Today s Quiz: What do hand grenades, stand-up comedy, and true love have in common?
Answer: Timing is Everything.
In past columns, we ve discussed the need for EMS to be involved in preventative care. Last week, we reviewed the paradox of public service. I ve recently come across another prevention conundrum I think you ll find of import as you focus on this vital work.
One of the keys to getting out a message for preventative care is to identify those persons whom you consider at risk for the particular medical condition you re exploring. For instance, if an EMS agency wishes to ensure that all children are riding in car seats, they would look to contact parents of small children. If there were a National Association of Parents with Small Kids Who Want to Know About Health, this job would be easy. Since no such group exists, however, we try to reach them where we think they are: shopping malls, health fairs, schools, faith organizations, and many other locations.
A sample scenario
So we ll go to the mall during the Annual Health Expo, and we ll set up a booth to promote car seat use. Maybe we ll get an eye-catching display to attract some attention (the Florida Highway Patrol has this crash simulator that is waaaaay cool). But while a fair number of people may turn their heads to look at us and a few may actually stop to talk, the vast majority of shoppers will probably simply walk by. And as for those flyers we send home with the children from school, I d wager real money that most wind up in the circular file.
What about the few who stopped? Can we have an effective intervention with them? Probably so, but only because they were already interested enough to stop and acquire information. These are the people who are most likely keen on health issues and who have likely heard your message before. Some may already be following your suggestions, but have come to you for more information or to confirm what they already know. Rarely, we may stumble upon someone who is on the border, someone who has not heard of our particular issue but is interested in healthy lifestyles, someone we can push over the edge.
Stop preaching to the choir
Those of us interested in injury and illness prevention spend a lot of time interacting with community groups. But our experience is the same as yours at the mall. In most cases, we re preaching to the choir. That s the paradox: We promote prevention to those who already know. People come to hear us because they re already interested. We simply serve to validate their beliefs.
The key is to get the message to those most at risk. Unfortunately, those at highest risk of injuries and illness are often those least likely to be active participants in the community. The intravenous drug user and the professional sex worker are at high risk of acquiring HIV, but we won t find them at the church meeting. The chronic alcoholic whom we wish to keep off the road does not come to an alcohol screening day. These people fly under the radar, invisible to the phalanx of prevention advice.
I think that our lack of effectiveness in accessing these patients is mainly a function of ourselves. It s not that we do anything intentionally wrong. But I do think that when we design health messages, we design them for people like us by and large educated, interested in healthy lifestyles, and socially and economically stable. It s nobody s fault, really. We can only plan for what we know and communicate with those we know.
But that doesn t help us to reach other populations. Parents of teenagers know this. You can tell your teen everything you want, but actual communication is difficult. Their head is in a different place than yours (that s why peer programs, such as Students Working Against Tobacco, are so effective in this age group). In order for our efforts to actually be effective, we need to get out of our own heads, access the community at risk and ask them how they want to be accessed and what messages they will hear. It requires getting out on the street and listening to the community, adopting innovative strategies far form the mainstream of health education. These activities often make many theory-bound bureaucrats uncomfortable. It is, nonetheless, the only way to succeed.
Timing is key
Not only do you have to get the right message to the right people, but you have to get it to them at the right time. It s better to teach someone a lesson about the dangers of excessive drinking while they re in the painful throes of a mind-crushing hangover than when they re enjoying the ecstatic effect of the two-carbon fragments. Like it or not, pain is a marvelous kind of negative reinforcement. Pavlov s dogs and Skinner s rats would be proud.
(As you know I'm wont to go off on tangents. I ll share this story of being at a Red Cross Disaster Management Course in Geneva. One night, the Red Cross took a bunch of us out on a boat ride. The beer was free, and a significant quantity made it into my system (this was in 1994, so it should be out of me by now). Anyway, the next day, I came dragging into the seminar somewhat worse for wear. One of our Japanese classmates looked at me with a puzzled expression, took out his Japanese-English dictionary and proudly announced that I had an overhang. I noted that these were fine words coming from a man with a Hello Kitty backpack. He was genuinely perplexed by my response. Wrenching up his face in a most bewildered fashion, he exclaimed, But everyone in Japan love Hello Kitty! Run, don t walk, to see Bill Murray in Lost in Translation. Do it now. Trust me.)
A health-care behavior model
Because social scientists and other observers of mankind require academic tenure to keep their families fed, they ve come up with a fascinating model to explain how people change their health-care behaviors. Known as the Transtheoretical Model, it suggests that the stages one goes through when processing a decision to change include:
Pre-contemplation: You re not thinking about a change.
Contemplation: You start to think about a change.
Preparation: You re getting ready to make a change.
Action: You make the change.
Maintenance: You continue the changed behavior.
Termination: You quit doing whatever you changed and go back to doing what you were doing.
I m sure that clears up this question for you. And it s easy to see how this theory differs from other notable cognitive theories of health behavior, including the health Belief Model, the Theory of Reasoned Action, the Theory of Planned Behavior and the Social Cognitive Theory. (Needless to say, there are a lot of social scientists out there, and they all need jobs).
I bring up this model to illustrate that in order to effect change, you have to hit someone at the right time. If we follow the Transtheoretical Model, the only time we can really make an intervention is when one is thinking about a change (if one is pre-contemplative, you really can t induce them to start thinking). Again, timing is critical.
Marketing your message
So how do we learn to hit the right people at the right time with the right message? We do the same things that companies who market to consumers would do. We hire an advertising agency. In public health, we call this discipline social marketing.
Social marketing is an interesting hybrid of science, altruism, and crass consumerism. The idea is to use marketing techniques to promote socially beneficial change. Social marketers base their work on the conceptual framework of marketing and a consumer orientation. They use research to determine the customer s wants and needs, and determine the optimal target audiences for the product. The difference, of course, is that the product is a behavior, the price is what the individual gives up to adopt the behavior, and the ultimate goal is not profit, but a more healthy community. If this seems like a perversion of the traditional advertising model, it probably is. But the fact is that the traditional advertising model works. There seems to be no reason not to adopt these same techniques to a higher call.The point of the exercise is that social marketing techniques help you to get your message to the population you want to receive it and, just as in comedy, love, and hand grenades, everything revolves around timing. I encourage you to work with social marketing experts as you plan your preventative programs. That way you ll not only be preaching to the choir, but letting the sermon get to the street as well.