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Introduction to Cancer Screening Health Promotion Strategies in Alberta

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CANCER SCREENING HEALTH PROMOTION ENVIRONMENTAL SCAN

ACKNOWLEDGEMENTS

Documents prepared by: Rosanna Taylor, MSc. Health Promotion Research Associate

Alberta Health Services, Health Promotion, Disease and Injury Prevention, Screening Programs, Health Promotion

Seema M. Parmar, MHA, PhD(c), Health Promotion Associate Alberta Health Services, Health Promotion, Disease and Injury Prevention, Screening Programs, Health Promotion

Documents reviewed by: Alberta Health Services, Health Promotion, Disease and Injury Prevention, Screening Programs, Health Promotion

Monica Schwann, Acting Manager Alison Nelson, Former Manager Charlene Mo, Health Promotion Coordinator Melissa Hyman, Health Promotion Coordinator Carmen Webber, Health Promotion Coordinator, Screen Test

Acknowledgements: The authors gratefully acknowledge the following individuals and organizations for their contribution to the development of various elements of each of the environmental scan documents.

Health Promotion, Alberta Health Services, Health Promotion, Disease and Injury Prevention, Screening Programs (Monica Schwann, Alison Nelson, Charlene Mo, Melissa Hyman, Carmen Webber, Amy Williams, Teresa Earl)

Screening Programs, Alberta Health Services, Health Promotion, Disease and Injury Prevention, Screening Programs (Dr. Huiming Yang, Dr. Laura McDougall, Krista Russell, MaryAnne Zupancic, Song Gao, Patricia Pelton)

Alberta Health Services (Dr. Lisa Petermann, Dr. Lorraine Shack, Graham Petz, Brianne Lewis, Robyn Sachs, Jennifer Doole, Vicky Vu)

Helix Designs (James Shrimpton)

Palomino (Lucas Bombardier, Christina Almeida) Suggested Citation: Alberta Health Services (2011). Introduction to Cancer Screening Health Promotion Strategies in Alberta. Calgary, Alberta: Alberta Health Services This document is current as of July 15, 2011. For a PDF version of this document, and more information on the environmental scan, please visit http://www.screeningforlife.ca/healthpromotion .

http://www.screeningforlife.ca/healthpromotion


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INTRODUCTION TO CANCER SCREENING HEALTH PROMOTION

STRATEGIES IN ALBERTA

INTRODUCTION TO CANCER SCREENING HEALTH PROMOTION STRATEGIES ALBERTA ....................................................................................................... 2

HEALTH COMMUNICATION ................................................................................................... 2

Health Communication Theory ........................................................................................ 2

Cancer Screening Health Communication Activities in Alberta .......................... 3

COMMUNITY ACTION .............................................................................................................. 4

Community Action Theory ................................................................................................ 4

Cancer Screening Community Action Activities in Alberta ................................... 5

EDUCATION ................................................................................................................................ 5

Education Theory .................................................................................................................. 5

The Health Belief Model ................................................................................................. 6

The Theory of Planned Behaviour .............................................................................. 8

The Stages of Change (Transtheoretical) Model .................................................. 9

Social Cognitive Theory ............................................................................................... 11

Cancer Screening Education Activities in Alberta .................................................. 12

KNOWLEDGE MANAGEMENT .............................................................................................. 12

Knowledge Management Theory .................................................................................. 12

Cancer Screening Knowledge Management Activities in Alberta .................... 14

SOCIAL MARKETING ............................................................................................................. 16

Social Marketing Theory .................................................................................................. 16

Examples of Social Marketing campaigns promoting cancer screening ....... 20

Cancer Screening Social Marketing Activities in Alberta .................................... 20

REFERENCES ............................................................................................................................ 22


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INTRODUCTION TO CANCER SCREENING HEALTH PROMOTION STRATEGIES

IN ALBERTA

Alberta Health Services (AHS) Screening Programs Health Promotion Unit (SP-HPU) uses five broad strategies to promote cancer screening in Alberta. These strategies are Health Communication, Community Action, Education, Knowledge Management and Social Marketing. This document will briefly explain each strategy, including theory, and present what is currently being

done in Alberta in each strategic area.

HEALTH COMMUNICATION

Health communication initiatives promote health using various communication strategies. A number of health communication frameworks and processes can be employed to promote health at the individual, group, organization, community, or society level. Examples of types of health communication include persuasive or behavioral communication, risk communication, media advocacy, entertainment education, interactive health communication, development health communication, or participatory communication.

Health communication is a growing field, combining theories and concepts from the fields of communication and public health. There are a number of definitions and health communication frameworks and strategies. The National Cancer Institute and the Centre for Disease Control and Prevention in the United States define health communication as “the study and use of communication strategies to inform and influence individual and community decisions that enhance

health.” 1

Health Communication Theory

Alone, health communication can increase knowledge and awareness, influence or reinforce perceptions, beliefs and attitudes, prompt action, demonstrate healthy skills or the benefits of behaviour change, advocate for health-related policy changes, increase health service demand, refute myths or misconceptions, and strengthen organizational relationships. Health communication initiatives alone, however, cannot solve issues related to poor healthcare access or quality or result in long-term changes in complex behaviours. Health communication initiatives can target many levels, including individuals, groups, organizations, communities, and societies.1 The National Cancer Institute’s Pink Book – Making Health Communication Programs Work discusses various health communication methods including media literacy and advocacy, public relations, advertising, education entertainment, individual and group instruction, and partnership development. Some of these methods overlap with techniques described in SP-HPU’s other strategic activities, suggesting that the lines defining the different health promotion action areas

are not always definite or distinct.

In Canada, The Health Communication Unit (THCU) based out of the University of Toronto, is one of the groups best known for their research and training in the field of health communication. The THCU defines health communication as “the process of promoting health by disseminating

messages through mass media, interpersonal channels, and events.” 2


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Health communication activities include clinician-patient interactions, classes, self-help groups, mailings, hotlines, mass media campaigns, and events.2 These activities can target individuals, networks, groups, organizations, communities, or entire nations. Table 1 includes different types

of health communication as described by the THCU.

Table 1. Types of Health Communication2

Type of Health Communication

Description

Persuasive or behavioral communication

Communication aimed at persuading specific audiences to adopt an idea or practice (e.g. social marketing).

Risk communication Communication aimed at helping people understand the nature and seriousness of a risk so that they can make an informed decision about how to deal with the risk.

Media advocacy The strategic use of mass media to advance a social or public policy initiative.

Entertainment education The use of entertainment channels (e.g. television shows, radio drams, comic books, theatre, etc) to transmit persuasive messages and lessons about health or environmental issues.

Interactive health communication

Interaction of an individual (e.g. consumer, patient, caregiver, or professional) with an electronic device or communication technology to access or transmit health information or to receive guidance and support on a health-related issue.

Development communication Communication initiatives used primarily in international development projects.

Participatory communication Communication initiatives involving the target population in the planning of the communication campaign.

Cancer Screening Health Communication Activities in Alberta

Alberta Health Services (AHS) Screening Programs Health Promotion Unit (SP-HPU) shares resources, data, and information related to cancer screening in Alberta on the www.screeningforlife.ca webpage. The different documents available on the webpage are updated on an ongoing basis to reflect new knowledge as it becomes available. Resources for healthcare providers and the public are available on the webpage, as well as information regarding the three provincial cancer screening programs in Alberta; the Alberta Breast Cancer Screening Program (ABCSP), the Alberta Cervical Cancer Screening Program (ACCSP) and the Alberta Colorectal Cancer Screening Program (ACRCSP). Other SP-HPU health communication activities include placing advertisements and articles in non-academic healthcare provider publications, such as Alberta RN and HealthBeat and public resources, such as Apple magazine and the Edmonton Senior’s Guide, among others. The SP-HPU supports the development of correspondence letters sent out by the ABCSP, the ACCSP and the ACRCSP to the public and to physicians and other healthcare providers. Corresponding with healthcare providers includes providing information regarding program rollouts, updated clinical practice guidelines, etc. Health communication

is also used through collaboration with Inform Alberta and Health Link.

http://www.screeningforlife.ca/


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COMMUNITY ACTION

Community action for health refers to collective efforts by communities directed towards increasing community control over the determinants of health, and thereby improving health3. The Ottawa Charter for Health Promotion3 emphasizes the importance of concrete and effective community action in setting priorities for health, making decisions, planning strategies and implementing them to achieve better health. Similar to community empowerment, in community action, individuals and organizations apply their skills and resources in collective efforts to

address health priorities and meet their respective needs.

Community Action Theory

Community Action is based on the Social Action Theory, a community-oriented model that is used to increase the problem-solving ability of entire communities through achieving concrete changes45. Specifically, individuals within communities come together to address health problems that are disproportionately affecting certain communities. Key concepts applied in using the Social Action Theory (shown in Table 2) include empowerment, critical consciousness, community capacity, social capital, issue selection, participation and relevance4. Table 2. Key Concepts of Social Action Theory4

Key Concept Definition

Empowerment Any social process that allows people to gain mastery over their lives and their community

Critical Consciousness A mental state by which members in a community recognize the need for social change and are ready to work to achieve those changes.

Community Capacity Characteristics of a community that affect their ability to mobilize and identify and solve social problems. (e.g. Leadership, participation, skills, sense of community, etc.)

Social Capital Community resources that exist via relationships formed between community members. Examples include trust, reciprocity and civic engagement.

Issue Selection The process by which communities identify winnable, specific goals relevant to the entire community.

Participation and Relevance

After selecting an issue, communities need to engage members and work on implementing their plan of action.

Summary of cancer screening health communication projects

www.screeningforlife.ca website

Advertisements and articles placed in non-academic healthcare provider and general public resources

Develops and supports correspondence letters sent by the ABCSP, ACCSP and ACRCSP

Collaboration with Inform Alberta and Health Link



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Cancer Screening Community Action Activities in Alberta

From 2002-2010, AHS Screening Programs awarded grants to community organizations and former health regions to support cancer screening health promotion projects. These grants were coordinated by the former Alberta Cancer Board. Through these grants the HPU learned the importance of community involvement, partnerships, collaboration, and building relationships. However, the nature of grants is short-term, and the grants were unsustainable and had limited evaluation capacity. To combat these issues a community action strategy is being created to work with each of the health zones in Alberta to implement sustainable targeted and individual interventions to increase cancer screening in

each zone.

The SP-HPU has undergone staff training in community engagement, and is beginning an ethnocultural community engagement project which will focus on increasing screening rates in ethnically and culturally

diverse populations in Alberta.

Other cancer screening community action projects include community consultations, continued development of partnerships (within AHS and with community organizations) and continued work on the Aboriginal Cancer Screening strategy. The Aboriginal Cancer Screening strategy includes development of Aboriginal cancer screening kits and resources using community consultations, engagement of

Aboriginal communities, training for the kits, and continuing to build relationships.

EDUCATION

Health education, as defined by the World Health Organization, is comprised of consciously constructed opportunities for learning involving some form of communication designed to improve health literacy, including improving knowledge, and developing life skills which are conducive to individual and community health. Health education is not only about communicating information, but nurturing the motivation and self-efficacy needed for the recipient to take action to improve health. Health education may involve the communication of information, development of skills, and various interventions to address socioeconomic and environmental determinants of health6.

Education Theory

There are several theories and models used to describe how people learn. Popular models for health education include the Health Belief Model7, 8, the Theory of Planned Behavior9, the Stages

Summary of cancer screening community action projects

Community action strategy; working with zones to leverage and coordinate cancer screening health promotion activities throughout Alberta

o Moved from a grant-based model to engaging the Health Zones

Staff community engagement training

Ethnocultural Community Engagement Project

Community consultations

Partnerships within Alberta Health Services and with community organizations

Aboriginal Cancer Screening Strategy


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of Change/Thranstheoretical Model10, and Social Cognitive Theory11. Each model/theory is described briefly below. More information can also be found in the document titled “Health

Promotion and Behavior Change Theory”, available at www.screeningforlife.ca/healthpromotion.

The Health Belief Model

The Health Belief Model (Figure 1) is one of the oldest and most popular models used to inform behaviour change interventions. The original Health Belief Model included only four constructs: perceived susceptibility, perceived severity, perceived benefits, and perceived barriers.7 Subsequently, a number of other constructs were added to the model including cues to action and self-efficacy. Constructs are concepts that when combined, form a theory. Table 3 provides definitions of the six most commonly used constructs in the Health Belief Model.

Figure 1. A recent version of the Health Belief Model7, 8

Likelihood

of Action

Modifying

Factors

Individual

Perceptions

Perceived susceptibility

and severity

Age, Sex, Ethnicity, Personality,

Socio-economics,

Knowledge

Perceived Benefits minus

Perceived Barriers

Likelihood of

Behaviour

Cues to Action

- education

- symptoms

- media information

Perceived Threat



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Table 3. Constructs in the Health Belief Model7, 12

Construct Definition Potential Change Strategies

Perceived Susceptibility

Beliefs about the chances of getting a condition

define population(s) at risk and levels of risk

tailor risk information based on individual characteristics or behaviours

help individuals develop accurate perceptions of own risk

Perceived Severity

Beliefs about the seriousness of a condition and its consequences

specify consequences of condition and recommended action

Perceived Benefits

Beliefs about the effectiveness of taking action to reduce risk or seriousness

explain how, where, and when to take action and potential positive results

Perceived Barriers

Beliefs about the material and psychological costs of taking action

offer reassurance, incentives, and assistance

correct misinformation

Cues to Action

Factors that activate "readiness to change"

provide how-to information, promote awareness, and employ reminder systems

Self-Efficacy Confidence in one's ability to take action

provide training and guidance in performing action

use progressive goal setting give verbal reinforcement demonstrate desired behaviours

In the context of cancer screening, the Health Belief Model states that individuals are more likely to adopt cancer screening behaviours when they believe that they are at-risk for those cancers and the cancer is severe enough to warrant preventive action. Individuals are also more likely to adopt screening behaviours if they are confident that they will be able to perform the behaviour successfully and they believe that the benefits of screening outweigh the risks.

The Health Belief Model has been used frequently for theoretical-based interventions that promote breast, cervical, and/or colorectal cancer screening13-30. Interventions that use the Health Belief Model are able to assess individual perceptions of susceptibility and severity of developing cancer, the likelihood of being screened, and benefits of and barriers to screening participation.13 As well, recent versions of the Health Belief Model, which include self-efficacy and account for socioeconomic and demographic factors, may be particularly useful when planning interventions that target the underserved, such as low-income, minority, and Aboriginal populations.


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A note about self-efficacy The construct self-efficacy is used in a number of behaviour change and psychological models, not just the Health Belief Model. Self-efficacy describes an individual’s confidence in successfully performing a behaviour.11 Individuals with more self-efficacy are more likely to attempt behaviours since they believe they will succeed. Self-efficacy shapes the initiation of a behaviour, amount of effort put towards that behaviour, and length of time the behaviour is sustained in the presence of obstacles or challenges. Self-efficacy is influenced by personal accomplishments, vicarious experiences (experiences of other people to whom the individual relates), verbal persuasion (social influences that encourage or discourage a behaviour), and the individual’s physical state.11

The Theory of Planned Behaviour

A second individual behaviour change model that is useful as a foundation for cancer screening promotion interventions is the Theory of Planned Behaviour (Figure 2).9 The Theory of Planned Behaviour created by Icek Ajzen combines constructs from the Theory of Reasoned Action31 and the concept of self-efficacy.11 The Theory of Planned Behaviour includes all of the constructs in the Theory of Reasoned Action plus the additional construct of perceived behaviour control which is created from Bandura’s concept of self-efficacy.11 Table 4 defines the constructs in the Theory of Planned Behaviour.

Figure 2. Theory of Planned Behaviour8, 31

Subjective

Norm

Attitude toward

Behaviour

Behaviour

Perceived Behavioural

Control

Behavioural

Intention

Theory of Reasoned Action

Theory of Planned Behaviour


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Table 4. Constructs in the Theory of Planned Behaviour12, 31

Construct Definition Measurement Approach

Behavioural Intention

Perceived likelihood of performing behaviour

Are you likely or unlikely to (perform the behaviour)?

Attitude Personal evaluation of the behaviour

Do you see (the behaviour) as good, neutral, or bad?

Subjective Norm

Beliefs about whether key people approve or disapprove of the behaviour; motivation to behave in a way that gains their approval

Do you agree or disagree that most people approve of/disapprove of (the behaviour)?

Perceived Behavioural Control

Belief that one has, and can exercise, control over performing the behaviour

Do you believe (performing the behaviour) is up to you, or not up to you?

With regard to cancer screening, the attitude construct reflects an individual’s desire to have the cancer detected early and belief that a screening behaviour will lead to early detection of cancer. Subjective norms reflect the social pressure an individual feels to be screened for cancer. This pressure arises from the perceived expectations from others such as family, friends, and colleagues who may encourage or discourage cancer screening, and an individual’s desire to comply with these expectations. Perceived behavioural control, similar to self-efficacy, reflects the individual’s belief in his or her ability to perform the cancer screening behaviour in the presence of constructive or obstructive factors.

The Theory of Planned Behaviour can potentially predict cancer screening behaviours such as initiation and continued screening by mammograms and Pap tests.32-37 In these studies, “Perceived Behavioural Control” was most associated with intention to perform a behaviour. When examining actual performance of a behaviour, existing and perceived barriers must also be considered.38, 39

The Stages of Change (Transtheoretical) Model

A third individual behaviour change model frequently mentioned in the literature is the Stages of Change model, also known as the Transtheoretical Model, developed by Prochaska and DiClemente (Figure 3).10 The model approaches behaviour change as a process in which a person moves through five different stages: precontemplation, contemplation, preparation, action, and maintenance. An individual can relapse into an earlier stage at any point in the process. Table 5 defines the stages in the model and presents potential behaviour change strategies for individuals in that stage. Behavioural interventions can be designed to meet the needs of individuals at different stages.


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Figure 3. Stages of Change Model10

Table 5. Stages and Change Strategies in the Stages of Change Model10, 12

Stage Definition Potential Change Strategies

Precontemplation No intention of taking action within the next six months

increase awareness of need for change

personalize information about risks and benefits

Contemplation Intends to take action in the next six months

motivate encourage making specific

plans

Preparation

Intends to take action within the next thirty days and has taken some behavioural steps in this direction

assist with developing and implementing concrete action plans

help set gradual goals

Action Has changed behaviour for less than six months

assist with feedback, problem solving, social support, and reinforcement

Maintenance Has changed behaviour for more than six months

assist with coping, reminders, finding alternatives, avoiding slips/relapses (as applicable)

The Stages of Change model is particularly popular when focusing on addictive behaviours, however, a number of studies in the literature have based cancer screening promotion interventions on this model.40-47 The model is used for identifying appropriate strategies for individuals depending on where they are in the Stages of Change process. For example, convincing participants who are in the precontemplation or contemplation stage to be screened

Precontemplation

Contemplation Relapse

Relapse Preparation

Relapse Action

Relapse Maintenance

Relapse


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requires more intensive interventions than ensuring that participants in the preparation stage be screened. As well, though participants in the action and maintenance stages are practicing screening, ensuring screening behaviour is sustained for those in the action stage requires different interventions than for those in the maintenance stage. The model is also used to determine if participants who have not adopted screening after the interventions have shown progress through the model and what additional support they may need in order to adopt the behaviour. In other words, though a participant may not have engaged in screening after the intervention, the intervention may have helped that participant move from the precontemplation or contemplation stage to the preparation stage.

Social Cognitive Theory

A learning theory frequently mentioned in the literature is Social Cognitive Theory, developed by Bandura11. Social Cognitive Theory (SCT) describes a dynamic, ongoing process in which personal, environmental and human behavioral factors exert influence upon each other. SCT evolved from research on Social Learning Theory, which emphasizes that people learn not only from their own experiences, but by observing the actions of others. According to SCT, three main factors affect the likelihood of changing a health behavior, including self-efficacy, goals and outcome expectancies12. Table 6 describes the main concepts of SCT. Table 6. Social Cognitive Theory12

Concept Definition Potential Change Strategies

Reciprocal determinism

The dynamic interaction of the person, behaviour, and the environment in which the behaviour is performed

Consider multiple ways to promote behaviour change, including making adjustments to the environment or influencing personal attitudes

Behavioral capability

Knowledge and skill to perform a given behavior

Promote mastery learning through skills training

Expectations Anticipated outcomes of a behavior

Model positive outcomes of healthful behavior

Self-Efficacy Confidence in one’s ability to take action and overcome barriers

Approach behavior change in small steps to ensure success; be specific about the desired change

Observational Learning (modeling)

Behavioral acquisition that occurs by watching the actions and outcomes of others’ behaviours

Offer credible role models who perform the targeted behaviour

Reinforcements

Responses to a person’s behaviour that increase or decrease the likelihood of reoccurrence

Promote self-initiated rewards and incentives


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Cancer Screening Education Activities in Alberta

AHS SP-HPU attends many different healthcare provider and public events throughout the year. At these events, SP-HPU staff provide important information regarding breast, cervical and colorectal cancer screening to doctors, nurses, other healthcare providers, and members of the public. Using concepts from the models described above, resources are developed to move all of the mentioned groups towards increased cancer screening. Resources include brochures, toolkits, display models, clinical guidelines, promotional items, etc. Presentations are also made at these events, educating

attendees about the importance of cancer screening

KNOWLEDGE MANAGEMENT

Knowledge management is defined by the World Health Organization (WHO) as “a set of principles, tools, and practices that enable people to create knowledge, and to share, translate and apply what they know to create value and improve effectiveness.”48 Knowledge management activities aim to bridge the “know-do” gap: the gap that results between what is known about resolving health problems and what is done to resolve health problems. In many cases, solutions to health problems are known, but not applied. Knowledge management aims to

encourage creating, sharing, and applying knowledge to improve health.48

The following are knowledge management strategic directions, developed by the World Health Organization and adapted by the Alberta Health Services Screening Programs Health Promotion

Unit:

1. Improving access to health information

2. Translating knowledge into policy and action

3. Sharing and reapplying experiential knowledge

4. Leveraging e-health

5. Foster an enabling environment

Knowledge Management Theory

The WHO has focused the goals and strategies of knowledge management on international development and the provision of health aid to the poor.48 The AHS SP-HPU has adapted the World Health Organization’s knowledge management strategic directions to promote cancer screening in Alberta. Table 7 provides a description of the different elements of the World Health Organization’s knowledge management strategic directions that are relevant to cancer

screening health promotion in Alberta.

Summary of cancer screening education projects

Healthcare Provider Events & Presentations

Public Events & Presentations

Development and Distribution of Resources


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Table 7. Aspects of knowledge management strategic directions relevant to Cancer Screening Health Promotion (adapted from WHO)48

Strategic Direction

Description Approach

Improving access to health information

Improve equitable access to health information and knowledge necessary to improve health and wellbeing of individuals, communities, and populations. Improve the use of available health information by multiple stakeholders including health professionals, policy makers, partners, and the public.

Make available and promote access to relevant information and services, which may include developing and providing information products and services such as document repositories, statistical databases, media libraries, and various electronic products and information resources for target audiences.

Translating knowledge into policy and action

Examine processes required to progress from knowledge generation to action. Recognize the influence of stakeholder involvement, context, perceived relevance, and knowledge itself on the knowledge translation process.

Identify the knowledge needs of decision-makers and engage in effective knowledge translation activities.

Sharing and reapplying experiential knowledge

Facilitate sharing of experiential knowledge, which many not exist in formats that can be easily accessed or used.

Examine techniques to build evidence and share knowledge and experiences among partners.

Leveraging e-health

Use information and communication technology applications to support “citizen-centered health management and large-scale public health information systems”.48

Integrate e-health into program activities (e.g. identify new e-health applications, promote use of ethical and evidence-based e-health standards and policies, use e-health applications in education and training).

Fostering an enabling environment

Incorporate knowledge management into public health practice by emphasizing the benefit of knowledge management to health promotion and developing new knowledge management methods. “Strengthen the capacity of partners to access, analyze, manage, and use knowledge, with the goal of translating research and experiential knowledge into action, communicating for different audiences, improving communication, and learning in a myriad of ways.”48

Work with partners to share experiences and methods, and build knowledge management capabilities and awareness. Engage in research and evaluation, knowledge sharing and translation.


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Summary of cancer screening knowledge management projects

A number of provincial and national groups are involved in activities related to knowledge management including gathering and analyzing data related to cancer screening, conducting and funding research related to cancer screening and cancer screening promotion, and advocating for improved policies and guidelines related to cancer screening.

o SP-HPU specific research projects include Knowledge, Attitude and Behavior (KAB) surveys, focus groups and literature reviews

A number of national initiatives are also in place to promote sharing of knowledge and experience related to cancer screening programs.

Alberta Health Services Screening Programs Health Promotion Unit compiles all available evidence related to cancer screening promotion at the local and provincial level.

Evidence to support cancer screening promotion activities are presented in the Cancer Screening Health Promotion Environmental Scan and through presentations at academic conferences and publications in peer-reviewed academic journals.

Cancer Screening Knowledge Management Activities in Alberta

AHS SP-HPU compiles and shares data and research related to cancer screening promotion in Alberta. One method of presenting all of this information is through www.screeningforlife.ca/healthpromotion. The different documents available on the webpage will be updated on an ongoing basis to reflect new knowledge as it becomes available. In addition, the SP-HPU conducts its own research, including literature reviews and surveys, to fill gaps in knowledge. For example, the results from Knowledge, Attitudes and Behaviours (KAB) studies related to cancer screening, along with focus groups providing feedback on cancer screening information resources, are used to understand the information needs and

preferences of Albertans.

The SP-HPU knowledge management activities also include academic dissemination of knowledge gained from various projects through oral and poster presentations at academic conferences and publications in peer-reviewed academic journals. The SP-HPU also supports the involvement of the provincial organized cancer screening programs in local, provincial, and national networks,

collaborations, workshops, and conferences that promote sharing of cancer screening knowledge.

Table 8 summarizes the organizations involved in cancer screening knowledge management and the types of knowledge management activities in Alberta. The table does not include specific universities or researchers who are involved in cancer screening promotion. In the past, the provincial organized cancer screening programs have collaborated with researchers at the University of Calgary. In the future, efforts will be made to identify and engage academic researchers who are interested in cancer screening and health promotion.



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TABLE 8. Summary of knowledge management activities by Alberta groups 2006-2011

PROGRAM NAME/ORGANIZATION Surveillance Research Fund research

Academic dissemination and knowledge sharing

Advocacy

PROVINCE-WIDE

Alberta Breast Cancer Screening Program

√ √ √

Alberta Cervical Cancer Screening Program

√ √ √

Alberta Colorectal Cancer Screening Program

√ √ √

Alberta Cancer Registry √

Alberta Health and Wellness √

NATIONAL (Provincial Chapter)

Canadian Breast Cancer Foundation (Prairies/NWT)

√

√

Canadian Breast Cancer Research Alliance

√

√

Canadian Cancer Society (Alberta-NWT) √ √

√

Canadian Partnership Against Cancer √ √ √

Pan-Canadian Cervical Screening Initiative

√ √

Colorectal Cancer Association of Canada √ √ √

Health Canada √ √

Public Health Agency of Canada √ √ √

Statistics Canada √


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SOCIAL MARKETING

Social marketing is a formalized process, involving rigorous research and planning, strategy design, implementation and evaluation methods. Social marketing uses commercial marketing strategies, such as the Four Ps framework (price, product, place, promotion) and market segmentation (dividing larger heterogeneous markets into smaller homogeneous segments), to promote socially beneficial products, including tangible goods (e.g. contraceptive methods), behaviours or practices (e.g. screening), or certain beliefs, values, or principles. Quantitative and qualitative research is conducted with target consumers prior, during, and following social marketing campaigns to design marketing

products and strategies that are responsive to consumers’ needs and wants.

Social marketing differs from commercial marketing in a number of ways, beyond just a difference in product. First, social marketing addresses both downstream individual behaviour influences and upstream social, environmental, economic, and behaviour influences. Second, social marketing targets consumers, policymakers, healthcare professionals, and other key stakeholders. Third, social marketing faces various unique challenges including aiming to influence hard-to-change behaviours in hard-to-reach populations, length of time require for behaviour change, and resource limitations faced

by policymakers and program planners.

Social marketing is one of the strategic activities used by AHS SP-HPU to promote breast, cervical, and colorectal cancer screening in Alberta. The AHS SP-HPU aims to increase cancer screening rates by improving knowledge, influencing positive attitudes, and

increasing cancer screening behaviour.

Social marketing is defined by Health Canada as "the application of marketing technologies developed in the commercial sector to the solution of social problems where the bottom line is behaviour change." Social marketing involves "the analysis, planning, execution, and evaluation of programs designed to influence the voluntary behaviour of

target audiences to improve their personal welfare and that of society."49

Social Marketing Theory

The origins of social marketing date back to the 1950s, when G.D. Wiebe found that the most successful social change campaigns involved strategies similar to those used in commercial marketing campaigns.50 In 1971, Kotler and Zaltman defined the term social marketing as “the design, implementation, and control of programs calculated to influence the acceptability of social ideas and involving consideration of product planning, pricing, communication, distribution, and marketing research”.51 During the 1970s and 1980s, the field of social marketing expanded as 1) chronic diseases became more prevalent, demanding that greater attention be paid to lifestyle and environmental factors associated with these chronic diseases, and 2) economic constraints limited efforts to alter social and physical environments, shifting the responsibility of better lifestyle and

behaviour choices to the individual.52


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Social marketing uses proven commercial marketing techniques, such as market analysis, advertising, and the four Ps (product, price, place, and promotion) to advance social causes.52 The products in social marketing include tangible goods, behaviour practices, or general beliefs, values, and principles. Early social marketing campaigns implemented in developing countries promoted immunization, family planning, various agricultural reforms, and nutrition using marketing techniques such as radio, mass media, and wide-scale advertising. The National Cancer Institute in the United States, through its Office of Communications, has been utilizing social marketing techniques to promote smoking

cessation and other cancer prevention practices.52

Social marketing distinguishes itself from social advertising and mass communication campaigns by including a formalized, structured planning process involving considerable formative research, using both quantitative and qualitative methods to examine consumer perceptions and practices.52 Key components of social marketing campaigns include a focus on behaviour change, consumer orientation, and market segmentation.53 Adopting a behaviour change focus means identifying behaviours related to an issue of interest that might be subject to change. For example, screening is a behaviour related to reducing cancer morbidity and mortality. Both the marketed product and social marketing campaign are designed to respond to consumer needs and wants. As well, using segmentation strategies, larger, heterogeneous markets are separated into smaller, more homogeneous market fragments.53 In 2009 the AHS Health Marketing Unit published their Social Marketing Development Process for cancer prevention and cancer screening, described in Table 9. Table 10 provides a 10-point checklist to assess social marketing programs released by the National Social Marketing Center in 2007. The most effective

social marketing programs generally include the ten characteristics listed.

Social marketing draws from health promotion and behaviour change theories. For example, many of the elements and characteristics described in table 9 are similar to frameworks used for behavioural change interventions, such as the PRECEDE-PROCEED framework.54 As well, various behavioural change theoretical frameworks are often applied during the consumer research phase, including the Health Belief Model,7 Stages of

Change Model,10 and Diffusion of Innovations Model.55

Social marketing also takes into consideration social, environmental, economic, and individual influences on behaviour change. Consequently, the targets of social marketing are not only consumers, but also policymakers, health professionals, and other key stakeholders. Like commercial marketing, social marketing has evolved to emphasize key relationships with consumers, suppliers, lateral partners (e.g. government and other social marketing groups), and internal groups (e.g. staff, functional units).56 Additionally, evaluation of social marketing campaigns are limited by the type of change addressed (e.g. voluntary behaviour, policy changes, etc), the targeted group (e.g. public, policymakers, etc.) and units (e.g. individuals versus groups), effects of continued versus discrete exposure to marketing strategies, and the amount of time necessary to observe an effect.57 Proponents of social marketing suggest that evaluations that strictly focus on immediate effects of an intervention underestimate the value of social marketing by ignoring other important aspects of health behaviour change such as relationships built and short-term effects along the continuum of behaviour change. Compared with general marketing approaches social marketing faces unique challenges especially when aiming to

influence hard-to change behaviours in hard-to-reach populations.


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Table 9. Alberta Health Services Health Marketing Unit Social Marketing Development

Process for Cancer Prevention and Screening58

Step Key Activities

1. Project Start-Up Define objectives, budget, milestones, scope, schedule, team, RFP for external support

2. Market/Audience Research

Secondary and primary data collection and analysis

3. Strategic Direction Research summary, audience segmentation/targeting, preliminary positioning and strategy, assess strategic options

4. Strategic Planning Final positioning and strategy, 5-year strategic social marketing plan, 1-2 year tactical implementation plan, preliminary evaluation and monitoring plan

5. Concept Creation and Testing

Creative strategy/brief, preliminary messaging, concept creating, assess concepts and communication vehicles, concept refinement, final creative implementation plan

6. Creative Development Final messaging, copywriting, and design, finalize materials approval, media buy

7. Production and Implementation

Marketing production and printing, implement social marketing campaign

8. Monitor and evaluate (ongoing)

Final evaluation and monitoring framework, campaign monitoring, summative evaluation

9. Social Marketing Process Dissemination

10. Return to Appropriate Phase


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Table 10. 10-Point Checklist for Assessing Social Marketing Programmes59

Characteristic Yes? No?

1. Evidence of systematic scoping and development phases?

2. Evidence of a deep understanding about the selected target groups: attitudes, feelings, and perceptions.

3. The advantages of the proposed behaviour change have been spelled out in a way that the target group believes are attractive and achievable.

4. Measurable behavioural goals have been set and form the bottom line for evaluation.

5. Local delivery staff have been engaged in development so they are primed to support the program.

6. Mechanisms are in place to coordinate national, regional, and local action.

7. Systematic short, medium, and long-term planning is in place.

8. Multi-sector delivery coalitions have been developed to assist in development, delivery, and evaluation.

9. An adequate budget has been allocated to deliver the aims and objectives of the programme.

10. Mechanisms are in place to track delivery and produce clear evaluation.


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Examples of Social Marketing campaigns promoting cancer screening

In 2002, a social marketing campaign was launched by the United Kingdom National Health Services Cervical Screening Programme (NHSCSP) that targeted London women aged 40-64 years who had no history of cervical cancer screening.60 The campaign included personalized correspondence with educational print materials from local health authorities or Primary Care Trusts and used mass media (press photo-call with local celebrity which was covered by broadcast and print media) followed by a month-long poster campaign on public buses and distribution of posters and reminders at physicians’ offices and various community sites. Screening coverage increased in all women 40-64 years (including women who had previously been screened for cervical cancer and women who had not previously been screened for cervical cancer) in nine out of the ten health authorities from which data was collected after the campaign. The increase was greater than the overall increase in London and in all of England during the same period. As well, the women who underwent cervical cancer screening targeted by the campaign (women who had not been screened previously) were significantly more likely to have a high-grade abnormality than other English women who participated in the NHSCSP in 2002-

2003.

The “BreastScreen Australia” program has also launched various social marketing campaigns in different regions of Australia. One example is the Cherry and the Pea campaign launched in New South Wales in 2006 and 2007.61 The campaign targeted women 50-69 years who were not receiving a mammogram every two years. The campaign’s message was that a mammogram identifies tumors the size of a pea, compared with physical exams that typically identify tumors that are the size of a cherry. The campaign included advertising through television, radio, and print media and distributing printed resources including posters, brochures, and bookmarks. Campaign materials were also translated into eight different languages. Evaluation of the campaign, including a baseline survey and telephone interviews during and following the campaign, showed an increase in awareness of the importance of early detection of breast cancer, mammography as a screening method for breast cancer, breast cancer screening services in New South Wales, and the recommendation for biennial screening of women aged 50-69 years.

Cancer Screening Social Marketing Activities in Alberta

In 2009, the ACRCSP implemented a Screening for Life social marketing campaign to promote colorectal cancer screening using the Social Marketing Development Process for Cancer Screening and Prevention created by AHS Health Marketing Unit. The campaign targeted adults 45-60 years. The goals of the campaign were to normalize colorectal cancer screening among Albertans 50 years and older and ensure that family physicians had the appropriate resources to recommend colorectal cancer screening to patients aged 50-74 years. Campaign implementation began in February 2009 with two separate launches of a physician communication package and a public communication package. The physician launch included a direct mail package to physicians, printed ads in Alberta Doctor’s Digest and Alberta Registered Nurse (RN) professional publications, cancer screening displays at healthcare provider conferences and events, the landing and colorectal cancer screening web pages for professionals on www.screeningforlife.ca, and



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promotion packages for clinics, health centers and Primary Care Networks. The public launch included radio ads in Calgary, Edmonton, Lethbridge, Red Deer, Medicine Hat, Fort McMurray, and Grande Prairie, web banners on Google, Yahoo Health, and WebMD and the colorectal cancer screening landing and web pages for the public on

www.screeningforlife.ca.

Evaluation of the campaign demonstrated that the media reach was good and in line with industry standards. There was an increase in new visitors to the www.screeningforlife.ca landing page and a number of requests for colorectal cancer screening resources at the time of the public launch. Baseline and follow-up surveys with healthcare providers and public were conducted 3-6 months after the launch. The response rate at follow-up was 38.8% for healthcare providers and 40.8% for the public. At follow-up there was little improvement in the overall percentage of healthcare providers offering screening to patients on a regular basis though 38% of healthcare providers indicated an increase in recommending colorectal cancer screening to patients after attending an event with a SP-HPU staff member present. The changes were attributed mostly to increased awareness of the Alberta Colorectal Cancer Screening Clinical Practice Guidelines and the Colorectal Cancer Screening for Life resources. With the public there was a 12% increase at follow-up in those indicating they would encourage others in the 50-74 years age range to be screened for colorectal cancer. As well, the majority of the public indicated that they would be likely or very likely to speak to their doctor about colorectal cancer screening because of the Colorectal Cancer Screening for Life resources and their interactions with SP-HPU Staff. The evaluation concluded that though public and providers agreed on the importance of colorectal cancer screening, actual screening practice was still low throughout the province. Though physician education materials were well received, there was some concern about whether materials were reaching family physicians. Recommendations included continuing a multi-prong effort targeting hard-to-reach

physicians and public segments.

As well, SP-HPU is also currently involved in developing a Breast and Cervical Cancer Screening Social Marketing Campaign that will use incentives to encourage women to be

screened.

Summary of cancer screening social marketing projects

In 2009, the Alberta Colorectal Cancer Screening Programs (ACRCSP) implemented a Screening for Life social marketing campaign with the support of the AHS Health Marketing Unit.

AHS SP-HPU is currently working a social marketing project with the AHS

Health Marketing Unit regarding Breast and Cervical Cancer Screening




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REFERENCES

1. Pink Book - Making Heatlh Communications Programs Work [Internet]United States National Cancer Instititute. [Cited on 2010 Jan 21]. http://www.cancer.gov/pinkbook/allpages.

2. The Health Communication Unit. Overview of Developing Health Communications Campaigns: Workshop Toolkit. Toronto, ON: Center for Health Promotion, University of Toronto; 2005.

3. World Health Organization. Ottawa Charter for Health Promotion. 1986.

4. Minkler, M., Wallerstein, N., Wilson, N. Improving Health through Community Organization and Community Building." In: Glanz, K, editor. Health behavior and health education: Theory, research, and practice. San Francisco: John Wiley & Sons; 2008.

5. Christopher S, Gidley AL, Letiecq B, Smith A, McCormick AKHG. A Cervical Cancer Community-Based Participatory Research Project in a Native American Community. Health Education & Behavior 2008;35(6):821-34.

6. Nutbeam D. Health Promotion Glossary. Geneva: World Health Organization; 1998.

7. Rosenstock IM. Historical Origins of the Health Belief Model. Health Education Monographs 1974;2:328-35.

8. Glanz K, Rimer BK, Lewis FM. Health Behavior and Health Education. Theory, Research and Practice. San Francisco: Wiley & Sons; 2002.

9. Ajzen I. The Theory of Planned Behavior. Organizational Behavior and Human Decision Processes 1991;50:179-211.

10. Prochaska JO, DiClemente CC. Stages and Processes of Self-Change of Smoking: Toward an Integrative Model of Change. Journal of Consulting and Clinical Psychology 1983;51(3):390-5.

11. Bandura A. Self-Efficacy: Toward a Unifying Theory of Behavioral Change. Psychol Rev 1977;84(2):191-215.

12. Glanz K, Rimer BK. Theory at a Glance: A Guide for Health Promotion Practice (2nd Ed.). 2005;NIH Publication No. 05-3896.

13. Bowie JV, Curbow BA, Garza MA, Dreyling EK, Benz Scott LA, McDonnell KA. A Review of Breast, Cervical, and Colorectal Cancer Screening Interventions in Older Women. Cancer Control 2005;12(Suppl 2):58-69.

14. Loerzel VW, Bushy A. Interventions that Address Cancer Health Disparities in Women. Family & Community Health 2005;28(1):79-89.

http://www.cancer.gov/pinkbook/allpages


23

15. Parsa P, Kandiah M, Abdul Rahman H, Zulkefli NM. Barriers for Breast Cancer Screening among Asian Women: A Mini Literature Review. Asian Pacific Journal of Cancer Prevention: Apjcp 2006;7(4):509-14.

16. Becker SA, Foxall M. An Analysis of Health Behavior Theories Applied to Breast-Screening Behavior for Relevance with American Indian Women. Journal of Transcultural Nursing 2006;17(3):272-9.

17. Russell KM, Champion VL, Skinner CS. Psychosocial Factors Related to Repeat Mammography Screening Over 5 Years in African American Women. Cancer Nursing 2006;29(3):236-43.

18. Lee-Lin F, Menon U, Pett M, Nail L, Lee S, Mooney K. Breast Cancer Beliefs and Mammography Screening Practices among Chinese American Immigrants. JOGNN: Journal of Obstetric, Gynecologic, & Neonatal Nursing 2007;36(3):212-21.

19. Yu M, Wu T. Factors Influencing Mammography Screening of Chinese American Women. JOGNN: Journal of Obstetric, Gynecologic, & Neonatal Nursing 2005;34(3):386-94.

20. Ho V, Yamal JM, Atkinson EN, Basen-Engquist K, Tortolero-Luna G, Follen M. Predictors of Breast and Cervical Screening in Vietnamese Women in Harris County, Houston, Texas. Cancer Nursing 2005;28(2):119-31.

21. Gorin SS, Heck JE. Cancer Screening among Latino Subgroups in the United States. Preventive Medicine 2005;40(5):515-26.

22. Champion V, Maraj M, Hui S, Perkins AJ, Tierney W, Menon U, Skinner CS. Comparison of Tailored Interventions to Increase Mammography Screening in Nonadherent Older Women. Preventive Medicine 2003;36(2):150-8.

23. Garza MA, Luan J, Blinka M, Farabee-Lewis RI, Neuhaus CE, Zabora JR, Ford JG. A Culturally Targeted Intervention to Promote Breast Cancer Screening among Low-Income Women in East Baltimore, Maryland. Cancer Control 2005;12(Suppl 2):34-41.

24. Wang JH, Liang W, Schwartz MD, Lee MM, Kreling B, Mandelblatt JS. Development and Evaluation of a Culturally Tailored Educational Video: Changing Breast Cancer-Related Behaviors in Chinese Women. Health Education & Behavior 2008;35(6):806-20.

25. Boling W, Laufman L, Lynch GR, Weinberg AD. Increasing Mammography Screening through Inpatient Education. Journal of Cancer Education 2005;20(4):247-50.

26. Byrd TL, Peterson SK, Chavez R, Heckert A. Cervical Cancer Screening Beliefs among Young Hispanic Women. Preventive Medicine 2004;38(2):192-7.


24

27. Green PM, Kelly BA. Colorectal Cancer Knowledge, Perceptions, and Behaviors in African Americans. Cancer Nursing 2004;27(3):206-17.

28. Greenwald B. Promoting Community Awareness of the Need for Colorectal Cancer Screening: A Pilot Study. Cancer Nursing 2006;29(2):134-41.

29. Janz NK, Wren PA, Schottenfeld D, Guire KE. Colorectal Cancer Screening Attitudes and Behavior: A Population-Based Study. Preventive Medicine 2003;37(6):627-34.

30. Ueland AS, Hornung PA, Greenwald B. Colorectal Cancer Prevention and Screening: A Health Belief Model-Based Research Study to Increase Disease Awareness. Gastroenterology Nursing 2006;29(5):357-63.

31. Fishbein M, Ajzen I. Belief, Attitude, Intention, and Behavior: An Introduction to Theory and Research. Reading, MA: Addison-Wesley; 1975.

32. Jennings-Dozier K. Predicting Intentions to Obtain a Pap Smear among African American and Latina Women: Testing the Theory of Planned Behavior. Nursing Research 1999;48(4):198-205.

33. Steele SK, Porche DJ. Testing the Theory of Planned Behavior to Predict Mammography Intention. Nursing Research 2005;54(5):332-8.

34. Tolma EL, Reininger BM, Evans A, Ureda J. Examining the Theory of Planned Behavior and the Construct of Self-Efficacy to Predict Mammography Intention. Health Education & Behavior 2006;33(2):233-51.

35. Duffett-Leger L, Letourneau NL, Croll JC. Cervical Cancer Screening Practices among University Women. JOGNN: Journal of Obstetric, Gynecologic, & Neonatal Nursing 2008;37(5):572-81.

36. Sheeran P, Orbell S. Using Implementation Intentions to Increase Attendance for Cervical Cancer Screening. Health Psychology 2000;19(3):283-9.

37. Bowie JV, Curbow B, Laveist TA, Fitzgerald S, Zabora J. The Theory of Planned Behavior and Intention to Repeat Mammography among African-American Women. Journal of Psychosocial Oncology 2004;21(4):23.

38. Terán L, Baezconde-Garbanati L, Márquez M, Castellanos E, Belkić K. On-Time Mammography Screening with a Focus on Latinas with Low Income: A Proposed Cultural Model. Anticancer Research 2007;27(6C):4325-38.

39. O'Neill SC, Bowling JM, Brewer NT, Lipkus IM, Skinner CS, Strigo TS, Rimer BK. Intentions to Maintain Adherence to Mammography. Journal of Women's Health 2008;17(7):1133-41.


25

40. Borrayo EA. Where's Maria? A Video to Increase Awareness about Breast Cancer and Mammography Screening among Low-Literacy Latinas. Preventive Medicine 2004;39(1):99-110.

41. Hou SI. Stage of Adoption and Impact of Direct-Mail Communications with and without Phone Intervention on Chinese Women's Cervical Smear Screening Behavior. Preventive Medicine 2005;41(3-4):749-56.

42. Champion V, Skinner CS, Hui S, Monahan P, Juliar B, Daggy J, Menon U. The Effect of Telephone Versus Print Tailoring for Mammography Adherence. Patient Education and Counseling 2007;65(3):416-23.

43. Kim JH, Menon U. Pre- and Postintervention Differences in Acculturation, Knowledge, Beliefs, and Stages of Readiness for Mammograms among Korean American Women. Oncology Nursing Forum 2009;36(2):E80-92.

44. Russell KM, Monahan P, Wagle A, Champion V. Differences in Health and Cultural Beliefs by Stage of Mammography Screening Adoption in African American Women. Cancer 2007;109(2 Suppl):386-95.

45. Menon U, Champion V, Monahan PO, Daggy J, Hui S, Skinner CS. Health Belief Model Variables as Predictors of Progression in Stage of Mammography Adoption. American Journal of Health Promotion : AJHP 2007;21(4):255-61.

46. Costanza ME, Luckmann R, Stoddard AM, White MJ, Stark JR, Avrunin JS, Rosal MC, Clemow L. Using Tailored Telephone Counseling to Accelerate the Adoption of Colorectal Cancer Screening. Cancer Detection & Prevention 2007;31(3):191-8.

47. Carney PA, Harwood BG, Greene MA, Goodrich ME. Impact of a Telephone Counseling Intervention on Transitions in Stage of Change and Adherence to Interval Mammography Screening (United States). Cancer Causes & Control : CCC 2005;16(7):799-807.

48. Knowledge Management and Health: Bridging the "Know-do" Gap in Global Health [Internet] World Health Organization. [Cited on 2010 Jan 15]. http://www.who.int/kms/en/.

49. Social Marketing [Internet] Health Canada. [Cited on 2010 02]. http://www.hc-sc.gc.ca/ahc-asc/activit/marketsoc/index-eng.php.

50. Wiebe GD. Merchandising Commodities and Citizenship in Television. Public Opinion Quarterly 1951-52;15(winter):679-91.

51. Kotler P, Zaltman G. Social Marketing: An Approach to Planned Social Change. Journal of Marketing 1971;35(3):3-12.

52. Walsh DC, Rudd RE, Moeykens BA, Moloney TW. Social Marketing for Public Health. Health Affairs 1993;12(2):104-19.

http://www.who.int/kms/en/

http://www.hc-sc.gc.ca/ahc-asc/activit/marketsoc/index-eng.php

http://www.hc-sc.gc.ca/ahc-asc/activit/marketsoc/index-eng.php


26

53. Lagarde F. Worksheets to Introduce some Basic Concepts of Social Marketing Practices (Training Initiative). Social Marketing Quarterly 2004;10(1):36-41.

54. Green LW, Kreuter MW. Health Promotion Planning: An Educational and Ecological Approach. 3rd ed. Mountain View, CA: Mayfield; 1999.

55. Rogers EM. Diffusion of Innovations. Fourth ed. New York, NY: Free Press; 1995.

56. Hastings G. Relational Paradigms in Social Marketing. Journal of Macromarketing 2003;23(1):6-15.

57. Doner L. ISM Conference Proceedings: Approaches to Evaluating Social Marketing Programs. Social Marketing Quarterly 2003;9(3):18-26.

58. Dooley JA, Jones SC, Desmarais K. Strategic Social Marketing in Canada: Ten Phases to Planning and Implementing Cancer Prevention and Cancer Screening Campaigns. Social Marketing Quarterly 2009;15(3):33-48.

59. National Social Marketing Centre. A Ten-Point Checklist for Assessing Social Marketing Programmes. United Kingdom: ; 2007.

60. Millett C, Zelenyanszki C, Furlong C, Binysh K. An Evaluation of a Social Marketing Campaign to Reduce the Number of London Women Who have Never been Screened for Cervical Cancer. Journal of Medical Screening 2005;12(4):204-5.

61. Perez D, Hardy M, Pimenta N, Walsberger S, Dessaix A, Lewis S, Cotter T, Bishop J. BreastScreen NSW Cherry and Pea Campaign 2006-07. Sydney: Cancer Institute NSW; 2009.