Health equity case studies
The examples of social marketing we have included have been selected because we believe they provide important lessons for those agencies that want to influence the wider social determinants of health. According to the WHO the social determinants of health are “the conditions in which people are born, grow, live, work and age, including the health system”. Although social marketing is a process that is specifically designed to influence very specific individual behaviours, it has also been used extensively to shape the external conditions that influence the adoption and maintenance of these behaviours by large groups of people.
Social marketing is a planning system that uses research techniques to design behaviour change interventions for large population segments and we now have compelling evidence that it can achieve measurable and sustained changes in behaviour. Because it starts by trying to understand the factors that influence specific behaviours the process has already helped a number of government agencies and NGO’s to improve the integration of existing influencing tools such as: regulation and enforcement, public services and products, economic incentives and the provision of information.
The video below explains a little about the Social Determinants of Health and how vitally important it is to engage with the people your programme is trying trying to help.
The case examples included in this demonstrate how government agencies and NGO’s have applied social marketing to successfully increase the adoption of healthy behaviours such as stopping smoking, getting a breast exam, or eating more fruit and vegetables. Other examples look at how social marketing can be used to address important social issues such as crime, problem gambling, unemployment and road safety. All of these cases also demonstrate practical and cost-effective attempts to change the social and environmental contexts that shape many of our, often unconscious and habitual, behaviours.
England’s National Marketing Strategy for Tobacco Control (2007-2010)
Reducing graffiti vandalism in Brent (2006 – ongoing)
Increasing the uptake of breast screening in Tower Hamlets (2007 – ongoing)
Using marketing to maintain support for sweden’s Alcohol Monopoly (2002 – ongoing)
The Change4life campaign to reduce childhood obesity (2008 ongoing)
KIWI LIVES addresses problem gambling in New Zealand (2005 ongoing)
“Take Charge. Take the Test” campaign to increase Hiv testing by african american women
Increasing the use of car seats by Hispanic Children in Dallas, Texas
Slovenia – let’s live healthy programme
Denmark U-Turn Project - improving young people's lives
North Tyneside – SUB21 Reducing kerbside drinking by young people
Reducing levels of worklessness - Lincolnshire
Riders for Health – Providing sustainable health transport services in Africa
England’s National Marketing Strategy for Tobacco Control (2007-2010)
Smoking is the primary cause of health inequalities in life expectancy and the single greatest avoidable cause of death and disease in the UK. Every year 80,000 people die prematurely as a result of tobacco use resulting in £2.7b direct costs to the NHS and £2.5b in sick leave & lost productivity.
Between 1998 and 2007 adult smoking rates in England had fallen from 28 per cent to 21 per cent, representing over 1.6 million fewer smokers. However the Government’s national marketing campaigns had not been as successful in helping to reduce higher smoking prevalence among Routine & Manual (R&M) workers.
In 2007 the England Department of Health developed a new and innovative marketing strategy to address smoking prevalence among routine and manual (R&M) workers to 26 per cent or less by 2010.
How did the project address the social determinants of health?
At the start of the project there were 4.25 million R&M smokers in England but it was estimated that prevalence would fall naturally to 28.2 per cent by 2010. However, with a £45 million investment in marketing activity, it was expected that prevalence would drop further to 26.5 per cent .In order to achieve this target some 317,000 R&M smokers would need to quit as a direct result of the social marketing activity.
How did the project apply a social marketing approach?
The Department of Health developed a new marketing strategy that was built on key insights into the R&M target group. The research found that:
- Family was very important but smoking was also much more of a social norm among this R&M group
- Many viewed smoking as one of their few pleasures in life
- Their impression was that the majority of people smoke, yet they are made to feel like ‘social lepers’
- Many were unaware of the benefits of using NHS Stop Smoking Services and more likely to try and go cold turkey
- They would often relapse because of the lack of emotional support from partners and peers
- They felt impervious to existing advertising messages and that services weren’t designed for people like them
These insights were used to develop a new two-pronged Marketing Strategy that:
- Focused on the harm being done to a smoker’s family as a way of;
- Driving people towards NSH stop smoking services
Rather than simply focusing on “motivation” the new marketing approach focused on:
- Encouraging smokers who want to quit to make a quitting-related action, such as phoning the helpline and;
- Encouraging people to use NHS support (which had been proven to be far more successful in helping people to maintain long-term quits).
This approach was based on the central insights that:
- “I can harm myself if I like but I’ve got no right to worry my kids”
- “The fags might not kill me for years but I know they're worrying my family right now”
Much of the marketing focused on the fact that the children of smokers were 3 times more likely to become smokers themselves. It also focused on the emotional driver that many children worried about the health of their parents and would do anything to help them stop. By making smoking a family issue it was far more difficult for R&M targets to deflect this new approach. The marketing effort also worked to raise awareness of the different forms of NHS support and to normalise these services by showing them being used by people like them.
A new “Quit Kit” was designed as a direct marketing tool that would appeal to cold turkey quitters. By taking a pragmatic view that not all R&M smokers would want to immediately use the NHS services they were able to build relationships with a huge number of “new” contacts. Between January and March 2010, over 480,000 ‘Quit Kits’ were ordered, and 95 per cent of these orders were from people who had not responded to previous marketing efforts.
The project also utilized a range of direct community-based marketing activities such as “pop up” shops in R&M “hot spots” and onsite clinics with big employers such as ASDA with 360 separate supermarket sites.
What impact did it have?
As a result of the marketing activity it is estimated that over 1.5 million people from the R&M group made quit attempts and nearly 220,000 successfully sustained their quit 1 year later. Over two years, the customer relationship marketing programme increased quitting success rates among participants by 57 per cent.
What are the key lessons?
The insights generated via audience research can be used to determine the best mix of tools needed to support smokers to make successful quit attempts and change the social norms that continue to make smoking normal for significant segments of our population.
The social marketing approach can help to design a more integrated approach that can directly respond to the unique needs of different audience segments such as R&M smokers. This project demonstrated the need to empower people with the confidence and tools to break down a daunting behavioural challenge into manageable steps and to understand how support services can be made more attractive target audience.
The investment in this national social marketing programme translated into many other local campaigns aimed to tackling the issue of high incidence of smoking in the R&M groups. One of the most successful was a social marketing programme developed by NHS Stockport in North-west England.
NHS Stockport - lose the fags: reducing smoking prealence in a deprived community in North west England
This community social marketing project, led by NHS Stockport in partnership with the NSMC, aimed to increase access to smoking cessation services in Brinnington, a housing estate in Stockport ranked in the top 3% of the most deprived areas of England. It suffers high unemployment, low education levels, premature death – with a high smoking prevalence of 54%.
How did the project address the social determinants of health?
NHS funded smoking cessation services initially attracted residents of the area but its popularity had steadily declined over a period of years. Smoking is very much part of life in Brinnington and it lies at the heart of many daily social interactions. Indeed stopping smoking was seen as going against the social norm. People complain of being stressed as a result dealing with financial worries, unruly family members and caring for children without the support of partners. For many people in the community, smoking provides an emotional crutch.
Despite these factors, research revealed that many women especially with children did actually want to quit, driven by fear of ill-health while also trying to provide a positive role model to their children. However, low confidence levels and practical issues around childcare prevented them from taking action. For men in the community, who often worked in irregular shift patterns, out of hours access was essential. In addition there was a lack of trust in “authority”. Residents perceived that they were being bombarded by “outsiders” offering help. To have any chance of success, the development of the intervention would need to be co-created with key community members and be situated in a trusted safe and familiar environment.
- The intervention for men: A convenient stop-smoking support at a local gym, available from 7am to 9pm where fitness instructors had been trained as smoking cessation advisors and were able to deliver vouchers for NRT, which could be exchanged at the local pharmacy. Additionally an anger/stress management advice was provided.
- The intervention for women: A child/mother friendly service was set-up at a local community centre serving refreshments, providing a crèche. The aim of the social marketing intervention was to build skills and confidence to ensure that participants were able to increase their self-esteem to tackle the issue of cigarette addiction.
Key impacts and lessons learnt for policy makers
The project was a triumph for developing long-term community partnerships. Many of the established organisations in the local area integrated smoking cessation services as part of their core offering. This singular focus on lowering the smoking rate helped to build greater social capital and belief that local resources could be mobilized to improve the health of the whole community. Quit attempts increased by 47% in the first year of the project (from 149 to 220 with successful quits rising from 60 to 84.) This momentum has been maintained over the last couple of years. Gradually non-smoking is becoming the social norm in Brinnington. Find out much more about this project by looking at our showcase database
Reducing graffiti vandalism in Brent (2006 – ongoing)
In 2006, Brent Council was spending approximately £450,000 a year cleaning up graffiti.
The Brent Graffiti Partnership Board used a social marketing approach to design a project that combined stronger enforcement with diversionary activities to help steer young people away from graffiti vandalism. This approach helped to reduce graffiti vandalism by 25% and increased the percentage of residents who felt that the clean streets were a good thing about living in Brent.
How did the project address the social determinants of health?
This project was specifically designed to improve the physical and social environment of the Brent community. With no direct funding the project used stronger community partnerships and a greater understanding of young people to build benefits for the entire community. By working to understand the drivers of graffiti behaviour the project was able to identify alternatives that provided the same sense of risk for young people while also contributing to their self-esteem and greater community pride in the wider Brent environment.
How did the project apply a social marketing approach?
Because the Brent Graffiti Partnership Board had no direct budget the project had to take a more integrated approach that built on the strategic objectives of the contributing agencies. The project generated insights from young people, graffiti offenders, victims of graffiti vandalism and local residents to develop an approach that included:
- Diversionary activities such as;
- The creation of community public artworks
- Workshops and competitions in street art
- Parkour[1] (free running) and
- Football sessions
The council also introduced stronger enforcement activities that directly resulted in penalties for 40 prolific taggers. Prior to the project no tagger had been apprehended or punished.
What impact did it have?
The project significantly reduced levels of graffiti and helped to provide many of the most disaffected young people with opportunities to build new skills and greater self-confidence. The project also led to greater community pride and a survey found that the percentage of residents who felt that the clean streets were a good thing about living in Brent increased from 13 per cent in 2005 to 21 per cent in 2009.
The project also helped to strengthen relationships among a wide range of agencies and community stakeholders and provide a model for addressing other social problems in the community.
What are the key lessons?
The project demonstrated the importance of providing a 2-pronged approach that combined enforcement with attractive alternatives based on a deeper understanding of what was motivating the current behaviour of the target audience. It also found that these alternatives had to provide an appropriate replacement for the benefit that the current behaviour was providing the target audience. That is why the risk and challenge provided by Parkour proved to be one of the most successful activities embraced by young people previously most engaged in graffiti tagging. More details are available on showcase
There has been considerable debate on what actions are most likely to have the biggest impact on reducing health inequalities. However, it is accepted that implementing programmes that are aimed at and have an impact on children and young people should be prioritised. The following social marketing programme successfully developed a significant change in eating habits of young people.
The Food Dudes programme has been consistently effective at increasing the consumption of fruit and vegetables among 4- to 11-year-olds. Following significant success in Ireland the programme was launched as a city-wide project in Wolverhampton in 2009 and it was awarded the Gold medal at England’s Chief Medical Officer’s Public Health Awards 2010.
The programme comprises three key elements:
- DVD adventures featuring hero figures, the “Food Dudes” who like fruit/vegetables and provide social models for children to imitate
- Small rewards to ensure children begin to taste new foods
- Repeated tasting of fruit and vegetables so that children develop a liking for these foods
Food Dudes letters and home packs provide on-going home support to ensure the behaviour change transfers from school to family and is maintained over time.
How did the project address the social determinants of health?
A diet rich in fresh fruit and vegetables is vital for health and wellbeing but low fruit and vegetable intake can lead to a variety of serious illnesses, such as cardiovascular disease, stroke and cancer. The recommended “5-a-day” means eating at least 400g of fruit and vegetables a day but the UK has one of the lowest fruit and vegetable intakes in Europe. Current British consumption levels are estimated to average only 245g and, in some age and social groupings, the real figure is substantially lower, especially among the poorest children.
How did the project apply a social marketing approach?
Food Dudes is based on the “Three R’s” of role-modelling, rewards and repeated tasting. It uses positive role-models, repeated tasting and rewards to encourage children to try and to learn to like fruit and vegetables. Food Dudes works on the premise that these simple techniques can be used encourage children to try new foods and to re-categorise themselves fruit and vegetable likers.
A strong brand was developed to compete with the cartoon figures and imagery used to market high sugar, fat and salt foods to children. The programme also sought to utilise peer pressure by getting older peers on board and making it “cool” to eat fruit and vegetables.
The programme focused on overcoming the barriers of getting children to eat fruit and vegetables by creating a positive environment (at home and school) in which they are encouraged to try new foods and develop a taste for them. Following the adventures of the Food Dudes DVD is a fun experience to share with friends and giving children pencils, beakers and small toys to reward good behaviour makes participation fun.
Children come to see themselves as 'fruit and vegetable eaters' and are proud of this new identity and they gain kudos and self-confidence from being able to succeed on the programme. Early rewards, such as stickers and juggling balls, are used to encourage children to taste new foods, but these are eventually phased out and replaced by the longer-lasting incentive of enjoying the taste of these foods.
What impact did it have?
Starting in 2005, the programme was piloted over a two-year period in two primary schools in Dublin. In these trials the fruit consumption of five- to six-year olds more than doubled, from 28 per cent to 59 per cent over six months, while vegetable consumption increased from 8 per cent to 32 per cent. This was true even when popular sweet and savoury snacks were presented alongside the fruit and vegetables, demonstrating the ability of fruit and vegetables to hold their own against strong food competitors if positive taste patterns can be established. By 2007 the Irish Government had made the Food Dudes programme available to every primary school in Ireland.
In its first year 22 schools and 5,000 children from Wolverhampton accessed the programme. Initial research in six participating schools found that children increased their fruit consumption by 54 per cent and vegetable consumption by 48 per cent. Following success in Ireland and Wolverhampton the project has been implemented in Bedfordshire, Coventry, Dudley, Yorkshire, Italy, California and Utah.
What are the key lessons?
The use of robust monitoring and evaluation techniques has helped to prove and promote the effectiveness of the “Three R’s” role-modelling, rewards and repeated tasting approach in changing and maintain behaviour, and providing value for money for funders.
Changing the eating behaviours of young people can have significant longer term impacts on the social gradient. By establishing a healthier diet at such an early stage we can help to increase concentration levels and more successful students will ultimately lead to improved education levels and greater employment opportunities
Increasing the uptake of breast screening in Tower Hamlets (2007 – ongoing)
In 2006 Tower Hamlets the breast screening rates were only 51 per cent, compared to the national rate of 76 per cent, and breast cancer was the most common cause of cancer deaths among women in the borough. In order to address this issue NHS Tower Hamlets allocated £106,000 towards a social marketing project designed to:
- Encourage members of target audience to attend breast screening and to;
- To make the breast screening service more client-focused.
How did the project address the social determinants of health?
Specific interventions were focused on white British/Irish and Bangladeshi women, particularly from lower socioeconomic classes, who had been identified as having especially low breast screening attendance rates.
Reducing the impacts of illness and premature death has huge impact on all families but it is especially difficult for those from lower social economic groups where the wider consequences can be particularly devastating for one parent families, wage earners and carers.
How did the project apply a social marketing approach?
Interventions included two distinct marketing campaigns for the two different audiences together with associated improvements to the breast screening service.
Bangladeshi women
Research found that this group responded very positively to a clear, directional approach from their GP with a message that screening was important for a woman’s health and that it was important to stay healthy for her family. A marketing campaign entitled “We’re here to help” was fronted by a local female Bangladeshi GP, Dr Anwara Ali, who was the GP screening lead for Tower Hamlets.
White British/Irish women
The approach for this group emphasised the benefits of screening rather than highlighting the dangers of cancer. A marketing campaign entitled ‘I’ve done it!’ was fronted by local white British women who had been screened. Their personal stories were written up as case studies to support media activity and they were also trained to participate in on-going media and community activities.
Service improvements
Specific system changes were designed to encourage greater responsiveness to customer needs:
- A system of “payment per woman screened” was introduced to replace block payments for providers
- A Local Enhanced Scheme was designed to incentivise GPs to increase participation in screening. Payment was based on the number of additional eligible women screened within each practice
- Customer service training was provided for staff and opening times were extended over evening and weekends
- A dedicated breast screening website enabled women to change or cancel appointments can be cancelled or changed
- New communications tools included: redesigned invitation letters, picture-based leaflets, and “talking invitations” aimed particularly at those with poor literacy
- Specific Did Not Attend (DNA) initiatives were used to follow up women who had missed their appointments
- Community groups called women to discuss their invitation to a breast screening appointment three days prior to their first appointment, or to discuss why they had not attended their appointment during the previous screening round, rebooking their appointments and providing transport for groups of women to attend for screening.
What impact did it have?
Breast screening rates increased from 52.3 per cent (2006/07) to 65.9 per cent (2009/10) and overall increase of more than 13 per cent. While rates varied across the participating GP practices, one practice reached a high of almost 80 per cent.
What are the key lessons?
Using a targeted social marketing approach enabled NHS Tower Hamlets to make overall system changes that ensured the whole screening process was more coordinated, client-focused and cost-effective. More details of the programme can be found on the NSMC showcase
Using marketing to maintain support for sweden’s Alcohol Monopoly (2002 – ongoing)
Social marketing programmes have helped to significantly lower rates of illness and premature deaths among some of the most vulnerable groups in society. To date most examples of social marketing in the United Kingdom have focused on influencing the behaviour of specific target audiences at the community level. However, in Scandinavia, it is well known that several countries have worked to maintain low levels of alcohol consumption by reducing access through state-owned retail monopolies shops and expensive taxation policies. The following example examines how a national social marketing campaign in Sweden worked successfully to maintain public support for this policy approach, despite major pressures from the private sector.
Alcohol is considered the fifth leading risk factor for death and disability in the world. Sweden once had high rates of alcohol consumption but now it is among the lowest in Europe. However, due to factors such as increases in accessibility and disposable income, alcohol consumption increased significantly in Sweden from 7.8 litres of pure (100%) alcohol in 1995 to 10.2 litres in 2005.
Because rates of alcohol consumption are affected by accessibility, price and the marketing activities of alcohol companies, the Swedish government decided to use an “upstream” social marketing approach to maintain public support for the country’s alcohol retail monopoly.
“Systembolaget” has a nationwide retail network of 418 stores and over 500 agents serving smaller communities. Its vision is to promote a “healthy drinking culture” where people are encouraged to focus on the quality and not the quantity of their drinking. The stores are brand-neutral which means promotion of individual products or producers is avoided, which allows the advice to be provided entirely on the customer’s terms. It is based on a non-profit idea because a lack of profit, along with limiting availability to specific shops with restricted opening hours, is expected to limit consumption.
Rather than focus on voluntary behaviour change, this use of marketing focused on influencing the choice architecture that influences the purchasing behaviour for alcohol products. When Sweden joined the EU in 1995 there was increasing pressure to open up the country’s alcohol market to the private sector but government marketing activities helped to ensure on-going public support for maintaining the alcohol monopoly.
How did the project address the social determinants of health?
In 2003 the cost of alcohol related harms in the EU was estimated at US$156 billion with spending on alcohol related problems such as crime, health and traffic accidents estimated at US$82 billion. It has also been estimated that an alcohol monopoly keeps alcohol consumption down by 30% compared with a free market where alcohol can be bought in any retail store.
How did the project apply a social marketing approach?
A Swedish advertising agency was commissioned to carry out a series of interrelated media campaigns to increase public understanding of the benefits of the alcohol monopoly while also increasing customer satisfaction with the service and selection of products provided by Systembolaget.
From 2002 the campaign focused on presenting facts about what would be likely to happen if the monopoly was removed. For example, the 2007 campaign focused on communicating findings from a report by the National Institute for Public Health that estimated selling alcohol in grocery would result in 1580 alcohol-related deaths, 14,200 assaults and 16.1 million sick days.
What impact did it have?
Before the first campaign was launched in November 2002 public surveys found that 49% of people wanted to maintain the alcohol monopoly. By the end of 2002 this figure had risen to 57%.The 2007 campaign saw this approval rating increase from 57% to 65% in November 2007.
What are the key lessons?
This project demonstrates the role that social marketing approaches can provide in shaping or maintaining the choice architecture that shapes our behaviours. By increasing customer satisfaction with its alcohol monopoly the Swedish Government has avoided the need for expensive public campaigns focused on increasing responsible drinking at an individual level. Social marketing campaigns that focus solely on changing individual “voluntary” behaviour without addressing key environmental factors such as accessibility, price and the intensive marketing of competing products are highly unlikely to succeed in reducing ingrained behaviours such as high levels of alcohol consumption.
The Change4life campaign to reduce childhood obesity (2008 ongoing)
The following example investigates an ambitious and challenging national programme that was designed to reducing the rising levels of obesity in England’s children.
Change4Life is England’s first ever national social marketing campaign to reduce childhood obesity and focuses on changing the eating and physical behaviour of children under 11 from those families at greatest risk. In 2008 the Government announced the allocation of £372 million towards major cross-government programme designed to change the behaviours and circumstances that lead to weight gain. As part of this programme £75 million was allocated towards Change4Life, a 3-year social marketing programme to help parents make healthier food choices for their children and encourage more physical activity.
How did the project address the social determinants of health?
Around one-third of children and two-thirds of adults in England are already overweight or obese. If trends continue as forecast, by 2050 only 1 in 10 of the adult population will be a healthy weight. This could mean a doubling in the direct healthcare costs of overweight and obesity, with the wider costs to society reaching £49.9 billion by 2050.
In order to help all individuals to maintain a healthy weight the government realised it would need to create an environment in which it would be easier for families to make healthier choices. Change4Life recognised the need to:
- Understand the specific attitudes and behaviours needed to prevent obesity in children;
- Work with those families most at risk;
- Create a wider movement and support for necessary changes to the wider environment that influences our choices and behaviours around eating and physical activity.
How did the project apply a social marketing approach?
The campaign initially worked to help families understand the health risks associated with current diets and low levels of physical activity. It then worked to encourage parents to focus on 8 behaviour areas including:
- Reducing sugar intake (‘Sugar Swaps’)
- Increasing consumption of fruit and vegetables (‘5 A Day’)
- Having structured meals, especially breakfast (‘Meal Time’)
- Reducing unhealthy snacking (‘Snack Check’)
- Reducing portion size (‘Me Size Meals’)
- Reducing fat consumption (‘Cut Back Fat’)
- 60 minutes of moderate intensity activity (‘60 Active Minutes’)
- Reducing sedentary behaviour (‘Up & About’)
At-risk families were given the opportunity to sign up to an on-going Customer Relationship Management (CRM) programme designed to support these new behaviours. Delivered online and by post, this programme provided encouragement, information and support for families to get their children eating better and moving more. The ‘How are the kids?’ mechanism was the main entry point for most of the 200,000 families that joined the Change4Life CRM programme which provided families with helpful information, games and resources such as pedometers.
At the start of the programme seven commercial organisations had signed the Change4life terms of engagement and made pledges to support the campaign. Activity has included:
- Providing lower-cost fruit and vegetables (Tesco)
- Selling 70,000 family bikes at cost (ASDA)
- Sponsoring the London Marathon as the Flora Change4Life London Marathon (Unilever)
- Funding breakfast clubs (Kellogg’s)
- Funding free swimming for all customers (British Gas)
With the change in government in summer 2010, the new coalition government has progressively scaled back Labour’s £75 million marketing budget for Change4Life in its plans to cut its ad spending by up to 50 per cent. The Health Secretary, Andrew Lansley, has been asking the food and drink industry to take greater responsibility for funding the anti-obesity initiative in exchange for no new regulation.
As part of this new approach, the ‘Great Swapathon’ campaign was launched in January 2011, which aims to urge families to swap at least one unhealthy habit for a healthier one. Partnering with News of the World and ASDA, Change4Life is giving away 5 million voucher booklets, worth over £50 each, with money off healthier foods, drinks and activities.
What impact did it have?
413,466 families joined Change4Life in the first 12 months and over 44,833 families were believed to still be involved with Change4Life after 6 months.
Three in 10 mothers who were aware of Change4Life claim to have made a change to their children’s behaviours as a direct result of the campaign. This equates to over one million mothers claiming to have made changes in response to the campaign
The number of mothers claiming that their children do all 8 behaviours increased from 16 per cent at the baseline to 20 per cent by quarter 4. The proportion of families having adopted at least four of the behaviours has increased, suggesting the campaign has persuaded people with much less healthy lifestyles to make an effort to improve their health.
Shopping basket analysis found differences in the purchasing behaviour of 10,000 families who were most engaged with Change4Life relative to a control group. In particular, there were changes in the purchases of beverages among Change4Life families, who favoured low-fat milks and low-sugar drinks
The proportion of mothers from the target segments claiming to serve child sized portions increased from 60%– 69%, but the proportion of target mothers from the target segments who were aware of the need to provide “Me Size Meals” increased dramatically from 4% to 36%.
What are the key lessons?
The Change4Life brand identity captured the imagination of the public and provided a rallying call for those already working in the area. It helped to raise far greater public awareness of the personal risks associated with being overweight and it helped to mobilise greater community support for healthier diet and physical activity choices for children.
Change4Life has helped to further the debate about the role of increased personal responsibility within a “choice environment” that has made it far easier for children to eat poorly and to exercise less. While the campaign has resulted in far greater awareness of the obesity issue, it has also posed serious questions about the further actions needed to support the adoption of healthier behaviours related to diet and physical activity.
KIWI LIVES addresses problem gambling in New Zealand (2005 ongoing)
The next case study examines the often “hidden” but rapidly growing issue of problem gambling. This programme aimed to reduce gambling addiction among New Zealand’s among most vulnerable communities. The impact that gambling can have on those addicted and on their dependants can be extremely detrimental in terms of severely reducing household income as well as the increase in stress, anxiety and often violence related to this highly addictive activity.
The New Zealand Health Sponsorship Council’s Kiwi Lives campaign was designed to prevent and reduce problem gambling and gambling harm among at-risk gamblers (particularly those that frequently play electronic gaming machines).
How did the project address the social determinants of health?
Problem gambling affects several groups disproportionately including Māori and Pacific peoples, those of low socioeconomic status, and some Asian communities. Problem gamblers and those close to them can experience a wide range of problems including: stress-related physical and psychological ill health; family breakdown; domestic violence; criminal activity such as fraud; disruption to or loss of employment; other dependencies such as alcoholism and substance misuse; and social isolation.
How did the project apply a social marketing approach?
The campaign began by raising awareness of problem gambling, then introduced messages on how to seek help, followed by focusing on specific behaviours, such as encouraging those at risk of gambling harm (particularly those that frequently play electronic gaming machines and others in their lives) to seek help early. The secondary audience for the campaign included friends and family of those at-risk gamblers, and staff within venues with gambling facilities such as electronic gaming machines.
The next stage used real people with real stories to show that it can affect every day New Zealanders, and showed what they have done to make things better. The first advertisements helped to identify risky behaviours and provide an example of how a friend or family member can intervene effectively. The aim was to demonstrate that help-seeking and self-management can be simple and private. A further advertisement demonstrates an example of good host responsibility. The aim of this is to make it acceptable that venue staff, as responsible hosts, can and will intervene with at-risk gamblers.
For problem gamblers or for those worried that someone close to them has a problem with gambling, the programme signposts to a number of support services including:
- Telephone hotlines – The 24-hour Gambling Helpline offers free and confidential information and support over the phone, and can help arrange for someone to see a counsellor. Specialist hotlines exist – Māori Gambling Helpline, Pasifika Gambling Helpline, Youth Gambling Helpline, Gambling Debt Helpline, and Problem Gambling Foundation Asian Hotline.
- Free face-to-face counselling – Provided through the Problem Gambling Foundation, the Salvation Army Oasis Centre and the smaller Māori and Pacific Services
- Support groups – Such as Gambling Anonymous meetings
What impact did it have?
The 2009 Evaluation found that
- 16 per cent said they did something as a result of seeing the advertisements
- 30 per cent said they had talked to friends and family about problem gambling
- 55 per cent were more concerned about problem gambling than before
- 51 per cent felt more able to take action about problem gambling
There was a particularly strong response to the advertisements by Māori and Pacific peoples, those who played a number of ‘continuous’ gambling activities and those who had seen first-hand the effects of problem gambling.
Calls to the Gambling Helpline increased approximately 30 per cent during the campaign.
What are the key lessons?
The campaign demonstrates the important role of the government in making the public aware of gambling related harms and in providing appropriate mechanisms for at risk groups to seek help and support. It also highlights the importance of providing friends, family and responsible “hosts” with the permission and support needed to intervene before gambling becomes harmful.
“Take Charge. Take the Test” campaign to increase Hiv testing by african american women
In 2006/7 the United States Centres for Disease Control and Prevention implemented a one-year social marketing campaign in Cleveland (OH) and Philadelphia (PA) to increase HIV testing among African American women at high risk for HIV infection.
How did the project address the social determinants of health?
In 2005 there were one million people living with HIV/Aids in the US and approximately 40,000 people were becoming infected each year. Up to two-thirds of new HIV infections are transmitted by persons who do not know they are infected.
Half of all new HIV infections in the US occur among African Americans, despite only making up 13 per cent of the US population. Among women 67% of all new cases are African American and HIV is the leading cause of death for black women ages 25 to 34. Poverty contributes significantly to the rising incidence of HIV/AIDS among African- American women. However few African Americans were getting tested for HIV regularly, with many unaware of the alarming HIV trends in their community.
How did the project apply a social marketing approach?
A social marketing segmentation approach was used to identify the primary target audience as single African American women aged 18 to 34
- With some college education or less
- Who warned US$30,000 or less per year
- That resided in certain zip codes with high HIV-prevalence
- And were having unprotected sex with men
The objective of the programme was to increase the number of women from this segment who were getting an HIV test after having unprotected sex but research found a number of barriers and motivators related to HIV testing.
Barriers
- Belief that testing will be expensive and time consuming
- Belief that good, affordable treatment is not available
- Unaware of facilities for testing
- Belief that HIV testing is part of annual physical
- Fear of being positive
- Fear of rejection from family and community if found to be positive
- Loss of insurance and/or employment if results reported to government/state authorities
- Anxiety about waiting for results
- Low perception of personal risk
Motivators
- Concern and uncertainty over whether a partner is being faithful and/or if heard something about a current or previous partner
- Desire to be present and available for children
- Desire to protect others and limit further HIV transmission (if found to be positive)
- Peace of mind and ability to control one’s life and future
- Potential to receive earlier treatment if found to be positive
The key message was based on the empowerment that comes with getting tested –
“Take Charge, Take the Test - You feel as if you’ve known him forever, but that doesn’t mean you know everything. Get an HIV test and look out for yourself”.
There was a strong emphasis on normative messages that reinforced the idea that many other African-American women were also getting tested for HIV. The programme also worked to improve the availability and convenience of testing with a number of fun community events where rapid HIV tests were also made available.
What impact did it have?
The campaign helped to improve the coordination and provision of existing HIV testing services but there was no significant rise in testing rates through existing services. However there was significant increase in rapid testing through the 48 community events that attracted more than 9600 attendees. These events administered 1492 rapid tests identifying 14 HIV-positive cases. The key lessons from this pilot programme have now been used to develop similar initiatives elsewhere throughout the United States.
What are the key lessons?
It is critical that any social marketing effort is designed to engage the support of both the target audience and the wider community that shapes behavioural norms and attitudes.
Campaign messages may motivate the target audience to find out more about HIV testing but expanding the number and reach of community-based testing events may have substantial potential to increase HIV testing by helping to remove the barriers between intention and action.
Increasing the use of car seats by Hispanic Children in Dallas, Texas
The following case study demonstrates how important people’s culture and beliefs are when an external organisation is seeking to have an impact on their behaviour. It also confirms the dramatic impact a social marketing programme can have when other “educational” approaches have failed.
This community-based, culturally integrated programme aimed to increase the use of child safety seats (CSSs) in a Hispanic neighbourhood in the west Dallas area of Texas. The ultimate aim was to reduce the number of child injuries and fatalities occurring due to the lack of use of car seats and booster seats. Based on structured observational surveys, use of safety restraints among Hispanic preschool-aged children increased from a baseline of 21 per cent to 73 per cent three years after the programme launch.
How did the project address the social determinants of health?
Child passenger motor vehicle crashes are the leading cause of death for children aged 1 to 14. However, many of these deaths and injuries associated with motor vehicle crashes can be prevented by using proper child passenger safety restraints, such as car seats and booster seats.
In the US the use of safety restraints in motor vehicles is lowest among minority and low-income populations. In Texas data clearly showed that a disproportionate percentage of car accidents involved people of Hispanic origin
Dallas has a large Hispanic population, which makes up 43.1 per cent of the city’s total population. A preliminary survey of Hispanic preschool children in west Dallas, carried out in 1997, showed much lower child restraint use (19 per cent of those surveyed) than among preschool children of all races in the rest of the city (62 per cent).
How did the project apply a social marketing approach?
Mothers of young children within Hispanic communities were targeted because they tended to be responsible for supervising their children and were seen as authority figures within the community. Research with this group found there was a lack of information on child restraint laws, the importance of using car seats and how to properly install and use them, especially among more recent immigrants.
Fatalistic views and the belief that any potential accidents were in God’s hands were key internal competitors to getting parents to use child safety seats. This led parents to believe that using car seats would have very little impact on changing their destiny. Even amongst those who were aware of the child restraint laws, many parents did not see the value of using car safety seats and felt that their child was safest in their arms. Parents also tended to believe they were safe drivers and therefore less likely to be in an accident, particularly when making ‘short’ trips. Lack of enforcement of child restraint use only contributed to parents dismissing the use of CSSs.
A number of interventions were designed and adapted to the Hispanic community using the insights gained from the focus groups. Interventions were delivered throughout community venues and by trained bilingual staff, often by people who were also residents of the target area. Key programme components included:
- Information and engagement activities would be provided at various community venues, such as schools, churches, community centres and local botanicas (traditional healers).
- Community based workshops with videos that graphically showed what happens to a child held on an adult’s lap during a car crash were therefore created to be shown in the classes
- As an additional incentive, parents who attended the classes would be offered a car seat for a low cost of US$10.
- To overcome the issue of fatalism in the Hispanic community, local priests would be asked to bless the child safety seats in a ceremony before they were given to parents.
What impact did it have?
Three years after the interventions were launched, the use of safety restraints among Hispanic preschool-aged children increased from an initial prevalence of 21 per cent to 73 per cent. Use of restraints among Hispanic preschool-aged children increased significantly in all three settings (health centre, day care and grocery store parking lots). By the sixth year, restraint use among clinic attendees had surpassed 85 per cent.
The programme found that efforts to increase the use of child restraints were only successful if driver seat belt use was also targeted. Only small increases in child restraint use were observed in vehicles in which drivers did not wear a seat belt. Males were also less likely to use a seat belt and child seat.
What are the key lessons?
Social marketing programs targeting behaviour change among ethnic groups can be successful if:
- Audience research is used to understand the core barriers and motivators related to the adoption of a specific behaviour
- Interventions use the right mix of effective messaging, direct community-based support, financial incentives and enforcement
Slovenia – let’s live healthy programme
The following programme is one of the most successful regional public health programmes that utilises social marketing theory and practice. It has had a dramatic result on the lives of its participants and has now expanded countrywide to cover the whole of Slovenia.
Pomurje is the poorest region in Slovenia. Mortality rates - levels of heart disease, diabetes and obesity - are the highest in the country. Historically the local population had been employed in agriculture and an active lifestyle had compensated for a diet high in animal fats with high salt content. Increasingly people have been moving away from the land to more inactive lifestyles in factories. Increasingly there are far fewer communal activities (both work and non-work) in rural areas resulting in social isolation and high levels of stress, leading to further ill-health.
How did the project address the social determinants of health?
This regional wide programme which has been largely community based with village cooking workshops, exercise classes, singing, village walks and community events. The aim of the programme wasn’t to just help people choose a healthier lifestyle but to rebuild rural communities and re-establish bonds within rural villages and between neighbouring communities. The development of communal gardens growing herbs for example has produced alternatives to salt for flavouring but most importantly it has brought together isolated members of the community.
How did the project apply a social marketing approach?
This project aimed to change behaviours of a whole region but the success of the programme means it has now been expanded to cover the whole country. It has used the exchange of learning and understanding the benefits of healthy behaviour around eating/drinking by giving inhabitants access to communal activities and better healthcare services. It has also been successful at developing a whole range of activities that have matched the needs of separate communities. They have increased activities that have worked and abandoned those that either are not popular or have had little impact on lifestyles. Because the planning and implementation of the project has been based in the influential public health institute of the region there has been a strong history of monitoring and evaluation which has led to constant re-assessment of activities and projects.
What impact did it have?
The Institute of Public health for Pomurje has evaluated the programme over the eight years that it has been operating. It has noted that over this period 52% of communities on the programme had changed their nutritional habits, replacing high fat/salty food with low fat alternatives. There has been a significant decrease in inhabitants that consume alcohol every day from 59% to 33%.
What are the key lessons?
This self-sustaining community project has not relied on a large central budget but it has generated a significant amount of political support and strong community links with the regional public health organisation. The programme has been led by a very influential and charismatic leader who has ensured that there has been long term funding. Although it has had a major impact on people’s health it has had a wider impact on social gradient reintegrating people back into the community reducing social isolation. People now feel better about themselves and community they live in and one local politician stated that the programme had re-energised villages.
Denmark U-Turn Project - improving young people's lives
This programme demonstrates the sometimes heavy investment required to turnaround the lives of the most vulnerable in society especially those youngsters who come from broken homes with generations of under privilege and deprivation. It is also exemplifies how when the right type of approach is used how successful these intensive programmes can be in rehabilitating young people’s lives.
This government funded programme aims to tackle the issues facing some of the most socially isolated and disadvantaged youngsters (15-23) in Copenhagen. Although the primary goal of the project is to reduce young people’s dependency on drugs, the project aims are much wider, working with young people in all aspects of their lives to develop their self-esteem so that they have the confidence to overcome their dependency.
How did the project address the social determinants of health?
Most of the youngsters referred onto the project come from dysfunctional/disadvantaged backgrounds. 75% of young people on the project parents/guardians were either divorced or had never lived together. Over 80% of the young people had been in out-patient treatment in relation to psychological or emotional problems.
The programme holds daily sessions for clients in a friendly “house” in Copenhagen. The sessions are completely voluntary and comprise of formal lessons, cooking and eating together, counselling, music expression and physical exercise. Talking therapies often include parents/guardians there is also sessions to support friends/peers of the youngsters on the project. Research shows without this form of intensive and person help these people will either end up in jail or live at margins of society often unable to cope, relying throughout their lives on state agencies for support.
How did the project apply a social marketing approach?
A huge amount of effort has gone into understanding the lives of these young people and what moves and motivates them. For example it offers a valid exchange through enabling these youngsters to get their school certificate that allows them access to further training or work. This is prized by the youngsters as it allows them to move on with their lives. It completely avoids a one size fits all approach treating each client individually tailoring the sessions to the exact needs of the individual. As the leader of the project states, “We try to build a whole picture of their lives. Our objective is to tackle all their issues including housing, nutrition, physical activity – we aim to get young people happier more contented, to get them to have high self-esteem then this will give them the courage to tackle drug addiction”.
What impact did it have and what are the key lessons?
Evaluation of the project demonstrates that 75% of young people referred to project either cease using or drastically reduce the use of drugs while 80% of young people go into work or full time education on completion of their time with the project. This is an extremely expensive programme – employing over 20 full time staff and the cost per young person on the programme is very high. Although there is little research on the long-term impact on the costs of getting these young people out of a drugs dependency cycle it is clear that the programme does have a huge impact on the lives of the youngsters it treats. One of the most important lessons, from the view of those working on the project, is that often for the very first time in their lives these young people’s needs are treated holistically - the responsibility for all their care needs are centred in one place instead of being fractured between a number of different agencies.
North Tyneside – SUB21 Reducing kerbside drinking by young people
This case study describes a project aimed at reducing anti-social drinking behaviour by young people in North-east England. By utilising a two-pronged approach it reduced the supply of alcohol to the target group while also developing attractive alternatives to “hanging around on the street and drinking”.
North Tyneside has some of the highest rates of hospital admissions for under 18’s due to alcohol-related causes in the UK. Related crime and disorder as well as residents fear of crime and anxieties about young people drinking on the streets were becoming critical and were having increasing detrimental impact on the quality of people’s life in North Tyneside. This collaborative project (North Tyneside PCT and the NSMC) aimed at reducing underage street drinking and antisocial behaviour.
How did the project address the social determinants of health?
Research with young people and off-licenses identified three main drivers for underage street drinking. These were a lack of suitable alternative activities for these young people, cheap easy supply of alcohol (with plenty of proxy sales) and finally the fact that street drinking had become the social norm in the area. From these findings a two pronged approach was developed, under the Sub21 brand. The intervention provided a rolling programme of out-of-hours activities designed by and for local young people as an alternative to street drinking. Alongside this, a programme was developed to support off-licences in reducing illegal and proxy alcohol purchases.
How did the project apply a social marketing approach?
Considerable effort was put into the research stage of the programme to ensure that the “offer” provided to get youngsters off the streets into alternative activities was made as attractive as possible. Activities included street dance, nail art cookery for girls and graffiti, bike and ramp building computer gaming for boys. These activities provided for youngsters were combined with measures designed to restrict the supply of alcohol to underage drinkers.
There was an extensive package of support for retailers including:
- Dedicated 24 hour Crime line
- Dedicated licensing line
- “Off watch” membership with monthly meetings to share information views and ideas
- Training sessions for staff on conflict management
- At least two visit by police every week
- A Charter Mark
What impact did it have and what are the key lessons?
The results showed that there had been a reduction in the most harmful types of drinking among females and that drinking in the street had dropped by 50%. In boys there does not seem to have been much change in behaviour although research demonstrated that they experienced much greater difficulty in accessing alcohol.
Evaluation of the project demonstrated that young people respond much better when there is a developmental element to the activities. Many projects aimed at young people often provide facilities (drop in centres for example) but the most important element for the youngsters in this particular project was the development of new skills over a series of sessions.
A very small amount of the budget was dedicated to conventional promotion and word of mouth was critical in getting more youngsters involved. The project team also constantly kept in touch with youngsters changing/adapting the programme to suit their needs and aspirations.
Some of the most important feedback from the project team was to emphasise that it is crucial that often community/social marketing projects waste time and effort trying to persuade reluctant and unsupportive partners to participate because there is an apparent good strategic and organisational fit. Their advice was to move on and invest time and energy encouraging those who are enthusiastic and committed.
Reducing levels of worklessness - Lincolnshire
Quite often programmes that aim to tackle inequalities and increase social capital ignore the talents, skills and expertise of the very communities they are trying to help. The following example demonstrates the importance of working to harness existing local enthusiasm and commitment when attempting to strengthen our communities.
This programme aims to reduce levels of worklessness in target communities in North-east Lincolnshire. The programme centres on the development of community teams of local residents and service providers to:
- Inspire individuals to achieve personal change;
- Enable them to access appropriate work;
- Reduce dependence on benefits in two deprived target areas, (South Ward and East Marsh Ward).
How did the project address the social determinants of health?
This project was designed to encourage local people to access existing support services. Initial research found that many people felt local services were “useful” but that they simply didn’t know how to access them. There was also a large amount of mistrust of the “officials” who were running the services, while they preferred and more importantly trusted the talents and resources of locals, peers and family. With this in mind two community teams, the “specialists” and the “locals” worked together to create community champions and these people helped to signpost people to services by promoting existing opportunities, attending interviews with participants, and provided peer to peer coaching. A “How2” campaign with very practical information on how to access existing services was also implemented and a resource pack was designed to provide really practical things to help prospective job seekers such as: a list of services; model CV’s; and tips for filling out application forms.
What impact did it have and what are the key lessons?
Often policy makers are tempted to start from scratch when they want to develop programmes aimed at increasing the social capital in communities. This project avoided this by working to adapt existing services and ensured signposting was more effective.
Dealing with public service design can be complex, costly and sap energy. There may be times when a complete overhaul and restructuring is necessary but in the case of this project it was ensuring there was a trusted “guide” and ensuring that the materials could be understood by the target audience. Many of the project team examined the basic practical materials and commented - “are we insulting people’s intelligence here?” However, when they were pre-tested with the target group they were surprised on how well they were received.
Riders for Health – Providing sustainable health transport services in Africa
This final example also demonstrates the power of harnessing and building local talents and expertise. When these programmes are successfully scaled up it shows the dramatic impact they can have on a number of the social determinants of health across an entire region.
One of the primary health issues in Africa is not just the lack of medicines and health workers but the transport to get those medicines and workers to the people who need them most. ‘Riders for Health’ provides a vital service in ensuring people living in rural areas have access to services by providing an effective and reliable means of transport. Riders for Health is a social enterprise which helps provide health services to over 20 million people living in sub Saharan Africa, in 8 countries managing 4000 vehicles.
It has developed a preventative maintenance system for managing vehicles, people and money involved in the delivery of healthcare and other vital services. The system incorporates training in driving skills, daily preventative routine maintenance procedures – supported by Riders technicians who provide regular servicing. A unique cost per km calculator also provides the true costs of running any vehicle in any given environment.
How did the project address the social determinants of health?
One of the most remarkable characteristics of this enterprise is that it is almost entirely funded by indigenous sources. The Ministries of Health of the countries that they operate in pay ‘Riders for Health’ for their services. The programme is also staffed with indigenous workers so that skills and expertise are built into the local communities. ‘Riders for Health’ trains the health workers and mechanics that provide the backbone of the organisation. The whole ethos of the organisation is to create business opportunities through development with the aim of pulling whole sections of society out of poverty through better healthcare but also developing new businesses.
What impact did it have and what are the key lessons?
Because ‘Riders for health’ is a business it has to monitor and evaluate both health outcomes and its business performance. It is critical that costs are reduced and that the organisation runs efficiently because, without this business ethos, the company would simply cease to exist and the vital services would be discontinued. Because the services ‘Riders for Health’ provides are so efficient (Introducing Riders services reduces maintenance/transport costs by an average of 60%) it means that often health budgets of the different states where ‘Riders for Health’ operates are used more effectively.
In terms of direct health benefits in Zimbabwe, malaria deaths decreased by 21% compared with a 44% increase in neighbouring areas where Riders was not operating. In the Gambia there has been a 263% increase in diagnoses in diarrhoea and a 75% increase in the diagnosis of acute respiratory infections.
[1] Parkour is a physical discipline developed in France that teaches participants how to move through the urban environment by vaulting, rolling, running, climbing, and jumping.