On Social Marketing and Social Change

Social Marketing in the News

User Fees, Optimal Pricing & Upward Sloping Demand Curves in Health

One of the most controversial subjects in global health is the topic of user fees for health services and commodities. Ever since Nancy Birdsall, David de Ferranti and John Akin declined to rule out user fees as a useful source of health financing way back in 1987, the World Bank has been pilloried for "advocating user fees" in the health sector, which the Bank has never done. By setting out explicit criteria for setting user fees in the 2004 World Development Report, the Bank resisted continuing political pressure to ban them outright and further fueled the debate. Among the donors, DFID (see also this white paper) has most adamantly rejected user fees as either effective or legitimate for improving access to health care by the poor. On the other hand, the social marketing of health care commodities, from condoms to antibiotics, is increasingly popular among actors such as PSI and KfW and presumes that the optimal price of these commodities, while heavily subsidized, is not free.

The obvious argument against user fees is based on the fundamental economic proposition that demand curves slope downward* - e.g. that the number of people willing to purchase a product or service declines as its price increases. It follows that lower prices should result in more health care utilization than higher prices, and that zero prices would be even better. However, a fascinating new study by Nava Ashraf, James Berry, and Jesse Shapiro of the market for home water purification solution in Zambia finds that in fact demand curves seem to flatten out as the price approaches zero, and may even slope upward - or, in plain English, that the act of paying a small amount (up to 18 cents, in this case) actually increases use over distributing Clorin free of charge.

The authors posit two reasons why people might behave contrary to the simple law of demand. First, the price effectively targets the distribution of the health commodity to those least likely to waste it. Second, people who have paid more for a product may have a greater psychological commitment to using it. They find strong statistical support for the first of these effects and weak support for the second.

If these results could be generalized to other health commodities, like bednets to prevent malaria, or to health services such as curative health clinic visits, the suggestion would be that sufficiently small user fees do little to discourage utilization; they might even increase it by stimulating the supply of health care quantity and quality.

Condom-inium!

Condoms and their sociology have indeed come a long way in India. But their, ahem, penetration has not really gone far into rural India, where they are distributed mostly through the State AIDS Control Societies (SACS) and social marketing channels. A lot of it is wasted due to the lack of proper distribution. Many of these pieces eventually find their way to making chappals, lining hut roofs, or oiling loom shuttles (with the non-staining lubricant). Bad distribution also leads to the problem of having outdated products in circulation. Vivek Anand, CEO of Humsafar Trust, says it’s silly to expect condom users to look at “user instructions and expiry dates in the dead of the night” when you have only one thing on your mind…

We tend to forget that this is the country that started the world’s first social marketing programme with the Nirodh campaign in the mid-1960s. The government procured condoms from various companies and coerced large-network FMCG and durables companies such as ITC, Union Carbide (till the Bhopal gas tragedy), Hindustan Lever and Voltas to distribute them. When the winds of liberalisation started blowing in the early 1990s, specialised social marketing agencies like PSI, Marie Stopes, Family Planning Association of India and DKT International entered the scene, and the private sector companies kept to their own domains.

A New Weapon in the Fight Against Anaemia

A nutritional supplement known as Sprinkles, which is a simple powder that parents can easily add to their children's food, reduces childhood anaemia by more than half, according to a recent study published in the Journal of Nutrition…

Among the children who received Sprinkles mixed into their food for two months, the incidence of anaemia declined from 54 percent to 24 percent, the study found. And even seven months after the children stopped taking Sprinkles, the rate of anaemia had declined even further, to 14 percent…

The study found that the use of iron-fortified food, such as wheat-soy blend or corn-soy blend, failed to reduce anaemia among young children on its own. In fact, the incidence of anaemia actually rose among the children who received only wheat-soy blend without Sprinkles.

Ruel is confident that Sprinkles -- a dry powder containing iron, zinc, and other vitamins -- could get around the problems facing iron syrups and other anti-anaemia measures…

Since 2005, the social marketing organisation Population Services International has been marketing Sprinkles commercially in Haiti under the name "Babyfer".

Pacific People Fail to Get Health Message

The majority of Pacific people have been left untouched by the healthy-food message of eating at least five servings of fruit and vegetables a day.

A survey for the Counties Manukau District Health Board found that less than 30 per cent of Pacific people knew this was the recommended intake of fruit and vegetables - set out in the '5-plus-a-day' message…

The "baseline" survey of 2400 adults was to gather more information for the health board's five-year, $10 million Let's Beat Diabetes scheme, an ambitious campaign to help defuse the timebomb of obesity and type 2 diabetes by changing eating, drinking and physical activity habits.

Fifty-six per cent of adults are overweight or obese and the rate of obesity has doubled in the past 30 years. Among children, 31 per cent are overweight or obese, but the rate is 41 per cent among Maori children and 61 per cent for Pacific youngsters aged 5-14.

When asked if the lack of Pacific awareness of the fruit and vegetables message was a concern, public health specialist Dr Tom Robinson said, "I guess it creates an opportunity".

"Let's Beat Diabetes is a social marketing campaign. That's partly about providing knowledge so, yeah, that creates opportunities to work with Pacific and Asian people in particular to increase their knowledge about healthy eating."

Social Marketing Conference News

17th Annual Social Marketing in Public Health Conference

The handouts and slides from many of the presentations at the conference and training academy held in Clearwater Beach 20-23 June 2007 are now available at the Florida Prevention Research Center website. Two presentations I was involved with that are online:

Marketing with the connected consumer [pdf]

Try it at home [pdf]

Second National Social Marketing Conference

The National Social Marketing Centre is organising the conference to be held at Keble College, University of Oxford, from 24 - 25 September 2007. It is designed for public health professionals, educators, health communication specialists, commercial marketers, charities/NGOs, environmental officers, sustainability specialists, researchers, academics and students.

The objectives are stated as:

• To understand how social marketing is being used increasingly by the Department of Health and other Government departments to drive policy and practice.
• To share examples of successful national and international social marketing interventions.
• To support practitioners in the application of social marketing.
• To cultivate professional contacts and networks with those who have the potential to collaborate on current or future projects, share knowledge, or assist with problem solving.

Maybe IT IS All About Social Networks

Obesity appears to spread through social ties. That's the bottom-line of a study in this week's New England Journal of Medicine (The Spread of Obesity in a Large Social Network over 32 Years - free pdf) that  puts the spotlight on social networks and health determinants for chronic diseases. I had to laugh when I saw a glossary of terms on the second page of the article (not at the end) - ego, alter, node, degree of separation, homophily - I guess to help people understand what they were reading (why don't they do that for more articles in NEJM?). And for those of you who have never seen social network analysis and graphs before, hang on - you will never go back to crosstabs. Hello medicine - welcome to the real world! It's about people, relationships, connectedness and engagement. Oh, and health.

Here is the front page coverage of the results in the Washington Post and the New York Times (and for the truly interested, there were over 275 reader comments on the article on the NYTimes site when I posted).

What I expect will have many people puzzling about the results is that social networks do not necessarily refer to your work mates and neighbors; in fact, geographical proximity was not the important factor for the effect of social networks on weight gain. Social distance is the important variable, and for those of you who have heard my talk, read the blog and otherwise pay attention to such things, you know what that means for interventions. For the newly tuned in, these data demonstrates perfectly why social media and mobile technologies will be such important tools for social marketing in the future.

To put these new findings into a context, here's an excerpt from my article that will be appearing soon in Social Marketing Quarterly:

What’s Social about Behavior?

An important point to reiterate about the new media world is that it is a networked one, not unidirectional or linear. This reality does not just pertain to how we depict our communication processes; it also reflects people’s reality. Just a cursory look at some of the health behaviors that are the focus of social marketing programs reinforces the fact that all health behaviors are, to a greater or lesser degree, social. New media now allows people to explore these social aspects with greater freedom than ever before. Freedom from geographic and temporal boundaries, open access to sources and information, and the ability to create the digital and social contours that surround health conversations, information-seeking, decision-making and behavioral choices.

Encouraging screening behaviors for conditions and diseases that presently do not bother someone has been the subject of much work since at least the 1950s when the Health Belief Model emerged as a way to conceptualize the process for tuberculosis screening. Over the years, HBM and other individual models of screening behavior have predominated much of our thinking despite the evidence that social influences are likely much more important. Whether my health care professional recommends that I get screened for high blood pressure or blood cholesterol levels; breast, cervical, skin or prostate cancer; and other potential (and silent) problems is a social communication process – not simply a perception of perceived risk and severity of the disease. Whether I know other people who have been screened for the condition, what their experiences were, whether they suggest to me that I should have it done too, are much more powerful influences on my decision-making than some theorists would have us believe. That I can sit down at with my desktop, laptop or smart phone, connect to the internet and now find like-minded others who want to share their experiences can have a tremendous impact on how social my treatment-seeking behavioral determinants become. The web is changing the weights in our models of determinants of health behavior.

The same types of issues hold true for other health behaviors. Consider the person who is trying to make lifestyle modifications that might include diet modifications or increasing her/his level of physical activity. How are those decisions to make such changes arrived at – in isolation in front of a mirror or lying in bed in the morning? How does the person decide how to begin to prepare for or address the problem? What are some of the stronger sources for motivation and inspiration? Where does the reinforcement for positive changes usually come from? Where does s/he go when they feel a weak moment or frustration with their progress? How do they celebrate success?

I venture to say that in at least 80% of all cases the answer is “other people.” The key questions for social marketing programs are not just what behaviors to focus on, how to create incentives and reduce barriers to engaging in them, opening up more opportunities to try them and sustain them, and then promote them – it is answering the ‘who’ question. Not just the relatively simple one of ‘who is the credible source of information,’ or the more complex one of ‘how do we change social norms and acceptability,’ but the audience-centric one: who does s/he interact with on a daily or weekly basis as part of their daily routines and are influential in the choices they make about health behaviors.

The same types of questions are also important when we address the cessation of addictive behaviors (where social support becomes such an important determinant of short-term and long-term success), compliance with medical regimens (where friends and family care-givers play a huge role), precaution adoption - taking actions or changing behaviors to avoid or reduce the threat of intentional and unintentional injuries, health information seeking (where over 66% of online searches involve looking for other people’s opinions, reading blogs, visiting social network sites), and taking collective action and advocacy – where the rise of mobile technologies have taken these activities to a whole new level of sophistication and effectiveness (see Smart Mobs).

In case you missed it - the paradigm has shifted.

P.S. [added 27 July AM]: For an introduction to network theory, see the book I have been featuring under 'New Reads:' Linked: The new science of networks by Barabasi.

Student Voices: On Social Media and Social Marketing

The conversations you have with your audience are the most important sources of learning for you. That applies whether you are planning a new social marketing  program or trying to understand how to think about and explain new media and its impact on social marketing practice.

At American University's School of Communication last Saturday morning I spent nearly 2 1/2 hours with a social marketing class doing a variation on the usual one hour spiel. With only a lunch break as a stopping point, we became so involved in discussions of almost every slide and idea I put up that even the lunch break went by with no one making a move for the door. Very exciting for me to have the luxury of complete engagement by everyone and not having to rush through slides, limit discussion and end in an hour.

And a few students did not stop there, sending me emails afterwards with more thoughts about the session that I want to share here.

I particularly enjoyed hearing about the Media Multiplexity Strategy. Not only does it make sense to use multiple media strategies, but it highlights the diversity of media tools available. The Media Multiplexity Strategy, coupled with the idea of personalized extended reach, makes this a very exciting time to be in social marketing. We are right smack in the middle of a transition in communication technology that is not only changing the way we communicate, but is restructuring social relationships. How exciting!

...your presentation of "the networked world" was refreshing. This networked world is so often presented as a barrier to communicating with publics, or as something that needs to be controlled (which is really scary because I don't know how that is even possible). It was refreshing to hear you say that this networked world is really an opportunity not to be dreaded, but to be embraced. It gave me hope.

One thing you mentioned in your presentation that really resonated with me is the recurring behavior of "teams" and organizations wanting to substantiate their existence through the creation of meaningless and cliche mission statements, which are a waste of time and mean nothing in the end to all those involved. I push back on this time and time again at work and yet its a tradition that's hard to break, particularly in such a large institution as mine. Breaking through that clutter of ideas and institutionalized beliefs is my "mission"...

The other point addresses just the concept of what Web 2.0 is. As you defined it, its not just an audience, it's a community. It's really a little scary at how quickly ideas can spread through individuals and catch wildfire. For social marketing this is a HUGE opportunity. The black hole for me is how to embrace that opportunity and create positive social change. Of particular importance to me is the international arena and in developing countries where internet and cellphone are existent, but are also exclusive to members within a hierarchical social structure.

For me, it showed how social media options will impact the social marketing sector in the future. It also brought home a new way of looking at branding. It's no longer about positioning a company name or logo but instead positioning behavior so that people want to help spread stories. Knowing about these new techniques and tools is essential to the work and success of communicators.

And my favorite: You have provided lots of room for thought and concern...

 

A fitting finale to a presentation that now begins with this quote from Ray Bradbury:

We need not to be let alone. We need to be really bothered once in a while. How long is it since you were really bothered? About something important, about something real?

Special thanx to Amy, Mei-Ling & Tomeka!
And Lynette Webb.

Customer-Centered Health Care Markets

When I heard that the Innovations in Social Marketing conference planning committee had chosen as this past year's theme, It's all About the Customer, I assumed that - well, since many of us are in the health sector - consumer-driven heath care would be a natural area of focus. How wrong I was as we instead heard about feel good magazines, synthetic cheese products and shoe stores.

But I am [slowly] learning not to be surprised. Since Health Affairs has published an interview with Regina Herzlinger, the originator of the concept that has been driving health care innovation and practice for the past 10 years (with its proponents and detractors), here are some of her thoughts.

When it comes to demand, what people call "consumer-directed benefit design" is a far cry from true consumer-driven markets, in which there's tremendous choice...To think that a high deductible and a PPO [preferred provider organization] define the consumer-driven market in an industry that's two trillion dollars! The consumer-driven supply innovations, like retail clinics and middle-class concierge medicine, have run into the barriers created by powerful status quo institutions.

[Q]Your application of market principles and consumer focus to health care, although not universally accepted, has been distinctly original... [A] You can be an academic who goes along with the tide: You figure out where the tide is going, you do your little thing in it, and you do it very well. That kind of academic helps the world go around. But, to me, academics should be intellectual path breakers... In the past five years I have written more than forty field-based cases about entrepreneurs in all parts of health care--from insurance to personalized medicine. These cases showed me how difficult entrepreneurship is in health care.

In insurance design, to focus on deductible as the only innovation is falling short. Some people like high-deductible, some people like savings accounts, some people want HMOs [health maintenance organizations]. But other innovations are possible. For example, why not reward those who go to the gym every day, don't smoke, and control their stress? Why don't those people get rewarded? Why aren't there insurance policies that say, if you stay healthy, I'm going to give you financial rewards? The market is clearly starved for insurance innovation.

Health insurance is among the lowest-rated sectors in consumer satisfaction. When people get involved, they're going to be both happy and unhappy. Is that good news or bad news? To me, that's terrific news. They're doing what consumers ought to do, and that is to voice their feelings. When they do, things change.

If you want to make an industry market-driven, you have to change both demand and supply. That is, you have to change how people buy and what they buy. The system has to change from being organized by inputs--by hospitals, doctors, nursing homes, drugs, technology--to being organized by what consumers need. And what consumers need are focused factories: integrated, total lifestyle solutions for their cancer, for their AIDS, for their diabetes.

And when you get an innovation, you do value pricing. Value pricing means that it's good for the customer, but it's also good for you. You take some of the extra productivity that you have enabled, and you keep it... You can't do that in health care. The top-down, one-size-fits-all pricing profoundly slows innovation.

Consumer markets have good information because consumers pay for the information... But there are no comparable sources in health care. I know more about my Raisin Bran than about the guy who delivered my children or the hospital in which he practiced. That's because there's no consumer market yet in health care, and these information organizations exist only in consumer market.

That is why we need consumer-friendly information, so consumers can know how good their doctors and hospitals are. Armed with information about cars, consumers drove General Motors, essentially, to bankruptcy, without really understanding technical details.

Fundamentally, single payer controls costs by rationing care to the sick, while consumer-driven health care controls costs through innovations in the care of the sick.

Consumer-driven health care is very threatening to a group of people in the health policy community that fundamentally believe that they're smarter than everybody else...Their fundamental idea is that they must play a central role in advising and managing the system. So, the notion that a market-based environment can radically improve health care, not with their controlling the system through a self-referential intellectual cartel, but through market-based entrepreneurs and empowered consumers, is very threatening.

Now that might make for some interesting discussions - no? Imagine helping to make the health marketplace work for the rich AND poor.

Teen Segmentation by Class in the US

danah boyd writes on the the division of American teen culture by class as she looks at the differences among users of MySpace and Facebook. She notes that while the use of social class as a construction in other countries (England and India being two examples) is accepted practice, 'class' is not an easy term to apply in American culture and is not the equivalent to socio-economic status. Class divisions in the United States have more to do with social networks (the real ones, not FB/MS), social capital, cultural capital, and attitudes than income...

The goodie two shoes, jocks, athletes, or other "good" kids are now going to Facebook. These kids tend to come from families who emphasize education and going to college. They are part of what we'd call hegemonic society. They are primarily white, but not exclusively. They are in honors classes, looking forward to the prom, and live in a world dictated by after school activities.

MySpace is still home for Latino/Hispanic teens, immigrant teens, "burnouts," "alternative kids," "art fags," punks, emos, goths, gangstas, queer kids, and other kids who didn't play into the dominant high school popularity paradigm. These are kids whose parents didn't go to college, who are expected to get a job when they finish high school. These are the teens who plan to go into the military immediately after schools. Teens who are really into music or in a band are also on MySpace. MySpace has most of the kids who are socially ostracized at school because they are geeks, freaks, or queers.

She uses this self-segregation, or social aggregation (it's your POV), to make the point that the technology allows these social gaps to become clearer even as we (as a society, as harbingers of a unified social norm) try to ignore them. When she notes how the military banned use of MySpace by the troops, but protected Facebook from the same treatment, it was case closed for me.

Read her article and ask yourself when you are working with a health issue how often it involves people from varying socio-economic and demographic backgrounds and how often does it REALLY involve differences in class? How much of the fatalism, lack of control and other 'barriers' we perceive among people engaging in risky behaviors is due to racial/ethnic and income level and how much is really a function of underlying class differences? What makes it relatively easy to stigmatize certain behaviors and then make them so resistant to change? And how often are we paying attention to these class attributes when we develop programs with one audience versus another? When we use 'tribes' to describe some groups of teens we are beginning to come to grips with the issue. But especially in public health the notion of focusing on tribes as priority audiences, and not some epidemiological defined segment of the population, seems to hit a nerve we'd rather leave unexposed - to whose detriment is the question we can discuss more.

As a society, we have strong class divisions and we project these values onto our kids. MySpace and Facebook seem to be showcasing this division quite well. I wonder how often we do it with our social marketing programs?

Sigh: and I wish we had more ethnographers to help us develop the insights to break away from the rationalistic, individualistic, and reductionist paradigms enshrined by the epidemiologists that, I believe, are among the strait-jackets for doing great social marketing.

Social Marketing in War

The Rand Corporation, not ever known as a repository for social marketing thought or activities, has decided that social marketing should be part of the military toolbox in Iraq [and we are not talking about the pretensions of the social network marketers]. In the report released this week, Enlisting Madison Avenue: The Marketing Approach to Earning Popular Support in Theaters of Operation, they look at using marketing approaches within the context of 'shaping,' or developing strategies and tactics that limit opponent options or increase friendly force options in battle. Recent analysis of field requirements and joint urban doctrine has expanded the concept of shaping to include influencing resident populations in military operational theaters. These populations constitute a significant component of stability operations, particularly through their decision to support friendly force objectives or those of the adversary.  Their recommendations for "using marketing in war zones" include:

• Branding. Just as people think “safety” when they think of Volvo automobiles, the U.S. military needs to establish a strong brand identity that is consistently communicated through all U.S. force actions and messages. U.S. forces entered Iraq with a “force of might” brand identity ill-suited to earning local support. The armed forces should craft a new brand identity that incorporates their civilian shaping mission into their war-fighting role.
• Instilling customer satisfaction. The armed forces should manage civilian expectations by not making promises they can't keep. They also should monitor civilian satisfaction through town hall meetings and other venues to continually improve operations and services.
• Customer-informed decision-making. Occupying a foreign territory automatically makes U.S. forces a target of resentment, but the U.S. military can help reduce this by making sure civilians are consulted on governance, civil affairs and reconstruction projects. Problems can ensue when U.S. and allied forces assume they know what the local civilians want, much like American businesses that mistakenly adopt an “if we build it, they will come” strategy.
• Harnessing the power of influencers. Many U.S. businesses have blogs or journals written on the Internet. Often, these are written by employees who follow a set of guidelines but are allowed to both praise and criticize the company. Criticism gives the bloggers a dose of credibility. Blogging provides a unique opportunity for indigenous civilians and government employees to express their opinions relatively safely and anonymously on the Internet without the risk of being killed by insurgents.
• Social marketing. In order to get civilians to cooperate with coalition forces, the U.S. military needs to identify and emphasize the benefits of doing so in a way that motivates the population. For example, providing tips on insurgents can improve civilians' safety, if safety is a motivating benefit.

[excerpts from the news release]

Social marketing is the application of well-grounded commercial marketing techniques to influence noncommercial behavioral change (e.g., quitting smoking and giving blood) in a target audience. Social marketing practices provide a template for U.S. military efforts to
motivate specific behaviors in the indigenous population. [from the Executive Summary, pdf file]

That's what happens when people read one introductory textbook on the subject.  From MySpace to Iraq; maybe it was better with a lower profile, or is it time to step up?

Safe Drinking Water for Children

I haven't posted a personal request before on the blog, but this is something unique and special for me. Here is a project that deserves your attention and action today. American Express is sponsoring The Members Project in which AMEX card members have nominated over 7,000 innovative projects to receive between $1-5 million dollars donated by AMEX ( the more people who register to vote - and you have to be an AMEX card holder to do so - the more money is in the pot). This list is now down to 25 semi-finalists and voting for the final 5 is now open until Sunday 22 August.

At PSI we have a project in the mix, and I'd like your vote. The project that is one of the 25 finalists is "Children's Safe Drinking Water." Here's the description:

For Two Cents We Can Change the World. Four thousand children die needlessly every day from drinking contaminated water. It's a tragedy that hundreds of millions of people obtain their drinking water from polluted sources such as muddy rivers, ponds, and streams. This public health crisis can be addressed today through an innovative and low-cost technology that effectively purifies and cleans water while removing bacteria, viruses, and parasites. Right now millions of people in Africa, Asia, and the Americas are being reached by a not-for-profit project, but millions more are in need. Help us reach a goal of providing 2 billion liters of safe drinking water. For only two pennies a day a child can have safe drinking water. We'd love to hear your thoughts. In fact, Give Us Your Two Cents Worth. Thank you.

The AMEX donation would help support this on-going public-private partnership between PSI and Proctor & Gamble that has been selected as a case study at the Harvard Business School. To vote for this project, go to membersproject.com or click below. The winning project will be announced on August 7th.

Remember: you have to be an AMEX card member to vote and you must do it by Sunday. Yes there are many deserving projects, but you only have one vote. Make it count - in more ways than one. And I hope many of you can pass this around for me (you know who you are ;)

Using New Media in Public Education Programs

In a follow up to their forum last year on New Media and the Future of Public Service Advertising, the Kaiser Family Foundation convened a meeting today on Using New Media for Public Education Campaigns. The panelists included Dan Solomon, CEO, MindShare Interactive Campaigns; Tina Hoff, vice president and director, Entertainment Media Partnerships, Kaiser Family Foundation; Joyce Joseph, student and winner of the MTV/Kaiser thinkHIV Vlog contest; and Jeff Berman, general manager for MySpace video and senior vice president for Public Affairs, MySpace Inc.

This was one of the first events for public health professionals that focused exclusively on using digital media in public education programs in response to the changing communication patterns of the millennial generation. The session focused particularly on the use of consumer-generated content among teens to exploit the trend that has only gathered more momentum since we reported the results from the Pew Internet and American Life Project back in November 2005. Highlighted programs included:

• the thinkHIV campaign that was launched in June 2006 and resulted in a total of 647 submissions from students around the US to be video bloggers on HIV issues. Forty-seven state finalists were selected, and the winner was one of the panelists with excerpts from her vlog shown during the presentations.
• The Reckless Driving Public Education Program.

The other notable for me was Jeff Berman's recitation of stats for MySpace:

• 74 million blogs on MySpace
• 185+ million registered profiles
• 70.5 million visitors/month
• 35% of all internet users age 25+ are on MySpace
• 1/4 of all Americans have visited MySpace in the past month

And for the DC venue his slides were replete with examples of how MySpace has been/could be used for voter registration and turnout campaigns, soliciting contributions, and complimenting other campaign communication activities.

A webcast of the event is posted on the KFF site.

Population Growth: A Call for a Return to Our Roots

Global population growth was among the top concerns in the late1960s. Some projections were that the world’s population was growing so rapidly as to outstrip the resources to sustain it. Something had to be done, and in the era before oral contraceptives and other reproductive technologies, the choices were few. Yet, the need for action was so strong that a few countries launched efforts to try and contain population growth. These efforts were viewed with deep skepticism by many policy makers and health professionals. Change fertility behaviors on a broad scale? Fly in the face of current microeconomic theory that promoting small families, fewer children especially among people living in poverty, was actually counter to the economic incentive and value of having more children? And while the first attempts at controlling population growth were generally regarded as failures, the pressure to do something better led to more experimentation and trials. What happened is that population fertility rates actually began to decline in some countries, and then more. And 30 years later, though the world’s population continues to increase in some regions, population-based methods of behavior change to achieve economic, social and health outcomes have become accepted wisdom. So much so that complacency and neglect has set in.

That’s the story recounted in detail in two publications by The World Bank that were launched at an event today I was invited to attend: The Global Family Planning Revolution: Three Decades of Policies and Programs and Population Issues in the 21st Century: The Role of the World Bank. How did population control programs actually work? One analysis in the opening remarks laid it on two factors:

• Good programs found woman in all societies who wanted to control their fertility, especially after having had 4, 5, 6 or more births. As one discussant put it: “They were tired of being pregnant.” This unmet need surfaced as programs began to be fielded, and coincidentally (?) the application of social marketing in these programs began to take root.

• Well-designed, well-managed programs were found to work in settings where social conditions were more favorable than the initial countries in which population control was attempted (better economic status, relatively higher status of women, higher education levels and low infant mortality rates – that worked to counter the economic value theory).

Several of the panelists emphasized the point that a new theory arose to counter the microeconomic model and explain what was being observed in these successful countries, a sociological one – Theory of Ideational Change.  Once the notion of family planning (“you can take control of your life”) diffuses through society, it has an impact on behavior adoption that is independent of the effects of economics.  It was a radical (where are the Freakonomics folks?) perspective that behavior can and will change even if living standards (economic incentives and costs) do not. Think about that for a minute: psychosocial benefits can trump financial costs and barriers.

The implication of this next generation of family planning programs was clear: improving welfare, creating supportive norms and offering good family planning services and products can have important impact on fertility behaviors.

As these programs were replicated and expanded into even more countries, global Total Fertility Rates (TFRs) began declining in most parts of the world by the 1970s; yet what we have seen over the past 10 years or so is a plateauing of progress. Discussants pointed to a lessened focus on family planning overall due, they believe, to a focus on other health priorities (notably the big shift in funding to HIV/AIDS prevention and treatment), a preoccupation with individual health outcomes rather than population ones (a familiar theme to our regular readers) and concerns that government programs aimed at socially beneficial outcomes were doing so at the expense of marginalizing some groups and not respecting the individual rights and concerns of others. And while many countries were experiencing moderate to substantial declines in their TFRs during this time, today 35 countries still have TFRs>5 (five or more births in a family) and have shown little change over the past 50 years.

These high fertility countries, 31 of which are in Sub-Saharan Africa, require renewed and increased attention to creating and growing family planning programs that stimulate demand for products and services (and accompanying changes in fertility behaviors), improving access to contraception and reproductive health services, and research to understand and serve the needs of ‘the youth bulge’ in the demographic composition of these countries. As one of the authors of the report later said to me: What we need to do is a better job of segmenting our populations, something we have not been terribly good at up to now.

The program came to a close with a call to return to the original agenda set by the World Bank in the 1960s: population growth is a menace. To do so would mean:

• A return to having evidence-based programs as a norm – where data makes a difference in how programs were funded, developed, implemented and managed. The point was made that political, bureaucratic and religious issues have always been part of the mix of concerns that need to be balanced in this area, but objective data should be the primary driver of decision-making.
• Increasing the historically prominent role that NGOs and civil society have played in research, service provision and advocacy for population issues and programs rather than what has become a reliance on the public sector to do everything – often without the capacity and infrastructure to do so effectively and efficiently.
• Rebalancing and invigorating the role of donors in leading efforts to manage what is still one of the major determinants of social and individual well-being and health. It is a call being echoed by a growing number of groups including a report of hearings held for the UK All Party Parliamentary Group on Population, Development and Reproductive Health (pdf file).

As I look at where social marketing has been, and what we’ve learned over the years outside of the family planning arena, there seems no better time or call for returning to our roots with the new ideas, methods and practices we have been honing elsewhere.

Diffusion of Calorie Labeling Initiatives

Last semester one of our projects in the GWU social marketing class was working on calorie labeling legislation in Washington, DC. At the time, we were in the innovator category. If the NY Times has it right today, it looks like the early adopters are arriving on the scene.

...some 20 other states and localities are considering measures that would require chain restaurants to provide calories or detailed nutritional information right on the menu or menu board, often next to the price and in the same size lettering.

Although the laws would apply only to chains, which make up just 10 percent of outlets, they serve about two-thirds of restaurant traffic, experts say.

Marketers LOVE to use point-of-purchase (or point-of-choice) to influence behavior (aka 'consumer choice'). There is a whole science and art to it. Tobacco manufacturers dominate check-out signage at convenience stores - and that's after decades of restricting tobacco advertising. Why, after traveling to a fast food restaurant, do you need to look at a picture of the meal before ordering it? [Hint: it is not an attempt by the store to communicate to non-English speakers or people with low literacy skills. Food photography has its own rules too - sell product!] The reason there is so much opposition by any industry to attempts to co-opt their POC space (and try and get material displayed at the check-out line in a grocery store) is because the PLACE is so powerful as a persuasion strategy - not 100%, but compared to a television ad...

I am a firm believer that simpler messages delivered at POC has to be part of a social marketer's behavior change arsenal. It's about providing people with healthy experiences when making eating out and food purchase choices. Consider these examples from the article:

The chicken Caesar salad at Chili’s is one of those items that might appear to be a healthier choice, but brace yourself: it contains 1,010 calories and 76 grams of fat, while the sirloin has 540 calories and 42 grams of fat (not counting side dishes).

Nor is a tuna sandwich the low-calorie choice at Subway: it has 530 calories, significantly more than the roast beef sandwich, which has 290. And a chai latte almost always has 100 more calories than a cappuccino of the same size prepared with the same kind of milk.

Notorious among nutritionists is the Bloomin’ Onion at Outback Steakhouse, a battered, deep-fried onion resembling a flower that is served with a dipping sauce. The damage, nutritionists say, is about 2,200 calories and more than 100 grams of fat, most of it trans fat.

And from Kelly Brownell:

“There was a time when an orange was an orange, and an apple was an apple...But people don’t recognize what’s in their food anymore — a Pop-Tart has 56 different ingredients. And the food industry is very good about cramming sugar, fat and salt into food, making it taste very good but making it a challenge to be healthy.”

So there's at least five reasons to focus on simple, direct POC programs for obesity prevention in addition to the other essential elements of your program. Remember: there are over 200 opportunities a day to influence food choices. That's a lot of openings.

Youth, Sex and Technology Conference

Got your attention?

I just received an invitation for a new conference focusing on youth and technology as they intersect with STD and HIV prevention.

The Internet and mobile technologies have strengthened youth networks, provided new avenues for expression, and increased youth access to tools and information designed to improve their sexual health.

The inaugural STD/HIV Prevention Conference focusing on Youth and Technology will be held January 22 - 23, 2008 in San Francisco, CA.

Sex::Tech will explore available tools and methods for reaching youth with culturally appropriate STD/HIV prevention and sex education interventions from a youth perspective, with input from public health professionals, educators, researchers, and technology developers.

The conference website with information for abstract submissions and early bird registration. Sounds like a winning combination if your worlds are colliding with theirs.

Mobile Payment is Here

I was presenting on new media at the Emerson Summer Institute for Social Marketing yesterday and flashed the stats I have from Communities Dominate Brands about the use of mobile phones in commercial transactions.

• 54% of Helsinki public transportation single tickets to the trams and subways are paid by mobile.
• In South Korea 45% of all music is sold directly to musicphones
• In Slovenia all vending machines, all taxis, all McDonald's restaurants etc accept payment by mobile.
• In South Africa you can have your full paycheck sent to you onto your mobile phone.

Part of the audience polling I do now, especially with more tech savvy crowds where almost all hands go up when asked if they had read a blog (a big change among public health audiences in one year - but wikis still seem to be a mystery to most until I mention Wikipedia), is how many have enabled their mobile phones to make financial transactions (via your bank or with PayPal for the newly informed). No hands went up, and as we talked later about when this might happen in the US my comment was 'sooner than you think.' Well... this via FierceMobile.

eBay-owned online payment service provider PayPal announced the launch of Mobile Checkout, a service enabling consumers in the United States, United Kingdom and Canada to make purchases via the mobile web. PayPal Mobile Checkout enables merchants with online storefronts to embed PayPal buttons on their sites, promising a simpler, more efficient interface for making and receiving payment for goods and services.

m-banking may seem like the latest 'cool' convenience; however, its implications for helping the world's poor are among the 'hot' topics in development. Stay tuned.

US Surgeon Generals Unmuzzled

In a classic inside-the-beltway politics and media dance, the Washington Post and the New York Times both ran front page stories that (I'm shocked!) - US Surgeon Generals, the nation's chief public health officer, have been told to withhold, edit, insert and otherwise inject political, ideological and theological viewpoints into their speeches and documents. The dance is that hearings for the administration's nominee to be the next Surgeon General are Thursday.

From Christopher Lee at the Post:

Carmona, a Bush nominee who served from 2002 to 2006, told the House Committee on Oversight and Government Reform that political appointees in the administration routinely scrubbed his speeches for politically sensitive content and blocked him from speaking out on public health matters such as stem cell research, abstinence-only sex education and the emergency contraceptive Plan B...

Satcher, Carmona's predecessor, who served from 1998 to 2002, said that under President Bill Clinton he could not release a report on sexuality and public health, in part because of sensitivities triggered by the Monica Lewinsky scandal.

Clinton also forced out Joycelyn Elders as surgeon general in 1994 after her controversial remarks that public schools should consider teaching about masturbation.

Koop, who served as surgeon general under President Ronald Reagan, spoke out on AIDS, despite political pressure not to do so. He said Reagan was pressured to fire him every day -- but he did not.

Gardiner Harris at the Times adds:

The administration, Dr. Carmona said, would not allow him to speak or issue reports about stem cells, emergency contraception, sex education, or prison, mental and global health issues. Top officials delayed for years and tried to “water down” a landmark report on secondhand smoke, he said. Released last year, the report concluded that even brief exposure to cigarette smoke could cause immediate harm...

Dr. Carmona said drafts of surgeon general reports on global health and prison health were still being debated by the administration. The global health report was never approved, Dr. Carmona said, because he refused to sprinkle the report with glowing references to the efforts of the Bush administration.

“The correctional health care report is pointing out the inadequacies of health care within our correctional health care system,” he said. “It would force the government on a course of action to improve that.”

The testimony was enough to get the Committee chair to write to the Secretary of Health and Human Services today this letter requesting all documents related to the above (and other) claims by Carmona.

And here are the links to all of the details.

And now the American Public Health Association comes out against the nominee. Where are you APHA when the lights go off and everyone says they have a badge?

Scaling Up HIV Prevention Programs - Step 2

Gaining insight into why programs achieve scale or not is not sufficient for change at any level of society. Learning how programs successfully achieve scale (what some might call observational learning), imitating them (a form of flattery that many are loathe to practice unfortunately) and monitoring performance (through relevant program outputs and behavioral outcomes to feed back to planners what is working and what needs to be adapted to local circumstances) are the components of turning lessons learned into action (note I deliberately left out epidemiological endpoints. Waiting until then is waiting way too long).

The Bringing HIV Prevention to Scale report also examined how the successful national efforts of Brazil, Senegal, Thailand and Uganda scaled up their national HIV prevention activities. These countries have demonstrated that it is feasible to reduce the incidence and prevalence of HIV, slow down the rate of predicted increases in prevalence and keep HIV infection rates at low levels. The common characteristics seem to be:

• Adequate and Sustained Funding
• Visible Political Support
• Targeted, Evidence-Informed Action
• Use of Mass Media and Other Channels to Raise HIV Awareness
• Anti-Stigma Measures
• Involvement of Affected Communities and Diverse Sectors

The report also highlights that truly comprehensive HIV prevention programs need to focus on (1) preventing sexual transmission, (2) preventing blood-bourne transmission (including through blood transfusions and sharing injection equipment), (3) preventing mother-to-child transmission, and (4) social strategies and supportive policies. These authors also note that expanding access to key HIV prevention services including HIV counseling and testing, expanding condom distribution and use, and targeting of high risk and vulnerable groups - injection drug users, sex workers and men who have sex with men - are all necessary for scaled up programs to succeed.

Reading these reviews I have to ask if this problem of scale is really a call for better social marketing - creating and managing markets and resources more strategically? Or has the international health community gotten to the point where social marketing is being marginalized as a term reserved only for the promotion and distribution of subsidized commodities through commercial sector channels?

Then again, I guess we could be talking about marketing through social network sites and blogs? Those people call themselves 'social marketing experts' too.

About the image: This map shows the distribution of all people between ages of 15 and 49 with HIV.

Scaling Up HIV Prevention Programs

Scaling up programs that have been shown to be effective in promoting health and other social causes in pilot and demonstration projects or larger efficacy and effectiveness trials should be a major focus of social marketers. I say 'should be' for while we talk about population-based or social change, the fact is that few evidence-based practices ever achieve the scale necessary to make their promise or vision reality for the thousands or millions of people who could benefit from them.

Though numerous examples abound to support this conclusion, I will focus on one: HIV prevention programs. The Global HIV Prevention Working Group has just released a report on the 'failure to scale' (my words, not theirs). Among their findings (excerpted from the Executive Summary): 

Despite the extraordinary potential of available prevention strategies, most people at risk of HIV infection have little or no access to basic prevention tools. Although necessary coverage levels vary depending on national circumstances, current coverage levels for essential prevention strategies are woefully inadequate for any national epidemic.

• Condoms. Only 9% of risky sex acts worldwide are undertaken while using a condom, and the global supply of condoms is millions short of what is needed.
• HIV Testing. In the most heavily affected countries of sub-Saharan Africa, only 12% of men and 10% of women know their HIV status.
• Treatment for Sexually Transmitted Infections. It is estimated that fewer than 20% of people with a sexually transmitted infection are able to obtain treatment, even though untreated STIs increase the risk of HIV acquisition and transmission by several orders of magnitude.
• Prevention of Mother-to-Child Transmission. Years after clinical trials demonstrated that a brief, inexpensive antiretroviral regimen could reduce the risk of mother-to-child HIV transmission by 50% (5), only 11% of HIV-infected pregnant women in low- and middle-income countries receive antiretroviral prophylaxis.
• Prevention for Vulnerable Populations. Prevention services reach only 9% of men who have sex with men, 8% of injection drug users, and under 20% of sex workers.
• Prevention in Health Care Settings. An estimated 6 million units of unscreened blood are transfused yearly in developing countries, and 40% of injections administered in health care settings are unsafe.

Among the factors the Working Group identifies as fueling the failure to scale HIV prevention efforts are:

Inadequate Financing. While financing for HIV has increased dramatically in recent years, available funding is only slightly more than half of amounts needed to support a comprehensive, scaled-up response. In Asia, where the number of HIV infections could double in the next five years to more than 20 million, current spending on HIV/represents roughly 10% of the amounts needed to mount a comprehensive response.
Misallocation of Resources. In part due to the weakness of HIV information systems, many countries do not target limited funds where they would have the greatest impact. Misallocation of limited resources by donors and affected countries also often occurs as a result of ideological, non-scientific restrictions imposed by donors on how HIV prevention assistance may be used.
Capacity Limitations. Due to inadequate human capacity, countries often have difficulty programming substantial infusions of new funding.
Service Fragmentation. HIV prevention has frequently not been integrated into schools, workplaces, and other institutions, and HIV efforts are insufficiently linked with other health-related service systems, such as TB or sexual and reproductive health.
Stigma and Discrimination. The stigma associated with HIV and with membership in a vulnerable group deters many at-risk people from seeking HIV prevention services or learning their HIV status and also discourages the kind of political leadership required to implement a robust and evidence-based HIV prevention effort.

Our challenge, whether it be in HIV prevention or the prevention of childhood obesity, it to apply the evidence-base of diffusion research through social marketing programs. Several impediments stand in the way of doing so, not the least of which is the overwhelming (at least to me) lack of understanding among health professionals and policy makers of what this research offers health and social programs (other than fleeting references to The Tipping Point). The second is that very few social marketers seem to know how to transform programs focused on individual behavior change to ones scaled for population impact. Even fewer researchers and their funders seem to get that developing and testing programs meant to achieve scale need to be designed that way to begin with and not focused on reductionistic minutiae that - again - focuses on individuals, not people. And finally, as the Working Group makes clear, and as an old saying goes (thanks to Thomas Friedman): A vision without resources is just an hallucination.