37?
svS/
MO,
DESIGNING A SOCIAL MARKETING PLAN TO PROMOTE
HISPANIC PARTICIPATION AT PROSTATE
CANCER SCREENINGS
THESIS
Presented to the Graduate Council of the
University of North Texas in Partial
Fulfillment of the Requirements
For the Degree of
MASTER OF SCIENCE
By
Suzanne M. Zimmerman, B.A.
Denton, Texas
December, 1995
37?
svS/
MO,
DESIGNING A SOCIAL MARKETING PLAN TO PROMOTE
HISPANIC PARTICIPATION AT PROSTATE
CANCER SCREENINGS
THESIS
Presented to the Graduate Council of the
University of North Texas in Partial
Fulfillment of the Requirements
For the Degree of
MASTER OF SCIENCE
By
Suzanne M. Zimmerman, B.A.
Denton, Texas
December, 1995
Zimmerman, Suzanne, M., Designing a social marketing plan to promote
Hispanic/Latino participation at prostate cancer screenings. Master of Science (Health
Promotion), December, 1995, 106 pp., 59 titles.
Prostate cancer is the most commonly occurring cancer and the second leading
cause of cancer death for men in the United States. Because early prostate cancer is
frequently without symptoms and data on how to prevent prostate cancer is lacking, early
detection has the greatest potential for decreasing mortality. Studies have shown
Hispanics/Latinos to be less likely than whites or African-Americans to utilize prostate
cancer screening exams. The purpose of this descriptive study was to design a social
marketing plan which could be used as a model to promote Hispanic/Latino participation
at prostate cancer screenings. Information obtained through medical and marketing
literature review, the author's experiences serving on the promotion committee of a
community-sponsored prostate cancer screening project, and interviews with 51
Hispanic/Latino prostate cancer screening participants is described and incorporated into a
guide with recommendations for future program planners.
Copyright by
Suzanne Marie Zimmerman
1995
ui
ACKNOWLEDGMENTS
The author wishes to thank Dr. Juan Franco, and Edie and Alex Ortega for their
advice and assistance in developing the Spanish language version of the questionnaire; and
Rosemary Galdiano, Carolyn Flores, and John Davila for their assistance in conducting the
study interviews.
IV
TABLE OF CONTENTS
Chapter
Page
1. INTRODUCTION
1
Purpose of the Study
Delimitations
Assumptions
Definition of Terms
Significance of the Study
2. REVIEW OF THE LITERATURE
10
General Profile of Hispanics in the United States
Statistics of Prostate Cancer Among Hispanics
Knowledge, Attitudes, and Beliefs Among Hispanics Regarding Cancer
Knowledge, Attitudes, and Practices Regarding Prostate Cancer and
Digital Rectal Examinations (DRE's) Among Hispanic Males
Important Elements for Inclusion in a Cancer Control Project for Hispanics
Review of Three Cancer Control Projects in Hispanic Communities
Special Issues Associated with Prostate Cancer Screening
Social Marketing Theory
Summary
3. METHODOLOGY
Study Design
Subjects
Procedure
Instrument
Data Collection
Data Analyses
37
4. INTERVIEW RESULTS
49
How Did Hispanic Screening Participants Leam About the Prostate Screening?
The Influence of Other Factors on Hispanic Screening Participation
Participants' Satisfaction With the Prostate Screening
Suggested Ways to Improve the Program and Attract More Hispanic Screening
Participants
5. RECOMMENDATIONS FOR DESIGNING A SOCIAL MARKETING
PLAN
59
Problem Definition
Goal Setting
Target Market Segmentation
Consumer Analysis
Influence Channel Analysis
Marketing Strategies and Tactics
Program Implementation
Program Evaluation
6. SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS FOR FUTURE
STUDIES
.74
Summary of the Research
Conclusions
Recommendations for Future Studies
APPENDICES
82
A-Interview Questionnaire with Cover Letter
B-American Cancer Society Mammography Questionnaire
C-1995 Tarrant County Prostate Screening Project Promotional Activities
D-How Did Interview Participants Leam About the Screening?
E-Other Factors Which Influenced Screening Participation
F-Map of Hispanic Attendance at Interview Sites
G-Social Marketing Plan to Increase Hispanic Participation at Prostate Cancer
Screening
REFERENCES
99
VI
CHAPTER I
INTRODUCTION
Hispanics/Latinos1 are a significant and increasingly growing minority in the United
States. According to the National Coalition of Hispanic Health and Human Services
Organizations (COSSMHO, 1990), "the Hispanic population is expected to continue to
increase at three to five times the rate of the non-Hispanic U.S. population, and to reach
25 million by the year 2000" (p. 10). Addressing the health needs of Hispanics is of
utmost importance. Poverty, little education, lack of insurance, and language barriers
often lead to underutilization of health services, which can predispose Hispanics to
increased morbidity and mortality (Council on Scientific Affairs, 1991).
Although data on cancer incidence rates for Hispanics is limited, overall cancer
rates for Hispanics are lower than for whites or African-Americans (American Cancer
Society, 1991). However, delay in obtaining diagnosis and receiving treatment often
results in poor prognosis (Daly, Clark, & McGuire, 1985; Morris, Lusero, Joyce,
Hannigan, & Tucker, 1989; Suarez, Martin, & Weiss, 1991). Studies have shown
Hispanics to be less knowledgeable and to have more misconceptions about cancer than
1
The terms "Hispanic" and "Latino" are used interchangeable in this paper to mean persons who are of
Mexican, Cuban, Puerto Rican, Central American, South American, Dominican Republican, or Spanish
descent. The term Hispanic will be used unless cited research article specifically uses the term "Latino".
persons of other races/ethnicities (Perez-Stable, Sabogal, Otero- Sabogal, Hiatt, &
McPhee, 1992; Sugarek, Deyo, & Holmes, 1988). Also, Hispanics have been reported to
be less likely to utilize screening exams for early cancer detection than other racial/ethnic
groups (American Cancer Society, 1991; Clark, Martire, & Bartolomeo, 1985; Harlan,
Berstein, & Kessler, 1991; Texas Department of Health, 1993). Interventions which
promote cancer education and early detection in the Hispanic community are warranted.
In Tarrant County, Texas, Hispanics are a significant population. According to a
July 5, 1995, telephone conversation with a spokesperson from the North Central Texas
Council of Governments, the 1990 U.S. Bureau of the Census reported that Hispanics
numbered 139,879 and comprised 12 % of the population in Tarrant County, Texas. A
May 1994 survey conducted by Rincon & Associates of Dallas, Texas concluded that
22 % of the population in Fort Worth is Hispanic (per a telephone conversation with a La
Estrella spokesperson in Fort Worth). Currently in Tarrant County there are special
programs and funding to increase cancer awareness and early detection in the Hispanic
female population through the Susan G. Komen Foundation and the Breast Cancer and
Cervical Cancer Control Program administered by the Tarrant County Public Health
Department. However, there are no similar programs which specifically target Hispanic
males for cancer education and prevention. Community-sponsored prostate cancer
screenings held in 1993 and 1994 had low participation of Hispanic males according to
project chairpersons and site coordinators. From the Tarrant County Prostate Screening
Project's beginnings in 1993, the goal was to reach minorities and the medically
underserved (McLinden & Bowden, 1993). However, according to data collected from
representatives of seven of the eight prostate screening sites utilized in 1994, 85 % of the
men screened were white; 84.2 % of the screening participants were non-indigent (had
incomes above 200 % of federal poverty guidelines). Only 50 of the 871 men screened at
the seven sites in 1994 were Hispanic.2 Percentages of white versus minority participants
remained virtually unchanged from 1993 to 1994, according to LeeAnne Vandegriff of the
Harris Methodist Cancer Program in Fort Worth.
Prostate cancer is the most commonly occurring cancer and the second leading
cause of cancer death for men in the United States (Iammarino & Werstein, 1994).
According to the American Cancer Society (ACS), it is estimated that 40,400 deaths in
1995 will be attributed to prostate cancer. An estimated 244,000 new cases will be
diagnosed in 1995 (ACS, 1995). Because the incidence of prostate cancer increases with
age, morbidity rates are expected to rise as the population ages (Frank, Graham, &
Nabors, 1991).
The etiology of prostate cancer remains unknown. In addition to age, risk factors
include family history and occupational exposure to cadmium (Frank, Graham, & Nabors,
1991). According to the American Cancer Society (1991), data from the Special
Populations Studies Branch of the National Cancer Institute, which included 9 SEER
(Surveillance, Epidemiology and End Results) registry areas, showed incidence rates
2
One screening site was not included in these statistics because data on the financial status and ethnicity
of its screening participants is lacking.
disproportionately higher for African-American males, 125.5 per 100,000, as compared to
males of other races/ethnicities. For example, Mexican Americans3 and whites had
prostate cancer incidence rates of 76.3 and 77.9 respectively per 100,000 during the 19771983 time period studied; the rate among Chinese was considerably lower at 29.6 per
100,000 (ACS, 1991). Causes for racial differences in cancer rates have not been
ascertained; however, genetic susceptibility has been suggested. International research
studies have suggested that a diet high in fat may be a risk factor (ACS, 1995).
Because early stage prostate cancer is frequently without symptoms (Greifzu &
Tiedemann, 1995; Scardino, Weaver, & Hudson, 1992) and data on how to prevent
prostate cancer is lacking, early detection has the greatest potential for decreasing
mortality. American Cancer Society screening guidelines recommend that all men have
annual digital rectal examinations beginning at age 40. Additionally, all men beginning at
age 50 and high risk groups (African-Americans and others with a family history of
prostate cancer) beginning at age 40 should have annual Prostate Specific Antigen (PSA)
tests. The American Urological Association (AUA) recommends that all men 50 years of
age or older (and high-risk males age 40 or older) have both digital rectal examinations
and tests for Prostate Specific Antigen (Iammarino & Werstein, 1994). Unfortunately,
studies have shown that many men have never had, nor even heard of screening
examinations for prostate cancer (American Cancer Society, 1991; Brown, Potosky,
3
Hispanic cancer incidence rates from this cited source were based on rates of Mexican Americans from
New Mexico. It is not known if these rates accurately represented the cancer incidence of other Hispanics
in mainland United States. Data on cancer morbidity and mortality in the Hispanic population is limits
Thompson, & Kessler, 1990; Clark, Martire, & Bartolomeo, 1985; Lantz, Dupuis, Reding,
Krauska, & Lappe, 1994).
African-American males in the United States have the highest prostate cancer
incidence in the world (American Cancer Society, 1995; Frank-Stromberg & Rohan,
1992); therefore, investigational and promotional efforts are focused primarily on them.
Although Hispanic males don't carry the same high risk, their unlikeliness to utilize cancer
screening exams makes them unlikely candidates for early detection. Hispanics are
reported to be more likely than whites to have advanced cases of prostate cancer at
diagnosis (Mettlin & Murphy, 1993; Villar & Menck, 1993). This is an issue that deserves
attention.
Increasingly, Hispanic leaders are appealing for increased efforts towards health
promotion and disease prevention for Hispanics, particularly in regard to diseases, such as
cancer, that affect mortality (Aguirre-Molina, Ramirez, & Ramirez, 1993; Latino Task
Force, 1992; Novello & Soto-Torres, 1993). The scarcity of research pertaining to
Hispanic health is of concern. Novello and Soto-Torres (1993) concluded that
"Hispanics-Latinos must be the subjects of—and be participants in—more research" (p.
532). Iammarino and Werstein (1994) suggested that more research be done on cancer
screening among Hispanics. The sparse data that is available has focused on Hispanic
females, not on Hispanic males. Iammarino and Werstein reported the need for research
dealing with the organization, implementation, and evaluation of screening programs
which are based on a sound theoretical approach. Questions still remain on the most
effective ways to attract cancer screening participants, especially from minority and
underserved populations.
Purpose of the Study
The purpose of this study was to design a social marketing plan which could be
used as a model to promote Hispanic participation at future prostate cancer screenings.
Limitations
This study was conducted from the perspective of a non-Hispanic medical
professional, thus may be unintentionally biased. Data obtained from Hispanic screening
participants at four sites at which the researcher had received permission to conduct study
interviews may not be representative of the viewpoints of other Hispanics. The role
acculturation may have played in screening participation was not addressed during the
interviews. Data regarding the financial status of 29 interview participants is lacking
because it was not collected by personnel at one site. Also, the researcher's desire to
incorporate social marketing incentives into the project was inhibited because of the need
in a democratic group process to defer to the wishes of fellow committee members.
Delimitations
This study involved data and experiences encountered during the planning,
implementing, and evaluating of the 1995 Tarrant County Prostate Screening Project
(September 16-23) in Tarrant County, Texas. Although males of other races/ethnicities
were also targeted for prostate cancer screening during this same time period, this study
focused on the project as it related to Hispanic males.
Assumptions
The researcher assumed that data pertaining to the planning, implementation, and
outcome of the 1995 Tarrant County Prostate Screening Project as obtained from site
coordinators, hospital representatives, and project chairperson was reliable, that study
participants answered honestly and accurately, and that fellow study interviewers reported
and recorded information received from interview participants accurately.
Definition of Terms
1)
Benign Prostatic Hyperplasia (BPHVA non-cancerous condition in which
an overgrowth of prostate tissue pushes against the urethra and the bladder,
blocking the flow of urine. Also called benign prostatic hypertrophy or BPH"
(National Cancer Institute, 1993, p. 24).
2)
Cancer Screening-"An organized effort to assess large numbers of people at
risk for disease. Screening involves the use of simple tests or examinations
customarily directed at asymptomatic individuals, the vast majority of whom will be
free of cancer. The purpose of screening is to detect cancer at an early stage when
it is most curable" (Knopp & Croghan, 1991, p. 40).
3)
Digital Rectal Examination (DREVA procedure used for detecting colorectal
and prostate cancer. In screening for prostate cancer the physician inserts a
glovedfingerwhich is covered with lubricant into the rectum of a patient in order to
examine the prostate by palpating through the wall of the rectum (American Cancer
Society, 1988).
4)
Family- (F amilismVF amilism is considered to be one of the most culturespecific values of Hispanics. It is usually described as including a strong
identification and attachment of individuals with their families (nuclear and
extended), and strong feelings of loyalty, reciprocity and solidarity among members
of the same family" (Sabogal, Marin, Otero-Sabergal, Marin, & Perez-Stable, 1987,
pp. 397-398).
5)
Prostate Specific Antigen (PSAVA substance secreted by the prostate, which if
found elevated may signify the possibility of prostate cancer. Its presence is
detected though a blood test (Greifzu & Tiedemann, 1995).
6)
Prostatitis-Inflammation of the prostate.
7)
Transrectal Ultrasonography (TRUSVA test for prostate cancer using sound waves.
"A probe is inserted into the rectum, and ultrasound images of the prostate are
recorded onfilm"(Frank-Stromberg & Cohen 1992, p. 138).
Significance of the Study
Prostate cancer is the most common male cancer and the second leading cause of
cancer death for males in the United States. Its incidence increases with age. Because
etiology has not been definitely determined and early stage disease is often without
symptoms, early detection has the greatest potential for saving lives. Hispanic males have
been reported to be lacking in knowledge regarding cancer and less likely than whites or
African-Americans to utilize prostate screening exams. Hispanics have been shown to be
more likely than whites to have advanced cases of prostate cancer at initial diagnosis, even
when compared with low-income non-Hispanic whites, as well as with moderate to high
income non-Hispanic whites. This is an issue that deserves attention because prostate
cancer survival is strongly associated with stage of disease at initial diagnosis and
treatment. There is a need for research regarding the organization, implementation, and
evaluation of cancer screening programs based on a sound theoretical approach. The
scarcity of research pertaining to cancer and Hispanics, particularly in regard to the
Hispanic male, is of concern.
CHAPTER II
REVIEW OF THE LITERATURE
This chapter includes a general profile of Hispanics in the United States; statistics of
prostate cancer among Hispanics; knowledge, attitudes, and beliefs among Hispanics
regarding cancer; knowledge, attitudes, and practices regarding prostate cancer and digital
rectal exams (DRE's) among Hispanic males; important elements for inclusion in a cancer
control program for Hispanics; review of three cancer control projects in Hispanic
communities; special issues relating to prostate cancer screening; and information
regarding Social Marketing Theory.
General Profile of Hispanics in the United States
The Hispanic population in the United States differs in many aspects. These include
national origin, culture, income, level of education, use of language, length of time in the
United States, and degree of acculturation. The following subgroups reflect the diversity
of ethnicity that exists among Hispanics: Mexican American, Puerto Rican, Cuban
American, Central or South American, and "other" (ie. persons from Spain and the
Dominican Republic). Mexican Americans are the largest subgroup in the United States
and tend to be concentrated in California and Texas (Council on Scientific Affairs, 1991).
The majority of Hispanics live in urban areas (Munoz, 1988; Ginzberg, 1991). High
10
11
birthrates and immigration are reasons that Hispanics are the fastest growing minority in
the United States (Council on Scientific Affairs, 1991). Hispanics in the United States
may be recent immigrants or may be descendents of families who have lived in the U.S. for
numerous generations.
Although culture and values varyfromgroup to group and from person to person,
religion (the majority of Hispanics in the United States are Catholic) and family (which
includes an extended network of blood relatives, generations, in-laws, and close friends)
are generally highly valued in Hispanic communities. Other cultural concepts which have
been associated with Hispanics include fatalismo, the belief that an individual is unable to
change his fate; simpatia, the importance of avoiding confrontation and maintaining
positive interpersonal relationships; and respeto, the importance of showing respect for
others, especially the elderly and those in positions of authority (Morris, Lusero, Joyce,
Hannigan, & Tucker, 1989; Perez-Stable, Sabogal, Otero-Sabogal, Hiatt, & McPhee,
1992). When Raul Yzaguirre, President of the National Council of La Raza, was in
Dallas, Texas in July 1995 for a convention, he said that the biggest problem facing
Hispanics today is "a cultural clash between our values and the values in American society.
We value manners. We talk in quiet voices in a country where loud voices are heard . . .
We value family in a society that rewards individualism" (Mena, 1995, p. A 26).
Acculturation, the process of adapting to a new culture which requires a
reorientation of thinking, feeling, and communicating (Brown, 1987), varies among
Hispanics in the United States. "As a minority group, Hispanics are exposed to the
12
mainstream cultural patterns of the United States and modifications in their values, norms,
attitudes, and behaviors may be expected to occur because of this contact" (Marin,
Sabogal, Marin, Otero-Sabogal, & Perez-Stable, 1987, p. 184). Acculturation has been
reported to affect health status and utilization of health services (Council on Scientific
Affairs, 1991; Marin, Sabogal, Marin, Otero-Sabogal, & Perez-Stable, 1987; Marin &
Marin, 1991). As Hispanics become more acculturated, their health status may worsen
due to adopting unhealthy lifestyles. Hispanics who are less acculturated may underutilize
health services due to cultural and language barriers.
Although many Hispanics of varying ethnicities share the common language of
Spanish, Hispanics in the U. S. may be bilingual, may speak English or Spanish only, or
may speak a mixture of both languages. Often Hispanics use idiomatic expressions unique
to their individual groups. Literacy abilities vary among individuals. Studies have shown
Hispanics to have lower educational levels than whites. It has been reported that in 1988,
only half of all Hispanics had completed 12 years of schooling (Council on Scientific
Affairs, 1991). Mexican Americans have been found to be the least educated of the
subgroups (Ginzberg, 1991).
Below average educational levels are reflected in less favorable occupational status
and lower incomes among Hispanics (Ginzberg, 1991; Council on Scientific Affairs,
1991). Hispanics are more likely than whites to live in poverty, be unemployed or
underemployed, and to be without health insurance (Council on Scientific Affairs, 1991).
Over seven million Hispanics (39 %) are without health insurance coverage (Valdez,
13
Giachello, Rodriguez-Trias, Gomez, & de la Rocha, 1993). Poverty, little education, lack
of insurance, culture, language, and a scarcity of Hispanic health professionals pose
barriers to health care for Hispanics (Council of Scientific Affairs, 1991; Ginzberg, 1991).
Statistics of Prostate Cancer Among Hispanics
"Since there is no nationwide cancer registry there is no way of knowing exactly
how many cases of cancer are diagnosed each year" (American Cancer Society, 1995).
Obtaining data which adequately represents cancer morbidity and mortality in the Hispanic
population is especially difficult for a number of reasons including: registries used in the
United States have not always used coding for Hispanic identification (Villar & Menck,
1993), available data may be based on populations in select geographical areas which may
not adequately represent or may overrepresent certain populations (American Cancer
Society, 1991; Palos, 1994), the practice of analyzing data by the use of surnames may
include those not of Hispanic ethnicity or may exclude those who are of Hispanic
ethnicity, data may not adequately adjust for illegal immigrants who may not be
represented accurately in the U.S. Census (Poledak, 1993), and data may not include
immigrants who return to their native countries for medical care.
Data on prostate cancer among Hispanics is limited. The American Cancer Society
(1991) reported that Mexican Americans from New Mexico had prostate cancer incidence
and mortality rates slightly lower than whites between 1977 and 1983. Eight hundred and
thirty-three Hispanics reportedly died of prostate cancer in the United States in 1991
14
according to the American Cancer Society (1995); however, it was further noted that
Hispanic origin reporting could be incomplete on death certificates in some states. The
statistics reported in the 1995 study were believed to include over 90 % of cancer deaths
anong Hispanics in 1991.
Unfortunately, mortality data at the National Center for Health Statistics does not
differentiate Hispanics; it only lists "blacks," "whites," and "others," according to a
telephone conversation August 4, 1995, with a spokesman from the Center. Cancer
morbidity and mortality data availablefromthe National Cancer Institute (Ries, Hankey,
Kosary, Harras, & Edwards, 1994) does not designate Hispanics either; categories consist
of "blacks," "whites," and "all races."
Data obtained from the Texas Cancer Registry, a division of the Texas Department
of Health, showed a wide variance of age-adjusted prostate cancer incidence rates
between 1985-1991 ranging from 88.42 (1985) to 141.05 (1991) per 100,000 for whites,
51.00 (1985) to 70.03 (1990) per 100,000 for Hispanics, and 105.72 (1985) to 144.19
(1991) per 100,000 for African-Americans. Unfortunately, incidence data from the Texas
Cancer Registry was obtained from limited sections of Texas which did not include the
metroplex areas of Houston and Dallas-Fort Worth, the most populous cities in the state.
Increased prostate cancer incidence rates in recent years are thought to be due to
improved detection (American Cancer Society, 1995).
Data from the Texas Department of Health reported that 206 Hispanics died in
Texas in 1993 from prostate cancer (19.24 per 100,000), as compared to prostate cancer
15
mortality rates of26.26 per 100,000 for whites and 60.31 per 100,000 for AfricanAmericans.
Hispanics reportedly have lower cancer incidence and mortality rates than whites;
however, Hispanics have been found to have more advanced cases of prostate cancer at
initial diagnosis, as compared to non-Hispanic whites (Villar & Menck, 1993). This
information was obtained from the National Cancer Data Base, a joint collaboration of the
Commission on Cancer and the American Cancer Society. Data was voluntarily submitted
by hospitals and central registries and was thought to include 39 % of cancer cases
diagnosed and treated in the United States in 1990. Non-Hispanic whites were reported
to be more likely to be diagnosed with more easily curable, early stage (0-11) prostate
cancer (65. 7 % of cases reviewed) than African-Americans (58.4 %) or Hispanics
(59.7 %). Also, Hispanics were found to have more advanced prostate disease at initial
diagnosis than non-Hispanic whites, even when compared with low income non-Hispanic
whites, as well as with moderate to high income non-Hispanic whites. This trend is
worrisome because "prostate cancer survival is strongly associated with stage of disease.
Five-year relative survival for stage I or stage II cancer is 67 % and 69 %, respectively.
For metastatic disease, the five-year relative survival falls to 32 %" (Mettlin & Murphy,
1993, p. 47).
Knowledge, Attitudes, and Beliefs Among Hispanics Regarding Cancer
In a 1985 American Cancer Society study (Clark, Martire, & Bartolomeo, 1985)
808 Cuban Americans, Mexican Americans, and Puerto Ricans were interviewed
16
regarding their attitudes regarding cancer and cancer prevention. Differences were noted
among the three subgroups, for example, regarding concerns with discrimination (the
Puerto Ricans were most concerned) and likeliness to go for routine check-ups (the
Mexican Americans were the least likely). However, the investigators concluded that
"perhaps one of the most importantfindingsof the study is the extent of homogeneity and
similarity in basic attitudes towards cancer prevention, early detection, and education"
(Clark, Martire, & Bartolomeo, 1995, p. 5) among the three groups. Seventy percent of
the survey participants said that cancer was the disease they worried most about getting.
Survey participants were found to be less knowledgeable about causes of cancer, less
optimistic about the chance of cure with early detection, and less optimistic regarding the
effectiveness of cancer treatments, when compared to a 1979 survey of the general public.
When compared to the 1979 study participants, 1985 Hispanic survey participants were
more likely to say that if they got cancer, they'd rather not know about it (35 % vs 16 %),
to believe that if you have cancer it is like getting a death sentence (60 % vs 30 %), and to
say they would feel uncomfortable working next to someone who had cancer (25 % vs 9
%). Sixty percent of the Hispanics said there wasn't much one could do to prevent cancer
because nearly everything causes it. Sixty-three percent felt that whether one survived
cancer was God's will. Forty-two percent believed that old remedies were more effective
at treating cancer than modern technology.
Sugarek, Deyo, and Holmes (1988) studied beliefs and attitudes about cancer
among 101 Mexican Americans, African-Americans, and non-Hispanic whites in a
17
community health center in southwestern United States and concluded that "the Mexican
American group was significantly less educated than the other groups, valued early
diagnosis least, and was the most fatalistic" (p. 481). The Mexican American study
participants averaged 6.4 years of formal education, while the white and African-American
participants averaged 10.2 and 11.1 years of education respectively. Only 27 % of the
Mexican Americans believed early diagnosis could improve a person's chance for a cure,
whereas 72 % of the whites and 75 % of the blacks valued early diagnosis. "Multivariate
analyses showed fatalism and failure to value early diagnosis were most strongly
associated with low levels of education. These attitudes were prevalent particularly
among Mexican Americans, but limited education appeared more important than cultural
factors" according to the authors.
A study conducted by Perez-Stable, Sabogal, Otero-Sabogal, Hiatt, and McPhee
(1992) found that Latino ethnicity significantly predicted misconceptions and fatalistic
attitudes about cancer. Members of the Kaiser Permanente Medical Care Program in San
Francisco were interviewed in order to evaluate knowledge and attitudes among selfidentified Latino and Anglo4 members. After adjusting for sex, education, age,
employment, marital status, county of residence, and self-perceived health status, the
investigators concluded that misconceptions and fatalistic attitudes regarding cancer were
more prevalent among Latinos. "Latinos were significantly more likely than Anglos to
think that sugar substitutes (58 % vs 42 %), bruisesfrombeing hit (53 % vs 34 %),
4
Anglo refers to non-Latino white in this study.
18
microwave ovens (47 % vs 23 %), eating pork (31 % vs 11 %), eating spicy foods (15 %
vs 8 %), breast feeding (14 % vs 6 %), and antibiotics (32 % vs 12 %) could cause cancer.
Compared with Anglos, Latinos more often misidentified constant dizziness (39 % vs 25
%) and arthralgias (35 % vs 20 %) as being symptoms of cancer. A higher proportion of
Latinos believed that having cancer is like getting a death sentence (46 % vs 26 %), that
cancer is God's punishment (7 % vs 2 %), that there is very little one can do to prevent
getting cancer (26 % vs 18 %), that it is uncomfortable to touch someone with cancer (13
% vs 8 %), and that they would rather not know if they had incurable cancer (35 % vs 23
%)" (p. 3219).
In a different study group, interviews were conducted with 55 Hispanic migrant
agricultural workers (22 women and 33 men) in Wisconsin to study knowledge, attitudes,
and beliefs regarding cancer (Lantz, Dupuis, Reding, Krauska, & Lappe, 1994). "In
regard to cancer, an intense fear of the disease coupled with fatalism regarding its
treatment and course were found to be pervasive among the migrant workers who
participated in the focus groups" (p. 519). Whether a person survived cancer or not was
commonly believed to be God's will, rather than the influence of early detection and
treatment. Study participants related stories of relatives and acquaintances who had
suffered severe pain, disfigurement, amputations, and eventual death due to cancer. Only
one participant mentioned chemotherapy and radiation therapy as forms of treatment for
cancer.
19
Knowledge, Attitudes, and Practices Regarding Prostate Cancer and Digital Rectal
Examinations (DRE's) Among Hispanic Males
In an 1985 American Cancer Society study, only 35 % of the Hispanic male survey
participants had ever heard of a rectal examination for cancer, as compared to 71 % of
male participants in a 1979 survey of the general public (Clark, Martire, & Bartolomeo).
Only 29 % of Hispanic males in the 1985 survey had ever had a rectal examination, as
compared to 56 % of the males from the 1979 general public survey.
Data obtained from the 1987 National Health Interview Survey demonstrated that
of male survey participants 40 years of age or older, Hispanic males were the most likely
to have never had a digital rectal exam (57.8 %), as compared to African American
(54.6 %) and white (39.2 %) males (American Cancer Society, 1991).
In focus group interviews with Hispanic migrant agricultural workers in 1994,
knowledge regarding cancer screening for males was also found to be lacking. Many of
the workers had never heard of the digital rectal exam and the majority had not heard of
the prostate gland or of prostate cancer (Lantz, Dupuis, Reding, Krauska, & Lappe,
1994). Many of the male study participants reported a reluctance to seek medical care or
have medical examinations. "One man said, 'I trust them (doctors). But as men, we're
really macho and we don't go. .. .it's embarrassing. You don't want people to say that
you're weak, you're a woman."' (p. 516). When asked if they would get a digital rectal
examination if it was free at the migrant health clinic, most men were silent until called
upon by the moderator. Comments received from the men included the following:
20
"It is embarrassing. (Why?) Because you're a man, and you don't want someone
looking at you there."
"They can't check you with machines? Like with x-rays or anything?"
"I'll have to find a doctor with a smallfinger!"(p. 517).
Although attitudes expressed by those Hispanic migrant workers may not be
representative of other Hispanic males, similar attitudes were found in a convenience
sample of 90 men (unspecified race/ethnicity) aged 39-78, who were members of a
community organization in the Midwest and averaged over 14 years of formal education
(Milton-Underwood, 1992). "Sixty-one percent stated that 'the rectal exams are a good
idea,' but find that having one is 'too embarrassing'. Forty-two percent of the total
sample indicated that they had had such an examination, yet 91 % stated that 'if a blood
test could identify prostate cancer they would probably have one'" (pp. 30-31), MiltonUnderwood concluded that education alone may not improve prostate cancer screening
participation if attitudinal barriers are not addressed.
Important Elements for Inclusion in a Cancer Control Project for Hispanics
Knowledge, attitudes, and beliefs regarding cancer, as well as underutilization of
screening examinations for cancer detection, need to be addressed in cancer control efforts
targeted for the Hispanic community. The following are important elements, as reported
in the literature, that should be considered when planning, implementing, and evaluating
cancer control projects in the Hispanic community:
21
1. Learn about the community you will be working with. Involving respected
community leaders and using already established community resources and facilities
(personnel, churches, community centers, etc.) is of great assistance in reaching the target
audience (Black & Ades, 1994; Palos, 1994). Although Hispanics often share common
language, religion, and values, they are a diverse population of varying heritages (ie.
Mexican or Mexican American, Puerto Rican, Cuban or Cuban American, Central or
South American). Studies have shown that Mexican Americans, Puerto Ricans, and
Cubans display differences in their health insurance coverage and utilization of health
services (Schur, Bernstein, & Berk, 1987; Trevino, Moyer, Valdez, & Stroup-Benham,
1991), infant mortality risks (Becerra, Hogue, Atrash, & Perez, 1991), reproductive
characteristics (Stroup & Trevino, 1991), and certain selected measures of health status
for children (Mendoza, Ventura, Valdez, Castillo, Saldivar, Baisen, & Martorell, 1991).
Also, it is important to recognize that "factors such as socioeconomic status, level of
education, and length of time in this country (recent arrivals, first or second generation
etc.) may influence individuals' health behavior more than cultural issues." (COSSMHO,
1990, p. 54). Degree of acculturation may be an influence also. Less acculturated persons
are often reluctant to utilize health services because of barriers due to language and
culture. Of equal concern is that studies have suggested that "as Hispanics become more
acculturated, their health status worsens" due to adopting unhealthy lifestyles, such as
increased tobacco use and less healthy diets (Council on Scientific Affairs, 1991, p. 252).
22
2. Involve the family. Family, an important part of the Hispanic culture, has the
potential of positively or negatively influencing one's decisions in health-related matters.
Health intervention strategies which involve family members can reinforce the importance
of health information (Morris, Lusero, Joyce, Hannigan, & Tucker, 1989). Also,
understanding the traditional roles of the woman as wife and mother who is responsible
for her family's health, and the man as economic provider, can be beneficial in health
promotion efforts. Hispanics have reported that "knowing that they have to stay healthy
to care for their families provides strong motivation to see a physician" (Lantz, Dupuis,
Reding, Krauska, & Lappe, 1994, p. 518).
3. Be sure that written materials are linguistically and culturally appropriate to
your target group. Consideration must be given to the educational and literacy levels of
the target group. "Hispanics are four to six times more likely than the general U.S.
population to read English below the fourth-grade level" (COSSMHO, 1990, p. 18).
Spanish-language materials should be developed by persons familiar with the language and
culture of the target population to ensure cultural sensitivity, and then reviewed prior to
publication, preferably by medical personnel, to ensure that information remains medically
sound.
4. Use mass media to promote your project. Involving the media in your project
will ensure that your health message is distributed to a wider audience. Studies such as
that of Richardson, Marks, Solis, Collins, Birba, and Hisserich (1987) show television,
radio, and printed media to be important in disseminating health care information.
23
Richardson and colleagues found that more elderly Hispanic women in their study had
heard about mammographyfromthe media, rather than from their physicians. Broadcast
media may be helpful in reaching clients whose educational and literary skills discourage
them from reading.
5. Fight fatalism by promoting wellness, not fear. Health intervention efforts, such
as the American Cancer Society urban demonstration projects (Black, & Ades, 1994),
have shown that health messages delivered with a positive approach focused on wellness
and disease prevention are more readily received than those based on fear and scare
tactics. It has been reported that one gastroenterologist doubled his audience by calling
his presentation "The Care and Feeding of Your Digestive Tract," instead of "Cancer of
the Colon" (Groenwald, Frogge, Goodman, and Yarbro, 1992). The use of positive role
modelsfromthe target community who have been personally successful with cancer
prevention, early detection, and treatment efforts can be an effective method for
promoting health (Amezcua, McAlister, Ramirez, & Espinoza, 1990).
6. Assist clients in accessing the health system. According to the Council on
Scientific Affairs (1991), poverty and lack of health insurance are the greatest barriers to
health care for Hispanics. Cancer education programs which promote screening exams for
early cancer detection will be of little value if persons in the target population have no
medical insurance and can't afford the exams. Educational programs targeted at poor
communities need to be partnered with opportunities for local low or no-cost screening
exams. (Notefinancialbarrier problem encountered during Su Vida, Su Salud project
24
discussed in the upcoming section, "Examples of Three Cancer Control Projects in
Hispanic Communities," of this chapter).
Language is another barrier to health care for many Hispanics in the United States.
Bilingual staff is an essential element of cancer education and early detection in the
Hispanic community. Because there is a scarcity of Hispanic health care professionals
(Ginzberg, 1991), using Hispanic volunteers "can help in virtually any stage of your work-canvassing the neighborhood, transporting patients, assisting with referrals and followthrough, interpreting and translating, education for disease prevention, and so on"
(COSSMHO, 1990, p. 85).
7. Evaluate the program's effectiveness. The National Coalition of Hispanic Health
and Human Services Organizations reported that "ongoing systematic program evaluation
is important for the following reasons:
* Evaluation provides information on ways tofine-tuneexisting programs.
* Evaluation documents a program's effectiveness and may highlight
strengths and weakness that will be important to consider when replicating
the program.
* Evaluation can help assess a program's applicability to other Hispanic
subgroups.
* Evaluation enables programs to document the cost-effectiveness of
prevention, so important in securing and maintaining funding.
* Evaluationfindings,when reported, enrich the weak data base on
25
programs for Hispanics" (COSSMHO, 1990, pp. 101-102).
Review of Three Cancer Control Projects in Hispanic Communities
Three cancer intervention projects targeting the Hispanic community, A Su Salud
(Ramirez & McAlister, 1988; Amezcua, McAlister, Ramirez, & Espinoza, 1990); Su Vida,
Su Salud (Suarez, Nichols, Pulley, Brady, & McAlister, 1993); and Mujer a Mujer (Palos,
1994) were reviewed. Although Su Vida, Su Salud and Mujer a Mujer targeted Hispanic
females, they are included in this review because literature on cancer projects targeting
Hispanic males is lacking, and because lessons can be learned from the positive and
negative aspects of these programs.
A Su Salud (To Your Health) was designed as a mass media, community effort to
promote positive health behaviors in the low-income, predominately Hispanic community
of Eagle Pass, Texas on the Mexican-American border. Initially, seven focus groups
consisting of community leaders, media personnel, health personnel, and others from the
target community were held to obtain information regarding knowledge and attitudes
about cancer and smoking, preventive health practices, diet, alcohol, nutrition, and health
care services. Focus interviews revealed the perception that individuals have no control
over whether they will contract cancer or not, and a skepticism regarding whether quitting
smoking could really promote longevity. Also, barriers such as cost of medical services,
lack of knowledge regarding preventive health care, and fear of learning that one had a
26
serious health problem were revealed by the focus group participants (Ramirez &
McAlister, 1988).
Before initiating the program, high-risk health behaviors were evaluated. Among
other data collected, it was determined that 38.1 % of the adult males smoked. Of women
over 30 years of age, 55 % percent reported that they had not had a Pap smear within the
past year and 47.5 % had not performed a breast self-exam in the last year. Seventy-nine
and two-tenths percent of persons 50 years of age or older reported that they had not had
a colorectal exam within the past year (Amezcua, McAlister, Ramirez, & Espinoza, 1990).
Six avoidable risk factors were chosen to be promoted during the A Su Salud project:
alcohol abuse, cigarette smoking, obesity and diet, lack of medical check-ups, lack of seat
belt use, and pollution. Individualsfromthe community were recruited to serve as role
models. In television programs scripted by a local media professional, the role models
discussed why and how they had changed their behavior, and how they felt after they
changed their behavior. Volunteers who were recruited from the community distributed
television program schedules and newspaper articles promoting the project, and provided
social reinforcement.
Some of the barriers encountered during the program included competing with
door-to-door salesmen and others canvassing the neighborhoods, a large number of
persons migrated for work in other states, economic depression (many said they would
prefer jobs or money, rather than surveys and life-style advice), and the belief that health
professionals were more oriented to business and academics, rather than human services.
27
Preliminary results from interviews with volunteers in 1987 reported 7,860 contacts with
hundreds of persons reporting life-style behavior changes since the initiation of the
program (Amezcua, McAlister, Ramirez, & Espinoza, 1990).
Su Vida, Su Salud (Your Life, Your Health) used A Su Salud as a model in order to
promote breast and cervical screening among Mexican American women in Corpus
Christi, Texas. Prior to initiation of the project, bilingual telephone interviews were
conducted randomly in the target community. "Less than 30 % of the women mentioned
the Pap smear or mammogram as a method to detect cervical cancer or breast cancer.
Forty-eight percent of Mexican American women thought their chances of surviving
cervical cancer were poor. Those who preferred to speak Spanish tended to have less
knowledge of cancer detection methods and a more fatalistic attitude" (Suarez, Martin, &
Weiss, 1993, p. 479). Three local television stations (including a Spanish-language
station) andfiveradio stations (three Spanish, two English) provided the media for stories
from local role models and other information regarding breast and cervical cancer
screening. In an 18-month period 54 storiesfromrole models were presented in the media
in Corpus Christi.
Volunteersfromthe target community were used extensively in the project. Within
18 months, 490 volunteers had been trained and were promoting breast and cervical
cancer screening in Corpus Christi. The result of the 18-month period was that 365
persons inquired about the program; 35 % or 129 of the inquiries werefromthe target
population, Mexican American women between 40 and 70 years of age. Of286 women
28
who received Pap smears during this time period, 37 % or 105 were from the target
group. Only 32 women received mammograms, 13 of whom were from the target
population. The researchers reported that the most difficult barrier encountered during
the project was the lack of affordable mammograms. They concluded that "to be most
effective, educational programs need to be coupled with services which are free or paid for
on a sliding fee scale" (Suarez, Martin, & Weiss, 1993, p. 481). Suarez and coinvestigators reported thatfinalevaluation of the program's success would include
telephone surveys and a (future) review of cancer registry data.
Mujer a Mujer (Woman to Woman) targeted Hispanic women, especially those 55
years of age and older, with the purpose of educating them about early detection and
screening for cervical cancer. Catholic churches in four Texas parishes served as the
settings for focus groups and educational programs. A Catholic church group consisting
of older Hispanic women helped recruit local Hispanic women who served as actresses
and provided guidance in producing a video by a Hispanic television station. The video,
done in Spanish with English subtitles, was an enactment of twofriendsdiscussing
attitudes, beliefs, and practices of Hispanic women regarding cervical cancer and preceded
an educational program. Palos stated the success of the project was evident "by the
attendance at the programs and subsequent requests for additional programs" (Palos,
1994, p. 111). Unfortunately, details as to the number of women who attended
programs, requested additional programs, or were screened for cervical cancer as a result
of the Mujer a Mujer project were lacking in this 1994 cited study.
29
Special Issues Associated with Prostate Cancer Screening
Prostate cancer can often be cured when it is detected early (Brawer, Catalona, &
McConnell, 1992). Unfortunately,frequentlyit is not diagnosed until it is already locally
advanced or metastatic (Scardino, Weaver, & Hudson, 1992). Currently the principal
screening examinations for prostate cancer, the digital rectal examination (DRE), the
prostate specific antigen (PSA), and transrectal ultrasonography (TRUS), each have their
limitations (Brawer, Catalona, & McConnell, 1992; Iammarino & Werstein, 1994;
Scardino, Weaver, & Hudson, 1992). The DRE tends to detect cancer at a relatively late
stage when it is large enough to be palpable; the PSA may be elevated due to noncancerous conditions, such as benign prostatic hypertrophy (BPH) and prostatitis, as well
as with prostate cancer; and the TRUS, although it can be a valuable tool when the DRE
or PSA is abnormal, is unable to differentiate between malignant and benign lesions and is
cost prohibitive for mass screenings.
The American Cancer Society and the American Urological Association recommend
the DRE and PSA combination for routine prostate cancer screening. Opponents of mass
prostate cancer screening say that mass screening shouldn't be done until results of a large
scale, randomized clinical trial are reported. Also, because of the varying nature of
prostate cancer, they are concerned about the numbers of latent cases (of no great threat
to the patient) that mass screening will encounter. Prostate cancer screening proponents
say that early diagnosis means more treatment options and are reluctant to postpone
screening during the years before results of trials currently in progress are obtained and
30
published. Furthermore, screening proponents say that it is less costly to treat localized
disease than late-stage prostate cancer (Brawer, Catalona, & McConnell, 1992). More
recent literature reported that "epidemiologic evidence supports the view that prostate
screening with DRE and PSA detects clinically significant, not latent, prostate cancers, but
detects them at an earlier, clinically more favorable stage" (Slawin, Ohori, Dillioglugil, &
Scardino, 1995, p. 139). This suggests the hope that increased prostate cancer screening
will mean improved survival rates in the future.
In the meantime, physicians and auxiliary personnel associated with prostate cancer
screening should address the psychological aspects that screening may present for their
patients. Iammarino and Wernstein (1994) reported that fear of a positive test is a
common barrier to screening. They recommended interventions to increase the selfefficacy of screening participants in coping with threatening messages, such as positive
test results. Health educators need to be aware that positive prostate cancer screening
examinations may not necessarily mean cancer. Another issue to consider is that if a man
is diagnosed with prostate cancer, the treatment options available to him may cause
problems such as impotence and incontinence, which potentially affect quality of life
(Greifzu & Tiedmann, 1995). Unfortunately, published data regarding effective ways to
deal with these special issues is lacking.
Social Marketing Theory
Social marketing, first introduced in 1971, is based on the concept that marketing
principles and techniques can be applied to advance social causes, ideas, and behavior
31
(Kotler, 1982). Philip Kotler defined social marketing as "the design, implementation, and
control of programs seeking to increase the acceptability of a social idea or cause in a
target group(s). It utilizes concepts of market segmentation, consumer research, concept
development, communication, facilitation, incentives, and exchange theory to maximize
target group response" (p. 490).
Kotler stated that there are 4 basic approaches to social change:
1)
the legal approach (ie. passing a law to prohibit smoking in public places)
2)
the technological approach (ie. developing a harmless cigarette)
3)
the economic approach (ie. raising the price of cigarettes)
4)
the informational approach (ie. providing persuasive information to smokers
regarding the risks of smoking and the benefits of not smoking)
According to Kotler, social marketing evolved from an informational approach
known as social advertising. Social cause groups (such as family planning groups in India
Sri Lanka, Mexico, and other countries) began to sponsor major advertising campaigns in
hopes of changing public attitudes and behavior. Kotler reported that although these types
of campaigns can be influential in changing attitudes and behavior, commercial advertising
alone may be inadequate. For example, campaigns which encourage people to limit their
offspring will prove to be inadequate, if information and provisions on how this might be
accomplished are not included. To overcome the limitations of social advertising alone, a
social communication approach evolved. In order to complement a media campaign in
32
India regarding family planning, for example, doctors, dentists, and barbers talked about
family planning with whomever they came in contact.
With the evolution of social marketing the following elements, which Kotler found
to be lacking in the social communication approach, were added:
1)
Marketing research-Social marketers study the target market, its behavioral
characteristics, and the benefit-cost impact of alternative marketing approaches.
2)
Product development-Social marketers consider ways to make it easier for
people to adopt desired behavior. "Whenever possible the social marketer does not
stick with the existing product and try to sell it—a sales approach—but searches for
the best product to meet the need~a marketing approach" (Kotler, 1982, p. 492).
3)
The use of incentives-Social communicators concentrate on advantages and
disadvantages of behaviors, while social marketers go further and use
incentives, such as "price specials" and small gifts to increase motivation.
4)
Facilitation-Social marketers consider ways to make it easier for clients to adopt
new behavior, such as providing smoking cessation classes in convenient locations,
and are also concerned with ways to make behavior maintenance easier for their
clients.
Although the goal of social marketing is to provide an ideal plan for bringing about
desired social change, Kotler admitted that there is no guarantee that a desired change will
be achieved, even with the best marketing plan. Some attitudinal and behavioral changes
33
are more difficult to achieve than others. Kotler differentiated between 4 types of social
changes, listed below from the easiest to the most difficult to change:
1)
Cognitive Change-Goal is to promote awareness and knowledge (ie. public
information or education campaigns), rather than change attitudes and behavior.
2)
Action Change-Goal is "to induce a maximum number of persons to take a specific
action during a given period" (ie. campaigns to attract persons to participate in
mass immunization campaign) (Kotler, 1982, p. 502).
3)
Behavioral Change-Goal is to bring about change in behavior for the purpose of
promoting well-being (ie. efforts to discourage smoking).
4)
Value Change-Goal is to change deep-rooted beliefs or values (ie. efforts to change
individuals' opinions regarding abortion).
Novelli (1990) stated that marketing health promotion and disease prevention may
not be as easy as marketing laundry detergent or cars; however, "marketing is proving to
be a useful process for problem solving in the health field. The same disciplined, step-bystep approach that makes it appealing in moving commercial goods and services gives it
strong appeal among health professionals" (p. 343). Listed below are the essential steps a
social marketer should use when planning a social marketing campaign according to
Kotler (1982):
1)
Problem Definition-The social marketer researches to determine the problem and
studies psychological, economic, political, and cultural influences that support and
reinforce ideas and behavior.
34
2)
Goal Setting-Goals that are reasonable and can be measured are set in order that a
plan and budget can be developed, and the success of the campaign can be
measured.
3)
Target Market Segmentation-Target population is segmented according to
demographic characteristics and other variables, such as needs, attitudes, language,
and mass media use, to allow more focused efforts and to identify the most costeffective marketing strategies.
4)
Consumer Analysis-Target segment is researched regarding how they can best be
assisted in going from their present attitudes and behavior towards achieving the
desired attitudes and behavior.
5)
Influence Channel Analvsis-Social marketers determine which influences will be
most effective for carrying out their program (mass media, general public, business
establishments, legislators etc.).
6)
Marketing Strategies and Tactics-Previouslv used strategies are reviewed Other
strategies are considered through brainstorming and using the four Ps of marketing:
Product, Price, Place, and Promotion.
7)
Program Implementation and Evaluation-Tasks need to be assigned to specific
persons with a timetable. The program needs to be supported by a budget.
Program implementation and evaluation need to be monitored.
Social Marketing "embraces classic health promotion models and other behavioral
theories and disciplines" (Morra, 1992, p. 1229) and has been used successfully in such
35
programs as the Metro Manila Measles Immunization Campaign and the National High
Blood Pressure Education Program (Novelli, 1990), as well as the Stanford Five-City
(smoking cessation) Project and the Pawtucket Heart Health Program (Lefebvre & Flora,
1988). It has been attributed to successful programs in third world countries which
increased contraceptive knowledge and use, and programs which promoted oral
rehydration therapy to counteract diarrheal disease (Novelli, 1989). Farquhar, Macoby,
and Solomon said that "the social marketingframeworkadds to theory and practice by
forcing one to consider the practical realities of marketing health promotion products in
the complex urban environments of the modern world" (1984, p. 440). Lefebvre and
Flora (1988) concluded that "health marketing has the potential of reaching the largest
possible group of people at the least cost with the most effective, consumer-satisfying
program" (p.314). Novelli (1990) has reported that applying marketing techniques
creatively can mean more effective health and social interventions.
Summary
Literature review found Hispanics, the fastest growing ethnic/racial group in the
United States, to be diversified in many ways including use of language, acculturation, and
utilization of health care services. Hispanics were more likely than whites to have lower
educational levels, live in poverty, be unemployed or underemployed, and to be without
health insurance. Generally, Hispanics were reported to be less knowledgeable about
cancer and cancer screening examinations, and more fatalistic in regard to cancer
36
prevention, early detection, and treatment, as compared to whites and African-Americans.
Although data is limited, Hispanic males were found to have lower prostate cancer
morbidity and mortality as compared to whites and African-Americans. However,
Hispanics were less likely than African-Americans or whites to utilize cancer screening
examinations, and more likely than whites to be initially diagnosed with more advanced
stages of prostate cancer. Potential barriers to prostate cancer screening among Hispanic
males included a lack of knowledge regarding prostate cancer and the digital rectal
examination, a reluctance to seek medical attention for fear of appearing less than manly,
and embarrassment with the idea of undergoing a digital rectal examination.
When designing a cancer control program in the Hispanic community it is important
to understand the culture, socioeconomic status, and educational levels of the target
population in order that needs will best be met. Three cancer control projects targeting
Hispanics were reviewed and found to have the following characteristics in common: the
use of focus groups/interviews prior to implementation of the project, the involvement of
mass media, the use of role modelsfromwithin the target community, and the involvement
of community leaders and other personsfromthe targeted community.
Special issues associated with prostate cancer screening include insufficient data
regarding the benefits of mass screenings and effectiveness of available methods for
screening, and the psychological effects that positive results may have on screening
participants. Social Marketing was reviewed as a multidisciplinary-based theoretical
approach to promoting community health programs.
CHAPTER III
METHODOLOGY
Study Design
This is a descriptive study of the process and outcome of organizing, promoting,
and implementing a community-sponsored prostate cancer screening project targeting
Hispanics. Although males of other races/ethnicities, particularly African-Americans, were
also targeted for prostate cancer screening during the same study time period, this
research focused on the project as it related to the Hispanic community.
Subjects
The subjects of this study were Hispanic screening participants in the 1995 Tarrant
County Prostate Screening Project in Tarrant County, Texas, who completed an interview
(see Appendix A) at the four screening sites targeted for this research project. All 51
participants who were asked to be interviewed for the survey agreed to participate. (A
total of 56 Hispanics were seen at the four sites. One was unable to participate in the
interview due to his having Alzheimer's disease. The remaining four, who were not
solicited for this study, were apparently screened at one site prior to the scheduled
screening time, according to a study interviewer.) Subjects ranged in age from 35 to 78
years, with a mean age of 59. The majority of them (43) were Mexican or Mexican
37
38
American, three were natives of South America (Colombia), two were natives of Spain,
one was a native of Cuba, one was a native of Central America (El Salvador), and one was
of mixed Puerto-Rican and South American (Peruvian) ancestry. Of the 28 subjects on
which data on family income status was available, 19 had incomes at 200 % or less of
federal poverty guidelines.
Twenty-seven of the 51 subjects chose English as their preferred language for the
interview, 23 chose to be interviewed in Spanish, and one chose to use a mixture of
English and Spanish during the interview. Twenty-one of the 51 interview participants
reported they had not had a prior rectal exam. Of those 40 years of age or older who had
never had a prior rectal exam (n=18), 12 chose Spanish as their preferred language for the
interview.
Procedure
A social marketing plan to promote Hispanic participation at prostate cancer
screenings was designed by the researcher based on Kotler's Social Marketing Process
(Kotler,1982), literature review, the researcher's experience working on the 1995 Tarrant
County Prostate Screening Project (and other past community health efforts targeting
Hispanics), and the results of a survey of 1995 Tarrant County Prostate Screening Project
Hispanic screening participants. Initially, literature was reviewed pertaining to Hispanics
and cancer. Topics included morbidity and mortality rates; cancer knowledge, attitudes,
and practices; utilization of health services; and reported cancer control projects in
39
Hispanic communities. Medical and marketing literature regarding social marketing was
also reviewed.
From May 1995 to September 1995, the researcher attended screening, educational
and promotional meetings relating to the 1995 Tarrant County Prostate Screening Project.
In early 1995, Tarrant County, Texas urologists and oncologists had met and concurred
that mass prostate cancer screening should again be offered by the medical community
(community-sponsored screenings had previously been held in 1993 and 1994). Screening
would be held September 16 through September 23, 1995, in conjunction with the 1995
Prostate Cancer Awareness Week program sponsored by the Prostate Cancer Education
Council, and would focus on the underserved ranging in age from 50-70 (40-70 for
African-American men or others with a family history of prostate cancer). By affiliating
with the Prostate Cancer Education Council, each screening site agreed to abide by criteria
for participation, which included testing with both DRE and PSA, informed consent
signed by all participants, and verification of follow-up on all abnormal test results.
The Harris Methodist Health Foundation (HMHF) agreed to be financially
responsible for the PSA testing of 1995 screening participants who met 200 % or less
federal poverty guidelines, plus promotional expenses and supplies (ie. gloves, lubricant,
and tissues for DRE's) for the week-long screening. This funding was made possible
through a program (Harris Associate Program) in which employees of the Harris
Methodist Health System are encouraged to contribute money or volunteer time to
community projects which provide preventive medical services to medically underserved
40
residents of north central Texas. The cost of the PSA for those not meeting specified
poverty guidelines was assessed at $11.00. The DRE was provided at no cost to
screening participants at all screening sites through services rendered by voluntary
physicians. Auxiliary staff (nursing, laboratory, and other personnel) were solicited to
provide their services on a voluntary basis.
Representatives from medical facilities who had participated in the 1994 screening
project met in April to begin planning for the 1995 screening. All facilities represented
were members of the Tarrant County Cancer Consortium, a group of health agencies and
service providers who meet monthly for the purpose of developing a broad spectrum,
community-based cancer control program targeting the underserved of Tarrant County.
By the end of May, eight hospital and clinic sites had been selected for the 1995 Prostate
Screening Project. Sites were chosen based on their location and availability, and the
willingness and availability of physician volunteers and auxiliary staff. Four of the eight
sites had served as sites in 1994. Four community clinics were selected as new sites due
to their location in targeted population neighborhoods. Two of the new sites were in
predominantly African-American neighborhoods and two were in neighborhoods heavily
populated by Hispanics. One site which had screened 18 of the 50 Hispanic males
screened in 1994 chose not to participate in 1995.
In May of 1995, a committee was formed to coordinate promotional activities for
the September screening. The Promotion Committee was composed of marketing and
communications directors from local medical facilities and the American Cancer Society, a
41
Hispanic nurse who is community service director of one of the proposed screening sites
and active in various Hispanic community organizations, an African-American nurse who
is community service director of one of the proposed screening sites, and the researcher of
this study, who is a bilingual nurse with experience working with medically underserved
populations, particularly in promoting breast and cervical cancer screenings. The
committee's first promotional activity was a mid-July luncheon underwritten by two local
medical facilities: MD Anderson/Moncrief Cancer Center and Osteopathic Health System
of Texas. The Promotion Committee invited 111 persons who were medical, social,
political, and religious leaders in the community, especially those who were leaders in the
African-American and Hispanic communities, as determined by committee members. A
letter which enlisted support for the project and announced the upcoming luncheon was
sent out in mid-June, followed by an invitation the following week to the July 13
luncheon. Invited persons who had not responded by the RSVP date noted on the
invitation (July 5th) were contacted by promotion committee members to ascertain and
encourage attendance.
Fifty-three persons attended the July 13 luncheon. The program consisted of
opening remarks by the African-American nurse Promotion Committee member, an
explanation of the Screening Project by the 1995 chairperson, an informational talk on
prostate cancer by a local urologist, an inspirational talk by an African-American minister
and prostate cancer survivor (attempts to locate a Hispanic prostate cancer survivor to
speak at this event were unsuccessful), and closing remarks by the Hispanic nurse member
42
of the Promotions Committee. Community leader luncheon attendees were encouraged to
support and promote the prostate cancer screening project. A card was mailed to
community leader attendees after the luncheon expressing thanks for attending and
offering speakers for community gatherings to promote the Prostate Screening Project.
A mini-conference which informed health professionals about cancer control
resources and the upcoming community cancer screenings was held at the American
Cancer Society at the end of July. Prostate health awareness programs were held at area
churches, senior centers and community centers. Hispanic males and females were
targeted for educational programs which were conducted by physicians and nurses. Also,
educational literature was distributed at a community health fair held in August.
A Spanish language pamphlet availablefromthe pharmaceutical company, Merck,
entitled Lo que todo hombre deberia saber acerca de su prostata (What every man should
know about his prostate) was used during the 1994 Prostate Cancer Screening Project and
was reviewed and approved for use during the 1995 Prostate Cancer Screening Project by
two local bilingual Hispanic nurses. The pamphlet consists of basic anatomy and
physiology of the prostate, as well as information regarding BPH, prostatitis, and cancer
of the prostate. The most current Spanish language pamphlets availablefromthe
American Cancer Society which related to prostate cancer dated back to 1985. No
Spanish language materials relating to the prostate could be found through the National
Cancer Institute, except for information on the Prostate Cancer Prevention Trial.
43
The main focus of mass media promotion took place during thefinaltwo weeks
prior to the screening. Press releases regarding prostate cancer and the upcoming prostate
screenings were sent to English and Spanish language news media. Two articles ran in the
Fort Worth Star Telegram (daily circulation 249, 097), one the week prior to the
screenings and the other the week of the screenings. The first article dealt with statistical
and other information regarding prostate cancer, plus listed scheduling information and
screening sites. The latter article featured the story of a prostate cancer survivor .
Another article regarding prostate cancer came out the week prior to the screenings in the
weekly bilingual edition of the Fort Worth Star Telegram's La Estrella (weekly circulation
130,000). Two articles ran in the Spanish language newspaper, El Informador
(distribution 30,000 households); one was two weeks prior and the other the week of the
prostate screenings. Press releases were also sent to neighborhood newspapers, such as
the White Settlement Bomber and the Extra.
Information regarding the prostate screening was given to local English and Spanish
language radio stations by a member of the Promotions Committee, but the author was
unable to ascertain the amount of air time that information was broadcast. All media
promotion for this screening project was provided as a community service. Attempts to
locate a Hispanic prostate cancer survivor to be featured in the media were not successful.
More than 3,000 bilingual flyers were distributed through area clinics, churches,
businesses, senior centers, and community centers, as well as on the local buses (the Fort
Worth Transit Authority). During this same time period, a large health network
44
representing three hospitals in Tarrant County which were not included in this study,
conducted a paid campaign via the Fort Worth Star Telegram to solicit screening
participants to their free screenings.
Starting September 1, Well Call, a physician and other medical services telephone
referral service affiliated with the Harris Methodist Health System, screened callers for age
and medical history eligibility and scheduled appointments for the study screening sites.
Although appointments were encouraged, media announcements and Well Call personnel
informed the public that men without appointments would also be accepted for screening.
Physicians, as well as auxiliary medical personnel, were recruited as volunteers for
each screening site by members of the screening committee and site coordinators with the
goal of having at least one urologist present at every screening site. Medical students and
nurse members of the Oncology Nursing Society served as site educators to counsel men
about their test results and possible follow-ups, and assisted with drawing blood for
PSA's. Bilingual Hispanic members of community groups served as site volunteers and
assisted with translation.
Dates and hours of operation were determined by each screening site depending on
availability of facility space, availability of physicians, and what was deemed to be
convenient for screening participants. Of the three sites located in communities with the
largest density of Hispanics, one (Bolt Street Clinic) chose to hold screenings from 5:30
P.M. to 8:00 P.M. one evening (Thursday, September 21) during the week, while the
45
other two (Diamond Hill Community Clinic and Northside Clinic) held screenings from
10:00 A.M. to 3:00 P.M. on the same Saturday, September 23.5
Patient flow on screening days began with registration, which included signing an
informed consent for prostate screening, followed by drawing the blood for PSA, followed
by the DRE, and concluded with an exit interview by a medical student, oncology nurse or
a nurse who had been specially trained in prostate cancer screening issues prior to the
screening project. Screening participants were instructed regarding the outcome of their
DRE's and were told to expect PSA results to be mailed to them within two to three
weeks. Screening participants who required follow-up due to abnormal DRE and/or PSA
results were instructed to see their primary care physicians. Those participants requiring
follow-up who did not have a primary care physician were referred to physicians. The
responsibility of assuring follow-up went to the medical facility responsible for the
screening sites at which abnormal results were found. The Osteopathic Medical System
and the Tarrant County Hospital District were available to provide care to low-income
participants on a sliding scale according to a patient's ability to pay.
Hispanic screening participants were solicited to participate in a study interview
(see Appendix A) after completing their exit interview at the screening site. Potential
subjects were given the opportunity to read a bilingual letter written by the researcher
5
Although two Saturdays (September 16 and September 23) were available during the screening
project, two Hispanic site coordinators chose to utilize September 23 as a day for screening and
September 16, a Mexican holiday celebrated widely in the area, as a day for promoting the serening
46
which explained the purpose of the study and contained essential components of informed
consent. Also, contents of the cover letter were discussed with potential subjects prior to
their participation in the interview. No signatures were obtained in order that the
responses of the interview participants would remain anonymous. A bilingual Hispanic
nurse experienced with prostate-related issues assisted the researcher with the majority of
the interviews. Also, two bilingual Hispanic members of a local community group assisted
with the interviews. Interviewers were trained by the researcher through a 30-minute
training session held prior to the screenings. The interviewers were instructed to conduct
the interview in the language preferred by the interview participant and to record
comments made by the survey participants. Quotations in Spanish which were used in this
study were translated to English by the interviewer who heard the quote, in order to
assure that the intended meaning of the interview participants was preserved. Twentynine of the interviews were conducted by the researcher and 22 of the interviews were
completed by the other three interviewers. This interview study was approved prior to the
screenings by the University of North Texas Committee for the Protection of Human
Subjects, the Tarrant County Prostate Screening Project Committee, the Nursing Research
Committee of the Tarrant County Hospital District, and representativesfromthe
individual screening sites.
Instrument
The interview questionnaire (Appendix A) was developed by the researcher to
obtain information as to what promotional strategies or other factors had influenced
47
Hispanic screening participation, to ascertain participant satisfaction with the screening,
and to obtain data on possible ways to attract other Hispanics to future prostate cancer
screenings. One question of the interview was based on a survey conducted by the
American Cancer Society-Fort Worth Unit in 1993 asking who had referred women to
have a mammogram (see Appendix B). Additional questions were added to gain data
regarding the role price, place,flexibleappointment scheduling, possible embarrassment of
the rectal exam, and worry regarding possible test results may have had on screening
participation. Also, questions regarding participants' satisfaction with the screening
program and possible ways to promote future prostate screenings targeting Hispanics
were included in the interview. The Director of Detection and Treatment of the American
Cancer Society-Fort Worth Metro Unit assessed the literacy level of the instrument and
appropriate changes were made, in order that questions would be more readily understood
by participants of lower educational levels. The researcher received assistance and advice
on the Spanish language version of the interview and cover letter from a Hispanic male
who is a Spanish professor at a local community college, one of the bilingual Hispanic
nurse site coordinators, and a member of the target population. The bilingual cover sheet
and interview were printed with the English version on one side and the Spanish version
on the reverse side.
Data Collection
Information regarding the 1995 Tarrant County Prostate Screening Project was
obtained from the 1995 chairperson, hospital representatives, and site coordinators, and by
48
the researcher's attendance at screening and promotion committee activities. The
researcher collected data at three of the 1995 screenings and had interviewers present at
another site which occurred simultaneously. At the conclusion of the 1995 Prostate
Screening Project, the researcher collected the interview questionnaires and data regarding
the numbers of Hispanic males screened from site coordinators and interviewers.
Data Analyses
Promotional activities for the 1995 Tarrant County Prostate Screening Project were
outlined according to the four P's of marketing (Appendix C). A bar graph was designed
to illustrate who or what promotional activities influenced 1995 interview participants to
be screened (Appendix D). A chart was made to show how important other factors
(learning about your health, convenience of screening location, days and hours of testing,
being able to come without an appointment, cost of exam, embarrassment of the exam,
and the worry offindinga serious medical condition) were in participants' decisions to be
screened (Appendix E). A map was overlaid to show the location of the four study
interview sites and the number of Hispanics screened at each site (Appendix F). A Social
Marketing Plan to promote Hispanic participation at future prostate cancer screenings was
designed by the researcher based on Kotler's Social Marketing Process, literature review,
experiences gained from the project, and interviews with 51 prostate cancer screening
participants (Outlined in Appendix G).
CHAPTER IV
INTERVIEW RESULTS
How Did Hispanic Screening Participants Learn About the Prostate Screening?
Fifty-five responses (some participants gave more than one answer) were received
to the question "Why did you come today or how did you hear about the program?"
Twenty-two reported they had heard about the screening in the newspaper: twelve from
the Fort Worth Star Telegram, one from La Estrella, the bilingual edition of the Fort
Worth Star Telegram, two from neighborhood newspapers-one from the White Settlement
Bomber, and one from the Extra; and seven from El Informador, a Spanish-language
newspaper in Fort Worth. Two interview participants said they had heard an
announcement on English radio, two thought they had heard an announcement on Spanish
radio, and one thought he had heard about the program on English language TV. (None of
thesefivewere sure about which radio and television stations they had heard the
announcements).
Thirteen men said they had heard about the screenings from family or friends. One
participant's son had seen an announcement in the Fort Worth Star Telegram and the
White Settlement Bomber and had told his father about it. Two wives and two daughters
of participants saw an article in the Fort Worth Star Telegram and convinced four of the
participants to be screened. Two participants said they had participated because their
49
50
wives, who were employees at the screening sites, had encouraged them to attend. Other
participants were influenced by their daughters (one), daughters-in-law (one), or friends
(four), but were not sure how their family or friends had heard about the prostate
screenings.
Twelve men reported attending the screening after reading aflyerin their church
bulletin. Three who had attended last year's screening project said they attended this year
because of receiving an announcement from the Screening Project reminding them of the
dates of this year's project.
The Influence of Other Factors on Hispanic Screening Participation
Interview participants were asked "How important were the following factors in
making your decision to attend today's program?" (See Appendix E) Factors included
learning about your health, convenience of the (screening) location, day and hours of
testing, being able to come without an appointment, cost of the exam, embarrassment of
the exam, and the worry offindinga serious medical condition. Participants were asked
to rate whether the factors were very important, of medium importance, or of little or no
importance in making their decision to be screened for prostate cancer.
Forty-six (90 %) of the 51 participants said that learning about their health was a
very important factor in their decision to be screened, whilefiveof the participants said it
was of medium importance. One man remarked that learning about his health was
essential for the sake of his family and their need for his financial support.
51
Eighty-two percent or 42 of the 51 survey participants reported that the convenience
of the screening site location was very important in deciding to attend (12 said they lived
within blocks of the site at which they had been screened), while eight rated it of medium
importance, and one rated it of little or no importance.
The four study screening sites were all held on Saturday during the day or during a
weekday evening. Thirty-five participants (70 %) said that the days and hours of testing
were very important in deciding to attend, seven (13.7 %) said they were of medium
importance, and nine (17.7 %) said they were of little or no importance. Generally, those
who favored the Saturday and evening hours tended to be younger and employed, while
those who were older and retired, or one who was off work due to medical disability, said
they were more readily able to come any day or time of the week.
Thirty-three of the 51 survey participants made an appointment prior to the
screening, while 18 came as "walk-ins," without scheduled appointments. Of the 46 men
who responded to being asked how important it was for them to be able to attend the
screening without an appointment (on five interviews done by fellow interviewers this
question was not completed), 18 (39 % of the respondents) thought it was a very
important option, eight thought it was of medium importance, and 20 thought it was of
little or no importance. Those who had made prior appointments reported that they
preferred to have an appointment for the peace of mind of having a reserved spot and to
avoid unnecessary waiting, while others preferred theflexibilityof being able to attend at
the last moment without an appointment. One man who had come with an appointment
52
said, "It's (being able to come without an appointment) great for those that decide at the
last moment."
The offering of the prostate exams at little or no cost was very important to 36
(71 %) of the 51 participants, while of medium importance to eight of the participants, and
of little or no importance to seven others. Among those who reported that cost was of
little or no importance was one man who told the investigator he had medical insurance.
Another man said that he had medical insurance, but it carried a $ 250 deductible. He was
working two jobs to support his family and found the offering of free prostate exams to be
very important in making his decision to be screened.
Although embarrassment associated with the rectal exam has been reported in the
literature as being a possible barrier to screening for prostate cancer, only two (4 %) of
the 51 interview participants said that embarrassment was a very important issue when
they decided to participate. Eight said embarrassment was of medium importance, while
41 (82 %) participants rated it as being of little or no importance. Seven men told the
interviewers that finding out about their health far outweighed any possible
embarrassment. One man who had never had a prior rectal exam remarked that any man
who had been in the Army would find prostate screening exams to be "no big deal."
Another man told the researcher that he had come to the screening without any idea of
what the exams were going to entail, but found the rectal exam to be simple with minimal
embarrassment associated with it. (It is not known what role, if any, embarrassment may
have played for those men that knew about the screening, but declined to attend).
53
The worry offindinga serious medical condition varied among participants, with 15
participants rating it a very important issue in making their decision to attend the
screening, 19 rating it of medium importance, and 17 rating it of little or no importance.
Two men said it was the worry that brought them in to be screened. One participant
explained that he was concerned and wanted the peace of knowing. Another said that his
wife was concerned and her nagging had caused him to become concerned enough to
come in. Two reported they were worried and had come to the screening because of
recent difficulties with urination. One man who rated his worry of medium importance
stated that "the sooner you find out (about a serious medical condition) the better off you
are." Those who rated worry offindinga serious medical condition of little or no
importance explained their lack of worry in a variety of ways. One man told the
researcher, "I'm pure Mexican. I never worry and I never hurry." Two men said they
were not worried about the outcome of the exams because they had never had any serious
medical problems before. Of similar note is the male who said he was not worried because
he had been examined for prostate cancer before and the exams had been normal. Another
man reported that prior to making his decision to attend the screening, he had worried far
more about his inability to speak or understand English than he had worried about the
embarrassment of the rectal exam or possibility offindinga serious medical condition.
Participants' Satisfaction With The Prostate Screening
When participants were asked, "If prostate exams are offered here again next year
will you attend?" 50 of the men answered "yes." The remaining participant planned to
54
return to Mexico in the near future, but said if he was in the Fort Worth area during next
year's prostate screening he would attend the screening. Reasons for returning included
"preventive maintenance," "efficient scheduling," "friendliness of the staff," "convenience
of being on a Saturday," "I live close," "my family needs me," and "because people are
concerned enough to have this project."
Health was the most common reason given for planning to return the following year
to be screened. "To find out about my health," "to be on the safe side," "because it is
important," "for my health," "because I need to be examined," "in order to know if I have
cancer," "to be checked again because one doesn't know if he will get sick from one year
to another," "because my health interests me," "for precaution," and "the exams are
important" were among the reasons cited for agreeing to return thefollowingyear.
When participants were asked, "Will you recommend this prostate testing program
to your friends?" all responded that they would and nine men reported that they had
already told friends and/or relatives about the program. Again health was the number one
reason given for recommending the program to their friends. "It's an excellent checkup,"
"to prevent something from happeningfromneglect," "to prevent problems," "because it
is important to everybody," "because it is important to take care of one's health," "so they
(myfriendsand family) don't have problems in later years and it may be too late," "to see
if they are sick or not," "to discover cancer and know more," and "es muy importante
porque uno puede tener cancer u otra infeccion" (it's very important because someone can
have cancer or another infection) were among the reasons given. Other reasons given for
55
recommending the program included "to increase awareness," "it's quick-no waiting,"
"it's free," "good staff," and "the efforts of the people" (those that made the program
possible).
Suggested Ways to Improve the Program and Attract More
Hispanic Screening Participants
"How can we make today's program better?" This question was asked of each
survey participant. All but two of the participants expressed satisfaction with the program
and did not offer any suggestions on ways to improve it. Two of the participants who had
scheduled appointment times voiced dissatisfaction with having to wait too long to be
seen. Of note is that two other interview participants said that the program was "quick-no
waiting" and "not very time consuming" in response to earlier questioning. At the four
sites that the researcher attended, it seemed that the bulk of the patients arrived early,
many 30-45 minutes prior to the scheduled starting time of the screening, but some of the
doctors arrived late, which caused some delays.
Participants were asked how to encourage more Hispanic participation at future
prostate screenings. Upon hearing the question many acknowledged that this was a
difficult task. One interview participant said, "Hispanics think differently. It (having
medical check-ups) is embarrassing. I don't know. I don't have any ideas." One man just
shook his head and said that "talking to them (Hispanic males) is like talking to the wall."
One participant said that "cultural beliefs, fear, machismo, and being uninformed" all serve
as barriers to being screened. Other commentsfrominterview participants included:
56
"Los hispanos se creen muy machos, pero la infermedad no respeta machismo."
(Hispanic males believe they're very macho, but the disease [cancer] doesn't respect
[show favoritism to] machismo).
"Todos tienen verguenza por una falta de preparation." (Everybody's ashamed,
embarrassed [to have the exams] due to a lack of preparation [knowledge about the
issues]).
"A lot of men don't come, maybe because they don't think it is important."
"People don't have the exams because they don't want to find out the results."
"Hispanics are generally afraid to find out what is wrong with them. They don't
want to know. They think that nothing is wrong with them."
One man told the researcher of his frustration in trying to convince his brother-inlaw to be screened. His brother-in law had refused to come saying, "If I'm going to die,
I'm going to die."
Many of the men offered advice on how to attract more Hispanic participants.
Eight of the participants said that the best way to promote the screenings would be "word
of mouth," promoting the project among themselves by encouraging friends and relatives
to participate. One of the men suggested that prior to next year's screening "promotional
packets" should be sent to this year's screening participants. He proposed that the
packets should contain educational literature regarding prostate cancer and promotional
information about the screening which could be passed along to friends and relatives.
57
Participants stressed the importance of creating awareness and educating the
community about prostate health issues. The importance of mass media in distributing the
information was mentioned by many of the participants. Suggestions on how to
accomplish this included running educational columns in newspapers. One 63 year-old
participant who had never had a prior rectal exam recommended, "Digales que 'vengan,
no tienen que pagar nada, que es bueno para nosotros, que es sencillo, y no es doloroso.'"
(Tell them [Hispanic men] to come, you don't have to pay anything, it's good for us, it's
simple, and it's not painful.) Neighborhood newspapers were mentioned by two
participants as a good avenue for dispersing the information. Promoting the screenings
through Spanish-language newspapers, radio, and television was recommended by six
participants. One interview participant suggested providing a speaker for a local Spanishlanguage radio talk show in which listeners could phone in questions. Two survey
participants told the researcher that wives should be educated about prostate cancer, so
that they can encourage their husbands to attend the screenings. "Tell the wives because
they go to doctors more," one said. Participants also recommended that educational and
promotional activities take place in the schools, so that children can educate their fathers,
grandfathers, uncles, and other family members.
Two participants recommended putting information on bulletin boards of
restaurants, hotels, factories, and other places where Hispanics are employed. One
participant suggested putting information in area barber shops, while two others suggested
that posters and educational literature be put in area hospitals, particularly the county
58
hospital and clinics, one to two months prior to the screening. Another participant said
that people are "flojos de leer" (lazy about reading) if the print is small, and recommended
the use of bilingual posters with large print.
Mailing cards and informational brochures to the homes of Hispanics was
recommended by two of the participants. One man said thatflyersdelivered to homes
with a personal face-to-face explanation would be beneficial. Others suggested that flyers
be distributed through more churches and also at places of recreation. The importance of
personal intervention was mentioned again by a man who recommended that
announcements be made in person, rather than just flyers, at church. "The priest should
say something at the end of Mass prior to the screening," he said.
Although participants acknowledged the importance of attracting more Hispanics to
be screened, some men said they couldn't think of any suggestions. As one man said,
"After all, it (publicity about the screening) has been in all the newspapers." One 71-year
old interview participant said he really couldn't think of anything to recommend that
hadn't already been done, but as he was leaving the screening site he called back to the
researcher, "You know what would REALLY bring in the men? Food!
and Beer!!!!
CHAPTER V
RECOMMENDATIONS FOR DESIGNING A SOCIAL MARKETING PLAN
The following sections discuss the researcher's recommendations for promoting
Hispanic participation at prostate cancer screenings. These recommendations are based
on Kotler's Social Marketing Process (1982), literature review, experiences acquired from
serving on the promotion committee of a community-sponsored prostate cancer screening
project (and other past community health efforts targeting Hispanics), and interviews with
51 Hispanic prostate cancer screening participants.
Problem Definition
According to Kotler (1982) a health campaign planner must first identify a problem
and study the influences that support and reinforce the ideas and behavior associated with
it. Literature review found Hispanics were less likely than African-Americans or whites to
utilize cancer screening exams and more likely than whites to be initially diagnosed with
advanced stages of prostate cancer. Potential barriers to prostate screening among
Hispanic males included poverty, lack of insurance, culture, language, lack of knowledge
regarding prostate cancer and the digital rectal examination, reluctance to seek medical
attention for fear of appearing less than manly, embarrassment with the idea of having a
digital rectal examination, and fatalistic attitudes regarding the benefits of early cancer
59
60
detection and treatment (discussed in Chapter 2, "General Profile of Hispanics,"
"Knowledge, Attitudes, and Beliefs Among Hispanics Regarding Cancer," and
"Knowledge, Attitudes, and Practices Regarding Prostate Cancer and Digital Rectal
Examinations Among Hispanic Males"). Interviews with Hispanic prostate screening
participants reiterated that low economic status, cultural beliefs, language, lack of
knowledge, fear, machismo, and fatalism may prevent Hispanic males from being screened
for prostate cancer.
Goal Setting
The goal is to increase the numbers of Hispanic males who are being screened for
prostate cancer, but the health planner needs to be more specific. Is the goal to screen the
largest number of Hispanics possible during a given time period? Is the goal to increase
the participation of low income Hispanic males in prostate screening? Is the goal to reach
those in the age group most at risk (age 50 and older)? Goals that are reasonable and can
be measured need to be set, so that campaign planning and budget development can take
place and the success of a campaign can be measured (Kotler, 1982).
Target Market Segmentation
"In social marketing, audiences are segmented so that health messages can be
designed with reference to specific attitudes, behaviors, preferences, and patterns of media
use" (Williams & Flora, 1995, p. 37). The problem is that Hispanics can not be segmented
into one specific homogenous group. Literature review and interviews conducted during
61
this study showed Hispanics to be heterogeneous with differences in ethnicity, language
preference, socioeconomic status, degree of acculturation, and media preference
(discussed in Chapter 2, "General Profile of Hispanics in the United States"). For
example, one of the interview participants, a native of South America, pointed out to the
researcher that although Spanish was his primary language, neither he nor his South
American friends ever listened to Spanish language radio, because it was so heavily geared
towards the Mexican American audience in regard to the music and messages delivered
(the majority of Hispanics in the Dallas-Fort Worth area are Mexican Americans).
Although Hispanics often share common language, religion, and values, they are a
diverse population of varying heritages (ie. Mexican or Mexican American, Puerto Rican,
Cuban or Cuban American, Central or South American). They have been shown to
display differences in socioeconomic status, health insurance coverage, health status, and
utilization of health services. Hispanics who are less acculturated are often reluctant to
utilize health services due to language and cultural barriers. Education and literacy levels
also vary among Hispanics. The diversity that exists among Hispanics must be
acknowledged when planning health programs, so that the needs and preferences of those
targeted can be effectively addressed.
Consumer Analysis
Determining how the target population can best be assisted in going from their
present health attitudes and behaviors to desired health attitudes and behaviors is critical.
62
Analyzing the target population can identify needs, desires, expectations, satisfactions, and
dissatisfactions. One of the most important concepts of social marketing is its intense
focus on the health consumer (Novelli, 1989). The interviews conducted during this study
provided insight regarding the consumers' likes and dislikes about the program,
information on who or what had influenced them to be screened, and provided the
interview participants' input to enhance future programs. Interview participants in this
study willingly provided information to the interviewers and expressed pleasure and
appreciation that someone was interested in learning their opinions. Program planners
need to talk with Hispanic males in their workplaces, churches, social organizations, at
senior citizen centers, clinics, health fairs, and other community locations in order to
determine ways to better promote cancer control programs and break down barriers.
Influence Channel Analysis
Program planners need to determine the most effective means for carrying out their
program. Mass media attracted more participants to the 1995 Tarrant County Prostate
Screening than any other means. More editors and producers of both English and
Spanish-language print and broadcast media should be encouraged to promote cancer
prevention and early detection as a public service.
Flyers distributed inside of church bulletins to worshipers was also an important
source of attracting participants during the Screening Project. One of the interview
63
participants suggested that priests should play a more active role by speaking about the
cancer screening at the end of Mass. The researcher has seen from personal experience
the powerful influence that priests can have on cancer control programs. Cancer
educational and screening programs which have been promoted through church and
community leaders, as well as through encouragement from priests speaking at the end of
Masses, have resulted in larger attendances than programs that were promoted through
the same leaders, at the same locations, without personal intervention by the priests.
Recognizing the importance of influencing community leaders (as discussed in
Chapter 2, "Important Elements for Inclusion in a Cancer Control Project for Hispanics"
and "Review of Three Cancer Control Projects in Hispanic Communities"), a luncheon
was held prior to the Tarrant County Prostate Screening Project. Community business
leaders can play an important role in promoting cancer control activities by allowing
educational and informational brochures, flyers, and posters at their places of business.
Supermarkets, restaurants, and barber shops are only a few of the key sites for distributing
cancer-related literature. As interview participants suggested, providing information at the
workplace would be beneficial in promoting cancer awareness. Employers should
promote the attendance of employees at mini-sessions on cancer prevention and early
detection during work hours. During the luncheon given for community leaders during
the Screening Project, one of the leaders suggested that even the mayor should become
involved by officially proclaiming Prostate Cancer Awareness Week in the city.
64
Influencing lay leaders is also important when designing a social marketing plan.
The utilization of lay persons for promoting health in Hispanic communities has been
successful in the United States (Chapter 2, "Review of Three Cancer Control Projects in
Hispanic Communities"), as well as in Latin American countries. Persons who are
respected and involved with the target community can assist in many aspects of health
program planning, implementation, and evaluation. Lay persons can be trained to educate
others in cancer prevention, early detection, and treatment; they can distribute educational
and promotional literature, assist with translating, transport clients to cancer screenings,
and assist in setting up sites for cancer education and screening.
As literature review (Chapter 2, "Important Elements for Inclusion in a Cancer
Control Project for Hispanics") and study interviews revealed, the influence of family and
friends is very important to the health practices of Hispanics, in contrast to the concept of
individualism that is prevalent in the United States. Twenty-six percent of the study
interview participants reported that they had participated in the prostate screening because
their wives, other family members, orfriendshad encouraged them to do so. Several of
the study participants suggested that cancer screening information be taught in the
schools, so that children can take the information home to their parents and other family
members. Understanding the traditional roles of the man as economic provider, and the
woman as wife and mother who is responsible for her family's health, can be beneficial in
health promotion efforts. Study participants emphasized that if women are educated about
the importance of cancer screening, they will convince their husbands to be screened.
65
Among the places at which women can be targeted are senior centers, churches,
supermarkets, and their employment sites. Women who are being screened for breast and
cervical cancer in doctors' offices, community clinics, and on mobile cancer screening
units should also be educated on other types if cancers, such as prostate cancer, which can
affect their family members.
One must not overlook the importance that medical personnel can make in
community cancer control efforts. The Screening Project would not have been possible
without the voluntary efforts of the doctors, nurses, and other health care professionals.
Health professionals should be encouraged to discuss and recommend cancer prevention
and early detection guidelines and strategies with their Hispanic patients. Interview
participants in this study emphasized that one of the best ways to increase awareness and
discourage misconceptions about cancer prevention and early detection is to "spread the
word" among themselves. Health care professionals need to provide their Hispanic
patients with the necessary information and positive cancer screening experiences, so that
these patients in turn can promote cancer awareness in their communities.
Marketing Strategies and Tactics
One important step in having a successful program is to review the literature and
"brainstorm" with community professionals in order to ascertain what strategies have been
successful, or not so successful in other programs. Assessing the Four P's of Marketing
(Product, Price, Place, and Promotion) is an important component of the social marketing
66
plan. In prostate screening the product should be a prostate health awareness program
which includes the Prostate Specific Antigen (PSA) and digital rectal exam (DRE). Well
planned health fairs organized by Hispanic community leaders in Fort Worth have been
successful in attracting Hispanics. Incorporating prostate screening into health fairs which
include blood pressure checks, cholesterol and glucose testing, eye exams, and other types
of screening could be a way to increase participation. Well-woman exams are promoted
among women. Why not promote well-man exams? Why not promote cancer screening
for Hispanic men and women on the same day? For example, men could be screened for
prostate cancer at a clinic while their wives were having mammograms done on a mobile
unit parked outside the clinic. Children and grandchildren could be educated on cancer
prevention, such as the dangers of smoking and exposure to the sun.
Because studies show many Hispanics are of low socioeconomic status and without
insurance (discussed in Chapter 2, "General Profile of Hispanics in the United States"),
prostate exams must be offered to the Hispanic community at low or no cost. The offering
of free prostate exams may be enough incentive for some males to participate. However,
for the multitude of men who do not participate even when exams are offered free, it is not
enough. In working with this study and in past projects, the researcher became very
interested in the concept of providing incentives in an effort to promote participation at
cancer screenings. During a July educational gathering at a local church, several Hispanic
women suggested that if female members of their church brought food to the prostate
screening sites, more men would attend. One of the interview participants also
67
recommended that food (and beer!) be served to promote future screenings. Incentives,
such as coupons, price specials, and small gifts, are an important component of social
marketing. Suggestions by the researcher to include incentives in the Prostate Screening
Project were not met with much interest or enthusiasm by fellow committee members.
One person expressed concern that offering incentives would "reduce the credibility" of
the Screening Project.
The difficulties of trying to "sell" health professionals on the value of social
marketing has been reported in the literature. "After all, many health professionals view
marketing as the undignified discipline that brings us such globally unimportant issues as
the cola and burger wars, conclusive evidence on which headache remedy doctors would
want with them if stranded on a desert island, and the classic of all classics, 'Ring around
the collar"' (Novelli, 1989, p. 36-38). It is noteworthy that incentives have been used in
Tarrant County on a regular basis to encourage participation of women and children in
health programs. For example, passes to the zoo and free school supplies are two of the
incentives that have been used to promote childhood immunizations. Coupons and gift
certificates, as well as the offer by one insurance company of the chance to win a $1,000
drawing, are only a few other incentives that have been offered to local women to
encourage them to have mammograms. Other means have not appreciably increased
Hispanic prostate screening participation in the community; therefore, creative ideas and
incentives should be explored and encouraged at future prostate cancer screenings.
68
Planning prostate screening sites in target population neighborhoods is essential.
Over 80 % of the interview participants in this study rated the convenience of the
screening site as very important in their decision to be screened. Northside Clinic, located
in the heart of a neighborhood which is predominantly Hispanic, attracted the highest
percentage of Hispanic screening participants who had never had a prior rectal exam
(75 % of their participants). One hundred percent of the 16 Hispanic participants screened
there reported household incomes of 200 % poverty level or below. More Hispanics were
seen at Diamond Hill Community Clinic than at any other screening site. Factors which
may have contributed to the increased Hispanic participation at this site include: being the
second year to serve as a prostate screening site, screening a larger percentage of Hispanic
men who were below the recommended screening age than any other site, and the
additional promotions by site personnel (although the majority of promotion activities
promoted the screening sites equally, thousands of flyers were distributed which listed this
site only).
Literature review (Chapter 2, "Important Elements for Inclusion in a Cancer
Control Project for Hispanics") and interviews with screening participants emphasized the
importance of promoting health (rather than cancer fear or scare tactics) when promoting
cancer control activities targeting Hispanics. For example, although the prime purpose of
prostate screening is to detect cancer, calling a project the Tarrant County Prostate
Screening Project, rather than Tarrant County Prostate Cancer Screening Project, projects
a greater sense of promoting prostate health and wellness. During one of the study
69
interviews, one of the participants told the researcher that he regularly watched TV
programs from his native Mexico via satellite. He remarked that a recent program which
focused on the importance of prostate examinations (along with an article in the Fort
Worth Star Telegram) had helped influence his decision to be screened. The researcher
asked him to summarize the message of the prostate program from Mexico and he replied,
"Be concerned, not afraid. Watch your family grow up and lead a prosperous life."
Program Implementation
Before a screening can take place, funding sources need to be secured. The
program planner needs to determine the number of anticipated screening participants and
which services won't be provided at no cost, in order that a budget can be determined.
Will physicians, nurses, phlebotomists, and other personnel provide their services without
charge during the screening? Will area broadcast and print media promote the screening
as a community service? Obtaining a grant or having community fond raisers may be
additional ways to obtain money to support a prostate cancer screening project.
Once necessary funding has been arranged, personnel should be assigned to
Screening, Education, and Promotion Committees. Duties of the Screening Committee
should include locating screening sites in target population neighborhoods, recruiting
voluntary coordinators, physicians, nurses, phlebotomists, and translators for each site and
setting up dates for screening. The amount of the budget, as well as the anticipated
number of screening participants and available personnel, will determine the number of
70
sites that should be chosen. One well-organized, successful screening at one site is better
than many less successful screenings. Information on becoming a prostate screening site
can be obtained from the Prostate Education Council in Denver, Colorado.
Educating the community is an important task. The Education Committee should
ideally consist of both health professionals experienced in prostate-related issues and
prostate cancer survivors, as well as interested members of the target community. During
the Tarrant County Prostate Screening Project, efforts to find a Hispanic prostate cancer
survivor to assist with the project were unsuccessful. During speaking engagements in the
community, the researcher has noted that whites are more likely to share positive stories
about themselves or persons they have known who have survived cancer, whereas
Hispanics often relate incidences offriendsand relatives who have foregone early
diagnosis and treatment and died of cancer, and may not know anyone who has survived
cancer. Health professionals who come in contact with Hispanic prostate cancer survivors
should encourage them to "come forward" in order to serve as positive role models and
encouragement for others to participate in cancer screenings.
Members of the target population who have had positive experiences related to
prostate cancer screening could also be good candidates for educating others on the
simplicity and importance of the prostate screening exams. Participants interviewed in this
study emphasized that talking among themselves was an ideal way to create awareness and
promote screening participation. The Education Committee can arrange sites and dates
for bilingual speaking engagements, and those persons willing to speak to the public can
71
educate and disperse bilingual literature in schools, workplaces, senior centers, and other
selected sites.
During this research study, Spanish-language information relating to the prostate
from the American Cancer Society and National Cancer Institute was found to be
outdated or lacking. A Spanish-language pamphletfromthe Merck pharmaceutical
company entitled lo que todo hombre deberia saber acerca de su prostata (What every
man should know about his prostate) was used during the 1995 Tarrant County Prostate
Screening Project. It consists of basic anatomy and physiology of the prostate, as well as
information regarding benign prostatic hyperplasia, prostatitis, and cancer of the prostate.
This pamphlet received favorable comments regarding contentfromtwo bilingual Hispanic
nurses who reviewed it, and an unfavorable commentfromone of the nurses who
questioned whether persons depicted in the photos were Hispanic. The researcher notes
thatfindinga "typical" Hispanic to use in a photo is difficult because Hispanics are diverse
in ethnicity and may be of the white or black races. Ideally, written health educational
materials for Hispanics should be at reading levels which do not exceed those of the target
audience, should be written in large print (as suggested by one of the study interview
participants), and should contain positive health messages, photos, and drawings which
reflect the image, culture, and lifestyle of the target audience.
The Promotion Committee should determine the most creative, cost-effective ways
to promote the prostate screening project in the community. Posters andflyerscarrying
positive health messages should be designed and dispersed to area churches, businesses,
72
workplaces, community centers, and other community locations. Media personnel should
be contacted and press releases sent out. Local businesses can be solicited to donate
"gifts," food, coupons, and other items as additional incentives for screening participants.
Program Evaluation
One of the most important parts of a screening program is the evaluation.
Calculating attendance, which includes the number of members of the target population
who were screened, is one way to evaluate the effectiveness of a screening program.
Evaluations should determine if program goals were met. Since the Tarrant County
Screening Project began in 1993, the goals have been to screen the medically underserved,
and to include more minority and low income men. Unfortunately, data regarding the
race/ethnicity of screening participants was not maintained at one site from 1994, and the
financial status of screening participants was not obtained at all of the 1994 or 1995
screening sites. Not only did that place limitations on this study, it also failed to allow
accurate measurement of 1995 Screening Project goals. In the future, it is recommended
that at least basic information on the race/ethnicity andfinancialstatus of screening
participants be obtained, even when community cancer screenings are provided at no
charge to the clients.
The focus of social marketing is on the health consumer, so a social marketing plan
is not complete unless it includes a means, such as a follow-up survey, to determine the
satisfactions and dissatisfactions of the participants and to provide information on ways to
73
enhance future health programs. Then, after a project is completed, it is recommended
that program planners share the program outcome and experiences with others. By giving
others the opportunity of learningfromboth the positive and negative aspects of the
program, additional information may be added to the limited published research currently
available relating to cancer control and Hispanic males.
Finally, the researcher recommends that community cancer control programs be
ongoing. In 1993 the researcher set up a mobile mammography program targeting the
underserved of Tarrant County, Texas, for the Harris Methodist Health System. In the
process of soliciting sites in key low-income minority neighborhoods, the project was met
with both enthusiasm and concern. Community leaders were enthusiastic because they
understood the value of bringing cancer screening directly to the people, but they were
also concerned because others had come into their communities for a time or two, then
never returned. After receiving the personal commitment of the researcher and the
researcher's institution that the project would be ongoing, the project was initiated. Two
years later, the mobile unit continues to make at least monthly visits to those same key
sites. Many of the women who have been screened for breast cancer at those sites
(including those who have been diagnosed and treated for cancer) have helped "spread the
word" and encouraged other women to be screened. Cancer control programs should be
ongoing in order to receive community trust and support, and to have a stronger longrange impact on cancer morbidity and mortality.
CHAPTER VI
SUMMARY, CONCLUSION, AND RECOMMENDATIONS FOR FUTURE STUDIES
Hispanics are diversified in many ways including ethnicity, use of language, degree
of acculturation, and utilization of health care services. They have been reported to be
more likely than whites to live in poverty, have lower educational levels, be
underemployed or unemployed, and to be without health insurance. Literature review
found Hispanics to be less knowledgeable about cancer and cancer screening
examinations, and more fatalistic in regard to cancer prevention, early detection, and
treatment, as compared to whites and African-Americans. Although data is limited,
Hispanic males were found to have lower prostate cancer morbidity and mortality, as
compared to whites and African-Americans. However, Hispanics were less likely than
whites or African-Americans to utilize cancer screening examinations, and more likely
than whites to have advanced cases of prostate cancer at initial diagnosis.
Summary of the Research
The purpose of this descriptive study was to design a social marketing plan which
could be used as a model to promote Hispanic participation at future prostate cancer
screenings. The social marketing plan was designed based on Kotler's Social Marketing
74
75
Process (Kotler, 1982), literature review, the researcher's experiences working with the
promotion committee of a community-sponsored prostate cancer screening project and
other community cancer screening efforts targeting Hispanics, and interviews with 51
Hispanic prostate screening participants. Subjects consisted of Hispanics, the majority
(80 %) of whom were Mexican American, who were screened at four prostate screening
sites in September of 1995 in Tarrant County, Texas. The study was conducted from the
perspective of a non-Hispanic medical professional, thus may be unintentionally biased.
Other study limitations are: (1) data regarding thefinancialstatus of 29 subjects was not
collected by personnel at one site, which limited the profile on who was attracted to the
screening, (2) data obtained from subjects in this study may not be representative of the
viewpoints of other Hispanics, (3) the role acculturation may have played in screening
participation was not addressed during the interviews, and (4) the researcher was unable
to incorporate incentives, an important aspect of social marketing, into the study because
of the need to defer to the wishes of other committee members in a democratic, decisionmaking process.
Conclusions
Literature review and interviews with study participants revealed that poverty, lack
of insurance, culture, language, lack of knowledge regarding prostate cancer and the
digital rectal examination, a reluctance to seek medical attention for fear of appearing less
than manly, embarrassment with the idea of undergoing a digital rectal examination, and
76
fatalistic attitudes regarding the benefits of early cancer detection and treatment may serve
as barriers to prostate cancer screening for Hispanic males.
Interviews with 51 Hispanic participants of a prostate cancer screening project in
Tarrant County, Texas, found the newspaper to be the most reported means for learning
about the screening, followed by family andfriends,andflyersin church bulletins. The
majority of participants reported that health, convenience of screening site location, the
offering of exams at little or no cost, and the availability of Saturday and evening hours
were important factors in making their decisions to be screened. Offering screening
participants the option of attending the prostate screening either with or without a prior
appointment resulted in 33 of the 51 participants making an appointment prior to the
screening, while 18 came as "walk-ins", without scheduled appointments.
Although embarrassment associated with the rectal exam has been reported in the
literature as being a possible barrier to screening for prostate cancer, only two (4 %) of
the 51 participants rated embarrassment of the exam as an important issue. It is not
known if "machismo" or other factors might have influenced participants' denying the
significance of embarrassment. The worry offindinga serious medical condition varied
among participants, with 15 participants rating it a very important issue, 19 rating it of
medium importance, and 17 rating it of little or no importance when deciding to attend the
screening.
All participants responded affirmatively when asked if they would return to be
screened for prostate cancer the following year and if they would recommend the
77
screening program to their friends. Health, free exams, convenience of screening site
location, convenience of scheduled screening hours (Saturdays and evening hours), and
the efforts of the staff that had made the program possible were among the reasons given
for planning to return and recommending the program to their friends.
Participants reported that cultural beliefs, fear, machismo, being uninformed, and
fatalism are reasons why many Hispanic males are not screened for prostate cancer. The
strategy mostfrequentlysuggested by participants to promote prostate screening among
Hispanics was to promote awareness among themselves. Others strategies suggested by
participants included: educational newspaper columns; radio talk shows; educating wives
and children; placing information at barber shops, places of employment, and recreation;
brochures delivered to the homes of Hispanics by mail or in person; personal
announcements about the screening by the priest or minister at the end of religious
services; and screenings which offer food and beer.
The importance of incorporating problem definition, goal setting, target market
segmentation, consumer analysis, influencing channel analysis, marketing strategies and
tactics, program implementation planning, and evaluation into a social marketing plan was
discussed. When designing a cancer control program in the Hispanic community it is
important to understand the culture, socioeconomic status, educational levels, media
preferences, and other aspects of the target population. The heterogeneity of Hispanics
must be acknowledged when designing a social marketing plan.
78
Literature review and experiences with the Tarrant County Prostate Screening
Project show how community effort and involvement can result in organized cancer
control programs for Hispanics. Other communities can set up similar programs by
involving the entire community: community leaders (medical, social, political, and
religious), as well as members of the target population and their family and friends, in
program planning, implementation, and evaluation. Combining resources through the
joining together of health professionals, marketing specialists from community medical
facilities and businesses, and members of the target community will produce more
successful, cost-effective, and client-pleasing health programs. Future program planners
are encouraged to use innovative approaches, which include incentives, in their programs
in order to attract more Hispanic participants. The researcher also recommends that
cancer control programs be ongoing in order to establish community trust and support and
to have a stronger long-range impact on cancer morbidity and mortality. It is hoped that
this study will inspire more health program planners to conduct and report about prostate
(and other) cancer screening programs targeting Hispanic males. The ultimate goal, of
course, is that if prostate cancer cannot be prevented, it will be diagnosed in early, more
easily treatable and curable stages.
Recommendations for Future Studies
The following specific recommendations are made for further research in the area
of health screening within the Hispanic community:
79
1)
During this study Spanish-language materials regarding the prostate and prostate
cancer were found to be sparse. For example, pamphlets available from the
American Cancer Society carried publishing dates of 1985, and the only Spanishlanguage pamphlet available from the National Cancer Institute related to
information on the Prostate Cancer Prevention Drug Trial. It is recommended that
more Spanish-language materials (both written and audiovisual) regarding the
prostate and prostate cancer be updated or developed.
2)
Literature review and interviews with Hispanic screening participants found
fatalism to be a potential barrier to prostate cancer screening. There is a need for
investigations to determine the effect education and other interventions have on
fatalistic attitudes and screening participation among Hispanics. Studies to
determine how interventions by priests and other religious leaders affect cancer
knowledge, attitudes, and practices among Hispanics would be useful.
3)
Acculturation was not addressed during study interviews. The researcher
acknowledges the importance of acculturation and Hispanic health, and suggests
that future studies address its role in cancer knowledge, attitudes, and practices
among Hispanics. Although acculturation is a complex issue and lengthy surveys
would be difficult, for example, in a mass cancer screening setting, shorter
acculturation scales, such as a 12-item acculturation scale by Marin and coinvestigators (Marin, Sabogal, Marin, Otero-Sabogal, & Perez-Stable, 1987) or a
4-item scale by Marin and Marin (1991), are available to incorporate into a study.
80
4)
During this study utilization of Hispanic cancer survivors who were willing to
serve as role models and promote cancer awareness in the community was lacking.
It is recommended that in future studies, Hispanic cancer survivors be interviewed
to determine reasons why they are willing or are not willing to share their
experiences with others. Is there a special stigma in the Hispanic community for
those diagnosed with cancer, as has been reported in the literature? Are cancer
survivors worried that others would feel uncomfortable touching or working with
someone who had cancer (Clark, Martire, & Bartolomeo, 1985; Perez-Stable,
Sabogal, Otero-Sabogal, Hiatt, & McPhee, 1992)? These questions need to be
answered.
5)
Which health messengers are most respected by Hispanic males? Priests?
Curanderas? Medical professionals? Family? Friends? What role does the gender
of the health messenger play in the acceptance of health messages among Hispanic
males? It is recommended that studies be conducted to evaluate these questions.
6)
A review of three cancer control projects targeting Hispanics reported in the
literature found focus groups/interviews to be a commonly included element. The
researcher suggests that focus groups of Hispanic males be organized to determine
ways to promote cancer education, prevention, and early detection in the
community. Emphasis should be placed on how Hispanic males can
become involved in promoting cancer awareness among themselves, as interviews
81
conducted with Hispanic prostate screening participants during this study
suggested that this would be an important strategy to explore.
7)
Data on cancer control interventions in the Hispanic community, particularly those
targeting Hispanic males, is lacking. Detailed descriptions on the process and
outcome of developing, implementing, and evaluating programs targeting
Hispanics need to be published, in order that successful approaches can be
replicated and problems encountered during a program can be avoided in future
programs.
8)
During this study the researcher noted that, although innovative approaches
which included incentives had been utilized for women and children in the county,
suggestions to include incentives to promote the participation of Hispanic males
in prostate screening were not readily accepted or utilized. Creative approaches
which include incentives to promote the participation of Hispanic males in cancer
screenings are to be encouraged. It is suggested that a follow-up study be
completed after an intervention in order to evaluate those who chose to participate
and those who chose not to participate.
9)
Obtaining adequate data regarding Hispanic health was difficult in this study
because statistics continue to be gathered which only differentiate between whites
and blacks with no differentiation for Hispanics. Data collected in future studies
should include Hispanic and Hispanic subgroup identifiers, as well as information
on socioeconomic status, to improve the weak data base on Hispanic health.
APPENDIX A
INTERVIEW QUESTIONNAIRE WITH COVER LETTER
82
83
Dear Prostate Screening Participant:
I'm a graduate student at the University of North Texas at Denton and a registered nurse
who is sincerely interested in health issues relating to the Hispanic community. Presently
I'm conducting thesis research on strategies to promote prostate cancer screening among
Hispanics. Although Hispanics have a lower incidence of prostate cancer than African
Americans or whites, studies have shown Hispanics to be the least likely to utilize
screening exams which assist in early prostate cancer detection. Studying influences
which are most effective in attracting Hispanic screening participants will assist in planning
better health programs for Hispanics in the future and will, hopefully, ultimately lead to a
decrease in cancer deaths among Hispanics.
I would like Hispanic males who are screening participants in the 1995 Tarrant County
Prostate Screening Project to voluntarily complete a brief interview. If you decide to
participate in this interview, we will not ask your name and the completed interview will
be put in a special sealed box, so that your answers will remain confidential. This study
has been approved by the University of North Texas Committee for the Protection of
Human Subjects and poses no risk to you. It will only take several minutes of your time
to complete the interview and I would appreciate your participation; however, your
participation is voluntary and you may choose not to participate without any penalty,
whatsoever. If you have questions or would like to talk to me personally about the survey
and I'm not available at the screening site, you may contact me at 685-4759.
Sincerely,
Suzanne Zimmerman RN
84
HISPANIC SCREENING PARTICIPANT INTERVIEW
Why did you come today or how did you hear about today's program?
How important were the following factors in making your decision to attend today's
program? (very important, of medium importance, of little or no importance)
Learning about your health
very
medium
not important
Convenience of location
very
medium
not important
Days, hours of testing
very
medium
not important
Being able to come without appointment
Had appt
Walk-in
Cost of exam
very
medium
not important
very
medium
not important
Embarrassment of exam
very
medium
not important
Worry offindingserious medical condition
very
medium
not important
Had you ever had a rectal test before today? If yes, when? Through Screening Project?
If prostate tests are offered here again next year, will you attend? Why or why not?
Will you recommend this prostate testing program to your friends? Why or why not?
How can we can make today's program better/Encourage other Hispanics to come?
How old are you?
What is your nationality?
Mexican or Mexican American
Central American
South American
Puerto Rican
Cuban or Cuban American
Other (please specify)
How much did your prostate tests cost you today?
The tests were free
Paid $11
85
Querido participante del programa de examination de la pr6stata:
Soy estudiante graduada en la universidad (University of North Texas) y enfermera y soy
sinceramente interesada en la salud de la comunidad hispana. Actualmente estoy
investigando maneras de promover los ertamenes de la pr6stata entre los hispanos. Los
hispanos corren menos riesgo de desarrollar el cancer de la pr6stata que los blancos o los
africoamericanos. Sin embargo, los estudios nos muestran que los hispanos tienen menos
probabilidad de tener los examenes que pueden detectar el dancer en las etapas mas
tempranas y curables.
Quiero estudiar los factores que influyen a los hispanos a participar en los programas de
exJimenes de la pfostata para que los programas de salud del futuro se mejoren y
<fltimamente menos personas hispanas mueran del cfancer. Quiero que todos los hispanos
del programa de hoy completen una breve entrevista. Si gusta participar en esta encuesta
no vamos a pedir su nombre y vamos a poner su entrevista completada en una especial
caja cerrada para que se mantengan confidenciales sus respuestas. Este estudio ha sido
aprobado por un comite especial de mi universidad que protege los derechos de humanos
que participan en las investigaciones y no presenta ningun riesgo. Solo le tomara varios
minutos para completar la entrevista y yo apreciana su participation. Sin embargo, su
participation es voluntaria y usted puede escoger no participar sin sancion ninguna. Si
tiene preguntas or quiere hablar conmigo personalmente sobre esta encuesta y no estoy en
el sitio de examinations usted puede comunicarse conmigo al (817) 685-4759.
Sinceramente,
Suzanne Zimmerman RN
86
ENTREVISTA PARA PARTICEPANTES HISPANOS
t
«
(iPor que vino hoy? dComo aprendio sobre el programa de hoy?
iQue tan importantes eran los siguentes factores en hacerle la decision a venir al programa
de hoy? (muy importante, de importancia mediana, de poco or ninguna importancia)
Aprender de su salud
muy
mediana
no importante
Conveniencia del sitio
muy
mediana
no importante
Dfas, horas de los examenes
muy
mediana
no importante
Poder venir sin cita previa
Tuvo cita hoy? Six
Costo del examen
muy
mediana
no importante
muy
mediana
no importante
Verguenza del examen
muy
mediana
no importante
Preocupacidn de encontrar condition seria
muy
mediana
no importante
No
a habia tenido anteriormente un examen del recto? dCuando?d.Por este programa?
Si se ofrecen los examenes de la prostata aquf el ano que viene^Asistira? d Por que? o
dPor que'no?
*
*
4
dRecomendar^ este programa de extfmenes de la prostata a sus amigos? dPor quefo (Jpor
queno?
/
*
dXiene sugerencias para mejorarse el programa de hoy? tComo podemos atraer a mas
Hispanos a este programa?
iCuantos anos tiene?
Cual es su nacionalidad?
mexicano o mexicoamericano
centroamericano
suramericano
puertorriqu^no
cubano o cubanoamericano
otro (favor de especificar)
d Cuanto le costaron los examenes de la prostata de hoy?
Los examenes fueron gratis
Yo pague $11
APPENDIX B
AMERICAN CANCER SOCIETY MAMMOGRAPHY QUESTIONNAIRE
87
88
EXAMPLE OF CARD USED TO COLLECT DATA
FROM PARTICIPATING MAMMOGRAPHY FACILITIES
Date:
Is this your first mammogram?
Yes
No
Age: Less than 39
; 40-49 ; 50-64 ; 65+
Zip code:
Ethnicity:
Caucasian (White)
African-American
Asian or Pacific Islander
Hispanic
Native American Indian
Other
Who Referred You?
Doctor/nurse/other health professional
Family/friend
Radio, TV, newspaper
American Cancer Society
Church
Other
I
I AV
/ UERfCAM
Thank you for helping in the fight against breast cancer.isStxfr
APPENDIX C
1995 TARRANT COUNTY PROSTATE SCREENING PROJECT
PROMOTIONAL ACTIVITIES
89
90
1995 Prostate Cancer Screening Project Promotional Activities (Four P's of Marketing)
PRODUCT
Prostate Health Awareness and Exams-PSA and DRE
PRICE
$ 0 monetary for 200 % federal poverty level or below
$ 11 for other participants
Nonmonetary costs may include machismo, embarrassment,
and fear
PLACE
2 new screening sites in neighborhoods heavily populated
with Hispanics
PROMOTION
Community leader luncheon
Cancer prevention/early detection conference for health
professionals
Educational programs at churches, senior centers, health
fair
English and Spanish-language newspaper and radio
Bilingual flyers
APPENDIX D
HOW DID PARTICIPANTS LEARN ABOUT THE SCREENING?
91
92
How Did Participants Learn About the Screening?
Reminder Card
MiJtlV.,.
Flyer
Friend
Family
•••nun*
•rififill ill i flu
nn
1B11. UU
l ILHJJH
l aB
iU JJi
Spouse
Television
Radio
h
iTrr-in
fTIali ii ilftVii
n
Newspaper
10
15
20
APPENDIX E
OTHER FACTORS WHICH INFLUENCED SCREENING PARTICIPATION
93
94
How important were the following factors in making your decision to attend today's
program? (very important, of medium importance, of little or no importance)
Note: Numbers indicate number of persons responding
Learning about your health
very
46
medium
5
not important
Convenience of location
very
42
medium
8
not important
1
Days, hours of testing
very
35
medium
7
not important
9
Being able to come without appointment*
Hadappt 33 Walk-in 18
very
18
medium
8
not important
20
Cost of exam
veiy
36
medium
8
not important
7
Embarrassment of exam
very
2
medium
8
not important
41
Worry of finding serious medical condition
very
15
medium
19
not important
17
*5 questionnaires received from interviewers were not answered on this question
APPENDIX F
MAP OF HISPANIC ATTENDANCE AT STUDY INTERVIEW SITES
95
96
' NOR
RICHLAND1
WATA JG
O
' LLEYVILLE
LAKE
! ; " t o i..
HITET
TTLl
MENT
cahswi
STOVER
tOtlDAll
,AKE
fJ7TIN
3
BROOK
KENNEDA^|_N
K LAKE
AA
NUMBER OFfflSPANICSSCREENED AT STUDY INTERVIEW SITES
A-Harris Methodist HEB 5
B-Northside
16
C-Diamond Hill
28
D-Bolt Street
7
APPENDIX G
SOCIAL MARKETING PLAN TO PROMOTE HISPANIC PARTICIPATION
AT PROSTATE CANCER SCREENINGS
97
98
Social Marketing Plan to Promote Hispanic Participation at Prostate Cancer Screenings
1) Problem Definition
Problem identified-Low Hispanic participation in prostate cancer screening exams
Literature review and interviews identified possible barriers
2) Goal Setting
Goal-To increase Hispanic participation at future prostate cancer screenings
3) Target Market Segmentation
Hispanic males age 50-70, particularly those of low income
4) Consumer Analysis
Talk with local Hispanic males who attend senior citizen centers, clinics, community
centers, health fairs, social organizations, churches, etc., as well as those who
are being screened regarding possible barriers and ways to increase Hispanic
N
screening participation
5) Influence Channel Analysis
Community leaders
Medical professionals
Business establishments
Mass media
Family and friends of target market
6) Marketing Strategies and Tactics
Review literature/ converse with authorities to ascertain strategies used by others
Assess the Four P's of Marketing (Product, Price, Place, Promotion)
Brainstorm! Concentrate on creative approaches and incentives
7) Program Implementation and Evaluation
Determine budget and funding source
Contact Prostate Education Council for information on becoming a screening site
Make assignments for Screening, Education, and Promotion Committees
Designate screening sites in target population neighborhoods
Recruit volunteers-urologists and other physicians, nurses, medical students,
phlebotomists, bilingual Hispanic volunteers from community
Develop participant survey to evaluate project
Calculate screening attendance
Tabulate survey
Share program outcome and experiences with future program planners
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