Social Marketing and Health Communication: From People to Places

Many of the significant challenges we face in public health require that individuals change their behavior as part of the solution. Barriers to behavior change, whether known or unidentified, compound these challenges even more. As guest editors of this issue, we propose that the complementary use of social ecological theory and robust social marketing practice offers significant promise to overcome these impediments to improving the public's health.

We know that people make decisions—healthy or not—within the context of the social and cultural environment in which they live. If people cannot find a safe environment in which to exercise, they probably won't. If they cannot afford fresh fruits and vegetables, they can't eat them. If condoms are socially unacceptable, they won't be used. Social ecological theory is one important framework that offers insight into how and why these behaviors occur. The theory identifies multiple levels of influence (intrapersonal, interpersonal, social, environmental, and institutional)¹ and employs a variety of disciplines and perspectives in an effort to understand and address complex public health problems.

Social marketing is an applied approach that fits well within this theoretical perspective. The approach uses strategies from commercial marketing, but focuses on how consumers interact with services and products that promote health. The fundamental axiom in social marketing is the notion of voluntary exchange: that individuals adopt products, ideas and behaviors from which they expect to benefit.² The combined approaches of social marketing and social ecological theory focusing on people and places can result in stronger and more permanent behavior changes.

SOCIAL MARKETING MIX

In addition, social marketing offers a model that can help systematize organizational responses to address public health challenges. The underlying premise is that there are many activities that an organization can use to influence behavior change, and for maximum effect they should be carefully designed in an integrated fashion. These activities are categorized into primary elements, sometimes called the “marketing mix,” to constitute a comprehensive marketing plan. These elements are called the 4 P's: product (including services, behaviors, and policy changes), price (what the consumer must “give up” to change), place (environmental and societal context in which health decisions and behaviors occur), and promotion (the provision of information and the appeal to the consumer emotion that makes them want to engage in healthy behaviors). This basic model has been extended to include other “P's” which can also impact intervention outcomes, such as policies, partners, packaging, and even purse strings.³

Scientific principles, theories, and methods from the fields of health communication and social marketing are increasingly being applied to improve public health.⁴ Contributing to the rigor of this applied, multidisciplinary area of practice is the incorporation of tested methods from commercial and cause marketing. A central tenet of these intervention approaches recognizes that changing complex behaviors starts with multiple levels of influence: addressing barriers in the environment, enabling policies and laws, shifting social norms, and adapting to the context in which people live to support the adoption of new, healthy behaviors. This approach goes beyond the capacity of traditional education or communication methods, and must include sufficient support and resources to be successful.

As a society, we often support contextual changes to make our environment safer for ourselves and our children: we install guard rails, we pass seat belt laws, we provide subsidized immunizations, we regulate safe food and water. In some cases, we support policies that restrict our behavior or require we pay for risks we take, such as cigarette and alcohol regulations and taxes. When public action or support is necessary, understanding the influences on the audience is essential, even when information itself is the “product.” Koehly et al. address the relevance of understanding the audience—in this case families at risk for hereditary cancer—by describing the characteristics of health information gatherers, disseminators, and blockers.⁵ Understanding how people gather information, and whether they use it to influence their family's health, can provide critical insights informing our approach to health behavior change within families.

FOR THE PEOPLE

The focus on audience is a basic principle of social marketing—given the differences in attitudes, preferences and behavior, each of the P's should be designed with the target audience in mind. Romer et al. provide an example of the importance of audience perspective at the intersection of cultural and environmental contexts.⁶ The authors examine the unique positive contribution of mass media within an HIV prevention campaign for high-risk, sexually active African American adolescents, while addressing specific concerns or perceptions (often misconceptions about condoms and their use). As in many marketing interventions, the segmentation strategy specifically addresses social norms and desires of the cultural subgroup, and this example uses drama and storytelling to extend the relevance and power of the message. The importance of applying the social marketing mix for the audience is universal: Rimal et al. also explore specific consumer perceptions in the global context of risk and efficacy perceptions toward HIV prevention in Malawi.⁷

Bridging the gap between understanding the audience, and testing approaches to the marketing mix is exemplified in the study by Kharbanda et al.⁸ of parental readiness for text message immunization reminders. In this case the “product”—easy, timely and helpful reminders about immunizations—was designed to fit the busy and hectic lives of parents. The authors study assumptions about messages, attitudes, and place (in this case texting to cell phones) for the product. Gollust et al. study the polarizing effect of news media messages about the social determinants of health, a reminder that well-intentioned health promotion messages can have negative consequences.⁹ The medical ethic of “do no harm” should also be applied by those in communication and marketing, through rigorous evaluation at both the formative and summative levels.

In applied public health communication, there is often over-attention to one of the P's—promotion. One social marketer describes this fault as the “un-4P's: PSAs, pamphlets, posters and publicity.”¹⁰ Communication campaigns are indeed very important and effective, as illustrated by Durkin's work describing how exposure to a mass media campaign helped to reduce disparities in smoking cessation among socioeconomic subgroups. However, they are seldom sufficient.¹¹ The positive results of using a rich and integrated marketing mix is demonstrated by all kinds of organizations, and public health professionals could make more progress by applying these same techniques to persistent health problems such as obesity.¹² The commercial marketing sector invests heavily in touting the “price” benefits of inexpensive fast food to consumers. Public health needs more well-reasoned and tested application of the marketing mix within comprehensive healthy eating campaigns, acknowledging the “price” of not eating healthy.

PUTTING PREVENTION IN PLACE

“Place” is perhaps an especially underutilized component of the marketing mix. Dodge et al.¹³ studies the effects of a school-based campaign promoting prevention and screening for STIs. Extending the reach of a prevention campaign through targeted media to a neglected area can also significantly increase awareness and may be especially helpful to the marketing mix. Kreuter and Bernhardt call for an increased focus on customer-centered distribution to increase the translation of science to practice, highlighting a conceptual and practical distinction between the common health communication focus on information-centered dissemination and the audience-centric emphasis of social marketing.¹⁴

Recognizing the societal context of many public health problems—and implicitly acknowledging the social nature of solutions—is an important step toward making real progress in improving health. The strengths of the social ecology and social marketing approaches are realized by understanding their interaction and complementary nature, through the focus on the social aspects of their respective models. Furthermore, they offer specific strategies for the application of systems thinking in public health, which is arguably another powerful broad framework and is based on the assertion that phenomena should be considered in the context of relationships with each other and with other systems, rather than in isolation. The effectiveness of social marketing for public health will depend on how well public health practitioners can consistently adopt and improve the relevant principles and techniques to the realities of public health. Within the framework of social ecology, the tools of health communication and the social marketing approach can help to resolve long-term, seemingly intractable problems of public health.