Good morning, my name is Craig Lefebvre. I am Managing Director for Health Communications and Social Marketing Programs at the American Institutes for Research. I appreciate this opportunity to testify before the National Committee of Vital Health Statistics Subcommittee on Privacy about the uses of social marketing concepts and techniques to help educate the public about the HIPAA privacy standards that will go into full effect April 14, 2003. Based on my experiences of developing, implementing and evaluating social marketing programs, and the empirical and practical lessons learned from over 25 years of work in this field, I will focus my comments on several key issues.
Issue 1: Communication messages are most effective when their content, form and style are tailored to the predispositions, attitudes, current behaviors, and aspirations of distinct and homogeneous segments of the total population. My colleagues and I have found that messages, whether they are informed by changes in science, technology, or in the case of HIPAA privacy standards, regulations, need to be crafted in ways that reflect the realities of discrete audiences. This means that a consumer-driven approach should guide public information and education initiatives that includes segmentation of the US population into smaller subgroups, research to understand and gain insight into their current life situations – especially as it relates to health privacy concerns, and the development of messages and strategies that fit into people’s lives – not our preconceptions about them.
For any public information campaign about privacy notices, for example, I would be thinking about specific segments such as married women with children who are often the health information gatekeepers for their families; people with low education and literacy levels; people for whom English is a second language; high versus low users of health care services; people with chronic diseases and disabilities; people with no usual source of medical care; and Medicaid and Medicare beneficiaries as just some of the more obvious examples of US citizens who will likely attend to messages about HIPAA privacy standards, understand them, remember them, and act on them in very different ways. We need to account for this variety of perspectives, as well as others, as messages are developed and delivered.
Issue 2: The selection of channels of communication that are used to reach each of these audiences needs to consider such factors as the intended reach and frequency of message delivery, the credibility and usage of various channels among the audience, and the complexity of the information being delivered. One thing we have learned to do very well in social marketing is how to use research with our audiences to develop messages that prove to be very effective when we test them with representatives of our target audience. What we often fall short on is actually putting those messages in front of our audience’s eyes and ears at times when they are most likely to be open and attentive to them. Public service announcements (PSAs) are the most obvious example of our attempting to achieve the broad reach and frequency of our commercial counterparts who pay for such time. Yet, a recent report by the Henry J. Kaiser Family Foundation (2002) noted that only 0.4% of all broadcast and cable television airtime is donated to free PSAs (approximately 15 seconds an hour). When one then considers that 27% of this time addresses health issues, the competitiveness for such a small amount of television airtime, let alone when the target audience might actually see it (43% of all PSAs are shown between midnight and 6AM), has led some of us to reconsider how and when to use PSAs and others to adopt paid advertising strategies to achieve the reach and frequency these messages need to have to be effective.
Even if television and radio advertising were within the reach of most social marketing budgets, I still do not believe that they are always a right choice. Nowhere is this better demonstrated than with HIPAA privacy notices. A quick 15 or 30 second PSA with a call to “ask you health care provider” about privacy notices can certainly “push” people to overwhelm health care providers and facilities with general questions and requests for information. However, these types of formats cannot be expected to provide people with the quality of information from perceived credible and authoritative sources that explains the various complexities of health information privacy. Rather, I would suggest that more extensive interpersonal and print-based tactics be considered such as editorial briefings and informational sessions with health reporters to increase their ability to understand and articulate these issues for their viewers, listeners and readers. Extended interviews on radio and television news programs; feature articles in monthly and weekly news and special interest magazines; town meetings hosted by health care professionals; and other types of longer format, interactive media would be important to consider and use to cultivate a more informed public.
Issue 3: Social marketing campaigns to influence behavior are long-term endeavors whose effectiveness has been found to be limited by the allocation of relatively few resources to achieve objectives; poor conceptualization of the problem and possible solutions from the audience’s perspective; and narrow strategic and tactical choices. Objectives for a public education program that are stated as increases in awareness of changes in health information privacy regulations, versus what percent of people return their acknowledgement of receiving a privacy notice, set different standards for success and the resources necessary to achieve them. Unfortunately, there is no “rule-of-thumb” for an expected ROI for a social marketing program, but we do know that the more behavior change becomes a goal, as opposed to simply building awareness, the more extensive and expensive the task becomes. We also have research evidence to suggest that the most effective programs take a broad, multi-level perspective of behavior change and use multiple communication channels to target a variety of audiences and create a “surround-sound” environment. And finally, what we have also learned in social marketing is that we have to clearly define and position desired behavioral changes in ways that are relevant to each target audience; understand and address how our audience perceives the costs, benefits and incentives for changing what he or she thinks and does now; offer the messages and opportunities to learn more about privacy issues at times, places and states-of-mind when they are most likely to attend and respond to them; and finally develop innovative and unexpected ways of promoting our messages that resonate with them.
Given this background, I have several recommendations for how to begin to develop a public education initiative around this issue.
As we look forward to potentially using communications to improve public understanding of the Privacy rule, our challenge is to strive for simplicity and clarity; audience understanding, empathy and insight; and focus, not volume, as we set our objectives and course.
I want to thank the committee for the time to present some of the essential points I believe should be considered in any public information or education program around the HIPAA privacy rule. I appreciate your attention and look forward to continuing to discuss the most effective ways of introducing and explaining the privacy rule to the public.