This project, which was jointly funded by NHS Tameside and Glossop and Tameside Metropolitan Borough Council (MBC), aimed to increase early cancer detection and reduce late presentations and death rates of breast cancer by encouraging women aged 35 to 50 to be breast aware.
Following an extensive scoping stage, a strategy was developed that incorporated communication, community-based and service-led initiatives. Interventions were piloted between February and April 2010 in Ashton Hurst, which is one of the most deprived communities in Tameside and has particularly low breast cancer survival rates.
- Increased awareness of the range of breast cancer symptoms to look out for and confidence in how to self-examine
- Disappointingly, the campaign did not achieve an increase in women examining their breasts at least once a month (as recommended by the NHS)
- 40 per cent awareness of the campaign, which made women clearer about what is normal for them and changes to look for
- The well-women event was the most well attended community event the Primary Care Trust/Council had ever held in the area
- The campaign prompted other positive health behaviours, such as exercise
In line with the rest of England, breast cancer is the most common cause of death from cancer amongst women in Tameside and Glossop. Although the incidence of breast cancer in the region is no higher than the national average, survival rates are lower due, in part, to late presentation. Early detection of breast cancer can lead to simpler, more effective treatment and improvement in survival rates. The NHS Breast Cancer Screening Programme provides free screening every 3 years to women aged between 50 and 70. However, breast screening uptake in NHS Tameside and Glossop (NHST&G) was showing a downward trend and as at 31 March 2007, coverage of women aged 53 to 70 in NHST&G was just 61.3 per cent, compared to 73.8 per cent in England.
Whilst breast screening programmes are an important method of detecting cancer, self-awareness and understanding of what clinical signs to look for also have an important role to play. In 1991, the Department of Health England (DH) abandoned systematic breast self-examination and replaced it with a policy that encourages women to be breast aware from age 18. This has been encapsulated by the NHS’s breast awareness five-point code:
- Know what feels normal for you
- Look and feel
- Know what changes to look for
- Report any changes without delay
- Attend full breast screening if aged 50 or over
Project initiation and funding
To increase early cancer detection and survival rates, NHST&G approached The NSMC to initiate a social marketing pilot project to increase breast awareness in women aged 35 to 50. There was a desire within the Primary Care Trust (PCT) to understand and act on real insight, rather than to continue doing what had always been done, and social marketing offered a way of managing this new approach.
Chosen as 1 of 10 social marketing learning demonstration sites, the project received free social marketing guidance from a member of The NSMC team, as well as funding for independent outcome evaluation to be conducted by the London School of Hygiene and Tropical Medicine (LSHTM).
The project was initiated by the Associate Director of Health Improvement, with £18,000 from the public health improvement budget. However, due to absence from long-term illness, plus staffing shortages from restructuring within the PCT, the project lacked dedicated local resource to push it through in the early stage. The project was subsequently picked up by the PCT cancer lead (a consultant in public health medicine), who was able to enlist the support of a colleague who held a joint commissioning post across the integrated Council and PCT Health Improvement Teams. Recognising the initial funding was not sufficient to scope, design and implement an effective project, they aligned their funding pots for preventative activities to boost the budget for the project to £55,000 (excluding evaluation). With this funding, a social marketing agency was commissioned to provide dedicated project management support and deliver the scoping and development work.
The short-term aim of the project was to increase the number of women aged 35 to 50 in Ashton Hurst ward who are aware of their breasts and who examine them regularly.
Longer-term aims of the project were to increase:
- The speed at which women report an abnormality to their GP
- The number of women who attend breast screening from aged 50
- The number of GPs, practice nurses and community workers who routinely and systematically inform, encourage and support women to be breast aware
The target audience was initially defined as women aged 35 to 50, living in the top 10 per cent of deprived communities in Tameside and Glossop. This age group was targeted to increase the possibility of early detection in younger women who are not yet eligible for free breast screening, and to increase interest in and uptake of breast screening once they reach 50. Late presentation is a particular issue amongst more deprived women. The Ashton Hurst ward was selected as the pilot area since it is one of the most deprived communities in the PCT and both breast screening uptake and breast cancer survival rates are particularly low.
The scoping stage of the project comprised desk-based research, primary research with the target audience and interviews with key stakeholders.
Desk-based research was carried out in summer 2008 to provide an overview and analysis of existing secondary research and what was known from the evidence base of social marketing and other work relating to breast awareness, cancer and screening. The research focused on gathering information about the target audience, current UK policy and examples of good practice. However, the evidence base around breast awareness, particularly among women aged under 50, was scant. Research that did exist suggested that breast awareness is affected by a host of psychographic factors, including self-efficacy, confidence, body image and embarrassment.
To establish a baseline of local knowledge, awareness and behaviour around breast awareness, LSHTM carried out a street survey in summer 2009 in Ashton Hurst (intervention area) and South Denton (comparison area), which had been matched for age structure, deprivation and rural/urban mix. A face-to-face questionnaire was implemented with 185 women aged between 35 and 50 across the intervention and control areas.
To further explore local women’s knowledge, behaviour and attitudes around breast awareness, and their barriers and motivators for being breast aware, primary research was conducted with women aged 35 to 50 living in Ashton Hurst and South Denton. This involved 2 focus groups with 6 to 8 members of the public, and 15 women were interviewed, either individually or as part of a friendship pair.
Twenty in-depth interviews were also conducted with key stakeholders (such as GPs, nurses, and a range of other health professionals and community workers) to explore if and how service improvements could be made to increase breast awareness.
The findings from the street survey and qualitative research were largely consistent: women were aware of the dangers of breast cancer, but few regularly examined their breasts or felt confident they were doing it correctly and knew what changes to look for, other than lumps.
While women were unlikely to visit a mobile unit or stand, or attend workshops, they were amenable to receiving health messages in the community from non-health professionals and in non-health settings, such as in community centres or the workplace. Poster advertising, direct mail and articles in local newspapers were regarded as the most effective media channels.
The baseline survey and primary research with women found that although many women were aware of the dangers of breast cancer and claimed to check their breasts, most only checked infrequently and felt they were probably doing it incorrectly. The majority of women associated breast awareness with finding lumps and few were aware of other changes to look out for.
While most women were concerned about breast cancer, the barriers to being breast aware were varied and included:
- Not seeing the benefits
- Not knowing what to look for
- Lack of confidence in their ability to self-examine
- Fear of finding cancer
- Having a fatalistic view
- Not wanting to bother their GP
Nurses seemed to have an accurate understanding of what it meant to be breast aware and reported giving lifestyle advice, including about being breast aware. GPs seemed to have a more basic understanding and did not routinely offer lifestyle advice. Health trainers also had a potential role to play as they engage directly with people to offer advice on a wide range of lifestyle issues, but not specifically on being breast aware.
Interestingly, none of the professionals interviewed were spontaneously aware of the breast awareness code, but were very positive about it when it was described to them. Although the nurses interviewed had a good understanding of what it meant to be breast aware and reported giving women advice about being breast aware, most of the women involved in the research had not received advice from their GP or nurse about breast awareness.
Since some women worried about bothering their GP and many considered the practice nurse the most appropriate person to give breast awareness advice, nurses and community workers (rather than GPs) in particular would be encouraged to proactively provide advice and support around breast awareness.
In light of these insights, there was a clear need to promote the breast awareness five-point code consistently to the target audience and service providers to give women a full understanding of how to check, what to look for and why to act fast. There was also a need to emphasise the flexibility and ease of becoming breast aware (and how there is no one right way to check), as well as how early detection, diagnosis and prompt treatment can significantly improve survival rates and give women peace of mind.
Further segmentation using Mosaic (a lifestyle segmentation tool that classifies all consumers in the UK into 61 types, aggregated into 11 groups) highlighted that within Ashton Hurst the key lifestyle groups with a sizeable population that fit the demographic segmentation were: G Municipal Dependency; D Ties of Community; and H Blue Collar Enterprise.
Key common characteristics of the three groups are:
- They lead generally unhealthy lifestyles
- They tend to lead passive lives – A significant proportion does not take deep responsibility for their own futures
- The focus of their lives is very local
- They are a homogenous market, without markedly distinct individual needs and preferences
- As consumers, they focus heavily on price, reliability and convenience, and are more influenced by straightforward benefit-based advertising, than by sophisticated lifestyle imagery (although they do value face-to-face contact)
- They are unlikely to be influenced much by issues such as healthy ingredients, social or environmental responsibility, or ethics
- They are receptive to the following communications channels – TV, posters, telemarketing and drop-in centres
Insights gathered through the primary research also allowed the audience to be segmented into three distinct groups according to their behaviour:
- Group 1 – Do not check their breasts and are least likely to present to a health professional if an abnormality is detected
- Group 2 – Might check their breasts, but not consciously or regularly, and are only likely to present to a health professional if a lump is detected
- Group 3 – Check their breasts regularly and are likely to present to a health professional if an abnormality is detected
The interventions would target groups 1 and 2, but efforts would be made to identify and use group 3 to spread their knowledge and behaviour throughout the community.
Based on the scoping work, the team arrived at an approach that mixed communication with community-based and service-led initiatives. This combination aimed to ensure that not only would the target audience be made aware of the importance of breast awareness, but they would also be prompted and facilitated to change their behaviour.
- To provide women with a compelling case for regularly checking their breasts and reporting any changes to their GP as soon as possible
- To provide women with the information they need to enable them to check their breasts and identify the changes requiring further investigation, as well as where to go for extra help and support
- Early breast cancer diagnosis results in simpler and more effective treatment and increased survival rates
- Take control of your health – Being breast aware significantly reduces your risk of dying from breast cancer
- It’s quick and easy to be breast aware and can be incorporated into your everyday routine
- Being breast aware gives you peace of mind
- Positive and empowering, with a focus on the benefits of being breast aware
- Poster advertising in outdoor, health and community settings
- Information leaflet distributed to pharmacies, GP surgeries, pubs, hairdressers and other community venues
- Direct mail – Letter and information leaflet sent to all women aged 35 to 50 on the PCT practice list
- PR using local media
- Breast awareness website linked to the PCT and Council websites
Four creative concepts were tested using focus groups with members of the target audience. The creative concept that clearly struck a chord with the audience was ‘Breast Expert’. Using images of strong and confident women, Breast Expert focused on the flexibility and ease of becoming breast aware and showed that getting to know your breasts gives you a sense of empowerment and control. Being breast aware was promoted as something women could easily incorporate into their everyday routines, such as when bathing, moisturising or getting dressed.
“I thought the posters were good because they were real looking women. They weren’t models, they weren’t anybody famous, but they were how women look in their bras, saying ‘I’m my own breast expert’. It was clear, it wasn’t complicated, it was a useful message to get out there.” Project stakeholder
- To provide women with the opportunity to learn about breast awareness from their peers
- To provide women with an opportunity to learn about breast awareness, alongside other health issues, through informal face-to-face contact with health professionals
- Breast awareness ‘community champions’ recruited from the local population to help spread the message through peer networks
- Free ‘well woman’ event, with a particular focus on breast awareness, co-delivered with other local health and community stakeholders
- To provide health professionals with the knowledge and resources they need to inform, encourage and support women to be breast aware
- To build breast awareness into service delivery to ensure its systematic inclusion in all relevant primary care appointments
- Breast awareness materials and training for practice nurses, health trainers and community development workers
- Inclusion in GP contracts to ensure that breast awareness is routinely raised and discussed during cervical screening and family planning appointments (long-term activity)
During the development phase, additional members from the PCT and Council were brought into the team to help deliver specific elements of the project.
A Health Improvement Manager took responsibility for organising the stakeholder launch event and led on the community-based initiatives, liaising with community development workers to pretest the communications materials and organise the well woman event. Working with the PCT cancer lead and external project manager, he also engaged with health and community stakeholders around spreading the breast aware message and delivering training materials to them.
The Head of Communications at the PCT and Head of Marketing and Media Management at the Council organised the printing of all communications materials and media buying, press releases, internal communications and direct mail to target women within Ashton Hurst. They also worked with the PCT Cancer Lead on sending communications about the campaign to GPs, practice nurses and practice managers.
The social marketing agency led on designing the communications materials and developing the campaign website.
LSHTM developed an evaluation plan that consisted of three components:
- Prospective case-control study – To assess any changes in knowledge and behaviour among women aged 35 to 50 in Ashton Hurst. This comprised two waves of fieldwork – a baseline ‘pre’ survey (completed in April to June 2009), followed by a ‘post’ survey (completed in June to July 2010), conducted in Ashton Hurst (intervention area) and South Denton (comparison area). The sample included around 100 women aged 35 to 50 in each of the two areas, and at both stages.
- Qualitative research with key stakeholders – To explore the extent to which operational plans proposed were carried out, capture learning surrounding the delivery of the project and examine factors that may have enhanced or hindered progress. This involved in-depth face-to-face interviews with eight stakeholders who were involved in the scoping, development and implementation of the campaign, and were held in July and August 2010.
- Qualitative research with target women – To explore women’s experiences of the interventions, how useful they found them and what effect (if any) they had on their breast awareness. This involved telephone interviews with 11 women who had attended the well women event. These were completed in July and August 2010.
Due to delays at the start of the project and funding for NSMC support through the learning demonstration sites scheme due to end in spring 2010, there was only three months left to pilot the campaign following completion of scoping and development.
Prior to implementation, the community development team approached local venues, such as schools, places of worship, library, pubs, hairdressers, stop smoking service and dental practices, to distribute campaign posters and leaflets. Although a stakeholder launch event was planned for January 2010 prior to the public launch, this had to be postponed to April to give key stakeholders enough of a lead-time to attend the event.
The campaign was launched in Ashton Hurst on 1 February 2010 with poster advertising at bus stops and on telephone kiosks. The posters encouraged women to visit www.breastaware.net for more details on why and how to be breast aware. The campaign website was also linked to the PCT and Council websites.
An information leaflet was distributed in health and community settings (such as GP surgeries, shops and fast-food outlets) and mailed with an accompanying letter from the PCT to all women in the target group informing them about the campaign and the local well woman event.
On 18 March 2010, a free well woman event was held from 2pm to 8pm at Hurst Community Centre, attracting over 160 women. Women were reminded about the event with an additional door drop and posters in Ashton Hurst in the lead-up to the event. During the day, the Health Improvement Service was on-hand to offer health checks and information on their services and a Macmillan breast cancer nurse provided information on becoming breast aware. Attendees were also able to enjoy beauty treatments (such as nail art and eyebrow threading), massages, pilates, yoga and a bra fitting service offered by other community providers. All attendees were also entered into a free prize draw and received refreshments and a free goody bag, including a branded nail file, mirror and booklet on being breast aware. The event attracted feature articles in two local newspapers, helping to build awareness of the campaign throughout the area.
Breast awareness information, in the form of a fact sheet and presentation developed by the Macmillan breast cancer nurse, was offered to GPs and practice nurses in Ashton Hurst, with a covering letter from the PCT Cancer Lead. Community workers received face-to-face training from the Macmillan cancer nurse. However, due to scheduling conflicts, training for practice nurses had to be postponed to autumn 2010.
The limited timescales for the project left little time to identify and develop community champions, or to engage fully with primary care staff to incorporate breast awareness into their consultations with target women.
“We did find it got a bit rushed and the timing, there needed to be more time to get an idea of working with others and there wasn’t a lot of lead-in time. Training needs planning ahead of time; some training is still to be run that ideally would have been run before the letters were sent out. And getting the GPs on board – it was the wrong time of year for them as March is their end of year and we didn’t give enough time.” Project stakeholder
The project managed to achieve its behavioural goal of getting women to be aware of their breasts, as well as its short-term objectives of increasing women’s knowledge of the changes to look for and their confidence in spotting these changes. However, the project did not manage to meet its goal of getting women in Ashton Hurst to examine their breasts more regularly.
Knowledge of breast awareness and the changes to look for
- When asked what the term ‘breast aware’ meant to them, the majority of post survey respondents had some knowledge and understanding of it. 42.5 per cent said it was about checking or regularly checking your breasts for changes, 20 per cent said it was about looking for lumps and other changes, and around 15 per cent said it was about being aware of your breasts more generally (rather than looking specifically for symptoms)
- However, 10 per cent of respondents said being breast aware was about looking for lumps (without mentioning other symptoms) and no respondents mentioned the other behaviours encapsulated in the five-point code (i.e. seeking medical advice or attending for breast screening)
- Most women who reported checking their breasts were looking for lumps when they examine and were not so vigilant about other symptoms, like changes in breast appearance or feeling. Compared to pre survey results though, a greater proportion of respondents to the post survey mentioned looking for ‘lumps and other abnormalities’, rather than looking for just lumps
- The key reasons cited by women for not examining more regularly were they forgot or they never thought about it. Fewer women in the post survey said it was because they were ‘not sure what to look for’ or were ‘not sure how to check properly’, suggesting an increased knowledge of the changes to look for and how to check
Confidence in spotting changes
- Compared to results gathered before the campaign, the intervention area saw a drop in the proportion of women who were ‘not at all confident’ of noticing a change
- Compared to the comparison area, a greater proportion of respondents in the intervention area reported being ‘very confident’ of noticing a change
- Disappointingly, following the campaign the proportion of respondents who reported examining their breasts at least once a month (as recommended by the NHS) fell in the intervention area
- According to the post survey, 40 per cent of respondents in Ashton Hurst had seen, heard or received something about breast awareness during the campaign period
- Of these, 25 per cent said the information prompted them to examine their breasts more regularly and 41.7 per cent said the information made them clearer about what is normal for them and what changes to look for
- GP staff were still considered key figures for disseminating the breast awareness message and both areas saw an increase in the number of women offered advice on breast awareness by their GP or practice nurse
- The community event delivered as part of this project was the most well attended community event the PCT/Council had ever held in the area
- Feedback from the community development team indicated the campaign had prompted other positive health behaviours
“Physical activity picked up after the event and the campaign; things like health walks and keep fit classes. Women-only activity increased about 10 to 15 per cent in the weeks imminently after the campaign. Exercise of course impacts on breast cancer, so a better general wellbeing is a positive thing.” Project stakeholder
Some of the interventions are still ongoing, with the longer-term aim of building breast awareness into service delivery to ensure its systematic inclusion in all relevant primary care appointments. One option would be to include this in GP contracts to ensure that breast awareness is routinely raised and discussed during cervical screening and family planning appointments.
Tameside and Glossop is currently highlighting breast cancer symptoms as part of the DH funded Greater Manchester ‘Don’t be a Cancer Chancer’ social marketing campaign. This campaign includes targeted community work in three localities and the approach used draws directly on the experience from the Breast Aware project.
Tameside and Glossop is also part of a Macmillan funded three-year pilot of community cancer champions. This will draw on the local experience of coordinating the Breast Aware project and include follow on work to continue promoting the breast aware message across a wider footprint.
The project has been written up as a case study in the Social Marketing Casebook, published in 2011.
What worked well
- A strong history of joint working between the PCT and Council, which established a shared function for public health commissioning, allowed extra local funding to be secured to supplement the initial £18,000 funding for the project
- Costs were kept down by using existing resources as much as possible. For example, community development workers and their networks, specialist cancer nurses and internal support mechanisms (like the PCT and Council communications teams and their own design and print suppliers) were used to capitalise on resources that required no extra cost
Recommendations for future work
- Despite efforts to engage GPs and nurses in the campaign, clinician involvement during the project was disappointing due to various reasons, and training planned for practice nurses by a Macmillan cancer nurse had to be postponed to late 2010. Sufficient lead-in time needs to be built in and senior level buy-in secured from the start to gain active involvement from GP staff
- Feedback from stakeholders and target women highlighted the importance of family and social networks as key avenues for encouraging women to become breast aware. In addition to print and online media, providing information and the option to discuss any issues or concerns in person would greatly increase women’s confidence to self-examine and spot any changes. Greater use of word-of-mouth and face-to-face communication would help to motivate and support women to become breast aware, without requiring the expenditure of paid-for advertising
- Further segmentation of the target audience based on their current knowledge and behaviour would allow for more targeted messaging and help ensure relevant information is sent to different segments of the target audience
- There was strong support from women interviewed that breast awareness needs to be introduced and promoted at a younger age, and a feeling that the campaign messages would resonate with younger women as part of understanding and caring for your body