The ‘Be Cancer Alert Campaign’: protocol to evaluate a mass media campaign to raise awareness about breast and colorectal cancer in Malaysia

The first project of the PACED initiative consists of two mass media cancer awareness raising campaigns under the slogan ‘Be Cancer Alert Campaign’ (BCAC). BCAC is based on successful programmes in other countries, principally the BCA campaign in Northern Ireland (Public Health Agency. Evaluation Report Breast Campaign, unpublished). BCAC will focus on the most prevalent cancers in Malaysia - BC and CRC. We are in the process of translating and adapting the BCA campaign, to ensure they are culturally sensitive towards the norms and beliefs of the new context and thus maximise the acceptability and reach of the campaign messages [29]. Several frameworks and guidelines exist for the cultural adaptation of health initiatives targeting minority populations e.g. the Chinese community living in the United States [29, 30] as well as for health initiatives adapted for use in different countries [31‐33]. We have scoped the different frameworks and guides and evolved an integrated model of cultural adaptation that will be used to sensitise the programme to the country-context and population profile of Malaysia. A separate manuscript reporting the cultural adaptation of BCAC will be prepared in due course.

We have completed two systematic reviews of the scientific literature regarding I) studies that assessed general population awareness and knowledge about, respectively, breast and colorectal cancer signs and symptoms and barriers towards screening in Malaysia and II) studies of mass and small media cancer campaigns in Asia that attempted to increase cancer awareness, knowledge and screening uptake for all cancers. Furthermore, a policy review is underway to describe the positioning of the campaign within the policy setting in Malaysia. The results of these reviews will be used to inform further the translation and implementation aspects of the programme including the content of the campaign, campaign messages and delivery.

A population-based, intervention study will be piloted to identify the impact of the BCAC campaign to raise awareness about CRC and BC warning signs and symptoms. The CRC and BC campaign will be carried out and evaluated consecutively (Fig. 1).

The CRC and BC campaign will last for 5 weeks each and will be kick-started with a media launch at the University of Malaya in the first week of the campaigns to increase press coverage of the campaign. Similar to the BCA campaign, the key messages will be promoted through various media channels. This is in line with findings from a systematic review by Wakefield et al. who concluded that mass media interventions that utilise multiple channels to convey a message increase the likelihood of achieving successful positive impact [38]. The main delivery mode will be via TV advertisements since findings from previous national and international campaigns suggest that TV was the intervention mode with the highest reach [39, 40]. In addition, BCA evaluation findings in Northern Ireland suggested that posters in health care settings were the most commonly reported location (Public Health Agency. Evaluation Report Breast Campaign, unpublished) [20]. Therefore, a local (print) campaign will be implemented. In addition, radio and social media advertisements will be created as well as a study website. All materials will include the call to action to I) visit the campaign website for further information and to II) call the National Cancer Society toll-free helpline to discuss any questions.

The BCAC campaigns are guided by best available evidence, qualitative ‘testing’ and behavioural theory particularly the Health Belief Model (HBM) [41, 42]^,49 which is one of the most commonly applied theories in cancer awareness raising programmes [43‐45]. The HBM was developed in the 1950s by Hochbaum, Rosenstock and Kegels and comprises six main components: (1) perceived susceptibility, (2) perceived severity, (3) perceived benefits, (4) perceived barriers, (5) cues to action and (6) self-efficacy [42]. Individuals who perceive themselves to be susceptible to contracting a certain condition such as BC or CRC, (due for example to age, family history, or health behaviours) are more likely to perceive this condition as a threat. Similarly, people who perceive the condition in severe terms e.g. debilitating poor health are also more likely to view cancer as a threat. Individuals are more likely to develop self-efficacy to self-detect early warning signs and to visit a doctor if the perceived benefits of taking the necessary steps to improve health outcomes (e.g. attending screening to discover cancer early and treat it) outweigh the perceived barriers (e.g. negative perceptions towards screening). The likelihood of taking action (e.g. consulting a doctor and attending screening) is high if perceived threat and perceived self-efficacy are high. Continuous reminders through mass media adverts (TV, radio, print and online) will serve as repeated cues to action and remind individuals to see their doctor if necessary. Although, the use of a behaviour change theory is included in a number of studies, many studies do not describe the application of a logic model, including the BCA and BCOC campaigns in the UK. A recent Cochrane systematic review which published a logic model that explained the underlying theory for changing health behaviours in ethnic minority communities [46] highlighted the importance of understanding the target population, their context and situation and then using this understanding to designe tailored and targeted campaign messages. The logic model of the BCAC illustrates the theoretical guidance from the HBM (see Fig. 2).

Trained, bilingual research assistants will visit the randomly selected households and all eligible individuals in a household will be informed about the purpose of the survey and asked to participate. Written informed consent will be collected from all study participants. The research assistants will offer to carry out the interview in either English or Malay, face-to-face with each participant individually, without the influence of other family members. We will conduct two surveys (starting three months before and continuing until three months after each campaign, excluding the campaign period) (Fig. 1). Online engagement and clinical data will be collected as described earlier.