Originally Published MX September/October 2005
TOPSPIN
Consumer PowerPatients informed through direct-to-consumer campaigns can effect changes in standards of care.
Pamela Rasmussen
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| Pamela Rasmussen is vice president for corporate communications at Digene Corp. (Gaithersburg, MD). |
The development of the Pap test more than 50 years ago dramatically improved our ability to prevent cervical cancer; in fact, the number of women in the United States affected by the lethal disease has dropped 75% since the Pap test was introduced. Still, the American Cancer Society projects that, during this year, about 10,370 women will develop cervical cancer and slightly more than 3700 will die of it.1
One reason cervical cancer still threatens women's lives and ability to have children is that some women are not getting screened as often as they should, or at all. But another reason, not widely known, is that the Pap test—even the newer liquid-based version—fails to identify some women with precancerous cells. That's because it is a subjective test. A laboratory professional looks at cells underneath a microscope to determine if any look abnormal. However, the sample may be insufficient, it may be contaminated, or the technologist may not be able to tell whether an abnormality exists. (The opposite problem may occur as well: The technologist raises a warning flag, but when the woman undergoes additional, more invasive, testing, she is found to be disease free.)
Digene Corp. (Gaithersburg, MD), a global diagnostics company, has developed the only FDA-approved test for the human papillomavirus (HPV), which is the cause of virtually all cases of cervical cancer. Unlike the subjective Pap test, the Digene HPV test uses advanced molecular technology to detect the presence of the virus through its DNA. This test has been approved for routine use, along with the Pap test, in women aged 30 and older. For younger women, who are less likely to develop cervical cancer, the test is used as a follow-up when Pap results are unclear.
The Digene HPV test was first approved for routine screening in April 2003. In traditional marketing fashion, the manufacturer's initial goals were to work with professional societies to incorporate HPV testing into medical guidelines, and to educate physicians and nurses regarding why and how a new approach to cervical cancer prevention should be incorporated into their practices. However, somewhat predictably, many healthcare professionals have been slow to change. Many have told Digene that they would be more likely to offer its test if women asked for it specifically.
But here was the problem: Most women are unaware of HPV, much less that an HPV test exists. They think that getting a regular Pap test is all they need to do. A poll conducted by Research!America in 2004 suggested that 82% of women did not know the primary cause of cervical cancer. Also, 85% reported that neither their doctor nor a nurse or other healthcare professional had ever talked to them about having an HPV test.2 Yet, once informed, as this poll and others have shown, most women would want to know their HPV status.
Educating the Consumer
To elevate women's awareness to a new level and increase their inclination to act, Digene moved this spring to supplement its extensive public relations and advocacy-outreach campaign with national magazine advertising and TV in targeted pilot markets. Public relations—working with the media to persuade journalists to tell your story—and outreach to advocacy organizations are important. They provide a credibility that advertising cannot duplicate. However, advertising guarantees repetition, a carefully crafted and controlled message, and specific, targeted vehicles. The ideal media mix includes all three of these channels.
The first step was research. Given Digene's size, the company's advertising budget was necessarily limited by comparison with Big Pharma or manufacturers of traditional consumer goods. Thus, it was particularly critical that the message, creative concepts, and vehicles chosen be highly targeted. The company enlisted a market-research company that specializes in women, and conducted three rounds of focus groups.
The first of these explored women's desire for health information and their search for it, their relationships with the doctors who provide their gynecologic care, and their attitudes toward their own role in making healthcare decisions involving themselves. Here, the aim was to discover which women were most likely to ask for a test their doctors may not yet be using.
The second and third focus group rounds tested specific ad concepts, with women and with physicians. The chosen advertising agency, Gotham Inc. (New York City), was selected on the basis of its experience in communicating to women and about movements, or public health issues. It was also the most creative in approaching Digene's special challenges.
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| Figure 1. In the winning concept, brand identification has been downplayed. Digene markets the only FDA-approved HPV test, and has no competition. (click to enlarge) |
Although four different advertising themes were tested, one emerged the clear winner (see Figure 1). The winning concept has several key elements. First, the overall approach is similar to that of a public-service announcement. The tone is educational rather than promotional. Branding—strong identification of either the company or the product—is downplayed. Because Digene markets the only FDA-approved HPV test, its primary competitor is lack of information, not another brand.
The ad headline focuses directly on the shortcomings of the Pap test. Research showed that this approach was the most attention- getting and the most likely to motivate action. The call to action is to "ask your doctor, tell your friends." Sources of further information that are cited are a newly redesigned Web site and a toll-free telephone number through which a brochure about the test can be obtained.
Early Advertising
The specific advertising vehicles for the first phase of Digene's campaign were selected for their ability to reach the desired demographic: women aged 30–49 with a household income of $50,000 or more. Nine national women's magazines were chosen for their capacity to build a sustained, intimate relationship with their readers. These were Cosmopolitan, People, Family Circle, First for Women, O (Oprah), Parents, Redbook, Real Simple, and Ladies Home Journal. In addition, the company entered three pilot TV markets—Philadelphia, Atlanta, and Baltimore—in order to generate instant excitement and visibility in cities where the company was well set up for success, with good reimbursement, strong rep coverage, and so on.
The magazine ads began appearing in the March or April 2005 issues, and are still running. Two versions with the same body copy were produced; the headlines and visuals are different. The 30-second TV ad first aired the week of March 7. It ran for 10 weeks in Baltimore and for 17 weeks in the other two cities (mainly for comparative purposes). Preliminary results from the campaign are being evaluated, but early indicators were positive enough to convince Digene to target two more cities for TV in the fall.
Meanwhile, various types of advertising and sponsorships via the Internet have been piloted, ranging from traditional healthcare sites such as WebMD to popular lifestyle communities such as eDiets.com.
DTC Reinforcement Activities
Advertising alone, as suggested previously, is not an advisable DTC marketing strategy. In light of its success, Digene's diversified campaign is instructive.
To help generate third-party media coverage, for example, Digene partnered with the Women's National Basketball Association (WNBA). The WNBA and a so-called dream team of participating players—with Lisa Leslie, center for the Los Angeles Sparks and a two-time MVP, prominent among them—are reaching out to women through media interviews and public appearances, encouraging them to talk to their doctors about cervical cancer screening and HPV testing. "Mind.Body.Spirit." is the theme logo of the WNBA's community- and cause-related activities, and cervical cancer prevention is a natural fit.
In addition, Digene's women's health team has facilitated unique, collaborative relationships with several nontraditional advocacy groups, one of them being Women in Government. A network of bipartisan female state legislators, Women in Government has adopted the elimination of cervical cancer as one of its primary goals. The group released a call to action in this arena in January 2005.3 By June 30, 2005, members of Women in Government had pushed for resolutions or legislation promoting cervical cancer prevention by means of the latest technologies in 41 states. Twenty-seven bills passed, including two calling for mandated insurance coverage of HPV testing.
Another organization that has adopted cervical cancer prevention as an issue is Balm In Gilead, which was originally formed to help stop the spread of HIV/AIDS through the African Diaspora by working with black churches and other faith communities in the United States. Its initiative is called the ISIS Project (for "intimate sessions for informed sexuality"). It was kicked off with a national advisory board on HPV and cervical cancer, a five-city educational tour, and a train-the-trainers program intended to equip black women faith leaders to spread the word.
Measured Results
Of course, the question is whether the campaign is worth the expense. Quantifying results from specific marketing or public relations activities is always difficult. It's a rare situation when the effect of one activity can be isolated from that of another, and then measured precisely. A particular challenge in Digene's situation is that women typically have a gynecologic exam only once a year; thus, it was unlikely that they would react immediately and measurably once educated by the ads.
However, measure we must. The only metric that means anything to the bottom line is whether test orders increase to an appreciable degree that is not obviously attributable to another influence. From a public health perspective, it was also important to show that women's knowledge of HPV had improved generally, and that this enhanced awareness was resulting in more conversations between women and their doctors.
Digene looked at two types of metrics: those known as leading indicators and the bottom-line changes in test orders that were reported by the company's laboratory partners. An example of a leading indicator is traffic to the company Web site. Since the campaign was launched, the number of monthly visitors to the site has risen 44%, and the average time a visitor spends at the site has increased from 5 minutes to slightly more than 12 minutes.
Another leading indicator is the change in women's awareness levels. Digene conducted a survey of 250 women in each of the three TV markets in March 2005 and again in June. (A national survey was also conducted, but it will not be repeated until September.) The findings included a 90% increase over that period in the number of women who were familiar with the HPV test, along with a corresponding 53% drop in those who had never heard of it. In addition, 41% more women reported having had the HPV test.
As for bottom-line measures, it's still a bit soon to draw definitive conclusions, owing to the lag time inherent in the market. Sustained results are needed for Digene to be able to differentiate a lasting effect from a temporary blip, or one market from another. However, there have been numerous anecdotal accounts from field representatives of doctors' offices being swamped with calls from patients and of physicians saying they will start offering HPV testing to more women. Philadelphia saw a 23% increase in test volume in February through April of this year, by comparison with the same three-month period in 2004.
These results are preliminary. Digene continues to collect data to measure the overall success of its DTC campaign. But perhaps the true measure of that success is exemplified by this story submitted to the Web site:
"I am 30 years old and have been getting my Pap religiously since I turned 23. None of my reports showed any abnormalities. . . . Then I [learned about] HPV testing and decided to go for it. Boy! Was I glad I did, coz the HPV test saved my life! I was found to be HPV-positive and my viral load was extremely high. My gyn then did a colposcopy for me immediately. I was found to have CIN stage III [advanced cervical disease]. A LEEP [a procedure to remove abnormal cells] was performed immediately. I was that close to cervical cancer."
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