The Best of Social Marketing in 2014

Keeping up with the evolution of social marketing research and practice can be a tough problem. To help you out, this is my fourth annual review of papers that document in the peer-reviewed literature how the field is developing (here are the links to the 2011, 2012, and 2013 selections). I do not consider papers published in our two journals, the Journal of Social Marketing and Social Marketing Quarterly, as I presume that people are looking at them already. I am also interested in how social marketing is presented outside our immediate orbit.

One of my priorities in reviewing the work is how they help strengthen the evidence base for the discipline. Just collecting more stories, or case studies, about social marketing needs to end; we need a stronger focus on research with better descriptions of methods, collection and analysis of relevant data – not convenient ones, and the use of experimental designs. Pick up most textbooks on social marketing and read the references. I have, and was stunned by the lack of citations to research studies about the effectiveness of social marketing (my highest count was 10 – about as many as are in this post, and was something I deliberately set out to change with my book). I have heard from colleagues that they wouldn’t, or couldn’t, teach a course in social marketing in their department using available textbooks because there was a lack of ‘scientific rigor’ in them (or words to that effect). Practitioners can carry on about the ‘art’ of social marketing (I do it as well), but if social marketing is to be taken seriously by others (leading academic institutions and policy makers to name two) it needs data, not stories, to demonstrate its value.

Two controlled trials caught my attention. The article by Cates et al discusses their project to increase HPV vaccination rates among preteen boys in 13 counties in North Carolina, USA  and compares the outcomes with another 15 control counties in the same state. Randomization by organizational unit, in this instance churches, was an especially strong experimental approach employed by DiGuiseppi et al to investigate how social marketing can increase recruitment and retention of older adults into balance classes in order to reduce fall-related injuries. It is note worthy that these studies explore applications of social marketing to topics outside the mainstream of msot social marketing articles: vaccinations and injury prevention.

Other research studies that merit your attention are the work of Bhagwat et al and Firestone et al. Yes, the Bhagwat piece is two case studies, but I can take a story that is sprinkled with data and demonstrates a new application of social marketing – to food fortification programs in India. The Firestone et al study does not have a comparison group, but when you are involved in large-scale programming across five countries in Central America to reduce HIV risk, the correct decision, in my mind, is Go Big and leave the small stuff to other investigators. They present a wealth of data, and I was particularly impressed to see the attention to measures of program exposure – and that exposure was related to behavioral outcomes. Measuring the relevant, not convenient, variables is the lesson in this study.

One article that should be in the social marketing canon is the results of a comprehensive review of the literature by the US Community Preventive Services Task Force by Robinson et al. For those outside the US, this task force judges whether interventions have sufficient empirical evidence to justify their widespread use in public health programs. Combining low cost (or free) and easily accessible products with mass communication campaigns is now one of those recommended approaches. Also note the concluding sentence of their abstract – that methods are not usually described in enough detail to allow for conclusions to be drawn about other social marketing practices – and be sure to download the entire report. This is the type of evidence your departmental colleagues and chairs, senior managers and policy makers are looking for.

The other paper in this section by Wilhelm-Reichmann et al is a market analysis using a social marketing framework to assess how conservation plans can be integrated into land-use planning in South Africa. I liked their use of a marketing framework to approach the issue and that it also extends social marketing into the conservation and policy arena (and in full disclosure, I was an advisor in the early stages of their process).

The next section includes two papers that focus on improved cookstoves to address many health and environmental issues. While this sector has more frequently been the province of engineers and so-called marketing programs that were often little more than mass exhortation campaigns, as Shankar et al note, the problem is now being defined as how to create campaigns that are consumer-focused. Their seven considerations for future efforts are ones that any social marketing program, regardless of its topic or behavioral focus, would do well to adopt. The Bhojvaid et al consumer research piece is a logical next step in this progressive use of social marketing of a product that has been struggling for decades to find a consumer (rather than a health or environmental) problem to solve.

Shifting from a topical focus, the last three articles are concerned with Place – the piece of the marketing mix that too often ends up being how messages are distributed rather than focusing on ‘where’ behaviors are engaged in. In all three of these studies, the authors approach the ‘where’ question from a critical perspective: how does the density of fast food outlets impact the prevalence of childhood obesity (Newman et al), how does the location of tobacco retailers affect adolescent smoking behaviors (Short et al), and the documentation of ‘pharmacy deserts’ that limit the accessibility to prescription medications in segregated minority neighborhoods (Qato et al). As social marketers, these results should remind us that we need to be thinking about larger ‘place’ questions and solutions to them.

The description of each article is drawn from its abstract and excerpts from the text. There is a link to the abstract, or more frequently, to the full paper. And for those who are interested in an even more extensive documentation of the social marketing literature, consider the Sage Library in Marketing Series on Social Marketing as an institutional investment.

Seniors-exercise-balls

Controlled Trials

Cates, J.R., Diehl, S.J., Crandellc, J.L. & Coyne-Beasley, T. (2014). Intervention effects from a social marketing campaign to promote HPV vaccination in preteen boys. Vaccine; 32:4171-4178.

Objectives: Adoption of human papillomavirus (HPV) vaccination in the US has been slow. In 2011, HPV vaccination of boys was recommended by CDC for routine use at ages 11–12. We conducted and evaluated a social marketing intervention with parents and providers to stimulate HPV vaccination among preteen boys.
Methods: We targeted parents and providers of 9–13 year old boys in a 13 county NC region. The 3- month intervention was based on four principles of social marketing: to promote (with radio public service announcements, posters, brochures, doctor’s recommendation) the product (HPV vaccine), while considering the price (cost, perception of safety and efficacy, and access), and place (healthcare providers’ office). Intervention counties were exposed to a campaign (Protect Him) with materials designed and pretested with racially and ethnically diverse parents of preteen boys, while control counties received no intervention. The campaign ran for 3 months before the school year started and when parents were most likely to seek vaccinations for their children. The intervention also included distribution of HPV vaccination posters and brochures to all county health departments plus 194 enrolled providers and an online CME training. A Cox proportional hazards model was fit using NC immunization registry data to examine whether vaccination rates in 9–13 year old boys increased during the intervention period in targeted counties (n=13) compared to control counties (n = 15) with similar demographics.
Results: The Cox model showed an intervention effect (B = 0.29, HR = 1.34, p = .0024), indicating that during the intervention the probability of vaccination increased by 34% in the intervention counties relative to the control counties. Comparisons with HPV vaccination in girls and Tdap and meningococcal vaccination in boys suggest a unique boost for HPV vaccination in boys during the intervention. Model covariates of age, race and VFC eligibility were all significantly associated with vaccination rates (p < .0001 for all).
Conclusions: This study is the first to use a social marketing intervention to boost HPV vaccination among preteen males. Social marketing techniques can encourage parents and health care providers to vaccinate preteen boys against HPV.

DiGuiseppi, C.G., Thoreson, S.R., Clark, L., Goss, C.W., Marosits, M.J., Currie, D.W., & Lezotte, D.C. (2014). Church-based social marketing to motivate older adults to take balance classes for fall prevention: Cluster randomized controlled trial. Preventive Medicine; 67:75-81.

Fifty-one churches (7101 total members aged ≥60) in Colorado, U.S.A. were randomized to receive no intervention or a social marketing program. The program highlighted benefits of class participation (staying independent, building relationships), reduced potential barriers (providing convenient, subsidized classes), and communicated marketing messages through church leaders, trained “messengers,” printed materials and church-based communication channels. Compared to 25 control churches, 26 churches receiving the social marketing program had a higher median proportion (9.8% vs. 0.3%; p < 0.001) and mean number (7.0 vs. 0.5; IRR = 11.2 [95%CI: 7.5, 16.8]) of older adult congregants who joined balance classes. Intervention church members were also more likely to recall information about preventing falls with balance classes (AOR=6.2; 95% CI: 2.6, 14.8) and availability of classes locally (AOR= 7.7; 95% CI: 2.6, 22.9).

The positive results of this RCT indicate that church-based social marketing that addresses product, price, place and promotion with more convenient, lower-cost classes and messages about staying independent and building social relationships, can successfully motivate older adults to enroll in balance and strength classes for fall prevention. These messages can be effectively disseminated through existing church communication channels. The involvement of church leaders and informal member-to-member contacts, rather than reliance on brochures and posters, appears important to marketing program success.

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Other Research Studies

Bhagwat, S., Gulati, D., Sachdeva, R., & Sankar, R. (2014). Food fortification as a complementary strategy for the elimination of micronutrient deficiencies: Case studies of large scale food fortification in two Indian States. Asia Pacific Journal of Clinical Nutrition; 23 (Suppl):S4-S11. PDF

The burden of micronutrient malnutrition is very high in India. Food fortification is one of the most cost-effective and sustainable strategies to deliver micronutrients to large population groups.  Lack of industrial concentration and large segments of the population being outside the reach of commercial markets are the major challenges for food fortification. The Global Alliance for Improved Nutrition (GAIN) is supporting large-scale, voluntary, staple food fortification in Rajasthan and Madhya Pradesh because of the high burden of malnutrition, availability of industries capable of and willing to introduce fortified staples, consumption patterns of target foods and a conducive and enabling environment.

High extraction wheat flour from roller flour mills, edible soybean oil and milk from dairy cooperatives were chosen as the vehicles for fortification. Micronutrients and levels of fortification were selected based on vehicle characteristics and consumption levels. Industry recruitment was done after a careful assessment of capability and willingness. Production units were equipped with necessary equipment for fortification. Staffs were trained in fortification and quality control. Social marketing and communication activities were carried out as per the strategy developed. A state food fortification alliance was formed in Madhya Pradesh with all relevant stakeholders.
Over 260,000 MT of edible oil, 300,000 MT of wheat flour and 500,000 MT of milk are being fortified annually and marketed. Rajasthan is also distributing 840,000 MT of fortified wheat flour annually through its Public Distribution System and 1.1 million fortified Mid-day meals daily through the centralised kitchens. Concurrent monitoring in Rajasthan and Madhya has demonstrated high compliance with all quality standards in fortified foods.

Demand generation campaigns are important to create consumer awareness about the “added nutritional advantages” of consuming the fortified foods. This would lead to increased demand, and consequently an increased sale of the fortified food products, thus strengthening the commitment of the industry to continue and sustain fortification of their food products. Consumer awareness is needed to achieve the long-term goal of consumer-driven fortification, and systematic social marketing will play an important role to achieve this. An enabling environment that encourages voluntary fortification and increasing demand from well informed consumers is a prerequisite for success of voluntary fortification.

Firestone, R., Rivas, J., Lungo, S., Cabrera, A., Ruether, S., Wheeler, J. & Vu, L. (2014). Effectiveness of a combination prevention strategy for HIV risk reduction with men who have sex with men in Central America: a mid-term evaluation. BMC Public Health; 14:1244  doi:10.1186/1471-2458-14-1244

Despite over a decade of research and programming, little evidence is available on effective strategies to reduce HIV risks among Central American men who have sex with men (MSM). The Pan-American Social Marketing Organization (PASMO) and partners are implementing a HIV Combination Prevention Program to provide key populations with an essential package of prevention interventions and services: 1) behavioral, including interpersonal communications, and online outreach; 2) biomedical services including HIV testing and counseling and screening for STIs; and 3) complementary support, including legal support and treatment for substance abuse. Two years into implementation, we evaluated this program’s effectiveness for MSM by testing whether exposure to any or a combination of program components could reduce HIV risks.
Methods: PASMO surveyed MSM in 10 cities across Guatemala, El Salvador, Nicaragua, Costa Rica, and Panama in 2012 using respondent-driven sampling. We used coarsened exact matching to create statistically equivalent groups of men exposed and non-exposed to the program, matching on education, measures of social interaction, and exposure to other HIV prevention programs. We estimated average treatment effects of each component and all combined to assess HIV testing and condom use outcomes, using multivariable logistic regression. We also linked survey data to routine service data to assess program coverage.
Results: Exposure to any program component was 32% in the study area (n = 3531). Only 2.8% of men received all components. Men exposed to both behavioral and biomedical components were more likely to use condoms and lubricant at last sex (AOR 3.05, 95% CI 1.08, 8.64), and those exposed to behavioral interventions were more likely to have tested for HIV in the past year (AOR 1.76, 95% CI 1.01, 3.10).
Conclusions: PASMO’s strategies to reach MSM with HIV prevention programming are still achieving low levels of population coverage, and few men are receiving the complete essential package. However, those reached are able to practice HIV prevention. Combination prevention is a promising approach in Central America, requiring expansion in coverage and intensity.

Robinson, M.N., Tansil, K.A., Elder, R.W. et al;. (2014). Mass media health communication campaigns combined with health-related product distribution. American Journal of Preventive Medicine; 47:360-371.

Context: Health communication campaigns including mass media and health-related product distribution have been used to reduce mortality and morbidity through behavior change. The intervention is defined as having two core components reflecting two social marketing principles: (1) promoting behavior change through multiple communication channels, one being mass media, and (2) distributing a free or reduced-price product that facilitates adoption and maintenance of healthy behavior change, sustains cessation of harmful behaviors, or protects against behavior-related disease or injury.
Evidence acquisition: Using methods previously developed for the Community Guide, a systematic review (search period, January 1980–December 2009) was conducted to evaluate the effectiveness of health communication campaigns that use multiple channels, including mass media, and distribute health-related products. The primary outcome of interest was use of distributed health-related products.
Evidence synthesis: Twenty-two studies that met Community Guide quality criteria were analyzed in 2010. Most studies showed favorable behavior change effects on health-related product use (a median increase of 8.4 percentage points). By product category, median increases in desired behaviors ranged from 4.0 percentage points for condom promotion and distribution campaigns to 10.0 percentage points for smoking-cessation campaigns.
Conclusions: Health communication campaigns that combine mass media and other communication channels with distribution of free or reduced-price health-related products are effective in improving healthy behaviors. This intervention is expected to be applicable across U.S. demographic groups, with appropriate population targeting. The ability to draw more specific conclusions about other important social marketing practices is constrained by limited reporting of intervention components and characteristics.

Wilhelm-Rechmann, A., Cowling, R.M. & Difford, M. (2014). Using social marketing concepts to promote the integration of systematic conservation plans in land-use planning in South Africa. Oryx; 48:71-79.

Local land-use planning procedures are increasingly recognized as potentially crucial to ensure off-reserve biodiversity protection. Mainstreaming systematic conservation planning maps in these decision-making procedures has been proposed as a mechanism to achieve this. However, research is lacking on how to convince officials and politicians to change their behaviour and include the maps in their decision-making. Social marketing is a tool commonly used to effect behaviour change in many sectors but its application in conservation is limited. In the formative research phase of a social marketing study we interviewed locally elected politicians in four coastal municipalities in South Africa. We found that conservation and environmental issues play virtually no role in their work; however, they do attribute value to the natural environment. Land-use planning procedures are considered important but dysfunctional and the role of conservation is perceived negatively in their municipalities. Their information-seeking behaviour is clearly localized. We present a marketing analysis of these results and argue for improving the attractiveness of the product: the maps should be more option- than veto-based and should identify locally relevant ecosystem services. Locally significant information should be provided at a time and location convenient for politicians. We conclude that engagement with councillors should be proactive, refer to land-use planning and services from ‘nature’ rather than ‘biodiversity’ and use terminology and information that is locally oriented and meaningful from the politician’s perspective. The analysis highlights the usefulness of the marketing approach for conservation.

Improved-stove-2
Focus on Improved Cookstoves

Shankar, A. Johnson, M., Kay, E. et al. (2014). Maximizing the benefits of improved cookstoves: moving from acquisition to correct and consistent use. Global Health: Science and Practice; 2:268-274.

This paper reports on a meeting of the Working Group to Address Increasing Adoption of Improved Cookstoves. Marketing campaigns to promote cookstoves have yielded mixed results over the past decades, and generally adoption rates remain low. Marketing of improved cookstoves (ICS) must meet consumer needs and preferences if they are to lead to correct and consistent use and to successfully displace traditional stoves. This is also necessary for reducing household air pollution and fuel consumption, and therefore providing maximum health and environmental benefits. However, consumer needs and preferences are complex and are influenced by many contextual and social factors that require a deep understanding of culture, going beyond technology and economics.

Successful ICS business models will need to be sensitive to cultural practices in both the design of the product and marketing strategies. Key considerations that can aid in large-scale ICS adoption include:
1. Recognizing that stove adoption does not equate with stove acquisition and that long-term consistent and continuous use requires consumer buy-in and understanding of the value proposition that ICS can provide.
2. Designing marketing campaigns that engage the consumer by identifying key attributes of importance to the consumer, rather than long lists of attributes that do not necessarily influence the consumer’s decision.
3. Ensuring effective user engagement by including demonstrations, training, and post-sales support.
4. Addressing intra-household gender dynamics to enhance equity in purchasing decisions.
5. Including women more effectively through-out the cookstove value chain by improving both resources and agency-based support.
6. Identifying and respecting the cultural significance of cooking food.
7. Understanding the actual-use scenarios of the stove (for example, boiling water for tea versus frying flat breads).

Ultimately, protecting health and the environment will depend on whether the household energy sector can provide cookstoves with low-pollutant emissions while also meeting consumer needs. Thus, addressing those needs will be fundamental to achieving health and environmental goals.

Bhojvaid, V., Jeuland, M., Abhishek Kar, A., Lewis, J.L., Pattanayak, S.K., Ramanathan, N., Ramanathan, V. & Rehman, I. H. (2014). How do people in rural India perceive improved stoves and clean fuel? Evidence from Uttar Pradesh and Uttarakhand. International Journal of  Environmental Research and Public Health; 11:1341-1358.

Improved cook stoves (ICS) have been widely touted for their potential to deliver the triple benefits of improved household health and time savings, reduced deforestation and local environmental degradation, and reduced emissions of black carbon, a significant short-term contributor to global climate change. Yet diffusion of ICS technologies among potential users in many low-income settings, including India, remains slow, despite decades of promotion. This paper explores the variation in perceptions of and preferences for ICS in Uttar Pradesh and Uttarakhand, as revealed through a series of semi-structured focus groups and interviews from 11 rural villages or hamlets. We find cautious interest in new ICS technologies, and observe that preferences for ICS are positively related to perceptions of health and time savings. Other respondent and community characteristics, e.g., gender, education, prior experience with clean stoves and institutions promoting similar technologies, and social norms as perceived through the actions of neighbours, also appear important. Though they cannot be considered representative, our results suggest that efforts to increase adoption and use of ICS in rural India will likely require a combination of supply-chain improvements and carefully designed social marketing and promotion campaigns, and possibly incentives, to reduce the up-front cost of stoves. Given current efforts to increase promotion of ICS technologies in India and other less-developed countries, we believe that issues related to stove promotion and marketing, stove pricing and subsidies, and the nature of peer effects and how they relate to the visibility of stoves deserve additional study and rigorous testing.

Fast food china
Place-Based Research and Social Marketing Interventions

Newman, C.L., Howlett, E. & Burton, S. (2014). Implications of fast food restaurant concentration for preschool-aged childhood obesity. Journal of Business Research; 67:1573-1580.

Marketers and consumer health advocates have recently devoted considerable attention to built environments. One key aspect of built environments is the type and concentration of retail establishments available to consumers. Prior research on the relationship between retail type, concentration, and consumer health largely focuses on a lack of healthy retail establishments, rather than on the high concentration of unhealthy establishments. In this research, the authors examine the effects on preschool-aged childhood obesity rates associated with the direct and moderating influence of fast food restaurant density levels, consumer poverty, and urbanization. Results show that higher levels of fast food restaurant saturation are associated with increased levels of childhood obesity in both urban and poor areas, with the largest negative effect of fast food availability on obesity occurring in more economically disadvantaged, urban areas. Findings highlight why the societal impacts of targeting vulnerable populations through corporate location selection strategies should be fully considered in social marketing initiatives, especially given that unhealthy products with long term health risks are increasingly accessible.

The typical (short-lived) social marketing approach to obesity-related problems is to encourage individuals to exercise more or to eat more fruits and vegetables. Traditional social marketing messages such as these may quickly be dismissed in more urban and poorer communities though, as the realities of accessing and paying for more healthy foods or exercise facilities are realized. Therefore, the built environment plays an important, but often overlooked, role in the practicality and effectiveness of potential solutions to the childhood obesity epidemic. The present findings suggest that opportunities exist for social marketers to focus more heavily on community-specific environmental factors and their relationship with childhood obesity. More specifically, social marketing approaches that may be effective when convenient access to unhealthy fast food is high include: (1) social marketing efforts that specifically target parents of pre-school children in more urban, poorer areas, and (2) social marketing efforts that specifically focus on educating parents about potentially detrimental environmental factors specific to their communities, such as increased fast food availability, as opposed to traditional messages focused on individual behaviors.

Qato, D.M., Daviglus, M.L., Wilder, J., Lee, T., Qato, D. & Lambert, B. (2014). ‘Pharmacy deserts’ are prevalent In Chicago’s predominantly minority communities, raising medication access concerns. Health Affairs; 33:1958-1965. doi: 10.1377/hlthaff.2013.1397.

Attempts to explain and address disparities in the use of prescription medications have focused almost exclusively on their affordability. However, the segregation of residential neighborhoods by race or ethnicity also may influence access to the pharmacies that, in turn, provide access to prescription medications within a community. We examined whether trends in the availability of pharmacies varied across communities in Chicago with different racial or ethnic compositions. We also examined the geographic accessibility of pharmacies to determine whether “pharmacy deserts,” or low-access neighborhoods, were more common in segregated black and Hispanic communities than elsewhere. We found that throughout the period 2000–2012 the number of pharmacies was lower in segregated minority communities than in segregated white communities and integrated communities. In 2012 there were disproportionately more pharmacy deserts in segregated black communities, as well as in low-income communities and federally designated Medically Underserved Areas. Our findings suggest that public policies aimed at improving access to prescription medications may need to address factors beyond insurance coverage and medication affordability. Such policies could include financial incentives to locate pharmacies in pharmacy deserts or the incorporation of pharmacies into community health centers in Medically Underserved Areas.

Short, N.K., Tisch, C., Pearce, J., Richardson, E.A. & Mitchell, R. (2014). The  density of tobacco retailers in home and school environments and relationship with adolescent smoking behaviours in Scotland. Tobacco Control; Published Online First: 4 November 2014 doi:10.1136/tobaccocontrol-2013-051473

Background: Neighbourhood retailing of tobacco products has been implicated in affecting smoking prevalence rates. Long-term smoking usually begins in adolescence and tobacco control strategies have often focused on regulating ‘child spaces’, such as areas in proximity to schools. This cross-sectional study examines the association between adolescent smoking behaviour and tobacco retail outlet density around home and school environments in Scotland.
Methods: Data detailing the geographic location of every outlet registered to sell tobacco products in Scotland were acquired from the Scottish Tobacco Retailers Register and used to create a retail outlet density measure for every postcode. This measure was joined to individual responses of the Scottish Schools Adolescent Lifestyle and Substance Use Survey (n=20 446). Using logistic regression models, we explored the association between the density of retailers, around both home and school address, and smoking behaviours.
Results: Those living in the areas of highest density of retailers around the home environment had 53% higher odds of reporting having ever smoked (95% CI 1.27 to 1.85, p<0.001) and 47% higher odds of reporting current smoking (95% CI 1.13 to 1.91 p<0.01). Conversely, those attending schools in areas of highest retail density had lower odds of having ever smoked (OR 0.66, 95% CI 0.50 to 0.86 p<0.01) and lower odds of current smoking (OR 0.75, 95% CI 0.59 to 0.95, p<0.05).
Conclusions: The density of tobacco retail outlets in residential neighbourhoods is associated with increased odds of both ever smoked and current smoking among adolescents in Scotland. Policymakers may be advised to focus on reducing the overall density of tobacco outlets, rather than concentrating on ‘child spaces’.

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