Public-Private Partnerships for Health Promotion

This article was downloaded by: [Judy Gold] On: 27 January 2013, At: 09:40 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

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Public-Private Partnerships for Health Promotion J. Gold a

a b

, M.E. Hellard

c d e

f

g

h

, M.S. Lim , H. Dixon , M. Wakefield & C.K. Aitken

i j

Centre for Population Health, Burnet Institute, Melbourne, 3004, Australia

b

Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, 3004, Australia c


d

Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, 3004, Australia e

Nossal Institute for Global Health, University of Melbourne, Melbourne, 3010, Australia

f


g

Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, 3053, Australia h

Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, 3053, Australia i


j

Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, 3004, Australia Version of record first published: 23 Jan 2013.

To cite this article: J. Gold , M.E. Hellard , M.S. Lim , H. Dixon , M. Wakefield & C.K. Aitken (2012): Public-Private Partnerships for Health Promotion, American Journal of Health Education, 43:4, 250-253 To link to this article: http://dx.doi.org/10.1080/19325037.2012.10599243

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Feature Article Public-Private Partnerships for Health Promotion: The Experiences of the S5 Project J. Gold, M.E. Hellard, M.S. Lim, H. Dixon, M. Wakefield, and C.K. Aitken

Downloaded by [Judy Gold] at 09:40 27 January 2013

ABSTRACT

There is increasing emphasis on involving the private sector in public health to harness the considerable resources and skills of the business world to address significant health issues. While such collaboration should be encouraged, the involvement of business in public health campaigns can raise unexpected challenges when the approaches and priorities of the public and private sectors clash. We report our experience in developing a public-private partnership to deliver a health promotion intervention using mobile phone text messages in Victoria, Australia. Although the partnership enabled the delivery of text messages on a far wider scale than previously possible, difficulties were experienced during implementation which are likely to have negatively impacted on project outcomes. Our experience has implications for any public health practitioner considering involving a private sector partner in program delivery. Gold, J, Hellard, ME, Lim, MS, Dixon, H, Wakefield, M, Aitken, CK. Public-private partnerships for health promotion: the experiences of the S5 project. Am J Health Educ. 2012;43(4):250-253. Submitted June 28, 2011. Accepted November 18, 2011.

INTRODUCTION There is increasing emphasis on involving the private sector in public health in order to harness the considerable resources and skills of the business world to address significant public health issues.1-5 Involvement of business, big and small, can greatly increase the reach and effectiveness of public health initiatives.6 The private sector can contribute greatly to public health goals; one example is the public-private arrangement of the International AIDS Vaccine Initiative, which involves joint research and development and funding to successfully increase the speed of vaccine development and ensure any future vaccine will be globally available.7 Involvement may also be more direct and localized, such as partnerships with media organizations to deliver education messages and

programming,8 involving local businesses in emergency preparedness,9 or distribution of health related products.10,11 Nevertheless, involvement of business may raise unexpected challenges when the approaches

and priorities of the public and private sector clash. This report is based on our experience of partnering with a large private telecommunications provider in order to deliver a

J. Gold is affiliated with the Centre for Population Health, Burnet Institute, Melbourne, Australia 3004 and Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia 3004; E-mail: judy@ burnet.edu.au. M.E. Hellard is affiliated with the Centre for Population Health, Burnet Institute, Melbourne, Australia 3004; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia 3004; The Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia 3010. M.S. Lim is affiliated with the

Centre for Population Health, Burnet Institute, Melbourne, Australia 3004. H. Dixon is affiliated with the Centre for Behavioural Research in Cancer, The Cancer Council Victoria, Melbourne, Australia 3053. M. Wakefield is affiliated with the Centre for Behavioural Research in Cancer, The Cancer Council Victoria, Melbourne, Australia 3053. C.K. Aitken is affiliated with the Centre for Population Health, Burnet Institute, Melbourne, Australia 3004 and Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia 3004.

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J. Gold, M.E. Hellard, M.S. Lim, H. Dixon, M. Wakefield, and C.K. Aitken


health promotion intervention using mobile phone text messages (SMS). Study findings have been reported separately.12 This report reflects on our experiences and provides useful recommendations for public health practitioners considering entering into partnership arrangements to deliver health related interventions.

GOALS OF PARTNERSHIP Our research group had previously conducted two studies to establish the efficacy and effectiveness of using text messages for sexual health promotion.13,14 The aim of establishing a partnership with a telecommunications provider was to utilize mobile advertising (advertising delivered directly to mobile phones) to reach a much larger population than previously achieved for health interventions using mobile phones. Subscribers to our corporate partner’s service “opt in” to receive mobile advertising from third parties; in return they obtain free access to selected internet sites via their mobile phones. In early 2008, we applied for funding to conduct the S5 project, a randomized controlled trial with simultaneous interventions to determine the impact of health promotion messages about sexual health and sun safety delivered via mobile advertising. During the funding application phase we investigated the availability of mobile advertising providers, and identified that one large telecommunications provider offered a service that met our needs. We discussed the project several times with representatives of this provider to establish an in-principle agreement regarding the use of the mobile advertising service. Once funding was secured (May 2008) we entered into formal discussions, and ultimately signed a commercial agreement with the telecommunications provider. The telecommunications provider was very enthusiastic and supportive of the project, as we represented a new type of advertising client (previous clients had all been commercial enterprises) and a way of exploring the potential for future business opportunities should mobile advertising

prove to be a successful means of delivering health promotion messages. Their enthusiasm for the project was overtly expressed, and evident in their substantial in-kind support of the project’s web development.

STRUCTURE OF PARTNERSHIP Under our agreement, each partner (the collaborating research institutions and the telecommunications provider) had clear roles and responsibilities. The research institutes were responsible for designing the text messages to be broadcast and questions for the baseline and follow-up questionnaires, as well as analyzing the data collected. The telecommunications provider was responsible for performing the randomization of eligible mobile advertising subscribers, broadcasting the text messages on specified dates, online format and upload of the baseline and follow-up questionnaires and providing broadcast and questionnaire data to the research institutes. The provider and the research institutes communicated regularly (usually at least weekly) during the message and survey design phase (Sept - Nov 2008) and throughout the message broadcast period (Dec 2008 – May 2009) to keep each other updated on progress with survey design and uptake, and message delivery. SUCCESSES The partnership with the telecommunications provider enabled the delivery of health promotion messages to a far greater number of individuals than previously achieved; all published trials using SMS for behavioral health interventions relied on individual recruitment and manual enrollment of individuals,13-26 and most reached 200 or fewer individuals.15-20,22-24,26 During the S5 project over 7,000 individuals received health promotion messages related to either safer sex or sun safety, with no resources consumed for enrollment. The project was also successful in utilizing Internet access on mobile phones to collect behavioral information, which is likely to be an increasingly common method of data collection as the use of ‘smartphones’ (mobile

phones with built-in applications and internet access27) increases. Data collected during the project also confirmed effectiveness of using SMS for sexual health promotion.12

CHALLENGES Despite the successes outlined above, several challenges were encountered during the partnership including: • Censoring of message content: Although the provider was aware of the message style and content from the outset of the project, and had viewed sample messages, during the message broadcast period the provider insisted on changes to five safer sex messages, describing them as “offensive,” and fearing that they could generate complaints. We made multiple requests for guidelines about acceptable content, but none were available or supplied. • Censoring of message length: Standard text messages are limited to 160 characters. Shortly before the planned broadcast of the first message, the provider informed us of the need for a compulsory 53-character “opt out” message (to advise subscribers how to cease receiving mobile advertising messages) reducing the space available for our messages. Three months into the broadcast schedule, the provider increased the length of its opt out message to 70 characters, effectively reducing our total advertising “space” by 44% overall. • Issues with data management: The data provided by the telecommunications provider were of poor quality; broadcast data were incomplete and difficult to interpret while extractions of questionnaire data often omitted key variables.

These challenges impeded the intended delivery of our intervention; although messages had been focus tested with (and well rated by) the target audience, and some messages had been used successfully in previous mass-media campaigns, we were asked to modify and shorten messages prior to broadcast on five occasions. Qualitative evaluation of one of our previous SMS projects had indicated that elements such as informal message style and use of a “sign off” (e.g. “Love the [institute name]”) were important in establishing message appeal

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and credibility,28 but the provider required these elements to be substantially modified or omitted. The issues with data management affected our ability to assess the effects of the intervention: in particular, the omission of an identifier for the group to which each individual was randomized in the baseline data precluded key analyses of changes over time within individuals.

TRANSLATION TO HEALTH EDUCATION PRACTICE Our experience has implications for any public health practitioner considering involving a commercial entity in program delivery. Despite a careful, cooperative and highly positive project development process, ultimately our priority of providing topical, health-orientated messages to our target audience appeared to conflict with our corporate partner’s priorities of attracting advertising revenue and maintaining a large customer base. Clearly public and private partners have different goals, and roles, within partnership arrangements; our experience suggests it is critical to ensure that these goals and roles co-exist to successfully deliver interventions. Although we did manage to deliver a wide-scale SMS intervention, project fidelity was not maintained and this was likely to have substantially impacted upon intervention effectiveness. If utilized effectively on a large scale, SMS could enable prompt, low cost per capita audience reach for public health communication and data gathering, and represent a significant business opportunity for telecommunications providers. Despite evidence of SMS being an effective tool for health promotion,29,30 the issues we experienced need to be considered carefully before further expansion is attempted, particularly as many decisions affecting intervention delivery were made unilaterally by our corporate partner. Similar to what has been reported previously regarding community coalitions and multi-sector partnerships,31-34 it is critical to establish the structures and processes for partnerships at the outset. It is particularly

important when engaging a private sector partner to have very clear written documentation of what is expected, as standard commercial contracts are generally focused on legal issues and do not include specific detail on project implementation. We recommend that additional written documentation is included for all partnerships with private partners, specifying in detail all aspects of the implementation process (such as in our case, the message content to be broadcast, the message delivery requirements, processes and standards for data collection, roles and responsibilities of all partners). In addition, it is vital to continually verify that all partners are “on the same page,” particularly as many standard research procedures (e.g. randomization, standardized delivery of interventions) may not be familiar to private partners. All arrangements and agreements, no matter how trivial, should also be documented in writing, as our disputes with our corporate partner often relied on “he said, she said” reports. In conclusion, the priorities of public and private partners are often very different, and recourse in disputes is limited in the legal sense due to the imbalance in financial resources between a large commercial entity and research institutes. Although it is likely that reliance on third party private enterprises will continue to increase, it is important to ensure that public health action is not unduly compromised by commercial objectives. The difficulties we experienced certainly compromised our methodological rigor, and very probably impacted on our study outcomes. We are not alone in having experienced difficulties relying on a corporate partner to deliver a health promotion intervention;35 unfortunately, our experience is unlikely to be the last. Ultimately, our advice is that public health practitioners need to be extremely careful when entering into partnership arrangements with private partners.

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