First for Family

By Zeina Fakhreddine, Laura Kelly, Gail Lewis, and Eyas Zakri

People should go to their doctors on a regular basis; if not for particular symptoms, then to seek preventive healthcare. There are many reasons people visit doctors, but in the United States there are many other reasons people avoid visiting them. The purpose behind this paper is threefold: to investigate the reasons people in the US avoid medical healthcare, to understand what Medicare is, and to raise awareness about the importance of prevention methods among people aged 60 and above through a Facebook campaign and radio advertisement. The reasons Facebook and radio were chosen for the campaign’s exposure are because 46% of American people aged 60 and above use Facebook (Pew Research Center, 2019), and 88% listen to the radio (Total Audience Report Q1, 2018).

Primary Reasons People in the US Avoid Medical Healthcare

To begin with the most common one, cost is the primary reason US citizens/residents resist visiting doctors. Around 60% of American citizens/residents delay or avoid seeking medical care owing to their cost concerns (Konstantinovsky, 2020; Kannan & Veazie, 2014). This is not surprising because 25% of the people who actually seek medical care and are under the age of 65 are in medical debt (Konstantinovsky, 2020; Kannan & Veazie, 2014). Second, fear and embarrassment play an important role (Taber et al., 2015). One the one hand, people refrain from visiting doctors out of fear because it is often associated with hospitals, doctors’ offices, bad news, or painful medical procedures, e.g., blood tests, needles, and so forth (Taber et al., 2015). On the other hand, some feel embarrassed to visit doctors, as they are not comfortable answering questions about their eating habits, sex life, weight-related issues, bowel movement, etc. (Taber et al., 2015). This is considered a key problem because they cannot lie to their physician; yet, they are not comfortable sharing (Taber et al., 2015). Third, lack of knowledge about health risks is an essential factor (Sauver et al., 2013). When people, especially the younger generation, are in good health, they tend to go years without visiting a physician due to their disbelief it is a necessity or their lack of information about illnesses to which they are prone (Sauver et al., 2013). To clarify, when a person is in good health and does not have serious illnesses in their family’s medical history, they tend to believe that their health is not at risk (Sauver et al., 2013). Fourth and finally, not having proper access to physicians is considered one of the major problems people, primarily the elderly, do not visit a doctor (Kannan, 2015). Many might be eager or willing to go to a doctor, but they either do not know how, or where to find one or do not have one (Kannan, 2015). Moreover, if they suffer from a chronic or a serious condition, they can become easily overwhelmed looking for the right healthcare that benefits their case the most (Kannan, 2015). Nevertheless, services as such are not accessible everywhere because people who live in rural areas have less resources than people who live in cities (Kannan, 2015). These are just some of the reasons that hold back people from regularly seeing a doctor.

What is Medicare USA?

In order to have a better understanding on why people aged 65 and above are concerned about their medical expenses, one must have an overview about their medical insurance, primarily Medicare. Medicare is a federal health insurance program in the United States that benefits people aged 65 and above, in addition to some young people with disabilities and people with End-Stage Renal Disease (Medicare Trustees Report, 2019). According to Medicare Trustees (2019), around 59.9 million individuals benefit from this program. Medicare covers up to 80% of the medical expenses of the people enrolled in the program, and beneficiaries usually rely on other medical insurance companies to cover the rest of their medical fees (Medicare Trustees Report, 2019). Medicare has four parts which are referred to as Part A, Part B, Part D, and Part C. Medicare Part A covers hospital expenses such as ambulance services, inpatient hospital and services, skilled nursing, and home healthcare and hospice (Shih et al., 2019). Medicare Part B is responsible for medical expenses (Alva, 2019). It basically handles the hospital charges Part A does not cover, i.e., outpatient services, doctor visits and preventive care, medical and lab services, and medical supplies and equipment (Alva, 2019). Medicare Part D only covers drug prescription (Lai et al., 2015). Medicare Part C is usually referred to as Medicare Advantage, for it covers the expenses of Parts A, B, and D in addition to further services (Amit et al., 2018). Along with Parts A, B and D’s benefits, it also includes vision, basic dental services, and hearing (Amit et al., 2018).

Medicare’s Limitations

Although Medicare seems like it is aiding a significant number of the United States’ elderly population, it still has a number of limitations and disadvantages. First, Medicare’s Parts A and B cover hospital and other medical benefits; however, they leave other important things not covered (Tabrizi et al., 2011; Rubin et al., 2001). These include drug prescriptions, dental care, hearing aids or hearing care, and gym and fitness club memberships (Tabrizi et al., 2011; Rubin et al., 2001). To benefit from full coverage, enrollees must upgrade to Medicare Advantage Plan, i.e., Medicare Part C which is a lot costlier than Parts A and B (Tabrizi et al., 2011; Rubin et al., 2001). Second, there are certain out-of-pocket costs to be taken into consideration (Tabrizi et al., 2011; Rubin et al., 2001). Beneficiaries must meet their Part A deductible which is $1,408/benefit period before their coverage starts (Tabrizi et al., 2011; Rubin et al., 2001). In 2020, beneficiaries became able to pay further coinsurance costs of approximately $704 a day to benefit from inpatient hospitalization of over 90 days (Medicare Gov, 2020). As for Medicare Part B, it only covers 80% of the costs, and beneficiaries have to pay for the remaining 20% to cover the rest of the expenses which are mostly high out-of-pocket costs (Tabrizi et al., 2011; Rubin et al., 2001). Third, there is no out-of-pocket limit for Original Medicare, i.e., Parts A and B (Tabrizi et al., 2011; Rubin et al., 2001). This means that beneficiaries do not have a maximum limit to the amount they might be required to pay (Tabrizi et al., 2011; Rubin et al., 2001). On the other hand, Medicare Advantage Plan, also referred to as Medicare Part C, has a maximum spending limit (Tabrizi et al., 2011; Rubin et al., 2001). But as aforementioned, the majority of beneficiaries enroll in Original Medicare due to the costliness of Advantage Plan (Tabrizi et al., 2011; Rubin et al., 2001).

Illnesses Leading to Hospitalizations

In order to approach the health campaign correctly, it is important to understand the chronic illnesses that lead people aged 60 and above to hospital admission. The senior citizen population in the United states is 49.2 million strong (Administration on Aging, 2018). Americans over 60 make up 15.2 % of the population, and by the year 2060, over 98 million of us will be considered elderly (Administration on Aging, 2018).

This ever-growing aging population has unique health care needs and illnesses (Administration on Aging, 2018). In 2017, 45% of Americans 60 and over assessed their health as excellent or very good (Administration on Aging, 2018). Most older persons have at least one chronic condition and many have multiple conditions (Administration on Aging, 2018). In 2015, the top five chronic conditions in this population were hypertension (58%), hyperlipidemia (48%), arthritis (31%), ischemic heart disease (29%), and diabetes (27%) (Administration on Aging, 2018). Although these are the most common causes for hospitalization among people aged 60 and above, there are some other factors which include cardiac arrhythmias, congestive heart failure, chronic obstructive pulmonary diseases (COPD), coronary atherosclerosis, infection, medication problems, pneumonia, and stroke (Foltz-Gray, 2012).

Persuasive Health Messages

Figure 1: The Persuasive Message Framework

Note. From “Identifying the Sociocultural Barriers and Facilitating Factors to Nutrition-related Behavior Change: Formative Research for a Stunning Prevention Program in Ntchisi, Malawi”, by S. Kodish, N. Aburto, N., M. N. Hambayi, C. Kennedy, & J. Gittelsohn, (2015), International Nutrition Foundation, 36(2), p. 149.

The Persuasive Health Message (PHM) Framework, developed by Witte in 1995, offers a step-by-step guide to develop effective health communications campaigns. The PHM finds its value in the communicator understanding the audience to develop messaging targeted for them, instead of depending on the audience’s understanding of the message themselves. It takes cues from three other persuasion theories — the Theory of Reasoned Action, the Elaboration Likelihood Model, and the Protection Motivation Theory — to guide the creation of successful health campaigns based on demographic, cultural and geographical considerations (Morton & Kim, 2015).

The PHM works by first identifying the constant characteristics of the audience for the messages. The characteristics of interest here are their susceptibility to whatever the health threat is, and their perception of how severe the threat could be; whether or not they believe the recommended action will work to ease the threat and whether or not they themselves can perform the recommended action; the audience profile, including demographics, values, psychographics, etc., and whether the messaging and the source of that message is credible. Regardless of the campaign or messaging, these constants must be in place for a PHM to be effective (Morton & Kim, 2015).

Next, the PHM sets up the variables that will differ from campaign to campaign. These include the goals of the messaging, the beliefs about the campaign goals the audience holds, as well as the cultural, environmental and influential beliefs the audience of the goal may be exposed to (Morton & Kim, 2015). Once these characteristics are identified, the persuasive message can be developed.

Developing the PHM for our Campaign

We identified the characteristics of our audience through interviews with 10 individuals. They ranged in age from 60 to 88, with two identifying as male and 8 identifying as female. All individuals identified as white or of European descent, except for one who chose not to disclose this information. All but two of the individuals use Medicare as a part of their health insurance coverage or are about to use Medicare within the next six months and have researched the programs.

All interviews were done by the same interviewer to achieve internal validity. The individuals were all given pseudonyms by the interviewer, and all were given assurance of confidentiality. The phone interviews were recorded after the consent of the participants was taken. These recorded interviews were then transcribed using Otter.ai, and initially coded using NVivo software. All interviews lasted between 20 and 30 minutes on average.

Threat and Susceptibility

In order to understand the threat individuals face to needed hospitalizations, we asked them if they lived with any chronic health conditions. Responses included insulin-dependent diabetes, high-blood pressure, and immobility. When asked to rate their health on a scale of 1 to 5 with 5 being the highest, all interviewees rated at a three or higher. The insulin-dependent diabetic, for example, rated her health as a 5. When asked to state her reason, she said:

“Because I get up in the morning… I keep moving, keep doing things. I can get up and I can do laundry. I still wash walls down in my house… I have energy. I have ambition.”

-Patricia, 77

Additionally, one individual with high-blood pressure rated his health as a four, and the

individual living with immobility also rated his health as four. This signaled to us that these individuals do not perceive their susceptibility to health events that would require hospitalizations as high. We also asked individuals why they avoid going to the doctor, if they in fact do. Three individuals cited home remedies as their ‘alternate choice’ over going to the doctor. Further reasons for avoiding the doctor included the cure being worse than the disease, frustration with the process, or just a simple dislike for going. Resoundingly, though, family obligations were the top reason for not going to the doctor with five individuals listing their family’s as priorities over their health.

Efficacy

All but two interviewees were on or about to go on to Medicare within the next six months. Five of those individuals expressed confusion when it came to Medicare and what it covered, how Medicare worked with their supplemental insurance, and whether they would be able to quit their employer-provided health insurance they maintained in retirement. Moreover, three individuals worried about the expense of Medicare. One individual complained about the initial cost. Others complained about the cost of prescriptions on Medicare, especially for chronic conditions that require regular medications. These responses indicated to us a low self-efficacy when it comes to Medicare-related issues, like understanding what doctors are in network, cost of prescriptions, and Medicare coverage versus supplemental coverage. We also asked the individuals about things they did to stay healthy and prevent illness or hospitalizations. Six respondents said they went to the doctors regularly, but of them, three do not think going is always necessary. For example, Darla explained needing a knee replacement and not having a primary care physician.

These responses showed that the self-efficacy may be high when it comes to going to the doctor, but the threat perception is low, as half of those responding that they do go to the doctor regularly don’t find it necessary. Individuals did respond that they eat well and exercise as ways to stay healthy. Six respondents mentioned a healthy diet or maintaining a healthy weight as a preventative measure they take to stay healthy, and seven exercise to prevent illness. With 70% of the respondents eating well and/or staying active as prevention, we inferred a high self-efficacy for lifestyle measures as a way to stay healthy and prevent hospitalizations.

Cues

Given the answers from the respondents, we decided on the following message and source for our campaign: 1) Message: Make healthy lifestyle choices for yourself so you can be there for your family; 2) Source: Dietitian or other preventative health care professional

Audience Profile

Our interviews led us to develop the following audience profile which consisted of adults aged 60 and above, who are parents and grandparents, put family first, and enjoy social activities. They enjoy family and social activities, with every respondent stating that as a reason to stay healthy. Nine of those listed family as their reason to stay healthy, and five went as far as to say they prioritize their family over their health. Social and family activities interviewees named as important to them include seeing their grandchildren grow up, participating in recreational activities, like bike riding and gardening, and being able to provide services for others. These socially-oriented parents and grandparents 60 and over are our audience for our campaign.

First for Family Campaign

Our campaign will take place on Facebook and on Radio, as our audience is very active on both of these mediums. We will target those audiences through advertising on the social platform, as well as radio stations with high-listening rates in our target audience, 60+. Based on our research and our interview results, we will focus on preventative measures in order to stay healthy for their families as the message of our campaign. These measures include exercise, healthy eating and weight management, and regular doctor visits.

After our initial campaign, we will evaluate to consider other inclusions, like television.

Conclusion

Preventative health care in adults 60 and over is important to decrease hospitalizations in seniors. By targeting adults beginning at age 60, we can encourage healthy lifestyle measures like exercise and regular doctor visits to prevent further complications as the person ages. Our hope is our messaging will prompt the audience to take healthful measures, for themselves and for their loved ones.

Appendix

Questionnaire:

1. What is your age?
2. Do you identify by a certain gender?
3. Do you identify by a certain ethnicity?
4. Why do you value your health?
5. Tell me about a time you prioritized something else over your health.
6. How do you feel about going to the doctors?
7. Do you suffer from any chronic diseases?
8. On a scale 1 to 5 with 5 being the highest, how do you rate your overall health?
9. What usually holds you back from visiting a doctor or getting hospitalized?
10. How does Medicare benefit you?
11. What are some of the drawbacks Medicare has?
12. Do you have any suggestions that would make Medicare a better program?
13. What are some of the health measures you take to prevent hospitalization?
14. Why do you think preventive health measures are important?
15. What are your reasons for staying healthy?
16. Do you have a Medicare supplemental plan, and why did you get it?

Campaign:

Facebook

One of the elements of our campaign is targeted advertising on Facebook. According to a Pew Research survey, 46% of U.S. adults over 65 use Facebook, compared with 8% on Instagram, 11% on LinkedIn, 7% on Twitter, and 15% on Pinterest. Usage for adults 50–64 follow a similar trend, with the exception of YouTube, and percentages can be found in the chart below (2019). Because of the much higher usage of Facebook by our target audience, a Facebook campaign will be utilized.

The campaign will feature an infographic encouraging preventative health measures, like exercise and eating healthy. The goal of the ad is awareness, so the ad will be optimized for reach.

We will set up Campaign Budget Optimization with Lowest Cost Bid ads running all the time. This will get our ad in front of as many eyes as possible for the most economical cost. Our budget will be capped at $40 per day, giving us a max reach of 3.7–11K people per day.

The ad will run for 31 days (an entire month), with a total reach of approximately 114,000–341,000 impressions. We will limit the number of times an individual user is served the ad to one impression every 10 days.

The custom audience demographics for the campaign are individuals living within a 25 mile radius of Indiana, PA, ages 60 and over, and of all genders. The potential audience reach is 52,000 people. With 114,000–341,000 impressions in our ad buy and with a limit of one impression per individual every 10 days, our goal is to reach each Facebook user at least once.

Radio

As mentioned above, 88% of adults age 60+ listen to the radio (Total Audience Report Q1, 2018). We will run our ad on WDAD-AM 1450, 100.3 FM. This radio station was chosen because of the music genre and current advertisers. The station plays classic hits, and its top advertiser is Aging Services, Inc., an organization “dedicated to meeting the diverse needs of older adults in Indiana County by providing opportunities to enhance their social, physical and mental skills utilizing our various programs” (wdadradio.com/agingservices).

The radio spot will be 60 seconds and run for the same time period as the Facebook ad, for one month. The budget for the campaign will be $300 per week, and will gain an approximate 78,000–105,000 impressions (iheartadbuilder.com).

References

Administration for Community Living. (2018). 2018 profile of older Americans. https://acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/2018OlderAmericansProfile.pdf

Alva, M. L. (2019). How Much Does Attendance Impact Weight Loss and Health Care Spending in a Diabetes Prevention Program Serving Older Adults?. American Journal of Health Promotion, 33(7), 1067–1072.

Coppola, V., Girandola, F., & Camus, O. (2020). A Strong Argumentative Orientation Makes the Cognitive Closure Easier: The Case for a Persuasive Health Message. Studia Psychologica, 62(1), 5–22.

Demographics of Social Media Users and Adoption in the United States. (2019, June 12). https://www.pewresearch.org/internet/fact-sheet/social-media/

Foltz-Gray. (2012). Most Common Causes of Hospital Admissions for Older Adults. AARP. https://www.aarp.org/health/doctors-hospitals/info-03-2012/hospital-admissions-older-adults.html

Kannan, V. D., & Veazie, P. J. (2014). Predictors of avoiding medical care and reasons for avoidance behavior. Medical care, 336–345.

Kannan, V. D. (2015). Capsule Commentary on Taber et al., Why Do People Avoid Medical Care? A Qualitative Study Using National Data. Journal of General Internal Medicine, 30(3), 342–342.

Kodish, S., Aburto, N., Hambayi, M. N., Kennedy, C., & Gittelsohn, J. (2015). Identifying the sociocultural barriers and facilitating factors to nutrition-related behavior change: formative research for a stunting prevention program in Ntchisi, Malawi. Food and nutrition bulletin, 36(2), 138–153.

Konstantinovsky, M. (2020, January 23). Common reasons we avoid the doctor. One Medical. https://www.onemedical.com/blog/live-well/common-reasons-we-avoid-doctor#:~:text=One%20major%20reason%20people%20cite,of%20their%20concerns%20around%20cost.

Kumar, A., Rahman, M., Trivedi, A. N., Resnik, L., Gozalo, P., & Mor, V. (2018). Comparing post-acute rehabilitation use, length of stay, and outcomes experienced by Medicare fee-for-service and Medicare Advantage beneficiaries with hip fracture in the United States: a secondary analysis of administrative data. PLoS medicine, 15(6), e1002592.

Lai, L. L., Bleidt, B. A., Singh‐Franco, D., Elusma, C., & Huh, G. (2015). Trends in benzodiazepine prescribing under Medicare Part D in USA: outpatient settings 2005–2009. Journal of Pharmaceutical Health Services Research, 6(3), 133–138.

Medicare Gov. (2020). Medicare costs at a glance. https://www.medicare.gov/your-medicare-costs/medicare-costs-at-a-glance

Medicare Trustees Report. (2019, April 22). 2019 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/TR2019.pdf

Morton, C. R., & Kim, H. (2015). Use of the PHM framework to create safe-sex ads targeted to mature women 50 and older. Health Marketing Quarterly, 32(2), 148–164.

Rubin, H. R., Pronovost, P., & Diette, G. B. (2001). The advantages and disadvantages of process‐based measures of health care quality. International Journal for Quality in Health Care, 13(6), 469–474.

Sauver, J. L. S., Warner, D. O., Yawn, B. P., Jacobson, D. J., McGree, M. E., Pankratz, J. J., … & Rocca, W. A. (2013, January). Why patients visit their doctors: assessing the most prevalent conditions in a defined American population. In Mayo Clinic Proceedings (Vol. 88, №1, pp. 56–67). Elsevier.

Shih, Y. C. T., Xu, Y., Chien, C. R., Kim, B., Shen, Y., Li, L., & Geynisman, D. M. (2019). Rising Economic Burden of Renal Cell Carcinoma among Elderly Patients in the USA: Part II — An Updated Analysis of SEER-Medicare Data. PharmacoEconomics, 37(12), 1495–1507.

Tabrizi, J. S., Gharibi, F., & Wilson, A. J. (2011). Advantages and disadvantages of health care accreditation models. Health promotion perspectives, 1(1), 1.

Taber, J. M., Leyva, B., & Persoskie, A. (2015). Why do people avoid medical care? A qualitative study using national data. Journal of general internal medicine, 30(3), 290–297.

Total Audience Report: Q1. (2018). The Neilson. https://www.nielsen.com/us/en/insights/report/2018/q1-2018-total-audience-report/