Exploring the Candidacy Framework: Understanding Women's Perceptions of Breast Cancer Risk and Alcohol Consumption

How the interpretative sociological framework ‘candidacy’ was used to understand women’s perspectives on breast cancer risk relative to alcohol consumption and their social class?
Paul Ward: Women’s alcohol consumption is a critical public health problem because of increased risks of developing breast cancer. The rather obvious solution is that women reduce drinking in order to reduce breast cancer incidence. But our research interviews with 50 midlife women (aged 45-64) found the acceptability of risk messages relies on women believing that they are personally at risk of breast cancer from drinking alcohol, and that they perceive their alcohol consumption makes them a ‘candidate’ for breast cancer. 
 

The notion ‘candidacy’ developed out of knowledge that there exists a lay epidemiology of risk factors for disease (initially applied to coronary heart disease [1] and later to cancer [2-5]), which is critical to whether people take heed of health promotion messages. 
 

We sought to understand women’s logics about who is a breast cancer candidate (if not her, then who?) as a pathway to innovating public health responses and as a crucial consideration for reducing inequities in breast cancer prevention that result from social class. Women effectively formulated a response to the question ‘who is the type of person who would get breast cancer from drinking alcohol’ and this seemed to drive their responses to public health advice.
 

We utilised ‘candidacy’ as a way of understanding why women continue to drink alcohol despite it being a known risk factor for breast cancer.  We interviewed 50 women in midlife who drink alcohol and have no previous breast cancer history with different levels of resources (social, cultural including education and economic) according to their social class. We asked women how they rationalised who is at risk for breast cancer, and for their own personal perceptions of breast cancer risk, and also how/why they denied or overlooked risk factors, specifically alcohol consumption. Indeed, this study allowed us to undercover that women’s perceptions of their own breast cancer risk are shaped by social class and women’s levels of agency to reduce alcohol consumption. Women with limited access to resources (working class women) were more likely than affluent women to identify risks that make them candidates for breast cancer (albeit with limited chances to change), while more affluent women tended to deny or mitigate risks associated with alcohol, and due to their higher levels of access to social, economic and cultural capital, some women seemed to trivialize how impactful breast cancer might be should it occur in their lives and that if it did it could be easily managed. Perspectives of alcohol-related breast cancer risk for middle class contained elements of both working class and affluent class women - with missile class women grappling with the notion that alcohol (something positive and enjoyable) could result in them becoming candidates for breast cancer (something negative) and seeking to balance or counteract the risks from alcohol not by giving it up but rather with other ‘compensatory’ health promoting behaviours. 

How did you select the 50 Australian mid-life women for the interviews, and what were the main criteria for their selection?
We wanted to understand the alcohol-related breast cancer risk perceptions of Australian midlife women aged 45-64 years because this is a time where they are at increased risk of breast cancer according to age[6]. It is also a life stage where they are consuming increased volumes of alcohol (compared to other age groups of women). We recruited women with no previous breast cancer diagnosis because our focus was on understanding their perceptions of the potential they would develop breast cancer in future (their candidacy), and specifically from drinking alcohol (a modifiable risk factor for breast cancer). We also wanted to understand how social class and differing levels of access to resources might shape women’s ideas about breast cancer candidacy – their own and other people’s. We recruited women with varying levels of social, cultural and economic capital so we could consider candidacy in relation to who they know, the activities they participate in, and the affordability of preventive health relative to daily living costs. 

 

To recruit these women, we advertised the study through in community centres, libraries, newspapers, Facebook and snowballing techniques. We recruited women from different social class groups – working, middle and affluent – according to measures of their income and assets, the occupational prestige of their social networks and the types of activities they participate in and with different levels and patterns of alcohol consumption, different living and working arrangements that contour their daily living experiences.

Can you elaborate on how Bourdieu’s relational capitals were used to show how social class shapes women’s ascriptions and enactments of breast cancer candidacy?
Bourdieu’s social class framework extends beyond socio-economic status to also consider access to cultural, social and economic capital and how varying combinations of these position people in differing social classes.  Bourdieu conceptualised social classes as engaged in a struggle for power, and seeking to maintain their privileged position in social order means the affluent classes find ways (forms of distinction) to distance themselves from working class groups. We observed this play out in our data in the ways women talked about who they thought were breast cancer candidates. Affluent women considered working class women to be candidates because of their ‘unhealthy lifestyles’. Similarly,  affluent women seemed to think their drinking practices were superior and certainly, in terms of adhering with social norms, their drinking was for enjoyment, they had control of it, they didn’t drink as much as others (presumably working-class women) and so risk for them was mitigated and denied – resulting in a ‘resistance’ that they are candidates at all. 

Can you provide some examples of how social class impacts modifying alcohol consumption for breast cancer prevention?
Women’s abilities to modify alcohol consumption correlates with the role and function that drinking plays in their lives, but also women’s willingness and capability to accept alcohol as a breast cancer risk and their abilities to prioritise health (over alcohol use as a valuable form of coping or social connection). Affluent women were more likely to question the link between alcohol and breast cancer, they did not particularly see themselves at risk for breast cancer and didn’t see alcohol as particularly harmful for them. However, if they did desire to reduce consumption, they could readily draw on their resources and mobilise their agency to modify drinking, – the only barrier for these women was that they said they still experienced pressure from peers to continue to drink, which was not mentioned by women in other social classes. For working class women, alcohol was used more to manage stresses resulting from their difficult lives - they reported more concerns about structural issues like financial worries, homelessness – and due to their ‘short horizons’ reducing consumption for breast cancer prevention was not able to be considered as a priority.

How does your study offer an important theoretical extension to ‘candidacy’ by demonstrating more or less fluidity in women’s assessment of breast cancer risk according to their agency to adopt breast cancer prevention messages?
This is the first study to apply and explore breast cancer candidacy among women from different social classes.  Our aim was to probe women’s alcohol related breast cancer risk perceptions – whether they think that their drinking alcohol has any impact on their chances of developing breast cancer.  When we examined the data by social class, we found that some women were more open to considering their breast cancer risk and acting on public health advice by reducing alcohol consumption (more middle and affluent-class women) compared to women who acknowledged the increased risk of breast cancer from drinking alcohol, but whose agency to reduce alcohol or substitute alcohol with other ways to achieve relaxation or reduce stress was limited (i.e. working class women). Varying access to social, economic and cultural capitals were also at play in the fluidity of candidacy – that is that women’s capacity to identify breast cancer risks and act on these. Working class women were more certain that they were at risk for breast cancer (potential candidates) and acknowledged that their unhealthy behaviours contributed to this, but they lacked the necessary social, cultural and economic capitals to act on prevention advice and reduce alcohol. While the most affluent women did not especially perceive themselves at risk for breast cancer, some women in this group did acknowledge concern about their breast cancer risk and used their agency and resources to act on these risks. For example, one woman recognised her breast cancer risk due to increasing alcohol consumption following divorce and employed varying capitals (social support/help-seeking) to help her redress this.  For some women there was shifting concern about their breast cancer risk over time.  One woman said that despite her family history of breast cancer, when her children were younger, she didn’t acknowledge this risk as she was prioritizing raising her children, not her own health. However, her perception of familial risk shifted in the context of her children becoming adults and reprioritizing her own long-term health – therefore she was considering how to act on this risk and whether to attend genetic testing. 

Can you discuss how understanding the social class possibilities and limitations in women’s perceptions of breast cancer risk provides a new opportunity to reduce inequities in breast cancer incidence?
To date, public health has had a strong focus on mammography screening and the general public also tends to consider this a key component of managing breast cancer risk. However, far less attention has focused on modifiable breast cancer risks, and public understanding of the link between alcohol and breast cancer remains low. Our work opens up opportunities to address this in an equitable manner. We have shown that women’s perceptions of their breast cancer risk relative to alcohol consumption are shaped by social class. This means that public health messaging about alcohol as a breast cancer risk needs to consider the impacts of social class on both women’s alcohol use, how they perceive this risk, and their ability to act on risk. Hence, messages could be tailored to better resonate with women in differing social classes. However,  health promoting messages may fall short if the underlying factors that propagate a need to drink alcohol are not addressed. For example, one participant who reported drinking alcohol to salve loneliness suggested a nightly walking group (a healthier alternative to drinking alcohol) would break her routine of coming home from work and having a drink. However, she was unable to access a group suitable to her in terms of affordability and demographic. A free community-based walking group could both increase individual and community social connection and build norms around non-drinking activities.

 

We are also currently exploring whether women’s perceptions of their breast cancer risk (candidacy) differ for women who attend mammography screening and those that don’t, and this may also contribute to our understanding of how to address breast cancer prevention.

References
1.    Davison, C., G. Davey Smith, and S. Frankel, Lay epidemiology and the prevention paradox: the implications of coronary candidacy for health education. Sociology of Health & Illness, 1991. 13(1): p. 1-19.
2.    Pfeffer, N., Screening for breast cancer: candidacy and compliance. Social Science & Medicine, 2004. 58(1): p. 151-160.
3.    Salant, T. and S. Gehlert, Collective memory, candidacy, and victimisation: community epidemiologies of breast cancer risk. Sociology of Health & Illness, 2008. 30(4): p. 599-615.
4.    Macdonald, S., G. Watt, and U. Macleod, In search of the cancer candidate: can lay epidemiology help? Sociology of Health & Illness, 2013. 35(4): p. 575-91.
5.    Bikker, A.P., et al., Perceived colorectal cancer candidacy and the role of candidacy in colorectal cancer screening. Health, Risk & Society, 2019. 21(7-8): p. 352-372.
6.    Cancer Australia, Risk factors for breast cancer: A review of the evidence. 2018, Cancer Australia: Surry Hills, NSW.