Social Marketing and Obesity

Dawn M Miller. Encyclopedia of Obesity. Editor: Kathleen Keller. Volume 2. Thousand Oaks, CA: Sage Publications, 2008.

Social marketing involves the adaptation of highly successful commercial marketing principles to promote health by effecting behavioral change in members of a target population. Social marketing is not a theory by itself, but rather draws upon theories and models from the behavioral and social sciences for understanding and influencing human behavior. These theories are useful starting points because the underlying causes of health problems are often rooted in individual behaviors.

While the goal of commercial marketing is to generate a profit from the given product or service, social marketing goals are organized around promoting health for the greater good. Social marketing campaigns have been successfully employed to address health concerns such as infant mortality, smoking cessation, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), and seat belt use. Social marketing is differentiated from “top-down” health promotion and communication programs by its incorporation of in-depth research with target audience members (a consumer-driven focus) and an ongoing process of program evaluation (rather than only at the beginning and end of an intervention). In addition, the target audience of social marketing has expanded to include “upstream” policy makers and organizations in order to facilitate an environment that removes barriers to and supports behavioral change. Obesity-related social marketing campaigns typically encourage target audience members to adopt healthier eating practices and increase physical activity levels.

While these two factors are cited as the main contributors to obesity, environmental, genetic and biological mechanisms are still under investigation as related factors. Because obesity is a complex health issue, social marketers will be challenged in new ways as they attempt to address this public health problem.

History and Key Components

Social marketing as a discipline began in the 1970s when Philip Kotler and Gerald Zaltman suggested that the same principles used by marketers to sell products could be applied to promoting ideas and behaviors. While marketers in the 1950s were considering application of the techniques to political and social themes, others were concerned that marketing might be used for social control and propaganda. By the 1960s, however, as public health policy began to shift from a treatment-focused model to one of disease prevention, health education campaigns, particularly in developing countries, began to incorporate commercial marketing techniques. By the 1980s, social marketing as an approach in promoting public health became widespread.

Social marketing utilizes an adaptation of the four P’s from commercial marketing: product, price, place, and promotion. In social marketing, the product can be a tangible item, but more often, it is the behavior (e.g., smoking cessation), service (e.g., preventive screenings), or idea (e.g., seat belts save lives) that individuals in the target audience are encouraged to adopt or endorse. Price usually equates to financial cost in commercial marketing, but in social marketing, price also pertains to the time, effort, or what must be given up to obtain the product.

Changes in attitudes or behaviors often require a concerted effort and long-term commitment on the part of members of the target audience. The exchange theory in marketing is relevant here in that when consumers enact a behavior (purchasing an item or service, for example, at a particular price), the payback (receipt of that item or service) takes place simultaneously or shortly thereafter. When an individual changes behavior in response to a social marketing campaign, the payback may take place months or years later, if at all.

Furthermore, when perceived costs exceed perceived benefits, individuals are unlikely to make behavior changes. The third component, place, describes how, when, and where the product can be obtained. Finally, promotion pertains to disseminating messages and information through channels such as advertising, the internet, or in community and family settings and peer-to-peer groups.

In addition to the four P’s from commercial marketing, social marketing incorporates additional P’s: publics, positioning, policy (or politics), partnership, and purse strings. Social marketers need to reach many different audiences, so they must take into account multiple publics. This includes external publics, or members of the target audience, and internal publics, individuals involved with the approval, funding, or implementation of the program. Positioning refers to how members of the target audience perceive the social marketing product in relation to other competing products and messages in the marketplace.

Social marketers must have a good understanding of the competition and be able to clearly demonstrate compelling benefits that will result from a change in behaviors, attitudes, or beliefs. Policy (or politics) is important to social marketers because while a program may be successful in bringing about behavior change in the short term, long-term success may depend upon sociocultural and political environments that support new behaviors. This often requires policy change. In addition, because health issues are complex and difficult for a single agency to address by itself, partnership is another key success component. This may mean partnering with other organizations with similar goals. Finally, purse strings (budgetary restrictions) play a large role in the design, implementation, and maintenance of social marketing campaigns because many organizations rely on limited funding from grants or donations.

Research and Evaluation are Fundamental

Unlike more traditional health promotion campaigns in which research is conducted at the beginning of an intervention and again at the end to evaluate outcomes, research and evaluation are the foundations of social marketing and should be engaged throughout the life of the campaign. Social marketing research is consumer driven, and formative research in the beginning stages assists in identifying the target audience, choosing messages that will resonate with the audience, and selecting the most appropriate channels for communicating those messages.

Research can illuminate changes that should be made during the program (process evaluation), and provide evidence of whether the program is achieving its objectives (outcomes evaluation). Ideally, the research should consist of both quantitative and qualitative methods. Quantitative methods, such as analysis of existing data and the conduct of surveys, for example, answer what is happening. Quantitative methods produce data generalizable to a larger population and are appropriate for conducting needs assessments or evaluating outcomes. Qualitative methods include in-depth interviews, ethnographic observation, focus groups, and informal conversations. Qualitative data can reveal why something is happening. Qualitative methods are well suited for uncovering target audience perspectives and understanding meanings and behaviors. Primary research (collecting the data firsthand) and secondary research (utilizing existing sources of data) can be accomplished using quantitative or qualitative methods.

Steps in Social Marketing

The process of social marketing involves several major steps: planning and strategy, message and materials development, pretesting, program implementation, and evaluation and feedback. The planning and strategy phase consists of gaining an in-depth understanding of the target audience, segmenting that audience, and developing the campaign strategy. Formative research in the planning stage ideally consists of both quantitative and qualitative methods using primary and secondary research sources to understand how target audience members make health-related decisions. Because the target audience is likely to be a heterogeneous mix of individuals who respond in different ways to different messages, social marketers must segment their intended audience by targeting subgroups based on common-ground characteristics. Segments have typically been grouped based on factors such as age, geographic location, race/ethnicity, gender, attitudes, or by behavior (e.g., smokers vs. nonsmokers). However, other factors such as attitudes and beliefs, lifestyle, leisure-time activities, or stages of life may prove to be more relevant, depending upon the goals of the particular campaign.

Developing the campaign strategy involves choosing a theory or model for understanding and influencing behavioral changes. Social marketing is considered a discipline (not a theory), however; social marketers draw upon theories and models of behavior change from disciplines such as psychology, sociology, anthropology, and communication. The use of theories and models is not always explicit in a social marketing campaign nor do social marketers necessarily incorporate all components of a given theory or model. Some of the most common theories and models are summarized here.

The Transtheoretical Model of Health Behavior Change (Stages of Change) suggests that individuals move through a series of stages before adopting a new behavior. At the precontemplation stage, an individual may not perceive that he or she is at risk and therefore the social marketing product is irrelevant. Making the target audience aware of the problem and associated risks can move individuals to the second stage, contemplation. At this point, social marketing messages must maximize perceived benefits and minimize perceived costs of behavior change to move individuals to the third stage, preparation for action. In the fourth stage, action, individuals have begun making behavioral changes. Action is facilitated when the behavior is portrayed as something many other people engage in and agree with. The fifth stage, maintenance, requires motivational and reinforcing messages to keep individuals from relapsing back to prior stages.

The Health Beliefs Model (HBM) was designed to explain why people do not participate in diagnosis or disease prevention programs. Core components of the HBM relevant to social marketing include an individual’s perceptions of susceptibility (risk for developing a health problem), severity (seriousness of consequences of the health problem), benefits (to taking action), barriers (negative aspects of taking action), and cues to action (bodily or environmental events triggering action). HBM incorporates the idea of self-efficacy (an individual’s perceived control over his or her behavior) as a predictor of health behaviors, particularly when lifestyle changes must be maintained over time. In addition, the model gives attention to factors such as socioeconomic status, age, gender, and knowledge as influential on an individual’s perceptions and behaviors. The HBM has been useful for addressing “at risk” populations who may not perceive themselves as such.

Social Cognitive Theory (SCT) suggests that human behavior is determined by a dynamic and reciprocal process between personal factors (individualized internal characteristics, e.g., self-efficacy), behavior, and the external environment. In addition, observational or vicarious learning by watching others is a key component of this model in that an individual’s behavior can be influenced by observing reinforcements (positive or negative) in response to someone else’s behavior. SCT is relevant to social marketing in that it suggests individuals are most likely to model behaviors observed in others if the others are perceived to be similar to themselves, and if the perceived benefits outweigh the perceived costs.

The Theory of Reasoned Action (TRA) posits that the most important predictor of human behavior is intention, and that intention is influenced both by the individual’s attitudes toward the behavior and by subjective norms (beliefs about what other people will think about the behavior). Each of the three components of TRA is weighted differently depending upon the individual and the situation. The Theory of Planned Behavior is an extension of TRA and includes self-efficacy as an influencing variable. When social marketing programs utilize these theories, in-depth open-ended interviews are helpful in identifying variables relevant to the population and the behavior of interest.

The Diffusion of Innovations Theory broadens the focus from individuals and their influencers to include how ideas, products, and practices from one group to another. Diffusion refers to how information flows through networks over time to reach the members of a group while innovations encompass the ideas or behaviors that individuals perceive as new. This theory centers on factors that will increase or decrease the probability that new idea, practice, or behavior will be adopted by individuals. In addition, the theory suggests that there are innovators, or early adopters, within a given group who are the first to adopt new ideas, attitudes or behaviors, and who are influential in encouraging others to do the same.

The second major step in creating a social marketing campaign involves developing messages and materials and identifying the most appropriate channels (channel analysis) for reaching the target audience. Effective messages are personal, designed to resonate with the experiences and realities of individuals within the target group. Effective messages also clearly communicate the specific desired behavior to the audience while creating and reinforcing positive attitudes about behavioral change. Channel analysis means finding out how and where members of the target audience obtain information, so that the most relevant channels can be used for communication.

Step three, pretesting, involves testing messages and materials with members of the target audience and other relevant parties to ensure that they evoke the expected response before launching a media campaign. Implementing the campaign is the fourth step and requires close coordination with participating partner agencies and organizations. Although evaluation and feedback are listed as the last step, in reality, these two components should be engaged throughout the campaign (process evaluation) to incorporate feedback. Outcomes evaluation measures campaign results and helps to determine whether or not the objectives were accomplished.

Examples of Successful Social Marketing Campaigns

Social marketing campaigns have been successfully implemented with positive results, both internationally and domestically. Some key examples are summarized here:

Mass Media and Health Practices Program, Honduras. This social marketing campaign to decrease infant mortality was initiated by a partnership between the Academy for Educational Development (AED) and the Honduran Ministry of Health in 1980. At the time, dehydration from diarrhea, the leading cause of infant mortality, accounted for 24 percent of all infant deaths in Honduras. Social marketers wanted mothers to use a new product, oral rehydration therapy (ORT), to increase child survival. Information, with easily remembered slogans and songs, was disseminated in a mass media campaign via print materials and radio. Healthcare workers trained in ORT preparation and administration gave hands-on demonstrations to village assistants, who in turn trained others within the community. Infant mortality due to dehydration from diarrhea decreased from 47.5 to 25 percent in the first year of the campaign.

Stop AIDS, Switzerland. Implemented as a national multimedia campaign in 1987, Stop AIDS is the longest running HIV/AIDS prevention program in the world. The campaign was created in partnership by the Swiss AIDS Foundation and the Swiss Federal Office for Public Health. Specific goals of the campaign included increasing condom use, reducing discrimination against individuals with HIV/AIDS, and increasing understanding among the general population for those members diagnosed with HIV/AIDS. Products included condoms, antidiscrimination, and needle exchange, and campaign messages were disseminated via billboards, posters, advertisements (print, radio, and television), movie theater commercials, and sporting events. Ongoing evaluations of the program measured both condom use and the change in attitudes toward HIV/AIDS. Within 1 year of program launch, more than 90 percent of the population recognized the campaign logo, and within 3 years, condom use among men aged 17-30 increased from 8 to nearly 50 percent.

Florida Truth® Campaign, Florida. The truth campaign, sponsored by the American Legacy Foundation, is a national antitobacco initiative targeted toward youth. The program was started by the State of Florida’s Office of Tobacco Control and was funded by monies from the 1998 Master Settlement Agreement (MSA) between 46 states and the tobacco industry. The campaign uses information from tobacco companies to expose both manufacturing and marketing practices of the industry, and provides facts about the health consequences, social costs, and addictiveness of tobacco. Campaign messages are distributed via radio, print advertisements, and television. The target teen audience is segmented by ethnic group, with specific advertising designed to mirror audience segmentation done by tobacco companies. In addition, a grassroots initiative helps teens share information in peer-to-peer settings. In the first two years of the campaign, the number of youth smokers decreased 22 percent.

Click It or Ticket, North Carolina. Launched in 1993, Click It or Ticket was designed to reduce fatal and serious traffic-related injuries by increasing seat belt and child safety seat use. The program was pilot tested before the launch of a major and sustained media campaign in conjunction with increased enforcement of the seat belt law. Click It or Ticket was supported by policy makers, high-ranking state officials, and influential organizations including the Governor, State Insurance Commissioner, Commander of the State Highway Patrol, and the Insurance Institute for Highway Safety. In addition, nearly every one of the state’s law enforcement agencies participated in the campaign. Fatal and serious traffic-related injuries decreased by 14 percent, while seat belt use increased to over 80 percent, one of the highest rates in the nation.

Social Marketing and Obesity

Social marketing campaigns designed to reduce the prevalence of and prevent obesity typically focus in some form on the adoption of healthier eating practices and increased physical activity levels. Both of the social marketing campaigns summarized below focus not only on the “downstream” individuals for behavioral change, but also on influencers in the familial and social spheres and “upstream” policy makers. The campaigns leverage partnerships on a number of levels to maximize resources and extend the reach of key messages. The social marketers who developed these campaigns incorporated behavioral theories and models in their strategies, and use ongoing research and evaluation as critical components to improve the campaigns and measure outcomes.

VERB™ It’s What You Do, Centers for Disease Control and Prevention (CDC). VERB is a national, multicultural social marketing campaign designed to increase and maintain physical activity among the target audience of youth aged 9-13 (tweens). Additional target audiences for the campaign include parents and other influential adults such as teachers and coaches, youth leaders, and health professionals. The campaign markets physical activity as something fun for tweens to do, and provides information via brochures, articles, posters, and stickers. Short-term outcomes focus on increasing tween and parent awareness of the campaign and key messages. Midterm outcomes are related to changes in subjective norms, beliefs, self-efficacy, and perceived behavioral control related to participating in physical activity. The long-term outcomes are focused on getting tweens to engage in and maintain physical activity, which will in turn reduce risk for diseases such as diabetes, hypertension, and sleep apnea.

The campaign engages formative research, process evaluation, and outcome evaluation. Formative research involved reviews of existing research, conduct of primary research with target audiences, consultation from experts, and reviews of other campaigns targeting the same age group. Exploratory research was used to understand the behaviors and mind-sets of tweens and their influencers to identify motivators and barriers to participation in and support of physical activity. The tween audience was then segmented into subgroups based on cultural, ethnic, and economic variables. Messages and communications strategies were tested prior to mass media release to gauge audience reactions and to ensure that the messages and advertisements were understandable, appealing, and motivating.

Process evaluation is ongoing throughout the campaign and includes analysis of campaign advertising. To accomplish this, the campaign utilizes a telephone survey conducted with tweens four times per year to find out what VERB means to them, what they think of the brand, and where they’ve seen VERB advertisements. VERB-sponsored events are evaluated on site, and follow-up interviews are conducted afterward. Outcomes evaluation assesses changes in awareness, attitudes, knowledge, and behaviors related to physical activity that have been directly influenced by the campaign. This step relies on a longitudinal cohort design telephone survey with children and parents to make measurements over time. After the first year of the campaign, 74 percent of children surveyed were aware of the campaign, and physical activity levels were increased for those children versus others who were not familiar with the campaign.

California Project LEAN (Leaders Encouraging Activity and Nutrition) (CPL). CPL is a collaborative effort between the California Department of Health Services (CDHS) and the Public Health Institute toward the vision that Californians will become physically active, eat healthy foods, and live in communities that support healthy lifestyles. CPL’s overall mission, aligned with the Governor’s vision for Healthy California, is to increase healthy eating and physical activity, which in turn, will help to reduce the prevalence of obesity and related health conditions such as cardiovascular disease, stroke, and diabetes. The campaigns goals include using policy and environmental changes to create healthier communities, provide education on choosing healthy food choices and physical activity, and to conduct research-based consumer-driven campaigns.

Originally, CPL began as an initiative to encourage low-fat diets for individuals living within the San Francisco Bay area. The CDHS expanded the initiative to work with state and local physical activity and nutrition leaders in conducting programs throughout the state. The CDHS provides funding for 10 regional offices across the state for social marketing programs including Food on the Run, Successful Students through Healthy Food Policies, and Huesos Fuertes, Familia Saludable (Strong Bones, Healthy Families).

CDHS is also a lead partner on the California Obesity Prevention Initiative (COPI), a campaign that promotes healthy eating and physical activity as mechanisms to reduce the prevalence of obesity and related health conditions. CPL developed Captive Kids Selling Obesity at Schools: An Action Guide to Stop the Marketing of Unhealthy Foods and Beverages in School, and the campaign’s research on soda and snack foods distributed in schools has contributed to new policies and legislation that will make healthier food choices available in schools.