On Social Marketing and Social Change

Health Communication Campaigns: The 5% Solution

I was recently asked to present on what are the essential ingredients for a health communication campaign and what type of impact should be expected from them. For the answer, I turned to Leslie Snyder who has studied the effectiveness of health communication campaigns. In her most recent publication on the subject, she combined the results of several reviews of the literature that together examined over 400 campaigns on a variety of health topics.

Her conclusion: The question isn’t whether health communication campaigns are effective – it’s what is the average effect size they achieve (how much change do they result in)?

Across all these studies she found that targeted behaviors increase above baseline by an average of about 5 percentage points; a baseline level of a behavior usually is increased, for example, from 60 to 65%. Campaigns for seat belt use (15%), dental care (13%) and adult alcohol reduction (11%) campaigns have had the strongest effects, while youth alcohol and drug campaigns have had the least (1-2%).

Among other risk behaviors that were included in a sufficient number of studies to allow her to arrive at estimates of impact:

• Family planning (6%)
• Youth smoking prevention (6%)
• Heart disease reduction (including nutrition and physical activity (5%)
• Sexual risk taking (4%)
• Mammography screening (4%)
• Adult smoking prevention (4%)
• Youth alcohol prevention and cessation (4-7%)
• Tobacco prevention (4%)

Preliminary findings on risk behaviors among an even smaller number of studies are that in international breast feeding campaigns the average effect size is r = .17 (or 17%), for fruit and vegetable campaigns r = .08 and for in-school nutrition programs aimed at 4th-5th graders the r = .12.

Obviously, there are several caveats to these conclusions including the reach and frequency of messaging, the audience, the number of channels that were used and differences in measurement and evaluation. However, as a rule-of-thumb, the 5% figure may be a good place to start when you are trying to estimate the impact of a health communications campaign. And another reason to suggest you move beyond 1P marketing.

Leslie also found a number of factors that are associated with improved outcomes.

1. Promote adoption of healthier behaviors or substitutions over stopping or preventing unhealthy ones.
2. Habitual behaviors are more difficult to modify than one-off ones (e.g., screening behaviors)
3. Have behavior change as an explicit goal or objective
4. Use formative research in design and planning
5. Focus on homogeneous population groups
6. Communicate directly with your audience and not just through intermediaries
7. Have multiple executions of messages
8. Have a high frequency of exposure to the messages
9. Practice media multiplexity (using multiple channels)
10. Strive for sustained activity to mitigate the observed declines in behavior change after the campaign ends

And at the end of the presentation I added four more rules for developing successful social marketing programs.

• Behaviors need to be relevant to audiences – not producers of the message
  
• Opportunities and access to engage in new behaviors is necessary
• Incentives, not barriers, determine behavior change
• People live in social networks – tap into them

So as you are writing your social marketing plan, some empirically-based places to start.

Planning a Social Marketing Program

Developing a marketing plan explicitly, and implicitly, captures many of the core assumptions and understandings of social marketing. In its essence, a social marketing plan is a translation document that distills...

1. Understanding of the epidemiology of the disease
2. The context in which the intervention is being planned
3. Organizational strengths and competencies
4. Partners' capabilities
5. Behavioral determinants
6. And audience insights

...into strategies and tactics that lead to positive impacts in health behaviors among priority audiences. What is included and excluded in it, how terms are defined, its implications for research and evaluation, how interventions are designed and resourced, and what it says as a statement for 'what is social marketing' are taken quite seriously, and literally, by many (and I have been in more than several impassioned debates and discussions over the years on all of the above).

Phil Kotler and Nancy Lee have taken the lead on developing a model outline of a social marketing plan that they will present at the World Social Marketing Conference later this month. The outline builds on the one presented in their book along with their principles of success for social marketing programs that I have talked about before. This latest version was reviewed, and contributions to it made, by a larger group of social marketers including Alan Andreasen, Carol Bryant, Mike Newton-Ward, Michael Rothschild, Bill Smith and myself. This, I am told by Nancy, is the final version, and with her permission I am posting it below for you to review, comment on and hopefully adopt in your practice of social marketing.

Executive Summary
Brief summary highlighting plan stakeholders, background, purpose, target audience, major marketing objectives and goals, desired positioning, marketing mix strategies (4Ps), and evaluation, budget, and implementation plans.

1.0    Background, Purpose and Focus
    Who’s the sponsor? Why are they doing this? What social issue and population will the plan focus on and why?

2.0    Situation Analysis
2.1    SWOT:  Organizational Strengths & Weaknesses and Environmental Opportunities & Threats
2.2    Literature review and environmental scan of programs focusing on similar efforts: activities & lessons learned

3.0    Target Audience Profile (See Note #1 below regarding alternative terminology.)
3.1    Demographics, geographics, relevant behaviors (including risk), psychographics, social networks, community assets and stage of change (readiness to buy)
3.2    Size of target audience

4.0    Marketing Objectives and Goals
4.1    Campaign Objectives: specifying targeted behaviors and attitudes (knowledge and beliefs)
4.2    SMART Goals: Specific, Measurable, Achievable, Relevant, Time bound changes in behaviors and attitudes

5.0    Factors Influencing Adoption of the Behavior (See Note #2 below regarding the iterative process.)
5.1    Perceived barriers to targeted behavior
5.2    Potential benefits for targeted behavior
5.3    Competing behaviors/forces
5.4    Influence of important others

6.0    Positioning Statement
How do we want the target audience to see the targeted behavior and its benefits relative to alternative/preferred ones?

7.0    Marketing Mix Strategies (Using the 4Ps to Create, Communicate and Deliver Value for the Behavior.)
7.1    Product:  Benefits from performing behaviors and any objects or services offered to assist adoption
Core Product:  Desired audience benefits promised in exchange for performing the targeted behavior
Actual Product: Features of basic product (e.g., HIV/AIDS test, exercise, # daily fruits & vegetables) 
Augmented Product:  Additional objects & services to help perform the behavior or increase appeal
7.2    Price:  Costs that will be associated with adopting the behavior

• Costs:  money, time, physical effort, psychological
• Price-Related Tactics to Reduce Costs:  Monetary & Nonmonetary Incentives and Disincentives

7.3    Place:  Making access convenient
Creating convenient opportunities to engage in the targeted behaviors and/or access products and services
7.4    Promotion:  Persuasive communications highlighting product benefits, features, fair price and ease of access

• Messages
• Messengers
• Creative/Executional Strategy
• Media Channels & Promotional Items

8.0    Plan for Monitoring & Evaluation
8.1    Purpose and audience for monitoring and evaluation
8.2    What will be measured:  inputs, outputs, outcomes (from Steps 4 & 6) and impact
8.3    How and when measures will be taken

9.0    Budget
9.1    Costs for implementing marketing plan, including additional research and monitoring/evaluation plan
9.2    Any anticipated incremental revenues, cost savings or partner contributions

10.0    Plan for Implementation and Campaign Management
Who will do what, when – including partners and their roles?

OF SPECIAL NOTE: (1) Alternative terms include: Target Market (the traditional term), Priority Market, Priority Audience. (2) The process is an iterative one. For example, you may need to revise objectives and goals after hearing of barriers and benefits in Step 5, or promotional ideas based on final budget realities in Step 9. (3) A separate plan will be needed for each target audience, even though part of one campaign. (4) Research will be needed to develop most steps, especially formative research for Steps 2-6 and pretesting for finalizing Step 7.

Brutally Honest Campaign on Binge Drinking

“It is time to be brutally honest about some of the worst effects of intoxication.”

The Alcohol Advisory Council of New Zealand’s [ALAC] social marketing program is covered at Scoop with a news release and background materials announcing the latest wave of advertisements depicting the harmful consequences of binge drinking. Three television commercials focus on a  ‘tipping point’ when drinking becomes harmful. Danny (a team drinker), Lisa (who drinks to boost her confidence) and Uncle Mark (a 'show off') are each shown making poor choices due to the amount of alcohol consumed.

The programme is a long-term strategy with the ultimate goal of changing New Zealand’s binge drinking culture. ALAC wants to increase the number of drinkers who have thought about the harmful effects of getting drunk, who agree they are more likely to cause serious harm to themselves and others if they get drunk and who agree it is never OK to get drunk. [Note that ALAC is funded by a levy on alcohol produced and imported for sale in New Zealand.]

In the backgrounder, the campaign's components are described as including policy, education, service provision and enforcement to support the change that the marketing messages are designed to stimulate.

The Supply Control strategies focus on achieving enforcement of and compliance with the Sale of Liquor Act, controlled purchase operations, parents’ programmes, policy measures designed to reduce overall consumption such as using tax/price, controlling outlet density, purchase age and regulating alcohol advertising.

Problem Limitation strategies focus on the group of dependent and hazardous drinkers who need support and assistance to reduce or stop their drinking. These strategies include early intervention programmes, treatment, supporting the Alcohol Helpline and other services.

Demand Reduction strategies focus on achieving culture change outcomes by persuading communities and individuals to make better choices about their consumption. It is in this area that ALAC identified a gap.

More information will be available at the campaign website.

PSP-One Online Social Marketing Conference

Be sure to check-in at the first online conference for social marketers being sponsored by USAID: Social Marketing for Health in the Developing World: What Have We Accomplished and What Does The Future Hold?

The third day of sessions opened today with the Panel 3 presentations: What's New in Social Marketing for Health?

Rochelle Rainey, Environmental Health Technical Advisor, USAID Global Health Bureau. Water, please! Lessons Learned from Social Marketing of Point-of-Use Drinking Water Treatment Products.

Steve Honeyman, Country Representative, PSI/Nepal. One Size Doesn't Fit All: Why Different Implementation Models are Needed for Different Social Marketing Health Interventions.

Claudia Velasquez, Senior Program Officer for Research and M&E, Institute for Reproductive Health, Georgetown University. Expanding Choice and Increasing Access Through Social Marketing: Offering the Standards Days Methods in Ecuador, Benin and Democratic Republic of Congo.

Robert Porter, Senior Technical Advisor & Margot Fahnestock, Project and Research Manager, Constella Futures. Reassessing HIV Risk in Sub-Saharan Africa: Have We Been Targeting the Right Populations?

James Shelton, Science Advisor, Bureau for Global Health, United States Agency for International Development. Depo-Provera in Uniject: Perfect for Social Marketing.

You will also continue to have access to:

• Panel 1: Presentations on Public Private Partnerships: What Have We Learned?
• Panel 2: Where is the "B" in Behavior Change Communication?
• The Expert Exchange Forum
• Discussion Rooms
• The Exhibit Hall
• Resource Center and the polls.

Registration continues to be free. View and listen to the presentations, contribute your ideas and look up and engage with over 900 of your colleagues on some of the leading issues in the field.

Principles for Success in Social Marketing

The 2008 version of my social marketing class is ready to begin. Among the changes is adapting Phil Kotler and Nancy Lee's 3rd edition of Social Marketing - subtitled now as influencing behaviors for good. In it, they list 15 principles for success. Here they are with some commentary.

Take advantage of prior and existing successful campaigns. They are referring to an environmental scan of campaigns,and applying lessons from them to your own. Unfortunately, few accessible descriptions of successful campaigns tell the real story about how they got to that point; that's usually where the lessons are. When you are doing this, focus on campaigns that are focused on your priority audiences, NOT the health issue. That's when you learn and possibly get some audience insights.

Start with target markets most ready for action. Almost every behavior change approach will echo this sentiment, and it is a correct one. Yet you also need to focus on the audience critical to the success of your program. And please stop referring them to targets. If you respect their dignity and ability to make choices they might be less inclined to try and dodge your messages. 

Promote single, simple, doable behaviors - one at a time. Again, a basic principle of any effort to change the behavior of an individual. But what model do you use when you are trying to change the behavior or hundreds, thousands or millions of people [pdf file]?  And be sure to avoid preaching the public healthy behavior and focus on what's relevant to them [pdf file].

Identify and remove barriers to behavior change. This approach to social marketing may have it's time and place, but it less frequent than advice like this should lead you to practice. I'll quote myself here: Addressing deficits and moaning about barriers seems to be in the DNA of too many public health programs; practice some positive deviancy and test whether building on aspirations and assets doesn’t suggest different strategies and approaches. If nothing else, you’ll have a more diverse collection of concepts to test with your audiences and partners.

Bring real benefits into the present. Another well-known principle of behavior change dating back to at least B.F. Skinner and operant conditioning - though the authors prefer to attribute it to economic theory. Also realize that the benefits don't have to be shouted out for the audience to understand and respond to them.

Highlight costs of competing behaviors. See also operant conditioning where the size of the consequence (or vicarious exposure to, or expectations of, positive consequences if you want to flip to social cognitive theory) is a major determinant of whether a behavior is acquired. I wonder how many people practicing social marketing really understand the essentials of behavior change rather than making it so complicated? My impression is that they get too wrapped up in cognitive activities (intentions, beliefs, attitudes) and economists' guesses (and Freakonomics may not explain things that well either) when the basics might be easier. And some behaviors may be more determined by social factors than they first appear.

Promote a tangible good or service to help target audiences perform the behavior. For international readers, this might seem to flip social marketing as generally understood on its head. For the social marketers in the developed world, a reminder that products are not just the 4Ps of pamphlets, posters, PSAs and publicity. Strive for products and services that help people change and not merely be channels to inform or expose them to messages.

Consider nonmonetary incentives in the form of recognition and appreciation. I completely agree that monetary incentives are too often a default position for many change agents. Learning a little more about what motivates people is worth looking into.

Make access easy. For services and products, I agree. But social marketers also need to insure that their audiences have the opportunities to try new behaviors, practice them and then be able to sustain them. Otherwise, behavior change is just an idea. This is where thinking about and targeting  (things, not people) environmental, structural and policy barriers makes sense.

Have a little fun with messages. They do point out that for some types of organizations even a little bit of fun might be out-of-bounds. But be careful not to make it a joke or have the fun overshadow the intent of the message ('I laughed so hard I didn't pay attention to what they were saying').

Use media channels at the point of decision making. Always a good strategy, though I prefer to think of this as just one of several openings (the right time, place and frame-of-mind) that we need to be present in. Research notes a person living in the US makes more than 200 decisions about food a day. Plenty to aim at for the obesity prevention folks.

Try for popular/entertainment media. Back to the 'make it fun idea' and entertainment education certainly can play a role in communication efforts - if you can get your audience to come and pay attention. But for scalable behavior change, I want to use media to reach an audience where ever they are and then worry about tone.

Get commitments and pledges. Another classic behavior management tool for individual behavior change that finds many applications as behavior contracts. A little more difficult to do for populations, but not impossible. And a nice way to begin to introduce price as incentives into the social marketing program.

Use prompts for sustainability. They are referring here to sustaining behavior, not the sustainability of social marketing programs (unfortunately). Their relentless focus on individual behavior change leaves a lot out of what concerns practitioners and policy makers.

Track results and make adjustments. Just be sure you are monitoring and evaluating the important things, not simply what is easy and measurable. Will you be able to answer the questions: So what? Who cares?

Here are five suggestions I have for successful programs.

What we will continue to grapple with throughout the course, and indeed in the profession (or discipline), is how to use social marketing for scalable impact on health issues and not be bound by theories and approaches that try and do it one person at a time. Been there, done that.

The National Diabetes Education Program

Diabetes is the 6th leading cause of death in the US and nearly 7% of the US population (20.8 million) is estimated to have the disease. Beginning in the late 1990s, the National Institute of Diabetes, Digestive and Kidney Diseases and the Centers for Disease Control and Prevention established the National Diabetes Education Program. The latest issue of Social Marketing Quarterly (subscribers get it before it goes up on the website) has an article about NDEP that nicely summarizes this large-scale social marketing effort to reduce the burden of diabetes.

The article provides an historical context, audience research base and theoretical framework for their approach (which, for full disclosure, our social marketing group at Prospect Associates partially supported). What is noteworthy is the focus on a 3-part action plan that encouraged people with diabetes to write down:

• 3 reasons for controlling their diabetes (I would insert the words ‘personally relevant’ to avoid a rote recapitulation of scientific facts)
• 3 things they will do in the next 3 months to improve their control of their diabetes (recognize the movement towards the Preparation stage here?)
• 3 people who could help them with implementing their action plan (social support even snuck in!)

I have been picky in the past about how programs are misrepresented in the literature as being social marketing ones [When is it social marketing?]; in this case the authors do a great job of laying it out. Their identification of the ‘price’ factors involved in diabetes control is particularly well done. One observation I do have is distinguishing between ‘place’ and ‘promotion’ where the blurring of marketing and communications can and does occur regularly.

The authors define ‘place’ as the channels used to reach priority populations (ahhh, someone is listening) with product messages where they live, work, play and receive their health care services. They then define ‘promotion’ as the communication channels and tactics used to reach campaign audiences. From my POV, the problem here is that both terms refer to the same essential feature - reaching audiences with messages - so why use two terms to refer to the same thing? I distinguish between them by reserving ‘place’ to talk about where and when people can engage in the behaviors or can access the products and services we are providing (or promoting). Caution needs to be taken to make clear the distinction between the distribution of messages (which in a communications plan is more appropriately the ‘place’ question) versus the distribution of products and services and providing the opportunities to engage in behaviors (more appropriate, I believe, the ‘place’ variable in a marketing plan). While the distinction may at first looked semantic, it has very real implications for strategy and the development of tactics that are often overlooked in many efforts.

For those interested in the success of social marketing programs, the NDEP paper also provides data to document the increase in awareness of the program and self-reported prevalence of blood glucose testing practices and use of the A1C test. A final section on lessons learned provides a useful summary of generalized principles that any program designer can benefit from. The most useful and least talked about one in my experience is: The most effective way to get buy-in is to involve partners early in the process and give them productive roles. The part of this lesson that the authors don’t spend time on is that these productive roles and responsibilities evolve over the life cycle of the project. In particular I find that the roles of organizers and developers of a program are much different from the later programmatic stages where roles are more concerned with implementation and management. The other lesson is that the same organizations are not necessarily the best at both, and giving space and permission in your programs to allow partners to engage, disengage and join later in the process is an important expectation to have and communicate early and often. And yes, partnership development and management can be a marketing process [pdf file] as well.

BTW – diabetes is not just a US problem: While diabetes affects persons of all ages and all races, it disproportionately afflicts people living in the developed world, where prevalence is higher. However, the number of 20– to 79–year–olds with diabetes is expected to jump 72 percent by 2025 most notably in the Middle East and North Africa, South Asia, and Sub–Saharan Africa. [From the Disease Control Priorities Project.]

So the work on population-based methods for diabetes control has just begun. This paper will quickly get you up to speed on using social marketing to get started.

The World Record for Longest Condom Chain

This is a story about a PSI program. From the World Records Academy:

"I do what I want, but I know what I am doing®" and Love Plus - Continue the Chain of Life. 

In order to draw attention to the increasing number of HIV/AIDS infections among Romanian youth, the "I do what I want, but I know what I am doing®" (Fac ce vreau dar stiu ce fac) program attempts to set a new world record for the longest condom chain.

The condom is one of the most effective ways to prevent the rising danger of HIV, along abstinence and fidelity.

On Sunday, the 28th of October, starting at 12.00 PM, on Bulevardul Unirii, in the presence of Romanian celebrities and NGOs active in the HIV/AIDS field, hundreds of people will tie a condom chain 3 kilometres long, which will set a new Guinness World Records™.

The current World Record adjudicated by Guinness World Records™ was set by UNESCO Thailand, on the 1st of December 2006, the International Aids Day, during the Condom Chain of Life festival, when a 2.7 km condom chain was tied. The chain was tied by 1436 participants who tied 24516 condoms together.

“This is an answer to the challenge to continue the chain of life launched by UNESCO Thailand. One condom is a small, often disconsidered object, but 30.000 condoms tied in a chain can tell a story: all over the world these small objects are our main ally in our fight against HIV, the virus responsible for the most destructive epidemic in the history of humanity.”, as Cristian Branea, the "I do what I want, but I know what I am doing®" ( Fac ce vreau dar stiu ce fac) Program Manager declared.

Through its social marketing programmes, PSI Romania protected, in its 9 years existence, over 50 million sexual contacts through the social brand Love Plus. Love Plus is the only social brand in Romania, which donates 100% of its sales revenues to fund its social HIV/AIDS prevention programs.

In the last three years, Love Plus donated over 500.000 euros for HIV/AIDS prevention among youth through the "I do what I want, but I know what I am doing®" (Fac ce vreau dar stiu ce fac) social program.

Note that this social marketing program uses all profits to fund HIV education programs.

Increasing Recycling Behavior with Social Media and Marketing

I first noted the North Carolina RE3 project last Fall. I was so impressed by their use of marketing and social media approaches that I encouraged Kelley Dennings to submit an abstract for presentation at the Social Marketing in Public Health Conference. Well, she had her own breakout session today and I hope that this is a milestone for the regular appearance of environmental social marketing in the program. That Jay Kassirer, who will do his 'Confessions of an Environmental Social Marketer' at tomorrow's plenary, as well as someone else doing water conservation programs in Florida were in the audience may also be a sign that we are moving out of the predominant 'health behavior' focus of the field (or the environmental people are feeling more comfortable about presenting their work to this audience!). Anyway, great job by Kelley! You can see some of the project's latest work on YouTube - Epiphany seems to be the audience favorite. Their blog is here. And their MySpace profile.

Her slides, as well as most of the other presentations made at the conference, will be available online in a few weeks. I'll keep you posted.

Unlocking Condoms

Almost half of CVS drug stores have been found to be locking up condoms in predominately low-income minority neighborhoods in Washington, DC - a city with the highest rate of HIV/AIDS in the country - and in the surrounding areas. In response to this finding, a grassroots organization Save Lives: Free the Condoms Coalition has been started by The Student Public Health Association at The George Washington University School of Public Health and Health Services. Their goal is to persuade CVS/Pharmacy to adopt a national written policy to make condoms freely accessible by unlocking condom displays in all of its stores.

The coalition asked me to make this request of readers and others who have an interest in public health and sexual health issues:

Please visit the website [or pass the word along] and share with us any difficulties you have experienced in purchasing condoms at CVS anywhere in the country.

The coalition's work has already attracted the attention and support of other organizations in the DC area. And apparently the practice of locking up condoms isn't restricted to DC area stores, but has been found in Arizona and Milwaukee, Wisconsin. Now all they need is an icon or avatar - and your help. 

RIP 5 A Day

The 5 A Day program was quietly retired last week. The press coverage focused on the finding that Fewer than a third of American adults eat the amount of fruits and vegetables the government recommends, a trend that's remained steady for more than a decade.

Actually, the figure from the CDC's BRFSS 2005 prevalence data is 23.2% - less than a third must have sounded better than less than a quarter. For a point of comparison I looked at the data from the NCI evaluation of the program: the prevalence of adults who reported eating at least 5 servings of fruits and vegetables a day was 19% at baseline in 1990; 22.1% in 1994 - 3 years after the launch of the campaign; and 22.7% in 1996.

The NCI evaluation report also noted that the addition of more intensive state level interventions beginning in 1994 had done very little to change fruit and vegetable consumption. In fact, the only deflection in the prevalence was when the campaign first launched with major national leadership and social marketing support from the NCI (that I did participate in). That support declined noticeably after the evaluation report, finally concluding with shifting the program to the CDC. Of course, if some people had known then what they know now, 3% increases (actually a 16% increase over baseline, but epidemiologists don't seem to calculate that way) would have been cause for celebration. The flat line since then supports the idea that the 16% change wasn't a secular trend either - the other favorite toss-off explanation at the time to move the money out of the program and back into research.

Now we have a broken program, 10 years of wasted time, a brand washed away (check with the stakeholders), a new information-based effort to replace 5 A Day that explains to people why more fruits and veggies matter, and bromides such as this (from the MMWR report on the new data):

The lack of success in meeting national goals for fruit and vegetable consumption indicates a need for additional measures to educate and motivate persons to make healthier dietary choices. Nutritional interventions should go beyond increasing individual awareness and target the family, local community, and overall society to eliminate barriers to healthy eating, provide support for persons who are making healthy changes, increase resources for populations with greater need, and emphasize nutritional policies that have an impact on society.

We could also go back to marketing - that's when it worked!

Watch for the one day media coverage: To get people to eat more of these nutrient-rich foods, the CDC, the Produce for Better Health Foundation and other leading health groups are launching a new initiative Monday called "Fruits & Veggies — More Matters." This will replace the "5 A Day" campaign.

I'll be wandering aimlessly.