"Tasi le Ola" Breast Cancer Prevention Radio Drama Short-term Impact Evaluation, Sara Krosch by Sara Krosch Consulting

Tasi le Ola radio drama

process assessment & short‐term impact evaluation 7/15/2009

Sara Krosch & Vaioge Tuito’elau

An American Samoa Community Cancer Coalition Pacific‐CEED Legacy Project Funded by REACH US Centers for Disease Control through the Department of Family Medicine & Community Health JABSOM, University of Hawaii

Table of Contents Introduction ................................................................................................................................................................... 3 Project Goals .................................................................................................................................................................. 5 Process Assessment ...................................................................................................................................................... 7 Community Participation Aims & Achievements ............................................................................................ 7 Key Stakeholder Forum & Workshop .............................................................................................................. 9 Text Messaging Campaign ............................................................................................................................ 10 Short‐term Impact Evaluation ..................................................................................................................................... 11 Women’s Survey Results ............................................................................................................................... 11 Summary & Recommendations ................................................................................................................................... 19 Works Cited ................................................................................................................................................................. 21

Tasi le Ola radio drama process assessment & short‐term impact evaluation American Samoa Community Cancer Coalition ‐ Pacific‐CEED Legacy project, 2009 Sara Krosch & Vaioge Tuito’elau ‐ amsamccn@gmail.com

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Introduction The American Samoa Community Cancer Coalition (ASCCC), a non‐profit, non‐governmental, community‐based organization, was funded by the Pacific Center of Excellence for Eliminating Disparities (Pacific‐CEED) Legacy grant to develop an innovative 5 episode radio drama focusing on breast cancer prevention and education for women over the age of 40 years old. The project had the specific focus of examining women’s beliefs and practices concerning traditional Samoan healing methods (massage and herbal remedies) as complementary or alternative therapy for cancer prevention and/or treatment. The Legacy project also aimed for high levels of community participation. Radio was the chosen channel of communication after research revealed it was one of the most effective means of conveying cancer information in the past for women in the target group and a top requested medium for future cancer education campaigns (Krosch, 2009). Formative research project activities commenced January 2009 with a literature review. Primary research happened in February with a breast cancer and traditional healing knowledge‐attitudes‐behaviors survey of 179 Samoan women age 40 and over; perceptions and practices of complementary and alternative medicine survey of 47 health care providers in American Samoa; and 13 semi‐structured interviews with cancer survivors, health care providers and traditional Samoan healers (Taulasea/Fofo). Data was compiled, transcribed and analyzed in March and the formative research results were shared with Key Stakeholders at a workshop in April. At the same event, Stakeholders completed a series of small group activities utilizing research results and their own experiences to decide the main health promotion messages for the radio drama, and outline character profiles and realistic plot situations in which to convey the health messages.

Key Stakeholders included health care providers, traditional Samoan healers, cancer survivors & media representatives. Photo: L. Scanlan

A Creative Brief was developed, based on formative research results and Key Stakeholder Workshop input, to enable the Writing Team to draft Samoan and English scripts for five, ten minute radio serial drama episodes. Preliminary scripts were pretested with the main target audience—Samoan women age 40 and older—in early May for character and plot realism, recognition of key health messages, and cultural appropriateness including Samoan language translation. In late May, the final scripts for the radio drama Tasi le Ola (One life) were recorded with an all volunteer cast and edited by project staff. A theme song competition also took place in May culminating in an outdoor Kick‐off event featuring theme song performances, promotional give‐aways, health information booths, and contests and activities that encouraged women to make their health their priority and tune in to the radio program. Tasi le Ola radio drama process assessment & short‐term impact evaluation American Samoa Community Cancer Coalition ‐ Pacific‐CEED Legacy project, 2009 Sara Krosch & Vaioge Tuito’elau ‐ amsamccn@gmail.com

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Tasi le Ola (TLO) aired on three radio stations for three weeks, May 25‐June 13, in American Samoa. One episode aired a day, Monday through Friday, and all five episodes were played on Saturday over the three‐week project period. TLO could be heard in Samoan twice in the morning and twice in the afternoon and in English once in the morning and once in the afternoon weekdays. TLO was heavily promoted on the island. The radio show was promoted daily on all three radio stations, on two television channels, and in two print newspapers and one online newspaper. A was banner posted in a high traffic area throughout the airing period. And promotional give‐aways were distributed to women at the hospital and main shopping centers during the first week of airing. A local cell phone company donated text messages to send 75 women in the main target audience four alerts encouraging them to listen to the show. Additionally, one radio station aired TLO daily on a local television station and the show could also be heard in the neighboring country of Samoa. CDs of the entire TLO series were donated to the public Library for patrons to access during and after the project period. Women wrote their “One Wish for My Life” on flags and received Tasi le Ola promotional bags filled with breast cancer prevention information & listening reminder items (magnet, bracelet, t‐shirt, etc.).

Photo: S. Krosch

Following the final airing of the show, a short‐term impact assessment was conducted consisting of a survey of 195 women in American Samoa, a telephone survey of women who were sent text messages and an internal assessment of community participation over the course of the project. This document reports the process evaluation results from the Key Stakeholder Workshop and the text messaging campaign, and the short‐term impact TLO had on the main target audience of women age 40 and older specifically focusing on amount and frequency of listenership, translated as exposure to key health promotion messages, and intended future behaviors related to breast cancer screening. For more information on the TLO radio drama project and to access all relevant outputs please visit the Project Coordinator’s web site (www.sarakrosch.com). To request a CD containing the entire TLO series email amsamccn@gmail.com. Sara Krosch, Project Coordinator Vaioge Tuito’elau, Project Assistant

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Radio Show Promotion included radio, TV, web & print advertisements

Project Goals As with any health promotion communication project, the ultimate goal is measureable/observable behavior change. Despite the short six‐month duration of the TLO project and the even shorter three‐week airing of the radio series itself, project planners were confident that the novelty of a cancer prevention radio drama along with multi‐faceted promotion and diverse stakeholder involvement would make a significant contribution towards reaching the overall project goal to:

Increase utilization of breast cancer detection/prevention services by 3% amongst Samoan women at risk for breast cancer, age 40 and older, in American Samoa as measured by self‐ reported behavior intentions.

Pre‐intervention surveys during the formative research phase found that 55% of women surveyed reported ever having screened for any type of cancer. More than half of these women (56%) reported ever having had a mammogram and 74% of women reported ever having performed a self‐breast exam (SBE)1 . Since mammograms can only be done at the hospital or via American Samoa Department of Health Clinics, measuring women’s intentions to utilize these services in light of their TLO listening status after the airing of the radio show will help determine if the main project goal was met.

Women were not asked if they had ever had a Clinical Breast Exam in the formative research survey.

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The TLO communication campaign also had a specific goal and several objectives as illustrated below.

Figure 1: Goals, Objectives & Strategies for TLO Communication Campaign

The impact evaluation surveys aimed to measure attainment of Objective 5 by determining: • • • •

how many women listened to TLO; how often they listened during the 3‐week airing; what health messages they received from the show; and by comparing past and future intended breast cancer screening behaviors.

Longer term impact evaluation activities should compare breast cancer screening service utilization numbers before, during and after the project period noting recall of TLO listening as a motivating factor.

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Process Assessment Community Participation Aims & Achievements High levels of community input were sought to complete the TLO project. Nearly 600 people participated in research, planning, production, promotion and evaluation activities, with only two being paid staff. At the onset of the project, staff and ASCCC representatives set community participation goals in terms of leadership, organization, needs assessment, management and resource mobilization based on Lehman’s (1999) model illustrated in Figure 2 2 . Project aims are shown in pink boxes. After the TLO radio show stopped airing and impact evaluation activities commenced, project staff revisited their aims to determine if they were achieved as shown by black stars.

Figure 2: Measuring Community Participation of Community‐based Health Initiatives (Source: Lehman, 1999)

= Aims = Achievements Aims were met in nearly all aspects of the model. Community based leadership in the TLO project contained health care providers, community‐based organizations, faith‐based organizations, government agencies, traditional healers, cancer survivors, media representatives, business and civic leaders and other concerned individuals, many of whom participated in more than one aspect of the project. Community Stakeholders beliefs and experiences were sought via formative research and their views and needs determined the key health messages and other aspects of the Creative Brief. Due to the large and diverse Stakeholder base, community

In order for the project to be truly “participatory” these aims and achievements should have been determined by the Stakeholders themselves rather than by the project staff and ASCCC representatives alone. But for the sake of time and experimentation with Lehman’s scale, project staff and ASCCC representatives alone determined these evaluation results. Future community‐based projects will seek to involve diverse Stakeholders in using this model. Tasi le Ola radio drama process assessment & short‐term impact evaluation American Samoa Community Cancer Coalition ‐ Pacific‐CEED Legacy project, 2009 Sara Krosch & Vaioge Tuito’elau ‐ amsamccn@gmail.com

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members managed some aspects of research, production and promotion activities and were especially involved in recruiting voice talent and volunteers for the Kick‐off event. And although the majority of the resources came from grant funding, community members were active in mobilizing resources to contribute to the promotion of TLO, primarily raffle prizes and donated media space. Aims were exceeded in terms of organization. Because the TLO project proposal was developed by a single ASCCC representative and the Project Coordinator and the timeline for the activities was short, the planners were uncertain how active the ASCCC membership and other community Stakeholders would be in developing project activities, thus a “restricted” level of involvement was anticipated. However, due to the many engaging aspects of the TLO project, the ASCCC membership and other community Stakeholders had interest and sustained involvement throughout the phases of the project. The TLO project thus proved to be a launching board for the ASCCC to partner with a broad base of Stakeholders and share lessons and successes.

Tasi le Ola was branded throughout the campaign. The title/theme was inspired by a quote from a cancer survivor—a sentiment echoed in several interviews. The logo was chosen by the target audience and found on all promotional items and advertisements.

Photos: S. Krosch

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Key Stakeholder Forum & Workshop Twenty‐six (26) Key Stakeholders attended a five‐hour Forum and Workshop event held at the Felti Barstow Public Library Friday May 23 to hear and discuss the results of formative research and to develop the messages, characters and plot of the TLO radio drama series. Twenty‐three (23) attended the research results presentation and discussion held in the morning and 15 participated in the script development workshop activities conducted in the afternoon. Evaluation surveys were completed by 18 of the 26 attendees (70%), 15 females and 3 males. Overall, Stakeholders were pleased with the event.

Table 1: Formative Research & Planning Stakeholder Workshop‐ Participant Evaluation Results Evaluation Items

Percent of Respondents Agree Disagree Strongly Disagree

Strongly Agree

No Response

1. The event gave me a better understanding of cancer in American Samoa. 2. The event date and time was convenient.

50%

33%

66%

3. The event location was comfortable.

45%

4. The event was well organized.

66%

33%

5. I enjoyed the radio script development activities.

44%

28%

6. I would attend more events like this one in the future.

45%

50%

0% 10% 0% 28% 5%

TheTLO theme song contest received 12 original entries, most of whom performed live at the Kick‐off event.

Photo: A. Tagarino

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Text Messaging Campaign Aside from the usual promotion activities including radio, television and print advertisements for TLO, the ASCCC partnered with a local cell phone provider, Blue Sky Communications, who donated free text message alerts to women reminding them to listen to the show. Blue Sky frequently sends out text messages to its customers to alert them of sales and promotions, but texting had never been used for health promotion in American Samoa before the TLO project. Researchers have found that age is the greatest determinant of mobile phone use and text messaging in particular with people ages 15‐24 most easily reached via this channel (Drotner, 2005), so using text messages to reach Samoan women age 40 and older was experimental.

The American Samoa Department of Health’s Breast and Cervical Cancer Early Detection Program (BCCEDP) contact cohorts of past clients quarterly to remind them to make an appointment for their yearly CBE/mammogram. The BCCEDP provided the ASCCC with a list of over 150 telephone numbers of women slated for their yearly breast screening in the 3 months following the airing of TLO. Project staff narrowed the list to just Blue Sky cell phone numbers belonging to 75 women whom Blue Sky agreed to send four free text messages to each (Table 2). The first message was an invitation to the TLO kick‐off event held Saturday May 23. The other three messages were sent on Mondays of the weeks TLO was aired encouraging women to listen to the show on the stations that played it.

Table 2: TLO Text Message Alerts Date Friday 5/22 Monday 5/25 Monday 6/1 Monday 6/8

Message Ladies Utulei Beach Sat 5/25 free music health info Tasi le Ola listen daily FM 103 104 92 Tasi le Ola daily daily FM 103 104 92 Tasi le Ola daily daily FM 103 104 92

According to Fogg (2007), US‐based health promotion and behavior change text message interventions fall into one of seven categories—TLO messages can fall into three categories (*): (1) a reminder to do health behavior*; (2) a request for data; (3) an offer of words of inspiration or motivation*; (4) a prompt to keep a schedule/routine*; (5) an alert to a health issue or crisis; (6) lab results or health status report; (7)and health information on demand.

In the week following the final airing of TLO, women who were sent text message reminders were contacted via phone for a short survey. Project staff attempted to contact each woman 3 times at different times of the day. When reached, the woman was asked if she recalled receiving any text messages about the kick‐off event or TLO; if so how many messages did she receive; if she listened to TLO; and if so how many times did she listen to the show. The majority of women, 53 (71%) could not be reached during the week after TLO aired due to no answer, disconnected phones or phones not in the possession of the woman. Only 22 women (29%) could be contacted. Of these 22 women, only 8 (36%) recalled receiving only 1 text message. No woman recalled receiving more than one text message3 , but 7 of these 8 women (88%) said they listened to TLO. Of the 14 women reached who did not recall receiving any text messages, only 2 (14%) listened to TLO. Most of the woman contact said they do not regularly read or send text messages.

The Project Coordinator’s cell phone number was included in the text list given to Blue Sky for monitoring purposes only. She did not receive the first message about the Kick‐off event because Blue Sky claimed her texting option had been discontinued due to lack of use, unbeknownst to her. After the texting option was reactivated she received only one message on Monday May 25. This lead project staff to believe that Blue Sky did not send women four text messages as agreed upon and several other women who are not frequent texters may have also had this service discontinued without their knowledge.

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Short‐term Impact Evaluation Women’s Survey June 15 – 24, 2009 project staff conducted a non‐random, convenience sample, self‐administered survey with 200 women—the primary audience for TLO health messages—in American Samoa. The 15‐item survey was developed in English, translated into Samoan and pre‐tested and back translated to English by one Samoan woman under 40 years old and one older than 40. Survey respondents received a dish towel or cloth bag if they completed the questionnaire. Six (6) surveys were missing more than 3 items and were excluded from analysis. The map below (Figure 3) shows that the majority of the villages in American Samoa contained at least one survey respondent—46 of the 68 villages in the Territory (68%). Because TLO was broadcast on 3 radio stations and could be heard on the only television station accessible without cable it is possible that all of Tutuila and Aunu’u could have heard TLO4 . Of the 46 villages surveyed, 91% contained at least one woman who reported having heard the radio program.

Figure 3

It is uncertain if respondents from the Manu’a Islands receive reliable radio from the main island of Tutuila. However, as stated before, villages in independent Samoa did receive the TLO program on V103, which widened the listening base beyond what was measured by this survey. Tasi le Ola radio drama process assessment & short‐term impact evaluation American Samoa Community Cancer Coalition ‐ Pacific‐CEED Legacy project, 2009 Sara Krosch & Vaioge Tuito’elau ‐ amsamccn@gmail.com

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Figure 4: Ages of Survey Respondents

39, 20%

43, 22%

More than three quarters of the sample (78%) was part of the main target audience for TLO, women age 40 and older who are more at risk for breast cancer (Figure 4).

under 40 40‐49

54, 28%

59, 30%

Women under age 40 were also surveyed because they are potential sources of influence to the main target group according to formative research findings. Three characters in TLO were under age 40 and they conveyed some of the key health messages women over 40 were encouraged to heed.

50‐59 60+

100%

% women

80%

Figure 5: Radio Station Listening during TLO Airing 7 6

None

60% 40%

Previous research showed that women age 40 and older in American Samoa listen to FM radio KSBS, V103, KWNW (Showers of Blessings‐SB) and KHJ most often, so airing contracts were sought with these stations and obtained with the three former (Krosch, 2009). During the three weeks TLO was aired, over 90% of survey respondents accessed one or more of these stations shown in Figure 5. KSBS and SB had the most listeners in the target audience, but V103 aired TLO most often and for the lowest price.

Other SB

KSBS V103

20% 37

0% All

under 40 40‐49

50‐59

60+

TLO listening status was used to analyze other data. Figure 6 shows that 62% (n=121) of women surveyed recalled listening to at least episode of TLO. The majority of women ages 40‐59 report listening. This is a promising statistic given that TLO was aired for only three weeks, so it can be assumed that longer airing would result in even more listeners.

# women

Figure 6: Listened to TLO 200 175 150 125 100 75 50 25 0

38%

no yes

62%

All

under 40 40‐49

50‐59

60+

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It is important to know the breast cancer prevention behaviors of the women in the target audience prior to TLO so as to determine if the radio show motivated new behaviors or supported maintaining actions. Longer‐ term impact evaluation activities should aim to track beliefs, attitudes and behaviors related to the key health messages.

Figure 7: Ever had a Clinical Breast Exam

# women

200 175 150 125 100 75 50 25 0

74%

no yes 26%

All

under 40 40‐49

50‐59

60+

Figure 8: Ever had a Clinical Breast Exam 100%

% women

80% 88

60%

56 no

40%

yes

20%

listeners

non‐listeners

# women

Figure 9: Ever had a Mammogram 200 175 150 125 100 75 50 25 0

no yes 26%

under 40 40‐49

50‐59

60+

Figure 10: Ever had a Mammogram 100%

% women

80% 60%

Listeners were no more likely than non‐listeners to have ever had a mammogram as shown in Figure 10. Similar to CBEs, there is no clear correlation between past breast cancer screening and listening to a breast cancer prevention radio drama.

54 no

40% 20%

Figure 8 compares women who listened to TLO to non‐ listeners in the sample. It was hypothesized that women who have already adopted important breast cancer screening behaviors may be more likely to have listened to a health promotion radio drama like TLO, given access to the program. But, listeners were only slightly more likely to have ever had a CBE than non‐listeners. Identical to past CBEs, 74% of women reported never having had a mammogram (Figure 9). (This is a larger percentage than found from the formative research survey in which 56% of women reported never having had a mammogram.) Older women age 50+ were most likely to have ever had a mammogram.

74%

All

TLO encouraged breast cancer screening—self‐breast exams, clinical breast exams (CBEs) and mammograms. Since CBEs and mammograms are available on the island it was important to encourage women to utilize these services in TLO. Figure 7 illustrates that nearly three quarters of women reported never having had a CBE. But the majority of women surveyed age 60 and older claimed to have had this screening.

yes 31

listeners

non‐listeners

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Figure 11: Aware of Free Screening Services

Figure 12: Aware of Free Screening Services

200 175

100%

27%

80%

125 100 75

% women

# women

150

no 73%

yes

60%

40%

yes

20%

25 0

0% All

under 40 40‐49

50‐59

60+

listeners

non‐listeners

The BCCEDP offers free breast cancer screening (CBEs and mammograms) by referral from the LBJ Tropical Medical Center (LBJ) and via three “after hours” clinics held at LBJ’s OB/Gyn Clinic, the Tafuna Family Health Clinic and the Amouli Dispensary. TLO characters specifically mentioned and modeled accessing these free services so listeners could have learned of or been reminded of them from the radio drama. Figure 11 shows that the majority, 73%, of women surveyed knew of these screening services before or directly after the TLO project period. There is a distinct difference between awareness levels of TLO listeners and non‐ listeners (Figure 12). Seventy‐nine percent (79%) of listeners knew of available screening services compared to 63% of non‐listeners. This 16% difference could possibly be due to listening to TLO specifically; to radio listening in general as the BCCEDP advertises its services via radio spots; to other unexplored factors; or to a combination of several causes. Despite high levels of awareness, only 36% of all women surveyed reported ever attending a free breast cancer screening clinic prior to or during the TLO airing with the majority accessing the LBJ‐Ob/Gyn Clinic (Figure 13) 5 . Figure 14 shows us that TLO listeners were more than twice as likely to have ever attended a screening clinic as were non‐listeners. This finding calls for more inquiry concerning the aforementioned hypothesis: are TLO listeners generally more inclined towards health prevention behaviors and could TLO have motivated immediate screening? Figure 14: Ever Attended Screening Clinic(s)

Figure 13: Ever Attended Screening Clinic(s) 80 1%

50 70%

# women

60 Amouli LBJ‐Ob‐Gyn

40 30

Amouli 72%

LBJ‐Ob/Gyn

Tafuna

29%

65% 26%

0 All

under 40 40‐49

50‐59

listeners

60+

35%

Tafuna

non‐listeners

Only one woman stated she had been screened at the Amouli Dispensary. It is uncertain if services are still being offered at this location although they were advertised as being available twice a week on print, billboard and radio ads prior to and during the project period. Tasi le Ola radio drama process assessment & short‐term impact evaluation American Samoa Community Cancer Coalition ‐ Pacific‐CEED Legacy project, 2009 Sara Krosch & Vaioge Tuito’elau ‐ amsamccn@gmail.com

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TLO listeners were asked how many times they listened to TLO. There were 5 episodes in the TLO serial drama, with one episode aired daily in sequence over the week (episode 1 on Mondays, episode 2 on Tuesdays, etc.) . If they responded “5 or more times” it was possible they had heard the entire series. Figure 15 illustrates that most listeners heard TLO 3‐4 times, but more than a quarter did hear the show at least 5 times. It is unknown if listeners heard the same episodes more than once or the entire series. Further focus group research with listeners would need to be conducted to determine which specific episodes women heard. Figure 15: Number of Times Listened to TLO 120 27%

100

# women

80 5 or more times

50%

3‐4 times

1‐2 times

23%

0 All

under 40

40‐49

50‐59

60+

Listeners in general tuned into TLO in almost equal proportions during the three main airing periods: morning, midday, and afternoon, but listening patterns fluctuated by age group (Figure 16). This is important to note for future radio audience targeting. For example, women over age 60 may be least likely to listen to the radio in the mornings. Time of TLO listening may also have to do with radio station preference. Women over 60 are the most regular KNWK/Showers of Blessings listeners (Krosch, 2009) and that was the only station that aired TLO midday. Future radio campaigns should therefore take station preference and time of airing into account for optimal reach of specific target audiences. Figure 16: Time(s) of Day Listened to TLO 100%

% women

80%

60%

Afternoon 55

Midday

40% 20%

Morning 41

0% All

under 40

40‐49

50‐59

60+

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Figure 17: Language Listen to TLO

Both Samoan and English versions of TLO were produced. TLO was aired in Samoan on all three radio stations and in English and Samoan only on V103. Most listeners said they heard TLO in Samoan and English (Figure 17). This finding echoes previous research conducted by the American Samoa Community Cancer Network that found most adults prefer cancer information in English or in English and Samoan (Krosch, 2009). Interestingly, Figure 5 (page 11) showed us that less than 25% of all survey respondents recalled listening to V103 during the TLO airing period, but since this was the only station airing the English version of TLO this percentage may not reflect the actual audience size of this station.

125 100 # women

75 50 25

61%

Both English 5%

Samoan 34%

0 All

under 40 40‐49

50‐59

60+

Most health promotion communication campaigns aim to increase informal communication about the health issue. An unstated goal of TLO was to “get people talking” about breast cancer, especially intergenerational groups of females. Figure 18 reveals that this goal was partially achieved when 59% of listeners said they discussed TLO with others. Unfortunately, women in the main target audience—age 40‐59—were less likely than other age groups to discuss the show with others. Future communication campaigns targeting this age range should provide opportunities for women to discuss the health messages they receive via media by way of call‐in shows, or workplace and village‐based outreach promotions and events.

Figure 18: Discussed TLO with Others 125

# women

100

41%

75 no

yes

59%

25 0 All

under 40 40‐49

50‐59

60+

TLO was a first in several respects: first radio drama produced in the Territory; first known serial drama produced in both Samoan and English; and first radio show focusing on breast cancer prevention using an edutainment model. The extensive formative research, adherence to health communication methodology, and an extraordinary community contribution made TLO a success that was not lost on the audience when the large majority of listeners (94%) said they would like more radio programs like it (Figure 19). Future programs can build on the achievements of TLO and produce more and longer episodes, and target different populations in need of cancer information and behavior change.

Figure 19: Would Like More Radio Programs Like TLO 125

# women

100 75 50

94%

no yes

25 0 All

under 40 40‐49

50‐59

60+

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The stated goal of the TLO health promotion communication campaign was to convey health messages and encourage cancer‐related behavior change. Formative research and other studies have found a need for ongoing cancer education to overcome several misconceptions about the causes of cancer and effective treatment amongst American Samoans. TLO sought to begin to address the use of traditional Samoan healing as an alternative cancer treatment as opposed to complementary care for symptoms as well as fears and fatalistic attitudes. Further qualitative research is needed with listeners to determine what messages they received, if any, about the use of Samoan healing for cancer. Most TLO listeners (89%) said they learned something new about cancer from listening to the show but it is unknown what specifically listeners learned (Figure 20). But this large percentage appears to show that radio drama can be an effective means of educating this target audience about cancer. Figure 20: Learned Something New about Cancer from TLO 125 11%

# women

100 75 50

89%

yes

25 0 All

under 40 40‐49

50‐59

60+

TLO was written to convey several heath messages directly and subtly in the dialogue, plot and songs. Five key health messages (* noted below) were determined by Key Stakeholders, and 3 secondary/ complementary messages and the overall theme/title message were crafted by the project staff based on formative research findings . Table 3 shows which health messages TLO listeners recall receiving. Not surprisingly, the title message was clearly received by the majority of listeners in all age groups. Messages related to overcoming fears and the benefits of early screening and treatment were also frequently recalled. TLO listener focus groups should be conducted to ask unprompted message recall (What do you think were the main messages in TLO?).

Table 3: Health Messages Identified by TLO Listeners TLO Messages *Personal health should be a priority I only have one life so I should live healthy *Body changes might be symptoms of disease *Cancer is not a curse *Fear should not stop me from testing for cancer I have the ability to eat healthy and be active *If cancer is found early it can be treated or cured I am in control of my health Smoking is bad for my health Other message

Respondents who Identified Message All

< 40yrs

40‐49yrs

50‐59yrs

41%

(1) 62%

34%

38%

60+yrs 37%

(#1) 72%

(2) 61%

(1) 68%

(1)75%

(1) 79%

58%

50%

(3) 59%

48%

(1) 79%

37%

39%

32%

38%

42%

(#2) 59%

(3) 56%

(3) 59%

(3) 53%

(2) 74%

31%

39%

34%

23%

32%

(#3) 56%

(2) 61%

(2) 66%

50%

42%

46%

33%

39%

(3) 53%

47%

(#3) 56%

44%

56%

(2) 58%

(3) 58%

11%

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In addition to the health messages described above, TLO specifically encouraged women to adopt and/or maintain one key health behavior: regular screening for breast cancer. Short of monitoring actual screening numbers, our survey measured intention to screen. Intention to adopt an action (during the contemplation‐preparation stages) is an important step in behavior change as illustrated below.

Figure 23: Stages of Change Model 6 (Source: Prochaska and DiClemente in NCI, 2005)

Precontemplation

Contemplation

Preparation

Action

Maintenance

Figure 21 points out that 72% of all women surveyed said they planned to screen for breast cancer this year and 8% already had a CBE and/or mammogram in 2009. There is a noticeable 13% difference in intended behavior between TLO listeners and non‐listeners—77% of listeners compared to 64% of non‐listeners intended to screen for breast cancer this year (Figure 22). And slightly more non‐listeners (10%) said they had already screened compared to 8% of listeners. Further qualitative inquiry with TLO listeners is needed to determine if listening to the radio drama motivated their intention to screen for breast cancer and if intention resulted in actual screening actions. Figure 22: Plan to Screen for Breast Cancer this Year

Figure 21: Plan to Screen for Breast Cancer this Year 200 175 150

100% 18

20%

80%

% women

# women

19 7

125 no

100 75

already did

72%

yes

60% 40%

no 90

already did 46

20%

yes

0 All

under 40‐49 50‐59 40

60+

listeners

non‐listeners

The script writing team also applied the Stages of Change Model to all characters in TLO to chart their adoption or lack of adoption of key health behaviors in light of relevant barriers discovered in the formative research process. This helped to ensure that TLO characters were true to life and relatable to the target audience. Tasi le Ola radio drama process assessment & short‐term impact evaluation American Samoa Community Cancer Coalition ‐ Pacific‐CEED Legacy project, 2009 Sara Krosch & Vaioge Tuito’elau ‐ amsamccn@gmail.com

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Summary & Recommendations Process Assessment °

Although the TLO project achieved a high level of community participation, future endeavors should aim to actively involve more ASCCC members and key stakeholders in project planning, goal setting and evaluation.

Several new collaborations were achieved with organizations, government agencies and individuals. Partnerships should be sustained with entities that showed a commitment to the participatory process. Clearer communication and more cooperation is needed between the ASCCC and the BCCEDP to bridge the gap between health messages and service uptake.

Lehman’s model for planning and measuring community participation proved useful and should be consulted for future projects to ensure meaningful Stakeholder input and involvement. The model could be improved by adding a “monitoring and evaluation” category so these important tasks are also driven by the community’s needs. The Key Stakeholder Forum was well attended by a diverse group of individuals who were unfamiliar with the small group activities but who quickly produced detailed products. However, language translation and lack of mutual respect between traditional healers and health care providers posed some barriers to the participatory process. More formative research is needed to determine if text messaging is a viable method of health promotion communication for different populations in American Samoa. Reliable service provision would also need to be found. That said, women who did receive at least 1 text message about TLO were three times more likely to have listened to the show. Telephone surveys are ineffective in reaching a large enough sample for meaningful data analysis.

Short‐term Impact Evaluation ° ° °

Providing low‐cost incentive gifts to women to complete surveys improves response rates and ensures more complete data. TLO promotional items were also very popular with the target population. Pre‐ and post‐intervention surveys should be more similar to draw more meaningful impact conclusions. For example, the formative research survey asked about SBEs but not CBEs. Formative and impact evaluation surveys arrived at different numbers of women having ever had a mammogram in non‐random, convenience samples of similar size —ranging from 26% to 44%. Future research should attempt larger, random samples of women and compare findings to clinical data. Because the key health messages conveyed in TLO were determined by the formative research results and Stakeholder input midway through the project it was not possible to precisely determine all related knowledge levels, attitudes and behaviors pre‐intervention. The TLO project data can now serve as a baseline for future projects that involve community Stakeholders from the beginning in determining what new formative research questions need exploring. Behavior intentions are proxy measures for the more informative comparison of actual CBE and mammogram numbers before, during and after TLO airing. Longer term impact evaluation activities should compare breast cancer screening service utilization numbers noting recall of TLO listening as a motivating factor. This level of evaluation calls for access to clinical data and cooperation with LBJ and the BCCEDP. TLO listeners were more likely to be aware of local breast screening services and more likely to say they intended to screen for cancer but they were no more likely than non‐ listeners to have ever had a CBE or

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mammogram. This may be an indication that listening to TLO positively moved some women through the Stages of Change—from pre‐contemplation/contemplation stages to preparation. But barriers still exist to move women to action. Future projects should directly aim to uncover and alleviate these barriers. A serial drama was a new format in radio programming in American Samoa. It is unknown what percentage of the population clearly understood that TLO was a story divided into 5 parts. The most ideal airing schedule would be one episode aired per week, at least twice daily, over a five‐week period so listeners would most likely to hear all segments of the story. It is important to segment the audience as much as possible (by gender, age, education level, language, etc.) in order to not only understand their knowledge, attitudes and behaviors related to breast cancer but to also tailor a health communication campaign to that segment’s media habits. Follow the segmentation steps outlined on page 23 in Target Audience Analysis: Media Habits and Preferences (Krosch, 2009). Cancer education materials and media should be produced in both Samoan and English using a translation‐back‐translation method. Future edutainment projects should build in opportunities for the target audience to discuss the key health messages with others. A radio drama can be followed up with a radio call‐in show. Workplace or village‐based outreach activities can provide opportunities to gather ongoing feedback about the ease or difficulty of acting on health messages. The survey asked for prompted message recall (the messages were provided and respondents were asked which they recalled receiving from TLO). Unprompted message recall would provide deeper insights into what the target audience gained from the program. Ask listener focus groups questions such as “What was TLO about? What lessons/messages do you think TLO was trying to provide? What do you think about those messages?” Messages about being physically active, eating healthy and taking control of one’s own health had the lowest percentages of prompted recall. These messages should be stressed more in future cnacer prevention communication campaigns. Qualitative focus groups are needed to determine opinions about TLO and details about persistent screening barriers. Questions should include: - What TLO characters do the target audience most identify with? - Which characters have the most potential for spin‐off plots? - What does the target audience feel about the cliff‐hanger ending to TLO? How do they think/want the story to end or continue? - How did listeners respond to aspects of the plot concerning traditional Samoan healing as alternative treatment for cancer? - Which TLO episodes did most women hear and what did they like and not like about the series as a whole? - What other health, social and/or environmental issues could be woven into a continuation of TLO? - What specific new cancer information did women receive from TLO? - Why have only a third of women accessed local breast screening services when three quarters of women are aware of these services?

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Works Cited Drotner, Kristen. (2005) Media on the Move: personalized media and the transformation of publicness. Journal of Media Practice. 6:1. 53‐64. Fogg, B.J. (2007) Stanford Persuasive Technology Lab. Accessed August 19 http://credibility.stanford.edu/captology/notebook/archives.new/2007/06/7_categories_of.html Krosch, Sara. (2009) Target Audience Analysis: Media Habits and Preferences. The American Samoa Community Cancer Network. Available at www.sarakrosch.com Lehman, Karen. (1999) An Instrument to measure the level of Community participation in Community‐based Health Initiatives: a tool for participatory planning and process monitoring. Presented at Third Annual CCPH National Conference for healthier Communities and Campuses, Seattle, Washington, USA. March 27‐30. National Cancer Institute (NCI). (2005) Theory at a Glance: A Guide for Health Promotion Practice. U.S. Department of Health and Human Services. National Institutes of Health.

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