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Building Awareness and Interest

Once you succeed in developing information on health care quality, you face two major challenges:

1. Letting people know that this information exists and is available to them.
2. Getting them interested in the information so that they are motivated to look at it and use it.

Remember that information on health care quality is still new. Even in markets where it has been around for several years, few people have had repeated exposure to it. As a result, you must prepare people before they receive or gain access to any reports. In fact, a lack of adequate preparation is thought to be responsible for the failure of some quality initiatives. This problem is especially likely when information is provided with no context or support, which can happen when reports are mailed directly to consumers' homes or distributed apart from enrollment materials. Since people don't understand what they are looking at (or even why they would want to open the envelope), they simply ignore it.

Workbook Reminder
Question
30

The solution to this problem is to develop an educational campaign that starts in advance of the distribution of performance information and continues long after the information finds its way into the consumers' hands. Ultimately, the goal of this approach is to create a demand for the information so that people will know that it's coming, and may even be proactive in finding it (not unlike the way that consumers seek out information on the comparative quality of vehicles).

Keep in mind that this is a long-term process. It may take several years for health care consumers to understand why and how they would use the new information you're offering to benefit themselves and their families. But each year, more people will become aware that the information is available, will become familiar with what they can do with it, and will have occasions when the information is relevant to them.

What can you do to move them along this road?

Define Your Audience.
Craft a Compelling Message.
Get the Message Out.

Define Your Audience

Before you can begin a communications campaign, you have to form a clear idea of who it is that you're trying to educate. Think about the audience for whom you are developing a quality report. How prepared are they to use this information? What do they already understand? What do they need to learn in order to use the information effectively? You may need to do some research with your audience to get a better sense of what they know and what they need to know.

For details, go to Know Your Audience.

How can you be a more effective communicator once you have a better sense of who your audience is?

Look for Opportunities to Segment.
Set Priorities.
Reach Out to Secondary Audiences.

Look for Opportunities to Segment

More than likely, your efforts to learn more about your audience will reveal that this audience is not homogenous. Just as consumers have different health care needs, they have different needs for information and different levels of understanding about health care quality. By focusing on these differences, you can divide your audience into manageable segments.

The concept of segmentation is important because it allows you to identify the unique needs and concerns of different constituencies in your audience and tailor your communications to address them appropriately. For example, suppose an employer is preparing educational materials for an audience that is dominated by two segments, one composed of well-educated, middle-aged men with families and chronic health problems, and the other composed of healthy, young, unmarried women with little education beyond high school. In the same way that companies target their advertisements to specific consumer segments, that company should design its communications strategy to reach both parts of its audience.

Market segments may reflect ethnic and racial groupings, but they do not have to. It can be useful to identify and focus on such differences in that culture plays a strong role in shaping how people take in information and how they view health care. For instance, media that are popular with Hispanics/Latinos may have little penetration in the African-American community, and vice versa. However, this approach to segmentation may gloss over important differences in information needs within an ethnic or racial group, as well as similarities across groups. Consequently, gathering information about needs and interests is a critical step for every kind of audience, even when the segments seem clearly defined.

Set Priorities

Once you have a sense of the segments within your audience, the next step is to set priorities for which audience segments you want to emphasize in your communications campaign. One reason to pursue this strategy is that it is not usually feasible or effective to reach out to everyone at once with the same message. A staged approach to raising awareness and interest in your audience will allow you to target your message and leverage your resources as efficiently as possible.

This approach is also consistent with various theories regarding the management of change and the diffusion of innovation. In essence, these theories suggest that innovations (such as reports on health care quality) are adopted in stages. First, they are accepted by a small group, known as early adopters, who are ready and willing to engage in the material. Over time, as word spreads, the innovation enters the mainstream.

Setting Reasonable Goals

In addition to setting priorities, set reasonable goals for yourself. While you may want to educate everyone, it is not realistic to expect a 100 percent response to your message. As with most commercial products, only a subset of the targeted segments is likely to pay attention to your message, let alone use the information you produce.

Practices and behaviors related to health tend to be deeply rooted and rock solid. No matter how compelling your message is, a large-scale response is not likely. Besides, there will always be people who have absolutely no interest in what you can tell them.

"It's not necessary to get all of the people interested in everything. In studying consumer behavior, we know that a much smaller percentage of people than we might have thought look at Consumer Reports or government crash statistics or anything like that when they're choosing a car. And yet, enough of those opinion leaders do look at such information to have changed the automobile industry. The point I'm trying to make is that 20 percent of consumers, the opinion leaders in the community, the people whom others ask, "Who's the best ophthalmologist in town?" may be enough not only to change consumer behavior, but by virtue of their being opinion leaders, to change the industry whose underlying quality improvement is the chief objective of consumer information."

— Mark Smith, M.D., M.B.A., President and CEO, California Health Care Foundation, in a keynote address at the National conference on "Making Quality Count: Helping Consumers Make Better Health Care Choices," December 1998

Select to read the speech (PDF file, 807 KB; HTML).

Finally, if your communication objectives are too ambitious, you are setting yourself up for failure. This can make it hard to get the support you'll need for the next round of quality information.

How Do You Decide Who to Target?

There are many different criteria you can use; the trick is to identify which ones are most appropriate for your audience and your community.

With which segment are you most likely to be successful?

Specifically, which segment is most likely to use the information? And which segment is most likely to be responsive to your messages about quality? For example, information on hospital quality may be available for everyone, but it is certainly most salient for those in need of hospital-based care. To begin the education process with that segment of your broader audience first, you might want to make brochures or other simple materials available at physician offices, with an emphasis on the specialties that tend to admit many patients. Honing in on those who are most likely to be receptive and interested makes it easier to figure out how to let people know what's available.

Which segments are most influential in the community?

You may want to identify and reach out to members of your primary audience who can share their knowledge and influence their peers. These people are referred to as "opinion leaders." Depending on your audience, you may need to do some research to find out who these leaders are and where you can find them. For example, in low-income populations, you can reach out to those who are attending GED (General Education Development) or ESL (English as a Second Language) programs or community colleges. Or you could focus your communications strategy on the people who are leaders in community, employee, or faith-based organizations.

Where are you mostly likely to find "early adopters"?

Early adopters are those people who would be likely to use information on quality. While it is hard to know exactly who this would be, you could guess at the characteristics and attitudes of someone likely to be receptive to the idea of using data on quality to select a health plan or provider. For example, the person probably uses data to help make other important decisions, has not established a strong connection or loyalty to any health care organization, is making decisions that affect other family members, and is not happy with his or her current choice.

Once you've picked the segments that best meet your criteria, focus your message and media strategy on them. As you roll out the educational campaign to other segments, adjust both the message and the media to meet their needs.

Reach Out to Secondary Audiences

It is also important to consider ways to build awareness and interest among secondary audiences—those who are in a position to influence and educate your primary audience. For example, let's say you want to publicize the availability of comparative information on health plans that serve children. In addition to communicating with parents (the primary audience), you could reach out to teachers, counselors, school administrators, and the staff of day-care centers in the communities where the children live. Or, if you want to stimulate interest in information for seniors about Medicare plans, your communications plan could include those who help seniors make decisions, such as staff at senior centers or the adult children of those seniors.

Medicare Choices for New Yorkers (PDF file, 138 KB; HTML)
© Copyright 2000. Baruch College School of Public Affairs. All Rights Reserved. Used with Permission.

Craft a Compelling Message

Once you have determined who you want to reach, you need to determine what will make them sit up and listen. In general, people pay attention when you tell them something they don't already know but that they think is useful. For example, many Americans have responded well to messages about the nutritional content of foods; they perceive it as filling a need for information that has value to them.

The problem with health care quality information is that many people don't even know that this is information they would like to have—at least, not in the same way that we know to watch our intake of calories, fat, and cholesterol. While health care quality is a widespread concern, it remains vague and highly conceptual. But in the same way we've come to understand how information about nutrition can help us make beneficial decisions, people can learn to use information about health care quality. One of your tasks as a sponsor is to craft a message that communicates how your information can help them address their concrete concerns.

Select links below to learn more about:

Preparing the Audience.
Developing a Message that Works.

Keep in mind that the messages you use to educate and motivate your intended audience shouldn't contradict the messages you convey in your report on health care quality. While you may deliver the message in a different way (e.g., by using different media or different appeals), the basic nature of your message should remain the same.

Preparing the Audience

Some audiences will not be receptive to any messages about quality until they have a better understanding of how to use the health care system. That is, quality is a "second-level" concern. Before they can be interested in quality, your audience may need to learn how to meet basic needs for health care and how to navigate the health care system.

In this situation, it would not be useful to deliver a message for which the audience isn't ready. What you can do is to help educate your audience and plant the seeds for your information on quality. For example, a sponsor could host workshops to help people understand that they need to ask questions to get what they want (such as access to a clinic in their neighborhood, or a provider who speaks their language). This is the first step in letting them know that information is available to answer those questions.

Your Health Plan Handbook: How to Get the Healthcare Your Family Needs from a Managed Care Plan (PDF file, 388 KB; HTML) provides basic information and guidance for Medicaid enrollees. It suggests questions to ask before choosing a plan.
© Copyright 1997. Community Service Society of New York. All Rights Reserved. Used with Permission.

Developing a Message that Works

What can you do to make sure your message is effective? This section discusses:

Factors that Determine Acceptance of a Message.
Tips for Making Your Message Effective.

Factors that Determine Acceptance of a Message

A variety of factors can influence whether your audience responds to the messages that are the keystone of your efforts to build awareness of and interest in quality information. Many of these factors are a function of the message itself:

Clarity. To avoid the possibility of misunderstanding or inappropriate action, make sure that your message is clear to your audience. Try to limit your use of technical, scientific, or bureaucratic terms and get rid of extraneous information, e.g., detailed explanations that don't actually enhance your audience's ability to make decisions. For more guidance, go to Saying It Clearly.
Consistency. Confirm that the message you convey is consistent across all the vehicles you use to deliver it. Also, consider how your message meshes with other messages that your audience may be receiving—perhaps from the mass media or local health plans. If forced to reconcile conflicting messages, the audience may become suspicious of everything or simply tune them all out.
Emphasis. Be sure to highlight the main point of your message. Messages sometimes fail because the main point is hidden within less important information.
Tone and appeal. A message can be designed to push different buttons by appealing to the intellect or the emotions. For example, a message about health care quality could be alarming, soothing, candid, or preachy. Which approach works best depends on who you are trying to reach and what impact you want to have. While information about quality has traditionally been based on an appeal to the reader's desire for knowledge, recent research suggests that a more emotional appeal may be effective.
Credibility. The credibility of a message is not an independent property of the message itself or its sender. Rather, it is the receiver of the message who determines whether it is credible. Find out whether the reader (or listener) believes and trusts the source of the information and, if applicable, the person presenting the message (e.g., a spokesperson, an intermediary). Also, consider this issue when you are selecting vehicles (including media) for delivering your message. Your audience may trust one vehicle (e.g., a long-time supervisor) more than another (e.g., an employee newsletter). Credibility also comes into play when there's a chance that your audience could attribute the message to another source—for example, if they could think that your message about the importance of health care quality really comes from the health plans. If that's a possibility, be careful to craft a message that is clearly distinct from those coming from the plans.
Public need. To a large extent, the effectiveness of a message is determined by how well it speaks to the perceived needs of the intended audience. Make sure your message reflects not just your beliefs as a sponsor, but the values, preconceptions, and information needs of your audience.

Adapted from: Making Health Communication Programs Work: A Planner's Guide. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, Office of Cancer Communications, National Cancer Institute, NIH Publication No. 92-1493, April 1992. p. 33.

Appeal to Anxiety about Health Care May Be Effective

In recent studies that looked at how consumers responded to different kinds of messages, researchers noticed that messages that are framed in a negative way (e.g., here's a way to avoid problems with your health plan) seemed to be more effective than those framed in a positive way (e.g., here's a way to get better care from your health plans). Their findings suggest that a more emotional appeal to the anxieties and concerns that underlie health care decisions can make quality information more salient to consumers.

Consumer Willingness to Obtain Higher Performing Health Plans (PDF file, 31 KB; HTML)
© Copyright 2000. Judith Hibbard. All Rights Reserved. Used with Permission.

Also: Hibbard JH, Harris-Kojetin L, Mullin P, Lubalin J, Garfinkel S. Increasing the Impact of Health Plan Report Cards by Addressing Consumers' Concerns. Health Affairs 2000 Sep/Oct;19(5):138-43.

However, although this approach has some promise, it may be difficult to implement. First, some sponsors are reluctant to draw attention to the potential for risks. Those willing to point out risks can anticipate opposition from certain stakeholders (particularly the health care organizations that are the subject of the reports). Finally, some audiences may overreact to negative framing, especially if the media pick up the message and reinforce it. It's possible that readers may never get beyond the emotional appeal to learn that they can get information that will help them. Before you put out a negative message, make sure it is appropriate for your particular audience and test it ahead of time to gauge the likely response. Also, make sure the information you are providing is up to the task of countering the anxiety you're provoking.

Tips for Making Your Message Effective

When you are trying to build awareness and generate interest, you need a simple message that can accomplish a great deal. After all, you want it to educate consumers, to generate curiosity, and even to motivate action (such as requesting the information)—and you want it to be succinct and memorable.

To develop a message that can meet this tall order, keep in mind the following two guidelines:

Tell people what they really want to know.

Many sponsors fall into the trap of focusing on what they think consumers need to know or what the sponsors believe is interesting, rather than developing a message that speaks directly to their audience's concerns. A key principle of successful marketing is to focus not on the features of your "product" but on the needs of your audience and on the benefits that can be derived from your product. The best way to do this is to work with representative of your audience to learn what they care about and what they need to know in order to make better health care-related decisions.

Ask them to tell you what's interesting.

Once you have a good understanding of your audience's information needs, forego the usual "top-down" approach to crafting a message. Rather, ask your audience to tell you how you can deliver an attention-grabbing message. Focus groups can help sponsors determine what their audience really cares about and what would make them pay attention. Once you've developed a few messages, test them with your audience to see how they respond.

For details, go to Techniques for Testing and Evaluation and Testing Your Materials and Dissemination Strategy.

Get the Message Out

Workbook Reminder
Question 30

What's the best way to deliver a message to your intended audience? While there's no one right answer to this question, there is a right approach: rather than handling communications with the public on an ad hoc basis, tackle this problem strategically. That is, identify all the pieces that will meet your needs and decide how they will fit together over time.

Here are some of the key elements of a successful strategy to reach your audience:

Build Coalitions with Like-Minded Organizations.
Use Multiple Outlets to Deliver Information.
Consider the Power of Mass Media.
Time Your Message for Maximum Impact.

In addition, be sure to allocate sufficient resources to this effort to make the public aware of the existence and usefulness of your quality information.

Build Coalitions with Like-Minded Organizations

To help publicize your efforts, sponsors may want to seek out local groups that serve the population segments you are trying to reach. Many community-based organizations are looking for opportunities to distribute educational materials and lead discussions about topics that affect the well-being of their members. If appropriate, these organizations could eventually become partners in your effort to distribute information on health care quality and support consumers in using that information.

To establish a foundation for such a partnership, you could start by meeting with influential community leaders to explain the issues, and submitting articles for local newsletters and bulletins. Over time, you may want to conduct "train the trainer" programs to prepare your partners to answer questions and provide advice.

Here are some examples of this approach:

The New York-based Medicare Rights Center (MRC) has partnered with several local and National community organizations—including Catholic Charities and the Visiting Nurse Service—to promote its messages about health care. Large health care provider organizations have also served as partners for the purposes of publicity. In addition to newsletters, such organizations may produce or regularly participate in radio or cable television shows that can be used as a forum for discussing the topic of health care quality. For example, MRC has talked about Medicare issues on a monthly cable show produced by the Metro New York Healthcare Campaign.
The Community Service Society of New York (CSSNY) also partners with different kinds of organizations to conduct outreach to specific populations. For example, they provided a small grant to Asian-Americans for Equality to publicize the services that CSSNY provides. With that grant, the organization is expected to do things like create brochures and posters, place ads in ethnic papers, and create radio spots that will be effective in reaching the constituency it serves.

For More on Partnering

To learn more about the benefits of partnering with organizations that share your interest in educating consumers about quality, contact the Foundation for Health Care Quality at 206-682-2811 or visit their Web site at http://www.qualityhealth.org and go to the "Publications" page.

Use Multiple Outlets to Deliver Information

Take advantage of whatever outlets are available to you to:

Let people know that information on quality is coming.
Remind them that they got it.
Communicate the purpose and value of the information.

This strategy is consistent with research on what it takes to get a message through to people. First, different people respond to different ways of getting messages—e.g., some need to see it, some need to hear it, some need examples, and some need to talk about it. Second, people typically need to receive a message several times and even in several ways before they really process it. Finally, it takes time and repetition to rise above the clutter of information that bombards people every day.

Some Options Available to Sponsors

To introduce quality concepts, publicize the availability of a report card, and reinforce those messages, consider using combinations of the following vehicles:

Posters.
Videos.
Slide presentations.
Articles and notices in employee or consumer newsletters.
Postcards.
Flyers.
Pay stub inserts.
E-mail distribution.
Web site notices.
Announcements at meetings.
Mass media.

	The CAHPS® 2.0 Video, Understanding Your Health Plan Choices
	Your Guide to Choosing Quality Health Care is a publication for consumers produced by the Agency for Healthcare Research and Quality (AHRQ).
	Year 2000 Health Care Decision Guide: Taking Charge of Your Health Care by the Ford Motor Company (PDF file, 463 KB; HTML) © Copyright 2000. Ford Motor Company. All Rights Reserved. Used with Permission.
	The Health Information Action Group, a business unit of the Greater Detroit Area Health Council, Inc. (GDAHC), offers multiple sources of information on its Web site and in Taking Charge of Your Health Care...A Closer Look at Quality (PDF file, 431 KB; HTML) © Copyright 1999. Ford Motor Company. All Rights Reserved. Used with Permission.
	Sharing the Quality Message With Consumers: A Guide From FACCT is an educational guide designed to help employers, unions, and consumer organizations provide consumers with "friendly" reports on health care quality. To receive this guide, contact FACCT at (503) 223-2228 or www.facct.org. © Copyright 1999. The Foundation for Accountability (FACCT). All Rights Reserved. Used with Permission.
	The "Choice Plus" Web site, sponsored by Buyers Health Care Action Group (BHCAG), contains an Information page with an informational newsletter that is published quarterly: Connection Choice Plus News for Members (www.choiceplus.com/Info.htm).

Consider the Power of Mass Media

Workbook Reminder
Question 32

For some—but certainly not all—sponsors, the mass media may be an important element of a communications strategy. The wide reach of the public media can be invaluable for those serving a broad constituency of consumers, especially if they are geographically diverse. A media campaign can also supplement more focused vehicles (such as materials directed specifically at employees), reinforcing the message received in the workplace. Finally, sponsors that are especially prominent and influential in their market can use mass media to help promote the idea that health plans and providers are accountable for health care quality.

Select links below to learn more about:

Good Uses for Mass Media.
Attracting Media Attention.
Educating the Media.

Good Uses for Mass Media

From a sponsor's perspective, the mass media are especially useful for "teasers" that are intended to spur interest in an issue and tell people where they can get more information. For instance, one agency serving Medicare beneficiaries (i.e., older adults and people with disabilities) uses newspapers articles and talk radio programs to deliver its message. Similarly, an organization that works with Medicaid beneficiaries found that coverage in the ethnic press, weekly papers, and call-in radio programs offered an affordable way to communicate a basic message and to let people know that more information is available.

The media can also be useful for educating the public. For example, the California HealthCare Foundation and La Opinión, the Nation's largest Spanish-language daily newspaper, entered into a partnership to produce a series of special supplements. Written primarily in Spanish, these publications provide information about public health insurance programs and health care quality issues for California's Spanish-speaking community.

However, it is not yet clear whether the mass media are also an appropriate vehicle for delivering data on quality.

Attracting Media Attention

Assuming you want to have media publicity for your project, how do you make that happen?

Aim for outlets that are likely to be a good fit.

First, you have to identify the media outlets that are most likely to be interested in the story you have to tell. To find them, take the time to network in your community; learn which reporters or talk show hosts focus on health care issues and who the large provider organizations tend to work with. Also think broadly and creatively about where you can find an audience for your message. For example, many hospital rooms now have televisions that air in-house programming on health care issues; your information on quality could provide a good educational story.

Tell a good story.

Second, think about your project from the perspective of a reporter who is looking for a story and a compelling reason to cover it. Ask yourself these questions:

Why is the project newsworthy?
What's the local angle? Why will the story matter to the audience?
How can I make it dramatic?

How can I put a human face on the story?

Keep in mind that the story has to have some relevance to the local community; it is not interesting just because you think it is or because of who you are (although who you are may be enough to make it relevant if you represent a dominant player in the community, like General Motors in Detroit or CalPERS in California). However, don't assume that the story has to be negative, with an emphasis on quality problems. You can try to frame your project as a "feel-good" story by focusing on the positive aspects (e.g., how the performance of local providers is better than the National or State average).

Keep it simple.

Deliver your message in broad strokes without too many details. You can always offer telephone numbers or Web site addresses for someone who wants more information. Media-savvy sponsors have found that it is better to repeat a few basic messages many times than to try to explain a complex message on the air. It is fine to share interesting data, but only if you can talk about what it means on a personal level.

Do their work for them.

Finally, you can often get attention simply by submitting press releases and even articles to the local press, which will sometimes run what you write practically verbatim.

Educating the Media

For some sponsors, their only contact with the media occurs at a once-a-year press conference—which gives reporters one shot at a story they barely understand. The result is often a negative twist on even a positive message.

Given the complexity of the message you want to deliver and the risk of miscommunication, sponsors that choose this route should take the time to develop a media strategy. The purpose of this strategy is to educate journalists about the sponsor's issues, learn more about what they need for a successful story, and develop relationships so that they have a context for your work and a contact for more information. This approach is not always effective, but it does minimize the chances that your message will be lost or misunderstood, and it provides a better basis for problem-solving if something does go wrong.

A Media Strategy Checklist

Consider incorporating the following elements into your media strategy:

Dedicate resources to staff press contacts and to actively promote the publication of results.
Prepare a list of contact information for the reporters, editors, and/or producers who deal with health and lifestyle issues at local media outlets. Update your list regularly to be sure that the information is accurate.
Invite select reporters to a roundtable with prominent representatives of health care organizations as well as local dignitaries to discuss the issue and educate them about the topic.
Invite local, State, or even Federal Government representatives to become part of the effort. Their participation will help to attract media attention.
To develop relationships with local media, get to know producers at local television stations and reporters on the health beat. You can also meet with the editorial boards of local newspapers to help get your project in front of high-level decision makers.
Develop background materials for members of the media about your organization or group. These materials should concisely summarize the significance of the information on quality that you want to share.
Include senior staff in the sponsoring organization in press conferences and make them available for interviews at the time that you release the data.
Look for opportunities to reach different segments of your audience through ethnic media: TV, radio, and newspapers.
Prepare all the stakeholders in your project to deal with the questions that the media coverage is likely to raise (such as one health plan's poor performance relative to others).

One benefit of thinking about the media strategically is that it will force you to weigh the costs and benefits of using mass media. Do you have the staff to handle this work, or the resources to hire an outside professional? Could the strategy backfire? For example, if media coverage is likely to create problems for your partners, especially health care organizations, this approach to building awareness may undermine your entire project.

The Prevention Marketing Initiative: Media Relations (PDF file, 65 KB; HTML).

Time Your Message for Maximum Impact

When you are planning your communications campaign, think carefully about the timing of your message presentation. Here are three suggestions for using timing to improve the effectiveness of an educational message:

Deliver the message in concentrated bursts.

Research with consumers suggests that, rather than string out the presentation of your message over a long period of time, it is more effective to present your message repeatedly in a short period, delay, then do it again. This kind of "pulsing" allows people to learn but avoids the risk of tuning out that comes with overexposure.

Prepare the audience in stages.

You can think of your campaign as a tool for moving your audience across a simple continuum that begins with becoming aware of and interested in quality information, continues with acquiring knowledge and understanding, and ends with using the information to shape decisions. As you schedule your communications, consider what stage your audience is at and make sure the messages are delivered at suitable intervals. For instance, an audience that is familiar with quality information may be able to move quickly to messages that talk about applying the information to decisions. However, one that is new to quality information may need many months of more basic messages that stimulate their curiosity.

Don't compete for attention.

While this can be hard to anticipate, it is useful to consider what other messages are vying for the attention of your audience. If possible, avoid presenting your messages at a time when your audience is likely to be either overwhelmed with information or strongly focused on other issues. For example, an employer may not want to distribute educational materials about health care quality just prior to a major holiday or vacation period, or at the same time that it is asking employees to make major decisions about retiree investment benefits.