Photo by Quino Al | Unsplash
My journey in improvement science and large-scale quality improvement (QI) implementation has been full of learning, innovation, and continuous adapting. As a Senior Quality Improvement Officer at the Institute of Human Virology, Nigeria (IHVN), I have been particularly interested in exploring social marketing as a patient-centered approach to scaling up interventions. Social marketing uses commercial marketing techniques to change or maintain behavior. It has been widely used in public health to prevent risky behavior (including smoking) and promote behavioral alternatives. Social marketing has not been widely used to improve the uptake of health care interventions, but its approach to understanding and creating value for a target audience are the keys to increasing patient demand and acceptance.
My work experience has been in resource-poor settings that are largely donor-funded and target-driven. Achieving these targets is key to continued funding. Sometimes these targets are hard to achieve and the work to meet these targets is often not patient-centered. I started to wonder how we could use social marketing techniques to meet and surpass donor targets by improving uptake and demand for services without putting an undue burden on patients and program managers.
Anticipating and Addressing Concerns
Prompt identification and treatment increases the the chances of survival of HIV-infected children. Testing the biological children of HIV-infected clients has demonstrated yield in other high HIV-burden countries. However, requests to HIV-positive adult clients to bring their biological children for testing had a lower than 5 percent response rate within our supported facilities. To encourage more people to get life-sustaining antiretroviral therapies, we decided to test a structured phone call script to ask patients who had already tested positive for HIV to bring their children in for testing.
Following a discussion with health care workers, we identified a major cause of low response was poor-quality counseling by volunteer staff that led to fear of the possible consequences of a positive result. Following my experience as a patient in the US, I realized that the language used in counseling was key to managing patient fear and anxiety and encouraging the acceptance of health care interventions.
To create an effective script, we anticipated patients’ fear of what would happen to their children if they tested positive. We predicted that they worried about the assurance of pediatricians available with the expertise to manage their child’s care and the chances of survival of their children.
The call script emphasized that the tests were free and described the availability of clinicians trained to manage pediatric HIV. Callers also allayed parents’ fears of discrimination.
Callers asked clients to present children under 14 for testing at their next scheduled antiretroviral appointment. English or local dialect scripts were used per client preference. Clients got reminder calls two days prior to their appointment. After the initial pilot, the testing uptake improved to 52 percent.
What Works and What Doesn’t
Prior to using the improved call script, a colleague proposed offering patients incentives to bring their children in for testing. This is a common practice. Consequently, the success of using QI in our first pilot was a game changer.
There are ways to make outreach messages more patient-centered in any setting. Here is what I would recommend:
- Understand the root cause of the problem you want to address and your target audience to design the best outreach messages.
- Start small. Test on a small scale and learn from your tests.
- Monitor the implementation of your outreach message. Over time, the language content of the outreach may get watered down.
- Analyze which elements of your messages had the most impact. Successful messages should be maintained while weak messages should be deleted.
- Refine messages based on post-evaluation results.
When the news of our outreach to parents reached the community, some HIV-positive adults called us! Those we couldn’t reach because we didn’t have their correct phone numbers updated their contact information so they wouldn’t miss out on similar interventions in the future.
Social marketing has immense potential if we can harness its power. By incorporating it into our QI work to make our outreach and care more patient-centered, we can bring value to all our stakeholders, including patients and health care workers.
Rita Okonkwo is a Senior Quality Improvement Officer at the Institute of Human Virology, Nigeria (IHVN). IHVN is an implementation partner working on a pediatric HIV collaborative supported by the Institute for Healthcare Improvement (IHI).