financial 51,52,54,84 and social
costs.17,18,62 Formative research also highlighted
the importance of informing the community that
those in the early stages of CRC often remain
asymptomatic. This longitudinal campaign identified and alleviated several potential barriers to
screening by establishing multiple community
partnerships; the campaign was recognized by
the Michigan Cancer Consortium with a Spirit of
Collaboration Award for coordinating and communicating resources to reduce the burden of
cancer among citizens of Michigan.89
Return rates for FOBT kits typically average 1020% with passive distribution methods, such as
requiring community members to pick up and to
35
www.casesjournal.org
return the kit.85,90-92 Utilizing previous studies
as a guide, the team aspired for a 20% return of
CRC kits in the inaugural year. Goals for return
rates of the CRC screening kits were raised in
2009 and 2010 to 30% and 35% respectively as
each of these targets was realized. Further, finding that the CRC screening test positive results,
which reflects the presence of blood in the stool
and is a possible indicator of CRC, decreased
annually (from 11.5%, 8.2%, to 4.6%), was
promising. This decline suggested, perhaps, that
the incidence of CRC was decreasing in the surrounding community although no formal statistical analyses were performed.
veyed would participate in routine CRC screening
if it were free.23
Examination of these previous campaigns also
yielded information on best practices and lessons learned. Many of our predecessors, for
instance, utilized theory to guide campaign efforts.17,39-45,49 This suggestion was particularly
useful as it provided the interdisciplinary team
a means by which to better understand how to
mitigate barriers and increase participation. Additionally, the use of social cognitive theory 71-75
prompted SJMO to expand the campaign from a
simple CRC screening effort, which might have
focused solely on having primary care providers
recommend the test kits to patients, to a community outreach endeavor which included persuasive
messages, community partnerships for FOBT
distribution, and other community events and
education activities. The principle of social proof
61,76 and diffusion of innovations theory 77 provided an effective means of building momentum
and communicating the campaign.
To increase campaign reach, it was essential to
establish as many community partners as possible. Utilization of the community partners as
distribution centers allowed SJMO to make the
screening kits available in 1/3 of all of the cities that comprise Oakland County by the third
year. While the initial years of the campaign
are discussed here, SJMO has implemented the
campaign each March since 2010 with continued
increases in return rates observed and a 2% positive rate and less than 4% positive rate in 2011
and 12 respectively.
In terms of lessons for practitioners, we would
encourage practitioners to assemble an interdisciplinary team. The team approach allowed SJMO to
expand the campaign in various ways (i.e., longitudinal, community outreach components) that the
Marketing Department might not have considered if
it had been solely leading the campaign. Additionally, the campaign organizers would recommend
enlisting a community member(s) as part of the
interdisciplinary team in the future to ensure that
their voice is heard at each stage of the campaign.
Lessons Learned
While many community health campaigns are
initiated and implemented by regional and national health agencies, increasingly marketing,
public relations and communication professionals
within hospitals and healthcare centers are being
charged with this task. To that end, the development aspects of this campaign offer several lessons learned and tangible solutions for developers
of local health and social marketing campaigns.
For instance, taking the time to review predecessors’ CRC campaigns allowed SJMO to capitalize
on their successes and avoid their limitations. By
example, previous campaigns provided complimentary screening kits only to those enrolled in
clinical trials or other research studies.1-5 Other
research reiterated that a number of those sur-
Another lesson learned was to refine the size
and scope, as well as distribution channels, of
the initial campaign. As noted, nearly 5,000 kits
were distributed the first year with only 1,186
returned; an approximately 25% response rate.
The lost cost of the other 75% kits was significant. So, in the subsequent years Oakland County
(instead of the entire Metropolitan Detroit area)
was selected as the primary target of focus. Due
36
www.casesjournal.org
to SJMO’s location within Oakland County, narrowing the focus to county residents may have
ultimately been more effective as more members
within the defined target audience were reached
through the campaign. Additionally, radio was
discontinued after the initial year due to Detroit’s
proximity to Canada, which created a demand
that could not be fulfilled due to international
shipping regulations.
social marketing campaigns can inspire large
groups of people to initiate and sustain a positive behavioral change,94,95 however, without a
formal campaign evaluation, promoters will not
be able to demonstrate causality. And, as a result,
campaign organizers cannot say with certainty
that people have increased consumption of fruits
and vegetables, for example, if they do not have
measures in place to indicate that the change
is due to their social marketing efforts. Those
without experience in evaluation are encouraged
to review published peer-reviewed social marketing campaigns, many of which provide prescriptive advice for survey distribution 96 or propose
innovative ideas for evaluation including the use
of journals97 or diaries.98
Limitations
While there were many campaign strengths,
there were also limitations that should be acknowledged. Although the scope of the campaign
expanded each year in terms of the numbers of
community partners and cities, the impact of
the progression from the individual focus, to the
dyadic focus and ultimately to the group focus
was not explicitly measured nor were quantifiable
goals set or outcome measures established for
this aspect of the campaign. And, while relevant
communication theories were used in developing
messages and strategies for campaign implementation, those messages were not tested directly,
but rather used as a strategy to guide message
and campaign development. The financial cost
and breadth of the campaign did not permit the
inclusion of measuring certain cognitive factors.
Thus, instead of measuring community awareness of CRC throughout the multiyear campaign,
the Marketing Department assessed primarily
the screening kit return rates and extent to which
community partnership goals were met. We
acknowledge that participation in FOBT screening may also have been increased if the test was
sent by mail directly to targeted individuals.93
Instead, the direct mail focused on promoting
participation by picking up a FOBT screening kit
through one of the participating partners.
Implications for Future
Research
In terms of future campaigns, it is recommended
that pre and post-tests be distributed to community members throughout the campaign. In addition
to examining return rates, it would be helpful to
establish a baseline regarding CRC awareness.
Just as many social norms marketing campaigns
create messages aimed at dispelling misconceptions regarding student drinking,56-59 it is recommended that future campaign designers report
the statistics regarding CRC screening practices.
By example, if the data had been captured in this
particular campaign, SJMO could have crafted a
message that utilized these percentages to inform community members about the number of
their peers participating in the annual screening.
Although the messages utilized in the campaign
were created to encourage community members
to participate in the CRC screening, it might have
been more persuasive to create specific messages
informing community members that there has
been a 20% increase in screening participation,
for instance, from 2008 to 2009.
While this campaign did not capture certain
outcome measures, it is recommended that future
campaign developers remain diligent in their efforts to conduct both formative and summative
evaluative research. When properly executed,
While the theory of diffusion of innovations
guided campaign development, efforts were not
made to identify innovators and early adopters
37
www.casesjournal.org
or to measure diffusion networks or perceptions
of the innovation characteristics (e.g., complexity, costs, etc). Due to limited resources, this fell
outside of the scope of the campaign activities,
but based on previous research would likely yield
interesting results. The identification of early
adopters would provide insight into those who
are most interested in making healthy lifestyle
changes and allow campaign designers to see
how the campaign was diffused throughout
interpersonal networks. Further, this approach
could allow campaign designers to develop more
persuasive messages that community members
could use with peers to encourage others to also
participate in annual CRC screening.
Acknowledgements
The authors wish to acknowledge the SJMO interdisciplinary team for their
invaluable contributions to the success of this program. Moreover, portions
of this campaign were recognized and supported by a grant from the Michigan Department of Community Health.
References
1. Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal cancer by
screening for fecal occult blood: Minnesota
Colon Cancer Control Study. N Engl J Med.
1993;328(19):225-249.
2. Mandel JS, Church TR, Ederer F, Bond JH.
Colorectal cancer mortality: effectiveness of
biennial screening for fecal occult blood. J
Natl Cancer Inst. 1999;91(5):434-437.
3. Hardcastle, JD, Chamberlain JO, Robinson
MH, et al. Randomized controlled trial of
faecal-occult-blood screening for colorectal
cancer. Lancet. 1996;348(9040):1472-1477.
4. Scholefield JH, Moss S, Sufi F, Mangham
CM, Hardcastle JD. Effect of faecal occult
blood screening on mortality from colorectal
cancer: results from a randomized controlled
trial. Gut. 2002;50(6):840-844.
5. Kronborg O, Fenger C, Olsen J, Jorgensen OD, Sondergaard O. Randomized
study of screening for colorectal cancer
using faecal occult blood test. Lancet.
1996;348(9048):1467-1471.
6. Jorgensen OD, Kronborg O, Fenger C. A
randomized study of screening for colorectal
cancer using faecal occult blood testing: results after 13 years and seven biennial screening rounds. Gut. 2002;50(1):29-32.
7. Centers for Disease Control and Prevention
(CDC). Vital signs: colorectal cancer screening among adults aged 50-75 years—United
States, 2008. MMWR Morb Mortal Wkly Rep.
2010;(59)1-5.
8. Colon Cancer Alliance. Colon cancer statistics [Web page]. Colon Cancer Alliance Web
site. http://www.ccalliance.org/what_statistics.html. Accessed January 4, 2012.
38
www.casesjournal.org
9. American Cancer Society. Colon/Rectum
Cancer [Web page]. American Cancer Society Web site. http://www.cancer.org/Cancer/
ColonandRectumCancer/index. Accessed
January 4, 2012.
10.American Cancer Society. What are the
key statistics about colorectal cancer? [Web
page]. American Cancer Society Web site.
http://www.cancer.org/Cancer/ColonandRectumCancer/DetailedGuide/colorectal-cancerkey-statistics. Accessed June 21, 2012.
11.Jorgensen CM, Gelb CA, Merritt TL, Seeff
LC. Observations from the CDC. CDC’s
screen for life: A national colorectal cancer
action campaign. J Womens Health Gend
Based Med. 2001;10(5):417-422.
12.Pignone M, Rich M, Teutsch SM, et al.
Screening for colorectal cancer in adults at
average risk: a summary of the evidence for
the U.S. Preventive Services Task Force. Ann
Intern Med. 2002;137(2):132-141.
13.Shapiro JA, Seeff LC, Thompson TD, et al.
Colorectal cancer test use from the 2005
National Health Interview Survey. Cancer
Epidemiol Biomarkers Prev. 2008;17(7):162330.
14.Centers for Disease Control and Prevention
(CDC). Use of colorectal cancer tests-United
States, 2002, 2004, and 2006. MMWR Surveill Summ. 2008;57(10):253-258.
15.Stacy R, Torrence WA, Mitchell R. Perceptions of knowledge, beliefs, and barriers to
colorectal cancer screening. J Cancer Educ.
2008;23(4):238-240.
16.Sarfaty M. How to increase colorectal cancer
screening rates in practice: A primary care
clinician’s evidence-based toolbox and guide.
2nd ed. The National Colorectal Cancer
Roundtable; 2008.
17.Janz NK, Wren PA, Schottenfeld D, Guire
KE. Colorectal cancer screening attitudes
and behavior: a population-based study. Prev
Med. 2003;37(6):627-634.
18.Marshall DA, Johnson FR, Phillips KA,
Marshall, JK, Thabane L, Kulin NA. Measuring patient preferences for colorectal cancer
screening using a choice-format survey. Value
in Health. 2007;10(5):415-430.
19.Levin B, Lieberman DA, McFarland B, et
al. Screening and surveillance for the early
detection of colorectal cancer and adenomatous polyps, 2008: A joint guideline from the
American Cancer Society, the U.S. MultiSociety Task Force on Colorectal Cancer, and
the American College of Radiology. Gastroenterology. 2008;134(5):1570-1595.
20.Akhtar S, Sinha S, McKenzie S, Sagar PM,
Finan PJ, Burke D. Awareness of risk factors amongst first degree relative patients
with colorectal cancer. Colorectal Disease.
2008;10(9):887-890.
21.Schroy PC, Glick JT, Robinson PA, Lydotes
MA, Evans SR, Emmons KM. Has the surge
in media attention increased public awareness about colorectal cancer and screening? J
Community Health. 2008;33(1);1-9.
22.Shapiro JA, Seeff LC, Nadel MR. Colorectal
cancer-screening tests and associated health
behaviors. Am J Prev Med. 2001;21(2):132137.
23.Keighley MRB, O’Morain C, Giacosa A,
et al. Public awareness of risk factors and
screening for colorectal cancer in Europe.
Eur J Cancer Prev. 2004;13(4);257-262.
24.Bignham SA, Day NE, Luben R, et al. Dietary fibre in food and protection against
colorectal cancer in the European Prospective Investigation into Cancer and Nutrition (EPIC): an observational study. Lancet.
2003;361(9368):1496-1501.
25.Rex DK, Johnson DA, Lieberman, DA, Burt
RW, Sonnenberg A. Colorectal cancer prevention 2000: Screening recommendations of the
American College of Gastroenterology. Am J
Gastroenterol Suppl. 2000;95(4):868-877.
39
www.casesjournal.org
26.Lieberman DA, Weiss DG. One-time screening for colorectal cancer with combined fecal
occult-blood testing and examination of the
distal colon. N Engl J Med. 2001;345(8):555561.
27.Frazier LA, Colditz GA, Fuchs CS, Kuntz
KM. Cost-effectiveness of Screening for
Colorectal Cancer in the General Population.
JAMA. 2000;284(15):1954-1961.
28.Towler B, Irwig L, Glasziou P, Kewenter J,
Weller D, Silagy C. A systematic review of
the effects of screening for colorectal cancer
using the faecal occult blood test, Humoccult.
BMJ. 1998:317 (7158):559-565.
29.Pignone M, Saha S, Hoerger T, Mandelblatt
J. Cost-effectiveness analysis of colorectal
screening: A systematic review for the U.S.
Preventative Services Task Force. Ann Intern
Med. 2002;137(2):96-104.
30.Imperiale TF, Ransohoff DF, Itzkowitz SH,
Turnbull BA, Ross ME. Fecal DNA versus
Fecal Occult Blood for Colorectal-Cancer
Screening in an average-risk population. N
Engl J Med. 2004;351 (26):2704-2715.
31.Terry P, Giovannucci E, Michels KB, et
al. Fruit, vegetables, dietary fiber, and risk
of colorectal cancer. J Natl Cancer Inst.
2001;93(7):525-533.
32.Seeff LC, Nadel MR, Klabunde CN, et al.
Patterns and predictors of colorectal cancer
test use in the adult U.S. population. Cancer.
2004;100(10):2093-2103.
33.Meissner HI, Breen N, Klabunde CN, Vernon
SW. Patterns of colorectal cancer screening
uptake among men and women in the United
States. Cancer Epidemiol Biomarkers Prev.
2006;15(2):389-394.
34.Levi F, Pasche C, La Vecchia C, Lucchini F,
Franceschi S. Food groups and colorectal cancer risk. Br J Cancer. 1999;79(7/8):1283-1287.
35.Faivre J, Tazi MA, El Mrini T, Lejeune C,
Benhamiche AM, Dassonville F. Faecal Occult blood screening and reduction of colorectal cancer mortality: a case-control study. Br
J Cancer. 1999;79(3/4):680-683.
36.Beeker C, Kraft JM, Southwell BG, Jorgensen
CM. Colorectal cancer screening in older men
and women: Qualitative research findings and
implications for intervention. J Community
Health. 2000;25(3): 263-278.
37.Walsh JME, Terdiman JP. Colorectal cancer
screening. JAMA. 2003;289(10):1288-1296.
38.Vijan S, Hwang EW, Hofer TP, Hayward RA.
Which colon cancer screening test? A comparison of costs, effectiveness, and compliance. JAMA. 2001;111(8):593-601.
39.Marcus AC, Ahned D, Cutter G, et al. Promoting cancer screening among the first-degree relatives of breast and colorectal cancer
patients. Prev Med. 1999;28(6):229-242.
40.Myers RE, Ross E, Jepson C, et al. Intention
to screen for colorectal cancer among white
male employees. Prev Med. 1998;27(2):279287.
41.Lipkus IM, Rimer BK, Lyna PR, Pradhan
AA, Conaway M, Woods-Powell CT. Colorectal cancer screening patterns and perceptions of risk among African-American users
of a community health center. J Community
Health. 1996;21(6):409-427.
42.Wardle J, Sutton S, Williamson S, et al. Psychosocial influences on older adults’ interest
in participating in bowel cancer screening.
Prev Med. 2000;31(4): 323-334.
43.Codori AM, Petersen GM, Miglioretti DL,
Boyd P. Health beliefs and endoscopic
screening for colorectal cancer. Prev Med.
2001;33(2):128–136.
44.Rawl S, Champion V, Menon U, Loehrer P,
Vance G, Skinner CS. Validation of scales to
measures benefits of and barriers to colorectal cancer screening. J Psychosoc Oncol.
2001;19(3-4):47-63.
45.Mandelson MT, Curry SJ, Anderson LA, et
al. Am J Prev Med. 2000;19(3):149-154
46.Subramanian S, Klosterman M, Amonkar
MM, Hunt TL. Adherence with colorectal
cancer screening guidelines: a review. Prev
Med. 2004;38(5):536-550.
40
www.casesjournal.org
47.McCaffrey K, Wardle J, Waller J. Knowledge, attitudes, and behavioral intentions in
relation to the early detection of colorectal
cancer in the United Kingdom. Prev Med.
2003;36(5):525-535.
48.Costanza ME, Luckmann R, Stoddard AM,
et al. Applying a stage model of behavior
change to colon cancer screening. Prev Med.
2005;41(3-4):707-719.
49.Hiatt RA, Klabunde C, Breen N, Swan J,
Ballard-Barbash R. Cancer screening practices from national health interview surveys:
Past, present, and future. J Natl Cancer Inst.
2002;94(24):1837-1846.
50.Khandker RK, Dulski JD, Kilpatrick JB, Ellis
RP, Mitchell JB, Baine WB. A decision model
and cost-effectiveness analysis of colorectal
cancer screening and surveillance godliness
for average-risk adults. Int J Technol Assess
Health Care. 2000;16(3):799-810.
51.James TM, Greiner KA, Ellerbeck EF, Feng
C, Ahluwalia JS. Disparities in colorectal
cancer screening: a guideline-based analysis
of adherence. Ethn Dis. 2006;16(1):228-233.
52.Pollack LA, Blackman DK, Wilson KM,
Seeff LC, Nadel MR. Colorectal cancer
test use among Hispanic and non-Hispanic U.S. populations. Prev Chronic Dis.
2006;3(2):A50.
53.Natale-Pereira A, Marks J, Vega M, Mouzon
D, Hudson SV, Salas-Lopez D. Barriers and
facilitators for colorectal cancer screening
practices in the Latino community: perspectives from community leaders. Cancer Control. 2008;15(2):157-165.
54.Sun WY, Basch CE, Wolf RL, Li XJ. Factors
associated with colorectal cancer screening
among Chinese-Americans. Prev Med. 2004;
39(2):323-329.
55.Berkowitz Z, Hawkins NA, Peipins LA,
White MC, Nadel MR. Beliefs, risk perceptions, and gaps in knowledge as barriers to
colorectal cancer screening in older adults. J
Am Geriatr Soc. 2008;56(11);307-314.
56.Glider P, Midyett SJ, Mills-Novoa B, Johannessen K, Collins C. Challenging the collegiate rite of passage: A campus-wide social
marketing media campaign to reduce binge
drinking. J Drug Educ. 2001;31(2):207-220.
57.Wechsler H, Nelson TF, Lee JE, Seibring M,
Lewis C, Keeling RP. Perception and reality:
A national evaluation of social norms marketing interventions to reduce students’ heavy
alcohol use. J Stud Alcohol. 2003;64(4):484494.
58.Steffian S. Correction of normative misperceptions: An alcohol abuse prevention program. J Drug Educ. 1999;29(2):115-138.
59.Berkowitz AD. An overview of the social
norms approach. In: Lederman LC, Stewart
LP, eds. Changing the Culture of College
Drinking: A Socially Situated Health Communication Campaign. Cresskill, NJ: Hampton
Press; 2005:193-214.
60.Kilmarting C, Smith T, Green A, Heinzen H,
Kuchler M, Kolar D. A real time social norms
intervention to reduce male sexism. Sex
Roles. 2008;59(3-4):264-273.
61.Schultz PW, Nolan JM, Cialdini, RB, Goldstein, NJ, Griskevicius, V. The constructive,
destructive, and reconstructive power of social norms. Psychol Sci. 2007;18(5):429-434.
62.MacKenzie R, Chapman S, McGeechan K,
Holding S. A disease many people still feel
uncomfortable talking about: Australian television coverage of colorectal cancer. PsychoOncology. 2010;19(3):283-288.
63.Marshall DA, Johnson FR, Phillips KA,
Marshall, JK, Thabane L, Kulin NA. Measuring patient preferences for colorectal cancer
screening using a choice-format survey. Value
in Health. 2007;10(5):415-430.
64.Gimeno-Garcia AZ, Quintero E, NicolasPerez d, Parra-Blanco A, Jimenez-Sosa A.
Impact of an educational video-based strategy on the behavior process associated with
colorectal cancer screening: a randomized
controlled study. Cancer Epidemiology.
41
www.casesjournal.org
73.Bandura A. Human agency in social cognitive
theory. Am Psychol. 1989;44(9):1175-1184.
74.Bandura A. Health promotion by social
cognitive means. Health Educ Behav.
2004;31(2):143-164.
75.Bandura A. Social cognitive theory and exercise of control over HIV infection. In DiClemente RJ, Peterson JL, eds. Preventing AIDS:
Theories and methods of behavioral interventions. New York, NY: Plenum; 1994:25-59.
76.Cialdini RB. Influence: Science and Practice. Needham Heights, MA: Allyn & Bacon;
2001.
77.Rogers EM. Diffusion of Innovations. New
York, NY: The Free Press, 2003.
78.Hornik R, Jacobsohn L, Orwin R, Piesse A,
Kalton G. Effects of the national youth antidrug media campaign on youths. Am J Public
Health. 2008;98(12):2229-2236.
79.Booth ML, Neville O, Bauman A, Clavisi O,
Leslie E. Social–cognitive and perceived environment influences associated with physical activity in older Australians. Prev Med.
2000;31(1):15-22.
80.Dearing JW. Improving the state of health
programming by using diffusion theory. J
Health Commun. 2004;9(1):21-36.
81.Goldman KD. Perceptions of innovations as
predictors of implementation levels: the diffusion of a nationwide health education campaign. Health Educ Q. 1994;21(12):433-445.
82.Haider M, Kreps GL. Forty years of diffusion
of innovations: Utility and value in public
health. J Health Commun. 2004;9(1):3-11.
83.Valente TW, Fosadso R. Diffusion of innovations and network segmentation: The part
played by people in promoting health. Sex
Transm Dis. 2006;33(7):S23-S31.
84.Rim SH, Joseph DA, Steele CB, Thompson
TD, Seeff LC. Colorectal cancer screening-United States, 2002, 2004, 2006, and 2008.
MMWR Surveill Summ. 2001;60(1):42-46.
2009;33(3-4):216-222.
65.Starfield B, Shi L. Policy relevant determinants of health: an international perspective.
Health Policy. 2002;60(3):201-218.
66.Collins R, Doty MM, Robertson R, Garber T.
Help on the horizon: How the recession left
millions of workers without health insurance,
and how health reform will bring relief. Findings from the Commonwealth Fund. Available
at: http://www.commonwealthfund.org/Publications/Fund-Reports/2011/Mar/Help-on-theHorizon.aspx?page=all. Accessed January 4,
2012.
67.National Institute for Health Care Reform.
National Institute for Health Care Reform Detroit Community Report [Web page]. National
Institute for Health Care Reform Web site.
Available at: http://www.nihcr.org/DetroitCommunity-Report.pdf. Updated August
2010. Accessed January 4, 2012.
68.Anderson LM, May DS. Has the use of cervical, breast and colorectal cancer screening
increased in the United States? Am J Public
Health. 1995;85(6):840-842.
69.Ruffin MT, Gorenflo DW, Woodman B.
Predictors of screening for breast, cervical, colorectal, and prostatic cancer among
community-based primary care practices. J
Am Board Fam Prac. 2000;13(1):1-10.
70.Kune GA, Kune S, and Watson LF. Body
weight and physical activity as predictors of colorectal cancer risk. Nutr Cancer.
1990;13(1-2):9-17.
71.Baranowski T, Perry CL, Parcel GS. How individuals, environments and health behavior
interact: Social cognitive theory. In Glanz K,
Rimer BK, Wisnanath K, eds. Health Behavior and Health Education: Theory, Research
and Practice. 4th ed. San Francisco, CA:
Jossey-Bass; 2008:165-184.
72.Glaz K, Bishop DB. The role of behavioral
science theory in development and implementation of public health interventions. Annu
Rev Public Health. 2010;31(1):399-418.
42
www.casesjournal.org
85.King J, Fairbrother G, Thompson C, Morris DL. Colorectal cancer screening: optimal
compliance with postal fecal occult blood
test. Aust N Z J Surg. 1992;62(9):714-719.
86.Kushi LH, Byers T, Doyle C, et al. American Cancer Society guidelines on nutrition
and physical activity for cancer prevention:
Reducing the risk of cancer with healthy food
choices and physical activity. CA Cancer J
Clin. 2006;56(5):254-281.
87.The Pew Research Center. Pew Research
Center Biennial News Consumption Survey
2006. Available at: http://www.scribd.com/
doc/10133/Pew-Research-Center-OnlinePapers-Modestly-Boost-Newspaper-Readership-2006. Accessed January 4, 2012.
88.Goldstein NJ, Martin SJ, Cialdiani RB. Yes!
50 scientifically proven ways to be persuasive. New York, NY: Free Press; 2008.
89.Michigan Cancer Consortium. MCC Spirit of
Collaboration Awards [Web page]. Available
at: http://www.michigancancer.org/AboutTheMCC/AwardsByYear.cfm. Accessed January 4, 2012.
90.Myers RE, Ross EA, Wolf TA, Balshem A,
Jepson C, Millner L. Behavioral interventions
to increase adherence in colorectal cancer
screening. Med Care. 1991;29(10):1039-50.
91.Myers RE, Ross EA, Wolf TA, et al. Modeling adherence to colorectal cancer screening.
Prev Med. 1994;23(2):142-151.
92.Elwood TW, Erickson A, Lieberman S. Comparative educational approaches to screening
for colorectal cancer. Am J Public Health.
1978;68(2):135-138.
93.Rossi PG, Grazzini G, Ani M, et al. Direct mailing of faecal occult blood tests for
colorectal cancer screening: a randomized
population study from Central Italy. J Med
Screen. 2011;18(3):121-127.
94.Kotler P, Roberto N, Lee N. Social Marketing: Improving the Quality of Life. Thousand
Oaks CA: Sage; 2002.
95.Grier S, Bryant CA. Social marketing in
public health. Annu Rev Public Health.
2005;26(1):319-339.
96.Tell E J, Cutler J A. A national long-term care
awareness campaign: A case study in social
marketing. Cases in Public Health Communication & Marketing. 2011;5:75-110.
97.Foerster SB, Gregson J, Beall DL, et al. The
California children’s 5 a day- power play!
campaign: Evaluation of a large-scale social
marketing initiative. Fam Community Health.
1998;21(1):46-64.
98.Thomas KB, Hauser K, Rodriguez NY, Quinn
GP. Folic acid promotion for Hispanic women
in Florida: A vitamin diary study. Health
Educ J. 2010;69(3):344-352.
43
www.casesjournal.org
Author Information
Leah M. Omilion-Hodges, Ph.D., is an Assistant Professor of Communication at Western Michigan University where she teaches courses in leadership, public relations and social influence/persuasion. Dr. Omilion-Hodges
contributed to the design, acquisition and analysis of data and manuscript
writing.
Rebecca O’Grady is widely experienced in health communication and
promotion, and is currently a Marketing Communication Specialist with
St. Joseph Mercy Oakland. Ms. O’Grady contributed to the acquisition and
interpretation of data as well as manuscript review.
44