Strategic Communication for Cancer Prevention and Control: Reaching and Influencing Vulnerable Audiences

This unique synthesis of chapters from top experts in their fields targets the unique and significant area of cancer prevention for different types of cancers. Perspective readers are invited to go through novel ideas and current developments in the field of molecular mechanisms for cancer prevention, epidemiological studies, antioxidant therapies and diets, as well as clinical aspects and new advances in prognosis and avoidance of cancer. The primary target audience for the book includes PhD students, researchers, biologists, medical doctors and professionals who are interested in mechanistic studies on cancer prevention and translational benefits for optimized cancer treatment.


Introduction
Strategic health communication efforts can help reduce cancer risks, incidence, morbidity and mortality, and improve quality of life for at-risk populations. However, providing relevant information about cancer prevention and control to vulnerable populations is fraught with difficulties. Just the ability to get members of at-risk populations to pay attention to information provided about cancer can often be a challenge. Most people do not want to hear or think about cancer unless they are forced into it because they or someone they care about has been diagnosed with some form of the dreaded disease. Since the term "cancer" is surrounded by a significant stigma in modern society that equates cancer with death and suffering, communication about cancer makes many people uncomfortable, forcing them to think about their potential to suffer and die. 1 Strategic cancer prevention and control communication campaigns should be designed to overcome the pervasive social stigma that influences public attitudes towards cancer education.
The good news for health communicators is that the extremely negative social stigma surrounding cancer as an unavoidably deadly disease does not reflect the reality of cancer care in the modern world. Increasingly, those who are diagnosed with cancers are able to get helpful treatments and live productive lives as cancer survivors. Some public health scholars have suggested that with the advent of viable cancer treatments, cancer is becoming a chronic, rather than a terminal, disease due to increases in long-term cancer survivorship. 1 There are also many good evidence-based health promotion strategies available to help people reduce their risks for developing cancers, to help them detect cancers early when the cancers can be most effectively treated, and to get the best care for living with cancer. 2 However, consumers who have elevated cancer risks need access to the relevant information about cancer prevention and control to make their best health promoting decisions. While the pervasive negative social stigma surrounding cancers makes communicating about cancer prevention very difficult to do well, cancer communication efforts can be strategically planned and executed to encourage key audiences to attend to and respond to relevant cancer prevention information. Access to relevant and persuasive health information is essential for helping vulnerable population members reduce their risks for cancer-related morbidity and mortality by guiding evidence-based decision-making about cancer prevention and control.
However effective cancer communication efforts are further complicated by the sense of fatalism about cancer control that is widely held by many members of at-risk populations. Data reported from recent administrations of the Health Information National Trends Survey (HINTS) conducted by the National Cancer Institute suggest that many members of the American public believe there is little that can be done to prevent cancers and even less that can be done to treat cancers once they are diagnosed. 2 A large numbers of HINTS respondents reported that they are confused by all the different recommendations they encounter concerning cancer prevention and control and are not sure what to do to reduce their risks for contracting cancers. 2 The range of competing recommendations about cancer that consumers often encounter gives them the impression that "everything causes cancer." What is worse, consumers report that the recommendations they hear concerning cancer www.intechopen.com Strategic Communication for Cancer Prevention and Control: Reaching and Influencing Vulnerable Audiences 377 prevention and control seem to change all the time, further confusing them. 2 To counter these communication challenges, cancer communicators should develop clear, easy to understand, and consistent communication strategies for breaking through the confusion. They need to reduce the inertia caused by public fatalism concerning cancer with the use of engaging and persuasive messages that motivate adoption of evidence-based cancer prevention recommendations. This chapter examines the challenges to communicating relevant cancer prevention and control information to vulnerable populations and suggests best practices for designing meaningful messages and effectively using relevant media to reduce cancer-related health disparities and to promote public health.

Vulnerable populations and health communication
Communication is the central social process in health promotion and care for informing cancer prevention and control for vulnerable populations. 1,2 The process of communication is the primary social mechanism used to both seek and deliver cancer care. Communication is the primary process for delivering cancer education and influencing cancer-related health behaviors. Communication is the coordinating process used to manage health care delivery systems. It is also the social process used to establish and reinforce health policies and practices. Health care consumers and providers depend upon communication to gather relevant health information for guiding evidence-based health decision making, encouraging participation in health care and health promotion activities, reducing uncertainty about cancers and increasing understanding about relevant health issues, as well as promoting needed cooperation and collaboration to achieve health goals.
Vulnerable populations are those groups of health care consumers who are most likely to suffer significantly higher levels of morbidity and mortality from cancers than other segments of the general population. 3 These vulnerable population members are typically the poorest, least well educated, and most disenfranchised members of modern society, including members of many immigrant and minority groups, the elderly, the socioeconomically deprived, the disabled, and people suffering from serious chronic diseases. 3 Many members of these vulnerable populations are likely to experience key health communication barriers such as health literacy challenges, limited access to and ability to use key channels of communication (such as new information technologies), as well as suffer from serious social and economic problems that can limit their ability to get needed care and to follow cancer prevention and control recommendations. 4,5 There are a broad range of significant health risks confronting members of vulnerable populations today, including risks from cancers, heart disease, diabetes, stroke, HIV/AIDS, and other serious health threats. 6,7 Effective health communication is needed to help those members of the public who are at greatest risk (most vulnerable) for suffering from these health threats to recognize, minimize, and respond effectively to potential health problems. 8,9 It is particularly important to effectively communicate clear, accurate, and persuasive information about cancer prevention and control to audiences who are at greatest risk for negative cancer outcomes, those who suffer from cancer health disparities. 10,11,12,13 Unfortunately, current efforts to educate the most vulnerable segments of society about cancer prevention and control strategies have been insufficient to significantly reduce cancer incidence, morbidity, and mortality for members of these groups by helping them make informed decisions about their best health care and health promotion choices. 15,16,17,18 The need for effective communication about cancer risks and responses is particularly acute, yet also tremendously challenging, for reaching vulnerable health care consumers. 19,20 These vulnerable population members are heir to serious disparities in cancer-related health outcomes, resulting in alarming levels of cancer-related morbidity and mortality, especially in comparison to the rest of the public. 19,21,22 The cultural barriers and health literacy challenges faced by many members of vulnerable populations, who are often immigrants, as well as non-native and substandard English speakers, readers, and writers, creates significant barriers to accessing and making sense of relevant cancer-related information. 23,24,25 These consumers are often confused and misinformed about the causes, preventive strategies, early detection procedures, and the treatments for different forms of cancer, which serves to exacerbate their poor cancer-related health outcomes. 25 Members of vulnerable populations who are likely to suffer from significant cancer-related health disparities are desperately in need of relevant, accurate, and timely health information about cancer prevention and control. 26,27,28 Some vulnerable group members, such as elderly health care consumers, have elevated risks for contracting different forms of cancer, while other vulnerable group members, such as African American women, are more likely to die from breast cancer than other women. 3,16,25,26 Many members of immigrant populations in the US are non-native English speakers and encounter serious language and health belief barriers that necessitate adaptive, culturally-sensitive communication strategies to provide them with needed cancer-related health information. 27,28,29,30 Furthermore, consumers with serious and chronic medical conditions, as well as individuals who confront physical and mental disabilities, are often particularly vulnerable to health risks and have unique communication needs that must to be adequately addressed to provide them with the relevant health information they need to preserve their health. 31 Strategic, adaptive, and culturally-sensitive health communication information dissemination programs are needed for reducing cancer-related health disparities by providing vulnerable consumers with relevant and persuasive health information to h e l p t h e m e v a l u a t e h e a l t h r i s k s , m a k e informed health care decisions, and direct their health behaviors.

Focus on cultural issues
Vulnerable consumers' unique cultural backgrounds and orientations have powerful influences on their communication practices that must be carefully accounted for when designing and implementing strategic cancer communication efforts. 32 It is critically important to identify and examine the relevant cultural issues that are likely to influence the ways consumers, particularly members of vulnerable populations, respond to communication about cancer prevention and control. 27,29,31 Several of the key cultural variables that influence cancer communication outcomes include the unique health beliefs, values, norms, and expectations that different consumers bring to health situations that influence their cancer-related health decisions and behaviors. 26 It is also important to assess consumers' culturally-based language skills and orientations, their health literacy levels (both their levels of literacy for language and numbers), their motivations to seek health information, their unique media use patterns, and their social network memberships. 33,34 Examination of these key cultural factors can provide relevant information for determining how to best design and deliver key messages for effectively communicating complex health information to diverse and vulnerable populations. 27,20,31 Culturally-sensitive health

Strategic health communication design
Health education messages must be carefully designed to be effective. The critical factor in strategic message design is adapting health education messages to meet the unique needs and communication orientations of specific audiences. This means that effective health communication efforts should adopt a consumer orientation to health education. 35,36 Careful audience analysis is essential to identify the salient consumer characteristics that can be used for guiding message design. 37,38 Good audience analysis research will help answer a variety of important questions for guiding cancer prevention and control efforts. These questions are likely to examine a number of relevant communication factors about members of targeted audiences. For example, what are the typical message exchange and information sharing processes employed by targeted groups of consumers? Who do these consumers typically talk to and acquire health related information from? Who do they trust? How do they receive and provide social support? What are their predispositions for interpreting cancer prevention and control messages? What are most influential factors for persuading members of targeted groups to attend to and respond positively to health messages? Which communication channels do members of these targeted groups prefer to use? What are the best ways to provide these consumers with feedback about their health behaviors that can promote and reinforce health behavior changes? What are the most influential communication strategies for developing cooperative and trusted relationships with members of targeted groups? The best health communication intervention programs will be designed to be responsive to audience communication patterns. They will be relevant to audience needs and interests. They will be easily accessible to targeted audience members. The messages will be culturally appropriate for key audience members. Messages and communication strategies will be adaptive to changing social situation. The messages provided will also be motivational and reinforcing, as well as engaging, interesting, and interactive.
Messages should be designed to appeal to key beliefs, attitudes, and values of targeted audience members, using familiar and accepted language, interesting images, and vivid examples to illustrate key points. 29 It is wise to pre-test sample health education messages with representatives of targeted audiences to make sure the messages hit the intended mark with these audiences before implementing health communication intervention programs. Formative evaluation data gathered through message pre-testing is essential to refining health education messages. 39 This is a form of user-centered design, where health education messages are shaped and refined by actively gathering feedback about campaign design from representatives of the actual audiences who are being targeted in health communication interventions. 39 Pre-testing is also a strategy for helping to increase audience participation in health education efforts. This active participation can not only help to increase the cultural sensitivity of health communication efforts, but can also enhance audience members receptivity to and cooperation with health promotion efforts. 39 Involving consumers, their family members, key members of their social networks, and community representatives can increase support and social encouragement for paying attention to, accepting, and utilizing health education messages. 40,41,42 To be effective at presenting cancer prevention and control information it is wise to design multiple, reinforcing strategic messages that will be delivered at several points in time over different complementary channels of communication for reaching, influencing, and reinforcing vulnerable audiences with health education information. This multiple complementary message strategy builds from the communication principles of redundancy and reinforcement to enhance message exposure and impact. 43 Multiple, reinforcing cancer prevention and control messages can help to capture audience attention by providing these consumers with relevant information at several points of time. This strategy helps to reinforce message content by repeating key ideas. This also helps to illustrate key health education concepts. The use of vivid imagery in health communication interventions through the use of powerful narrative and visual illustrations can also reinforce message content, especially for audiences with limited health literacy, as well as audience members who have problems with numeracy (understanding numerically presented information) that may make it difficult for them to comprehend statistics and numerical risk estimates. 39,40,44,45,46,47 Tailored communication is a powerful approach for designing customized health messages to meet the unique needs and backgrounds of specific individuals. 48 Tailored approaches provide specific customized messages to an individual that match the person's unique www.intechopen.com Strategic Communication for Cancer Prevention and Control: Reaching and Influencing Vulnerable Audiences 381 background, beliefs, and orientations. Key bits of an individual's background information, such as the person's name, age, cultural memberships, or health status are gathered and included in the specific health messages sent to that person. For example, a tailored message might state, "Research has shown that mammograms should be scheduled every other year for a woman of your age, race, and family history with breast cancer Helen." By including specific key information about Helen's background in the message, the information becomes much more interesting and relevant for her. Typically, tailored communication systems employ interactive computer systems that can be used to gather relevant background information from consumers concerning key communication variables (age, race, gender, occupation, health history, etc.) through questions posed to these individuals, including questions eliciting information about individual demographics, psychographics, and health beliefs/behaviors. Once key background information is gathered from the individual, the information is used to select specific messages stored in a library of messages that match the unique background features of the individuals selected to receive health education messages. In this way, information about the individual health risks and orientations of a specific consumer, for example an elderly, African-American, male, with a history of prostate cancer and diabetes, will automatically be selected and used to provide contentappropriate health information to the individuals through a tailored health information communication system. As the consumer continues to interact with the tailored health information system, providing the system with additional background information, a tailored communication computer program can store and catalog this information to continually refine the content of message sent to this consumer to match his or her unique personal characteristics and interests.
In addition to developing strategic messages that match the cultural orientations of at-risk consumers, it is critically important to determine the most effective communication channels for reaching targeted populations of consumers. The best communication channels to utilize are those that are close, familiar, and easily accessible for targeted audience members. 49 For example, it is important to employ communication channels that are easy for members of the intended audience to use. It would be a serious error to develop an online health education website for consumers who do not have access to computers or who are not sophisticated computer users. Communication channels that are dramatic and memorable can have strong influences on audience attention and interpretation of health messages. 49 Health educators should consider using communication channels that can be accessed over time, channels that can retain important information for later review, and even interactive channels that can enable consumers to ask questions and receive clarifications about complex health information. The best strategic communication designs use interactive channels where consumers can provide feedback and ask questions to clarify the information provided. Multiple overlapping communication channels can present complementary messages that are reinforcing over time and delivered by multiple credible sources.
It is important to decide what the best sources are for delivering key messages about cancer prevention and control strategies to different audiences. 39 It is crucial to identify the most credible sources of health information for members of the intended audiences. 49 Decisions need to be made about whether it is best to utilize familiar sources of information, expert sources, or perhaps peer communication as the most influential ways to provide cancer-