British Dental Journal 186, 436 - 441 (1999)
Published online: 8 May 1999 | doi:10.1038/sj.bdj.4800135

Subject Category: Patient management

Patient care: 
Marketing dental care to the reluctant patient

R Ashford1 & A S Blinkhorn2

  • The consideration of sequential consumer behavioural models helps to identify key issues relating to reluctant patients.
  • Dental practitioners need to consider a range of marketing communications for changing reluctant behaviour.
  • The OPTIMEM acronym offers a framework for the management of marketing communications within the practice.

There are many varying factors which impact on the behaviour of reluctant patients and the understanding of theoretical behavioural models can help to understand some of the key issues. This paper considers such models and the effective use of marketing communications in helping to change behaviour. The paper concludes with an acronym — OPTIMEM to help dental practitioners and practice managers plan realistic and efficient marketing communications within the overall management strategy.

In order to maintain a viable practice, general dental practitioners have to be astute managers, using their business skills and acumen to survive. However, research suggests that most of the managerial skills dentists use appear to have been learnt experientially.1 For example, marketing is one of the key management skills required in dentistry, especially as communication is one of the important parts of marketing management. Dentists should take time to consider the value of communication as a marketing tool.

This article will discuss how to communicate with 'reluctant patients' as they tend to demonstrate poor attendance patterns.2 In fact previous research suggests that communication messages for reluctant patients should be developed by sharing information, feelings and beliefs in positively framed messages from the dental team to the patient.3 There is also the added advantage that if reluctant patients can understand and act on information from the practitioner then it will be that much simpler to interact with interested patients.

This article is concerned with the behaviour of reluctant patients and the possible impact of marketing communications from GDPs. However, before looking into the role of communications within dental practices, some of the characteristics of these types of patients should be considered. Previous researchers in this area classified the reluctant patient as a 'rejecter' or 'waverer', defining them as:2

  • Rejecters — not interested in dental care unless they are in pain, they may be cost conscious and have dental phobias.
  • Waverers — do not attend on a regular basis as defined by the dental profession but who understand the benefits of dental care. They may accept advice when prompted.

A number of models have been developed to try and explain why people do or do not act on advice or seek medical care. One of the these models used frequently is the Health Belief Model (HBM).4 This is a conceptual formulation designed to help understand why individuals engage in a wide variety of health related actions. It has been criticised as being too simplistic and formulaic; ignoring factors such as fear,5 dental fatalism,6 and aesthetics,7 which are important concerns for patients. Figure 1 shows the basic components of the HBM which consists of four dimensions:

  • Perceived susceptibility
  • Perceived severity
  • Perceived benefits
  • Perceived barriers.

Although useful in identifying some of the key factors relating to health behaviour, the HBM could be classed as being psychosocial and really gives little help to those interested in understanding why patients do or do not take certain decisions. It is certainly time for dental researchers to look beyond the traditional HBM, therefore other behaviour models should be considered.

In the field of marketing there are a number of behavioural models which could help dentists understand the stages of the general decision-making process.8Figure 2 illustrates a useful and fully validated American model9 which shows the sequential consumer decision-making process, and the many variables which may have some influence on final outcome. It refers to different stages of behaviour:

  • Need recognition (which could be pain or concern about appearance)
  • Search (for information/new dentist/ appointment)
  • Pre-purchase evaluation (discussions with families/friends/colleagues about good or bad dentists in the area)
  • Purchase (attendance at a dental practice)
  • Consumption (treatment experience)
  • Post-purchase evaluation (perceptions of treatment/experience after the visit has taken place)
  • Positive satisfaction (may result in a change of purchasing behaviour)
  • Dissatisfaction (may be likely to result in rejection or reinforced 'waverer' characteristics caused by the patient considering pre-purchase alternatives linked to beliefs, negative attitudes and future non regular attendance intentions).

This is a more realistic model than the HBM as it also considers other influences such as memory, environment and individual differences. The first part of the model considers the importance of communication. It shows that a patient (or consumer) is exposed to a range of communications, such as general media, and planned communications such as dental brochures, leaflets and reminder letters.

Successful marketing communications should allow patients to follow the stages shown in the second part of the model shown in figure 2. The key points are:

  • Exposure (the exposure to all general and specific communication messages)
  • Attention (communication messages should draw attention to personal benefits)
  • Comprehension (messages should be easily and fully understood)
  • Acceptance (they should be related to the beliefs and values of the patient)
  • Retention (the messages should be strong enough to be retained and will have some bearing on the patient's search and pre-purchase evaluation process).

Although figure 2 is a rather busy model, it highlights the stages of a highly complex decision process for any patient and looks at the impact of communication. However, one could argue that the key problem related to this process and the reluctant patient, is that there is often no need recognition. If someone is not in pain or sees little benefit in dental care then this would explain the resulting non-attendance. This is an important point when thinking about the timing of communications to reluctant patients.

A number of studies have been undertaken using marketing techniques to improve the value of dental communications to reluctant patients. Two different categories of marketing tools have been employed which are mass media techniques and internally generated communications.


Mass media campaigns

Much of the research relating to mass media communications (such as adverts appearing in newspapers, magazines, television, radio, cinema or outdoor posters) by GDPs comes from American sources.10, 11, 12 These studies tend to concentrate on their home market and were prompted by the American Dental Association's changed Code of Ethics, removing the restrictions on advertising in 1979. The effectiveness and moral integrity of such advertising campaigns has been questioned13, 14 with a further study concluding that radio, television and newspaper advertisements were not as effective as internally generated communications such as newsletters, press releases and direct letters.15

An interesting British study aimed to test the use of generic advertising to overcome some of the perceived barriers to dental care for rejecters and waverers.2 Its aim was to increase the uptake of general dental practitioner services by those people who did not attend regularly. A promotional campaign (costing £210,000) featuring Phil Cool, a well known comedian, was commissioned. The message was not to actually promote dental health but to improve the image of dental services by informing the public that the barriers to care are not as they perceived them. Therefore a visit for a dental check up should be the outcome.

This was done by 'repositioning' dental services using the slogan 'dentistry is not what you think it is; it has changed in recent years' — a positive message. This was coupled with a 'free dental update' which was a pass giving an individual permission to approach a dental practice and discuss any aspect of dental treatment without any obligation to actually have the treatment. The campaign used outdoor poster sites, local newspaper advertisements and door-to-door leaflet drops. It included 'teaser' posters — this is where posters are changed weekly, building up a changing picture without saying what the advert is all about — in other words, teaser posters aim to initially gain interest before the main message is given. This research was conducted in Dudley, West Midlands and it was assumed that reluctant patients from the lower socio-economic groups would be the main respondents.

The results showed that the awareness of the campaign was high, but there were equally high levels of misinterpretation which led to rejection by many in the target population. The campaign did not achieve its stated objective — which was to encourage the non-attenders to go to the dentist. However, it did persuade a group of people, 'waverers', who were dentally conscious but had not attended for some time, to seek advice. The general conclusion of the research was that a friendly approach, the provision of treatment in a confident way and the creation of effective relationships put people at their ease and was therefore an effective marketing communication tool.

Another British study16 used an advertising poster campaign (costing £120,000) with the objective of increasing the uptake of dental treatment among young adults at work, young mothers (socio-economic grouping C2, D & E) and their children up to 11 years of age. Again, the results showed that although the campaign had raised awareness, there was very little change in dental visiting behaviour.


Internally generated marketing communications

Studies have shown that dentists should be considering the use of tangible internally generated communications,17 such as the practice brochure, business cards, in-house information centres (a glass enclosed case designed to give information about the practice and the staff's continuing education), thank you notes and direct mail. Further studies18, 19 highlight the impact of personal communication skills as part of the marketing effort.

The ability of dentists to interact well with patients, especially with anxious individuals, or those holding negative attitudes to dentistry, may result in increased patient satisfaction, leading to retention of these patients with the practice. Many dentists are aware of their own lack of knowledge and training in social and communication skills.18 In a recent American study,19 of professional and patient views of dentistry, it was found that of the 3,275 patients surveyed, 1,836 (56%) patients mentioned the interpersonal caring (eg gentle, patient and friendly) in response to the open question 'What do you like most about this (their) dentist?' This research concluded that although dentists should provide skilful dentistry, they should take the time to communicate articulately and clearly with patients ie showing patients that they are cared for. This is an important finding as other studies have shown that people respect their own dentist more favourably than dentists in general.20, 21, 22 This may explain the negative media image of dentists, as it may reflect how patients view dentists in general rather than their own.


Framing messages

It is essential to consider the actual message which a communication aims to project. The 'framing' of the message is very important.23, 24 A decision about whether the message should be considered in relation to prevention, detection or cure should be analysed. The message should be 'framed' in a positive manner (gain-framed). A poster in the waiting room saying 'Do you want healthy, attractive teeth?' (showing a good mouth) is an example of a gain-framed message, rather than 'Do you want your teeth to end up like this?' (showing a problem mouth) which is a loss-framed message. However, the message should not only be gain-framed, it should be given in enough depth to be accepted, believed and relevant to the patient if it is to have any effect on behaviour.23 It is a salutatory lesson for the dental team to take a close look at posters in the waiting room, practice brochures and reminder letters. Indeed, dental practitioners should consider their own practice communications in terms of projecting gain-framed messages.


So what can dentists do to communicate messages to the reluctant patient?

It has been acknowledged25 that an understanding of the decision process is vital if the correct type of message is to be transmitted to modify any behaviour. Indeed, all marketing communications messages need to be underpinned by an understanding of the patient's decision process if they are to be effective and this is essential when considering the reluctant patient. Referring to the American behavioural model in figure 2, dentists should be aware of the environmental variables and individual differences which impact on the patient's decision process. As the model illustrates, the patient's memory will recall the processing of information from any communication (or exposure to stimuli such as practice letters, brochures, adverts), which will lead to the understanding, believing and ultimately remembering of any messages which they convey. Therefore, dentists should plan their marketing communications to commit desired messages to memory which will, in turn, impact on the patient's decision process.

In light of recent previous research relating to male patients displaying irregular attendance behaviour,26 it is important to also consider the communications strategy related to the messages and tools used in practices, as much of the current communications are perceived as negative. Therefore, to ensure that the practice communications are effective, dentists should follow a systematic planned approach.

Communications objectives

It is important that dentists carefully evaluate their current letters, brochures, Yellow Pages advert, office stationery, business cards, promotional materials/ stickers, considering the key objectives which dentists want to achieve by their communications. For example, the main objective could be to convey a caring, friendly and convenient service to help to reduce the patient's anxiety and fear of the unknown. If this is to be the main objective then each form of communication should endorse that message.


The messages projected by each form of communication should be consistent and planned to achieve the objectives set. Therefore, it is important to identify what perceived messages are being received by reluctant patents from the current Yellow Pages advertisement, reminder letters or from the dental receptionist when making an appointment. In other words, the dentist needs to consider exactly what messages should be projected and what messages are projected — a list of ideal objectives can be formed from this.

Communications tools and costs

An in-depth look at the current methods or communications tools used should be undertaken. The costs of these methods should be considered, remembering that verbal communications can be very effective, in terms of cost and strength of message.27 There are a wide range of such communications tools available, such as:

Business cards and stationery should reflect the culture and image of the practice and include a logo, emergency line, map illustrating convenient parking, opening hours and any special services. Include the first names of the reception staff as well as the dentist if a friendly message is to be projected. This could communicate information which patients (especially reluctant) tend to require to minimise the risk of uncertainty.

Letters (adopting a friendly tone) should be used to send to patients after their initial visit as well as for their recall visit, thanking them for attending and emphasising any other required messages. The aim should be to communicate a caring tone rather than a functional or impersonal message.26

Promotional material or give-aways from the practice, should have the name and logo printed. It is often possible to arrange sponsorship of these by local firms such as leisure centres, to stretch the budget further. These could be used to reinforce the practice image in the eyes of the patient.

Staff communications (verbal communication) are one of the most powerful internal marketing tools available. Reception staff should be encouraged to add the personal touch when dealing with a patient — using pleasantries such as taking an interest in the patient's journey to the practice, reassuring them about the treatment and explaining basic information when completing any forms.

In-house information centre is a useful internal tool. This is a board or cabinet which houses information relating to the practice staff and dentists, such as documentation about recent educational/ training courses which staff have attended. Apart from communicating success, this would also reassure the patient of the current skills of the service providers, again minimising the 'potential risk' of harm in the eyes of the reluctant patient.

Telephone on-hold information can be effective also. If possible, use the on-hold recordings to turn a negative situation into an educational one, perhaps explaining about new developments in the practice or dentistry in general, raising awareness of such innovations.

Practice brochures can be expensive but a tool which should convey the practice image and values, subtly selling the benefits of attendance. They should be informative and contain the policies and attributes of the surgery, including the logo and photos of all of the staff to encourage a caring, friendly approach.

Press releases in the local press can stimulate interest with the target patients. Regular articles should be written, for example, the new techniques now offered at the practice, a before and after story (with pictures), a 'dad and lad' initiative (emphasising the benefits of a double appointment), pictures of the 'friendly' staff and dentist(s) celebrating an anniversary (eg the practice operating for 20 years communicating stability and assurance of standards to the reluctant patient).

An in-house camera can be a useful marketing tool when used to give the patient an 'after' photo at the conclusion of a course of clinical care. Again this can project and create a positive, caring image.

Measurement of effectiveness

As with all strategies it is important to check the effectiveness from time-to-time. Communication strategy is no different. Once it has been launched the results should be monitored. This could be completed by reviewing, on a twice-yearly basis, the number of new patients who have returned and are continuing to attend on a regular basis. A 'quick' questionnaire for patients as they are waiting for treatment could investigate their perception of the messages which they feel that they are receiving from all the practice staff. These should then be reviewed against the objectives which the practice team have set; for example, the objective could be to encourage a positive image of dentistry and the questionnaire could monitor achievement. Obviously, if there is a short-fall in the objectives set and those met, then further analysis of the communications should be undertaken. In other words, the messages should be reviewed and refined on a regular basis.

This article does not report on new empirical research, but considers previous successful work in health communications and shows the complexity of communications aimed at changing behaviour. Although different studies vary in their results (related to communications), a very recent study, from general health education, concluded that both interpersonal (verbal communications) and mass methods (advertising) of health education can contribute effectively to the promotion of health.28 However, it is unrealistic to think that mass media communication tools are suitable for individual dental practices. The costs are too high, unless, of course, a group of practices joined together to commission a media based project. Dentists should look first at their verbal and written communications with view to a planned approach, with the intention of 'converting' the 'rejecter' or 'waverer' when they come in for emergency treatment.

With this in mind, dental practitioners should consider their communication skills as part of an overall management strategy, recognising the differing buyer behaviour processes of their patients. Communications should be positively-framed and stress the personal benefits of dental services as previously identified.29 All of the dental team (including dental nurses and receptionists) should be encouraged to think about their verbal communications and the messages given to patients, especially to the reluctant ones.

The acronym — OPTIMEM — covers most of the areas discussed in this article (Table 1). This could be used with practice staff to help formulate their marketing communications strategy when considering reluctant patients.

This general article has sought to stimulate the dental team to consider marketing communications targeted at the reluctant patient, and the need to develop key marketing communication skills. The British Dental Journal's Management Research Initiative (MRI) has been a successful trail blazer, but more joint work between academics in management, marketing and general dental practitioners is required. Communications are only a small part of the marketing and management process but an important one which can bring benefits to a practice, improving both the patients' and staff's interest and expectations.



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  1. Senior Lecturer, Department of Business and Management Studies, The Manchester Metropolitan University, Crewe+Alsager Faculty, Crewe Green Road, Crewe, Cheshire, CW1 5DU
  2. Professor of Oral Health, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester M15 6FH

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