25

Effects of Social Marketing

Potential and Limitations

Michael D. Basil

Communication and Information Campaigns

Many efforts to improve people's health behaviors have employed communication campaigns. Most typically this has involved the use of the mass media and other forms of communication to promote health behaviors (see Chapter 24, this volume). The historical basis of this approach can be traced to “information campaigns” in the 1940s (Hyman & Sheatsley, 1947). Over the next few years many communication and public health practioners have continued to focus on “information campaigns” and examined their power in influencing human behavior, especially in the realm of health (Mendelsohn, 1973). The general strategy underlying this approach is that when people are given appropriate information, they can make better decisions. A good many studies have examined the effects of these campaigns. A couple of recent meta-analyses of health communication campaigns have examined these health campaigns and concluded that information campaigns are generally effective in altering knowledge but not very effective in shaping behaviors (Keller & Lehmann, 2008; Snyder et al., 2004). That is, people learn some information, but only sometimes do they take action.

My own background has parallels with the story here. With an educational background in psychology and communication, it was easy and natural to draw on information theories to attempt to influence people's health behavior. The persuasion orientation can be seen in literature in information campaigns and in cognitive psychology. But as I became involved in working in the area of health, often with “health education specialists,” I became aware that convincing people of possible negative consequences of products such as tobacco often was insufficient to motivate action. In many cases educational efforts competed with campaigns that were based on needs and motivations which targeted people of different ages, ethnicities, and races (Altman, Schooler, & Basil, 1991; Basil et al., 1991). For example, tobacco ads ignored health issues such as cancer and emphysema to focus on more immediately tangible social benefits such as attractiveness and popularity (Schooler, Basil, & Altman, 1996).

Another important issue underlying the success of social marketing efforts is the difficulty of remaining, in the face of dozens of competing health messages and health risks, as they say in public relations, “on message.” For example, as a result of the competing tobacco messages, people seem to have combined the arguments to conclude that smoking could make them attractive, popular, and thin, after which they might die, but many believing this would mean a fast and easy death. The health data do not support the easy death assertion, though, and the lack of response to this conclusion was a problem that was never adequately addressed. Similarly, my own research has examined how social agencies fighting over whether abstinence or condoms offered the best approach to the HIV issue, sidetracked and interfered with HIV prevention efforts for many years (Basil, 2008). Eventually, churches and public health agencies agreed to compromise on the use of a combined “ABC” approach, which allowed health prevention efforts to get back “on message” and return their efforts to attempts to combat HIV infection.

Fear Appeals

In addition to information campaigns, a parallel line of theory and research is in the area of fear or threat appeals. Fear is an intuitive approach that can be traced back as far as information campaigns (Janis & Feshbach, 1953). The general strategy underlying this approach is that when people are more cognizant of the risks they face this should result in higher involvement with the issue, which would result in taking action (Roser & Thompson, 1999). A considerable body of research in this area has also shown that a threat does not necessarily equate to fear, and fear does not necessarily result in the most appropriate action (Rogers, 1975; Witte, 1994; Witte & Allen, 2000). That is, people learn what to be afraid of, but do not necessarily change their behavior in response. Sometimes the action they take is to “bury their head in the sand” to avoid exposure to additional fear appeals (Witte, 1992). In addition to limited effects, another problem with the use of fear appeals is the ethics of scaring people or reminding them of tragedies in their lives (Benet, Pitts, & LaTour, 1993; Hastings, Stead, & Webb, 2004; Jones & Rossiter, 2002). Overall then, the effects of fear appeals are limited and ethically concerning.

Although it is the opinion of this author that fear appeals are limited in their effectiveness and overworked, there are some circumstances when they can be effective. The protection motivation model (Rogers, 1975) and the extended parallel process model (Witte, 1992) predict that not only is the level of fear important, but so is people's confidence, or efficacy, towards being able to enact a protective behavior. Supportive of those predictions, my own research, with colleagues, is finding that fear appeals are more effective when they include ways to enhance self-efficacy and response efficacy with specific behavioral options (Basil et al., 2007). This research demonstrates that when fear appeals also provide simple behaviors that can reduce the threat, these messages result in much higher behavioral intentions.

Personalization

As I was becoming disenfranchised with information-based approaches, AIDS was becoming one of the most important health issues of the day. On a November day in 1991, I, along with millions of people, learned that “Magic” Johnson was diagnosed with HIV and was retiring from basketball. Bill Brown, who was a colleague and a basketball fan, and I were convinced that Magic would make a remarkable spokesperson. We tried to explain to each other why we felt that way. There were many reasons to suspect that celebrities could be powerful, the foremost being Horton and Wohl's (1956) theory of parasocial identification. Celebrities are people with whom millions of people develop a false sense of personal friendship. This is one of the reasons that celebrities are used frequently in commercial advertising (Alperstein, 1991; Erdogan, Baker, & Tagg, 2001). In addition, as former students of Ev Rogers, we were aware of a large body of “diffusion” research which has shown that friends and similar (“homophilous”) others are much more powerful influences than unknown (“heterophilous”) others (Rogers, 1995).

Armed with these theories of celebrity effects, including Bill's dissertation on parasocial identification (Brown, 1991), we quickly put together a survey and experiment to examine if this was true. The results were remarkably strong – parasocial identification, or a feeling of being close to “Magic” Johnson, was a very large predictor of news diffusion as well as attitudinal changes such as attitudes toward HIV and behavioral intentions to use condoms in future sexual encounters (Basil & Brown, 1994; Brown & Basil, 1995). In fact, the effects were so strong they remained a year later (Basil, 1996). Concern about a friend, virtual or not, is more powerful than simple knowledge of risk factors (Basil & Brown, 1997), and celebrities are people with whom millions of people develop a false sense of personal friendship, which appears to explain their power.

After having discovered the importance of celebrities through Magic Johnson, in subsequent studies we found similar effects for baseball player Mark McGwire (Brown, Basil, & Bocarnea, 2003a), and – although outside the scope of health-related outcomes, per se – Diana, Princess of Wales (Brown, Basil, & Bocarnea, 2003b). In the case of Mark McGwire, identification with him predicted attitudes toward child abuse and interest in steroids. For Princess Diana, identification predicted intentions just after her death to watch the funeral on TV and to blame the press for her passing. So friends, whether real or virtual, are an important way to make an issue feel “personalized.”

Social Marketing

Given the often limited behavioral outcomes of information and fear campaigns, another more extensive strategy that is increasingly applied to health communication efforts is the use of “social marketing.” Social marketing applies commercial marketing methods to health issues and other social goals (Andreasen, 2006). In the same way that commercial marketing focuses on sales, the social marketing approach is all about behavior, with a focus on finding ways to facilitate and reward those behaviors.

Social marketing has been applied to a number of issues, with some evidence that the approach was first applied in Asia to health issues such as the distribution of condoms (Harvey, 1999). Research supports the notion that general “calls to action” without additional incentives often result in little or no behavioral change, thus supporting the potential power of social marketing (Rothschild, 1999). Social marketing efforts that increase incentives, better accessibility to products such as condoms or mosquito nets, or provide additional value to the target market should be more effective in producing behavior change than information-only efforts (Rothschild, 2009; Smith, 2009).

The main strategy to successful social marketing is to provide direct exchanges to consumers based on their needs and wants. For example, providing attractive protection appropriate to the person, such as hard hats promoting their favorite football team, is an example of an exchange. This is rooted in economic exchange theory, which explains that people will act if they perceive they are receiving something of adequate value in return (Rothschild, 1999). How do marketers find those potential exchanges that are attractive to consumers? Social marketing draws on several tools from marketing strategy such as consumer analysis, segmenting, targeting, branding, and positioning. Current social marketing generally puts a great deal of emphasis on identification of consumer segments and targeting. The use of segmentation and targeting tools does not necessarily result in social marketing however, as these tools are also used in a number of campaigns that only focus on education or fear (e.g., Bellows, Anderson, Gould, & Auld, 2008; Berkowitz et al., 2008). So segmentation and targeting tools are a necessary, but not a sufficient condition, for a social marketing effort.

What else is needed to make a “social marketing” and not a communication campaign? In commercial marketing, before a promotion occurs, the current selection of products, their price, and their availability are examined and customers' use and satisfaction with these products is analyzed. To be effective, social marketing campaigns need to take efforts to improve the products and their variety, reduce the costs to consumers, and increase the product's availability. For example, in one attempt to reduce drunk driving, used limousines were purchased and used to transport people to and from bars where they would be drinking (Rothschild, Mastin, & Miller, 2006). When done correctly the communication component is only applied later, largely to provide awareness of the product or service; and sometimes mass communication may not even be necessary if the marketing program can grow organically using word-of-mouth communication to disseminate awareness of the program.

Theorists suggest that communication efforts work best when they constitute an integrated part of an overall marketing effort (Alden, Basil, & Deshpande, 2011). A focus on communication as the sole basis of social marketing is almost always a mistake – social marketing is not a matter of finding the right way to say something so much as it is a matter of understanding a problem, finding a feasible solution, and providing an effective and practical solution to people.

Although many in the health field focus on education or fear campaigns about nutrition, and nutrition is important to many consumers, so are taste, cost, and convenience (Glanz, Basil, Maibach, Goldberg, & Snyder, 1998). So although people can make use of nutrition labels (Basil, Basil, & Deshpande, 2009), these information-focused approaches are missing the important human behavioral factors of taste, convenience, price, culture, and habit. Similarly, although cognitive models such as the health belief model, which examines people's rational and intentional behavior can be used to predict food choices (Deshpande, Basil, & Basil, 2009), there are other factors that come into play, such as taste, emotion, culture, and habit. Social marketing efforts need to realize that people have already discovered foods that are tasty, convenient, and inexpensive. So instead of just suggesting that people “eat healthy,” taste-testing, recipe-development, and availability of specific options should all be used to ensure that specific suggestions can be offered which are tasty, convenient, inexpensive, and nutritious.

The importance of a behavior being relatively easy to perform can be seen in dog waste bags. By providing doggie bags at the entrance to parks and such, dog owners are encouraged to pick up after their pet. So can the behavior be explained by a lack of knowledge or a lack of fear? Given the ease with which doggie bags were adopted, this is not very tenable. Instead, there is good reason to believe that the additional appeal and convenience of doggie bags can explain this phenomenon. What can we learn from this example? Finding ways to make doggie bags more available to people is critical. After these efforts are in place, communication efforts can then be used to promote these doggie bags, though in many cases this may not be necessary at all.

As I train more and more public health practioners in social marketing I become more convinced that, in order to be effective, we need to widen our approach beyond education and fear-based campaigns. Although communication is an important aspect of social marketing, to qualify as “marketing” it needs to do more by finding easy, practical, and simple solutions for people and then communicate those options to people through integrated efforts (Alden et al., 2011).

Potential

The potential of using the media for social marketing is greatest when behaviors are relatively easy. The potential is also greater when behaviors are not just encouraged, but facilitated and rewarded. In other words, making a behavior easier to perform is usually more effective than simply providing information about the problem and solution (Kotler & Roberto, 1989). The focus on behavioral approaches can be seen in a variety of social marketing efforts such as in promoting the use of bicycle helmets where efforts may involve a bike event to raise awareness, or a contest which gives away a few bike helmets (to increase their desirability) and bike helmet coupons (decrease the price and make them more attractive in the short term; e.g., Alden et al., 2011). Some have recently suggested that social marketing also works best when products that help people to perform the desired behavior are created for the target markets (Rothschild, 2009; Smith, 2009). So if the behavior can be made easier to perform, this should also increase the likelihood of compliance.

Consider, for the point of illustration, the obesity issue. Research evidence demonstrates a rising incidence of overweight and obesity (see Chapter 15, this volume). Research also demonstrates the epidemiological connection between overweight, obesity and health risks. Based on these findings, governments have decided it is important to act. So they try to convince people to avoid being overweight by becoming more active. These types of information campaigns are often where the efforts stop. People learn that to lose weight they should be more active but find it difficult for a variety of very real reasons. Perhaps they become frustrated with their own efforts and limited success. That's when the marketing efforts kick in. Commercial enterprises use this opportunity to create or expand their fitness facilities and make them more available by opening newer or more convenient locations, opening for longer hours (some are available 24 hours a day), or offering more attractive services (such as swimming pools and babysitting). They may offer assessment and training services so users are not as intimidated by the equipment. They promote these facilities with media advertising or direct mail offering low or free introductory memberships to enroll people in these facilities and make them financially viable.

A good social marketing program not only finds out what people are doing, but what the barriers are, and then finds ways to encourage behaviors at minimal cost or effort before launching communication efforts. Examples of good government and NGO efforts in the area of physical activity can be found in a variety of efforts to promote walking and taking the stairs (e.g., Reger et al., 2002). To be successful, social marketing needs to go beyond providing information or fear to providing solutions. Efforts may include getting older people to walk together and opening shopping malls to help mitigate concerns about weather and safety. These are examples of how social marketing can go beyond merely providing information to providing actionable solutions.

In support of the importance of actionable solutions, a meta-analysis of condom distribution programs demonstrated that it was not an increase in awareness of condoms that made the programs successful, but the increased distribution and availability of the condoms (Cohen et al., 1999). Similarly, in a study of bicycle helmet use, it was not increased awareness, but coupons that lowered prices that increased compliance (Ludwig, Buchholz, & Clarke, 2005). Another effort, mentioned earlier, demonstrated that it was not increased awareness of drunk driving, but the provision of rides to drinkers that was responsible for a decrease in drunk driving (Rothschild et al., 2006). In summary, social marketing efforts that introduce new products, lower the costs, or increase the availability demonstrate more behavioral effects than information-only efforts.

Limitations

Despite the promise offered by social marketing, as in commercial marketing, intervention efforts are limited by competition. In commercial marketing, despite billions of dollars spent on advertising to promote products, a majority of new products fail, largely because of competition. In social marketing, competition can consist of people's existing behaviors, beliefs, social forces, or structural factors that stand in the way. In both commercial and social marketing, people are naturally resistant to new ideas and it is only those ideas or products that strike a chord with consumers by providing considerable value for the price that the new product or behavior has any chance for success over the competition.

Education and information efforts can be effective to the extent that the problem is a lack of knowledge. In most of the world the notion that gaining weight comes from eating more calories than one burns, that fruit and vegetables are healthy, that physical activity has a variety of health benefits, and that reducing one's exposure to environmental toxins reduces risk for cancer are all well-known. What is hard is providing a means for people to achieve these ends. For example, finding a way to provide fruits and vegetables to satisfy people's hunger in a way that is as tasty, convenient, and as inexpensive as unhealthy foods is difficult. Imagine the difficulty of reducing your exposure to environmental toxins, if your current home is near a powerline or your basement emits radon gas – you would need to sell your home (possibly at a loss, since the hazard is now known), move, and locate a home that would have fewer environmental risks from those factors (and others). Who can know what all these factors are? To the extent that we cannot develop viable products or solutions, social marketing efforts are, like many communication campaigns, probably limited to raising awareness of a problem or issue.

Review of Previous Studies

In this section, the assertions about the power and limitations of social marketing will be examined in a review of research in social marketing interventions from around the world. This review demonstrates how important it is to provide more than just information, but to provide effective interventions with products that are affordable and easy to use.

The general approach to social marketing is very different in different parts of the world. In what we often term the “developed world,” largely English-speaking countries such as the United States, Canada, the United Kingdom, and Australia, many efforts labelled as “social marketing” tend to consist of information and fear appeals. This can be seen across a range of social marketing interventions. These include alcohol use (DeJong et al., 2006; Gomberg, Schneider, & DeJong, 2001), food choice (Bellows, Cole, & Gabel, 2005; Reger, Wootan, Booth-Butterfield, & Smith, 1998), physical activity (Bauman, Bellew, Owen, & Vita, 2001; Bellows et al., 2008; Berkowitz et al., 2008; Hillsdon, Cavill, Nanchahal, Diamond, & White, 2001; Huhman et al., 2005, 2007; Huhman, Bauman, & Bowles, 2008), sexually transmitted diseases (Ahrens et al., 2006; Bull et al., 2008; Darrow & Biersteker, 2008; Futterman et al., 2001; Kennedy, Mizuno, Seals, Myllyluoma, & Weeks-Norton, 2000; Montoya et al., 2005; Plant et al., 2008), and tobacco use (Dietz, Delva Woolley, & Russello, 2008; Hersey et al., 2003). For almost all of these interventions, the entire effort was built around informational messages that simply provided information to the target audiences.

When examining the effects of these campaigns, the results are similar to what was found with other information and fear campaigns, specifically that most efforts demonstrate change in knowledge or awareness (e.g., Dietz et al., 2008; Hersey et al., 2003; Huhman et al., 2008). Similarly, social norms campaigns often report a decrease in people's estimates of how prevalent an undesirable behavior is in others (e.g., Davis et al., 2007; DeJong et al., 2006; Gomber et al., 2001), but with regard to actual behavioral outcomes, the effects of these efforts are otherwise limited. A few studies have demonstrated that people will perform a behavior that is relatively simple or cost-free, such as getting a free STD test (Futterman et al., 2001), switching from high- to low-fat milk (Reger et al., 1998), or wearing a condom (Kennedy et al., 2000). In other cases any effects were limited to those populations who reported greater awareness of the campaign, which suggests that information was a helpful but insufficient condition for behavior change (Huhman et al., 2007; Montoya et al., 2005; Plant et al., 2008). For the majority of these attempts, however, the efforts resulted in no significant changes in behavior (e.g., Bull et al., 2008; Darrow & Biersteker, 2008; Dietz et al., 2008; Hersey et al., 2003; Huhman et al., 2008).

In the case of social marketing efforts focused on the “developing world,” the efforts are often more varied. Of course there are some programs that use communication-only campaigns. These can be seen in efforts to alter behaviors such as antibiotic use (Goossens et al., 2006), condom use (Meekers, Agha, & Klein, 2005), and multivitamin use (Warnick et al., 2004). However, many social marketing efforts are based on marketing efforts that include increasing the availability of products such as condoms (Eloundou-Enyengue, Meekers, & Calves, 2005; Foss, Hossain, Vickerman, & Watts, 2007) or mosquito netting (Abdulla et al., 2001; Minja et al., 2001; Schellenberg et al., 2001). In these cases, the effectiveness of these approaches is measured in terms such as product ownership (Minja et al., 2001) or product use (Abdulla et al., 2001; Eloundou-Enyengue et al., 2005; Foss et al., 2007; Warnick et al., 2004). The most impressive efforts often show measureable differences in blood markers such as haemoglobin, prevalence of anemia (e.g., Abdulla et al., 2001), and even measures such as infant survival (Schellenberg et al., 2001). In these cases, increasing the availability of condoms or mosquito netting and providing them at affordable prices resulted in efforts that were not only effective in changing knowledge and attitudes, but behavior that resulted in meaningful measures of population health.

Conclusions

Evidence supports the notion that social marketing is most effective when it goes beyond education to provide simple behavioral alternatives, and when these options are consistent with individual beliefs and social forces. In the same way that commercial marketers bring products to the market such as fitness facilities or fruits and vegetables, findings ways to make products more accessible is a critical part of social marketing. As commercial marketers use coupons to reduce the cost of a product, social marketing interventions should also find ways to increase availability and lower price to encourage and shape desired behaviors.

The evidence suggests that the effects of social marketing are limited when focused solely on fear. Fear can cause people to bury their head in the sand and avoid additional messages (e.g., Witte, 1992). Adding easy and simple ways that people can protect themselves is more effective than focusing on fear itself (e.g., Witte & Allen, 2000). The evidence suggests that the effects of these efforts are limited by competing forces such as the cost and difficulty of safety gear. It is difficult to overcome inertia. It is also difficult when different parties act at cross-purposes, such as in the example in which churches and public health agencies fought as to whether abstinence or condoms should be the target, and distracted from the goal of AIDS prevention (Basil, 2008).

This chapter has proposed that social marketing has its greatest potential when it is not limited to information and fear but finds ways to make the performance of desired behaviors easier, when it finds ways to fit those behaviors within the context of existing beliefs, and finds ways to work out solutions that are amenable to a variety of consumers and constituents. Conversely, this chapter has also shown that social marketing is limited by existing beliefs, social forces, and other structural factors. As a result, social marketing is most effective when we can develop viable products or solutions that help people find alternative behaviors that are relatively easy to perform, such as wearing a condom, using mosquito netting to reduce malaria, or getting an inoculation to prevent disease.

Some of the desire to rely on appeals or interventions that focus on information and fear are likely to be as a result of habit, funding and mandates. The idea of shaping behavior can be seen as too coercive, so funding organizations, government agencies, and NGOs are often more comfortable with familiar education campaigns and fear appeals (Smith, Brugha, & Zwi, 2001). As a result, it is important to figure out a solution that is amenable to all constituencies. The social marketing approach requires finding those potential common solutions and employing methods of shaping behavior. As people become more aware of the potential of social marketing we hope they will be more likely to employ it to encourage positive change in health and social behaviors.

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FURTHER READING

Andreasen, A. R. (1995). Marketing social change: Changing behavior to promote health, social development, and the environment. San Francisco, CA: Jossey-Bass.

Andreasen, A. R. (2001). Ethics in social marketing. Newbury Park, CA: Sage.

Andreasen, A. R. (2002). Marketing social marketing in the social change marketplace. Journal of Public Policy and Marketing, 21, 3–13.

Burroughs, E. L., Peck, L. E., Sharpe, P. A., Granner, M. L., Bryant, C. A., & Fields, R. (2006). Using focus group in the consumer research phase of a social marketing program to promote moderate-sntensity physical activity and walking trail use in Sumter country South Carolina. Preventing Chronic Disease: Public Health Research, Practice, and Policy, 3, 1–19.

Donovan, R., & Henley, N. (2004). Social marketing: Principles and practice. Melbourne, VIC, Australia: IP Communications.

Donovan, R., & Henley, N. (2010). Principles and practice of social marketing: An international perspective. Cambridge, UK: Cambridge University Press.

Dorfman, L., Wallack, L., & Woodruf, K. (2005). More than a message: Framing public health advocacy to change corporate practices. Health Education and Behavior, 32, 320–336.

Hastings, G. R. (2007) Social marketing: Why should the devil have all the best tunes? Oxford, UK: Butterworth-Heinemann.

Hastings, G., & Haywood, A. (1991). Social marketing and communications in health promotion. Health Promotion International, 6, 135–145.

Kotler, P., & Lee, N. R. (2008). Social marketing: Influencing behaviors for good. Thousand Oaks, CA: Sage.

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Maibach, E. W. (2002). Explicating social marketing: What is it and what isn't it? Social Marketing Quarterly, 8(4), 7–13.

Reichert, T., Heckler, S. E., & Jackson, S. (2001). The effects of sexual social marketing appeals on cognitive processing and persuasion. Journal of Advertising, 31, 13–27.