Expanding Program Reach and Participant Recruitment Diane M. Dowdy, PhD March 27, 2008

1. Expanding Program Reach and Participant Recruitment Diane M. Dowdy, PhD March 27, 2008

2. Topics for Today • Revisiting RE-AIM model: Reach aspect • Defining and enhancing Reach • Know Your Target Market

3. RE-AIM www.re-aim.org

4. “Reach” Definition • Participation rate among eligible individuals • Representativeness of participants

5. Assessing Reach Public health goal is to have large and representative segments of target population included Who’s participating in the program/study? • What percentage of the target population was excluded due to • Exclusionary/inclusionary guidelines • Refusal to participate • Are participants similar to those who are excluded Klesges et al 2005

6. Strategies for Enhancing Recruitment • Recruitment now legitimate topic for study • Older people can be successfully recruited into prevention studies—ditto other previously hard to reach groups • Lots of different recruitment strategies utilized • Recruitment expense will vary by selection criteria Ory et al 2002

7. Strategies for Enhancing Recruitment (cont.) • Two stage recruitment screening often utilized • Effectiveness of recruitment strategies vary in different settings (e.g., media coverage) • Modifications are often made over course of the study • Diminishing returns in pursuit of reluctant participants Ory et al 2002

8. What Do We Know About Reaching Older Adults • Most older adults are concerned about their health • They have gotten general message that activity is good for you Then why aren’t more adults active and how can we reach them?

9. Messages that Motivate* • Ordinary people doing ordinary things. • Physical activity must look like fun – the “no pain, no gain” straining, sweating image is not motivating to 50+ audience. • Stress the social aspect of physical activity. • Be specific and concrete: e.g. 30 minutes/5x week. • Provide information: direction, guidance, resource info. Also give places and times of activities. *AARP Focus Groups

10. Marketing physical activity to older adult • Clearly identify audience • Have clear concept of what you want to communicate • Target your message to your audience’s preferences • Understand audience’s media habits • Use a mix of media to deliver your message, but keep message consistent Sanner2003

11. Wave One Advertising Motivational ads, to generate requests for AFL handbook “Retail” ads, to promote specific activities and programs

12. Wave Two Advertising…as Easy as Walking… • “Believable:” 68% • “Meaningful:” 56% • Definitely would consider walking as exercise: 82% • Liked it very much or somewhat:91%

13. Recruiting and Retention in Underserved Populations • Awareness of group customs and values • Appreciation of intra group differences • Emphasis on cultural assets vs deficits • Flexible menu of offerings vs one size fits all approach Yancey et al 2006

14. Redefining Recruitment Strategy Successes Strategies that build recognition and community partnerships

15. What worked in A4L? • Lots of variability depending on population and organizational setting • Personal communications and networks (videos/teaser course) • Tagging into existing membership lists • Using respected authorities • Need for combined approaches (follow-up calls)

16. Strategies for Enhancing Retention Multiple strategies often needed: • Emphasize benefits of participation* • Minimize respondent burden • Provide incentives • Give instrumental or tangible supports • Be patient yet persistent • Be flexible* • Enlist support from others • Maintain good tracking system* Coday 2005

17. Defining and Getting to Know Your Target Population Adapted from presentation by Brigid Sanner, September 2006

18. Mining the marketing data: What we can learn to promote healthy behaviors among midlife and older adults

19. Socio-demographic factors associated with physical activity • 25% of adults with an advanced degrees engage in high levels of physical activity compared to 14% of those with less than a high school diploma. • Adults with incomes below poverty level 75% as likely to be inactive as those in the highest income group. • Married women more likely than never married women to engage in a high level of overall physical activity. • Adults in the South more likely to be inactive than adults in any other region. HHS Report, Physical Activity Among Adults: U.S. 2000

20. Socio-demographic factors associated with physical activity • As people age they become less active, though males remain more active than females in the 65-74 and 75+ age groups.* • Non-Hispanic white adults more likely to engage in regular leisure-time physical activity than Hispanic and non-Hispanic Black adults.* • Low-income adults more likely than wealthier peers to feel limited in doing basic activities like climbing stairs and lifting objects.** • People 55-64 living below poverty line 6 times more likely to say they have physical limitations.** • ** New England Journal of Medicine. Aug. 17, 2006 • Early Release of Selected Estimates Based on Data from the Jan. – Sept. 2005 NHIS

21. Market segmentation • Customer groups with varying needs and wants are recognized. • Markets can be segmented on a variety of factors including age, gender, location, geographic factors, demographic characteristics, family life cycle, desire for relaxation or time pressures. Ohio State University Fact Sheet. Finding Customers: Market Segmentation. Small Business Series. Nancy H. Bull & Gregory R. Passewitz

22. Segmenting the audience • Age 45 + audience spans more than 60 years • Multiple generations • Variety of life stages • Different lifestyles • Generational cohorts consider influencers • Social • Cultural • Economic JWT Mature Market Basics 2005

23. Generational cohorts • WWII/Depression/GI Generation • Formative years 1930 – 1945 • Ikes/Silents • Formative years 1946 – 1963 • Baby Boomers • Leading edge – Formative years 1960 – 1970 • Middle – Formative years 1967 – 1977 • Trailing – Formative years 1974 – 1983

24. WWII – Depression – GI Generation • Values: • Thrifty • Patriotic • Sacrificing / Delayed reward / Duty before pleasure • Adherence to rules • 35% married • 62% women (73% of those are single) • Men age 76+ likely to be married • Least diverse – almost 81% non-Hispanic white (10.5% Black, 5.8% Hispanic, 3% Asian) • Less than 15% completed college

25. Ikes • Values • Status quo/ Don’t rock the boat • Respect authority / Adherence to rules • 65% married • Growth in diversity (12.4% Black, 7.8% Hispanic, 4.5% Asian) • 22% completed college (GI Bill)

26. Leading Baby Boomers • Values • Idealistic • Relevance • Ask questions/challenge status quo/rock the boat • Acceptance of differences • Informality/Non-conformity • Youth (changing the concept of ‘growing old’) • Hippies • Demanding • Immediate gratification • First wave turning 60 now

27. Middle Boomers • Similar values at leading edge boomers • More defined by end of Vietnam War, Watergate (question and challenge authority) • Status conscious • Disco • Individualistic/anything goes • Immediate gratification

28. Trailing Boomers • Beginning to merge with values of Gen X • Conservatism • Pragmatic • Health • Personal values • Formative years in height of “fitness craze” • Apolitical • Fade to Gen X

29. Cultural markers of age cohorts

30. Example of a market segmentation tool PRIZM NE® PRIZM NE®, a product of Claritas, combines demographic and consumer behavior segmentation to identify, understand, and target audiences. It defines households in terms of 66 demographically and behaviorally distinct types, or "segments.” Information about Prizm NE® accessed from www.claritas.com. Used with permission

31. Examples of Prizm segmentsDifferent strokes, different folks • Gray Power: Middle class, own home, aging in place, mostly white, 55+, suburban, HH Income $50,222. Trait example: Veterans’ clubs. • Close-In Couples: High school educated, empty nesters, older city neighborhoods, diverse (Black, Hispanic), 55+, HH Income $38,613. Trait examples: Eat at Denny’s, read Sunday newspaper Information about Prizm NE® accessed from www.claritas.com. Used with permission

32. Examples of Prizm segmentsDifferent strokes, different folks • Old Glories: Aging in place in older apartment complexes. Fixed incomes, home-centered lives. Ardent television fans, diverse (Black), 65+, some high school, HH Income $30,013. Trait examples: Bingo, veterans’ clubs, daytime TV. • Old Milltowns: Retired singles and couples living on downscale incomes in pre-1960 homes. Mostly white, 55+, high school graduates, HH Income $28,404. Trait examples: Gardening, veterans’ clubs, and eating at casual restaurants. Information about Prizm NE® accessed from www.claritas.com. Used with permission

33. Looking closely at the male audience

34. Shrinking numbers U.S. Census Bureau

35. Male & female AFL participants

36. AFL male & female participantsby site (data as of 8/8/06)

37. Taking lessons from other fields • Tobacco use/cessation • Melanoma prevention • STD prevention • AIDS prevention • 9 A Day • Worksite programs • Adult education

38. ♀ & ♂Response to health messages Tobacco use initiation • Girls: Stress, self-medication, weight control, improve self-esteem • Boys: Friends who smoke, peer pressure, authoritative parenting, mother’s education Tobacco cessation issues • Women: Stress, weight control, negative emotions often lead to relapse • Men: Social influences are more influential on men, as are nicotine replacement therapies Sex Matters in Health Promotion and Disease Prevention, Phyllis Greenberger, Society of Women’s Health Research

39. ♀ & ♂Response to health messages Melanoma prevention • Women: Use sunscreen, wear protective clothing. • Men: Use sunscreen, get regular screenings. Sexually transmitted diseases • Women: Skill building techniques to better negotiate condom use with partner. • Men: Personal experience and direct condom use message. Sex Matters in Health Promotion and Disease Prevention, Phyllis Greenberger, Society of Women’s Health Research

40. ♀ & ♂Response to health messages • Talk with men about sexuality and safety. Link self-interest to responsibility for wives, partners, & children. • Recognize that all sexually-active men may be at risk, not just those who appear promiscuous. • Get men in the public eye to acknowledge issue and promote responsibility. Department of Peace Studies, University of Bradford, UK

41. Joining groups Based on study in Cancer Practice • 33% of women diagnosed with breast cancer joined a support group • 13% of men diagnosed with prostate cancer joined a support group

42. Worksite programs • Men welcome workplace-based health promotion campaigns targeted at them. • Men are often under-represented in worksite health programs, this may be due to an emphasis on programs and activities attractive to women.

43. Adult education • Women participate in non-work-related courses more than men. • When women and men with the same labor force status are compared, women also participate in work-related courses at a higher rate than men. Education Statistics Quarterly. Vol 3, Issue 4, Topic: Featured Topic: National Household Education Surveys Program

44. Give’m what they want • When developing a weight control program, one may want to consider a separate program (with a name like Gut Busters) offered to men only. • Disease avoidance is not a significant motivation for most men. • Prevention of illness is not as exciting as the quest for optimal health. The Men’s Health Network of Washington, D.C. http://www.imp.net/~randolfi/healthymen/

45. ♀ & ♂ Response to health messages Today's big portion sizes may affect your perception of what a "serving" is. Take a look at these real-life portions of a few fruits and vegetables that fit easily into what you eat every day — and that easily count up to 9 for the day.

46. ♀ & ♂Response to health messages If you eat fruits and vegetable throughout the day, it's easy to reach your 7 A Day goal. Servings are pretty small, so it's easy to eat 2 or 3 at a time. See how easy it really is.

47. Men aren't eating enough fruits and vegetables. Men eat only about 4 1/2 servings of fruits and vegetables a day on average. Only 4 percent of men say they eat the 9 servings of fruits and vegetables a day recommended as part of an active lifestyle. Men aren't aware of the benefits. Men are significantly less likely than women to recognize the health benefits of fruits and vegetables, such as their role in reducing the risk of many cancers, heart disease, high blood pressure, and diabetes. Men have high rates of diet-related diseases. Men have approximately 1 1/2 times the death rate of total cardiovascular diseases as women. Men have approximately 1 1/2 times the death rate of total cancers as women. Men have approximately 2 times the death rate of lung cancer as women. Men have approximately 1 1/2 times the death rate of colorectal cancer as women. More than two-thirds of men are overweight or obese. Among Americans overall, at least 58 million have some form of cardiovascular disease, including high blood pressure, and 8.2 million Americans alive today have a history of cancer.

48. ♀ & ♂Response to health messages Healthy is beautiful. Eating right and getting lots of physical activity can do wonders for your body. You feel more energetic — more confident in yourself. And when you feel good about yourself, it shows. Fortunately, you have some powerful friends in fruits and vegetables. After all, they're filled with many important nutrients our bodies need to stay healthy, like vitamins, minerals, fiber and disease-fighting phytochemicals. And when you combine fruits and vegetables with physical activity, it can help lead to a healthier, more beautiful you

49. Why do people exercise? • 94% to feel good about self • 77% to reduce stress • 77% to control weight • 54% to fight aging • 40% socialize with others (46% men) • 25% active respondents more as aging to lose weight • Fewer than 25% good for them • Fewer than 25% health condition Physical Activity Survey. AARP April 2006

50. Exercise and aging • 31% of women cite weight reduction as reason to start exercising more as they age compared to 17% of men. • 66% of active respondents age 65+ said they exercise the same amount now as they always have. Physical Activity Survey. AARP April 2006