A breast cancer diagnosis can be life-changing. That’s rarely been truer than in the case of Judith Fletcher-Brown, Senior Lecturer in Marketing and Sales at the University of Portsmouth.
Judith’s diagnosis came in 2010. Following a mastectomy, Judith’s sister took her on holiday to India.
“It was a sort of recuperation, but as a reward, something to look forward to.”
In India, Judith had a revelation. She asked herself a question that has set in motion a chain of events which may end up saving tens of thousands of lives every year.
“India is such a complex country,” Judith explains. “It’s got everything – wealth, extreme poverty, amazing high-rise buildings and people living in shacks in the middle of motorways.
“But it struck me – what happens to that woman going into that office block, what happens to that women out in that field, if she gets breast cancer?”
The answers were chilling.
India is outstripping China to be the number one economy in 2020. Not a lot of the money being injected into India’s economy is finding its way into the health service. There is no focus at all on women’s healthcare. Breast cancer is still a taboo. There is a huge lack of awareness. Women don’t know the signs, they can’t spot the signs, they don’t know how to self-examine.
Judith learned that the survival rate for Indian women is only about 50 per cent - and India has the fastest growing incidence-rate of breast cancer in the world. By 2020, it is forecast that 76,000 women in India could die from breast cancer every year.
This rising rate is linked to India’s rapid economic development. As the economy booms, more women pursue careers. This leads to what Judith terms their “Westernisation.”
Urban Indian women who work start having sex later, have fewer children and breastfeed them less than their rural counterparts. They also tend to eat a more Western diet, which leads to obesity. All of these factors increase the risk of breast cancer.
That explains the rise in incidents, but not the mortality rate.
As Judith says: “I’m a living example that if it’s caught early enough, nobody needs to die. So I delved a little deeper, and found a whole host of reasons.”
This rising rate is linked to India’s rapid economic development. As the economy booms, more women pursue careers. This leads to what Judith terms their “Westernisation.”
Urban Indian women who work start having sex later, have fewer children and breastfeed them less than their rural counterparts. They also tend to eat a more Western diet, which leads to obesity. All of these factors increase the risk of breast cancer.
That explains the rise in incidents, but not the mortality rate.
As Judith says: “I’m a living example that if it’s caught early enough, nobody needs to die. So I delved a little deeper, and found a whole host of reasons.”
Marketing the key
You might expect a booming economy to go hand-in-hand with longer life expectancy.
“India is outstripping China. It’s going to be the number one economy in 2020,” Judith notes. “You’ve got a lot of Western firms internationalising there, but not a lot of the money being injected into India’s economy is finding its way into the health service. There is no focus at all on women’s healthcare.”
But there’s an even bigger challenge than lack of funding.
“The biggest problem is cultural. Breast cancer is still a taboo. There is a huge lack of awareness. Women don’t know the signs, they can’t spot the signs, they don’t know how to self-examine.”
Judith believes that social marketing could be part of the answer:
“Social marketing is all about intervention messages. It’s moving someone from a negative type of behaviour into a more positive behaviour.
Our research showed lack of awareness was a problem, so we were looking for a sustainable strategy that makes breast examination normal … normal for wives and husbands, mothers and sons, boyfriends and girlfriends to talk about it.
“It aligns very well with health and well-being - stopping someone smoking, or driving too fast. For example, if we can stop people in the UK having too much sugar, our Type 2 diabetes rate, which costs the NHS billions, goes down. So social marketing is really important.”
The crux of social marketing is understanding why people behave in a certain way. Then you can work out how to influence their way of thinking about an issue, and so their behaviour.
“When you’re looking at intervention and normalising behaviour patterns, marketing is the way to do it. You have to understand the people and have the right messages.”
This is where social marketing in India poses particular challenges.
“Think about it in terms of the UK. If the Government wants to stop people smoking, they can do a massive campaign that looks the same to everybody in the country.
“But in India, it’s complex. There are over a billion people in 29 states, and they’re all different. It’s too costly to have so many different campaigns in different dialects. Plus you’re talking about the female body, which is taboo.”
Judith’s research made the challenge clear:
“Our research showed lack of awareness was a problem, so we were looking for a sustainable strategy that makes breast examination normal … normal for wives and husbands, mothers and sons, boyfriends and girlfriends to talk about it.
“And we needed buy-in at every level. Hospitals, schools, universities, and the government – they should all be normalising the message. And obviously it also needs to be done at the micro level, the individual.”
The next question was, where to start?
The crux of social marketing is understanding why people behave in a certain way. Then you can work out how to influence their way of thinking about an issue, and so their behaviour.
“When you’re looking at intervention and normalising behaviour patterns, marketing is the way to do it. You have to understand the people and have the right messages.”
This is where social marketing in India poses particular challenges.
“Think about it in terms of the UK. If the Government wants to stop people smoking, they can do a massive campaign that looks the same to everybody in the country.
“But in India, it’s complex. There are over a billion people in 29 states, and they’re all different. It’s too costly to have so many different campaigns in different dialects. Plus you’re talking about the female body, which is taboo.”
Judith’s research made the challenge clear:
“Our research showed lack of awareness was a problem, so we were looking for a sustainable strategy that makes breast examination normal … normal for wives and husbands, mothers and sons, boyfriends and girlfriends to talk about it.
“And we needed buy-in at every level. Hospitals, schools, universities, and the government – they should all be normalising the message. And obviously it also needs to be done at the micro level, the individual.”
The next question was, where to start?
Culture challenge
Back in India, at a conference, Judith was about to find out first-hand just how complex the challenge of breaking down barriers could be.
“Some Indian women who fitted the demographic agreed to come and talk to me about breast cancer and what it’s like being a woman in India. I’d told them that I had experienced it myself, so they knew where I was coming from.
“I set up a room and got everything there I needed to collect the data. And nobody turned up. Not one woman. None. I thought, ‘My God, what am I going to do now?’”
I set up a room and got everything there I needed to collect the data. And nobody turned up. Not one woman. None. I thought, ‘My God, what am I going to do now?
On returning home to the UK, Judith emailed the women individually and asked what had happened. Their responses were illuminating.
“They wanted to come, but they didn’t want to talk about such a sensitive thing with a stranger. Others said they had thought about it and decided their husband wouldn’t want them to come.
“They wanted to come, but they didn’t want to talk about such a sensitive thing with a stranger. Others said they had thought about it and decided their husband wouldn’t want them to come.
I suggested we just have a dialogue by email and they did open up to a degree. Not a lot, but enough to establish that they might talk to their mother or mother-in-law but not their husband or son. You can see why there is such lack of awareness.
“So I suggested we just have a dialogue by email and they did open up to a degree. Not a lot, but enough to establish that they might talk to their mother or mother-in-law but not their husband or son.
“You can see why there is such lack of awareness.”
However, speaking to medical professionals at an Indian hospital, Judith had a breakthrough. She realised that there was a small group of women who could change everything. In fact, these women are already making big changes happen in Indian healthcare.
“You can see why there is such lack of awareness.”
However, speaking to medical professionals at an Indian hospital, Judith had a breakthrough. She realised that there was a small group of women who could change everything. In fact, these women are already making big changes happen in Indian healthcare.
Breaking through barriers
Judith witnessed whole families coming to a hospital as a group – mum and dad and kids together. They were on their way to innovative clinics with a focus on family wellness.
It showed there were people starting to think, actually, it’s okay to go and get checked out together, and a door to breaking down gender-oriented taboos was being eased ajar. Through this crack, Judith could see the women responsible.
They are known as ASHAs (Accredited Social Health Activists) and they run the family clinics. They are, essentially, community nurses.
“They go out into people’s homes and they’re almost like the frontline of medicine and healthcare. They’ve got a big remit, and part of it is about prevention.”
In India, it’s complex. There are over a billion people in 29 states, and they’re all different. It’s too costly to have so many different campaigns in different dialects. Plus you’re talking about the female body, which is taboo.
Judith’s contacts in the medical professions agreed that ASHAs were the conduit to making change happen.
“We discovered in our research that the ASHAs have the trust of the families, of the menfolk.”
Having established this as a potential breakthrough, Judith began exploring the next steps to take.
That way forward, which would open up a whole new avenue of research and innovation, presented itself over a casual coffee.
“We discovered in our research that the ASHAs have the trust of the families, of the menfolk.”
Having established this as a potential breakthrough, Judith began exploring the next steps to take.
That way forward, which would open up a whole new avenue of research and innovation, presented itself over a casual coffee.
Gaming messenger
Thinking about India’s strengths, Judith realised that there is massive investment, and a broad skills base, in IT.
Of particular importance, most families have a mobile phone.
This led her to the idea of utilising mobile health, or mHealth.
“We’ve moved from eHealth, which is all about disseminating information via a website. Now it’s mobile health using apps. So the message can get a lot closer. Also, mHealth is being promoted by the World Health Organisation.”
Back in Portsmouth, Judith was having coffee with her friend Diane Carter, Academic Skills Tutor in the University’s Faculty of Cultural and Creative Industries. Diane agreed to come on board the project. This interdisciplinary collaboration was a game-changer for Judith’s research.
mHealth is being promoted by the World Health Organisation. We’ve moved from eHealth, which is all about disseminating information via a website. Now it’s mobile health using apps. So the message can get a lot closer.
“I needed someone who would know all about the capabilities and possibilities, and what sort of things can be constructed.”
Judith and Diane came up with a conceptual model for an mHealth solution to India’s breast cancer crisis.
The idea is to equip ASHAs with a digital device, probably a tablet, enhanced with computer gaming technology.
“On the device, we’ll produce something which enables them to go out with all the information about self-examination. It might even have more biological information, maybe 3D effects, so they can show what’s happening in the breast and signs to look out for.
“We want the ASHAs to be the first contact, so they need to be in at the creation of the app. We have the concept. The next thing is to go to India and get feedback from the ASHAs and the women they support.”
Judith is clear about the potential of this concept.
“It will empower women. They’ll know what to do, how to do it, and where to go for help.”
Judith and Diane came up with a conceptual model for an mHealth solution to India’s breast cancer crisis.
The idea is to equip ASHAs with a digital device, probably a tablet, enhanced with computer gaming technology.
“On the device, we’ll produce something which enables them to go out with all the information about self-examination. It might even have more biological information, maybe 3D effects, so they can show what’s happening in the breast and signs to look out for.
“We want the ASHAs to be the first contact, so they need to be in at the creation of the app. We have the concept. The next thing is to go to India and get feedback from the ASHAs and the women they support.”
Judith is clear about the potential of this concept.
“It will empower women. They’ll know what to do, how to do it, and where to go for help.”
Real-world research
Judith has big ambitions for her research. After all, it’s a matter of life and death. And it has personal resonance.
“I’d like to see mortality rates decline, and if the model works I’d like it to be transferred to other similar hotspots… Brazil and South America generally. It seems to be the pattern where economies develop too quickly for support infrastructure, such as healthcare, to cope.”
Judith has huge drive, and believes this may be partly due to coming to research after having already built a career and a family.
I’d like to see mortality rates decline, and if the model works I’d like it to be transferred to other similar hotspots… Brazil and South America generally. It seems to be the pattern where economies develop too quickly for support infrastructure, such as healthcare, to cope.
“Portsmouth has given me this opportunity to start my research career, and has been very open to the different angle I’ve brought to our marketing subject.
“We’re starting an undergraduate module in social marketing, which will have research-led teaching. It’s a really exciting development. The idea is to get students thinking about how marketing can be used in ways other than just selling and packaging products.
“Marketing can actually be really useful in society.”
Judith Fletcher-Brown is the epitome of a University of Portsmouth researcher. Driven to make a difference, open to the wider world, and with a personal passion for what she does.
“We’re starting an undergraduate module in social marketing, which will have research-led teaching. It’s a really exciting development. The idea is to get students thinking about how marketing can be used in ways other than just selling and packaging products.
“Marketing can actually be really useful in society.”
Judith Fletcher-Brown is the epitome of a University of Portsmouth researcher. Driven to make a difference, open to the wider world, and with a personal passion for what she does.