Study design

Cross-sectional study using quantitative and qualitative analysis techniques.

Selection criteria

We selected the three open social networks with still image content with the largest number of regular users in Argentina ¹⁶: Facebook, Instagram and Twitter.

Given the fragmented nature of Argentina’s health system, dissemination pieces published by representatives of the state, private and social security sectors on Facebook, Instagram and Twitter, between October 1 and 31, 2019, were identified. We included the pieces issued by the National Ministry of Health and the ministries of the 24 provinces, the 24 provincial “obras sociales”, the 11 national “obras sociales” and the 10 prepaid medicine companies with the largest number of affiliates ¹⁷ (Table 1). Scientific societies and civil society organizations related to breast cancer were also included.

Any diffusion piece composed of text and/or images, created with the purpose of disseminating the breast cancer theme and including the institution’s logotype, was considered eligible.

The initial search was conducted by two investigators (SVG and MRT). Six institutions were randomly selected and independently assessed whether the total number of articles published by these institutions (n=206) met the inclusion criteria. For the 206 pieces identified, perfect concordance (Kappa=1, p < 0.001) between investigators was documented for compliance with the eligibility criteria. Given the optimal concordance, the remaining pieces were reviewed by a single investigator (SVG). Each piece was assigned an identifying number, and its degree of impact was documented (number of clicks on “like” and number of times it was shared).

Procedures

For the quantitative analysis

Initially, we analyzed the pieces issued by 15 institutions (pilot test), and then all the pieces from the selected institutions. The analysis of each piece was carried out independently by a pair of researchers (SVG-MRT or SVG-MRY) through an online form. Out of a total of 2491 responses by each pair of researchers there was some degree of disagreement in 141 responses (5.6%), all resolved by consensus during a final meeting in which all of them participated.

For the qualitative analysis

We selected the six pieces from each subgroup that had obtained the highest degree of repercussion (selection by quotas) and then analyzed the empirical corpus content (identification and interpretative analysis); the methodological proposal of Acal Diaz ¹⁸ for the analysis of still images was used as a reference, adapted specifically for this scenario through a problematization work carried out jointly by the whole team.

Based on the adapted categories, a pre-analysis of the empirical corpus was carried out with the intention of detecting emerging ideas and concepts, then a coding guide was created in an online form that allowed the uploading of examples and quotations. Based on the review of five pieces, two researchers (MAW and SVG) completed it independently (pilot test), trying to detect loading problems. Once the loading process was optimized, they continued with the remaining dissemination pieces. The information obtained independently by each of the two researchers was shared with a third researcher (SAT) in weekly meetings, during which (through an iterative process) concepts and ideas were identified from the analysis of the pieces, jointly constructing the emerging categories and subcategories, and preparing the final narrative report. The final sample size was subject to the criterion of theoretical saturation, and was reached with the 30 pieces initially selected.

Variables

For the quantitative analysis

We analyzed whether each piece included recommendations on primary and secondary prevention of breast cancer, documenting the recommended screening methods, the starting and completion age and the proposed periodicity, and also evaluated the compliance of these recommendations with those of the INC. In addition, we analyzed whether the benefits and risks of screening were mentioned.

For the qualitative analysis

Five main aspects were analyzed: the structure and content of the diffusion pieces, the function of the image within the visual communication, the design of the campaign, the connotative resources used, and the relationship established between the piece and the receiver (supplementary material).

Data analysis

Quantitative analysis

The analysis of the comlpiance of the data obtained with the INC recommendations was expressed as proportions.

Ethical aspects

This study was approved (approval 4039) by the Ethics Committee for Research Protocols of the Hospital Italiano de Buenos Aires (IRB00010193).

Quantitative aspect

We found that 46 of the 54 institutions (85%) made a recommendation on secondary prevention. Of these 46, 32 (69.5%) included mammography, alone or accompanied by other strategies, such as physical breast examination by a professional, which was also recommended by five institutions (10.8%) (Table 2).

Among the recommendations that did not comply with the INC, breast self-examination was mentioned by 18 institutions (39%), five of them on a monthly basis. In eight institutions (17%) it was the only screening strategy recommended, while breast ultrasound was recommended by four institutions (8.7%).

As shown in Table 3, of the 32 institutions that recommended mammography, a total of 22 (69%) specified the starting age and only 9 (28%) the age of screening completion, and 20 (63%) of them specified the recommended periodicity.

The National Ministry of Health was the only institution that issued a recommendation in complete agreement with that of the INC.

Of the 54 analyzed institutions, 44 (81%) mentioned benefits of screening and only three expressed them quantitatively (two of them in relative terms and one in absolute terms). Among the clinically relevant benefits, the increased chance of cure was the most mentioned one (42%) followed by decreased mortality (18%), increased survival (11%) and early or less invasive treatment (14.8%). In contrast, 6 institutions (11%) mentioned “prevention” as a benefit of screening and 19 (35%) mentioned early diagnosis as a benefit in itself (Table 4). No institution mentioned possible harms of screening.

The pieces from 6 of the 54 institutions (11%) mentioned an endorsement or entity cited as a reference and/or source of information for the recommendation issued, which in all cases were not consistent with those of the INC (data not shown).

Qualitative aspect

Thirty dissemination pieces (supplementary material) were analyzed and the main emerging categories (and their subcategories) were identified, which are described below.

a. Images and design of the pieces

The images were classified according to their function within the piece and the content of the message they convey.

The exhibition of naked female bodies was a widely used strategy to attract attention, pieces 1 and 2 of the supplementary material (SM). On the other hand, those that seek to create identification with the receiver do so by showing women with stereotyped bodies according to the hegemonic “ideal” of current beauty (pieces 1 and 3 of the SM), or also by representing the “fighting” woman, using images of scarves, a symbol of empowerment and the vindication of women’s rights (piece 5 of the SM). In addition, the images support the information provided by the text (pieces 4 and 6 of the SM), and sometimes only have an aesthetic purpose (pieces 8 and 9 of the SM) showing bodies reminiscent of works of art (pieces 10, 11 and 12 of the SM).

Content of the message conveyed by the image (gender and beauty stereotypes)

There is a predominance of images of slim and young women, outside the recommended screening age (pieces 1, 14 and 16 of the SM), and with characteristics that reflect the currently most socially accepted beauty stereotype (piece 13 of the SM). There is only one piece that shows diversity in the women represented (SM piece 4). The women appear to be healthy, without showing women undergoing oncological treatments or in advanced stages of the disease (piece 13 of the SM). Many pieces show women without faces, focusing the attention on their hands, torso (often naked), or only on one breast (pieces 12, 14 and 15 of the SM), and often showing poses that give the image an erotic connotation (piece 1 of the SM).

Concepts that reinforce the stereotype of the feminine gender prevail, the color pink, cursive letters, and the use of hearts or flowers predominate (pieces 17, 18 and 30), and the woman is shown with a passive, smiling and delicate attitude (pieces 16, 19 and 20).

b. The text

The textual elements that make up the diffusion pieces fulfill various functions: awareness-raising, persuasion and transmission of information.

Awareness and persuasion

Textual elements aim to consolidate the concept of October as a month dedicated to breast cancer (pieces 19, 20 and 21 of the SM). We observed that persuasion strategies are usually applied by asking the recipient “When was your last check-up?” and affirming “Prevention is in your hands” (pieces 5, 11 and 22 of the SM). Some pieces include warning signs or false beliefs about breast cancer (SM pieces 4 and 23).

Transmitted (Dis) information

The lack of message segmentation by age, the promotion of practices without scientific support, the overestimation of their benefits and the omission of risks derived from their implementation are prevalent. The messages are usually addressed to women of all ages; the question “Have you already had your annual studies?” seems to convey that screening should be performed at any age without distinction (piece 21 of the SM).

A large number of the pieces highlight the importance of prevention with high-impact phrases such as “Prevention saves lives” (pieces 10, 24 and 25 of the SM), feeding the false idea that the development of all cancers could be avoided by performing timely studies. On the other hand, many campaigns recommend breast self-examination, without evidence to support it, since it has not been found that its implementation reduces mortality ¹⁹. Even so, slogans such as “Today your hand saves lives” and “Touch them once a month” provide counseling without scientific support (parts 3 and 8 of the SM).

There was a tendency to overestimate the benefits of screening with statements such as “A study in time can save your life” (item 1 of the SM) without mentioning the extent to which screening reduces mortality. On the other hand, in statements such as “Don't give up, you can do it” (SM item 25), the idea that cancer can always be cured or that its evolution is conditioned by the behaviors adopted prevails.

c. The images, the design of the piece and the text: feelings and emotions evoked by the diffusion pieces.

Both the images and the information conveyed by the textual elements can evoke various feelings and emotions in the receiving audience.

Many campaigns evoke commitment and unity. Phrases such as “For me, for you, for all of us”, “Today we unite against breast cancer”, convey that the “fight” is collective, as a phenomenon of social responsibility (pieces 4, 7 and 8 of the SM).

On the other hand, there is a tendency to make women responsible by affirming that “Prevention is in your hands”, (part 1 of the SM) which, by assuring that cancer can be prevented and that doing so depends on the woman herself, can generate guilt and stigmatization in those who have not carried out the recommended studies or who have received a diagnosis of cancer.

Some pieces evoke concern and fear by highlighting “1 in 8 women can suffer breast cancer, the older the woman, the higher the risk” (SM piece 27), while other pieces convey hope “A study in time can save your life” (SM piece 27). It is common for both messages to coexist in the same campaign, first stating that the risk is “high” and then recommending studies to “avoid it” (piece 7 of the SM).

The importance of empowerment prevails, defined by these campaigns as a way of taking responsibility for one’s own health, and of carrying out the recommended studies (item 5).

On the other hand, heroism is referred to in women who manage to be cured by using epic language. There is talk of “Fighting”, “Beating this disease” (pieces 7, 24 and 26 of the SM), which implies that the results depend on individual strength and will and does not consider other variables, such as the characteristics of the type of cancer ²⁰ or the social determinants of the patient.

Many pieces also convey a notion of obligatory nature: “Have you already undergone the annual studies?”, “Don't give up”, assuming that there is only one valid option: to undergo studies and then treatment. We also observed that recommendations are usually formulated in an imperative way: “Have your first mammogram at 35 years of age” (pieces 3, 16 and 25 of the SM).