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What is Social Marketing?
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The health communications field has been rapidly changing over the past two decades. It has evolved from a one-dimensional reliance on public service announcements to a more sophisticated approach which draws from successful techniques used by commercial marketers, termed "social marketing." Rather than dictating the way that information is to be conveyed from the top-down, public health professionals are learning to listen to the needs and desires of the target audience themselves, and building the program from there. This focus on the "consumer" involves in-depth research and constant re-evaluation of every aspect of the program. In fact, research and evaluation together form the very cornerstone of the social marketing process.
Social marketing was "born" as a discipline in the 1970s, when Philip Kotler and Gerald Zaltman realized that the same marketing principles that were being used to sell products to consumers could be used to "sell" ideas, attitudes and behaviors. Kotler and Andreasen define social marketing as "differing from other areas of marketing only with respect to the objectives of the marketer and his or her organization. Social marketing seeks to influence social behaviors not to benefit the marketer, but to benefit the target audience and the general society." This technique has been used extensively in international health programs, especially for contraceptives and oral rehydration therapy (ORT), and is being used with more frequency in the United States for such diverse topics as drug abuse, heart disease and organ donation.
Like commercial marketing, the primary focus is on the consumer--on learning what people want and need rather than trying to persuade them to buy what we happen to be producing. Marketing talks to the consumer, not about the product. The planning process takes this consumer focus into account by addressing the elements of the "marketing mix." This refers to decisions about 1) the conception of a Product, 2) Price, 3) distribution (Place), and 4) Promotion. These are often called the "Four Ps" of marketing. Social marketing also adds a few more "P's." At the end is an example of the marketing mix.
Product
The social marketing "product" is not necessarily a physical offering. A continuum of products exists, ranging from tangible, physical products (e.g., condoms), to services (e.g., medical exams), practices (e.g., breastfeeding, ORT or eating a heart-healthy diet) and finally, more intangible ideas (e.g., environmental protection). In order to have a viable product, people must first perceive that they have a genuine problem, and that the product offering is a good solution for that problem. The role of research here is to discover the consumers' perceptions of the problem and the product, and to determine how important they feel it is to take action against the problem.
Price
"Price" refers to what the consumer must do in order to obtain the social marketing product. This cost may be monetary, or it may instead require the consumer to give up intangibles, such as time or effort, or to risk embarrassment and disapproval. If the costs outweigh the benefits for an individual, the perceived value of the offering will be low and it will be unlikely to be adopted. However, if the benefits are perceived as greater than their costs, chances of trial and adoption of the product is much greater.
In setting the price, particularly for a physical product, such as contraceptives, there are many issues to consider. If the product is priced too low, or provided free of charge, the consumer may perceive it as being low in quality. On the other hand, if the price is too high, some will not be able to afford it. Social marketers must balance these considerations, and often end up charging at least a nominal fee to increase perceptions of quality and to confer a sense of "dignity" to the transaction. These perceptions of costs and benefits can be determined through research, and used in positioning the product.
Place
"Place" describes the way that the product reaches the consumer. For a tangible product, this refers to the distribution system--including the warehouse, trucks, sales force, retail outlets where it is sold, or places where it is given out for free. For an intangible product, place is less clear-cut, but refers to decisions about the channels through which consumers are reached with information or training. This may include doctors' offices, shopping malls, mass media vehicles or in-home demonstrations. Another element of place is deciding how to ensure accessibility of the offering and quality of the service delivery. By determining the activities and habits of the target audience, as well as their experience and satisfaction with the existing delivery system, researchers can pinpoint the most ideal means of distribution for the offering.
Promotion
Finally, the last "P" is promotion. Because of its visibility, this element is often mistakenly thought of as comprising the whole of social marketing. However, as can be seen by the previous discussion, it is only one piece. Promotion consists of the integrated use of advertising, public relations, promotions, media advocacy, personal selling and entertainment vehicles. The focus is on creating and sustaining demand for the product. Public service announcements or paid ads are one way, but there are other methods such as coupons, media events, editorials, "Tupperware"-style parties or in-store displays. Research is crucial to determine the most effective and efficient vehicles to reach the target audience and increase demand. The primary research findings themselves can also be used to gain publicity for the program at media events and in news stories.
Additional Social Marketing "P's"
Publics--Social marketers often have many different audiences that their program has to address in order to be successful. "Publics" refers to both the external and internal groups involved in the program. External publics include the target audience, secondary audiences, policymakers, and gatekeepers, while the internal publics are those who are involved in some way with either approval or implementation of the program.
Partnership--Social and health issues are often so complex that one agency can't make a dent by itself. You need to team up with other organizations in the community to really be effective. You need to figure out which organizations have similar goals to yours--not necessarily the same goals--and identify ways you can work together.
Policy--Social marketing programs can do well in motivating individual behavior change, but that is difficult to sustain unless the environment they're in supports that change for the long run. Often, policy change is needed, and media advocacy programs can be an effective complement to a social marketing program.
Purse Strings--Most organizations that develop social marketing programs operate through funds provided by sources such as foundations, governmental grants or donations. This adds another dimension to the strategy development-namely, where will you get the money to create your program?

Example of a Marketing Mix Strategy
As an example, the marketing mix strategy for a breast cancer screening campaign for older women might include the following elements:
• The product could be any of these three behaviors: getting an annual mammogram, seeing a physician each year for a breast exam and performing monthly breast self-exams.
• The price of engaging in these behaviors includes the monetary costs of the mammogram and exam, potential discomfort and/or embarrassment, time and even the possibility of actually finding a lump.
• The place that these medical and educational services are offered might be a mobile van, local hospitals, clinics and worksites, depending upon the needs of the target audience.
• Promotion could be done through public service announcements, billboards, mass mailings, media events and community outreach.
• The "publics" you might need to address include your target audience (let's say low-income women age 40 to 65), the people who influence their decisions like their husbands or physicians, policymakers, public service directors at local radio stations, as well as your board of directors and office staff.
• Partnerships could be cultivated with local or national women's groups, corporate sponsors, medical organizations, service clubs or media outlets.
• The policy aspects of the campaign might focus on increasing access to mammograms through lower costs, requiring insurance and Medicaid coverage of mammograms or increasing federal funding for breast cancer research.
• The purse strings, or where the funding will come from, may be governmental grants, such as from the National Cancer Institute or the local health department, foundation grants or an organization like the American Cancer Society.
Each element of the marketing mix should be taken into consideration as the program is developed, for they are the core of the marketing effort. Research is used to elucidate and shape the final product, price, place, promotion and related decisions.
Social Marketing
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 principlesSad1) 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 healthful diets 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 projects 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.
INTRODUCTION
Societies worldwide face an ever-increasing array of health challenges, heighten-
ing the importance of social change efforts. Social marketing, the use of marketing
to design and implement programs to promote socially beneficial behavior change,
has grown in popularity and usage within the public health community. In recent
years, the Centers for Disease Control and Prevention (CDC), the U.S. Depart-
ment of Agriculture (USDA), the U.S. Department of Health and Human Services
(USDHHS), and other governmental and nonprofit organizations have used social
marketing to increase fruit and vegetable consumption, promote breastfeeding,
decrease fat consumption, promote physical activity, and influence a wide variety
of other preventive health behaviors (12). State and local communities are using
social marketing to increase utilization of the Supplemental Food and Nutrition
Program for Women, Infants, and Children (WIC), prenatal care, low cost mam-
mograms, and other health services (9). Internationally, social marketing has been
used to improve access to potable water (42), eliminate leprosy in Sri Lanka (55),
increase tuberculosis medicine adherence (37), and promote immunizations and
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universal iodization legislation (15, 31), among other applications. Social market-
ing has enormous potential to affect other health problems such as observed health
disparities between members of ethnic minority and majority groups (54).
There also has been increasing professional activity in the field by academics,
nonprofit organizations, and governmental agencies. New textbooks and work-
books, multiple annual conferences, the inclusion of social marketing in national
public health conferences, training programs, including CDCynergy–Social Mar-
keting Edition and other materials developed by the Turning Point Program (avail-
able online at http:/turningpointprogram.org), and a certificate program for
graduate trained public health professionals have emerged in the past decade. [See
Andreasen (4) for a review of social marketing’s history.] Public health has been
important in the field’s growth, with the promotion of condom use internationally
being among social marketing’s first applications (22).
The widespread adoption of social marketing in public health has garnered
important successes. Among these is VERBTM,a national, multicultural, social
marketing program coordinated by CDC (56). The VERBTM program encourages
“tweens” (young people ages 9–13) to be physically active every day. The program
was based on extensive marketing research with tweens, their parents, and other
influencers. Resultswere used to design an intervention that combinesmass-media
advertising, public relations, guerrilla (i.e., interpersonal) marketing, and partner-
ship efforts with professional sports leagues and athletes, as well as well-known
sporting-goods suppliers and retailers, to reach the distinct audiences of tweens
and adult influencers. VERBTM also partners with communities to improve access
to outlets for physical activity and capitalize on the influence parents, teachers, and
other people have on tweens’ lives.After just one year, this award-winning program
resulted in a 34% increase in weekly free-time physical activity sessions among
8.6 million children ages 9–10 in the United States. In communities that received
higher levels of VERBTM interventions, the increases in physical activity were
more dramatic (45). Another well-known example is the TRUTHTM campaign,
which contributed to the reduction of smoking among teenagers nationwide (16).
Despite its popularity and influence, many public health professionals have an
incomplete understanding of social marketing (28, 36, 38). In Hill’s (28) review of
the health promotion literature between 1982 and 1996, he concluded that health
promoters’ views of marketing differed considerably from how the marketing
discipline is usually defined. Specifically, he found that many health promoters
perceive social marketing as a predominantly promotional or, even more narrowly,
a communication activity. Other common problems he noted were neglect of the
exchange process and a lack of integration of the marketing mix in planning pro-
gram interventions. These misunderstandings persist today as evidenced by the
large number of abstracts submitted to the SocialMarketing in Public Health con-
ference and manuscripts submitted to Social Marketing Quarterly, which use the
social marketing label to describe social advertising or communication activities
not developed with marketing’s conceptual framework. In this chapter, we provide
an overview of social marketing in hopes of overcoming misconceptions about
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SOCIAL MARKETING IN PUBLIC HEALTH 321
its key elements and advancing current knowledge. First, we provide a practical
definition, discuss social marketing’s conceptual underpinnings, and present case
studies to illustrate its application in public health. Next, we discuss challenges
that may inhibit the effective and efficient use of social marketing by public health
professionals. Finally, we reflect on future developments needed in the field. Our
objective is to enhance public health professionals’ understanding of the key ele-
ments of social marketing and their ability to use social marketing to design public
health interventions.
Defining SocialMarketing
Although a variety of definitions have been proposed by social marketers, and
debate continues (49), social marketing is typically defined as a program-planning
process that applies commercial marketing concepts and techniques to promote
voluntary behavior change (1, 34). Social marketing facilitates the acceptance,
rejection, modification, abandonment, or maintenance of particular behaviors (34)
by groups of individuals, often referred to as the target audience. Although so-
cial marketing’s target audience is usually made up of consumers, it is used also
to influence policy makers who can address the broader social and environmen-
tal determinants of health (15, 48). Hastings & Saren’s (27) definition of social
marketing includes also the analysis of the social consequences of commercial
marketing policies and activities, e.g., monitoring the effects of the tobacco or
food industries’ marketing practices.
The defining features of social marketing emanate from marketing’s concep-
tual framework and include exchange theory, audience segmentation, competition,
“the marketing mix,” consumer orientation, and continuous monitoring. Although
social marketing shares many features with other related public health planning
processes, it is distinguished by the systematic emphasis marketers place on the
strategic integration of the elements in marketing’s conceptual framework.
THE NOTION OF EXCHANGE The field of marketing attempts to influence vol-
untary behavior by offering or reinforcing incentives and/or consequences in an
environment that invites voluntary exchange (47). Exchange theory (6) views con-
sumers acting primarily out of self interest as they seek ways to optimize value
by doing what gives them the greatest benefit for the least cost. Contrary to com-
mercial exchanges, in which consumers receive a product or service for a cash
outlay, in public health situations, there is rarely an immediate, explicit payback
to target audiences in return for their adoption of healthy behavior (47). Neverthe-
less, exchange theory reminds social marketers that they must (a)offer benefits
that the consumer (not the public health professional) truly values; (b) recognize
that consumers often pay intangible costs, such as time and psychic discomfort
associated with changing behaviors; and © acknowledge that everyone involved
in the exchange, including intermediaries, must receive valued benefits in return
for their efforts (15).
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AUDIENCE SEGMENTATION Social marketers know it is not possible to be “all
things to all people.” Rather, marketing differentiates populations into subgroups
or segments of people who share needs, wants, lifestyles, behavior, and values that
make them likely to respond similarly to public health interventions. Public health
professionals have long recognized intragroup differences within populations, but
they typically use ethnicity, age, or other demographics as the basis for identifying
distinct subgroups. Social marketers are more likely to divide populations into
distinct segments on the basis of current behavior (e.g., heavy versus light smok-
ing), future intentions, readiness to change, product loyalty, and/or psychographics
(e.g., lifestyle, values, personality characteristics). Compared with other system-
atic planning processes, social marketing devotes greater attention and resources
to segmentation research, the identification of one or more segments as the target
audience to receive the greatest priority in program development, and develop-
ment of differential marketing strategies (e.g., in how products will be positioned,
placed, or promoted) for selected population segments (17).
The VERBTM program initially segmented its target population by age (e.g.,
youth aged 9–13 and parents/influencers) and then conducted research that iden-
tified important differences among specific segments within the tween audience
on the basis of activity level, receptivity to physical activity, ethnicity, and gender.
Segmentation and target marketing increase program effectiveness and efficiency
by tailoring strategies to address the needs of distinct segments (17) and helping
to make appropriate resource allocation decisions.
COMPETITION In commercialmarketing, competition refers to products and com-
panies that try to satisfy similar wants and needs as the product being promoted. In
social marketing, the term refers to the behavioral options that compete with pub-
lic health recommendations and services, e.g., bottle-feeding versus breastfeeding
(23). The marketing mindset asks, what products (behaviors, services) compete
with those we are promoting, and how do the benefits compare to those offered by
competing behaviors? Answers to these questions enable social marketers to offer
benefits that best distinguish healthy behaviors from the competition and develop
a sustainable competitive advantage that maximizes their products’ attractiveness
to consumers (23).
An assessment of the competition also may be useful in determining which
behaviors are best to promote andwhich segments are best to target.AsNovelli (43)
explains, “Thinking about where, how, and with whom to compete is important—
you might do that analysis and decide not to compete because the foe is too
formidable. And that is okay: “we need to have the courage not to compete.” We
may also decide to compete for specific population segments in which we can
provide better value than the competition (25).
THE MARKETING MIX Another core concept adopted from the commercial sector
is the marketing mix, also known as the four Ps: product, price, place, and pro-
motion. These key elements of social marketing are central to the planning and
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SOCIAL MARKETING IN PUBLIC HEALTH 323
Product refers to the set of benefits associated with the desired behavior or
service usage. Kotler et al. (34) distinguish between the core product (what people
will gain when they perform the behavior) and the actual product (the desired
behavior). They also use the concept of the augmented product to refer to any
tangible objects and services used to facilitate behavior change. However, it is
important to note that pamphlets and other promotional activities are designed to
facilitate adoption of the behavior and are not the actual product.
To be successful, social marketers believe the product must provide a solution
to problems that consumers consider important and/or offer them a benefit they
truly value. For this reason, research is undertaken to understand people’s aspira-
tions, preferences, and other desires, in addition to their health needs, to identify
the benefits most appealing to consumers. For instance, the VERBTM program po-
sitioned physical activity as a way to have fun, spend time with friends, and gain
recognition from peers and adults rather than to prevent obesity or chronic disease
later in life. Themarketing objective is to discover which benefits have the greatest
appeal to the target audience and design a product that provides those benefits. In
some cases, public health professionals must change their recommendations or
modify their programs to provide the benefits consumers value most.
Price refers to the cost or sacrifice exchanged for the promised benefits. This
cost is always considered fromthe consumer’s point of view.As such, price usually
encompasses intangible costs, such as diminished pleasure, embarrassment, loss of
time, and the psychological hassle that often accompanies change, especiallywhen
modifying ingrained habits. In setting the right price, it is important to know if
consumers prefer to paymore to obtain “value added” benefits and if they think that
products given away or priced low are inferior to more expensive ones. Consumer
research conducted by Population Services International, for instance, revealed
that many teens did not trust condoms that were given away by public health
agencies. But even a small, affordable monetary price (25 cents) was sufficient to
reassure them that the condoms were trustworthy.
Place refers to the distribution of goods and the location of sales and service
encounters. In social marketing, place may be thought of as action outlets: “where
and when the target market will perform the desired behavior, acquire any related
tangible objects, and receive any associated services” (34). Place includes the
actual physical location of these outlets, operating hours, general attractiveness and
comfort, and accessibility, e.g., parking and availability by public transportation
(15). It also includes intermediaries—organizations and people—that can provide
information, goods, and services and perform other functions that facilitate the
change process. Researchmay be necessary to identify the life path points—places
people visit routinely, times of the day, week, or year of visits, and points in the
life cycle—where people are likely to act so that products and supportive services
or information can be placed there. In the Kentucky Youth Nutrition and Fitness
Program, a community coalition offered numerous opportunities for tweens to try
out new forms of physical activity (or VERBS) at multiple times and locations
throughout the summer months. The public parks, YWCAs, Children’s Museum,
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the Lexington Legends (a minor league baseball team), and other organizations
designed action outlets where tweens could have a summer scorecard validated
each time they tried a new VERB. Tweens that participated in a designated number
of activities received special recognition and eligibility to win prizes (13). A key
element in this project’s placement strategy is providing sufficient incentive to the
intermediaries to provide opportunities, consistent with the VERBTM program’s
exciting and edgy brand attributes, for tweens to be physically active.
Promotion is often the most visible component of marketing. Promotion in-
cludes the type of persuasive communications marketers use to convey product
benefits and associated tangible objects and services, pricing strategies, and place
components (34). Promotional strategy involves a carefully designed set of ac-
tivities intended to influence change and usually involves multiple elements: spe-
cific communication objectives for each target audience; guidelines for designing
attention-getting and effective messages; and designation of appropriate commu-
nication channels. Promotional activities may encompass advertising, public rela-
tions, printed materials, promotional items, signage, special events and displays,
face-to-face selling, and entertainment media. In public health, policy changes,
professional training, community-based activities, and skill building usually are
combined with communication activities to bring about the desired changes.
An integratedmarketingmix is essential. Though promotion, one of the four Ps,
is generally what people think of when considering social marketing, marketers
use their understanding of consumers to develop a carefully integrated strategy ad-
dressing all four Ps. By integration, we mean that each element has been planned
systematically to support clearly defined goals, and all marketing activities are
consistent with and reinforce each other. For instance, a program offering the
emotional benefits associated with breastfeeding would use a warm, emotional ap-
peal rather than one that instills fear, and advertisements for a breastfeeding advice
program would not be aired until those support services were readily available. In
similar fashion, theVERBTM programuses a tone consistentwith its positioning of
physical activity as fun and exciting rather than using a serious, factual description
of the health benefits of physical activity.
The emphasismarketers place on understanding the exchange process and com-
petition, and the development of an integrated marketing strategy based on the 4
Ps, are social marketing’s most distinctive features.
CONSUMER ORIENTATION AND THE IMPORTANCE OF RESEARCH Marketing’s con-
ceptual framework demands a steadfast commitment to understanding consumers,
the people whose behavior we hope to change. The premise is that all program
planning decisions must emanate from a consideration of the consumers’ wants
and needs (1).
The backbone of a customer orientation is consumer research. Formative re-
search is used to gain a deeper understanding of a target audience’s needs, aspira-
tions, values, and everyday lives. Of special interest are consumers’ perceptions of
the products, benefits, costs, and other factors (e.g., perceived threat, self-efficacy,
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SOCIAL MARKETING IN PUBLIC HEALTH 325
social influences) that motivate and deter them from adopting recommended be-
haviors. Research also provides information on distinct population subgroups and
the social and cultural environments in which the people act on behavioral deci-
sions. This information is used to make strategic marketing decisions about the
audience segments to target, the benefits to offer, and the costs to lower, and about
how to price, place, and promote products. Although consumer research need not
be expensive or complex, itmust be done. [For a discussion of inexpensive research
methods, see Andreasen (3)].
The importance of evidence-based program planning and community-based
approaches in public health has increased dramatically during the past two decades
(30). As a result, social marketers are not alone in their reliance on research and
careful consideration of consumers’ needs when designing strategies to change
behavior. Social marketing is distinctive, however, in its reliance on marketing’s
conceptual framework to guide the research process and the development of a
strategic plan (i.e., based on the 4 Ps and an understanding of the competition).
The VERBTM program, for instance, used existing data and consumer research
to understand the behaviors, lifestyle, and mindsets of tweens, parents, and other
key influencers. Research explored the cultural, ethnic, and economic dynamics
that unify and differentiate the tween audience and provided insights into the
competitive environment in which tweens make decisions about how to spend
their time. Results were used to develop an integrated marketing plan based on
the 4 Ps and communication guidelines that served as a blueprint for the national
media campaign (56).
Ideally, the consumer orientation represents a commitment to provide con-
sumers with satisfying exchanges that result in long-term, trusting relationships
(15). If, for instance, health services are underutilized or dietary change recom-
mendations are overlooked, program planners listen to consumers to find out what
they can do to improve program offerings and make their recommendations more
helpful. This willingness to change the product to meet consumer preferences is
an essential feature of social marketing, one shared by total quality management
or continuous improvement approaches but which is divergent from more tradi-
tional, expert-driven approaches in which public health professionals determine
what consumers need to do.
CONTINUOUS MONITORING AND REVISION Plans for evaluating and monitoring
a social marketing intervention begin at the outset of the planning process. As pro-
gram interventions are implemented, each is monitored to assess its effectiveness
to determine if it is worthy of being sustained, and to identify activities that require
midcourse revision. Although many public health programs conduct process and
impact evaluations, marketing devotes considerable resources to this activity and
practices it on a continuous basis. Social marketers are constantly checking with
target audiences to gauge their responses to all aspects of an intervention, from the
broadmarketing strategy to specificmessages andmaterials (7). TheVERBTM pro-
gram, for example, uses observation and intercept interviews at sponsored events
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326 GRIER BRYANT
to assess visitor demographics and interaction patterns of the tweens with the
activities.
ComparingMarketing to Other BehaviorManagement Tools
Social marketing can also be understood by comparing it with other approaches
to managing behavior change. Rothschild (47) developed a conceptual framework
that contrasts marketing with education and law. In his view, education informs
and persuades people to adopt healthy behaviors voluntarily by creating awareness
of the benefits of changing. When health professionals educate people about the
benefits of adopting healthy lifestyle behaviors, citizens have free choice in how
they respond, and society accepts the costs when some people continue to practice
undesirable behaviors. Education is most effective when the goals of society are
consistent with those of the target audience, the benefits of behavior change are
inherently attractive, immediate, and obvious, the costs of changing are low, and
the skills and other resources needed to change are readily available [e.g., putting
a baby to sleep on its back to prevent sudden infant death syndrome (SIDS)].
Lawor policy development uses coercion or the threat of punishment tomanage
behavior. Legislation is the most effective tool for public health when society is
not willing to pay the costs associated with continued practice of an unhealthy
or risky behavior (e.g., drunk driving) yet citizens are unlikely to find it in their
immediate self-interest to change.
In contrast, marketing influences behavior by offering alternative choices that
invite voluntary exchange. Marketing alters the environment to make the rec-
ommended health behavior more advantageous than the unhealthy behavior it is
designed to replace and then communicates the more favorable cost-benefit re-
lationship to the target audience. Marketing is the most effective strategy when
societal goals are not directly and immediately consistentwith people’s self-interest
but citizens can be influenced to change by making the consequences more advan-
tageous. Like education, marketing offers people freedom of choice; but unlike
education, it alters the behavioral consequences rather than expects individuals
to make a sacrifice on society’s behalf. Education and policy changes are often
components in a social marketing intervention; however, marketing also creates
an environment more conducive for change by enhancing the attractiveness of the
benefits offered and minimizing the costs.
Steps in the SocialMarketing Process
The social marketing process is a continuous, iterative process that can be de-
scribed as consisting of six major steps or tasks: initial planning; formative re-
search; strategy development; program development and pretesting of material
and nonmaterial interventions; implementation; and monitoring and evaluation.
The initial planning stage involves gathering relevant information to help identify
preliminary behavioral objectives, determine target markets, and recognize poten-
tial behavioral determinants and strategies. Formative research is then conducted
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SOCIAL MARKETING IN PUBLIC HEALTH 327
to investigate factors identified during the initial planning phase to segment audi-
ences and determine those factors that must be addressed to bring about behavior
change. Strategy development involves the preparation of a realistic marketing
plan comprised of specific, measurable objectives and a step-by-step work plan
that will guide the development, implementation, and tracking of the project. The
plan includes the overall goals of the program, a description of the target audience,
specific behaviors that will bemarketed toward them, and strategies for addressing
the critical factors associated with the target behavior. The social marketing plan
is organized around marketing’s conceptual framework of the four Ps. Campaign
strategies and materials are then developed, pretested, piloted, and revised prior to
program implementation. Monitoring and evaluation activities continue through-
out the program implementation to identify any necessary program revisions, as
well as to understand program effectiveness and make midcourse corrections as
needed.
CASE EXAMPLES OF SOCIALMARKETING
APPLICATIONS
Three case studies are provided to illustrate how social marketing can be used to
develop new public health products (the Road Crew), improve service delivery
and enhance program utilization (the Texas WIC Program), and promote healthy
eating behaviors (the Food Trust).
The Road Crew
In the Road Crew project, social marketing was used to develop a new product to
compete with a dangerous brand, “I can drive myself home, even though I’ve had
too much to drink” (32). In an effort to curb alcohol-related automobile crashes,
this program targets 21- to 34-year-old men who drive themselves home after an
evening of drinking at taverns in ruralWisconsin. Formative research revealed that,
although alternative forms of transportation were unavailable in these communi-
ties, even if offered a ride home, men were unwilling to leave their automobiles
at the bars overnight. In response, program designers created a ride service that
transported men from their homes to the bars, between bars, and back home again,
allowing themto enjoy their evening without risk of driving while intoxicated. The
program was not without controversy, as some critics argued that the ride service
would lead to increased individual-level drinking. Nonetheless, three rural com-
munities were given funds to establish ride services tailored to meet the unique
opportunities and constraints in respective areas. Each community also developed
a pricing scheme to cover costs. An advertising agency developed the program’s
name (Road Crew), slogan, and logo. At the end of the first year, and 19,575 rides
later, evaluation results suggest that the program has decreased alcohol-related
crashes by 17% and saved the state ofWisconsin $610,000 (32). Additionally, the
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328 GRIER BRYANT
evaluation found no evidence to support the criticism that the program increased
individual-level drinking.
The TexasWIC Program
The second case study examines a socialmarketing programconducted to increase
enrollment and improve customer and employee satisfaction with the Special Sup-
plemental Nutrition Program for Women, Infants, and Children (WIC) in Texas.
Participant observation, in-depth interviews, telephone interviews, focus groups,
and surveys were used to understand the needs, preferences, and characteristics
of four target audiences: families eligible but not participating in the program,
program participants, program employees, and professionals who refer people to
the program (9, 10). Research results were used to develop a comprehensive social
marketing plan that included policy changes, service delivery improvements, staff
and vendor training, internal promotion, public information and communications,
client education, and community-based interventions. This plan worked to change
families’ perceptions ofWIC as a welfare program that provided free food to poor
people by emphasizing nutrition education, health checkups, immunizations, and
referrals. It included recommendations for lowering costs by repositioning the pro-
gram as a temporary assistance nutrition and health program—“WIC—Helping
Families Help Themselves”—in which families can maintain their pride and self-
esteem as they earn theirWIC benefits and learn about nutrition and other ways to
help their families. Because many women did not know they were eligible for the
program and/or had trouble enrolling, the marketing plan also emphasized ways
to help families understand eligibility guidelines, streamline the certification pro-
cess, and make it easier for health and social service professionals to refer eligible
women. Placement strategies recommended the location ofWIC clinics outside of
government assistance venues, and professional training programswere developed
to enhance employees’ skills in dealing with customers and teach grocery store
cashiers to processWIC clients more efficiently and respectfully. Promotional ef-
forts included a community outreach kit to reach referral sources as well as the use
of mass media to reach eligible families. The Texas WIC Program was launched
in the fall of 1995. Program data was used to monitor the number of families who
called the toll-free number for more information after the program was launched
and, more importantly, the number of people participating in Texas WIC. When
results showed that increases in programenrollmentwere not sustained,midcourse
revisions were made to improve program delivery. The program’s caseload then
grew from its baseline level of 582,819 in October 1993 to 778,558 in October
1998—an increase of almost 200,000 participants.
The Food Trust
The last case study examines the Food Trust, a nonprofit organization in Philadel-
phia, Pennsylvania, which aims to increase people’s access to affordable and
nutritious foods. The Food Trust’s Corner Store Campaign seeks to reduce the
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SOCIAL MARKETING IN PUBLIC HEALTH 329
incidence of diet-related disease and obesity by improving the snack food choices
made by youth in local corner stores. The campaign uses social marketing to in-
crease demand for healthy snacks, promote student participation in the school
meals programs, and target the food industry to increase the availability of health-
ier choices in local stores. An initial budget of $10,000 (not including staff time)
was allocated to develop the social marketing plan for the Corner Store Campaign.
At the start of the planning process, Food Trust staff members interviewed 33 key
informants on best practices in social marketing and also worked to identify other
programs aimed at affecting youth snack choices nationwide. Survey research was
conducted to understand the food choices available in the corner stores in five
local communities and to provide a baseline for the development of strategies to
increase the distribution of healthier snacks. Survey results found that healthy food
choices were available only in limited quantities in most of these stores, e.g., only
one store carried low-fat milk in single serving containers and none sold fresh
fruit. Results of the assessment of the food environment were used to determine
(a) which healthy snacks could be promoted in the short termand (b)how to facili-
tate foodmanufacturers and retailers distribution of healthier snacks. For example,
the Food Trust developed partnerships with individual snack food companies to
increase the distribution of healthier choices in neighborhood stores. Formative
research was also conducted with youth ages 5–12 to understand their snacking
behavior and how to best promote the currently available healthier snack choices.
This formative research informed the development of a social marketing plan that
was piloted in two local communities in the summer of 2004.
CHALLENGES ANDMISCONCEPTIONS
Andreasen (4) has argued that socialmarketing is nowmoving into a period of early
maturity with growing popularity among public health professionals. However, to
continue developing, social marketing must overcome a variety of challenges.
In public health, these challenges can be grouped into four categories: (a) mis-
conceptions and other barriers to diffusion, (b) formative research and evaluation
methodologies, © theoretical issues, and (d) ethical considerations.
Barriers to Diffusion
After initial resistance, the field of public health has readily embraced marketing’s
reliance on advertising and other promotional techniques and has begun to rely
increasingly on consumer research to make evidence-based decisions (27). It has
yet, however, to fully appreciate social marketing’s “flexibility, range, and breadth
of potential for addressing behavioral and social issues” (38). As previously noted,
social marketing is often viewed as a method for designing communication cam-
paigns rather than developing comprehensive interventions that integrate the full
marketing mix of product, price, place, and promotion. In part, the diminished at-
tention given to nonpromotional elements of the marketing mix reflects confusion
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330 GRIER BRYANT
surrounding the adaptation of these concepts to socialmarketing situations (a theo-
retical issue we discuss at greater length below). It also reflects difficulties social
marketers have in modifying public health products (e.g., creating new and more
attractive benefits for eating fruits and vegetables), lowering the costs associated
with healthy behaviors (e.g., making fruits and vegetables cheaper to purchase
or easier to prepare), and creating accessible action outlets (such as placing fruits
and vegetables on fast-food restaurantmenus). Finally,many of socialmarketing’s
earliest adopters were dazzled by advertising or came from the public relations
and advertising fields and did not recognize the difference between marketing and
health communication (51). Whatever the reason, the disproportionate amount of
attention given to promotional activities has created the misconception that social
marketing relies primarily on advertising to achieve its goals. To overcome this
problem and realize social marketing’s full potential, its practitioners must rec-
ognize the power that lies in the integration of all elements of the marketing mix
rather than the magic of advertising messages.
Another criticism of social marketing is that it “blames the victim” by focus-
ing on individual behavior rather than on the underlying environmental and social
causes of the problems it addresses. Perhaps the most articulate of social market-
ing’s critics is Wallack (52), who argues that social marketing, like many public
health approaches, tries to rescue people from drowning “downstream,” when the
importantwork lies “upstream,” combating the environmental and social structural
factors that create the health problems. There is an element of truth in this criti-
cism: Social marketers have been guilty of relying too heavily on strategies aimed
at changing individual behavior and paying too little attention to environmental
factors (15, 26). The field has benefited from this criticism, and today the impor-
tance of understanding the social environment and making it more conducive to
individual healthy behavior is well established (25). For instance, Goldberg (20)
describes how an intervention designed to persuade individual motorcyclists to
wear helmets can be successful downstream in increasing individual helmet usage
and succeed upstream by demonstrating health care savings that prompt policy
makers to pass mandatory helmet laws. Nevertheless, although more cognizant of
environmental factors, social marketing practitioners too infrequently target pol-
icy makers who can address the broader social determinants of health (e.g., social
inequality, illiteracy, lack of community cohesiveness, poor housing, racism) (15,
26). [See Siegel & Doner (48) for a discussion of social marketing and policy
development.]
Another long-standing complaint against social marketing is that it is manip-
ulative. Some public health professionals in the developing world view social
marketing as a colonial approach that implies disrespect by using language based
on military metaphors (e.g., target markets) and commercialism (e.g., customers).
As Wallack (52) points out, “even the term consumer evokes a metaphor of lim-
ited power that values people only for what they can purchase and not for how
they can participate.” Some public health professionals still reject socialmarketing
because of its ties to Madison Avenue—style advertising, a field that has come
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SOCIAL MARKETING IN PUBLIC HEALTH 331
under increased scrutiny and criticism (27). Yet, as Hastings & Saren (27) note,
these criticisms ignore social marketing’s consumer orientation and commitment
to using research to understand and meet the wants and needs of consumers, an
approach that “challenges the expert-driven hegemony in the health sector....” To
successfully dispel the claimthatmarketing ismanipulative, socialmarketers need
to focus less on communication to inform people about public health products and
place greater emphasis on developing affordable, accessible products that allow
people to solve their problems and realize the aspirations that matter most in their
lives and to modify the environment to make it easier and more enticing to adopt
the healthy behavior. Efforts to involve consumers in goal-setting, participatory
research and strategy developmentwould also enable themto become true partners
instead of targets of professionals’ programs.
Social marketing’s diffusion has also been affected by some public health pro-
fessionals’ reluctance to invest time and resources in consumer research. Fortu-
nately, some funding agencies (e.g., the CDC, USDHHS, USDA, and the Robert
Wood Johnson Foundation) now require a planning phase and allocate funds for
community assessments, environmental scans, and consumer research formany of
the grants they award. But many other federal, state, and nonprofit funding agen-
cies still expect grantees to begin implementation before they have had ample time
to understand their consumers and develop appropriate intervention strategies.
Whereas social marketing may be inappropriate when time and resources are
not available to conduct formative research, in other cases, it may be possible to
truncate planning time andminimize costs by relyingmore on existing information
to develop a marketing plan. In addition to the published literature, local and
state program data sets can provide important insights into service utilization
rates, characteristics of current and previous program participants, and customer
satisfaction ratings. Also, social marketers can now access unpublished reports of
federally sponsored audience research on prevention topics from the Prevention
Communication Research Database (PCRD) created by the U.S. Department of
Health and Human Services (health.gov/communicat
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