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I n c r e a s i n g C o n s u m e r S a t i s f a c t i o n

O ne socia l service an d pub l ic hea l th in it ia t ive show s h ow

socia l m arket ing can increase consu m er sa t is faction

B y C a r o l B r y a n t E l l e n B . K e n t J a m e s L i n d e n b e r g e r J a n e t M o g g S c h r e i h e r M a r s h a W a l k e r C a n r i g h t

S t e v e C o l e V a l e r i e U c c e l l o n i C h r i s t o p h e r

A .

B r o w n R . C l i f f o r d B l a i r a n d M a r t a M . B u s t i l l o - H e r n a n d e z

T

he Special Supplemental Nutrition Program

for

Women, Infants

Children

(WIC) is

considered

one

of

the most successful social service

and pub-

lic health initiatives

in the

nation. Numerous studies

have shown panicipation

in WiC to be

associated with

improved nutritional status

of

pregnant women, nursing

mothersandyoung childrenaswellasreductionsin low

birth weight, pre-term delivery

and

fetal death.

In

light

of these successes, many states have attempted

to

increase enrollment

in

previously underserved popula-

tions. However, sometimes

the

state

WIC

programs have

not beeti prepared

for

this expansion. This

has

resulted

in

administrative difficulties

and

decreased support from

participants (clients;,

staff, and the

comm unity.

Administrators

of

state

WIC

programs

are

increas-

ingly aware

of the

critical importance

of

controlled

growth whereby more people

can be

served without

sac-

rificing program quality

and

participant

and

staff satis-

faction. Moreover, they realize that satisfaction levels

will

in

turn determine whether participants choose

to

return

to the

clinics

and

redeem their food cards

and

whether staff chooses

to

continue working

for WIC,

Efforts

to

enhance

the WIC

experience

for

both groups

is thus essential

to

ensure their

continued participation

in a pro-

gram that improves

the

health

s ta tus

of

American women,,

infants,

and

young children.

With rapid expansion

of

an e thn ica l ly d iverse c l ien t

population, Texas

WIC may

be considered

a

microcosm

of

the national

WIC

program.

In

1 9 9 3 ,

T e x a s

WIC

c o m m i s -

sioned

a

comprehensive social

marketing project with goals

of increasing enrollment,

par-

ticipant satisfaction

and

staff morale

and

productivity.

This article presents

the

project's participant

and

staff

research s tudy components

and

im p l i ca t io n s

for

improving participant

and

employee satisfaction with

the program.

The purpose of this article on satisfaction in the

Texas

WIC

program

is to

illustrate

how

formative

con-

sumer research

was

used

to

guide program

and

service

delivery improvements,

so

that participants

and

staff will

ideally find their

WIC

experiences

to be

more pleasant

and rewarding.

We

begin with

a

review

of

the consumer

satisfaction literature

and an

overview

of

social market-

ing.

The

participant

and

staff satisfaction studies

are

then

presented, followed

by a

summary

of the

social market-

ing plan that evolved from the research. We conclude

with

a

discussion

of

potential applications

of the

social

marketing approach

to

developing

and

implementing

positive, customer-centered changes

in

other public

and

private health care programs.

R E V I E W O F T H E L I T E R T U R E

X U T I V

H I G H L I G H T S

T he

key to a

successful social mai'keting

approach

to

health care

is

continually

lis-

tening

to

consum ers feedback

and

being

willing

to

change

the

health product

or

service according

to

their needs

and pref-

erences. This approach

can

increase

the

likelihood

ot'

consum ers being satisfied

wilh,

and

continuing

to

utilize

or

provide

the particular health service.

In marketing terms,

the

Texas

WIC

program

may be

considered

a

service enti ty.

Al though there

are

l imi ted

studies

on

satisfaction with

publ ic heal th serv ices ,

the

available literature

on

service

quality

and

patient/ provider

satisfaction

in the

private health

care arena offers

a

framework

for understanding levels

and

sources

of

satisfaction/dissatis-

faction within Texas WIC.

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Theories of Consumer Satisfaction

The

dominant theory of consumer satisfaction is the dis-

confirmation of the expectancy paradigm. This pos-

tulates that a consumer's level of satisfaction may

be determined by comparing his expectations of

what he thinks

will/should

be the benefits and/or

costs of a product/service with its performance. If

performance surpasses expectations, he experiences

positive disconfirmation and is satisfied, strength-

ening his intentions to reuse the product or service,

Conversely, if performance falls below expecta-

tions,

negative disconfirmation and dissatisfaction

occur. (Both clients and providers are considered

consumers, as they both utilize the service entity).

Service Quality

Researchers have also noted

that a consumers level of satisfaction with a single

service encounter can determine his long term atti-

tudes about service quality mean. In Parasuraman,

Zeithaml and Berry's newest model, published in

9 9 4

consum ers have a zone of to leran ce

bounded by adequate and desired .service levels. If

a service encounter does not meet their minimal

performance criteria, then they become dissatis-

fied and develop a negative image of the service.

Client Satisfaction with Health Care

Services

Variables affecting client satisfaction

with health care can be grouped into four cate-

gories. First,

socio-emotional factors

are a major

determinant of client satisfaction, and refer to

clients' perceptions of their providers' communi-

cation and interpersonal skills (e.g. caring, empa-

thy, and courtesy). Second,

system factors

refer to

the physical or technical aspects of the service

encounter, such as: waiting time for appointments,

access to services, technical quality of care, costs,

com fort/co nven ience of off ice facil i t ies, and

length of the visit.

In addition,

moderating factors

that affect a

patient 's degree of satisfaction include socio-

demographic variables and health status. Finally, a

patient's network of family and friends can be

considered

influencing factors.

Provider Satisfaction with Health Care

Services

Determinants of provider satisfaction

include adequate time for patient visits, availabili-

ty of equipment and services, meetings with Qther

providers, relationships with patients, and patient

compliance.

Interrelat ionships Between Pat ient and

Provider Satisfaction

Studies also indicate that

successful service encounters occur when both

groups share similar expectations and communi-

cate effectively. When providers give detailed and

unambiguous explanations, share control, seek

feedback , and d isp lay warmth and concern ,

patients are satisfied, will continue with treatment

and recommend the i r p rov ider . This fu r ther

s t rengthens the pa t ien t -prov ider re la t ionsh ip .

However, gaps may occur between patients' and

providers ' expectations, particularly regarding

provider responsiveness and empathy that may

resu l t in pa t ien ts becom ing d issa t i sf ied and

spreading negative rumors.

Implications for Satisfaction with Texas

W I The literature on satisfaction with private

heal th care demonst ra tes tha t pa t ien ts and

providers desire courtesy from each other and con-

venience in utilizing or delivering a health service.

When either group feels that their expectations are

not being met. they may become dissatisfied and

decide to leave the particular health service. We

were interested in determining if consumers of

public health programs would display similar reac-

tions and we used a social marketing approach to

explore these satisfaction issues within Texas WIC.

T H E S O C I L M R K E T I N G P P R O C H

In the most widely used textbook on the

approach, Alan Andreasen defines social market-

ing as:

...the application of commercial market-

ing technologies to the analysis, plan-

ning, execution, and evaluation of pro-

grams designed to influence the voluntary

behavior of target audiences in order to

improve their personal welfare and that

of society.

As indicated by this defmition, social market-

ing is more than just marketing or social advertis-

ing. Similar to commercial marketers, social mar-

keters emphasize consumer-driven research and

constantly listen to customers' needs and expecta-

tions.

However, while commercial marketers apply

this infonnation to design and sell attractive prod-

ucts or services that will benefit their companies,

social marketers use this information to encourage

people to voluntarily adopt practices or use prod-

ucts that will benefit them and the societies in

which they live.

Social marketers also differ from their commer-

cial sector counterparts because of the many unique

challenges they must face. These can include: nega-

tive demand for products/services (e.g. taking medi-

cations); less flexibility in modifying products to

meet consumer demands (e.g., breastfeeding); ask-

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ing people to change deeply personal, complex

habits and adopt behaviore with intangible benefits

(e.g. family planning, smoking cessation): and tar-

geting non -literate audiences w ith limited resources.

To meet tbese challenges, social marketers

have developed special skills in survey develop-

ment, message design, pretesting, and other tech-

niques. They have also applied an interdisci-

plinary approach, by combining research tools

and planning techniques from commercial mar-

keting, education, the social sciences and mass

communications.

First, social marketers adopt commercial mar-

keting's consumer researcb methods to determine

consumers ' perceptions of the 4 P's (product,

price, place, and promotion) associated with cer-

tain products/services and use marketing's seg-

mentation analysis techniques to describe key

population subgroups. Social marketers also bor-

row the social sciences' qualitative research tools

to understand the ethnic/cultural backgrounds of

special groups (e.g. migrant workers) which may

affect their desire and ability to use certain prod-

ucts/services (e.g. family planning clinics).

Second, social marketers adopt commercial

marketing's metbods of developing strategic plans

and reshaping the 4 P's according to their consumer

research findings. Because of their unique task of

motivating people to adopt socially beneficial

behaviors, social marketers must carefully coordi-

nate marketing activities with consumer education,

policy development, and community interventions

to avoid promoting services that are not available,

or creating expectations that cannot be met. Finally,

they share commercial marketers' commitment to

ongoing monitoring and e\aluation and are willing

to modify the product or change the offer if their

strategies are inappropriate, tbeir target groups'

expectations cbange, or new consum ers arrive.

S T U D Y D E S I G N N D M E T H O D S

As part of our researcb study components on

participant and staff satisfaction witb WIC, we

applied the extensive exploratory research process

central to social marketing to gain an in-deptb

understanding of tbese consumers' perceptions of

service quality and their respective sources of sat-

isfaction/dissatisfaction with the Texas WIC pro-

gram. Our research questions included:

What are the key determinants of satis-

faction and dissatisfaction for partici-

pants and staff and are they similar to the

determinants m entioned in tbe literature?

Which segments of participants and staff

are most likely to be satisfied/dissatisfied

with W IC?

Are there any interrelationships between

participants' and staffs concerns about

the program?

What are participants' and staff's recom-

mendations for improving Texas WIC?

Samples, Data Collection, and Participant

Study. Qualitative data from focus group, tele-

phone and individual interviews were collected

from 293 participants and family members in rural,

mid-size city and metropolitan locales in distinct

geographic areas throughout Texas. The sample

was comprised of 49% Hispanics, 31 % Anglos,

and 20% African Am ericans. Qualitative data were

analyzed by site and ethnicity and used to design

the quantitative survey. Tbe survey employed a

purposive sample of clinic sites, in order to obtain

representativeness with respect t o : agency and clin-

ic sizes/types, geographic locations, ethnic compo -

sition of caseloads, and the frequency of partici-

pa n t c om pla in t s t o t be s t a t e ' s I n f o r m a t ion

Response Tea m.' All participants visiting the clinic

sites during the day the survey was being adminis-

tered were asked to complete a 42-item survey,

resulting in a 95% response rate, with 1,562 partic-

ipants at 31 clinic sites in 15 local agencies. The

survey sample included 63.7% Hispanics. 21.5%

Anglos, and 14.8% African-Americans. Among

Hispanics, 58% spoke Spanish, and 42% spoke

English at home. The ethnic distribution of this

sur\'ey sample was similar to that of all Texas WIC

participants for 1993, which was 5 9.1 % Hispanic.

2 3 . 4 Anglo, and 17.4% African-American.

Staff Study. In-depth interviews and focus

groups w ere conducted with administrators, agency

directors, and staff (clerical and clinical). A 77-item

questionnaire was developed from the qualitative

researcb and distributed to staff providing WIC ser-

vices to participants in all local agencies. Seventy-

two percent of these staff (1.358 of an estimated

1 900 in 69 of the 78 agencies returned completed

sur\'eys. Within this staff sample. 56% held clerical

posit ions, followed by 35% in clinical , 6% in

administrative, and 3 % in otber po sitions.

D a t a n a l y s i s

Qualitative data. Focus group and in-depth

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XHI IT

1

C H W r e s u l t s

o r

sat isfact ion

V

G :

F:

t^gend

Very good

Good

Fair

Total sample

V G ; 64,10%

G:

30.44%

F : 5.46%

African

Americans

V G ;

G;

F ;

30.23%

38.14%

11.63%

Anglos

and

English-speaking

Hispanics

V G ;

58.77%

G: 35.52%

F :

5 .71%

n - 7 0 1

Spanish-speaking

Hispanics

Y G ;

74.57%

G:

22.31%

F :

3.t2

n=641

O n totxl stamps

V G :

G:

F :

63.28%

32.10%

4 . 6 2

n=433

N ol on

f(KK] stamps

V G ;

51.49%

G: 41.04%

F : 7.46%

n-268

1

8 th grade or less

V G ;

G;

F ;

83.39%

15.169

1.44%

n-277

I th grade or less

V G ; 69.23%

G:

29.12%

F : 1.65%

n=182

H S . GE D

o r college

V G ;

66.48%

G; 26.37

F ; 7.14%

n=182

Spanish-speaking Hispanics with limited education (8th grade or less) represent the subgroup with the highest pro-

portion of" women who rated Texas WIC as very good (83.4 % ). African-Americans represent the subgroup w ith the

lowest proportion of women who rated Texas WIC as very good (50.23%) and the highest proportion who rated the

program as only fair (11.6%).

interviews were t ranscribed and entered into a

computer and transcripts were then loaded into

Text Based Alpha (Qualitative Research Manage-

ment 1992), a software package used to sort text

by coded topics. For each topic, two researchers

identified recurring, emergent themes as well as

the range of diversity among responses."

Quantitative data. Frequency distributions

and cross-tabulations were performed with SPSS

PC-f. Multiple regression analyses were performed

using SPSS for a UNIX system and SPSS PC+.

CHAID (Chi-square Automatic Interaction Detec-

tor System) was applied to segment tbe participant

sample into homogeneous subgroups with the

highest/lowest proportions of respondents with the

dependent variable {e.g. overall program rating),'

This method of audience segmentat ion can be

helpful in defining target groups of participants

who are likely to benefit from communication

strategies and program modifications.

R E S U L T S P A R T I C I P A N T

S T U D Y

C O M P O N E N T

Perceptions of the Program: Overall Satis-

faction. Survey respondents had positive percep-

tions of Texas W IC. with 64 % rating the program

"very good", as compared to 30% "good" and

6% "fair" . Only one respondent gave a "poor"

rating. Chi square analysis revealed that the vari-

able s of race ( X -= 67 .6 9 . ;< .OOO1) , age

{X-=38.07. / ;< .000i ) and education (X-= 45. I9 .

/;

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women with less education rating the program as

"very good." CHAID analysis indicated that the

subgroup with the highest proportion of women

rating WIC as "very good" was comprised of

Spanish-speaking Hispanics wi th less than a

ninth grade education (83.4%). The subgroup

with the lowest proportion of women rating WIC

as "very g ood" w as comprised of A frican-Ameri-

cans (50.23%) (sec Exhibit 1).

Perceived Program Benefits

Responses to

an open-ended survey question ("Using the WIC

program makes me fee becau se", .) helped

identify factors contributing to women's satisfac-

tion. Survey resjrondents used a num ber of phrases

to describe how the program helped them provide

for their children's health and well being. They

ment ioned tha t the program made tbem fee l

"relieved," "reassured," "secure." "protected,"

"capable," "responsible," and "a better mother,"

witb comments sucb as:

WIC m akes me feel grateful because it

helps with subsistence and teaches us

how to feed our children better and how

to nourish ourselves, as mothers, before

giving birth.

Using the WIC program makes me feel

good because I can provide for my son.

Women were also asked to select from a list of

seven benefits tbe two tbings they liked most about

WIC.

The benefits chosen most frequently were:

health and nutrition information (57%); money

saved on grocery bills

{5\%);

nutritiou s foods

(39%); and having tbeir children's blood, beigbt

and weigbt cbecked (23%). Wbile women placed

different values on certain benefits (e.g. Anglos

were more likely to value saving money), they all

believed tbese benefits empowered tbem to pro-

vide for their children's health, which increased

their self-esteem as mothers. Exhibit 2 displays the

common sources of satisfaction and dissatisfaction

mentioned during the qualitative research.

Sources of Dissatisfaction

While women

valued WIC's many services, they also encoun-

tered difficulties that made them feel they were

not being given the respect they deserved; given

their commitment in time and energy to p articipat-

ing in WIC. Multiple regression indicated that the

four problems tbat were significantly associated

with less favorable ratings of the program includ-

ed: wai t ing too long to rece ive food cards

(p

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education expressed dissatisfaction with food card

redemption and food package items (Exbibit 3).

Embarrassment. Underlying eacb of the ser-

vice delivery and food package problems was a

common feeling of embarrassment, with signifi-

cantly higher proportions of Anglo-Americans,

women wi th more educa t ion and women not

receiving food stamps stating they were embar-

rassed to be on WIC (Exhibit 3). CHAID analysis

revealed that the subgroup witb tbe highest pro-

portion of women who were embarrassed was

coiiiprised of Anglo-Americans with at least a

high school education (33.94%) (Exhibit 4). Their

comments on tbe open-ended survey question

reflect tbe bumiliation tbey felt:

"I was embarrassed... thought: God,

this is just one more, you kno w, sign that

I've

just,

I've

failed...

'

Women who were able to overcome tbis

embarrassment developed tbeir own strategies to

protect their pr ide and dignity, and perceived

WIC as: a program for children; a source of nutri-

t ion educa t ion ; a se rvice for fami l ies who se

income is too high for other welfare program s;

and temporary assistance. In focus groups, these

wom en said they were not like otber welfare

recipien ts because tbey attended nutrition classes

to earn their WIC benefits, wouid not take more

food than they needed, and planned to stop partic-

ipating in WIC as soon as tbeir economic situa-

tion enabled tbem to.

Summary and Par t ic ipants ' Recommenda-

tions. Tbe underlying tbeme among participants

was respect: they were very proud that they

earned WIC benefits through nutrition education,

yet tbey lost this self-esteem and became dissatis-

fied when tbey were not treated courteously by

staff or grocery store cashiers. Tbeir recommenda-

tions focused on enhancing the program compo-

nents which tbey valued most {e.g. nutrition educa-

tion; free food) wbile strengthening those problem

areas wbich caused the most inconvenience, frus-

tration and humiliation (e.g. clinic waits, interac-

tions with staff and purchasing foods).

XHI IT

4

C H AID resultsforembarrassment

egfty

Y:Yes

N:No

Spanish-speaking

Hispanics and

African-Americans

Y: 8.78

N: 91.22

n=831

Total Sample

Y: 15.27

N: 84.73

n=1.532

Anglos

Y: 27.88

N: 72.12

English-speaking

Hispanics

Y: 19.02

N: 80.98

HS diploma.

GED or less

Y: 7.07

N : 92.9:1

n=679

College or more

Y: 16.45

N; 83.55

n=153

I Ih L[r;LdL'

() i less

Y; 13.19%

N :

86.81%

HS . G E D

i)r college

Y:

N : 66.06%

n-221

On food stamps

Y: 13.55

N ;

86.4.'i

Nol on

food stamps

28.99

71.01

The subgroup with the highest proportion of women who were embarrassed to be on WIC was comprised of Anglos

with at least a high school education (Y: 33.9%), The subgroup with the lowest proportion of women who were

embairassed to be on WIC comprised of Spanish-speak ing Hispanics and African-Am ericans with no more than a

high school education (Y: 7.1%).

M A R K E T I N G

HEALTH SERVICES

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XHI IT 5

e g r e s s i o n a n a l y s isf o r d e t e r m i n a n t s o f s ta f f d i s s a t i s fa c t i o n

Variable

Pressuretoincrease numberof participants

Poor supervision

Racial tension

Lying participants

Not enough staff

Small clinic size

Beta

.9965

.9734

.6631

.6529

.5078

.4990

Signiflcance ipValue

.00(X)

.(X)00

.0057

.0118

.0245

.0425

Odds ratio Exp B))

2.7087

2.6468

1.9409

1.9212

1.6617

1.6471

This exhibit illustratestheregression coefficients forstaff concerns that were signifcantly associated with theirhav-

ing experienced adecline in satisfaction duringthe past year.Forexample, whena WIC staff member states that

pressuretoincreasethenumberofparticipantsis aproblem (minorormajor), then he/sheis2.7087 times more like-

lytohavehad adeclineindissatisfaction during the past year.

R E S U L T S S T A F F S T U D Y C O M P O N E N T

Perceptionsof the Program: Overal l Satis-

fac t ion .

Overal l sat isfact ion among part icipants

wa s m e a s u re d w i t h

the

d i r e c t q u e s t i o n

How

would you rate the WICprogram overal l? Over-

al l sat isfact ion among s taff was measured with

two related inquiries of; Do you feel more satis-

fied, less satisfied with your jo bor thesameas last

year?

and If you

could take

a job for the

same

benefi ts

and pay at

ano ther agency , wou ld

you

leave WIC ? Am ong those .staff with

a

minimum

of one year ' s exper ience , 38 % reported feel ing

more satisfied than last year, ascompared to 35%

saying the same and 27% saying less sat isfied.

Significantly higher proportionsof staff with more

years

of WIC

employment

(2-5 and

over

5

years)

(X2=971.26, /7

8/10/2019 1365442

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We

re

being stressed

out to the m x

trying

to

help these people

but we

cannot

help them right

now

because we're

stressed

out

with each other...

Employees a lso spoke of their frustration

withtheabundant,andconstantly chang ing feder-

a l (USDA) . s ta te

and

loca l pol ic ies gu iding

income eligibil i ty, proof

of

residence require-

ments, delivery of WIC services, and food card

issuance. They wanted more clarity and consis-

tency in state and federal regulations, to enable

themto befairto participants. Tbey also soughta

new pol icy of a l lowing loca l agenc ies more

autonomy in developing nutrition educationcur-

riculato meet tbeir clientele's needs. Similarly,as

part of a series of questions in wbich staff were

asked

to

describe individual problem areas

as a

big problem' , a minor problem or not aprob-

lem

at all for you , tbe

majority

of

staff survey

respondents felt that policies changing too often

(61%)and too mucb paperwork (51%)represent-

ed big or minor problemstothem.

Diff icult ies With Participants. Employees

were also concerned about their relationships

with participants, witb over 70% stating tbattbe

issues

of

participants rudeness, unresponsive-

ness and lying about residency or income each

represented big or minor problems to them.

They attributed tbese problems to participants '

own personal concerns, bad manners, and reac-

tionsto employee behavior. They recognized tbe

interdependence between participant

and

staff

tensionsand were aware tbatif one staff member

is over taxed and m a ke s tbe mis take of be ing

short with one participant, tben the participant

may express his/her frustration by being rude to

anotber staff member.

Frequent Staff Turnover . In the qualitative

researcb, siaff mentioned that high turnover result-

ed in staff shortages, which in turn made it diffi-

cult

for

participants

to

build relationships with

familiar staff, required constant trainingof new

employees and created more strain on overbur-

dened staff Over half (52%)

of the

staff surveyed

bad workedfor WiC for twoyearsorless.

Limited Professional Growth. Only 41%of

the staff surveyed felt tbeybadroomforprofession-

al growth. Concern about limited advancementwas

significantly associated witb lengthof time worked

forWIC (X-=54.94, /7

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their behavior-when they were being curt with

staff,

dropping

out of the

program

or

speaking

poorly

of WIC to

other women. Similarly, when

staff

had to

deal with

the

same noisy, crowded

working condit ions

and

inefficient certification

procedures, and felt theirown efforts were unap-

preciated by participants or management, then

they,

too,

becam e disillusioned with

the

program

and sought jobs elsewhere.

Since completing theTexas WICM arketing

Project, Best Start social marketers have conduct-

ed similar participant satisfaction studies

for

three

other State

WIC

Programs. Results have heen

remarkably s imi la rlong wai ts , d iscour teous

treatment

by

staff

and

grocery store cashiers,

bor-

ing or repetitive nutrition education, and embar-

rassment to accept governm ent assistance were

identified as predictors of low customer satisfac-

tion

and

disenrollment from

the

program.

Not surprisingly, participant

and

staff satis-

faction levels in the Texas WIC program were

m utua l ly r e in f o r c ing . Whe n

the

system

ran

smoothly, both groups encountered

few

difficul-

ties

and

were more likely

to

appreciate

the pro-

gram

and

each other's efforts. However, when

the

system became overcrowded and less efficient, it

created staff-participant conflicts. They became

overworked and highly stressed, participants were

unappreciative

of

staffs efforts,

and

staff subse-

quently grew even more impatient with partici-

pants

and

felt burned-ou t with their jobs .

R E S E A R C H A P P L I C A T I O N S T H E S O C IA L M A R K E T I N G P L A N

Results from

the

participant

and

staff compo-

nents were combined with

the

enrollment compo-

nent

to

formulate

a

social marketing plan with

guidelines for developing strategies to strengthen

WIC's image, increase enrollment, and enhance

the WICexperienceforboth groups.Theplanhas

seven components: policy

and

legislative o utreach,

he a l th c om m unic a t ions , t r a in ing , s e r v i c e

delivery/local clinic needs, community outreach,

nut r i t ion educa t ion,

and

tracking satisfaction.

These components were developed instrategyfor-

mation sessions in a collaborative effort by the

social marketing team, state

W C

administrators,

participants,

staff,

program partners,

and

vendors.

Specific strategies were designed

for

each com po-

ne n t

to

i m p r o v e

the "WIC

e x p e r i e n c e

and

decrease

the

price

of

participation

by

eliminating

sourcesof dissatisfaction revealedin theconsumer

research (Exhibit6).

Development

of

these seven components

was

also

a

team effort, requirin g content e xpe rtise

from

a

variety

of

specialists including: advertis-

ing

staff,

evaluation specialists, systems design

experts, pretesting research personnel, printing

professionals, and training consultants. These

team members ' activit ies were coordinated to

assure continuity

in

their efforts

to

achieve

pro-

gram goals.

The last component,

a

permanent data collec-

tion system (PDCS)

to

track program satisfaction,

is

a

particularly important element

of

the plan.

The

PDCS consists

of

satisfaction surveys

for

staff

and

new andalready enrolled participants. Local agen-

cy directors and staff can use feedback from the

PDCS

to

evaluate

the

impact

of

programmat ic

changes, develop action plans

to

refine parts

of the

social marketing plan,

and

identify

new

problem

areas

in

need

of

improvements.

Implementation

of the

plan

has

been

a

gradu-

al process, starting with

the

media campaign

in

1995

and

proceeding

to

implementation

of the

PDCS

in

1996.

The

majority

of

strategies outlined

in Exhibit

6

have been pilot tested

and

will

be

gradually phased

in

throughout

the

state. Baseline

data from the PDCS surveys were collected in

1996

and

provided

to

local agency directors

for

prioritizing problematic is.sues

in

their agencies.

After complete implementation

of the

plan,

the

PDCS will beused to evaluate the plan's impact

and provide cont inuous , in-depth ana lys is of

staff 's

and

par t ic ipants ' r eac t ions

to

program

changes.

The

Texas

WIC

Social Marketing Plan

thus provides positive direction

for an

on-going

consumer-based change process, while respond-

ing to feedback from participants and staff gath-

ered through thePDCS.

L I M I T A T I O N S

While this study presents some very r ich

data,it does have some limitations. Eirst, this is a

formative research study,

and

does

not

attempt

to

test hypotheses.

The

second limitation relates

to

generalizability. Although

the

reported

values

for

chi

square

and

multiple regression analyses

are statistically significant

for

this sample,

and

the ethnic distributionof thesample is similar to

that of TexasWIC participants in 1993, we can-

not assume that differences found in this sample

wi l l genera l ize

to

other samp les . Hence ,

the

authors recommend that

WIC

managers

or

health

planners working

in

other states

use

these results

4 WINT R 998

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XHI IT 6

T h e

T e x as

W IC

Soc ia l Marke t ing Plan

Major compunents

Poliiy recommendations

Service delivery

Tritining

Nuiriiion education

Tracking sysiem

H::alth connnuniciiiion

pliUl

Communily outreach

Examples of specific strategies

I. Recognition lor siaff pertbnnantT, including customer service awards.

2. Career growth opportunities tor stall', with a clear career ladder structure.

3.

Use of compu lers to commun icate policy chang es more effeciively bcEween state and t>cal

staff

4 . Revised appointmen t stheiJuling policies to improve clinic efliciency and create more "user-friendly" certifica-

tion and food card issuance procedures (e.g. on-line, computerized poliey manuals for staff).

1. Increased accessibilily by offering WIC services al day care cenlers. employers, grocery stores, migrani camps,

and more tlexible clinic hours might, lunch time & one Sal./monthl.

2

Child friendly clinics where children can play, eat nuiritious snacks and learn about nutriiioii in chiltl-priKifed

areas supervised byslalf paraprofessionals. and volunteers.

3. Peer buddy system - para pro lessioaals acL as advoc ates/guides for participants waiting for ciinic services,

ensuri; Ihai panitipanis have required documenialion, answer quesiions about certification and food cards, and

give "smart shopping" lips.

4 . tmp ioveme nls in groceiy store experiences with a new foot card redemption system (fewer cards lo be signed al

register) and a "products broc hure" to depict allowable WIC foods for participants und serve as a reference for

cashiers.

1.

SlaEf training and continuing education.

2.G rocery slore cashier training program, videotape about customer service, and the WIC transaction.

1. Nutrition education faciliiator (raining in interactive teaching skills to discuss nutrition and new. non-traditional

WIC subjects (e.g. pjireming. child developnient) issues with participants.

2 "Food and Fam ily" educational magazine for WIC participants.

1.

PDCS to track paiticrpjuit saUsfaciion with the food package, nutrilion education, food redemption, clinic

serv-ice and clinic environment, and suff satisfaction with supervision, clinic eaviroiinient. ability to provide

WIC services, and panicipani conuct,

2.

Training for local agency directors in interpreting results, identifying and overcoming service delivery problems.

1. Messages tti reposition WIC 's image - to a comprehensive health and education pro gnun offering nutritious

foods, screening, st>cial support, and referral to other services, e.g. through

}Q

.sec. ""Nutrition Tips " radio spots.

2. Messages lo increase awareness of income eligibility criieria.

1. Comm unity organize rs" kit lo a.ssist tx;al agency diiecto rs in working with program partners iti increasing

referrab of eligible families to WIC.

2. Ki includes outreach mate rials targeted lo health professionals and eligible families.

Noies

1. Tlus Lhiiit includes examples of ihe many strategies which have heen developed for each component of Ihe sticiLiI tiijirketing plan.

2 The first five compunenls are designed lo increase panicipani and sialf salistacricm: Ihe last Iwii are iniended ti> increase panicipani e(ii-olliiien( irefer tn Bryant

el al IWSl.

as an impetus to guide furtber researcb, as out-

lined below.

S U M M R Y N D P U B L I C P O L I C Y I M P L I C T I O N S

Tbis article describes a case study in wbicb

consumer research into participant and staff satis-

faction witb tbe Texas WIC program was used to

develop a comprehensive social marketing plan

designed to enbance both groups" experiences in

WiC.

Ideally, implementation of this plan will cre-

ate a positive loop of satisfaction between both

groups, increased program uiilizaiion by partici-

pants and greater commitment from staff

The issue of consumer sa t i sfac t ion wi tb

bealth care services will undoubtably become

increasingly important in the 21st century, with

the changing trends in our nation's systems of

health care delivery. Health care administrators

are becoming increasingly aware of the impact of

customer satisfaction on: participants' utilization

rates, compliance rates, therapeutic outcomes,

positive health behavior, health status, partiei-

pant-staff interactions, and staff loyalty. Witb tbe

growing emphasis upon relationship marketing, it

will become increasingly important to design

programs that "keep the customers bappy," so

they continue to utilize (or provide) preventive

bealth services that can reduce the enormous

bealth care expenditures associated with long

term care . WIC program adminis t ra tors , fo r

example, can use consumer research to better

understand bow to meet the needs of a rapidly

growing segment of the marketworking fami-

lies who are eligible for WIC but have less finan-

cial incentive to participate tban Ihe unemployed.

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By identilying

and

responding

to

working partic-

ip an t ' s p r o g r am n eed s

and

wants , they

can

improve their retention

of

these families

and con-

tinue

to

help parents raise healthy children even

after they find employment.

Other public

and

private health care leaders

can also apply

the

social marketing approach

in

their efforts

to

enhance

and

successfully m arket

their programs,

as

summarized below.

Quantitative

and

qualitative research methods

ca n

be

used

to

determine sources

of

participant

and staff satisfaction/dissatisfaction

and

each

group's suggestions

for

improving

the

program.

The results

can be

shaped into

a

plan with strate-

gies

to

meet each group's needs jind expectations.

A system

for

tracking participant

and

staff

satisfaction

can

also

be

developed,

to

continually

improve service delivery

and

evaluate

the

impact

of programmatic changes.

The following examples illustrate

how

health

care leaders

can

apply this social m arketin g

framework

as

they strive

to

compete

in

today's

health care marketplace. First, social marketing

methods

can

help health planners

in the

private

sector learn

lo

carefully listen

to, and

understand,

the special health, social,

and

educational needs

of

low

income groups. This will become increas-

in g ly im p o r t an t

as

p r io r h ea l th d e p a r tm en t

patients enter

the

private health care marketplace

through

the

doors

of

managed care. Private health

care administrators have

not

been accustomed

to

communicating with,

or

competing

for,

groups

traditionally served

by

public health departments,

and will find that social marketers' experiences

can guide them

in

adapting their services

to

these

new target populations.

Second, social marketing holds promise

as an

effective tool

for

public health leaders

in the

midst

of

the

current welfare reform trends. With increas-

ing threats

of

public spending cuts

in

popular

health

and

social programs, public health leaders

may

use

consumer research

to

document that they

are satisfying

the

majority

of

their clients

and

staff,

wh ich

may be

e ssen t i a l

for

co n t in u ed

state/federal support

of

their programs. Further-

more, this formative research

can

document major

areas

of

concern

to

both clients

and

staff that

can

be remedied

by

increases

in

funding (e.g,

for

more

staff,

better facilities,

etc.)

Third, public health managers accustomed

to

a more traditional

top

dow n program planning

approach (whereby experts

use

best practice

models

to

design service delivery programs

for

the public)

may

find that social marketing offers

a

refreshing

new

outlook

on

planning. With

the

social marketing approach, consumers become

the

experts,

and

their opinions

of

how

a

particular

pro-

gram should function actually serves

as the

basis

for program planning.

Finally, with

the

increasing emphasis

on

health care reform, there

is

renewed interest

in the

use

of

health education

to

motivate people

to uti-

lize preventive health services

and

adopt healthier

behaviors, which

can

ultimately reduce health care

expenditures associated with costly hospitalization

and long term care. Social marketers' experience

in this area

can

help public

and

private health

leaders encourage their clients

to

continue

to uti-

lize beneficial health services

(e.g.

attending

WIC

classes)

and

follow their providers' recommended

health guidelines

(e.g. not

smoking during preg-

nancy, following

a

healthy diet).

Indeed, social marketing

can

provide both

public

and

private health administrators with

a

wide variety

of

tools

for

listening

to

health care

consumers, whether they

are

clients

or

providers,

and then developing responsive, comprehensive

programs designed

to

truly meet their needs

and

expectations. With this potential, social market-

ing certainly deserves recognition

by

health plan-

ners

as a

promising approach

for

increasing

the

public's satisfaction with

and

utilization

of

bene-

ficial health services that

can

ult imately

con-

tribute

to

improvements

in the

nation 's health

and well-being.

O O T N O T S

'

The

Information R esponse Team answers

questions from program applicants, participants

and local project staff and also responds

to

partici-

pants' complaints about

the

program.

^

We

have identif ied

the

major em ergent

themes from

the

qualitative research

in the

results

section

of

this article. Readers

who are

interested

in

the

full range

of

responses which

we

obtained

in

our

qualitative research findings,

as

well

as ver-

batim quotes from

the

in t e r v i ews

and

focus

groups,

are

referred

to our

final report

of the

study,

WIC at the

Crossroads,

the

Texas

WIC

Marketing Study Final Report, (1994), Best Start,

Inc.,

Tampa,

FL.

^ Ad d i t io n a l ap p l i ca t io n s

of

C H A I D

are

described

in an

article published

by

Ter rance

Albrech t

and

Carol Bryant

in the

Journal o

Health ommunication

in its

inaugural issue

pub-

lished

in 1996.

Staff could choose between response cate-

6

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gories of b ig problem , minor problem, or not

a problem to me for this survey item and a num-

ber of otber survey questions. We have grouped

together big or minor problems as simply

pro blem s in our discussion of these questions in

our article.

D D I T I O N L R E D I N G

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M arketing Social Change.

San Francisco: Jossey-Bass Publishers.

Bowers. Michael R.. John E. Swan, and William

Koehler (1994), What Attributes Determine

Quality and Satisfaction With Health Care

Delivery?

Health Care Management Review,

49-55.

Joos. Sandra K., David H. Hickam and Borders

LM . (199 3), Patients Desires and Satisfac-

t ion in Gen era l Medica l C l inic s ,

Public

Health Reports,

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Kellam, S. (1992), Praise is High, Funds are Low

for Welfare That Works ,

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Quarterly Weekly Report,

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Kotler. Philip and Alan R. Andreason (1991), Strate-

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Social Marketing and Public Health Interven-

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3 1 5 .

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Pa r a sur a m a n , A . , V a la r i e A . Z e i tha m I a nd

Leonard L. Berry (1994),

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Service Quality Research: Measuring Differ-

ent Customer-Expectation Levels, Comparing

Alternative Scales and Examining the Perfor-

mance-Behavioral Intentions Link.

Cambridge.

Massachusetts: Marketing Science Institute,

Report Number 94-114.

Strasser, Stephen, Schweikhart, Sharon, Welch,

Gerald E. II, and Jean C. Burge (1995), Satis-

faction With Medical Care, Journal of Health

Care Marketing.

15 (Fall), 34-44.

Sutton Sharyn M., Balcb George B. and R. Craig

Lefebvre. (1996),

Strategic Questions

or

Consum er-Based Health C omm unications,

Public Health Repo rts, 110, (6), 725 -33.

This research was funded by Texas WIC Bureau,

Texas Department of Health

We would l ike to express our appreciation to

Carol Cannon, M.A. and Julia Rosenbaum, Sc.M.

for their assistance with data collection and sur-

vey design.

U T H O R S

Carol Bryant is an associate professor in the

Department ot Community and Family Health at

the University of South Florida.

Ellen B. Kent is tbe grants support coordinator in

the Department of Community and Family Health

at the University of South Florida.

James Lindendberger

is an executive director in

the Department of Community and Family Health

at the University of South Florida.

Janet Mogg Schreiher

works for the grief counsel-

ing program at Southwestern College in Santa Fe.

Marsha Walker Canright is the education out-

reach and marketing coordinator for the Texas

Department of Health, Health Communications

Division.

Steve Cole is an associate epidemiologist at the

Bingham & Women's Hospital at Harvard Medi-

cal School.

Valerie Uccellani is senior program officer for the

Academy for Educational Development in Wash-

ington, D.C.

Christopher A.Brownis a health co mmun ications

consultant for the Texas Department of Health.

R. Clifford Blair is a professor in the Department

of Epidmiology and Biostatistics at the University

of South Florida.

Marta M. Bustillo Hernandez

is an instructor in

the Social Sciences Unit. Department of Biosocial

Science at the University of Puerto Rico.

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