1. Introduction

Modern marketing requires much more than developing a good product or service, making attractive pricing, and making available products or services accessible. Businesses have to communicate with existing and potential stakeholders and the public. Businesses in public communication; be going to say what, how, where, when, how often, and to whom should well planned. Consumers are actively using communication tools such as hundreds of cable and satellite broadcasts, thousands of magazines and newspapers, and millions of web pages ([1], p. 579).

Marketing communication is a very popular topic today. No field of marketing is changing as fast and drastic as marketing communication. Because with the emergence of concepts such as online, mobile, and social media marketing, customer participation is increasing day by day ([2], p. 425).

Marketing communication (promotion) can be defined as the process of information transmission between the seller and the potential buyer or other people ([3], p. 344). In other words, marketing communication can be defined as the means used by the company to communicate with customers and other stakeholders ([2], p. 426). Promotion is one of the marketing mix; the right products and/or services include those described to the target audience, which can be reached at the right place and at the right price. Promotion activities should be compatible with other elements of the marketing mix and differentiation and positioning strategies, requiring serious work for the target audience ([3], p. 344).

Marketing communication is defined as the method in which enterprises try to inform and persuade consumers about the products or services they sell directly or indirectly. It represents the brand and voice of the business. These methods are also the means for the enterprise to establish dialog and develop relationships with consumers. It contributes to customer value by strengthening customer loyalty. In addition to increasing sales, it affects brand value. It creates a brand image by keeping the brand in mind and contributes to brand equity ([1], p. 580). Building good customer communication requires more than developing a good product or service, making attractive pricing, or making it available to customers. When developing products or services, businesses should involve consumers in this process, communicate their value suggestions to their customers, and leave communication to chance ([2], p. 425).

The importance of marketing communication has increased in recent years for various reasons. Increasing products and services are seen as the similarity of their life cycles at maturity stage. As a result, it is seen that it is very difficult to make a difference in terms of distinguishing the brands related to the specific qualities of products and services. Marketing communication elements contribute to the creation of points that make a difference. In markets with uncertainty and complexity, marketing communication becomes very important for enterprises to gain competitive advantage ([4], p. 823).

2. Communication process

Communication is basically the transmission of information. In order for communication to take place, the information must have some things in common with both the sender and the recipient. There must be a common understanding of symbols, words, and images used to convey information. Accordingly, communication can be expressed as a sharing of meaning ([5], p. 430). Figure 1 shows the communication process in detail.

Figure 1.
Communication process. Source: Ref. ([6], p. 568).

As shown in Figure 1, business communication process starts with sources. Source is defined as a person, group, or organization attempting to share a meaning with the audience or recipient. Source can be a salesperson explaining the characteristics of the TV to the customer in a TV store or a TV manufacturer advertising through the TV to inform the consumer. A strategy can be developed to increase the communication efficiency of a source. For example, a sales person can influence a customer’s decision by comparing it to the competitor’s products. Receiver or audience is a person, group, or organization that decodes a coded message sent by the source. Coding is the process by which a source converts a series of signs or symbols representing meaning, ideas, or concepts to convey the message. The source has to take into account some features of the receiver or audience when encoding a message. In order to share the meaning, it is necessary to use the signs and symbols of source appropriate to the receiver or audience. Research shows that messages from a source are more convincing when addressing a person’s character. For this reason, enterprises should recognize their target audience and carry out promotional activities accordingly ([6], pp. 568-569).

Source selects and uses a communication means, i.e., a communication channel, which carries the encoded message from the source to the viewer or receiver to share a coded message with the receiver or audience. Communication tools include printed media (newspapers, magazines, etc.), visual media (TV, etc.), and digital communication. Although TV is used as the most common means of communication today, it is becoming widespread in digital channels. Decoding is defined as the conversion of signs and symbols into concepts or ideas. Noise arises from the different perceptions of the encoded message as a result of the decoding step. In other words, it is defined as anything that reduces the clarity and accuracy of communication. Sometimes the communication channel also causes noise. Examples include the difficulty in transmitting from radio or television or the slow Internet connection speed. Feedback is defined as the response of recipient or viewer to a decoded message. Therefore, communication refers to the circular process between the source and the receiver or audience ([5], pp. 431-432).

In order to carry out a healthy communication with the target audience, the marketing manager should pay attention in establishing a marketing communication, and some system issues should be taken into consideration [7]:

Target audience should be well-defined.
Targets and the reaction to be created in the target audience should be determined.
Communication should be designed, and the most appropriate communication channel (media) should be selected.
Provide feedback and measure results.
Factors preventing communication should be eliminated.

3. Promotion mix

The promotion mix—also called marketing communication—consists of advertising, public relations, personal selling, sales promotions, direct sales, and digital marketing used to contact with consumers, establish relationships with customers, and persuade customers. These promotional means are described as follows ([2], pp. 425-426):

Advertising: It may be defined as any nonpersonal paid element used for the promotion of ideas, goods, or services through a particular financier.
Sales promotions: Short-term incentives used to promote the purchase or sale of a product or service.
Personal selling: Personal customer interactions to attract customers, make sales, and establish relationships with customers.
Public relations: Establishing good relations with various groups in order to create a good corporate image and deal with and prevent negative rumors or situations related to the business.
Direct and digital marketing: The goal is to interact directly with individual customers or customer communities, both for instant response and to make customer relationships more permanent.

According to Keller ([4], pp. 820-821), marketing communication tools consist of many tools. These tools are media advertising, direct response and interactive advertising, place advertising, store signage and point of purchase advertising, trade and consumer-oriented promotions, event marketing and sponsorships, marketing-oriented public relations and publicity, and personal selling. Media advertising is carried out by using media tools such as TV, radio, newspapers, and magazines. Direct response and interactive advertising are carried out by using channels such as direct mail, online advertising, and telephone solicitation. Place advertising is carried out by using media tools billboards and bulletins, posters, transit ads, and cinema ads. Store signage and point of purchase advertising is carried out by the means of external store signs, in-store shelf signs, shopping cart ads, and in-store radio and TV. Trade and consumer-oriented promotions are carried out by using promotions such as trade deals and buying allowances, display and advertising, trade shows, cooperative advertising, samples, coupons, premiums refunds/rebates, contests/sweepstakes, promotional games, bonus packs, and price-off deals. Event marketing and sponsorships are carried out through activities such as sponsorship of sporting events and sponsorship of arts, fairs, and festivals.

There are clear differences between the challenge marketers face 20–30 years ago and today’s challenges. One of the most important of these changes is the increase in the variety and number of communication options that marketers can use to reach consumers. In recent years, there have been some changes in marketing communication. These are fragmentations of traditional advertising media and the emergence of new (non-traditional) media, publicity, and other means of communication. These developments pushed marketing communication to use different communication methods. One of these methods of communication is any form of communication initiated by any marketer who is directly or indirectly related to the brand. As indicated in Table 1, communication options are often categorized by broad communication options or media types ([4], pp. 820-821).

Advertising for consumer markets	National advertising It can be expressed as advertising by large companies nationwide or in many regions of the country. Most advertisements for well-known companies and brands seen in the major national or regional media can be considered in this category. The goals of national advertisers are to inform or remind consumers about the characteristics, benefits, advantages, or uses of the company or brand and to create an image for consumers to tend to purchase
	Retail/local advertising It can be expressed as a type of advertising by retailers or local merchants to encourage consumers to shop in a particular store, use a local service, or become a customer of a particular business. The advertisements in this category apply to certain protective activities such as price, working hours, service, atmosphere, and image or variety of commercial products.
	Primary versus selective demand advertising Primary versus ads are ads designed to promote demand for the overall product class or the entire industry. Selective demand advertising is intended to create a demand for the goods or services of a particular company The advertiser’s brand is the market leader, and the primary demand is focused on advertising. Primary demand ads are used as part of promotional strategies for a new product to be accepted in the market
Advertising for business and professional markets	Business-to-business advertising (B2B) B2B advertising is an advertisement used to persuade owners to purchase industrial goods or services for their companies. Industrial goods can be either raw materials or machines used to produce another product. Insurance, travel, and health services are considered in this category. In addition, these goods may also be products used in the production of other goods and used to assist in the conduct of a company’s business (office equipment, computers, etc.). Insurance, travel, and health services are considered in this category
	Professional advertising Professional advertising targets professionals such as physicians, lawyers dentists, and engineers to encourage them to use a company’s product in their business operations. In addition, it can be used to encourage professionals to recommend the use of a company’s product by end users
	Trade advertising It targets marketing channel members such as wholesalers, distributors, and retailers. The goal is to encourage channel members to stock, promote, and sell the manufacturer’s branded products to their customers.

Table 1.

Advertising classification.

Source: Ref. ([8], p. 20).

Marketing communication is a concept beyond the abovementioned promotion mix elements. Many elements such as the design of the product, price, shape and color of the package, and the stores where the product is sold convey something to the buyers. Therefore, although the promotion mix is the main task and communication activity of the enterprise, it should be coordinated to make a big impact with all marketing mix elements such as the product, price, and distribution promotion ([2], p. 425).

Basic forms of marketing communication include traditional mass advertising (TV, magazines, etc.), online advertising (websites, emails, text messaging, etc.), sales promotions (samples, coupons, discounts and premium products, etc.), stores and point of sale signs, direct mail supply, marketing-oriented public relations and promotional presentations, sponsorship, and sales personnel presentation. All of these communication and media tools constitute promotion components ([9], p. 4).

Marketing managers should understand that many sales promotion activities will not produce results in a short time. Therefore, long-term sales promotion objectives of enterprises should be long enough to predict real success. It should also have the patience to create a concrete market position that will continue its sales promotion strategy. In addition, creativity is at the forefront of sales promotion activities ([7], p. 230).

4. Advertising

In-line with economic, political, technological, and social changes, one of the promotional tools used by organizations to reach their target audiences is advertising ([7], p. 230). Advertising is the transmission of information about products and services to an audience through mass media, including TV, radio, the Internet, newspapers, magazines, direct mail, outdoor shows, and signs on public transport. Advertisements change as consumers’ habits of mass media use change. Nowadays, businesses use digital media extensively to maintain their existence and maximize their impact. Advertisements that appeal to even smaller audiences are designed. The use of traditional advertising tools is decreasing day by day ([6], pp. 574-575). Individuals and organizations use advertising to promote their products, services, ideas, and problems to people. The flexibility of the advertisements allows it to reach a larger audience and can focus on a small and undefined group. For example, while Quizno’s ads focus on a wide range of potentially fast-food customers, from children to adults, advertising for Gulfstream jets focuses on a much smaller and more specific target market. On the other hand, outdoor advertising related to the dangers of passive smoking is used to increase awareness among children. The more people can focus on people at a low cost per person, the more economical it is ([5], p. 437).

There are limitations as well as what the ad can achieve. Consumers often perceive the ad as a guest who comes in without being invited. When they see the advertisement, consumers try to avoid the advertisement by turning the pages of newspapers and magazines, muting the sound of TV and radio, and dealing with other issues during the advertisement. In particular, ads that interrupt consumers’ favorite programs may have negative effects on consumers. Another negative aspect of mass media advertising is that it reaches more people than the actual target audience. For example, TV broadcasting of cosmetic products for women does not only reach women consumers but also the audience of men and children ([10], p. 540).

Advertising varies from sector to sector. Businesses, retailers, etc. that sell products or services to the consumer market are usually rely on advertising to communicate with the target audience. However, advertising increases the demand for products or services. Advertising is also widely used by businesses competing in professional markets to reach existing or potential customers. For example, marketers help raise awareness about businesses and their products and services, guide sales force, build confidence in customers’ products and services, and create an appropriate environment ([8], pp. 18-19).

The objectives of the advertisement can be grouped into three categories. These are information, persuasion, and reminder. In addition, advertising can be done for the following purposes ([7], p. 233):

Introducing new products to the market and introducing them or entering the new market section
Encouraging the use of products and services used by a small audience for large masses by creating purchasing motivation
Giving information about the usage of the product
To create brand preference
To create company image and brand loyalty
Helping the sellers by explaining the company and the properties of the goods
Expanding the volume of goods or services to maintain demand
Reaching individuals or groups that vendors cannot reach directly
Correcting prejudices and false and negative impressions
Educating consumers
Reminding consumers where to buy products or services
Keeping the product alive in the minds of consumers during periods of low sales

In order to achieve the goals of the advertisement, decisions should be made on how to make advertising campaigns and how many budgets will be allocated and which media will be used and the effectiveness of the advertisement.

In Table 1, advertising is expressed in two main categories. These are advertising for business and professional markets and consumer markets. Advertising for consumer markets, national advertising, local/retail advertising, and primary versus selective demand advertising, and advertising for business and professional markets, business-to-business advertising (B2B), professional advertising, and trade advertising, are examined separately.

Direct-to-consumer advertising (DTCA) is one of the most controversial issues in the health sector. Historically, prescription drug and medical device advertising in the United States were primarily intended for professional individuals and organizations rather than consumers, but in 1997 the Food and Drug Administration (FDA) guided direct marketing guidelines for pharmaceutical companies for advertising in mass media. With this published guide, DTCA became widespread [11]. Figure 1 shows the increase in direct consumer expenditures in the pharmaceutical sector. In 1997, advertising spending reached a record level following the FDA’s guidance on changing DTCA rules.

With the increasing knowledge of healthcare users about product and service selection, health service providers, health insurance companies, pharmaceutical companies, and medical device manufacturers have recognized the benefits of advertising for end users. This has been the result of the rapid increase in healthcare expenditures in the United States [12].

The most important factor among the benefits of advertising in health services is the power of individuals to make decisions about their health. Individuals will be able to know how, where, and when to use medical products and services when their knowledge of health is increased through advertising. On the other hand, the most important concern about advertising is the difficulty of the relationship between the physician and patient. The clinical decision-making role of the physician may potentially be diminished [13].

5. Personal selling

It is a paid form of personal communication that persuades customers to inform and purchase products in the event of change. Personal selling is the most commonly used promotional activity for high-quality products such as home, car, electronic products, and furniture in inter-business and consumer markets ([5],p. 438). Personal selling includes face-to-face communication with the customer. Unlike advertising, promotion, and other nonpersonal forms of communication, there is a direct interaction between the buyer and the seller. This two-way communication means that the seller receives information about the buyer instantly and makes a sales presentation in accordance with his specific needs and problems ([14], p. 491). The most effective way to establish meaningful dialog with the customer is personal selling. Businesses use personal selling to promote new products, services, brands, and facilities. Because it is less costly than consumer advertisements, low-budget businesses use personal selling to increase their influence in the market ([15], p. 291).

Personal selling provides all kinds of customer relationships from real sales relationships to personal friendships. An effective salesperson protects the interests of customers to solve long-term relationships by solving customer’s problems. After the sales presentation, even if the buyer gets the answer “no, thank you,” he usually feels the need to listen and respond. Despite the fact that advertising can be increased and decreased, it is difficult to change the size of the sales force, which requires a longer-term agreement than advertising. It is the most expensive promotion tool of businesses. Therefore, businesses spend three times the amount they spend on advertising ([2], p. 441).

Personal selling often includes very fast and precise feedback as the sales presentation can be evaluated according to customer reactions. If the sales staffs notice that the sales presentation is inappropriate from the customer feedback, they can change the message. Although it is one of the elements of personal selling promotion mix, it is not a direct part of marketing communication in many companies. Personal selling is often referred to as a different management department that is not included in the advertising or marketing department. In addition, various promotional elements such as media advertising, digital marketing, and sales promotions should be conducted in coordination with personal selling ([8], p. 27).

Home visits of health personnel in institutions that provide preventive health services in health services are examples of personal selling. During these visits, health personnel determine the health needs of the household and invite individuals to the health institution. Another example is the medical representatives of pharmaceutical companies. Medical agents inform physicians about the medicines offered by the company and try to convince physicians to prescribe them. In therapeutic health services, personal selling is not meaningful due to the characteristics of health services.

In addition, sales activities for pharmaceuticals and medical supplier representatives for physicians, insurance providers for consumers, biomedical planting suppliers for health institutions are examples personal selling in health services [16].

6. Sales promotions

Sales promotions are defined as an activity or material that directly provides incentives and means of product or service, provides added value, and provides incentives to sellers and customers, such as free samples, games, discounts, sweepstakes, contests, premiums, coupons and so on. Sales promotion should not be confused with promotion. Sales promotion is only part of the promotion, which is a much more comprehensive field of activity. Marketers spend more on sales promotions than ads. In addition, sales promotion is an area that grows faster than advertising ([5], p. 440).

With the incentives provided by sales promotions, there is a rapid support for sales. The impact of such promotional activities is very short-lived. In addition, the excessive use of certain incentives may damage the brand image ([14], p. 431).

Sales promotions attract the attention of the consumer and engage the consumer and provide strong incentives for the purchase. Customers are rewarded with sales promotions to react quickly. Advertising activities tells consumers to “buy our products or services,” and sales promotions say “buy our products or services now.” Ensuring long-term brand preference and building customer mass is not as effective as advertising or personal selling ([2], p. 440).

Sales promotion in health services is a more modest tool than other marketing communication mix elements. An example of sales promotions in health care is the free presentation of things such as pens, calendars, and similar objects with the logo of the institution or organization [17]. In addition, participating in trade fairs, professional meetings, and conferences of the personnel working within the health institution may be a means of sales promotion. This provides an opportunity for people who are difficult to reach, such as physicians or health managers, to display the product/service offered by the institution or institution. While it can be quite difficult to reach the physician in the healthcare institution, such sales promotions can be easily reached with the target audience [16].

7. Public relations

Many of the promotional elements focus on the company’s customers. But for businesses—suppliers, employees, shareholders, media, educators, potential investors, government, and society in general—other stakeholders are also very important. In order to communicate with customers and other stakeholders, public relations is an important concept. Public relations are a wide range of communication efforts used to establish and maintain positive relationships between an organization and its stakeholders. Establishing a positive relationship with one or more stakeholders contributes to the sales, profitability, and survival of the entity ([6], p. 576).

Public relations include corporate promotion, seminars, publications, lobbying, and charitable donations ([14], p. 450). Public relations activities in international enterprises are generally carried out by independent departments within the headquarters of the companies. The public relations department basically carries out the following activities ([7], p. 250; [14], p. 450):

Relations with the media
Product and company presentation
Recognizing the target audience
Improving image and communication in enterprises
Lobbying and sociocultural activities
Sponsorship
Image studies
Participation in fairs and exhibitions
Consultancy
Charitable donations
Seminars
Publications

Publicity is one of the most important elements of public relations. The information about a product, service, or organization is transmit to the society through media channels. The three main tasks of the promotion department are to respond to information requests from the media, to provide information to the media about important events in the organization, and to encourage the media to communicate the information and perspective of the organization to the society. The dissemination of information can take place through news, as well as through long-length articles, interviews, and public meetings (conferences, seminars, etc.). Regardless of which of these tools is used to communicate information to society, promotion has three important features. These ([14], p. 451) are the following:

High reliability of the message to be transmitted to the society.
No direct media costs.
No broadcast controls.

Since the transfer of corporate information to the society through the media is done through a media and not directly by the institution, it needs to have higher reliability. In addition, the fact that there is no direct cost of the information to be transmitted to the society does not mean that it has no cost. Taking part in a media tool’s newsletter, organizing a conference or taking part in an interview requires a particular organization. This organization is carried out through agencies. In addition, there is no guarantee that the news will be published unlike advertisements, as there is no fee for information to be transmitted through the media. The decision is made by the editors of the media organization. Table 2 shows the issues that may be news for a business.

Marketing issue	Financial issues
New products Research Breakthroughs: future new products Large orders/contracts Sponsorships Price changes Service changes New logos Export success	Financial statements Acquisitions Sales/profit achievements
	Personal issue
	Training awards Winners of company contests Promotions/new appointments Success stories Visits by famous people Reports of interviews
Production issues	General issues
Productivity achievements Employment changes Capital investments	Conferences/seminars/exhibitions Anniversaries of significant events

Table 2.

Issues with potential news value.

Source: Ref. ([14], p. 452).

The most important feature of health institutions in terms of public relations is that it addresses all public sectors and serves people of all ages and genders. In addition, another feature of public relations units is the requirement of health institutions to protect patient interests. More importantly, all health managers, doctors, nurses and staff have effective elements in their activities [18].

There are important objectives of public relations in health institutions. These objectives can be expressed as the public disclosure of the service policies of the health institution and the adoption of these policies by the public, ensuring that the activities carried out by the organization are welcomed by the society in a positive manner, learning what is thought about the organization by the society, and providing cooperation with the public [19].

8. Direct marketing

Direct marketing, involves “an interactive system of marketing that uses one or more advertising media to effect a measurable response and/or transaction.” The main difference between direct marketing and other promotion tools is that marketers target a direct audience to deliver a message for specific needs [16]. Direct marketing is one of the fastest growing areas of the US economy. Traditionally, direct marketing is not considered among the promotion mix elements. However, in many companies, it is considered as an element of promotion mix as it is an integral part of marketing communication ([8], p. 62).

Direct marketing is the introduction of products to customers through the use of telephone, the Internet, or nonpersonal media, enabling customers to purchase them through these tools ([5], p. 409). According to the American Direct Marketing Association’s definition, direct marketing is defined as “an interactive (bi-directional) marketing system that uses one or more advertising tools to induce measurable response and/or activity from anywhere, or to influence customers’ ideas.” ([7], p. 252). For example, a business can announce through letters, brochures, mail, etc. to its specified target audience. It can even make it easier for the target audience to purchase the product or service by adding an order form related to the products and services to the specified promotional tools. In the globalizing world, changing customer profiles and changing lifestyles of people, the change and spread of the technology used in marketing and the spread of customer-oriented marketing understanding have led to the spread of direct marketing ([10], p. 65). Direct marketing provides the opportunity to supply products in new ways. In addition, direct marketing differs from other methods of communication and usually requires a direct response. This allows quantitative assessment of the effectiveness of many direct marketing campaigns ([14], p. 481).

Businesses use direct marketing to tailor their offerings and content to the needs and interests of narrowly defined groups or individual buyers. In this way, customer participation is ensured, brand community is formed, and sales are realized ([2], p. 512).

Health institutions can use direct marketing to inform customers about existing or new services or to propose special offers to customers. In this communication method, the recipient should have the attention to open the e-mail. The advantage of e-mail compared to direct mail is that it reaches the target in a very short time and has a minimum entitlement [20].

Telemarketing, a direct marketing method that consumers are familiar with, is a method which is based on periodical communication of health institution with consumers via call center informing them about the products/services produced offered. In other words, it is a direct marketing method used to reach potential customers regarding various services and programs. In addition, telemarketing is more expensive than e-mail, but it is more effective in attracting the patient to the healthcare facility [16].

Promotion mix elements consist of advertising (newspaper, magazine, TV etc.), personal selling (personal communication with customers), direct marketing (e-mail, telemarketing etc.), digital communications (social media, blog, website etc.), sales promotion (coupons, sample product, discount etc.), publicity (corporate identity, institutional advertising etc.), and sponsorship. All of these tools have typical strengths and weaknesses. Direct marketing has strengths such as personalizing communication, facilitating the measurement of short-term activities, sustaining communication with customers through periodic contact, and minimizing competitors’ access to activities performed. In contrast, the low response rate and direct marketing activities targeting the poor may cause consumer disturbance and weaknesses ([14], p. 432).

9. Health services and promotion

Today, health institutions have become consumer-centered and aim to produce high-quality services at reasonable prices. Therefore, health marketing has become increasingly competitive all over the world [21].

Health care and promotion are two concepts that have been difficult to think together. It is always debated which messages will be given to people with health problems related to a hospital or similar health institution. Moreover, it is not clear when the need for health services will arise. It is natural that healthy person does not pay much attention to a doctor, hospital, or health care. Because of these features, it is possible to say that there are different dimensions of promotion in health services ([7], p. 252). Promotion is a remarkable issue in health services. In broad terms, the product/service, price, distribution, promotion, and human element in the marketing mix constitute the means of communication. The promotion function in any service organization consists of efforts to communicate with old, current, and future customers. Customers must be aware of the service provided by the organization. Promotion includes promotional activities such as advertising, sales promotion, and personal selling. Health institutions do not carry out aggressive promotion activities. They believe that word of mouth communication is more reliable [21].

It is necessary to address the image of the organization before discussing how promotion activities can be carried out in healthcare facilities. For example, is the organization innovative, dynamic, and using advanced technology, or is it more traditionally committed? Answering these questions is very important. The answers to these questions vary depending on the type of service offered by the health institution and the market conditions in which it operates. Some questions need to be answered about how to manage promotional activities. These ([22], p. 136) are the following:

What image does the hospital or unit currently have?
What kind of image do health managers want?
What kind of image do patients and applicants want, and what will be most comfortable?
What images are there in other local hospitals or units?

Promotion indicates how health enterprises will provide information and training to the market on their products and services. The information process includes public relations, advertising, and other activities. For example, the publicity function can be used for present and new services, management of the crisis situation, partnership with organizations, and promotion of the new method that will lead the future of the organization. In addition, it is advertised to the masses on billboards by service providers to inform potential patients, healthcare organizations, and local employers the type of product or service, the cost status of the organization, and ease of transportation ([7], p. 253). In addition, five activities that are generally used as promotion or communication tools in health institutions are mentioned (Figure 2).

Figure 2.
The growth of pharmaceutical DTCA spending. Source: [12].

While some of the promotion mix elements (brochures, etc.) mentioned inFigure 3 require low cost and coordination, others (advertisements, exhibitions, public relations, sponsorship, etc.) are applications with higher budgets. As it can be understood from the statements, it is necessary to use many elements together in which only one or two promoter elements will not contribute much to the establishment ([22], p. 138).

Figure 3.
The promotion or communications mix. Source: Ref. ([22], p. 137).

Despite some negative opinions in the health sector, advertising has been implemented by hospitals for many years under the headings of public relations and press and community relations. Today, such communication activities have been expanded not only to assist in the promotion of the services offered but also to carry out a training and motivation and attitude development function. As an effective means of communication, advertising should draw people facing health services to existing services while warning them against certain facts. Although there have been some criticisms of unethical practices and wasted resources, it has been successful in increasing the consumption of the services provided. If it is done in an appropriate and moral way, advertising will continue to be a powerful tool for the healthcare sector that wants to promote its services to consumers [23].

Health care is one of the sectors that has grown the most in the service sector. With increasing interest in health, advertising plays an important role in determining the market share and profitability of hospitals. Reasons for this include increased competitive pressures for hospitals, increased customer training levels, greater awareness, and better discrepancy between the qualities of service provided by different hospitals [24].

Public relations are at the forefront in terms of creating a positive image in the society in terms of services and works offered in health institutions rather than advertising in marketing communication. Health services marketing with image management, it aims to create communication programs that will enable customers to evaluate the hospital and the health services provided positively ([7], p. 253). Health institutions and staff should have the ability to communicate effectively with their customers and stakeholders. Communication can be more effective with a clear audience and when the audience’s media habits are in-line with what is known. Successful communication involves nine elements of communication. These are the source, coding, message, media, decoding, receiver/viewer, response, noise, and feedback. In addition, the audience must understand the responses from awareness to knowledge, preference, taste, beliefs, and purchasing. Developing effective marketing communication consists of eight important steps. These ([25]: 426) are the following:

Identify the target audience: It is the determination of the audience that each marketing communication tool used by the company will reach. At the same time, the answers to the questions to what extent the target group will be reached are determined.
Determining communication objectives: It is sought to answer questions about how communication processes consumers, increases awareness, and improves the image of the healthcare organization.
Designing communication: The healthcare organization has to determine how to establish communication in order to reach its target audience. It should use well-designed communication to help customers remember the brand more easily and improve their relationship with customers. For example, it is illegal to broadcast DTC-branded drugs on Canadian television channels. However, the firm is able to strengthen the communication with its customers by advertising to the American TV channels considering that Canadians can access the TV channels in the United States.
Selecting communication channels: The healthcare organization should determine which channel (TV commercials, social media, brochures, billboards, etc.) to use to communicate with its target audience. When determining the communication channel, determining a suitable channel for the customer is very important in terms of brand recognition and retention.
Estimate the total marketing communication budget: The healthcare organization should determine the budget to be allocated to the tools to be used in marketing communication. For this reason, the communication medium that can reach the target audience must be in-line with the budget of the healthcare organization. Otherwise, it will be inevitable that the healthcare organization will face financial problems in the future.
Deciding which media channels to use: The healthcare organization can have multiple communication tools to reach its target audience. Deciding which of these communication tools to choose is very important for effective and efficient customer communication.
To measure the results: The measurement of the effectiveness and efficiency of the communication channels determined and applied to reach the target audience is realized at this stage.
Managing integrated communications: In summary, a healthcare provider should decide the best mix of marketing communication tools (advertising, personal selling, public relations, promotion, direct marketing, etc.). It should continually evaluate the decision-making methods with criteria such as awareness, interest, information, preference, and procurement. The organization should try to manage a well-integrated marketing communication program over time.

As mentioned before, personal selling is the most powerful promotion method in the service sector. Research on this subject shows that the sales process of a service depends on the quality of the relationship between the seller and the buyer. However, when used well, advertising can have more positive results than public relations. Inter-customer communication, also called word of mouth marketing, is also very important for the health sector ([7], p. 254). Healthcare companies generally prefer to use their own staff instead of professional salespeople. Should a professional sales person be trained and used in the sale of health services, or should staff such as nurses and doctors be trained in sales techniques? A complete answer to this question has not yet been found. In one view, health care is no different from other goods or services, so a person who has previously been successful in the sale of construction equipment can also be successful in this field. Another alternative is to benefit from people who have proven their ability to sell in health-related branches. Companies that produce or sell pharmaceuticals and medical supplies use many sales representatives. The medical knowledge of such a salesperson cannot be as much as a physician but it is undoubtedly more than any person [18].

Some people see physicians referring patients to the hospital as sales persons, which is wrong. The sales representative acts for the purpose of sale. However, the physician refers the patient to a higher health institution for medical reasons. The physician is free to send the patient to any organization and physician, and the seller does not have such freedom [26].

Providing health services effectively is perhaps the only way to reach healthy generations. Hospitals, which are one of the places where health services are provided, can provide these services through the integrated marketing communication efforts of the hospitals. Integrated marketing communication in the health sector is to communicate health services to potential users through communication and to convince them of the benefits to be achieved. Through integrated marketing communication studies, it is aimed to convey the existence, quality, access, and use of services to potential patients. Although personal selling and sales promotion activities, which play an important role in product marketing, do not have a wide application in health services, advertising and public relations can find a very important and wide application area. These subjects are explained in detail in this book ([23]. p. V). The advertisement gives a reason for the purchase of the product, and the sales promotion offers an incentive for the purchase. Sales promotion includes efforts for consumer promotion such as samples, coupons, cash back, discounted prices, gifts, free trials, warranties, binding promotions, point of sale displays, and exhibitions. Commercial promotion includes discounted prices, advertising and display costs, and free items, and business and sales promotion includes commercial exhibitions and congresses, competitions for sales representatives, and special advertisements [27]. Compared to sales development activities implemented in other sectors, the methods of sales promotion in health services are very limited. However, some creative solutions can still be found. For example, patients who come to the health facility for the first time can be given a certain discount or to children who come with the patient can be given small gifts. Sales incentives applied in the health services sector can be given as a positive work, action, or attitude response. Trying, buying more, and participating in marketing effort are positive behavior. However, sometimes penalties may be imposed to prevent the opposite of a desired behavior. For example, while in some countries financial assistance is provided to families with fewer children for the purpose of population control, tax rates of families with many children have been increased [18].

Along with the difficulties arising from the abstractness of health services, health promotion strategies are as follows ([7], p. 254);

Ensure that employees are aware of opportunities to promote health as part of their work.
Provide health information to employees, visitors, and patients in order to inform them of their health decisions.
Support the changing behavior of individuals.
Beautify the environment of the health institution for its users.
Establish contact with other health institutions for proper planning and distribution.
Ensure that all marketing communication activities are research-based.
Evaluate the results of promotion activities.

Social media marketing in the field of health is another marketing communication tool. There are several ways in which social media can be used for health promotion education. The digitization of human interactions and intimacy has led to a distance of convergence and even disappearing at the touch of a button. As a result of digitalization, social media is a source of interaction for public health. It has the potential to change many health-related behaviors, especially in times of crisis. With the interaction in social media, multifaceted communication takes place and public health messages are spread more rapidly. As a result, health knowledge of the society increases and contributes to the development of health level ([28], p. 301).

Consumers’ widespread use of electronic tools forces marketing experts to find new technology strategies. The aim of health marketing is to learn and understand the needs and aspirations of potential patients in order to meet these requirements at the highest standards. Tools such as the Internet, social media, and e-mail provide a direct cost to direct marketing, as well as provide virtual customers with an opportunity to market the service, eliminate distances, and make consumers aware of the service provided. Another important advantage increases the ability of marketing managers in health institutions to identify target audiences by using electronic media as advertising tools in the development of marketing strategies ([29], p. 44; [30]). In a study examining the effectiveness of social media in plastic surgery marketing, researchers compared the prevalence of social media with classical marketing methods. This research was conducted in Beverly Hills, California; Dallas, Texas; Houston, Texas; Las Vegas, Nevada; Miami, Florida; New York City, New York; and San Francisco, California. Plastic surgeons in Florida prefer social media (50% Facebook and 46% Twitter) for their promotional activities. Fifty-six percent of plastic surgeons in New York use magazines and newspapers in their promotional activities, while surgeons in Beverly Hills use television commercials. As a result, although social media seems to be a unique means of communication, it is emphasized that it is important to maintain the profession in a professional way and to create a traditional website and to maintain these activities in line with ethical principles [31].

It is always a good idea to have a good website for corporations. The fact that organizations have an interactive and user-friendly website that provides a lot of information also points to an excellent advertising platform. The website may be a source of information for potential patients, employees, or other stakeholders. Patients use the organization’s websites to learn about the services provided by the healthcare provider, read user reviews, access photo and video content about the organization, and compare healthcare prices and offers with other healthcare organizations. At the same time, access to consumers is facilitated through keywords added to websites. This makes it easier to reach the target audience. The healthcare provider communicates with consumers through their website about their own or the price offers of products and services and helps the Internet user to search for the information they want and to make the dialog between consumers and the organization sustainable [32].

Advertising and promotion, which are among the promotion activities in health services, are marketing strategies aimed at developing and sustaining relations with the target group (patients). In order to carry out these activities, ethical rules are needed in health marketing. Because health services are open to abuse. Therefore, promotion activities of health institutions should be consistent and should not create unnecessary expectations for patients. Physicians or health institutions providing health services should be able to provide the health services claimed in the advertisements. A patient who is in severe pain is easily affected by advertising and will tend to rely on any promise of recovery [33].

10. Result

Marketing communication is done to inform consumers about whom, when, where, how, and why the product or service will be used. Through marketing communication, consumers can learn by whom the product or service is being produced and what the manufacturer or brand means. It also contributes to brand equity by increasing sales, increasing brand value, and creating brand image [1]. Organizations try to provide competitive advantage through marketing communication or promotion activities and to protect and increase their superiority. Although these activities are thought to be aimed at consumers, they are carried out in the works for intermediary institutions [34]. Marketing communication activities in corporations are carried out with many tools such as advertising, sales promotions, personal selling, public relations, direct marketing, and digital marketing. Promotion can be done not only in nonprofit organizations but also by nonprofit organizations and manufacturers. The main purpose of promotion in corporations is to inform, convince, and remind current or potential customers about the corporation and the products and services it produces. The result of these activities is to attract the attention of customers and realize the sale.

Due to some factors arising from consumers, the importance of promotion is increasing day by day. Some of these factors are changing the demands, needs, and expectations of consumers, increasing the number of conscious consumers; increasing competitors; increasing the number of intermediary institutions; or being in different positions of producers and consumers. However, increasing cost pressures hinder promotion activities in some cases. For this reason, it is possible to reduce the costs of promotion with technological developments in today’s world. Technological advances have brought the concept of digital marketing to the agenda and traditional marketing methods have become much less used. Corporations use many digital tools such as web sites, social media, and e-mail in their promotional activities, and these modern marketing methods can reach more people at a lower cost than classical marketing. Consumers can easily find the corporation, product, or service they want to reach through search engines, and in the light of the information on their web sites, they both know the business and obtain information about the product or service. In addition, promotional activities through social media reinforce the image of the business and create a communication between the business and the consumer.

Promotion activities in health services, which are very difficult to deliver and manage within the service sector are very important. Although it is not as active as the promotion mix elements used in other sectors, advertising and public relations occupy an important and wide place in the health sector. Promotion in the health sector means to conduct the products or services presented in the healthcare facility to the potential users by using promotional tools such as advertising and public relations and convincing them about the benefits to be obtained. The aim is to provide information about the existence, quality, access, and use of services to be provided to potential patients.

In the health sector, the services provided are not only communicated to potential users but are also considered as promotions in trainings provided on social platforms in order to increase the reliability and the image of the company or serve the society. As in other sectors, promotion activities in the health sector have changed in parallel with the development of technology. In the past, the services provided by the healthcare facility were communicated to potential users through mass media such as magazines, newspapers, or TV channels, but now they communicate directly or indirectly with patients through their own web sites or social media accounts. At the same time, it is easier for healthcare organizations to communicate with their existing or potential patients through their own mobile applications developed on platforms such as Apple Store and Play Store.

The most important marketing communication tool used in health institutions is public relations. As in all other organizations, there are many groups (stakeholders) where health institutions interact. These are divided into two as internal stakeholders (employees, managers, hospital owners, etc.) and external stakeholders (patients, relatives of patients, media, Ministry of Health, competing hospitals, supplier groups, etc.). Public relations, which is one of the marketing communication tools, can be expressed as efforts to create a positive image in society by establishing correct and reliable relations with internal and external stakeholders. Furthermore, sharing the policies implemented by the health institution with the stakeholders and adopting these policies by the stakeholders, ensuring that the activities of the organization are positively met by the stakeholders, are among the activities of public relations. If good communication is established with the society, it is inevitable that the health institution will increase its market awareness and superiority over its competitors. For this reason, public relations, which is one of the marketing communication tools, is among the indispensable marketing activities of the health institution.

The aim of health promotion activities is not to direct existing or potential patients to unnecessary consumption but to inform them, to convince them of the benefits to be provided, and to include patients in the diagnosis and treatment process. In this way, it helps in the early diagnosis and treatment of diseases. It can also be used to provide new financial resources through donations to the organization through the efforts of the public relations unit. As a result, the promotion of the health service marketing mix, or the so-called marketing communication, is vital.

Hiromichi Ishii

Chapters authored

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