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Loud and clear

As the NHS calls for patients to take a more active role in their own healthcare, effective patient communication needs to become an integral part of the marketing mix
TinsThe marketing mix framework is still based on the traditional four Ps of marketing namely product, price, promotion and place, however, as the variety of products and markets widens, some marketers have introduced a fifth P. The fifth P has been proposed as process and principles, or the people involved in the selling.

Although pharma marketingís target audience has traditionally been the prescriber, this article proposes that the fifth P refers to the patient.

Think about patients 
Cultural change, growth of the worldwide web and improved literacy mean that patients have greater access to health information and, hence, have an improved understanding of their diseases. Patients increasingly view themselves as active participants, working with their healthcare team to agree on and implement optimal and appropriate care for their condition and their lifestyle. Government emphasis on healthcare is also changing to promote wellness instead of the treatment of illness. The new patient-centred NHS calls for patients to take a more active role in their own health, and initiatives such as the NHS choices website (; the Department of Health Expert Patients programme; the Our Health, Our Care, Our Say white paper and the Choosing Health white paper aim to support this drive for increased patient participation.

The role of patient education
The developments highlighted above present the pharmaceutical industry with an opportunity to educate patients about their health in a proactive manner. A recent survey of industry experts examined attitudes and perceptions about the current and future role of patient education in the pharmaceutical industry and the value of patient education and health literacy. The results clearly showed a lack of definition for patient education and a strong consensus that it is currently underused.

Reasons for these problems are multifactorial. Uncertainty exists about the regulations surrounding pharma and patient education. Because all materials must be unbranded, many marketers consider patient education pointless unless they have no competitors or are clear market leaders. Cost pressures are also forcing marketers to restrict their educational activities, and patient education is often the first activity to be sacrificed.

Effective patient communication
The value of effective patient communication cannot be underestimated. In order to be considered effective, patient communications activities must:
- Help patients take control of their treatment and become active partners with their doctors in the treatment of their conditions
- Reflect the principles of health literacy, meaning that the content is understandable, accessible and personally relevant to the patient
- Be rooted in the scientific concepts and techniques of behavioural modification and not merely pass on information
- Foster long-term prescription adherence by giving patients reasons and resources to willingly adopt recommended medical and lifestyle regimens
- Span the entire life cycle of the brand and touch patientsí lives in different ways throughout the course of their therapy.

Patient education
Patient education is the process of influencing patient behaviour and producing the changes in knowledge, attitudes and skills necessary to maintain or improve health. Printed materials are still commonly used for this purpose as printing is still considered a cost-effective means of mass communication. However, poor health literacy and, in some cases, a lack of clarity in the materials themselves, can restrict their impact. For effective patient education, three areas must be considered: 

1. Regulatory requirements 
The regulatory environment surrounding patient communications is often far from clear. The ABPI Code of Practice prohibits pharmaceutical companies from undertaking, or sponsoring any activity deemed to be promoting a prescription-only medicine (or certain other medicines) to the public. However, many decisions on what to allow are based on individual interpretations of the regulations. 

2. Health literacy principles 
Health literacy is the ability to read, understand and act on healthcare information. The Medicines and Healthcare products Regulatory Agency (MHRA) has highlighted factors that should be addressed when designing and setting out patient information. It gives particular emphasis to writing style (choice of words, punctuation, sentence length, use of short paragraphs and bullets), typeface (easy to read serif fonts and larger font sizes), design and layout (clear spacing, sections, column formats), headings (bold and stand out), colour (contrast is important for readability) and the use of symbols and pictograms (meanings of symbols must be clear and user tested).

Most patient education materials, however, fail to address the many other barriers that contribute to poor health literacy and so fail to harness the potential of health education. Applying a patient-centred approach and following the additional guidelines outlined below can help marketers close the communication gaps that exist between prescription and treatment plans and patient compliance.

The additional factors that should be taken into account when developing effective communications with patients include:
- Reading ability - The largest single contributor to health literacy is reading ability. In 1999, the Moser Report found that approximately one in five adults had low literacy skills. Some people have difficulty understanding and acting on written health information. Designing patient education resources in plain language and culturally appropriate formats can overcome this problem.
- Health and scientific understanding - Even among the well educated, understanding of health, disease and related concepts, such as risk, can be poor. Materials should explain basic concepts simply, but without patronising the reader.
- Visual impairment - According to the Royal National Institute of Blind People (RNIB), approximately two million people in the UK have significant sight loss. People with moderate to severe vision loss need to use low-vision aids to read a typical patient information brochure, but even with such aids the small print on a prescription package insert is illegible. Using black text printed on a light background to heighten contrast improves legibility for those with impaired eyesight (including colour blindness). Wherever possible, educational materials should be provided in alternative formats such as large print, Braille, audiocassette or digital formats compatible with speech synthesiser software.
- Limited proficiency in English - More and more people in the UK speak English as a second language; of those most speak English less than ëvery wellí and many read or write English poorly. Appropriate language and cultural adaptations are therefore needed and materials should be developed by working directly with various cultural groups from an early stage.
- Cultural background - Culture strongly influences health beliefs and attitudes towards health management and outcomes. Working with various cultural groups to develop educational materials can ensure that key messages are conveyed in such a way that health interventions are accepted.
- Emotional roadblocks - Illness, anxiety and medications are likely to interfere with patientsí and carersí ability to read, comprehend and retain new information, so materials must be concise, clear and written in plain language.
- Health beliefs - Health beliefs can influence how people process and act on medical information. Materials that encourage dialogue between patients and healthcare professionals regarding medications, non-medical interventions and lifestyle changes can help patients understand and accept the intervention.
- Learning style - Even among good readers, learning styles vary widely. While some prefer to acquire new knowledge by reading, others need to hear it or see it. A mixture of formats, including print, video, audio and web alternatives can maximise the participatory nature of the materials and reach a wider audience.

3. Changing behaviours 
Helping patients change their behaviour - taking their medication, making healthy lifestyle choices and following healthcare instructions - is an important goal of patient education and ultimately helps to improve treatment outcomes. Five key influences on behaviour change have been identified. They are:
1. Subjective norms - what a person believes ësignificant othersí expect regarding this behaviour and the personís motivation to comply with these expectations
2. Attitudes - the positive or negative evaluations of the possible consequences of behaving in this way
3. Self-efficacy for the behaviour or change of behaviour - the extent to which people believe they have the necessary skills and abilities to perform the behaviour
4. Peer support - the availability of support from peers and particularly the extent to which peers also model or demonstrate the relevant behaviour
5. Knowledge from information/education - the extent to which a person has knowledge of the causes and consequences of their current behaviour and possible alternative behaviours.

The impact of patient educational materials may be increased if they are designed with an understanding of behavioural change. The Health Belief Model is a psychological model that attempts to explain and predict health behaviours by focusing on the attitudes and beliefs of the individual and is a useful tool to adopt.

Making it work 
A multidisciplinary advisory team including clinicians, scientists, nurses, pharmacists, patients and patient group representatives, will provide meaningful and relevant feedback on educational materials and ensure they are accurate, balanced and accessible to the patient. These teams should guide, not only content, but the strategy for delivery as well.

The fifth P: patient participation 
Increasing patient participation in treating illness and promoting wellness is becoming increasingly important. The quality of patient education materials will differentiate brands and pharma companies from one another and from generic competitors. Well designed patient education campaigns maximise the return on investment and improve treatment adherence and patient outcomes.

For marketers with sales, market share and patient retention goals, nothing should be more important than removing barriers for patients to seek, receive and stay on treatment.

The Authors
Heather Bennett
is account director at HealthEd

18th July 2008


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