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American Journal of Public Health logoLink to American Journal of Public Health
. 2009 Dec;99(12):2123–2127. doi: 10.2105/AJPH.2008.155218

Reframing the Dissemination Challenge: A Marketing and Distribution Perspective

Matthew W Kreuter 1,✉, Jay M Bernhardt 1
PMCID: PMC2775768  PMID: 19833993

Abstract

A fundamental obstacle to successful dissemination and implementation of evidence-based public health programs is the near-total absence of systems and infrastructure for marketing and distribution.

We describe the functions of a marketing and distribution system, and we explain how it would help move effective public health programs from research to practice. Then we critically evaluate the 4 dominant strategies now used to promote dissemination and implementation, and we explain how each would be enhanced by marketing and distribution systems.

Finally, we make 6 recommendations for building the needed system infrastructure and discuss the responsibility within the public health community for implementation of these recommendations. Without serious investment in such infrastructure, application of proven solutions in public health practice will continue to occur slowly and rarely.

FROM 2003 TO 2008, THE American Journal of Public Health published 100 research papers about programs and policies that were found to significantly improve health or behavioral outcomes in areas including condom use, prenatal care, drug abuse, smoking, and obesity. Unfortunately, history tells us that few of these promising programs will be used outside a research setting. Fewer still will become ubiquitous in public health practice; those that do will take decades to achieve that status.1 We argue that the fundamental obstacle to successfully disseminating and implementing evidence-based public health programs is the near-total absence of systems and infrastructure to carry out marketing and distribution. This perspective is consistent with new dissemination and implementation models2 and recent calls to build greater delivery capacity to support the spread of evidence-based programs.3

WHAT IS A MARKETING AND DISTRIBUTION SYSTEM?

The ultimate dissemination goal for public health program developers is to get their evidence-based products into use by organizations whose job it is to deliver effective public health programs. Marketing and distribution systems are designed to meet this need; they bring products and services from development to use through a system of intermediaries.4 In the automobile industry, for example, much happens from the time a car rolls off a manufacturer's assembly line to the time it rolls into a buyer's driveway. Cars are packaged and shipped to a national network of local dealers, where they are cleaned, displayed, and advertised. Local sales agents are in place to provide information and test-drive experiences to potential buyers. Online sales systems provide similar functions for virtual customers. A financing system is in place to help customers get purchase loans. Repair shops and parts suppliers are widely available to service automobiles after purchase.

Collectively, this chain of intermediaries identifies potential users, promotes the product to them, provides them with easy access to the product through multiple channels, allows them to evaluate the product before acquiring it, helps them buy it, and supports the product after purchase.5 Without such systems, every producer would have to interact directly with every potential user to promote, distribute, and support every product. Such interaction would be impractical and inefficient, and it is rare in business practice.6

In customer-centered dissemination systems, marketing is used to increase demand for a product, and distribution infrastructure is put in place to deliver the product to potential users. Robert Woodruff, CEO of Coca-Cola in the 1930s, famously invoked the notion of customer-centered dissemination systems when he said that Coca-Cola products should always be “within an arm's reach of desire” for anyone who wanted them.7(p16-17) This principle became the cornerstone of Coca-Cola's marketing and distribution practices as they developed a worldwide system of local bottlers and vending machines to serve as intermediaries, guaranteeing close proximity between demand and supply.

Marketing and distribution are equally important in public health. We have produced effective products through research, but we have not invested in customer-centered marketing and distribution systems to bring these products to public health organizations when, where, and how they are needed. Such systems fulfill a range of critical operational functions that most program developers are ill-equipped to carry out, including:

  • Customer research and segmentation—collecting and analyzing data from potential adopting organizations and developing data-driven segmentation strategies to inform targeted marketing and distribution systems;

  • Packaging—ensuring that products can be easily and safely transferred, are attractive to potential users, include all information required for use, and are simple to set up and operate;

  • Promotion—segmenting potential adopters into homogeneous groups by product needs, clustering together the product types that appeal to each group (rather than disseminating products one by one), and increasing both awareness of and demand for available products;

  • Transfer—moving products from producer to distributor;

  • Distribution—ensuring convenience, access, and choice in acquiring products;

  • Inventory management—tracking and maintaining supply of products and ordering;

  • Sales—developing pricing strategy, negotiating price, processing payments, and evaluating sales;

  • Communication—developing product information for users and ensuring that appropriate information is delivered before, during, and after user acquisition of a product;

  • Training—teaching users and potential users how to use a product, and developing appropriate self-guided instructional materials to accompany the product;

  • Technical assistance—providing implementation support and ensuring availability of local agents who can assist in adapting product use to local conditions;

  • Customer service—ensuring rapid response to user needs and inquiries;

  • Product service—repairing products when broken and honoring warranties;

  • Coordination—ensuring that all intermediaries work harmoniously and adapt their functions to changing conditions, and evaluating their collective performance; and

  • Evaluation and data analysis—assessing all aspects of marketing and distribution and applying findings to maximize system effectiveness and efficiency.

The question is not whether these marketing and distribution functions are needed but rather who will perform them.5 In public health, this responsibility is largely unassigned. With a few notable exceptions (e.g., the National Vaccine Plan8 and the Centers for Disease Control and Prevention's Replicating Effective Programs and Diffusion of Effective Behavioral Interventions projects9,10), we lack coordinated systems to carry out these functions. Although some organizations may be well-positioned to execute some of these functions, there are far more gaps in the chain than links.

Contrast this situation with the vast infrastructure we have built to support research in public health. We have innumerable funders and funding mechanisms with highly coordinated systems for soliciting, processing, reviewing, and scoring research applications. We have peer-review systems for evaluating research findings from individual studies, and we have multiple structured processes for performing systematic evidence reviews. We have extensive population-health surveillance systems that describe health problems, provide a basis for research, aid in formulating hypotheses, and guide the evaluation of programs and policies. To better apply evidence-based programs in public health practice, we must make a significant investment in building a comparable marketing and distribution infrastructure.

WHAT GAPS NEED TO BE ADDRESSED?

To date, our attempts to bridge the gap between evidence and practice in public health have centered around 4 strategies: (1) increasing scientists' dissemination efforts, (2) assembling inventories of effective programs, (3) building partnerships for dissemination, and (4) increasing demand for evidence-based approaches among practitioners. All of these strategies make important contributions, but even if they were highly coordinated—and they are not—there would remain significant gaps to fill. An examination of these strategies from a marketing and distribution perspective underscores the need for dissemination systems.

Increasing Scientists' Dissemination Efforts

We have used a combination of education, incentives, and admonishments to encourage public health scientists who develop and test programs to also find ways to disseminate them. Of the current approaches, this is the most misguided. It is entirely appropriate to demand that researchers work with practitioners to design programs that can be sustained in practice conditions (e.g., designing for dissemination11) and to evaluate the programs in real-world settings.12 It is also appropriate to expect researchers to think strategically about how and by whom the programs they develop could be applied and to design their studies accordingly. But asking them to be central players in dissemination is unrealistic and inefficient. Scientists lack the necessary training, just as automobile engineers lack the training to deliver, sell, and service the cars they design. Also, public health scientists usually operate in organizational environments that lack the infrastructure and reward structure to motivate and support systematic dissemination.13

Assembling Inventories of Effective Programs

Several government health agencies have undertaken major initiatives to systematically review program evidence (e.g., the Guide to Community Preventive Services14), identify proven programs, and make them available to potential users through a single source (e.g., the National Cancer Institute's Research-Tested Intervention Programs15). Such services help potential users search more efficiently for effective programs by providing access to a variety of offerings from different developers through a single storefront. In some cases these services also allow users to seek training and technical assistance from program developers.

This major advance is a much-needed complement to the aforementioned educational efforts, but it still has important limitations. First, it is a passive approach to dissemination, which studies have shown to be ineffective.16 Second, researchers and developers are often reluctant to share their programs or commit to providing the training and technical assistance needed to support implementation by others.15 Third, poor packaging of these programs makes them less appealing and more difficult for potential adopters to use. Finally, and perhaps most important, awareness of these program registries among potential users is low.17 All of these gap areas are routinely addressed by marketing and distribution intermediaries.

Building Partnerships for Dissemination

Partnerships are critical to dissemination success.18,19 In public health, dissemination partners are usually chosen because they provide access to a target population of potential users, are trusted by those users, and have mechanisms in place to facilitate distribution of programs and services.20,21 But current partnership strategies can be improved in at least 3 ways. First, we should focus on a system of partners rather than a single partner because only the most basic of needs can be met by a single intermediary between the producer and user.4 In the specific case of disseminating public health programs, many partners can provide access to and trust among targeted end users, but far fewer can reasonably claim to also have the resources to readily distribute and support such programs.

Second, there is great inefficiency and a risk of partner fatigue when every developer of an evidence-based program is independently courting the same set of public health organizations to forge dissemination relationships for each program found to be effective. Finally, when the responsibility for building these partnerships falls solely on researchers and developers, there is a risk that dissemination will be unduly influenced by convenience—for example, by an investigator's limited set of contacts—rather than systematic audience analysis. As a consequence, dissemination will tend to take the form of isolated “science fair” projects rather than systematic, widespread distribution of programs that work.

Increasing Demand for Evidence-Based Approaches

Many public health practitioners prefer locally developed programs, even when they are not evidence based.22,23 Thus, a variety of workshops, training sessions, online and in-person courses, and self-guided manuals have been developed and delivered to increase awareness of and interest in using evidence-based interventions.24–26 Policy approaches have also required or encouraged practitioners to use evidence-based approaches.27 From a marketing perspective, increasing consumers' understanding and valuation of a product is critical to cultivating demand for it.28 Informed consumers will search for a desired product more effectively and efficiently than uninformed consumers.29 But consumers also respond negatively when a desired product is not readily available.30,31 Therefore, encouraging or requiring the use of evidence-based programs that are not readily available may have the unintended effect of increasing frustration rather than implementation.

HOW CAN WE DO BETTER?

We recommend 6 action steps for establishing marketing and distribution infrastructure to disseminate evidence-based public health programs and policies more efficiently and effectively: (1) promote programs strategically, (2) build distribution capacity, (3) develop a proactive, systematic process for identifying and obtaining proven programs that meet a priori standards of evidence-based effectiveness, (4) transform research-tested interventions into programs and products that are easy to adapt and use, (5) build a comprehensive system of user support, and (6) establish evaluation measures and processes.

Promote Programs Strategically

Audience research should be conducted to identify the universe of potential users for a product, understand their needs, create homogeneous user segments based on the types of programs they are likely to use, and target promotional activities accordingly. For example, in disseminating model tobacco-control policies, Americans for Nonsmokers' Rights distinguishes among those seeking to adopt a policy for their home, workplace, or community, then further targets these groups by describing current tobacco-control policy activities in their state.32

Build distribution capacity

For each user segment, distinct systems (or linked subsystems) should be established to give its members convenient access to a range of proven programs that they want or need. For example, distribution of all evidence-based programs designed for use in school settings might be coordinated through a single system, rather than having some in a tobacco-control system, some in an alcohol-abuse prevention system, and some in a physical-activity system.

Systematically Identify Proven Programs

The distribution systems described in action step 2 should be populated with all worthy programs, not just those whose developers went out of their way to share.

Transform Research-Tested Interventions

A team of seasoned marketers and public health practitioners should critically review and modify programs to maximize their readiness for use in practice settings. Intervention materials developed by researchers—who are notorious for being aesthetically challenged—must also be given the polish and professionalism users expect from other consumer products, and they must be packaged and presented to facilitate ease of use.

Build a Comprehensive System of User Support

Program users should have easy access to knowledgeable (and ideally local) agents who can provide timely technical assistance and support for adapting and implementing programs. For example, the National Cancer Institute's new National Outreach Network will have local staff in medically underserved communities across the United States helping organizations that serve disadvantaged populations to put science into practice to eliminate cancer disparities.33 Alternatively, just as health information systems now offer “live help” online to the information-seeking public,34 similar systems could be made available to provide assistance and support to those implementing proven programs.

Establish Evaluation Measures and Processes

All steps in the marketing and distribution process should be routinely measured, analyzed, and enhanced in a continuous cycle of quality improvement.

Some of the elements needed to implement these steps already exist. There are a growing number of proven programs, and we are getting better at identifying and vetting them. There are also many partner organizations—state and local departments of health, not-for-profit health and social service agencies, for-profit and nontraditional sector partners, and networks of health care providers—that reach thousands of potential program adopters and could be distributors or local agents to support implementation. But taking these steps will also require a new set of dissemination partners with specialized skills not available in most public health and research organizations.

Who will convene these partners and coordinate their efforts? The Centers for Disease Control and Prevention has demonstrated its ability to build effective delivery systems for vaccines, and it may be well-positioned to do the same for other public health programs. Its Prevention Research Centers program aims to connect the science of public health with the needs of communities and public health agencies, and its Cancer Prevention and Control Research Network seeks to increase dissemination and implementation of evidence-based cancer-control programs.35 Its National Center for Health Marketing shared similar goals.36

Large not-for-profit health organizations have extensive, well-established networks of local affiliates that could provide training and technical assistance to support implementation. Health foundations and other philanthropic organizations could fulfill their health-improvement missions by helping create, coordinate, or support systems for disseminating and implementing evidence-based programs.37 This could also be an opportunity for social entrepreneurs, who create social value by developing innovative solutions for problems that existing markets and institutions have failed to solve.38,39

Of the main types of public health innovations that might be disseminated—programs, policies, processes, and principles40—we have primarily focused on programs and policies that can be “packaged” for users to adapt and apply. But the systems and infrastructure we advocate should apply equally well to disseminating evidence-based processes and principles.

Marketing and distribution systems have received little attention in public health conversations about putting science into action. If the dissemination and implementation challenge is reframed to reflect this perspective, and if investments are made in system infrastructure to execute our recommendations, public health practice could be transformed.

Acknowledgments

Funding from the National Cancer Institute's Centers of Excellence in Cancer Communication Research program (CA-P50-95815) and the Centers for Disease Control and Prevention's Cancer Prevention and Control Research Network (US48 DP000060) helped support this work.

The authors thank Ross Brownson, Charlene Caburnay, Larry Green, Jeffrey Harris, Martha Katz, Marshall Kreuter, and Ambar Rao, for excellent reviews of drafts of the article. We also thank Jennifer Morgan for assistance with preparing the article.

Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention or the United States Department of Health and Human Services.

Human Participant Protection

No protocol approval was needed because no human participants were involved in this endeavor.

References

  • 1.Balas E, Boren S. Managing Clinical Knowledge for Health Care Improvement. Yearbook of Medical Informatics 2000: Patient-Centered Systems Stuttgart, Germany: Schattauer; 2000 [PubMed] [Google Scholar]
  • 2.Wandersman A, Duffy J, Flaspohler P, et al. Bridging the gap between prevention research and practice: the Interactive Systems Framework for Dissemination and Implementation. Am J Community Psychol 2008;41:171–181 [DOI] [PubMed] [Google Scholar]
  • 3.Orleans CT. Increasing the demand for and use of effective smoking-cessation treatments: reaping the full health benefits of tobacco-control science and policy gains—in our lifetime. Am J Prev Med 2007;33(suppl 6):S340–S348 [DOI] [PubMed] [Google Scholar]
  • 4.Coughlan A, Anderson E, Stern L, El-Ansary A. Marketing Channels Upper Saddle River, NJ: Pearson Prentice Hall; 2006 [Google Scholar]
  • 5.Kotler P. Marketing Management Upper Saddle River, NJ: Prentice Hall; 2000 [Google Scholar]
  • 6.Andreasen A. Marketing Social Change: Changing Behavior to Promote Health, Social Development, and the Environment San Francisco, CA: Jossey-Bass; 1995 [Google Scholar]
  • 7.Walton MS. Generating Buy-in: Mastering the Language of Leadership New York, NY: AMACOM; 2004 [Google Scholar]
  • 8.US Department of Health and Human Services. The Mission of the National Vaccine Program and the Purpose of the National Vaccine Plan Washington, DC: US Dept of Health and Human Services; 2008 [Google Scholar]
  • 9.Neumann M, Sogolow E. Replicating effective programs: HIV/AIDS prevention technology transfer. AIDS Educ Prev 2000;12(suppl 5):35–48 [PubMed] [Google Scholar]
  • 10.Collins C, Harshbarger C, Sawyer R, Hamdallah M. The Diffusion of Effective Behavioral Interventions Project: development, implementation, and lessons learned. AIDS Educ Prev 2006;18(4)(suppl A):5–20 [DOI] [PubMed] [Google Scholar]
  • 11.Klesges L, Estabrooks P, Dzewaltowski D, Bull S, Glasgow R. Beginning with the application in mind: designing and planning health behavior change interventions to enhance dissemination. Ann Behav Med 2005;29(2):66–75 [DOI] [PubMed] [Google Scholar]
  • 12.Green L, Glasgow R. Evaluating the relevance, generalization, and applicability of research: issues in external validation and translation methodology. Eval Health Prof 2006;29(1):126–152 [DOI] [PubMed] [Google Scholar]
  • 13.Lomas J. Diffusion dissemination, and implementation: who should do what? Ann N Y Acad Sci 1993;703:226–237 [DOI] [PubMed] [Google Scholar]
  • 14.Task Force on Community Preventive Services. The Guide to Community Preventive Services: What Works to Promote Health? New York, NY: Oxford University Press; 2005 [Google Scholar]
  • 15.Kerner J, Guirguis-Blake J, Hennessy K, et al. Translating research into improved outcomes in comprehensive cancer control. Cancer Causes Control 2005;16(suppl 1):27–40 [DOI] [PubMed] [Google Scholar]
  • 16.Bero L, Grilli R, Grimshaw J, Harvey E, Oxman A, Thompson M. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ 1998;317(7156):465–468 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Hannon PA, Fernandez ME, Williams R, Mullen PD, Escoffery C, Kreter MW, et al. Cancer control planners' perceptions and use of evidence-based programs. J Public Health Manage Pract In press [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Israel B, Schulz A, Parker E, Becker A. A review of community-based research: assessing partnership approaches to improve public health. Annu Rev Public Health 1998;19:173–202 [DOI] [PubMed] [Google Scholar]
  • 19.Best A, Stokols D, Green L, Leischow S, Holmes B, Bucholtz K. An integrative framework for community partnering to translate theory into effective health promotion strategy. Am J Health Promot 2003;18(2):168–176 [DOI] [PubMed] [Google Scholar]
  • 20.Dearing J. Improving the state of health programming by using diffusion theory. J Health Commun 2004;9(suppl 1):21–36 [DOI] [PubMed] [Google Scholar]
  • 21.Dearing J, Maibach E, Buller D. A convergent diffusion and social marketing approach for disseminating proven approaches to physical activity promotion. Am J Prev Med 2006;31(suppl 4):11–23 [DOI] [PubMed] [Google Scholar]
  • 22.Green L, Kreuter M. Community coalitions against substance abuse and their use of best practices. Am J Prev Med 2002;23(4):303–306 [DOI] [PubMed] [Google Scholar]
  • 23.Hallfors D, Cho H, Livert D, Kadushin C. Fighting back against substance abuse: are community coalitions winning? Am J Prev Med 2002;23(4):237–245 [DOI] [PubMed] [Google Scholar]
  • 24.Brownson R, Diem G, Grabauskas V, et al. Training practitioners in evidence-based chronic disease prevention for global health. Promot Educ 2007;14(3):159–163 [PubMed] [Google Scholar]
  • 25.Dreisinger M, Leet L, Baker E, Gillespie K, Haas B, Brownson R. Improving the public health workforce: evaluation of a training course to enhance evidence-based decision-making. J Public Health Manag Pract 2008;14(2):138–143 [DOI] [PubMed] [Google Scholar]
  • 26.O'Neall M, Brownson R. Teaching evidence-based public health to public health practitioners. Ann Epidemiol 2005;15(7):540–544 [DOI] [PubMed] [Google Scholar]
  • 27.Fairbrother G, Hanson K, Friedman SR, Butts G. The impact of physician bonuses, enhanced fees, and feedback on childhood immunization coverage rates. Am J Public Health 1999;89(2):171–175 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Alba J, Hutchinson J. Dimensions of consumer expertise. J Consum Res 1987;13(4):411–454 [Google Scholar]
  • 29.Bettman J, Park C. Effects of prior knowledge and experience and phase of the choice process on consumer decision processes: a protocol analysis. J Consum Res 1980;7:234–238 [Google Scholar]
  • 30.Campo K, Gijsbrechts E, Nisol P. Dynamics in consumer response to product unavailability: do stock-out reactions signal response to permanent assortment reductions? J Bus Res 2004;57(8):834–843 [Google Scholar]
  • 31.Fitzsimons G. Consumer response to stockouts. J Consum Res 2000;27:249–266 [Google Scholar]
  • 32.Americans for Nonsmokers' Rights Americans for Nonsmokers' Rights Web site. Available at: http://www.no-smoke.org/index.php. Accessed January 21, 2009
  • 33.Robinson B. NCI plans to expand outreach through community-based research programs. NCI Cancer Bull 2009;6(16):9 [Google Scholar]
  • 34.National Cancer Institute LiveHelp Web site. Available at: https://cissecure.nci.nih.gov/livehelp/welcome.asp. Accessed January 21, 2009
  • 35.Harris J, Brown P, Coughlin S, et al. The Cancer Prevention and Control Research Network. Prev Chronic Dis 2005;2(1). Available at: http://www.cdc.gov/pcd/issues/2005/jan/04_0059.htm. Accessed January 21, 2009 [PMC free article] [PubMed] [Google Scholar]
  • 36.Bernhardt J. Improving health through health marketing. Prev Chronic Dis 2006;3(3). Available at: http://www.cdc.gov/pcd/issues/2006/jul/05_0238.htm. Accessed January 21, 2009 [PMC free article] [PubMed] [Google Scholar]
  • 37.Porter M, Kramer M. Philanthropy's new agenda: creating value. Harv Bus Rev 1999;77(6):121–130 [PubMed] [Google Scholar]
  • 38.Austin J, Stevenson H, Wei-Skillern J. Social and commercial entrepreneurship: same, different or both? Entrepreneurship Theory Pract 2006;30(1):1–22 [Google Scholar]
  • 39.Peredo A, McLean M. Social entrepreneurship: a critical review of the concept. J World Bus 2006;41(1):56–65 [Google Scholar]
  • 40.Saul J, Wandersman A, Flaspohler P, Duffy J, Lubell K, Noonan R. Research and action for bridging the gap between prevention research and practice. Am J Community Psychol 2008;41(3–4):165–170 [DOI] [PubMed] [Google Scholar]

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