Introduction

One in 11 people in the United States has diabetes, the eighth leading cause of death in the country. Diabetes has a considerable financial impact as well, costing an estimated $327 billion in medical expenses and lost work and wages in 2017, the latest year for which data were available. Even though the federal government offers a national evidence-based prevention program that has helped participants prevent or delay type 2 diabetes, enrollment remains a challenge, especially among rural residents. To help address this, my team and I conducted a study to identify the most effective media and messages as well as the lowest media frequency needed to increase enrollment in the program from people living in rural areas. We worked with North Carolina State University’s (NC State) online lifestyle change program, which is part of the larger federal program. In this blog post, I discuss how and what we learned from a study that did not produce expected results. We did not enroll any residents from the study’s rural intervention counties. We did, however, try to figure out what our findings do suggest, and we considered what may be needed to successfully enroll rural residents in a diabetes prevention lifestyle change program.

Background and Methods

The U.S. Centers for Disease Control and Prevention’s (CDC) National Diabetes Prevention Program is a year-long program that uses a proven approach to prevent or delay type 2 diabetes. This includes the use of trained lifestyle coaches and a CDC-approved curriculum that helps participants improve their food choices and physical activity. It is delivered in person and online by local community organizations.

Our study used mixed methods, including a field experiment employing a quasi-experimental design and qualitative interviews. We conducted the study in five rural counties in North Carolina. Four counties together received a six-month, $100,000 paid media campaign, and a fifth county served as a control county. Over a six-month period, we tracked website traffic and enrollment, and adjusted media (billboards, radio ads, local newspaper ads, gas station ads, Facebook ads, Google Display ads) and frequencies each month based on campaign performance. We compared impressions, website traffic, and enrollment among and between the implementation and control counties to identify any substantial differences by media channel and frequency. For digital data, we examined the number of impressions, clicks, click-through rates, and costs per click to identify which digital channels and messages were more effective at engaging the primary audience. We also compared these rates to industry standards for health care and beauty/fitness to evaluate the success of our ads compared to typical ads. Using historical website data, we compared the number of NC State’s online program website users during the campaign to the same period the prior year to assess whether there was more website traffic from our intervention counties (but not the control county) during the paid media intervention.

Following the main study, we conducted two follow-up studies to test a new value-based message (“For just $30 you get…”) and gather additional context for our results. The studies included an A/B test of two Google Display ads and qualitative interviews with nine women in rural North Carolina who were at risk for diabetes or enrolled in NC State’s online program. We also evaluated how all enrollees of NC State’s online program heard about the program during the six-month intervention period and whether there were any differences if they were in a rural, urban, or suburban county.

Recommendations for Further Study

Our paid media campaign did not lead to program enrollments in the intervention counties. This suggests that low-level paid media alone is not effective on its own for increasing rural enrollment in an online diabetes prevention lifestyle change program. Our team of health communication experts analyzed the data from the original study and two follow-up studies and identified three areas we recommend for further research.

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  Sample ad for an online lifestyle change program funded by the CDC.

  Combine paid media with a more personal, one-to-one approach. In our study, paid media alone did not increase enrollment, but certain paid media tactics showed promise. Our short, cost-efficient radio ads ran frequently during station traffic and weather reports and led to the most program enrollments from other counties in NC, including rural counties. Our Google Display ads had the highest click-through rates and drove the most traffic to the program website. Analysis of the program’s “How did you hear about us” data showed that some rural audiences outside our intervention counties enrolled in the program after receiving workplace emails from the program. They were not learning about the program through their doctors, a “How did you hear about us” choice and often considered credible sources for personal health information. Combining paid media with a more personal approach, such as emails and referrals or recommendations from trusted health care professionals or pharmacists, may be what’s needed to move rural audiences from awareness to enrollment. Programs should explore adding this more personal component.

• Plan for a longer “contemplation” period. The lack of program enrollments from residents of the study counties could indicate that residents were not ready to enroll, and recruitment strategies might need to plan for a longer “contemplation” period. Someone can be aware of a diabetes prevention program for months or even years before deciding to sign up. Residents of the study counties had never received marketing from NC State’s online program prior to the study’s campaign. Much like quitting smoking, there often must be a catalyst in someone’s life before they make a firm commitment to act. To plan for this longer “contemplation” period, programs should consider implementing a steady media push over a longer timeframe to increase the likelihood of reaching people when they are ready to enroll. Further research can help identify what this timeframe should be or explore other tactics for addressing contemplation periods.
• Further explore promising messaging. Following our main study, we conducted an A/B test comparing the highest performing Google Display ad (ad with the highest click-through rates) to a new ad. The highest performing original ad used social norms messaging (“Join others like you”) while the new ad used a value-based message (“For just $30 you get…”) highlighting the program’s key selling points. The value-based ad, which used messaging similar to what commercial weight loss programs use, performed better in the A/B test. The value-based ad had a click-through rate of 1.57% compared to the original ad’s click-through rate of .99% and was the preferred ad in follow-up study interviews. This suggests that messages that lead with the program’s value and price may be effective for online audiences (see text box for a sample ad). Future studies can continue to explore the effectiveness of these kinds of messages on a larger scale.

We hope these recommendations can help shape future studies related to diabetes prevention and National DPP enrollment. They also can help those trying to promote diabetes prevention to rural populations, as well as lifestyle change programs that are trying to market their programs to rural and other audiences.

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