Social Marketing Proposal

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Social Marketing Proposal
Introduction
The UK National Social Marketing Centre (NSMC) defines social marketing as “the
systematic application of marketing, alongside other concepts and techniques, to
achieve specific behavioural goals for a social good” (NSMC, 2007a, p. 32). While
there are many definitions of social marketing, Stead et al. (2007b) identifies four key
elements which are the involvement of a voluntary behaviour change, the principle of
exchange, the use of marketing techniques and the aim of improving individual or
societal welfare. However, the NSMC definition acknowledges that a wide range of
methods may be employed which go beyond the traditional marketing mix of product,
price, place and promotion (the 4 P’s) (Kotler and Lee, 2008). While the 4P’s have
long provided a core marketing mix (Hastings, 2007), the approach in more recent
years has turned from a seller to a consumer focus (Dev and Schultz, 2005).
While research has shown social marketing interventions are effective in changing
behaviour (Stead et al., 2007a), there is limited systematic evidence which are the
most effective in health (Boyce et al., 2008). In Dibb and Carrigan (2013) Kotler
reflects social marketing has evolved through four key stages; focusing on behaviour
rather than knowledge and attitudes; modelling the planning process; the three levels
of downstream, mid-stream and upstream and finally, the incorporation of social
media which presents new channels of communication. Chau et al. (2018) however,
point out that despite the ongoing evolution of social marketing there remains a
propensity to focus on ‘promotions’. While Dibb (2014) argues social marketers
remain more focused on downstream consumers and lack experience in working
with wider stakeholder groups such as policy makers.
Maryon-Davis and Jolley (2010) point out that consultation with consumers can
indicate an involuntary behaviour change is called for, such as the introduction of
laws regarding smoking in public areas. They argue that within the concept of social
(what and why) marketing (how), the social element is the superordinate concept but
does require the consent of the general population. Indeed, the greatest reductions
in alcohol and tobacco consumption have been achieved through government policy
(Hoek and Jones, 2011). This approach appears justified when considering the
alcohol industry spends £600-800 million each year on promoting their products,
while the UK government spent £17.6 million on alcohol education in 2009-2010
(House of Commons Health Committee, 2010).
This social marketing proposal will outline and critically analyse the management
implications and application of social marketing for health. The issue to be
addressed within this proposal is the significant reduction in attendance of cervical
cancer screening amongst women (Public Health England, 2019). Cervical cancer is
the 14th most common cancer in females in the UK, accounting for 2% of all new
cancer cases in females in 2015 (Cancer Research UK, 2019). Cervical smears are
an effective screening test for early signs of cervical cancer. The test is invasive and
can be uncomfortable for some women but is completed within a few minutes and is
recommended every 3-5 years (Jo’s Cervical Cancer Trust, 2019). Cervical cancer
incidence is related to age, with the highest rates seen in the 25 to 29 age group
(Cancer Research UK, 2019).
In order to plan the social marketing intervention a flexible and iterative framework
has been selected which will provide a structure for planning and staging the tasks
required (Ong and Blair-Stevens, 2010). The Total Process Planning (TPP)
framework by French and Blair-Stevens (2005) consists of 5 stages; Scoping,
Development, Implementation, Evaluation and Follow-up. A social marketing mix tool
will also be used to support analysis and development at each stage of the process.
The tool selected is a social marketing model by Gordon (2012) as it goes beyond
the 4 P’s taking a more relational and upstream approach. Gordon (2011)
acknowledges behaviour change involves long-term interventions, requiring a
relational and systems oriented approach which involves a range of stakeholders
and considers all relevant people. The elements of the tool comprise of
circumstances, organisation and competition, cost, consumers, process and
channels/strategies. The 4 P’s remain evident within this tool but the consumer, cocreation of value and evaluation remain very much at the core of this process.
Scoping
The initial stage of scoping focuses on building relationships with stakeholders,
planning and collecting information (Reynolds and Merritt, 2010). Firstly, the
circumstances of this proposal will be considered. The 37 GP practices within
Central London (Westminster) clinical commissioning group (CCG) are the focus of
this proposal. The national standard for cervical cancer screening is 80% of women
to have had adequate screening in the last 3.5 years (Public Health England,
2018a). None of the GP practices within this CCG have managed to achieve the
standard for women aged 25-49 (Public Health England, 2018b). Based on this data
and the high incidence rates of cervical cancer within this age group, a social
marketing intervention will be developed to increase screening rates within this age
group in Central London CCG.
In order to develop an intervention which is relevant, research must be performed to
provide insight into the consumer, inform segmentation of the target audience and
identify competition (Stone, 2004). For example, research using secondary data
already available reveals that within this CCG, just over half of the resident
population were born outside the UK. Black, Asian, Arabic and other minority ethnic
groups comprise 30% of the population (Rayjaguru and Obuka, 2018). Qualitative
formative research can then be used to obtain views on the accessibility and
acceptability of services, what needs to be communicated, how and to whom (Biran
et al., 2005). The quantitative data available on attendance rates can then provide
triangulation of data (Nutbeam and Bauman, 2006). Thus, the consumer and how
they should be served is the focus rather than the product on offer (McVey and
Walsh, 2010).
Segmentation of the target audience involves the identification of distinct sub-groups
with similar needs, attitudes and behaviours and prevents (Andreasen, 2002, French
and Blair-Stevens, 2006). Segmentation can be achieved by using demographic,
geodemographic, epidemiological, behavioural and psychographic data (Kotler,
2002). The target audiences for this proposal have been segmented in the following
way. The overall experience of the procedure itself is a significant barrier to
attendance, contributors are the communication skills of the health professional, their
gender, service location and opening times (Marlow et al., 2015, Ekechi et al., 2014).
Therefore, the primary target audience is the health professionals performing
cervical cancer screening and the secondary target audience is the primary care
services within the CCG who provide the service.
Qualitative research with Asian women has also shown cognitive barriers were
misperceptions about the causes of cervical cancer, while emotional barriers were
fear and pain during the procedure (Marlow et al., 2015). Consequently, the tertiary
target audience is the women aged 25-49 eligible for cervical cancer screening
within Central London CCG from an Asian (Indian, Pakistani, Bangledeshi)
background.
Next, the organisation and competition will be considered. Ong and Blair-Stevens
(2010) recommend forming a steering group and identifying relevant stakeholders
during the scoping stage. Understanding the external and internal environments of
the organisations involved will assist in identifying potential barriers to forming a
good relationship with the consumer (Kotler and Lee, 2008). For example,
information on how many people are trained to perform cervical smears and what
funding is available to provide out of hours services or cultural awareness training. In
this case, potential stakeholders would be the local Health and Wellbeing Board,
CCG, primary care providers, Health Education England (HEE), Public Health
England (PHE), community groups which represent eligible women, and third sector
organisations such as Cancer Research UK.
Understanding what is competing for the time, attention and behaviour of the
audience is also an important criteria of social marketing (Langford and Panter-Brick,
2013). For health professionals within primary care there are many demands on their
time and areas of clinical practice which require professional development and
training (Sambrook and Stewart, 2007). For women in the target audience age
range, work commitments, childcare and lack of perceived risk are often cited as
competitors to arranging appointments for screening (Cancer Research UK, 2019).
Finally, a decision on what intervention to take into the development stage needs to
be made. There is a consensus in the literature that an effective intervention must be
guided by behaviour change theory (Chau et al., 2018, Hastings et al., 2011, French
et al., 2010). However, there are a wide range of theories available and Donovan
and Henley (2010) advocate an eclectic approach which uses elements from
different models depending on the behaviour to be influenced. Cognitive decision
models such as the health belief model (Rosenstock et al., 1988) tend to focus on
the individual and have been criticised for victim-blaming (Lefebvre, 2011). Social
cognitive theory considers the personal, behavioural and environmental factors
which influence an individual’s ability to control their behaviour (Bandura, 1986).
While social models such as diffusion theory, provide an opportunity to achieve
behaviour change across groups by segmenting a target audience into innovators,
early adopters, early majority, late majority and laggards (Rogers, 1995). BlairStevens et al. (2010) and Nutbeam and Bauman (2006) argue that the review and
evaluation process is enhanced if theoretical assumptions are highlighted at the
scoping stage. However, despite the consensus on the importance of theory in social
marketing interventions, research has revealed a lack of use or reporting of the use
of theory (Luca and Suggs, 2013, Truong, 2014).
This proposal takes a relational upstream approach to social marketing which
focuses on consumer satisfaction, long-term change, building trust and targeting
hard to reach groups (Hastings, 2007, Gordon, 2013). There is an emphasis on
moving beyond the individual to effect social change (Wymer, 2011), incorporating
Brennan et al. (2016) behavioural ecological model which applies a system lens to
influencing behaviour change. The interventions will focus on collaboration between
stakeholders (Domegan et al., 2013) within micro (individual/health professional),
meso (community organisations, CCG) and macro (PHE, HEE) systems and the
outcomes/behaviours they produce (Brennan et al., 2016, Luca et al., 2016). A
scoping report will be completed outlining the audience segments, their current
behaviours, desired behaviours and the interventions to be taken through to the
development stage.
Development
The aim of the development stage is to create a tailored program of interventions
which encourage and promote social change, with each decision relating to the
audiences’ perspective (Da Silva and Mazzon, 2016, Merritt, 2010a). The current
and desired behaviour of the target audiences and proposed interventions are as
follows. The primary target audience of health professionals currently provide a
service which is not viewed as positive by the consumer. The desired behaviour is a
service where the health professional feels confident in providing a positive
experience for the consumer. The proposed intervention is a collaboration between
consumers, health professionals and HEE to develop training in communication and
cultural awareness.
The secondary target audience are the service providers who currently do not
provide out of hours appointments or female health professionals. The desired
behaviour is to increase flexibility in service provision across the CCG which meets
the needs of the consumer. The proposed intervention would be collaboration
between the consumer and stakeholders to create appropriate appointment times
and service delivery.
The tertiary target audience is the consumers themselves who currently have
misperceptions regarding cervical screening and fear of pain during the procedure.
The desired behaviour would be improved understanding, reduced fear and
increased attendance at cervical screening appointments. The proposed intervention
is health professionals who provide the service to attend community groups or
places identified by the consumer in order to build a relationship of trust, provide
requested information and increase confidence in the procedure. This will occur once
the first two interventions have been implemented.
The objectives of the social marketing plan are to achieve a 20% increase in Asian
women attending for a cervical screening appointment within 5 years; health
professionals to report increased confidence in performing the service for Asian
women within 2 years; Asian women to rate their overall experience more positively
and indicate willingness to attend future appointments within 2 years of the
intervention.
In order to develop interventions McCarthy’s (1960) marketing mix of product, price,
place and promotion (4 P’s) is often used (Kotler and Lee, 2008), but many other
strategies are now used within social marketing (Stead et al., 2007a, NSMC, 2007a).
The interventions within this proposal take a more relational approach as the focus is
the ongoing relationship between the consumer and the service, consumer
satisfaction and long-term commitment to returning for another cervical screen when
invited (Hastings, 2007, Grönroos, 1994). However, the 4 P’s will be considered in
relation to the proposed interventions as part of Gordon’s (2012) social marketing
model.
Gordon (2012) includes the 4 P’s within the strategies section of his model. The
‘product’ is the desired behaviour and associated benefits and there are 3 levels.
The ‘core product’ in this case is intangible and not immediate, as it is the benefit of
health and wellbeing following early detection of pre-cancer or cancer cells. The
‘actual product’ is the cervical screening test and service which is tangible, while the
‘augmented product’ is the features which encourage attendance. When considering
‘price’, the intangible nature of the core product can bring complexity (Da Silva and
Mazzon, 2016) but it is important to consider both actual and perceived financial,
physical and emotional costs to the consumer (Merritt, 2010a). Lefebvre (2011)
argues the concept of exchanging cost for benefit is made feasible in health, by
taking the time to understand the target audience during the scoping stage. The
relational approach also requires co-creation of value and collaboration with the
consumer/target audience occurs throughout the process (Desai, 2009, Dev and
Schultz, 2005, Blocker et al., 2013). ‘Place’ is where the desired behaviours and
cervical screening service will occur, which should be easily accessible to all
individuals (Bernhardt et al., 2012). ‘Promotion’ is using communication to persuade
someone to consider the costs and benefits of behaviour change and a range of
techniques such as advertising, public relations and sponsorship can be utilised
(Donovan and Henley, 2010). Again, the research performed during scoping is
crucial to informing how messages will be received and translated into action by
different audiences (Peattie and Peattie, 2009, Kotler and Lee, 2008).
The various approaches to social marketing have added additional P’s which
acknowledge the move away from one-off transactions to establishing a relationship
of trust with the consumer (Grönroos, 1994). However, it is recommended by Merritt
(2010a) to focus on those most relevant, for example, when providing a service
Lovelock and Wirtz (2011) recommend adding professional, process, performance
and program. While Gordon’s (2012) model has added people, policy and process. A
lot of emphasis is given to ‘process’ by Gordon (2012) and Lovelock and Wirtz
(2011); the method through which social marketing is designed and delivered and
must be improved continuously in order to add value and avoid failure. Pre-testing of
interventions is an important part of the process in this proposal and feedback will be
used to create the final interventions (Cheng et al., 2011). It will also be used to
inform the methods of ongoing evaluation and monitoring of the process, impact and
outcomes of the interventions (Nutbeam and Bauman, 2006). At the end of the
development stage a marketing plan, describing how the intervention will make a
difference and the steps required to achieve the outlined objectives will be in place
(Da Silva and Mazzon, 2016).
Implementation
The aim of the implementation stage is to actively manage and monitor the actions of
the marketing plan (Hastings, 2007). Langford and Panter-Brick (2013) argue that
qualitative data that provides insight into the wider context should be used more at
this stage. This would allow for more critical reflection on the unintended
consequences of interventions (Kleinman, 2010) and consideration of what works for
whom, how and in what circumstances (Pawson and Tilley, 1997). Macintyre (2003)
also warns against overlooking the differential effects between socio-economic
groups. However, the upstream approach taken in this proposal is less likely to
increase health inequities than a more downstream individual behaviour approach
(Lorenc et al., 2013). Overall, it is acknowledged that a combination of collaborative
approaches is required which operate at the different levels of the behavioural
ecological model underpinning this proposal (Brennan et al., 2016). During the
implementation stage it is important all activities, feedback and lessons learned are
clearly documented to inform the evaluation report (Merritt, 2010b).
Evaluation
The aim of the evaluation stage is to understand the strengths and weaknesses of
the interventions and measure their effects (McVey et al., 2010, Nutbeam and
Bauman, 2006). While Lefebvre (2012) notes there is a risk of focusing on the
implementation of the plan rather than meaningful social change, Saunders et al.
(2015) argue there is a need to measure both effect (efficiency and effectiveness)
and process (equity, fairness and sustainability). Otherwise there is a danger of overreliance on neo-liberal and paternalistic approaches which focus on individual
responsibility (Crawshaw, 2012, Wise, 2011) and deny the effect of social
determinants on people’s ability to respond to health messages (Cockerham, 2005,
Langford and Panter-Brick, 2013, Hoek and Jones, 2011).
Therefore, when considering effectiveness the World Health Organisation (WHO)
acknowledges a strong social marketing and public health partnership can create
environments that make healthy choices easier (WHO, 1986). However, the time and
financial investment available to social marketing interventions within public health is
extremely limited in comparison to those promoting risk behaviours such as
consuming alcohol (Hoek and Jones, 2011). Therefore, in the current financial
climate and rising health costs, targeting the right people and those most in need,
while creating upstream environments and policy change which will support
sustainable behaviour change, appears to be a legitimate focus for social marketers
(Gordon, 2013, Bethune and Lewis, 2009). The cost efficiencies of improving
existing services and the potential to influence beyond the target audience this
creates must also be considered (Merritt, 2010a, Bethune and Lewis, 2009).
Addressing any unintended outcomes, whether positive or negative, is an important
part of evaluation and can highlight the need for a set of measures which incorporate
long-term and relational objectives (Spotswood et al., 2012). For example, Bethune
and Lewis (2009) found that attendance to cervical screening appointments
increased for all women following an intervention targeted at Maori women, as the
flexibility in service provision and improved communication impacted all service
users.
The balance between the power to change individuals or society and the need for
ethical transparency has led to increasing calls for an ethical code of conduct for
social marketing (Spotswood et al., 2012, Olson, 2018, Carter et al., 2017).
Maintaining independence and objectivity in the evaluation process and reporting of
findings is crucial if lessons are to be learned (McVey et al., 2010). It is
recommended the evaluation report be actively disseminated via research journals
and conferences in order to add to the evidence base and promote wider learning
(Gordon, 2013, McVey et al., 2010). The final stage of follow-up can then build on
any learnings, focus on maintaining stakeholder engagement and secure future ‘buyin’, in order to ensure the long-term sustainability and ongoing development of the
service or intervention (Christopoulos et al., 2010).
Summary
It is clear there are many approaches and strategies to social marketing within health
(NSMC, 2007b, Boyce et al., 2008, Hastings et al., 2011). There is also evidence
that social marketing is appropriate for health as it approaches issues from the
consumers’ perspective, follows a clear marketing plan and target audience, uses
messages and communication appropriate to the audience, uses insight to co-create
product value and plans for sustainability from the beginning (Donovan, 2011,
Henley et al., 2011). While there appears to be a clear consensus on the main
elements of social marketing (Andreasen, 2002, Stead et al., 2007b, Chau et al.,
2018) authors such as Gordon (2012), Langford and Panter-Brick (2013) and
Brennan et al. (2016) warn against a fixed adherence to marketing principles,
cognitive drivers of change and consumer myopia.
Along with the commercial sector, social marketers now recognise the value of
relational marketing and the interactive long-term relationships it supports (Hastings,
2007, Gordon, 2012, Brennan and Parker, 2013). There have also been calls for
more upstream approaches which tackle the macro environment (Gordon, 2013,
Hoek and Jones, 2011) and address both the social determinants of health and
equity (Langford and Panter-Brick, 2013). More recently, models such as the
behavioural ecological model have been proposed which attempt to address public
health issues through interactions between the macro, meso and micro systems and
focus on stakeholder collaboration (Brennan et al., 2016).
What comes across clearly is the need for social marketers to have the skills
required for researching, analysis, implementation and evaluation of a marketing
plan (Lindsey and Hawk, 2013). Unfortunately, along with the time and investment
needed to compete with the commercial sector this is not always available in health.
However, there are opportunities to partner with universities and support from
organisations such as the NSMC. There is also a need for a planning framework
such as the TPP used in this proposal and for all theoretical assumptions to be
declared at the beginning of the process in order to deepen learning of what is
effective (Blair-Stevens et al., 2010, Truong, 2014).
Finally, a social marketing ethical code of conduct may support and encourage
debate about the strategies used to achieve individual and/or societal good
(Spotswood et al., 2012). Public health now faces issues such as climate change
which present complex challenges in terms of population and competition (Watts et
al., 2015). Given the health, social and financial costs associated with current
behaviour challenges, social marketing models which support collaboration and
encourage activism downstream, midstream and upstream present an opportunity to
achieve effective, equitable, fair and sustained social transformation (Gordon, 2013,
Saunders et al., 2015, Brennan et al., 2016).
Word Count 3202
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