On Social Marketing and Social Change

Social Marketing Objectives for Healthy People 2020

Will social marketing play a role in pubic policy for disease prevention and health promotion over the next 10 years? One arena in which social marketing could 'be at the table' are the Health People 2020 objectives - the national health priorities for the decade. For those new to the process, these objectives help guide the development of Federal programs, how grants and contracts are crafted and dispersed, and when the question is asked 'What are the priorities?' - where many people go to for the answers.

While I and some guests have been writing about HP 2020 regularly here over the past few months, very few social marketers took advantage of the opportunity to provide public input into their formation (kudos to Bob Marshall. Mike Rothschild and Mike Basel for making comments on the HP workspace about them). Whether there will be ANY draft objectives related to social marketing will now be in the hands on the Federal Interagency Workgroup (FIW) over the Summer. We will have to wait to see what emerges from that group in the Fall when there should be one more round of public comments before the final objectives are set for a public launch in 2010.

For those of you who are interested in how social marketing could be represented in HP 2020, I did put together some of the ideas talked about in the Health Communication and Health IT Workspace as draft objectives for the FIW to consider. You can download the entire 6 page document by going to the site, registering and then clicking on the library section where it is posted in its entirety. Here's the nut of it:

1.1.    All Federally-funded public health programs that aim to improve the health of population groups (segments) through changes in voluntary behaviors, social norms and customs, environmental and structural changes, and/or regulations and policies should demonstrate adherence with the following principles:
a. Actively engage people and organizations for whom the program is intended to serve in the development of program outcomes and strategies.
b. There must be a set of integrated activities that analyze, design for, implement and evaluate programs that specifically address (1) products, services and behaviors that will improve individual health and well-being; (2) realign incentives and costs to facilitate behaviors for the individual and organizations; (3) create opportunities and improve access to beneficial products, services and places that encourage and support behavior change; and (4) employ state-of-the-science communication strategies and tools to promote and support positive change at all levels of society - individuals, families and other social networks, organizations and communities.

1.2     Increase access to training opportunities and capabilities of public health professionals to develop and implement disease prevention and health promotion programs based on a systematic social marketing approach
·        Undergraduate and graduate training in schools of public health
·        Continuing education training for public health practitioners.

Whether you agree or disagree with what is here is less important than if you care. If you care, then I hope you will get onto the site and start leaving more comments - support it, trash it, offer other ideas. What is written in the work space is the official record of the public process - not your tweets, postings on blogs and SNS, hallway conversations or emails. And if you are not the social media (wiki) sort, start talking it up with people who represent you in other public health organizations who will be lobbied (or educated) by numerous interests who want to see their agenda part of the Federal agenda.

As the saying goes, If you aren't at the table, you're likely on the menu.

Comparative Effectiveness Research and Social Marketing

Comparative Effectiveness Research (CER) is one of the buzz words in the health care reform and economic stimulus package conversations in which $1.1 billion is allocated for CER.

CER studies offer the opportunity to evaluate social marketing under more rigorous conditions than are typically present in our applied work. Yet, one danger is that many policy staff, grant makers and investigators will mistakenly operationalize the term 'social marketing' to include interventions that only use communication strategies or only sell products to consumers. I hope funders of CER research, and the policy makers, will educate themselves that social marketing is more than either of those extremes, and that incentive systems coupled with better access and improved opportunities for more people to lead healthier lives are part of the social marketing mix and the CER that is eventually funded.

The Institute of Medicine (IOM) just released their list of the 100 national priority areas for CER. I have pulled from their list some examples where social marketing should be at the table.

1. Compare the effectiveness of primary prevention methods, such as exercise and balance training, versus clinical treatments in preventing falls in older adults at varying degrees of risk.

2. Compare the effectiveness of dissemination and translation techniques to facilitate the use of CER by patients, clinicians, payers, and others.

3. Compare the effectiveness and costs of alternative detection and management strategies (e.g., pharmacologic treatment, social/family support, combined pharmacologic and social/family support) for dementia in community-dwelling individuals and their caregivers.

4. Compare the effectiveness of school-based interventions involving meal programs, vending machines, and physical education, at different levels of intensity, in preventing and treating overweight and obesity in children and adolescents.

5. Compare the effectiveness of various strategies (e.g., clinical interventions, selected social interventions [such as improving the built environment in communities and making healthy foods more available], combined clinical and social interventions) to prevent obesity, hypertension, diabetes, and heart disease in at-risk populations such as the urban poor and American Indians.

6. Compare the effectiveness of the various delivery models (e.g., primary care, dental offices, schools, mobile vans) in preventing dental caries in children.

7. Compare the effectiveness of wraparound home and community-based services and residential treatment in managing serious emotional disorders in children and adults.

8. Compare the effectiveness of interventions (e.g., community-based multi-level interventions, simple health education, usual care) to reduce health disparities in cardiovascular disease, diabetes, cancer, musculoskeletal diseases, and birth outcomes.

9. Compare the effectiveness of literacy-sensitive disease management programs and usual care in reducing disparities in children and adults with low literacy and chronic disease (e.g., heart disease).

10. Compare the effectiveness of clinical interventions (e.g., prenatal care, nutritional counseling, smoking cessation, substance abuse treatment, and combinations of these interventions) to reduce incidences of infant mortality, pre-term births, and low birth rates, especially among African American women.

11. Compare the effectiveness of innovative strategies for preventing unintended pregnancies (e.g., over-the-counter access to oral contraceptives or other hormonal methods, expanding access to long-acting methods for young women, providing free contraceptive methods at public clinics, pharmacies, or other locations).

12. Compare the effectiveness of strategies for enhancing patients’ adherence to medication regimens.

13. Compare the effectiveness of patient decision support tools on informing diagnostic and treatment decisions (e.g., treatment choice, knowledge acquisition, treatment-preference concordance, decisional conflict) for elective surgical and nonsurgical procedures—especially in patients with limited English-language proficiency, limited education, hearing or visual impairments, or mental health problems.

And those are from just the first 30 or so top priorities - you get the idea.

I know that some social marketers will shudder at the idea of pigeon-holing social marketing programs into randomized clinical trials. For them, and other readers, I suggest you take a look at an article in the Annals of Internal Medicine (2009;151) by Luce et al Rethinking randomized clinical trials for comparative effectiveness research: The need for transformational change. Their thesis is:

…many RCTs as currently designed and conducted are ill suited to meet the evidentiary needs implicit in the IOM definition of CER: comparison of effective interventions among patients in typical patient care settings, with decisions tailored to individual patient needs. Without major changes in how we conceive, design, conduct, and analyze RCTs, the nation risks spending large sums of money inefficiently to answer the wrong questions—or the right questions too late.

My point is that there are many ways in which social marketing can be the subject of pragmatic research studies and applied to the solution of many challenges facing the health of Americans and the people who care about them. What are you doing to insure that society benefits from all that we have been learning in social marketing over the past 25 years (some references)?

Tremendously Courageous Researchers!

That was the declaration by Marc Mathieu in his talk with us at the Transformative Consumer Research Conference. His play on TCR reflected his experience at Coca-Cola where, he explained, he learned to 'never mess with acronyms.'

His point was that the world needs TCR now more than ever; researchers with a POV (make it a better world) and an idealism that drives them forward.

Marc was formerly the Senior Vice President of Global Brand Marketing at Coca-Cola and now CEO of MyBeDo. During his tenure at Coke, he introduced the 'Coke Side of Life' global marketing platform:

We live in a world where we make choices every day and The Coke Side of Life encourages people to make those choices positive ones... This new campaign invites people to create their own positive reality, to be spontaneous, listen to their hearts and live in full color.

He also led the redefinition of Coca-Cola's Way of Marketing, "the Coca-Cola DNA", a fusion of art & science approach to creating Brand Value and Brand Love - what he called 'happiness in a bottle.' The Live Responsibly program he fashioned is part of the Coke culture, vision and mission: Be a responsible citizen that makes a difference by helping build and support sustainable communities.

Marc left Coke to form BeDo around the vision: We believe that one day, every citizen on earth will have, at the center of their life, not just work and home, but also a third place, a place of purposeful pursuit that improves our world. We call it BeDo.

Some of Marc's quotes from his talk that I offer you to consider here are:

We have built a world around the perception of scarcity, rather than abundance.

The more we fear the future, the more we act in self-interest.

You cannot change people's behavior unless you have a positive view of the future.

He challenged each of us to identify our BeDo, and to live a BeDoful life. The we let our (biodegradable) balloons drift into the warm Pennsylvania sky.

My BeDo: (actually I have two - depending on the context):

1. Be the advocate for the audience - who are people too!

2. Be a disruptive force to allow positive change to emerge

(some may recognize the second as a variation on the themes of: The manager accepts the status quo, the leader challenges it - Warren Bennis; Status quo, you know, that is Latin for "'the mess we're in" - Ronald Reagan; or I'm not interested in preserving the status quo; I want to overthrow it - Niccolo Machiavelli.)

And on a personal note to consumer researchers who may read this I want to add my thanks for the enrichment and ideas I received at the conference - and the kind words about some of my positive disruptions. TCRs are bucking their academic status quo where social issues and social marketing are seen by many of their colleagues as not relevant to the business school environment; relegates their research to second (or third) tier marketing journals (because the first tier doesn't value or accept them - note: be sure to keep Social Marketing Quarterly in mind as a publishing option); the lucrative corporate consulting gigs aren't there; and the idea of applying their work to solving real people problems in the real world is perhaps the most daunting (and yet potentially most rewarding) BeDo of all.

I have often wondered in my years in social marketing 'where are the consumer researchers?' Well, glad to have finally met many of you and hope to have you around for many years to come! I know you will find the social marketing community, as well as some public health spaces, very open to your ideas, skills and expertise. Thank you for your courage!

Transformative Consumer Research and 'At Risk' Populations

What insights, opportunities and projects does transformative consumer research offer people and organizations who work to improve the lives of people identified as being in an 'at risk' group? That was the assignment for our small group that met at the Second Annual Transformative Research Conference. Our discussion group was one of nine convened during the day designed to create an agenda for the field that will continue in ongoing intellectual exchange, research collaborations, and/or projects aimed at social change.

Our group began by working through the many different types of determinants and moderating variables that are used to traditionally define 'at risk' - among them genetic susceptibilities; social determinants; socio-demographic characteristics; cognitive, emotional and physical (CEP) handicaps; and behaviors. We soon realized that we could spend the day (and even longer) on this descriptive exercise - one that has been ably addressed by many others including the WHO Commission on Social Determinants and McGinnis and Foege's review of the actual causes of death in the US in the Journal of the American Medical Association (free pdf - and updated by Mokdad et al, 2004). What, we asked, is the unique contribution that consumer research and marketing can make towards understanding the concept of 'at risk?'

A definition of an 'at-risk' population, from a marketer's POV, that we roughed out is: someone who has a personal or situational disadvantage in the marketplace that might create negative outcomes for the individual or society. It is a draft idea at this point, and will need more discussion and refinement. However, putting 'at risk' in the context of the marketplace - and here marketplace is a broad space and not restricted to shopping and financial transactions - offers social marketers a starting point for what we (should) do best: conduct market analysis to uncover what forces in the marketplace potentiate the impact of personal factors (genetic, biological, CEP handicaps, risky behaviors) and situational ones (poverty, housing, transportation, life stressors, environmental disasters) and how market forces - including changes in the product, service and behavioral choices that are available; their accessibility; the incentive structures and rewards; and how they are communicated to people - can be harnessed to mitigate or even eliminate their impact. [See Making change happen: The marketing approach].

Throughout the day, our discussion ranged over a number of ideas and approaches to thinking about and serving 'at risk' groups. At one point we stopped to identify some of the tensions emerging in our conversation. The point of this list is not to decide which is necessarily 'right' or 'wrong,' but to offer you what a few consumer researchers and social marketers see as important issues to address when working with these populations:

1. Framing people in these groups as 'vulnerable' versus possessing unique strengths and assets.

2. Focusing on the characteristics of 'typical' people (i.e., how do we work towards inclusion?) versus the uniqueness of people identified as being 'at risk.'

3. Planning for marginal changes in their status (or what was referred to as a corporate model) versus seeking radical changes that are fostered by grassroots activities.

4. Using targeting to focus marketing and other resources versus protecting these groups from it (think about minority population groups and their resistance to targeting by tobacco and alcohol advertisers, other groups who shun being targeted by public health programs because it may lead to further marginalization and stigma).

5. Thinking about people in these groups as being unaware or naive of their elevated risk status (with an accompanying sense of calm) versus stimulating them into action (with the attendant sense of worry and/or fear - is this where people who question when to use fear-based communications need to think a bit longer and harder about what they are doing?).

The challenge for our group, and the others, was to develop several ideas for research projects or programs that could be used to create a transformative consumer research agenda. Our suggestions, that I am sure will be massaged many more times and adapted, are:

1. Conduct a sociological or historical analysis of consumer movements by 'at risk' groups that resulted in positive effects on the marketing practices of corporations and brands. We are especially interested in how a subset of these movements changed the marketers' perception of them as being marginalized (for example, they did not talk about the problem, develop offerings specifically for them, or use models in their ads like them) to being included in the range of target audiences they serve (for example, the emergence of the gay market, people with CEP handicaps, seniors).

2. How to design decision-making environments that lead to better outcomes in at-risk situations, such as how to display foods in cafeteria lines that lead to lower caloric trays at the cashier or providing health insurance and health care information to different consumer groups.

3. Conduct consumer studies of at-risk groups to understand how to create an ideal consumer space that can then be used by change agents to inform and guide corporate, government, NGO and community actions to achieve them.

4. Studies on how social networks and new information and communications technologies are creating or affecting at-risk populations, for example, by their influence on information processing abilities and skills. [See The social life of health information.]

5. Studies on whether there are shared motivational drivers for risky behaviors that may need to be considered in designing programs to address them to avoid unintended effects such as substitution or adoption of other addictive behaviors.

For researchers who are looking for other ideas on topical issues, we just heard a number of them from Cynthia Baur of the CDC at the Social Marketing in Public Health Conference.

The World We Want - Transformative Consumer Research Conference

I made a choice to get off the public health - social marketing - health communication carousel of conferences and seek out some new perspectives at least once a year. This weekend I am with over 110 consumer researchers at the Second Transformative Consumer Research Conference at Villanova University (flashbacks to dorm life and all!) discussing "The World We All Want" as part of the Halloran Philantrophies' eponymous project.

Transformative Consumer Research is a movement within the Association of Consumer Research that seeks to encourage, support, and publicize research that benefits consumer welfare and quality of life for all beings affected by consumption across the world. Actually sounds like a branch of social marketing except for the disquieting feature that there is almost no communication amongst us. SO thanks to Marv Goldberg, here I am along with a few other people I know from the social marketing community: Alan Andreasen, Sonja Greer and Debra Scammon.

The conference is intended to bring together consumer researchers to discuss how our scholarship and actions can help alleviate the most pressing social and economic problems. Participants are divided into small groups for the weekend to discuss: poverty, sustainable consumption, developing markets, materialism, general health, food and health, at risk groups, social justice and immigration, culture and ethnicity.

Tonight was the reception and mingle opening. Among some of the conversations I had:

• Research on the use of emotional intelligence for weight loss among teens and college students.
• The use of color to improve conceptual understanding (think 'green' = environment).
• The use of narratives to gain insight into patient decision-making about breast cancer treatment.
• How another study initially designed to explore the same methodology with women contemplating hormone replacement therapy was redesigned when 70% of the women they began talking to about HRT became focused on their 'hidden' anti-depressant use - complete with the same language to describe their use that people with other addictions employ. Now it's about anti-depressant use - an interesting area I have not seen much about in the literature I read.
• The use of archetypes for designing and measuring commercial (and public health) branding programs - and why there should be more attention focused on this (if the London UK brand agencies have anything to say about it).

And I also had the pleasure of spending some time with Marc Mathieu, formerly the Senior Vice President of Global Brand Marketing at Coca-Cola and now CEO of MyBeDo. We'll be hearing more from him tomorrow night.

So consumer researchers are interested in learning how they can help transform society? Busy weekend. Should be some fascinating conversations.

Social Media: Threats and Opportunities for Social Marketing and Public Health

Social media emerged from the breakout rooms of past years at the Social Marketing in Public Health Conference to the Plenary Session this past Friday morning. With Paul Gillin and Bob Gold, we designed this 2 hour session to focus our presentations on the shifts in thinking brought about by social media and other new technologies and then allow about an hour for audience discussion and questions. A recurring theme across all our talks is captured in this picture from Lynette Webb.

 

My introductory comments followed much of the same trajectory as the presentation at the APHA social media and risk communication roundtable a couple months ago. My key themes revolved around the challenge of masses of media vs using mass media; personalization of social media use; thinking about social networks, engagement, interactivity and multiplexity rather than sources, channels, messages and receivers; communities, not audiences; mobility (cellphones); and that most people use the internet for tapping into social networks (not looking for information).

As we listened to the rest of the morning’s speakers and discussion, I proposed answering these four questions for how social media poses opportunities for social marketers and their mix of marketing strategies:

• How do I add social media features to my behavior change products, services and programs?
• How do I use these technologies to overcome psychological and social barriers (costs) people have to engaging in new behaviors, develop new incentives and reinforcers and create new ways of providing social support to people who are trying to change behaviors?
• How can I place-shift; use SNS, co-presence and virtual worlds; and add GPS to create scalable behavior change programs?
• How do I facilitate conversations among people, not aim messages at them?

Paul Gillin picked up on several of these themes, beginning with the changing landscape of marketing media including the observations that teens watch 60% less TV and are online 600% more than their parents; in 1965, 80% of consumers could be reached with three 60-second TV spots - in 2002, that same reach required 117 TV spots.

He also spoke of the rise of information democratization. He noted the many different ways there no are to interact with consumers and not just talk at them. He used several case studies to illustrate social media ‘gone wrong’ including the J&J Motrin backache ad and the consumer backlash it generated of more than 15,000 tweets, 400 media stories and 3,500 blog entries they had to contend with.

He then shared his secrets of engagement:

• Embrace the power of micro community
• Speak to people as people
• Enable sharing and linking
• Filter and aggregate for insight
• Make it a club
• Show that you care
• Never edit or censor

Bob Gold opened his part of the plenary with his perspective on eTools and social marketing :

• We have enormous technical capability; most of which is underutilized
• Applications have not yet caught up with the technical capacity of hardware
• eTools is plural
• The only digital divide is in our own minds
• Effective use of eTools benefits everyone
• The greatest mistake we make is in using eTools in ways that reflect what we do best and what we most enjoy doing

Why, we asked, could we harness technologies to do such things as land a man on a moon (which he pointed out was done with less computing power than most people in the room have in their cell phones), read ancient texts but not social interactions, decode the human genome but not how children learn, build impressive structures such as the Taj Mahal but not healthy communities, and have so many best practices such as the Guide to Community Preventive Services but not get practitioners to use them effectively?

Bob also focused on how we need to use these new technologies to enhance how we do our own work. He illustrated this by showing people how Google is more than a search engine, but a whole suite of productivity tools. He demonstrated Newsmap as a way for public health officials to understand what the important health issues are for media now. And he closed by showing a clip from Project Natal, one that when you see it, brings home the idea (and feeling) that it is indeed “tomorrow’s technology today.”

The challenge is: how do people in public health, and especially in social marketing, begin to tap into these technologies to do our work bigger and better? The discussion that followed barely scratched the surface, and it will take meetings dedicated to this question, and much experimentation and prototyping, to come up with reasonable answers.

Note: This was also the first Social Marketing in Public Health Conference to have a host of tweeters using #smph. You can follow what they were hearing and thinking about during the sessions.

Managing Personal Health Information: A Patients' Rights Movement

Will the new surge for digital health records (calling them 'electronic' is so...quaint) favor the technologists, providers and payors or will the voice of the citizen be heard and triumph? Steve Lohr at Bits reports on a new group, HeathDataRights.org, organized to insert patients' rights to their health and medical data into the discussion.

The new Web-based push comes a week after the Obama administration published a “preamble” document outlining the goals for electronic health records and the broad criteria for their “meaningful use” to qualify for incentive payments to doctors and hospitals. The administration document declared that its “ultimate vision” is one in which “all patients are fully engaged in their health care,” while physicians and clinics have real-time access to all the medical information they need to ensure the quality and safety of care...

The group’s declaration of “health data rights” states that individuals should have: the right to their own medical information; the right to know the source of each element of information; the right to take a complete copy of their health information; and the right to share their health data with others as they see fit.

In another of those 'there are no coincidences' moments, I have also come across a report developed by the National Institute for Health Innovation (NIHI) at The University of Auckland - Organizing Health Information in a eHealth Environment (pdf). These authors take the discussion of citizen data rights even further by proposing the following health information management principles that the HealthDataRights group should consider embracing.

• Health information should be recorded in a form that allows all relevant actors to be able to trust that information where appropriate
• Health information must always identify source and method of derivation
• Health information should be encoded to international standards wherever practical
• Primacy of patient safety
  
• All individual health information will be made available to all clinicians engaged in care of a patient with the understanding that there are ‘get permission or break glass’ components and ubiquitous audit trails
  
• Health information of all individuals will be shared in privacy-protected form to support healthcare quality improvement
• Statutory adherence
• Citizens can access their own health information
• Citizens can contribute to their own healthcare record
• Citizens can define additional access rights on their health information for other citizens, including granting of full proxies and other more limited access rights for specific purposes
• Citizens can review who has accessed their health information and have a clear and effective means of directing queries concerning such access

I particularly appreciated their analysis of the need to explicitly adopt a citizen-centric (NOT patient-centric) approach and to incorporate people’s social networks into health information and care policy:

If the health sector is citizen centric in its approach to health risks, threats, illnesses and other aspects of the healthcare spectrum, then it is essential to engage the ‘we’ in peoples’ support networks. People do not live in a social vacuum – the social context of people’s health is essential to building continuity dependability into the care network. To achieve this, there is a need for developing trust and respect in the supporting networks of people, which in turn may result in a growing capability to work and learn together in the interests of mutually supported health activities and outcomes. Should a person need complex care in such a complex environment, the person should be able to take advantage of the right context and functions in a multi-provider collaborative shared care structure. However, the kind of paradigm shift to citizen centric care requires the right policy context that supports enacting actual person centric continuity of care. This means, for example, that funding models will need to align with new strategic business plans for health care providers so that continuity is defined by the person’s (in their social context) need for care, rather than the provider’s capacity to provide care according to the system’s business model for care. Statutory changes are implied by this approach but were not explored in the interviews or by the expert panel. 

You can read more about the declaration of health data rights and endorse them here. There are several clear roles for social marketers and health communicators to play in this debate including serving as advocates for the citizens who otherwise do not have a voice in these coin-operated policy debates. As I said in my endorsement: Access, openness, transparency, transportability, reliability, accuracy and personal ownership need to be dominant themes in these efforts.

Note: Coin-operated healthcare: when healthcare policy, treatment and access issues are determined by the number of coins you bring to the machine (cue Roger Waters).

Healthy People, Social Determinants and Social Marketing

The implications of Healthy People 2020 for social marketing and health communication were the focus of Cynthia Baur’s plenary session at the Social Marketing in Public Health Conference. Cynthia is the the Director, Division of Health Communication and Marketing, National Center for Health Marketing, Centers for Disease Control and Prevention.

I have talked about the development of social marketing, health communication and health information technology objectives for HP2020 in a number of posts. And with the deadline for submission of objectives looming in the next month, her talk was a reminder that for many social marketers and health communicators the world will be shifting in the next year or so as the US adopts a social determinants framework to health promotion, disease prevention and the elimination of heath disparities. One key point she made is:

Communication and marketing can also be analyzed and applied as social interventions, not just individual level behavior change. Communication and marketing are part of the environment in the same way that housing stock and educational facilities are.

We must start thinking about how marketing, communication and health information technologies in themselves can contribute to health and disease outcomes, as well as the disparities we see between people with unequal access to them, who cannot use and understand them, and lack the skills and resources to act on them.

We also need to shift our thinking from a focus on individuals to social networks, communities and other social groupings. She said: Determining how we as communication and social marketing professionals can affect both the disparities related to health information, products and services as well as the other social factors will be a major advancement for our fields and in the health of the public.

Over the past 18 months, Cynthia has been a co-lead of a process to determine how health communication, health IT and social marketing can contribute to the social determinants of health model of Healthy People 2020 (a process I have been participating in as well) and aid in its implementation. She listed 8 opportunities we should be talking about, planning for, and responding to over the next months and years (as well as in the next month!).

1. Change the unit of analysis from individuals to social groups.
2. Address communication and marketing disparities.
3. Communication and social marketing can be used to build consensus about priorities to address critical social factors.
4. Communication and social marketing are uniquely positioned to serve as a crosscutting framework to build communities and partnerships across organizations and health issues.
5. Communication and social marketing can be used to foster citizen participation in developing solutions to everyday problems.
6. Communication and social marketing can leverage the interactivity of social media to engage consumers and impact social determinants.
7. Communication and social marketing can be their own interventions designed to impact different health promotion and disease prevention outcomes.
8. Communication and social marketing can provide critical data on who interacts with whom, what they are and aren’t interested in and how they think their problems can be solved.

And she concluded:

…communication and social marketing have several roles and opportunities in a social determinants of health framework which are both broad and necessary. We as social marketers and health communicators must be proactive in demonstrating our capabilities to impact the fundamental factors influencing our health. As the social determinants of health framework takes on a broad inter-connected view of the systems impacting our health, we make clear that we are uniquely positioned to help facilitate the broad inter-connectivity necessary to achieve that goal. Communication and marketing professionals are equip with specialized skills, tools, and processes that allow us to build consensus around the framework; bring awareness to the framework; coordinate across health topics and areas; build and maintain partnerships; engage citizens in the process, leverage social media to impact the social factors; conduct interventions, research and evaluation to further identify the problem and solutions; and invoke policy change.

It is not too late to get involved in the development of the health communication and social marketing objectives. Register for the Healthy People 2020 Health Communication and Health Information Technology Workgroup online workspace to comment and share your ideas.

Social Marketing Resonance with Students: Part 2

What students take away from the classes is one of my intermediate endpoints in teaching social marketing. A second is how well they do with their group projects that always address real-time issues and often involve real-life partners. The third one is whether they then move on to a professional career in social marketing (a little more time is needed to evaluate that one, but there is at least one so far!). SO to pass-on the feedback I receive from them about the ideas that resonate with them, a few more of their thoughts meant to provoke your own reflections.

Concept of “extraordinary normal” – this was new to me. People don’t want to be something totally different from what they see as possible; they strive for something just above what they see as mundane.  We need to capitalize on these desires more in health, not just in the commercial sector.

Importance of the critical “takeoff zone” [in diffusion of innovations], where 15-20% of the population practices a behavior and it can spread by word of mouth. This is why the early adopters and early majority are so important.

Importance of social connections and connectedness in determining a person’s role in the diffusion of innovations. Convincing the laggards is hardest because of their attitudes but also because of their near-isolation.

INSIGHT! Exploratory research is not to confirm others’ research. You want to “change your world” by gaining invaluable insight into your audience.

Evaluations answer the “So what who cares.”

Co-presence – you are in reality and also in another co-present space. Ex. Watching a TV show with friends – and chatting online about it at the same time with an absent friend, or tweeting a conference.  Digital natives are growing up with co-presence.

How do you create that co-presence as a marketer?  Interesting thought.  Will try to remember this one!

That the best brands are the consumers who tell the best stories is very striking - it reminds me of the concept of consumer evangelism and the importance of having a brand that engages the consumer.  This also reinforces the idea that good marketers aren’t the ones who concentrate on sending the most creative messages, but good marketers are facilitators of communication amongst people…the second striking concept was being reminded that a brand is more than just a logo - it is how consumers think, feel, and identify with a brand.  To consider branding just a logo is tantamount to considering marketing just promotion.

Technological literacy has become a new social determinant of health, as telehealth emerges as one of, if not the most, dominant means of health interaction with professionals.  How will this further marginalize those with low literacy levels, or low SES?

The role of mobile technology is to enable, simplify, and navigate, not just to communicate.  This is poorly understood or utilized by too many organizations, who are missing the boat on mobile technology.  I think this is why Twitter has taken off.  Companies missed Facebook, they missed MySpace, and now they saw Twitter early and wanted to make it the next big thing.  Will corporate involvement on Twitter ultimately be its downfall?

Concept of “social franchising” – using a commercial model can be very successful.  I think the franchise element builds trust, because there is an element of continuity, people know what to expect when they come into a MinuteClinic at CVS.

Behavioral Economics – people make decisions based on approximate rules of thumb or heuristics that makes things easier to think about – but these are not always rational decisions.  Framing – the way a problem or a decision is presented to the decision maker will affect their course of action.  Reward good stuff – remove rewards for bad stuff.

I had never heard the term digital immigrant (learning the technological world) vs. digital native (grew up using the web, other new technologies)  – but after hearing it in class I started hearing and seeing it in all kinds of places.

Coalition-building takes years – this is something that organizations for whom I have worked attempted to do in months, if not weeks, and shortcomings were always attributed to unwillingness on the part of people, not on the fact that trust and relationships take time to build.  Good message.

Trust is a price.  Social capital builds assets and lowers cost.  This trust becomes especially important when considering community development programs – who does the community already trust, and how can this be leveraged?

Social Marketing Resonance with Students: Part 1

What students find interesting or memorable from our classes on Social Marketing at George Washington University School of Public Health and Health Services is one of my most anticipated opportunities of the year to get into the mind of the consumer. In this case, it is our MPH students in the Public Health Communication and Marketing Program, and an assortment of students from other programs and universities, who provide me with the valuable feedback of what am I talking about in class with them that makes sense to them.

Most faculty will argue that everything we talk about in a class is important, but the learning and experiences I have lead me to believe that if I can get 5-9 memories made in the 3 hrs we have together each week, then that is success. Two years ago I created a whole set of posts around each class entitled Student Voices. The idea for creating them is this:

At the end of each weekly class, or during the week, write down the 3-5 major points you got out of that class. Not what notes you made about a lecture or discussion, but the highlights – something that was said, a point that somebody made during the discussion, a thought or question you had that really had an impact on you or stuck with you.

The point is to have them consolidate their thoughts and provide me with some indication of what we have been talking about that resonates with them, gets a reaction, or completely misses the mark. In that way, these 'lesson logs' reflect the perspective of master’s level students in a MPH program (or related degree program) who have sat through, participated or engaged in classroom social marketing content for an extended period of time. I let them know ahead of time that some of their comments in the logs may be used on my blog without direct attribution.

SO without further introduction, some thoughts from this year's students about social marketing. Hopefully, you will find a few that resonate with you as well.

The definition of social marketing has certainly evolved since the 1970s, which reveals the shift in focus from influencing ideas (i.e. racism) to influencing behavior change.  The current definition also demonstrates the need to solidify the scope and purpose of social marketing, and further establish its presence within the realm of public health.

Understanding various theories is crucial to providing a foundation for social marketing campaigns.  As someone who is highly interested in the creative aspect and the implementation of campaign strategies, this particular class session made me realize that before these stages of the campaign can begin, selecting theoretical elements serves as an anchor for the campaign and is needed to ensure a successful end result.

This was the first behavioral theory class that I have enjoyed in a very long time.  While learning about the theories was repetitive, I felt like I learned a more useful way to apply them to interventions.  This was a nice break from prior classes that examined behavioral theory.  The other enjoyable aspect of this particular session is that we learned about theories that were developed recently... and not in the 1950's.  We also discussed how new technologies "expand the scope and capacity for learning".  The lesson's slide at the end was particularly useful.  I especially enjoyed, "Theories should be tools, not straight jackets"... "It's a complex world" and "Theories can inform - And Blind".

The idea of designing behaviors for a target audience that fit their reality was new to me.  It makes sense that the behavior must be compatible with the audience, but in the world of public health people often think about only one “right” behavior.  But if the “right” behavior is too complicated, or incompatible with the target audience – no one will do it

To change health behaviors, public health professionals must conduct exploratory research to gain insight from the target audience, not just validate already held beliefs about the population.

One point from tonight’s lecture I found particularly salient was that focus groups are too often seen as the go to method for collecting research.  “Go to the jungle not the zoo,” instead of creating orderly controlled groups; there is an entire realm of ethnographic research where we can observe behaviors and communities in their natural setting.

The idea of marketing to a segment less than one was intriguing.  As people supposedly develop multiple on-line personas, marketers seem poised to capture on these self-defined psychographic differences.  Whereas previously marketers would make their best guess about a person’s preferences, the new web sharing media allows marketers more information than ever before on consumer preferences.  Interesting comparisons promise on how the same person is marketed to on LinkedIn versus Facebook or MySpace.  In essence, this seems to give more importance to the Place variable in the online world as it seems analogous to how someone is marketed to at a bar versus their workplace. 

In lecture, we went over formative research which was very useful for our group projects. There are three components to formative research, exploratory, concept testing, and pre-testing of materials. From my understanding of each component of formative research, exploratory research is used to better understand the target audience, identify behaviors, and factors that contribute to the issues. Concept testing is actually testing the methods we discovered and created. This can be tested by using a representative sample of the intended audience through a focus group. Here we can examine our strategies/tactics of the four Ps with our sample population, and learn new information that we did not gain in our exploratory research. Before implementing a campaign, it is important to test the materials created. This provides an opportunity to test if the materials are coming across the way the marketers want it to. Also process evaluation is an important aspect to see if the campaign messages are reaching the intended audience, and if it is having a desired or undesired effect on the population.

The idea of making benefits of a behavior change personally relevant – I had usually thought of the health benefits to a behavior change as fairly obviously connected to the health problem (i.e., quitting smoking to reduce lung cancer risk, rather than to stop smelling like smoke) rather than needing to connect benefits to each individual, even in a mass market campaign.

Chanel perfumes – “We don’t market smelly waters, we market dreams.”  In other words – the product in social marketing is not only the behavior but also the benefits of that behavior and any tangible objects and services that will help support the desired behavior change.

The Social Life of Health Information

How social media has impacted people's online health information seeking and sharing is the subject of the latest report from the Pew Internet and American Life Project - The social life of health information.

A number of people have already written up toplines for the report, and I suggest Susannah Fox's cheat sheet at e-patients.net and Josh Seidman at the Information Therapy Blog. They provide lots of the details so I am not going to repeat them here.

I did find two quotes from the report worth pondering for how they might influence our work:

Mobile access is changing the behavior of internet users and, in particular, changing the behavior of health care consumers. The mobile internet draws people into conversations about health as much as online tools enable research.

…technology is not an end, but a means to accelerate the pace of discovery, widen social networks, and sharpen the questions someone might ask when they do get to talk to a health professional. Technology can help to enable the human connection in health care and the internet is turning up the information network’s volume.

I also was playing around with understanding the data in a more visual way than the charts and graphs in the report. Here is what I came up as the critical pieces of the puzzle - with the caveat that there are differences among demographic groups. But overall, the view from my POV and the data is this:

What this chart depicts are the percentage of Americans (note: not internet users) that report using different sources for health information. Health professionals (86%) are the most frequently reported ones, followed by friend or family member (68%); going online (57%); books or other print reference materials (54%); social media including blogs and social network sites (37%) and insurance providers (33%).

One of the difficulties I have with reporting data in this manner is that we do not get a dynamic picture of what sources of information people access FIRST and in what sequence. How do they go about solving the health challenge they are facing - whether it be symptoms they or a family member are experiencing, how to lose weight, which doctor or hospital to go to? And I am sure some health issues are approached differently than others. However, the authors of the report offer two snippets of information on page 16 that start bringing this dynamic into focus as it relates to online activities. As shown in the red and purple lines, once people have accessed information online, 66% report they are likely to discuss it with a friend or family member (red line), whereas only 'a handful' of people said that they discussed it with a health professional (purple one).

These two paths raise an interesting question about how people go about validating the health information they find on websites. And I am also willing to wager that health professionals, except in the cases of immediate needs and emergencies, are not the first place people go for their information. How the search and problem-solving process unfolds for different health issues needs to be looked at much more closely and with a full appreciation of the social network effects that are entwined in them. The data available in this report begin to articulate some of the contours we should be investigating.

Americans Favor Prevention as a Health Care Reform Priority

More than three-quarters of Americans (76 percent) support increasing funding for prevention programs that provide people with information and resources and creating policies that help people make healthier choices. Investing in prevention is popular across the political spectrum, with 86 percent of Democrats, 71 percent of Republicans, and 70 percent of Independents supporting investing more in prevention [from media release].

Invest in more prevention to help people stay healthy and reduce diseases such as diabetes, cancer and heart disease was ranked higher than the other policy options they were presented with and asked how big a priority each one was for them in reforming health care in the US.

• Provide tax credits to small businesses to help small businesses provide affordable health insurance to their employees. 
• Prohibit insurance companies from denying coverage because of age, medical history, or pre-existing condition.
• Require all Americans to have health insurance while providing financial assistance to those who cannot afford it.
• Require all businesses to provide health care for their employees or contribute to a fund to help pay for their coverage.
• Give all Americans a choice of keeping their current insurance or joining a national insurance pool with a choice of private and public plans administered by the government.

Results from a new poll sponsored by the Trust for America's Health and The Robert Wood Johnson Foundation.

Nice to see that people have their priorities lined up about what's good for them.

Digital Access: Pew Internet Data

Pew Internet: Internet, Broadband, Cell Phone Use: December 2008 Data

View more OpenOffice presentations from PewInternet.

Health Care Reform is a Wicked Marketing Problem

Members of Congress are seriously considering proposals to rein in the growth of health spending by taking tens of billions of dollars of Medicare money away from doctors and hospitals in high-cost areas and using it to help cover the uninsured or treat patients in lower-cost regions reports Robert Pear in the NY Times today. This is but another step towards curtailing the skyrocketing costs of health care in the US that President Obama has called ‘the biggest threat to our nation’s balance sheet.’

Findings from a series of studies he cites in the article point out that in higher spending areas of the country, Medicare patients have fewer visits to primary care physicians, are referred more to specialists and are hospitalized more frequently. Yet, these higher cost areas do not show better health outcomes than the lower costs ones. The Director of the OMB says: …health spending could be reduced by as much as 30 percent, or $700 billion a year, without compromising the quality of care, if more doctors and hospitals practiced like those in low-cost areas.

But, other researchers and policymakers are not so convinced by the data (especially those from high cost areas naturally).

This debate has taken hold because in many meetimgs President Obama is quoting from an article in The New Yorker in which the author, Atul Gawande, visits McAllen, Texas, (among the highest Medicare cost areas in the country) to discover the reasons why. His first finding: the hospital CEOs and doctors in McAllen did not know they were unique. One CEO was ‘surprised’ and genuinely interested in seeing the data; another attempted to explain it away by suggesting that patients were better off in ways not measured by the surveys.  Some physicians he talked with were ‘dubious’ and ‘skeptical’ of the claim that health care was so expensive. Arguments about having a less healthy population, protection against threats of malpractice suits, and offering better services were summarily shot down by one of their own:

‘We all know these arguments are bullshit. There is overutilization here, pure and simple.’ Doctors, he said, were racking up charges with extra tests, services, and procedures.

An analysis of Medicare payment data support his contention.

In contrast, in Rochester, MN where the Mayo Clinic is located, health care costs rank in the lowest 15 percent in the country. Gawande frames the issue as this (note: this is where social marketing kicks in):

Most Americans would be delighted to have the quality of care found in places like Rochester, Minnesota, or Seattle, Washington, or Durham, North Carolina - all of which have world-class hospitals and costs that fall below the national average. If we brought the cost curve in the expensive places down to their level, Medicare’s problems (indeed, almost all the federal government’s budget problems for the next fifty years) would be solved. The difficulty is how to go about it. Physicians in places like McAllen behave differently from others. The $2.4-trillion question is why. Unless we figure it out, health reform will fail.

The first insight he came away with was: …[hospital administrators and physicians] have only the vaguest notion of whether the doctors are making their communities as healthy as they can, or whether they are more or less efficient than their counterparts elsewhere. The second was to answer the question – why aren’t more areas like McAllen, which is clearly responding to market forces and economic incentives, instead of how did McAllen become the anomaly? A nice use of the positive deviant approach to uncover the high leverage behaviors.

Answers that presented themselves were better communication, coordination of information, community peer review and reducing economic incentives to physicians to cherry-pick patients and self-refer (for tests and other procedures) by putting them on salaries. In the case of the Mayo Clinic, there is also a collaborative culture where ‘the needs of the patient come first.’

Gawande writes: Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.

He goes on to note that the health care reform debate tends to center on who writes the checks. I also have been troubled by some advocates for health information technology ‘solutions’ to health care costs who focus on how these will make the lives of health care provider, billers and payers easier – the patients come last, if indeed their needs are discussed at all! For Gawande the lesson from positive deviants is clear: [in] high-quality, low-cost communities…someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes. Now that would make a nice platform for a reinvented public health system!

His proposal is to create accountable health organizations in which doctors collaborate to increase prevention services and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering. He offers that this will require experimentation, research and dissemination of effective practices to address these core issues. And it will take time – a decade or more he presumes.

From a social marketing POV, the shift in thinking Gawande and others are proposing walks away, rightly, from solely focusing on the economic policy levers – the easy ones too often reached for by policymakers in the face of seemingly intractable, wicked problems of all sorts. The marketing mix heuristic offers a wider aperture to address more of the problem, and potentially focus on the more important aspects of it – not just who pays the bills, but to what purpose?

Perhaps the biggest issue I see here is one of information asymmetry. It happened in McAllen with the CEOs and physicians (they honestly had no idea they were the big spenders). It happens between patients and their providers and insurance carriers. What gets fogged over in the health care reform debate is the lack of access to timely information one can understand and act on that is hindering health care administrators, health care providers, and patients from acting in more responsible ways. Not in the streamlined version of fiscal responsibility health IT offers providers and payors, but in responsible and accountable patient management practices that provide high quality care and improve community health. And I believe that it focusing the debate on the lack of standardized reporting systems, fracturing of medical information and other payment-related issues that keeps the power in the hands of the few rather than with the community. It keeps us asking the wrong questions so that they don't have to worry about the answers. Entrenched health insurance and health care provider interests will not easily shift to a paradigm of conversations about transparency and community (social) accountability – they threaten the foundations on their business model.

The next issue Gawande touches on is how to create incentives for innovation. Not incentives for how health care is delivered per se, but for how the system is structured. Who gets rewarded for devising the next Mayo Clinic or Grand Junction, CO model, or even adopting one of them? Who is rewarded for taking on the task of truly disseminating best practices in this regard by segmenting the marketplace and designing approaches that are tailored to their circumstances, and not simply by writing more reports. When does stimulus money become a driver for investing in innovation and prototyping new models of health care delivery; if ever there were a case to be made for ‘critical infrastructure,’ doesn’t health care deserve to be at the top of the list?

Why don’t we think about health care delivery as a service delivery system with all the inherent, and yes idiosyncratic, marketing problems that beset every other service delivery system (marketing, that is, that goes beyond the objectives of reputation enhancement, branding, staff recruitment and patient referrals. See McDondald’s sacred text and ask yourself if any health care organization you know could come up with one).  Some of the marketing problems include recognizing that our service offerings are totally out of whack – where preventive medicine is the last thought (and funded), not the first. Where access to information is a critical problem for the system, while access to care remains a priority for too many people. Where the incentives for service delivery exist for the insurers, health care organizations and individual practitioner’s self-interest, and not those of the patients and the communities in which they live and serve. And where policy communication is centered around the hospitals, the providers, and the payors – not the patients. Social marketing offers some complimentary ways to think about and get to work on designing health care reform. We start by asking – what is best for the patient [attributes of patient-centered care]? And we would be thinking about policy makers as a key audience.

The MBA Oath: A Case of Social Shifting

Today's NY Times reports that over 20% of the graduating class from Harvard Business School have signed The MBA Oath, a student-led movement to develop a professional code of conduct for business leaders. It begins:

As a manager, my purpose is to serve the greater good by bringing people and resources together to create value that no single individual can create alone. Therefore I will seek a course that enhances the value my enterprise can create for society over the long term. I recognize my decisions can have far-reaching consequences that affect the well-being of individuals inside and outside my enterprise, today and in the future. As I reconcile the interests of different constituencies, I will face choices that are not easy for me and others.

A code of ethics for business leaders that is driven by student demand is something I celebrate today. As a social marketer who has chimed in about the need to realign business practices with social goals, not just self-interests, the timing could not be better. One of the core issues NOT being discussed very openly in the rush for a Total Market Approach to banking, finance and, yes, automobiles is how to leverage government interventions to address the systemic sociopathic qualities of these and other businesses. Seeing a shift in thinking among the business leaders of tomorrow should give current ones a reason to pause, shift and embrace what will be the sequel to The Cluetrain Manifesto - the one that is authored and acted upon from within. Corporate social responsibility programs are a placebo - what is needed is systemic change demanded and designed by the entire marketplace including business leaders and workers, government, shareholders, nonprofit organizations and consumers.

If you are a graduating MBA, or already have one, join the shift today and sign the Oath. I will be happy to post your reflection here.

Reviewing the CDC's HIV/AIDS Program

Several months ago I received this invitation:

The Centers for Disease Control and Prevention (CDC), Division of HIV/AIDS Prevention (DHAP), invites you to participate in a comprehensive External Peer Review of its HIV/AIDS program…Data recently published by CDC indicate that the number of new HIV infections occurring annually in the United States is 40% higher than previously estimated, that new infections have been steadily increasing among men who have sex with men (MSM) since the early 1990s, and that the epidemic continues to have a disproportionately severe impact on African Americans and Hispanics/Latinos. These data have led DHAP to initiate this comprehensive review of its surveillance, research, program, and evaluation portfolios to help determine whether they are appropriately configured to address the current epidemic…

The purpose of the review is three-fold: 1) to provide DHAP with objective input and guidance on its scientific and programmatic priorities and direction, 2) to serve as a basis for CDC’s HIV Prevention Strategic Plan, and 3) to provide a platform for the development of a National HIV Prevention Plan that incorporates stakeholder perspectives and needs.

Not being a researcher in the HIV arena, nor a CDC grantee or member of a stakeholder group, I was curious as to what prompted their invitation (I later learned that having ‘a social marketing perspective’ was an important element in their participant mix). Still, after a week of talking with some colleagues and mulling it over, I agreed to be one of about 50 or so external experts to review their activities over a 3-day period organized under five panels of Planning, Prioritizing, and Monitoring; Surveillance; Biomedical Interventions, Diagnostics, Laboratory, and Health Services Research; Behavioral, Social, and Structural Interventions Research; and Prevention Programs, Capacity Building, and Program Evaluation. It proved to be a daunting task, especially since the last full programmatic review was in 1993.

Each panel was asked to review DHAP’s HIV research and prevention programs in light of their:

• relevance to DHAP’s mission
• scope and prioritization;
• scientific and technical quality, approach, and direction;
• adequacy of translation and dissemination of research findings for use in programs;
• strengths, gaps, challenges, and opportunities; and
• extent to which the National Center for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) programmatic imperatives of program collaboration and service integration, reducing health disparities, and maximizing global synergies are addressed.

I was asked to sit on the panel that focused on the Behavioral Research portfolio. The report of our collective deliberations and recommendations is anticipated to be available in the Fall of 2009; in the meantime, here are some of the major themes that emerged during our panel’s work.

First, some context. The total DHAP budget in FY2009 was $853 million, of which $28 million (that’s 3.2%!) was for behavioral intervention research. What impressed me (and others on the panel) was how this limited budget was spent on mimicking a drug R&D process of uncovering the most effective elements of HIV prevention programs, testing them, packaging them and then promoting their availability to the community. There was limited attention to what one panel member referred to as ‘the science of the street’ or learning from what is working in communities. Indeed, these activities were labeled ‘homegrown’ solutions and had little weight or prominence in the Diffusion of Effective Behavioral Interventions (DEBI) model.

The panel concurred that focusing such a small budget on the full spectrum of R&D activities was not practical or effective. Rather, we suggested more of the CDC behavioral research endeavor should focus on the improving the science at the ends of the spectrum – innovation (often gleaned from communities) and dissemination (how to achieve scale for effective programs). We threw around phrases such as ‘community-driven research’ and ‘community-to-science’ to reinforce our point. We asked: How about establishing an Innovations Lab for behavioral change research for HIV prevention to respond to emerging needs through formative research and Phase 1 studies and leave Phase 2 and 3 work to other agencies (NIH, HRSA, SAMHSA) to fund? Why not have a Systems Lab to improve our ability to influence/study diffusion and employ social marketing to scale-up proven interventions through health departments and CBOs rather than rely on the discredited idea of passively ‘diffusing’ or promoting them (for example)? Looking at the CDC as an institution, we were also asking ourselves quite often: What are the rewards and incentives for staff who conduct innovative behavioral research and dissemination of practices? Are they similar to the epidemiological and clinical research that is being done? And if not, why not?

At the conclusion of the 3 days, our top-line recommendations included:

• CDC should engage in behavioral and social research - primarily formative and operations/effectiveness.
• Research should target practices, social factors and behaviors that fuel HIV epidemics across populations and settings.
• Work with Community-Based Organizations (CBOs) and Health Departments (HDs) to determine how best to focus and tailor these responses in their particular communities.
• Linkage and exchange of global behavioral, social and operations research findings.
• Research should focus on the process of dissemination that emphasizes studies of training procedures, end-user response to guidance, implementation strategies, contract manager effectiveness, enhancers and barriers to scale up, evidence in the real world for effectiveness, and capacity building.
• Use social marketing as a strategy for capacity building and dissemination.
• CDC should undertake a community-driven research agenda that takes advantage of its unique relationships with CBOs and HDs and encourages their input in the identification of emerging issues and potentially effective practice-based interventions.
• CDC should work with HDs and CBOs in operational research to ensure that evidence-based and data-supported linkage to care strategies are used in conjunction with HIV testing.  The goal is to make sure that persons newly diagnosed with HIV and persons not connected to care are linked and retained in care.

More detailed recommendations for communication and social marketing research that I drafted for our panel were:

• Communication research needs to expand focus from individual-level behaviors to more social and structural outcomes (e.g., stigma, discrimination, organizational practices).
• Social marketing has a central role to play in scaling up interventions and in research-to-practice strategies.
• Audiences need to be broadened from at-risk populations and service providers to include DOH and CBO implementation agents (for example, Learning from the Community: What Community-Based Organizations Say About Factors that Affect HIV Prevention Programs -pdf).
• Theoretical models that drive program development, implementation and evaluation do not reflect a unified conceptualization of behavior change.

After a number of posts about the need for more radical behavioral research in HIV prevention and to scale up demonstrably effective programs for HIV prevention, it was an honor and privilege to serve on the DHAP review team and to part of a very knowledgeable, dedicated and fun panel. While I cannot predict what the final report might look like, or how CDC may choose to implement the recommendations of our panel and from the other four, hopefully you will find a new idea or inspiration in these recommendations to improve your ability to design public health change.

The US Commitment to Global Health

Over the past decade, the United States government has made a number of pledges towards improving global health. How those pledges are funded and operationalized is often a matter of opinion and perspective. And no doubt that the current economic situation is posing challenges to maintaining the current pledges, tamping down enthusiasm for expanding upon them, and yet exacerbating already critical health issues in many developing countries.  A new publication from the Board on Global Health and the Institute of Medicine of the National Academy of Sciences adds a weighty voice to the discussions. From the prepublication blurb -

Health is a highly valued, visible, and concrete investment that has the power to both save lives and enhance the credibility of the United States in the eyes of the world. While the United States has made a major commitment to global health, there remains a wide gap between existing knowledge and tools that could improve health if applied universally, and the utilization of these known tools across the globe.

The U.S. Commitment to Global Health concludes that the U.S. government and U.S.-based foundations, universities, nongovernmental organizations, and commercial entities have an opportunity to improve global health. The book includes recommendations that these U.S. institutions

• increase the utilization of existing interventions to achieve significant health gains;

• generate and share knowledge to address prevalent health problems in disadvantaged countries;

• invest in people, institutions, and capacity building with global partners;

• increase the quantity and quality of U.S. financial commitments to global health;

• and engage in respectful partnerships to improve global health.

Among the action steps contained in the prepublication version of the Executive Summary is one calling on President Obama to create a White House Interagency Committee on Global Health to lead, plan, prioritize, and coordinate the budgeting for major U.S. government global health programs and activities.

The outline of the report for quick viewing and ordering information.

A Proposal for Dr. Thomas Frieden: An Agenda for Transformation at the CDC

What will the appointment of Dr. Thomas Frieden as head of the CDC mean for the agency and public health? There are plenty of opinions already.

As the nation’s, and some would argue, the world’s, preeminent public health organization, the CDC often sets the course and tone for a broad expanse of public health issues. The CDC does many things very well, yet I also see places where the lack of innovation and even perspective (call it marketing myopia) can be maddening. The description of him in the NYT story about his appointment makes me hopeful:

[He] has cut a high and sometimes contentious profile in his seven years as New York’s top health official under Mayor Michael R. Bloomberg. He led the crusade to ban smoking in restaurants and bars, pushed to make H.I.V. testing a routine part of medical exams, and defended a program that passes out more than 35 million condoms a year.

The article goes on to list a number of issues he will likely have to deal with immediately including ‘serious morale and administrative issues’ at CDC, whether to green light production of a swine flu (whoops, H1N1) vaccine, health care reform and food safety. Some regard him as a ‘transformational leader’ and this is what public health needs now.

So for the transformational agenda Dr. Frieden might be developing for his new position, I offer a list of 10 ideas that he and others at the CDC consider:

1.    Move the applied research portfolios throughout the agency from randomized clinical trials (RCTs) and experimental designs that focus on identifying effective components and comparative evaluations to the ends of the research spectrum – become the innovators for new methods and approaches and then the masters of diffusion (expanding the adoption of best practices, not passively disseminating them). Let NIH and other groups devote the resources to hypothesis-testing. Create a culture that allows public health research to be both exciting and practical. This is not to suggest that ALL RCTs under ALL circumstances should be avoided. Rather, they should be undertaken only when emerging and existing public health threats are not being adequately addressed by other scientific branches of the government and nonprofit sectors. CDC should become more of a C&D operation (connect and develop) for public health interventions rather than the old school R&D one it currently embraces

2.    Question what we measure in our health surveys, from the National Health Interview Survey, to NHANES to the BRFSS. How do we measure for success and to gain insight into how to address many of the wicked public health problems we continue to have after decades of monitoring them? Knowing what is wrong is not the same as knowing what to do about them. Can we bold enough to ask how we shift our surveys from description to inspiration?

3.    Flip the telescopic lens of a majority of the research and intervention portfolios in all Centers from the micro view to the social view (see marketing myopia). Yes, understanding all the nuances may be important to furthering the scientific enterprise, but the public health enterprise would benefit immediately from the consistent application of all that we already know in every city and county in the nation. The question is: what business (or science) is CDC in? We also have to expend more time and effort in making the shift from individual-level to population and social determinants of public health. This is the arena that CDC is uniquely positioned to lead in – and don’t be side-tracked by people who believe that advocating for a single-payer health care system is where CDC’s (public health’s) efforts should be focused. Instead, focus on how it becomes more patient-centered. Be the voice of people, not interests.

4.    Make a community-science cycle of innovation and application real by incentivizing it. This is part of the C&D idea; how can we learn from what is working in communities (and other places outside the CDC) and then apply the science to scale these for broader application? For people who say that the science of scaling up, diffusion and sustainability are weak – my point! This is where CDC scientists can change the game. Banish the culture of ‘not invented here’ that blocks listening to the field in productive ways. Co-production of effective public health programs with CDC partners in state and local health departments, indeed, wherever innovation is flourishing, needs to have the same (if not more) value and prestige as writing research articles for peer-reviewed publications. Focus more on understanding how we improve the practice of public health – not adding more things to the list of what we ‘should’ do.

5.    Fight to make OMB less onerous for the research that is critical to addressing public health issues and their diffusion. Lengthy reviews of research protocols and instruments is not helpful for understanding public health problems in an ever-changing environment. Review and clearance procedures offer another set of impediments once the data are collected and analyzed.  How do we get current snapshots of audiences, practices and determinants of behavior to inform what we do now? Think of this way: How many people, in real life, take months or years to compose and frame their subject, finally take one picture, and then wait 2 years or more to have it developed and show to their friends? Exactly.

6.    Address the dragon gap that exists at CDC; startle them with a vision that moves from denial (all the problems are ‘administrative ones’), status quo and cynicism to imagining and creating a better CDC. What will be the story of the CDC under your leadership? How will you convince them to go beyond where the dragons are?

7.    Integrate the learning that goes on in the international and domestic work of the agency. Start with getting the international and domestic HIV/AIDS programs to talk with each other about what is working, and not, to prevent the infection from spreading (that C&D idea again).

8.    What is CDC doing to combat the obesity epidemic the agency identified and led?  What was the front page epidemic a few years ago seems to have lost focus.

9.    Adjust the opportunities and incentives for innovation among the staff. Satisfaction with the status quo, don’t rock the boat, CYA, and internal competitions are some of the countervailing forces. People join CDC to make change or a difference, and many of them find themselves on the wrong end of ‘whack-a-mole’ where sticking their necks out to try something different is a license for others to organize a posse.

10.    And to end on a top note, restructure only where it fits the mission, not certain people’s passions. After 20 years of working with the agency I have one suggestion: create a line of authority and responsibility that parallels the Office of the Chief Science Officer and is focused on the quality of change programs throughout the agency. It has been called ‘Health Communications’ and ‘Health Marketing’ in earlier, but denervated, versions. Or think more broadly – Marketing (though not some people’s favorite word), Population Interventions (boring) or Public Health Design (forward leaning). Infuse the same respect, rigor and quality into prevention programs that goes into what CDC does when it investigates and controls outbreaks of disease. Insist that they be audience-focused and not science-directed, engage with partners and communities and not talk at them, utilize population methods for public health change (behavioral economics, choice architecture, community development, public health communication, social marketing), seek and reward innovation and change the practice of pubic health in the 21st century. The CDC Mission: Collaborating to create the expertise, information, and tools that people and communities need to protect their health – through health promotion, prevention of disease, injury and disability, and preparedness for new health threats.

And good luck Dr. Frieden! We look forward with hope and support for your success.

The Future of Social Marketing: A Call for Collective Engagement for the Creation of a Global Organization

An electronic petition calling for the creation of a worldwide social marketing organization is now available for signing at epetitions (or cut and paste - http://fusomar.epetitions.net/). After over a year of meetings at several conferences, informal discussions and surveys of the social marketing community, Bob Marshall drafted this petition with help from friends Jim Lindenberger, Mike Newton-Ward, Bill Smith and me. The current version was reviewed and endorsed by the Social Marketing Quarterly Editorial Board at their meeting earlier this month. It starts off:

We, the undersigned, agree that the moment has arrived for the development of a social marketing organization. We will support, in words and actions, the creation of a global social marketing organization by July 2010. To work towards this end, we share the following core principles.
•    Social marketing starts from the personal perspectives of the people with whom we work.
•    Social marketing is a well-established professional discipline with a strong academic and practical foundation.
•    Social marketing is a systematic approach to large-scale behavior and social change.
•    Social marketing is a “community of practice” that is open to all disciplines and types of practitioners and can be applied to a range of environmental, public health, and social issues.
•    The development of a professional social marketing organization should be a widely participatory and transparent process.
•    A social marketing organization should represent the views of practitioners, organizations, academics, researchers, donors, policy-makers and others who advocate for, practice, and support the use of social marketing applications to address social problems.

Yes it could be done more quickly, but perhaps in not as open and transparent a process as envisioned in the next section. And we do have in mind that the 20th anniversary of the Social Marketing in Pubic Health conference, the one constant meeting place for social marketers over the past two decades, will convene next June. And yes, there are other core principles that could be enumerated, but we have a year to formalize them in an association. The point is to get started from a place that few can quibble with. On with the work:

To move this process forward, we endorse these steps in the creation of the organization:
•    Create an Ad Hoc Guidance Group of no more than 20 members with Craig Lefebvre serving as the voluntary chair. This Group will work during the next year to develop the necessary principles and provide counsel to the work groups (see below) that will develop the organizational structure of the proposed global social marketing organization.
•    Establish a date for convening a “Congress” for the social marketing organization prior to the 2010 National Conference on Social Marketing in Public Health. This Congress will serve as the ratifying body for the organization’s name, mission, governance structure, business plan, bylaws, and select the first slate of officers for election.
•    In next four months, the Guidance Group will oversee a process that solicits Delegate nominations from the social marketing community who will serve on work groups charged with developing the process and materials necessary for the Congress, including proposed names of the organization, mission statement(s), governance structure(s), bylaws, and whatever other requirements the groups decide are needed. In the event that more than 50 names are submitted, Delegates will be selected by an open vote of anyone who identifies themselves as part of the social marketing community. The work group members should represent the diversity of the social marketing community, particularly with respect to practitioners, organizations, academics, researchers, donors, disciplines and geographic locations.
•    These volunteer Delegates will be charged with participating in the deliberations and authorizing further organizing activities for the Congress on behalf of the social marketing community. We suggest that work groups be created from this group of delegates to achieve the following objectives:
o    Discuss and propose the goals, scope, structure, business model and operations of the association;
o    Draft a charter, mechanism to elect officers and other elements of the organization (by-laws);
o    Offer a guide for the emerging organization through all stages of development;
o    Establish workgroups for achieving other objectives (for example, education resources, staffing, practice standards, credentialing, communications, and advocacy);
o    Establish steps, stages, and timelines for further organizational development; and
o    Provide timely and regular communications with the larger social marketing community through electronic channels and social marketing publications during this process and be prepared to present their completed work at the Congress for open discussion and voting among all attendees.
•    All work group and Guidance Group members are encouraged to attend the Congress to ratify the work of these groups. We envision that the outcomes of this Congress will then be presented for discussion and affirmation to a larger group of the social marketing community attending the social marketing conference in Clearwater Beach, FL in June 2010. Officers should be elected at this time and the organization formally announced to colleagues, stakeholders and professional communities.

What the petition advocates for is a small group of guides and mentors to set into motion an open process that solicits nominations and oversees the election of delegates from this pool of delegates. Our intention is that these delegates should represent the diversity of social marketing across settings, geography, topic area and experience. It will be up to you to decide how this vision is realized. Now is the time to think about who You want to represent YOUR interests and perspective. Most of their work will be done digitally, and we see a Congress as a time for them to all come together to collectively finalize their work and present it to the broader community for ratification. How these delegates go about doing their work is up to them, but we intend for it to be as transparent a process as possible.

We all recognize that there will be many challenges in the year ahead to realize our hopes for a strong, diverse, and active social marketing community under one banner. We hope you will join us over the next year with whatever resources, skills and talents you can offer to support the development of a social marketing organization that will strengthen, deepen and expand the scope of our work to improve the lives of people around the world. And we look forward to seeing many of you in June 2010 to participate in and witness the next milestone in the evolution of our field.

Our signatures affirm our support for and commitment to this endeavor.

It is personally exciting for me to see the movement take this big step. I know there is a lot of pent-up energy among many people to make this happen. Please help us get started by going to the site now and signing on.

And on an historic (and circular) note, Phil Kotler (pdf) was the first one to sign it.

Onward to June 2010!

Social and Risk Communication During Times of Crisis

In the midst of the global response to swine flu, it seems uncanny that only a few weeks ago a group of invited guests and speakers were sitting in the headquarters of the American Public Health Association to examine the full range of challenges, opportunities, lessons learned, and best practices in the development and application of strategy to social media and public health communications (click on image to enlarge).

Federal agencies including the Departments of  Health and Human Services and Homeland Security, and nonprofits such as The Red Cross presented their experiences with social media. Representatives from media organizations including National Public Radio and DC FOX 5 News talked about how social media were changing their approach to news gathering and reporting during emergencies.

A key objective of the Thought Leaders Round Table for Strategy Development in Social Media and Public Health Communications was to differentiate strategy from “tactics” or immediate decisions and actions that tend to drive the use of social media and public health communication in both traditional public health (e.g., diabetes) and emergency public health response. It was on this point that I had the opportunity to contribute to the gathering with a talk on social media as a strategic shift in risk communication (transparency, audience engagement, collaboration) or simply a new tool for message dissemination (regular readers know where I and others come down on this issue).

The discussions in response to panel presentations were augmented by smaller work group discussions. Among the issues noted were the benefits of social media for increasing the situational awareness of response teams. On the negative side was the potential to threaten or impede response by conveying inaccurate or inappropriate information (such as when the senders do not appreciate the implications of some of the information they are reporting). An exemplary practice we heard was from The Red Cross who rather than simply push information out, use social media to pull information from volunteers during times of crisis and have trained over 150 of them to use social media tools in emergency situations.

The conference produced no breakthrough ideas or methods; a report from the 4 working groups should be available soon. One of the central issues that did emerge was the need for a guidance document for how to do an evaluation of social media.

The results of a recent survey by the APHA of social media practices (pdf) among Federal, state and nonprofit agencies (n=542) were also made available at this meeting. Among the findings were that 43% of the responding agencies currently used social media – social network sites, blogs and SMS (text messaging) are the most popular ones. Among the obstacles to using social media that were endorsed by 50% or more of the respondents were other competing priorities, staff time/capacity, level of familiarity with the tools and organizational culture.

The critical POV of all the participants was that social media was no longer a choice; it was a necessity in real-time risk communications (and what happens during the recovery period when the crisis has passed was barely addressed during the day). Many of the presentations were of the ‘show and tell’ variety and every Federal agency had a story. That was the good news. The challenges these people confront within their own agencies to using social media are daunting, most notably lawyers, being blocked from accessing social media sites at their offices, lengthy clearance procedures (I particularly liked the example of a now stream-lined FEMA process that still could not compete with the fellow standing at the flood gauge tweeting continuous updates on the rising Red River) and ill-advised postures by senior administrators to ‘avoid creating panic’ by NOT disclosing timely information (as opposed to enlisting people to help which tends to be the overwhelming response of people during emergencies as disparate as the landing of the US Airways flight in the Hudson River and the floods then ravaging the upper Midwest). Yet, participants agreed there was no turning back the clock on social media – it has achieved a solid position in all communicators’ consciousness about what they should be doing. But again, that ‘should’ often focuses on trying to extend the ‘command-and-control’ and message inoculation strategies – thinking of social media as new communication channels rather than as new ways to think about what they are doing, tools to engage in conversations with people and shifting their thinking to recognize that the people formerly known as the audience may often be better sources of information than the officially sanctioned ones. And there was also expressed the idea that in public health emergencies and other crises people are no longer audiences, but active participants in the drama that is unfolding.

[Image via Google News Timeline]