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Do The Same Findings Hold For Patient Compliance?

Readers may recall that I recently promoted Expanding The Patient Compliance Knowledgebase by considering data from fields beyond healthcare that are potentially pertinent to treatment adherence.

With that in mind, read the following excerpts from Texts You Can Believe In¹ By Farhad Manjoo, published at Slate.com Oct. 27, 2008, mentally changing the context from political campaigns to patient compliance (don’t worry - it’s not difficult):

… you might think that automated phone calls will make a difference in the presidential race. They won’t. Robo-calls are the pyrotechnics of politics: They create a big disturbance, but they don’t have a prolonged effect. Numerous studies of robo-call campaigns show that they’re ineffective both as tools of mobilization and persuasion—they don’t convince voters to go to the polls (or to stay away), and they don’t change people’s minds about which way to vote. So why do campaigns run robo-calls? Because they’re cheap and easy. Telemarketing firms charge politicians between 2 and 5 cents per completed robo-call; that’s as low as $20,000 to reach 1 million voters right in their homes.

Compared with TV advertising, door-to-door canvassing, and mega-rallies, automated phone calls are seductive because they harness modern telecommunications technology in the service of political persuasion. …

On the surface, these texts don’t seem that different from robo-calls—they’re both automated messages and both easy to ignore. But for reasons that aren’t completely understood, text messaging is different: We pay attention to short messages that pop up on our phones.

These conclusions arise out of work by Donald Green and Alan Gerber, two political scientists at Yale whose book, Get Out the Vote: How To Increase Voter Turnout, is considered the bible of voter mobilization efforts. Green and Gerber are the product of a wave of empiricism that has washed over political science during the past decade. Rather than merely theorizing about how campaigns might get people to vote, Green, Gerber, and their colleagues favor randomized field experiments to test how different techniques work during real elections. Their method has much in common with double-blind pharmaceutical studies: With the cooperation of political campaigns (often at the state and local level), researchers randomly divide voters into two categories, a treatment group and a control group. They subject the treatment group to a given tactic—robo-calls, e-mail, direct mail, door-to-door canvassing, etc. Then they use statistical analysis to determine whether voters in the treatment group behaved differently from voters in the control group.

Political scientists have run dozens of such studies during the past few years, and the work has led to what you might call the central tenet of voter mobilization: Personal appeals work better than impersonal ones. Having campaign volunteers visit voters door-to-door is the “gold standard” of voter mobilization efforts, Green and Gerber write. On average, the tactic produces one vote for every 14 people contacted. The next-most-effective way to reach voters is to have live, human volunteers call them on the phone to chat: This tactic produces one new vote for every 38 people contacted. Other efforts are nearly worthless. Paying human telemarketers to call voters produces one vote for every 180 people contacted. Sending people nonpartisan get-out-the-vote mailers will yield one vote per 200 contacts. (A partisan mailer is even less effective.)

Meanwhile, pinning leaflets to doors, sending people e-mail, and running robo-calls produced no discernible effect on the electorate. Green and Gerber cite many robo-call studies, but the most definitive is a test they ran during the 2006 Republican primary in Texas. Gov. Rick Perry recorded a call praising a state Supreme Court candidate as a true conservative. The robo-call was “microtargeted” to go out only to Perry supporters—people who’d be most open to his message. But as Green and Gerber show, Perry supporters who received the call reacted no differently from those who’d been kept off the list. They were no more likely to vote, nor, if they voted, to vote for Perry’s candidate.

These findings create an obvious difficulty for campaigns: It’s expensive and time-consuming to run the kind of personal mobilization efforts that science shows work best. Green and Gerber estimate that a door-canvassing operation costs $16 per hour, with six voters contacted each hour; if you convince one of every 14 voters you canvass, you’re paying $29 for each new voter. A volunteer phone bank operation will run you even more—$38 per acquired voter. This is the wondrous thing about text-messaging: Studies show that text-based get-out-the-vote appeals win one voter for every 25 people contacted. That’s nearly as effective as door-canvassing, but it’s much, much cheaper. Text messages cost about 6 cents per contact—only $1.50 per new voter.

… I joined Obama’s text list around that time. (I would have joined McCain’s text message list as well, but he doesn’t have one.) Since then, I’ve received two or three messages a week from the Obama campaign. A typical one: “Help Barack. Tell your friends & family the last day to register to vote in CA is this Monday, Oct 20th! Visit VoteForChange.com to register NOW. Please forward.”

The texts reminded me to watch the convention and the debates and to donate money to the Red Cross when Hurricane Gustav hit. In September, Obama asked me to text him my ZIP code. I did, and now I get location-specific messages—alerts to phone banks and debate-watching parties in my area, reminders of registration deadlines in my state, and appeals for me to volunteer in neighboring states. The messages are rendered in a friendly, professional tone (they refer to the candidate as Barack) and have been free of both fundraising appeals and any kind of negative campaigning.

The beauty of text messaging is that it is both automated and personalized. This is true of e-mail, too, but given the flood of messages you get each day (no small amount from Obama), you’re probably more attuned to ignoring e-mail. Text messages show up on a device that you carry with you all day long—and because you probably get only a handful of them each day, you’re likely to read each one.

This is especially true when the message seems to have been tailored to you specifically—Obama’s often are. The campaign knows a lot about me: At the least, it knows that I live in California, and because I joined the text-message list in order to learn the V.P. pick, that I’m fairly interested in politics (and therefore likely to vote). It’s possible that they might know even more; given my ZIP code and my phone number, they could potentially have tied my text-message account to my voter registration file, allowing the campaign to send me messages based on my party registration, whether I usually vote by mail, and whether I sometimes forget to vote. (It doesn’t appear that the campaign knows what’s in my registration file, though; I’m registered as a permanent absentee voter, but the campaign hasn’t asked me to mail in my ballot yet.)

Because text messages allow for such precise targeting, it seems likely that over the next week the Obama campaign will direct its appeals to voters in battleground states, especially first-time voters that the campaign has registered during the past year. In 2006, political science grad students Aaron Strauss and Allison Dale studied how newly registered voters responded to text-message reminders sent out just before the election. The text messages increased turnout by 3.1 percentage points. Strauss says there’s a simple reason why: “The most prevalent excuse for registered voters who don’t cast a ballot is, ‘I’m too busy’ or ‘I forgot.’ Texting someone is a convenient, targeted, and noticeable reminder for them to schedule their Election Day activities with a block of time set aside for going to the polling place.” In a post-election survey, Strauss and Dale asked voters whether they found the text messages helpful; 59 percent said yes.

Vote For Treatment Adherence

So, does text messaging research done in the political arena apply to the world of healthcare recommendations?

Well, I dunno.

For one thing, it may be a moot point.While I have surveyed the basic research on personalized text messaging as a compliance enhancement tool, I’m not well versed enough in this field to ascertain if  counterparts to the type of election campaign messaging studies described in the article already exist.

For example, that I’m not familiar with a healthcare equivalent of Get Out the Vote: How To Increase Voter Turnout by Donald Green and Alan Gerber, the how-to handbook based on well designed research utilizing control groups ²  described in the Slate article, does not mean it hasn’t been produced.

But, it seems to me that there are only a limited number of possible scenarios:

1. There are no healthcare counterparts to the type of research described for voter mobilization text-messaging.³ In this case, the seemingly obvious next step is, absent evidence that the healthcare and political fields are fundamentally different, using the work already done in the latter sphere as a basis for confirmatory studies applicable to healthcare.

2. There are healthcare counterparts to the type of research described for voter mobilization text-messaging. In this case, it becomes useful to ask how those results compare.

If voter mobilization and healthcare compliance behaviors with respect to text-messaging are similar, the likelihood that there exists a universal  set of responses to recommendations  made to individuals - whether the recommendation is to floss after meals, buy a hybrid rather than a gas-guzzler, take medication as prescribed,  vote for Ralph Nader, buckle up, read the AlignMap blog, or see the new Mel Gibson movie - is enhanced, as is the utility of exploring what is known about this phenomenon in other fields.

If voter mobilization and healthcare compliance behaviors with respect to text-messaging do not correlate, the key becomes investigating why those differences exist.

3. We stick with the isolationist party line, AKA the Fortress Healthcare approach, pretending that our field is so fundamentally different that it is a unique universe unto itself.⁴

Footnotes

1. Subtitle: “Forget robo-calls—Obama’s text messages are this campaign’s secret weapon”↩
2. I am making, for the purposes of this post,  the somewhat daring assumption that the research methodology used in Get Out The Vote and the other voter mobilization  studies is as designed as carefully  and executed as  rigorously as claimed.↩
3. Again, I’m making the assumption that the research methodology used is valid↩
4. It is also, one suspects, a unique universe in which the stars and planets revolve around a flat Earth.↩