How-to Health Communication: Crisis Public Relations and the Susan G. Komen For the Cure Foundation

Crisis communication has to be a part of any organization’s make-up.  Why? The same reason the words “I’m sorry” are part of human vocabulary:  humans make mistakes.  Being able to effectively deal with a blunder,  can tell a lot about an organization.

So, what can be learned about the Susan G. Komen For the Cure Foundation from its continuing difficulties since February 2012?  A lot.

Historically, Komen has had positive press: after all, its creation is based one woman’s promise to her dying sister.  So it isn’t surprising that in January 2010 the Harris Interactive Survey ranking of 79 non-profits brand along a number of criteria,  Komen ranked # 2 in Trust and #1 in Brand Equity (familiarity and quality).  It also ranked as the #1 non-profit to which people are most likely to donate.

Yet, in December, 2011 executives at Komen decided that the Foundation would not be funding cancer screening exams at Planned Parenthood.  In March, a month after the story broke, Harris International’s press release described a huge drop in Brand Equity for SGK: a fall from #1 to #56. 

Without a crisis management strategy, the Komen Foundation has stumbled  for months. Why?  Summing up, it is because the Foundation has not followed the five steps that are basic to public relations crisis communication.

STEP 1:  The first step is to be prompt and address the situation immediately.  Once the story broke, Komen should have addressed their reasoning for their decision.  Yet in this case, when the news broke via the Associated Press, Planned Parenthood used social media, Facebook, email and twitter to spread the news.   In contrast, Komen did nothing.  Planned Parenthood framed the story.

STEP 2:  Another step in crisis public relations is to be informative.  When the rationale for the decision was not fully explained, rumors proliferated. After letting Planned Parenthood frame the initial story, a public outcry occurred over the decision (with protests from its own affiliates) and the Foundation reversed its decision.  The explanation that Komen gave for their first decision was that they wanted to avoid funding organizations that are under investigation by authorities.  Yet Komen’s continued funding Penn State’s Milton S. Hershey Medical Center to the tune of $7.5 million despite also being under investigation by local, state and federal investigations.

STEP 3: This inconsistency calls attention to the third step in crisis management:  be honest with the public.  As the above illustrates there may be a history of problems with Komen’s communication strategy along these lines.

As Rachel Moro stated on her blog

On their website, Komen clearly states that is their mission “to end breast cancer forever”.  This mission ties in nicely with the organization’s recent name change to Susan G. Komen for the Cure®. Straight-forward. For. The. Cure.  What does this statement mean?  To anyone reading it or hearing it, the mission “to end breast cancer forever” and to be “for the cure” would mean there would be a significant amount of money going from the Komen Foundation to research to actually end it forever and find a cure.

Moro, an accountant, did an analysis on The Komen Foundation’s public records.  She states that “Komen’s total “Net Public Support and Revenue”for 1982-2010 would total somewhere in the order of $2.1 billion.  Only $491 million of that has been spent directly on research.  That means that $1.6 billion has been spent on other things.”  What has it been spent on?

Komen’s records state that between 2004 to 2009, Komen allocated a total of $1.54 Billion of “Net Public Support and Revenue” to the following categories: Education 36%; Research 25%, Administration and Fundraising Expenses 22%; Screening 11%, and Treatment 6%.  As can be clearly seen similar amounts of funding were spent on administration and fundraising as on research.

So there is an important message that anyone who donates to the Susan G. Komen Foundation For the Cure needs to know. As Andrea Rader from Komen stated, finding a cure doesn’t mean actually doing research,”Research is just one piece of delivering cures for cancer. Education is critical: even today, many women don’t know they’re at risk for breast cancer, or they continue to believe myths like underwire bras cause cancer (they don’t).”  Komen’s definition of “for the cure” does not mean doing research.

STEPS 4 and STEPS 5:  Steps four and five in public relations crisis management go hand-in-hand. Step four is showing the public you care.  Step five is maintaining two-way communication, that is, listening to the public.  There has been a vocal group of women with breast cancer who have been trying to get the Komen Foundation’s attention. One blogger and journalist, Brenda Coffee, was able to ask a spokesperson, Leslie Aun, the National Director of Marketing and Communication for Komen for the Cure,  to post on her blog.  The requirement of that posting opportunity was for Aun to respond to the many concerns of the breast cancer blogging community, for example, the partnerships Komen has made with brands like Mike’s Hard Lemonade (alcohol consumption associated with breast cancer) or the selling of “Promise Me” a perfume with carcinogenic ingredients. Aun was supposed to respond to comments to her post and thus provide a mechanism of communication.  Aun wrote her post.   According to Coffee, it was a defense of the Komen Foundation.  Aun did not respond to any of the comments that were made to her post.

So the Susan G. Komen Foundation For the Cure has been going through some significant personnel shifts over the past few months.  But is this enough?  Susan G. Komen was a young woman who had an extremely aggressive breast cancer that metastasized.   The Foundation that is named after her needs to remember that this terrible tragedy of her loss is being repeated.  Breast cancer is not being cured.

In those who have metastases, it is a life sentence to constant invasive, painful medical treatment and eventual death. Moro  poignantly wrote, “For me and the people I know who are in treatment for breast cancer, we understand a “cure” for our disease to mean that we will be completely healed and never have to worry about breast cancer invading our lives ever again. “  This is poignant since she died of breast cancer in February 2012, close to the time when all of the decisions about Planned Parenthood broke in the press.

The case of the Susan G. Komen Foundation For the Cure is not over.  There is time to work through this crisis with openness, honesty, information, and two-way communication with those who have breast cancer and their loved ones.  The officials leading Komen just need to take a few steps.





Awareness Months

In Action:  Beyond Awareness I broached the subject of Awareness Months.  Because there is some confusion, I am going to discuss the Transtheoretical Model to clarify.

Prochaska, Norcross, and DiClemente developed the Transtheoretical Model.  It is used extensively in developing behavioral change programs for individuals.  The model describes the series of stages that an individual goes through in the process of change.

Precontemplation:  This is the first stage.  It is when the individual is unaware or underaware of their problems.     There is no intention of changing behavior.

Contemplation:  The second stage is contemplation; the person is aware that a problem exists and is thinking about it.  They have not made any commitment to take action.

Preparation:  Some behaviorists parcel out this stage into 2 parts.  First, the individual  intends to take action in the next month.  Second, they have made a commitment to do so.

Action:  This is the stage where the individual makes overt behavioral changes.  Modifications in behavior, environment or experiences occur.

Maintenance:  During this stage, the person works to prevent a relapse.  The gains achieved during the action period are integrated into their life.

Relapse:  Unfortunately, there is the opportunity for relapse.  Those who have relapsed may move into the preparation stage again or remain relapsed.

One of the most important features of this model is that it is all about the individual–moving the individual along a path toward change.

What does this change model have to do with Awareness Months?

Awareness Months assume that everyone who is receiving information is in the precontemplation stage.  They assume that all individuals being targeted by the campaign are unaware or underaware of the disorder/disease.   This is not the case.

When measuring the impact of an awareness campaign, pre-test/post-test surveys are done. The people who didn’t know anything about the disease/disorder or the material in the campaign (found in pre-test) are asked if they learned anything during the campaign.  If there is a change in knowledge among those people, the campaign can be termed “successful.”  There can also be questions about intent to do certain actions that the campaign promotes or even checks to see if actions actually occurred.  {An example of an effective campaign among those with low health literacy can be found here.}

What happens if an Awareness Month is only about letting people know how to determine if they or their loved one has a disorder?  Or what if an Awareness Month is only about preventing an individual from getting a disorder?

If the focus is on preventing the disorder, isn’t there an unintentional stigma “out there” for those who have the disorder?   It is as if  having the disorder is something that you could have controlled/prevented.  In most cases, this is not true.  Genetics plays a significant role in our lives.  The environment that we are surrounded by, pollutions or toxins we do not know about, impact us from babyhood.  The interaction between our genes and our environment can result in diseases and disorders.  Is that the fault of the individual?

People with the disease or disorder and/or their caregivers are fully aware.

Awareness Months that focus only on prevention or only on determining if an individual has a disorder leaves out people who have the disorder.  It doesn’t make anyone aware of what it is like living with the disorder nor does it help those dealing with that reality.  It doesn’t make anyone aware of the financial burden of the disorder; or the incredible efforts made by caregivers on behalf of those who have the disorder.  

So, where do you think change is needed?

Begin With the End In Mind: Let Evaluation Lead

Nothing says success better than provable results! So it is easy to see why the folks at Health Literacy Wisconsin are smiling from ear to ear. This past fall they put together a winning health communication campaign by sticking with the fundamentals: they did their research. Erin Aagesen, MS, MSPH, the Health Literacy Coordinator at Health Literacy Wisconsin, a division of Wisconsin Literacy, Inc., joined the Health Communication, Health Literacy and Social Sciences tweetchat to explain their process. Erin manages statewide health literacy interventions in partnership with Wisconsin Literacy’s 63 member literacy agencies, community-based agencies and health care organizations throughout Wisconsin. The plain language health communication campaign, ‘Let’s Talk about Flu’ was conducted this past fall and winter of 2011-2012. During this short timeframe, 53 workshops served 921 adults with low health literacy. Funding and support came from Anthem BCBS and Walgreens and resulted in a lesson book, a 1-hour workshop and flu vaccine vouchers. According to Erin, a key to their success was “making the information relevant to participants’ lives.” Another vital component to success was delivering workshops in “trusted settings where people already live, work, study and socialize.” “Most participants were adults from our 63 member literacy agencies, who are reading below the 5th grade level. We also worked with populations in which there is generally a large overlap with low literacy, including [the] homeless.” Community based organizations often take shortcuts to save time and money. Pre-testing campaign content is often left out. In this case, Health Literacy Wisconsin didn’t skip this important step, they “pre-tested our lesson book with physicians, adult learners and adult literacy program directors. This was an essential step; we learned a great deal and revised our program and materials based on this feedback. We’re all rushed, but I think scheduling time for feedback and revision upfront saved us time in the long run.” “You have to prioritize. We were successful because we made some decisions about what was crucial data and what was not.” All their stakeholders were gathered together prior to developing their evaluation plan. And they followed the crucial advice to “begin with the end in mind!” By taking that advice, the results were worth sharing. With an 85% completion rate of the pre- and post-tests they found that flu knowledge increased from 56% to 83%. The participants intention of getting the flu shot increased from 74% to 83% and 42% obtained the flu shot (tracked through voucher system provided by Walgreens). The University of Wisconsin Extension Cooperative Extension pamphlet provided Erin and her colleagues with the tools and the self-confidence to do it right. As Erin assures other community based organizations, “it’s OK not to be research experts. ‘There is no blueprint or recipe for conducting a good evaluation.’ Make it work for you!” For further information check out Erin’s tweetchat and the University of Wisconsin Extension Cooperative Extension evaluation tools, especially their booklet.

Post Three–Bringing Targeting, Tailoring and Engagement Together

Ok…the first post in this series called Targeting versus Tailoring describes the difference between the two.  To summarize, a targeted message is created for a specific group of people.  A tailored message is directed to one individual, created specifically for that one person.  Both strategies of reaching the audience require formative research. Post two is called Engagement…making it relevant. As one commenter notes, targeting has been done in the advertising world for many years.Reaching an individual through tailoring is comparatively new.Research that has been done on tailoring has been in phases.The first phase compared tailored messages to nontailored messages.This research, conducted in the 90’s, consistently showed that using tailored messages resulted in greater recall of the information.The messages were more carefully read and believed to be more relevant than nontailored messages.Positive behavioral change was documented. Another phase of research examines the aspects of tailoring, like message source or cultural variables.  In one study in African American churches, message source was tested because formative research had  revealed much distrust of research. yet confidence in the Bible and scripture to provide health guidance.  In the study, the tailored communications were either endorsed by the church pastor or by nutrition experts.  Those who received the pastor sourced messages thought them more credible than those endorsed by the nutrition experts and pastor endorsed recipients had greater intention of modifying their health behavior. Okay, so now how do we use tailored communications?  Although the results of intervening at the individual level are impressive,  people do not live in a vacuum.  Indeed, sickness is not a result of personal failure.  Use a multi-level intervention, one that takes into account social networks social norms, and environmental factors, for example.  Although more complex to conceptualize and execute, multi-component health promotion interventions are more likely to result in lasting behavior change. Next post…gamification of health interventions

Part Two: Engagement…or how to make it matter

For a long time cognitive scientists have been studying how we receive and process messages.   Petty and Cacioppo are the big names in this area of study, coming up with the Elaboration Likelihood Model or ELM to describe what they observed.  In a nutshell they found that we process messages in two ways, via  central or  peripheral processing.  As health communicators our goal is to engage indepth or central processing.  When people have little interest in a message, they tend to process it peripherally.  When processing peripherally, they don’t think about the arguments in the message but rather they  use cues like attractiveness, reputation or credibility to guide their decision to perform a behavior.  Alternatively, central processing is energy consuming.  It is only engaged in when a message is  very important and relevant to the person and when the person has the intellectual or technical ability to process a message centrally.    Processing centrally requires careful listening and evaluation of message content.  Whenever possible you want to promote central processing.   When you’ve thought about an issue and made a decision to perform a recommended behavior your’re more committed to really doing it.   Central processing is more likely to lead to long-term and stable change.

One of the best ways to engage the central processing route is to make your message relevant to the audience.  Tailoring achieves relevance. Studies have found that compared to non-tailored messages, tailored messages are more likely to be read and remembered, rated as attention getting, saved and discussed with others and perceived as personally relevant. Tailored messages are patient-centered.  Patient-centered messages are associated with better adherence to treatment than are topic-centered messages.  In particular, they can enhance self-efficacy, or the perceived ability to complete a specific task.Here is an example to illustrate the tailoring process.   Suppose we were to develop tailored messages to encourage an adult female to quit smoking, an interview or assessment survey would be used to query her about her life to better understand her smoking behavior.  The assessment would find that her name is Shelia Shephard, a cashier at a supermarket.  She identifies herself as an African American; she is 43 years old and has been smoking since she was 14.  Her smoking is done to relieve stress.  She has tried to quit before but has been unsuccessful.  She wants to try to quit again but can’t afford nicotine alternatives that can help her quit.  She socializes with other smokers during breaks.  Her main barrier to quitting is low self-esteem after having been previously unsuccessful in quitting; she believes that she will not reduce her risk of cancer by quitting.  A tailored message designer might create a message addressing her by name, acknowledging her long-time identification as a smoker and providing her feedback on ways to reduce stress without smoking.  The message would address her low self-esteem by providing supportive messaging to increase self-esteem.  It might provide her with coupons for nicotine gums and include a testimonial from a cashier who has quit.

The pace of interactivity has accelerated.   The opportunities for using tailoring have moved from print to Web to Blackberries.  Connection is just a text message away.  With the advent of tracking devices that can input data for real-time monitoring, the possibility of tailored texting to support behavioral change is not a pipe dream.  It is reality.  And that’s not all folks…stay tuned for more…

Part One: Targeting and Tailoring Messages: What’s the difference and why should I care?

Think about doing a little target practice.  Imagine the target board…concentric rings coming to a small bull’s-eye in the center. What kind of gun would you choose to hit the mark?  A sawed off shotgun or a rifle with a scope?  The choice is obvious. Airing PSAs or producing health websites with messages crafted for a “general audience” is like shooting a target with a sawed-off shotgun.  The buckshot may or may not hit the paper marker, some may hit the bull’s-eye but a lot of the shot will miss the mark.  One way to achieve more accuracy is to direct your message at a smaller audience.
Targeting refers to the process of segmenting a general, heterogeneous audience into smaller more homogeneous groups. Targeting is based on the advertising principle of market segmentation.Factors that are generally used to segment a population are age, sex, race, income, ethnicity, location and diagnosis.It involves developing a single intervention approach for the subgroup. The subgroup can be very well defined, for example, Chinese-American men, aged 50 to 60 who frequent a certain health center.Targeted materials are based on an aggregate profile of a specific population subgroup.  The focus is on characteristics that are assumed to be shared within the group, hopefully based on formative research.  For example a heart healthy cookbook might be created for a group of Latina mothers in San Antonio. It might be written in Spanish at a sixth grade reading level, use Latina models to explain messages and include testimonials from members of the Latina community about the importance of heart healthy nutrition.

Targeting and tailoring are not the same thing.  To carry the target practice analogy to its conclusion, if you use a rifle with a scope you are extremely likely to hit the bulls-eye.  Tailoring is like hitting the bull’s-eye.    Tailored messages or strategies are not for a group of people but are created for one particular individual.   The process of tailoring segments your target audience to its smallest unit, one person.   Messages, derived from an assessment answered by that individual,  are crafted to address individual level factors that relate to the health or behavioral outcome of interest.  Psychosocial behavioral determinants, like perceived barriers, or perceived self-efficacy to engage in behavior change, are collected in survey format.   Given the capabilities of computers and software, crafting a message specific to one recipient is possible.  In fact it is possible to create tailored message programs to maximize individuality by producing thousands to millions of combinations of tailored messages.So, why should I, as a health communicator, care about targeting and tailoring?  Stay tuned to find out.