In her 1996 book It Takes a Village, current presidential candidate and former United States Senator, First Lady, and Secretary of State Hillary Rodham Clinton detailed her view that multiple determinants, such as community involvement, cultural/environmental influences and social interactions, contribute to how a child is raised. Similarly, inciting a consumer call to action with disease prevention outreach programs takes an amalgamation of different social and behavioral theories which rely on the same factors as the village concept. Studies assert that outreach programs based on more than one theoretical foundation, including Million Hearts which was established by combining the Health Belief Model (HBM) and the Theory of Planned Behavior (TPB), are more likely to produce a desired positive outcome than those that lack theory or are based on only one theory.
The Health Belief Model
The first social behavioral theoretical foundation, Health Belief Model (HBM), emphasizes that the willingness to take action and prevent risk depends upon the beliefs about the susceptibility and severity of disease; the perceptions about the benefits and barriers; cues to action and self-efficacy.
In a hypertension prevention study, Hispanic respondents not only misperceived that certain behaviors are barriers that would increase their risk factors, but also expressed a lack of confidence in their ability to perform such behaviors as having their BP checked regularly, limiting their salt intake, eating five or more servings of fruit and vegetables daily, exercising at least 30 minutes four or more days of the week, and controlling their weight. The general perception that hypertension was not a severe disease and the susceptibility misunderstanding resulted in 68.6% of the respondents being at increased risk for developing hypertension.
The Theory of Planned Behavior
The second social behavioral theoretical foundation, Theory of Planned Behavior (TPB), assumes that attitude, subjective norms, and perceived behavioral control predict actual behavior. Attitude refers to beliefs merged with the value placed on the behavioral performance outcome. Subjective norm signifies the perception of the social expectations to adopt a specific behavior. Perceived behavioral control reflects the beliefs about the level of ease or difficulty of performance behavior.
A circle of culture surfaced in a hypertension prevention study concerning poor eating patterns passed from generation to generation; physician distrust and questioning reasons doctors would want to lower BP because of the belief that physicians would not have a job if they addressed this health issue; and an unwelcome move that changes consumers from insiders to outsiders when they act differently by engaging in healthy behaviors. Severing cultural traditions and adopting preventive behaviors suggested by health care professionals resulted in social pressures.
Combining HBM & TPB: The Million Hearts™ Program
The Million Hearts™ national outreach program engages Community Health Workers (CHWs) to help achieve the goal of preventing one million heart attacks and strokes in the United States by 2017. The CHWs educate consumers about the importance of fit lifestyles and specifically promote these tenets for maintaining a healthy BP:
1) Having routine screenings for high BP;
2) Understanding BP numbers and the significance of lowering BP while searching for economical ways to increase lower sodium and whole grain foods and still keep their weight within BMI;
3) Comprehending the ramifications of uncontrolled BP that include damage to eyes, kidneys, heart blood vessels, and brain; high risk of heart attack and stroke; and chronic kidney failure requiring dialysis.
CHWs encourage consumers to interact with other members of the community including their physicians about clearly defined health goals and keep a daily record of BP readings to track progress. CHWs also introduce consumers to social workers and others who can teach them how to apply for programs and insurance that help pay for health care. Many Hispanic consumers prefer to learn information with plain language fotonovelas, similar to comic books, which are common in the culture. Personal interaction is carried out by “promotoras” from the same ethnic background who honor the tradition of reading a fotonovela with consumers.
Controlling Hypertension by Learning to Control Sodium Intake: A Fotonovela
In summary, creating a consumer call to action with disease prevention outreach programs such as a Million Hearts™ takes a village of community involvement, cultural/environmental influences and social interactions supported by different theories including HBM and TPB. The underlying premise is that a combination of theories informs the message. Theories determine why, what, and how a health issue should be addressed and assist in developing successful program strategies that reach targeted priority populations to affect a positive impact.
Del Pilar Rocha-Goldberg, María et al. “Hypertension Improvement Project (HIP) Latino: Results of a Pilot Study of Lifestyle Intervention for Lowering Blood Pressure in Latino Adults.” Ethnicity & Health 15.3 (2010): 269–282. PMC. Web. 19 May 2015.
Glanz, Karen, Rimer, Barbara K., andViswanath, K. Health Behavior and Health Education: Theory, Research, and Practice (4th ed). San Francisco: Jossey-Bass. 2008.
Noar, Seth M., Chabot, Melissa, and Zimmerman, Richard S. “Applying Health Behavior Theory to Multiple Behavior Change: Considerations and Approaches.” Prevention Medicine. Volume 46. March 2008.
Peters, Rosalind M., and Thomas N. Templin. “Theory of Planned Behavior, Self-Care Motivation, and Blood Pressure Self-Care.” Research and Theory for Nursing Practice 24.3 (2010): 172–186.
Peters, Rosalind M., Karen J. Aroian, and John M. Flack. “African American Culture and Hypertension Prevention.” Western Journal of Nursing Research 28.7 (2006): 831–863. PMC. Web. 19 May 2015.
Most pharmaceutical marketers understand the importance of including search marketing in their media plans. Often the champion of the final click, a good paid search campaign contributes to the overall success of any advertising effort and connects your brand to active seekers within the marketplace. Unfortunately, advertisers often focus the majority of their attention on the brand.com site and, at times, overlook the importance role disease awareness (DA) sites play within search strategy through enabling the option of executing a multiple listing strategy.
Let’s take a step back and look at how a good DA site provides marketers with the opportunity to better capitalize search results.
But… what if I’m not first-to-market?
I know what you’re thinking – unless you’re at the helm of a first-to-market treatment, you’re probably thinking that a DA site just doesn’t fit your strategy. Certainly first-to-market competitors have a great opportunity to educate and grow interest in a category for patients and HCPs with an awareness site. However, the opportunity to influence this audience on a condition or disease state exists for more than just the first-to-market competitor. Unbranded education content generally resonates strongly with audiences wary of an overtly branded message and provides marketers with a forum to set the stage for a branded message to follow at a later point in time.
What’s more, a proper DA site need not be overly complex or represent the pinnacle in site design to be effective. Instead, focus investment on good, quality content that stands out from the crowd and strikes a new position on the condition. Savvy digital marketers can take this opportunity to set the table and influence what patients and HCPs should expect or demand from the category. Following on-brand messages can then reinforce differentiation to maximize this added perception. Examples of differentiation can include cost, safety, or even dosage and delivery (e.g., why take an injection when treatment is available via pill).
Finally, DA sites generally resonate better than brand.com sites for unbranded search campaigns. Diagnostic indicators of post-click success – including bounce rate, page views per visit, and even time on site – generally return stronger numbers when an unbranded searcher consumes DA content. With the right site design and layout, the engaged audience can be converted to the brand.com site and ultimately shaped to take the action the advertiser desires.
Once advertisers commit to adding a DA site to the portfolio, a multiple listings approach can be pursued within search. Below, I’ve broken out what makes this tactic so powerful for search advertisers.
This additional listing provides added flexibility to advertisers looking to provide active seekers with as many opportunities as possible to connect with their brand and their message. You may already be following this strategy without knowing it – having a separate website for HCPs and patients enables a second listing to populate the search results with a message unique to each audience. The DA site furthers this approach and provides the opportunity to reach both audiences who may be higher up the funnel.
Some advertisers truly embrace the multiple listing approach and create separate DA sites for patients and HCPs, creating yet another additional search listing. The possibilities are endless!
Added coverage and efficiency
Employing a multiple listing strategy provides a great way to even the playing field against competitors with deep pockets determined to remain in the top position. Added listings provide added impression share and SOV opportunities at greater efficiency than an all-or-nothing approach to search positioning (which is why I always advocate employing a separate domain for your patient and HCP brand sites).
If each of your site properties achieves even a 15% impression share, you can quickly begin accruing over half of the available search opportunity without spending the same cost per visitor that you would with fewer listings forced to remain at the top to ensure traffic volume forecasts are achieved.
Flexible messaging opportunities
Multiple listings provide advertisers with greater opportunities to determine the optimal investment levels within search. What’s more, using a test-and-learn approach often reveals which unbranded categories make sense to drive directly to brand.com and which respond better to the unbranded table setting of your DA site – and of course, which terms should have the opportunity to drive to both!
Know thy funnel
Many brand managers regard the branded site as the best chance to engage patients and HCPs. Unfortunately, speaking to a brand naïve audience searching on general condition terms via a branded site usually leads to poor engagement and a questionable user experience. Since we know that qualified patients and HCPs tend to search using basic, single-phrase keywords, it remains difficult to assume what level of brand awareness a searcher has based on the keyword they input.
Disease awareness websites play a critical role in successfully engaging patients and HCPs who may remain higher up in the conversion funnel. Multiple listings provide the opportunity to not only engage in message testing but also audience A/B testing. Which site property makes the most sense for these keywords and ad groups?
Creating a DA site provides brand managers with added flexibility in how they create and execute their paid search campaigns. Having the advantage of added listings in the search results allows advertisers the opportunity to customize their messaging and audience alignment approach at a much more granular level, all while returning greater efficiency and engagement.
It’s pretty much impossible to count how many people in the world are afflicted with disease; there are simply too many diseases and too many people to count. And if you count the loved ones of those with diseases, then it’s safe to say that virtually everyone is affected by disease.
Our global population of roughly 7 billion people is afflicted with all kinds of diseases, from infectious to non-communicable. Yet education and action are sorely lacking in developing countries and even powerhouse nations like the United States.
It isn’t till one is burdened with illness that one can actually be aware of the severity and implications of it. Unfortunately, by then we must act in a reactive mode, rather than a proactive, preventative, and healthier one.
Activating: a year of disease awareness
Disease awareness months have been around since at least 1985, when the American Cancer Society and the pharmaceutical division of Imperial Chemical Industries (now part of AstraZeneca) formed National Breast Cancer Awareness Month. Since then, every month has been claimed as an awareness month for many diseases. For example, May is Mental Health Month, Stroke Month, Lyme Disease Awareness Month, Celiac Awareness Month, Healthy Vision Month, and Arthritis Awareness Month, to name a few. The monthly “real estate” is totally crowded and the months have less impact when they are sharing with other groups who are also trying to build awareness.
The goal of awareness months is to educate and drive screening. They promote action by driving checkups, and get the larger communities involved in many different initiatives, from walks and runs to health fairs.
The abundance of disease awareness days, weeks, and months provides an opportunity to take a holistic educational view on disease states at large. Even if you’re living with and being treated for only one particular disease, it’s necessary to understand that there’s a whole universe of diseases out there. Get screened and try to prevent illness. The more you’re aware and understand what you need to do, the better chance you have of avoiding disease. And helping others avoid it, too.
Social platforms: spread disease awareness
HealthWellNext, a thought leadership publication, has created a social platform called HealthAwareNext to spotlight and educate around disease months throughout the year. They refer to it as “A Year of Disease Awareness.”
The goal of HealthAwareNext is to educate and drive awareness about disease states. Each month will feature impactful call-to-action content showcasing unique graphics that not only grab attention but educate as well, with real-world information on screening and testing for that month’s condition. The content will be spread via healthawarenext.com as well as through the social media platforms Facebook, Pinterest, Twitter, Tumblr, and Instagram. The hashtags #HealthAwareNext and #YearofDiseaseAwareness, as well as disease-specific hashtags, will drive to relevant content.
HealthAwareNext started in January by focusing on cervical health, followed by heart health in February. March was dedicated to vision health and colon cancer awareness. April put a spotlight on sexually transmitted infections (STIs), and May highlights mental health and stroke. When 2015 ends, it will be with a collection of disease month assets that are as informative as they are visually arresting, and that provide always welcome attention for these diseases. The ultimate goal is to get people to take charge of their health – and make prevention a year-round activity.
Diabetes. Heart Disease. Obesity. These are three preventable conditions that millions of Americans are living with today. Is misinformation or lack of information the cause? Are they educated but lack motivation to take necessary precautions? Each day people make numerous decisions that have a tremendous impact on their overall health. As health industry marketers, our job is to give them the right information, support, and inspiration to help them make judicious decisions to live healthy lives and prevent chronic conditions, when possible.
According to the CDC, diabetes, heart disease, and obesity are among the top diseases that are the most preventable. “Diabetes is the leading cause of kidney failure, lower limb amputations (other than those caused by injury), and new cases of blindness among adults.” One would think these consequences could provide enough motivation to make healthy choices, yet millions of Americans continue to be diagnosed because they fail to take action. Unfortunately, the number of cases keeps rising year-after-year. Fortunately, we can break the cycle and reverse the trend.
Knowing the facts & their future
The American Academy of Family Physicians stated that patient education and filling prescriptions have about the same impact on health outcomes. Our responsibility is to provide the necessary information patients need to understand the impact of these conditions, steps to prevent them and the difficult future they may experience living with these conditions if precautions are not taken. Empowering patients to act now, by taking steps to wellness, starts with education. Pharmaceutical brand marketers, health content developers, and healthcare providers must work together to create expert disease prevention content. But what is the right time and method to make an impact? The encounter must be highly engaging personal experiences filled with emotion, and distributed through key platforms for easy access by patients.
Support through connections
After educating patients and instilling motivation, the next step is ensuring prolonged commitment to health. This can be accomplished by creating connections between people through online communities and social groups. In a recent Remedy Heath Media study, 7 in 10 people said they were motivated by others to take an action such as eating healthier, exercising regularly, and getting a routine physical. It’s pretty amazing how contagious good health decisions become when surrounded by other like-minded individuals. Plus, there is the opportunity to make new friends who will push you when you need it most.
Through online outlets, health experts such as Amy Hendel (The Health Gal) – physician assistant, nutritionist, and health coach – provide connections for people needing support with their weight-loss, nutrition and fitness goals. These experts give people a sense of belonging and that they are not alone – they have somebody to turn to for trustworthy insights, advice, and guidance – keeping them focused and on track.
Other connections can be made through health and wellness social groups, like the one my wife started last year by connecting with neighbors, exercising together and sharing healthy family eating habits, grocery shopping, fitness tips, and more. Not only did it build a community focused on health and wellness, it created a support system sustaining their commitment. When a member of our wellness group cannot attend meetings the group reaches out and rallies together to ensure they remain engaged. Yes, peer pressure is still alive and well… but for good reason.
Remarkable health heroes spark inspiration
We have found that people become empowered through emotional storytelling. Remedy’s research indicates that among respondents who were highly motivated by emotional storytelling, 90% felt inspired after hearing an emotionally charged personal story.
To spark motivation, sites such as BerkeleyWellness.com are developing emotional marketing programs including Be Well, Be Brave™, which captures the spirit of being brave by challenging themselves to lead a healthy life. Be Well, Be Brave™ presents emotional personal stories of everyday health heroes, who, despite huge hurdles, made important choices needed to live well. These stories depict the real-life transformations of people taking charge of their health. In turn, they inspire others to take action. The health hero’s story are chronicled in a long-form multi-media experience with video and text infused with expert supporting content – buying guides, diet and fitness plans – providing support, inspiration, and engagement for others to go above and beyond what they thought possible.
Whether it’s connecting online, through a social group, or via emotional storytelling, people need to spark their motivation to live healthier. That motivation comes from being educated, not just about where they are today, but what their future holds if changes aren’t made. Motivation will drive action and ultimately lead to a more healthy life, without the worry of preventable conditions. Remember, today the number of people being diagnosed with diabetes, heart disease, and obesity is climbing year-after-year; but by working together, our mission is to break this cycle, stop the trend, and reverse these growing numbers.
Pharma marketers spend much time and effort developing and improving ways to support patients in their specific disease areas. This is important work. An estimated 150 million people are living with at least one chronic condition in 2015, and by 2030 the number is estimated to grow to 171 million.
However, this effort does not take into account an important reality: many patients are dealing with more than one condition at the same time. This means that current efforts may be too narrow to offer the full breadth of support that your consumers need every day. Almost one in three Americans has multiple chronic conditions (MCCs). Specifically, about 27.9% of adults aged 45 to 64 and more than half (51.6%) of adults 65 and over suffer from two or more chronic conditions, with the major burden of MCCs on older Americans aged 65 and over. As the baby boomer generation continues to age, the problem is expected to increase.
The CDC reports that the most prevalent combination of two chronic conditions in the United States is hypertension and arthritis, and for people who have the most common combination of three diseases, they add diabetes to that duo. Other common chronic conditions include high cholesterol, heart disease, cancer, depression, substance use disorders, asthma, HIV/AIDS, and dementia. But what makes this challenge so pervasive is that even though these diseases are most common, there are many others. Each person is unique, and so are the health challenges they face every day.
The price of living with MCCs is steep: 71 cents of every dollar of US healthcare spending goes to treating people with MCCs, according to the US Department of Health and Human Services Agency for Healthcare Research and Quality (see the details in a great infographic here). And these are definitely your customers. People with three chronic conditions fill an average of 23 prescriptions per year, and that number jumps to 50 prescriptions per year for people with five chronic conditions.
What can we do to provide information and support for people with multiple conditions? It is a conceptual, logistical, and IT challenge to be sure, and one that pharma does not face alone: government, nonprofit groups, and other health organizations are also structured to provide support that is segmented:
The nonprofit National Council on Patient Information and Education (NCPIE) recently launched a 10-step adherence program called Accelerating Progress in Prescription Medicine Adherence: The Adherence Action Agenda as part of its campaign platform at www.bemedicinesmart.org. Though the resource gallery includes links and resources for the most common, costly, and preventable of all health problems in the US, there is not one place where patients can turn to address all of their conditions and symptoms.
Data aggregators, sites you probably know that are set up for patients to log their health data to be combined with others and inform clinical research, are set up for patients to track their diagnosis and treatment for one disease/condition at a time.
How can pharma marketers face this challenge to help their patient consumers? It’s a multi-faceted problem, but here are some starting points to open the discussion:
Stop focusing on just disease and focus instead on the tools of coping, juggling and living. Not only do most people have more than one medical condition, but everyone is trying to get through each day successfully managing their health along with their relationships, their jobs, and more.
Engage with patients the way patients want to engage (not the way pharma prefers). It’s not about controlling the message – instead, put yourselves in your customer’s shoes, work to deeply understand their journey, and see how you can help.
Provide peer-to-peer support. When it comes to their health, patients want to hear from people that they feel are like them. Because it is likely that others are dealing with multiple conditions, peer support that connects patients with real people who have volunteered to share their experiences and provide support can make a significant impact on disease management. Helping to connect people so they can share what has worked for them in their journey means they can learn from and help each other.
The takeaway here is that the convergence of social media, empowered patients, and The Internet of Things has brought us to a point where consumers expect the tools they rely on to blend seamlessly into their lives, providing the information and support they need, the way they need it. Pharma needs to help patients navigate the complexities of their own health in all aspects, not just around one drug.
Wu, S. Green, A. “A Projection of Chronic Illness and cost inflation 2000”