Identify and discuss both a successful social marketing effort and an effort that has not been successful.

Identify and discuss both a successful social marketing effort and an effort that has not been successful. What might be the reason for success on the one hand and lack of success on the other in these cases?The article below discusses the use of social marketing as it related to Breast Cancer AwarenessTo receive full credit, the exercise assignment must be 1-2 pages, respond to all areas of the assignment, follow APA guidelines, and include at least one reference.INTRODUCTIONThe global disease burden posed by cancer is increasing at an alarmingpace. At its current pace, cancer could become a global pandemic in notime. According to International Research on Cancer (2013), an estimated 14.1 million new cancer cases and 8.2 million cancer‐relateddeaths occurred in 2012 worldwide, compared with 12.7 million and7.6 million respectively in 2008. This has made the cancer menacethe leading cause of death, causing more deaths than HIV/AIDS, tuberculosis, and malaria put together (American Cancer Society [ACS],2015; Ferlay et al., 2014). Among the cancerous diseases, breast cancer is the second most common cancer of all the cancers diagnosedin 2012 and ranks fifth as cause of death (Ferlay et al., 2014). Breastcancer is the most common cancer among women globally, accountingfor 25% of all new cancer cases in women (ACS, 2015). More than half(53%) of the new cases of breast cancer and deaths (58%) occurred indeveloping countries (ACS, 2015; De Martel et al., 2012). The sharpincrease in breast cancer incidence in developing countries is mainlyattributed to changes in reproductive patterns, increase in obesity,and physical inactivity (Dey, Mishra, Govil, & Dhillon, 2015).In Ghana, the incidence and mortality of breast cancer are on therise as 2,900 cases and 1,450 deaths were recorded in 2012 (Ministryof Health [MoH], 2012). The high incident–mortality ratio is attributedto the fact that over 70% of breast cancer patients seek medical attention after the disease has reached an advanced stage (MoH, 2012). Toreverse the current trend of breast cancer in Ghana, there is the needto determine how social marketing intervention programme (SMIP) canbe used to influence the behaviour of Ghanaian women towards theirparticipation in breast screening and other prevention activities. SMIPsare more successful when they are grounded in the appropriate healthbehaviour change models (Andreasen, 1994; Fraze, Rivera‐Trudeau, &McElroy, 2007). The extant literature indicated that in Ghana, the limited numbers of research carried out on social marketing (SM) haveconcentrated mostly on HIV/AIDS (Adu‐Mireku, 2003; Tweneboah‐Koduah & Owusu‐Frimpong, 2013), contraceptives, and condom use(Addai, 1999; Tawiah, 1997), alcohol and drug use (Doku, Koivusilta,& Rimpelä, 2012), and malaria (Tweneboah‐Koduah, Braimah, & Otuo,2012). Thus, researchers have focus little attention on SMIPs on breastcancer prevention. The current study therefore seeks to understandhow SIMPs could utilize the health belief model (HBM) to preventthe spread of breast cancer among women in Ghana.2 | SM INTERVENTIONS ON BREASTCANCERIn Ghana, several organizations (Breast Care International [BCI], Ministry of Health, Pink for Africa, the Cancer Society of Ghana, and theNational Coalition for Cancer in USA) have embarked on SMIPs to curbthe breast cancer menace. For instance, BCI has engaged in severalSMIPs such as walk for cure, drug donation, community breast healthpromoters training, peer navigation training, training nurses on basiconcology, and community outreach programmes (BCI, 2015). Theseprogrammes were mainly to change the behaviour of Ghanaian womenReceived: 2 June 2016 Revised: 1 December 2016 Accepted: 6 February 2018DOI: 10.1002/nvsm.1613Int J Nonprofit Volunt Sect Mark. 2018;23:e1613.https://doi.org/10.1002/nvsm.1613wileyonlinelibrary.com/journal/nvsm Copyright © 2018 John Wiley & Sons, Ltd. 1 of 7by creating awareness on breast cancer and encouraging women toundertake regular self and clinical examination as well as seek earlytreatment. Irrespective of the various SMIPs on breast cancer inGhana, incident and mortality rates among women have been increasing consistently over the years (MoH, 2012). This has resulted in thegovernment spending huge sums of money on breast cancer‐relatedactivities instead of other productive sectors of the economy.3 | LITERATURE REVIEWApplication of behavioural change model to SM is necessary to influence, modify, or change peoples’ attitude towards the breast cancerdisease. This is because many social and health issues have behaviouralcauses and because the main objective of SM is to influence humanbehaviour; its application provides a better strategy for promotingand improving health and well‐being (McDermott, Stead, & Hastings,2005). SM is the application of marketing techniques alongside otherconcepts to influence a target audience to voluntarily accept, reject,or modify a behaviour for the benefit of individuals, groups, or societyas a whole (French & Blair‐Stevens, 2010). It is clear that the focus ofSM is to influence target audience to voluntarily accept a desiredbehaviour. Sheau‐Ting, Mohammed, and Weng‐Wai (2013) posit thatbehaviours adopted voluntarily can be sustained for a longer periodof time and SM is unique in achieving this objective. Thus, if peoplevoluntarily adopt positive attitude towards breast cancer prevention,it would yield a positive result that could be sustained for a longerperiod of time.SM has grown in popularity and usage within the public healthcommunity (Grier & Bryant, 2005). Despite its popularity and influence, previous studies have revealed that many public health professionals have an incomplete understanding of SM and its role indesigning an effective intervention to influence behaviour change(Glanz, Rimer, & Viswanath, 2008). Understanding why people behavethe way they do is critical to designing an effective intervention(Fishbein & Cappella, 2006). Behavioural change models play an important role in this regard because they serve as a valuable framework tohelp identify the root cause of any given behaviour, which is an important first step in the development of a successful intervention tochange behaviour (Luca & Suggs, 2013). Based on the above literature,the study employs the HBM to identify critical beliefs influencingbreast screening and other prevention activities (see Figure 1 below)and suggest appropriate SM strategies to help change behaviourtowards breast self‐examination and early treatment.The HBM posits that the willingness of an individual to engage in ahealthy behaviour to prevent, to screen for, or to control illness conditions is influenced by such factors as perceived susceptibility, severity,benefits, barriers, cues to action, and self‐efficacy (Champion & Skinner, 2008). Perceived susceptibility refers to beliefs individuals haveabout the likelihood of getting a disease or condition (Champion &Skinner, 2008).Thus, when individuals perceive that they are at risk to a particulardisease such as breast cancer, they are likely to take preventive healthmeasures. Based on the above, the following hypothesis is formulated:H1: There will be no relationship between respondents’perceived susceptibility to breast cancer and their performance of breast cancer preventive behaviour.Perceived severity refers to the individual’s perception of howserious the consequences of contracting the disease is (Kowalski &Czajka, 2015). The more severe the consequences are perceived tobe, the more likely the individual is to act to avoid it (Kowalski &Czajka, 2015). Based on the above discussion, the hypothesis belowis formulated.H2: There will be no relationship between respondents’perceived severity of breast cancer and their likelihoodof engaging in breast cancer preventive behaviour.Perceived benefits are the individual’s perception of the efficacyof the suggested health behaviour in preventing, treating, or improvingthe impact of the health condition (Kowalski & Czajka, 2015). In otherwords, the greater the benefit, the higher the likelihood that the targetaudience will take action to perform the behaviour in question. Hence,the following hypothesis is formulated:H3: There will be no relationship between respondents’perceived benefits of breast cancer protective behavioursand their actions to adopt breast cancer preventivebehaviour.Perceived barriers are obstacles that hinder an individual from pursuing new behaviour. The barriers represent the cost or difficulties thetarget audience has to overcome in order to perform the behaviour(D’Souza, Zyngier, Robinson, Schlotterlein, & Sullivan‐Mort, 2011).The barriers may include embarrassment or fear of pain (Julinawati,Cawley, & Domegan, 2013). A study conducted in Botswana, forinstance, reveals that women failed to attend cervical cancer screeningdue to the absence of female health workers (Ibekwe, Hoque, & Ntuli‐Ngcobo, 2011). The above discussions informed the hypothesis below:H4: There will be no relationship between perceived barriers associated with the performance of breast cancerpreventive behaviour and the performance of breast cancer preventive behaviour.Self‐efficacy is the individual’s belief that he can exercise controlover his or her health habits in question irrespective of environmentaland social challenges (Bandura, 2004). People’s perception of theirability to perform a particular behaviour is fundamental to the adoptionFIGURE 1 Health belief model. Source: Adapted from Yazdanpanah,Forouzani, and Hojjati (2015)2 of 7 TWENEBOAH‐KODUAHof new habits (Champion & Skinner, 2008). According to Bandura(2004), self‐efficacy is the foundation of human motivation to engagein behaviour, and without it, no action would be taken to acquire anew behaviour. The hypothesis below is deduced from the discussionsabove.H5: There will be no relationship between respondents’self‐efficacy and their performance of breast cancer preventive behaviour.Cues to action refers to anything that triggers or reminds peopleto take action (Champion & Skinner, 2008). These may include mediapublicity, advice from friends, and newspaper article on breast cancer(Champion & Skinner, 2008). It is therefore hypothesized as follows:H6: There will be no relationship between cues to actionand the respondents’ performance of breast cancer preventive behaviour.4 | METHODOLOGYThis is a cross‐sectional survey conducted in Accra, the capital city ofGhana, using the HBM to explain breast cancer protective behaviouramong women. Quantitative research method was employed to determine the factors influencing the intention of women to engage inbreast cancer protective behaviours. The study focused on womenin Accra because most of the breast cancer awareness campaignshad been done in Accra. In order to capture the views of women withdifferent backgrounds, A&C shopping mall and Agbogbloshiemarket all in Accra were purposively selected. The middle‐classwomen prefer shopping at the A&C Mall due to the convenience,whereas the working‐class women do their shopping at theAgbogbloshie market for its low prices. According to 2010 Ghana population and housing census, there are 2,210,054 women in Accra(Ghana Statistical Service, 2013). Using a 95% confidence interval, asample size of 400 was determined (Bartlett, Kotrlik, & Higgins,2001). With 46% literacy rate among women in Ghana (Ghana Statistical Service, 2013), 184 women were selected for the survey at theA&C mall and the remaining 216 from the Agbogbloshie market. Aconvenience sampling technique was used in selecting the respondents for the survey due to lack of a sampling frame for shoppers. A5‐point Likert scale questionnaire was administered face to face tothe respondents measuring the degree of agreement of 1 for stronglydisagree to 5 for strongly agree. The questionnaire contained threesections that covered sociodemographic profile of age, income, levelof education, and marital status. The sections 2 and 3 measuredknowledge and impact of SM interventions on breast cancer preventive behaviours and the constructs of HMB, namely, perceived susceptibility, severity, benefits, barriers, self‐efficacy, and cues to action.The middle‐class women self‐completed their questionnaires becausethey were able to read and understand English language, the officiallanguage of Ghana. The questionnaire was however translated intothe local Ghanaian language to the working‐class women to enhanceunderstanding and cooperation. This was based on the five‐stepprocess for translating survey questionnaires by Forsyth, Kudela,Lawrence, Levin, and Willis (2007), which included translation, review,initial adjudication, cognitive interview pretesting, and final review andadjudication. In all, 363 questionnaires representing 90.75% wereused for analysis. The data were analysed using frequencies andmultiple regression.5 | RESULTS, DISCUSSION, ANDRECOMMENDATIONSThe results show that majority of respondents (59.3%) were below35 years of age with 21.5% between ages 35 and 44, 13.2% betweenages 45 and 54, and remaining 6% belonging to age 55 and above. Atotal of 63.4% of the respondents earn below GHS 1,000.00 a monthwith 47.9% of them having below senior high education and 22.9%had tertiary education. Majority of them (57.9%) were married,28.1% were single, and 14% cohabitating.Regarding knowledge on breast cancer, all the women interviewedwere aware or had heard about breast cancer. Consistent with thefindings of Alharbi, Alshammari, Almutairi, Makboul, and El‐Shazly(2012), respondents received SM on breast cancer from TV (62.8%)and radio (16.5) with medical practitioners (5.8%) being the lowestsource of information on breast cancer. A total of 26.2% of the respondents identified environmental factors as the major cause of breastcancer, and 44.9% of the respondents attributed breast cancer to suchfactors as spiritual and too much breast feeding. This is worrying as itsuggests that the respondents lack knowledge regarding the actualcauses of breast cancer. Of the respondents, 25.1% believe that breastcancer is best prevented through prayer. Although 69.1% of therespondents are aware that the impact of breast cancer is best reducedthrough regular breast self‐examination, 86.5% of them do not knowhow to perform the breast self‐examination.The proposed measurement model was first validated using confirmatory factor analysis in SmartPLS to assess measurement reliabilityand validity (Ringle, Wende, & Will, 2005). This was done based onthree main criteria: (a) convergent validity; (b) reliability; and (c)discriminant validity following the suggestion of Hair, Hult, Ringle,and Sarstedt (2014). Table 1 indicates that convergent validity of theitems was assessed by outer loadings and average variance extracted(AVE). The convergent validity of the measurement scales is supportedbecause all of the outer loadings are above the minimum acceptablethreshold of 0.4. Convergent validity was also supported using AVEfor each construct being greater than the recommended 0.5 (Gefen& Straub, 2005).Discriminant validity was evaluated based on the Fornell–Larckercriterion. The Fornell–Larcker criterion suggested by Fornell andLarcker (1981) states that the square root of AVE should be greaterthan the correlation shared between the construct and the other constructs. The diagonals in Table 2 below presented the square root ofthe AVE and the correlations among constructs. The correlationsamong the constructs are less than the square root of the AVE, an indication of discriminant validity. The reliability of each construct wasassessed by composite reliability. Table 2 revealed that the reliabilitymeasures in this study are above the acceptable satisfactory levels(AVE > .50, composite reliability > .70) as recommended by scholars(Hair et al., 2014; Nunnally, 1978).TWENEBOAH‐KODUAH 3 of 7In Table 3, multiple regressions were done to test and validate H1to H6 of the study. An aggregated breast cancer protective behaviourwas used as the dependent variable whereas the constructs of HBMTABLE 1 Confirmatory factory analysisItem Loading CR AVEPerceived benefits 0.97 .85Doing regular breast screening is good for me. .965Doing breast self‐examination regularly would help me detect breast lump and breast change early. .946Early detection of breast cancer reduces my cost of treatment and enhances my chance of survival. .938Early detection of breast change and seeking early treatment are the best way to prevent breast cancer. .927Regular breast self‐examination (BSE) decreases the rate of death from breast cancer. .836Perceived self‐efficacy 0.84 0.52I am confident that I can examine my own breast regularly. .832I am confident in my ability to find small lumps and breast changes when I examine my own breasts .738I can perform breast self‐examination correctly using the right parts of my fingers. .705I can recognize any abnormal changes in my breast when I look at it in the mirror. .686I am able to identify normal and abnormal breast tissue when I do breast self‐examination. .614Perceived barriers 0.86 0.55I am afraid my breast would be cut off, if I notice change in my breast and go to the hospital. .854I am afraid of finding lump in my breast if I do regular breast self‐examination. .758Examining my breast regularly would make me worry about getting breast cancer. .727Treating breast cancer is expensive. .683Breast self‐examination is painful and difficult to perform. .653Perceived susceptibility 0.91 0.77It is likely that I will get breast cancer. .973My chances of getting breast cancer is high. .922I feel I will get breast cancer sometime during my life. .707Perceived severity 0.84 0.52The thought of breast cancer scares me. .852It is very serious to get breast cancer. .803Breast cancer is a deadly disease that is difficult to cure. .668Getting breast cancer can affect the relationship with my partner/husband. .631Having breast cancer can affect my relationship with my family and friends. .627Cues to action 0.76 0.62Seeing pictures about breast cancer prompts me to do breast self‐examination to avoid it. .842Hearing from breast cancer patient makes me feel like doing breast self‐examination to avoid it. .727Breast self‐examination behaviour 0.84 0.63I do breast self‐examination once every month. .886I hardly perform breast self‐examination (R). .832I will report any change in my breast to a doctor immediately. .650Note. R = reverse coded. AVE = average variance extracted; CR = composite reliability.TABLE 2 Interconstruct correlation12345671. Breast self‐examinationbehaviour12. Cues to action 0.42 13. Perceived barriers 0.43 0.03 14. Perceived self‐efficacy 0.42 0.32 0.39 15. Perceived severity 0.44 0.46 0.36 0.35 16. Perceived susceptibility 0.46 0.18 0.41 0.34 0.29 17. Perceived benefits 0.41 0.35 0.06 0.40 0.44 0.21 1TABLE 3 Regression modelSE Beta T p(Constant) .147 12.224 .000Susceptibility .024 .528 10.001 .000Severity .018 .084 1.766 .078Benefits .013 .753 14.795 .000Barriers .023 −.218 −3.604 .000Efficacy .015 .659 15.479 .000Cues to action .012 .105 2.456 .015R .830R2 .689Adj. R2 .683Dependent variable: Breast cancer protective behaviour4 of 7 TWENEBOAH‐KODUAHwere used as independent variables. The regression model was significant in predicting and explaining 68.9% of the variance in the dependent variable (sig = .000, R2 = .689). In other words, the HBM providesa better means of understanding why people do not undertake breastcancer preventive behaviours. Thus, designing and implementing anintervention based on HBM can result in changing behaviour towardsbreast cancer prevention. This finding corroborates with Parsa,Kandiah, Mohd Nasir, Hejar, and Nor Afiah (2008) and Tavafian,Hasani, Aghamolaei, Zare, and Gregory (2009) who found the modelto be effective in predicting breast self‐examination among womenin Malaysia and Iran, respectively.Perceived susceptibility was found to have a statistically significant influence on breast cancer protective behaviours (p = .000). Thefinding is consistent with previous studies (Champion & Skinner,2008; Noroozi & Tahmasebi, 2011; Parsa et al., 2008). However, theresult of the descriptive analysis shows that respondents perceivelower levels of susceptibility towards the breast cancer disease. Thestudy recommends that to change the breast cancer protective behaviour of Ghanaian women, SMIP should be designed to raise the susceptibility levels of women in Ghana by making them believe that they arevulnerable to breast cancer.Even though the respondents perceive breast cancer to be severe,the study found no statistically significant relationship between severity and performance of breast cancer protective behaviours (p = .078).This suggests that designing interventions based on severity may notyield effective result of changing behaviour towards breast cancer prevention. This contradicts Kowalski and Czajka (2015) who found severity to be a significant influence on behaviour.On perceived benefit, the study concludes that there is a positiveand statistically significant relationship between perceived benefitsand behaviour (p = .000). This is in tandem with D’Souza et al. (2011)and Noroozi and Tahmasebi (2011) who assert that the greater theperceived benefit of the suggested behaviour, the higher the likelihoodof taking preventive action to prevent the disease. In other words,positioning the benefits of performing breast self‐examination as aneffective means of preventing or reducing the threat posed by breastcancer would have a significant influence on the performance of thebehaviour.Regarding perceived barrier, the study found a negative but statistically significant relationship between perceived barrier and performance of breast cancer protective behaviours (p < .000). Thissuggests that the higher the barrier, the less likely the respondentsare to perform breast cancer protective behaviours. The result fromthe descriptive analysis shows high perceived barriers, which negatively impacted the women to perform breast cancer protective behaviours. This is consistent with previous findings (Calnan & Moss, 2016;Romano & Scott, 2014), which conclude that when perceived barriersare high, it increases noncompliance levels of the behaviour. The studytherefore recommends that the implementers of SMIP on breast cancer should do upstream SM to influence the government to reducebarriers women in Ghana encounter in their attempts or efforts atperforming breast cancer protective behaviours.On self‐efficacy, the study found a positive and statistically significant relationship between self‐efficacy and performance of breastcancer protective behaviours (p = .000). This finding confirms previousfindings (Champion & Skinner, 2008; Noroozi & Tahmasebi, 2011),which conclude that when self‐efficacy is high, the compliance levelfor the recommended behaviour is usually high. The study thereforerecommends that interventions should be put in place to increase theself‐efficacy of women in Ghana on breast cancer protectivebehaviours.Regarding cues to action, the study found positive and statisticallysignificant relationship between cues to action and performance ofbreast cancer protective behaviours (p = .015). This means that if thereis enough SMIP to remind women in Ghana on breast cancer protective behaviours, they would protect themselves against breast cancer.This is consistent with Champion and Skinner (2008). Based on this,the study recommends that reminder postcards, newspaper or magazine article on breast cancer, and interviews with breast cancerpatients on TV should be a regular feature in SMIP on breast cancerin Ghana.An analysis of variance was conducted to determine whetherthere is a significant difference between the women's current level ofeducation and their performance of breast cancer preventive behaviours. The result inTable 4 reveals that on the average, the women irrespective of their level of education disagree that they have adoptedbreast cancer preventive behaviours (Mean = 2.311). The study however found statistically significant difference (F = 8.808, p < .000)between the respondents' level of education and their performanceof breast cancer preventive behaviours. The women with no formaleducation are more likely to disagree (Mean = 2.195) that they haveperformed breast cancer preventive behaviours than their counterparts with levels of education.This is because the women with no formal education are unable toreceive and synthesize SM interventions on breast cancer as comparedwith their counterparts who are educated.6 | THEORETICAL IMPLICATIONS ANDLIMITATION OF THE STUDYThis study has for the first time applied the HBM to SMIP on breastcancer in the Ghanaian context. The HBM used as the conceptualframework of the study has generally been helpful in predicting andunderstanding breast cancer‐related behaviours of women in Ghana.The study found statistically significant relationship between all theconstructs of HBM and the performance of breast cancer protectivebehaviours except the relationship between severity and performanceof breast cancer protective behaviours as proposed by the model. TheHBM posits that the more severe the consequence is perceived to be,TABLE 4 Differences between level of education and breast cancerpreventive behaviourFactor Education level Mean F pBehaviour No formal education 2.1958 8.808 .000JHS 2.3575SHS/A' level 2.2642Tertiary 2.3916Total 2.3113TWENEBOAH‐KODUAH 5 of 7the more likely the individual is to act to avoid it. However, in the Ghanaian context, the findings do not support this and indicate that thereis no statistically significant relationship between perceived severityand performance of breast cancer protective behaviours. The authorcontends that the women in Ghana perceived severity of gettingbreast cancer do not affect their intentions to perform breast cancerprotective behaviours. On the basis of the findings, the author concludes that HBM is generally applicable to the Ghanaian situation forunderstanding breast cancer protective behaviours. However, to helpdesign effective SMIP on breast cancer in Ghana, the author recommends the removal of severity as a construct from HBM. The authorasserts that the modified HBM will help implementers of SMIPs inGhana to facilitate an understanding of why women in Ghana are notadopting breast cancer protective behaviours. The study found majority (62.8%) of the respondents receiving SM interventions on breastcancer from television. Therefore, the study recommends that implementers of SMIP on breast cancer should use television as the effective medium to communicate to Ghanaian women. It is alsorecommended that implementers of SMIP on breast cancer shoulduse local languages to communicate the interventions to women withno formal education.The study utilized quantitative techniques to understand the relationship between HBM constructs and breast cancer protectivebehaviours among women in Ghana. Using qualitative method forfuture research would help provide a deeper understanding of breastcancer‐related behaviour based on HBM. Future studies should consider including men as respondents as their knowledge and acceptanceof the behaviour may help prevent breast cancer among women.