CHCS Center for Health Care Strategies, Inc.

Case Study

Vermont’s Campaign to Improve Children’s Oral Health Funded by the Center for Health Care Strategies, Inc. under The Robert Wood Johnson Foundation’s State Action for Oral Health Access Program

October 2004

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Introduction Vermont's coverage of oral health services, dentist participation in the Medicaid program, and utilization rates by Medicaid eligibles are among the highest in the country. Despite these achievements, low reimbursement rates, narrow use of auxiliaries such as dental assistants and dental hygienists, limited professional recruitment strategies, and lack of consumer education regarding oral health prevention and treatment has resulted in utilization rates that are far below Healthy Vermonter 2010 goals. Under the Vermont Department of Health's (VDH) nearly $1 million State Action for Oral Health Access grant, funded by The Robert Wood Johnson Foundation and managed by the Center for Health Care Strategies, Vermont is addressing many of those issues. To improve consumer education, Vermont is conducting a social marketing campaign that includes radio, television, and print advertisements of oral health messages along with an 800 number to call for more information. Vermont chose to target the “back to school” time period (early Fall 2004) for its launch of the campaign to tie in to other preventive health care messages and its highly successful Tooth Tutor program, a school-based initiative to meet the oral health needs of underserved children. A second wave will launch in early 2005. The media campaign began August 30, 2004, and preliminary results are encouraging. In the first month, the hotline has received nearly a dozen calls from Vermonters who need to find a dentist as well as from county health departments requesting packets of information for health fairs. In order to evaluate the effectiveness of the messages, a pre-campaign telephone survey was conducted to establish baseline knowledge, attitudes, and behaviors. A post-campaign survey will be conducted in late 2005 and the results measured against the initial survey to determine which messages stuck with consumers. How did Vermont determine its oral health education messages? Social marketing and media campaigns take months of planning, research, analysis, and perseverance. The state hired a marketing firm, Marketing Partners, which specializes in health care issues, to lead the charge. To uncover the most relevant messages for consumers, the firm began an in-depth research process that included: a literature review; focus groups with caregivers to identify barriers, beliefs, and behaviors; and focus groups with caregivers to test the effectiveness of sample messages. The firm conducted a baseline survey prior to the media campaign and will conduct a repeat survey following the campaign.

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The Research Marketing Partners conducted six focus groups with 59 parents and caregivers to identify barriers, beliefs, and behaviors around oral health and to test the inital concepts developed from the literature review. The target population was households with at least one child enrolled in the state sponsored dental insurance program, Dr. Dynasaur. The focus groups were held in three distinct areas of the state, based on population and urban/rural status. A total of 1,050 invitations were sent out (350 per region). The focus groups addressed three main questions:

1. What are the barriers to parents/caregivers seeking and keeping appointments for appropriate health services for their children?

2. What are the baseline beliefs, attitudes, and behaviors around this subject for parents/caregivers of Medicaid-eligible children?

3. What are parents/caregivers preferred resources and distribution materials?

Focus group participants also identified their:

• Information preferences: short flyer, longer brochure, text versus pictures, internet, videos, etc.

• Distribution preferences: TV/Radio/print/internet; print materials available at WIC, doctor's offices, schools, etc.

• Parents' and caregivers' specific recommendations to improve the oral health of their children.

Marketing Partners synthesized the findings from the focus groups into key themes. Key Findings Five issues emerged from the six focus groups:

1. Parents/caregivers may not be able to define good oral health care for children, especially if they never had it.

2. Parents/caregivers believe they and their children are discriminated against, provided substandard care, and are stigmatized because they are members of the publicly financed Dr. Dynasaur program.

3. Multiple factors negatively affect making and keeping appointments including: lack of knowledge, difficulty finding a provider, inconvenient appointment times, long travel distances, unreliable

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transportation, fear of unexpected costs, concern about perceived mistreatment, and family crises.

4. Many parents/caregivers are unaware of what is covered, what is not, how to resolve problems, or what support services are available to them.

5. Most parents/caregivers feel they have no choice of provider because there is only one accepting new Medicaid patients.

After condensing these findings, Marketing Partners developed a draft set of messages addressing those issues and tested them with the public in a second round of focus groups. Participants were recruited from mailings and toll-free telephone screening. Fifty-one parents of 124 children were recruited; 37 parents ultimately participated in the second round. The marketing firm tested each sample message on preventive oral health care on the participants and had them rank them. The participants viewed storyboards for the television and radio ads and mock-ups for the print ads. Based on the feedback from the focus groups, the final ads were produced by Marketing Partners. There will be four ads, each one produced for television, radio, and print. Other marketing materials include the development of an informational packet that is sent out to people who call the 800 number. In addition, Marketing Partners developed a "Mutual Expectations" brochure, which highlights some important statistics about Vermonters' oral health habits and beliefs. This brochure is part of the informational packets, but it also will be distributed to dentist and pediatrician offices, other state agency locations frequented by the target population, and via other avenues that arise, such as health fairs. The marketing firm also conducted a pre-campaign telephone survey. The goal of the survey was to confirm/refute focus group findings and establish baseline knowledge, attitudes, and behaviors. This is important for evaluation of the project upon its completion. Key findings from the phone survey included:

• Vermont families move fluidly in and out of public and private insurance status.

• Appointment keeping behavior is similar between those covered by Dr. Dynasaur and those covered by private insurance.

• There is no significant difference in the likelihood of having a dental home for those eligible for Dr. Dynasaur and those who are ineligible.

• Eighty-five percent of respondents reported that they are able to access care when they need it.

• Available transportation assistance is not used—supporting focus group findings that most Vermont families with children enrolled in Dr. Dynasaur are unaware of this service.

• More than one-third of respondents did not realize the importance of

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early teeth cleaning for their children. • Twenty-five percent of respondents did not understand the

importance of avoiding giving their child a bottle in bed or at naptime.

The survey also revealed music preference, how many people watch television and/or listen to the radio, and where they would look for oral health information. All of the findings are being used to improve the reach of the campaign.

In addition to the focus groups and pre-campaign survey, there was another important group of people that participated in each step of this process, the Media Advisory Committee. This committee, created specifically for this project and lead by the Vermont Department of Health, is composed of major stakeholders such as representatives from advocacy groups, private and public dental providers, the dental society, and state agency personnel. This group was an invaluable sounding board as the messages took shape. Value of Partnerships With agreement on the parent education approach, the next hurdle was figuring out how to provide information in the most effective manner. This is where partnerships began to form. VDH knew it had to have a toll-free number for parents/caregivers to call for more information. They looked into developing an 800 number to be answered at the Department, but it was cost prohibitive and, even more importantly, people would get an answering machine, not the best way to build consumer confidence. The goal was to figure out how to provide a toll-free number that was more than a recording but did not cost a lot of money to operate. VDH looked to the United Way, which already operates an information hotline for numerous public health services. This was the answer. An agreement was reached such that a specific 800 number, 1-888-9VT-SMILE, would ring into the United Way call center, and be answered by a United Way employee with the words “Smile Vermont." This provides the personal touch that is so critical to a social marketing campaign, and the cost-efficiency the state needed. The United Way employees have fact sheets and other materials that they can provide to callers, including an updated list of every licensed dentist in the state and a list of all the Tooth Tutor schools. Because the oral health number rings into to a call center that handles other public health calls, employees are trained to recognize other needs, and they have information at their fingertips to help people find the assistance they need.

An important part of any social marketing campaign is the evaluation of its

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effectiveness. This is another area where the partnership was valuable. The level of detail on calls is more than the state expected. Not only can the United Way track what medium the caller found the number through, they are documenting specifics such as, “A man called in wanting to locate a dentist for his three-year-old daughter.” This is encouraging news for VDH, because in its first month, the ad campaign already is demonstrating that people are looking for oral health care for their children, and the message is getting out about where they can get it.

Beyond the data captured by the call center, Marketing Partners also will conduct a post-campaign telephone survey to assess attitude and usage changes. VDH also is taking advantage of other statewide education activities such as the “Covering Kids and Families Initiative,” which promotes enrollment of qualified children in the state's Medicaid and State Children's Health Insurance Programs, and the “Give Kids a Smile Day,” created by the American Dental Association, to further disseminate information about oral health. Printed brochures, pamphlets, and other education materials are being developed. They will be distributed to various locations such as Head Start and WIC. Finally, the Department of Health is working closely with the state dental association. In addition to having a representative on its Media Advisory Committee, it sent a letter announcing the media campaign to every dentist in the state. The Department, with the assistance of Marketing Partners, also is developing a Brochure to share its findings with dental providers.