Public health policy and the behavioural turn: The case of social marketing

Introduction

In the autumn of 2011 the UK coalition government launched a new strategy for the prevention of obesity in England and Wales to be supported by an extensive social marketing programme in the form of Change4Life, an established campaign instigated by the previous Labour administration. In the summer of 2011 the Secretary of State for Health, Andrew Lansley, announced in a speech to the UK Faculty of Public Health Conference that poor lifestyles and behaviours were the main challenges faced by the public health community in preventing the promotion of good health, and that for too long these had been ignored in public health practice. ¹

In the same speech Mr Lansley went on to note the significant impact of environmental and social factors on wellbeing (housing; education; the built environment) and acknowledged the disproportionate burden of ill health shouldered by disadvantaged communities. The stark contradiction of positing individual behaviours as the key driver for improving health and reducing inequalities, whilst simultaneously acknowledging environmental and material determinants provides the basis of the discussion that follows. The key theme will be the ongoing tension in public health policy and practice between behavioural and structural approaches to the alleviation of health inequalities in the UK and beyond. The empirical focus will be the seemingly uncontroversial adoption of social marketing in public health policy as a methodology capable of influencing behavioural change. Data from a sample of professionals involved in both strategic planning and implementation of public health policy are presented to explore understandings, and rationale for adoption, of social marketing methods. The relationship of these methods to commercial marketing and their assumptions regarding behavioural change, choice and responsibility become a key focus.

Mr Lansley posits two key strategies for addressing what public health academics and activists have long highlighted as deeply entrenched issues of inequalities in morbidity and mortality (see Bambra et al., 2011). The first is the expansion of the Change4Life scheme, not as the prescriptive, top down, government led initiative instigated by the previous administration, which he describes and critiques, but as a ‘new social movement’, part of the much discussed ‘Big Society’ (Norman, 2011) model, which aims to draw on a range of community and voluntary sector partners as well as public involvement. The second is closely tied to the controversial Public Health Responsibility Deal ² that aims to engage the commercial sector in the promotion of health across a range of settings, with particular emphasis upon the food and drink industries. The vision is that Change4Life will be adopted as part of this deal and become a brand used by retailers and others in promoting healthy choices and behaviours.

Clearly expressed in the Secretary of State’s speech and subsequent policy documents (DoH, 2011) is the centrality of social marketing to improving public health outcomes. In turn these outcomes are predicated upon bringing about behavioural change in individuals who will be nudged (Thaler and Sunstein, 2009) into making the ‘right’ choices. Driven by the philosophy of libertarian paternalism, these approaches are presented as a necessary alternative to the top down ‘nannying’ with which Lansley takes issue, and rather, are intended to become part of a process of encouraging active citizenry that has gained widespread currency in policy discourses (Burgess, 2012). The emphasis upon behavioural change described here is not limited to public health and has become influential in a range of areas in social policy (House of Lords Science and Technology Select Committee, 2011).

Central to the UK coalition’s standpoint on health improvement is a belief in individuals’ ability to choose and determine their own behaviours, evidenced by the creation of a dedicated Behavioural Insight Team within the Cabinet Office. It is acknowledged that this is done most effectively alongside regulation (for example the UK smoking ban of 2007). Particular credence is given to so-called ‘nudge’ approaches that seek to influence behaviour by altering the context or environment in which people ‘choose’. A key contention of this discussion is that such approaches are diametrically opposed to the findings of three decades of research into inequalities in health (see for example Bambra et al., 2011). The most recent review of UK evidence in this area, the Marmot Report of 2010, was unequivocal in its recommendations regarding the need for planned, structural interventions at both national and local levels and across all aspects of social life. As Marmot states:

When we consider [the] social determinants of health, it is no mystery why there should continue to be health inequalities. Persisting inequalities across key domains provide ample explanation: inequalities in early child development and education, employment and working conditions, housing and neighbourhood conditions, standards of living, and, more generally, the freedom to participate equally in the benefits of society. A central message of this Review, therefore, is that action is required across all these social determinants of health and needs to involve all central and local government departments as well as the third and private sectors. (Marmot, 2010: 16–18)

Marmot’s findings clearly support action at a societal level, in sharp contrast to the emphasis upon behaviours and choice outlined by Mr Lansley and the work of the Insights Team. The implication of the latter is that social policy interventions should be guided by behavioural principles, rather than the structural principle of achieving fairness or equity through strategies intended to help groups who, epidemiologically, are the most likely to experience higher rates of morbidity and premature mortality.

The implied reversal of direction of justification for intervention (premised upon behaviour rather than need) is interesting in both ideological and pragmatic terms. Public health has traditionally aimed to ‘serve society’ (Juth and Munthe, 2012), to intervene at the level of the population in order to provide the greatest benefit to all, in direct contrast to more individualized medical interventions. Newer methodologies in public health work, such as social marketing, which take as their starting point the individual and their own behaviours, represent a rupture from this original aim, and reflect prevailing market-oriented, neo-liberal modes of welfare that increasingly eschew the social in favour of a re-responsibilization of the individual for their own health outcomes.

The paradox of using ‘social’ marketing strategies to work upon ‘individuals’ is stark. As Burgess (2012) notes, such approaches encourage no development of capacity to manage the better outcomes they hope to achieve, contradicting a wider mandate to encourage more responsible citizenship, as well as taking place concurrently with extensive welfare reforms that are likely to damage the health expectations of those in the most need, ultimately increasing inequality.

The aim of this discussion is to criticize the use of social marketing as a public health strategy; a strategy predicated upon the normative principle that individuals should take responsibility for modifying their own health behaviours. It is argued that these methodologies are indicative of a wider behavioural turn (Mair, 2011) in public health policy that has increasingly posited responsibility for wellbeing with the individual without reference to the wider social determinants of health that have consistently been identified as the main influences upon morbidity and mortality over the life course (see for example Marmot, 2010; Bambra et al., 2011). Such individualized approaches obviate the relational nature of how health behaviours and practices are acted out as part of everyday lives in complex cultural and social contexts; these contexts, in the case of socio-economically disadvantaged groups, being more characterized by constraint than opportunities for the self determination and actualization required by behavioural change models.

Further, these approaches are indicative of prevalent neo-liberal modes of social and political organization that import market models into all aspects of social life (Foucault, 2009). In shaping public health policy and practices in this way, it is argued that the use of behaviourally driven, individualized solutions such as social marketing illuminates a broader process of the importation of commercial methodologies into health services already increasingly characterized by neo-liberal market models of organization (Pollock, 2004).

Attempts to create a marketplace in health services are already well documented (see for example Pollock, 2004), with the implementation of the controversial Health and Social Care Bill in England heralding even greater privatization amidst significant opposition and controversy (see Hunter and Williams, 2012). Their introduction and influence in public health policy and practice has received less empirical attention, however. The original contribution of the following is to present in-depth qualitative data collected with a sample of public health strategists, decision makers and practitioners (n = 17) from the North East of England.

Although behaviours and lifestyle are not synonymous, they are often used interchangeably in both scientific and lay literature, as individuals’ lifestyle ‘choices’ (for example a lack of engagement in exercise, dietary habits and so on) are said to result in behaviours deleterious to wellbeing. The direct relationship between ‘risky’ behaviours and ‘poor’ lifestyles and morbidity and mortality remains a central tension in public health research, despite significant challenges from empirical work (see for example Lantz et al., 1998; Rothstein, 2003). Despite this, behavioural methods are increasingly proposed as a panacea for health improvement, particularly with more disadvantaged social groups. The following considers critically the political and ideological shift in public health policy and practice from the social to the individual as the target of interventions, positing a behavioural turn (Mair, 2011) in methodologies and approaches guided by neo-liberal conceptions of health and responsibility.

From the social to the individual: The shifting politics of public health

Public health is a complex discipline that draws on a range of cognate subjects and methodologies with the broad aim of protecting and improving the health of populations. It is the latter, health improvement, which has become the main focus of public health in Western industrialized nations in the late twentieth and early twenty-first centuries. Despite its origins in social engineering and environmental interventions (from the sanitary innovations of the Graeco-Roman world to the great public health projects of the mid-nineteenth century in the UK), Western public health has more latterly focused upon individual lifestyles and the promotion of behavioural change in populations in order to reduce inequalities and bring about health improvement. Enshrined in the Ottawa Charter of 1986, this shift in practice and orientation is said to be a response to the so-called epidemiological transition (Omran, 1971) from infectious or communicable to chronic diseases as causes of morbidity and mortality. A focus upon lifestyle and behaviours has led to new interventions often predicated upon education and the promotion of individual agency in improving health with decreasing emphasis upon structural or environmental changes. These newer modes of governing the health of populations, described by some as characterized by a troubling politics of behaviour (Mair, 2011), have been identified as indicative of the emergence of ‘health societies’ (Kickbusch, 2007): societies characterized by an ever growing territorialization of health alongside an almost limitless promotion of health reflexivity. Under these conditions myriad imperatives to be healthy have emerged from diverse sources including the media, government offices, non-governmental organizations and health governance agencies (e.g. the World Health Organisation). Health has thus emerged as a new mode of governing populations, closely linked to particular moral imperatives regarding the individual and responsibility within late modern capitalist economies (Lupton, 1993).

These tensions apparent in public health policy reflect wider debates in both social policy and the health social sciences and a perennial tension between individual agency and choice (and by implication behaviours) and social structural factors as determinants of health. As Townend (2009) has noted, the recent history of both government and private sector approaches is one of the pursuit of individualized models driven by both particular moral imperatives regarding specific population groups and their perceived propensity to make ‘bad’ choices, and neo-liberal doctrines that promote a retreat of the state from social life in favour of the promotion of individual agency and choice and the inculcation of new forms of health reflexivity. Implicit in these approaches is that ‘individuals … want to be healthy, and enjoined to freely seek out the ways of living most likely to promote their own health’ (Rose, 1999: 86–87). These desires do not necessarily arise from individuals themselves, but from a reconfiguring of moral discourses that posit the healthy self as the telos of worthy citizenship (Brown and Baker, 2012: 45).

In this way, debates regarding what constitute appropriate methods for improving the health of populations and reducing inequality become a paradigm of wider tensions in social policy and the social sciences more generally. It is clear, as Jones et al. (2011) suggest, that ‘The desire to change, modify and influence behaviour is a defining characteristic of economic, cultural and political power’ (p. 483). In direct contrast, the use of interventionist policies more capable of addressing structural and systemic issues has increasingly been rescinded, evidenced by significant activity under the euphemistic banner of welfare reform. In the UK behavioural approaches have been championed, often informed by emerging libertarian paternalistic approaches (Thaler and Sunstein, 2009). These approaches are explicit in their unwillingness to promote enforcement or legislation, in favour of ‘nudging’ individuals into making more healthy choices (putting fruit at eye level counts as a nudge. Banning junk food does not (Thaler and Sunstein, 2009: 6)). Implicitly behavioural in approach, nudges guided from the standpoint of libertarian paternalism draw on psychological methods to encourage ‘positive’ choices. Though Jones et al. (2011) posit that these methods come about, not in collaboration with neo-liberal modes of rationality, but as a response and attempt to ameliorate some of their excesses (the creation of inequality), with their narrow focus upon changes in individual behaviours as the route to improvement in health, they conform to dominant political conceptions of the healthy subject as self determining.

The proposed behavioural turn in public health policy represents continuation and entrenchment of these approaches as it fails to account for both the wider systemic and structural determinants of health as well as the complex relational settings in which behavioural practices take place. Further, it assumes a reflexive, health conscious individual, willing and able to make appropriate ‘choices’. Social marketing both is an exemplar of such approaches and, further, reflects an uncritical importation of neo-liberal market models into public health strategies and practice.

Understanding social marketing

The key claim of social marketing is that it seeks to promote ‘social good’ (National Social Marketing Centre, 2007) using the methods of commercial marketing. These methods include: a customer/consumer orientation, the setting of behavioural goals for a social good, use of a marketing mix to achieve those goals, audience segmentation to target customers effectively, and use of the concepts of ‘exchange’ and ‘competition’ (Robinson and Robertson, 2010). Social marketing for health typically targets individuals and communities with the aim of encouraging behavioural change, often with populations deemed to be ‘at risk’. Though this is typically presented as a preventative approach, in reality it constitutes a downstream (Raphael, 2003) method of targeting populations already likely to be experiencing the negative effects of more upstream structural and systemic determinants of ill health.

The popularity of social marketing is fuelled by the contention that many of the health challenges facing Western societies have significant behavioural elements including obesity, alcohol misuse, infection control, recycling, saving for retirement and crime (French, 2009: 262). These challenges are coupled, French (2009) argues, with growing resistance to state paternalism and its perceived propensity to breed dependency. In contrast, social marketing operates with ‘consumers’ as its starting point, guided by the nostrum that under the right guidance and with appropriate ‘nudges’ (Thaler and Sunstein, 2009), individuals can and should take responsibility for their own wellbeing. Here, social marketing takes its place alongside a range of ‘soft’ or ‘libertarian’ paternalistic (Pykett, 2012) approaches to behaviour change. To achieve these goals it uses advertising and other forms of media alongside traditional health interventions. For example, the UK’s Change4Life combines advice and encouragement to engage in more physical activity with events that are free to access and is supported by a range of online resources. ³ These methods are posited as distinct from earlier ‘rational choice’ (Kahneman and Tversky, 1983) approaches, often predicated upon models drawn from psychological research such as the Theory of Reasoned Action or Stages of Change. In these models, behaviour is seen as a psychological property of individuals who are influenced by consciously chosen goals (Chin et al., 2000: 319). Trenchant criticisms of these methods have been offered, with particular emphasis upon their lack of appreciation of structural determinants of health alongside their potential for victim blaming, as well as oversimplification of the complex construction of health as a social and relational practice (Crawford, 2006). In contrast, libertarian paternalistic approaches claim sensitivity to context by directly promoting environmental changes. However, a key assumption is that these approaches are transferable across social groups, without real cognizance of material determinants of both behaviours, and, most significantly, morbidity and mortality.

Data from seventeen interviews with a range of professionals involved in either the strategic development or the implementation and operationalization of social marketing programmes, and drawn from a range of organizations including Primary Care organizations and Local Authorities, are presented to critically consider how social marketing is understood within contemporary public health practice in the UK. The aims of social marketing are explored and its construction of individuals and their health as objects of intervention is considered. The overall purpose is to consider critically how social marketing may reflect a troubling commercialization of health reflected in a range of service delivery that has continued to embrace neo-liberal modes of operation, constructing an increasingly diverse health marketplace. Respondents present a number of understandings and constructs of social marketing as a model for health improvement and reflect upon its wider role in bringing about behavioural change in individuals.

Methods

Data were collected in a locality in the North East of England. A series of in-depth, semi-structured interviews were carried out with professionals working in a range of health and health related fields. Professionals were selected on the criterion that they had some involvement with social marketing for health at either strategic or operational level. This led to the identification of a small initial sample, with snowball sampling used for further recruitment. A total of seventeen participants were recruited overall. Respondents ranged from those in senior local and regional public health directorate roles to operational leads for particular services, for example smoking cessation. All data were anonymized and participants coded as Operational (e.g. O1) or Strategic (e.g. S2) or both (e.g. O/S2).

Qualitative methods were used because of their potential to elicit in-depth understandings of respondents’ own experiences and constructions of social marketing for health (Marvasti, 2004: 7). Interviews were conducted on the premises of the various organizations to which individuals were attached in a room allocated specifically for these purposes. Data were collected by a research assistant using a topic guide developed in consultation with the project supervisor. As the overall focus of the data collection was to explore experience, understandings and constructions of social marketing for health, questions explored themes such as: what do you understand by social marketing; what are its key methods and methodologies; what are its strengths and weaknesses as a method? Interviews ranged in length from one hour to one hour and thirty minutes. Data were analysed using the conventions of thematic qualitative analysis (Miles and Huberman, 1994). The analysis was conducted collaboratively between the research assistant and the project supervisor. The relevant School Research Ethics Committee in the author’s institution granted ethical approval.

The commercial and the social

Respondents engaged fluently with the concept of social marketing and were often able to describe it in terms of a complex set of interrelated ideas intended to influence individual behaviours with the aim of promoting ‘social good’. A consistent theme was the synthesis between social and commercial marketing.

Social marketing links in very much with traditional marketing so it’s getting your message out there as much as possible, getting people to buy into that message, so it’s building the bridge between the product and the customer. (O1)

Here, and elsewhere, it was presented as unproblematic to approach social marketing as a means of operationalizing or segmenting individuals and communities with perceived shared needs (e.g. new mothers) as customers or consumers within a market relationship in which they were to be sold more appropriate and healthy behaviours as products (for example breast feeding of infants). This simplistic approach of ‘getting people to buy into the message’ obfuscates significant material factors, as well as deeply entrenched cultural norms and practices. Further, a key contradiction exists. Commercial marketing seeks to make particular products saleable, typically over short periods of time, before moving on to the next product and or appropriate market segment of consumers. Public health aims to work towards long-term, sustainable changes in behaviours and wellbeing with the aim of reducing morbidity and mortality, often for highly disadvantaged social groups that remain relatively stable over time.

Respondents described the key tenets of social marketing in considerable depth and consistently noted the link between commercial methodologies and the implications of this for new ways of working with individuals and communities, or ‘service users’, as they were often described.

Social marketing relating to health is using marketing systematically to gain an understanding about population needs, lifestyle, their preferences, their beliefs in order to tailor an intervention or a new service or a pathway to meet their needs. So it’s using more of the marketing tools that traditionally commercial sectors used, but in a way to benefit people’s health, rather than purchasing a commercial commodity. (O6)

These methods were presented as unproblematic, and judged to be an ‘evidence based’ and pragmatic response to meeting the health needs of populations in more comprehensive and ‘bottom up’ ways, with the efficacy of social marketing implicit, despite the paucity of evidence to support this claim (see Stead et al. (2006) for a systematic review that highlights the limited effectiveness of social marketing interventions that do not include face-to-face contact with clients). Here, the methods of commercial marketing were understood as something that could be learned from and imported directly into health settings.

I think we can learn a lot from what the commercial sector have done in the sense of they really do understand their target audience, and that the link there, that where there’s a lot in common. They don’t try to sell their product to everybody. It’s about using the consumer insight in order to market your intervention to do good for the populations’ health. (O6)

Throughout the sample respondents clearly expressed the idea that social marketing was merely a logical extension of the discipline of commercial marketing from which many lessons could be learned in order to better target health improvement interventions.

Using the principles of marketing for social good. So ensuring that in a public health context when we are looking at the health of a population and designing interventions that we actually take into consideration the lifestyles, attitudes and beliefs, the cultures of people within that population so that we ensure that services are focused around their needs and take into consideration anything that may cause barriers to them, either changing their behaviour or entering into a service so it’s kind of using the discipline in terms of communication marketing and how you would analyse those things, then use what solutions you would have applied to selling a product or a service, using those skills but for social good. (O5)

In this way there was clear evidence of social marketing for health being understood as an adaptation of commercial methods; an adaptation that was felt to be unproblematic in transferring approaches designed to sell products to promoting the adoption of behavioural changes in the complex social, environmental and relational settings in which health identities are constructed and in which health behaviours become part of wider meaningful social practices (Crawford, 2006).

Respondents echoed the position of Hastings (2007), who, following Weibe (1952), has questioned why it is that methods that are known to be successful in commercial settings cannot simply be imported to the public realm. Asking why it is that ‘the devil should have all the best tunes’, Hastings (2007) proposes that it is by providing us with the ability to make the right choices in particular settings that we can change behaviours for the good of all. It is here that the institutionalization of a market model in public health practice is apparent. Respondents posit marketing as a pragmatic and effective strategy for meeting the needs of populations through techniques such as segmentation. Consideration of the contradictions raised by attempting to promote complex behavioural changes using the same methods employed to sell commercial products was not offered and social marketing was presented as an important addition to the public health toolkit.

Achieving ‘behavioural goals’

Behaviour change has become a key tenet of public health strategies charged with tackling the incidence of chronic diseases (cardiovascular disease; cancers; diabetes) through the reduction of risk. Here, behaviours (alcohol consumption; tobacco use; diet; exercise) become risk factors for potential future morbidities, and complex profiling tools are used to make individuals aware of their likelihood (or risk) of future illness based upon current measures of health status (blood pressure readings; cholesterol) as well as their behaviours (smoking status; diet; exercise). For example, the recently implemented UK NHS Health Check screening programme aims to provide ‘well’ individuals (aged 40–74) with a risk ‘score’ for their likelihood of experiencing a cardiovascular incident within the next ten years.

The promotion of behavioural change is not limited to such semi-clinical encounters but is central to broader social marketing strategies; the Change4Life campaign, for instance, promotes the simple message of ‘eat well, move more, live longer’. Here, although tied in with a variety of activities and interventions and used as a recognizable branding to promote the making of healthier choices as part of the Public Health Responsibility Deal, the emphasis is upon the individual choosing healthier behaviours rather than commercial organizations taking responsibility for the potentially harmful products they might promote.

Respondents universally recognized that social marketing’s key aim is to bring about behavioural change, and described how it might be used to achieve this goal.

Social marketing is used to support behaviour change in an audience segment. So it’s basically selling a message or selling a behaviour change to them in a way that they would respond to using a whole load of commercial principles like exchange principles. (S8)

Simultaneously respondents were quick to recognize that this was a highly ambitious aim and one that could be much harder to achieve in social than commercial marketing. As a respondent with experience of both sectors noted:

It’s easier to work in commercial marketing because usually when you’re selling a product to someone there’s a reason for them to want it whereas in social marketing in particular social marketing in health we’re often asking people to do things that are not particularly going to be pleasant for them so giving up smoking which especially if somebody’s been smoking for a long period of time there’s a whole host of other factors that influence social marketing as opposed to commercial marketing like you know, there’s a lot less emphasis on like families and surroundings and the social networks when it comes to commercial marketing as opposed to social marketing. (S8)

Respondents stressed the challenges of sustaining behavioural change on ‘wicked’ issues such as smoking and alcohol use when environmental and cultural pressures rendered these ingrained and persistent.

I guess what marketing wants is behaviour change but that there was some differences potentially in the competencies around (A) How you market something in a traditional sense in a marketing sense and (B) What you need to do in effective piece of social marketing work with local people because ultimately some of them in public health we want to use it as something that creates long term positive behaviour change in a vulnerable part of the population usually if you want to reduce inequality. (S3)

Despite claims that the role of social marketing was to both provide a greater understanding of the context in which health behaviours take place and align this with appropriate interventions, ultimately, changing behaviours was felt to be something that individuals themselves were responsible for. It was often argued that if a greater understanding of both context and attitudes was available, if health beliefs could be understood more clearly, then it was possible to encourage behaviour change.

You know if we’re doing smoking we do exactly the same as if we’re doing drugs and health but I think we need to consider a little bit better what do the communities whose behaviour health beliefs and behaviours, we’re trying to influence, what are those health beliefs and you know what are the attitudes towards them and what can we do to support that change. (S5)

Here, although a fuller understanding of the context of health beliefs and behaviours is expressed as vital for achieving health improvement, the main aim is to bring about changes in the behaviour abstracted from context. In current popular neo-liberal parlance, behavioural change may be something that can be supported by the provision of appropriate choice architecture (Thaler and Sunstein, 2009). However, ultimate responsibility lies with the individual taking messages on board and acting in a rational and risk-averse manner. In contexts where no increased capacity for making changes is offered, with the simultaneous impact of austerity measures on those who already experience the poorest health (Burgess, 2012), the contradictions of this approach become clear.

Choice

Choice has become a key theme in health work in the UK throughout the past decade. In primary and secondary care this has been epitomized by schemes such as ‘Choose and Book’, conceived to empower patients to have greater control over where and when they receive an approved treatment. These initiatives represent part of a greater push for a patient centred National Health Service (NHS). Some respondents referred to this as an important aspect of patient choice, although not always uncritically, recognizing the social and environmental barriers that may exist.

The first thing is do you understand the choices, but the second thing is are you in the position to exercise that choice. So for example Choose and Book is potentially a very good thing for patients. Right you’ve got a choice to go to a number of hospitals. You choose as a patient, it’s your right to choose as a patient and then we’ll book you in then so before you leave this surgery you know when your appointment is. Great for patients when it works, my concern is that will they understand the choices and secondly have the wherewithal to actually exercise my any of those choices because if you lived alone and you haven’t got a car then your choice is much more limited. You may understand the choices but your choice is more limited. Really it’s pretty much restricted to which one you can get to. So you might have to wait longer in more pain. (S1)

Here, respondents identified some of the limitations of introducing choice as a universal ‘good’ in service delivery without awareness of the potential inhibitors of such choices. In relation more specifically to health improvement and the role of social marketing, respondents stressed the importance of basic health education in allowing people to make healthier decisions.

It’s important to raise people’s raise awareness of different issues but it’s also important to educate people so that they can understand and make changes to their lifestyles with well informed choices, to make informed choices about their own health so it’s important that they’re educated enough to make those informed choices and it’s important that we educate people in order for them to make those informed choices and equally interventions you know we need to kind of give them a hook to engage with to begin with. (S8)

Here the imperative for change rests upon a well-informed individual with the capacity to make the ‘right’ choices regarding their own and their family’s health. Such perspectives on health improvement assume a rational, calculating, autonomous individual who is willing and able to make appropriate choices (Petersen and Lupton, 1996) or, even where autonomy is conceptualized as relative, the existence of an organic culture that values and reproduces these choices. Elsewhere choice was presented as key in bringing about behaviour change, with emphasis upon individuals being given the right tools to make healthy choices, often regardless of wider social determinants. Social marketing was understood as having the potential to access ‘hard to reach’ groups, for example, persistent smokers concentrated within lower socio-economic strata.

If we know how to engage with our so called hard to reach and if we know that if we invested so much we’ll get the message across then help them make healthier lifestyle choices, helping to engage with preventative services such as screening, stop smoking, engaging with their GPs earlier so rather than waiting until they are actually blue lighted into hospital if we can demonstrate that we’ve got, we’ve found a communication channel and if we can then demonstrate outcomes that we endorse then it would be a resource well spent, rather than trying to do a broad brush approach which we know over the years hasn’t made a significant impact on those hard to reach groups. (S4)

Some respondents recognized that social and environmental factors were key determinants of an individual’s ability to choose and that these must be taken into account. Here there was clear understanding of the challenges of using social marketing methods to bring about behavioural changes, and ultimately social good (French and Blair-Stevens, 2005) when other significant factors impinged upon people’s day-to-day lives and opportunities to be healthy.

Well if the wider determinants of your health are not right, if you don’t have a job, if you don’t have a decent home, if you don’t have the fabric and the infrastructure to make a positive behaviour change that is difficult so I do think you know holistically all those things need to be in relative order and a good place before anybody’s going to have the most supreme and excellent lifestyle. (S7)

Some consistently returned to these wider determinants of lifestyle, choice and behaviours, and ultimately argued that, although social marketing had become a key tool in public health methodologies overall, its limitations must be recognized for populations experiencing high levels of social inequality, which, it has been consistently acknowledged, must be challenged through ‘social action’ (Marmot, 2010). As one respondent commented regarding smoking and diet for mothers living in areas of high deprivation (a feature of the locales in which this research took place):

Anybody who lives in a deprived area knows people smoke for different reasons. Take for instance the young mum who’s maybe got 3 small children and not much money you know she’s kinda thinking ‘oh my god, what can I get for the tea’ and what she chooses is probably going to be something that’s cheap, not necessarily nutritious, full of salt, full of whatever because that’s what she can afford. When she gets them to bed her reward is to sit down and have cigarettes. (O/S2)

Rose (2001: 18) argues that in the twenty-first century, it is a well-regulated body and an outward concern for health which have become the most significant organizing principles of a life of prudence, responsibility and choice. If Rose (2001) is accurate, it is perhaps unsurprising that the discourse of choice has so profoundly permeated public health policy and become a key tenet of strategies such as social marketing, premised as they are upon facilitating ‘better’ choices, and allowing individuals to take ‘control’ over their long-term health and wellbeing through judicious management of behaviours. As data presented above highlight, however, choice is a highly complex and contested area, with many variables impacting upon the ability to choose healthier options, behaviours and strategies, such as socio-economic status, education, cultural and commercial pressure and so on.

Lifestyle change and responsibility

The theme of responsibility for health improvement and the role of social marketing in positioning populations as determiners of their own health emerged consistently throughout the sample, with respondents expressing a variety of perspectives.

It’s the balance between rights and responsibilities and it’s the balance between what is and isn’t the deal here and what can be expected and you know what services we can provide and should provide and where are we nanny stating and where are we morally and ethically judging. There is an element of responsibility for us all you know and there is an element in taking that responsibility that some of us are in much better places to take on that responsibility than others so I suppose when we look at what Michael Marmot is saying about social gradients and social inequality and it’s the social justice issue. (S3)

Here and elsewhere, respondents stressed that responsibility for health resided with the individual who should respond appropriately to health messages and attempts to ‘enable’ their own wellbeing and that of their families. Although respondents suggested that the aim of such work should be to allow individuals to recognize that they have the potential to take more control and responsibility, there was recognition that this must be understood in the context of wider social and environmental determinants of health.

It’s not a ‘lay the blame’ and saying you absolutely must and we are the experts telling you that you’ll be all damned if you don’t. It’s not about that, it’s about saying you know come on now you’ve got it within you, you’ve got the opportunity here but I think you can’t expect social marketing strategies on their own to be sufficient to start behaviour change if somebody’s fundamentals aren’t right. (O4)

Here, respondents were cautious of the potential for victim blaming. It was recognized that individual lifestyle changes were part of a wider matrix of determinants of health and that these were potentially profound in shaping people’s potential to make healthy choices.

In some respects yes but if you look at Dahlgren and Whitehead’s wider determinants of health model you will see from that that individual lifestyle changes are only part of the problems. You need to look at the bigger picture. All of the things that influence your individual lifestyle changes are influenced by things like your educational attainment, your employment status, your housing conditions, what foods you can even access you know, your agricultural area, sanitation, the economic climate. All of these things are in the macro environment that you don’t have any particular control over and necessarily influence your health choices as an individual which is where public health has a role and a responsibility to provide and to support the environment of the individual to support them in making those informed, educated choices around their own lifestyle and health and where we can support that and where we can educate people and give them an incentive to do so it’s our responsibility to do that so I guess the answer to your question is potentially no. (S8)

Some respondents recognized the significance of social class in determining to what degree individuals are willing and able to take responsibility for their own health and that of their immediate families. Socio-economic factors were reiterated as determining how much responsibility for health could be taken, and overall it was felt that this presented some real challenges for public health interventions:

You have your individual choices shaped by environment in which you’re living. So whilst for me, comfortably middle-class with a car and all the rest of it can quite easily go and buy vegetables from the supermarket for example but if I was in some council estate without a car and the nearest place that I can buy fresh veg is you know three bus rides away and my kids don’t eat fresh veg. (S5)

Education was identified as a key factor, inextricably linked to socio-economic status, which was said to shape dispositions to health and healthy behaviours, morbidity and mortality.

People who are better educated tend to make better choices in terms of their health needs for example professional people. You’d find nowadays smoking rates among those groups are very low, very low. That’s because for people to achieve those positions are well educated, they tend to have more control of their lives and have greater self esteem, and they tend to be in a position to make choices which are healthy choices over time one of which will be to choose not to smoke or if they’ve smoked when they were younger to have the ability to understand it’s not a good thing to do and to choose to try and stop. (S1)

Long-standing tensions between individual responsibility and the role of the state in maintaining health (Minkler, 1999) are played out here, with respondents expressing the contradictory debates that arise. Respondents often argue (echoing Minkler, 1999) for a balanced and ecological model, stressing individual responsibility for health within a broader social responsibility and ultimately reiterating the core values of health promotion of providing enabling environments in which individuals can exercise ‘healthy’ choices. Despite this, it is apparent that these professionals believe that there remains a powerful role for individual responsibility despite recognition that this is equally shaped and inhibited by structural and systemic factors.

Discussion

The National Social Marketing Centre (2007) proposes that the role of social marketing for health is to ‘enable consumers to critically interpret mass media messages in order to make informed decisions’ and ‘to gain greater control over the factors that influence their health’. French and Blair-Stevens (2005) go further, to argue that social marketing is the systematic application of marketing, alongside other concepts and techniques, to achieve specific behavioural goals, for a social good. Both definitions belie ambitious goals for social marketing as a methodology with the potential to bring about health and social improvement. Both are predicated on individual behavioural change.

It is here that many of the challenges and contradictions of using social marketing in public health and wider social policy lie. The reiterated goal of ‘social good’ is to be achieved, not through attempts to promote or engineer systemic or structural changes (e.g. campaigns for more progressive taxation; attempts to mobilize particular interest groups around specific issues; community organizing; renewed attention to tax credits), but rather, through encouraging people to make better choices within their own lives, regardless of the wider structural and relational determinants of health so well documented in the literature on health inequalities. To achieve this, the individual must be reflexive and rational in pursuit of their own health.

The discussion above illuminates how social marketing for health has been adopted as a form of governance judged capable of importing commercial methods into new sectors and areas of public life with the aim of improving health and creating social good. Although respondents clearly recognize the tensions and contradictions between individual agency in particular contexts and the structural determinants of health, overall, marketing methods are posited as a valuable piece of the public health toolkit, which, if used appropriately, can bring about behavioural changes. The efficacy of commercial approaches is cited as evidence for these claims. This, it is argued, is indicative of the institutionalization of market driven, neo-liberal imperatives into diverse areas of social and welfare provision and illuminates how, as Harvey (2005: 3) argues, neo-liberalism has become incorporated, and accepted into the common sense way in which many of us view the world. Governmental health strategies administered through discourses of social marketing fit neatly within such domains of conduct which were not previously market forms of behaviour but which have become so under more and more explicit attempts to construct ‘health marketplaces’ in the UK and beyond.

Recent public health policies bear less and less resemblance to the interventionism and social engineering of the Victorian reformists’ policies (Rosen, 1993), or even the aims of the new public health movement to engage communities and improve environments (Ashton and Seymour, 1988; Baum, 2008). Rather, they operate with governmental rationalities that aim to inculcate regimens of self-discipline in diet, exercise and the regulation of consumption of risky substances such as alcohol and tobacco, reflecting a wider behavioural turn and a shift from the social to the individual as the target of interventions. These in turn reflect a more explicit institutionalization of neo-liberal values within public health strategies and practice. In the case of marketing, these methods are predicated on the promotion of consumption of particular goods or services to maximize profit, objectives that do not sit comfortably with the long-term aims of making sustainable improvements in health through attempting to tackle issues that evidence suggests remain stubbornly intransient. Data presented here explore professionals’ understanding and constructions of social marketing, with critical issues such as the importing of commercial methodologies into ‘social’ endeavours discussed, the aim of behavioural change examined and issues of choice and responsibility explored. Respondents acknowledge that health behaviours are acted out in complex settings, with often considerable pressure from external factors that may be deleterious to wellbeing. However, a key theme becomes the power of pseudo-commercial methods such as social marketing in identifying, engaging and influencing individuals and communities in their health choices and behaviours.

From the UK Black Report of 1979 to the most recent Marmot Review of 2010, a stream of evidence and policy documents has been produced locally and globally which have consistently highlighted the role of external environmental and socio-economic factors in determining health and systematically constructing and reproducing structural inequalities between social groups stratified on the basis of income (see Bambra et al., 2011). Recent studies have continued to emphasize the social determinants of health and the economic and structural basis of health inequalities (see for example Dorling, 2011; Marmot, 2010; Wilkinson and Pickett, 2009). Despite this, by embracing methodologies such as social marketing, public health continues to plough a decontextualized behavioural furrow, focusing upon the capacities of individuals to change, rather than the possibilities for structural and systemic alterations to improve health. In this way it is argued that public health strategies have come to reflect a wider and deeper neo-liberalism apparent within public policies in the UK and beyond, policies that posit decontextualized behaviourism as the solution for combating social evils and a wider promotion of social goods. If this is the case, methodologies such as social marketing for health represent little more than, at best, resignation of the unlikelihood of governments implementing bolder structural changes to improve health, as recommended by commentators such as Marmot (2010), or, at worst, a wilful and ideologically driven disregard for the weight of evidence of the social determinants of health. Whilst ever the latter runs contra to modes of market organization as the key tenets of neo-liberal democracies and sits uncomfortably with strategies predicated upon austerity and reduced state intervention in the UK and beyond, it is perhaps not unreasonable to argue that the placing of responsibility with the individual represents a cynical preparation for the failure of social policy.