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Ideas and Evidence for Marketing People

safefood: Reaching the unreachable, convincing the inconvincible; persuading all sexually active women, not just those planning a family, to take folic acid daily

McCannBlue and Mindshare

Introduction & Background

In 2015, safefood were tasked with encouraging women across the island of Ireland to take folic acid supplements, in order to help prevent Neural Tube Defects (NTDs) in new-born babies. NTDs are severe abnormalities of the central nervous system that develop in babies during the first weeks of pregnancy. The most common of these is spina bifida (meaning split spine), the effects are illustrated in Figure 1. 

Ireland has one of the highest incidence rates of NTDs in Europe, with between 0.8 and 1.5 cases recorded per 1,000 births annually or, to put it another way, somewhere between 49 and 93 babies are affected every year 1, 2. What’s even more distressing is that these rates have sharply increased in recent years. (See Figure 2)

A high proportion of we, the Irish population, has a genetic make-up that’s vulnerable to the development of NTDs because of the inefficient use of the vitamin folate or folic acid in our bodies 3.

A healthy diet will provide enough folic acid for normal bodily function, but women here must supplement it in the early stages of pregnancy to aid the normal development of their baby’s spinal cord and brain.

Just one 400mcg folic acid supplement vitamin taken daily, 12 weeks before conception and throughout the first 12 weeks of pregnancy, could potentially prevent two thirds of NTDs 4, equating to approximately 50 fewer Irish babies born with these conditions every year 5.

Despite this relatively simple step, recent Irish research showed that 3 out of 4 women attending antenatal care hadn’t taken folic acid supplements before becoming pregnant 6, the main reason being that 1 in 2 pregnancies is unplanned, with many women not realising that they’re pregnant 7.

Increasing rates of NTDs and low consumption rates of folic acid supplements had to be addressed quickly.

 

1 McDonnell, R. (2013). Epidemiology of Neural Tube Defects in Ireland. National Meeting on Neural Tube Defects; George’s Hall, Dublin Castle, Dublin, 2013.

2 Department of Health, Social Services and Public Safety (2013). Chief Medical Officer Annual Report 2011-12. Northern Ireland: Department of Health, Social Services and Public Safety.

2 Department of Health, Social Services and Public Safety, (2013). Chief Medical Officer Annual Report 2011-12. Northern Ireland: Department of Health, Social Services and Public Safety.

3 Food Safety Authority of Ireland, (2006). Report of the National Committee on Folic Acid Food Fortification. Dublin: Food Safety Authority of Ireland.

MRC Vitamin Study Research Group, (1991). Prevention of neural tube defects: Results of the Medical Research Council Vitamin Study. The Lancet, 338(8760), pp.131-137.

5 Turner, M. (2015). UCD Professor of Obstetrics and Gynaecology at the Coombe Women and Infants University Hospital, speaking at safefood launch, 21st July 2015.

Cawley, S., Mullaney, L., McKeating, A., Farren, M., McCartney, D. and Turner, M. (2015). An analysis of folic acid supplementation in women presenting for antenatal care. J Public Health, 38(1), pp.122-129.

Department of Heath (2011). Your Health is Your Wealth – HSE Public Health Policy Framework 2012-2020.

Marketing Objectives

i: Commercial Objective

safefood typically only sets behavioural goals, not commercial ones. The behavioural goal here was to increase folic acid supplement consumption amongst all sexually active women with a chance of becoming pregnant. As such, sales of 400mcg folic acid supplements were used as a measure of behavioural change and campaign effectiveness.

safefood engaged the Pharmaceutical Association of Ireland, the Ulster Chemist’s Association, their network of pharmacies and finally, manufacturers to measure sales and ultimately the commercial return of the campaign. Sales of folic acid during the four-week period of the campaign (July 20th to August 16th 2015) were compared with sales in the same period in 2014.

 

ii: Marketing Objectives

The objectives were to change knowledge, attitudes and behaviour relating to  folic acid supplements.

To achieve them, three behavioural change techniques from Susan Michie’s taxonomy of behavioural change were employed; education, persuasion and enablement 8

 

iii: Role for Communications

Most women have heard of folic acid but there is confusion about what it is, what it does and when, and by whom, it should be taken; all of which creates barriers for behavioural change with regard to taking it. The key misconceptions and myths, in our audience’s words 9, are:

  • You only need to take folic acid when you get pregnant, not before.
  • I’m using contraception, so why bother taking folic acid?
    (Even though 50% of pregnancies are unplanned)
  • Taking folic acid will give everyone the idea I’m trying for a baby.
  • I’ll get all the folic acid I need from food.
  • Folic acid will help make me get pregnant.
  • Vitamins are expensive. (Taking a folic acid supplement costs only a few cents a day) (See appendices i for average cost analysis)
  • I don’t want to be taking loads of tablets and vitamins every day. (It only requires one small 400mcg pill per day)
  • My other kids weren’t born with NTDs, so any more I have will be fine as well.
  • You can’t be thinking negatively like that. Something like that wouldn’t happen to me.
  • Sure what good will one little tablet do against something as terrible as spina bifida?

(See Figure 3 For Qualitative Quotes From Female Focus Groups Discussing Folic Acid Supplement Beliefs and Behaviours)

Michie, S., Ashford, S., Sniehotta, F. F., Dombrowski, S. U., Bishop, A. and French, D. P. (2011). A refined taxonomy of behaviour change techniques to help people change their physical activity and healthy eating behaviours: the CALO-RE Taxonomy. Psychology & Health, 26(11), pp. 1479-1498.

9 Faughnan, M. F., Cahill, D., Burgoyne, L. N. and Perry, I. J. (2009). Barriers and facilitators to taking folic acid supplements among women aged 18–30 years. Proceedings of the Nutrition Society, 68(OCE3). E149. 

 

Appendix i. Folic acid prices as at 20 July 2015

Retailer

Product

Tablets per pack

Price*

Price per tablet

Hickey's

 

 

 

 

 

“Trying for a baby” Seven Seas with folic acid

28

€4.99

 

0.18c

 

Clonfolic

28

€3.75

0.13c

 

Clonfolic

98

€6.20

0.06c

Dunnes

 

 

 

 

 

 

Healthpoint Folic Acid

120

€1.99

0.02c

 

Seven Seas Pregnancy with folic acid

28

€3.34

0.12c

Boots

 

 

 

 

 

 

Sona Range of folic acid

90

€5.99

0.07c

 

Boots Own brand

60

€2.99

0.05c

 

Boots Own brand

180

€6.99

0.04c

 

Kelkin

60

€4.99

0.08c

 

Beeline

90

€6.99

0.08c

 

Clonfolic

28

€3.79

0.14c

 

Clonfolic

98

€6.39

0.07c

Tesco

 

 

 

 

 

Tesco folic acid

90

€0.50

0.01c

 

Beeline folic acid

90

€6.65

0.07c

Aldi

 

 

 

 

 

Activ – Max Women’s Health

180

€0.99

0.01c

Lloyds

 

 

 

 

 

Lloyds Pharmacy Folic Acid

90

€3.99

0.04c

All products purchased contain the recommended daily intake 400mcg of folic acid per tablet.

*All purchases made between 17th and 20th July 2015 in Dublin and Kildare and may include retailer discount or promotional pricing instore at that time.

Average price per tablet surveyed: 0.04 cent

The Task

80% of babies born with NTDs survive the newborn phase with the majority (85%) experiencing lifelong disability 10.

Patients with spina bifida often require repeated surgeries to repair the damaged spinal cord. Other complications include hydrocephalus, foot and knee deformities, learning difficulties and chronic bladder and bowel malfunctions.

A child with spina bifida is likely to wear nappies their entire life. If they are lucky enough to walk, they’ll be too unbalanced to ever hop, skip, run or climb. A child with spina bifida needs a shunt in their brain to drain cerebral spinal fluid into their abdomen, a job normally done by the spinal cord. Their families must constantly look out for shunt blockages, as the effects would be devastating.

The costs of operations and treatments for children with spina bifida average €500,000 over a lifetime. This means that if 70 – 80 NTD births occur each year, there’s a potential annual cost to the health service of €40 million 11, a significant sum that could help others.

This was and is a major public health issue.

If two-thirds of NTDs were to be prevented through folic acid uptake, almost 53 less babies could be born with an NTD, resulting in a saving of €26.4 million for the health service.

The sudden and sharp increase in babies born with NTDs 12 in recent years coincided with a decline in folic acid intake amongst pregnant women.

Previous public debate on whether or not to fortify food with folic acid appeared to have added to confusion. In 2013, a recommendation was made by the Food Safety Authority of Ireland (FSAI) not to fortify food with folic acid in Ireland, because there was a need for more EU-wide regulation of this area.

Unfortunately, media headlines such as ‘FSAI says no gain from adding folic acid to food’, left many with the misconception that they’re actually getting enough folic acid from diet alone 13.

There had been no mass media communications on folic acid and its benefits since the Health Promotion Agency ran an advertising campaign in Northern Ireland in 1999, which was adapted for ROI in 2000 14.

So, following 15 years of ‘radio silence’, safefood was tasked with running a campaign, on a small budget of €75,000, targeting women across the island of Ireland, who were unsure or confused about folic acid. There was no new ‘scientific silver bullet’ to reverse misconceptions; there was no new news at all.

The campaign also had an unreceptive audience issue to overcome, in that half of the audience did not consider themselves the audience. 50% of pregnancies are planned; the other 50% are not, so logic insisted that 50% of our audience would be closed off to a folic acid message.

In short, the challenge was tough and complex: targeting women who don’t think unplanned pregnancy will happen to them, and that if it does, they would never have a baby born with any kind of birth defect, let alone something like spina bifida.

 

10 Food Safety Authority of Ireland, Department of Health and Children (2006). Report of the implementation group on folic acid food fortification to the Department of Health and Children. Dublin: Food Safety Authority of Ireland.

11 Cullen, P. (2015). Folic acid could prevent 40 spina bifida cases yearly. The Irish Times. [online]. 26 June. Available from: http://www.irishtimes.com/news/health/folic-acid-could-prevent-40-spina-bifida-cases-yearly-1.2264444. [Accessed 30 April 2015].

12 McKeating, A., Farren, M., Cawley, S., Daly, N., McCartney, D. and Turner, M. (2015). Maternal folic acid supplementation trends 2009-2013. Acta Obstetricia et Gynecologica Scandinavica, 94(7), pp.727-733.

13 McKinley, C. (2013). FSAI says no gain from adding folic acid to food. The Irish Times. [online]. 9 September. Available from: http://www.irishtimes.com/news/health/fsai-says-no-gain-from-adding-folic-acid-to-food-1.1521397. [Accessed 30 April 2015]

14 Health Promotion Agency (2000). What is folic acid? [online]. Available from: https://www.yumpu.com/en/document/view/22214673/what-is-folic-acid-health-promotion-agency  [Accessed 30 April 2015]

The Strategy

Defining the audience

With approximately 50% of pregnancies unplanned, the target was all sexually active women of childbearing age who could become pregnant.

Specific groups included:

 

a. Young women sexually active but not considering pregnancy

b. Women considering pregnancy

c. Women who already have children, could become pregnant, but are not taking folic acid

d. Lower income groups (as incidence rates are higher amongst these women) 15

 

Developing the key messages and selecting behaviour change techniques

To bust folic acid myths, our campaign needed to communicate the facts and deliver them through supportive behavioural change techniques:

Increased Knowledge Through Education: Key Facts

  • Folic acid needs to be taken if you are pregnant or planning to get pregnant
  • Folic acid should be taken by all women whether they are trying to get pregnant or not
  • Getting folic acid from fruit and veg is not enough
  • Folic acid does not help you get pregnant
     

Attitude Change Through Persuasion: Key Facts

  • Folic acid is important for the development of healthy babies
  • Folic acid protects babies from spina bifida
     

Behavioural Change Through Enablement: Key Supports

  • Facilitate open, honest, non-judgmental conversation amongst women
  • Give women the right information, in the right place along their behavioural change journey (i.e. on social, online, in doctor’s surgeries and in pharmacies)
  • Help women adopt a positive daily supplement habit

 

(See Figure 4a)

 

The overarching message;

Whether or not you’re planning (or even want) to get pregnant: whether it’s later this year or later this century, you need to get into the routine of taking folic acid every day.

 

(See Figure 4b)

 

Strategy: Science wrapped in entertainment

Given that 50% of our audience was not in the ‘pregnancy-planning zone’ and would be closed off to the message, we needed a ‘Trojan Horse’. Our planned strategy was to reel our audience in with entertaining content and then, when their minds were open, highlight the factual information we wanted to impart.

We took learnings and inspiration from other public bodies awarded for effectively using a similar ‘edutainment’ approach, including ‘Dumb Ways to Die’ by Melbourne Rail Safety 16 and ‘Choose A Different Ending – Knife Crime’ by The Metropolitan Police 17.

For the other half of our audience in the ‘pregnancy planning zone’, this approach was important too. While we knew they would be more open to our message, we also knew they would be less likely to discuss and share it, because when it comes to talk of broodiness, pregnancy or family planning, women keep their feelings and plans close and only share with a select and trusted few. Entertaining content gave women in this zone an opportunity to share without revealing their plans18.

(See Figure 5) 

 

15 Grewal, J., Carmichael, S., Song, J. and Shaw, G. (2009). Neural tube defects: an analysis of neighbourhood- and individual-level socio-economic characteristics. Paediatric and Perinatal Epidemiology, 23(2), pp.116-124.

16 Chan, D., and Mills, A. (2013). Metro: Dumb Ways to Die. Retrieved from Warc database.

17 Warc (2011). The Metropolitan Police: Knife Crime - Choose A Different Ending. Retrieved from Warc database.

18 Warc (2014). Danone:Karimums - Connecting mums and mums-to-be on the journey. Retrieved from Warc database.

 

The Idea

Channel Selection

Digital and social were chosen as key channels through which to educate, persuade and enable.

  • We needed a medium that allowed us to engage and re-engage with women, educating, persuading and enabling, targeting one misconception at a time.
  • We wanted to promote open, stigma-free conversation amongst women. Social networks offered the perfect platform.
  • With a limited budget of €75,000 to develop a campaign for Northern Ireland and the Republic of Ireland, online channels offered cost-effective reach and engagement.
  • Building shareability into our content allowed us to drive earned reach beyond paid media.

 

Pharmacies, retailers and doctor surgeries

  • We wanted to give women our folic acid message at the most critical point of decision-making to enable behavioural change; in-store where they could buy the supplement.
  • Pre-campaign, we contacted 1,362 pharmacies with an e-mail through the Pharmaceutical Society of Ireland (PSI). We also publicised the campaign via the Ulster Chemists’ Association (NI) and the Irish Pharmacy Union (ROI). We also contacted the major pharmacy chains directly in both ROI and NI, as well as major supermarket retailers on the island e.g. Tesco, Dunnes and Asda.
  • We also employed paid media in doctor’s surgeries, another important point on the journey to behavioural change.

 

Creative Strategy

We needed a highly engaging creative vehicle to drive our facts-based communication, something very engaging, ‘clickable’ and ‘shareable’. So our Trojan Horse was born of a combination of two of the strongest forces on the Internet: babies… and Irish Mammies.

This practically guaranteed sharing and engagement amongst women across the island of Ireland. (See Figure 6)


Babies

When it comes to what has high shareability with women, cute and funny is high on the list. And nothing ticks those boxes more than funny baby content, whether or not the woman watching and chuckling has babies of her own. Social channels are swimming with memes featuring babies juxtaposed with humorous copy. It seems that babies have almost become a social currency (See Figure 7). We hoped tapping into this rich vein would connect us with our audience and get them sharing the facts about folic.


Irish Mammies

The Irish Mammy has become a legend in her own teatime (thanks to @ColmORegan). Some of the strangest (and funniest) advice, when it comes to pregnancy and babies, originates from her. Just like some of the misconceptions around folic acid, much of what she has to say isn’t just ridiculous, it’s downright hilarious. And she happens to be a lot of young mothers’ first port of call for advice. Irish Mammy-isms had also become social currency. (See Figure 8) Also, in Irish society, mammies have a licence to tell it straight.

We brought together these two powerhouses of the Internet to develop our creative concept.

 

‘Babies know the facts about folic’

 

The creative content for this idea was built around babies themselves dispelling the myths about folic acid. Short video pieces were created and spearheaded the campaign. In these videos, the legendary nonsensical wisdom of the Mammy meets the no-nonsense common sense of a child. These short video pieces were produced using still photography coupled with animated elements. This new technique allowed for a very engaging and highly cost-effective creative solution.

 

The creative elements of the campaign were tested online pre-launch to ensure they appealed to the target audience in both NI and ROI, and communicated the right information in an easy-to-understand way. 57 participants took part in the testing including two participants from SHINE, the charity for NTDs, in the United Kingdom (UK). We wanted to be sensitive to those who had children with Neural Tube Defects. The response was very positive and we were excited that we had an idea which would connect, educate and be passed on 19.

 

Use of channels

safefood Website and Inbound and Outbound Marketing Strategy

To dispel misconceptions and encourage behaviour change, we needed a factual, interesting and accessible hub of information to educate and persuade women.

A hub was designed for the safefood website. (See Figure 9a) A quick link to this hub featured on the safefood website homepage for the duration of the campaign. 

This hub included information on:

  1. Folic acid facts
  2. Folic acid myths
  3. A folic acid quiz
  4. Real life stories from families who have been affected by Neural Tube Defects (NTDs). (See Figure 9b)
  5. Useful blogs on getting into the folic habit. (See Figure 9c)
  6. Useful links
  7. Folic acid FAQs
  8. Social media links for women to discuss and share

This information was pushed out through safefood’s newsletter, Twitter and Facebook, with paid spend carefully targeted towards our audience. (See Figures 10a and 10b)

Word of mouth remains globally one of the most trusted sources of information 20. Spreading the folic acid message through social media and encouraging sharing and conversation was key.

Expert video also featured on the safefood social media channels. These videos featured foetal medicine experts such as Prof. Jim Dornan, Prof. Michael Turner and Dr Rhona O’Mahony, who discussed a range of issues including NTDs, who should take folic acid and why it is important. Healthcare professional opinions gave credibility to the messages.

All advertising communications linked back to this hub where women could find out more information and get help to adopt a positive folic habit.

 

Digital advertising and search marketing

To ensure reach of the creative vehicle and message, digital display advertising was implemented across a range of high-traffic websites. We placed the message on publisher sites with high daily traffic from the target audience to ensure the message was seen every day (DailyMail, Evoke.ie, Her.ie, and Independent.ie), but also on sites that spoke to specific life stages – weddings and parenting websites and newsletters (EUMom, Shemazing, Weddings Online and NI4Kids). Retargeting and behavioural targeting was also utilised to ensure those who engaged with the advertising would be served additional advertising information. (See appendix ii for full list of websites that featured the display advertising).

A search marketing campaign using keywords relating to folic acid and key life stages for planning conception was delivered through Google AdWords. This ensured interest generated from all marketing was answered with the correct information on the safefood hub.

 

Public Relations

To launch the campaign, safefood organised events in ROI on July 20th, 2015 and in NI on July 27th, 2015. Twenty relevant influencers including health correspondents, news editors, parenting media, parenting bloggers, beauty media and bridal media attended the ROI and NI events. (See Figures 11a, 11b and 11c). Social media conversation relating to the campaign by attendees was high. Key patient advocates and foetal experts spoke at the events. #FolicFacts gave scale and visibility to the conversation.

 

Stakeholder Engagement and Point of Decision Materials

safefood developed a suite of design materials that pharmacies and manufacturers could tailor and print for their own in-store advertising, signposting folic acid more prominently to their own customers (at their own expense, as our small budget was spent). This enabled women to access the right information at critical behavioural decision points. Pharmacies and retailers were also encouraged to share the safefood campaign content through their own social channels like Facebook or Twitter during the campaign.

(See Figure 12)

19 Safefood. (2015). Analysis of vizzata testing for folic acid campaign.

20 Nielsen Global. (2015). Global trust in advertising. [online]. Available from: http://www.nielsen.com/content/dam/nielsenglobal/apac/docs/reports/2015/nielsen-global-trust-in-advertising-report-september-2015.pdf [Accessed 30 April 2015]. 

Appendix ii. Display advertising websites and networks

Site/Network

Environment

Daily Mail

Run of site, Showbiz, Femail

Evoke.ie

Run of site

Her.ie

Run of site

Independent.ie

Style section

Mirror NI

NI and Belfast Live

Belfast Telegraph

Parenting

Electric Media

Fashion, Beauty, Weddings, Celebrity

Yahoo

Behavioural targeting

 

The Results

We monitored both claimed and actual behavioural change through online research of 1,300 ROI and NI women, pre and post campaign, and through pharmacy sales of folic acid during our campaign. So how did the campaign deliver against its objectives?

 

1. Knowledge Change Through Education

We delivered 5.7 million digital display impressions with total cross-website reach of 903,284 women on the island of Ireland.

Social media posts were seen more than 1,086,000 times (Facebook 830,000, Twitter 256,000) with 25,000 engagements (sharing, commenting, liking these posts). (See Figure 13) The PR campaign generated 135 pieces of media coverage.

75% of women surveyed now believe all women who are sexually active should take folic acid. This figure was at 26% pre-campaign, representing an increase of 48%. (See Figure 14)

 

2. Attitude Change Through Persuasion

Conversation was generated around folic acid across the campaign period. On social media, there were 961 mentions of it (of which only 17% originated from safefood). There was a significant increase in Twitter mentions during the campaign. On launch day, 21st July, there were almost 8 times more Twitter mentions (227) of folic acid than on an average day (30). (See Figures 15, 16, 17)

On social media, women began to quote the facts about folic acid and share their own experiences. (See Figures 18, 19)

Importantly, women are now more open to discussing the topic of folic acid with family/friends; an increase from 22% to 26% pre and post campaign). (Figure 20)

 

3. Enablement – Enabling New Behaviours

Messages were promoted through digital channels with all information available on the website. There were 33,481 visits to the folic acid hub.

Of the 1,362 pharmacies that were contacted through the Pharmaceutical Society of Ireland mailing list, 42% opened the email and 11% clicked through to the campaign resources. (See appendix iii) Pharmacies were also active on social media promoting the campaign. (See Figure 21)

With regards to new behaviour, an increase of 10% was evident in women currently taking folic acid supplements. This is broken down as follows by those who are and who are not planning a pregnancy. (See Figure 22) 

This is a positive starting point in terms of behavioural change.

 

Commercial sales

Measurement of folic acid supplement sales indicated that consumption had increased. During the campaign period, folic acid sales increased by 26% on average compared to the same period in 2014. (See appendix iv).

 

Discounting factors

Given the significant increase in claimed positive behaviour change and increase in sales, it is prudent to discount other factors.

 

  1. Was there any other media coverage or campaigns on folic acid?

safefood’s campaign, including the stakeholder outreach, was the only folic acid campaign during this period. Clonfolic, a leading manufacturer of folic acid supplements, got behind the campaign by creating their own posters and radio ads that drove people to the folic facts hub. (See Figure 23)

 

2.Were folic acid supplements on price promotion anywhere at this time?

There weren’t any price promotions on folic acid supplements at this time.

 

3.Can we attribute the increase of sales of folic acid to an increase in pregnancies at this time?

No, there is no evidence to suggest an increase in pregnancies. In fact, the birth rate has declined 10% from 2010 to 2014 and 2015 Q1- Q3 is down -2% compared to same period in 2014. (See Figures 24 and 25)

 

Saving to society

 

  1. Economic impact of treating children with NTDs

 

The cost of treatment for children with NTDs averages €500,000 across a lifetime. With 70-80 NTD births occurring every year, this amounts to a cost of €40,000,000. Potentially, two-thirds of these NTD births could be prevented by women regularly taking folic acid supplements, meaning a saving of €26,500,000. Comparing this potential saving to the safefood campaign marketing budget of €75,000, this would amount to a return on marketing investment of 1:353.

Specifically relating to the results of the safefood campaign, an extra 7% (92,820) of women 18-45 years old (not currently planning a pregnancy) are now regularly taking folic acid supplements. Looking at this 7% of women not planning a pregnancy, and assuming 50% had an unplanned pregnancy, we calculated the potential impact of the campaign. (See Figure 26)

 

Also, the post-campaign research showed that an extra 3% of women who are planning a pregnancy are now taking folic acid supplements regularly. (See Figure 27)

More modestly, if this campaign prevents even one NTD birth, it is a return on investment of 1:6, i.e. €425,000.

 

2.Could spending the budget elsewhere have more effectively encouraged women?

With €75,000, safefood could have purchased 22,321 x 12 weekly supplies of folic acid supplements (average cost per supplement per day €0.04). So technically, safefood could have given 22,321 women a 12-week supply of folic acid, or given 11,161 women a 24-week supply.

This might seem like a lot; however, our post campaign research shows that 14% of women 18-45 years old (not planning a pregnancy) claim to be taking folic acid, an increase of 7% from the pre-campaign research. 7% amounts to an extra 92,820 18-45-year-old women on the island of Ireland. (See Figure 28)

 

This return on investment is calculated based on women taking folic acid for 12-24 weeks, whereas in reality, women would take it 52 weeks of the year, every year – of which the cost would be considerably higher.

 

Appendix iii. Participating pharmacies, manufacturers, health stores and retailers

Pharmacies:

O’Neills Chemist

Health Centre Pharmacy

McKeevers

Clear Healthcare

Boots NI

Lloyds Pharmacy

Boots ROI

Sam McCauley

Hickey's Pharmacy

Whelan’s Pharmacy

Confrey Pharmacies

Manufacturers:

Clonfolic

Beeline Healthcare

Health Stores:

Viridian Nutrition

Wholefoods Wholesale

Retailers:

ASDA (NI)

 

Appendix iv.  

Folic acid supplement sales

Folic acid supplement sales increased by 26% on average from the same period in 2014. The following pharmacies, manufacturers and health stores reported the following sales figures:

Pharmacy/ Manufacturer /Health Store

Sales increased by

Lloyds Pharmacy

30%

Confrey Pharmacy

47%

Wholefoods Wholesales

19%

Clonfolic

24%

Beeline Healthcare

10.5%

The Impact

There are three key statistics that succinctly indicate the effect the campaign has had on attitudes and behaviour towards folic acid. (See Figure 29)


In addition, the qualitative response to the campaign creative would indicate how it has impacted a change in attitudes. (See Figure 30)

 

The creative testing also illustrated that a high number of women from the group (28) would be willing to share the videos online. Given the 90-9-1 rule (90% of online users passively consume, 9% of users contribute a little and 1% of users account for all the action) 21, this is a high level of participation for the safefood campaign.

Importantly, the women agreed that the main reason for sharing the videos was that it is an important message for all women and that advice is the best form of prevention. This is powerful given that these are key messages to encourage new behaviours. (See Figure 31)

This research also proved that our funny babies giving mammy-like advice was another key reason for engaging and sharing the campaign. (See Figure 32)

The commentary on social media would also indicate a positive change in attitude toward folic acid taking, with women encouraging each other to take folic acid and instilling the norm of taking folic acid supplements, regardless of your stage of life. (See Figure 33)

The impact of the campaign has been recognised by experts in this field. (See figure 34)

The safefood folic acid campaign has also been recognised by the eGovernment 2016 awards, winning the Marketing Award. The award recognises the pioneering work of digital leaders in the public sector, state agencies and local authorities. Commenting on the safefood "Babies Know the Facts about Folic" campaign, Kathryn O'Donoghue, Director of Ad Quality Operations EMEA, Google said,

 

“What was really nice about the campaign was not just the use of online channels with offline PR, but also the fact that they used humour to address a very serious issue.”

 

In conclusion, each objective was met, proven by the research data and sales figures. While this was a short campaign, with immediate visible results, it is in the long term where this campaign will leave its mark. Preventing NTD births will not only improve the health of our children but will also save money, which can be reinvested, to benefit society at large.

It is also important to note that the costs above do not factor the indirect emotional and financial costs of raising a child with a NTD.  For example, evidence suggests that caregivers of a child with a NTD worked an average 7.5 to 11.3 hours less per week. In addition, the estimated caregiver time costs for a child with spina bifida until age 25 range from €142,477 to €171,303.

 

21 Nielsen, J., (2006). The 90-9-1 Rule for Participation Inequality in Social Media and Online Communities.[online]. Available from: https://www.nngroup.com/articles/participation-inequality/  [Accessed 30 April 2015].

New Learnings

Past domestic and international campaigns for folic acid had employed sexual innuendo (Figure 35). But if women in Ireland found discussing pregnancy when it was planned a taboo subject, they would certainly be closed to it when it was the farthest thing from their minds. Instead, we analysed social networks to identify subjects that were culturally relevant, acceptable and popular to share, and used these as vehicles to carry our important message.

 

We also proved that finding a cost-effective way measure behavioural change, actual as well as reported, was possible and important, if not mandatory. 

Summary

Most women have heard of folic acid, but there’s confusion about what it is, does, when it should be taken and by whom; creating barriers to taking it as a supplement.

To address low consumption rates of folic acid supplements that aid the normal development of baby’s spinal cord and brain in early stages of pregnancy, safefood busted the folic myths with facts, using two powerhouses of the Internet: babies and Irish mammies.

75% of women surveyed now believe all women who are sexually active should take folic acid, an important message given 1 in 2 pregnancies are unplanned.

Videos

In 2015, safefood were tasked with encouraging women across the island of Ireland to take folic acid supplements, in order to help prevent Neural Tube Defects (NTDs) in new-born babies. NTDs are severe abnormalities of the central nervous system that develop in babies during the first weeks of pregnancy. The most common of these is spina bifida (meaning split spine), the effects are illustrated in Figure 1. 

Ireland has one of the highest incidence rates of NTDs in Europe, with between 0.8 and 1.5 cases recorded per 1,000 births annually or, to put it another way, somewhere between 49 and 93 babies are affected every year 1, 2. What’s even more distressing is that these rates have sharply increased in recent years. (See Figure 2)

A high proportion of we, the Irish population, has a genetic make-up that’s vulnerable to the development of NTDs because of the inefficient use of the vitamin folate or folic acid in our bodies 3.

A healthy diet will provide enough folic acid for normal bodily function, but women here must supplement it in the early stages of pregnancy to aid the normal development of their baby’s spinal cord and brain.

Just one 400mcg folic acid supplement vitamin taken daily, 12 weeks before conception and throughout the first 12 weeks of pregnancy, could potentially prevent two thirds of NTDs 4, equating to approximately 50 fewer Irish babies born with these conditions every year 5.

Despite this relatively simple step, recent Irish research showed that 3 out of 4 women attending antenatal care hadn’t taken folic acid supplements before becoming pregnant 6, the main reason being that 1 in 2 pregnancies is unplanned, with many women not realising that they’re pregnant 7.

Increasing rates of NTDs and low consumption rates of folic acid supplements had to be addressed quickly.

 

1 McDonnell, R. (2013). Epidemiology of Neural Tube Defects in Ireland. National Meeting on Neural Tube Defects; George’s Hall, Dublin Castle, Dublin, 2013.

2 Department of Health, Social Services and Public Safety (2013). Chief Medical Officer Annual Report 2011-12. Northern Ireland: Department of Health, Social Services and Public Safety.

2 Department of Health, Social Services and Public Safety, (2013). Chief Medical Officer Annual Report 2011-12. Northern Ireland: Department of Health, Social Services and Public Safety.

3 Food Safety Authority of Ireland, (2006). Report of the National Committee on Folic Acid Food Fortification. Dublin: Food Safety Authority of Ireland.

MRC Vitamin Study Research Group, (1991). Prevention of neural tube defects: Results of the Medical Research Council Vitamin Study. The Lancet, 338(8760), pp.131-137.

5 Turner, M. (2015). UCD Professor of Obstetrics and Gynaecology at the Coombe Women and Infants University Hospital, speaking at safefood launch, 21st July 2015.

Cawley, S., Mullaney, L., McKeating, A., Farren, M., McCartney, D. and Turner, M. (2015). An analysis of folic acid supplementation in women presenting for antenatal care. J Public Health, 38(1), pp.122-129.

Department of Heath (2011). Your Health is Your Wealth – HSE Public Health Policy Framework 2012-2020.

i: Commercial Objective

safefood typically only sets behavioural goals, not commercial ones. The behavioural goal here was to increase folic acid supplement consumption amongst all sexually active women with a chance of becoming pregnant. As such, sales of 400mcg folic acid supplements were used as a measure of behavioural change and campaign effectiveness.

safefood engaged the Pharmaceutical Association of Ireland, the Ulster Chemist’s Association, their network of pharmacies and finally, manufacturers to measure sales and ultimately the commercial return of the campaign. Sales of folic acid during the four-week period of the campaign (July 20th to August 16th 2015) were compared with sales in the same period in 2014.

 

ii: Marketing Objectives

The objectives were to change knowledge, attitudes and behaviour relating to  folic acid supplements.

To achieve them, three behavioural change techniques from Susan Michie’s taxonomy of behavioural change were employed; education, persuasion and enablement 8

 

iii: Role for Communications

Most women have heard of folic acid but there is confusion about what it is, what it does and when, and by whom, it should be taken; all of which creates barriers for behavioural change with regard to taking it. The key misconceptions and myths, in our audience’s words 9, are:

  • You only need to take folic acid when you get pregnant, not before.
  • I’m using contraception, so why bother taking folic acid?
    (Even though 50% of pregnancies are unplanned)
  • Taking folic acid will give everyone the idea I’m trying for a baby.
  • I’ll get all the folic acid I need from food.
  • Folic acid will help make me get pregnant.
  • Vitamins are expensive. (Taking a folic acid supplement costs only a few cents a day) (See appendices i for average cost analysis)
  • I don’t want to be taking loads of tablets and vitamins every day. (It only requires one small 400mcg pill per day)
  • My other kids weren’t born with NTDs, so any more I have will be fine as well.
  • You can’t be thinking negatively like that. Something like that wouldn’t happen to me.
  • Sure what good will one little tablet do against something as terrible as spina bifida?

(See Figure 3 For Qualitative Quotes From Female Focus Groups Discussing Folic Acid Supplement Beliefs and Behaviours)

Michie, S., Ashford, S., Sniehotta, F. F., Dombrowski, S. U., Bishop, A. and French, D. P. (2011). A refined taxonomy of behaviour change techniques to help people change their physical activity and healthy eating behaviours: the CALO-RE Taxonomy. Psychology & Health, 26(11), pp. 1479-1498.

9 Faughnan, M. F., Cahill, D., Burgoyne, L. N. and Perry, I. J. (2009). Barriers and facilitators to taking folic acid supplements among women aged 18–30 years. Proceedings of the Nutrition Society, 68(OCE3). E149. 

 

Appendix i. Folic acid prices as at 20 July 2015

Retailer

Product

Tablets per pack

Price*

Price per tablet

Hickey's

 

 

 

 

 

“Trying for a baby” Seven Seas with folic acid

28

€4.99

 

0.18c

 

Clonfolic

28

€3.75

0.13c

 

Clonfolic

98

€6.20

0.06c

Dunnes

 

 

 

 

 

 

Healthpoint Folic Acid

120

€1.99

0.02c

 

Seven Seas Pregnancy with folic acid

28

€3.34

0.12c

Boots

 

 

 

 

 

 

Sona Range of folic acid

90

€5.99

0.07c

 

Boots Own brand

60

€2.99

0.05c

 

Boots Own brand

180

€6.99

0.04c

 

Kelkin

60

€4.99

0.08c

 

Beeline

90

€6.99

0.08c

 

Clonfolic

28

€3.79

0.14c

 

Clonfolic

98

€6.39

0.07c

Tesco

 

 

 

 

 

Tesco folic acid

90

€0.50

0.01c

 

Beeline folic acid

90

€6.65

0.07c

Aldi

 

 

 

 

 

Activ – Max Women’s Health

180

€0.99

0.01c

Lloyds

 

 

 

 

 

Lloyds Pharmacy Folic Acid

90

€3.99

0.04c

All products purchased contain the recommended daily intake 400mcg of folic acid per tablet.

*All purchases made between 17th and 20th July 2015 in Dublin and Kildare and may include retailer discount or promotional pricing instore at that time.

Average price per tablet surveyed: 0.04 cent

80% of babies born with NTDs survive the newborn phase with the majority (85%) experiencing lifelong disability 10.

Patients with spina bifida often require repeated surgeries to repair the damaged spinal cord. Other complications include hydrocephalus, foot and knee deformities, learning difficulties and chronic bladder and bowel malfunctions.

A child with spina bifida is likely to wear nappies their entire life. If they are lucky enough to walk, they’ll be too unbalanced to ever hop, skip, run or climb. A child with spina bifida needs a shunt in their brain to drain cerebral spinal fluid into their abdomen, a job normally done by the spinal cord. Their families must constantly look out for shunt blockages, as the effects would be devastating.

The costs of operations and treatments for children with spina bifida average €500,000 over a lifetime. This means that if 70 – 80 NTD births occur each year, there’s a potential annual cost to the health service of €40 million 11, a significant sum that could help others.

This was and is a major public health issue.

If two-thirds of NTDs were to be prevented through folic acid uptake, almost 53 less babies could be born with an NTD, resulting in a saving of €26.4 million for the health service.

The sudden and sharp increase in babies born with NTDs 12 in recent years coincided with a decline in folic acid intake amongst pregnant women.

Previous public debate on whether or not to fortify food with folic acid appeared to have added to confusion. In 2013, a recommendation was made by the Food Safety Authority of Ireland (FSAI) not to fortify food with folic acid in Ireland, because there was a need for more EU-wide regulation of this area.

Unfortunately, media headlines such as ‘FSAI says no gain from adding folic acid to food’, left many with the misconception that they’re actually getting enough folic acid from diet alone 13.

There had been no mass media communications on folic acid and its benefits since the Health Promotion Agency ran an advertising campaign in Northern Ireland in 1999, which was adapted for ROI in 2000 14.

So, following 15 years of ‘radio silence’, safefood was tasked with running a campaign, on a small budget of €75,000, targeting women across the island of Ireland, who were unsure or confused about folic acid. There was no new ‘scientific silver bullet’ to reverse misconceptions; there was no new news at all.

The campaign also had an unreceptive audience issue to overcome, in that half of the audience did not consider themselves the audience. 50% of pregnancies are planned; the other 50% are not, so logic insisted that 50% of our audience would be closed off to a folic acid message.

In short, the challenge was tough and complex: targeting women who don’t think unplanned pregnancy will happen to them, and that if it does, they would never have a baby born with any kind of birth defect, let alone something like spina bifida.

 

10 Food Safety Authority of Ireland, Department of Health and Children (2006). Report of the implementation group on folic acid food fortification to the Department of Health and Children. Dublin: Food Safety Authority of Ireland.

11 Cullen, P. (2015). Folic acid could prevent 40 spina bifida cases yearly. The Irish Times. [online]. 26 June. Available from: http://www.irishtimes.com/news/health/folic-acid-could-prevent-40-spina-bifida-cases-yearly-1.2264444. [Accessed 30 April 2015].

12 McKeating, A., Farren, M., Cawley, S., Daly, N., McCartney, D. and Turner, M. (2015). Maternal folic acid supplementation trends 2009-2013. Acta Obstetricia et Gynecologica Scandinavica, 94(7), pp.727-733.

13 McKinley, C. (2013). FSAI says no gain from adding folic acid to food. The Irish Times. [online]. 9 September. Available from: http://www.irishtimes.com/news/health/fsai-says-no-gain-from-adding-folic-acid-to-food-1.1521397. [Accessed 30 April 2015]

14 Health Promotion Agency (2000). What is folic acid? [online]. Available from: https://www.yumpu.com/en/document/view/22214673/what-is-folic-acid-health-promotion-agency  [Accessed 30 April 2015]

Defining the audience

With approximately 50% of pregnancies unplanned, the target was all sexually active women of childbearing age who could become pregnant.

Specific groups included:

 

a. Young women sexually active but not considering pregnancy

b. Women considering pregnancy

c. Women who already have children, could become pregnant, but are not taking folic acid

d. Lower income groups (as incidence rates are higher amongst these women) 15

 

Developing the key messages and selecting behaviour change techniques

To bust folic acid myths, our campaign needed to communicate the facts and deliver them through supportive behavioural change techniques:

Increased Knowledge Through Education: Key Facts

  • Folic acid needs to be taken if you are pregnant or planning to get pregnant
  • Folic acid should be taken by all women whether they are trying to get pregnant or not
  • Getting folic acid from fruit and veg is not enough
  • Folic acid does not help you get pregnant
     

Attitude Change Through Persuasion: Key Facts

  • Folic acid is important for the development of healthy babies
  • Folic acid protects babies from spina bifida
     

Behavioural Change Through Enablement: Key Supports

  • Facilitate open, honest, non-judgmental conversation amongst women
  • Give women the right information, in the right place along their behavioural change journey (i.e. on social, online, in doctor’s surgeries and in pharmacies)
  • Help women adopt a positive daily supplement habit

 

(See Figure 4a)

 

The overarching message;

Whether or not you’re planning (or even want) to get pregnant: whether it’s later this year or later this century, you need to get into the routine of taking folic acid every day.

 

(See Figure 4b)

 

Strategy: Science wrapped in entertainment

Given that 50% of our audience was not in the ‘pregnancy-planning zone’ and would be closed off to the message, we needed a ‘Trojan Horse’. Our planned strategy was to reel our audience in with entertaining content and then, when their minds were open, highlight the factual information we wanted to impart.

We took learnings and inspiration from other public bodies awarded for effectively using a similar ‘edutainment’ approach, including ‘Dumb Ways to Die’ by Melbourne Rail Safety 16 and ‘Choose A Different Ending – Knife Crime’ by The Metropolitan Police 17.

For the other half of our audience in the ‘pregnancy planning zone’, this approach was important too. While we knew they would be more open to our message, we also knew they would be less likely to discuss and share it, because when it comes to talk of broodiness, pregnancy or family planning, women keep their feelings and plans close and only share with a select and trusted few. Entertaining content gave women in this zone an opportunity to share without revealing their plans18.

(See Figure 5) 

 

15 Grewal, J., Carmichael, S., Song, J. and Shaw, G. (2009). Neural tube defects: an analysis of neighbourhood- and individual-level socio-economic characteristics. Paediatric and Perinatal Epidemiology, 23(2), pp.116-124.

16 Chan, D., and Mills, A. (2013). Metro: Dumb Ways to Die. Retrieved from Warc database.

17 Warc (2011). The Metropolitan Police: Knife Crime - Choose A Different Ending. Retrieved from Warc database.

18 Warc (2014). Danone:Karimums - Connecting mums and mums-to-be on the journey. Retrieved from Warc database.

 

Channel Selection

Digital and social were chosen as key channels through which to educate, persuade and enable.

  • We needed a medium that allowed us to engage and re-engage with women, educating, persuading and enabling, targeting one misconception at a time.
  • We wanted to promote open, stigma-free conversation amongst women. Social networks offered the perfect platform.
  • With a limited budget of €75,000 to develop a campaign for Northern Ireland and the Republic of Ireland, online channels offered cost-effective reach and engagement.
  • Building shareability into our content allowed us to drive earned reach beyond paid media.

 

Pharmacies, retailers and doctor surgeries

  • We wanted to give women our folic acid message at the most critical point of decision-making to enable behavioural change; in-store where they could buy the supplement.
  • Pre-campaign, we contacted 1,362 pharmacies with an e-mail through the Pharmaceutical Society of Ireland (PSI). We also publicised the campaign via the Ulster Chemists’ Association (NI) and the Irish Pharmacy Union (ROI). We also contacted the major pharmacy chains directly in both ROI and NI, as well as major supermarket retailers on the island e.g. Tesco, Dunnes and Asda.
  • We also employed paid media in doctor’s surgeries, another important point on the journey to behavioural change.

 

Creative Strategy

We needed a highly engaging creative vehicle to drive our facts-based communication, something very engaging, ‘clickable’ and ‘shareable’. So our Trojan Horse was born of a combination of two of the strongest forces on the Internet: babies… and Irish Mammies.

This practically guaranteed sharing and engagement amongst women across the island of Ireland. (See Figure 6)


Babies

When it comes to what has high shareability with women, cute and funny is high on the list. And nothing ticks those boxes more than funny baby content, whether or not the woman watching and chuckling has babies of her own. Social channels are swimming with memes featuring babies juxtaposed with humorous copy. It seems that babies have almost become a social currency (See Figure 7). We hoped tapping into this rich vein would connect us with our audience and get them sharing the facts about folic.


Irish Mammies

The Irish Mammy has become a legend in her own teatime (thanks to @ColmORegan). Some of the strangest (and funniest) advice, when it comes to pregnancy and babies, originates from her. Just like some of the misconceptions around folic acid, much of what she has to say isn’t just ridiculous, it’s downright hilarious. And she happens to be a lot of young mothers’ first port of call for advice. Irish Mammy-isms had also become social currency. (See Figure 8) Also, in Irish society, mammies have a licence to tell it straight.

We brought together these two powerhouses of the Internet to develop our creative concept.

 

‘Babies know the facts about folic’

 

The creative content for this idea was built around babies themselves dispelling the myths about folic acid. Short video pieces were created and spearheaded the campaign. In these videos, the legendary nonsensical wisdom of the Mammy meets the no-nonsense common sense of a child. These short video pieces were produced using still photography coupled with animated elements. This new technique allowed for a very engaging and highly cost-effective creative solution.

 

The creative elements of the campaign were tested online pre-launch to ensure they appealed to the target audience in both NI and ROI, and communicated the right information in an easy-to-understand way. 57 participants took part in the testing including two participants from SHINE, the charity for NTDs, in the United Kingdom (UK). We wanted to be sensitive to those who had children with Neural Tube Defects. The response was very positive and we were excited that we had an idea which would connect, educate and be passed on 19.

 

Use of channels

safefood Website and Inbound and Outbound Marketing Strategy

To dispel misconceptions and encourage behaviour change, we needed a factual, interesting and accessible hub of information to educate and persuade women.

A hub was designed for the safefood website. (See Figure 9a) A quick link to this hub featured on the safefood website homepage for the duration of the campaign. 

This hub included information on:

  1. Folic acid facts
  2. Folic acid myths
  3. A folic acid quiz
  4. Real life stories from families who have been affected by Neural Tube Defects (NTDs). (See Figure 9b)
  5. Useful blogs on getting into the folic habit. (See Figure 9c)
  6. Useful links
  7. Folic acid FAQs
  8. Social media links for women to discuss and share

This information was pushed out through safefood’s newsletter, Twitter and Facebook, with paid spend carefully targeted towards our audience. (See Figures 10a and 10b)

Word of mouth remains globally one of the most trusted sources of information 20. Spreading the folic acid message through social media and encouraging sharing and conversation was key.

Expert video also featured on the safefood social media channels. These videos featured foetal medicine experts such as Prof. Jim Dornan, Prof. Michael Turner and Dr Rhona O’Mahony, who discussed a range of issues including NTDs, who should take folic acid and why it is important. Healthcare professional opinions gave credibility to the messages.

All advertising communications linked back to this hub where women could find out more information and get help to adopt a positive folic habit.

 

Digital advertising and search marketing

To ensure reach of the creative vehicle and message, digital display advertising was implemented across a range of high-traffic websites. We placed the message on publisher sites with high daily traffic from the target audience to ensure the message was seen every day (DailyMail, Evoke.ie, Her.ie, and Independent.ie), but also on sites that spoke to specific life stages – weddings and parenting websites and newsletters (EUMom, Shemazing, Weddings Online and NI4Kids). Retargeting and behavioural targeting was also utilised to ensure those who engaged with the advertising would be served additional advertising information. (See appendix ii for full list of websites that featured the display advertising).

A search marketing campaign using keywords relating to folic acid and key life stages for planning conception was delivered through Google AdWords. This ensured interest generated from all marketing was answered with the correct information on the safefood hub.

 

Public Relations

To launch the campaign, safefood organised events in ROI on July 20th, 2015 and in NI on July 27th, 2015. Twenty relevant influencers including health correspondents, news editors, parenting media, parenting bloggers, beauty media and bridal media attended the ROI and NI events. (See Figures 11a, 11b and 11c). Social media conversation relating to the campaign by attendees was high. Key patient advocates and foetal experts spoke at the events. #FolicFacts gave scale and visibility to the conversation.

 

Stakeholder Engagement and Point of Decision Materials

safefood developed a suite of design materials that pharmacies and manufacturers could tailor and print for their own in-store advertising, signposting folic acid more prominently to their own customers (at their own expense, as our small budget was spent). This enabled women to access the right information at critical behavioural decision points. Pharmacies and retailers were also encouraged to share the safefood campaign content through their own social channels like Facebook or Twitter during the campaign.

(See Figure 12)

19 Safefood. (2015). Analysis of vizzata testing for folic acid campaign.

20 Nielsen Global. (2015). Global trust in advertising. [online]. Available from: http://www.nielsen.com/content/dam/nielsenglobal/apac/docs/reports/2015/nielsen-global-trust-in-advertising-report-september-2015.pdf [Accessed 30 April 2015]. 

Appendix ii. Display advertising websites and networks

Site/Network

Environment

Daily Mail

Run of site, Showbiz, Femail

Evoke.ie

Run of site

Her.ie

Run of site

Independent.ie

Style section

Mirror NI

NI and Belfast Live

Belfast Telegraph

Parenting

Electric Media

Fashion, Beauty, Weddings, Celebrity

Yahoo

Behavioural targeting

 

We monitored both claimed and actual behavioural change through online research of 1,300 ROI and NI women, pre and post campaign, and through pharmacy sales of folic acid during our campaign. So how did the campaign deliver against its objectives?

 

1. Knowledge Change Through Education

We delivered 5.7 million digital display impressions with total cross-website reach of 903,284 women on the island of Ireland.

Social media posts were seen more than 1,086,000 times (Facebook 830,000, Twitter 256,000) with 25,000 engagements (sharing, commenting, liking these posts). (See Figure 13) The PR campaign generated 135 pieces of media coverage.

75% of women surveyed now believe all women who are sexually active should take folic acid. This figure was at 26% pre-campaign, representing an increase of 48%. (See Figure 14)

 

2. Attitude Change Through Persuasion

Conversation was generated around folic acid across the campaign period. On social media, there were 961 mentions of it (of which only 17% originated from safefood). There was a significant increase in Twitter mentions during the campaign. On launch day, 21st July, there were almost 8 times more Twitter mentions (227) of folic acid than on an average day (30). (See Figures 15, 16, 17)

On social media, women began to quote the facts about folic acid and share their own experiences. (See Figures 18, 19)

Importantly, women are now more open to discussing the topic of folic acid with family/friends; an increase from 22% to 26% pre and post campaign). (Figure 20)

 

3. Enablement – Enabling New Behaviours

Messages were promoted through digital channels with all information available on the website. There were 33,481 visits to the folic acid hub.

Of the 1,362 pharmacies that were contacted through the Pharmaceutical Society of Ireland mailing list, 42% opened the email and 11% clicked through to the campaign resources. (See appendix iii) Pharmacies were also active on social media promoting the campaign. (See Figure 21)

With regards to new behaviour, an increase of 10% was evident in women currently taking folic acid supplements. This is broken down as follows by those who are and who are not planning a pregnancy. (See Figure 22) 

This is a positive starting point in terms of behavioural change.

 

Commercial sales

Measurement of folic acid supplement sales indicated that consumption had increased. During the campaign period, folic acid sales increased by 26% on average compared to the same period in 2014. (See appendix iv).

 

Discounting factors

Given the significant increase in claimed positive behaviour change and increase in sales, it is prudent to discount other factors.

 

  1. Was there any other media coverage or campaigns on folic acid?

safefood’s campaign, including the stakeholder outreach, was the only folic acid campaign during this period. Clonfolic, a leading manufacturer of folic acid supplements, got behind the campaign by creating their own posters and radio ads that drove people to the folic facts hub. (See Figure 23)

 

2.Were folic acid supplements on price promotion anywhere at this time?

There weren’t any price promotions on folic acid supplements at this time.

 

3.Can we attribute the increase of sales of folic acid to an increase in pregnancies at this time?

No, there is no evidence to suggest an increase in pregnancies. In fact, the birth rate has declined 10% from 2010 to 2014 and 2015 Q1- Q3 is down -2% compared to same period in 2014. (See Figures 24 and 25)

 

Saving to society

 

  1. Economic impact of treating children with NTDs

 

The cost of treatment for children with NTDs averages €500,000 across a lifetime. With 70-80 NTD births occurring every year, this amounts to a cost of €40,000,000. Potentially, two-thirds of these NTD births could be prevented by women regularly taking folic acid supplements, meaning a saving of €26,500,000. Comparing this potential saving to the safefood campaign marketing budget of €75,000, this would amount to a return on marketing investment of 1:353.

Specifically relating to the results of the safefood campaign, an extra 7% (92,820) of women 18-45 years old (not currently planning a pregnancy) are now regularly taking folic acid supplements. Looking at this 7% of women not planning a pregnancy, and assuming 50% had an unplanned pregnancy, we calculated the potential impact of the campaign. (See Figure 26)

 

Also, the post-campaign research showed that an extra 3% of women who are planning a pregnancy are now taking folic acid supplements regularly. (See Figure 27)

More modestly, if this campaign prevents even one NTD birth, it is a return on investment of 1:6, i.e. €425,000.

 

2.Could spending the budget elsewhere have more effectively encouraged women?

With €75,000, safefood could have purchased 22,321 x 12 weekly supplies of folic acid supplements (average cost per supplement per day €0.04). So technically, safefood could have given 22,321 women a 12-week supply of folic acid, or given 11,161 women a 24-week supply.

This might seem like a lot; however, our post campaign research shows that 14% of women 18-45 years old (not planning a pregnancy) claim to be taking folic acid, an increase of 7% from the pre-campaign research. 7% amounts to an extra 92,820 18-45-year-old women on the island of Ireland. (See Figure 28)

 

This return on investment is calculated based on women taking folic acid for 12-24 weeks, whereas in reality, women would take it 52 weeks of the year, every year – of which the cost would be considerably higher.

 

Appendix iii. Participating pharmacies, manufacturers, health stores and retailers

Pharmacies:

O’Neills Chemist

Health Centre Pharmacy

McKeevers

Clear Healthcare

Boots NI

Lloyds Pharmacy

Boots ROI

Sam McCauley

Hickey's Pharmacy

Whelan’s Pharmacy

Confrey Pharmacies

Manufacturers:

Clonfolic

Beeline Healthcare

Health Stores:

Viridian Nutrition

Wholefoods Wholesale

Retailers:

ASDA (NI)

 

Appendix iv.  

Folic acid supplement sales

Folic acid supplement sales increased by 26% on average from the same period in 2014. The following pharmacies, manufacturers and health stores reported the following sales figures:

Pharmacy/ Manufacturer /Health Store

Sales increased by

Lloyds Pharmacy

30%

Confrey Pharmacy

47%

Wholefoods Wholesales

19%

Clonfolic

24%

Beeline Healthcare

10.5%

There are three key statistics that succinctly indicate the effect the campaign has had on attitudes and behaviour towards folic acid. (See Figure 29)


In addition, the qualitative response to the campaign creative would indicate how it has impacted a change in attitudes. (See Figure 30)

 

The creative testing also illustrated that a high number of women from the group (28) would be willing to share the videos online. Given the 90-9-1 rule (90% of online users passively consume, 9% of users contribute a little and 1% of users account for all the action) 21, this is a high level of participation for the safefood campaign.

Importantly, the women agreed that the main reason for sharing the videos was that it is an important message for all women and that advice is the best form of prevention. This is powerful given that these are key messages to encourage new behaviours. (See Figure 31)

This research also proved that our funny babies giving mammy-like advice was another key reason for engaging and sharing the campaign. (See Figure 32)

The commentary on social media would also indicate a positive change in attitude toward folic acid taking, with women encouraging each other to take folic acid and instilling the norm of taking folic acid supplements, regardless of your stage of life. (See Figure 33)

The impact of the campaign has been recognised by experts in this field. (See figure 34)

The safefood folic acid campaign has also been recognised by the eGovernment 2016 awards, winning the Marketing Award. The award recognises the pioneering work of digital leaders in the public sector, state agencies and local authorities. Commenting on the safefood "Babies Know the Facts about Folic" campaign, Kathryn O'Donoghue, Director of Ad Quality Operations EMEA, Google said,

 

“What was really nice about the campaign was not just the use of online channels with offline PR, but also the fact that they used humour to address a very serious issue.”

 

In conclusion, each objective was met, proven by the research data and sales figures. While this was a short campaign, with immediate visible results, it is in the long term where this campaign will leave its mark. Preventing NTD births will not only improve the health of our children but will also save money, which can be reinvested, to benefit society at large.

It is also important to note that the costs above do not factor the indirect emotional and financial costs of raising a child with a NTD.  For example, evidence suggests that caregivers of a child with a NTD worked an average 7.5 to 11.3 hours less per week. In addition, the estimated caregiver time costs for a child with spina bifida until age 25 range from €142,477 to €171,303.

 

21 Nielsen, J., (2006). The 90-9-1 Rule for Participation Inequality in Social Media and Online Communities.[online]. Available from: https://www.nngroup.com/articles/participation-inequality/  [Accessed 30 April 2015].

Past domestic and international campaigns for folic acid had employed sexual innuendo (Figure 35). But if women in Ireland found discussing pregnancy when it was planned a taboo subject, they would certainly be closed to it when it was the farthest thing from their minds. Instead, we analysed social networks to identify subjects that were culturally relevant, acceptable and popular to share, and used these as vehicles to carry our important message.

 

We also proved that finding a cost-effective way measure behavioural change, actual as well as reported, was possible and important, if not mandatory. 

Most women have heard of folic acid, but there’s confusion about what it is, does, when it should be taken and by whom; creating barriers to taking it as a supplement.

To address low consumption rates of folic acid supplements that aid the normal development of baby’s spinal cord and brain in early stages of pregnancy, safefood busted the folic myths with facts, using two powerhouses of the Internet: babies and Irish mammies.

75% of women surveyed now believe all women who are sexually active should take folic acid, an important message given 1 in 2 pregnancies are unplanned.

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