On Social Marketing and Social Change

Marketing a Total Response to H1N1

‘What does social marketing offer us to improve the nation’s preparedness activities for H1N1?’ was the question posed to a group of social marketers at the CDC National Conference on Health Communication, Marketing & Media. Nancy Lee picked it up first and talked about the need to establish a new brand for H1N1…starting with perhaps a new name. I could not jump onto that more quickly: ‘H1N1 already has a brand, and it sucks’ I said. I went on to talk about how most brands happen while we’re busy doing something else, and that a new brand (or name) was not going to change things in the next few months (certainly not before October-November). ‘As a marketing problem, I would focus on logistics and distribution. No matter what the communication strategy is, if the vaccine isn’t where it’s needed when it’s needed, if the health professionals don’t trust its safety and that it will be there when they need it, NO communication effort is going to ultimately be successful. Word-of-mouth will rule the day.’

Mike Rothschild jumped in and agreed that marketing distribution and logistics were the crux of the issue facing H1N1 preparedness. Bill Smith managed to agree with everyone.

It is remarkable to me that ‘marketers’ jump to the communication solution so easily and quickly – despite all the evidence to the contrary. Having personally been through or debriefed on innumerable planning scenarios for infectious biologic agent outbreaks, and planning national and statewide responses to them, communication programs become important when every thing else is going wrong: there are not enough stockpiles of vaccine or drugs to treat the problem, surge capacity of the health care system is quickly overwhelmed, people can't afford to NOT go to work, health care workers and first responders stay at home (often times because their spouse insists on it), and local news stations see the opportunity to dramatize and drive up viewership. These things quickly escalate not because ‘we had a communication problem,’ but because we had a significant disregard of the marketing mix and the problems we unearth when we talk with people who are important for success, not the planners in conference rooms and offices.

I was in Connecticut last week for some social media workshops and started asking health care professionals who were there about their perspective on H1N1 readiness. After listening to the cracks about changing the name from swine flu to H1N1 to satisfy the pork producers and politicians (and the irony was palpable when they said it), ‘brand sucks’ fits rather well. Then when I asked them what they are most concerned about – supply and distribution were uniformly the number one answer. It was also interesting to hear that colleges and universities had to demand guidelines for how to be prepared – they had somehow been overlooked.

Now I realize that a lot of commercial businesses don’t get that coordinated and integrated product, distribution, pricing and communications are marketing. They, like most public health agencies, see marketing as the messages, sales brochures, television and radio ads, publicity events and, oh yes, a Twitter account. But when facing the task of trying to mobilize a complacent nation – as HHS Secretary Sibelius put it yesterday – re-making ‘brands’ and refining talking points and risk communication messages is not going to do it. Show us you mean business!

Over a month ago when talking with some colleagues late one night, they asked me about the H1N1 vaccine being ready for the announced date of early October. Though I don’t have the inside track on what is happening with this current vaccine testing and production effort, knowing enough about it led me to state unequivocally that there was no way that would happen in any meaningful way. It was a pipe dream. The CDC is now publicly revising their shipment dates.

July 30, 2009 - The CDC expects about 120 million doses of the vaccine to be available by the end of October, obviously not enough to cover all of the recommended groups. Los Angeles Times

August 17, 2009 - Health officials had predicted having 120 million doses of vaccine ready by mid October. Now they say it will be more like 45 million. And with two doses needed to be effective, the nation's protection blanket will start out much smaller than the experts hoped. CBS News

August 24, 2009 – [HHS Secretary] Sebelius said it will take until Thanksgiving to fully immunize people against H1N1 because most will need to undergo two vaccinations. The first would be given in mid-October; the second would be administered three weeks later and it takes about two weeks after the second shot to build up full immunity to the virus. FOX News

August 24, 2009 - CDC officials say they expect between 45 million and 52 million doses of vaccine by mid-October, followed by roughly 195 million doses by the end of the year. FOX News

Confused? Poor ‘branding’? Is what we have here is a problem to communicate?

Now we could assume that once availability of the vaccine is solved, we can rest easy. But look again. Consider this story from The Globe and Mail yesterday: Canada does not have the manpower to deliver the H1N1 influenza vaccine as quickly as it becomes available, despite ordering enough doses to inject all of its citizens.

At least they are starting to focus on the rest of the marketing issues, and not the horse race as to when the vaccines will be in the starting gate. That’s when you’ll see the real problems start. (Then again, Canada has done their planning after a real-life response with SARS).

What I suggest is that the entire marketing complex (whether you think that includes you or not) for the H1N1 response to get into the room and integrate logistics with in-the-arm delivery points (not hospital and clinic refrigerators), distribution systems mapped onto the locations of high priority groups, and communication messages that enhance and compliment local capacities and plans. And stop trying to control the message from top down if they are being used to manage expectations rather than to be honest and transparent. Every time 'the message’ changes from government sources, another measure of trust is tapped from the well. Judging from what I hear, that well is already running dry. Setting and changing expectations for whatever reasons is setting the stage for more complacency and failure to adopt appropriate precautions.

It all comes down to a matter of trust. If health care providers and the informed public cannot trust what is being said one week to another, they are certainly conveying that sense in ways large and small to their patients, colleagues, friends and neighbors. They are where brand building needs to begin. They are the critical element for the success of the vaccination effort – not the perceived risk and susceptibility of the person-in-the-street. They need to feel confident and able to receive and deliver vaccines to as many people as are in need of it without the begging, waiting, cajoling and fielding questions from frightened parents, worried well and local reporters who ‘thought everything was under control.’

And as for renaming H1N1, maybe CDC should adopt the NOAA policy and name each new flu variant with a person’s name (I suggested ‘Bob’ for this one in a conversation later). Then maybe the rest of us can look forward each year to having a relationship with our ‘flu brand.' [And I love this from the NOAA site: Experience shows that the use of short, distinctive given names in written as well as spoken communications is quicker and less subject to error… The use of easily remembered names greatly reduces confusion when two or more tropical storms (read ‘flu strains’) occur at the same time.]

Today’s updates on ‘swine flu’ from Kaiser Health News is filed with more sobering news - 50% may be affected, a call to get vaccines into the field by mid-September, intensive care units' limited surge capacity, and packaging problems. So many people in public health keep saying that 'we don't DO marketing' like it is beneath them. Perhaps it really is beyond them?

Photo from Getty Images with permission.

Mad Men Meets Health Care

The great paradox for communicators and marketers is that while we give rhetorical priority to concepts of interactivity and audience-focused programs, we continue to hammer away at “breaking through the clutter,” “capturing people’s attention” and “getting people to do things.” Yet, even before the emergence of social media the music was already echoing off the walls: It’s no longer about getting attention, it’s about earning it.

That was written in January 2007 as an introduction to a post Moving Towards Engagement in which I began describing the results of a research initiative that looks beyond behavioral targeting, or simply counting the clicks (the 21st century version of 'beans'). Our team just presented the results from developing the eHealth Engagement Scale at the National Conference on Health Communication, Marketing and Media last week. The title (with a link to the presentation) and abstract as printed in the program follow.

The Assessment of User Engagement with eHealth Content: The eHealth Engagement Scale.

This presentation describes a scale for measuring the engagement properties of eHealth content that was adapted from commercial advertising research. Accompanying research suggests that a 9-item revised eHealth Engagement Scale is a robust tool to operationalize this concept across a variety of health topic areas. The eHealth Engagement Scale may prove to be an important mediator of user retention of information, intentions to change, and ultimately efforts to undertake and achieve behavior change. 

There are many different ways to think about engagement. This scale begins to get at the consumer/user experience of engagement that we define as the process of involving users in health content in ways that motivate and lead to health behavior change.

'Increasing the engagement of people' with advertisements, brands, communities, issues and media gets thrown around by many, however, rarely do I see someone operationalize it beyond eyeballs and clicks.

From our scale:

Engagement = Involving + Credible + [not dull + hip, cool]

See the presentation for more details, including the path model, and I look forward to your comments!

Post title from Susannah Fox on Twitter.

How Do We Address the Wicked Problems: The Australian POV

Wicked problems are all around us. They are defined in Wikipedia as ones that are difficult or impossible to solve because of incomplete, contradictory, and changing requirements that are often difficult to recognize. Moreover, because of complex interdependencies, the effort to solve one aspect of a wicked problem may reveal or create other problems. Examples include what to do about climate change, health care, the HIV pandemic, flu preparedness, drug use, mental health and care and obesity prevention.

I have written about how social marketing provides a complimentary approach to the more traditional public policy tools that are used to tackle these and many other types of social problems (see the previous links for more examples). For another, independent point of view (POV), I have selected some of the summary comments from the Australian Public Service [APS] Commission's report on Changing Behavior: A Public Policy Perspective (pdf). For those of you who work in and around policy-shapers and makers (for more about these people as market agents), it makes several relevant points about the need to move away from outmoded and largely discredited 'rational choice' models to more comprehensive approaches in which social marketing can serve as a useful heuristic and integrating framework. Be sure to share this with them.

Governments regularly use a range of traditional policy tools to influence citizens’ behaviour, including legislation, sanctions, regulations, taxes and subsidies, the provision of public services and information and guidance material. In many areas this range of traditional tools works well. For some social policy problems such as so-called wicked problems, however, influencing human behaviour is very complex and the effectiveness of traditional approaches may be limited without some additional tools and understanding of how to engage citizens in cooperative behavioural change. It has become increasingly clear that government cannot simply deliver key policy outcomes to a disengaged and passive public. In the areas of welfare, health, crime, employment, education and the environment, achieving significant progress requires changing behaviour.

Detailed cost-benefit analyses in a number of key areas of public policy such as health and crime have shown that more sophisticated behaviour-based interventions can be very much more cost-effective than traditional approaches to policy and service delivery. This is particularly the case if a longer-term time frame is taken to evaluate the constraints, costs and benefits. Agencies may have more impact on key policy outcomes by using their limited resources to more effectively engage, involve and change the behaviour of users and other parties, than by concentrating only on traditional policy tools and service delivery.

Accordingly, policy makers in the APS need to have a better understanding of how the rational choice model of behavioural change can be supplemented by insights from behavioural change theory and evidence at the individual, interpersonal and community levels. A social marketing approach is one practical tool that tries to integrate these three levels of theories.

…The need to formulate a comprehensive approach to behavioural change, to understand how components interact, to work cooperatively across jurisdictions and organisations and to engage stakeholders, highlights the need for a range of core skills in addition to the more traditional analytical, conceptual and project management skills. These include communication and influencing skills, the ability to work cooperatively, and big-picture thinking skills. There is also a need for policy makers to be aware of and apply behavioural change theory, and to understand the importance of investing in evaluation and research.

Obama's Wired Campaign: Lessons for Public Health Communication

Lorien Abroms and I take a look at the Obama campaign's use of social media in the latest issue of Journal of Health Communications (2009;14:415-423).

Lessons for public health campaigns include the following:

• Consider new media--social networking sites, uploaded videos, mobile text messages and blogs—as part of a comprehensive media mix.

• Encourage horizontal (i.e., peer to peer and social network) communications of campaign messages as social influence and modeling are important drivers of behavior. Embrace user-generated messages and content, especially in the case where top-down campaign messages are straight-forward and translatable by the public.

• Use new media to encourage small acts of engagement. Small acts of engagement lay the groundwork for relationship building and larger tasks in the future. are important for relationship building and can lead to larger acts of engagement in the future.
  

• Use social media to facilitate in-person grassroots activities, not to substitute for them.

More on

• developing strategies for social media;
  
• social media: threats and opportunities for social marketing and public health;
  
• social and risk communiction during times of crisis; 
• bridging the new media culture chasm: can elephants dance?
• unwinding social media marketing.
  

Avoiding 8 Deadly Sins of Social Media Campaigns

Chris Aarons and Geoff Nelson look at failed social media campaigns and make this list of suggestions to avoid the common problems and expectations people have when embarking on social media efforts.

1. Good strategy results in viral, but viral is not a strategy.
2. What someone says about you is more important than what you say about yourself.
3. People are already motivated to do many different things. By identifying where their motivation intersects with yours, you can avoid creating a contrived campaign. However, if you are ready and able to compensate people for their effort, the likelihood of participation goes up exponentially.
4. Money isn't the best social currency; relationships and knowledge are.
5. PR is great for news and launches, but social media creates the ongoing and sustained interest between news and launches.
6. Buying advertising space on social media sites doesn't return a quarter of the value you could be getting. Further, the costs of the campaign drive up the ROI bar you need to justify it.
7. Social media sites, people, and applications have vastly differing capabilities. Random, unplanned usage of these tactics will deliver poor results.
8. Social media is a strategic amplifier for your campaign, not the entire campaign.

Via @blueeyepath on Twitter

Also check out his recent post: It Takes More Than Grit to Build a Global Village for Social Marketers at Walking the Path.

Making Theory Relevant: Part 2

Unfortunately, the stages of change model has become ubiquitous to many social marketing programs. First the disclaimer or bonafide: I was using this theory to develop the "Imagine Action' community physical activity campaign many years ago – long before Alan Andreasen popularized it in his book and since has been promulgated by others (including Kotler & Lee) as THE social marketing theory. However, stages of change has been used, in my opinion, more often as a segmentation system (think of it as behavioral epidemiology, descriptive but not very helpful to change agents) than as the tool it was meant to be to select specific types of interventions to match people where they were in the stages of change process. And the notion that it is all about increasing the benefits and reducing the costs of engaging in a behavior is being waaay too simplistic. If people really acted that rationally we wouldn’t need behavioral economics for example – not to mention several hundred theories of learning and behavior change.

What I talk with my students about is that all theories of behavior are initially developed to explain a particular type of problem. Originally, stages of change was an attempt to develop a typology of psychotherapies – that’s why it is know formally as the ‘transtheoretical model’ (hmmm, social marketing as mass psychotherapy?). It quickly found utility and parsimony in working with addictive disorders – smoking cessation in particular, though over the years many of us have pushed its applications. The Health Belief Model, to pick on another frequently invoked theory among social marketing and health communications people, was developed to explain, predict and increase screening behaviors (NOTE: someone can fix the Wikipedia entry, it is wrong). Not that these humble beginnings should stop you from using them in other circumstances, but being mindful of their limits is important – and one reason why HBM in particular has spawned so many offshoots to explain other types of health behaviors.

So when a family planning program wants to use the stages of change model – why do I cringe? Well, because there is a better model specifically developed to address issues of family planning. And, here’s the punch line, it looks remarkably similar to stages of change with one notable exception. It allows us to look at the social context of the behaviors. Indeed, it offers a very cogent, theoretical rationale for why we should be using social media to address family planning issues.

The Process of Behavior Change framework proposes that people seeking or using family planning and reproductive health services move through a variety of intermediate steps, or stages, in the behavior change process. These stages are:

Preknowledgeable where they are unaware of the problems or their personal risk.

Knowledgeable in which people are aware of the problem and understand what the desired behaviors are (i.e., use of modern contraceptive methods).

Approving is the stage at which they personally are in favor of the desired behaviors.

Intending is the stage at which people personally express the desire to take the desired action.

Practicing or when people are actively using contraceptive methods.

Advocating is when people not only practice family planning methods, but advocate them to others. Once people reach this stage, they become effective change agents among their peers and within their social networks that, in turn, acts to reinforce their continuing to engage in contraceptive practices. That is, it is a strong predictor of people adhering to and not discontinuing their birth control practices.

For the family planning program, this model allows us to think about and talk with people at each of these stages who may constitute distinct audiences or segments for our program, each requiring different methods and actions they can take that are relevant to their current situation with respect to using family planning methods. What is noteworthy here is the notion of the advocacy behaviors within one’s social network as a behavioral maintenance strategy, a recruitment strategy and as a social media one. For us the obvious became: how do we work with users to become advocates for family planning through their SNS and mobile tools and networks?

That’s a very different slant than just thinking about reducing environmental constraints, addressing intentions and improving skills. Let alone simply focusing on increasing benefits and reducing costs. One theoretical model is rarely enough in the complex world of learning new behaviors. Or as I leave my class:

• Theories should be tools – not straight jackets
• Theories can inform – and blind
• “The one with the biggest toolbox wins” - Frank Lawlis, one of my psychotherapy mentors
  
• “It’s a complex world” - The Young Adults
  
• “There’s nothing so practical as a good theory” - Kurt Lewin
  

Enterprise Social Media

Jacob Nielsen, the guru of usability testing, has a new Alertbox on Social Networking on Intranets that is worth the read. From 14 business case studies he draws five conclusions (direct quote):

• Underground efforts yield big results. Companies are turning a blind eye to underground social software efforts until they prove their worth, and then sanctioning them within the enterprise.
  
• Frontline workers are driving the vision. Often, senior managers aren't open to the possibilities for enterprise 2.0 innovation because they're not actively using these tools outside of work. Indeed, many senior managers still consider such tools as something their kids do. One of the dirty secrets of enterprise 2.0 is that you don't have to teach or convince younger workers to use these tools; they expect them and integrate them as easily into their work lives as they do in their personal lives.
  
• Communities are self-policing. When left to their own devices, communities police themselves, leaving very little need for tight organizational control. And such peer-to-peer policing is often more effective than a big brother approach. Companies that we studied said abuse was rare in their communities.
  
• Business need is the big driver. Although our report discusses specific tools (blogs, wikis, and such), enterprise 2.0's power is not about tools, it's about the communication shift that those tools enable.
  
• Organizations must cede power. Using Web 2.0 technologies to communicate with customers has taught many companies that they can no longer control the message. This also rings true when using Web 2.0 tools for internal communication. Companies that once held to a command-and-control paradigm for corporate messaging are finding it hard to maintain that stance.

In his discussion he also has some comments about community management, participation inequalities, tagging and rating systems and the reciprocal influences of social media and corporate culture.

And concludes …social software isn't really about the tools. It's about what the tools let users do and the business problems the tools address.

Making Theory Relevant: A Case from Family Planning

The comment I received from a student about the 'theory' class in social marketing spoke for not only students, but I expect many professionals.

This was the first behavioral theory class that I have enjoyed in a very long time. While learning about the theories was repetitive, I felt like I learned a more useful way to apply them to interventions. This was a nice break from prior classes that examined behavioral theory. The other enjoyable aspect of this particular session is that we learned about theories that were developed recently... and not in the 1950's.

What is a given for most social marketing and health communications programs is that they are based on theories from long ago and/or far away from the topic at hand. When I have done research into what theories people use in public health programs, practitioners can describe (maybe) one or two, and academics describe their own (developing your own theory must be a prerequisite for tenure now). That some authors want to impose a single theory on social marketers borders on malpractice.

People in the advertising and public relations worlds who work on social marketing projects don’t even know what a theory is – unless they have been in the game for a while. They want you to believe that their past ‘experiences’ give them a better feel for what will work with an audience than any textbook. What they often fail to intuit is that these ‘experiences’ form their own naïve or folk psychological theories. The difference between their theories and the ones in the textbooks? About several dozen to several thousand research studies validating them (and some will still argue ‘what do the researchers know! I do this for a living!’ Walk widely around them.).

Theories are helpful AND harmful for several reasons:

• Explains how or why things are related
• Guides you to what’s important
• What questions to ask
• What you should do about it
• How you should measure success

In other words, the theory you use – whether old, new or personal – frames the way you look at a problem, try to understand it, go about solving it and attempt to measure it (for example, not one epidemiological survey has ever give me a clue about HOW to change risk behaviors, only that it needed to be done for certain population groups).

I was recently called into a family planning project at the beginning (thankfully) to help develop an overall approach and strategy. The initial discussion included something like ‘We are going to use a theory-driven approach, you know, theory of reasoned action and stages of change, to enroll more women in our services.” At one level I appreciated the nod to the conscious and deliberate use of theoretical models from the outset, but I also shuddered at the choices.

Let’s take the first one today.

Nothing wrong with TRA, if you want to use a theory that even one of its originators has moved beyond. This is, what the student above referred to, as theory from the 1950s (well, not quite that long ago, but you get the idea). It is the canon for behavior change academics, one that must (?) be passed down to the graduate students of today for it’s historical importance – although, unfortunately, most of those instructors I expect still believe it to be operational. OK, now some reality for the TRA and TPB folks (and if you have to look those up, don’t worry, it means you are less susceptible to their influences).

The integrative theory proposed by Fishbein & Yser, I will say from the outset, has its detractors in the academic realm, mostly, I gather, because it includes too much. However, among the practitioners I have worked with, they find it a very useful and comprehensible road map for thinking about a variety of public health problems.

The integrative theory incorporates elements of 3 widely used theories in behavior change and communication interventions: the health belief model, social cognitive theory and theory of reasoned action. In this model, whether a specific behavior is performed depends upon (1) if one intends to engage in that behavior - which you can see depends on a whole lot of things, (2) if they have the requisite skills and abilities to perform the behavior, and (3) if there are no environmental constraints (broadly defined) to performing the behavior. Those are 3 pretty big IFs that research and social marketing efforts need to address.

Here’s an example of how the model was used in the strategic planning document for the family planning program:

To improve the likelihood of engaging in family planning behaviors then, we must first look at what environmental constraints may be preventing women from engaging in them and act on those (or help people overcome them).

Among the constraints identified in the audience research are the few facilities available in rural counties, busy clinic staff that makes local outreach and promotion efforts difficult, making time in their busy schedules for setting clinic appointments, and difficulties using the centralized referral service.

Second, we need to assess if the person has the necessary skills to access and effectively use family planning methods over time.

Here we found that not understanding the eligibility criteria (due to confusing messaging and low literacy skills) and non-adherence with birth control methods over time (discontinuing pills or missing doses, reports of broken condoms leading to unwanted pregnancies) were the most common problems reported by research participants.

However, if the person does have not strong intentions to perform the behavior, we need to look at changing (1) attitudes towards performing the behavior, (2) perceived norms about performing the behavior, and/or (3) the person’s perceived self-efficacy, or confidence in being able to perform the behavior.

Among the determinants of these intentions we found that conservative community values can play an important role in reducing conversations and public education activities around family planning. We heard few comments related to negative personal, peer or social attitudes towards their personally using birth control.  Indeed, there were generally favorable attitudes about delaying pregnancy until the woman had graduated from school, had a steady job and boyfriend and otherwise was ‘ready’ to raise a child. We did not hear much about women believing they were not susceptible to becoming pregnant (though other research informs us that this is the most common reason from women to discontinue using contraceptives). There was also evidence that women do talk with each other about birth control, though no common times or places were discovered that might guide communication strategy.

Now some people will ask ‘what about…?’ And if you think that’s an important variable to consider, first make sure your audience does too. While I am not going to defend this particular theory as all-encompassing (that is why there will be a second installment to this topic), what you can take away from this is: the theory you use helps you to focus in thinking about the issue, asking relevant questions of your audience and forming program strategies that are both theoretically- and research-driven.