On Social Marketing and Social Change

Asking Questions About Education Innovation and Reform

The reform of education - it’s products, policies, processes and people - poses all kinds of wicked problems, from what should (and should not be) in curricula, to how classes and schools are designed to achieve better outcomes for students and parents, how success is measured, and what the role of school personnel are in this most modern of ages. Innovations are widely touted, but few seem to be broadly adopted. Top-down approaches are rarely swapped out for more bottom-up processes (see these examples from the BIF Student Experience Lab for some exceptions). In over 4 decades of work in social marketing, I have seen few examples published in the literature that apply marketing ideas to solving some of these issues. And I wonder why?

I have many different hypotheses ranging from total indifference to ‘outside the box’ thinking to real or imagined concerns that introducing ‘marketing’ into education will somehow trivialize and contaminate the lofty aspirations (and ideologies) that educators and policy makers have of their calling. In work I have done with STEM education initiatives and school readiness, my involvement seems to start and end with the ‘planning’ meetings (“We’d like to have a social marketer’s POV”). And then…nothing seems to take shape. At one meeting a brand marketer also involved in STEM issues and I were pushing the idea to explore student-driven STEM communication and programming strategies. Our progress was summed up when he shouted out in exasperation near the end: “Doing it the way you’ve always done it (expert-driven directives and ‘messages’) is DOOMED!” [See The change we need: New ways of thinking about social issues]

The opportunities for me to insert a marketing perspective into education discussions and arguments are few and far in-between. So when I learned that a noted education reform specialist was coming to town to talk about initiatives underway in Sarasota and Manatee (Florida) county schools through the Annie E. Casey Foundation’s Campaign for Grade-Level Reading, I decided to drop in and listen.

Ralph Smith, the campaign’s managing director, had many encouraging things to say about what he experienced during his visit. We also heard from the principal of one exemplary grade school in Sarasota. You may have been in similar types of discussions. Philosophies and data are cited to make the case for “Why this problem [reading at grade level by 3rd grade]?” Emotional appeals to do what’s right for children and their parents. Exhortations that ‘we must all work together’ and that it ‘takes a community to educate a child.’ Glimmers of hope, such as offered by the school principal, into what might be working. Calls for ‘scaling up.’

What can a social marketer add to these discussions?

Near the end of the 90 minutes of the town hall meeting there was time for a Q+A session. I had several questions going through my mind:

• How do we focus people on an objective of children in the 3rd grade reading at that grade level when there are so other many competing concerns and issues that schools and communities face every day?
• How can nonprofits (not just the Casey Foundation, but local nonprofits who are supporting the program) who invest in these innovations design sustainability (or exit) strategies and not endanger the systems, people and processes they put into place to make the program work in the first place?
• How can local media continue to set and keep visible a public and policy agenda to support growth and long-term durability of attaining the objectives?
• What are the most important barriers that need to be addressed to make community action feasible - to cross the line between the schools’ and the community’s interests and bring them together?
• What are the most important elements of success (at least so far)?

Near the end of the Q+A I was able to ask ‘one question.’ So with three panelists (the local paper’s editorial page editor was the host), I wrapped up the last three into one. What I received in response was intriguing: the editor committed to a Sunday editorial on the issue and outlined his three main points, the principal pointed to the success of her schools efforts to bring community residents into her school to volunteer as reading tutors (something my wife already does with her), and Ralph Smith talked about the first and most important step being the building of trust between schools and communities. His central concern was that schools have to learn to not be afraid to share their data, regardless of the flaws and problems they expose. Communities, in turn, have to refrain from using those same data as a club to beat up the educators. Who is going to share their data when they fear the consequences [See The costs of fear]? And how can we have a meaningful conversation to address a problem without data? My take away was: until school and community leaders shift from being problem describers and blamers to solution seekers, with data driving their discussions, not ideology, bringing together the necessary community and school resources to improve education seems doomed (to quote a colleague). To start that process we need to earn trust from one another.

As social marketers we often talk about programs, policies and behaviors to improve society and the need for partnerships to make them happen. But rarely do we get down to the fundamentals of what makes any potential partnership work. It’s not the quality of the people and organizations at the table, the creative ideas that are expressed, or the evidence that supports a proposed strategy or intervention. It is the trust that exists, or is developed, among the participants. That is not a new idea for social marketers; trust is one of the pillars of the Value Space I proposed in Transformative Social Marketing [pdf]. As I said in that article (Lefebvre, 2013, p. 126):

“Trust is a larger idea than just a variable of interpersonal relationships or a characteristic of sources of messages. It also extends to organizations and companies that support and sponsor social marketing activities… We live in a world where trust is no longer a commodity that is acquired, but rather a value that we receive from the people we serve and our stakeholders. Without trust, social marketing risks slipping into coercion, liberal paternalism, propaganda and irrelevancy. Trust also underlies important concepts including social capital formation as well as the development of effective partnerships.”

The education system may not yet be ready to use social marketing as a tool to develop new products and services, promote innovative reforms and initiatives, or to build demand for more effective, efficient, equitable and sustainable programs. But could it be ready for trust? Is this an opportunity to bring new light to education about what life might be? To begin to contemplate the answers to some questions social marketers ask?

And for those of you who might go to similar types of meetings and stumble over what question to ask, here are ten suggestions I wrote about some time ago. Be sure to check #10.

Reference:

Lefebvre, R.C. Transformative social marketing: Co-creating the social marketing discipline and brand. Journal of Social Marketing, 2012; 2:118-129.

The Future of Social Marketing: Craig's Happiness Talk

This June I was honored to receive the Phillip Kotler Social Marketing Distinguished Service Award, “The Kotler Glass,” at the Social Marketing Conference in Clearwater Beach, FL. In his presentation of the award, Dr. Kotler noted that “[Craig] is known for many things; a prolific writer, a creative architect of programs, an innovator and risk taker, and an outspoken and long-time guiding force in our field…In fact, if one word could be used to describe him, catalyst is the perfect one. He is that agent that provokes significant change… For those who know him, he is a brilliant and courageous innovator that has provided the field with enough insight to last the rest of us for a lifetime.”

After receiving The Kotler Glass I took the opportunity to talk about happiness and well-being. The video of the talk was just completed (thanks to Eric Weaver!) and is embedded below [or use that last link].

 

I started with where I left off in my book, Social Marketing and Social Change, suggesting several opportunities for the future of social marketing. One of them concerned happiness or well-being.

How the deliberate use of social marketing could lead to positive change in personal subjective well being and national happiness indicators through increasing perceived and actual freedoms and tolerance is an area ripe for exploration; it could invite the discipline into global policy discussions and debates—and one could rightfully inquire, Are we back to asking, “can we sell brotherhood like soap?” (Wiebe, 1951). Perhaps. But now we have the benefit of sixty more years of experience to draw upon (p. 498).

Bhutan has recognized the supremacy of national happiness over national income since the early 1970s.  It has famously adopted the goal of gross national happiness over gross national product (GNP).  Such thinking is now gaining traction in other regions.

Costa Rica is well-known for being the greenest country in the world — an example of holistic and environmentally responsible development.  Compared to other countries with similar income levels, it ranks higher in human development and is a beacon of peace and democracy.  In the United Kingdom, statistical authorities are experimenting with National Well-being. The European Commission has its GDP and Beyond project. One of the overarching targets of the European Health 2020 policy is how to set targets for well-being. Quality of Life and Well-Being are foundational health measures of Healthy People 2020.

And the Organization for Economic Cooperation and Development (OECD) has issued guidelines for the measurement of well-being. Their definition of subjective well-being includes three elements:

● Life evaluation – a reflective assessment on a person’s life or some specific aspect of it.

● Affect – a person’s feelings or emotional states, typically measured with reference to a particular point in time.

● Eudaimonia – a sense of meaning and purpose in life, or good psychological functioning (you can also take a look at the OECD Better Life Index).

Also noteworthy is that the Center for Disease Control and Prevention (CDC) has developed and validated a well-being index. Happiness and well-being are becoming mainstream topics in public policy, economic and, yes, public health circles. It is time for social marketing to be at that table.

A few months ago the International Day of Happiness came onto my radar screen. It is an international observance brought into being by a resolution of the United Nations General Assembly. The resolution in its entirety reads:

Resolution adopted by the UN General Assembly on 28 June 2012

Recalling its resolution 65/309 of 19 July 2011, which invites Member States to pursue the elaboration of additional measures that better capture the importance of the pursuit of happiness and well-being in development with a view to guiding their public policies,

Conscious that the pursuit of happiness is a fundamental human goal,

Recognizing the relevance of happiness and well-being as universal goals and aspirations in the lives of human beings around the world and the importance of their recognition in public policy objectives,

Recognizing also the need for a more inclusive, equitable and balanced approach to economic growth that promotes sustainable development, poverty eradication, happiness and the well-being of all peoples,

Decides to proclaim 20 March the International Day of Happiness

Concomitant with this action, two World Happiness Reports have been issued. The 2013 report states that “Happiness is an aspiration of every human being, and can also be a measure of social progress.”

In a review of the research on the topic from around the world, the authors conclude that six key variables explain three-quarters of the variation in annual national happiness or well-being average scores over time and among over 150 countries. These six factors include: real GDP per capita, healthy life expectancy, having someone to count on, perceived freedom to make life choices, freedom from corruption, and generosity.

“In conclusion, there is now a rising worldwide demand that policy be more closely aligned with what really matters to people as they themselves characterize their lives.”

Many cities and other organizations created videos for the International Day of Happiness in 2014, all of them using the song "Happy" by Pharrell Williams as the soundtrack. One of my favorites is from Paris (over 2.6 million views when I posted this), though it was a little long for the conference. There are hundreds of these videos on YouTube to choose from. I chose one from Tel Aviv. The version that appears in the video is produced by students at the University of South Florida. Since they labored to edit and put the video together, and I am on the faculty there, why not? The idea is the same - user generated content around a social object.

At the end of the video I called for social marketing to take a lead role in taking International Day of Happiness to a new level. It’s time we showed the world that marketing can, indeed, be used to improve people’s well-being (or happiness) and make the world a better place.

Stay tuned for more… and let me know how you can help make this happen in your corner of the universe.

Demarketing Obesity

An op-ed piece in The New York Times by Ezekiel Emanuel and Andrew Steinmetz ("Finally, some optimism about obesity," 4 May 2014) suggests that we should be optimistic about our efforts in controlling obesity. They lay out the game plan for how the smoking rates in the US were reduced (advertising restrictions, prohibitions on where people could smoke, and taxation), and go on to say that the response to the obesity epidemic has been even faster than it was for tobacco use. They note that 'within a decade' of the first reports of an increase in childhood and adolescent obesity, salt and saturated fat were limited in the school lunch program (full disclosure: I was involved in the development, implementation and evaluation of that effort, aka Team Nutrition). Later, a few voluntary actions by industry, a "Call to Action" (not annual reports as with smoking) by the Surgeon General,  the "Let's Move" campaign, requirements for restaurant menu labeling, and some types of local and state sales taxes on sodas round out what they call this 'nimble response.'

Perhaps these responses to data about a new public health threat are happening more quickly than in past decades, but they pall in comparison to the restrictions placed on tobacco advertising (within 6 years of the first Surgeon General's report on smoking), the smoking ban on domestic airline flights and in government buildings (and many other places), and large increases in tobacco excise taxes in most states and many local jurisdictions (taxes applied to the companies, as opposed to sales taxes applied to consumers).

The response to the puzzle of the increase in obesity across most age groups may be nimble, but hardly effective. The authors embody the problem with their proposed solutions: more calorie counting, more explicit nutrition labeling, and banning advertising of junk foods to children. These education ideas may be well intended, but off the mark. What if all that had been done for tobacco control was to ban tobacco advertising to children, require prominent labeling of nicotine and tar levels on packs of cigarettes, and also have ingredients posted for each cigarette brand in places where people smoke? Would we be applauding the declines in smoking rates and lung cancer deaths? I don't think so.

A better set of solutions would start with where tobacco control became so effective - by demarketing tobacco use. Yes, you read that correctly, using marketing not to sell more cigarettes or food, but to reduce demand. How might that look for managing and reducing levels of obesity?

It may be difficult to ban food advertising, but what if all food advertising were regulated so that no images could be used in the ads or on packaging - just text and colors (not just for so-called 'kids' foods, but all foods)? What if vending/self-service machines were removed from all worksites and schools, thus reducing accessibility to foods and impulse decisions? What if food companies began to pay excise taxes on foods that in standard portion sizes (used as intended) exceeded daily standards for calories and sugars (think about the fast food offerings that this would include)? And what if we had a commitment to long-term, multi-faceted obesity control programs that went beyond information and education efforts run by lawyers and focused on increasing the price of doing business in the obesity creation marketplace? That helped communities and states reduce the ubiquity of food choices and access? And worked with organizations and industries, and not just those involved in health care, to increase incentives and opportunities for physical activity that could fit into people's lives and into organizational practices? We might have more than a nimble response, we could actually start bending the obesity curve.

Behavioral Economics and Policy Development

Behavioral economics has emerged as a major driver of regulatory policy around the world in the past five years. Regulatory Policy and Behavioural Economics, authored by Pete Lunn, explores more than 60 examples of how behavioral science has been explicitly used to design and deliver better regulations. While pensions, tax and consumer protection in financial services and health insurance markets are the more common areas for the application of behavioral economics, public health, employment, energy conservation and charitable giving have also been successfully addressed.

Three major findings emerge from this review:

1. Consumer choices are influenced by how simply the information and range of options are presented to people, though the evidence of their effectiveness is mixed. "Much more work empirical work is needed to understand when and how the simplification of information improves decisions" (p.44).

2. People tend to choose the more convenient options, especially when they are the default ones ('nudges'). This approach seems especially relevant when immediate costs have to be considered against long-term gains - pension or retirement policies being a popular focus.

3. The importance of the attributes of choices can affect how they are weighed in consumer decision-making. Modifying these choice attributes can be applied to official warnings and advice, but also point to the need to guard against companies who downplay costs and relevant information through providing adequate regulatory guidelines for disclosure.

"It is much easier to identify behavioural problems and to devise potential solutions than it is to judge or to measure the associated impacts." Indeed, one of the conclusions of this work is the need for better research and to generate evidence for effectiveness in the specific context in which the regulations are implemented.

It is reassuring, though not explicitly stated as a social marketing precept, that the secret to the sauce of behavioral economics is in designing and delivering regulations that are relevant to consumers - not the policy makers and special interests. Mandating or supplying information that simplifies consumer decision-making, makes better options more convenient, and increases the salience of key information are goals many of us in social marketing are also working towards achieving.

Public Health Competencies: The Place for Social Marketing

The public health professional core competencies, in my opinion, have not adequately reflected or prepared people for critical elements of their jobs-to-be-done: improving health behaviors of individuals and in communities, increasing the adoption and use of evidence-based practices by public health and allied organizations, and promoting and strengthening environmental and policy changes to improve and sustain public health. The Council on Linkages Between Academia and Public Health Practice (Council on Linkages) is in the process of reviewing and revising the current Core Competencies for public health professionals. As part of this process, the Council on Linkages is collecting feedback on the Core Competencies from the public health community. Please consider the following observations and suggestions for how they could be improved to be more relevant to the practice of public health as I have observed and participated in it over the past 30 years. If you agree with these, and have other opinions about competencies for public health professionals, you have until December 31st to submit them. Feel free to copy and paste these comments, edit them, and add to them in the comments section of their feedback form.

In reviewing the current core competences, only three - rather weak - competencies touch on the jobs-to-be-done by public health professionals as outlined above: 2A6 - 2B7 - 2B8: participates, develops and implements plans and programs consistent with policies (Policy Development/Program Planning Skills). A second one in that domain, 2A8 - 2B9 - 2C10, mentions the need for program monitoring and evaluation skills. Finally, 3A4 -3B4 - 3C4 address using a variety of approaches to disseminate public health information (e.g., social networks, media, blogs). These isolated competencies stand in marked contrast to the more detailed 6-7 'Communication skills' and an equal number of 'Cultural competency skills' currently identified in the Core Competencies.

Despite the existence of the Core Competencies and others (for example, for MPH and DrPH programs), there have been few investigations of what is needed for success in the context of practice, not academics. And when one turns to whether characteristics of the public health workforce are associated with improved effectiveness and changes in population health outcomes, a recent survey of the public health workforce literature found no published study that had investigated the question (Beck & Boulton, 2012). My point here is that we need to pay more attention to what is needed in the real world of public health practice; not theories and fashions.

The needs for competencies in communication and marketing in the public health workforce have been consistently voiced. In the context of reducing health disparities, Golding & Rubin (2011) noted that the success of any expansion of programs and services to close gaps in health status rests on the effectiveness of the information and communication that is provided by health communicators and health marketers.  In their survey of members of the National Public Health Information Coalition, 66% of respondents identified the planning, development and implementation of interventions, and marketing and advertising as major job responsibilities. The leading training topic survey respondents identified for themselves – and for other staff in their state or local health department – was to “understand how to tailor and target campaigns that will improve the well-being of diverse individuals and communities.”  Social marketing has been identified as part of the continuing education competencies for the currently employed public health education workforce, and public health leadership training initiatives include marketing as part of their curriculum (Allegrante, Moon, Auld & Gebbie, 2000; Hawley, Romain, Molgaar & Kabler, 2011). Harris et al (2012) note that the marketing discipline can significantly contribute to the frameworks that are used, and the dissemination and implementation strategies that are selected, to bring more evidence to the daily practice of public health.

Consistent with these views, Healthy People 2020 included social marketing among the objectives for the Nation to achieve over the course of the next decade. Specifically, Healthy People 2020 Objectives HC/HIT – 13.2 and HC/HIT-13.3 are:


Increase the proportion of schools of public health and accredited master of public health (MPH) programs that offer one or more courses in social marketing.

Increase the proportion of schools of public health and accredited master of public health (MPH) programs that offer workforce development activities in social marketing for public health practitioners.

Just this past week the Federal Interagency Workgroup for National Health Objectives for 2020 met and approved revisions to the other related HC/HIT objective that now reads:

[13.1] Increase the number of State health departments that report using social marketing in health promotion and disease prevention programs.

Social marketing is a systematic process for developing behavior and social change programs with documented successes for many public health issues, across many different population groups and in many different contexts (see Lefebvre, 2013). The strategies and tools, discussed below, are a foundation for the best in public health change programs, whether it is truth®, Verb™ or the current TIPS campaign. Indeed, when read alongside a social marketing textbook such as Lefebvre (2013), the discussion of the "six components necessary for public health intervention" by the Director of the CDC (Frieden, 2014) includes many of the key features and ideas that characterize a marketing orientation and approach to public health.

A set of tiered competencies, recently approved by the International Social Marketing Association's Board of Directors, for the Council to consider are:

Tier 1:  Entry level professionals
Explains and differentiates a social marketing approach and demonstrates the appropriate application of social marketing approaches and tools (audience segmentation, behavior selection, consumer research, application of evidence-based theories and models, use of integrated marketing strategies, behavior change evaluation) to support development of health promotion and disease prevention programs and policies.

Tier 2: Individuals with management and/or supervisory responsibilities
Manages and leads the development of health promotion and disease prevention programs and policies using a social marketing strategic planning approach and community input.

Tier 3:  Senior managers and/or leaders
Communicates, encourages and ensures professional, organizational and community support for the ethical development of health promotion and disease prevention programs and policies based on social marketing approaches. 

These competencies might be considered for inclusion under a broader domain of competencies.

I propose to the Council to consider what if they developed a separate set of competencies under the domain of Public Health Change skills (or behavior, community and social change skills)? For people in the field, this is what they have to do to be successful. And for many students entering public health, this is what they want to do, change the world - or at least their corner of it. They should be prepared by public health education and training programs to be as good as they can be at it. For a more articulated vision of what a set of competencies for Public Health Change Skills could be, I propose starting with:

1. Describe social marketing to colleagues and other professionals, differentiate it from other approaches to behavior and social change, advocate for its appropriate application to social policy development and implementation.

2. Work with colleagues and stakeholders to identify community or national priorities and identify those to which a social marketing approach may be usefully applied.

3. Identify affected populations and select appropriate segments to give the greatest priority to in program planning.

4. Prioritize and select measurable behaviors, organizational practices, environments or policies to influence.

5. Design and conduct a situational analysis, evidence reviews and formative research needed to understand the perspectives on the problem and its possible solutions by people affected by it and stakeholders, and identify their perceived value (benefits) for the change objective as compared to the alternatives.

6. Apply appropriate behavioral and social science theories and models to the development of a framework to describe the problem and its potential solution.

7. Analyze, synthesize and apply theory, evidence and research insights to create an integrated marketing strategy and plan.

8. Develop and test the relevance and potential effectiveness of marketing strategies (e.g., concepts and approaches) and tools (e.g., products, services and messages) with representatives of priority groups and stakeholders.

9. Implement, manage and lead social marketing interventions.

10. Design and implement a program evaluation plan, including a monitoring system to assure programs are on track to achieve goals.

11. Apply ethical principles to conducting research, and developing and implementing a social marketing plan.

12. Communicate the results of the program and its evaluation to colleagues, stakeholders, communities and other relevant organizations and groups.

Again, we can debate whether 'social marketing' needs to be incorporated into every competency listed above (for example, #1, 2, 9 and 11). However, I think few seasoned public health program planners would argue against the importance of each of these items in any well developed and implemented public health program - whether it is aimed at individual, organizational or policy change.

Finally, I recommend that the framers of the Council on Linkages' revised competencies give special attention to their role in fostering evidence-based public health. As Brownson, Fielding & Maylahn (2009) have noted, the development of an evidence-based approach to public health practice involves more than a knowledge of the science of what works with what identified problem, when, under what circumstances and with whom. There is also a need to have frameworks that can serve to translate this scientific knowledge into effective, efficient, equitable and sustainable programs in real-world settings. And there must also be broad and consistent dissemination and implementation of proven interventions at both the state and local level of public health practice. I believe that incorporating the concepts and tools of social marketing into the next version of public health competencies is a significant step in that direction.

References
Allegrante JP, Moon RW, Auld E, Gebbie KM. Continuing-education needs of the currently employed public health education workforce. Am J Public Health; 2000; 91:1230-1234.

Beck AJ, Boulton ML. Building an effective workforce: A systematic review of public health workforce literature. Am J Prev Med. 2012; 42:S6-S16.

Brownson RC, Fielding JE, Maylahn CM. (2009). Evidence-based public health: A fundamental concept for public health practice. Annu Rev Publ Health. 2009;30:175-201.

Frieden TR. Six components necessary for effective public health program implementation. Am J Public Health; 2014: 104:17-22. Abstract

Golding L, Rubin D. Training for public information officers in communication to reduce health disparities: A needs assessment. Health Promot Pract. 2011; 12:406-413. Abstract

Hawley SR, St. Romain T, Orr SA, Molgaar CA,  Kabler BS. Competency-based impact of a statewide public health leadership training program. Health Promot Pract. 2011; 12:202-208. Abstract

Harris JR, Cheadle A, Hannon PA, Forehand M, Lichiello P, Mahoney E, Snyder S, Yarrow J. A framework for disseminating evidence-based health promotion practices. Prev Chron Dis. 2012; 9:E22 PMCID: PMC3277406

Lefebvre RC. Social marketing and social change: Strategies and tools for improving health, well-being and the environment. San Francisco, CA: Jossey-Bass; 2013.

Can We Market Biomass? Social Entrepreneurship and Bioenergy Villages

Citizens can self-finance and profit from building a bioenergy facility that uses biomass (plants, wood and manure) to generate enough heat and electricity for the village that the surplus can be sold to the national grid. Nina Adam at the Wall Street Journal (WSJ) reported earlier this week that in Germany "a swarm of households and small-scale investors…are producing and selling renewable energy." Germany currently ranks 2nd among nations whose share of electricity generation comes from renewable sources, and it has a national goal of generating 80% from renewable sources by 2050. Could this be a blueprint for the world? What can we learn from these positive deviants?

This village of 750 people created a cooperative, applied for and received government grants and low interest loans, kicked in about $5,900 each for capital funding and to upgrade their homes' heating systems, and within three years had their money back in energy savings. And this is not one of those 'amazing communities' projects when the question is "Yes, but how do you scale this up?" Adam notes there are 92 similar bioenergy villages in Germany, with another 350 considering making similar social investments.

The appeal to me is that these are not large-scale efforts where the barriers to entry are so formidable. I can imagine bioenergy villages in small towns across the US, as well as for every major housing development and sub-division. All we may need is about a thousand people to make a biomass facility feasible and viable. What if we, as Chrisoph Burger is quoted in the article as saying, followed Germany and "turned the traditional one-way street - from energy producers to consumers - upside down" and encouraged citizens to become energy suppliers as well as users. And to further the impact of biomass energy, in the village profiled in the article the talk is now about how to use some of their surplus electricity to power electric cars. This is the type of puzzle that social marketing can be so useful in helping weave the pieces together - not only encouraging new behaviors, but helping communities find and harness the assets and capacities to bring their vision to reality, enlisting partners to create win-win-win scenarios, and helping to bridge the divides among public, private and nonprofit groups - and among the latter, I think especially of all the community foundations in the US.

If you believe that there are no coincidences, then today's story fuels the idea of local and state initiatives to create renewable energy towns in the US.

Ryan Tracy reports in the WSJ that there are no Federal requirements to use renewable energy sources that include wood and wood waste, municipal soilid waste, landfill gas and biogas (methane), ethanol and biodiesel, water, geothermal, wind and solar. Instead, those decisions are left up to the states (29 do have requirements, 14 are considering them). Several states are considering repealing their renewable energy requirements - and that's where interesting things are happening. In Kansas, wind turbine manufacturers and local famers have teamed up to block a repeal; same thing in Texas. In North Carolina, environmental groups and the pig farmers connected to kill similar efforts. It turns out that Smithfield Foods, the nation's largest pork producer, has spent tens of millions of dollars to turn manure into renewable energy.

 Conservative political action groups are fingered as behind these efforts to repeal; Tracy notes that one prominent group receives funding from the fossil fuel industry. As you might expect, getting 'BIG' government out of regulating energy production and use (aka preserve the status quo) and the supposed higher costs of renewable energy sources are key arguments. But they can't seem to argue well against the fact that renewable energy sources can create local jobs (someone is sourcing the materials and running those plants) and that local solutions may be more cost-effective than having large utilities 'convert' to renewable sources. Just take a look at the "Powering Up" chart that compares the capital and on-going costs of different types of electric plants.

SO what?

Marketing the use of biomass as a renewable energy source seems to be a time that has come for both the marketplace and consumers. As long as local and state jurisdictions can continue to exercise their rights and responsibilities (that is, we don't see efforts by big business to supersede or pre-empt their ability to experiment with renewable energy and especially biomass energy projects), the pieces of a puzzle are becoming clear. Local action to create and socially profit from biomass energy production and household use can involve many different sectors of society in some innovative and productive ways. If you are a social marketer or social entrepreneur in your community, you should be watching - and thinking about action.

Examination Questions for Advanced Social Marketers

What if social marketers began tackling the really wicked problems around health and health care? Where might we start?

More than 100 CEOs were recently convened by The Wall Street Journal to discuss and prioritize the most pressing public policy and business issues. One of the task forces focused on remaking health care. Here are their top four recommendations.

Population Health Management
Explicitly gear our system around population health. Create public-private partnerships to encourage healthy behavior, and identify specialty populations with unique needs, such as the seriously mentally ill. Reshape financial incentives to meet the goal of population health, and build capacity and reimbursement systems to support it. Have the administration clarify how to deal with the huge shift into insurance exchanges.

Transparent Standards
The Center for Medicare and Medicaid Services should develop, and require all public-health programs to adopt, uniform standards for health-care service quality, performance and price transparency so consumers can make value choices. And it should encourage states to follow suit.

New Delivery Models
Use the full continuum of care givers, such as nurses and other professionals. Create uniform standards for licensing care givers across the country, and encourage more care in retail clinics, pharmacies and other sites. Require patients' medical data to be available electronically.

Primary Care
Provide incentives to correct the imbalance of specialists to primary-care doctors by changing reimbursement rates, increasing funding for undergraduate and graduate medical education for primary care, and forgiving medical-school loans. Increase focus on advanced nurses and nurse practitioners as care providers.

If I were giving an essay final examination for advanced social marketers, it would look something like this:

• Assume this group of CEOs has asked you to help them design an approach to address one of these four issues. Select one of them and draft a situation analysis that includes important individual, organizational and marketplace variables that are contributing to the current situation. What are some of the major competitive forces to consider? Identify any existing practices, programs or policies that might shed light on possible solutions to the puzzle. List up to five 3-5 year potential objectives. What are possible strategies to consider?
  
• Based on this analysis, identify up to five priority groups that would be the focus of your social marketing approach.
• Describe three research studies you would conduct to better inform your strategy and approach – especially questions they would each address and among what group(s).
• From what you currently know (given the results of your research projects are not yet available), outline a social marketing approach for at least three priority groups that moves towards solutions for this issue.

Yes, this would be a “take-home” and “open book” examination and you have a week to complete it.  Are you ready?

Social Marketing and Wicked Problems

Many courses in social marketing have started up over the last week or so, including an Advanced Social Marketing course I am co-leading as part of the Online Social Marketing Graduate Certificate Program at University of South Florida. The course includes a number of readings, including chapters from my textbook to be published early next year. If you are studying or teaching social marketing now, there are many texts you might be using, and I hope you might consider the book of readings from this blog as one supplemental source. And many you may be interested in what my new book may be covering.

For the next 14 weeks of so, I intend to post a brief excerpt from each of the chapters of Social Marketing and Social Change: Strategies and Tools for Improving Health, Well-Being and the Environment. Hopefully you'll find them interesting in their own right, but also useful for starting conversations about social marketing in the classroom and where you work. The first selection is about wicked problems, something I first touched on in the post on The Change We Need: New Ways of Thinking About Social Issues.

 [Click on image to enlarge and sharpen]

In many disciplines the dominant model of defining and solving problems features a scientific-rational approach that assumes every problem is definable, understandable, and consensual (that is, everyone can agree on the causes and proposed solutions). This approach has worked quite well in many cases involving developing mass transportation, preventing infectious diseases, providing clean water and sanitation, and improving access to health services (though there is clearly a need to further improve access and equity for all people everywhere). Rittell and Webber (1973) distinguished between these tame problems, with clear causes and solutions that can be achieved by these deductive approaches, and wicked problems, which are diabolical in their ability to resist the usual ways of resolving problems.

A wicked problem involves complex issues and defies complete definition, its stakeholders have different ideas about what the real problem is and what the solution is, there is no final solution, and given that any solution will generate further issues, that solution is merely the best that can be done at that time. For example, the Australian Public Service Commission (APSC; 2007) notes in its publication Tackling Wicked Problems: A Public Policy Perspective, that issues as diverse as climate change, obesity, indigenous disadvantage (disparities between native populations and majorities), and land degradation are complex, or 'wicked,' policy problems. “Usually,” the commission says, “part of the solution to wicked problems involves changing the behaviour of groups of citizens or all citizens. Other key ingredients in solving or at least managing complex policy problems include successfully working across both internal and external organizational boundaries and engaging citizens and stakeholders in policy making and implementation. Wicked problems require innovative, comprehensive solutions that can be modified in the light of experience and on-the-ground feedback. All of the above can pose challenges to traditional approaches to policy making and programme implementation” (p. 1).

From my perspective this statement offers a compelling rationale for using social marketing approaches - they are important for improving social welfare, the well-being of people, and the health of our planet. It also propels the idea that social marketing can and should look beyond behavior change in its contribution to social change…

Linear models for solving problems are not relevant to most social issues of our time. Wicked problems require innovative and flexible solutions, yet most programs are locked into highly regimented and prescribed step-by-step processes that might work for people doing experiments or changing a discrete behavior for awhile but that have little validity in the messy world we live and work in. Social marketing, as I will demonstrate in this book, provides a framework for and a variety of approaches to solving environmental, health, and social puzzles (and the tame problems too). Yes, we can continue to pick around the edges of issues such as overconsumption, climate change, tobacco use, malaria control, poverty, and obesity with what worked in the past for different types of problems - but only at the risk of becoming inconsequential to real change. Or we can start thinking about using social marketing as a planned approach to social innovation.

References

Australian Public Service Commission. (2007). Tackling wicked problems: A public policy perspective. Canberra: Commonwealth of Australia.

Rittell, H.W.J., & Webber, M.M. (1973). Dilemmas in a general theory of planning. Policy Sciences; 4: 155-169.

 

 

Priorities for Health: Leading Health Indicators for 2020

The US Institute of Medicine (IOM) has again tackled the difficult problem of turning a cacophony of priorities and objectives for improving Americans' health that is Healthy People 2020 into something that, as they put it in their Leading Health Indicators for Healthy People 2020 Letter Report this week:

"...should prove valuable in eliciting interest and awareness among the general population; motivating diverse population groups to engage in activities that will exert a positive impact on specific indicators and, in turn, improve the overall health of the nation; and providing feedback on progress toward improving the status of specific indicators."

Hopefully this list of Leading Health Indicators (LHIs) will survive longer than the ones created for Healthy People 2010. In that case, the LHIs were developed by the IOM at the end of the Clinton administration. When President Bush's team then took over, it was not long until items such as Responsible Sexual Behavior attracted their attention. The LHIs were quickly dumped, and evolved into the Steps to a HealthierUS initiative (remember that one? If not, you can download a ppt overview of it) that featured a set of objectives for both behaviors and specific diseases (including asthma and diabetes, that curiously enough, were not included as chronic disease objectives in the newest version of LHIs).

The 2020 Leading Health Indicators, and the specific Healthy People 2020 Objectives to which they are linked, include:

Topics	Indicators	Objectives
Access to care	Proportion of the population with access to health care services	1. Increase the proportion of persons with health insurance. 2. Increase proportion of persons with a usual primary care provider. 3. Increase the proportion of persons who receive appropriate evidence-based clinical preventive services.
Healthy behaviors	Proportion of the population engaged in healthy behaviors	4. Increase the proportion of adults who meet current federal physical activity guidelines for aerobic physical activity and for muscle-strengthening activity. 5. Reduce the proportion of children and adolescents who are considered obese. 6. Reduce consumption of calories from solid fats and added sugars in the population aged 2 years and older. 7. Increase the proportion of adults who get sufficient sleep.
Chronic disease	Prevalence and mortality of chronic disease	8. Reduce coronary heart disease deaths. 9. Reduce the proportion of persons in the population with hypertension. 10. Reduce the overall cancer death rate.
Environmental determinants	Proportion of the population experiencing a healthy physical environment	11. Reduce the number of days the Air Quality Index exceeds 100.
Social determinants	Proportion of the population experiencing a healthy social environment	12. Improve the health literacy of the population. 13. Increase the proportion of children who are ready for school in all five domains of healthy development: physical development, social-emotional development, approaches to learning, language, and cognitive development. 14. Increase educational achievement of adolescents and young adults.
Injury	Proportion of the population that experiences injury	15. Reduce fatal and nonfatal injuries.
Mental health	Proportion of the population experiencing positive mental health	16. Reduce the proportion of persons who experience major depressive episodes.
Maternal and infant health	Proportion of healthy births	17. Reduce low birth weight and very low birth weight.
Responsible sexual behavior	Proportion of the population engaged in responsible sexual behavior	18. Reduce pregnancy rates among adolescent females. 19. Increase the proportion of sexually active persons who use condoms.
Substance abuse	Proportion of the population engaged in substance abuse	20. Reduce past-month use of illicit substances. 21. Reduce the proportion of persons engaging in binge drinking of alcoholic beverages.
Tobacco	Proportion of the population using tobacco	22. Reduce tobacco use by adults. 23. Reduce the initiation of tobacco use among children, adolescents, and young adults.
Quality of care	Proportion of the population receiving quality health care services	24. Reduce central line-associated bloodstream infections.

Source: Institute of Medicine.

As states and communities consider how they will be allocating their resources to improve people's health, the LHIs can be considered the first among equals of the 42 topic areas and hundreds of specific objectives in HP2020 (depending on where you sit, and the conditions you find there, which HP2020 objectives you  focus on will shift).

In the IOM letter report, the authors conclude;

"HHS may wish to highlight the indicators and objectives in communications to state and local health departments, use them as a guide for funding priorities in department programs, and use them as priority guides for ongoing departmental public health data collection and reporting activities."

For social marketers in the United States, the LHIs can point us to where we should strive to demonstrate our capabililties to address the most important health issues (see Comparative Effectiveness Research and Social Marketing for other priority areas for social marketing research).

 

Social Marketing to Achieve National Health Objectives

Social marketing was included among the 10-year national health objectives for the US that were announced yesterday by the Department of Health and Human Services. For over two years, I’ve been involved in the Health Communication and Health Information Technology workgroup that was charged with developing national objectives in this topic area. In an open and transparent fashion, we sought the input and advice of many professionals in the field (you can catch up on some of these conversations at my Healthy People 2020 archive). As you might expect, dozens of suggestions for objectives were received through the public comment period and in a number of teleconferences. And I must single out Robert Marshall of the Rhode Island Department of Health who was instrumental in soliciting letters of support for our proposed social marketing objectives from a number of major public health and health promotion organizations. After being vetted using a number of criteria, 13 health communication and health IT objectives were submitted to the Department of Health and Human Services for final review and approval.  The social marketing objectives are:

HC/HIT-13: (Developmental) Increase social marketing in health promotion and disease prevention.
HC/HIT–13.1 Increase the proportion of State health departments that report using social marketing in health promotion and disease prevention programs.
HC/HIT–13.2 Increase the proportion of schools of public health and accredited master of public health (MPH) programs that offer one or more courses in social marketing.).
HC/HIT–13.3 Increase the proportion of schools of public health and accredited MPH programs that offer workforce development activities in social marketing for public health practitioners.

The final hurdle for an objective to be included in Healthy People 2020 was the requirement of having a national monitoring and reporting system proposed or in place to track progress towards each objective over the next decade. As we scrambled to meet this requirement, I have to thank the National Public Health Information Coalition who are incorporating the monitoring of objective 13.1 into their ongoing national survey of public health information activities and colleagues at the University of South Florida's Florida Prevention Research Center who have taken on the task of monitoring the two social marketing education and training sub-objectives.  Without their commitments and support, we would not be where we are today with social marketing becoming part of the national plan for improving the health of all Americans.

Now on to living up to our potential and promise.

Improving Public Health: Getting Better at Doing the Right Things

The development and vetting of national health objectives for disease prevention and health promotion is coming to a close as the final recommendations for what is in and what is out are being made to DHHS. Being a participant in the Healthy People process for 3 iterations now, I am well aware of the promises, frustrations, disappointments and exasperation it entails. After this last round, however, two possibly fatal flaws seem to loom even larger than usual for me. These flaws not only impact the deliberative process of what becomes an objective for the year 2020 and beyond, but also undermine our efforts to achieving a healthier nation through public health programs.

The first flaw has to do with our data, or lack of it, to monitor and evaluate progress towards goals. Fundamental management and social marketing premises are: ‘what gets measured gets done’ and what we monitor we can adapt and change. Yet, despite the intentions to manage by objectives, the latest comprehensive reviews of progress towards the Healthy People 2010 objectives found that only 51% of the health objectives for four major racial/ethnic groups had at least two data points during the decade from which to make judgments of our progress in meeting them [see the accompanying table I have compiled].

And where we can make judgments on our collective progress over the past decade to improve the health of Americans, the results are modest at best. For example, between 7.8%-17% of the targets set for Hispanic/Latino, non-Hispanic Black, non-Hispanic white or Asian population groups have been met or exceeded (keep in mind only 51% of the targets have such data). Depending on the racial/ethnic group, positive progress in moving towards the 2010 targets have been documented for another 37.4% (Asian) to 55.3% (Black) of those for which baseline and follow-up data are available. And for another 29.3% - 30.4% of the objectives with two or more data points, health indicators are moving in the opposite direction from the targets.

Let’s put that in a nutshell: for the half of Healthy People 2010 objectives we have data for, about 30% are moving in the wrong direction. Can we draw the conclusion that over the past decade we have been successful at even making a dent in fewer than 20% of all of the objectives we set for ourselves in 2000?

These figures are based on the data available as of August 2007. While we can expect some changes to the figures when the final report is compiled, it seems clear that less than half of the objectives for which we have data will be met. More importantly, for at least a quarter of these objectives we will have lost ground.

The discussions about how and why these improvements and setbacks have occurred will focus on any number of issues ranging from how the targets themselves were set; how data were (or were not) collected and reported; secular trends; improvements and impediments in the health care and public health systems; and lack of adequate resources or diversions of them into other priorities (e.g., public health preparedness).

However, these elaborations of the problem will not lead to the solutions to the second flaw I see: that we are not measuring, in most instances, the right things – we measure what we can measure. We use national surveys and datasets of morbidity and mortality, risk behaviors and the like to set outcomes for many Healthy People objectives. But in my mind, this is like a business setting a 10-year, or even 5-year, revenue goal – and stopping there. Healthy People 2020 is NOT a strategic document that lays out objectives and how we will reach them – and it should be if we want to deliberately (i.e., not haphazardly) improve health.

Another plausible response to the lack of progress on many Healthy People objectives is to call for more research into causes and treatments (or even prevention), greater use of evidence- and theory-based practices and greater involvement by more sectors of society to address these and other issues. There are clearly such needs that I support. However, I also view our current situation as one in which to focus on how to stimulate and support more innovation among public health staff, agencies and partners to improve the effectiveness (the behavioral outcomes, not awareness and information surrogates) and efficiency of our policies, partnerships, programs and interventions.  And any and all of these recommendations must be backed up by metrics; how do we measure whether health departments are implementing more evidence-based programs for, say, obesity prevention, reducing infant mortality or increasing levels of physical activity among specific age groups?  How do we know if community coalitions are adopting best practices and measuring behavioral outcomes in, for example, illicit drug use or injury prevention programs? Or how do we know that best practice guidelines are being taught in our schools of public health and are consistently applied throughout the public health infrastructure? Is innovation in addressing pubic health priorities driving research and development funding in the public sector (as opposed to investigator interests and review panel ideologies)? And these are just the ‘tops of the trees’ for questions we should be asking, and measuring, if we are in the business of improving health, and not just the rhetoric of it.

Over the past year, and certainly the past few months, we have seen and heard a lot about health insurance and health care reform in the US. As we look forward to launching Healthy People 2020, I suggest we start looking at public health system reform that builds accountability, innovation and direction (what to do and what to avoid) into not just what we measure, but how, when and to what purpose we do it. Why not have the American Public Health Association and other groups start working now on these issues of measuring what is meaningful rather than what is easy so that by the time we start developing Healthy People 2030 we will have a national set of data collection tools that can tell us whether we are doing the right things to improve health?

National Objectives for Health Communication and Health Information Technology

In a process that began more than 15 months ago, the US national health objectives are beginning to take final form. Yesterday, the Federal Interagency Workgroup (FIW) approved 13 objectives for the Health Communication and Health Information Technology area. Of particular note for this forum is that social marketing has been included in the list to be forwarded to the Department of Health and Human Services for final clearance and approval this Fall. The social marketing objectives are:

Increase social marketing in health promotion and disease prevention.

a: Increase the proportion of state health departments that report using social marketing in health promotion and disease prevention programs.

b: Increase the proportion of Schools of Public Health and accredited MPH programs that offer one or more courses in social marketing.

c: Increase the proportion of Schools of Public Health and accredited MPH programs that offer workforce development activities in social marketing for public health practitioners. 

As many of us celebrate this accomplishment, I want to extend my thanks and props, first and foremost, to Bob Marshall for his untiring efforts and perseverance to co-lead our work with the HC/HIT workgroup and organize the outreach to the social marketing community and stakeholders during the public comment period. Then it's for all of you who worked with us to make this happen by being on the conference calls and, more importantly, submitting comments in support of the social marketing objectives (which, by the way, generated the largest number of comments for ANY objective).

In the last few months, we were faced with the need to develop national data sources to measure progress towards our proposed objectives in order to move the ball (objectives) further down the field. A special thank you to the National Public Health Information Coalition that stepped up and will include measurement of subobjective a in their Healthy People survey. The other important evaluation gap was filled by the Florida Prevention Research Center whose leadership committed to, and submitted a design for, a national survey to monitor progress towards subobjectives b and c. Both of these national surveys will be in the field this Fall to establish baselines for all three subobjectives. Our proposal is to then set the goal of a 10% increase over baseline by 2020. Easy? Then let's gets started!

Finally but not least, a special thank you to the co-leads of the Health Communication part of the HP2020 puzzle, Linda Harris at ODPHP and Cynthia Baur at CDC, who guided, challenged, cajoled and ultimately championed our case to the FIW.

We likely will look back at this event as a major milestone for social marketing. I am already being asked what it means for funding of social marketing programs, the future of the field and the future of public health. That's for another time to consider. Right now I am enjoying the moment: social marketing may soon become part of national disease prevention and health promotion policy in the US. A tremendous outcome for 15 months worth of work.

And for those who are interested in the entire list of health communication and health information technology objectives, they appear (as provisionally approved) below:

1: Increase the proportion of persons who report that their health care providers have satisfactory communication skills.

    1a: Increase the proportion of persons who report that their healthcare provider always listened carefully to them;

    1b: Increase the proportion of persons who report that their healthcare provider always explained things so they could understand them.

    1c: Increase the proportion of persons who report that their healthcare provider always showed respect for what they had to say; and

    1d: Increase the proportion of persons who report that their healthcare provider always spent enough time with them. 

2: Increase the proportion of persons with access to the Internet.

    2a: Increase the proportion of persons with broadband access to the Internet.

   2b: Increase the portion of persons who use mobile devices. 

3: Improve the health literacy of the population.

    3a: Increase the proportion of persons who report their healthcare provider always gives them easy to understand instructions about what to do to take care of their illness or health condition.   

    3b: Increase the proportion of persons who report their healthcare provider always asks them to describe how they will follow the instructions.   

    3c: Increase the proportion of persons who report their healthcare providers’ office always offers help in filling out a form.

4: Increase the proportion of quality, health-related Web sites.

    4a: Increase the proportion of health-related Web sites that meet three or more evaluation criteria, disclosing information that can be used to assess information reliability; and

    4b: Increase the proportion of health-related Web sites that follow established usability principles.

5: Increase the proportion of online health information seekers who report easily accessing health information. 

6: Increase the proportion of persons who report that their healthcare providers always involved them in decisions about their healthcare as much as they wanted.

7: Increase the proportion of persons who use electronic personal health management tools.

    7a: Increase the proportion of persons who use the Internet keep to track of personal health information, such as care received, test results, or upcoming medical appointments.

    7b: Increase the proportion of persons who use the Internet to communicate with their provider.

8: Increase the proportion of patients whose doctor recommends personalized health information resources to help them manage their health. 

9: Increase the proportion of adults who report having social support.

    a: Increase the proportion of adults who report having friends or family members that they talk to about their health.

10: Increase the proportion of crisis and emergency risk messages, intended to protect the public’s health, that demonstrate the use of best practices. 

11: Increase the proportion of medical practices that use electronic health records.

12: Increase the proportion of meaningful users of health information technology (HIT).

13: Increase social marketing in health promotion and disease prevention.

    13a: Increase the proportion of state health departments that report using social marketing in health promotion and disease prevention programs.

    13b: Increase the proportion of Schools of Public Health and accredited MPH programs that offer one or more courses in social marketing.

    13c: Increase the proportion of Schools of Public Health and accredited MPH programs that offer workforce development activities in social marketing for public health practitioners.

MINDSPACE for Behavior Change

Many of the biggest policy challenges we are now facing – such as the increase in people with chronic health conditions – will only be resolved if we are successful in persuading people to change their behaviour, their lifestyles or their existing habits. Fortunately, over the last decade, our understanding of influences on behaviour has increased significantly and this points the way to new approaches and new solutions.

That statement appears in the Foreword of a new joint publication by the Cabinet Office and the Institute for Government MINDSPACE: Influencing behaviour through public policy. The authors of the report, intended for policy-makers, distill behavior change principles into MINDSPACE:

Messenger: We are heavily influenced by who communicates with us.
Incentives: Our responses to incentives are shaped by predictable mental shortcuts, such as strongly avoiding losses.
Norms: We are strongly influenced by what other people do.
Defaults: We tend to ‘go with the flow’ of pre-set options.
Salience: Our attention is drawn to what is novel and seems relevant for us.
Priming: Our actions are often influenced by sub-conscious clues.
Affect: Our emotional associations can powerfully shape our actions.
Commitments: We seek to be consistent with our public promises, and reciprocate acts.
Ego: We act in ways that make us feel better about ourselves.

Some of you will wonder why some of the other tried and true principles of behavior change are not on this list; why not include models, intentions, needs, desires, stages of change, positive reinforcement, attitudes, connections (or social support) and efficacy?

The authors note that there are at least two models for thinking about behavior change. The first approach is the ‘rational’ or ‘cognitive’ model. They continue: Most traditional interventions in public policy follow this model. The presumption is that citizens and consumers will analyse the various pieces of information from politicians, governments and markets, the numerous incentives offered to us and act in their best interests (however they define their best interests, or - more paternalistically - however policymakers define them).

The contrasting model of shaping behaviour focuses on the more automatic processes of judgment and influence. This shifts the focus of attention away from facts and information, and towards altering the context within which people act. We might call this the ‘context’ model of behaviour change. The context model recognises that people are sometimes seemingly irrational and inconsistent in their choices, often because they are influenced by surrounding factors.’

So MINDSPACE becomes a methodology for, as they put it, changing behavior without changing minds. It certainly provides something for us to think about when we try and use policy-making as a way of changing behaviors. Are we, in fact, simply applying our old prejudices for rational decision-making and persuasion by implementing policies that mandate the delivery of more information (think about BMI report cards in schools, restaurant menu-labeling programs for example)? Or are we focusing on changing the context in which judgments and decisions about health behaviors are made? And should we also be asking how we can expand the frame for policy-making even more and focus on the marketplace itself to improve health behaviors by increasing access and opportunities to healthier behavioral options, products and services?

[Graphic is from the publication.]

The 4Ps of Demarketing Tobacco Use

Demarketing as a strategy for social marketers is a popular, but unknown or poorly understood part of social marketing practice. Those are my initial conclusions from the feedback and hits from the recent post, Demarketing Sugar Consumption in Drinks. Popular in that many people are obviously interested in the topic; unknown or misunderstood either because people tell me they have never heard the term before, or thought 'it had something to do with counter-advertising.'

I have talked about how such strategies were employed to frame tobacco control in the NCI ASSIST study [Social Marketing and Tobacco Control Policy], and I noted in the Demarketing Sugar post that demarketing tobacco was studied recently by Edward Shiu and his colleagues. Because of the curiosity in demarketing approaches, here is a synopsis from their article to broaden your perspective on this social marketing strategy and how it intersects with many public policy approaches to the topic.

In a social marketing context, they define demarketing as having the objective to decrease  demand by discouraging consumption or use of products such as alcohol and cigarettes that pose health risks. They note that while governments use various demarketing strategies and instruments independently to curb smoking (increasing taxes, clean indoor regulations, banning advertising), little research is available on how the 4Ps work in conjunction with each toward reducing tobacco use and how they influence consumer behavior over time.

This chart by the authors shows how traditional marketing and demarketing approaches to tobacco can be thought about. Working through the 4Ps, product is framed as product replacement and displacement – most often by offering free or low-cost replacement products (e.g., nicotine replacement therapies) as well as support services (e.g., telephone quit-line and other information services). Increasing taxes and therefore the sales price primarily realigns the price variable. They view place interventions as restricting tobacco consumption opportunities through such instruments as  bans on smoking on public transportation and clean-air policies in public places. Promotion interventions are most familiar to readers who lean towards communication approaches to the issue: implementing counter-advertising campaigns, mandatory package warning labels and restrictions on tobacco advertising.

To summarize their overall approach, the authors write:

Conceptualizing the 4Ps from a consumer perspective and linking them to consumer intention via attitudinal mediators is novel and contributes to the literature. Modeling governmental demarketing from a consumer perspective allows one to determine the impact of this government approach not only on consumers' intention to cease consumption, but also on consumer attitudes both toward consuming the product and toward companies that promote and sell these products.

They then go on to develop and test a model of demarketing using data from the International Tobacco Control Four Country Survey (http://www.itcproject.org) – a nationally representative, longitudinal panel survey of adult smokers that was designed to evaluate whether and how a number of key government policy initiatives led to reductions in tobacco consumption. The authors used structural equation modeling to test the hypothesized relationships among policy initiatives aimed at each of the 4Ps, attitudes towards smoking, attitudes towards the tobacco industry, and intentions to quit smoking at two points in time.

The results show that the two attitudinal variables only partially mediated the effects of each of the 4Ps on intention to quit. In each case, the direct effect of each demarketing element on intention is significant over and above the effects of the mediators in the hierarchical regression. The only exceptions to a number of hypotheses about the effects of demarketing strategies on attitudes and intentions were:

1. The demarketing element of product does not affect their attitude toward smoking nor their intention to quit (they suggest that many smokers are already familiar with many of these quit smoking products and services and have already been unsuccessful in using them to quit themselves).

2. Price does negatively affect their attitude toward the tobacco industry (respondents attribute price increases to the industry, not government taxation policies, is their assumption to explain this).

3. The demarketing element place does not affect their attitude toward smoking.

Their results demonstrated that governmental demarketing activities during 2002 and 2003 in the U.S. have resulted in significant beneficial changes in smokers' attitude toward smoking and their intention to quit. They conclude:

This study demonstrates the differential effect of the 4Ps of demarketing and the central significance of promotion and price, which are the only demarketing mix elements that influence all three outcome variables, attitude toward the tobacco industry, attitude toward smoking, and intention to quit smoking. At the same time, the empirical evidence from this study shows that the demarketing mix element product, in terms of product replacement and displacement through the promotion of NRT [nicotine replacement therapies] and behavioral support programs, is less effective in terms of changing smokers' attitude toward smoking and intention to quit smoking. Lastly, smoking restrictions at work and in public places do not influence attitude but have a small direct effect on intention to quit.

Two lessons the researchers draw for social marketers are:

1. Social marketers and consumer-policy makers cannot assume individual demarketing measures will be effective in changing the attitudes and behavior of the priority audience. Rather, a comprehensive demarketing mix aimed at decreasing the attractiveness of tobacco and impeding the availability and consumability of cigarettes is needed to result in measurable changes.

2. Ad hoc and one-off demarketing measures are unlikely to have the desired effect. The results show an effect over time of the 4Ps of demarketing, suggesting that governments should equip anti-smoking campaigns with sufficient and sustained demarketing resources.

SO when you consider 'upstream social marketing,' think demarketing and all 4Ps.

Reference: Shiu E, Hassan LM & Walsh G. (2009)  Demarketing tobacco through governmental policies – The 4Ps revisited. Journal of Business Research; 62:269–278

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.

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.

Social Marketing Objectives for Healthy People 2020

Will social marketing play a role in pubic policy for disease prevention and health promotion over the next 10 years? One arena in which social marketing could 'be at the table' are the Health People 2020 objectives - the national health priorities for the decade. For those new to the process, these objectives help guide the development of Federal programs, how grants and contracts are crafted and dispersed, and when the question is asked 'What are the priorities?' - where many people go to for the answers.

While I and some guests have been writing about HP 2020 regularly here over the past few months, very few social marketers took advantage of the opportunity to provide public input into their formation (kudos to Bob Marshall. Mike Rothschild and Mike Basel for making comments on the HP workspace about them). Whether there will be ANY draft objectives related to social marketing will now be in the hands on the Federal Interagency Workgroup (FIW) over the Summer. We will have to wait to see what emerges from that group in the Fall when there should be one more round of public comments before the final objectives are set for a public launch in 2010.

For those of you who are interested in how social marketing could be represented in HP 2020, I did put together some of the ideas talked about in the Health Communication and Health IT Workspace as draft objectives for the FIW to consider. You can download the entire 6 page document by going to the site, registering and then clicking on the library section where it is posted in its entirety. Here's the nut of it:

1.1.    All Federally-funded public health programs that aim to improve the health of population groups (segments) through changes in voluntary behaviors, social norms and customs, environmental and structural changes, and/or regulations and policies should demonstrate adherence with the following principles:
a. Actively engage people and organizations for whom the program is intended to serve in the development of program outcomes and strategies.
b. There must be a set of integrated activities that analyze, design for, implement and evaluate programs that specifically address (1) products, services and behaviors that will improve individual health and well-being; (2) realign incentives and costs to facilitate behaviors for the individual and organizations; (3) create opportunities and improve access to beneficial products, services and places that encourage and support behavior change; and (4) employ state-of-the-science communication strategies and tools to promote and support positive change at all levels of society - individuals, families and other social networks, organizations and communities.

1.2     Increase access to training opportunities and capabilities of public health professionals to develop and implement disease prevention and health promotion programs based on a systematic social marketing approach
·        Undergraduate and graduate training in schools of public health
·        Continuing education training for public health practitioners.

Whether you agree or disagree with what is here is less important than if you care. If you care, then I hope you will get onto the site and start leaving more comments - support it, trash it, offer other ideas. What is written in the work space is the official record of the public process - not your tweets, postings on blogs and SNS, hallway conversations or emails. And if you are not the social media (wiki) sort, start talking it up with people who represent you in other public health organizations who will be lobbied (or educated) by numerous interests who want to see their agenda part of the Federal agenda.

As the saying goes, If you aren't at the table, you're likely on the menu.

Comparative Effectiveness Research and Social Marketing

Comparative Effectiveness Research (CER) is one of the buzz words in the health care reform and economic stimulus package conversations in which $1.1 billion is allocated for CER.

CER studies offer the opportunity to evaluate social marketing under more rigorous conditions than are typically present in our applied work. Yet, one danger is that many policy staff, grant makers and investigators will mistakenly operationalize the term 'social marketing' to include interventions that only use communication strategies or only sell products to consumers. I hope funders of CER research, and the policy makers, will educate themselves that social marketing is more than either of those extremes, and that incentive systems coupled with better access and improved opportunities for more people to lead healthier lives are part of the social marketing mix and the CER that is eventually funded.

The Institute of Medicine (IOM) just released their list of the 100 national priority areas for CER. I have pulled from their list some examples where social marketing should be at the table.

1. Compare the effectiveness of primary prevention methods, such as exercise and balance training, versus clinical treatments in preventing falls in older adults at varying degrees of risk.

2. Compare the effectiveness of dissemination and translation techniques to facilitate the use of CER by patients, clinicians, payers, and others.

3. Compare the effectiveness and costs of alternative detection and management strategies (e.g., pharmacologic treatment, social/family support, combined pharmacologic and social/family support) for dementia in community-dwelling individuals and their caregivers.

4. Compare the effectiveness of school-based interventions involving meal programs, vending machines, and physical education, at different levels of intensity, in preventing and treating overweight and obesity in children and adolescents.

5. Compare the effectiveness of various strategies (e.g., clinical interventions, selected social interventions [such as improving the built environment in communities and making healthy foods more available], combined clinical and social interventions) to prevent obesity, hypertension, diabetes, and heart disease in at-risk populations such as the urban poor and American Indians.

6. Compare the effectiveness of the various delivery models (e.g., primary care, dental offices, schools, mobile vans) in preventing dental caries in children.

7. Compare the effectiveness of wraparound home and community-based services and residential treatment in managing serious emotional disorders in children and adults.

8. Compare the effectiveness of interventions (e.g., community-based multi-level interventions, simple health education, usual care) to reduce health disparities in cardiovascular disease, diabetes, cancer, musculoskeletal diseases, and birth outcomes.

9. Compare the effectiveness of literacy-sensitive disease management programs and usual care in reducing disparities in children and adults with low literacy and chronic disease (e.g., heart disease).

10. Compare the effectiveness of clinical interventions (e.g., prenatal care, nutritional counseling, smoking cessation, substance abuse treatment, and combinations of these interventions) to reduce incidences of infant mortality, pre-term births, and low birth rates, especially among African American women.

11. Compare the effectiveness of innovative strategies for preventing unintended pregnancies (e.g., over-the-counter access to oral contraceptives or other hormonal methods, expanding access to long-acting methods for young women, providing free contraceptive methods at public clinics, pharmacies, or other locations).

12. Compare the effectiveness of strategies for enhancing patients’ adherence to medication regimens.

13. Compare the effectiveness of patient decision support tools on informing diagnostic and treatment decisions (e.g., treatment choice, knowledge acquisition, treatment-preference concordance, decisional conflict) for elective surgical and nonsurgical procedures—especially in patients with limited English-language proficiency, limited education, hearing or visual impairments, or mental health problems.

And those are from just the first 30 or so top priorities - you get the idea.

I know that some social marketers will shudder at the idea of pigeon-holing social marketing programs into randomized clinical trials. For them, and other readers, I suggest you take a look at an article in the Annals of Internal Medicine (2009;151) by Luce et al Rethinking randomized clinical trials for comparative effectiveness research: The need for transformational change. Their thesis is:

…many RCTs as currently designed and conducted are ill suited to meet the evidentiary needs implicit in the IOM definition of CER: comparison of effective interventions among patients in typical patient care settings, with decisions tailored to individual patient needs. Without major changes in how we conceive, design, conduct, and analyze RCTs, the nation risks spending large sums of money inefficiently to answer the wrong questions—or the right questions too late.

My point is that there are many ways in which social marketing can be the subject of pragmatic research studies and applied to the solution of many challenges facing the health of Americans and the people who care about them. What are you doing to insure that society benefits from all that we have been learning in social marketing over the past 25 years (some references)?

Get Involved in Creating a Healthier World by 2020

Healthy People 2020, an initiative of the US Department of Health and Human Services, is now in the Action Phase in which objectives are being debated and developed to continue the tradition of earlier Healthy People initiatives of advocating for improvements in the health of every person in our country. If you are in the health space, your agency, organization or business has a stake in its outcome as this is a primary Federal policy-making tool. The Mission for HP 2020, as outlined in the Framework document is:

To improve health through strengthening policy and practice, Healthy People will:

    * Identify nationwide health improvement priorities;
    * Increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress;
    * Provide measurable objectives and goals that can be used at the national, state, and local levels;
    * Engage multiple sectors to take actions that are driven by the best available evidence and knowledge;
    * Identify critical research and data collection needs.

Several guest contributors and I have been writing about Health Communication (HC), Social Marketing and Health Information Technology (HIT) issues that HP 2020 should address on this blog. In the past week, two teleconferences have been held to open up the process of HC and HIT objective development to all interested parties. In these calls, some of the major points that were raised were:

• The adoption of a social determinants framework signals that objectives should not only address individual decisions and practices that increase or decrease the risk of disease and disability, but also the physical and social environments that contribute to, or protect against, diseases and disabilities.

• Objectives should also consider a life course approach to their development where Life Stages are used to divide the life course into discrete blocks (e.g., infancy, childhood, etc.) to facilitate monitoring and interventions and Developmental Stages are used as a way to examine the impact of early life experiences and exposures on health status later in life.

• The current Health Communication objectives need to be reviewed to see which ones are still salient and relevant as we move into the next decade. For example, is ‘at home use of the internet’ still what to focus on for the next ten years, or should we be thinking about mobile broadband internet access for all people? Is disclosure on health websites still important, and if so, how does this objective need to be adjusted to focus on the world of 2020?  Preliminary recommendations about HC/HIT objectives from the work group are due 11 March 2009 (see below for more information about how to join).

• Data sources against which to set baselines, benchmarks and outcomes are a critical need (and in short supply) for many health communication, social marketing and HIT objectives. We need to have steady and reliable sources of data to measure progress over the next decade for any objectives that are proposed.

• What new areas do we need to create objectives for – social marketing, risk communication, global health programs (health diplomacy), personal health records, security and privacy of wireless data exchange?

The conversations have begun. One of the most open and collaborative approaches to national health policy development yet devised, an online work space for the HC and HIT discussions and objective-setting, will be available by Monday, February 23.

If you would like to participate, you need to send an email by 12PM EST on Friday, February 20, 2009 to receive a user name and password [or copy and paste into your email address line [email protected]]. On Monday you will receive your user name and password so you can start making recommendations regarding the health communication and health IT objectives right away. You will also receive weekly emails to notify you of new blog posts and discussion.

The Change We Need: New Ways of Thinking About Social Issues

One definition of insanity is doing the same thing, over and over again, but expecting different results. As we enter another era of change, will we continue thinking about and trying to solve social and public health issues using the same paradigms and tools, or will rediscovering social innovation lead to original and improved solutions?

Coping with the many challenges confronting our country and world requires, just like with individuals under stress, the development of new ways of coping with them. Economic and policy initiatives are only partial solutions to issues as diverse as safer neighborhoods, childhood obesity and poverty. Education and information campaigns only go so far in reducing the use of tobacco products, increasing the use of preventive health services and engaging parents in their children’s education. Laws and regulations improve the safety of our food supply, reduce environmental pollutants and protect against unintentional injuries involving all types of consumer products – yet they too are only partial solutions.

The use of marketing principles and practices in the private sector has been demonstrated to be among the most important sources of success in solving the core business problem of achieving organizational success (generating profits) through satisfying consumer wants and needs. Marketing goes beyond advertising and sales. When applied as intended, it becomes a systematic way for management to structure its relationships with consumers and stakeholders from the products and experiences it offers, the structure of the incentives and costs associated with them, and their accessibility to how they are promoted in the marketplace with an ever expanding palette of communication tools. This same marketing management approach should be adopted in the analysis, planning, implementation and sustainability of programs aimed at social problems.

Social marketing, the application of the marketing discipline to social issues and causes, provides a framework for developing innovative solutions to social problems that have long perplexed and frustrated us. It has emerged from business marketing practice as a social change tool uniquely suited to achieve social profits by designing integrated programs that meet individual needs for moving out of poverty, enabling health, improving social conditions and having a safe and clean environment. Marketing principles are embedded in such success stories as the Grameen Bank enabling poor people to earn a sustainable income in developing countries, reducing teenage smoking rates in the truth® campaign, improving children’s food choices and what they eat in schools through Team Nutrition and reducing childhood deaths from malaria though the distribution of insecticide-treated mosquito nets in endemic countries. Indeed, when we examine some of the more well-known and successful public health programs over the past three decades, the principles of social marketing are being applied by the US Agency for International Development, the Centers for Disease Control and Prevention, the National Institutes of Health and the Office of National Drug Control Policy among others.

Individuals in our society do not live in just a consumer or economic marketplace where monetary concerns and self-interest reign supreme and rational decision-making is believed to be the norm. People’s everyday lives include exposure to all types of ideas and behaviors, whether through their family and friends or through television and the internet. The recognition that these marketplaces of ideas and behaviors also exist, and are subject to forces such as proximity and access, incentives and costs, role models and social norms, health and digital literacy and the quality of their communications environment illuminates how programs that focus on only economic levers, or education, or laws and their enforcement fail to achieve all the social good that is intended. Similarly, understanding that individual and social change are products of a marketplace of ideas and behaviors that are, in turn, constantly being shaped by the activities of public, private and nonprofit sector actors means that all of these actors must become part of sustainable, long-term solutions and not merely bit players (or partners) in short-term campaigns – if they are engaged at all.

To move society forward in developing new ways of addressing old problems, I suggest that policy-makers in all three sectors of society that agree on areas of common concern – recognizing that there are many different concerns that involve often different sets of actors – begin to adopt these premises of a social marketing perspective in their work.

There must be a set of integrated activities that analyze, design for, implement and evaluate programs that specifically address (1) products, services and behaviors that will improve individual and social well-being; (2) realign incentives and costs to facilitate behaviors for the individual and social good; (3) create opportunities and improve access to beneficial products, services and places that encourage and support behavior change; and (4) employ state-of-the-science communication strategies and tools to promote and support positive change at all levels of society - individuals, families and other social networks, organizations and communities.

Programs should be audience-centric; that is, based on understanding the people to be served by the program, having insights into how they perceive the problem and possible solutions in the context of their everyday lives, and engaging them to be co-creators and eventual owners of relevant solutions.

Audience engagement, from who is sitting at the policy table to who is sitting across from a teacher, is both a core value and outcome for success. It becomes part of a common framework for understanding and implementing programs with population-wide benefits.

And finally, I look forward to a time when marketing becomes a lingua franca for all agencies involved in social change activities rather than the current balkanization of efforts by agencies that are fueled by their own unique frameworks and theories for how problems exist and how they should be solved. Bringing together public, private and nonprofit (NGO) sectors face this challenge; so too do multi-sector approaches that attempt to bring together agriculture, education, environment, healthcare, health promotion, transportation, housing, law enforcement and other actors. Until people and agencies share common frameworks for understanding and communicating with each other, do not expect much beyond blind men describing an elephant.

I know that in some quarters marketing as practiced in the commercial sector is sharply criticized. Yet marketing as it can be thought about and practiced for social change may be one way to have the types of multiple sector, integrated collaborations that are needed to solve many of the wicked social programs that have been intractable for too long for so many.

Image from Wikimedia Commons.