Open Journal Systems

ORIGINAL CONTRIBUTIONS

Received: May 5^th 2014

Accepted: December 2^nd 2015

Perceptions of adolescents Jalisco campaign on breast cancer

Amparo Tapia-Curiel,^a,b Bertha Lidia Nuño-Gutiérrez,^a,b Luis Flores-Padilla,^c Martha Villaseñor-Farías,^b José Luis López-López,^b María de los Ángeles Covarrubias-Bermúdez^b

^aUnidad de Investigación Epidemiológica y en Servicios de Salud del Adolescente, Instituto Mexicano del Seguro Social, Tonalá, Jalisco (Epidemiology and Adolescent Health Services Research Unit, Mexican Institute of Social Security, Tonala, Jalisco)

^bLaboratorio de Salud Pública, Departamento de Salud Pública, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco (Public Health Laboratory, Department of Public Health, Health Sciences University Center, University of Guadalajara, Guadalajara, Jalisco)

^cUnidad de Investigación Epidemiológica y en Sistemas de Salud, Instituto Mexicano del Seguro Social, Ciudad Juárez, Chihuahua, Mexico (Epidemiology and Health Systems Research Unit, Mexican Institute of Social Security, Ciudad Juárez, Chihuahua, Mexico)

Communication with: Amparo Tapia-Curiel

Telephone numbers: (01 52) (33) 3683 2189; (01 52) (33) 3683 2193; (01 52) (33) 3683 2195; (01 52) (33) 3683 2966, extension: 31797.

Email: amp_tap_cur@hotmail.com

Background: Breast cancer campaigns and awareness strategies with limited evidence of their effectiveness in youth. Behavioral model of perception that shows how individuals choose, organize and interpret information. This study shows the perceptions of youth from Jalisco regarding breast cancer campaigns.

Methods: Cross-sectional qualitative exploratory study based on constructionist and associationist theories of perception. Informed consent interviews with 13 focus groups, 129 men and women between 12 and 19 years old, enrolled students, residents of 6 regions of Jalisco. The sampling consisted in snowball technique. Interviews transcribed and processed with Atlas Ti version 4.1, open coding analysis.

Results: 10 campaigns were identified and the perceptions about them showed 3 processes: 1) Selection: permeated by the campaign design elements; 2) Organization: influenced by pre-structured meanings of the color pink, scope and limitations of the campaigns; and 3) Interpretation: showed judgments about the visibility of breast cancer, accessibility of knowledge and resources, permeability of positive ads and cultural codes and the lack of coverage meeting expectations.

Conclusions: A high awareness of breast cancer among teenagers was evident as well as the extensive need of information and services. We recommend creating strategies for formal education about breast cancer during adolescence.

Keywords: Adolescent; Perception; Prevention; Breast cancer

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In Mexico, breast cancer (BC) campaigns are based on acts of participation, communication, social marketing strategies, health education,¹ and the participation of public and private entities.² However, the reported participation of Mexican women 40 to 69 years in preventive health services in 2012 was low (36.3% for clinical examination and 41% for mammography),³ reflecting significant challenges in terms of education and awareness of BC in adult and adolescent women.⁴

Internationally, we have sought to measure the impact of various BC campaigns in communities, with special attention to these groups’ perception of them, to identify the elements that achieve greater awareness. Studies in Nigeria⁵ and Saudi Arabia⁶ with university students show that campaigns broadcast on television and radio were viewed more than those in other media. In the United States a television advertisement on International Breast Cancer Day increased informational internet searches about BC.⁷ Studies in the United States concerning the impact of television series that aired the story of a character with BC showed increased knowledge of BC in viewers;^8.9 this research identified other results, one that evaluated the series Grey's Anatomy showed increased attendance of women to health units for clinical examinations after the airing of the series;⁸ the other examined the soap opera Thieves of Hearts, through focus groups showing that the viewers who identified with a character were more willing to learn about BC, and men were more willing to recommend mammography to a woman.⁹ In Canada it was identified that women sick with BC prefer the Internet as a source of information because they perceived it as more enriching than information in other media,¹⁰ another study in Turkey¹¹ showed that the Internet was inaccessible to women from marginalized groups, and for them brochures or workshops provided more enriching information.

One of the criticisms of the campaigns in which a character with BC appears in television series, is that they overrepresent young women with BC, which significantly affects individuals’ perception of the epidemiology of the disease.¹² The studies described show important knowledge, but they also show the existence of gaps in knowledge about the adolescent population in Mexico.

According to constructionist and associationist theories,¹³ perception is conceptualized as a benchmark for individual behavior allowing them to adapt to groups;¹⁴ through this, sensory experience (visual and auditory stimuli) becomes a perceptual experience (recognize, interpret and make judgments of sensory experience).^15.16 It is a cognitive, biosocial, spatial and temporal process, based on learning through socialization, consisting of processes that interact with each other and shaped by patterns (generalities about a culture) and cultural codes (elements explaining the various meanings of one entity of reality).16

The processes that constitute perception are selection, organization and interpretation.^15,16 Selection is the search for, exclusion, and attribution of qualities to stimuli (symbolic thought) to generate descriptive categories.^15,16

Organization is the management and categorization of descriptive categories by comparison, to generate perceptual references (pre-structured frameworks of meaning that give meaning to stimuli) that make new sensory experiences recognizable to the individual under the collective concept of reality,^15,16 the latter being the basis of interpretation, in which judgments or opinions are made that make an individual aware of their reality.^15,16 Judgments are shared by groups, have universality, and manifest the perception of a society.^15,16

The study presented below was aimed at showing the perception of adolescents in the state of Jalisco regarding BC campaigns with which they have had contact. This knowledge is invaluable, given its contribution to new reflections on the work of health promoters and educational projects on BC.

Methods

Cross-sectional qualitative exploratory study based on constructionist and associationist theories of perception, 13-16, that included adolescents (men and women 12-19 years old) enrolled in school in the regions of Altos Sur, Centro, Ciénega, Norte, Sureste, and Valles of the state of Jalisco, Mexico, in the period from November 2011 to June 2012. 

With the approval of the project by the Local Committee of Health Research No. 1309 of the Office of Health Education and Research of the State Delegation in Jalisco of the Mexican Social Security Institute (Instituto Mexicano del Seguro Social or IMSS), schools that allow research were identified using the non-probability sampling technique snowball,¹⁷ with the help of members of municipal health services, the Mexican Social Security Institute, the Ministry of Health Jalisco, the School of Medicine of the University of Guadalajara, and the research team. Informed consent was obtained and the anonymity and confidentiality is assured, obtained from 100% of participants.

Focus group interviews were conducted,¹⁸ using an interview guide previously piloted (Table I). The number of interviews (average length: 1 hour) depended on the point of saturation of information, giving a total of 13, which were conducted by an interviewer accompanied by two observers. At the end of the interview an educational session on BC was given. Analysis of the data was done using open coding in 4 stages:¹⁹

• Interviews transcribed and processed with Atlas Ti version 4.1.
• The procedure for reading and rereading them, which allowed the identification of three "processes of perception" with "categories", [subcategories] and <2nd. sub categories>, which were: "Selection Process", "descriptive categories", [Context] <urban area>, <rural area> [Timing] <Variable> [Media] <Audiovisual>, <Digital>, <Print>, [Target audience], <adult population> [Images], [messages] <Referring to>, <Characteristics>; "Organizational process", "Perceptual References" [connection] <Pink Ribbon - Breast Cancer> [interest], <Attacking Breast Cancer> [Reach] <Participation across groups> <reaching a large section of the population> [Limitations] <Not directed towards youth>, <Very limited in marginal places>, <reaches some marketing goals>; "interpretation process" "Judgments" [Visibilization of breast cancer] [Accessibility of knowledge and resources], [Raising awareness of detection actions], [Permeating cultural patterns and codes] [does not meet all expectations] [Expectations for campaigns], <Context>, <Timing>, <Media>, <Objectives>, <Images>, <Messages.
• A search was performed to find the original references concerning the campaigns described by the youth, in order to identify their characteristics.
• Based on the theory described 13-16, a model was built of the perception of adolescents about the campaigns with which they had contact, which integrated the processes and categories identified that to allow the interpretation of results (Figure 1).

Results

1. Characteristics and context of participants

Sample: 129 adolescents, men (40%) and women (60%). Average age: 16.2 years. Groups from urban areas (7) and rural (6),²⁰ wellbeing level low (4), medium (5) and high (4) (Table II).²¹

2. Campaigns

The groups identified 10 campaigns concerning BC (Table III), the most mentioned being the "pink campaign" in 5 groups and "the pink ball campaign" in 4.

3. The perceptual process

Figure 1 shows the graphic expression of the model that we built to represent the perceptual process of adolescents in relation to BC campaigns with which they had contact. It shows the three processes of perception with three ovals interconnected by dashed arrows symbolizing the constant interaction between them and their permeability. Within each oval elements in each of the processes are identified, which are described below.

 

3.1. Selection process

Through discussion, the following "descriptive categories" (Figure 1) were identified: The [context] in which contact with the campaigns had, <urban> and <rural>, first being predominant, the [timing] which was variable since some were part of the World Breast Cancer Day and other permanent: "every year it happens ..." Man (M), "the little trucks are there, for several days giving information" Woman (W), the [media] with further reference to the <audiovisual> TV: "you see them on TV" W, the [target audience] the <adult population>: "they give information to people over 30 or with kids" W, the [Images] such as the pink ribbon, the human figure and breasts decorated with designs that caught his attention"... they put a little pink ribbon…" M, "it’s a lot of women ..." M, "... they make the shape of breasts with parentheses" M, the [messages] <referring to> promoting early detection of BC: "... four days after menstruation ... check yourself ..." W, with <characteristics> in its structure such as a lyrical format, brief, that encouraged reflection "they are simple phrases that stick with you ... and you start thinking "W.

 

3.2. Organization process

This second process shows "perceptual references" that gave meaning to the descriptive categories, the [connection] between the <pink ribbon and BC>: "... you see the little pink thing and you make the connection" W, making very clear that the [interest] of the campaign was <attacking BC>: "they it do to fight cancer" W, they visualized significant [reaches] of the campaigns in several ways, the <participation across groups> and penetration to large sections of the population "... everyone has have joined the campaign ... athletes, media and social networks" W, campaigns not exempt from [limitations] such as not being directed to the youth: "... they don’t tell us young women" W, minimal reach in marginal areas: "information doesn’t reach the small towns" M and marketing aids: "they want you to buy their products ..." M.

 

3.3. Interpretation process

The "interpretation process" demonstrated concretely how adolescents perceive campaigns, that is, through their "judgments", such as that BC is already [made visible] in virtually all of the population that participated and that could reflect the other groups in their context; the [access to knowledge] of the vast majority of the population: "... campaigns give good and useful information" W, and an important part of the [resources] for prevention, detection and cure: "carts come ... for several days giving information ..."M, "... to check yourself" W," ... to low-income people ... they support them with medicine, tests, transport "M; with a very important role in [permeating cultural patterns and codes] as the abandonment of machismo and marianismo and promoting pro-feminism and feminism, "my dad tells my mom to go and get herself checked" M, "she won’t care whether her husband wants it or not, she’s going to get examined, and that’s that." W; one of the major criticisms of the campaigns is that [they do not meet all expectations], they are not addressed to teens: "... if they do not tell me, it is because I am not at risk" W, in almost all of them the information is limited: "they don’t all tell you how to check yourself"W, that the information was exaggerated: "they show statistics and now everybody has cancer ... "M; those criticisms were supplemented with [expectations of campaigns], relative to the <context>: "they should give them in public places like tortillerias, squares, festivals" W, "in school" M, and that they should be regular, "they should rotate one week in one center, another in another"M, diffused in audiovisual <media> using music and videos: “I would put music in it"W, "through videos "M, in television programs and commercials: "in soap operas"H, "they could be in ads"M, digital media:" I would like it on the Internet ... in Facebook, My Space, Twitter ... Google, Wikipedia "M, that campaigns should <familiarize and offer clinical processes> "to show how mammography works, so you can go to get checked with confidence"M, "they should do exams at no cost" M, that the images should illustrate the transition: "of a woman who is healthy and then sick" M, that the <messages> should be <referring to> forms of prevention: "how to prevent it" W, techniques, cost, and care centers for detection: "to show them how they can do it themselves" W, "put how much it costs" M, "centers where they do the exams"M, on the epidemiology of the disease: “statistics on cancer”M, that the <messages> should incorporate youth language "with language that young people understand"M, brief: “it should be brief"M, without eroticism, "not in a sexual way ... to not offend people”M, broadcast by women: "... so she can pass it on to another woman"M, health personnel, "a doctor"W and survivors "by someone who it has happened to”W.

Conclusions

Adolescents’ perception of campaigns shown in this work revealed similar issues with the following investigations: those of Nigeria⁵ and Saudi Arabia⁶ regarding television campaigns reaching large groups and high capacity to raise awareness of BC; the one in the United States^8,9 on the effect of television campaigns in strengthening the positive view and confidence in action for early detection of BC, pro-feminist behavior and increased attendance of adult women to health units for preventive actions; as well as the Turkey study¹¹ on the perception of adult women about digital media, who considered them almost inaccessible to the marginalized sectors.

These studies show that television campaigns have greater penetration than those in digital media, in different contexts, time frames and age groups; in Mexico, probably because more than 90% of homes by 2012 had TV, this medium is used for 13 hours per week on average, and even more for the group between 16-20 years old; while only 32.2% of households had a computer and 26% had access to the Internet.³⁰

New findings included:

• The need for adolescents to receive formal education about breast health through campaigns designed according to population sector.
• Campaigns have permeated urban and rural areas almost similarly, and have enabled a significant amount of access to knowledge, boosted recognition of early detection as a vital strategy for combating BC, and led the transition from cultural elements that hinder early detection to elements that help it. There are design elements of campaigns that have generated distorted perceptions in adolescents about the vulnerability to BC and statistical data.
• Teens believe there are no health services for them.

This new knowledge supports that the use of BC campaigns in Mexico has been effective to sensitize adults and adolescents, but insufficient for the dissemination of preventive measures and strategies for early detection of BC, and that it caused in adolescents erroneous knowledge, unmet needs, and perceived discrimination by health services, generating a feeling of helplessness about one’s health.

The scope of this study lies in the representativeness of the results and its ability to show the collective perception of adolescents of BC campaigns in Mexico. The high BC awareness identified in this group of adolescents is a breakthrough in the health field, but we should consider this not only be attributed to campaigns, but probably also to family and school counseling, issues not explored in this study, which is a limitation.

In light of the results it is possible to recommend the following items for the production of BC campaigns:

1. Elements should be kept that benefit enjoyment and memory of the campaigns; they should include informative materials on prevention and early detection of BC, formulated to be accessible to marginalized groups, including screening, and
2. Formal BC education activities should be implemented for teens.

Acknowledgements

We thank Prof. Aida Araceli Rodriguez Carlos for her part in the fieldwork, Dr. Efrain Salas Gonzalez for his advice on building the project, Dr. Carmen Amalia Garza Aguila and Ms. Josefina Fausto Guerra for providing the means to do fieldwork in the municipality of San Martin de Hidalgo, Mr. Jorge Laureano Eugenio who it helped carry out the fieldwork in the municipality of Jocotepec.

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