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Health education What social marketing can do for you Getting patients to adopt healthier behaviour can feel like an uphill struggle. One way to improve your success may be to use commercial strategies for influencing consumers. W Douglas Evans looks at the evolution of social marketing in health care while Gerard Hastings and Laura McDermott examine strategies in practice

How social marketing works in health care W Douglas Evans

Social marketing applies commercial marketing strate- gies to promote public health. Social marketing is effective on a population level, and healthcare provid- ers can contribute to its effectiveness.

What is social marketing? In the preface to Marketing Social Change, Andreasen defines social marketing as “the application of proven concepts and techniques drawn from the commercial sector to promote changes in diverse socially important behaviors such as drug use, smoking, sexual behavior . . . This marketing approach has an immense potential to affect major social problems if we can only learn how to harness its power.”1 By “proven techniques” Andreasen meant methods drawn from behavioural theory, persuasion psychology, and mar- keting science with regard to health behaviour, human reactions to messages and message delivery, and the “marketing mix” or “four Ps” of marketing (place, price, product, and promotion).2 These methods include using behavioural theory to influence behaviour that affects health; assessing factors that underlie the recep- tivity of audiences to messages, such as the credibility and likeability of the argument; and strategic marketing of messages that aim to change the behaviour of target audiences using the four Ps.3

How is social marketing applied to health? Social marketing is widely used to influence health behaviour. Social marketers use a wide range of health communication strategies based on mass media; they also use mediated (for example, through a healthcare provider), interpersonal, and other modes of commu- nication; and marketing methods such as message placement (for example, in clinics), promotion, dissemination, and community level outreach. Social marketing encompasses all of these strategies.

Communication channels for health information have changed greatly in recent years. One-way dissemi- nation of information has given way to a multimodal transactional model of communication. Social market- ers face challenges such as increased numbers and types of health issues competing for the public’s attention; limitations on people’s time; and increased numbers and types of communication channels, including the internet.4 A multimodal approach is the most effective way to reach audiences about health issues.5

Figure 1 summarises the basic elements or stages of social marketing.6 The six basic stages are: developing plans and strategies using behavioural theory; selecting communication channels and materials based on the required behavioural change and knowledge of the tar- get audience; developing and pretesting materials, typically using qualitative methods; implementing the communication programme or “campaign”; assessing effectiveness in terms of exposure and awareness of the audience, reactions to messages, and behavioural

Research

2 Select

channels and materials

5 Assess

effectiveness

1 Plan strategy

3 Develop

materials and pretesting

6 Feedback to refine

programme

4 Implementation

Fig 1 Social marketing wheel

Health Promotion Research, RTI International, WA 20036, USA W Douglas Evans vice president

[email protected]

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outcomes (such as improved diet or not smoking); and refining the materials for future communications. The last stage feeds back into the first to create a continuous loop of planning, implementation, and improvement.

Audience segmentation One of the key decisions in social marketing that guides the planning of most health communications is whether to deliver messages to a general audience or whether to “segment” into target audiences. Audience segmentation is usually based on sociodemographic, cultural, and behavioural characteristics that may be associated with the intended behaviour change. For example, the National Cancer Institute’s “five a day for better health” campaign developed specific messages aimed at Hispanic people, because national data indicate that they eat fewer fruits and vegetables and may have cultural reasons that discourage them from eating locally available produce.6

The broadest approach to audience segmentation is targeted communications, in which information about population groups is used to prepare messages that draw attention to a generic message but are targeted using a person’s name (for example, marketing by mass mail). This form of segmentation is used commercially to aim products at specific customer profiles (for exam- ple, upper middle income women who have children and live in suburban areas). It has been used effectively in health promotion to develop socially desirable images and prevention messages (fig 2).

“Tailored” communications are a more specific, indi- vidualised form of segmentation. Tailoring can generate highly customised messages on a large scale. Over the past 10-15 years, tailored health communications have been used widely for public health issues. Such commu- nications have been defined as “any combination of information and behavior change strategies intended to reach one specific person, based on characteristics that are unique to that person, related to the outcome of interest, and derived from an individual assessment.”7

Because tailored materials consider specific cognitive and behavioural patterns as well as individual demo- graphic characteristics, they are more precise than targeted materials but are more limited in population reach and may be more expensive to develop and implement.

Media trends and adapting commercial marketing As digital sources of health information continue to proliferate, people with low income and low education

will find it more difficult to access health information. This “digital divide” affects a large proportion of people in the United States and other Western nations. Thus, creating effective health messages and rapidly identifying and adapting them to appropriate audiences (which are themselves rapidly changing) is essential to achieving the Healthy People 2010 goal of reducing health disparity within the US population.8

In response, social marketers have adapted commercial marketing for health purposes. Social marketing now uses commercial marketing techniques—such as analysing target audiences, identi- fying the objectives of targeted behaviour changes, tailoring messages, and adapting strategies like branding—to promote the adoption and maintenance of health behaviours. Key trends include the recogni- tion that messages on health behaviour vary along a continuum from prevention to promotion and maintenance, as reflected by theories such as the “transtheoretical model”9; the need for unified message strategies and methods of measuring reactions and outcomes10; and competition between health messages and messages that promote unhealthy behaviour from product marketers and others.11

Prevention versus promotion Social marketing messages can aim to prevent risky health behaviour through education or the promotion of behavioural alternatives. Early anti-drug messages in the US sought to prevent, whereas the antismoking campaigns of the US Centers for Disease Control and Prevention and the American Legacy Foundation offered socially desirable lifestyle alternatives (be “cool” by not smoking).12 13 The challenge for social marketing is how best to compete against product advertisers with bigger budgets and more ways to reach consumers.

Competing for attention Social marketing aimed at changing health behaviour encounters external and internal competition. Digital communications proffer countless unhealthy eating messages along with seductive lifestyle images associ- ated with cigarette brands. Cable television, the web, and video games offer endless opportunities for comorbid behaviour. At the same time, product marketers add to the confusion by marketing “reduced risk” cigarettes or obscure benefits of foods (such as low salt content in foods high in saturated fat).

How is social marketing used to change health behaviour? Social marketing uses behavioural, persuasion, and exposure theories to target changes in health risk behaviour. Social cognitive theory based on response consequences (of individual behaviour), observational learning, and behavioural modelling is widely used.14

Persuasion theory indicates that people must engage in message “elaboration” (developing favourable thoughts about a message’s arguments) for long term persuasion to occur.3 Exposure theorists study how the intensity of and length of exposure to a message affects behaviour.10

Social marketers use theory to identify behavioural determinants that can be modified. For example, social marketing aimed at obesity might use behavioural

Fig 2 Image used in the American Legacy Foundation’s Truth antismoking campaign aimed at young people

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theory to identify connections between behavioural determinants of poor nutrition, such as eating habits within the family, availability of food with high calorie and low nutrient density (junk food) in the community, and the glamorisation of fast food in advertising. Social marketers use such factors to construct conceptual frameworks that model complex pathways from messages to changes in behaviour (fig 3).

In applying theory based conceptual models, social marketers again use commercial marketing strategies based on the marketing mix.2 For example, they develop brands on the basis of health behaviour and lifestyles, as commercial marketers would with prod- ucts. Targeted and tailored message strategies have been used in antismoking campaigns to build “brand equity”—a set of attributes that a consumer has for a product, service, or (in the case health campaigns) set of behaviours.13 Brands underlying the VERB cam- paign (which encourages young people to be physically active) and Truth campaigns were based on alternative healthy behaviours, marketed using socially appealing images that portrayed healthy lifestyles as preferable to junk food or fast food and cigarettes.14 15

Can social marketing change health behaviour? The best evidence that social marketing is effective comes from studies of mass communication cam- paigns. The lessons learned from these campaigns can be applied to other modes of communication, such as communication mediated by healthcare providers and interpersonal communication (for example, mass nutrition messages can be used in interactions between doctors and patients).

Social marketing campaigns can change health behaviour and behavioural mediators, but the effects are often small.5 For example, antismoking campaigns, such as the American Legacy Foundation’s Truth cam- paign, can reduce the number of people who start smoking and progress to established smoking.16 From 1999 to 2002, the prevalence of smoking in young people in the US decreased from 25.3% to 18%, and the Truth campaign was responsible for about 22% of that decrease.16

This is a small effect by clinical standards, but it shows that social marketing can have a big impact at the population level. For example, if the number of

young people in the US was 40 million, 10.1 million would have smoked in 1999, and this would be reduced to 7.2 million by 2002. In this example, the Truth cam- paign would be responsible for nearly 640 000 young people not starting to smoke; this would result in millions of added life years and reductions in healthcare costs and other social costs.

In a study of 48 social marketing campaigns in the US based on the mass media, the average campaign accounted for about 9% of the favourable changes in health risk behaviour, but the results were variable.17

“Non-coercive” campaigns (those that simply delivered health information) accounted for about 5% of the observed variation.17

A study of 17 recent European health campaigns on a range of topics including promotion of testing for HIV, admissions for myocardial infarction, immunisa- tions, and cancer screening also found small but posi- tive effects.18 This study showed that behaviours that need to be changed once or only a few times are easier to promote than those that must be repeated and maintained over time.19 Some examples (such as breast feeding, taking vitamin A supplements, and switching to skimmed milk) have shown greater effect sizes, and they seem to have higher rates of success.19 20

Implications for healthcare practitioners This brief overview indicates that social marketing prac- tices can be useful in healthcare practice. Firstly, during social marketing campaigns, such as antismoking campaigns, practitioners should reinforce media mes- sages through brief counselling. Secondly, practitioners can make a valuable contribution by providing another communication channel to reach the target audience. Finally, because practitioners are a trusted source of health information, their reinforcement of social marketing messages adds value beyond the effects of mass communication.

Contributors and sources: WDE’s research focuses on behaviour change and public education intervention programmes designed to communicate science based information. He has published extensively on the influence of the media on health behaviour, including the effects of social marketing on changes in behaviour. This article arose from his presentation at and discussions after a recent conference on diet and communication. Competing interests: None declared.

1 Andreasen A. Marketing social change. San Francisco, CA: Jossey-Bass, 1995.

2 Borden N. The concept of the marketing mix. J Advertis Res 1964;4:2-7. 3 Petty RE, Cacioppo JT. Communication and persuasion: central and peripheral

routes to attitude change. New York: Springer-Verlag, 1986.

1. Social marketing initiatives National five a day campaign Messages for African Americans and Hispanics Health promotion value of fruits and vegetables

3. Knowledge, attitudes, and beliefs Belief in health promotion value of fruits and vegetables Attitude that consuming more fruits and vegetables is good Intention to consume more fruits and vegetables

2. Exposure to five a day message Audience awareness Message receptivity

4. Behaviour Consuming five servings of fruits and vegetables every day

Fig 3 Example of social marketing conceptual framework

Summary points

Social marketing uses commercial marketing strategies such as audience segmentation and branding to change health behaviour

Social marketing is an effective way to change health behaviour in many areas of health risk

Doctors can reinforce these messages during their direct and indirect contact with patients

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4 Backer TE, Rogers EM, Sonory P. Designing health communication campaigns: what works? Newbury Park, CA: Sage, 1992.

5 Hornik RC. Public health communication: evidence for behavior change. Mahwah, NJ: Erlbaum, 2002.

6 National Cancer Institute. Making health communication programs work: a planner’s guide. Bethesda, MD: NCI, 2002.

7 Kreuter M, Farrell D, Olevitch L, Brennan L. Tailored health messages: customizing communication with computer technology. Mahwah, NJ: Erlbaum, 2000.

8 US Department of Health and Human Services. Healthy people 2010: understanding and improving health. 2nd ed. Washington, DC: US Govern- ment Printing Office, 2000.

9 Prochaska JO, DiClemente CC. Stages of change in the modification of problem behaviors. Newbury Park, CA: Sage, 1992.

10 PACT Agencies. PACT: positioning advertising copy testing. J Advertis 1982;11:3-29.

11 Aaker D. Building strong brands. New York: Simon & Schuster, 1996. 12 Hornik R, Yanovitsky I. Using theory to design evaluations of communi-

cation campaigns: the case of the national youth anti-drug media campaign. Commun Theory 2003;13:204-24.

13 Evans D, Price S, Blahut S. Evaluating the truth™ brand. J Health Commun 2005;10:181-92.

14 Bandura A. Social foundations of thought and action: a social cognitive theory. Englewood Cliffs, NJ: Prentice Hall, 1986.

15 Huhman M, Heitzler C, Wong F. The VERB campaign logic model: a tool for planning and evaluation. Prev Chronic Dis 2004;1(3):A11.

16 Farrelly MC, Davis KC, Haviland ML, Messeri P, Healton CG. Evidence of a dose-response relationship between “truth” antismoking ads and youth smoking. Am J Public Health 2005;95:425-31.

17 Snyder LB, Hamilton MA. Meta-analysis of U.S. health campaign effects on behavior: emphasize enforcement, exposure, and new information, and beware the secular trend. In: Hornik R, ed. Public health communication: evidence for behavior change. Hillsdale, NJ: Erlbaum, 2002:357-83.

18 Grilli R, Freemantle N, Minozzi S, Domenighetti G, Finer D. Mass media interventions: effects on health services utilization (Cochrane review). Cochrane Library. Issue 3. Oxford: Update Software, 2000:CD000389.

19 Snyder LB, Diop-Sidibé N, Badiane LA. Meta-analysis of the impact of family planning campaigns conducted by the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs. Presented at the International Communication Association annual meet- ing, San Diego: May 2003.

20 Hornik RC. Public health education and communication as policy instruments for bringing about changes in behavior. In: Goldberg M, Fishbein M, Middlestadt S, eds. Social marketing. Mahwah, NJ: Erlbaum, 1997:45-60.

(Accepted 20 February 2006)

Putting social marketing into practice Gerard Hastings, Laura McDermott

Social marketing is acquiring a familiar ring to people in the health sector. The UK government’s recent pub- lic health white paper talks of the “power of social mar- keting” and “marketing tools applied to social good [being] used to build public awareness and change behaviour.”1 This has led to the formation of the National Social Marketing Centre for Excellence, a col- laboration between the Department of Health and the National Consumer Council. The centre will develop the first social marketing strategy for health in England. Similarly, the Scottish Executive recently commissioned an investigation into how social market- ing can be used to guide health improvement. Australia, New Zealand, Canada, and the United States all have social marketing facilities embedded high within their health services. Evans has outlined social marketing’s basic precepts.2 We develop some of these

ideas and suggest how social marketing can help doc- tors and other health professionals to do their jobs more effectively.

An old enemy and a new friend Marketing has long been a force to be reckoned with in public health. In the hands of the tobacco, alcohol, and food industries it has had a well documented effect on our behaviour.3–6 In the case of tobacco companies this has culminated in extensive controls being placed on their marketing activities. Social marketing argues that we can borrow marketing ideas to promote healthy behaviour. If marketing can encourage us to buy a Fer- rari, it can persuade us to drive it safely.

Marketing is based on a simple and unobtrusive idea: putting the consumer and the stakeholder at the heart of the business process. Whereas Henry Ford focused on selling what he could produce—any colour you want as long as it’s black—modern marketers invert this rubric and produce what they can sell. This decep- tively simple change has revolutionised commerce over the past 50 years, making Nike and Coca-Cola the behemoths they are. It has succeeded because, paradoxically, listening to consumers and taking care to understand their point of view makes it easier to influence their behaviour.

Social marketers argue that attempts to influence health behaviour should also start from an under- standing of the people we want to do the changing. The task is to work out why they do what they do at present—their values and motivations—and use these to encourage healthy options.

Often the picture is much more complex than ignorance of the public health facts. Most people know, for instance, that smoking is dangerous or how their

Selling lifestyle

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A summary of the effect of social marketing in nutrition is on bmj.com

Analysis and comment

Institute for Social Marketing, Stirling and the Open University, Stirling FK9 4LA Gerard Hastings director Laura McDermott research officer

Correspondence to: G Hastings gerard.hastings@ stir.ac.uk

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