Behaviour Change Perspectives

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An Intervention to Increase the Uptake of Free School Meals
Managing Health Improvement Through Social Marketing
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May 2019
Word Count: 3296
Part One: An Introduction to Social Marketing Page 2
Social Marketing
Behaviour Change Perspectives
Part Two: The Issue Being Addressed Page 5
The Uptake of Free School Meals
A Public Health Issue
Part Three: The Social Marketing Plan Page 8
The STELa Model
Learn & Act
Conclusion Page 13
References Page 14
Part One: An Introduction to Social Marketing
Social Marketing is a discipline used to initiate positive behaviour change amongst members
of targeted populations using a range of marketing tools and behaviour change strategies
and has become a standardised approach to health improvement within the field of Public
Health (French, 2017). Although behaviour change approaches are useful in attempting to
understand health-related behaviours, the success of social marketing to improve
population health heavily relies on marketing concepts used in the commercial sector, due
to the influential impact marketing strategies can have on the behaviours people make
(Kotler and Lee, 2011).
This social marketing proposal focuses on increasing the uptake of Free School Meals (FSM).
Whilst FSM are a welcome provision to many low-income families across the United
Kingdom (UK), uptake since they were first implemented has been consistently lower than
expected (Department for Education, 2018) There are many theories regarding why this
could be, including lack of awareness that people are entitled, the quality of meals provided
by schools, and the stigma experienced by claiming state benefits (Woodward et al, 2015).
Providing extra support to low-income families through government-funded initiatives like
FSM are believed to reduce food insecurity which is an increasing concern in the UK due the
negative implications on health (Holley and Mason, 2019). Therefore, encouraging parents
to apply for the meals that their children are entitled to has the potential to improve the
health and wellbeing of children across the UK.
Social Marketing
The idea of social marketing was developed by Kotler and Zaltman (1971) who suggested
marketing techniques, such as market research; the careful design of products;
consideration of price and place; and, carefully planned promotion, could be used to
encourage positive behaviour change amongst targeted populations to to reduce some of
the detrimental challenges faced by society. It is suggested that the concept has been
developed over time to facilitate change rather then influence it (Saunders et al, 2015).
Nonetheless, social marketing practice now has an international reach which has evolved
into promoting upstream change by targeting policy makers and international government
agencies to make a greater impact on eradicating societal issues (Stewart, 2015). The use of
social marketing has played a fundamental role in tackling many public health challenges in
the past five decades. This includes targeting a wide range of social determinants of health,
including reducing health-damaging behaviours such as smoking, improving road safety and
encouraging enrolment into further education (Kotler and Lee, 2011).
It is suggested that the lack of concise definitions and descriptions of social marketing and
the use of different languages when research is published coupled with inconsistent or
poor-quality studies can make it difficult to collaborate and evaluate existing evidence
(Evans, 2016). Despite this, the effectiveness of Social marketing to improve health outcome
is considered highly evident, with research continually being funded, conducted and
reviewed by agencies such as the European Centre for Disease Prevention and Control
(French, 2017) and the National Social Marketing Centre in the UK (Evans, 2016). A
systematic review by Gordon and colleagues (2006) found that interventions using social
marketing techniques were successful in improving diet, increasing physical activity and
reducing alcohol, tobacco and illegal drug use amongst various populations in various
settings and locations. However, not all initiatives are successful. Many interventions simply
do not work for various reasons such as lack of engagement by the target audience or
outside factors which cannot be controlled, or impact is too small to make any real social
impact on the issues faced (French, 2010).
Behaviour Change Perspectives
The fundamental aim of any public health based social marketing initiative is to improve
health-related behaviours, which are defined as any activities or habits which influences the
maintenance or improvement of health (Gochman, 1997). However, marketing tools alone
cannot generate social change. Prior to attempting to change the behaviour of others, it is
important to gain an understanding of the rationale behind said behaviours (Hayden, 2009).
Therefore, it is key that behaviour change theory is applied to any social marketing
intervention to increase the chances of success (Thackeray and Neiger, 2000). There are
various perspectives which attempt to do this, including The Health Belief Model, The Social
Change Model, The Innovation Model and Social Cognitive Theory. It is common practice to
utilise several behaviour change theories in social marketing. For example, the Centers for
Disease Control and Prevention (2003) developed a social marketing framework, Prevention
Is Care, integrating aspects of both Social Cognitive Theory and the Innovation Model to
encourage the routine screening of HIV transmission behaviours for patients infected by the
HIV virus. Despite the importance of incorporating behaviour change theory in the
development of social marketing interventions, research often fails to include this stage in
their published results, making it difficult to determine which models are favoured or
produce greater outcomes (Fraze et al, 2010). However, according to Glanz and Bishop
(2012) The Health Belief Model is the most utilised approach in the field of public health.
The Health Belief Model attempts to explain the rational behind health-seeking or healthdamaging behaviours as well as predicting them amongst targeted populations (BlairStevens et al, 2010). Developed in the 1950s, this approach suggests that individuals will
assume improved health-related behaviours if they have the desire to prevent illness or
improve their health, and if they believe the new behaviour(s) they adopt will help them to
achieve this (Gochman, 1997). Health promotion theory is often consolidated with
behaviour change theory as it provides an insight into the processes and environments
needed to facilitate change in order to improve their health (Hayden, 2009). The Education
Approach is a health promotion theory which is often utilised to provide key information
and skills to people, thus allowing them to make informed decisions which can positively
impact their health outcomes (Hastings and Domegan, 2018). Due to their relevance in
addressing public health issues through behaviour change and informing targeted audiences
in order to facilitate positive health-behaviours, the Health Belief Model and Education
Approach will be collectively utilised to inform and underpin this proposed intervention.
Part Two: The Issue Being Addressed
The Uptake of Free School Meals
Children with parents receiving qualifying benefits, such as Universal Credit or Housing
Benefit, are entitled to a free meal during the school day (Department for Work and
Pensions, 2013). FSM are worth on average £2.30 per day per child (UK Parliament, 2018),
meaning a family with two children eligible for FSM could save up to £874 each year if they
opted to claim FSM rather than paying for them themselves. However, the number of
children entitled but not in receipt of FSM is high, despite most of these children living in
low-income households. In the 2017/2018 school year, 86.6% of primary school aged
children and 87.6% of secondary school aged children who were entitled to free school
meals did not receive them due to their parents or carers not applying (Public Health
England, 2019).
There are various reasons why the uptake of FSM is low. These include confusion about
eligibility due to insufficient or unclear information provided by local authorities (Child
Poverty Action Group, 2018); reluctance by parents to seek support with the claiming
process due to low confidence or poor literacy and language skills; the desire to remain
financially independent (Sahota et al, 2014); children or parents unhappy with the meals
provided by schools; or the preference of taking a packed lunch (Woodward et al, 2015).
A Public Health Issue
Not receiving FSM which they are entitled to can lead to children not consuming enough
food throughout the school day which can have a detrimental effect on both their health
and their educational attainment (O’Connell et al, 2019). Research shows that inadequate
nutrition is linked to poor academic performance (Banjeree, 2016), which can result in
further problematic issues in adulthood such as unemployment and homelessness (Farrugia
and Gerrard, 2016).
Children not consuming enough food through the school day are also likely to be
experiencing hunger out-of-school hours (Gooseman et al, 2019). However, there are
multiple factors which must be addressed to eradicate this issue. Nonetheless, food
insecurity is a prevailing issue, affecting around 20% of school-aged children in the UK (The
Food Foundation, 2018). The health implications of hunger due to experiencing food
insecurity include stomach-aches, iron deficiency and headaches amongst others
(Gundersen and Kreider, 2009). Research by Petralias and colleagues (2016) found that
receiving a nutritious meal during the school day can help reduce food insecurity thus
leading to improved academic attainment and improved health. However, research by
Oostindjer et al (2017) suggested that despite the consumption of school meals having
positive short-term impacts on the health and wellbeing of children, further research is
needed to establish the long-term benefits.
Social marketing strategies alone cannot facilitate positive social change due to the wide
range of social and environmental factors which determine both the behaviours of
individuals and their health outcomes (Akhtar and Bhattacharjee, 2013). The wide range of
social determinants impacting child health in the UK at present include living in inadequate
quality housing; low household income; parents’ poor mental or physical health (TaylorRobinson et al, 2019); anxiety and depression in children; social isolation; and, experiencing
discrimination and bullying (Pearce et al, 2019). Promoting the health and wellbeing of
children requires collaborative action from the children themselves, their parents and
carers, school staff, local authorities, health professionals, policy makers, and organisations
from the public, voluntary and private sectors (Blair et al, 2010).
The stigma surrounding children receiving FSM has been identified by multiple researchers
as a fundamental cause of the low uptake of FSM (Sahota et al, 2014: Woodward et al,
2015). This is particularly the case for school which do not have any systems in place to
anonymise children in receipt of FSM, with children receiving vouchers to claim their meal,
being placed in a separate lunch queue to their peers who pay for their meals themselves,
or during school trips when free packed lunches are provided to those entitled to FSM
(Woodward et al, 2015). This makes interventions to encourage parents to claim FSM for
their children challenging.
Part Three: Social Marketing Plan
The STELa Model
Many social marketing planning tools have been developed to assist with the development
and implementation of behaviour change interventions, such as the Total Process Planning
Tool and the STELa Model, and which one is utilised is dependent on the complexity or
enormity of the behaviours and populations targeted (French et al, 2011). The STELa Model
incorporates four domains: Scope, Test, Enact and Learn and Act, and is used within this
proposal as it is a useful tool to assist with the planning and design of social marketing
interventions (French, 2017).
The initial stage of the STELa planning tool is to a) establish the rationale behind the
intervention; b) determine factors which can assist or threaten any actions taken during the
implementation of the intervention; c) establishing a target audience; d) how and why the
exchange will be structured; and e) establishing relevant aims and objectives (French, 2010).
a) Increasing the uptake of FSM is a priority to improve individual welfare, help reduce
food insecurity and to reduce health inequalities, thus improving health outcomes
(Woodard et al, 2015). It is also important to ensure children receive adequate nutrition
throughout the school day as this increases the chances of improved academic success,
which can help reduce health inequalities in adulthood (Petralias et al, 2016).
b) Possible threats to the intervention include the willingness of school staff or local
authorities in facilitating the intervention, lack of available resources or knowledge to
implement the initiative, or existing policies regarding the eligibility of FSM. Woodward and
colleagues (2015) found that interventions to increase the uptake of FSM in both primary
and secondary schools required full support from school staff to succeed. Additionally, the
stigma surrounding FSM entitlement poses a substantial threat, therefore it is essential this
be addressed (Sahota et al, 2014). Enabling factors include children wanting to participate in
activities alongside their peers, and the fact that school staff value the health and academic
performance of their students (Gleddie, 2012), increasing the likelihood that they will
encourage the implementation of an intervention to increase the uptake of FSM.
Additionally, many school staff establish a good relationship with children, parents and
carers, meaning they can help influence and encourage parents to participate in activities
which may benefit them (Sahota et al, 2014).
c) The primary audience for this intervention will be parents who are entitled to claim FSM
but do not. Despite statistics existing showing a large proportion of school children are
eligible but not receiving FSM, identifying the parents of these children will prove difficult,
therefore all parents of primary school-aged children leaving Year 2 and entering Year 3 will
be targeted. The secondary audience will be the school children themselves, namely those
entering Year 3 of primary school, as this is when they are no longer entitled to Universal
FSM, which are provided to all children aged 4 to 7 years attending state schools (Sellen et
al, 2018). This will include those not entitled to free school meals in attempt to educate all
children about the importance of nutrition and reduce stigma and bullying. Finally, the
tertiary audience will be school staff and local authorities, who will be encouraged to
facilitate the intervention. Research at this stage of the intervention will be crucial in order
to gain an insight into the needs of the target audience, as it is fundamental that the
consumer needs are at the centre of all social marketing activities (French, 2017).
d) The proposed intervention will include an exchange, which Kotler and Zaltman (1971)
suggest is the central idea of any marketing strategy. The exchange in this case will be the
parents applying for the FSM their child is entitled to, and in return will receive the financial
benefits of not having to provide a packed lunch or fund school meals themselves to
improve their overall financial situation.
e) The primary aim of this social marketing intervention is to increase the number of
primary school children entering Year 3 receiving free school meals, by educating their
parents or carers of eligibility and encouraging schools to support them during the claiming
The Marketing Mix, also known as the 4Ps: Product, Price, Place and Promotion, forms the
foundation of any marketing strategy and is one of the marketing tools used in social
marketing (French, 2017). The Product on offer within this intervention is a reduction in the
costs of providing a meal to children during the school day. The Price of this will include time
reading literature which they are provided, and time spent filling in forms, however parents
will receive support during this process. The intervention will take place within the school
environment, as it is accessible to all parents and children. The uptake of FSM will be
promoted through literature provided to all children and parents, with key information on
eligibility, the claiming processes, where they can access further support and the benefits of
FSM for children and their parents. Customer insight generated during the scoping stage will
assist with the development of the literature.
Andreasen (1994) suggests that any initiative to incite changes in behaviour must
encompass the 4 Ps. However, Tapp and Spotswood (2013) argue that the marketing mix is
often overly depended on and is not suitable for all social marketing interventions due to
the wide range of social issues they attempt to improve. People, Policy and Partnership are
further additions which are commonly used in social marketing (Donovan and Henley,
2010). The Strategic Intervention Mix embraces these additional factors, incorporating
Design, Educate, Control, Inform and Support as key areas which can influence positive
behaviour change (French, 2017). Considering the Strategic Intervention Mix, this
intervention will focus primarily on educating parents about the eligibility of FSM and
supporting them throughout the claiming process. This will include providing literature to all
children in Year 3 who are no longer entitled to Universal FSM but may be entitled to claim,
in addition to establishing a designated member of school staff who parents can approach
for additional information or support.
Pre-testing and its evaluation are essential at this stage to determine whether the evidencebase is relevant to the target audience, whether the intervention is feasible and whether an
action needs to be taken to improve the intervention (French et al, 2011). Pre-testing will
take place within 5 primary schools, one of them receiving no intervention to determine
whether there are any other factors which affect uptake.
The intervention will be rolled out in July when children are leaving year 2 and again in
September when they enter Year 3. This is because children lose their eligibility of Universal
FSM at the end of Year 2 (Sellen et al, 2018). Parents will receive literature which will clearly
outline who is eligible for FSM, how to claim, the benefits of claiming, what types of food is
on offer and how they can access school support. Children will receive information on the
types of food on offer, the benefits of eating nutritious meals, and the importance of
nutrition for academic success. Relating to The Health Belief Model, it is crucial that the
literature provided enforces the message that claiming FSM can benefit childhood health, as
well as providing parents with the knowledge and support needed to apply.
Learn & Act:
Evaluating a social marketing intervention is key to determining whether aims and
objectives are met, what challenges arise, if there are any additional costs or resources
needed which were not initially planned for, and what improvements are needed to further
interventions (Kotler and Lee, 2011). Evaluation for this intervention will take place both
after the pre-testing stage, and after the intervention has concluded.
In October of the same year parents will be asked to complete a short survey to determine
whether they applied for FSM for their child, whether the literature they received and
support from school staff influenced their decision to claim, and what difficulties they may
have encountered at any time during the intervention. This will allow the school to improve
the future support they provide to both children, parents and carers. Parents who were not
eligible will be asked to return the survey indicating they are not eligible, as it would not be
correct to assume that any unreturned surveys were due to lack of relevance.
These findings will be shared with school staff to inform them of any issues or challenges
faced by parents or children during the intervention. This could potentially improve the
support given to parents in the future. Local authorities will also be provided with
information about the accessibility and ease of use of literature and forms in attempt to
improve the claiming process.
Social marketing is a well-established concept in the public health field, tackling a wide
range of social issues. Whilst interventions can have small-scale positive outcomes and
influence individual behaviour change, it is difficult to tackle population-wide issues as a
wide range of social determinants must be addressed to incite lasting improvements. This is
particularly the case for increasing the uptake of Free School meals, due to the enormity of
the issue and the different factors which can affect whether those eligible are willing to
access them. It is recommended that further research is needed to determine the types of
interventions that can successfully increase FSM uptake and the long-term benefits of
consuming school meals, in addition to ongoing support and education from school staff
and local authorities to ensure those eligible know how to apply and can be supported
during the claiming process. However, this proposal established that this is a great
challenge, particularly when using a social marketing strategy.
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