Putting social marketing into practice

An old enemy and a new friend

Marketing has long been a force to be reckoned with in public health. In the hands of the tobacco, alcohol, and food industries it has had a well documented effect on our behaviour.3^–6 In the case of tobacco companies this has culminated in extensive controls being placed on their marketing activities. Social marketing argues that we can borrow marketing ideas to promote healthy behaviour. If marketing can encourage us to buy a Ferrari, it can persuade us to drive it safely.

Marketing is based on a simple and unobtrusive idea: putting the consumer and the stakeholder at the heart of the business process. Whereas Henry Ford focused on selling what he could produce—any colour you want as long as it's black—modern marketers invert this rubric and produce what they can sell. This deceptively simple change has revolutionised commerce over the past 50 years, making Nike and Coca-Cola the behemoths they are. It has succeeded because, paradoxically, listening to consumers and taking care to understand their point of view makes it easier to influence their behaviour.

Social marketers argue that attempts to influence health behaviour should also start from an understanding of the people we want to do the changing. The task is to work out why they do what they do at present—their values and motivations—and use these to encourage healthy options.

Often the picture is much more complex than ignorance of the public health facts. Most people know, for instance, that smoking is dangerous or how their diet could be improved. They continue with unhealthy behaviour because they see some other benefit in doing so—relaxation, perhaps, or a treat. The secret for the social marketer is to devise a way of enabling them to get the same benefit more healthily. In this sense social marketing has a great deal in common with good, patient centred health care. The extensive health expertise of doctors and other health professionals is much more effectively deployed when combined with empathy for the patient. Ultimately, better health has to be a joint endeavour.

More than communication

To work at a population level, this consumer orientation has to be scaled up. Relevant health behaviours and target groups are identified, motivating interventions developed, and people told about them. The last often involves some form of communication campaign, but not always. Social marketing is sometimes seen as a synonym for media activity, but in fact this is only one of several possible tools; and these tools typically work much better in combination than in isolation.

The West of Scotland cancer awareness project is a case in point. It used television and other advertising to target low income groups and encourage people with symptoms of mouth or bowel cancer to present earlier (box). It was a huge success: the number of people presenting to the NHS increased, those who attended had symptoms, and more cancers were detected. But the advertising was only the visible tip of a much bigger iceberg of activity. In particular, the involvement of health professionals was crucial. They had to be convinced from the outset that the campaign would not put undue pressures on their services or simply generate a stampede by the worried well. They also had to gear up to cope with additional consultation work if and when the campaign succeeded. Above all, they had to deliver the all important service.

The case confirms that social marketing is much more than advertising; in this instance it was about providing a patient and stakeholder centred service that met a real and valued need. The advertising simply served to flag this up. It also shows that, with suitable planning and management of relationships, health professionals can have a key role in this success. The two codicils are vital; the project's success was completely dependent on the early and constructive involvement of health professionals.

Evidence of effectiveness

The Scottish cancer project is not an isolated case. Evidence of the effectiveness of social marketing is burgeoning. A recent systematic review showed how its principles have been applied successfully in nutrition—and especially among marginalised groups (see bmj.com).8 Other reviews have shown a similar capacity to tackle alcohol, tobacco, and drug use and encourage physical activity.9 10 In addition, in the North East of England social marketing has successfully encouraged general practitioners to prescribe sugarfree medicines and health visitors to recruit low income women to smoking cessation services. 11 12

Long term aims

Commercial marketers do not just want to define and satisfy our needs once, they want to do it again and again. Their aim is to build ongoing, mutually beneficial relationships with us. That is why they have invented loyalty cards and air miles and linked them up with evocative brands painstakingly developed over decades. Needless to say they do not do this out of kindness; they do it because it works. Keeping existing customers is cheaper and more profitable than winning new ones; satisfied customers readily come back for more and, most gratifyingly, they will even sell your product for you. A friend recommending a car or holiday is much more convincing than an advert.

Again, the thinking can be applied in health. Stop smoking services, for example, provide a valued benefit. Successful quitting is a tremendously important achievement for many smokers. At the moment these services put all the effort into the first six weeks, despite the fact that successful quitting is deemed to take 12 months. Then, whatever progress has been made, links are severed. This is a terrible waste.13

Let us think for a moment about the 15% of users who quit successfully. They will be delighted with both themselves and the service. Just suppose we did not lose interest in these people, but, like Tesco, gave them a loyalty card, kept in touch, and built relationships with them. They would persuade friends and family to use cessation services (they are living, breathing testimonials) and could be encouraged to think about their other health behaviours. From a marketing point of view, there is an obvious opportunity to build on success. It comes back to the basic point of marketing—and indeed medicine—that progress is made by cooperation and partnership. The doctor has the medical expertise, but it is the patient's behaviour.

No man (or woman) is an island

That said, social context also has an important effect on our behaviour. The tobacco, food, and alcohol industries all put a great deal of effort into lobbying for favourable policy decisions. Over the past 30 years, for example, the tobacco industry has gone to great lengths to try to influence the decisions of the European Commission and met with some success.14 By the same token, some of the greatest improvements in public health come about through changes in policy rather than individual behaviour. Seat belt legislation, water fluoridation, and laws prohibiting smoking are obvious examples.

Social marketing and health professionals can also contribute here. At base, public policy and other upstream interventions are still a matter of behaviour change—it is just that the changing has to be done by stakeholders rather than individuals. The principles are identical: “stakeholder marketing” depends on learning more about the motivations and needs of, say, a cabinet minister and ensuring that the required change meets his or her needs. When the public health community in Ireland wanted the minister of health, Micheál Martin, to ban smoking in public places, it encouraged him by presenting a clear public health case for the move and always being on hand to answer difficult media questions and challenges from groups with vested interests. It also made certain that he got full and appropriate credit for his courageous stance. In short, it met his political needs.

Doctors and other health professionals can have a vital role here both by talking to patients about potential benefits of specific policies and thereby contributing to a groundswell for change and by approaching policy makers directly. Marketers talk about “source effect”—the tendency for the power of a message to vary depending not just on what is said but on who says it. The trust enjoyed by health professionals makes them a particularly powerful source.

Fighting back

For decades the health sector has watched as big companies have used marketing to wreak havoc on public health. Social marketing enables us to fight fire with fire. Ideas like patient orientation, multifaceted interventions, strategic planning, and stakeholder marketing provide a useful way of thinking about how to change behaviour. They also sit comfortably alongside current views on patient centred health care and reinforce the role of doctors and health professionals in health improvement. In short, social marketing can help you do what you currently do better. And it works.