Understanding Parents' Perceptions of School-Based BMI Screening and BMI Report Cards Using Perceptual Mapping: Implications for School Nurses.

Half of U.S. states measure students' body mass index (BMI), with many communicating that information to parents through a "BMI report card" or notification letter. School nurses are usually responsible for implementing these programs and communicating results to parents. The purpose of this study was to understand parents' perceptions of BMI screening programs to help inform school nurses about messages that are most helpful to use in report cards to motivate parents to follow-up with a health-care provider or to make behavioral changes for their child. Using a cluster analysis and perceptual mapping methods, a commercial marketing technique that creates three-dimensional graphic maps, we identified four unique clusters of parents based on their core attitudes and beliefs related to BMI screenings and report cards. Based on vector modeling techniques, key message strategies were developed that can be used by school nurses to enhance parent response to a BMI report card.

Using perceptual mapping methods to understand gender differences in perceived barriers and benefits of clinical research participation in urban minority HIV+ patients.

Minority participation in HIV clinical trials research is critical to understanding the impact of medications or behavioral interventions, but little is known about gender differences in perceptions of participation. We surveyed 50 minority HIV+ patients from an urban clinic to assess perceived risks/benefits of clinical trial research participation and used innovative marketing methods to analyze results. Perceptual mapping and vector message-modeling, a method that creates 3-D models representing how groups conceptualize elements, were used to assess how male and female participants could be motivated to participate. Results showed men farther away from participation and more concerned with HIV disclosure and experimentation than women. Men expressed distrust of the medical system, doubted HIV's origin, and knew less about research implementation. Women were closer to participation in both behavior and medical trials and perceived medication issues as more significant, including fear of losing medication stability, medications not working, being in the placebo group, and experiencing side effects. Vector modeling shows that messages would need to focus on different aspects of clinical research for men and women and that interventions aimed at minority HIV+ patients to encourage clinical trial participation would need to be targeted to their unique perceptions. Understanding gender perceptions of HIV clinical research has significant implications for targeting messages to increase minority participation.

Understanding help-seeking intentions in male military cadets: An application of perceptual mapping.

BACKGROUND: Research suggests that men are less likely to seek help for depression, substance abuse, and stressful life events due to negative perceptions of asking for and receiving help. This may be exacerbated in male military cadets who exhibit higher levels of gender role conflict because of military culture. METHODS: This exploratory study examined the perceptions of 78 male military cadets toward help-seeking behaviors. Cadets completed the 31-item Barriers to Help Seeking Scale (BHSS) and a component factor analysis was used to generate five composite variables and compare to validated factors. Perceptual mapping and vector modeling, which produce 3-dimensional models of a group's perceptions, were then used to model how they conceptualize help-seeking. RESULTS: Factor analysis showed slightly different groupings than the BHSS, perhaps attributed to different characteristics of respondents, who are situated in a military school compared to general university males. Perceptual maps show that cadets perceive trust of doctors closest to them and help-seeking farthest, supporting the concept that these males have rigid beliefs about having control and its relationship to health seeking. Differences were seen when comparing maps of White and non-White cadets. White cadets positioned themselves far away from all variables, while non-White cadets were closest to "emotional control". CONCLUSION: To move these cadets toward help-seeking, vector modeling suggests that interventions should focus on their general trust of doctors, accepting lack of control, and decreasing feelings of weakness when asking for help. For non-White cadets a focus on self-reliance may also need to be emphasized. Use of these unique methods resulted in articulation of specific barriers that if addressed early, may have lasting effects on help-seeking behavior as these young men become adults. Future studies are needed to develop and test specific interventions to promote help-seeking among military cadets.

Randomized Trial of a Computerized Touch Screen Decision Aid to Increase Acceptance of Colonoscopy Screening in an African American Population with Limited Literacy.

The goal of this study was to assess the effectiveness of a touch screen decision aid to increase acceptance of colonoscopy screening among African American patients with low literacy, developed and tailored using perceptual mapping methods grounded in Illness Self-Regulation and Information-Communication Theories. The pilot randomized controlled trial investigated the effects of a theory-based intervention on patients' acceptance of screening, including their perceptions of educational value, feelings about colonoscopy, likelihood to undergo screening, and decisional conflict about colonoscopy screening. Sixty-one African American patients with low literacy, aged 50-70 years, with no history of colonoscopy, were randomly assigned to receive a computerized touch screen decision aid (CDA; n = 33) or a literacy appropriate print tool (PT; n = 28) immediately before a primary care appointment in an urban, university-affiliated general internal medicine clinic. Patients rated the CDA significantly higher than the PT on all indicators of acceptance, including the helpfulness of the information for making a screening decision, and reported positive feelings about colonoscopy, greater likelihood to be screened, and lower decisional conflict. Results showed that a touch screen decision tool is acceptable to African American patients with low iteracy and, by increasing intent to screen, may increase rates of colonoscopy screening.

Using eye tracking and gaze pattern analysis to test a "dirty bomb" decision aid in a pilot RCT in urban adults with limited literacy.

BACKGROUND: Eye tracking is commonly used in marketing to understand complex responses to materials, but has not been used to understand how low-literacy adults access health information or its relationship to decision making. METHODS: This study assessed how participants use a literacy appropriate "dirty bomb" decision aid. Participants were randomized to receive a CDC "factsheet" (n = 21) or literacy-appropriate aid (n = 29) shown on a computer screen. Using 7 content similar slides, gaze patterns, mean pupil fixation time and mean overall time reading and looking at slides were compared. Groups were also compared by literacy level and effect on 'confidence of knowledge' and intended behavior. RESULTS: Results revealed differing abilities to read densely written material. Intervention participants more precisely followed text on 4 of 7 content-similar slides compared to control participants whose gaze patterns indicated unread text, or repeated attempts at reading the same text, suggesting difficulty in understanding key preparedness messages. Controls had significantly longer pupil fixations on 5 of 7 slides and spent more overall time on every slide. In those with very low literacy, intervention participants were more likely than controls to say they understood what a "dirty bomb" is and how to respond if one should occur. CONCLUSIONS: Results indicate limited- literacy adults, especially those with very low literacy, may not be able to understand how to respond during a "dirty bomb" using available materials, making them vulnerable to negative health events. This study provides insights into how individuals perceive and process risk communication messages, illustrating a rich and nuanced understanding of the qualitative experience of a limited literacy population with written materials. It also demonstrates the feasibility of using these methods on a wider scale to develop more effective health and risk communication messages designed to increase knowledge of and compliance with general health guidelines, and enhance decision making. This has application for those with learning disabilities, those with limited media-literacy skills, and those needing to access the diverse array of assistive technologies now available. Eye tracking is thus a practical approach to understanding these diverse needs to ensure the development of cogent and salient communication.

Developing a typology of African Americans with limited literacy based on preventive health practice orientation: implications for colorectal cancer screening strategies.

Preventive health messages are often tailored to reach broad sociodemographic groups. However, within groups, there may be considerable variation in perceptions of preventive health practices, such as colorectal cancer screening. Segmentation analysis provides a tool for crafting messages that are tailored more closely to the mental models of targeted individuals or subgroups. This study used cluster analysis, a psychosocial marketing segmentation technique, to develop a typology of colorectal cancer screening orientation among 102 African American clinic patients between the ages of 50 and 74 years with limited literacy. Patients were from a general internal medicine clinic in a large urban teaching hospital, a subpopulation known to have high rates of colorectal cancer and low rates of screening. Preventive screening orientation variables included the patients' responses to questions involving personal attitudes and preferences toward preventive screening and general prevention practices. A k-means cluster analysis yielded three clusters of patients on the basis of their screening orientation: ready screeners (50.0%), cautious screeners (30.4%), and fearful avoiders (19.6%). The resulting typology clearly defines important subgroups on the basis of their preventive health practice perceptions. The authors propose that the development of a validated typology of patients on the basis of their preventive health perceptions could be applicable to a variety of health concerns. Such a typology would serve to standardize how populations are characterized and would provide a more accurate view of their preventive health-related attitudes, values, concerns, preferences, and behaviors. Used with standardized assessment tools, it would provide an empirical basis for tailoring health messages and improving medical communication.

Perceived colonoscopy barriers and facilitators among urban African American patients and their medical residents.

African Americans suffer from higher colorectal cancer morbidity and mortality than do Whites, yet have the lowest screening rates. To understand barriers and facilitators to colorectal cancer screening, this study used perceptual mapping (multidimensional scaling) methods to compare patients' perceptions of colonoscopy and general preventive health practices to those of their doctors in a general internal medicine clinic in a large urban hospital. African American patients (n = 102) were surveyed about their own screening beliefs; third-year resident physicians (n = 29) were asked what they perceived their patients believed. The perceptual maps showed significant differences between the patients' and physicians' perceptions of barriers, facilitators, and beliefs about screening. Physicians believed logistical lifestyle issues were the greatest screening barriers for their patients whereas fears of complications, pain, and cancer were the most important barriers perceived by patients. Physicians also underestimated patients' understanding of the benefits and importance of screening, doctors' recommendations, and beliefs that faith in God could facilitate screening. Physicians and patients perceived a doctor's recommendation for screening was an important facilitator. Better understanding of patient perceptions can be used to improve doctor-patient communication and to improve medical resident training by incorporating specific messages tailored for use with African American patients.

Developing a computer touch-screen interactive colorectal screening decision aid for a low-literacy African American population: lessons learned.

African Americans have higher colorectal cancer (CRC) mortality than White Americans and yet have lower rates of CRC screening. Increased screening aids in early detection and higher survival rates. Coupled with low literacy rates, the burden of CRC morbidity and mortality is exacerbated in this population, making it important to develop culturally and literacy appropriate aids to help low-literacy African Americans make informed decisions about CRC screening. This article outlines the development of a low-literacy computer touch-screen colonoscopy decision aid using an innovative marketing method called perceptual mapping and message vector modeling. This method was used to mathematically model key messages for the decision aid, which were then used to modify an existing CRC screening tutorial with different messages. The final tutorial was delivered through computer touch-screen technology to increase access and ease of use for participants. Testing showed users were not only more comfortable with the touch-screen technology but were also significantly more willing to have a colonoscopy compared with a "usual care group." Results confirm the importance of including participants in planning and that the use of these innovative mapping and message design methods can lead to significant CRC screening attitude change.

Why fathers are too important to ignore: communication about sexuality between fathers and daughters.

This cross-sectional study examined perceptions of sexual communication between 38 dyads of fathers and daughters. Results indicate agreement about the 3 topics most and least frequently discussed but significant differences in perceived extent of sexual communication. These differences indicate that interventions may be needed to increase fathers' comfort with sexual communication.

Perceptions of colorectal cancer screening in urban African American clinic patients: differences by gender and screening status.

African Americans have higher colorectal cancer (CRC) morbidity and mortality than whites, yet have low rates of CRC screening. Few studies have explored African Americans' own perceptions of barriers to CRC screening or elucidated gender differences in screening status. Focus groups were conducted with 23 African American patients between 50 and 70 years of age who were patients in a general internal medicine clinic in a large urban teaching hospital. Focus groups were delimited by gender and CRC screening status. Focus group transcripts were analyzed using an iterative coding process with consensus and triangulation to develop thematic categories. Results indicated key thematic differences in perceptions of screening by gender and CRC screening status. While both men and women who had never been screened had a general lack of knowledge about CRC and screening modalities, women had an overall sense that health screenings were needed and indicated a stronger need to have a positive relationship with their doctor. Women also reported that African American men do not get colonoscopy because of the perceived sexual connotation. Men who had never been screened, compared to those who had been screened, had less trust of their doctors and the health care system and indicated an overall fear of going to the doctor. They also reiterated the sexual connotation of having a colonoscopy and were apprehensive about being sedated during the procedure. Overall, men expressed more fear and were more reluctant to undergo CRC screening than women, but among those who had undergone CRC screening, particularly colonoscopy, men expressed advantages of having the screening. All groups were also found to have a negative attitude about the use of fecal occult blood testing and felt colonoscopy was the superior screening modality. Results suggest that messages and education about CRC screening, particularly colonoscopy, might place more emphasis on accuracy and might be more effective in increasing screening rates among African Americans if tailored to gender and screening status.

Prospective assessment of contralateral prophylactic mastectomy decision-making in women with average risk: an application of perceptual mapping.

Women with early-stage unilateral breast cancer and no familial or genetic risk factors are increasingly electing contralateral prophylactic mastectomy (CPM), despite the lack of evidence demonstrating improved outcomes. To better understand and extend the literature focused on treatment decision-making, a survey was conducted among women with early-stage breast cancer and no associated risk factors, who were in the process of making a surgical decision. This prospective study sought to expand our understanding of the factors that influence patients' decision to have CPM, with the goal of providing healthcare providers with useful guidance in supporting breast cancer patients who are making treatment decisions. Data were collected for this prospective study through an internet survey. Results were analyzed using perceptual mapping, a technique that provides visual insight into the importance of specific variables to groups of women making different surgical decisions, not available through conventional analyses. Results suggest that women more likely to elect CPM demonstrate greater worry about breast cancer through experiences with others and feel the need to take control of their health through selection of the most aggressive treatment option. The information obtained offers guidance for the development of targeted intervention and counsel that will support patients' ability to make high quality, informed decisions.

Experiences of Patients After Withdrawal From Cancer Clinical Trials.

Importance: Cancer clinical trials (CCTs) provide patients an opportunity to receive experimental drugs, tests, and/or procedures that can lead to remission. For some, a CCT may seem like their only option. Little is known about experiences of patient-participants who withdraw or are withdrawn from CCTs. Objective: To examine patient-participants' experiences during withdrawal from CCTs. Design, Setting, and Participants: This qualitative, descriptive study used a semistructured interview designed specifically for it, with open-ended and probing questions. The study took place at a National Cancer Institute-designated comprehensive cancer center affiliated with the University of Pennsylvania. The need for a sample of 20 interviewees was determined by code and meaning saturation (ie, no new themes revealed and identified themes fully elaborated). Interviews were transcribed verbatim and analyzed with a qualitative software program. Data coded with the software were refined into categories reflecting broad themes. A criterion-based sampling approach was used to select a subset of adult patients with cancer who were former CCT participants and who agreed on exit from those CCTs to a later interview about withdrawal experiences. They were contacted one by one by telephone from September 2015 through June 2019 until 20 agreed. Data analysis was completed in October 2020. Main Outcomes and Measures: Themes characterizing patient-participants' perceptions of their withdrawal experiences. Results: Respondents' mean (SD) age was 64.42 (8.49) years; 12 (63.2%) were men. Most respondents were White (18 respondents [94.7%]) and college educated (11 respondents [55.0%]). Cancer stage data were available for 17 participants, 11 of whom (64.7%) had stage IV cancer at CCT enrollment. Thirteen respondents reported withdrawal as a result of disease progression, and 5 withdrew because of adverse effects. Other reasons for withdrawal included acute illness and participant uncertainty about the reason. Analysis of interview data yielded 5 themes: posttrial prognostic awareness, goals of care discussions, emotional coping, burden of adverse effects, and professional trust and support. Subthemes included regrets or hindsight, urgency to start next treatment, and weighing benefits and burdens of treatment. Limited discussions about patient-participants' immediate posttrial care needs left many feeling that there was no clear path forward. Conclusions and Relevance: Patient-participants transitioning from a CCT described feeling intense symptoms and emotions and awareness that their life span was short and options seemed to be limited. Communication that includes attention to posttrial needs is needed throughout the CCT to help patient-participants navigate posttrial steps. Research should focus on components of responsible and ethical CCT transitions, including types and timing of discussions and who should begin these discussions with patient-participants and their families.

Resident physicians' perceptions of barriers and facilitators to colorectal cancer screening for African Americans.

BACKGROUND: African Americans experience disproportionately higher morbidity and mortality from colorectal cancer (CRC), yet they complete screening at lower rates than Caucasians. While studies have identified barriers and facilitators to CRC screening among African Americans, no study has examined physician perceptions of these barriers. OBJECTIVE: The purpose of this study was to determine how resident physicians view barriers and facilitators to CRC screening among their African American patients, and to compare residents' perceptions with barriers and facilitators that have been reported in studies with African Americans. DESIGN: Both quantitative and qualitative data were obtained during in-depth interviews with 30 upper-year residents from an urban academic internal medicine program. RESULTS: Residents recognized the low levels of awareness of CRC that have been reported among African American patients. The most common barriers reported by residents were lack of knowledge, fears, personal/social circumstances, and colonoscopy-specific concerns. Residents reported a need for increased education, increased public awareness, and easier scheduling as facilitators for screening. Residents failed to appreciate some key perceptions held by African Americans that have been documented to either impede or facilitate CRC screening completion, particularly the positive beliefs that could be used to overcome some of the perceived barriers. CONCLUSIONS: Residents may be missing opportunities to more effectively communicate about CRC screening with their African American patients. Residents need more explicit education about African Americans' perceptions to successfully promote screening behaviors in this high-risk population.

Mapping perceptions related to acceptance of smallpox vaccination by hospital emergency room personnel.

Emergency department personnel would be first responders in the event of a bioterror smallpox outbreak, yet few were willing to be vaccinated during the 2002 federal campaign. To better understand vaccination concerns, perceptual mapping methods were used to create multidimensional models of how emergency department personnel (N= 73) in the Philadelphia area perceive the risks and benefits of smallpox vaccination under 4 levels of threat: (1) today; (2) if another terrorist attack happened anywhere in the U.S.; (3) if a smallpox attack happened somewhere in the U.S.; (4) if a smallpox attack happened locally. The perceptual maps show significant shifts in factors that are important for motivating respondents to accept vaccination under increasingly higher levels of threat. In the today scenario, endorsement of vaccination from a credible source, such as a major hospital in the area, was a very important factor (mean =7.10 on a 0-10 scale).However, endorsement was not as important under the 2 higher levels of threat. Under these conditions, respondents'sense of wanting to help in a disaster emerged as an important element the closer the hypothetical attack was to the respondent,ranging in importance from 3.87 under the least threat to 7.35 under the greatest threat scenario. The perceptual maps yield information that would assist planners in designing more effective risk communication strategies tailored to particular audiences and levels of threat. Such communications are important to prepare for a smallpox event or other uncertain outbreak, where it is essential to rapidly vaccinate a critical mass of healthcare workers.

Increasing colorectal cancer screening among African Americans, linking risk perception to interventions targeting patients, communities and clinicians.

Colorectal cancer (CRC) screening remains significantly underutilized by African Americans despite their increased risk compared to whites. The purpose of this article is to review recent research on patterns of screening, perceptions of CRC screening methods and outcomes of seven intervention trials specifically designed to increase screening among African Americans in light of the recommendation of the American College of Gastroenterologists to make colonoscopy the screening method of choice for this population. This review shows that progress has been made in understanding the complexity of perceived barriers to CRC screening among African Americans. Interventions that used community-based education targeting individuals and clinically based education targeting clinicians showed modest increases in screening rates. Targeting entire communities did not show significant results. However, because intervention studies use not only different types of interventions but different screening outcome measures, results are not easily comparable. While there is growing evidence that interventions can increase the use of fecal occult blood test (FOBT), it is not yet known if similar interventions can increase rates of screening colonoscopy. Clinicians, patients and policymakers also need to consider the array of social, cultural and financial issues associated with CRC screening in African-American communities.

Developing the "Control Identity" Typology to Create More Effective Testicular Health Promotional Messaging.

Testicular self-examination (TSE) promotional interventions historically operate without a theoretical framework, which negatively influences their effectiveness. As TSE is critical to the early detection of testicular cancer, this behavior is an essential component to improving overall male well-being. To address this need, the Control Identity personality typology was developed to assist in creating more effective TSE promotional interventions. Four outcome control dispositions were defined a priori based on the dimensions of illusions of control and locus of control. An original 41-item survey, the Control Identity Assessment Scale, was used to assess perceived vulnerability, value of health promotion, and health outcome control among a convenience sample of 300 university males aged 18 to 35 years via a cross-sectional research design. Factor and cluster analyses were employed to extract salient factors in the data and to identify subgroups within the sample. A consistent five-factor structure matrix (~70% explained variance) served as the foundation from which a k-means cluster analysis was employed to classify four types of individuals. Significant differences were detected between clusters on primary variables, including behavioral intentions to conduct TSE. The Control Identity typology aims to provide the needed mechanism for health practitioners to create more effective preventive health messaging to promote TSE. Future implications on employing this typology to segment audiences in order to increase overall effectiveness are offered. Application of this typology could ultimately lead to increasing TSE knowledge retention, behavioral intentions, actual performance, and adherence.

Use of Emotional Response Modeling to Develop More Effective Risk Communication for Limited Literacy Adults: Evaluation of a "Dirty Bomb" Decision Aid.

Behavioral, attitudinal, and emotional reactions to terrorism can be minimized by communication that promotes successful response through preparedness. However, a challenge to adequate preparedness is the substantial proportion of adults with "below basic" or "basic" literacy skills and how this affects development of health messages. This research explored whether a non-verbal emotional measurement and modeling technique (AdSAM®) can be used with a limited literacy population to support the development of message strategies for disaster situations such as a "dirty bomb" terror event. Adults with limited literacy were randomly assigned to review either a standard CDC decision aid written at a 9th grade level (n=22) or an adapted aid written at a 6rd grade level (n=28). Using the AdSAM® emotional response instrument, participants answered questions regarding their feelings about a 'dirty bomb'. The group shown the adaptive aid had more positive emotional responses, including less arousal and greater empowerment. The AdSAM® approach can provide researchers with insights into the design of tailored messages for a limited literacy population in high risk, high-emotion situations.

How Do Low-Literacy Populations Perceive "Dirty Bombs"? Implications for Preparedness Messages.

Potential terror events such as "dirty bombs" could have significant public health effects, but little is known about how low-literacy populations perceive dirty bombs, their trust in public health or government officials to provide credible information, and their willingness to comply with recommended actions. We surveyed 50 low-literacy adults from a large urban center; they were mostly members of ethnic minority groups. We used unique social marketing methods-perceptual mapping and vector message modeling-to create 3-dimensional models that reflected respondents' knowledge of what a dirty bomb is, their intended behaviors should one occur, and their concerns about complying with "shelter in place" recommendations. To further understand individual variations in this at-risk group, a k-means cluster analysis was used to identify 3 distinct segments, differing on trust of local authorities and their emergency response, willingness to comply with emergency directives, and trust of information sources. Message strategies targeting each segment were developed to focus on concepts important to moving the groups toward a "shelter in place" behavior, revealing key differences in how best to communicate with risk communication. We discuss how these methods helped elucidate specific differences in each segment's understanding of and likely response during the event of a "dirty bomb" and how these techniques can be used to create more effective message strategies targeted to these groups.

Attitudes and perceptions of urban African Americans of a "dirty bomb" radiological terror event: results of a qualitative study and implications for effective risk communication.

OBJECTIVES: Radiological terror presents a real threat, but little is known about how low-income, urban African Americans may respond to such threats. The aim of this study was to understand the unique challenges of this group and to explore their knowledge of what a "dirty bomb" is, their intended behaviors should one occur, and their barriers to complying with "shelter in place" recommendations. METHODS: Thirty-seven 18-65-year-olds who were users of community centers in disadvantaged areas participated in 3 focus groups in Philadelphia. Results were analyzed by using the Krueger method of analyzing narrative text. RESULTS: The responses highlighted little knowledge or concern about a dirty bomb. Lack of trust in local authorities was expressed, with participants indicating that they did not feel their needs were addressed. While shelter in place was understood, most said they would still check on family or talk with others to get the "whole truth" because the most trusted information sources were neighbors and community leaders. CONCLUSION: Our results indicate that a risk communication intervention for urban minorities may support desirable behaviors in the event of a dirty bomb, but successful communication will require establishing a local leader as a spokesperson to convince people of the importance of sheltering in place.

Perceptions of testicular cancer and testicular self-examination among college men: a report on intention, vulnerability, and promotional material preferences.

Testicular self-exam (TSE) is an important tool to prevent late-stage diagnosis of testicular cancer (TC). However, most young men remain unaware of their risk for TC despite a growing number of interventions promoting knowledge and awareness of the disease. Of those interventions, very few discuss perceived vulnerability, perceived value of health promotion, and/or preference for informational materials as viable predictors of behavioral change. In this study, 300 university males were surveyed on their perceptions of vulnerability, perceived value of health promotion methods, TC/TSE knowledge, and preference for health promotional information. The results indicated that men were generally unaware of TC and were unsure of their risk of developing the disease. Participants reported very positive responses to questions about the value of health promotion methods, particularly TSE, and indicated a high intention to perform health promotion behaviors. Most important, participants noted that they preferred personalized, tailored information to learn about TC and TSE. Significant predictors of intention to perform TSE include knowledge and awareness of TC/TSE, perceived value of health promotion, and attitudes. Significant predictors of promotional tool preferences differed among generalized pamphlets, personalized messages, and group training sessions. The authors recommend that researchers tailor promotional messages in TC/TSE awareness campaigns with an individual's preference for promotional tool.