# Presentation: 527302

## Marketing “evidence” to healthcare consumers:  Applying social marketing to evidence about the harms and benefits of pharmaceuticals Presented byW. Douglas Evans, Ph.D.Lauren McCormack, Ph.D., M.S.P.HPresented atAgency for Healthcare Research and Quality Conference:Communicating Harms and Benefits of Prescription Drugs to Healthcare Consumers Rockville, MD, September 13, 2006

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## What is Social Marketing?

- Andreasen (1995) defines social marketing as “the application of proven concepts and techniques drawn from the commercial sector to promote changes in diverse socially important behaviors such as drug use, smoking, sexual behavior...This marketing approach has an immense potential to affect major social problems if we can only learn how to harness its power...”

## Theoretical Foundations

- Behavior change theory
- SCT (Bandura), TPB (Ajzen), Transtheoretical Model (Prochaska)
- Message theory
- Elaboration Likelihood (Petty, Cacioppo)
- Exposure theory
- (Hornik)
- Marketing theory
- (Kotler, Zaltman, and many others)

## 3 Basic Approaches

- How to maximize audience exposure to messages?
- Channels
- Leverage
- “Beg” for it – PSAs
- “Buy” it – paid promotion (e.g., advertising)
- “Borrow” it – earned media coverage
- Most campaigns represent some combination

## Social Marketing Strategies

- Audience Segmentation
- Targeting
- Tailoring
- Marketing Strategy
- 4 Ps – Place, Price, Product, Promotion
- Aspiration or social modeling
- Branding
- Create a social movement

## Social Marketing Wheel

**Source: NCI 2002**

## Evidence of Effectiveness

- Bottom line: Small effect sizes for social marketing, but potentially large population impacts
- From 1999-2002, prevalence of smoking in young people in the US decreased from 25.3% to 18%, and
- American Legacy Truth campaign was responsible for about 22% of that decrease
- Small effect by clinical standards, but approximately 300,000 fewer youth smokers in the US

## Evidence of Effectiveness (2)

- Snyder & Hamilton (2002) reviewed recent US mass media campaigns: Average campaign accounted for 9% of favorable changes in health risk behavior, with highly variable results
- “Non-coercive” campaigns (simply delivering health information) accounted for about 5% of the observed variation in behavior
- Grilli et al. (2000) studied 17 recent European campaigns on several topics (HIV, nutrition, etc.) and found behaviors requiring one-time (or few) change are easier to promote than those that must be repeated and maintained.
- Hornik (1997) and Snyder et al. (2003): Some examples (breastfeeding, vitamin A supplements, switching to 1% milk) have shown greater effect sizes and long-term maintenance.

## Portion of Decline in Youth Smoking Attributable to truth® 

- Approximately 22% of total decline in youth smoking attributable to the “truth” campaign
- Represents roughly 300,000 fewer youth smokers as a result of “truth”

## Social Marketing in Health Care

- Some efforts to change consumer behavior, primarily through risk communication
- Good examples from prostate & breast cancer screening (McCormack et al., in press)
- Very little published research on social marketing to change health care provider behavior
- Recent work on understanding marketing by pharmaceutical firms to psychiatrists & physicians (Steinman, Bero et al., 2006)

## Many Opportunities for Social Marketing in Health Care...

- AHRQ purposes:
**Synthesize knowledge:** Evidence-based Practice Centers systematically review published & unpublished scientific evidence
**Generate knowledge:** DEcIDE Research Network studies new scientific evidence and analytic tools in an accelerated and practical format.
**Translate knowledge:** The John M. Eisenberg Clinical Decisions and Communications Science Center compiles the research results into a variety of useful formats for stakeholders.
- Target Populations:
- Elderly – Medicare/Medicaid (SCHIP)
- Pregnant women and young children
- People with disabilities

## Social Marketing Opportunities

- All of these purposes and populations are currently targets of social marketing efforts by major funders (e.g., CDC, NIH, foundations)
- Significant opportunities to apply social marketing
- Goal is to identify social marketing strategies that can be translated to health care settings
- Reinforcement of messages/campaigns
- Which ones seem most readily translatable?

## What Strategies & Tactics Work in Social Marketing?

- Countermarketing
- Argument credibility and likeability
- Theory-based change models
- Social modeling & behavioral alternatives
- Risk communication (with certain populations)

## What Does NOT Work in Social Marketing

- Negative messaging can be ineffective with specific audiences (young people)
- High cost tradeoffs (loss of immediate, desirable lifestyle options in return for long-term health gains)
- Ambiguous messages (do _**this**_, except when...)
- Evidence-based messages need to have clear associated behaviors
- Low exposure

## Global Social Marketing Challenges

- Increase in health issues competing for public attention (tobacco, obesity, drug abuse, HIV/AIDS)
- Busy lifestyles, people’s time limitations, technology
- Cluttered media environment for health information
- Increase in the number and type of communication channels, including the Internet
- Consumers & practitioners: Demands on time, multiple education/information sources, changing practice guidelines, fads in health promotion

## Specific Challenges with Health Care Consumers

- Informed decision making (or shared decision making) to address scientific uncertainty
- Patient behavior change can be talking to your provider about pros and cons of different decisions
- How to give providers discussion points to raise with patients?
- How to give providers easy access to evidence & discussion points at point of patient contact (e.g., PDAs, pocket info)
- After the discussion, the decision may be to do nothing (e.g., not get tested, at least not now)
- Encourage additional learning about the clinical area

## Case Studies

- Following slides offer 4 brief examples from successful social marketing efforts that illustrate key principles of what works
- Each example focuses on possible applications in health care

## Case Study 1: Countermarketing

- Counter-marketing is a strategy to deliver information to counter the effects of marketing by companies with competing interests (e.g., tobacco, pharmaceuticals)
- Has been widely used in public health to promote population-level health behavior change and prevention (e.g., smoking)
_**Competition**_ between messages: Countermarketers take away “market share” by providing more compelling facts, information, imagery (rational and affective appeals)
- Recently, counter-marketing has been used to reach practitioners such as psychiatrists to counter pharmaceutical industry misinformation

## Countermarketing - Competition

- In tobacco control, countermarketing “brands” encourage non-smoking lifestyle (Evans et al., 2005)
- Use persuasive imagery to sell non-smoking, counter to imagery used by industry to sell smoking as socially desirable
- Countermarketers compete with tobacco industry marketing to take away “market share”
- Encourage adoption of alternative behaviors to take away “market share” from the smoking behavior

## Rebellion against industry

## Potential Lessons for Health Care

- Countermarketing offers strategies for dissemination of best practices (e.g., patient-provider communication)
- Evidence of success in delivering rational arguments (tobacco use risks) with credible messages
- Countermarketing could deliver credible science-based information to consumers to counter inaccurate messages or promote informed decisions (e.g., Medicare Part D)
- Countermarketing could counter misleading pharmaceutical marketing to practitioners and reinforce other information such as CME, conferences, publications

## Case Study 2: Credibility & Likeability

- Message theory suggests people must engage in “elaboration” (agree with a message’s arguments) for persuasion to occur (Petty & Cacioppo 1986)
- Elaboration has both cognitive (rational) and affective (emotional) aspects – credibility & likeability
- Effective social marketing campaigns use targeted and/or tailored messages to affect behavioral factors

## Effectiveness of Targeted Messages

- Evidence that targeted message strategies used in countermarketing influence specific attitudes and beliefs.
- Sly et al. (2002) found teens with high levels of anti-tobacco industry attitudes promoted by the Florida TRUTH campaign were 4 times less likely to initiate smoking and more than 13 times less likely to become established smokers.
- Ohio **stand** campaign (Hersey, et al., 2006) followed youth over an 18 month period and found reduced likelihood of initiation among 15-17 year olds that self-reported campaign awareness.
- Consortium to Lower Obesity in Chicago Children (CLOCC) has developed a clinic- and community-based intervention – 5-4-3-2-1 Go! – that targets specific nutrition and physical activity behaviors for multicultural audiences (Evans et al., in press)

## The stand Campaign

## stand Awareness and Smoking Uptake

- Longitudinal Survey: Time 1 (Y1) - Time 3 (Y3)
- Never Smokers at Y1
- Aware of **stand **at Y1 - Less likely to try smoking at Time 3
- 6.5% vs. 9.5% or
- 44% less uptake

**Notes:**
Bivariate analysis – In other words, did not control for any demographic characteristics.

Not significant	

Graph of “Never smokers at Baseline” who had “Tried smoking” by Time 3
(Blue)  Not confirmed awareness of stand:  
9.5% tried smoking
(Orange) Confirmed stand:             
6.5% tried smoking
OR:  0.36, n.s. 
44% more likely to smoke
TUPE: OR: 0.76, n.s.

## Potential Lessons for Health Care

- Social marketing messages for health care (e.g., immunization, screening) should be delivered to consumers by trusted sources that enhance credibility
- Consumers are more likely to change behavioral precursors and health care behaviors if messages are credible, likeable, and have source credibility.
- Providers have a unique opportunity to serve as trusted sources for some target audiences (provider-to-patient population relationship may be important in multicultural, low income, etc., settings)

## Case Study 3: Theory-based Behavior Change Models

- Social marketers use theory to identify behavioral determinants that can be modified.
- For example, social marketing aimed at obesity might use theory to identify connections between behavioral determinants of poor nutrition, such as:
- Eating habits within the family,
- Availability of food with high calorie and low nutrient density (junk food) in the community
- Glamorization of fast food in advertising
- Social marketers use such factors to construct conceptual frameworks that model complex pathways from messages to changes in behavior

## Example Behavior Change Model

## Promotion of Evidence-based Nutrition & PA Using Theoretical Framework

## Example Theoretical Frameworks

- Social cognitive theory (Bandura 1986): Modeling a positive, nonsmoking lifestyle encourages emulation
- Countermarketing campaigns can effectively project images of socially desirable behavioral choices (lifestyle)
- Social images projected by Legacy Truth campaign are of coolness & popularity of non-smoking (Evans, et al. 2005)
- Science-based messages presented in appealing, culturally appropriate way are better received (Evans et al., in press)
- Additional evidence from public health:
- Hornik et al. (2003): ONDCP anti-drug campaign
- Huhman et al. (2004): VERB: It’s What You Do campaign

## Potential Lessons for Health Care

- Health care consumer behavior can be changed through underlying behavior change principles
- For example, health care choices can be portrayed as socially desirable while also providing accurate, science-based facts and information
- Science-based information can be made appealing
- Opportunity to merge behavior change theory and health science dissemination & translation fields

## Case Study 4: Risk Communication About Pharmaceuticals

- Recent research on marketing/promotion of gabapentin (anti-epileptic drug (AED)) to prescribers (psychiatrists) & consumers (mood disorder patients)
- Settlement between Pfizer (former Warner-Lambert) and NAAG provides insight into industry marketing (document discovery)
- Promotion generally ignored evidence base for appropriate prescription, put consumers at undue risk
- How can social marketing - dissemination of evidence to prescribers and consumers - counteract this?

## Gabapentin Marketing

- Continuing Medical Education
- Warner-Lambert used CME events at which speakers could communicate directly to physicians
- Advisory Boards & Consultant Meetings
- Informal exploratory & concept testing “research”
- Research Strategy & Publications
- Disseminate through publication as promotion tool

## Evidence-based AED Dissemination Model

## Potential Lessons for Health Care

- Pharmaceuticals using many of same marketing strategies proven effective in social marketing
- Countermarketing could target both physicians and consumers
- Physicians reached through dissemination of evidence-based drug information: CMEs, conferences, Web-based dissemination, pocket cards, PDA applications
- Publication of evidence base on gabapentin & drug class
- Consumers reached through mass media (Web), physician-patient interaction (mediated communication)

## Personalize risk data -- use stories, narratives, and anecdotes
Use graphics and other pictorial materials to clarify messages
Be sensitive to local norms, such as culture, speech, and dress
Use a variety of approaches such as written, oral, and electronic
Use clear, non-technical “plain” language appropriate to the target audience (www.plainlanguage.gov)

- Personalize risk data -- use stories, narratives, and anecdotes
- Use graphics and other pictorial materials to clarify messages
- Be sensitive to local norms, such as culture, speech, and dress
- Use a variety of approaches such as written, oral, and electronic
- Use clear, non-technical “plain” language appropriate to the target audience (_[www.plainlanguage.gov](http://www.plainlanguage.org/)__)_

## Conclusion: Implications of Social Marketing for Health Care Practice

- Social marketing can be useful in health care practice
- Evidence on social marketing suggests underlying principles can influence health care consumer decision making through multiple strategies
- Health care setting provides a unique opportunity to reinforce messages aimed to consumers through brief counseling
- As a trusted source, practitioners’ reinforcement of social marketing messages adds value beyond the effects of mass communication

## Questions/comments?

- W. Douglas Evans, Research Triangle Institute, _[devans@rti.org](mailto:devans@rti.org)__, 202-728-2058_