Elizabeth W. Mitchell, PhD Division of Birth Defects and Developmental Disabilities June 13, 2011

1. Developing a National Social Marketing Plan for Preconception Health and Health Care: Perspectives from the Consumer Workgroup Elizabeth W. Mitchell, PhD Division of Birth Defects and Developmental Disabilities June 13, 2011 National Center on Birth Defects and Developmental Disabilities Division of Birth Defects and Developmental Disabilities

2. Presentation Overview • Social marketing- what is it? • Phases of a social marketing plan • Status of the consumer workgroup’s social marketing planning by phase • Next steps

3. What is social marketing?

4. Social marketing is: "The application of commercial marketing technologies to the analysis, planning, execution, and evaluation of programs designed to influence voluntary behavior of target audiences in order to improve their personal welfare and that of society." * Andreasen, AR. Marketing Social Change: Changing Behavior to Promote Health, Social Development, and the Environment. San Francisco, CA: Jossey-Bass; 1995.

5. 1 Problem Description • 2 • 6 Market Research Implementation • Social Marketing Phases • 5 • 3 Market Strategy Evaluation • 4 Interventions Source: http://www.orau.gov/cdcynergy/demo/

6. 1 • 1 • Social Marketing Phases Problem Description Public health, social marketing and consumer workgroup

7. Defining the Issue - Public Health Perspective • Goal: To improve women’s health before pregnancy in order to optimize pregnancy outcomes • Pregnancy intention is associated with improved health behaviors and birth outcomes* Shah PS, Balkhair T, Ohlsson, A, Scott F, and Frick C. (2009). Systematic Review. Matern Child Health J. Published online: 10 December 2009).

8. Key Challenges • Half of all pregnancies are not planned* • Target audience has a wide age range (18-44) and is diverse • The list of PCH behaviors is long • Messaging is challenging (language of PCH ; time period for promoting behaviors is unclear) • Health disparities Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health2006;38(2):90-6

9. Defining the Issue- Social Marketing Perspective • The social marketing process involves • Identifying an effective marketing mix • 5 P’s (product, price, promotion , place and partners) • What is the preconception health concept we are trying to sell to consumers? (product) • What are the costs to consumers ? (price) • How should demand for preconception health and healthcare (PCH & HC) to consumers be achieved? (promotion) • Where should PCH & HC messages be promoted? (place) • How can efforts be supported and sustained? (partners*) • Offering the customer clear and compelling benefits • Minimal barriers • And advantage over other options (competition)** *Luca, NadinaRalulca and Suggs, L. Suzanne (2010) ‘Strategies for the Social Marketing Mix: A systematic Review’, Social Marketing Quarterly, 16: 4, 122-149. ** CE Prue, KL Daniel. Social marketing: planning before conceiving preconception care. Matern Child Health J2006;10(5 Suppl):S79-84.

10. Defining the Issue- Consumer Workgroup Perspective • Responding to call to action • Strategic planning (2010-11) • Revisited overarching goals • Developing an actionable multi-organizational social marketing plan • Group attributes, gaps, needs • Sustainable • Monthlycalls among partners to work on plan

11. 2 • Social Marketing Phases • 2 Market Research research to inform Social marketing strategy

12. Market Research Conducted or Underway • Literature review (2009-2010) • Materials evaluation (2009) • Environmental scanning (2010) • Partner assessments (2010 & 2011) • Audience segmentation analyses (2009 & 2010) • Focus groups (2010) • Couple interviews (2010) • Secondary data analysis- underway • Concept development and testing (2011) • Adcept development and testing- underway

13. Market Research (cont’d) • Literature review • Synthesized research on PCH & HC by audience (women, couples and clinicians) and by 4 P’s to inform formative research plan • Materials evaluation • Analysis of consumer PCH materials to understand what is being communicated, to whom, and with what clinical emphasis • Findings- D. Levis (CON1)

14. Market Research (cont’d) • Environmental scanning • Web based assessments across range of areas • PCH branding, target audiences, existing materials, tools and campaigns, focus area (preconception, pregnancy, general health etc.) • Among a number of sectors: insurance, media (TV, magazine), foundations, public health, advocacy, web, business • Provided insight into the landscape of PCH, partnership and dissemination opportunities

15. Market Research- Partner Assessments • Two partner assessments conducted (partner “P”) • August 2010 and February 2011 • Conducted in order to assess the attributes of the consumer workgroup in order to inform strategic planning, “center” social marketing planning efforts, assess gaps and opportunities • Focused on: • Each organization’s goals • Their audiences • Activities (research, evaluation, education, communication) • Opportunities/barriers • Partnerships • Desired role in a national social marketing plan • Created a partnership database

16. Market Research- Audience Segmentation Analyses • Purpose • Explore how women of childbearing age can be disaggregated into smaller groups so that effective and appropriate PCH social marketing interventions can be crafted

17. Market Research- Audience Segmentation Process Entire Population Determined by Epidemiology or stratification data Target Population Groups i.e. Women of Childbearing Age Kirby Marketing Solutions

18. Market Research- Audience Segmentation Process Entire Population Determined by Epidemiology or Stratification Data Target Population Groups i.e. Women of Childbearing Age Determined by Behavioral, Theoretical, or Multivariate Data Audience Segments Kirby Marketing Solutions

19. Market Research- Audience Segmentation Process Entire Population Determined by Epidemiology or Stratification Data Target Population Groups i.e. Women of Childbearing Age Determined by Behavioral, Theoretical, or Multivariate Data Audience Segments Determined by Selection Criteria Intended Audience Kirby Marketing Solutions

20. Market Research- Audience Segmentation Analyses • Data • Porter Novelli’sHealthStyles survey (2007 & 2009) • Methods • Classification and regression tree (C&RT) and Chi- square automatic interaction detection (CHAID) to define factors most associated with level of pregnancy planning • Results • Factors most associated with pregnancy planning** • timing,* contraception, marital status*, income • Insight into segmentation strategies *Mitchell, E. W., Lewis, MA., Bann, C. et al. Formative Research on Preconception Health for Consumers. Poster presentation at the National Conference on Health Marketing Communication, Marketing and Media, August 11-13th, 2009, Atlanta GA **Mitchell, EW. , Miracle-McMahill, H, Levis, D. Opportunities for Preconception Health Social Marketing among Women- A U.S. Consumer Perspective. Presented at the First European Congress on Preconception Health, October 2010, Brussels, Belgium

21. Market Research- Focus Groups • Purpose • To learn more about women’s knowledge, attitudes, and beliefs about PCH behaviors and services (4 P’s) • What do women know, think and believe about PCH & HC? • What does PCH as a term mean? • What are the motivators and barriers ? • How do we communicate with women about PCH & HC? • 10 focus groups (N= 65) in Atlanta • Segmented by pregnancy planning status (planner, non-planner, interconception) • By low and middle SES • Findings- L. Squiers (CON1)

22. Market Research- Couple Interviews • Purpose • To understand how couples consider, discuss, and support each other in the context of PCH and related behaviors (4 P’s) • What do couples know, think and believe about PCH & HC? • What does PCH as a term mean to them? • What are the motivators and barriers for them? • How do we communicate with couples about PCH & HC? • Telephone interviews (N = 58 couples), ~5,000 screened • Women 18-44 who were married or in committed relationship with a partner who was willing to participate in the interview • Segmented by pregnancy planning status (planner, non-planner, interconception) • By low and middle SES • Findings- M. Lewis (CON1)

23. Market Research- Secondary Data Analysis • Additional data sources triangulated • PRAMS (2004-2008) • Growth from Knowledge/Mediamark Research and Intelligence (2009-2010) • GFK/MRI- E. Mitchell (CON1) • Accumulation of data streams used to inform • Segmentation recommendations • Social marketing plan • Dissemination opportunities

24. Audience segments for social marketing plan

25. Women of Childbearing Age- Planners and Non-Planners • Pregnancy Planners • Women who intend to have a child in the next 1-2 years • Non-Pregnancy Planners • Women who do not intend to have a child in the next 1-2 years • Segmentation based on • Desire to make concepts and messages relevant • Increase attention and engagement in messages • Desire to reach the audience • What channels and why?

26. Planners are Contemplators • More likely to pay attention to and be receptive to messages about PCH • In the “pregnancy mindset” • May be starting to mentally prepare to get pregnant or are actively trying to get pregnant • Motivated by messages that focus on • Health of the baby • Health of mother during pregnancy and delivery • Prospect of enhancing fertility • Desire to be pregnant is a strong motivator to engage in PCH behaviors

27. Non-Planners are Pre-Contemplators • Lower levels of awareness of PCH • Less likely to be receptive to messages about PCH • Pregnancy is not on their radar • Less likely to engage in and be motivated to engage in PCH behaviors (e.g., folic acid) • Viewed as irrelevant to their current life • More likely to engage in unhealthy lifestyle behaviors (e.g., smoke) and question need to stop • More likely to be receptive to messages about overall healthy behaviors/lifestyle • There is not a trigger event for non-planners to motivate behavior change

28. Stages of Change PLANNERS Pre- contemplation Contemplation NON- PLANNERS Preparation Action Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390-395.

29. Short Term Communication Goals • Planners • Increase awareness of PCH behaviors • Increase awareness that there is a preconception time period • Increase awareness that what they do before they get pregnant can affect the health of their baby • Increase awareness about where to obtain information about PCH • Non-Planners • Increase awareness about being healthy (PCH) • Increase awareness about contraception (RLP) • Increase awareness about where to obtain information about women’s health (PCH)

30. Creative development and testing

31. Market Research- Concept Development and Testing • Purpose (product “P”) • Position PCH & HC (empowering, engaging, memorable) • Create an overarching umbrella brand that can be used by the CDC and partners • Link PCH to consumer values • A relationship between a product, service, or behavior and its consumers • Creates a set of expectations in the mind of consumers (brand promise) • Create a vehicle for promoting PCH & HC • One communication channel will reinforce another and increase credibility (among partners, health care providers, media, web etc.)

32. Market Research- Concept Development and Testing • Positioned PCH and HC • A unique time (WOMAN’S WINDOW) • An opportunity (CREATE YOUR FUTURE) • An invitation (Baby YOURSELF, BABY yourself)

34. Market Research- Concept Development and Testing • Concept testing completed in May • 4 focus groups (N = 32) in Atlanta • Segmented by planning status (planners vs. non-planners) • Two age groups: 18-30 and 31-44 • All low to middle income • Purpose • Gauge women’s understanding, impressions and attitudes toward concepts • Clarity, appeal, motivation (text, images and then PCH context)

35. Market Research- Concepts, Adcepts and Testing • Findings • Important feedback • Creative executions (headline, tagline, images, text box) • Making revisions to a “Woman’s Window” and “Baby Yourself” • Developing one new concept • “Create Your Future”- dropped • Instead of inspiring respondents it evoked stress (school, career, financial) • Kaiser Women’s Health Survey (2008): “Approximately a quarter of women report feeling high levels of stress from career (23%), and financial concerns (26%)”.

36. Market Research- Concepts, Adcepts and Testing • Next steps • Analyze transcripts and develop creative recommendations • Develop adcepts (will include logo, more PCH messaging) • Test adcepts via on-line survey • Nationally representative sample of women 18-44 years of age using a panel with an oversample of African American and Latina women (N=1200) • Groups: • Non-planners (never intend or intend to have a baby in more than 2 years) • Planners (intend to have a baby <2 years) • Early Winter 2011

37. Social Marketing Phases 3 • 3 Market Strategy Marketing mix and action plan

38. PRODUCT Literature review Materials evaluation Environmental scanning Partner assessments Audience segmentation analyses Focus groups Couple interviews Secondary data analysis Concept/Adcept testing

39. 1 Problem Description • 2 Market Research • Social Marketing Phases Source: http://www.orau.gov/cdcynergy/demo/

40. 1 Problem Description • 2 • 6 Market Research Implementation • Social Marketing Phases • 5 • 3 Market Strategy Evaluation • 4 Interventions Source: http://www.orau.gov/cdcynergy/demo/

41. Next steps

42. Next Steps • Finalize • Marketing strategy, intervention, implementation and evaluation plan (early 2012) • Complete and disseminate PCH & HC social marketing tools • Audience profiles • Brand support products (sample materials, logos etc.) • Manuscripts and reports • Recruit additional partners

43. Thank You Project Team Project team Consumer Workgroup CDC : Heidi Miracle-McMahill, MPH, MS; Denise Levis, MA, PhD, Mindy Barringer RTI : Linda Squiers, PhD; Megan Lewis, PhD; Molly Lynch, MPH; Karen Isenberg, MPH; Julia Kish-Doto, PhD; Rebecca Munch AIR : Lori Agin, Mark Cohen, Lynda Bardfield, Jon Stapp, Tom Hrabal, Martha Mater, Margarita Hurtado, PhD, Tamika Owens, Allison Fratto

44. Questions? • On-line social marketing planning tool: • http://www.orau.gov/cdcynergy/demo/

45. Thank you National Center on Birth Defects and Developmental Disabilities Division of Birth Defects and Developmental Disabilities