BREAST cancer is the most common cancer affecting women in Australia and alcohol accounts for 10% of diagnoses. Alcohol is a Class-1 carcinogen. However, we live in an “alcogenic” society in Australia where alcohol is everywhere.
Australian midlife women (45–64 years) are drinking more alcohol than ever before – more than previous generations of women in this stage of life, and more than any other age group of women currently. Alcohol, combined with their age, puts midlife women at increased risk of breast cancer.
Ironically, this risk of harm from alcohol “competes” with how alcohol provides women with a form of stress relief and self-care – sometimes within a limited range of options – that is socially acceptable within our alcohol-saturated society.
With the various “positives of alcohol” in view, women do not necessarily see their drinking as a problem to be fixed. Even if they are aware of the message that alcohol causes breast cancer (and not many midlife women are aware), they may accept their risk of breast cancer because alcohol plays such an important role in their lives (as a source of pleasure or a coping mechanism) and is not something they want to (or feel that they can) give up or even reduce.
Where does this leave GPs and health professionals, who have a critical role in increasing women’s awareness of modifiable breast cancer risk factors such as alcohol use?
Women need accurate and appropriate risk communication delivered through reliable channels such as their health care provider. Alcohol as a modifiable risk factor for breast cancer has received less attention than others in Australian campaigns aimed at prevention. Social contexts, generally involving alcohol in Australia, and widely accepted social norms surrounding alcohol use, as well as misleading information about the health risks of alcohol resulting from the alcohol industry “pink washing” alcohol products, cause women to feel confused about breast cancer and alcohol risk messaging.
Our recent study published in PLOS One found women want information on alcohol and breast cancer risk. They think that if knowledge became more common, risk messages may not be rejected; as study participant “Abigail” says:
“I think sometimes the more information comes out or the more it’s repeated, the more it becomes common knowledge for people rather than easily dismissed.”
Health care providers, as trusted sources of information, are a well placed and sometimes the only health promotion information source, and can help women judge new information about alcohol and breast cancer risk.
Our study involved interviewing 50 South Australian women from different social classes (affluent, middle and working), who drink alcohol and with no previous breast cancer diagnosis. We asked how they access information specific to breast cancer risk as it relates to alcohol and how they determined whether or not such information is trustworthy.
Generally, when women have positive perceptions of the competence, knowledge and skills of those delivering the message – such as a familiar health care provider who knows their patient history – the message is more likely to be seen as being in their best interest and is taken up.
The approach health care providers use and the style of message delivery has important implications for women’s acceptance of the alcohol and breast cancer risk message. Prevention messaging will not always be suitable for every woman or in all instances, particularly when alcohol is used as a coping mechanism. In such cases, the message that alcohol causes breast cancer, even if known, may be hard for some women to hear without feeling blamed.
We found the alcohol and breast cancer risk messages women look to, and trust, vary according to the social, cultural and economic resources they can access. This impacts their reasons for consuming alcohol, their ability to make reductions, and also women’s acceptance of risk messaging – offering clues to health providers in how to deliver the message that alcohol causes breast cancer.
Women living with more privilege are more likely to question the source of information before deciding whether to trust the message. They use “common sense” or a “gut feeling” to discern the trustworthiness of the message and this had an impact on interest in the message.
For example, when describing what influences trust in prevention messaging, “Lois” (middle class) said:
“If they’re trying to push a certain point of view without having any basis or back-up for that rather than someone being even-minded [and] even-handed about things … it’s also what sources they site, I’d certainly be interested in that.”
For delivering messages to women like Lois, health care providers require up-to-date information about breast cancer prevention and alcohol reduction, delivered from sources women told us they felt were reliable.
Advantaged women expressed feeling distrusting of information provided by entities they felt had competing institutional objectives (ie, making money versus supporting public health outcomes), offering pharmaceutical companies as an example.
The most affluent women were clear about who they distrusted as a source of breast cancer prevention information, like “Laureen”, who said she distrusted news media because of interests in advertising profits. She preferred reputable information sources such as women’s health organisations, but added that she felt a personal anecdote gave credibility to the message:
“I’d be more inclined to take notice of a women’s health organisation promotion and/or a breast cancer support organisation than some media outlet that’s purely and simply news.com, just because of advertising. I’m not a big fan of advertising and a lot of the time if I see something advertised, I’ll be averse to it rather than inclined to take it on … Sometimes and mostly … I’d rather a personal story. I’d rather something biographical than advertising a product or produced by somebody who’s got something to sell”
Instead, they trusted information from social institutions and used universities, publicly funded hospitals, and the Cancer Council as examples of such trusted sources because, as one participant said, they are “in the business of public health”. For example, “Anna” (affluent) said:
“I think if there’s something that’s actually researched and usually if it says [a medical centre] or it has the research name behind it that you recognise from another hospital, then you do … I think you probably do tend to believe it and if you see that someone else is quoting the research from that base.”
But affluent women also do not want to have the reasons for their alcohol consumption overlooked and they require “even-minded” approaches to message delivery that account for the social and emotional contexts of drinking, such as to ease the struggle with multiple caring responsibilities or menopause symptoms that disrupt sleep and unsettle mood.
The most advantaged women thought information was trustworthy based on the credentials and believability of the individual “expert” (their health care provider), as well as on the basis of the organisation providing the message (specifically, if the message contained “scientific terminology”).
Women living with disadvantage were more likely to take information with a “pinch of salt”. They were skeptical of information (even if it was based on research) and described needing time to accept information and to judge it as trustworthy. For example, “Joanne” (working class) felt that even research evidence could be skewed to serve different interests:
“Well, I know there’s been various research done, but I have to admit I tend to be rather sceptical about certain research because my understanding and experience and things I’m aware of is that it often depends on how it’s done. It depends on how it’s analysed and things can be found that really say ‘oh, yes, this is what’ – and then someone will come along and ‘no, it’s not like that at all,’ so I am a little bit sceptical.”
Working class women spoke about trust in messaging only at the systems level – trusting in messages based on “evidence” (described in broad terms) and being careful of “trends” or “fads”. Unlike affluent or middle-class women, working class women seemed to start from a default position of distrust when hearing a risk message (their skepticism is clear in our data).
These women require alcohol and breast cancer risk messaging that is gradually provided allowing time for judgements and trust to establish. The best approach for communicating risks may not be within a one-on-one consult (although this would work for women in affluent or middle classes) but rather building trust by providing women with the tools to critically evaluate and form their own health decisions within their capacities is needed.
Working class women were the most likely to consume alcohol to cope with life’s difficulties and with few alternative options for achieving wellness. They require that health care providers are aware of these limitations and that a standard message to reduce consumption may be complicated in the absence of other social supports.
These evidence-based ideas give clues for tailored approaches to messaging for different women, with the potential to increase all women’s knowledge of and the likelihood they are capable of accepting the message that alcohol causes breast cancer. It could improve social inequities in breast cancer risk and prevention efforts.
Dr Belinda Lunnay is a Post-Doctoral Researcher at the Research Centre for Public Health, Equity and Human Flourishing at Torrens University in Adelaide.
Associate Professor Samantha Meyer is with the School of Public Health Sciences at the University of Waterloo in Waterloo, Canada.
Professor Paul Ward is Director of the Research Centre for Public Health, Equity and Human Flourishing at Torrens University in Adelaide.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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