Sharing best practices for publicly communicating about breast cancer screening using a multidisciplinary workflow

Introduction

Applied health fields, including cancer prevention, have shifted greater resources and focus toward supporting community-led initiatives (CDC, 2013; Economos et al., 2013, 2023; Rechis et al., 2021). Community-led initiatives are favored because they align values between funders and beneficiaries and also promote a work process more likely to create programs that can be sustained in the long term. Furthermore, community-led initiatives reach populations that larger initiatives may miss, including those experiencing larger health burdens, due to their unique connections within their community and ability to foster trust (Giachello et al., 2019; Southwell, 2013).

Community-led initiatives present unique opportunities and challenges for health communication. The greatest opportunities are the ability to apply health communication strategies and tactics at scales smaller than a state or nation, which may offer opportunities for greater interpersonal collaboration and more customized messaging. This creates more flexibility and more uncertainty. Within community-led projects, it is challenging to disseminate health communication best practices to local partners across a wide range of potential message considerations.

Below, a pragmatic method for promoting collaboration among local health promotion teams and outside communication experts is described with information showing the effectiveness of such an approach. This case study reviews challenges in breast cancer screening and the positive outcomes of comprehensive interventions. The workflow for ensuring that health communication best practices reach community-led initiatives focused on breast cancer screening will be described. Communication dilemmas and solutions are discussed.

Breast cancer screening guidelines to address disparities

The United States Preventative Services Task Force (USPSTF) (2024) recently updated breast cancer screening guidelines to focus more explicitly on reducing disparate outcomes, with a particular emphasis on reducing the higher mortality rates for Black women (Nicholson et al., 2024). The task force estimates that the 5-year adjusted mortality rate of breast cancer for white women is 19.7 per 1,000 women, compared with the significantly higher rate for Black women (27.6 per 1,000 women). Evidence reviews suggest that a combination of social inequalities and a greater likelihood of developing hormonal-receptor negative tumors, which are more aggressive and harder to treat, drive much of the mortality gap (Nicholson et al., 2024).

In 2024, the USPSTF lowered the recommended age for universal, biennial mammography from 50 years to 40 (Nicholson et al., 2024). This was largely a response to consistent findings that more aggressive cancers are more likely to be diagnosed at younger ages, with the relationship between younger ages and aggressive subtypes of cancer being even stronger for Black women (Chen et al., 2023; Guzmán-Arocho et al., 2022).

Black women overall report the same or higher mammography rates as other racial groups yet experience greater mortality, which was partly why the age recommendation was lowered (Kim et al., 2019; Kim et al., 2022; Nicholson et al., 2024). However, reaching younger women for mammography poses unique challenges, and they remain underscreened (Gu et al., 2024). Against a backdrop of societal enthusiasm for cancer screening (Biller-Andorno and Jüni, 2014; Hoffmann and Del Mar, 2015; Mathioudakis et al., 2019), the gap between favorable attitudes and underscreening of women between ages 40 and 50 may best be explained by barriers that are inherent to being younger. Although the cost and lack of access to healthcare are issues for women across age groups, younger women of all races are more likely to report scheduling and work constraints (Gu et al., 2024; Zeballos Torrez et al., 2024).

In terms of addressing the issue of greater mortality for Black women, the USPSTF also emphasized that another meaningful driver of the morality gap in breast cancer outcomes is related to insufficient follow-up care across the continuum from prevention and early detection to treatment and survivorship (Nicholson et al., 2024). Each phase of the continuum, from prevention to survivorship, requires resources and knowledge of how to engage with complex healthcare systems. Even when women are screened initially with mammography, many may miss important follow-up steps without comprehensive support.

Comprehensive breast cancer prevention

The recommendations from the USPSTF, persistent disparities for Black women, and an interest in reaching younger women have led initiatives to embrace holistic approaches redressing layered factors driving the disparities in breast cancer mortality. These initiatives seek to connect women to screening and adequate follow-up care through comprehensive patient education and navigation and other clinic quality improvement measures.

A previous quality improvement project in New York City focused on under-resourced inner-city neighborhoods, which featured mammography mobile vans, education, patient navigation, and improvements in health technology, was able to increase the mobile mammography screening rate by more than 15% in a year (Bakhai et al., 2024). The Chicago Cancer Health Equity Collaborative (ChicagoCHEC), which started as a mission to reduce breast cancer disparities (Simon et al., 2016, 2019), has developed a long-running, multisector initiative that focuses on education, training, and healthcare quality improvement across health areas (Giachello et al., 2019). The ChicagoCHEC initiative, “Helping Her Live,” is illustrative of innovative approaches to reducing disparities in breast cancer specifically (Hunt et al., 2017; Simon et al., 2020). ^“Helping Her Live” embraced community health workers (CHWs) as primary health educators and patient navigators to meaningfully increase mammography rates among the most underserved communities in Chicago in coordination with local health providers (Hunt et al., 2017; Simon et al., 2020).

Collaborating among health communication professionals

CHWs, especially when recruited from within the communities they serve, can build trust and gain much greater influence to increase access to health services and redress social or economic barriers to care (Knowles et al., 2023; Zulu and Perry, 2021). For CHW certification, education and continuing education focuses on interpersonal communication. Most often, new CHWs are selected based on their aptitude at persuasion and communication, alongside their established connections in the community (Knowles et al., 2023; Zulu and Perry, 2021). However, much of community health work relies on a mix of true interpersonal communication with supporting materials (e.g., flyers, slide decks, telephone scripts, and websites). Local CHWs and healthcare providers often need support to maximize their supporting media materials.

In addition, within community-based programming, many community health workers are certified health education specialists (CHES®). CHES® professionals are guided by eight areas of responsibility, which include components such as needs assessment, planning, implementation, evaluation and research, advocacy, communication, leadership and management, and ethics and professionalism (National Commission for Health Education Credentialing, Inc., and Society for Public Health Education, Inc., 2020). The number of community health workers seeking certification has increased, more employers request the certification, and some national guidelines recommend hiring CHES® professionals specifically (CDC, 2011; National Commission for Health Education Credentialing, 2025).

As part of the certification process, CHES® professionals are taught communication competencies aligned closely with guidelines offered by the National Cancer Institute (2013). These competencies apply at the strategic level. Thus, although experts themselves, CHES® team members can still benefit from content area health communication expertise, especially when it comes to insights related to message design choices and effects.

Across complex health initiatives, there are too many decisions for any one expert to make alone. The intervention below, and projects within, offers a workflow for professionals to collaborate on complex communication challenges to improve health outcomes.

Intervention

Launched in 2023, the Texas Health Equity Alliance for Breast Cancer (THEAL) is a multisector collaborative focused on reducing breast cancer mortality gaps in Harris County, Texas (Houston), led by The University of Texas MD Anderson Cancer Center. THEAL is grounded in the principles of cross-sector collaboration, system strengthening, and aligned multilateral impact (Texas Health Equity Alliance for Breast Cancer. (n.d.)). THEAL was designed with inspiration from previous initiatives (UT MD Anderson, 2023). Through a governance structure that includes more than 20 organizations and multiple funding mechanisms, THEAL implements community-led projects regarding patient navigation, patient education, clinic-based quality improvement, provider and staff training, reducing structural barriers to care, and reducing patient out-of-pocket costs.

Health communication workflow

A unique feature of THEAL is its extensive partnership with a wide range of experts, including health communication experts. The University of Texas at Austin Center for Health Communication serves both in a leadership role within the initiative and provides opportunities for members of the alliance to learn about specific communication topics relevant to breast cancer prevention.

The Center for Health Communication is also funded to provide technical assistance and guidance to specific projects funded by THEAL. This agreement allows any funded project to reach out to the center for consultation on communication strategy and material production. The process was set up such that organizations that wanted to seek advice had minimal restrictions or requirements for participating. Both projects that used this health communication workflow chose to start with materials that were already drafted. Organizations reached out with an initial request through an intake form, and then they met with health communication experts. The initial meeting was one hour or less and focused on making sure that the health communication team understood the goals of the projects and challenges that they were facing. After the initial meeting, the health communication expert team provided written feedback on materials, including line-by-line suggested edits, alongside strategic reasoning and evidence utilized.

Projects seeking to address breast cancer disparities, including those in THEAL, face a myriad of challenges related to communication. By providing evidence-based technical assistance, the Center for Health Communication assisted groups with confronting two related challenges central to the goals of THEAL: (a) balancing appeals to fear and efficacy and (b) communicating health risks and disparities. In tackling these challenges, the Center embraces social-cognitive models of health behavior change, including reasoned action approaches as well as theories related to fear and risk.

The relationship between appeals to fear and self-efficacy

Fear appeals are among the most common, and well-theorized, strategies utilized in health communication. Major health campaigns, community health workers, healthcare providers, and everyday people often reach for fear appeals in attempts to motivate and persuade. A meta-analysis of message effects experiments studying fear appeals, which included almost 30,000 participants, showed that they were highly effective at influencing attitudes, intention, and behavior across a number of behavior categories, including detection and prevention (Tannenbaum et al., 2015).

However, health communication scholars and historians have long been concerned about the unintended effects of fear appeals, particularly over time. At the individual level, scholars have been concerned about overdoses of fear impeding self-efficacy and encouraging helplessness. This is a serious concern in cancer, where fatalistic beliefs are frequently endorsed by the public (U.S. Department of Health and Human Services, National Cancer Institute, 2024). Therefore, most theories of fear appeals recommend including efficacy statements (Tannenbaum et al., 2015; Witte, 1992, 1994). The meta-analysis also showed that efficacy statements moderated the effect sizes of fear appeals such that fear appeals have greater effects when paired with efficacy statements (Tannenbaum et al., 2015).

Recommendation regarding fear appeals and risk information

In considering the evidence that risk statements are effective, but are even more effective with appeals to efficacy, the Center for Health Communication advised projects to pair risk and efficacy statements. Appeals to both response efficacy (i.e., belief in the recommendation) and self-efficacy (i.e., belief in one's own abilities) were encouraged regarding mammography, breast self-exams, and the importance of talking to one's doctor about breast health. Subsequently, all project materials with stand-alone risk information were revised or removed from circulation. An example text message from one of the implementing projects illustrates the pairing: “Did you know? 1 in 8 women are diagnosed with breast cancer in their lifetime. Take control of your health! Schedule your preventative well woman exam today with [clinic] by calling 713-462-6565!” Another example comes from a voiceover for a social media video:

“Delays in screening and late diagnosis can lead to complications in treatment and higher mortality rates, especially seen among women of color. The good news is that early detection of breast cancer can mean more treatment options, so speak up and talk to your healthcare team about what screening options are best for you.”

Communicating about health risks and disparities

Helping audiences internalize threats presented by health risk is an essential function of health communication (Tannenbaum et al., 2015; Witte, 1992, 1994). However, overloading individuals with cancer risk information may lead to feelings of helplessness, instead of spurring behavior change. A meta-analysis of 100 studies with 115,043 participants around the world found that cancer fatalism is negatively associated with self-efficacy and cancer detection intentions and positively associated with information avoidance (Chen and Kim, 2024).

Fatalism may further be compounded for individuals who identify with social groups that experience health disparities (Cunningham et al., 2019). The issues surrounding communication about disparities are complex. Considering the theoretical risk that emphasizing disparities to individuals will discourage self-efficacy, alongside limited but consistent evidence (Nicholson et al., 2008), some communication scholars have suggested that disparities framing should be used cautiously. Specifically, disparities framing is likely most useful in communication about policy and systems change, but have many unintended consequences when communicating to individuals, the general public, and affected groups (Liu and Niederdeppe, 2024; Niederdeppe et al., 2013). Concerned about the unintended effects of disparities framing, Nicholson et al. (2008) tested two alternate frames to discuss cancer outcomes for Black Americans in the context of colorectal cancer screening. The “impact” frame pointed out the high risk for Black Americans but removed comparisons with other groups, and “progress” framing emphasized improvements over time. The “progress” framing performed best, followed by “impact” framing. Disparity framing performed poorly.

Recommendation regarding communicating disparities

In response to the evidence surrounding fatalism and disparities communication, the health communication suggested embracing progress framing for both projects. See Table 1 for a comparison of changes. For both projects, it was agreed that both framing types would be tested in the beginning. After some initial pilot testing, both implementing projects reported that their clients had a consistent preference for progress framing.

Table 1. Comparing frames for discussing cancer outcomes by race.

All disparity frames are original messages from projects, and progress frames are suggested revisions from the Center for Health Communication.

Implementation and results

Two healthcare organizations, one federally qualified health center (FQHC) and an academic health center, were funded to execute comprehensive breast cancer screening and clinic quality improvement interventions through THEAL.

UTHealth Houston

UT Physicians, the clinical practice plan of the UTHealth Houston McGovern Medical School, includes a network of community-based clinics and has a unique ability to pursue quality improvement projects. UT Physicians employs over 2,000 clinicians, has 100 + locations across the greater Houston area, and provides multispecialty care to 2 million unique patients annually. The Healthcare Transformation Initiatives Department implements research and quality improvement projects aimed at increasing access to primary and specialty care, improving the effectiveness and efficiency of care, and reducing healthcare costs.

With support from THEAL, UTHealth Houston implemented a comprehensive multicomponent quality improvement project focused on bridging data gaps related to breast cancer screening results and provider notification. One component of improving breast cancer screening rates included a patient navigation intervention to contact Black women who had never had a mammography or were due or overdue on mammography based on the electronic health record. The intervention focused on two community-based clinics performing lower than the organizational benchmark.

CHESs incorporated the components of motivational interviewing and adapted a telephone intervention from the “Breast Cancer Screening Consortium Mammography Telephone Counseling Protocol” produced by the Duke Cancer Prevention and Kaiser Foundation Health Plan of NC (NCI, n.d.). CHESs modified the language to make it more culturally relevant to the target population and easy to navigate while contacting patients on the phone, in consultation with the Center for Health Communication.

Outcomes

For the patient navigation component of the project, UTHealth Houston reached 130 Black women patients and used the modified phone script with 101 women. Patients were either navigated to resources, assisted with scheduling of mammogram appointments, or assisted with updated orders or sharing results in the electronic health record. A review of the EHR showed that 46 Black women who had never been screened or were behind on their screening schedule completed their mammogram with a success rate of 45.54%.

Spring Branch Community Health Center

The Spring Branch Community Health Center (SBCHC) is a private, non-profit community health center providing medical care, behavioral health, and dental care to both children and adults. The SBCHC has been designated an FQHC since 2003, with seven locations, two mobile health units, and a school-based facility. They serve many designated Medically Underserved Areas, with mammography screening rates as low as 36%, below the state-wide and national averages.

For the fiscal year 2025, the SBCHC undertook a quality improvement project with the primary objective of navigating 250 women to mammography services. Within the project, several interventions were utilized, including supporting a community health director to lead training of five CHWs, implementing a provider recall system, and implementing a patient reminder system. CHWs were trained through the Leadership in Oncology Navigation program provided by the American Cancer Society. The health system hosted 11 community events and more than 30 clinic events to promote screening. They also audited and updated all their health promotion materials related to breast health with support from the Center for Health Communication.

Outcomes

Through fiscal year 2025, the SBCHC reached a total of 1,648 women in Houston in breast cancer screening and reported that 535 mammograms were completed out of 811 total scheduled appointments, a 65% success rate (compared with 52.97% at baseline). For their text message reminder service, they reported that 1,711 out of 9,630 texts were opened. They reduced their no-show rate from 14% to 9.8%.

Discussion

As applied health fields seek to embrace community-led interventions across the cancer care continuum, there is a greater need to diffuse specialized knowledge related to health communication and clinical practice. Within complex initiatives, there are often too many strategic communication decisions for any single health professional to determine on their own. Health communication knowledge related to persuasion and materials production is particularly crucial. This case study showcases a workflow for disseminating health communication best practices in two different clinical settings and contexts.

Two mammography projects implemented through UT MD Anderson's Texas Health Equity Alliance for Breast Cancer were case studies in how multidisciplinary teams can collaborate to ensure that insights from health communication research are utilized by local teams. In this workflow, local health professionals working in clinics, including CHWs and CHES, collaborated with The University of Texas at Austin Center for Health Communication and received written feedback on materials produced.

The most common issues groups consulted health communication experts about concerned patient education content. Specifically, groups sought advice on how best to communicate about disparities and risk without damaging self-efficacy or encouraging fatalism. The health communication group recommended that risk information always be presented with efficacy statements and calls to action. As such, materials without efficacy statements were revised or removed, including social media graphics, video scripts, and telephone scripts.

The health communication group also recommended to both projects a shift from “disparity” to “progress” frames when discussing breast cancer disparities and to never present risk information without accompanying efficacy statements and calls to action. Both projects chose to follow this advice. Explicit discussion of disparities remains an invaluable tool for program planning and advocacy, but it is not always the best tool for promoting behavior change at the individual level (Liu and Niederdeppe, 2024; Nicholson et al., 2008; Niederdeppe et al., 2013).

Both projects drove greater numbers of completed mammograms. Spring Branch Community Health Center, a federally qualified health center, was able to exceed its mammography goal by more than double by utilizing a mix of patient navigation, health promotion on social media, text-message reminders, and community events.

UTHealth Houston employed a multilevel approach: systems-level reminders that reached thousands of eligible women and tailored navigation for Black women at two selected clinics. The tailored navigation intervention was able to navigate 101 women who had never completed breast cancer screening or were behind on their screening schedule to resources they needed, and it reported that 46 mammograms were completed. Both projects achieved success rates similar to mammography interventions implemented by ChicagoCHEC (Simon et al., 2020).

Teams reported similar strategic dilemmas, despite using very different channels to reach women at risk. Both projects showcase that health communication insights apply to messages of varying length and complexity. Health communication insights can be applied to materials made for public consumption through social media, newsletters, or other channels and also to materials that support interpersonal communicators such as interview guides.

These projects contained many components that operate outside of health communication and education. Both groups completed significant data quality interventions and embraced new reminder systems. These likely had significant impacts on mammography rates as well. Furthermore, with patient navigation interventions, there is a component of persuasion, but often, the biggest drivers of impacts are connecting patients to resources that they need, including finding no-cost or low-cost services. Any conclusions drawn about the impact of persuasive message strategy from this initiative should consider that many evidence-based interventions were deployed.

Health communication is meant to serve as a catalyst of “system activation,” thus spurring on multiple change factors at different socioecological levels (Hornik, 2002; Love et al., 2024). Therefore, it is reasonable to conclude that strategic collaboration on several health communication issues likely contributed to overall project success. Furthermore, each group reported that the communication advice that they were given helped improve their project's impact significantly.

The emphasis on holistic, multicomponent projects to address the mortality gaps in breast cancer is a welcome development for their increased efficacy. However, the nature of these initiatives makes evaluating the specific impact of subcomponents and separate strategies difficult, if not impossible. This is a common challenge in long-running, comprehensive health campaigns and programming (Hornik, 2002; Love et al., 2024).

Real-world evidence from a comprehensive breast cancer initiative to reduce mortality gaps shows that health communication advice can be embedded into clinical practice to improve health outcomes. A strategic adviser workflow, where health professionals and health communication experts collaborate on complex challenges, should be replicated by other initiatives.

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Footnotes

Edited by: Julie E. Volkman, Bryant University, United States

Reviewed by: Kristin L. Gosselink, Burrell College of Osteopathic Medicine, United States

Rebecca Selove, Tennessee State University, United States