Impact of a mass media campaign on breast cancer symptoms awareness and screening uptake in Malaysia: findings from a quasi-experimental study

Objective To evaluate the impact of a mass media campaign in terms of improving breast cancer (BC) symptoms awareness and screening uptake. Design Before—and after—study with comparator groups. Setting Selangor State, Malaysia. Participants Malaysian women aged >40 years (n=676) from randomly selected households. Intervention A culturally adapted mass media campaign (TV, radio, print media and social media). Primary and secondary outcome measures The primary endpoint was BC symptoms awareness, which was assessed with the Breast Cancer Awareness Measure precampaign and postcampaign. Secondary outcomes included campaign reach, self-efficacy to notice BC symptoms and clinical outcomes. Clinical breast examination and mammogram screening data were collected from hospitals and clinics. Results Most participants recognised at least one of the campaign materials (65.2%). The odds of seeing the campaign were lowest for Chinese women (adjusted OR 0.25, 95% CI 0.15 to 0.40) compared with Malays and for women aged >70 years (adjusted OR 0.47, 95% CI 0.23 to 0.94) compared with younger women. Participants who recognised the campaign were significantly more likely to have improved awareness postcampaign compared with non-recognisers particularly for key symptoms such as ‘a lump or thickening in your breast’ (88.9% vs 62.1%) and ‘discharge or bleeding from nipple’ (79.7% vs 55.3%). Improvement in symptoms awareness scores was not associated with sociodemographic variables. Conclusions Implementation in Malaysia of an evidence-based mass media campaign from the UK that was culturally adapted appeared to lead to improved awareness about some BC symptoms, though various modes of media communication and perhaps other health education approaches may be required to extend the reach to diverse, multiethnic populations and all age groups.


GENERAL COMMENTS
I"m pleased to have the opportunity to review this manuscript. This is an important topic and I was hooked to read your paper. I strongly agree with the authors that it"s important to leverage mass media to educate the public and conduct rigorous evaluations of campaigns, especially in the context of multicultural societies. I"ve included my comments below, some of which are major recommendations while others are simply minor clarifications. I"ve organized these comments by manuscript section. Introduction: • I think this section is well organized and aligned to the research topic. It would be helpful to clarify the sentence "Particularly in settings where resources are limited and population-based cancer screening is unavailable, nation-wide education programmes are encouraged as a first step to improve early detection of breast cancer." I would think a high level of awareness may not be translated into more early detection cases if resources are limited or Methods: • It seems there"s an inconsistency about the campaign timeline between the main text and the appendix table 1. In the main text, campaign occurred from September -October but in the appendix table 1, campaign was from April -May. Related to the timeline, it would be helpful if the authors could also specify the time frame for data collection instead of saying "one-to-twelve weeks before-andafter implementation." With such information, readers can better assess the effectiveness of the intervention. (major) Results: • I think the results section was well written. My only question is that whether there"re any substantial differences between people who completed the post-measures versus those who didn"t. I saw the authors presented some information about this in Table 1 but it"s worth mentioning in the main text. (minor) Discussion: • The authors said "the high reach and improvement in symptoms awareness suggested that the campaign impacted successfully and achieved its primary objective." But results showed knowledge improvement was significant for only one comparison between recognisers and non-recognisers using the unprompted measures (i.e., a lump or thickening in your breast). Although there"s more evidence that recognisers improved their awareness and knowledge (prompted) compared with non-recognisers, this may be influenced by the sequence of questions (i.e., if aided recall was assessed before prompted awareness, then people may increase knowledge because of the survey exposure rather than campaign exposure). Also, as mentioned in the manuscript, there were other BC awareness activities going along with the BCAC campaign. The effects of knowledge/awareness improvement may be because of exposure to such activities or other factors (e.g., BC history, personal conversation about BC). With that being said, I think the authors need to be more careful about concluding that the campaign impact was successful. Some of the aforementioned points need to be addressed as limitations. (major)

VERSION 1 -AUTHOR RESPONSE
2. Reviewer 2 Introduction: I think this section is well organized and aligned to the research topic. It would be helpful to clarify the sentence "Particularly in settings where resources are limited and population-based cancer screening is unavailable, nation-wide education programmes are encouraged as a first step to improve early detection of breast cancer." I would think a high level of awareness may not be translated into more early detection cases if resources are limited or people have limited access to these medical services.
-We have rewritten the sentence to be more specific.
3. It would be helpful to add some contextual information for the current communication about breast cancer screening (e.g., move some of the discussion upfront

Methods:
It seems there"s an inconsistency about the campaign timeline between the main text and the appendix table 1. In the main text, campaign occurred from September -October but in the appendix table 1, campaign was from April -May. Related to the timeline, it would be helpful if the authors could also specify the time frame for data collection instead of saying "one-to-twelve weeks beforeand-after implementation." With such information, readers can better assess the effectiveness of the intervention. (major) -We have corrected the timeline in the appendix and also clarified the data collection timeframe in the methods section.

Results
: I think the results section was well written. My only question is that whether there"re any substantial differences between people who completed the post-measures versus those who didn"t. I saw the authors presented some information about this in Table 1 but it"s worth mentioning in the main text.
-Any significant differences between the pre-and post-study populations have been summarised at the end of "study population" in the results section.
6. Discussion: The authors said "the high reach and improvement in symptoms awareness suggested that the campaign impacted successfully and achieved its primary objective." But results showed knowledge improvement was significant for only one comparison between recognisers and non-recognisers using the unprompted measures (i.e. a lump or thickening in your breast). Although there"s more evidence that recognisers improved their awareness and knowledge (prompted) compared with nonrecognisers, this may be influenced by the sequence of questions (i.e., if aided recall was assessed before prompted awareness, then people may increase knowledge because of the survey exposure rather than campaign exposure). Also, as mentioned in the manuscript, there were other BC awareness activities going along with the BCAC campaign. The effects of knowledge/awareness improvement may be because of exposure to such activities or other factors (e.g., BC history, personal conversation about BC). With that being said, I think the authors need to be more careful about concluding that the campaign impact was successful. Some of the aforementioned points need to be addressed as limitations. (major) -Thank you, we very much appreciate your comments. We would like to highlight that both, campaign recognisers and non-recognisers were exposed to the same questions, that were asked in the same order. There are still significant differences between prompted awareness in recognisers and nonrecognisers. We have rephrased the sentence and emphasised the potential impact it had, and removed the term "success". We have included both points under limitations.

REVIEWER
Weijia Shi Hubbard School of Journalism and Mass Communication, University of Minnesota, US REVIEW RETURNED 04-May-2020

GENERAL COMMENTS
Thank you for addressing my concerns/suggestions. I think your research is interesting and useful for practitioners as well as researchers.