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? Refractive errors
? Cataract
? Age-related macular disease
? Glaucoma
? Diabetic retinopathy.
Older people from deprived areas and poorer backgrounds often put off accessing eye care services and often present with advanced disease and visual impairment.7 The consequence of not detecting and managing these conditions is permanent visual impairment and low vision.
Seventeen per cent of visual impairment in the over-65s,7 and 30 per cent in over 75s,8 was found to be due to uncorrected refractive errors. Seventy-three per cent of the over-65s in one study7 had not visited an optometrist within the past 12 months despite their visual impairment. Improving sight test uptake would result in reduction of visual impairment among Dudley's population due to uncorrected refractive errors, undetected cataracts, AMD, glaucoma, diabetes and vascular diseases and promote better health.
Attending for a sight test is, however, dependent on individual motivation, not just failing vision. Thus it was necessary to understand why sight tests paid for by the NHS in the older population may not be taken up, and what potential solutions could be employed to remove barriers.
Social marketing, a term coined by Kotler and Zaltman,9 is the 'systematic application of marketing, alongside other concepts and techniques to achieve specific behavioural goals for a social or public good'.10 It uses marketing techniques of the commercial sector to influence behavioural change in targeted areas of society. However, there are differences. In social marketing the products tend to be more complex, demand is more varied, target groups are more challenging to reach, consumer involvement is more intense and competition is more subtle and varied.
The white paper Choosing Health11 set out a commitment to improving the nation's health by assisting people to make healthier choices. Along with the earlier Wanless Report,12 it recognised that encouraging positive health behaviour (and related behaviour change) can be complex and challenging, and to achieve this requires sustained and coordinated action across sectors and at all levels. Social marketing was specifically highlighted in the white paper as important, and an approach that has real potential to make a significant contribution to both national and local work. Social marketing asks not 'What is wrong with these people or why won't they understand?', but 'What is wrong with us? What don't we understand about our target audience?'
Dudley NHS's Communications team began a social marketing project to understand what motivates older patients to attend or otherwise, for sight tests with a view to supporting a communications strategy that began in October 2008 to increase uptake of sight examinations among 60-70 year-olds as the prevalence of eye diseases increases with age.
Qualitative research
? One-to-one interviews were held with representatives from the local authority, Age Concern and the commissioner for older people at NHS Dudley
? A focus group was held with 14 borough residents at the Older Peoples Forum
? Small semi-structured interviews of between one and four participants were held at four locations across the borough (Age Concern day centres, Friendship Groups, WRVS Luncheon Clubs, and Sheltered Accommodation). A total of 38 people participated in these interviews.
Actionable outcomes
Throughout the research the most common word used by participants was 'precious', both when describing eyesight and their quality of life. This word was used on 26 separate occasions by the focus groups and during the semi-structured interviews in addition to:
? Biggest motivation to attend for a sight test was the risk of not being able to enjoy life
? Tacit acceptance that sight failure is part of growing old
? People in Dudley trust independent opticians as opposed to chains
? Poor understanding of the range of conditions that could be discovered from the test
? The cost of spectacles was a big factor in people not attending
? Personalised communication messages as opposed to generic advertising was preferred.
Participants were reluctant to be called old and many 60-70 year-olds stated they were enjoying the best years of their lives. However, there was a consensus among the groups that failing eyesight was a sign of getting old and that they accepted and expected this to happen.
When asked what activities would be affected by failing sight and what patients feared missing out on, the following were offered:
? Driving
? Family events
? Reading
? Watching TV
? Hobbies
? Exercise.
As a result of this insight Dudley NHS engaged the Dudley public with eye health messages, using press coverage, and promotional material that capitalised on the 'precious' dimension of activities that would be affected with failing eyesight (Figures 1a and 1b).
There were 11.278 million NHS sight test claims in England processed in the 12 months to March 31 2009.12 This is an increase of 231,000 (2.1 per cent) on the previous year. In Dudley, for a similar period, a greater than the national increase in NHS sight tests was noted, suggesting a successful raising of the awareness of the importance and benefits of sight tests and improved access. ?
References
1 www.medscape.com/viewarticle/514448 Klesert T and Chang T. Quality of life in age related macular degeneration. Medscape Ophthalmology, 2005; posted 19.10. Last accessed Sept 6 2008.
2 Ivers RQ, Cumming RG, Mitchell P et al. Visual impairment and falls in older adults: the Blue Mountains Eye Study. J Amer Ger Soc, 1998; 46(1):58-64.
3 Evans JR, Fletcher AE and Wormald PL. Depression and anxiety in visually impaired older people. Ophthalmology, Feb 2007; Vol 114 issue 2 p283-288.
4 Waern M et al. Burden of illness and suicide in elderly people. British Medical Journal, 2002.
5 Dudley Strategic Needs Analysis Part 1 Demography.
6 Dudley Strategic Needs Analysis Part 2 Health Risks.
7 Reidy A, Minassian DC, Vafidis G et al. Prevalence of serious eye disease and visual impairment in a north London population: population-based, cross sectional study. BMJ, 1998; 316:1643-1646.
8 Choosing Health, Making healthy choices easier, Nov 2004. Department of Health
9 Kotler P, and Zaltman G. Social Marketing: An Approach to Planned Social Change. Journal of Marketing, July 6, 1971; Vol 35, pp3-12,
10 Freren, Blair-Stevens. 2006. www.nsms.org.uk/what-is-social-marketing.html
11 Securing good health for the whole population, Feb 2004, Department of Health.
12 General Ophthalmic Services: Activity Statistics for England and Wales Year Ending 31 March 2009, http://www.library.nhs.uk/Eyes/ViewResource.aspx?resID=323066 last accessed 8.1.10.
? Nizar Hirji is consultant optometrist at Hirji Associates in Birmingham, visiting professor, University of Manchester and City University, London, and optometric adviser, Black Country Cluster. Rebecca Marsden, at the time of writing, was communications and social marketing manager, NHS Dudley