In the healthcare industry, marketers and consumers alike have become quite familiar with massive social marketing and cause-related efforts such as campaigns to prevent teenage smoking, Susan G. Komen’s pink ribbon, LA’s AIDS Walk, and even the more recent Movember where men grow moustaches during November “to spark conversation and raise vital funds for men’s health programs.”[1] However, we are less acquainted with the impact of small grassroots programs (e.g., volunteer recruitment and training, neighborhood outreaches and blood drives, diabetes awareness rallies and workshops) that help save lives more quietly. Indeed it is often these more intimate interventions that can afford organizations the insight needed to better serve and motivate their target consumer.[2] Participatory Action Research (PAR) is a method of investigation that can be employed to better understand the consumer landscape particularly among groups that are underserved or difficult to reach. Incorporating social marketing practices, PAR provides an alternative approach to traditional marketing that can more directly surface and address issues in many segments of the U.S. population (e.g., rural, ethnic, racial, elderly, and minority) that consistently receive lesser quality healthcare and also tend to experience poorer health outcomes.
Given the existing gaps and inequalities in healthcare provision and experience among various segments of the U.S. population, it is incumbent on companies within the healthcare industry to develop and employ effective strategies to address the needs of these underserved groups. Beyond obvious concepts of justice and “doing no harm,” the responsibility of fiscal stewardship in bringing better balance in successful healthcare outcomes is additional incentive. In the discussion that follows, the authors present PAR as an appropriate social marketing response to the call for “improving the quality of health and health care for all Americans.”[3] [4]
The Need for Alternative Approaches to Address Healthcare Disparities
In 2012, the U.S. Department of Health and Human Services charged “health care stakeholders across the country—patients, providers, employers, health insurance companies, academic researchers, and local, State, and Federal governments”—with three aims and six priorities for quality improvement in the realm of U.S. healthcare (See Exhibit 1).[5] The main thrusts are to improve the quality of healthcare, reduce healthcare cost, and make care more accessible and affordable to all. All six of the priorities have marketing implications in regards to promotion, delivery, or consumer behavior and engagement. These priorities also challenge healthcare stakeholders to consider alternative approaches in addition to the traditional marketing methods they currently employ to assure the needs of underserved communities are addressed.[6] [7]
Exhibit 1. National Quality Strategy Aims and Priorities
What Are Healthcare Disparities?
Well-documented in the Institute of Medicine’s report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” healthcare disparities continue to be the subject of extensive research.[8] [9] Although a number of factors such as personal behaviors, choices, and genetics contribute to health outcomes that are present at individual levels, the current conversation addresses disparities in the healthcare system. Health disparity outcomes involve clinical and person-based observations while healthcare disparities reflect broader systemic issues that are less under the control of individual patient consumers.[10] [11] Specifically,
Health disparities: “differences between two or more population groups in health status and outcomes and in the prevalence, incidence, or burden of disease, disability, injury, or death.”[12] (e.g., biological factors, clinical measures/stats, environmental triggers, lifestyle choices).
Healthcare disparities: “differences between two or more population groups in health care access, coverage, and quality of care, including differences in preventive, diagnostic, and treatment services.”[13] (e.g., provider bias, provider training, systemic issues, insurance benefits).[14] [15]
As our current focus, healthcare disparities manifest in systemic organizational, cultural, and epidemiological inequities in the access to and delivery of health services across various populations. “Health gaps occur among groups who have persistently experienced historical trauma, social disadvantage, or discrimination and who systematically experience worse health or greater health risks than more advantaged social groups.”[16] The Institute of Medicine reports the following “overwhelming” evidence:[17]
- Disparities exist even when insurance status, income, age, and severity of conditions are comparable.
- Minorities are less likely than whites to receive needed services.
- Differences in treating heart disease, cancer, and HIV infection partly contribute to higher death rates for minorities.
Still, factors beyond race and ethnicity play a role in healthcare disparities as studies indicate, for example, that insurance coverage disparities persist in preventative care.[18] Additionally, socio-economic status, gender, and age also are considerations as disparities are present among poor, rural, female, and elderly segments.[19] [20] When these factors overlap, target marketing of healthcare services and options needs to be well-informed and sophisticated.
Why Do Healthcare Disparities Matter?
Almost half of all Americans, or 133 million people, live with a chronic condition such as heart disease, stroke, cancer, diabetes, obesity, and arthritis.[21] As the most prevalent and expensive healthcare considerations, chronic conditions impact vulnerable consumers—populations most at risk of healthcare disparities–at an alarming rate of 2:1.[22] Additionally, the percentage of vulnerable healthcare consumers is increasing at a faster rate than any other segment within the healthcare market. As Dr. David Satcher, the 16th Surgeon General of the United States noted, “The demographic changes that are anticipated…magnify the importance of addressing disparities in health status; groups currently experiencing poor health status are expected to grow as a proportion of the total U.S. population. Therefore the future health of America depends substantially on our success in improving the health of racial and ethnic minorities.”[23]
Furthermore, the financial implications of the chronic illness crisis are profound:
- In 2010, 86 percent of all healthcare spending was for people with one or more chronic medical conditions.[24]
- Healthcare coverage costs are roughly five times higher ($6,032 per year on average) for people with a chronic condition than for those without such a condition.[25]
- A Milken Institute study estimates that by 2023 the U.S. could reduce the economic impact of chronic disease by 27 percent ($1.1 trillion) annually if there were concerted efforts towards wellness. Obesity is the most important factor; if rates decline, Milken indicates savings of $60 billion in treatment costs and $254 billion in increased productivity.[26]
Considering the tremendous physical and fiscal burden facing healthcare providers, insurers, and patients, each constituency has ample ammunition for seeking a healthier lifestyle both individually and corporately. Anticipated inroads ushered in by the Affordable Care Act to improve medical insurance access and coverage too often are ineffective among the most vulnerable participants because marginalized patients tend to be more reticent to trust or share the health system.[27] [28] As a result, alternate methods of soliciting and integrating feedback on their healthcare experience are imperative. Social marketing offers one such approach.
What is Social Marketing?
Social marketing is “a process that applies marketing principles and techniques to create, communicate, and deliver value in order to influence target audience behaviors that benefit society (e.g., public health, safety, the environment, and communities) as well as the target audience.”[29] Because social marketing emphasizes influencing or modifying target behaviors vs. purchasing a product or service, companies need to employ unique methods of both research and communication to overcome a different set of end user objections and obstacles. Indeed most behavior to enact social change requires personal sacrifice on the part of the consumer. Consider the following examples:[30]
- Change a comfortable lifestyle (e.g., adjust thermostat levels)
- Be inconvenienced (e.g., donate blood, carpool)
- Learn a new skill (e.g., generate and follow a budget)
The demands being made in a healthcare context are similar and the rewards are not always immediate:
- Establish new habits (e.g., exercise more frequently)
- Give up an addictive behavior (e.g., stop smoking)
- Risk relationship (e.g., prepare healthier meals that clash with cultural expectations)
Accordingly, engaging directly with end users will be an important aspect of tackling the current challenges and opportunities facing the healthcare industry. In fact, calls for “patient-centered care” have dominated the dialogue in recent years. However, practical methods to do so are lacking.[31] Social marketing approaches offer options, and PAR in particular presents opportunities.
How Can Participatory Action Research Help Reduce Disparities?
Both traditional and social marketing practice emphasize the importance of incorporating the voice of the consumer into marketing communication efforts, yet healthcare initiatives tend to overlook this very critical aspect of message generation and program creation. Social media discourse affords more transparent and immediate feedback, for example, healthcare providers and business partners can garner end user input into all aspects of their marketing efforts instead of merely providing an opportunity for interaction or post-encounter response.[32] Campaigns that invite end-users to share insights and encouragement (e.g., online forums) engender a sense of ownership and collaboration.
Participatory Action Research (PAR) employs methods that seek to actively invite select patients/consumers into nascent research processes so that investigators can be highly effective in capturing insights that a standard survey could never uncover. A key element of PAR is community involvement. Studies have clearly shown that engagement of the community is essential to the development and implementation of any community-based health intervention.[33] [34] PAR differs from social marketing and other traditional marketing efforts in the high degree of agency and target collaboration in both the strategic development (i.e., market research) and tactical execution (i.e., mammogram screening) of a given program.[35]
Photovoice is a popular PAR practice where participants “create and discuss photographs as a means of catalyzing personal and community change.”[36] A group of participants are trained in how to document their lives via photographs for a particular period of time concerning predetermined themes (e.g., obesity, healthy eating, or cancer recovery). They then share, reflect, and engage in critical conversations about how the photographs inform personal and community issues.[37] Participants are encouraged to write or dictate narratives about their experience. Subsequent workshops may involve exhibiting participant-selected photographs in order for researchers, community partners, and other relevant personnel to get a collective representation of persistent patterns, overlooked opportunities for improved service, or potential new partners.
All data collected such as photos, narratives, and transcripts of the discussion undergoes thorough qualitative analysis. Continued input and discussion with community personnel, company representatives, and patients transform that content into fodder for:
- Improved employee training,
- Better marketing communications collateral, and
- More authentic relationship marketing efforts (e.g., recruiting neighborhood advocates).
Because end users’ own voices are incorporated on their own terms, the degree of disclosure is quite helpful.[38] [39] Strategies that incorporate effective, culturally-appropriate communication tools to encourage behavior change in these communities fare better than those that do not.[40] Although the costs associated with these efforts are highly variable (e.g., volunteers vs. paid staff, disposable cameras), the time and effort can prove invaluable in pursuing creative means to reducing healthcare disparities.
PAR solutions are collaborative and transparent three-way partnerships, highly-customizable to the task and locale. As such, they are applicable in numerous contexts beyond healthcare. Their fundamental requirement is active engagement among the intended audience (e.g., patient/consumer/community group), trained researchers (e.g., academicians), and companies/organizations (e.g., healthcare providers). Consider the following Photovoice studies in partnership among hospitals, community groups, and academic scholars:
- At-risk children take pictures of daily life in their neighborhoods for a week. Seeing the world through their eyes provides nuanced insights in the fight against childhood obesity.[41]
- Preadolescent Latina girls capture images over the course of three weeks that vary in scope (i.e., “what makes me happy/sad,” “health positives/health negatives”) that ultimately reveal their health-related concerns. Hosting a photo exhibit and holding a series of conversations yielded language and disclosure that fueled more effective interventions.[42]
As these examples demonstrate, some issues and multifaceted questions can benefit from patiently-pursued, deep inquiry. This is particularly the case among target groups that include vulnerable consumers or otherwise reticent communicators. The sense of ownership possessed by all persons involved in the effort typically translates to a willingness to continue in the changes pursued.[43] Additionally, healthcare companies and organizations can uncover insights, language, and perspectives that enhance marketing communication efforts. [44]
PAR Collaborations for Long-Term Success
Taking steps to reduce healthcare disparities is a noble undertaking, as well as an urgent responsibility for the healthcare community. Social marketing approaches such as PAR respond to the call for patient-based care and integrative healthcare that more deliberately incorporates patients in both prevention and management.
Initiatives that employ PAR or other forms of social marketing can be as simple or multilayered as resources allow. However, the success of these PAR activities is grounded in the partner relationships cultivated over time and well-established at the onset of the project. Collaboration and transparency in these three-way partnerships is vital. Accordingly, the authors encourage any organization contemplating a PAR-type undertaking to thoughtfully build the study partnering team with a long-term mindset.
Healthcare industry leaders have both incentive and opportunity to pursue better healthcare and health outcomes for all patients/consumers and to respond with vision and conviction to the challenge of healthcare disparities via intentional cooperation. The social marketing method of Participatory Action Research offers an effective alternative to traditional marketing that, through creative research design and collaborative efforts, can capture underserved segments of our U.S. population and better address their healthcare needs.
[1] Movember Foundation website. http://us.movember.com/about
[2] Ozanne, J. L. and B. Saatcioglu, “Participatory Action Research,” Journal of Consumer Research, 35, no. 10 (2008): 423-39.
[3] U.S. Department of Health and Human Services, “Annual Progress Report to Congress: National Strategy for Quality Improvement in Health Care,” (April 2012); Corrected August 2012.
[4] Institute of Medicine, “What Healthcare Providers Need To Know About Racial And Ethnic Disparities In Healthcare.” (2002).
[5] U.S. Department of Health and Human Services, “Annual Progress Report to Congress: National Strategy for Quality Improvement in Health Care,” (April 2012); Corrected August 2012.
[6] Gallegos, A. “Retail Medicine: The Cure for Healthcare Disparities?” Journal of Healthcare Management 52, no. 4 (2007): 227-234.
[7] Institute of Medicine, “What Healthcare Providers Need To Know About Racial And Ethnic Disparities In Healthcare,” (2002).
[8]Smedley, B. D, A. Y. Stith, and A. R. Nelson, eds., Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (National Academies Press, 2002).
[9] https://www.nlm.nih.gov/hsrinfo/grantsites.html
[10] Institute of Medicine, “Crossing the Quality Chasm: A New Health System for the 21st Century,” (2001).
[11] U.S. Department of Health and Human Services, “Annual Progress Report to Congress: National Strategy for Quality Improvement in Health Care,” (April 2012); Corrected August 2012.
[12] Medicaid.gov http://www.medicaid.gov/medicaid-chip-program-information/by-topics/data-and-systems/health-disparities.html
[13] Medicaid.gov http://www.medicaid.gov/medicaid-chip-program-information/by-topics/data-and-systems/health-disparities.html
[14] van Ryn M. and J. Burke, “The Effect of Patient Race and Socio-Economic Status on Physicians’ Perceptions of Patients.” Journal Social Science Medicine, Mar; 50(6) (2000):813-28.
[15] Institute of Medicine, “What Healthcare Providers Need To Know About Racial And Ethnic Disparities In Healthcare,” (2002).
[16] Medicaid.gov http://www.medicaid.gov/medicaid-chip-program-information/by-topics/data-and-systems/health-disparities.html
[17] Institute of Medicine, “Crossing the Quality Chasm: A New Health System for the 21st Century,” (2001).
[18] Trivedi, A. N. and J. Z. Ayanian, “Perceived Discrimination and Use of Preventive Health Services,” Journal of General Internal Medicine, 21, no. 6 (2006): 553–558.
[19] Kellis, Dana S., Jill S. Rumberger, and Bruce Bartels. “Healthcare Reform and the Hospital Industry: What can we Expect?” Journal of Healthcare Management 55, no. 4 (2010): 283-297.
[20] O’Hara, B. and K. Caswell, “Health Status, Health Insurance, and Medical Services Utilization: 2010,” Current Population Reports, Household Economic Studies, (July 2013).
[21] Partnership for Solutions, “Chronic Conditions: Making the Case for Ongoing Care,” (2004 Update).
[22] Partnership for Solutions, “Chronic Conditions: Making the Case for Ongoing Care,” (2004 Update).
[23] Institute of Medicine, “What Healthcare Providers Need To Know About Racial And Ethnic Disparities In Healthcare,” (2002).
[24] Gerteis J., Izrael D., Deitz D., LeRoy L., Ricciardi R., Miller T., Basu J. “Multiple Chronic Conditions Chartbook.” [PDF – 10.62 MB] AHRQ Publications No, Q14-0038. Rockville, MD: Agency for Healthcare Research and Quality; (2014).
[25] Partnership for Solutions. “Chronic Conditions: Making the Case for Ongoing Care.” (September 2004 Update).
[26] DeVol, R. and A. Bedroussian, “An Unhealthy America: The Economic Burden of Chronic Disease Charting a New Course to Save Lives and Increase Productivity and Economic Growth” (2007). Milken Institute.
[27] Trivedi, A. N. and J. Z. Ayanian, “Perceived Discrimination and Use of Preventive Health Services,” Journal of General Internal Medicine, 21, no. 6 (2006): 553–558.
[28] Institute of Medicine, “What Healthcare Providers Need To Know About Racial And Ethnic Disparities In Healthcare.” (2002).
[29] Lee, Nancy and Phillip Kotler, Social Marketing: Influencing Behaviors for Good, (SAGE Publications, October 2011).
[30] Lee, Nancy and Phillip Kotler, Social Marketing: Influencing Behaviors for Good, (SAGE Publications, October 2011): p.15
[31] Danis, M., and M. Solomon. “Providers, Payers, the Community, and Patients are all Obliged to Get Patient Activation and Engagement Ethically Right.” Health Affairs 32, no. 2 (2013): 401-407.
[32] Danis, M., and M. Solomon. “Providers, Payers, the Community, and Patients are all Obliged to Get Patient Activation and Engagement Ethically Right.” Health Affairs 32, no. 2 (2013): 401-407.
[33] CDC 1999.
[34] Institute of Medicine, “What Healthcare Providers Need To Know About Racial And Ethnic Disparities In Healthcare,” (2002).
[35] Ozanne, J. L. and B. Saatcioglu, “Participatory Action Research,” Journal of Consumer Research, 35, no. 10 (2008): 423-39.
[36] Wang, C. C., Yi, W., Tao, Z. W., and Carovano K., “Photovoice as a Participatory Health Promotion Strategy,” Health Promotion International, 13 no: 1 (1998): 75-86.
[37] Vaughn, L. M., L. Rojas-Guyler, and B. Howell. ““Picturing” Health: A Photovoice Pilot of Latina Girls’ Perceptions of Health.” Family & community health 31, no. 4 (2008): 305-316.
[38] Wilson, N. , M. Minkler, S. Dasho, N. Wallerstein, and A. C. Martin. “Getting to social action: The youth empowerment strategies (YES!) project.” Health Promotion Practice 9, no. 4 (2008): 395-403.
[39] Wilson, N. , M. Minkler, S. Dasho, N. Wallerstein, and A. C. Martin. “Getting to social action: The youth empowerment strategies (YES!) project.” Health Promotion Practice 9, no. 4 (2008): 395-403.
[40] Grier, S. A., J. Mensinger, S. H Huang, S. K. Kumanyika, and N. Stettler (2007), “Fast-Food Marketing and Children’s Fast-Food Consumption: Exploring Parents’ Influences in an Ethnically Diverse Sample,” Journal of Public Policy & Marketing, 26 (2) 221-235.
[41] Nsiah-Kumi, P. A. & Scott, A. D. (2011). Engaging North Omaha Youth in Type 2 Diabetes Prevention Using Photovoice Methods. Presented at the University of South Florida Social Marketing Conference. Clearwater, FL.
[42] Vaughn, L. M., L. Rojas-Guyler, and B. Howell. ““Picturing” Health: A Photovoice Pilot of Latina Girls’ Perceptions of Health.” Family & community health 31, no. 4 (2008): 305-316.
[43] Ozanne, J. L. and B. Saatcioglu, “Participatory Action Research,” Journal of Consumer Research, 35, no. 10 (2008): 423-39.
[44] Grier, S. A., J. Mensinger, S. H Huang, S. K. Kumanyika, and N. Stettler (2007), “Fast-Food Marketing and Children’s Fast-Food Consumption: Exploring Parents’ Influences in an Ethnically Diverse Sample,” Journal of Public Policy & Marketing, 26 (2) 221-235.
