Empowering people to take control of their persistent low back pain through public awareness campaigning

Compelling and targeted public health campaigning can be effective in engaging individuals with persistent low back pain. Dear Editor, The estimated mean delay to diagnosis in axial spondyloarthritis (axial SpA) is 8.65 years in the UK, which is greater than the mean delay worldwide (6.7 years) [1]. Results from a UK-based survey show that almost 40% of people living with axial SpA report contacting a healthcare practitioner more than 1 year after developing symptoms [2]. Indeed, patient and public lack of awareness of axial SpA may contribute to the delay in seeking medical help for their symptoms [3]. In response to this diagnostic delay, the National Axial Spondyloarthritis Society (NASS) launched the ‘Act on Axial SpA’ campaign in June 2021. Its long-term goal is that people with axial SpA across the UK are diagnosed within 12 months of symptom onset. The campaign includes research and audit, public awareness raising, education and training for healthcare professionals, quality improvement interventions and policy and Parliamentary activity. It seeks to test and spread interventions and promotes an integrated approach that follows the person from symptom onset to diagnosis in rheumatology [4]. Public awareness campaigns in this area are sparse; however, an earlier television-based campaign in New Zealand was successful in increasing the number of referrals of suspected radiographic axial SpA to rheumatology services [5]. Here, we describe the performance and learning of a multiyear public awareness campaign in the UK aiming to help individuals recognize that their back pain might be axial SpA and understand the actions they should take. Phase 1 comprised a national public awareness campaign (Jun 2021–Dec 2023) aiming to increase awareness of axial SpA in the UK and encourage people with persistent low back pain (LBP) to visit the campaign website (https://www.actonaxialspa.com/) and use an online symptom checker (https://www.actonaxialspa.com/symptoms-checker/). The symptom checker integrates the three validated sets of inflammatory back pain criteria into a single eight-point set [6–8]. The campaign primarily utilized organic and paid social media advertisements on platforms such as Facebook and Instagram. The advertisements featured campaign iconography, patient case studies (static and video) and advice from healthcare professionals (video). Press coverage (newspapers, magazines and television), posters in general practice and other multimedia were also employed. The social media campaign adverts appeared 2.7 million times on people’s profiles, and the campaign website received 71 573 visits. The symptom checker was completed over 18 000 times, with an estimated 69% meeting the threshold for referral to rheumatology (see Table 1). Overall, phase 1 demonstrated the power of social media in reaching a broad audience for health campaigning. However, using ‘axial SpA’ in first-contact messaging may have resulted in suboptimal engagement from people with persistent LBP. Performance of NASS public awareness campaigns Some individuals completed the symptom checker more than once. Mar–Jun 2024. Ads: advertisements; NASS: National Axial Spondyloarthritis Society; NI: Northern Ireland. Impressions = the number of times content appeared to users (includes multiple views). Reach = number of people (profiles) that saw the advert. Engagements = interactions with the ads (such as clicks, likes, comments, shares, video views). Phase 2 encompassed a 6-week geo-targeted public awareness campaign in Belfast (Jan–Feb 2024). This campaign specifically targeted younger individuals (18–40 years) with persistent LBP. NASS partnered with a local creative agency to develop a campaign, shaped around ‘broken dreams’. The campaign utilized out-of-home advertising (e.g. 85 static and digital panels at 85 locations including shopping malls, bus stops and billboards), a radio campaign on Cool FM (running 30 s adverts 100 times and 2 magazine articles) and a paid social media campaign on Facebook and Instagram. Striking language and vivid imagery were used to drive people to take the symptom checker (see https://www.actonaxialspa.com/hcp-toolkit/). In just 6 weeks, the social media advertisements successfully reached 831 390 people. Further, the out-of-home advertising engaged 88 000 people, reaching 81% of 18–40-year-olds in Belfast. In turn, the symptom checker was viewed by 3000 people from Belfast and completed 389 times. An estimated 73% met the threshold for referral to rheumatology (see Table 1). The geo-targeted approach in Belfast was more effective than the broader national campaign, largely due to the localised approach, provocative language and targeting a cold audience with ‘LBP’. Phase 3 covered a National Social Media Campaign (Mar–May 2024) targeting people (18–40 years) with persistent LBP across the UK. Materials were adapted from phase 2 for national implementation and case study placements added for personalized messaging. The social media advertisements reached 746 884 people, whilst the case study placements reached 30 783 people. The symptom checker was completed over 12 000 times, with an estimated 65% being suggestive of inflammatory back pain and meeting the threshold for referral to rheumatology (see Table 1). Phase 3 demonstrated that short video clips (10–15 s), striking language and compelling visual imagery could be used nationally to maintain high engagement during health campaigning. As of September 2024, the three phases achieved 5 million impressions (i.e. the number of times content appeared to users) on social media. Overall, the ‘Act on Axial SpA’ public awareness campaign provides valuable insights into how health campaigning can effectively engage individuals with persistent LBP. The following lessons and strategies could help inform future public awareness initiatives: (i) target cold audiences with relatable symptoms (i.e. LBP) and avoid specific medical terminology on first contact (i.e. axial SpA); (ii) utilize short and concentrated geo-targeted approaches; and (iii) use visually dynamic and concise messaging. Increasing public awareness needs to be done in conjunction with education for primary care professionals, referral pathway development and dedicated rheumatology capacity for assessment. Without this synchronized approach, the delay to diagnosis may be shifted later in the patient journey. These findings offer critical lessons for future public health initiatives, especially those aimed at reducing diagnostic delays for chronic conditions. The data utilized in this study is generated for Google Analytics and Meta Business Suite. A copy of the data can be shared upon reasonable request from the corresponding author. This work was supported by UCB Pharma Ltd [grant number: UK-N-DA-RH-2100001]. Disclosure statement: R.S. has been sponsored to attend regional, national and international meetings by UCB, AbbVie, Novartis and Lilly. He has received honoraria for speaking and attended advisory boards with Pfizer, AbbVie, Biogen, BMS, Lilly, Novartis, UCB. He has received grants from UCB, BMS, AbbVie and Novartis. K.G. has received meeting expenses from AbbVie, Lilly, Roche, Novartis, Pfizer and UCB; honoraria or consultancy fees from Novartis, AbbVie, UCB, Lilly and Pfizer; participated in speaker’s bureau for Novartis, UCB, AbbVie and Lilly; obtained grant support from NASS, Vs Arthritis, AbbVie, Alfasigma, Pfizer, UCB, Novartis, Eli Lilly, Medacpharma, Celltrion, Janssen and Biogen, and is a shareholder of Rheumatology Events. C.C. has received consulting/speaker fees from AbbVie, Novartis, Galapagos, Gilead and Bristol Myers Squibb. J.E., T.A.I., C.C., J.H. and D.W. received institutional grant funding from AbbVie, Biogen, Janssen, Lilly, Novartis and UCB. We thank Mammoth (Belfast creative agency) for supporting our campaign with media strategy advice, creative development, media space buying, social media delivery and local partnership oversight. We also acknowledge Public Health Northern Ireland and the Belfast Health & Social Care Trust for providing local advice on the Belfast health system. This work is part of the NASS ‘Act on Axial SpA’ campaign, which is fully funded by UCB Pharma Ltd UCB Pharma Ltd has had no editorial control over the content or output of the programme.

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