Engaging the Population: Innovative Strategies in Marketing, Outreach and Enrollment

Slide Presentation by William Smith

The following slide presentation was used during the State Children's Health Insurance Program (SCHIP) Workshops held during July and September, 1998. This is the text version of William Smith's slide presentation. Select to access the slides (PowerPoint® File, 1.1 MB).

Slide 1

Science Based Social Marketing: Innovations to Promote Enrollment in CHIP

Wm. A. Smith
Academy for Educational Development
1255 23rd St. NW, Washington DC 20037
www.besmith@aed.org

Slide 2

Families with Uninsured Children

This slide shows a image of 3 people and a series of text boxes. The first box is labeled "Know About It," and an arrow points from this box to the next box, which is labeled "Believe It." An arrow points from this second box to a third box, which is labeled "Care About It." An arrow points from this box to a fourth box, which is labeled "Go Get It."

A numbered list within a circle reads:

1. Wage Verification.
2. Housing Docs.
3. Child Support Info.

Slide 3

CHIP: Who is Uninsured?

• Working Poor—Hispanic.
• South and West.

An arrow is labeled "Readiness to Change." Below it, a box labeled "Unaware" points to a second box, labeled "Aware"; three arrows point from the "Aware" box to three text items:

• Ready to Go.
• Barriers (Structural/Perceptual).
• Resistors (Last 10%).

Slide 4

Barriers

Eligibility Requirements

• Medicaid = Welfare = Dependence.
• Language/Cultural.
• Fear of Dealing with Government.

Slide 5

Cost/Benefits

Image of a woman, thinking:

1. Why bother? — Protect against future disaster.
2. How easy is it to get/use? — Not that easy.
3. Have any of my friends done this? — Not many.
4. What is this going to cost me? — Time, transportation, day off work, embarrassment at being turned down.

Slide 6

Image of a woman, thinking:

Do I bother trying to get this benefit for my kids and run the risk of being turned down, or do I use this time...

• To go to my job?
• To stay home with my kids?
• To get a million other things done?

Slide 7

Image of a woman, thinking:

• Cost... It's free or low-cost.
• Available NOW.
• You are eligible.
• Program in NEW.
• Avoid "Federal" label.
• Avoid mentioning numerical limits (ten million available).

Each item has a red check-mark beside it.

Slide 8

Social Marketing is not:

• A Slogan...A Condom Wrapper.
• A Public Service Announcement.
• A Communication Campaign or Mass Media.

Social Marketing is a process to organize the business of behavioral change.

• Continuous & Adaptive.
• Empirical & Self Correcting.
• Multi-dimensional—Interpersonal/Mediated/Community.

Slide 9

3 Approaches to HIV/AIDS Prevention

• Product...Social Marketing.
• Behavioral...Social Marketing.
• Policy...Social Marketing.

Slide 10

Social Marketing

All marketing is behavioral... but

Image of an oval divided into three sections: The first is labeled "Buy a Condom," and below, a caption reads "Product." The second section is labeled "Talk to Partner about Condoms," and below, a caption reads "Behavioral." Over these two sections is a bracket labeled "At Risk Population." The third section is labeled "Needle Exchange, Discrimination" and below, a caption reads "Policy." A bracket over this section is labeled "Policymakers."

Slide 11

Can we change behavior as a result of deliberate, organized programs of social change?

Slide 12

Heart Disease

Slide 13

Annual Number of New HIV Infections in SF

Line graph shows 0 new infections prior to the 1970s, then a sharp rise to 8,000 in 1987. After 1987, new infections decrease to 200 in 1995, with a note that infections are "Rising in young, gay men."

Slide 14

Number of Sexual Partners in Gay/Bisexual Men

Slide 15

Condom Use Among Boys 15-19

Did you use a condom during your first sexual encounter?

Line graph shows 62% of boys asked this question responded "Yes" in 1988; in 1995, the number had risen to 73%.

Slide 16

Condom Use Among Female Teens Rose from 23% ('82) to 45% ('88)

Pie charts show the increase in condom use between 1982 and 1988. Notes below read that this statistic is from "Sexually experienced women aged 15-19 in interviews: 1982, 4,484,000; 1988, 4,883,000."

Source: J.D. Forrest and S. Singh, "The Sexual and Reproductive Behavior of American Women, 1982-1988, Family Planning Perspectives 22:206-4, 1990, Table 5, p.209.

Slide 17

Not Everything that Gets Better Stays Better

Slide 18

Measles Cases

Line graph shows 894,124 cases of measles in 1941, 1,500 in 1983, 25,000 in 1990, and 281 in 1993.

Slide 19

Teen Smoking in the U.S.

Line graph shows 26.9% of teens smoked in 1975, 18.1% smoked in 1988, 14.3% in 1990, then the numbers rise again to 22.2% in 1996. (For 12th-graders smoking daily; for 8th-graders with 30-day prevalence, 21.0% smoked in 1996.)

Slide 20

Multiple Reasons for Behavior Change

• Intervention Program—Poor Program.
• Secular Events—News Reports.
• Fatigue—Old Message.
• Competing Behaviors—Child Care Needs.
• New Audiences—Newlyweds.

Slide 21

What Works Best to Influence Behavior on a Larger Scale?

Slide 22

Secular Trend?

Line graph shows Quit Rates Over Time (APJ, Feb. '95). Light and Moderate Smokers quit in greater numbers than Heavy Smokers.

Slide 23

Tactics

• PSAs.
• Hotlines.
• School Programs.
• Peer Outreach.
• Medical Programs.
• Media Briefings.
• Collaborative Training.
• News Briefings.
• Paid Advertising.
• Pamphlets.
• Billboards.
• Direct Mailings.
• Celebrities.
• Entertainment Media.
• Etc...

No single tactic accounts for very much change in behavior.

Slide 24

Flow chart shows oval at the center of the slide, labeled "Programs." A dotted line divides the chart into two sections, one labeled "Perceptual" and the other "Structural."

On the "Perceptual" side of the dotted line, one solid line leads from the "Programs" oval to a large gray box labeled "Social Impact"; beneath it is a smaller white box labeled "Less Cancer." Another line leads from the "Programs" oval to a large gray box labeled "Behavior"; above it, a smaller white box is labeled "People Use Test & Mitigate." Another line points from the "Behavior" box to a gray box labeled "Internal"; above it, a smaller white box is labeled "Is Risk Serious?"

On the "Structural" side of the dotted line, a solid line leads from the "Programs" oval to a large gray box labeled "Technology"; beneath it is a smaller white box labeled "Home Tests." Another line from the box labeled "Behavior" to a gray box labeled "External"; below it, a smaller white box is labeled "Can I Afford the Mitigation?"

Arrows point to the boxes labeled "Internal" and "External," noting that these are "Determinants."

Slide 25

Social Marketing

A Process to Integrate Various Tactics

A large orange arrow points downward. Above the arrow is a caption that reads "Force - Regulation"; below the arrow, another caption reads "Education - Knowledge." A smaller orange arrow perpendicular to the large arrow points to a cyclical circle—i.e., three arrows of red, green, and blue, curved together to form a circle. This circle is captioned, "People do things in exchange for value." Below the circle, another caption reads, "What must I offer people in exchange for the behavior I want them to adopt?"

Slide 26

Five Tactics to Influence Behavior

• Force.
• Facts.
• Feelings.
• Freebees.
• Facilitation.

Slide 27

FORCE: It's the law.

Slide 28

Click it or Ticket

Program of Regulation plus Communication.

Slide 29

Click it or Ticket

Seat-belt Use in North Carolina
(Journal of Safety Research Vol. 27, 1996)

Line graph shows that seat-belt use was at 63% in Oct. 1992, then rose to 80% in Nov. 1993, dropped to 73% in May 1994 and rose again to 81% in August 1994. An icon of a police badge and a television set above the graph, pointing to time periods of increased law enforcement and media promotion suggests that the points where seat-belt use rose were in response to these incentives.

Slide 30

Click it or Ticket

Results:

Slide 31

Click it or Ticket

Flow chart shows oval at the center of the slide, labeled "Click it or Ticket" A solid line leads from the "Click it or Ticket" oval to a large gray box labeled "Health"; beneath it, a caption reads "Seat-belt Use, Fatalities, Cost Savings."

A second line leads from the "Click it or Ticket" oval to a large gray box labeled "Behavior"; above it, a caption reads "Use Seat Belts." Two lines point from the "Behavior" box to a gray boxes labeled "Internal" and "External"; above the "Internal" box is a caption that reads "Publicity about the Law," and below the "External" box, a caption reads "New Enforcement, Policy & Action." A large black arrow points up and down between these two boxes.

A third solid line leads from the "Click it or Ticket" oval to a large gray box labeled "Technology"; beneath it, a caption reads "Seat Belts."

Slide 32

FACTS: Knowledge/Awareness

Does knowledge alone change behavior?

Slide 33

Cost-effectiveness of the Turkish Media Campaign for Family Planning

There is a red dotted line between items 3. and 4. in the above table. A red arrow pointing down over the column headed "Estimated Number of Women Reached" emphasizes the decrease in numbers in each successive category. A red arrow pointing up over the two Cost columns emphasizes that the costs are smaller for the first items.

Note: Total Costs = Direct Costs plus donated time.

Slide 34

SIDAS: Sudden Infant Death Syndrome

Placing an infant in a prone (face-down) position increases the risk of SIDS.

Line graph shows that, during a "pro-prone" campaign, SIDS cases rose from 10% to 55% in the Netherlands, then dropped to 27% during a one-year "anti-prone" campaign.

Line graph shows that SIDS cases dropped from 44% to 3% in New Zealand in 3 years.

Slide 35

Reyes Syndrome

Use of aspirin in small children (Soumerai, et al. 1992).

Line graph shows that, during a "window of change," use of aspirin decreased while public debate and changes in policy and labeling rose.

Slide 36

D. Matthews/Kettering, 1996

Is there a public for pulbic schools?

Line graph shows that Public Debate/Attention and Test Scores rose in Mississippi, Arkansas, and Tennessee.

Public Strategies—public talk
Public Relation—people as audience
Community Organizing—people as means

Slide 37

FEELINGS: We have good science about Perceptions

Slide 38

Chart shows oval at the center of the slide, labeled "Program." A dotted line divides the chart into two sections, one labeled "Perceptual" and the other "Structural."

On the "Perceptual" side of the dotted line, one solid line leads from the "Program" oval to a large gray box labeled "Social Impact." Another line leads from the "Program" oval to a large gray box labeled "Behavior"; above it. Another line points from the "Behavior" box to a gray box labeled "Internal" and an arrow points back from "Internal" to "Behavior."

On the "Structural" side of the dotted line, a solid line leads from the "Program" oval to a large gray box labeled "Technology." Another line leads from the box labeled "Behavior" to a gray box labeled "External". An arrow points to the "Internal" box to indicate "Determinants".

Slide 39

Internal Determinant Definitions

• Social Norms: A "We Statement" Together: Who matters to you? What do you think they want to do?
  Someone the individual cares about has a problem with them using a condom. It might be family, friends, or their proposed sexual partner.

  The solution can best be handled by the individual coming to believe that person(s) has changed his/her mind.

• Self Efficacy: Do I feel I can do this?
  The individual is worried he/she cannot do something associated with condom use very well. He/she is afraid to be embarrassed or fail at the task. It might be using a condom or talking to partner about a condom.

  The solution can best be handled through some kind of training, formal or informal.

• Perceived Consequences (Benefit) is Missing: Something I want... that is better than I have.
  The individuals really want something which the use of condom is not necessarily going to give them.

  The solution is to add some missing benefit.

• Perceived Consequences (Barrier): The individuals feel that something outside of themselves is going to interfere with the use of a condom.

  The solution is to remove the something that is in the way.

• Perceived Risk: The individual does not believe he/she is at risk for AIDS.

  The solution is to demonstrate personal relevance.

• Skill: Someone's actual ability to do something as measured by an objective, observable outcome.

• Knowledge: Correctness of a factual statement.

• Access to Services/Support: The dollar price, convenience, or physical accessibility of a product or service.

Slide 40

Dominican Republic:
HIV Infection Rates High
Knowledge of AIDS Very High
Use of Condom Low

How to Increase Condom Use?

• Scare people some more?
• Teach people they are at risk?

So, we did a survey...

Slide 41

Why Don't People Use Condoms?

...because they do not feel at risk of AIDS.

Bar graph shows that 93% of persons asked know about AIDS; only 30% feel at risk. These two items are pointed out as "Determinants."

Slide 42

Doer/Non-Doer Comparison

Step 1: Do you use condoms regularly?

Box chart shows that the majority answered "no" by about 3/4.

Step 2: Do you feel at risk of AIDS?

Bar graph without numbers shows that both Non-doers and Doers responded at about the same level, with Non-doers slightly higher.

Slide 43

Condom Use and Knowledge

Bar chart compares those who "Never Use" condoms with "Ever Users":

• One can get AIDS through sex with an infected person: "Never Users" - .75%; "Ever Users" - .76%.
• Infected persons who look and feel well can infect others: "Never Users" - .85%; "Ever Users" - .85%.
• You can NOT tell by looking whether someone has AIDS: "Never Users" - .8%; "Ever Users" - .79%.

Arrows mark which group is more correct. For the first two questions, the "Ever Users" are more often correct; for the third question, the "Never Users" are.

Slide 44

Condom Use and Severity

Bar chart compares those who "Never Use" condoms with "Ever Users":

• AIDS is a most serious problem: "Never Users" - .65%; "Ever Users" - .7%.
• AIDS causes great suffering: "Never Users" - .9%; "Ever Users" - .93%.
• There is NO cure: "Never Users" - .8%; "Ever Users" - .8%.

Slide 45

Condom Use and Efficacy: General and Condom Efficacy

Bar chart compares those who "Never Use" condoms with "Ever Users":

• Yes, one can do something to protect: "Never Users" - 1%; "Ever Users" - .9%.
• One can use condoms to protect: "Never Users" - .85%; "Ever Users" - .8%.
• Yes, condoms prevent STDs and AIDS: "Never Users" - 1%; "Ever Users" - .9%.

Slide 46

Condom Use and Perceived Susceptibility

Bar chart compares those who "Never Use" condoms with "Ever Users":

• I am at Risk: "Never Users" - .25%; "Ever Users" - .3%.
• AIDS is Serious in the this Country: "Never Users" - .25%; "Ever Users" - .26%.
• I think about getting AIDS: "Never Users" - .54%; "Ever Users" - .55%.

Slide 47

Condom Use and Social Norms: Strong Relationship

Bar chart compares those who "Never Use" condoms with "Ever Users":

• Talk with Friends about Condoms: "Never Users" - 43%; "Ever Users" - 77%.
• Friends use Condoms: "Never Users" - 25%; "Ever Users" - 61%.
• Sex Partner ever suggested using a condom: "Never Users" - 14%; "Ever Users" - 72%.

Slide 48

The words "You are at Risk?" appear at the top of the slide, crossed out. Below, another line reads "Everybody's doing it!" The graph from Slide 47 is repeated in smaller form.

Slide 49

FREEBEES: Incentive to do the right thing?

Slide 50

Dayton, Ohio
Managed Care
Excessive Use of ER

• Hypothesis: Women use emergency rooms (ERs) because it is easier and they don't understand the system.
• Response: Organize a cadre of social workers to visit and provide friendly information about use of primary providers.
• Result: 0% use in ER.

Slide 51

Dayton, Ohio
Managed Care
Excessive Use of ER

Study Consisting of:

• Direct observation in ER rooms.
• Focus groups with patients and providers.
• Individual interviews with providers, patients, and staff.
• Data analysis of existing usage data.

Slide 52

Dayton, Ohio
Managed Care
Excessive Use of ER

• Direct Observation: Improper Usage.
• Focus Groups: Women did understand.
• Individual Interviews: # of system problems.
• Admininstrative Data Analysis: 12 of 223 providers accounted for 50% of ER Primary Care visits.

Slide 53

Chart shows oval at the center of the slide, labeled "Program." A dotted line divides the chart into two sections, one labeled "Perceptual" and the other "Structural."

On the "Perceptual" side of the dotted line, one solid line leads from the "Program" oval to a large gray box labeled "Social Impact." Another line leads from the "Programs" oval to a large gray box labeled "Behavior"; above it. Another line points from the "Behavior" box to a gray box labeled "Internal" and an arrow points back from "Internal" to "Behavior."

On the "Structural" side of the dotted line, a solid line leads from the "Program" oval to a large gray box labeled "Technology." Another line leads from the box labeled "Behavior" to a gray box labeled "External"; below it is a box labeled "Provider Instructions" with an arrow that points to the "Internal" box.

Slide 54

FACILITATION: Making it easier to do the right thing.

Slide 55

Fatal Drunk Driving

• Air Bags.
• Safer Cars.
• Driving Age.
• Enforcement.
• MADD.
• Messages.

Percent of Alcohol-related Fatalities dropped 31%.

Percent of Alcohol-related Accidents dropped 27%.

Slide 56

Facilitation Strategies

Simplifying...
Streamlining...
Integrating...

Eligibility process

Graphic depicts a grey box labeled "External"; a line connected this box to a circle labeled "Pricing/Distribution." Another grey box labeled "Technology" is connected by a line to a circle labeled "Products." Lines also lead away from both boxes over a thick dotted line that crosses the slide.

Slide 57

What do we Measure to Determine Success?

Slide 58

Evaluation

An arrow points from a box labeled "Intervention" to a box labeled "Determinant." Another arrow points from the "Determinant" box to one labeled "Behavior." An arrow points from the "Behavior" box to a box labeled "Social Benefit." These boxes are placed left to right on the slide.

Beneath the "Social Benefit" box are captions that read "Less Disease" and "Is there less disease?" To the right of these, beneath the "Behavior" box, are are captions that read "No. Enrolled" and "Did it increase?" To the right, beneath the "Determinant" box, are are captions that read "Social Norm" and "Did it change?" On the far right, beneath the "Intervention" box, the captions read "Campaign" and "Did it happen?"

Beneath these questions a large caption reads NO? and an arrow points to the phrase "Was it the right one?" Another arrow points from this phrase to "Did enough of it happen?"

Slide 59

What does this suggest for the CHIP Program?

1. Look for benefits people care about.
2. Emphasis on facilitation strategies (making it easier to get and use) may be important.
3. Emphasis on incentives for system middlemen, rather than incentives for enrollment, may be important.
4. Better to measure behavior than knowledge or even attitudes.
5. Size (scale of exposure) matters.
6. Regular monitoring better than formal evaluation.

Slide 60

References

Increasing Seat Belt Use in North Carolina. Journal of Safety Research 1996;27(1):33-41.

Hall B. Interventions to Prevent HIV Risk Behaviors. NIH Consensus Development Statement, February 1997.

For a Healthy Nation: Returns on Investment in Public Health. U.S. Department of Health & Human Services.

Pingree S, Hawkins RP, Gustafson DH, Boberg EW, Bricker E, Wise M, Tillotson T. Will HIV-positive people use an interactive computer system for information and support? A study of CHESS in two communities. Center for Health Systems Research and Analysis, University of Wisconsin-Madison. AMIA 1994.

Slide 61

References

Engelberts AC, de Jonge GA, Kostense PJ. An analysis of trends in the incidence of sudden infant death in The Netherlands 1969-89. J Paediatr Child Health 1991.

Farquhar JW, et al. Effects of community-wide education on cardiovascular disease risk factors. The Stanford Five-City Project. JAMA 1990;Jul 18;264(3):359-65.

Soumerai SB, et al. Effects of professional and media warnings about the association between aspirin use in children and Reye's syndrome. 63 Refs. Milbank Q 1992;70(1):155-82.

Demographics of Non-enrolled Children Suggest State Outreach Strategies. GAO Report to the Honorable John M. Cain. (GAO/HEHS-98-93, 1998).

Slide 62

Outreach is not Convincing and Selling.

Outreach is Learning and Negotiating.

Slide 63

Three Things to Believe

1. Service Matters More Than Outreach.
2. Perceptions Matter More Than Reality.
3. No One Tactic Will Work.

Slide 64

• Be Skeptical About Focus Groups.
• Outreach and Retention are Different Problems.

Slide 65

Two things when you get back:

1. Do/Non-doer Research:
   • 300 people.
   • Real barriers are...
2. Focus Messenger Rather Than Message:
   • Get on news.
   • Organize events.
   • Youth (13-18).
   • (?) Credible Sources.
   • Take advantage of controversy.

Slide 66

Current as of April 2001

Internet Citation:

Smith, W. Engaging the Population: Innovative Strategies in Marketing, Outreach and Enrollment. Slide presentation (Text Version) at SCHIP Workshop, 1998. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/chip/text/CONTENT/workshop_materials/smith3ohd/smith3ohdtxt.htm

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