Social marketing: how might this contribute to tackling obesity?

Abstract

As the recently established National Social Marketing Centre points out, the term 'social marketing' can be used in two different ways: first as 'a set of concepts and principles' used to inform the development and implementation of strategies aimed at behaviour change, that is a theory or 'a frame of reference or a mindset for helping examine, understand and provide insight into issues and enhance impact and effectiveness' of interventions aimed at behaviour change; and second 'as a specific intervention method or planned process' to achieve targeted behavioural goals (1). These two meanings will be discussed separately. Given that behaviour change is central to tackling obesity, the use of social marketing is, on the face of it, an attractive option. But social marketing theory is limited in its usefulness, being based on a particular and limited set of concepts and principles. On the other hand, social marketing as a specific intervention method may be effective in promoting behavioural change depending on what it entails. Before outlining some of the problems with using social marketing theory in tackling obesity, it is worth distinguishing between concepts and principles, as they are often confused. Concepts cover theoretical assumptions, which are open to empirical verification and hypotheses, which are open to empirical falsification, about the way the world objectively is. Principles, on the other hand, are theoretical assumptions based on subjective values ('mindsets') about the way the world should be. Some of the concepts of social marketing theory seem useful. Indeed, many of them are common to other theories used to inform strategies aimed at behaviour change. But there are other concepts – not shared by, or playing only a minor role in – social marketing theory, which are also helpful in informing strategies aimed at behaviour change. Furthermore, the principles of social marketing theory have limited usefulness, based, as they are, on commercial marketing theory. And, indeed, as a set of concepts and principles, social marketing theory may be unhelpful. However, social marketing is becoming so well entrenched as a theory used to inform strategies aimed at behaviour change that its rivals are fading by comparison and it will take a fair degree of effort to find an alternative. One common misunderstanding about social marketing theory is that it is solely concerned with advertising for social ends. Virtually, all proponents are adamant that it is not. However, as a theory, social marketing, generally traced back to the work of Kotler and Zaltman (2), does have one defining feature – that it is based on, and borrows heavily from, concepts and principles from commercial marketing theory and practice, including advertising and other marketing methods (1,3,4). Andreasen – one of the originators of social marketing theory – defines it as being 'the application of commercial marketing technologies to the analysis, planning, execution, and evaluation of programs designed to influence the voluntary behaviour of target audiences in order to improve their personal welfare and that of society' (5). That said, it is somewhat difficult to define the concepts and even harder to define the precise principles that are critical to social marketing theory. This is because different proponents (and critics) express the theory in different ways. However, there are some concepts that are generally seen as necessary for anything more than a superficial explanation of the theory – for example, those 'benchmark criteria' of a social marketing programme as outlined by Andreasen (5) and as described by Hastings et al. in this supplement. Some of these concepts are relatively distinctive to the theory, e.g. that communication involves an exchange. Some are less distinctive, being shared with many other theories that inform the development and implementation of strategies aimed at behaviour change, e.g. that effective strategies for behaviour change involve a degree of 'targeting' of particular individuals (generally called 'segmentation' by proponents of social marketing). The principles of social marketing theory are harder to define than the concepts, because different proponents put more emphasis on some than on others. For example, the UK's National Social Marketing Centre (1) places rather less emphasis on the principle that individuals should be held responsible for their own behaviour than earlier versions of the theory. The plurality of perspectives on what constitutes social marketing theory makes critical appraisal difficult. Moreover, there are many other theories that can be used to help inform interventions aimed at behaviour change, some of which inform current versions of social marketing theory. These can be divided into theories of behaviour change and planning models for interventions aimed at behaviour change. A useful website – that of the Communication Initiative – gives brief details of over 40 theories of behaviour change [http://www.comminit.com/changetheories.html (accessed October 2006)] and 30 or so planning models [http://www.comminit.com/planningmodels.html (accessed October 2006)]. Social marketing theory is generally conceived of as a planning model rather than a theory of behaviour change, although it makes a series of theoretical assumptions about behaviour change. Perhaps its closest rival for popularity among health promotion practitioners is the PRECEDE–PROCEED planning model developed by Green, Kreuter and associates (6). Very few of the assumptions underpinning theories of behaviour change and the theoretical assumptions behind planning models – including social marketing theory – have been subject to empirical verification. Choice between theories is therefore informed more by value judgements than by an assessment of the extent or quality of the evidence in support of the theories. For example, theories that focus on 'intrapersonal' factors that determine behaviour, such as beliefs and attitudes, tend to be favoured by those who see (or value) behaviour as the responsibility of the individual rather than of society as a whole, while theories that see features of the wider community and/or society, such as price and availability of goods and services as more important, tend to be favoured by those who see governments or big business as having a major responsibility in determining individuals' behaviour. In basing its assumptions about the causes of behaviour change on the theories that underpin commercial marketing, social marketing theory assumes that the purpose of an intervention aimed at behaviour change is to 'market' that behaviour change, using a mixture of marketing techniques. Social marketing theory therefore tends to see (or value) behaviour as largely the responsibility of the individual, rather than of society as a whole. This means that social marketing theory is a popular model in relation to tackling obesity at the current time. This is because the behaviour patterns that are related to obesity – low levels of physical activity and unhealthy eating habits – are often seen as inextricably linked with a range of different personal choices – car ownership, consumption of luxury foods such as chocolate and ice cream, etc. – rather than society-wide factors, such as the declining cost of car ownership relative to other forms of transport, increasing availability of cheap luxury foods, etc. Governments are increasingly unwilling, and may be increasingly unable, to interfere in societal trends but see some hope in persuading people of their personal responsibility and choice in the matter (7–9). There may be other reasons why social marketing theory is currently popular. The commercial marketing of tobacco, alcohol and, more recently, 'unhealthy' food has received much attention from public health bodies. One reaction to this has been to suggest that the techniques used for commercial marketing could be employed for social ends. But it should also be pointed out that only the most ardent supporters of social marketing theory see it as the one and only all-embracing theory of the causes of behaviour change that can be used to inform the development and implementation of strategies aimed at behaviour change. It can be readily seen that the validity of the assumptions behind social marketing theory rests on a number of analogies. First, social marketing theory assumes that the products to be marketed – behaviour, behaviour change or the benefits of behaviour change – are equivalent to goods and services marketed commercially. But whether, for example, physical activity is a 'commodity' that can be 'sold' in the same way as running shoes is doubtful. The benefits of the former will only be realised in the long term, whereas those of the latter are much more immediate. Second, social marketing theory assumes that the target audience for the interventions acts as 'consumers' of the behaviour change. Again, this seems doubtful. In what sense can behaviour be viewed as being consumed? Running shoes satisfy various needs and desires, they are consumed in the sense that they wear out and you need to buy some more. Physical activity, and particularly an increase in physical activity, is rarely desired and does not wear out, although, of course, an increase or 'renewal' of physical activity may be necessary, even if it is not recognized. Third, social marketing theory assumes an 'exchange'. In commercial marketing a transaction occurs between the producer of the good or service and the consumer. The consumer takes control over the good/service in exchange for money. This has led those developing social marketing theory to see an analogous exchange in the 'selling' of the behaviour change. Kotler and Zaltman argue: 'Marketing does not occur unless there are two or more parties, each with something to exchange, and both able to carry out communications and distribution' (2). However, it is not immediately obvious what is exchanged in the 'selling' (communication and distribution) of a behaviour change. Fourth, social marketing theory assumes analogies between the methods of commercial marketing and the promotion of desirable changes in behaviour. But if the basic transaction in social marketing – the selling of a behaviour change to a target audience – is only weakly analogous to the selling of a good or service to consumers during commercial marketing, the methods of commercial marketing, traditionally conceptualized as the four Ps of 'product', 'place', 'price' and 'promotion', may also have limited parallels in interventions aiming at behaviour change. It is, of course, possible to stretch the metaphors of marketing. Take one of the four Ps – price. It is possible to view a behaviour such as physical activity as having a 'price' to a person in terms of money (fees for gym membership etc) and other resources (such as time). It is not clear, however, that people view physical activity as having a price, in the same way as they view running shoes as having a price. Furthermore, the metaphorical use of 'price' in social marketing theory underscores its emphasis on commercial values like personal responsibility. The 'price' or 'cost' of the behaviour is seen as being chargeable to the individual rather than society as a whole. It is, of course, possible to view the costs of a behaviour as being charged and chargeable to either individuals or society (10), but social marketing theory is only generally concerned with the former. Most theories of behaviour change and planning models, including social marketing theory, put too much emphasis on a particular type of explanation for behaviour. This is most easily seen in some sociological theories, which view behaviour as essentially determined by societal factors, and in some psychological theories, which see behaviour as determined largely by intra- or at most interpersonal factors. Social marketing theory is largely a psychological theory, although it does take note of societal factors (at least in some later formulations). But there is also a tension between realist or objectivist and constructivist or subjectivist theories: the former seeing behaviour as measurable, open to rational inquiry and manipulation, and the latter seeing it as a function of interior states – emotions and feelings – reflected in cultural, political and religious principles (11). Social marketing theory is essentially a realist theory, taking as 'given' certain interior states and cultural, political and religious principles. That theories of behaviour change do not necessarily need to stress one particular set of explanatory factors is demonstrated by Ken Wilber in various works, but particularly in his A Theory of Everything (12). Wilber proposes that explanations of the way things are, and should be, can be divided into four basic types: individual/objective; group/objective; individual/subjective and group/subjective. This classification can used to categorize different theories of behaviour change as shown in Fig. 1. Categorizing different theories of behaviour change. The essential problem with social marketing theory is its limited perspective. It is essentially a psychological theory with a few theoretical assumptions borrowed from organizational theories (i.e. it can be located in the top right quadrant of Fig. 1, just above the horizontal divide). A more integral theory would, for example, view behaviour (extending the basic metaphor of social marketing theory) as not only a commodity to be sold and exchanged but also a commodity to be produced. This notion of behaviour as something that is produced – and particularly as something co-produced by the individual and society – has been proposed by others (8) and reflects a rather different perspective on responsibility for behaviour. Regardless of its underlying concepts and principles, social marketing can be viewed as a specific intervention method for tackling obesity. The number of possible ways by which obesity might be tackled is almost infinite. Swinburn et al. have developed a framework – the Analysis Grid for Environments Linked to Obesity framework – and a process for examining the options (13). There are other ways of scoping the possibilities. Choosing between possibilities is not as difficult as choosing between theories of behaviour change. There are a number of good-quality studies that have examined the effectiveness of different interventions (14). A subset of interventions aimed at reducing overweight and obesity can be described as social marketing. Is social marketing effective as a specific intervention method aimed at tackling obesity? In theory, this question can be answered without making any judgement about its theoretical concepts and principles, provided that there is an adequate and clear definition of a social marketing intervention. The way the question should initially be considered is by carrying out a systematic review of studies of interventions that can be described as social marketing. Systematic reviews of studies of interventions designed to promote behaviour change are now becoming relatively commonplace. The National Institute of Health and Clinical Excellence (NICE) has taken over responsibility from the Health Development Agency for commissioning such reviews, and there is a growing literature on the methodology for them. NICE has already published guidance on some interventions designed to promote physical activity and prevent obesity based on such systematic reviews. Some progress in carrying out reviews of social marketing as a specific intervention method has been made by the Institute for Social Marketing at Stirling University (15). The reviewers note that not all interventions that are called social marketing by those responsible for the intervention would be called social marketing by those carrying out the review and, conversely, that some interventions that are not called social marketing by those responsible for the interventions would be called social marketing by those carrying out the review. Furthermore, just as social marketing theory is not an all-embracing theory of behaviour change, social marketing interventions should not be regarded as the sole means of changing behaviour. A useful analysis in this regard is that by Rothschild – an advocate for social marketing interventions – who argues that the 'management of public health and social issue behaviours' needs 'education, marketing, and law as its three primary classes of strategic tools' (16). The above critique indicates that social marketing theory may only be temporarily popular as a model for planning interventions aimed at behaviour change. Many of the concepts are shared by other models and the concepts and principles on which the model is based are too limited. It seems likely that social marketing theory will be replaced by a more integral theory but that this will be in the face of some opposition and a Kuhnian paradigm shift will be needed for this to occur (17). Meanwhile, further research will always be needed into the effectiveness of interventions aimed at behaviour change, including those described as social marketing. No conflict of interest was declared.

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