On Social Marketing and Social Change

The MBA Oath: A Case of Social Shifting

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

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

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

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

Reviewing the CDC's HIV/AIDS Program

Several months ago I received this invitation:

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

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

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

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

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

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

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

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

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

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

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

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

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

The US Commitment to Global Health

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

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

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

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

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

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

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

• and engage in respectful partnerships to improve global health.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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