CHAPTER 8 Social marketing approaches to health promotion
In Chapter 8 we move further along the continuum of health promotion approaches outlined in Chapter 1 and examine some of the social marketing approaches to health promotion. The aim of social marketing strategies in health promotion is to change health behaviour. The strategies are often criticised because they focus on individual action and not necessarily the context of people’s lives, which may be a barrier to change. Social marketing approaches are useful when there are clear links between them and other approaches which are grounded in the social setting.
the application of commercial marketing technologies to the analysis, planning, execution and evaluation of programs designed to influence voluntary or involuntary behaviour of target audiences in order to improve the welfare of individuals and society.
Social marketing has produced important gains in raising awareness of certain diseases and prevention of those diseases. Clearly we must address diseases that cause human suffering and premature death. Social marketing is an important addition to the toolkit of skills, especially when used in combination with other approaches at community level. However, by only focusing on specific illnesses or using selective approaches to health promotion we risk perpetually attempting to address the end result of the problem instead of addressing the root causes of the diseases themselves or the social conditions that perpetuate disease and other suffering.
The principles of social justice, equity, community control and working for social changes that impact on health and wellbeing do not necessarily form the foundation of social marketing. The health promotion approaches at this end of the continuum have usually constituted selective Primary Health Care because they have concentrated on prevention of diseases and conditions based on epidemiological evidence, although more recently, social marketing strategies have been designed to take account of the broader environment and to address issues of social change.
Social marketing involves the application of marketing approaches, developed to sell commercial products, to ‘sell’ health-enhancing ideas. The term ‘marketing’ sometimes has negative connotations for people because they don’t approve of the tactics or priorities used by some industries (Donovan & Henley 2003). How social marketing is defined has been broadened to encompass strategies to influence changes to the environment or context of people’s lives, such as through manufacturing, which will make it easier for people to make a health protective choice. Thus, a good understanding of marketing can be a valuable asset to health promotion practitioners.
Social marketing is built on recognition of the powerful influence of the mass media on the choices that people make. Social marketing really came into the public agenda in Australia in the 1970s with the use of ‘Norm’ and the ‘Life. Be in it’ campaign. This occurred following the recognition of the relationship between so-called ‘lifestyle’ behaviours and epidemiological health outcomes, and the realisation that health promotion practitioners were not necessarily the most effective way of communicating health messages to wider audiences (Egger et al 1993).
While social marketing is usually associated with use of the mass media, it can be used in any communication medium. Social marketing aims to influence people’s values or attitudes about a social issue that puts health at risk or to influence behaviour by encouraging individuals to make healthy choices. It therefore uses the mass media as an information tool to advise or motivate individuals or companies. Social marketing is underpinned by behavioural psychology — understanding what motivates people and how they can be persuaded to refrain from something they enjoy, or to make a change in their setting or products, for the sake of possible long-term health gains (Donovan & Henley 2003). While they are seen as selective Primary Health Care approaches because they focus on individual behaviour change, social marketing strategies are usually aimed at a large well-defined audience. At the national level, social marketing is an example of how national governments might become involved in health promotion. The focus of the campaign and development of the strategy may or may not be underpinned by Primary Health Care philosophy. An integrated public health approach is demonstrated in health promotion strategies to reduce smoking in Victoria. Social marketing has been used very widely through the QUIT campaign of Cancer Council Victoria. Different messages have been used over the years, usually emphasising the personal, physical or wider social costs of the complications of smoking. These social marketing approaches, clearly emphasising individual behaviour change, have been supported by personal education and support services (on the telephone QUITline), and progressive legislative changes, including increasing tax on cigarettes, restrictions on sale of cigarettes to minors and restrictions on smoking in public places.
As the term ‘social marketing’ suggests, a significant function, in addition to providing health information, is the ‘selling’ of a social idea; bringing about gradual social change. For example, the concept of ‘safe sex’ being everyone’s responsibility has widely permeated society following the initial publicity about the spread of HIV and AIDS. Previously, the topic of sexual behaviour was considered to be a personal and private matter, not discussed in public forums. See Insight 8.1 for a summary of a health promotion project with a social marketing focus. The ‘WayOut’ (Insight 8.1) project won a 2004 State Government of Victoria Public Health excellence award for innovation in the capacity-building category.
Advertising: perhaps most notable as well-funded national campaigns about key social health issues, such as safe driving and smoking cessation. Campaigns conducted by the Transport Accident Commission (TAC), Land Transport New Zealand (LTNZ) and the Cancer Council — QUIT and SunSmart — have achieved prominence.
Publicity materials: mass media campaigns that have a memorable logo or catchy slogan have promoted wide awareness. For example, the red tick of approval from the Heart Foundation for ‘heart safe’ foods (www.pickthetick.org.nz/TickProducts/products.fruitveges.html), or up until recently ‘Slip Slop Slap’ for sun protection — Cancer Council Australia (www.cancer.org.au/cancersmartlifestyle/SunSmart/Campaignsandevents/SlipSlopSlap.htm).
Edutainment: this is an under-recognised role of the media in promoting or changing social awareness about various issues. Specific themes, such as respect for people suffering mental health problems, or the issue of domestic violence, and violence against women are crafted into television series and films. Health promotion professionals provide advice in script development. For an excellent example of the successful use of edutainment in social marketing see the comprehensive description of the Soul City multimedia edutainment program that was developed in South Africa in 1994 and has now run for eight series. Soul City is a dynamic and innovative multi-media health promotion and social change project. Through drama and entertainment Soul City reaches more than 16 million South Africans. ‘Through its multi-media and advocacy strategies the program aims to create an enabling environment empowering audiences to make healthy choices, both as individuals and as communities’ (Goldstein et al 2004; Soul City available at: www.soulcity.org.za/). Detailed evaluation of this program and the associated resources has demonstrated the effectiveness of the approach when the focus moves away from individual behaviour to interpersonal and social change (Scheepers et al 2004).
Those who support social marketing in health promotion believe that it can contribute positively if it is part of an integrated health promotion program and if too much is not expected of it, given the context in which it is being used. Social marketing activities may be aimed at individuals, networks, organisations, manufacturers and planners and at societal levels. They are most effective when they are combined with interpersonal and community-based events to enhance health options. Media interventions alone, without complementary health education and community development approaches, are likely to have little impact on behaviour (Egger et al 2005). It is important to bear in mind that the advertising industry itself conducts considerable market research and targets its advertising very specifically to the groups it wishes to convince. Health workers at a
The WayOut project works across rural Victoria to raise awareness about the needs of same sex attracted young people and homophobia. Studies show that life for same-sex attracted young people can be very difficult. Since commencement, our project was committed to young people’s participation in the design and delivery of services. Through networks in one shire we established our first committee of young people, all aged under 25 years. The group decided that it would be open to all young people, irrespective of their sexuality, who shared our aim of challenging homophobia. Same-sex attracted young people are not necessarily identifiable and, indeed, may be going to great lengths to remain invisible, particularly in rural areas.
The young people in our committee decided that the best way to reach others was to ‘flood’ the environment with merchandise that included positive messages about sexual diversity and/or slogans to challenge homophobia. The group was confident that young people ‘love free stuff’ and we could get our messages out by distributing free stickers, T-shirts and posters etc. The group subsequently designed an innovative range of products and they proved enormously successful.
We have also produced pens, badges and wristbands with the ‘We’re all human, Fight Homophobia’ slogan and an information card for same-sex attracted young people, their family and friends. We have made a 10-minute DVD/video called ‘Homophobia Exposed’ which is being used as a resource to raise awareness in schools, community groups and a range of human service agencies. Our latest product is a cap with the slogan ‘Make Homophobia History’ printed on the front. We have now formed partnerships with other similar youth groups in rural Victoria to share our learnings and now they are also designing their own T-shirts, stickers and wristbands.
(Written in collaboration with Sue Hackne, WayOut Rural Victorian Youth and Sexual Diversity Project, Cobaw Community Health, Kyneton)
local level simply do not have the resources or the skills to match these activities. This is an important point because it alerts health workers to the problems inherent in trying to emulate (and undo) the larger campaigns run by the advertisers. Local initiatives will have more impact when they are based on thorough knowledge of the prospective audience (John-Leader et al 2008; Nelson et al 2008). Added impact can be gained if they can be planned to coincide with a national media campaign about the issue, or a national ‘awareness week’. Calendars of national campaigns are available and can be a valuable resource to assist planning to make the greatest impact locally. However, at other times, especially where the budget is small, or it is a specific local issue, workers may need to get their message across by developing their own media resources. It may be more appropriate for a health worker to draw on the expertise of a graphic artist or advertising agency than to prepare materials ‘in-house’; the combined expertise will be more successful than acting alone.
National awareness campaigns can be ‘tagged’ onto local community-driven activities, thus gaining greater awareness of the issue, enhancing the credibility of a local project and bringing efficiencies in program planning.
Knowledge is itself enabling and empowering. Thus, social marketing messages should provide an ‘action plan’ informing the person what to do if they decide to take action on the issue (see Chapter 7).
At a national level social marketing can enhance people’s understanding of complex issues using short, accessible and memorable messages, especially to groups who may not access more traditional health education resources.
A significant challenge for social marketing approaches is that most commercial products offer instant gratification (and long-term risk), whereas the benefits of health behaviour change are often delayed. One recent attempt to help balance the influence of advertising unhealthy and healthy products in Australia has been the banning of some advertising; most notably tobacco advertising. However, for an impact to be made on advertising unhealthy products overall, there would need to be considerable legislative control of advertising. This would probably be vigorously opposed, because it would be regarded as seriously eroding people’s expectations about freedom of speech and freedom of choice. Targeted health behaviours are often at odds with social pressures. For example, harm minimisation approaches contrast with strong teenage peer pressure to drink to excess.
Legislative control of advertising raises ethical questions about the right of the state to take over the life of the individual. This is by no means a simple issue; after all, it is argued that mass media advertising itself manipulates people’s free choice, often beyond recognition (Andreasen 2001, 2002). The current debate about banning television advertising of unhealthy foods designed specifically to appeal to children, in the after-school programming time, is an example of this dilemma for policy-makers. In addition, health risk behaviours are often complex and involve several determinants, as we have outlined in earlier chapters. Short messages are necessarily simplistic and cannot account for the complexities in individual situations.
Millions of dollars are spent annually on advertising unhealthy, but profitable, products. Health workers, even when they are supported by national media campaigns, are in no position to match the extent to which unhealthy products are marketed — they simply do not have the same financial resources at their disposal. However, social marketing strategies can be a form of advocacy directed at policy-makers, manufacturing, commercial and government systems, and social structures just as readily as they can be directed at the individual (Egger et al 2005). The very successful HomeSafe.WorkSafe social marketing campaign for WorkSafe Victoria is an example of social marketing directed at commercial enterprises and individuals. It emphasises the responsibility of employers to provide safe working conditions for employees, and is supported by workplace protection policies (WorkSafe Victoria 2008).
Social marketing can be used effectively in a way that supports Primary Health Care work and is empowering for those it is designed to assist. For example, it can be used as a reminder of healthy behaviours and can therefore be supportive of other health promotion strategies (Mckenzie-Mohr 2000). It can inform the public about the importance of new health policy or legislation at the same time that those changes are being developed. It can be used to influence manufacturing, such as in safer vehicle design. The principles of Primary Health Care, however, are not an inherent component of social marketing and so it is up to governments and each individual health worker to ensure that he or she uses social marketing in a way that supports the principles of Primary Health Care.
The whole notion of social marketing does not sit comfortably with everyone. The tactics advertising companies use are often held to be unethical because they are based on the idea of influencing people’s choices, often without their awareness. Using the same tactics, and therefore trying to beat advertisers at their own game, does have some ethical problems (Andreasen 2001).
Much media advertising is built on unhealthy stereotypes of people, and much social marketing seems to accept these unquestioningly, rather than challenge them. There is, therefore, much work to be done in challenging these stereotypes, which themselves can contribute to narrow views of health and normality and reduced feelings of self-worth in individuals. If social marketing builds on these stereotypes, rather than challenging them, the overall health benefit from any messages may be limited (Downing 2008).
Stereotyping — in order to generate wider appeal the ‘ideal’ type is used (young, blond, beautiful). The ‘target’ audience for the message may not associate themselves and their situation with the message.
It may ignore the social, economic and environmental determinants of health. Messages are usually short and cannot accommodate wider social issues. This has potential to reinforce the disadvantage of disadvantaged groups, and raises the potential of ‘victim blaming’ (discussed in detail in Chapter 2).
Successful social marketing campaigns achieve their aim of creating awareness of an issue or bringing about change because they understand the characteristics of their audience; their knowledge, attitudes, values and beliefs. Gathering information to clearly understand the audience enables the strategy to be specifically targeted at a small, fairly homogenous priority audience. The aim is to address and build on existing knowledge and beliefs and to correct misconceptions that are impeding adoption of healthier actions. Using a planning model, such as the Health Belief Model (see Chapter 7) at this stage of planning will enable a broad understanding of the audience segment. Good preparation, making use of research data and pilot-testing ideas with the audience, such as using focus groups, is essential to ensure the expected effects are achieved (Nelson et al 2008). Understanding the characteristics of a sub-set of the wider audience, who have relevant characteristics in common, and directing the message to them, will have more impact. ‘Segmenting’ the audience in this way will mean the strategy is likely to ‘reach’ the priority group, saving money and effort entailed in a ‘one-size-fits-all approach’, and it will help prevent the possibility of failing to engage with the group(s) you want to reach most (Egger et al 2005; Kotler et al 2002).
Who is your primary audience? Outlined below are the key things that need to be known about an audience in order to create the right message for them. For social marketing at social or policy levels, the themes would need to be modified accordingly.