Toward the end of the twentieth century, public health professionals embraced a new strategy for promoting healthful behaviors and increasing the utilization of health services. The Centers for Disease Control and Prevention (CDC), the United States Department of Health and Human Services (USDHHS), the United States Department of Agriculture (USDA), and other federal and state agencies began using social marketing practices to promote protective and preventive health behaviors—such as fruit and vegetable consumption, physical exercise, and breastfeeding—and to increase utilization of programs and services like the Supplemental Food and Nutrition Program for Women, Infants and Children (WIC), prenatal care, and family planning.
Within the last thirty years, social marketing's application to public health problems has grown rapidly. Today, a wide range of public health and social service organizations in the United States are using social marketing, including the Centers for Disease Control and Prevention (CDC), the National Cancer Institute (NCI), the United States Department of Agriculture (USDA), the United States Department of Health and Human Services (USDHHS), and the American Association of Retired Persons (AARP). Public health administrators and health educators at the state and local level have also begun using social marketing as an approach for developing programs to bring about behavior change. Social marketing organizations have emerged to meet the growing demand for technical assistance with consumer research, strategic planning, communications, media advocacy, and other components in the social marketing process. Although formal degrees and credentialing are not awarded at this time, social marketing courses are now offered in many colleges of public health and business schools.
THE SOCIAL MARKETING APPROACH
The term "social marketing" was coined in 1971 by Kotler and Zaltman in their seminal article "Social Marketing: An Approach to Planned Social Change." It is defined as "the application of commercial marketing technologies to the analysis, planning, execution, and evaluation of programs designed to influence voluntary behavior of target audiences in order to improve their personal welfare and that of their society" (Andreasen, 1995. p.7). Social marketing is distinguished from other management approaches by six basic principles:(1) the marketing conceptual framework is used to design behavior change interventions; (2) there is recognition of competition; (3) there is a consumer orientation; (4) formative research is used to understand consumers' desires and needs; (5) there is a segmentation of populations and careful selection of target audiences; and (6) continuous monitoring and revision of program tactics help to achieve desired outcomes.
MARKETING'S CONCEPTUAL FRAMEWORK
Social marketing relies on commercial marketing's conceptual framework to guide program development and implementation. This framework places consumers at the center of an exchange process in which they act primarily out of self-interest—attempting to maximize the ability to satisfy wants and needs and minimize the cost to do so. Social marketing identifies consumer wants and needs and then develops ways to satisfy them. Marketing's framework, or the marketing mix, includes five components involved in the exchange process: the product (in social marketing, the product is the health behavior or service being promoted); its competition (the risk behavior currently practiced); the price (social, emotional, and monetary costs exchanged for the product's benefits); place (where the exchange takes place, or the target behavior is practiced); and promotion (activities used to facilitate the exchange).
Social marketing may be used to get people to adopt new protective behaviors such as healthfuldiets or exercise, or to stop practicing risky behaviors such as smoking. The product may also be a service such as prenatal care or immunization, with the objective being to increase people's utilization of the service. A commodity, such as a condom, may also be promoted, but again the focus is on the behavior associated with the commodity.
The behavior being promoted must provide benefits relevant to consumers. For this reason, marketers are interested in people's aspirations and desires, as well as their social or medical needs.
The marketing model also considers the competition posed by unhealthful or risky behaviors. Often, people must make a choice between protective or healthful behaviors and risky alternatives.
In marketing terms, the price of adopting a healthful behavior is also considered from the consumer's perspective. What will the consumer exchange in order to obtain the product's benefits? Some health behaviors require consumers to exchange money for the product, such as the cost of an exercise or weight loss program. Other public health products, such as the WIC program, may appear to be free. Closer examination reveals indirect monetary costs, such as lost wages, bus fares, or childcare fees that accompany the utilization of WIC services. Often costs are nonmonetary, including time, effort, embarrassment, and the perceived loss of pride and dignity associated with participation in government assistance programs or adopting certain behaviors.
To make the exchange more attractive to consumers, social marketing seeks to lower costs and to maximize benefits. Unfortunately, many protective health behaviors come with costs that are difficult to control. For some people, safe sex practices are not as pleasurable as the riskier competition. Many people have a hard time sacrificing the taste, satiety, and perceived pleasure of a highfat diet. Nevertheless, social marketers work to create an acceptable cost-benefit ratio.
The third "P" in marketing's framework is place—the location where services are provided, where tangible products are distributed, or where consumers receive information about new products or behaviors. Research is conducted to identify "life path points"—places that consumer's frequent—so that products and information can be placed there. Social marketing also identifies when and where a target audience will be most receptive to promotional messages.
The fourth "P" is promotion. Social marketing relies on health communications to inform and educate consumers. However, education and public information are only a part of a carefully planned set of activities designed to bring about change. In fact, an effective promotional strategy may include several communication elements, including objectives for each target audience; guidelines for designing attention-getting and effective messages; designation of appropriate communication channels; and credible, trustworthy spokespersons. Some large-scale, multifaceted projects rely on mass communications, public information, public relations, consumer education, lotteries, direct mail, and other means. Projects with more limited communications components may rely solely on personal counseling and print materials. Finally, to be effective, promotional strategies must be carefully coordinated with other components of the marketing mix. Promotional efforts cannot succeed if the product's benefits, price, and placement are not also in line with the people's wants and needs.
CONSUMER ORIENTATION
A central principle in the social marketing mindset is a commitment to understand the consumer and to design products to satisfy consumers' wants and needs. Those applying social marketing methods need to know about the people whose behavior they want to change—their aspirations and values; their relevant beliefs and attitudes; and their current behavioral patterns. They also look at the broader social and cultural factors that influence consumer behavior, recognizing that behavioral change is influenced by a combination of environmental as well as personal and interpersonal factors.
Unfortunately, many people still incorrectly equate marketing with sales and advertising. Marketing's consumer orientation is actually the antithesis of a sales orientation. In contrast to the belief that sales-stimulating devices are needed to bring results, a consumer orientation requires program planners to understand and respond to consumers' desires and needs. The social marketing approach seeks ways to design services and develop behavioral recommendations that are compatible with consumers' values and beliefs. In contrast to top-down, expert-driven approaches, social marketing attempts to create interventions that enable the target audience to solve problems and realize the dreams that people consider important.
Social marketers believe that the behaviors being promoted should contribute to the consumers' and society's well-being. However, people may have aspirations and desires that work against society's interests or conflict with their own health and well-being. There is a responsibility inherent in health promotion and education to design and deliver offerings that preserve and enhance social health, and marketing techniques do not abrogate this responsibility—they are tools that may help public health professionals reach those they need to reach.
CONSUMER RESEARCH
A consumer orientation requires an examination of consumer perceptions of product benefits, product price, the competition's benefits and costs, and other factors that influence consumer behavior. Marketing healthful behaviors relies on the social and behavioral sciences to guide formative research and subsequent program design.
Program planners use consumer research findings to identify the factors to address in promoting behavior change to the people they hope to reach. Drawing on a theoretical framework that combines elements from the Health Belief Model, Social Cognitive Theory, the Theory of Reasoned Action, and the Trans-theoretical Model of Behavior Change, research is designed to identify the mix of internal and external factors that have the greatest impact on people's health behavior. The behavioral orientation helps keep program planners on track by setting behavioral objectives for program interventions, and designing strategies that address the critical factors that determine a specific audience segment's adoption of the desired behavior. Research also helps program planners determine the specified behavioral recommendations that are most likely to be adopted by specific segments in the target population. Consumer research conducted to develop the Loving Support Makes Breastfeeding Work program for the National WIC Breastfeeding Promotion project revealed that families place a strong value on establishing a close, loving bond with their babies. While health concerns are also important, the emotional benefits associated with breastfeeding are paramount for pregnant women and their relatives. This knowledge helped program planners avoid the common mistake of promoting breastfeeding as a wise medical choice instead of a way to realize parents' dreams of creating of strong family bonds. Research also learned that recommendations to breastfeed for thirteen months or longer was not viewed as realistic by many WIC participants. Program planners were careful to avoid recommending a specific time period in an effort to motivate mothers who doubted their ability to breastfeed for more than a few months. This approach helped foster successful lactation initiation, which subsequently helps instill as sense of pride efficacy to breastfeed for even short periods of time.
AUDIENCE SEGMENTATION
Another distinguishing feature of social marketing is audience segmentation. Audience segmentation is the process of dividing a population into distinct groups based on characteristics that influence their responsiveness to interventions. Segmentation may be used to identify subgroups they can realistically be reached with available resources or to determine the best way to reach particular groups. Segments may differ in terms of the benefits they find most attractive, the price they are willing to pay, the best place to communicate with them or to locate services, or their differential responsiveness to promotional tactics.
CONTINUOUS MONITORING AND REVISION
Social marketing also relies on continuous program monitoring to assess program efficacy in encouraging the desired behavior changes. Monitoring also aids in identifying activities that are effective and those that are not, and in making midcourse corrections in program interventions. Many public health programs rely on process and impact evaluations to identify components that are working and those that should be discontinued, and social marketing devotes considerable resources to this activity. There are constant checks with target audiences to gauge their responses to all aspects of an intervention, from the broad marketing strategy to specific messages and materials.
Andreasen, A. (1995). Marketing Social Change: Changing Behavior to Promote Health, Social Development, and the Environment. San Francisco: Jossey-Bass.
Bryant, C.A.; Coreil, J.; D'Angelo, S.; Bailey, D.; and Lazarov, M. (1992). "A New Strategy for Promoting Breastfeeding Among Economically Disadvantaged Women and Adolescents." NAACOG's Clinical Issues in Perinatal and Women's Health Issues: Breastfeeding 3(4):723–730.
Cooper, P. D. (1994). Health Care Marketing. A Foundation for Managed Quality, 3rd edition. Gaithersburg, MD: Aspen Publishers.
Duncan, W. J.; Ginter, P. M.; and Swayne, L. E. (1998). Handbook of Health Care Management. Malden, MA: Blackwell Business.
Furse, D. H.; Burcham, M. R.; Rose, R. L.; and Oliver, R. W. (1994). "Leveraging the Value of Customer Satisfaction Information." Journal of Health Care Marketing 14(3):16–20.
Kotler P. (1999). On Marketing. New York: The Free Press.
Kotler, P., and Andreasen, A. (1991). Strategic Marketing for Non Profit Organizations, 4th edition. Englewood Cliffs, NJ: Prentice-Hall.
Kotler, P., and Armstrong, G. (1996). Principles of Marketing, 7th edition. Englewood Cliffs, NJ: Prentice Hall.
Kotler P., and Clarke, R. N. (1987). Marketing for Health Care Organizations. Englewood Cliffs, NJ: Prentice-Hall.
Kotler, P., and Zaltman, G. (1971). "Social Marketing: An Approach to Planned Social Change." Journal of Marketing 35:3–12.
Fishbein, M.; Guenther-Grey, C.; Johnson, W.; Wolitski, R. J.; McAlister, A.; Rietmeyer, C. A; and O'Reilly, K.(1997). "Using Theory-Based Community Intervention to Reduce AIDS Risk Behaviors: The CDC's AIDS Community Demonstration Project." In Social Marketing: Theoretical and Practical Perspectives. eds. M. E. Goldberg, M. Fishbein, and S. E. Middlestadt. Mahwah, NJ: Erlbaum.
Lefebvre, R. C.; Doner, L.; Johnston, C.; Loughrey, K.; Balch, G. I.; and Sutton, S. M. (1995). "Use of Database Marketing and Consumer-Based Health Communication in Message Design: An Example from the Office of Cancer Communications' '5 a Day for Better Health' Program." In Designing Health Messages: Approaches from Communication Theory and Public Health Practice. eds. E. Maibach and R. Parrot. Thousand Oaks, CA: Sage.
Lefebvre, C., and Flora, J. A. (1998). "Social Marketing and Public Health Intervention." Health Education Quarterly 15(3):299–315.
Lindenberger, J. H., and Bryant, C. A. (2000). "Promoting Breastfeeding in the WIC Program: A Social Marketing Case Study." American Journal of Health Behavior 24(1):53–60.
McCormack-Brown, K.; Bryant, C. A.; Forthofer, M.; Perrin, K.; Guinn, Q.; Wolper, M.; and Lindenberger, J. (2000). "Florida Cares for Women Social Marketing Campaign: A Case Study." American Journal of Health Behavior 24(1):44–52.
Middlestadt, S. E.; Schechter, C.; Peyton, J.; and Tjugum, B. (1997). "Community Involvement in Health Planning: Lessons Learned from Practicing Social Marketing in a Context of Community Control, Participation & Ownership." In Social Marketing: Theoretical and Practical Perspectives. eds. M. E. Goldbert, M. Fishbein, and S. E. Middlestadt. Mahwah, NJ: Lawrence Erlbaum.
Nitse, P. S., and Rushing, V. (1996). "Patient Satisfaction: The New Area of Focus for the Physician's Office." Health Marketing Quarterly 14(2):73–84.
Smith, W. A., and Middlestadt, S. E. (1993). "The Applied Behavior Change Framework." In The World Against AIDS: Communication for Behavior Change. Washington, DC: The Academy for Educational Development.
Wheatley, E. W. (1997). "Patient Expectations and Marketing Programming for OB/GYN Services." Health Marketing Quarterly 14(3):35–51.
