On Social Marketing and Social Change

Social Marketing and Hand Hygiene Promotion

Social Marketing Analysis of 2 Years of Hand Hygiene Promotion

Infection Control and Hospital Epidemiology, 2008.

Authors: Mah MW, Tam YC, Deshpande S

Objective: To assess published hand hygiene behavioral interventions that employed a social marketing framework and to recommend improvements to future interventions.

Methods: We performed a systematic literature review by searching the PubMed database and the Cumulative Index to Nursing and Allied Health Literature for published articles about hand hygiene behavioral interventions in healthcare facilities, schools, and community settings. Our analysis included articles that describe multifaceted interventions and evaluated them with predefined social marketing benchmark criteria.

Results: Of 53 interventions analyzed in this review, 16 (30.2%) employed primary formative audience research, 5 (9.4%) incorporated social or behavioral theories, 27 (50.9%) employed segmentation and targeting of the audience, 44 (83.0%) used components of the "marketing mix," 3 (5.7%) considered the influence of competing behaviors, 7 (13.2%) cultivated relationships with the target audience, and 15 (28.3%) provided simple behavioral messages. Thirty-five (66.0%) of the interventions demonstrated a significant improvement in performance, but only 21 (39.6%) were considered to have a strong evaluative design. The median duration of the interventions was 8.0 months.

Conclusions: From a social marketing perspective, the promotion of hand hygiene could be improved in several ways. The effectiveness of social marketing in hand hygiene promotion should be tested in future interventions.

Comment: While the title suggests a review of studies in which a social marketing approach was used for hand hygiene interventions, the abstract suggests that this review included any behavioral intervention and used social marketing benchmarks to determine how many used one of more components of a social marketing approach (unfortunately, another journal that does not allow for an online read of the full text of the article to get the details without paying the price). It looks from their reporting that very few, if any, of the 53 interventions they reviewed would be classified as a social marketing one. With the limited information available from the abstract, it seems that the authors could have made a stronger case for any efficacy of a social marketing approach by comparing studies that met multiple benchmarks (see the NSMC model, pdf file) vs those that had few or none. Reading between the lines, the analysis is done to set up recommendations that can be summed up as more social marketing is needed.

The report does little to address whether social marketing interventions are useful or more effective than traditional behavioral or health communication interventions in addressing this public health problem. One question the analysis raises for me is what are the most useful benchmarks to use to decide whether an intervention is a social marketing one or not? Having a standard tool for investigators to use to assess the relative advantages of approaches that incorporate many elements of social marketing may help us establish an, albeit indirect, empirical base to support assertions that social marketing is indeed an improvement upon other approaches for many different health behaviors.

These types of reviews can be useful to highlight where social marketing could be employed to strengthen behavioral interventions aimed at achieving public health impact. However, one would hope that more can be done with the available data that simply ticking off benchmarks. Whether the social marketing 'dose' or strength of a public health program (e.g., how many elements are incorporated into the program design) has an incremental impact on behavior change is an interesting question that this type of meta-analysis could be examining. But then again, having individual studies to work with that have a robust enough research design and report statistics that allow you to draw these types of conclusions is always the Achilles heel in this line of work.

And a note to authors: In the digital age, good abstracts may be your only chance to have an online presence with your work. Make the most of them!

Could Making Bednets Become a Viable Business?

President Bush handed out hugs and bed nets in Tanzania's rural north on Monday, saying the U.S. is part of a new international effort to provide enough mosquito netting to protect every child between one and five from contracting malaria in this east African nation (Time).

The coverage of the Tanzania stop on the President's Africa trip featured a stop at the A to Z Textile Mills, a local manufacturer of bednets. The news accounts I saw were notable for their lack of controversy - not a mention of paid vs. free distribution - and a focus on the bottom-line: the success of a multi-pronged approach in saving lives.

The visit at A to Z was remarkable as this company has achieved status of what could go right with private sector solutions to health problems: African entrepreneurs creating jobs while improving the health of millions. However, it is also a company that could stand to lose the most if policy-makers are not paying attention; the good news is maybe they are in this case.

Brian Trelstad at The Acumen Fund blog provides four ideas of how policy changes in the allocation of  funding for malaria control and prevention might benefit economic development in the region:

• Give preference to African manufacturers or suppliers of anti-malarial commodities.
• For long-lasting bednets, Global Fund-supported projects should award contracts on the basis of delivered costs, not factory prices.
• Begin to set aside subsidies for the private distribution of nets to complement the free distribution programs.
• Anticipate the problem of recycling the nets now. In five years, Africans will be throwing away 100 million used bednets a year.

Exploring the intersection of public, private and civil society in comprehensive malaria control and prevention (whether it be through creative capitalism, social businesses, or a Total Market Approach) is one of the more challenging and rewarding (and sometimes frustrating and maddening) places for social marketers to be these days.

[Image from The Acumen Fund.]

CSR and Corporate Growth Strategy

A survey of 250 global business leaders finds that 2/3s of them are focusing on Corporate Social Responsibility (CSR) activities to generate new revenue streams. The report by the IBM Institute for Business Value finds:

Driving these beliefs is the rising influence of customers who, thanks to their ability to research and share information on the Internet, have become highly sensitized to a broad range of issues -- everything from concerns about climate change, to product safety issues, to labor practices, to corporate financial accountability, to questions about whether corporations are returning enough of their profits to the community... "The more information these stakeholders get, the more they want to know. This increased visibility of corporate behavior is driving consumers' decisions on what to buy and who to buy from, who to work for, who to partner with, where to invest," said George Pohle, VP and Global Leader of IBM's Business Strategy Consulting Practice.

The focus of revenue streams as a guiding principle for so many CSR programs among these businesses is reinforced by the finding that only 16 percent of survey respondents engage and collaborate with their customers on CSR activities. However, 48 percent report they are working with NGOs or local governments for business purposes.

One of the recommendations in the report is entitled The New Customer Conversation; The only way to decide what’s really relevant is to engage customers. Capture their questions. Listen to their ideas. Make it easy for them to find the answers to their questions online, on labels, and from sales and service employees. Analyze underlying themes so you can make your actions and information increasingly relevant.

In other words, be a marketer, not a seller, of socially responsible ideas and practices. And if you are on the nonprofit side of the CSR model, I suggest you understand and engage with your audiences in ways that make sense to your potential business partners.

Then there are upstream approaches to CSR that move us closer to real social change.

2008 International Nonprofit and Social Marketing Conference

The Centre for Health Initiatives at the University of Wollongong will be hosting the International Nonprofit and Social Marketing Conference 15-16 July 2008. The Call for Papers on this year's theme - Partnerships, Proof and Practice - has a deadline of Monday 28 April.

In addition, papers and special interest sessions may cover any of the following topics:

• Arts marketing
• Ethical and corporate social responsibility
• Environmental marketing
• Indigenous issues
• Marketing and public policy
• Political marketing
• Public health and healthcare
• Public sector marketing and e-government
• Social marketing
• Social entrepreneurship
• Sponsorship and fundraising
• Voluntary sector marketing

It's been a couple of years since I have had a report from this conference; guest columnist Stephen Dann noted then it has been a rare conference to find yourself sitting in one session, dying to see the other papers being presented but completely unwilling to leave the presentation at hand.

I'm curious if the Social marketing downunder network is involved with this conference?

Social Marketing and Democracy

With the presidential nomination process claiming most of the news holes in the US, the authors of Greater Good: How Good Marketing Makes for Better Democracy are interviewed at the Harvard Business School Working Knowledge site. Here are some salient excerpts for social marketers and government officials.

...what's needed in politics is not less marketing but better marketing. The two major parties should focus on learning current and emerging citizen needs, developing policy and program solutions, informing interested citizens about themselves, and making themselves easily accessible. They should embrace reforms, such as lifelong voter registration, that remove barriers to participation. Politicians need to view citizens not as occasional voters, donors, and taxpayers but as their customers.

Q: In the United States it seems the public has a very low opinion of the federal government. Can government market itself more effectively to its constituents and customers?

A: The federal government and local governments can market themselves more effectively to constituents. First of all, they have to view their organization from a customer viewpoint and ask: Who are our customer groups? How are we going to add value to those customers?

Federal agencies that provide services to citizens can institute service improvements and metrics modeled after those in the private sector. They can call on social marketers to aid in communicating with customers and creating attractive exchanges that will achieve desired customer behavior. [emphasis added]
 

And this closing thought - ...what is needed is an international institute funded by multiple countries, representing different models of democracy, to create pull demand for democracy around the world.

Sometimes I hear people wonder aloud: is social marketing losing its relevance? Articles like this lead me to believe we are just finding it.

Thanx to Joe for the tip!

Social Marketing for Health in the Developing World:

People are always asking about opportunities to learn more about social marketing and engage with like-minded professionals about their passion. Opportunities tend to be few, far between and out of reach for most social marketers. Not next month!

Social Marketing for Health in the Developing World:
What Have We Accomplished and What Does the Future Hold?
Online Conference March 10-17, 2008

The Private Sector Partnerships One project (PSP-One) and the United States Agency for International Development's Office of Population and Reproductive Health invite you to participate in the global online conference on social marketing in the developing world, from March 10-17, 2008.

Share ideas, results and lessons learned with social marketing professionals. Listen to, or read presentations on Behavior Change Communications approaches, What's New in Social Marketing, and Building Effective Public Private Partnerships. The conference is free of charge and open to everyone from across the globe 24 hours a day. Access presentations, discussion forums, polls, and publications on-line. Internet connectivity is required to participate.

Register now to access the pre-conference Expert Exchange Forum with thought-leaders in the field of social marketing from Abt Associates Inc., Academy for Educational Development, Constella Futures, DKT International, HLSP, Society for Family Health/Nigeria and Population Services International.

Sign up for the conference and then create your own circle of friends or community of practice to discuss the presentations and exchanges among yourselves in the office, across your organization or within your region. Use the e-conference as a starting point for exploring and talking about social marketing with your colleagues, collaborators and donors. Pass the word. Become engaged. Learn how marketing can help you change your own corner of the world.

If you don't find the time to change the world, then you're busy keeping it the way it is.

100 Years of Mobile Telephones

When the expectations of wireless experts are realized everyone will have his own pocket telephone and may be called wherever he happens to be…When that invention is perfected, we shall have a new series of daily miracles [from Jim Rasenberger, 1908, in Smithsonian, credited to an article in Hampton's Magazine, 1908].

One hundred years later, Tomi Ahonen updates and contextualizes the mobile phone stats at Communities Dominate Brands.

• Worldwide there are about 800 million registered automobiles.
• 850 million people use PCs.
• 1.1 billion people around the world access the internet.
• Today there are 1.3 billion fixed landline phones.
• 1.4 billion people carry at least one credit card.
• There are about 1.5 billion TV sets in use.
• Last year the total worldwide mobile subscriber base grew from 2.1 billion to 2.7 billion.

Whatever its precise form, this new device would have the potential to transform the poor woman's life. It could become her constant friend, philosopher, guide, business consultant, health, education and marketing consultant, trainer - her link to the larger world, her digital Aladdin's lamp. She'll touch the lamp or utter a magic word of her choice, and the digital genie will emerge from this lamp, ready to help her find the solution she is looking for. With the help of this technological friend, she'll  come out of her shell, step by step, discover her talents, and lift her family out of poverty. Her children, in turn, will grow up with the IT genie as their best friend and mentor [Muhammad Yunus].

What have you done that is mobile today - or for tomorrow?

Artwork from Ellis Parker Butler.

Social Marketing and Energy Efficiency

I received a note about Accelerating Change for Energy Efficiency and Renewables Using Education, Outreach, and Social Marketing to Move Markets, a conference sponsored by companies in the energy sector in Denver, CO April 8-9, 2008. I confess to being initially skeptical of what social marketing would mean in this context, and am pleasantly surprised by the agenda, including sessions on:

• Customer Priorities: CO2, kWh, and Lattes
• Moving Markets: Barriers, Beliefs, and Brands
• Beyond the Brand: Why Engaging the Right Customers Is Essential to Winning in Business
• Turning on a Million Lights in Peoples’ Heads
• Closing the Gap Between Attitude and Action
• Swimming Upstream: Influencing the Influencers
• Community-Based Marketing: The Lines Are Getting Blurry
• Target Marketing, Segmentation, and Channels
• Behavior Change Is Hard to Meter: Measuring the Impact of Information Programs

If you are in the environmental social marketing space, this is worth looking into.   

PEPFAR 2007 Annual Report

The re-authorization of the President's Emergency Plan for AIDS Relief (PEPFAR) has been getting into the news here in Washington as policy debates over by how much to increase its funding, what gets included or not in the legislation, and when it will even come up for a vote. In the midst of all of this, the Annual Report of the Program to Congress has been released.

As the chart below demonstrates (left click on it to enlarge), funding for HIV/AIDS treatment accounts for the largest proportion of the dollars spent in the program (47%), followed by total care funding services (including counseling and testing). HIV prevention constitutes 21% of the current budget allocations - 12% for prevention activities aimed at sexual transmission.

Some of the prevention highlights from the overview of the report:

In the 15 PEPFAR focus countries, home to approximately half of the world’s HIV-infected persons...infant mortality has declined in 12 of the 15 focus countries since 1987; in most of them, the decline has been very substantial. This is a major achievement for these nations and one that should be expected to reflect an overall improvement in health...

Yet ...few of these countries have experienced significant improvements in life expectancy. Tragically, seven of the 15 have actually seen life expectancy drop, and those declines have been especially dramatic in Botswana, Mozambique, Namibia, and South Africa - the four focus countries in southern Africa, where HIV prevalence is the highest in the world...

In many regions, 50 percent or more of hospitalizations are due to HIV/AIDS...

Of the countless developments taking place in the global fight against the pandemic, perhaps the most important in recent years is the growing number of nations in which there is clear evidence of declining HIV prevalence as a result of changes in sexual behavior...

Another key trend in HIV/AIDS is the growing importance of HIV-discordant regular partnerships, in which one partner is living with HIV and the other is not, as a means of transmission....Many HIV-discordant couples do not know their HIV status. Several studies in Africa have shown that provision of voluntary counseling and testing for couples reduces HIV transmission by 56 percent and that consistent condom use in discordant couples is associated with an 80 percent reduction in HIV transmission. However, the rate of condom usage in regular partnerships is very low — in Uganda, it rose from 0 percent in the early 1990s to 1.9 percent in the late 1990s. Despite massive provision of condoms by the USG and others, increasing usage has proved difficult, even when couples know their HIV status. A promising new prevention approach is safe male circumcision, which lowers transmission rates where the man is the HIV-negative partner. Discordant couples represent an extremely important opportunity for prevention, so further innovation is needed to address this vulnerable population. This could include the use of antiretroviral treatment — as pre-exposure prophylaxis for the HIV-negative partner, or to reduce the level of HIV, and therefore the transmission rate, in the HIV-positive partner...

For all populations, multiple concurrent partnerships remain a significant challenge. While, on average, Africans have numbers of life-time partners comparable to Americans or Europeans, in certain areas multiple concurrent partnerships are common, and this practice promotes more rapid spread of HIV. The challenges of multiple concurrent partnerships parallel those of discordant couples. Data show that decreases in partnerships could have a significant impact on HIV transmission, and this issue will continue to be a key focus for PEPFAR in the coming year...

One of the central themes of PEPFAR programming over the past year has been “Knowing Your Epidemic” - understanding where, why and in whom infections are occurring, both in terms of geography and in terms of vulnerable populations, and tailoring programs accordingly. An HIV prevention program in Vietnam, where the epidemic is largely concentrated among injecting drug users and people in prostitution and their clients, must have a very different approach from a prevention program in Uganda, where most infections occur through sexual partnerships in the general population (and, increasingly, within discordant couples).

But regardless of the key factors in transmission, in the absence of an effective vaccine and microbicide - and in 2007 the global community experienced setbacks in identifying either - behavior change will remain the keystone of success. Even with the new advances in prevention related to male circumcision, behavior change — and maintenance of behavior change — is essential. [All emphasis added.]

The Pros and Cons of (Red)

The (Red) campaign gets a closer look in the NYT today. The focus on Red takes on importance as it is one of the largest corporate social responsibility (CSR) programs for international issues - the 15th largest donor to the Global Fund for AIDS, Tuberculosis and Malaria. Yet, mixing business with philanthropy has its detractors, who get lots of space here. And how is money really being spent?

Over all, more than $59 million has been contributed by Red and its corporate partners to the Global Fund. Red-financed projects have helped put more than 30,000 people on antiretroviral treatment and provided more than 300,000 H.I.V.-positive pregnant women with counseling and treatment, according to data from Red and the fund.

Important to others is how Red and other CSR programs come by their resources and the potential unintended consequences of business activity in this arena.

Mark H. Rosenman, a professor of public service at Union Institute and University in Cincinnati...“There is a broadening concern that business marketing is taking on the patina of philanthropy and crowding out philanthropic activity and even substituting for it.”

Or as Bill Easterly recently asked on a panel about creative capitalism, how can we be sure that the partners in these types of programs actually share the same objectives?

Another Questionable Call on Bednets

Yet another report that calls for universal giveaways for bednets was noted in The Economist last week. That the report is authored by the UN and stands (again) in contrast to their stated position is a bit confusing. April Harding at the Center for Global Development unpacks it for us. I find it interesting that the review has not been available for public review yet.

Creative Capitalism and Social Marketing

Bill Gates recently called for a revision of capitalism to make the aspects of capitalism that serve wealthier people serve poorer people as well. In his speech at The World Economic Forum in Davos, he outlined creative capitalism this way:

Such a system would have a twin mission: making profits and also improving lives for those who don't fully benefit from market forces. To make the system sustainable, we need to use profit incentives whenever we can.

At the same time, profits are not always possible when business tries to serve the very poor. In such cases, there needs to be another market-based incentive - and that incentive is recognition. Recognition enhances a company's reputation and appeals to customers; above all, it attracts good people to the organization. As such, recognition triggers a market-based reward for good behavior. In markets where profits are not possible, recognition is a proxy; where profits are possible, recognition is an added incentive.

The challenge is to design a system where market incentives, including profits and recognition, drive the change...

This kind of creative capitalism matches business expertise with needs in the developing world to find markets that are already there, but are untapped. Sometimes market forces fail to make an impact in developing countries not because there's no demand, or because money is lacking, but because we don’t spend enough time studying the needs and limits of that market.

The speech has touched off a number of conversations, including one convened last week at the Hudson Institute - Creative capitalism: Can it meet the needs of the world's poor. Ryan Baebler at NextBillion.net provides a summary of the discussion.

I was also at the meeting and here are some of my notes.

This isn't the first time self-interest and social interest have been combined in a new form of capitalism - Bill Schambra.

Bill Easterly identified two problems with this formulation of creative capitalism: (1) it provides weak incentives for the private sector to do things differently (i.e., if recognition is the goal, might corporations decide to provide goods and services that get the broadest media coverage rather than what does the most good and is responsive to the needs of the poor?), and (2) it doesn't address the question of choosing which goods to give to the poor (for example, with limited resources do you expend them on antiretrovirals for people with AIDS or a basic health package of oral rehydration therapy, antibiotics, nutrition supplements and vaccines that would save 10 million lives a year).

His position is capitalism may be one of the worst ways to reduce poverty, except for everything else that has been tried. The right answer, he states, is to enable the poor to pay for whatever goods they decide they need most and not have them continue to depend on someone to give it to them for free.

Al Hammond directed attention to the divisions at Microsoft, Intel and other companies that are devoted to identifying needs of the poorest and innovating products and services that meet those needs as examples of what Gates calls for in his speech.

He talked of the need to understand base of the pyramid (BOP) markets and referred to the recent report on The Next 4 Billion marketplace that, I believe, should be required reading for anyone working in this area. He focused on the implications of the report for health and access to essential products and services and how the proliferation of mobile phones at the BOP (something I have been talking about here as well) offers new ways to think about programs and interventions. His take on paying for products and services is that the evidence is people are willing to pay if it enhances their productivity and economic well-being. Some of his other research suggests that access is the most important issue for people at the BOP; they spend more on getting to health services and products than the actual goods themselves.

Later, in response to a question about strengthening public-private partnerships, Al made the point that the public sector often doesn't know how to harness the profit motive to achieve its goals. Indeed, the mistrust with which both the public and NGO sectors view the private sector is one of the greatest impediments to moving to action. Bill Easterly called these partnerships the latest fad in development and wondered whether the public and private sector really have the same objectives in these partnerships.

During the past week, I also had a reporter contact me asking about the implications of creative capitalism for social marketing. He sent me four questions that I have paraphrased below and include for your inspection the answers I sent back to him [note: this was prior to the Hudson meeting].

1. What does this mean for Africa?

It helps set an agenda for people to think and talk about development issues in Africa - and indeed around the world - in an innovative way. Let's move beyond partnerships to ask how the role of governments, civil society and corporations can change to expand the reach of market forces to serve all people in need. I hope it flips the conversation from asking whether the private sector should be more effectively engaged in development issues to how? How do we innovate and adapt those aspects of markets that work so well for so many of us to work as well for the next billion people on earth who live on less than a dollar a day?

2. Is it a new idea or a retread?

I believe it reinforces, among other things, the need to focus on private sector values such as speed and efficiency in more of our work. I see it as an approach that can embrace the ideas of Bill Easterly in supporting the urgency to search for new approaches to aid, and to do that we need to understand markets and the people they serve in a truly market-driven sense where the people participate in shaping their own destiny. George Ayittey talks about the 'cheetahs' - the new breed of African he describes as not wanting to wait for governments to decide on how to solve problems. These social entrepreneurs can be inspired to make change by new ways of thinking about capitalism. After all, he points out, markets existed in Africa long before the colonialists arrived.

The other trends I see this tying into are recent work on 'the next 4 billion market' and efforts to measure the business opportunities at the base of the pyramid (BOP) and the Total Market Approach that is evolving out of social marketing.

3. Will corporations listen?

I expect that when Bill Gates talks in Davos they listen. The question is whether they will act. And as Bill points out in his speech, whether they do so or not is contingent in some respects on how governments (and large donors) set policy and disburse funds to create market incentives for companies to improve the lives of the poor.

4. Does it (implicitly) endorse a social marketing approach?

The idea of creative capitalism moves in a similar direction to where some of us in social marketing are going; a total market approach where the public, NGO and private sectors work together to expand the reach of market forces to serve all people in need. TMA recognizes the power of markets to bring dignity and choice to the everyday lives of all people, regardless of their current ability to access or pay for essential health information, products and services. It is when barriers are lowered, and opportunities increased, that choosing to act in ways that lead to meaningful changes in one's own life are possible. Markets have a major role to play in making that happen.

The Mobile Internet in Africa

A new report on MobileCrunch suggests that demand for mobile internet access in Africa will rise between 40-50% by 2009.

“The poor state of fixed line infrastructure is creating the potential for the African mobile internet market to boom,” states Frost & Sullivan Research Analyst Spiwe Chireka. “Mobile internet has emerged as the solution to the continent’s last mile connectivity.

Yet, the lack of reliable electricity, inadequate road networks that make access to remote areas difficult, the costs of internet-compatible handsets and pricing for access still put it out of reach for most Africans.

The report calls for more partnership formation among mobile providers and various technology and infrastructure groups. Might this be the opportunity for some creative capitalism?