Reaching Soldiers with Untreated Substance Use Disorder: Lessons Learned in the Development of a Marketing Campaign for the Warrior Check-Up Study

Abstract

The Warrior Check-Up, a confidential telephone-delivered intervention, is designed to reach active-duty soldiers with untreated substance-use disorder at a large US military base. This paper describes the development and successful implementation of the study’s marketing strategies at the recruitment period’s midpoint (2010–2012). Qualitative analyses of focus groups (n = 26) and survey responses (n = 278) describe the process of campaign design. Measures of demographics, media exposure, post-traumatic stress, anxiety and depression gathered from callers (n = 172) are used in quantitative analysis assessing the campaign’s success in reaching this population. Implications, limitations, and suggestions for future research are discussed. Department of Defense provided study funding.

INTRODUCTION

The United States Military faces public health challenges in addressing substance use disorders among active-duty personnel (Institute of Medicine, 2012). Over the past decade of ongoing wars, stressors, including multiple deployments, have taken a psychological toll on service members. At the same time, rates of substance use disorder have climbed, causing additional burdens to service members, their families and the military at large (Bray et al., 2009). Despite increased substance use in the Army, few soldiers are engaging in treatment (the terms “soldier” and “Army personnel” will both be used to denote individuals of any rank with active-duty status in the US Army). TheWarrior Check-Up (WCU) is a brief intervention to promote behavior change among soldiers not engaged in substance abuse treatment. This paper describes the development and successful implementation of a marketing campaign designed to engage this difficult to reach population.

With 20% of military personnel binge drinking on a weekly basis and 12% reporting use of illicit substances in the past month, the Institute of Medicine (2012) recently issued a major report that declared substance use in the military to be a public health crisis (Bray et al., 2009; IOM, 2012). On one Army base, 36% of soldiers were identified as engaging in hazardous or harmful alcohol use as measured by the Alcohol Use Disorder Identification Test (Mattiko, Olmsted, Brown & Bray, 2011). These rates have risen with the increase in combat deployments over the past decade. Calls have been made for structural and cultural changes in the military to manage the problem (Bray et al., 2009; IOM, 2012; Jacobson et al., 2008; Lande et al., 2008; Santiago et al., 2010).

Substance misuse has serious consequences for the military. Lost worker productivity, the most commonly endorsed consequence of alcohol misuse across all military branches, is reported by 32% of heavy drinkers (Bray, 2009; Williams, Bell, & Amoroso, 2002). Further, substance misuse increases burden on medical and installation commands, as it is linked to increased medical disease burden, mental healthcare utilization, legal problems, driving under the influence, and perpetration of domestic violence (Bray, 2009; Foran, 2012; Possemato, Wade, Andersen, & Ouimette, 2010).

Despite the prevalence and impact of problematic substance use, few receive treatment. Of 43,342 soldiers screened for alcohol abuse post-deployment in 2008, nearly half (n = 19,744) were found to be at risk for alcohol abuse, yet only 215 (1%) were referred to the Army Substance Abuse Program (ASAP) (Clinton-Sherrod, Barrick & Gibbs, 2011). Moreover, rates of self-referral for alcohol use disorder treatment are low (IOM, 2012; US Army, 2009).

In the military, the barriers to substance use disorder treatment are formidable. Key aspects of military culture and hierarchy, as well as actual or perceived adverse consequences for fitness for duty status, promotion, command assignment, and security clearance, converge to dissuade active duty personnel in need of behavioral health services from requesting help (Britt, 2000; Castro, 2006). Stigma and negative beliefs about treatment are common. Seeking assistance for a substance use disorder is commonly seen as a sign of personal weakness demonstrating an inability to handle stressors faced by one’s fellow soldiers (Gibbs, Olmsted, Brown, & Clinton-Sherrod, 2011). Fear that disciplinary action will be taken against someone who seeks treatment add to these barriers (Hoge et al., 2004; Vogt, 2011; Zinzow et al., 2012).

In addition to negative beliefs about treatment, practical barriers also exist. Because ASAP is not confidential and occurs during regular work hours, those contemplating requesting treatment may be apprehensive of the consequences of their commanders being notified and of their fellow unit members possibly believing they are attempting to shirk their duties by self-referring to treatment. Social isolation may exacerbate the experience of stigma when a soldier stops drinking and is thus excluded from one of the most common forms of bonding among Army peers (Gibbs, Olmsted, Brown, & Clinton-Sherrod, 2011).

Confidential treatment options, currently being tested in the Army, show promise for reducing barriers related to career damage and stigma. When it has been offered, confidential treatment has increased self-referral (Gibbs & Olmsted, 2011). These findings make a compelling case for designing and evaluating innovative approaches to promote motivation for change, voluntary treatment entry, and completion (IOM, 2012).

The Present Study

The WCU is a study comparing a motivational enhancement intervention and a psychoeducational intervention both being evaluated in a trial funded by the Department of Defense (DoD). Brief, delivered by telephone, and offering the option of anonymous participation, the WCUis designed to reach soldiers who have concerns about their use of alcohol or drugs, but are not enrolled in treatment. The study has two main goals. The first is to develop a marketing campaign that reaches and resonates with members of this population. This will be measured by the number of untreated soldiers who call the publicized phone number, taking the first step toward help-seeking for their substance use. The longer-term goal is to complete a randomized clinical trial evaluating the interventions described above and adapted for soldiers with untreated substance use disorders.

This paper will focus on the development and evaluation of an outreach campaign. This goal was completed in two phases. In the first, focus group discussions and openended survey responses were analyzed to provide qualitative guidelines for creating an effective marketing plan. During the second phase, these guidelines were used to develop, implement, and evaluate the campaign. Explanation of methods and findings for both phases will be followed by discussion.

A “check-up” approach is a specific variant of motivational enhancement therapy (MET) originally developed to reach and attract voluntary participation from untreated heavy drinkers (Miller & Sovereign, 1989). The “check-up” approach is framed as a no-pressure opportunity to take stock of one’s experiences and think through one’s options. As such, marketing is an integral part of the intervention and has been successfully applied as a means for attracting people struggling with, but ambivalent about changing, high risk behavior, e.g., adults and teens with marijuana use disorders (Stephens, Roffman, Fearer, Williams, Picciano, & Burke, 2004; Walker et al., 2011), gay and bisexual men engaging in risky sexual behavior (Picciano, Roffman, Kalichman & Walker, 2007), and male domestic violence perpetrators (Mbilinyi et al., 2008). The WCU is an adaptation of the MET “checkup” model and is being tested as a means of engaging active-duty Army personnel stationed at Joint Base Lewis- McChord in the state of Washington.

PHASE 1: CAMPAIGN DEVELOPMENT

The first year of the trial was devoted to designing recruitment products to reach the target population. During that time, and continuing throughout the trial, staff employed by the Army Substance Abuse Program (ASAP) at the base were highly instrumental in training the researchers about military culture, helping to ensure that the project’s marketing strategies were relevant and appropriate. Together, the researchers and ASAP staff members brainstormed a wide variety of potential marketing components, e.g., project names, logo designs, images, and messages. Subsequently, the members of three focus groups reviewed draft iterations of the project’s marketing products. Finally, once recruitment had begun, additional feedback was sought by surveying members of the Army community attending a large on-base event.

Concepts and theory from the field of social marketing guided this developmental process. Social marketing uses communication strategies to increase knowledge or awareness, change thoughts, and/or stimulate behavior change (Kotler & Roberto, 1989). McGuire’s (1985) communication and persuasion matrix offers a useful conceptual framework to develop marketing strategies, particularly those inclusive of a “call to action” such as prompting Army personnel concerned about or questioning their substance use to take a first step toward change.

McGuire’s matrix incorporates inputs, consisting of five communication components, and outputs, i.e., the desired outcomes. The five communication components include: (1) receiver, the intended recipient of the message, with characteristics such as gender, age, race, rank; (2) message, the content being communicated (e.g., focusing on the negative impact of substance abuse, highlighting benefits of changing the negative behavior, and/or relief of talking to someone who understands); (3) channel, the means or strategies used to deliver the message to the receiver (e.g., advertisements, briefings, flyers); (4) source, the institution or person sending the message; and (5) target, the anticipated outcome (i.e., what action the receiver should be prompted to take).

Use of the matrix gave rise to a number of recruitment-related questions. Who are we trying to reach? What thoughts go through the mind of a soldier concerned about his/her alcohol, drug, or prescription medication use? What hopes and fears do soldiers have about reaching out for help? What message will likely resonate with this soldier and prompt a response to an ad? What variations in marketing will be needed to recruit an inclusive sample with reference to gender, age, race, and rank? What words and images will likely be counter productive? What means of message delivery will be most likely to reach these soldiers? Where are the best locations to place these messages?

Phase 1 Methods

The University of Washington’s institutional review board and the Army Human Research Protections Office approved both the clinical trial and the recruitment campaign development and evaluation process.

Focus Groups

Three separate focus groups were conducted: Army personnel who were current alcohol or drug users but not engaged in treatment (“nontreatment seeking”; n = 10), Army personnel who had completed or were currently enrolled in substance abuse treatment (“treatment-engaged”; n = 7), and Joint Base Lewis-McChord substance abuse and behavioral health service providers (“providers”; n = 9).

Participants were recruited through newspaper advertisements, flyers, and word of mouth from collaborators at ASAP. Advertisements made clear that participants would not be asked personal questions about their own use of substances and that personnel of all ranks, genders, and racial and ethnic backgrounds were encouraged to call.

Applicants were screened and selected to enhance diversity in terms of race/ethnicity, age, gender, and military rank, when possible. Of those invited, several were unable to attend due to scheduling conflicts. Only one female screened for the two focus groups of soldiers, but she was unable to attend. Consequently, the nontreatment-seeking and treatment-engaged groups were entirely male, whereas the provider group was split with five males and four females. The provider group also showed the most diversity of age with participants ranging from 24 to 60 years old. Both soldier groups included a participant in his forties, while the others ranged in age from 22 to 33. Of the 46 individuals who screened, only 5 identified as Hispanic, 2 of whom participated in the nontreatment-seeking focus group. The provider group was 88% and both soldier groups where approximately 60% Caucasian, which matched the racial distribution of the screening sample. Lastly, the majority of those screened for participation in the nontreatment-seeking group were higher ranking enlisted soldiers (E6 and above). One Private (E1) participated in the treatment-engaged group and the remaining soldiers ranged in rank from Specialist (E4) to Staff Sergeant (E6).

Each focus group lasted two hours and was held on base at an Army housing community center, outside of regular work hours. Focus group participants were compensated $75 for their time if they were participating in off-duty hours.

After introductions of UW staff, an orientation to the focus group, and review and signing of consent forms, drafts of six mock advertisements were provided to the participants. This original set of ads consisted of basic adaptations of marketing materials from the research team’s prior “check-up” studies with other populations.

Participants were first directed to look at each advertisement and record initial reactions individually without group discussion. Each ad was then discussed with the group as a whole. The focus groups ended with discussion centered on where and how the program should be promoted. Group facilitators guided the discussion to cover each of McGuire’s (1985) communication components: receiver (target population), message (content and appeal), source (institution conducting the study), target behavior (suggested action for the receiver), and channel (medium for relaying the message to the receiver).

Survey

After recruitment had begun, project staff sought additional input from soldiers stationed at the base. The study team set up a booth at a large on-base event that all soldiers were required to attend. Large signs were posted advertising a raffle to win a $150 gift certificate to a large local sporting and outdoors retailer. Those who entered the raffle were invited to answer a brief anonymous pen and paper survey. The primary purpose of this informal pilot test was to gain direct reactions to ads as well as suggestions for marketing channels from a convenience sample of Army community members. Respondents were asked to look at four project ads and then answer several free response questions: (1) Which ad do you think would get soldiers concerned about their drinking or drug use interested in the study? Why? (2) Where do you suggest we advertise on base and in the community? (3) Besides these ads, what ideas do you have for getting the word out about this project?

Data were collected from 279 respondents during the one-day event. Privacy concerns and the fast-paced, high volume collection period prohibited the gathering of demographic data. However, only soldiers, Army spouses and service providers working on base were allowed to attend the event, so it is understood that all respondents were members of the Army community and had first-hand knowledge of the base and its culture.

Analysis

Guided by McGuire’s framework, rudimentary qualitative analysis was used to first categorize data from focus group sessions and survey responses into categories pertaining to receiver, message, source, and channel. Coded quotations were then grouped to identify the emerging concepts or recommendations within each category of McGuire’s framework. Differences in data between groups were noted to highlight the codes or concepts that were most salient to specific groups. Lastly, channels suggested by survey respondents were coded into groups that were simply tallied to find the most frequently suggested recruitment avenues and locations for print media placement.

Phase 1 Findings

Again using McGuire’s framework, data obtained from focus group sessions, and community members’ survey responses were categorized as pertaining to receiver, message, source, and channel. Qualitative review of responses did not reflect systematic differences between groups.

Receiver

Concern about stigma among members of the target population was the most salient issue to emerge from all focus groups. Multiple members of each group (25%; n=7) suggested including assurances of confidentiality and noting that the WCU offered a “nonjudgmental” experience. “Tell [them] they can get help without someone breathing down their neck,” a member of the treatment-engaged group suggested.

Other than the unifying concern over stigma and confidentiality, participants stressed that soldiers face a wide variety of unique stressors. A number of the draft ads presented to the focus groups featured discussion of deployment-related stress (e.g., “The memories of war seem a lot to bear on my own. If this sounds familiar, sometimes it helps to talk. . .”). Members urged the researchers to not focus only on soldiers who had been deployed. As one member currently in treatment commented, “It’s not only deployments. You drink because of stress, relationships, and being away from family and friends.” Indeed, many of the soldiers who subsequently enrolled in the project had not been deployed, but nonetheless faced significant stressors and struggled with anxiety, depression, isolation, post-traumatic stress disorder (PTSD) symptoms, and concern about stigma.

Message

Following McGuire’s Communication Matrix, before developing a message it is necessary to consider the outcome that the message is intended to elicit. In this case, that outcome is a behavior, i.e., calling the study’s toll-free number to learn more about the project. Getting to that behavior, however, is likely to first require that the receiver who recognizes the existence of a problem, but is ambivalent about making change, perceives the “check-up” as both safe and desirable. An initial call to a substance use service provider of any sort is a major step. Therefore, the “check-up” message must help the ambivalent viewer perceive that there will be personal value from making that call.

With this in mind, four elements of a message emerged from discussions with focus group members and survey respondents. The message must: (1) connect with the viewer and spark self-reflection, (2) convey hope for change, (3) lower the threshold for seeking help, and (4) offer assurance of the program’s legitimacy.

Connect with the viewer and spark self-reflection

Seven soldiers and one provider emphasized that messages need to convey respect for the receiver and honor his/her service. Perceiving too much emphasis on pathology in one draft ad, one focus group soldier stated discouragingly, “They think I’m broke.” A treatment-engaged soldier wrote that an ad which mentioned drinking as a way to “numb memories of war” would be “discriminating to soldiers if used off-post,” i.e., reinforce a negative stereotype. Another soldier currently in treatment said that he would like an ad that “leaves a person feeling that they are a good soldier even though they may need help.”

Several soldiers stressed the importance of including an image of a soldier in uniform with a combat patch, a symbol of having been deployed (Figure 1). However, a concern among service providers was that images of soldiers in combat and/or carrying a rifle in a war zone would be too invasive because they could trigger a negative reaction or memory. One provider specifically suggested “the memories of war line” should be deleted. A number of participants, primarily from the treatment-engaged group believed ads which directly discussed deployment and emotional numbing from combat confused the study’s focus. “Is this [for] alcohol or PTSD or both – not sure,” was one soldier’s response to early advertisements. At the same time, members of each focus group and a number of survey respondents agreed that showing a uniformed soldier was a good way to immediately connect with the target audience.

FIGURE 1.

“Signature Ad,” adapted from an earlier ad to feature a combat patch.

Some of the input favored ads that reference specific substances, e.g., alcohol or prescription medication. The soldiers’ groups suggested ad content asking viewers to consider how alcohol affects work responsibilities, loved ones, and life goals as a means to connect and spark self-reflection.

In terms of advertisement design, simplicity, visual appeal, and a concise and clear message were emphasized. Ads with unique or provocative imagery were favored. The most highly rated ad presented to survey respondents was one depicting a young man trapped in a bottle of beer (Figure 2). Second was an ad showing a bottle of pills caught on a fish-hook and asking, “Worried you might get hooked?” (Figure 3). Community members made positive survey comments about an ad depicting a young female soldier and another with a young man in civilian clothes, however, the most popular ad received over three times the number of votes as these two more conventional images combined. Many preferred the top two ads because they were either “funny,” “eye-catching,” or “creative.” These ads attracted the viewer, and their unique imagery prompted more thought than the other ads.

FIGURE 2.

“Bottle Ad,” most-preferred by survey respondents.

FIGURE 3.

“Hooked Ad,” targets concerns about prescription misuse.

Convey hope for change

Strong criticism came from focus group members, five from the treatment-engaged group and one from both of the other groups, who believed a draft ad did not offer hope for change or improvement. A number were concerned about ads mentioning that the WCU was a study. One soldier asked, “Will I be helped, or studied and made a stat?” Another concern related to the prospect for real change. Would WCU participants see an ad and believe they would just be talking about their problems? One soldier who was receiving treatment said of a specific ad, “I like how it refers to other substances. It means hope for things besides just alcohol.” Another soldier urged “Don’t be depressing,” suggesting the need for a positive message.

Further support for providing a message of hope may be extrapolated from survey respondents’ overwhelming preference for an ad which asked, “Looking for a way out [of the bottle]?” (Figure 2). This was the only ad to reference a path to recovery rather than consequences or ambivalence.

Lower the threshold for seeking help

A final and critically important element of a social marketing campaign to encourage help-seeking is to lower the threshold for services. As reported previously, focus group participants encouraged including “confidential” and “nonjudgmental” in ad text. This feedback reiterated the concern held by active-duty personnel about potentially negative career consequences if they engage with Army social services. Additionally, stating clearly in ads that participation is “all by phone,” was seen as lowering the threshold for engagement.

Source

Perspectives for conveying the fourth important part of an effective recruitment message, a sense of the program’s legitimacy, falls under what McGuire describes as the Source component. To comply with Institutional Review Board requirements, each ad identified the project as a study being conducted by the University of Washington. Fortunately, focus group participants saw the university’s role as giving the project credibility and reinforcing the assurance that military Command is not involved.

The draft ads seen by focus groups and survey respondents also included the phrase “funded by the DoD,” which was a required part of informed consent but not advertisements. Later feedback from survey respondents conveyed concern about this phrase as it relates to confidentiality. If the DoD funded the study, would the Army have access to identifiable information about participants? Soldiers in the focus groups did not raise this concern. On the other hand, on-base service providers and commanders communicated to the researchers that noting the DoD funding source on posters provided the legitimacy needed to justify displaying marketing materials at various locations under their control. It gave the study official, military-approved status.

Channel

The 279 survey respondents offered 657 suggestions regarding marketing channels. As seen in Table 1, the most commonly suggested channel identified by the base’s community was AAFES (Army and Air Force Exchange Services) locations on base such as the Post Exchange and other retailers. AAFES was followed by paid media placement such as television commercials and bill-boards. Briefings were the third most endorsed channel. The “other” category encompassed a wide range of suggestions such as bars/clubs, restrooms, dining facilities, on-base circulars, and libraries. Identifying specific marketing locations or channels was not a primary topic in the focus groups.

TABLE 1.

Survey respondents’ suggested marketing channels

	N	%
AAFES locations (PX, shopettes, commissary, class 6, etc.)	192	29.2%
Paid commercial media placement (TV, billboards, fences on post)	100	15.2%
Briefings (readiness/reintegration)	64	9.7%
Gyms & rec centers	37	5.6%
Unit/company/brigade areas and barracks	55	8.4%
Facebook/internet	29	4.4%
MWR facilities and events (other than gym)	28	4.3%
Word of mouth (family, friends, commanders)	26	4.0%
Welcome and processing center	21	3.2%
Medical facilities (clinics, hospital, pharmacies, etc.)	18	2.7%
On-post service agencies (ASAP, ACS, ACAP, BOSS, FRG’s, etc.)	17	2.6%
Other (restrooms, banks, DFACs, etc.)	70	10.7%
Total	657	100%

Note. 297 respondents provided 657 suggestions.

PHASE 2: CAMPAIGN IMPLEMENTATION AND EVALUATION

In the next phase of the project, study staff revised ads, created new ones, and pursued marketing channels according to the guidelines established in the first phase. Then, after nearly 2 years of implementation, an evaluation of the campaign described who it reached in terms of demographics and clinical symptom severity, as well as channel effectiveness. Evaluation methods and findings will follow a discussion of the implementation process.

While project ads portray soldiers wearing uniforms with combat patches, the staff learned to be wary of making any assumptions about the experience of being in a war. A statement familiar to those who have worked with soldiers is that “no one can understand what war is like who has not been through it.” This points to the necessity of deference to service in combat without presumption of its personal meaning.

Language in early advertisements that had asked rhetorical questions about problems related to combat exposure was dropped entirely. Instead, subsequent ads directed rhetorical questions at soldiers’ ambivalence about confronting problematic substance use (“Wonder if you might drink or use too much?” “Questions about your use of alcohol or drugs?”), and potential negative consequences of use (“Alcohol or drugs slowing you down?” “Alcohol or drugs holding you back?”) The intention was to elicit the viewer’s thoughts specifically about substance use behavior rather than past combat experiences.

Responding to feedback about simplicity, later ad materials greatly reduced the number of words per ad from over 70 in the first round to less than 40 in later versions. Amore concise message had a greater likelihood of reaching the intended audience. But, because the project’s messages were more extensive than any one ad could convey, multiple versions of ads were developed. With ample ad placement of multiple versions, viewers were exposed to all of the project’s messages but in smaller, more easily digested doses. Additionally, a webpage was created that includes all project ads for those seeking more information prior to picking up the phone.

Lastly, survey respondents’ strong preference for ads depicting a young man trapped in a beer bottle and pills caught on a hook suggested that somewhat provocative images had more impact. It was hoped that illustrating a problem in a novel way had a better chance of bypassing one’s usual defenses and striking a chord of self-reflection, so these ads were used prominently in the campaign.

Though discussing a serious subject, project staff learned from WCU participants that it was important to keep the tone of ads from becoming dour. This project sought participants who were ambivalent about change and likely not fully perceiving the darker side of their use. One who is ambivalent about change – seeing both positive and negative consequences of use – would likely be put off by too grim of a message. Later ads conveyed messages that recognize the viewer’s potential for a life with fewer negative substance-use related problems.

To avoid concerns of a time burden or judgmental attitudes, the WCU was described in ads as a brief and nonjudgmental opportunity to take stock of one’s behaviors and explore options. A tagline (“Take stock and explore your options”) was added to emphasize a no pressure conversation in lieu of committing to behavior change. The term “check-up” in the project name was intended to differentiate this conversation from substance abuse treatment. The program’s logo contains an image of a telephone and the ads included the phrase “all by phone.” These additions underscore a minimal time burden associated with participating and offer another level of protection against disclosure of problems, potential career damage, and social stigma.

All recruitment materials stated that the program is free and participants would be compensated for their time. At the initial screening call, the interviewer explained to participants that they would be compensated for completing interviews over a seven month period but would not receive payment for their conversation with the counselor. For active-duty Army personnel, one of the only ways to get confidential behavioral health services is to go to a civilian provider and pay out-of-pocket. Consequently, soldiers who are exploring their options may associate non-military confidential services with high fees, so it was important to be clear about the no-cost aspect of the WCU.

All suggested channels for marketing were pursued and can be grouped into three main categories: (1) print and visual media (2) presentations at soldier briefings, and (3) outreach to military leaders, service providers, and military families.

Print and Visual Media

Study staff contacted the directors or facility managers of all recommended locations to seek permission to display printed recruitment materials. Materials included brochures, half-page flyers, stacks of business-card sized ads, larger wall posters, and acrylic stands. All materials were printed with a variety of designs.

Unfortunately, AAFES facilities, the most recommended channel for media placement, was the only on-base entity that prohibits any form of recruitment marketing, stating their mission is strictly to provide commerce. Study staff eventually gained direct access to all locations recommended for print ad placement, except for company areas and barracks where non-military civilians are prohibited. Fortunately, the staff gained indirect access to these areas having developed a strong relationship with an on-base champion of the study, an upper-level ASAP employee who worked within the system to access these locations. Part of her job included giving presentations at each unit, and she was able to talk with unit commanders about the WCU at those times and gain permission to post materials. She also gave trainings to Unit Prevention Leaders and had them take materials back to barracks and Company offices.

Paid commercial ad placement, the third most recommended channel, included ads in local periodicals, on-base billboards or banners, and on Facebook. Ads ranged in size from an eighth of a page to a half page in circulars distributed solely on the base, as well as civilian publications with a large military audience. Advertising space was also purchased for a billboard near the base’s entry gate. A website was created with a home page featuring the project’s standard ad images and language, links to a fuller project description, frequently asked questions, and contact information. Facebook ads that linked to this website were also attempted.

Briefings

ASAP collaborators were integral to implementing the third most suggested recruitment channel, soldier briefings. Several obstacles, e.g., unpredictable scheduling, travel limitations due to distance between study offices and base, and rules regarding nonmilitary access to briefings limited project staff’s ability to present at briefings. Fortunately, the strong relationship negotiated with ASAP provided proxy. ASAP prevention leaders were trained to present the study, provided PowerPoint slides for inclusion in their presentations, and given access to materials for distribution. Collaborators included the WCU in Reintegration Briefings for soldiers returning from deployment, substance use education and prevention presentations to units, and Newcomer Orientations for service members newly stationed at the base.

Outreach to Leaders, Providers, and Families

The majority of channel recommendations pertained to visual media placement. However, WCU staff and on-base collaborators believed it was also important to reach out to military leaders, on-base social service providers and military families. Staff met with directors from multiple departments, including Social Work; Chaplain Corps; Child, Youth & School Services; Army Community Services; Suicide Prevention; Military and Family Life Counselor Program; Better Opportunities for Single Soldiers (BOSS); and Non-Commissioned Officer Academy and the Warrior Transition Battalion. Program information and recruitment materials were given to the program leaders for distribution.

When meeting leaders and making presentations, staff provided print materials and guided their explanations with talking points that mirrored print advertisements in order to maintain a cohesive message across channels. Presentations emphasized confidentiality and the study’s low-pressure, noncoercive approach. Individuals were encouraged to recommend the study and distribute project marketing materials to any soldier who disclosed concerns or asked questions about their substance use or treatment options.

Phase 2 Methods

Two years into the 3-year recruitment period, preliminary analyses were performed to evaluate the marketing campaign’s reach. All callers answered a marketing exposure questionnaire that asked where they heard about or saw advertisements for the study. At screening, participants completed a demographic questionnaire (gender, age, race, ethnicity, rank/paygrade, deployment history, combat exposure, etc.), and the Structured Clinical Interview for DSM Disorders – Substance Use Disorder section (Kranzler, Kadden, Babor, Tennen & Rounsville, 1996). In addition to baseline measures of substance use behaviors, histories, beliefs, and motivators not analyzed here, participants completed the PTSD Checklist (PCLS), a 17-item measure of PTSD symptom severity; the GAD-7, a seven-question scale of generalized anxiety disorder; and the PHQ-9 measuring depression severity (Keen, Kutter, Niles & Krinsley, 2008; Kroenke, Spitzer & Williams, 2001; Spitzer, Kroenke, Williams & Lowe, 2006). These measures were summed to create a total severity score.

The following analyses concerning the demographics of those reached by various marketing channels are based on enrolled participants who completed a screening assessment during the first 93 weeks of recruitment (n = 262). Analyses of participants’ psychological health (anxiety, depression, and PTSD) and intervention completion rates are based on enrolled participants, those who were eligible at screening and then completed the baseline assessment, by week 93 (n = 136).

Data analyses were completed using one-way ANOVAs for continuous measures and chi-square tests for categorical measures. In the event of an overall significant finding, post hoc tests were completed using the least square differences algorithm to test for pair-wise differences among continuous variables, and 2 × 2 chi-square tests were used to measure pair-wise differences among categorical variables. The significance level was set at .05. Participants with unknown channels were not included in the analyses (n = 19).

Phase 2 Findings

Response Rates

Over the first 93 weeks of recruitment, 459 individuals responded to the marketing campaign and called to inquire. Of those callers, 262 were interested in enrolling and completed the initial 15-minute screening. One-hundred and 72 callers met eligibility criteria for inclusion in the randomized trial of MET.

Participants responded to one or more of four main recruitment channels utilized by the study. Print and visual media generated 63% of all screened callers. Eight percent of callers who completed the initial screening came to the study via personal referrals (spouse, friend, or fellow soldier), 18% called in response to military briefings, and the remaining 10% were referred through service providers or military leaders. Advertising through paid media (newspapers, circulars, billboards, and Facebook) was not generally successful in recruiting participants as less than 2% of all calls identified these as referral sources. In contrast, flyers and posters accounted for 56% of all referrals, with company areas (16%), gyms (23%), and the welcome center (19%) being the most common sites for responding to flyers. Reintegration briefings (13%) were also successful in generating referrals. While there was some variation in the percentage of overall callers elicited by the different channels who were eligible for the project (ranging from 60% of those responding to briefings to 70% of those referred by service providers or military leaders), this response rate did not differ statistically across channels (see Table 2).

TABLE 2.

Response and completion rates by recruitment channel

	Total	Print and visual	Briefings	Family and friend	Providers and military leaders	Test (p value)
All screened callers (n)	262	164	48	21	27
Eligible (n) % of all callers	172 66%	110 42%	29 11%	14 5%	19 7%	χ2 = .98
Enrolled (n) % of eligible	136 79%	91 53%	21 12%	9 5%	15 9%	χ2 = 4.61
Completed (n)* % of eligible	106 78%	73 53%	15 11%	7 5%	11 8%	χ2 = .98

Note. Callers with unknown channel not included (n = 19).

^*Participants who completed the intervention session.

Overall, 136 callers completed the initial baseline assessment and were enrolled in the study, representing 49% of all callers who completed screening and 79% of callers who were eligible at screening. Seventy-eight percent of the participants who completed baseline also completed treatment, which is 38% of screened callers. Although there was variation across channels, there were no significant differences in initial study enrollment (60% from briefings to 70% from service providers and military leaders), completion of our baseline assessment (64% from family and friends to 84% from advertisements and flyers), or treatment completion (71% from briefings to 80% from advertisements and flyers) based on channel of recruitment.

Channel Effectiveness by Specified Participant Characteristics

Table 3 presents data on specific participant characteristics, with reference to each channel, for callers who were both interested and eligible for the study (n = 172). Demographics did not generally differ significantly across the four mechanisms for recruitment. Thus individual gender, marital status, race/ethnicity, and military rank did not significantly differ across recruitment channel. There were significant differences with reference to age F (3, 171) = 4.76, p < .01, where significantly younger participants were recruited via family and friends (mean age: 23.43 years) or briefings (mean age: 25.31 years) compared to older participants recruited via advertisements and flyers (mean age: 28.68 years). There were no significant differences in channel of recruitment regardless of deployment, combat exposure, or alcohol or substance use diagnoses. Mental health symptoms did appear to differ by channel among those who were enrolled in the study. There was no effect for PTSD or depression symptom severity in channel effectiveness. However, those who were referred by family and friends had significantly greater anxiety symptoms than those who responded to military briefings F (3, 134) = 2.85, p < .05.

TABLE 3.

Channel effectiveness by participant characteristics, eligible participants (n = 172)¹

	Print and visual (n = 110)	Briefings (n = 29)	Family and friends (n = 14)	Providers and military leaders (n = 19)	Test (p value)	Total
Gender (n, % male)	99 (90%)	28 (96%)	11 (79%)	18 (95%)	χ2 = 4.14 (.25)	156 (91%)
Age (mean, SD)3	28.7 (6.66)b	25.3 (3.75)ab	23.4 (2.71)a	26.5 (7.64)ab	F (3, 171) = 4.76 (.003)	28 (6.51)
Ethnicity (n, % white)	61 (55%)	17 (59%)	9 (64%)	9 (47%)	χ2 = 7.53 (.28)	96 (56%)
Marital status (n, % married)	55 (50%)	14 (48%)	7 (50%)	6 (32%)	χ2 = 7.58 (.27)	82 (48%)
Rank / pay grade		18 (64%)	11 (79%)	12 (63%)	χ2 = 5.10 (.53)	98 (57%)
E1–E4	57 (52%)	9 (32%)	2 (14%)	6 (32%)		61 (36%)
E5–E9	44 (40%)	1 (4%)	1 (7%)	1 (5%)		12 (7%)
Officer	9 (7%)
Deployment (n, % deployed)	89 (81%)	25 (86%)	11 (79%)	16 (84%)	χ2 = .61 (.89)	141 (82%)
Combat (n, % exposed)	82 (75%)	19 (66%)	10 (77%)	15 (79%)	χ2 = 1.38 (.71)	126 (73%)
Alcohol use disorders
Abuse	13 (12%)	7 (24%)	0 (0%)	2 (11%)	χ2 = 6.81 (.34)	22 (13%)
Dependence	87 (80%)	21 (72%)	12 (86%)	16 (84%)		136 (79%)
Substance use disorders
Abuse	4 (4%)	0 (0%)	0 (0%)	0 (0%)	χ2 = 2.98 (.81)	4 (2%)
Dependence	27 (25%)	8 (28%)	5 (36%)	5 (26%)		45 (26%)
PTSD symptom severity (mean, SD)2	45.87 (17.63)	45.42 (16.85)	52.61 (14.25)	47.02 (17.04)	F (2, 127) = 1.52 (.22)	47 (17.04)
Generalized anxiety disorder (mean, SD)2,3	9.28 (5.78)ab	9.04 (4.94)a	12.83 (6.55)b	9.87 (5.93)ab	F (2, 134) = 3.80 (.03)	9.9 (5.93)
Depression (mean, SD)2	10.23 (6.30)	11.29 (5.05)	13.30 (6.48)	10.93 (6.22)	F (2, 133) = 2.32 (.10)	10.9 (6.22)

¹Callers with unknown channel not included (n = 19).

²Measure administered only for enrolled participants (n = 136); summed severity score (PCL-S; GAD-7; PHQ-9).

³p < .05. Means and proportions with different superscripts (a or b) are significantly different from one another.

CONCLUSIONS

Substance abuse is at the forefront of public health concerns facing the military. Recently, the DoD charged the Institute of Medicine with the task of assessing and analyzing the policies and programs related to substance abuse in the military (IOM, 2012). Overwhelmingly, the IOM committee identified several barriers that limit access to substance abuse treatment and recommended that efforts should increase to prevent substance use disorders and increase access to care, including encouraging self-referral to treatment. The WCU is one program currently being evaluated designed to address untreated substance abuse in the military. Lessons learned through recruitment efforts of this project will be valuable for other researchers focused on the military, treatment providers, and those in the DoD who inform policies and campaigns to promote health.

The WCU project presents one method for designing recruitment advertisements targeting a military population. Focus groups with selected stakeholders as well as continual feedback from interested callers and soldiers on base highlighted the need to be culturally competent when creating ads and the value of continual dialogue with the target population. Additionally, on-base recruitment efforts in the form of advertisements, flyers, and cards proved most successful in attracting the target population. Having an on-base presence was also valuable. Finding and cultivating a program “champion” from within the military is essential in navigating the many processes for approval to advertise on base as well as identifying and accessing opportune interactions with soldiers (soldier processing, substance use prevention trainings, etc.). Given that 36% of participants called the study in response to a briefing, a service provider or friend or family member, personal interaction that educates the soldier about the service offered is also key. This included WCU staff’s presence at events, ASAP prevention personnel informing soldiers of the project, and briefing unit commanders to increase their ability to refer to the project for soldiers they were concerned about.

The content of the messages are vital as well. Focus groups and survey participants shaped the wording and images of the advertisements and brochures. The messages tapped into ambivalence surrounding substance use, but also conveyed hope for a solution. Keeping messages brief and highlighting important aspects of the project that address concerns about stigma such as confidentiality, and command not being notified helped to decrease barriers to calling. Focus groups and interactions with soldiers (including participants) reiterated and emphasized the idea that confidentiality is a key to action in the military. This is one of the most common aspects that participants point to when asked what attracted them to participate in the study. Additionally, how the confidentiality of the project eased their fear of punishment from the Army about seeking help for a substance use problem was also a very common sentiment expressed. Although the ads intentionally evolved away from associating drinking with memories of war or PTSD, consonant with others’ findings, the rate of trauma exposure, PTSD, anxiety, and depression among the interested callers was high. This suggests that marketing for a substance use program can and will reach soldiers who are struggling with mental health and may create an opportunity for providers to assess and provide feedback to enhance treatment seeking for these issues as well.

One noteworthy limitation of the study is that ads mention financial compensation for research participants. This adds to the service’s attractiveness and therefore limits the generalizability of these findings to social service providers and studies that do not offer compensation. Additionally, a cost analysis of various channels was not possible with available data.

Overall, the check-up model has been successfully adapted for use with a variety of at-risk populations (see Walker, et al., 2007). Successful marketing has been key to all these adaptations. How do you get at-risk individuals to reach out for help has been the question at the heart of the marketing for the check-up. The WCU suggests that an adaptation of the check-up to specifically focus on soldiers has been effective in reaching individuals who are troubled by their substance abuse, but are unsure of what to do. And specifically, that marketing materials can be successfully developed with thoughtful and persistent feedback from military personnel. Further research should continue to explore the utility of a check-up model for military populations, particularly for addressing highly stigmatized topics such as substance abuse, PTSD, suicide, and military sexual trauma.

GLOSSARY

Check-up model

A form of brief intervention designed to attract individuals with untreated behavioral health issues to facilitate self-appraisa,l and to promote self-referral to treatment. Social marketing is used to attract the target population to the service. Following an assessment of the client’s behaviors, beliefs, and perceived norms, the counselor uses a Motivational Interviewing approach to engage the client in a no-pressure discussion of the problem area with the goal of bolstering one’s motivation to make positive changes.

McGuire’s communication matrix

A conceptual framework to develop marketing strategies, particularly those inclusive of a “call to action” or behavior change. It consists of five communication components and outputs, i.e., the desired outcomes: (1) receiver, the intended recipient of the message; (2) message, the content being communicated; (3) channel, the means or strategies used to deliver the message to the receiver; (4) source, the institution or person sending the message; and (5) target, the anticipated outcome (i.e., what action the receiver should be prompted to take).

Motivational interviewing

A client-centered counseling style designed to promote self-reflection and self-appraisal of beliefs and problematic behaviors in order to overcome ambivalence about behavior change.

Social marketing

Communication strategies designed to increase knowledge or awareness, change thoughts, and/or stimulate behavior change.

Substance use disorder

A term used to encompass both Substance Abuse and Dependence disorders as described by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition.

Biographies

Clayton Neighbors, PhD—Dr. Clayton Neighbors received his PhD from the University of Houston. He is currently a Professor and the Director of the Social Psychology Program at the University of Houston. His work focuses on social, motivational, and spiritual influences in etiology, prevention, and treatment of health and risk behaviors. He has applied his research toward better understanding and alleviating problems related to alcohol and substance abuse, intimate partner violence, problem gambling, body image and eating disorders, and aggressive driving. Support for this research has been provided by the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, the National Institute on Mental Health, and the Department of Defense.

Debra Kaysen, PhD—Dr. Kaysen is an Associate Professor and is the Depression Therapy Research Endowed Professor in the Psychiatry and Behavioral Sciences Department at the University of Washington. She has received grants from the National Institute of Alcohol Abuse and Alcoholism, the National Institutes of Drug Abuse, and the Alcohol Beverage Medical Research Foundation. Dr. Kaysen’s research is situated at the interface of PTSD and Addictions, and includes both etiologic and prevention/treatment-oriented studies. She has published over 50 journal articles and was awarded the New Investigator Award from the Women’s SIG of the Association for Behavioral and Cognitive Therapies and an early Career poster award from Division 50 of the American Psychological Association and NIAAA.

Denise Walker, PhD—Trained in clinical psychology, Dr. Walker’s expertise is in the fields of addictive behaviors and Motivational Enhancement Therapy. Her research focuses on the development, testing, and implementation of interventions that bring about positive changes in patterns of behavior. Dr. Walker has applied her work to a number of hard-to-reach populations including adolescents, marijuana-dependent adults, substance-abusing active-duty military personnel, and domestic-violence perpetrators. She received her MS and PhD in clinical psychology from the University of New Mexico and is currently a Research Associate Professor and the codirector of the Innovative Programs Research Group at the University of Washington.

Lyungai Mbilinyi, PhD–Research Assistant Professor Lyungai Mbilinyi’s research interests focus on intimate partner violence prevention and early intervention and the intersections of race, gender, and class among social and health issues. Dr. Mbilinyi began her social work career over 15 years ago as a domestic violence group counselor. It was during her tenure as a counselor when she became interested in applied research and evaluation. Dr. Mbilinyi has taught research courses for Masters of Social Work students. She has published on children’s exposure to domestic violence, and marketing to and intervening with intimate partner violence perpetrators. Born in Dar Es Salaam, Tanzania, Dr. Mbilinyi has a personal and professional interest in the experience of African immigrants and refugees in the United States. Dr. Mbilinyi also codirects the School’s Innovative Programs Research Group.

Roger Roffman, DSW—Dr. Roger Roffman is a Professor Emeritus at the University of Washington School of Social Work. His research interests focus on behavioral interventions in the fields of addictive disorders, marijuana dependence, and sexual health. His studies of checkup interventions are tailored for individuals who have concerns about current behaviors that are causing adverse effects, but are ambivalent about committing to change. His studies of behavioral counseling interventions focus on supporting individuals to change their behaviors. Dr. Roffman founded the Innovative Programs Research Group in 1987.

ThomasWalton, MSW—Mr. Walton has engaged in research with a diversity of populations, including homeless adolescents, people living with dementia, perpetrators of domestic violence, and soldiers grappling with substance use. Mr. Walton is a social worker and Project Director for the WCU study at the University of Washington’s Innovative Programs Research Group. He earned his Master of Social Work from the University of Washington, focusing on policy and social service systems.